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V. Stan. Montana State University College of Technology, Great Falls.

Similarly purchase 20 mg rosuvastatin visa, the shapes of some muscles are very distinctive and the names buy rosuvastatin 10 mg amex, such as orbicularis purchase rosuvastatin 5mg with amex, reflect the shape. For the buttocks, the size of the muscles influences the names: gluteus maximus (largest), gluteus medius (medium), and the gluteus minimus (smallest). Names were given to indicate length— brevis (short), longus (long)—and to identify position relative to the midline: lateralis (to the outside away from the midline), and medialis (toward the midline). The direction of the muscle fibers and fascicles are used to describe muscles relative to the midline, such as the rectus (straight) abdominis, or the oblique (at an angle) muscles of the abdomen. Other muscle names can provide information as to how many origins a particular muscle has, such as the biceps brachii. For instance, the sternocleidomastoid muscle of the neck has a dual origin on the sternum (sterno) and clavicle (cleido), and it inserts on the mastoid process of the temporal bone. Some examples are flexor (decreases the angle at the joint), extensor (increases the angle at the joint), abductor (moves the bone away from the midline), or adductor (moves the bone toward the midline). Some of the axial muscles may seem to blur the boundaries because they cross over to the appendicular skeleton. The first grouping of the axial muscles you will review includes the muscles of the head and neck, then you will review the muscles of the vertebral column, and finally you will review the oblique and rectus muscles. Muscles That Create Facial Expression The origins of the muscles of facial expression are on the surface of the skull (remember, the origin of a muscle does not move). The insertions of these muscles have fibers intertwined with connective tissue and the dermis of the skin. Because the muscles insert in the skin rather than on bone, when they contract, the skin moves to create facial expression (Figure 11. The orbicularis oris is a circular muscle that moves the lips, and the orbicularis oculi is a circular muscle that closes the eye. The muscle has a frontal belly and an occipital (near the occipital bone on the posterior part of the skull) belly. In other words, there is a muscle on the forehead ( frontalis) and one on the back of the head ( occipitalis), but there is no muscle across the top of the head. Instead, the two bellies are connected by a broad tendon called the epicranial aponeurosis, or galea aponeurosis (galea = “apple”). There are several small facial muscles, one of which is the corrugator supercilii, which is the prime mover of the eyebrows. These muscles are located inside the eye socket and cannot be seen on any part of the visible eyeball (Figure 11. If you have ever been to a doctor who held up a finger and asked you to follow it up, down, and to both sides, he or she is checking to make sure your eye muscles are acting in a coordinated pattern. Muscles of the Eyes Target Prime Movement Target motion Origin Insertion mover direction Superior Common Moves eyes up and toward (elevates); Superior tendinous ring Superior surface of nose; rotates eyes from 1 Eyeballs medial rectus (ring attaches to eyeball o’clock to 3 o’clock (adducts) optic foramen) Inferior Common Moves eyes down and (depresses); Inferior tendinous ring Inferior surface of toward nose; rotates eyes Eyeballs medial rectus (ring attaches to eyeball from 6 o’clock to 3 o’clock (adducts) optic foramen) Common Moves eyes away from Lateral Lateral tendinous ring Lateral surface of Eyeballs nose (abducts) rectus (ring attaches to eyeball optic foramen) Common Medial Medial tendinous ring Medial surface of Moves eyes toward nose Eyeballs (adducts) rectus (ring attaches to eyeball optic foramen) Surface of eyeball Moves eyes up and away Superior Inferior Floor of orbit between inferior from nose; rotates eyeball Eyeballs (elevates); oblique (maxilla) rectus and lateral from 12 o’clock to 9 o’clock lateral (abducts) rectus Moves eyes down and Suface of eyeball Superior away from nose; rotates Superior between superior Eyeballs (elevates); Sphenoid bone eyeball from 6 o’clock to 9 oblique rectus and lateral lateral (abducts) o’clock rectus Table 11. Muscles involved in chewing must be able to exert enough pressure to bite through and then chew food before it is swallowed (Figure 11. The masseter muscle is the main muscle used for chewing because it elevates the mandible (lower jaw) to close the mouth, and it is assisted by the temporalis muscle, which retracts the mandible. Muscles of the Lower Jaw Target motion Prime Movement Target Origin Insertion direction mover Maxilla arch; zygomatic Closes mouth; aids chewing Mandible Superior (elevates) Masseter Mandible arch (for masseter) Table 11. Muscles That Move the Tongue Although the tongue is obviously important for tasting food, it is also necessary for mastication, deglutition (swallowing), and speech (Figure 11. Extrinsic tongue muscles insert into the tongue from outside origins, and the intrinsic tongue muscles insert into the tongue from origins within it. The extrinsic