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1Shashi Mar-03
Cellular Injury & Ageing
Disease
• Dis + Ease = Disease.
• “Discomfort due to Structural or functional abnormality”
• Disease is caused by an agent.
• Causes (etiology) can be – External / Environmental. E.g.. Heat, Bacteria. – Internal E.g. stress, genes, ageing.
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Cellular Injury & Adaptation:
• Normal cell is in a steady state “Homeostasis”
• Change in Homeostasis due to stimuli - Injury
• Injury - Reversible / Irreversible
• Adaptation / cell death
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Response to Injury:
• Adaptations (reversible)– Hydropic degeneration– Hypertrophy– Hyperplasia– Atrophy– Accumulations - hyaline, fat, etc.
• Necrosis (irreversible) – cell death.
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Terminology:
• Necrosis: Morphologic changes seen in dead cells within living tissue.
• Autolysis: Dissolution of dead cells by the cells own digestive enzymes. (not seen)
• Apoptosis: Programmed cell death. Physiological, for cell regulation.
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Types of Necrosis:
• Coagulative – Eg. Infarction
• Liquifactive - Brain, abscess
• Caseous - Bacterial / Tuberculosis
• Gangrene - With infection
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Sequels of Necrosis:
• Cell Death
• Necrosis
• Autolysis
• Phagocytosis
• Organization & fibrous repair.
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Ageing:
“Progressive time related loss of structural and functional capacity of cells leading to
death”
• Senescence, Senility, Senile changes.
• Ageing of a person is intimately related to cellular ageing.
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Factors affecting Ageing:
• Genetic – Clock genes, (fibroblasts)
• Diet – malnutrition, obesity etc.
• Social conditions -
• Diseases – Atherosclerosis, diabetes etc.
• Werner’s syndrome.
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Cellular mechanisms of ageing
• Cross linking proteins & DNA.
• Accumulation of toxic by-products.
• Ageing genes.• Loss of repair
mechanism.• Free radicle injury• Telomerase shortening.
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Telomerase in ageing:
GermCells
SomaticCells
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11Shashi Mar-03
Ageing –changes:
• Gradual atrophy of tissues and organs.
• Dementia
• Loss of skin elasticity
• Greying and Loss of hair
• BV damage – atherosclerosis/bruising.
• Loss of Lens elasticity opacity vision
• Lipofuscin pigment deposition – Brown atrophy in vital organs.
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Pathology of elderly
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13Shashi Mar-03
Factors affecting ageing:
• Stress• Infections• Diseases• Malnutrition• Accidents
• Diminished stress response.
• Diminished immune response.
• Good health.
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Conclusions:
• Cellular Injury - Various causes
• Reversible Injury Adaptations– Hypertrophy, Hyperplasia, Atrophy– Accumulations - Hydropic, hyaline, fat..
• Irreversible Injury - Necrosis– Coagulative, Liquifactive, Caseous
• Ageing - Causes, Changes, Factors
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15Shashi Mar-03
Inflammation
• “Inflame” – to set fire.• Inflammation is “dynamic response of
vascularised tissue to injury.”• Is a protective response.• Serves to bring defense & healing
mechanisms to the site of injury.
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Lewis Triple Response:
• FlushFlush:: capillary dilatation.
• FlareFlare:: arteriolar dilatation.
• WealWeal:: exudation, edema.
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Red, Warm & Swollen(Flare, Flush & Weal – Lewis)
Triple response
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18Shashi Mar-03
Cardinal Signs of Inflammation
• RuborRubor : : Redness – Hyperaemia.
• CalorCalor : : Warm – Hyperaemia.
• DolorDolor : : Pain – Nerve, Chemical med.
• TumorTumor:: Swelling – Exudation
• LossLoss ofof FunctionFunction: :
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Inflammation - Mechanism
1. Vaso dilatation
2. Exudation - Edema
3. Emigration of cells
4. Chemotaxis
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Mechanism of Inflammation:
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22Shashi Mar-03
Chemical Mediators:• Chemical substances synthesised or
released which mediate the changes in inflammation.
