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If the tumor releases only norepinephrine treatment efficacy 5 mg olanzapine purchase mastercard, a compensatory bradycardia may also be present, but most patients release enough epinephrine to maintain heart rate at a normal or even increased level. Describe the major organ system effects of a pure agonist, a pure agonist, and a mixed and agonist Describe a clinical situation in which the effects of an indirect sympathomimetic would differ from those of a direct agonist. All of these agents are pharmacologic antagonists or partial agonists and most are reversible and competitive in action. Because and blockers differ markedly in their effects and clinical applications, these drugs are considered separately in the following discussion. Classification Subdivisions of the blockers are based on selective affinity for 1 versus 2 receptors or a lack thereof. Other features used to classify the -blocking drugs are their reversibility and duration of action. Irreversible, long-acting-Phenoxybenzamine is the prototypical long-acting blocker; it differs from other adrenoceptor blockers in being irreversible in action. Reversible, shorter-acting-Phentolamine is a competitive, reversible blocking agent that does not distinguish between 1 and 2 receptors. Alpha1-selective-Prazosin is a highly selective, reversible pharmacologic 1 blocker. Alpha2-selective-Yohimbine and rauwolscine are 2-selective competitive pharmacologic antagonists. Pharmacokinetics Alpha-blocking drugs are all active by the oral as well as the parenteral route, although phentolamine is rarely given orally. Phenoxybenzamine has a short elimination half-life but a long duration of action-about 48 h-because it binds covalently to its receptor. Mechanism of Action Phenoxybenzamine binds covalently to the receptor, thereby producing an irreversible (insurmountable) blockade. This difference may be important in the treatment of pheochromocytoma because a massive release of catecholamines from the tumor may overcome a reversible blockade. The most important effects of nonselective blockers are those on the cardiovascular system: a reduction in vascular tone with a reduction of both arterial and venous pressures. The term refers to a reversal of the blood pressure effect of large doses of epinephrine, from a pressor response (mediated by receptors) to a depressor response (mediated by 2 receptors). The effect is not observed with phenylephrine or norepinephrine because these drugs lack sufficient 2 effects. Epinephrine reversal, manifested as orthostatic hypotension, is occasionally seen as an unexpected (but predictable) effect of drugs for which blockade is an adverse effect (eg, some phenothiazine antipsychotic agents, antihistamines). Selective blockers-Because prazosin and its analogs block vascular 1 receptors much more effectively than the 2modulatory receptors associated with cardiac sympathetic nerve endings, these drugs reduce blood pressure with much less reflex tachycardia than the nonselective blockers. The best-documented application is in the presurgical management of pheochromocytoma. Such patients may have severe hypertension and reduced blood volume, which should be corrected before subjecting the patient to the stress of surgery. Phenoxybenzamine is usually used during this preparatory phase; phentolamine is sometimes used during surgery. Phenoxybenzamine also has serotonin receptor-blocking effects, which justify its occasional use in carcinoid tumor, as well as H1 antihistaminic effects, which lead to its use in mastocytosis. Accidental local infiltration of potent agonists such as norepinephrine may lead to severe tissue ischemia and necrosis if not promptly reversed; infiltration of the ischemic area with phentolamine is sometimes used to prevent tissue damage. Overdose with drugs of abuse such as amphetamine, cocaine, or phenylpropanolamine may lead to severe hypertension because of their indirect sympathomimetic actions. Sudden cessation of clonidine therapy leads to rebound hypertension (Chapter 11); this phenomenon is often treated with phentolamine. Phentolamine or yohimbine has been used by direct injection to cause penile erection in men with erectile dysfunction, but phosphodiesterase inhibitors are more popular (see Chapter 12). Selective blockers-Prazosin, doxazosin, and terazosin are used in hypertension (Chapter 11). These 1 blockers, as well as tamsulosin and silodosin are also used to reduce urinary hesitancy and prevent urinary retention in men with benign prostatic hyperplasia. The epinephrine response exhibits reversal of the mean blood pressure change from a net increase (the response) to a net decrease (the 2 response). The response to phenylephrine is suppressed but not reversed, because phenylephrine lacks action. Toxicity the most important toxicities of the blockers are simple extensions of their -blocking effects. The main manifestations are orthostatic hypotension and, in the case of the nonselective agents, marked reflex tachycardia. The 1-selective agents are associated with an exaggerated orthostatic hypotensive response to the first dose in some patients. Note that, except for blockers that start with the letter "c," blockers with names starting with letters "a" through "m" are 1 selective. These drugs are optically active, and different isomers have - or -blocking action. Nebivolol has vasodilating action in addition to dose-dependent 1-selective antagonism. Partial agonist activity-Partial agonist activity ("intrinsic sympathomimetic activity") may be an advantage in treating patients with asthma because these drugs (eg, pindolol, acebutolol)-at least in theory-are less likely to cause bronchospasm.

