By K. Anktos. University of Tennessee Health Science Center.

A small bursa (the The contents of the extensor compartment of the leg are as follows: retrocalcaneal bursa) occupies the space between the upper third of the • Muscles: tibialis anterior purchase viagra with fluoxetine visa, extensor hallucis longus buy line viagra with fluoxetine, extensor digito- posterior surface of the calcaneus and the Achilles tendon discount viagra with fluoxetine 100/60mg online. Within rum longus and peroneus tertius (unimportant in function) (see Muscle soleus, and to a lesser extent gastrocnemius, there is an extensive index, p. Midtarsal (calcaneocuboid) ligament Talus talocalcaneal Sustentaculum tali Tibialis ligament posterior Facet for medial malleolus Calcaneofibular Head of talus Flexor ligament Navicular digitorum Peroneus brevis Tuberosity of navicular longus Peroneus longus Medial cuneiform Flexor 1 2 hallucis longus First metatarsal 3 Fig. Posterior The major joints are shown tibiofibular Anterior tibiofibular ligament ligament Posterior Talus talofibular Navicular Tendo Deltoid ligament calcaneus ligament Position Medial of bursa cuneiform First metatarsal Bifurcate ligament Cuboid Cervical ligament Long plantar ligament Calcaneofibular ligament Fig. The articular surfaces are covered with cartilage and synovial the tendocalcaneus by a bursa (retrocalcaneal bursa) (Fig. The capsule is Medial and lateral tubercles are present on the inferior surface to which reinforced on either side by strong collateral ligaments but is lax anter- the plantar aponeurosis is attached. The peroneal tubercle, a small projection on the lateral sur- deep component which is a vertical band passing from the medial face of the calcaneus, separates the tendons of peroneus longus and malleolus to the talus. It has a tuberosity on its and posterior talofibular ligaments and the calcaneofibular ligament medial aspect which provides attachment for tibialis posterior. Abduction/adduction forces on the ankle can cause a • Cuneiforms: there are three cuneiforms which articulate anteriorly sprainaan incomplete tear of one of the collateral ligaments. Their wedge- tears of the ligaments also occur and lead to painful instability at the shape helps to maintain the transverse arch of the foot. Severe forces on the ankle joint can • Metatarsals and phalanges: these are similar to the metacarpals and result in fracture or fracture dislocation. The movements at the ankle The head is grooved on its inferior surface for the two sesamoid bones It is important to note that the inversion and eversion movements of within the tendon of flexor hallucis brevis. Inversion and eversion • Dorsiflexion: tibialis anterior and to a lesser extent extensor hallucis movements occur at the subtalar joint. This joint is com- faces for articulation with the tibia, medial malleolus and lateral malle- posed of the calcaneocuboid joint and the talonavicular component of olus, respectively. To the groove’s lateral • The calcaneocuboid jointais a synovial plane joint formed side is the posterior (lateral) tubercle, sometimes known as the os between the anterior surface of the calcaneus and the posterior trigonum, as it ossifies from a separate centre to the talus. Other from the sustentaculum tali to the tuberosity of the navicular forming a muscles insert on the dorsum of the foot but arise from the leg. It reinforces the digitorum longus is joined on its lateral side by a tendon from extensor capsule of the talocalcaneonavicular joint. The latter supplies extensor digitorum brevis • Interosseous talocalcaneal ligament: runs in the sinus tarsi, a whereas the former receives cutaneous branches from the skin. The skin of the sole is supplied by the medial and lateral plantar The arches of the foot branches of the tibial nerve. The medial calcaneal branch of the tibial The integrity of the foot is maintained by two longitudinal (medial and nerve innervates a small area on the medial aspect of the heel. The arches are held together by a combination of bony, ligamentous and muscular factors The plantar aponeurosis so that standing weight is taken on the posterior part of the calcaneum This aponeurosis lies deep to the superficial fascia of the sole and and the metatarsal heads as a result of the integrity of the arches. The arch is bound together by the spring ligament, muscles split into two parts which pass on either side of the flexor tendons and and supported from above by tibialis anterior and posterior. The arch is bound together by The muscular layers of the sole the long and short plantar ligaments and supported from above by per- • 1st layer consists of: abductor hallucis, flexor digitorum brevis and oneus longus and brevis. The arch is bound together by the deep transverse ligament, and the tendons of flexor digitorum longus and flexor hallucis longus plantar ligaments and the interossei. The dorsal venous arch lies within the subcutaneous tissue overlying Neurovascular structures of the sole the metatarsal heads. It receives blood from most of the superficial tis- • Arterial supply: is from the posterior tibial artery which divides into sues of the foot via digital and communicating branches. The latter branch contributes the saphenous vein commences from the medial end of the arch and the major part of the deep plantar arch (p. The shaft of the • The greater trochanter of the femur lies approximately a hands- fibula is mostly covered but is subcutaneous for the terminal 10 cm. It is made more prominent by adducting • The popliteal pulse is difficult to feel as it lies deep to the tibial nerve the hip. It is best felt by palpating in the popliteal fossa with • The ischial tuberosity is covered by gluteus maximus when the hip the patient prone and the knee flexed. The lat- the anterior superior iliac spine and the symphysis pubis (mid-inguinal eral is more elongated and descends a little further than the medial. The femoral head lies deep to the femoral artery at the mid- • When the foot is dorsiflexed the tendons of tibialis anterior, extensor inguinal point. The femoral vein lies medial, and the femoral nerve lat- hallucis longus and extensor digitorum are visible on the anterior eral, to the artery at this point. The hernial sac always lies below and • Passing behind the medial malleolus lie: the tendons of tibialis pos- lateral to the pubic tubercle (cf. The tendon of peroneus brevis inserts onto the tuberosity on • The sciatic nerve has a curved course throughout the gluteal region. Consider two linesaone connects the posterior superior iliac spine and • The heel is formed by the calcaneus. The tendocalcaneus (Achilles) the ischial tuberosity and the other connects the greater trochanter and is palpable above the heel. The division of the sciatic nerve into tibial and • The tuberosity of the navicular can be palpated 2. The tendon of tibialis posterior lies above the sustentaculum tali • The common peroneal nerve winds superficially around the neck of and the tendon of flexor hallucis longus winds beneath it. Footdrop can • The dorsalis pedis pulse is located on the dorsum of the foot be- result from fibular neck fractures where damage to this nerve has tween the tendons of extensor hallucis longus and extensor digitorum. The • The patella and ligamentum patellae are easily palpable with the small saphenous vein drains the lateral end of the arch and passes pos- limb extended and relaxed. The ligamentum patellae can be traced to its terior to the lateral malleolus to ascend the calf and drain into the attachment at the tibial tuberosity. The great saphenous vein passes anterior to the medial • The adductor tubercle can be felt on the medial aspect of the femur malleolus to ascend the length of the lower limb and drain into the above the medial condyle. This vein can be accessed consistently by ‘cutting down’ • The femoral and tibial condyles are prominent landmarks. With the anterior to, and above, the medial malleolus following local anaesthe- knee in flexion the joint line, and outer edges of the menisci within, are sia. Surface anatomy of the lower limb 119 53 The autonomic nervous system Visible Sympathetic Parasympathetic Sympathetic ganglion Cranial outflow 3, 7, 9, 10/11 Parasympathetic T1 Spinal cord Microscopic ganglion Fig. The former initiates the ‘fight or flight’ reac- ramus and are then distributed with the branches of that nerve. B They may pass to adjacent arteries to form a plexus around them Both systems have synapses in peripheral ganglia but those of the sym- and are then distributed with the branches of the arteries. Other pathetic system are, for the most part, close to the spinal cord in the gan- fibres leave branches of the spinal nerves later to pass to the arter- glia of the sympathetic trunk whereas those of the parasympathetic ies more distally. The fibres leave these spinal nerves as the white rami Loss of the supply to the head and neck will produce Horner’s syn- communicantes and synapse in the ganglia of the sympathetic trunk.

