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Label the tissue types illustrated here and on the next page erectile dysfunction at age 31 buy sildalis 120 mg on-line, and identify all structures provided with leaders erectile dysfunction treatments diabetes purchase sildalis 120 mg amex. Set out models of the skin impotence journal discount sildalis 120mg line, prepared slides of human scalp with hair follicles and skin of palm or sole erectile dysfunction diagnosis generic sildalis 120 mg with mastercard, lens paper, and lens cleaning solution. Decide on the terminology to be used, and inform the students at the onset of the laboratory session if there is a discrepancy between the laboratory manual and the text. Some students will confuse the fibers of the dermis (dense fibrous irregular connective tissue) with smooth muscle. Apocrine Answers to Activity Questions Activity 3: Comparison of Hairy and Relatively Hair-Free Skin Microscopically (p. The stratified squamous epithelium of the skin is comprised of several recognizable layers, the outermost of which are keratinized or dead. The thickness of the skin can be attributed to the presence of a fifth epithelial layer, the stratum lucidum, and a thicker stratum corneum and dermis. Thick skin lacks hair follicles, arrector pili muscles, and sebaceous glands that are present on thin skin of the scalp. In most students, the palm has a greater density of sweat glands when compared to the forearm. However, some students show a greater sweat gland density in the forearm when compared to their palm. This has to do with the clarity of the prints taken and the fact that more information on fingerprints is necessary to make accurate identifications. The same individual would probably affect the fingerprinting process in the same way each time. Complete the following statements by writing the appropriate word or phrase on the correspondingly numbered blank: the two basic tissues of which the skin is composed are dense irregular connective tissue, which makes up the dermis, and 1, which forms the epidermis. Using the key choices, choose all responses that apply to the following descriptions. Label the skin structures and areas indicated in the accompanying diagram of thin skin. Hair shaft Stratum corneum Stratum granulosum Epidermis Stratum spinosum Stratum basale Dermal papillae Hair root (layers) Papillary layer Dermis Sebaceous gland Hair follice Arrector pili muscle Reticular layer Sweat gland Blood vessel Subcutaneous tissue or Hair bulb Nerve fiber Adipose cells hypodermis Pacinian corpuscle (deep pressure receptor) a. Laminated (or lamellated) granules extruded from the keratinocytes prevent water loss by diffusion through the epidermis. Glands that respond to rising androgen levels are the sebaceous (and apocrine sweat) Phagocytic cells that occupy the epidermis are called epidermal dendritic or Langerhans cells A unique touch receptor formed from a stratum basale cell and a nerve fiber is a tactile or Merkel disc What layer is present in thick skin but not in thin skin? Stratum lucidum What cell-to-cell structures hold the cells of the stratum spinosum tightly together? What substance is manufactured in the skin that plays a role in calcium absorption elsewhere in the body? Pressure areas (points of increased pressure over bony areas) restrict the blood supply to the area. Describe two integumentary system mechanisms that help in regulating body temperature. Based on class data, which skin area-the forearm or palm of hand-has more sweat glands? Which other body areas would, if tested, prove to have a high density of sweat glands? E X E R C I S E 8 Classification of Covering and Lining Membranes Time Allotment: 1/2 hour. If a slide of a mesentery artery is unavailable, use the visceral serosa on a slide of a cross section of the ileum, or substitute a slide of an artery (cross section) and study the endothelium.