• Histamine by mast cells - vasodilatation.
• Prostaglandins – Cause pain & fever.
• Bradykinin - Causes pain.
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Morphologic types• Acute:
– Exudative Inflammation: excess fluid. TB lung.– Suppuration/Purulent – Bacterial - neutrophils– Fibrinous – pneumonia – fibrin – Serous – excess clear fluid – Heart, lung– Haemorrhagic – b.v.damage - anthrax.
• Chronic inflammation: with healing. – Grannulomatous – clusters of epitheloid* cells
eg. TB, Fungus, Foreign body.
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Inflammation Outcome
Acute Inflammation
Resolution
Chronic Inflammation
Abscess
SinusFistula
Fibrosis/Scar
Ulcer
Injury
FungusVirusCancersT.B. etc.
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Acute Vs Chronic
• Flush, Flare & Weal
• Acute inflammatory cells - Neutrophils
• Vascular damage
• More exudation
• Little or no fibrosis
• Little signs - Fibrosis,
• Chronic inflammatory cells – Lymphocytes
• Neo-vascularisation
• No/less exudation• Prominent fibrosis
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Stages of Healing:
• Hemorrhage
• Inflammation
• Granulation tissue (soft callus)
• Scar – Fibrosis (hard callus)
• Remodeling & Wound strength
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Repair
• Regeneration of injured tissue by parenchymal cells of the same type
• Replacement by connective tissue
• In other words– Regeneration– Scar
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Proliferative Potential
• Labile cells - continuously dividing – Epidermis, mucosal epithelium, GI tract
epithelium etc
• Stable cells - low level of replication– Hepatocytes, renal tubular epithelium,
pancreatic acini
• Permanent cells - never divide– Nerve cells, cardiac myocytes, skeletal mm
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29Shashi Mar-03
Polypeptide growth factors
• Most Important Mediators affecting Cell Growth
• Present in serum or produced locally• Exert pleiotropic effects; proliferation, cell
migration, differentiation, tissue remodeling• Regulate growth of cells by controlling
expression of genes that regulate cell proliferation
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Repair by connective tissue
• Occurs when repair by parenchymal regeneration alone cannot be accomplished
• Involves production of Granulation Tissue
• replacement of parenchymal cells with proliferating fibroblasts and vascular endothelial cells
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Components of the processof fibrosis
• Angiogenesis - New vessels budding from old
• Fibrosis, consisting of emigration and proliferation of fibroblasts and deposition of ECM
• Scar remodeling, tightly regulated by proteases and protease inhibitors
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Wound healing
• Induction of acute inflammatory response by an initial injury
• Parenchymal cell regeneration
• Migration and proliferation of parenchymal and connective tissue cells
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Wound healing (cont’d)
• Synthesis of ECM proteins
• Remodeling of parenchymal elements to restore tissue function
• Remodeling of connective tissue to achieve wound strength
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Healing byFirst Intention
Focal Disruption of Basement Membrane and loss of only a few
epithelial cellse.g. Surgical Incision
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Healing by Second Intention
Larger injury, abscess, infarction
Process is similar butResults in much larger
Scar and then CONTRACTION
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Wound Strength
• After sutures are removed at one week, wound strength is only 10% of unwounded skin (Walker’ Law)
• By 3-4 months, wound strength is about 80% of unwounded skin (Walker’s Law)
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Factors affecting Healing:
SystemicSystemic
• Age
• Nutrition
• Vitamin def.
• Immune status
• Other diseases
LocalLocal
• Infection
• Size or extent.
• apposition
• Blood supply
• Mobility
• Foreign body
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Summary:
• Healing – Proliferation & Differentiation.
• Labile, Stabe & Permanent cells
• Stages of Healing: 1-2-3-4….
• Healing by First or Second intention.
• Skin wound healing - bone healing.
• Factors affecting healing – Local / Systemic
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Circulatory disorders:
• BV - Narrowing, rupture, aneurism.
