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Associate Professor, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine
The sarcolemma is highly Tendon indented and invested by a prominent external lamina gastritis diet сбербанк buy generic nexium. Collagen fibrils of the adjacent tendon penetrate intervillous clefts and are in close contact with the sarcolemma gastritis diet en espanol purchase nexium in united states online. It is an interface between two diverse yet interconnected tissues with a complicated communication system and a high shear component. Biomechanically, this area involves a concentration of tensile forces and marks a site of abrupt change in the modulus of elasticity, which represents the point of maximum stress in this unit. Developmentally, it is the rapidly growing area of the muscle fiber during postnatal life. Light and electron microscopy can show that the interface between muscle and tendon is highly interdigitated and consists of branching finger-like extensions of myofibrils that interlock with projections of adjacent tendon-like the fingers of a hand inserted into a tight-fitting glove. The extensive infolding of the sarcolemmal membrane increases surface area, which enhances mechanical stability at the site of force transmission and in response to junctional stress. Specific membrane-associated proteins including -actinin, vinculin, talin, and integrins are found at these sites. Immobilization reduces the tensile strength of the junction and predisposes it to strain injuries. Symptoms typically begin at the muscle-tendon junction and then spread throughout the affected muscle. Although distressing for novice exercisers, it is a normal, adaptive response to unusual exertion that rarely requires clinical treatment. Muscle fibers undergo repair and remodeling via an increase in protein synthesis and activation of satellite cells. The cytoplasm contains scattered free ribosomes, and a few profiles of rough and smooth endoplasmic reticulum. A narrow gap separates the cell from the underlying muscle fiber, where plasma membranes of the two cells are parallel to each other. The underlying muscle fiber contains tightly packed but poorly defined myofibrils and a few mitochondria. The narrow space between their apposed membranes is difficult to distinguish at this magnification. The cytoplasm contains a sparse collection of mitochondria, rough endoplasmic reticulum, and free ribosomes. Well-defined myofibrils with intervening elements of sarcoplasmic reticulum and mitochondria characterize the underlying muscle fiber. The close location of these cells to the surface of a fiber, with an intervening space of about 15 nm, makes them identifiable by electron microscopy or by immunocytochemical staining and molecular markers. Satellite cells serve as a population of reserve stem cells, or resting myoblasts, either for normal postnatal growth or for repair and regeneration of damaged segments of the skeletal muscle fiber after injury. Also, more satellite cells occur in slowtwitch muscles than in fast-twitch muscles. Although the cells are normally quiescent in adults and their numbers and mitotic capacity decline with age, they have proliferative potential throughout life, and they increase in number in response to denervation, in mildly traumatized muscle, and in regenerating diseased muscle. A single nucleus contains clumped peripheral heterochromatin; the cytoplasm normally contains a paucity of organelles. Free ribosomes, scattered small mitochondria, occasional rough endoplasmic reticulum, and Golgi complex are the only distinguishing features. Activation of satellite cells after muscle injury leads to cell proliferation, followed by differentiation and fusion to either form new muscle fibers or repair damaged ones. Advances in our knowledge of satellite cell dynamics hold promise for progress in treatment of diseases, such as muscular dystrophy, that affect skeletal muscle. The most common adult muscular dystrophy, it often occurs in early adulthood and has an extremely variable degree of severity.
