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It involves examining both testes on a monthly basis to check for changes in contour buy discount levitra super active 40mg erectile dysfunction zyprexa, nodules discount 20mg levitra super active visa erectile dysfunction and proton pump inhibitors, or areas of tenderness. If performed properly and at timely intervals this exam may result in earlier detection of testicular neoplasms. By detecting these cancers at earlier stages it is hoped that they may be more effectively treated. The phonetic spellings reflect standard scientific usage and can easily be inter- genetic diseases. Any unmarked vowel that ends a syllable or that stands alone as a syllable has the long suspended in amniotic fluid; commonly sound. For example, ba, ma, and na rhyme with fay; be, de, and we rhyme with fee; bi, di, and known as the “bag of waters. It gives rise to the fetal umbilical spinal cord composed of axons of motor, or contraction. An ear-shaped appendage of each blood The fluid connective tissue that arrangement of white matter within the atrium of the heart. It is essential for the absorption tendons and bones or at points of friction atrioventricular valve A cardiac valve located of fats. It includes the embryo or fetus, as arise from the inferior surface of the brain. An material between the nucleus and the cell origin; the opposite of proximal. One of posterior, portion of a body part; the opposite the convex folds on the surface of the brain. Deciduous teeth are shed and The blood vessel that connects the the epidermis. It stores spermatozoa and expiration The process of expelling air from recording of the electrical impulses or transports them from the seminiferous the lungs through breathing out; also called activity of a muscle; EMG. Van De Graaff: Human Back Matter Glossary © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 808 Glossary middle-ear chamber and through which fibrous joint A type of articulation bound by frontal plane See coronal plane. The anterior aspect of the head not gap between the incompletely formed cranial chromosome containing the information supporting or covering the brain. The bones of a fetus or baby; commonly known as needed to synthesize a particular protein exposed surface of a structure. It extends formed elements The cellular portion of side-to-side and back-and-forth movements. Pertaining to the forehead or frontal extensions that is capable of forming bone. It merges with the cystic duct intestine and large intestine that forms a hormones. It hepatopancreatic ampulla (hep'a˘-to-pan'kre- commonly known as the “anvil. It is covered by portions of extremity, consisting of the carpus, type, occurring at the articular ends of bones, the frontal, parietal, and temporal lobes. It functions in the transport of oxygen control center located below the thalamus enzymes; also called the crypt of Lieberkühn. A secondary cancerous growth the incus; commonly known as the system, composed of the dura mater, formed by transmission of cancerous cells “hammer. The region in the center of the quadrigemina, the cerebral peduncles, and divides the body or an organ into right and thorax separating the lungs; contains the specialized nuclei that help to control posture left halves; also called the median plane. The pelvic floor autonomic nervous system concerned with bone tissue formation. Its cell body is outside the permits light to enter the posterior cavity of shaped endocrine gland situated in the sella central nervous system, and it terminates at the eyeball and be refracted by the lens. Its cell body is thick ring of smooth muscle encircling the pivot joint A synovial joint in which the within the central nervous system, and it opening between the stomach and the rounded head of one bone articulates with terminates on a postganglionic neuron. It regulates the passage of food the depressed cup of another, permitting material into the small intestine and prevents pregnancy The condition in which a female is rotational movement. It controls inspiratory channel of the cochlea that is filled with gray matter of a reddish color located in the and expiratory phases. It contains sac that contains the testes and their neck, thorax, or abdomen. Nerves arising from the sacral plexus of male accessory reproductive organs, lying organism. It is located below the mandible and bone formed in a tendon in response to joint stress (e. It is attached by mesenteries to the or toward the head; also called cephalic. It vestibular (oval) window of the inner ear; of the hand anteriorly; the opposite of contracts in an involuntary, rhythmic fashion commonly known as the “stirrup. A ligament that supports systemic circulation The circuit of blood flow thigh The proximal portion of the lower an organ or a body part, such as that from the left ventricle of the heart to the extremity between the hip and the knee in supporting the lens of the eye. Its two broad processes join anteriorly between the articulating bones that provides target organ A tissue or organ that is affected to form the “Adam’s apple.

