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The superior vena cava drains blood from regions superior to the diaphragm: the head discount 20mg protonix otc, neck discount protonix 20mg online, upper limbs discount protonix 40 mg otc, and the thoracic region purchase 40 mg protonix amex. The inferior vena cava drains blood from areas inferior to the diaphragm: the lower limbs and abdominopelvic region of the body order protonix 40 mg mastercard. It, too, empties into the posterior portion of the atria, but inferior to the opening of the superior vena cava. Immediately superior and slightly medial to the opening of the inferior vena cava on the posterior surface of the atrium is the opening of the coronary sinus. The majority of the internal heart structures discussed in this and subsequent sections are illustrated in Figure 19. While the bulk of the internal surface of the right atrium is smooth, the depression of the fossa ovalis is medial, and the anterior surface demonstrates prominent ridges of muscle called the pectinate muscles. The atria receive venous blood on a nearly continuous basis, preventing venous flow from stopping while the ventricles are contracting. While most ventricular filling occurs while the atria are relaxed, they do demonstrate a contractile phase and actively pump blood into the ventricles just prior to ventricular contraction. Each flap of the valve is attached to strong strands of connective tissue, the chordae tendineae, literally “tendinous cords,” or sometimes more poetically referred to as “heart strings. They are composed of approximately 80 percent collagenous fibers with the remainder consisting of elastic fibers and endothelium. They connect each of the flaps to a papillary muscle that extends from the inferior ventricular surface. There are three papillary muscles in the right ventricle, called the anterior, posterior, and septal muscles, which correspond to the three sections of the valves. Blood, like any fluid, flows 836 Chapter 19 | The Cardiovascular System: The Heart from higher pressure to lower pressure areas, in this case, toward the pulmonary trunk and the atrium. To prevent any potential backflow, the papillary muscles also contract, generating tension on the chordae tendineae. This prevents the flaps of the valves from being forced into the atria and regurgitation of the blood back into the atria during ventricular contraction. In addition to these muscular ridges, a band of cardiac muscle, also covered by endocardium, known as the moderator band (see Figure 19. It arises from the inferior portion of the interventricular septum and crosses the interior space of the right ventricle to connect with the inferior papillary muscle. When the right ventricle contracts, it ejects blood into the pulmonary trunk, which branches into the left and right pulmonary arteries that carry it to each lung. At the base of the pulmonary trunk is the pulmonary semilunar valve that prevents backflow from the pulmonary trunk. Left Atrium After exchange of gases in the pulmonary capillaries, blood returns to the left atrium high in oxygen via one of the four pulmonary veins. While the left atrium does not contain pectinate muscles, it does have an auricle that includes these pectinate ridges. Blood flows nearly continuously from the pulmonary veins back into the atrium, which acts as the receiving chamber, and from here through an opening into the left ventricle. Most blood flows passively into the heart while both the atria and ventricles are relaxed, but toward the end of the ventricular relaxation period, the left atrium will contract, pumping blood into the ventricle. Left Ventricle Recall that, although both sides of the heart will pump the same amount of blood, the muscular layer is much thicker in the left ventricle compared to the right (see Figure 19. There are two papillary muscles on the left—the anterior and posterior—as opposed to three on the right. The left ventricle is the major pumping chamber for the systemic circuit; it ejects blood into the aorta through the aortic semilunar valve. Heart Valve Structure and Function A transverse section through the heart slightly above the level of the atrioventricular septum reveals all four heart valves along the same plane (Figure 19. It typically consists of three flaps, or leaflets, made of endocardium reinforced with additional connective tissue. The flaps are connected by chordae tendineae to the papillary muscles, which control the opening and closing of the valves.

