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Neurophysiol Clin 17:25–43 Bull Mem Soc Anthropol Paris 4(7):14–33 Olivier F (1978) Note sur la variabilité des axes basicrâniens generic 60 mg mestinon muscle relaxant vs analgesic. Guiot G cheap mestinon 60mg with mastercard muscle relaxant bath, Brion S (1958) La destruction stéréotaxique du Bull Ass Anat 62:325–331 pallidum interne dans les syndromes parkinsonniens mestinon 60mg sale spasms kidney stones. J Comput Assist Tomogr 8:922– Rumeau C order mestinon 60mg without prescription spasms 1983 movie, Gouaze A, Salamon G, Laffont J, Gelbert F, 927 Einseidel H, Jiddane M, Farnarier P, Habib M, Perot S Hamy D (1873) Discussion sur le plan horizontal de la tête (1988) Identification of cortical sulci and gyri using mag- par P. Springer, Berlin Heidelberg New York, pp His W (1876) Über die Horizontalebene des menschlichen 11–32 Schädels. Mammalia 16:77–92 liam B (ed), Norgate, London, p 159 Saban R (1980) Les plans d’orientation de la tête. J Comput Gouaze A, Salamon G (eds) Brain anatomy and magnetic Assist Tomogr 2:141–149 resonance imaging. Springer, Berlin Heidelberg New York, Schaltenbrand G, Bailey P (eds) (1959) Introduction to ster- pp 71–83 eotaxis with an atlas of human brain. Joint meeting of Schaltenbrand G, Wahren W (1977) Atlas for stereotaxonomy the European Society of Neuroradiology and the Interna- of the human brain. Confin Neurol (Basel) 26:474–475 Morphometrie encephalique dans la maladie du cri du Szikla G, Bouvier G, Hori T, Petrov V (1977) Angiography of chat. Neuroradiology Takase M, Tokunaga A, Otani K, Horie T (1977) Atlas of the 14:67–71 human brain for computed tomography based on the gla- Topinard P (1882) Crâniomètre de Hoelder et méthode bella-inion line. Thieme, Stuttgart 563 Talairach J, De Ajuriaguerra J, David M (1952) Etudes Van Damme W, Kosman P, Wackenheim C (1977) A standard stéréotaxiques des structures encéphaliques chez method for computed tomography of orbits. Masson, Paris for anatomical interpretation of cerebral computed Talairach J, Szikla G, Tournoux P, Prossalentis A, Bordas- tomogragrams. J Comput Assist 9(4):715–724 Ferrer M, Covello L, Iacob M, Mempel E (1967) Atlas Villemin F, Beauvieux J (1937) Les relations des limites d’anatomie stéréotaxique du télencéphale. Masson, Paris inféireures du crâne avec le plan horizontal de la tête chez Tamraz J (1983) Atlas d’anatomie céphalique dans le plan les vertébrés. Tamraz J (1991) Morphometrie de l’encephale par resonance In: Smith L, (ed) Neuroophthalmology update. Masson, magnetique: application à la pathologie chromosomique New York, pp 271–279 humaine, à l’anatomie comparée et à la teratologie. J Clin anatomisch-physiologischen Untersuchungen des Neurophysiol 11:500–518 Gehirns und Schädelbanes. Bull Soc Fr Ophtalmol 8-9(85):853–857 Regulation of Cerebral Blood Flow 51 3 Brain Cortical Mantle and White Matter Core I Historical Notes and Landmarks ta 1940). These pupil, Gratiolet, attempted to classify the fissures of preliminary qualitative morphometric results the human brain. However, the first to give a detailed showed a clear cortical and brain phenotype accom- account of the structure of the cerebral cortex was panying the clinical syndromes. Baillarger (1840), who in addition described the gray The extensive work on racial differences in the and white matter. Meynert (1867, 1868) expanded on early part of this century, aimed at disclosing brain this finding and gave a detailed account of the re- morphological peculiarities, failed to a large extent. Follow- adequately studied, as most series of brains analyzed ing this major contribution, Betz (1874) described from an encephalometric aspect are too small to the motor area and its giant pyramidal cells which yield significant results. The brain index, 1870; Baillarger 1840; Jensen 1875; Giacomini 1878; also described by Ariens Kappers, was determined Flechsig 1898; Campbell 1905; Benedikt 1906; Brod- by measuring, on the lateral aspect of the brain, the mann 1909; Henneberg 1910; Ramon y Cajal 1911; length of the hemisphere and on the medial side, the Jaeger 1914; Aresu 1914; von Economo and Koskinas occipital and temporal lobe length, (Fig. A difference of about 2 reported, such as the callosal index, the central or the 136 cm between brachicephalics and dolichocepha- occipital index, as well as the temporal indexes of lics in favor of the former was reported by Calori frontal height and frontal depth or length. The ratio between external to buried surface The relationship between the sulcation pattern of has been reported by Henneberg (1910) and Jensen the cerebral hemispheres and genetics is still contro- (1875). Both emphasized the larger development of versial despite the efforts of several authors (Karplus the buried cortical surface averaging two thirds of 1905, 1921; Sano 1916; Rossle 1937; Geyer 1940; Hige- the total cortical surface. A 1, The horizontal lateral line, tangent to the ventral aspect of the occipital lobe and the fronto-orbital lobe; 2, the parietal perpendicular line, from the highest parietal point; 3, the temporal perpendicular line, from the lowest temporal point. The corti- showing wide variations in its intrinsic structural cal ribbon of the central sulcus is thicker than the composition and thickness, as previously reported. The cortex is generally fundamental types based on the partitioning of the thicker on the apex of the convolution, decreasing in pyramidal and granular cells. The heterotypical, limited to particular areas, cortical thickness and will enhance the detection of