By I. Goose. Emmanuel College. 2018.

The thermal conductivity of water is also high cheap nimotop 30mg with mastercard, thereby facil- itating heat dissipation from high energy-using areas such as the brain into the blood and the total body water pool buy cheap nimotop 30 mg online. Its heat capacity and heat of vaporization are remarkably high purchase 30mg nimotop free shipping; as liquid water is converted to a gas and evaporates from the 44 SECTION TWO / CHEMICAL AND BIOLOGICAL FOUNDATIONS OF BIOCHEMISTRY Table 4 generic 30mg nimotop overnight delivery. Distribution of ions in body skin nimotop 30 mg on line, we feel a cooling effect. Water responds to the input of heat by decreasing fluids. Electrolytes K 4 150 Anions Both extracellular fluid (ECF) and intracellular fluid (ICF) contain electrolytes, a Cl 105 5 general term applied to bicarbonate and inorganic anions and cations. The elec- HCO3 25 12 Inorganic 2 100 trolytes are unevenly distributed between compartments; Na and Cl are the major Phosphate electrolytes in the ECF (plasma and interstitial fluid), and K and phosphates such 2 *The content of inorganic ions is very similar in as HPO4 are the major electrolytes in cells (Table 4. Osmolality and Water Movement was rehydrated with intravenous Water distributes between the different fluid compartments according to the con- saline, which is a solution of 0. The semipermeable cellular membrane that separates the extracellular and Di Abietes has an osmotic diuresis. Likewise, water can freely move and ketone bodies are so high, these through the capillaries separating the interstitial fluid and the plasma. As a result, compounds are passing from the blood into water will move from a compartment with a low concentration of solutes (lower the glomerular filtrate in the kidneys and then osmolality) to one with a higher concentration to achieve an equal osmolality on into the urine. As a consequence of the high both sides of the membrane. The force it would take to keep the same amount of osmolality of the glomerular filtrate, much water on both sides of the membrane is called the osmotic pressure. Thus, Di has polyuria (increased urine another to maintain a nearly constant osmolality. As a result of water lost from the blood into the urine, water passes from of dissolved negatively charged proteins and the electrolytes needed to balance inside cells into the interstitial space and into these charges. As water is passed from the blood into the urine to balance the excre- the blood, resulting in an intracellular dehy- tion of ions, the blood volume is repleted with water from interstitial fluid. The dehydrated cells in the brain are the osmolality of the blood and interstitial fluid is too high, water moves out of the unable to carry out their normal functions. The loss of cellular water also can occur in hyperglycemia, because the high As a result, Di is in a coma. ACIDS AND BASES Acids are compounds that donate a hydrogen ion (H ) to a solution, and bases are compounds (such as the OH ion) that accept hydrogen ions. Water itself dissociates + – H2 + OH to a slight extent, generating hydrogen ions (H ), which are also called protons, and hydroxide ions (OH )(Fig. The laboratory reported that Di Abietes’ blood pH was 7. The concentration of hydrogen ions in a solution is usually denoted by the term pH, which is the negative log10 of the hydrogen ion concentration expressed in mol/L (Equation 4. The dissociation constant for water, Kd, expresses the relationship between the hydrogen ion concentration [H ], the hydroxide ion concentration [OH ], pH log [H ] CHAPTER 4 / WATER, ACIDS, BASES, AND BUFFERS 45 and the concentration of water [H2O] at equilibrium (Equation 4. Because K , the product of [H ] and [OH ], is w w Equation 4. A pH of 7 is termed neutral because [H ] and [OH ] are equal. The K acid have a greater hydrogen ion concentration and a lower hydroxide ion concentration For the reaction HA 4 A H than pure water (pH 7. Strong and Weak Acids During metabolism, the body produces a number of acids that increase the hydrogen ion concentration of the blood or other body fluids and tend to lower the pH (Table 4. These metabolically important acids can be classified as 0. NaCl has a molecular weight of 58 g/mole, so and a base (the anion component). Inorganic acids such as sulfuric acid (H2SO4) the concentration of NaCl in isotonic saline and hydrochloric acid (HCl) are strong acids that dissociate completely in solu- is 0. In general, a weak acid (HA), called the con- NaCl is not completely dissociated and some jugate acid, dissociates into a hydrogen ion and an anionic component (A ), of the hydration shells surround undissoci- called the conjugate base. The name of an undissociated acid usually ends in “ic ated NaCl molecules, the osmolality of iso- acid” (e.

