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The distal convoluted tubules also are the major site where parathyroid hormone stimulates reabsorption of Ca2 antibiotics for staph acne purchase vantin 100mg on-line. Recall that two different types of cells are present in the last part of the distal convoluted tubule and throughout the collecting duct: principal cells and intercalated cells. Then Na passively diffuses in to the peritubular capillaries from the interstitial fluid. Normally, most filtered K is returned to the bloodstream by reabsorption in the proximal convoluted tubule and nephron loop. K diffuses down its concentration gradient through K leakage channels in both the apical and basolateral membranes. Some K is returned to the interstitial fluid but most K diffuses from a high K concentration in the principal cells in to the tubular fluid, where the K concentration is very low. By contrast, intercalated cells salvage K by reabsorbing it from tubular fluid while secreting H in to the tubular fluid. Describe the two ways in which substances can be absorbed across the tubule cells. It decreases glomerular filtration rate by causing vasoconstriction of the afferent arterioles. Five hormones influence tubular reabsorption of Na, Cl, Ca2, and water as well as tubular secretion of K. In addition, as systemic blood pressure falls, sympathetic innervation directly stimulates juxtaglomerular cells to release renin. Renin converts angiotensinogen, which is synthesized in the liver, in to angiotensin I. It enhances reabsorption of Na, Cl, and water in the proximal convoluted tubule by stimulating the activity of Na /H antiporters. It regulates facultative water reabsorption by increasing the water permeability of principal cells in the last part of the distal convoluted tubule and the collecting duct. Because the basolateral membranes are always permeable to water, water molecules then move rapidly in to the blood. As facultative water reabsorption increases, the water concentration in the blood increases to normal. These effects increase the excretion of Na and water in urine, which increases urine output and decreases blood volume and blood pressure. Parathyroid Hormone Although the hormones mentioned there far involve regulation of water loss in urine, the kidney tubular also respond to a hormone that regulates ionic composition. For example, a lowerthan-normal level of Ca2 in the blood stimulates the parathyroid glands to release parathyroid hormone. Parathyroid hormone in turn stimulates cells in the distal convoluted tubules to reabsorb more Ca2 in to the blood. How is the juxtaglomerular apparatus involved in blood pressure regulation by the kidneys As solutes are reabsorbed from the filtered fluid in the proximal convoluted tubule, water follows the solutes by osmosis.

It will return as soon as that movement becomes maintained or a new position taken up infection rate generic vantin 100mg on-line. It is accompanied by cogwheel rigidity at the wrist and fingers and slowing of each movement. Rubral tremor, so-called, is really a severe cerebellar tremor with the responsible lesion more likely in the superior cerebellar peduncles. It is grossly increased by further voluntary move ment, and may then become a wild, incoordinate, choreic flinging of the arm in all directions. It is absent on total relaxation, so that the patient may be able to conceal it, but it appears as soon as any attempt is made to maintain posture. The youth of the patient, the family history, increasing dementia and, of course, the pathogno monic Kayser-Fleischer ring confirm the diagnosis, and evidence of liver disease usually being present only at a late stage. Perioral tremor A constant, coarse tremor of the orbicularis oris and chin is seen in the general paralysis of the insane, and may be the only site of the tremor. It is indicative of disease of the cerebellar connections, and is seen in multiple scle rosis and some variants of ataxias and essential tremor. It differs from the isolated head nodding forming part of the torticollis spec trum, and is always accompanied by marked signs of other neuro logical disease, although there is an idiopathic variety associated with the so-called essential tremor. Enhanced physiological tremor Anxiety and nervousness the tremor is rapid, varying from fine to coarse, affecting mainly the fingers, but capable of spreading to the whole arm or body. It is present at rest, increased by any voluntary movement which the patient fears he may not do correctly or quickly enough (such as the finger-nose test, or undressing), not increased during au to matic movement, made worse by speaking sharply to the patient, reducing towards the end of the examination as he realizes that it is not a very alarming experience and often absent on a second examination for the same reason. Thyrotoxicosis this is a fine rapid tremor, present constantly, greatly influenced by emotion and accompanied by sweating and tachycardia, but the extremities are very warm; there is lid retraction, possibly exoph thalmos, and loss of weight. Other toxic trem ors Almost any drug taken in excess over a prolonged period may give rise to a tremor that resembles alcoholic tremor. Inorganic mercury compounds are particularly liable to produce coarse tremor, but are rarely a problem these days. Addiction to stimulant drugs, includ ing some of those used as antidepressants, is now more commonly responsible than industrial toxins. Lithium, nicotine and L-dopa are further examples of agents that can induce this form of tremor. Slow wandering movements of the fingers occur, accompanied by flexion at the metacarpophalangeal joints so that the