Lynn Anne Bowlby, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/lynn-anne-bowlby-md

D2 partial agonism and subsequent stabilization of dopamine neurotransmission (aripiprazole) skin care in your 20s buy cheap cleocin gel online, 3 acne vacuum purchase cleocin gel 20gm line. Olanzapine also produced higher cholesterol elevations than aripiprazole skin care zinc cleocin gel 20gm otc, risperidone acne 8 yr old girl purchase 20 gm cleocin gel with amex, and ziprasidone acne 30 years old order genuine cleocin gel, but no difference compared to clozapine or quetiapine skin care therapist purchase discount cleocin gel on line. Quetiapine was shown to cause greater cholesterol elevations than risperidone and ziprasidone. Lastly, glucose elevations were higher for olanzapine than for aripiprazole, quetiapine, risperidone, and ziprasidone, with no difference compared to clozapine (Rummel-Kluge et al. Consolidation to a single daily dosing regimen results in lower pill burden and enhanced patient adherence. This will avoid any interruptions in treatment if the patient brings in the prescription to be filled and finds they cannot afford the medication or they have to wait for prior authorization before the medication can be filled. However, further titration to dosages above 6 mg pushes the D2 receptor occupancy to approximately 77%. The higher D2 binding affinity and concentration of paliperidone at this site gives it a slightly higher risk of hyperprolactinemia than risperidone. The clinical sequelae that may result from excess prolactin production include amenorrhea in females, and sexual dysfunction, galactorrhea, gynecomastia, and bone mineral density changes in both males and females. However, prolactin levels do not acutely correlate with these adverse events and are only of concern in actively symptomatic patients. Paliperidone is available as a sustained-release oral formulation that utilizes osmotic pressure to slowly push the active compound out of a laser-drilled pore in an insoluble tablet. The faster absorption and higher Cmax give risperidone more concentration-dependent side effects, such as orthostasis and excess sedation, versus paliperidone. Therefore, risperidone is routinely dosed twice daily when first initiated, then consolidated to once-daily dosing once tolerability is established. Paliperidone should be dosed once daily in the morning due to the kinetics of its sustained-release dosage formulation. The patient should be counseled that a "ghost shell" of the insoluble tablet may be present in stool and can cause complications if the patient has any gastrointestinal narrowing or obstruction. Both risperidone and paliperidone are available in long-acting injectable dosage forms. The long-acting injectable formulation of risperidone (Risperdal Consta) is available as 12. The risperidone is suspended in glycolic acid-lactate copolymer microspheres that are slowly hydrolyzed, resulting in a delayed absorption of approximately three weeks. The dose of paliperidone palmitate needs to be reduced to 156 mg day 1 followed by 117 mg day 8 (both administered in the deltoid) in patients with mild renal impairment (creatinine clearance 50 mL/min to < 80 mL/min). Both injections should still be administered in the deltoid and followed by a monthly maintenance dose of 78 mg given in either the deltoid or gluteal muscle. Paliperidone palmitate should not be administered in patients with severe renal impairment (creatinine clearance below 50 mL/min). In patients who express this decreased activity enzymatic phenotype, the half-lives of risperidone and 9-hydroxyrisperidone will be approximately 17 hours and 30 hours, respectively. Paliperidone is primarily excreted unchanged (57%) in the urine and does not undergo hepatic metabolism. This would in theory suggest antidepressant actions, but there is little evidence to support this. Food will increase the absorption of ziprasidone by two-fold; therefore, it must also be administered with a meal of at least 500 calories. Ziprasidone has a lower propensity to cause weight gain, dyslipidemia, increased fasting triglycerides, or insulin resistance. No cases of torsades de pointes were observed in the 4,571 ziprasidone-treated patients. Clinically, this necessitates caution and careful consideration of the risks and benefits when contemplating the initiation of, or continued treatment with, ziprasidone. Asenapine (Saphris) the chemical structure of asenapine closely resembles that of the tetracyclic antidepressant mirtazapine. The bioavailability of asenapine is severely limited by extensive first-pass metabolism. The time of onset is not as rapid as might be expected due to compartmentalization in the oral mucosa. Upon administration, the compound is rapidly dissolved in the saliva and transported into the mucosal membranes until a pseudoequilibrium is reached. The limited surface area available for absorption requires split-day dosing for doses greater than 5 mg even though asenapine has a 24-hour half-life. The rate-limiting step in the absorption of asenapine is the transfer from the mucosal membranes into systemic circulation. However, it is differentiated by its potent alpha1 blockade, which results in high rates of orthostasis and sedation. This agent has low incidence of dyslipidemias but carries a moderate risk for weight gain. The addition of a potent inhibitor of either enzyme has the potential to increase the serum concentration of iloperidone; therefore, it is recommended to decrease the dose of iloperidone by 50% if concomitant administration is deemed necessary. Quetiapine (Seroquel) Quetiapine is a dibenzothiazepine derivative structurally related to clozapine. The high H1 and 1 blockade results in the high 216 Schizophrenia and Related Disorders incidence of sedation, dizziness, and orthostasis observed with quetiapine. The active metabolite of quetiapine, norquetiapine, possesses some differing pharmacological activity than the parent compound. The mean terminal half-life of quetiapine is approximately six hours, allowing it to reach steady-state concentrations within two days of administration. Quetiapine has no clinically significant impact on the pharmacokinetics of other medications. However, quetiapine may have additive sedative and hypotensive effects when combined with similar agents or alcohol. After one week of administration, olanzapine will reach steady-state concentrations and have an elimination half-life of 30 hours. Only 60% of the parent compound will reach systemic circulation following oral administration. Should smoking cessation occur, the resultant reversal in enzymatic induction will cause an increase in olanzapine serum levels. Therefore, changes in patient smoking status should be consistently monitored, and adjustments to the olanzapine dose should be made accordingly. This interaction should be kept in mind when patients are being admitted and discharged from smoke-free facilities. In addition to the oral capsule formulation, olanzapine is also available as an orally disintegrating tablet, a short-acting injectable, and a long-acting