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Although the statement is often heard that a child has regurgitation because of "inadequate leaflet tissue blood pressure normal reading bystolic 5 mg buy with mastercard," we believe that a more common problem is that repair has been delayed too long allowing ventricular dilation secondary to the volume load of the left to right shunt. Once regurgitation of any cause is present it is likely to worsen over time because the regurgitation per se causes annular dilation resulting in worsening central regurgitation. Furthermore, there are likely to be secondary changes in the valve leaflets such as thickening and rolling of the free edges which will also exacerbate regurgitation. Mitral regurgitation can be a result of structural abnormalities of the valve that are similar to those causing mitral stenosis. Leaflets may be dysplastic and retracted, there may be thick and short chords and the papillary muscles may be abnormal. Other structural abnormalities include isolated cleft of the anterior leaflet, leaflet prolapse secondary to chordal elongation or rupture (usually in the setting of a connective tissue disorder such as Marfan syndrome) or leaflet perforation or other injury by bacterial endocarditis. The symptoms are the usual symptoms of congestive heart failure and are likely to be indistinguishable from the symptoms of mitral stenosis. The degree of mitral regurgitation can be quantitated by assessment of the width of the jet at the level of the leaflets. It is important to do this in two planes as there may be a knife-thin jet coming through the cleft area. As with mitral stenosis, the echocardiographer should analyze the mechanism of the regurgitation. Most commonly this will involve distinguishing regurgitation through the cleft versus central regurgitation. Assessment of the regurgitant mitral valve in the adult with degenerative mitral valve disease is becoming increasingly sophisticated with application of computerized analysis of the various segments of the valve. Because of the variability of congenitally malformed valves this uniform approach to valve description is less useful to the pediatric surgeon than the adult cardiac surgeon. Cardiac catheterization is not necessary or indeed useful in defining the degree or the mechanism of mitral regurgitation. Afterload reduction is particularly helpful in the setting of mitral regurgitation and should be maximized. There are no interventional catheter methods that are useful in the management of mitral regurgitation in the infant or young child. In the adult with acquired mitral regurgitation various innovative catheter methods have been explored, including reshaping the mitral annulus using devices placed in the coronary sinus or annular shrinking with magnets. Indications for Surgery the indications for mitral valve repair for mitral regurgitation should be quite a bit less stringent than those applied for mitral stenosis. This is because it is very likely that the valve can be significantly improved no matter what the cause of the regurgitation. On the other hand, if surgery is delayed there will be secondary changes of the valve which will increase the difficulty of repair and reduce the probability that repair will be successful. It should be highly unlikely that valve replacement is required at a first attempt to improve a regurgitant mitral valve surgically. Cardiopulmonary bypass is managed with bicaval cannulation, mild or moderate hypothermia, and cardioplegic arrest.

Syndromes

• Seizures
• Discomfort or bleeding from vascular birthmarks (occasional)
• Washing of the skin  or eyes (irrigation)
• Wheezing, in people with asthma
• Extreme weight loss
• Obesity
• Surgery or injury involving the nerves

