This document discusses the anatomy related to pediatric anorectal surgery and continence. It covers the anatomy of the rectum, anal canal, levator ani muscles, internal and external anal sphincters, and their roles in continence. It also discusses techniques for evaluating postoperative continence, including subjective and objective scoring systems that assess various anorectal properties and functions.
This is an oblique intermuscular passage in the lower part of the anterior abdominal wall ,
Situated just above the medial half of the inguinal ligament
This is an oblique intermuscular passage in the lower part of the anterior abdominal wall ,
Situated just above the medial half of the inguinal ligament
Bladder exstrophy is a congenital (present at birth) abnormality of the bladder. It happens when the skin over the lower abdominal wall (bottom part of the tummy) does not form properly, so the bladder is open and exposed on the outside of the abdomen. In epispadias, the urethra does not form properly.
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
In this presentation I have shown the etiology, clinical features and treatment for both Phimosis & Paraphimosis. I have also showed various methods of circumcision for both infants and adults.
Bladder exstrophy is a congenital (present at birth) abnormality of the bladder. It happens when the skin over the lower abdominal wall (bottom part of the tummy) does not form properly, so the bladder is open and exposed on the outside of the abdomen. In epispadias, the urethra does not form properly.
Rectal prolapse (Surgical anatomy of rectum, pathology and management0sunil kumar daha
Please find the powerpoint on Rectal prolapse. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references.
In this presentation I have shown the etiology, clinical features and treatment for both Phimosis & Paraphimosis. I have also showed various methods of circumcision for both infants and adults.
In this playlist I discussed about groin swellings and the various causes for this problem. I discussed about Inguinal hernia, femoral hernia, ventral hernia and undescended testis. If you watch all these videos together you will become confident in managing groin swellings
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Fundamentals of pelvis, perineum and male genitalia anatomy. contains short notes with atlas. easy for self study of preclinical and clinical students and residents. clinically important common correlations are included. well animated power point presentation.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
5. The anatomy of continence 27 The ability to retain-voluntarily or involuntarily-the intestinal contents until an evacuation is desired”. Holschneider
22. Defecation reflex 10 Initiation by voluntary abdominal contraction, gastrocolic reflex, colonic reflex, direct rectal mucosal stimulation, rectal distention Filling and distension of lower rectum Increase rectal pressure Stimulation of receptors in the pelvic floor – desire to defecate- relaxation of the internal sphincter If not voluntary inhibited The external sphincter also relaxes No social opportunity, contraction of external anal sphincter and puborectalis- Rectal adaptation occurs Defecation
A normal anorectum is one of the greatest creation of nature and is one of the best examples of structural and physiological coordination which is under voluntary human control. This is best appreciated by the patients who have structural and neurological deficiencies in this regard. This group of patients is represented by the ones having anorectal malformations and spina bifida. Applying the clinical anatomy of normalcy is one of the basic requirements when we treat the mentioned set of pediatric surgical patients. Hence today we will try to understand the basics of the normal structural anatomy with the understanding of various factors responsible for continence.
Within this discussion and the alloted time it will be difficult to describe the complex structural and neural organisation of the normal anorectum. However we will try to highlight of the basic structural anatomy and the continence appratus of the anorectum with the physiology of the defecation. I guess the following speakers will be speaking on the abnormal and the ARM part of it, it will be irresistable not to mention the structural and neural abberations in patients of ARM.
The rectum as we know is a hindgut derivative which can be differentiated from the proximal sigmoid by the absence of the tanea and the haustration it arbitarily starts opposite the sacral promontary. The upper one third is is covered by the peritoneal reflection whereas the lower 2/3 rd ir devoid of any peritoneum. The middle part of the rectum is capacious and contributes to the major capacity of the rectum called as the ampula. This serves to store the fecal matter and contributes to the system of continence, this storage function is absent to some extent in the pulled through gut (colon/small intestine). The rectum terminates into the anal canal and has an angulation at this level which again contributes to the continence. There are several other anatomical features of the normal rectum which shall be described as an when they find mention while I describe the anatomy of continence later in the presentation.
The anal canal is the final exit conduit for what we eat, is an ectodermal derivative. The books have always confused the medical student over the definition of extent of surgical anal canal and anatomical anal canal. What I feel is that it is more than sufficient to understand that it commences at the level where the rectum passes through the levator diaphragm and angulates ending at the anal verge. Still for some understanding the surgical anal canal is at the level at which the internal anal sphincter turns into a less bulky circular muscle coat of rectum and is appreciated on a pr examination. The anatomical canal is till where the anal columns end in their height This is the most important structure with its entire apparatus of surrounding sphincters. This can be appreciated by the fact that all the patients of hirschsprungs who undergo a pull through operation don’t have a rectum but are continent as this anal canal with the sphincter is intact, in contrast to the ARM patients who do not posses an anal canal (except for rectal atresia, even rectal atresia patients are continent by the virture of intact anal canal). The dentate line is the sensing zone capable of unimaginable differention between touch, pain, tenprature, air/solid fecal matter. Again the finer details are described later on.
