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The chromosomes within the nucleus of a zygote (zı˘go¯t) of the morula fills with fluid absorbed from the uterine cavity effective kamagra super 160mg erectile dysfunction oil treatment. As (fertilized egg) contain all the genetic information necessary for the fluid-filled space develops inside the morula cheap 160mg kamagra super amex erectile dysfunction at age 30, two distinct the differentiation and development of all body structures. There are two major categories of epithelia: membranous and Objective 6 Define gland and compare and contrast the glandular. Membranous epithelia are located throughout the body various types of glands in the body. Glandular epithelia are specialized tissues that form the secretory portion of glands. Characteristics of Membranous Epithelia Objective 4 Compare and contrast the various types of Membranous epithelia always have one free surface exposed to a membranous epithelia. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 (continued) TABLE 4A Derivatives of the Germ Layers Ectoderm Mesoderm Endoderm Epidermis of skin and epidermal derivatives: Muscle: smooth, cardiac, skeletal Epithelium of pharynx, auditory canal, tonsils, hair, nails, glands of the skin; linings of oral, Connective tissue: embryonic, mesenchyme, thyroid, parathyroid, thymus, larynx, trachea, nasal, anal, and vaginal cavities connective tissue proper, cartilage, bone, blood lungs, GI tract, urinary bladder and urethra, and Nervous tissue; sense organs vagina Dermis of skin; dentin of teeth Lens of eye; enamel of teeth Liver and pancreas Epithelium (endothelium) of blood vessels, Pituitary gland lymphatic vessels, body cavities, joint cavities Adrenal medulla Internal reproductive organs Kidneys and ureters Adrenal cortex wall is known as the trophoblast, and the inner aggregation of is closer to the amniotic cavity, and a lower endoderm, which cells is known as the embryoblast. A short time later, a the trophoblast differentiates into a structure that will later form third layer called the mesoderm forms between the endoderm and part of the placenta; the embryoblast will eventually become the ectoderm. With the establishment of these two groups of cells, the The primary germ layers are of great significance because morula becomes known as a blastocyst (blas′to˘-sist). Implantation all the cells and tissues of the body are derived from them (see of the blastocyst in the uterine wall begins between the fifth and fig. Ectodermal cells form the nervous system; the outer seventh day (see chapter 22). Mesodermal cells form the week of development, the embryoblast undergoes marked differen- skeleton, muscles, blood, reproductive organs, dermis of the skin, tiation. A slitlike space called the amniotic (am′ne-ot-ic) cavity and connective tissue. Endodermal cells produce the lining of the forms within the embryoblast, adjacent to the trophoblast. The GI tract, the digestive organs, the respiratory tract and lungs, and embryoblast now consists of two layers: an upper ectoderm, which the urinary bladder and urethra. The upper surface may be exposed to gases, as in the case Some of the functions of membranous epithelia are quite of epithelium in the integumentary and respiratory systems; to specific, but certain generalities can be made. Epithelia that cover liquids, as in the circulatory and urinary systems; or to semisolids, or line surfaces provide protection from pathogens, physical injury, as in the GI tract. Epithelia lining the GI tract function in lia is bound to underlying supportive tissue by a basement mem- absorption. The epithelium of the kidneys provides filtration, brane, that consists of glycoprotein from the epithelial cells and whereas that within the pulmonary alveoli (air sacs) of the lungs a meshwork of collagenous and reticular fibers from the underly- allows for diffusion. With few exceptions, membranous epithe- buds and in the nasal region has a chemoreceptor function. Histology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 Chapter 4 Histology 81 (b) (c) (a) FIGURE 4. Simple squamous epithelia that line the lumina of vessels are referred to as endothelia, and that which cover visceral or- gans are referred to as mesothelia. Many membranous epithelia are exposed to friction or spherical central nucleus. This epithelium is adapted for diffusion harmful substances from the outside environment. It occurs in the pulmonary alveoli within the son, epithelial tissues have remarkable regenerative abilities. The lungs (where gaseous exchange occurs), in portions of the kidney mitotic replacement of the outer layer of skin and the lining of (where blood is filtered), on the inside walls of blood vessels, in the GI tract, for example, is a continuous process. Membranous epithelia are histologically classified by the The simple squamous epithelium lining the inner walls of blood number of layers of cells and the shape of the cells along the ex- and lymphatic vessels is termed endothelium (en″do-the′le-um) posed surface. That which covers visceral organs and lines body cav- layer of cells are called simple; those that are layered are said to ities is called mesothelium (mes″o˘-the′le-um). Squamous cells are flattened; cuboidal cells are cube- shaped; and columnar cells are taller than they are wide.