injectable formulation. Due to concerns about excessive orthostatic hypotension, the short-acting injectable should be dosed at least two hours after the initial 10 mg Im dose or four hours after a second 10 mg Im dose. The patient should be assessed for orthostatic hypotension and subsequent doses be withheld if significant orthostasis or syncope is observed. The turbidity in the bloodstream leads to the rapid dissolution of olanzapine pamoate. The injection must be given in a facility with readily available access to emergency response services, and the patient must be continuously observed for three hours post-injection by a healthcare professional for symptoms consistent with olanzapine overdose. The high administrative burden of coordinating the post-injection monitoring limits its use in routine clinical practice. The partial D2 agonism may also cause nausea and vomiting early in treatment and be somewhat activating in certain patients. In this subset of patients, morning dosing will help avoid disrupting sleep architecture. Aripiprazole is also differentiated by its lack of m1 and H1 activity and low risk of inducing weight gain, fasting triglyceride elevations, or insulin resistance. However, this does not mean it cannot induce weight gain in select individuals, particularly in the child and adolescent population. The 75-hour elimination half-life of aripiprazole may be of particular benefit in patients who have difficulty with medication adherence. If concurrent administration is clinically indicated, the dose of aripiprazole should be doubled. Aripiprazole is unlikely to exert any clinically relevant pharmacokinetic effect on other agents metabolized through cytochrome P450. An orally disintegrating tablet, short-acting Im injection, liquid, and long-acting injection are all available. The short-acting Im injection has a bioavailability of 100% versus the 87% of the oral tablet. The tablet, orally disintegrating tablet, and liquid formulation can be substituted at a 1:1 ratio. Mild renal impairment (CrCl 50 mL/min and < 80mL/min): Initiate with 156 mg Im on day 1, then 117 mg Im day 8. Like that of aripiprazole and ziprasidone, the metabolic profile of lurasidone is relatively clean, with low risk for weight gain or dyslipidemias. The absorption of lurasidone, like ziprasidone, is greatly increased by administration in a fed versus fasted state. This effect was seen independently of the dietary fat content of the meal, and drug exposure did not increase any further when the size of the meal was greater than 350 calories. Lurasidone has an elimination half-life of approximately 18 hours and will reach steady-state concentration at a given dose within seven days of consistent administration. Lurasidone was not observed to have any appreciable effects on the metabolism or concentrations of other medications. The recommended total daily dose should also not exceed 40 mg in patients with moderate to severe renal or hepatic impairment. These side effects range from the more common and bothersome sialorrhea, constipation, orthostatic hypotension, and sedation, to the rare yet more serious seizures, myocarditis, cardiomyopathy, and agranulocytosis. A dose-dependent risk for seizure was described by Devinsky and colleagues (1991) in a retrospective review of premarketing data for 1,418 clozapine-treated patients. Evidence for increased risk of seizures at higher serum clozapine levels is limited to case reports of tonic-clonic seizures occurring at serum levels above 1300 ng/mL. Agranulocytosis is a rare side effect, occurring in slightly less than 1% of clozapinetreated patients. It was first identified in a population of Finnish patients in 1975, eight cases of which were fatal. Clozapine was then approved for use in patients with schizophrenia who have failed to respond to adequate trials of other antipsychotics. It is also important to keep in mind the cholinergic rebound that may occur with abrupt discontinuation of clozapine. The patient should be monitored for profuse sweating, headache, nausea, vomiting, and diarrhea. There is some evidence for initiating an anticholinergic medication, such as benztropine, for a short time to counteract these withdrawal effects. We know, for instance, that patients are more likely to respond to clozapine when the level is above 350 ng/mL. There is no consensus or consistent evidence to support an upper limit of therapeutic efficacy, but at higher levels, the increasing sideeffect burden begins to outweigh the marginal benefit gained by raising the dose. Once a patient has responded to a stable dose of clozapine, drawing a serum level can provide a useful basis for comparison if levels are drawn in the future. Unfortunately, very little evidence exists about appropriate strategies for augmentation. We know that up to 20% of patients with primary psychotic disorders end up taking more than one antipsychotic medication (particularly young male patients who have high symptom burdens), but there is little evidence that such antipsychotic polypharmacy actually improves outcomes. As such, there have been many efforts to limit such antipsychotic polypharmacy unless clearly warranted. Probably the best-studied antipsychotic polypharmacy approach is "clozapine plus": prescribing a second antipsychotic to a treatment-refractory patient already taking clozapine. When such patients have partial responses, providers often feel extremely limited, not wanting to take a patient off of the gold standard treatment. Additionally, there are theoretical reasons to combine a strong D2-blocking agent. There are about 10 trials, for instance, of adding risperidone, which has strong D2-binding, but unfortunately few showed added benefit. There has been more attention given to combining other psychotropics with antipsychotics to augment response, particularly for specific target symptoms like depression, aggression, or negative symptoms. The classic augmentation strategy for antipsychotics is adding lithium, although the evidence supporting this is surprisingly limited. Other mood stabilizers have been studied as add-ons, with good data supporting the use of valproate as a way to accelerate response to acute psychosis, and lamotrigine has been shown to be effective as a clozapine augmenter. Betablockers and benzodiazepines may help for aggression or anxiety in the context of psychosis, and antidepressants may help with depressive or negative symptoms. Newer studies have looked at amino acids like glycine or serine, or fish oil, as antipsychotic augmenters, and early data look promising. When facing very sick patients with overwhelmed families, desperate to "do something" that might help, and with insurance companies demanding "active treatment" to justify ongoing care, providers may experience intense pressure to add medications to existing antipsychotics. However, given the limited data, the strategy for treatment-refractory patients should generally follow established clinical care guidelines. Sequential monotherapies of antipsychotics should be trialed, each at a good dose and duration, until response.

