By I. Orknarok. Utica College.

The gallstone may then impact in the lower ileum as it traverses the gut to produce intestinal obstruction (gall- stone ileus) order 100mg viagra mastercard. Erosion of the gastro- duodenal artery by such an ulcer results in severe haemorrhage 25mg viagra for sale. Simi- larly, the right kidney lies directly behind this part of the duodenum, which may be injured in performing a right nephrectomy. Within a few minutes of swallowing a barium meal, the first part of the duodenum becomes visible as a triangular shadow termed theduodenal cap. Every few seconds the duodenum contracts, empty- ing this cap, which promptly proceeds to fill again. It is in this region that the great majority of duodenal ulcers occur; an actual ulcer crater may be visual- ized, filled with barium, or deformity of the cap, produced by scar tissue, may be evident. The rest of the duodenum can also be seen, the shadow being floccular due to the rugose arrangement of the mucosa. Small intestine The length of the small intestine varies from 10 to 33 feet (3–10m) in 78 The abdomen and pelvis different subjects; the average is some 24 feet (6. Resection of up to one- third or even half of the small intestine is compatible with a perfectly normal life, and survival has been reported with only 18in (45cm) of small intestine preserved. The mesentery of the small intestine has a 6in (15cm) origin from the posterior abdominal wall, which commences at the duodenojejunal junc- tion to the left of the 2nd lumbar vertebra, and passes obliquely down- wards to the right sacro-iliac joint; it contains the superior mesenteric vessels, the lymph nodes draining the small gut and autonomic nerve fibres. The upper half of the small intestine is termed the jejunum, the remain- der is the ileum. There is no sharp distinction between the two and this division is a conventional one only. The bowel does, however, change its character from above downwards, the following points enabling the surgeon to determine the level of a loop of small intestine at operation. The ileum is supplied by shorter and more numerous terminal vessels arising from complete series of three, four or even five arcades (Fig. Large intestine The large intestine is subdivided, for descriptive purposes, into: •caecum with the appendix vermiformis; •ascending colon (5–8in (12–20cm)); •hepatic flexure; •transverse colon (18in (45cm)); Fig. The gastrointestinal tract 79 •splenic flexure; •descending colon (9–12in (22–30cm)); •sigmoid colon (5–30in (12–75cm), average 15in (37cm)); •rectum (5in (12cm)); •anal canal (1. The large bowel may vary considerably in length in different subjects; the average is approximately 5 feet (1. The colon (but not the appendix, caecum or rectum), bears characteris- tic fat-filled peritoneal tags called appendices epiploicae scattered over its surface. The colon and caecum (but not the appendix or rectum) are marked by the taeniae coli. These are three flattened bands commencing at the base of the appendix and running the length of the large intestine to end at the rec- tosigmoid junction. They represent the great bulk of the longitudinal muscle of the large bowel; because the taeniae are about a foot shorter than the gut to which they are attached, the colon becomes condensed into its typical sacculated shape. These sacculations may be seen in a plain radi- ograph of the abdomen when the large bowel is distended and appear as incomplete septa projecting into the gas shadow. The radiograph of dis- tended small intestine, in contrast, characteristically has complete trans- verse lines across the bowel shadow due to the transverse mucosal folds of the valvulae conniventes. Peritoneal attachments The transverse colon and sigmoid are completely peritonealized (the former being readily identified by its attachment to the greater omentum). The ascending and descending colon have no mesocolon but adhere directly to the posterior abdominal wall (although exceptionally the ascending colon has a mesocolon). The caecum may or may not be com- pletely peritonealized, and the appendix, although usually free within its own mesentery, occasionally lies extraperitoneally behind caecum and ascending colon or adheres to the posterior wall of these structures. The rectum is extraperitoneal on its posterior aspect in its upper third, posteriorly and laterally in its middle third and completely in its lower third as it sinks below the pelvic peritoneum. The appendix The appendix arises from the posteromedial aspect of the caecum about 1in (2. In the fetus it is a direct outpouching of the caecum, but differential overgrowth of the lateral caecal wall results in its medial displacement. The position of the appendix is extremely variable—more so than that of any other organ (Fig. The appendix is usually quite free in this position although occasionally it lies beneath the peritoneal covering of the caecum. If the appendix is very long, it may actually extend behind the ascending 80 The abdomen and pelvis Fig. In about 20% of cases, the appendix lies just below the caecum or else hangs down into the pelvis.

