Synchronizers (time givers) are environmental factors that help to keep the organism in phase generic zebeta 10 mg free shipping blood pressure 55 years age. One adapts more easily after a flight west cheap 5 mg zebeta arteria carotida externa, because there is a longer day and we have an endogenous clock of about 25 hours order zebeta 5 mg without prescription heart attack 9gag. In other words 5 hours time difference will require approximately 5 days adaptation. The current recommendation is for pilots having sleep disturbance to take a Benzodiazepine such as Temazepam. A 356 combination of treatment including light, Melatonin and Diazepams may be needed. No "hangover " effects were noted as assessed by mood and performance tests administered the morning after treatment. There were no adverse side effects and behavioral and social benefits were significant. The authors concluded that Melatonin has an important role in the treatment of certain types of chronic sleep disorders. One of the potential major causes of age related destruction of neuronal tissue is toxic free radical that are a natural result of aerobic metabolism. The brain is particularly susceptible to free radical attack, vitamin antioxidants, vitamin E and vitamin C aid in protecting the brain from oxidative stress by directly scavenging toxic radicals. There are data, which indicate that Melatonin antagonizes the mitogenic effects of estrogens. The benefit appeared to be related to light rather than Melatonin inhibition as these workers found that pharmacological suppression of Melatonin did not improve their depression. Changes in magnetic fields alter Melatonin secretion and affect circadian rhythms. Both acute exposure to light and exposure to magnetic fields suppress Melatonin secretion and may be beneficial for patients with winter depression. It has been proposed that the synergistic effect of light and magnetic therapy in these patients may be superior to photo therapy alone. Low Melatonin levels have been observed in depressed subjects, unipolar or bipolar affective disorders, and chronic schizophrenia. Low nocturnal Melatonin has been proposed as a trait marker for major depressive disorders. Other psychotropic drugs, which interfere with monoamine pathways, also affect pineal Melatonin. Receptors for Benzodiazepines have been reported to exist in the pineal gland of several animal species. In humans, Alprazolam (Xanax) given before lights out suppressed nocturnal Melatonin and Cortisol. The conventional view that the underlying abnormality in endogenous depression is due to an abnormality in the body clock has been challenged. They suggest that the circadian system in endogenous depression resembles its state in healthy individuals after time zone transitions or in shift work maladaptation syndrome and disturbances result from changes in the phasing of external time givers rather than from an abnormality in the clock itself. Melatonin and Endocrine Disorders External magnetic fields have been found to synchronize Melatonin secretion in experimental animals and humans and may be beneficial in the treatment of postmenopausal osteoporosis. Pineal Melatonin has been shown in animals to be involved in the regulation of calcium and phosphorus metabolism by stimulating the parathyroid glands and by inhibiting calcitonin release and prostaglandin synthesis. The menopause is associated with a decline in Melatonin secretion and increased pineal calcification. The pineal gland has been linked to the immune system and immunodepression has been counteracted by Melatonin administration. The thymus is one of the main targets of Melatonin and its immunoenhancing effects may be mediated by opioids derived from T helper cells, lymphokines and possibly pituitary hormones. Lymphokines, such as gamma- interferon and L2, as well as thymic hormones can modulate the synthesis of Melatonin in the pineal gland. Normal pubertal development does not appear to be linked to alterations in Melatonin profile. However, there is some evidence that 358 delayed puberty, precocious puberty and hypothalamic amenorrhoea may have altered Melatonin profiles. Melatonin and Adverse Effects Controlled release Melatonin effectively improved sleep quality in 12 elderly people. The subjects were treated with 2 mg per night for 3 weeks, 2 cases developed pruritis, one on Melatonin and one on placebo. Melatonin was combined with a synthetic progestin norethisterone to study its influence on the pituitary ovarian axis. An additive or synergistic effect between Melatonin and norethisterone was suggested. Medications did not alter sleep/wake rhythms and were not complicated by any side effects. Present data suggest that Melatonin and mel/net combinations