Anatomy of The Leg and Foot

Histology of Lung

Histology of Esophagus

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Eye Examination Video

Carpal Tunnel Syndrome 3D Animation

Migraine Pathophysiology 3D Animation

M.Torabi Nami MD, PhDc Department of Neuroscience Institute for Cognitive Science Studies (ICSS), Tehran 15948 Iran Torabi_m@iricss.org Abstract Sleepiness, tiredness and fatigue are complaints which must be thoroughly analyzed to eliminate blur and ambiguity. Physiological sleepiness (“sleep pressure”) increases while being awake and additionally underlies the circadian rhythm with a lower threshold to fall asleep during night time. Excessive daytime sleepiness (EDS) is considered normal only after sleep deprivation. Clinically, EDS manifests by frequents daytime napping and/or reduced alertness with automatic behavior or - in its extreme form - in recurrent attacks of sudden, uncontrollable compulsion to sleep also in inappropriate situations (= “sleep attacks”). EDS is “objectively” addressed by measuring the mean sleep latency to four to five nap opportunities throughout the day using the multiple sleep latency test (MSLT) or the maintenance of wakefulness test (MWT). EDS denotes both, a ready entrance into sleep as well as difficulty in staying awake during daytime or accordingly in inappropriate situations. These two partially independent aspects of EDS are separately assessed by the “passive” MSLT and the “active” MWT respectively. For that reason the MSLT and MWT only weakly correlate with each other when tested over a broad range of patients with EDS. It is important to keep in mind, that these tests are importantly influenced by a great variety of factors such as mood, anxiety, and motivation. “Vigilance” comprises wakefulness, alertness and attention and therefore is more than just the reciprocal to sleepiness. Cognitive performance tasks such as Steer Clear Reaction Time Test (SCRTT) or driving simulators require the complete integrity of vigilance to achieve normal results. Hypersomnia is usually broadly defined as the combination of abnormally prolonged night-time sleep (regularly >10 h) with EDS during ≥1 months. On the other hand, the term hypersomnia has also been used in a narrower scene for the isolated abnormality of a prolonged night-time sleep need (>10 h). “Tiredness”, also in colloquial language often used for sleepiness, in a broader sense also describes the feeling of lack of energy, motivation and initiative. These patients seek rest rather than sleep. They often cannot fall asleep when given the opportunity in spite of feeling tired, and hence, in an MSLT, do not show an abnormally short sleep latency. Furthermore, tiredness (and fatigue) as opposed to sleepiness has a mental (“central”) and physiological (bodily or “peripheral”) component, which the patients can readily distinguish. Patients with insomnia, mild sleep apnea syndrome, or depression rather suffer from mental tiredness than sleepiness during the day. The simple subjective self-assessment using the Epworth Sleepiness Scale (ESS) quite reliably differentiates between sleepiness and mental tiredness (without sleepiness), which makes it a widely used test. The term “fatigue” is also heterogeneously used. In physiology the “fatigue” implied a “time on task performance decrement” to describe decreasing muscle force during a sustained physical effort. In clinical medicine one distinguishes physical (“peripheral”) from mental (“central”) fatigue and the term usually denotes a chronic and more abnormal situation than tiredness. In a broad sense “fatigue” implies a deficiency in coping satisfactorily with mental and physical work load. The chronic fatigue syndrome entails both mental as well as a physical fatigue (so called “leaden paralysis” of limbs). Depressive states are often associated with insomnia and fatigue, but there are also cases with hypersomnia rather than insomnia ( non organic hypersomnia , “atypical depression” or “hypersom

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Stay active and push your body to its limit – tips on how you can mend strained muscles and prevent injury.

A new natural painkiller based on a body-own molecule, available as supplement. An educational video on its mechanism of action: palmitoylethanolamide (PEA) is a new compound ready 4 use in the clinic to calm glia and mast cells in all states of chronic pain. Thus it focusses on 2 new targets in the treatment of pain: these extra-neuronal targets in chronic pain can be modulated by PEA.

