By B. Knut. The Scripps Research Institute. 2018.
Culture the specimen - Flame and sterilize wire loops before & after use - Flame the necks of specimen bottles cheap kamagra 100 mg fast delivery, culture bottles buy discount kamagra 50 mg line, & tubes after removing & before replacing caps. Gram staining technique - Required reagents; o Crystal violet stain o Lugol’s iodine o Acetone – alcohol decolorizer o Neutral red – 1g/l (0. Note: when the smear is for the detection of Gonococci or Meningococci, it should be fixed with methanol for 2 minutes (this avoids damaging pus cells) 2. Rapidly wash off the stain with clean water Note: - when the tap water is not clean, use filtered water or clean boiled rainwater 4. Decolorize rapidly (few seconds) with acetone – alcohol wash immediately with clean water Caution –Acetone alcohols are highly flammable therefore use it well away form an open flame 115 7. Examine the smear microscopically, first with the 40-x objective to check the staining and to see the distribution of material and then with the oil immersion objective to report the bacteria and cells. Results: - Gram positive bacteria ……………………………… Dark purple - Yeast cell ………………………………………………Dark purple - Gram negative bacteria ……………………………. Pale red Reporting gram smears The report should include the following information; - Numbers of bacteria present, whether many, moderate, few or scanty, - Gram reaction of bacteria, whether gram positive or gram negative - Morphology of bacteria, whether cocci, diplococci, streptococci, rods, or coccobacilli. The skin should be squeezed well and small incision made with sharp blade and the tissue fluid is scraped by turning the blade at a right angle. Sites for slit skin smear include eye brow, ear lobe, elbow gluteal area, knees and active edge of a lesion. Explain the procedure to the patient (or parent if the patient is a child) The patient should sit with his or her back to the table on which the equipment for taking the smear is placed. Sterilize the blade by wiping it carefully with a piece of absorbent cotton wool soaked in 70% ethanol (alcohol) and flaming it for 2-3 seconds in the flame of a spirit lamp. Using the sterile blade, make a small cut through the skin surface, about 5mm long and deep enough in to the dermis (2-3mm) where the bacteria will be found. Note: providing the pressure is maintained between the thumb and index finger, little or no bleeding should occur. Using the blunt edge of the blades, scrape firmly two or three times along the edges and bottom of the cut to collect a sample of tissue juice and cells 8. When the smear has dried, gently heat-fix by holding the smear upper most over the flame of a spirit lamp or the pilot flame of a Bunsen burner for a few seconds. Allow the heated stain to remain on the slide for 10-15 minutes (ensure the stain does not dry on the smear). Examine the smear microscopically, first with the 40x objective to see the distribution of material and then with the oil immersion to look for acid-fast bacilli. Red solid bacilli or beaded forms, occurring singly or in masses Macrophage cells ……………………… green* *Blue if methylene blue counter stain has been used - Reporting M. Leprae bacteria are seen or ‘Negative’ if no bacteria are seen after examining entire smear or at least 100 high power microscope fields. Diagnosis of Fungal skin infection Fungi are usually larger than bacteria and in skin specimens they can be seen by direct microscopy provided the material is first softened and cleared with a strong alkali to digest the keratin surrounding the fungi so that the hyphae and spores can be seen. Fungal sample collection and processing In skin infections a fungal lesion usually spreads outwards in concentric fashion with healing in the central region. Material should therefore be collected by scraping out wards from the edges of the lesions with a scalpel blade; when there is minimal scaling as, for example, with lesions of the glabrous skin, it is preferable and sometimes necessary to use celotape to remove adequate material for examination. In all cases, cleaning the site with 70% alcohol before taking the specimen may be helpful and should be done if greasy ointments or if powders have been use for treatment. This permits drying of the specimen, reduces bacterial contamination and also provides conditions under which specimens may be stored for long periods with out appreciable loss in viability of fungi and parasites. As soon as the specimen has cleared, examine it microscopically using 10x and 40 x objectives with the condenser iris diaphragm closed sufficiently to give good contrast. Dermatophytes in skin scales: look for branching septate hyphae with angular or spherical arthrospores, usually in chains. All