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The arteries and veins in the placenta fan out and penetrate into the wall of the uterus to interact with the mother’s circulatory system 100 mg kamagra soft. This enables the baby to draw oxygen and food from the mother’s system kamagra soft 100mg, and send waste products to the mother for removal 100mg kamagra soft. The mother usually becomes quite elated at this time kamagra soft 100 mg, as she realises that there really is a baby inside her . The movements become gradually stronger throughout pregnancy , until it is possible to trace the movement of a limb across the belly . Babies vary dramatically in how much they move - some are very active indeed , while others are relatively quiet . During the last couple of weeks of pregnancy the baby does not move as much , as the amount of space available becomes more restricted. This is the earliest that a baby has a reasonable chance of surviving outside the mother, although infants are still at high risk if born before 32 weeks. The trigger for this is not accurately known, but a series of nervous and hormonal stimuli dilates the cervix that guards the opening into the womb, and starts the rhythmic contractions of the womb, which will bring another human being out into the world. Usually the internal foetus is deformed, incapable of independent existence and very small but may appear as a non- cancerous mass that causes symptoms at birth or later in life. This failure of foetus to achieve its full growth potential may be due to problems with the foetus, mother or placenta. Factors due to the mother include high blood pressure (maternal hypertension), german measles (rubella), toxoplasmosis, Herpes infection, cytomegalovirus, cytotoxic medications, irradiation, diabetes, chronic renal disease, malnutrition, anaemia, family history, drug abuse, alcoholism, heavy smoker and high altitude. Factors due to the foetus include congenital, genetic or chromosomal abnormalities, cerebral palsy, foetal infections and twins. The usual factor due to the placenta is abruptio placentae (separation of the placenta from the uterus). It is essential for the basic functioning of the nucleus in cells, and extra amounts may be needed during pregnancy, breast feeding, and in the treatment of anaemia and alcoholism. It is found naturally in liver, dark green leafy vegetables, peanuts, beans, whole grain wheat and yeast. The amount in red blood cells can also be measured (normal range is a level greater than 318 nmol/L or 140 ng/mL), which gives a longer term picture than the normal folic acid level in blood which may be affected by recent changes in diet. Low levels can be due to long-term alcoholism, oral contraceptive use, anticonvulsant medications, malnutrition, sprue (poor food absorption), sickle cell anaemia, cytotoxic drugs (used to treat cancer), pregnancy and food malabsorption syndromes. They can be used not just to help pull out the child, but to turn the head into a more appropriate position if the head is coming out at the wrong angle. Once placed carefully in position, the doctor, in time with the contractions, will apply traction (and sometimes rotation) to deliver the head. The baby may be born with some red marks on its face and head from the forceps, but they disappear after a few weeks. During this time, routine tests and checks are performed, and the anaesthetist will check the heart, lungs and other vital systems. About an hour before an operation, the patient is changed into an easily removable gown and given an injection to dry up the saliva and induce relaxation. While breathing oxygen through a mask a needle is placed in a vein and a medication is injected to induce sleep and relax the muscles (eg. The drugs used last only a short time, and the anaesthesia is maintained by gases that are given through a mask or by a tube down the throat (endotracheal tube). The anaesthetist regularly checks the pulse, blood pressure, breathing and heart during the operation to ensure there is no variation from the normal. When the operation is finished, the anaesthetist turns off the gases and gives another injection to wake up the patient. The first memory after the operation is of the recovery room where the patient stays under the care of specially trained nurses and the anaesthetist until fully awake. Side effects of a general anaesthetic can include a sore throat (from the tube that was placed down the throat), headache, nausea, vomiting and excessive drowsiness (all side effects of the medication). General anaesthetics are now extremely safe, and the risk of dying from the effects of a general anaesthetic are now no greater than one in 250,000. Humans have a gestation period of about 38 weeks (although pregnancy is calculated as lasting 40 weeks from the last menstrual period). The abbreviation G4P2M1 in medical notes would indicate a pregnancy history of a woman in her fourth pregnancy who had delivered two live babies and had one miscarriage (gravida four, parturition two, miscarriage one). Symptoms may be reduced by eating small, frequent meals so that there is never too much food present but always enough to absorb the stomach acid. Antacids can usually be taken safely at most stages of pregnancy, and may be used to relieve more severe symptoms. If a doctor examines the uterus through the vagina with one hand, while the other feels the uterus by pressure on the belly, an empty softened area can be felt between the firmer cervix and the globular uterus in a pregnant woman between the 6th and 10th weeks. It occurs in less than one in ten thousand pregnancies, and is an autoimmune reaction that may be aggravated by oestrogen. Patients develop extremely itchy, fluid filled, scattered small lumps on the body, particularly the belly, sides of the trunk, palms and soles. The prognosis is good and the condition usually does not affect the baby, but it tends to recur in subsequent pregnancies. Labour can be induced in a number of ways, including rupturing the membranes that surround the baby through the vagina, stimulating the cervix, by tablets, vaginal gel (eg. Using these methods, doctors can control the rate of labour quite accurately to ensure that there are no problems for either mother or baby. There is some evidence that labour can be induced in the last week or two of pregnancy by an orgasm after sexual intercourse or by the constant stimulation of the nipples. Iron is used as a medication in tablet, capsule, mixture or injection forms to treat or prevent iron deficiency and some types of anaemia. Pregnant women are at risk of iron deficiency because the developing baby to build muscle and blood cells. In medication, it is not pure iron that is used, but various salts (compounds) of iron such as ferrous gluconate, ferrous phosphate, ferrous sulfate, ferric ammonium citrate, ferric pyrophosphate, ferrous fumarate and iron amino acid chelate. Iron is absorbed from the gut at a set rate, and using higher doses is unlikely to have any clinical effect. Iron should not be used if suffering from haemochromatosis, ulcerative colitis, ileostomy or colostomy, anaemia not due to iron deficiency. Iron supplements interact with many other drugs including tetracycline, penicillamine, antacids, calcium, methyldopa, levodopa, chloramphenicol, cimetidine, thyroxine, phenytoin, cholestyramine and St. This is called a Ker incision and causes fewer long-term problems to the woman than any other form of incision into the uterus as it heals very well. Every few hours you have Branxton-Hicks contractions that can be quite uncomfortable and sometimes wake you at night, but they always fade away. Your back aches, and you are going to the toilet every hour because your bladder has nowhere to