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Figure 5:18 90 Essential Surgical Skills Circumcision erectile dysfunction doctor lexington ky buy 20 mg apcalis sx with visa, Phimosis and paraphimosis Diseases of the penile foreskin include:  Phimosis  Paraphimosis Phimosis Phimosis is a condition in which the foreskin cannot be retracted behind the glans penis erectile dysfunction doctor nyc discount apcalis sx generic. Phimosis usually not painful erectile dysfunction treatment new jersey discount apcalis sx 20mg without prescription, but it may produce urinary obstruction with ballooning of the foreskin It may also follow improper circumcision Definitive treatment is circumcision Treatment: circumcision • the resection of the prepuce is the definitive surgical treatment. Case Scenario A 4 years old child presented with difficulty of urination of a month duration He has history of circumcisions by local healer 4 months back. She also noticed ballooning at the tip of the shaft of penis whenever he ties to urinate a. If the prepuce can be retracted, carefully clean the glans and the preputal furrow with soap and water. If the prepuce cannot be retracted, gently stretch the preputal opening by inserting the blades of a pair of artery forceps and slowly opening them until the area can be properly cleaned (Figure 5:19). Take hold of the prepuce dorsally in the midline with pairs of forceps and cut down between the forceps with scissors until the blades nearly reach the corona (Figures 5:20, 5:21) 92 Essential Surgical Skills Figure 5;20 Figure 5:21 6. Check that the lower blade really is lying between the glans and prepuce and has not been inadvertently passed up the external meatus. Then excise the prepuce by extending the dorsal slit obliquely around on either side to the frenulum, and trim the inner preputial layer, leaving at least 3 mm of mucosa (Figure 5:22). Catch the cut edges of the frenulum and the bleeding artery of the frenulum with absorbable suture, leaving the suture long as a traction stitch to steady the penis (Figure 5:23). Insert a similar traction stitch to unite the edges of the prepuce dorsally (Figure 5:24). Unite the edges of the prepure with interrupted stitches and cut the stitches short (Figure 5:25 &5: 26). Complications • Bleeding • Hematoma Paraphimosis • Paraphimosis is a condition in which the foreskin has been retracted and left behind the glans penis, constricting the glans and causing painful vascular engorgement and edema. The glans penis is visible, and is surrounded by an oedematous ring with a proximal constricting ring (Figure 5:27). Malpresentation & Malpositions Breech Transverse Lie Brow presentation Mentoposterior Occiputoposterior 3. Destructive operations Case Scenario A 23 years old primigarvid who is living in a village 50 kms away from a hospital came with a complaint of pushing down sensation of 5 days duration. The three checks • the median angle of the posterior fontanel should be located halfway between the blades and approximately 1-1. The inset shows a left occipitoanterior fetal position (fig 6:5) 104 Essential Surgical Skills Figure 6. Use a scalpe to make a 3 cm transverse incision in the lower segment of the uterus, about 1 cm below the level where the vesico-uterine serosa was incised to bring the bladder down. Widen the incision by placing a finger at each edge, and by pulling up and laterally at the same time. If the lower uterine segment is thick and narrow, extend the incision using scissors instead of fingers in a crescent shape to avoid extension to the uterine vessels. Repair the incision and any extensions with a continuous locking stitch of 0 chromic non absorbable (or polyglycolic) suture. If there is any further bleeding from the incision site, close with figure of eight sutures. Fracture of the clavicle Common in children Require no X-ray for diagnosis Chest x-ray may be needed to rule out pneumothorax can be treated by arm neck triangular splint (fig 7:1) 116 Essential Surgical Skills Figure 7. Subcapital humerus fracture 117 Essential Surgical Skills Is commonly at the surgical neck Commoner in the elderly Displacement is minimal Can be treated by immobilizing the affected arm with the chest wall using sling and elastic bandage (Desault) for three weeks Chest Arm Bandage (Desault)( fig 7:3) Figure 7.