comprises the agranular (type I) and the granular focal abnormalities. This classification differs from 1234 Brain Cortical Mantle and White Matter Core 53 those previously proposed by Baillarger (1840) or cerebral cortex with 40 cortical fields grouped into Ramon y Cajal (1911). The functional sory areas, the intermediate as associative, and the anatomical approach was inaugurated by Broca and remaining terminal areas are specific to humans, as followed by Jackson. The cytoarchitectural myeloge- may be distinguished from the anthropoid brains netic study was initiated by Baillarger, followed by (Fig. In 1905, Campbell presented his own map of the The third approach was based on the study of the cerebral cortex based on cytoarchitectural patterns gyral and sulcal patterns. At the same time, Brodmann also proposed converged as correlations between gross morpholo- his widely used map of the human brain (Fig. Primordial areas numbered 1–8 (cross-hatched areas); terminal areas numbered 30–40 (open areas); intermediate areas numbered 9–32 (lines). This attempt A major contribution to cortical architecture and to “overparcelize” the cortex was criticized in the surface morphology was made by the work of von 1950s and 1960s. However, the Brodmann map sur- Economo and Koskinas (1925; von Economo 1927, vived these criticisms, and the numbers he used be- 1929) (Fig. Clearly the Brod- clature of the cortical surface pattern accompanied by mann map is the closest to the modern definition of a description of cytoarchitectural peculiarities of the cortical field, as defined by Jones as an area: each region (Fig. With sharp, singular cytoarchitectural bound- von Bonin (1951) provided a new cytoarchitectural aries map (Fig. Receiving afferent fibers from a particular knowledge of cortical patterns following the initial nucleus of the thalamus contribution of Eberstaller (1884, 1890) (Fig. Receiving a set of cortical and commissural axons Most of the proposed maps, with their variable from a limited, defined and constant set of other complexity, lack data concerning the transitional ar- cortical areas eas. Giving a constant output to a particular set of cant inhomogeneities in cytoarchitectural areas cortical, subcortical, and thalamic targets considered distinctive. The deactivation of which may lead to the loss of cavities, to opacification of the cerebral vasculature, a particular function then to the two dimensional sectional brain anatomy Brain Cortical Mantle and White Matter Core 55 Fig. Description of the cytoarchitec- tonic areas has been provided almost exclusively for the cercopithecus (1905), and only a few data concern areas 1, 3, 4, 6, 17, 18. Further advances in this Singly, these different approaches were limited and technique rendered it possible, for the first time, to the results obtained suffered from lack of correlation obtain a routine vision of an entire brain in three di- between morphology and function. This has in A Gross Morphology and Fissural Patterns large part corroborated the precise work in brain of the Brain mapping. The tedious work of the neuroscientists in their laboratories and the neurosurgeons in the op- 1 Gross Morphology erating rooms is progressively being replaced by the work of neuroradiologists, who are integrating data The cerebral hemispheres are ovoid in shape with an gathered from various metabolic and functional anterior-posterior long axis. The base lies on the skull This process requires a knowledge of the gyral base and the convexity is related to the cranial vault and sulcal anatomy and its variations. The two hemispheres are sepa- anatomists, we need to grasp the complexity of the rated by the interhemispheric fissure which pene- Brain Cortical Mantle and White Matter Core 57 trates deeply to the advent of the corpus callosum.
Pregnancy increases the need for vitamins and Thiamin purchase generic mestinon online muscle relaxant comparison chart, Riboﬂavin discount mestinon 60mg line spasms coughing, Niacin trusted 60 mg mestinon spasms shoulder, Vitamin B6 purchase mestinon 60mg with mastercard muscle relaxant triazolam, Folate, iron in general. B Vitamins, homocysteine, and neu- of the patient to determine whether higher levels of rocognitive function. You schedule a series of ber from medical school for beriberi, but you fail to tests, including a cardiac stress test. If the pa- the stress test suggest that the patient is in moder- tient were consuming most of his calories as alco- ate congestive heart failure. The patient suffered a hol, he may have a nutritional deﬁciency, a beriberi- personal loss last year with the death of a son. Soon like syndrome, as a result of insufﬁcient intake of after his son’s death he began drinking heavily. You prescribe a daily vitamin tablet and suspect that the drinking is responsible for his pres- admonish the patient to cut back on alcohol intake. John’s wort 793 Ginseng 790 Soy and other phytoestrogens 794 Herbal therapies have become an integral part of being extraneous, contribute signiﬁcantly to the herb’s the American health care scene. This does not include the pharmacognosy, which includes the study of herbal many (up to 25%) pharmaceutical products used in medicine. The resurgence of herbal medicine use has conventional practice that originally were, and in some once again made pharmacognosy extremely relevant to cases still are, derived from plants (Table 69. For much of the world’s popu- The popular western herbalism discussed in this chapter is lation, herbal treatments remain the ﬁrst and some- one of many philosophical systems