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Disco-Computed Tomography in Extraforaminal and Foraminal Lumbar Disc Herniation - Influence on Surgical Approaches fungus gnats root aphids generic ketoconazole 200mg on-line. Diagnostic accuracy fungus gnats human skin buy discount ketoconazole 200 mg on line, patient outcome fungus ear discount 200 mg ketoconazole with mastercard, and economic factors in lumbar radiculopathy antifungal polish purchase ketoconazole 200mg with amex. H-reflex latency and nerve root tension sign correlation in fluoroscopically guided fungus gnat glow worm buy cheap ketoconazole 200 mg on-line, contrast-confirmed fungus gnats tea order 200mg ketoconazole visa, translaminar lumbar epidural steroid-bupivacaine injections. Motor evoked responses after lumbar spinal stimulation in patients with L5 or S1 radicular involvement. Dermatomally stimulated somatosensory evoked potentials in lumbar disc herniation. A preoperative and postoperative study of the accuracy and value of electrodiagnosis in patients with lumbosacral disc herniation. A quantitative analysis of sensory function in lumbar radiculopathy using current perception threshold testing. Motor evoked potential study suggesting L5 radiculopathy caused by L1-2 disc herniation: Case report. This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Outcome Measures for Medical/Interventional and Surgical Treatment What are the appropriate outcome measures for the treatment of lumbar disc herniation with radiculopathy? The North American Spine Society has a publication entitled Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders. This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Medical/ Interventional Treatment What is the role of pharmacological treatment in the management of lumbar disc herniation with radiculopathy? Grade of Recommendation: B Genevay et al1 conducted a prospective randomized controlled trial to assess the efficacy of adalimumab, a tumor necrosis factor alpha inhibitor, in patients with radicular pain due to lumbar disc herniation. Of the 61 consecutively assigned patients included in the study, 31 received adjuvant treatment with two subcutaneous injections of adalimumab at seven-day intervals and 30 received placebo. A significant, small effect size is reported in favor of the experimental group on days one and two after treatment for leg pain. At six months, the number of patients meeting the "Responder" and "Low Residual Disease" criteria was significantly greater in the experimental group. At six months the number of patients meeting the "Responder" criteria for back pain was significantly greater in the experimental group. At week six, one patient in the experimental group and five patients in the placebo group proceeded to surgery. The authors concluded that a short course of adalimumab added to the treatment regimen of patients experiencing acute and severe sciatica resulted in a small decrease in leg pain and significantly fewer surgical procedures. The 2005 study described 12-week results and the 2006 study reported results at one year. Of the 40 consecutive patients included in the study, 21 were assigned to receive a 5 mg/kg, single infusion of infliximab while 19 patients were infused with saline. The authors concluded that results do not support the use of a single infusion of infliximab 5 mg/kg to treat moderate to severe disc herniation induced sciatica. The authors concluded that they could not recommend the clinical use of infliximab in disc herniation induced sciatica. Of the 60 patients included in the study, 31 received an intravenous bolus of 500 mg of methylprednisolone and 29 received an injection of normal saline. For the primary outcome measure, the maximum mean OutcOme nterventiOnal treatment medical/i measures fOr treatment this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. None of the secondary outcome measures was significantly different between the two groups. As expected, no durable benefit was observed at day 30 with a single intravenous bolus of glucocorticoids for any outcome. The authors concluded that a single intravenous pulse of glucocorticoid provides a small and transient improvement in sciatic leg pain. The transient benefit and small effect size of intravenous glucocorticoids on symptoms of acute sciatica probably do not warrant a large clinical use in this indication. This study provides Level I therapeutic evidence that a single intravenous infusion of glucocorticoids provides only temporary (three days) relief of pain. A glucocorticoid bolus has no effect on functioning or objective signs of radicular irritation related to lumbar disc herniation. Kasimcan et al6 reported results of a prospective case series assessing the effects of gabapentin on reduction of the severity of radicular pain and improvement of quality of life in patients with lumbar disc herniation and /or lumbar spinal stenosis over a relatively short period. Of the 78 patients included in the study, 33 had lumbar disc herniation with radiculopathy. Patients received a titration of gabapentin three times daily to a maximum dose of 2400 mg/day. Walking distance improved from 0-100 m in 29 patients to 1000 m in 24 patients at three months. The authors concluded that gabapentin monotherapy can reduce pain and increase walking distance significantly in patients with lumbar disc herniation. There is insufficient evidence to make a recommendation for or against the use of agmatine sulfate in the treatment of lumbar disc herniation with radiculopathy. Grade of Recommendation: I (Insufficient Evidence) Keynan et al7 conducted a prospective randomized controlled trial to evaluate the therapeutic efficacy of agmatine sulfate in patients with herniated lumbar disc associated radiculopathy. Of the 99 consecutively assigned patients, 38 patients dropped out or were excluded because of "unreliable data collection. Concomitant treatment was permitted which could include physical therapy, medication, epidural steroid injections and discectomy. In the period immediately following treatment, at 15-20 days, statistically significant enhanced improvements were seen in the treatment group compared to the placebo group. At 4550 days and 75-80 days, the difference between treatment and placebo group did not meet statistical significance. There was no significant difference in the use of physical therapy, medication, epidural steroid injections and discectomy between the groups. The authors concluded that during the period immediately after taking agmatine sulfate, people suffering from lumbar disc associated radiculopathy undergo significant improvement in their symptoms and general health-related quality of life as compared to those taking placebo. Grade of Recommendation: I (Insufficient Evidence) this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. There is insufficient evidence to make a recommendation for or against the use of amitriptyline in the treatment of lumbar disc herniation with radiculopathy. Grade of Recommendation: I (Insufficient Evidence) Pirbudak et al8 conducted a prospective randomized controlled trial to determine the efficacy of amitriptyline as an adjunct to epidural steroid injections in the management of chronic lumbar radicular pain. All patients received a blind interlaminar epidural injection at the involved level with 10 ml solution of betamethasone dipropionate (10mg) plus betamethasone sodium phosphate (4mg) and bupivacaine (0. In addition, a postural exercise program was initiated during the follow-up period. The injection was repeated at the end of the second week, if the improvement was partial, and at the end of the sixth week, if there was still incomplete recovery. Of the 92 patients included in the study, 46 received 10 mg/day amitryptiline orally (titrated up to 50 mg/day according to clinical response) for nine months. The 46 patients assigned to the control group received placebo (sugar) tablets instead of amitryptiline. At six months and nine months results, the placebo group outcomes did not differ statistically when compared with baseline values. The amitryptiline group experienced statistically significant improvements compared with baseline values (p=0. The authors concluded that epidural steroid and amitryptiline combination proved beneficial in the management of chronic low back pain associated with radiculopathy. This study provides Level I therapeutic evidence that the addition of amitriptyline to blind lumbar interlaminar epidural steroid injections provides significant relief as compared with placebo and interlaminar epidural steroid injections at up to nine months. The work group identified the following suggestions for future studies, which would generate meaningful evidence to assist in further defining the role of medical treatment for lumbar disc herniation with radiculopathy. Adalimumab in severe and acute sciatica: A multicenter, randomized, double-blind, placebo-controlled trial. The treatment of disc herniation-induced sciatica with infliximab: results of a randomized, controlled, 3-month follow-up study. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. New treatment of lumbar disc herniation involving 5-hydroxytryptamine2A receptor inhibitor: a randomized controlled trial. Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. Safety and efficacy of dietary agmatine sulfate in lumbar disc-associated radiculopathy. An open-label, dose-escalating study followed by a randomized, double-blind, placebo-controlled trial. Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy. This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Short-term efficacy of intravenous pulse glucocorticoids in acute discogenic sciatica. Adalimumab in severe and acute sciatica: A multicenter, randomized, double-blind, placebo-controlled trial. Effectiveness of Levetiracetam in the Treatment of Lumbar Radiculopathy: An Open-Label Prospective Cohort Study. New treatment of lumbar disc herniation involving 5-hydroxytryptamine2A receptor inhibitor: a randomized controlled trial. Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. An open-label, dose-escalating study followed by a randomized, double-blind, placebo-controlled trial. The treatment of disc herniation-induced sciatica with infliximab: results of a randomized, controlled, 3-month follow-up study. Comparison of Epidural Steroid Injections with Conservative Management in Patients with Lumbar Radiculopathy. Tumor necrosis alpha-blocking agent (etanercept): a triple blind randomized controlled trial of its use in treatment of sciatica. Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy. What is the role of physical therapy/exercise in the treatment of lumbar disc herniation with radiculopathy? There is insufficient evidence to make a recommendation for or against the use of physical therapy/structured exercise programs as stand-alone treatments for lumbar disc herniation with radiculopathy. Grade of Recommendation: I (Insufficient Evidence) Bakhtiary et al1 reported results of a prospective randomized controlled trial investigating the effect of lumbar stabilizing exercise in patients with lumbar disc herniation. Of the 60 patients included in this crossover design study, 30 were assigned to each treatment group. Patients in Group A received four weeks of lumbar stabilizing exercise, followed by four weeks of no exercise. Patients in Group B received four weeks of no exercise, followed by four weeks of lumbar stabilizing exercise. The lumbar stabilizing exercise protocol included four stages of stabilizing exercises from easy to advanced. Significant differences between groups A and B were seen in the mean changes on all outcome measures at the end of four weeks. After crossover, there were no significant differences between the groups in any of the outcomes measured at eight weeks. The authors concluded that a this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Intention-to-treat analysis (adjusted) and as-treated analysis both showed no significant difference in outcomes between the control and treatment groups. Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation. A pilot study examining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial. Work Group Consensus Statement Whereas a systematic search of the literature revealed limited evidence regarding the usefulness of structured exercise programs as stand-alone treatments in patients with lumbar disc herniation with radiculopathy, clinical experience suggests that structured exercise may be effective in improving outcomes as part of a comprehensive treatment strategy. This conclusion is inferred from the literature noted throughout the lumbar disc herniation with radiculopathy guideline. Lumbar stabilizing exercises improve activities of daily living in patients with lumbar disc herniation. The quality of life of lumbar radiculopathy patients under conservative treatment. Functional restoration for a chronic lumbar disk extrusion with associated radiculopathy. Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Resolution of pronounced painless weakness arising from radiculopathy and disk extrusion. Treatment of protrusion of lumbar intervertebral disc by pulling and turning manipulations. A Nonsurgical Approach to the Management of Patients with Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study with Follow-Up. High lumbar OutcOme nterventiOnal treatment medical/i measures fOr treatment this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up.
Encysted hydrocele of spermatic cord: Sometimes processus vaginalis is closed at the upper end of testis and at the site of deep inguinal ring but in the middle remains patent which produces encysted hydrocele of the spermatic cord fungus mouth ketoconazole 200mg discount. The prostate is a fibromuscular glandular organ of the male reproductive system 2 xifaxan fungus order 200 mg ketoconazole with visa. Human Anatomy for Students Consistency Firm (due to presence of fibromuscular stroma in which glandular tissue are embedded) fungus pedicure generic ketoconazole 200mg mastercard. This surface is related to the rectum separated by the rectovesical fascia of denovilliers 5 anti fungal shampoo india buy cheap ketoconazole 200mg. This surface can be easily palpated on digital examination through the anus which is 4 cm above the anus on its anterior aspect 6 fungal lung infection generic 200mg ketoconazole with amex. The lower larger part is again divided into two lateral lobes by a median sulcus 9 fungus quest ni no kuni generic ketoconazole 200 mg online. The horizontal groove close to the median plane is pierced on each side by the ejaculatory duct (meeting of the vas deferens with the ducts of the seminal vesicle). It is pierced by the urethra on its midline the junction between anterior one-third and the posterior two-thirds of the gland. Between the prostate and the levator ani lies a plexus of veins embedded in the fibrous prostatic sheath. It is a small part of the gland called isthmus connects the two lateral lobes of the gland Lobes. It is bounded Anteriorly-By the urethra Posterior and on each side-Ejaculatory ducts Posterior and median plane-Prostatic utricle 2. It forms the uvula vesicae which is an elevation produced by the median lobe in the lower part of the trigone of the bladder 5. Urethra traverses the gland junction between the anterior one-third and posterior two-thirds. It opens at the colliculus seminalis on each side of the opening of the prostatic utricle. True capsule: It is formed by the condensation of the fibrous stroma of the gland ii. False