inhibit ovarian function in women and the authors suggest a future effective oral contraceptive. A study was done in 1972 to assess the effects of Melatonin in Parkinsonism giving Melatonin alone or plus Levadopa. Melatonin induced some episodes of cutaneous flushing, abdominal cramps, diarrhoea, scotoma lucidum and migraine headaches, 300-1000mgs/night were given for 1 - 4 weeks. Effects of Metoprolol and Atenolol on plasma Melatonin levels revealed lower plasma Melatonin levels in moderate hypertensives receiving betablockers than in those on diuretics alone or in combination. General comments Once Melatonin is on prescription, it will be possible to document side effects more accurately. A major side effect appears to be fatigue, which is understandable given that one is resetting the "body clock". Melatonin will almost certainly have a role in the treatment of jetlag and sleep disorder syndromes but the exact dose regime still requires to be worked out, as there appears to be a variable in the recommendations. Some studies suggest taking Melatonin 3 days prior to departure and others on arrival. Some studies have been done using very large doses and these have produced adverse effects. Melatonin as sold at the present time is not a pure pineal extract and is therefore regarded by some workers to be impure. One format contains Melatonin, herbs such as valerian and chamomile, together with amino acids, calcium and magnesium. There appears to be some consensus about its efficacy as an adjuvant therapy in advanced cancer, especially when used with Interleukin 2. There may therefore be some justification for taking it in these conditions under strict medical supervision. Anti aging claims will require detailed investigation and are difficult to measure given the vast differences in memory recall and physical fitness that exist between individuals. The use of Melatonin in psychiatric patients is under investigation and some guidelines may be forthcoming given that there are pineal receptors to Benzodiazepines and that there appears to be suppression of Melatonin secretion by Alprazolam (Xanax – antianxiety) a Benzodiazepine Suppression of Melatonin by exposure to bright light may alleviate symptoms in some cases and may be a helpful treatment for winter depression, but this remains unproven. It has been recommended that as Fluoxetine (Prozac - antidepressant) and Melatonin may interact (due to the effect on Serotonin secretion by Fluoxetine (Prozac – antidepressant) that they should not be taken at the same time. An alteration in Melatonin rhythm leading to altered sleep patterns requires further research and recommendations are needed as to how best to manipulate Melatonin secretion to affect these rhythms and benefit depressed patients.
Within the protect sperm from the acidic environments of testes are numerous small tubes that twist and the male urethra and the female vagina discount zebeta online american express hypertension portal. Two pea- coil to form (3) seminiferous tubules order 5 mg zebeta with mastercard blood pressure 5 year old, which shaped structures buy zebeta 5 mg with mastercard arteria appendicularis, the (9) bulbourethral (Cowper) produce sperm. The testes also secrete testos- glands, are located below the prostate and are terone, a hormone that develops and maintains connected by a small duct to the urethra. Lying over the bulbourethral glands provide the alkaline fluid superior surface of each testis is a single, tightly necessary for sperm viability. It is cylindrical stores sperm after it leaves the seminiferous and composed of erectile tissue that encloses the tubules. The urethra expels semen and urine which sperm passes after its production in the from the body. Tracing the duct upward, the epididymis at the base of the bladder closes, which not only forms the (5) vas deferens (also called the semi- stops the urine from being expelled with the nal duct or ductus deferens), a narrow tube that semen, but also prevents semen from entering passes through the inguinal canal into the the bladder. The vas deferens extends over (12) glans penis, contains the (13) urethral ori- the top and down the posterior surface of the fice (meatus). A movable hood of skin, called the bladder, where it joins the (6) seminal vesicle. Midsagittal section of male reproductive structures shown through the pelvic cavity. Connecting Body Systems–Genitourinary System The main function of the genitourinary system is to enable sexual reproduction and to regulate extracellular fluids of the body. Specific functional relationships between the genitourinary system and other body systems are summarized below. Blood, lymph, and immune Endocrine • Male reproductive system transports • Kidneys regulate sodium and water bal- testosterone throughout the body in ance, which is essential for hormone trans- blood and lymph. Cardiovascular Female reproductive • Kidneys help regulate essential electrolytes • Male organs of reproduction work in con- needed for contraction of the heart. Digestive • Kidneys aid in removing waste products • Kidneys aid in removing glucose from the produced by the fetus in the pregnant blood when excessive amounts are con- woman. Anatomy and Physiology 315 Connecting Body Systems–Genitourinary System Integumentary Nervous • Kidneys compensate for extracellular fluid • Kidneys regulate sodium, potassium, and loss due to hyperhidrosis. Respiratory Musculoskeletal • Kidneys and lungs assist in regulating acid- • Kidneys work in conjunction with bone base balance of the body. It is time to review male reproductive anatomy by completing Learning Activity 11–2. Medical Word Elements This section introduces combining forms, suffixes, and prefixes related to the genitourinary system. The onset of the disease is usually acute, with Pathology of the urinary system includes a range of symptoms including pain around the kidney, disorders from those that are asymptomatic to dysuria, fatigue, urinary urgency and frequency, those that manifest an array of signs and symp- chills, fever, nausea, and vomiting. However, in some anomalies, infectious diseases, trauma, or condi- cases, organisms may have developed a resistance tions that secondarily involve the urinary struc- and alternative antibiotics may be required. Many times, asymptomatic urinary diseases are first diagnosed when a routine urinalysis shows Glomerulonephritis abnormalities. Forms of glomerulonephritis and chronic urinary tract infection are two such dis- Any condition that causes the glomerular walls orders. Symptoms specific to urinary disorders to become inflamed is referred to as glomeru- include changes in urination pattern, output, or lonephritis. Endoscopic tests, radiological evaluations, glomerular inflammation is a reaction to the toxins and laboratory tests that evaluate renal function are given off by pathogenic bacteria, especially strepto- typically employed to diagnose disorders of the uri- cocci that have recently infected another part of nary system. Glomerulonephritis Signs and symptoms of male reproductive dis- is also associated with diabetes and autoimmune orders include pain, swelling, erectile dysfunction, diseases such as systemic lupus erythematosus, and loss of normal sexual drive (libido). Red blood cells and include pain, discharge, or lesions as well as a vague protein pass through the glomerulus and enter the feeling of fullness or discomfort in the perineal or tubule.. A complete evaluation of the genitalia, nephron tubules and forms solid masses that take reproductive history, and past and present geni- the shape of the tubules in which they develop. They commonly pass identify disorders associated with male reproduc- out of the kidney by way of the urine and may be tive structures. For diagnosis, treatment, and management of The clinical picture for glomerulonephritis genitourinary disorders, the medical services of a includes blood and protein in the urine (hema- specialist may be warranted. The physician who specializes in diagnoses and with acute glomerulonephritis associated with a treatment of genitourinary disorders is known as a streptococcal infection recover with no lasting kid- urologist. Stones (calculi) may form in any part of the uri- nary tract (urolithiasis), but most arise in the kid- Pyelonephritis ney, a condition called nephrolithiasis. These stones may is pyelonephritis, (also called kidney infection or increase in size and obstruct urinary structures. In this disor- they lodge in the ureters, they cause intense throb- der, bacteria invade the renal pelvis and kidney tis- bing pain called colic. Because urine is hindered sue, commonly as a result of a bladder infection that from passing into the bladder, it flows backward has ascended to the kidney via the ureters. When (refluxes) into the renal pelvis and the tubules, the infection is severe, lesions form in the renal causing them to dilate. If the stone is large, an ultrason- ic or electrohydraulic probe is used to break the stone into smaller fragments, which are then more easily removed. For stones that have descended into the ureters, it may be pos- Kidney stones sible to remove them using a specialized uretero- scope fitted with a small basket. The ureteroscope is passed through the urethra and bladder and into the ureter where the basket collects the stone. For larger stones, it may be necessary to break them into smaller pieces using an endoscope fitted with a laser beam