of herbal treatment. Proponents of is also sometimes described as eclectic, since it has drawn herbal therapy also state that the multiple compounds on many other traditions, including the native American found in most herbal preparations have the advantage and Chinese. Chinese traditional medicine, Ayurvedic of acting synergistically; that is, they act in concert to (Indian), and Tibetan traditions use complex herbal produce a more enhanced effect than would a single recipes and nutrition to achieve “balance” in the ill pa- isolated component. Although these practices are most commonly found (Hypericum perfoliatum), which contains not only hy- in ethnic populations, they are also becoming popular in pericin, the ingredient it is usually standardized for, but some western complementary and alternative circles. The difference is that homeopathic reme- Capsule Encapsulated herbal material dies are serially diluted and shaken until they may lack Syrup Concentrated sugar solution to preserve any molecule of the original herb ingredient. Therefore, infusion there is no risk of pharmacological toxicity from a Compress Cloth soaked in herbal solution Poultice Application of moist herbal paste homeopathic preparation. Bach’s Flower Remedies are a homeopathic variation in which ﬂower essences are created by ﬂoating ﬂowers in sunlit water. Thus, herbal products like digitalis, while quite and spiritual rather than speciﬁc physical complaints. Other herbs may not be superior to better- treat mood or physical problems either topically (as an researched pharmaceuticals, or they may delay the use adjunct to massage) or through inhalation. While herbal research has un- these oils are quite potent, and if not used in proper di- derstandably lagged far behind that of patented med- lution, they may cause skin irritation or contact allergy. Tinctures consist of an herb arrays of studies both supporting and questioning the steeped in a mix of alcohol and water, and extracts con- effectiveness of a particular herbal product. The alco- ﬂicting ﬁndings may result from ﬂawed study design, the hol content can be a concern, particularly with children. In one assessment, 24% of cerns about dosage variability, possible toxicity and imported herbs were found to contain ingredients not adulteration, herb–drug interactions, and above all, lack on the label. Far from being intrinsically harm- pirin, caffeine, diuretics, and even benzodiazepines), not less, many pharmacologically active plant alkaloids and to mention heavy metals, such as lead. Some Asian for- other compounds are natural defensive poisons; their mulations may also contain animal components. Some herbs, such as ginkgo, Herbal Preparation Type of Toxicity garlic, ginger, chamomile, horse chestnut, and feverfew, Aristolochia Nephrotoxicity can prolong bleeding time and should be avoided with Bloodroot General toxicity coumadin and antiplatelet regimens. John’s wort, and valerian, also Comfrey tea Liver toxicity Ephedra (ma huang) Arrhythmias, stroke, elevated blood must be discontinued prior to surgery because they can pressure unpredictably alter the effects of common anesthetics. Lobelia Nervous system toxicity, respiratory Panax ginseng may cause blood pressure ﬂuctuations, paralysis and some herbs, notably St. Blanket condemnation of herb use of- United States in that the manufacture of the more phar- ten has the counterproductive effect of terminating any macologically active herbs is for the most part regulated further communication between physician and patient. These perennials are native be either safe or effective as long as they avoid thera- to the prairies of North America and are now widely peutic claims on the label. The root and aerial parts of regard to delivering accurate doses, although some the plant are the portions used, and the preparation’s consumer-oriented organizations, such as Consumer potency can be veriﬁed by the transient tingling sensa- Lab (www. Echinacea contains manufacturers more accountable through random test- alkamides, caffeic acid esters (echinacoside, cichoric ing and reporting of their results. Supplements are per- acid, caftaric acid), polysaccharides (heteroxylan), and mitted to have “structure–function” statements on their an essential oil. Some echinacea products are standard- label stating only the product’s supposed physiological ized for their echinacoside content. For instance, an Echinacea product label ation with American feverfew (Parthenium integri- might read “supports immune function” but may not folium) was common. The ex- it does not appear to be helpful in preventing viral in- tracts also have antiviral and antiinﬂammatory proper- fections, and long-term use should be avoided. Feverfew Indications Feverfew (Tanacetum parthenium) is a common There are numerous studies on echinacea in the litera- European composite herb with daisylike white ﬂowers ture, many of which indicate either an in vitro immune now widely naturalized in the United States. While its stimulation or a signiﬁcant clinical reduction in the name (a corrupted version of the Latin febrifugia) indi- severity and duration of upper respiratory viral symp- cates a long history in herb lore, feverfew’s current pop- toms, especially when taken early in the onset of symp- ularity is due to its use in the prevention and treatment toms. Feverfew has also been used for rheuma- that echinacea is an effective immunomodulator of toid arthritis and numerous other conditions with far acute infection, there is still controversy as to the extent less substantiation. A number