expand. Suddenly you notice that you have lost some bloodstained fluid through the vagina, and the contractions are worse than usual. You have passed the mucus plug that seals the cervix during pregnancy, and if a lot of fluid is lost, you may have ruptured the membranes around the baby as well. When you find that two contractions have occurred only five to seven minutes apart, it is time to be taken to hospital or the birthing centre. This stage will last for about 12 hours with a first pregnancy, but will be much shorter (4 to 8 hours) with subsequent pregnancies. By the time the obstetrician calls in to see how you are progressing, the contractions are occurring every three or four minutes. The obstetrician examines you internally to check how far the cervix (the opening into the womb) has opened. A fully dilated cervix is about 10 cm in diameter, and you may hear the doctors and nurses discussing the cervix dilation and measurement. In a typical hospital delivery room, white drapes hide bulky pieces of equipment, there are large lights on the ceiling, shiny sinks on one wall, and often a cheerful baby poster above them. The breathing exercises you were taught at the antenatal classes should prove remarkably effective in helping you with the more severe contractions. Even so, the combined backache and sharp stabs of pain may need to be relieved by an injection offered by the nurse. Your cervix will be fully dilated by this stage, and you are now entering the second stage of labour, which will last from only a few minutes to 60 minutes or more. The contractions are much more intense than before, but you should push only at the time of a contraction, as pushing at other times is wasted effort. Another push, and another, and another, and then a sudden sweeping, elating relief, followed by a healthy cry from your new baby. A minute or so after the baby is born the umbilical cord, which has been the lifeline between you and the baby for the last nine months, is clamped and cut. About five minutes after the baby is born, the doctor will urge you to push again and help to expel the placenta (afterbirth). Labour commences when the cervix starts to dilate and finishes with delivery of the baby and placenta. The exact triggers that start the labour of pregnancy are unknown, but the hormones responsible come from the pituitary gland in the brain. There is some evidence that labour can be induced in the last week or two of pregnancy by an orgasm after sexual intercourse or by the constant stimulation of the nipples. The vagina (birth canal) is a curved cylinder and the baby’s head must move through various positions in order to pass through it. This is followed by flexion of the head, descent of the head, internal rotation, extension of the neck, external rotation and finally expulsion. These movements will differ if the baby’s head is in a different position to the normal one of coming out with the back of the head at the front of the mother. A line between the spines on the ischial bone, which can be felt by a doctor when examining the vagina, is station zero. It last on average 14 hours in a woman having her first baby and seven hours in a woman who has already had a baby. In second stage the baby’s head descends further into the pelvis and lasts until the birth of the baby with forceful contractions of the uterus lasting from 60 to 90 seconds every two to five minutes. The patient develops an almost unbearable urge to push, which should be resisted until it can be timed with a contraction. The second stage lasts on average one hour in a first time mother and twenty minutes in a second time mother. The third stage of labour lasts from the birth of the baby to the expulsion of the placenta (afterbirth), which takes ten to fifteen minutes. The baby moves down through the vagina and is expelled from the uterus by the force exerted by the powerful muscle contractions in the uterus, and is assisted by contractions of the muscles in the wall of the abdomen and in the diaphragm as the mother voluntarily pushes. After the baby is delivered further contractions of the uterus over the next few minutes cause the placenta to separate from the wall of the uterus and be expelled. The muscles of the uterus may not produce sufficiently strong contractions, or may not contract regularly. Some women have uncoordinated contractions, which cause different parts of the uterine muscle to contract at different times. This can be caused by the baby having a large head, having the head twisted in an awkward position, or having an abnormal part of the baby presenting (eg. Sometimes forceps can be used to assist these situations, but often a Caesarean section is necessary for the wellbeing of the baby. In some women, the cervix fails to dilate and remains as a thick fibrous ring that resists any progress of the baby down the birth canal. In an emergency the cervix may be cut, but in most cases doctors would again prefer to perform a Caesarean section. It involves four steps:- - gentle controlled delivery in a quiet dark room - avoiding any pulling on the baby’s head - avoiding over stimulating the baby in any way - encouraging immediate bonding between mother and baby and breastfeeding. The presence of the father in the delivery room, massaging of the baby’s back after birth, not cutting the umbilical cord until it stops pulsating, and gentle bathing in warm water by the father may be other factors. In adults and children, the bacteria usually causes no symptoms and is harmless, but if a pregnant woman is infected, the bacteria may spread through her bloodstream to the placenta and foetus, where it may cause widespread infection, miscarriage, or death of the foetus and a stillbirth. Treatment is more successful if started during pregnancy, but the infection is rarely detected before the infant is born. Infants that survive birth suffer from a form of septicaemia (blood infection) that soon progresses to a form of meningitis that is frequently fatal. It starts as blood stained, but gradually becomes brown and then pale yellow, slowly disappearing over the next four to six weeks. Initially it consists of blood, amniotic fluid, lining of the uterus (endometrial tissue) and foetal skin cells, and has a rather unpleasant odour. If the baby is breech (sitting with the bottom down) or transverse in the uterus, a doctor may try by a series of pressure movements on the mother’s belly, to push the baby’s head around and down into the pelvis. It usually occurs if one of the many lobes in the breast does not adequately empty its milk, and may spread from a sore, cracked nipple. The breast becomes painful, very tender, red and sore, and the woman may become feverish, and quite unwell. Antibiotic tablets such as penicillin or a cephalosporin usually cure the infection rapidly and the woman can continue breastfeeding, but if an abscess forms, an operation to drain away the accumulated pus is necessary. The presence of meconium in the amniotic fluid surrounding the foetus before birth is a sign that the foetus is distressed and should be delivered as soon as possible. The vomiting and subsequent inhalation (breathing in) of meconium by the baby immediately after birth, can cause serious breathing problems for the baby including pneumonia or asphyxiation. The blockage may resolve naturally, with the help of special fluids given by mouth and in a drip, or may need to be removed surgically. If pregnancy does not occur, the endometrium starts to deteriorate as the hormones that sustain it in peak condition alter. After a few days, the lining breaks down completely, sloughs off the wall of the uterus, and is washed away by the blood released from the arteries that supplied it in a process known as menstruation or the menses.

