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As the name implies proven 45mg midamor, skeletal muscles attach to the skeleton and are used throughout the central nervous system for movement discount 45mg midamor with visa. Muscle fibers are cylindrical with several nuclei in each cell (which makes them multinucleated) and cross-striations throughout. Part I: Building Blocks of the Body 54 Figure 4-3: Muscle tissues: Smooth, cardiac, and skeletal. Smooth muscle cell Intercalated disc Muscle fiber Nuclei Nucleus Nuclei Illustration by Imagineering Media Services Inc. Deltoid Getting the Signal Across: Nerve Tissue There’s only one type of nerve tissue and only one primary type of cell in it: the neuron. Nerve tissue is unique in that it can both generate and conduct electrical sig- nals in the body. That process starts when sense receptors receive a stimulus that causes electrical impulses to be sent through finger-like cytoplasmic projections called Chapter 4: The Study of Tissues: Histology 55 dendrites. From there, the impulse moves through the body of the cell and into another type of cytoplasmic projection (or nerve process) called an axon that hands the signal off to the next cell down the line. The cytoplasmic projection of a neuron that carries impulses away from the cell body is called a. Smooth muscle Part I: Building Blocks of the Body 56 Answers to Questions on Histology The following are answers to the practice questions presented in this chapter. Tubules of the kidney i A tissue that’s one layer thick but appears to be multilayered and is composed of cells taller than they are wide is c. To arrive at the correct answer, consider this question one piece at a time: pseudo is “false,” stratified means “layered” (so you have “false-layered”), and columns are taller than they are wide. Knowing that the Greek word thrombos means “clot” can help you spot the correct answer in this question. Intercalated discs, as you should or will know from studying the circulatory system, are involved in conducting signals for the heart to pump. Chapter 4: The Study of Tissues: Histology 57 C Skeletal muscle tissue has prominent lines across the fiber called d. The other answer choices contain striated tissue, which technically means that they aren’t smooth. F The cytoplasmic projection of a neuron that carries impulses away from the cell body is called c. Each neuron cell usually has only one axon, although it may branch off several times. First we focus on how bones are formed before broadening the view to the axial skeleton (the parts that line up from head to toe) and the appendicular skeleton (the parts that reach out from the central axis). You review how muscles attach to that framework and watch the body take shape before wrapping this newly layered package in the body’s largest single organ: the skin. Chapter 5 A Scaffold to Build On: The Skeleton In This Chapter Getting to know your bones Keeping the axial skeleton in line Checking out the appendicular skeleton Playing with joints uman osteology, from the Greek word for “bone” (osteon) and the suffix –logy, which Hmeans “to study,” focuses on the 206 bones in the adult body endoskeleton. But it’s more than just bones; it’s also ligaments and cartilage and the joints that make the whole assembly useful. In this chapter, you get lots of practice exploring the skeletal functions and how the joints work together. Understanding Dem Bones The skeletal system as a whole serves five key functions: Protection: The skeleton encases and shields delicate internal organs that might other- wise be damaged during motion or crushed by the weight of the body itself. For exam- ple, the skull’s cranium houses the brain, and the ribs and sternum of the thoracic cage protect organs in the central body cavity. Movement: By providing anchor sites and a scaffold against which muscles can con- tract, the skeleton makes motion possible. The bones act as levers, the joints are the fulcrums, and the muscles apply the force. For instance, when the biceps muscle con- tracts, the radius and ulna bones of the forearm are lifted toward the humerus bone of the upper arm. Support: The vertebral column’s curvatures play a key role in supporting the entire body’s weight, as do the arches formed by the bones of the feet. Upper body support flows from the clavicle, or collarbone, which is the only bone that attaches the upper extremities to the axial skeleton and the only horizontal long bone in the human body. Mineral storage: Calcium, phosphorous, and other minerals like magnesium must be maintained in the bloodstream at a constant level, so they’re “banked” in the bones in case the dietary intake of those minerals drops. The bones’ mineral content is con- stantly renewed, refreshing entirely about every nine months. Blood cell formation: Called hemopoiesis or hematopoiesis, most blood cell formation takes place within the red marrow inside the ends of long bones as well as within the ver- tebrae, ribs, sternum, and cranial bones. Marrow produces three types of blood cells: erythrocytes (red cells), leukocytes (white cells), and thrombocytes (platelets). Most of these are formed in red bone marrow, although some types of white blood cells are pro- duced in fat-rich yellow bone marrow. In cases of severe blood loss, the body can convert yellow marrow back to red marrow in order to increase blood cell production. If you hesitated to choose “all of hemostasis, which is the stoppage the above,” ask yourself this: If you of bleeding or blood flow.

