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We will see how skeletal system 108 Human Anatomy and Physiology produce movement and we will describe the principal skeletal muscles of the human body buy clarinex 5 mg free shipping; their action and innervation order clarinex 5mg with visa. Functions of muscle tissue Through sustained contraction or alternating contraction and relaxation, muscle tissue has three key functions: producing motion, providing stabilization, and generating heat. Motion: Motion is obvious in movements such as walking and running, and in localized movements, such as grasping a pencil or nodding the head. Stabilizing body positions and regulating the volume of cavities in the body: Besides producing movements, skeletal muscle contractions maintain the body in stable positions, such as standing or sitting. Postural muscles display sustained contractions when a person is awake, for example, partially contracted neck muscles hold the head upright. In addition, the volumes of the body cavities are regulated through the contractions of skeletal muscles. For example muscles of respiration regulate the volume of the thoracic cavity during the process of breathing. Physiologic Characteristics of muscle tissue Muscle tissue has four principal characteristics that enable it to carry out its functions and thus contribute to homeostasis. Excitability (irritability), a property of both muscle and nerve cells (neurons), is the ability to respond to certain stimuli by producing electrical signal called action potentials (impulses). For example, the stimuli that trigger action potentials are chemicals-neurotransmitters, released by neurons, hormones distributed by the blood. Contractility is the ability of muscle tissue to shorten and thicken (contract), thus generating force to do work. Elasticity means that muscle tissue tends to return to its original shape after contraction or extension. Connective Tissue Component A skeletal muscle is an organ composed mainly of striated muscle cells and connective tissue. Each skeletal muscle has two parts; the connective tissue sheath that extend to form specialized structures that aid in attaching the muscle to bone and the fleshy part the belly or gaster. The extended specialized structure may take the form of a cord, called a tendon; alternatively, a broad sheet called an aponeurosis may attach muscles to bones or to other muscles, as in the abdomen or across the top of the skull. Connective tissue also extends into the muscle and divides it into numerous muscle bundles (fascicles). Microscopic structures The muscle bundles are composed of many elongated muscle cells called muscle fibres. Each muscle fibre is a cylindrical cell containing several nuclei located immediately beneath the cell membrane (sarcolemma). Myofibrils consist of two major kinds of protein fibres: actins or thin myofilaments, and myosin or thick myofilaments. The actins and myosin myofilaments form highly ordered units called sarcomers, which are joined end-to-end to form the myofibrils (see Figure 6-1). The ends of a sarcomere are a network of protein fibres, which form the Z-lines when the sarcomere is viewed from side. The arrangement of the actin and myosin myofilaments in a sarcomere gives the myofibril a banded appearance because the myofibril appears darker where the actin and myosin myofilaments overlap. The alternating light (I-band) and dark (A-band) areas of the sarcomers are responsible for striation (banding pattern) seen in skeletal muscle cells observed through the microscope. Within the sarcoplasm of the muscle fibre there is an extensive network of branching and anastomosing channels, which forms the sarcoplasmic reticulum (this structure is a modified endoplasmic reticulum). The channels of the sarcoplasmic reticulum lay in close contact around the ends of T-tubules, and contain stores of calcium. The thin myofilaments are composed of a complex protein called actin, arranged in a double stranded coil. Structure of a skeletal muscle (From Memmler, Ruth Lundeen et al: The human body in Health and disease,ed. When a nerve impulse reaches a muscle fibre it is conducted over the sarcolemma and in to the T-tubules, then to the sarcoplasmic reticulum. The liberated calcium ions combine with troponin causing it to push tropomysin away from the receptor sites on the actins filaments. The myosin crossbridges interact 114 Human Anatomy and Physiology with the actin receptor sites and pull the actins myofilaments toward the centre (H-zone) of each sarcomere. The bond between the myosin crossbridges and actin breaks down under the influence of enzymes and the crossbridges are then free to rejoin with other actin receptor sites. The actin filaments do not shorten but slide past the myosin filaments overlapping them so that the Z lines are drawn toward each other, shortening the sarcomere. Relaxation of the muscle fibres occurs when the calcium ions are actively reabsorbed by the sarcoplasmic reticulum thus allowing troponin and tropomysin to again inhibit the interaction of the actins and myosin filaments (see Table 6-1 for summary of events in the contraction of a muscle fibre).