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In the inactive parietal cell erectile dysfunction mental discount 120 mg sildalis with amex, the proton pumps are sequestered in tubulovesicles in the cytosol erectile dysfunction treatment electrical order 120mg sildalis with amex. The small intestine is an absorptive organ with folds at several levels (plicae male erectile dysfunction statistics cheap 120 mg sildalis otc, villi drugs for erectile dysfunction list generic 120mg sildalis otc, and microvilli) that increase surface area for more efficient absorption. The microvilli also contain specific enzymes for the breakdown of sugars (disaccharidases), lipids (lipases), and peptides (peptidases). The major digestive processes in the small intestine occur through the action of the pancreatic juice, which contains trypsinogen, chymotrypsinogen, procarboxypeptidases, amylase, lipase, and other enzymes. Lipids are broken down to triglycerides in the small intestinal lumen which are subsequently degraded to glycerol, fatty acids, and monoglycerides that are transported into the enterocyte. The chylomicra are exocytosed into the lacteals and travel to the cisterna chyli and through the thoracic duct to the venous system. Other digested materials travel through the hepatic portal vein to the liver where hepatocytes process the digested nutrients. Cell types in the small intestine include enterocytes (absorption), Paneth cells (production of lysozyme, defensins, and cryptidins), goblet cells (mucus), and enteroendocrine cells (secretion of peptide hormones). New cells are born in the crypt, move up the villus, die by apoptosis, and are sloughed off at the tip. The primary function of the colon, which appears histologically as crypts with prominent goblet cells and no villi, is water resorption. The major salivary glands (parotid, submandibular, and sublingual) are exocrine glands that secrete amylase and mucus, primarily regulated by the autonomic nervous system. The liver is also a dual-function gland whose exocrine product is bile, synthesized by hepatocytes, and transported by a duct system to the gallbladder for storage and concentration. The endocrine products include glucose and major blood proteins (albumin, fibrinogen, coagulation proteins). Alcohol detoxification is one of the major processes carried out in the hepatocyte. The bile canaliculus is defined as apical, the junctional complexes as lateral, and the blood surface with the space of Disse and hepatic sinusoids is considered basal. The sinusoids are lined by hepatic stellate cells, endothelial cells, and Kupffer cells. The hepatic stellate cells are affected following chronic alcohol toxicity and are converted into myofibroblasts during the onset of cirrhosis. Those cells synthesize large quantities of High-Yield Facts 31 collagen and are responsible for the fibrotic changes observed in cirrhosis. The Kupffer cells are the antigen-presenting cells of the liver and are derived from monocytes. Hepatocytes are arranged in interlocking cords and plates so there are several ways of analyzing the histological organization of the liver. The classic lobule emphasizes the endocrine function of the liver; the portal lobule emphasizes the exocrine function of the liver, and the liver acinus focuses on actual blood supply and regeneration. The neurohypophysis is derived from the floor of the diencephalon and consists of astrocyte-like glial cells (pituicytes) and expanded terminals of nerve fibers originating in the hypothalamus. The neurohypophysis contains the hormones vasopressin and oxytocin, which are synthesized primarily in the supraoptic and paraventricular nuclei respectively. The adrenal medulla, derived from the neural crest, synthesizes epinephrine and norepinephrine (see figure on the following page). Most of the blood that reaches the adrenal medulla has passed through the adrenal cortex and contains glucocorticoids that regulate the norepinephrine/epinephrine balance in the adrenal medulla through regulation of phenylethanolamine-Nmethyl-transferase. The fetal adrenal cortex functions to produce dehydroepiadrosterone, an androgen that is transported to the placenta where it serves as a precursor of estrogen. The gland is covered by a connective tissue capsule and divided into a cortex containing steroid-producing cells with prominent lipid droplets and a medulla containing chromaffin cells that secrete catecholamines and neuropeptides. Congenital virilizing adrenal hyperplasia results from the deficiency of an enzyme required for cortisol production.

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The abdominal exam should asses for masses secondary to erectile dysfunction in teenage 120 mg sildalis with visa enlarged urinary organs (bladder erectile dysfunction pills natural buy sildalis 120mg low price, kidney) and for evidence of palpable stool in the colon suggesting fecal impaction impotence pump medicare buy sildalis 120mg with amex. Color Doppler ultrasound scanning of the scrotum demonstrates the absence of blood flow to causes of erectile dysfunction in 40s generic sildalis 120 mg on line the left testicle and epididymis. Scrotal exploration, under anesthesia, reveals a 720 degree torsion of the left spermatic cord, an ischemic testicle, and a "bell-clapper" deformity. Post-operatively, his pain was markedly relieved with the detorsion of the left testicle, and the remainder of his recovery is unremarkable. The window of opportunity to salvage a torsed, ischemic testicle is only 6 hours (1). Acute scrotal swelling should be considered testicular torsion until proven otherwise. Puberty is the most common age at which testicular torsion occurs, with the newborn period being the second most common. Extravaginal torsions occur perinatally, during testicular descent and prior to testicular fixation in the scrotum (2). This incomplete fixation of the gubernaculum (the fibrous cord extending from the fetal testis to the fetal scrotum which occupies the potential inguinal canal and guides the testis in its descent) to the scrotal wall allows the entire testes and tunica free rotation within the scrotum (3). The rotation of the cord is "extravaginal" because the rotation of the cord is proximal to the attachment of the tunica vaginalis that encloses the testes. A congenital high attachment of the tunica vaginalis on the spermatic cord allows the testes to rotate on the cord, within the tunica vaginalis. This is the "bell-clapper" deformity which is a horizontal lie of the testicle instead of the normal vertical lie. It is called a bell clapper deformity because the testicle resembles a horizontal oval hanging from a cord at its midpoint (like the clapper in a bell) as opposed to the normal testicle which resembles the letter "b" or "d" with the testicle positioned vertically attached to the cord on its side. This deformity is commonly bilateral, which places the contralateral testicle at risk for torsion also (3). As viewed from below, the testes rotate inward or medially during a torsion; the right