Now the following discussion will intererst the audience more as it is always been fascinating to know how a normal individual is capable of defecating on will, passing flatus only when u had a bad lunch at the office, and how can our anorectal malformation patients be made to achieve all this. The anorectal continence as seen in this slide occupying the central space is a result of several structural and neural organization. I have divided them into 4 groups. Striated muscle complex, the internal sphincter or the smooth muscle complex, the minor anatomical factors as the perineal body, anorectal angle, rectal ampula and hutson valves and last but even more important the neural innervations in the form of somatic and autonomic control. We shall now try to gain knowledge on the structure and the role played by them.
The striated muscle complex is a two part muscle. It comprises of the external anal sphincter and the levator ani. By virtue of being striated they are under volunatary control. The levator ani forms the pelvic diaphragm and is a major muscular support to the rectum. These are decscibed in detail in the subsequent text.
Levator ani is the 3 part muscle which arises from the inside walls of pelvis converging in midline it forms a funnel shapped portal of exit for the terminal part of the rectum and upper anal canal. The muscle comprises of 3 striated muscles Puborectalis, Pubococcygeous and illiococcygeous. The puborecatlis is the bulkiest and innermost of the three. It orignates from the myotome S1234. It encircles the rectum in a sling like fashion with the two arms inserted onto the inferior ramus of pubes on both sides. This sling is responsible for the acute angle between the rectum and the anal canal. The muscle is capable of shutting the lumen of the anorectum as a voluntary action. The arching fibers of the muscle merge with the deep part of the external sphincter. The muscle is supplied by the pudendal nerve and carries several proprioceptive sensory stimulus generated by rectal distention or increased intrabdominal pressure. Thisis later described.
It is said that patients with complete sacral agenesis will have no puborectalis. If S3 is missing there will be thin PR muscle continence will be doubtful if S4 is missing PR will be week. The remaining two muscles PC and IC help to close the urogenital diaphragm they will also help to elevate straighten steady and suspend the rectum which is supported by the perineal body which is another major structure responsible for pelvic visceral stability
The second part of the striated muscles are the external sphincter which completely surrounds the anal canal. It forms a color of varied thickness around the anal canal is again under voulntary control. It is structurally composed of slow twitch fibers and have the property of muscle fatigue.
This muscle is a three part muscle comprising of subcutaneous, superficial and deep part. The three parts essentially forms a tripple loop system around the anus. This as observed in the diagrams have varying thickness in their coccygeal and perineal parts. the configuration of these loops have some variation in the the two sexes, by virtue of the differences anterior to the anal canal, however they do not differ in the strength.
The deep part of the external sphincter is bulkier perineally that coccygeally. It merges above with the fibers of puborectalis above. The anatomy of the parts of the internal sphincters is best revealed when we study them in relation to the sphincteric abscesses which follow the rules of the anatomical boundries when spreading. The resting tone of the pelvic diaphragm muscles as well as the external sphincter although is taken as of relaxation state but researchers have demonstrated a continuous low level tonicity which is accurately modulated by the sensory reflexes generated from the nerve endings present around the dentate line.
Internal anal sphincter is the second most important spoke of the wheel of continence described earlier. It is essentially the continuation of the circular muscular coat of the rectum. Below it stays in a tear drop configuration. The intersphincteric fascial plane which seperated the external and the internal sphincter is the derivative of the longitudnal muscle coat of the rectum. The muscle is a non fatigable smooth muscle and the in the basal resting state is that of continous tonic contraction. This tonic state of contraction generates a high pressure zone in the lower rectum keeping it empty. The muscle tends to relax with rectal distension a reflex known a the recto anal inhibitory reflex. This reflex is absent in Hirschsprungs owing to the absence of the ganglion cells. Here actually we can understand the orign of the cause of the tonic contracted state of the distal colon producing functional obstruction. As also described later on the autonomic supply of the rectum is by the nervi errigentis – para sympathetic exitatory (increasing peristalsis) and sacral plexus – sympathetic inhibitory (decreasing peristalsis making the bowel lie in contracted state). The misseners and the aurbachs plexus in the hirschsprungs carry predominantly the parasympathetic components and since they are missing it will result in a sympathetic overdrive resulting into a state of tonic contraction. This presumption is still debatable in the literature.