species of ringworm fungi have a similar appearance Fungi need to be distinguished from epidermal cell outlines, elastic fibers, and artifacts such as intracellular cholesterol (mosaic fungus) and strands of cotton or vegetable fibers. Ringworm fungal hyphae can be differentiated from these structures by their branching, uniform width, and cross- walls (septa), which can be seen when using 40-x objective. In Superficial Candidiasis, the fungus may be seen as budding yeast cells and in the majority of instances mycelium is also present. Right: Gram stain preparation of skin scales preparation showing gram positive as seen with the 40x objective C albicans yeasts and psuedohyphe 5. Wood’s light can be used to assist clinical diagnosis and to select suitable scalp material for laboratory investigation. Care must be taken to differentiate between true fungal fluorescence (bright green) and 121 the auto fluorescence of keratin (dull blue) or the fluorescence of creams and ointments that may have been applied to the lesion. It is clear that a primary infection produces partial local immunity to reinfection but this protection varies in duration and extent depending on the host, the site of infection and the species of Dermatophytes. Cutaneous hypersensitivity (immediate and/or delayed) may occur and circulating antibodies have been detected in infected individuals but neither phenomenon has been shown to be of any diagnostic value. Although many dermatophytes may develop recognizable colonies 0 with in 5-7 days, cultures should be retained for at least 3 weeks at 25-30 C and longer at lower temperatures before making a final diagnosis.
In need to add to this the costs of a further randomized controlled administration cheap kamagra 50mg line, including surgeons trial buy kamagra 50mg with visa, Sahai et al report profound fees, theatre time and disposables. This device works by implanting a pacemaker-like neurostimulator The main adverse event following in the lower back that sends mild Botulinum injections is temporary electrical impulses to electrodes urinary retention, with a reported that are usually placed adjacent incidence of between 19% to to the third sacral nerve root. This involves stimulation of Another trial that followed somatosensory ascending tracts patients up for a mean of more projecting from the bladder into than 5 years reported continued the pontine micturition centre success in 76% of the cohort. The electrical impulses also activate the pelvic Despite these success rates, this efferent hypogastric sympathetic therapeutic option is not accessible nerves, which promotes to the majority of women largely continence. The test phase includes the available in South Africa, supplied temporary insertion of a needle by Medtronic, but retails for into the sacral foramen under approximately R55000. If the subject reports a equipment including pain and satisfactory response after three to discomfort, seroma formation, four weeks, defned as more than disturbed bowel function and 50% improvement in symptoms, wound dehiscence. Posterior Tibial Nerve of a long-term battery and Stimulation neurostimulator in the buttock and Because of the technical and lower back. The follow up, with a further 29% technique is performed by passing reporting more than 50% an electric current between a 43 small acupuncture needle 4cm of neuromodulation and Botox above the medial malleoulus and has provided us with additional an electrode on the sole of the options prior to resorting to patient’s foot. Alternative therapy equipment, including a single use A number of studies have shown electrode and needle and this acupuncture to be a useful unfortunately drives up the cost of adjunct to therapy. The treatment performed in the late 1980’s regime consists of up to 12 weekly reported a 77% reduction in sessions of 30 minutes although urgency and frequency in 77% of it may be effcacious after shorter their patients versus only 20% treatment periods, it does not last in placebo. These fndings have indefnitely and it needs to be been confrmed by Bergstrom et repeated after a few months. The most It has been shown to be effcacious interesting data have emerged in two trials with one reporting from a trial where women were more than 50% reduction in randomised to acupuncture in leakage episodes in 70% of bladder specifc points versus their cohort, 46% of the subjects relaxation point acupuncture. Acupuncture is Clam ileocystoplasty and readily available, is inexpensive augmentation procedures are and can be performed by many usually reserved for patients physiotherapists- and hence should with neurogenic detrusor be kept in mind for those women overactivity and high pressure who do not want medication. The advent 44 Chapter 