Diffusion-limited transport of a substance is limited by the diffusion of the substance across the capillary membrane rather than by the amount of flow delivered to the tissues buy kamagra effervescent 100 mg erectile dysfunction over 70. Bulk filtration or absorption of water occurs across capillaries through pores in adjacent endothelial cells buy kamagra effervescent 100mg without a prescription erectile dysfunction injections cost. Plasma hydrostatic and colloid osmotic pressures are the primary forces affecting fluid filtration and absorption across capillary walls generic kamagra effervescent 100 mg with mastercard impotence of proofreading poem. The ratio of postcapillary to precapillary resistance is a major determinant of capillary hydrostatic pressure. Lymphatic vessels collect excess water and protein molecules from the interstitial space between cells. Myogenic arteriolar regulation is a response to increased tension or stretch of the vessel wall muscle cells. Nitric oxide from the endothelium is a major local vasodilator of arterioles and controller of multiple vascular functions and properties. The axons of the sympathetic nervous system release norepinephrine, which constricts the arterioles and venules. Autoregulation of blood flow allows some organs to maintain nearly constant blood flow when arterial blood pressure is changed. During digestion, intestinal smooth muscle motility as well as the energy requiring processes used for cellular transport of substrates across the intestinal mucosa are greatly increased. Oxygen transport in the intestine during digestion would therefore likely be characterized by: A. Increased oxygen requiring activities by the intestine during digestion would induce an active hyperemia through dilation of arterioles. This would increase blood flow to the intestine and increase the number of open perfused capillaries. Therefore, oxygen delivery to the intestine would be increased, the capillary surface area available for diffusion would increase, and the distance between an intestinal cell and its nearest capillary would decrease. Thus, transport into and across the intestinal capillaries would increase and help meet the increased oxygen demand of that tissue during digestion. Diffusion parameters would be improved, not reduced, so that diffusion-limited transport would not occur. Which of the following would limit local edema formation following traumatic injury to a lower limb? Arteriolar vasoconstriction will decrease the postcapillary:precapillary ratio of resistance and therefore reduce hydrostatic pressure in the capillary. This reduces filtration of fluid at the capillary and can even cause the capillary to absorb water from the interstitium. Capillary injury would disrupt capillary integrity and increase their hydraulic conductance, which would exacerbate edema formation. Blood clots in the large veins will increase back pressure into the capillaries that favor water filtration and edema formation. Rupture of lymph channels would remove the vascular component used to drain excess fluid from the interstitial spaces and thereby favor edema formation. Compared to a normal arteriole, an arteriole in an individual with chronic arterial hypertension would: A. Endothelial damage in hypertension would not affect myogenic constriction in response to an increase in intravascular pressure or metabolic dilation in response to low blood flow because these factors work at the level of the smooth muscle cell. Similarly, the receptors for norepinephrine that link the sympathetic nervous system to vasoconstriction are on the smooth muscle cells and not the endothelium. Histamine is released in tissues in response to allergens and mediates characteristic changes in the microcirculation associated with an allergic reaction. Histamine is an arterial vasodilator that also affects the cytoskeleton of capillary endothelium such that the clefts between cells are opened. Which of the following would characterize the microcirculation in response to histamine? Capillary hydrostatic pressure and the capillary filtration coefficient are reduced. Capillary hydrostatic pressure is reduced, but the capillary filtration coefficient is increased. Capillary hydrostatic pressure is increased, but the capillary filtration coefficient is decreased. Capillary hydrostatic pressure and the capillary filtration coefficient are increased. Capillary hydrostatic pressure and the capillary filtration coefficient are unchanged. Arteriolar dilation favors an increase in capillary hydrostatic pressure and an increase in blood flow into the capillary network. Venules also are dilated by histamine, which further augments blood flow, although it mitigates somewhat the increase in pressure caused by precapillary vasodilation. The capillary filtration coefficient is a measure of the hydraulic conductance across the capillary and is increased by anything that increases capillary permeability. The increase in filtration across capillary networks in response to an allergic reaction is often great enough to cause local edema in the tissue. All of the following will favor tissue edema formation in splanchnic organs except: A. Arterial vasoconstriction to splenic organs will reduce intracapillary hydrostatic pressure and thus reduce the probability of edema formation. Dilation of arterioles in such organs will have the opposite effect, especially because organs of the digestive tract have such high capillary filtration coefficients. Hypoalbuminemia reduces plasma oncotic pressure everywhere in the body and favors capillary fluid filtration and edema formation. Portal hypertension increases capillary hydrostatic pressure in the small intestines and, in spite of a notable venous–arteriolar response in that organ, is almost always associated with intestinal edema formation and ascites. Her reaction to the sting is a greater-than-normal redness and itching at the site of the sting but is otherwise uneventful. During her regularly scheduled physical exam, her physician warns her mother that this child might be allergic to bee venom and should try to avoid being stung again. Unfortunately, 1 month later while playing in her backyard near a bed of flowers, she gets stung on her hand by a bee. However, the area of the sting begins to turn red and swells, developing a wheal of about a 3-cm radius around the sting within 2 minutes. The girl then rapidly develops severe difficulty breathing and is rushed to the emergency room. What is the cause of the redness and swelling at the site of the bee sting on this girl’s hand? What is the likely predominant mediator of the redness and swelling at the sight of the bee sting?

