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Judges should also see the captioned picture prompts contestants were given to erectile dysfunction 5k discount stendra 100 mg visa use in creating their stories erectile dysfunction causes tiredness order cheap stendra online. The stories must contain at least one of the pictured items erectile dysfunction questions to ask cheap stendra 200 mg without a prescription, but there is no requirement that all items on the prompt page be included erectile dysfunction treatment nz cheap 200 mg stendra otc. Criteria the stories are to be evaluated as to relative excellence in creativity and interest (60%), organization (30%) and correctness of style (10%). While judges are to consider all three elements in selecting the most effective stories, more weight should be given to creativity and interest than to organization, and to organization more than to correctness of style. It depends next upon clarity and upon including specifc details and examples which individualize the story as an outgrowth of the writer’s character and experience. Completing Evaluation Sheets Comments on the Creative Writing Evaluation Sheet should frst identify and focus on the positive aspects of the story and then offer constructive criticism. Rating the compositions Judges shall read all of the stories submitted and, without marking on the manuscripts, shall rank them in order of their excellence; 1, 2, 3, 4, etc. If more than one judge is used, they shall then discuss the stories which have been ranked frst through sixth place, any judge being permitted to alter his/ her ranking as a result of the discussion. Circle score rating in each of the three major areas of creativity & interest, organization, and correctness of style and tally the points. Please make your comments using language understandable to the contestant and make all comments constructive and supportive. While judges are to consider all three elements in selecting the most effective compositions, they should weigh creativity and interest more than organization, and organization more than correctness of style. Judge’s signature Dictionary Skills Thorough knowledge of the dictionary is a way to increase a student’s ability to fnd the information that is needed for class work as well as everyday living. The subject matter of all tests is taken from Merriam-Webster’s Intermediate Dictionary. Contestants may use other dictionaries in the contest, but the correct test answers will be found in the offcial dictionary. All personnel in this conability to find the information that is test may be coaches of participating needed for class work as well as everyday students. Contestants and taken from Merriam Webster’s Intermecoaches shall be given a period not diate Dictionary. Contestants may use to exceed 15 minutes to examine other dictionaries in the contest. Each test consists of the contest director, whose decision 40 objective questions. Points are awarded who are eligible under Sections 1400 and as specified in Section 1408 (i). Districts shall offer either a individual or the team component Skills separate division for each participatof this contest. Tied contestants or grade level ing grade level or combined grade level teams split the total points equally divisions as specified in official contest for the two or more places in which divisions= procedures. For each division, for first place, there will be no seceach participant school may enter as ond place. Should there be a tie for many as three contestants in the district second place, there will be no third meet. No materielected to include team competition, als from district contests may be the combined scores of the three conreturned to contestants prior to testants in each division from a school official release dates. A team shall have three contestants competing to participate in the team competition. At least three graders should be familiar with the instructions for grading and the contest rules. Test questions will be based on this dictionary; however, contestants may use older editions or other dictionaries. One test will be provided for grades 5 and 6; another test will be provided for grades 7 and 8. Initials University Interscholastic League Papers contending to place: A+ Dictionary Skills Contest • Answer Sheet out of 120. Initials Write your contestant number in the upper right corner, and circle your grade below. Editorial Writing Texas teachers have always looked for ways to improve their students’ writing skills. The editorial writing contest will build those skills as well as refne the students’ ability to prepare a well-balanced persuasive paper. If contestants and analytical thinking, as well as the ability choose to use their own computers, they to write persuasively and