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By J. Abbas. West Virginia Wesleyan College.

The mesonephric duct now loses its renal connection buy kamagra effervescent 100mg without prescription, atrophies in the female (remaining only as the epoöphoron) but persists in the male generic kamagra effervescent 100mg amex, to become the epididymis and vas deferens. Its blood supply is first obtained from the common iliac artery but, during migration, a series of vessels form to supply it, only to involute again when the renal artery takes over this duty. This theory of origin does not explain their occasional association with multiple cysts of the liver, pan- creas, lung and ovary. These ureters may fuse into a single duct anywhere along their course or open separately into the bladder (where the upper ureter enters below the lower ureter). Rarely, the extra ureter may open ectopically into the vagina or urethra resulting in urinary incontinence. The bladder (Figs 62, 63, 87) The urinary bladder of a normal subject is uncomfortably distended by half a pint of fluid. When fully distended, the adult bladder projects from the pelvic cavity into the abdomen, stripping the peritoneum upwards from the anterior abdominal wall. The surgeon utilizes this fact in carrying out an extraperitoneal incision or suprapubic puncture into the bladder. In chil- dren up to the age of about 3 years, the pelvis is relatively small and the bladder is, in fact, intra-abdominal although still extraperitoneal. The urinary tract 113 (a) Bladder Prostate Urethral crest Colliculus seminalis Prostatic part of urethra Membranous part of urethra Bulb Crus Corpus cavernosum penis Corpus spongiosum penis Spongy part of urethra Small lacuna Fig. The circular component of the muscle coat condenses as an (involun- tary) internal urethral sphincter around the internal orifice. This can be destroyed without incontinence providing the external sphincter remains intact (as occurs in prostatectomy). Cystoscopy The interior of the bladder and its three orifices (the internal meatus and the two ureters) are easily inspected by means of a cystoscope. The submucosa and mucosa of most of the bladder are only loosely adherent to the underlying muscle and are thrown into folds when the bladder is empty, smoothing out during distension of the organ. Over the trigone, the triangular area bounded by the ureteric orifices and the internal meatus, the mucosa is adherent and remains smooth even in the empty bladder. Between the ureters, a raised fold of mucosa can be seen called the interureteric ridge which is produced by an underlying bar of muscle. Blood supply Blood is supplied from the superior and inferior vesical branches of the internal iliac artery. Lymph drainage Lymphatics drain alongside the vesical blood vessels to the iliac and then para-aortic nodes. Nerve supply Efferent parasympathetic fibres from S2 to S4 accompany the vesical arteries to the bladder. They convey motor fibres to the muscles of the bladder wall and inhibitory fibres to its internal sphincter. Sympathetic efferent fibres are said to be inhibitory to the bladder muscles and motor to its sphincter, although they may be mainly vasomotor in function, so that normal filling and emptying of the bladder are probably controlled exclusively by its parasympathetic innervation. It is also concerned in the control of micturition and is supplied by the pudendal nerve (S2, 3, 4). Sensory fibres from the bladder, which are stimulated by distension, are conveyed in both the sym- pathetic and parasympathetic nerves, the latter pathway being the more important. Its posterior wall bears a longitudinal elevation termed the ure- thral crest, on each side of which is a shallow depression, the prostatic sinus, into which the 15–20 prostatic ducts empty. At about the middle of the crest is a prominence termed the colliculus seminalis (verumontanum) into which opens the prostatic utricle. This is a blind tract, about 5mm long, running downwards from the substance of the median lobe of the prostate. It is believed to represent the male equivalent of the vagina, a remnant of the paramesonephric duct (see page 148). On either side of the orifice of the prostatic utricle open the ejaculatory ducts, formed by the union of the duct of the seminal vesicle and the terminal part of the vas deferens. It first passes upwards and forwards to lie below the pubic symph- ysis and then in its flaccid state bends downwards and forwards. Clinical features 1Where the urethra passes beneath the pubis is a common site for it to be ruptured by a fall astride a sharp object, which crushes it against the edge of the symphysis. Immediately within the meatus, the urethra dilates into a terminal fossa whose roof bears a mucosal fold (the lacuna magna) which may catch the tip of a catheter. Instruments should always be introduced into the urethra beak downwards for this reason.

