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Without these nerves purchase viagra plus 400mg on-line, not only would your food be without taste order 400 mg viagra plus with amex, but you would also be unable to feel either the food or the structures of your mouth order 400 mg viagra plus otc, and you would be unable to avoid biting yourself as you chew generic 400 mg viagra plus fast delivery, an action enabled by the motor branches of cranial nerves order 400mg viagra plus. Intrinsic innervation of much of the alimentary canal is provided by the enteric nervous system, which runs from the esophagus to the anus, and contains approximately 100 million motor, sensory, and interneurons (unique to this system compared to all other parts of the peripheral nervous system). The myenteric plexus (plexus of Auerbach) lies in the muscularis layer of the alimentary canal and is responsible for motility, especially the rhythm and force of the contractions of the muscularis. The submucosal plexus (plexus of Meissner) lies in the submucosal layer and is responsible for regulating digestive secretions and reacting to the presence of food (see Figure 23. Extrinsic innervations of the alimentary canal are provided by the autonomic nervous system, which includes both sympathetic and parasympathetic nerves. They transport the protein and carbohydrate nutrients absorbed by mucosal cells after food is digested in the lumen. The blood vessels’ second function is to supply the organs of the alimentary canal with the nutrients and oxygen needed to drive their cellular processes. Specifically, the more anterior parts of the alimentary canal are supplied with blood by arteries branching off the aortic arch and thoracic aorta. Below this point, the alimentary canal is supplied with blood by arteries branching from the abdominal aorta. The celiac trunk services the liver, stomach, and duodenum, whereas the superior and inferior mesenteric arteries supply blood to the remaining small and large intestines. The veins that collect nutrient-rich blood from the small intestine (where most absorption occurs) empty into the hepatic portal system. This venous network takes the blood into the liver where the nutrients are either processed or stored for later use. To appreciate just how demanding the digestive process is on the cardiovascular system, consider that while you are “resting and digesting,” about one-fourth of the blood pumped with each heartbeat enters arteries serving the intestines. The Peritoneum The digestive organs within the abdominal cavity are held in place by the peritoneum, a broad serous membranous sac made up of squamous epithelial tissue surrounded by connective tissue. It is composed of two different regions: the parietal peritoneum, which lines the abdominal wall, and the visceral peritoneum, which envelopes the abdominal organs (Figure 23. A few milliliters of watery fluid act as a lubricant to minimize friction between the serosal surfaces of the peritoneum. Chemical peritonitis can develop any time the wall of the alimentary canal is breached, allowing the contents of the lumen entry into the peritoneal cavity. For example, when an ulcer perforates the stomach wall, gastric juices spill into the peritoneal cavity. Hemorrhagic peritonitis occurs after a ruptured tubal pregnancy or traumatic injury to the liver or spleen fills the peritoneal cavity with blood. Even more severe peritonitis is associated with bacterial infections seen with appendicitis, colonic diverticulitis, and pelvic inflammatory disease (infection of uterine tubes, usually by sexually transmitted bacteria). Peritonitis is life threatening and often results in emergency surgery to correct the underlying problem and intensive antibiotic therapy. When your great grandparents and even your parents were young, the mortality from peritonitis was high. Aggressive surgery, improvements in anesthesia safety, the advance of critical care expertise, and antibiotics have greatly improved the mortality rate from this condition. The visceral peritoneum includes multiple large folds that envelope various abdominal organs, holding them to the dorsal surface of the body wall. Within these folds are blood vessels, lymphatic vessels, and nerves that innervate the organs with which they are in contact, supplying their adjacent organs. Note that during fetal development, certain digestive structures, including the first portion of the small intestine (called the duodenum), the pancreas, and portions of the large intestine (the ascending and descending colon, and the rectum) remain completely or partially posterior to the peritoneum. The Five Major Peritoneal Folds Fold Description Greater Apron-like structure that lies superficial to the small intestine and transverse colon; a site of fat omentum deposition in people who are overweight Table 23. Note the route of non-fat nutrients from the small intestine to their release as nutrients to the body. Functions of the Digestive Organs Organ Major functions Other functions Ingests food Moistens and dissolves food, allowing you to Chews and mixes food taste it Mouth Begins chemical breakdown of carbohydrates Cleans and lubricates the teeth and oral cavity Moves food into the pharynx Has some antimicrobial activity Begins breakdown of lipids via lingual lipase Propels food from the oral cavity to the Pharynx Lubricates food and passageways esophagus Esophagus Propels food to the stomach Lubricates food and passageways Mixes and churns food with gastric juices to form chyme Begins chemical breakdown of proteins Stimulates protein-digesting enzymes Stomach Releases food into the duodenum as chyme Secretes intrinsic factor required for vitamin Absorbs some fat-soluble substances (for B12 absorption in small intestine example, alcohol, aspirin) Possesses antimicrobial functions Mixes chyme with digestive juices Propels food at a rate slow enough for digestion and absorption Small Provides optimal medium for enzymatic activity Absorbs breakdown products of carbohydrates, intestine proteins, lipids, and nucleic acids, along with vitamins, minerals, and water Performs physical digestion via segmentation Table 23. The first of these processes, ingestion, refers to the entry of food into the alimentary canal through the mouth.

