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If the rating is exceeded super p-force oral jelly 160mg generic impotence guide, the n = number of windings transformer may overheat and burn out its A = core cross-sectional area insulation and windings order 160 mg super p-force oral jelly erectile dysfunction doctor nashville. The rating is ex­ For a given transformer effective 160 mg super p-force oral jelly erectile dysfunction doctors in texas, we can main­ pressed as the maximum safe output of its tain a constant output voltage by increasing secondary winding in kowatts. Remem­ the frequency and decreasing the number ber that a watt is the unit of electric (as well of turns or the core cross-sectional area. For larger generators kW = kilowatts kV = kilovolts (80 kW and 100 kW) the high-voltage mA = milliamperes transformer is not contained in the tube head, but is still reduced to about one-third Thus, the ratings of a three-phase gener­ the size of a conventional twelve-pulse ator operating at 100 kV and 500 rA is transformer. But one must also inquire about the 1000 available kW output at the kV and rA lev­ The factor 0. To fgure considering a unit for use at high-kV tech­ the average power we must consider the niques. These problems So, the formula for single-phase-generator arise from switching off the currents in the power rating converts the kV to R. Since the transformer is driving an x­ improperly, high-voltage spikes may be in­ ray tube, we can consider the current to be troduced that can damage the equipment. This but how they do this need be of little con­ slight difference actually serves as a safety cern to the radiologist. There are two categories of switching for Kilowatt ratings of x-ray generators are modern generators. Switching may take determined when the generator is under place in the primary circuit of the high­ load, and it is convenient to test at a voltage voltage transformer where there are high level of 100 kVp, because calculations are currents and low voltage. Thus, an 80-kW constant po­ also take place in the secondary circuit tential generator would be one that could where there are low currents and high volt­ operate at 100 kV and 800 milliamperes age. Some constant potential units, switching occurs in the primary cir­ generators are rated at 150 kVp, and are cuit and is called primary switching. The same gen­ Switching in the secondary circuit is gen­ erator may have the capability of produc­ erally used in units designed for rapid, re­ ing 1000 rA. It is wrong to think of this petitive exposures or where extremely as a 150-kW generator unless it can operate. The response of the gate is almost switches and thyratrons are being phased instantaneous, making the thyrister useful out. A control rec­ Secondary Switching tifer is a rectifier that can be turned on Secondary switching takes place on the and of by a logic signal (which in reality high voltage side of the transformer or at is just a small voltage pulse). This thyrister con­ prevent high-voltage breakdown, so they sists of a cathode (negative end), an anode must be insulated to withstand high volt­ (positive end), a gate, and three junctions. Grid-con­ member, electrons in a diode will flow trolled x-ray tubes are described in Chap­ freely from N-type material to P-type ma­ ter 2. While the technical details of switching This is the way a thyrister functions: a small need not bother us, it will be of some value positive pulse (the logic signal) to the gate to consider the appropriate practical uses causes a large current to fow through the or advantages of primary versus secondary switching. This technology makes it easier, compared to primary switching, 600 ( to have sharp, crisp exposures with rapid w 500 a on-and-off rates with many repeated ex­ g 400 posures. In the fnal analysis, few physicists and The operator does not set an exposure no radiologists care how the switching is time, but tells the generator to produce 200 done so long as it meets the specifications mAs at 70 kVp. Corresponding reduc­ is to produce an x-ray exposure in the tions of tube current will occur at 400 and shortest possible exposure time by oper­ 300 rA until the required 200 mAs has ating the x-ray tube at its