An obstetrician 100 mg kamagra soft, midwife kamagra soft 100 mg, or nurse can estimate how well a newborn is doing by obtaining an Apgar score kamagra soft 100mg. Virginia Apgar as a method to assess the effects on the newborn of anesthesia given to the laboring mother 100mg kamagra soft. Healthcare providers now use it to assess the general wellbeing of the newborn , whether or not analgesics or anesthetics were used . Five criteria—skin color , heart rate , reflex , muscle tone , and respiration—are assessed, and each criterion is assigned a score of 0, 1, or 2. High scores (out of a possible 10) indicate the baby has made the transition from the womb well, whereas lower scores indicate that the baby may be in distress. The technique for determining an Apgar score is quick and easy, painless for the newborn, and does not require any instruments except for a stethoscope. Poor scores for either of these measurements may indicate the need for immediate medical attention to resuscitate or stabilize the newborn. In general, any score lower than 7 at the 5-minute mark indicates that medical assistance may be needed. Normally, a newborn will get an intermediate score of 1 for some of the Apgar criteria and will progress to a 2 by the 5-minute assessment. Breast milk provides ideal nutrition and passive immunity for the infant, encourages mild uterine contractions to return the uterus to its pre-pregnancy size (i. The non-pregnant and non-lactating female breast is composed primarily This OpenStax book is available for free at http://cnx. The mammary gland is composed of milk-transporting lactiferous ducts, which expand and branch extensively during pregnancy in response to estrogen, growth hormone, cortisol, and prolactin. Moreover, in response to progesterone, clusters of breast alveoli bud from the ducts and expand outward toward the chest wall. Breast alveoli are balloon-like structures lined with milk-secreting cuboidal cells, or lactocytes, that are surrounded by a net of contractile myoepithelial cells. Clusters of alveoli that drain to a common duct are called lobules; the lactating female has 12–20 lobules organized radially around the nipple. Milk drains from lactiferous ducts into lactiferous sinuses that meet at 4 to 18 perforations in the nipple, called nipple pores. They secrete oil to cleanse the nipple opening and prevent chapping and cracking of the nipple during breastfeeding. The Process of Lactation The pituitary hormone prolactin is instrumental in the establishment and maintenance of breast milk supply. Near the fifth week of pregnancy, the level of circulating prolactin begins to increase, eventually rising to approximately 10–20 times the pre-pregnancy concentration. We noted earlier that, during pregnancy, prolactin and other hormones prepare the breasts anatomically for the secretion of milk. The level of prolactin plateaus in late pregnancy, at a level high enough to initiate milk production. However, estrogen, progesterone, and other placental hormones inhibit prolactin- mediated milk synthesis during pregnancy. It is not until the placenta is expelled that this inhibition is lifted and milk production commences. After childbirth, the baseline prolactin level drops sharply, but it is restored for a 1-hour spike during each feeding to stimulate the production of milk for the next feeding. When the infant suckles, sensory nerve fibers in the areola trigger a neuroendocrine reflex that results in milk secretion from lactocytes into the alveoli. The posterior pituitary releases oxytocin, which stimulates myoepithelial cells to squeeze milk from the alveoli so it can drain into the lactiferous ducts, collect in the lactiferous sinuses, and discharge through the nipple pores. It takes less than 1 minute from the time when an infant begins suckling (the latent period) until milk is secreted (the let-down). Frequent milk removal by breastfeeding (or pumping) will maintain high circulating prolactin levels for several months. However, even with continued breastfeeding, baseline prolactin will decrease over time to its pre-pregnancy level. In addition to prolactin and oxytocin, growth hormone, cortisol, parathyroid hormone, and insulin contribute to lactation, in part by facilitating the transport of maternal amino acids, fatty acids, glucose, and calcium to breast milk. In contrast, mature breast milk does not leak during pregnancy and is not secreted until several days after childbirth. Compositions of Human Colostrum, Mature Breast Milk, and Cow’s Milk (g/L) Human colostrum Human breast milk Cow’s milk* Total protein 23 11 31 Immunoglobulins 19 0. Only a small volume of colostrum is produced—approximately 3 ounces in a 24-hour period—but it is sufficient for the newborn in the first few days of life. Colostrum is rich with immunoglobulins, which confer gastrointestinal, and also likely systemic, immunity as the newborn adjusts to a nonsterile environment. After about the third postpartum day, the mother secretes transitional milk that represents an intermediate between mature milk and colostrum. Moreover, the proteins in cow’s milk are difficult for an infant’s immature digestive system to metabolize and absorb. The first few weeks of breastfeeding may involve leakage, soreness, and periods of milk engorgement as the relationship between milk supply and infant demand becomes established. As the infant goes through growth spurts, the milk supply constantly adjusts to accommodate changes in demand. A woman can continue to lactate for years, but once breastfeeding is stopped for approximately 1 week, any remaining milk will be reabsorbed; in most cases, no more will be produced, even if suckling or pumping is resumed. During the first days of a newborn’s life, it is important for meconium to be cleared from the intestines and for bilirubin to be kept low in the circulation. Recall that bilirubin, a product of erythrocyte breakdown, is processed by the liver and secreted in bile. Breast milk has laxative properties that help expel meconium from the intestines and clear bilirubin through the excretion of bile. Some degree of jaundice is normal in newborns, but a high level of bilirubin—which is neurotoxic—can cause brain damage. Newborns, who do not yet have a fully functional blood–brain barrier, are highly vulnerable to the bilirubin circulating in the blood. Indeed, hyperbilirubinemia, a high level of circulating bilirubin, is the most common condition requiring medical attention in newborns. Each of these chromosomes carries hundreds or even thousands of genes, each of which codes for the assembly of a particular protein—that is, genes are “expressed” as proteins. The characteristics that the genes express, whether they are physical, behavioral, or biochemical, are a person’s phenotype. Homologous chromosomes—those that make up a complementary pair—have genes for the same characteristics in the same location on the chromosome. Because one copy of a gene, an allele, is inherited from each parent, the alleles in these complementary pairs may vary. A child may inherit the allele encoding for dimples on the chromosome from the father and the allele that encodes for smooth skin (no dimples) on the chromosome from the mother. The banding patterns are nearly identical for the two chromosomes within each pair, indicating the same organization of genes. The expression of an allele can be dominant, for which the activity of this gene will mask the expression of a nondominant, or recessive, allele. In some cases, both alleles are expressed at the same time in a form of expression known as codominance. Moreover, although any one person can only have two alleles corresponding to a given gene, more than two alleles commonly exist in a population. Over 100 years of