When the head is displaced laterally and out of contact with the glenoid order 100mg kamagra effervescent with visa, the term lateral fracture-dislocation is descriptive cheap kamagra effervescent 100 mg with mastercard. However, the pathomechanics seem clearer when this le- sion is classified as a severely displaced fracture rather than a fracture- dislocation. The displacement of the humeral head may be anteroinferior, posterior, or superior; but no instance of superi- or displacement, associated with a fracture of the proximal end of the humerus, was encountered in this study. In two-part and three-part fracture-dislocations, the blood supply to the humeral head is usually adequate because one of the tuberosities, with soft tissue attachments, remains in continuity with the articular segment. The lesser tuberosity always remains attached to the humeral head in anterior three-part frac- ture-dislocation while the greater tuberosity remains to provide circula- tion to the head in posterior three-part fracture-dislocations. Neurovascular symp- toms occur more commonly with anterior four-part displacements. Displaced fractures of the articular surface are classified with frac- ture-dislocations because, while part of the articular cartilage has been crushed by impact against the glenoid and stays within the joint space, other fragments of cartilage are extruded from it. The impression frac- ture is commonly encountered with a posterior dislocation but rarely occurs to a significant extend with an anterior dislocation. When the impression defect is small and the lesion is recognized early, closed re- duction is effective. When the impression involves more than 20% of the articular surface, redislocation tends to occur unless the main ar- ticular fragment is stabilized, as by transplantation of the subscapularis tendon into the defect in the head. When the articular defect involves more than 50% of the cartilage-covered surface, the joint is unstable and dislocation readily recurs despite transplantation of the subscapu- laris. The head-splitting fracture results from a central impact which may extrude fragments of cartilage both anteriorly and posterior. The Roman numerals used to designate the six subgroups were deleted, and the definitions of the categories were re-stated. It was emphasized that the 4-segment classification is not meant to be a nu- merical classification that is oversimplified or pattern for easy roentgen 124 11 Classifications of proximal humeral fractures Fig. The four-segment classification system and terminology for proximal humeral fractures and fractures dislocations. In a one-part fracture (minimal displacement) no segment is displaced more than 1. The terminology for displaced lesions relates a pattern of displacement (two-part, three-part, or four-part) and the key segment displaced. In the two-part pattern, the segment named is the one displaced, including the two-part articular segment (anatomic neck) fracture, the two-part shaft (surgical neck) fracture of three types (A, impacted, B, unimpacted, and C, comminuted), the two-part greater tuberosity fracture, the two-part lesser tuberosity fracture, and the two-part fracture/dislocations. In all three-part displacements, one tuberosity is dis- placed and there is a displaced unimpacted surgical neck component that allows the head to be rotated by the tuberosity, which remains attached to it, including the three-part greater tuberosity fracture, the three-part lesser tuberosity fracture, and the three-part fracture/dislocations. The need for un- derstanding the pathology and knowing the criteria for each category, as described in Fig. Thirty years later Neer updated the criteria for the categories and outlined the requirements for the reliable use. The pathoanatomy of displaced proximal humeral fractures will not change; however, treat- ment will change as improvements are made. Terminology The terminology for the 4-segment classification is illustrated in Fig. If no major segment (groups of fragments) is displaced more than 1 cm or 458, the fracture is 1-part, or minimal displacement, regardless of he number of facture lines. The terminology for displace fractures and fracture dislocations relates a pattern of displacement (i. In all 3-part fractures and fracture-dislocations, there is an unimpacted, displaced surgical neck component to allow the rotary displacement of the head caused by the muscle forces on the tuberosity that remains attached to the articular gus four-part fracture (A) is less displaced and considered to be, in the continuum of lateral displacement, the precursor to B, the four-part fracture (lateral fracture/dislo- cation) in which the head is dislocated laterally and detached from both tuberosities and from its blood supply. In fracture/dislocation, the fracture occurs with a true dis- location, which implies damage outside the joint so that neurovascular injuries and periscapular bone occurs more often. They are named according to the pattern of the fracture (two-part, three-part, or four-part) and the location of the head (anterior, posterior, inferior, etc. Displaced fractures of the articular surface, the impression and head-splitting fractures, are classified with fracture/dislocations because, while part of the articular cartilage is crushed or fragmented against the glenoid, other frag- ments are extruded from it. Large-impression fractures usually occur with posterior dislocations, as drawn in the diagram, and head-splitting fractures usually extrude fragments both anteriorly and posteriorly.