• Thrombosis
• Embolism
• Venous congestion
• Edema
• Shock
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40Shashi Mar-03
Thrombosis:• Intravascular coagulation• Vessel damage - atheroma, toxins
• Blood changes - stasis, *coagulation factors
• Types: White, Red & Mixed.• Sites:
– Arterial: Brain, Heart, limbs, eys.– Venous: Leg– Capillary: DIC in septicemia
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Embolism:
• Abnormal solid mass carried in blood.• Source – destination• Types.
– Thromboembolism - atherosclerosis– Fat - Fractures– Tumor - cancers– Gas – ‘Caisson disease’– Liquid – Amniotic fluid in new born.
• Rapid onset of infarction –vs. Thrombosis
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Sequels of Block
• Collateral circulation:
• Ischemia,
• Infarction, Gangrene
• Haemorrhage
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43Shashi Mar-03
Common Sites of B.V block:
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Edema & Shock….!
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Normal Microcirculation
Capillary Arterial VenousHydrostatic Pressure + 36 + 16Oncotic Pressure - 26 - 26Net filtration Pressure + 10 mmHg - 9 mm Hg
(leak-out) (Reabsorb)
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Edema:• Increased interstitial fluid volume
• Two major types
• Local - inflammation
• Generalised - anasarca - Systemic causes.
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Edema mechanism:• Leaky vessels – inflammation.
• Increased capillary hydrostatic pressure– Venous obstructions– Cardiac failure
• Decreased Osmotic pressure – Hypoproteinemia – liver disease, anemia.
• Lymphatic obstruction– Elephantiasis
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Shock:
• “Depressed vital functions due to decreased circulating blood volume”
• Types: – Hypovolaemic - true/vasovagal– Cardiogenic – Heart failure, MI.– Obstructive – Pulm embolism.– Anaphylactic – vasodilation due to allergy.– Septic – capillary damage by infection.
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Shock Featurs:
• Hypotension
• Tachycardia
• Cold clammy skin
• Rapid shallow respiration.
• Drowsiness, confusion, irritability
• Multi organ failure.
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Shock Mechanisms:
• Compensatory mechanisms: – Adrenaline cold, clammy skin
• Complications: Ischemic damage.
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Shock Management:
• Position, clothing – vital organs….!
• Airway
• Stimulants – ammonia inhalation.
• Fluids, electrolytes, Blood pressure
• Treat the cause.
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52Shashi Mar-03
Disorders of GrowthDisorders of Growth
• Understand Growth disorders.
• Difference between Neoplastic & Non neoplastic growths.
• Classification of growth disorders.
• Characters of tumors – Biology of tumors
• Diagnosis & management of tumors. (Basic)
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New Cancer Statistics – USA 1996
Prostate 317,000 Breast 184,000 Lung 112,000 Colon-rectum 82,000 Lung 78,000 Colon-rectum 68,000
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Introduction:
• Inflammatory, Degenerative & Neoplastic
• Tumor – Swelling / new growth / mass
• Two types of growth disorders:
• Non-Neoplastic – Secondary / adaptation due to other cause.
• Neoplastic.– Primary growth abnormality.
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Non-Neoplastic Proliferation:
*Controlled & Reversible• Hypertrophy – Size• Hyperplasia – Number• Metaplasia – Change• Dysplasia – Disordered
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Neoplastic Proliferation:
Uncontrolled & Irreversible*• Benign
– Localized, non-invasive.• Malignant (Cancer)
– Spreading, Invasive.
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Pathogenesis – Smoke - Lung Dis.
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58Shashi Mar-03
Polyclonal Monoclonal
Normal Adaptation Benign
Malignant
Mechanism of Growth Disorders
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59Shashi Mar-03
Nomenclature:
Cell of origin + Suffix
(Oma, Carcinoma & Sarcoma)
• Fibroma - Fibrosarcoma
• Osteoma - Osteosarcoma
• Adenoma - Adencarcinoma
• Papilloma - Squamous cell carcinoma
• Chondroma – Chondrosarcoma
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Diagnosis:
• History of Clinical examination
• Radiographic analysis – X-Ray, US, CT, MRI
• Laboratory analysis – Tumor markers
• Cytology –Pap smear, FNAB
• Biopsy - Histopathology, markers.