But unlike the other parts gastritis diet 911 order generic nexium canada, its muscularis externa consists of two types of muscle tissue gastritis vitamin c cheap 40 mg nexium with visa. The upper third of the esophagus has skeletal muscle fibers; the middle third, a mixture of smooth and skeletal muscle; and the lower third, only smooth muscle. The upper sphincter is an anatomically distinct structure of skeletal muscle fibers of the cricopharyngeus muscle. At the lower end (distal 5 cm), in contrast, is a physiologic sphincter, less well defined histologically, that usually prevents reflux of gastric contents. At rest, the esophageal lumen is collapsed and plicated by temporary longitudinal folds. During passage of a food bolus, the distensible esophageal wall allows the folds to flatten out because of its high content of elastic tissue. When portal blood flow is obstructed, these veins serve as collateral vessels between portal and systemic circulations. Increased endothelin-1 (a vasoconstrictor) and decreased nitric oxide (a vasodilator) have been implicated in pathogenesis of portal hypertension and esophageal varices. The muscularis externa has inner (In) and outer (Ou) smooth muscle layers; the adventitia, nerves (Ne) and lymphatic channels (Ly). Basophilic cuboidal cells form the basal layer, which, as in other stratified epithelia, is mainly a mitotic and regenerative zone. Continuous renewal of epithelial cells normally takes 14-21 days as cells slowly migrate to the surface and desquamate. Above the basal layer, maturing cells become flatter and accumulate glycogen, which is seen as washed-out areas in conventional preparations. The basal layer also contains scattered melanocytes and Merkel cells; the intermediate layer, Langerhans cells and T lymphocytes. The surface cells retain their nuclei, and their cytoplasm may have a few keratohyalin granules. These cells are usually nonkeratinized in humans but may become keratinized if subjected to an unusual degree of trauma. The lamina propria is loose fibroelastic connective tissue richly endowed with capillaries, nerves, and small lymphatic channels. Its conical papillae project into the epithelium at irregular intervals and usually penetrate up to two thirds of the epithelial thickness. The muscularis mucosae has two ill-defined layers of smooth muscle cells, arranged helically and longitudinally, that contract to allow localized movements and folding of the mucosa. A response to esophagitis or injury, it can occur anywhere above the gastroesophageal junction. Patients with persistent gastroesophageal reflux disease, in which acid reflux disrupts the esophageal mucosal barrier, are predisposed to metaplastic change in the esophageal epithelium. Epithelium lining the duct merges with stratified epithelium (Ep) on the mucosal surface. A predominance of elastic fibers in this layer provides the esophageal wall with considerable distensibility. During development, they migrate into underlying connective tissue, but they retain connections to the surface via ducts. Two types of mucous glands occur in the esophageal wall-named superficial or submucosal glands on the basis of location. Superficial glands are simple tubular glands that occur in the lamina propria only at proximal and distal ends of the esophagus, close to the cricopharyngeus muscle and gastroesophageal junction, respectively. They pursue a tortuous course in the mucosa and drain secretory product-a neutral mucin-by short ducts to the surface. They resemble small cardiac glands of the stomach, so they are also called cardiac glands. Deeper glands-whose secretory acini lie in the submucosa-are diffusely scattered along the entire esophagus. These small-compound tubular glands produce an acidic mucin and are drained by ducts that are initially composed of simple cuboidal epithelium, which then becomes stratified cuboidal epithelium with a double layer of cells.
For example gastritis fiber diet discount 40 mg nexium otc, corticotrophin releasing hormone or factor induces the release of adrenocorticotropic hormone from the anterior pituitary gastritis symptoms and diet purchase generic nexium line, which is released into the systemic circulation and activates the adrenal cortex to release cortisol and other steroid hormones. This hypothalamo-pituitary-adrenal system helps to regulate glucose metabolism, insulin secretion, immune responses, adipose distribution, and a host of other vital functions. The corticotrophin releasing hormone neurons are under extensive regulatory control by neural inputs, hormonal feedback, and inflammatory mediators; these neurons help to orchestrate stress reactivity for the organism as a whole. Vasculature 113 Anterior View Posterior cerebral artery Superior cerebellar artery Basilar artery Anterior inferior cerebellar artery Posterior inferior cerebellar artery Anterior spinal artery Vertebral artery Anterior radicular arteries Ascending cervical artery Deep cervical artery Subclavian artery Anterior radicular artery Cervical vertebrae Posterior View Posterior inferior cerebellar artery Posterior spinal arteries Vertebral artery Posterior radicular arteries Deep cervical artery Ascending cervical artery Subclavian artery Posterior radicular arteries Posterior intercostal artery Posterior intercostal arteries Thoracic vertebrae Artery of Adamkiewicz (major anterior radicular artery) Anterior radicular artery Posterior radicular arteries Lumbar artery Anastomotic loops to posterior spinal arteries Lumbar arteries Lumbar vertebrae Anastomotic