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By: S. Fabio, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Clinical Director, University of Nebraska College of Medicine

Right subclavian artery crossed by right vagus nerve symptoms 9 weeks pregnancy dulcolax 5 mg generic, whose inferior laryngeal branch loops under the vessel treatment neuroleptic malignant syndrome purchase 5 mg dulcolax otc. When the neck is extended in surgical position symptoms ebola purchase 5mg dulcolax amex, as seen in Plates 3 and 4, its general outline assumes a quadrilateral shape, approaching to a square. The sides of this square are formed anteriorly by the line ranging from the mental symphysis to the top of the sternum, and posteriorly by a line drawn between the occiput and shoulder. The superior side of this cervical square is drawn by the horizontal ramus of the lower maxilla, and the inferior side by the horizontal line of the clavicle. This square space, R 16, 8, 6, Plate 4, is halved by a diagonal line, drawn by the sterno-cleido-mastoid muscle B, which cuts the square into two triangles. In the anterior triangle, F 16, 6, Plate 4, is located the superficial common carotid artery, C, and its branches, D, with accompanying nerves. In the posterior triangle, 9, 8, 6, Plate 4, is placed the superficial subclavian artery, A, its branches, L M, and the brachial plexus of nerves, I. Both these triangles and their contents are completely sheathed by that thin scarf-like muscle, named platysma myoides, A A, Plate 3, the fibres of which traverse the neck slantingly in a line, O A, of diagonal direction opposite to and secant of that of the sterno-mastoid muscle. When the skin and subcutaneous adipose membrane are removed by careful dissection from the cervical region, certain structures are exposed, which, even in the undissected neck, projected on the superficies, and are the unerring guides to the localities of the blood-vessels and nerves, &c. In Plate 4, the top of the sternum, 6; the clavicle, 7; the "Pomum Adami, " 1; the lower maxilla at V; the hyoid bone, Z; the sterno-cleido-mastoid muscle, B; and the clavicular portion of the trapezius muscle, 8; will readily be felt or otherwise recognised through the skin, &c. When these several points are well considered in their relation to one another, they will correctly determine the relative locality of those structures-the blood-vessels, nerves, &c. The middle point, between 7, the clavicle, and 6, the sternum, of Plate 4, is marked by a small triangular space occurring between the clavicular and sternal divisions of the sterno-cleido-mastoid muscle. This space marks the situation (very generally) of the bifurcation of the innominate artery into the subclavian and common carotid arteries of the right side; a penetrating instrument would, if passed into this space at an inch depth, pierce first the root of the internal jugular vein, and under it, but somewhat internal, the root of either of these great arterial vessels, and would wound the right vagus nerve, as it traverses this region. For some extent after the subclavian and carotid vessels separate from their main common trunk, they lie concealed beneath the sterno-mastoid muscle, B, Plate 4, and still deeper beneath the sternal origins of the sterno-hyoid muscle, 5, and sterno-thyroid muscle, some of whose fibres are traceable at the intervals. The omohyoid muscle and the deep cervical fascia, as will be presently seen, conceal these vessels also. The subclavian artery, A, Plate 4, first appears superficial to the above-named muscles of the cervical region just at the point where, passing from behind the scalenus muscle, N, Plate 4, which also conceals it, it sinks behind the clavicle. The artery passes beneath the clavicle at the middle of this bone, a point which is indicated in most subjects by that cellular interval occurring between the clavicular origins of the deltoid and great pectoral muscles. The posterior cervical triangle, 9, 8, 7, Plate 4, in which the subclavian artery is situated, is again subdivided by the muscle omo-hyoid into two lesser regions, each of which assumes somewhat of a triangular shape. The lower one of these embraces the vessel, A, and those nerves of the brachial plexus, I, which are in contact with it. The posterior belly of the omo-hyoid muscle, K, and the anterior scalenus muscle, N, form the sides and apex of this lesser triangular space, while the horizontal clavicle forms its base. This region of the subclavian artery is well defined in the necks of most subjects, especially when the muscles are put in action. In lean but muscular bodies, it is possible to feel the projection of the anterior scalenus muscle under the skin, external to the sterno-mastoid. But in all subjects may be readily recognised that hollow which occurs above the clavicle, and between the trapezius, 8, and the