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What are other options for surgical hypertrophic pyloric stenosis trusted kamagra effervescent 100 mg erectile dysfunction books, duode- suggests proper hydration best purchase for kamagra effervescent vegetable causes erectile dysfunction. Only gastrojejunostomy in elderly frail Antral contraction fails to expel gastric increased renal loss cheap 100 mg kamagra effervescent erectile dysfunction treatment philadelphia. What is the drawback of gastrojejunos- peristaltic waves set in to cause vomiting. Correction of hypoproteinemia by oral improves and there is chance of stomal or weakness? Gastric lavage is done before each feed mucolytic agent, it will produce more weakness. Normal saline is allowed to run through Na – 45 mmol/liter on the background of metabolic alkalo- the Ryle’s tube and aspirated back. Tere is no history of radiation of pain adhesion with or without abscess Technetium (99mTc) labeled chicken to right shoulder. Hourglass contracture in gastric The 45-year-old male patient presents with tuberculosis? The pain is burning in character with perature, loss of weight, anorexia, night 10. How does chronic duodenal ulcer difer tract by an interaction of acid and pepsin relieved by taking food and antacids. How will you confrm the diagnosis of occurs for 2-3 months with a pain-free inter- istics of pain in chronic gastric ulcer peptic ulcer disease? Endoscopy – Esophagogastroduodeno- Tere is no history of vomiting, hematem- duodenal ulcer. Onset of pain – Soon afer eating (15 directly and multiple biopsies are taken Bowel and bladder habits are normal. Rapid urease test is done with the aspi- Personal history – He belongs to low soci- iii. Aggravating factor – Food genesis of gastric ulcer is breakdown abdomen and bowel sounds audible. Hemorrhage – Hematemesis more of gastric mucosal barrier by various common than melena in gastric ulcer. Gastric mucus, a vis- It is uncomplicated because there is no undergo a malignant change. It is deep tender spot in the transpyloric is enhanced by the presence of bicarbo- Chronic duodenal ulcer is suggested by plane 2. Gastric mucus the presence of hunger pain, well-marked sometimes felt in active duodenal ulcer. Tere are three types of complications: acts as a physiological barrier to protect 3. Chronic intestinal tuberculosis tric ulcer and melena in duodenal hypersecretion is the main cause of d. Subacute acid hypersecretion are: 459 Section 15A  Clinical Surgery (Long Cases) i. Peptic ulceration (Gastric ulcer and edema and subsequently due to scar- increased vagal activity. It is seen that around 90 percent of duode- which occur due to damage of mucosal b. Acid output studies – Basal acid out nal ulcer patients and 70 percent of gastric defences. It type epithelium and in the duodenum in result of stasis and gastritis due to is abnormally high in Zollinger – Ellison association with patches of gastric meta- fbrous stenosis or pylorospasm. Middle or lower part of lesser cur- bition of gastrin release by the antral tritis associated with depletion of soma- vature–90 percent within 5 cm of G cells. The normal value ranges In the majority of cases this has no the risk of malignant change. It measures the acid production during efect is exaggerated leading to duodenal Chronic duodenal ulcer usually occurs in stimulation by pentagastrin injection (a ulceration. In duodenal ulcer this is of stomach is removed) with gastrodu- • Nutritional problems, e. Truncal vagotomy with gastrojeju- is shifed from blood vessel or veins into others. Early complications: sodes occur in the form of hemateme- • Hemorrhage sis or melena and remains uncontrolled • Paralytic ileus with medical measures. It can be prevented by In frail and poor risk patient this is done It is therefore, mandatory to do a drain- i. A gastrojejunocolic fstula is an internal of 1 to 2 cm segment of each vagal trunk 48. What is the diference between antrec- communication between stomach, jeju- as it enters the abdomen, on the distal tomy and hemigastrectomy? The terms antrectomy and hemigastrec- a recurrent ulcer afer gastrojejunostomy, 41. What is the most efective surgery for should arouse the suspicion of Zollinger- • Postvagotomy diarrhea occurs in 10 reducing gastric acid output? Why a drainage operation is required with Vagotomy removes the vagal cholinergic to enteritis, caused by colonic content truncal vagotomy? The nature of upper abdominal pain is principal stimuli of gastric secretion are controlling the ulcer. What are the presentations in chronic It removes the major source of gastrin and Regarding pain patient gives the following cholecystitis? Suction of duodenal discharge if the signs and symptoms of any systemic complications like empyema, perfora- drain is in situ, if the drain is not present disease present. Barrier cream like zinc oxide is applied patient is of average build, pulse – 80/ Biliary colic is a sharp, intermittent pain to protect the skin. Abdomen moves normally by contraction of the gallbladder against a gastrojejunostomy. Tis sign is positive in acute this syndrome consisting of- • On palpation, mild tenderness is cholecystitis. The patient is asked to take a deep (stomach, esophagus, jejunum and no lump palpable. Marked increase in gastric acid and there is no free fuid in the abdo- point (a point beneath the right costal secretion. Tere is a catch in breath at the height of Tere will be diarrhea and hypokalemia rectal and per vaginal examination not inspiration and the patient complains of with hypergastrinemia and massive acid done. The patient is female, fertile and 40 and 11th ribs posteriorly on the right Omeprazole in the doses of 20-40 mg years old.