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The outward expansion o the bellies o contracting muscles is limited by deep ascia and becomes a compressive orce blood pressure goes down when standing purchase bystolic cheap online, propelling the blood against gravity. In some situations, blood passes through two capillary beds beore returning to the heart; a venous system linking two capillary beds constitutes a portal venous system. The venous system by which nutrient-rich blood passes rom the capillary beds o the alimentary tract to the capillary beds or sinusoids o the liver-the hepatic portal system-is the major example. A common orm, atherosclerosis, is associated with the buildup o at (mainly cholesterol) in the arterial walls. A calcium deposit orms an atheromatous plaque (atheroma)-well-demarcated, hardened yellow areas or swellings on the intimal suraces o arteries. The consequences o atherosclerosis include ischemia (reduction 42 Chapter 1 Overview and Basic Concepts o blood supply to an organ or region) and inarction (local death, or necrosis, o an area o tissue or an organ resulting rom reduced blood supply). Varicose veins have a caliber greater than normal, and their valve cusps do not meet or have been destroyed by infammation. Varicose veins have incompetent valves; thus, the column o blood ascending toward the heart is unbroken, placing increased pressure on the weakened walls, urther exacerbating the varicosity problem. Incompetent ascia is incapable o containing the expansion o contracting muscles; thus, the (musculoascial) musculovenous pump is ineective. A weakened vein dilates under the pressure o supporting a column o blood against gravity. The Starling hypothesis (see "Blood Capillaries" in this chapter) explains how most o the fuid and electrolytes entering the extracellular spaces rom the blood capillaries is also reabsorbed by them. Furthermore, some plasma protein leaks into the extracellular spaces, and material originating rom the tissue cells that cannot pass through the walls o blood capillaries, such as cytoplasm rom disintegrating cells, continually enters the space in which the cells live. I this material were to accumulate in the extracellular spaces, a reverse osmosis would occur, bringing even more fuid and resulting in edema (an excess o interstitial fuid, maniest as swelling). However, the amount o interstitial fuid remains airly constant under normal conditions, and proteins and cellular debris normally do not accumulate in the extracellular spaces because o the lymphoid system. The lymphoid system thus constitutes a sort o "overfow" system that provides or the drainage o surplus tissue fuid and leaked plasma proteins to the bloodstream, as well as or the removal o debris rom cellular decomposition and inection. Lymphatic vessels (lymphatics), thin-walled vessels with abundant lymphatic valves that comprise a nearly body-wide network to drain lymph rom the lymphatic capillaries. In living individuals, the vessels bulge where each o the closely spaced valves occur, giving lymphatics a beaded appearance. Lymphatic trunks are large collecting vessels that receive lymph rom multiple lymphatic vessels.

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The anterior surace o its proximal and distal thirds is covered with peritoneum; however arteria zygomatico orbital order bystolic 5 mg, the peritoneum refects rom its middle third to orm the double-layered mesentery o the transverse colon, the transverse mesocolon. It is crossed by the superior mesenteric artery and vein and the root o the mesentery o the jejunum and ileum. The anterior surace o the inerior part is covered with peritoneum, except where it is crossed by the superior 464 Chapter 5 Abdomen mesenteric vessels and the root o the mesentery. The ascending part o the duodenum runs superiorly and along the let side o the aorta to reach the inerior border o the body o the pancreas. Contraction o this muscle widens the angle o the duodenojejunal fexure, acilitating movement o the intestinal contents. The suspensory muscle passes posterior to the pancreas and splenic vein and anterior to the let renal vein. The arteries o the duodenum arise rom the celiac trunk and the superior mesenteric artery. The celiac trunk, via the gastroduodenal artery and its branch, the superior pancreaticoduodenal artery, supplies the duodenum proximal to the entry o the bile duct into the descending part o the duodenum. The superior mesenteric artery, through its branch, the inerior pancreaticoduodenal artery, supplies the duodenum distal to the entry o the bile duct. The pancreaticoduodenal arteries lie in the curve between the duodenum and the head o the pancreas and supply both structures. The basis o this transition in blood supply is embryological; this is the junction o the oregut and midgut. The veins o the duodenum ollow the arteries and drain into the hepatic portal vein, some directly and others indirectly, through the superior mesenteric and splenic veins. The anterior lymphatic vessels drain into the pancreaticoduodenal lymph nodes, located along the superior and inerior pancreaticoduodenal arteries, and into the pyloric lymph nodes, which lie along the gastroduodenal artery. The close positional relationship o these organs results in sharing o blood vessels, lymphatic vessels, and nerve pathways, in whole or in part. Abdominal Viscera 465 o the pancreas and drain into the superior mesenteric lymph nodes. Eerent lymphatic vessels rom the duodenal lymph nodes drain into the celiac lymph nodes. The nerves o the duodenum derive rom the vagus and greater and lesser (abdominopelvic) splanchnic nerves by way o the celiac and superior mesenteric plexuses. The nerves are next conveyed to the duodenum via peri-arterial plexuses extending to the pancreaticoduodenal arteries (see also "Summary o the Innervation o Abdominal Viscera," p. The third part o the small intestine, the ileum, ends at the ileocecal junction, the union o the terminal ileum and the cecum. The terminal ileum usually lies in the pelvis rom which it ascends, ending in the medial aspect o the cecum. The mesentery is a an-shaped old o peritoneum that attaches the jejunum and ileum to the posterior abdominal wall.