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The data are reported according to time from last symptomatic ischaemic event to randomisation or surgery cheap 400 mg viagra plus with visa. The two trials used different techniques to measure the degree of carotid stenosis and each trial made different recommendations regarding the degree of stenosis above which surgery was effective 400mg viagra plus with mastercard. Twelve patients underwent the procedure within 24 hours of symptom onset for stroke in evolution discount 400 mg viagra plus mastercard. The degree of stenosis cheap viagra plus 400mg on line, or its statistical association with outcome generic viagra plus 400 mg otc, was not reported in this study. This shows that the effects of surgery are modified by time since last event, gender and age such that the benefit statistically decreases as the time since last symptoms increases, and is significantly greater in males than females and in the elderly. These results are consistent across patients with 50 to 69% and 70% or more stenosis. No evidence for early carotid stenting (within the 2-week time period of the guideline) was identified. The National Service Framework for the Elderly (Standard 5: stroke)50 recommended that all stroke patients should be admitted to organised stroke units. The National Audit Office Report6 in 2005 noted that there had been no increase in stroke beds between 2001 and 2004 in the National Sentinel Audits; in 2004, half of eligible patients were treated in a stroke unit at some point and only 41% spent most of their hospital stay there. There is much less trial evidence available for the efficacy of acute stroke units than for rehabilitation units. The clinical question to be addressed is whether patients who are rapidly admitted to a specialist stroke unit have better clinical outcomes than those admitted through a general ward. Features of stroke units included continuous monitoring of physiological functions, high staff-to-patient ratio, rapid access to diagnostic tests and treatment interventions. One Cochrane systematic review was identified comparing organised inpatient (stroke unit) care for stroke with alternative care. Here we report the subgroup analysis that compared acute (semi- intensive) stroke units (continuous monitoring, high nurse staffing levels but no life support) with ‘comprehensive wards’ (a cerebrovascular ward and a stroke unit) or mixed rehabilitation wards. One study restricted the analysis to those patients who were living at home without community support prior to the stroke63 and the remaining study involved patients with intracerebral haemorrhage. The results were for cost per trimester spent in minor disability, which cannot be compared with other evaluations and so would be difficult to use as evidence of the cost effectiveness of a stroke unit. The units involved were all in different hospitals and so care varied even under each definition. The stroke care units and mobile services were at teaching hospitals, whereas the conventional care was in smaller suburban hospitals. Stroke units were compared to care by a mobile stroke team on a general ward, or domiciliary care. The mobile stroke team comprised a specialist registrar, nurse, physiotherapist and an occupational therapist. The team assessed every patient at admission and recommended a diagnostic and treatment plan based on stroke unit guidelines for implementation by the ward team. Cost effectiveness was evaluated both including the costs of informal care and excluding them. Informal care costs were calculated by two alternative methods: a) time was valued using the minimum wage b) time was valued at the average wage of a social services home help. The evaluation had a one-year time horizon to reflect the one-year trial follow-up. The results are reported for all patients with acute ischaemic stroke and for specific subgroups where appropriate. Level 3 The study on patients with intracerebral haemorrhage reported a significantly lower mortality rate associated with a stroke unit compared with a general medical ward. Pharmacological interventions were more likely to be either inappropriately stopped or delayed if patients were admitted to a general ward compared with being admitted directly to a stroke unit. The mobile stroke team was less effective than domiciliary care, 69% of patients avoided death or institutionalisation compared to 78% in domiciliary care. The stroke unit was most effective with 87% of patients avoiding death or institutionalisation after one year.

