Now, it is common for full-term pregnant people to have contractions, even if they do not hurt. After abdominal trauma, contractions can indicate an obstetrical emergency, and it is somewhat routine to have a cervical exam to rule out labor or other complications. It is also okay for a patient to decline a cervical exam given all that information. 

But my sister was kept in the hospital for several hours because she declined a cervical exam. She did not “refuse” or act belligerent, she enacted her right to decline a procedure based on knowledge of her body and the risks/benefits of the cervical exam. 

The nurse, however, told her, “Well, then we’re not letting you go since you won’t let us examine you.” Honestly. Repeat that sentence out loud. 

Once you’re as mad as I am about that sentence, think about this: Millions of people refuse medical treatment/procedures every day and are often given consequences or ridicule by healthcare providers. 

There can be a significant perception of inequality by patients, most notably if they feel the provider is condescending or “knows best.”

As a healthcare provider, I want the very best for my patients. But I also know that what I want for my patients may not be what the patient wants. And that’s okay. 

As long as I have educated my patient on the risks, benefits, and alternatives of a medication, procedure, or screening option, then the patient has every right to decline or accept treatment without punishment or derisive comments by the healthcare team. 

On the flip side, the provider has the right to refuse further treatment for a patient that declines care because the liability may be too risky. And that’s also okay! 

The most important aspect of any treatment plan is ensuring the patient is informed of every aspect of the plan, and not just what I want to tell the patient to get them to concede to my plan.

Shared decision-making between a patient and provider is supposed to be shared, not dominated by the provider because patriarchal healthcare is no care at all. 

Compliance is not the same as informed consent; healthcare compliance may be an acquiescence to the standard line, “Well, my provider knows what’s best for me.” No, my friends, the provider knows the best recommendation or treatment options based on conditions, risk factors, socioeconomic status, and historical medical issues. 

What is best for you is to understand why the provider is recommending/prescribing a treatment for you, and to understand that you can say no.

You don’t want a cervical exam? You don’t want to undergo a biopsy? You don’t want a specific medication? Then just say no. But in all fairness, if your provider provided you with all the education on risks, benefits, and alternatives, then have the decency to tell your provider why you are declining. If there is a lack of understanding or knowledge, then your provider can clarify those issues for you. 

Before you consent or refuse a treatment, always make sure you understand what that will mean for you and your body.

For the healthcare providers, ask yourselves why it is so important for a patient to consent to your treatment plan. Is it due to compassion for the patient’s well-being, or because you believe you know more than the patient?

Incomplete and inadequate education puts patients at risk. 

Uninformed or partially informed consent is not consent. 

Don’t put all of your success as a provider on your ability to get patients to do what you want. I am always curious about patient motives when they actively seek treatment but don’t want to follow through with my recommendations, but it is not my job to understand. It is my job to inform.

One last point to consider. The internet is full of information and not all that information is accurate or applicable to all people. If you have a medical question, ask a medical provider. 

Do not limit your decisions based on the experience or limited knowledge of some Keyboard Karen on social media.

This article was contributed by MacArthur Medical Center’s Certified Nurse Midwife Jen Rockhold.

The post Putting the Information Back into Informed Consent and Refusal appeared first on Medika Life.

What is the Predatory Health (PH) sector 

This broad term, which Medika has coined for convenience, encompasses practitioners from almost all the fields of healthcare and includes the complimentary and alternate health (alt-Health) sectors,

For clarification, the alt-Health sector we refer to includes Complimentary and Alternate Health (CAM) – which includes fields like homeopathy and chiropractic – and is far less strictly regulated. The same is true of the other included sectors under this heading, including but not limited to, the natural products and supplement market, new age life coaches, and the grey area of unregulated health (medical) devices. 

The alt-Health sector tends to far more representative of Predatory Health practices. Traditional medicine is broadly regulated and therefore less susceptible to the quackery of PH, but by no means immune to its perpetrators.

Predatory Health practitioners gravitate towards the alt-Health sector, attracted by lax regulation and the vast legally grey areas that allow them to operate and ply their wares almost with impunity. 

The more outlandish and non-traditional the peddled cure or treatment becomes, the more likely the PH practitioner is to gravitate away from traditional medicine by embracing these fields, where their cohort welcomes them with open arms. 

What does a Predatory Health practitioner sell?

Their main product is intangible. They are selling hope, albeit false, something terminal patients and those afflicted with conditions like chronic pain are desperate for. These patients cling to the hope of finding some relief or miracle cure and the predatory health market preys on this. Below is a non-exhaustive list of the typical markets (marks) and strategies these individuals exploit with their health cons.

• Offering miracle cures, treatments, and relief to the terminally ill. Cancer patients are a favored target, but any deadly disease offers these quacks the opportunity to peddle their dangerous and untested wares.
• If you or your child suffers from conditions like autism, you are a primary target. Support groups, especially closed groups on Telegram, Facebook, and other social media groups offer these practitioners the opportunity to exploit you in relative safety. Be wary of any individuals offering treatments for conditions that do not have known medical remedy.
• Chronic pain sufferers are a massive target for Predatory Health. They have an unlimited number of relatively safe, but ineffective treatments and natural products they can peddle to you. It isn’t in their interest to kill their cash cow, but there are unscrupulous merchants who will offer you products that are known to be very dangerous and sometimes fatal
• Obesity, eczema, high blood pressure, influenza, and covid. The list is endless as are the techniques and strategies these unscrupulous merchants will engage to appear legitimate.
• Mental Health is also catered for with New Age life courses offering all sorts of benefits from attending costly online seminars and retreats. It is hocus pocus and has no foundation in solid science. None of these things will cure your chronic pain, cancers, or autism.
• Machines claiming to offer some sort of medical benefit, some working on sound, some using vibration, and others still, claiming amazing unvalidated results and health benefits. Never, ever take endorsements at face value. If these devices actually worked, don’t you think your doctors would be using them?
• The exploitation of misguided activist groups like anti-vaxers to further promote their sales. More damage is done to the cause of vaccines by these individuals than any other group combined. It serves the interests of Predotory Health to promote distrust in traditional medicine.

False Prophets and Fake Prophets

There is a distinction between the two and in the examples and names I will highlight below, most occupy one camp or the other. 

False prophets are usually doctors and medically trained individuals who, for unknown reasons, have latched onto treatments that are not evidence-based and they believe, without conclusive medical evidence to support their beliefs, in the safety and efficacy of the treatments they peddle. 

Belief is a dangerous drug and the sustenance of religion. It has no place in evidence-based medicine. 

Fake prophets, on the other hand, are under no such illusions. They know full well the potential dangers and risks of the products or treatments they peddle. They are highly skilled at manipulating marketing channels to ensure they reach their potential ‘marks’ and will often possess no formal medical training. 

Both are equally dangerous. The fake prophets are usually limited to the alt-Health markets and prefer this environment as it allows for greater freedom to ply their deadly wares. 