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Type 2 diabetes is characterized by insulin resistance medicine 93 5298 7.5 mg olanzapine buy with visa, which can have multiple causes. Stimulates pyruvate dehydrogenase to acetyl CoA formation Diabetes increases risk of microvascular disease (retinopathy, nephropathy), macrovascular disease (atherosclerosis), and peripheral neuropathy. Pituitary gigantism is a rare condition seen in children before bone epiphyseal growth plates have closed. Using the boxed numerals as a guide, explain how adrenocortical hormone synthesis and release is regulated. Primary adrenal insufficiency (Addison disease) is caused by destruction of the adrenal cortex, usually as a result of an autoimmune response, but it may also be caused by infection. What are the two principal pathways regulating aldosterone synthesis and secretion, as shown Rise in plasma K concentration (hyperkalemia) Primary aldosteronism presents as hypertension and, in many cases, hypokalemia. Review three or more physiologic actions by which cortisol prepares the body for stress. The two catecholamines are synthesized from tyrosine, with a dopamine intermediate. The patients may also develop goiter due to infiltration by immune cells, fibrosis, and follicular hyperplasia. What happens to this axis when circulating thyroid hormone levels rise above optimal T3 has a greater physiologic effect than T4 because T4 is mostly converted to T3 by the liver, kidneys, and other target tissues. T3 and T4 T3 and T4 inhibit their own secretion through negative hypothalamic feedback. Inflammation and mucopolysaccharide deposition within these tissues cause the characteristic swelling and orbital protrusion. The figure shows how changes in circulating thyroid hormone levels impact basal O2 consumption. Identify three or more cellular pathways affected by thyroid hormone to produce the changes shown. What are the consequences of congenital hypothyroidism if left untreated after birth If left untreated, congenital hypothyroidism causes cretinism, a condition characterized by mental retardation and short stature. Congenital hypothyroidism is difficult to detect at birth because maternal thyroid hormones cross the placenta and may support near-normal development in utero. Parathyroid hormone gene transcription and secretion Vitamin D is a mix of vitamin D2 (ergocalciferol), which is obtained from the diet, and vitamin D3 (cholecalciferol), which forms in skin through the actions of ultraviolet light on 7-dehydrocholesterol. A-plus: Rickets can also be caused by renal phosphate wasting (phosphopenic rickets). Which two ovarian cell types must cooperate in order to produce estradiol, and what is the nature of the cooperation Estradiol production requires cooperation between ovarian theca cells and granulosa cells. Symptoms include hirsutism and virilization, menstrual irregularities, obesity and associated insulin resistance, and polycystic ovaries. Menstrual: Uterine wall sloughing is initiated by declining levels of progestins and estrogens. Secretory: Proliferation halts with a drop in estrogen levels following ovulation. Menstruation results from intense vasospasms that prevent flow through the spiral arteries and cause local ischemia and inflammation. Endometriosis refers to the establishment of endometrial tissue at extrauterine sites, possibly due to retrograde travel through the fallopian tubes during menstruation.

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You suggest that cellular and molecular markers would help you answer that question medicine x pop up 5 mg olanzapine order with mastercard. Markers for which of the following cells could be used to monitor neural crest cell differentiation in vitro After fertilization, the male and female pronuclei join to form the nucleus of the zygote. Maternal enzymes and transcription factors regulate nuclear reprogramming and activate zygotic gene transcription. During this mitotic cell division, sister chromatids are partitioned to genetically identical daughter cells (blastomeres). After telophase, the daughter cells enter interphase of the cell cycle (choice B). Totipotency of the blastomeres is lost after the third cleavage division (eight-cell stage) as the embryo undergoes compaction to form the blastocyst. The spindle apparatus organizes and separates chromosomes during mitosis and meiosis. Microtubules of the spindle apparatus link chromosomes to microtubule organizing centers and mediate the movement of paired chromosomes to opposite poles of the cell during anaphase. Bundles of microtubules (spindle fibers) originate from microtubule-organizing centers (centrosomes, choice D). Centrosomes are composed of two centrioles (choice B) and a zone of pericentriolar proteins that regulate microtubule nucleation. Centrosomes are associated with the nuclear membrane during interphase and replicated during S phase of the cell cycle. They move to opposite poles of the cell during mitotic prophase as the nuclear envelope disintegrates. Astral fibers (choice A) are microtubules that anchor centrosomes to the plasma membrane. Dyneins are molecular motor proteins that move chromosomes along the spindle apparatus. Failure of sister chromatids to separate during anaphase is referred to as nondisjunction. The plasma membrane separates the cytoplasm and intracellular organelles from the external environment. Integral proteins pass through the lipid bilayer, whereas peripheral proteins do not. Membrane proteins are essential for cell viability and differentiated cell functions. For examples, membrane proteins serve as pumps, enzymes, channels, receptors, structural molecules, and attachment sites. Oligosaccharides and polysaccharides conjugated to membrane proteins and sphingolipids form a cell surface coat (glycocalyx). In polarized epithelial cells, the plasma membrane exhibits distinct apical, basal, and lateral domains. Tight junctions provide a barrier to the lateral diffusion of membrane proteins and lipids. In some cells, the plasma membrane forms microdomains (lipid rafts, choice A) that regulate cell signaling. Patching and capping (choice C) describe the clustering of cell surface molecules by specific cross-linking agents, such as antibodies or pollen. Protein trafficking and endocytosis (choices D and E) do not regulate the lateral diffusion of lipids and proteins in the plasma membrane. Motility is a remarkable property of cells that is essential for embryonic development, wound healing, and lymphocyte trafficking. Cell locomotion involves the coordinated assembly and disassembly of actin microfilaments. Actin filaments are helical structures, with a growing end that adds globular (G-actin) to filamentous F-actin. Assembly of microfilaments can generate membrane protrusions, such as filopodia and lamellipodia. Changes in the shape of lamellipodia over time are referred to as "membrane ruffling. Desmin and vimentin (choices B and E) are intermediate filament proteins found in mesenchymal cells. Lamins (choice C) are nuclear matrix proteins that stabilize the nuclear membrane and organize chromatin. Tubulins (choice D) form the spindle apparatus, regulate intracellular transport, and control the movement of cilia and flagella. Keywords: Neural crest cells, actin microfilaments 5 the answer is E: Nuclear pyknosis. Apoptosis is a programmed pathway of cell death that is activated by a variety of extracellular and intracellular signals. It is often a self-defense mechanism, destroying cells that harbor viruses or have acquired genetic alterations. In this example, secretory cells of the sebaceous gland Cell Biology initiate programmed cell death in order to release their intracellular stores of lipid and wax. Cytologic features of cells undergoing apoptosis include nuclear condensation (pyknosis) and chromatin fragmentation (karyorrhexis and karyolysis).

