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By: Dimitri T. Azar, MD, B.A.
- Field Chair of Ophthalmologic Research, Professor and Head, Department of Ophthalmology and Visual Sciences, University of Illinois Eye and Ear Infirmary, Chicago, IL, USA
Rest of the surface is covered by the obturator internus muscle and its fascia (forms the lateral wall of the ischiorectal fossa) virus respiratorio purchase bacticel 480mg on-line. Pudendal (Alcok`s) canal-lies on the lateral wall of the ischiorectal fossa formed by the splitting of the obturator fascia containing i virus removal discount bacticel 960mg overnight delivery. Pudendal nerves with its divisions the dorsal nerve of penis or clitoris and the perineal nerve antibiotics oral thrush order 960 mg bacticel with amex. Ends Upper end Character: It is fused with the ilium and pubis at the acetabulum (along the floor) antibiotics and mirena order 960 mg bacticel mastercard. Borders Anterior border Character: It forms the posterior margin of obturator foramen. It is converted into lesser sciatic foramen by the sacrotuberous and sacrospinous ligaments. Nerve to the obturator internus Except the tendon of obturator internus all structures enter into the pelvis again. It starts from the body and passes upward, forwards and medially to join with the inferior pubic ramus. Anterior or external surface Directed towards the thigh, continuous with the anterior surface of the inferior pubic ramus. Divided into three areas-upper, intermediate and lower by upper and lower bony ridges b. Anterior surface of the ramus-origin of obturator externus laterally and adductor magnus medially. Upper ridge gives attachment to the superior fascia of the urogenital diaphragm ii. Lower ridge gives attachment to the perineal membrane or inferior fascia of urogenital diaphragm iii. Symphyseal surface Character: Rough, elongated and articulates with similar surface of the opposite side to form the symphysis pubis. Origin of adductor longus-immediately below the junction of pubic crest and pubic tubercle ii. Upper part separated from the urinary bladder by the fibrofatty tissues with a plexus of veins. Between the two symphyseal surfaces lies the fibrocartilage and forms the symphysis pubis which is a secondary cartilaginous joint. Origin of lateral head of rectus abdominis and pyramidalis (if present) muscles d. Begins from the posterior part of the pubic tubercle then goes laterally and backwards, continuous with the arcuate line. Obturator membrane is attached along the margins of the foramen except in the above. Its periphery gives attachments to a fibrocartilage called acetabular labrum except below where forms the acetabular notch. Two ends of acetabular notch gives attachment transverse acetabular ligament and the base of the ligamentum teres femoris. Ilium contributes two-fifths, ischium contributes two-fifths and pubis contributes one-fifth of the acetabulum. Attachments Medial to lateral: Origin of gracilis, adductor brevis, adductor magnus and obturator externus. Superior layer of urogenital diaphragm-to the ridge between the intermediate and lateral areas. Secondary centers: these appears with commencement of puberty in the iliac crest, at the bottom of acetabulum triradiate cartilage, in the ischial tuberosity, anterior inferior iliac spine and symphyseal surface of the pubis. Side Determination On holding the bone in anatomical position the head on which side belongs will determine the opposite side of the bone. Upper End the upper end consists of head, neck, greater and lesser trochanters and intertrochanteric crest. It is covered by the articular cartilage except near its center where presents a rough depression called fovea capitis femoris or pit. Attachments Articulation: Head articulates with the acetabulum of the hipbone to form the hip joint (ball socket joint). Ligament: Ligament of the head of the femur (ligamentum teres femoris)-to the fovea capitis Neck Characters 1. Hipbone fractures and dislocation is uncommon but fracture may occur in highenergy motor vehicle accident, falls during skiing and ice dancing.
