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The upper border is thickened to form the vocal ligament because the uninjured cord can cross the midline to reach the para- which purchase atarax 10mg amex, with the mucous membrane that covers it purchase 25 mg atarax with mastercard, forms the vocal lysed cord. If both nerves are damaged but not • Cricothyroid joint: a small synovial joint between the inferior horn completely divided the cords are adducted since the abductors are of the thyroid cartilage and the cricoid, permitting a hinge-like move- more affected than the adductors (Semon’s law). The pharynx and larynx 139 63 The root of the neck Middle cervical ganglion Scalenus medius Vertebral artery Scalenus anterior Sympathetic trunk Phrenic nerve Inferior thyroid artery Upper trunk of brachial plexus Superficial cervical artery Vagus Suprascapular artery, nerve Subclavian artery Dorsal scapular artery Subclavian vein Carotid sheath Internal thoracic artery Inferior cervical ganglion Thoracic duct Fig. The curved arrow on the right side of the diagram indicates the course of the thoracic duct Scalenus posterior Sympathetic trunk Superior intercostal artery Attachment of scalenus medius 1st thoracic nerve Serratus anterior 8th cervical nerve (first digitation) Lower trunk of brachial plexus Scalene tubercle, Subclavian artery for attachment of Subclavian vein scalenus anterior Subclavius Costoclavicular ligament Fig. The subclavian artery and the Through this relatively confined space pass the trachea and oesopha- trunks of the brachial plexus are between the two muscles and the sub- gus, the carotid and subclavian arteries and the corresponding large clavian vein is in front of scalenus anterior. At the outer border of the 1st rib it becomes the axillary scalenus anterior before crossing the subclavian artery and entering the artery. The The veins middle cervical ganglion is close to the entry of the artery into the fora- • The subclavian vein: begins at the outer border of the 1st rib and lies men transversarium of C6 and the inferior cervical ganglion is near the in a shallow groove on the upper surface of the rib in front of scalenus neck of the 1st rib behind the origin of the vertebral artery. At the medial border of this muscle it is joined by the internal fused with the 1st thoracic ganglion to form the stellate ganglion. The internal jugular vein is enclosed in the carotid sheath, along with the common carotid artery The thoracic duct (Fig. The duct ascends out of the thorax between the ies but the inferior thyroid veins are solitary and run down from the trachea and oesophagus and arches laterally between the carotid sheath lower border of the thyroid gland, in front of the trachea, to reach the in front and the vertebral artery behind. The nerves • The upper, middle and lower trunks of the brachial plexus: emerge from between the scalenus anterior and medius and pass down The root of the neck 141 64 The oesophagus and trachea and the thyroid gland Thyrohyoid Superior thyroid artery Sternothyroid Cricothyroid Common carotid artery Inferior thyroid artery Inferior thyroid artery Right recurrent laryngeal nerve Inferior thyroid veins Left brachiocephalic vein Fig. A large part of the right lobe has been removed The oesophagus These infrahyoid muscles are all supplied by the ansa cervicalis (C1, The oesophagus begins at the level of the cricoid cartilage and runs 2 and 3). Their function is to fix the hyoid bone so that the suprahyoid down behind and slightly to the left of the trachea. Their main importance lies in their close laryngeal nerve is in the groove between the oesophagus and trachea relation to the thyroid gland. The thyroid gland The trachea The thyroid is an endocrine gland with an extremely rich blood supply The trachea begins at the level of the cricoid cartilage and ends by (Fig. Its isthmus lies across the 3rd, 4th and 5th rings of the tra- dividing into left and right bronchi at the level of the manubriosternal chea and the lobes lie on either side, reaching up as far as the ‘pocket’ joint. The trachea can be palpated in the midline just above the sup- under the attachment of sternothyroid to the thyroid cartilage. The upper enclosed in the thin pretracheal fascia and also has its own fibrous part of the trachea is crossed by the isthmus of the thyroid. When the gland is enlarged, the strap muscles are stretched bronchi and lungs develop from a groove in the floor of the embryonic tightly over it and the carotid sheath is displaced laterally. It divides into two branches which run down the posterior border and The infrahyoid (‘strap’) muscles along the upper border. It is thus possible to tie all four arteries during subtotal • Sternohyoid: is superficial to the other two and runs from the