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What is Myelomeningocele and how does it affect my baby? Myelomeningocele (MMC), one of the most severe forms of spina bifida, is a condition where the fetus’ spinal cord fails to close during development. This happens between 20 and 28 days of gestation, often before a woman knows she is pregnant. Because the spinal cord does not close, many of the nerves are exposed, resulting in damage to the cord as the pregnancy continues. Spina bifida can impact the nervous system, bones and muscles, kidneys and bladder. The location on the spine where the undeveloped area occurs is called the level of the spina bifida. Because nerve damage at this site prevents function below that level, the higher the level, the greater the impact on normal development and function. The opening in the spinal cord also results in loss of the fluid surrounding the nervous system. This causes the brain to be positioned further down into the upper spinal column than normal, which is called an Arnold Chiari II malformation. When this happens, the normal flow of fluid out of the brain is obstructed, causing Hydrocephalus, an excess of cerebrospinal fluid within the brain. After birth, most children with Hydrocephalus need to have the extra fluid shunted out of the brain into the abdomen via a ventriculoperitoneal shunt. MMC affects about 1 in every 1,000 babies, and it ranges in severity. Some children, with mild cases very low on the spinal cord, can function nearly normally. More severe cases can cause leg weakness and paralysis, as well as Hydrocephalus, and the Arnold Chiari malformation. People with MMC often live long lives, especially if the condition is diagnosed and treated early. How is Myelomeningocele diagnosed? At about 15 weeks gestation, a blood test measuring the levels of alpha-fetoprotein can show the physician that there might be a problem. After that, an ultrasound is performed to detect the MMC, but also to detect the conditions that can result from it, such as Hydrocephalus, the Chiari malformation, and any problems with the lower extremities. In all cases, we perform a fetal MRI to gain more detailed information and we perform a fetal echocardiogram (echo) to rule out any problem with the heart. What is the prenatal surgery for Myelomeningocele, and how does it differ from postnatal surgery? Until recently, the only way to treat MMC was surgery after birth. But, now that the nine-year long Management of Myelomeningocele (MOMS) trial has been completed, we know that repairing the MMC before birth, in the womb, can be beneficial to the baby’s outcome. The SSM Health St. Louis Fetal Care Institute has one of the fastest growing fetal MMC repair programs in the country. The results of the trial found that prenatal treatment helps reduce, or even eliminate, the major complications of MMC—the Hydrocephalus, the Chiari malformation, and the lack of movement in the lower extremities. Diagnosis and repair of the MMC before birth can make a big difference in the way the baby develops. The MOMS trial showed that babies treated in the womb need half the VP shunts, often have reversal of the Arnold-Chiari malformation, and are more likely to walk, at least until 30 months. Long-term follow up data of children treated with prenatal surgery is still being collected, so the benefit beyond 30 months is not fully known. The operation for open fetal surgery for MMC repair involves making a small opening in the uterus, then closing the spinal cord opening just like after birth. The womb is repaired and the mother is in the hospital for four to five days. The surgery is performed between 19 and 26 weeks of the pregnancy. Mothers usually stay locally for about two weeks so that we can monitor the pregnancy. After this, they can return home for delivery. Because of the scar caused by the surgery on the uterus, the baby and all future babies have to be delivered by Cesarean birth. The benefit to the fetal repair is several fold. First, the spine is protected after the fetal repair. The spine can no longer be damaged during the pregnancy and after. Second, the leakage of CSF is stopped. We think that this causes the brain to rise back into the skull, allowing the fluid within the brain to drain normally and preventing the development of Hydrocephalus. As with any prenatal surgery, there are risks to both the mother and the baby. Our team at the Fetal Care Institute will discuss all of the risks and benefits of the surgery with you and your family, so you can make the best decision for your baby. The standard care for babies with spina bifida is to repair the defect after birth. The neurosurgeon closes the opening of the spinal cord, and restores the muscle, skin, and tissue to cover it. Unfortunately, postnatal surgery cannot restore any of the function that has been lost during the pregnancy, and the damage from Hydrocephalus, the Chiari malformation, and/or loss of movement are then permanent. How will Myelomeningocele impact my baby after birth? MMC is a disease affecting many parts of the body. There can be a major impact on a baby’s leg and hip movement, depending on the level of the defect. Problems with Hydrocephalus and the Arnold-Chiari malformation need to be followed carefully. Because the spinal cord also affects urine and bowel function, these bodily functions often need to be managed to prevent complications. Optimally, babies need to be followed in a spina bifida clinic, where a team of specialists work together to help determine the best course of treatment. At SSM Health Cardinal Glennon Children’s Hospital, a long established spina bifida clinic is available for follow up care after birth. This is a very specialized clinic in which many doctors of different specialties and nurses are dedicated to the care of these babies.