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What psychosocial issues might you at work generic levitra super active 40mg with amex erectile dysfunction fpnotebook, was taken to the emergency consider in Mr levitra super active 20mg amex kratom impotence. Physical Medicine and Rehabilitation; A comparison of acute and postdischarge predic- State of the Art Reviews, 6, 1–19. Rehabilitation Counseling Bulletin, spective: Review of results of a community-based 47(2), 112–120, 122. New York: Demos mild traumatic brain injury: A review of current Publications. Mild traumatic brain injury traumatic brain injury: Coma, the vegetative state, in persons with multiple trauma: The problem of and the minimally responsive state. A psychodynam- Rehabilitation treatment of sexuality issues due to ic model of behavior after acute central nervous acquired brain injury. Driving considerations following mild traumatic brain after brain injury. Sexuality issues NIH Consensus Development Panel on among survivors of traumatic brain injuries. Rehabilitation of Persons with Traumatic Brain Journal of Applied Rehabilitation Counseling, 27(1), Injury. Disability after severe head injury: severe head trauma: Coma to community. Archives Observations on the use of the Glasgow outcome of Physical Medicine and Rehabilitation, 63, scale. Activity status, life satisfaction, Screening for mild traumatic brain injury: A guide and perceived productivity for young adults with for rehabilitation counselors. Moderating factors in return to work and Predicting discharge after traumatic brain injury. Journal American Journal of Physical Medicine Rehabilitation, of Head Trauma Rehabilitation, 18(2), 128–138. Use of Archives of Physical Medicine Rehabilitation, 81(8), injury severity variables in determining disabili- 1007–1015. Clinical Infectious Disease, 33(10), and initial management of head injury. New England Journal of Medicine, 349(18), seizure and status epilepticus. C HAPTER 3 Conditions of the Nervous System: Part II Conditions of the Spinal Cord and Peripheral Nervous System and Neuromuscular Conditions NORMAL STRUCTURE AND information traveling up the right side of FUNCTION OF THE SPINAL CORD the spinal cord crosses over to the left side AND PERIPHERAL NERVOUS SYSTEM of the brain, so, for example, the left hemisphere of the brain would interpret pain in the right hand. Conversely, motor The Spinal Cord impulses originating in the left brain cross The spinal cord is part of the central to the right side of the spinal cord and ini- nervous system (see Chapter 1) and tiate a response to the right side of the extends from the brain stem to the lower body. Bony coverings called damage on one side of the brain typical- vertebrae surround the spinal cord and ly causes symptoms on the opposite side protect it. The vertebral The inner gray matter of the spinal column consists of 7 cervical vertebrae cord, which is composed of cell bodies located in the neck area; 12 thoracic verte- and unmyelinated neurons, acts as a coor- brae located in the upper and middle dinating center for reflex and other activ- back; and 5 lumbar vertebrae located in the ities, such as voluntary movements and lower back. A reflex cen- lumbar vertebrae consists of fused (joined) ter in the gray matter of the spinal cord bone. At the tip of the sacrum is the coc- is where sensory and motor neurons con- cyx, or tailbone. This part of the spinal cord serves as The spinal cord conducts impulses to a center for spinal reflexes. The outer white mat- defined as an automatic response to a giv- ter of the spinal cord, which consists of en stimulus. Spinal reflexes control not bundles or tracts of myelinated fibers of only muscle reflexes but also the reflexes sensory (afferent) and motor (efferent) of internal organs. The projections of the H peripheral nervous system (those nerves are named according to the direction to lying outside the central nervous system) which they project. In most instances, sensory extend toward the back, and the anterior 73 74 CHAPTER 3 CONDITIONS OF THE NERVOUS SYSTEM: PART II horns project toward the front. Cere- the brain and are contained entirely brospinal fluid, which nourishes and pro- within the central nervous system. Lower tects the spinal cord, fills both the central motor neurons, although originating in the canal, located within the center of the central nervous system, have fibers gray matter, and the subarachnoid space extending to the peripheral nerves in vol- surrounding the outer portion of the untary muscles. The the motor cortex of the brain, extend location of the dysfunction determines down the spinal cord through descending the nature of the disorder. Sensory (afferent) impulses A nerve is a bundle of fibers outside the from the body enter the spinal cord central nervous system that transmits through spinal nerve roots that also information between the central nervous extend through openings between verte- system and various parts of the body. The brae and then travel up ascending tracts in peripheral nervous system consists of all the spinal cord to the brain. For ly, the peripheral nerves must be connect- example, the nerve roots that leave the ed to the central nervous system.