• Autopsy – Research, learning & teaching
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Biology of Tumor
• Grading – Differentiation
• Staging – Progression
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TNM: Staging of tumor:
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TNM: Staging of tumor:
• T1N1M0 – Means primary tumor is within the organ but cancer cells have spread to local lymphnodes, there is no metastasis.
• T3N0Mo - Means tumor has spread beyond primary organ but has not spread to lymphnodes or other sites.
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64Shashi Mar-03
Immune Disorders
• Humoral Immunity–B lymphocytes - Antibody
• Cell mediated Immunity–T lymphocytes – Macrophages
• Non-Specific immunity–Neutrophils, Macrophages
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Introduction:
• Immunity is not inherited.• Antigen / Antibody• Active / Passive immunity.• Vaccine, Toxoid, Live/Killed • Primary response – slow, weak.
–Learning period, memory cells.• Secondary response – rapid,
strong
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Immune Disorders:
• Immunodeficiency disorders–AIDS, antibody deficiency
• Hypersensitivity Disorders (allergy)–Type-I (IgE), II-IgG, III-
Immunecomplex, IV-Cell mediated.
• Autoimmune disorders–SLE, Rhematoid, Rheumatic fever.
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Rheumatic fever:
• Autoimmune disorder.
• Group A, streptococcal pharyngitis.
• Antibody cross react with connective tissue in - susceptible individuals*
• 2-3 weeks – Autoimmune reaction.
• Inflammation - T lymphocytes, macrophages.
• Heart, skin, brain & joints.
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Morphology:• Acute Rheumatic Fever
– – Acute Inflammatory Phase– Heart – Pancarditis– Skin – Erythema Marginatum– CNS – Sydenham Chorea– Migratory polyarthritis
• Chronic Rheumatic Fever – Deforming fibrotic valvular
disease.
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What is Asthma?• Hypersensitivity – Allergy , Type I• of airways of lungs - Bronchi• Allergens – in the air, mast cell - IgE ab.• Inflammation of airways – Bronchitis.• Genetic, Environmental, Race, Age.• High in industrial cities 4-19%, Fiji < 1% • Increasing incidence …!
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Pathogenesis - Atopic Asthma:
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Asthma Mechanism:
• AllergyAllergy• Inflammation Of Inflammation Of
BronchiBronchi• ObstructionObstruction• Mucous PlugsMucous Plugs
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INFLAMMATIONINFLAMMATION
TRIGGERSExercise
Cold Air, diseases,
AirwayHyperresponsiveness
Genetic*
INDUCERSAllergens,pollutants
Airflow Limitation
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Asthma - Bronchial morphology
• inflammation • Eosinophils• Gland
hyperplasia• Mucous plug in
lumen• Hypertrophy of
muscle layer
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Autoimmune Disorders
• Immune response against self antigen resulting in Tissue damage.
• Single organ or systemic multi organ.• Common in females.• Normally immune system is tolerant to self
antigens (learns during fetal development).• Autoimmune disorders result from
Defective tolerance, cross reacting antibodies or antigenic mimicry.
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Immunodeficiency& AIDS
• Serious, persistent, unusual, recurrent Opportunistic infections.
• Secondary causes more common.
• Antibody deficiency – Bacterial inf.
• Cell Mediated imm def. – viral / fungal
• AIDS – infection by HIV virus – destruction of T helper cells – deficiency of humoral & CM immunity.
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Introduction:
• Specific Immune System – Humoral– Cell medicated
• Non-Specific Immune System– Phagocytes– Complements
• Single or multiple component deficiency.• Susceptibility - Opportunistic infections.
