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The solitary nucleus and tract (nucleus tractus solitarius) is a complex integrative nucleus that is lateral to the dorsal motor nucleus impotence quit smoking order 100 mg kamagra effervescent visa. The nucleus tractus solitarius has connections with multiple structures including the reticular formation and the dorsal motor nucleus. The nucleus ambiguus lies ventrolateral to the dorsal motor nucleus and the nucleus tractus solitarius. It con- Medial longitudinal fasciculus the medial longitudinal fasciculus is a white matter tract containing ascending and descending fibres that extend throughout the brainstem. The medial longitudinal fasciculus is close to the midline dorsally in the medulla and retains its midline position as it ascends but becomes increasingly ventral. This permits coordination of eye movements with movement of the head, and plays a role in the vestibulo-ocular reflex. Spinocerebellar tract the spinocerebellar tracts are composed of a dorsal and a ventral component and are described in further detail on p. The reticular formation the reticular formation is considered to be phylogenetically ancient given its role in controlling cardiovascular and respiratory function. It also has a range of functions related to awareness, consciousness, modulation of pain and motor function. It is an extensive, polysynaptic, ill-defined neuronal network forming the central core of the brainstem that is present throughout the tegmentum of the midbrain, pons and medulla. Anatomically the reticular formation can be organized into three longitudinal columns: median, paramedian and lateral. Despite being an ill-defined network, various nuclei can be discerned within the reticular formation. Certain nuclei have specific neurotransmitters that project widely across the forebrain and have a wide range of functions related to consciousness, awareness, movement, learning and reward. For example, the pedunculopontine nucleus contains cholinergic neurons, the locus coeruleus in the dorsal pons contains noradrenergic neurons, and serotinergic neurons are present in the raphe nuclei. Certain nuclei in the pons and medulla are considered to be cardiovascular and respiratory centres. The reticular formation has a wide range of afferent inputs from the spinal cord, cerebellum, cranial nerves and forebrain structures. It has major ascending and descending outputs that are known as the reticular activating system and the reticulospinal tract, respectively. The ascending reticular activating system is vital for achieving consciousness and connects the brainstem to the thalamus, through which it can influence various cortical structures. Various nuclei in the pons and midbrain contribute to the ascending reticular activating system and damage to these structures can result in impaired consciousness. The descending medial and lateral reticulospinal tracts originate from the medulla and caudal pons. Their functions vary from the control of posture and limb movement to the modulation of pain. The spinal cord is approximately 40­50 cm in length and has variable anteroposterior and transverse diameters. It has cervical and lumbar enlargements to account for the increased number of sensory and motor neurons of the upper and lower limbs. The ventral median fissure and dorsal median sulcus split the spinal cord into left and right halves. The spinal cord is covered by the three layers of meninges forming the thecal sac. The thecal sac extends beyond the level of the conus medullaris and ends at the second sacral vertebral level. From the apex of the conus, a fibrous extension, the filum terminale, continues caudally (see Chapter 25, p. The filum terminale internum passes through the lumbar cistern and penetrates the caudal aspect of the thecal sac, becoming the filum terminale externum.

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The marginal artery is capable of supplying the colon even in the absence of one of the main feeding trunks erectile dysfunction muse generic kamagra effervescent 100 mg buy on-line. However, at the junctional points between the main vessels, there may be variations in the competence of the anastomoses. It runs upwards and to the left, behind the peritoneum of the posterior wall of the left infracolic compartment and after a variable course divides into an ascending and a descending branch. The ascending branch enters the transverse mesocolon and anastomoses with the middle colic artery. Inferior mesenteric vein lies in the free margin of paraduodenal fold before draining into splenic vein. In case of strangulated internal hernia in duodenojejunal recess, these folds may be cut to enlarge the space. It is called the portal vein because its main tributary, the superior mesenteric vein, begins in one set of the portal vein is about 8 cm long. It is formed by the union of the superior mesenteric and splenic veins behind the neck of the pancreas at the level of second lumbar vertebra. Course Abdomen and Pelvis It runs upwards and a little to the right, first behind the neck of the pancreas, next behind the first part of the duodenum, and lastly in the right free margin of the lesser omentum. The portal vein can thus be divided into infraduodenal, retroduodenal and supraduodenal parts. Termination the vein ends at the right end of the porta hepatis by dividing into right and left branches which enter the liver. Retroduodenal Part 2 Anteriorly 1 First part of duodenum 2 Bile duct 3 Gastroduodenal artery. It is usually measured by splenic puncture and recording the intrasplenic pressure. Section 2 Abdomen and Pelvis 1 the right branch is shorter and wider than the left branch. It traverses the porta hepatis from its right end to the left end, and furnishes branches to the caudate and quadrate lobes. Just before entering the left lobe of the liver, it receives during foetal life: a. Portosystemic Communications (Portocaval Anastomoses) these communications form important routes of collateral circulation in portal obstruction. Veins around umbilicus drain via superior and inferior epigastric veins into superior and inferior vena