It plays an important role in supporting and guiding cell migration during tissue repair acne face wash buy generic cleocin gel 20gm on-line. The basement membrane is typically porous acne emedicine cheap cleocin gel 20 gm visa, which allows substances to move to and from the epithelial tissue above it skin care heaven purchase cleocin gel with amex. A few epithelial tissues acne on buttocks order cleocin gel 20gm visa, such as those in lymphatic capillaries and liver sinusoids acne 911 zit blast order 20gm cleocin gel visa, do not have basement membranes skin care after 30 buy cleocin gel 20gm line, and some epithelial tissues, such as those in some endocrine glands, do not have a free surface or a basal surface with a basement membrane. Specialized cell contacts bind adjacent epithelial cells together and to the extracellular matrix of the basement membrane. Blood vessels in the underlying connective tissue do not penetrate the basement membrane to reach the epithelium; thus, all gases and nutrients carried in the blood must reach the epithelium by diffusing from blood vessels across the basement membrane. In epithelial tissues with many layers of cells, diffusion must also occur across cells, and the most metabolically active cells are close to the basement membrane. Epithelial tissue has the ability to replace damaged cells with new epithelial cells. In some types of epithelial tissues, such as those in the skin and the digestive tract, new cells continuously replace cells that die. Classification of Epithelial Tissues Epithelial tissues are classified primarily according to the number of cell layers and the shape of the superficial cells. There are three major types of epithelium based on the number of cell layers in each: 1. Simple epithelium consists of a single layer of cells, with each cell extending from the basement membrane to the free surface. Stratified epithelium consists of more than one layer of cells, but only the basal layer attaches the deepest layer to the basement membrane. The prefix pseudo- means false, so this type of epithelium appears to be stratified but is not. It consists of one layer of cells, with all the cells attached to the basement membrane. There appear to be two or more layers of cells because some of the cells are tall and extend to the free surface, whereas others are shorter and do not extend to the free surface. There are three types of epithelium based on idealized shapes of the epithelial cells: 1. Columnar (tall and thin, similar to a column) cells tend to be taller than they are wide. In most cases, an epithelium is given two names, such as simple squamous, stratified squamous, simple columnar, or pseudostratified columnar. The first name indicates the number of layers, and the second indicates the shape of the cells at the free surface (table 4. Simple squamous epithelium consists of one layer of flat, or scalelike, cells that rest on a basement membrane (table 4. Near the basement membrane, the cells are more cube-shaped, but at the free surface the cells are flat or scalelike (table 4. Pseudostratified columnar epithelial cells are columnar in shape (taller than they are wide) and, although they appear to consist of more than one layer, all the cells rest on the basement membrane (table 4. For example, the outer layer of the skin and the epithelium of the oral cavity protect the underlying structures from abrasion. For example, the skin acts as a barrier to water and reduces water loss from the body. The skin also prevents many toxic molecules and microorganisms from entering the body. Though epithelium acts as a barrier for some substances, it also permits many other substances to move through it. For example, oxygen and carbon dioxide are exchanged between the air and blood by diffusion through the epithelium in the lungs. Epithelium acts as a filter in the kidney, allowing many substances to pass from the blood into the urine but retaining other substances, such as blood cells and proteins, in the blood. Mucous glands, sweat glands, and the enzyme-secreting portions of the pancreas are all composed of epithelial cells that secrete their products onto surfaces or into ducts that carry them to other areas of the body. The plasma membranes of certain epithelial tissues contain carrier proteins (see chapter 3), which regulate the absorption of materials. In contrast, keratinized (ker-ti-nzd) stratified squamous epithelium, found in the skin (see chapter 5), consists of living cells in the deepest layers, and the outer layers are composed of dead cells containing the protein keratin. The dead, keratinized cells give the tissue a dry, durable, moisture-resistant character. In addition to the skin, keratinized stratified squamous epithelium is also found in the gums and hard palate of the mouth. The shape of the cells and the number of cell layers vary, depending on the degree to which transitional epithelium is stretched. The surface cells and the underlying cells are roughly cuboidal or columnar when the epithelium is not stretched, and they become more flattened or squamouslike as the epithelium is stretched. Also, as the epithelium is stretched, the epithelial cells can shift on one another, so that the number of layers decreases from five or six to two or three. Predict 2 Explain the consequences of having (a) nonkeratinized stratified epithelium rather than simple columnar epithelium lining the digestive tract, (b) nonkeratinized stratified squamous epithelium rather than keratinized stratified squamous epithelium in the skin, and (c) simple columnar epithelium rather than stratified squamous epithelium lining the mouth. How do nonkeratinized stratified squamous epithelium and keratinized stratified squamous epithelium differ Describe the changes in cell shape and number of cell layers in transitional epithelium as it is stretched. List the types of epithelial tissue, giving the structure, functions, and major locations of each. Why are cuboidal or columnar cells found where secretion or absorption is occurring Functional Characteristics Epithelial tissues have many functions, including forming a barrier between a free surface and the underlying tissues and secreting, transporting, and absorbing selected molecules (table 4. The structure and organization of cells within each epithelial type reflect these functions. Free Surfaces the free surfaces of epithelial tissues can be smooth or folded; they may have microvilli or cilia. For example, the lining of blood vessels is a simple squamous epithelium that reduces friction as blood flows through the vessels (see chapter 21). They occur in cells that absorb or secrete, such as serous membranes and the lining of the small intestine (see chapter 24). Stereocilia are a specialized, elongated form of microvilli found in sensory structures, such as the inner ear (see chapter 15), where they play a role in sound detection. Stereocilia are also found in some places where absorption is important, such as in the epithelium of the epididymis. In contrast, motile cilia contain microtubules, which