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The ureters are retroperitoneal and lead from the renal pelvis of the kidney to the trigone area at the base of the bladder proven 5mg clarinex. A thick muscular wall consisting of longitudinal and circular smooth muscle helps move urine toward the bladder by way of peristaltic contractions purchase 5mg clarinex with visa. The renal arteries arise directly from the aorta, and the renal veins drain directly into the inferior vena cava. A portal system is formed when the blood flows through a second capillary bed surrounding the proximal and distal convoluted tubules and the loop of Henle. This filtrate is processed and finally gathered by collecting ducts that drain into the minor calyces, which merge to form major calyces; the filtrate then proceeds to the renal pelvis and finally the ureters. Cortical nephrons have short loops of Henle, whereas juxtamedullary nephrons have long loops of Henle extending into the medulla. A filtration membrane is formed by the fused basement membranes of the podocytes and the capillary endothelial cells that they embrace. Contractile mesangial cells further perform a role in regulating the rate at which the blood is filtered. The hydrostatic pressure of the glomerulus depends on systemic blood pressure, autoregulatory mechanisms, sympathetic nervous activity, and paracrine hormones. The kidney can function normally under a wide range of blood pressures due to the autoregulatory nature of smooth muscle. Even so, it only influences the last 10 percent of water available for recovery after filtration at the glomerulus, because 90 percent of water is recovered before reaching the collecting ducts. Depending on the body’s fluid status at any given time, the collecting ducts can recover none or almost all of the water reaching them. Movement of water from the glomerulus is primarily due to pressure, whereas that of peritubular capillaries and vasa recta is due to osmolarity and concentration gradients. The descending loop of the juxtaglomerular nephrons reaches an osmolarity of up to 1200 mOsmol/kg, promoting the recovery of water. The ascending loop is impervious to water but + actively recovers Na , reducing filtrate osmolarity to 50–100 mOsmol/kg. The descending and ascending loop and vasa + recta form a countercurrent multiplier system to increase Na concentration in the kidney medulla. The collecting ducts actively pump urea into the medulla, further contributing to the high osmotic environment. Sympathetic nervous activity decreases blood flow to the kidney, making more blood available to other areas of the body during times of stress. The arteriolar myogenic mechanism maintains a steady blood flow by causing arteriolar smooth muscle to contract when blood pressure increases and causing it to relax when blood pressure decreases. Natriuretic hormones, released primarily from the atria of the heart in response to stretching of the atrial walls, stimulate + Na excretion and thereby decrease blood pressure. Progesterone is similar in structure to 1244 Chapter 25 | The Urinary System aldosterone and can bind to and weakly stimulate aldosterone receptors, providing a similar but diminished response. Blood pressure is a reflection of blood volume and is monitored by baroreceptors in the aortic arch and carotid sinuses. The kidneys catalyze the final reaction in the synthesis of active vitamin D that in turn helps regulate ++ Ca. The kidneys work with the adrenal cortex, lungs, and liver in the renin–angiotensin–aldosterone system to regulate blood pressure. The kidneys share pH regulation with the lungs and plasma buffers, so that proteins can preserve their three-dimensional conformation and thus their function. Give the approximate osmolarity of fluid in the large urine volumes, but how would other characteristics of proximal convoluted tubule, deepest part of the loop of the urine differ between the two diseases? In the human body, the substances that participate in chemical reactions must remain within narrows ranges of concentration. Because metabolism relies on reactions that are all interconnected, any disruption might affect multiple organs or even organ systems. The interactions of various aqueous solutions—solutions in which water is the solvent—are continuously monitored and adjusted by a large suite of interconnected feedback systems in your body. Understanding the ways in which the body maintains these critical balances is key to understanding good health. In the human body, solutes vary in different parts of the body, but may include proteins—including those that transport lipids, carbohydrates, and, very importantly, electrolytes. Often in medicine, a mineral dissociated from a salt that carries an + - electrical charge (an ion) is called and electrolyte. In the body, water moves through semi-permeable membranes of cells and from one compartment of the body to another by a process called osmosis.

