By R. Diego. Cheyney University of Pennsylvania. 2018.

The vascular remodeling results to be withdrawn periodically to permit the heart to pump in narrowing of the small pulmonary arteries and leads to a effectively buy viagra plus 400 mg with amex erectile dysfunction in diabetes type 1. Oxygen delivery to the cells is also favored by significant increase in pulmonary vascular resistance and hy- an increased concentration of 2 generic viagra plus 400mg line low testosterone erectile dysfunction treatment,3-DPG in the red cells, pertension. With severe hypoxia, the pulmonary veins are which shifts the oxyhemoglobin equilibrium curve to the also constricted. The increase in venous pressure elevates right, and favors the unloading of oxygen in the tissues the filtration pressure in the alveolar capillary beds, leading (see Chapter 21). Pulmonary hypertension also in- Although the body undergoes many beneficial changes creases the workload of the right heart, causing right heart that allow acclimatization to high altitude, there are some hypertrophy, which, if severe enough, may lead to death. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (C) Rapid shallow breathing (B) Central effects are mediated by items or incomplete statements in this (D) Systemic vasoconstriction direct effects on cells of the section is followed by answers or by (E) Skeletal muscle relaxation DRG/VRG complex completions of the statement. Which of the following is true about (C) Sensitivity of the control system is ONE lettered answer or completion that is cerebrospinal fluid? Generation of the basic cyclic pattern (B) Its PCO2 equals that of systemic than control in response to oxygen of breathing in the CNS requires arterial blood (E) Transection of cranial nerves IX participation of (C) It is freely accessible to blood and X at the skull would have no (A) The pontine respiratory group hydrogen ions effect (B) Vagal afferent input to the pons (D) Its composition is essentially that 10. Which of the following relationships (C) Vagal afferent input to the of a plasma ultrafiltrate can be represented by a straight line medulla (E) Its pH is a function of PaCO2 sloping downward from left to right? Slow-wave sleep is characterized by (A) Minute ventilation as a function of (E) An intact spinal cord (A) A fall in PaCO2 arterial pH (B) A tendency for breathing to vary (B) Minute ventilation as a function of 2. Quiet expiration is associated with in a periodic fashion arterial oxygen percent saturation (A) A brief early burst by inspiratory (C) Facilitation of the cough reflex (C) Carotid chemoreceptor firing neurons (D) Heightened ventilatory (B) Active abduction of the vocal frequency as a function of PaCO2 responsiveness to hypoxia cords (D) Minute ventilation as a function (E) Greater skeletal muscle relaxation (C) An early burst of activity by of PaO2 while PaCO2 is held constant than REM sleep expiratory muscles (E) Arterial pH as a function of 7. Which of the following is not true (D) Reciprocal inhibition of arterial [H ] during sleep? The ventilatory response to hypoxia (D) Airway occlusion evokes arousal Application in Medicine. O2-sensing mecha- carotid chemoreceptors (A) Would not apply to the regulation nisms in excitable cells: Role of plasma (C) Is exaggerated by hypoxia of the membrane K channels. Annu Rev of PaCO2 medullary chemoreceptors (B) Anticipate future events Physiol 1997;59:23–41. Nunn’s Applied Respiratory relationship to arterial oxygen content sensitive Physiology. Oxford, UK: Butterworth- (E) Is a sensitive mechanism for (D) Are ineffective if the properties of Heinemann, 2000. Potassium and breathing in range of blood gases (E) Are not necessarily stable exercise. CHAPTER 22 The Control of Ventilation 375 CASE STUDIES FOR PART V • • • antiproteases. In emphysema, excess proteolytic activity de- CASE STUDY FOR CHAPTER 19 stroys elastin and collagen, the major extracellular matrix Emphysema proteins responsible for maintaining the integrity of the A 65-year-old man went to the university hospital emer- alveolar-capillary membrane and the elasticity of the lung. He also complained of arise through an increase in protease levels, a decrease in a cough productive of green sputum. Chronic obstructive pulmonary disease: An overview smoked two packs of cigarettes a day for the past 30 years, of pathology and pathogenesis. Novartis Found Symp he had recently decreased his habit to one pack a day. Although CASE STUDY FOR CHAPTER 20 he has had dyspnea upon exertion for the last 2 years, he continues to maintain an active lifestyle. He still mows his Chest Pain lawn without much difficulty, and can walk 1 to 2 miles on A 27-year-old accountant recently drove cross-country to a flat surface at a moderate pace. He denied having had any other sig- move, she started to experience chest pains. She drove nificant past medical problems, including heart disease, to the emergency department after experiencing 24 hypertension, edema, childhood asthma, or any allergies. She denied any sputum pro- An initial exam shows that the patient is thin but has duction, hemoptysis, coughing, or wheezing. His tive and walks daily and never has experienced any blood pressure is 130/80 mm Hg; respiratory rate, 28 to swelling in her legs. She has never been treated for any 32 breaths/min; heart rate, 92/minute; and oral tempera- respiratory problems and has never undergone any sur- ture, 37. Oral contraceptives are breath sounds in both lung fields, with expiratory wheez- her only medication.

