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By: G. Altus, M.B. B.A.O., M.B.B.Ch., Ph.D.
Associate Professor, Icahn School of Medicine at Mount Sinai
Although the anatomical details of the region will not be described blood pressure medication drowsiness discount altace 5mg fast delivery, it must be pointed out that the submandibular gland hypertension young living buy discount altace 2.5 mg on-line, located on the inferior surface of this muscle zytiga arrhythmia order altace 1.25mg fast delivery, includes a small heart attack remixes 20 buy altace 1.25mg visa, deep part which hooks around the posterior border of the mylohyoid muscle. This projection and the submandibular duct which accompanies it testify to the existence of a passage between the sublingual and submandibular regions. Three principal arterial trunks are distributed to this region: the facial, the lingual, and the superior thyroid arteries. Its course is distinctive; it ascends vertically and somewhat posteriorly to supply the base of the tongue. Further forward, the arterial trunk connects small vessels, which are distributed to the mobile portion of the tongue. Around the sublingual gland, an arterial circle can exist, anastomosing the lingual artery posteriorly and superiorly with the submental artery arising from the facial artery. In addition to supplying the gland, this circle also gives rise anteriorly to a medial mandibular branch which supplies the anterolateral surface of the body of the mandible on the same side. Depending on the hemodynamic balance of the region, the lingual artery, through its anastomotic branches, can take over the supply to the gland, the anterior mandible, and even part of the submental territory. If, on the other hand, the submental artery is dominant, the glandular and mandibular system will arise from this vessel. In both of these extremes, a small anastomotic the Arteries of the Floor of the Mouth. The catheter tip is located in the distal portion of the submental artery (asterisks). The anastomoses permit a precise demonstration of the supply to the floor of the mouth: 1, artery of the sublingual gland; 2, medial mandibular artery; 3, lingual root of the sublingual arterial ring; 4, submental root of the sublingual arterial ring; 5, submental artery; 6, middle mental artery; 7, suprahyoid branches of the submental system; 8, facial artery; 9, lingual artery 357 A 8 9 6 7 8 channel will remain on the hypoplastic side. The lingual artery can also supply the tonsils and give branches to the hyoid region, and it will supply the thyroid gland when it fails to migrate. The vessels supplying the floor of the mouth are seen, with submental dominance in the supply of that area. Arrowhead, periglandular ring; solid arrow: lingual branch; small arrow, submental branch; double arrow, submental artery; curved arrow, medial mandibular branch the Arteries of the Floor of the Mouth 359. Diagrammatic representation of the arterial supply of the floor of the mouth, after dissection of the horizontal branch of the mandible and elevation of the tongue A Indeterminate supply to the oral floor with a periglandular ring (arrowhead) from which the medial mandibular branch (curved arrow) arises. The two possible arterial sources of that system are indicated: lingual branch (solid arrow) and submental branch (small arrow). The submental artery (double arrow) supplies the medial mandibular system, while the lingual artery has taken over the glandular portion of the territory. D Submental dominance in the supply of the area the Arterial Branches of the Suprahyoid Region. A superior source accompanies the muscles coming from the styloid process (the stylohyoid, styloglossus, and digastric muscles) and includes branches which may originate from the posterior auricular artery, the initial segment of the maxillary artery, or even the terminal part of the external carotid system. An alternate superior source is a branch of the proximal part of the lingual artery which runs obliquely down and forward to the lesser horn of the hyoid bone. Up to three branches arising from the most anterior part of the submental artery may contribute to the supply. These suprahyoid branches anastomose with the corresponding branches of the superior thyroid artery. Arrowhead, periglandular ring; curved arrow, medial mandibular branch; small arrow, submental branch. Note also the suprahyoid branch (double arrowhead) arising from the lingual artery (A) A. Diagrammatic representation of the arterial branches supplying the suprahyoid area. Curved arrow, arterial branch of the stylohyoid muscle; triple arrow, superior branch of the superior thyroid artery; double arrowhead, lingual branch; 7, suprahyoid branches of the submental system 361. Curved arrow, arterial branch of the stylohyoid muscle; triple arrow, superior branch of the superior thyroid artery 362 4 Skull Base and Maxillofacial Region 4. In addition, the oral origin of part of the thyroid tissue is responsible for the role played by the superior thyroid artery in the collateral circulation of the linguofacial area. However, two routes of resupply to the area (floor of the mouth), the submental and sublingual arteries, are characteristic for this pattern. It is understandable that the congenital disposition of the submental artery will be the key to predicting further development of the collateral circulation.