before the fragments are removed. This procedure is called ureteroscopic stone removal, and no incision is required. Bladder infection (cystitis) and, ultimate- this procedure, a small incision is made in the skin, ly, kidney infection (nephritis) may result. Pathology 321 the entire prostate may be done through the per- disorder involves surgical suspension of the testes ineum (perineal prostatectomy) or an abdominal (orchiopexy) in the scrotum. This procedure is opening above the pubis and directly over the usually done before the child reaches age 2. These pro- Because an inguinal hernia commonly accompa- cedures are invasive and are performed when the nies cryptorchidism, the hernia may be sutured entire prostate must be removed, such as when (herniorrhaphy) at the same time. At the conclusion of the surgery, the urethra may occur because of circulatory collapse, severe and bladder are irrigated to remove the small hypotension, hemorrhage, dehydration, or other chips. In many mental apathy, nausea, vomiting, and increased infants born with this condition, the testes blood levels of calcium (hypercalcemia). When descend spontaneously by the end of the first tubular damage is not severe, the disorder is usually year. Urinary bladder Resectocope in urethra Testis Benign prostatic hyperplasia Rectum Figure 11-6. Two The most common form of cancer in men is carci- forms of radiation oncology include brachytherapy noma of the prostate. In brachytherapy ease is rarely found in men younger than age 50; (also called internal radiation therapy), radioactive however, the incidence dramatically increases with “seeds” are placed directly in the malignant tissue. Symptoms include difficulty starting urina- They remain in place for long or short periods of tion (hesitancy) and stopping the urinary stream, time depending on the type of malignancy, its loca- dysuria, urinary frequency, and hematuria.
The exocrine function is the production and release of the protease enzymes and bicarbonate order zebeta once a day hypertension. These are released via the pancreatic duct back into the gastrointestinal tract via the ampulla of Vater in the duodenum purchase zebeta 5mg on-line blood pressure understanding. The donor pancreas retains these two functions order 10mg zebeta with amex blood pressure medication zapril, and the surgical connections are related to these two functions. Hence, the donor portal vein is the conduit by which the insulin produced in the donor pancreas is released into the vascular system in the recipient. Likewise, the attached donor duodenum is the conduit by which the exocrine function is facilitated. Surgical Techniques The endocrine function can be drained into the iliac venous system of the recipient (systemic drainage) or into the mesenteric venous system of the recipient (portal drainage). The exocrine function can be drained either into the bladder (bladder drainage) or into the gastrointestinal tract (enteral drainage). The advantage of systemic drainage is more historical, in that most transplant surgeons were trained to use this method and therefore are more comfortable in its surgical technique and, even more importantly, in its results. The insulin production goes into the systemic system by way of the donor portal vein into the recipient iliac vein (Fig. Thus, the insulin produced does not get metabolized ﬁrst, since the ﬁrst-pass phenomenon does not come into play. These patients are, in fact, hyperinsulinemic, much like a type 2 diabetic, but they do not become hypoglycemic because there is still some degree of insulin resistance present. The insulin production drains back into the portal system by way of the donor portal vein to the recipient’s superior mesenteric vein, thereby preserving the ﬁrst-pass phenomenon (Fig. Technique for whole-organ pan- creas transplantation with portal venous and enteric exocrine drainage. Com- parison of pancreas transplantation with portal venous and enteric exocrine drainage to the stan- dard technique utilizing bladder drainage of exocrine secretions. Lim this method is the theoretical improvement of the lipid proﬁle of the recipient, since there is no longer any hyperinsulinemia. To date, graft and patient survivals based on systemic versus portal drainage are similar. When portal drainage is used, the exocrine func- tion drains back into the enteric system by way of the recipient loop of small bowel, be it a Roux-en-Y limb or adjacent recipient jejunum. Hence, this method preserves the physiologic nature of the pancreas by draining the endocrine function back into the portal system and the exocrine function back into the enteric system, hence, the terminology portal/enteral drainage. This is in distinction to systemic/bladder