Tricor

By A. Irhabar. Boston University.

The limbic lobe has strong connections with the hypothalamus and influences the state of its activity on the basis of emotional state tricor 160mg mastercard. For example discount tricor 160mg amex, when you are anxious or scared, the amygdala will send signals to the hypothalamus along the medial forebrain bundle that will stimulate the sympathetic fight-or-flight response. The hypothalamus will also stimulate the release of stress hormones through its control of the endocrine system in response to amygdala input. The Medulla The medulla contains nuclei referred to as the cardiovascular center, which controls the smooth and cardiac muscle of the cardiovascular system through autonomic connections. When the homeostasis of the cardiovascular system shifts, such as when blood pressure changes, the coordination of the autonomic system can be accomplished within this region. Furthermore, when descending inputs from the hypothalamus stimulate this area, the sympathetic system can increase activity in the cardiovascular system, such as in response to anxiety or stress. The preganglionic sympathetic fibers that are responsible for increasing heart rate are referred to as the cardiac accelerator nerves, whereas the preganglionic sympathetic fibers responsible for constricting blood vessels compose the vasomotor nerves. It receives sensory input about blood pressure and cardiac function from the glossopharyngeal and vagus nerves, and its output will activate sympathetic stimulation of the heart or blood vessels through the upper thoracic lateral horn. Another brain stem nucleus important for visceral control is the dorsal motor nucleus of the vagus nerve, which is the motor nucleus for the parasympathetic functions ascribed to the vagus nerve, including decreasing the heart rate, relaxing bronchial tubes in the lungs, and activating digestive function through the enteric nervous system. The nucleus ambiguus, which is named for its ambiguous histology, also contributes to the parasympathetic output of the vagus nerve and targets muscles in the pharynx and larynx for swallowing and speech, as well as contributing to the parasympathetic tone of the heart along with the dorsal motor nucleus of the vagus. For example, it comes into play when homeostatic mechanisms dynamically change, such as the physiological changes that accompany exercise. Getting on the treadmill and putting in a good workout will cause the heart rate to increase, breathing to be stronger and deeper, sweat glands to activate, and the digestive system to suspend activity. These are the same physiological changes associated with the fight-or- flight response, but there is nothing chasing you on that treadmill. This is not a simple homeostatic mechanism at work because “maintaining the internal environment” would mean getting all those changes back to their set points. Instead, the sympathetic system has become active during exercise so that your body can cope with what is happening. A homeostatic mechanism is dealing with the conscious decision to push the body away from a resting state. Without any input from the autonomic system, the heart would beat at approximately 100 bpm, and the parasympathetic system slows that down to the resting rate of approximately 70 bpm. Homeostatic mechanisms are trying to keep blood pH in the normal range, or to keep body temperature under control, but those are in response to the choice to exercise. The autonomic system, which is important for regulating the homeostasis of the organ systems, is also responsible for our physiological responses to emotions such as fear. The video summarizes the extent of the body’s reactions and describes several effects of the autonomic system in response to fear. On the basis of what you have already studied about autonomic function, which effect would you expect to be associated with parasympathetic, rather than sympathetic, activity? These effects will primarily be based on how drugs act at the receptors of the autonomic system neurochemistry. The signaling molecules of 678 Chapter 15 | The Autonomic Nervous System the nervous system interact with proteins in the cell membranes of various target cells. In fact, no effect can be attributed to just the signaling molecules themselves without considering the receptors. A chemical that the body produces to interact with those receptors is called an endogenous chemical, whereas a chemical introduced to the system from outside is an exogenous chemical. Exogenous chemicals may be of a natural origin, such as a plant extract, or they may be synthetically produced in a pharmaceutical laboratory. Broad Autonomic Effects One important drug that affects the autonomic system broadly is not a pharmaceutical therapeutic agent associated with the system. The effects of nicotine on the autonomic nervous system are important in considering the role smoking can play in health. When the neurotransmitter released from the preganglionic fiber binds to the receptor protein, a channel opens to allow positive ions to cross the cell membrane. For example, the sympathetic system will cause sphincters in the digestive tract to contract, limiting digestive propulsion, but the parasympathetic system will cause the contraction of other muscles in the digestive tract, which will try to push the contents of the digestive system along. The end result is that the food does not really move along and the digestive system has not appreciably changed. The system in which this can be problematic is in the cardiovascular system, which is why smoking is a risk factor for cardiovascular disease. Only a limited number of blood vessels are affected by parasympathetic input, so nicotine will preferentially cause the vascular tone to become more sympathetic, which means blood pressure will be increased. Unlike skeletal or smooth muscles, cardiac muscle is intrinsically active, meaning that it generates its own action potentials. The autonomic system does not cause the heart to beat, it just speeds it up (sympathetic) or slows it down (parasympathetic). The mechanisms for this are not mutually exclusive, so the heart receives conflicting signals, and the rhythm of the heart can be affected (Figure 15.