allow them to move materials across the free surface of the cell (see chapter 3). Three types of ciliated epithelium line the respiratory tract (see chapter 23), where cilia move mucus containing foreign particles out of the respiratory airways. Cilia are also found on the apical surface of the simple columnar epithelial cells of the uterus and uterine tubes, where the cilia help move mucus and oocytes. Transitional epithelium has a rather unusual plasma membrane specialization: rigid sections of membrane separated by very Cell Layers and Cell Shapes Simple epithelium, with its single layer of cells, covers surfaces. In the lungs it facilitates the diffusion of gases; in the kidneys it filters blood; in glands it secretes cellular products; and in the intestines it absorbs nutrients. Stratified epithelium is found in areas where protection is a major function because it is able to hinder the selective movement of materials through the epithelium. The multiple layers of cells in stratified epithelium are well adapted for a protective role. As the outer cells are damaged, they are replaced by cells from deeper layers; thus, a continuous barrier of epithelial cells is maintained in the tissue. Stratified squamous epithelium is found in areas of the body where abrasion can occur, such as the skin, mouth, throat, esophagus, anus, and vagina. For example, simple squamous epithelium forms blood and lymphatic capillaries, alveoli (air sacs) of the lungs, and parts of the kidney tubules. They have greater cytoplasmic volume relative to surface area than seen with squamous cells. When transitional epithelium is stretched, the folded regions of the plasma membrane can unfold. Transitional epithelium is specialized to expand in tissues such as the urinary bladder. Cell Connections Cells have structures that hold them to one another or to the basement membrane. These structures do three things: (1) mechanically bind the cells together, (2) help form a permeability barrier, and (3) provide a mechanism for intercellular communication. Epithelial cells have cell surface glycoproteins, which attach to other glycoproteins located on adjacent cells and in the basement membrane. Among the glycoprotein connections between cells, there are some relatively strong adhesive structures called desmosomes (dezm-smz). Desmosomes consist of adhesive glycoproteins that bind cells together and intracellular proteins attached to intermediate filaments that extend into the cytoplasm of the cells (figure 4. Many desmosomes are found in epithelial tissues that are subjected to stress, such as the stratified squamous epithelium of the skin. Hemidesmosomes, similar to one-half of a desmosome, attach epithelial cells to the basement membrane. Tight junctions are formed by proteins in the plasma membranes of adjacent cells that join one another to make a very tight seal. Near the free surface of simple epithelial cells, the tight junctions form a ring that completely surrounds each cell and binds adjacent cells together to prevent the passage of materials between cells. For example, in the stomach and the urinary bladder, chemicals cannot pass between cells. Thus, water and other substances must pass through the epithelial cells, which can actively regulate what is absorbed or secreted. Tight junctions are found in areas where a layer of simple epithelium forms a permeability barrier. For example, water can diffuse through epithelial cells, and active transport, symport, and facilitated diffusion move most nutrients through the epithelial cells of the small intestine. It is located between the plasma membranes of adjacent cells and acts as a weak glue that holds cells together. A gap junction is a small, specialized contact region between cells containing protein channels that aid intercellular communication by allowing ions and small molecules to pass from one cell to another (figure 4. In epithelium, the function of gap junctions is not entirely clear; gap junctions between ciliated epithelial cells may coordinate the movements of cilia. In cardiac and smooth muscle tissues, gap junctions are important in coordinating important functions. Because ions can pass through the gap junctions from one cell to the next, electrical signals can pass from cell to cell to coordinate the contraction of cardiac and smooth muscle cells. Thus, electrical signals that originate in one cell of the heart can spread from cell to cell and cause the entire heart to contract. In the heart, the gap junctions between cardiac muscle cells are found in specialized cell-to-cell connections called intercalated disks (see chapter 20). Intercalated disks contain both gap junctions and desmosomes that help hold adjacent cells in close contact. Predict 3 If a simple epithelium has well-developed tight junctions, explain how NaCl can move from one side of the epithelial layer to the other, what type of epithelium it is likely to be, and how the movement of NaCl causes water to move in the same direction. What is the function of each of the following characteristics of an epithelial free surface: is smooth, has cilia, has microvilli, is folded Name the possible ways by which epithelial cells are bound to one another and to the basement membrane. Glands are composed primarily of epithelium, with a supporting network of connective tissue. If the gland maintains an open contact with the epithelium from which it developed, a duct is present. Alternatively, some glands become separated from the epithelium of their origin and have no ducts; these are called endocrine (end-krin) glands. The cellular products of endocrine glands, which are called hormones (hrmnz), are secreted into the bloodstream and carried throughout the body. Most exocrine glands are composed of many cells and are called multicellular glands, but some exocrine glands are composed of a single cell and are called unicellular glands (figure 4. Multicellular exocrine glands can be classified according to the structure of their ducts and secretory regions (figure 4. If there are multiple secretory regions that branch off the duct, then the gland is called branched. For both simple and compound glands, the shape of the secretory regions further defines the gland. Cell shed into the duct (c) Holocrine gland Entire cells are shed by the gland and become part of the secretion. Merocrine secretion involves the release of secretory products by exocytosis (figure 4. Merocrine secretion is used by water-producing sweat glands and the exocrine portion of the pancreas. Apocrine (ap-krin) secretion involves the release of secretory products as pinchedoff fragments of the gland cells (figure 4. The milkproducing mammary glands release milk by a combination of apocrine and mostly merocrine secretion. Products accumulate in the cytoplasm of each epithelial cell, the cell ruptures and dies, and the entire cell becomes part of the secretion. How are multicellular exocrine glands classified on the basis of their duct system Describe the three main components of the extracellular matrix of connective tissue.