buy viagra with fluoxetine 100/60mg otc

For reasons that are unclear buy cheap viagra with fluoxetine 100 mg on-line, cervicitis the suspected cause purchase 100/60mg viagra with fluoxetine with mastercard, all partners in the past 60 days before the can persist despite repeated courses of antimicrobial therapy viagra with fluoxetine 100mg. Because the sensitivity of microscopy (commonly referred to as mucopurulent cervicitis or cervicitis) to detect T. Several factors should affect the decision to provide presumptive therapy for cervicitis or to await the results of Management of Sex Partners diagnostic tests. Expedited partner treatment and patient referral (see For women in whom any component of (or all) presumptive Partner Management) are alternative approaches to treating therapy is deferred, the results of sensitive tests for C. Women who receive such therapy should return infectious disease in the United States, and prevalence is high- after treatment so that a determination can be made regard- est in persons aged ≤25 years (93). Some women who have uncomplicated cervical infection are clearly attributable to cervicitis, referral to a gynecologic already have subclinical upper-reproductive–tract infection specialist can be considered. To detect chlamydial infections, health-care provid- Follow-up should be conducted as recommended for the ers frequently rely on screening tests. If symptoms persist, sexually active women aged ≤25 years is recommended, as is women should be instructed to return for re-evaluation because screening of older women with risk factors (e. Recent evidence to recommend annual chlamydia screening of sexually active suggests that the liquid-based cytology specimens collected for women aged ≤25 years. Among Treating infected patients prevents sexual transmission of women, the primary focus of chlamydia screening eforts the disease, and treating all sex partners of those testing positive should be to detect chlamydia and prevent complications, for chlamydia can prevent reinfection of the index patient and whereas targeted chlamydia screening in men should only be infection of other partners. Treating pregnant women usually considered when resources permit and do not hinder chlamydia prevents transmission of C. An appropriate sexual Chlamydia treatment should be provided promptly for all per- risk assessment should be conducted for all persons and might sons testing positive for infection; delays in receiving chlamydia indicate more frequent screening for some women or certain treatment have been associated with complications (e. Te following recommended treat- urethral infection in men can be made by testing a urethral ment regimens and alternative regimens cure infection and swab or urine specimen. Unlike the test-of-cure, which is not recommended, to treat patients for whom compliance with multiday dosing repeat C. If retesting at 3 months In patients who have erratic health-care–seeking behav- is not possible, clinicians should retest whenever persons next ior, poor treatment compliance, or unpredictable follow-up, present for medical care in the 12 months following initial azithromycin might be more cost-efective in treating chla- treatment. Erythromycin might be less efcacious than either azithromycin or doxycycline, mainly Patients should be instructed to refer their sex partners for because of the frequent occurrence of gastrointestinal side evaluation, testing, and treatment if they had sexual contact efects that can lead to noncompliance. Levofoxacin and with the patient during the 60 days preceding onset of the ofoxacin are efective treatment alternatives but are more patient’s symptoms or chlamydia diagnosis. To minimize Among heterosexual patients, if concerns exist that sex disease transmission to sex partners, persons treated for chla- partners who are referred to evaluation and treatment will mydia should be instructed to abstain from sexual intercourse not seek these services (or if other management strategies are for 7 days after single-dose therapy or until completion of a impractical or unsuccessful), patient delivery of antibiotic 7-day regimen. To minimize the risk for reinfection, patients therapy to their partners can be considered (see Partner also should be instructed to abstain from sexual intercourse Management). Patients must also inform their partners of their 3–4 weeks after completing therapy) is not advised for persons infection and provide them with written materials about the treated with the recommended or alterative regimens, unless importance of seeking evaluation for any symptoms suggestive therapeutic compliance is in question, symptoms persist, or of complications (e. Abstinence should be continued until 7 days after successfully could yield false-positive results because of the a single-dose regimen or after completion of a multiple-dose continued presence of nonviable organisms (197). Pregnant Doxycycline, ofoxacin, and levofoxacin are contrain- women aged <25 years are at high risk for infection. Pregnant women is most frequently recognized by conjunctivitis that develops diagnosed with a chlamydial infection during the frst trimester 5–12 days after birth. Specimens for culture isolation and noncul- during pregnancy because of drug-related hepatotoxicity, the ture tests should be obtained from the everted eyelid using a lower dose 14-day erythromycin regimens can be considered dacron-tipped swab or the swab specifed by the manufacturer’s if gastrointestinal tolerance is a concern. The results of one study involving a limited number of patients suggest that a short Recommended Regimen course of azithromycin, 20 mg/kg/day orally, 1 dose daily for 3 days, might be efective (292). Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days Topical antibiotic therapy alone is inadequate for treatment of chlamydial infection and is unnecessary when systemic Follow-Up treatment is administered. Follow-up of infants is recom- approximately 80%, a second course of therapy might be mended to determine whether the pneumonia has resolved, required. Terefore, follow-up of infants is recommended although some infants with chlamydial pneumonia continue to to determine whether initial treatment was efective. Mothers of infants who have chlamydia pneumonia and Management of Mothers and Their Sex Partners the sex partners of these women should be evaluated and Te mothers of infants who have chlamydial infection and treated according to the recommended treatment of adults for the sex partners of these women should be evaluated and treated chlamydial infections (see Chlamydial Infection in Adolescents (see Chlamydial Infection in Adolescents and Adults). In addition, peripheral eosinophilia (≥400 cells/ treatment is not indicated, and the efcacy of such treatment is mm3) occurs frequently. Sexual abuse must be considered a cause of chlamydial Diagnostic Considerations infection in preadolescent children, although perinatally trans- Specimens for chlamydial testing should be collected from mitted C. Tissue culture is the defnitive standard for tract, and rectum might persist for >1 year (see Sexual Assault chlamydial pneumonia. However, because of lower sensitivity, a negative Gram stain should not be considered sufcient for ruling out infection in asymptom- other Management Considerations atic men. Te majority specimen types including endocervical swabs, vaginal swabs, of