concisely. Students shall bring their own printers, associated learn to examine both sides of an issue, hardware, software and paper. Spell select and develop a stance and support that check and thesaurus functions may be stance with logical, clear writing. Contestants will be provided entries on computers accept the risk of a fact sheet from which they will develop and computer malfunction. Forty-five minutes will be malfunction, the contestant may use the allotted for the writing period exclusive of remaining allotted time to complete the time required for instructions. Districts shall offer either a own evaluations and stories and verify separate division for each participating grade identification. Each participant been collected, the contest director shall school may enter as many as three announce the official results. A single or district contests may be returned to an odd number of judges should be selected. Practice & Preparation • Junior High Study Materials Booklet • Prompts from previous years • Independent Vendors 53 Is the script Contest Administration Script mandatoryfi Inform contestants and coaches of the time and place of the optional viewing period, if one is scheduled. The contest director shall be responsible for preventing any communication between contestants or any reference on the part of contestants to notes, books or printed material other than a standard bound or electronic thesaurus and/or dictionary. The contest director shall be timekeeper of the contest and give warnings of the time remaining at 15 and 5 minutes, even if the contest is held in a room where a clock is clearly visible to the contestants. When 45 minutes have elapsed from the time the contestants have been instructed to begin the contest, the contest director shall collect all entries. The contest director shall select a properly qualified and impartial single judge or an odd number panel of judges. The papers shall be graded in accordance with the list of journalism contest judging criteria. The contest director shall make these criteria available to judges prior to the contest. The following is a general outline of an editorial for judges and contestants: (1) Introduction presents problem and establishes staff stance. Comments should be specific enough to provide a clear sense of the positive elements of the editorial and where improvement is needed. Judges should discuss the compositions contending for rank, and reach a consensus on the rankings. This is a Remember that many of these writers have not been trained in proper editorial writing. Therefore key sample considerations should be that they have made a statement of the situation and formed a stance. The contestant the editorial then should come to a specifc solution or recommendation. Also, when they refer to the school board they do not have to say “Leaguetown School Board. You are a reporter for the Judging criteria has been developed to help you score the papers. The criteria are intended to help you Leaguetown Press, evaluate the writing, not as a control over your background in editorial writing or the writing process. If passed by From the given the school board, the proposal would go into effect for the fall semester. Students can’t learn if they don’t feel comfortable in their Remember that environment. For example, the school has a student that doesn’t want to go as an editorial to school because of hurtful remarks made by other students. It will teach students how to respect those who are different than them writer you should and what is not okay to say. Accepting and understanding or action; you differing cultures is necessary in society.
Traditional Preparation: To prepare a refreshing and therapeutic beverage from the fruit effective erectile dysfunction treatment purchase 200 mg stendra free shipping, the ripe seed pods are broken open impotence groups discount stendra amex, the stringy veins erectile dysfunction treatment doctors in bangalore buy stendra 100mg low price, seeds and rind are removed and the fruit pulp is squeezed out impotence natural home remedies buy stendra australia. This pulp is lightly pounded and allowed to soak in water so that it softens, releases its juices and imparts a tangy flavor to the water. Traditional Uses: the fruit pulp and leaves of this plant are considered cooling (fresca) and blood purifying/cleansing remedies. A beverage made from the fruit-pulp (called refresco de tamarindo or jugo de tamarindo) is a remedy for insomnia, headache, migraines, menopausal hot flashes, nightsweats, hormonal imbalance and conditions associated with excess heat in the body. A decoction of the fruit pulp is used for menopausal hot flashes and is often combined with cornsilk (barba de maiz), prepared with the pulp of one tamarind fruit and one