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However safe 40 mg protonix, due to the demands of the tissues and organs buy cheap protonix 20mg on-line, blood glucose levels must be maintained in the normal range of 80–120 mg/ dL buy protonix 20 mg. In response to a drop in blood glucose concentration order 40 mg protonix, the hormone glucagon is released from the alpha cells of the pancreas protonix 20 mg otc. Glucagon acts upon the liver cells, where it inhibits the synthesis of glycogen and stimulates the breakdown of This OpenStax book is available for free at http://cnx. Gluconeogenesis will also begin in the liver to replace the glucose that has been used by the peripheral tissues. After ingestion of food, fats and proteins are processed as described previously; however, the glucose processing changes a bit. The gluconeogenesis that has been ongoing in the liver will continue after fasting to replace the glycogen stores that were depleted in the liver. After these stores have been replenished, excess glucose that is absorbed by the liver will be converted into triglycerides and fatty acids for long-term storage. Starvation When the body is deprived of nourishment for an extended period of time, it goes into “survival mode. Therefore, the body uses ketones to satisfy the energy needs of the brain and other glucose-dependent organs, and to maintain proteins in the cells (see Figure 24. Because glucose levels are very low during starvation, glycolysis will shut off in cells that can use alternative fuels. Pyruvate, lactate, and alanine from muscle cells are not converted into acetyl CoA and used in the Krebs cycle, but are exported to the liver to be used in the synthesis of glucose. As starvation continues, and more glucose is needed, glycerol from fatty acids can be liberated and used as a source for gluconeogenesis. After several days of starvation, ketone bodies become the major source of fuel for the heart and other organs. Once these stores are fully depleted, proteins from muscles are released and broken down for glucose synthesis. The hypothalamus in the brain is the master switch that works as a thermostat to regulate the body’s core temperature (Figure 24. These include increasing the circulation of the blood to the surface of the body to allow for the dissipation of heat through the skin and initiation of sweating to allow evaporation of water on the skin to cool its surface. Conversely, if the temperature falls below the set core temperature, the hypothalamus can initiate shivering to generate heat. In addition, thyroid hormone will stimulate more energy use and heat production by cells throughout the body. An environment is said to be thermoneutral when the body does not expend or release energy to maintain its core temperature. If the temperature is higher, for example, when wearing clothes, the body compensates with cooling mechanisms. Each of these mechanisms relies on the property of heat to flow from a higher concentration to a lower concentration; therefore, each of the mechanisms of heat exchange varies in rate according to the temperature and conditions of the environment. For example, when holding a glass of ice water, the heat from your skin will warm the glass and in turn melt the ice. Alternatively, on a cold day, you might warm up by wrapping your cold hands around a hot mug of coffee. When the water temperature is lower than the body’s temperature, the body loses heat by warming the water closest to the skin, which moves away to be replaced by cooler water. The convection currents created by the temperature changes continue to draw heat away from the body more quickly than the body can replace it, resulting in hyperthermia. Because it takes a great deal of energy for a water molecule to change from a liquid to a gas, evaporating water (in the form of sweat) takes with it a great deal of energy from the skin. However, the rate at which evaporation occurs depends on relative humidity—more sweat evaporates in lower humidity environments. Sweating is the primary means of cooling the body during exercise, whereas at rest, about 20 percent of the heat lost by the body occurs through evaporation. Metabolic Rate The metabolic rate is the amount of energy consumed minus the amount of energy expended by the body.

Outcome data also are subjective and assure compliance with written procedures for vary according to the setting and the particular evaluating admissions cheap protonix 40mg visa, continued care and instruments used to measure them discount protonix 20 mg visa. Given these discharges discount 20 mg protonix amex; linking treatment plans to barriers buy 20 mg protonix fast delivery, quality assurance efforts tend to focus established goals generic protonix 40mg with amex; clinical record keeping; and on the process of care, which examines the requiring that the group of professionals within frequency with which interventions known to the program or facility that develops patient care correlate with positive outcomes are policies review and act upon recommendations 209 210 performed. State The federal regulations for opioid maintenance quality assurance requirements for addiction therapy programs require continual quality treatment programs and facilities are highly assurance measures which must include ongoing variable and focus mainly on process. For assessment of patient outcomes (not specified) example, a program that is run efficiently and and annual review of program policies and 211 maintains good records would be considered a procedures. In although this may take the form of simply order to fulfill their requirements under the Act, requiring the establishment of a quality each federal agency must develop a strategic improvement plan. Fewer than half of these plan (including annual performance targets) states (21 states) have explicit requirements that covering each of their programs, conduct patient outcome data be collected but, even for evaluations to assess how well a program is those that do, the types of data required rarely working and why particular outcomes have (or are specified. Four of the states that require the have not) been achieved and produce program collection of patient outcome data have performance reports based on analyses of 212 explicitly-defined categories of such data, but program effectiveness. The absence of funds state prevention, treatment, recovery other indicators linked to improved health and -196- * 213 supports and other services. Programs must analyze patient outcomes--including abstinence; reduction in relapse, criminal activity and hospitalizations; improved psychological function; housing situation; employment status-- 216 to determine the effectiveness of services. Joint Commission standards for addiction treatment facilities and programs focus more on performance improvement measures by requiring programs to conduct data collection and data analysis and to identify any opportunities for improving performance (e. Only opioid maintenance therapy programs are required specifically to collect outcome data, which include measures of the use of illicit opioids, criminal involvement, health