of trials now lactones, including parthenolide, which is thought to be clearly indicate that echinacea is unlikely to be effective the most active and important ingredient. Feverfew in the prevention of colds, even if it may slightly shorten preparations are frequently standardized for partheno- their course. Most studies have used feverfew standardized externally for wound healing, psoriasis, and the reduc- to 0. Mechanism of Action Adverse Reactions, Contraindications, Parthenolide inhibits serotonin release, an action that is and Interactions thought to be a likely source of its effectiveness in mi- graine. Interestingly, melatonin has allergic reaction, usually in atopic patients already sensi- been identiﬁed in feverfew, a possibly signiﬁcant obser- tized to other members of the Compositae plant family. Indications It is recommended that echinacea not be taken by anyone for more than 8 continuous weeks, and most At least three studies have demonstrated that feverfew clinical use is under 2 weeks’ duration. Echinacea has (dried leaf, not extract) can reduce the frequency and not yet been shown to be safe in pregnant or breast- severity of migraine headaches, although one study failed feeding women and small children. Pro- herb–drug interactions are reported, but for theoretical phylaxis appears to be more effective than acute treat- reasons those taking immunosuppressant drugs should ment. Dose Although feverfew has also been used for rheumatism, it has never been veriﬁed to be effective in clinical trials. The use of echi- Adverse Reactions, Contraindications, nacea tea is less desirable, since not all of the compo- and Interactions nents are water soluble. Unfortunately, there are signif- icant differences in the potency of commercially Although feverfew appears generally safe in nonpreg- available supplies, depending on the plant species and nant adults, the use of fresh leaves has caused mouth ir- the part and age of the plant used. Allergic reactions some blood pressure studies have shown a modest re- (contact dermatitis) have occurred with topical use in duction in diastolic more than systolic blood pressures, sensitized individuals, and ingestion may also produce while others have not.
It contains also the super- Superior: internal oblique arches posteriorly to form the roof of the ior and inferior epigastric vessels and anterior rami of the lower six canal cheap 60mg mestinon otc spasms to the right of belly button. Posterior: transversalis fascia forms the lateral part of the posterior The sheath is made up from the aponeuroses of the muscles of the wall cheap mestinon line spasms synonym. The linea alba represents the fusion of the nal oblique and transversus into the pectineal line) forms the medial aponeuroses in the midline discount 60mg mestinon with visa yellow muscle relaxant 563. The composition of the sheath Contents of the inguinal canal is purchase mestinon with visa muscle relaxant jaw pain, however, different above the costal margin and above the pubic The spermatic cord (or round ligament in the female). Above the costal margin: only the external oblique aponeurosis is present and forms the anterior sheath. The lateral border of the rectusathe linea semilunarisacan usually Cremasteric fascia and muscle: from the internal oblique be identiﬁed in thin subjects. Three tendinous intersections ﬁrmly attach the anterior sheath wall The contents of the spermatic cord include the: to the muscle itself. Pampiniform plexus of veins: these coalesce to form the testicular vein in the region of the deep ring. Short gastric Red labels: ventral branches Spleen Blue labels: lateral branches Green labels: branches to body wall Gastroduodenal Superior Pancreatic pancreatico- branches duodenal Left Right gastroepiploic gastro- epiploic Omental branch Inferior pancreatico- duodenal Jejunal and Superior ileal branches Superior mesenteric pancreaticoduodenal artery Inferior Fig. Superior The three primary branches are labelled in red mesenteric Middle colic Jejunal and ileal branches Right colic Ileocolic Anterior and posterior caecal branches Fig. Note the anastomosis with the inferior rectal artery (green) halfway down the anal canal The abdominal aorta (Fig. These include the: Ileocolic artery: passes in the root of the mesentery over the right Left gastric artery: passes upwards to supply the lower oesophagus ureter and gonadal vessels to reach the caecum where it divides into ter- by branches which ascend through the oesophageal hiatus in the minal caecal and appendicular branches (Fig. The left gastric then descends in the lesser omentum along Jejunal and ileal branches: a total of 12–15 branches arise from the the lesser curve of the stomach which it supplies. These branches divide and reunite within the Splenic artery: passes along the superior border of the pancreas small bowel mesentery to form a series of arcades which then give rise in the posterior wall of the lesser sac to reach the upper pole of the left to small straight terminal branches which supply the gut wall. From here it passes to the hilum of the spleen in the lienorenal Right colic artery: passes horizontally in the posterior abdominal ligament. Hepatic artery: descends to the right towards the ﬁrst part of the The renal arteries duodenum in the posterior wall of the lesser sac. Before reaching the porta hepatis it divides into right and left on the posterior abdominal wall to reach the ovary in the female, or pass hepatic arteries and from the right branch the cystic artery is usually through the inguinal canal in the male to reach the