Meanwhile, Back At The Ranch…

Segway company owner dies riding a Segway over a cliff in the U.K.

I have no words.

Graduate School 10-12 Blunt Force Trauma

11. Blunt Force Injury

Irregular Cat Blogging

Alpaca-cat

My Cake.

There’s a gun control meme wandering around the internet.  Two people put it much better than I ever could, and more cogently.  Go thou and read OK, I’ll Play and An Unintended Gun Control Meme.

I really think there should be few restrictions of civil rights, particularly the enumerated rights of the bill of rights.  Imagine the outcry if analogues of the Firearms Act of 1934 or the Gun Control Act of 1968 applied to the first amendment.  licensure for bloggers, a waiting period to post on the internet, the inability to purchase a religious book by mail?

Good Heavens

This is extremely significant.  Tell the Megratheans.  Hat tip, TAM.

Sappy Cat Blogging

Noodle

This Could Save Us All So Much Time

Hat Tip, Lili

Graduate School #9 Examination of the Heart

Examination of the heart

I.              Introduction

The specimen usually consists of both ventricles and atria and the attached aorta at the arch

II.           Processing the specimen:

1. The pulmonary veins are opened in situ, to look for pulmonary emboli

1. In general, hearts are cut fresh in a manner dictated by the pathology to be demonstrated.

1.             Infant and child hearts with dilated cardiomyopathy are cut longitudinally from apex to base, bivalving both ventricles and bisecting tricuspid and mitral valves (“apical 4 – chamber” cut).

2.             Hearts with ischaemic heart disease are cut transversely at approximately 1 to 2 cm intervals beginning at the apex to the level of the mitral valve (“serially sectioned” or “breadloafed”).

3.             The base of the heart is opened along the line of flow.

1. Weight of the specimen.

1.             Males 350 gm +/- 40 gm

2.             Females 300 gm +/- 30 gm

3.             Roughly double the weight in pounds and put grams after it.

4.             Cardiomegaly >2 SD, 450-500 gm significant

5.             Cor bovinum > 700gm Normal weights for the entire heart are 270- 350

1. Describe epicardial surface

1.             Including pericardial fat (abundant, scant),

2.             Petechiae

3.             Adhesions.

1. Measure the wall thickness of both ventricles and the septum

1.             LV           1-1.5 cm

2.             S              1-1.5 cm

3.             RV           0.3-0.5 cm

1. Describe the left ventricle

1.             hypertrophy or dilatation

2.             fibrosis (endocardial, epicardial, transmural, location and degree),

3.             infarcts (old or recent, size, location, transmural or subendocardial)

4.            trabeculations

5.             papillary muscles (hypertrophied, thinned, scarred, infracted),

6.             presence of mural thrombus.

1. Describe the valves

1.             Dimensions

2.             Thickness or lesions

1. Describe the arteries.  Cut in transverse sections every three-five mm

1.             Left, right, circumflex

2.             Thrombi

3.             Degree of Atherosclerosis, Calcifications

7.             Patence and number of ostia

8.             Describe any bypass grafts including type (saphenous vein, left internal mammary), location of graft to native vessel patency.

1. In a non-complicated heart, submit three sections, LV, S, RV
2. In a heart with lesions, take the above three sections and representative sections of the lesion(s)
3. Section and submit the coronary arteries.

Coronary artery anatomy

I.

A.            the coronary arteries are the first branches of the aorta

1.             Arise within the aortic sinuses of Valsalva.

2.             There are two arteries, right and left

3.             Three sinuses.

a.             as right coronary, left coronary and non-coronary.

1. The right coronary artery emerges from the sinus
   1. Antero-superior part of the right arterioventricular groove
   2. Encircles the tricuspid valvar orifice, giving rise to ventricular and atrial branches.
   3. In nine-tenths of individuals, it gives rise to the posterior interventricular artery and in most continues beyond the crux to supply part of the diaphragmatic surface of the left ventricle (right coronary dominance).

1. The left coronary artery emerges from its sinus into the space between the pulmonary trunk and the left atrial appendage.

1.             After a short course, ≈ one centimeter

2.             Divides into anterior descending

a.             Interventricular groove main left ventricle

3.             Circumflex branches.

a.             Runs round the mitral orifice,

b.             Obtuse ventricular and atrial branches.

c.             In one-tenth of individuals, it is the circumflex artery which gives rise to the posterior interventricular artery (left coronary dominance).

D.            The areas of heart supplied by the three coronary arteries are as follows:

1              Left anterior descending:

a.             Anterior wall of left ventricle

b.             Adjacent area of anterior right ventricle

c.             Anterior two-thirds of the interventricular septum

2.             Left circumflex

a.             Lateral wall of the left ventricle.

3.             Right coronary artery:

a.             Remainder of the right ventricle

b.             posterior region of left ventricle

c.             posterior third of the interventricular septum.

