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By: Rasheed Adebayo Gbadegesin, MBBS

• Professor of Pediatrics
• Professor in Medicine
• Affiliate of Duke Molecular Physiology Institute

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In the inflammatory stage thyroid gland la gi discount 200mcg levothroid with amex, bacterial the evacuation of hematomas can be performed using a overgrowth ensues thyroid gland levels normal discount 50 mcg levothroid free shipping, with progressive edema and intensi skin incision parallel with the natural auricular skin folds thyroid gland boost buy levothroid 200 mcg fast delivery. Incomplete resolution or persistent inflamma the irrigation of evacuated hematomas with topical anti tion for more than 3 months refers to thyroid cancer tnm staging discount levothroid online visa the chronic inflam biotics reduces the likelihood of infection thyroid symptoms upset stomach buy 50mcg levothroid. Symptoms of otitis externa may vary thyroid cancer scar buy levothroid 100mcg amex, depending on the stage and extent of disease. In certain circumstances, even completely of the periauricular and anterior cervical lymph nodes. A culture may hematoma formation, and cartilage-penetrating antibiotics be helpful for infections that are refractory to treatment. Analgesia can be achieved with nonsteroidal of external ear anatomy and embryology, as well as the surgi cal management of auricular deformities and trauma. Available antiseptic preparations include acetic and • Otalgia, otorrhea, pruritus, hearing loss, history of boric acids, ichthammol, phenol, aluminum acetate, gen water exposure. Patients with diabetes mellitus or an immunocompromised state are particularly susceptible to otomycosis. Clinical Findings Patients with otomycosis most frequently present with pruritus, aural fullness, and otorrhea, and may also complain of otalgia and hearing loss. The hearing loss associated with otomycosis usually results from the accumulation of mycotic debris. Patients have typically been tried on topical antibacterial agents with no significant response. For Commonly used specific antifungals include clotrim chronic otitis externa, a canalplasty may be indicated for azole, Nystatin (otic drops or powder), and ketocona thickened skin that has caused canal obstruction. General Considerations Otomycosis is an inflammatory process of the external ear General Considerations canal due to infection with fungi and is responsible for more than 9% of the diagnoses of otitis externa. In 80% of Skull base osteomyelitis, also known as malignant exter cases, the etiologic agent is Aspergillus, whereas Candida is nal otitis or necrotizing external otitis, is a bacterial infec the next most frequently isolated fungus. This disease process is fungal pathogens include Phycomycetes, Rhizopus, Actino most frequently seen in elderly diabetics and immuno myces, and Penicillium. Pathogenesis Skull base osteomyelitis commonly begins as an external otitis that progresses to cellulitis, chondritis, osteitis, and, ultimately, osteomyelitis. Unlike otitis media, which spreads through the pneumatized portion of the tempo ral bone, skull base osteomyelitis disseminates through the haversian canals and vascularized spaces of the skull base. As this progresses along the base of the skull, the facial nerve (stylomastoid foramen); hypoglossal nerve (hypoglossal canal); the abducens and trigeminal nerves (petrous apex); and the glossopharyngeal, vagus, and spi nal accessory nerves (jugular foramen) may be involved. The most frequently isolated causative organism is P aeruginosa, which may exhibit high levels of antibiotic resistance. In contrast to that seen in adults, the tympanic ease, Paget disease, fibrous dysplasia, and nasopharyn membrane and middle ear are often involved. Cranial neuropathies occur in more advanced presenta tions of disease, and the facial nerve is the most frequently affected cranial nerve. Further progression may lead to sig moid sinus thrombosis, meningitis, sepsis, and death. Cultures and sensitivity should be obtained to aid in selecting appropriate antibiotics. Bone scans are sensitive for assessing bony involvement but are not specific (Figures 47–7, 47–8, and 47–9). Gallium scans are used to track the resolution of the infection, since bone Figure 47–8. Control of hyperglycemia and immuno suppression is necessary to maximize treatment. The use of hyperbaric oxygen has been described in cases refractory to antibiotics, with variable results. In an effort to prevent skull base osteomyelitis, all diabetic and immu nocompromised patients must be followed up closely and treated aggressively if they present with symptoms sugges tive of external otitis. The changing face of malignant (necrotizing) external otitis: clinical, radiological, and anatomic correlations. Aminoglycosides (eg, tobramycin) and antipseudo • Psoriasis— oval salmon-pink plaques with silvery monal lactam antibiotics, including piperacillin, ticarcil scales on elbows, knees, scalp, and buttocks. Some physicians recom mend the use of outpatient fluoroquinolones such as • Seborrheic dermatitis— pruritic greasy scales with ciprofloxacin or ofloxacin; however, this is appropriate erythematous bases on ears, scalp, forehead, eye brows, glabella, or nasolabial folds. Sagittal image of a bone scan in a pa tient with skull base osteomyelitis revealing focal en Though not completely understood, the clinical presenta hancement of the skull base. Atopic skin lesions have been shown Clinical Findings to have higher levels of Th2 T-lymphocytes, which produce Psoriasis is characterized by erythematous papules that coa inflammatory mediators such as interleukin 4, 5, and 10. These lesions bleed in pinpoint areas when the diagnosis of atopic dermatitis is a clinical one. Opacification or “oil spots” of the is variability in skin lesions ranging from erythematous nails, as well as pitting and subungual hyperkeratosis, are patches to weeping plaques. Lesions typically over areas of trauma, an entity known as Koebner phe persist for more than 1 month. Psoriatic arthritis occurs in 5–10% of all psori S aureus, herpes simplex virus, vaccinia, and molluscum atic patients. Atopic dermatitis is characterized by the absence of Treatment specific laboratory and histologic markers. For the and eosinophilia may be present yet are not specific for ears and face, treatment includes low-dose topical nonflu the diagnosis. Warm-water soaks, 1–5% coal tar treatment, and topical anthralin C the differential diagnosis includes seborrheic dermatitis may also be helpful. Treatment Methotrexate may be required for severe cases and for Topical corticosteroids are the mainstay of treatment. The response to treatment is variable, Antihistamines and lubricants may be used for the and the condition may become chronic. Though often self-limited, the disease may recur spon Seborrheic dermatitis is a chronic inflammatory skin dis taneously and can become chronic. Bacterial superin ease of unknown etiology with a predilection for areas of fection may require topical and systemic antibiotics. General Considerations Pathogenesis Psoriasis is a chronic inflammatory disorder of the skin. The cause of seborrheic dermatitis remains unknown, Eighteen percent of patients with psoriasis have some but an association with Pityrosporum ovale and Malasse involvement of the external ear, which may be secon zia