testis. Prior to its ascent towards the porta hepatis the hepatic artery gives rise to gastroduodenal and right gastric branches. The former The inferior mesenteric artery arises from the abdominal aorta at the passes behind the ﬁrst part of the duodenum and then branches further level of L3. It passes downwards and to the left and crosses the left into superior pancreaticoduodenal and right gastroepiploic branches. The left colic artery: supplies the distal transverse colon, the splenic ﬂexure and upper descending colon. From above downwards, it passes over the left renal vein The superior rectal artery: passes into the pelvis behind the rectum behind the neck of the pancreas, over the uncinate process and anterior to form an anastomosis with the middle and inferior rectal arteries. This establishes a strong branches of the superior mesenteric artery include the: collateral circulation throughout the colon. The arteries of the abdomen 33 13 The veins and lymphatics of the abdomen Inferior phrenic Suprarenal Ureteric branch Renal Lumbar Gonadal Common iliac Median sacral Fig. Note the anastomoses with the systemic system (orange) in the oesophagus and the anal canal 34 Abdomen and pelvis The portal vein (Fig. Effer- to the liver where the products of digestion can be metabolized and ent lymph from the skin below the umbilicus drains to the superﬁcial stored. The portal vein is formed behind the neck of the pancreas by the union of the superior mesenteric and splenic The lymph nodes and trunks veins. It passes behind the ﬁrst part of the duodenum in front of the in- The two main lymph node groups of the abdomen are closely related to ferior vena cava and enters the free border of the lesser omentum. At the porta hep- of the aorta and consequently receive lymph from the territories that are atis it divides into right and left branches. This includes most of the gastrointestinal the branches of the coeliac and superior mesenteric arteries drain into tract, liver, gall-bladder, spleen and pancreas. The inferior mesenteric vein the pre-aortic nodes coalesce to form a variable number of intestinal drains into the splenic vein adjacent to the fourth part of the duodenum. The para-aortic nodes are arranged around the lateral branches of the Porto-systemic anastomoses aorta and drain lymph from their corresponding territories, i. The efferent vessels from the para-aortic nodes coalesce to form (such as in cirrhosis) the pressure within the portal vein rises and under a variable number of lumbar trunks which deliver the lymph to the cis- these circumstances the porto-systemic anastomoses form an alternat- terna chyli. The periumbilical region: formed by small paraumbilical veins The lymphatic drainage of the stomach which drain into the left portal vein and the superﬁcial veins of the anter- Lymph from the stomach drains to the coeliac nodes. It ascends in the retroperitoneum on the right Lymph from the skin of the scrotum and the tunica albuginea drains to side of the abdominal aorta. Lymph from the testes, however, drains forms the posterior wall of the epiploic foramen of Winslow and is along the course of the testicular artery to the para-aortic group of embedded in the bare area of the liver in front of the right suprarenal nodes. The inferior vena cava passes through the caval opening in the enlargement of the superﬁcial inguinal nodes whereas testicular diaphragm at the level of T8 and drains into the right atrium. The veins and lymphatics of the abdomen 35 14 The peritoneum Subphrenic space Diaphragm Epiploic foramen (of Winslow) Upper recess of omental bursa Portal vein Inferior vena cava Liver Aorta Lesser omentum Epiploic foramen Left kidney (in the distance) Splenic artery Omental bursa Pancreas Lienorenal ligament Stomach Spleen Transverse mesocolon Short gastric Duodenum (third part) vessels Transverse colon Gastrosplenic Small intestine ligament Stomach Mesentery Lesser omentum Greater omentum Hepatic artery Fusion between layers Common bile duct of greater omentum Liver Fig. Note how the epiploic foramen lies between two major veins Lesser sac Greater sac Upper layer of Upper layer of Left triangular coronary ligament coronary ligament Bare area ligament Lower layer of coronary ligament Gall bladder B Ligamentum teres A Portal vein, hepatic Falciform ligament artery and bile duct in free edge of lesser Ligamentum teres omentum leading to porta hepatis Position of umbilicus Cut edge of lesser Fundus of (b) omentum (a) gall bladder Left triangular Right Peritoneum ligament triangular covering Fissure for ligament caudate lobe ligamentum venosum Fig. The narrow spaces between the liver and the diaphragm labelled A and B are the right and left subphrenic spaces 36 Abdomen and pelvis The mesenteries and layers of the peritoneum ment while the right layer turns back on itself to form the upper and The transverse colon, stomach, spleen and liver each have attached to lower layers of the coronary ligament with its sharp-edged right tri- them two ‘mesenteries’adouble layers of peritoneum containing arteries angular ligament. The layers of the coronary ligament are widely and their accompanying veins, nerves and lymphaticsawhile the small separated so that a large area of liver between themathe bare areaa intestine and sigmoid colon have only one. This mesentery is exceptional in that the layers of the which passes from the hilum of the spleen to the greater curvature of the coronary ligament are widely separated so that the liver has a bare area stomach (Fig. The general peritoneal cavity comprises the main cavityathe