Foundations 2

What does EBM stand for?Evidence based medicine  What is the definition of EBM?The conscientious, judicious and explicit use of current best evidence when making decisions about the care of individual patients What three things make up EBM?1. Individual clinical expertise 2. Best external evidence 3. Patient values and expectations What is the AAAA framework?1. Assess - what type of healthcare question -> what type of study 2. Access - finding the best evidence -> validity and relevance 3. Appraise - evaluating the quality of the evidence and interpreting the results 4. Act - is this evidence relevant to my clinical practice -> should it change my practice? Why is the AAAA framework important?1. Essential professional and academic skill 2. Medical knowledge is continually evolving 3. Medical profession frequently fails to use effective treatments 4. Keeping up to date is a lifelong commitment of every doctor What is the evaluation bypass?Where an unevaluated procedure is taken up into healthcare services because of professional enthusiasm or conviction, and/or commercial pressure. EBM and the use of the AAAA framework aims to prevent this from happening. Examples of evaluation bypass1. Front sleeping to prevent SIDS -> made sense rationally because this should prevent babies from chocking on vomit -> actually increased deaths 2. Thalidomide -> marketed as a sleeping pill -> claimed to be safe in pregnancy -> used offf label to combat morning sickness as it seemed effective -> led to congenital defects and high infant mortality rates What are the catorgories of healthcare questions?"1. How common is it?/Who gets it? = Frequency 2. What causes it? = Aetiology 3. What happens to those who have it? = Prognosis 4. Are there any treatments for it?/What are the side effects of treatments? = Effectiveness 5. How do we find out if someone has it? = Diagnosis 6. Is the patient's day to day life affected? = Patient experience" Most appropriate study design for frequency questionsEcological and cross-sectional Most appropriate study design for aetiology questionsCase-control and cohort studies Most appropriate study design for effectiveness questions Randomised controlled trial (RCT) Most appropriate study design for diagnosis questions Special cross-sectional/ test accuracy study Most appropriate study design for patient experience questions Qualitative research  What types of descriptive studies are there?1. Population level - ecological 2. Individual level - cross-sectional and case report/series What are descriptive studies?- Observational - Look into patterns of desease -who/where/when - Used for hypothesis generation proceding more expensive analytic studies What is a case report?A detailed report of an unusual condition or occurrence in a single patient What is a case series?A detailed report of an unusual condition or occurrence in several patients What is a cross-sectional study (Prevalence/incidence study/survey)A study in which information is collected in a planned way from individuals in a defined population at one point in time Define an ecological studyA study in which information is collected from population groups to compare disease frequencies either in the same population at different points in time (population defined temporally) or between different populations (population defined geographically) at the same period in time. What types of analytical studies are there?1. Observational (either cohort or case control) 2. Intervention (clinical trials) What is a key feature of an analytical study?They make explicit comparison between two or more groups of individuals What is the aim of an analytical study?To establish whether an exposure causes an outcome (investigate cause and effect) What is an observational study?Researcher is an observer of exposures and outcomes What is an interventional/experimental study?The researcher allocates exposure and observes outcomes Analytic Observational StudiesExposure is not under the control of the researcher because of ethical or logistical constraints, e.g. if investigating whether an exposure causes harm or disease.  What is a case control study?Study starts with identification of the outcome  What is a cohort study?Study starts with identification of the exposure What is an analytical observational study?"Exposure is not under the control of the researcher because of ethical or logistical constraints, for example if they're investigating whether an exposure causes harm or disease. " What types of analytical observational studies are there?1. Case control - study starts with the identification of the outcome (e.g. disease) 2. Cohort - study starts with the identification of the exposure (e.g. risk factor Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be [...]Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor. Analytic Observational studies: Case control study ❖A case-control study compares those [...] Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor.Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor. Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is [...] the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor.Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor. Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according [...]  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor.Analytic Observational studies: Case control study ❖A case-control study compares those with a condition (cases) to those without the condition (controls). Subjects are grouped for comparison according to the outcome of study.  ❖The level of “exposure” to one or more factors is measured and compared between the two groups (cases and controls). ❖If the level of exposure is higher in the cases than in the controls the exposure might be a risk factor. Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to [...] ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor.Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor. Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and [...] is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor.Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor. Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a [...]Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor. Analytic Observational Studies: Cohort studies ❖A cohort study compares [...] Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor.Analytic Observational Studies: Cohort studies ❖A cohort study compares those exposed to a factor of interest (exposed) to those not exposed to a factor of interest (non exposed). Subjects are grouped for comparison according to whether they have been exposed or not ❖The two groups are followed up over time and the amount of disease developing over a specified time period (incidence) is compared between the two groups (exposed and unexposed). ❖If the incidence of the outcome is higher in the exposed compared to the unexposed the exposure might be a risk factor. Case control or cohort study? Consider: -how many exposures do you want to capture? [...] -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case controlCase control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case control Case control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? [...] -is the outcome rare or common?  Rare - case controlCase control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case control Case control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common? [...]Case control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case control Case control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? [...] -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case controlCase control or cohort study? Consider: -how many exposures do you want to capture? More than one then case control -how many outcomes do you want to measure? More than one then cohort studies -how long between exposure and development of outcome? Long period - case control -is the outcome rare or common?  Rare - case control Summary points for case control trials1)Can investigate multiple exposures 2)Can only investigate one outcome 3)Recruitment is based on presence or absence of outcome, so do not have to wait for this to occur 4)Groups for comparison are based on the presence of the outcome: active case finding overcomes the problem of rare outcomes Summary points for cohort study1)Can only investigate one exposure 2)Can investigate multiple outcomes 3)You have to wait for the outcome to occur after recruiting on the basis of exposure –so loss to follow up is a problem for diseases with long latency periods 4)For rare outcomes a lot of exposed individuals would need to be recruited to be sure of enough outcomes occurring What is a randomised controlled trial (RCT)?An experimental study where participants are randomised by researchers to either receive the new intervention being tested or to receive a control treatment, usually either the standard/existing treatment or placebo. What are RCTs used for?To investigate effectiveness of treatment In an RCT what do patients importantly consent to?Not having a choice of which treatment option they recieve Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including [...]Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups). Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a [...] ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups).Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups). Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection [...]: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups).Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups). Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand [...] ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups).Qualitative Research: Patient / Carer / Health Professional Experience ❖Collection of non numerical data about people’s subjective understandings of their lives and experiences: ‘why and how’ rather than ‘how often’ ❖In depth study of a small number of individuals in a specific setting rather than aiming for generalisability across different settings in quantitative research (which requires larger sample sizes) ❖Interpretation of the meaning of the data helps us understand individual’s behaviour and social phenomena ❖Multiple methods available for collecting data including direct observation of behaviour, individual interviews and group interviews (focus groups). The AAAA framework ❖Assess: [...] ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice?The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice? The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: [...] ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice?The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice? The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: [...]The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice? The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: [...] ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice?The AAAA framework ❖Assess: what type of healthcare question – what type of study? ❖Access: finding the ‘best’ evidence (validity and relevance) ❖Appraise: evaluating the quality of the evidence & interpreting the results ❖Act: is this evidence relevant to my clinical practice. Should this evidence change my practice? What does PICO stand for?P - population I - Intervention  C - comparator O - outcome Why is formulating a PICO important?1. It helps with searching for evidence in electronic bibliographic databases such as medline. 2. It helps with the assessment of applicability of population based research to your patient population Where should you search for RCTs?1. Cochrane Library (only contains RCTs) 2. MEDLINE (specify RCT) 3. PUBMED (specify RCT) 4. EMBASE (specify RCT) What 4 things does Appraisal ask?❖Does the study address a research question which is relevant to my clinical problem (is there a match between my PICO & the study question?) ❖Did they use the study design most likely to provide a valid answer to the clinical question (for effectiveness was it an RCT?) ❖ Was the study done well / is the study trustworthy ? (were steps taken to reduce bias?) ❖If the study was done well (valid), what were the results? (direction, size, precision and statistical significance of results) Define biasAny factor that results in a systematic deviation of results from the truth. Consequently bias undermines validity What is the importance of blinding?Blinding is used to avoid measurement bias - it reduces the affect of the placebo effect. What is the placebo effect?"a beneficial effect produced by a placebo drug or treatment, which cannot be attributed to the properties of the placebo itself, and must therefore be due to the patient's belief in that treatment" "What might patients do if they know they're in the intervention arm?"They may offer socially desirable responses. Other than measurement bias, what else is blinding used for?Performance bias.  What is performance bias?This is where healthcare professionals have preconceived ideas about how effective a treatment is, which can influence (either consciously or subconsciously) how they deliver treatments, leading to participants in either the intervention or comparator arm receiving extra Where can blinding take place?At several levels: 1. Participants 2. Clinicians delivering treatment 3. Researchers measuring outcomes 4. Statisticians undertaking analysis What is attrition bias?"A type of selection bias due to systematic differences between study groups in the number and the way participants are lost from a study." Where relative risk = 1 : no difference between treatment and comparator Where RR is > 1 : more outcomes in treatment group compared to comparator. Where RR <1 : [...]Where relative risk = 1 : no difference between treatment and comparator Where RR is > 1 : more outcomes in treatment group compared to comparator. Where RR <1 : less outcomes in treatment group compared to comparator group Where relative risk = 1 : [...] Where RR is > 1 : more outcomes in treatment group compared to comparator. Where RR <1 : less outcomes in treatment group compared to comparator groupWhere relative risk = 1 : no difference between treatment and comparator Where RR is > 1 : more outcomes in treatment group compared to comparator. Where RR <1 : less outcomes in treatment group compared to comparator group Where relative risk = 1 : no difference between treatment and comparator Where RR is > 1 : [...] Where RR <1 : less outcomes in treatment group compared to comparator groupWhere relative risk = 1 : no difference between treatment and comparator Where RR is > 1 : more outcomes in treatment group compared to comparator. Where RR <1 : less outcomes in treatment group compared to comparator group Where risk difference = 0 : no difference between treatment and comparator Where RD >0: [...] Where R <0 : less risk of outcome in treatment group compared to comparator groupWhere risk difference = 0 : no difference between treatment and comparator Where RD >0: more risk of outcome in treatment group compared to comparator group Where R <0 : less risk of outcome in treatment group compared to comparator group Where risk difference = 0 : [...] Where RD >0: more risk of outcome in treatment group compared to comparator group Where R <0 : less risk of outcome in treatment group compared to comparator groupWhere risk difference = 0 : no difference between treatment and comparator Where RD >0: more risk of outcome in treatment group compared to comparator group Where R <0 : less risk of outcome in treatment group compared to comparator group What does a lower p value mean?A lower chance that any difference between our intervention group and comparator group is due to chance. What are the reasons for differences between RCTs?• chance • differences in people • differences in intervention/ comparator • differences in care other than that being investigated • differences in the way treatment effects are assessed • differences in follow-up • reporting of the available evidence • selection from the available evidence Hopefully not: – “Bad science” – “Fraudulent Science” What is publication bias, and what are the two types?When the publication of research results depends on their nature and direction. – Positive results bias - when authors are more likely to submit, or editors accept, positive than negative or inconclusive results – Outcome reporting bias - when several outcomes within a trial are measured but are reported selectively depending on the strength and direction of those results. What is a systematic review?the research method generally used to synthesis multiple pieces of research evidence on the effectiveness of a treatment What does a systematic review entail?- Clear question being addressed by the review • An explicit and detailed statement of the methods used • Comprehensive ascertainment of the literature relevant to the review question • Steps to reduce bias in the review process /documenting of any bias with or without: • An appropriate numerical summary of the size of effect with confidence intervals What are the stages of conducting a systematic review?1. Define question 2. Write protocol 3. Search for evidence and studies 4. Select relevant studies from the search 5. Appraise studies 6. Extract, analyse, and summarise data 7. Interpret Review Results 8. Discussion and conclusions What is a summary effect?" the pooled effect size, generated by combining individual effect sizes in a meta-analysis." Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - [...] 5. Method is included and reproducible - Systematic ReviewDifferences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - [...]Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - [...] 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic ReviewDifferences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - [...] 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic ReviewDifferences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - [...] 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic ReviewDifferences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review Differences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - [...] 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic ReviewDifferences Between Non-systematic Reviews and Systematic Reviews 1. More often involve general discussion of subject with no stated hypothesis - Non-Systematic Review 2. Sophisticated search strategies, planned, inc. looking for published and unpublished studies. Comprehensive - Systematic Review 3. Explicit description of types of studies to be included to limit selection bias (on behalf of reviewer) 2 people selecting studies independently - Systematic Review 3. Often do not consider differences in study methods or study quality. Often subjective extraction of data - Non - systematic review 4. Validated methods. Assess heterogeneity between studies, appropriate use of meta-analysis - Systematic review 5. Method is included and reproducible - Systematic Review What is a meta-analysis?It is a statistical technique(s) used to combine the quantitative results from a number of studies What are the advantages of systematic reviews?1. Can be the best source of evidence on the effects and effectiveness of healthcare interventions 2. Assimilation of large amounts of research evidence 3. Provide reliable unbiased estimates of effect 4. Increase precision of estimates of effects  5. Provide information about the generalisability and consistency of effect  6. Identify what information is missing  7. Useful for making decisions Where can we find systematic reviews?1. Cochrane library 2. Epistemonikos - contains all cochrane reviews and other sources (the go too) 3. NHS Evidence  3. MEDLINE and EMBASE What does internal validity mean?The degree to which the effect observed is attributable to the evidence, rather than any other cause (such as bias and other methodological problems of the review) What is external validity?– The degree to which the reviews conclusions apply to other persons in other places and at other times What does NEET stand for?Young people not in education, employment or training How does a biomedical model of health see health and illness?As natural, objective, and mutually exclusive phenomena, with health being the absence of disease.  