By R. Mufassa. College of the Holy Cross.

Within minutes order viagra gold with mastercard, some of these paralyzed persons can begin to function normally Muscle twitch Contraction of a whole muscle can be of varying strength cheap viagra gold 800 mg with visa. A twitch buy viagra gold 800mg low price, which is too short and too weak for any use in the body, is produced as a result of a single action potential in a muscle fiber. Muscle fibers are arranged into a whole muscle and function with cooperation producing contraction of varying grades of strength stronger than a twitch. The number of muscle fibers contracting within a muscle The tension developed by each contracting fiber. Motor unit: Each whole muscle is innervated by a number of different motor neurons. One motor neuron innervates a number of muscle fibers, but each muscle fiber is supplied by only one motor neuron. Muscles producing very precise, delicate movement such as extraocular eye muscles and the hand digit muscles contain a few dozen muscle fibers. Muscles designed for powerful, coarsely controlled movement such as those of legs, a single motor unit may have 1500-2000 muscle fibers. This tension generated by the contractile elements is transmitted to the bone via the connective tissue and tendon before the bone can be moved. Intracellular components of the muscle such as the elastic fiber proteins and connective tissue collagen fibers have a certain degree of passive elasticity. There are 2 primary types of movement depending on whether the muscle changes length during contraction. Isotonic contraction: In this type, muscle tension remains constant as the muscle changes length. Isometric contraction: In this type, the muscle is prevented from shortening, so tension developed at constant muscle length. Isotonic contractions are used for body movements and for moving external objects. The submaximal isometric contractions are important for maintaining posture and for supporting the object in a fixed position. During a given movement, a muscle may shift between Isotonic and isometric contractions. Isotonic contraction 90 Steps of Excitation-contraction coupling and relaxation • Ach released from a motor neuron terminal initiates an action potential in the muscle cell that is conducted over the entire surface of the muscle cell membrane. The active transport of Ca++ ions back in to the sarcoplasmic reticulum, is energy dependent. Smooth muscle The majority of these muscles are present in the walls of hollow organs, blood vessels and tubular structures in the body. Their contraction exerts pressure on the contents and regulates the forward movement of contents of these structures. Smooth muscles are spindle-shaped, have 1 nucleus and are much smaller in size (2-10 μm in diameter 92 and 50-100 μm in length). Three types of filaments present in smooth muscles are • Thin actin filaments, which have tropomyosin but lack troponin • Thick myosin filaments, longer than those found in skeletal muscles. Smooth muscles do not form myofibril and are not arranged in sarcomere pattern of skeletal muscle. Smooth muscle myosin interacts with actin only when the myosin is ++ phosphorylated. During excitation, cytosolic Ca increases, that acts as an intracellular messenger, initiating a series of biochemical events that result in phosphorylation of myosin. In Smooth muscles Ca++ binds with calmodulin and intracellular protein similar to troponin in structure. This calcium- calmodulin complex binds to and activates another protein, myosin kinase, which in turn phosphorylats myosin. Phosphorylated myosin then binds with actin thin filament starting cross bridge cycle. Single- unit smooth muscle (visceral smooth muscles) • Found in the walls of hollow organs/viscera - digestive, reproductive, urinary tract and small blood vessels. Slow wave potential Slow contractile response of smooth muscle A smooth muscle contractile response is slower than of muscle twitch. A single smooth muscle contraction may last as long as 3 sec (3000 msec) compared to the maximum of 100 msec for a single contraction response skeletal muscle. Describe the generation of action potential, its phases, ionic basis and mode of propagation 4. Describe the transmission of neural signals at the neuromuscular junction of skeletal muscle. It transports substances from place to place, buffers pH changes, carries excess heat to the body surface for loss, plays a very crucial role in the body’s defense against microbes and minimizes blood loss by evoking homeostatic responses when a blood vessel is injured. Cells need a