cava, respectively Superior rectal vein continues up as inferior mesenteric vein which drains into portal vein. Intercostal veins and phrenic veins end in systemic circulation Veins of colon end in the portal circulation. These anastomosing veins result in piles or haemorrhoids There is some anastomoses between portal vein and systemic veins No significance There is some anastomoses between these 2 sets of tributaries these may get injured in procedures done in these areas It may be accompanied by other congenital anomalies Abdomen and Pelvis 2. Position Lower end of oesophagus Lower end of rectum Umbilicus Portal vein Left gastric Superior rectal Paraumbilical 4. Other oesophageal veins drain into hemiazygos and then into vena azygos and superior vena cava. In liver cirrhosis, portal venous pressure is raised, leading to oesophageal varices, which may rupture leading to blood in the vomit. Normally, the anastomoses between tributaries of portal vein and those of superior vena cava is very little. These anastomotic channels develop in an attempt to take portal blood into caval blood. Abdomen and Pelvis Section From Medical Council of India, Competency based Undergraduate Curriculum for the Indian Medical Graduate, 2018;1:44­80. What is the importance of portosystemic anastomoses at the lower end of oesophagus and anal canal It runs downwards for about 3 cm and is joined on its right side at an acute angle by the cystic duct to form the bile duct. Therefore, it is always better to use a drain to avoid retention of bile in the depths of the wound. The fundus projects beyond the inferior border of the liver, in the angle between the lateral border of the right rectus abdominis and the ninth costal cartilage.

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Further amounts of diluents impotence ring buy kamagra effervescent with a visa, equal to the amount of material in the mixer, can then be added and mixed, the process being continued until all material has been added. It may be more appropriate to preblend the active component with a diluent in a smaller mixer prior to transferring it to the main mixer in cases where the amount of active ingredient is very low. Care must be taken to ensure that the volume of powder in the mixer is appropriate, as both over and underfilling may significantly reduce mixing efficiency. In the case of overfilling, for example, sufficient bed dilation may not take place for diffusive mixing to occur to the required extent or the material may not be able to flow in a way that enables shear mixing to occur satisfactorily. Underfilling may mean the powder bed does not move in the required manner in the mixer or that an increased number of mixing operations may be needed for a batch of material. The mixer used should produce the mixing mechanisms appropriate for the formulation. For example, diffusive mixing is generally preferable if potent drugs are to be mixed, and high shear is needed to break up aggregates of cohered material and ensure mixing at a particulate level. The impact or attrition forces generated if too-high shear forces are used may, however, damage fragile material and thus produce fines. The mixer design should be such that it is dust tight, it can be easily cleaned and the product can be fully discharged. These features reduce the risk of cross-contamination between batches and protect the operator from the product. In order to determine the appropriate mixing time, the process should be checked by removing and analysing representative samples after different mixing intervals. This may also indicate if segregation is occurring within the mixer and whether problems could occur if the mixing time is extended. When particles rub past each other as they move within the mixer, static charges will be produced. To avoid this, mixers should be suitably earthed to dissipate the static charge and the process should be carried out at a relative humidity greater (although not excessively) than approximately 40%. Powder-mixing equipment Tumbling mixers/blenders Tumbling mixers are commonly used for mixing/ blending granules or free-flowing powders. Mixing containers are generally mounted so that they can be rotated about an axis. Shear mixing will occur as a velocity gradient is produced, the top layer moving with the greatest velocity and the velocity decreasing as the distance from the surface increases. When the bed tumbles, it dilates, allowing particles to move downwards under gravitational force, and so diffusive mixing occurs. Most mixing will occur towards the surface of the bed, where the velocity gradients are highest and the bed is most dilated. Too high a rotation speed will cause the material to be held on the mixer walls by centrifugal force and too low a speed will generate insufficient bed expansion and little shear mixing. The material typically occupies approximately a half to two-thirds of the mixer volume. The rate at which the product is mixed will depend on the mixer geometry and rotation speed because they influence the movement of the material in the mixer. Tumbling mixers are good for free-flowing powders/ granules but are less effective for cohesive/poorly flowing powders because the shear forces generated are usually insufficient to break up any aggregates. Care also needs to be taken if there are significant differences in particle size as segregation is likely to occur. A common use of tumbling mixers is in the blending of lubricants, glidants or external disintegrants with granules prior to tableting. Tumbling mixers can also be used to produce ordered mixes, although the process is often slow because of the cohesiveness of the adsorbing particles. Bachofen, Muttenz, Switzerland) is a more sophisticated form of tumbling mixer which utilizes inversional motion in addition to the rotational and translational motion of traditional tumbling mixers. This leads to more efficient mixing and makes it less likely that material of different size and density will segregate. High-speed mixer-granulators In pharmaceutical product manufacture it is often preferable to use one piece of equipment to carry out more than one function.

