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By K. Hernando. Bay Path College. 2018.

Individuals with traumatic brain injury cheap viagra plus 400mg fast delivery, Symptoms of some conditions of the stroke buy viagra plus 400mg amex, or multiple sclerosis may have cog- nervous system generic viagra plus 400mg overnight delivery, such as epilepsy, can be nitive and emotional impairments as well controlled with medication. Other condi- as impairment of motor function as a tions, such as multiple sclerosis and direct consequence of their injury or con- Parkinson’s disease, involve progressive dition. Because they need to learn com- deterioration, and treatment focuses on pensatory strategies for a number of controlling symptoms, preventing com- activities and social interactions, psycho- plications, and promoting function and logical adaptation to the disorder be- General Issues in Nervous System Conditions 113 comes multifaceted. It is often difficult to Reactions may include hostility, anger, or determine the degree to which behavioral withdrawal. If the accident was the available treatment is limited and direct- fault of a third party, they may feel chron- ed mainly toward controlling symptoms ic anger toward the offender or may turn or preventing complications. In individuals with these conditions may some instances, the quest for retribution feel they have little control over the con- becomes a negative force, eroding the dition or their future. When conditions individual’s life as he or she continually are progressively debilitating, as in multi- seeks some sort of justice. Individ- Under these circumstances, they may uals may harbor resentment over the experience a helpless rage or bitterness dependency imposed by the condition. The uncertainty about whether reaction may vary from overdependence disability will be minimal or will progress to overcompensation, in which they take to severe disability can produce stress and unnecessary risks to test or prove their hardship. Learning to accept nec- reaction to using a wheelchair, viewing essary assistance from others for basic it instead as a symbol of the inability to needs, such as feeding, personal hygiene, walk. In other instances, even though and bowel and bladder care, requires the disability experienced is minimal, reconstituting views of privacy and self- they may grieve over the lost ability to reliance. Not only are such not only impose permanent loss of func- activities private and mishaps a potential tion, but also involve complex self-con- source of embarrassment, but both may cept and body image changes. Traumatic also be associated with the shame and brain injury, stroke, and spinal cord humiliation experienced in early child- injury provide no time for gradual adjust- hood when control of these most basic ment. Individuals who had been previ- bodily functions was a central issue of ously active are suddenly faced with development. Just as al time for dressing, bathing, and other neurological conditions have a spectrum self-care needs. If wheelchairs are used, of functional consequences, so also the the environment must be made naviga- adjustment of individuals with neurolog- ble. Wheelchairs can provide more free- ical conditions is highly individualized, dom of movement for those with paralysis, and no two individuals with the same dis- for those who have difficulty walking ability will have a reaction that is quite because of problems with coordination, the same. Freedom Lifestyle Issues of movement is limited, however, if there are stairs but no elevator, if bathrooms are The effects of neurological disorders on too small to accommodate a wheelchair, an individual’s lifestyle are varied and or public transportation is unequipped complex. Activities of daily living are of- with lifts or mechanisms for transporting ten altered so that help from family mem- individuals in wheelchairs. Subsequent Individuals with neurological disorders loss of privacy for most intimate details of can usually drive, even with paralysis, if the daily life, such as bathing or other aspects vehicle is equipped with special controls. Even when individuals are able ceptual deficits, however, driving may not to manage their own personal care, the be possible. Although regulations vary from additional time required to carry out most state to state, individuals with epilepsy activities may be considered a liability. When fatigue exacerbates the symp- Although not all neurological conditions toms of a neurological disorder, as in mul- require the use of a wheelchair, most re- tiple sclerosis, or when fatigue is part of quire some consideration of environmen- the symptomatology, as in post-polio tal factors. For example, individuals with syndrome, it may be necessary to space epilepsy may need to avoid environmen- out activities or to arrange for frequent tal conditions such as flashing lights, rest periods during the day. Because times helpful to divide activities that were General Issues in Nervous System Conditions 115 once completed in a short amount of time Although loss or alteration of sexual into a series of smaller tasks, allowing rest function is initially a severe blow to self- periods in between. Generally, needs through a variety of alternate physiologic responses require an intact means. Sexual function may be can develop long-term intimate relation- most disrupted by conditions involving ships that include love, respect, and mu- the spinal cord. Although women with a tually satisfying expression of sexual spinal cord injury are still capable of inter- feelings.