If one shoulder is pulled inwards more than the other 75mg viagra with mastercard, the chest and ribs will have to twist in compensation buy discount viagra 50 mg. This in turn will create subtler compensation further down the body—the pelvis may shift, the knee may have to be adjusted and the ankles may collapse. Each compensatory adjustment is linked, to support the body in relation to gravity. The body is in a state of compromised balance, where the neuromuscular system is constantly working against a subtle (or not so subtle) lean, or twist. Through the practice of the postures of Hatha yoga the intention is to bring the body into an alignment that uses energy more efficiently and triggers a relaxation response in the body. The process of performing the postures or asanas, paying attention to the breath and meditation, cultivates an awareness of subtle asymmetries and relationships that affect our health and ability to move freely, which in turn creates the ability to make a change in alignment. CLINICAL EVIDENCE A search of Pubmed and the Indian scientific medical journals revealed almost 200 clinical trials on Hatha yoga, pranayama and meditation. Many of these publications did not have an adequate description of the methodology used in the clinical trials so that assessing the quality of the research is difficult. Nevertheless, they serve as a useful starting point in beginning to evaluate the potential areas of therapeutic application of Hatha yoga. It has been used and is being used as an adjunctive therapy for a variety of neurological conditions including headaches, essential hypertension, postpolio syndrome, 2–8 chronic pain and seizures (Table 1). It is also used in the treatment of asthma, Complementary therapies in neurology 192 cardiovascular disease, diabetes, mental disorders, osteoarthritis and rheumatoid arthritis, and stress reduction. A recent randomized trial of yoga and exercise in patients with multiple sclerosis evaluated the effect of yoga and aerobic conditioning on several quality-of-life endpoints: fatigue, cognitive function and mood. There was a trend suggesting improvement in mood and there were no statistically significant differences in cognitive function 9 between groups. Latha investigated the use of Hatha yoga for the treatment of headaches in a series of randomized controlled clinical trials and demonstrated a significant reduction in 8 headaches, use of medications and perception of stress in the group receiving yoga therapy. Other clinical trials have shown that Hatha yoga may be useful in the treatment 5–7,10 of hypertension. One of these studies found that daily practice of Hatha yoga was as effective as pharmacological agents at reducing blood pressure. Forward bends and inversions, and their modifications, are felt to be particularly beneficial for hypertension. Garfinkel and colleagues (1998) published a study in the Journal of the American Medical Table 1 Clinical trials in Hatha yoga Diagnosis Reference Type of study Chronic pain (carpal 2 randomized clinical trial tunnel syndrome) Chronic pain 3 observational study (osteoarthritis) Chronic pain 4 controlled clinical trial (rheumatoid arthritis) Hypertension 5 uncontrolled clinical trial Hypertension 6 prospective clinical trial Hypertension 7 randomized, placebocontrolled clinical trial Headaches 8 randomized controlled clinical trial Low back pain Pilot study in progress—Kaiser controlled clinical trial Permanente and Brad Jacobs, UCSF, San Francisco, CA Postpolio syndome Pilot study in progress—Conemaugh controlled clinical trial Health System, Barbara Duryea, Johnstown, PA Hatha yoga and meditation for neurological conditions 193 Association demonstrating that Hatha yoga was useful in the treatment of carpal tunnel 2 syndrome. In this clinical trial patients with carpal tunnel syndrome were given 11 Hatha yoga postures to perform. The control group was given a splint to augment their current treatment regime; nothing else was added to their treatment. The group treated with the 11 Hatha yoga postures showed significant improvement in grip strength, pain reduction and range of motion. The same authors also evaluated Hatha yoga for pain relief in the 3 treatment of osteoarthritis of the hand. Compared with the control group, the treatment group demonstrated significant improvement with regards to pain, tenderness and range of motion. In another study of patients with rheumatoid arthritis, yoga postures improved 4 the hand grip strength in patients with rheumatoid arthritis and in the control group. The Arthritis Foundation has suggested that patients suffering from a variety of 12 types of arthritis might benefit from practicing Hatha yoga. There are also group and individualized treatment plans available for the treatment of a wide range of musculoskeletal problems from yoga teachers who have had