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The aortotomy is extended from the point of left subclavian origin across the coarctation and beyond for several millimeters blood pressure names order bystolic with a mastercard. The mobilized left subclavian artery is now advanced and is sutured into the aortotomy as a flap. Although this procedure has the advantage of maintaining flow to the left arm it suffers from the same disadvantage as the standard subclavian flap procedure in that it does not include excision of the abnormal ductal tissue resulting in a risk of late aneurysm formation at this site. Synthetic Patch Aortoplasty Although this approach was popular in the 1970s and was particularly championed at that time by Ebert and Mavroudis,38 it is now generally accepted that this technique carries an unacceptable risk of late aneurysm formation. In the growing child, it is probably preferable to perform a synthetic patch aortoplasty rather than placing a nongrowing tube graft. After mobilization of the aorta proximal and distal to the coarctation area, clamps are applied above and below. A longitudinal incision is made on the anterior and leftward face of the aorta across the coarctation area. Once again there is some controversy as to whether the coarctation shelf should be resected since it is believed that this can increase the risk of late aneurysm formation. A patch of synthetic material, usually Gore-Tex or Dacron, is sutured into aortotomy using continuous nonabsorbable suture. If a Gore-Tex patch is employed, it is generally wise to use a Gore-Tex suture since bleeding through needle holes at aortic pressure can be persistent. One approach is to use a left thoracotomy incision and to place a pulmonary artery band at the time of coarctation repair. This approach also might reduce the probability of requiring a period of circulatory arrest. The disadvantage of this approach includes the need for an extended hospitalization, the risks of two operations rather than one, the expense of two operations rather than one, additional psychological stress for the family, and the cosmetic disadvantage of two incisions rather than one. Cannulation of the ascending aorta is modified in that the arterial cannula is inserted into the right lateral side of the mid-ascending aorta. During cooling, the arch vessels are thoroughly mobilized, as well as the proximal descending aorta. Considerable care is taken to preserve the left recurrent laryngeal and vagus nerves, as well as the phrenic nerve. A fine neonatal vascular clamp is placed across the proximal aortic arch and a C-clamp is placed on the descending aorta. The left common carotid and left subclavian arteries are controlled with fine tourniquets. With bypass continuing, the coarctation area can be excised and an extended end-to-end anastomosis performed.

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The origins blood pressure chart by age and gender purchase bystolic canada, courses, and distribution o the arteries and the arterial anastomoses ormed are described in Table 6. The ureter crosses the common iliac artery or its terminal branches at or immediately distal to the biurcation. The internal iliac artery is separated rom the sacro-iliac joint by the internal iliac vein and the lumbosacral trunk. It descends posteromedially into the lesser pelvis, medial to the external iliac vein and obturator nerve and lateral to the peritoneum. Although variations are common, the internal iliac artery usually ends at the superior edge o the greater sciatic oramen by dividing into anterior and posterior divisions (trunks). The branches o the anterior division o the internal iliac artery are mainly visceral. Beore birth, the umbilical arteries are the main continuation o the internal iliac arteries, passing along the lateral pelvic wall and then ascending the anterior abdominal wall to and through the umbilical ring into the umbilical cord. Prenatally, the umbilical arteries conduct oxygen- and nutrient-decient blood to the placenta or replenishment. When the umbilical cord is cut, the distal parts o these vessels no longer unction and become occluded distal to branches that pass to the bladder. The ligaments raise olds o peritoneum (medial umbilical olds) on the deep surace o the anterior abdominal wall (see Chapter 2, Back). Postnatally, the patent parts o the umbilical arteries run antero-ineriorly between the urinary bladder and the lateral wall o the pelvis. The origin o the obturator artery is variable; usually, it arises close to the origin o the umbilical artery, where it is crossed by the ureter. It runs anteroineriorly on the obturator ascia on the lateral wall o the pelvis and passes between the obturator nerve and vein. Within the pelvis, the obturator artery gives o muscular branches, a nutrient artery to the ilium, and a pubic branch. Anterior divisions o the internal iliac arteries usually supply most o the blood to pelvic structures. In a common variation (20%), an aberrant or accessory obturator artery arises rom the inerior epigastric artery and descends into the pelvis along the usual route o the pubic branch. The extrapelvic distribution o the obturator artery is described with the lower limb (Chapter 7). In emales, it may occur-with nearly equal requency-as a separate branch o the internal iliac artery or as a branch o the uterine artery. The uterine artery is an additional branch o the internal iliac artery in emales, usually arising separately and directly rom the internal iliac artery. It descends on the lateral wall o the pelvis, anterior to the internal iliac artery, and passes medially to reach the junction o the uterus and vagina, where the cervix (neck) o the uterus protrudes into the superior vagina. The relationship o ureter to artery is oten remembered by the phrase "water (urine) passes under the bridge (uterine artery). On reaching the side o the cervix, the uterine artery divides into a smaller descending vaginal branch, which supplies the cervix and vagina, and a larger ascending branch, which runs along the lateral margin o the uterus, supplying it.