furfur has led to the approval of ketoconazole sham dary to extension from the scalp. Clinical Findings the incidence of psoriasis in the United States Seborrheic dermatitis is characterized by greasy scales ranges from 2% to 5%. The affected, with the onset of disease typically occurring in distribution is frequently not limited to the ears and adolescence. The cause of psoriasis is unknown, yet there is a strong Differential Diagnosis genetic component. Medicated shampoos with sulfur, tar, selenium sulfide, or zinc are helpful in the treatment of the associated dan • May be intertwined with the facial nerve. Intermediate or high-dose glucocorticosteroids (eg, betamethasone or fluocinonide) are needed for more severe presentations and to alleviate pruritus. Fluorinated topical glucocorticoids may worsen lesions when used on the face Pathogenesis or ear. Ketoconazole cream and shampoo are helpful in First branchial cleft anomalies occur as a result of anoma refractory cases. Seborrheic dermatitis can often become lous fusion of the first and second branchial arches, with chronic with periods of exacerbation and remission. One may General Considerations also see a corresponding tract at the junction of the bony and cartilaginous ear canal. The patient may have a his Contact dermatitis can be an acute or chronic inflamma tory of recurrent infection and drainage from the ear or tory disorder of the skin caused by contact with an aller neck. Incomplete excision predisposes the Pathogenesis patient to recurrence and re-infection. This is in contrast to irritant dermatitis, which • Auricle initially numb, then subsequently painful. Treatment the avoidance of exposure to irritants and allergens and Pathogenesis high-dose topical glucocorticoids are the mainstays of therapy. Freezing temperatures lead to both direct cellular injury as well as vascular compromise. Treatment Ultimately, as the ear thaws, pain, erythema, and sub Superficial burns do not scar and may be treated with cutaneous bullae secondary to extravasated extracellular moisturizing creams. Full-thickness, subdermal, and deep par the initial treatment for auricular frostbite consists of tial-thickness burns of the auricle heal with scarring and rapid rewarming of the ear to 40–42 °C. Nonhemor contracture and may be complicated by suppurative rhagic blisters may be debrided, and patients should be chondritis. Aloe vera has anti topical (usually silver based) and systemic cartilage pen thromboxane properties and, together with ibuprofen, etrating antibiotics. Secondary reconstruc debridement should be delayed for several weeks until tion is usually performed at approximately 1 year after demarcation is complete. Clinical Findings Patients may present with pain, pruritus, conductive hearing loss, and bleeding. A persistent foreign body may lead to infection and the formation of granulation General Considerations tissue. Subdermal Treatment burns extend into the subcutaneous tissue, including fat, muscle, tendon, cartilage, and bone. In children, general anesthesia is often these burns are red and moderately painful. Irrigation may help dislodge cerumen or with partial-thickness burns usually present with blisters smaller objects. Cerumen impaction may require prior that blanch on direct pressure and are very painful. Two percent lido partial-thickness burns are associated with less pain, and caine may be used for the removal of insects both to there may be an eschar. Full-thickness and subdermal achieve topical anesthesia and also to kill the insect. The wound surface is of varying color, adhesives (ie, “superglue”) may require surgical removal but may be gray or black and charred. This subtype is characterized by slow-growing lesions •S quam uscellcarcino a— laque,no dule, r with histologically differentiated glandular or ductal ulceration. Composed of highly invasive keratinized lesions, this • Any suspicious skin lesion should be biopsied. Clinical Findings Patients may initially present with a skin lesion that is nodular, ulcerated, and/or bleeding. The diag nosis of any suspicious lesion should be confirmed with General Considerations biopsy. The system for nonmelanoma cancer of the skin, which is a incidence of cancer increases with age. This tors include fair skin, outdoor occupations, and a his staging system is limited by the fact that it does not tory of skin carcinoma. Radiation therapy—Indicated for poor surgical nodular form, but with brown pigmentation. Curettage with electrodissection—Operator depen the carcinoma is composed of wartlike lesions that are dent and typically used to excise nodular lesions and locally invasive. Cryosurgery—Indicated for small basal cell carci nomas (< 1 cm) with well-defined borders. This type of squamous cell carcinoma consists of aggressive and deeply penetrating tumors named for 3. Local excision—Ninety-five percent of basal cell car their elongated fusiform cells. Mohs surgical technique—Refers to complete micro the appearance of these tumors is variable and includes graphic excision of the tumor using intraoperative histopa plaques, nodules, and ulcerations. Auricular lesions frequently particularly useful for recurrent basal cell carcinomas, occur on the helix or pre-auricular region, but may those larger than 2 cm, or those with an aggressive his occur on any sun-exposed areas. This staging system is limited by the fact that it does not account for histo General Considerations logic subtypes or the anatomic variability of the external Squamous cell carcinomas account for 20% of all cuta ear skin compared with other skin sites. Differential Diagnosis the differential diagnosis includes basal cell carcinoma, Pathogenesis actinic keratosis, seborrheic keratosis, keratoacantho Risk factors for squamous cell carcinoma include immu mas, scars, psoriatic lesions, melanomas, and sarcomas. Mohs surgical technique—This technique is par Generic squamous cell carcinoma is the most common ticularly useful for recurrent lesions, those > 2 cm, or histologic group. Radio nuclide bone scans can be used to diagnose bony In addition to the patient’s age and overall immune metastases. Auricular melanoma the differential diagnosis is diverse and includes benign accounts for 1% of all melanomas. Management of the regional lymphatics is controversial this subtype accounts for approximately 75% of mela and may include elective regional lymph node dissec nomas and often occurs on the lower extremities or the tion and parotidectomy. The lesions are irregular and hyperpigmented and biopsy has become a well-accepted approach in the may develop central nodularity. The natural history of management of the N0 neck for lesions more than 1 these lesions begins with a superficial spreading lesion mm deep. Lesions Prevention that have already begun the vertical growth phase por tend a worse prognosis. The avoidance of and protection from sun exposure are important in preventing disease, as is early detection. A thorough head • Otorrhea, fullness, otalgia, and conductive hear and neck examination requires attention to enlarged ing loss. Histologically, • Usually asymptomatic; may present with ceru these tumors may show cribriform, tubular, or solid men impaction, otitis externa, or conductive hear patterns of cellular arrangement.

Syndromes

• You try over-the-counter lice treatments and they are not effective
• Women are more likely to be affected than men.
