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The patient is asked to contact a pharma- cist order uroxatral now prostate cancer 97, should the situation get worse or if it is not managed within a few days quality 10mg uroxatral prostate 02. A24 B Helicobacter pylori cheap uroxatral 10 mg without prescription prostate health vitamins, a Gram-negative bacterium, is implicated as a cause of chronic gastritis and peptic ulceration. Its eradication in the stomach entails a triple-therapy regimen that is based on a proton pump inhibitor such as omeprazole, and two anti-infective agents, namely amoxicillin and either clari- thromycin or metronidazole. In patients who are penicillin sensitive, the triple therapy regimen considered consists of a proton pump inhibitor, clarithromycin and metronidazole. Telithromycin is a derivative of erythromycin that is not used in Helicobacter pylori eradication therapy. Before starting treatment or when changing drug therapy, viral sensitivity to antiretroviral agents should be established. The onset of drug resistance is reduced by using combination of drugs so as to have a synergistic or additive effect. Care should be taken to ensure that the combination used does not have an additive toxicity as antiretrovirals are toxic. Factors that could precipitate the condition include infection, dehydration, surgery, sustained strenuous exercise, trauma. Patients with diabetic ketoacidosis present with a fruity odour of acetone on the breath, mental confusion, dyspnoea, nausea, vomiting, and dehydration. Questions 27–31 Pulmonary oedema may result from the failure of a number of homeostatic mechanisms and it is a condition that can develop acutely and can be fatal. Owing to the accumulation of extravascular ﬂuid in lung tissues, alveoli and in the extremities, the patient may present with an increase in weight. A28 C An acute attack of pulmonary oedema may develop due to progressive heart failure or when the patient is not compliant with medication, particularly the diuretic therapy. It may also occur due to hypervolaemia, such as when compromised and non-compromised patients are exposed to an excessive ﬂuid Test 1 Answers 39 infusion rate or to a high sodium intake. Conditions that lead to an increased metabolic demand, such as high fever and hyperthyroidism, may also precipi- tate acute pulmonary oedema. A29 B Metolazone is a diuretic that is associated with profound diuresis, especially when it is combined with a loop diuretic. Patients receiving metolazone should be monitored for electrolyte imbalance and outcome of therapy may be assessed by measuring change in body weight and urine production. A30 A Metolazone is a diuretic with actions similar to a thiazide diuretic, and bumetanide is a loop diuretic. Metolazone has a long duration of action of about 12–24 h compared with intravenous bumetanide, which has a duration of action of 0. Metolazone treatment should be withdrawn, after which a change from bumetanide to oral therapy should be attempted. The patient should be advised about the importance of compliance with bumetanide, and that the unwanted effect of increased diuresis with oral treatment usually decreases with time. Potassium levels should be monitored and, if the patient is not taking any drugs with a potassium-sparing effect, then potassium supplements should be considered when bumetanide therapy is given long-term. Upon discharge the pharmacist needs to advise the patient on her condition and on her medication so as to avoid future deterioration. The anti- bacterial agent is continued and patient is started on an antidiabetic drug (glibenclamide) to control blood glucose levels. The extent of rehydration, which is being undertaken using intravenous infusion of sodium chloride, should be assessed by monitoring urine output. Regular blood glucose monitoring is required and, if necessary, antidiabetic therapy should be reviewed. A34 B Clinical features of hyperglycaemia include thirst, dry mouth, reduced skin turgor, polyuria, nocturia. A diabetic complication is an increased suscepti- bility to infection especially in the skin, vaginal area and peripheries. The sodium chloride infusion is required to rehydrate the patient, and should be continued until normal urine ﬂow is achieved. The pharmacist could monitor the patient’s progress and advise the prescribing team when to withdraw the infusion. Haloperidol has a rapid effect on hyperactive states and initial doses