loops to anterior spinal artery Lateral sacral (or median sacral) artery Lateral sacral (or median sacral) artery Sacrum 7. The actual blood flow through these arteries, derived from the posterior circulation, is inadequate to maintain the spinal cord caudally beyond the cervical segments. Radicular arteries, deriving from the aorta, provide major anastomoses with the anterior and posterior spinal arteries and supplement the blood flow to the spinal cord. The largest of these anterior radicular arteries, often from the L2 region, is the artery of Adamkiewicz. Impaired blood flow through these critical radicular arteries, especially during surgical procedures that involve abrupt disruption of blood flow through the aorta, can result in spinal cord infarct. The anterior spinal artery sends alternating branches into the anterior median fissure to supply the anterior two thirds of the spinal cord. Occlusion of one of these branches can result in ipsilateral flaccid paralysis in muscles supplied by the affected segments, ipsilateral spastic paralysis below the affected level (resulting from upper motor neuron axonal damage), and contralateral loss of pain and temperature sensation below the affected level (resulting from damage to the anterolateral spinothalamic/spinoreticular system). Occlusion affects the ipsilateral perception of fine discriminative touch, vibratory sensation, and joint position sense below the level of the lesion (resulting from damage to fasciculi gracilis and cuneatus, the dorsal columns). Vasculature 115 Posterior spinal arteries Anterior spinal artery Anterior radicular artery Posterior radicular arteries Branch to vertebral body and dura mater Spinal branch Dorsal ramus of posterior intercostal artery Posterior intercostal arteries Paravertebral anastomosis Prevertebral anastomosis Aorta Section through Thoracic Spine Right posterior spinal artery Peripheral branches from pial plexus Central branches to right side of spinal cord Anterior radicular artery Central branches to left side of spinal cord Left posterior spinal artery Zone supplied by penetrating branches from pial plexus Zone supplied by central branches Zone supplied by both central branches and branches from pial plexus Posterior radicular artery Anterior radicular artery Pial arterial plexus Pial arterial plexus Posterior radicular artery Anterior spinal artery Schema of Arterial Distribution 7. This intercostal blood supply also distributes to adjacent bony and muscular structures. The penetrating vessels supplying the spinal cord derive from central branches of the anterior spinal artery and from a pial plexus of vessels that surround the exterior of the spinal cord. Following an infarct in the anterior spinal artery, acute radiating leg pain is experienced. Depending on the level of insult, acute flaccid paraparesis or quadraparesis occurs, resolving to spastic paraparesis or quadraparesis with hyperreflexia as the result of the upper motor neuron lesion resulting from damage to the bilateral lateral funiculi. Only at the level of the infarct, where lower motor neurons are lost, does flaccid paralysis remain, along with hyporeflexia. Bilateral loss of pain and temperature sensation is seen because of ischemia to the anterolateral territory of the spinothalamic/ spinoreticular protopathic system. Descending fibers for control of the bladder and bowel travel in the lateral funiculus and are damaged by an anterior artery infarct. These channels do not have valves and permit free communication between these venous systems and the venous sinuses. This is a significant factor in the possible spread of infections from foci outside the cranium to the venous sinuses. The cerebral veins also extend across the subarachnoid space and enter into the superior sagittal sinus. With severe head trauma, these bridging veins can be torn, with resultant venous bleeding into the subdural space; this bleed dissects the dura from the arachnoid and becomes a space-occupying mass. Acute subdural hematomas can be life-threatening, especially in young individuals with head trauma. Chronic subdural hematomas often occur in the elderly with relatively minor trauma; the bridging veins tear because of some mild atrophy of the underlying hemisphere, making the course of the bridging veins more extended and more vulnerable to tearing. Slow accumulation of subdural blood eventually can result in increased intracranial pressure with headache, lethargy, confusion, seizures, and focal neurological abnormalities. Surgical drainage is often performed for large subdural hematomas, whereas small hematomas usually regress naturally in the elderly. Vasculature 117 Scalp, Skull, Meningeal, and Cerebral Blood Vessels Superior sagittal sinus Diploic vein Emissary vein Frontal and parietal tributaries of superficial temporal vein Frontal and parietal branches of superficial temporal artery Arachnoid granulation indenting skull (foveola) Venous lacuna Inferior sagittal sinus Thalamostriate and internal cerebral veins Deep and superficial middle cerebral veins Arachnoid Cerebral vein penetrating subdural space to enter sinus (bridging veins) granulation Dura mater (two layers) Epidural space (potential) Arachnoid Subarachnoid space Pia mater Middle meningeal artery and vein Deep middle and superficial temporal arteries and veins Diploic and Emissary Veins of Skull Parietal emissary vein Frontal diploic vein Posterior temporal diploic vein Occipital emissary vein Occipital diploic vein Anterior temporal diploic vein Mastoid emissary vein 7.