7 The Treatment of Stress Incontinence Peter de Jong Stress Urinary Incontinence is exercises extending over a number defned as the complaint of of weeks. Do 45 pelvic muscle exercises every day, 15 at a time, 3 times a day: Stress incontinence occurs when 15 lying down in the morning one coughs, sneezes or jumps, 15 standing up in the afternoon resulting in a few drops or urine 15 sitting down in the evening leaking out. Relax for 10 seconds – Physiotherapy Remember to relax at the muscles in your abdomen when you do The frst step in therapy is to have these exercises, and continue to the sufferer visit a physiotherapist breathe normally. The physio will Test the power and effectiveness of assess the strength of the patient’s your exercises by placing 2 fngers pelvic foor, and suggest exercise in the vagina, and squeezing. The incontinence weights begin at 20g, and increase until the woman can manage to retain a cone of 100g, for 30min When Is Surgery twice daily. Faradism, where tiny electric When the relief obtained by impulses are sent through an physiotherapy is unsatisfactory, electrode placed in the vagina. For women with signifcant symptoms (for example, they need Bio feedback, where the patient to wear a pad daily), some form of squeezes a balloon placed in the surgical option may be indicated. The Surgical If a woman persists in Management Of physiotherapy, there is no doubt Stress Incontinence that the technique will result in better muscle strength and control, Vaginal birth and aging are with a corresponding improvement important causes of urinary in bladder control. Ingenious operations to cure this common Bear in mind that physiotherapy and distressing symptom in women is without side effects, may be have been devised. As a better done at home, and empowers understanding of the mechanisms the sufferer to take charge of her of continence have evolved, 46 operations to cure the condition long – term voiding complication have improved. Over the years there have been many operations for the treatment One of the frst effective of urinary incontinence, suggesting procedures to gain acceptance no single procedure is effective was the Burch colposuspension. Colposuspension is still applicable today, if the patient Historical Perspective requires a continence procedure and is fortuitously undergoing laparotomy. Traditionally the anterior repair of a cystocoele using Kelly While the Burch procedure is as plication sutures have been useful in the management of stress effective as modern sub – urethral incontinence. However the effect slings, a prospective randomized is transient, and while it cures trial showed higher morbidity than the sling so it is nowadays anterior compartment prolapse, probably best reserved for women the anterior repair is not an authentic continence operation. Several drawbacks attend the operation, chief of which is studies suggest a continence rate of 67% - 72%, but generally the subsequent enterocoele formation. Long term Voiding dysfunction, detrusor results are poor, and at 5 years overactivity and uterovaginal success falls to 37%. Needle province of the laparoscopic suspensions do not produce a affecionado, but showed no lower complication rate than advantage over the other the colposuspension, and there procedures of the time. Burch procedure, and the evidence on laparoscopic Burch is limited Having been described and used by short – term follow – up, small more than a century previously, the numbers, poor methodology and rectus sheath sling was all the rage its technical diffculty. Although short procedures with the same tension term effcacy in some agents is – free sub – urethral principle, but satisfactory, evidence shows that avoiding the pelvic cavity and its long term durability of more than viscera completely. No well described, standardized data is available suggesting how procedure, easily reproduced stem cells obtain innervation, or by most urogynaecologists with functional potential. Given that transobturator with a small incision using various approaches are probably safer and trochar devices. Initially fatalities have occurred due to a welded semi – rigid tape of bowel damage and uncontrolled non – woven monoflament retropubic haemorrhage. Women are placed transobturator procedures show in the Lithotomy position, and the similar cure rates, but these 10mm tape passes sub – urethrally studies are too underpowered through the obturator fossa to exit to show meaningful differences the skin through a small incision in complications rates. The introducer passes from obturator approaches are safer the obturator fossa medially because of avoidance of pelvic inwards towards the vagina, hence cavity viscera – but no hard 50 the “outside – in” appellation.