Special forceps for roots in the upper jaw Bayonet-forceps is a specially designed for extraction of retained roots of upper wisdom tooth and roots of all classes of the upper teeth safe 160 mg tricor. Wisdom teeth forceps for the upper jaw 83 Figure 13: wisdom forceps for the upper jaw 84 Special beaks of the forceps They are designed in such a way that best tricor 160 mg, they are suitable for extraction of - Misplaced or partly erupted teeth, - Where mouth is small, - For bicuspids to be able to extract standing in front of the patient, - To remove retained roots, etc. As wheel and axel Position of the patient Position of the patient may be sitting, semi sitting or lying according to the condition of the patient. Position of Operator For extraction upper teeth the doctor stands in front of the patient, the arm of the dental chair raised for the upper left side. Apply traction The pressure which should be applied to dislocate should depend on the thickness of the jaw i. Therefore the pressure should be applied to the buccal aspect of the maxilla for extraction of premolars and molars of upper teeth. The various spaces cellulitis will be difficult to be discussed here but the only ones which are more serious and which should be given attention as they may cause air way distress will be discussed as follows: General 1. Only the shortest and most direct and dependent route to the abscess cavity or cellulitis, with preservation of anatomical structures and placement of the incision in esthetically acceptable area. Use blunt dissection with hemostats advancing into all areas of involved space to ensure that all loculi of pus have been allowed to drain. Clean drains in a sterile fashion daily, advance them gradually, and remove them when the drainage stops or becomes minimal. Medical supportive care The patients who need hospitalization are with all the following conditions: 1. Significant clinical presentations, high fever 0 (>101 F), dehydration, malaise, inability to take fluids, trismus, neurological changes, or lower cervical and deep space involvement. Need for parentral antibiotics: based on presentation of the patient, previous culture and sensitivity testing or acute illness. Other considerations need for other medical or surgical consultation for patient management; organisms resistant to oral antibiotics, bone involvement, or need for surgical debridement. During the initial examination, ligation of obvious bleeding vessels and application of occlusive pressure dressings may be necessary to control the bleeding. The lip should be examined bimnually and bidigitally inorder to avoid missing penetrating wound of the lip. The wound should be inspected for: • Foreign bodies and • Cleaned thoroughly 103 Wound healing depends on the following: • Minimal tissue damage • Debridement of necrotic tissue • Maximal tissue perfusion and oxygenation • Proper nutrition and moist environment Rx:- • Careful cleansing of the skin and wounds is an essential preliminary step in the care of all facial injuries. Soft tissue wounds heal in three general ways:- • Primary intention refers to the reapproximated tissues. This type of healing is seen with surgical incisions that are closed with sutures or well approximated by adhesive plasters. Fracture of teeth a) Fracture of crown (only enamel) b) Fracture of crown (enamel and dentine) c) Fracture of crown (with exposure of the pulp) d) Fracture of roots, (oblique horizontal, apical and vertical) 