greater The sigmoid colon: (1) The sigmoid mesocolon (the sigmoid arteries sacaand a diverticulum from itathe omental bursa (lesser sac). It lies behind the free border of tinue downwards to form the posterior two layers of the greater omen- the lesser omentum and its contained structures, below the caudate pro- tum, which hangs down over the coils of the small intestine. They then cess of the liver, in front of the inferior vena cava and above the ﬁrst turn back on themselves to form the anterior two layers of the omentum part of the duodenum. The four layers of The subphrenic spaces are part of the greater sac that lies between the the omentum are fused and impregnated with fat. There are right and left plays an important role in limiting the spread of infection in the peri- spaces, separated by the falciform ligament. In the pelvis the parietal peritoneum covers the upper two-thirds of From its attachment to the pancreas, the lower layer of the transverse the rectum whence it is reﬂected, in the female, onto the posterior mesocolon turns downwards to become the parietal peritoneum of the fornix of the vagina and the back of the uterus to form the recto-uterine posterior abdominal wall from which it is reﬂected to form the mesen- pouch (pouch of Douglas). The upper layer of the transverse mesocolon passes upwards to form the parietal peritoneum of the posterior abdominal wall, covering the The anterior abdominal wall upper part of the pancreas, the left kidney and its suprarenal, the aorta The peritoneum of the deep surface of the anterior abdominal wall and the origin of the coeliac artery (the ‘stomach bed’). It thus forms the shows a central ridge from the apex of the bladder to the umbilicus pro- posterior wall of the omental bursa. Two medial umbilical ligaments converge to the From the diaphragm and anterior abdominal wall it is reﬂected onto umbilicus from the pelvis. They represent the obliterated umbilical the liver to form its ‘mesentery’ in the form of the two layers of the fal- arteries of the fetus.
Drug resistance relates to point mu- sides are combined with other potentially ototoxic tations in the gene (EmbB) that encodes the arabinosyl agents order 60 mg mestinon with mastercard bladder spasms 5 year old. Ethambutol is widely Para-aminosalicyclic Acid distributed in all body ﬂuids order mestinon 60 mg mastercard spasms 1st trimester, including the cere- brospinal ﬂuid mestinon 60mg discount muscle relaxant egypt, even in the absence of inﬂammation purchase mestinon on line spasms pronunciation. Both the acetylated and unaltered drug ﬁrst week of therapy, consist of dizziness, confusion, ir- are rapidly excreted in the urine. Other the introduction of more effective drugs, such as ri- side effects include occasional peripheral neuropathy fampin and ethambutol. It has is unknown but is believed to involve inhibition of a spectrum of activity against gram-positive and gram- oxygen-dependent mycolic acid synthesis. The mo- that mutations in the region of the (inhA) gene that are lecular basis for resistance to rifabutin is shared by both involved in mycolic acid synthesis can cause both isoni- rifampin and rifabutin; this explains the virtually com- azid and ethionamide resistance. Ethionamide is well absorbed following oral admin- Rifabutin is well absorbed orally, and peak plasma istration. Less than 1% half-life range of 16 to 96 hours and is eliminated in of the drug is eliminated in the urine unchanged. In addition, ethion- treatment of drug-susceptible tuberculosis and is used amide may cause a wide range of neurological side in the treatment of latent tuberculosis infection either effects, such as confusion, peripheral neuropathy, psy- alone or in combination with pyrazinamide. Neurological effects can be mini- of rifabutin has increased in recent years, especially in mized by pyridoxine supplementation. It is a less potent effects include gynecomastia, impotence, postural hy- inducer of cytochrome 450 enzymes pathways than ri- potension, and menorrhagia. Rifabutin levels will be increased with concurrent administration of ﬂuconazole and clar- Viomycin ithromycin, resulting in anterior uveitis, polymyalgia syndrome, and a yellowish-tan discoloration of the skin Viomycin is a complex polypeptide antibiotic that is ac- (pseudojaundice). Cross-resist- to those of rifampin, such as hepatitis, red-orange dis- ance between viomycin and kanamycin is less frequent coloration of body ﬂuids, and drug interactions due to than between viomycin and capreomycin. Further details mechanism of action, cross-resistance, hepatic induction are discussed later, under the treatment of leprosy. The macrolide antibiotics (see Chapter 47) clar- ithromycin and azithromycin have demonstrated in Capreomycin vitro activity against mycobacteria, although they have limited activity against M. Clarithromycin Capreomycin (Capastat) is a polypeptide antibiotic de- is four times as active as azithromycin against M. Capreomycin is a used as a second-line agent in combi- However, because of its low cost, it is used as a ﬁrst-line nation with other drugs. It appears to be particularly agent in East Africa, especially in combination with useful in multidrug regimens for the treatment of drug- compounds such as isoniazid. It causes signiﬁcant ototoxicity, es- nephrotoxicity, and these adverse effects can be severe pecially when coadministered with streptomycin. Amikacin and Kanamycin Amikacin and kanamycin (see Chapter 46) have been Quinolones: Ciproﬂoxacin, Levoﬂoxacin used in the treatment of tuberculosis. Amikacin is very and