Intercondylar Groove
The femur is the longest bone of the human body. It consists of a rounded proximal head that articulates with the acetabulum at the hip, a nearly cylindrical shaft, and a distal metaphysis that forms two large rounded condyles that articulate with the tibia. Forensic Medicine of the Lower Extremity Human Identification and Trauma Analysis Edited by J. Rich, D. E. Dean, and R. H. Powers The Humana Press Inc., Totowa, NJ Fig. 1. Anterior femur (A) Anterior view of the entire femur (B) The distal...
Love Charms
Fenland girls used YARROW as a love charm, by pinning it on the dress, and then taking every opportunity to get as near as possible to young men, in order to declare their love by means of the flowers. If a girl found that the man she was interested in ignored the hint, then she was likely to wait for a full moon, go to a patch of yarrow and walk barefoot among them. She would then shut her eyes, bend down and pick a bunch. If she found next morning that the dew was still on the yarrow, then...
Lentigo Senilis
INTRODUCTION Also known as senile lentigines, solar lentigo, age spots, or liver spots, these are the most common lesions found on sun-exposed areas of light-skinned older individuals. They may also occur in younger individuals after prolonged sun exposure, and are common in patients with xeroderma pigmentosum. They are related to aging phenomena in light-skinned individuals where areas of hypopigmentation may be seen along side of focal hyperpigmentation (lentigo senilis). The...
Adult Congenital Heart Disease In General Echocardiography Practice
The spectrum of adult congenital heart defects seen in echocardiography practice varies according to institutional practice and expertise. Half a century ago, survival with severe congenital heart disease was less common. Today, nearly 80 of such patients in industrialized societies now survive into adulthood. Most are followed up in centers that specialize in adult congenital heart diseases CHDs , but it is not uncommon for such adults to be seen in general echocardiography practice. Most CHDs...
How Many Events Should Be Acquired
In the early years of flow cytometry, the instruments were predominantly used for the analysis of DNA content of isolated cell nuclei and it was common practice to acquire 10,000 nuclei (data events) into each file. This value seems to have acquired a mystical significance within the flow community, with every paper stating 10,000 events were acquired as list mode data. Unfortunately, quite often in the data seen in papers, these files contain 500 cells of interest and 9500 events of no...
How to Lighten Skin Naturally
You don't have to explain your reasons for wanting learn how to lighten your skin to us. Some people just like their own skin tone better when they are less tan and more pale. In some cultures, it's seen as a sign of higher ranking caste to have lighter skin (as dark skin is associated with having to work manual jobs in the sun). Even celebrities are know to get procedures done and take cream and pills to get lighter skin, such as we've seen with the Beyonce skin lightening.
Transtheoretical Model
The Transtheoretical Model (TTM) was originally developed to understand behaviour change related to smoking cessation (Prochaska and DiClemente, 1983), but has since been applied to exercise behaviour (Prochaska and Marcus, 1994). Interventions based on the TTM have been effective in promoting and maintaining physical activity (Marcus, et al., 1992a Marcus, et al., 1998a, 1998b Bock, et al., 2001). The model proposes that individuals attempting to change their physical activity behaviour...
The Measurement of Fluorescence Intensity
A regular use of flow cytometers is the determination of the density of specific molecules on the surface of one or more cells in a population. These measurements may be relative, semiquantitative, or quantitative depending upon the question asked and the reagents available. In most cases, the measurement of relative fluorescence intensity is adequate, where the fluorescent channel number that best approximates the average fluorescence of one population is compared with the same value.
How to Recognize a Pericardial Friction
What adjectives and analogies have been used to describe the quality of friction rubs ANS They are usually described as crunching, scraping, creaking, grating, crackling, or scratching. They often sound like squeaky shoes or like two pieces of sandpaper rubbed against one another. Occasionally, however, they sound no different from any mixed-frequency murmur. They often sound surprisingly superficial, and increased stethoscope pressure sometimes seems to make them unexpectedly louder. They may...
Absence of secondary sexual characteristics
In this particular situation, it is extremely important to make an assessment of the patient's height. If the patient is of normal height for age, measurement of gonadotrophin will reveal levels that are either low or high. Low levels of gonadotrophins confirm the diagnosis of hypogo-nadotrophin hypogonadism, and elevated levels should provoke the clinician to perform a karyotype. The 46XX patient will have premature ovarian failure, the resistant ovary syndrome or gonadal agenesis while the XY...
Torsional Fractures
When a twisting motion is applied to a long bone e.g., when a ski tip is caught on the ice and acts as a moment arm for the lower extremity the most elegant of fracture Fig. 11. Is this axial loading or bending Fig. 11. Is this axial loading or bending patterns results a spiral Fig. 14 . The pattern is completely unique and diagnostic of torsional force as the primary mechanism of injury. A fracture initiates at some point on the bone and then travels at an angle of approx 45 degrees with...
Lightning Plants
Yggdrasil, the ASH tree, was sacred to Odin (Graves), and that would be enough to make ash a lightning tree BRACKEN must be included here - it will protect the house from lightning if hung up inside (but if you cut or burn it, it will bring on rain) (Waring). HAWTHORN too is a lightning tree, thought to avert lightning. In many parts of England, hawthorn gathered on Holy Thursday (whether that means Maundy Thursday or Ascension Day is not clear), was used as a protection against lightning...