Since alcohol dehydrogenase is required for the con- Four groups of drugs have been shown to affect the version of retinol to retinal 100mg kamagra effervescent amex, excessive and prolonged absorption of vitamin B12 cheap kamagra effervescent 100mg on line. These include the oral hypo- ethanol ingestion can impair the physiological function glycemic biguanides, colchicine, ethanol, and aminosali- of vitamin A. Night blindness may result, since the visual cy- the use of isonicotinic acid hydrazide, which interferes cle is a retinol-dependent physiological process. Admin- istration of ethanol or the antimetabolites 6-mercaptop- Vitamin D urine and 5-fluorouracil also may lead to niacin defi- ciency. The uricosuric effects of sulfinpyrazone and Laxatives and agents that bind bile salts inhibit the gas- probenecid may be inhibited by nicotinic acid. The glucocorti- Drugs that increase intestinal motility or induce di- coids in high dosages may interfere with the hepatic me- arrhea may decrease riboflavin absorption. Prolonged administration of roidism and the administration of thyroxine also reduce hepatic microsomal enzyme inducers, such as pheno- riboflavin absorption. ANEMIA Vitamin K Anemia occurs when the hemoglobin concentration of The most common group of drugs that produce vitamin blood is reduced below normal levels. The hy- result from chronic blood loss, abnormal hemolysis, or nu- poprothrombinemic effects of dicumarol can be over- tritional deficiency. Anemias due to cell hy- poproliferation include aplastic anemia and iron defi- Megaloblastic Anemia ciency anemia. Megaloblastic Megaloblastic anemia is characterized by the appear- anemia, sideroblastic anemia, and iron deficiency ane- ance of large cells in the bone marrow and blood due to mia result from an abnormality in the maturation of red defective maturation of hematopoietic cells. Malabsorption, impaired use, chronic infections, and drugs can lead to folic acid or vitamin B12deficiency. Iron Deficiency Anemia Folic acid or folate salts (Folvite) are administered Iron is a constituent of hemoglobin, and iron deficiency to correct folate-deficient megaloblastic anemia. Since min B12–deficient patients receive cyanocobalamin sup- iron is conserved by the body, deficiency usually results plements. Dosage is very important, since patients with from acute or chronic loss of blood or insufficient iron severe megaloblastic anemia may develop hypokalemia intake during physiological stress. This type of mega- growth, pregnancy, and loss of blood during menstrua- loblastic anemia causes neurological damage if it is not tion. Treatment of Vitamin B12–deficient megaloblas- by the hookworm parasite is a common cause of iron tic anemia with folic acid may improve the symptoms; deficiency. Parenteral injections of tigue, weakness, shortness of breath, and soreness of the vitamin B12must be given. Oral administration of ferrous Sideroblastic Anemia salts (generic ferrous sulfate, Feosol, Slo Fe) is preferred, but parenteral iron (iron dextran, InfeD) can be given if Sideroblastic anemia is characterized by excessive iron in oral therapy fails. Toxic reactions occur more frequently the cells that cannot be incorporated into porphyrin to after parenteral iron administration. A patient with pancreatic disease complains of diffi- (D) No vitamin supplement culty driving at night because of vision problems. An epileptic patient who is taking phenytoin and tant to determine whether megaloblastic anemia is lamotrigine to control her seizures is in the first from a deficiency of folic acid or vitamin B12. Vitamin A defi- tion with vitamins C and E, beta carotene, and zinc ciency symptoms include night blindness that can for age-related macular degeneration and vision lead to corneal ulceration. Pregnancy increases the need for vitamins and Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, iron in general. B Vitamins, homocysteine, and neu- of the patient to determine whether higher levels of rocognitive function. Case Study Vitamin Deficiency and Alcoholism patient has muscular weakness, apathy, and ANSWER: The symptoms resemble those you remem- Aedema in both legs. You schedule a series of ber from medical school for beriberi, but you fail to tests, including a cardiac stress test. If the pa- the stress test suggest that the patient is in moder- tient were consuming most of his calories as alco- ate congestive heart failure. The patient suffered a hol, he may have a nutritional deficiency, a beriberi- personal loss last year with the death of a son. You prescribe a daily vitamin tablet and suspect that the drinking is responsible for his pres- admonish the patient to cut back on alcohol intake. This does not include the pharmacognosy, which includes the study of herbal many (up to 25%) pharmaceutical products used in medicine.