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On occasion a third annuloplasty suture must be placed directly posteriorly to tighten the annulus further blood pressure chart over 60 bystolic 5 mg order with visa. It is important to remember that the circumflex coronary artery lies close to the annulus posteriorly and laterally. Chordal Shortening, Chordal Transfer the various techniques popularized by Carpentier for rheumatic mitral valve disease and degenerative valve disease are rarely used for children with congenitally abnormal valves. However, the pediatric surgeon should certainly be familiar with these techniques that are widely applied by adult cardiac surgeons for repair of mitral valves with degenerative disease. It should be possible to essentially eliminate any regurgitant jet with the low pressure testing that can be done in this way. The contraction of the annulus that occurs with ventricular systole should further tighten the valve and compensate for the higher pressure it will be exposed to when the heart is ejecting. If there is a possibility that the valve can be significantly improved by further maneuvers such as an additional annuloplasty suture, then this is the best time to do it. Mitral Valve Replacement for Regurgitation the technique for mitral valve replacement for regurgitation is the same as for stenosis. The important difference is that the annulus is very likely to be a generous size so that supraannular positioning is unlikely to be necessary. There were two hospital deaths and two late deaths in patients who underwent mitral valve repair. Three of these four patients underwent mitral valve replacement because of residual mitral incompetence. There were no hospital deaths in the patients who underwent mitral valve replacement although there were two late deaths. Six patients had a total of 10 episodes of prosthetic valve thrombosis though in all cases thrombolytic therapy with urokinase was successful. Actuarial survival and freedom from cardiac events at 10 years after operation were 87% and 73% in children who underwent mitral valve repair and 90% and 67% for those who underwent replacement. The cause of regurgitation was chordal anomalies in 69% of patients, annular dilation in 16%, and platelet anomalies in 14%. Of these patients, 88% had commissural plication annuloplasty, 11 had modified Devega procedures, five had cleft closure and three had plication of the anterior leaflet. The only communication between the atrialized ventricle and the infundibulum is through the anteroseptal commissure of the tricuspid valve. It is important to distinguish structural pulmonary atresia from functional atresia in which the pulmonary valve fails to open because of high pulmonary artery pressure from a patent ductus.