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However buy 100 mg kamagra effervescent amex erectile dysfunction pills in pakistan, the emergency may provide the the community cheap 100 mg kamagra effervescent overnight delivery erectile dysfunction holistic treatment, however generic kamagra effervescent 100mg with amex erectile dysfunction medication insurance coverage, will be determined by the opportunity of extending normal immunization level of sanitation prior to the disaster. A partial or total disruption of control programs, settlements and camps, who might earlier have been compounded by the tendency to divert available scattered and difficult to reach. Control of Communicable Diseases in Man Medicine (9th edn): New York: McGraw Hill, 1980. Disinfection, Sterilization and Preservation (3rd 1985), Newsletter of the Emergency Preparedness and edn): Philadelphia: Lea and Febiger, 213, 1983. Central Bureau of Health Intelligence: Health Information Clinical Medicine, Series One (2nd edn), Delhi: Arnold of India, 1991. Preventive Medicine for the Doctor in his Progress in Clinical Medicine, Series Four, 31-56, 1981. The reason for their inclusion in this chapter is that these, as well Among the acute respiratory illness two-thirds to three- as others described in this chapter, have the respiratory fourths are caused by viruses. Detailed and syndromes, such as common cold, pharyngitis, croup, systematic epidemiological description of an infective tracheobronchitis, bronchiolitis, pneumonia, etc. It occurs more in winter and in cold this will be done only in case of major infections. It is an acute infection of the respiratory tract specific infections, the source of infection is always characterized by sneezing, running nose, exogenous, e. In nasopharyngeal irritation and malaise lasting two to nonspecific infections, the source may be exogenous or seven days. The patient preexisting infection becomes active due to lowered is highly infective 24 hours preceding and five days resistance and results in disease. Transmission is by The following infections will be described in this droplet method or through fomites such as chapter: handkerchief. Immunity is short- • Nonspecific viral infections lived and lasts for a month or so. Cold vaccines have • Specific viral infections been used but the results are not encouraging. The influenza virus, known to – Pneumonias be circulating as a human pathogen since at least the – Streptococcal sore throat 16th century is notable for its unique ability to cause • Specific bacterial infections recurrent epidemics and global pandemics. Genetic – Diphtheria reassortments in the influenza virus cause fast and – Whooping cough unpredictable antigenic changes in important immune – Meningococcal meningitis targets leading to recurrent epidemics of febrile – Tuberculosis. Usual symptoms are flushed emerged strain, which can then spread to cause an face, congested conjunctivae, cough, sore throat, fever ‘Influenza pandemic’. Pandemics occur every 10 to 50 for two to three days, headache, myalgia, back pains years. Pneumonia due to secondary century and in the last 400 years; at least 31 pandemics bacterial infection is the most common complication. During the twentieth century, three Laboratory confirmation is made by recovery of virus influenza pandemics occurred (Table 16. The virus has three distinct genera (types A, B peak is reached in three to four weeks before declining. The epidemic lasts for subtypes based on two proteins on the surface of the six to eight weeks at a place. Type C influenza virus has been associated with sporadic cases New influenza virus strain may evolve due to point and minor localized outbreaks. Antigenic drift occurs in both maximally attacks those in the age group 5 to 15 years Influenza A and B viruses. Drift are highest among children, but death and serious ensures an ongoing turnover of viral strains and thus illness are common amongst persons aged 65 years, a constant renewal of susceptible hosts, which is the basis children below two years and persons of any age with for the regular occurrence of influenza epidemics. Antigenic shift is noted only with 1968 H3N2 (“Hong Kong”) Mild type A influenza virus. Antigenic shift appear to result Source: Pandemic Influenza, C D Alert, May-June 2006 Vol. An example of antigenic shift of India Immunity: The antibody to H type of antigen prevents is most frequently isolated from nasopharyngeal or initiation of the infection while that to N antigen prevents throat swabs, nasal washings or sputum obtained within virus release and spread. During an appear in about seven days after an attack and peak in outbreak of respiratory illness, however, testing can be the blood by two weeks. The level drops to preinfection very helpful in determining if influenza is the cause of level by 8 to 12 months. Following laboratory tests that can be Antibody against one influenza virus type or subtype carried out are: confers limited or no protection against another type • Detection of antigen in nasal secretions by: or subtype of influenza. Furthermore, antibody to one – Rapid test: It can be used to detect influenza antigenic variant of influenza virus might not completely viruses within 30 minutes. Transmission of viruses starts one day before the viruses that normally infects only birds and less onset of symptoms and continue up to five to seven days commonly pigs. Transmission is possible from but has on rare occasions crossed the species barrier to asymptomatic carriers. Influenza viruses can be of pathogenicity, the milder one may even go unnoticed inactivated by sunlight, disinfectants and detergents easily. This is the reason why presence of H5 and Wild birds are the primary natural reservoir for all H7 virus in poultry is always a cause of concern, even subtypes of influenza A viruses and are thought to be when the initial signs of infection are mild. The current outbreak of highly infective avian Pigs can be infected with human, avian and swine influenza which began in S E Asia in mid-2003, are the influenza viruses and there is possibility of