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In order to be effective discount 60 ml rumalaya liniment amex, the respiratory system On the basis of general function cheap 60 ml rumalaya liniment amex, the respiratory system is must comply with certain physical requirements proven rumalaya liniment 60 ml. The conducting division includes all of the cavities and • The surface for gas exchange must be located deep within structures that transport gases to and from the pulmonary alveoli order rumalaya liniment 60 ml. Early Greek and Roman scientists placed great emphasis on the invisible material that was breathed in generic 60 ml rumalaya liniment free shipping. They knew nothing • The membrane must be kept moist so that oxygen and car- about oxygen or the role of the blood in transporting this vital sub- bon dioxide can be dissolved in water to facilitate diffusion. For that matter, they knew nothing about microscopic structures like cells because the microscope had not yet been in- vented. Early Greeks referred to air as an intangible, divine spirit called respiration: L. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 604 Unit 6 Maintenance of the Body Nasal cavity Nostril Choana Hard palate Soft palate Pharynx Epiglottis Esophagus Larynx Left principal (primary) bronchus Trachea Lobar bronchus Segmental bronchus Right lung: Superior lobe Left lung: Superior lobe Middle lobe Inferior lobe Inferior lobe Cardiac impression FIGURE 17. Objective 4 List the types of epithelial tissue that characterize Knowledge Check each region of the respiratory tract and comment on the 1. What are the physical requirements of the respiratory sys- Objective 5 Identify the boundaries of the nasal cavity and tem? List in order the major passages and structures through of the respiratory system. Objective 6 Describe the three regions of the pharynx and identify the structures located in each. Objective 7 Discuss the role of the laryngeal region in digestion and respiration. CONDUCTING PASSAGES Objective 8 Identify the anatomical features of the larynx Air is conducted through the oral and nasal cavities to the phar- associated with sound production and respiration. These structures deliver warmed and humidified air to the respira- tory division within the lungs. The conducting passages serve to transport air to the respiratory structures of the lungs. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 17 Respiratory System 605 types of epithelia that cleanse, warm, and humidify the air. The majority of the conducting passages are held permanently open by muscle or a bony or cartilaginous framework. Nose The nose includes an external portion that protrudes from the face and an internal nasal cavity for the passage of air. The external portion of the nose is covered with skin and supported by paired nasal bones, which form the bridge, and pliable cartilage, which forms the distal portions (fig. The septal cartilage forms the anterior portion of the nasal septum, and the paired lateral carti- lages and alar cartilages form the framework around the nostrils. The nasal vestibule is the anterior expanded portion of the nasal fossa (fig. There are several openings into the nasal cavity, including the openings of the various paranasal sinuses, those of the nasolacrimal ducts that drain from the eyes, and those of the audi- tory tubes that drain from the tympanic cavities. Respiratory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 606606 Unit 6 Maintenance of the Body Simple squamous epithelium (lining pulmonary alveoli) FIGURE 17. The roof of the nasal cavity is formed anteriorly by the frontal bone and paired nasal bones, medially by the cribriform plate of the ethmoid bone, and posteriorly by the sphenoid bone (see figs. In the trachea and bronchi, there are The anterior openings of the nasal cavity are lined with stratified squa- about 300 cilia per cell. The cilia move mucus-dust particles toward mous epithelium, whereas the conchae are lined with pseudostratified the pharynx, where they can either be swallowed or expectorated. Mucus-secreting gob- let cells are present in great abundance throughout both regions. Dust, pollen, smoke, and other fine particles are trapped • The nasal epithelium covering the conchae serves to warm, along the moist mucous membrane lining the nasal cavity. The nasal epithelium is highly vascular and covers an extensive surface • The olfactory epithelium in the upper medial portion of area. This is important for warming the air but unfortu- the nasal cavity is concerned with the sense of smell.