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The anterior and lateral columns are composed of many different groups of axons of both ascending and descending tracts—the latter carrying motor commands down from the brain to the spinal cord to control output to the periphery generic 5mg clarinex amex. Basal Nuclei Parkinson’s disease is a disorder of the basal nuclei discount 5 mg clarinex with visa, specifically of the substantia nigra, that demonstrates the effects of the direct and indirect pathways. Without that modulatory influence, the basal nuclei are stuck in the indirect pathway, without the direct pathway being activated. The increased activity of the indirect pathway results in the hypokinetic disorder of Parkinson’s disease. Parkinson’s disease is neurodegenerative, meaning that neurons die that cannot be replaced, so there is no cure for the disorder. With levels of the precursor elevated, the remaining cells of the substantia nigra pars compacta can make more neurotransmitter and have a greater effect. According to one hypothesis about the expansion of brain size, what tissue might have been sacrificed so energy was available to grow our larger brain? Based on what you know about that tissue and nervous tissue, why would there be a trade-off between them in terms of energy use? To protect this region from the toxins and pathogens that may be traveling through the blood stream, there is strict control over what can move out of the general systems and into the brain and spinal cord. The next branches give rise to the common carotid arteries, which further branch into the internal carotid arteries. The bases of the common carotids contain stretch receptors that immediately respond to the drop in blood pressure upon standing. The orthostatic reflex is a reaction to this change in body position, so that blood pressure is maintained against the increasing effect of gravity (orthostatic means “standing up”). Heart rate increases—a reflex of the sympathetic division of the autonomic nervous system—and this raises blood pressure. Branches off the left and right vertebral arteries merge into the anterior spinal artery supplying the anterior aspect of the spinal cord, found along the anterior median fissure. The two vertebral arteries then merge into the basilar artery, which gives rise to branches to the brain stem and cerebellum. The left and right internal carotid arteries and branches of the basilar artery all become the circle of Willis, a confluence of arteries that can maintain perfusion of the brain even if narrowing or a blockage limits flow through one part (Figure 13. The circle of Willis is a specialized arrangement of arteries that ensure constant perfusion of the cerebrum even in the event of a blockage of one of the arteries in the circle. The animation shows the normal direction of flow through the circle of Willis to the middle cerebral artery. Where would the blood come from if there were a blockage just posterior to the middle cerebral artery on the left? The superior sagittal sinus drains to the confluence of sinuses, along with the occipital sinuses and straight sinus, to then drain into the transverse sinuses. The dura mater is a thick fibrous layer and a strong protective sheath over the entire brain and spinal cord. Beneath the arachnoid is a thin, filamentous mesh called the arachnoid trabeculae, which looks like a spider web, giving this layer its name. It is directly attached to the inner surface of the bones of the cranium and to the very end of the vertebral cavity. Two infoldings go through the midline separations of the cerebrum and cerebellum; one forms a shelf-like tent between the occipital lobes of the cerebrum and the cerebellum, and the other surrounds the pituitary gland. Arachnoid Mater The middle layer of the meninges is the arachnoid, named for the spider-web–like trabeculae between it and the pia mater. The name pia mater comes from the Latin for “tender mother,” suggesting the thin membrane is a gentle covering for the brain. This procedure is called a lumbar puncture and avoids the risk of damaging the central tissue of the spinal cord. Blood vessels that are nourishing the central nervous tissue are between the pia mater and the nervous tissue. The particular pathogens are not special to meningitis; it is just an inflammation of that specific set of tissues from what might be a broader infection. Bacterial meningitis can be caused by Streptococcus, Staphylococcus, or the tuberculosis pathogen, among many others. Viral meningitis is usually the result of common enteroviruses (such as those that cause intestinal disorders), but may be the result of the herpes virus or West Nile virus. The symptoms associated with meningitis can be fever, chills, nausea, vomiting, light sensitivity, soreness of the neck, or severe headache. More important are the neurological symptoms, such as changes in mental state (confusion, memory deficits, and other dementia-type symptoms). A serious risk of meningitis can be damage to peripheral structures because of the nerves that pass through the meninges. A needle inserted into the lumbar region of the spinal column through the dura mater and arachnoid membrane into the subarachnoid space can be used to withdraw the fluid for chemical testing.