capsule/prostatic sheath: It is formed by the visceral layer of the pelvic fascia. A pair of medial puboprostatic and a pair of lateral puboprostatic ligaments extend from the false capsule to the back of pubic bones 2. The medial pair situated near the apex; where as the lateral pair is closed to the base 3. It runs vertically downwards from the base of the prostate to slightly infront of the apex Arterial Supply 1. The veins form a prostatic venous plexus which lies in the space between the true and false capsules 2. Parasympathetic Nerve Pelvic splanchnic nerves derived from S2, S3, S4 spinal segments. The ducts of the glands curve posteriorly to open into the prostatic sinuses Nerve Supply Sympathetic Nerve Superior hypogastric plexus. Submucosal glands, with ducts opening in the prostatic sinuses and colliculus seminalis ii. The simple mucosal glands lies in innermost group surrounding the upper part of the prostatic urethra iii. The posterior surface of the prostate can be palpable at the anterior wall of the rectum iii. If urinary bladder is full it gives more resistance, the prostate remains in its position and the gland is more readily palpable. The median lobe of the gland enlarges and obstructs the internal urethral orifice iii. The more strain, the more prostate occludes the internal urethral orifice by forming uvula vesicae which acting like a valve and blocks the opening iv. With the enlargement of the median lobe there is enlargement of the lateral lobes which produces elongation and lateral compression and distortion of the urethra as a result there is difficulty in passing urine and stream is weak v. The enlarged median lobe causes enlargement of the uvula vesicae which results in formation of a pouch of stagnant urine behind the internal urethral orifice within the bladder vi. The main complains are nocturia (more urination at night), dysuria (painful urination) and urgency (intense desire to urinate). In advanced stages the cancer cells, metastasize to the internal iliac and sacral lymph nodes, and also to distant lymph nodes and bone iv. As prostatic venous plexus connects with the internal vertebral venous plexus which is known as para-vertebral veins of batson, during coughing, sneezing or abdominal Age Changes in the Prostate 1. During first few weeks after birth show hyperplasia of the mucous membrane by the stimulation of circulating maternal estrogen iii. Thereafter the prostate grows slowly and formation of rudimentary follicles bud from the sides of the ducts 2. Between the ages of approximately 14 and 18 years the prostate gland enters a maturation phage ii. Approximately one year during this time the gland becomes more than double of its neonatal size due to rapid growth of the follicles iii. Condenasation of the stroma, which diminishes relative to the glandular tissue iv. These changes take place probably due to the secretion of testosterone by the testis. From the ages of 20 to 30 years: Glandular epithelium grows by irregular multiplication into the lumen of the follicles. After 45 to 50 years: Porstate may undergo benign hypertrophy or may undergo progressive atrophy. Situation In Nulliparous Adult It is situated one on each side of the uterus below the pelvic brim in the ovarian fossa close to the lateral wall of lesser pelvis. After Repeated Pregnancies It may be prolapsed in the pouch of Douglas due to relaxation of broad ligaments. It is narrower than the superior pole and directed downwards towards the pelvic floor 2. In multiparous women It is in horizontal axis so upper pole changes towards laterally and lower pole changes towards medially. Its surfaces are smooth before puberty but after that become irregular due to repeated ovulations. It is connected to the lateral angle of the uterus, posteroinferior to the uterine tube by a rounded ligament called ovarian ligament 4. The ovarian ligament lies between the two layers of the broad ligament of the uterus 5. This border attached with the posterior layer of broad ligament by a short peritoneal fold called Mesovarium 3. A peritoneal recess known as ovarian bursa between the mesosalpinx (upper part of the broad ligament) and the ovary. This a rounded ligament lies in the broad ligament and contains some smooth muscle cells 2. Attachments: From the uterine (inferior) pole of the ovary to the lateral angle of the uterus, posteroinferior to the fallopian tube. Attachments: From the tubal (superior) pole of the ovary and fallopian tube to the peritoneum on the psoas major posterior to the cecum on right side and descending colon on the left side 3. Attachments: From the anterior border of the ovary to the posterior layer of the broad ligament 3. Lymphatic Drainage Lymphatics run along the ovarian vessels and drain into the lateral and preaortic group of lymph nodes. Parasympathetic Peritoneal Relation of the Ovary It is intra-peritoneal except along the mesovarian or anterior border where two layers of peritoneum 228 Human Anatomy for Students. It gradually increases size with growth of the body and interstitial tissue decreases. The stroma becomes denser, the tunica albuginea thickens and the surface epithelium becomes thin 3. Many follicles persist in the cortex, some of them without oocytes, but others apparently normal 4. During excision of the ovary (ovariectomy) the ureter may injured when the ovarian vessels are tied off because these structures closely related each other where they cross the pelvic brim, where the ureter lies medial to the ovarian vessels. Follicular cyst: the follicular cysts are common which are originate from the unraptured graffian follicles, they rarely exceed 1. Luteal cysts: They are formed in the corpus luteum where fluid is retained, they rarely exceed 3 cm in diameter. Twisted ovarian cyst: It can be an emergency as ovarian pedicle obstructs the arterial supply and venous drainage of the cyst. After repeated pregnancies the ovary may be prolapsed in the recto-uterine pouch (pouch of Douglas) ii. In this case the ovary may be tender and cause discomfort on sexual intercourse (dyspareunia) iii. The ovary in the recto-uterine pouch may be palpated through the posterior fornix of the vagina. Ectopic ovary: It is rare occasion where ovary may found in the inguinal canal or labium majus due to errors of descent. Inflammation of the ovary may produce localized peritonitis of the ovarian fossa which causes irritation of the obturator nerve and results in persistent pain along the medial aspect of the thigh or at the knee joint. Sometimes ovary contains Abdomen and Pelvis 229 cells that are capable of differentiating into various tissues like bone, cartilage, hair, etc. Ampulla It is the expanded part of the uterine tube where fertilization commonly occurs. It emerges out of the uterus and then passes laterally along the upper free margin of the broad ligament to reaches up to the uterine end of the ovary 2. Then it passes upwards, backwards then downwards up to the medial surface of the ovary. Communication Medially Into the superolateral angles of the uterine cavity called uterine os. Uterine artery (approximately medial twothirds) branch of anterior division of internal iliac artery 2. On the right side via the right ovarian vein drains into the inferior vena cava 2. Nerve Supply Sympathetic T10 - L2 segments of spinal cord via the ovarian and superior hypogastric plexuses. Salpingitis: It is the inflammation of uterine tube, the major cases of infertility in women is due to blockage of the uterine tubes as a result of salpingitis. Tubal pregnancy is the most common type of ectopic gestation where implantation of fertilized ovum in the tube b. Effects It results in tubal rupture and bleeding in the peritoneal cavity (in the pouch of Douglas) and can be fatal which requires immediate