It is important to note that sales may not be the only motivating factor that drives certain Predatory Health practitioners. It can simply be a desire to spread disinformation, or, as they may see it, deeply insightful information they have come upon. These are possibly the most disruptive and dangerous voices from within the Predatory Health sector as they enable and empower the real charlatans by creating doubt in people’s minds. 

Take for instance Dr Christiane Northrup, whose divergence from a reasonably distinguished medical career in women’s health has been abrupt and complete. Her adoption of conspiracy theories, 5G cell towers, microchips in vaccines, and other nonsensical rantings on YouTube and social media beggars belief.

Whatever her motivation, this doctor enjoys a broad following on social media, and her voice has impact. I have no doubt whatsoever that her rantings will result in eventual deaths. People avoiding the Covid vaccine because of baseless lies, people not inoculating their children, and an avoidance of traditional medicine because of the distrust she sows. She epitomizes the False Prophet. 

Meet the Predatory Health Practitioners

The names below are linked to Medika’s Quack Scale, a tool designed to enable the public to identify quacks and charlatans operating in the Predatory Health sector. 

The other end of the scale (Fake Prophets) is occupied by individuals like Dr Fitt, a marketing pseudonym for a disgraced doctor, Roby Mitchell, who now peddles bleach treatments and enemas to autistic children from his base in Texas. Purely driven by financial gain, Mitchell ranks among the bottom feeders in the world of predatory health. 

Dr. Kerri Rivera is another example of a doctor gone bad. Her exploitation of vulnerable mental health patients for profit is well documented and her association with Sayer Ji, an alt-Health proponent who used to sell health foods, has resulted in them spewing a sea of misinformation on Covid and other medical topics. Once again, their motivation is the sale of their products and treatments ay any cost

Kelly Brogan, Joseph Mercola, Zach Bush, the list is as endless as it is dangerous and the reason it grows daily is simply this. Money. There are fortunes to be made in the alt-Health sector, particularly if you claim to have the “cure for Covid” marketed of course as a drug or treatment to boost your immune system against influenza viruses. The FDA might be watching.

Millions of dollars change hands daily, paid over freely by those duped into believing the lies. Often, customers also pay with their lives. 

The individuals who engage in Predatory Health are willing to risk being caught. The system grinds slowly and by the time the FDA catches up with them, the damage is already done. Their message is out there and they simply move the supply of their “toxins” to less mainstream channels. Loopholes and blindspots in current U.S legislation leave room enough to drive buses through. The system offers little more negligible punitive fines and smacks on the wrist, which are not a deterrent.

This is the nature of predatory health and it isn’t always easy to spot. Particularly if your desperation and need for relief or hope outweigh your common sense.

Buying from a “large” business isn’t always a guarantee of safety either. Take the following company Phoenix Biotechnology, whose aggressive marketing campaign to sell a “natural extract” called Oleander 4x is a textbook case of manipulating the health market to promote sales of a product that can potentially cause death. 

Through the misrepresentation and manipulation of clinical studies, they have produced the illusion of medical acceptance and the latest FDA warning issued against them for offering their toxin as a treatment for Covid has exposed the true nature of their business. 

Many other similar companies operate below the radar for years in relative safety, selling and enabling Predatory Health practitioners by making their fake treatments and products available to a global market. 

It is a monumental problem that the healthcare industry and the American government can no longer afford to ignore. Every Predatory Health practitioner we allow to operate, particularly those who still have a foot firmly placed in traditional medicine, bring disrepute to the industry. 

They encourage mistrust of conventional treatments to the detriment of many critically-ill people. The formally qualified quacks breach the oath they have taken and a legal option must be explored to permanently strip them of their qualifications and the right to their use.

Many of these individuals took an oath and their actions are a clear breach of this oath, thereby rendering the conditions of the degree null and void. Simply removing their right to practice is an insufficient response and continues to endanger public health. Where clear intent to harm and deceive is established, the full force of the law should be brought to bear on these quacks.

Legislation enabling medical boards to act more aggressively against medical professionals in the predatory health sector is desperately needed on a federal level. It is in the interests of public safety and in the continued interests of maintaining credulity in existing public healthcare institutions.

Dealing with alt-Health

Policing the alt-Health sector requires an entirely different approach which may include clear legal guidelines of operation, enforceable by institutions like the FDA. This is simply one mechanism though, and the problem will require a multi-faceted approach. 

What compounds the complexity of the problem is the alt-Health sector itself. There are definite and real health benefits to certain treatments and therapies offered by the sector. Recognizing, regulating, and protecting these practitioners, products, and therapies will be critical to the future of this market. An excellent example of how a legitimate profession can be ruined by its association with predatory health is the Chiropractic industry.

Left unchecked, the alternative will be an eventual wholesale ban on many potentially helpful drugs, therapies, and products. This would be a knee-jerk response, an oversimplified solution to a complex problem and needs to be avoided at all costs. Sadly, all too often, this type of exaggerated response is typical of politicians who lack a clear grasp of an industry’s dynamics and are looking to simply exercise damage control.

There has been little effort shown by the alt-Health sector to police themselves and whatever results now from the proliferation of fraudsters within their sector, they will share blame in the outcomes. 

If you’ve been affected by Predatory Health practitioners what can you do to stop others falling victim?

Stop enabling Predatory Health Practioners

Every time you come across these individuals and you paths will cross, perhaps frequently, as they proliferate on social media, call them out, unfollow them, report them, block them. 

Their current success is largely attributable to the internet and their mastery of social media as a sales and marketing tool. The privacy of private groups on Facebook and other platforms allows them to operate with impunity, away from prying eyes. 

They are usually only exposed when tragedy occurs, when someone dies from the poisons they peddle and that death is often a child. You can help by exposing them before this happens. 

Websites like Medika Life and others offer pages that highlight the unethical and dangerous practices of these doctors. We also offer a page where the public can confidentially bring names to our attention. You can also report the professionally registered quacks to the relevant boards within their states or directly to the FDA if medication is involved. 

Reporting accounts to the social media platforms is often futile as they are slow to respond, if ever, particularly if groups are closed. Take screenshots of offending materials and include these in a report to the websites listed below. 

Your actions are essential to saving lives and stopping the spread of the rot of predatory health within our communities. By using your voice, you can join a growing community of people speaking out against disinformation. You will not be alone and somewhere on the planet, a child may owe you their life. 

You can also sign a MOBILIZE™ Health petition if you would like to add your voice to a campaign to rid the industry of this blight by creating a formal watchdog, an Organization tasked with and legally enabled to, root out health fraud and the dangerous practices of predatory health practitioners. 

Help us to help protect the most vulnerable sectors of our communities. 

The post Exposing the Dark World of Predatory Health appeared first on Medika Life.

If you would like your local retailers to stop selling this drug to your children and other vulnerable members of the community, there is a link at the end of this article to report the drug and actions you can take to have the product removed from shelves.