theoretical and experimental genetics studies, and the more recent sequencing and annotation of the human genome, have helped scientists to develop a better understanding of how an individual’s genotype is expressed as their phenotype. This body of knowledge can help scientists and medical professionals to predict, or at least estimate, some of the features that an offspring will inherit by examining the genotypes or phenotypes of the parents. One important application of this knowledge is to identify an individual’s risk for certain heritable genetic disorders. However, most diseases have a multigenic pattern of inheritance and can also be affected by the environment, so examining the genotypes or phenotypes of a person’s parents will provide only limited information about the risk of inheriting a disease. Only for a handful of single-gene disorders can genetic testing allow clinicians to calculate the probability with which a child born to the two parents tested may inherit a specific disease. Mendel’s Theory of Inheritance Our contemporary understanding of genetics rests on the work of a nineteenth-century monk. Working in the mid-1800s, long before anyone knew about genes or chromosomes, Gregor Mendel discovered that garden peas transmit their physical characteristics to subsequent generations in a discrete and predictable fashion. When he mated, or crossed, two pure- breeding pea plants that differed by a certain characteristic, the first-generation offspring all looked like one of the parents. For instance, when he crossed tall and dwarf pure-breeding pea plants, all of the offspring were tall. Mendel called tallness dominant because it was expressed in offspring when it was present in a purebred parent. He called dwarfism recessive 1356 Chapter 28 | Development and Inheritance because it was masked in the offspring if one of the purebred parents possessed the dominant characteristic. Mendel performed thousands of crosses in pea plants with differing traits for a variety of characteristics. And he repeatedly came up with the same results—among the traits he studied, one was always dominant, and the other was always recessive. By crossing the second-generation offspring of purebred parents with each other, he showed that the latter was true: recessive traits reappeared in third-generation plants in a ratio of 3:1 (three offspring having the dominant trait and one having the recessive trait). Mendel then proposed that characteristics such as height were determined by heritable “factors” that were transmitted, one from each parent, and inherited in pairs by offspring. In the language of genetics, Mendel’s theory applied to humans says that if an individual receives two dominant alleles, one from each parent, the individual’s phenotype will express the dominant trait. If an individual receives two recessive alleles, then the recessive trait will be expressed in the phenotype. Individuals who have two identical alleles for a given gene, whether dominant or recessive, are said to be homozygous for that gene (homo- = “same”). Conversely, an individual who has one dominant allele and one recessive allele is said to be heterozygous for that gene (hetero- = “different” or “other”). In this case, the dominant trait will be expressed, and the individual will be phenotypically identical to an individual who possesses two dominant alleles for the trait. It is common practice in genetics to use capital and lowercase letters to represent dominant and recessive alleles. A dwarf pea plant must be homozygous because its dwarfism can only be expressed when two recessive alleles are present (tt). A heterozygous pea plant (Tt) would be tall and phenotypically indistinguishable from a tall homozygous pea plant because of the dominant tall allele. Mendel deduced that a 3:1 ratio of dominant to recessive would be produced by the random segregation of heritable factors (genes) when crossing two heterozygous pea plants. In other words, for any given gene, parents are equally likely to pass down either one of their alleles to their offspring in a haploid gamete, and the result will be expressed in a dominant–recessive pattern if both parents are heterozygous for the trait. Because of the random segregation of gametes, the laws of chance and probability come into play when predicting the likelihood of a given phenotype. All of the parental gametes from the dominant individual would be A, and all of the parental gametes from the recessive individual would be a (Figure 28. All of the offspring of that second generation, inheriting one allele from each parent, would have the genotype Aa, and the probability of expressing the phenotype of the dominant allele would be 4 out of 4, or 100 percent. This seems simple enough, but the inheritance pattern gets interesting when the second-generation Aa individuals are crossed. Because segregation and fertilization are random, each offspring has a 25 percent chance of receiving any of these combinations. This figure follows the possible combinations of alleles through two generations following a first-generation cross of homozygous dominant and homozygous recessive parents. The recessive phenotype, which is masked in the second generation, has a 1 in 4, or 25 percent, chance of reappearing in the third generation. Mendel’s observation of pea plants also included many crosses that involved multiple traits, which prompted him to formulate the principle of independent assortment. The law states that the members of one pair of genes (alleles) from a parent will sort independently from other pairs of genes during the formation of gametes. Applied to pea plants, that means that the alleles associated with the different traits of the plant, such as color, height, or seed type, will sort independently of one another. This holds true except when two alleles happen to be located close to one other on the same chromosome. Mendelian genetics represent the fundamentals of inheritance, but there are two important qualifiers to consider when applying Mendel’s findings to inheritance studies in humans. Although all diploid individuals have two alleles for every gene, allele pairs may interact to create several types of inheritance patterns, including incomplete dominance and codominance. He was able to identify a 3:1 phenotypic ratio in second-generation offspring because his large sample size overcame the influence of variability resulting from chance. If we know that a man and woman are both heterozygous for a recessive genetic disorder, we would predict that one in every four of their children would be affected by the disease. For example, if a man and a woman are both heterozygous for cystic fibrosis, a recessive genetic disorder that is expressed only when the individual has two defective alleles, we would expect one in four of their children to have cystic fibrosis. However, it is entirely possible for them to have seven children, none of whom is affected, or for them to have two children, both of whom are affected. For each individual child, the presence or absence of a single gene disorder depends on which alleles that child inherits from his or her parents. Autosomal Dominant Inheritance In the case of cystic fibrosis, the disorder is recessive to the normal phenotype. When the dominant allele is located on one of the 22 pairs of autosomes (non- sex chromosomes), we refer to its inheritance pattern as autosomal dominant. An example of an autosomal dominant disorder is neurofibromatosis type I, a disease that induces tumor formation within the nervous system that leads to skin and skeletal deformities. Consider a couple in which one parent is heterozygous for this disorder (and who therefore has neurofibromatosis), Nn, and one parent is homozygous for the normal gene, nn.