sterno cleido-mastoid, 7 B, in the centre of which hollow the artery lies. The contents of the larger posterior cervical triangle, formed by B, the sternomastoid before; 9, the splenius; and 8, the trapezius behind, and by the clavicle below, are the following mentioned structures-viz. All these structures, except some of the lymphatic glands, are concealed by the platysma myoides A, as seen in Plate 3, and beneath this by the cervical fascia, which latter shall be hereafter more clearly represented. In somewhat the same mode as the posterior half of the omo-hyoid subdivides the larger posterior triangle into two of lesser dimensions, the anterior half of the same muscle divides the anterior triangle into two of smaller capacity. The great anterior triangle, which is marked as that space inclosed within the points, 6, the top of the sternum, the mental symphysis and the angle of the maxilla; and whose sides are marked by the median line of the neck before, the sterno-mastoid behind, and the ramus of the jaw above, contains C, the common carotid artery, becoming superficial from beneath the sterno-mastoid muscle, and dividing into E, the internal carotid, and D, the external carotid. The anterior jugular vein, 3, also occupies this region below; while some venous branches, which join the external and internal jugular veins, traverse it in all directions, and present obstacles to the operator from their meshy plexiform arrangement yielding, when divided, a profuse haemorrhage. The precise locality at which the common carotid appears from under the sternomastoid muscle is, in almost all instances, opposite to the thyroid cartilage. At this place, if an incision, dividing the skin, platysma and some superficial branches of nerves, be made along the anterior border of the sterno-mastoid muscle, and this latter be turned a little aside, a process of cervical fascia, and beneath it the sheath of the carotid artery, will successionally disclose themselves. In many bodies, however, some degree of careful search requires to be made prior to the full exposure of the vessel in its sheath, in consequence of a considerable quantity of adipose tissue, some lymphatic glands, and many small veins lying in the immediate vicinity of the carotid artery and internal jugular vein. This latter vessel, though usually lying completely concealed by the sternomastoid muscle, is frequently to be seen projecting from under its fore part.

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Each of these variations from the normal type is more or less frequent; and though it certainly is of practical import to medications jejunostomy tube cheap 5 mg dulcolax amex bear them in mind medicine zalim lotion order genuine dulcolax on-line, still medications via g tube cheap dulcolax online visa, as we never can foretell their occurrence by a superficial examination of the limb, or pronounce them to be present till we actually encounter them in operation, it is only when we find them that we commence to reason upon the facts; but even at this crisis the knowledge of their anatomy may prevent a confusion of ideas. That generalization of the facts of such anomalies as are liable to occur to the normal character of the brachial artery, represented in Plates 15 and 16, which appears to me as being most inclusive of all their various conditions, is this-viz. At the bend of the elbow, the brachial artery usually occupies the middle point between e, the inner condyle of the humerus and the external margin of the supinator radii longus muscle, G. The structures which overlie the arterial vessel, C, Plate 16, at this locality, numbering them from its own depth to the cutaneous surface, are these-viz. Above all three structures is stretched that dense fibrous band of the fascia, H, Plate 16, which becomes incorporated with the common fascial covering of the forearm. Over this fascial process lies the median basilic vein, F B, Plate 15, accompanying which are seen some branches of the internal cutaneous nerve. If it be required to ligature the artery at this locality, an incision two inches and a half in length, made along the course of the vessel, and avoiding the superficial veins, will expose the fascia; and this being next divided on the director, the artery will be exposed resting on the brachialis anticus, and between the biceps tendon and pronator teres muscle. As this latter muscle differs in width in several individuals, sometimes lying in close contact with the artery, and at other times leaving a considerable interval between the vessel and itself, its outer margin is not, therefore, to be taken as a sure guide to the artery. The inner border of the biceps indicates much more generally the situation of the vessel. The bend of the elbow being that locality where the operation of phlebotomy is generally performed, it is therefore required to take exact