may help to calm down the patient. A36 A Glibenclamide and gliclazide are oral sulphonylureas that are used in diabetes to augment secretion of insulin. It has a duration of action of about 12 h whereas glibenclamide has a duration of action of up to 24 h. She should be educated on the foods to include in her diet and about the importance of having a regular schedule of food intake to avoid hypoglycaemic attacks. She should be reminded that she has to continue taking the glibenclamide tablet daily at breakfast to avoid recurrence of hyperglycaemia. Conditions that are associated with alcoholism include liver disease, cardiomyopathy, pancreatitis and gastro- intestinal disease. Signs and symptoms of alcohol withdrawal include tremor, tachycardia, diaphoresis, labile blood pressure, anxiety, nausea and vomiting, hallucinations and seizures. Side-effects that could occur with the use of pro- methazine, especially in overdosage include drowsiness, headache, and antimuscarinic effects such as blurred vision and urinary retention. A40 C Promethazine is a sedating antihistamine that could be used in the symptom- atic relief of allergy of nasal or dermatological origin, as a hypnotic and in motion sickness. A41 D Long-acting benzodiazepines such as diazepam could be used in alcohol withdrawal to counteract the withdrawal symptoms. In alcohol withdrawal, Test 1 Answers 43 symptoms of the initial phases do not necessarily diminish as withdrawal advances. This depends on the amount of alcohol consumed, on the abrupt- ness of discontinuation and on the patient’s general well-being. Also the patient should be referred to patient-support groups, to provide the necessary psychosocial support for the management of alcohol abuse. Questions 42–44 A myocardial infarction, also referred to as a heart attack, is the necrosis of a portion of the cardiac muscle and occurs due to occlusion of the coronary artery, either because of atherosclerosis or thrombus or a spasm. The patient presents with a crushing chest pain that may radiate to the left arm, neck and epigastrium. Statins are used as lipid-lowering agents in conjunction with diet to reduce total cholesterol and low-density-lipoprotein cholesterol as a secondary prevention of the recurrence of cardiovascular disease. A42 B Simvastatin is a statin and it may cause rare but signiﬁcant side-effects of myalgia, myositis and myopathy. Patient should be advised to report any muscle pain, tenderness and weakness as they could be signs of these side- effects.
The primary neural control of total peripheral re- Any sudden alteration in the mean arterial blood pres- sistance is through sympathetic nerves buy uroxatral discount prostate oncology associates. The diameter of sure tends to produce compensatory reﬂex changes in blood vessels is controlled by the tonic activity of nor- heart rate uroxatral 10mg mastercard man health in pakistan, contractility cheap uroxatral 10 mg mastercard prostate cancer percentage, and vascular tone, which will adrenergic neurons. There is a continuous outﬂow of oppose the initial pressure change and restore the noradrenergic impulses to the vascular smooth muscle, homeostatic balance. The primary sensory mechanisms and therefore some degree of constant vascular con- that detect changes in the mean arterial blood pressure striction is maintained. An increase in impulse outﬂow are stretch receptors (baroreceptors) in the carotid sinus causes further contraction of the smooth muscle, result- and aortic arch. A decrease in impulse The injection of a vasoconstrictor, which causes an outﬂow permits the smooth muscle to relax, leading to increase in mean arterial blood pressure, results in acti- vasodilation. The reﬂex compensation for the drug-induced hyper- The Heart tension includes an increase in parasympathetic nerve The heart is innervated by both sympathetic and activity and a decrease in sympathetic nerve activity. Postganglionic noradrener- diac rate and force and the tone of vascular smooth gic ﬁbers from the stellate and inferior cervical ganglia muscle. As a consequence of the altered neural control innervate the sinoatrial (S-A) node and myocardial tis- of both the heart and the blood vessels, the rise in blood sues of the atria and ventricles. There is decreased impulse trafﬁc from the atrioventricular (A-V) conduction tissue (positive dro- cardiac inhibitory center, stimulation of the cardiac ac- motropic effect). These changes in cardiac and vasomotor