palm is drawn away from a flat surface. As this happens, the fingers gradually close, the wrist flexes and there is internal rotation of the pronated forearm. In many ways, the movements resemble athetosis, but it is suppressed when the patient watches his hand, and he is usually unaware of its occurrence. When such a limb is moved passively, the examiner gains the impression (incorrectly) that the patient is resisting voluntarily. Any lesion causing very severe loss of position sense may produce this phe nomenon. In this condition, it may affect only the arms, but it is also seen in carcinomatous sensory neuropathy where it may affect the arms and legs equally. It occurs with cerebellar ectopia at foramen magnum level and very occasionally, unilaterally, in parietal lobe lesions. It can occur, but it is rare, in multiple sclero sis, and here it may remit completely. Other involuntary movements of the face and neck Almost any of the movements described may involve the face and neck, but in certain conditions, the abnormality is limited to this part of the body. They are present when under observation, sometimes absent when concentrating on something else, common in childhood, increased by nervousness, and though they may remain stereotyped for months or years, singly or occasionally, multiple tics may persist or even evolve throughout life. Volun tary suppression is possible for a while, but increasing inner urge ultimately causes their return, with associated momentary relief from tension. Though commonest in the face, such movements frequently involve the shoulder girdle, causing shrugging move ments, retraction of the neck and, at times, contraction of individ ual muscles such as the platysma, the pectorals or even one-half of the abdominal muscles. The whole muscle is always in action and the movement is in every respect similar to voluntary contrac tions of those muscles. A rare disorder, the syndrome of Gilles de la Tourette, is characterized by multiple persistent tics often accom panied by inarticulate cries or barks or compulsive utterance of obscenities.

Sertoli cells also produce fluid for sperm transport and secrete the hormone inhibin to decrease the rate of spermatogenesis taking antibiotics for acne buy vantin 200 mg amex. An androgen is a hormone that promotes the development of masculine characteristics. Spermatogenesis Before you read this section, please review the topics of somatic cell division and reproductive cell division in Concept 3. When spermatogonia undergo mitosis, some spermatogonia remain near the basement membrane of the seminiferous tubule in an undifferentiated state to serve as a reservoir of cells for future sperm production. As spermatogenic cells proliferate, they fail to complete cytoplasmic separation (cytokinesis). This pattern of development most likely accounts for the synchronized production of sperm in any given area of a seminiferous tubule. The larger X chromosome may carry genes needed for spermatogenesis that are lacking on the smaller Y chromosome. An acrosome (described shortly) forms atop the condensed, elongated nucleus, a flagellum develops, and mitochondria multiply. Finally, sperm are released from their connections to Sertoli cells and enter the lumen of the seminiferous tubule. Fluid secreted by Sertoli cells pushes sperm along their way, toward the ducts of the testes. In meiosis I, homologous pairs of chromosomes line up at the metaphase plate, and crossing-over occurs to rearrange genes between chromatids. Then, the meiotic spindle pulls one (duplicated) chromosome of each pair to an opposite pole of the dividing cell. The flattened, pointed head of the sperm cell contains a nucleus with 23 highly condensed chromosomes. The tail (flagellum) of a sperm cell is subdivided in to four parts: neck, middle piece, principal piece, and end piece. The principal piece is the longest portion of the tail, and the end piece is the terminal, tapering portion of the tail. Once ejaculated, most sperm do not survive more than 48 hours within the female reproductive tract. Testosterone stimulates the final steps of spermatogenesis in the seminiferous tubules. Testosterone and dihydrotestosterone both bind to the same androgen receptors within the nuclei of target cells. Before birth, testosterone stimulates the male pattern of development of reproductive system ducts and the descent of the testes. Dihydrotestosterone stimulates development of the male external genitals (penis and scrotum). Testosterone also is converted in the brain to estrogens (feminizing hormones), which may play a role in the development of certain regions of the brain in males. At puberty, testosterone and dihydrotestosterone bring about development and enlargement of the male sex organs and muscular and skeletal growth that results in masculine secondary sexual characteristics. Secondary sex characteristics are traits that distinguish males and females but do not have a direct role in reproduction. In males these include wide shoulders and narrow hips, facial and chest hair (within hereditary limits) and more hair on other parts of the body, thickening of the skin, increased sebaceous (oil) gland secretion, and enlargement of the larynx and consequent deepening of the voice. Androgens contribute to male sexual behavior and spermatogenesis and to sex drive (libido) in both males and females. This effect is obvious in the heavier muscle and bone mass of most men as compared to women. It contains the ductus deferens as it travels through the scrotum, the testicular artery, veins that drain the testes and carry testosterone in to circulation, autonomic nerves, lymphatic vessels, and the cremaster muscle.