What are the key features of a biomedical model of health?1. Mind/body dualism 2. Mechanical metaphors 3. Reductionist (to biology) 4. Claims to objectivism and neutrality How does the WHO define health?As a state of complete physical, mental and social well-being and not merely the absence of disease "What is the key fault to the WHO's definition of health?"The stress on complete health is unattainbale for most people - it is idealistic rather than realistic "These are the types of definitions of health that we may hold: • Health as [...] • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as [...] • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as [...] • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a [...]  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a [...] • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as [...]  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health [...] • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a [...] • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as [...]  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as [...]""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " "These are the types of definitions of health that we may hold: • Health as not-ill • Health as [...] • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community) ""These are the types of definitions of health that we may hold: • Health as not-ill • Health as absence of disease • Health despite disease • Health as a reserve  • Health as a behaviour (i.e. healthy lifestyle) • Health as a function (being able to do things) • Health as physical fitness  • Health as psycho-social wellbeing (purely mental state)  • Health as spiritual wellbeing • Health as energy, vitality • Health as positive social relationships (family, friends, community)  " What is an explanatory model in relation to ill health?An explanatory model is the how, why, what, when, where, and what next of an illness experience according to the person her/himself. An explanatory model thereby encompasses the beliefs that a person holds about the cause of their illness, the personal and social meaning they attach to it, and their expectations and wishes regarding its course and their recovery. Explanatory models are never solely individual; they are profoundly shaped by the social and cultural contexts of a person’s life. What is humanism?A philosophy grounded in the intrinsic value of human beings What are the key features of humanism?● all individuals should be respected by default ● human happiness should be optimised and suffering reduced ● the most effective path to achieve this is through the use of science and evidence What are care ethics?Any ethic which is oriented around meeting the needs of individuals through caring relationships What is the importance of listening to patients in the medical profession?It decreases stress and anxiety which are detrimental to health, and it promotes the patients agency over their condition and wider health. Why do we undertake research?1. Develop new models of disease 2. Discover new treatments  3. Ultimately improve patient care Define participation (in research)Where people take part in a research study Define engagement (in research)Where information and knowledge about research is shared with the public Define involvement (in research)Where people are actively involved in research projects and/or in research organisations  What are some ways that patients, family members, and the public can make a difference to health and social care research?1. Making sure that researchers ask the right questions and in a way that the public understand 2. Keeping the research on track so that it stays relevant 3. Making sure the people being researched are approached in the right way 4. Improving the quality of the research by adding another point of view to its design and conduct What does does PPI (public and patient involvement) lead to?1. Enhanced quality and appropriateness 2. Development of user-focused research objectives  3. Development of user-relevant research questions  4. Development of user-friendly info, questionaires, and interview schedules 5. More appropriate recruitment strategies for studies  6. Consumer-focused interpretation of data 7. Enhanced implementation and dissemination of study results What are the different types of PPI?"1. Consultation - where researchers choose to ask their views  2. Collaboration - involves more of a partnership where the researcher has chosen to give up some control 3. User-controlled - research only involves professionals if they're invited by users" What is Experimental Knowlege?The knowledge originating through a person living through an experience. What are the qualities of a professional?1. Integrity 2. Compassion 3. Altruism 4. Continuos improvement 5. Excellence  6. Working in partnership with members of the wider healthcare team What is empathy?"It is a process that begins with gaining an insight into the patient's concerns, feelings and sources of distress, followed by engagement with these things. " What are TED questions?1. Tell - tell me why your here today? 2. Explain - explain how this affects you? 3. Describe - describe what the pain feels like? What are the conditions for rapport?1. Mutual attentiveness 2. Positivity 3. Co-ordination Define patient activation"It is a measure of a person's skills, confidence and knowledge to manage their own health." What is the ICE framework?I - ideas - have you (the patient) got any ideas of what might be causing this problem? C - concerns - What concerns you about this?  E - expectations - what is the patient expecting from this consultation and their care? KSA listening framework1. Knowledge 2. Skills 3. Attitudes What are the different types of attitudes?1. Evaluative  2. Subjective 3. Explicit vs implicit 4. Learned 5. Enduring but possible to change How are attitudes formed?1. Imitation and rolemodelling 2. Conditioning  3. Experience  4. Social norms Why are attidues formed?1. To express who we are 2. To protect our self-esteem 3. To express what we believe  4. To avoid punishment 5. To understand the world Under what conditions can attitudes predict behaviour?1. When they are measured specifically  2. When an attitude is formed through experience  3. When there is more at stake  4. When there are fewer potential barriers 5. When the attitude is repeatedly expressed Why is understanding attitudes important to doctors?Because patient attitudes can be used to predict: 1. Adherence to lifestyle advice 2. Concordance with treatment 3. Engagement with non-pharmocological interventions  4. Uptake of screening tests 5. Willingness to attend appointments What is responder bias?It is where: 1. People tend to always agree/disagree 2. People generally avoid extreme responses 3. People generally choose responses that make them look good 4. People ted to choose socially acceptable responses What are the 5 As of a Brief Intervention?1. Ask  2. Advise 3. Assess 4. Assist 5. Arrange What are the two important processes in child development?1. Muturation  2. Learning Define plasticityThe capacity for change in response to negative or positive life experiences  What are the two important processes that underline child development?Maturation and learning What is maturation?Biological development of a child into an adult according to their genetics of their species What is learning?The process by which our experiences produce relatively permant changes to our feelings, thoughts, and behaviours What is plasticity?Capacity for change in response to negative or positive life experiences What emotions to we have from birth?Contentment, disgust, distress, and interest What emotions to we have from 2-7 months?Anger, fear, joy, sadness, and surprise What emotions to we have from 12-24 months?Embrarrassment, envy, guilt, pride, and shame What is temperament?Individual differences in emotional, motor, and attentional reactivity and self regulation. Emotional and behavioural building blocks of adult personality What is attachment?An intense emotional relationship that is specific to two people that endures over time and in which prolonged seperation from the partner is accompanied by stress and sorrow. What is reciprocal relationships?Two way relationship How does the baby parent bond develop?Synchronised routines What are the phases of attachment?1. Pre-attachment phase 2. Indescriminate phase 3. Descriminate phase 4. Multiple attachment phase What are the possible signs of physical and emotional abuse in children?"1. Unexplained or repeated injuries 2. Injuries in the shame of an object 3. Injuries not likely to happen given the age or ability of the child 4. Disagreement between the child's and the parent's explanation of the injury 5. Obvious neglect of the child  6. Fearful behaviour  7. Agressive or withdrawn behaviour  8. Afraid to go home " What are the possible signs of sexual abuse?1. Difficulty in walking or sitting 2. Stained or bloody underwear 3. Genital or rectal pain, itching, swelling, redness, or discharge 4. Bruises or other injuries in the genital or rectal area 5. Soiling or wetting pants or bed after being potty trained 6. Withdrawn from activities and others 7. Talking about or acting out sexual acts beyond normal sex play for age  What is an asylum seeker?A person who has left their country of origin and applied for asylum in another country, but whose application has not yet been concluded What is an Undocumented Migrant?A person who enters or stays in the UK without the necessary documentation required under immigration regulations "What are Kohlberg's Stages of Moral Development?"" - Stage 1: Authority-punishment (if I don't do it, i'll be punished)  - Stage 2: Egoistic exchange (I'll do it if there is something in it for me)  - Stage 3: Interpersonal conformity (if everybody else is doing it then I will)  - Stage 4: Societal Maintenance (to keep systems running we would accept refugees)  - Stage 5: The Greatest Good (accept refugees to reduce suffering)  - Stage 6: Commitment to ethical principles  " What is humanistic care?attitudes and behaviours that demonstrate interest in and respect for patients’ psychological, social and spiritual concerns and values What are the signs of developmental problems in children up to 24 months?" At any age – any loss  of skills or language  By 12 months – no  babble or gesture (e.g.  pointing)  By 18 months – no  single words  By 24 months – no two  spontaneous words" What are the signs of developmental problems seen by 2 and three years onwards?1. Communication problems  2. Lack of poor eye contact 3. Extreme emotional reactions and aggression  4. Over or under-sensitivity to stimuli What is precocious puberty?Early onset puberty - pubic hair or genital enlargement in boys before 9.5 years and pubic hair before 8 and breat development before 7 years in girls, as well as menstruation before 10 years  What are the consequences of early onset puberty?"1. Induces early bone maturation and so reduces eventual adult height 2. Emotional and social consequences  3. Harmful to children who mature physically when they're immature mentally 4. Development of sex drive inappropriate for their age " Is aggression a stable characteristic?Yes. What is a histrionic patient?"1. Has a dramatic, emotional, and overwhelming style of presenting  2. May be seductive towards their doctor because of fear that if they're not sexually desirable they will not be taken seriously 3. Often come across as emotional and flirtatious  4. Risk of innapropriate response by doctro to seduction" What is a dependent patient?"1. Patient that needs inordinate amount of attention but still isn't reassured 2. Needy, passive, and clinging behaviour, fear of seperation, inability to make decisions without reassurance 3. Likely to make repeated urgent calls between appointments and to demand special consideration  4. Risk that doctor may react with callous disregard" What is a demanding patient?1. Patients who have difficulty delaying gratification and demand that their discomfort and problems be eliminated immediately 2. Often act entitled and superior to mask own sense of helplessness 3. Easily frustrated and hostile What is a narcissistic patient?"1. Patient with excessive need for admiration with lack of empathy for others 2. Act superior to everybody including the doctor 3. Initially idealise doctor but soon changes to feeling of contempt for doctor's inadequacies " What is a suspicious patient?1. Chronic, deeply ingrained suspicion that other people are unreliable and untrustworthy and only want to cause them harm 2. Likely to interpret neutral events as evidence of a conspiracy against them 3. May behave hostily and stubbonly 4, Hypersensitive to criticism What is a help-rejecting complainer?Patient who only communicates through a litany of complaints and dissapointments What is a manipulative patient?- Patient who uses lying and manipulation as a means of communication - They may pretend to be ill ub order to obtain insurance settlements or narcotic analgesia - History of using violence to obtain their wishes What is somatisation?This is where a patient with a psychiatric disorder or psychological difficulty presents with physical symptoms which are attributed by the patient to a physical cause What is hypochondrial disorder?Where the patient is pre-occupied with fears of having a serious disease based on misinterpretation of bodily symptoms, and where the belief is not of dilusional intensity and symptoms last for 6 months or longer What is a conversion disorder?"A condition that presents as an alteration or loss of physical function suggestive of a physical disorder:  - Psychological conflicts or stressors precede the initiation or exacerbation of symptoms  - Symptoms are not intentionally produced but are the result of unconscious motives - Can't be explained by any physical disorder or known pathological mechanism. " What is body dysmorphic disorder?"Where the patient is preoccupied with an imagined defect in appearance or if a slight physical anomaly is present, the person's concern is markedly excessive, and this preoccupation causes clinically significant distress." What is a factitious disorder?It is where a patient intentionally produces physical and psyhological signs or symptoms, with the motivation of assuming the sick role. Why is the population ageing?1. Older population itself is living longer 2. Improved health care  3. Decreases in infant and childbirth mortality  4. Improved standards of living Why is an ageing populatin worrying?1. High prevalence of disease in the elderly  2. Draw heavily on healthcare resources What are the two types of ageing?1. Primary - natural decline 2. Secondary - resulting from disease, disuse, or abuse (lifestyle and environmental factors) Why do we age?1. Wear and tear 2. Cellular 3. Rate of living - born with a limited amount of physiological capacity 4. Programmed cell death  What are the 4 types of cellular ageing?- Type 1: Hayflick - limit to number of times cells can divide and divisions decrease with age - Type 2: Cross linking - proteins in cells interact to produce molecules that make the body stiffer; this process increases with age - Type 3: Free radicals - interact with molecules and cause cellular damage and shut organs down - Type 4: DNA is unable to replicate itself when cells divide What physiological changes occur with age?1. In the brain: - Structural changes 2. Cardiovascular system: - accumulation of fat deposits - stiffening of walls of arteries due to tissue change 3. Respiratory system: - rib cage and air passageways become stiffer 4. Appearance and movement: - skin and muscle tissue decline, internal bone mass decline 5. Senses: - cataracts 6. Immune function: - changes in immune system cells Cognitive decline associated with aging1. Cystalised abilities improve up till 60 and then plateau 2. Fluid abilities steadily decline from 20-80 3. Cumulative knowledge and experiental skills well maintained  Healthy lifestyle factors that decrease rate of cognitive decline 1. Physical activity 2. Mental stimulation 3. Avoiding excessive exposure to alcohol 4. Treating depression and managing stress 5. Controlling common medical conditions Are good social relationships important to healthy ageing?Yes. The more varied the network, the more healthy and happy a person will be. What is the menopause?<ul><li>The end of reproductive years, which naturally occurs in all women</li><li>Loss of periods</li><li>Caused by decline in oestrogen (and possibly endorphins) - causes instability in thermo-regulation</li><li>Primary symptoms: hot flushes and night sweats</li><li>Secondary symptoms: vaginal dryness, depression, somatic symptoms, fatigue</li><li>Large cultural variation in hot flushes and night sweats</li><li>Lifestyle effects occurence of symptoms</li></ul> What are the characteristics of dementia?" communication difficulties – spatial & temporal disorientation – aberrant behaviours – (e.g. physical aggression, shouting, repetitive questioning) – incontinence & inappropriate toilet behaviours – memory loss – changes in personality – depression & paranoia – diminished ability for self care – inappropriate sexual behaviours – wandering – family stress & burden" What is healthy ageing?The process of developing and maintaining the functional ability that enables wellbeing in older age What factors make the transition to retirement positive and stress free?1. Financial planning 2. Maintaining a life beyond work 3. If not motivated to retire - delay it 4. Keep busy - voluntary work 5. Maintain friendships, see friends regulary, make new ones 6. Be optimistic  "Define 'Gender role'"The behaviours, attitudes, values, and beliefs which society expects from males/females "Define 'Sex typing'"The process by which children acquire sex/gender identity and learn gender appropriate behaviours What differet types of intersexuality are there?1. Androgen insensitivity syndrome 2. Androgenital syndrome 3. DHT deficient males 4. Chromosomal abnormalities What is androgen insensitivity syndrome?Males develop female external appearance due to insensitivity to androgens  What is androgenital syndrome?Females develop male external appearance due to prenatal exposure to high levels of androgens What happens in DHT deficient males?Males develop female external appearance due to deficiency of alpha-reductase What is Turner Syndrome?<ul><li>XO</li><li>Short stature, swollen hands and feet, webbed neck</li><li>Infertility, amenorrhoea, absent or incomplete pubertal development</li></ul> What is Klinefelter?<ul><li>XXY</li><li>Gynaecomastia, small testes, less air, infertility</li><li>Tall with abnormal body preportions (long legs, short trunk, shoulder equal to hip size)</li></ul> What is the management of paraphilas?1. Aversive conditioning 2. Reconditioning techniques 3. Cognitive techniques 4. Psychotropic medication, e.g. SSRIs 5. Hormonal treatment  6. Efficacy of castration and neurosurgery controversial and considered unethical What are stereotypes?Widely shared assumptions about personalities, attitudes, and behaviour of people based on group membership "What is the 'Out-Group Homogeneity' effect?"Where people tend to peceive members of an out-grou as similar to each other, e.g. they all look the same "What is the 'In-Group Differentiation Effect'?"Where people percieve many differences between members of their own group "What is 'Steretype Threat'?"When a person experiences anxiety or concern that they may conform to a negative stereotype linked to their in-group What is stigma according to Goffman?An attribute that is deeply discrediting and reduces the bearer from a whole and usual person to a tainted and discounted one What are the stages of stigmatisation?1. People distinguish and label human differences; some are seen as undesirable characteristics  2. What is undesirable is decided by society (macro or micro), differences between times/ cultures 3. Impact of people/ institutions in power as the effect of labelling will spread 4. People experience emotional reactions to labelled people – fear, repulsion, disgust  5. Labelled persons may feel shame, humiliation  6. Labelled persons experience status loss and discrimination as a consequence What may be the origin of stigma?The fear of contagion Causes of stigma of cancer?1. ‘Incurable’ disease can lead people to avoid even saying the word (the Big C…) 2. Unclear causes makes it more frightening 3. Can lead to visible difference (hair loss/ mastectomy) 4. Potentially embarrassing outcomes (impotence/ colostomy bag) 5. Blaming patients might make others feel safer 6.  