• Wine
• Increased need to urinate
• Smaller-than-normal eyes (microphthalmia)
• Medicines called chelators to remove mercury from the bloodstream
• Abnormal placement of the heart toward the right side of the chest instead of the left

This is another related stress protein which has as under: ubiquitous presence in human body cells thyroid gland body temperature buy discount levothroid 100mcg on line. Ubiquitin has been found to thyroid questions quizlet purchase cheap levothroid line be Reparative stimulation of mitosis occurs when a tissue is involved in a variety of human degenerative diseases thyroid symptoms elderly discount 200mcg levothroid free shipping, injured thyroid nodules bad taste in mouth purchase levothroid us. Premitotic phases are the G1 thyroid gland yoga purchase levothroid 100mcg on-line, S and G2 phase while M (mitotic) phase is accomplished in 4 sequential stages: prophase thyroid nodules during pregnancy purchase genuine levothroid on line, metaphase, anaphase, and telophase. On completion of cell division, two daughter cells are formed which may continue to remain in the cell cycle or go out of it in resting phase (interphase), the G0 phase. The cells may be broadly injured by two major ways: In a given situation, more than one of the above etiologic A. The acquired causes of disease comprise vast essentially require oxygen to generate energy and perform majority of common diseases afflicting mankind. Deficiency of oxygen or hypoxia results underlying agent, the acquired causes of cell injury can be in failure to carry out these activities by the cells. Chemical agents and drugs by reduced supply of blood to cells due to interruption i. Physical agents in causation of anything that causes harm to the patient, there are some disease are as under: diseases as well as deaths attributed to iatrogenic causes mechanical trauma. An ever increasing list of the etiology of diseases, there still remain many diseases for chemical agents and drugs may cause cell injury. For example, most examples include the following: common form of hypertension (90%) is idiopathic (or chemical poisons such as cyanide, arsenic, mercury; essential) hypertension. Similarly, exact etiology of many strong acids and alkalis; cancers is still incompletely known. However, infections caused by bacteria, rickettsiae, viruses, fungi, in general, the following principles apply in pathogenesis of protozoa, metazoa, and other parasites. A deficiency or an muscle can withstand hypoxic injury for long-time while excess of nutrients may result in nutritional imbalances. Morphologic consequences: All forms of biochemical ability of the cells to undergo replication and repair, and changes underlying cell injury are expressed in terms of ultimately lead to cell death culminating in death of the morphologic changes. Patho genesis of hypoxic and ischaemic cell injury is, therefore, membrane transport, protein synthesis, lipid synthesis and 29 described in detail below followed by brief discussion on phospholipid metabolism). Although underlying intracellular mechanisms and is generated from glucose/glycogen in the absence of ultrastructural changes involved in reversible and oxygen). If the ischaemia or hypoxia is accumulation of metabolic waste products in the cells. These biochemical anaerobic glycolytic pathway for the requirement of energy changes have effects on the ultrastructural components of. Damage to plasma membrane pumps: Hydropic Excess intracellular calcium collects in the mitochondria swelling and other membrane changes. Morphologically, mitochondrial interferes in generation of phospholipids from the cellular changes are vacuoles in the mitochondria and deposits of fatty acids which are required for continuous repair of amorphous calcium salts in the mitochondrial matrix. Damage operating for regulation of sodium and calcium as under: to membrane function in general, and plasma membrane in i) Failure of sodium-potassium pump. As a result of sustained ischaemia, there at the plasma membrane allows active transport of sodium is increased cytosolic influx of calcium in the cell. Besides, results in intracellular accumulation of sodium and diffusion there is also decreased replacement-synthesis of membrane of potassium out of cell. The normal cytoskeleton of the cell (microfilaments, microtubules ii) Failure of calcium pump. Membrane damage causes and intermediate filaments) which anchors the cell disturbance in the calcium ion exchange across the cell membrane is damaged due to degradation by activated membrane. The damage is seen in the form of loss of microvilli, nucleoproteins are damaged by the activated lysosomal intramembranous particles and focal projections of the enzymes such as proteases and endonucleases. Myelin figures may be seen lying in the damage to the nucleus can be in three forms: cytoplasm or present outside the cell, these are derived from i) Pyknosis: Condensation and clumping of nucleus which membranes (plasma or organellar) enclosing water and becomes dark basophilic. Lysosomal hydrolytic enzymes: Lysosomal damage, cell reticulum and Golgi apparatus swell up. The lysosomal membranes are detached from granular endoplasmic reticulum and damaged and result in escape of lysosomal hydrolytic polysomes are degraded to monosomes, thus dispersing enzymes. These enzymes are activated due to lack of oxygen ribosomes in the cytoplasm and inactivating their function. These hydrolytic enzymes include: Similar reduced protein synthesis occurs in Golgi apparatus. Persistence of ischaemia or masses of phospholipids called myelin figures which are either hypoxia results in irreversible damage to the structure and phagocytosed by macrophages or there may be formation of function of the cell (cell death). Two essential phenomena always estimation of which may be used as clinical parameters of distinguish irreversible from reversible cell injury (Fig. While cell damage from oxygen deprivation by above Ischaemia-Reperfusion Injury and mechanisms develops slowly, taking several minutes to Free Radical-Mediated Cell Injury hours, the cell injury is accentuated after restoration of blood Depending upon the duration of ischaemia/hypoxia, supply and subsequent events termed ischaemic-reperfusion restoration of blood flow may result in the following injury and liberation of toxic free radicals, discussed below. Generation of reactive oxygen radicals (superoxide, H2O2, Enzyme Disease hydroxyl radicals). Amylase Acute pancreatitis molecular forms as reactive oxygen radicals or reactive Sialadenitis oxygen species can be most devastating for the cells. When the period of with hydrogen atom (H) and in the process forms water ischaemia is of short duration, reperfusion with resupply of (H2O). This reaction of O2 to H2O involves ‘four electron oxygen restores the structural and functional state of the donation’ in four steps involving transfer of one electron at injured cell i. These for longer duration, then rather than restoration of structure are generated within mitochondrial inner membrane where and function of the cell, reperfusion paradoxically cytochrome oxidase catalyses the O2 to H2O reaction. This is termed intermediate molecules of partially reduced species of oxygen ischaemia-reperfusion injury. Cell death in such cases is not attributed to these are generated from enzymatic and non-enzymatic formation of activated oxygen species. But instead, on reaction as under: reperfusion there is further marked intracellular excess of 1. Superoxide (O’2): Superoxide anion O’2 may be generated sodium and calcium ions due to persistent cell membrane by direct auto-oxidation of O2 during mitochondrial electron damage. Alternatively, O’2 is produced the underlying mechanism of reperfusion injury and free enzymatically by xanthine oxidase and cytochrome P450 in radical mediated injury is complex but following three main the mitochondria or cytosol. Oxygen-derived free radicals cause of H O with ferrous (Fe++) ions; the latter process is termed 2 2 cell injury by oxidation of protein macromolecules of the cells, as Fenton