account of the structures which occupy this region, and more especially the relation which the superficial veins hold to the deeper seated artery. While opening any part of the vessel, F B, which overlies the artery, it is necessary to proceed with caution, as well because of the fact that between the artery, C, and the vein, F B, the fascia alone intervenes, as also because the ulnar artery is given off rather frequently from the main vessel at this situation, and passes superficial to the fascia and flexors of the forearm, to gain its usual position at K, Plate 15. The cephalic vein, D, is accompanied by the external cutaneous nerve, which branches over the fascia on the outer border of the forearm. The basilic vein, B, is accompanied by the internal cutaneous nerve, which branches in a similar way over the fascia of the inner and fore part of the forearm. The numerous branches of both these nerves interlace with the superficial veins, and are liable to be cut when these veins are being punctured. Though the median basilic, F, and the basilic vein, B, are those generally chosen in the performance of the operation of bleeding, it will be seen, in Plate 15, that their contiguity to the artery necessarily demands more care and precision in that operation executed upon them, than if D, the cephalic vein, far removed as it is from the course of the artery, were the seat of phlebotomy. As it is required, in order to distend the superficial veins, D, B, F, that a band should be passed around the limb at some locality between them and the heart, so that they may yield a free flow of blood on puncture, a moderate pressure will be all that is needful for that end. It is a fact worthy of notice, that the excessive pressure of the ligaturing band around the limb at A B, Plate 15, will produce the same effect upon the veins near F, as if the pressure were defective, for in the former case the ligature will obstruct the flow of blood through the artery; and the vein, F, will hence be undistended by the recurrent blood, just as when, in the latter case, the ligature, making too feeble a pressure on the vein, B, will not obstruct its current in that degree necessary to distend the vessel, F. Whichever be the vein chosen for phlebotomy at the bend of the elbow, it will be seen, from an examination of Plates 15 and 16, that the opening may be made with most advantage according to the longitudinal axis of the vessel; for the vessel while being cut open in this direction, is less likely to swerve from the point of the lancet than if it were to be incised across, which latter mode is also far more liable to implicate the artery. Besides, as the nerves course along the veins from above downwards-making, with each other, and with the vessels, but very acute angles-all incisions made longitudinally in these vessels, will not be so likely to divide any of these nerves as when the instrument is directed to cut crossways. The brachial artery usually divides, at the bend of the elbow, into the radial, the ulnar, and the interosseous branches. The point F, Plate 16, is the common place of division, and this will be seen in the Plate to be somewhat below the level of the inner condyle. From that place, where the radial and ulnar arteries spring, these vessels traverse the forearm, in general under cover of the muscles and fascia, but occasionally superficial to both these structures. The radial artery, F N, Plate 16, takes a comparatively superficial course along the radial border of the forearm, and is accompanied, for the upper two-thirds of its length, by the radial branch of the musculospiral nerve, seen in Plate 16, at the outer side of the vessel. The supinator radii longus muscle in general overlaps, with its inner border, both the radial artery and nerve. At the situation of the radial pulse, I, Plate 15, the artery is not accompanied by the nerve, for this latter will be seen, in plate 16, to pass outward, under the tendon of the supinator muscle, to the integuments. The ulnar artery, whose origin is seen near F, Plate 16, passes deeply beneath the superficial flexor muscles, L M K, and the pronator teres, I, and first emerges from under cover of these at the point O, from which point to S, Plate 16, the artery may be felt, in the living body, obscurely beating as the ulnar pulse. On the inner border of the ulnar artery, and in close connexion with it, the ulnar nerve may be seen looped round by small branches of the vessel. The radial and ulnar arteries may be exposed and ligatured in any part of their course; but of the two, the radial vessel can be reached with greater facility, owing to its comparatively superficial situation. The inner border of the supinator muscle, G, Plate 16, is the guide to the radial artery; and the outer margin of the flexor carpi ulnaris muscle, K, Plate 16, indicates the locality of the ulnar artery.