maximum kil­ been accumulated. Let us go directly to an example to ex­ By operating the x-ray tube at its maximum plain how this generator functions. Look tolerance, the falling load generator has at Figure 3-27, the theoretical chart for an x-ray tube operating at 70 kVp. If an ex­ posure of 70 kVp and 200 mAs is desired, � 600 this x-ray tube could be operated at 70 f 500 kVp, 200 rA, and 1. Notice that any � 400 � attempt to get a shorter exposure would ::: 300 _ fail, because the tube is limited to 0. Operating the tube at Automatic Exposure Control high rA causes maximum focal spot (Phototimer) blooming. Heating the anode to its maxi­ Mechanical and electronic timers are mum capacity with each exposure shortens subject to human error. Manufacturers generally set lects the exposure time that he believes will the tube to operate at somewhat lower than produce a film of the desired density. They measure the They find their greatest use with automatic amount of radiation required to produce exposure generators where simple opera­ the correct exposure for a radiographic ex­ tor controls are desired. Once the kV p is selected, either the tech­ A variety of ways to control the length nologist or a phototimer must select the of an x-ray exposure have been developed. We will mention these briefy, and consider The goal is to produce a satisfactory radi­ only phototimers in any detail. Automatic exposure control (photo­ response to this radiation, produce a small timers) electric current. The length of the x-ray exposure Phototimers can be located in front of the is determined by the time required to cassette, and are called entrance types, or charge a capacitor through a selected re­ behind the cassette as exit types. This is posure and also starts charging the capac­ the most common type of automatic ex­ itor. The detector is capacitor is charged to a value necessary to made of lucite, which is a material that can turn on associated electronic circuits. The lucite is coated with one exposure time is therefore determined by or more (commonly three) areas of a phos­ the length of time for the capacitor to phor that will emit light when irradiated charge, and this time can be varied by vary­ with x rays (these lucite detectors are usu­ ing the value of the resistance in the charg- ally called lucite paddles). Sensors detect the kVp being used, and the phototimer detector will be decreased in sensitivity if low kVp is being used. When light strikes the pho­ Figure 3-29 Photomultiplier automatic ex­ toemissive layer on the photocathode, the posure control (phototimer) photoemissive material emits photoelec­ trons in numbers proportional to the in­ area is about 100 square centimeters (100 tensity of the light. When a phosphor generates trodes are coated with a material that emits light, the intensity of the light is obviously secondary electrons when struck by an­ proportional to the intensity of x rays that other electron. The lucite transmits ated by a positive potential from one dy­ this light to an output region called a "light node to the next, with each dynode giving gate. Photomultiplier photocathode of a photomultiplier tube, tubes come in many sizes and shapes, and where the light is converted to an electric are used extensively in nuclear medicine current that is amplifed to produce an and physics laboratories. The electric current gen­ of electrons collected at the anode repre­ erated by the photomultiplier tube may be sents the output current, and this output used to charge a capacitor. When the ca­ current is proportional to the intensity of pacitor reaches a predetermined charge it the light that struck the photocathode. In­ can be used to bias the gate of a thyrister herent in the operation of a photomulti­ in the x-ray circuit and cause the exposure plier tube is the requirement for a stable to terminate. Ioni­ lucent, so it will not produce a detectable zation chambers are almost always used as image if placed in front of a cassette. An ionization lucite serves two functions: it is the support chamber is very slightly imaged on flm, but that holds the fuorescent screen or the image is so faint it is lost in the images screens, and it transmits light to the pho­ of anatomic parts.