Interorgan amino acid exchange after an overnight fast generic 30mg nimotop with visa. After an overnight fast (the postabsorptive state) purchase 30 mg nimotop free shipping, the utilization of amino acids for protein synthesis nimotop 30 mg visa, for fuels buy generic nimotop 30 mg line, and for the synthesis of essential functional compounds continues 30mg nimotop sale. The free amino acid pool is supported largely by net degradation of skeletal muscle protein. Glutamine and alanine serve as amino group carriers from skeletal muscle to other tissues. Glut- amine brings NH to the kidney for the excretion of protons and serves as a fuel for the kidney, gut, and cells of the immune system. Alanine 4 transfers amino groups from skeletal muscle, the kidney, and the gut to the liver, where they are converted to urea for excretion. The brain con- tinues to use amino acids for neurotransmitter synthesis. Amino acid release from human forearm Composition of average protein 25 20 15 10 5 0 Alanine Glutamine Branched- chain amino acids Fig. The arteriovenous difference (concentration in arterial blood minus the concentration in venous blood) across the human forearm has been measured for many amino acids. This graph compares the amount of alanine, glutamine, and BCAA released with their composition in the average protein. Alanine and glutamine represent a much higher percentage of total nitrogen released than originally present in the degraded protein, evidence that they are being synthesized in the skeletal muscle. The BCAA (leucine, valine, and isoleucine) are released in much lower amounts than those present in the degraded protein, evidence that they are being catabolized. Aspartate and glutamate also contribute nitrogen to the formation of alanine and glutamine 766 SECTION SEVEN / NITROGEN METABOLISM Glucose -keto acids, and some glutamine from the blood. Alanine and other amino acids are oxidized and their carbon skeletons converted principally to glucose. Glucagon and + glucocorticoids stimulate the uptake of amino acids into liver and increase gluconeo- Gluconeogenesis Glucagon genesis and ureagenesis (Fig. Alanine transport into the liver, in particular, is Carbon enhanced by glucagon. The induction of the synthesis of gluconeogenic enzymes by skeletons Urea glucagon and glucocorticoids during the overnight fast correlates with an induction of + Urea NH4 cycle many of the enzymes of amino acid degradation (e. Urea synthesis also increases Amino acid because of the increased supply of NH4 from amino acid degradation in the liver. METABOLISM OF AMINO ACIDS IN OTHER TISSUES DURING FASTING Alanine, other amino acids Glucose, produced by the liver, is used for energy by the brain and other glucose- dependent tissues, such as erythrocytes. Hormonal regulation of hepatic amino acid metabolism in the postabsorptive when the AMP-activated protein kinase is active, also oxidizes some of this glucose state. Circled glucagon-mediated activa- to pyruvate, which is used for the carbon skeleton of alanine (the glucose-alanine tion of enzymes or proteins; circled c induc- cycle; see Chapter 38). Induction of the lungs and brain for the removal of NH4 formed from amino acid catabolism urea cycle enzymes occurs both during fasting or entering from the blood. The kidney, the gut, and cells with rapid turnover rates and after a high-protein meal. Because many such as those of the immune system are the major sites of glutamine uptake (see individuals in the United States normally have Fig. Glutamine serves as a fuel for these tissues, as a nitrogen donor for a high-protein diet, the levels of urea cycle purine synthesis, and as a substrate for ammoniagenesis in the kidney. Much of enzymes may not fluctuate to any great extent. Alanine then carries the unused nitrogen back to the liver. The brain is glucose dependent, but, like many cells in the body, can use BCAA for energy. The BCAA also provide a source of nitrogen for neurotransmitter syn- The body normally produces thesis during fasting. Other amino acids released from skeletal muscle protein approximately 1 mmol of protons per kilogram of body weight per degradation also serve as precursors of neurotransmitters.