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A urinary bladder biopsy is eventually obtained and examined in the pathology department (shown in the image) symptoms 6 year molars purchase olanzapine 5 mg. The histologic features of this specimen suggest that it was obtained from which of the following anatomic locations The urinary system is composed of paired kidneys and ureters, as well as the urinary bladder and urethra. The bladder stores urine before it is released through the urethra during urination (micturition). The pelvis and calyx of the kidney are common sites for the formation and retention of calculi (stones). Patients typically complain of severe intermittent pain, caused by forceful peristaltic contractions of the ureter, as it attempts to expel the renal calculus. The pain is typically referred to the overlying cutaneous region, where it is described as passing from "loin to groin. Stones in the other anatomic locations would not typically present with flank pain radiating to the inguinal region. The presence of stones in the collecting system of the kidney is termed nephrolithiasis. The presence of stones elsewhere in the collecting system of the urinary tract is termed urolithiasis. Keywords: Urolithiasis, renal calculi 2 the answer is C: Inadequate hydroxylation of calcidiol (vitamin D2). Principal functions of the kidney include removal of metabolic waste from blood and balancing serum electrolytes. For example, the kidneys synthesize the biologically active form of vitamin D (calcitriol). Calcitriol (also referred to as vitamin D3) is required for intestinal absorption of calcium and phosphate. Dietary deficiency of vitamin D in children leads to developmental bone deformities and fractures. Keywords: Vitamin D, rickets 3 the answer is B: Decreased serum levels of erythropoietin. The other mechanisms of disease are unlikely causes of anemia in a patient with a history of chronic renal disease. The kidneys filter blood to remove metabolic waste and excess water and balance concentrations of serum electrolytes. The nephron consists of a (1) renal corpuscle (glomerulus and Bowman capsule), (2) proximal convoluted tubule, (3) thin and thick limbs of the nephron loop (loop of Henle), (4) distal convoluted tubule, and (5) collecting tubule. Collecting ducts transport urine to minor and then to major calyces, which drain via the ureter to the urinary bladder. Loops of Henle are straight tubules that extend deep into pyramids of the renal medulla. Cortical labyrinth (choice A) refers to regions of the cortex that contain glomeruli and convoluted tubules. Renal columns (choice C) are extensions of the cortex that lie between renal pyramids. Renal lobules (choice D) are composed of nephrons that drain to a single collecting duct. Renal pyramids (choice E) are conical structures within the medulla that provide a passage for the numerous collecting ducts that drain to the renal papillae located at the apex of the pyramid. The metanephros (true kidney) begins to develop during the 5th and 6th weeks of development. In brief, a diverticulum (ureteric bud) of the mesonephric duct pushes its way into a mass of undifferentiated mesenchyme referred to as the metanephric blastema. The collecting system of the kidney is derived entirely from the embryonic ureteric bud. The ureteric bud undergoes extensive branching morphogenesis to generate medullary collecting ducts, renal calyces, renal pelvis, and ureter. Mesonephric ducts and tubules (choices A and B) give rise to the male genital excretory ducts. The fetal kidneys (metanephroi) begin to produce urine after the 9th week of gestation. After 16 weeks of 212 Chapter 15 gestation, urine produced by the fetal kidneys make an essential contribution to the amniotic fluid. Amniotic fluid serves many crucial functions during development, including (1) protection of the embryo and fetus; (2) regulation of fluid volume and electrolyte homeostasis; and (3) provision of space for symmetric growth of the embryo and fetus. Fetal kidneys are not essential for filtering the blood in utero, because the placenta regulates the exchange of blood gases, nutrients, electrolyte, and metabolic waste between the fetus and the mother. None of the other choices describe the primary function of the fetal kidney during gestation. The internal architecture of the kidney consists of an outer zone (cortex) and inner zone (medulla). In living tissue, the cortex takes on a reddish brown color, since most of the blood in the renal arteries is delivered to the cortex (90% to 95%). The characteristic features of the kidney cortex are renal corpuscles and their associated tubules. Medullary rays (choice D) are portions of the cortex consisting of collecting tubules that drain to collecting ducts in the renal medulla. None of the other anatomic zones/regions exhibit key histologic features of the renal cortex. The outer layer features typical dense connective tissue that is composed of collagen fibers/bundles and fibroblasts.

