By L. Amul. Oklahoma State University Tulsa.

The breasts are accessory sexual organs that are utilized after the birth of a child to produce milk in a process called lactation buy 100mg modafinil free shipping insomnia psychology. Testosterone produced by Leydig cells in the embryonic testis stimulates the development of male sexual organs generic 100 mg modafinil free shipping insomnia 2017. Whereas the gonads and some other reproductive tissues are considered bipotential, the tissue that forms the internal reproductive structures stems from ducts that will develop into only male (Wolffian) or female (Müllerian) structures. To be able to reproduce as an adult, one of these systems must develop properly and the other must degrade. These changes lead to increases in either estrogen or testosterone, in female and male adolescents, respectively. Increases in sex steroid hormones also lead to the development of secondary sex characteristics such as breast development in girls and facial hair and larynx growth in boys. What specialized structures help guide the oocyte This interrupts the path taken by sperm through the ductus from the ovary into the uterine tube? What would likely occur if the cilia were spermpath) to explore the structures of the male paralyzed at the time of ovulation? A baby’s gender is determined at conception, and the the testes and ends as the sperm leave the penis through different genitalia of male and female fetuses develop from the urethra. Endometriosis is a disorder in which endometrial cells not in somatic cells, and how do these specializations implant and proliferate outside of the uterus—in the uterine function? Explain how these changes lead to the up muscles, they can also affect testosterone production in increases of sex steroid hormone secretions that drive many the testis. Explain how the internal female and male reproductive the testis if a male takes large amounts of synthetic structures develop from two different duct systems. The dramatic changes of fertilization, embryonic development, and fetal development are followed by remarkable adaptations of the newborn to life outside the womb. An offspring’s normal development depends upon the appropriate synthesis of structural and functional proteins. This, in turn, is governed by the genetic material inherited from the parental egg and sperm, as well as environmental factors. Because each of these reproductive cells is a haploid cell containing half of the genetic material needed to form a human being, their combination forms a diploid cell. This new single cell, called a zygote, contains all of the genetic material needed to form a human—half from the mother and half from the father. Almost immediately, millions of these sperm are overcome by the acidity of the vagina (approximately pH 3. Thus, the race into the uterine tubes, which is the most typical site for sperm to encounter the oocyte, is reduced to a few thousand contenders. Their journey—thought to be facilitated by uterine contractions—usually takes from 30 minutes to 2 hours. If the sperm do not encounter an oocyte immediately, they can survive in the uterine tubes for another 3–5 days. In comparison, an oocyte can survive independently for only approximately 24 hours following ovulation. During the journey, fluids in the female reproductive tract prepare the sperm for fertilization through a process called capacitation, or priming.

Contemporary Biochemistry plays a crucial role in the Medical field generic modafinil 200 mg otc insomnia 7 year old, be it metabolic pathways generic modafinil 100mg with amex insomnia online, storage diseases, mechanism action of varied biomolecules or inter and intra cellular communications. Topics are carefully selected to cover the essential areas of the subject for graduate level of Health sciences. Molecular events in gene expression and regulation Enzymes: Body proteins perform a large number of functions. They direct the metabolic events and exhibit specificity toward substrates, regulate the entire metabolism. They assist to know damaged tissues, the extent of tissue damage, helps to monitor the course of the disease and used as a therapeutic means of diagnosing a vast array of diseases. Proteins are the molecular instruments in which genetic information is expressed, Hormones, Antibodies, transporters, the lens protein, the architectural framework of our tissues and a myriad of substances having distinct biological activities are derived. Acid base properties of amino acids are important to the individual physical and chemical nature of vi the protein. The unfolding and disorganization of the proteins results in denaturation, the process is mostly irreversible. Many amino acid derived peptides are of biological importance and special products formed from them are of critical importance to the body. Mono is the smallest sugar unit, disaccharide is made up of two monosaccharides joined by glycosidic linkages. The failure of Galactose and fructose metabolism due to deficient enzymes leads to turbidity of lens proteins (Cataract). People suffer from Diabetes if the insulin hormone is less or not functioning well, such people are prone to atherosclerosis, vascular diseases, and renal failure. Integrative Metabolism and Bioenergetics Oxygen is utilized for the conversion of glucose to pyruvate. The main breakdown product of pyruvate is acetyl CoA, which is the common intermediate in the energy metabolism of carbohydrates, lipid and amino acids. Lipids are water insoluble, but can be extracted with non-polar solvents like Benzene, methanol, or ether. Transport forms of lipids (Lipoproteins),are present in combination with proteins Building blocks of lipids are fatty acids. Lipids are constituents of cell membrane and act as hydrophobic barrier that permits the entry/exit of certain molecules. Break down of fatty acid produce energy, excessive breakdown cause ketosis, ketoacidosis, coma and death. Vitamins and Minerals They are organic compounds required in small quantities for the functioning of the body. A third group includes trace elements, which are required in small amounts for example Fe, I, Zn, etc. Vitamins and trace elements are particularly important for patients with gastrointestinal disorders, who are fed on artificial diets or parenteral nutrition. They increase the rate of chemical reactions taking place within living cells with out changing themselves. Depending on the presence and absence of a non- protein component with the enzyme enzymes can exist as, simple enzyme or holoenzyme 1.