reaction. In addition to superoxide, H2O2 of cytosolic neutral proteases and cell destruction. This results in cell injury; it may also cause malignant transformation of i) Release of superoxide free radical in Fenton reaction (see below). Free radicals are formed iv) Chemical carcinogenesis in physiologic as well as pathologic processes. Basically, v) Hyperoxia (toxicity due to oxygen therapy) oxygen radicals are unstable and are destroyed spon vi) Cellular aging taneously. The ix) Destruction of tumour cells net effect of free radical injury in physiologic and disease x) Atherosclerosis. These However, if not degraded, then free radicals are highly substances include the following: destructive to the cell since they have electron-free residue Vitamins E, A and C (ascorbic acid) and thus bind to all molecules of the cell; this is termed Sulfhydryl-containing compounds. Incoming activated neutrophils utilise oxygen radicals—lipid hydroperoxy radicals and lipid hypo quickly (oxygen burst) and release a lot of oxygen free radicals. Pathogenesis of Chemical Injury Chemicals induce cell injury by one of the two mechanisms: by direct cytotoxicity, or by conversion of chemical into reactive metabolites. Some chemicals combine with components of the cell and produce direct cytotoxicity without requiring metabolic activation. Depending upon the severity of cell injury, degree of damage and residual effects on cells and tissues are variable. In general, morphologic changes in various forms of cell injury can be classified as shown in Table 3. However, now it is realised that this poisoning, the greatest damage occurs to cells of the alimen term does not provide any information on the nature of tary tract where it is absorbed and kidney where it is excreted. Other examples of directly cytotoxic chemicals include Following morphologic forms of reversible cell injury are chemotherapeutic agents used in treatment of cancer, toxic included under this heading: heavy metals such as mercury, lead and iron. Mucoid change cells in this group of chemicals may not be the same cell that metabolised the toxin. This is the commonest and earliest form of cell 3 bolising P enzyme system in the liver cells. The common causes include 450 produces profound liver cell injury by free radical generation. Reversible cell injury Retrogressive changes Injuries caused by mechanical force are of medicolegal (older term: degenerations) significance. Irreversible cell injury Cell death—necrosis by changes in atmospheric pressure. Programmed cell death Apoptosis by accidental or therapeutic exposure is of importance in 4. Residual effects of Subcellular alterations treatment of persons with malignant tumours as well as may cell injury have carcinogenic influences (Chapter 8). Deranged cell metabolism Intracellular accumulation Killing of cells by ionising radiation is the result of direct of lipid, protein, carbohydrate formation of hydroxyl radicals from radiolysis of water 6. Intracellular hyaline is 35 such as bacterial toxins, chemicals, poisons, burns, high fever, mainly seen in epithelial cells. A few examples are as follows: intravenous administration of hypertonic glucose or saline 1. Hyaline degeneration of rectus abdominalis muscle called regulation of sodium and potassium at the level of cell Zenker’s degeneration, occurring in typhoid fever. This results in intracellular accumulation of muscle loses its fibrillar staining and becomes glassy and sodium and escape of potassium. Mallory’s hyaline represents aggregates of intermediate and hence cellular swelling occurs. In addition, influx of filaments in the hepatocytes in alcoholic liver cell injury. Nuclear or cytoplasmic hyaline inclusions seen in some reversible change upon removal of the injurious agent. Grossly, the affected in the rough endoplasmic reticulum of the plasma cells organ such as kidney, liver, pancreas, or heart muscle is (Fig. Extracellular hyaline is seen Microscopically, it is characterised by the following in connective tissues. Hyaline arteriolosclerosis in renal vessels in hypertension distended cisternae of the endoplasmic reticulum. Corpora amylacea are rounded masses of concentric hya line laminae seen in the prostate in the elderly, in the brain Hyaline Change and in the spinal cord in old age, and in old infarcts of the lung. Hyaline is a descriptive histologic term for glassy, homogeneous, Mucoid Change eosinophilic appearance of material in haematoxylin and Mucus secreted by mucous glands is a combination of eosin-stained sections and does not refer to any specific proteins complexed with mucopolysaccharides. Though fibrin and amyloid have hyaline appear glycoprotein, is its chief constituent. Mucin is normally ance, they have distinctive features and staining reactions produced by epithelial cells of mucous membranes and and can be distinguished from non-specific hyaline material. The tubular epithelial cells are distended with cytoplasmic vacuoles while the interstitial vasculature is compressed. The cytoplasm shows pink homogeneous globular material due to accumulated immunoglobulins. The centres of whorls of smooth muscle and connective tissue show pink homogeneous hyaline material (connective tissue hyaline). These occur at the level of cytoskeleton, lysosomes, of cell injury in mitochondria may be seen in the following 37 endoplasmic reticulum and mitochondria: conditions: 1. Megamitochondria consisting of skeleton may show the following morphologic abnormalities: unusually big mitochondria are seen in alcoholic liver disease and nutritional deficiency conditions. Their In Chediak-Higashi syndrome characterised by poor number increases in hypertrophy and decreases in atrophy. This phenomenon was previously referred to as infiltration, implying thereby that something unusual iii) Accumulation of intermediate filaments: Various classes has infiltrated the cell from outside which is not always the of intermediate filaments (cytokeratin, desmin, vimentin, case. Intracellular accumulation of the substance in mild glial fibrillary acidic protein, and neurofilament) may degree causes reversible cell injury while more severe damage accumulate in the cytosol. Mallory’s body or alcoholic hyaline as intracytoplasmic Such abnormal intracellular accumulations can be divided eosinophilic inclusion seen in alcoholic liver disease which into 3 groups: is collection of cytokeratin intermediate filaments. Lysosomes contain powerful ii) Accumulation of abnormal substances produced as a result hydrolytic enzymes. Heterophagy and autophagy are the two of abnormal metabolism due to lack of some enzymes. Some indigestible exogenous degeneration and fatty infiltration because fatty change neither particles such as carbon or endogenous substances such as necessarily involves degeneration nor infiltration. The lipofuscin may persist in the lysosomes of the cells for a long deposit is in the cytosol and represents an absolute increase time as residual bodies. As discussed in Chapter 10, a group of but may occur in other non-fatty tissues like the heart, skeletal lysosomal storage diseases due to hereditary deficiency of muscle, kidneys (lipoid nephrosis or minimum change enzymes may result in abnormal collection of metabolites in disease) and other organs. Hypertrophy of smooth endoplasmic Liver is the commonest site for accumulation of fat because reticulum of liver cells as an adaptive change may occur in it plays central role in fat metabolism. Mitochondrial injury and reversible, or severe producing irreversible cell injury plays an important role in cell injury. Fatty change in the liver may result from one From diet as chylomicrons (containing triglycerides and of the two types of causes: phospholipids) and as free fatty acids; and 1. Conditions with excess fat (hyperlipidameia), exceeding the From adipose tissue as free fatty acids. Most of free fatty acid is esterified to triglycerides by the these causes are listed below: action of glycerophosphate and only a small part is 1. Conditions with excess fat: changed into cholesterol, phospholipids and ketone bodies.