training in therapeutic yoga, or physical therapists who have integrated yoga into their practices. The current information from the therapeutic application of Hatha yoga and clinical research is consistent with the hypothesis that one of the primary actions associated with the regular practice of Hatha yoga may be a resetting of the resting tone of the autonomic nervous system and the neuroendocrine axis. In addition, it is a component of the 13 cardiovascular risk reduction programs developed by Ornish and co-workers, and 14 others. There are also studies that have shown some reduction of stress, improvement in concentration and increased relaxation in individuals who regularly practice Hatha yoga, 15–17 pranayama and meditation. Pranayama, the yogic science of breathing involving awareness and control of aspects of inhalation and exhalation, as well as the spaces in between, is a sophisticated discipline in itself and an integral part of the regular practice and therapeutic application of yoga. Cultivation of breath awareness, its patterns and the possibilities of using it as a therapeutic fulcrum, is not well-known in Western science. Its deeper importance, however, seems to lie in the way it can train the mind and influence both the neuroendocrine axis and the tone of the autonomic nervous system. In a recent study published in Human Neurobiology, Werntz and coworkers measured the alternating dominance of cerebral hemispheric activity that was correlated with increased air flow in 18 the contralateral nostril. RELAXATION AND RESTORATIVE YOGA When used therapeutically with patients, the practice of Hatha yoga is often referred to as restorative. Here the poses of Hatha yoga are adapted and modified from the traditional yoga poses, often through the use of props so that some or most of the benefits can be attained by those under stress or suffering from an illness.

generic viagra 50mg without prescription

When this information is added to what Pulmonary you already know about the blood and the heart cheap 75 mg viagra, a picture valve Left of the cardiovascular system as a whole will emerge discount viagra 25 mg fast delivery. Right atrium ventricle Left AV Right AV valve ◗ Blood Vessels valve Left Right Blood vessels may be divided into five groups, named ventricle atrium below according to the sequence of blood flow from the Superior Aortic heart: and inferior valve venae cavae Aorta ◗ Arteries carry blood away from the heart and toward the tissues. The pulmonary vessels differ from those in the sys- They continue the transport of blood until it is returned temic circuit in that the pulmonary arteries carry blood to the heart that is low in oxygen, and the pulmonary veins carry blood that is high in oxygen. Figure 15-1 shows trients and oxygen to all the tissues and carry waste ma- the vessels in these two circuits; the anatomic relation of terials away from the tissues for disposal. The pulmonary vessels that ◗ The systemic capillaries, through which materials are carry blood to and from the lungs include the following: exchanged ◗ The systemic veins, which carry blood back toward the ◗ The pulmonary artery and its branches, which carry heart. The venous blood flows into the right atrium of blood from the right ventricle to the lungs the heart through the superior vena cava and inferior ◗ The capillaries in the lungs, through which gases are vena cava. BLOOD VESSELS AND BLOOD CIRCULATION ✦ 309 Vessel Structure The vessels become narrower (constrict) when the mus- cle contracts and widen (dilate) when the muscle relaxes. The arteries have thick walls because they must be In this manner, the arterioles regulate the amount of strong enough to receive blood pumped under pressure blood that enters the various tissues at a given time. The three tunics Change in the diameter of the arterioles is also a major (coats) of the arteries resemble the three tissue layers of factor in blood pressure control. The capillary walls are transparent and are cells makes up the endothelium (en-do-THE-le-um), made of smooth, squamous epithelial cells that are a con- forming a smooth surface over which the blood flows tinuation of the lining of the arteries. Elastic tissue between the layers of the arterial wall al- The smallest veins, the venules, are formed by the lows these vessels to stretch when receiving blood and union of capillaries, and their walls are only slightly then return to their original size. A vein wall is much 15 Artery Vein Elastic tissue Inner tunic (endothelium) Middle tunic (smooth muscle) Outer tunic (connective tissue) Blood flow Valve Arteriole Venule Capillary Figure 15-2 Sections of small blood vessels. In the digestive tract, fenestrated capillaries permit found in muscle, connective tissue, the lungs, and the central rapid absorption of water and nutrients into the bloodstream. In addition