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Here medicine qvar inhaler dulcolax 5mg visa, too symptoms 6 days post iui order generic dulcolax on-line, we observe that the 2009 ranking shifts downward treatment for plantar fasciitis purchase dulcolax 5mg free shipping, indicating less concentration of women in industry relative to men, especially in those countries where the ratio had been higher in 1990 (and in some cases, in favour of women). Those with greater family responsibility, particularly women, find themselves less likely to obtain jobs than those who do not signal such care responsibilities, i. Employers in capital-intensive firms may inaccurately (or accurately) predict that men are the major breadwinners and therefore be unwilling to hire women workers who are predicted to leave the labour market at higher rates due to care responsibilities. The binding constraint is an absence of gender-equitable care policies, although there are other barriers as well, including gender norms and stereotypes. Panel C provides a regional summary of trends in the ratio of female-to-male shares employed in the industrial sector from 1990 to 2009. In all regions, female shares employed in the industrial sector have declined, except in Africa. Taken as a group, trends in outcome indicators explored in this section are much less positive than gender progress in education in the capabilities domain. Very few countries have reached parity in employment and unemployment gaps have widened in a number of countries. Of particular concern is the fact that relative female employment gains coincide with a decline in male employment rates in a number of countries, although men appear to be able to disproportionately hold onto jobs in the industrial sector. Humanity Divided: Confronting Inequality in Developing Countries 175 Gender inequality Figure 5. Shares of females and males employed in the industrial sector, 1990 and 2009 Panel A. Employment is a particularly salient domain for the fulfilment of norms of masculinity. Because industrial-sector jobs tend to be of higher quality than those in other sectors (they are less likely to be informal and more likely to offer benefits and a job ladder than jobs in services and agriculture), this outcome indicates a decline in gender equality. Trends in this sector are also indicative of persistent job segregation by gender. Given the importance of access to and control over material resources for well-being, persistent and in some cases widening gender gaps in this domain are indicative of real challenges to gender equality in well-being. Other data on livelihoods that would be useful include are assets, 15 access to credit, the level of social insurance (such as pensions, unemployment insurance) and other entitlements to commodities. Thus, it should be acknowledged that this analysis presents only a partial picture. The data gap might not be problematic if the labour market data presented here are a close proxy for these other indicators. Although we lack global data to assess this possibility, it is likely that the labour market data provide a lower bound estimate of gender inequality. We know from some country-level studies that the gender distribution of wealth, land and credit is more unequal than income, for example. Agency, empowerment, and relative political representation Gender equality in agency and empowerment can theoretically be measured in a number of ways: political representation, trade union membership, managerial and supervisory positions held, corporate leadership and board representation. Were we to possess comprehensive time-series data in each of these categories, we would be able to provide a global picture of trends in gender equality in this domain. Because we do not, the female share of parliamentary seats is a commonly used measure of Figure 5. Female/male shares of parliamentary seats gendered political agency for the Panel A. For example, a country with a 25 percent female share of parliamentary seats is assigned a ratio of 25 (for women) to 75 (for men) or 0. Humanity Divided: Confronting Inequality in Developing Countries 177 Gender inequality than in 1997. Unlike the other indicators in this study, the greatest gains have been made in those countries already closer to gender parity in 1997. Panel B provides a regional representation of trends, with the percentage point change in the female/male ratio plotted on the left axis and the female/male ratio in 2011 on the right axis. The gender gap is remarkably large as compared to the ratio of F/M educational attainment (Figures 5. Trends in subjective well-being and attitudes In addition to measures of objective well-being, it is useful to examine trends in subjective measures to gain further insight into trends in gender equality. We also examine how responses to several prompts indicating attitudes towards gender equality have changed over time.