Thus erectile dysfunction urban dictionary cheap 20 mg apcalis sx amex, natural substances were used increasingly instead as well as any substances used for antimicrobial purposes impotence from priapism surgery order apcalis sx visa. The second reason is that new alternative drugs are human hope for better fighting with existed diseases and pathogens erectile dysfunction protocol review article apcalis sx 20mg with amex. They may replace currently used drugs in points of more efficiency, more abundant, lower side-effect or safer or even lower production cost. It is fact that most alive organisms should have some mechanisms or substances fight with all time contacting pathogens so that they can be survived in nature. Although a plenty of antibiotics were discovered after first time Fleming’s declaration, but they were still relatively low amounts compared with overall real natural antimicrobial substances. This mean the natural sources still flourish with novel antimicrobial substances waiting for discovered. The natural substances are usually good leading compound sources for mostly synthetic drug from the long past due to their diversities are far from human imagination. New chemical structures are always found in natural resources as higher frequency than artificial deducing structures. The final reason is that the mechanism used to synthesize natural substances are available and they are usually can be imitated in small, medium, and even large scale production with present biotechnological knowledge which looks easier than newly designed plants. They are, together with a small group of bacteria, the only living organisms which are capable of harvesting and storing solar energy by virtue of their photosynthetic apparatus which converts light energy into chemical energy through the reductive assimilation of carbon dioxide. Virtually all other life on earth depends on the organic molecules they synthesize. Evidently, the fact that the majority of heterotrophic organisms depends on them makes plants favorite targets of a whole variety of parasites and predators. They directly interfere with the growth, multiplication and spread of microbial organisms (Lehrer and Ganz, 1999). Different proteins with antibacterial and/or antifungal activity have been isolated from seeds, tubers, and rhizomes, where they accumulate to high levels and may also function as storage proteins. Homologous of the seed proteins have also been identified at very low concentrations in floral and vegetative tissues (Terras et al. There are several classes of proteins having antimicrobial properties which include thionins, lipid transfer proteins, plant defensins, chitinases, glucanases, 2S albumins, ribosome inactivating proteins and lectin (Ye et al. Lectins are proteins or glycoproteins of a ubiquitous distribution in nature, which have at least one carbohydrate or derivative binding site without catalytic function or immunological characteristics. They have the unique ability to recognize and bind reversibly to specific carbohydrate ligands without any chemical modification; this distinguishes lectins from other carbohydrate binding proteins and enzymes, and makes them invaluable tools in biomedical and glycoconjugate research (Peumans and Van Damme, 1995). Plants were the first discovered source of lectins and, although lectins have since been found to be universally distributed, plants remain the most frequently used source of lectin studies due to both the ease of their extraction and the relatively high yields that can be obtained. Moreover, different families of plants, as well as different tissues within the same plant, can contain different lectins with different bioactivities, including different carbohydrate binding specificities. It has been suggested that plant lectins may have important roles according to their abundance, including in the immune defence, and also that lectins have been co-opted adapted for several functions during evolution (Sharon and Lis, 2001). The role of lectins in the defense mechanism of plants may have evolved from the ability to lectins to agglutinate and immobilize microorganisms. The supporting evidence for this proposed role in defense against pathogens falls into two main observed categories, namely (a) the presence of lectins at potential sites of invasion by infectious agents, and (b) the binding of lectins to various fungi and their ability to inhibit fungal growth and germination. A number of studies with respect to the potential defense role of plant lectins have been reported.

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Zero order kinetic: It is independent of the amount of drug present at the particular sites of drug absorption or elimination erectile dysfunction jet lag order apcalis sx 20mg. On repeated administration of drug after certain stage it goes on accumulating in the body and leads to toxic reactions erectile dysfunction and diabetes type 1 purchase 20 mg apcalis sx. Steady state plasma concentration: When a drug dose is given repeatedly over a given period erectile dysfunction natural cures buy 20 mg apcalis sx amex, a steady state is eventually reached, at which point the amount of drug absorbed is in equilibrium with that eliminated from the body. For example a drug with half life of 6 hours will be expected to be at steady state after more than 24 hours of administration. The pattern of drug accumulation during repeated administration of drug at intervals equal to its elimination half-life. For some drugs, the effects are difficult to measure, toxicity and lack of efficacy are both potential dangers, and/or the therapeutic window is narrow. In these circumstances doses must be adjusted carefully to a desired steady state concentration by giving loading and maintenance doses. Loading dose: the loading dose is one or a series of doses that may be given at the onset of therapy with the aim of achieving the target concentration rapidly. Maintenance dose: To maintain the chosen steady-state or target concentration, the rate of drug administration is adjusted such that the rate of input equals to rate of loss. Factors modifying the dosage and action of drugs : Individuals differ both in the degree and the character of the response that a drug may elicit and therefore the optimum dose of a drug which produces the desired therapeutic effect varies from person to person. Drug intolerance: It is a quantitative deviation from the anticipated response to a given dose of a drug. Sex difference: Special care should be exercised when drugs are administrated during menstruation, pregnancy and lactation. Drugs which may stimulate the uterine smooth muscle, are contraindicated during pregnancy. Further, many drugs administered to mother are capable of crossing the placenta and affecting the foetus. Teratogenicity means congenital malformation i) Drugs known to produce teratogenicity e. Therefore the drugs, which are excreted in the milk and harm the infant health should be, avoided by breast-feeding mothers e. Body Weight: the average dose is mentioned either in terms of mg per kg body weight or as the total single dose for an adult weighing between 50-100kg. However, dose expressed in this fashion may not apply in cases of excessively obese individuals or those suffering from edema, or dehydration nutritional factors can sometimes alter drug metabolizing capacity and this should be kept in mind in malnourished patients. Thus gastric emptying is prolonged and the gastric pH fluctuates in neonates and infant, further the liver capacity to metabolize drugs is low, renal function is less developed and the proportion of body water is higher in the newborn and the neonates. With a few exceptions, drugs are more active and more toxic in the new born than the adults. Like children, old people also present problems in dosage adjustment and this may vary widely with different people. The metabolism of drugs may diminish in the elderly and the renal function declines with age. Elderly are sensitive to the drugs like hypnotics, tranquilizers, phenylbutazone, diazepam, pethidine, etc. So a) Using age of the child the dose will be 3 x 10 = 3 x100 = 20mg 3+12 15 b) Using body weight of the child it will be 30 x 100 = 1 x 100 = 20mg 150 5 5. Disease state: Some antimicrobial agents penetrate the cerebrospinal fluid well across the normal meninges while other antimicrobials penetrate well only when the meninges are inflammed (meningitis) e. Acute or chronic liver diseases markedly modify the rate and extent of biotransformation of drugs. The t1/2 of chlordiazepoxide and diazepam in patients with liver cirrhosis is greatly increased with corresponding prolongation of their effects.