As a successful example purchase 100mg kamagra effervescent visa, iterative closest points (ICP) method proposed by Besl and McKay (1992) buy kamagra effervescent 100 mg fast delivery, maybe the most widely used medical image registration approach in medical imaging applications, for example, Fitzpatrick, West, and Maurer (1998). When points are available, Thin-Plate Splines (TPS) which produce a smoothly interpo- lated spatial mapping, are often used to determine the transformation for 2-D medical image registration, for example, Bookstein (1989). Boundaries or surfaces are distinct features in medical image registration due to various segmentation algorithms which can successfully locate such features. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Feature-based registration procedure Preprocessing Isolation of features for direct comparison (Segmentation) 1. Computation of the optimal transformations to register features in B onto features in A. Usually through visual check Verifying Phantom Studies… In rigid surface-based registration methods, the same anatomical structure surfaces are extracted from the images and used as input for the registration procedure. The first surface extracted from the higher-resolution images, is represented as a stack of discs, and is referred to as “head”. The second surface, referred to as “hat”, is represented as a list of unconnected 3D points. The registration is determined by iteratively transforming the hat surface with respect to the head surface, until the closest fit of the hat onto the head is found. Because the segmentation task is comparatively easy, and the computational cost is relatively low, this method remains popular. In deformable surface-based registration methods, the extracted surfaces or curves from one image is elastically deformed to fit the second image. The deformable curves are known as snakes or active contours which help to fit contours or surfaces to image data. Snakes operate by simulating a controllable elastic material, much like a thin, flexible sheet. We can initially position the model by using information from anatomical atlases; then, the model is allowed to relax to a stationary position. This minimum energy position seeks to find the best position to trade off internal and external forces. The internal forces are due to the elastic nature of the material and the external forces stem from sharp boundaries in image intensity. Important deformable surface-based registration ap- proaches include, for example, the elastic matching approach proposed by Bajcsy and Kovacic (1989), and the finite-element model technique proposed by Terzopoulos and Metaxas (1991), and so on. Deformable surface-based registration is suited for intersubject and atlas registration. A drawback of these methods is that a good initial pre-registration is required to achieve a proper convergence. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Biomedical image registration can be used in medical and surgical areas, including diagnostic planning and simulation, treatment monitoring, image-guided surgery, pathology detection, and radiotherapy treatment. Multimodal image registration methods play a central role in therapeutic systems, for example, Hill et al. By registering the information from different imaging modalities, better and more accurate information can be obtained to aid the therapy planning. For example, the registration of functional images with anatomical images helps early diagnosis and better localization of pathological areas. Also, by quantitative comparison of images taken at different times, the information about evolution over time can be referred, for example, the monitoring of tumor growth in image sequences. Many surgical procedures require highly precise 3D localization to extract deeply buried targeted tissue while minimizing collateral damage to adjacent structures (Grimson, 1995). In surgical practice, surgeons usually examine 2-D anatomical images (MRI or CT) and then mentally transfer the information to the patient. Thus, there is a clear need for registered visualization technique which allows the surgeons to directly visualize important structures to guide the surgical procedure. Biomedical image registration is important for telemedicine, which is the integration of telecommunication technologies, information technologies, human-machine interface technologies, and medical care technologies, when distance separates the participants. In the case of healthcare, a telemedicine system should be able to register multiple sources of patient data, diagnostic images, and integrate other information to enhance healthcare delivery across space and time. For example, biomedical image registration is an important component in teleradiology, which is a primary image-related application.