Causes of a Loud A2 or P2
What conditions tend to make the aortic component of the second sound louder than normal ANS a. Conditions that raise aortic systolic pressure, e.g., systemic hyper tension, which occasionally produces a drumlike sound or tambour S2. A tambour is a small drum that is covered only on one side. The tambour effect may persist even after the blood pressure has been lowered to normal by medication. b. Conditions that produce a hyperkinetic systemic circulation, e.g., youth, or thyrotoxicosis. The...
Xeric Ferns
The ferns of the world's drylands offer a total contrast to the stereotypical concept of fern. Seeing them growing in the wild is an amazing sight indeed. One of my earliest exposures was at a remote place called Bumblebee 4 no, I do not know why , Arizona. In a dry gulch that would serve as a site for a cowboy's last gasp in a western movie were assorted ferns nestled up against boulders. Here their roots reached deeply down for the minimal water source with the boulder providing a cool root...
Cheilanthes
Cheilanthes are dryland ferns and quite the opposite of the traditional, stereotypical and beautiful woodland shade lovers that evoke visions of greenery in the world's forests. We cherish and cultivate those for a myriad of reasons, but many avid gardeners also attempt the xerics, including cheilanthes, for their unique ornamental qualities as well as the challenge of establishing notoriously difficult species. And challenging they are. Cheilanthes like arid, desertlike habitats and have...
Asplenium trichomanes Maidenhair spleenwort
Also from Theophrastus, hair madness. Evergreen, 4 to 8 in. (10 to 20 cm).Zones 3 to 9. description The rhizome is ascending. Glossy reddish-brown stipes with a flattened groove are one-fourth to one-third of the frond length and barely visible under the foliage. Some are persistent for years with batons of upright, naked spikes. Narrow, once-pinnate blades are linear with 20 to 30 pairs of round to oblong, matte green pinnae. Sori and indu-sia are linear in a...
Selaginella uncinata Peacock fern
Subevergreen to evergreen, prostrate. Zones 6 to 10. description Creeping and branching stems create extended mats of stubby overlapping segments of iridescent electric-blue to blue-green foliage. The plant roots easily as it travels about. range and habitat Although native to China, this species has escaped in the southeastern tier of the united states. it needs moist shade. culture and comments While it is generally recommended for Zone 6 and up, peacock fern can...
Cheilanthes feei slender lip fern
Epithet is after French botanist Antoine F e (1789-1874). Evergreen, 6 to 10 in. (15 to 25 cm).Zones 5 to 8. Apogamous. Upright fronds of Cheilanthes eatonii among rocks in the Horder garden. The underside of a fertile frond on Cheilanthes farinosa showing the namesake white farina. Cheilanthes fendleri silhouetted against a stump in the Carstensen garden. Cheilanthes fendleri silhouetted against a stump in the Carstensen garden. A colony of Cheilanthes feei on the east side of the Ladronas...
Argyrochosma
Synonyms Cheilanthes, Notholaena, Pellaea Argyrochosma gathers together some 20 intriguing xeric species that until 1987 (Windham) were classified under one or another of the above synonyms. The appropriately descriptive genus name Argyrochosma, from the Greek argyros, silver, and chosma, powder, references the waxy, white protective foliar undercoat that decorates many of the species. Others are included by virtue of the stalks and cordate bases on the minute ultimate segments. These are...
Cheilanthes covillei Covilles lip fern
Epithet is after Frederick Coville (1867-1937), chief botanist for the U.S. Department of Agriculture. Evergreen, 6 to 12 in. (15 to 30 cm).Zones 7 to 9. description The rhizome is short-creeping. Coffee-brown, rounded stipes are up to one-half of the length of the frond. The lanceolate tripinnate blades have 10 to 12 pairs of pinnae with beady segments. The upper surface is glabrous, but the rachis and midveins of the pinnae undersides have small, overlapping, ovate scales with a heart-shaped...
Cliff brakes
Pellaeas, the cliff brakes, are those dusky blue charmers that enchant and taunt from cliff sides, mortared crevices, and other stressful and fern-forbidding sunny habitats with dry and lean, gritty soil. As such, those that are natives of the U.S. Southwest flourish in the challenging sites that delight passing tourists with periodic spring bursts of desert wildflowers but are not traditionally associated with our friends, the ferns. Their exquisitely adapted blue-toned fronds offer beauty to...
The Four Types Of Mental Health Consultation
Caplan and Caplan delineate four types of MHC, which are based on two major considerations whether the content focus is on a client concern or an administrative concern, and whether the primary goal is to provide information drawn from the consultant's area of expertise or to improve the problem-solving capacity of the consultee. Client-centered case consultation perhaps is the most frequent type of consultation conducted by school psychologists.
Polystichum setiferum Soft shield fern
Evergreen, 2 to 3 ft. 60 to 90 cm . Zones 5 to 8. description The rhizome is erect, supporting wide fans of soft, willowy fronds. The grooved stipes are coated with warm-brown scales that are a glittering silver on emerging fiddle-heads. They are one-fifth of the frond length. The bipinnate, lanceolate blade is broadest in the middle with 30 to 40 pairs of pinnae with stalked, toothy spinulose pinnules. Sori with peltate indusia are medial. range and habitat Soft...