What is Kratom?

According to a very detailed analysis of the plant on Wikipedia, Mitragyna speciosa (commonly known as kratom) is a tropical evergreen tree in the coffee family native to Southeast Asia. It is indigenous to Thailand, Indonesia, Malaysia, Myanmar, and Papua New Guinea, where it has been used in herbal medicine since at least the nineteenth century. Kratom has opioid properties and some stimulant-like effects.

As of 2018, the efficacy and safety of kratom are unclear, and the drug was unapproved as a therapeutic agent due to the poor quality of the research. FDA and other investigations suggest that any applications for licensing would fail, based on the drug’s current safety profile and reported interactions with other medications and substances, reactions that are often fatal.

In 2019, the Food and Drug Administration (FDA) stated that there is no evidence that kratom is safe or effective for treating any condition. Some people take it for managing chronic pain, for treating opioid withdrawal symptoms (no shred of clinical evidence exists to support this), as a herbal cure-all sold on various websites as a treatment for pretty much everything, from the common cold to cancers, or for recreational purposes.

The onset of effects typically begins within five to ten minutes and lasts for two to five hours. It’s worth noting that most opioid users end up taking both opioids and Kratom (or cycling), clear evidence that Kratom is useless as a treatment against opioid addiction.

Common and more serious side effects include;

• nausea
• itching
• sweating
• dry mouth
• constipation
• increased urination
• loss of appetite
• seizures
• hallucinations
• respiratory depression (decreased breathing),
• seizure
• addiction
• psychosis

Other serious side effects may include high heart rate and blood pressure, trouble sleeping, and, rarely, liver toxicity. When use is stopped, withdrawal symptoms often occur. Deaths have occurred with kratom both by itself and mixed with other substances. Serious toxicity is relatively rare and generally appears at high doses or when kratom is used with other substances.

Kratom is a controlled substance in 16 countries and, in 2014, the FDA banned importing and manufacturing of kratom as a dietary supplement. As of 2018, there is growing international concern about a possible threat to public health from kratom use. In some jurisdictions, its sale and importation have been restricted, and several public health authorities have raised alerts.

The real danger posed by Kratom

Availability is a key problem. Your child can stop in to shop at a gas station and buy the product off the shelf. A fact verified today by my colleague in Texas. It also doesn’t show up on regular drug tests, so many deaths associated with Kratom go unlisted.

If in some weird alternate universe Kratom is shown to possess any real medical benefits (none have been discovered or scientifically validated as yet) it would still require a lengthy regulation process for certification by the FDA. This process exists to protect consumers against products exactly like Kratom. In 2013, the US Drug Enforcement Agency (DEA) issued a warning about Kratom, stating that there was no proven medical use for the drug.

To be 100% clear on this. Kratom is considered highly dangerous by the FDA and many other countries’ drug licensing authorities. It can lead to death, dependency, and a host of other nasty conditions. It is a psychedelic, so please don’t feed me bullshit about pain management. Get stoned enough and your pain tends to magically evaporate for the duration of the high. The effects reduce with each usage, leading to increased dosages and almost guaranteed addition.

Kratom also won’t cure any diseases or conditions, no matter what the quacks and con-artists selling Kratom promise you.

New drugs often enjoy a honeymoon period with the public, a window where they can be freely distributed simply because legislation has not yet been enforced to protect the public. Cocaine was legally sold across the counter not so many years ago. The system isn’t perfect and it is slow to react. Sadly, death and addition are an all too common byproduct of this window.

There is a reason doctors don’t (or shouldn’t) keep their patients permanently stoned up the yazoo and there is a reason America has a MASSIVE problem with opioid addiction. Psychotropic and psychedelic drugs aren’t the answer for management of chronic pain. In fact, they aren’t a medical solution for just about anything.

If you’re a late-stage cancer patient or other, bedridden and on death’s door, that is a different issue. Don’t confuse chronic pain with end of life scenarios.

On overdose and related interactions

There have been multiple reports of deaths in people who had ingested kratom, but most have involved other substances. A 2019 paper analyzing data from the National Poison Data System found that between 2011–2017 there were 11 deaths associated with kratom exposure. Nine of the 11 deaths reported in this study involved kratom plus other drugs and medicines, such as diphenhydramine (an antihistamine), alcohol, caffeine, benzodiazepines, fentanyl, and cocaine. Two deaths were reported following exposure from kratom alone with no other reported substances.

In 2017, the FDA identified at least 44 deaths related to kratom, with at least one case investigated as possible use of pure kratom. The FDA reports note that many of the kratom-associated deaths appeared to have resulted from adulterated products or taking kratom with other potent substances, including illicit drugs, opioids, benzodiazepines, alcohol, gabapentin, and over-the-counter medications, such as cough syrup.

Also, there have been some reports of kratom packaged as dietary supplements or dietary ingredients that were laced with other compounds that caused deaths. The FDA also seized various Kratom products that were contaminated with Salmonella. Still think your local retailer should be selling this?

Figures above provided by the National Institute on Drug Abuse

The FDA and Kratom in the US

According to a 2019 statement on the FDA website the FDA stated the following regarding Kratom.

The U.S. Food and Drug Administration is warning consumers not to use Mitragyna speciosa, commonly known as kratom, a plant which grows naturally in Thailand, Malaysia, Indonesia, and Papua New Guinea. FDA is concerned that kratom, which affects the same opioid brain receptors as morphine, appears to have properties that expose users to the risks of addiction, abuse, and dependence.

There are no FDA-approved uses for kratom, and the agency has received concerning reports about the safety of kratom. FDA is actively evaluating all available scientific information on this issue and continues to warn consumers not to use any products labeled as containing the botanical substance kratom or its psychoactive compounds, mitragynine and 7-hydroxymitragynine. FDA encourages more research to better understand kratom’s safety profile, including the use of kratom combined with other drugs.

To date, they have taken the following actions against the product’s import into the US.

• In September 2014, U.S. Marshals, at the FDA’s request, seized more than 25,000 pounds of raw kratom material worth more than $5 million from Rosefield Management, Inc. in Van Nuys, California.
• In January 2016, U.S. Marshals, at the FDA’s request, seized nearly 90,000 bottles of dietary supplements labeled as containing kratom and worth more than $400,000. The product, manufactured for and held by Dordoniz Natural Products LLC, located in South Beloit, Illinois, is marketed under the brand name RelaKzpro.
• In August 2016, U.S. Marshals, at the FDA’s request, seized more than 100 cases of products labeled as containing kratom and worth more than $150,000. The products are distributed by Nature Therapeutics LLC, which does business as Kratom Therapy and is located in Grover Beach, California. The seized products are marketed under the brand name Kratom Therapy.

