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Clinical Features: It usually has sub-acute onset and can present with Localized muscle pain and swelling order 10 mg zetia otc cholesterol in salmon, late tenderness Induration cheap zetia 10mg cholesterol foods high in, erythema and heat Muscle necrosis due to pressure Fever and other systemic manifestations later after some days Treatment: Immediate intravenous antibiotics before surgery Surgical drainage of all abscess Excision of all necrotic muscles Supportive care Madura Foot This is a chronic granulomatous disease commonly affecting the foot with extensive granulation tissue formation and bone destruction generic 10 mg zetia cholesterol pressure chart. The disease is common in the tropics and occurs through a prick in barefoot walkers in 90% of cases quality 10mg zetia cholesterol levels by age group. Etiology: The causative microorganisms for this infection are various fungi or actinomycetes found in road dust. Treatment: Sulphonamides and Dapson (prolonged course) Broad spectrum antibiotics for secondary infection Amputation if severe and disfiguring infection Necrotizing fasciitis This is an acute invasive infection of the subcutaneous tissue and fascia characterized by vascular thrombosis, which leads to tissue necrosis. It is idiopathic in origin but minor wounds, ulcers and surgical wounds are believed to be initiating factors. The condition is described as "Meleneys synergistic gangrene" if it occurs over the abdominal wall and Fourniers gangrene if in the scrotum and perineal area. Bacteriology: Mixed pathogens of the following microorganisms are usually cultured. The following surgical procedures may be required: - Debridement and excision of all dead tissue - Multiple incisions for drainage - Repeated wound inspection - Skin graft may be needed later if extensive skin involved. It can practically be eliminated by tetanus vaccine immunization if properly initiated and maintained. Etiology: Clostridium tetani, a gram-positive rod found in soil and manure is the causative agent. It require anaerobic environment for growth, invasion and elaboration of toxin, tetano-spasmin for its dramatic virulence. Clinical Features: - Can be latent with healed and forgotten wounds - Local or generalized weakness - Stiffness or cramping pain on the back, neck and abdomen - Difficult of chewing and swallowing - Tonic muscles spasms - Sardonic smile as evidence of onset of tonic spasm - Severe pain and opisothonus due to reflex convulsion of all muscles - Progressive difficulty of respiration - Fever, tachycardia, cyanosis - Respiratory failure and death due to repeated cyanotic convulsive attacks. Patients with grossly contaminated wounds and no or unclear history of immunization should receive an intramuscular antitoxin therapy. Gas Gangrene Gas gangrene is another clostridia associated with soft tissue infection (Clostridial myonecrosis). It is a rare but devastating infection characterized by muscle necrosis and systemic toxicity due to the elaboration and release of toxins. It usually follows wounding with trauma or surgery and requires factors contributing to tissue hypoxia like foreign bodies, vascular insufficiency or occurs as a complication of amputation. More than one species can be isolated or polymicrobial infection with other microorganisms can occur. A) Urinary tract infection after catheterization for Prostatectomy B) Abscess formation following injection on the thigh C) Wound abscess following excision of big lipoma on the back D) Lung atelectasis following intubation for laparotomy E) None of the above 2. A) Virulent microorganism B) A tissue of decreased or no blood supply C) A decrease in the immune response of a patient D) All of the above E) None of the above 3. A) Fever B) Loss of function of body part C) Local hyperemia D) Tachycardia E) All of the above 5. The correct way of managing a patient with an abscess is A) Start with effective antibiotics and send home B) Drainage and no antibiotics if no systemic signs C) Apply local ointments for aiding the abscess to burst D) Give effective antibiotics and analgesics E) All except B 7. In a patient with gas gangrene A) Little circulatory support is needed B) Surgical removal of gangrenous tissue is the primary management C) Penicillin is the preferred antibiotic D) B and C are correct E) Systemic signs are not commonly seen 74 Key to the Review Questions 1. Introduction Trauma is one of the leading causes of mortality, morbidity and disability worldwide. In developing countries, the magnitude of the problem has been increasing consuming more and more of the meager health resources of these nations. Moreover, trauma mostly affects people in their productive years of life, hence the high economic and social burden to society. The causes of trauma are various and their relative incidence varies in different populations. Immediate death (50%) Occur in the first few minutes after the accident Are due to extensive and lethal injuries to the brain, heart & major blood vessels 2. Early deaths (30%) Occur in the first few hours Are due to the collections and bleedings in the chest and abdomen, extensive fractures and increased intracranial pressure Early resuscitation, diagnosis and appropriate management can prevent these deaths. Types of Trauma: Trauma can be classified according to the: I- Cause: Homicidal injuries Road traffic accident and falls Industrial accidents, burn, etc. I- The primary survey and resuscitation This part of management comprises a quick evaluation of the patient to detect immediately life threatening situations and institution of measures to correct them. It may be compromised by pneumothorax, hemothorax or multiple rib fractures causing flail chest. Look for external hemorrhage and arrest it by pressure, bandaging or tourniquet if the other methods fail. Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound. E- Expose (undress) the patient fully for examination not to miss serious injuries. It includes the following aspects: A- Take History: The informant may be the injured patient, relatives, police or ambulance personnel. However, never send a patient with unstable vital signs for investigation or referral before resuscitation. These include poor condition and design of roads, traffic mix (sharing of road by vehicles of different speeds and pedestrians), poor condition of the vehicles and poor traffic rule enforcement. The incidence of this serious problem can be reduced by improving the public awareness and the quality of training given to the drivers and strict enforcement of traffic rules. Moreover, improving the design and quality of the roads and regular checkup of vehicle fitness would help alleviate the problem. In many developing countries like Ethiopia, the magnitude of the problem is big due to high distribution of firearms among civilians who have little or no knowledge on safe handling and usage. It is made worse by the presence of large number of land mines, which are remnants of repeated wars and conflicts in these poor nations. Generally, missile injuries may be caused by bullets from pistols, rifles, machine guns or fragments from exploded grenades and mines. The degree of injury sustained depends on the amount of energy transferred from the missile to the patient as formulated below. The extensive tissue injury with the high degree of contamination creates a perfect medium for life threatening infection to occur. Missile injuries are classified into: I- Low- velocity missile injuries Comprise missiles fired from hand guns (<400m/s) Injury is limited to the path of the bullet. All patients with missile injuries should receive broad spectrum antibiotics and tetanus prophylaxis. It is mostly seen in developing countries where there is overcrowding, poor housing designs and wide spread usage of open fire for cooking. Types of burns, according to the mechanism, include: Flame burn Scalding Chemical burn Electrical burn, etc.
The very next day he felt a thousand times better than he had felt for a long time buy zetia 10mg lowest price cholesterol ratio mg/dl. On November 4 buy zetia 10 mg with amex cholesterol lowering super foods, after his extractions discount zetia 10mg with mastercard cholesterol in duck eggs, he was Positive for urethane and malonates again! It was during Bernards stay that we found urethane pollution in the wormwood capsules purchase zetia 10 mg fast delivery high cholesterol definition wikipedia. Self Health provided us with samples of wormwood and several brands of gelatin cap- sules. Self Health sent their inventory to the landfill and ordered new worm- wood capsules made, using the safe brand of capsules. Tested cap- sules were filled with wormwood by hand till the safe ones were again avail- able. He was given D-glucuronic acid immediately in an attempt to detoxify the urethane which was showing up at his kidneys. His iron level had not yet come up sufficiently; he was still wearing his metal rimmed glasses, a source of copper. A shocking number were there, including tartrazine (a yellow azo dye) and asbestos. It would be a while, however, before I discovered how damaging asbestos and azo dyes were. Fortu- nately, I had already sent them to be reproduced, or we would not have this story to tell. Summary: Bernard had the patience and tenacity it takes, in a research setting, to accomplish his purpose and to leave no stone unturned. He had been diag- nosed three years ago with bladder cancer and had twenty-eight radiation treatments for it. He was very gassy and also had pain at the back of his neck on the right side (an obvious dental symptom). He had obtained The Cure For All Cancers book and started on the life- style change two weeks ago. He was started on marshmallow root tea2 cups a day for his abdomi- nal pain that I guessed might be coming from the bladder. The usual interpretation is exceptionally good kidney function keeping this muscle waste so low. Perhaps this explains the fa- tigue that is so devastating in tumor-bearing people. This was understandable since vita- min D is activated in the kidneys, and the kidneys were part of Marks cancer problem. In addition to the parasite program, Lugols, kidney program, Mark was started on potas- sium gluconate powder even though his potassium level was not seriously low; it would certainly help. By now, the fall of 1996, we had already learned that dental plastic both contained and was polluted with carcinogens. We had begun sampling the artificial teeth in each patients mouth for testing purposes. Only five of Marks new plastic