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James Dunn, MD, PhD is a pediatric surgeon at Stanford Children's Health. He is board certified in General Surgery and Pediatric Surgery.

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The dentin is a hard tissue that forms the bulk of the tooth. It is similar to bone but is slightly harder, although softer than enamel. The dentin has numerous dentinal tubules that run across its length. Each dentinal tubule houses the cytoplasmic process of an odontoblast (odontoblastic process).
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📖Oral pathology Revision Ninja (Notes, Videos & MCQs): https://www.hackdentistry.com/bundles/oral-pathology-revision-ninja
📖Oral Histology Revision Ninja (Notes, Videos & MCQs): https://www.hackdentistry.com/....bundles/revision-nin
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References and further reading:
💡Berkovitz BKB, Hollan GR, Moxham BJ. Oral Anatomy, Histology and Embryology. 4th ed. Mosby Elsevier; 2009.
💡Nanci A. Tencate’s Oral Histology. Development, Structure and Function. 8th ed. Elsevier; 2013.
💡Kumar GS. Orban’s Oral Histology and Embryology.13th ed. Elsevier; 2011.
💡Avery JK. Oral development and Histology. 3rd ed. Thieme Medical Publishers; 2002.

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Background: The number of patients demanding endoscopic neck surgery is rising. The access trauma of the axillary, breast and chest approaches is bigger than in open or video assisted surgery. We tested the feasibility of he sublingual transoral access which is in our opinion the only real minimally...-invasive extracollar endoscopic access to the thyroid gland Methods: We performed an experimental investigation in a porcine model. In 10 pigs we made 10 endoscopic transoral thyroidectomys with a modified axilloscope with the help of ultrasonic scissors and a neuro-monitoring system for identification of the recurrent laryngeal nerve. Results: The average operation time from the introduction to the removal of the obturator just above the larynx was 57 seconds. The mean operation time was 43 minutes. With the help of the neuro-monitoring system we proved in all cases the function of the recurrent laryngeal nerve on both sides. The pigs were observed for another two hours after operation. During and after the operation no complications appeared. Conclusions: We could show that the endoscopic transoral thyroid resection in pigs is possible and save. Our results might be useful for using this access for endoscopic thyroid resection in humans.

This 38 year old woman has increasingly intractable RUQ pain after cholecystectomy done one year prior. LFTs and pancreatic enzymes have been normal, and ducts are non-dilated, thus she is a Type III possible SOD patient. Initial goal is to define course of pancreatic duct for manometry. 5-4-3 Co...ntour catheter (Boston Scientific) is used to perform the pancreatogram which shows a small straight distal duct. The aspirating triple lumen manometry catheter (Wilson Cook) is used to cannulate the pancreatic duct, with continuous aspiration of fluid once the duct is entered. Careful stationed pullthrough manometry shows markedly abnormal basal pressures in both leads in the pancreatic sphincter. Plan is dual pancreatic and biliary sphincterotomy. Biliary manometry will not now change our plan therefore is omitted. Our first goal is to access the pancreatic duct so we can guarantee wire access for placement of a small caliber pancreatic stent which is critical for safety. Contrast is injected as the 0.018in Roadrunner wire (Wilson Cook) is advanced in order to outline the course of main duct. A separate biliary orifice is clearly seen, unusual in SOD patients. A soft 4Fr 3cm single inner flange pancreatic stent (Hobbs Medical) is placed. We did not want to use our typical 9cm long unflanged stent as even a 3 or 4 French stent might be traumatic to the tiny caliber of this duct out in the body of the gland. Next the bile duct is cannulated with a papillotome (Autotome 39, Boston Scientific), showing a small perhaps 6mm bile duct. Biliary sphincterotomy is performed in very careful stepwise fashion as landmarks are unclear and perforation is higher risk in small duct SOD patients. On the other hand, inadequate sphincterotomies offer limited chance of symptom relief. You can see here a patulous sphincterotomy. Next a pancreatic sphincterotomy is performed with the needle knife (Boston Scientific) over the pancreatic stent. Again this is performed cautiously due to the small size of the pancreatic duct. We are reaching along the stent and cutting the fibers deeply. This is a limited pancreatic sphincterotomy due to small pancreatic duct size, and concern for scarring of the pancreatic duct. It is important to document passage of the stent by xray or remove it endoscopically with two weeks or so. We and many other specialized centers perform dual sphincterotomies at the first ERCP in all SOD patients with abnormal pancreatic manometry and frequent or intractable symptoms based on the belief that response rates are better than for biliary sphincterotomy alone.