constant supply of oxygen to execute energy-producing chemical reactions that produce carbon dioxide that must be eliminated continuously. Blood is about 8% of total body weight and has an average volume of 5 liters in women and 5. A very tiny portion of the cardiac output passes through each capillary, bringing oxygen, nutrients, and hormones to each cell and removing carbon dioxide and metabolic end products (waste products). Blood composition Blood consists of erythrocytes, leukocytes, and platelets suspended in liquid called plasma. The white cells and platelet after centrifugation are packed in a thin, cream colored layer because they are colorless, the “buffy coat”, on top of the packed red cell column. The hematocrit averages 42% for women, 45% for men, with average volume occupied by plasma being 58% for women and 55% for men. They are biconcave disks, manufactured in the red bone marrow, losing their nuclei before entering the peripheral circulation. Red cells having nuclei seen on the peripheral smear suggest an underlying disease state. Their biconcave shape gives them enough 104 flexibility so they can easily pass through small capillaries to deliver oxygen to the tissues. The other 2 bonds (besides 4 nitrogen) are formed on either side of the planar porphyrin ring. The affinity of hemoglobin for oxygen is affected by pH, temperature, and 2, 3-diphosphoglycerate concentration. These factors facilitate oxygen uptake in the lungs and its release in the tissues. Structure of a hemoglobin molecule Globin is a tetramer, consisting of two pairs of polypeptide chains. Changes in the polypeptide subunits of globin can also affect the affinity of hemoglobin for oxygen.

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It leads to lower medical appointments due to cancer related morbidities plus a higher quality of life (Stanton et al order viagra gold overnight delivery, 2002) purchase viagra gold cheap online. However the expression of fear and anxiety is associated with lower quality of life and higher depression (Lieberman and Goldstein 2006) buy generic viagra gold 800mg on line. The New Zealand cancer foundation provides a variety of methods for dealing with such a stressful time in a person’s life: http://www. Due to the rarity of this condition, it is often over looked and when found, is at an advanced stage. Signs and symptoms, diagnosis and treatment options are all the same as those previously described. After lumpectomy, all the tissue removed from the breast is examined carefully to see if cancer cells are present in the margins. If cancer cells are found in the margins, additional surgery (re-excision) will be performed to remove the remaining cancer. Sometimes both breasts are removed (a double mastectomy), often as preventive surgery in women at very high risk for breast cancer. Modified Radical Mastectomy Involves the removal breast tissue and axillary lymph nodes (B and C in illustration). Less extensive surgery (such as modified radical mastectomy) has been found to be just as effective and so radial mastectomies are now rarely performed. However, this operation may still be done for large tumours that are growing into the pectoral muscles under the breast. Subcutaneous (“Nipple Sparing”) Mastectomy All of the breast tissue is removed, but the nipple is left alone. Skin Sparing Mastectomy Technique that preserves as much of the breast skin as possible during simple, total, or modified radical mastectomy to provide the skin needed for immediate reconstruction. Only the skin of the nipple, areola, and the original biopsy scar are removed to create a small opening for removal of the breast tissue. Usually done at the same time as the mastectomy or lumpectomy, but can also be performed after through a separate incision. This procedure is a way of learning if cancer has spread to lymph nodes without removing as many of them. In this procedure the first lymph node to which a tumour is likely to drain is removed (known as the sentinel node). Infection of the mastectomy wound may progress to late postoperative lymphoedema of the arm (Morrow et al, 2009). Risk factors include; open biopsy before mastectomy, obesity, diabetes, increase in age and prolonged suction catheter drainage (Vitug and Newman, 2007). After mastectomy, seromas occurs in the dead space beneath the elevated skin flap in approximately 30% of cases (Hashemi et al, 2004). Recent research recommends that in the presence of a seroma, arm mobility should be allowed immediately after surgery but structured physiotherapy exercise should be delayed until