By W. Peratur. Bastyr University.

Drawings show the thick wall of an artery minocycline 50mg low price, the thin wall of a vein buy 50mg minocycline, and the single- layered wall of a capillary buy 50mg minocycline amex. ZOOMING IN Which vessels have valves that control blood flow? Rates of exchange vary because purchase minocycline 50mg online, based on their many holes buy 50mg minocycline overnight delivery, or fenestrations, in the endothelium. These sieve- structure, different types of capillaries vary in permeability. In the digestive tract, fenestrated capillaries permit found in muscle, connective tissue, the lungs, and the central rapid absorption of water and nutrients into the bloodstream. These capillaries are composed of a In the kidneys, they permit rapid filtration of blood plasma, continuous layer of endothelial cells. Adjacent cells are the first step in urine formation. In addition to fenestrations, they have large spaces be- ies are the least permeable, water and small molecules can dif- tween endothelial cells that allow the exchange of water, large fuse easily through their walls. Large molecules, such as solutes, such as plasma proteins, and even blood cells. In certain regions of soids are found in the liver and red bone marrow, for exam- the body, like the CNS, adjacent endothelial cells are joined ple. Albumin, clotting factors, and other proteins formed in tightly together, making the capillaries impermeable to many the liver enter the bloodstream through sinusoids. In red bone substances (see Box 10-1 in Chapter 10, The Blood Brain Bar- marrow, newly formed blood cells travel through sinusoids to rier: Access Denied). The aorta is one contin- vessels also have less elastic tissue between the layers. As uous artery, but it may be divided into sections: a result, the blood within the veins is carried under much ◗ The ascending aorta is near the heart and inside the lower pressure. Because of their thinner walls, the veins pericardial sac. Only slight pressure on a vein by a ◗ The aortic arch curves from the right to the left and tumor or other mass may interfere with return blood also extends posteriorly. Such valves are most numerous in the veins of the extremities. Figure 15-3 is a cross-section of Smooth muscle an artery and a vein as seen through a microscope. Checkpoint 15-3 What type of tissue makes up the middle layer of arteries and veins, and how is this tissue controlled? Checkpoint 15-4 How many cell layers make up the wall of a capillary? Artery Vein ◗ Systemic Arteries The systemic arteries begin with the aorta, the largest ar- tery, which measures about 2. This vessel receives blood from the left ventricle then travels downward through the body, branching to all or- gans. Connective tissue The Aorta and Its Parts Figure 15-3 Cross-section of an artery and vein. The The aorta ascends toward the right from the left ventricle. Philadelphia: Lippincott downward posterior to the heart and just anterior to the Williams & Wilkins, 2001. BLOOD VESSELS AND BLOOD CIRCULATION 311 The arch of the aorta, located im- Right common Left common mediately beyond the ascending aorta, carotid artery carotid artery divides into three large branches. Right subclavian Left subclavian ◗ The brachiocephalic (brak-e-o-seh- artery artery FAL-ik) artery is a short vessel that Brachiocephalic supplies the arm and the head on the artery right side. After extending upward Aortic arch Ascending aorta somewhat less than 5 cm (2 inches), it divides into the right subclavian Coronary (sub-KLA-ve-an) artery, which ex- arteries Thoracic aorta tends under the right clavicle (collar bone) and supplies the right upper Celiac trunk to: Intercostal extremity (arm), and the right com- Left gastric artery arteries mon carotid (kah-ROT-id) artery, Splenic artery which supplies the right side of the Hepatic artery neck, head and brain. It supplies the left Renal side of the neck and the head. Branches of the Thoracic Aorta 15 The thoracic aorta supplies branches to the chest wall, esophagus (e-SOF-ah- gus), and bronchi (the subdivisions of the trachea), and their treelike subdivi- Common sions in the lungs. There are usually 9 iliac to 10 pairs of intercostal (in-ter-KOS- External iliac artery tal) arteries that extend between the artery ribs, sending branches to the muscles Testicular Internal iliac artery and other structures of the chest wall. ZOOMING IN How many brachio- cephalic arteries are there? The most important of ◗ The abdominal aorta is the longest section of the aorta, these visceral branches are as follows: spanning the abdominal cavity.