to fenestrations, they have large spaces be- ies are the least permeable, water and small molecules can dif- tween endothelial cells that allow the exchange of water, large fuse easily through their walls. Albumin, clotting factors, and other proteins formed in tightly together, making the capillaries impermeable to many the liver enter the bloodstream through sinusoids. As uous artery, but it may be divided into sections: a result, the blood within the veins is carried under much ◗ The ascending aorta is near the heart and inside the lower pressure. Only slight pressure on a vein by a ◗ The aortic arch curves from the right to the left and tumor or other mass may interfere with return blood also extends posteriorly. BLOOD VESSELS AND BLOOD CIRCULATION ✦ 311 The arch of the aorta, located im- Right common Left common mediately beyond the ascending aorta, carotid artery carotid artery divides into three large branches. Right subclavian Left subclavian ◗ The brachiocephalic (brak-e-o-seh- artery artery FAL-ik) artery is a short vessel that Brachiocephalic supplies the arm and the head on the artery right side. After extending upward Aortic arch Ascending aorta somewhat less than 5 cm (2 inches), it divides into the right subclavian Coronary (sub-KLA-ve-an) artery, which ex- arteries Thoracic aorta tends under the right clavicle (collar bone) and supplies the right upper Celiac trunk to: Intercostal extremity (arm), and the right com- Left gastric artery arteries mon carotid (kah-ROT-id) artery, Splenic artery which supplies the right side of the Hepatic artery neck, head and brain. Branches of the Thoracic Aorta 15 The thoracic aorta supplies branches to the chest wall, esophagus (e-SOF-ah- gus), and bronchi (the subdivisions of the trachea), and their treelike subdivi- Common sions in the lungs. There are usually 9 iliac to 10 pairs of intercostal (in-ter-KOS- External iliac artery tal) arteries that extend between the artery ribs, sending branches to the muscles Testicular Internal iliac artery and other structures of the chest wall. Arch The first, or ascending, part of the aorta has two ◗ The superior mesenteric (mes-en-TER-ik) artery, the branches near the heart, called the left and right coronary largest of these branches, carries blood to most of the arteries, which supply the heart muscle. Subdivisions The paired lateral branches of the abdominal aorta in- The abdominal aorta finally divides into two common clude the following right and left vessels: iliac (IL-e-ak) arteries. This vessel gives rise to ◗ Four pairs of lumbar (LUM-bar) arteries extend into branches in the thigh and then becomes the popliteal the musculature of the abdominal wall. The subdivisions include the posterior and anterior tibial Checkpoint 15-5 What are the subdivisions of the aorta, the arteries and the dorsalis pedis (dor-SA-lis PE-dis), which largest artery? BLOOD VESSELS AND BLOOD CIRCULATION ✦ 313 Arteries That Branch to the Arm carotid arteries and from the basilar (BAS-il-ar) artery, which is formed by the union of the two vertebral ar- and Head teries. This arterial circle lies just under the center of Each common carotid artery travels along the trachea en- the brain and sends branches to the cerebrum and other closed in a sheath with the internal jugular vein and the parts of the brain. Just anterior to the angle of the mandible ◗ The superficial palmar arch is formed by the union of (lower jaw) it branches into the external and internal the radial and ulnar arteries in the hand. In this type of shunt, a small vessel known as a the transverse processes of the first six cervical vertebrae metarteriole or thoroughfare channel, connects the arterial and supplies blood to the posterior portion of the brain. It first be- rapid flow and a greater blood volume to these areas, thus comes the axillary (AK-sil-ar-e) artery in the axilla protecting these exposed parts from freezing in cold (armpit). The brachial artery subdivides Cerebrum (frontal lobe) into two branches near the elbow: the radial artery, which continues down Cerebrum 15 the thumb side of the forearm and (temporal lobe) Arteries of the circle of Willis: wrist, and the ulnar artery, which ex- Anterior communicating tends along the medial or little finger Anterior cerebral side into the hand. Middle cerebral Just as the larger branches of a tree divide into limbs of varying sizes, so Internal carotid the arterial tree has a multitude of sub- Posterior communicating divisions. Examples of these include the femoral Artery and the external and internal iliac ves- Precapillary sels of the lower part of the body, and sphincter the brachial, axillary, and subclavian vessels of the upper extremities. The two jugular Capillary (JUG-u-lar) veins on each side of the neck drain the areas supplied by the carotid arteries (jugular is from a Latin word meaning “neck”).