However, positive impact of better prognosis for many, awareness raising, charity activities "What are Goffman's three types of stigma?"1. “Abominations of the body”: physical disfigurement/ deviations from a social norm 2. “Blemishes of character”: a known record eg of alcoholism, long-term unemployment seen as character flaw 3. “Tribal identities” negative evaluation of people due to association with a particular group, most often via family e.g. class, ethnicity, religion Discredited vs discreditable stigma"Discredited - characteristic is visible or well known and can't be hidden Discredible - characteristic can be hidden" What does having a spoiled indentity mean?Where an individuals social identity is dominated by the stigmatised illness or attribute How do people manage a spoiled identity?1. Passing as normal - concealing signs of illness 2. Information control - deciding who to trust 3. Avoiding all social contact - in extreme cases 4. Trying to avoid blame - e.g. by focussing on the role of genetics and stressing responsible behaviour 5. Refusing to be ashamed - seeking group solidarity and pride What is the difference between stigma and stereotype?Stereotype focuses on group identity whereas stigma focuses on the stigmatised individual and the effect on them What can physical stigma lead to?1. Heightened social anxiety 2. Embarrassment 3. Depression 4. Low self-esteem 5. Social withdrawal 6. Isolation What is aggression?Behaviour that is intended to injure a person or to destroy property What is the Agreessive Cue Theory of aggression?1. Frustratio produces anger rather than aggression 2. Frustration is psychologically painful, and anything that is psychologically or physically painful can lead to agression  3. For anger and psychological pain to be concerted into agression, cues are needed. What are the warning signs of aggressive behaviour?1. Irritability - rising tension 2. Fast speech 3. Restless pacing 4. Loud voice - shouting 5. Glaring eyes 6. Verbal threats 7. Intrusion into others personal space 8. Gut instinct What is the definition of harrassment?The unwanted conduct that is related to a protected characteristic or unwanted conduct of a sexual nature What things is someone who has experienced bullying or harassment likely to experience?1. Anxiety 2. Difficulty sleeping 3. Loss of appetite 4. Inability to switch off from work 5. Self-doubt, loss of confidence 6. Feeling isolated 7. Hyper-vigilance or need to constantly double-check your work How do you do a root cause analysis of a medical mistake?5 whys What is an adverse event?Where an medical mistake event has either a serious consequence or it offers the potential for great learning. What classifies as a serious incident?<ul><li>unexpected or avoidable death</li><li> unexpected or avoidable injury resulting in serious harm </li><li>abuse </li><li> Never Events </li><li>incidents that prevent delivery of an acceptable quality of healthcare services </li><li>incidents that cause widespread public concern/loss of confidence</li></ul> What constitutes a near miss?Potential harm avoided but weaknesses still revealed What is a never event?A serious incident that is wholly preventable What does medical errors constitue in law?Usually a civil wrong - tort - medical negligence  What is the function of the digestive tract?1. The breakdown of food for absorption into the body 2. Elimination of waste What makes up the digestive tract?Gastrointestinal tract, oral cavity, oesophagus, stomach, small and large intestine, and the anus. phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: [...] - elimination: rectum holds faecus prior to defaecation via anal canal.phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal. phases of digestion: - ingestion: oral cavity - fragmentation: [...] - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal.phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal. phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: [...]phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal. phases of digestion: - ingestion: [...] - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal.phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal. phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: [...] - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal.phases of digestion: - ingestion: oral cavity - fragmentation: oral cavity during mastication and saliva secretion. completed in stomach. - digestion: enzymatic breakdown of food into molecules of absorption. oral cavity with salivary amylase, continues in stomach forming chyme. pancreatic enzymes and bile in duodenum, completed as passes through small intestine. - absorption: mainly small intestine. water absorbed in large intestine. - elimination: rectum holds faecus prior to defaecation via anal canal. What makes up the vestible?1. Lips and cheek (buccinators muscle) externally 2. Teeth and gums internally What makes up the mouth proper?<ul><li> anteriorly/laterally: dental arches;</li><li>floor: anterior 2/3rd of tongue, mylohyoid muscles, geniohyoid muscles;</li><li> roof: hard and soft palate;</li><li>posteriorly: oropharyngeal isthmus</li></ul> Describe the surface of the tongueFront of the tongue: <ul><li>Fungiform papillae at the front laterally</li><li>Filiform papillae at the front medially (these have no taste buds)</li><li>Posteriorly - vallate papillae</li><li>Foliate papillae on the edge</li></ul> What seperates the lymphoid/pharyngeal part of the tongue from the front?The terminal sulcus What are the intrinsic muslces of the tongue?- Superior and inferior longitudinal - Vertical - Transverse What do the intrinsic muscles of the tongue allow for?Precise movement What nerve supplies the intrinsic muscles of the tongue?Hypoglossal nerve - CN XII What are the extrinsic muscles of the tongue?1. Palatoglossus  2. Styloglossus 3. Hypoglossus 4. Genioglossus What nerve innervates the extrinsic muscles of the tongue?Hypoglossal nerve - CN XII Except the genioglossus - vagus nerve  Sensory Innervation of the tongueAnterior 2/3rds (oral): - general sensation: mandibular nerve - special sensation (taste) facial nerve CN VII Posterior 1/3rd (pharyngeal) - glossalpharyngeal nerve CN IX What are the three main salivary glands?1. Parotid 2. Submandibular 3. Sublingual What is the paratid gland?<ul><li>Large gland located anteriorly and inferiorly to the ear</li><li>Serous acini - amylase and antimicrobial proteins </li><li>Recieves parasympathetic innervation from CN IX</li></ul> What is the submandibular gland?<ul><li>Sits in the submandibular fossa </li><li>Mixed serous and muscous gland (predominance of serous acini)</li><li>Amylase, proteins, lysozyme for bacterial wall hydrolysis</li></ul> What is the sublingual gland?<ul><li>Sits anteriorly within the mandible </li><li>Mixed but predominantly mucinous</li></ul> What is the soft palate?"<ul><li>It can swing down to seperate the oral cabity and pharynx during chewing so you csn still breath</li><li>Swings up during swallowing so food doesn't enter the nasopharynx</li></ul>" What is the pharynx?It is the tube of muscle involved in voluntary swallowing and connects the oral and nasal cavity to the lalarynx and oesophagus What are the 4 main layers of the gut tube?1. Mucosa: - epithelial lining - underlying lamina propria (connective tissue) - muscularis mucosae (smooth muscle) 2. Submucosa: - connective tissue - blood vessels - submucosal plexus - glands - lymphoid tissue 3. Muscularis externa: - smooth muscle layers (inner circular, outer longitudinal) - blood and lymphatic vessels between layers - myenteric plexus 4. Serosa: - loose connective tissue - blood vessels and lymphatics - adipose tissue - squamous epithelium covering What is the oesophagus?The muscular tube approximately 25cm long from the laryngeal pharynx (C6) to the stomach (T11) What are the three regions of the oesophagus?1. Cervical - anterior to vertebral column, and posterior to the trachea 2. Thoracic - runs superiorly then posteriorly to the mediastinum before passing through the oesophageal hiatus of the diaphragm at T10 3. Abdominal (short 1.5cm) enters cardia of the stomach What is the blood supply of the oesophagus?All derived from the coeliac trunk: 1. Upper third - inferior thyroid artery 2. Middle third - descending thoracic aorta 3. Lower third - left gastric artery What is the venous drainage of the oesophagus?1. Upper third - inferior thyroid veins 2. Middle third - azygous vein 3. Lower third - left gastric vein  What is the innervation of the oesophagus?Parasympathetic from vagus, sympathetic from sympathetic trunk  Histology of the oesophagus1. Non-keratinised stratified squamous epithelium 2. Submucosal mucous secreting oesophageal glands 3. Muscles: <ul><li>Upper 1/3rd skeletal muscle muscularis</li><li>Middle 1/3rd mixed skeletal and smooth</li><li>Lower 1/3rd smooth muscle</li></ul> Where is the stomach located?- Upper abdomen from left costal margin into epigastrium and umbilical regions  - fixed at ends but mobile in between Structure of stomach1. Cardia - opening 2. Fundus - superior part 3. Body (lesser and greater curvatures) 4. Antrum - inferior part 5. Pylorus - exit Vasculature of StomachLeft gastric artery -> lesser curvature Splenic artery: 1. Short gastric arteries - fundus 2. Left gastro-omental artery - greater curvature  Common hepatic artery: 1. Right gastric artery - lesser curvature 2. Gastroduodenal artery - greater curvature  Drains into portal circulation What are the 4 parts of the duodenum?D1 - superior part, from pylorus to the neck of the gallbladder and the duodenal cap D2 - descending part, just to the right of the midline, contains major and minor duodenal papilla D3 - inferior part, crosses the inferior vena cava and aorta and the vertebral column D4 - ascending part, passes upwards to the left of the aorta, terminating at the duodenojejunal flexure  Vasculature of duodenumForegut ends and the hindgut begins midway along at the changing of arteries Ceoliac trunk - foregut - Common hepatic artery, and superior pancreaticoduodenal artery  Superior mesenteric artery (hindgut) - Inferior pancreaticoduodenal artery  - jejunal branch  Venous drainage: - superior pancreaticoduodenal veins to portal vein - inferior to superior mesenteric vein Surface anatomy of the liverInferior to the diaphragm and is covered by the lower ribs and costal cartilages What is the vasculature of the liver?Hepatic portal vein - 70% Hepatic artery proper - 30% Drains into hepatic vein -> inferior vena cava Lymphatic drainage: - hepatic, coeliac lymph nodes - phrenic, parasternal lymph nodes - anterior abdominal wall What is the histology of the liver?- hepatocytes arranged into lobules - blood vessels and bile ducts at the corners of the lobules making up portal triads - sinusoids emerge from branches of portal vein and hepatic artery and converge on central vein of lobule - blood from lobule drained by central vein - bile carried from hepatocytes in canaliculi to bile ducts which merge into hepatic ducts Describe the gallbladder- lies in gallbladder fossa on visceral surface of the liver - superior to the superior part of duodenum - pear shaped sac with a capacity of 30-50ml - stores bile produced by the liver, concentrates it, and releases it into the duodenu in response to the presence of fatty foods What are the two functions of the pancreas?Exocrine - enzymes hydrolyse proteins, fats, and carbs Endocrine - insulin and glucagon for carbohydrate metabolism  Where is the pancreas located?retroperitoneal organ located in the epigastrum and left upper quadrant, and is anterior to the inferior vena cava and abdominal aorta, posterior to the stomach What is the structure of the pancreas?<ul><li>head and uncinate process lie medial to concavity of duodenum. </li><li>neck overlies the origin of hepatic portal vein and superior mesentery artery </li><li>body extends across midline posterior to stomach </li><li>tail lies in left upper quadrant in contact with spleen. </li></ul> Describe the two pancreatic ducts1. Main pancreatic duct: - drains tail, neck, and head - unites with common bile duct for form hepatopancreatic ampulla - opens onto major duodenal papilla (D2) - opening surrounded by hepatopancreatic sphincter 2. Accessory pancreatic duct: - drains head and ucinate process - opens onto minor duodenal papila Histology of the pancreas- thin capsule of connective tissue with septa projecting into it, seperating gland into lobules - islets: endocrine 1. alpha cells - glucagon 2. beta cells - insulin 3. delta cells - somatostatin 4. PP cells - pancreatic polypeptide  - acini: exocrine 1. acinar cells produce and store enzymes in inactive form in secretory granules  2. secretions contain bicarbonate ions and digestive enzymes like protease Where does the jejunum start?At the duodenojejunal flexure Where does the ileum end?The ileocecal junction Histology of the small intestine1. Submucosal folds - plicae circulares 2. Mucosol outgrowths - villi 3. Enterocytes with microvilli 4. Goblet cells - mucous producing  5. Intestinal crypts 6. Lymphoid tissue What is the function of the large intestine?1. Absorption of water and electrolytes 2. Storage and expulsion of undigested material What is the structure of the large intestine?1. Caecum and appendix 2. Ascending colon - bound to the posterior abdominal wall by the peritoneum 3. Hepatic flexure - right colonic flexure 4. Transverse colon - suspended by the lengthy mesentery making position variable 5. Splenic flexure - left colonic flexure 6. Descending colon - bound to the posterior abdominal wall by the peritoneum 7. Sigmoid colon - pelvic inlet to S3, mobile suspended by sigmoid mesocolon 8. Rectum 9. Anal canal What causes the shortening and sacculation of the colon?The outer longitudinal muscle of the colon are condensed into three bands which run the length of it called the taeniae coli. These muscles are shorter than the gut tube which causes this. Vasculature of the colonright colic artery - ascending colon middle colic artery - proximal 2/3rds of transverse colon left colic artery - distal 1/3rd of transverse colon and the descending colon sigmoid arteries - sigmoid colon  superior rectal artery - upper rectum What cells does the colon contain?1. Colonocytes - simple columnar epithelium (absorptive) 2. Goblet cells produce lubricating mucous What happens histology wise between the rectum and anal canal?Simple columnar glandular epithelium of rectum changes to stratisfied squamous in anal canal Describe the rectum<ul><li>follows concave contour of sacrum</li><li>3 lateral curves</li><li>lower part widens intp rectal ampulla </li><li>anorectal junction pulled anteriorly by puborectalis</li></ul> Describe the anal canal<ul><li>Rectal ampulla to anus</li><li>Internal anal spincter - skeletal muscle</li><li>External anal spincter - skeletal muscle</li><li>Upper part has longitudinal folds called anal columns </li><li>Anal columns unite inferiorly at anal valves</li></ul> What forms the posterior abdominal wall? <ul><li>Central part formed from the lumbrar vertebral column</li><li>Laterally psoas major and quadratus lumborum</li><li>Transverse abdominus muscles curve forward to form the anterolateral wall along with the internal and external oblique</li></ul> What forms the anterior abdominal wall?Rectus abdominus muscles  Where is the inguinal ligament?It stretches between the anterior superior iliac spine and the pubic tubercule What is the inguinal canal?a gap in the inferior part of the anterior abdominal wall just above the medial half of inguinal ligament. inguinal herniae occur when digestive tract herniates through this canal. What is the gross anatomy of the digestive tract?Muscular tube lined with mucosa and submucosa surrounded by an outer connective tissue layer  Innervation of the GI tractAutonomic: Enteric nerves within gut tissue organised into two plexuses: - myenteric plexus between the two layers of muscle in the muscularis externa - submucosa plexus in the submucosa Pain arising from the visceral peritoneum is...poorly localised How did the gut tube develop?As a simple tube divided into three parts: foregut, midgut, and hindgut What is the foregut?<ul><li>extends from the terminal oesophagus to the part of the duodenum where the bile duct enters (D2) </li><li>supplied by branches of the coeliac trunk of the aorta </li><li>venous drainage: portal vein + splenic vein </li><li>receives sympathetic innervation via the celiac plexus (greater splanchnic nerve) and parasympathetic innervation from the vagus nerve</li><li>lymphatic drainage: coeliac lymph nodes</li></ul> What is the midgut? - extends from the duodenum to the distal 1/3rd of the transverse colon; - supplied by branches of the superior mesenteric artery; - venous drainage: superior mesenteric vein; - sympathetic from superior mesenteric plexus (lesser splanchnic nerve) and parasympathetic from vagus; - lymphatic drainage: superior mesenteric lymph nodes. What is the hindgut?o from the distal transverse colon to the rectum; o branches of the inferior mesenteric artery; o venous drainage: inferior mesenteric vein; o sympathetic from inferior mesenteric plexus (least splanchnic nerve) and parasympathetic from S2-S4; o lymphatic drainage: inferior mesenteric lymph nodes What is the peritoneum?a serous membrane lining the internal walls of the abdominal cavity and viscera What is the parietal peritoneum?The peritoneum that covers the abdominal wall, pelvic, and thoracic diaphragm.. What is the visceral peritoneum?Invagination of the peritoneum that covers most of the abdominal viscera What is the peritoneal cavity?A potential space between the parietal peritoneum and visceral peritoneum which has a volume of 5 ml and is filled with lubricating fluid to allow the viscera to move during filling, periastalsis, and the movement of the trunk What are intraperitoneal organs?Organs enveloped by visceral peritoneum - stomach, liver, spleen, and transverse and sigmoid colon What are retroperitoneal organs?Organs not associated with the visceral peritoneum - their anterior surface is onlu covered in parietal peritoneum Primary retroperitoneal organs...develop and remain outside of the perietal peritoneum - oesophagus, rectum, and kidneys  Secondary retroperitoneal organs...were initially intraperitoneal, suspended by mesentery, but through the course of embryogenesis their mesentery fused with the posterior abdominal wall (ascending and descending colon) SAD PUCKER helps to remember retroperitoneal organs • suprarenal (adrenal) glands • aorta • duodenum (D2-D4) • pancreas • ureters • colon (ascending + descending) • kidneys • (o)esophagus • rectum What is a mesentery?A double layer of peritoneum that connects organs to the posterior abdominal wall providing a pathway for nerves, blood vessels, and lymphatics the foregut is suspended by the...ventral and dorsal mesentery the hindgut is suspended by the... dorsal mesentery There are two sacs within the superior peritoneal cavity1. Right-sided sac = lesser sac 2. Left-sided sac = greater sac Where does the liver develop?In the ventral mesentery and expands to contact the abdominal wall Where does the spleen develop?Within the dorsal mesentery What are omenta?Sheets of visceral peritoneum that extend from the stomach and proximal part of the duodenum to other abdominal organs Describe the greater omentum?Descends from the greater curvature of the stomach and proximal part of the duodenum all the way down to the base of the small intestine, then folds back up and attaches to the anterior surface of the transverse colon What is the role of the greater omentum?"It moves to surround infected areas of the small bowel so infection doesn't spread" Describe the lesser omentumDouble layer stretching from the lesser curvature of the stomach to the inferior liver consisting of the hepatogastric ligamet and the hepatoduodenal ligament What are the two compartments of the greater sac?Supracolic compartment - above transverse colon containing stomach, liver, and spleen Infracolic compartment - below transverse colon containing small intesting, ascending and descending colon What is the purpose of the lesser sac?Lieing posteriorly to the stomach is allows the stomach to move freely against structures posterior and inferior to it. It communicates with the greater sac via the epiploic foramen What are the functions of the mouth?1. Digestion - recieves food, preparing it for digestion 2. Communication - modifies sound produced in the larynx 3. Breathing - acts as air inlet in addition to nasal cavity Where does the vestibule communicate with the mouth proper?Via the space behind the third molar, and with the exterior via the oral fissure  What is the hard palate?The bony plate that seperates the nasal vacity from the oral cavity, covered superiorly by respiratory mucosa and inferiorly by oral mucosa made up of stratified squamous epithelium The soft palate is [...]The soft palate is the posterior continuation of the hard palate. It is a muscular structure, acting as a valve that lowers to close oropharyngeal isthmus (back of the mouth) and elevates to seperate the nasopharynx from the oropharynx (back of the nose) sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: [...]sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) sensory innervation of the oral cavity is supplied by branches of [...]: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial)sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: [...] o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial)sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: [...] o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial)sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: [...] o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial)sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: [...] o tongue: chorda tympani (facial)sensory innervation of the oral cavity is supplied by branches of the trigeminal nerve: o hard palate: greater palatine and nasopalatine nerves (branch of maxillary) o soft palate: lesser palatine nerve (branch of maxillary) o floor: lingual nerve (mandibular) o cheeks: buccal nerve (mandibular) o tongue: chorda tympani (facial) What are the boundaries of the parotid region?Superiorly - zygomatic arch Inferiorly - inferior border of the mandible Anteriorly - masseter muscle Posteriorly - external ear and the sternocleidomastoid What is the clinical relevance of the parotid gland?