small handful of cornsilk (equivalent to the silky tassel of one ear of corn) per 2 cups of water. For treating disorders of the liver, kidney and prostate, the dried leaves, branches or bark can be prepared as a tea or decoction and taken orally. For severe liver disorders or Hepatitis C, this plant may be combined with other medicinal plants such as Caribbean coralfruit (batata de burro) or cockleburr (caudillo de gato). Availability: Seed pods are available at select grocery stores and supermarkets that sell ethnic foods and can also be purchased at botanicas (Latino/Afro-Caribbean herb and spiritual shops) along with the dried leaves. Leaves are pinnately compound such that they are composed of several leaflets arranged in opposite pairs; each leaflet is oblong-oval in shape with a blunt or rounded tip and asymmetric base. Fruits are oblong legumes (10-15 cm long) that are leathery when ripe, can be straight or curved in shape and tan to light brown in color; each pod contains several dark brown seeds surrounded by a tart, brown, edible, sticky pulp that has a fruity, sweet aroma (Acevedo-Rodriguez 1996). Distribution: Native to India, this plant is cultivated and naturalized throughout the tropics including the Caribbean, commonly growing in open, dry areas (Acevedo-Rodriguez 1996). No known negative side effects or health risks have been identified in the scientific literature associated with the appropriate therapeutic use of this plant (Gruenwald et al. However, the fruits or seed pods of this plant contain an irritating, hypoglycemic alkaloid. Insufficient information is available on the toxicity of the leaves or the bark (Germosen-Robineau 1995). Animal Toxicity Studies: No evidence of acute toxicity was shown when a polyphenolic extract of the seeds was administered to mice at doses of 100-500 mg/kg (Komutarin et al. In laboratory and/or animal studies, this plant has shown the following effects: antidiabetic, anti-inflammatory, antioxidant, colon cell proliferation stimulation, hepatoprotective, immunomodulatory and nitric oxide inhibition (see “Laboratory and Preclinical Data” table below). In one animal study, this plant did not show hypocholesterolemic effects (see “Effect Not Demonstrated” table below). According to secondary references, the fruit pulp and/or dried seeds have demonstrated laxative, anti-inflammatory, antimicrobial, immunomodulatory effects and wound-healing (Gruenwald et al. Also, it is registered in the following directories: Directory of Japanese Drugs 1973; List of the Office of Control of Medications, Berna 1978; and the Pharmaceutical Codex of India 1953 (Penso 1980). Active constituents include fruit acids: tartaric, malic, citric and lactic acids; pectin, pyrazines and thiazols (Gruenwald et al. In particular, research is needed to support the following popular uses reported in the Caribbean: internal use of the leaf decoction to treat chickenpox and decoctions of various parts of the plant for treating jaundice. Based on results from a Chinese dosification study on medicinal plants, the daily therapeutic dose of the dried fruit is 2 g (Germosen-Robineau 1995). The seed pods are often sold as a raw paste which can be added to hot water or pureed with other laxative ingredients (such as figs) with a daily dosage of 10-50 g of the cleaned paste (Gruenwald et al. Clinical Data: Tamarindus indica Activity/Effect Preparation Design & Model Results Reference Ibuprofen Fruit extract, Clinical study; healthy Increase in plasma levels of Garba et al. Influences d’extraits de Cuscuta americana et Tamarindus indicus sur hepatocytes fraichement isoles de rats. Effect of Tamarindus indica L on the bioavailability of ibuprofen in healthy human volunteers. Extract of the seed coat of Tamarindus indica inhibits nitric oxide production by murine macrophages in vitro and in vivo. Effect of cumin, cinnamon, ginger, mustard and tamarind in induced hypercholesterolemic rats. Traditional Preparation: To prepare a tea, steep a small handful of dried flowers in hot water for 5 minutes and take 1 cup 2-3 times daily, as needed. Traditional Uses: this plant is attributed calming and cooling properties and is a popular remedy for insomnia, stress and nervousness or anxiety (nervios). It is also a common remedy for women’s health conditions, including menorrhagia, uterine fibroids and menopausal hot flashes. Combined with chamomile (manzanilla) flowers, it can be used as a tea for difficulty with falling asleep and is sometimes given to children. Availability: Sold as an herbal tea in some supermarkets and grocery stores, the dried flowers are available for purchase at several botanicas. Some Dominicans have reported collecting tilo flowers from trees growing in New York City parks or tree-lined streets as it is