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Direct amplification of Mycobacterium tuberculosis deoxyribonucleic acid in paucibacillary tuberculosis 100 mg kamagra soft. Detection of Mycobacterium tuberculosis in clinical specimens from children using a polymerase chain reaction kamagra soft 100 mg. Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pul- monary tuberculosis in children kamagra soft 100mg. A meta-analysis of the effect of Bacille Calmette Guerin vaccination on tuberculin skin test measurements 100mg kamagra soft. This unexpected encounter between the ancient and the new plague is an intriguing biological issue (Heney 2006) . Poverty , social inequities , difficult access to public health systems , and lack of sanitary education leads to a critical public health situation that is hampering the international efforts aimed at controlling both diseases . Indeed , it was shown that a single patient can be infected and/or re-infected with more than one strain of M. On chest X-ray, the typical pulmonary localizations can be observed, often with images of lung cavitation (Figure 17-1). As in the immunocompetent host, the clinical presentation of the disease involves fever, night sweats and weight loss accompanied by productive cough with muco- purulent or hemoptoic sputum or even hemoptysis. However, the frequency of extrapulmonary and disseminated presentation scales up to near 50 % of cases and extrapulmonary involvement disease often coexists with pulmo- nary disease. The so-called “atypical” presentations are frequently observed in the chest X-ray (Figures 17-2, 17-3, 17-4) (Daley 1995). These include basal opacities, absence of cavitation, micronodular (miliary) patterns, hilar and mediastinal ade- nopathy, pleural and/or pericardial effusion. Sputum can be easily obtained by spontaneous cough, induced by hypertonic saline nebulization, or recovered through an early morning gastric washing after over- night fasting. Bronchoscopy is a technique that allows the visualization of the ac- cessible respiratory tract, the obtention of bronchial washings, bronchoalveolar lavages and bronchial or transbronchial lung biopsies. Therefore, bronchoscopy offers the advantage of expanding the diagnostic spectrum to non-infectious dis- eases (sarcoidosis, lymphoma, endobronchial tumors). Other organs may be involved, including the gastrointestinal tract, liver, kidneys, urinary tract, adrenal gland, lar- ynx and genital (male and female) tract. Pleural biopsy and mycobacte- rial culture of the fluid are the most useful and specific diagnostic tools. Clinical characteristics 565 nostic procedures such as peritoneal fluid aspiration, laparoscopy or fiber colonos- copy can be performed and provide samples for culture and biopsy. The most common localizations are the thoracic and lumbosacral vertebrae, where there is risk of spinal cord compres- sion and subsequent paraplegia. The specimen for bacteriological confirmation is obtained by aspiration and/or biopsy of the affected vertebral body. Headaches and mental confusion may be the first symptoms to induce the suspicion of a meningeal involvement. The classical meningeal syndrome with the Kernig and Brudzinsky signs and cranial nerve palsies, usually appears late in its evolution (Figure 17-7). In addition to the lum- bar puncture, brain computed tomography imaging is needed to rule out or confirm the diagnosis of tuberculous meningitis. The central nervous system involvement may include intracranial tuberculomas and brain abscesses that require brain biopsy and/or aspiration for bacteriological and/or histopathological confirmation. The cerebrospinal fluid is hypertensive with an elevated protein content, low glucose levels and mononuclear pleocytosis. Both etiological agents produce a subacute meningeal syndrome and very similar abnormalities in the cerebrospinal fluid. In most cases, however, a direct India ink coloration of the spinal fluid allows the immediate identification of the typically capsulated Cryptococcus cells. Multiple nodular lesions (microabscesses) in both organs can be detected as hypoechoic images on the ultrasound ecography (Figure 17-8) and also on computed tomography scans. Another consequence of the hematoge- nous spread is the above-mentioned meningeal involvement, which has a poor survival prognosis (Berenguer 1992, Sanchez Portocarrero 1996, Cecchini 2007). Retroperitoneal, multiple adenopathies and psoas abscesses can be diagnosed by ultrasonography or computed tomography guided aspirate. The reasons for this association appear to be multiple, including mal- absorption, drug interaction and previous administration of a related rifamycin (rifabutin) as a prophylactic treatment for M. A proportion of mutants resistant to a sin- gle drug are generated spontaneously in any bacilli population, even if not exposed to any antituberculosis drug. Thus, it is highly improbable that a –9 patient with a pulmonary cavity lesion containing approximately 10 bacilli can be spontaneously multidrug-resistant. For a long time, drug resistant strains were thought to be less fit than pansuscepti- ble strains and therefore less likely to be transmitted. Actually, mutations leading to antibiotic resistance may or may not have an effect on the fitness of drug-resistant tuberculosis strains (Cohen 2003) (see Chapter 18). The results from different studies are controversial regarding the risk of infection among contacts exposed to resistant bacilli (Burgos 2003, Snider 1985, van Soolingen 1999). The risk of exposure is en- hanced if the patient has a history of previous hospitalizations, stays in shelters or imprisonment. Evidence has been gathered supporting the idea that some Beijing strains, which are highly prevalent in East Asia and former Soviet Union Republics, have an increased potential for spontaneous mutation − which increases the possibility of selection for drug-resistant clones − and apparently an increased virulence, too (European Concerted Action 2006). In the early stages of the outbreak, most patients died before culture and drug susceptibility testing confirmed the diagnosis. Later on, methods for speeding up the diagnosis were implemented, adequate second-line drug treatment could be instituted promptly, and survival was substantially elongated. Also, the implementation of internationally recognized hospital infection control measures helped to contain the outbreak (Waisman 2005). Afterwards, the outbreak spread to other cities in the country and even to Canada (Samper 1997, Long 1999, Rivero 2001). A deadly outbreak occurred more recently in Tugela Ferry, a rural district in Kwala Zulu-Natal province, South Africa. The classifi- cation of control measures in administrative, environmental and personal respira- tory protection described in Chapter 11 is widely accepted and efficacy-proven. This allows the perpetuation of chains of transmission involving inpa- tients, outpatients, healthcare workers and community members. Prospective studies of this kind of approach evidenced poor treatment outcomes when compared with regimens tai- lored