center sympathetic nervous system terminate in the S-A node, activity accelerate the heart and increase sympathetic atria, and A-V conduction tissue. Cholinergic ﬁbers do transmission to the vasculature; thus, the drug-induced not innervate the ventricular muscle to any signiﬁcant fall in blood pressure is opposed and blunted. Activation of the parasympathetic outﬂow to the heart results in a decrease in rate (negative The Eye chronotropic effect) and prolongation of A-V conduc- tion time (negative dromotropic effect). There is a de- Two sets of smooth muscle in the iris control the diameter crease in the contractile force of the atria but little ef- of the pupil. Stimulation of them causes contraction of gastrointestinal tract are postganglionic noradrenergic the radial smooth muscle cells, leading to dilation of the ﬁbers, stimulation of which inhibits gut motility and pupil (mydriasis). Most of the the iris (constrictor pupillae) is circular and is innervated noradrenergic ﬁbers terminate either in blood vessels or by parasympathetic neurons arising from cells in the cil- on the cholinergic ganglionic cells of the intramural iary ganglion. These ﬁbers alter gut motility by inhibiting causes contraction of the circular smooth muscle of the acetylcholine release from the intramural nerves. When the smooth muscles of the ciliary body Salivary Glands are relaxed, the ciliary body exerts tension on the lens, causing it to ﬂatten. Stimulation of parasympathetic cholinergic neu- tems work in opposition to each other is secretion by the rons, which arise in the ciliary ganglion, causes contraction salivary glands; both sympathetic (noradrenergic) and of the smooth muscle of the ciliary body; this decreases parasympathetic (cholinergic) activation of these glands the lateral tension on the lens. The saliva produced by activation of Since the parasympathetic system is dominant in the eye, the sympathetic system is a sparse, thick, mucinous se- blockade of this system by atropine or of both autonomic cretion, whereas that produced by parasympathetic acti- systems by a ganglionic blocking agent will result in pupil- vation is a profuse, watery secretion. The adrenal medulla may in fact be considered a thetic neurons innervate bronchial smooth muscle di- modiﬁed sympathetic ganglion. Sympathetic noradrenergic neurons appear to also the primary neurotransmitter of sympathetic post- innervate vascular smooth muscle and parasympathetic ganglionic neurons. There is some con- General activation of the sympathetic system during troversy concerning the role of noradrenergic ﬁbers in stress, fear, or anxiety is accompanied by increased se- the regulation of airway smooth muscle tone. There is cretion of adrenal medullary hormones, which consist no doubt, however, that adrenoceptors are present on primarily of epinephrine in the human. A variety of exogenously ad- ministered drugs, such as cholinomimetic agents and The innervation of the gastrointestinal tract is complex. These possess a number of neurotransmit- of medullary hormones is antagonized by ganglionic ters and neuromodulators, including several peptides, blocking agents. Within each Regardless of the type of neuron under consideration, varicosity are mitochondria and numerous vesicles con- the fundamental steps in chemical transmission are taining neurotransmitters. Each of these steps is a potential site for phar- The vesicles are intimately involved in the release of macological intervention in the normal transmission the transmitter into the synaptic or neuroeffector cleft in process: response to an action potential. Following release, the transmitter must diffuse to the effector cells, where it in- teracts with receptors on these cells to produce a re- 1. Release of the transmitter by a nerve action poten- Smooth muscle, cardiac muscle, and exocrine gland cells tial do not contain morphologically specialized regions 4. Rapid removal of the transmitter from the vicinity of into close contact primarily with the dendrites of the the receptors ganglionic cells and make synaptic connection with 6. Also shown are the release of acetylcholine (exocytosis) and the location of acetylcholinesterase, which inactivates acetylcholine. Synthesis, Storage, Release, and Modiﬁcation of extracellular calcium concentration or Removal of Acetylcholine of calcium entry therefore can markedly affect neuro- The processes involved in neurochemical transmission transmission. The ini- The