The British Pteridological Society
The British Pteridological Society, the world's oldest fern society, offers members a balance between horticultural interests and the purely botanical. The Society publishes three annual journals The Fern Gazette, which presents scholarly articles The Bulletin, which reports on the annual activities, field excursions, and society business and The Pteridologist, which includes a broad range of articles of general fern interest. In addition special publications are released periodically with the...
Osmunda claytoniana Interrupted fern Synonym Osmunda interrupta
Epithet is after John Clayton 1686-1773 , a British botanist in North America. Deciduous, 2 to 3 ft. 60 to 90 cm .Zones 2 to 8. Dimorphic. description The rhizome is thick and upright. The unique fertile fronds have leafy tissue at the bottoms and tops, with Osmunda claytoniana showing fertile fronds interrupted with sporangia between top and bottom. blackish sporangia in the middle, hence the common name, interrupted fern. It also leads some customers to wonder whether the middle is diseased....
Osmunda regalis Royal fern flowering fern Epithet means royal
Deciduous, 2 to 6 ft. (60 to 180 cm) or more. Zones 2 to 10. description Here is the royal fern and regal it is with broadly ovate fronds occasionally up to 9 ft. (2.7 m) on trunklike rhizomes. One third is stipe and the remainder is made up of a bipinnate blade, with opposite pinnae suggestive of Osmunda regalis 'Gracilis' in the Schmick garden. Osmunda regalis 'Gracilis' in the Schmick garden. locust tree foliage. The fertile portion replaces the leafy tissue at the tips of the spore-bearing...
The Tao Of Badass Review
Product The Tao of Badass Author Joshua Pellicer Money Back Guarantee Yes Refund 60 Days Bonuses Yes The Tao of Badass is a system created by Joshua Pellicer. This is my real review of this unbelievably powerful course on how to date and take control over your own life. Joshua Pellicer, the creator, is one of the most famous dating coaches around the world.
Contributions Of Sleeter And Grant
Sleeter and Grant 1987, 1999 argue that much of the existing literature addresses only limited aspects of multicultural education. Recognizing that Four Approaches to Content Integration Primary focus on ethnic heroes, holidays, cultural elements e.g., food, dances, and music and artifacts with little attention to other aspects of ethnic content. The addition of content, concepts, themes, and perspectives to the curriculum without change in the basic structure, purpose, and characteristics of...
Typical design of a biological database
Usually, the creation of a biological database involves three main steps (see Figure 1.3). INTEGRATION DATABASE DESIGN WEB INTERFACES Figure 1.3 Main steps of the development of a biological database (design, integration, INTEGRATION DATABASE DESIGN WEB INTERFACES Figure 1.3 Main steps of the development of a biological database (design, integration, 1. The modelling and creation of the database. For example, the definition of a relational database results in formal descriptions of tables and...
Pw Pressure On Echo
Two-dimensional-guided M-mode measurements and derived indices. M-mode is simple, reproducible, and accurate when ventricular geometry is normal. It provides good endocardial resolution. The ejection fraction EF, Teich is an automated calculation based on the Teichholz method see Table 4 . Fig. 3. Two-dimensional-guided M-mode measurements and derived indices. M-mode is simple, reproducible, and accurate when ventricular geometry is normal. It provides good endocardial resolution. The...
Taxonomy and Classification
The genus Carlavirus belongs to the family Flexiviridae. The type species of the genus is Carnation latent virus. The name carlavirus was derived from the type species. The genus contains a large number of members. In total, 68 members of the genus Carlavirus (39 definitive species and 29 tentative species) are listed in Table 1. Some members listed as species and all members listed Virus species in the genus Carlavirus Strawberry pseudo mild yellow edge virus as tentative species have no...
Single Stage Extraction
In the case that carrier and solvent are immiscible, the concentration of solute in extract and raffinate can be graphically depicted with the equilibrium curve in the loading diagram. Together with the volumes of feed and solvent, the mass balance for the solute leads to the amount of solute that can be recovered. Whenever the miscibility of the two phases varies and is dependent on concentration, a triangular diagram is employed Fig. 2.5 . Here the three corners of the equilateral triangle...
Eccrine Nodular Hidradenoma
INTRODUCTION Eccrine hidradenoma is also referred to as nodular hidradenoma, eccrine spiradenoma, or clear cell hidradenoma. These lesions are uncommon on the eyelids. They presumably arise from eccrine sweat glands and do not show any apocrine differentiation. These tumors occur primarily in middle-aged females and have a predilection for the head region. Very rarely they may undergo malignant change. CLINICAL PRESENTATION The eccrine hidradenoma presents as a solitary slowly progressive...
Pediatric Asthma Case Study
A 14-year-old African-American female is brought to the pediatrician's office by her mother. She has just started running on her high school track team, but has been complaining to her mother that her running feels different this year. When she ran in middle school she could race longer distances without becoming winded. She now says her chest burns and she is running fewer miles before she has to stop to catch her breath. Her girlfriend told her she could hear her wheezing and she should go to...