urethral infections caused by N. Although widespread screening is not recommended compromised by cross-reaction with nongonococcal Neisseria because gonococcal infections among women are frequently species. Health departments should prioritize partner notifcation cline and azithromycin, routine cotreatment might also hinder and contact tracing of patients with N. Ceftriaxone in a single injection of 250 mg provides time; during 1987–2008, only four isolates were found to sustained, high bactericidal levels in the blood. Extensive clini- have decreased susceptibility to ceftriaxone, and 48 isolates cal experience indicates that ceftriaxone is safe and efective had decreased susceptibility to cefxime. In 2008, no isolates for the treatment of uncomplicated gonorrhea at all anatomic demonstrated decreased susceptibility to ceftriaxone; cefxime sites, curing 99. A 250-mg dose of ceftriaxone is now recommended been reported (300), approximately 50 patients are thought to over a 125-mg dose given the 1) increasingly wide geographic have failed oral cephalosporin treatment (301–304). To ensure appropriate antibiotic therapy, clinicians utility of having a simple and consistent recommendation for should ask patients testing positive for gonorrhea about recent treatment regardless of the anatomic site involved. However, it has been efective oral cephalosporins) for treating gonococcal infections of the in published clinical trials, curing 98. Spectinomycin and if reported, treat these patients with ceftriaxone because has poor efcacy against pharyngeal infection (51. Azithromycin 2 g orally is efective against uncomplicated Single-dose injectible cephalosporin regimens (other than gonococcal infection (99. None of the recommended because several studies have documented treat- injectible cephalosporins ofer any advantage over ceftriaxone ment failures, and concerns about possible rapid emergence of for urogenital infection, and efcacy for pharyngeal infection antimicrobial resistance with the 1-g dose of azithromycin are is less certain (306,307). Some evidence suggests that cefpodoxime 400- Pharynx mg orally can be considered an alternative in the treatment of Most gonococcal infections of the pharynx are asymp- uncomplicated urogenital gonorrhea; this regimen meets the tomatic and can be relatively common in some populations minimum efcacy criteria for alternative regimens for urogenital (103,278,279,314). Few antimicrobial regimens, including 400 mg orally was found to have a urogenital and rectal cure rate those involving oral cephalosporins, can reliably cure >90% of of 96. Gonococcal strains patients should be treated with a regimen with acceptable with decreased susceptibility to oral cephalosporins have been efcacy against pharyngeal infection. Most infections allergy and occur less frequently with third-generation cepha- result from reinfection rather than treatment failure, indicat- losporins (239). In those persons with a history of penicillin ing a need for improved patient education and referral of sex allergy, the use of cephalosporins should be contraindicated partners. Clinicians should advise patients with gonorrhea to only in those with a history of a severe reaction to penicillin be retested 3 months after treatment. Retesting losporin allergy, providers treating such patients should consult is distinct from test-of-cure to detect therapeutic failure, which infectious disease specialists.

buy 100mg viagra with fluoxetine with mastercard

Combination Oral Selective Antihistamine Plus Intranasal Corticosteroid Versus Intranasal Corticosteroid Key Points Adverse event reporting in trials included in the efficacy review for this comparison was inadequate to permit analysis 100/60mg viagra with fluoxetine. Synthesis and Evidence Assessment 62 100/60 mg viagra with fluoxetine with visa, 90 viagra with fluoxetine 100mg with visa, 98, 131, 132 All five trials that reported efficacy outcomes reported adverse events. The remaining trial reported statistically nonsignificant risk differences of 0 percent for sedation, and 4 percent for headache, both favoring combination therapy. Risk differences of 2 percent and 3 percent for burning and nosebleeds, respectively, favored intranasal corticosteroid monotherapy, and neither was statistically significant. This single trial provides insufficient evidence to support the use of one treatment over the other to avoid adverse events. Combination Intranasal Corticosteroid Plus Nasal Antihistamine Versus Intranasal Corticosteroid Key Points 115, 117, 121 All five trials that reported efficacy outcomes also reported adverse events. Synthesis and Evidence Assessment 115, 117, 121 All five trials that reported efficacy outcomes also reported adverse events. Table 66 displays the risk differences and elements for the synthesis of evidence for this comparison. This trial was included in the synthesis of evidence only to assess consistency of effect. Seventy-five percent of the patient sample for this 115 adverse event was in the good quality trial that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. Eighty- 115 five percent of the patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Seventy-two 115 percent of the patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nasal discomfort. Forty 115 percent of the patient sample for this adverse event was in trials that reported statistically nonsignificant risk differences. Evidence was insufficient to conclude that either comparator is 115 favored to avoid a bitter aftertaste. Of note, three trials, representing 85 percent of the patient sample for this adverse event, used a newly approved (May 2012) formulation that includes a corticosteroid and an antihistamine in the same device. Eighty-five percent of the patient sample for this adverse event was in good quality trials115 that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nosebleed Combination Intranasal Corticosteroid Plus Nasal Antihistamine Versus Nasal Antihistamine Key Points 115, 117, 121 All five trials that reported efficacy outcomes also reported adverse events. Evidence from four trials was insufficient to support using either combination intranasal corticosteroid plus nasal antihistamine or nasal antihistamine monotherapy to avoid common adverse events of sedation, headache, nasal discomfort, bitter aftertaste, and nosebleed. In these three trials, an older version of nasal antihistamine rather than a newer formulation designed to mitigate bitter aftertaste was used as a comparator. Synthesis and Evidence Assessment 115, 117, 121 All five trials that reported efficacy outcomes also reported adverse events. Table 67 displays the risk differences and elements for the synthesis of evidence for this comparison. This trial was included in the synthesis of evidence only to assess consistency of effect. Seventy-five percent of the patient sample for this adverse event was 115 in a good quality trial that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. Eighty-five percent of the patient 115 sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Seventy-two percent of the patient 115 sample for this adverse event was in good quality trials that actively ascertained adverse 172 events. Evidence was insufficient to conclude that either comparator is favored to avoid nasal discomfort. Eighty-five percent of 115 the patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Thirty-five