Once we have an understanding of the structural integration of the muscles of continence it will be easy to understand the dynamics involved in the system of continence. In a resting state the intra rectal pressure is approximately 30 mm Hg. Of this almost 2/3 rd is contributed by the puborectalis and the external sphincter when ever the individual wants to hold the defecation. The remaining 1/3 rd is from internal sphincter which is tonically contracted, this preassure is good enough to prevent leakage during resting state or sleep. But during times of raised intra abdominal pressure like coughing and sneezing additional pressure is generated by the striated muscle complex.
Apart from the muscles described there are several other anatomical components which help in continence. Perineal body is an important structure which I feel has not been adequately described in relation to the continence structures. The importance of perineal body can be realized from the fact that if an episiotomy incision made during vaginal child birth is not sutured at all or not done properly will result in total anorectal incontinence or stress fecal incontinence. Anatomically perineal body is a central tendinous area with 4 muscles conversing onto it. 2 are paired and 2 are unpaired. Superficial transverse perineii and deep TP are paired coming from lateral origins. The arching fibers of puborectalis along with fibers of bulbospongiosus being unpaired come from the posterior and anterior direction respectively. Thus there will be a null movement of the perineal body if all the four muscles are contracting. Lact of structural integrity of specially the anterio-posterio direction will result in instability and resulting incontinence. Apart from this there are other minor factors like the anorectal angle and the rectal mucosal valves which will act as a speed breakers to the downstream of the fecal matter bolus. Rectal ampula act as a storage area allowing to decrease the bulk of fecal bolus travelling down at one time. There minor components are missing in the ARM pullthrough patients.
The neural supply of the anorectum comes from the S2,3 and 4 th nerves. The somatic supply is via the pudendal nerve. the autonomic supply is via the hypogastric plexus and the nervi erigentis for the parasympathetic component. Onuf nucleus which innervates the pelvic floor muscles occupies an intermediate position between the visceral and somatic nuclei it recives suprasegmental afferents which are direct corticospinal fibers.
Hence one can see the basic neural gear is the S234 sacral vertebrae nerves which drive both the somatic as well as the parasympathetic part of the neural control. Some of our ARM patients with sacral agenesis are unfortunate to have this important component missing and hence are incontinent.
With all the structural components intact an incredible physiological co ordination is present for the mechanism of continence. This is contributed by the sensory and the motor reflex pathways and some unique properties of the rectal peristalsis. We will now eloborate on this one by one.
Two types of sensory reflexes prevail. One is the reflex generated by the rectal distension resulting in the relaxation of the internal sphincter. This results in the initial urge in an individual to defecate, and one an opportunity is present the remaining external sphincters also relax and if not the striated muscle complex will prevent the stool coming down in fact it will be pushed proximally. There is another finer proprioceptive reflex which is generated by the sensitive receptors at the dentate line and the upper anal canal. These receptors sample the content coming in their contact and allow the individual to discriminite between air and solid. Subsequently the external anal sphincter is made to relax via the cortical afferents through the onuf nucleus and the pudendal nerve. So it is again quite unfortunate to have a missing anal canal and dentate line in our ARM patients who are not able to make this discrimination and have soiling accidents.
The motor reflex is contributed by the tonic contraction of the internal anal sphincter and the reflex levator with external anal sphincter once the individual decides to hold. This again may be fine tuned by the sensory reflexes for gas discrimination.
There are some some unique rectal properties of its contractility which is not present in the proximal colon. Mass isoperistaltic waves are generated by various GI reflexes as the gastrocolic reflex it results in the initiation of the defecation. As described in one of the previous slides the lower part of the rectum is kept empty because of some low amplitude basal electrical rhythm which tend to push the contents proximally. This reverse peristalsis also helps in times of restraint when we decide against defecaton this along with the strong contraction of the levator will push the rectal contents up into the sigmoid. And this is how and urge to defecate will dissapear one the rectum is empty and rectal distension is relived. Rectal adaption is something similar to what happens with our urinary bladder where a larger volume of urine is accomodated without the urge to urinate but this is not by the virtue of the mucosal properties of the rectum unlike the urinary bladder. It is rather by the phenomenas described above.
Now the sequence of events in the defecation can be understood easily via this diagram.
So far if we have understood the importance of all the structural and neural components taking part in the continence mechanism. It will now be easy to appreciate why ARM patients are incontinent even after reconstructive surgery. The fig explains the missing important structural components.
Similarly the there are several missing neural components. These are highlighted in the fig.