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It passes back through the orbit and optic canal to the middle cranial fossa vascular erectile dysfunction treatment kamagra effervescent 100 mg buy visa, where it unites with that of the opposite side to form the optic chiasma lying on the body of the sphenoid. Here the medial or nasal fibres (carrying the temporal visual field) cross to the opposite optic tract while the lateral or temporal fibres, con- Olfactory bulb Optic nerve Optic chiasma Trochlear nerve Oculomotor nerve Sensory and smaller motor roots of trigeminal nerve Abducent nerve Vagus nerve and cranial accessory Hypoglossal nerve Motor branch of facial nerve Sensory branch of facial nerve (N. Relations In the posterior cranial fossa, the nerve, medial to the trochlear nerve, lies close to the tentorium cerebelli. In the middle cranial fossa it passes forwards on the lateral wall of the cavernous sinus. Relations Within the orbit, enclosed in its meningeal sheath, the nerve lies surrounded by the cone of extraocular muscles. The ciliary ganglion is posterolateral and the ophthalmic artery and nasociliary nerve medial. The central artery of the retina (a branch of the ophthalmic artery) enters the nerve in this part of its course. The intracranial course is short and lies on the sphenoid bone medial to the internal carotid artery. Visual defects may result from pressure on the optic nerves or chiasma from pituitary tumours or aneurysms (swellings) of the internal carotid arteries. The inferior division has the same course through the fissure, and supplies the medial and inferior recti and inferior oblique muscles. The ciliary ganglion lies in the posterior orbit lateral to the optic nerve and receives preganglionic parasympathetic fibres, sympathetic fibres from the internal carotid plexus and sensory fibres from the nasociliary nerve. Efferent fibres from the ganglion supply the ciliary muscle and muscles of the iris. Parasympathetic stimulation produces pupillary constriction; sympathetic stimulation produces pupillodilatation. Because of its close relationship to the edge of the tentorium cerebelli the oculomotor nerve may be damaged if there is a lateral shift of the brain, as may occur with an intracranial haemorrhage. One of the earliest localizing signs of increasing intracranial pressure may be a selective palsy of the parasympathetic fibres; dilatation of the pupil is due to damage to the parasympathetic fibres passing to the ciliary ganglion. The somatic fibres supply the extrinsic eye muscles, except for superior oblique and lateral rectus. The parasympathetic fibres synapse in the ciliary ganglion and supply the sphincter pupillae and ciliary muscle. The oculomotor nerve leaves the midbrain between the cerebral peduncles and passes through the posterior and middle cranial fossae to divide into superior and inferior divisions near the superior orbital fissure. Emerging from the lower dorsal midbrain, it decussates and passes forwards through the posterior and middle cranial fossae to enter the orbit through the superior orbital fissure. It traverses the superior orbital fissure outside the tendinous ring and gains the roof of the orbit to supply the superior oblique muscle. If the superior oblique muscle is paralysed and no other extraocular muscle is affected, which is rare, diplopia will be found when the patient is looking downwards. The affected eye is pulled downwards only by the inferior rectus and thus in a slightly different direction. The sensory fibres supply the anterior part of the scalp and the dura, the face, nasopharynx, nasal and oral cavities and the paranasal air sinuses. The nerve arises in the pons and emerges at the root of the middle cerebellar peduncle as a large sensory and a smaller motor root. It passes forwards to the trigeminal ganglion on the temporal bone in the middle cranial fossa. The lacrimal nerve traverses the lateral part of the fissure to reach and supply the lacrimal gland, after which it supplies the skin and conjunctiva of the lateral part of the upper lid and adjacent conjunctiva. Parasympathetic secretomotor fibres are carried to the gland by a branch of the zygomaticotemporal nerve. The frontal nerve traverses the superior orbital fissure and then gains the roof of the orbit, where it divides into the supraorbital and supratrochlear nerves. The former leaves the orbit by the supraorbital notch to supply the upper eyelid, frontal sinuses and scalp as far back as the vertex. The supratrochlear nerve supplies the skin of the upper eyelid and medial forehead. The nasociliary nerve traverses the superior orbital fissure to gain the medial wall of the orbit, where it divides into anterior and posterior ethmoidal, infratrochlear and long ciliary nerves: Anterior ethmoidal nerve ­ leaves the orbit through a foramen on its medial wall to reach the anterior cranial fossa, where it descends through the cribriform plate to pass through the nose, supplying the anterior cranial fossa dura, ethmoidal air cells, upper anterior nasal cavity and skin of the tip of the nose. Posterior ethmoidal nerve ­ supplies the ethmoidal air cells and sphenoidal air sinuses.

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