In some prominent in the airways of the lungs discount rumalaya liniment 60 ml visa, where it regulates cases discount rumalaya liniment 60 ml fast delivery, it closely approaches the cell membrane order 60 ml rumalaya liniment fast delivery, but there is the flow of air trusted rumalaya liniment 60 ml. A further specialization of the circular muscle arrange- The bulk of the cell interior is occupied by three types ment is a sphincter 60 ml rumalaya liniment amex, a thickening of the muscular portion of of myofilaments: thick, thin, and intermediate. The thin fil- the wall of a hollow or tubular organ, whose contraction aments are similar to those of skeletal muscle but lack the CHAPTER 9 Skeletal Muscle and Smooth Muscle 167 Dense body Mitochondrion Myofilaments Caveoli Autonomic nerve fiber Gap junction Nucleus Connective tissue fibers FIGURE 9. General smooth muscle, showing cells in cross sec- Histology of the Mammal. The length of the individual fil- filaments and to transmit the force of contraction to adja- aments is not known with certainty because of their irregu- cent cells. The thick filaments are composed of Smooth muscle lacks the regular sarcomere structure of myosin molecules, as in skeletal muscle, but the details of skeletal muscle. Studies have shown some association the exact arrangement of the individual molecules into fila- among dense bodies down the length of a cell and a ten- ments are not completely understood. The thick filaments dency of thick filaments to show a degree of lateral group- appear to be approximately 2. However, it appears that the lack of a strongly periodic than in skeletal muscle (1. The intermediate fila- arrangement of the contractile apparatus is an adaptation of ments are so named because their diameter of 10 nm is be- smooth muscle associated with its ability to function over a tween that of the thick and thin filaments. Intermediate fil- wide range of lengths and to develop high forces despite a aments appear to have a cytoskeletal, rather than a smaller cellular myosin content. Prominent throughout the cytoplasm are small, dark-staining areas called dense bodies. Because smooth muscle cells are associated with the thin and intermediate filaments and are so small compared to the whole tissue, some mechanical considered analogous to the Z lines of skeletal muscle. In- Dense bodies associated with the cell margins are often dividual cells are coupled mechanically in several ways. A called membrane-associated dense bodies (or patches) or proposed arrangement of the smooth muscle contractile focal adhesions. They appear to serve as anchors for thin and force transmission system is shown in Figure 9. This 168 PART III MUSCLE PHYSIOLOGY Cell-to-cell phenomenon is under hormonal control; in the uterus, for Paired membrane-associated Myofilaments inserting connective example, gap junctions are rare during most of pregnancy, dense bodies in membrane-associated tissue strands and the contractions of the muscle are weak and lack coor- dense body dination. However, just prior to the onset of labor, the number and size of gap junctions increase dramatically and the contractions become strong and well coordinated. Nucleus Shortly after the cessation of labor, these gap junctions dis- appear and tissue function again becomes less coordinated. Electrical coupling among smooth muscle cells is the ba- sis for classifying smooth muscle into two major types: • Multiunit smooth muscle, which has little cell-to-cell Collagen and elastin communication and depends directly on nerve stimula- fibers between cells tion for activation (like skeletal muscle). Its cells form a The contractile system and cell-to-cell con- functional syncytium (an arrangement in which many FIGURE 9. Note regions of association between thick and thin filaments that are anchored by up the bulk of the muscle in the visceral organs. A net- work of intermediate filaments provides some spatial organization (see, especially, the left side). Several types of cell-to-cell me- The Regulation and Control of chanical connections are shown, including direct connections and connections to the extracellular connective tissue matrix. Struc- Smooth Muscle Involve Many Factors tures are not necessarily drawn to scale. In addition to contraction picture represents a consensus from many researchers and in response to nerve stimulation, smooth muscle responds areas of investigation. Note that assemblies of myofila- to hormonal and pharmacological stimuli, the presence or ments are anchored within the cell by the dense bodies and lack of metabolites, cold, pressure, and stretch, or touch, at the cell margins by the membrane-associated dense bod- and it may be spontaneously active as well. The contractile apparatus lies oblique to the long axis ity of controlling factors is vital for the integration of of the cell. When single isolated smooth muscle cells con- smooth muscle into overall body function. Skeletal muscle tract, they undergo a “corkscrew” motion that is thought to is primarily controlled by the CNS and by a relatively reflect the off-axis orientation of the contractile filaments. The control of In intact tissues, the connections to adjacent cells prevent smooth muscle is much more closely related to the many this rotation.

