ANATOMY AND PHYSIOLOGY LYMPHATIC SYSTEM consists (1) of complex capillary networks which collect the lymph in the

e various organs and tissues; (2) of an elaborate system of collecting vessels which conduct the lymph from the capillaries to the large veins of the neck at the junction of the internal jugular and subclavian veins, where the lymph is poured into the blood stream; and (3) lymph glands or nodes which are interspaced in the pathways of the collecting vessels filtering the lymph as it passes through them and contributing lymphocytes to it. The lymphatic capillaries and collecting vessels are lined throughout by a continuous layer of endothelial cells, forming thus a closed system. Three Fundamental Functions of the Lymphatic System 1. development and maintenance of the immune system 2. transport of fluids and proteins (and other colloid substances) from the interstitial spaces back to the veins. 3. reabsorption of fats from the small intestine. LYMPHATIC CAPILLARIES These vessels are found in all body tissues except the central nervous system, which has a circulatory system known as the cerebrospinal system. The lymphatic capillaries run together to form larger ducts that intertwine about the arteries and veins. The lymph in these larger ducts, which are similar to thin, dilated veins, is moved along by the muscular movements of the body as a whole; it is prevented from moving back through the ducts by valves located along them at intervals. The ducts from the lower limbs and abdomen come together at the dorsal left side of the body to form a channel, known as the cisterna chyli, that gives rise to the chief lymphatic vessel of the body, the thoracic duct. This vessel receives lymph from the left side of the thorax, the left arm, and the left side of the head and neck; it empties into the junction of the left jugular and left subclavian veins. Another, smaller vessel, known as the right lymphatic duct, receives lymph from the right side of the thorax, the right arm, and the right side of the head and neck and empties its contents into the right subclavian vein. LYMPH NODES Along the course of the lymphatic vessels are situated the lymph nodes, more commonly called the lymph glands. These nodes are bean-shaped organs containing large numbers of leukocytes, embedded in a network of connective tissue. All the lymph being returned along the lymphatics to the bloodstream must pass through several of these nodes, which filter out infectious and toxic material and destroy it. The nodes serve as a center for the production of

phagocytes, which engulf bacteria and poisonous substances. During the course of any infection, the nodes become enlarged because of the large number of phagocytes being produced; these nodes are often painful and inflamed. The swollen glands most often observed are located on the neck, in the armpit, and in the groin. Certain malignant tumors tend to travel along the lymphatics; surgical removal of all nodes that are suspected of being involved in the spread of such malignancies is an accepted therapeutic procedure. VASCULAR SYSTEM Blood circulates inside the blood vessels, which form a closed transport system. The flow of blood is essential for sustaining human life. The vascular system provides conduits for blood to travel from he heart to nourish body tissues, to carry away cellular wastes to the excretory organs, to allow lymphatic flow to drain tissue fluid back into the circulation and to return blood to the heart for recirculation. Blood flow depends on the efficiency of the heart as a pump and the patency of the blood vessels. Circulation is influence by viscosity, hydration, and mechanisms affecting coagulation and fibrinolysis, and local changes in the size of the vessels as well as by inflammatory, neurogenic and iatrogenic processes. Structure of Blood Vessels There are three types of blood vessels: arteries, veins and capillaries. Arteries carry blood away from the heart after it has been oxygenated in the pulmonary circulation. Arteries are composing of three distinct layers: 1. Tunica intima, the innermost layer that provides a smooth passageway through which blood flows. 2. Tunica media, the middle layer compose of elastic connective tissue and circular smooth muscle; this layer is responsible for regulating the diameter of the Bessel by dilation and constriction. 3. Tunica adventitia, composed of elastic and collagen fibers; this outermost layers gives support to the vessel and maintain its shape.