clockwise and the left counter clockwise. The acute onset of severe testicular pain with associated nausea and vomiting is very suggestive of testicular torsion, especially in the adolescent. Intermittent testicular torsion is suspected when brief episodes of acute testicular pain occur recurrently. Torsion of a testicular or epididymal appendage (appendix testis or appendix epididymis) usually presents in mid childhood with mild discomfort of a few days duration (2). Epididymitis and/or orchitis, on the other hand, may be associated with fever, dysuria, and a more gradual onset of scrotal pain, usually over several days. A history of urethral strictures, posterior urethral valves, myelodysplasia with neurogenic bladder, and severe hypospadias with utricular enlargement may predispose to urinary tract infection, with secondary reflux into the ejaculatory ducts causing epididymitis (2). A history of scrotal pain and swelling associated with fever and parotid gland swelling suggest mumps orchitis. Inguinal hernia and/or hydroceles may present with similar symptoms to acute testicular torsion. A history of constipation or upper respiratory infection, both causing increases in intraabdominal pressure may be present. Henoch-Schonlein purpura, an uncommon cause of acute scrotal swelling (usually bilateral), is associated with a history of vasculitis and associated onset of a cutaneous purpuric scrotal rash (2). Trauma, even minor, may be a cause of testicular pain and should be sought in the history (straddle injury, wrestling, sports). A history of trauma may suggest a traumatic etiology of pain and swelling, but this does not necessarily rule out the presence of testicular torsion. The level of distress is noted along with vital signs and examination of the abdomen. There should be a specific notation of the presence or absence of inguinal and scrotal swelling, urethral discharge, scrotal or perineal ecchymoses or rashes, and lastly the appearance of the testes and area of pain and/or tenderness. The absence of a cremasteric reflex, in conjunction with testicular tenderness, is commonly associated with testicular torsion (5). It is elicited by gently stroking the skin of the inner thigh: the presence of the cremasteric muscle results in movement of the testicle in the ipsilateral hemiscrotum. Acute testicular torsion should be considered the leading diagnosis until it is ruled out.

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During that time do erectile dysfunction pumps work buy sildalis 120 mg low cost, each organ system has its own specific period of peak susceptibility erectile dysfunction remedies trusted 120mg sildalis. Exposure of the embryo to causes of erectile dysfunction include cheap sildalis 120 mg otc teratogens during the first 2 weeks of fetal life (answers a and b) generally induces spontaneous abortion and is erectile dysfunction filthy frank discount 120 mg sildalis otc, therefore, lethal. After the eighth week of intrauterine development (answers d and e), teratogenic exposure generally results in retardation of organ growth rather than in new structural or functional changes. Retinoic acid directs the polarity of development in the central nervous system, the axial skeleton (vertebral column), and probably the appendicular skeleton. Retinoic acid induces transcription of various combinations of homeobox genes, depending on tissue type and location (distance and direction from the source of retinoic acid). Exogenous sources of retinoic acid may induce the wrong sequence or combination of homeobox genes, leading to structural abnormalities in nervous and skeletal systems. The other organ systems listed are not as susceptible to vitamin A (answers a, b, c, and d). Duodenal and/or esophageal atresia result in an inability of the fetus to swallow amniotic fluid (answer c). The result is that normal recirculation of amniotic fluid through the embryo is greatly reduced or eliminated, causing an excess of amniotic fluid. Low volumes of amniotic fluid (oligohydramnios) are caused by rupture of the fetal membranes, bilateral agenesis of the kidneys (answer b), or obstructive uropathy (answer e, blockage of the calyces or ureters), which prevents urine from being added to the amniotic fluid. Hypoplasia of the lungs (answer d) and compression of the umbilical cord are associated with oligohydramnios, but do not cause it. The presence of adequate fluid in the uninflated lungs is essential for lung maturation, and growth factors in the amniotic fluid may also be important. Low levels of Embryology: Early and General Answers 91 amniotic fluid severely inhibit lung development. The formula for understanding the relationship between urine and amniotic fluid is: Less urine output = less amniotic fluid; less swallowing = more amniotic fluid. This first stage of neural tube development is followed by a reshaping phase, neurulation, and neural tube closure. The somatopleuric mesoderm (answer c) makes important contributions to the skin (dermis) and nonmuscle portions of the limbs. The hypoblast (answer e) is the thin layer of cells ventral to the epiblast; it is displaced by the epiblast cells, which form endoderm. The intermediate mesoderm is the origin of the urogenital systems and the adrenal cortex (answer a). The humerus (answer c) forms from somatopleuric mesoderm, but the muscles attached to it are of somite origin. The masseter (answer e) is a muscle of mastication formed from the first branchial arch and innervated by branchial visceral efferent (special visceral efferent) fibers from the nucleus ambiguus compared with the general somatic efferent innervation of the biceps and other muscles, not of branchial arch origin. The cortex, peripheral areas of gray matter, is formed through the migration of cells from the mantle zone to the marginal zone. Segmentation of the cranial neural tube forms the brain vesicles listed in the table below. Primary Brain Vesicle Prosencephalon (forebrain) Mesencephalon (midbrain) Rhombencephalon (hindbrain) Secondary Brain Vesicle Telencephalon Diencephalon Mesencephalon Metencephalon Myelencephalon Adult Brain Derivative Cerebral cortex, corpus striatum Hypothalamus, thalamus Superior and inferior colliculi Pons and cerebellum Medulla 25. During embryonic folding, the dorsal part of the yolk sac is incorporated into the embryo as the primitive gut. The primordial germ cells subsequently migrate along the dorsal mesentery of the hindgut (answer a) and into the gonadal (genital) ridge by week 6 (answer b). The primary sex cords grow into the mesenchyme underlying the ridge, and the primordial germ cells become incorporated into the primary sex cords (answer d). The chorion (answer e) is the outermost fetal membrane and is composed of extraembryonic somatic mesoderm, cytotrophoblast, and the syncytiotrophoblast. It is divided into the chorion frondosum, where the villi form and proliferate, and the smooth chorion, also known as the chorion laevae. Embryology: Early and General Answers 93 (Modified, with permission, from Sweeney L.