Follicle-stimulating hormone and testosterone stimulate Sertoli cells to secrete androgen-binding protein antibiotics bladder infection order vantin 100mg with mastercard, which binds to testosterone and keeps its concentration high in the seminiferous tubule. Sertoli cells secrete inhibin, which inhibits follicle-stimulating hormone release to help regulate the rate of spermatogenesis. Testosterone stimulates development of male reproductive structures and secondary sex characteristics, development of male sexual behavior, male and female libido, bone growth, protein anabolism, and sperm maturation. Fluid from Sertoli cells pushes sperm through the testis in the straight tubules, through the rete testis, then through the epididymis in the efferent ducts. The epididymis lies along the posterior border of each testis and contains the tightly coiled ductus epididymis, the site of sperm maturation and storage. The spermatic cord passes the ductus deferens, the testicular artery and veins, autonomic nerves, lymphatic vessels, and cremaster muscle through the inguinal canal. The ducts of the ductus deferens and seminal vesicle unite to form the ejaculatory duct, the passageway for ejection of sperm and secretions of the seminal vesicles in to the first portion of the urethra, the prostatic urethra. The urethra extends from the urinary bladder to the tip of the penis and is subdivided in to the prostatic, membranous, and spongy urethra. Seminal fluid constitutes about 60% of the volume of semen and contributes to sperm viability. The prostate lies inferior to the urinary bladder and surrounds the prostatic urethra. Its secretion constitutes about 25% of the volume of semen and contributes to sperm motility and viability. Paired bulbourethral glands lie inferior to the prostate on either side of the membranous urethra. They secrete mucus for lubrication and an alkaline fluid that neutralizes acids from urine in the urethra. Semen is a mixture of sperm and seminal fluid, which consists of secretions from the seminiferous tubules, seminal vesicles, prostate, and bulbourethral glands. Semen provides the fluid in which sperm are transported, supplies nutrients for sperm, and neutralizes the acidity of the male urethra and the vagina. The penis contains the urethra and is a passageway for ejaculation of semen and excretion of urine. The body of the penis is composed of three masses of erectile tissue: two corpora cavernosa penis and a corpus spongiosum penis that contains the spongy urethra and keeps it open during ejaculation. Engorgement of the penile blood sinuses under the influence of sexual excitation is called erection. Ejaculation is the expulsion of semen from the urethra to the exterior of the body. The female organs of reproduction include the ovaries, uterine tubes (oviducts), uterus, vagina, and vulva. Mammary glands are considered part of both the integumentary and reproductive systems. The ovaries are located on each side of the uterus and held in position by the broad, ovarian, and suspensory ligaments. The ovarian cortex contains ovarian follicles with oocytes in different stages of development. A corpus luteum, the remains of a follicle after ovulation, degenerates in to the corpus albicans. The secondary oocyte is released from the ovary during ovulation and is usually swept in to the uterine tube. The uterine tubes extend laterally from the uterus and are the normal sites of fertilization. Their distal end is an open, funnel-shaped infundibulum with fingerlike fimbriae that sweep the oocyte in to the uterine tube. Ciliated cells and peristaltic contractions help move a secondary oocyte or zygote toward the uterus. The uterus functions in menstruation, implantation of a fertilized ovum, fetal development, and labor. It also is part of the pathway for sperm to reach the uterine tubes to fertilize a secondary oocyte. The uterus wall is composed of an outer perimetrium; a middle myometrium consisting of three layers of smooth muscle important during labor; and the inner endometrium that lines the lumen of the uterus.

