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Group A and Group B consisted of 30 patients each. The completion of procedure without a need to convert was considered as successful proceedure, and complete clearence of all fragments in the follow up period of six weeks was considered stone free. All selected patients agreed to enter this study, and the study was approved by the Ethical committee. Operative Technique-Retroperitoneal Laparoscopic Ureterolithotomy After induction of anesthesia to the patient, the patient was placed in lateral decubitus position on the operating table.
At a point midway between subcostal margin and iliac crest along midaxillary line a skin incision was made and the aponeurosis bluntly perforated under safe control of both hands. The peritoneum was pushed forward using an index finger, and an indigenous balloon dilator was introduced into the space to create a working space in the retroperitoneal space. After blunt dissection of the retroperitoneal space the dissection balloon was removed.
Under the direction of index finger, two more ports were made. One in infra-lumbar region and one mid way between first port and renal angle. Both ports being at 45 0 angle in relation to the first port. Pneumoretroperitoneum was created using C Important landmark in the retroperitoneum i. After removal of the extra peritoneal adipose tissue the ureter was recognized on the psoas muscle. The ureter was dissected to trace the stone location, which could be easily identified by its conspicuous bulge.
The ureter wall was incised longitudinally over the bulging stone using an endo-knife. The stone was extracted and removed.
An indwelling double-j ureteric stent was placed through the port in selected cases as per requirement. The ureterotomy was closed using absorbable sutures. The ureteral stent was removed three to four weeks after operation. Operative Technique Ureteroscopic Pneumatic Lithotripsy Under spinal or general anesthesia with the patient in lithotomy position, ureteroscopy was conducted using a 8- 9.
Access to the ureter will be made by retrograde insertion of a 0. The stone was fragmented using a pneumatic lithoclast. A double-J stunt was placed in selected cases as per the need and removed on an outpatient basis. A Foley catheter was placed for two to three days.
Plain abdominal X-ray and abdomenopelvic ultrasound scans was obtained four weeks after the procedure. The presence of stone fragment smaller than 3mm in diameter in the follow up period was considered as successful fragmentation, and complete removal of all fragments was considered stone free.
Results None of the patients withdrew from the study. The success rate of group A In group A, four complications occurred, including intaoperative bleed, abdominal distention caused by peritoneal rupture, and urine leakage. In group B, the dominant postoperative complications were prolonged hematuria and urosepsis. The rate of complications was Discussion Ureteric stone disease is known since eternity, even in the era of modern medicine, urinary stones continue to be 1 of the major diseases encountered in urologists daily practice.
The only well-documented exceptions are found among members of the Spirochaetaceae that use ornithine instead of DAP for cross-linking PG for example, refs 25 , All four investigated planctomycetal cell hydrolysates showed the specific fragment ion set for DAP at the respective retention time in the extracted ion chromatograms.
The signals were significantly stronger than in Spirochaeta asiatica that served as a negative control Fig.
Figure 2: Mass spectrometric detection of the cell wall component DAP in planctomycetal cells.
Planctomycetes do possess a peptidoglycan cell wall
In conclusion, our biochemical analyses provide an evidence for the existence of PG in Planctomycetes. Images of untreated Planctomycetes show subcellular details under phase-contrast illumination that potentially correspond to the planctomycetal cell compartmentalization Fig. After lysozyme treatment, the cells lose these details along with their shape or lyse entirely Fig.
Thus, lysozyme disrupts the planctomycetal cell structure. Figure 3: Effect of lysozyme on planctomycetal cells. Phase-contrast micrographs of a P.
Untreated cells I and II serve as negative control. Full size image Cell wall sacculi were prepared from P.
Both species yielded intact sacculi of cell size Fig. Treatment of isolated sacculi with lysozyme led to disintegration and fragmentation of the sacculi structures Fig.
Moreover, we could verify the presence of DAP in P. Figure 4: Effect of lysozyme on planctomycetal PG sacculi. Sacculi of G. Full size image P. This layer could be seen in cells from different growth phases and in all the 25 tomograms inspected.
The location and somewhat fuzzy appearance is typical for a thin PG network of Gram-negative cells However, the cell wall layer can be detected in tomographic slices from central cell regions and particularly clearly in averaged subframes of the cell envelope Fig.
Figure 5: CET of P.
A cell wall layer between the outer and inner membrane is visible in regions where the two membranes run parallel arrowheads. The layer remains close to the outermost membrane where the inner membrane is invaginated arrow. The reconstruction is binned three times and filtered. Scale bar, nm.