- Merkle tumors
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Superficial epigastric vein Superficial circumflex iliac vein Superficial external pudendal vein Deep external pudendal vein Thoraco-epigastric vein bacteria animation safe bacticel 480mg. It is a condition where the superficial veins of the lower limb more commonly the great saphenous vein and its tributaries become dilated antimicrobial irrigation buy cheap bacticel 960mg online, elongated and tortuous infection 13 lyrics discount bacticel 480 mg with visa. Thrombophlebitis of the deep veins result in incompetence of the valves in the perforating veins antibiotic resistance data purchase bacticel 480mg online, causes high venous pressure in the deep veins (normally blood flow from superficial veins to deep veins) will flow into the superficial veins, which produces varicosity d. Consequently, valves within the great saphenous vein are more numerous in the leg than the thigh, itself are incompetent. The pull of gravity of blood column results in increased pressure in the great saphenous vein, which exacerbates the varicosity f. On the medial side of knee: the vein is accompanied by the saphenous branch of the descending genicular artery. In the thigh: the vein is accompanied by some branches of the medial femoral cutaneous nerve. Two constant valves are present; one lies just before piercing the cribriform fascia and another at the junction with the femoral vein. About 10 to 20 valves are present, which are more numerous in the leg than the thigh. The gravid uterus press on the pelvic veins which may produce varicose veins of lower limb ii. The great saphenous vein is commonly used for occlusive coronary arterial disease caused by atherosclerosis ii. The diseased arterial segment can be bypassed by inserting a graft consisting a part of the great saphenous vein iii. Due to sufficient distance between its tributaries and perforating veins so that useable length is obtain c. Its wall has percentage of muscular and elastic fibers than other superficial veins d. After removal of the great saphenous vein the superficial venous blood will flow via the perforating vein into the deep veins. The venous segment is placed reversely so that its valves do not obstruct the arterial flow f. The great saphenous can also be grafted to bypass obstruction of the brachial or femoral arteries. The great saphenous vein often used for venous cutdown to insert a cannula for infusion of prolonged administration of blood, plasma, electrolytes or drugs ii. This vein is chosen even when it is not visible in infants and obese persons or in patients in shock whose veins are collapsed and invisible, this vein can always be identified by giving a small incision on the skin anterior to the medial malleolus iii. Always care to avoid injury to the saphenous nerve which lies just anterior to the great saphenous vein iv. Before great saphenous vein cutdown anterior to medial malleolus always branches of the saphenous nerve blocked anterior to the medial malleolus with local anesthetic agent v. When cutdown in the groin the branches of the ilioinguinal nerve and the intermediate cutaneous nerve of thigh 1. In the lower one-third of the calf it ascends lateral to the tendocalcaneus and only covered by superficial fascia and skin ii. Then it pierces the deep fascia and ascends on the gastrocnemius to about intermediate and proximal one-third of the calf iv. It is continue to ascend between the two heads of the gastrocnemius and terminates 3 to 7. It drains the blood from the lateral border of the foot, heel and back of the leg ii. Arches of foot are well-adapted to make the foot as a suitable platform to support the weight of the body in upright posture and as a lever to propel the body forwards during walking, running or jumping ii. Structures of Arches Longitudinal Arches Medial longitudinal arch Formation By the following: a. It is much higher than the lateral longitudinal arch Short Notes on Inferior Extremity 361 Posterior pillar i.
