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Follow the diagram of the small intestine in Figure 11-1 as we describe the layers of this wall from the innermost to the outermost surface erectile dysfunction treatment spray generic silagra 100 mg fast delivery. First is the mucous membrane erectile dysfunction filthy frank lyrics purchase silagra us, so called because its epithelial layer contains many mucus-secreting cells female erectile dysfunction drugs buy genuine silagra online. The layer of connective tissue beneath this erectile dysfunction depression medication order cheapest silagra and silagra, the submucosa, contains blood vessels and some of the nerves that help regulate digestive activity. The inner layer has circular fibers, 311 Human Anatomy and Physiology and the outer layer has longitudinal fibers. The alternate contractions of these muscles create the wavelike movement that propels food through the digestive tract and mixes it with digestive juices. Most of the abdominal organs have an additional layer of serous membrane that is part of the peritoneum. The Peritoneum the abdominal cavity is lined with a thin, shiny serous membrane that also covers most of the abdominal organs (Figure 11-2). The portion of this membrane that lines the abdomen is called the parietal peritoneum; that covering the organ is called the visceral peritoneum. In addition to these single layered portions of the peritoneum there are a number of double-layered structures that carry blood vessels, lymph vessels, and nerves, and sometimes act as ligaments supporting the organs. The mesentery is a double-layered portion of the peritoneum shaped somewhat like a fan. The handle portion is attached to the back wan, and the expanded long edge is attached to the small intestine. Between the two layers of membrane that fOl1ll the mesentery are the blood vessels, lymphatic vessels, and nerves that supply the intestine. The section of the peritoneum that extends from the colon to the back wall is the mesocolon. This greater omentum extends from the lower border of the stomach into the pelvic part of the abdomen and then loops back up to the transverse colon. There is also a smaller membrane, called the lesser omentum that extends between the stomach and the liver. It is composed of several parts: the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The digestive tract is sometimes called the alimentary tract, derived from a Latin word that means "food". It is more commonly referred to as the gastrointestinal (Gl) tract because of the major importance of the stomach and intestine in the process of digestion. In to this space projects a muscular organ, the tongue, which is used for chewing and swallowing, and is one of the principal organs of speech. The tongue has on its surface a number of special organs, called taste buds, by means of which taste sensations (bitter, sweet, sour, or salty) can be differentiated. A child between 2 and 6 years of age has 20 teeth; an adult with a complete set of teeth has 32. Among these, the cutting teeth, or incisors, occupy the front part of the oral cavity, whereas the lager grinding teeth, the molars, are in the back. Usually, the 20 baby teeth have all appeared by the time a child has reached the age of 2 or 21/2 years. During the first 2 years the permanent teeth develop within the jawbones 317 Human Anatomy and Physiology from buds that are present at birth. Because decay and infection of adjacent deciduous molars may spread to and involve new, permanent teeth, deciduous teeth need proper care. Permanent Teeth As a child grows, the jawbones grow, making space for additional teeth. After the 6-year molars have appeared, the baby incisors loosen and are replaced by permanent incisors. Next, the baby canines (cuspids) are replaced by permanent canines, and finally, the baby molars are replaced by the bicuspids (premolars) of the permanent teeth. Now the larger jawbones are ready for the appearance of the 12-year, or second, permanent molar teeth.