according to drug susceptibility test results (Mitnick 2003). Testing for second-line drugs is usually not available − or results only become available after a consider- able delay because the tests are performed on traditional solid media. In addition, the results are less reliable than those of the first line drugs due to insufficient stan- dardization and external quality control. Often, the specialist physician is constrained to select a drug scheme merely on the basis of the pattern of resistance to the first-line drugs. Organs in the gastrointestinal tract, mainly the esophagus, are affected by pathogens, includ- ing Candida sp, cytomegalovirus, herpes virus, Cryptosporidium, etc. These infec- tions contribute to the wasting of the patient and hamper the ingestion, tolerance and absorption of oral medicines. Moreover, the multiple treatments simultaneously required for different pathologies contribute to drug-drug interactions. In view of this, a first-line antituberculosis drug should never be discontinued in the absence of solid evidence of such a drug being the cause of an adverse reaction (American Thoracic Society/Centers for Disease Control and Prevention/Infectious Disease Society of America 2003). However, the simultane- ous implementation of both treatment regimens conveys an elevated risk of adverse effects. Most of the adverse events occurred in the first two months and consisted of peripheral neuropathy, rash, hepatitis, and gastrointestinal upset (Dean 2002). Once the treatment starts to produce an effect, an “immune restoration” occurs that reflects the reconstituted immunity to M. The syndrome includes an enlargement of the affected lymph nodes and of the lung lesions accompanied by an exacerbation of the general symptoms. This syndrome is observed most frequently when the treatment of both in- fections is started in close temporal proximity. New infections and other reactions to therapy must be taken into account in the differential diagnosis of this syndrome. As a consensus has not been reached on its clinical definition, the syndrome is probably being over-diagnosed (Lipman 2006). Both antituberculosis and antiretroviral therapy should be continued during the entire reconstitution syndrome. Particularly in this population, the reliability of the method of detection of latent infection is highly dependent on the level of immuno- suppression. Quantiferon is a whole blood assay for the detection of interferon gamma produced by peripheral lymphocytes in response to specific M. Both drugs are administered in their usual dosages (Centers for Dis- ease Control and Prevention 2000). The use of two drugs was expected to prevent the development of resistance, while the short-course treatment would grant a better adherence. Unfortunately this regimen proved unsafe for the general population due to the high incidence of severe liver toxicity associated with its use (Centers for Disease Control and Prevention 2001). When present, they affect mainly predisposed hosts and produce disease in organs with underlying conditions. Several other mycobacterial species can cause local and/or disseminated disease in these patients, including M. Pe- ripheral lymphadenitis with frequent abscesses as well as liver and spleen enlarge- ment are frequently observed. The main clinical presentations were peripheral lymphadenitis, pulmonary disease and intra-abdominal disease (Phillips 2005). On the other hand, a positive culture from a sterile source, such as blood or bone marrow, is enough to confirm the diagnosis of disseminated M. The results of drug susceptibility testing often have a poor correlation with the clinical evolution and empirical treatment has to be used. Indeed, together with a dramatic deterioration of the clinical status, this syndrome induces an inflamma- tory response that is often accompanied by a restoration of the immune response (Shelburne 2003). In addition, clarithromycin interacts with protease inhibitors, in par- ticular with atazanavir, which increases its concentration by 95 %. Rifabutin can be discontinued after several weeks of treatment when clinical im- provement is observed. The clarithromycin dose should not exceed 1,000 mg/d because high doses were found to be significantly associated with high rates of death (Cohn 1999). Azithromycin has less drug-drug interactions and therefore can be used more safely in place of clarithromycin. Large placebo-controlled clinical trials have shown that rifabutin, as well as the macrolides clarithromycin and azithromycin, significantly reduce the incidence of M. There are substantial arguments against the use of rifabutin, a drug rich in pharmacological interactions with the additional disadvantage of selecting rifamycin monoresistant M. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Dis- eases Society of America: Treatment of Tuberculosis. A prospective, randomized trial examining the efficacy and safety of clarithromycin in combination with ethambutol, rifabutin, or both for the treatment of disseminated Mycobacterium avium complex disease in per- sons with acquired immunodeficiency syndrome. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities, 1994. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. Incidence and natural hisptory of Mycobacterium avium complex infections in patients with advanced human immunodeficiency virus disease treated with zidovudine. An outbreak of multidrug-resistant tuberculosis among hospitalized patients with the acquired immunodeficiency syndrome. Standard short-course chemotherapy for drug- resistant tuberculosis: treatment outcomes in 6 countries. European Concerted Action on New Generation Genetic Markers and Techniques for the Epidemiology and Control of Tuberculosis. A multi-institutional outbreak of highly drug- resistant tuberculosis: epidemiology and clinical outcomes. A randomized, placebo-controlled study of rifabutin added to a regimen of clarithromycin and ethambutol for treatment of dissemi- nated infection with Mycobacterium avium complex. Prophylaxis against disseminated Mycobacterium avium complex with weekly azithromycin, daily rifabutin, or both. Life-threatening cutaneous reactions to thiacetazone-containing antituberculosis treatment in Kumasi, Ghana. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. Nosocomial transmission of multidrug- resistant Mycobacterium tuberculosis: a risk to patients and health care workers. A randomized trial of clarithromycin as prophylaxis against disseminated Mycobacterium avium complex infection in patients with advanced acquired immunodeficiency syndrome. Effect of katG mutations on the virulence of Myco- bacterium tuberculosis and the implication for transmission in humans. Nosocomial spread of human immunodefi- ciency virus-related multidrug-resistant tuberculosis in Buenos Aires. High rate of tuberculosis reinfection during a nosocomial outbreak of multidrug-resistant tuberculosis caused by Mycobacterium bovis strain B. Molecular epidemiology of multidrug-resistant Mycobacterium bovis isolates with the same spoligotyping profile as isolates from ani- mals.