muscles move the whole tongue in different directions, whereas the intrinsic muscles allow the tongue to change its shape (such as, curling the tongue in a loop or flattening it). The extrinsic muscles all include the word root glossus (glossus = “tongue”), and the muscle names are derived from where the muscle originates. The genioglossus (genio = “chin”) originates on the mandible and allows the tongue to move downward and forward. The palatoglossus originates on the soft palate to elevate the back of the tongue, and the hyoglossus originates on the hyoid bone to move the tongue downward and flatten it. The normal homeostatic controls of the body are put “on hold” so that the patient can be prepped for surgery. Control of respiration must be switched from the patient’s homeostatic control to the control of the anesthesiologist. Among the muscles affected during general anesthesia are those that are necessary for breathing and moving the tongue. Under anesthesia, the tongue can relax and partially or fully block the airway, and the muscles of respiration may not move the diaphragm or chest wall. To avoid possible complications, the safest procedure to use on a patient is called endotracheal intubation. Placing a tube into the trachea allows the doctors to maintain a patient’s (open) airway to the lungs and seal the airway off from the oropharynx. Post-surgery, the anesthesiologist gradually changes the mixture of the gases that keep the patient unconscious, and when the muscles of respiration begin to function, the tube is removed.

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Quantified minimal clinically important differences for total nasal symptom score purchase rosuvastatin. Minimum clinically important differences used to assess seasonal allergic rhinitis outcomes generic rosuvastatin 10mg visa. Results of literature searches for Key Question 1 and Key Question 2 comparisons of interest buy 5 mg rosuvastatin free shipping. Strength of evidence: oral selective antihistamine versus oral nonselective antihistamine. Treatment effects: nasal symptoms–oral selective antihistamine versus oral nonselective antihistamine. Treatment effects: quality of life–oral selective antihistamine versus oral nonselective antihistamine. Treatment effects: nasal symptoms–oral selective antihistamine versus nasal antihistamine. Treatment effects: quality of life–oral selective antihistamine versus nasal antihistamine. Strength of evidence: oral selective antihistamine versus intranasal corticosteroid. Treatment effects: nasal symptoms–oral selective antihistamine versus intranasal corticosteroid. Treatment effects: eye symptoms–oral selective antihistamine versus intranasal corticosteroid. Treatment effects: quality of life–oral selective antihistamine versus intranasal corticosteroid. Treatment effects: nasal symptoms–oral selective antihistamine versus oral decongestant. Treatment effects: eye symptoms–oral selective antihistamine versus oral decongestant. Strength of evidence: oral selective antihistamine versus oral leukotriene receptor antagonist. Treatment effects: nasal symptoms–oral selective antihistamine versus oral leukotriene receptor antagonist. Treatment effects: eye symptoms–oral selective antihistamine versus leukotriene receptor antagonist. Treatment effects: asthma outcomes–oral selective antihistamine versus leukotriene receptor antagonist. Treatment effects: quality of life outcomes–oral selective antihistamine versus leukotriene receptor antagonist. Treatment effects: nasal symptoms–intranasal corticosteroid versus nasal antihistamine. Treatment effects: eye symptoms–intranasal corticosteroid versus nasal antihistamine. Treatment effects: quality of life outcomes–intranasal corticosteroid versus nasal antihistamine. Treatment effects: nasal symptoms–intranasal corticosteroid versus nasal cromolyn. Strength of evidence: intranasal corticosteroid versus oral leukotriene receptor antagonist. Treatment effects: nasal symptoms–intranasal corticosteroid versus oral leukotriene receptor antagonist. Treatment effects: asthma outcomes–intranasal corticosteroid versus oral leukotriene receptor antagonist. Strength of evidence: combination oral selective antihistamine plus intranasal corticosteroid versus oral selective antihistamine. Treatment effects: nasal symptoms–combination oral selective antihistamine plus intranasal corticosteroid versus oral selective antihistamine. Treatment effects: eye symptoms–combination oral selective antihistamine plus intranasal corticosteroid versus oral selective antihistamine. Treatment effects: quality of life–combination oral selective antihistamine plus intranasal corticosteroid versus oral selective antihistamine. Strength of evidence: combination oral selective antihistamine plus intranasal corticosteroid versus intranasal corticosteroid. Treatment effects: nasal symptoms–combination oral selective antihistamine plus intranasal corticosteroid versus intranasal corticosteroid. Treatment effects: eye symptoms–combination oral selective antihistamine plus intranasal corticosteroid versus intranasal corticosteroid. Treatment effects: quality of life–combination oral selective antihistamine/intranasal corticosteroid versus intranasal corticosteroid.

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Stage I a) Fracture surfaces are still irregular (Fresh) b) The size of proximal fragment is 2 purchase discount rosuvastatin on line. Treatment Stage I: In this stage the success rate of various procedures aimed at osteosynthesis is very high order rosuvastatin 10mg without a prescription. Closed reduction and internal fixation with one screw and double fibular graft or 2 screws and one fibular graft cheap 5mg rosuvastatin fast delivery. If the neck of the femur is narrow then one screw and one fibular graft may be given. Closed reduction or open reduction and bone muscle pedicle graft based on quadratus femoris or sartorius or tensor fascia femoris can be used. This procedure is particularly useful when the fracture is situated more near the base and length of proximal fragment is 3. Closed reduction and internal fixation with one screw and double fibular graft or 2 screws and 1 fibular graft. Open reduction, freshening of fracture surfaces and internal fixation with 2 screws and one free fibular graft. Open reduction and internal fixation with multiple screws and bone muscle pedicle graft based on quadratus femoris or sartorius or tensor fascia femoris. Other methods of treatment which can be useful (although they will not achieve union of fracture but improve the function of hip) are a. Patient may be left alone if the patient is poor and cannot afford treatment or is unfit for surgery. Later on he can walk with the support of stick or even without than in about 3-4 months time. Osteosynthesis if the patient wants it and is prepared to wait for 5 - 7 months for independent walking. It also depends upon the training of the Orthopaedic surgeon and facilities available to him. Use of free fibular graft/vascularised fibula in addition to internal fixation with screws particularly where there is posterior comminution improve the chances of union and may be carried out in such cases. If the reduction of the fracture is less than anatomical but otherwise satisfactory addition of free fibular graft can improve the chances of union. If the patient is suffering from a generalized disease like diabetes mellitus, congestive heart failure, chronic kidney or liver disease, malignancy etc. The intertrochanteric and the subtrochanteric fractures pose a number of management dilemmas depending on the fractures configuration and status of the bones. A number of different treatment modalities for management of these fractures have been proposed and tried with varying results for both intertrochanteric and subtrochanteric fractures of proximal femur. Intertrochanteric hip fractures account for approximately half of the hip fractures in the elderly; out of this more than 50% fractures are unstable. Unstable pattern occur more commonly with increased age and with low bone mineral density. The presence of osteoporosis in intertrochanteric fractures is important because fixation of the proximal fragment depends entirely on the quality of cancellous bone present, Unstable intertrochanteric fractures are those in which comminution of posteromedial buttress exceeds a simple lesser trochanteric fragment or those with subtrochanteric extension. The results of unstable fractures are less reliable and have a high rate of failure - 8%- 25%. The goal of treatment of any intertrochanteric fracture in the elderly is to restore mobility safely and efficiently while minimizing the risk of medical complications and technical failure and to restore the patient to preoperative status. Unstable intertrochanteric fractures are technically much more challenging than stable fractures; a stable reduction of an intertrochanteric fracture requires providing medial and posterior cortical contact between the major proximal and distal fragment to resist varus and posterior displacing forces. Hence Surgeons must understand implant options available and should strive to achieve accurate realignment and proper implant placement. The common problem for these fractures has been malunion, delayed union or non-union. Many newer designs of implants bas been designed for fixation of subtrochanteric fractures. The newer implants were designed to avoid bending, breakage of plates and nails, the loosening of screws and inadequate fixation. This is mainly because elderly people are unable to dissipate energy as compared to the young person, and diminished ambulatory speed. Their protective responses are also 48 diminished because of slow reaction time, weakness, disorientation and the side effect of medication. Elderly people also lack shock absorbers such as pad of fat or muscles over the trochanteric region and finally diminished bone strength because of osteopaenia allows fractures to occur with trivial fall. The injured should be referred to the higher centre earliest feasible causing no further harm. Investigations: X-rays of the pelvis including both hips and knee joint and of other areas if required, General Investigations and specific if required according to the status of the health of the patient.

In females purchase rosuvastatin 5mg overnight delivery, the ovaries secrete small amounts of testosterone purchase rosuvastatin mastercard, although most is converted to estradiol purchase rosuvastatin with american express. Control of Testosterone The regulation of testosterone concentrations throughout the body is critical for male reproductive function. The intricate interplay between the endocrine system and the reproductive system is shown in Figure 27. The hypothalamus and the pituitary gland in the brain integrate external and internal signals to control testosterone synthesis and secretion. These polypeptide hormones correlate directly with Sertoli cell function and sperm number; inhibin B can be used as a marker of spermatogenic activity. The resulting reduction in circulating testosterone concentrations can lead to symptoms of andropause, also known as male menopause. While the reduction in sex steroids in men is akin to female menopause, there is no clear sign—such as a lack of a menstrual period—to denote the initiation of andropause. Instead, men report feelings of fatigue, reduced muscle mass, depression, anxiety, irritability, loss of libido, and insomnia. A reduction in spermatogenesis resulting in lowered fertility is also reported, and sexual dysfunction can also be associated with andropausal symptoms. Whereas some researchers believe that certain aspects of andropause are difficult to tease apart from aging in general, testosterone replacement is sometimes prescribed to alleviate some symptoms. Recent studies have shown a benefit from androgen replacement therapy on the new onset of depression in elderly men; however, other studies caution against testosterone replacement for long-term treatment of andropause symptoms, showing that high doses can sharply increase the risk of both heart disease and prostate cancer. Unlike its male counterpart, the female reproductive system is located primarily inside the pelvic cavity (Figure 27. External Female Genitals The external female reproductive structures are referred to collectively as the vulva (Figure 27. The labia majora (labia = “lips”; majora = “larger”) are folds of hair-covered skin that begin just posterior to the mons pubis. The thinner and more pigmented labia minora (labia = “lips”; minora = “smaller”) extend medial to the labia majora. Although they naturally vary in shape and size from woman to woman, the labia minora serve to protect the female urethra and the entrance to the female reproductive tract. The superior, anterior portions of the labia minora come together to encircle the clitoris (or glans clitoris), an organ that originates from the same cells as the glans penis and has abundant nerves that make it important in sexual sensation and orgasm. An intact hymen cannot be used as an indication of “virginity”; even at birth, this is only a partial membrane, as menstrual fluid and other secretions must be able to exit the body, regardless of penile–vaginal intercourse. The outer walls of the anterior and posterior vagina are formed into longitudinal columns, or ridges, and the superior portion of the vagina—called the fornix—meets the protruding uterine cervix. The walls of the vagina are lined with an outer, fibrous adventitia; a middle layer of smooth muscle; and an inner mucous membrane with transverse folds called rugae. Together, the middle and inner layers allow the expansion of the vagina to accommodate intercourse and childbirth. The hymen can be ruptured with strenuous physical exercise, penile–vaginal intercourse, and childbirth. The Bartholin’s glands and the lesser vestibular glands (located near the clitoris) secrete mucus, which keeps the vestibular area moist. The vagina is home to a normal population of microorganisms that help to protect against infection by pathogenic bacteria, yeast, or other organisms that can enter the vagina. This family of beneficial bacterial flora secretes lactic acid, and thus protects the vagina by maintaining an acidic pH (below 4. However, douching—or washing out the vagina with fluid—can disrupt the normal balance of healthy microorganisms, and actually increase a woman’s risk for infections and irritation. Indeed, the American College of Obstetricians and Gynecologists recommend that women do not douche, and that they allow the vagina to maintain its normal healthy population of protective microbial flora. The ovaries are located within the pelvic cavity, and are supported by the mesovarium, an extension of the peritoneum that connects the ovaries to the broad ligament. Extending from the mesovarium itself is the suspensory ligament that contains the ovarian blood and lymph vessels. The ovary comprises an outer covering of cuboidal epithelium called the ovarian surface epithelium that is superficial to a dense connective tissue covering called the tunica albuginea. The cortex is composed of a tissue framework called the ovarian stroma that forms the bulk of the adult ovary. Beneath the cortex lies the inner ovarian medulla, the site of blood vessels, lymph vessels, and the nerves of the ovary. You will learn more about the overall anatomy of the female reproductive system at the end of this section.