percent of the 115, 117 patient sample for this adverse event was in trials that reported imprecise risk differences. Evidence was insufficient to conclude that either comparator is favored to avoid a bitter 115 115, 117 aftertaste. Of note, three of four trials reporting bitter aftertaste (85 percent of the patient sample for this adverse event) used a newly approved (May 2012) formulation that includes a corticosteroid and an antihistamine in the same device. In these three trials, an older version of nasal antihistamine rather than a newer formulation designed to mitigate bitter aftertaste was used as a comparator. Eighty-five percent of the patient 115 sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nosebleed. This evidence was from four 2-week trials, each with statistically significant differences in the proportion of patients reporting insomnia. The body of evidence was consistent, precise and associated with moderate risk of bias. Evidence was insufficient to support using either oral antihistamine or oral decongestant to avoid sedation, headache or anxiety. Synthesis and Evidence Assessment 101-107 All seven trials that reported efficacy outcomes also reported adverse events. Table 68 displays the risk differences and elements for the synthesis of evidence for this comparison. In a third trial it was unclear if the reporting unit was the patient or an incident event. These three trials were included in the synthesis of evidence only to assess 105 consistency of effect. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. Fifty-six percent of the patient sample for this adverse event was in poor quality 104, 105 105 trials, one of which also had inadequate surveillance for adverse events, and forty-four 101, 103 percent was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Fifty-six percent of the patient 104, 105 sample for this adverse event was in poor quality trials, one of which also had inadequate 105 101, 103 surveillance for adverse events, and forty-four percent was in good quality trials that actively ascertained adverse events. To avoid insomnia, there is moderate strength evidence to support the use of oral antihistamine rather than oral decongestant. Fifty-five percent of the patient sample for this adverse event was in good 101, 103 quality trials that actively ascertained adverse events, and 45 percent was in a poor quality 105 trial that ascertained adverse events in a passive fashion. Evidence was insufficient to conclude that either comparator is favored to avoid anxiety.

generic viagra with fluoxetine 100/60 mg online

The lungs are enclosed by the pleura discount 100mg viagra with fluoxetine, a membrane that is composed of visceral and parietal pleural layers purchase viagra with fluoxetine online pills. The mesothelial cells of the pleural membrane create pleural fluid buy discount viagra with fluoxetine on line, which serves as both a lubricant (to reduce friction during breathing) and as an adhesive to adhere the lungs to the thoracic wall (to facilitate movement of the lungs during ventilation). The force exerted by gases within the alveoli is called intra-alveolar (intrapulmonary) pressure, whereas the force exerted by gases in the pleural cavity is called intrapleural pressure. Air flows when a pressure gradient is created, from a space of higher pressure to a space of lower pressure. A gas is at lower pressure in a larger volume because the gas molecules have more space to in which to move. The same quantity of gas in a smaller volume results in gas molecules crowding together, producing increased pressure. The surface tension of the alveoli also influences pressure, as it opposes the expansion of the alveoli. However, pulmonary surfactant helps to reduce the surface tension so that the alveoli do not collapse during expiration. Pulmonary ventilation consists of the process of inspiration (or inhalation), where air enters the lungs, and expiration (or exhalation), where air leaves the lungs. During inspiration, the diaphragm and external intercostal muscles contract, causing the rib cage to expand and move outward, and expanding the thoracic cavity and lung volume. This creates a lower pressure within the lung than that of the atmosphere, causing air to be drawn into the lungs. The air pressure within the lungs increases to above the pressure of the atmosphere, causing air to be forced out of the lungs. However, during forced exhalation, the internal intercostals and abdominal muscles may be involved in forcing air out of the lungs. Respiratory volume describes the amount of air in a given space within the lungs, or which can be moved by the lung, and is dependent on a variety of factors. Tidal volume refers to the amount of air that enters the lungs during quiet breathing, whereas inspiratory reserve volume is the amount of air that enters the lungs when a person inhales past the tidal volume. Expiratory reserve volume is the extra amount of air that can leave with forceful expiration, following tidal expiration. Residual volume is the amount of air that is left in the lungs after expelling the expiratory reserve volume. Anatomical dead space refers to the air within the respiratory structures that never participates in gas exchange, because it does not reach functional alveoli. Respiratory rate is the number of breaths taken per minute, which may change during certain diseases or conditions. Both respiratory rate and depth are controlled by the respiratory centers of the brain, which are stimulated by factors such as chemical and pH changes in the blood. These changes are sensed by central chemoreceptors, which are located in the brain, and peripheral chemoreceptors, which are located in the aortic arch and carotid arteries. A rise in carbon dioxide or a decline in oxygen levels in the blood stimulates an increase in respiratory rate and depth. Dalton’s law states that each specific gas in a mixture of gases exerts force (its partial pressure) independently of the other gases in the mixture. Henry’s law states that the amount of a specific gas that dissolves in a liquid is a function of its partial pressure. The greater the partial pressure of a gas, the more of that gas will dissolve in a liquid, as the gas moves toward equilibrium. Gas molecules move down a pressure gradient; in other words, gas moves from a region of high pressure to a region of low pressure. The partial pressure of oxygen is high in the alveoli and low in the blood of the pulmonary capillaries. In contrast, the partial pressure of carbon dioxide is high in the pulmonary capillaries and low in the alveoli. Ventilation is the process that moves air into and out of the alveoli, and perfusion affects the flow of blood in the capillaries. Both are important in gas exchange, as ventilation must be sufficient to create a high partial pressure of oxygen in the alveoli. If ventilation is insufficient and the partial pressure of oxygen drops in the alveolar air, the capillary is constricted and blood flow is redirected to alveoli with sufficient ventilation. External respiration refers to gas exchange that occurs in the alveoli, whereas internal respiration refers to gas exchange that occurs in the tissue. These cells contain a metalloprotein called hemoglobin, which is composed of four subunits with a ring-like structure. When all of the heme units in the blood are bound to oxygen, hemoglobin is