Oﬂoxacin active against several mycobacterium species; however, it is expensive and has signiﬁcant toxicity. Alternative regimens include isoniazid, rifampin, Quinolones are important recent additions to the pyrazinamide, and either streptomycin or ethambutol therapeutic agents used against M. Clinical trials of oﬂoxacin in com- for 6 weeks, and subsequently with biweekly adminis- bination with isoniazid and rifampin have indicated ac- tration of isoniazid and rifampin for 16 weeks. Host defenses are crucial in determin- agents against intracellular mycobacteria is generally ing the patient’s response to the disease, the clinical pres- poor. Current recommendations for the treatment of Or leprosy suggest multidrug regimens rather than Rifampin and pyrazinamide daily for 2 months is monotherapy because such a regimen has proven to be appropriate for isoniazid-resistant tuberculosis. Rifampin daily for 4 months may be given to indi- Established agents used in the treatment of leprosy are viduals who cannot tolerate pyrazinamide. Dapsone (Avlosulfon) is the most widely used patients may develop acute skin lesions described as sulfone for the long-term therapy of leprosy. Some rare side the sulfones are highly effective against most strains of effects include fever, pruritus, paresthesia, reversible M. Clofazimine Before the introduction of current multidrug regimens, resistance rates were as high as 20% with dapsone Clofazimine is a weakly bactericidal dye that has some monotherapy. Clofazimine of dapsone are reached within 1 to 3 hours of oral ad- achieves signiﬁcant concentrations in tissues, including ministration and have a half-life of 21 to 44 hours; about the phagocytic cells; it has a plasma half-life of 70 days. Clofazimine is given to treat sulfone-resistant lep- The concentration in inﬂamed skin is 10 to 15 times rosy or to patients who are intolerant to sulfones. The sulfones are exerts an antiinﬂammatory effect and prevents ery- retained in the circulation for a long time (12–35 days) thema nodosum leprosum, which can interrupt treat- because of hepatobiliary drug recirculation. This is a major advantage of clofaz- fones are acetylated in the liver, and 70 to 80% of drug imine over other antileprosy drugs. It may prove useful in leprosy patients who cannot toler- Ethionamide and Prothionamide ate long-term oral dapsone therapy. The sulfones can produce nonhemolytic anemia, Ethionamide and prothionamide are weakly bacterioci- methemoglobinemia, and sometimes acute hemolytic dal against M. A 35-year-old man under treatment for pulmonary (C) Pyrazinamide tuberculosis has acute-onset right big toe pain, (D) Rifampin swelling, and low- grade fever. Mexico, could not obtain a Florida driving license Which of the following antituberculosis drugs is because of his poor performance in red-green color known to cause high uric acid levels? He is (B) Thiacetazone taking a four-drug regimen for pulmonary tubercu- 49 Drugs Used in Tuberculosis and Leprosy 565 losis. Ethambutol is associated with retrobulbar neu- treatment for lepromatous leprosy has increasing ritis, resulting in loss of central vision and impaired red-brown pigmentation. Ethionamide (B) is an tileprosy drugs is responsible for the patient’s skin analogue of isonicotinic acid and is associated with pigmentation? A 23 year-old college student is diagnosed with red-orange discoloration of saliva, tears, and urine Neisseria meningitidis based on his clinical presenta- but not the color vision problems. Isoniazid (E) is tion, gram-negative diplococci on Gram stain, and associated with peripheral neuritis in chronic alco- isolation of bacteria from cerebrospinal ﬂuid. Which holics and malnourished individuals and requires of the following drugs can be used as a prophylactic pyridoxine supplements. Its most disturbing side effect is (C) Dapsone red-brown pigmentation of skin, particularly in (D) Clarithromycin light-skinned persons. A 32-year-old Haitian man has acute-onset confu- Johnson syndrome (dapsone dermatitis), but it is not sion and suicidal ideation. Rifampin combination therapy for multi–drug resistant pul- (B) imparts a harmless red-orange discoloration of monary tuberculosis. He has a history of depression saliva, sweat, urine, feces, tears, and contact lenses that required intermittent treatment in the past. Which of the following antitubercular agents is re- Capreomycin (D) is similar to streptomycin and can sponsible for the patient’s neurological symptoms? Its use is not (A) Pyrazinamide associated with skin discoloration or pigment prob- (B) Aminosalicylic acid lems.
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What clinical parameters are necessary to evaluate and monitor the therapeutic goals listed above (see Desired Outcome)? What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects? She also states she is awakened from sleep about two to three times per week needing to change her bed clothes and linens. She walks on her treadmill three times a week and is trying to follow a dietitian-designed low- A Hot Topic. Research nonhormonal therapies that have been studied for the versus other treatment options relief of menopausal symptoms and compare the scientific evi- dence of their efficacy to traditional hormonal medications. What are the goals of therapy for this patient’s menopausal would be an appropriate therapy option as it remains the most effective symptoms? What drug, dosage form, dose, schedule, and duration are best for Women’s Health Initiative Investigators. Nonestrogen treatment modalities for vasomotor estrogen in