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The lines along which the bers o the abdominal aponeuroses interlace are also potential sites o herniation blood pressure of 10060 purchase bystolic 5 mg overnight delivery. Occasionally, gaps exist where these ber exchanges occur-or example, in the midline or in the transition rom aponeurosis to rectus sheath. These gaps may be congenital, the result o the stresses o obesity and aging, or the consequence o surgical. An epigastric hernia, a hernia in the epigastric region through the linea alba, occurs in the midline between the xiphoid process and the umbilicus. These types o hernia tend to occur in people older than 40 years and are usually associated with obesity. The hernial sac, composed o peritoneum, is oten covered with only skin and atty subcutaneous tissue, but may occur deep to the muscle. Abdominal muscles protect and support the viscera most eectively when they are well toned; thus, the wellconditioned adult o normal weight has a fat or scaphoid (lit. The six common causes o abdominal protrusion begin with the letter F: ood, fuid, at, eces, fatus, and etus. Intense guarding, board-like refexive muscular rigidity that cannot be willully suppressed, occurs during palpation when an organ (such as the appendix) is infamed and in itsel constitutes a clinically signicant sign o acute abdomen. The involuntary muscular spasms attempt to protect the viscera rom pressure, which is painul when an abdominal inection is present. The common nerve supply o the skin and muscles o the wall explains why these spasms occur. Palpation o abdominal viscera is perormed with the patient in the supine position with thighs and knees semifexed to enable adequate relaxation o the anterolateral abdominal wall. Otherwise, the deep ascia o the thighs pulls on the membranous layer o abdominal subcutaneous tissue, tensing the abdominal wall. Some people tend to place their hands behind their heads when lying supine, which also tightens the muscles and makes the examination dicult. An oblique subcostal incision, used or liver/ pancreas surgery (in the past or open cholecystectomy), can result in denervation o part o the abdominal wall i the nerves are not careully identied and spared, which is not always possible. In the inguinal region, such a weakness may predispose an individual to development o an inguinal hernia (see the Clinical Box "Inguinal Hernias," p. Abdominal Surgical Incisions Surgeons use various abdominal surgical incisions to gain access to the abdominal cavity. The incision that allows adequate exposure, and secondarily, the best possible cosmetic eect, is chosen. The location o the incision also depends on the type o operation, the location o the organ(s) the surgeon wants to reach, bony or cartilaginous boundaries, avoidance o (especially motor) nerves, maintenance o blood supply, and minimizing injury to muscles and ascia o the abdominal wall while aiming or avorable healing. Thus, beore making an incision, the surgeon considers the direction o the muscle bers and the location o the aponeuroses and nerves.

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Following pancreatitis (infammation o the pancreas) hypertension over the counter medication cheap bystolic 2.5 mg mastercard, the posterior wall o the stomach may adhere to the part o the posterior wall o the omental bursa that covers the pancreas. This adhesion occurs because o the close relationship o the posterior wall o the stomach to the pancreas. The hernias occur most oten in people ater middle age, possibly because o weakening o the muscular part o the diaphragm and widening o the esophageal hiatus. Although clinically there are several types o hiatal hernia, the two main types are paraesophageal hiatal hernia and sliding hiatal hernia (Skandalakis et al. In the less common para-esophageal hiatal hernia, the cardia remains in its normal position. However, a pouch o peritoneum, oten containing part o the undus o the stomach, extends through the esophageal hiatus anterior to the esophagus. In these cases, usually no regurgitation o gastric contents occurs because the cardial orice is in its normal position. In the common sliding hiatal hernia, the abdominal part o the esophagus, the cardia, and parts o the undus o the stomach slide superiorly through the esophageal hiatus into the thorax, especially when the person lies down or bends over. Some regurgitation o stomach contents into the esophagus is possible because the clamping action o the right crus o the diaphragm on the inerior end o the esophagus (the lower "esophageal sphincter") is weak. Displacement o Stomach Pancreatic pseudocysts and abscesses in the omental bursa may push the stomach anteriorly. Pylorospasm Spasmodic contraction o the pylorus sometimes occurs in inants, usually between 2 and 12 weeks o age. Pylorospasm is characterized by ailure o the smooth muscle bers encircling the pyloric canal to relax normally. As a result, ood does not pass easily rom the stomach into the duodenum and the stomach becomes overly ull, usually resulting in discomort and vomiting. Proximally, the stomach may become secondarily dilated because o the pyloric stenosis (narrowing). Although the cause o congenital hypertrophic pyloric stenosis is unknown, genetic actors appear to be Pyloric canal Pyloric stenosis Congenital Hypertrophic Pyloric Stenosis Congenital hypertrophic pyloric stenosis is a marked thickening o the smooth muscle (hypertrophy) in the pylorus that aects approximately 1 o every 150 male inants and 1 o every 750 emale inants (Moore, Persaud, and Torchia, 2016). Normally, gastric peristalsis pushes chyme through the pyloric canal and orice into the small intestine at irregular intervals. In neonates with pyloric stenosis, the elongated overgrown pylorus is hard and the pyloric canal is narrow. Pyloric stenosis can be treated by a simple operation, pyloromyotomy, in which the surgeon cuts through the hypertrophied circular muscle layer o the pylorus, allowing ree passage. Carcinoma o Stomach When the body or pyloric part o the stomach contains a malignant tumor, the mass may be palpable. Using a gastroscope, physicians can inspect the mucosa o the air-infated stomach, enabling them to observe gastric lesions and take biopsies. The extensive lymphatic drainage o the stomach and the impossibility o removing all the lymph nodes create a surgical problem. The nodes along the splenic vessels can be excised by removing the spleen, gastrosplenic and splenorenal ligaments, and the body and tail o the pancreas.