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However buy clarinex 5mg mastercard, adult men have been reported to be more at risk of occupational exposures than adult woman discount clarinex 5 mg with amex. Route of entry of exposures reported was by mouth in most cases: 77% were the result of ingestion, 7. In general, nearly everyone is at risk of acute and chronic toxic exposures to hazardous substances in the ambient environment. Toxicologic terms and definitions A) Important toxicologic terms  Toxin- a poison of natural origin. It is a qualitative term which depends on the amount of chemical absorbed, severity of the exposure, dose & others. It can be acute (toxic event which occurs soon after acute or limited exposure), or chronic (apply to an event which occurs many weeks, months or years after exposure). B) Presence of mixtures Humans normally come in contact with several (or many) different chemicals concurrently or sequentially. The resulting biologic effect of combined exposure to several agents can be characterized as synergistic, additive, Potentiation & antagonistic Synergism-when the effect of two chemicals is greater than the effect of individual chemicals e. Antagonism -is the phenomenon of opposing actions of two chemicals on the same system e. Basic classification of toxicology Toxicology is broadly divided into different classes depending on research methodology, socio-medical & organ/specific effects. Descriptive toxicology Descriptive toxicology deals with toxicity tests on chemicals exposed to human beings and environment as a whole. Mechanistic toxicology Mechanistic toxicology deals with the mechanism of toxic effects of chemicals on living organisms. Instead of organophosphates, drugs which reversibly bind to cholinesterase would be preferable in therapeutics) 6 Toxicology C. Regulatory toxicology Regulatory toxicology studies whether the chemical substances has low risk to be used in living systems E. Predictive toxicology Predictive toxicology studies about the potential and actual risks of chemicals /drugs. Based on specific socio-medical issues A) Occupational toxicology Occupational toxicology Deals with chemical found in the workplace E. B) Environmental toxicology Environmental toxicology deals with the potentially deleterious impact of chemicals, present as pollutants of the environment, to living organisms. It is concerned with the toxic effects of chemical and physical agents on living organisms, especially in populations and communities with defined ecosystems. C) Clinical toxicology Clinical toxicology deals with diagnosis and treatment of the normal diseases or effects caused by toxic substances of exogenous origin i. D) Forensic toxicology Forensic toxicology closely related to clinical toxicology. It deals with the medical and legal aspects of the harmful effects of chemicals on man, often in post mortem material, for instance, where there is a suspicion of murder, attempted murder or suicide by poisoning. Toxicokinetics and Toxicodynamics - Toxicokinetics deals with absorption, distribution, biotransformation (biotransformation) and excretion of chemicals. Toxicokinetics i) Absorption Absorption is the process by which the chemical enters the body. It depends on the route of administration, dissociation (to become ionized), dissolution (ability of solid dosage form to become soluble), concentration, blood flow to the site, and the area of the absorptive site. Bioavailability is the fraction of unchanged drug reaching the systemic circulation following of non-vascular administration. Volume of distribution (Vd) is calculated from the dose taken and the resulting plasma concentration: Vd = dose /plasma concentration The importance of volume of distribution in toxicology is - Predicting peak blood concentration of the chemical taken - Calculating the amount of substance in the body to verify the quantity ingested - Deciding whether to apply systemic toxin elimination techniques Factors determining the rate of distribution of chemicals in the body are - Protein binding – chemicals highly bound to protein have small volume of distribution - Plasma concentration – when the volume of distribution of chemicals is small, most of the chemical remains in the plasma - Physiological barriers – chemicals will not uniformly distributed to the body due to specialized barriers e. It is a process by which the body transforms a chemical and makes it more water soluble so the chemical can be eliminated more rapidly via the kidney into the urine. Biotransformation can produce metabolites that are pharmacologically active and toxic E. Liver is the major site of biotransformation for many chemicals & other organs that are involved are lungs, kidneys, skin &so on. Interactions during biotransformation includes There are two phases of biotransformation Phase I – the drug is converted into more polar compound e. Half life (t ½) –is the time required to reduce the blood concentration of the chemical to half. Excretion through the lungs is the major route for gaseous substances; and in the case of non-volatile water – soluble drugs, the kidneys are the most important routes of excretion. Additional routes include sweat, saliva, tears, nasal secretions, milk, bile and feces. It is a quantitative measure of the volume of blood cleared of drug per unit time, usually expressed in milliliter pe4r minute.