105 Cause ™ Car accident ™ Fall accident ™ Homicidal injury Common sites of trauma of teeth: ™ Upper frontal teeth ™ Lower frontal teeth in order of priority. Diagnosis: ™ History ™ Physical examination ™ Dental X-ray Treatment ™ If patient comes to the hospital with in 6-12 hours inter-dental fixation and administration of antibiotics (for intrusion and extrusion) ™ If Fracture of crown, Restoration ™ If Fracture of crown with exposed pulp, root canal therapy or extraction depending on the availability of the dental facilities. Fracture of the oro-facial region Signs of fracture A) Certain • deformity, • dislocation, • abnormal movement • Creptation • Post X-ray pictures B) Uncertain • Pain, • heamatoma, • loss of function 107 Systematic examination 1. Manual investigation, pain on pressure or push o Palpation of deformities, o creptation, o Sensitivity of the trigeminal nerve. Intra-oral examination, • Ability to open the mouth, • Disturbance of the occlusion, • Deviation of the jaw (upper/lower) • Inspect for the posterior displacement or swelling of the tongue • Inspect for the presence of broken tooth or denture 108 General management and treatment 1. First aid measures • Clearing of air way • Stopping of bleeding • Treatment of pain • Treatment of shock • Prophylaxis of tetanus Once air way obstruction is recognized or the patient’s condition is predictive of impending respiratory difficulties, the air way should be cleared and a systemic air way management established. Reduction of displacement and Immobilization o Internal wiring o Cast metal cap splints o Intra-osseous wiring o Plating o Pin fixation (extraoral fixation) 2. Of the bone Syphilis Age - - etc Maxillary fracture The maxilla forms the frame work of the midface, and it supports or is closely associated with the appurtenances of the face. Majority of maxillary fractures displacement follows the direction of the force they receive and they tend to stay in that position until reduced. It extends horizontally through the maxilla above the palate and through the lateral wall of the sinus and nasal aperture and septum. Primary cleft lip Unilateral complete z Malpositionof the nostril skin on the lip z Retraction of labial skin z Alteration in the white roll z Abnormalities in neighbouring mucosa 2. Premaxilla palate Unilateral cleft ¾ The premaxilla is under developed on both sides(clefted /nonclefted) ¾ Deviation of the interincisive suture ¾ Septal deviation , causes an internal rotation of the ascending pillarof the maxilla and ¾ Attendant lateral displacement of the medial canthus on the cleft side ¾ There by disturbing the entire symmetry of the face 120 Classification of Cleft Palate 1. These are- Natural inhabitants such as acidophilic bacillus, trepanoma microdentium, diplococci, streptococcus salvarius, entoameba gingivalis act and those which are in the environment ingested together with food, water and air. It has an optimal temperature, a sufficient amount of food substances and has a weakly alkaline reaction. Frequency of cleaning of the oral cavity Great amount of microbes are found at the neck of teeth and in the space between teeth (interdental space). There are many microbes in other parts of the oral cavity which are in accessible to the bathing action of saliva and the action of lysozyme. The presence of carious teeth is a condition for increasing the micro flora in the oral cavity, for the appearance of decaying process and unpleasant odors.