thyroidectomy and still leave an adequate blood supply to the manubrium to the lower border of the hyoid. They (thyroglossal duct) in the position of the future foramen caecum of the are about the size of a pea and are embedded in the back of the thyroid tongue. They develop from the third (inferior parathy- The stem of the outgrowth, the thyroglossal duct, normally disappears roid) and fourth (superior parathyroid) pharyngeal pouches of the although it may remain in part. The thymus also develops from the third pouch and may drag where along the course of the duct or thyroglossal cysts may appear. The oesophagus and trachea and the thyroid gland 143 65 The upper part of the neck and the submandibular region Hypoglossal nerve Internal jugular vein Internal carotid artery Occipital artery Glossopharyngeal nerve Spinal accessory nerve Superior laryngeal nerve Vagus nerve Hypoglossal nerve C2 Lingual artery Internal laryngeal nerve C3 External laryngeal nerve Superior ramus of ansa cervicalis Fig. The contents of the submandibular • The glossopharyngeal runs forwards, across the internal carotid region include: artery but deep to the external carotid (p. On its surface lies the anterior belly of the digastric • The spinal root of the accessory runs backwards, crossing the inter- muscle, and the two have the same nerve supply (the mylohyoid nerve). Suspended from it is the which enters through the foramen ovale and immediately breaks up submandibular ganglion, in which parasympathetic fibres from the into branches (Chapter 57). The lingual nerve carries sensory fibres from the anter- • The medial and lateral pterygoid muscles: the medial pterygoid is ior two-thirds of the tongue as well as taste fibres which are carried in inserted into the inner surface of the ramus and thus separates the the chorda tympani. The lateral pterygoid runs backwards from the lateral pterygoid then runs forwards on the hyoglossus, below the lingual nerve, to enter plate to the neck of the mandible and the intra-articular disc. From this the submandibular with an intra-articular disc but, unlike most other synovial joints, the (Wharton’s) duct travels forwards to enter the mouth at the sublingual articular cartilage and the disc are composed of fibrocartilage or even papilla near the midline. The lateral pterygoid muscle can pull the disc and the then passes deep to the nerve to enter the tongue. This occurs embedded in the posterior part of the gland before turning down, when the mouth is opened so that the joint is not a simple hinge joint. Its upper surface is covered by the mucous membrane of the such as mylohyoid and geniohyoid and closed by the masseter, tem- mouth and its numerous ducts open onto a ridge in the floor of the poralis and medial pterygoid. The upper part of the neck and the submandibular region 145 66 The mouth, palate and nose Fungiform papillae Filiform papillae Vallate papillae Foramen caecum Palatoglossal fold Lingual lymphatic Fig.

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They gh atarax 25 mg low price, pb discount atarax 25mg with mastercard, and tvl measurements will always represent the extent of prolapse, have a positive value be it above the introitis ( ie All measurements, except for tvl, are made negative) or below the introitis ( ie while patient is bearing down positive) 20 Point Aa Point Bp If an imaginary small man walked Again, this point describes more from the introitis up the anterior extensive prolapse beyond the vaginal wall and made a mark once 3 cm mark of Ap similar to Ba. This point is therefore for example, is 7cm above the never more than 3 and represents introitis, this point is then -7, if it is the bottom 3cm of the vagina. Point Ba Point D This point describes additional This describes the descent of the prolapse of the anterior vaginal posterior fornix again similar to wall that goes beyond the frst the cervix. It can therefore be Total vaginal Length greater than the +3 described for This is the measurement of point Aa. It is usually Because it essentially defnes more measured with the marked spatula extensive prolapse, when there inserted to its maximum into the is no prolapse, by convention we vagina. Urogenital hiatus Point Ap The measuring spatula is placed Again our imaginary man makes anteroposteriorly along the the 3cm trip up the posterior wall introitis and measures from the where he marks off point Ap. The diagnosis in women two separate catheters are used with urinary incontinence based for flling and pressure recording. There is a large intra-abdominal pressure (Pabd) overlap between symptoms and and this pressure could therefore examination and urodynamic also be obtained by inserting the fndings. The cystometrogram usually gives 3 pressure tracings: becomes essential, in a