A number of clinical-radiologic factors including age thyroid and anxiety purchase 100 mcg levothroid, history of breast surgery thyroid symptoms in children discount levothroid 50 mcg with amex, indication for mammography thyroid meaning purchase levothroid with visa, volumes of fibroglandular tissue or total breast and the percentage breast density were compared between the two groups thyroid nodules feeling like something throat order levothroid 50 mcg free shipping. The aim of this study was to thyroid gland body cavity order discount levothroid online compare the degree and type of enhancement of benign lesions with pathology results thyroid cancer necklace generic levothroid 200 mcg free shipping. Type 0 and type 1 findings were considered to be probably benign,and type 1 and type 2 findings were considered to be probably malignant. Histopathologically,the 171 benign lesions with type 1 enhancement were:87 sclerosing adenosis,63 fibroadenomas,5 postoperative scar,3 ductal ectasia,1 paget disease,2 intramammary lymph node,5 inflammation,5 no specific findings. Concerning,the 146 lesions with type 2 enhancement,histological proof of benign was:64 sclerosing adenosis,63 fibroadenomas,3 intramammary lymph node,4 ductal ectasia,2 inflammation,2 abscess,8 no specific findings. Breast biopsies in lesions which had type 0 or 1 enhancement(according to our recommendation)can be avoided,because these lesions are very likely to be benign. The surgical repair of common conotruncal abnormalities is complex from both physiologic and imaging perspectives, requiring intimate knowledge of the goals of procedures. Over the years, surgical techniques have been retooled, so as to improve upon common complications with classic surgical approaches. As technique improves, so do patient outcomes, and a new population of patients who survived once-fatal congential abnormalities is emerging. The radiologist must adapt to these changes, and find novel, safe, and effective ways to screen for and monitor such patients. Review historic and current surgical techniques in the treatment of common congenital conotruncal abnormalities. Among them, 218 patients with normal coronary artery who can evaluate the coronary artery and do not recognize a small amount of plaque were followed. To review the principles of 3D printing, technical aspects, materials and printing procedures, segmentation tools and fusion algorithms for 3D segmentation in thoracic neoplasms. To detail, in a cased based approach, the steps necessary to do a pre surgical 3D printing model combining magnetic resonance and computed tomography datasets. To show our initial clinical results in the application of hybrid 3D printing prospectively for surgical planning of lung cancer and impact on the procedure. The initial results of our clinical essay about the application of hybrid 3D printing in lung cancer will also be available: 1. Especially, airway analysis is essential for patients with small airway diseases; however, it is predisposed to the effect of image quality including special resolution and noise, and intra and inter observer variability. We assessed the adequacy of the histological sample and the rate of post-procedural chest radiography and complications. Lesions without an adjacent airway were on average 13 mm from the adjacent airway (range 6 mm 23 mm). Total of 2300 radiomic features are extracted from original and filtered (Exponential, Laplacian of Gaussia, Logarithm, Gabor, Wavelet) 1. These features are divided into four classes, including histogram, volumetric, morphologic, texture features. To generalize the result, ensemble technique is used to identify the final feature set. This work aims to demonstrate the feasibility of using deep learning method to identify findings, specifically emphysema. To evaluate the effect of potential labeling error caused by per case rating system, three different approaches were taken: 1) using the entire lung region, 2) using only the top 50% of the lung since emphysema due to smoking tends to affect the upper lobes more than the lower lobes, and 3) using only the bottom 50% of the lung as a control. The predictions were first performed on a per slice basis and averaged to acquire per case prediction. Fine-tuning work is currently on-going, and given the high performance already achieved with transfer learning, fine-tuning is likely to achieve even higher performance. Having a suite of algorithms that automatically searches for multiple incidental findings has the potential to increase efficiency and prevent missing important findings. The spectrum of pelvic emergencies discussed in this exhibit will include those of infectious, inflammatory, ischemic, obstructive, traumatic, & neoplastic etiologies 2. Our secondary endpoint is length of stay in the Emergency Department and whether this time is affected by the additional testing. We compared the duration of time spent in the Emergency Department between the two sets of patients. Four of these were seen on abdominal ultrasound and 4 were seen on pelvic ultrasound (none of which were ovarian torsion). All cases had sagittal T2-weighted imaging of the entire spine with additional T1 and T2-weighted axial imaging covering the known injury. Insurance, race/ethnicity, primary language, and education level were obtained from the electronic medical record. Multivariate linear regression was performed to determine crude and adjusted parameter estimates for length of stay. For each metric, the estimates generated from linear regression are interpreted as difference in length of stay associated with one unit change in each covariate. Free care, Medicaid and Medicare patients have increased length of stay and increased odds of post-operative complication. Hispanics and Blacks have lower odds of having complicated intraoperative findings. The pathologic features of xanthogranulomatous inflammation are abundant lipid-laden macrophages or histiocytes. Xanthogranulomatous inflammations are usually seen in cholecystitis and pyelonephritis. But they have been reported involving the various organs in the abdomen and pelvis. A variety of imaging features were identified in xanthogranulomatous inflammation of various organs in the abdomen and pelvis. The xanthogranulomatous inflammation of various organs in the abdomen and pelvis include xanthogranulomatous cholecystitis, xanthogranulomatous pyelonephritis, xanthogranulomatous peritonitis, xanthogranulomatous appendicitis, xanthogranulomatous inflammation of urachal cyst, xanthogranulomatous prostatitis and xanthogranulomatous salpingitis. Review appearance on different imaging modalities and provide tips and case examples for modality selection 3. Using advanced dual-energy imaging a more precise diagnosis can be obtained, and might hold promising potential as an imaging biomarker, risk-stratification, monitoring of disease progression and therapy, and outcome prediction. Application for gastrointestinal tumors Tumor detection Assessment of the malignant potential, tumor differentiation grades, and genetic status Assessment of lymph node metastases Evaluating response to treatment 3. Application for gastrointestinal emergencies Small bowel ischemia Gastrointestinal bleeding 6. Albuquerque, Sao Paulo, Brazil (Abstract Co-Author) Nothing to Disclose For information about this presentation, contact: nataliaborgesnunes@gmail. It allows radiologists to more effectively recognize adverse effects and differentiate them from tumor progression, and can therefore more effectively guide oncologists in the management of adverse effects and treatment decisions. Adverse effects were classified into four