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Norepinephrine increases the pacemaker potential in the presence of norepinephrine (a) results from increased Na permeability cheap viagra plus 400 mg free shipping erectile dysfunction age. The hyperpolarization and slope of the pacemaker potential by opening channels car- 2 slower rising pacemaker potential in the presence of ACh results rying Na and Ca and closing K channels generic viagra plus 400 mg otc causes for erectile dysfunction and its symptoms. Both effects from decreased Na permeability and increased K permeability, result in faster movement of the pacemaker potential to- 2 due to the opening of ACh-activated K channels. Norepi- nephrine and ACh exert these effects via Gs and Gi protein- mediated events. Third, calcium moves in through the voltage- 2 to the ones outlined above. All three of these changes move the membrane potential in a positive direc- 2 tion toward the Na and Ca equilibrium potentials. THE INITIATION AND PROPAGATION This action potential rises more slowly than the ventricular OF CARDIAC ELECTRICAL ACTIVITY action potential because the fast voltage-gated Na chan- nels play an insignificant role. Instead, the opening of slow Cardiac electrical activity is normally initiated and spread 2 in an orderly fashion. The heart is said to be a functional voltage-gated Ca channels is primarily responsible for the upstroke of the action potential in nodal cells. The ab- syncytium because the excitation of one cardiac cell even- tually leads to the excitation of all cells. The cellular basis sence of a well-defined plateau occurs because K channels for the functional syncytium is low-resistance areas of the open and pull the membrane potential toward the K equi- librium potential. Gap junctions but the rate of depolarization during phase 4 is much slower between adjacent cells allow small ions to move freely from than that of the nodal cells. In the normal heart, phase 4 of one cell to the next, meaning that action potentials can be Purkinje fibers is usually thought to be a stable resting propagated from cell to cell, similar to the way an action membrane potential. The Refractory Period Is Caused by a Delay Excitation Starts in the SA Node Because in the Reactivation of Na Channels SA Cells Reach Threshold First As discussed in Chapter 10, cardiac muscle cells display Excitation of the heart normally begins in the SA node be- long refractory periods and, as a result, cannot be cause the pacemaker potential of this tissue (see Fig. A prolonged re- reaches threshold before the pacemaker potential of the AV fractory period eliminates the possibility that a sustained node. The pacemaker rate of the SA node is normally 60 to contraction might occur and prevent the cyclic contrac- 100 beats/min versus 40 to 55 beats/min for the AV node. The refractory period be- Pacemaker activity in the bundle of His and the Purkinje gins with depolarization and continues until nearly the system is even slower, at 25 to 40 beats/min. This occurs because the and ventricular cells do not exhibit pacemaker activity. Many cells of the SA node reach threshold and depolar- Na channels that open to cause phase 0 close and are in- active until the membrane repolarizes. This leads to depolarization of the neighboring the relatively smaller current brings neighboring cells to right atrial cells and a wave of depolarization begins to threshold more slowly, decreasing the rate at which elec- spread over the right and left atria. Other significant factors are the slow upstroke of the action potential because it depends on 2 slow voltage-gated Ca channels and, possibly, weak elec- The Action Potential Is Propagated by Local trical coupling as a result of relatively few gap junctions. Currents Created During Depolarization Propagation of the action potential through the AV node takes approximately 120 msec. Excitation then proceeds As Na ions enter a cell during phase 0, their positive through the AV bundle (bundle of His), the left and right charge repels intracellular K ions into nearby areas where depolarization has not yet occurred. Inflammation, hypoxia, vagus nerve activity, and cer- The local buildup of K depolarizes adjacent areas until threshold is reached. Excitation proceeds as succeeding cycles of hand, its tendency to conduct slowly is sometimes of ben- local ion current and action potential move out of the SA efit in pathological situations in which atrial depolariza- node and across the atria. This process is called the propa- tions are too frequent and/or uncoordinated, as in atrial gation of the action potential. In these conditions, not all of the elec- trical impulses that reach the AV node are conducted to the ventricles, and the ventricular rate tends to stay below the Excitation Usually Spreads From the SA Node level at which diastolic filling is impaired (see Chapter 14). A fibrous, nonconducting connective tissue ring separates the atria from the ventricles everywhere except at the AV Rapid Conduction Through the Ventricles. For this reason, the transmission of electrical activity system is composed of specialized cardiac muscle cells with from the atria to the ventricles occurs only through the AV large diameters. Action potentials in atrial muscle adjacent to the AV locity up to 2 m/sec) action potentials throughout the suben- node produce local ion currents that invade the node and docardium of both ventricles.