interactions between transmitters and their tial substrates for the synthesis of acetylcholine are glu- receptors are readily reversible, and the number of cose and choline. Glucose enters the neuron by means transmitter–receptor complexes formed is a direct func- of facilitated transport. The to whether choline enters cells by active or facilitated length of time that intact molecules of acetylcholine re- transport. Pyruvate derived from glucose is transported main in the biophase is short because acetylcholinesterase, into mitochondria and converted to acetylcoenzyme A an enzyme that rapidly hydrolyzes acetylcholine, is highly (acetyl-CoA). The acetyl-CoA is transported back into concentrated on the outer surfaces of both the prejunc- the cytosol. With the aid of the enzyme choline acetyl- tional (neuronal) and postjunctional (effector cell) mem- transferase, acetylcholine is synthesized from acetyl- branes. The acetylcholine is then transported results in a lowering of the concentration of free trans- into and stored within the storage vesicles by as yet un- mitter and a rapid dissociation of the transmitter from its known mechanisms. Any acetylcholine that does reach the circulation is minal branches of an axon causes depolarization of the immediately inactivated by plasma esterases. As a conse- extracellular space (biophase), acetylcholine interacts quence of rapid removal, the magnitude and duration of with cholinoreceptors. This same transport system is essential for the by which the transmitter is removed from the biophase storage of norepinephrine. In the neuronal that leaks out of the vesicle is rapidly returned to the cytosol, tyrosine is converted by the enzyme tyrosine hy- storage vesicles by the same transport system that car- droxylase to dihydroxyphenylalanine (dopa), which is ries dopamine into the storage vesicles. It is important converted to dopamine by the enzyme aromatic for a proper understanding of drug action to remember L–amino acid decarboxylase, sometimes termed dopa- that this single transport system, called vesicular trans- decarboxylase. The dopamine is actively transported port, is an essential element of both synthesis and storage into storage vesicles, where it is converted to norepi- of norepinephrine. In this proximately four times as much epinephrine as norepi- instance, the receptors are adrenoceptors. The absence of this enzyme in noradrenergic Three processes contribute to the removal of nor- neurons accounts for the absence of signiﬁcant amounts epinephrine from the biophase: of epinephrine in noradrenergic neurons. Diffusion from the synapse into the circulation and Tyrosine hydroxylase ultimate enzymatic destruction in the liver and renal H H excretion. This reaction reduces ronal cytosol across the membrane of the vesicle and the biological activity of norepinephrine or epinephrine into the vesicle.
For all these arousal neurotransmitters order uroxatral with paypal prostate define, sleep arousal and produces sleep purchase uroxatral androgen hormone blood test, and eventually anaesthesia buy uroxatral 10 mg online prostate foods to avoid. For example many over-the- throughout the brain but a particular cluster in the hypo- counter sleep-promoting agents contain antihistamines, thalamus (ventrolateral preoptic nucleus) can be consid- which block the histamine H -receptor and so decrease ered to be the sleep ‘switch’. The relatively low efficacy of these compounds brain arousal systems at the level of the cell bodies and may be explained by the fact that they target only one therefore promote sleep. The same is true for any can also promote sedation and sleep by inhibiting the drug which blocks one of the other arousal systems; they target neurones of the arousal system. Higher doses activity (or increase in glutamate) elicits arousal, anxiety, of longer-acting benzodiazepines partially suppress slow restlessness, insomnia and exaggerated reactivity. Benzodiazepines are effective after allowing more chloride ions into the neurone and decreas- administration by mouth but enter the circulation at very ing excitability. Injectable preparations are used for rapid tranquillisation Benzodiazepines in psychosis (see previous section), anaesthesia and seda- A general account of the benzodiazepines is appropriate tion for minor surgery and invasive investigations (see In- here, although their indications extend beyond use as hyp- dex). All benzodiazepines, and newer