categories: (a) Category 1, On-target adverse effects associated with treatment response (Ipilimumab and Pembrolizumab Colitis; Nivolumab Sarcoidlike lymphadenopathy); (b) Category 2, On-target adverse effects without associated treatment response (Bevacizumab Enteritis, Proctitis, Pneumatosis intestinalis, Mesenteric emphysema, Anastomotic Dehiscence, Bowel perforation; Imatinib Splenic Rupture, Pancreatitis); (c) Category 3, Off-target adverse effects (Ipilimumab and Nivolumab Fluid retention; Trastuzumab Steatosis); and (d) Category 4, Tumor necrosis-related adverse effects (Imatinib Intratumoral Hemorrhage; Sunitinib Hemoperitoneum). A radiomics signature was then constructed with the least absolute shrinkage and selection operator algorithm in the training set. Nomogram performance was assessed in the training set and validated in the validation set. The sensitivity and specificity of radiomics signature in the training set were 0. Hoffmann-La Roche Ltd Advisory Board, Amgen Inc Advisory Board, sanofi-aventis Group Julian Holch, Munich, Germany (Abstract Co-Author) Advisory Board, F. Linear regression, ridge regression and logistic regression model was applied to select features and develop the predicting model for bone metastases. These results provide an illustrative example of precision medicine and may affect treatment strategies. Rovers, PhD, Nijmegen, Netherlands (Abstract Co-Author) Nothing to Disclose Jurgen J. Both non-blinded and blinded annotations were linearly correlated and demonstrated good agreement with histology. As such, extensive search of unpublished literature for imaging systematic reviews may not be indicated. Grades of recommendation are from the most reliable grade A to not recommended grade C, and grade I which means no recommendation. Regarding the survey, of 66 members, 32 members finished the survey and responded (response rate of 45%). Twenty-four (70%) of the 32 respondents were the working group and eight of the 32 respondents were the consulting group. It will be helpful to assist the physicians for an appropriate utilization of imaging modalities. Background A method for assessing radiology report quality is based on whether the report advances a patient forward along a clinical spectrum: does the report (1) describe essential findings, (2) provide a differential diagnosis, (3) derive a definitive diagnosis, and (4) follow an established diagnosis consistently until resolution We have incorporated these principles into the development of a structured reporting system that provides radiologists with visual prompts and compliance checks during image interpretation so that they may incorporate missing elements and link historical data in timelines to improve report quality. The ontology comprises hierarchies of anatomy and pathology terms that progress from generic observations to definitive diagnoses. Nondescript observations trigger the presentation of differential diagnoses and other salient features as a reminder to the radiologist to include these elements. When a definitive diagnosis is established by correlation with pathology or other information, that data can be included in the timelines to inform the radiologist during subsequent image interpretation. Timeline displays of graphed images and metrics prompt the radiologist to record consistent data during subsequent exams to achieve accurate disease assessment. Discussion Several radiology quality metrics have been proposed for use in pay-for-performance initiatives; however, the assessment of radiology report quality remains a holy grail. The determination of whether a report advances a patient forward along a clinical spectrum has been proposed as a quality measure, and we have incorporated this concept into a structured reporting system that enables radiologists to generate high quality information. Perception of radiology reporting by referring physicians, including the concept of referring physician feedback as a mechanism for quality improvement 3. Report fails to mention details critical to a planned procedure or diagnosis (Figure 2) c. Report has emergent or urgent findings that are not communicated to the referring team h. To explain why immune checkpoint inhibitors are becoming the standard of care in many cancer types. To review key elements that are expected to improve the monitoring of immunotherapeutic efficacy at the patient and clinical trial level. To discuss new patterns of response and progression, as well as immune related adverse events. To explain the utility of imaging modalities in solid tumors, brain tumors and lymphomas. Distinguishing different patterns of uveal melanoma has significant clinical implications in terms of choosing the most effective treatment. We have further shown that the addition of targeting moiety do not reduce its strong metal binding affinity to Gd3+ and 1011-fold higher selectivity towards Gd3+ over Zn2+ than Eovist. Kaul, Hamburg, Germany (Presenter) Nothing to Disclose Isabel Molwitz, Berlin, Germany (Abstract Co-Author) Nothing to Disclose Caroline Jung, Hamburg, Germany (Abstract Co-Author) Nothing to Disclose Johannes M. The main blood vessels and the ureter were connected to tubes allowing in and out flow of fluids. Quality of the data was also sufficient to produce time of arrival maps of the inflowing tracer. Its first application will be probably be vessel imaging and will feature dynamic 3D imaging without ionizing radiation. Data and image acquisition (proper patient positioning and placement of regions of interest). Images of the deltoid muscle were blindly reviewed by 3 musculoskeletal radiologists as to whether the appearance was normal, suspected diabetic or definite diabetic. Obesity alone cannot solely explain the appearance of an echogenic deltoid muscle in diabetics. It could be related to impaired insulin-stimulated intramuscular glycogen synthesis or issues with collagen synthesis. Bloem, Leiden, Netherlands (Abstract Co-Author) Nothing to Disclose For information about this presentation, contact: d. Parameters were compared with a reference standard consisting of a, non-imaging dependent, histopathological diagnosis of resected specimens using univariate, multivariate logistic regression analysis. Most useful parameters are chondroid matrix, soft tissue mass, reactive soft tissue edema, peri-tumoral intraosseous edema, dynamic enhancement, expansion of the medullary canal and cortical thickening. Recent investigations in the pyramidalis and adductor insertions have shed new light on this anatomy. The pubic ligament is made of true strong ligament fibers and no cartilage or fibrocartilage nodule is present. The posterior aponeurosis of the rectus abdominis forms a 2 cm wide and 2 mm thick band that inserts directly onto the superior aspect of the pubic ligament. Connections of the piramidalis or when absent rectus abdominus continue laterally over the adductor longus but are actually quite delicate and surprisingly less thick and strong than has been typically believed. This is related to the historical fact that this area is difiifcult to analyse in embalmed cadavers. The disease is characterized by widespread deposition of collagen and other extracellular matrix proteins. Although a rare disease, scleroderma in its more aggravated forms has been described as "one of the most terrible of all human ills. Whilst its use for tumour grading has decreased in our institution over the last 10 years, its emerging role in radionecrosis has resulted in a resurgence in its use. In 26 patients, all available histopathological samples as well as results of follow-up imaging were used for reference standard.