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It is initially tense erectile dysfunction best treatment purchase 120mg sildalis mastercard, but over the next few days as the hematoma begins resorption erectile dysfunction homeopathic treatment cheap 120 mg sildalis overnight delivery, the hematoma becomes very soft erectile dysfunction medication samples buy sildalis 120mg with amex, which is often alarming to erectile dysfunction when pills don work discount sildalis 120 mg with mastercard parents, prompting them to bring the child to a physician. Skull radiographs frequently identify a small linear fracture beneath the subgaleal hematoma which does not require further diagnostic or therapeutic intervention if the child is doing well clinically. However, radiographs occasionally demonstrate large fractures, comminuted fractures, or multiple fractures which suggest more serious injury and/or non-accidental injury. A skull fracture that is pushed in a distance equivalent to the thickness of the skull table is called a depressed skull fracture. A concussion is defined as, "a trauma induced alteration of mental status that may or may not involve a loss of consciousness" (1). The "Second Impact Syndrome," is characterized by rapid death due to a second concussion prior to a return to baseline functioning after an initial one. This has been reported to occur in adolescent athletes in contact sports, and the appropriate time to return to activity after sustaining a concussion is under much debate. Practice guidelines for the return of activity after sustaining a concussion have been recommended in the literature (10). Very often the blood is arterial originating from the middle meningeal artery in association with a parietal skull fracture. However, in younger children, 20% of epidural hematomas are due to venous blood (1). The classic clinical coarse is that of a child who sustains a head injury and may have been rendered unconscious. He may then have the "classic" lucid interval at which time he may be able to interact with the examiner. Subsequent middle meningeal bleeding causing the hematoma results in ensuing decompensation from the expanding blood collection, causing increased intracranial pressure and a reduction in cerebral perfusion (a secondary injury). This is a neurosurgical emergency, and craniotomy with evacuation of the hematoma can be life saving. This is most often due to venous blood from the bridging veins that traverse this space. This is usually not a neurosurgical emergency, since evacuation of the clot will not usually reverse the significant primary damage inflicted on the brain parenchyma. When a child presents with unexplained vomiting, lethargy, and/or head trauma, non-accidental injury must be included in the differential diagnosis. Especially when subdural hematomas are found, the possibility for child abuse must be explored. Associated findings of non-accidental trauma are failure to thrive, retinal hemorrhages, intra-abdominal injuries, and various fractures of different ages. In one retrospective review, cases of acute head injury caused by child abuse were often initially misdiagnosed if the patient was well appearing, Caucasian, and living with both biological parents (11). Thus, the examining clinician should have a low threshold to perform a skeletal survey and attain ophthalmology consultation for suspicious cases of head injuries. This type of acute subdural hematoma is very different from the type of subacute subdural hematoma found in the elderly. Subacute subdural hematoma in the elderly results from a slow bleed from bridging brains often due to minor head trauma. If the hematoma is identified and evacuated early, the brain is preserved with little injury. The difference between acute subdural hematoma (usually a poor prognosis) should be contrasted with subacute subdural in the elderly (usually a good prognosis). The latter is more similar to an epidural hematoma (usually a good prognosis as well). The concept of primary versus secondary injury is important in understanding the prognosis. Compare this to an acute subdural in which case, there is substantial primary brain injury (damage) which cannot be reversed with evacuation of the hematoma. Sometimes a subarachnoid hematoma and an intracerebral contusion can accompany a subdural hematoma.

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