The FDA has issued warnings to companies. The companies receiving warning letters use websites and social media to illegally market kratom products, making unproven claims about the ability of the kratom drug products they distribute to cure, treat, or prevent disease. Examples of claims being made by these companies include:

• “Kratom acts as a μ-opioid receptor-like morphine.”
• “In fact many people use kratom to overcome opiate addiction.”
• “Of course, people who are using kratom to overcome a preexisting opiate addiction may need to use kratom daily to avoid opiate withdrawal.”
• “Usage: It is for the management of chronic pain, as well as recreationally.”
• “Kratom is frequently used as a natural alternative to treat depression, anxiety, addiction, diabetes, chronic pain and fatigue…Kratom has been reported to have taken the place of brand name drugs like Hydrocodone or Oxycodone for individuals, all the way to weaning people off of Heroin.”
• “Some researchers have even claimed that kratom can protect you against cancer!”
• “Kratom is used for energy, to increase attention/focus, to relax, and also to treat pain and addiction. Here is just some of what our customers have used kratom to treat . . . Chronic Pain, Migraines, Opiate Addiction, ADHD/ADD, Anxiety, Depression, Arthritis, Insomnia, and much more!”

Health fraud scams like these can pose serious health risks. These products have not been demonstrated to be safe or effective for any use and may keep some patients from seeking appropriate, FDA-approved therapies. Selling these unapproved products with claims that they can treat opioid addiction and withdrawal and other serious medical conditions is a violation of the Federal Food, Drug, and Cosmetic Act.

There are a lot of advisories issued by the FDA on this drug, you can find an extensive list in the footer of the article linked to above.

Reporting This Drug

You can use this link provided by Medwatch to report the drug and any adverse interactions you, or someone you know, may experience.

MedWatch Online Voluntary Reporting Form

What can you do about retailers making these products freely available in your town or city? If they are large chains, reach out with a formal letter to their head office, notifying them of the dangers of Kratom, and copy in your local government and press. For smaller private retailers, try dropping off or sharing information on the dangers of the product and if they show disregard for your children’s safety and others within their community, consider boycotting the stores.

The post Kratom is an Unregulated Addictive Drug That Kills appeared first on Medika Life.

1. We’ve heard your embarrassing question before.

Unless you make a big deal, we likely won’t remember how you once asked us about toenail fungus.

By the time we’ve graduated, we’ve been exposed to all types of questions and scenarios. We have heard the stories about how patients accidentally brushed their teeth with hemorrhoid cream, tried to swallow suppositories, and have been unable to remove tampons.

Those of us working in hospitals have likely experienced trauma patients and death. Although we never get used to it, familiarity does make it easier.

So relax, we would rather you ask us than guess or choose not to treat your condition. We promise not to laugh (unless you want us to).

2. Although we are drug experts, we know about general health conditions too.

Pharmacy school isn’t only studying drugs. We spend the first few semesters on basic anatomy and physiology. Once we know how the body normally functions, then we move on to disease states. Learning what can go wrong helps us to understand how drugs work. Each lesson builds on the other.

So, we will know about chronic disease states like high blood pressure, diabetes, and osteoporosis, and be able to answer questions you may have.

3. Please don’t ask us where the sale items are in the store.

We probably don’t know, and unless it’s a slow day, usually don’t have the time to check for you. And don’t expect us, or the people in line behind you, to appreciate checking out all the items in your cart.

That being said, we don’t mind going into the cold medication aisle and pointing out a few choices since that is within our scope of practice.

4. We’re masterminds at solving insurance issues, but we appreciate your patience.

Every insurance card is a puzzle. Some of them require a zero before the member ID, some want the person code after. Some don’t want the letters, some require a special group number that isn’t on the card. We likely know the major carriers, but sometimes we get thrown for a loop.

We are also used to insurance rejections. “Refill too soon”, “drug not covered”, “prior authorization required”. All of these issues require time to dig into.

Also, please know that we have no control over your copay. Yes, last time it was $20, and now it’s $30. Copays go up all the time. Deductibles start over every year.

If we have billed the insurance, the price comes from them.

5. We will remember if you are rude to us and our technicians.

We see a lot of patients and fill a ton of prescriptions every day. Unless you are a frequent guest, we will likely have forgotten your name five minutes after saying goodbye.

However, we remember the ones that yell. We remember the ones that make unreasonable demands. We remember the ones that try to bully our students and technicians for problems that are out of their control.

We understand that you may be sick and in pain. We know you likely spent hours in the ER or doctor’s office and just want to go home. We’ll give you a pass for that, but we are still human and deserve to be treated with respect.

6. Technicians aren’t pharmacists, don’t ask them drug questions.

Speaking of our technicians, they do a heck of a lot of work. Without them, our pharmacies would implode. They receive special education and training to be able to perform their job.

That being said, save your medication questions for the pharmacist. Legal requirements aside, the pharmacist is the one with 6 plus years of education, residencies, and credentials.

On the flip side, we are extremely busy and if every caller asks to “speak with the pharmacist” just to find out the price of their medication or if it’s ready for pick-up, questions a technician is more than qualified to answer, then we can’t do our work efficiently.

7. We work tirelessly behind the scenes during your hospital stay too.

A pharmacist will review each medication order for every patient who enters the hospital. Just like at the drug store, you can rest assured that we have screened the order against your allergies, checked if the dose is appropriate for your weight and age, and reviewed it for interactions with other medications you may be taking.

Sometimes we even consult with other members of your health care team in determining your treatment plan.

If you have ever received an antibiotic or blood thinner in the hospital, chances are a pharmacist calculated the initial dose and monitored it daily.

8. Don’t bring a grocery bag full of your prescriptions to the hospital.

Patients are not usually allowed to keep medications at the bedside, so guess what will happen to the prescriptions you bring in with you? Your family member will be asked to take them right back home.

The alternative is to have your medications stored in the pharmacy. This means they go into a drawer somewhere in the back corner. The nurse who drops off your medication receives a receipt. It’s up to them (and you) to remember to pick them up at discharge.

You can imagine how many “patient’s own meds” get left behind.

The exception to this rule is if you are taking a rare, brand-new, or essential drug. Hospital pharmacies stock the basics, but we won’t carry everything. If we don’t have it, we will ask a family member to bring it in so it can be continued during your stay.

9. If we don’t have the drug in stock, we will help you find it.

Did your doctor order a medication that we don’t stock? No problem. Chain drug stores are all connected by the same computer system making transferring prescriptions easy.

The same goes for hospital stays. We can call our buddy hospitals and borrow medications from them. A courier will pick up the drug and deliver it to us. Again, we appreciate your patience as this process can take a few hours.

10. We are human.

We have an outstanding assortment of technology at our disposal. Robots fill medications. Barcode scanners ensure the correct bottle of pills is chosen. Electronic prescriptions reduce transcription errors. Automated dispensing machines allow nurses to choose the correct drug at the hospital.

Many sets of eyes see a prescription order from start to finish but remember that the last link in the chain is you.