A specialized region of this layer buy clarinex 5mg low price, the neuroectoderm buy 5 mg clarinex mastercard, becomes a groove that folds in and becomes the neural tube beneath the dorsal surface of the embryo. The brain develops from this early tube structure and gives rise to specific regions of the adult brain. As the neural tube grows and differentiates, it enlarges into three vesicles that correspond to the forebrain, midbrain, and hindbrain regions of the adult brain. The spinal cord develops out of the rest of the neural tube and retains the tube structure, with the nervous tissue thickening and the hollow center becoming a very small central canal through the cord. The rest of the hollow center of the neural tube corresponds to open spaces within the brain called the ventricles, where cerebrospinal fluid is found. The frontal lobe is responsible for motor functions, from planning movements through executing commands to be sent to the spinal cord and periphery. The most anterior portion of the frontal lobe is the prefrontal cortex, which is associated with aspects of personality through its influence on motor responses in decision-making. The occipital lobe is where visual processing begins, although the other parts of the brain can contribute to visual function. The temporal lobe contains the cortical area for auditory processing, but also has regions crucial for memory formation. Nuclei beneath the cerebral cortex, known as the subcortical nuclei, are responsible for augmenting cortical functions. The basal nuclei receive input from cortical areas and compare it with the general state of the individual through the activity of a dopamine-releasing nucleus. The output influences the activity of part of the thalamus that can then increase or decrease cortical activity that often results in changes to motor commands. The cerebellum is connected to the brain stem, primarily at the pons, where it receives a copy of the descending input from the cerebrum to the spinal cord. It can compare this with sensory feedback input through the medulla and send output through the midbrain that can correct motor commands for coordination. The arterial blood to the brain comes from the internal carotid and vertebral arteries, which both contribute to the unique circle of Willis that provides constant perfusion of the brain even if one of the blood vessels is blocked or narrowed. The blood that nourishes the brain and spinal cord is behind the glial-cell–enforced blood-brain barrier, which limits the exchange of material from blood vessels with the interstitial fluid of the nervous tissue. This fluid is produced by filtering blood at the choroid plexuses in the four ventricles of the brain. It then circulates through the ventricles and into the subarachnoid space, between the pia mater and the arachnoid mater. It surrounds the venous space known as the dural sinuses, which connect to the jugular veins, where blood drains from the head and neck. Sensory ganglia contain unipolar sensory neurons and are found on the dorsal root of all spinal nerves as well as associated with many of the cranial nerves. Autonomic ganglia are in the sympathetic chain, the associated paravertebral or prevertebral ganglia, or in terminal ganglia near or within the organs controlled by the autonomic nervous system. Nerves are classified as cranial nerves or spinal nerves on the basis of their connection to the brain or spinal cord, respectively. The twelve cranial nerves can be strictly sensory in function, strictly motor in function, or a combination of the two functions. Sensory fibers are axons of sensory ganglia that carry sensory information into the brain and target sensory nuclei. Motor fibers are axons of motor neurons in motor nuclei of the brain stem and target skeletal muscles of the head and neck. Spinal nerves emerge from the spinal cord and reorganize through plexuses, which then give rise to systemic nerves. As the anterior end of the as the basal ganglia), which have two pathways that process neural tube develops, it enlarges into the primary vesicles information within the cerebrum. Those the indirect pathway is the longer pathway through the structures continue to develop throughout the rest of system that results in decreased activity in the cerebral embryonic development and into adolescence. What is the end of the three regions of the brain when comparing the early result on the thalamus, and therefore on movement initiated (25th embryonic day) brain and the adult brain? The caption for the video describes it as “less The cervical and lumbar spinal cords have enlargements as gray matter,” which is another way of saying “more white a result of larger populations of neurons. That evolutionary history is as the basal ganglia), which have two pathways that process long and is still an area of intense study. As shown in this video, happened to increase the size of the human brain relative the direct pathway is the shorter pathway through the to the chimpanzee. The direct pathway is author explores the current understanding of why this described as resulting in “disinhibition” of the thalamus. What are the two neurons According to one hypothesis about the expansion of brain doing individually to cause this? Based on what you know about that tissue and nervous tissue, why would there be a trade-off between them in terms of energy use?