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Recognizes and respects the patient’s right to care regardless of age generic viagra plus 400mg with amex erectile dysfunction in diabetes management, race cheap viagra plus 400mg free shipping erectile dysfunction vacuum pumps, gender, ethnicity, religion, lifestyle, sexual orientation, economic status, or level of disability. Recognizes the patient’s right to treatment and therapies, including experimental treatments. Knows that patients have the right to be informed and under- stand advanced healthcare directives (living wills and durable CHAPTER 4: MULTIPLE SCLEROSIS NURSES’ CODE OF ETHICS 15 powers of attorney), concerning the right to receive resuscita- tion, refuse appropriate treatment, request do-not-resuscitate orders, or request the discontinuation of life support measures. Is responsible for providing information to the MS patient and family in order to facilitate informed consent for all treatments and procedures. Participates in research and is aware of the principles of informed consent, criteria for inclusion and exclusion in research protocols, and the right of the individual to withdraw from a protocol at any time. Recognizes and maintains the patient’s privacy, assuring confidentiality, except when there is a clear, serious, and immediate danger to the patient or others. Has a moral obligation to offer access to care, cost containment, and quality care. Affirms that MS patients have a right to be informed, without bias, coercion, or deception, about treatment options, potential effect, and adverse effects of treatments. Supports the fact that MS patients have a right to refuse treatment, continuing to receive alternative care. Recognizes that the MS patient has a right to review his medical record and the right to have information explained. Requires participation of the MS patient in an ongoing partner- ship to develop an effective plan of care. This process considers diversity, individual autonomy, and responsibility. Practices competently, consulting and referring when indicated by professional judgment. Takes appropriate action to protect patients from harm when endangered by incompetent or unethical clinical practice. Promotes and supports improved practice through profession- alism, education, certification, and nursing research. Promotes local and national efforts to improve public education, legislation to ensure access to quality care, and long-term care initiatives that meet the health needs of MS patients and families. This page intentionally left blank Chapter 5 Epidemiology Objectives: Upon completion of this chapter, the learner will: Describe the difference between disease incidence and prevalence Provide an overview of the epidemiology of multiple sclerosis Discuss the implications of MS epidemiology in patient and family educationResearch into MS includes epidemiologic inquiries. This is usually given as an annual incidence rate in cases per 100,000 per year. The date of onset of clinical symptoms decides the time of accession although, occasionally, the date of first diagnosis is used. Nevertheless, accurate assessment of prevalence is still difficult because of the difficulty of full disease ascertainment. High-risk areas such as northern and central Europe, 17 18 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM Italy, the northern United States, Canada, southeastern Australia, New Zealand, and parts of the former Soviet Union are considered high risk, with rates greater than 30 per 100,000 populations. Low-risk areas (less than 5 per 100,000) include other areas of Africa and Asia, the Caribbean, Mexico, and possibly northern South America. In general, people who reside in temperate climates in economically developed occidental countries tend to have a higher rate of MS. There is a seven-fold decrease in exacerbations during pregnancy and a seven-fold increased risk during the six months after delivery. No data strongly link associations but anecdotal reports CHAPTER 5: EPIDEMIOLOGY 19 exist of relationships to diabetes mellitus, rheumatoid arthritis, myasthenia gravis, and bipolar illness. Incidence and death rates refer to new cases and to deaths per unit time and population. Those migrating before the age of 15 acquire the lower risk of their new residence. This page intentionally left blank Chapter 6 The Complete Neurologic Examination Objectives: Upon completion of this chapter, the learner will: Describe key components of a neurologic examination Discuss clinical implications of positive findings Cite the importance of patient and family education to explain the neuropathology of diseaseTaking the history: A.