They are usually clearly visible as not pregnant at pregnancy diagnosis a full gynaeco strands of necrotic chorioallantois and amnion hang logical examination is carried to thyroid symptoms breathing problems 200mcg levothroid fast delivery detect any reasons ing from the vulva thyroid symptoms worse before period buy cheap levothroid on line. Vaginal exami lapse or eversion of the vagina may be seen in the peri nation – especially if a speculum is used – may thyroid gland exercise cheap levothroid 50 mcg on line, how parturient period thyroid cancer symbol cheap levothroid 200mcg overnight delivery. Uterine prolapse with exposure of ever thyroid biopsy results discount 50mcg levothroid visa, result in aspiration of air into the vagina which the endometrium and caruncles may be a complica can make subsequent rectal examination more dif tion of the postparturient period thyroid overdose purchase levothroid pills in toronto. Any air in In the normal breeding period, 40 to 82 days after the vagina can be expelled by gently pressing down calving, the clinician should look for any signs of wards and backwards on the vagina with the hand in abnormal vaginal discharge. If the rectal examination is performed white discharge, either scant or profuse, may indi rst, care must be taken to ensure that faecal material cate the presence of endometritis. This exami Observation of cow nation is chie y con ned to the vulva and caudal General condition (condition score) and signs of health vagina. Evidence of a vulval or vaginal discharge Signs of oestrus may be seen at this stage and will require further in Evidence of abnormal vaginal discharge vestigation. In the last trimester of pregnancy the Changes in body shape fetus may be ballotted through the lower part of the right abdominal wall. Examination of the female genital system Vulva the vulval lips should form a seal which, with the this has the following components: cervix, prevents the entry of potentially dangerous organisms into the uterus. The vulva should be posi (1) external examination of the female genital tioned vertically below the anus. The lips of the vulva system, should normally be of approximately similar size (2) rectal examination of the genital system includ and should have no visible space between them. Sinking of the anus in an anterior direction is seen in When possible and appropriate all components of many older cows. As a result natal check 21 days after calving, speci c checks are of anal displacement the upper commisure of the made for uterine involution, evidence of uterine in vulva is dragged forwards, causing a variable degree fection and ovarian activity. When the cow is pre of distortion of the vulva; thus the vulval seal may be 128 Clinical Examination of the Female Genital System Sunken anus displacing the vulva Figure 10. This type of discharge can also be seen in cases or just within the vulva, areas ofnecrotic vaginitismay of necrotic vaginitis and in association with infected be present caused by fetal or human pressure at calv wounds in the vaginal wall. Early lesions appear dark and congested; later smelling discharge in a very sick animal may be an lesions are green and necrotic. The In the immediate postparturient period, the vulval clinician must always check, through a full clinical lips may be oedematous and bruising may be pre examination, that any unpleasant odour at the hind sent. Scar formation in the tissues of the vulval lips end of the patient is actually emanating from the may follow injuries sustained during calving. Granular vulvovaginitis may be caused by can also reduce the ef ciency of the vulval seal and mycoplasma infection. The clear bulling string, the red Ballottement of the right side of the abdomen in the last metoestrus bloodstained discharge and the appear trimester of pregnancy will often make contact with ance of retained fetal membranes have been men the fetus and sometimes cause it to move. Absence purulent material may originate from the bladder or of movement, either spontaneous or by ballottement, renal pelvis, most bovine vulval and/or vaginal dis does not necessarily mean that the fetus is dead. A ther evaluation of fetal well-being can be made by white or yellowish discharge may indicate the pres rectal examination and by ultrasonography. A foul-smelling part of the fetus can be scanned per rectum in the rst bloody and purulent discharge may be associated trimester of pregnancy. After this time the fetus slips with acute septic metritis or with a macerated fetus. The accuracy of such ndings the clipped ank in late pregnancy usually con rms can be enhanced in many cases by the use of ultra the presence of fetal uids and placentomes. Parts of sonographyper rectumand also by an appraisal of the the fetus can sometimes be seen, depending on its progesterone pro le of the cow. It may be possible to detect fetal heart ductive history of a cow may be inaccurate. The movements, check fetal pulse rate and the expected ndings reported must always be those actually absence of echogenicity in the normal clear fetal identi ed and where possible con rmed. The use of ultrasonography in examination cases a further rectal examination after a nite period of the female genital system is discussed in greater of time may be necessary to con rm a tentative clini detail below. Findings should be accurately recordedand preserved at the time of each rectal examination. Fingernails should Vulval and/or vaginal discharge – colour,quantity and be short and all hand jewellery removed before com consistency mencing rectal examination. Both arms should be covered with long plastic sleeves, and ideally these should be changed between cows. Some clinicians prefer to use both genital system hands sequentially during a rectal examination. This must be carried out methodically and with great the ngers and thumb are formed into a cone care and sensitivity. The examination should provide and the gloved hand is covered with obstetrical useful information about all palpable parts of the fe lubricant. The size and condition of the cervix, the uterine body and hand is gently but rmly advanced through the anus horns, and the right and left ovaries. The anus normally relaxes after a possible to identify and assess the ovarian bursae few moments allowing the hand and wrist to enter and the oviducts. Any faeces are gently removed by enclos ily detected when they are diseased than when they ing them in the hand and carrying them out through are normal. As a result of rectal examination it should be possi Care must be taken to avoid large quantities of air ble to determine whether the animal is more than 6 entering the caudal rectum. The risk of this occurring weeks pregnant, whether she is cycling and the stage can be reduced by the clinician easing faecal material of her oestrous cycle. The reproductive information through the anal ring without fully withdrawing and history available for each animal will to some ex the hand on each occasion. If distended with air, the tent direct the rectal and other examinations, to pro rectal wall becomes so tense that palpation of struc vide the detailed assessment required at that time. Thus in the recently calved cow rectal examination the cow can usually be encouraged to expel rectal air. At 40 the clinician’s hand is advanced into the anterior rec to 82 days postcalving, palpation of the ovaries tum where normal peristaltic tension in the walls is should indicate whether the ovaries are active and in still present. By making gentle stroking movements 130 Clinical Examination of the Female Genital System with the ngers on the rectal wall muscular tension is Middle uterine artery this is the main source of restored and atus is expelled. The artery arises from the internal iliac artery shortly after this vessel leaves the Position of the female genital tract aorta. In non-pregnant animals it passes caudally In heifers and young cows the whole genital tract through the broad ligament, over the wing of the may be palpable lying on the pelvic oor. It then enters the concave animals part or all of the uterus