- Benign tumour -> treatment involves surgical excision of tumour -> critical to preserve facial nerve  - Parotitis - inflammation of gland -> pain referred to external ear as sensory nerve supplying gland also supplies external ear.  What are the boundaries of the submandibular triange?Superiorly - inferior body of the mandible Anteriorly - anterior belly of the digastric muscle Posteriorly - posterior belly of the digastric muscle What are the two arms of the submandibular gland?1. Superficial arm - comprises greater portion of the gland and lies partially inferior to the posterior half of the mandible. Situated outside boundaries of the oral cavity 2. Deep arm - hooks around the posterior margin of the mylohoid muscle through a triangular aperture to enter the oral cavity proper, lying on the lateral surface of the hyoglossus Describe the sublingual glandAlmond shaped and lies on the floor of the oral cavity proper. Bordered: - laterally by the mandible - medially by the genioglossus muscle Describe the intrinsic muscles of the tongueIn the longitudinal, vertical, and horizontal orientations and are mainly concerned with the shape of the tongue Purpose of the tongue in terms of eatingMuscles of the tongue manipulate food so that it meets the occlusal surfaces of the teeth, mixing it with saliva and forming it into a cohesive bolus for swallowing, then passes to back of mouth where bolus touches soft palate and swallowing relex is activated Soft palate extends down to form: <ul><li>Palatoglossal and palatopharyngeal arches anterior and posterior to the tonsils</li><li>[...]</li></ul>Soft palate extends down to form: <ul><li>Palatoglossal and palatopharyngeal arches anterior and posterior to the tonsils</li><li>Oropharyngeal isthmus</li></ul> Soft palate extends down to form: <ul><li>[...] anterior and posterior to the tonsils</li><li>Oropharyngeal isthmus</li></ul>Soft palate extends down to form: <ul><li>Palatoglossal and palatopharyngeal arches anterior and posterior to the tonsils</li><li>Oropharyngeal isthmus</li></ul> What is the pharynx?A muscular half-tube in front of the first 6 cervical vertebrae and connecting the oral and nasal cavities with the laryngopharynx which is continuos with the oesophagus Where does the oesophagus enter the abdomen?The oesophageal hiatus at T10 Describe the upper oesophageal sphincterAnatomical, striated muscle spincter at the junction between the pharynx and oesophagus, produced by the cricopharyngeus muscle Describe the lower oesophageal spincter It is physiological sphincter located in the gastro-oesophageal junction marked by a change from oesophageal to gastric mucosa What are the 4 main areas where food is likely to get stuck in the oesophagus? nb ABCD1. Arch of aorta 2. Bronchus 3. Cricoid cartilage 4. Diaphragmatic hiatus Vasculature of oesophagusArterial supply from brances of thoracic aorta and inferior thyroid artery Drainage via azygois veins and inferior thyroid vein. What is the innervation of the oesophagusOesophageal plexus - formed by combination of parasympathetic vagal trunks and sympathetic fibres What is the pyloric sphicter?Sphincter lying between pylorus and duodenum that controls the exit of chyme from the stomach. Emptying occurs intermittently when intragastric pressure overcomes the resistance of the pylorus. Relations of the stomachSuperior - oesophagus and left dome of the diaphragm Anterior - diaphragm, greater omentum, anterior abdominal wall, left lobe of the liver, gall bladder Posterior - lesser sac, pancreas, left kidney, left adrenal gland, spleen, splenic artery, transverse mesocolon What are the relations of the stomach?Superior - oesophagus and left dome of the diaphragm Anterior - diaphragm, greater omentum, anterior abdominal wall, left lobe of the liver, gall bladder Posterior - lesser sac, pancreas, left kidney, left adrenal gland, spleen, splenic artery, transverse mesocolon What is the arterial suppl of the stomach?From coeliac trunk What is the venous drainage of the stomach?Left and right gastric veins  What is the innervation of stomach?Parasympathetic - vagal trunks Sympathetic - coaliac plexus via greater splanchnic nerve What type of epithelial tissue lines the oesophagus?Non-keratinised, stratified, squamous epithelium What makes up the gastric epithelium?Simple columnar epithelium What is the small intestine? <ul><li>Consists of the duodenum, jejunum, and ileum</li><li>Primary site for absorption of nutrients from ingested material </li><li>Extents from pylorus to the ileocecal junction where the ileum joins the cecum</li></ul> What is the superior duodenum (D1)?<ul><li>5cm long</li><li>First 2cm has mesentery - ampulla</li><li>Ampulla has distinctive radiographical appearance</li><li>Ascends from the pylorus and is overlapped by the liver and gallbladder</li></ul> What is the descending duodenum (D2)?<ul><li>10cm</li><li>Descends along right side of L1-L3 vertebrae</li><li>Curves around head of pancreas</li><li>Bile and main pancreatic ducts enter its posteromedial wall -> usually united to form hepatopancreatic ampulla -> opening into major duodenal papilla</li><li>Retroperitoneal</li></ul> What is the inferior (D3) duodenum?<ul><li>8cm long </li><li>Runs transverse to the left, passing over the IVC, aorta, and L3</li></ul> What is the ascending (D4) duodenum?<ul><li>5cm</li><li>Begins at the left of the L3 vertebra and rises superiorly as far as the superior border of the L2 vertebra</li></ul> Vasculature of the duodenum<ul><li>Arteries from the celiac trunk</li><li>Superior mesenteric artery</li><li>Pancreaticoduodenal arteries</li><li>Drainage into the hepatic portal vein, either directly or indirectly via the superior mesenteric and splenic veins</li></ul> Innervation of the duodenumVagus and greater and lesser splanchnic nerves via the superior mesenteric plexuses Lymphatics of duodenum<ul><li>Anterior lymphatic vessels drain into pancreaticoduodenal lymph nodes and pyloric lymph nodes</li><li>Posterior lymphatic vessels drain into superior mesenteric lymph nodes</li></ul> Neurovasculature of jejunum and ileum<ul><li>Superior mesenteric artery and vein</li><li>Lymph -> specialised lymphatic vessels in the intestinal villi absorb fat -> these are lacteals -> juxta-intestinal lymph nodes, mesenteric lymph nodes, and superior central nodes</li></ul> Innervation of the jejunum and ileumThrough the superior mesenteric nerve plexus What is the cecum?<ul><li>most proximan part of the large intestine, found in the right iliac fossa of the abdomen</li><li>inferior to the ileocecal junction</li><li>palpated if enlarged due to faeces, inflammation, or malignancy</li><li>Superiorly continuos with ascending colon</li><li>Intraperitoneal</li><li>Between cecum and ilium is the ileocecal valve</li></ul> Vascular supply of the cecumSuperior mesenteric vessels What is the lymphatic drainage of the cecum?Ileocolic lymph nodes What are the 4 parts of the colon?1. Ascending 2. Transverse 3. Descending 4. Sigmoid What are paracolic gutters?Gaps between ascending/descending colon and the posterolateral abdominal wall that allow material released from inflamed or infected abdominal organs to accumulate elsewhere in the abdomen.  What is the arterial supply of the colon?<ul><li>Ascending colon and proximal 2/3rds of transverse colon derived from midgut and so supplied by superior mesenteric artery</li><li>distal 1/3rd of transverse and remaining is hindgut and supplied by inferior mesenteric artery. </li></ul> Venous drainage of the colonHepatic portal vein Innervation of colonMidgut - superior mesenteric plexus Hindgut - inferior mesenteric plexus Parasympathetic - pelvic splanchnic nerves Sympathetic - lumbar splanchnic nerves Lymphatic drainage of colon<ul><li>Ascending and transverse - superior mesenteric nodes</li><li>Descending and sigmoid - inferior mesenteric nodes</li></ul> How is the rectum anatomically distinct from the colon?Lacks taeniae coli, haustra, and omentum What are the two flexures of the rectum?1. Sacral flexure - follows curve of sacrum and coccyx 2. Anorectal flexure - formed by the tone of puborectalis muscle and contributes to faecal continence What is the arterial supply to the rectum?1. Superior rectal artery 2. Middle rectal artery 3. Inferior rectal artery Venous drainage - same but veins Innervation of the rectum1. Sympathetic nervous from lumbar splanchnic nerves and superior and inferior hypogastric plexuses 2. Parasympathetic from S2-S4 via pelvic splanchnic nerves Lymphatic drainage of rectumVia pararectal lymph nodes into inferior mesenteric nodes Except during defaecation, [...] Sphincters: <ul><li> internal anal sphincter surrounds upper 2/3rds of anal canal, formed by thickening of involuntary circular smooth muscle in bowel wall.</li><li> external anal sphincter is voluntary muscle that surrounds lower 2/3rds of the canal (overlapping with internal sphincter). blends superiorly with puborectalis muscle.</li></ul>Except during defaecation, anal canal is collapsed by internal and external anal sphincters to prevent passage of material. Sphincters: <ul><li> internal anal sphincter surrounds upper 2/3rds of anal canal, formed by thickening of involuntary circular smooth muscle in bowel wall.</li><li> external anal sphincter is voluntary muscle that surrounds lower 2/3rds of the canal (overlapping with internal sphincter). blends superiorly with puborectalis muscle.</li></ul> Except during defaecation, anal canal is collapsed by internal and external anal sphincters to prevent passage of material. Sphincters: <ul><li> internal anal sphincter surrounds upper 2/3rds of anal canal, formed by thickening of involuntary circular smooth muscle in bowel wall.</li><li> external anal sphincter is v[...]</li></ul>Except during defaecation, anal canal is collapsed by internal and external anal sphincters to prevent passage of material. Sphincters: <ul><li> internal anal sphincter surrounds upper 2/3rds of anal canal, formed by thickening of involuntary circular smooth muscle in bowel wall.</li><li> external anal sphincter is voluntary muscle that surrounds lower 2/3rds of the canal (overlapping with internal sphincter). blends superiorly with puborectalis muscle.</li></ul> Except during defaecation, anal canal is collapsed by internal and external anal sphincters to prevent passage of material. Sphincters: <ul><li> internal anal sphincter [...]</li><li> external anal sphincter is voluntary muscle that surrounds lower 2/3rds of the canal (overlapping with internal sphincter). blends superiorly with puborectalis muscle.</li></ul>Except during defaecation, anal canal is collapsed by internal and external anal sphincters to prevent passage of material. Sphincters: <ul><li> internal anal sphincter surrounds upper 2/3rds of anal canal, formed by thickening of involuntary circular smooth muscle in bowel wall.</li><li> external anal sphincter is voluntary muscle that surrounds lower 2/3rds of the canal (overlapping with internal sphincter). blends superiorly with puborectalis muscle.</li></ul> What function does the watery component of saliva have?To moisten ingested food and lubricate the masticatory process What function does the mucus component of salivary have?To bind food into a bolus before swallowing What does the pancreas do (digestion)?It produces the enzymes required for chemical digestion in the small intestine and also produces bicarbonate ions for neutralisation of acid chyme What does the liver do?It aids in the digestive process through the production of bile, but is also the site of homeostatic metabolism as all blodd draining from the digestive tissues passes through the liver first What do the liver and pancreas develop from?As offshoots from the foregut Where is the liver located?In the right hypochondrium and epigastric areas, extending into the left hypochondrium What are the two surfaces of the liver?<ol><li>Diaphragmatic surface (anterosuperior)</li><li>Visceral surface (posteroinferior) </li></ol> Describe the diaphragmatic surface of the liver<ul><li>Smooth and convex, fitting snugly beneath the curvature of the diaphragm</li><li>Posterior aspect of the diaphragmatic surface is not coverered by visceral peritoneum and is in contact with the diaphragm itself</li></ul> Describe the visceral surface of the liver<ul><li>With the exception of the fossa of the gall bladder and porta hepatis, it is covered with peritoneum</li><li>Moulded by the shape of the surrounding organs, making it irregular and flat</li><li>Lies in contact with the right kidney, right adrenal gland, right colic flexure, transverse colon, first part of the duodenum, gall bladder, oesophagus, and stomach</li></ul> What is the falciform ligament?• sickle-shaped ligament attaches the anterior surface of the liver to the anterior abdominal wall and forms natural anatomical division between the left and right lobes of the liver. • free edge of this ligament contains the ligamentum teres, a remnant of the umbilical vein. What is the coronary ligament of the liver?• attaches superior surface of liver to inferior surface of the diaphragm and demarcates the bare area of the liver. • anterior and posterior folds unit to form the triangular ligaments on the left and right lobes of the liver. What is the left triangular ligament?formed by the union of anterior and posterior layers of the coronary ligament at the apex of the liver and attaches the left lobe to the diaphragm. What is the right triangular ligament?formed in similar fashion adjacent to the bare area and attaches the right lobe of the liver to diaphragm. What is the lesser omentum?• attaches liver to lesser curvature of the stomach and first part of duodenum. • consists of the hepatoduodenal ligament and hepatogastric ligament. "What is Morison's pouch?"It is a potential space between the visceral surface of the liver and the right kidney. It is the deepest part of the peritoneal cavity when supine, so fluid likely to collect here in bedridden patient What is the name of the fibrous capsule that covers the liver?"Glisson's capsule" How many lobes does the liver have and what devides them?2 - the left and right lobe -> right lobe divided into 2 accessory lobes -> caudate and quadrate lobe Describe the caudate lobelocated on the upper aspect of the visceral surface. lies between the inferior vena cava and a fossa produced by the ligamentum venosum (ligament of vena cava) Describe the quadrate lobelocated on lower aspect. lies between gall bladder and a fossa produced by the ligamentum teres (round ligament). What is the porta hepatis?A deep transverse fissure seperating the caudate and quadrate lobes of the liver that transmits all vessels, nerves, and ducts entering or leaving the liver with the exception of the hepatic veins How are the cells of the liver arranged?Into lobules Describe a liver lobuleEach lobule is hexagonal shaped and is drained by a central vein. At the periphery of each lobule are 3 structures known as the portal triad Describe a portal triad<ol><li>Arteriole branch of the hepatic artery entering the liver </li><li>Venule branch of hepatic portal vein entering the liver</li><li>Bile duct - branch of the bile duct leaving the liver</li></ol> Describe the unique dual blood supply of the liver<ol><li>Hepatic artery proper - accounts for 25% of blood supply -> supplies non-parenchymal structures of the liver with arterial blood -> derived from coeliac trunk</li><li>Hepatic portal vein - accounts for 75% of blood supply -> partially deoxygenated, carries nutriends absorbed from small intestine -> collects from splenic vein, superior mesenteric and the inferior mesenteric veins.</li></ol> Venous drainage of the liverCenteal vein of the hepatic lovule form collecting veins which combine into hepatic veins, which drain into the IVC What innervates the parenchyma of the liver?The hepatic plexus "What innervates the glisson's capsule?"Branches of the lower intercostal vein - distension of capsule results in sharp, well-localised pain Describe the relations of the gallbladderIt is an intraperitoneal organ located within the right hypochondrial region of the abdomen: <ul><li>Anteriorly and superiorly - inferior border of the liver and the anterior abdominal wall</li><li>Posteriorly - transverse colon and the proximal duodenum</li><li>Inferiorly - biliary tree and the remaining parts of the duodenum </li></ul> What are the three parts of the gallbladder?<ol><li>Fundus</li><li>Body</li><li>Neck</li></ol> What part of the gallbladder do gallstones commonly get lodged?"The Hartmann's Pouch in the neck " What is the biliary tree?A series of ducts allowing synthesised bile from the liver to be concentrated and stored in the gallbladder Describe biles jouney in the biliary tree 1. bile initially secreted from hepatocytes and drains from both lobes of the liver via canaliculi, intralobular ducts and collecting ducts into the left and right hepatic ducts which amalgamate to the common hepatic duct. 2.  this is joined by cystic duct as it descends, allowing bile to flow in and out of gallbladder for storage and release. they merge to from common bile duct. 3.  this descends and passes posteriorly to first part of duodenum. here, joined by main pancreatic duct forming the hepatopancreatic ampulla of Vater which empties into duodenum via the major duodenal papilla. regulated by sphincter of Oddi. Vasculature of the gallbladderCystic artery supplies, neck drains into cystic veins, body and fundus drain into hepatic sinusoids Innervation of the gallbladder1. Sympathetic and sensory - coeliac plexus 2. Parasympathetic - vagus nerve Lymphatic drainage of the gallbladderCoeliac lymph nodes What are cholelithiasis?Small lumps of cholesterol, bile salts, or a mixture of both, which may form within the gallbladder Biliary colicTypically right upper quadrant pain following a fatty meal as gallstones obstruct the cystic duct during contraction of the gall bladder CholecystitisInflammation of the gallbladder. Pain often associated with nausea, vomiting, and/or fever CholedocholithiasisGallstones within the common bile duct often causes deranged liver function tests CholangitisInfection of the common bile duct often secondary to choledocholithiasis. Typicall presents with right upper quadrant pain, fever, and jaundice Treatment of symptomatic gallstonesSurgical removal of the gallbladder performed by laparoscopic surgery during acute phase or once recovery has taken place. Prescribed analgesia and antibiotics in the interim. Describe the pancreasOblong shaped organ positioned at the level of the transpyloric plane, retroperitoneal, located deep within the upper abdomen in epigastrium and left hypochondrial regions What are the parts of the pancreas?