commonly cultivated as an ornamental tree. Leaves are alternate, dark green, smooth and rounded-oval to heart-shaped (15 cm long) with fine, long-pointed, uneven teeth along the edges; upper surface is sparsely covered with short, soft hairs and the lower surface is thickly covered with grayishor whitish-wooly hairs without tufts at the intersections of veins (as in other Tilia species). Flowers occur in rounded clusters of 7-10 individuals and have 5 petals that are light yellowish to white and sweetly fragrant (to 2 cm across); each flower stalk is attached for half its length to a long, slender, pale green leaf bract that is rounded at the tip. Fruits are round and nutlike with 5 ribs along the base and containing 1-3 seeds (Bailey Hortorium Staff 1976). Distribution: Native to Northeast Asia, this plant is cultivated widely in temperate regions of the northern hemisphere as an ornamental tree, a source of nectar for bees and to furnish fiber from the inner bark and wood. Species within this genus are relatively similar and frequently hybridize to form different varieties (Bailey Hortorium Staff 1976). This plant has been rated as “relatively safe” as long it is not taken in excessive amounts or for an extended period of time (Griffith 1998). Excessively frequent and repeated use of the tea may be harmful to the heart (Pahlow 1979). Bacterial (Bacillus cereus) and yeast contamination have been detected in commercial supplies of dried flowers (Martins et al. Proper storage is important because heat and moisture may decrease the therapeutic action of this plant (List and Horhammer 1979). In European herbal medicine, this plant has been used since medieval times as a diaphoretic (to promote perspiration) and as both a nervine (tranquilizer) and a stimulant. It has also been used to treat headaches, indigestion, hysteria, diarrhea and epilepsy (Foster and Tyler 1999). Major chemical constituents of the leaf include: flavonoids: tiliroside, kempferol-3,7dirhamnoside, kempferol-3-O-glucoside-7-O-rhamnoside, linarine, quercetin-3,7-di-O-rhamnoside, quercetin-3-O-glucoside-7-O-rhamnoside; tannins and mucilage. The flower contains: afzelin, astragalin, hyperoside, isoquercitrin, kempferitrin, quercitrin, tiliroside, quercetin-3-O-glucoside-7-O-rhamnoside, kempferol-3-O-rhamnoside, kempferol-3-O-glucoside-7-O-rhamnoside, quercetrin-rhamnoxyloside, rutin; hydroxycoumarins: calycanthoside, aesculin; caffeic acid derivatives: chlorogenic acid; mucilage; tannins; and volatile oil: linalool, germacrene, geraniol, 1,8-cineole, 2-phenyl ethanol, phenyl ethyl benzoate and alkanes (Gruenwald et al. Indications and Usage: Flowers are approved by the Commission E for the treatment of cough and bronchitis (Blumenthal et al. Dried flowers are available in crushed or powdered form and administered as a tea. To prepare a tea, infuse 2 g herb (1 heaping teaspoonful) in 1 cup hot water and steep for 5-10 minutes. Activity/Effect Preparation Design & Model Results Reference Antigenotoxic Infusion of Tilia In vitro: hydrogen Active; desmutagenic; Romerocordata peroxide used as detoxified the mutagen Jimenez et al. Tilia argentea method significant at fi 100 µg 2000 Anxiolytic Complex fraction In vivo: mice; Active; showed anxiolytic Viola et al. Pharmacological evaluation of the anxiolytic and sedative effects of Tilia americana L. Tyler’s Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies, Fourth Edition. Comparative immunomodulatory effect of scopoletin on tumoral and normal lymphocytes. Evaluation of microbiological quality of medicinal plants used in natural infusions. Hepatoprotective principles from the flowers of Tilia argentea (linden): structure requirements of tiliroside and mechanisms of action. Evidence for bioadhesive effects of polysaccharides and polysaccharidecontaining herbs in an ex vivo bioadhesion assay on buccal membranes. Flavonoids with antinociceptive and anti-inflammatory activities from the leaves of Tilia argentea (silver linden).
Open fractures of the lower leg are a major cause of morbidity because of the high propensity for development of osteomyelitis and inadequate bone healing erectile dysfunction drugs boots cheap stendra 50mg line. With poor healing of the fracture erectile dysfunction protocol free ebook purchase stendra 50mg online, the patient may not be able to impotence test purchase stendra in united states online walk without assist devices (cane or crutches) erectile dysfunction medication buy cheap stendra 50 mg line, may have chronic pain, and often is unable to work. Amputation may become necessary to control infection and improve overall function. The underlying fracture must be anatomically reduced in a stable position to allow healing of the soft tissues. Basic Treatment the goal is to achieve a healed