There are a number of clinical diseases associated with the breakdown and destruction of the myelin sheath surrounding brain impotence etymology trusted silagra 100mg, spinal cord or peripheral nerve axons erectile dysfunction houston best order for silagra. Degenerative myelopathy erectile dysfunction doctor nyc cheap 50 mg silagra with amex, for instance erectile dysfunction essential oil buy generic silagra 100mg on line, is a progressive disease of the spinal cord in older dogs. The breeds most commonly affected include German Shepherds, Welsh Corgis, Irish Setters and Chesapeake Bay Retrievers. The disease begins in the thoracic area of the spinal cord and is associated with degeneration of the myelin sheaths of axons that comprise the spinal cord white matter. The affected dog will wobble when walking, knuckle over or drag their feet, and may cross their feet. A group of axons and associated lemmocytes are surrounded by basal lamina and endoneurium. Along with epinephrine, norepinephrine also underlies the fight-or-flight response, directly increasing heart rate, triggering the release of glucose from energy stores, and increasing blood flow to skeletal muscle. Norepinephrine can also suppress neuroinflammation when released diffusely in the brain from the locus ceruleus. The resulting increase in vascular resistance triggers a compensatory reflex that overcomes its direct stimulatory effects on the heart, called the baroreceptor reflex, which results in a drop in heart rate called reflex bradycardia. The actions of norepinephrine are carried out via the binding to adrenergic receptors. Norepinephrine 2 Etymology the term "norepinephrine" is derived from the chemical prefix nor-, which indicates that norepinephrine is the next lower homolog of epinephrine. The two structures differ only in that epinephrine has a methyl group attached to its nitrogen, while the methyl group is replaced by a hydrogen atom in norepinephrine. The prefix nor-, is derived from the German abbreviation for "N ohne Radikal" (N, the symbol for nitrogen, without radical),[8] referring to the absence of the methyl functional group at the nitrogen atom. Origins Norepinephrine is released when a host of physiological changes are activated by a stressful event. In the brain, this is caused in part by activation of an area of the brain stem called the locus ceruleus. Noradrenergic neurons project bilaterally (send signals to both sides of the brain) from the locus ceruleus along distinct pathways to many locations, including the cerebral cortex, limbic system, and the spinal cord, forming a neurotransmitter system. Norepinephrine is also released from postganglionic neurons of the sympathetic nervous system, to transmit the fight-or-flight response in each tissue respectively. The adrenal medulla can also be counted to such postganglionic nerve cells, although they release norepinephrine into the blood. Norepinephrine system the noradrenergic neurons in the brain form a neurotransmitter system, that, when activated, exerts effects on large areas of the brain. Anatomically, the noradrenergic neurons originate both in the locus coeruleus and the lateral tegmental field. The axons of the neurons in the locus coeruleus act on adrenergic receptors in: · · · · · · · · · Amygdala Cingulate gyrus Cingulum Hippocampus Hypothalamus Neocortex Spinal cord Striatum Thalamus On the other hand, axons of neurons of the lateral tegmental field act on adrenergic receptors in hypothalamus, for example. This structure explains some of the clinical uses of norepinephrine, since a modification of the system affects large areas of the brain. Norepinephrine 3 Mechanism Norepinephrine is synthesized from tyrosine as a precursor, and packed into synaptic vesicles. It performs its action by being released into the synaptic cleft, where it acts on adrenergic receptors, followed by the signal termination, either by degradation of norepinephrine, or by uptake by surrounding cells. Tyrosine Levodopa Dopamine Norepinephrine Vesicular transport Between the decarboxylation and the final -oxidation, norepinephrine is transported into synaptic vesicles. This transporter has equal affinity for norepinephrine, epinephrine and isoprenaline. Many substances modulate this release, some inhibiting it and some stimulating it. For instance, there are inhibitory 2 adrenergic receptors presynaptically, that gives negative feedback on release by homotropic modulation. Receptor binding Norepinephrine performs its actions on the target cell by binding to and activating adrenergic receptors. The target cell expression of different types of receptors determines the ultimate cellular effect, and thus norepinephrine has different actions on different cell types. Uptake Extracellular uptake of norepinephrine into the cytosol is either done presynaptically (uptake 1) or by non-neuronal cells in the vicinity (uptake 2). Furthermore, there is a vesicular uptake mechanism from the cytosol into synaptic vesicles.