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Classification:• Primary Deficiencies (Inherited)
– B cell defects – Ig def. Bacterial infections.– T cell defects – T cells. – Viral & fungal infect.– Combined defects – T & B
• Secondary Deficiencies –(Acquired) – T*– Malnutrition – Protein– Immunosuppressive therapy, drugs.– Infections – viral, chronic bacterial, malaria.– Chronic diseases – Diabetes*, Malignancy.
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History
• 1979 – Increased Kaposi sarcoma and Pneumocystis carinii infections in homosexuals noted in Africa.
• 1981 – First case in California.
• > 30 million in world – 1999 – increasing
• 0.01% incidence in Australasia
• 67% in Sub-Saharan Africa…!
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Pathogenesis
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HIV
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Retrovirus Replication:
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Immune Response to HIV
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Genetic DisordersGenetic Disorders Congenital Disorders
• Non Genetic:– Developmental defects – Malformations
• Genetic Disorders– Chromosomal– Gene - Mendelian
• Multifactorial
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Mutations:
• Genome: whole set – Polyploidy 4n, 8n etc.
• Chromosomal: change in chromosome. – Number: Trisomy, monosomy – Structure: Deletion, Translocation etc.
• Gene: Submicroscopic.– Point mutation – single base sequence– Deletions - – Insertions
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Cell Cycle
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Mitosis
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Meiosis
• Reduction Division (4n-2n)– Prophase-1(Synapsis, g.rec) – Metaphase-1– Anaphase-1– Telophase-1
• Equatorial Division (2n-n)– Prophase-2– Metaphase-2– Anaphase-2– Telophase-2
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Cytogenetic Abnormalities:
• Abnormal number of chromosomes:– Non-disjunction - Down’s Syndrome– Anaphase lag - Turner’s xxx
• Abnormal Structure: (normal no)– Deletion of short arm 5q- Cri-du-chat
syndrome– Inversion - – Translocation - Ph Chromosome - t(9:22)
CML,
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Non-disjunction:
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Downs Sy.
Trisomy-21
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Downs Syndrome:
• Mental retardation• Neck folds• Epicanthic folds• Flat facial profile• Simian crease• Hypotonia• Umbilical hernia• Leukemia
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Anatomy of Heart
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Circulation
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Coronary Arteries
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Major Disorders of CVS
•Atherosclerosis•Hypertension•Myocardial Infarction (MI)•Stroke •IHD - Ischemic Heart Disease•VHD - Valvular Heart Disease •RHD – Rheumatic Heart Disease•CHD - Congenital Heart Disease
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Atherosclerosis:
“Chronic inflammatory disorder of intima of large blood vessels characterised by formation of
fibrofatty plaques called atheroma”.
Hardening of arteries - Arteriosclerosis
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Introduction:
• Large elastic arteries – Starts in Intima
• Fat deposits, Hardening and destruction.
• Major cause of IHD, MI & Stroke.
• Incidence is decreasing since 1995
• Better understanding & Change in life style.
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98Shashi Mar-03
Risk Factors:
• Non modifiable• Age – middle to late.• Sex – Males,
complications• Genetic - Hyperchol. • Family history.
• Potentially Modifiable• Hyperlipidemia –
HDL/LDL ratio.• Hypertension.• Smoking.• Diabetes• Life style, diet,
excercise
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Pathogenesis:
• Unknown etiology – Hyperlipidemia, life style, hypertension, smoking, genetic etc.
• Starts with Initial intimal injury, inflammation, necrosis, Lipid accumulation, Fibrosis - Atheroma.
• Leads to Obstruction or destruction of vessel
• Organ damage due to ischemia.• Complications - Thrombosis, embolism,
aneurism, dissection & rupture.
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Common Sites:
• Aorta, Carotid & Iliac. (large vessels)
• Major Vessels - Heart, Brain & Kidney.
• Coronary
• Renal
• Abdominal
• Limbs
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Morphology:
• Fatty Dots
• Fatty Streaks
• Atheromatous – Soft Plaque
• Fibrofatty – Hard Plaque
• Complications– Ulceration, Rupture,Hemorrhage, Thrombosis– Atheroemboli or cholesterol emboli.