bone, surrounded by healthy soft tissue. Be sure to remove all foreign material and dead tissue, and copiously irrigate the wound with saline. In patients with significant contamination or soft tissue injury, it is best to pack the wound with gauze moistened with antibiotic solution or saline and to immobilize the leg in a splint. Return the patient to the operating room in 24–48 hours to wash out and debride the wound again and to stabilize the fracture. Because of swelling, a tight closure actually increases the chances for further Fractures of the Tibia and Fibula 213 tissue loss, making the wound more difficult to manage. If only a small area of bone (< 1–11fi2 cm in diameter) is exposed, the wound may heal secondarily with dressing changes. For larger wounds, a local muscle flap or distant flap is required to cover the fracture and promote proper healing. Optimally, the fracture site should be covered within the first week after injury. Local Muscle Flaps Local muscle flaps should be undertaken only by someone with surgical skills. Several muscles in the calf can be used as a local flap to cover an exposed tib-fib fracture site. Muscle flaps also bring robust circulation to the fracture site and thereby improve healing of the injured bone. The use of muscle flaps has markedly decreased the morbidity associated with open fractures. Studies have shown that muscle flaps promote fracture healing; the average time for proper healing decreases from 9 to 5 months. The risk of developing osteomyelitis also decreases from 40% to 5%, and the amputation rate decreases from almost 30% to 5% when muscle flap coverage of an exposed bone or fracture is done within the first week after injury. Proximal and Middle Third of the Calf: Gastrocnemius Flap the gastrocnemius muscle is the most superficial muscle of the posterior aspect of the calf. The gastrocnemius muscle originates from the distal femur and joins the underlying soleus muscle to form the Achilles tendon. The main vascular supply enters the gastrocnemius muscle proximally near the knee joint. The muscle can be divided from the Achilles tendon and underlying soleus muscle without interfering with its blood supply. It should be divided longitudinally at its midline so that you take only one-half of the muscle. The gastrocnemius muscle then can be easily moved to cover wounds in the middle and proximal third of the calf. Sometimes the origin of the muscle has to be divided to allow increased movement into the wound. If the lateral muscle is used, it must swing around the fibula, which decreases the range of the flap. The tendon of the gastrocnemius muscle joins with the tendon of the soleus muscle to form the Achilles tendon. Be sure that the wound is adequately debrided and that all dead tissue or bone is completely removed. Extend the open wound onto the medial calf skin to visualize the underlying muscle. Try not to leave skin bridges because they have diminished circulation and may become necrotic. Fractures of the Tibia and Fibula 215 Patient with an exposed, open tib-fib fracture. The injury is less than 48 hours old, and the bone is being covered with a gastrocnemius flap. Separate the gastrocnemius muscle from the overlying skin and underlying soleus muscle. You will see the vascular pedicle coming into the deep surface of the muscle around the knee. In the back of the calf, the medial and lateral parts of the muscle come together in the midline. The muscle fibers form a V, whose point marks a natural plane between the two halves of the muscle. The muscle can be divided along this line and then detached from the Achilles tendon using electrocautery. This procedure can be done safely, but be careful not to injure the vascular pedicle. If it remains dark purple, the vascular pedicle has been injured and you are in trouble. Another flap option, perhaps a soleus flap (see below under mid-calf injury) or a distant flap, is necessary. The muscle should be sutured loosely to the wound edges with absorbable sutures. Place a suction drain (if available) or a Penrose drain under the muscle flap and at the donor area. They prevent blood and other fluids from accumulating under the muscle flap and under the skin flap that was created when the muscle was dissected free. The leg should remain elevated and immobilized in either a splint or, if an orthopedic surgeon is available, some type of internal or external fixation device. The leg should not be in a dependent position for at least 7 days after surgery. Antibiotic ointment and saline-moistened gauze or a wet-to-wet dressing is best to use over the skin graft. Swelling improves dramatically over the first 2–3 weeks and continues to improve over the next several months. After 7 days, when the wounds are healing well, the patient can