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This leads to inflammation of the bladder (cystitis) and unpleasant urinary B symptoms purchase 45mg midamor. If a bladder infection is not treated properly order 45 mg midamor, it can spread to the kidneys and become very serious. This is often due to a structural abnormality in the urethra or bladder affecting the flow of urine. Infections of the bladder are the second most common infection in women and the most common complication of pregnancy. When urine is left to stagnate in the bladder, the risk of developing infec- tion increases. While necessary, there are various drawbacks to the use of antibiotics, including side effects such as diarrhea, stomach upset, and yeast overgrowth. Overuse of anti- biotics causes resistance—the bugs become stronger than the drugs, leaving people vulnerable to attack by bacteria. To relieve the pain and burning, a drug called phenazopyridine (Pyridium) may be prescribed. This is given for two to three days; it contains a dye and will cause discolouration of the urine and feces. Dietary Recommendations Foods to include: • Drink eight or more glasses of water daily to help flush bacteria out of your bladder. You can sweeten it with stevia, which is a natural, low-calorie plant-based sweetener. Juice cocktails are an alternative that offer better taste and toler- ability, but contain less juice and have added sugar; drink three 16 oz. Foods to avoid: • Caffeine has diuretic properties, which promote fluid loss, making the urine more concen- trated. Wear cotton un- derwear, which allows the skin to breathe; change clothing promptly after swimming. Top Recommended Supplements Cran-Max: Studies show that it prevents bladder infections and may also be effective in treating early bladder infections if taken at the first sign of symptoms. Vitamin C: Acidifies urine, making it more difficult for bacteria to grow; inhibits the growth of E. Complementary Supplements Oil of oregano: Has antibacterial properties, and is available in capsules or liquid. Probiotics: Support immune function, help fight off infections, and are essential for those on antibiotics because they restore the friendly bacteria destroyed by antibiotics. Acute bronchitis most commonly occurs follow- ing a respiratory infection, such as a cold or flu. It can also develop due to exposure to cigarette smoke or pollution, or in those who have gastroesophageal reflux disease due to backflow of acids into the lungs. Acute bronchitis caused by a viral infection B often clears up on its own in a week or two without lasting effects. Long-term exposure to lung irritants (particularly cigarette smoke) can lead to continual inflammation and thickening of the lining of your bronchial tubes, which is called chronic bronchitis. People with chronic bronchitis have a persistent productive cough and shortness of breath. If you have a cold or flu and symptoms persist beyond a few weeks, consult with your doctor. Those with chronic bronchitis who smoke are at increased risk of lung cancer above and beyond the normal risk that a smoker faces. Since most cases of acute bronchitis are caused by a viral infection, antibiotics offer little benefit unless your doctor suspects a bacte- rial infection or you are at risk of this. Taking an antibiotic when not necessary can lead to resistance and secondary infections, such as thrush, yeast, and urinary tract B infections, so it is important to ask your doctor if antibiotics are necessary if one is prescribed. Cough suppressants are not recommended because coughing helps the lungs remove irritants. However, if your cough disrupts your sleep, then you may want to take a cough medicine at bedtime. For severe cases of bronchitis, your doctor may prescribe an inhaler to reduce inflammation and help you breathe. Herbal teas, such as Throat Coat, which contains marshmallow and licorice, can help relieve sore throat. Studies have shown that increasing fruit and vegetable consumption may reduce the risk of developing bronchitis. Researchers at Harvard did a study of 2,112 teenagers and found an association between good lung function and levels of dietary intake of fruit and fish rich in omega-3 fatty acids. Teens who ate less of these foods (two servings of fruit per week and less than 22 mg of omega-3 fatty acids per day) had higher rates of asthma, wheezing, and symptoms of chronic bronchitis such as cough and phlegm (Chest, 2007: 132; 238–245). Some practitioners feel that dairy products can increase mucus formation, and that people with bronchitis should minimize these foods. Avoid adding sugar to foods and minimize high- sugar foods (candy, soft drinks, and sweets).