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Synthetic oligofructose contains -(2 symptoms quadriceps tendonitis order dulcolax online now, 1) fructose chains with and without terminal glucose units symptoms 5 days before your missed period purchase online dulcolax. Synthetic fructooligosaccharides have the same chemical and structural composition as oligofructose treatment eczema discount dulcolax 5 mg amex, except that the degree of polymerization ranges from two to four. Because many current definitions of dietary fiber are based on methods involving ethanol precipitation, oligosaccharides and fructans that are endogenous in foods, but soluble in ethanol, are not analyzed as dietary fiber. With respect to the definitions outlined in this chapter, the naturally occurring fructans that are found in plants, such as chicory, onions, and Jerusalem artichoke, would be classified as Dietary Fibers; the synthesized or extracted fructans could be classified as Functional Fibers when there are sufficient data to show positive physiological effects in humans. Lignin is a highly branched polymer comprised of phenylpropanoid units and is found within "woody" plant cell walls, covalently bound to fibrous polysaccharides (Dietary Fibers). Although not a carbohydrate, because of its association with Dietary Fiber, and because it affects the physiological effects of Dietary Fiber, lignin is classified as a Dietary Fiber if it is relatively intact in the plant. Lignin isolated and added to foods could be classified as Functional Fiber given sufficient data on positive physiological effects in humans. Pectins, which are found in the cell wall and intracellular tissues of many fruits and berries, consist of galacturonic acid units with rhamnose interspersed in a linear chain. Pectins frequently have side chains of neutral sugars, and the galactose units may be esterified with a methyl group, a feature that allows for its viscosity. While fruits and vegetables contain 5 to 10 percent naturally occurring pectin, pectins are industrially extracted from citrus peels and apple pomace. Isolated, high methoxylated pectins are mainly added to jams due to their gelling properties with high amounts of sugar. Low methoxylated pectins are added to low-calorie gelled products, such as sugar-free jams and yogurts. Polydextrose is a polysaccharide that is synthesized by random polymerization of glucose and sorbitol. Polydextrose serves as a bulking agent in foods and sometimes as a sugar substitute. Polydextrose is not digested or absorbed in the small intestine and is partially fermented in the large intestine, with the remaining excreted in the feces. Psyllium refers to the husk of psyllium seeds and is a very viscous mucilage in aqueous solution. The psyllium seed, also known as plantago or flea seed, is small, dark, reddish-brown, odorless, and nearly tasteless. Indigestible components of starch hydrolysates, as a result of heat and enzymatic treatment, yield indigestible dextrins that are also called resistant maltodextrins. Unlike gums, which have a high viscosity that can lead to problems in food processing and unpleasant organoleptic properties, resistant maltodextrins are easily added to foods and have a good mouth feel. Resistant maltodextrins are produced by heat/acid treatment of cornstarch, followed by enzymatic (amylase) treatment. The average molecular weight of resistant maltodextrins is 2, 000 daltons and consists of polymers of glucose containing -(1-4) and -(1-6) glucosidic bonds, as well as 1-2 and 1-3 linkages. Resistant dextrins can potentially be classified as Functional Fibers when sufficient data on physiological benefits in humans are documented. Resistant starch is naturally occurring, but can also be produced by the modification of starch during the processing of foods. Resistant starch is estimated to be approximately 10 percent (2 to 20 percent) of the amount of starch consumed in the Western diet (Stephen et al. Along the gastrointestinal tract, properties of fiber result in different physiological effects. Effect on Gastric Emptying and Satiety Consumption of viscous fibers delays gastric emptying (Low, 1990; Roberfroid, 1993) and expands the effective unstirred layer, thus slowing the process of absorption once in the small intestine (Blackburn et al. A slower emptying rate means delayed digestion and absorption of nutrients (Jenkins et al. For example, Stevens and coworkers (1987) showed an 11 percent reduction in energy intake with psyllium gum intake.

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