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During their reproductive years symptoms 5 days before your missed period olanzapine 5 mg buy with mastercard, women are up to three times more likely to develop cholesterol gallstones than men. If the bile contains excess cholesterol, it becomes supersaturated and precipitates to form stones. None of the other components of bile is associated with the pathogenesis of gallstones. The mucosa of the gallbladder is lined by a simple columnar epithelium and a lamina propria of loose connective tissue. The mucosa of the gallbladder has numerous deep folds that may appear as glands in some tissue sections (shown in the image). The lining epithelium is characterized by the presence of tight junctions, apical membrane microvilli, and lateral membrane plications (interdigitations). Approximately 20% of men and 35% of women are found to have gallstones at autopsy. Most complications associated with cholelithiasis are related to obstruction of the biliary tree. Stones that obstruct the common bile duct lead to obstructive jaundice, cholangitis, and acute pancreatitis. Canals of Herring (choice A), hepatic ducts (choice B), and submucosal glands (choice E) are not found in the gallbladder. Mucin-secreting mucosal glands may be seen in the neck of the gallbladder; however, the epithelial structures identified in this image are not composed of mucous cells. The wall of the gallbladder is unusual in that it does not feature a muscularis mucosae or submucosa. Contraction of the smooth muscle forces bile through the cystic duct and down the common bile duct to the duodenum. Because the gallbladder attaches to Liver, Biliary System, and Pancreas the inferior surface of the liver, it features both an adventitia and a serosa (choices A and D). The concentration of bile within the lumen of the gallbladder depends on active and passive transport. This energy-dependent process creates a gradient of electrolytes that draws water from the lumen of the gallbladder, through the epithelium, to the lamina propria, for removal by vascular and lymphatic channels. This active transport mechanism is supplemented by passive transport of water through special membrane pores. These water channels are composed of integral membrane proteins, termed aquaporins. Perforin (choice D) is a cytotoxic protein that is secreted by killer T lymphocytes. The pancreas is a retroperitoneal organ situated between the second part of the duodenum and the spleen. Endocrine cells in the pancreas are organized as compact microglands, referred to as islets of Langerhans. The image shows four spherical islets surrounded by acini of the exocrine pancreas. Functional cell types in the islets of Langerhans include alpha, beta, and delta cells. The secretory units of the exocrine pancreas are small berry-shaped structures (acini) that are lined by a simple epithelium of enzyme-secreting serous cells. These epithelial cells store zymogen granules in their apical cytoplasm and secrete digestive enzymes that are activated within the lumen of the duodenum. The eosinophilia of pancreatic acinar cells reflects stores of zymogen granules in their apical cytoplasm. The cells are pyramidal in shape, with a broad basal membrane and a narrow apical membrane that surrounds an intercalated duct. Goblet cells (choice B) are unicellular glands found in the respiratory tree and gastrointestinal tract. Mucous cells are filled with heavily glycosylated proteins that do not stain with H&E. Exocrine secretions of the pancreas drain through ducts of various sizes to reach the main pancreatic duct of Wirsung (choice E) or the accessory pancreatic duct of Santorini (choice D). The acinar cells release digestive enzymes into intercalated ducts that originate within the secretory unit. Intercalated ducts join to form intralobular (choice C) ducts that coalesce to form larger interlobular (choice B) ducts. Proenzymes secreted by the acinar cells are diluted with an alkaline pH fluid that is produced primarily by epithelial cells lining the intercalated ducts. Submucosal (Brunner) glands in the proximal part of the duodenum also secrete an alkaline fluid that helps to neutralize the acidity of gastric juice. The arrow identifies a large pancreatic duct surrounded by dense irregular connective tissue. This duct is best described as an interlobular duct, because it is located in connective tissue septa between pancreatic lobules. Interlobular ducts are lined by low columnar epithelium, whereas intralobular ducts are lined by cuboidal epithelium. The duct indicated in the image is not large enough to be the main pancreatic duct (choice D). None of the other structures exhibit the morphologic features of a pancreatic interlobular duct. The pancreas secretes about 1 L of fluid per day (about the same volume as the gallbladder). Digestive proenzymes secreted by the pancreas are activated when they reach the lumen of the duodenum.

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Pancreatic amylase and membranebound disaccharidases (isomaltase medicine list discount 2.5 mg olanzapine with visa, glucoamylase, lactase, sucrase) complete carbohydrate digestion. Colonic bacteria then digest it to short-chain fatty acids and H2, the latter of which can be detected in breath samples (20 ppm is considered diagnostic). The pellagra-like symptoms of disease are the result of a deficiency caused by an inability to absorb (and other neutral amino acids). The pellagra-like symptoms of Hartnup disease are the result of a niacin deficiency caused by an inability to absorb tryptophan (and other neutral amino acids). What is the physiologic stimulus for pancreatic lipase secretion into the intestinal lumen Fat passes through the small intestine to the colon undigested as a result, causing steatorrhea. Short- and medium-chain fatty acids diffuse across the epithelium and enter the circulation directly. Long-chain fatty acids are absorbed by diffusion or transported across the apical membrane in association with fatty acid-binding proteins. Incorporation of fatty acids into triglycerides, phospholipids, and cholesterol esters 4. Chylomicrons are exocytosed across the basolateral membrane and enter the lymphatic system. Lipid Absorption 1 Long-chain fatty acids Mixed micelles 2 Cholesterol Lysolecithins Monoglycerols 3 4 Portal circulation 5 Lymphatic circulation Vitamins A, D, E, and K are fat-soluble. They are incorporated into micelles and absorbed from the gut lumen by mechanisms similar to those used for other fatty acids. Once inside the enterocyte, they are packaged into chylomicrons and transferred to the lymphatic system for distribution. Vitamin E deficiency is rare in otherwise healthy populations but can cause hemolysis and neurologic symptoms. Vitamin E is an antioxidant that normally protects membrane fatty acids from peroxidation. The cause is unknown (possibly infectious), but intestinal villi are stunted as a result, causing malabsorption. Reduced absorption and increased excretion of divalent cations, including Ca2, causes hypocalcemia. Mouth What two main large intestine features allow it to absorb all but 100 mL of water per day from feces What are the four different types of diarrhea (based on stool characteristics) and the mechanisms by which water absorption is impaired Na follows the negative charge carried by Cl, and H2O is drawn into the lumen by osmosis. This causes pancreatic insufficiency and can lead to recurrent bouts of pancreatitis. Vagal efferents cause sphincter of Oddi relaxation through vasoactive intestinal peptide release, permitting bile to flow into the small intestine. Bile contains water, various electrolytes, bile salts, cholesterol, fatty acids, phospholipids, and bilirubin. Symptoms arise when stones enter the bile duct and obstruct flow, causing pain (biliary colic). Review three or more mechanisms by which islet neuroendocrine cells are regulated. What characteristic symptom triad do somatostatinomas produce, and what is their etiology What are the three enzymes being modulated by glucagon receptor binding, and what are the consequences Glucagon is therapeutic because it increases cardiac through a rise in intracellular and concentration. Glucagon acts primarily on hepatocytes but also on striated muscle and adipocytes. Stimulates glucose 6-phosphatase to circulating glucose levels Glucagon is a first-line antidote for beta-blocker overdose.