Fifth disease is a mild rash illness caused by parvovirus B19. This disease, also called erythema infectiosum, got its name because it was fifth in a list of historical classifications of common skin rash illnesses in children. It is more common in children than adults. A person usually gets sick with fifth disease within 4 to 14 days after getting infected with parvovirus B19.

Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol, certain drugs), and autoimmune diseases can also cause hepatitis. There are 5 main hepatitis viruses, referred to as types A, B, C, D and E. These 5 types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer. Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact. Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

The hepatitis E virus, responsible for major epidemics of viral hepatitis in subtropical and tropical countries, was cloned only 7 years ago.1 Hepatitis E was found to belong to the family of Caliciviridae, which includes the Norwalk virus—a common cause of gastroenteritis in humans—and consists of a single, plus-strand RNA genome of approximately 7.2 kb without an envelope (Fig. 1). The virus contains at least three open reading frames encoding viral proteins against which antibodies are made on exposure. These antibodies, especially those against the capsid protein derived from the second open reading frame2 and a protein of unknown function derived from the third open reading frame, are detected by currently available serologic assays. Retrospective studies on stored sera of past epidemics of viral hepatitis in Mexico, Africa, Afghanistan, Pakistan, India, Bangladesh, Burma, Nepal, and Borneo have revealed that all were caused by strains of hepatitis E. In addition, hepatitis E was found to be responsible for the hepatitis epidemic in the southern part of Xinjiang, China, in which 120,000 persons became infected between September 1986 and April 1988.3 Hepatitis E predominantly affects young adults (15 to 40 years old). The symptoms of hepatitis E are similar to those of hepatitis A. Frequently, a prodrome consisting of anorexia, nausea, low-grade fever, and right upper abdominal pain is present 3 to 7 days before jaundice develops. Aminotransferase levels peak (usually between 1,000 and 2,000 U/L) near the onset of symptoms; bilirubin levels (10 to 20 mg/dL) peak later. Jaundice usually resolves after 1 to 2 weeks. In about 10% of cases, the disease is fulminant—especially in pregnant women, among whom mortality rates as high as 20% due to hemorrhagic and thrombotic complications have been reported. No evidence has suggested that hepatitis E can cause chronic infection. Transmission is by the fecal-oral route, predominantly through fecally contaminated drinking water supplies. In addition, however, preliminary reports have suggested transmission of the hepatitis E virus through blood transfusions. Volunteer studies confirmed the presence of the virus in serum and feces before and during clinical disease.4 The virus is shed into feces approximately 1 week before symptoms develop. The incubation period varies from 2 to 9 weeks (mean duration, approximately 45 days). Until now, a few reports had described symptomatic hepatitis E acquired in Europe;5, 6 all patients with symptomatic hepatitis E in the United States were travelers returning from Mexico, Africa, or the Far East, in whom hepatitis E developed after their return home.7 In this issue of the Mayo Clinic Proceedings (pages 1133 to 1136), Kwo and associates describe a case of hepatitis E in a man who had not left the United States during the previous 10 years. Specific serologic tests for hepatitis E virus IgG (enzyme immunoassays and a fluorescent antibody blocking assay) and IgM8 (US strain-specific enzyme-linked immunosorbent assay with use of synthetic polypeptides deduced from the viral genome, as shown in Figure 1), developed at Abbott Laboratories (IgG and IgM) as well as at the Centers for Disease Control and Prevention (IgG), were used to prove that the patient indeed had acute hepatitis E. Researchers at Abbott Laboratories have prepared a report that describes most of the viral genome in this patient (Fig. I).8 Their results are interesting because this strain from the United States differs considerably from hepatitis E strains isolated in Mexico, Burma, Pakistan, or China. Furthermore, the sequence of the US strain is highly homologous (98% and 94% homology at the amino acid level to the second and third open reading frames, respectively) to a recently isolated hepatitis E strain from American swine.9 This finding suggests that, in the United States, hepatitis E is a zoonosis with the swine population as one of its hosts. This relationship would confirm earlier studies in Asia, where swine were also found to carry variants of the hepatitis E virus.10 Why are these two recent discoveries important for medicine in the United States? First, other sporadic, locally acquired cases of acute hepatitis may be caused by hepatitis E. Second, these back-to-back discoveries strongly suggest that a common natural host for hepatitis E is present in countries with more moderate climates. Because swine do not seem to experience any symptoms associated with infection and because symptoms in humans can be minor or absent, we now may also have an explanation for the 1 to 2% of positive hepatitis E serologic results in blood donors in the United States,11 Netherlands,12 and Italy,6 countries with large swine staples. Clearly, more research needs to be done to confirm this hypothesis. Third, in countries with more moderate climates, hepatitis E may often result in a subclinical infection. Is this variation in manifestation due to less virulent strains, and do sequence variations determine virulence? Fourth, swine may be used as an animal model for study of the disease as well as vaccine development.