Milk is weakly acidic 45 mg midamor free shipping, so drugs that are weak bases are concentrated in breast milk by trapping of Key points the charged form of the drug (compare with renal elimination; At birth order midamor 45mg fast delivery, renal and hepatic function are less efficient than see Chapter 6). Drug effects may be prolonged and the fetus in breast milk is seldom clinically appreciable, accumulation may occur. These factors are exaggerated in although some drugs are contraindicated (Table 10. Appendix 5 of the British National Formulary provides very helpful practical advice. Carbimazole should also on why it is being prescribed, for how long the treat- be prescribed at its lowest effective dose to reduce the risk ment should continue and whether any adverse effects are of hypothyroidism in the neonate/infant. There is a theoretical risk of Reye’s syndrome if aspirin is prescribed to the breast-feeding Case history mother. Warfarin is not contraindicated during breast-feed- A two-year-old epileptic child is seen in the Accident and ing. The more experi- enced medical staff are dealing with emergencies else- where in the hospital. Children under the age of five years may have diffi- Even after adjustment of dose according to surface area, culty in swallowing even small tablets, and hence oral calculation of the correct dose must consider the relatively preparations which taste pleasant are often necessary to large volume of distribution of polar drugs in the first four improve compliance. Liquid preparations are given by means months of life, the immature microsomal enzymes and of a graduated syringe. The British National Formulary and containing elixirs encourages tooth cavities and gingivitis. With a few notable exceptions, drugs in children generally Only in unusual circumstances, i. Of par- application (especially to inflamed or broken skin), or in ticular significance is the potential of chronic corticosteroid infants, does systemic absorption of drugs (e. Intravenous therapy is less painful, but of unknown aetiology consisting of hepatic necrosis and skill is required to cannulate infants’ veins (and a confident encephalopathy, often in the aftermath of a viral illness. Children find intravenous Tetracyclines are deposited in growing bone and teeth, caus- infusions uncomfortable and restrictive. Rectal administration ing staining and occasionally dental hypoplasia, and should (see Chapter 4) is a convenient alternative (e. Dystonias with meto- valuable in the treatment of status epilepticus when intra- clopramide occur more frequently in children and young venous access is often difficult. Rectal administration should also be increased in young children with learning difficulties receiv- considered if the child is vomiting. On examina- tion, he has a mild fever (38°C), bilateral swollen cervical lymph nodes and bilateral wheeze. Not What is the likely cause of the nocturnal cough and how only is there concern about the potential for adverse effects may this be treated? Answer 1 of new drugs on those who are growing and developing Ampicillin rash in infectious mononucleosis (glandular fever). Pharmaceutical companies seldom seek to license their products for use in Baber N, Pritchard D. When drugs are prescribed to children that are Clinical Pharmacology 2003; 56: 489–93. Prescribers take sole responsibility for prescribing disposition, action and therapy in infants and children. The elderly are subject to a variety of complaints, many of which are Absorption of carbohydrates and of several nutrients, includ- chronic and incapacitating, and so they receive a great deal of ing iron, calcium and thiamine, is reduced in elderly people. There is a growing evidence base for the use of Lipid-soluble drugs are absorbed by simple diffusion down drugs in elderly patients, with important implications for pre- the concentration gradient (Chapter 3), and this is not scribing of many important classes of drugs, including statins, impaired by age. However, age per se does not affect drug angiotensin receptor blockers, vitamin D and bisphosphonates absorption to a large extent (Figure 11. Adverse drug reactions and drug interactions become more common with Drug increasing age. In one survey in general ↓Intestinal blood flow practice, 87% of patients over 75 years of age were on regular drug therapy, with 34% taking three to four Absorption↔ different drugs daily. The most commonly prescribed drugs were diuretics (34% of patients), analgesics (27%), ↓Weight tranquillizers and antidepressants (24%), hypnotics (22%) ↓Lean body mass and digoxin (20%). All of these are associated with a high ↑Fat ↓Hepatic blood flow incidence of important adverse effects. Drug elimination becomes less efficient with increasing ↓Concentration of age, leading to drug accumulation during chronic dosing. Homeostatic mechanisms become less effective with water-soluble drugs advancing age, so individuals are less able to compensate for adverse effects, such as unsteadiness or postural Metabolism↓ hypotension. The central nervous system becomes more sensitive to the actions of sedative drugs. Increasing age produces changes in the immune response ↓Renal blood flow Excretion↓ that can cause an increased liability to allergic reactions. Impaired cognition combined with relatively complex dose regimens may lead to inadvertent overdose. Although diazepam and lidocaine, whereas the distribution of polar glomerular filtration rate declines with age, this is not necessar- drugs such as digoxin is reduced compared to younger adults.