<ol><li>Head</li><li>Uncinate process</li><li>Neck</li><li>Body </li><li>Tail</li></ol> What is the head of the pancreas?It is the widest part. Lies within a C-shaped curve created by the duodenum and is connected to it with connective tissue What is the uncinate process of the pancreas?The projection arising from the lower part of the head and extending medially to lie beneath the body of the pancreas. Lies posterior to superior mesenteric vessels What is the neck of the pancreas?Located between the head and the body. It overlies superior mesenteric vessels which form a groove in its posterior aspect. What is the body of the pancreas?It is centrally locted, crossing the midline of the human body to lie behind the stomach and to the left of the superior mesenteric vessels. What is the tail of the pancreas?Left end of the pancreas that lies within close proximity to the hilum of the spleen. Contained within the splenorenal ligament with splenic vessels. It is the only intraperitoneal part of the pancreas. What is the arterial supply of the pancreas?Splenic artery What is the venous drainage of the pancreas?Superior mesenteric branches of hepatic portal vein What are the two major components of the skeleton?1. Axial - skull, ribs, vertebrae - protection 2. Appendicular - lower and upper libs and their girles - locomotion What happens at the interface between a muslce and a tendon?The perimysium and epimysium consolidate to form the tendon What is a tendon?A dense regular non-elastic connective tissue structure that maximises the effeciency of muscle contraction moving a bone  What is a ligament?Connective tissue that attaches bones to each other and are important in stabilising joints formed from tightly packed collagen bundles arranged in parallel so that they can respond to stress in a single direction What is superficial fascia?<ul><li>the subcutaneous connective tissue lying beneath and merging with the dermis of the skin</li><li>categorised as fibrous fatty tissue and consists of varies proportions of fibroblasts, aqueous matrix, elastin, and collagen fibres, fat, and immune cells</li><li>can be firmly tethered or loosely attached</li></ul> what is deep fascia?Covers muscles, helping them attach to bones, and provides attachment for intermuscular septa which partition muscle groups, termed compartments. What is fascia?"a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place (basically fascia = connective tissue)" What is compartment syndrome?An acute medical problem following injury or surgery where increased pressure occures within a compartment. This compresses the blood vessels leading to necrosis and ischaemia. What are retinacula?Thick fibrous bands of deep fascia found near the wrist and ankle What does flexor retinaculum do in the ankle?Prevents partial dislocation of the tendons, and protects the tibial artery, vein, and nerve. What is fascia lata?A deep fascial investment of the musculature of the thigh. It attaches to the inguinal ligament superiorly and is continuos with the deep fascia of the leg inferiorly. What is the clinical relevance of the potential space between fascial layers?They can fill with pus following infection What are bursae?Sacs lined with a delicate smooth membrane called the synovial membrane and are filled with fluid. What is the role of bursae?<ul><li>Lubrication - found wherever tendons rub against bones, ligaments, or other tendons</li><li>Allow the skin to move easily over bony prominences</li></ul> What is a synovial sheath?It is a tubular bursa wrapping around a tendon where it passes through a bony or rigid structure  What is an adventitious bursae?Bursas that develop in response to excessive friction, e.g. a bunion. What is the upper respiratory tract?The parts of the respiratory tract concerned with bulk air movement rather than gaseous exchange extending from the nose to the main bronchi which start at the terminal bifurcation of the trachae at T5. What are the important functions of the upper respiratory tract?To clean, humidify and warm up air before it enters the lungs What are the 4 main functions of the nasal cavity?<ol><li>Warms and humidifies air</li><li>Removes and traps pathogens and particulate matter from the air</li><li>Responsible for sense of smell</li><li>Drains and clears paranasal sinuses and lacrimal ducts</li></ol> What are the three divisions of the nasal cavity?<ol><li>Vestibule - area surrounded by the nostrils and contains hairs</li><li>Respiratory region - lined by ciliated pseudostratisfied columnar epithelium. Very closely lying on bone, but thin well vascularised layer between. Interspersed with mucous secreting goblet cells</li><li>Olfactory region - apex of the nasal cavity, lined by olfactory cells</li></ol> Describe the floor of the nasal cavity<ul><li>Anterior 2/3 - palatine process of the maxilla</li><li>Posterior 1/3 - horizontal plate of the palatine bone</li></ul> Describe the roof of the nasal cavity<ul><li>largely formed from the cribriform plate of the ethmoid bone</li><li>Posteriorly consists of the inferior body of the sphenoid</li><li>anteriorly formed by the nsal bone and the maxilla</li></ul> Describe the medial wall (septum) of the nasal cavity<ul><li>Posteriorly consists of the vomer bone</li><li>Anteriorly and superiorly consists of the perpendicular plate of the ethmoid </li><li>Anteriorly and inferilry consists of the septal cartilage </li></ul> Describe the lateral wall (from anterior to posterior) of the nasal cavity<ul><li>Frontal process of the maxilla</li><li>Lacrimal bone</li><li>Ethmoid bone</li><li>Perpendicular </li></ul> What are nasal conchae?Curved shelves projecting from the lateral wall of the nasal cavity Inferior conchaIndependent nose bone Middle and superior conchaeProjections from the ethmoid bone What do the nasal conchae do?Create 4 pathways for air to flow through called meatuses: - Inferior meatus - between inferior concha and cavity floor - Middle meatus - between inferior and middle conchae - Superior meatus - between middle and superior conchae - Spheno-ethmoidal recess - superiorly and posteriorly to superior concha Why are the meatuses the conchae of the nasal cavity produce important?Increase surface area of the cavity, decreasing the speed of the air flow, increasing the humidity of the air What are the paranasal sinuses?Hollow air filled spaces in the skull that make the skull lighter and connect to the nasal cavity, which they drain into, and act as a resonating chamber for the voice. What are the 4 paranasal sinuses?1. Frontal sinuses 2. Sphenoid sinuses 3. Ethmoidal sinuses 4. Maxillary sinus Frontal sinuses<ul><li>Most superior of the sinuses in location, triangular in shape</li><li>drains via frontonasal duct opening at hiatus semilunaris</li></ul> Sphenoid sinuses<ul><li>superior and posterior</li><li>drains into the spheno-ethmoidal recess</li><li>pituitary gland can be surgically accessed via the sinus</li></ul> Ethmoidal sinuses<ul><li>3 on either side of the skull.</li><li>anterior drains at hiatus semilunaris</li><li>middle drains at ethmoidal bulla</li><li>posterior drains into superior meatus</li></ul> maxillary sinus"<ul><li>laterally and slightly inferiorly to the nasal cavity</li><li>drains into the hiatus semilunaris beneath the opening of the frontal sinus </li><li>the maxillary sinus doesn't drain well itself because the opening is in the roof</li></ul>" What is the nasolacrimal duct?Duct that drains tears from the eyes and opens into the inferior meatus Auditory tube<ul><li>Opens into the nasopharynx at inferior meatus level</li><li>allows equalisation of the middle ear</li><li>possible path for spead of infection</li><li>4 muscles </li><li>posterior 1/3 bony (temporal bone)</li><li>anterior 2/3 is cartilaginous </li></ul> Access to the nasal cavity1. Cribriform plate of the ethmoid bone - contains very small perforations, allowing olfactory nerve fibres access 2. Sphenopalatine foramen 3. Incisive canal Vascular supply of the nasal cavityRich vascular supply allows for change in humidity and temperature of air passing through: 1. Internal carotid artery - branches anterior and posterior ethmoidal arteries  2. External carotid artery branches - sphenopalatine artery, greater palatine artery, superior labial artery, and lateral nasal artery Venous drainage of the nasal cavitydrainage into pterygoid plexus, facial vein or cavernous sinus. Innervation of the nasal cavityspecial sensory olfactory nerve (olfactory bulb of brain lies on the cribriform plate) o general sensory of septum + lateral walls: nasopalatine nerve (branch of maxillary), nasociliary nerve (branch of ophthalmic). What are the three parts of the pharynx?<ol><li>Nasopharynx</li><li>Oropharynx</li><li>Laryngopharynx</li></ol> Sensory innervation of nasopharynxMaxillary nerve What epithelium lines the nasopharynx?Respiratory epithelium - ciliated psuedostratified columnar epithelium with goblet cells  Where are the adenoid tonsils located?Postero-superior nasopharynx Adenoid tonsils- enlarge between 3-8 years of age then regress. - can become pathologically enlarged due to viral infections of the upper respiratory tract, or chronically enlarged due to recurrent infections. - when enlarged, can obstruct the opening to auditory tube which prevents the equalising of pressure of middle ear, leading to glue ear (chronic otitis media). What provides sensory innervation to the oropharynxglossopharyngeal nerve What is the oropharynx?The middle part of the pharynx, located between the soft palate and the superior border of the epiglottis What is the oropharynx involved in?Voluntary and involuntary phases of swollowing "What is Waldeyer's ring?"The ring of lymphoid tissue in the naso and oropharyn formed by the paired palatine tonsils, adenoid tonsils, and lingual tonsils What does the oropharynx contain?"<ol><li>Posterior 1/3 of the tongue</li><li>Lingual tonsils (lymphoid tissue at base of tongue</li><li>Palatine tonsils (lymphoid tissue in the tonsillar fossa)</li><li>Superior constrictor muscle</li><li>Waldeye's ring</li></ol>" Where is the laryngopharynx located?Between the superior body of the epiglottis and inferior body of the cricoid cartilage Sensory innervation of the laryngopharynxVagus nerve Relation of the laryngopharynx to the larynxLaryngopharynx is posterior to the larynx and communicates with it via the laryngeal inlet, lateral to which are the piriform fossae What does the laryngopharynx contain?<ol><li>Middle pharyngeal constrictor </li><li>Inferior pharyngeal constrictor</li></ol> What are the 2 groups of muscles in the laryngopharynx?1. 3 circular constrictor muscles 2. 3 longitudinal muscles 3 cirular constrictor muscles of the laryngopharynx...stacked like glasses and contract sequentially to propel bolus of food inferiorly to oesophagus. innervated by vagus  3 longitudinal muscles...that act to shorten and widen the pharynx and elevate the larynx during swollowing: <ol><li>stylopharyngeous - innervated by glossopharyngeal nerve, origin styloid process of temporal bone, insertion pharynx</li><li>palatopharyngeus - origin hard palate, insertion into pharynx</li><li>salpingopharyngeus - eustachian tube origin, insertion pharynx</li></ol> Arterial supply to the pharynxExternal carotid Venous drainage by pharyngeal venous plexus What covers the larynx anteriorly?Infrahyoid muscles What is the function of the larynx?"1. Ensuring that food and drink don't enter the larynx or trachea, byt rather are diverted to enter the oesophagus 2. Eliciting a cough reflex that will rid the larynx of any aspirated debris or mucus 3. Permitting the production of sound during expiration " How does the cough reflex work?1. Sensation picked up by respective nerves 2. Vagus muscles efferent via medulla oblongata provokes: <ul><li>short breath in</li><li>closing of vocal cords</li><li>expulsion of air</li></ul> Hyaline and elastic cartilages...form the skeleton of the larynx, which form articulations with each other, and are moved by extrinsic and intrinsic laryngeal muscles What are the unpaired cartilages of the larynx?<ol><li>Thyroid cartilage</li><li>Cricoid cartilage</li><li>Epiglottis</li></ol> What are the paired cartliages of the larynx?1. Arytenoid cartilage  2. Corniculate cartilages 3. Cuneiform cartilages What are the arytenoid cartilages?Pyramidal shaped structures that sit on the cricoid cartilage consisting off:  <ul><li>Superior porcess - articulates with the corniculate cartilage</li><li>Base - articulates with the superior border of the cricoid cartilage</li><li>Vocal process (anterior) - provides attachment for the vocal ligament</li><li>Muscular process (lateral) - provides attachment for the posterior and lateral cricoarytenoid muscles</li></ul> What are the corniculate cartilages?Minor cartilaginous structures that articulate with the apices of the arytenoid cartilages What are the cuneiform cartilages?Located within the ary-epiglottic folds. No direct attachment, but act to strengthen the folds What is the thyroid cartilage?"<ul><li>A large prominent structure that is easily visible in adult males, composed of 2 sheets which join together anteriorly to form the laryngeal prominence (adam's apple). </li><li>posterior border of each sheet project superiorly and inferiorly to form the superior and inferior horns. superior horns are connected to the hyoid bone via the lateral thyrohyoid ligament, while the inferior horns articulate with the cricoid cartilage. </li></ul>" What is the cricoid cartilage?• the cricoid cartilage is a complete ring of hyaline cartilage, consisting of a broad sheet posteriorly and a much narrower arch anteriorly. • completely encircles the airway, making the inferior border of the larynx at the level of C6. articulates with the paired arytenoid cartilages posteriorly. • only complete circle of cartilage in the larynx or trachea. What is the epiglottis?A leaf shaped plate of elastic cartilage that marks the entrance to the larynx. It is attached to the back of the anterior aspect of the thyroid cartilage via a small stalk. What are the extrinsic ligaments and membranes of the larynx?<ol><li>Thyrohyoid membrane</li><li>Hyo-epiglottic ligament</li><li>Cricotracheal ligament</li><li>Median cricothyoid ligament</li></ol> What are the intrinsic membranes and ligaments of the larynx?Cricothyroid ligament and the quadrangular membrane What is the thyrohyoid membrane?Spans between the superior aspect of the thyroid cartilage and the hyoid bone and is pierced laterally by the superior laryngeal vessels and internal laryngeal nerve into: <ol><li>median thyrohyoid ligament </li><li>lateral thyrohyoid ligament</li></ol> Hyo-epiglottic ligamentConnects the hyoid bone to the anterior aspect of the epiglottis Cricotracheal ligamentConnects the cricoid cartilage to the trachea Median cricothyoid ligamentAnteromedial thickening of the cricothyroid ligament connecting the thyroid and cricoid cartilages Cricothyroid ligamentoriginates from the cricoid cartilage and extends superiorly, where it terminates with a free upper margin which forms the vocal ligament. additionally attached anteriorly to the thyroid cartilage and posteriorly to the arytenoid cartilage What is the quadrangular membrane?spans between the anterolateral arytenoid cartilage and the lateral aspect of the epiglottis. What lines the inferior surface of the larynx?Pseudostratified ciliated columnar epithelium Describe the characteristics of the vocal folds"They're under the control of the muscles of phonation <ul><li>non-keratinised stratified squamous epithelium that provide extensive protection against foreign bodies which may accidentaly enter the larynx</li><li>reinke's space - watery, amorphous layer is rich in glycosaminoglycans</li><li>vocal ligament lies at the free upper edge of the cricothyroid ligament</li><li>vocal muscle - exceptionally fine muscle fibres that lie lateral to the vocal ligaments</li></ul>" How are the vocal folds attached?Attached anteriorly to the inner surface of the thyroid cartilage, posteriorly to the vocal process of the arytenoid cartilage The folds of the larynx divide it into three compartments:<ul><li>Supraglottis (vestible) - superior to the vestibular folds (false vocal cords) and beneath the epiglottis, supplied by the internal laryngeal nerve</li><li>Glottis (ventricular space) - between the folds - contains the vocal cords</li><li>Infraglottis - inferior to the vocal folds to the the inferior border of the cricoid cartilage. The vocal ligaments are the free edges of the conus elasticus membrane and are involved in the regulation of the airway size and in phonation. Supplied by the inferior laryngeal nerve</li></ul> What are the two types of movement of the laryn<ol><li>Those that protect the larynx during swallowing.</li><li>Those which vary the aperture of rima glottidis (opening between the vocal cords and arytenoid) during respiration and phonation.</li></ol> What do the intrinsic muscles of the larynx do?Move the cartilages relative to one another Cricothyroid muscle<ul><li>stretches and tenses the vocal ligaments -> important for creation of foreful speech</li><li>orgin - anterolateral aspect of the cricoid cartilage </li><li>Insertion - the inferior margin and inferior horn of the thyroid cartilage</li></ul> Thyroarytenoid muscle<ul><li>relaxes ligaments, allowing for a softer voice</li><li>origin - inferoposterior aspect of the angle of the thyroid cartilage </li><li>insertion - the vocal process of the arytenoid cartilage</li></ul> Posterior cricoarytenoid <ul><li>Sole abductor of vocal folds, thus only muscle capable of widening the rima glottidis</li><li>origin - posterior surface of the cricoid cartilage</li><li>insertion - muscular process of the arytenoid cartilage </li></ul> Lateral cricoarytenoid <ul><li>major adductor of vocal folds, narrowing rima glottidis and modulating the tone and volume of speech</li><li>origin - arch of the cricoid cartilage </li><li>insertion - muscular process of the arytenoid cartilage </li></ul> Transverse and oblique arytenoids<ul><li>Adduct the arytenoid cartilages, closing the posterior portion of rima glottidis and narrowing laryngeal inlet</li><li>Spans from one arytenoid cartilage to the opposite one</li></ul> External muscles of the larynx<ul><li>the muscles of the pharynx which attach to the laryngeal cartilages (stylopharyngeus)</li><li>the strap muscles of the neck which control the position of the larynx</li><li>suprahyoid muscles (attached to the hyoid bone) elevate the larynx</li><li>infrahyoid - muscles lower the larynx</li></ul> Innervation of the larynx...is from the vagus nerve for sensation and motor activity. Specifically: <ul><li>the recurrent laryngeal nerve - sensory innervation to infraglottis and motor innervation to all intrinsic muscles of the larynx (accept cricothyroid)</li><li>Superior laryngeal nerve - sensory innervation to the supraglottis and external branch provides motor innervation to the cricothyroid muscle.</li></ul> Arterial supply to the larynx1. Superior laryngeal artery 2. Inferior laryngeal artery Venous drainage of the larynx<ol><li>Superior laryngeal vein ->  internal jugular vein</li><li>Inferior laryngeal vein -> brachiocephalic vein</li></ol> What does the thoracic cage consist of?Sternum, ribs, costal cartilages, and 2 thoracic vertebrae Why is the thoracic cavity smaller than the thorax?Because of the interior intercostal muscles  Thoracic inlet<ul><li>Superior borders - upper surfaces of the first ribs and their costal cartilages, the manubruim of the sternum, and the body of T1.</li><li>All structures supplying and leaving the neck must pass through the inlet</li></ul> The lungs Major organs of respiration. Function is to oxygenate blood, acheieved by bringing inspired air in close contract with oxygen-poor blood in pulmonary capillaries Anatomical position of the lungsLie either side of the mediastinum within the thoracic cavity: 1. Each lung surrounded by a pleural cavity (formed by visceral and parietal pleura) 2. Suspended from mediastinum by the lung root, a collection of structures entering and leaving the lungs Describe the structure of the lungsRougly cone shaped, left is smaller due to presence of the heard, each consists of: <ul><li>apex - the blunt, superior end of the lung, projecting upwards, above level of 1st rib and into floor of the neck</li><li>base - inferior surface, sitting on diaphragm</li><li>lobes - seperated by fissues within the lung: left has two, right has three </li></ul> Describe the right lungs lobes<ul><li>three lobes - superior, middle, and inferior</li><li>divided from each other by 2 fissures</li><li>oblique fissue - runs from inferior border of the lung in a superoposterior direction until it meets posterior lung border</li><li>horizontal fissure - runs horizontally from the sternum to the meet the oblique fissue</li></ul> What seperates the left lungs two lobes?Oblique fissue What are the three surfaces of the lungs?