Diabetes Destroyer Review
Diabetes Destroyer ReviewDiabetes Destroyer is a relatively new diabetes treatment program from diabetesdestroyer.com , designed by David Andrews in order to help type 2 diabetes sufferers find a different diet and lifestyle to all of their diabetes symptoms under control and lower blood sugar levels, ultimately to the point where you would no longer need Metformin or Insulin.
Development of Ceredase
With the proof of concept demonstrated, significant effort was required to scale up the extraction and purification of placental glucocerebrosidase to make it clinically and commercially viable. The magnitude of this challenge can be appreciated by the fact that it took 20,000 placentas to extract enough p-glucocerebrosidase to treat 1 patient for 1 year. Genzyme Corporation adapted the purification and carbohydrate remodeling schemes developed by Brady, et al., to improve both the purification...
Oromandibular Dystonia
INTRODUCTION Oromandibular dystonia (OMD) is a focal dystonic movement disorder affecting the mid and lower face, particularly the jaw and tongue. It is characterized by spasms along the sides of the nose, the cheek, mouth, and chin. Uncontrolled spasms make opening and closing of the mouth difficult and can have a profound influence on eating and speaking. Meige's syndrome is a term used for a regional dystonia consisting of the two adjacent focal dystonias, benign essential blepharospasm, and...
Grow Taller 4 Idiots Review
This is a special height increasing program that was composed by Darwin Smith, your average below-average height male who got sick of his short stature. Smith, standing at only 5'3, could consider himself vertically challenged to say the least. One day, he got fed up and with extreme conviction began to start searching for methods to grow taller naturally. He wanted to avoid having to use something extreme, such as height increasing surgery.
Neti Pot Use and Safety Tips
Neti pots often look like minature tea pots and can be used to flush the nose to help sinus pressure. Water and a salt mixture are combined and then with some head tilting, the salt water goes up one nostril and back out the other. Neti pots have been around for centuries and originated with the Ayurvedic and yoga medical tradition. A few recent stories have me re-thinking my neti pot and how I use it.
Does Muscle Really Weigh More Than Fat?
Ever start a workout program and find that after a few weeks of exercise the scale doesn't budge or actually goes up Don't stress, this is a common occurrence and brings up the question if muscle weighs more than fat. One pound equals 16 ounces no matter what the substance, so one pound of fat is equal to one pound of muscle.
Conditions That May Simulate Tinea
Tinea of the scalp may be confused with any scalp disorder that causes patchy alopecia, inflammation, or scale. The presence of hairs broken off a short distance above or right at the scalp surface should cause immediate suspicion. Occasionally TCa does not produce hair breakage. The noninfectious dermatidities seborrhea and psoriasis can both cause inflammation and scaling of the scalp, but do not cause patchy hair shedding. Both are more diffuse than TCa. When any inflammatory scalp condition...
The Protocerebrum
The ground structure of the protocerebrum suggests its ancestral affinities with segmental ganglia. In the protocerebrum, as in postoral ganglia, ascending sensory interneuron tracts enter it ventrally, whereas premotor interganglionic interneurons exit dorsally. Afferents (here the optic lobe output neurons see later) distribute to local interneurons in a manner reminiscent of sensory afferents within postoral ganglia. Despite its basic similarities with segmental ganglia, the protocerebrum...
Degeneration In Adults
A chapter on cell death in Drosophila would not be complete without at least a few words about degeneration of adult structures. Adult fly cells, similar to our own, retain the capacity to undergo apoptosis. Many cells, particularly in the nervous system, require continual trophic support for their survival. This has been perhaps best demonstrated with the mutual requirement for connections between photoreceptor neurons in the eye and their target neurons in the optic lobes of the brain....
Brain and Optic Lobes
Authors variously use the term brain either to include all neuropils located within the head capsule or, restrictively, to refer to only those neuropils (called preoral neuropils) that lie dorsal to the esophagus. These are considered to lie anterior to the mouth. Preoral neuropils are also known as the supra-esophageal ganglion, which comprises three fused ganglia the protocerebrum, deutocerebrum, and tritocerebrum. The preoral brain of the larger Hymenoptera, such as the predatory wasp Pepsis...
Echocardiograghy For Rheumatic Mitral Stenosis
Echocardiography features of rheumatic mitral stenosis. A Diastolic doming of the thickened anterior mitral valve leaflet hockey stick appearance, curved arrow is indicative of restricted anterior leaflet motion. Note the thickened subvalvular structures, including the chordae arrow . Note also the posterior pericardial effusion PE . B A systolic frame showing thickened mitral valve leaflets. C Commissural fusion arrowheads and bilateral leaflet thickening curved arrows resulting in...
Other Auscultatory Signs of PDA
What auscultatory signs of the increased flow through the mitral valve and large volume load on the LV may be heard in patients with a PDA ANS There may be an S3 and or a mitral diastolic flow murmur and the S2 split may be paradoxical. 2. What are the multiple clicks or crackles heard at the end of systole and the beginning of diastole called Their significance ANS Eddy sounds. They signify a large flow ductus 11 . PDA with High Pulmonary Artery Pressure 1. What causes differential cyanosis...