postmenopausal women with hysterectomy: the Women’s symptoms associated with menopause. A 60-year-old woman trying to discontinue hormone replace- symptoms and vaginal atrophy with lower doses of conjugated equine ment therapy. On questioning, he states that for the last year he has been able to achieve only partial erections that are insufficient Lungs/Chest for intercourse. Clear to A & P bilaterally He feels that the problem is leading to a strained relationship with his wife. Investigate the treatments for priapism, and write a two-page report that includes your conclusion about the most effective Na 139 mEq/L Hgb 16. What clinical parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects? What information should be provided to the patient to enhance After completing this case study, students should be able to: compliance, ensure successful therapy, and minimize adverse • Recognize the clinical manifestations of benign prostatic hyper- effects? Which of this patient’s complaints are consistent with obstruc- and to detect or prevent adverse effects? Long-term safety and efficacy of tamsulosin for the treatment of lower urinary tract symptoms í Chief Complaint associated with benign prostatic hyperplasia. Susan Jones is a 60-year-old woman with urinary urgency and Long-term 6-year experience with finasteride in patients with benign frequency. The patient has inhibitor of 5-alpha-reductase types 1 and 2 (dutasteride) in men with curtailed much of her volunteer work and social activities because benign prostatic hyperplasia. Differentiate urge incontinence from stress incontinence, over- No palpable thyroid masses; no lymphadenopathy flow incontinence, and functional incontinence. In addition to the medications the patient is currently taking, Clear to A & P what other drugs could exacerbate overactive bladder syndrome? What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome Ext and to detect or prevent adverse effects? Although her voiding symptoms resolved, she A drug with pharmacologic selectivity for muscarinic receptor experienced severe constipation and dry mouth. After 1 week of drug subtypes in the detrusor muscle produces dose-related undesired treatment, the patient returns to the physician complaining that she anticholinergic adverse effects outside of the urinary bladder. Why should anticholinergic drugs be used cautiously in elderly bladder: the issue of treatment tolerability. Trospium chloride in the management of overactive agent–induced dry mouth is severe enough to require treatment bladder. Darifenacin, an M3 selective receptor antagonist, is an effective and well-tolerated once-daily treatment for 3. Presently, her urinalysis and labs are significant for Supple without adenopathy proteinuria, hematuria, and elevated serum creatinine. Her renal biopsy is significant for focal proliferative changes, indicative of Lungs/Thorax lupus nephritis. Methylprednisolone and cyclo- Desired Outcome phosphamide, alone or in combination, in patients with lupus nephritis: 2. What are the goals of pharmacotherapy for iron deficiency with ranitidine for ulcers associated with nonsteroidal antiinflamma- anemia? What feasible pharmacotherapeutic alternatives are available cyclophosphamide plus pulse methylprednisolone improves long-term for the treatment of lupus nephritis? What clinical and laboratory parameters are necessary to evaluate patients with diffuse proliferative lupus nephritis. What information should be provided to the patient to enhance ulins: an option in the treatment of systemic lupus erythematosus. Sylvia, PharmD í Physical Examination Gen 55-year-old Caucasian man appearing older than his stated age in moderate respiratory distress. Neck/Lymph Nodes • Select appropriate antibiotic therapy for a patient with multiple (–) bruits, (–) lymphadenopathy antibiotic allergies. What clinical and laboratory parameters should be evaluated during and after the desensitization procedure to detect or í Assessment prevent allergic events? Outline the process by which the clini- Problem Identification cian would determine the most appropriate course of action for 1. Be specific to the type of allergy to the penicillin to ampicillin-sulbactam and ceftazidime be categorized—as. Apply the concept of graded challenge dosing (see Clinical Pearl) the patient’s risk of hypersensitivity reactions to β-lactam to the issue of β-lactam hypersensitivity. What additional information would be helpful to assess whether dosing with structurally related antibiotics. A graded challenge dose (test dosing) involves the cautious admin- istration of a medication to a patient. Second sympo- sium on the definition and management of anaphylaxis: summary Therapeutic Alternatives report—Second National Institute of Allergy and Infectious Disease/ Food Allergy and Anaphylaxis Network Symposium. Clinical cross-reactivity administration schedule, and any preventive measures that should between amoxicillin and cephadroxil in patients allergic to amoxicillin be employed during the desensitization process. Halper is married with 4 children, Michael, James, í Labs Suzanna, and Catherine, who are alive and well. What pharmacotherapeutic alternatives are available for treat- í Stool Culture ing hyperkalemia in this patient? Dyslipidemia and its management after renal Unremarkable, except for the following findings transplantation. Aspirin 81 mg po once daily × 12 years • Provide appropriate patient education regarding osteoporosis Omeprazole 20 mg po once daily × 1 year and its therapy.
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