<ol><li> Mediastinal surface</li><li>Diaphragmatic surface </li><li>Costal surface </li></ol> Describe the anterior border of the lungsformed by the convergence of the mediastinal and costal surfaces. On the left lung, the anterior border is marked by a deep notch known as the cardiac notch Describe the inferior border of the lungsSeperates the base of the lungs from the costal and mediastinal surfaces Describe the posterior border of the lungsSmooth and rounded, formed by costal and mediastinal surfaces meeting posteriorly What structures make up the lung root?<ul><li>bronchus</li><li>pulmonary artery</li><li>two pulmonary veins</li><li>bronchial vessels</li><li>pulmonary plexus of nerves </li><li>lymphatic vessels</li></ul> Vasculature of the lungs- Supplied with deoxygenated blood by the paired pulmonary arteries  - Oxygenated blood leaves lungs by 4 pulmonary veins - Bronchial arteries provide extra nutritive support to lung tissues - Bronchial veins provide drainage: <ul><li>right bronchial vein drain into azygous vein</li><li>left bronchial vein into hemiazygous vein</li></ul> What is a pulmonary embolism?An obstruction of a pulmonary artery by a substance that has travelled from elsewhere in the body. Most commonly: <ul><li>thrombus </li><li>fat - following bone fracture or orthopaedic surgery</li><li>Air - following cannulation in neck</li></ul> What are the features of a pulmonary embolism?<ul><li>dyspnoea</li><li>chest pain</li><li>cough</li><li>haemoptysis</li><li>tachypnoea</li></ul> What is the treatment for pulmonary embolism?anticoagulation and thrombolytic therapy Innervation of lungsParasympathetic - vagus nerve Sympathetic - sympathetic trunk What is the tracheobronchial tree?System of airways bringing air to lung located in thorax and neck What are the components of the tracheobronchial tree?<ol><li>Trachea</li><li>Bronchi</li><li>Bronchioles</li></ol> Describe the position of the trachea<ul><li>arises from lower border of cricoid cartilage in neck as a continuation of larynx</li><li>travels inferiorly to the superior mediastinum, bifurcating at the level of the sternal angle</li><li>anterior and slightly to the right of the oesophagus</li><li>extends from C6 to T4 or 5</li></ul> Describe the structure of the trachea <ul><li>held open by c-shaped rings of cartilage. the free ends of are supported by trachealis muscle - this allows the oesophagus to expand when swallowing</li><li>lined with ciliated pseudostratified columnar epithelium, interspersed by goblet cells that produce mucus. This combined with the sweeping of cilia forms the mucociliary escalator which traps inhaled particles and pathogens</li><li>at bifurcation of primary bronchi, a ridge of cartilage called carina runs anteroposteriorly between openings of two bronchi. Most sensistive area for triggering cough reflex.</li></ul> Describe the neurovascular supply of the trachea<ul><li>innervation from recurrent laryngeal nerve</li><li>arterial supply from tracheal branches of the inferior thyroid artery</li><li>drainage from the brachiocephalic, azygous, and accessory hemiazygous vein</li></ul> What supplies each lobe of the lungs?Secondary bronchi Describe the structure of the right main bronchi<ul><li>wider, shorter, and descends more vertically than the left</li><li>clinically, results in higher incidence of foreign body inhalation</li><li>right superior lobar bronchus arises before right main bronchus enters the hilum</li></ul> Describe the structure of the left main bronchus<ul><li>passes inferiorly to arch of the aorta</li><li>anteriorly to thoracic aorta and oesophagus</li></ul> Describe the structure of the bronchi within the lungs"<ul><li>main bronchi branch to lobar bronchi - three on right, 2 on left</li><li>lobar bronchi then bifurcate into several segmental tertiary bronchi which supply the bronchopulmonary segments - functional units of the lungs</li><li>in main bronchi, cartilage rings completely encircle the lumen, in smaller bronchia they're found in crescent shapes</li></ul>" What is the neurovascular supply to the bronchi?<ul><li>Innervation - pulmonary branches of the vagus nerve</li><li>Bronchial arteries</li><li>Bronchial vein</li></ul> Descrine the structure of bronchiolesSegmental bronchi undergo further branching to form numerous smller airways: <ul><li>Contain no cartilage or mucus-secreting goblet cells</li><li>Instead, club cells produce a surfactant lipoprotein, instrumental in preventing walls sticking together during expiration</li></ul> Initally many generation of conducting bronchioles that transport air but lack glands: <ul><li>eventually end as terminal bronchioles, which branch even further into respiratory bronchioles</li><li>these are distinguishable by the presence of alveoli</li><li>alveoli are air-filled pockets with thin walls (simple squamous)</li></ul> What is asthma?<ul><li>chronic inflammatory disorder of the airways, characterised by hypersensitivity and bronchospasm</li><li>there is remodelling of small airways, causing increased smooth muscle thickness around bronchioles, damaged epithelium and thickened basement membrane</li><li>attacks are acute exacerbations of the condition where a trigger causes sudden inflammation and contraction of the smooth muscle.</li></ul> What are pleurae?The serous membranes that line the lungs and the thoracic cavity that permit efficient and effortless respiration Describe the basic structure of pleurae<ul><li>Consist of a serous membrane (simple squamous epithelium supported by connective tissue, also known as mesothelium)</li><li>Consist of two membranes (one for each lung).</li></ul> Parietal pleauraCovers the internal surface of the thoracic cavity, and is thicker than visceral pleura and can be subdivided according to the part of the body: <ol><li>Mediastinal</li><li>Cervical</li><li>Costal</li><li>Diaphragmatic</li></ol> Mediastinal pleura Covers the lateral aspect of the mediastinum (central component of the thoracic cavity containing a number of organs) Cervical pleuraLines the extension of the pleural cavity of the neck Costal pleuraCovers the inner aspect of the ribs, costal cartilages, and intercostal muscles Diaphragmatic pleura covers superior surface of the diaphragm Visceral pleuraCovers outer surface of the lungs and extends into the interlobar fissures What is a pneumothorax?It is a collapsed lung. It occurs when air or gas is present within the pleural space. It removes surface tension, reducing lung expansion  Features of a pneumothoraxChest pain, shortness of breath, asymmetrical chest expansion, hyper-resonant chest upon percussion What are the two classes of pneumothorax?<ol><li>Spontaneuous - occurs without a cause, subdivided into primary (no underlying respiratory disease) and secondary (disease present)</li><li>Traumatic - occurs as a result of blunt or penetrative chest trauma</li></ol> Treatment of pneumothoraxPrimary - small, minimal intervention Secondary and traumatic - requires decompression to remove extra air/gas (via insertion of a chest drain) Recesses in pleurae"Costodiaphragmatic and costomediastinal recesses - where pleural cavity isn't completely filled by lungs" Parietal pleura neurovascular supply<ul><li>sensitive to pressure, pain and temperature, innervated by phrenic and intercostal nerves</li><li>intercostal arteries</li></ul> Neurovascular supply of the visceral pleura<ul><li>not sensitive to pain and touch, sensory fibres only detect stretch. </li><li>recieved autonomic innervation from pulmonary plexus</li><li>bronchial arteries</li></ul> What are the three subdivision of the intercostal muscles1. External 2. Internal 3. Innermost External intercostal muscles<ul><li>11 pairs, run inferoanteriorly from above rib to below</li><li>continuos with external oblique of abdomen</li><li>membranous anteriorly</li><li>origin - lower border of the rib</li><li>insertion - superior border of the rib</li><li>elevates rib</li><li>intercostal nerves T1-11</li></ul> Internal intercostals Orign - lateral edge of costal groove Insertion - superior aspect of the rib below Interosseous part reduces thoracic volume by depression ribcage, and interchondral part elevates the rib Intercostal nerves T1-11 Innermost intercostal muscles<ul><li>deepest muscles</li><li>similar in structure to inner</li><li>seperated from inner by intercostal neurovascular bundle and found in the most lateral portion of the intercostal spaces</li><li>origin - medial edge of costal groove</li><li>insertion - superior surface of rib</li><li>interosseous part reduces thoracic volume, interchondral elevates ribs</li><li>intercostal nerves T1-11</li></ul> Describe transversus thoracis<ul><li>continuos with transversus abdominis inferiorly</li><li>from posterior surface of inferior sternum to internal surface of costal cartilages 2-6</li><li>weakly depress ribs</li><li>intercostal nerves T2-6</li></ul> Subcostal muscles<ul><li>found inferior portion of thoracic wall</li><li>comprise of thin slips of muscle which run from internal surface of one rib to second and third rib below</li><li>share action of internal intercostals</li><li>intercostal nerves</li></ul> Muscles that comprise the thoracic wall"<ul><li>Pectoralis major and minor</li><li>Serratus anterior and scalene</li><li>external intercostal muscles, internal intercostal muscles, innermost intercostal muscles, subcostalis, and transversus thoracis. </li></ul>" What are the ribs?A set of 12 bones which foprm the protective cage of the thorax and articulate with the vertebral column posterioly and terminate anteriorly as costal cartilages What are the two types of rib?<ul><li>typical (3-9)</li><li>atypical (1,2,10,11,12)</li></ul> What is the structure of a typical rib?<ul><li>wedge shaped head with 2 articular facets seperated by a wedge of bone that articulates with the numerically corresponding vertebrae and the one above at plane joints</li><li>a neck with no prominences</li><li>tubercle where neck meets the body</li><li>the body is flat and curves</li><li>internal surface has a costal groove for the neurovascular supply</li></ul> Describe the structure of rib 1<ul><li>Shorter and wider and only has one facet</li><li>Superior surface marked by 2 grooves for subclavian vessels</li><li>Primary cartilaginous joint with sternum</li><li>Tubercles for scalene, medial scalene, and first digitation of serratus anterior</li></ul> Describe the structure of rib 2<ul><li>Thinner and longer than 1</li><li>Facets as normal</li><li>Roughened area on upper surface where serratus anterior attaches </li><li>Tubercle for posterior scalene attachment</li></ul> Describe the structure of rib 10<ul><li>One facet</li></ul> Describe the structure of rib 11 and 12No neck and only have one facet Posterior articulations of the ribs<ul><li>All 12 ribs articulate with vertebrae of spine forming 2 joints each</li><li>Costotransverse joint between tubercle of rib and transverse costal facet of corresponding vertebrae</li><li>Costovertebral joint between head of rib, superior costal facdt of corresponding vertebrae and inferior costal facet of vertebrae above </li></ul> Anterior articulations of the ribs<ul><li>ribs 1-7 attach independently to sternum - these are the true ribs</li><li>ribs 8-10 attach to costal cartilage superior to them - false ribs</li><li>11-12 dont have anterior attachments and end in abdominal musculature</li></ul> Attachments of the diaphragmThree peripheral attachments:  - lumbar vertebrae and arcuate ligaments  - costal cartilages of ribs 7-10 and directly to ribs 11 and 12  - Xyphoid process of sternum Parts arising centrally from the vertebrae are tendinous in structure and known as crura:  - right crus: arises from L1-3 and their intervertebral discs. Some fibres from right crus surround oesophageal opening, acting as physiological sphincter  - left crus arises from L1-2 and their intervertebral discs Salivary glands secretions <ul><li>Parotid (20% of salivar) - serous (enzymes), watery secretion</li><li>Submandibular (70%) - mized viscous secretion</li><li>Sublingular (10%) mucous, highly viscous secretion</li></ul> What do acinar cells do in the salivary glands?Produce enzymes - amylase and lipase What do ductal cells do in salivary glands?- Produce mucous - Secrete water and electrolytes - Antibacterial functions -  Secrete lysozyme  - secrete lactoferrin - modify the secretion of acinar cells How does lysozyme work against bacteria?It attacks the bacterial cell walls in a process called cell lysis How does lactoferrin work against bacteria?It binds iron and because bacteria require iron, this makes it bactericidal How do duct cells modify the secretions of acinar cells?- extracts Na+ and Cl- - secretes K+ and HCO3- - therefore salivar is hypotonic and alkaline: -> protects teeth from bacterial acid -> neutralises gastric acid that refluxes into the oesophagus Diseases of the salivary glands"<ol><li>Sjogren's syndrome - autoimmune attach of salivary and tear glands resulting in dry mouth and eyes that commonly affects women, and is associated with rheumatoid arthritis</li><li>Mumps virus (parotitis) </li></ol>" Control of salivary secretions done to both parasympathetic and sympathetic<ul><li>7th cranial nerve at submandibular ganglion causes submandibular and sublingual secretion (para)</li><li>9th cranial nerve at otic ganglion causes parotid gland secretion (para)</li><li>sympathetic at the superior cervical ganglion causes vasocontriction, causing thick, mucous secretions</li></ul> Describe the 4 phases of swallowing<ol><li>Oral preparatory phase - mastication puts food into a swallowable consistency</li><li>Oral phase - tongue propels food posteriorly until the pharyngeal swallow is triggered</li><li>Pharyngeal phase - once pharyngeal swallow is triggered, bolus transported through the pharynx along with: closure of glottis via movement of epiglottis, cessation of breathing, and relaxation of the upper oesophageal sphincter</li><li>Oesophageal phase - periastalsis moves bolus down towards the stomach</li></ol> Nearal control of swallowing...comes from the swallowing centre in the medulla Structure of the oesophagus<ul><li>Normal GI structure of mucosa, inner circular, and outer longitudinal muscle, but has no serosa or mesentery </li><li>Myenteric and submucosal nerve plexuses</li><li>Stratified squamous until gastro-oesophageal junction </li></ul> What are the causes of GORD?<ul><li>obesity</li><li>hiatus hernia</li><li>drugs that lower tone at lower oesophageal sphincter like anti-cholinergics, beta-agonists, and benzodiazapines</li><li>pregnancy</li><li>zollinger ellison syndrome (gastrin secretion tumour)</li></ul> Symptoms of GORD<ul><li>heartburn - characterised by retrosternal discomfort or burning sensation. Intermittend following eating and exacerbated by exercise or lying </li><li>regurgitation</li><li>dysphagia (swallowing problems) due to inflammation or stricture - 30%</li><li>cough, hoarseness, chronic earache</li></ul> Effects of GORD"<ul><li>Oesophagitis </li><li>Stricture - narrowing</li><li>Barret's metaplasia</li><li>Oesophageal adenocarcinoma</li></ul>" What are the two types of hiatus hernia?1. Sliding - stomach slides upwards through diaphragm 2. Rolling - part of the stomach pokes through the diaphragm How is GORD diagnosed?<ul><li>24 hr pH monitoring -> defines reflux -> especially useful if endoscopy is normal -> characterises other conditions with abnormal</li><li>Contrast swollowing -> surpassed by endoscopy -> demonstrates reflux</li></ul> Conservative treatment of GORD<ul><li>weight loss</li><li>avoid food and alcohol close to bedtime</li><li>decrease alcohol</li><li>raise head of bed by 20-30cm</li></ul> Medical treatments of GORD<ul><li>Proton pump inhibitors (PPIs) and H2 blockers to reduce acid production</li><li>Antacids to increase pH of stomach</li><li>Alginates (gaviscon) coat mucosa and act as a raft to prevent reflux</li></ul> Surgical treatments of GORD<ul><li>anti-reflux surgery (fundoplication)</li><li>repair hiatus hernia</li></ul> "What is Barret's Metaplasia?"It is the change of oesophageal epithelia from squamous epithelium to specialised intestinal metaplasia in response to environmental stress - stomach acid How many GORD patients develop BM?10% What is the pre-malignant condition of oesophageal adenocarcinoma?"Barret's Metaplasia" "Management of Barret's Metaplasia"1. Manage reflux symptoms  2. Surveillance endoscopy to catch BM progression into oesophageal adenocarcinoma -> controversial as it is expensive and labour intensive when only 0.5% of BM patients progress to ADC -> plus majority of ADC patients arise from patients with undiagnosed BM -> so no effect upon overall survical from ADC -> only method available What are the two oesophageal cancers?<ul><li>Squamous cell carcinoma -> incidence decreasing -> mid and upper oesophagus -> caused by alcohol, tobacco, strictures, and achalasia</li><li>Adenocarcinoma -> incidence increasing -> lower oesophagus  - > causes by reflux</li></ul> What is achalasia?"<ul><li>Failure of the LOS to relax due to the loss of the myenteric plexus at lower oesophageal sphincter</li><li>Symptoms include: dysphagia, regurgitation, chest discomfort, halitosis (bad breath), weight loss</li><li>Cause unknown</li><li>Treatments include: botox injection at LOS, oesophageal dialtion, and surgery - Heller's myotomy. </li></ul>" Oesophageal rupture<ul><li>Due to trauma -> endoscopy of stricture, blunt trauma, penetrating trauma, during vomiting  </li><li>Clinical features - severe chest pain, subcutaneous emphysema, sepsis, pleural effusion (usually left side)</li><li>treatment - conservative with chest drainage or early surgery to repair defect</li></ul> What are oesophageal varices?Abnormal enlarged veins in oesophagus What are the causes of oesophageal varices?1. Pre-hepatic: - portal vein thrombosis - external compression of portal vein by tumours 2. Post-hepatic - right heart failure - budd-chiari syndrome 3. Hepatic - alcoholic liver disease - viral hepatitis - schistosomiasis What are the complications of portal hypertension?1. Visceral bleeding 2. Ascites 3. Encephalopathy Therapy for oesophageal varices1. Medical - beta blockers and nitrates decrease portal pressure - endoscopic banding - transjugular intrahepatic portosystemic shunt 2. Surgical - liver transplant - spleno-renal anastomosis What are the functions of the stomach?1. Stores food 2. Mixes food with secretions 3. Regulates release of food into duodenum 4. Secretes gastric juices Cell types of the stomach- In the corpus -> predominantly parietal and chief cells (some ECL and D cells) - Antrum and pylorus -> no parietal cells -> contains G-cells and D-cells What types of cells are found in the stomach?1. Mucous Neck Cells - mucous and bicarbonate 2. Parietal Cells - Acid and IF 3. ECL cells - Histamine 4. Chief cells - Pepsinogen and lipase 5. D Cell - Somatostatin 6. G Cell - Gastrin What are the 4 phases of gastric acid secretion?<ol><li>Basal</li><li>Cephalic</li><li>Gastric</li><li>Intestinal</li></ol> What is the basal phase of gastric acid secretion?<ul><li>follows a circadian rhythm - acid secretion lower in am and higher in the pm</li><li>direct function of number of parietal cells, so size matters</li><li>enhanced several fold by eating</li></ul> What is the cephalic phase of gastric acid secretion?<ul><li>smell, sight, taste, thought, and swallowing of food initiates, mediated by ACh release from vagus nerve thus triggering acid secretion</li><li>accounds for approx 30% of acid secretion </li></ul> What is the gastric phase of acid secretion?<ul><li>accounds for 50-60% of secretion</li><li>occurs when food in stomach</li></ul> What is the intestinal phase of gastric acid secretion?<ul><li>partially digested peptides/amino acids in the proximal portion of the small intestine stimulate acid secretion by stimulation of duodenal G cells to secrete gastrin</li><li>5-10% of secretion</li></ul> What are pepsinogens?Proteolytic proenzymes secreted by chief cells which are converted to pepsin upon exposure to gastric acid (occurs spontaneously at pH <5 and most active at pH <3 What is pepsin?It is an endopeptidase which intiates protein digestion  Secretion of pepsinogens interlinked with...acid secretion because of similar trigger (ACh) and resulting peptides trigger antral G-cell gastrin secretion How is the gastric mucosa protected?