Although overall performance of the network is good buy 200mg modafinil with amex insomnia 2016, annually trusted 100 mg modafinil melatonin sleep aid 3 mg, one or two laboratories within the network will show suboptimal performance. This indicates the difficulty of executing high-quality drug-susceptibility testing year after year, and also highlights the importance of internal quality assurance. Results are determined judicially, and through the course of 13 rounds of proficiency testing, “borderline” strains have been encountered, where up to half the network has found these strains to be susceptible and the other laboratories have found them to be resistant. Since round 9, thorough pretesting has been used to exclude such strains from panels, but has not always been successful. Therefore, strains with less than 80% concordance within the network have been excluded from overall performance measures, so that judicial results are not distorted. Over a five-year period, 40 of 600 strains, or approximately 7% of strains included in annual panels, have been excluded. The study on borderline strains has been useful in confirming that the most important factor explaining the variation of the results of panel testing is strain selection. Currently, there is no established gold standard to replace the judicial 80 system. One possible solution would be a definition of “intermediary” resistant results; however, this would require testing at two concentrations. Many high- income countries will test drugs (at least isoniazid) at two concentrations. To date, no study has systematically evaluated all available methods for testing, established critical concentrations for all available second-line drugs, or evaluated a large number of clinical isolates for microbiological and clinical end-points. In July 2007, guidance was developed for the selection of and testing for second-line drugs. Based on evidence or expert consensus (where no evidence was available), a hierarchy was developed recommending drug-susceptibility testing based on both clinical relevance and reliability of the test available. Rifampicin and isoniazid were prioritized, followed by ethambutol, streptomycin and pyrazinamide, and then the second-line injectables (amikacin, kanamycin and capreomycin) and fluroquinolones. The policy guidance is available, and full technical guidelines for the drug-susceptibility testing of second-line drugs became available in 2008. Tests for rapid identification of second-line drug resistance are not yet available. The variation in resistance among countries within the region is relatively narrow; however, roughly half of the data points used to look at the distribution are at least five years old. Only Botswana, Côte d’Ivoire, Sierra Leone and Mpumalanga Province, South Africa, have carried out repeat surveys. Detection of this outbreak was only possible because of the extensive laboratory infrastructure available in the country. It is likely that similar outbreaks of drug resistance with associated high mortality are taking place in other countries, but are not being detected due to insufficient laboratory capacity. Botswana, Mauritania and Mozambique have nationwide surveys under way, and Angola, Burundi, Lesotho, Malawi, Namibia, South Africa, Uganda and Zambia have plans to initiate nationwide surveys over the next year. Nigeria and the Congo plan to begin a survey covering selected districts in their respective countries in 2008. Currently, Botswana and Swaziland are surveying high-risk populations to examine the extent of first and second-line drug resistance; results should be available in early 2008.

