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Academic proven etoricoxib 120mg arthritis medication and weight gain, New York cheap 60 mg etoricoxib with visa arthritis in the knee bone on bone, pp 389–413 (nucleus hypothalamicus; corpus Luysi) Arch Neuro Psy- Schlesinger B (1976) The upper brainstemin the human order etoricoxib 60 mg line idiopathic arthritis definition. Springer etoricoxib 90 mg on-line arthritis in the back of the head, Berlin Willis T (1664) Cerebri anatome, cui accessit nervorum de- Heidelberg New York scriptio et usus. This coronal ap- These successive coronal cuts are performed us- proach to brain anatomy is in routine use in our de- ing a high field system, at 3 mm slice thickness and 1 partment. Successive coronal cuts made using the commissural- obex reference line and a high field system, with 3 mm slice thickness and 1 mm gap, in an inversion recovery T1 weighted, pulse sequence The Basal Forebrain, Diencephalon and Basal Ganglia 221 Fig. Cut through the interventricular foramen and the mamillary bodies The Basal Forebrain, Diencephalon and Basal Ganglia 223 Fig. The func- tional anatomy of the brainstem and cerebellum, necessary for accurate clinical and anatomic correla- tions, is reviewed in this chapter. The hindbrain comprises the pons, the medulla oblongata, and the cerebellum, the latter forming the roof of the fourth A ventricle which is the cavity of the rhombencepha- lon. The last portion of the brainstem, the midbrain, corresponds to the upper portion connecting the pons and cerebellum with the forebrain. The relation- ships of the brainstem to the cerebellum posteriorly and laterally and to the diencephalon superiorly are best appreciated on midsagittal (Fig. A,B 1, Lingula, vermis; 2, central lobule, vermis; 3, culmen, vermis; 4, declive, vermis; 5, folium, vermis; 6, tuber, dulla oblongata which is continuous below with the vermis; 7, pyramis, vermis; 8, uvula, vermis; 9, nodulus, ver- spinal cord. The definition of the term “brainstem” is mis; 10, central white matter; 11, superior medullary velum; variable and for some authors may include the dien- 12, tectal plate; 13, cerebral aqueduct; 14, midbrain; 15, pons; cephalon. In the following, we will exclude the dien- 16, medulla oblongata; 17, decussation of superior cerebellar cephalon, considered as part of the deep core struc- peduncles; 18, corticospinal (pyramidal tract); 19, pyramid (pyramidal tract); 20, third ventricle; 21, thalamus; 22, ante- tures of the brain and discussed in Chap. This cor- physis (pineal body); 30, mamillary bodies responds to a supratentorial part and infratentorial posterior fossa structures. Such a distinction seems 228 Chapter 8 more practical from an imaging point of view, be- cause axial or horizontal cuts performed perpendic- ular to the long axis of the brainstem contribute more to anatomic imaging correlations and struc- tural analysis. A In the following, we will develop the gross mor- phology and the structural and functional anatomy of the mesencephalon, or midbrain, with special empha- sis on the functional aspects of the colliculi, the mes- encephalon, composed of both the pons and the cere- bellum, and the myelencephalon or medulla oblongata. A The Midbrain The midbrain is the smallest of the three major sub- divisions of the brainstem, situated between the pons caudally and the diencephalon dorsally. The midbrain connects the pons conjunctivum); 7, midbrain tegmentum; 8, lateral lemniscus; and the cerebellum caudally with the diencephalon 9, midbrain-thalamic region; 10, middle cerebellar peduncle; rostrally. It is the shortest segment of the brainstem, 11, inferior cerebellar peduncle; 12, pontine tegmentum; 13, measuring 2 cm in length. Its long axis inclines ven- flocculus and paraflocculus; 14, superior aspect of cerebellar trally from its caudal to its rostral aspect. Dorsal to the cerebral aqueduct is the tectum, represented by the superior and inferior colliculi 1234 The Brainstem and Cerebellum 229 Fig. The cru- ra cerebri are massive bundles of white fibers consti- tuting the ventral surface of the midbrain and emerging from the cerebral hemispheres on each side of the median plane. The pedun- cles form the posterior and lateral boundaries of the interpeduncular fossa, the posterior portion of which corresponds to the posterior perforated sub- stance, through which pass the central branches of the posterior cerebral arteries. The crura cerebri consist almost entirely of descending fibers, the cor- ticospinal tract projecting to the spinal cord, the cor- ticopontine tracts terminating in the pontine nuclei and the corticobulbar tract projecting into specific regions of the lower brainstem and mainly to the brainstem reticular formation. The ventral surface of each crus is crossed from medial to lateral by the proxi- B mal segments of the posterior cerebral and superior Fig. The main anatomic structures found of Magendie; 20, basilar artery; 21, epiphysis; 22, third ven- tricle; 23, thalamus; 24, optic chiasm; 25, anterior commis- are the cerebral aqueduct, surrounded by the central sure; 26, fornix; 27, splenium of corpus callosum; 28, caudate gray matter (periaqueductal gray) separating the nucleus tectum, represented by the quadrigeminal plate, 1234 230 Chapter 8 from the tegmentum. The latter is separated by the mainly from the visual cortex, are also highly orga- darkly pigmented substantia nigra from the cerebral nized, reaching the superior colliculus via its brachi- peduncles or crura cerebri most ventrally. A correspondence exists between terminations larly prominent are the red nuclei and the substantia of both retinotectal and corticotectal fibers in the nigra as well as the cerebral peduncles, which are superior colliculus.