<ul><li>contents of stomach lumen represent harsh environment</li><li>protection comes in the form of mucous later which traps local HCO3- secretion to maintain a pH of 7</li><li>prostaglandins are important in this protection because they inhibit acid secretion and stimulate HCO3- secretion and mucus secretion </li></ul> How can NSAID drugs lead to gastric mucosal harm?Because they inhibit the production of prostaglandins What is Helicobacter pylori (H. Pylori)?- gram-negative, microaerophilic bacteria - leading cause of peptic ulceration - causes gastritis, gastric and duodenal ulcers, and gastric cancer - urease produced by HP converts Urea into HCO3- which neautralises stomach acid and causes ulcers - location of infection is important as only infection in the corpus (hypochlorhydria) is associated with gastric ulcers. How is H. Pylori infection treated?With triple therapy of amoxicillin and clarithromycin and a PPI. What is Pernicious Anaemia?Autoimmune atrophic gastritis in which auto-antibodies are directed against parietal cells and destroys them, and as parietal cell produced intrinsic factor is neccessary for the absorption of vitamin B12 in the terminal ileum, anaemia develops. Structure of the pancreasIt is divided into lobules, which drain into a ductular network which connects the entire gland to the lumen of the GIT. What is the ampulla of vater?The swelling in the duodenal wall where the major pancreatic duct merges with the common bile duct. The muscular wall here is thickened, forming the spincter of oddi, which regulates flow and prevents reflux. Where are the secretions of the pancreas emptied into the duodenum?In the descending duodenum at the major duodenal papilla. Describe the structure of a pancreatic lobuleA pancreatic lobule is the secretory unit of the pancreas composed of acini cells, clustered into an acinus, surrounding a small intercalated duct. What do pancreatic acinar cells secrete?Zymogens (inactive enzyme precursors); digestive enzyme; and an isotonic, plasma-like fluid that accompanies the secretory proteins. How are pancreatic acini cells stimulated?Through the activation of cholecystokinin (CCK) receptors and muscarinic ACh receptors located on the basolateral membrane. CCK is made in i-cells in the duodenum and are stimulated in the presence of fat. What pathway do CCK receptors in acini cells of the pancreas use to stimulate increased enzyme production?PLC/Ca2+ signal-transduction pathway. Describe the importance of secretin<ul><li>Secretin from S cells in the small bowel mucosa stimulates HCO3- and fluid secretion by the pancreatic ducts predominantly in response to duodenal acidifcation </li><li>most important humoral regulator of ductal secretion. activation of secretin receptor on duct cell stimulates AC which raises cAMP and triggers PKA</li><li>ultimately stimulates apical CFTR channal and basolateral Na/HCO3 transporter</li></ul> How does cystic fibrosis affect the pancreas?<ul><li>disease results from mutations in the CFTR gene</li><li>subsequent loss of CFTR expression at plasma membrane dirupts the apical transport process of the duct cell and results in decreased secretion of HCO3 and water by ducts</li><li>results in protein-rich primary secretion which thickens within the duct lumen and leads to obstruction and eventual pancreatic tissue degradation</li><li>subsequent deficiency of pancreatic enzymes that occurs leads to maldigestion of nutrients</li></ul> What inhibits pancreatic secretion?<ul><li>Somatostatin inhibits the release of CCK and secrtin, as well as insulin and glucagon</li><li>analogues of somatostatin used clinically to inhibit pancreatic secretions</li></ul> What is the role of CCK in regulating pancreatic secretion?<ul><li>CCK produced in duodenal I cells stimulate pancreatic acinar cells to increase protein secretion </li><li>in response to fatty meal, plasma CCK levels increase 5-10 fold within minutes</li><li>CCK secretion also stimulated by CCK releasing factors (e.g. luminal CCK releasing factor - LCFR) which are endogenously produced proteins secreted into the gut lumen</li><li>in fasting state, LCRFs are degraded by digestive enzymes so no CCK stimulation, during a mean, digestive enzymes act on chyme and LCRFs stimulate I-cells to release CCK and prancreatic secretions </li></ul> Phases of pancreatic secretion<ol><li>Cephalic</li><li>Gastric</li><li>Intestinal</li></ol> Cephalic phase of pancreatic secretion<ul><li>sight, smell of food</li><li>25%</li><li>mediated by stimulation of ACh receptors on acinar cells and to lesser extent duct cells</li><li>no involvement of CCK and secretin</li></ul> Gastric phase of pancreatic secretion<ul><li>10-20%</li><li>release of Gastrin from G Cells of the antrum signals through CCK receptors on acinar cells</li><li>stimulating neural pathways -> gastric distension stimulates low levels of pancreatic secretion through a vasovagal gastro-pancreatic reflex</li></ul> Intestinal phase of pancreatic secretion<ul><li>50-80%</li><li>chyme entering proximal small intestine stimulates pancreatic secretion by -> gastric acid stimulates duodenal S cells to release secretin </li><li>lipids predominantly stimulate duodenal I cells to release CCK</li><li>lipids also activate a reflex that predominantly stimulates acinar cells</li></ul> How does the pancreas avoid autodigestion?<ul><li>Digestive proteins are stored in secretory granules as inactive precursors called zymogens</li><li>zymogens become activated only after coming into contact with the small bowel brush border enzyme enterokinase</li><li>enterokinase converts trypsinogen into trypsin which then activates all other zymogens </li><li>secretory granulae membrane is impermeable to proteins, thus zymogens are seperated from other proteins in the cytoplasm</li><li>enzyme inhibitors are co-packaged in granuale</li><li>condensation of zymogens, low pH and ionic conditions within secretory pathway further limit enzyme activity.</li></ul> What are the acute causes of pancreatitis?G - gallstones E - ethanol T - trauma in children S - steroids M - mumps A - autoimmune  S - scorpion sting H - hypothermia E - ERCP D - drugs What does a diagnosis of pancreatitis require?<ul><li>characteristic abdominal pain located in epigastrium that radiates to lower back, often associated with nausea and vomiting</li><li>serum amylase/lipase more than three times the upper limit of normal</li><li>characteristic findings on CT scan</li></ul> What are the three phases of pancreatitis?1. Phase 1 - premature activation of trypsin withi pancreatic cells by: - disruption of calcium signalling in acinar cells - cleavage of trypsinogen to trypsin by lysosomal hydrolase cathepin-B - decreased activity of intracellular pancreatic trypsin inhibitor 2. Phase 2: intra-pancreatic inflammation (activation of inflammatory cells) 3. Phase 3: extra-pancreatic inflammation including systemic sepsis and multi-organ failure What is the treatment for pancreatitis?80 % of cases are mild, treatment by: 1. Resting pancreas through use of IV fluids to combat dehydration 2. Hourly fluid balance 3. Pain relief Patients with severe pancreatitis: - intensive care  - ultrasound scan of gall stones or CT scan if still unwell - may require endoscopic retrogade cholangiopancreatography (ERCP)  What are the causes of chronic pancreatitis?<ul><li>most commonly is alcholism </li><li>hereditary disorders</li><li>cystic fibrosis</li><li>hypercalcaemia</li><li>hyperlipidaemia</li></ul> What is chronic pancreatitis?"Inflammation of the pancreas that doesn't heal or improve and gets worse with time leading to permanent damage" Treatment of chronic pancreatitis<ul><li>hospitalisation for pain management, IV hydration, nutritional support</li><li>normal diet supplemented by pancreatic enzymes </li><li>diet low in fat and small frequent meals</li><li>ERCP: enlarges duct openings and drain pseudocysts, stent placement to keep open a narrowed pancreatic bile duct, ballon dilation </li></ul> What makes up a lobule of the liver?<ul><li>hepatocytes</li><li>sinusoidal channels</li><li>inlet and exit blood vessels</li><li>bile canaliculi</li></ul> Describe the blood supply of the liver<ul><li>enters and leaves through the hilum of the liver</li><li>portal vein (venous from gut) accounts for 75% </li><li>hepatic artery 25%</li><li>enters, mixes in the sinusoids and drains via hepatic veins into the IVC near the right atrium</li></ul> What composes the stroma of the liver and what cells produce this?ECM materials - dynamic and complex macromolecules made up of mainly collagens I-VI produced by stellate cells.  Cells of the liver<ol><li>Hepatocytes</li><li>Polarised cuboidal and columnar epithelial cells of the biliary epithelium </li><li>Endothelium </li><li>Kupffer cells</li><li>Stellate cells</li></ol> What are hepatocytes?<ul><li>60-65% of liver tissue</li><li>Polarised polyhedral epithelial cells</li><li>Low mitotic index</li></ul> Biliary epithelium<ul><li>1-3% of liver tissue</li><li>form collecting vessels of increasing size to collect canalicular bile</li><li>polarised cuboidal or columnar epithelial cells</li><li>dense basement membrane</li><li>transport proteins and secretion</li></ul> Endothelium of the liver<ul><li>sqaumous epithelial cells</li><li>line the hepatic vasculature </li><li>protect the parenchyma from blood cells, bacteria and viruses</li><li>filter fluids</li><li>nomral functions include anti-thrombogenic surface, regulation of coagulation, and regulation of leukocyte traffic</li><li>selective uptake of solutes and particles</li><li>scavenging of waste products</li></ul> What are Kupffer cells?<ul><li>hepatic macrophages located within the sinusoids</li><li>80% of all macrophages in the body</li><li>multiple functions including phagocytosis, regulation of microcirculation, removal of endotoxin</li><li>very active receptor-mediated endocytosis</li><li>can produce cytokines, present antigens, and stimulate the immune response </li></ul> What are stellate cells?<ul><li>also called Ito cells or lipocytes</li><li>15% of non-hepatocyte cells in the liver</li><li>perisinusoidal fat/retinoid (vitamin A) storing cells</li><li>star shaped with multiple membrane processes and branching structure </li><li>can transform to a more fibroblast-like morphology in disease</li></ul> What are the functions of the liver?1. Digestion 2. Cholesterol synthesis 3. Bile production 4. Immune function 5. Detoxification and elimination  Describe the digestive function of the liver<ul><li>carbohydrate and fat metabolism</li><li>storage of vitamins and minerals</li></ul> Why is cholesterol important?<ul><li>essential component of cell membranes - it establishes proper membrane permeability and fluidity </li><li>it is an important component for the production of bile acids, steroid hormones, and vitamin D</li></ul> Describe the livers role in the production of bile"<ul><li>about 0.5L produced per day by hepatocytes</li><li>recycled 6-8 times a day </li><li>a few 100ml can be stored in the gall-bladder</li><li>released into the intestine on demand</li><li>involved in emulsification of fat in the intestine</li><li>fat soluble vitamine uptake (A,D,E,K) </li><li>also for excretion of some substances which can't be cleared by kidneys - cholesterol and bilirubin</li></ul>" Describe the immune function of the liver<ul><li>Protection against pathogens arriving in the blood</li><li>Phagocytosis of old or dying cells</li><li>Innate immune functions</li><li>Induction of tolerance</li></ul> Describe the detoxification and elimination functions of the liver<ul><li>Urinary excretion - solubilization of compounds</li><li>Biliary excretion - lipophilic compounds</li><li>Biotransformation and detoxification: phase 1 - oxidation or reduction to make soluble by p450 enzyme, phase 2 - conjugation to make water soluble</li><li>CYPs (cytochrome p450 and others) are major enzymes involved in drug metabolism. Levels vary with age and gender. </li><li>Elimination of ammonia by product of protein metabolism </li></ul> Describe the synthetic functions of the liverProduces: <ul><li>albumin</li><li>fibronectin and components of the coagulation cascade</li><li>plasminogen</li><li>alpha-1 antitrypsin</li><li>transferrin</li><li>hepcidin</li></ul> What are the complications of liver cancer?<ul><li>Oesophageal varices</li><li>Renal failure</li><li>Ascites - fluid in the abdomen</li></ul> Main causes of liver cancer<ul><li>Viral hepatitis</li><li>Alcohol</li><li>Non-alcoholic fatty liver disease</li></ul> What are the main ways of detecting hepatitis?<ul><li>Biopsy (used in trails)</li><li>Blood tests to check for increased levels of bilirubin, hepatic enzymes, hepatobiliary enzymes, and decreased albumin levels, and total protein counts</li></ul> What is jaundice?<ul><li>yellow discolouration of the skin, eye, and other tissues due to a build-up of bilirubin in tissue fluids and bloodstream (in excess of 2mg/ml)</li><li>not necessarily a liver disease - neo-natal jaundice</li></ul> What is bilirubin?<ul><li>product of haem catabolism from red blood cells, myoglobin, cytochromes, and perioxidases</li><li>production about 250-300mg/day</li></ul> What is the total bile salt pool?<ul><li>3.5g</li></ul> Why is bile important?"Because they solubilize ingested fat and fat-soluble vitamins, facilitating their digestion and absorption" What is the scientific name of red blood cells?Erythrocytes Where are erothryocytes broken down, and what are they broken down into?The spleen and bone marrow degrade erythrocytes and release globin and haem into the blood What is globin broken down into?Amino acids that re-enter the blood and are reused in erythropoiesis What is erythropoiesis?Formation of red blood cells to maintain oxygen levels in the blood What is haem broken down into?Broken down to iron and unconjugated bilirubin (or biliverdin), which has a yellowish, orange colour, and is lipid soluble, so is carried through the blood by albumin What happens to biliverdin in the liver?It is conjugated in by the enzyme UDP glucanosyltransferase with glucuronic acids to become conjugated bilirubin, which is water soluble and is excreted via the common bile duct into the small intestine. What happens to conjugated bilirubin once it is excreted via the common bile duct into the small intestine?It is converted to urobilinogen by small intestine bacteria, becoming lipid soluble again. After which: <ul><li>10-15% is reabsorbed by the blood and binds to albumin</li><li>remaining is oxidised by bacteria, becoming stercobilin, which is brown and is excreted in faeces, making it brown.</li></ul> What happens to urobilinogen once it is reabsorbed in the small intestine?It is carried back to the liver by the portal system where: <ul><li>50% of reabsorbed participates in enterohepatic urobilinogen cycle, taken back up by the liver and re-secreted into bile</li><li>50% of reabsorbed is transferred to kidneys where it is converted into yellow urobilin and is excreted, giving urine its yellow colour.</li></ul> What is pre-hepatic jaundice and what are its features?"It is jaundice where the liver isn't involved and its features are: <ul><li>increased unconjugated serum bilirubin</li><li>normal levels of liver enzymes</li></ul>" What are the causes of pre-hepatic jaundice?"<ul><li>haemolytic anaemia</li><li>paroxysmal nocturnal haemoglobinuria</li><li>sickle cell disease</li><li>gilberts' syndrome</li><li>neo-natal jaundice</li></ul>" How does sickle cell disease lead to pre-hepatic jaundice and how is this treated?<ul><li>genetic cause - variant forms of Hb present which lead to red cell rupture</li><li>treated by injection of excessive amounts of normal red blood cells to reduce sickled Hb, fresh plasma and vitamin K</li></ul> "What is Gilberts' syndrome and how does it cause pre-hepatic jaundice?"<ul><li>genetic cause - mutation in UBP-glucuronyl transferase 1 gene leads to elevated levels of unconjugated bilirubin</li><li>10% of caucasian populations have mutation</li><li>Only presents if other trauma present</li><li>Diagnosis - increased level of unconjugated bilirubin after a period of fasting</li><li>Need to exclude haemolysis and other liver diseases</li><li>benign, worth knowing to prevent unneccessary investigation if jaundice occurs later in life </li></ul> What is neo-natal jaundice?"<ul><li>common (up to 90% of babies, more if premature)</li><li>caused by the breakdown of faetal red blood cells upon birth and a delay in clearance of bilirubin from red cell breakdown</li><li>treated by phototherapy</li><li>only a concern if it persists and is accompanied by pale stool and dark urine because this indicates bilirubin isn't been excreted</li></ul>" What are the features of hepatic jaundice?<ul><li>raised AST/ALT by 2-20 times</li><li>mild increase in ALP/gGT</li><li>increase in unconjugated and conjugated</li><li>histology - cholestasis in HBV infection, build-up of bile</li><li>upon cell death the conjugated bilirubin leaks into the blood</li></ul> What are the causes of hepatic jaundice?<ul><li>Viral infection.</li><li>Alcohol.</li><li>Non-alcoholic fatty liver disease (NAFLD).</li><li>Autoimmune liver disorders.</li><li>Metabolic causes of intra-hepatic jaundice.</li><li>Drugs.</li><li>Malignancy of the biliary system</li></ul> What are the types of viral hepatitis?A,B,C,D, and E Characteristics of hep A/B<ul><li>faecal-ora transmission</li><li>endemic in developing countries</li><li>hospitalisation rarely neccessary</li><li>flu-like symptoms</li><li>nausea</li><li>anorexia</li><li>jaundice - dark urine, pale faeces</li><li>no chronicity </li><li>vaccine available</li></ul> What is hep B?<ul><li>sexually transmitted infection</li><li>400 million carries globally</li><li>1 million deaths/year</li><li>60% subclinical infection and recovery</li><li>30% acute hepatitis - may go into liver failure and may recover</li><li>10% chronic hepatitis - 30% of these develop cirrhosis and 70% are asymptomatic carriers</li><li>vaccine available</li></ul> What is hep C?<ul><li>blood born </li><li>150 million carriers globally</li><li>0.5 million deaths per year</li><li>jaundice leading to immunity clearance</li><li>asymptomatic/jaundice -> chronic carrier -> cirrhosis after many years </li><li>90% of people chronic</li><li>no vaccine</li></ul> What is cholestasis?The interruption of bile flow as a result of damage to the liver What are the signs of cholestasis secondary to a systemic injury, pregnancy, or drug toxicity?<ul><li>normal transferases</li><li>very high alkaline phosphate</li><li>high bilirubin in blood - due to antibiotics</li><li>encephalopathy illustrated by hand flap reflux</li></ul> What should you do if cholestasis is suspected?Ultrasound to exclude cancer, test albumin levels to see if function okay What are the features of post-hepatic jaundice (blockage)?<ul><li>increased bilirubin</li><li>modest increase in AST/ALT</li><li>raised ALP/gGT (greater than 3 times normal)</li></ul> What causes post-hepatic jaundice?An obstruction of the bile ducts caused by: <ul><li>gallstones</li><li>disease of the ducts (cancer, inflammation)</li><li>compression of the ducts (lymph nodes, pancreatic cancer)</li></ul> What is the prevalence of gallstones?<ul><li>20-30% of women and 10-20% of men</li></ul> Most gallstones are asymptomatic - true/falsetrue What happens when gallstones migrate to the ducts?Obstruction -> jaundice -> cholangitis (infection within the bile)  How are gallstones diagnosed?Ultrasound, soreness in region upon palpation and MRCP scan What type of gallstones are the most common?Cholesterol gallstones - 80% How are gallstones treated?Endoscopic retrogate CP in bile duct or removal of the gallbladder What happens when pancreatic cancer causes compression of the bile ducts?<ul><li>Painless jaundice often with weight loss</li><li>Very poor prognosis</li><li>Common in older patients</li><li>Growth obstructs bottom of the common bile duct</li></ul> What are the two types of smooth muscle behaviour?1. Phasic: <ul><li>rapid contraction and relaxation</li><li>body of the oesophagus, stomach antrum, small and large intestines </li></ul>2. Tonic  <ul><li>sustained contractions</li><li>sphincters </li></ul> What are the interstitial cells of cajal (ICC)?Pace-making cells of the GI tract smooth muscle What is the role of the myenteric plexus in enteric smooth muscle motility?