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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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Como primera medida, asegúrese de estar bien hidratada. Si usted bebe la cantidad de líquido necesaria, logrará eliminar las toxinas y desechos que se encuentran acumulados en su organismo, los cuales en muchas ocasiones colaboran con la aparición de los fibromas

Por otro lado, el estreñimiento también puede ser una consecuencia de la falta de hidratación y esto también colabora con la acumulación de toxinas y desechos que vuelven a ser absorbidos por el cuerpo.

Prefiera alimentos como el salmón, las aceitunas, el aceite de oliva, la palta, etc.
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Renal transplantation is the treatment of choice for a minority of patients with end-stage renal disease (ESRD). Most adult patients with ESRD are never referred for evaluation for transplantation, and have a 70% 5-year mortality on dialysis. Marked improvements in early graft survival and long-term graft function have made kidney transplantation a more cost-effective alternative to dialysis. In the United States, over 375,000 kidney transplants have been performed, and in 2012, 191,400 patients were alive and with a functioning transplanted kidney; currently, more than 101,000 patients are waiting for kidney transplants.[1, 2] Before the advent of immunosuppression, renal transplantation was limited to identical twins and was not applicable to the vast majority of patients with ESRD. The introduction of combined azathioprine-steroid therapy in 1963 produced encouraging results and became the mainstay of immunosuppression. Although this therapy improved the results of transplantation, acute rejection and complications associated with steroid therapy persisted. The introduction of cyclosporine in 1983 significantly improved the outcomes of all solid-organ transplants by reducing the risk of rejection. Further innovations, including anti–T cell antibodies (both monoclonal and polyclonal preparations), as well as other maintenance immunosuppressants (eg, tacrolimus, mycophenolate, sirolimus), have made a significant impact on both patient and graft survival. Currently, 1-year patient and graft survival rates exceed 90% in most transplant centers. For patient education information, see Kidney Transplant and the Mayo Clinic's kidney transplant information Web page.

What is polycystic kidney disease? Polycystic kidney disease (also called PKD) causes numerous cysts to grow in the kidneys. These cysts are filled with fluid. If too many cysts grow or if they get too big, the kidneys can become damaged. PKD cysts can slowly replace much of the kidneys, reducing kidney function and leading to kidney failure. How common is PKD? In the United States about 600,000 people have PKD. It is the fourth leading cause of kidney failure. It is found in all races and occurs equally in men and women. It causes about 5% of all kidney failure. What other organs besides the kidney are affected by PKD? PKD can affect other organs besides the kidney. People with PKD may have cysts in their liver, pancreas, spleen, ovaries, and large bowel. Cysts in these organs usually do not cause serious problems, but can in some people. PKD can also affect the brain or heart. If PKD affects the brain, it can cause an aneurysm. An aneurysm is a bulging blood vessel that can burst, resulting in a stroke or even death. If PKD affects the heart, the valves can become floppy, resulting in a heart murmur in some patients. What are the clues that someone has PKD? Most people do not develop symptoms until they are 30 to 40 years old. The first noticeable signs and symptoms may include: Back or side pain An increase in the size of the abdomen Blood in the urine Frequent bladder or kidney infections High blood pressure High blood pressure is the most common sign of PKD. Occasionally, patients may develop headaches related to high blood pressure or their doctors may detect high blood pressure during a routine physical exam. Because high blood pressure can cause kidney damage, it is very important to treat it. In fact, treatment of high blood pressure can help slow or even prevent kidney failure. Fluttering or pounding in the chest About 25% of PKD patients have a so-called floppy valve in the heart, and may experience a fluttering or pounding in the chest as well as chest pain. These symptoms almost always disappear on their own but may be the first hint that someone has PKD. How is PKD diagnosed? Ultrasound is the most reliable, inexpensive and non-invasive way to diagnose PKD. If someone at risk for PKD is older than 40 years and has a normal ultrasound of the kidneys, he or she probably does not have PKD. Occasionally, a CT scan (computed tomography scan) and MRI (magnetic resonance imaging) may detect smaller cysts that cannot be found by an ultrasound. MRI is used to measure and monitor volume and growth of kidneys and cysts. In some situations, genetic testing might also be done. This involves a blood test that checks for abnormal genes that cause the disease. Genetic testing is not recommended for everyone. The test is costly, and it also fails to detect PKD in about 15% of people who have it. However, genetic testing can be useful when a person: has an uncertain diagnosis based on imaging tests has a family history of PKD and wants to donate a kidney is younger than 30-years old with a family history of PKD and a negative ultrasound, and is planning to start a family