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This clot postoperative pyrexia buy cheap etoricoxib line arthritis young living oils, and limb swelling can be helpful may break of and pass through the heart to enter the clues cheap etoricoxib 120mg with visa arthritis diet amazon. The diagnosis is made by duplex Doppler pulmonary circulation purchase etoricoxib without prescription arthritis in dogs and panting, resulting in occlusion of the sonography or ascending venography etoricoxib 90mg line inflammatory arthritis in back. They drain, via vessels that fcial and deep inguinal nodes located in the fascia just accompany the femoral vessels, into external iliac nodes inferior to the inguinal ligament (Fig. Superfcial inguinal nodes Deep inguinal nodes The superfcial inguinal nodes, approximately ten in The deep inguinal nodes, up to three in number, are number, arein the superfcial fascia andparallel thecourse medial to the femoral vein (Fig. Medially, they The deep inguinal nodes receive lymph from deep lym­ extend inferiorly along the terminal part of the great phatics associated with the femoral vessels and fom the saphenous vein. The space through which the lymphatic vessels pass Inguinal ligament under the inguinal ligament is the femoral canal. Popliteal nodes Tuberculum In addition to theinguinal nodes, there is a small collection of iliac crest of deep nodes posterior to the knee close to the popliteal Saphenous opening vessels (Fig. These popliteal nodes receive lymph from superfcial vessels, which accompany the small Anterior superior iliac spine saphenous vein, and from deep areas of the leg and foot. Pubic tubercle lata Deep fascia and the saphenous opening Fascia lata The outer layer of deep fascia in the lower limb forms a thick "stocking-like" membrane, which covers the limb and lies beneath the superfcial fascia (Fig. The fascia lata is anchored superiorly to bone and sof tissues along a line of attachment that defnes the upper margin of the lower limb. Beginning anteriorly and cir­ cling laterally around the limb, this line of attachment includes the inguinal ligament, iliac crest, sacrum, coccyx, A B sacrotuberous ligament, inferior ramus of the pubic Fig. Iliotibial tract The fascia lata is thickened laterally into a longitudinal band (the iliotibial tract), which descends along the lateral margin of the limb from the tuberculum of the iliac • Most of the gluteus maximus muscle inserts into the crest to a bony attachment just below the knee (Fig. The superior aspect of the fascia lata in the gluteal region splits anteriorly to enclose the tensor fasciae latae The tensor fasciae latae and gluteus maximus muscles, muscle and posteriorly to enclose the gluteus maximus working through their attachments to the iliotibial tract, muscle: hold the leg in extension once other muscles have extended the leg at the knee joint. The iliotibial tract and its two • The tensor fasciae latae muscle is partially enclosed by associated muscles also stabilize the hip joint by preventing and inserts into the superior and anterior aspects of the lateral displacement of the proximal end of the femur away iliotibial tract. The fascia lata hasoneprominent aperture on the anterior • The floor of the triangle is formed medially by the pec­ aspect of the thigh just inferior to the medial end of the tineus and adductor longus muscles in the medial com­ inguinal ligament (the saphenous opening), which partment of the thigh and laterally by the iliopsoas allows the great saphenous vein to pass from superfcial muscle descending from the abdomen. The femoral nerve, artery, and vein and lymphatics pass between the abdomen and lower limb under the Femoral triangle The femoral triangle is a wedge-shaped depression formed by muscles in the upper thigh at the junction between the anterior abdominal wall and the lower limb (Fig. Pelvic inlet External iliac vein Anterior superior iliac spine Sartorius muscle Inguinal ligament Adductor hiatus Saphenous Femoral vein Fascia Great saphenous vein Pubic tubercle Pubic bone Pubic symphysis Fig. The femoral artery and vein pass inferiorly through the Femoral sheath adductor canal