number Pves (bladder pressure), Pabd of women, to enhance diagnostic (abdominal) and Pdet (detrusor accuracy and therefore enable us pressure). The Urodynamics system comprises two catheters, one placed in the The Procedure bladder and another in the rectum, a computer and the urodynamics The test comprises three software and pressure transducers, phases. Free fow phase are measuring appropriately, The woman is asked to arrive when the women coughs, there at the investigation with a full should be no deviation of the bladder. She is then asked to Pdet – only on the vesical line and void on the fowmeter, which is the abdominal line since these usually mounted on a commode, in are both under the infuence privacy. In other part of the test differs from the words, when there is a rise in voiding cystometry, which is done abdominal pressure with coughing, after the flling phase once the the same pressure is transferred bladder is full and the lines are in to the bladder. The patient is asked to report on her frst desire as well as the moment she has a strong desire to void. Filling phase include asking the woman to heel The bladder and rectal lines are bounce, wash hands and cough. The women trace by a fowmeter but if this is asked to cough to check that modality is not available on the the Pdet measurement is correct. If tolerate any more flling, the pump both the vesical and rectal lines is stopped, this is the maximum 24 cystometric capacity. Voiding Cystometry the voiding cystometry phase This is done by asking the patient and therefore parameters such to void while the pressures are as PdetQmax, the detrusor recorded. If the Detrusor pressure curve rises slowly during the flling phase, this would suggest poor compliance. The prevalence increases with The term “overactive bladder” increasing age being 4 percent in was proposed as a way of women younger than 25 years and approaching the clinical problem 30 percent in those older than 65 from a symptomatic rather than years. While not take into account the individual’s life threatening, it can have a lifestyle and any appropriate considerable adverse impact on interventions that can be the quality of lives of those who employed to minimize symptoms. In the past, clinical results investigations are undertaken to of treatment have often been ensure that the correct problem disappointing due to both to poor is being addressed. Earlier preparations were a diagnosis of detrusor overactivity not subjected to the current in which case, further trials rigorous randomised controlled of different antimuscarinic trials and, therefore, lack evidence preparations would be desirable, – based data. Comparison of whereas in the absence of drug therapies for this condition proven detrusor overactivity, is diffcult due to the placebo an alternative diagnosis should effect of 30 – 40%, and since the be sought to avoid further response to any of the available ineffectual treatment and, hence drugs is only in the region of 60%, disillusionment and a waste of any differences that are detected resources. Data were are suggestive of urodynamically collected using a population – demonstrable detrusor overactivity, based survey of men and women but can be due to other forms of aged ≥ 40 years, selected from urethro – vesical dysfunction. This adversely affects their possibly because of the mistaken physical and psychological state by opinion that effective treatment is limiting daily activities, intimacy, not available. It is no surprise therefore that The management of improvements in urgency are often stated by people to be the most overactive bladder noticeable response to therapy. Data services play a pivotal role in obtained on the basis of 3 – or 4 the management of incontinent – day diaries suggest that short – patients. About 50% of people show positive results with existing gain satisfactory beneft from antimuscarinic therapy. The role of physiotherapy in the treatment of Initial assessment must include urge incontinence remains unclear a thorough history and physical as evidenced by systematic review examination. Urine analysis, and include lifestyle modifcations, microscopy and culture will exclude medications, bladder retraining, urinary infections. Lifestyle modifcations incontinence should commence • The patient should limit with conservative methods before intake of foods and drinks progressing to more complex that may irritate the bladder surgical procedures if these do not or stimulate the production work. Eat high fbre foods activity acting primarily on the such as wholewheat bread M1 and M3 receptor over the M2 and pastas. Tablet doses between 5 and been sought that would avoid 10 mg are available, and several oral administration and frst randomized controlled studies pass metabolism.