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As blood is filtered in the capillary bed of the glomerulus generic minocycline 50 mg without a prescription, urea buy minocycline 50mg on-line, sugars 50 mg minocycline with amex, amino acids cheap minocycline 50 mg without a prescription, ions buy generic minocycline 50 mg on line, and H2O enter the renal tubular fluid (glomerular filtrate). As this fluid passes through a progression of tubules (the proximal convoluted tubule, the loop of Henle, the distal convoluted tubule, and the collecting duct) on its way to becoming urine, various components are reabsorbed or added to the filtrate by the epithelial cells lining the tubules. Specific transporters in the membranes of the renal tubule cells transport protons into the tubule lumen in exchange for Na so that the glomerular filtrate becomes more acidic as it is trans- formed into urine. The protons in the tubule fluid are buffered by phosphate, by bicarbonate, and by NH3. The ammonia, which is uncharged, is able to diffuse through the membrane of the renal tubule cells into the urine. As it combines with a proton in the urine, it forms NH ,which 4 cannot be transported back into the cells. The removal of protons as NH decreases the requirement for bicarbonate excretion to buffer the urine. Major Fuel Sources for the Kidney % of Total CO2 Formed in Different Physiologic States Fuel Normal Acidosis Fasted Lactate 45 20 15 Glucosea 25 20 0 Fatty acids 15 20 60 Glutamine 15 40 25 aGlucose used in the renal medulla is produced in the renal cortex. Ammonia (NH3), which is uncharged, enters the urine by free diffusion through the cell membrane. As it combines with a proton in the fluid, it forms ammonium ion (NH4 ), which cannot be transported back into the cells and is excreted in the urine. GLUTAMINE AS A FUEL FOR THE KIDNEY Glutamine is used as a fuel by the kidney in the normal fed state and, to a greater extent, during fasting and metabolic acidosis (Table 42. The carbon skeleton forms -ketoglutarate, which is oxidized to CO2, converted to glucose, or released as the car- bon skeleton of serine or alanine (Fig. PEP can then be converted to pyruvate and subsequently acetyl CoA, alanine, serine, or glucose. The glucose is used principally by the cells of the renal medulla, which have a relatively high dependence on anaero- bic glycolysis because of their lower oxygen supply and mitochondrial capacity. The lactate released from anaerobic glycolysis in these cells is taken up and oxidized in the renal cortical cells, which have a higher mitochondrial capacity and a greater blood supply. Glutamine + Glucose NH4 Glutamate Gluconeogenesis GDH NH+ 4 α-Ketoglutarate Alanine Pyruvate Serine (ATP) TA CO2 TCA CO2 cycle Malate PEPCK OAA PEP CO Glu α-KG 2 Alanine CO2 TA Acetyl CoA Pyruvate Glucose Fatty acids Lactate Glycolysis Fig. Metabolism of glutamine and other fuels in the kidney. To completely oxidize glu- tamate carbon to CO2, it must enter the TCA cycle as acetyl CoA. Carbon entering the TCA cycle as -Ketoglutarate ( -KG) exits as oxaloacetate and is converted to phosphoenolpyru- vate (PEP) by PEP carboxykinase. PEP is converted to pyruvate, which may be oxidized to acetyl CoA. PEP also can be converted to serine, glucose, or alanine. GDH glutamate dehydrogenase; PEPCK phosphoenolpyruvate carboxykinase; TA transaminase; OAA oxaloacetate. Skeletal Muscle Skeletal muscle, because of its large mass, is a major site of protein synthesis and degradation in the human. After a high-protein meal, insulin promotes the uptake of certain amino acids and stimulates net protein synthesis. The insulin stimulation of protein synthesis is dependent on an adequate supply of amino acids to undergo pro- tein synthesis. During fasting and other catabolic states, a net degradation of skele- tal muscle protein and release of amino acids occur (see Fig. The net degra- dation of protein affects functional proteins, such as myosin, which are sacrificed to meet more urgent demands for amino acids in other tissues. During sepsis, degra- dation of skeletal muscle protein is stimulated by the glucocorticoid cortisol. The effect of cortisol is exerted through the activation of ubiquitin-dependent proteoly- sis. During fasting, the decrease of blood insulin levels and the increase of blood cortisol levels increase net protein degradation. Skeletal muscle is a major site of glutamine synthesis, thereby satisfying the demand for glutamine during the postabsorptive state, during metabolic acidosis, and during septic stress and trauma. The carbon skeleton and nitrogen of glutamine are derived principally from the metabolism of BCAA.