Repletion technique of the stomach antibiotics and iud buy discount bacticel 480 mg on line, small bowel or colon for which the concentration should not exceed 100% w/v infection jokes generic bacticel 960mg with amex. Double-contrast techniques of the stomach for which the concentration can be as high as 250 w/v antibiotics for pimples acne cheap bacticel 480mg mastercard. Double-contrast technique of the small bowel and of the colon for which concentrations as high as 100% are used treatment for giardia dogs buy 480mg bacticel. Fluidity or viscosity the required viscosity depends on the concerned examination. Examination of the pharynx and oesophagus require the use of a highly viscous paste which will not fall quickly into the stomach. Double-contrast examination of the stomach requires the use of low-viscosity suspensions to visualise all details of the mucosa, and possibly of high density (in weight and to X-rays) in order to obtain a better contrast. Barium sulphate suspensions are non-Newtonian and thixotropic: the relation between shear rate and stress is non-linear and the curves displaying the correspondence between stress and shear rate form a hysteresis loop when shear rates are increased and subsequently decreased. Viscosity is sometimes measured in seconds needed to empty a standardised cup through a hole. Viscosity of the barium sulphate suspension is related to its coating and mucosal adherence performance. The bowel preparation agents prior to double-contrast barium enemas can influence it. Stability Stability is usually measured by the sedimentation rate of the suspension, which is expressed by the depth of the supernatant lying over the suspensionupernatant interface after a given period of time. The derived loss of elasticity and uniformity would induce difficulties in image interpretation. C Conclusion Availability of Barium Contrast Media It is estimated that around 9,000 t of barium sulphate have been used for medical imaging worldwide in 2003. Barium sulphate contrast media have been made available from more than 20 manufacturers worldwide in forms varying from bulk material to ready-to-use presentations in sophisticated packaging. Dynamic studies of deglutition and defecation functions are also often based on the use of barium contrast media. Table 1 Contrast Media Safety Committee of the European Society of Urogenital Radiology guidelines for preventing and managing extravasation of contrast media Risk factors are related to The technique Use of a power injector Less optimal intravenous sites, including lower limb and small distal veins Large volume of contrast medium High-osmolar contrast medium The patient is Unable to communicate With fragile or damaged veins With arterial insufficiency With compromised lymphatic and venous drainage Always use careful intravenous technique, preferably with plastic catheters Use low-osmolar contrast medium Most injuries are minor. Severe injuries include skin ulcerations, necrosis of soft tissue, and compartment syndrome Conservative management is adequate in most cases Limb elevation Application of ice packs Careful monitoring If a serious injury is suspected, seek the advice of a surgeon Bibliography 1. Brit J Radiol 60:1215219 Bachem C, Gunther H (1910) Bariumsulfat als schattenbildendes Kontrantmittel bei Rontgenuntersuchungen. Most extravasations involve small volumes of contrast material and induce minimal swelling or localized erythema, which rapidly diminish. Extensive tissue necrosis and severe skin and subcutaneous ulceration are rare and usually follow high-volume extravasations. The Contrast Media Safety Committee of the European Society of Urogenital Radiology has produced guidelines for preventing and managing extravasation of contrast media (Table 1) (1). Characteristics Risk Factors Patient Factors High-risk patients include noncommunicative patients (infants, small children, and unconscious patients) and patients receiving chemotherapy, because chemotherapy may induce fragility of the vein wall (1, 2). Extravasation injuries are more severe in patients with low muscular mass Definition Subcutaneous extravasation is a well-recognized complication of intravenous administration of iodinated and Contrast Media, Extravasation 489 and atrophic subcutaneous tissue. In addition, patients with arterial insufficiency (such as atherosclerosis, diabetes mellitus, or connective tissue diseases) or compromised venous drainage (such as thrombosis) or lymphatic drainage (such as radiation therapy, surgery, or regional node dissection) are less able to tolerate extravasation than those with unimpaired circulation (1). Contrast Media Type and Volume Extravasation of low-osmolar contrast media is better tolerated than extravasation of high-osmolar media. The vast majority of extravasations involve small volumes of contrast material, and symptoms resolve completely within 24 h. Rarely, severe skin ulceration and necrosis can follow extravasation of volumes as small as 10 mL. Large-volume extravasation may lead to severe damage to extravascular tissue and is most likely to occur when contrast medium is injected with an automated power injector and the injection site is not closely monitored. The fourth factor is the mechanical compression caused by large-volume extravasations that may lead to compartment syndromes.