and become the popliteal vessels behind the In thefemoral triangle, thefemoral artery andvein andthe knee where they meet and are distributed with branches associated lymphatic vessels are surrounded by a funnel­ of the sciatic nerve, which descends through the posterior shaped sleeve of fascia (the femoral sheath). The femoral artery structures surrounded by the sheath is contained within a can be palpated in the femoral triangle just inferior to the separate fascial compartment within the sheath. The most inguinal ligament and midway between the anterior supe­ medial compartment (the femoral canal) contains the lym­ rior iliac spine and the pubic symphysis. The opening of this canal superiorly is potentially a weak point in the lower abdomen and is the site for femoral hernias. In the clinic Vascular access to the lower limb Deep and inferior to the inguinal ligament are the femoral artery and femoral vein. Thefemoral artery is palpable as it passesoverthe femoral head and may be easily demonstrated using ultrasound. If arterial or venous access is needed rapidly, a physician can use the Femoral femoral approach to these vessels. Femoral vei symphysis Many radiological procedures involve catheterization of the femoral artery or the femoral vein to obtain access tothe contralateral lower limb, the ipsilateral lower limb, the vessels of the thorax and abdomen, and the cerebral vessels. Cardiologists also use the femoral artery to place catheters in vessels around the arch of the aorta and into the coronary arteries to perform coronary angiography and angioplasty. Access to the femoral vein permits catheters to be maneuvered into the renal veins, the gonadal veins, the right atrium, and the right side of the heart, including the pulmonary artery and distal vessels ofthe pulmonary tree.

However cheap etoricoxib 120 mg on-line rheumatoid arthritis knee, the The penis is composed mainly of the two corpora caver­ bulbo-urethral glands are located within the deep perineal nosa and the single corpus spongiosum discount etoricoxib 60mg with mastercard arthritis pain pills, which contains pouch cheap etoricoxib 90mg arthritis pain vicodin, whereas the greater vestibular glands are in the the urethra (Fig order 90 mg etoricoxib with mastercard arthritis treatments queensland. Two of these three pairs of muscles are associ­ ated with the roots of the penis and clitoris; the other pair The base of the body of the penis is supported by two is associated with the perineal body. Each muscle is anchored abdominal wall and split below into two bands that pass on to the medial margin of the ischial tuberosity and related each side of the penis and unite inferiorly). The two bulbospongiosus muscles are associated The corpus spongiosum expands to form the head of the mainly with the bulbs of the vestibule in women and penis (glans penis) over the distal ends of the corpora with the attached part of the corpus spongiosum in men cavernosa {Fig. In women, each bulbospongiosus muscle is anchored Erection posteriorly to the perineal body and courses anterolaterally Erection of thepenis andclitoris is a vascular event gener­ over the inferior surface of the related greater vestibular ated by parasympathetic fbers carried in pelvic splanchnic gland and the bulb of the vestibule to attach to the surface nerves from the anterior rami of S2 to S4, which enter the of the bulb and to the perineal membrane (Fig. This allows blood to fll the tissues, causing midline to a raphe on the inferior surface of the bulb of the the penis and clitoris to become erect. The raphe is anchored posteriorly to the perineal Arteries supplying the penis and clitoris are branches of body. Muscle fbers course anterolaterally, on each side, 508 the internal pudendal artery; branches of the pudendal from the raphe and perineal body to cover each side of the Regional anatomy • Perineum Suspensory ligament of clitoris Ischiocavernosus muscle Bulbospongiosus muscle A Perineal body Supericial transverse perineal muscle Fundiforr ligament of penis Ischiocavernosus muscle Bulbospongiosus muscle B Perineal body Superficial transverse perineal muscle Fig. Others extend