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The endogenous creatinine clearance is calculated from the formula (6) or creatinine clearance equals the ratio of urine to plasma creatinine concentration times the urine flow rate buy super p-force oral jelly 160 mg low price erectile dysfunction 60784. This elevates urinary excretion of creatinine order super p-force oral jelly with amex erectile dysfunction my age is 24, normally causing a 20% increase in the numerator of the clearance formula cheap super p-force oral jelly 160mg without prescription impotence and diabetes 2. The second drawback is related to errors of measuring creatinine concentration in the plasma. The colorimetric method usually used also measures other plasma substances, such as glucose, leading to a 20% increase in the denominator of the clearance formula. This results from higher plasma creatinine levels and increased tubular secretion of creatinine. A young, muscular man will have a higher plasma creatinine concentration than an older woman with reduced muscle mass. These equations often take into consideration such factors as age, gender, race, 2 and body size. Net tubular reabsorption or secretion of a substance can be calculated from renal clearance. The rate at which the kidney tubules reabsorb a substance can be calculated if we know how much is filtered and how much is excreted per unit time. If the filtered load of a substance exceeds the rate of excretion, the kidney tubules must have reabsorbed the substance. The rate at which the kidney tubules secrete a substance is calculated from this equation: (12) Note that the quantity excreted exceeds the filtered load, because the tubules secrete X. If, however, substance X is bound to the plasma proteins, which are not filtered, then it is necessary to correct the filtered load for 2+ this binding. For example, about 40% of plasma Ca is bound to plasma proteins, and so, 60% of plasma 2+ Ca is freely filterable. Equations 11 and 12, which quantify tubular transport rates, yield the net rate of reabsorption or secretion of a substance. It is possible for a single substance to be both reabsorbed and secreted; the equations do not give unidirectional reabsorptive and secretory movements, only the net transport. Insights into the nature of glucose handling by the kidneys can be derived from a glucose titration study (Fig. The plasma glucose concentration is elevated to increasingly higher levels by the infusion of glucose-containing solutions. The rate of glucose reabsorption is determined from the difference between the filtered load and the rate of excretion. At normal plasma glucose levels (about 100 mg/dL), all of the filtered glucose is reabsorbed and none is excreted. When the plasma glucose concentration exceeds a certain value (about 200 mg/dL in Fig. Glucose appears in the urine because the filtered amount of glucose exceeds the capacity of the tubules to reabsorb it. At high filtered glucose loads, the rate of glucose reabsorption reaches a constant maximal value, called the tubular transport maximum (Tm) for glucose (G). At Tm, the tubule glucose carriers are all saturated and transportG glucose at the maximal rate. The plasma glucose concentration was elevated by infusing glucose-containing solutions. The amount of glucose filtered per unit time (top dashed line) is determined from the product of the plasma glucose concentration and glomerular filtration rate (measured with inulin). Excreted glucose (bottom line) is determined by measuring concentration of glucose in the urine and urine flow rate. Reabsorbed glucose is calculated from the difference between filtered and excreted glucose. A reduced Tm lowers the threshold, because the tubules have a diminished capacity toG reabsorb glucose. One reason forG splay is that not all nephrons have the same filtering and reabsorbing capacities. Thus, nephrons with relatively high filtration rates and low glucose reabsorptive rates excrete glucose at a lower plasma concentration than nephrons with relatively low filtration rates and high reabsorptive rates. A second reason for splay is the fact that the glucose carrier does not have an infinitely high affinity for glucose, so glucose escapes in the urine even before the carrier is fully saturated. In uncontrolled diabetes mellitus, plasma glucose levels are abnormally elevated, so more glucose is filtered than can be reabsorbed. Urinary excretion of glucose, glucosuria, produces an osmotic diuresis or an increase in urine output caused by abnormal effective osmoles in the tubular fluid of the nephron. In osmotic diuresis, the increased urine flow results from the excretion of osmotically active solute. Diabetes (from the Greek for “siphon”) gets its name from this increased urine output and secondary increased water intake. The kidneys form urine continuously, and urine flows through the ureters to the bladder. The movement of urine to the bladder is aided by the contraction of the smooth muscles in the ureter wall. The bladder is a balloon-like structure with walls containing smooth muscle that stores the urine. The bladder fills with urine at a low pressure but then empties during urination, or micturition. Urinary tract provides the pathway for transporting, storing, and eliminating urine. As mentioned previously, the ureters are muscular tubes that propel the urine from the pelvis of each kidney to the urinary bladder. Peristaltic movements originate in the region of the calices, which contain specialized smooth muscle cells that generate spontaneous pacemaker potentials. These pacemaker potentials trigger action potentials and contractions in the muscular regions of the renal pelvis that propagate distally to the ureter. Peristaltic waves sweep down the ureters at a frequency of one every 10 seconds to one every 2 to 3 minutes. Sensory fibers mediate the intense pain that is felt when a stone distends or blocks a ureter. The urinary bladder is a distensible hollow vessel containing smooth muscle in its wall (Fig. The parasympathetic pelvic nerves and sympathetic hypogastric nerves innervate the body of the bladder and bladder neck. The external sphincter is composed of skeletal muscle and is innervated by somatic nerve fibers that travel in the pudendal nerves. The parasympathetic pelvic nerves arise from the S2 to S4 segments of the spinal cord and supply motor fibers to the bladder musculature and internal (involuntary) sphincter. Sympathetic motor fibers supply the bladder via the hypogastric nerves, which arise from lumbar segments of the spinal cord. The pudendal nerves supply somatic motor innervation to the external (voluntary) sphincter.