development largest and most severe on record. Never before in the of new strain due to genetic reassortment among the histories of this disease have so many countries been viruses of different species. While it is unusual for people simultaneously affected resulting in death of so many to get influenza infections directly from animals, sporadic birds (150 million). The causative agent, H5N1 virus is human infections and outbreaks caused by certain avian now considered endemic in many parts of Asia. The incubation time for influenza ranges from one to Alarmingly most cases have occurred in the previously five days with an average of two days. A second risk of even greater concern is that the virus may change highly Diagnosis infectious form for humans and spreads easily from 172 Traditionally, the definitive diagnosis of influenza is made person to person. Such a change would mark the either on the basis of virus isolation or by serology. Currently, two subtypes of influenza A (A/H1N1 and A/H3N2) Direct contact is presently considered as the main route virus as well as influenza B virus are included in the of transmission while come in contact with infected bird vaccine. Among healthy adults, appropriate influenza (slaughter, defeathering, butchering and preparation of vaccines will in general achieve protection rates of about poultry for cooking, etc. Infections also occur from 50 to 80 percent against clinical disease, whereas virus in their feces and the environmental exposure to vaccination of the elderly reduces the risk of serious such dropping. The virus can improve its transmissibility among humans via two principal mechanisms. The first is a “re- Route and dose: Most inactivated influenza vaccines assortment” event in which the genetic material is are given via the intramuscular route in the deltoid muscle, exchanged between human and avian viruses during except in infants where the recommended site is the co-infection of a human or pig resulting in emergence antero-lateral aspect of the thigh. Other inactivated vaccine annually is appropriate, except for mechanism is the adaptive mutation increasing the previously unvaccinated preschool children pre-existing capacity of the virus to bind to human cells.

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Hebb (1974) noted that while human beings a part of the broader rehabilitation enterprise discount 100mg kamagra effervescent visa impotence and smoking. Emotional attachments purchase cheap kamagra effervescent online impotence bicycle seat, or bonds generic kamagra effervescent 100mg free shipping impotence 36, which deserves further discussion in light of recent theoret- become crucial for survival and greatly influence interper- ical and empirical advances. Psychotherapists must understand that the adaptive both the process and outcome of rehabilitation (see Chapter management of sex and aggression in a given society for a 19, Awareness of Deficits). Strict behavioral approaches have not shown that for the better or for the worse (Jung 1964). Understanding an increase in error detection monitoring translates into im- what symbols individuals relate to will provide useful in- proved self-awareness (Ownsworth et al. Suggested tactics for the psychotherapeutic process Tactic Description Gain a historical perspective Obtain information from family, friends, employers, and teachers concerning preinjury growth and development, health, education, occupation, personality, interests, values, goals, and impediments. Specifically, include a discussion of the patient’s favorite fairy tales, stories, music, and topics that help mold the patient’s personal life. Understand key and early memories that seem to influence how the patient approaches key relationships in life. Find areas of shared meaning Determine what having a brain injury means to the patient and how he or she perceives its effects. At first, the psychiatrist (or psychotherapist) may have to take the initiative, explaining the mechanism of traumatic brain injury in simple terms, relating the patient’s difficulties to the injury, and describing the problems, events, and so on that can be expected in the future. Encourage the patient to take Concentrate on the concrete real-life difficulties that the injury has caused the patient. Early in the lead treatment, focus on the here and now, avoid discussing the past (it requires good memory, and it is over), avoid discussing the future (it requires the ability to abstract, and at this point it is beyond comprehension). However, be prepared to discuss topics that you suspect are relevant to the patient’s neuropsychological and psychosocial difficulties, even if the patient cannot articulate them on certain days. Help the patient develop For example, suggest that the patient keep a notebook, follow a sequence of predetermined steps, rest simple coping strategies before becoming too fatigued, request that a confusing message be repeated slowly and in simpler terms, set up priorities for a series of necessary tasks. Through cognitive rehabilitation exercises, demonstrate how compensations are helpful, but be mindful as to their cost in terms of time and energy. Manipulate aspects of the For example, suggest organizing household equipment, utensils, dishes, and so on in a systematic environment to enable the fashion; labeling drawers and closets; using an alarm or calendar watch. Teach the patient to use a patient to function more memory compensation notebook during the process of psychotherapy. Build on the patient’s assets Build on the patient’s remaining assets and avoid focusing on the residual deficits. But “keep in front of the patient” in a therapeutic way what, in fact, are the patient’s neuropsychological deficits that he or she must deal with on a daily basis. This touches on the important issue of separating denial from unawareness after traumatic brain injury. Engage the patient in Use members of professional groups that are action oriented, such as actors, dancers, and artists, in meaningful goal-directed addition to the more traditional rehabilitation staff. Provide guidance to