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For fusible anions (such as Cl ) are higher in interstitial fluid 2 2 singly charged (univalent) ions 400 mg viagra plus otc, such as Na discount viagra plus 400mg mastercard, K buy discount viagra plus 400mg on-line, Cl , or than in plasma. For doubly charged (di- extent (about 40% and 30%, respectively) by plasma pro- 2 2 2– valent) ions, such as Ca , Mg , or SO4 , 1 mmol is equal teins, and it is only the unbound ions that can diffuse 2 to 2 mEq. Some electrolytes, such as proteins, are polyva- through capillary walls. The usefulness of ex- Mg concentrations are higher than in interstitial fluid. The cells have a higher K , Mg , and protein concentration than in the surrounding intersti- 3 cations 3 anions (4) 2 tial fluid. The intracellular Na , Ca , Cl , and HCO3 If we know the total concentration (mEq/L) of all cations levels are lower than outside the cell. The anions in skele- in a solution and know only some of the anions, we can eas- tal muscle cells labeled “Others” are mainly organic phos- ily calculate the concentration of the remaining anions. Na is the major cation in plasma, and Cl and [Na ] are a consequence of plasma membrane Na /K - HCO3 are the major anions. The plasma proteins (mainly ATPase activity; this enzyme extrudes Na from the cell serum albumin) bear net negative charges at physiological and takes up K. The electrolytes are actually dissolved in the plasma in skeletal muscle cells are primarily a consequence of the water, so the second column in Table 24. The water content of plasma is vors the outward movement of these small, negatively 2 usually about 93%; about 7% of plasma volume is occupied charged ions. The intracellular [Mg ] is high; most is not 2 by solutes, mainly the plasma proteins. Intracellular [Ca ] is 2 tration in plasma to concentration in plasma water, we di- low; as discussed in Chapter 1, the cytosolic [Ca ] in rest- 7 vided the plasma concentration by the plasma water con- ing cells is about 10 M (0. Therefore, 142 mEq Na /L Ca is sequestered in organelles, such as the sarcoplasmic plasma becomes 153 mEq/L H2O or 153 mEq/kg H2O reticulum in skeletal muscle. It contains all of the small electrolytes in es- Intracellular and Extracellular Fluids Are sentially the same concentration as in plasma, but little pro- Normally in Osmotic Equilibrium tein. The proteins are largely confined to the plasma Despite the different compositions of ICF and ECF, the to- because of their large molecular size. Differences in small tal solute concentration (osmolality) of these two fluid ion concentrations between plasma and interstitial fluid compartments is normally the same. ICF and ECF are in os- (compare Columns 2 and 3) occur because of the different motic equilibrium because of the high water permeability protein concentrations in these two compartments. Two of cell membranes, which does not permit an osmolality factors are involved. If the osmolality changes in one cause the plasma proteins are negatively charged, they compartment, water moves to restore a new osmotic equi- cause a redistribution of small ions, so that the concentra- librium (see Chapter 2). But the lat- added to an original total body water volume of 42 L, the ter depends on the amount of solute present and the osmo- new total body water volume is 44 L. This fact follows from the definition of the term con- so the new osmolality at equilibrium is (7,980 3,990 centration: concentration amount/volume; hence, volume mOsm)/44 kg 272 mOsm/kg H2O. The main osmotically active ICF at equilibrium, calculated by solving the equation, 272 solute in cells is K ; therefore, a loss of cell K will cause mOsm/kg H2O volume 7,980 mOsm, is 29. From these cal- motically active solute in the ECF is Na ; therefore, a gain culations, we conclude that two thirds of the added water or loss of Na from the body will cause the ECF volume to ends up in the cell compartment and one third stays in the swell or shrink, respectively. This description of events is artificial because, in real- The distribution of water between intracellular and ex- ity, the kidneys would excrete the added water over the tracellular compartments changes in a variety of circum- course of a few hours, minimizing the fall in plasma osmo- stances. The y-axis represents total solute concentration and lution) were added to the ECF. Isotonic saline is isosmotic the x-axis the volume; the area of a box (concentration to plasma or ECF and, by definition, causes no change in times volume) gives the amount of solute present in a com- cell volume.