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Medicines By Design I Molecules to Medicines 43 by learning how to hijack molecular transporters to shuttle drugs into cells 10mg atarax visa. Gordon Amidon purchase 10mg atarax fast delivery, a pharmaceutical chemist at the University of Michigan-Ann Arbor, has been studying one particular transporter in mucosal membranes lining the digestive tract. The challenge is a chemistry wants to extend this list by synthesizing hundreds problem—most drugs are water-soluble, but of different molecules and testing them for their membranes are oily. Membranes are genomics, and bioinformatics have sped the search usually constructed to permit the entry of only for molecules that Amidon and other researchers small nutrients and hormones, often through can test. Many pharmacologists are working hard to devise ways to work not against, but with nature, 44 National Institute of General Medical Sciences Scientists are also trying to slip molecules Act Like a Membrane through membranes by cloaking them in disguise. Researchers know that high concentrations of Steven Regen of Lehigh University in Bethlehem, chemotherapy drugs will kill every single cancer Pennsylvania, has manufactured miniature cell growing in a lab dish, but getting enough of chemical umbrellas that close around and shield these powerful drugs to a tumor in the body with­ a molecule when it encounters a fatty membrane out killing too many healthy cells along the way and then spread open in the watery environment has been exceedingly difficult. So far, Regen has only used test mole­ drugs can do more harm than good by severely cules, not actual drugs, but he has succeeded in sickening a patient during treatment. The ability to do this particles called liposomes to package and deliver in humans could be a crucial step in successfully drugs to tumors. Liposomes are oily, microscopic delivering therapeutic molecules to cells via capsules that can be filled with biological cargo, gene therapy. They are very, very small—only Anesthesia Dissected Scientists who study anesthetic medicines little physical resemblance to each other—can all have a daunting task—for the most part, produce anesthesia. Researchers do Sloan-Kettering Institute for Cancer Research in New know that anesthetics share one common York City clarified how certain types of these mys­ ingredient: Nearly all of them somehow terious medicines work. Veselis and his coworkers target membranes, the oily wrappings measured electrical activity in the brains of healthy surrounding cells. However, despite the volunteers receiving anesthetics while they listened fact that anesthesia is a routine part of to different sounds. To determine how sedated the surgery, exactly how anesthetic medicines people were, the researchers measured reaction work in the body has remained a mystery for more time to the sounds the people heard. It’s an important problem, since memory effects, they quizzed the volunteers at the anesthetics have multiple effects on key body func­ end of the study about word lists they had heard tions, including critical processes such as breathing. Veselis’ experiments Scientists define anesthesia as a state in which show that the anesthetics they studied affect sepa­ no movement occurs in response to what should rate brain areas to produce the two different effects be painful. The findings may help loses a pain response, the anesthesiologist can’t doctors give anesthetic medicines more effectively tell what is happening inside the person’s organs and safely and prevent reactions with other drugs and cells. Researchers have known about liposomes for many years, but getting them to the right place in the body hasn’t been easy. Once in the blood­ stream, these foreign particles are immediately shipped to the liver and spleen, where they are destroyed. Materials engineer David Needham of Duke University in Durham, North Carolina, is investi­ gating the physics and chemistry of liposomes to better understand how the liposomes and their cancer-fighting cargo can travel through the body. David Needham designed liposomes resembling tiny molecular “soccer Needham worked for 10 years to create a special balls” made from two different oils that wrap around a drug. The end result is a tiny dogs revealed that, when heated, the drug-laden molecular “soccer ball” made from two different capsules flooded tumors with a chemotherapy oils that wrap around a drug. Researchers ture, the liposomes are solid and they stay solid at hope to soon begin the first stage of human studies body temperature, so they can be injected into the testing the heat-triggered liposome treatment in bloodstream. The results their drug cargo into a tumor when heat is applied of these and later clinical trials will determine to the cancerous tissue. Heat is known to perturb whether liposome therapy can be a useful weapon tumors, making the blood vessels surrounding for treating breast and prostate cancer and other cancer cells extra-leaky. Needham and Duke oncologist Mark Dewhirst teamed up to do animal studies with the heat- activated liposomes. Experiments in mice and 46 National Institute of General Medical Sciences The G Switch (a) (b) (c) Hormone Plasma Membrane Active Cell Enzyme Receptor Inactive Cell Enzyme Inactive G Protein Active G Protein Cell Response G proteins act like relay batons to pass Imagine yourself sitting on a cell, looking messages from circulating hormones outward to the bloodstream rushing by. You don’t realize it, but your own (c) The G protein passes the hormone’s message to the cell by switching on body sent this substance—a hormone called a cell enzyme (purple) that triggers epinephrine—to protect you, telling you to a response. Your body reacts, whipping up the familiar, spine-tingling, “fight-or-flight” response that gears you to respond quickly to potentially threatening situations such as this one. Getting into a cell is a challenge, a strictly guarded process kept in control by a protective gate called the plasma membrane. Figuring out how molecular triggers like epinephrine communicate important messages to the inner parts of cells earned two scientists the Nobel Prize in physiology or medicine in 1994. Getting a cellular message across the membrane is called signal transduction, and it the world have focused on these signaling occurs in three steps. Research on G proteins and on all epinephrine) encounters the outside of a cell aspects of cell signaling has prospered, and as Got It? In the fall of 2000, Gilman embarked on transducer, or switch molecule, passes the a groundbreaking effort to begin to untangle What is a liposome? The group has a big dream: to understand One of the Nobel Prize winners, pharma­ everything there is to know about signaling cologist Alfred G. According to Gilman, Alliance Describe how Texas Southwestern Medical Center at Dallas, researchers focus lots of attention on G G proteins work. As with any switch, G proteins must be revolution in biomedical turned on only when needed, then shut off.

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