teeth were found to be free of copper, cobalt, vanadium and the M-family toxins. In the meantime the bleeding had stopped, leading him to think that all was well again and he might not need to make such heroic efforts. By the ninth day the bleeding was back; he had not yet changed his metal glasses frames to plastic either. This would help pull the copper, cobalt, and vanadium out while he deliberated about his teeth. It showed that his right kidney was dilated, perhaps due to a small nodule or stone, causing blockage. He agreed immediately to switch to our smoking herbs that can be chewed all day to keep the mouth happy and busy. The bladder had not been pictured; it was missed due to an error in communication with the radiologist. He was still get- ting trace amounts, not enough to show up in his daily toxin Nov 4 2. We arranged for another dental appointment, this time with a dentist using a magnifying lens and a monitoring screen to see every tiny remnant left in an old cavity. Mark now reminded us that his air flight home was only a week away, and we hadnt even seen his bladder tumor yet. Even after his second dental plastic removal he still tested Positive for copper, urethane, and vanadium in the bladder. Nov 12 bladder tumor shows up on magni- This was just at the time we discov- fied ultrasound ered urethane in a supplements gelatin capsulesthe capsules themselves. We stopped all his capsules of supple- ments: he was requested to use bulk supplies only. In desperation, our entire toxin test of 80 elements was done at kidneys and bladder. Indeed, he was using up an old supply of vitamin C, not procured from our specially-tested stock. Instead, several molars and one upper front tooth appeared to have large infections! This proved to be insufficient to make them appear at his kidneys so amounts were dou- bled. We sent him back to the dentist whose dental microscope and painstak- ing procedure would surely give him the final cleanup so much needed this time. After this final microscopic cleaning, we expected to see a little im- provement on his blood test, but we were astonished to see his results (Dec. We advised him to have the colon checked to see if there was anything suspicious on the inside. Only zinc ox- ide and eugenol was used; we had tested many such products and always found them pure. Or had unsafe plastic strips been used to contain and polish the wet cement-like mass before dry- ing? He had only three days left before his flight; we could not persuade him to extend his stay to tend to his edema problem. He agreed to return to the microscope dentist for complete removal again, by air abrasion; (this does not enlarge the hole). He rushed right over to yet another dentist for the approved zinc oxide and eugenol. Summary: If Mark had lessons to learn about patience, we, too, had les- sons to learn. It would be better to extract as many as possible, before the patient is too weak or anemic to sit in the dentists chair. Like other Mexicans in Tijuana, he had become habituated to drink- ing bottled water, instead of boiling it, and soda pop as a beverage.
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Glucose uptake and metabolism increases more during epileptic seizures than during most other brain activities (McIlwain buy zetia 10 mg line ideal cholesterol ratio individual would include, 1969; Meldrum and Chapman generic zetia 10mg without prescription cholesterol score explained, 1999; Cornford et al 10 mg zetia for sale configuring users of cholesterol lowering foods a review of biomedical discourse. Also discount zetia 10mg visa cholesterol in food good or bad, blood glucose levels positively correlate with flurothyl-induced seizures in rats and high levels of glucose may exacerbate human seizure disorders (Schwechter et al. Neuronal excitability and epileptic seizures are directly related to rapid glucose utilization and glycolysis (McIlwain, 1969; Ackermann and Lear, 1989; Meric et al. It is not yet clear, however, to what extent enhanced glycolysis is related to the cause or effects of seizure activity (Greene et al. Nevertheless, a transition in brain energy metabolism from glucose utilization to ketone body utilization reduces neural 19 excitation and increases neural inhibition through multiple integrated systems (Greene et al. The mice were maintained in the Boston College Animal Care Facility as an inbred strain by brother x sister mating. The mice were group housed (prior to initiation of study) in plastic cages with Sani-chip 20 bedding (P. Cotton nesting pads were provided for warmth when animals were individually housed. Only females were used for these studies as adult males die sporadically with age from acute uremia poisoning due to urinary retention (Todorova et al. Briefly, the testing procedure included repetitive handling and simulated the stress normally associated with weekly cage changing, i. In each trial, a single mouse was held by the tail for 30 sec at approximately 10-15 cm above the bedding of its home cage. After 30 sec, the mouse was placed into a clean cage with fresh bedding for 2 min. The epileptic seizures commenced during holding or soon after the mice were placed on the clean bedding. Mice that developed an epileptic seizure while handled were placed immediately in