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Doctors then started to become aware of an increasing incidence of lung cancer and noticed that the patients were smokers medications i can take while pregnant discount olanzapine on line. By 1950, an epidemic of lung cancer had become apparent and studies, such as those of Doll and Hill in the 1950s, established the causative link between smoking and lung cancer. At that time, 83% of doctors smoked, but thereafter the medical profession was the first to put research into practice, by stopping smoking! In the early 1960s, the Royal College of Physicians of London and the Respiratory Medicine Lecture Notes, Ninth Edition. Small-cell (oat-cell) carcinoma arises from neuroendocrine cells of the bronchial tree and its endocrine potential is sometimes manifest clinically by ectopic hormone production. Squamous-cell carcinoma is the most common type of lung cancer and shows the greatest tendency to cavitate. About 13% of lung cancers do not show squamous or glandular differentiation and are classified as large-cell undifferentiated carcinomas. Some studies suggest that a high dietary intake of fruit and vegetables containing -carotene reduces the risk of lung cancer. Exposure to ionising radiation such as that from radon gas arising from the ground and from building materials in some homes may be important and accounts for a proportion of lung cancers in nonsmokers. Occupational exposure to asbestos is associated with an increased risk of lung cancer, with an approximately linear relationship between the dose of asbestos and the occurrence of lung cancer. Diagnosis Lung cancers arising centrally in the bronchial tree often present with chest symptoms. Such tumours may be found coincidentally on a chest X-ray or present with nonspecific general symptoms. As a rough approximation, small-cell carcinomas double monthly, squamous-cell carcinomas 3-monthly and certain adenocarcinomas 6-monthly. A tumour typically becomes evident on a chest X-ray when it reaches about 1 cm in diameter, corresponding to about 30 doubling volumes. Paraneoplastic syndromes arise at sites distant from the tumour or its metastases and result from the production of hormones, peptides, antibodies, prostaglandins or cytokines by the tumour. Hypercalcaemia in patients with lung cancer may be indicative of bone metastases, but squamous-cell carcinomas sometimes secrete a parathyroid hormone-related protein that causes nonmetastatic hypercalcaemia. Clearly, some patients will present primarily with chest symptoms, often against a background of pre-existing smoking-related lung disease. Equally, a diagnosis of lung cancer must be considered in patients presenting with a variety of medical problems. Tumours in certain specific locations may cause problems by direct invasion of adjacent structures. Direct invasion of the mediastinum can cause paralysis of the phrenic nerve, manifest by elevation of the hemidiaphragm, or of the recurrent laryngeal nerve, particularly on the left side, where it passes around the aortic arch to the superior mediastinum, causing vocal cord palsy with hoarseness and diminished cough reflex. Injection of Teflon or Bioplastique into the paralysed vocal cord under general anaesthesia can improve voice quality by building up the volume of the vocal cord, enabling better apposition. Obstruction of the superior vena cava causes venous engorgement of the upper body with facial oedema, headache, distended pulseless jugular veins and enlarged collateral veins over the chest and arms. These symptoms require urgent treatment by chemotherapy in the case of small-cell cancer or radiotherapy in the case of other tumours. Insertion of an expandable metallic wire stent into the strictured vein under radiological guidance can give rapid relief of symptoms in severe cases. The chest X-ray shows a mass at the apex of the left lung eroding the first and second ribs posteriorly. Anhydrosis is due to stellate ganglion involvement, with pain resulting from erosion of the posterior first and second ribs and wasting of the small muscles of the hand due to brachial plexus invasion. The chest X-ray plays a pivotal role in the investigation of lung cancer, and a range of abnormalities may be apparent. Sputum cytology is positive in about 40% of cases, and is particularly useful in patients unfit for invasive tests. Diagnosis may also be achieved by obtaining material from a site of metastasis. Bronchoscopy Flexible fibreoptic bronchoscopy is usually performed as an outpatient procedure under sedation. The chest X-ray shows a triangular-shaped opacity in the right upper zone, indicating collapse of the right upper lobe. Bronchoscopy showed a tumour occluding the orifice to the right upper lobe and biopsy showed a large-cell undifferentiated carcinoma. Coincidentally, the X-ray also shows an old un-united fracture of the right clavicle. The procedure caused a small pneumothorax, which resolved spontaneously without the need for intervention. The bronchial tree is illuminated by light transmitted from a light source to the tip of the bronchoscope and the image is transmitted to the eyepiece or displayed on a screen. About two-thirds of lung cancers are visible through the bronchoscope, and therefore bronchoscopy is a key investigation for lung cancer or haemoptysis. Bronchoscopy is a very safe procedure but is contraindicated in patients with uncontrolled angina or recent myocardial infarction. Sedation should be avoided or used with particular caution in patients with respiratory depression.