They cause dorsiflexion acne at 30 discount cleocin gel american express, eversion acne tips purchase cleocin gel 20 gm with mastercard, and inversion of the foot as well as extension of the toes skin care heaven purchase 20gm cleocin gel free shipping. The fibularis brevis inserts onto the fifth metatarsal bone and everts and plantar flexes the foot skin care talk cheap 20 gm cleocin gel amex. The fibularis longus crosses under the lateral four metatarsal bones to insert onto the first metatarsal bone and medial cuneiform skin care 08 order cleocin gel with a visa. The tendons of the fibularis muscles can be seen on the lateral side of the ankle (see figure 10 acne blemishes order cleocin gel once a day. The superficial muscles of the posterior compartment of the leg, the gastrocnemius (gas-trok-nm-s) and the soleus, form the bulge of the calf (posterior leg; see figure 10. The deep muscles of the posterior compartment plantar flex and invert the foot and flex the toes. They are arranged in a manner similar to that of the intrinsic muscles of the hand. When Achilles was a baby, his mother dipped him into magic water, which made him invulnerable to harm everywhere the water touched his skin. However, his mother held him by the heel and failed to submerge this part of his body under the water. Consequently, his heel was vulnerable and proved to be his undoing; at the battle of Troy, he was shot in the heel with an arrow and died. Thus, saying that someone has an "Achilles heel" means that the person has a weak spot that can be attacked. Achilles tendon injuries are often due to overexertion by doing too much too quickly or too soon after a break from exercise. The main keys to preventing an injury are wearing the appropriate footwear and performing proper warm-up and stretching exercises. The muscles in the plantar region of the foot are covered with thick fascia and the plantar aponeurosis. Running on a hard surface wearing poorly fitting or worn-out shoes can result in inflammation of the plantar aponeurosis, called plantar fasciitis. Patients experience pain in the fascia over the heel and along the medial-inferior side of the foot. Wearing supportive shoes with heel inserts is a good first step toward treating plantar fasciitis. Studies show that wearing nonsupportive shoes, such as flip-flops, for extended periods of time leads to increased pain in the feet, heels, and ankles. Its participants combine diet and specific weight training to develop maximum muscle mass and minimum body fat, with the goal of achieving a complete, well-balanced physique. Skill, training, and concentration are required to build a well-proportioned, muscular body and to know which exercises develop a large number of muscles and which are specialized to build up certain parts of the body. An uninformed, untrained muscle builder can build some muscles and ignore others; the result is a disproportioned body. Historically, although bodybuilders had a lot of muscle mass, they were not "in shape. For instance, scientific evidence has shown that restricted-calorie diets increase life span, yet some bodybuilders consume at least 4500 calories a day when in the "bulking" phase of training. However the overwhelming evidence at this time shows that the life span of active people is longer than that of sedentary people, even when the activity is extreme. As bodybuilders age and reduce the intensity of their workouts, their muscle mass decreases, but not at a porportionally higher rate than other people with a lower activity level. In chapter 9, see the section "Effects of Aging on Skeletal Muscle" for more information on the effects of reduced muscle mass as people age. They refer to "lats," "traps," and "delts" rather than latissimus dorsi, trapezius, and deltoids. The exercises have special names, such as "lat pulldowns," "preacher curls," and "triceps extensions. Therefore, we can conclude that movements involving hip and knee flexion, such as walking up and down stairs, would be affected. Any tasks that require Pedro to walk up and down stairs would be more difficult for him. In addition, we are told that the injury affected action potential conduction to the muscles of these regions. Chapter 9 described the relationship between action potential conduction and the force of muscle contractions. The reduction in action potential conduction to the muscles of the hip and thigh reduced the stimulation of these muscles, reducing the contraction force. As a result of his injury, we can predict that Pedro experienced weakness in his left hip and thigh, limiting his activity level. Name the muscles of each compartment, and describe the movements for which each muscle is responsible. Summary Tongue Movements Intrinsic tongue muscles change the shape of the tongue; extrinsic tongue muscles move the tongue. The less movable end of a muscle attachment is the origin; the more movable end is the insertion. An agonist causes a certain movement, and an antagonist acts in opposition to the agonist. Muscles open and close the openings to the nasal cavity, auditory tubes, and larynx. Movements of the Eyeball Six muscles with their origins on the orbital bones insert on the eyeball and cause it to move within the orbit. Muscle Shapes Muscle shape is determined primarily by the orientation of muscle fascicles. Muscle Names Muscles are named according to their location, size, shape, orientation of fascicles, origin and insertion, number of heads, or function. A more superficial group of muscles runs from the pelvis to the skull, extending from the vertebrae to the ribs. Muscle Movements Contracting muscles generate a force that acts on bones (levers) across joints (fulcrums) to create movement. Thoracic Muscles Muscle Anatomy the study of muscle anatomy is usually broken down into body regions: head and neck, trunk, upper limbs, and lower limbs. They cause flexion, extension, rotation, and lateral flexion of the head and neck. Abdominal wall muscles hold and protect abdominal organs and cause flexion, rotation, and lateral flexion of the vertebral column. Facial Expression the origins of facial muscles are on skull bones or fascia; the insertions are into the skin, causing movement of the facial skin, lips, and eyelids. Muscles of the buttocks are responsible