considered to be saturated. An oxygen–hemoglobin saturation/dissociation curve is a common way to 1080 Chapter 22 | The Respiratory System depict the relationship of how easily oxygen binds to or dissociates from hemoglobin as a function of the partial pressure of oxygen. At the same time, once one molecule of oxygen is bound by hemoglobin, additional oxygen molecules more readily bind to hemoglobin. Other factors such as temperature, pH, the partial pressure of carbon dioxide, and the concentration of 2,3-bisphosphoglycerate can enhance or inhibit the binding of hemoglobin and oxygen as well. Fetal hemoglobin has a different structure than adult hemoglobin, which results in fetal hemoglobin having a greater affinity for oxygen than adult hemoglobin. Carbon dioxide is transported in blood by three different mechanisms: as dissolved carbon dioxide, as bicarbonate, or as carbaminohemoglobin. For this conversion, carbon dioxide is combined with water with the aid of an enzyme called carbonic anhydrase. This combination forms carbonic acid, which spontaneously dissociates into bicarbonate and hydrogen ions. As bicarbonate builds up in erythrocytes, it is moved across the membrane into the plasma in exchange for chloride ions by a mechanism called the chloride shift. At the pulmonary capillaries, bicarbonate re-enters erythrocytes in exchange for chloride ions, and the reaction with carbonic anhydrase is reversed, recreating carbon dioxide and water. The partial pressures of carbon dioxide and oxygen, as well as the oxygen saturation of hemoglobin, influence how readily hemoglobin binds carbon dioxide. The less saturated hemoglobin is and the lower the partial pressure of oxygen in the blood is, the more readily hemoglobin binds to carbon dioxide. However, in certain cases, the respiratory system must adjust to situational changes in order to supply the body with sufficient oxygen. For example, exercise results in increased ventilation, and chronic exposure to a high altitude results in a greater number of circulating erythrocytes. Hyperpnea, an increase in the rate and depth of ventilation, appears to be a function of three neural mechanisms that include a psychological stimulus, motor neuron activation of skeletal muscles, and the activation of proprioceptors in the muscles, joints, and tendons.

Parents would also be asked to answer the following three questions: 1) Was this information useful to you? The posters were intended for display along the hallways of obstetrical wards buy genuine viagra with fluoxetine on line, in full view of parents and outside visitors order discount viagra with fluoxetine line. Nurses would be encouraged to provide the information about shaken baby syndrome separately from other standard hospital discharge information (Dias & Barthauer generic 100 mg viagra with fluoxetine with visa, 2001). The inclusion of the commitment statement in the program design was a key improvement over virtually all other existing shaken baby syndrome prevention programs. The commitment statement was designed to accomplish two main objectives: 1) to actively engage parents in their own education about shaken baby syndrome, and 2) to facilitate program data collection and tracking. By signing a commitment statement, parents would feel that they were entering a “social contract” with the hospital, their infant, and their community in protecting their child against shaken baby syndrome. An exhaustive monitoring strategy for identifying new cases of shaken baby syndrome was outlined: 1) all admissions of inflicted infant head injury to the Children’s Hospital of Buffalo during the program would be identified and recorded, 2) nurses at each 20 21 hospital were to notify the program coordinators of any known cases that were not referred to the Children’s Hospital, 3) regular contact with regional child fatality teams, child protective services workers, law enforcement officials and medical examiners would be established, and 4) regional media sources, including television and newspapers, would be periodically reviewed (Dias et al. A child abuse specialist working at Strong Memorial Hospital in Rochester, New York was also to be regularly contacted to identify any additional new cases, in the unlikely event that Western New York patients were referred outside of the region. Based on these investigations, the incidence of inflicted infant head injury in Western New York would be calculated and compared with the historical incidence rate from the previous six years (Dias et al. Upon identifying a case of shaken baby syndrome, the infant’s birth date and birth hospital would be identified and then cross-referenced with the mother’s last name. This tracking method would indicate whether the parents had participated in the program, and whether or not they had signed a commitment statement. Hoyt Memorial Children and Family Trust Fund, and allotted Dias $8,000 in 1998 and $11,000 in 1999 to initiate the program. The grant money was predominately used to purchase and distribute program materials to participating hospitals (Dias & Barthauer, 2001). The new four-year grant provided $132,000 each year for the first two years, followed by a decrease in funding to 50% and 25% of the original amount in the third and fourth years, respectively. The grant was intended to finance the operation of the existing program in Western New York and also to fund a major program expansion into the adjacent Finger Lakes Region. The additional finances enabled Dias to hire two nurse project co-ordinators, registered nurses Kim Smith and Kathy deGuehery, to run the expanded program. With the anticipated involvement of 33 hospitals spanning the two regions, the total program budget reached over $450,000. The remaining funding needs were addressed by the Matthew Eappen Foundation, the Children’s Hospital of Buffalo, Strong Children’s Hospital in Rochester, the State University of New York at Buffalo, the University of Rochester, and other participating hospitals in the form of various in-kind donations (Dias & Barthauer, 2001; Dias et al. He took responsibility for tracking new cases of shaken baby syndrome, building the program database and fulfilling all program roles outside of those within each specific hospital. Within the first two months, all hospitals in Western New York were providing parents with the 22 23 program materials. From a logistical standpoint, smaller hospitals were able to embrace and implement the program more rapidly than larger centres, due to lower daily delivery rates and timely approval by hospital Institutional Review Boards. Dias found that personal contact with the nurse managers was essential for establishing each hospital’s commitment to the program and ensuring consistent participation from hospital staff. A survey of maternity nurses in 2000 revealed that the program was virtually unanimously well received (Dias & Barthauer, 2001). Nurses reported routinely providing program materials to new parents and having them sign the commitment statements. The video was being regularly shown in over 1/2 of the hospitals, and over 2/3 of participating hospitals were displaying the posters. Feedback from parents was also very positive; over 90% claimed that they already knew about the dangers of shaking an infant, but felt that the program information was helpful. Ninety- five percent of parents that signed a commitment statement