<ul><li>lies between circular and longitudinal muscle</li><li>increases tonic contraction</li><li>increases intensity of rhythmic contractions </li><li>increases velocity of contractions</li></ul> What is the role of the submucosal plexus in enteric muscle motility?<ul><li>lies between submucosa and circular muscle</li><li>increases secretory acitivity</li><li>modulates intestinal absorption </li></ul> What is the role of enteric sensory neurones in enteric muscle motility?<ul><li>mechano-reception senses distension (stretch in muscle cells activates a reflex contractile response)</li><li>chemo-reception - acid, short-chain fatty acids, enterocytes and entero-chromaffin cells</li></ul> What is the role of the parasympathetic nervous system in enteric muscle motility?<ul><li>increases motility</li></ul> What parts of the GI tract recieve parasympathetic innervation from the dorsal vagus nerve?<ul><li>oesophagus</li><li>stomach</li><li>small intestine </li><li>proximal large intestine</li><li>these all developed from foregut and midgut</li></ul> What parts of the GI tract recieve parasympathetic innervation by the sacral spinal cord (S1-3)?<ul><li>distal 2/3rds of the colon</li><li>rectum </li><li>anus</li></ul> What is the role of the sympathetic nervous system in enteric muscle motility?inhibits motility What reflexes inhibit GI tract motility?<ul><li>ileo-gastric - distension in the ileum inhibits stomach contraction to slow emptying </li><li>intestino-intestinal </li></ul> What reflects are excitory towards GI tract motility?<ul><li>gastro-enteric</li><li>gastro-ileal</li><li>gastro-colic - e.g., chyme in stomach stimulates contraction in colon</li><li>duodenal colic</li></ul> What pathologies of the GI tract are there?<ul><li>Hirschsprung disease</li><li>Chagas disease</li><li>Achalasia</li></ul> What is Hirschsprung disease?It is the congenital lack of neuronal ganglionic cells in the ENS plexuses due to the arrest of craniocaudal migration of vagal neural crest cells in the hindgut at weeks 5-12 of gestation during the formation of the enteric nervous system. "How is Hirschsprung's disease classified?""<ul><li>Classical - 75% of cases, aganglionic segment doesn't extend beyond upper sigmoid</li><li>Long segment - 20% of cases</li><li>Total colonic aganglionosis (3-12%)</li></ul>" What is megacolon?It is where the aganglionic bowel segment effectively prevents propulsion of faecal stream What are the symptoms of Hirschsprung disease? <ul><li>vomiting</li><li>constipation</li><li>distension of abdomen</li><li>instestinal obstruction</li><li>new-borns failure to pass meconium within 48 hours</li></ul> Is there a male or female predominance to Hirschsprung disease?Male 4:1 What associated disorders are there to Hirschsprung disease?Down syndrome and Waardenburg How is Hirschsprung disease evaluated?<ul><li>plain abdominal radiograph followed by a contrast enema examination</li><li>rectal manometry - 75% accurate and shows absence of normal relaxation of internal sphincter with reduction in intraluminal pressure</li><li>biopsy</li></ul> How is Hirschsprung disease treated?Surgical removal of aganglionic segment and subsequent anastomosis of two ganglionic segments of GI tract. What is Chagas disease?Infectious disease due to infection with protozoan parasite Trypanosoma cruzi that results in a significant reduction in the number of ganglionic cells in the ENS. What region of the GI tract does Chagas disease primarily involve?The Oesophagus Can chagas disease cause megacolon?Yes, not common Describe the storage function of the stomach"<ul><li>highly folded (empty volume is 50ml) and upon filling the folds flatten out so the wall tension and intraluminal pressure changes only slightly</li><li>relaxation in the fundus is regulated by vago-vasal reflex termed 'receptive relaxation'. If vagal innervation interrupted then intra-gastric pressure increases</li></ul>" What is the sieving function of the stomach?Where liquids and small particles leave the stomach more rapidly than large particles.  How is the movement of particles towards the antrum accomplished?By the interaction of propulsive gastric contractions and occlusion of the pylorus Describe the three phases of stomach sieving<ol><li>Propulsion - movement of solid particles toward the antrum is accomplished by the interaction of propulsive gastric contractions and occlusion of the pylorus. Contractions propel luminal contents towards pylorus, which is partially closed by contraction of musculature before delivery of bolus.</li><li>Grinding - once a bolus is trapped near antrum, churned to help reduce size of particles and only small portion of gastric material is propelled through pylorus to duodenum.</li><li>Retropulsion - most gastric contents returned to body of stomach for pulverization and shearing of solid particles. These phases repeat until the stomach is emptied.</li></ol> What are the functions of the pylorus?1. Allow carefully regulated emptying of gastric contents 2. Prevents regurgitation of duodenal contents into the stomach to prevent the stomach mucosa being damaged by bile 3. Duodenal mucosa is resistant to bile but may be damaged by acid from stomach if emptying is rapid What are the three phases of gastric emptying control?1. Cephalic 2. Gastric 3. Intestinal Describe the cephalic phase of gastric control<ul><li>sight, smell</li><li>taste and chewing</li><li>inhibitory phase - inhibitory vagus fibres result in relaxation of stomach enabling it to store large volumes </li></ul> Describe the gastric phase of gastric emptying control<ul><li>excitory phase in which stomach empties at a rate preportional to the volume in it</li><li>myogenic reflex - stretching smooth muscle causes reflex contraction</li><li>activation of pressure receptors which send impulses in local nerve plexuses and in the vagus nerve</li><li>gastrin released in response to peptides</li></ul> Describe the intestinal phase of gastric emptying control"<ul><li>where food is in the duodenum, ileum, or colon</li><li>mainly inhibitory phase through which the duodenum adapts the 'work-load' as a function of the state of the digestive process </li><li>mainly controlled through hormonal and paracrine mechanisms activated by duodenum chemoreception. general scheme: low ph - secretin, high fats/lipids - CCK, amino acids - gastrin, carbohydrates - GIP</li></ul>" Describe the differences between bone and cartilage"<ul><li>bone is highly vascular, cartilage is virtually avascular </li><li>bone cells embedded in a mineralised matrix, cartilage cells embedded in a proteoglycan and collagen matrix</li><li>bone is designed to be strong and resilient, cartilage is able to resist shearing and compressive forces but doesn't have the same inherent toughness as bone</li><li>bone provides skeletal shape and support to the body, cartilage found in smoothen surfaces in bone and joints</li></ul>" What are the two types of bone?Compact and spongy Describe the structure of compact bone"Compact bone consists of closely packed osteons or haversian systems. The osteon consists of a central canal called the osteonic (haversian) canal, which is surrounded by concentric rings (lamellae) of matrix. Between the rings of matrix, the bone cells (osteocytes) are located in spaces called lacunae." Describe the structure of spongy bone "Spongy bone consists of plates (trabeculae) and bars of bone adjacent to small, irregular cavities that contain red bone marrow. The canaliculi connect to the adjacent cavities, instead of a central haversian canal, to receive their blood supply." What cells make up bone?osteoblasts, osteocytes, osteoclasts What is the function of osteoblasts?bone formation What is the function of osteoclasts?reabsorption or break done of bone What is the function of osteocytes?maintain bone matrix Describe the process of bone remodelling"1. Osteoblasts detect microcracks  2. Osteoblasts then produce and sececrete substance called RANKL 3. RANKL binds to receptors on monocyte cells leading them to bind together and form osteoclasts 4. Osteoclasts secrete enzymes to digest collagen in the organic matrix 5. Produces pits called Howship's Lacunae  6. Osteoclasts secrete HCl to breakdown hydroxyapatite into soluble calcium ions which dissolve into the bloodstream 7. Osteoblasts secrete osteoprotegerin to control osteoclast breakdown of bone 8. Once reabsorption is complete, osteoblasts secrete osteiod seam to fill lacunae and then calcium and phosphate deposit on the seam forming hydroxyapatite 9. In this process, some osteoblasts get trapped in the matrix and become osteocytes" What are the three types of cartilage?Hyaline, fibrous, and elastic Which type of cartilage is the strongest?Fibrous <div>What are the properties of hyaline cartilage?</div><div>tough but mildly flexible, smooth, good in articular surfaces</div> What types of bones are there?<div>1. Flat bones: Sternum</div><div>2. Long bones: Femur, tibia, humerus</div><div>3. Short bones: cuneiforms</div><div>4. Seasamoid bones: Have a tendon running through them: Patella</div><div>5. Irregular bones: Sphenoid, innominate bone</div> What are the two types of joints?Fibrous and cartilaginous List the types of cartilaginous jointsB and S Hinge Saddle Condyloid Pivot List the types of fibrous jointsSutures of the skull Syndesmosis Gomphosis What are primary cartilaginous joints?Temporary ones found during the growth of long bones What are secondary cartilaginous joints?Actual joints AbductionMovement away from the midline of the body AdductionMovement towards the midline of the body FlexionDecreases the angle of a joint Extension Increases the angle of a joint PronationMovement that turns the palm down Supination Movement that turns the palm up Inversion Turning the sole of the foot inward Eversion Turning the sole of the foot outwards Internal rotationRotation of a joint toward the middle of the body External rotation Rotation of a joint away from the middle of the body MedialCloser to the midline LateralFurther away from the midline of the body Describe the three main functions of motor activity of the GI tract in the intestines<ul><li>Producing segmental contractions that are associated with non-propulsive movement of luminal contents, resulting in mixing that enhances the digestion and absorption of dietary nutrients</li><li>Producing peristaltic contractions that cause propulasion or the propagated movement of food and its digestive productucts in the caudal direction, resulting in the elimination of non-digested, non-absorbed material</li><li>Allowing some hollow organs to act as reserviors for holding luminal content made possible by the sphincters</li></ul> What is the function of motor activity in the small intestine?<ol><li>Mixing chyme from stomach with secretions from liver and pancreas</li><li>Propulsion </li><li>Release of chyme into the colon</li></ol> What are the two types of motor acitivty in the small intestine during a fed state?Segmentation and peristalsis Describe the process of segmentation in the small intestine<ul><li>rings of circular muscle at intervals contract and then relax</li><li>then adjacent rings contract and relax</li><li>results in mixing</li></ul> Describe the process of peristalsis in the small intestine<ul><li>sequential contractions of rings of circular muscle followed by sequential relaxation</li><li>combination of activity between muscular layers with sequential activity in each of them</li><li>propulsion </li></ul> What happens to motor acitivity in the small intestine during a fasted state?Development of the migrating motor complex meaning there are large sweeps of acitivity every few hours What are the 4 phases of the migrating motor complex?<ol><li>Prolonged quiescent period </li><li>Period of increasing action-potential frequency and contractility</li><li>Period of peak electrical and mechanical activity that lasts a few minutes</li><li>Period of declining activity that merges into the next quiescent period </li></ol> What is the function of the migrating motor complex?<ul><li>Clear small intestine of residual content (undigested food, desquamated cells, intestine and pancreatic biliary secretions</li><li>Stop colonic bacteria from migrating into terminal ileum</li><li>Usually initiate in the stomach and often travels down to distal end of ileum</li><li>feeding terminates this</li><li>ENS, hormonal factors and extrinsic innervations all impact to regulate (dominant hormone is motilin)</li></ul> How is smooth muscle contraction controlled in the small intestine?<ul><li>neurotransmitter - ACh</li><li>hormones - motilin and somatostatin cause contraction, vasoactive intestinal peptide causes relaxation</li><li>stretch (myogenic reflex)</li><li>ENS</li></ul> Describe the motility of the ileum<ul><li>ileo-gastric relex - ileal distension leads to decreased gastric motility</li><li>gastro-ileal reflex - increased gastric activity causes increased ileal motility and increased movement of chyme through the ileocaecal valve</li><li>ileocaecal sphincter -> distension of the ileum results in the relaxation of sphincter whereas distension of the proximal colon causes contraction -> ileal flow into colon regulated by luminal contents and pressure</li></ul> What muscles are responsible for motility in the colon?In the colon the longitudinal muscle layers thicken to form three muscular bands which run the length of the colon called the taeniea coli:  <ul><li>extent and retract</li><li>contractions gather up colon forming haustra</li></ul> What is the function of the proximal colon?<ul><li>absorb large quantities of fluid and electrolytes thus converting liquid content of ileocaecal matter to solid </li><li>avidly absorb SCFA - product of carbohydrate fermentation</li><li>provides environment for beneficial bacteria which synthesise vitamins (K, B)</li></ul> What is the function of the distal colon?<ul><li>Storage/reservoir functions </li><li>Regulate release of faecal material</li></ul> What are the two types of motility in the colon?Colonic rhythmic phasic contractions and colonic giant migrated contractions Describe the features of colonic rhythmic phasic contractions - fluid contents of ascending colon gradually become semi-solid to solid in sigmoid colon as water is absorbed -generates two types of contractions - highly disorganised in space and varies widely in amplitude and duration, effective in turning over of faecal material with slow rate of propulsion What are the two types of contractions of colonic rhythmic contractions?<ol><li>Short-duration (2-3 seconds) with no propagation, and large variation in amplitudes</li><li>Long duration (15-20 seconds) which propagate over short distances, enabling them to turn over and propel semi-solid contents more effectively</li></ol> Describe the features of colonic giant migrated contractions<ul><li>these are large-amplitude lumen-occluding contractions that propagate very rapidly (1cm/sec) in distal direction over appreciable distances to produce mass movements</li><li>Spontaneous GMCs occur randomly 2-10 times a day in proximal, middle, or descending colon </li><li>occur in both a fed or fasting state</li></ul> Diseases of the colon due to diet<ul><li>constipation </li><li>diverticular disease</li><li>haemorrhoids</li><li>polyps</li><li>cancer of the colon</li><li>irritable colon</li><li>ulcerative colitis</li></ul> How is motility in the colon controlled?Two ways: 1. By substances in food: - bulk causes distension - fibre stimulates pressure receptors 2. By autonomic nervous control: - parasympathetic innervation increases motility - sympathetic inhibits motility What are the 4 types of laxatives?<ol><li>Stimulant</li><li>Saline</li><li>Emollient</li><li>Bulk-forming</li></ol> Describe stimulant laxatives<ul><li>act by increasing motility through chemoreceptor activation and myenteric nerve plexus activation</li><li>senna, cascara</li><li>castor oil that contains ricinoleic acid (inhibitor of Na ion transport)</li></ul> Describe saline laxatives<ul><li>act by drawing water into bowel through osmosis due to high concentrations of osmotic particles</li><li>Mg, sufate or phosphate, and non-absorbable sugar</li></ul> Describe emollient laxatives<ul><li>faecal softeners </li><li>non-absorbing lubricants</li></ul> Describe bulk-forming laxatives<ul><li>dietary fibre</li><li>bran, methycellulose</li><li>safest and generally preferred</li></ul> Describe the defaecation reflex<ol><li>internal anal sphincter - circular involuntary smooth muscle</li><li>external anal sphincter - striated voluntary muscle</li><li>faeces enters the rectum and causes distension due to mass peristalsis</li><li>intrinsic defaecation reflex - myenteric plexus</li><li>peristalsis and relaxation of internal anal sphincter (weak): requires reinforcement</li><li>reinforcement in the form of parasympathetic defaecation reflex</li><li>this is mediated by the sacral segments of the spinal cord</li><li>results in amplification of peristaltic waves and relaxation of the internal anal sphincter</li><li>defaecation can be inhibited by conscious control over the external anal sphincter</li></ol> What are the 6 categories of chronic diarrhea?<ol><li>Osmotic</li><li>Secretory</li><li>Inflammatory</li><li>Malabsorptive </li><li>Chronic infections </li><li>Motility disorders diarrhea</li></ol> What is the algorithm for diagnosing acute inflammatory diarrhoea?History: - duration of travels + food/water - stool characteristics - abdominal pain - drug intake Physical examination: - general status - abdomen - rectal exploration  Initial evaluation: - toxic status, bleeding, dehydration - blood count, serum chemistry, and stool tests - colonoscopy - non-toxic status, no-bleeding, no tenderness What causes acute diarrhoea?<ul><li>acute gastroenteritis </li><li>drug induced by NSAIDs</li><li>chemical (alcohol and bleach)</li><li>inflammatory bowel disease</li><li>food intolerances </li><li>emotional stress</li></ul> What is the cause of chronic inflammatory diarrhoea?Inflammatory Bowel Disease - either ulcerative colitis or crohns disease What are the features of ulcerative colitis?<ul><li>typically begins in the rectum and may extend continuously to involve the entire colon</li><li>usually only affects the inner layer of the bowel wall</li><li>incidence is 7 per 100,000</li><li>presents at 20-40 years equally in males and females</li><li>granulomas absent</li><li>extent and severity - entire colon leads to pancolitis, whereas proctitis is inflammation of the lining of the rectum</li></ul> What are the features of Crohns disease?<ul><li>most commonly involves the end of the small intestine and beginning of the colon and may affect any part of the GI tract in a patchy pattern</li><li>may affect all layers of the bowel wall</li><li>incidence is 2-3 per 100,000 </li><li>onset at 15-30 years, can occur in childhood, M=F</li><li>non caseating granulomas characterised</li><li>mucosal ulceration leads to fibrosis, stricturing, fistula formation </li></ul> What are the external manifestations of both Crohns and UC?<ul><li>aphthous ulceration</li><li>erythema nodosum </li><li>arthropathy</li><li>pyoderma gangernosum</li><li>anterior uveitis</li></ul> What are the external manifestations specific to Crohns disease?<ul><li>sacroiliitis</li><li>ankylosing spondylitis</li><li>primary sclerosing cholangitis</li><li>cholangiocarcinoma</li></ul> How is inflammatory bowel disease investigated?<ul><li>history and examination</li><li>bloods - full blood count, urea and electrolytes, liver function tests, C reactive protein</li><li>stool pathogens</li><li>abdominal x-ray</li><li>sigmoidoscopy</li><li>colonoscopy</li><li>small bowel imaging (CT, MRI, barium follow through)</li><li>histology</li></ul> How is inflammatory bowel disease managed medically?- Induction of remission through steroids either orally or IV - Maintenance: <ul><li>aminosalicylates - oral or rectal</li><li>azathioprine, mercaptopurine - purine analogues</li><li>ciclosporin, tacrolimus - calcineurin inhibitors</li><li>infliximab, adalimumab - anti-TNF alpha antibodies</li></ul> "What is the surgical management of Crohn's?"<ul><li>Treatment of complications </li><li>Segmental resections </li><li>High risk of disease in remaining bowel</li></ul> What is the surgical management of UC?<ul><li>for recurrent episodes or disease not responding to medical management</li><li>severe colitis - sub-total colectomy with end ileostomy</li><li>elective surgery - panproctocolectomy with ileo-anal pouch</li><li>permanent cure possible</li></ul> What is atheroma?The degeneration of walls of arteries due to plaque build-up

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