It is obtainable at 10 yearly intervals as per may also help in assessment of community health cheap super p-force oral jelly 160mg with visa erectile dysfunction drugs from canada. It is a very good index to compare the level of health References in different countries super p-force oral jelly 160 mg amex erectile dysfunction caused by obesity. However buy 160 mg super p-force oral jelly with amex erectile dysfunction medication injection, by the very nature of its derivation, it is not suitable for quantifying the change 1. Life Table: It is a particular way of expressing the Population Division, Department of Economic and Social death rates experienced by a particular population Affairs. Registrar-General of India: Provisional Population Totals: required in order to construct a life table: India, Part I: Released on April 4, 2001. Census Office of the Registrar General and Census Commissioner, A life table helps in answering several vital questions, India. Brief Analysis of provisional population figures 2011 • What is the average length of life expected at birth? The woman as final arbiter: a case yees likely to die after getting insured or joining for the facultative character of the human sex ratio. As a health administrator, he should tricts to achieve be able to understand and even formulate policies, to goals make plans and to implement them. These and related aspects will be dis- daily beat on a particular cussed in this chapter. For the sake of convenience, the day subject matter will be dealt within six parts as follows: 1. Government Health Organization in India Simply stated, a plan is a course of action one intends 4. Since a plan gives objectives, goals and targets, one can measure its Planning is defined as an organized, conscious and effectiveness in reducing the problem and its efficiency continual attempt to select the best available alternatives in terms of costs. The word State level- Objectives to be Prioritization of districts program means the sequence of activities designed to strategic planning based on local needing additional resour- implement the plan and fulfill the objectives. In reference to health, the health needs • Medical and technical audit of health units are defined as deficiencies in health that call for • Inspection and appraisal in the field. Since the resources are usually limited, thorough and independent scrutiny of their progress at proper planning is a must. Mid ‘priorities’, which signifies selection of outstanding needs term evaluation helps in executing the plan according and meeting them more urgently than others that may to schedule. Requirements for proper evaluation include the Aspects to be considered while formulating a health following: related plan are listed below: • Establishment of definite criteria which may be both • Existing level of health of the community subjective and objective but which must be capable • The reasons for the existence of such level of definite measurement • The outstanding health and disease problems and • Unbiased assessment and proper randomization of their causes samples • Resources in men, money and materials available • Independent appraisal (not by those executing the for raising such level program). The National Malaria Eradication Program is a Health Planning In India good example of planning and execution of a health program. Five-year developmental plans were drafted 477 • Monetary and financial controls, e. From a highly centralized planning system, the Indian economy is gradually moving towards indicative plan- ning where Planning Commission concerns itself with the building of a long-term strategic vision of the future and decide on priorities of nation. It works out sectoral targets and provides promotional stimulus to the economy to grow in the desired direction. Planning Commission plays an integrative role in the development of a holistic approach to the policy formu- by the Planning Commission from 1950-51 onwards. In the social sector, schemes which require the Planning Commission for futuristic planning over coordination and synthesis like rural health, drinking next 20-25 years. The three major wings of the water, rural energy needs, literacy and environment Planning Commission are the General Secretariat, the protection have yet to be subjected to coordinated Technical Divisions and the Program Advisers. An integrated approach can lead to better results at The Prime Minister is the Chairman of the Planning much lower costs. Commission, which works under the overall guidance of the National Development Council. Divisions exist for the formulation of Five-year community health problems, identifying unmet needs Plans, annual plans, state plans, monitoring plan and surveying the resources to meet them, establishing programmes, projects and schemes. India resorted to health planning soon after independence, when the first five years plan • Agriculture Division was initiated in 1951. This was the 20-point program-described as an agenda for national action to promote social justice of health services depends upon the states and their and economic growth. The health expenditure in various States is On August 20, 1986, the existing 20-Point Program given in Table 26. It has • Effective implementation of the provisions of food been