for extension of the hip and abduction and rotation of the thigh. Flexion and extension of the elbow are accomplished by three muscles in the arm and two in the forearm. The anterior thigh muscles extend the leg, and the posterior thigh muscles flex the leg. Forearm muscles that originate on the medial epicondyle are responsible for flexion of the wrist and fingers. Muscles in the anterior compartment cause dorsiflexion, inversion, or eversion of the foot and extension of the toes. Muscles of the posterior compartment flex the leg, plantar flex and invert the foot, and flex the toes. Which of these movements is not caused by contraction of the erector spinae muscles Given these muscles: (1) external abdominal oblique (2) internal abdominal oblique (3) transversus abdominis Choose the arrangement that lists the muscles from most superficial to deepest. A prominent lateral muscle of the neck that can cause flexion of the neck or rotate the head is the a. An aerial circus performer who supports her body only with her teeth while spinning around should have strong a. Which of these muscles would you expect to be especially well developed in a boxer known for his powerful jab (punching straight ahead) Given these muscles: (1) iliopsoas (2) rectus femoris (3) sartorius Which of the muscles flex the hip For each of the following muscles, (1) describe the movement the muscle produces, and (2) name the muscles that act as synergists and antagonists for them: longus capitis, erector spinae, coracobrachialis. Consider only the effect of the brachioradialis muscle for these questions: If a weight is held in the hand and the forearm is flexed, what type of lever system is in action A patient was involved in a rear-end auto collision, resulting in a whiplash injury to the head (hyperextension). When a person becomes unconscious, the tongue muscles relax and the tongue tends to retract, or fall back, and obstruct the airway. The mechanical support of the head of the humerus in the glenoid fossa is weakest in the inferior direction. What muscles help prevent dislocation of the shoulder when a person carries a heavy weight, such as a suitcase Examination of her right leg revealed the following symptoms: inability to plantar flex the foot against resistance, normal ability to evert the foot, abnormal dorsiflexion of the foot, and abnormal bulging of the calf muscles. Answers in appendix F Learn to Predict 11 365 Once she turned 21, Amanda expected good times ahead. So why could she Functional Organization of Nervous Tissue barely manage to climb the two flights of steps to her chemistry class When she started experiencing weakness in her left hand, Amanda consulted a physician. By combining F rom thinking and feeling to breathing, moving, and eating, virtually everything our body does is controlled by the nervous system. There are two major control systems in the body, the nervous system and the endocrine system. The nervous system is made up of the brain, spinal cord, nerves, and sensory receptors. We begin the study of the nervous system in this chapter by focusing on the physiology of nervous tissue. Chapters 12 and 13 discuss the anatomy of the spinal cord and spinal nerves and the brain and cranial nerves. Chapter 14 focuses on the integration of the nervous system components and discusses the effects of aging on the nervous system. Photo: Light photomicrograph of pyramid-shaped neurons (orange) growing on a fibrous network (green) in the central nervous system. The regulatory and coordinating activities of the nervous system are necessary for the human body to function normally. The trillions of cells in the human body do not function independently of each other but must work together to maintain homeostasis. For example, heart cells must contract at a rate that ensures adequate delivery of blood to all tissues of the body. The nervous system can stimulate or inhibit these activities to help maintain homeostasis. We are aware of sensations from some stimuli, such as sight, hearing, taste, smell, touch, pain, body position, and temperature. Other stimuli, such as blood pH, blood gases, and blood pressure, are processed at an unconscious level. The brain and spinal cord are the major organs for processing sensory input and initiating responses. Skeletal muscles normally contract only when stimulated by the nervous system; thus, the nervous system controls the major movements of the body by controlling skeletal muscle. Some smooth muscle, such as that in the walls of blood vessels, contracts only when stimulated by the nervous system or by hormones (see chapter 18). Cardiac muscle and some smooth muscle, such as that in the wall of the stomach, contract autorhythmically-that is, no external stimulation is necessary for each contraction event. Although the nervous system does not initiate contraction in these muscles, it can cause the contractions to occur more rapidly or more slowly. Finally, the nervous system controls the secretions from many glands, including sweat glands, salivary glands, and glands of the digestive system. The brain is the center of mental activities, including consciousness, thinking, memory, and emotions. The nervous system can be divided into two major divisions: the central nervous system and the peripheral nervous system (figure 11. The brain is located within the skull, and the spinal cord is located within the vertebral canal formed by the vertebrae (see chapter 7). The brain and spinal cord connect with each other at the foramen magnum of the skull. Neurons send electrical messages from their cell body to other cells with long extensions called axons. Sensory receptors are the endings of neurons, or separate, specialized cells that detect temperature, pain, touch, pressure, light, sound, odor, and other stimuli. Sensory receptors are located in the skin, muscles, joints, internal organs, and specialized sensory organs, such as the eyes and ears. There are 12 pairs of nerves originating from the brain, called cranial nerves, and 31 pairs of nerves originating from the spinal cord, called spinal nerves (figure 11. The nerves, which are shown cut in the illustration, actually extend throughout the body.

Cleocin gel 20gm amex. RAWKANVAS AUSTRALIA SKINCARE REVIEW | NATURAL VEGAN CRUELTY FREE SKINCARE.