Graves disease is an autoimmune disorder that leads to an overactive thyroid gland (hyperthyroidism). An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks healthy tissue. Causes The thyroid gland is an important organ of the endocrine system. The gland is located at the front of the neck above where the collarbones meet. This gland releases the hormones thyroxine (T4) and triiodothyronine (T3), which control body metabolism. Controlling metabolism is important for regulating mood, weight, and mental and physical energy levels. When the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.) Graves disease is the most common cause of hyperthyroidism. It is due to an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormone. Graves disease is most common in women over age 20. But the disorder can occur at any age and can affect men as well. Symptoms Younger people may have these symptoms: Anxiety or nervousness, as well as problems sleeping Breast enlargement in men (possible) Problems concentrating Fatigue Frequent bowel movements Hair loss Heat intolerance and increased sweating Increased appetite, despite having weight loss Irregular menstrual periods in women Muscle weakness of the hips and shoulders Moodiness, including irritability and anger Rapid or irregular heartbeat Shortness of breath with activity Tremor Many people with Graves disease have problems with their eyes: The eyeballs may seem to be bulging out and may be painful. Eyes can feel irritated and be tearing. Double vision may be present. Older people may have these symptoms: Rapid or irregular heartbeat Chest pain Memory loss Weakness and fatigue