described as the cutting edge of the plan for the poor. Its objective was to ensure a • Laws and regulations to facilitate planning basic minimum standard of life for all sections of people • A planning organization for overall socioeconomic living in the rural areas of the country. The strategy was planning at policy level to establish a network of facilities to attain an acceptable • Administrative capacity essential for planning. First, it was felt that the competing demands for Programing is generated from Policy data, Demographic greater investment in other development sectors left data, Economic data, Health status data, Environmental relatively small allocations for social services. In the face health data, Data on health service resources and faci- of resource constraint, the tendency was to impose lities, Health manpower data and Unit cost data. Second, there were wide inter-state differences Plan periods are given in Table 26. Health being a in the provision of social services and infrastructure state subject according to the constitution, the expansion which called for governmental intervention. Streamlining of the Public Distribution System with States Male Female focus upon the poor. While the Sixth and the The Conference endorsed the seven basic minimum Seventh Plan witnessed major expansion of the rural services as of paramount importance in securing a better health care infrastructure, the Eighth Plan concentrated quality of life for the people, especially those residing the efforts on development, consolidation and in rural areas. Further, it observed that it would be in strengthening of the existing health care infrastructure the best interests of the country, if time-bound action to bring about improvement in quality and outreach plans are formulated to secure full coverage of the of services. The seven basic services identified for priority attention are: Urban Primary Health Care: Nearly 30 percent of 1. Due to urban water in rural and urban areas migration and massive inflow of population to the towns 2. Universalization of primary education been any well planned and organized efforts to provide 4. Provision of Public Housing Assistance to all primary health care services to the population within 2 shelterless poor families to 3 km of their residence and to link primary, secondary 5. Extension of Mid-day Meal Program in primary and tertiary care institutions in geographically defined schools, to all rural blocks and urban slums and areas. As a result there is either a nonavailability or at 480 disadvantaged sections times under-utilization of available primary health care 6. Provision of connectivity to all unconnected villages facilities and consequent overcrowding at the secondary and habitations and tertiary care centers. Further, the be provided with two Medical Officers and other sources of water supply should be within 1.

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The axons from these cells travel in the ipsilateral ventrolateral spinal cord white matter to terminate at all levels of the spinal cord where they excite interneurons and α and γ extensor motor neurons that innervate truncal and proximal limb muscles buy discount super p-force oral jelly erectile dysfunction drugs kamagra. These extensor motor neurons and their musculature are important for maintaining posture and modulating posture-related reflexes that help stabilize the body’s position against the forces of gravity purchase super p-force oral jelly 160 mg without a prescription erectile dysfunction doctors in atlanta. As these axons descend order super p-force oral jelly 160mg amex erectile dysfunction pills at walgreens, they give off collateral branches at multiple spinal cord levels, which ensure proper coordination of postural reflexes across multiple levels. Lesions in the brainstem secondary to stroke or trauma may abnormally enhance the influence of the vestibulospinal tract and produce dramatic clinical manifestations. The medial vestibulospinal tract arises primarily from the medial vestibulospinal nucleus and descends bilaterally to terminate on motor neuron in the cervical spinal cord that controls neck extensor and flexor muscles. The function of this pathway is to reflexively activate neck muscles in response to changes in head position. Reticulospinal tracts The reticular formation is a complicated network of neurons located in the central gray matter core of the brainstem. Within this network are also discrete circuits that control a diverse set of functions such as sleep, autonomic functions, and eye movements. Within the medial regions of the caudal reticular formation are groups of large neurons that are involved in somatic motor control of both cranial nerve and spinal cord motor neurons. Two descending tracts important in the control of spinal lower motor neurons arise from medial reticular formation cells. These pathways mostly influence motor neurons that innervate truncal and limb extensor muscles. Through their influence on gamma motor neurons, these pathways modulate muscle tone and help make anticipatory adjustments in posture during movement. The medial (pontine) reticulospinal tract arises from pontine reticular nuclei and descends bilaterally with an ipsilateral preponderance in the anterior spinal cord