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However purchase levitra super active 20mg overnight delivery erectile dysfunction young age, spiration is brought about by a progressive increase in acti- there is no single pacemaker that sets the basic rhythm of vation of inspiratory muscles discount 40 mg levitra super active with visa erectile dysfunction fact sheet, most importantly the di- breathing and no single muscle devoted solely to the task aphragm (Fig. Breathing depends on the cyclic with time causes the lungs to fill at a nearly constant rate excitation of many muscles that can influence the volume until tidal volume has been reached. Control of that excitation is the result of is associated with a rapid decrease in excitation of inspira- multiple neuronal interactions involving all levels of the tory muscles, after which expiration occurs passively by nervous system. Furthermore, the muscles used for breath- elastic recoil of the lungs and chest wall. For ex- inspiratory muscles resumes during the first part of expira- ample, talking while walking requires that some muscles tion, slowing the initial rate of expiration. As more ventila- simultaneously attend to the tasks of posturing, walking, tion is required—for example, during exercise—other in- phonation, and breathing. Because it is impossible to spiratory muscles (external intercostals, cervical muscles) 363 364 PART V RESPIRATORY PHYSIOLOGY Diaphragm electromyogram Diaphragm electrical activity per unit time Inspiration Expiration Inspiration Expiration Pleural pressure FIGURE 22. During inspiration, the number of active muscle medulla oblongata and a cross section in the region of the fourth fibers, and the frequency at which each fires, increases progres- ventricle. C1, first cervical nerve; X, vagus nerve; IX, glossopha- sively, leading to a mirror-image fall in pleural pressure as the di- ryngeal nerve. In addition, expiration becomes an active complex, but the exact anatomic and functional description process through the use, most notably, of the muscles of remains uncertain. The neural basis of these breathing pat- does not arise from a single pacemaker or by reciprocal in- terns depends on the generation and subsequent tailoring hibition of two pools of cells, one having inspiratory- and of cyclic changes in the activity of cells primarily located in the other expiratory-related activity. An integrator-based theoretical model, as Oblongata Control the Basic Breathing Rhythm described below, is suitable for a first understanding of res- The central pattern for the basic breathing rhythm has piratory pattern generation. Cells in the medulla oblongata associated Onset of Inspiration with breathing have been identified by noting the correla- tion between their activity and mechanical events of the Many different signals (e. Two different groups of cells have been loskeletal movements, pain, chemosensor activity, and hy- found, and their anatomic locations are shown in Figure pothalamic temperature) provide a background ventilatory 22. Inspiration begins by the abrupt re- dorsal location in the region of the nucleus tractus solitarii, lease from inhibition of a group of cells, central inspiratory predominantly contains cells that are active during inspira- activity (CIA) integrator neurons, located within the tion. The ventral respiratory group (VRG) is a column of medullary reticular formation, that integrate this back- cells in the general region of the nucleus ambiguus that ex- ground drive (see Fig. Integration results in a pro- tends caudally nearly to the bulbospinal border and cra- gressive rise in the output of the integrator neurons, which, nially nearly to the bulbopontine junction. The VRG con- in turn, excites a similar rise in activity of inspiratory pre- tains both inspiration- and expiration-related neurons. The rate of ris- groups contain cells projecting ultimately to the bul- ing activity of inspiratory neurons and, therefore, the rate bospinal motor neuron pools. The DRG and VRG are bi- of inspiration itself, can be influenced by changing the laterally paired, but cross-communication enables them to characteristics of the CIA integrator. Inspiration is ended respond in synchrony; as a consequence, respiratory move- by abruptly switching off