either the clean cage or their home cage depending on the testing stage. Mice were tested each week for a total of 13 measurements over a 12-week period using this method. Mice were undisturbed between testing phases (no cage changing) and testing was performed between 12 to 3 pm. Seizure Phenotype Mice were designated seizure susceptible if they experienced a generalized seizure during seizure testing. An erect forward- arching Straub tail, indicative of spinal cord activation, was also seen in most mice having generalized seizures. Mice that displayed only vocalization and twitching without progression to generalized seizure were not considered seizure susceptible (Todorova et al. Seizure susceptibility scores were generated for each mouse according to the seizure severity scores previously described (Table 2) (Todorova et al. The seizure susceptibility for each mouse was then averaged over multiple tests and the mean seizure susceptibility for a mouse dietary group was determined. The fat in this diet was derived from lard and the diet had a ketogenic ratio (fats: proteins + carbohydrates) of 5. The difference was then divided by seven to estimate the average daily food intake. Thus, all mice were highly seizure susceptible at the initiation of the diet therapy. Dietary Treatment After the three-week pre-trial period, the mice were placed into four groups (n = 6 mice/group) where the average body weight of each group was similar (about 31. Each mouse in 24 the two R groups served as its own control for body weight reduction. Based on food intake and body weight during the pre-trial period, food in the R-fed mouse groups was reduced until each mouse achieved the target weight reduction of 20-23%. In other words, the daily amount of food given to each R mouse was reduced gradually until it reached 77-80% of its initial (pre-trial) body weight. An empty water bottle was placed on top of the dish to prevent dish movement during animal feeding. Measurement of Plasma Glucose and -Hydroxybutyrate Blood was collected approximately 1 hr after seizure testing except for the pre-trial period where blood was not collected. The blood was centrifuged at 6,000 x g for 10 min, the plasma was collected, and aliquots were o stored at 80 C until analysis. Plasma glucose concentration was measured spectrophotometrically using the Trinder Assay (Sigma-Aldrich, St. Briefly, for measuring -Hydroxybutyrate using Williamsons modified assay, 50 l of a substrate containing cocktail buffer, containing: 0. Initial absorbance for all samples is read at 340 nm, using a 5 min kinetic absorbance mode on a SpectaMax M5 spectrophotometer. Absorbance is then corrected using the pathcheck function (normalize the well absorbance to a cuvette of an equivalent 1 cm pathlength) on the plate reader. After absorbance is corrected once more using the pathcheck function, and the final absorbance for all samples is read at 340 nm, using a 40 min kinetic absorbance mode. After making a standard curve by plotting the corrected change of absorbance (Absfinal- Absinitial) for each standard, the -hydroxybutyrate concentration for each sample was calculated. Chi-square analysis was performed on the association between glucose and seizures. All statistical data were presented according to the recommendations of Lang et al. These findings are consistent with the well-recognized health benefits of mild to moderate caloric 28 restriction in rodents (Keenan et al. Influence of Calorie Restriction on Body Weight All mice were matched for age (approximately 210 days) and body weight (approximately 31. The 20-23% body weight reduction was achieved in the R-fed groups after about two weeks of gradual food restriction. The seizures occurred occasionally during routine cage changing prior to the pre-trial period and regularly from handling during the pre-trial test period. Seizure susceptibility was analyzed in all mouse groups after the R-fed mice achieved a stable body weight reduction, i. In both R-fed mouse groups, the plasma glucose levels decreased from about 10 mM to about 5. These findings demonstrate that circulating -hydroxybutyrate levels were inversely related to circulating glucose levels and that elevated -hydroxybutyrate levels alone are not associated with seizure susceptibility. Positive correlations were found among body weight, food intake, glucose, and seizure susceptibility. On 31 the other hand, -hydroxybutyrate was negatively correlated with all variables. The data indicate that regardless of diet, glucose could predict seizure susceptibility with an approximate 75 to 78 % accuracy (Table 5).