Pedal edema can also appear idiosyncratically and is independent of either renal or cardiac failure order minocycline 50mg mastercard. Its presence has generally been attributed to a redistribution of fluid and does not appear to represent a fluid excess best minocycline 50 mg. Quinn reported a few cases of congestive heart failure occurring in association with the use of amantadine proven 50 mg minocycline, but this appears to be an exception to routine clinical use (25) cheap 50 mg minocycline overnight delivery. The presence of either livedo reticularis or pedal edema does not always necessitate discontinuation of amantadine purchase minocycline 50mg free shipping. There is no specific treatment for the cosmetic discoloration associated with livedo reticularis. Diuretics may be used if the pedal edema is uncomfortable, though specific benefit tends to be uncertain. Symptoms are generally expected to resolve with discontinuation of the drug, but may take up to several weeks. Rarely, these conditions may be severe and associated with leg ulceration and peripheral neuropathy (26). A prudent combination of discontinuing the drug and of providing appropriate referrals to exclude important secondary causes (such as a superimposed renal failure, cardiac failure, autoimmune or vasculitic livedo, and ruling out deep vein thrombosis) must be an important part of continued clinical follow-up for patients on amantadine. Nonspecific symptoms such as lightheadedness, insomnia, jitteriness, depression, and concentration difficulties are potential side effects of amantadine (9). Amantadine itself also possesses mild anticholinergic properties, which contribute to further reported side effects such as dry mouth, orthostatic hypotension, constipation, dyspepsia, and urinary retention. Therefore, reasonable care should be taken when administering amantadine in conjunction with anticholinergics (27). Cardiac arrhythmias have been reported with amantadine in one report (8). Amantadine is not recommended during pregnancy as it has more teratogenic potential than other PD medications (28). Acute toxicity presenting as delirium (15) and psychosis (11) has been reported. Abrupt withdrawal has also been reported to produce delirium (29) as well as neuroleptic malignant syndrome (30). In many of these cases patients had either baseline cognitive deficits, psychiatric background, or excessive amantadine use. In general, the cognitive side effects such as confusion and concentration difficulties are more common in those with underlying, preexisting cognitive dysfunction. In advanced PD, amantadine may even carry comparable propensity for cognitive side effects to levodopa Copyright 2003 by Marcel Dekker, Inc. As such, conservative use in the elderly and avoidance of use even in the mildly cognitively impaired patient is necessary. Because of the renal predominant excretion of amantadine, patients with impaired kidney function carry a higher risk of toxicity. Dosing schedules have been developed for patients with poor renal function according to creatinine clearance (32). However, as a practical matter, with the availability of many other antiparkinsonian agents, it is best to avoid the use of amantadine in patients with poor renal clearance. In the event of suspected toxicity, dialysis is not helpful in decreasing toxic levels, probably due to extensive tissue binding (33). Mechanisms of Action Many studies have suggested putative mechanisms of action for amantadine that may explain antiparkinsonian effects, but the clinical significance of any given individual mechanism remains uncertain. It seems likely that amantadine has a combination of multiple effects on both dopaminergic and nondopaminergic systems. Dopaminergic mechanisms described for amantadine include findings of increased dopamine release (34), increased dopamine synthesis (35), inhibition of dopamine reuptake (36) and modulation of dopamine D2 receptors producing a high affinity state (37). This latter effect may speculatively play a role in modulating levodopa-induced dyskinesias. The relevance of these dopaminergic mechanisms is uncertain given that studies have demonstrated that the antiparkinsonian effects can occur without changes in brain concentrations of dopamine or its metabolites (38) and without evidence for dopamine synthesis or release (39). Other neurotransmitter effects reported with amantadine include serotonergic, noradrenergic, anticholinergic, and antiglutaminergic proper- ties (40).