surgical attempt. Sterility: In female sterility may occur due to the blockage of the uterine tube which may be congenital or caused by infection. Tubectomy: It is done for family planning of women by cesarean section or abdominal hysterotomy, where the tube is cut and the cut ends of the tubes are ligated. Endoscopy of uterine tubes/Salpingoscopy: Investigations of the uterine tube can be done by endoscopy, using the fiberoptics introduced through the vagina and uterus. Salpingography: It is the radiological technique by introducing a water soluble radiopaque medium into the uterus and the uterine tube. Uterine tube directly communicates between the exterior of the genital tract with the pelvic cavity through the ostium of the uterine tube as a result produces salpingitis and pelvic inflammatory diseases. Situation It is situated in the true pelvis between urinary bladder infront and rectum behind. This surface is covered by peritoneum, which is reflected on the upper surface of the bladder as uterovesical fold at the level of internal os b. Peritoneal relations: this surface is also covered by the peritoneum which is reflected from the cervix and upper part of vagina up to the rectum and forms the rectouterine pouch or pouch of Douglas. It is the angle between the long axis of cervix and long axis of vagina, in the condition of empty bladder. It is the angle between the long axis of the body of the uterus and long axis of the cervix uteri. Borders Lateral Borders these are two borders which are rounded and non-peritoneal for the attachments of the broad ligaments of the uterus. Round ligaments of uterus: Attached to the anteroinferior parts of fallopian tubes. Fundus of Uterus Definition It is the dome shaped mobile part above the line joining the two cornu of the uterus. Relations Peritoneal relation: It is covered by the peritoneum along its whole extent. Compare to the Body of the Uterus In newborn Twice the length of the body of the uterus. Isthmus Definition It is the constricted part of the uterus at the junction of cervix and body. Human Anatomy for Students Shape Fusiform (longitudinally), Flattened (transversely).
Gentamicin-induced ototoxicity in hemodialysis patients is ameliorated by N-acetylcysteine le fungus definition proven 200 mg ketoconazole. Clusterin protects renal tubular epithelial cells from gentamicin-mediated cytotoxicity fungus diet order ketoconazole 200 mg on line. Gentamicin binds to the lectin site of calreticulin and inhibits its chaperone activity fungus gnats mulch generic 200 mg ketoconazole otc. Aminoglycoside-associated severe renal failure in patients with multiple myeloma treated with thalidomide antifungal indications buy cheap ketoconazole 200 mg. Protective effect of aminoguanidine against nephrotoxicity induced by amikacin in rats antifungal at home 200mg ketoconazole free shipping. Targeted prevention of renal accumulation and toxicity of gentamicin by aminoglycoside binding receptor antagonists fungus gnats drains discount 200 mg ketoconazole visa. Protective effect of fosfomycin on gentamicin-induced lipid peroxidation of rat renal tissue. Extended-interval aminoglycoside dosing for treatment of enterococcal and staphylococcal osteomyelitis. Efficacy and tolerability of extendedinterval aminoglycoside administration in pediatric patients. Aminoglycoside extended interval dosing in neonates is safe and effective: a meta-analysis. Aminoglycoside toxicity: daily versus thrice-weekly dosing for treatment of mycobacterial diseases. Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity. Once-daily versus multiple-daily dosing with intravenous aminoglycosides for cystic fibrosis. A meta-analysis of the relative efficacy and toxicity of single daily dosing versus multiple daily dosing of aminoglycosides. A meta-analysis of extended-interval dosing versus multiple daily dosing of aminoglycosides. A meta-analysis of studies on the safety and efficacy of aminoglycosides given either once daily or as divided doses. Efficacy of ampicillin combined with ceftriaxone and gentamicin in the treatment of experimental endocarditis due to Enterococcus faecalis with no high-level resistance to aminoglycosides. Once-daily aminoglycoside in the treatment of Enterococcus faecalis endocarditis: case report and review. Application of Bayes theorem to aminoglycoside-associated nephrotoxicity: comparison of extendedinterval dosing, individualized pharmacokinetic monitoring, and multipledaily dosing. Pharmacodynamic characterization of nephrotoxicity associated with once-daily aminoglycoside. Individualized pharmacokinetic monitoring results in less aminoglycoside-associated nephrotoxicity and fewer associated costs. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Acute renal failure after antibiotic-impregnated bone cement treatment of an infected total knee arthroplasty. Intermittent administration of inhaled tobramycin in patients with cystic fibrosis. Acute renal failure associated with use of inhaled tobramycin for treatment of chronic airway colonization with Pseudomonas aeruginosa. Clinical and economic outcomes of conventional amphotericin B-associated nephrotoxicity. Clinical significance of nephrotoxicity in patients treated with amphotericin B for suspected or proven aspergillosis. Assessment of effective renal plasma flow, enzymuria, and cytokine release in healthy volunteers receiving a single dose of amphotericin B desoxycholate. Nephrotoxicity of cyclosporine A and amphotericin B-deoxycholate as continuous infusion in allogenic stem cell transplantation. Continuous infusion of amphotericin B deoxycholate: does decreased nephrotoxicity couple with time-dependent pharmacodynamics? Amphotericin B treatment for Indian visceral leishmaniasis: response to 15 daily versus alternate-day infusions. Alternate-day versus once-daily administration of amphotericin B in the treatment of cryptococcal meningitis: a randomized controlled trial. Renal impairment and amphotericin B formulations in patients with invasive fungal infections. Prospective study of amphotericin B formulations in immunocompromised patients in 4 European countries. Reduced renal toxicity of nanoparticular amphotericin B micelles prepared with partially benzylated poly-L-aspartic acid. Liposomal amphotericin B as initial therapy for invasive mold infection: a randomized trial comparing a high-loading dose regimen with standard dosing (AmBiLoad trial). Adverse effects of antifungal therapies in invasive fungal infections: review and meta-analysis. Amphotericin B lipid complex versus liposomal amphotericin B monotherapy for invasive aspergillosis in patients with hematologic malignancy. Safety and efficacy of liposomal amphotericin B compared with conventional amphotericin B for induction 348. Comparative efficacies, toxicities, and tissue concentrations of amphotericin B lipid formulations in a murine pulmonary aspergillosis model. Liposomal amphotericin B for empirical therapy in patients with persistent fever and neutropenia. Intravenous and oral itraconazole versus intravenous amphotericin B deoxycholate as empirical antifungal therapy for persistent fever in neutropenic patients with cancer who are receiving broad-spectrum antibacterial therapy. Amphotericin B versus fluconazole for controlling fungal infections in neutropenic cancer patients. Novel antifungal agents as salvage therapy for invasive aspergillosis in patients with hematologic malignancies: posaconazole compared with high-dose lipid formulations of amphotericin B alone or in combination with caspofungin. Caspofungin is less nephrotoxic than amphotericin B in vitro and predominantly damages distal renal tubular cells. Does off-pump coronary artery bypass reduce the incidence of clinically evident renal dysfunction after multivessel myocardial revascularization? Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. The effect of N-acetylcysteine on renal function, nitric oxide, and oxidative stress after angiography. N-acetyl-L-cysteine improves renal medullary hypoperfusion in acute renal failure. N-acetyl-L-cysteine enhances interleukin1beta-induced nitric oxide synthase expression. N-acetylcysteine attenuates kidney injury in rats subjected to renal ischaemia-reperfusion. The value of N-acetylcysteine in the prevention of radiocontrast agent-induced nephropathy seems questionable. Effect of N-acetylcysteine on renal function in patients with chronic kidney disease. Anaphylactoid reactions to intravenous N-acetylcysteine: a prospective case controlled study. Fatal anaphylactoid reaction to N-acetylcysteine: caution in patients with asthma. Meta-analysis of N-acetylcysteine to prevent acute renal failure after major surgery. Utility of N-acetylcysteine to prevent acute kidney injury after cardiac surgery: a randomized controlled trial. Effect of intravenous N-acetylcysteine on outcomes after coronary artery bypass surgery: a randomized, double-blind, placebo-controlled clinical trial. N-acetylcysteine for prevention of acute renal failure in patients with chronic renal insufficiency undergoing cardiac surgery: a prospective, randomized, clinical trial. N-acetylcysteine for preventing acute kidney injury in cardiac surgery patients with pre-existing moderate renal insufficiency. N-acetylcysteine for the prevention of kidney injury in abdominal aortic surgery: a randomized, double-blind, placebo-controlled trial. A comparison of contemporary definitions of contrast nephropathy in patients undergoing percutaneous coronary intervention and a proposal for a novel nephropathy grading system. Early creatinine shifts predict contrast-induced nephropathy and persistent renal damage after angiography. Frequency of serum creatinine changes in the absence of iodinated contrast material: implications for studies of contrast nephrotoxicity. Impact of the definition utilized on the rate of contrast-induced nephropathy in percutaneous coronary intervention. Contrast-induced nephropathy in the critically-ill patient: focus on emergency screening and prevention. Associations of increases in serum creatinine with mortality and length of hospital stay after coronary angiography. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose. Impact of chronic kidney disease on prognosis of patients with diabetes mellitus treated with percutaneous coronary intervention. Chronic kidney injury in patients after cardiac catheterisation or percutaneous coronary intervention: a comparison of radial and femoral approaches (from the British Columbia Cardiac and Renal Registries). A population-based study of the incidence and outcomes of diagnosed chronic kidney disease. Determination of serum creatinine prior to iodinated contrast media: is it necessary in all patients? Nephropathy induced by contrast media: pathogenesis, risk factors and preventive strategies. Serious renal dysfunction after percutaneous coronary interventions can be predicted. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. Gadolinium-contrast toxicity in patients with kidney disease: nephrotoxicity and nephrogenic systemic fibrosis. Gadolinium-based contrast agents and nephrotoxicity in patients undergoing coronary artery procedures. Gadolinium-based contrast media compared with iodinated media for digital subtraction angiography in azotaemic patients. Comparison between gadolinium and iodine contrast for percutaneous intervention in atherosclerotic renal artery stenosis: clinical outcomes. Safety of gadolinium contrast angiography in patients with chronic renal insufficiency. Safety and pharmacokinetic profile of gadobenate dimeglumine in subjects with renal impairment. Nephrogenic systemic fibrosis: a gadolinium-associated fibrosing disorder in patients with renal dysfunction. Two cases of nephrogenic systemic fibrosis after exposure to the macrocyclic compound gadobutrol. Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy. Dosing of contrast material to prevent contrast nephropathy in patients with renal disease. Volume-to-creatinine clearance ratio: a pharmacokinetically based risk factor for prediction of early creatinine increase after percutaneous coronary intervention. Contrast volume during primary percutaneous coronary intervention and subsequent contrastinduced nephropathy and mortality. Risk of nephropathy after intravenous administration of contrast material: a critical literature analysis. Contrast-induced nephropathy in patients with chronic kidney disease undergoing computed tomography: a double-blind comparison of iodixanol and iopamidol. Reducing the risk of contrast-induced nephropathy: a perspective on the controversies. Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Nephrotoxicity of iso-osmolar versus low-osmolar contrast media is equal in low risk patients. Renal effects of contrast media in diabetic patients undergoing diagnostic or interventional coronary angiography. Nephrotoxic effects of iodixanol and iopromide in patients with abnormal renal function receiving Nacetylcysteine and hydration before coronary angiography and intervention: a randomized trial. Nephrotoxicity of iodixanol versus iopamidol in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures. A prospective, double-blind, randomized, controlled trial on the efficacy and cardiorenal safety of iodixanol vs. Nephrotoxicity of iso-osmolar iodixanol compared with nonionic low-osmolar contrast media: metaanalysis of randomized controlled trials. Contrast-induced nephropathy and its prevention: What do we really know from evidence-based findings?
Astigmatism: It occurs when curvatures of the cornea is more in one meridian than another fungus gnats neem oil discount 200mg ketoconazole. It is the blockage or decrease drainage of aqueous humor through the sinus venosus sclerae or canal of Schlemm causes rise of pressure in the anterior and posterior chambers of the eyeball randall x fungus ketoconazole 200 mg low cost. It may cause blindness due to compression on the neural layer of the retina and the retinal blood supply antifungal during pregnancy purchase ketoconazole 200 mg with amex. In severe hypertension fungus mulch order ketoconazole 200 mg, the arteries may press on the veins and cause visible dilatations distal to the crossing which can be seen in ophthalmoscopic examination fungus speed run generic 200mg ketoconazole with mastercard. Any blockage at the central artery to retina causes loss of vision in the corresponding part of the visual field antifungal for lips buy generic ketoconazole 200mg line. Cornea scratches (abrasion) by the foreign bodies like dirt and sand causes stabbing pain and excessive tear ii. Corneal lacerations are caused by sharp particles like finger nails and skate blades. It is indicated in persons with scarred or opaque cornea, who may receive corneal transplant from the donor as it is avascular, ii. Articulate eye: An artificial eye is fitted in the cup like fascial sheath (fascia bulbi) which forms a socket in the eyeball, when the eyeball removed (enucleated). The pupils appear small and irregular, they are nonreactive to light but accommodation reflex is present. End Lower border of cricoid cartilage at the level of lower border of C6 vertebra. Relations Anteriorly Infrahyoid muscles as thyrohyoid, sternohyoid, and superior belly of omohyoid. They are connected by ligaments, joints and membranes and moved by number of muscles. Posterior surface: It is covered with mucous membrane and forms the anterior wall of the upper part of the laryngeal cavity, and presents a tubercle in the lower part. Unpaired Cartilages Epiglottic cartilage or epiglottis It is a leaf