the rising excitation of inspira- ments are symmetric. The CIA integrator is reset before the begin- The neural networks forming the central pattern gener- ning of each inspiration, so that activity of the inspiratory ator for breathing are contained within the DRG/VRG neurons begins each breath from a low level. CHAPTER 22 The Control of Ventilation 365 may serve to integrate many different autonomic functions Pontine respiratory in addition to breathing. This effect is greatest early in off-switch Chemoreceptors neurons expiration and recedes as lung volume falls. Inspiratory muscle activity is essentially absent in the second phase of expiration, which includes continued passive recoil during quiet breathing or activation of expiratory muscles if more than quiet breathing is required. The duration of expiration is determined by the inten- CIA integrator sity of inhibition of activity of inspiratory-related cells of the DRG/VRG complex. Inhibition is greatest at the start of expiration and falls progressively until it is insufficient to prevent the onset of inspiration. The progressive fall of inhibition amounts to a decline of threshold for initiating the switch from expiration to inspiration. The rate of de- Pulmonary Pulmonary Inspiratory stretch irritant premotor cline of inhibition and the occurrence of events that trig- receptors receptors neurons ger the onset of inspiration are subject to several influ- ences. The duration of expiration can be controlled not only by neural information arriving during expiration but also in response to the pattern of the preceding inspira- To tion. How the details of the preceding inspiration are spinal cord stored and later recovered is unresolved. Various Control Mechanisms Adjust Breathing to Meet Metabolic Demands The basic pattern of breathing generated in the medulla is Inspiratory Activity Is Switched Off extensively modified by several control mechanisms. Mul- to Initiate Expiration tiple controls provide a greater capability for regulating breathing under a larger number of conditions.

The best studied of these is the lipopolysac- is not so cold that a blunted metabolic response would al- charide endotoxin of gram-negative bacteria generic 20mg levitra super active free shipping impotence therapy. A thalamus (and perhaps elsewhere in the brain) to alter their lower core-to-skin conductance (i cheap 20 mg levitra super active causes of erectile dysfunction young males. This effect of climatization in which a reduction in the metabolic re- endogenous pyrogens is mediated by the local synthesis and sponse to cold occurred. This increased insulation is not due to subcutaneous fat (in fact, it has been observed in release of prostaglandin E2. Aspirin and other drugs that in- very lean subjects), but apparently results from lower blood hibit the synthesis of prostaglandins also reduce fever. In general, the cold liable indicator of the presence of disease that body tem- stresses that elicit a lower shell conductance after acclima- perature is probably the most commonly measured clinical tization involve either cold water immersion or exposure to index. Many of the body’s defenses against infection and air that is chilly but not so cold as to risk freezing the vaso- cancer are elicited by a group of polypeptides called cy- constricted extremities. However, other cytokines, par- ticularly tumor necrosis factor, interleukin-6, and the in- Cold-Induced Vasodilation and the Lewis Hunting Re- terferons, are also pyrogenic in certain circumstances. As the skin is cooled below about 15 C, its blood vated body temperature enhances the development of flow begins to increase somewhat, a response called cold- these defenses. If laboratory animals are prevented from de- induced vasodilation (CIVD). This response is elicited veloping a fever during experimentally induced infection, most easily in comfortably warm subjects and in skin rich in survival rates may be dramatically reduced. The this chapter, fever specifically means an elevation in core mechanism has not been established but may involve a di- temperature a resulting from pyrogens, some authors use rect inhibitory effect of cold on the contraction of vascular the term more generally to mean any significant elevation smooth muscle or on