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Effects of inhibitory casts and orthoses on bony alignment of foot and ankle during weight-bearing in children with spasticity order minocycline 50 mg mastercard. Gait assessment of fixed ankle- foot orthoses in children with spastic diplegia generic minocycline 50mg with amex. Hainsworth F purchase 50mg minocycline mastercard, Harrison MJ order 50mg minocycline overnight delivery, Sheldon TA order 50 mg minocycline, Roussounis SH. A preliminary evalu- ation of ankle orthoses in the management of children with cerebral palsy. An evaluation of the posterior leaf spring orthosis using joint kinematics and kinetics. Ankle-foot orthoses for preambula- tory children with spastic diplegia. Effect of adaptive seating on pulmonary function of children with cerebral palsy. The influence of adap- tive seating devices on vocalization. Effects of adaptive seating devices on the eating and drinking of children with multiple handicaps. Seating orientations and upper extremity function in children with cerebral palsy. The effects of the saddle seat on seated postural control and upper-ex- tremity movement in children with cerebral palsy. DESEMO seats for young children with cere- bral palsy. Trefler E, Hanks S, Huggins P, Chiarizzo S, Hobson D. A modular seating sys- tem for cerebral-palsied children. Comparison of anterior trunk supports for children with cerebral palsy. McPherson JJ, Schild R, Spaulding SJ, Barsamian P, Transon C, White SC. Analy- sis of upper extremity movement in four sitting positions: a comparison of per- sons with and without cerebral palsy. Effects of body orientation in space on tonic muscle activity of patients with cerebral palsy. Role of the wheelchair in the management of the muscular dystrophy patient. Transportation resources for pediatric orthopaedic clients. Transportation of children with spe- cial seating needs. Comparison of straddling and sitting apparatus for the spastic cerebral-palsied child. Effect of altering handle position of a rolling walker on gait in children with cerebral palsy. There are only a minority of patients whose motor function is so limited that ambulation is of no concern. From children with the most mild effects of hemiplegia to children with quad- riplegia who are just able to do standing transfers, lower extremity function for mobility is usually a major concern of parents. The first task in the or- thopaedic treatment plan is to individually identify how significant the gait impairment is to a child’s whole disability. The second task is to determine if treatment of the impairment is likely to improve this child’s function. The final goal is to explain the treatment plan to the parents and children and to inform them of the specific functional gains that can be expected and the as- sociated risks. Normal human gait is one of the most complex functions of the human body, and gait is clearly the most complex impairment treated by pediatric orthopaedists. To understand and develop a specific treatment plan for children with gait impairments due to CP, orthopaedists have to have a good understanding of normal gait, understand measurement techniques used to evaluate gait, and be able to evaluate pathologic gait. This discussion starts with an overview description of the basic scientific concepts required to understand gait. This basic science background is cru- cial to understanding normal gait and is even more important to under- standing the pathologic gait of children with CP. The goal of this text is not to provide a comprehensive review of all the basic science of gait.

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Exercise programmes designed to prevent falls in older people have two important advantages order minocycline 50mg on line. Falls are very common so programmes are likely to be cost effective when compared with other public health measures in this population discount minocycline 50mg with mastercard. Exercise is also beneficial to the participants in additional ways such as decreasing fear of falling buy generic minocycline 50 mg line, improving functional reserve by increasing strength and in improving other important health areas as varied as cardiovascular health discount minocycline 50mg line,45 sleep buy minocycline 50 mg fast delivery,46 depression47 and mortality. She is normally fit and well and on no medications except for the occasional sleeping tablet. She was on her way to visit the optometrist when she tripped on the curb and put her hand out to break the fall. History was obtained from the nursing staff as AM suffers mild dementia. She is normally fit and active and independent with ADLs. Usual medications include: Gliclazide, Calcitriol, Digoxin, Metoprolol, Doxepin, and Furosemide. According to staff AM never lost consciousness but collapsed when trying to rise from a chair using one crutch. She landed on her left hip immediately complaining of pain and was unable to walk on the hip. She said she was not dizzy or nauseated at the time of the fall. He has a history of angina, heart disease, heart failure, CORD, NIDDM, all poorly controlled on maximal therapy. He recently gave up smoking but still drinks one or two pints of beer a day. His wife has observed that he has been less active of late with weight loss and reduced appetite for six months. Medications include Digoxin, Furosemide, Captopril, Temazepam, GTN Spray, Prednisone, Ventolin and Becotide inhalers, and insulin. Sample examination questions Multiple choice questions (answers on p 561) 1 Falls prevention exercise programmes work on which of the following premises: A Muscle strength and balance are common risk factors for falls B Exercise must be continued to be effective 147 Evidence-based Sports Medicine C Only fit elderly people should take part D Strength training should be a gentle, optional extra exercise 2 Proven benefits of falls prevention exercise programmes to date include: A Decreased fear of falling B Reduced admissions to rest home C Improved functional independence D Reduced hip fractures 3 In a systematic review on falls which electronic databases would be searched? A Web of Science B Ovid C Generator D Cochrane Database of Systematic Reviews Essay questions 1 Are falls prevention interventions targeting multiple risk factors in older people more effective than those targeting single risk factors? Would this programme be suitable for residents with cognitive impairment? Acknowledgements The authors are grateful to Lesley Gillespie for the literature searches and The Cochrane Collaboration Musculoskeletal Injuries Group for quality assessment of the included trials. We thank the authors who contributed additional information for the review. The authors were investigators for three of the trials included in the review. Falls in old age: a study of frequency and related clinical factors. Falls, injuries due to falls, and the risk of admission to a nursing home. The prognosis of falls in elderly people living at home. Health care utilization and costs in a Medicare population by fall status. Risk factors for falls among elderly persons living in the community. Risk factors for falls in a community-based prospective study of people 70 years and older. Risk factors for injurious falls: a prospective study. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Effects of physical activity on health status in older adults. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. Interventions for preventing falls in elderly people (Cochrane review).

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