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What is anchored to this membrane so that they can be activated by movement of the fluids within the cochlea? As stated above generic viagra plus 400 mg online, a given region of the basilar membrane will only move if the incoming sound is at a specific frequency purchase 400 mg viagra plus mastercard. Because the tectorial membrane only moves where the basilar membrane moves order viagra plus 400mg with amex, the hair cells in this region will also only respond to sounds of this specific frequency purchase viagra plus 400mg free shipping. Therefore cheap viagra plus 400mg otc, as the frequency of a sound changes, different hair cells are activated all along the basilar membrane. The cochlea encodes auditory stimuli for frequencies between 20 and 20,000 Hz, which is the range of sound that human ears can detect. Most auditory stimuli contain a mixture of sounds at a variety of frequencies and intensities (represented by the amplitude of the sound wave). The hair cells along the length of the cochlear duct, which are each sensitive to a particular frequency, allow the cochlea to separate auditory stimuli by frequency, just as a prism separates visible light into its component colors. Therefore, hair cells at the base of the cochlea are activated only by high frequencies, whereas those at the apex of the cochlea are activated only by low frequencies. Which ear structures are responsible for the amplification and transfer of sound from the external ear to the inner ear? Specific wavelengths of sound cause specific regions of the basilar membrane to vibrate, much like the keys of a piano produce sound at different frequencies. Based on the animation, where do frequencies—from high to low pitches—cause activity in the hair cells within the cochlear duct? Equilibrium (Balance) Along with audition, the inner ear is responsible for encoding information about equilibrium, the sense of balance. A similar mechanoreceptor—a hair cell with stereocilia—senses head position, head movement, and whether our bodies are in motion. Head position is sensed by the utricle and saccule, whereas head movement is sensed by the semicircular canals. The neural signals generated in the vestibular ganglion are transmitted through the vestibulocochlear nerve to the brain stem and cerebellum. The moving otolithic membrane, in turn, bends the sterocilia, causing some hair cells to depolarize as others hyperpolarize. The exact position of the head is interpreted by the brain based on the pattern of hair-cell depolarization. The difference in inertia between the hair cell stereocilia and the otolithic membrane in which they are embedded leads to a shearing force that causes the stereocilia to bend in the direction of that linear acceleration. One is oriented in the horizontal plane, whereas This OpenStax book is available for free at http://cnx. The anterior and posterior vertical canals are oriented at approximately 45 degrees relative to the sagittal plane (Figure 14. The base of each semicircular canal, where it meets with the vestibule, connects to an enlarged region known as the ampulla. The ampulla contains the hair cells that respond to rotational movement, such as turning the head while saying “no. As the head rotates in a plane parallel to the semicircular canal, the fluid lags, deflecting the cupula in the direction opposite to the head movement. The semicircular canals contain several ampullae, with some oriented horizontally and others oriented vertically. By comparing the relative movements of both the horizontal and vertical ampullae, the vestibular system can detect the direction of most head movements within three- dimensional (3-D) space. As one of the canals moves in an arc with the head, the internal fluid moves in the opposite direction, causing the cupula and stereocilia to bend. The movement of two canals within a plane results in information about the direction in which the head is moving, and activation of all six canals can give a very precise indication of head movement in three dimensions. Somatosensation (Touch) Somatosensation is considered a general sense, as opposed to the special senses discussed in this section. Somatosensation is the group of sensory modalities that are associated with touch, proprioception, and interoception.