improve inappropriate behavior from that of the psychiatrist with authority. Maintain flexibility Many patients are adolescents or young adults in various stages of development; for most of these patients, some improvement in physical condition and cognitive function can be expected over time. Remember that a patient’s abilities and emotional state can vary from moment to moment depending on preceding events, the character of the task, the degree of alertness and motivation, and the environmental conditions. To help maintain flexibility, periodically obtain consultation from other psychotherapists to get their view on how to manage difficult problems with the patient. Recognize that the approach to This should happen both within and across treatment sessions. Ideally, the treatment approach therapy should change as the should move gradually from one that is concerned primarily with the management of concrete, patient changes here-and-now, practical problems to one that places greater demands on the patient to consider psychodynamic issues. Instill hope Instill hope in the patient and family without expressing unwarranted optimism. The hope must always be realistic in nature in order for it to be helpful to the patient and the family. Measure the outcome of your Measure outcome in both objective and subjective terms to determine the value of this service for clinical interventions patients. This becomes crucially important for future funding (see Prigatano and Pliskin 2003). Present author’s modifications to the original suggestions by Pollack (2005) are shown in italics. With partial knowledge of one’s neurolog- ical and neuropsychological limitations, one can use both Perplexity: Living With defensive and nondefensive methods of coping. Long-Term Cognitive Dysfunction Social Isolation and Loneliness Perplexity is low-grade confusion. They become progressively disillusioned and humil- relationship to addiction is important for successful psy- iated by their difficulties and consequently seek out a more chotherapeutic work. Engaging patients in activities that they that in mammals a “separation cry” occurs when the infant can manage becomes important in reducing the social isola- is removed from its mother. MacLean (1985, 1987) chological rehabilitation that are applied in early stages after argued that this connection is important for the expression brain injury should also be kept in mind when managing of distress associated with forced isolation that threatens these patients over their lifetime (Prigatano 1999). He suggested that various illicit drugs used in Western culture directly act on the neurotransmitters in these regions. The basis of drug abuse in our society, there- Conclusion fore, may have something to do with the distress experi- enced by emotional isolation. People with brain injury In this chapter, I have attempted to revisit and modestly may be prone to various addictive behaviors if the problem expand on some of the important observations made by of social isolation is not effectively dealt with. Pollack (2005) in his chapter on psychotherapy in the first To help the patient reduce social isolation, the therapist edition of this book. It is hoped the definition of psycho- may use a variety of methods tailored to the individual pa- therapy offered in this chapter makes it clear that psycho- tient’s interests and abilities. Involvement in group interac- therapy is not the purchase of friendship (Schofield 1964) tion, particularly within the context of group psychother- or simply healing via persuasion (Frank and Frank 1991). Group ter suggests that much more is needed than behavioral psychotherapy may include specific training at reading so- therapy. The goal is not simply behavioral change, but cial cues and learning appropriate social responses. Once rather productively and creatively dealing with the com- psychotherapy is completed, support groups may be helpful plex emotions and motivations that a person experiences in providing social interaction with others who understand when adjusting to the effects of brain injury in his or her the context for the individual’s social behaviors. It is for this reason that both civilians and returning patient resumes regular employment, voluntary work trials veterans from war need neuropsychological rehabilitation may assist the patient gain social experience within the con- programs that incorporate psychotherapeutic interven- text of the work environment. Behavioral mod- ropsychological rehabilitation is to reduce psychosocial iso- ification programs in and of themselves are not enough. Psychotherapy 577 • Psychotherapy with brain-dysfunctional patients requires that the treating clinician have a very good knowledge of human nature and behavior, attained by understanding animal behavior, reinforcement or learning theory, and analytic psychology as well as psychodynamic theories. Ownsworth T, Fleming J, Desbois J, et al: A metacognitive contex- Recommended Readings tual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single case ex- Goldstein K: Effects of brain damage on the personality. In that talk, to examine the process of performance, individuals were I drew on my long history of research collaboration with observed while they were performing visual motor tasks, pioneers of cognitive rehabilitation research at New York such as block design.