Glucose control during this period is unpredictable and difficult generic 10 mg zetia overnight delivery cholesterol ratio normal range, requiring skill and experience on the part of Action plan the clinicians50 buy discount zetia 10 mg online cholesterol hdl ratio. Staff skilled in diabetes management should supervise surgical wards routinely and regularly buy 10mg zetia with mastercard cholesterol levels life insurance. During the pre-operative purchase 10mg zetia free shipping cholesterol test strips lloyds pharmacy, operative and immediate post-operative recovery period patients are normally 2. Allow patients to self-manage their diabetes as cared for by experienced anaesthetic staff, ensuring soon as possible, where appropriate. Monitor electrolytes and fluid balance daily and hyperglycaemia and ketogenesis and it is crucial to prescribe appropriate fluids. Health has added insulin maladministration to the The wide range of preparations and devices available list of Never Events for 2011-1261. Of these 972 incidents resulted in Uses any abbreviation for the words unit or moderate harm with severe or fatal outcomes in a units when prescribing insulin in writing further 1821. Nursing staff may not be recommendations to promote safer use of insulin authorised to administer glucose without a 21,62 : prescription glucose products are not always readily available in clinical areas. The recent introduction of A training programme should be put in place for national guidelines for the management of all healthcare staff (including medical staff) hypoglycaemia should address this problem57 expected to prescribe, prepare and administer insulin All staff prescribing or administering insulin should Policies and procedures for the preparation and receive training in the safe use of insulin. Trusts administration of insulin and insulin infusions in should specify an appropriate training programme clinical areas are reviewed to ensure compliance and it is recommended that this be mandatory. Insulin is included in the list of top ten high Patients often return to surgical wards from theatre alert medicines worldwide26,58,59. The following errors with an intravenous insulin infusion in place but no account for 60% of all insulin-related incidents directions for its withdrawal. Doctors are often Wrong kind of insulin unaware of how to do this and infusions are Wrong dose (either wrong prescription or misread continued or discontinued inappropriately. Treatment requirements may differ from usual in the immediate post-operative period where there is a risk of both hypo and hyperglycaemia and clinical staff may need to take decisions about diabetes management. Training in blood glucose management is essential for all staff dealing with patients with diabetes64. The diabetes specialist team should be consulted if there is uncertainty about treatment selection or if the blood glucose targets are not achieved and maintained. Emergency surgery By definition, emergency surgery is unplanned and the additional metabolic stress of the emergency situation is likely to lead to hyperglycaemia. The diabetes specialist team should be involved at an early stage to optimise blood glucose management. Involve the diabetes specialist team if diabetes operative assessment process in collaboration with related delays in discharge are anticipated. The patient or carers defined discharge criteria to prevent unnecessary ability to manage the diabetes should be taken delays when the patient is ready to leave hospital. Discuss with the diabetes Multidisciplinary teamwork is required to manage all specialist team if necessary. Systems should be in place to ensure effective The diabetes specialist team should be involved at an communication with community teams, early stage if blood glucose is not well controlled35. Diabetes expertise should be available to support safe discharge and the team that normally looks after the patients diabetes Aims should be contactable by telephone. Etzwiler68 described three phases of patient education: acute or survival education, in depth Action plan education, and continuing education. In consultation with the patient, decide the skills are limited to topics essential in the short term clinical criteria that the patient must meet for safe patient discharge. Identify whether the patient has simple or last for several days and patients and/or carers should complex discharge planning needs and plan be advised about blood glucose management during how they will be met. The hospital pharmacist has a Nutritional intake crucial role to play in ensuring that the discharge medication is safe and that the patent has the Blood glucose lowering medications equipment and education required to manage safely Activity levels at home. Ensure that the diabetes specialist team is inpatient stay and this may be continued on involved if necessary discharge. Education must be provided to ensure that the patient or carer has sufficient understanding to In partnership with the patient or their carer agree manage independently. Patients already established diabetes therapy on discharge depending on on insulin may experience variations in insulin clinical status, social support and ability to self- requirements on discharge. Specialist advice on manage diabetes management should be available in the Agree a blood glucose monitoring plan with self- immediate post-discharge period. Arrange community support for those who require blood glucose monitoring but are unable to Self-monitoring of blood glucose self-care Patients who normally monitor their blood glucose Agree blood glucose targets and provide a record may wish to increase the frequency of monitoring in book the immediate postoperative period until glycaemic Revise principles of dose adjustment for patients control and treatment are stable. Those who have on insulin therapy who are able to self-care been commenced on insulin or sulphonylureas during Discuss any treatment changes with the