felt that shaken baby syndrome information should be provided to all new parents. The exceedingly small proportion of parents who felt that the program information was not helpful mostly perceived it to be redundant. The Finger Lakes Region Hospitals Join the Program Hospitals in the Finger Lakes Region were phased in beginning in January 2001. Since the Finger Lakes Region shares many of the same population and geographical features as Western New York, the expansion effort did not require any major structural changes to the program. Strong Children’s Hospital in Rochester is analogous to the Children’s Hospital of Buffalo in 23 24 that it is the sole tertiary referral centre for pediatric neurosurgical cases in the region. A similar Perinatal Outreach Program was also in full operation; its staff network and hospital linkages were used to introduce and run the program. Linda Barthauer, a pediatrician specializing in child abuse from Strong Children’s Hospital, was appointed to be the principal investigator (Dias & Barthauer, 2001). The two new project co-ordinators assumed many of the administrative roles that Dias had previously fulfilled. During the expansion phase, the commitment statement was amended to include a request that parents consent to receive a follow-up call seven months after their infant’s birth. The call was intended to assess parents’ recollection of the information received in the hospital and to solicit program feedback. The timing of the follow-up call coincided with the midpoint in the peak incidence of shaken baby syndrome and was designed to test the hypothesis that parental retention of the program material could endure for a minimum of seven months (Dias et al. With the addition of the Finger Lakes Region, 33 hospitals in 17 counties would be participating in the Upstate New York Shaken Baby Syndrome Parent Education Program. The following quantitative program performance goals were set at the outset of the expansion: 1) to establish a regional program including all 17 counties in Western New York and the Finger Lakes Region, 2) to educate at least 70% of new parents about shaken baby syndrome prior to discharge from the hospital, and 3) to reduce and maintain the incidence rate of shaken baby syndrome in each region to 50% of the historical baseline figures (Dias & Barthauer, 2001). All other aspects of the program, including staff 24 25 infrastructure, program materials, and incidence-tracking strategies, were introduced in the same manner as in Western New York. They also act as a valuable resource for staff regarding program innovations, trouble-shooting, and the provision of feedback. Additionally, they supervise and communicate directly with the two project co-ordinators, who are responsible for the bulk of the administrative tasks associated with routine program operations. The project co- ordinators orchestrate the purchase, receipt, and delivery of all program materials to the hospitals and conduct obstetrical and perinatology nurse training sessions. Additionally, they communicate regularly with the nurse managers and assist them in tackling local logistical problems. They also monitor the monthly collection of signed commitment statements and maintain the program database. As active participants in the vigilant tracking of new shaken baby syndrome cases, project co-ordinators regularly contact hospitals, the media, and other child abuse professionals to identify new cases. They also conduct the seven-month follow-up phone calls, assist with the preparation of program data for statistical analysis, and provide program updates for a monthly newsletter distributed to all participating centres regarding ongoing concerns, progress reports, and project status. Finally, the project co-ordinators are public speakers and community advocates for the prevention of shaken baby syndrome, as requested by local public service groups, researchers, and other regions interested in replicating the program (Dias & Barthauer, 2001). The nurse managers are responsible for: 1) educating the maternity nurses about shaken baby syndrome and about how to implement the program; 2) receiving and delivering all program materials; 3) collecting and delivering all signed commitment statements from the maternity nurses to the project co-ordinators each month; and 4) providing the project co-ordinators with monthly delivery statistics to be used in future incidence rate calculations. Any logistical difficulties that arise are solved through direct communication with the project co-ordinators. Maternity ward nurses are trained to educate parents, distribute program materials, and collect signed commitment statements from a maximal number of parents, especially fathers. They return signed commitment statements to the nurse managers for delivery to the project co- ordinators each month.

order 100/60 mg viagra with fluoxetine mastercard

The trigeminal pathway carries somatosensory information from the face purchase viagra with fluoxetine 100/60 mg online, head buy viagra with fluoxetine without a prescription, mouth buy genuine viagra with fluoxetine on line, and nasal cavity. As with the previously discussed nerve tracts, the sensory pathways of the trigeminal pathway each involve three successive neurons. The spinal trigeminal nucleus of the medulla receives information similar to that carried by spinothalamic tract, such as pain and temperature sensations. Other axons go to either the chief sensory nucleus in the pons or the mesencephalic nuclei in the midbrain. These nuclei receive information like that carried by the dorsal column system, such as touch, pressure, vibration, and proprioception. Axons from the third neuron then project from the thalamus to the primary somatosensory cortex of the cerebrum. The sensory pathway for gustation travels along the facial and glossopharyngeal cranial nerves, which synapse with neurons of the solitary nucleus in the brain stem. Finally, axons from the ventral posterior nucleus project to the gustatory cortex of the cerebral cortex, where taste is processed and consciously perceived. The sensory pathway for audition travels along the vestibulocochlear nerve, which synapses with neurons in the cochlear nuclei of the superior medulla. Within the brain stem, input from either ear is combined to extract location information from the auditory stimuli. Whereas the initial auditory stimuli received at the cochlea strictly represent the frequency—or pitch—of the stimuli, the locations of sounds can be determined by comparing information arriving at both ears. Sound localization is achieved by the brain calculating the interaural time difference and the interaural intensity difference. A sound originating from a specific location will arrive at each ear at different times, unless the sound is directly in front of the listener. If the sound source is slightly to the left of the listener, the sound will arrive at the left ear microseconds before it arrives at the right ear (Figure 14. Also, the sound will be slightly louder in the left ear than in the right ear because some of the sound waves reaching the opposite ear are blocked by the head. Connections between neurons on either side are able to compare very slight differences in sound stimuli that arrive at either ear and represent interaural time and intensity differences. Axons from the inferior colliculus project to two locations, the