at least one week post-operatively (Shamley et al, 2005, Shcutz et al, 1997). The patient usually experiences moderate pain in the shoulder and arm in the immediate postoperative period (Kroner et al, 1992). The patient may note hyperesthesia and paraesthesia, as well as occasional "phantom" hyperesthesia in the mastectomy site (Stubblefield and Custodio 2006). It presents as a non-painful phantom sensation such as itching, nipple sensation, and premenstrual-type breast discomfort. There is currently a lack of high quality literature around the physiotherapy management of phantom breast syndrome however treatment generally involves education and analgesics (Stubblefield and Custodio 2006). Physiotherapists will also be part of an ongoing multidisciplinary pain management programme. Manual techniques such as myofascial release have also been considered useful in improving tissue extensibility and enhancing mobility. After discharge:  Patients should be advised to use their limb as normally as possible  The unaffected limb should be used for heavier or repetitive tasks e. Todd et al (2008): conducted a randomised single-blind control trial of 116 women undergoing surgery that included axillary node dissection for early breast cancer. The intervention group completed an alternative programme limiting movements to less than 90 degrees in all planes for the first week postoperatively before progressing to the standard protocol. There were no significant differences between groups for other musculoskeletal morbidities, however abduction limitation was -11. We see only ones backward shoulder rolls to decrease referred to us from surgical, apprehension and pain, improve medical, and radiation postoperative pulmonary function, and oncologists, nurse prepare the patient for progression. Distal upper extremity exercises are Once drain(s) are removed, Skin stretching and 32 included but not stressed. One cycle entails a treatment period (could be one day, a few days in a row or every other day for a set period) followed by a recovery period during which no treatment is given. The number of cycles in a regimen and the duration of each regimen varies depending on the drugs used, but most take 3-6 months to complete. Symptoms include:  Numbness  Tenderness  Tingling, burning,  Rash  Redness  Cracked, flaking, or peeling skin  Swelling  Blisters, ulcers, or sores  Discomfort  Intense pain 34  Difficulty walking or using your hands Patients should be advised not to exercise with this condition so therefore physiotherapist must liaise with doctor before starting an intervention. Supervised group exercise significantly reduces depression and anxiety levels in a wide range of cancer patients undergoing chemotherapy (Midtgaard et al, 2005). Sexuality Breast surgery as well as chemotherapy, can induce a change in “body image, femininity, power of seduction and sexuality”, which can adversely affect the patient’s relationship with their partner (Hannoun-Levi 2005). External radiotherapy: delivered by a machine, most commonly a linear accelerator. Internal radiotherapy: a radioactive pellet is placed inside the body, close to the tumour, for a set amount of time. Indications/Uses 1) Adjuvant (after surgery): Lumpectomy followed by whole breast radiation is often referred to as “breast preservation surgery” and is very common. It is recommended if the cancer is at an early stage, 4 cm or smaller, located in one site, removed with clear margins. It is also recommended after a mastectomy if: 36 - The cancer is 5 centimetres or larger. It is usually given on most days of the week for 5-7 weeks in an outpatient setting, but this may differ between patients. Side effects  Skin colour changes  Itching, burning, blistering, peeling, irritation/discomfort/pain over radiation site  Chest pain  Fatigue  Low white blood cell count  Cardiac complications  Pulmonary complications (especially pulmonary fibrosis)  Although now considered very rare, brachial plexopathies have historically been shown to develop up to 20 years post radiotherapy (Hayes et al, 2012). Psychological Impact Patients can have high levels of anxiety prior to starting radiotherapy. The most common source of anxiety for women is the effects of radiation on their future health (Halkett et al 2012). Patients tend to have a better experience of radiotherapy than they expect and so their anxiety decreases once treatment is over (Halkett et al, 2012; Rahn et al, 1998) Hormone Therapy Background/ Indications Cancer cells can be similar to or very dissimilar from normal cells in appearance and structure.