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By contrast treatment of criminals order olanzapine in united states online, venules (line 3) typically feature a very thin wall and exhibit a collapsed lumen. Cross sections of a few skeletal muscle fibers are present in this microscopic field (line 5). Keywords: Oral cancer, arterioles 35 the answer is A: Dense irregular connective tissue. Dense irregular connective tissue fills the space between the structures described above. It is typically less cellular and poorly organized, with pink-stained collagen fibers running in various directions. The thyroid features large follicles that are filled with a pink-stained gelatinous material (colloid). A series of C-shaped cartilaginous rings provide structural support to the trachea. The rings are composed of hyaline cartilage that features chondrocytes in lacunae and a glassy translucent matrix. It is lined by a stratified squamous epithelium and features a thick muscular wall that is lined by striated muscle (upper esophagus) or smooth muscle (lower esophagus). The recurrent branch of the vagus nerve (cranial nerve X) ascends in a groove between the trachea and esophagus to innervate the larynx. Arrow 1 points to a stratified epithelium composed of a basal layer of cuboidal cells and an upper layer of columnar cells. The shape of the upper layer of cells designates the type of stratified epithelium. This arrow points to a section through a large excretory duct that is lined by stratified columnar epithelium. Intralobular ducts in salivary glands are lined by cuboidal to low columnar epithelium, depending on the diameter of the duct. Note the wavy appearance of the axons and the pale-stained space where lipid-rich myelin was removed in tissue processing. These are the characteristic features of peripheral nerves in routine H&E slide preparations. This arrow points to the lining epithelium of a blood vessel that is filled with red blood cells. Simple squamous epithelial cells (endothelial cells) line all vascular and lymphatic channels in the body. Some of the nuclei assume a "corkscrew" appearance, due to postmortem contraction of the muscle cells. These nuclear features help distinguish smooth muscle from connective tissue (choices A and B). Large, coarse, and densely packed collagen bundles with few fibroblast cell nuclei are the characteristic features of dense connective tissue. The presence of collagen fibers running in many different directions provides evidence of irregular collagen assembly. Keywords: Dense irregular connective tissue 46 the answer is D: Respiratory bronchiole. Respiratory bronchioles are distal to terminal bronchioles (the space indicated by number 2). They are transitional regions between conducting and respiratory portions of the respiratory system. They have incomplete walls that are interrupted by openings to respiratory alveoli. Smooth muscle cells are still visible in portions of the bronchiole wall located beneath the simple cuboidal epithelium. Keywords: Respiratory system, respiratory bronchioles Comprehensive Review 47 the answer is C: Space 3. Alveolar ducts are long, thin-walled tubules whose walls are entirely lined by openings of alveoli and alveolar sacs. The muscle fibers demonstrate relatively large diameters with centrally located nuclei. Smooth muscle fibers are spindle-shaped cells with single, centrally located nuclei. Thus, in a given transverse section, many cells are expected to appear without nuclei. In cells whose nuclei are visible in the section plane, the nuclei are located in the center of the cytoplasm. Smooth muscle fibers are smaller in diameter than those of skeletal and cardiac muscle. The dark-stained axons are surrounded by a pale circular space that represents the lipid-rich myelin sheath that was removed during tissue processing. Endoneurium is a delicate layer of connective tissue that encloses each axon and its associated myelin sheath. This section through compact bone reveals bone-forming cells in lacunae and well-organized, eosinophilic collagen lamellae. The concentric layers of collagen surround a centrally located canal (haversian canal) that forms part of the haversian system.

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Sedation Sedative actions medications 3605 buy olanzapine once a day, with relief of anxiety, occur with all drugs in this class. Anxiolysis is usually accompanied by some impairment of psychomotor functions, and behavioral disinhibition may also occur. In animals, most conventional sedative-hypnotics release punishment-suppressed behavior. Hypnosis Sedative-hypnotics can promote sleep onset and increase the duration of the sleep state. Effects on sleep patterns occur infrequently with newer hypnotics such as zaleplon and zolpidem. Anesthesia At high doses of most older sedative-hypnotics, loss of consciousness may occur, with amnesia and suppression of reflexes. Anterograde amnesia is more likely with benzodiazepines than with other sedative-hypnotics. Anesthesia can be produced by most barbiturates (eg, thiopental) and certain benzodiazepines (eg, midazolam). Anticonvulsant Actions Suppression of seizure activity occurs with high doses of most of the barbiturates and some of the benzodiazepines, but this is usually at the cost of marked sedation. Selective anticonvulsant action (ie, suppression of convulsions at doses that do not cause severe sedation) occurs with only a few of these drugs (eg, phenobarbital, clonazepam). High doses of intravenous diazepam, lorazepam, or phenobarbital are used in status epilepticus. Muscle Relaxation Relaxation of skeletal muscle occurs only with high doses of most sedative-hypnotics. However, diazepam is effective at sedative dose levels for specific spasticity states, including cerebral palsy. Medullary Depression High doses of conventional sedative-hypnotics, especially alcohols and barbiturates, can cause depression of medullary neurons, leading to respiratory arrest, hypotension, and cardiovascular collapse. Tolerance and Dependence Tolerance-a decrease in responsiveness-occurs when sedativehypnotics are used chronically or in high dosage. Psychological dependence occurs frequently with most sedative-hypnotics and is manifested by the compulsive use of these drugs to reduce anxiety. Physiologic dependence constitutes an altered state that leads to an abstinence syndrome (withdrawal state) when the drug is discontinued. Withdrawal signs, which may include anxiety, tremors, hyperreflexia, and seizures, occur more commonly with shorter-acting drugs. Anxiety States Benzodiazepines are favored in the drug treatment of acute anxiety states and for rapid control of panic attacks. Although it is difficult to demonstrate the superiority of one drug over another, alprazolam and clonazepam have greater efficacy than other benzodiazepines in the longer term treatment of panic and phobic disorders. Note the increasing use of newer antidepressants in the treatment of chronic anxiety states (see Chapter 30). Sleep Disorders Benzodiazepines, including estazolam, flurazepam, and triazolam, have been widely used in primary insomnia and for the management of certain other sleep disorders. More recently there has been increasing use of zolpidem, zaleplon, and eszopiclone in insomnia, since they have rapid onset with minimal effects on sleep patterns and cause less daytime cognitive impairment than benzodiazepines. Note that sedativehypnotic drugs are not recommended for breathing-related sleep disorders, eg, sleep apnea. Other Uses Thiopental is commonly used for the induction of anesthesia, and certain benzodiazepines (eg, diazepam, midazolam) are used as components of anesthesia protocols including those used in day surgery. Special uses include the management of seizure disorders (eg, clonazepam, phenobarbital) and bipolar disorder (eg, clonazepam) and treatment of muscle spasticity (eg, diazepam). Longer acting benzodiazepines (eg, chlordiazepoxide, diazepam) are used in the management of withdrawal states in persons physiologically dependent on ethanol and other sedative-hypnotics. However, all prescription drugs used as sleep aids may cause functional impairment, including "sleep driving," defined as "driving while not fully awake after ingestion of a sedative-hypnotic product, with no memory of the event. Overdosage Overdosage of sedative-hypnotic drugs causes severe respiratory and cardiovascular depression; these potentially lethal effects are more likely to occur with alcohols, barbiturates, and carbamates than with benzodiazepines or the newer hypnotics such as zolpidem. Management of intoxication requires maintenance of a patent airway and ventilatory support. Other Adverse Effects Barbiturates and carbamates (but not benzodiazepines, eszopiclone, zolpidem, or zaleplon) induce the formation of the liver microsomal enzymes that metabolize drugs. Barbiturates may also precipitate acute intermittent porphyria in susceptible patients. Chloral hydrate may displace coumarins from plasma protein binding sites and increase anticoagulant effects. Buspirone has a slow onset of action (>1 week) and is used in generalized anxiety disorders, but is less effective in panic disorders. Tolerance development is minimal with chronic use, and there is little rebound anxiety or withdrawal symptoms on discontinuance. Side effects of buspirone include tachycardia, paresthesias, pupillary constriction, and gastrointestinal distress. Psychomotor Dysfunction this includes cognitive impairment, decreased psychomotor skills, and unwanted daytime sedation. These adverse effects are more common with benzodiazepines that have active metabolites with long half-lives (eg, diazepam, flurazepam), but can also occur after a single dose of a short-acting benzodiazepine such as triazolam.