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Conditions Affecting the Brain 61 Classification of Seizures dergoes rapid kamagra super 160 mg mastercard erectile dysfunction protocol real reviews, jerky movements buy kamagra super 160 mg amex does erectile dysfunction cause low libido. The teeth are clenched tightly together and Individuals with epilepsy can exhibit a control of the bladder or the bowel may be variety of seizures with varying symptoms, lost. The seizure generally lasts less than ranging from muscle spasms or confusion a few minutes. Seizures can sciousness is gradually regained, but indi- be mild or severe, can occur frequently or viduals may experience confusion, rarely, and can change their pattern of difficulty in speaking, and headache. Depending on the though postseizure symptoms usually dis- type, seizures usually last only seconds to appear within several hours, the fatigue minutes. Between seizures most individ- experienced may be overwhelming, often uals are able to function normally. Classification of seiz- Table 2–5 Common Types of Seizures ures is important so that appropriate man- Associated with Epilepsy agement and treatment can be determined. Seizures are classified as generalized, in which nerve cells discharge abnormally Generalized seizures throughout the brain, or partial, in which 1. Absence (petit mal) ited to one specific part of the brain (Browne & Holmes, 2001). Although there Partial seizures are many classifications of seizures relat- 1. Although a tonic-clonic seizure may be Generalized Tonic-Clonic Seizure frightening to those who witness it, indi- (Grand Mal) viduals experiencing the seizure are usu- ally in no imminent danger unless there An abnormal discharge of nerve cells are hard, sharp, or hot hazards within the throughout the brain results in a general- immediate environment. No attempt ized tonic-clonic seizure, sometimes called should be made to move individuals ex- a grand mal seizure. Some individuals ex- periencing a seizure except when neces- perience an aura (warning sign) immedi- sary to protect them from such hazards. They may To avoid injury, there should be no at- see a flash of light, have an unusual taste tempt to restrain individuals during a ton- in the mouth, or have other unusual ic-clonic seizure, to pry open clenched sensations. As the seizure develops, indi- teeth, or to place hard objects in the indi- viduals lose consciousness and fall down, vidual’s mouth. Individuals should be entering a tonic state in which there is gen- placed on their side during a seizure so eralized body rigidity. Muscles then enter that secretions can drain from the mouth a clonic state so that the whole body un- and do not compromise the airway. Jacksonian Like tonic-clonic seizures, absence seizures can remain limited to one part of seizures are classified as generalized, the body or can go on to develop into full- because nerve cells discharge throughout blown tonic-clonic seizures. Children most commonly ex- Other types of partial seizures may have perience this type of seizure. Complex-partial seizures are characterized by brief blank (psychomotor) seizures are characterized by spells or staring spells and a loss of aware- a loss of awareness of the surroundings. The seizure Individuals may pace, wander aimlessly, generally lasts for only seconds. The indi- make purposeless movements, and utter vidual does not fall, and there are usual- unintelligible sounds. The seizure can last ly no outward motor manifestations of up to 20 minutes, with mental confusion absence seizures, although abnormal lasting for a few minutes after the seizure blinking or slight twitching may occur is over. Because of the limited visi- toms of complex-partial seizures, often ble symptoms of the seizure, those around attributing the symptoms to alcohol, the individual may misinterpret absence drug abuse, or mental illness. When children experience frequent Status Epilepticus absence seizures, school performance may be disrupted. Because there may be no Status epilepticus is a term used to de- significant signs that are easily observed scribe seizures that are prolonged or that during the seizure, the seizure disorder come in rapid succession without full re- may not be diagnosed, and poor school covery of consciousness between seizures. Recognition of symptoms and life–threatening and consequently re- appropriate diagnosis are crucial to enable quires immediate medical attention and children to achieve maximum school treatment (Lowenstein & Alldredge, 1998). Absence seizures may disappear spontaneously with age, although some Diagnosis of Epilepsy individuals who have had absence seizures later go on to develop tonic-clonic seizures. Individuals who are having a seizure for the first time usually undergo medical Partial Seizures evaluation by a neurologist to determine whether the seizure is a symptom of an When nerve cells discharge in an isolat- acute medical or neurological illness that ed part of the brain, partial seizures occur. Exten- and symptoms are very localized, depend- sive physical examination and blood tests ing on the part of the brain affected.