benzodiazepine-like determined by pharmacokinetic properties (see before, and Table 20. Commonly there is a kind of psychological dependence based on the fact that the treatment works to reduce pa- Fig. This explains why barbiturates longer sleep onset latency and increased waking during and alcohols are more toxic in overdose than the sleep – this is common. Yes ✓ Prolonged release X 3–4 2 mg No ✓ melatonin (patients over 55) Nitrazepam ✓ þ 20–48 5–10 mg Yes ✓ Lorazepam ✓ þ 10–20 0. More rarely, Withdrawal of benzodiazepines should be gradual after there is a longer withdrawal syndrome that is characterised as little as 3 weeks’ use, but for long-term users it should by the emergence of symptoms not previously experienced, be very slow, e. Withdrawal should be slo- fatigue, depersonalisation, hypersensitivity to noise and wed if marked symptoms occur and it may be useful to sub- visual stimuli. Physical symptoms include nausea, vomit- stitute a long t½ drug (diazepam) to minimise rapid ing, muscle cramps, sweating, weakness, muscle pain or fluctuations in plasma concentrations. In difficult withdrawal may cause confusion, delirium, psychosis cases withdrawal may be assisted by concomitant use of and convulsions. In addition to the above, benzodiaze- research, mainly focusing on their personality and cogni- pines affect memory and balance. The t½ subsequent to administration occurs with high doses given of 1 h is much shorter than that of most benzodiazepines i. Paradoxical behaviour effects and needs supervision lest sedation recurs; if used in day surgery perceptual disorders, e. Benzodiazepines is useful for diagnosis of self-poisoning, and also for treat- should be avoided in early pregnancy as far as possible ment, when 100–400 micrograms are given by continuous as their safety is not established with certainty. The principal pharmaco- these drugs act on the same receptor, so their effects can dynamic interaction of concern is exacerbation of sedation be blocked by flumazenil, the receptor antagonist. Those with other centrally depressant drugs including, antide- described below are all effective in insomnia, have low pressants, H1-receptor antihistamines, antipsychotics, propensity for tolerance, rebound insomnia, withdrawal opioids, alcohol and general anaesthetics. Data from long-term stud- exacerbate breathing difficulties where this is already com- ies suggests these agents are safe and effective over at least promised, e. Withdrawal effects similar to the benzodiaze- hypotension may occur with any co-prescribed antihyperten- pines hypnotics occur but to a lesser extent. Zopiclone, a cyclopyrrolone, has an onset of action that is Pharmacokinetic interactions occur with drugs that slow relatively rapid (about 1 h) and that lasts for 6–8 h, making metabolism by enzyme inhibition, e. The duration of action is prolonged in acceleration of metabolism, lowering of plasma concentra- the elderly, and in hepatic insufficiency. Care should overdose and even 10 times the therapeutic dose only pro- be taken with concomitant medication that affects its met- duces deep sleep from which the subject is easily aroused. It is said that there is no reliably recorded case of death from Zolpidem is an imidazopyridine, and has a faster onset a benzodiazepine taken alone by a person in good physical (30–60 min) and shorter duration of action. In patients (particularly respiratory) health, which is a remarkable trib- over 80 years clearance is slower and action longer lasting. In volunteers, it appeared to have But deaths have occurred in combination with alcohol no effect on psychomotor (including driving) skills when (which combination is quite usual in those seeking to end taken at least 5 h before testing. Flumazenil selectively reverses benzodiazepine effects to sleep, as long as this is at least 5 h before having to drive. Heavily tional capacity directly to open the membrane chloride 341 Section | 4 | Nervous system channel; this may lead to potentially lethal respiratory de- disorder, probably because of the combination of pression and explains their low therapeutic ratio. Their long ac- Chloral hydrate has a fast (30–60 min) onset of action tion leads to daytime sedation, and extrapyramidal and 6–8 h duration of action. Chloral hydrate, a prodrug, movement disorders may result from their blockade of is rapidly metabolised by alcohol dehydrogenase into the dopamine receptors (see above, Antipsychotics). Chloral hydrate