Blood vessels circulate blood through the body. The three major types of blood vessels are the arteries, veins, and capillaries. Arteries carry blood away from the heart, while veins carry blood toward the heart. Capillaries form at the junction between arteries and veins and they are the only blood vessel to come into direct contact with tissue cells. Oxygen, nutrients, and other substances transported in blood through the arteries pass through thin capillary walls into tissue cells. Wastes and other products of cellular metabolism pass from cells back through the capillary walls and into veins. The walls of arteries and veins are composed of three tunics (layers) that surround a central opening called a lumen, through which blood flows. The innermost layer is the tunica intima, composed of endothelial cells that form a slick lining that minimizes friction as blood moves through the lumen. The middle layer is the tunica media. Composed of smooth muscle cells and sheets of elastic tissue, this layer enables the lumen to narrow or widen to regulate blood flow in the body. The tunica adventitia forms a protective outer layer of the blood vessel wall and it also anchors the blood vessel to surrounding structures. Arterioles are small, thick-walled vessels with an overall diameter of about 0.2 cm. They are important regulators of the peripheral circulation because they are innervated with sympathetic nerves in the muscle of the tunica media. Therefore, the arteriole constricts and dilates to regulate peripheral vascular resistance, a component of blood pressure. Before blood enters the capillary network, it passes through structures called Precapillary Sphincters. These sphincters work in conjunction with the autonomic nervous system to relax and constrict capillary openings. The precapillary sphincters can also be influenced by local changes in temperature, pH and oxygen.

 Capillaries are the functional units of the vascular system because they are the vessels that allow substances to diffuse to and from the blood into the interstitial space. The capillary network is composed of single layer of endothelial cells. Constriction of the capillary network increases peripheral vascular resistance and increases systolic and diastolic pressure. Dilation decreases peripheral vascular resistance and diastolic blood pressure. From the capillaries, blood flows into venules. Venules are tiny veins that have extremely thin walls that allow the passage f substances and serve to remove waste products from capillaries. The venules merge to form veins that eventually combine to form larger veins that carry deoxygenated blood back to the heart. Approximately 75 percent of the total blood volume at any given time can be found in the venous system. Veins are also known as capacitance vessels because of their ability to stretch. Veins lie closer to the skins surface than arteries do, and although they still contain three walls, their walls are thinner and contain less smooth muscle and less elastic tissue. Most veins also contain valves that prevent the backflow of venous blood. Valves consists of two frail cusps compose of endothelial folds. Valve competence depends on the integrity of the vein wall. The valve becomes incompetent when the cusps no longer meet at the midline. Valvular incompetence develops when veins have been overstretched by excess venous pressure for a prolonged period of time, as occurs during pregnancy or when the person is standing still for long periods. Systemic Circulation The heart ejects oxygen-rich blood under high pressure out of the hearts main pumping chamber, the left ventricle, through the largest artery, the aorta. Smaller arteries branch off from the aorta, leading to various parts of the body. These smaller arteries in turn branch out into even smaller arteries, called arterioles. Branches of arterioles become progressively smaller in diameter, eventually forming the capillaries. Once blood reaches the capillary level, blood pressure is greatly reduced. Capillaries have extremely thin walls that permit dissolved oxygen and nutrients from the blood to diffuse across to a fluid, known as interstitial fluid, that fills the gaps between the cells of tissues or organs. The dissolved oxygen and nutrients then enter the cells from the interstitial fluid by diffusion across the cell membranes. Meanwhile, carbon dioxide and other wastes leave the cell, diffuse through the interstitial fluid, cross the capillary walls, and enter the blood. In this way, the blood delivers nutrients and removes wastes without leaving the capillary tube. After delivering oxygen to tissues and absorbing wastes, deoxygenated blood in the capillaries then starts the return trip to the heart. capillaries merge to form tiny veins, called venules. These veins in turn together to form progressively larger veins. Ultimately, the veins converge the The join into