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Complications:
• Heart attack – Myocardial infarction.
• Stroke – Cerebral infarction
• Gangrene – tissue infarction.
• Kidney failure – Kidney infarction.
• Aneurysms
• Rupture
• Thromboembolism.
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Hyperlipidemia:
• Hypercholesterolemia – Risk
• Hypertriglyceridemia - less significant
• LDLLDL – Increased risk
• HDLHDL – lowers the risk – Reverse transport– Mobilises the cholesterol from tissues to liver.
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Good Fats:
• Mono unsaturated fats
• Poly unsaturated fats
• Omega-3 fatty acids (Fish)
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106Shashi Mar-03
Lipoprotiens - LDL & HDL
• Good and Bad Fats?• Lower LDL, Increase HDL• Mono unsaturated fats• Poly unsaturated fats• Omega-3 fatty acids (Fish)• LDL indicate Positive lipid
balance, HDL – negative.• No Cholesterol in any
vegetable oil…?
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Shashi Mar-03
Ischaemic Heart Disease
• Common Health problem.• High Mortality & Morbidity. • Etiology – common Atherosclerosis • Two major types Angina & MI.• Risk factors –
– Hypertension– Hypercholesterolemia– Diabetes– Smoking, Life style, Diet, Genetic.
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Shashi Mar-03
Patterns of CHD:• Angina Pectoris:
• Acute Myocardial Infarction:
• Sudden cardiac death:
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Shashi Mar-03
Pathogenesis:
• Obstruction to blood flow.– Atheroma, Thrombosis Embolism
• Diminished coronary perfusion.
• Ischemia – Angina
• Infarction – Necrosis– Inflammation– Granulation tissue– Fibrous scarring.
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Shashi Mar-03
Myocardial Infarction-MI
• “Death of heart tissue due to lack of blood supply”
• Atherosclerosis is the common cause.• Coagulative necrosis – intact cell shape.• Severe chest pain, breathlessness &
sweating• Complications –cardiogenic shock, Death or
Cardiac failure.
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Shashi Mar-03
Gross - Morphology - Micro
• 1-18h – none• 24h – Pale, edema• 3-4D – Hemorrhage• 1-3W – Thin, yellow• 3-6W – Tough white
• None• Edema, inflammation• Necrosis, granulation• Granulation tissue• Dense Fibrosis
Myocardial Infarction-MI
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Complications:
Cardiogenic shock, death Arrhythmias and conduction defects, Congestive heart failure (pul edema) Mural thrombosis, - embolization Myocardial wall rupture, tamponade Ventricular aneurysm
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Laboratory Diagnosis
• LDH - 1-5 (1 - 2 flip)
• CK- Isoenzymes (Fractions)– MM - Muscles– MB - Cardiac muscle.– BB - Brain
• Troponins
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Management:• Aimed to prevent complications.
1. Rest & sedation*
2. Supportive mesures
3. Thrombolytic agents - Streptokinase
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HEMATOLOGY:RBC Disorders
C.B.C• Haemoglobin - 15±2.5, 14 ±2.5 - g/dl • PCV - 0.47 ±0.07, 0.42 ±0.05 - l/l (%)
– Haematocrit, effective RBC volume - better• RBC count - 5.5 ±1, 4.8 ± 1 x1012/l• MCHC - Hb/PCV - 30-36 - g/dl
– Hb synthesis within RBC• MCH - Hb/RBC - 29.5 ± 2.5 pg/l
– Average Hb in RBC • MCV - PCV/RBC 85 ± 8 - fl
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RBC disorders (Anemias) :
““Anemia is decreased red cell mass Anemia is decreased red cell mass affecting tissue oxygenation”affecting tissue oxygenation”
* Low Hb <13.5 (males), <11.5 (females)* Low Hb <13.5 (males), <11.5 (females)
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RBC disorders :
• Decreased Production:– Aplastic, Hypoplastic anemias - drugs– Deficiency anemias Iron, B12, Folate etc.