These cells migrate ventrolaterally along each side of the neural tube to form a series of somites gastritis diet chart buy cheapest nexium and nexium. The neural tube lumen gives rise to fluid-filled ventricles of the brain and central canal of the spinal cord gastritis diet mayo order nexium online. They are composed of three distinct layers: an outermost dura mater, arachnoid, and innermost pia mater. Anencephaly is a congenital malformation caused by failure of fusion of neural folds in rostral regions. Degeneration of unfused folds leads to failure of development of neural tissue and absence of most of the brain, the result being stillbirth or premature death. A defect at more caudal levels of the primitive spinal cord is called spina bifida. This condition typically produces paralysis depending on the level of the lesion and is usually not life-threatening. Underlying the arachnoid (Ar), a more delicate connective tissue, is the subarachnoid space (*), which, in life, contains cerebrospinal fluid. The thickest and toughest layer, the dura, is dense, fibrous connective tissue consisting of interlacing bundles of collagen and elastic fibers associated with flattened fibroblasts. The outer aspect of the dura attaches to the periosteum of the skull; the inner dural surface is lined by a layer of flattened fibroblasts. Two potential spaces associated with it are the epidural space (exterior) and subdural space (between dura and arachnoid). These normally potential spaces can in some pathologic conditions accumulate fluid such as blood. The arachnoid and pia mater are thinner and more delicate than the dura and are known together as the leptomeninges. The arachnoid comprises several layers of flattened, closely packed fibroblasts linked by tight junctions with some intervening collagen. Peripherally, the arachnoid is continuous with the perineurium around peripheral nerve fascicles. At certain sites, the pia protrudes into the ventricles close to modified ependymal cells to form the choroid plexus. A leading cause of meningitis in children is Haemophilus influenzae type b, and a vaccine for it has dramatically reduced its incidence. Meningitis may occur at any age, but it is most common in children, the elderly, and immunocompromised people. The shading difference is due mainly to the amount of myelin, which stains darker in the white matter. Neuronal somas in the cortex are surrounded by the neuropil consisting of a feltwork of intermingled axons, dendrites, and glia. Unmyelinated neuronal processes and glial cells, tracts of myelinated nerve fibers, and associated glia dominate the white matter, whereas gray matter consists mostly of neuron bodies. In the spinal cord, gray matter is located internally and is enveloped by an external layer of white matter. Because of the complexity and intricate nature of nervous tissue, ordinary staining methods have limited value when used alone to examine its cytologic features. Pyramidal cell in the rat hippocampus injected iontophoretically with a fluorescent marker to highlight the soma and multiple dendrites. A mouse neocortical neuron immunofluorescently labeled with microtubule-associated protein and fluorescein. Multipolar neurons in the base of the human forebrain stained immunocytochemically with an antibody to calbindin, a calcium-binding protein. The light brown demonstrates the spatial distribution of calbindin in somas, axons, and dendrites. These cholinergic neurons project to the cerebral cortex and are commonly affected in Alzheimer disease. Cortical pyramidal neuron labeled with the lipophilic dye, DiI, and imaged by confocal microscopy. High-magnification rendered confocal microscopic view of two dendrites from a pyramidal neuron. Basic cationic dyes such as cresyl violet and toluidine blue elucidate cell nuclei and neuronal Nissl substance (rough endoplasmic reticulum and ribosomes).