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Pronation and supination are the rotational movements o the orearm and hand that swing the distal end o the radius (the lateral long bone o the orearm) medially and laterally around and across the anterior aspect o the ulna (the other long bone o the orearm) while the proximal end o the radius rotates in place hypertension yoga poses buy cheap bystolic online. Pronation rotates the radius medially so that the palm o the hand aces posteriorly and its dorsum aces anteriorly. When the elbow joint is fexed, pronation moves the hand so that the palm aces ineriorly. Supination is the opposite rotational movement, rotating the radius laterally and uncrossing it rom the ulna, returning the pronated orearm to the anatomical position. When the elbow joint is fexed, supination moves the hand so that the palm aces superiorly. Inversion moves the sole o the oot toward the median plane (acing the sole medially). Pronation o the oot actually reers to a combination o eversion and abduction that results in lowering o the medial margin o the oot (the eet o an individual with fat eet are pronated), and supination o the oot generally implies movements resulting in raising the medial margin o the oot, a combination o inversion and adduction. Opposition is the movement by which the pad o the 1st digit (thumb) is brought to another digit pad. Reposition describes the movement o the 1st digit rom the position o opposition back to its anatomical position. Protrusion is a movement anteriorly (orward) as in protruding the mandible (chin), lips, or tongue. Retrusion is a movement posteriorly (backward), as in retruding the mandible, lips, or tongue. The similar terms protraction and retraction are used most commonly or anterolateral and posteromedial movements o the scapula on the thoracic wall, causing the shoulder region to move anteriorly and posteriorly. Elevation raises or moves a part superiorly, as in elevating the shoulders when shrugging, the upper eyelid when opening the eye, or the tongue when pushing it up against the palate (roo o mouth). Depression lowers or moves a part ineriorly, as in depressing the shoulders when standing at ease, the upper eyelid when closing the eye, or pulling the tongue away rom the palate. Anatomical variations are oten discovered during imaging or surgical procedures, at autopsy, or during anatomical study in individuals who had no awareness o or adverse eects rom the variation. A congenital anomaly or birth deect is a variation oten evident at birth or soon aterward due to aberrant orm or unction. It is important to know how such variations and anomalies may infuence physical examinations, diagnosis, and treatment. Anatomy textbooks describe (initially, at least) the structure o the body as it is most oten observed in people, that is, the most common pattern.