Since a capillary bed (the glomerulus) drains into a vessel that in turn forms a second capillary bed kamagra 100 mg generic, the definition of a portal system is met buy kamagra 100 mg. This is the only portal system in which an arteriole is found between the first and second capillary beds. The efferent arteriole is the connecting vessel between the glomerulus and the peritubular capillaries and vasa recta. Cortex In a dissected kidney, it is easy to identify the cortex; it appears lighter in color compared to the rest of the kidney. About 15 percent of nephrons have long loops of Henle that extend deep into the medulla and are called juxtamedullary nephrons. Even then, serial sections and computer reconstruction are necessary to give us a comprehensive view of the functional anatomy of the nephron and its associated blood vessels. The term forming urine will be used hereafter to describe the filtrate as it is modified into true urine. The principle task of the nephron population is to balance the plasma to homeostatic set points and excrete potential toxins in the urine. Renal Corpuscle As discussed earlier, the renal corpuscle consists of a tuft of capillaries called the glomerulus that is largely surrounded by Bowman’s (glomerular) capsule. It transitions onto the glomerular capillaries in an intimate embrace to form the visceral layer of the capsule. Here, the cells are not squamous, but uniquely shaped cells ( podocytes) extending finger-like arms ( pedicels) to cover the glomerular capillaries (Figure 25. These projections interdigitate to form filtration slits, leaving small gaps between the digits to form a sieve. Where the fenestrae (windows) in the glomerular capillaries match the spaces between the podocyte “fingers,” the only thing separating the capillary lumen and the lumen of Bowman’s capsule is their shared basement membrane (Figure 25. This membrane permits very rapid movement of filtrate from capillary to capsule though pores that are only 70 nm in diameter. In (a), the large cell body can be seen at the top right corner, with branches extending from the cell body. The fenestrations prevent filtration of blood cells or large proteins, but allow most other constituents through. These substances cross readily if they are less than 4 nm in size and most pass freely up to 8 nm in size. An additional factor affecting the ability of substances to cross this barrier is their electric charge. The proteins associated with these pores are negatively charged, so they tend to repel negatively charged substances and allow positively charged substances to pass more readily. There are also mesangial cells in the filtration membrane that can contract to help regulate the rate of filtration of the glomerulus. Overall, filtration is regulated by fenestrations in capillary endothelial cells, podocytes with filtration slits, membrane charge, and the basement membrane between capillary cells. The result is the creation of a filtrate that does not contain cells or large proteins, and has a slight predominance of positively charged substances. In response to the concentration of Na in the fluid flowing past them, these cells release paracrine signals. In other words, when osmolarity goes up, filtration and urine formation decrease and water is retained. When osmolarity goes down, filtration and urine formation increase and water is lost by way of the urine. A second function of the macula densa cells is to regulate renin release from the juxtaglomerular cells of the afferent arteriole (Figure 25. Active renin is a protein comprised of 304 amino acids that cleaves several amino acids from angiotensinogen to produce angiotensin I. Aldosterone + stimulates Na reabsorption by the kidney, which also results in water retention and increased blood pressure. Simple cuboidal cells form this tubule with prominent microvilli on the luminal surface, forming a brush border. These microvilli + – create a large surface area to maximize the absorption and secretion of solutes (Na , Cl , glucose, etc. Loop of Henle The descending and ascending portions of the loop of Henle (sometimes referred to as the nephron loop) are, of course, just continuations of the same tubule. They run adjacent and parallel to each other after having made a hairpin turn at the deepest point of their descent. The descending loop of Henle consists of an initial short, thick portion and long, thin portion, whereas the ascending loop consists of an initial short, thin portion followed by a long, thick portion. As you will see later, these are important differences, since different portions of the loop have different permeabilities for solutes and water. Collecting ducts merge as they descend deeper in the medulla to form about 30 terminal ducts, which empty at a papilla.
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