Working in concert modafinil 100 mg on line sleep aid zazen, these muscles perform three important digestive functions in the mouth: (1) position food for optimal chewing generic modafinil 200 mg on-line sleep aid pills cvs, (2) gather food into a bolus (rounded mass), and (3) position food so it can be swallowed. The top and sides of the tongue are studded with papillae, extensions of lamina propria of the mucosa, which are covered in stratified squamous epithelium (Figure 23. Fungiform papillae, which are mushroom shaped, cover a large area of the tongue; they tend to be larger toward the rear of the tongue and smaller on the tip and sides. Fungiform papillae contain taste buds, and filiform papillae have touch receptors that help the tongue move food around in the mouth. The filiform papillae create an abrasive surface that performs mechanically, much like a cat’s rough tongue that is used for grooming. Lingual glands in the lamina propria of the tongue secrete mucus and a watery serous fluid that contains the enzyme lingual lipase, which plays a minor role in breaking down triglycerides but does not begin working until it is activated in the stomach. A fold of mucous membrane on the underside of the tongue, the lingual frenulum, tethers the tongue to the floor of the mouth. People with the congenital anomaly ankyloglossia, also known by the non-medical term “tongue tie,” have a lingual frenulum that is too short or otherwise malformed. The Salivary Glands Many small salivary glands are housed within the mucous membranes of the mouth and tongue. These minor exocrine glands are constantly secreting saliva, either directly into the oral cavity or indirectly through ducts, even while you sleep. Secretion increases when you eat, because saliva is essential to moisten food and initiate the chemical breakdown of carbohydrates. In addition, the buccal glands in the cheeks, palatal glands in the palate, and lingual glands in the tongue help ensure that all areas of the mouth are supplied with adequate saliva. The Major Salivary Glands Outside the oral mucosa are three pairs of major salivary glands, which secrete the majority of saliva into ducts that open into the mouth: • The submandibular glands, which are in the floor of the mouth, secrete saliva into the mouth through the submandibular ducts. They secrete saliva into the mouth through the parotid duct, which is located near the second upper molar tooth (Figure 23. Perhaps the most important ingredient in saliva from the perspective of digestion is the enzyme salivary amylase, which initiates the breakdown of carbohydrates. Food does not spend enough time in the mouth to allow all the carbohydrates to break down, but salivary amylase continues acting until it is inactivated by stomach acids. Salivary mucus helps lubricate food, facilitating movement in the mouth, bolus formation, and swallowing. Saliva contains immunoglobulin A, which prevents microbes from penetrating the epithelium, and lysozyme, which makes saliva antimicrobial. Saliva also contains epidermal growth factor, which might have given rise to the adage “a mother’s kiss can heal a wound. The submandibular glands have cells similar to those of the parotid glands, as well as mucus-secreting cells. Therefore, saliva secreted by the submandibular glands also contains amylase but in a liquid thickened with mucus. The sublingual glands contain mostly mucous cells, and they secrete the thickest saliva with the least amount of salivary amylase. Mumps manifests by enlargement and inflammation of the parotid glands, causing a characteristic swelling between the ears and the jaw. Symptoms include fever and throat pain, which can be severe when swallowing acidic substances such as orange juice.

The carotid sinus and aortic arch baroreceptors increase the rate of firing in their afferent nerve purchase modafinil 200 mg on-line insomnia 26 weeks pregnant. These efferent signals decrease heart rate 100mg modafinil for sale insomnia 478 breathing, decrease stroke volume, and produce arteriolar and venous dilation, which in turn lead to decrease in cardiac output and decrease in total peripheral resistance, with a consequent decrease in blood pressure back towards normal. Conversely, when blood pressure falls below normal baroreceptor activity decreases, inducing the cardiovascular center to increase sympathetic cardiac and vasoconstrictor nerve activity, while the parasympathetic output is decreased. This efferent activity pattern leads to an increase in heart rate and cardiac output coupled with arteriolar and venous vasoconstriction. These changes result in an increase in both cardiac output and total peripheral resistance, producing an elevation in blood pressure back towards normal. These include: sympathetic cholinergic vasodilatation in 203 skeletal muscle which promote immediate increase in blood flow to the muscles to be used, sympathetic vasoconstriction else where which increase blood pressure, increase heart rate and contractility, increased catecholamines production, increased respiratory rate, piloerection (in animals). The heart slows (bradycardia), blood pressure falls, and a state similar to fainting occurs. There appears to be a very strong inhibition of the sympathetic cardiovascular centers. After stimulating of the amygdala, both pressure & depresser responses have been observed both the hypothalamus and amygdale are capable of strongly influencing all circulatory