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This yields a mineral bank that can be mobilized to optimize plasma Ca2 and phosphate levels 5ht3 medications generic olanzapine 2.5 mg with amex. Although both men and women lose bone mass with age, men achieve a greater bone mass during their early years, so the effects of osteoporosis. A-plus: Loss of bone mass is due to declining estrogen and androgen levels with age. These hormones promote bone deposition, so when levels drop, the normal balance between deposition and resorption tips in favor of bone loss. Most patients with Paget disease remain asymptomatic, but some present with deformities, arthritis, and pain associated with nerve compression and bone remodeling. Osteoclasts resorb and then osteoblasts rebuild bone at accelerated rates, leaving insufficient time for bone maturation. Eccrine sweat gland (cooling) Sebum is a lipid-based secretion produced by sebocytes, which are located within sebaceous glands. Sebum continues to accumulate and provides a substrate that sustains proliferation of Propionibacterium acnes, a normal constituent of skin flora. The follicle typically ruptures and precipitates an inflammatory response that manifests as a skin pustule. Review the ionic and cellular events involved in sweat formation by an eccrine sweat gland. Why are sweat glands stimulated during shock, including during hypovolemic shock. Cholinergic nerve terminals [Note: Not shown is a layer of mesangial cells that surround the coil. Lidocaine is commonly used topically to relieve skin itching and pain and as a local anesthetic prior to dental surgery. Aorta What sounds are associated with normal valve function, and which valves are responsible Aortic valve Heart Valves Aorta the first and second heart sounds (S1 and S2) are associated with normal valve function. Mitral valve incompetence (or insufficiency) is a common congenital heart valve defect. Oxygenated blood flows from the left atrium to the right, which is at slightly lower pressure. The shunt thereby creates a volume load on the right ventricle and increases pulmonary flow. The pulmonary vasculature adapts to the volume load through capillary recruitment and angiogenesis. What are the advantages and disadvantages to using gap junctions in signal propagation A heartbeat originating in a region of the heart other than the node is known as an. This excitation sequence yields a similarly sequenced ventricular contraction that forces blood up toward the valve outlets. Transmission speed is enhanced through increased Na -channel density, and increased fiber diameter. Lippincott Illustrated Reviews Flash Cards: Physiology Inward Outward Three principal ion currents: 1. Phase 2 correlates with Ca2 influx, so prolonging this phase increases intracellular Ca2 availability, crossbridge cycling, and contractility. What channel type is responsible for the rising phase 4, and why is the ionic event it mediates known as a "funny current" A pacemaker current (the funny current or If) activates, and the membrane depolarizes toward threshold. The "funny current" is so described because it activates following membrane repolarization rather than upon depolarization. Membrane potential (mV) 0 Refractory periods are common to both neurons and myocytes. An increase in P-wave height suggests atrial enlargement, perhaps because the ventricle requires additional preload. A-plus: An injury current flows between healthy and ischemic myocardium, even at rest. Retrograde flow during atrial systole is minimal because the large volume of blood contained within the venous compartment has high inertia. When left atrial thrombi embolize, they enter the systemic circulation and place the patient at grave risk of stroke. S3 ventricular filling (in children and healthy thin adults, otherwise pathologic) S2 may split into separate aortic (A2) and pulmonary (P2) valve components during inspiration. Intrathoracic pressure falls during inspiration, enhancing the pressure gradient driving blood flow from the venous system to the right heart. The right ventricle preloads to a greater extent than the left as a result, and the added volume takes longer to eject, thus delaying P2.