References On Lipids
Pergamon Press, New York, 1982, p. 1. 2. M. Kates. Techniques of Lipidology Isolation, Analysis and Identification of Lipids. Elsevier, New York, 1986, p. 1. 3. M. I. Gurr and A. T. James. Lipid Biochemistry and Introduction. Cornell University Press, Ithaca, NY, 1971, p. 1. 4. R. H. Schmidt, M. R. Marshall, and S. F. O'Keefe. Total fat. In Analyzing Food for Nutrition Labeling and Hazardous Contaminants (I. J. Jeon and W. G. Ikins, eds.). Dekker, New York, 1995,...
The DNA p Satellites of Begomoviruses
Identification of the Begomovirus Satellites The first begomovirus satellite discovered, referred to as tomato leaf curl virus-sat (ToLCV-sat), was identified in tomato plants infected with the monopartite begomo-virus tomato leaf curl virus (ToLCV) originating from Australia. The component is a small (682 nt) circular ssDNA with no extensive open reading frames (ORFs) and sequence similarity to its helper virus limited to sequences within the apex of two stem loop structures. The first...
The Role of Transcription in Nuclear Organization of VDJ Recombination
Where does non-coding RNA transcription fit in Rather than taking place randomly in the nucleus, transcription is concentrated in metastable pre-formed sub-nuclear foci of active RNA PolII complexes, termed transcription factories (Mitchell and Fraser 2008). Factories transcribe several genes simultaneously, and these genes can be up to 40 MB apart in cis, or on separate chromosomes (Osborne et al. 2004, 2007). Genes co-transcribed in the same factory often have related functions, which...
The Muscle Spindle
The driving force on lower motor neurons comes from three major sources (1) sensory pathways from the spinal cord and brain stem that trigger reflex actions, (2) inter-neurons within the spinal cord that interconnect syner-gistic and antagonistic motor neuron pools, and (3) upper motor neurons in the motor cortex and other motor areas in the brain that provide complex motor commands. One of the major sensory inputs to the lower motor neuron is derived from specialized end organs located within...
Multiple Sclerosis Myelopathies and Spinal Cord Injury
Multiple sclerosis (MS) is a progressive neurologic disease that results from multiple demyelinating lesions within the CNS and that shows a variety of clinical presentations and courses determined by the location and number of the same lesions. Bladder and bowel dysfunction is the third most important discomfort in MS patients after spasticity and fatigue 33, 34 . Genitourinary dysfunctions in MS patients frequently occur due to the spinal involvement, with an incidence of 78 35-38 ....
ENU mutagenesis phenotypedriven mouse mutagenesis screens
At Harwell, and in collaboration with colleagues at SmithKline Beecham, Imperial College and the Royal London Hospital, we have begun a major ENU mutagenesis programme incorporating a large genome-wide screen for dominant mutations. Over 18 000 mice have been produced to date and the majority screened employing a systematic and semi-quantitative screening protocol SHIRPA (Rogers et al 1997). SHIRPA is a hierarchical screening protocol employing a rapid and efficient primary screen for deficits...
Neurological manifestations
Secondary to anticoagulation therapy Loss of all sensory modalities below the level of the lesion, e.g. pain, temperature, light touch, position sense, and vibration. Localized vertebral pain accentuated by vertebral palpation or percussion may occur with destructive lesions (e.g. infections and tumors), and may have some value for locating the lesion. Pain that is worse when recumbent and better when sitting or standing is common with spinal malignancies - Paraplegia or Initially flaccid and...
Anal Sphincter Tone and Reflexes Internal Anal Sphincter
The internal sphincter is primarily responsible for ensuring that the anal canal is closed at rest 14, 38 . The other contributors to anal resting tone include the external anal sphincter, the anal mucosal folds, and the puborectalis muscle. Penninckx et al. 39 estimated that anal resting tone was generated by nerve-induced activity in the internal sphincter 45 of anal resting tone , myogenic tone in the internal sphincter 10 , the external sphincter 35 , and the anal hemorrhoidal plexus 15 ....
The Injectable Bulking Agents
In broad terms, an agent should be biocompatible, nonmigratory, nonallergic, nonimmunogenic, non-carcinogenic, easy to inject and able to produce durable results. Such an agent probably does not yet exist. Scientific studies have looked at particle size in relation to their potential for local and distant migration. It would appear that particles should be at least 80 mm in diameter to avoid phagocytosis and transport throughout the body. As with sacral nerve stimulation, there is no consistent...
And Radical Prostatectomy
A further point of controversy is the craniocaudal extension of the external sphincter over the prostate and bladder. Dorschner's groups and others advocate that the urethral sphincter is ventrally more strongly developed. Furthermore, the apex of the prostate is ventrally overlapped by the striated muscle fibres of the external urethral sphincter. In contrast, Oelrich et al. and Myers et al. described a vertically orientated sphincter muscle system, from the base of the bladder to the bulb of...
Pelvic Plexus Inferior Hypogastric Plexus Pelvic Ganglion
The pelvic plexus is a collection of ganglia which is located lateral to pelvic organs. It has a rhombic shape with a longitudinal diameter of ca. 5 centimetres and is located at the apex of the seminal vesicles. In the male the plexus is situated laterally to the rectum, seminal vesicle, prostate and posterior part of the bladder (Fig. 2.1.2). These structures may be injured during radical cystectomy, rectal resection, ure teric antireflux surgery or extended radical hysterectomy (Wertheim's...