None was more important than the recognition of the Council on Chiropractic Education (CCE) as the accrediting agency for chiropractic education by what was then the US Office of Education (now the US Department of Education) in 1974 purchase 100mg viagra visa. The CCE established a minimum standard for admission and pre-professional requirements as well as prescribing minimum standards for facilities and the course of study in accredited chiropractic teaching institutions purchase viagra 50mg overnight delivery. Current standards require that all prospective students have a minimum of 2 years of pre-professional education, with specific requirements in the sciences and a minimum grade point average (GPA). The course of study in chiropractic schools is 4–5 academic years, with much of the final year being devoted to training in a supervised clinical setting (with defined standards for this clinical experience). The first 3–4 years of the program is evenly divided between the basic medical sciences and the clinical sciences. An accreditation process, under the direction of the CCE, with periodic reaccreditation, ensures that colleges continue to meet these standards. Many chiropractic schools have also received accreditation from their regional post-secondary accreditation body, permitting them to grant undergraduate degrees based on their course of basic science instruction. The CCE has also been instrumental, through involvement with the Councils on Chiropractic Education International, in helping to establish minimum education standards in other parts of the world. Under the guidance of the CCE, the great majority of the basic sciences are taught by professors with advanced degrees in the particular area of study. Most of the clinical sciences are taught by chiropractors, although there is a growing educational involvement of medical physicians and individuals with dual degrees. Additionally, an increasing Chiropractic 35 number of chiropractic students are receiving part of their clinical experience in medical facilities. The great majority of chiropractic students take a national board examination that is administered under the auspices of the National Board of Chiropractic Examiners (NBCE), which was established in 1963. This examination consists of a basic science part, a clinical part, a problem-solving portion and a practical examination. LICENSURE Chiropractic licensure is the responsibility of each state, subject to its own chiropractic practice act and the interpretations of that law. Therefore, there is some variability between states in the licensure requirements. Although the great majority of states require graduation from a chiropractic school accredited by the CCE, the role of the National Board examination in licensure varies. Many states require their own examination, often in addition to the National Board, prior to licensure. Furthermore, the requirements for postgraduate continuing education vary from state to state. All states permit direct access of patients to chiropractors as portal-of-entry providers. In the great majority of states, chiropractors are permitted to employ diagnostic measures necessary to ensure the suitability of patients for treatment. This includes the performance of physical examination procedures and the interpretation of laboratory tests. Most states also permit chiropractors to maintain and use radiological facilities. To a large extent this is the result of a long-standing boycott of chiropractors by radiologists who would not perform radiological tests at their request. The more recent co-operation between these professions has led to a decrease in the number of chiropractic offices maintaining their own radiographical facilities. Chiropractic schools have historically devoted a significant amount of training to the study of radiology, and studies have shown that the ability to interpret X-rays for pathological red flags by chiropractors is at 11 least as good as that of family physicians and orthopedic residents and specialists. Despite the relative uniformity of chiropractic laws, there remain a few states where chiropractors are permitted to recommend or prescribe medications and perform minor surgical procedures, and other states where they are not even permitted to perform such procedures as a prostrate physical examination. Most of these practice variations fly in the face of education, which has become increasingly uniform as the result of national accreditation. SPECIALTIES The chiropractic profession has several established specialty councils, most of which have a diplomate or certification process. These councils are established under the auspices of the American Chiropractic Association (ACA) and/ or the International Chiropractic Association (ICA) to recognize and encourage greater expertise in particular disciplines. At the present time, recognized programs include radiology, orthopedics, sports medicine, rehabilitation, industrial medicine and nutrition. Complementary therapies in neurology 36 With the exception of the diplomate program in radiology, which has an established 2year residency, most of these programs consist of postgraduate courses of at least 300 h (diplomate programs) or 100 h (certification programs) of study in the field. SCOPE OF PRACTICE State law and the legal interpretations of the law define the scope of chiropractic practice. As described above, there is some variability in the diagnostic and therapeutic interventions that are permitted from state to state, but in most locations these include the diagnostic procedures that are required to determine the appropriateness of patients for chiropractic care.