thalamus and the superior colliculus. The medial geniculate nucleus of the thalamus receives the auditory information and then projects that information to the auditory cortex in the temporal lobe of the cerebral cortex. The superior colliculus receives input from the visual and somatosensory systems, as well as the ears, to initiate stimulation of the muscles that turn the head and neck toward the auditory stimulus. An important function of the vestibular system is coordinating eye and head movements to maintain visual attention. Some axons project from the vestibular ganglion directly to the cerebellum, with no intervening synapse in the vestibular nuclei. The cerebellum is primarily responsible for initiating movements on the basis of equilibrium information. One target is the reticular formation, which influences respiratory and cardiovascular functions in relation to body movements. A second target of the axons of neurons in the vestibular nuclei is the spinal cord, which initiates the spinal reflexes involved with posture and balance. To assist the visual system, fibers of the vestibular nuclei project to the oculomotor, trochlear, and abducens nuclei to influence signals sent along the cranial nerves. Finally, the vestibular nuclei project to the thalamus to join the proprioceptive pathway of the dorsal column system, allowing conscious perception of equilibrium. During head movement, the eye muscles move the eyes in the opposite direction as the head movement, keeping the visual stimulus centered in the field of view. Instead of the connections being between each eye and the brain, visual information is segregated between the left and right sides of the visual field. In addition, some of the information from one side of the visual field projects to the opposite side of the brain. For example, the axons from the medial retina of the left eye cross over to the right side of the brain at the optic chiasm. For example, the axons from the lateral retina of the right eye project back to the right side of the brain. Therefore the left field of view of each eye is processed on the right side of the brain, whereas the right field of view of each eye is processed on the left side of the brain (Figure 14. This is different from “tunnel vision” because the superior and inferior peripheral fields are not lost. Visual field deficits can be disturbing for a patient, but in this case, the cause is not within the visual system itself. A growth of the pituitary gland presses against the optic chiasm and interferes with signal transmission. Therefore, the patient loses the outermost areas of their field of vision and cannot see objects to their right and left. Extending from the optic chiasm, the axons of the visual system are referred to as the optic tract instead of the optic nerve. The connection between the eyes and diencephalon is demonstrated during development, in which the neural tissue of the retina differentiates from that of the diencephalon by the growth of the secondary vesicles. The majority of the connections of the optic tract are to the thalamus—specifically, the lateral geniculate nucleus. Axons from this nucleus then project to the visual cortex of the cerebrum, located in the occipital lobe. The perceived proportion of sunlight to darkness establishes the circadian rhythm of our bodies, allowing certain physiological events to occur at approximately the same time every day. In the somatic nervous system, the thalamus is an important relay for communication between the cerebrum and the rest of the nervous system. In addition, the hypothalamus communicates with the limbic system, which controls emotions and memory functions. Sensory input to the thalamus comes from most of the special senses and ascending somatosensory tracts. The thalamus is a required transfer point for most sensory tracts that reach the cerebral cortex, where conscious sensory perception begins. The olfactory tract axons from the olfactory bulb project directly to the cerebral cortex, along with the limbic system and hypothalamus. White matter running through the thalamus defines the three major regions of the thalamus, which are an anterior nucleus, a medial nucleus, and a lateral group of nuclei. The anterior nucleus serves as a relay between the hypothalamus and the emotion and memory- producing limbic system. The medial nuclei serve as a relay for information from the limbic system and basal ganglia to the cerebral cortex. The special and somatic senses connect to the lateral nuclei, where their information is relayed to the appropriate sensory cortex of the cerebrum. Cortical Processing As described earlier, many of the sensory axons are positioned in the same way as their corresponding receptor cells in the body.

The inferior vena cava passes through the caval opening in the enlargement of the superficial inguinal nodes whereas testicular diaphragm at the level of T8 and drains into the right atrium viagra with fluoxetine 100/60 mg lowest price. The veins and lymphatics of the abdomen 35 14 The peritoneum Subphrenic space Diaphragm Epiploic foramen (of Winslow) Upper recess of omental bursa Portal vein Inferior vena cava Liver Aorta Lesser omentum Epiploic foramen Left kidney (in the distance) Splenic artery Omental bursa Pancreas Lienorenal ligament Stomach Spleen Transverse mesocolon Short gastric Duodenum (third part) vessels Transverse colon Gastrosplenic Small intestine ligament Stomach Mesentery Lesser omentum Greater omentum Hepatic artery Fusion between layers Common bile duct of greater omentum Liver Fig buy viagra with fluoxetine 100/60 mg with mastercard. Note how the epiploic foramen lies between two major veins Lesser sac Greater sac Upper layer of Upper layer of Left triangular coronary ligament coronary ligament Bare area ligament Lower layer of coronary ligament Gall bladder B Ligamentum teres A Portal vein buy viagra with fluoxetine 100/60mg without a prescription, hepatic Falciform ligament artery and bile duct in free edge of lesser Ligamentum teres omentum leading to porta hepatis Position of umbilicus Cut edge of lesser Fundus of (b) omentum (a) gall bladder Left triangular Right Peritoneum ligament triangular covering Fissure for ligament caudate lobe ligamentum venosum Fig. The narrow spaces between the liver and the diaphragm labelled A and B are the right and left subphrenic spaces 36 Abdomen and pelvis The mesenteries and layers of the peritoneum ment while the right layer turns back on itself to form the upper and The transverse colon, stomach, spleen and liver each have attached to lower layers of the coronary ligament with its sharp-edged right tri- them two ‘mesenteries’adouble layers of peritoneum containing arteries angular ligament. The layers of the coronary ligament are widely and their accompanying veins, nerves and lymphaticsawhile the small separated so that a large area of liver between themathe bare areaa intestine and sigmoid colon have only one. This mesentery is exceptional in that the layers of the which passes from the hilum of the spleen to the greater curvature of the coronary ligament are widely separated so that the liver has a bare area stomach (Fig. It lies behind the free border of tinue downwards to form the posterior two layers of the greater omen- the lesser omentum and its contained structures, below the caudate pro- tum, which hangs down over the coils of the small intestine. They