Kapotth, 56 years: The inhalation of these antigens provokes a complex immune response in susceptible individuals, involving antibody reactions, immune-complex formation, complement activation and cellular responses, resulting in alveolitis. Single-lung transplant A diseased lung is removed through a thoracotomy incision, leaving the heart and contralateral lung intact. Hyaluronan is a high molecular weight polysaccharide that retains extracellular (interstitial) water. None of the other choices describe the principal function of the stratum basalis of the uterine endometrium.

Karrypto, 62 years: Volvulus (choice E) is an example of intestinal obstruction, in which a segment of the gut twists on its mesentery, kinking the bowel and interrupting its blood supply. The mammary glands consist of 15 to 25 lobes separated by dense, irregular connective tissue. Columnar epithelial cells line the papillary ducts, which drain urine into minor calyces (visible in the image). Likewise, people who participate in the sport of pigeon racing or who keep pet birds, such as budgerigars, can inhale avian antigens.

Irmak, 57 years: In patients with portal hypertension secondary to cirrhosis of the liver, these portal�systemic anastomoses become distended with blood. Not all asthma patients have vagal reflex output to the bronchi as a major contributor to the bronchospasm, and these patients will not respond well to an antimuscarinic. After a very brief activation, most sodium channels enter a more prolonged period of inactivation. Management of overdose includes maintenance of a patent airway plus ventilatory support.

Folleck, 43 years: Lymph enters a node through afferent channels and percolates through lymphatic sinuses that are spanned by a fine meshwork of extracellular reticular fibers, reticular cells, and macrophages. Fentanyl has also been used by the transdermal route providing analgesia for up to 72 h. Here, the axon is covered by thin cell membranes with a high concentration of voltage-gated Na+ and K+ channels. When this organism is first identified, an attempt should be made to eradicate it using oral ciprofloxacin 750 mg b.

Kafa, 35 years: Assuming the structure is part of the thoracolumbar system, norepinephrine acts at which of the following sites in the diagram The mammary glands undergo extensive branching morphogenesis both during and after pregnancy. Viral infections often precipitate attacks of asthma, so it is advisable for patients to monitor symptoms (or even peak flow measurements) carefully during such infections and to intensify asthma treatment as required. Thus, quantal studies are used to determine the therapeutic index and the variation in sensitivity to the drug.

Pakwan, 27 years: Goblet cells located within the respiratory epithelium also produce abundant mucus. Keywords: Bacterial pneumonia, Streptococcus pneumonia 16 the answer is C: Purulent exudate. The stomach relaxes as a result, thereby accommodating a meal with minimal increase in gastric pressure. In sweat ducts, failure of reabsorption of chloride ions results in elevated concentrations of chloride and sodium in the sweat, a characteristic feature of the disease and the basis for the sweat test used in diagnosis.

Nafalem, 54 years: Keywords: Bronchi, bronchopulmonary segments 27 the answer is A: Bronchopulmonary segment. His chest X-ray shows cavitating consolidation throughout the right upper lobe, with further areas of consolidation in the left upper and right lower lobes. Fluid leaks into the surrounding cutaneous tissue and 144 Chapter 10 causes stasis dermatitis. Hydrochlorothiazide and spironolactone are not adequate for first-line therapy of edema in failure.

Sebastian, 52 years: Infections near the openings of the ducts of the tarsal glands of Special Sense Organs meibomian can cause internal styes that appear as red bumps beneath the eyelid. Which of the following structures is removed from late spermatids prior to the release of sperm into the lumen of the seminiferous tubules Secretory cells in sebaceous glands are large and swollen cells, and they exhibit a central pyknotic nucleus. A-plus: Rickets can also be caused by renal phosphate wasting (phosphopenic rickets).

Varek, 30 years: The urine is then stored in the bladder until it is expelled from the body through the urethra. How do they cause increased arterial pressure and a decrease in maximal attainable heart rate Rapid movements associated with head trauma can shear these axons, causing anosmia. The basilar membrane stretches from the osseous spiral lamina medially to the lateral spiral ligament, whereas the tectorial membrane hinges from the spiral limbus.

Falk, 31 years: Inflammatory responses to the infection cause chronic gastritis and, ultimately, gastric mucosa erosion. In many species, spermatogenesis occurs in cycles that appear as "waves" running along the seminiferous tubules (choice E). Paresthesias and gastrointestinal distress are common adverse effects of acetazolamide, especially when it is taken chronically, as in glaucoma. The kidney produces erythropoietin; patients with chronic renal insufficiency often require exogenous erythropoietin to avoid chronic anemia.

Campa, 39 years: Identify the delicate apical membrane feature indicated by the arrows (shown in the image). The traditional treatments of cystic fibrosis have focused on managing the consequences of the disease, such as lung infection, inflammation and thick mucus secretions. Alcohol enhances psychomotor depression and the amnestic effects of the benzodiazepines. Other Tissues the effects of these drugs on the heart are discussed in Chapter 14 (see group 1 antiarrhythmic agents).

Ramon, 42 years: These tissue functions include (1) protection, transport, and secretion (epithelial tissue); (2) contraction and movement (muscle tissue); (3) reception and transmission of information (neural tissue); and (4) support (connective tissue). This disease is caused by smoking-related injury to which of the following components of the respiratory system Oral administration of diphenhydramine is a possibility, but the patient may find it difficult to swallow and it would take a longer time to act. Inhibitors of the receptors for the prostaglandins and the leukotrienes are being actively sought.