may hang over ventral surface of the uterus. In these animals it is necessary to es the artery is pulled forwards by the enlarging attempt to retract the uterus into the pelvis so that its uterus. By the second half of pregnancy it may be pal component parts can be more readily examined. The this may be done by hooking a nger over the inter blood ow through the middle uterine artery in cornual ligament or by using the hand to scoop the creases greatly as pregnancy progresses. It can be anterior parts of the genital tract back into the pelvis readily recognised when the clinician’s hand is (Fig. Once retracted, the uterus is held in place passed laterally and upwards from the uterus and by gentle manual pressure before being examined cervix. The internal iliac artery is relatively immobile and then released to slip back over the pelvic brim. The the genital tract of the cow is supported by the pudendal artery is palpable in the wall of the pelvic broad ligament of the uterus which is attached to the canal 10cm anterior to the anus. Asmall fold of the broad artery is quite mobile and somewhat tortuous within ligament – the ovarian bursa – loosely surrounds each the broad ligament. The ovarian bursa may become adherent to bulent ow (‘fremitus’) is usually palpable within the the ovary in cases of ovarian bursitis. In heifers the clinician’s hand enclosed within its protective the cervix is about 2cm in width and 4cm in length. In plastic sleeve and the rectum can be moved quite these animals, where the entire genital tract is within widely within the cow’s pelvis. The bony limits of the pelvis, the cervix is found on the pelvic oor ap the pelvis can be readily identi ed as rm immobile proximately half way between the caudal border of structures. The cervix is sacrum and coccygeal vertebrae, the walls by the much rmer than adjacent soft tissues and can be wing of the ilium on either side and the oor by moved laterally to a limited extent. The caudal border of the lobed In older multiparous cows the cervix is 4 to 5cm left kidney can be palpated just anterior to the pelvic in width and 8cm in length. Just before and after inlet: it lies just to the right of the midline beneath the calving the cervix feels softer to the touch and may be lumbar vertebrae. It may lie just behind, on or variable depending on the age of the animal and its over the pelvic brim. The cervix is usually readily movement of the cervix is very limited as it is pulled found and the other parts of the tract can be identi ed tightly forwards by the weight of the pregnant uterus. Uterus this is located by moving the hand for Cervix this is found close to the midline of the wards from the cervix. It is located by initially exerting gentle of the uterus, which normally lies entirely in the manual pressure on the pelvic oor and resting the pelvis, can be readily enclosed in the clinician’s hand. The body and horns be palpated per rectum and can be further evaluated may lie on the abdominal oor anterior to the pelvic by ultrasonography. Retraction may be impossible in Pregnancy diagnosis by rectal palpation Details pregnant animals or in those in which uterine adhe are beyond the scope of this book. The uterine horns are coiled and may be summarised as follows: their anterior extremities are not directly palpable. The uterus feels turgid and very tightly coiled in 35 days – unilateral enlargement of the pregnant animals in oestrus, but such turgidity can also be horn; presence of corpus luteum on the ipsilateral induced in some cattle by manual palpation of the ovary genital tract. In early pregnancy the uterine walls are 42 days – palpation of amniotic vesicle (2 to 3cm in lacking in muscular tone. Later on as fetal size and diameter) in the pregnant horn uterine uid content increase the tone of the uterine 42–70 days – palpation of membrane slip. The uterine wall also increases the short uterine body is palpable wall is lifted and allowed to slip between the clini as a cylindrical structure just in front of but much cian’s nger and thumb. In heifers allantoic membrane slipping independently of the the uterine body is approximately 3cm in length. Disparity non-pregnant animals the two uterine horns should between pregnant and non-pregnant horns is normally be approximately the same size (2 to 3cm more distinct (Fig. In older animals the horns are larger and there >120 days – cotyledons palpable in the dorsal wall of may be a disparity of size caused by an earlier preg the uterus. The uterus undergoes great enlargement dur meter, increasing to 6 to 8cm towards the end of ing pregnancy. Cotyledons have been described as Uterine involution commences immediately after being like ‘corks oating on water’. Initial involution is rapid in healthy animals initially quite close together but later, as allantoic but may be delayed by dystocia, uterine inertia and uid volume increases, they move further apart. The anterior poles of the Cotyledons are readily detected by advancing uterus should be palpable by 14 days postpartum. Postpartum uterine uid normally disappears wards stroking the dorsal wall of the uterus. After that time the cotyledons are palpated as elevations in the uterus should contain little uid. In some animals a uterine wall low grade infection – endometritis – is present in the 150 days – fremitus palpable in the middle uterine uterus and is accompanied by the accumulation of artery on the pregnant side varying amounts of purulent uid. Avisible vaginal 240 days–bilateral fremitus palpable; the exact timing is discharge may be present and the uterus may be variable found to be enlarged and uid lled on rectal exami the fetus, which is very small, is not palpable within nation. The presence of purulent material can be con the tense amniotic vesicle in the rst 10 weeks of rmed by ultrasonography. After this, fetal extremities may be pal Large amounts of purulent material are present in pable through the uterine wall. By 14 weeks the the uterus in cases of pyometra but the animal rarely fetus has often passed beyond reach. In the serious disease ities may be palpable again from 26 weeks of preg acute septic metritis the uterine wall may be hard nancy. In the last 4 weeks of pregnancy the calf is and occasionally emphysematous on rectal examina usually readily palpable as it increases in size. In the last few days of pregnancy the feet of the calf often enter the pelvis in preparation for birth. Occasionally, if the calf is very large and heavy, in late pregnancy it may slip under the cau dal parts of the rumen and cannot be palpated per rectum. Ovaries In non-pregnant animals these are located on the pelvic oor approximately level with and quite close to the junction of the body and horns of the uterus (Fig. In searching for themper rectum the clinician should remain in manual contact with the uterus to which they are attached. Maintaining contact with the uterus enables the clinician to limit the area in which the ovaries may be sought. Occasionally one ovary, often the left, is not immedi ately palpable and may have slipped under the an terior border of the broad ligament. Both ovaries must be examined before the clinician can evaluate their activity and identify the stage of the patient’s oestrous cycle. Ovulation may Right ovary Left ovary occur sequentially on the same ovary or alternate Figure 10. The absence of follicles or mature follicle on her left ovary and the regressing corpus luteum from the corpora lutea may suggest that the patient is in previous cycle on her right ovary. Further evaluation of the ovaries by ultrasonography and a plasma or the ovaries are rmer than adjacent tissues and milk progesterone pro le of the patient are extre one, currently the more active ovary, is larger than mely useful in con rming the physiological state of the other. Ovarian shape is very variable and is in u Cystic ovarian disease Ovarian cysts are very com enced by the ovary’s physiological activity and the mon in dairy cattle and can be readily diagnosed on presence of follicles and corpora lutea.

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