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To paraphrase one of my clinical colleagues “Parkin- ble purchase viagra plus 400mg impotence kidney disease, to the requirements of the clinical experience generic viagra plus 400mg with visa erectile dysfunction doctors in sri lanka. It is commonplace son did not die of his disease (Parkinson disease), he died of a stroke; to present brain structure in an anatomical orientation (e. McKusick However, when the midbrain is viewed in an axial MRI or CT, the re- (1998a,b) has also made compelling arguments in support of using the verse is true: the colliculi are “down” in the image and the interpedun- non-possessive form of eponyms. There are many good reasons for making brainstem views differ on this question—much like debating how many angels images available in an anatomical orientation and for teaching this view can dance on the head of a pin. On neurosurgery colleagues, a review of some of the more comprehensive the other hand, the extensive use of MRI or CT in all areas of medi- neurology texts (e. To address this important question, a series of sociation’s Manual of Style (1998) clearly indicate an overwhelming illustrations, including MRI or CT, are introduced in the spinal cord preference for the non possessive form. These images are arranged to show of this book will enter clinical training, it was deemed appropriate to 1) the small colorized version of the spinal cord or brainstem in an encourage a contemporary approach. Consequently, the non posses- anatomical orientation; 2) the same image flipped bottom-to-top into sive form of the eponym is used. With the publication of Terminologia Anatomica (Thieme, rable to the line drawing and corresponding stained section. This ap- New York, 1998), a new official international list of anatomical terms proach retains the inherent strengths of the full-page, colorized line for neuroanatomy is available. This new publication, having been v vi Preface to the Sixth Edition adopted by the International Federation of Associations of Anatomists, References: supersedes all previous terminology lists. Every effort has been made Council of Biology Editions Style Manual Committee. Scientific Style and to incorporate any applicable new or modified terms into this book. The number of changes is modest and related primarily to directional Cambridge: Cambridge University Press, 1994. Terminologia Ana- previous term appears in parentheses following the official term, i. American Medical Association Manual of Style—A Guide have eluded detection; these will be caught in subsequent printings. Last, but certainly not least, the sixth edition is a few pages McKusick, VA. On the naming of clinical disorders, with particular ref- longer than was the fifth edition. Mendelian Inheritance in Man, A Catalog of Human Genes clinical information, including more clinical examples (text and il- and Genetic Disorders. Baltimore: The Johns Hopkins Uni- lustrations), and the inclusion of Study/Review and USMLE style versity Press, 1998. Preface to the First Edition his atlas is a reflection of, and a response to, suggestions from pro- dents in the laboratory and greatly enhances their ability to grasp and Tfessional and graduate students over the years I have taught human retain information on CNS connections. Admittedly, some personal philosophy, as regards tempt to teach clinical concepts, a chapter correlating selected views teaching, has crept into all parts of the work. These examples formation, in the form of photographs and drawings, so that the initial illustrate that a clear understanding of normal morphological relation- learning experience will be pleasant, logical, and fruitful, and the re- ships, as seen in the laboratory, can be directly transposed to clinical view process effective and beneficial to longterm professional goals. First, the entire This atlas was not conceived with a particular audience in mind. It anatomy of the central nervous system (CNS), external and internal, was designed to impart a clear and comprehensive understanding of has been covered in appropriate detail. Second, a conscientious effort CNS morphology to its readers, whoever they may be. It is most obvi- has been made to generate photographs and drawings of the highest ously appropriate for human neurobiology courses as taught to med- quality: illustrations that clearly relay information to the reader. In addition, students in nursing, complementary information always appears on facing page. This may physical therapy, and other allied health curricula, and psychology as take the form of two views of related structures such as brainstem or well, may also find its contents helpful and applicable to their needs. Fourth, illustrations of blood supply have been in- ternal, and the summary pathway drawings may be useful to the indi- cluded and integrated into their appropriate chapters. When gross vidual requiring a succinct, yet comprehensive review before taking anatomy of the brain is shown, the patterns of blood vessels and rela- board exams in the neurological, neurosurgical, and psychiatric spe- tionships of sinuses appear on facing pages. If one is to err, it seems more judi- ternal vascular patterns represents a distinct departure from what is cious to err on the side of greater detail than on the side of inadequate available in most atlases, and illustrations of internal vessel distribution detail.

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