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Transport in the distal nephron differs from that hibited by thiazide diuretics discount rumalaya liniment 60 ml visa. Na is pumped out the baso- in the proximal tubule in several ways: lateral side by the Na /K -ATPase cheap 60 ml rumalaya liniment with mastercard. Water permeability of 1) The distal nephron reabsorbs much smaller amounts the distal convoluted tubule is low and is not changed by of salt and water discount rumalaya liniment 60 ml fast delivery. The Cortical Collecting Duct Is an Important 2) The distal nephron can establish steep gradients for Site Regulating K Excretion salt and water generic rumalaya liniment 60 ml fast delivery. For example order rumalaya liniment 60 ml without a prescription, the [Na ] in the final urine Under normal circumstances, most of the excreted K may be as low as 1 mEq/L (versus 140 mEq/L in plasma) and comes from K secreted by the cortical collecting ducts. By contrast, the proximal tubule reabsorbs Na and collecting ducts may secrete so much K that more K is water along small gradients, and the [Na ] and osmolality excreted than was filtered. With severe K depletion, the of its tubule fluid are normally close to that of plasma. This explains why the distal nephron can establish steep volves active uptake by a Na /K -ATPase in the basolat- gradients for small ions and water, whereas the proximal eral cell membrane, followed by diffusion of K through tubule cannot. Outward diffusion of K 4) Na and water reabsorption in the proximal tubule from the cell is favored by concentration gradients and op- are normally closely coupled because epithelial water per- posed by electrical gradients. By contrast, Na and water reab- dient opposing exit from the cell is smaller across the lumi- sorption can be uncoupled in the distal nephron because nal cell membrane than across the basolateral cell water permeability may be low and variable. The luminal cell membrane po- coarse operation that reabsorbs large quantities of salt and tential difference is low (e. By contrast, distal reabsorption because this membrane has a high Na permeability and is is a finer process. Recall that the The collecting ducts are at the end of the nephron sys- entry of Na into a cell causes membrane depolarization tem, and what happens there largely determines the excre- (see Chapter 3). Transport in the collect- The magnitude of K secretion is affected by several ing ducts is finely tuned by hormones. Increased amounts of The Luminal Cell Membrane of the Distal Na in the collecting duct lumen (e. In 2) The lumen-negative transepithelial electrical poten- this nephron segment, Na and Cl are transported from tial promotes K secretion. The ability to concentrate the urine decreases the urine principal cell amount of water we are obliged to find and drink each day. Na+ ATP + Arginine Vasopressin Promotes the Excretion Na of an Osmotically Concentrated Urine ADP + Pi K+ Changes in urine osmolality are normally brought about largely by changes in plasma levels of arginine vasopressin + K+ (AVP), also known as antidiuretic hormone (ADH) (see K Chapter 32). In the absence of AVP, the kidney collecting ducts are relatively water-impermeable. Reabsorption of -50 mV -70 mV -70 mV 0 mV solute across a water-impermeable epithelium leads to os- motically dilute urine. In the presence of AVP, collecting A model for ion transport by a collecting duct water permeability is increased. The hormone binds men maintains the cell-to-lumen concentration gradient, to a specific vasopressin (V2) receptor in the basolateral cell membrane. By way of a guanine nucleotide stimulatory pro- which favors K secretion. Cyclic AMP then activates a Na entry into the collecting duct cell is by diffusion cAMP-dependent protein kinase (protein kinase A [PKA]) through a Na channel (see Fig. This channel has been cloned and sequenced and is known as ENaC, for ep- that phosphorylates other proteins. This leads to the inser- tion, by exocytosis, of intracellular vesicles that contain wa- ithelial sodium (Na) channel. The entry of Na through ter channels (aquaporin-2) into the luminal cell membrane. The resulting increase in number of luminal membrane wa- Intercalated cells are scattered among collecting duct ter channels leads to an increase in water permeability. Wa- principal cells; they are important in acid-base transport (see ter can then move out of the duct lumen through the cells, and the urinary solutes become concentrated. A H /K -ATPase is present in the luminal cell membrane of -intercalated cells and contributes to renal to AVP occurs in minutes.