then cess of the liver, in front of the inferior vena cava and above the first turn back on themselves to form the anterior two layers of the omentum part of the duodenum. The four layers of • The subphrenic spaces are part of the greater sac that lies between the the omentum are fused and impregnated with fat. There are right and left plays an important role in limiting the spread of infection in the peri- spaces, separated by the falciform ligament. It thus forms the shows a central ridge from the apex of the bladder to the umbilicus pro- posterior wall of the omental bursa. Two medial umbilical ligaments converge to the • From the diaphragm and anterior abdominal wall it is reflected onto umbilicus from the pelvis. They represent the obliterated umbilical the liver to form its ‘mesentery’ in the form of the two layers of the fal- arteries of the fetus. It represents the obliterated left folds back on itself to form the sharp edge of the left triangular liga- umbilical vein. The peritoneum 37 15 The upper gastrointestinal tract I Cardiac notch Lesser curvature Fundus Angular incisure Pyloric sphincter Body Duodenum Greater curvature Pyloric antrum Fig. The stomach is outlined but the shape is by no means constant 38 Abdomen and pelvis The embryonic gut is divided into foregut, midgut and hindgut, sup- verse colon. The anterior and posterior vagal trunks descend along the plied, respectively, by the coeliac, superior mesenteric and inferior lesser curve as the anterior and posterior nerves of Latarjet from which mesenteric arteries. The latter includes a supply The midgut extends down to two-thirds of the way along the transverse to the acid-secreting partathe body. It largely develops outside the abdomen until this congenital ‘umbilical hernia’ is reduced during the 8th–10th week of gestation. It is • The lower third of the oesophagus is a site of porto-systemic venous considered in four parts: anastomosis. The sphinc- • The pyloric sphincter controls the release of stomach contents into ter of Oddi guards this common opening. The sphincter is composed of a thickened layer of circu- pancreatic duct (of Santorini) opens into the duodenum a small lar smooth muscle which acts as an anatomical, as well as physiolo- distance above the papilla. The junction of the pylorus and duodenum can be seen • Third part (10 cm)athis part is crossed anteriorly by the root of externally as a constriction with an overlying veinathe prepyloric vein the mesentery and superior mesenteric vessels. The cardiac sphincter acts to prevent reflux of peritoneal fold stretching from the junction to the right crus of stomach contents into the oesophagus. The discrete anatomical sphincter at the cardia; however, multiple factors terminal part of the inferior mesenteric vein lies adjacent to the contribute towards its mechanism. The superior artery arises from the coeliac axis compression of the short segment of intra-abdominal oesophagus by in- and the inferior from the superior mesenteric artery. The body are denervated thus not compromising the motor supply to the coeliac branch of the posterior vagus passes to the coeliac ganglion stomach and hence bypassing the need for a drainage procedure (e. A large internal surface area throughout the towards the right iliac region on the posterior abdominal wall. The small and ileal branches arise which divide and re-anastomose within the intestine is suspended from the posterior abdominal wall by its mesen- mesentery to produce arcades. End-artery vessels arise from the tery which contains the superior mesenteric vessels, lymphatics and auto- arcades to supply the gut wall. The origin of the mesentery measures approximately 15 sists of few arcades and little terminal branching whereas the vessels to cm and passes from the duodenojejunal flexure to the right sacro-iliac the ileum form numerous arcades and much terminal branching of end- joint. No sharp distinction occurs between the jejunum and ileum; however, certain characteristics help distinguish between them: Small bowel obstruction (Fig. Loops of jejunum tend to occupy the umbilical region adhesions and herniae are the most frequent causes. In the pelvic position the appendix may be close to the ovary in the female Longitudinal muscle Circular muscle Rectum Levator ani Obturator internus Fat of ischiorectal fossa Sphincter Deep Submucosa ani Superficial Sphincter ani internus externus Subcutaneous Pudendal canal Adductor muscles Inferior rectal vesels and nerve Fig. It commences in front of ascending, transverse, descending and sigmoid colon have similar the 3rd sacral vertebra as a continuation of the sigmoid colon and fol- characteristic features. The teniae coli fan out over the rec- course from the base of the appendix (and form a useful way of locating tum to form anterior and posterior bands. These sacculations are visible • Peritoneum covers the upper two-thirds of the rectum anteriorly but not only at operation but also radiographically. In the female it is reflected forwards onto ray, the colon, which appears radiotranslucent because of the gas within, the uterus forming the recto-uterine pouch (pouch of Douglas). They are adherent to the posterior The anorectal junction is slung by the puborectalis component of lev- abdominal wall and covered only anteriorly by peritoneum. This is the site where the The appendix varies enormously in length but in adults it is approxim- proctodeum (ectoderm) meets endoderm. The base of the appendix arises from the postero- tion is reflected by the following characteristics of the anal canal: medial aspect of the caecum; however, the lie of the appendix itself is • The epithelium of the upper half of the anal canal is columnar. In most cases the appendix lies in the retrocaecal posi- trast the epithelium of the lower half of the anal canal is squamous. The appendix has the follow- mucosa of the upper canal is thrown into vertical columns (of Mor- ing characteristic features: gagni). The only blood supply to the appendix, the appendicular artery (a • The blood supply to the upper anal canal (see Fig. In superior rectal artery (derived from the inferior mesenteric artery) cases of appendicitis the appendicular artery ultimately thromboses. The lower anal canal is sensitive to pain as it is sup- • The bloodless fold of Treves (ileocaecal fold) is the name given to a plied by somatic innervation (inferior rectal nerve). Most surgeons still opt to invaginate the appendix stump as a precau- tionary measure against slippage of the stump ligature. The lower gastrointestinal tract 43 18 The liver, gall-bladder and biliary tree Opening in central tendon of diaphragm Hepatic vein Liver Spleen Portal vein Splenic vein Inferior mesenteric vein Superior mesenteric vein Fig. The transmission of blood from the portal system to the inferior vena cava is via the liver lobules (fig. The extensive length of gut that is surface is related to the diaphragm and its lower border follows the con- drained by the portal vein explains the predisposition for intestinal tour of the right costal margin. These are separated antero-superiorly by the falciform ligament The gall-bladder lies adherent to the undersurface of the liver in the and postero-inferiorly by fissures for the ligamentum venosum and liga- transpyloric plane (p. In the anatomical classification the right lobe includes The duodenum and the transverse colon are behind it.