The inner membrane is only imperfectly aligned because of its varying distance to the outer membrane also visible in a. Contrary to the inner and outer membrane layers, which show high electron density, typically originating from phosphate in lipid head groups, the PG layer produces less contrast.
Green: external membrane, cyan: internal membrane, red: PG layer, magenta: crateriform structures, violet: ribosomes, yellow: storage granules and white: holdfast substance.
Full size image Discussion Planctomycetes belong together with Verrucomicrobia and Chlamydiae to the PVC superphylum 32 , an unusual group of bacteria that comprise several exceptional traits Besides Chlamydiae 19 , Planctomycetes and certain Verrucomicrobia for example ref.
However, contrary to the longstanding belief, we found that Planctomycetes do possess a rigid PG cell wall. All our results are in agreement with what is known about typical constituents and features of PG from Gram-negative bacteria.
We assume that the PG sacculi completely cover the cells but can currently not exclude that local or temporary discontinuities occur. In group B, the dominant postoperative complications were prolonged hematuria and urosepsis. The rate of complications was Discussion Ureteric stone disease is known since eternity, even in the era of modern medicine, urinary stones continue to be 1 of the major diseases encountered in urologists daily practice.
Long term large upper ureteral stones may cause interruption of urinary flow and progressive backpressure on the ureter and kidneys, resulting in hydroureteronephrosis. Raboy et al. Most laparoscopic ureterolithotomies were reported as being performed with a transperitoneal approach, which carried the risk of bowel injury . Retroperitoneal approach reduces the interference of the abdominal cavity and avoids the risk of abdominal organ damage .
The groups being Group A and Group B. Patients in both the groups were comparable with respect todistribution of age, sex,mean stone size,stone side TABLE The results, on basis of,mean operative time, hospital stay in days ,success rate, stone free rate, complications and post-operative pain were analysed statistically TABLE The mean operative time in group A and B was calculated to be The difference was found to be statistically significant. The reason for difference in mean operative time between the two groups was mainly due to RPUL being more invasive procedure as compared to URSPL; thereby placement of ports and creating a retroperitoneal space in this procedure is time consuming.
Moreover this being our early experience with laparoscopic ureterolithotomy was another reason for longer operative time in RPUL group A. The mean hospital stay in days in two groups was observed to be 4. The difference was statistically significant. The reason for longer hospital stay in RPUL group was quite obvious, as the procedure involves retroperitoneal dissection, placement of drain in this space in postoperative period, thereby leading to a longer hospital stay.
The success rate of the two groups was found to be Two patients in RPUL group were converted to open due to bleed which could not be controlled laparoscopically.
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There were four failed cases in URSPL group, due to proximal migration of the stone into calyces, which could not be dealt with by rigid ureteroscope. These were subsequently posted for PCNL percutaneous nephrolithotomy. The difference was found to be statistically insignificant. Therefore, the success rate in both the groups was comparable. The stone free rates in RPUL were higher, due to stone being taken out in toto, whereas in URSPL, stone is identified and broken down using pneumatic lithotripter and then larger fragments retrieved using a forcep, leaving a chance of few significant fragments being left over.
The complication rate both intraoperative and post- operative were found out to be The difference was statistically insignificant. In Group A RPUL group two patients had uncontrolled intra-operative bleed, which warranted conversion to open ureterolithotomy. One patient developed abdominal distension in post- operative period due to gas leak into peritoneal cavity.
One patient developed post-operative urine leak from ureterotomy site. Both patients were managed conservatively and recovered completely. All patients were managed conservatively. The post-operative analgesia requirement in form of injectable and oral analgesics was calculated. The postoperative analgesia required was understandably high in RPUL group because of retroperitoneal dissection involed in the procedure and thereof longer hospital stay in this group.
The complications in both the groups were managed conservatively. Morever,there were no procedure related adverse effects or mortality in either group. Conflict of interests There was no conflict of interests.Still certain issues remain controversial and the best choice of treatment for proximal ureteral stone should be left to the practicing physician.
Both patients were managed conservatively and recovered completely. The results of this study mark Planctomycetes as second phylum after Chlamydiae 19 , in which simultaneous presence of PG and absence of the otherwise universal and essential bacterial cell division protein FtsZ was observed. The stone was extracted and removed. An indwelling double-j ureteric stent was placed through the port in selected cases as per requirement.
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