individual admission should be taught to self-monitor before and also ensure these are communicated to their discharge. Clear blood glucose targets should be usual provider of diabetes care documented as part of the discharge care plan and Review advice for identification and treatment of patients should be able to access specialist advice if hypoglycaemia they are concerned about their blood glucose level. Medicines management on discharge Care should be taken to ensure that there is no interaction between the patients usual medication 33 Controversial areas - glycaemic control What is the evidence that tight glycaemic increase expression of leukocyte and endothelial control improves the outcome of surgery? High glucose values were tolerated these glucose-induced changes is to enhance on the basis that permissive hyperglycaemia was inflammation and increase vulnerability to safer than rigorous blood glucose control with the infection. A number of these deleterious effects can be shown is studies have looked at the impact of tight blood surprisingly uniform, usually greater than 9 or 10 glucose control on post-operative outcomes, with mmol/L, which is similar to the values at which varying conclusions. It also outcome was not improved in patients with reduces the risk of variability in blood glucose, tight control regardless of diabetes status72 which is more likely to occur if the target is less A retrospective cohort study found that than 6. In a recent study of patients Trials in which strict glucose control was undergoing hip and knee arthroplasty patients with implemented, typically less than 6. An upper limit between 64-75 mmol/mol Close and effective coordination with other (8 and 9%) is acceptable, depending on individual specialist teams involved in caring for the patient circumstances. HbA1c is achievable, but for those at high risk of hypoglycaemia a higher target may be appropriate. An elevated pre-operative HbA1c is associated with Does optimisation of co-morbidities improve poorer outcomes whether diabetes has been outcomes? There may be a role for Cardiac and renal dysfunction are common long- routine measurement of HbA1c at pre-operative term complications of diabetes. Previous assessment in undiagnosed patients with risk myocardial infarction, atrial fibrillation and a factors for diabetes. It is likely that the incidence of Can input from the diabetes specialist team peri-operative morbidity and mortality among improve outcomes? The recommended carbohydrate load or short stay and if the starvation period is short it of 180 g glucose per day was designed to may be possible to manage the diabetes without minimise catabolism associated with starvation and 90-94 an insulin infusion. Alberti and Thomas described the data available demonstrated that this approach is use of other intravenous fluids in conjunction with 94 safe. A recent prospective study of 106 patients Diabetic surgical patients are not only at risk of the requiring laparotomy found that 54% suffered at inherent complications associated with standard least one iatrogenic complication as a result of fluid and electrolyte management, but are at post-operative fluid and electrolyte higher risk of hyponatraemia through the use of mismanagement99. A revised approach to responsible for intravenous fluid prescriptions but peri-operative diabetic fluid management is may not be aware of daily fluid and electrolyte needed to ensure glycaemic control and prevent requirements or the composition of commonly excess catabolism. Accurate fluid and electrolyte management is essential for patients with diabetes for whom the focus of fluid Aims of fluid therapy for the patient administration has previously tended to be with diabetes provision of a substrate for insulin and prevention Major surgery or prolonged starvation (more than of ketogenesis, rather than maintenance of fluid one missed meal) places the diabetic surgical and electrolyte balance.
Endoloops are useful to ligate tissues during operations (Endoloop 10 mg zetia mastercard cholesterol chart for cheese, Roeder-loop ) discount zetia 10 mg line cholesterol level chart in urdu. Among these parameters zetia 10mg low cost lowering good cholesterol foods list, we can change the values of intraabdominal pressure and the flow rate buy 10mg zetia overnight delivery cholesterol chart by age. Here are the optic with the camera and the light cable, and they are joined to the camera set and the light source. Cutting function is fulfilled by pressing the yellow pedal, while the coagulating function is excuted by the blue one. To work with the monopolar electrocautery system the negatve electrode should touch the patients dry skin. On the top of the box there are some holes to lead the laparoscopic instruments and the optic. The instruments are inserted through the ports and we can follow our activity only on the monitor. Task: red, green, and blue slips of the paper are grasped one-by-one and based on their colours are put in the Petri dishes. This is done first with right and then with left hands (for the left-handed students, in a reversed manner). It will not be successful if the needle and the case are not parallel to each other. Practice Laparoscopic training in trainer box Task: based on numbers and first with your