Neuroanatomical Basics of Radical Prostatectomy
During radical prostatectomy the surgeon encounters nerve fibres that run dorsally and laterally to the prostate, also known as neurovascular bundles (NVB). This term does not have an exact anatomical correlate as it describes a topographically related cluster of nerves and blood vessels. In the literature the description of the NVB differs widely and in regard to its existence and exact position is subject to inter-individual variations 9-12 . These autonomic nerve fibres originate in the...
Components of the Urethral Sphincter
The urethral sphincter is horseshoe shaped and does not converge dorsally, where muscular fibres insert in a strongly built raphe of connective tissue which again serves as an anchor for the external sphincter in the boundary layer towards the rectum. Some groups prefer the description omega shaped rather than horseshoe shaped 5-8 . Although the shape seems to be broadly accepted, there is no concurrence re garding the course and structure of the urethral sphincter. Dorschner et al. were the...
Episiotomy and perineal lacerations
Perineal lacerations may occur with normal or instrumental vaginal delivery. Vulval and anterior vaginal tears do occur with vaginal delivery but posterior vaginal tear associated with perineal injury is more common and occurs with the delivery of the head and at times with the shoulders. Perineal tears are classified based on the involvement of the perineum. First degree tear involves the skin only while the second degree involves the perineal muscle. Injury to anal sphincter is classified as...
Pelvic floor Figs 19 and 110
The obturator internus muscle sits on the medial side of the ischial bone and, together with the body of the pubis, forms a wall that supports the origins of the pelvic floor. The pelvic floor itself is a sling of various muscles which are pierced by the urethra, the vagina and the anal canal. Posterior to the vagina these muscles form the perineal body. The puborectalis muscle forms a sling around the junction of the anus and rectum and posterior to the anus, these fibres are made up by the...
Surgical Treatment Sphincter Repair
There are three methods of repairing the sphincter apposition, plication reefing, and overlapping sphincteroplasty 37 . Apposition has classically been associated with low success rates 91 . Scar tissue Table 1. Cleveland Clinic Florida Fecal Incontinence CCF-FI scorea. From 37 Table 1. Cleveland Clinic Florida Fecal Incontinence CCF-FI scorea. From 37 a0 perfect continence, 20 complete incontinence a0 perfect continence, 20 complete incontinence Table 2. Influence of pudendal neuropathy on...
Lateral Internal Anal Sphincterotomy
Internal sphincterotomy was introduced into surgical practice more than 50 years ago 169 , with the lateral subcutaneous sphincterotomy becoming the procedure of choice after it was first reported by Notaras in 1969 170 . This represents a controlled division of the internal anal sphincter in its caudal part, usually to the dentate line. Although lateral internal sphincterotomy remains the surgical treatment of choice for chronic anal fissures unresponsive to medical therapy, with healing rates...
Anal Dilatation
Although first described almost two centuries ago, anal dilatation became the primary treatment for anal hypertonia associated with chronic fissure-in-ano and haemorrhoids after the introduction of the now-infamous Lord's procedure originally an eight-finger anal stretch in 1968 186 . The concept was that forceful dilatation would loosen the sphincter muscle and increase blood flow to the anoderm 187 . Despite reported success rates with respect to pain relief of 55-80 188-190 , it is now well...
Proctological Procedures General Introduction
Studies often underestimate iatrogenic incontinence, as follow-up is often short and trials are powered to show difference in intervention efficacy, not effect on continence. Anal-canal pressures decrease with age, and the initial iatrogenic injury may be compounded by subsequent obstetric injury 1 . Therefore, incontinence resulting from the proctological procedure may not be unmasked for a number of years. We recently published our experience of patients with incontinence after proctological...
Suprasphincteric Dysfunction
Stool Consistency Volume and Gastrointestinal Transit The consistency of the faeces and the rate at which they are introduced into the rectum may play a role in determining incontinence. Liquid stools rapidly delivered to the rectum are able to determine urgency and incontinence even in normal subjects 6 . Many patients with idiopathic FI have chronic diarrhoea, often secondary to irritable bowel syndrome (IBS). In these subjects, sigmoid pressures and sigmoid motility index are usually higher...
Large Intestinal Motility
Approximately 7-10 L of ingested or secreted water enters the small intestine during a 24-hr period. Of this amount, about 600 mL reach the colon. The motility patterns of the large intestine are organized so that all but about 100 mL are absorbed. The remaining fecal material is then stored until it can be evacuated conveniently. Structure and Innervation of the Large Intestine Beginning from the ileocecal junction, the large intestine is anatomically divided into the cecum the ascending,...
Rectal Evacuatory Disorder
Faecal impaction is an important risk factor for incontinence and predominantly affects older people, especially those living in institutions 41,95 , but also children 25, 41, 145 . In the elderly, approximately 50 of nursing home residents will suffer from faecal incontinence 41, 233, 234 prolonged retention of stool in the rectum, perhaps secondary to incomplete evacuation during defecation but also as a consequence of other factors, such as physical immobility, inadequate diet and water...