two large veins: the inferior vena cava, bringing blood from the lower half of the body; and the superior vena cava, bringing blood from the upper half. Both of these two large veins join at the right atrium of the heart. Because the pressure is dissipated in the arterioles and capillaries, blood in veins flows back to the heart at very low pressure, often running uphill when a person is standing. Flow against gravity is made possible by the one-way valves, located several centimeters apart, in the veins. When surrounding muscles contract, for example in the calf or arm, the muscles squeeze blood back toward the heart. If the one-way valves work properly, blood travels only toward the heart and cannot lapse backward. Veins with defective valves, which allow the blood to flow backward, become enlarged or dilated to form varicose veins. Pulmonary Circulation A single blood cell takes roughly 30 seconds to complete a full circuit through both the pulmonary and systemic circulation. In pulmonary circulation, deoxygenated blood returning from the organs and tissues of the body travels from the right atrium of the heart to the right ventricle. From there it is pushed through the pulmonary artery to the lung. In the lung, the pulmonary artery divides, forming the pulmonary capillary region of the lung. At this site, microscopic vessels pass adjacent to the alveoli, or air sacs of the lung, and gases are exchanged across a thin membrane: oxygen crosses the membrane into the blood while carbon dioxide leaves the blood through this same membrane. Newly oxygenated blood then flows into the pulmonary veins, where it is collected by the left atrium of the heart, a chamber that serves as collecting pool for the left ventricle. The contraction of the left ventricle sends blood into the aorta, completing the circulatory loop. On average, a single blood cell takes roughly 30 seconds to complete a full circuit through both the pulmonary and systemic circulation.

HODGKINS LYMPHOMA A cancer of the immune system that is marked by the presence of a type of cell called the Reed-Sternberg cell. Usually starts in a single lymph node or single chain of nodes. characterized by usually painless but progressive enlargement of lymph nodes (or glands) and other lymphoid tissue. Most commonly occurs in people 15 to 35 years of age and over 50. Equally affects younger men and women, but the disease is more prevalent in men in the older group.

RISK FACTORS Age/Sex -- Hodgkin's disease occurs most often in people between 15 and 34 and in people over the age of 55. It is more common in men than in women. Family History -- Brothers and sisters of those with Hodgkin's disease have a higher-than-average chance of developing this disease. Viruses -- Epstein-Barr virus is an infectious agent that may be associated with an increased chance of getting Hodgkin's disease. Symptoms of Hodgkin's disease A painless swelling in the lymph nodes in the neck, underarm, or groin Unexplained recurrent fevers Night sweats Malaise Unexplained weight loss Itchy skin Lethargy Easy fatigability STAGING CRITERIA FOR HODGKINS LYMPHOMA STAGE 1A Disease is confined to a single lymph node region only one extranodal site. STAGE 1B Disease is confined to a single lymph node region or only one extranodal site. The client also experiences some or all of the following systemic symptoms: persistent fever, night sweats, and significant weight loss. STAGE 2A Disease is confined to either two or more lymph node regions on the same side of the diaphragm or contagious extranodal sites on the same side of diaphragm.

STAGE 2B Disease is confined to either two or more lymph node regions on the same side of the diaphragm or contiguous extranodal sites on the same side of diaphragm. Client also experiences some or all of the following systemic symptoms: persistent fever, night sweats, and significant weight loss. STAGE 3A Disease extends to lymph node regions on both sides of the diaphragm. STAGE 3B Disease extends to lymph node regions on both sides of the diaphragm. The client experiences some or all of the following systemic symptoms: persistent fever, night sweats, and significant weight loss. STAGE 3C Disease extends to lymph node region on both sides of the diaphragm. The client also experiences some or all of the following systemic symptoms: persistent fever, night sweats, and significant weight loss. The spleen is also involved in the disease. STAGE 4 Disease has widely disseminated foci of involvement, including one or more extranodal tissues and organs. HISTOLOGIC TYPES OF HODGKINS DISEASE 1. LYMPHOCYTE PREDOMINANT Almost all of the cells appear to be mature lymphocytes or a mixture of lymphocytes and benign histiocytes, with only occasional Reed-sternberg cells. This type affects 10-20% of patients, and generally has the least dissemination at time of diagnosis, and has the best prognosis. NODULAR SCLEROSING This is the most common, affecting about 50% of patients. Broad bands of collagen divide the involved lymph node into nodular cellular areas. A special cystologic feature is clear spaces surrounding lacunar cells which are variants of the Reed-Sternberg cell. This form occurs most frequently in the mediastinum and to a lesser degree in the abdomen. MIXED CELLULARITY The second most common form is characterized by accumulations of lymphocytes, plasma cells, eosinophils, histiocytes, malignant reticular cells, and Reed Sternberg cells. Foci of necrosis may be present. This form is more likely to involve extranodal areas at the time of diagnosis and further progression and has a less favorable prognosis. LYMPHOCYTE DEPLETION This affects fewer than 10% of patients. Numerous bizarre malignant reticular cells are found, with Reed-Sternberg cells and relatively few lymphocytes. There may also be varying degrees of partly hyalinized fibrosis with a paucity of cells, mostly of reticular and Reed-Sternberg types.