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It divides into two branches which run down the posterior border and The infrahyoid (‘strap’) muscles along the upper border kamagra soft 100mg. 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 kamagra soft 100 mg. 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 100mg kamagra soft. They develop from the third (inferior parathy- The stem of the outgrowth 100 mg kamagra soft, 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. The nerve supply of the pharynx Muscles The pharyngeal plexus is a plexus of nerves formed by: • Levator palati: elevates the palate. This provides the motor supply to the muscles palate so that it moves towards the back wall of the oropharynx where except for the tensor palati which is supplied by the mandibular divi- it meets a part of the superior constrictor which contracts strongly sion of the trigeminal. The mouth and nasal cavi- • The glossopharyngeal nerve, which provides the sensory supply to ties are thus separated so that food does not regurgitate into the nose the pharynx. They raise two ridges, the palatoglossal and palatopharyngeal nasopalatine nerves from the maxillary division of the trigeminal arches, that are also called the anterior and posterior pillars of the (Fig. Posterior one third by the glossopharyngeal • The tonsil: a mass of lymphatic tissue lying in the tonsillar fossa nerve. A small part of the tongue near the epiglottis is supplied by the which, like the rest of the lymphatic system, reaches its maximum size internal laryngeal branch of the vagus nerve. Lateral to the tonsil is its fibrous capsule and the superior Since the anterior part of the tongue develops from a pair of lingual constrictor. It is supplied by the tonsillar branch of the facial artery swellings, the nerves and blood vessels of each side of the tongue do not but the bleeding that occurs after tonsillectomy is usually from the cross the midline (although some lymphatics do) so that a midline inci- paratonsillar vein. If the motor supply is cut off on been mentioned and there is also a lingual tonsil lying in the back of one side, the tongue will diverge to the affected side when protruded the tongue. The permanent teeth comprise two The boundaries of the nasal cavity include the: incisors, a canine, two premolars and three molars. The first milk teeth • Nasal septum: perpendicular plate of the ethmoid, vomer and a large to erupt are usually the lower central incisors at about 6 months and the plate of cartilage. The tongue is divided developmentally and anatomically into an an- • Roof: nasal bones, cribriform plate of the ethmoid, body of the terior two-thirds and a posterior one third, separated by the sulcus sphenoid. The spaces beneath the conchae are the meatuses and the region In front of the sulcus is a row of vallate papillae. The paranasal sinuses • The maxillary sinus: inside the body of the maxilla, it opens into the Muscles (Fig. Since the opening is in the upper part of the sinus it does • Intrinsic muscles: run in three directions, longitudinally, trans- not drain easily. Genioglossus is especially important as it is inserted along the whole • The sphenoidal sinus: inside the body of the sphenoid. Drains into the inferior • Sensory: anterior two-thirds by the lingual nerve; taste fibres travel meatus. The mouth, palate and nose 147 67 The face and scalp Frontal belly of occipitofrontalis Temporalis Orbicularis oculi Zygomaticus major Zygomaticus minor Levator labii superioris (elevator of the upper lip) Buccinator Levator anguli oris (elevator of the angle of the mouth) Orbicularis oris Outline of parotid (salivary) gland Masseter Depressor anguli oris (depressor of the angle of the mouth) Depressor labii inferioris (depressor of the lower lip) Fig. They are all sup- has an orbital part which surrounds the eye as a sphincter and closes the plied by the mandibular division of the trigeminal (p. They have only one attachment to bone, or sometimes no attach- to keep the cheeks in contact with the gums so that food does not collect ment at all, the other end of the muscle being inserted into skin or in this region. It • The facial nerve: having left the stylomastoid foramen, the facial extends deeply to come into contact with the pharynx and posteriorly it nerve enters the parotid and divides into frontal, zygomatic, buccal, is moulded around the mastoid process and sternomastoid. The whole gland is enclosed in dense fascia so mandibular branch lies below the mandible for part of its course so that that swelling of the gland, as in mumps for instance, is very painful. Lesions of the facial nerve, for example superficial to deep: the facial nerve, the retromandibular vein (the by tumours of the parotid, cause unilateral drooping of the face with beginning of the external jugular) and the external carotid artery, with loss of the normal skin creases, and it can be shown up by asking the its maxillary and superficial temporal branches. The face and scalp 149 Supraorbital artery and nerve Temporal branch Supratrochlear artery Zygomatic branch Facial artery Superficial Infraorbital nerve temporal artery Facial vein Parotid duct Labial branches Lesser occipital nerve Buccal branch Greater auricular nerve Mental nerve Posterior auricular vein Marginal mandibular branch Retromandibular vein Cervical branch Fig. It has a fibres of the palpebral part of the orbicularis oculi, some loose areolar tortuous course, passes close to the corner of the mouth and then along- tissue and skin. Partly embedded in the deep surface of the tarsal plates side the nose to end near the medial angle of the eye. It anastomoses are the tarsal (Meibomian) glands which open onto the edge of the eye- freely across the midline and with other arteries on the face. This is a possible route for infection to travel the superior fornix of the conjunctiva and thence across the eye to the from the face to the sinus. From here the tears pass into the lacrimal puncta, two minute openings in the upper and lower eyelids, and thence The eye into the lacrimal sac lying in a groove in the lacrimal bone. This drains • The conjunctiva: covers the surface of the eye and is reflected onto the tears into the nasolacrimal duct which opens into the inferior mea- the inner surface of the eyelids, the angle of reflection forming the tus of the nose. The conjunctiva over the surface of the eye is thin so that a conjunctival haemorrhage is bright red as the blood remains fully oxygenated. Small veins that pass through the skull and unite the veins of the scalp • Loose areolar tissue: this forms a plane of cleavage in head injuries with the intracranial veins. The face and scalp 151 68 The cranial cavity Cerebral veins Falx cerebri Tentorium cerebelli Endothelium of superior sagittal sinus Diaphragma sellae Emissary vein Fibrous dura Serous dura Fig. The cere- also forms two large sheetsathe falx cerebri and the tentorium cere- brospinal fluid is produced in the choroid plexuses of the lateral, 3rd belli (see below). The subarachnoid space contains the cerebrospinal between the arachnoid and pia and serves to protect the brain and spinal fluid. It tapers to a point anteriorly but pos- which forms a roof over the pituitary fossa and the pituitary gland. Veins from the cerebral hemispheres drain into the superior The cavernous sinus lies on either side of the pituitary fossa and the sagittal sinus or into diverticula from it, the lacunae