An estimated 90% of men who have sex with men and as many as 5% to 10% of sexually active women engage in receptive anal intercourse. Often referred to simply as anal sex, anal intercourse is sexual activity that involves inserting the penis into the anus. People may engage in anal intercourse, which has health risks, because the anus is full of nerve endings, making it very sensitive. For some recipients of anal sex, the anus can be an erogenous zone that responds to sexual stimulation. For the giving partner, the anus may provide a pleasing tightness around the penis. While some people find anal sex enjoyable, the practice has downsides and requires special safety precautions. Is Anal Sex Safe? There are a number of health risks with anal sex, and anal intercourse is the riskiest form of sexual activity for several reasons, including the following: The anus lacks the natural lubrication the vagina has. Penetration can tear the tissue inside the anus, allowing bacteria and viruses to enter the bloodstream. This can result in the spread of sexually transmitted infections including HIV. Studies have suggested that anal exposure to HIV poses 30 times more risk for the receptive partner than vaginal exposure. Exposure to the human papillomavirus (HPV) may also lead to the development of anal warts and anal cancer. Using lubricants can help some, but doesn't completely prevent tearing. The tissue inside the anus is not as well protected as the skin outside the anus. Our external tissue has layers of dead cells that serve as a protective barrier against infection. The tissue inside the anus does not have this natural protection, which leaves it vulnerable to tearing and the spread of infection. The anus was designed to hold in feces. The anus is surrounded with a ring-like muscle, called the anal sphincter, which tightens after we defecate. When the muscle is tight, anal penetration can be painful and difficult. Repetitive anal sex may lead to weakening of the anal sphincter, making it difficult to hold in feces until you can get to the toilet. However, Kegel exercises to strengthen the sphincter may help prevent this problem or correct it. The anus is full of bacteria. Even if both partners do not have a sexually-transmitted infection or disease, bacteria normally in the anus can potentially infect the giving partner. Practicing vaginal sex after anal sex can also lead to vaginal and urinary tract infection

Cystinuria is a condition characterized by the buildup of the amino acid cystine, a building block of most proteins, in the kidneys and bladder. As the kidneys filter blood to create urine, cystine is normally absorbed back into the bloodstream. People with cystinuria cannot properly reabsorb cystine into their bloodstream, so the amino acid accumulates in their urine. As urine becomes more concentrated in the kidneys, the excess cystine forms crystals. Larger crystals become stones that may lodge in the kidneys or in the bladder. Sometimes cystine crystals combine with calcium molecules in the kidneys to form large stones. These crystals and stones can create blockages in the urinary tract and reduce the ability of the kidneys to eliminate waste through urine. The stones also provide sites where bacteria may cause infections.

Catheter ablation is a minimally invasive procedure to treat atrial fibrillation. It can relieve symptoms and improve quality of life. During an ablation, the doctor destroys tiny areas in the heart that are firing off abnormal electrical impulses and causing atrial fibrillation. You will be given medicine to help you relax. A local anesthetic will numb the site where the catheter is inserted. Sometimes, general anesthesia is used. The procedure is done in a hospital where you can be watched carefully. Thin, flexible wires called catheters are inserted into a vein, typically in the groin or neck, and threaded up into the heart. There is an electrode at the tip of the wires. The electrode sends out radio waves that create heat. This heat destroys the heart tissue that causes atrial fibrillation or the heart tissue that keeps it happening. Another option is to use freezing cold to destroy the heart tissue. Sometimes, abnormal impulses come from inside a pulmonary vein and cause atrial fibrillation. (The pulmonary veins bring blood back from the lungs to the heart.) Catheter ablation in a pulmonary vein can block these impulses and keep atrial fibrillation from happening. View a slideshow of catheter ablation to see how the heart's electrical system works, how atrial fibrillation happens, and how ablation is done. Atrial Fibrillation: Should I Have Catheter Ablation? AV node ablation AV node ablation is a slightly different type of ablation procedure for atrial fibrillation. AV node ablation can control symptoms of atrial fibrillation in some people. It might be right for you if medicine has not worked, catheter ablation did not stop your atrial fibrillation, or you cannot have catheter ablation. With AV node ablation, the entire atrioventricular (AV) node is destroyed. After the AV node is destroyed, it can no longer send impulses to the lower chambers of the heart (ventricles). This controls atrial fibrillation symptoms. After AV node ablation, a permanent pacemaker is needed to regulate your heart rhythm. Nodal ablation can control your heart rate and reduce your symptoms, but it does not prevent or cure atrial fibrillation. AV node ablation helps about 9 out of 10 people.1 The procedure has a low risk of serious problems.2 View a slideshow of AV node ablation to see how the heart's electrical system works, how atrial fibrillation happens, and how AV node ablation is performed.