The length of survival of blood ce4lls after infusion into the human body discount tricor 160 mg on line, believe to be related to the structural and metabolic status of the cell membran Prenatal cheap tricor 160mg on line. A possible cause of false- negative antigen- antibody reactions due to an excessive amount of antibody. Reagent red cells red cells used in laboratory testing Recessive gene A gene that gives rise only to its corresponding character when present in “double dose”(i. Secondary response A second response to exposure to a foreign antigen, resulting in the production of large amounts of antibody. Pseudoagglutination or the false cluming of erythrocytes when the cells are suspended in their own serum. This phenomenon resembles agglutination and is due to the presence of an abnormal protein in the serum, plasma expanders, such as dextran, or wharton’s jelly from cord blood samples. The complementary relationship between the binding sites of anibodies directed against determinants of a similar- type antigen. Sensitization(of red cells) The specific attachment of antibody to its antigenic receptors on red cells without agglutination or lysis. Sialic acid Any of a family of amino sugars containing nine or more carbon atoms that are nitrogen- and oxygen- substituted acylderivatives of neuraminic acid. It is a component of lipids, polysaccharides, mucoproteins and it is the main substance removed from the red cells by enzyme treatment. The complementary relationship between the binding sites of anibodies directed against determinants of a similar- type antigen. A type of enzyme that catalyzes the transfer of a monosaccharide molecule from a donor substrate to the precusrsor substance. This type of biochemical activity is related to the development of A,B, and H antigens Transplacental hemorrhage. Wharton’s jelly A mucoid connective tissue that makes up the matrix of the umbilical cord Zeta potenitial The difference in electrostatic potential between the net charge at the cell membrane and the charge at the surface of shear. Tibebu M, The Blood Bank Manual, Ethiopian Red cross society, National Blood Transfusion Service, Addis Ababa, 1998. It is not all-inclusive and is not intended to replace good clinical judgment nor in-depth textbooks which should be consulted whenever appropriate. As in most areas of medicine, there may be more than one way to deal with any particular gynecologic problems. Removing just experience and training may be required the ovarian cyst and not the entire to perform gynecologic surgery. The bowel, bladder and ureters are very close to the uterus, Gynecologic Surgery cervix, tubes and ovaries. Damage to The basic principles of surgery apply to adjacent structures is not uncommon gynecologic surgery with a few special even when surgery is performed considerations: competently, by experienced gynecologic surgeons, in well- Preservation of Childbearing equipped settings. Repair of Vaginal or Vulvar Lacerations If the rectal sphincter has been torn, it will retract back into the surrounding These lacerations may result from tissue, creating a 1-2 cm. Suture the edges of the primary closure is preferred in an acute sphincter together, making sure to setting. In cases involving delayed include the fibrous capsule of the treatment (>24 hours after the injury), it muscle. This will allow proper healing may be preferable because of tissue and promote subsequent fecal inflammation and infection to allow continence. Failure to close the sphincter secondary healing followed, if is not disastrous, but will usually result necessary, by a later repair. Bladder Lacerations Other Lacerations Lacerations of the bladder can be Other soft tissue lacerations are usually diagnosed with retrograde injection of easily repaired with such absorbable dye through a Foley catheter. A should be in multiple layers, using simple running or running locking stitch absorbable sutures, without tension. Placing a Foley catheter in the bladder prior to suturing will help to outline the important anterior structures to be Rectal Lacerations avoided. Lacerations of the rectum may be closed If the laceration involves the posterior primarily with multiple layers of vaginal wall, remember that the rectum absorbable suture. The need for fecal can be within a few millimeters of the diversion should be determined by the vaginal mucosa. Local anesthetic may be Lacerations involving the lateral vaginal used but is often unnecessary if the skin walls are best sutured with good is thin and attenuated. When these lacerations are high in the After drainage of pus from the cavity, vagina, they are both more difficult loosely pack the cavity with narrow (because of exposure and lighting gauze (iodoform tape works well for problems) and more dangerous. The this), primarily to keep the incision open, ureter courses next to the cervix in the allowing continued drainage over the parametrial tissues but becomes next few days. The cut edges of the accessible to accidental vaginal suturing drainage incision may need to be sutured if the sutures are placed deep and high in for hemostasis but this is usually the vagina. Place a Foley catheter in the These draining abscesses usually resolve bladder and treat the hematoma with ice over the next few days but may return at packs.