Graduate School #8 Natural Disease

I.          Introduction

A.        Natural Disease

B.         Sudden Death Unexpected Death

C.        No Physician

II.         No Physician

A.        Poverty

B.         Christian Scientists

1.         Pretty darn old

2.         Healthy lifestyle

3.         Cancer

C.        Fear

1.         Breast tumor

2.         Rodent ulcer

III.       Sudden Death

Death within ~12 hours of symptoms

Went to bed, woke up dead.

C.        Hypertensive and atherosclerotic cardiovascular disease

1.         50% Sudden and unexpected

2.         85% ACVD

3.         DM makes it worse

4.         Tamponade, ruptured infarct 100%

5.         AMI, 90%

6.         1-2-3 vessels > 75% stenosis 70%

7.         Angina

a.         Stable

b.         Unstable

c.         Prinzmetal’s

8.         Claudication

9.         Silent killer

a.         labile

b.         Not show up in Dr.’s Office

c.         If physical signs present, it existed.

d.         Weasel words

D.        Systematic examination of the heart

1.         Heart weight 0.05% TBW in kg

a.         350 g M, 300 g F; +/- 40 gm M 30 gm F

b.         2 SD 410, 360

c.         Over 500 g sudden death at any time

i.          Big hearts don’t beat right

d.         Over 750 g cor bovinum

e.         IHSS

i.          hypertrophic cardiomyopathy

ii.          Death in 40’s

iii.         Genetic

iv.         Wavy fibers

2.         Coronary arteries

a.         Anomalous origin, course, tunneling

b.         Cystic medial necrosis

c.         CA dissection women, peripartum

3.         Chambers

a.         Scarring

b.         Thinning

c.         Fatty replacement

4.         Valves

a.         Floppy valves–Marfan’s other collagen vascular diseases

b.         Artificial valves

i.          Anticoagulation

ii.          Mechanical breakage

5.         Conduction system

a.         Pain in the arse

b.         SA node anteriolateral junction of the SVC/RA artery

c.         Funny right ventricle

i.          Dysplasia of the fibers

ii.          Fatty infiltration

d          Long QT–molecular studies

i.          Mayo Clinic

ii.          Takes for bloody ever

6.         Commotio Cordis

Vasculature

a          Aorta

i.          atherosclerosis

ii.          CMN

Marfan’s

b.         Atherosclerotic aneurysms

i.          Smoking

ii.          Infrarenal distribution

iii.         >5 cm operate

iv.         90% mortality emergent disease

v.         1% elective procedure

vi          Gore-tex grafts

c.         What other things do you have to graft?

I. Aorta bi-fem, fem distal, fem-popleteal, amputation (fem-chop)

Carotid atherosclerosis

Plaque disruption

E.         Pulmonary Emboli Truly instantaneous

1.         90% come from popleteal veins

a.         Saddle emboli

2.         Hypercoagualable state

a.         Balance between clotting and anticoagulants

i.          Factor V Leiden

ii.          Activated protein C resistance

iii.         Lupus anticoagulant (anti cardiolipin antibodies)

iv.         OCP

v.         Smoking

vi.         Obesity

vii.        Immobilization

3.         History, best predictor is previous PE

a.         Hemoptysis, dyspnea, anxiety

b.         V/Q mismatch

c.         >60% of one lung fatal

d.         Little ones resolve

F.         CNS

1.         Berry Aneurysms

a.         Circle of Willis middle and anterior

b.         Congenital

c.         1 in 20 adults have one

d.         Worst headache of life

2.         AVM

a.         Blood vessels with arteries going directly to veins

b.         Spontaneously bleed

c.         Embolize

3.         Strokes

a.         60% atherosclerotic

b.         20% embolic

c.         Brain exquisitely sensitive to anoxia/ischemia

i.          Neurons, astrocytes, oligodendroglia, microglia, vascular endothelium

ii.          Sommer’s sector in the Hippocampus, Purkinje cells of cerebellum, watershed

iii.         Hemorrhagic vs. ischemic reperfusion injury

iv          Calpains, Ca++ channel blockers

v.         Lenticulostriate branches of middle cerebral artery a)     Anatomic reason Little arteries off big

Total head

4.         Epilepsy–SUDEP–SUdden DEath in EPelepsy

a.         Poorly controlled males

b.         Epileptics drown

c.         Driving and epilepsy

i.          Some states required report

ii.          Kinds of seizures

F.         Infectious Diseases

1.         Not usually sudden or unexpected

a.         These things take time

b.         Setting of immunosuppression

i.          Lots of immunosuppressed people running around out there

ii.          Clostridium perfringens and rectal

2.         Nisseria meningiditdis

a.         Respiratory route

b.         Dorms and barracks

c.         Young adults

d.         People freak out news media etc.

3.         Legonella pneumophilia

a.         Water organism

b.         Chevy plant

4.         Lemierre’s syndrome

a.         Supperative jugular thrombophelbitis

b.         Fusobacterium necrophorum

c.         Toxic shock

Sappy Cat Blogging

It’s Friday, so it is time for sappy cat blogging.  Cats at IKEA.  Oh, interesting.

The idea:

The finished product: