The collateral slips reunite and are inserted into the base of the distal phalanx Contd. Muscle Extensor digitorum brevis 265 Origin Insertion Action Nerve supply Anterior part of cal- 1. Helps extensor digito- Deep peroneal nerve caneus (on superior and dons (for first, second, rum longus in exten- (S1, 2) lateral aspect) third and fourth digits) sion of 2nd, 3rd, and 4th toes 2. Extension of proximal responding tendon of phalanx of great toe extensor digitorum longus 3. The tendon for the first digit is inserted into the dorsal surface of the base of the proximal phalanx of the great toe 1. Eversion of foot of base) Deep peroneal nerve (L5, S1) Peroneus tertius note on extensor Digitorum longus 1. In the middle two-fourths of the fibula, the area of origin of this muscle is lateral to that of the extensor hallucis longus. Over the proximal phalanx, the tendon for each digit is expanded into a triangular dorsal digital expansion, which receives the insertions of interosseous and lumbrical muscles (12. This muscle may be regarded as the lower separated part of the extensor digitorum longus. Around the ankle, the deep fascia forms a number of thickened bands that hold underlying tendons in place. On the lateral side there are (much less prominent) superior and inferior peroneal retinacula. The tendons passing under cover of the extensor retinacula are (from medial to lateral side in 12. The relationship of the inferior extensor retinaculum to the tendons is as follows: a. The stem is in the form of a loop through which the tendons of the extensor digitorum and peroneus tertius pass. The superior limb has two layers one passing superficial to the extensor hallucis and the tibialis anterior, and the other deep to them. The inferior limb is superficial to these tendons; it may sometimes have an additional layer deep to the tendons. As they pass under the retinacula, the extensor tendons are surrounded by synovial sheaths (12. There is a gap between the areas of origin of this muscle from the head of the fibula and from the shaft. The muscle ends in a tendon that passes along a groove behind the lateral malleolus; here it is covered by the superior peroneal retinaculum. It passes just below the peroneal trochlea, where the tendon is covered by the inferior peroneal retinaculum. Thereafter, the tendon winds round the lateral side of the cuboid bone to reach its plantar aspect (12. This aspect of the cuboid bone bears a groove for the tendon (which is converted into a canal by the long plantar ligament). The muscle helps to maintain the arches of the foot (both longitudinal and transverse). Medial cuneiform bone (lateral side) Superficial peroneal Shaft of fibula (lower 1. Steadies the leg on the nerve (L5, S1, S2) surface) ing anterior to that of foot peroneus longus) 2. Tendon gets inserted into fifth metatarsal bone (lateral side of base) Peroneus brevis (Fibularis brevis) Chapter 12 Front and Lateral Side of Leg and the Dorsum of Foot 269 12. Because of the fact that the posterior border of the fibula turns medially in its lower part, the area of origin of the peroneus brevis (on the lateral surface) extends onto the posterior aspect of the bone. At the ankle the tendon passes behind the lateral malleolus: here it lies anterior to the tendon of the peroneus longus. It then runs forwards on the lateral surface of the calcaneus; here it lies above the longus tendon, the two being separated by the peroneal trochlea. The superior peroneal retinaculum is attached above to the lateral malleolus and below to the lateral surface of the calcaneus. The inferior peroneal retinaculum is attached below to the lateral surface of the calcaneus. As the tendons of the peroneus longus and brevis run downwards and forwards on the lateral side of the ankle, they are held in place by the superior and inferior peroneal retinacula. They are enclosed in a synovial sheath that is common to the two tendons above, but bifurcates below (12. The synovial tendon sheaths around the tendons of the peroneus longus and peroneus brevis may be inflamed. Occasionally, these tendons can be dislocated from their position behind the lateral malleolus. The anterior tibial artery begins as a terminal branch of the popliteal artery near the lower border of the popliteus muscle (12. Almost immediately, the artery turns forwards through the upper part of the interosseous membrane to enter the anterior compartment of the leg. It gradually passes medially so that in the lower part of the leg it comes to lie in front of the tibia. It terminates in front of the ankle joint, midway between the medial and lateral malleoli, by becoming continuous with the dorsalis pedis artery. In the upper part of the leg, the artery lies deep in the interval between the tibialis anterior (medially) and the extensor digitorum longus (laterally). In the middle of the leg, it is related laterally to the extensor hallucis longus. The tendon of this muscle crosses the artery from lateral to medial side above the ankle. For a short distance above the ankle the artery is covered only by skin, superficial fascia and deep fascia including the retinacula. Here it lies between the tendons of the extensor hallucis longus (medially) and the extensor digitorum longus (laterally). The artery is accompanied by the deep peroneal (anterior tibial) nerve which lies lateral to the artery. The anterior tibial recurrent artery ascends to take part in the anastomoses around the knee. The posterior tibial recurrent artery arises from the uppermost part of the anterior tibial artery in the back of the leg. Numerous muscular branches (m) supply muscles of the anterior compartment of the leg. The anterior lateral malleolar artery arises near the ankle and runs to the lateral malleolus. The anterior medial malleolar artery arises near the ankle and runs to the medial malleolus. Beginning in front of the ankle it runs forwards, downwards and medially on the dorsum of the foot to reach the space between the first and second metatarsal bones (12. Here it turns downwards through the space (between the two heads of the first dorsal interosseous muscle) to enter the sole of the foot. Medial to the artery there is the tendon of the extensor digitorum longus, and the medial terminal branch of the deep peroneal nerve. The medial tarsal branch goes to the medial side of the foot and ankle (Also see 12. The dorsal metatarsal arteries are connected to the arteries of the sole by two sets of perforating arteries: proximal and distal. The distal perforating arteries connect them to the plantar metatarsal branches of the plantar arch. The dorsalis pedis artery lies in front of the ankle where it can be palpated and pressed upon to stop bleeding. Veins of the Front of the Leg Superficial veins over the dorsum of the foot and the front of the leg have been described in Chapter 10. The anterior tibial artery is accompanied by venae comitantes that end in the popliteal vein. The fibres of this nerve are derived from ventral rami of spinal nerves: L4 to S3. Separating from the common peroneal at the junction of the middle and lower-thirds of the thigh it descends through the popliteal fossa, and passes into the back of the leg. The relations and branches of the tibial nerve in the leg will be described in Chapter 13. In the upper part of the popliteal fossa the nerve lies lateral to the popliteal artery and vein. At the upper angle of the popliteal fossa the nerve is covered by the semimembranosus medially, and by the biceps femoris (laterally). At the lower end of the fossa the nerve is covered by the overlapping margins of the medial and lateral heads of the gastrocnemius. Muscular branches given off in the lower part of the popliteal fossa supply the two heads of the gastrocnemius, the plantaris, the soleus and the popliteus (12. After running down superficial (posterior) to this muscle the nerve turns round its lower border to reach its anterior surface that it enters. The upper part of the tibial nerve gives three branches to the knee joint: They accompany the superior medial genicular, the middle genicular, and the inferior medial genicular arteries. Starting at the bifurcation of the sciatic nerve, it runs downwards and laterally along the lower part of the biceps femoris muscle to reach the head of the fibula. It winds round the lateral side of the neck of the fibula: as it does so it lies deep to the peroneus longus. Apart from these terminal branches the common peroneal nerve gives off the following branches: a. The lateral cutaneous nerve of the calf supplies the skin over the upper two-thirds of the lateral side of the leg. The area of supply also extends onto the anterior and posterior aspects of the leg. It runs downwards and medially across the lateral head of the gastrocnemius muscle to join the sural nerve along with which it is distributed. The foot is plantar flexed (as the dorsi flexors are paralysed, but the plantar flexors are not). Because of paralysis of the peronei (which are evertors) the foot may be inverted. There is loss of sensation in the areas of skin supplied by the deep peroneal and superficial peroneal nerves. It begins on the lateral side of the neck of the fibula, deep to the peroneus longus. It passes downwards and medially, enters the anterior compartment of the leg and descends in front of the interosseous membrane, and lower down on the anterior aspect of the shaft of the tibia. Accompanied by the anterior tibial artery it reaches the front of the ankle joint. In the leg the nerve gives branches to muscles of the anterior compartment: these are the tibialis anterior, the extensor hallucis longus, the extensor digitorum longus, and the peroneus tertius. This branch runs forwards on the dorsum of the foot along with the dorsalis pedis artery. It divides into two dorsal digital nerves that supply the adjacent sides of the great toe and the second toe. The metatarsophalangeal joint of the great toe receives a branch from the medial terminal branch. Excessive (or unaccustomed) use of muscles of the anterior compartment can lead to oedema in the compartment and pressure on the deep peroneal nerve. This nerve can also be compressed as it passes under the inferior extensor retinaculum in persons wearing tight boots. It is the nerve to muscles of the lateral compartment of the leg: these are the peroneus longus and the peroneus brevis. Reaching the lower part of the leg the nerve becomes superficial and supplies the skin on its lateral side. The medial branch gives one dorsal digital nerve to the medial side of the great toe; and another to the adjacent sides of the second and third toes. The lateral branch gives one dorsal digital nerve to the contiguous sides of the third and fourth toes and another to the adjacent sides of the fourth and fifth toes. CliniCal Correlation Superficial Peroneal Nerve the nerve can be stretched in atheletes. Ingrowing Toe Nail In this condition, seen in the big toe, one end of the distal edge of the nail grows into soft tissue causing pain and setting up inflammation. The condition can be prevented by trimming the nail straight (not curved) and making sure that it does not grow into soft tissue. Paronychia this is infection of soft tissue in relation to a nail bed similar to that seen in the hand. The superficial veins drain into the deep veins at their terminations, and are also connected to them through a series of perforators. The atmospheric pressure within the thoracic cavity is negative and this tends to suck blood in the venous system towards the heart. When muscles contract they increase in thickness raising the pressure within the sleeve. This pressure compresses the deep veins and, because of the presence of valves, blood is pushed towards the heart. In this way muscular contraction acts as a pump that helps venous return from the lower limbs. Venous return through deep veins is also aided by pulsations of adjoining arteries. In some persons veins over the calf (or sometimes over other regions) become dilated and tortuous.

Additional information:

• Tranexamic acid
• Atenolol

The more rapidly the sine waves return to baseline, the more damped is the current. Damped current coagulates tissue, adding to hemostasis, but causes collateral tissue damage. Passage of current is restricted between these two tines, which results in substantially less tissue damage than in monopolar devices. Owing to direct tissue contact, charring depth may be slightly deeper in electrodesiccation than in electrofulguration Both electrodesiccation and electrofulguration cause superficial coagulation and have hemostatic effects. Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicilllin. Due to their bulk and high metabolic demand, composite grafts survive poorly if sized > 1. However, it may also be classified as a transposition design since it crosses over intervening island of normal skin to reach the defect. Recruits some adjacent tissue laxity laterally Lateral restraint Pivotal (movement is in an arc) Random pattern or Axial (paramedian forehead flap, lip-switch flap) 2-4:1 (flap:defect ratio may be greater with axial flap) Tension is reduced, redistributed, and redirected. In general, repairs within a subunit or incisions placed at junctions of subunits yield the best cosmetic results · Local flap: adjacent and contiguous · Regional flap: nearby but not directly adjacent · Advancement flap: a random-pattern flap where the primary flap movement is linear and provides the least mobility among the different flap types · Rotation flap: a random- or axial-pattern flap where the donor tissue pivots in a curved or arclike motion · Transposition flap: a subset of either a rotation or advancement flap where the donor tissue is nearby but not directly adjacent to defect. The flap, therefore, must move across and over an intervening segment of normal skin to close the defect · Interpolation flap: a subset of transposition flap that is usually indicated for larger defects and typically requires at least two separate stages of surgery (usually separated by 3 weeks between stages). The extent of scar lengthening depends on the degree of transposition of the Z-plasty Pedicle: the vascular supply to a flap (blood vessels are contiguous with the flap) Random-pattern flap: flap that is nourished by unnamed vessels from underlying arterial perforators. Random flaps rely on a rich vascular plexus of subcutaneous tissue that directly connects with the flap Axial-pattern flap: flap that has a named vessel for its pedicle · Paramedian forehead flap (supratrochlear artery). Able to cover large wounds, line cavities, resurface mucosal deficits, exposed bone, close donor sites of flaps, and resurface muscle flaps. Donor site is usually sutured or closed Provides scaffolding (cartilage) as well as soft tissue covering (skin). Most composite grafts over 1 cm do not survive completely Donor sites Selected based on matching qualities for thickness, texture, pigmentation, actinic damage, and morbidity of donor harvesting. Nesacaine Topical Infiltration Topical Infiltration Topical Infiltration Topical Rapid 8 Rapid 1 1 Rapid Rapid 2­10 min Slow Short Slow Short Short 0. Put the following items in order from least to most sensitive to cryogen exposure: 1. Melanocytes are more sensitive than keratinocytes, and with cold injury, dyspigmentation should be discussed as an adverse outcome when treating dark skinned individuals. This includes algae, bacteria, fungi, protozoa, viruses dormant endospores and poorly characterised agents such as viroids and the agents that are associated with spongiform encephalopathies B. Refers to the removal of some microbes from an environment that may cause disease C. Amide anesthetics are N-dealkylated and hydrolyzed by microsomal liver enzymes cytochrome P450 3A4. Ester anesthetics are hydrolyzed by tissue pseudocholinesterases and excreted by kidney. Suture reactivity is another characteristic defined as the amount of inflammatory response that is elicited, which is dependent on the material from which it is made. In contrast, natural sutures are made from natural materials such as collagen derived from the gastrointestinal track of animals, woven cotton, raw silk, linen, or steel. Of the answer choices listed, polypropylene and silk are non-absorbable suture made from synthetic and natural materials, respectively. Suture characteristics include: tensile strength, knot strength, configuration, elasticity, memory or suture stiffness, plasticity, and pliability. Synthetic sutures are made from synthetic collagen derived from polymers and are broken down by hydrolysis as opposed to enzymatic degradation in natural sutures, causing less tissue reaction. Of the answer choices listed, polyglactin 910 and gut suture are absorbable suture made from synthetic and natural materials, respectively. Fibroblasts and other stromal structures are less sensitive to cold, which may contribute to the lack of scarring after superficial cold injury and/or cryosurgery. Macrophages are the most important cells for wound healing, releasing numerous growth factors and cytokines. Neutropenic or lymphopenic patients do not have impaired wound healing, whereas macrophage-deficient (quantity or function) patients heal poorly 1, A; 2, B; 3, C. Techniques used to destroy all infectious agents from an environment is called sterilization. In contrast, disinfection and antisepsis are terms that should be used to reduce microbe burden, with disinfection utilizing harsher agents that, in general, would not be used on human tissue. Although the risk of wound infection after skin surgery is small (1­2%), routine prophylactic antibiotics are usually indicated for: 1) certain patient populations: immunosuppressed, debilitated patients, and those with reduced blood flow to the surgical site. Prophylactic antiobiotic regimen depends on the endogenous flora of the operative site, as well as, patient specific issues. The Z-plasty is a form of transposition flap that is often used for scar revision for scar length and changing scar orientation. It alters the change (redirection) of tension vectors of the original wound/scar, in addition to lengthening and breaking up of a scar into multiple zigzag lines. The extent of scar lengthening depends on the degree of transposition of the Z-plasty. Prilocaine is metabolized to ortho-toluidine, an oxiding agent capable of converting hemoglobin to methemoglobin, potentially causing methemoglogbinemia. A skin graft is any skin that is detached completely from its blood supply, removed from its donor site, and transplanted to a recipient site for wound closure in the same individual. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcome Research Interdisciplinary Working Group. Active medium determines the emission wavelength, which is restricted to a very narrow band ­ Coherency: monochromatic light in phase. Note that the initial wavelength of the emitted laser beam is determined by the lasing medium, although this can be altered. Laser energy is delivered to the target via an articulated arm or fiberoptic cable. Wait at least 6 months) Abrasive wire or diamond wheel Rotational speeds of 12,000 to 15,000 rpm High-speed rotary motors are used to drive an abrading end piece Indications Superficial skin conditions Early photoaging, fine lines, and superficial scarring Effective microdermabrasion usually requires a series of 5­12 treatments Instruments Components common to all systems Pump: generates a high-pressure stream of aluminum oxide or salt crystals Connecting tube and handpiece: delivers the crystals to the skin Vacuum: removes the crystals and exfoliated skin Crystals are discarded after use Eye protection from stray crystals Active herpes infection Malignant skin tumors Evolving dermatoses Certain keratoses Contraindications History of hypertrophic scarring Isotretinoin within 6 to 12 months Active herpetic infection Malignant skin tumors Evolving dermatoses Certain keratoses Milia formation and a flare-up of acne Transient postoperative hyperpigmentation Postoperative viral infections Hypertrophic scarring Complications Rare; only mild postinflammatory hyperpigmentation Ocular complications (ie. Currently available in United states · Available in Europe under the name Neurobloc · · Packaging Comes in a vial containing 100 units Must be stored frozen and then refrigerated when reconstituted · Comes in a vial containing 500 units Can be stored at room temperature Available in vials containing 2500, 5000, and 10,000 units Storage · · Does not require constitution and is ready to use at pH 5. History of a neuromuscular disease (EatonLambert syndrome, amyotrophic lateral sclerosis, or myasthenia gravis) B. From shortest to longest wavelength: gamma rays, x-ray, ultraviolet, visible, infrared, microwave, radio wave. Other laser characteristics include: wavelength (nanometer), spot size (millimeter), pulse duration (seconds), fluence (joules/cm2), power (joules/ second). Uniform white frost with pink showing through correlates with what depth of injury after a trichloroacetic acid peel Depth of peel can be correlated with the intensity of the frost: no frost (stratum corneum), irregular light frost (superficial epidermis), and uniform white frost with pink showing through (full thickness epidermis). They are present in the presynaptic element, bind to post-synaptic receptors, and must be in sufficient quantity to affect the post-synaptic cell. Botulinum toxin blocks neurotransmitter release at peripheral cholinergic nerve terminals. Epinephrine, dopamine, norepinephrine, gamma aminobutyric acid, melatonin, serotonin and glutamic acid are other neurotransmitters. Seven botulinum toxin serotypes (A­G) bind to different sites on the motor nerve terminal and within the motor neuron. Cleavage of these proteins prevents exocytosis of acetylcholine into the synapse between the motor neuron and the skeletal muscle cell. Contraindications for use of Botox include: history of a neuromuscular disease (Eaton-Lambert syndrome, amyotrophic lateral sclerosis, or myasthenia gravis); known history of sensitivity to Botox or human albumin; aminoglycoside use which can interfere with neuromuscular transmission; pregnancy; lactation; and age younger than 12 years of age. Fillers are derived from various sources and should be avoided if patients are allergic to components within each filler. For instance, Zyderm and Zyplast are derived from bovine dermal collagen, Restylane is derived from non-animal hyaluronic acid gel, Evolence from porcine collagen, and Hylaform from rooster combs. Complications include ulceration and involvement of underlying bone structures ­ Papules/plaques/nodules ­ Head and neck more common for papules ­ Legs: plaques; angiolupoid sarcoid (plaques with telangectasias); marker for pulmonary fibrosis ­ Subcutaneous nodules (Darier-Roussy): firm, painless subcutaneous nodules that represent sarcoidosis; this subset is higly associated with systemic disease ­ Scar sarcoidosis. A sunburn results in local immunosuppression allowing activation of herpes simplex eruption. In Th2 polarized and mixed Th1/Th2 responses, infection and progression of disease can occur. A vesicular eruption on the lips following a sunburn is most likely caused by production of which cytokine Low natural protection from developing skin ulcers following infection with Leishmania brazilliensis are seen in patients with elevated production of what cytokine Pick the correct pairing of enzyme and end-product involved in arachidonic acid metabolism A. In inflammatory responses, arachidonic acid can be metabolized by many enzymes including cyclooxygenase (involved in production of prostaglandins, prostacyclin, and thromboxane) and lipooxygenase (generates leukotrienes). Several naturally occurring and experimental populations of regulatory T cells have been recently identified. Recognition of antigen resulting in clonal expansion of lymphocytes is a feature of adaptive immunity. C3a and C5a are anaphylatoxins that can trigger rapid reactions and induction of local inflammatory responses. Functions of C5a include triggering mast cell release of histamines, activation of neutrophils and macrophages, and as a chemoattractant for leukocytes. Assmann T, Ruzicka T: New immunosuppressive drugs in dermatology (mycophenolate mofetil, tacrolimus): unapproved uses, dosages, or indications. Craze M, Young M: Integrating biologic therapies in to a dermatology practice: practical and economic considerations. Cytokine milieu of atopic dermatitis, as compared to Psoriasis, skin prevents induction of innate immune response genes. Sakaguchi S, Yamaguchi T, Nomura T, Ono M: Regulatory T cells and immune tolerance. Translation of pre-pro chains on the ribosomes of the rough endoplasmic reticulum 2. The biochemical abnormalities have been demonstrated in only a limited number of patients in each group, and it is not known whether the biochemical changes are the same in each patient with given disease. Which is the only protein known to be present in both desmosomes and adherens junctions: A. At the 8th week of fetal development melanocytes develop from the neural crest cells. It is not until the 12th week that melanocytes begin synthesis of melanin beginning in the head region. Matrix metalloproteinases can be upregulated during normal development and physiologic tissue repair. It takes 13­14 days for maturation of keratinocytes from the basal layer to the corneum and another 13­14 days for shedding. Fibulins are calcium-binding extracellular matrix proteins that do not form large aggregates but are capable of joining other supramolecular structures. Fibulin-2 is capable of binding fibrinogen, fibronectin, nidogen, proteoglycans, aggrecan, and versican. It is cross-linked by transglutaminase-3 to form homodimers and heterodimers with other proteins to increase solubilization. These structures are found at the vermillion border of the lips, glans penis, and clitoris. In adherens junctions, the N-terminus of desmoplakin can bind plakoglobin and plakophilin and in desmosomes, it can bind plakoglobin, plakophilin, and desmocollin. Fuchs E, Weber K: Intermediate filaments: structure, dynamics, function, and disease. However, we often want to represent outcomes as numbers · A random variable is a function that associates a unique numerical value with every outcome of a study. The value of the random variable will vary over time or vary from individual to individual · There are two types of random variable-discrete and continuous · A random variable has either an associated probability distribution (discrete random variable) or probability density function (continuous random variable) the probability that a measurement will fall within 1. In general, we fix the · Odds · Ratio of the probability of an event occurring (p) to the probability of the event not occurring (1­p) · Odds=p /(1­p) · Odds ratio · the ratio of the odds of an event occurring in one group to the odds of it occurring in another group · these groups might be control and treated, or any other two groups classification · If the probabilities of the event in each of the groups are p1 (first group) and p2 (second group), then the odds ratio is: Confidence Interval. The goal of a study is to have the power as close to 1 as possible · the power of a study depends on: alpha, beta, effect size (small effect size decreases the power), and sample size (a small sample size, decreases the power of a study). Could the observed effect be produced in other settings, beyond the studied populations and at other times The following characteristics of studies can decrease bias: randomization (minimizes selection bias), blinding, matching. Used for measuring frequency or magnitude of parameters, but can also be used to measure associations between variables. They can be repeated at time intervals and then combined to predict trends · Experimental study: investigator intervenes in some way to effect the outcome, tests causal hypotheses where treatment can be given to patients. The types include: simple experiment, Table 29-4 Different Types of Study Designs Usual Purpose of Study Type of Study Design Sampling Procedure/Type of Survey Descriptive Hypothesis generating Hypothesis testing Survey study Observational study Experimental or observational studies One that uses the sample population Case control, cohort or cross sectional Clinical trials, case control, cohort, or cross sectional 578 repeated-measure, repeated measure with crossover, and factorial design) Data Collection: · Retrospective study: the events of interest transpired before the onset of the study, · May also be called "case-control" studies in which profiles of subjects in a particular "case" group. Each phase can be viewed as an individual clinical trial · the process of drug-development typically proceeds through all four phases, which could take several years in the groups to which they were originally randomly assigned; clinical effectiveness may be overestimated if an intention to treat analysis is not done · Repeated measure study (prospective, experimental) · Used when significant baseline variation is expected. The outcome event is measured several times during the trial · Factorial design study (prospective, experimental) · Evaluation of two interventions compared to a control in a single trial. Main disadvantage is the possibility of interaction and the diminution of the power of the trial. Calculate the sensitivity and specificity of the test using the information below. A trial has been performed in a clinic population similar to the one that you treat and produced the following results. Population Fungal Infection No Fungal Infection Test Results Total Positive Negative Total 200 20 220 10 770 780 210 790 1,000 582 3. When the data are distributed normally, the mean and median are very close and may be identical C. A study which is done in a very specific population that is not generalizable to the population that you treat, would be said have low: A. The results of a randomized controlled trial using a therapy to treat a severe skin malignancy showed a mortality rate of 18% in the untreated group and 5% in the treated group. When looking at the possible outcomes of a randomized controlled trial that compare two treatments, you generate a table based on your conclusions about treatment and what is the true outcome.

Bannal (Scotch Broom). Imdur.

• Are there any interactions with medications?
• How does Scotch Broom work?
• Fluid retention, sore muscles, swelling, low blood pressure, menstrual disorders, heavy bleeding after giving birth, bleeding gums, gout, arthritis-like pain, nerve disorders, gallbladder and kidney stones, spleen disorders, heart disorders, and other conditions.
• Are there safety concerns?
• Dosing considerations for Scotch Broom.

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Near the anterior end of the notch, and just behind the styloid process we see the stylomastoid foramen. Additional Features on the Occipital Bone the greater part of the occipital bone is seen when the skull is viewed from below. The most conspicuous feature on it is the large foramen magnum through which the cranial cavity communicates with the vertebral canal. Anteriorly, the basilar part of the occipital bone is directly continuous with the body of the sphenoid bone. These two bones are separated by a plate of cartilage in the young, but fuse with each other in the adult. The parts of the occipital bone lateral to each side of the foramen magnum are its lateral (or condylar) parts. Each condyle (right or left) articulates with the corresponding superior articular facet on the atlas vertebra to form an atlanto-occipital joint. The hypoglossal (or anterior condylar) canal opens on the surface of the skull just above the lateral border of the anterior part of the condyle, and is hidden from view by the condyle. Behind the condyle there is a depression, the condylar fossa in which the opening of the posterior condylar canal is sometimes seen. The part of the occipital bone lateral to the condyle is called the jugular process. Posteriorly, the squamous part forms the posterior part of the vault of the skull. When the top of the skull (skull cap) is removed by a transverse cut we can view the floor of the cranial cavity. It is seen to be divided into three depressions called the cranial fossae, anterior, middle, and posterior. Anteriorly, the right and left halves of the frontal bone are separated by a median projection called the frontal crest. Between the right and left orbital plates of the frontal bone there is a notch occupied by the cribriform plate of the ethmoid bone. It also bears a median vertical projection called the crista galli that lies immediately behind the foramen caecum. The posterior part of the floor of the anterior cranial fossa is formed by the sphenoid bone. In the median part it is formed by the anterior part of the superior surface of the body of the sphenoid. The lesser wing also forms the sharp posterior edge of the floor of the anterior cranial fossa. The medial edge of each lesser wing projects backwards as the anterior clinoid process. The features to be seen in relation to the body of the sphenoid are as follows: a. Immediately behind the jugum sphenoidale the body of the sphenoid is crossed by a transverse shallow groove that connects the two optic canals. It is called the sulcus chiasmaticus (even though the optic chiasma does not lie over the sulcus). Behind the sulcus the superior surface of the body of the sphenoid shows a median elevation, the tuberculum sellae; and behind the tuberculum there is a depression called the hypophyseal fossa. Posterior to the hypophyseal fossa there is a vertical plate of bone called the dorsum sellae. The deep hollow bounded anteriorly by the tuberculum sellae, and posteriorly by the dorsum sellae is called the sella turcica. The superolateral angles of the dorsum sellae are called the posterior clinoid processes. On each side the body of the sphenoid slopes downwards into the floor of the deep lateral part of the middle cranial fossa. In this situation each side of the body of the sphenoid is marked by a shallow carotid groove. Anteriorly, the carotid groove turns upwards medial to the anterior clinoid process. On either side, the anterior wall of the middle cranial fossa is formed by the greater and lesser wings of the sphenoid. The lesser wings are attached to the sides of the body of the sphenoid by two roots; anterior (or upper), and posterior (or lower). The optic canal passes forwards and laterally between the body of the sphenoid and the two roots of the lesser wing. The greater and lesser wings are separated by the superior orbital fissure that leads into the orbit. Just below the medial end of this fissure, and just lateral to the carotid groove we see the foramen rotundum. The posterior wall of the middle cranial fossa is formed, on either side, by the anterior sloping surface of the petrous temporal bone. The apex of the bone is separated from the body of the sphenoid by the foramen lacerum already seen from below. A little above and lateral to the foramen the surface of the petrous temporal bone shows a shallow depression called the trigeminal impression. The anterior surface of the petrous temporal bone is formed by a thin plate of bone that separates the middle cranial fossa from the cavities of the middle ear, the auditory tube and the mastoid antrum. The floor of the deep lateral part of the middle cranial fossa is formed by the greater wing of the sphenoid, medially, and by the squamous part of the temporal bone, laterally. Near the posterior margin of the greater wing we see the foramen ovale, and the foramen spinosum that have already been seen from below. The lateral wall of the middle cranial fossa is formed, anteriorly, by the greater wing of the sphenoid, and posteriorly by the squamous temporal bone. Anterior to the foramen magnum the wall of the fossa is formed by the basilar part of the occipital bone that is continuous above with the posterior surface of the body of the sphenoid. The lateral margin of the basilar part of the occipital bone is separated from the petrous temporal bone by a fissure that ends below in the jugular foramen. Between the jugular foramen, laterally, and the anterior part of the foramen magnum, medially, there is a rounded elevation called the jugular tubercle. In the interval between the jugular tubercle and the foramen magnum there is a fossa. When present, the posterior condylar canal opens just lateral to the jugular tubercle immediately behind the jugular foramen. The lateral part of the anterior wall of the posterior cranial fossa is formed by the posterior surface of the petrous temporal bone. A little above the jugular foramen this surface presents the opening of the internal acoustic meatus. The floor and lateral walls of the posterior cranial fossa are formed, posteriorly, by the squamous part of the occipital bone; and in the anterolateral part by the mastoid part of the temporal bone. Behind the foramen magnum the two halves of the fossa are separated by a ridge called the internal occipital crest. Posteriorly, the crest ends in an elevation called the internal occipital protuberance. Running laterally from the protuberance, in the transverse plane, we see a prominent wide groove (transverse sulcus) in which the transverse sinus is lodged. The groove first lies on the occipital bone, and near its lateral (or anterior) end it crosses the posteroinferior angle of the parietal bone. It then runs downwards and medially with an S-shaped curve to reach the jugular foramen. The terminal part of the groove lies on the occipital bone just behind the jugular foramen. Foramina of the Skull the bones of the skull show numerous foramina, small and large. The most important foramina are those that give passage to very important structures like cranial nerves, large blood vessels, etc. The lower end of the medulla oblongata passes through the foramen magnum to become continuous with the spinal cord. Other important structures passing through the foramen magnum are the vertebral arteries and the spinal part of the accessory nerve. The internal carotid artery enters the skull by passing through the carotid canal. The junction of the upper end of the internal jugular vein with the sigmoid sinus lies in the jugular foramen. Bundles of nerve fibres that constitute the olfactory nerve pass through minute apertures in the cribriform plate of the ethmoid bone. The optic nerve passes from the middle cranial fossa into the orbit through the optic canal. The oculomotor, trochlear and abducent nerves enter the orbit through the superior orbital fissure. The trigeminal nerve has three divisions each of which leaves the middle cranial fossa through a different foramen. The mandibular division passes through the foramen ovale to reach the infratemporal region. The facial nerve leaves the posterior cranial fossa by passing into the internal acoustic meatus. After a complicated course through the petrous part of the temporal bone, it emerges on the external surface of the skull through the stylomastoid foramen. The vestibulocochlear nerve leaves the posterior cranial fossa by passing through the internal acoustic meatus, to reach the internal ear. The internal ear lies within the substance of the petrous part of the temporal bone. The glossopharyngeal, vagus and accessory nerves leave the posterior cranial fossa through the jugular foramen, to enter the neck. The hypoglossal nerve leaves the posterior cranial fossa through the hypoglossal canal. The nasal cavity consists of right and left halves that are separated by a nasal septum (36. The cavity opens, anteriorly, on the front of the skull through the anterior nasal aperture; and, posteriorly, on the base of the skull just above the posterior edge of the bony palate, through the right and left posterior nasal apertures. Each half of the cavity has a lateral wall, a medial wall formed by the nasal septum, a floor formed by the upper surface of the palate, and a roof. Each half of the palate is formed anteriorly by the palatine process of the maxilla, and posteriorly by the horizontal plate of the palatine bone. Around the edges of the septum there are small contributions to the septum from the nasal, frontal, sphenoid, maxillary and palatine bones. The openings into the nasal cavity are described along with those of the paranasal sinuses (see below). The paranasal sinuses are spaces present in bones around the nasal cavity, and into which they open (36. The frontal sinus extends for some distance into the orbital plate of the frontal bone between the roof of the orbit and the floor of the anterior cranial fossa. Each frontal sinus usually opens into the middle meatus through a funnel-like space, the ethmoidal infundibulum (36. Each sinus opens into the corresponding half of the nasal cavity through an aperture on the anterior aspect of the body of the sphenoid. The part of the nasal cavity into which the sinus opens lies above the superior nasal concha and is called sphenoethmoidal recess (36. The ethmoidal air sinuses are located within the lateral part (or labyrinth) of the ethmoid bone. Each labyrinth (right or left) is bounded medially by the medial plate of the ethmoid, and laterally by the orbital plate. The anterior ethmoidal sinuses open into the ethmoidal infundibulum, or into the upper part of the hiatus semilunaris. The posterior ethmoidal sinuses open into the superior meatus of the nasal cavity. Other Apertures in the Nasal Cavity In addition to the anterior and posterior nasal apertures, and the openings of the paranasal sinuses, we see the following openings in the nasal cavity. The sphenopalatine foramen opens behind the superior meatus, just above the posterior end of the middle concha (36. The nasal cavity communicates with the anterior cranial fossa through numerous apertures in the cribriform plate of the ethmoid bone. In the anterior part of the floor of the nasal cavity there is a funnel-shaped opening that leads into the incisive canals that open on the lower surface of the palate. In the skull of the newborn, there are some gaps in the vault of the skull that are filled by membrane. The anterior fontanelle lies at the junction of the sagittal, coronal and frontal sutures. The sphenoidal (anterolateral) fontanelle is present in relation to the anteroinferior angle of the parietal bone, where it meets the greater wing of the sphenoid. The mastoid fontanelle (posterolateral) is present in relation to the posteroinferior angle of the parietal bone (that meets the mastoid bone). The fontanelles disappear (by growth of the bones around them) at different ages after birth. Two rami (right and left) that project upwards from the posterior part of the body.

Usage: q.d.

In the female the corresponding fibres pass across the sides of the vagina to end in the perineal body. The intermediate fibres pass across the sides of the rectum and become continuous with those of the opposite side behind the anorectal junction. They merge with the internal and external sphincters of the anal canal to form the anorectal ring. The most posterior fibres are attached to the coccyx, and to a fibrous band called the anococcygeal ligament. The origin of the muscle from the pelvic aspect of the lower part of the hip-bone is shown in 32. The levator ani is related above to the urinary bladder, prostate or vagina, and rectum. The levator ani and the coccygeus form a transverse partition across the pelvis which is called the pelvic diaphragm. This diaphragm separates the pelvic viscera (above) from structures in the perineum (32. The coccygeus can pull the coccyx forwards after it has been pushed back during defecation or parturition. It separates the internal iliac vessels and their branches from the muscle; but the sacral nerves lie between the muscle and the fascia. The pelvic diaphragm is covered by one layer of fascia above it, and another below it. Laterally the superior layer merges with the obturator fascia and reinforces its upper part. Each internal iliac artery (right or left) begins as a terminal branch of the common iliac artery, in front of the sacroiliac joint (31. Branches of Internal Iliac Artery the branches arising from the anterior trunk of the internal iliac artery are as follows: 1. The stem of the artery represents the proximal part of the umbilical artery of the fetus. That is why it is continuous with the medial umbilical ligament that represents the distal obliterated part of the umbilical artery. The inferior vesical artery (present only in the male) runs forwards and medially to supply the urinary bladder, the prostate, the seminal vesicle and the lower end of the ureter (32. In the female the inferior vesical artery is replaced by the vaginal artery that supplies the vagina, the urinary bladder and part of the rectum. The uterine artery (present in the female only) runs medially on the pelvic floor (formed by the levator ani) to reach the lateral side of the upper end of the vagina (lateral vaginal fornix) (32. Leaving the pelvic wall it runs along the side of the uterus, within the two layers of the broad ligament to reach the junction of the uterus with the uterine tube. Finally it turns laterally (still within the broad ligament) to reach the hilum of the ovary. Apart from branches to the uterus, the uterine tube, and to the ovary, it gives some branches to the vagina (32. The obturator artery runs forwards and downwards on the lateral pelvic wall (formed here by obturator fascia covering the obturator internus). It is accompanied by the obturator nerve (which lies above it) and the obturator vein (below it). Note in particular the pubic branch that runs over the pubis and anastomoses with the pubic branch of the inferior epigastric artery. Sometimes the anastomosis is large and then the obturator artery appears to be a branch of the inferior epigastric artery. The importance of an abnormal obturator artery lies in the fact that it is closely related to (the neck of the sac of) a femoral hernia. In cases of strangulation of the hernia the surgeon may cut the lacunar ligament to enlarge the femoral canal. Usually the abnormal obturator artery passes lateral to the femoral canal, in contact with the femoral vein and is safe in such an operation. Such an artery is likely to be cut if an attempt is made to enlarge the femoral ring. Starting within the pelvic cavity the artery passes out of it through the greater sciatic foramen to enter the gluteal region. After a short course in this region the artery passes through the lesser sciatic foramen to reach the lateral wall of the ischiorectal fossa. The inferior gluteal artery begins within the pelvis where it lies anterior to the piriformis. It passes through the greater sciatic foramen, below the piriformis, to enter the gluteal region. The branches arising from the posterior trunk of the internal iliac artery are as follows: 1. The superior gluteal artery is the main continuation of the posterior trunk of the internal iliac artery. It leaves the pelvic cavity by passing through the greater sciatic foramen, above the piriformis muscle. The lateral sacral arteries, superior and inferior, pass medially and divide into branches that pass through the anterior sacral foramina to supply the sacrum and related structures. The iliolumbar artery arises from the posterior trunk of the internal iliac artery (32. Here it divides into a lumbar branch that supplies the psoas major and an iliac branch that supplies the iliacus and can be seen on its surface. Each internal iliac vein is formed by the confluence of several veins that accompany the branches of the internal iliac artery (with the exception of the iliolumbar veins which end in the common iliac veins). The pelvic organs are drained through a number of venous plexuses that ultimately drain into the internal iliac vein. These plexuses surround the urinary bladder (vesical plexus), the prostate, the uterus, the vagina and the rectum. This vein is placed on the dorsum of the penis, in the middle line, deep to the deep fascia, in between the right and left dorsal arteries. The prostatic plexus communicates with the vesical plexus and drains into the internal iliac vein through the veins from the urinary bladder. The internal plexus lies in the submucosa, whereas the external plexus lies outside the muscular coat (In other words the two plexuses are separated by the muscle coat). The superior rectal vein is a tributary of the portal venous system, while the middle and inferior rectal veins are part of the systemic circulation. The portal and systemic circulations, therefore, communicate through the rectal venous plexuses. The internal rectal plexus has a series of dilatations that are placed immediately above the anal orifice. These veins are present in relation to the entire length of the vertebral column but it is convenient to consider them here. The plexus is divisible into an external part on the outer surface of the vertebra; and an internal part lining the vertebral canal. A basivertebral vein from each vertebral body drains into the anterior internal plexus. Apart from veins draining blood from the vertebrae, the plexus receives veins from the meninges and from the spinal cord. It emerges from the surface of the psoas major muscle and runs downwards over its anterior surface. It runs forwards over the lateral wall of the true pelvis just above the obturator artery and leaves the pelvis through the obturator canal to reach the thigh. It descends into the true pelvis by passing over the ala of the sacrum to join the sacral plexus. The main continuation of the sacral plexus is the sciatic nerve that passes out of the pelvis (into the gluteal region) through the greater sciatic foramen. The sciatic nerve and some other branches of the sacral plexus are described in Chapter 11. Along with the internal pudendal artery the nerve passes through the greater sciatic foramen to enter the gluteal region. After a short course in this region the nerve passes through the lesser sciatic foramen to reach the lateral wall of the ischiorectal fossa. The lower sacral rami (S4, S5) join the coccygeal nerve to form the coccygeal plexus that lies over the pelvic surface of the coccygeus muscle. These nerves pass through the sacrotuberous ligament to reach the skin overlying the coccyx. In front of the coccyx the right and left sympathetic trunks both end a median ganglion, the ganglion impar. Branches arising from the pelvic part of the sympathetic trunk are distributed mainly to blood vessels of the lower limbs. Preganglionic neurons that constitute the sacral parasympathetic outflow are located in segments S2, S3 and S4 of the spinal cord. Some fibres pass through hypogastric plexuses to reach parts of the gut derived from the hindgut (left one-third of transverse colon, descending colon, pelvic colon). Lymph from some organs reaches the external iliac nodes and through them to common iliac nodes. Lymph from the testis (or ovary), part of uterine tube and part of uterus reaches the lateral aortic nodes directly. Some structures in the perineum drain into superficial or deep inguinal lymph nodes. CliniCal Correlation As the pelvic wall is closely related to pelvic viscera any pathological condition affecting the viscera can have effects on the pelvic wall. The viscera to be seen in the true pelvis belong to the gastrointestinal, urinary and reproductive systems. The viscera belonging to the alimentary system are the sigmoid colon, the rectum and anal canal. The viscera belonging to the urinary system are the pelvic parts of the ureters, the urinary bladder and the urethra (male or female). The main reproductive organs to be seen in the male pelvis are the pelvic part of the right and left ductus deferens, the seminal vesicles, and the prostate gland. Reproductive organs present in the female pelvis are the uterus, the right and left uterine tubes, and the vagina. The greater part of the gastrointestinal tract has been described in chapter 27 in which the sigmoid colon has also been described. The lower end of the rectum lies a little below and in front of the tip of the coccyx. The lower part of the rectum which is wider than the upper part, is called the ampula. The rectum has an anteroposterior curve corresponding to that of the sacrum and coccyx. In addition to its downward direction the upper part of the rectum is directed backwards, and the lower part is directed forwards. Peritoneal Relations the upper one-third of the rectum is covered by peritoneum in front and also on the sides (33. In the male, the peritoneum passes from the front of the rectum to the urinary bladder forming the rectovesical pouch (33. In the female the rectum is related anteriorly to the vagina and the lower part of the uterus (33. In both sexes the upper part of the rectum may be related anteriorly to the sigmoid colon and/or coils of ileum (33. These parts of the intestine may also form lateral relations of the upper part of the rectum. Lower down the lateral walls of the rectum are embraced by the right and left coccygei and the right and left levator ani muscles (33. Supports of the Rectum the rectum is held in place by thickenings of fascia or ligaments. The fascia of Waldeyer connects the posterior aspect of the anorectal junction to the lower part of the sacrum. The lateral rectal ligaments connect the lateral aspect of the rectum to the posterolateral part of the wall of the pelvis (33. Considerable information about the structures surrounding the rectum and anal canal can be obtained, in the living, by palpation with a finger inserted through the anus. The structures that can be felt through the anterior wall of the rectum and anal canal in the male are (from below upwards): a. In the female the main structures in front of the anal canal are the vagina and uterus, but as these are directly accessible for examination (through the vagina) a rectal examination is needed for them only when for some reason a vaginal examination is not desirable. Posteriorly, in both the male and female, the coccyx and the lower part of the sacrum can be felt; and laterally, the ischial spine and ischial tuberosity can be palpated. In addition, an experienced surgeon can recognise abnormalities in surrounding viscera (ovary, uterine tube, ureters, a pelvic appendix) such as inflammation or enlargement. Enlarged internal iliac lymph nodes, abnormalities in the rectovesical or rectouterine pouches, or in the ischiorectal fossae can also be detected. However, it may not be possible to see the upper part of the rectum with a proctoscope. In passing a sigmoidoscope into the rectum the curvatures of the rectum and the presence of transverse folds within it has to be remembered. Spread of a rectal carcinoma is usually slow but it can ultimately invade surrounding structures including a. While the lower part of the rectum is directed downwards and forwards, the anal canal is directed downwards and backwards. The anorectal junction lies at the level of the pelvic diaphragm (formed here by the levator ani muscles). The rectum lies above the pelvic diaphragm in the true pelvis, whereas the anal canal lies below the diaphragm in the perineum.