like thin, elastic fibrocartilage. Lower margin or end It is pointed and connected to the upper part of the posterior surface of thyroid angle. The upper parts of the anterior borders do not meet; forming a Vshaped superior thyroid notch or incisure. These are far apart, thick and rounded, extends above and below as superior and inferior, cornua or horns ii. Attachments-Stylopharyngeus and palatopharyngeus and salpingo pharyngeus muscles. It is nearly straight in front and concave behind, between them lies the inferior thyroid tubercle 390 Human Anatomy for Students ii. It is connected to the greater cornu of the hyoid bone by the lateral thyrohyoid ligament. It articulates with the side of the cricoid cartilage to form the cricothyroid joint. Cricoid cartilage It is a complete ring like and lower most cartilage of the larynx. It consists of a narrow anterior arch and a broad posterior part known as posterior lamina iii. The inferior cornua or horns of thyroid cartilage articulates with the side of the cricoid arch and posterior lamina. On the median plane: Connected to the anterior arch of cricoid cartilage by conus elasticus b. Presents a shallow oblique ridge (oblique line), which passes downwards and forwards, ii. The oblique ridge extends from the superior thyroid tubercle lying a little anterior to the root of the superior cornu to the inferior thyroid tubercle lying behind the middle of inferior border of the lamina. Relation Upper pole of the lateral lobe of the thyroid gland extends up to the oblique ridge between the inferior constrictor and sternothyroid muscles. It smooth above and behind, slightly concave and covered by mucous membrane Head, Neck and Face 391 ii. Posterior cricoarytenoid (safety muscle) from outer aspect of the cricoids lamina. Cricotracheal ligament: From the inferior border cricoids to the first tracheal cartilage ii. Cricothyroid ligament and membrane: To the superior border of the cricoids or the anterior median part and lateral part respectively. Paired Cartilages Arytenoid cartilages these are two small cartilages situated on the lateral part of the upper border of the cricoids lamina at the back of the larynx. Apex: the Apex is directed backwards and medially and articulates with the corniculate cartilage. Base: the base is concave, with the smooth surface for articulation with the lateral part of the upper border of the cricoids lamina. Corniculate cartilages these are a paired small conical nodules of elastic fibrocartilage. Cuneiform cartilages these are a paired small elongated nodules of elastic fibrocartilage. Situation: In the aryepiglottic folds anterosuperior to the corniculate cartilages. Joints of Larynx Cricothyroid joint A pair of joints between the inferior cornua of the thyroid cartilage and side of the cricoid cartilage. Important Relation Recurrent laryngeal nerve passes behind the joint to enter the larynx. Cricoarytenoid Joint these are paired joints between the upper border of lamina of cricoid and base of the arytenoid cartilages. The lateral and median parts are thickened to form the lateral and median thyroid ligaments Structures piercing the thyroidhyoid membrane i. Cricotracheal Ligament Ligament connecting the lower border of cricoid cartilage to the first ring of trachea. Middle Part or Sinus of Larynx Situation It lies between the rima vestibule above and the rima glottidis below. Lower Part Situation It lies between the vocal folds above and the lower border of the cricoid cartilage below. In the living conditions it appears pearly white in color as it is least vascular. Interior of the Larynx or Cavity of Larynx Extent It extends from the inlet of larynx to the lower border of cricoid cartilage. The space between the vocal folds is known as rima glottidis (the narrowest part of the larynx) Rima vestibuli a. It acts as an exit valve so that it allows the entry of air and prevents exit of air during inspiration. It increases the intrathoracic and intra abdominal pressure which is essential for act of coughing, micturition, defecation and parturition. Intermembranous part: Anterior threefifths of the space between two vocal folds ii. Intercartilaginous part: Posterior twofifths of the space between vocal processes of arytenoid cartilages. Movements of rima glottidis It depends upon type of breathing and phonation which affect the shape and size of the rima glottidis. During quiet breathing at rest: Intermem branous part is triangular and the inter cartilaginous part is quadrangular. During forced inspiration: Intermembranous part is triangular but wide apart due to abduction of vocal folds and intercartilaginous part becomes triangular due to lateral rotation of the arytenoid cartilages. During phonation and production of high pitched sound: Rima glottidis becomes a narrow as vocal folds adducted and arytenoids become medially rotated. During whispering: Intermembranous part becomes closed but intercartilaginous part remains open. As entry valve: It allows exit of air during expiration but prevents entrance of the air during inspiration. During expiration the air produces vibration of the vocal folds and produces sound b. Laryngeal Sinus or Sinus of Larynx Definition On the lateral wall of larynx, between vestibular and vocal folds, presence of a pocket like recess called sinus of larynx or laryngeal sinus. Saccule of Larynx Definition It is a blind sac, arising from the upper part of laryngeal sinus. Head, Neck and Face 395 Situation In between the two vestibular folds in the inner surface of thyroid cartilage. It extends blindly upwards between the vestibular fold and the lamina of the thyroid cartilage. It may go beyond thyroid cartilage and thyrohyoid membrane in neck and up to axilla in some animals. Secretion of these glands lubricates the vocal folds particularly during production of voice. Lateral Cricoarytenoid Origin From the lateral aspect of the upper margin of anterior arch of cricoid cartilage. Aryepiglotticus Few fibers of oblique arytenoid from the apex of arytenoid continue to edge of epiglottis known as aryepiglotticus. Vocalis Those fibers of thyroarytenoid muscle from arytenoid cartilage extending to the vocal fold are called vocalis. Intrinsic Muscles of Larynx Cricothyroid Origin From the lower border and lateral surface of the cricoid cartilage. Posterior Cricoarytenoideus or Safety Muscle of Larynx Introduction the safety muscle of larynx is the posterior cricoarytenoideus because it is the only abductor of vocal cords, paralysis of both these muscles produces severe dyspnea. Origin On either side of the ridge on the posterior surface of the lamina of the cricoid cartilage. Action Abduction of the vocal cords or opening out of the glottis, so it is called safety muscle of larynx. From arytenoid cartilage extending in a curve manner up to the aryepiglottic fold c. All the intrinsic muscles except cricothyroid are supplied by the recurrent laryngeal nerves b. Arterial Supply Up to the vocal folds By the superior laryngeal artery branch of the superior thyroid artery. Below the vocal folds Inferior laryngeal artery branch of the inferior thyroid artery. Larynx is developed from the median diverticulum of the foregut as the tracheobronchial groove ii. The laryngeal muscles developed from the mesoderm of the ventral aspect of the foregut iii. Rest of the cartilages developed from the branchial mesoderm of the upper part of the respiratory diverticulum. Sphincteric valve for prevention of entry of foreign body and specially by closing the laryngeal inlet during swallowing iii. Formation of vocal nodule: It occurs on the vocal cord due to excessive use of vocal cords in professional singers and public speakers produces hoarseness of voice. The recurrent laryngeal nerves and the external laryngeal nerve may be injured or