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The veins draining the cervical vertebrae and the posterior surface of the skull cheap viagra gold 800mg otc, including some blood from the occipital sinus order 800mg viagra gold visa, flow into the vertebral veins order discount viagra gold on line. These parallel the vertebral arteries and travel through the transverse foramina of the cervical vertebrae. Major Veins of the Brain Vessel Description Enlarged vein located midsagittally between the meningeal and periosteal layers of the dura Superior sagittal mater within the falx cerebri; receives most of the blood drained from the superior surface of sinus the cerebrum and leads to the inferior jugular vein and the vertebral vein Great cerebral Receives most of the smaller vessels from the inferior cerebral veins and leads to the vein straight sinus Enlarged vein that drains blood from the brain; receives most of the blood from the great Straight sinus cerebral vein and leads to the left or right transverse sinus Cavernous Enlarged vein that receives blood from most of the other cerebral veins and the eye socket, sinus and leads to the petrosal sinus Enlarged vein that receives blood from the cavernous sinus and leads into the internal Petrosal sinus jugular veins Enlarged vein that drains the occipital region near the falx cerebelli and leads to the left and Occipital sinus right transverse sinuses, and also the vertebral veins Transverse Pair of enlarged veins near the lambdoid suture that drains the occipital, sagittal, and sinuses straight sinuses, and leads to the sigmoid sinuses Table 20. From here, the veins come together to form the radial vein, the ulnar vein, and the median antebrachial vein. The radial vein and the ulnar vein parallel the bones of the forearm and join together at the antebrachium to form the brachial vein, a deep vein that flows into the axillary vein in the brachium. The median antebrachial vein parallels the ulnar vein, is more medial in location, and joins the basilic vein in the forearm. As the basilic vein reaches the antecubital region, it gives off a branch called the median cubital vein that crosses at an angle to join the cephalic vein. The cephalic vein begins in the antebrachium and drains blood from the superficial surface of the arm into the axillary vein. It is extremely superficial and easily seen along the surface of the biceps brachii muscle in individuals with good muscle tone and in those without excessive subcutaneous adipose tissue in the arms. The subscapular vein drains blood from the subscapular region and joins the cephalic vein to form the axillary vein. As it passes through the body wall and enters the thorax, the axillary vein becomes the subclavian vein. Many of the larger veins of the thoracic and abdominal region and upper limb are further represented in the flow chart in Figure 20. Veins of the Upper Limbs Vessel Description Digital veins Drain the digits and lead to the palmar arches of the hand and dorsal venous arch of the foot Palmar venous Drain the hand and digits, and lead to the radial vein, ulnar veins, and the median arches antebrachial vein Vein that parallels the radius and radial artery; arises from the palmar venous arches and Radial vein leads to the brachial vein Vein that parallels the ulna and ulnar artery; arises from the palmar venous arches and Ulnar vein leads to the brachial vein Deeper vein of the arm that forms from the radial and ulnar veins in the lower arm; leads to Brachial vein the axillary vein Table 20. Lying just beneath the parietal peritoneum in the abdominal cavity, the inferior vena cava parallels the abdominal aorta, where it can receive blood from abdominal veins. The lumbar portions of the abdominal wall and spinal cord are drained by a series of lumbar veins, usually four on each side. The ascending lumbar veins drain into either the azygos vein on the right or the hemiazygos vein on the left, and return to the superior vena cava. Blood supply from the kidneys flows into each renal vein, normally the largest veins entering the inferior vena cava. Each adrenal vein drains the adrenal or suprarenal glands located immediately superior to the kidneys. The right adrenal vein enters the inferior vena cava directly, whereas the left adrenal vein enters the left renal vein. From the male reproductive organs, each testicular vein flows from the scrotum, forming a portion of the spermatic cord. The right gonadal vein empties directly into the inferior vena cava, and the left gonadal vein empties into the left renal vein. Each side of the diaphragm drains into a phrenic vein; the right phrenic vein empties directly into the inferior vena cava, whereas the left phrenic vein empties into the left renal vein. Since the inferior vena cava lies primarily to the right of the vertebral column and aorta, the left renal vein is longer, as are the left phrenic, adrenal, and gonadal veins. The longer length of the left renal vein makes the left kidney the primary target of surgeons removing this organ for donation. Major Veins of the Abdominal Region Vessel Description Inferior vena Large systemic vein that drains blood from