Ischemia of the arms Atherosclerosis and ischemia of the arm are much less common than in the lower limb impotence questions proven 100 mg silagra. The most common location for development of atherosclerosis in the arteries supplying the upper extremity is in the brachiocephalic trunk and subclavian arteries central for the origin of the vertebral arteries impotence exercise generic silagra 100mg with mastercard. Rarely erectile dysfunction va disability cheap silagra american express, occlusive lesions are located more peripherally in the subclavian or axillary arteries impotence after robotic prostatectomy buy discount silagra 100 mg on-line. If the source of embolism cannot be eliminated, anticoagulation must be considered. Atherosclerosis of renal and mesenteric arteries Renal artery obstruction Renal artery obstruction can cause severe hypertension and renal failure but interventional treatment may improve both conditions. Today, open surgical management is only rarely performed because endovascular management is much less invasive and feasible in the majority of cases. Mesenteric artery occlusive disease Mesenteric artery occlusive disease may cause abdominal angina. Just like atherosclerotic lesions in other locations, many cases are asymptomatic and probably do not need intervention with regard to the obstructive disease, but lifestyle changes and medical preventive treatment are indicated. Patients with classic symptoms ­ post-prandial pain occurring 10­20 minutes after a meal and weight loss ­ often benefit from revascularization; however, many patients have less obvious symptoms, and the mere occurrence of a lesion on one of the three main vessels supplying blood to the gastrointestinal tract (celiac trunk, superior and inferior mesenteric artery) does not warrant interventional treatment. In general, a single lesion in one of the three arteries is seldom thought to cause ischemia. Long occlusions of the superior mesenteric artery and/or occlusive mesenteric disease combined with other Typical symptoms of chronic arm ischemia Theses include "claudication"; i. In typical cases pain is encountered when performing tasks with the arms elevated, such as hanging laundry, or other physical use of the arm. Additionally, or in case of severe ischemia, finger pressure measurement by strain gauge technique may be used. The prognosis is often good because development of critical ischemia and the necessity for amputation is rare. Treatment of upper extremity atherosclerosis is similar to that of atherosclerosis in other vascular distributions: risk factor reduction by lifestyle changes and preventive medications for all, and revascularization in some. In fact, only rarely is interventional treatment indicated, but in cases of incapacitating functional pain and/or critical ischemia, revascularization should be considered. Endovascular treatment dominates because of its less invasive nature for lesions near the origin of the brachiocephalic trunk and subclavian arteries. For lesions that cannot be treated by endovascular techniques, such as long lesions or lesions that cannot be crossed by a guide wire, bypass surgery is indicated (carotid­subclavian bypass). Acute arm ischemia this is most often caused by embolization, but alternatively can be caused by thrombosis in an existing stenosis such as of the subclavian artery. Whereas the former may be treated easily by embolectomy via a small incision in the cubital fossa, the latter may be more complex to treat, perhaps requiring intra-arterial thrombolysis before vascular reconstruction. Embolism is most often of cardiac origin, either from atrial fibrillation, mural thrombus in the heart or valve disease. Microemboli may occur periph- 717 Part 8 Macrovascular Complications in Diabetes erally and present as gangrene of one or more fingers. Treatment of the peripheral ischemia may include thrombolysis, but in most cases collaterals develop and amputation does not become necessary. The main difference between those with and without diabetes with respect to treatment of aneurysms is that patients with diabetes are more prone to complications after surgery; however, because of the nature of preventive surgery for aneurysms, this only rarely causes changes in management once the risk of surgery has been weighed against non-surgical treatment. Aneurysm of the aorta is a common condition in the elderly, especially in the infra-renal aorta. An artery by definition becomes aneurysmal when the diameter locally increases more than 50% compared to the "normal" diameter proximal or distal to this site. In case of the infra-renal aorta, an aneurysm is present when the diameter exceeds 30 mm. Some patients will sense a pulsation in the abdomen, while large aneurysms may cause discomfort or compress surrounding organs, mainly the gastrointestinal tract. The main risk is rupture which, when intraperitoneal, most often leads to immediate death. If rupture is into the retroperitoneal space, a hematoma may be contained and the patient may survive for hours. Aneurysms may cause peripheral embolization, causing a cyanotic or gangrenous toe as the first symptom.

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