reflex responses. Higher Centers: - The fronto-orbital cortex modulates hypothalamus integration of cardiovascular activity. The most important is to help the hypothalamus resetting the responses to the baroreceptor reflexes. This resetting is important for the maintenance of an adequate high blood pressure during exercise or response to danger. The role of the cortex in these control mechanism is not still clear other than that if it is removed there is impairment of cardiovascular responses. In some it may cause fainting probably due to powerful stimulation, through the hypothalamus, of the medullary cardioinhibitory and vasodilator centers. Some reflexes and 204 responses influence blood pressure though they primarily are concerned with the regulation of other functions. The chemorecepor function is to reflexly increase respiration to bring more oxygen or to blow off acid-forming carbon dioxide, but they also reflexly increase blood pressure by sending stimulatory impulses to the cardiovascular centers. Blood pressure may fall when eliminating excess heat from the body even though baroreceptors reflex is for coetaneous vasoconstriction. Long-term Regulation of blood pressure: Long-term regulation of blood pressure involves many factors in addition to the integrated neural control of cardiovascular reflexes. Its secretion is controlled by the following factors: • The juxtaglomerular cells not only secrete rennin but also act as baroreceptors responding to these changes in afferent arterioles blood pressure. The macula densa responds to sodium excretion and by some unknown mechanism, feedback this information to the juxtaglomerular cells, causing a rise in renin secretion, and corresponding retention - a befitting response to increased sodium excretion in the urine. Its vasoconstrictor effect on arteriolar smooth muscles causes a sharp rise in peripheral resistance and hence arterial blood pressure. Aldosterone acts on the distal renal tubule to decrease the amount of NaCl excreted in to the urine. Thus blood volume rises, blood pressure increases, & rennin secretion is inhibited. Role of the renin-angiotensin system in arterial pressure control 208 Circulatory Shock ‘Shock’ is a popular term used by the layperson to describe a sudden and severe setback due to any reason. But circulatory shock or ‘cardiovascular collapse’ is characterized by a reduction in circulatory blood volume and results in inadequate tissue perfusion.

Spinal anaesthesia • Positioning of the patient either during or after Spinal (intrathecal) anaesthesia results from the in- the injection buy modafinil 100mg on-line insomnia 7 weeks pregnant. The spinal needle can only be in- will extend to the thoracic nerves around T5–6 purchase 100 mg modafinil with amex insomnia zoloft, the serted below the second lumbar and above the first point of maximum backwards curve (kyphosis) of sacral vertebrae; the upper limit is determined by the thoracic spine. Further extension can be ob- the termination of the spinal cord, and the lower tained with a head-down tilt. The first indication of extensive intravenously), but this must not be at the expense spread of anaesthesia may be a complaint of diffi- of the above. The incidence is greatest with large holes, that is, when a hole is These are usually mild and rarely cause any lasting made accidentally with a Tuohy needle, and least morbidity (Table 2. Complications seen in patients frontal or occipital, postural, worse when standing receiving epidural analgesia postoperatively are and exacerbated by straining. Persistent headaches can be relieved (>90%) by injecting 20–30mL of the Hypotension and bradycardia patient’s own venous blood into the epidural space (epidural blood patch) under strict aseptic Anaesthesia of the lumbar and thoracic nerves conditions. If the block ex- Regional anaesthesia, awake or after tends cranially beyond T5, the cardioaccelerator induction of anaesthesia? Small falls in blood often combined with general anaesthesia to reduce pressure are tolerated and may be helpful in reduc- the amount and number of systemic drugs given ing blood loss. London: British to ensure that there is full recovery of normal Medical Association and the Royal function. Trauma resuscitation: A low, fixed cardiac output As seen with severe aortic the team approach, 2nd edn. Where heparins intensive care A to Z: an encyclopaedia of principles are used perioperatively to reduce the risk of and practice. It is • Monitoring equipment Transducers and a moni- now accepted that all patients recovering from tor capable of displaying two or three pressure anaesthesia should be nursed in an area with ap- waveforms, end-tidal carbon dioxide monitor and propriate facilities to deal with any of the problems thermometer. Patients who have undergone pro- longed surgery, or where a prolonged stay is The anaesthetist’s responsibility to the patient expected, may be recovered on their beds to does not end with termination of the anaesthetic. Each patient Although care is handed over to the recovery staff should be cared for in a dedicated area equipped (nurse or equivalent), the ultimate responsibility with: remains with the anaesthetist until discharge from • oxygen supply plus appropriate circuits for the recovery area. If there are inadequate numbers administration; of recovery staff to care for a newly admitted pa- • suction; tient, the anaesthetist should adopt this role. In addition the following