gradually let the leg dangle for increasing amounts of time. When the leg is dependent, it should be gently wrapped with an Ace wrap to prevent swelling. Middle and Possibly Distal Third of the Calf: Soleus Flap the soleus muscle lies immediately deep to the gastrocnemius muscle and joins with the gastrocnemius distally to form the Achilles tendon. Fractures of the Tibia and Fibula 217 the soleus flap is most useful for wounds in the middle of the calf. Although sometimes it can be used for wounds of the lower third, it is not as reliable in the lower leg. The soleus muscle has a somewhat segmental blood supply without one dominant vessel (as seen in the gastrocnemius muscle). In addition, a few smaller vessels in the distal portion of the muscle can nourish the entire soleus if the proximal vessel is divided. The flap is based most commonly and reliably on its proximal, main blood supply, but at times it can be based on the smaller, distal vessels. In patients with proximal calf soft tissue damage, it may be prudent to base the flap on the distal vessels. If the injury has injured the distal tissues, base the flap on the proximal vessel. Extend the open wound onto the medial calf skin to visualize the underlying muscles.
A metal gag (Boyle Davis) is used to erectile dysfunction medicine in bangladesh buy discount stendra hold the mouth open and allow access to erectile dysfunction specialists generic stendra 50 mg otc the tonsils vascular erectile dysfunction treatment purchase cheapest stendra and stendra. The surgeon makes a mucosal incision with scissors and starts by freeing the superior pole of the tonsil the use of gentle retraction medially helps to homeopathic remedy for erectile dysfunction causes order genuine stendra identify the correct plan and dissection can be blunt using a Gwynne-Evans tonsil dissector or using bipolar diathermy to allow simultaneous haemostasis too the lower pole can then either be clamped and ligated with an appropriate tie. The post nasal space and pyriform fossae are suctioned with a flexible nasal catheter to remove any “coroner’s clot”. This is a clot that if missed can suddenly obstruct the airway once the patient is extubated. Regular analgesia Encourage an early return to a normal diet 2 weeks recovery period. Consent and complications Need to warn patients about the risk of primary (within first 24 hours) and secondary haemorrhage (usually day 4-7), infection, dental injury, taste disturbance and 2 weeks off work/school. A mouth gag is used to open the mouth and the postnasal space and adenoid tissue is palpated. Monopolar suction diathermy is used to remove the adenoid tissue to clear the choanaes without damaging the laterally positioned Eustachian tubes. An alternative technique is to use an appropriately sized curette to remove the adenoids followed by haemostasis with packs/bipolar. The post nasal space is suctioned with a flexible nasal catheter to remove any “coroner’s clot” Consent and complications ConsentRisk of postoperative haemorrhage, dental trauma, velopalatal insufficiency, transient hypernasal speech. Peri-operative care A period of observation is required to ensure no bleeding, but can be done as a daycase. Most surgeons will use a preoperative preparation to help decongest the nose and aid in haemostasis. This usually consists of a mixture of lignocaine, epinephrine, and cocaine (Moffat’s solution). Most of the procedure is performed with a 0 degree endoscope; other viewing angles are also available for specific steps. The sequence of steps commonly performed are uncinectomy (removal of the uncinate bone), followed by enlargement of the maxillary ostium, anterior and posterior ethmoids air cells are then cleared, followed by clearance of the sphenoid and frontal recess if required. During this process microbiology swabs may be taken if pus is encountered or biopsies taken of polyps or abnormal tissue. Overall the aim of this procedure is to remove disease in the osteomeatal complex in order to allow the natural drainage pathways of the sinuses to function. The patient needs to be aware that he or she is likely to require nasal sprays long term postop. Peri-operative Care this procedure can be performed as a day case however some centres prefer an overnight stay depending on the extent of disease and the comorbidities of the patient. Blood stained nasal secretions are common and tend to settle over the next few days. Regular analgesia is required and usually a period of 2 weeks recovery is advised. Patients may be instructed to use saline nasal douching +/steroid nasal drops post operatively. A facial nerve monitor is used and when draping the patient the ipsilateral eye and corner of the mouth should be exposed. A cervico-mastoid-facial incision is created and skin flaps