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The result is inade- tivity kamagra super 160mg generic erectile dysfunction treatment dublin, with a low or normal aldosterone level purchase 160 mg kamagra super treatment of erectile dysfunction using platelet-rich plasma, which sug- quate secretion of glucocorticoids, mineralocorticoids, and gests that the zona glomerulosa is affected first during dis- androgens. The initial symptoms Treatment for acute adrenal insufficiency should be di- generally have a gradual onset, with only a partial gluco- rected at reversal of the hypotension and electrolyte ab- corticoid deficiency resulting in inadequate cortisol in- normalities. Mineralocorticoid deficiency in saline should be infused as quickly as possible. Progres- ethasone or a soluble form of injectable cortisol should sion to complete glucocorticoid deficiency results in a de- also be given. Daily glucocorticoid and mineralocorticoid creased sense of well-being and abnormal glucose metab- replacement allows the patient to lead a normal active life. Lack of mineralocorticoid leads to decreased renal potassium secretion and reduced sodium retention, the Reference loss of which results in hypotension and dehydration. In: Wilson JD, combined lack of glucocorticoid and mineralocorticoid can Foster DW, Kronenberg HM, Larsen PR, eds. Philadelphia: WB Saun- drogen deficiency is observed in women only (men derive ders, 1998;517–664. The rapid rise in cAMP produced by ACTH stimulates the mechanism that transfers cholesterol into the inner mi- ACTH Regulates the Synthesis of tochondrial membrane. This action provides abundant cho- Adrenal Steroids lesterol for side-chain cleavage enzyme, which carries out Adrenocorticotropic hormone (ACTH) is the physiologi- the rate-limiting step in steroidogenesis. As a result, the rates cal regulator of the synthesis and secretion of glucocorti- of steroid hormone formation and secretion rise greatly. It has a very rapid stimulatory effect on Gene Expression for Steroidogenic Enzymes. Adreno- steroidogenesis in these cells, which can result in a great corticotropic hormone maintains the capacity of the cells rise in blood glucocorticoids within seconds. It also exerts of the zona fasciculata and zona reticularis to produce several long-term trophic effects on these cells, all directed steroid hormones by stimulating the transcription of the toward maintaining the cellular machinery necessary to genes for many of the enzymes involved in steroidogenesis. These For example, transcription of the genes for side-chain actions of ACTH are summarized in Figure 34. When the level of ACTH in the blood cortical cells have been stimulated by ACTH. Because nor- rises, increased numbers of ACTH molecules interact with mal individuals are continually exposed to episodes of receptors on the plasma membranes of adrenal cortical ACTH secretion (see Fig. These ACTH receptors are coupled to the enzyme zymes is well maintained in the cells. Again, this long-term adenylyl cyclase by stimulatory guanine nucleotide-bind- or maintenance effect of ACTH is due to its ability to in- ing proteins (Gs proteins). ATP greatly increases, and the concentration of cAMP rises The importance of ACTH in gene transcription be- CHAPTER 34 The Adrenal Gland 615 CH2OH CH2OH Zona fasciculata cell or zona reticularis cell C O O HO OH HO OH Nucleus O O Cortisol Dihydrocortisol cAMP PKA P proteins CH2OH AC C O mRNAs ATP Lipid HO OH G droplets s Steroidogenic ACTH enzymes Cholesterol Mitochondrion H Tetrahydrocortisol Pregnenolone CH2OH CO Smooth HO OH ER COO- H O Glucocorticoids Androgens O H H Blood OH H Urine HO H FIGURE 34. ACTH binds to plasma membrane recep- H OH tors, which are coupled to adenylyl cyclase (AC) by stimulatory Tetrahydrocortisol glucuronide G proteins (G ). These proteins presumably initiate steroidogenesis and cortisol glucuronide in the liver. Because it is more water- soluble than cortisol, it is easily excreted in the urine. An example of the latter is a human It increases the abundance of LDL receptors and the activ- treated chronically with large doses of cortisol or related ity of the enzyme HMG-CoA reductase in these cells. It is not clear whether ACTH exerts these ACTH decreases the transcription of the genes for effects directly. The abundance of LDL receptors in the steroidogenic enzymes, causing a deficiency in these en- plasma membrane and the activity of HMG-CoA reductase zymes in the adrenals. As a result, the administration of in most cells are inversely related to the amount of cellular ACTH to such an individual does not cause a marked in- cholesterol. By stimulating steroidogenesis, ACTH reduces crease in glucocorticoid secretion. Chronic exposure to the amount of cholesterol in adrenal cells; therefore, the in- ACTH is required to restore mRNA levels for the steroido- creased abundance of LDL receptors and high HMG-CoA genic enzymes and, hence, the enzymes themselves, to ob- reductase activity in ACTH-stimulated cells may merely re- tain normal steroidogenic responses to ACTH. A patient sult from the normal compensatory mechanisms that func- receiving long-term treatment with glucocorticoid may suf- tion to maintain cell cholesterol levels.