drainage, whereby the endocrine function drains into the iliac venous system and the exocrine functions drains via the bladder. The advantages of the enteric drainage technique over the bladder drainage technique are many. First, the classic complications associ- ated with draining active enzymes and bicarbonate with the resultant volume loss are alleviated. Approximately 12% of all patients drained via the bladder route must be corrected surgically within 2 years of the original P Tx. The main advantage for performing the bladder drainage tech- nique is to measure the urinary amylase produced by the donor pan- creas as a means to diagnose rejection. A decrease of 25% to 60% of the baseline urinary amylase is used by these centers to monitor for rejection. Although the ability to collect the urinary amylase is lost with the enteric drainage technique, direct biopsy of the donor pancreas is used to diagnose rejection deﬁnitively. Monitoring of the donor pan- creas is performed by checking serum amylase and lipase. Any persis- tent increase from the baseline serum amylase and lipase is taken as being abnormal, and, if appropriate measures do not indicate infection or technical problems, then a percutaneous U. The other main advantage of bladder drainage over enteric drainage is that leaks at the donor duodenal anastomosis are tolerated better if urine is leaking rather than enteric contents. Most often, a placement of a Foley catheter to decompress the bladder is enough to control the urinary leak. The main advantage of performing a Roux-en-Y limb anastomosis to the donor duodenum is that, should a leak occur, the enteric contents from a defunctionalized loop of bowel usually can be better controlled than if an adjacent loop of recipient jejunum is used. Transplantation of the Pancreas 729 Side-to-side Small bowel Duodenoenterostomy Figure 41. Procedure of enteric conversion after pancreas transplantation with bladder drainage. Indications for enteric conversion after pancreas transplantation with bladder drainage. Bleeding enough to warrant going back to the operating room is uncommon; however, the incidence of blood transfusions either in the original operation or after the procedure approximates 5%. If thromboses are seen after 1 month, they usually are secondary to an immunologic issue rather than a technical one. Unfortunately, by the time this occurs, the graft already is thrombosed, with very little or no chance for salvage. The patient is taken back to the operating room, and, most often, the thrombosed graft is removed, since the incidence of graft thrombectomy to viability is exceedingly rare. Vascular graft thrombosis after pan- creatic transplantation: univariate and multivariate operative and nonoperative risk factor analysis. If undetected, the leaks may lead to deep wound infections that may cause worsening renal or pancreatic function and potential multiorgan dysfunction. Much of the cause of the leak is secondary to the attenuated donor bowel wall, which may facilitate pulling through of sutures and resul- tant leak. The immunocompromised state does not lend itself to faster or better healing of the duodenal anastomosis. The patient usually has a nasogastric tube to help with the perioperative ileus associated with any intraabdominal procedure. The usual postoperative course consists of 7 to 10 days of hospitalization, with frequent glucose monitoring in the ﬁrst 48 hours postoperation. Thereafter, the patient recovers as with any other intraabdominal procedure and proceeds to ambulate as quickly as pos- sible. Some centers keep their patients at bed rest for at least 48 to 72 hours postoperatively so as to minimize any chance of the donor pan- creas moving and potentially kinking at the vascular anastomoses. Knowledge about immunosuppression medications is imperative, and patients are not discharged until they have proven that they know their medications. Immunosuppression Medications Recent immunosuppressive regimens have stressed corticosteroid sparing or elimination, with rejection-free survival rates approach- ing 90% at some centers. One year outcomes in simul- taneous kidney-pancreas transplant recipients receiving an alternative regimen of daclizumab. The higher incidence of potential diabetogenicity seen with Prograf does not offset its use for this subset of P Tx patients. Islet Cell Transplant Most recently, a major breakthrough in pancreas islet cell transplant was reported in the New England Journal of Medicine. In this landmark report, seven of seven patients had 100% success, had no rejection, and were insulin free. Islet transplantation in seven patients with type I diabetes mellitus using a glucocorticoid-free immunosuppressive regimen.