therefore should be used with great care in the context is dangerous in serious hepatic or renal impairment, and of insomnia. Interaction with ethanol is to be quetiapine, are being used for intractable insomnia, expected since both are metabolised by alcohol dehydro- usually at a dose well below the one required to treat genase. When taken orally, it is subject to extensive hepatic first- Melatonin may also be used therapeutically to reset circa- pass metabolism (which is defective in the old and in dian rhythm to prevent jet-lag on long-haul flights, and liver-damaged alcoholics who exhibit higher peak plasma for blind or partially sighted people who cannot use day- concentrations); the t½ is 4 h. Dependence occurs and use should and may interact with other active substances that affect always be brief. For this reason it should not be taken with Barbiturates are hardly ever used as they have a low ther- fluvoxamine, 5- or 8-methoxypsoralen, or cimetidine, and apeutic index, i. Most proprietary (over-the-counter) sleep Summary of pharmacotherapy for insomnia remedies contain H1-receptor antihistamines with sedative • Drug treatment is usually effective for a short period action (see Ch. Alimemazine • Discontinuing hypnotic drugs is usually not a (trimeprazine) is used for short-term sedation in children. There Most antihistamine sedatives have a relatively long action will be a short period (usually 1–2 nights) of and may cause daytime sedation. Nevertheless, some patients are more Hypersomnia likely to continue with medication if there is a short-term improvement, in which case mirtazapine or trazodone may Sleep-related breathing disorders causing excessive provide effective antidepressant together with sleep- daytime sleepiness are rarely treated with drugs. Anti- dard treatment of continuous positive airway pressure psychotics have been used to promote sleep in resistant overnight, and wake-promoting drugs, e. Methylphenidate has a low sys- tacks, usually accompanied by cataplexy (attacks of muscle temic availability and slow onset of action, making it less weakness on emotional arousal). Modafinil is usually preferred as it is not a con- expected weight gain and has been associated with slight trolled drug, failing which methylphenidate or dexamfeta- growth retardation. In narcolepsy, patients height and weight, also blood pressure and blood counts usually need a stimulant for their hypersomnia and an an- (thrombocytopenia and leucopenia occur). Modafinil is used in narcolepsy and other hypersom- the dream and inventing a different pleasant ending. Exacerbations commonly coincide with periods of stress, Amfetamines releasedopamineandnoradrenaline/ and alcohol increases their likelihood. Thiscausesabehavioural patients usually sit or jump up from deep sleep (mostly excitation, with increased alertness, elevation of mood, in the first few hours of sleep ) with a loud cry, look ter- increase in physical activity and suppression of appetite. They appear asleep and uncommunicative, is about twice as active in humans as the laevo- isomer and often returning to sleep without being aware of the event.
All sympathetics passing into the head have gray rami communicantes and are distributed along the preganglionic fbers that emerge from spinal cord level posterior and anterior rami of the spinal nerves order genuine uroxatral online androgen hormone. Tl and ascend in the sympathetic trunks to the highest The ascending and descending fbers purchase uroxatral without prescription androgen hormone ovulation, together with all ganglion in the neck (the superior cervical ganglion) cheap 10 mg uroxatral amex prostate cancer home remedies, the ganglia, form theparavertebral sympathetic trunk, where they synapse. Often, these nerves and cervical viscera join branches from the parasympathetic system to form Preganglionic sympathetic fbers may synapse with post plexuses on or near the surface of the target organ, for ganglionic motor neurons in ganglia and then leave the example, the cardiac and pulmonary plexuses. Branches ganglia medially to innervate thoracic or cervical viscera of the plexus innervate the organ. The preganglionic fbers in these regions and the adrenals nerves are derived from spinal cord levels T 5 to 12. Preganglionic sympathetic fbers may pass through the The splanchnic nerves generally connect with sympa sympathetic trunk and paravertebral ganglia without syn thetic ganglia around the roots of major arteries