Syndromes

• Carotid duplex (ultrasound) to see if the carotid arteries in your neck have narrowed
• Neck pain
• If you smoke, try to stop. Ask your doctor or nurse for help. Smoking can slow down wound and bone healing.
• Bacterial infection ( Scalded skin syndrome)
• Is there excessive anxiety?
• Seizures
• Klebsiella pneumoniae
• Changes in vision
• Meningitis
• Turbinado sugar is unrefined sugar made from sugar cane juice.

Two other muscles acne medication oral buy cleocin gel 20gm cheap, the superior and inferior oblique muscles skin care x buy discount cleocin gel 20gm on line, are positioned at an angle to the globe of the eye acne x out reviews order cleocin gel once a day. The movements of the eye can be described graphically by a figure resembling the letter H acne x tretorn order cheap cleocin gel line. The nerve is so named because the superior oblique muscle goes around a little pulley acne keloidalis nuchae buy cheapest cleocin gel, or trochlea skin care with hyaluronic acid buy cleocin gel australia, in the superomedial corner of the orbit. The middle layer is the vascular tunic and it consists of the choroid, ciliary body, and iris. Describe the structures and state the functions of the eyebrows, eyelids, and eyelashes. How do the conjunctiva, lacrimal apparatus, and extrinsic eye muscles aid in the function of the eye Fibrous Tunic As stated previously, the fibrous tunic consists of the sclera and the cornea. The sclera (sklr) is the white, outer layer of the posterior five-sixths of the eyeball. It is a firm, opaque tissue layer that consists of dense collagenous connective tissue with elastic fibers. Usually, a small portion of the sclera can be seen as the "white of the eye" when the eye and its surrounding structures are intact (see figure 15. The cornea (krn-) is an avascular, transparent structure that permits light to enter the eye. The cornea consists of a connective tissue matrix containing collagen, elastic fibers, and proteoglycans, with a layer of stratified squamous epithelium covering the outer surface and a layer of simple squamous epithelium on the inner surface. Large collagen fibers are white, whereas smaller collagen fibers and proteoglycans are transparent. The cornea is transparent, rather than white, like the sclera, in part because fewer large collagen fibers and more proteoglycans are present in the cornea than in the sclera. In the presence of water, proteoglycans trap water and expand, which scatters light. In the absence of water, the proteoglycans decrease in size and do not interfere with the passage of light through the matrix. Contact lenses worn for long periods must therefore be permeable, so that air can reach the cornea. The most common eye injuries are cuts or tears of the cornea caused by a stick, a stone, or some other foreign object hitting the cornea. Extensive injury to the cornea may cause connective tissue deposition, thereby making the cornea opaque. Several characteristics make it relatively easy to transplant: It is easily accessible and relatively easily removed; it is avascular, so it does not require extensive circulation, as other tissues do; and it is less immunologically active and therefore less likely to be rejected than other tissues are. The iris regulates the amount of light entering the eye by controlling the size of the pupil. The smooth muscle of the iris is organized into two groups: a circular group called the sphincter pupillae (p-pil) and a radial group called the dilator pupillae (figure 15. When the sphincter pupillae contract, the iris decreases, or constricts, the size of the pupil. The ciliary muscles, sphincter pupillae, and dilator pupillae are sometimes referred to as the intrinsic eye muscles. It consists of the outer pigmented layer, which is composed of pigmented simple cuboidal epithelium, and the inner neural layer, which responds to light. The neural layer contains numerous photoreceptor cells: 120 million rods and 6 or 7 million cones, as well as numerous relay neurons. A more detailed description of the histology and function of the retina is presented later in this section. When the posterior region of the retina is examined with an ophthalmoscope (of-thalm-skp), several important features can be observed (figure 15. The macula (mak-l) is a small, yellow spot, approximately 4 mm in diameter, near the center of the posterior retina. The fovea centralis is the region of the retina where light is most focused when the eye is looking directly at an object. The fovea centralis contains only cone cells, and the cells are more tightly packed there than anywhere else in the retina. Because of the high number of photoreceptors in this area, the fovea centralis is the portion of the retina with the greatest visual acuity (the ability to see fine images). This is why Vascular Tunic the middle tunic of the eyeball is called the vascular tunic because it contains most of the blood vessels of the eyeball (figure 15. The arteries of the vascular tunic are derived from a number of arteries called short ciliary arteries, which pierce the sclera in a circle around the optic nerve. These arteries are branches of the ophthalmic (of-thalmik) artery, which is a branch of the internal carotid artery. The vascular tunic contains a large number of melanincontaining pigment cells and appears black in color. The portion of the vascular tunic associated with the sclera of the eye is the choroid (koroyd). The term choroid means "membrane" and suggests that this layer is relatively thin (0. The ciliary (sil-ar-) body is continuous with the choroid, and the iris is attached at its lateral margins to the ciliary body (figure 15. The ciliary body consists of an outer ciliary ring and an inner group of ciliary processes, which are attached to the lens by suspensory ligaments. The ciliary body contains smooth muscles called the ciliary muscles, which are arranged with the outer muscle fibers oriented radially and the central fibers oriented circularly. The ciliary muscles function as a sphincter, and contraction of these muscles can change the shape of the lens. The iris is the "colored part" of the eye, and its color differs from person to person. If there is no pigment in the iris, as occurs in albinism, the iris appears pink because blood vessels in the eye reflect light back to the iris. Many genes affect eye color, which explains the complexity of eye colors and inheritance patterns. Interestingly, although many newborn babies have blue eyes, their eye color changes over the first year of life. As melanin production increases during the first year, it accumulates in the iris, resulting in the more permanent eye color. The iris is a contractile structure, consisting mainly of smooth muscle, surrounding an opening called the pupil. Hypertension, or