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The parents’ usual response to the physician is buy nimotop 30 mg online, “You wrote the prescription cheap 30 mg nimotop mastercard, so the school has to do what you said cheap nimotop 30 mg otc. In general order nimotop 30mg overnight delivery, a child with this level of motor function probably has more long-term side effects from therapy than benefits purchase 30mg nimotop with visa, especially if the therapy interferes with any academic classroom work. In this situation, the parents need to be educated and the school decision needs to be reinforced with the parents. The opposite example occurs with a middle school child with severe quadriplegia, who has made no motor gains over several years, and the school IEP plans to maintain motor function with classroom activities pro- vided by a teacher and a schoolroom teacher’s aide. The educator believes that the focus of the this child’s educational goals should be teaching him to use augmentative communication. These are difficult subjective decisions and the orthopaedist may find himself siding with the parents; however, an aggressive response by letter or phone call will not help the parents’ position because it will only give the school administration physical evidence that this need is medical rehabilita- tion. It is much more helpful for the orthopaedist to recognize that this is an educational decision, and offer the parents and school additional data as a way of helping the school and parents negotiate the disagreement. This ne- gotiation will be more profitable with this approach than getting involved with a litigation. Another major area where prescription need arises is obtaining adaptive equipment. All adaptive equipment purchased through medical reimburse- ment sources, such as private insurance or Medicaid, must include a medical prescription and usually a letter of medical need. Examples include orthotics, wheelchairs, and standers. If devices are purchased with educational dollars, no prescriptions are needed; these would typically include writing desks and computers used as augmentative writing devices. Many devices fall in be- tween, such as augmentative communication, classroom standers, and floor positioning devices. The specifics of who pays for what may be negotiated at the state level between agencies, or in other states, debated at length, often to the major advantage only of the legal profession. Physician–Educator Relationship In almost all school environments in special education, administrators really try to provide the best services for the children in their care. A major con- straint many special education systems work under is poor funding; how- ever, cost may not legally be considered in determining what children need. The pediatric orthopaedist can be very helpful to further a child’s education by providing documentation and perscriptions for the required services but at the same time must have a clear understanding of their limited role in determining the child’s program. Annual visits to special schools are very beneficial to both the educator and the medical care provider. This kind of interaction helps both to understand the different environments, and it is helpful to have time for face-to-face conversation. The professionals in the educational system are very interested in staying up to date on advancing medical practice. Parents often ask for medical advice from the educational staff, just as parents ask educational questions from the medical staff. This kind of bilateral educational and communication process between the sys- tems can only help children and families in the overall goal of allowing them to become all they can be. Therapy, Education, and Other Treatment Modalities 171 Inclusive Education The special education legislation currently requires that these children be educated in the least restrictive environment. The goal of this education is to encourage placement of these children in classrooms with their peers when- ever possible. Because this is a very active current issue, parents frequently want to enlist the help or opinion of their orthopaedist. For many children, the correct placement is clear; for example, a child with ambulatory diplegia and good cognitive function should be in a regular classroom with their age- matched peers. Also, it is clear that a child who requires frequent nursing attention because of respiratory dysfunction and has no recognized accessible cognitive function is not served well in a standard classroom. This child also becomes a distraction to other children in the room who are trying to learn. Neither the child with the disability nor his age-matched peers gain anything from this experience. This movement toward education in the least restric- tive environment has led to a great reduction in the number of special educa- tion schools that were built as a result of the 1975 legislation. Some children with severe impairments are placed in neighborhood schools and are being cared for by an on-the-job trained aide who sits with them in a classroom, with some occasional therapy services provided in the school.