that apsing and, together with similar fbers from other levels, branch from the abdominal aorta. These ganglia are part form splanchnic nerves (greater, lesser, least, lumbar, of a large prevertebral plexus that also has input from the Greater splanchnic nerves Lesser splanchnic nerves Least splanchnic nerves Lumbar splanchnic nerves White ramus communicans Prevertebral plexus and ganglia Gray ramus communicans Paravertebral - sympathetic trunk Abdominal and pelvicviscera Sacral splanchnic nerves Fig. Postganglionic sympathetic fbers are distributed in ganglionic neurons and secrete adrenaline and noradrena extensions of this plexus, predominantly along arteries, to line into the vascular system. These branches contribute to plexuses associ the head and neck only, whereas X (the vagus ated with thoracic viscera or to the large prevertebral nerve) also innervates thoracic and most abdominal plexus in the abdomen and pelvis. Visceral sensory fbers generally accompany visceral Like the visceral motor nerves of the sympathetic part, motor fbers. Visceral sensory fbers follow the course of sympathetic fbers entering the spinal cord at similar spinal cord levels. Sacral preganglionic parasympathetic fbers However, visceral sensory fbers may also enter the spinal In the sacral region, the preganglionic parasympathetic cord at levels other than those associated with motor fbers form special visceral nerves (the pelvic splanchnic output. For example, visceral sensory fbers from the heart nerves), which originate from the anterior rami of S2 to may enter at levels higher than spinal cord level Tl. Vis S4 and enter pelvic extensions of the large prevertebral ceral sensory fbers that accompany sympathetic fbers are plexus formed around the abdominal aorta. The postganglionic motor neurons are Visceral sensory fbers accompany parasympathetic fbers in the walls of the viscera. The enteric system • bundles of nerve fbers, which pass between ganglia and The enteric nervous system consists of motor and sensory from the ganglia into surrounding tissues. Interestingly, more neurons are reported to be in the enteric system than in the spinal cord itself • ganglia, which house the nerve cell bodies and associ Sensory and motor neurons within the enteric system ated cells, and control reflex activity within and between parts of the 47 http://medical. These activities can occur independently of the brain and spinal cord, but Referred pain can also be modifed by input frompreganglionic parasym Referred pain occurs when sensory information comes pathetic and postganglionic sympathetic fbers. Usually, this happens when the pain information comes from a region, such Nerve plexuses as the gut, which has a low amount of sensory output. These aferents converge on neurons at the same spinal Nerve plexuses are either somatic or visceral and combine cord level that receive information from the skin, which fbers from different sources or levels to form new nerves is an area with a high amount of sensory output. Pain is most ofen referred from a region innervated Somatic plexuses by the visceral part of the nervous system to a region Major somatic plexuses formed from the anterior rami of innervated, at the same spinal cord level, by the somatic spinal nerves are the cervical (Cl to C4), brachial (C5 to side of the nervous system. Tl),lumbar (11 to 14), sacral (14 to S4), and coccygeal (S5 Pain can also be referred from one somatic region to another. Except for spinal nerve Tl, the anterior on the inferior surface ofthe diaphragm, which is rami of thoracic spinal nerves remain independent and do innervated by the phrenic nerve, can be referred to not participate in plexuses. Visceral nerve plexuses are formed in association with viscera and generally contain efferent (sympathetic and parasympathetic) and afferent components (Fig. The massive prevertebral plexus nents of the respiratory, gastrointestinal, and urogenital supplies input to and receives output from all abdominal systems will be discussed in each of the succeeding chap and pelvic viscera. Pain interpreted as When the appendix becomes infamed, the visceral originating in distribution sensory fbers are stimulated. These fbers enter the of somatic sensory nerves spinal cord with the sympathetic fbers at spinal cord level Tl 0. The pain is difuse, not focal; every time a peristaltic wave passes through the ileocecal region, the pain recurs. In the later stages of the disease, the