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Sepsis Sepsis rates increased by 137 per cent between 1984–94 (Bone 1994) purchase 45 mg midamor visa, largely due to escalating risks from: ■ increasingly invasive techniques ■ improved survival from simpler pathologies increasing immunocompromise ■ ageing populations (immunity is impaired with age) ■ greater use of immunosuppressive therapy (including steroids) ■ more resistant organisms buy cheap midamor 45mg. Mortality The 1909 mortality rate from sepsis of 41 per cent remains essentially unchanged today (Ellis 1995), a stark (if alarmist) reminder of the problems and limits facing medicine. Shock 259 Pathology Bacteria initiate sepsis, but shock is a problem of inflammatory response rather than bacterial invasion so that treatment should limit excessive inflammatory responses (Deitch 1995). Cell membrane damage (from microorganisms and inflammation) release vasoactive mediators (e. As inflammation becomes systemic, inflammatory responses throughout the body cause ■ total body vasodilation ■ grossly increased intravascular space ■ increased capillary permeability with extravasation of plasma into tissues, oedema formation, hypovolaemia, hypoperfusion and generalised tissue hypoxia. Many chemical mediators also depress myocardial function, further reducing systemic blood pressure. Local vasoconstrictive mediators unsuccessfully attempt to compensate, making peripheries cold and cyanosed. Fluid resuscitation with colloids (see Chapter 33) should therefore restore colloid osmotic and perfusion pressures, without compounding interstitial oedema. Exogenous albumin only temporarily increases serum albumin, so that endogenous production (through adequate nutrition) should be promoted. Shoemaker and Beez (1996) suggest that mortality correlates with oxygen debt, and so treatment to reverse oxygen debt improves survival prospects. Oxygen debt, the difference between oxygen demand and oxygen delivery, cannot be measured directly, but Shoemaker et al. Phospholipidase is activated by endotoxin, which then triggers the platelet activating factor (Clarke 1997). Implications for practice ■ severe shock necessitates close haemodynamic monitoring and observation Shock 261 ■ where possible, underlying causes of shock should be removed (e. Reviews of particular types of shock, such as Visser and Purday’s (1998) article on cardiogenic shock, appear periodically. Clinical scenario Brian Geller is a 62-year-old man, who was originally admitted to hospital with severe abdominal pain from ruptured gastric and duodenal ulcers. He admits to smoking more than 20 cigarettes and drinking over half a bottle of spirits per day. Surgery was performed and Mr Geller was recovering when he developed a chest infection. Review treatment goals and justify choice of: Invasive ventilation (mode, rates, volumes, etc. The syndrome is largely a creation of the success of intensive care: within living memory single failure of a major organ was usually terminal. The treatment and support of each organ and system follow those described in previous chapters, and so are not repeated here. Instead, this chapter provides a synthesis of progressive pathology, prognosis and issues specific to the syndrome as a whole, rather than the individual parts discussed elsewhere. The syndrome extends problems originating at cellular level, complex interactions of mediators creating a range of (sometimes contradictory) effects. Lack of consensus about both terms and interpretation hinders comparison; for example, prognosis is considerably better for failure of two rather than four major organs. However caused, gross ischaemia causes hypoxia, anaerobic metabolism and failure of most or all organs. Cytokines (especially tumour necrosis factor and interleukin 1) trigger hyperglycaemia and extreme protein catabolism (‘autocannibalism’) (Beal & Cerra 1994). As mitochondria develop abnormalities, energy production is severely impaired (Tan & Oh 1997b), leading to cell failure. Widespread cell failure impairs healing, exposing patients to further nosocomial infection (Tan & Oh 1997b). The liver, being especially rich in xanthine oxidase (Davidson & Boom 1995), is particularly prone to ischaemic damage. Systemic hypotension and hypoperfusion leads to hepatic and respiratory failure and renal failure, often (but not always) in that order. The lack of support for Shoemaker’s use of supranormal treatments is discussed in Chapter 25. Infection rates from central lines are far higher than from peripheral lines; sicker patients have more central lines, and so the risk to critically ill patients may not reflect the much cited sevenfold from peripheral versus ninetyfold from central lines. However, the transfer of drugs that can be given peripherally may enable removal of a central line, or the removal of an unused peripheral line, which may significantly reduce infection risks. Critically ill patients have low antioxidant levels (especially vitamins C and E) (Davidson & Boom 1995). Giving vitamin E, the most important intracellular chain-breaking antioxidant (Davidson & Boom 1995), appears particularly beneficial. Other antioxidants that may Multiorgan dysfunction syndrome 265 prove useful include intracellular glutathione (Davidson & Boom 1995) and enzymes such as cytosolic superoxide dismutase (which includes zinc, long used for skin healing).

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