anterolaterally The paired superfcial transverse perineal muscles to associate with the crura and attach anteriorly to the follow a course parallel to the posterior margin of the infe­ ischiocavernosus muscles. These In bothmen and women, the bulbospongiosus muscles flat band-shaped muscles, which are attached to ischial compress attached parts of the erect corpus spongiosum tuberosities and rami, extend medially to the perineal body and bulbs of the vestibule and force blood into more distal in the midline and stabilize the perineal body. In men, the bulbospongiosus muscles have two additional functions: Superfcial features of the external genitalia In women • They facilitate emptying of the bulbous part of the penile urethra following urination (micturition). In women, the clitoris and vestibular apparatus, together • Their reflex contraction during ejaculation is responsi­ with a number of skin and tissue folds, form the vulva ble for the pulsatile emission of semen from the penis. On either side of the midline are two thin folds Mons pubis Pubic symphysis (palpable) Urogenital triangle Ischial tuberosity (palpable) Anal triangle Anal aperture A Coccyx (palpable) Prepuce of clitoris Glans clitoris Lateral fold Urethral opening Medial fold Vestibule Opening of duct of (between labia minora) paraurethral gland Hymen Vaginal opening Opening of duct of greater vestibular gland B Fig. The region enclosed The orifces of the urethra and the vagina are associated between them, and into which the urethra and vagina with the openings of glands. The lateral folds unite ventrally over the adjacent to the posterolateral margin of the vaginal glans clitoris and the body of the clitoris to form the opening in the crease between the vaginal orifce and rem­ prepuce of the clitoris (hood). Posteriorly, the labia majora do not unite and are separated Within the vestibule, the vaginal orifce is surrounded by a depression termed theposterior commissure, which to varying degrees by a ring-like fold of membrane, the overlies the position of the perineal body. Following rupture of the hymen (resulting from frst sexual inter­ Superfcial components of the genital organs in men course or injury), irregular remnants of the hymen fringe consist of the scrotum and the penis (Fig. Inthe fetus, labioscrotal swellings fuse across the It defnes the external limits of the superfcial perineal midline, resulting in a single scrotum into which the testes pouch, lines the scrotum or labia, and extends around the and their associated musculofascial coverings, blood body of the penis and clitoris. The remnant of the line of fusion ous over the pubic symphysis and pubic bones with the between the labioscrotal swellings in the fetus is visible on membranous layer of fascia on the anterior abdominal the skin of the scrotum as a longitudinal midline raphe wall. In the lower lateral abdominal wall, the membranous that extends from the anus, over the scrotal sac, and onto layer of abdominal fascia is attached to the deep fascia of the inferior aspect of the body of the penis. The attached root Because the membranous layer of fascia encloses the of the penis is palpable posterior to the scrotum in the superfcial perineal pouch and continues up the anterior urogenital triangle of the perineum. The pendulous part of abdominal wall, fluids or infectious materials that accumu­ the penis (body of penis) is entirely covered by skin; the tip late in the pouch can track out of the perineum and onto of the body is covered by the glans penis. This material will not track into The external urethral orifce is a sagittal slit, normally the anal triangle or the thigh because the fascia fuses with positioned at the tip of the glans. The base of this raphe is continuous with the frenulum of the glans, which is a median fold of skin that attaches the glans to In the clinic more loosely attached skin proximal to the glans. The base of the glans is expanded to form a raised circular margin Urethral rupture (the corona of the glans); the two lateral ends of the Urethral rupture may occur at a series of well-defned corona join inferiorly at the midline raphe of the glans.

Poison Centres and Clinical Toxicologists review the therapeutic 3Irrigation with large volumes of a polyethylene glycol–electrolyte usefulness of various procedures for gut decontamination discount 60mg etoricoxib otc arthritis pain before rain. Klean-Prep purchase generic etoricoxib arthritis foods, by mouth causes minimal fluid and appear in the Journal of Toxicology generic 120mg etoricoxib chinese arthritis relief hand movements, Clinical Toxicology from 1997 electrolyte disturbance (it was developed for preparation for onwards cheap etoricoxib 60 mg fast delivery arthritis neuropathic pain, the latest position statements being in 2004 and 2005. In adults, activated charcoal 50 g the removal of sustained-release or enteric-coated formula- is given initially, then 50 g every 4 h. Vomiting should be tions from patients who present more than 2 h after inges- treated with an antiemetic drug because it reduces the tion, e. Activated charcoal in frequent (50 g) doses is the dose may be reduced and the frequency increased, generally preferred. Whole-bowel irrigation is also an option for the removal Alteration of urine pH and diuresis of ingested packets of illicit drugs. It is contraindicated in patients with bowel obstruction, perforation or ileus, It is useful to alter the pH of the glomerular filtrate such that with haemodynamic instability and with compromised a drug that is a weak electrolyte will ionise, become less unprotected airways. The effectiveness of activated this process, but the alteration of tubular fluid pH is the im- charcoal may be reduced by co-administration with whole portant determinant. Alkalinisation4 may be used for: salicylate (>500 mg/ Techniques for eliminating absorbed poisons have a role Lþmetabolic acidosis, or in any case >750 mg/L) pheno- that is limited, but important when applicable. Repeated doses of activated Haemodialysis charcoal The system requires a temporary extracorporeal circulation, Activated charcoal by mouth not only adsorbs ingested e. A semipermeable drug in the gut, preventing absorption into the body (see membrane separates blood from dialysis fluid; the poison above), it also adsorbs drug that diffuses from the blood passes passively from the blood, where it is present in high into the gut lumen when the concentration there is lower. Charcoal may also adsorb salicylate (>750 mg/Lþrenal failure, or in any case drugs that secrete into the bile, i. The procedure is effective for overdose and window-cleaning solutions); lithium; methanol; ethyl- of carbamazepine, dapsone, phenobarbital, quinine, ene glycol; ethanol. Repeated-dose activated charcoal is increasingly pre- 4Proudfoot A T, Krenzelok E P, Vale J A 2004 Position paper on urine ferred to alkalinisation of urine (below) for phenobarbital alkalinisation. Poison in the blood diffuses down the concentra- tion gradient into the dialysis fluid, which undergoes re- Receptor • Direct antagonism, e. The technique requires antagonism organophosphate poisoning and little equipment; it may be worth using for lithium and many other examples methanol poisoning. N- Haemofiltration and peritoneal dialysis are more readily depleted natural acetylcysteine in paracetamol available but are less efficient (one-half to one-third) than ‘protective’ poisoning haemodialysis. Its use should be confined to cases of severe, conversion to prolonged or progressive clinical intoxication, when toxic metabolite high plasma concentration indicates a dangerous degree of poisoning, and its effect constitutes a Protective action • Pralidoxime competitively significant addition to natural methods of elimination. Even ‘minor’ cases of deliberate self-harm should 5 not be dismissed, as 20–25% of patients who die from delib- Mithridates the Great (? Interpersonal or poisons with which his domestic enemies sought to kill him social problems precipitate most cases of self-poisoning (Lempriere). Consider the impact of any associated had taken in the early part of his life had so strengthened his medical problems and their symptom control. Modern physicians have to be content with less comprehensively effective hospitals such assessments are usually performed bythe hos- antidotes, some of which are listed in Table 10. Blocks muscarinic cholinoceptors organophosphorus insecticides b-Blocker poisoning Vagal block accelerates heart rate Benzatropine Drug-induced movement disorders Blocks muscarinic cholinoceptors Calcium gluconate Hydrofluoric acid, fluorides Binds or precipitates fluoride ions Desferrioxamine Iron Chelates ferrous ions Dicobalt edetate Cyanide and derivatives, e. Competitively reactivates cholinesterase organophosphorus insecticides Propranolol b-Adrenoceptor agonists, ephedrine, Blocks b-adrenoceptors theophylline, thyroxine Protamine Heparin Binds ionically to neutralise Prussian blue (potassium Thallium (in rodenticides) Potassium exchanges for thallium ferric hexacyanoferrate) Sodium calcium edetate Lead Chelates lead ions Unithiol Lead, elemental and organic mercury Chelates metal ions patient from the hospital. Most patients can be discharged agents form stable, biologically inert complexes that pass without psychiatric follow-up. Adverse effects are common, particularly with larger use of chelating agents doses, and include nausea, vomiting, lachrymation, saliva- Acute or chronic exposure to heavy metals can harm tion, paraesthesiae, muscular aches and pains, urticarial the body.

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