laterales. Like the other venous sinuses, it is formed by a the underlying arachnoid sends small outgrowths through the serous layer of serous dura lined by endothelium. These are the arachnoid villi and they are dura from the posterior cranial fossa projects forwards into the side of the site of absorption of cerebrospinal fluid into the bloodstream. The cranial cavity 153 69 The orbit and eyeball Frontal Superior oblique Lacrimal Optic nerve Trochlear Central artery of retina Oculomotor Ophthalmic artery Abducent Oculomotor Nasociliary Fibrous ring Inferior oblique Fig. The most important branch of the ophthalmic artery is the central and 6th cranial nerves and the three branches of the ophthalmic division artery of the retina which enters the optic nerve and is the only blood of the trigeminal nerve. The outermost is a tough superior and inferior ophthalmic veins drain it, passing through the fibrous layer, the sclera. Anteriorly, the • The superior orbital fissure: this slit-like opening is divided into sclera is replaced by the transparent cornea, which is devoid of vessels two parts by the fibrous ring that forms the origin of the main muscles or lymphatics and can therefore be transplanted. Behind the cornea, the choroid is replaced by • Above the ringafrontal, lacrimal and trochlear nerves. These, when they contract, • The inferior orbital fissure: transmits the maxillary nerve and some relax the lens capsule and allow the lens to expand; thus they are used in small veins. The lens the levator palpebrae superioris which is inserted into the upper eyelid lies behind the pupil and is enclosed in a delicate capsule. The ciliary body secretes the aqueous humour into the posterior • The medial rectusaturns the eyeball medially. The aqueous then passes • The superior rectusabecause of the different long axes of the orbit through the pupil into the anterior chamber and is reabsorbed into the and of the eyeball, turns the eye upwards and medially. Any interference with this process can give rise • The inferior rectusafor the same reason, turns the eye downwards to a dangerous increase in intra-ocular pressure, a condition known as and medially. It turns the eye down- The retina consists of an inner nervous layer and an outer pigmented wards and laterally. The nervous layer has an innermost layer of ganglion cells whose tract together, the eye turns directly downwards. Outside this is a layer of bipo- • The inferior obliqueaarises from the floor of the orbit, passes lar neurones and then the receptor layer of rods and cones. Near the under the eyeball like a hammock and is inserted into its lateral posterior pole of the eye is the yellowish macula lutea, the receptor area side. Since the subarachnoid space and its contained (the ‘muscle with the pulley’) is supplied by the trochlear nerve. All the cerebrospinal fluid reach to the back of the eyeball, any increase in others, including levator palpebrae superioris, are supplied by the ocu- intracranial pressure can give rise to changes in the optic disc which lomotor nerve. The orbit and eyeball 155 70 The ear, and lymphatics and surface anatomy of the head and neck Ridge produced by lateral semicircular canal Tegmen tympani Stapes Geniculate ganglion Facial nerve Greater petrosal nerve Aditus Incus Lesser petrosal nerve Malleus Auditory tube Tympanic plexus Chorda Promontory tympani Internal carotid artery Tympanic membrane Round window Tympanic branch Internal jugular vein Glossopharyngeal nerve Fig. The inset (right) shows the two major groups into which the others eventually drain 156 Head and neck The ear mandible and also deep to sternomastoid. They drain the head and the The ear is subdivided into the outer ear, the middle ear and the inner ear. The outer ear • The lower deep cervical nodes (): in the The outer third of this is cartilaginous and the inner two-thirds is bony. They drain the lower part of the neck and also receive lymph from the upper deep cervical nodes, from the breast and some of the lymph The middle ear from the thorax and abdomen. The • The runs backwards and then downwards in a bony may be represented on the surface by a pencil placed behind the canal in the medial wall. Its function • The supraorbital, infraorbital and mental nerves: all lie on a ver- is to equalize the pressure between the middle ear and the pharynx. It consists of two • The sternomastoid muscle (with the on its sur- components: face) may be made to contract by asking the patient to turn his head to • The osseous labyrinth: comprises the , the the side against resistance. The labyrinth itself consists of spaces in the • The trunks of the brachial plexus can be palpated in the angle petrous temporal bone and it contains the. The utricle and saccule are con- • The hyoid bone, and the thyroid and cricoid cartilages are easily cerned with the sense of position and the semicircular ducts are con- felt. Abduction of the upper limb (assisted by supraspinatus and • serratus anterior), flexion (anterior fibres) and extension (posterior From the common flexor origin on the medial epicondyle of the fibres) of the arm. Acting together, these muscles maintain the stability of the • shoulder joint as well as having their own individual actions, as From the common flexor origin. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Human Anatomy and Physiology Preface There is a shortage in Ethiopia of teaching / learning material in the area of anatomy and physicalogy for nurses. To help get the students and instructions involved in the study of this subject, a number of special features are incorporated throughout the lecture note. Each chapter contains: - The Learning objectives: what the students are expected to accomplish upon completion of a particular chapter. We would like to extend our appreciation to the different professionals involved in reviewing this manuscript through its process specially Dr. Our gratitude also goes to the assistance offered by Jimma and Alemaya Universities for facilitating the opportunities and resources utilized to develop the lecture note. Equipping the student nurse with the knowledge of anatomy and physiology will further assist the student in understanding what happens and what to do when the body is injured, diseased or placed under stress. This teaching and learning material (lecture note) for nursing students at a diploma level is prepared in line with this concept. Therefore, the students are expected to achieve the following general educational objectives after completion of the course: - Understand and use anatomical terms. Systemic anatomy studies functional relationships of organs within a system whereas Regional anatomy studies body part regionally. Both systemic and regional approaches may be used to study gross anatomy Microscopic anatomy (Histology) requires the use of microscope to study tissues that form the various organs of the body. Homeostasis When structure and function are coordinated the body achieves a relative stability of its internal environment called homeostasis / staying the same. Although the external environmental changes constantly, the internal environment of a healthy body remains the same with in normal limits. Under normal conditions, homeostasis is maintained by adaptive mechanisms ranging from control center in the brain to chemical substances called hormones that are secreted by various organs directly into the blood streams.

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