Many creased venous return buy cheap viagra plus 400mg line, decreased cardiac output and nerves including the sciatic viagra plus 400mg lowest price, lateral femoral cutaneous hypotension 400mg viagra plus free shipping. This is particularly relevant when the 60 and common peroneal nerves are at risk of either • radiation (e order viagra plus 400 mg with amex. Furthermore order 400mg viagra plus overnight delivery, the normal responses to hypothermia Other organ systems may be vulnerable in the prone (shivering, vasoconstriction) are abolished under anes- position. Procedures which are prolonged, involve large nal ischemia by either arterial compression or obstruc- abdominal incisions or require administration of large tion of venous flow. The eye socket itself provides a volumes of intravenous fluids can be associated with natural protection and specially designed head rests particularly severe hypothermia. Constant vigilance must be maintained as Heat loss can be minimized by keeping the operating patient position may shift during anesthesia. The male room temperature as high as tolerable (>21 C, prefera- patient’s genitalia must be free of pressure. Fluid mized as skin sloughing can result after prolonged sur- warmers should be used whenever blood products or gery in the prone position. A Hypothermia forced air warming system should be used routinely ex- Hypothermia has deleterious effects on the cardiovascu- cept for those cases which are very short in duration. As well, it decreases the rate of recovery from ventative measures then, depending on the underlying the effects of muscle relaxants. This has largely eliminated the use of inhaled agents for in- definition hints at the fact that a specific concentration duction except in the pediatric population, they con- of gas does not correlate to a predictable clinical effect. The volatile agents can also be termed “potent” vapours, because concentrations in the range hypothermia hyperthermia of 0. You may no- because other agents (such as opioids) are also being tice this theory being put into practice in the operating given. Table 13 summarizes these pharmacokinetic Onset of action, duration of action and elimination The solubility of a gas in blood determines its rate of properties. The ex- is relatively insoluble in blood, will build up its alveo- ception, of historical interest, is halothane of which up to 20% can undergo metabolism in the liver. In the case of re- The use of nitrous oxide is contraindicated in patients mifentanil, which is extremely short-acting, a bolus fol- with pneumothorax or bowel obstruction. Caution should be There are five different opioid receptors of which the used in those patients with coronary artery disease or most clinically relevant are the Mu and Kappa recep- emphysema. Activation of Mu receptors produces analge- Opioids sia, respiratory depression, bradycardia, euphoria and Opioids are used intra-operatively to provide analge- decreased gastrointestinal motility. Binding to Kappa sia, and to reduce the requirement of other mainte- receptors produces analgesia, sedation and meiosis. The commonly used intravenous agents The major receptors for analgesia are the Mu-1 receptor are the synthetic opioids fentanyl, sufentanil, remifen- at the periaqueductal gray area of the midbrain and the tanil and alfentanil. They are favoured by anesthesiolo- Kappa receptor at the substantia gelatinosa of the spi- gists over the more familiar agents, such as morphine nal cord. Unfortunately, finer titration to provide adequate analgesia during the an agent which possesses agonism exclusively at the variable, but intense nature of surgical stimulation, analgesia receptors has not yet been developed. While there are many different opioids avail- able for use, the discussion below is limited to the three synthetic agents which are most commonly used in an- esthetic practice. The greater the summarizes the clinically useful pharmacology of the lipid solubility, the greater the potency. Fentanyl and sufentanil are metabolized in the liver to (mostly) inactive metabo- lites which are then excreted in the urine. Remifentanil Onset of action is determined by lipid solubility and on the other hand, is susceptible to metabolism by ionization (pKa). Duration of action is determined by blood and tissue esterases which accounts for its ul- trashort duration of action. Table 14 Pharmacology of commonly used opioids Effects Fentanyl Sufentanil Remifentanil Opioids have effects on almost every system in the body. Nor- Non-Depolarizing Muscle Relaxants mally a nerve impulse travels the length of the nerve to The decision to use non-depolarizing muscle relaxants arrive at the motor nerve terminal where it causes re- during maintenance of anesthesia depends on both the lease of acetylcholine (Ach) into the synaptic cleft. Ach then binds to post-synaptic nicotinic Ach receptors Some procedures require muscle relaxation to facilitate causing a conformational change in those receptors.

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