right hand, put the rubber bands on the sticks located at the left side. Practice Microsurgery: basic instrumentation and adjustement of microscope, microsurgical stich insertion Aim of the parctice: to learn and practice the appropriate usage of basic microsurgical instruments, the suture-tying under magnification with a help of silicone rubber practice pad. Appropriate handling of microsurgical instruments: to hold the following instruments as a pen. The eyepieces of loupe are adjustable to the surgeons pupil diameter, but the magnification is fixed. Put ont he instrument and adjust to our own pupil diameter, than fix the position. Training in a laboratory with an operating microscope often takes long hours of concentrated work. This task is impossible to accomplish unless the surgeon has a comfortable and perfectly balanced position. One should remove every object from the way of the legs on the ground which can disturb convenience. It is also important to have enough place for the knees, hence sitting at a table with drawers is not always suitable. On one hand, it affects the ability of manipulation, on the other hand it affects how we see through the microscope. One should not achieve this immobility by leaning on the elbows, as it quickly leads to fatigue and tremor of the hands. Turn the light source on, focus on the filed and instruments held in both hands into the middle of the field trying different magnifications. The final adjustment is provided by the conformity of body position and microscope adjustments. Choose the lowest magnification and focus on the spot that you previously marked by using the coarse focus. Choose the highest magnification and adjust the fine focus also for this magnification. The reason for starting the fine focusing at the highest magnification is that the microscope will be focused in the smallest depth of the field, thus allowing a perfect focus at all magnifications. Switch to the lowest magnification without modifying the focus, and set the eyepieces to the lowest possible diopter. Adjust the diopters separately for each eye by rotating the lens of the eyepiece clockwise. It is particularly important to practice the stitching and knotting in microsurgery. We use 10/0-7/0 atraumatic needles which are permanently attached to a fine monofilament thread. The cross section of the needle is somewhat flat so it cannot turn around along its axis when held in the needle holder. Holding the thread in the left hand, lay the greater curvature of needle on the surface a way it gets into position where it is suitable to grab it with and instrument held in the right hand. The axis of the needle should be held perpendicularly to the surface to be sutured. On the left side: Let us make the tip of the needle get out exactly in line with the stitch on the right side. When the tip of the needle is visible on the left side, we grab it with the left forceps and pull the needle out. Let us try to avoid surface friction by retracting with the left forceps when the needle is pulled through the rubber. When we pull the thread through counteract the friction by retracting with a forcep held int he right hand. Microsurgical knotting evolves the simultaneous use of two instruments, similarly to the laparoscopic approach. In the clinical practice, two major methods of tying knots are applied: the one-handed and the two-handed versions. The one-handed version resembles the method used in macroscopic instrument-aided knotting procedures, because the long part of the thread is held always in the same hand, whereby the thread is passed into the other hand during the two-handed procedure. Grab the long thread with the right needle holder at a distance which can be easily looped around the tip of the left forceps (direction: towards the short end, distance: 3 times the length of the short end. Reach and pull the short end through the loop with the left forceps (meanwhile do not let the loop slip off). Pull only the long end while firmly holding the short end, and tighten the knot. When the knot is tightened, the edges of the rubber should only touch each other - do not overlap! In order to achieve this, the distance of the stitch from the edge should not be large and the knot must not be very much tightened. Do not pull the short end, pull only the long end otherwise the knot looses its ideal structure. Move thelong thread to the side of the short end, grab the long end now with the left hand (distance: 3 times the length of the sort end) and wrap it around the right forceps (direction: opposite to the short end) than grab the short end with the right forceps and pull it through the loop, and tighten the knot. Practice Microsurgery: insertion stiches The matter of the previous lesson is repeated during this section. Practice of the grabbing and adjustment of the needlethread complex under magnification. A repeat the above mentioned excersises 5 or 10 times on the incisions lay in different directions. The trainee should be able to tie 6 knots in 10 minutes to consider himself proficient in this excersise. Maximal absorption of iron occurs in the duodenum Question 2 Which portion of the gastrointestinal tract is most responsible for the absorption of bile acids and folate?
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