neuromuscular transmission. After repeated cold exposure, CIVD begins Many Factors Affect Thermoregulatory Responses earlier during cold exposure, produces higher levels of and Tolerance to Heat and Cold blood flow, and takes on a rhythmic pattern of alternating vasodilation and vasoconstriction. This is called the Lewis Regular physical exercise and heat acclimatization increase hunting response because the rhythmic pattern of blood heat tolerance and the sensitivity of the sweating response. This re- Aging has the opposite effect; in healthy 65-year-old men, sponse is often well developed in workers whose hands are the sensitivity of the sweating response is half of that in 25- CHAPTER 29 The Regulation of Body Temperature 547 year-old men. Heat exhaustion, also called heat col- ously those used for their anticholinergic effects, such as lapse, is probably the most common heat disorder, and rep- atropine and scopolamine. In addition, some drugs used for resents a failure of cardiovascular homeostasis in a hot en- other purposes, such as glutethimide (a sleep-inducing vironment. Collapse may occur either at rest or during drug), tricyclic antidepressants, phenothiazines (tranquil- exercise, and may be preceded by weakness or faintness, izers and antipsychotic drugs), and antihistamines, also confusion, anxiety, ataxia, vertigo, headache, and nausea or have some anticholinergic action. The patient has dilated pupils and usually sweats others have been associated with heatstroke. As in heat syncope, reduced diastolic filling of heart failure and certain skin diseases (e. Although blood pressure may be low patients with these diseases, heat exposure and especially during the acute phase of heat exhaustion, the baroreflex exercise in the heat may raise body temperature to danger- responses are usually sufficient to maintain consciousness ous levels. Lesions that affect the thermoregulatory struc- and may be manifested in nausea, vomiting, pallor, cool or tures in the brainstem can also alter thermoregulation. Patients with heat ex- Such lesions can produce hypothermia (abnormally low haustion usually respond well to rest in a cool environment core temperature) if they impair heat-conserving re- and oral fluid replacement. However, hyperthermia (abnormally high core intravenous replacement of fluid and salt may be required. However, heat exhaustion accompanied circadian rhythm of core temperature. Certain drugs, such as barbiturates, alcohol, and phe- Therefore, patients should be actively cooled if rectal tem- nothiazines, and certain diseases, such as hypothyroidism, perature is 40. Hypovolemia cially in debilitated patients, may be accompanied by hy- contributes if the patient is dehydrated, but heat exhaustion pothermia, instead of the usual febrile response to infec- often occurs without significant dehydration. This is reversed shortly before the maintenance of blood pres- failing appears to be due to an impaired ability to conserve sure fails. The most severe and dangerous heat disorder is characterized by high core temperature and the develop- Heat Stress Causes or Aggravates ment of serious neurological disturbances with a loss of Several Disorders consciousness and, frequently, convulsions. In the classical The harmful effects of heat stress are exerted through car- form, the primary factor is environmental heat stress that diovascular strain, fluid and electrolyte loss and, especially overwhelms an impaired thermoregulatory system, and in heatstroke, tissue injury whose mechanism is uncertain. In exer- In a patient suspected of having hyperthermia secondary to tional heatstroke, the primary factor is high metabolic heat heat stress, temperature should be measured in the rectum, production. Patients with exertional heatstroke tend to be since hyperventilation may render oral temperature spuri- younger and more physically fit (typically, soldiers and ath- ously low. Rhabdomyoly- sis, hepatic and renal injury, and disturbances of blood clot- Heat Syncope. Heat syncope is circulatory failure result- ting are frequent accompaniments of exertional heatstroke. Symptoms range from light-headedness patients with exertional heatstroke may have somewhat and giddiness to loss of consciousness.

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