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To visualize the relationship o the pleurae and lungs arrhythmia pvc order bystolic 5 mg online, push your st into an underinfated balloon. The inner part o the balloon wall (adjacent to your st, which represents the lung) is comparable to the visceral pleura; the remaining outer wall o the balloon represents the parietal pleura. The cavity between the layers o the balloon, here lled with air, is analogous to the pleural cavity, although the pleural cavity contains only a thin lm o fuid. At your wrist (representing the root o the lung), the inner and outer walls o the balloon are continuous, as are the visceral and parietal layers o pleura, together orming a pleural sac. Note that the lung is outside o but surrounded by the pleural sac, just as your st is surrounded by but outside o the balloon. During the embryonic period, the developing lungs invaginate (grow into) the pericardioperitoneal canals, the precursors o the pleural cavities. The invaginated celomic epithelium covers the primordia o the lungs and becomes the visceral pleura in the same way that the balloon covers your st. The epithelium lining the walls o the pericardioperitoneal canals orms the parietal pleura. During embryogenesis, the pleural cavities become separated rom the pericardial and peritoneal cavities. The pleural cavity-the potential space between the layers o pleura-contains a capillary layer o serous pleural uid, which lubricates the pleural suraces and allows the layers o pleura to slide smoothly over each other during respiration. The surace tension o the pleural fuid provides the cohesion that keeps the lung surace in contact with the thoracic wall; consequently, the lung expands and lls with air when the thorax expands while still allowing sliding to occur, much like a lm o water between two glass plates. The visceral pleura (pulmonary pleura) closely covers the lung and adheres to all its suraces, including those within the horizontal and oblique ssures. In cadaver dissection, the visceral pleura cannot usually be dissected rom the surace o the lung. It provides the lung with a smooth slippery surace, enabling it to move reely on the parietal pleura. The visceral pleura is continuous with the parietal pleura at the hilum o the lung, where structures making up the root o the lung. It is thicker than the visceral pleura, and during surgery and cadaver dissections, it may be separated rom the suraces it covers. The parietal pleura consists o three parts-costal, mediastinal, and diaphragmatic-and the cervical pleura. The costal part o the parietal pleura (costovertebral or costal pleura) covers the internal suraces o the thoracic wall.

Aila, 56 years: On the let side o the descending part o the duodenum, the bile duct comes into contact with the main pancreatic duct.

Innostian, 58 years: Adduction o the digits is the opposite-bringing the spread ngers or toes together, Anatomicomedical Terminology 9 Extension Flexion 1 Extension Flexion Flexion Extension Flexion and extension of vertebral column at intervertebral joints Flexion Extension Extension Flexion Flexion and extension of forearm at elbow joint and of leg at knee joint (A) Flexion and extension of upper limb at shoulder joint and lower limb at hip joint Extension sion Flexion Supination Flexion n Pronation Extension (B) Flexion and extension of hand at wrist joint Opposition Reposition (D) Pronation and supination of forearm at radio-ulnar joints Flexion and extension (C) Opposition and reposition of thumb of digits (fingers) at and little finger at carpometacarpal joint of thumb combined with flexion at metacarpophalangeal and interphalangeal joints metacarpophalangeal joints Adduction Abduction Abduction Adduction (E) Abduction and adduction of 2nd, 4th, and 5th digits at metacarpophalangeal joints Lateral Medial abduction abduction Abduction of 3rd digit at metacarpophalangeal joint Extension Flexion (F) the thumb is rotated 90° relative to other structures.

Josh, 23 years: The inerior border o the pectoralis major orms the anterior axillary old, and the latissimus dorsi and teres major orm the posterior axillary old.

Eusebio, 40 years: The arteries supplying the middle Pubovaginalis Pubovesicalis Rectovesicalis Vagina Bladder Rectum Coccyx and inerior parts o the vagina derive rom the vaginal and internal pudendal arteries.

Chenor, 44 years: Arteries have both elastic and muscle fbers in their walls, which allow them to propel blood throughout the cardiovascular system.

Jose, 46 years: It also assists in elevating the ribs or deep inspiration when the pectoral girdle is xed or elevated.

Curtis, 53 years: Fluid-lled spaces orm within this layer and coalesce to produce the subarachnoid space (Moore et al.

Roy, 43 years: There is also anterolateral drainage rom the external aspects o the vertebrae into segmental veins.

Koraz, 31 years: The prominences o the greater trochanters are normally responsible or the width o the adult pelvis.

Yorik, 37 years: In addition, at all levels, primordial "ribs" (costal elements) appear in association with the secondary ossication centers o the transverse processes (transverse elements).

Ingvar, 29 years: The mesenchymal cells condense and dierentiate into chondroblasts, dividing cells in growing cartilage tissue, thereby orming a cartilaginous bone model.

Enzo, 35 years: For example, people with trisomy 21 (Down syndrome) have dermatoglyphics that are highly characteristic.

Kayor, 26 years: Scarring also could distort the neoaortic valve and did lead to an important incidence of neoaortic valve incompetence.