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Which factors affect the accuracy of the urine dipstick for the detection of bacteriuria or urinary tract infections? The test of Lasègue: systematic review of the accuracy in diagnosing herniated discs discount rumalaya liniment 60 ml on line. Method guidelines for systematic reviews in the Cochrane Collaboration Back Review Group for spinal disorders cheap rumalaya liniment 60 ml. Selecting the language of the publications included in a meta-analysis: is there a Tower of Babel bias? Diagnostic value of the CAGE questionnaire in screening for alcohol abuse and alcohol dependence: a meta-analysis buy 60 ml rumalaya liniment free shipping. The diagnostic value of macroscopic haematuria in diagnosing urological cancers 60 ml rumalaya liniment otc. A note on graphical presentation of estimated odds ratios from several clinical trials buy 60 ml rumalaya liniment otc. Invited commentary: a critical look at some popular meta-analytic methods. Appendix: statistical formulae Pooling of proportions Homogeneous sensitivity and/or specificity For example, for the sensitivity: k Sensitivitypooled a ai> a (ai ci) i 1 where a true positives, c false negatives, i study number, and, k total number of studies, with standard error: p(1 p) SE B n where p sensitivitypooled, and k n a (ai ci) i 1 Cut-off point effect: SROC curve Basic meta-regression formula: ln(DOR)pooled a bS where intercept, regression coefficient, and sensitivity (1 specificity) S estimate of cut-off point lnc d 1nc d (1 sensitivity) specificity With standard error: 1 1 1 1 SEln(DOR) Ba b c d Pooling of likelihood ratios ND log(LR)pooled logc d a bx ND where LR likelihood ratio ND log c d correction factor ND log(number non-diseased/number diseased) i ntercept in logistic regression, regression coefficient, and x test measurement. When workers and researchers in that domain begin to appreciate the potential of ICT, this initial stage is followed by more fundamental changes in that domain that take advantage of the potential of ICT. The explicit purpose of automating medical records is to use the data in those records to support not only the care of individual patients, but also applications such as decision support, quality control, cost control, or epidemiology. First, data recorded on computer can readily be retrieved and reused for a variety of purposes. Second, once data are available on computer, they can easily be transported. Third, as clinicians (and patients) are using computers to record medical data, the same electronic record can be used to introduce other computer programs that interact with the user. Thus the experience in developing decision support systems and analysing observational databases feeds back into the requirements for electronic medical records. Paper as a medium to record data limits our ability to exploit that potential. Electronic medical records will facilitate research that relies on data recorded in routine medical practice. The potential of ICT, however, lies in its ability to close the loop between clinical practice, research, and education. Introduction The term medical informatics dates from the second half of the 1970s and is based on the French term informatique médicale. Although the term is now widely used, other names, such as medical computer science, medical information sciences, or computers in medicine, are sometimes used. Research in informatics ranges from fundamental computer science to applied informatics. Several definitions of medical informatics take both the scientific, fundamental aspect and the applied, pragmatic aspect into account. Shortliffe, for example, provides the following definition: “Medical Information Science is the science of using system-analytic tools … to develop procedures (algorithms) for management, process control, decision-making and scientific analysis of medical knowledge. Medicine identifies the area of research; informatics identifies the methodology used. In medical informatics, we develop and assess methods and systems for the acquisition, processing, and interpretation of patient data. If the medical informatics research is applied, the objective is to develop a computer system that will be used by healthcare professionals, for example 168 DIAGNOSTIC DECISION SUPPORT research aimed at the development of electronic medical records. If the research is more fundamental, the computer plays a role as an experimental environment for models that are developed; the objective is not to build a system, but to verify a hypothesis or to investigate the limitations of models. Some research in the area of artificial intelligence in medicine, for example, fits this last category. Applying ICT to a given medical domain is not merely adding a new technique: ICT has the potential to radically change processes in that domain.

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