• Increased loss/destruction:– Blood loss anemias - parasites, bleeding– Hemolytic anemias – Immune,
mechanical, drugs & toxins.– Congenital disorders – Sickle cell,
thalassemia
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Iron Deficiency Anemia:
• Most abundant metal, common deficiency..!
• Limited absorption and no excretory mech.
• Recycling of iron – dead cells to new cells
• 1mg/day 3-6G body 1mg/day
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Microcytic Anemia (IDA)
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Iron Metabolism
• 10% of the 10 to 20 mg of dietary iron is absorbed each day to balance the 1 to 2 mg daily loss.
• Iron is absorbed in Jejunum. • Stored as Ferritin & Hemosiderin.
• Laboratory tests: • Serum iron(1mg/l)• Serum iron binding capacity (3mg) • Serum ferritin (>20ug)
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Causes of Iron deficiency Anemia
1. Chronic Blood loss – parasites, ulcers, hernia, drugs (NSAID), Carcinoma, colitis, diverticulosis etc. Rarely hematuria.
2. Increased need – Pregnancy, children
3. Malabsorption – gastrectomy, coeliac disease.
4. Poor diet – Contributory but rarely the sole cause.
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Clinical Features:• Anemia
• Pallor, Weakness, Lethargy
• Breathlessness on exertion
• Palpitations may lead to heart failure - edema
• IDA:
• Angular cheilosis, atrophic glossitis,
• dysphagia, koilonychia, gastric atrophy.
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123Shashi Mar-03
Megaloblastic anemia:• Vitamin B12/Folic acid deficiency• Low DNA – less division – more cell
size• Megaloblasts, Abnormal – destruction
– pan-cytopenia• Multi System disease – All organs with
increased cell division.• Macrocytic anemia, pancytopenia.• Pernicious anaemia –
– autoimmune, Gastric atrophy, VitB12 def.
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Macrocytic Anemia (Meg.):
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Blood Loss anemias
• All have Polychromasia (Marrow response)
• Acute blood loss
• Hemolytic anemias (+ Jaundice)
–Immune – Auto immune & Allo immune
–Mechanical - Valve, DIC
–Hereditary – Sickle, Thalassemia
–Infection Clostridia, malaria.
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Hemolytic anemias
• Laboratory evaluation
• Blood smear – Morphology very important
• CBC, Bilirubin levels
• Direct and indirect Coombs test (antibody)
• Hemoglobin electrophoresis – abnormal Hb.
• Tests for parasites.
• Kidney & Liver function tests important*
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127Shashi Mar-03
SHOCK
Introduction
Definition:
SHOCK is an acute circulatory failure, characterized by dysfunction of the microcirculation , inadequate blood flow to vital organs and inability of the body cell mass to metabolize the nutrients normally.