Acquired ptosis is most often the result of disinsertion or attenuation of the levator aponeurosis buy kamagra effervescent mastercard erectile dysfunction pills non prescription, which is most commonly related to aging but can be related to chronic ocular inflammation or eyelid edema (Fig order 100mg kamagra effervescent impotence organic origin definition. What clinical findings help to differentiate congenital ptosis from acquired aponeurotic ptosis? The ptotic eyelid frequently appears higher than the normal eyelid as the patient moves toward downgaze buy kamagra effervescent 100 mg amex erectile dysfunction myths and facts. Involutional (aponeurotic) ptosis is maldevelopment of the levator muscle, characteristically mild to moderate with high upper with poor ability to contract in elevation eyelid crease. Congenital ptosis is dystrophy or maldevelopment in the levator muscle/superior rectus complex (Fig. Most patients demonstrate poor levator function on examination and, at surgery,havefattyinfiltrationofthelevatormuscle. Patients may or may not demonstrate motility defects because of superior rectus dysfunction. It is thought that levator dehiscence causes ptosis related to previous intraocular surgery. The exact etiology is uncertain; however, it has been linked to superior rectus bridal sutures, eyelid speculums, retrobulbar and peribulbar injections, and other draping maneuvers Figure 37-2. A, associated with manipulation of the Decreased levator muscle function occurs along eyelids. B, The ptosis tendency toward levator dehiscence is exaggerated in upgaze because of the poor preoperatively. C, In downgaze the ptosis is reduced or absent because the fibrotic levator muscle cannot stretch. With aponeurotic ptosis, these attachments are disinserted, causing the eyelid crease to elevate. Neurologic conditions that must be considered in a ptosis evaluation include third-nerve palsy, Horner’s syndrome, myasthenia gravis, Marcus Gunn’s jaw- winking syndrome, ophthalmoplegic migraine, and multiple sclerosis. Blepharophimosis with bilateral and telecanthus (widening of the distance ptosis, eyelid phimosis, telecanthus, and epicanthus inversus. The history of any patient with acquired ptosis should include questions searching for symptoms of myasthenia gravis. They also may notice increased ptosis during periods of fatigue or toward the end of the day. They may give a history of diplopia or difficulty with swallowing as well as other muscular weakness. On examination, patients may demonstrate eyelid fatigue on sustained upgaze, with curtaining of the eyelid on returning to the primary position. On return to primary position, the eyelid may show an upward twitch before it settles to its final resting place. Orbicularis strength may be weak, allowing the examiner to open the patient’s eyelids even during attempted forceful closure. What measurements should be taken during the preoperative examination of patients with ptosis? Other critical parts of the preoperative evaluation include a careful pupillary examination for anisocoria, a cover test for strabismus, and evaluation of corneal sensation and tear film. The lid position is carefully evaluated in primary position with the action of the frontalis muscle negated. The eyelid position is also evaluated in downgaze, looking for eyelid lag that suggests congenital ptosis or previous thyroid ophthalmopathy. The eyelid is evaluated in upgaze for signs of muscle fatigue and curtaining, which suggest myasthenia gravis. Finally, it is important to document the presence of a good Bell’s phenomenon (upshoot of the cornea with eyelid closure). Hering’s law of equivalent innervation of yoke muscles applies to the two levator muscles. It needs to be considered during the preoperative evaluation to determine accurately the degree of ptosis on each side. The normal eyelid in a patient with unilateral ptosis may become ptotic when bilateral stimulation is broken. The eye with which the patient prefers to fixate affects the degree to which Hering’s law contributes to ptosis. If the ptotic eye is preferred for fixation, the opposite eyelid may develop a retracted position because of increased stimulation during attempts to open the ptotic eyelid. On occluding the ptotic fixating eye, the previously retracted eyelid may resume a more normal position. The Neosynephrine test is an evaluation of the effect of Muller’s muscle contraction on the¨ degree of ptosis. The phenylephrine causes contraction of the sympathetic Horner’s muscle, sometimes causing dramatic improvement in the degree of ptosis. If phenylephrine corrects the ptosis completely, many surgeons elect to perform a Muller’s¨ muscle resection as opposed to a levator resection. The most common surgical approaches to ptosis correction include levator resection, either from an internal or external approach; Muller’s muscle resection; and frontalis suspension. Although rarely used, spectacle adaptations are a reasonable option for patients with neurologic ptosis who have a poor Bell’s phenomenon and are considered to be at high risk for exposure keratopathy. The most common complication is overcorrection or undercorrection of the ptosis and/or abnormalities in eyelid contour. Other complications include eyelid lag on downgaze and lagophthalmos on eyelid closure. These complications may result in corneal exposure and superficial keratopathy or even corneal ulceration and scarring. In addition, retrobulbar hemorrhage is a risk with all eyelid surgery, and, although rare, infection is a potential complication. Marcus Gunn’s syndrome is a unilateral congenital ptosis with synkinetic innervation of the levator and ipsilateral pterygoid muscle. Patients demonstrate retraction of the ptotic eyelid on stimulation of the ipsilateral pterygoid muscles by either opening the mouth or moving the jaw to the opposite side. Whitnall’s ligament, also known as the superior transverse ligament, is a condensation of collagen and elastic fibers on the anterior levator sheath as it changes from muscle to aponeurosis. It attaches medially near the trochlea and laterally traverses through the lacrimal gland, attaching to the lateral orbital wall approximately 10 mm above the lateral orbital tubercle. It serves as a suspensory ligament for the upper eyelid and is the point where the vector forces of the levator muscle transfer from an anterior-posterior direction to a superior-inferior direction. Patients with neck pain, facial pain, or headache and acute Horner’s syndrome should be suspected of having a carotid artery dissection. Work-up should be urgent and include magnetic resonance imaging or angiography and carotid Doppler ultrasound of the neck. A carotid dissection usually requires urgent anticoagulation and neurovascular consultation. Chan C, Paine M, O’Day J: Carotid dissection: A common cause of Horner’s syndrome.