When the patellar tendon is tapped while the foot is hanging free bacteria nitrogen cycle purchase cheap vantin on line, the knee is held in extension for a few seconds before relaxing. This is probably due to the super imposed choreic movement over the contracting quadriceps. Sometimes, the vital clinical question is whether the deep tendon reflexes are asymmetrical (compressive versus degenerative cause), and the above examination is imclear. With both forearms relaxing over the abdomen, place your index finger over the manubrium sterni and tap with the hammer. Normally, there is either no response or symmetri cal movement flexion of both the forearms with and without finger flexion. With the patient supine, abdominal mus cles relaxed and thighs in mild flexion, abduction and external rotation tap over the symphysis pubis. Difficulties and fallacies Failure of relaxation is the major difficulty in examining tendon reflexes. Re-examination is wise just before leaving the patient, because, knowing that it is all over, he will be in a greater state of relaxation than at any other time, providing the techniques used have been gentle and sympathetic. Part 5 the motor-sensory links Faulty positioning of the limb, especially for the ankle jerk, is another cause of difficulty and advice has been given at some length on this point. Many patients make a confusing, semi-voluntary jerk of the limb shortly after the reflex has occurred. Pointing out to the patient that it is he who is doing it, that it is confusing and bluntly asking him to stop it seems to be effective. Arthritic patients often fear that the test will be painful, hold themselves rigid and jump violently when the tendon is struck. Start with a very gentle tap and gradually work up to the normal strength of stimulus. When the biceps reflex is absent, on striking the tendon the elbow may appear to flex, but a glance at the biceps itself will show no contraction at all. The jaw jerk is often thought to be of little importance, but its value is, in fact, very great (see p. In amputees, the reflex muscular contraction may be normal, but the amount of limb to be moved is so small that there is apparently a very brisk response. In a normal patient with a below-the-knee amputation, the stump may even go in to a form of clonus. No apology is made for repeating that clonus is only a manifesta tion of heightened muscle tone, and it may occur in very tense or frightened individuals, after straining, or after exercise. It is, how ever, rarely long-sustained as in pyramidal system disease, is usu ally equal on the two sides and truly clonic reflexes are not obtained. Th e superficial reflexes For practical purposes, only four of the many superficial reflexes are routinely tested - the abdominal reflexes, the cremasteric reflexes, the anal reflex and the all-important plantar reflexes. The abdominal reflexes (including the ep ig astric reflex) Technique: the patient should first lie flat. Palpate the abdomen gently to assess the degree of relaxation and the sensitivity of the skin. Then explain that something is about to be drawn across the stomach, illustrating the manoeuvre on the chest. Any physician who has unexpectedly had his abdominal reflexes examined will appreciate the value of this warning. Lightly stroke the abdomen with a pencil, key or two-point discriminator, from without inwards, stimulating each of the Chapter 25 the reflexes four quadrants of the abdomen and the lower margins of the thoracic cage in turn. However, if the objective is segmental localization, then the stimulus may be applied along the derma tomes. Normal result: the muscles in the quadrant stimulated contract and the umbilicus moves in that direction. Abnormal responses 1 Exaggerated abdominal reflexes occur in psychoneurosis, often in the absence of overt anxiety, and may also be brisk in simple nervousness. This is more common in spinal lesions (ipsilateral or bilateral) than in cerebral lesions (contralateral), but the reflexes are not necessarily absent in all such cases, or in one case on all occasions. Occasionally, when the abdominal reflexes are absent on one side, stimulation on that side produces mus cular contraction on the normal side, so that the umbilical devi ation takes place towards the normal side. Difficulties and fallacies If the patient has a very fat abdomen, one scarred by enthusiastic surgeons, or exhausted by frequent pregnancies, muscular contrac tion may not be visible or may not occur.

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