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Metabolic Disturbances
Inadequate Blood Flow
Circulatory Failure
Different kind of Reason
Special Clinical Syndrome
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SHOCK Etiology and Classification of Shock
1. Classification of Shock by Causes
(1) Hypovolemic shock Hemorrhagic shock Traumatic shock(2) Cardiogenic shock(3) Neurogenic shock(4) Anaphylactic shock(5) Infectious shock
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2. Classification of Shock according to hemodynamic changes:
⑴Hypodynamic Shock: Cardiac Output ,
Vascular Resistace,
Cold Skin;
⑵ Hyperdynamic Shock: Cardiac Output ,
Vascular Resistace ,
Worm Skin;
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SHOCK
Pathophysiologic process of Shock by severity
⑴ Stage — Early reversible shock (compensated shock);Ⅰ ⑵ Stage — Late reversible shock (decompensated shock);Ⅱ ⑶ Stage — Refractory shock; Ⅲ
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SHOCK
Systemic pathophysiologic responces of Shock
1. Initial changes of shock
⑴ Reduction of blood volume: volume and rate;
⑵ Decrease in myocardial contractility: infarction;
⑶ Increased vascular-bed volume;
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Low blood flow
Skin,fat,skeletal
muscls,kidney,intestines
Heart,brain normal or
Systemic pathophysiologic responces of Shock
Redistribution of blood flow
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2. Changes of Microcirculation
⑴ Neurogenic mechanisms : carotid, aortic sympathetic NS, BP (50mmHg) CNS;
⑵ Cellular mechanisms: Polymorphonuclear leukocytes, ⑶ Humoral mechanisms: Noradrenaline and adrenaline;①
② Renin and angiotensin; ③ Vasopressin (posterior pituitary); ④ Histamine and serotonin; ⑤ Kinin; ⑥ Neuropeptides;
Systemic pathophysiologic responces of Shock
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SHOCK
1. Stage of Vasoconstriction (Ischemic Anoxia)
Changing in the microcirculation : catecholamine ;
Maintenance of blood pressure, shift of fluid, redistribution of of blood supply, conservation of sodium and water;
Clinical aspects: pale, cool limbs, clammy skin, fast and weak impulse, decreased urine output, BP n;
Systemic pathophysiologic responces of Shock
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2. Stage of Vasodilation (Stagnant Anoxia)
Changing in the microcirculation : acidosis, histamine , endotoxin;
Clinical aspects: BP ↓, poor heart beat, unconscious, less to no urine, cynosis;
Blood in the liver, intestine, lung ↑; venous return ↓; shift of fluid, blood concentrated; BP↓; no urine;
SHOCK
Systemic pathophysiologic responces of Shock
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3. Stage of Vasofailure :
DIC
MOF septa
SHOCK
Systemic pathophysiologic responces of Shock
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SHOCK
Responses of specific organ systems of shock
1. Disturbance of cell metabolism : a. Hypoxia, anaerobic metabolism ↑; b. Disturbance of Na+-Ka+ pump, cell swelling ; c. Local acidosis; ↓
2. Effects on kidneys : (shock kidney), oliguria , hyperkalemia, acidosis; a. Functional renal failure; b. Parenchymal renal failure;
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SHOCK
5. Effects on Gastrointestinal tract and Liver: peptic ulcer, acidosis and sepsis; 6. Effects on brain: restless, lassitude and coma;
Responses of specific organ systems of shock
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Skin system Pale of the skin, Cool and wet limbs
Kidney Oliguria;
Heart Weak and Fast Impulse; BP
Lung Rapid and Deep rest
Clinical manifestation of shock
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Monitoring of shock
1.Phsychologic 1.Phsychologic StatesStates
General monitoring
Heart rateBreathing
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Monitoring of shock
22 .. Colour and Colour and temprature of skin temprature of skin
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Monitoring of shock
3 . BP Systolic Pressure was
lower than 12kPa(90mmHg)
4. Urina
Oliguria
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Special monitoring
1.CVP 5-10cmH2O CVP<5cmH2O Inadequecy of blood volume CVP>12cmH2O Cardiac dysfunction 2.Lung arterial pressure 3.Cardiac output 4.Blood gas PO2 75-100mmHg Pco2 40mmHg PH 7.35—7.45 5.Coagulation test
Monitoring of shock
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SHOCK
Treatment of the shock
1.Emergency care;
2.Restore of the blood volume;
3.Correction of the acidosis;
4.Application of vasoactive drugs;
Fundamental principleFundamental principle
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1.Recognition of ventilatory insufficiency
2.Establishment of airway
3.Oxygenation and ventilation
Treatment of the shock
Pulmonary dysfunction
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Treatment of the shock
Establishment of Airway
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Treatment of the shock
Other Emergency Care
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Treatment of the shockPosition of Body 30 。
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Treatment of the shock
Keep the body worm
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Treatment of the shock
Control the bleeding
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Treatment of the shock
Common Reason
1. Big vascular rupture
2. Organ rupture
3. Intestinal bleeding
4. Bone fracture