Gastrointestinal Smooth Muscle
The smooth muscle cells in each part of the gastrointestinal (GI) tract have structural and functional differences. However, certain basic properties are common to all of these cells. Smooth muscle cells make up all of the contractile tissue of the GI tract with the exception of the pharynx, the upper one-third to one-half of the esophagus, and the external anal sphincter, which are striated muscle. Smooth muscle cells are smaller than skeletal muscle cells and are long, narrow, and spindle...
Pathophysiology of Anorectal Dysfunction in Diabetes Effects of Autonomic Dysfunction and Hyperglycaemia
Many studies of anorectal function in diabetes have substantial limitations the techniques used were often suboptimal, only isolated aspects of anorectal function were evaluated, and no account was taken of the potential impact of acute or chronic glycaemia. A number of factors, including autonomic neuropathy, glycaemic control, and psychiatric comorbidity, may potentially influence the development and or regression of gastrointestinal symptoms, including incontinence, in diabetes. As...
Internal Anal Sphincter Atrophy
Internal anal sphincter (IAS) atrophy will often occur combined with EAS atrophy. Although the IAS is innervated by autonomic nerves, often the same injuries can afflict both somatic and autonomic nerves. Generally, IAS problems will lead more to soiling (leakage) of fecal fluid or mucous. Several reports have emerged about rare causes of fecal incontinence, such as primary IAS degeneration in passive fecal incontinence 22 and IAS sclerosis in mixed connective tissue disease 23 and systemic...
Diagnostic Tools Endoanal Ultrasound
Since the early 1990s, anal ultrasound has become an important tool in studying the anal sphincter complex. The technique's popularity began after a publication by Law and Bartram in 1989 18 . Ultrasound gained popularity in visualizing, defining, and describing the anatomy of the anal canal and the sphincter complex 19, 20 . The ultrasonographic findings were compared and correlated to elec-tromyography (EMG) and manometry. Law et al. 21 studied 15 patients with fecal incontinence due to...
Patient Selection
Baseline evaluation of symptoms described by a patient presenting with FI is fundamental in order to establish severity of continence dysfunction and its impact on the patient's lifestyle. Usually, this can be derived from a clinical assessment (including clinical history and physical examination), as well as from the evaluation of a diary kept by the patient concerning normal bowel movements and episodes of FI, specifying which kind of material has been lost (gas, liquid, solid stool)....
Physiological Investigations
The primary aims of tests used in FI patients are to better elucidate the pathophysiology and address the treatment. This is particularly complex, not only due to the lack of comprehensive knowledge on pelvic floor morphology and physiology but also because of the wide variety of tests used, not always as standard procedures. This assessment must concern both function mostly provided by anorectal manometry (ARM), rectal sensations investigation, and anorectal electrophysiology (AREP) and...
Diagnosing External Anal Sphincter Atrophy
Establishing atrophy of the anal sphincter complex has been evaluated with endoanal magnetic resonance imaging (MRI) 13-17 . Studies with endoanal MRI have demonstrated that severe atrophy of the EAS corresponded with a poor clinical outcome 15 and histopathology in biopsies taken from the EAS during surgery 13 . In general, atrophy can be established by measuring EAS thickness and surface area, and the subjective evaluation of the amount of fat. Another study found no relationship between fat...
Functional Anatomy and Physiology
Fecal continence is a complex function that requires coordinated responses in the pelvic floor sphincter muscles and abdominal and anorectal muscles. Consequently, fecal incontinence occurs when the normal anatomy or physiology of the anorectal unit is disrupted. In most cases, different pathophysiological mechanisms are involved in the pathogenesis of fecal incontinence, resulting in multifactorial etiology 3 . Physiological interaction of rectal motility and sensation with the tonic activity...
Sphincteric Risk Factors Obstetric Events
With respect to acquired faecal incontinence in women, we have recently reported the results of a (necessarily) retrospective cohort analysis of 475 women referred to our Gastrointestinal Physiology Unit for investigation of their symptoms of faecal incontinence 92 . The pertinent findings of that study can be summarised as follows The median age of symptom onset was 47 years and symptom duration 26 (range 2-502) months, with symptomatology usually being combined passive and urge incontinence....
Etiology of Fecal Incontinence
Fecal incontinence occurs when one or more mechanisms that maintain continence are disrupted to an extent that another mechanism(s) is unable to compensate. Thus the cause of fecal incontinence if often multifactorial 13-17 . In a prospective study, 80 of patients had more than one pathogenic abnormality 17 . Following is a list of important information that should be elicited when taking a history in a patient with suspected fecal incontinence - Onset and precipitating event(s) - Duration,...
Mechanisms of Faecal Incontinence in Diabetes
As discussed elsewhere in this volume, defecation involves close integration of the peripheral autonomic and enteric nerves. Therefore, it is reasonable to infer that ischaemic or toxic damage to these nerves caused by diabetes can lead to disorders of defecation that will vary according to the site and type of nerve(s) that are affected. As mentioned, it is important to not attribute the disturbances in defecation that occur in patients with diabetes as necessarily complications of diabetes...