When you get your refill home, take a moment to look at it. Are the pills the same color and shape as last time? Is it a new prescription? Most pharmacies include descriptions of what the tablet looks like on the bottle’s label. Did the nurse scan your wristband before scanning the medication bar code at the hospital?

All of these steps will help to ensure your safety. Medication mix-ups happen. They can be bad. Help us to prevent them.

11. Doctors’ handwriting really is terrible.

Sometimes we rely on clues in the strength or indication. Sometimes we pass it around and everyone takes a guess. Worst case, we have to call the office. That’s why we are grateful that most prescriptions these days are electronic.

However, electronic doesn’t mean fool-proof. Doctors can still choose an incorrect drug from a drop-down or predictive text list.

That’s another reason you should always ask questions about your prescription. We can determine pretty quickly that the wrong medication was filled if we counsel you on diabetes medication for your earache.

12. We went into this to help others, not for the money.

Even though we sometimes look frazzled and stressed, please know we genuinely want you to understand your medications. We will always take time out for questions, counseling, and concerns.

We went into pharmacy school to be health-care providers, not to drive around in Lamborghinis.

Trust us, the money we are making barely covers the cost of our education. Most of us work more than one job. There are easier ways to make money.

We do it because we care.

The post 12 Things Pharmacists Want You to Know appeared first on Medika Life.

Layers of the Heart Wall

Three layers of tissue form the heart wall. The outer layer of the heart wall is the epicardium, the middle layer is the myocardium, and the inner layer is the endocardium.

Chambers of the Heart

The internal cavity of the heart is divided into four chambers:

• Right atrium
• Right ventricle
• Left atrium
• Left ventricle

The two atria are thin-walled chambers that receive blood from the veins. The two ventricles are thick-walled chambers that forcefully pump blood out of the heart. Differences in thickness of the heart chamber walls are due to variations in the amount of myocardium present, which reflects the amount of force each chamber is required to generate.

The right atrium receives deoxygenated blood from systemic veins; the left atrium receives oxygenated blood from the pulmonary veins.

Valves of the Heart

Pumps need a set of valves to keep the fluid flowing in one direction and the heart is no exception. The heart has two types of valves that keep the blood flowing in the correct direction. The valves between the atria and ventricles are called atrioventricular valves (also called cuspid valves), while those at the bases of the large vessels leaving the ventricles are called semilunar valves.

The right atrioventricular valve is the tricuspid valve. The left atrioventricular valve is the bicuspid, or mitral, valve. The valve between the right ventricle and pulmonary trunk is the pulmonary semilunar valve. The valve between the left ventricle and the aorta is the aortic semilunar valve.

When the ventricles contract, atrioventricular valves close to prevent blood from flowing back into the atria. When the ventricles relax, semilunar valves close to prevent blood from flowing back into the ventricles.

Pathway of Blood through the Heart

While it is convenient to describe the flow of blood through the right side of the heart and then through the left side, it is important to realize that both atria and ventricles contract at the same time. The heart works as two pumps, one on the right and one on the left, working simultaneously. Blood flows from the right atrium to the right ventricle, and then is pumped to the lungs to receive oxygen. From the lungs, the blood flows to the left atrium, then to the left ventricle. From there it is pumped to the systemic circulation.

Blood Supply to the Myocardium

The myocardium of the heart wall is a working muscle that needs a continuous supply of oxygen and nutrients to function efficiently. For this reason, cardiac muscle has an extensive network of blood vessels to bring oxygen to the contracting cells and to remove waste products.

The right and left coronary arteries, branches of the ascending aorta, supply blood to the walls of the myocardium. After blood passes through the capillaries in the myocardium, it enters a system of cardiac (coronary) veins. Most of the cardiac veins drain into the coronary sinus, which opens into the right atrium.

Physiology of the Heart

The conduction system includes several components. The first part of the conduction system is the sinoatrial node . Without any neural stimulation, the sinoatrial node rhythmically initiates impulses 70 to 80 times per minute. Because it establishes the basic rhythm of the heartbeat, it is called the pacemaker of the heart. Other parts of the conduction system include the atrioventricular node, atrioventricular bundle, bundle branches, and conduction myofibers. All of these components coordinate the contraction and relaxation of the heart chambers.

Cardiac Cycle

The cardiac cycle refers to the alternating contraction and relaxation of the myocardium in the walls of the heart chambers, coordinated by the conduction system, during one heartbeat. Systole is the contraction phase of the cardiac cycle, and diastole is the relaxation phase. At a normal heart rate, one cardiac cycle lasts for 0.8 second.

Heart Sounds

The sounds associated with the heartbeat are due to vibrations in the tissues and blood caused by closure of the valves. Abnormal heart sounds are called murmurs.

Heart Rate

The sinoatrial node, acting alone, produces a constant rhythmic heart rate. Regulating factors are reliant on the atrioventricular node to increase or decrease the heart rate to adjust cardiac output to meet the changing needs of the body. Most changes in the heart rate are mediated through the cardiac center in the medulla oblongata of the brain. The center has both sympathetic and parasympathetic components that adjust the heart rate to meet the changing needs of the body.

Peripheral factors such as emotions, ion concentrations, and body temperature may affect heart rate. These are usually mediated through the cardiac center.

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Anatomical Structure

The uterus is a thick-walled muscular organ capable of expansion to accommodate a growing fetus. It is connected distally to the vagina, and laterally to the uterine tubes.

The uterus has three parts;

• Fundus – top of the uterus, above the entry point of the uterine tubes.
• Body – usual site for implantation of the blastocyst.
• Cervix – lower part of uterus linking it with the vagina. This part is structurally and functionally different to the rest of the uterus.

The Cervix

The cervix is the lower portion of the uterus, an organ of the female reproductive tract. It connects the vagina with the main body of the uterus, acting as a gateway between them.

The cervix is composed of two regions; the ectocervix and the endocervical canal. The ectocervix is the portion of the cervix that projects into the vagina. It is lined by stratified squamous non-keratinized epithelium. The opening in the ectocervix, the external os, marks the transition from the ectocervix to the endocervical canal.

The endocervical canal (or endocervix) is the more proximal, and ‘inner’ part of the cervix. It is lined by a mucus-secreting simple columnar epithelium. The endocervical canal ends, and the uterine cavity begins, at a narrowing called the internal os.

Functions of the cervix

The cervix performs two main functions:

• It facilitates the passage of sperm into the uterine cavity. This is achieved via dilation of the external and internal os.
• Maintains sterility of the upper female reproductive tract. The cervix, and all structures superior to it, are sterile. This ultimately protects the uterine cavity and the upper genital tract by preventing bacterial invasion. This environment is maintained by the frequent shedding of the endometrium, thick cervical mucus and a narrow external os.