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PERIPHERAL VASCULAR DISEASE Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation. Affects the lower extremities much more frequently than the upper extremities. And It occurs mostly in people older than 50 years Manifestation of systemic atherosclerosis and is a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients. It is caused by build-up of fatty material within the vessels, called atherosclerosis.

CAUSES o Peripheral artery disease is due to atherosclerosis o Blood clot: A blood clot can block a blood vessel (thrombus/emboli) o Diabetes: Over the long term, the high blood sugar level of persons with diabetes can damage blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Plus, people with diabetes frequently also have high blood pressure and high fats in the blood, which accelerates the development of atherosclerosis. o Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries. Several autoimmune conditions can develop vasculitis, and, besides the arteries, other organ systems are also affected. o Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels. Both salmonellosis (infection with Salmonella bacteria) and syphilis have been two infections traditionally known to infect and damage blood vessels. o Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown. Takayasu disease is a vascular disease affecting the upper vessels of the body and affects usually Asian females. o Injury: Blood vessels can be injured in an accident such as a car wreck or a bad fall. RISK FACTORS Positive family history of premature heart attacks or strokes Older than 50 years Overweight or obesity Inactive (sedentary) lifestyle Smoking

 Diabetes High blood pressure High cholesterol or LDL (the bad cholesterol), plus high triglycerides and low HDL (the good cholesterol) People who have coronary heart disease or a history of heart attack or stroke generally also have an increased frequency of having peripheral vascular disease. SYMPTOMS OF THE PERIPHERAL VASCULAR DISEASE Pain usually occurs while you are walking or climbing stairs and stops when you rest. This is because the muscles' demand for blood increases during walking and other exercise. The narrowed or blocked arteries cannot supply more blood, so the muscles are deprived of oxygen and other nutrients. This pain is called intermittent (comes and goes) claudication. It is usually a dull, cramping pain. It may also feel like a heaviness, tightness, or tiredness in the muscles of the legs. Buttock pain Numbness, tingling, or weakness in the legs Burning or aching pain in the feet or toes while resting A sore on a leg or a foot that will not heal One or both legs or feet feel cold or change color (pale, bluish, dark reddish) Loss of hair on the legs Impotence STAGES OF CHRONIC PERIPHERAL ARTERIAL DISEASE STAGES 1: ASYMPTOMATIC No claudication is present. Bruit or aneurysm may be present. Pedal pulses are decreased or absent. STAGES 2: CLAUDIFICATION Muscle pain, cramping, or burning occurs with exercise and is relieved with rest. Symptoms are reproducible with exercise. STAGES 3: REST PAIN Pain while resting commonly awakens the client at night. Pain is described as numbness, burning, toothache-type pain. Pain usually occurs in the distal portion of the extremitytoes, arch, forefoot, or heelrarely in the calf or the ankle. Pain is relieved by placing the extremity in a dependent position.

STAGES 4: NECROSIS/GANGRENE Ulcers and blackened tissue occur on the toes, the forefoot, and the heel. Distinctive gangrenous odor is present. DIAGNOSTIC EXAMS Segmental systolic blood pressure measurementsusing a Doppler probe, segmental systolic blood pressure measurements of the lower extremities at the thigh, calf, and ankle area are an inexpensive, noninvasive method of assessing peripheral arterial disease. Normally, blood pressure readings in the thigh and calf are higher than those in the upper extremities. With the presence of peripheral arterial disease, these pressures are lower than the brachial pressure. Exercise tolerance testingby stress test or treadmill may give valuable information about claudication without rest pain. The technician obtains resting pulse volume recordings and has the client walk on a treadmill until the symptoms are reproduced. At the time of symptom onset or after about 5 minutes, the technician obtains another pulse volume recording. Plethysmographycan also be performed to evaluate arterial flow in the lower extremities. The measurement provides graphs or tracings of arterial flow in the limb. If an occlusion is present, the waveforms are dampened to flattened, depending on the degree of occlusion. Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy Arterial revascularization