must be available imme- diately: • Airway equipment Oral and nasal airways, a The length of time any patient spends in recovery range of endotracheal tubes, laryngoscopes, a will depend upon a variety of factors, including bronchoscope and the instruments to perform length and type of surgery, anaesthetic technique a cricothyroidotomy and tracheostomy. Most • Breathing and ventilation equipment Self-inflating units have a policy determining the minimum bag-valve-masks, a mechanical ventilator and a length of stay, which is usually around 30mins, chest drain set. Hypoventilation is always • Adequate breathing accompanied by hypercapnia, as there is an in- • Stable cardiovascular system, with minimal bleeding verse relationship between arterial carbon dioxide from the surgical site (PacO2) and alveolar ventilation. Common causes • Adequate pain relief of hypoventilation include: •W arm • Obstruction of the airway Most often due to the tongue. Partial obstruction causes noisy breathing; in complete obstruction there is Complications and their little noise despite vigorous efforts. It is pre- vented by recovering patients in the lateral posi- Hypoxaemia tion, particularly those recovering from surgery This is the most important respiratory complica- where there is a risk of bleeding into the airway tion after anaesthesia and surgery. An oropharyngeal or nasopharyn- advent of pulse oximetry has had a major impact geal airway may be required to help maintain the on the prevention of hypoxaemia and should be airway (see page 18). If hypoxaemia is se- vere, persistent or when there is any doubt, arterial blood gas analysis should be performed. Hypox- No patient should be handed to the care of the recovery aemia can be caused by a number of factors, either nurse with noisy respiration of unknown cause. If severe, the Alveolar hypoventilation administration of the specific antagonist naloxone This is the commonest cause of hypoxaemia and may be required (see page 39). Eventually a point is reached where there is commonly, a deeply unconscious patient unable only ventilation of ‘dead space’, that is, the volume to maintain a patent airway.

Many infections occupy a non-vascularized space of tissue generic modafinil 200 mg without prescription sleep aid zolip, thus are likely to respond to non-surgical treatments discount modafinil 100mg on line sleep aid hallucination. These types of infection therefore definitely require surgery as a primary or definitive therapeutic approach. Examples of such infections, which definitely need surgery, can be: - Gas gangrene - Abscess - Appendicitis. On the other hand, any infection that is related to surgical therapy but that may not definitely require surgery is also categorized as a surgical infection. Examples: - Urinary tract infections after catheterization for surgical purpose - Pulmonary complications following intubation for surgery - Tracheotomy site infection All wounds that follow operative procedure or incision are also grouped as surgical infections. According to temporal relation to surgery, surgical infections are grouped into three types. Ante/pre operative infections: These infections happen before a surgical procedure. Example: - Accidents - Appendicitis - Boils - Carbuncle - Pyomyositis… Operative infections: These are types of surgical infections that happen during a surgical procedure. It can occur either due to contamination of the site or poor tissue handling technique. These include: - An infectious agent - A susceptible host - Favorable external factors or local condition with closed, less or non-per fused space. An infection becomes overt only when the equilibrium between the bacterial and host factors becomes disturbed. The common organisms in decreasing order are:- 1- Aerobic bacteria - Staphylococcus aureus - Streptococci - Klebsiella - E. Host Susceptibility: Reduced immune host defense predisposes to surgical infections. Local and external factors: Closed spaces, usually with poor vascularization, are areas susceptible to infection. Favorable situations under such condition contributing to infection include:- - Poor perfusion of blood and oxygen - Presence of dead tissue 63 - Presence of foreign bodies - Closure under tension etc. External factors like a break in the sterility technique also contribute to the development of surgical infection. Post-Operative Wound Infection This is contamination of a surgical wound during or after a surgical procedure. Source of infection: The source of contamination in more than 80% cases is the patient (endogenous). In about 20% of cases, the source is from the environment, operating staff or unsterile surgical equipment (exogenous). It contains necrotic tissue and suppuration from damage by the bacteria, and white blood cells. It is surrounded by area of inflamed tissue due to the body’s response to limit the infection. Clinical features: Patients with an abscess anywhere in the body may present with the following findings. It usually involves the extremities and identifiable portal of entry is detectable. Etiology: The most common etiologic organisms are - Beta hemolytic streptococci - Staphylococci - Clostridium perfringens Clinical Features: There is usually an identifiable portal of entry which can be a surgical wound, puncture site, skin ulcer or dermatitis. Clinical Pictures: - Series of small intra epithelial abscesses , multiple - Bullous lesions - Skin erosion and - Crust formation.