status, 217 retention in treatment and abstinence. Providing quality care to identify and reduce risky use and diagnose, treat and manage addiction requires a critical shift to science- based interventions and treatment by medical professionals--both primary care providers and specialists. Significant barriers stand in the way of making this critical shift, including an addiction treatment workforce that is largely unqualified to implement evidence-based practices; a health professional that should be responsible for providing addiction screening, interventions, treatment and management but does not implement evidence-based addiction care practices; inadequate oversight and quality assurance of treatment providers and intervention practices; limited advances in the development of pharmaceutical treatments; and a lack of adequate insurance coverage. Recent efforts by government agencies and professional associations have begun to tackle these challenges to closing the evidence-practice gap, but are insufficient. Instead, Patient Education, Screening, Brief risky users of addictive substances are in most Interventions and Treatment Referrals cases sanctioned in terms of the consequences that result--such as accidents, crimes, domestic Despite the documented benefits of screening violence, child neglect or abuse--while effective * and early intervention practices, medical and interventions to reduce risky use rarely are other health professionals’ considerable provided. Those with addiction frequently are potential to influence patients’ substance use referred to support services, often provided by decisions, and the long list of professional health similarly-diagnosed peers who struggle with organizations that endorse the use of such limited resources and no medical training, to activities, most health professionals do not assist them in abstaining from using addictive educate their patients about the dangers of risky substances. While social support approaches are substance use or the disease of addiction, screen helpful and even lifesaving to many--and can be for risky substance use, conduct brief important supplements to medically-supervised, interventions when indicated, treat the condition evidence-based interventions--they do not or refer their patients to specialty care if qualify as treatment for a medical disease. Based on those principles, risky current approaches is required to bring practice substance use and signs of addiction are highly in line with the evidence and with the standard conducive to screening by general health of care for other public health and medical practitioners: they are significant health conditions. Unfortunately, there is a addictive substances and provide brief considerable gap between what current science interventions, physicians should be essential suggests constitutes risky substance use and the providers of the full range of addiction treatment thresholds set in some of the most common services. There are many venues where health identify, intervene and treat it, continued failure professionals can conduct patient education, to do so signals widespread system failure in screening and brief interventions with relative health care service delivery, financing, ease and most patients would be receptive to professional education and quality assurance. These include primary care This gap between evidence and practice is medical offices, dental offices, pharmacies, particularly acute for adolescents because of the school-based health clinics, mental health critical importance of prevention and early centers and clinics, emergency departments and intervention in this population. Screening and trauma centers, hospitals or encounters with the intervention services by health professionals for justice system due to substance-involved adolescents rarely is part of routine practice 7 crimes. A survey th- th patients about their substance use when they of 6 through 12 -grade students found that 9 suspect a patient has a problem. This asymptomatic patients in clinical settings contrasts significantly with referrals to other estimates that only 35 percent of the population specialists wherein the treatment is regularly communicated and a collaborative relationship is receives tobacco screening and brief 10 interventions in accordance with the maintained. Mistaking symptoms of risky who quit smoking in the past year for six months or substance use for signs of other conditions may longer) had made a quit attempt that lasted longer lead to a misdiagnosis or to prescribing than one day in the past year; however, only 6. Another national survey of their patients’ smoking status at 68 percent of of nurses’ interventions with patients who † 24 office visits, they provided smoking cessation smoke found similar results. A promulgated widely by the United States Public national survey of medical professionals-- Health Service and the Agency for Healthcare including primary care physicians, emergency Research and Quality, approximately three in 10 medicine physicians, psychiatrists, registered dental professionals still do not advise patients nurses, dentists, dental hygienists and who smoke to quit and approximately three- pharmacists--indicates that whereas most report quarters do not refer a patient who smokes to a 26 asking patients if they smoke and advising those smoking cessation program. This is despite the who smoke to quit, they are much less likely to fact that many patients expect their dentists to follow through with assessments or referrals to a inquire about their smoking status and to discuss 19 smoking cessation program. Although most cessation intervention can expect that up to 10 to (86 percent) report asking patients about their 15 percent of their patients who smoke will quit 28 smoking and advising them to quit, few do much in a given year. This is in spite pulmonologists, cardiologists and family of the facts that pharmacists are one of the most physicians were the physician specialists most accessible groups of health professionals and likely to be familiar with resources regarding they work in settings frequented by smokers and 30 treatment for addiction involving nicotine and where tobacco cessation products are available. Only 24 percent of nurses recommended medications to patients for cessation, * Both female patients and patients ages 65 and older 22 percent referred patients to cessation resources were less likely to be prescribed medication. While behind the pharmacy counter where customers respondents ages 18-25 years were most likely would have to ask for them, or within view of to engage in excessive drinking, they were least * the pharmacist but accessible to customers, is likely to be asked about their alcohol use (34 related to a greater likelihood of pharmacist- percent of excessive drinkers ages 18 to 25 years initiated smoking cessation counseling. The American customers were three times likelier to offer College of Surgeons Committee on Trauma counseling than those who stored them out of designated alcohol and other drug screening as 33 customers’ sight.

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