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When such a flea feeds generic 100 mg kamagra effervescent mastercard erectile dysfunction causes mnemonic, it regurgitates Reservoir the bacterial culture and transmits the infection order kamagra effervescent in india erectile dysfunction diabetes viagra. Man acts as the source in case of pneumonic plague Blocked flea is an efficient transmitter of plague and only order kamagra effervescent 100 mg visa erectile dysfunction pills available in stores. Domestic rat (Rattus rattus) is the normal reservoir partially blocked flea is more dangerous than of plague. An epizootic in domestic rats precedes human completely blocked flea, because it live longer. They convey the infection to Rattus rattus Usually 3 to 4 days but varies from 2 to 12 days. It is moderately susceptible infective for a few months under suitable conditions. Spread of man when there is pneumonic plague or when a infection is probably related to the migratory nature of 2 person comes in contact with suppurating bubos. International Incidence is a little higher in women because of their certificate is valid for 6 months, starting from the 6th greater proximity to house rats. It is said to be more These are as follows: effective, but is associated with more marked local • Notification: Continuous surveillance of human and and general reactions. Dead measures applicable to ships, aircrafts and land rats should be dissected for microscopic evidence of transport arriving from the plague affected areas. It is hourly, till the temperature remains normal for 3 to difficult to inspect and treat the containers at any 4 days. When antibiotics are not available, sulphonamide such as An epidemic of pneumonic plague occurred India in 1994. For chemoprophylaxis, if required, an as per the well known epidemiological principles. All the necessary ingredients were present,6 namely: antibiotic, 1 g per day, or sulphadiazine, 2 to 3 g per day, may be given for 6 days. The measures include: wild rodents undergo aestivation in hot summer and – Patient’s clothes should be boiled. In view of the above, various researchers claimed7 patients may become comatose and die. In order to settle He is only accidentally infected and represents a dead the controversy, the Central Ministry of Health and end in the chain of transmission. The infection occurs Family Welfare appointed a Committee under the naturally among vertebrates such as monkeys, shrews, Chairmanship of Dr V Ramalingaswami to give its rats and carnivorous bats. The committee gave its report in 1995, ticks belonging to genus Hemophysalis, especially certifying that the epidemic was caused by plague. Tick borne corresponds to the high density of nymphal stage of the ticks and also to human activity in the forest. All stages resembles the Omsk hemorrhagic fever found in in this life cycle, except the eggs, can become infected. Spraying operations: Spraying of acaricides on forest There is high continuous fever for 5 to 12 days accom- tracks which are used by man is done regularly. Though it continues to be called epidemic is currently being manufactured at the Virus typhus, it is no longer seen now in the form of Diagnostic Laboratories at Shimoga (Karnataka). The body louse or the head louse becomes infected 3 Medical Times (Published by Sandoz). A rash appears The basis for control of the disease is louse control and on the fourth or fifth day of fever on axillary folds, immunization. The vaccine • A complement fixation test with group specific is administered subcutaneously in 2 doses of 1. Occurrence • Chemoprophylaxis: A single dose of doxycycline to all members in a community will stop an epidemic Spread is favored by cold and temperate climate, war, immediately. It was a dreaded diseases in Laboratory personnel and medical staff should be the past and caused vast epidemics among soldiers and immunized regularly. Endemic foci have been found in Poland, Russia, Mexico, Bolivia, Burundi, Ethiopia and North Scrub Typhus (Tsutsugamushi Africa. Lice become infected by feeding on infected humans and remain infected for a year. It is not certain whether human infection is caused by the bite or by Identification fecal contamination. The disease is found in all ages and The bite of the infected larval stage of trombiculid mites sexes. Incubation period is 10 produces an itch which develops into a local papule, to 30 days. Mild It is also known as murine typhus, urban typhus or flea- and ambulatory types are common. It manifests as a fever of slow or sudden is often unreliable, being present in only 50 percent onset. The fever lasts 7 to 14 days and ends blood into mice and isolating the organisms from the by lysis. Philippines, Hong Kong, China, Thailand, Burma, Malaysia, India, Sri Lanka, Pakistan and Maldives. Occurrence In India, indigenous pockets exist in Andaman and Worldwide in endemic form. Tamil Nadu, Maharashtra, Punjab, certain areas in North America, Mexico, India, Pakistan, Himachal Pradesh and Bihar. Majority of cases occur in The disease occurs in scrubby terrain, forests, and summer and autumn. Man gets infected when infected mite larva attaches itself to man, sucks lymph and tissue fluids and introduces 3 to 14 days. No effective vaccine is available for prevention Control measures are based upon tick control, preven- tion of tick bites and immunization. Tick bites may Control is based upon regulation of the environment be prevented by avoiding notorious areas in spring and and animate measures. Reference Two other tick borne rickettsial infections are African tick-typhus and Q fever, caused by R. Washington: American Public Health influenza like disease and is recognized allover the world. African tick typhus is also known as Indian tick typhus as it is also found in India. It manifests as fever lasting 2 to 3 weeks, accompanied by a maculo-papular rash, first appearing on wrists and Identification ankles. In louse-borne relapsing fever, there are 2 to 3 bouts of Gangrene of scrotum may sometimes occur. Guinea pig inoculation results in fever borne relapsing fever and bouts of fever are shorter, and scrotal reaction. When spirochetemia cannot be demonstrated in this way, patient’s blood may be inoculated intraperitoneally into Occurrence young mice which develop spirochetemia within 14 days.