Histological Structure

The fundus and body of the uterus are composed of three tissue layers;

• Peritoneum – a double layered membrane, continuous with the abdominal peritoneum. Also known as the perimetrium.
• Myometrium – thick smooth muscle layer. Cells of this layer undergo hypertrophy and hyperplasia during pregnancy in preparation to expel the fetus at birth.
• Endometrium – inner mucous membrane lining the uterus. It can be further subdivided into 2 parts:
  • Deep stratum basalis: Changes little throughout the menstrual cycle and is not shed at menstruation.
  • Superficial stratum functionalis: Proliferates in response to oestrogens, and becomes secretory in response to progesterone. It is shed during menstruation and regenerates from cells in the stratum basalis layer.

Ligaments

The tone of the pelvic floor provides the primary support for the uterus. Some ligaments provide further support, securing the uterus in place.

They are:

• Broad Ligament: This is a double layer of peritoneum attaching the sides of the uterus to the pelvis. It acts as a mesentery for the uterus and contributes to maintaining it in position.
• Round Ligament: A remnant of the gubernaculum extending from the uterine horns to the labia majora via the inguinal canal. It functions to maintain the anteverted position of the uterus.
• Ovarian Ligament: Joins the ovaries to the uterus.
• Cardinal Ligament: Located at the base of the broad ligament, the cardinal ligament extends from the cervix to the lateral pelvic walls. It contains the uterine artery and vein in addition to providing support to the uterus.
• Uterosacral Ligament: Extends from the cervix to the sacrum. It provides support to the uterus.

Vascular Supply and Lymphatics

The blood supply to the uterus is via the uterine artery. Venous drainage is via a plexus in the broad ligament that drains into the uterine veins.

Lymphatic drainage of the uterus is via the iliac, sacral, aortic and inguinal lymph nodes.

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The testes are located within the scrotum, with the epididymis situated on the posterolateral aspect of each testicle. Commonly, the left testicle lies lower than the right. They are suspended from the abdomen by the spermatic cord – collection of vessels, nerves and ducts that supply the testes.

Originally, the testes are located on the posterior abdominal wall. During embryonic development they descend down the abdomen, and through the inguinal canal to reach the scrotum. They carry their neurovascular and lymphatic supply with them.

Anatomical Structure

The testes have an ellipsoid shape. They consist of a series of lobules, each containing seminiferous tubules supported by interstitial tissue. The seminiferous tubules are lined by Sertoli cells that aid the maturation process of the spermatozoa. In the interstitial tissue lie the Leydig cells that are responsible for testosterone production.

Spermatozoa are produced in the seminiferous tubules. The developing sperm travels through the tubules, collecting in the rete testes. Ducts known as efferent tubules transport the sperm from the rete testes to the epididymis for storage and maturation.

Inside the scrotum, the testes are covered almost entirely by the tunica vaginalis, a closed sac of parietal peritoneal origin that contains a small amount of viscous fluid. This sac covers the anterior surface and sides of each testicle and works much like the peritoneal sac, lubricating the surfaces of the testes and allowing for friction-free movement.

The testicular parenchyma is protected by the tunica albuginea, a fibrous capsule that encloses the testes. It penetrates into the parenchyma of each testicle with diaphragms, dividing it into lobules.

The epididymis consists of a single heavily coiled duct. It can be divided into three parts; head, body and tail.

• Head – The most proximal part of the epididymis. It is formed by the efferent tubules of the testes, which transport sperm from the testes to the epididymis.
• Body – Formed by the heavily coiled duct of the epididymis.
• Tail – The most distal part of the epididymis. It marks the origin of the vas deferens, which transports sperm to the prostatic portion of the urethra for ejaculation.

Vascular Supply

The main arterial supply to the testes and epididymis is via the paired testicular arteries, which arise directly from the abdominal aorta. They descend down the abdomen, and pass into the scrotum via the inguinal canal, contained within the spermatic cord.

However, the testes are also supplied by branches of the cremasteric artery (from the inferior epigastric artery) and the artery of the vas deferens (from the inferior vesical artery). These branches give anastomoses to the main testicular artery.

Venous drainage is achieved via the paired testicular veins. They are formed from the pampiniform plexus in the scrotum – a network of veins wrapped around the testicular artery. In the retroperitoneal space of the abdomen, the left testicular vein drains into the left renal vein, while the right testicular vein drains directly into the inferior vena cava.

Lymphatics

Since the testes are originally retroperitoneal organs, the lymphatic drainage is to the lumbar and para-aortic nodes, along the lumbar vertebrae. This is in contrast to the scrotum, which drains into the nearby superficial inguinal nodes.

Spermatogenesis

Sperm are produced by spermatogenesis within the seminiferous tubules. A transverse section of a seminiferous tubule shows that it is packed with cells in various stages of development. Interspersed with these cells, there are large cells that extend from the periphery of the tubule to the lumen. These large cells are the supporting, or sustentacular cells (Sertoli’s cells), which support and nourish the other cells.

Early in embryonic development, primordial germ cells enter the testes and differentiate into spermatogonia, immature cells that remain dormant until puberty. Spermatogonia are diploid cells, each with 46 chromosomes (23 pairs) located around the periphery of the seminiferous tubules. At puberty, hormones stimulate these cells to begin dividing by mitosis. Some of the daughter cells produced by mitosis remain at the periphery as spermatogonia. Others are pushed toward the lumen, undergo some changes, and become primary spermatocytes. Because they are produced by mitosis, primary spermatocytes, like spermatogonia, are diploid and have 46 chromosomes.

Each primary spermatocytes goes through the first meiotic division, meiosis I, to produce two secondary spermatocytes, each with 23 chromosomes (haploid). Just prior to this division, the genetic material is replicated so that each chromosome consists of two strands, called chromatids, that are joined by a centromere. During meiosis I, one chromosome, consisting of two chromatids, goes to each secondary spermatocyte. In the second meiotic division, meiosis II, each secondary spermatocyte divides to produce two spermatids. There is no replication of genetic material in this division, but the centromere divides so that a single-stranded chromatid goes to each cell. As a result of the two meiotic divisions, each primary spermatocyte produces four spermatids. During spermatogenesis there are two cellular divisions, but only one replication of DNA so that each spermatid has 23 chromosomes (haploid), one from each pair in the original primary spermatocyte. Each successive stage in spermatogenesis is pushed toward the center of the tubule so that the more immature cells are at the periphery and the more differentiated cells are nearer the center.

Spermatogenesis (and oogenesis in the female) differs from mitosis because the resulting cells have only half the number of chromosomes as the original cell. When the sperm cell nucleus unites with an egg cell nucleus, the full number of chromosomes is restored. If sperm and egg cells were produced by mitosis, then each successive generation would have twice the number of chromosomes as the preceding one.

The final step in the development of sperm is called spermiogenesis. In this process, the spermatids formed from spermatogenesis become mature spermatozoa, or sperm. The mature sperm cell has a head, midpiece, and tail. The head, also called the nuclear region, contains the 23 chromosomes surrounded by a nuclear membrane. The tip of the head is covered by an acrosome, which contains enzymes that help the sperm penetrate the female gamete. The midpiece, metabolic region, contains mitochondria that provide adenosine triphosphate (ATP). The tail or locomotor region, uses a typical flagellum for locomotion. The sperm are released into the lumen of the seminiferous tubule and leave the testes. They then enter the epididymis where they undergo their final maturation and become capable of fertilizing a female gamete.