damaged during operation of the thyroid gland because the nerves and arteries of the gland are closely related. The enlarged thyroid gland (goiter), may itself compressed the laryngeal nerves and impaired innervations of the larynx. The right and left recurrent laryngeal nerves may be damaged by malignant involvement of the deep cervical lymph nodes. The left recurrent laryngeal nerve may be involved due to bronchial or esophageal carcinoma or due to secondary metastatic deposits in the mediastinal lymph nodes. Because its injury causes paralysis of the cricothyroid muscle resulting weakness of voice because the vocal folds cannot be tensed. To avoid injury to the external laryngeal nerve, the superior thyroid artery is ligated and sectioned more superior to the thyroid gland, where the artery is not closely related to the nerve. In this lesion, the vocal fold on the affected side remains in the midway position between abduction and adduction, just lateral to the midline. In this condition the voice is not greatly affected because the unaffected vocal fold compensate to some extent. In this condition, the vocal folds remains midway between abduction and adduction position. There is a bilateral paralysis of the abductor muscles and the drawing together of the vocal folds. Result is dyspnea and stridor follows, and in this case cricothyroidotomy or tracheostomy is required. It causes submucosal hemorrhage and edema, respiratory obstruction, hoarseness, and temporary inability to speak. The involvement of the cancer in larynx is high in individuals, who smoke cigarettes or chew tobacco. Most patients present persistent hoarsensess of voice, often associated with pain in ear and dysphagia iii. The interior of the larynx may be examined indirectly through a laryngeal mirror passed through the open mouth into the oropharynx or by laryngoscopy. Procedure of Indirect Laryngoscopy the anterior part of the tongue is gently pulled from the oral cavity to clear the area of epiglottis and laryngeal inlet. Procedure of Direct Laryngoscopy Introduce a type of hollow tube or flexible fiber optic endoscopes equipped with electrical lighting for examining the interior of the larynx through the mouth. Expiration of air from the lungs occurs by contraction of abdominal, intercostal and other expiratory muscles, mainly diaphragm. The vocal folds or cords act as vibrators, are blown by the pressure of expired air and thereby produced the sound ii.
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Now identify three palmar metacarpal arteries arises from the deep palmar arch to join with common palmar digital arteries (branches of superficial palmar arch) close to their bifurcation into proper palmar digital arteries 16 fungus fly ketoconazole 200mg online. The opponens pollicis covered by the abductor pollicis brevis fungus gnat larvae uk generic ketoconazole 200mg with mastercard, which is exposed by cutting the abductor pollicis brevis iii fungus stop buy ketoconazole 200mg cheap. The flexor pollicis brevis is partly covered by the abductor pollicis brevis and incompletely fused with the medial margin of the opponens pollicis which is also to be separated iv antifungal drinks generic 200 mg ketoconazole visa. Follow the origin of all the three thenar muscles from flexor retinaculum and the tubercle of trapezium antifungal nipple cream purchase 200 mg ketoconazole, but the flexor pollicis brevis has a deep head arises from the trapezoid and capitate bones v quantum antifungal cream discount ketoconazole 200 mg line. Now cut across the middle of flexor longus, and behind it the adductor pollicis Dissection 653 vi. Now identify the synovial sheaths of the long flexor tendons then expose and divide the fibers flexor sheath in the thumb to follow the tendon and its synovial sheath to the terminal phalanx. A transverse incision is given at the back of wrist between the styloid processes of ulna and radius 2. Another transverse incision is given along the dorsal aspect of the roots of the fingers just proximal to the webs in between fingers 3. The longitudinal incision is given between the midpoints of the previous 1 and 2 incisions, which is extended up to nail of the middle finger. From the medial side of the dorsal venous arch basilic vein and from the lateral side the cephalic vein begins. The superficial branch of the radial nerve: It pierces the deep fascia 7 cm above the styloid process of the radius 3. It arises about 5 cm proximal to the wrist and descends along with ulnar nerve up to pisiform bone ii. It descend along medial side of the wrist and hand then divides into two dorsal digital nerves. Deep fascia is very thin and transparent after identification of the tendon it is reflected: 1. Traces the radial artery, which passes through the anatomical snuffbox deep to the tendons then enters the proximal end of the first intermetacarpal space 2. Now identify the tendons of the dorsum of the hand which passes through the different compartments deep to the extensor retinaculum. Abductor pollicis longus, lies most laterally inserted to the base of the first metacarpal bone ii. Extensor pollicis brevis, inserted to the base of the proximal phalanx of the thumb iii. Extensor carpi radialis longus and brevis inserted to the base of the second and third metacarpals respectively iv. Extensor pollicis longus cross the extensor carpi radialis longus and brevis of the wrist, and inserted to the base of the distal phalanx of the thumb v. Extensor digitorum, it divides into four tendons for the second to fifth digits and inserted through dorsal digital expansions vi. Extensor indicis, it blends with the lower and medial side of the extensor digitorum tendon for index finger vii. Extensor digiti minimi, it blends with extensor digitorum for the little finger on its medial side viii. Now, expose the anatomical snuffbox-By retracting the abductor pollicis longus and extensor pollicis brevis laterally and extensor pollicis longus medially which contain from superficial to deep i. Now, expose the floor of the anatomical snuffbox which is formed, by the following bones from proximal to distal-styloid process of radius, scaphoid, trapezium and base of the first metacarpal bones. Now, remove the fat and fasciae in the dorsal surface of the intermetacarpal spaces and expose dorsal interosseous muscle in each space. Now, separate the dorsal interosseous muscle from the two adjacent metacarpal bones from where it originates. Steps of Dissection Position of Body Body will be in supine position with hip joint extended. An oblique incision is given along the inguinal ligament from the symphysis pubis to the anterior superior iliac spine iii. Superficial fascia on abdomen is divided into two layers below the level of umbilicus: a. The membranous layer of superficial fascia known as fascia of Scarpa lying deep to it. Superficial circumflex iliac artery going towards anterior superior iliac spine d. Anterior cutaneous branches of the arteries accompanying the anterior cutaneous nerves found on either side of midline. Iliohypogastric nerve at the upper part of inguinal canal going downwards and medially c. The superficial fascia in two layers are cut and reflected like skin-structures exposed. External oblique muscle going downwards and medially, becoming aponeurotic below the line joining anterior superior iliac spine with umbilicus b. Linea alba: It is avascular fibrous structure connecting symphysis pubis to xiphoid process c. The iliohypogastric nerve enters the rectus sheath by piercing the external obliquus aponeurosis g. Superficial inguinal ring transmitting the ilio inguinal nerve and spermatic cord in male or round ligament of uterus in female. Rectus abdominis going upwards to become expanded from pubic crest and symphysis pubis to