Turbulent blood flow If the velocity of flow is very high buy 160 mg tricor with mastercard, or if the blood has to pass an obstruction vessel buy tricor 160mg low cost, flow becomes turbulent so that eddy currents are formed. Cross-sectional area and flow velocity The mean velocity of blood flow is inversely proportional to the cross-sectional area provide that the total volume of fluid flowing through each segment is constant. Blood volume distribution & blood pressure Blood volume is very unevenly distributed through the various vascular segments even though the volume flowing through is relatively constant. Thick, elastic arteries and arterioles contain 18%, capillaries hold only 3-4 percent of blood volume, while the heart contains about 7% blood pressure is almost inversely proportional to volume distribution and vascular resistance. There is little change in pressure in large arteries, but resistance increases rapidly in small arteries, causing the pressure to drop to about 70 mm Hg at the beginning of the arterioles. The arterioles have the greatest resistance of the systemic circulation, so that by the time blood reaches the capillaries, pressure has dropped to about 30 mmHg. Direct methods 1 Mercury manometer The principle behind manometry is that the vertical column of manometer fluid exerts a downward Pressure which opposes the blood pressure. When the column reaches a stable height (h), the blood pressure must be equal to the pressure at the bottom of the column, namely ρgh (fluid density ρx force of gravity g x h). Electronic pressure transducer To record the pressure wave form, a fast-responding electronic pressure transducer is needed. The transducer contains a metal diaphragm which deforms slightly when arterial pressure is applied to it via a catheter. The deformation of the diaphragm alters the resistance of a wire Connected to it and the resistance is recorded. Indirect methods Auscultator method (sphygmomanometry) The mercury manometer is used in medical practice throughout the world to measure human blood pressure, by an indirect method called sphygmomanometry. Auscultation of the brachial artery at the antecubital fossa (inner aspect of elbow) with a stethoscope therefore reveals no sound at this stage. As long as this pressure is higher than systolic pressure, the brachial artery remains collapsed and no blood whatsoever flows into the lower artery during any part of the pressure cycle. The transient spurt of blood vibrates the artery wall downstream and creates a dull tapping noise called Korotkoff sound. The jet causes turbulence in the open vessel beyond the cuff, and this sets up vibrations heard through the stethoscope). The sound, this time, has less of the tapping quality but more of a rhythmic harsher quality. Therefore, the sounds suddenly change to a muffled quality and usually disappear entirely. Direct versus indirect methods Several investigators have compared the pressure readings obtained from a cannula inserted into the brachial artery in one arm with the recordings obtained in the other by the auscultatory method. Normal values Many attempts have been made to define normal values for blood pressure but all such efforts have been unsatisfactory. For an adult under certain conditions he would be right, but it is quite wrong to adopt 120/80 mmHg as the normal standard for a resting child, a pregnant woman in midterm or an elderly man. It is not equal to the average of systolic and diastolic pressure because the pressure remains nearer to the diastolic pressure than to the systolic pressure during the greater part of the cardiac cycle. If heart rate increases, the relative amount of time the heart spends in diastole decreases. The increase in pulse pressure is especially striking and iscaused by reduced arterial compliance. Reduced compliance is due to arteriosclerosis (hardeningof the arterioles by fibrosis and calcinosis), and is universal accompaniment to ageing. Conversely, pressure is reduced in the arteries above the heart level and is only 60mmHg or so in human brain during standing. Indirect effect Upon moving from lying to standing, arterial pressure changes at heart level due to changes in cardiac output and peripheral resistance. A transient fall in aortic pressure (which can produce a passing dizziness) is followed by a small but sustained reflex rise. Compared with the relaxed states, while attending a meeting often raise it by 20mmHg. The pressor effect of stress is particularly harmful to patients with ischemic heart disease. Valsalva maneuver: Valsalva maneuver, a forced expiration against a closed or narrowed glottis, causes a complex sequence of pressure changes. Pregnancy: In pregnancy blood pressure gradually falls and reaches a minimum at approximately 6 months. Veins don’t show distensibility are filled; they contain 3- times blood volume than in that of arteries. Veins have more capacity arteries expand and recoil, store pressure during systole of the heart and release it during cardiac diastole -the pressure stores. Capacitance vessels: act as blood reservoirs - veins & venules Regulation of flow through blood vessels Blood vessel caliber, an important factor in the determination of resistance and capacitance, is actively regulated by neural and humoral mechanisms and passively affected by the pressure within it. Vasomotor refers to rhythmic oscillating changes in the caliber of the arterioles, metarterioles, and precapillary sphincters resulting from vasoconstriction or vasodilatation and venomotion.