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By increasing perception of person risk and life skills training students learn alcohol discount clarinex 5 mg mastercard, tobacco purchase clarinex 5 mg with mastercard, and drug abuse information and resistance skills to deal with peer and media pressure through coaching and practice. Personal Self-Management Skills teach students how to examine their self-image and its effects on behavior. Students learn to set goals, make decisions, analyze problems and consider the consequences of each solution before making a decision. Implement the most promising prevention strategy available and reinforce it across the school environment – good practice The field of drug abuse prevention is based on extensive research. It is not advisable for teachers and other school personnel to try to develop prevention curricula without extensive study and training. Anyone who develops a prevention curriculum should have a thorough understanding of the critical ingredients of effective prevention programming. Drug abuse school prevention programs which is based on normative expectance theory and social resistance theory. They teach students that most of the people they admire, including their peers, do not use drugs and do not think drug use is “cool. These programs provide teachers with training, so that they feel comfortable directing discussions about the acceptability of drug use, and eliciting information from students to show that most young people do not approve of drug use. They also use a variety of demonstration techniques, such as having students move to one side of the room or the other depending on whether they agree or disagree to various opinion statements about drugs, to show in a very concrete and public way 12 Mónica Gázquez Pertusa, José Antonio García del Castillo, Diana Serban and Diana Bolanu where they “stand” on an issue. Drug abuse school prevention programs, which are based on effectively resist social influences by media and peers. Students learn about the kinds of influences and pressures they are likely to be exposed to, including media influences, and the subtle messages in advertising. In particular, they learn how to question messages they hear and say no to peers without losing friends. To do this effectively they learn explicit, step-by-step instructions and are given ample time to develop and practice this new skill inside and outside of class. Drug abuse school prevention programs which is based on normative education and social resistance skills training/ social skills. Normative education, social resistance skills training and personal and social skills training are best accomplished using interactive teaching techniques such as: - Brainstorming. It is important that teachers receive training and are comfortable using these techniques and implementing the lessons as program developers intended. These programs have evolved from more traditional models, which are based on the transmission of information and affective approaches, into the most current models. These current models produce their effects by affecting the risk and protective factors associated with drug use; this is done by combining the best didactics and pedagogy of knowledge transmission with cognitive-behavioral techniques based on the development of personal and social skills. The main objective of the current models is to train adolescents to deal with conflict and pressure situations, make decisions and clarify goals. Furthermore, they promote attitudes that are critical toward drug use and favorable to the maintenance of health. In short, these are the personal competencies that act as protective factors for health (Espada, Rosa, and Mendez, 2003). Using as reference the content they include, school-based prevention programs can be classified into: − Traditional approaches. Below the most defining characteristics of each of the school-based preventive approaches developed to date are reviewed through an analysis of the advantages and limitations that evaluative research of these interventions yield. Before the 1960s, the phenomenon of drug use was already beginning to generate concern among governments and groups of health professionals. Nevertheless, the main government policies and measures carried out were based on legislative approaches aimed at reducing the drug supply; such measures did not achieve great results. In the late sixties and coinciding with the commonly called drug epidemic, earlier repressive measures began to be replaced by programs based on the transmission of information and those resorting to fear. The first programs developed assumed that the use of drug occurred because of a lack of information about the risks associated with their consumption. The basic premise from which they started was that if people have adequate knowledge about drugs then they will not have attitudes or intentions to consume them; therefore, they will make rational decisions leading them to not use drugs (Becoña, 2002; Goodstadt, 1978). For this reason, these programs based their plan of action on providing information about negative consequences, drug use patterns, and the pharmacology and process of addiction. The strategies employed in these models were limited to talks given by experts, police officers and ex-drug addicts. Various studies show that these programs, when implemented as the only preventive strategy, have shown some impact on the level of information and very poor results in attitudinal change; they even indicate a possible counter- preventive effect. Because by providing information inappropriate for certain ages, target groups do not perceive messages in the same way that they are transmitted and curiosity regarding the possible pleasurable effects of drugs is piqued.