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At present generic kamagra super 160mg mastercard erectile dysfunction at age 35, the emphasis has shifted from replacing paper documents to sharing data between colleagues cheap kamagra super 160 mg with visa erectile dysfunction foods that help. As clinicians increasingly share data, issues such as the standardisation of the content of medical records are becoming important areas of research. In addition, the fact that data can be transferred easily over distances enables clinicians to interpret data while the patient is located miles away (resulting in, for example, the so-called “telediagnosis”), or to communicate with patients over longer distances using, for example, the internet. In this chapter we will focus on the contribution of medical informatics to diagnostic decision support. We believe that the use of ICT in the domain of diagnostic decision support is still in an early stage. Although in a few specialties (for example radiology), ICT is used extensively for decision support, most clinicians have little or no experience with decision support systems. Many researchers argue that the fundamental enabling technology is the introduction of electronic medical records. Once electronic medical records are available, they argue, we will witness a rapid increase in the use of diagnostic decision support systems. The entries in the record enabled the clinician to recall previous episodes of illness and treatment. In recent years, however, medical records have been used increasingly for other purposes: they are used as a data source for purposes ranging from billing the patient to performing epidemiological studies, and from performing quality control to defending oneself against legal claims. One of the major barriers for using the data in such ways is the inaccessible and often unstructured nature of the paper record. The introduction of computer based medical records to a large degree, removes that barrier. Recent decades have seen a rapid increase in the role of computers in medical record keeping, and professional organisations have started to play an active role in the introduction of electronic records. For example, in 1978 the first Dutch general practitioners started using personal computers in their practices. In 1990, 35% of Dutch GPs were using one or more computer applications; although the majority of these are administrative, an increasing number of clinicians use computer stored medical records. Other countries, such as the United Kingdom, have also witnessed a rapid introduction of electronic records into primary care. In secondary care, although progress has been made, the introduction of electronic records is slower. The explicit purpose of automating medical records is to use the data in those records to support not only the care of individual patients, but also applications such as decision support, quality control, cost control, or epidemiology. The reliability of clinical data, for example, has long been questioned, and tensions between reimbursement schemes and coding schemes have been discussed. Some researchers argue that the process of automation may further reduce the reliability of data. Burnum,4 for example, states: “With the advent of the information era in medicine, we are pouring out a torrent of medical record misinformation”. Although we disagree with this pessimistic view, we acknowledge that medical data are recorded for a specific purpose and that this purpose has an influence on what data are recorded and how. In developing systems that record medical data, designers make decisions about how to model those data in order to perform a given task. For example, in designing the computer based medical record system Elias,3 the designers focused on issues such as ease of data entry and emulating existing paper records. The same designers 170 DIAGNOSTIC DECISION SUPPORT subsequently discovered significant limitations in the Elias records when they developed a decision support system that uses these records as a data source. First, data recorded on computer can be readily retrieved and reused for a variety of purposes. As a result, databases containing data on millions of patients are available. Although the subsequent analysis of the data may prove difficult, both clinicians and researchers are moving from a period of “data starvation” to “data overload”. Second, once data are available in this way, they can easily be transported. The result is that processes that interpret the data (for example diagnosis or consultation) are no longer closely associated with the physical location where they were collected. Data can be collected in one place and processed in another (for example telediagnosis).

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