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By P. Jaffar. Rhode Island College.

Referral Criteria No need to refer anywhere since the patient is already in a tertiary care hospital cheap kamagra 50mg with amex lipo 6 impotence. Who does What Doctor – Diagnosis cheap kamagra 100mg amex erectile dysfunction therapy treatment, chemo therapy advice and surgery Nurse – General care like nutrition advise, care of the wounds. Introduction: India is classified as a country with a high burden and the least prospects of a favourable time trend of the disease. The average prevalence of all forms of tuberculosis in India is estimated to be 5 per thousand. Neurological complications and progressive deformity are the dreaded complications of tuberculosis of spine. It is imperative to diagonose this condition early and initiate early medical treatment while recognising and treating patients requiring surgical interventions for optimal outcomes. Osteoarticular tuberculosis is always secondary, so primary infection should be treated effectively for sufficient time. Once diagnosed, close follow up, regular anti tubercular treatment and aggressive surgical approach may prevent dreaded complications V. Any back pain not responding to conservative treatment for more than 6 weeks and/or accompanied by constitutional symptoms should be investigated further Neurologic abnormalities occur in 50% of cases and can include paraplegia, paresis, impaired sensation, nerve root pain. The following are radiographic changes characteristic of spinal tuberculosis o Paradiscal involvement with decreased disc space o Increased anterior wedging o Collapse of vertebral body 13 o Enlarged psoas shadow with or without calcification o Fusiform paravertebral shadows suggest abscess formation. Goals of management in active tuberculosis Eradication/ Control of Disease Decompression of spinal cord Prevention of progressive deformity and later neurological complications Early mobilization of the patient. In Patient In patients without deficit,chemotherapy alone is sufficient if the risk of progressive deformity is not there. A close watch on development of neurological symptoms is to be kept and at signs of deterioration, the patient may be referred. In Patient Tuberculosis spine with no neurological deficit Chemotherapy alone is sufficient if there is no risk of progressive deformity Efforts should be made to identify patients who are at risk of developing kyphosis in active disease. Growing children with dorsal and dorsolumbar caries with more than 3 body involvement or in which there is destruction more than 1. Indications of surgery Failure to respond to conservative treatment Deformity/risk of progresion Recurrence of the disease 15 Doubtful diagonosis Tuberculosis spine with neurological deficit Middle path regime In patients with mild deficit trial of chemotherapy can be done, however a close observation is must Indications for surgery for management of tuberculosis with deficit Severe neurologic symptoms Progressive neurologic symptoms Unsuccessful nonoperative treatment Instability with spinal deformity, Spinal tumour syndrome. By providing structural support and by its osteogenic potential, the graft may prevent progression of kyphosis. Anterior grafting procedure should be accompanied by instrumentation either anterior or posterior. Out Patient Regular follow up of operated patients as well as patients on conservative treatment. At each follow-up detailed neurological examination should be performed and serial x rays should be taken and deformity progression should be noted. Doctor Clinical diagnoses Investigations Clinical decision making Surgical procedure Maintenance of record and follow up b. Indications and Timing of surgery There is a definite role of conservative management in neck pain and radiculopathy with minor sensory symptoms. Patients with very mild and subtle signs of myelopathy can be managed conservatively but close observation and regular follow up is must. Once moderate signs and symptoms of myelopathy develop patients are less likely to improve on their own and surgical intervention is required. Manipulation and traction are not recommended in myelopathy because of potential risk of aggravating neurological deficit Indications for surgery in degenerative disease of cervical spine – Cervical spondylotic myelopathy – Radiculopathy with a significant motor deficit – Radicular pain not responding to conservative treatment – Intractable Neck pain due to pseudarthrosis Choice of Surgical approach The decision of which surgical approach is to be used should be based on: 1. Primary focal ventral pathology causing cord compression is best treated by anterior approach. Primary posterior compression related to facet hypertrophy and ligamentum flavum should be tackled by posterior approach In multisegmental pathology(>3 levels) In presence of lordotic spine either posterior approach or anterior approach should be considered. Supplemental posterior procedure may be needed in multilevel corpectomy Anterior approach Anterior plating improves the rate of fusion, reduces the length and type of postoperative immobilization, reduces the prevalence of graft-related complications, and leads to less postoperative kyphosis, particularly in patients undergoing two or more levels of anterior cervical discectomy and fusion Autograft is superior to allograft in terms of fusion rates,duration to fuse and graft collapse. Long-term results will be needed before use of structural supports such as metallic cages or synthetic spacers in conjunction with local autograft or allograft can be unequivocally recommended. In revision cases when a contralateral anterior approach is contemplated, preoperative laryngoscopy should be done to rule out subclinical vocal cord paresis on the previously treated side. Myelopathy due to single level disc herniation in absence of facet joint or posterior disease.