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The subunit is made shortly after ovulation and produces significant amounts of of 145 amino acids discount viagra plus 400mg with visa, with six N- and O-linked oligosaccha- progesterone and estrogen to prepare the uterus for receiv- ride units 400 mg viagra plus visa. If the egg is not fertilized cheap viagra plus 400 mg free shipping, the corpus acid extension at the C-terminal end. Because of extensive luteum regresses at the end of the luteal phase, as indicated glycosylation, the half-life of hCG in the circulation is by declining levels of progesterone and estrogen in the cir- longer than that of LH. After losing ovarian steroidal support, the superfi- hCG in early pregnancy is the stimulation of luteal cial endometrial layer of the uterus is expelled, resulting in steroidogenesis. If the egg is fertilized, the developing em- receptors and increase the formation of pregnenolone from bryo signals its presence by producing hCG, which extends cholesterol by a cAMP-dependent mechanism. This signaling process is The hCG level in plasma doubles about every 2 to 3 called the maternal recognition of pregnancy. Syncytiotro- days in early pregnancy and reaches peak levels at about 10 phoblast cells produce hCG 6 to 8 days after ovulation (fer- to 15 weeks of gestation. It is reduced by about 75% by 25 tilization), and hCG enters the maternal and fetal circula- weeks and remains at that level until term (Fig. Very similar to LH, hCG has a molecular weight of concentrations of hCG follow a similar pattern. The hCG approximately 38 kDa, binds LH receptors on the corpus levels are higher in pregnancies with multiple fetuses. Dur- luteum, stimulates luteal progesterone production, and pre- ing the first trimester, GnRH locally produced by cytotro- vents menses at the end of the anticipated cycle. It can be phoblasts appears to regulate hCG production by a detected in the pregnant woman’s urine using commercial paracrine mechanism. Human placental lactogen (hPL) has lactogenic and Mother Fetus growth hormone-like actions. As a result, it is also called human chorionic somatomammotropin and chorionic Oxygen growth hormone. This hormone is synthesized by syncy- CO tiotrophoblasts and secreted into the maternal circulation, 2 where its levels gradually rise from the third week of preg- Water, electrolytes nancy until term. Although hPL is produced by the same cells as hCG, its pattern of secretion is different, indicating Water, urea the possibility of control by different regulatory mecha- Carbohydrates, nisms. The hormone is composed of a single chain of 191 lipids, amino acids, amino acids with two disulfide bridges and has a molecular vitamins weight of about 22 kDa. Its structure and function resemble Waste products those of prolactin (PRL) and growth hormone (GH). Hormones (some) Human placental lactogen promotes cell specialization in the mammary gland but is less potent than PRL in stim- Antibodies ulating milk production and is much less potent than GH in Hormones stimulating growth. Its main function is to alter fuel avail- Drugs (some) ability by antagonizing maternal glucose consumption and enhancing fat mobilization. Its effects on carbohydrate, protein, and Viruses (most) fat metabolism are similar to those of GH. The amniotic fluid also contains large amounts of PRL produced mainly by the decidual compartments. Steroid Production During Pregnancy Involves the Ovary and Fetoplacental Unit feedback by placental progesterone or other steroids pro- duced by the fetus. Progesterone secretion by the corpus Progesterone is required to maintain normal human preg- luteum is maximal 4 to 5 weeks after conception and de- nancy. During the early stages of pregnancy (approxi- clines, although hCG levels are still rising. Corpus luteum mately the first 8 weeks), the ovaries produce most of the refractoriness to hCG results from receptor desensitization sex steroids; the corpus luteum produces primarily proges- and the rising levels of placental estrogens. As the placenta develops, trophoblast 10 of gestation, steroid production by the corpus luteum is cells gradually take over a major role in the production of gradually replaced by steroid production by the placenta. Although the corpus luteum Removal of the corpus luteum after week 10 does not ter- continues to secrete progesterone, the placenta secretes minate the pregnancy. Progesterone levels gradually regulators affecting hCG production are activin, inhibin, rise during early pregnancy and plateau during the transi- and transforming growth factors and. Thereafter, plasma progesterone levels continue crease progesterone production by the trophoblast. There- fore, hCG may have a critical role in maintaining placental 100 20 steroidogenesis throughout pregnancy and replacing luteal Total progesterone secretion after week 10 when the ovaries are hCG estrogen no longer needed to maintain pregnancy.