Tis is 1/3rd of tongue drain bilaterally into jugu- done for growths on the lateral lodigastric and juguloomohyoid nodes buy generic kamagra effervescent 100mg online erectile dysfunction treatment san diego. Lateral or marginal vessels drain the lat- It consists of (A) Management of the primary c discount kamagra effervescent uk effective erectile dysfunction treatment. Subtotal glossectomy-Tis means eral borders of anterior 2/3rd of the tongue growth order kamagra effervescent 100mg on line erectile dysfunction causes and symptoms, (B) Management of the neck nodes excision of the whole of anterior homolaterally to the submandibular nodes and (C) Management of advanced cases. Preliminary measures mandibulectomy is done in addition to side of the median raphe and may run • To maintain oral hygiene with regular glossectomy. Tis is done for large growths from growth on the margins of anterior 2/3rd ment of choice. Tis opera- is homolateral while that from the posterior contraindicated in the following situa- tion is so named because of its extensive 1/3rd and tip of tongue are bilateral. Minor salivary gland, tumors which • Usual presentation is a nodule or an ulcer ii. However, radio- Carcinoma Lip • Submental, submandibular and upper therapy is of little value for the unresect- deep cervical nodes may get enlarged. Exposure to sunlight Differential Diagnosis growth trigeminal nerve block with 5 per- ii. Treatment of the primary lesion Prognosis Carcinoma of lips is slow growing and can If lymph nodes are involved 5 years survival Pathology be cured by surgery or radiotherapy. Plastic reconstruction is needed in skin, fat, fbrous tissue, muscles, blood Blood spread is rare. From the upper lip, to the submental and managed in the same line as in case of car- ii. Hemangioma (Juguloomohyoid and Jugulodigastric is 80 percent if the lymph nodes are not v. It arises from a damaged sublingual gland (Tese sublin­ gual glands are called glands of Blandin and Nuhn). The lining wall is composed of deli­ cate capsule of fbrous tissue, and the content Fig. Section 5  Head and Neck Swellings complication • Bursting and reformation • Infection • Difculty in speech or eating if the tongue is pushed upwards. Diagnosis-by bidigital palpation (one finger in the oral cavity and the other on the neck). The ranula is not attached to the over­ lying mucosa, mylohyoid or muscles of the tongue. Chapter 22  Neck Swellings which proliferate and ultimately liquify in thyroglossal cyst • The cyst is sof, cystic, fuctuant and tran­ future to form the cystic swelling. Types (as to position) • Beneath the foramen cecum • In the foor of the mouth complications Median variety Lateral variety • Above the hyoid bone 1. Abscess and fstula formation The patient’s age is usually between 10 On the thyroid cartilage 3. Supramyelohyoid or sublingual type- nant of the thyroglossal duct, the other name Excision–Fistula with entire thyroglossal Cystic swelling in the foor of mouth placed being median thyroid diverticulum which tract is excised. Removal is Diferential diagnosis – Ranula the tuberculum (see below fate of thyroglos­ facilitated by pressing the posterior 1/3rd of b. Care should be taken not to perfo­ swelling in the region of the submandibular Structures which move up with deglutition rate the thyrohyoid membrane. Preoperative measure-For better visu­ are approached via a curved incision • Content-Tick jelly like fuid. BrancHial cySt It is a cystic swelling arising in connection with the persistent cervical sinus which is formed due to the fusion of overgrowing 2nd branchial arch, with the 6th branchial arch (Fig. Normally the cervical sinus disappears, but if it persists, accumulation of fuid occurs inside the sinus and gives rise to the branchial cyst. Differential Diagnosis Usually seen in growing adults, but can The fuid is usually secreted by the appendages, occur at any age. Cold abscess-A caseating tuberculous Nature of discharge: Mucoid or Mucopurulent dermal lining of the enclosed space. It is soft, If the epithelial lining remains, recurrence • Sometimes a second incision is needed cystic, fluctuant and transillumination will follow. Tis is known as ‘step Fluctuation is ofen difcult to elicit as the be held by any tissue forceps. If • Branchial cartilage-Elongated piece of contents are aspirated it contains choles­ cartilage deep to the cutaneous dimple types: See above terol crystals. If so one should recon­ • Cervical auricle-It is the cutaneous pro­ Site sider the diagnosis in favor of cold abscess. Tis muscle at the junction of lower and mid­ Precaution during Operation can be explained because of the develop­ dle 1/3rd. Acquired variety-The opening is at the tion of common carotid artery, the vessel the myotome of second branchial arch. It develops as a result of caseation necrosis of cyStic Hygroma cervical lymph nodes. Usually, it lar lymph sacs situated between the internal rounded by a shell of lymphoid tissue. Sudden increase in size of the cyst may (cold abscess in the posterior triangle of cause respiratory distress, when the treat­ neck). Site ment is aspiration of the cyst with or with­ • It is one of the commonest causes of cer­ At the base of the neck, in the posterior out tracheostomy. It may extend upto the jaw above est cause of cystic swelling in the carotid and down over the anterior chest wall and treatment triangle. Aspiration alone, especially when the Stage of lymphadenitis to develop, even before sternomastoid tumor. Stage of Periadenitis or Matting So these sites are to be examined during ii) The cyst becomes more localized. During birth, a big cystic hygroma may • Other rare causes of matting are chronic cause obstructed labor. Tere are fnger­like projections from the • It occurs due to caseation necrosis of the drome characterized by dyspnea, dysphagia, cyst wall invading the surrounding struc­ lymph nodes. So every care should be taken for uefes and breaks through the capsules of The swelling is complete excision. Stagewise treatment is given in Table Diffrential Diagnosis of chronic abscess gradually enlarges and becomes 22. Enlarged lymph nodes usually present with It is the commonest swelling in the neck. Chronic neck-To examine scalp, ear, nose, tion surrounded by epithelioid cells with A. Chemodectoma, Potato Tumor) It is a slow growing tumor which arises in the carotid body at the carotid bifurcation. It is a laterally placed swelling of the neck Microscopic located behind the sternomastoid muscle It shows the same histologic pattern of a nor­ below the thyroid cartilage. The later is a weak area of pharyngeal Tis is a frm, homogeneous and compact a tumor.