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It is far more likely that Julius Caesar was a descendent from such a caesones and his family adopted that title as their surname order 50mg kamagra amex erectile dysfunction occurs at what age. In the last 2000 years the operation has been considerably refined to the point where about a quarter of all babies are now delivered in this manner order 50 mg kamagra fast delivery erectile dysfunction treatment in vijayawada. These include a baby that is presenting side on instead of head-first, a placenta (afterbirth) that is over the birth canal, a severely ill mother, a distressed infant that may not survive the rigours of the passage through the birth canal, and the woman who has been labouring for many hours with no success. Caesarean sections may also be performed if the mother has had a previous operative birth, if she is very small, if previous children have had birth injuries or required forceps delivery, for a baby presenting bottom first, if the baby is very premature or delicate, in multiple pregnancies where the two or more babies may become entangled, and in a host of other combinations and permutations of circumstances that cannot be imagined in advance. The decision to undertake the operation is often difficult, but it will always have to be up to the judgement and clinical acumen of the obstetrician, in consultation with the mother if possible, to make the final decision. The reasons for this include the convenience of the mother, the convenience of the doctor, the legal risks associated with natural labour and the medical risks. The rate now exceeds a quarter of all deliveries in many areas, and up to 28% in some countries, an increase from less than 20% ten years ago. A spinal or epidural anaesthetic is given to the mother, and the baby is usually delivered within five minutes. After delivery the longer and more complex task of repairing the womb and abdominal muscles is undertaken. In most cases, the scar of a caesarean is low and horizontal, below the bikini line, to avoid any disfigurement. The woman feels nothing below the waist, and although sedated is quite awake and able to participate in the birth of her baby, seeing it only seconds after it is delivered by the surgeon. Recovery from a caesarean is slower than for normal childbirth, but most women leave hospital within seven days. It does not affect breastfeeding or the chances of future pregnancies, and does not increase the risk of miscarriage. It has no medical meaning and can be easily peeled from the baby’s head, but superstitious people believe that a baby born with a caul will never die by drowning. It allows blood to flow out of the uterus during the menstrual period, and sperm to enter after intercourse for possible fertilisation of an egg. The cervix is normally filled with mucus, the composition of which changes at different stages of the menstrual cycle. It is usually thick to stop bacteria and other infections from entering the uterus, but when an egg is released (ovulation) it becomes thinner so as to make it easier for sperm to enter and fertilise the egg. Some forms of birth control are based on a woman analysing the consistency of the cervical mucus she produces, since it is an obvious indicator of when an egg is about to be released. When a baby is due to be born and the mother goes into labour, the canal through the centre of the cervix expands in a few hours to many times its normal diameter of about 3 millimetres up to about 10 centimetres to allow the baby out. The first stage of labour is when the muscles of the wall of the uterus start contracting while at the same time the muscle fibres of the cervix relax to allow expansion. If the cervix opens abnormally during pregnancy, the foetus may escape and the woman will have a miscarriage. Some women have a cervix that is prone to weakness (an incompetent cervix), and if detected early enough, the cervix can be held closed by stitches, a procedure generally carried out under general anaesthetic. Sometimes the delicate cells forming the inner lining of the cervix spread to cover the tip and replace the stronger tissue normally occurring there. Generally the treatment for cervical erosion is to destroy the unwanted cells by heat (cauterisation) or laser. Deaths from cervical cancer are second only to deaths from breast cancer, but the death rate could be dramatically reduced if all women had regular Pap smears. The deposits of pigment on the forehead, cheeks, upper lip, nose and nipples are often triggered by pregnancy or starting the oral contraceptive pill. Numerous blanching agents have been tried with minimal success, but the pigmentation usually fades slowly over several years. Its presence can be used as a diagnostic test for pregnancy, but can only be detected at least ten days after conception. False positive results can occur with cancers of ovary or testes (seminomas, choriocarcinoma) or placental tumour (hydatidiform mole). Chorionic gonadotrophin can also be injected as a medication in the treatment of infertility in women, delayed puberty in girls, failure of testicular development and failure of sperm production.