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The pri- about half cheap 400 mg viagra plus mastercard, and remains unchanged throughout the re- mary buds give rise to secondary buds 400mg viagra plus, which are separated mainder of pregnancy order viagra plus 400mg overnight delivery. In sheep, the rounded by myoepithelial cells derived from epithelial pro- concentration of ACTH and cortisol in the fetal plasma rise genitors. In response to oxytocin, myoepithelial cells will during the last 2 to 3 days of gestation. The nipple and are- lamb pituitary or removal of the adrenals prolongs gestation, ola, which are first recognized as circular areas, are formed while administration of ACTH or cortisol leads to premature during the eighth month of gestation. Cortisol enhances the conversion of progesterone the mammary glands in utero appears to be independent of to estradiol, changing the progesterone-to-estrogen ratio, hormones but is influenced by paracrine interactions be- and increases the production of prostaglandins. Although underdeveloped, they have the capacity lack a pituitary and have atrophied adrenal glands, have an to respond to hormones, revealed by the secretion of small unpredictable length of gestation. Witch’s exhibit low estrogen levels because of the lack of adrenal an- milk results from the responsiveness of the fetal mammary 698 PART X REPRODUCTIVE PHYSIOLOGY Gestational Age Fertilization Male Female XY XX/XO SRY positive SRY negative 6 weeks Testis Ovary 8 weeks Antimüllerian Testosterone DHT Estradiol Absent antimüllerian hormone hormone No müllerian Wolffian duct Müllerian duct duct 8-10 weeks No uterus Vas deferens Uterus Epididymis Fallopian tube Seminal vesicles Upper vagina 10-12 weeks 12-14 weeks Penis (genital tubercle) Clitoris Penile urethra (urogenital folds) Labia minora Scrotum (labioscrotal swellings) Labia majora (vaginal cord) Lower vagina FIGURE 39. Sexual dimorphism in growth and branching of the ducts, whereas progesterone breast development begins at the onset of puberty. The action of male breast is fully developed at about age 20 and is similar both hormones, however, requires synergism with PRL, to the female breast at an early stage of puberty. In females, estrogen exerts a major influence on breast The mammary glands undergo significant changes during growth at puberty. The ducts become elaborate during the first crease in size and pigmentation of the areola and acceler- trimester, and new lobules and alveoli are formed in the sec- ated deposition of adipose and connective tissues. Prostaglandins promote dilatation and ef- peutic induction and augmentation of labor. Therapeutic facement of the cervix and can be used for various reasons induction implies that labor is initiated by the use of a intravaginally, intravenously, or intra-amniotically. Augmentation indicates that labor has started and other therapeutic agent being tested for efficacy in labor that the process is further stimulated by a therapeutic induction and augmentation is mifepristone (RU-486), a agent. It is used to induce labor Oxytocin, the natural hormone produced from the pos- and to increase the sensitivity of the uterus to oxytocin and terior pituitary, is widely used to induce and augment la- prostaglandins. Several synthetic forms of oxytocin can be used by in- these drugs is that they reduce postpartum hemorrhage by travenous routes. CHAPTER 39 Fertilization, Pregnancy, and Fetal Development 699 secretory cells, replacing most of the connective tissue. The Arterial blood development of the secretory capability requires estrogen, progesterone, PRL, and placental lactogen. Their action is supported by insulin, cortisol, and several growth factors. Myoepithelial Lactogenesis begins during the fifth month of gestation, but cell Capillaries only colostrum (initial milk) is produced. Full lactation dur- ing pregnancy is prevented by elevated progesterone levels, which antagonize the action of PRL. The ovarian steroids synergize with PRL in stimulating mammary growth but an- tagonize its actions in promoting milk secretion. Lactogenesis is fully expressed only after parturition, on the withdrawal of placental steroids. Lactating women Lumen produce up to 600 mL of milk each day, increasing to 800 to 1,100 mL/day by the sixth postpartum month. Milk is isosmotic with plasma, and its main constituents include Milk-secreting proteins, such as casein and lactalbumin, lipids, and lac- alveolar cell tose. Colostrum, produced in small quantities during Venous blood the first postpartum days, is higher in protein, sodium, Capillary milk duct and chloride content and lower in lactose and potassium than normal milk. Colostrum also contains immunoglob- ulin A, macrophages, and lymphocytes, which provide Lobuloalveolar duct passive immunity to the infant by acting on its GI tract. Milk- decreases, whereas that of lipids, lactose, and water-solu- producing cells are surrounded by a meshwork ble vitamins increases. The milk-secreting alveolar cells form a single layer of epithelial cells, joined by junctional complexes (Fig. The bases of the cells abut on the contractile myoepithelial cells, and their luminal surface is enriched with microvilli.

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