Nerve Supply to the Pelvic Floor Autonomic Innervation
The anorectum and pelvic floor are supplied by sympathetic, parasympathetic, and somatic fibers 13 . Sympathetic pre ganglionic fibers originate from the lowest thoracic ganglion in the paravertebral sympathetic chain and join branches from the aortic plexus to form the superior hypogastric plexus. Because the superior hypogastric plexus is not a single nerve, the alternative term for this plexus, i.e., presacral nerve, should be avoided. The superior hypogastric plexus provides branches to the...
Normal Anatomy and Morphology with Anal Ultrasound
The normal rectum is 11- to 15- cm long and has a maximum diameter of 4 cm. It is generally not empty but is filled with some remainders of faecal material and or air. This makes it not always easy to obtain an optimal acoustical surrounding for anal ultrasound. On EUS, the normal rectal wall is 2- to 3-cm thick and is composed of a five-layer structure, as is the rest of the digestive tract. The anal canal is 2- to 4- cm long and is closed in the normal situation. Therefore, excellent images...
Motor Neurons For Head And Neck Muscles
Muscles of the head and neck are for the most part highly specialized, and each exhibits unique functional properties. Extraocular muscles are innervated by lower motor neurons in cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which originate from the brain stem. They are among the fastest muscles in the body and are continually active during awake hours as well as during certain segments of the sleep cycle, called rapid eye movement (REM) sleep. As described below, the...
The Golgi Tendon Organ
The second type of specialized sensory receptor found in muscle tissue is the Golgi tendon organ. Its function is to signal the amount of tension generated by muscle contraction. The end organ is composed of braided collagen fibers within a capsule approximately 1 mm in length and 0.1 mm in diameter (Fig. 3). It is innervated by a free nerve ending classified as Ib, slightly smaller than Ia fibers of the muscle spindle. Golgi tendon organs are located at junctions between muscles and their...
Reciprocal Reflexes
Two important principles should be recognized (1) The myotactic and reverse myotactic reflexes reflex measure the force between the muscle and its insertion. When the receptor of the Golgi tendon organ is stretched, either by passive stretching or muscle contraction, it activates an interneuron that inhibits the motor neurons going to the same muscle. Shown in blue are neurons that are excited when the Golgi tendon organ is stretched. reflex measure the force between the muscle and its...
Synthesis Biological Evaluation NMR Solution Structural Models of New Oxytocin Analogues
Raptis2, G. A. Spyroulias1, V. Magafa1, J. Slaninova3 and P. Cordopatis department of Pharmacy, University ofPatras, GR-265 04 Patras, Greece 2Technological Education Institute, Egaleo, GR-12210 Athens, Greece 3Department of Peptide Biochemistry, Institute of Organic Chemistry and Biochemistry, Academy of Sciences of Czech Republic, Flemingovo square 2, Prague 6, CZ-166-10, We report the solid-phase synthesis of four oxytocin analogues in which the residues...
Physiological Actions Of Ovarian Steroid Hormones
As described above, intraovarian actions of estradiol and progesterone are intimately connected to ovulation and formation of the corpus luteum. In general, extra-ovarian actions of these hormones ensure that the ovum reaches its potential to develop into a new individual. Ovarian steroids act on the reproductive tract to prepare it for fulfilling its role in fertilization, implantation, and development of the embryo, and they induce changes elsewhere that equip the female physically and...
Prelabour and labour hormonal and immunological mechanisms
The multitude of biological substances which interact in the control of the human birth process seem to increase almost daily. To catalogue more than 60 such factors might Table 7.1 A far from comprehensive list of substances and categories of substances which are known to participate in the birth process Table 7.1 A far from comprehensive list of substances and categories of substances which are known to participate in the birth process Those shown in italic are discussed in detail in the text...
Performance Of Dyslexics And Nondyslexics On The Rorschach Ink Blot Test
Ann Williams was a very experienced clinical psychologist whose home was in North America but whose family had had connections with Wales. She therefore Table 15.1. Frequency distribution of differences in dyslexia index between first and second assessments Table 15.1. Frequency distribution of differences in dyslexia index between first and second assessments came over to Bangor to study for her Ph.D. This was in the 1970s. At this stage we felt we knew a certain amount about the cognitive...
Urodynamic stress incontinence
Urodynamic stress incontinence is defined as the involuntary leakage of urine during increased abdominal pressure Pressure catheters _ Analogue to digital converter Urine loss detector Sampling at 10Hz Solid state memory 2Mbyte Internal clock Personal computer Recording downloaded Traces analyzed on appropriate scale Pressure flow analysis Diary kept by patient _ Diary merged with traces , ., , . , Fig. 49.19 Schematic flow diagram 1 representing ambulatory urodynamics 4-h test, standardized...
Could Clarithromycin Prevent Asthma
Kundsin, and Sharon A. Poulin Brig ham and Women's Hospital, The Children's Hospital Medical Center and Harvard Medical School Boston, Massachusetts Asthma is the most disabling of all chronic diseases in childhood, and one of the commonest. About 30 of individuals who are subsequently diagnosed, in middle childhood or later, as having asthma began with symptoms of recurrent wheezing, cough, and bronchospasm in the first year of life, A longitudinal study of infants...