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Depression Symptoms of depression are commonly observed in patients with PD cheap nimotop 30mg mastercard. Prevalence rates for depression in PD range from 7 to 90% (although 40% is the most frequently cited estimate) buy nimotop 30 mg otc. Approximately one half of PD patients become depressed at some point during the disease course (77) nimotop 30 mg with visa, with about half of these patients developing minor depression nimotop 30mg amex, while the other half develops major depression purchase nimotop 30 mg with amex. Depression is a known risk factor for PD and PD-related dementia (52,78) and has been shown to adversely impact functional ability (79,80) and accelerate the progression of cognitive decline in PD (81,82). Depression in PD is unique in that, unlike in other neurodegenerative conditions such as AD, it significantly affects cognition (83). Executive functions and memory are foremost among the neuropsychological abilities impaired by depression (84–86). The negative impact of depression on cognition is more readily evident in the latter stages of PD, and depression must be of at least moderate severity before it markedly impacts cognition (87,88). In light of depression’s detrimental effect on cognition, an important clinical question with treatment implications is whether cognitive and/or functional decline in PD is a dementia due to neurodegeneration or due to depression. Little literature addresses the incidence and prevalence of dementia due to depression in PD and whether dementia in patients with comorbid depression improves with treatment and resolution of depressive symptomatology (89). Etiological inferences about an individual PD patient’s dementia, when the dementia is accompanied by marked depression, should probably be deferred until such time as the depression has been adequately treated and neuropsychological revaluation has been performed. Recent attention has also been drawn to the need to distinguish depression from apathy in PD (90). Apathy may occur in as many as 45% of patients with PD and, like depression, may be associated with executive deficits (91). Anxiety Anxiety disorders are seen in approximately 40% of patients with PD (92). Despite their frequent occurrence and contribution to morbidity and caregiver burden (10), anxiety symptoms in PD have received relatively little attention, perhaps because they overlap with symptoms of depression and medication effects and are thus difficult to measure (93). The relationship between anxiety and cognition in PD has received virtually no attention. Self-reported trait anxiety was negatively related to performance on a neuropsychological screening battery, accounting for approximately 70% of the variance. The authors posit that anxiety may partly explain the association between depression and cognition in PD, although replication of their findings and additional large-scale studies are needed. EFFECT OF PHARMACOLOGICAL AND SURGICAL TREATMENTS ON COGNITIVE FUNCTIONS IN PARKINSON’S DISEASE Modern treatment algorithms for patients with PD consist of both pharmacological and surgical intervention strategies (95). Neuropsycholo- gical evaluation can facilitate objective measurement of cognitive, neuro- behavioral, emotional, and quality-of-life outcomes associated with treatment as well as aid in determinations regarding treatment (96). Pharmacological Treatments Anticholinergics and Cholinesterase Inhibitors Anticholinergic medications used to treat motor symptoms in PD potentially produce adverse effects on memory, executive functions, as well as global cognitive abilities. In placebo-controlled studies, Bedard and colleagues found anticholinergics to induce executive deficits in PD but not in control participants (97,98). Although anticholinergic-induced memory decrements are observable even in patients without preexisting cognitive impairments (99), Saint-Cyr (100) found that confusional states are more likely to be induced by anticholinergics in patients with preexisting cognitive impairment. Thus, anticholinergics should be avoided in elderly patients who are susceptible to developing confusional states (101). Cholinesterase inhibitors were initially used sparingly and rarely in PDD and LBD. There is increasing recognition that cholinesterase inhibitors such as rivastigmine may improve not only cognition, but also neuropsychiatric symptoms in both conditions, and that these agents are well tolerated by patients with PD (102,103). Levodopa and Dopamine Agonists Findings concerning the impact of levodopa on cognitive functions are inconsistent, with studies showing improvement, decrements, and an Copyright 2003 by Marcel Dekker, Inc. Despite these inconsistent findings, evidence is accumulating that levodopa has short-term effects on certain aspects of memory and executive functions, perhaps as mediated by disease stage. For example, Kulisevsky and colleagues (105) reported short-term improve- ments in learning and memory, visuoperception, and certain executive functions associated with dopamine-replacement therapies but stated that these cognitive improvements were not maintained over time. That levodopa affects only certain components of cognitive functions is consistent with the findings of Fournet and colleagues (107), who reported poorer performance only on working memory tasks in patients with PD after withdrawal from levodopa, and of Lange et al. Levodopa’s rather selective effects on working memory and certain executive functions may be related to its mediation of dorsolateral frontal cortex blood flow in response to executive task activation (109).

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