white matter. This pathway relays excitatory action potentials to interneurons that influence α and γ motor neuron pools. The medullary reticulospinal tract arises from the reticular formation in the medulla and descends ipsilateral in the spinal cord white matter adjacent to the anterior horn. This pathway has an inhibitory influence on interneurons that modulate extensor motor neurons. The rubrospinal tract terminates mostly on interneurons in the lateral spinal intermediate zone, but it also has some monosynaptic connections directly on motor neurons to muscles of the extremities. This tract supplements the corticospinal tract for independent movements of the upper extremities. The vestibulospinal and reticulospinal tracts terminate in the ventromedial part of the intermediate zone, an area in the gray matter containing propriospinal interneurons (Fig. There are also some direct connections with motor neurons of the neck and back muscles and the proximal limb muscles. The vestibulospinal and reticulospinal tracts influence motor neurons that control axial and proximal limb muscles. In accordance with their medial or lateral distributions to spinal motor neurons, the reticulospinal and vestibulospinal tracts are thought to be most important for the control of axial and proximal limb muscles, whereas the rubrospinal (and corticospinal) tracts are most important for the control of distal limb muscles, particularly the flexors Sensory and motor systems work together to control posture. The maintenance of an upright posture in humans requires active muscular resistance against gravity. For movement to occur, the initial posture must be altered by flexing some body parts against gravity. Balance must be maintained during movement, which is achieved by postural reflexes initiated by several key sensory systems. Vision, the vestibular system, and the somatosensory system are important for postural reflexes. Somatosensory input provides information about the position and movement of one part of the body with respect to others. The vestibular system provides information about the position and movement of the head and neck with respect to the external world. Vision provides both types of information as well as information about objects in the external world. Visual and vestibular reflexes interact to produce coordinated head and eye movements associated with a shift in gaze. Vestibular reflexes and somatosensory neck reflexes interact to produce reflex changes in limb muscle activity. The quickest of these compensations occurs at about twice the latency of the monosynaptic myotatic reflex. The extra time reflects the action of other neurons at different anatomic levels of the nervous system. The cortex modifies sensory-evoked involuntary movements like brainstem- and spinal cord–related postural adjustments by continuous modulation of brainstem descending motor pathways and spinal cord reflex pathways. The role of this modulation is readily apparent when it is damaged (see Clinical Focus 5. Cortical control of skilled voluntary movements, most of which involve the distal extremities, is accomplished through connections with cranial nerve motor nuclei and spinal cord interneurons and motor neurons that control skilled movement. In addition, these skilled movements are performed on a background of ongoing postural adjustments, which the cortex accomplishes by simultaneously activating brainstem descending motor pathways. A neurologic examination performed about 30 minutes after onset shows no response to verbal stimuli. A painful stimulus, compression of the soft tissue of the supraorbital ridge, causes immediate extension of the neck and all of the limbs. The study demonstrates a large area of hemorrhage bilaterally in the upper portion of the brainstem. The posture this patient demonstrated in response to the noxious stimulus is termed decerebrate rigidity. Its occurrence is associated with lesions of the mesencephalon that eliminate the influence of higher brainstem and cortical centers. The abnormal posture is a result of extreme antigravity extensor muscle activation by the unopposed action of the reticulospinal and vestibulospinal tracts. A model of this condition can be produced in experimental animals by a surgical lesion located between the mesencephalon and pons. Cortical areas associated with voluntary motor control are located in the frontal lobe rostral to the central sulcus and include primary motor cortex (M1), Brodmann area 4 (Fig. Other cortical areas that contribute to descending control of voluntary movements are the postcentral gyrus, areas 1, 2, and 3 and areas 5 and 7 of the parietal lobe. Each of these motor areas contributes fibers to the corticospinal tract, the principal efferent motor pathway from the cortex. Motor-related cortex receives information from cortical and subcortical areas that process sensory information, from cortical areas that underlie the motivation to move, and from subcortical structures that modulate motor activity like the cerebellum and basal ganglia. Area 4 is the primary motor cortex; area 6 is the premotor cortex on the lateral and supplementary motor area on the medial aspect of the hemisphere. Areas 1, 2, 3, 5, and 7 have sensory functions but also contribute axons to the corticospinal tract.