are elevated to allow adequate exposure. The facial nerve is located most commonly using the tympanomastoid suture as the nerve bisects the apex of this grove 5mm below the bony meatal edge. The nerve is also known to lie just superior to the posterior belly of digastric and 1cm deep and inferior to the tragal pointer. In particularly difficult cases, retrograde dissection of the peripheral branches is an option. The nerve stimulator can be used to verify the presence of the nerve and great care must be taken to avoid thermal damage when using diathermy. Great care is taken to avoid tumour spillage as this increases the chance of tumour recurrence. Consent and complications During the consent process, patients must be warned about bleeding and the potential of a haematoma and the need of postoperative drains. There is a 10% risk of temporary facial weakness or 1% risk of permanent weakness. The lower half of the pinna may be numb postoperatively due to great auricular nerve sacrifice. Also there is a risk of a salivary fistula and Frey’s syndrome, which is characterised by gustatory sweating due to cross over innervation between local parasympathetic secretomotor fibres with sympathetic sweat fibres after severing the parasympathetic fibres of the auriculotemporal nerve. Peri-operative Care Most patients will have a postoperative drain in place to avoid a wound haematoma and reduce the dead space. This means they are admitted into hospital until the drain is removed which is usually 2448 hours later. A collar incision is made 2 fingers’ breadth above the suprasternal notch in a skin crease. The strap muscles are then divided in the midline and retracted to expose the thyroid. The superior thyroid artery and vein are ligated and divided close to the gland to avoid injury to the external branch of the superior laryngeal nerve. The middle thyroid vein and inferior thyroid vessels are also ligated and divided close to the thyroid gland to avoid disrupting the blood supply to the parathyroids. The thyroid gland is mobilised and the recurrent laryngeal nerve is identified and preserved. The nerve is closely related to the inferior thyroid artery and after ascending from the mediastinum in the tracheoesophageal grooves, enters the larynx behind the cricothyroid joint. The thyroid is then freed from the ligament of Berry and removed followed by haemostasis and wound closure. Consent and complications Patients should be warned of bleeding and the need for surgical drains. The external laryngeal nerve may be affected causing difficulty with changing the pitch of the voice and voice fatigability. Unilateral recurrent laryngeal nerve palsy could give rise to hoarseness and dyspnoea on exertion. Bilateral vocal cord palsy can cause airway obstruction with the need for a tracheostomy. There is a risk of hypocalcaemia due to inadvertent direct injury to the parathyroid glands or their vascular supply. In patients with thyrotoxicosis, surgical manipulation of the gland can cause a ‘thyroid storm’ with sudden release of thyroid hormones into the circulation; therefore patients should ideally be euthyroid. Postoperative Care Most patients will be kept in hospital overnight for a period of observation to ensure no wound haematoma. Patients who have had a total thyroidectomy need postoperative calcium checks and appropriate management of any subsequent hypocalcaemia. Consent and complications Complications include bleeding and haematoma, infection, risk of chyle leak, nerve damage, facial lymphedema and disease recurrence. Surgical Tracheostomy Description A tracheostomy is a surgically created opening in the front of the neck into the trachea. It can be performed electively or as an emergency depending on the indication and can be permanent or temporary. Tracheostomy reduces physiological dead space therefore helps with weaning patients from mechanical ventilation and allows trachea-bronchial suctioning. Surgical Technique Ideally performed under general anaesthetic, however, if endotracheal intubation cannot be achieved, tracheostomy can be performed under local anaesthesia. The patient is positioned supine with a shoulder roll and a head ring to achieve neck extension. The thyroid isthmus is divided in the midline using diathermy or can be hemitransfixed. At this point the trachea should be visible and the anaesthetist should be alerted that you are close to making an incision into the trachea. Ensure the cuff of the tube has been tested and that your assistant has suction to hand. A window is created into tracheal rings 3 and 4 or alternatively a linear incision can be created. The anaesthetist at this point withdraws the endotracheal tube slowly to allow insertion of the tracheostomy tube.
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