appendix contacts and irritates the parietal peritoneum in the right iliac fossa, which is innervated by somatic sensory nerves. This produces a constant focal pain,which predominates over the colicky pain that the patient felt some hours previously. The appendix is situated in a retrocecal position in approximately 70% of patients; therefore it may never contact the parietal peritoneum nerve anteriorly in the right iliac fossa. The back Bony elements consist mainly of the vertebrae, although contains the spinal cord and proximal parts of the spinal proximal elements of the ribs, superior aspects of the pelvic nerves, which send and receive information to and from bones, and posterior basal regions of the skull contribute most of the body. Cervical curvature (secondary curvature) As stresses on the back increase from the cervical to lumbar regions, lower back problems are common. Thoracic curvature Movement (primary curvature) Muscles of the back consist of extrinsic and intrinsic groups: • The extrinsic muscles of the back move the upper limbs Lumbar curvature and the ribs. Although the amount of movement between any two vertebrae is limited, the effects between vertebrae are addi tive along the length of the vertebral column. Also,freedom of movement and extension are limited in the thoracic region relative to the lumbar part of the vertebral column. In the cervical region, the frst two vertebrae and associ ated muscles are specifcally modifed to support and posi tion the head. Protection ofthe nervous system The vertebral column and associated soft tissues of the back contain the spinal cord and proximal parts of the spinal nerves (Fig. The more distal parts of the spinal nerves pass into all other regions of the body, including certain regions of the head. There are seven cervical, twelve thoracic, fve lumbar, fve sacral, and three to four coccygeal verte Bones brae. The sacral vertebrae fuse into a single bony element, The major bones of the back are the 33 vertebrae (Fig. The number and specifc characteristics of the verte structure, vary in number from three to four, and often fuse brae vary depending on the body region with which they into a single coccyx. In all other regions, these rib elements are small and are The vertebral arch is frmly anchored to the posterior incorporated into the transverse processes. Occasionally, surface of the vertebral body by two pedicles, which form they develop into ribs in regions other than the thorax, the lateral pillars of the vertebral arch. The superf The vertebral arch of a typical vertebra has a number cial group of these muscles is related to the upper limbs, of characteristic projections, which serve as: while the intermediate layer of muscles is associated with the thoracic wall. One group A spinous process projects posteriorly and generally of intrinsic muscles also moves the ribs relative to the ver inferiorly from the roof of the vertebral arch. Anterior Superior aricular process Superior Transverse process Vertebral body Anterior Posterior Fused costal (rib) element Vertebral Lamina Inferior arch Verebral body Inferior articular process Inferior vertebral notch A Posterior B Fig. In the vertebral canal, the dura mater is separated Within the vertebral canal, the spinal cord issurrounded from surrounding bone by an extradural (epidural) space by a series of three connective tissue membranes (the containing loose connective tissue, fat, and a venous meninges): plexus. Spinal cord Anterior internal vertebral venous plexus Arachnoid mater Posterior longitudinal ligament Position of spinal ganglion Posterior ramus Extradural space Extradural fat Vertebral body Transverse Intervertebral disc process Spinous process Fig. Theanterior rami form themajor somatic plexuses (cer Each nerve is attached to the spinal cord by a posterior root vical, brachial, lumbar, and sacral) of the body. Prevertebral ganglion (sympathetic) Vertebral body Anterior root Sympathetic ganglion Visceral components Anterior ramus Arachnoid mater Spinal cord Spinous Fig. The paired vertebral arteries ascend, one on each Head side, through foramina in the transverse processes of cervi Cervical regions of the back constitute the skeletal and cal vertebrae and pass through the foramen magnum to much of the muscular framework of the neck, which in participate, with the internal carotid arteries, in supplying turn supports and moves the head (Fig.
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