high blood pressure, results in "nicking" (compression) of the retinal veins where the abnormally pressurized arteries cross them. Furthermore, cataracts (opacity of the lens; see the Diseases and Disorders table 15. The optic disc is a white spot just medial to the macula through which the central retinal artery enters and the central retinal vein exits the eyeball. This is also the spot where nerve processes from the neural layer of the retina meet, pass through the two outer tunics, and exit the eye as the optic nerve. Because of its lack of photoreceptors, the optic disc is called the blind spot of the eye (figure 15. Chambers of the Eye the interior of the eye is divided into three chambers: the anterior chamber, the posterior chamber, and the vitreous (vitr-s) chamber (postremal chamber; see figure 15. The anterior and posterior chambers are filled with aqueous humor, which helps maintain intraocular pressure. It is transparent and biconvex, with the greatest convexity on its posterior side. Cells from the anterior epithelium proliferate and give rise to the lens fibers at the equator of the lens. The lens fibers lose their nuclei and other cellular organelles and accumulate a set of proteins called crystallines. The lens is suspended between the posterior chamber and the vitreous chamber by the suspensory ligaments of the lens, which are connected from the ciliary body to the lens capsule. Name the three tunics of the eye, describe the parts of the tunics, and explain their functions. The optic disc is the white area where the blood vessels and optic nerve associate with the retina. The macula with the fovea centralis (the part of the retina with the greatest visual acuity) is the darker spot at the center. At a certain point, when the image of the spot is over the optic disc, the red spot seems to disappear. Functions of the Eye As light passes through the pupil of the iris, it is focused on the retina by the cornea, lens, and humors. The light striking the retina is converted into action potentials, which are relayed to the brain. The electromagnetic spectrum comprises the entire range of wavelengths, or frequencies, of electromagnetic radiation, from very short gamma waves at one end of the spectrum to the longest radio waves at the other end (figure 15. Visible light is the portion of the electromagnetic spectrum that can be detected by the human eye and includes wavelengths between 380 and 750 nm. As light passes from air to a denser substance, such as glass or water, its speed slows. If the surface of that substance is at an angle other than 90 degrees to the direction the light rays are traveling, the rays bend, because the speed of light varies as it encounters the new medium. If the surface of a lens is concave, with the lens thinnest in the center, the light rays diverge as a result of refraction. If the surface is convex, with the lens thickest in the center, the light rays tend to converge. No image forms exactly at the focal point, but an inverted, focused image can form on a surface some distance past the focal point. How far past the focal point the focused image forms depends on a number of factors. The aqueous humor also refracts light and provides nutrition for the structures of the anterior chamber, such as the avascular cornea. Aqueous humor is produced by the ciliary processes as a blood filtrate and is returned to the circulation through a venous ring at the base of the cornea called the scleral venous sinus (canal of Schlemm; see figure 15. The production and removal of aqueous humor result in the "circulation" of aqueous humor and maintenance of a constant intraocular pressure. If circulation of the aqueous humor is inhibited, a defect called glaucoma (glaw-kma), characterized by an abnormal increase in intraocular pressure, can result. The vitreous chamber of the eye is much larger than the anterior and posterior chambers. It is almost completely surrounded by the retina and is filled with a transparent, jellylike substance called vitreous humor. Vitreous humor is not produced as rapidly as the aqueous humor is, and its turnover is extremely slow. Like the aqueous humor, the vitreous humor helps maintain intraocular pressure and therefore the shape of the eyeball, and it holds the lens and retina in place. If the glasses are then Increasing wavelength removed, another adjustment period is 0. Gamma rays X-rays light Infrared Microwaves Radio waves When the ciliary muscles are relaxed, the suspensory ligaments of the ciliary body maintain elastic pressure on the lens, thereby keeping it relatively flat and allowing for cm = 10-2 m mm = 10-3 m distant vision (figure 15. The condition nm = 10-9 m in which the lens is flattened so that nearly parallel rays from a distant object are Visible light focused on the retina is referred to as emmetropia (em-trp-) and is the normal resting condition of the lens. The visible light spectrum is enlarged to show the wavelengths of the various colors. When an object is brought closer than 20 feet to the eye, three events bring the image into focus on the retina: accommodation by the lens, condoes a lens with a single convex surface. If light rays strike an object that is not transparent, they bounce off the surface. If the surface is very smooth, such as the surface of a mirror, the light rays bounce off in a specific direction. If the surface is rough, the light rays are reflected in several directions and produce a more diffuse reflection. Additional convergence occurs as light encounters the aqueous humor, lens, and vitreous humor. The greatest contrast in media density is between the air and the cornea; therefore, the greatest amount of convergence occurs at that point. However, the shape of the cornea and its distance from the retina are fixed, so that the cornea cannot make any adjustment in the location of the focal point. Fine adjustment in focal point location is accomplished by changing the shape of the lens. In general, focusing can be accomplished in two ways: (1) by keeping the shape of the lens constant and moving it nearer or farther from the point at which the image will be focused, as occurs in a camera, microscope, or telescope, or (2) by keeping the distance constant and changing the shape of the lens, which is the technique used in the eye. As light rays enter the eye and are focused, the image formed just past the focal point is inverted. Action potentials that represent the inverted image are passed to the visual cortex of the cerebrum, where the brain interprets them as being right side up. Because the visual image is inverted when it reaches the retina, the image of the world focused on the retina is upside down. However, the brain processes information from the retina so that the world is perceived the way "it really is.