Sperm production begins at puberty and continues throughout the life of a male. The entire process, beginning with a primary spermatocyte, takes about 74 days. After ejaculation, the sperm can live for about 48 hours in the female reproductive tract.

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The external genitalia are the accessory structures of the female reproductive system that are external to the vagina. They are also referred to as the vulva or pudendum. The external genitalia include the labia majora, mons pubis, labia minora, clitoris, and glands within the vestibule.

The clitoris is an erectile organ, similar to the male penis, that responds to sexual stimulation. Posterior to the clitoris, the urethra, vagina, paraurethral glands and greater vestibular glands open into the vestibule.

The vulva (pudendum) refers to the external female genitalia. Its functions are threefold:

• Acts as sensory tissue during sexual intercourse
• Assists in micturition by directing the flow of urine
• Protects the internal female reproductive tract from infection.

Structures of the Vulva

The vulva is a collective term for several anatomical structures:

• Mons pubis – a subcutaneous fat pad located anterior to the pubic symphysis. It formed by the fusion of the labia majora.
• Labia majora – two hair-bearing external skin folds.
  • They extend from the mons pubis posteriorly to the posterior commissure (a depression overlying the perineal body).
  • Embryologically derived from labioscrotal swellings
• Labia minora – two hairless folds of skin, which lie within the labia majora.
  • They fuse anteriorly to form the hood of the clitoris and extend posteriorly either side of the vaginal opening.
  • They merge posteriorly, creating a fold of skin known as the fourchette.
  • Embryologically derived from urethral folds
• Vestibule – the area enclosed by the labia minora. It contains the openings of the vagina (external vaginal orifice, vaginal introitus) and urethra.
• Bartholin’s glands – secrete lubricating mucus from small ducts during sexual arousal. They are located either side of the vaginal orifice.
• Clitoris – located under the clitoral hood. It is formed of erectile corpora cavernosa tissue, which becomes engorged with blood during sexual stimulation.
  • Embryologically derived from the genital tubercle

Vascular Supply and Lymphatics

The arterial supply to the vulva is from the paired internal and external pudendal arteries (branches of the internal iliac).

Venous drainage is achieved via the pudendal veins, with smaller labial veins contributing as tributaries.

Lymph drains to the nearby superficial inguinal lymph nodes.

Male External Genitalia

The penis is an external organ of the male reproductive system. It has two main functions:

• Sexual intercourse – During erotic stimulation, the penis undergoes erection, becoming engorged with blood. Following emission, (mixing of the components of semen in the prostatic urethra) ejaculation can occur, whereby semen moves out of the urethra through the external urethral orifice. Finally, the penis undergoes remission, returning to a flaccid state.
• Micturition –The penis also has an important urinary role. It contains the urethra, which carries urine from the bladder to the external urethral orifice, where it is expelled from the body.

Structure of the Penis

The penis can be anatomically divided into three parts:

• Root – the most proximal, fixed part of the penis. It is located in the superficial perineal pouch of the pelvic floor, and is not visible externally. The root contains three erectile tissues (two crura and bulb of the penis), and two muscles (ischiocavernosus and bulbospongiosus).
• Body – the free part of the penis, located between the root and glans. It is suspended from the pubic symphysis. It is composed of three cylinders of erectile tissue – two corpora cavernosa, and the corpus spongiosum.
• Glans –the most distal part of the of penis. It is conical in shape, and is formed by the distal expansion of the corpus spongiosum. This contains the opening of the urethra, termed the external urethral orifice.

Erectile Tissues

The erectile tissues fill with blood during sexual arousal, producing an erection. The root and body of the penis are spanned by three masses of erectile tissue.

In the root, these tissues are known as the left and right crura, and the bulb of the penis. The bulb is situated in the midline of the penile root, and is traversed by the urethra. The left and right crura are located laterally; attached to the ipsilateral ischial ramus, and covered by the paired ischiocavernosal muscles.

The erectile tissues continue into the body of the penis. The left and right crura continue anteriorly into the dorsal part of the penis – they form the two corpora cavernosa. They are separated by the septum of the penis, although often incompletely. The bulb forms the corpus spongiosum, which lies ventrally. The male urethra runs through the corpus spongiosum – to prevent it becoming occluded during erection the corpus spongiosum fills to a reduced pressure.

Distally, the corpus spongiosum expands to form the glans penis.

Muscles

There are four muscles located in the root of the penis:

• Bulbospongiosus (x2) – associated with the bulb of the penis. It contracts to empty the spongy urethra of any residual semen and urine. The anterior fibres also aid in maintaining erection by increasing the pressure in the bulb of the penis.
• Ischiocavernosus (x2) – surrounds the left and right crura of the penis. It contracts to force blood from the cavernous spaces in the crura into the corpus cavernosa – this helps maintain erection.

Fascial Coverings

Each mass of erectile tissue has two fascial coverings. The most superficial layer, immediately under the skin, is the external fascia of Colles (which is in continuity with the fascia of Scarpa which covers the abdominal wall).

A deeper stratum is the deep fascia of the penis (also known as Buck’s fascia). This is a continuation of the deep perineal fascia, and forms a strong membranous covering which holds all three erectile tissues together.

Underneath the deep fascia is the strong fascia called tunica albuginea, forming an individual capsule around each cavernous body and fused in the midline. The incomplete septum between the two corpora is comprised of tunica albuginea.

Ligaments

The root of the penis is supported by two ligaments, which attach it to the surrounding structures:

• Suspensory ligament – a condensation of deep fascia. It connects the erectile bodies of the penis to the pubic symphysis.
• Fundiform ligament – a condensation of abdominal subcutaneous tissue. It runs down from the linea alba, surrounding the penis like a sling, and attaching to the pubic symphysis.

Skin

The skin of the penis is more heavily pigmented than that of the rest of the body. It is connected to the underlying fascias by loose connective tissue.

The prepuce (foreskin) is a double layer of skin and fascia, located at the neck of the glans. It covers the glans to a variable extent. The prepuce is connected to the surface of the glans by the frenulum, a median fold of skin on the ventral surface of the penis. The potential space between the glans and prepuce is termed the preputial sac.

Neurovascular Supply

The penis receives arterial supply from three sources:

• Dorsal arteries of the penis
• Deep arteries of the penis
• Bulbourethral artery

These arteries are all branches of the internal pudendal artery. This vessel arises from the anterior division of the internal iliac artery.

Venous blood is drained from the penis by paired veins. The cavernous spaces are drained by the deep dorsal vein of the penis – this empties into the prostatic venous plexus. The superficial dorsal veins drain the superficial structures of the penis, such as the skin and cutaneous tissues.