In contrast treatment for dogs chocolate purchase 480 mg bacticel fast delivery, rifampin is tuberculocidal antibiotics zomboid purchase 480mg bacticel with mastercard, m eaning that it destroys the mycobacteria antibiotics for dogs dental infection generic 480mg bacticel with visa. B ecause bacterial resistance to infection control certification 960mg bacticel sale isonia zid a nd rif ampin ca n develop rapidly, they should a lways be used with other antitubercular drugs. Antireplication station the exa ct mecha nism of action of ethambutol remains unclear, but it may be related to inhibition of cell meta bolism, a rrest of m ultiplication, a nd cell death. The drug is ef fective primarily in replica ting bacteria, but may have some effect on resting bacteria as well. Pharmacotherapeutics Isoniazid usually is used with ethambutol, rifampin, or pyra zinamide. Isonia zid is typica lly given orally, but may be given intra venously, if necessary. It combats many gram -positive and some gram -negative ba cteria, but is seldom used for nonmycobacterial infections because bacterial resista nce develops rapidly. Adverse reactions to antitubercular drugs Here a re common adverse reactions to antitubercular drugs. Although rare, hypersensitivity reactions to etha mbutol may produce rash a nd f ever. Severe and occa sionally fatal hepatitis associated with isoniazid may occur even many months after treatment has stopped. Rifampin the most com mon adverse reactions include epigastric pain, nausea, vomiting, a bdominal cramps, f latulence, a norexia, and dia rrhea. Isoniazid m ay increase levels of phenytoin, carbamazepine, dia zepam, ethosuximide, primidone, theophylline, and warfarin. When corticosteroids a nd isonia zid are taken together, the ef fectiveness of isoniazid is reduced while the effects of corticosteroids a re increased. Oral contraceptives and rifampin taken together may decrea se the effectiveness of the oral contra ceptive. When given together, rifampin, isonia zid, ethionamide, and pyrazinamide increase the risk of hepatotoxicity. Antimycotic drugs Antimycotic, or antifungal, drugs are used to treat f ungal infections. The ma jor a ntifungal drug groups include: polyenes fluorinated pyrimidine imidazole synthetic tria zoles glucan synthesis inhibitors synthetic a llylamine derivatives. Pharmacodynamics Amphotericin B works by binding to sterol (a lipid) in the f ungal cell m embrane, altering cell permea bility (ability to allow a substa nce P. Other antimycotic drugs Several other antimycotic drugs of fer a lternative forms of treatment for topical fungal infections. Clotrimazole An imidazole derivative, clotrima zole is used: topically to trea t derma tophyte a nd Candida albicans infections orally to treat ora l candidiasis vaginally to trea t va ginal ca ndidiasis. Griseofulvin Griseofulvin is used to trea t fungal infections of the: skin (tinea corporis) feet (tinea pedis) groin (tinea cruris) beard area of the f ace and neck (tinea barbae) nails (tinea unguium) scalp (tinea ca pitis). Long -term treatment To prevent a relapse, griseof ulvin therapy must continue until the fungus is eradicated and the infected skin or na ils are repla ced. Miconazole Available a s miconazole or miconazole nitrate, this imidazole deriva tive is used to treat local f ungal infections, such a s vaginal and vulvar ca ndidiasis, a nd topica l f ungal infections such as chronic ca ndidiasis of the skin a nd m ucous membranes. Other topical antimycotic drugs Ciclopirox ola mine, econazole nitrate, haloprogin, butoconazole nitrate, naftifine, tioconazole, tercona zole, tolnaftate, butenafine, terbina fine, sulcona zole, oxiconazole, clioquinol, triacetin, a nd undecylenic a cid are a vailable only a s topical drugs. A license to kill Amphotericin B usually acts as a fungistatic drug (inhibiting fungal growth and multiplication), but ca n become fungicidal (destroying fungi) if it reaches high concentrations in the fungi. Nystatin binds to sterols in fungal cell membranes and alters the permeability of the membranes, leading to loss of cell components. Nystatin ca n act as a fungicidal or fungistatic drug, depending on the organism present. Last-ditch effort Because a mphotericin B is highly toxic, its use is lim ited to the patient who has a definitive diagnosis of lif e -threatening infection a nd is under close medical supervision. D ifferent forms of nystatin are available for trea ting different types of candidal infections.
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