In general generic clarinex 5mg line, surgery should be avoided in the treatment of prostatitis patients except for drainage of prostatic abscesses purchase clarinex 5mg overnight delivery. Perioperative Antibacterial Prophylaxis in Urological Surgery The main aim of antimicrobial prophylaxis in urology is to prevent symptomatic / febrile genitourinary infections, such as acute pyelonephritis, prostatitis, edpididymitis and urosepsis as well as serious wound infections. Antibiotic prophylaxis is recommended only for a maximum of 24 hours after surgery in most situations. More rampant use leads to antibiotic resistance and places an additional economic burden. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Effect of norfloxacin, trimethoprim- sulfamethoxazole and nitroffurantoin on fecal flora of women with recurrent urinary tract infections. Comparison of short-term treatment regimen of ciprofloxacin versus long-term treatment regimens of trimethoprim/sulfamethoxazole or norfloxacin for uncomplicated lower urinary tract infections: a randomized, multicentre, open-label, prospective study. The latest updates have been published in 2010 The significant differences in the socioeconomic and disease pattern (mode of presentation, stone bulk, health care delivery facilities) for urolithiasis in India make it imperative to formulate our own guidelines. Indian references have been cited, particularly so, if they are prospective randomized studies and/or metanalysis. Case definition The index patients are defined as follows:- Ureteral stones 18 A non pregnant adult patient with unilateral ureteral calculi (no renal stones) and normal functioning contralateral kidney, the body habitus, anatomy and medical condition should not (2) preclude the application of any of the available treatment options Staghorn calculi A staghorn calculi is defined as a stone with central body and at least one calyceal branch. Index patient (staghorn calculi):- Adult with a staghorn stone (non Cystine, non uric acid) who has two functioning kidneys (functioning both kidneys) or a solitary kidney with normal function. Any pelvic and /or calyceal calculi which do not fit in the definition of staghorn calculi Incidence in our country Although a few studies have been reported for a small group of subjects in screening camps. It is commonly seen in western states, hypothetically, attributable to high salinity of water. Renal stones Investigations:- Imaging is absolutely imperative if, the patient has a solitary kidney or a history of fever. Recommendation:-Excretory urography is the gold standard in work up for urolithiasis and is mandatory in solitary kidney, history of fever and when the diagnosis is in doubt. Analysis of stone composition Stone analysis is desirable in recurrent stone formers. Special investigations which are ordered on case to case merit are renal scintigraphy, antegrade, retrograde contrast study. Indications for intervention The indication for stone removal depends on the size, site and shape of the calculus. The likelihood of spontaneous passage, presence of obstruction should be assessed. The indications for intervention are:- 1) When the stone diameter is more than 7 mm (because of low rate of spontaneous passage). Recommendation:-For1, 2 stone removal with or without prior decompression(depending on the clinical situation) is recommended ,in situation ,3,4,5,6 emergency deobstruction of the collecting system is recommended. Various studies have attempted to show the correlation of geometry of the lower calyx to predict the clearance of stone in this location. However the calyceal stone burden is the most important factor in predicting the clearance. Specific stone compositions have different clearance rates because of the varying 22 fragility of stones. Better fragmentation can be achieved with starting the fragmentation (17) at lower energy setting and then ramping up the power. In case of infected stones, antibiotics should be given according to urine culture sensitivity, the (2) same should be continued after surgery for 4 days Clinical experience suggests that stones in the ureter rather than the kidney should be treated with shorter intervals between sessions. Antibiotics should be given according to urine culture sensitivity, the same should be continued after surgery for 4 days. The physicians should refer to the manufacturer recommendation regarding the decision of number, frequency and power of shocks. The tract should be the shortest possible tract from 24 the skin to the desired calyx traversing the papilla. Depending on the stone configuration a calyx should be selected (Supracostal, infracostal or subcostal) so that maximum stone bulk can (23) be cleared minimum number of tracts. Renal tract dilatation either balloon, amplatz or (2) metallic dilators are a matter of surgeon preference and availability. In uncomplicated cases, tubeless percutaneous nephrolithotomy with or without application of (25) (26) tissue sealants is a safe alternative i) Complications The patients should be counseled regarding the complications which are likely to be encountered such as life threatening bleeding with a possible need for angioembolisation or even nephrectomy. The patients should be counseled regarding the possibility of residual calculi and the consequences thereof. The procedure becomes challenging in complex stones, although the complications are not specific to them.