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The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills.

The second layer in the walls is the submucosa, which supports the mucous membrane. It is composed of connective tissue with elastic fibers.

The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and, collectively, these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter.

Shape of the Bladder

The appearance of the bladder varies depending on the amount of urine stored. When full, it exhibits an oval shape, and when empty it is flattened by the overlying bowel.

The external features of the bladder are:

• Apex – located superiorly, pointing towards the pubic symphysis. It is connected to the umbilicus by the median umbilical ligament (a remnant of the urachus).
• Body – main part of the bladder, located between the apex and the fundus
• Fundus (or base) – located posteriorly. It is triangular-shaped, with the tip of the triangle pointing backwards.
• Neck – formed by the convergence of the fundus and the two inferolateral surfaces. It is continuous with the urethra.

Urine enters the bladder through the left and right ureters, and exits via the urethra. Internally, these orifices are marked by the trigone – a triangular area located within the fundus.

In contrast to the rest of the internal bladder, the trigone has smooth walls (this is explained by the different embryological origin: the trigone is developed by the integration of two mesonephric ducts at the base of the bladder).

Musculature

The musculature of the bladder plays a key role in the storage and emptying of urine.

In order to contract during micturition, the bladder wall contains specialised smooth muscle – known as detrusor muscle. Its fibres are orientated in multiple directions, thus retaining structural integrity when stretched. It receives innervation from both the sympathetic and parasympathetic nervous systems.

The fibers of the detrusor muscle often become hypertrophic (presenting as prominent trabeculae) in order to compensate for increased workload of the bladder emptying. This is very common in conditions that obstruct the urine outflow such as benign prostatic hyperplasia.

There are also two muscular sphincters located in the urethra:

• Internal urethral sphincter:
  • Male – consists of circular smooth fibres, which are under autonomic control. It is thought to prevent seminal regurgitation during ejaculation.
  • Females – thought to be a functional sphincter (i.e. no sphincteric muscle present). It is formed by the anatomy of the bladder neck and proximal urethra.
• External urethral sphincter – has the same structure in both sexes. It is skeletal muscle, and under voluntary control. However, in males the external sphincteric mechanism is more complex, as it correlates with fibers of the rectourethralis muscle and the levator ani muscle.

The Bladder Stretch Reflex

The bladder stretch reflex is a primitive spinal reflex, in which micturition is stimulated in response to stretch of the bladder wall. It is analogous to a muscle spinal reflex, such as the patella reflex.

During toilet training in infants, this spinal reflex is overridden by the higher centres of the brain, to give voluntary control over micturition.

The reflex arc:

• Bladder fills with urine, and the bladder walls stretch. Sensory nerves detect stretch and transmit this information to the spinal cord.
• Interneurons within the spinal cord relay the signal to the parasympathetic efferents (the pelvic nerve).
• The pelvic nerve acts to contract the detrusor muscle, and stimulate micturition.

Although it is non-functional post childhood, the bladder stretch reflex needs to be considered in spinal injuries (where the descending inhibition cannot reach the bladder), and in neurodegenerative diseases (where the brain is unable to generate inhibition).

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Healthy kidneys filter about a half cup of blood every minute, removing wastes and extra water to make urine. The urine flows from the kidneys to the bladder through two thin tubes of muscle called ureters, one on each side of your bladder. Your bladder stores urine. Your kidneys, ureters, and bladder are part of your urinary tract.

Each of your kidneys is made up of about a million filtering units called nephrons. Each nephron includes a filter, called the glomerulus, and a tubule. The nephrons work through a two-step process: the glomerulus filters your blood, and the tubule returns needed substances to your blood and removes wastes.

Kidney Structure

The kidneys are encased in complex layers of fascia and fat. They are arranged as follows (deep to superficial):

• Renal capsule – tough fibrous capsule.
• Perirenal fat – collection of extraperitoneal fat.
• Renal fascia (also known as Gerota’s fascia or perirenal fascia) – encloses the kidneys and the suprarenal glands.
• Pararenal fat – mainly located on the posterolateral aspect of the kidney.

Internally, the kidneys have an intricate and unique structure. The renal parenchyma can be divided into two main areas – the outer cortex and inner medulla. The cortex extends into the medulla, dividing it into triangular shapes – these are known as renal pyramids.

The apex of a renal pyramid is called a renal papilla. Each renal papilla is associated with a structure known as the minor calyx, which collects urine from the pyramids. Several minor calices merge to form a major calyx. Urine passes through the major calices into the renal pelvis, a flattened and funnel-shaped structure. From the renal pelvis, urine drains into the ureter, which transports it to the bladder for storage.

The medial margin of each kidney is marked by a deep fissure, known as the renal hilum. This acts as a gateway to the kidney – normally the renal vessels and ureter enter/exit the kidney via this structure.

Arterial Supply

The kidneys are supplied with blood via the renal arteries, which arise directly from the abdominal aorta, immediately distal to the origin of the superior mesenteric artery.  Due to the anatomical position of the abdominal aorta (slightly to the left of the midline), the right renal artery is longer, and crosses the vena cava posteriorly.

The renal artery enters the kidney via the renal hilum. At the hilum level, the renal artery forms an anterior and a posterior division, which carry 75% and 25% of the blood supply to the kidney, respectively. Five segmental arteries originate from these two divisions.

The avascular plane of the kidney (line of Brodel) is an imaginary line along the lateral and slightly posterior border of the kidney, which delineates the segments of the kidney supplied by the anterior and posterior divisions. It is an important access route for both open and endoscopic surgical access of the kidney, as it minimizes the risk of damage to major arterial branches.

The segmental branches of the renal undergo further divisions to supply the renal parenchyma:

• Each segmental artery divides to form interlobar arteries. They are situated either side every renal pyramid.
• These interlobar arteries undergo further division to form the arcuate arteries.
• At 90 degrees to the arcuate arteries, the interlobular arteries arise.
• The interlobular arteries pass through the cortex, dividing one last time to form afferent arterioles.
• The afferent arterioles form a capillary network, the glomerulus, where filtration takes place. The capillaries come together to form the efferent arterioles.

In the outer two-thirds of the renal cortex, the efferent arterioles form what is a known as a peritubular network, supplying the nephron tubules with oxygen and nutrients. The inner third of the cortex and the medulla are supplied by long, straight arteries called vasa recta.

Venous Drainage

The kidneys are drained of venous blood by the left and right renal veins. They leave the renal hilum anteriorly to the renal arteries, and empty directly into the inferior vena cava.

As the vena cava lies slightly to the right, the left renal vein is longer, and travels anteriorly to the abdominal aorta below the origin of the superior mesenteric artery. The right renal artery lies posterior to the inferior vena cava.

Lymphatics

Lymph from the kidney drains into the lateral aortic (or para-aortic) lymph nodes, which are located at the origin of the renal arteries.

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