the lower costal cartilages It is adherent to the anterior wall of rectus sheath by tendinous intersections but free from posterior wall ii. Pyramidalis muscle when present arising from the pubic crest to be inserted into the linea alba iii. The rectus abdominis muscle is retracted laterally preserving its supplies-structures exposed: i. Posterior wall of rectus sheath formed by the posterior lamina of the internal oblique and transversus abdominis muscles It is deficient above the costal margin where the rectus abdominis lies directly on the costal cartilages to give entry to superior epigastric vessels. Superior epigastric artery enters the rectus sheath where the posterior wall of rectus sheath is deficient above. Inferior epigastric artery enters into the rectus sheath through the posterior wall where it is deficient below. A long with the superior and inferior epigastric arteries the accompanying veins also present. Posterior wall is deficient: Here the rectus abdominis muscle directly lies over the costal cartilages. At the region starting from xiphoid process up to the midpoint between the xiphoid process and umbilicus: i. The region starting from midpoint between xiphoid process and umbilicus up to the midpoint between the umbilicus and symphysis pubis: i. Steps of Dissection Position of Body Body will be in supine position with hip joint extended. A horizontal incision is given at the level of anterior superior iliac spine going from it to the midline of abdomen ii. A vertical incision is given along the midline from the medial end of 1st incision, downwards to the symphysis pubis. Now, the triangular skin flap thus mapped is reflected downwards and laterally-structures exposed: i. Superficial circumflex iliac artery, going upwards and laterally to the anterior superior iliac spine vi. Superficial veins are dissected out in this region accompanying with the superficial arteries vii. Iliohypogastric nerve, going down wards and medially from the middle of the region. The external oblique aponeurosis with its fibers are dissected downward medially and forwards ii. The inguinal ligament formed by the condensation of external obliquus abdominis aponeurosis iii. The superficial inguinal ring lying above and lateral to the pubic tubercle, transmitting the spermatic cord in male or round ligament of uterus in female, along with ilioinguinal nerve. The superficial inguinal ring is a triangular aperture bounded by upper or medial crus attached to the pubic tubercle, a lower or lateral crus attached to the pubic crest and intercrural fibers connecting two, being directed upwards and laterally. The iliohypogastric nerve piercing the aponeurosis about 3 cm above the superficial inguinal ring passes forward and medially. The external oblique aponeurosis is reflected from its insertion-structures exposed: i. The internal oblique muscle arising from the lateral twothirds of the inguinal ligament going upwards and medially to reach over the inguinal canal to form the conjoint tendon medial part of inguinal canal 658 Human Anatomy for Students. The inguinal canal transmitting the spermatic cord in male and round ligament of uterus of female along with the ilioinguinal nerve only in its medial part iii. The iliohypogastric nerve piercing the internal oblique about 2 cm medial to the anterior superior illiac spine v. The internal oblique muscle is cut in its origin and reflected-structures exposed: i. The transversus abdominis muscle is arising from the lateral onethird of inguinal ligament going backwards forming the roof of the inguinal canal, and turning downwards and medially to form conjoint tendon ii. The cremasteric muscle and its fascia arising from the transversus abdominis and also internal oblique to join the covering of spermatic cord in male and is less prominent in female iii. The circumflex iliac artery going upwards between transversus abdominis and internal oblique v. The whole length of inguinal canal containing the spermatic cord in male and round ligament of uterus in female vi. So, the inguinal canal is a canal in the anterior abdominal wall lying in the inguinal region made by the passage of gubernaculum, directed downwards, forwards and medially, nearly about 4 cm long. A vertical incision is given connecting the medial ends of the previous two incisions. The superficial fascia of the thigh contains abundant fat especially on the medial side ii. Veins: Which accompany these arteries converges towards the saphenous opening and joins the great saphenous vein before it pierces the cribriform fascia. An oblique incision is given along the inguinal ligament from the anterior superior iliac spine to the pubic tubercle ii. A transverse incision is given at the junction of upper onethird and lower twothirds of anterior aspect of the thigh. One or two small lymph nodes of this group may be found above the inguinal ligament along the course of superficial epigastric vessels c. A lower group of variable number of large nodes placed along the both sides of upper part of great saphenous vein. Superficial circumflex iliac artery: Going upwards and laterally in curved manner to the anterior superior iliac spine ii. Superficial epigastric artery: Going upwards and medially towards the epigastric region iii. Superficial external pudendal artery: Going upwards and medially towards the symphysis pubis iv. The other tributaries of great saphenous vein which may vary considerably on two sides of same body and from persontoperson. The anterior branch of medial femoral cutaneous nerve of thigh in the medial part of this region ii. Intermediate cutaneous nerve of thigh: In the medial aspect of the area giving medial and lateral branches iii. The femoral branch of genitofemoral nerve below the midpoint of inguinal ligament. Horizontal row: Along the inguinal ligament draining the lower part of abdominal wall ii. The membranous layer of superficial fascia- extending in the thigh to be attached to fascia lata along the line 1 inch below and parallel the inguinal ligament. Incisions on the Superficial Fascia the superficial fascia is cut and reflected like skin and keeping the structures passing through it as much as possible. The medial part which is thin contains an opening for long saphenous vein called the saphenous opening It has an upper superficial margin and lower margin deep to long saphenous vein and a lateral margin connecting the two: a. The structures piercing the deep fascia which are the medial femoral cutaneous nerve of thigh, femoral branch of genitofemoral nerve, superficial branches of femoral artery and the long saphenous vein. Incisions on the Deep Fascia the deep fascia is cut and reflected like skin preserving the structures passing through it as much as possible. Saphenous Opening It is an oval opening in the fascia lata of the femoral triangle. Dissection 661 Cribriform Fascia It overlies the saphenous opening perforated by following structures: i. Lymph vessels from the superficial inguinal lymph nodes to the deep inguinal group of the lymph nodes v. Deep inguinal lymph nodes specially near the termination of long saphenous vein 3. The femoral sheath with its contents-It is a conical shaped fascial sheath mainly around the femoral vessels derived anteriorly from fascia transversalis and posteriorly from fascia iliaca It is divided into three compartments by two fibrous tissue septa. The lateral/arterial compartment contents-the femoral artery with its superficial branches and femoral branch of genitofemoral nerve Its anterior wall is perforated by the following: a. The arteries dissected out in this region are the femoral artery and its deep branches. The femoral artery goes downwards and medially to overlap the femoral vein at the apex of the triangle and gives the following branches: a.