The left recurrent laryngeal nerve branch loops under the arch erectile dysfunction protocol free apcalis sx 20 mg otc, lateral and posterior to the ligamentum arteriosum (an embryological remnant) impotence or ed cheap apcalis sx online american express. The left vagus nerve continues posterior to the root of the left lung and along the esophagus as the anterior vagal trunk through the esophageal hiatus erectile dysfunction jason buy apcalis sx overnight delivery. Observe also the right and left (paravertebral) sympathetic chains and associated structures (ganglia, white and grey rami communicantes) as well as the thoracic splanchnic nerves. Recall that preganglionic sympathetic fibers travel in greater splanchnic nerve (T ), lesser splanchnic nerve 5-9 (T10-11), and least splanchnic nerve (T12). D Center for Anatomical Studies and Education Department of Regenerative Medicine and Cell Biology College of Medicine Medical University of South Carolina Slide 1. In this lecture, we will discuss the gross anatomical structures of the respiratory system, namely the trachea, the bronchi, the lungs and the pleurae. In this slide, please visualize the structures that will be discussed during the course of this lecture. The trachea is an approximately 5 inches long, 1 inch wide, mobile cartilaginous and membranous tube starting at the lower border of the cricoid cartilage and ending by bifurcating (branching) into the right and the left main (primary) bronchi at the level of the sternal angle. Recall that the cricoid cartilage (upper end of the trachea) is at the level of the C6 vertebra and the sternal angle (lower end of the trachea) is at the lower level of th the 4 thoracic vertebra. Note that during a bronchoscopy, a keel shaped anatomical structure, the carina can be observed at the level of the bifurcation. In this cross-section of the trachea, we can observe that the trachea: Has a fibroelastic wall with an embedded series of U-shaped bars of hyaline cartilage keeping the lumen patent (open) Has a mucosa lining the inside lumen Has a band of smooth muscle, the trachealis muscle, closing the posterior free end of the U-shaped cartilage. In terms of relationship, the trachea is surrounded by: Anteriorly: the brachiocephalic trunk and the arch of the aorta (the sternum, the thymus, the left common carotid artery, and left brachiocephalic vein) Posteriorly: the esophagus and the left recurrent laryngeal nerve. In terms of relationship, the trachea is surrounded by: On the right side: the azygos vein, the right vagus nerve and the pleura On the left side: the arch of the aorta, the left common carotid and left subclavian arteries, the left vagus, left phrenic nerve and pleura. The trachea receives its innervation through branches of: the vagus and the recurrent laryngeal nerves the sympathetic trunks these branches are distributed to the: the trachealis muscle the mucous membrane lining the trachea. Understand that the right lung divides into 3 lobes, the superior, the middle and the inferior lobe whereas the left lobe divides in 2 lobes, the superior and the inferior lobe with an additional structure not present in the right lung the lingual. Note how the right bronchus is wider, shorter and more vertical than the left bronchus. This is clinically important as small swallowed foreign objects (like peanuts, coins, etc…) will have a higher probability of lodging themselves in the right bronchus than in the left bronchus. Observe that:  the primary bronchi divide into secondary bronchi  On the right side, the primary bronchus divides into a superior bronchus and an intermediate bronchus before entering the hilum of the right lung  On the left side, the primary bronchus first enters the hilum of the left lung and then divides into a superior and an inferior bronchus  the terms “secondary” and “lobar” bronchi are synonymous terms because the secondary bronchi ventilate the lobes of the right and left lungs. The secondary bronchi further divide into tertiary bronchi, also called segmental bronchi because they ventilate the bronchopulmonary segments of the lungs (see next). Note that the bronchi continue to undergo division until the level of the terminal bronchiole (up to a total of 27 divisions). They are separated by the heart, the great vessels and the other structures found in the mediastinum. Note that each lung: Is conical in shape, covered with a visceral pleura and suspended by its root Has an apex, a concave base that sits on the diaphragm, a convex costal surface and a concave mediastinal surface. As already described, the left lung has two lobes (superior and inferior) separated by a single oblique fissure. The root of the lung allows the passage through the hilum of the lung of the left pulmonary artery, the left pulmonary bronchus and the left pulmonary veins.