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This explains the very specific symptoms associated with an injury to localized areas of the cerebral cortex after a stroke or traumatic injury to the head cheap 50mg kamagra with amex erectile dysfunction is often associated with. Spinal Cord Location of the Spinal Cord In the embryo kamagra 100 mg visa erectile dysfunction doctors in st louis mo, the spinal cord occupies the entire spinal canal and so extends down into the tail portion of the vertebral column. However, the column of bone grows much more rapidly than the nerve tissue of the cord, so that eventually the 159 Human Anatomy and Physiology end of the cord no longer reaches the lower part of the spinal canal. This disparity in growth continues to increase; in the adult the cord ends in the region just below the area to which the last rib attaches (between the first and the second lumbar vertebrae. Structure of the Spinal Cord The spinal cord lies within the vertebral canal and extends from the foramen magnum to the level of the second lumbar vertebrae after which a fibrous remnant, the filum terminale, descends to be attached to the back of the coccyx. It is cylindrical in shape, flattened slightly anteroposteriorly, and has cervical and lumbar enlargements where the nerves supplying the upper and lower limb originatethe enlargements lie opposite the lower cervical and lower thoracic vertebrae. Since the spinal cord is shorter than the vertebral canal, the nerves descend with increasing obliquity before leaving the canal through the intervertebral foramina. The collection of lower lumbar, sacral and coccygeal nerves below the spinal cord, with the filum terminale, is known as the cauda equina. The gray matter is so arranged that a column of cells extend up and down dorsally, one on each side; another column is found in the ventral region on each side. These two pairs of columns, called the dorsal and ventral horns, give the gray matter an H-shaped appearance in cross section. In the center of the gray matter is a small channel, central canal that contains cerebrospinal fluid, the liquid that circulates around the brain and spinal cord. The white matter consists of thousands of nerve cell fibers arranged in three areas external to the gray matter on each side. Lippincot Company) Functions of the Spinal Cord The spinal cord is the link between the spinal nerves and the brain. It is also a place where simple responses, known as reflexes can be coordinated even without involving the brain. The functions of the spinal cord may be divided into three categories: 162 Human Anatomy and Physiology 1. Conduction of motor impulses from the brain down through descending tracts to the efferent neurons that supply muscles or glands 3. When you fling out an arm or leg to catch your balance, withdraw from a painful stimulus, or blink to avoid an object approaching your eyes, you are experiencing reflex behaviour. A reflex pathway that passes through the spinal cord alone and does not involve the brain is termed a spinal reflex. If you tap the tendon below the kneecap (the patellar tendon), the muscles of the anterior thigh (quadriceps femoris) contracts, eliciting the knee jerk. Such stretch reflexes may be evoked by appropriate tapping of most large muscles (such as the triceps brachii in the arm and the gastrocnemius in the calf of the leg). Because reflexes occur automatically, they are used in physical examinations to test the condition of the nervous system. The meninges, spinal nerves, and sympathetic trunk are visible in the illustration (Source: Carola, R. Lippincot Company) 165 Human Anatomy and Physiology Figure 7-9 Flow of cerebrospinal fluid (Source: Carola, R. This system includes cranial and spinal nerves that connect the brain and spinal cord, respectively, to peripheral structures such as the skin surface and the skeletal muscles. These connect the brain and spinal cord to various glands in the body and to the cardiac and smooth muscle in the thorax and abdomen. Tracts are located within the brain and also within the spinal cord to conduct impulses to and from the brain. As with muscles, the "wires," or nerve cell fibers in a nerve, are bound together with connective tissue. A few of the cranial nerves contain only motor fibers for conducing impulses away from the brain and are classified as motor, or efferent, nerves. However, the remainder of the cranial nerves and all of the spinal nerves contain both sensory and motor fibers and are referred to as mixed nerves. Cranial Nerves Location of the Cranial Nerves Cranial nerves are nerves that are attached to the brain. There are 12 pairs of cranial nerves (henceforth, when a cranial nerve is identified, a pair is meant). They are numbered according to their connection with the brain; 168 Human Anatomy and Physiology beginning at the front and proceeding back (Figure 7-10).

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