areas largely inferior to the diaphragm; empties cava into the right atrium Series of veins that drain the lumbar portion of the abdominal wall and spinal cord; the Lumbar veins ascending lumbar veins drain into the azygos vein on the right or the hemiazygos vein on the left; the remaining lumbar veins drain directly into the inferior vena cava Largest vein entering the inferior vena cava; drains the kidneys and flows into the inferior Renal vein vena cava Table 20. The anterior tibial vein drains the area near the tibialis anterior muscle and combines with the posterior tibial vein and the fibular vein to form the popliteal vein. The fibular vein drains the muscles and integument in proximity to the fibula and also joins the popliteal vein. The small saphenous vein located on the lateral surface of the leg drains blood from the superficial regions of the lower leg and foot, and flows into to the popliteal vein. Close to the body wall, the great saphenous vein, the deep femoral vein, and the femoral circumflex vein drain into the femoral vein. The great saphenous vein is a prominent surface vessel located on the medial surface of the leg and thigh that collects blood from the superficial portions of these areas. The femoral circumflex vein forms a loop around the femur just inferior to the trochanters and drains blood from the areas in proximity to the head and neck of the femur. As the femoral vein penetrates the body wall from the femoral portion of the upper limb, it becomes the external iliac vein, a large vein that drains blood from the leg to the common iliac vein. The pelvic organs and integument drain into the internal iliac vein, which forms from several smaller veins in the region, including the umbilical veins that run on either side of the bladder. The external and internal iliac veins combine near the inferior portion of the sacroiliac joint to form the common iliac vein. In addition to blood supply from the external and internal iliac veins, the middle sacral vein drains the sacral region into the common iliac vein. Similar to the common iliac arteries, the common iliac veins come together at the level of L5 to form the inferior vena cava. Veins of the Lower Limbs Vessel Description Plantar veins Drain the foot and flow into the plantar venous arch Dorsal venous Drains blood from digital veins and vessels on the superior surface of the foot arch Plantar venous Formed from the plantar veins; flows into the anterior and posterior tibial veins through arch anastomoses Anterior tibial Formed from the dorsal venous arch; drains the area near the tibialis anterior muscle and vein flows into the popliteal vein Posterior tibial Formed from the dorsal venous arch; drains the area near the posterior surface of the tibia vein and flows into the popliteal vein Fibular vein Drains the muscles and integument near the fibula and flows into the popliteal vein Table 20. It packages nutrients absorbed by the digestive system; produces plasma proteins, clotting factors, and bile; and disposes of worn-out cell components and waste products. Instead of entering the circulation directly, absorbed nutrients and certain wastes (for example, materials produced by the spleen) travel to the liver for processing. In this case, the initial capillaries from the stomach, small intestine, large intestine, and spleen lead to the hepatic portal vein and end in specialized capillaries within the liver, the hepatic sinusoids. You saw the only other portal system with the hypothalamic-hypophyseal portal vessel in the endocrine chapter. The hepatic portal vein itself is relatively short, beginning at the level of L2 with the confluence of the superior mesenteric and splenic veins. It also receives branches from the inferior mesenteric vein, plus the splenic veins and all their tributaries. The superior mesenteric vein receives blood from the small intestine, two-thirds of the large intestine, and the stomach. The inferior mesenteric vein drains the distal third of the large intestine, including the descending colon, the sigmoid colon, and the rectum. The splenic vein is formed from branches from the spleen, pancreas, and portions of the stomach, and the inferior mesenteric vein. After its formation, the hepatic portal vein also receives branches from the gastric veins of the stomach and cystic veins from the gall bladder. The hepatic portal vein delivers materials from these digestive and circulatory organs directly to the liver for processing. Because of the hepatic portal system, the liver receives its blood supply from two different sources: from normal systemic circulation via the hepatic artery and from the hepatic portal vein. The liver processes the blood from the portal system to remove certain wastes and excess nutrients, which are stored for later use. This processed blood, as well as the systemic blood that came from the hepatic artery, exits the liver via the right, left, and middle hepatic veins, and flows into the inferior vena cava. Overall systemic blood composition remains relatively stable, since the liver is able to metabolize the absorbed digestive components.

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