Genetic defects in the production of specific acid hydrolases or in transport proteins of the lysosomal membrane results in lysosomal storage diseases blood pressure medication pictures purchase altace 1.25 mg without prescription. Diseases blood pressure 50 over 0 order 5mg altace with visa, such as adrenoleukodystrophy prehypertension pregnancy cheap 5mg altace overnight delivery, are due to defects in peroxisomal enzymes of peroxisomes and present as metabolic disturbances arrhythmia stress altace 5 mg. Mitochondrial diseases may present at any age from early childhood to well into adult life. Mitochondrial cytopathy is characterized by metabolic disturbances, muscle weakness or degenerative disease of the central nervous system. Membranous organelles Cell membrane (plasmalemma) Morphologic features Electron-lucent layer (3. Usually contain material of some type (crystalloids, debris, organelle remnants, lipofuscin pigment) Numerous small vesicles limited by a single, smooth membrane Spherical, membrane-bound bodies 0. Lipid Pigment granules Melanin Hemosiderin Lipofuscin Dark brown; complexed in ellipsoidal melanosomes Gold-brown; ultrastructurally appears as collections of 9-nm particles Coarse, irregularly shaped, brown-gold granules Inert Degraded product of hemoglobin; inert End product of lysosomal activity; inert Beta particles (20-30 nm) occur singly and are irregular in outline Alpha particles are variously sized aggregates of the beta form Storage form of glucose Spheroidal droplets of varying size and density; lack a limiting membrane Primarily a storage form of short carbon chains (triglycerides) 27 Crystalline structures Vary considerably in size and structure; may occur in cytoplasmic matrix, organelles, or nucleus Membrane-bound; vary in size, density, and internal consistency Most thought to be a storage form of protein Materials synthesized to be released by cell Secretory granules Nuclear constituents Nuclear envelope Consist of inner and outer membranes that become continuous around nuclear pores; outer membrane studded with ribosomes, inner membrane smooth; are separated by a perinuclear cistern; a nuclear pore complex is associated with each pore Thin network of interwoven filaments Specialized segment of endoplasmic reticulum that bounds nucleus; nuclear pores permit communication between cytoplasm and nucleoplasm Nuclear lamina Stabilized inner nuclear membrane; attachment site for components of chromatin Inactive; part of genome not being expressed Active; part of genome being expressed Synthesis of ribosomes Heterochromatin Euchromatin Nucleolus Dense staining; condensed chromatin Light-staining; dispersed chromatin Conspicuous round body in nucleus; nucleolonema consists of dense granules in a matrix of filaments; amorphous component may be present 28 2 Mitosis Nearly all multicellular organisms grow by increasing the number of cells. The zygote, which is formed at conception, divides repeatedly and gives rise to all the cells of the body. Every true cell in the resulting individual contains a nucleus, and each nucleus possesses identical genetic information. In the adult, most cells have a finite life span and must be replaced continuously. Mitosis usually lasts from 30 to 60 minutes and involves division of the nucleus (karyokinesis) and the cytoplasm (cytokinesis). Both events usually take place during mitosis, but karyokinesis may occur without division of the cytoplasm, resulting in formation of multinucleated cells, such as the megakaryocytes of bone marrow. Although mitosis is a continuous process, for descriptive purposes it is convenient to divide mitosis into prophase, metaphase, anaphase, and telophase. The time between successive mitotic divisions constitutes interphase and is the period when the cell performs its usual functions, contributes to the total economy of the body, and makes preparations for the next division. Shortly thereafter, the chromosomes begin to coil, shorten, and become visible within the nucleus, and the cell enters the prophase of mitosis. Replication begins at the ends of the chromosomes, the telomeres, and progresses toward the center, where a small area of the chromosome, the centromere, remains unduplicated. At prophase each chromosome consists of two coiled subunits called chromatids that are closely associated along their lengths. As prophase progresses, the chromatids continue to coil, thicken, and shorten, reaching about one-twenty-fifth of their length by the end of prophase. As these events occur, nucleoli become smaller and finally disappear, and the nuclear envelope breaks down. When this occurs, the center of the cell becomes more fluid, and the chromosomes move more freely, making their way to the equator of the cell. Simultaneous with the nuclear events, the centrioles replicate, and the resulting pairs migrate to the opposite poles of the cell. The two chromatids of each chromosome separate and begin to migrate toward the centrioles at the opposite poles of the cell. Duplication of the centromeres and migration of chromatids occur simultaneously in all chromosomes of a given cell. As the chromatids move toward the opposite poles, the centromeres travel in advance of the telomeres (arms) of the chromosomes that trail behind. Movement of chromatids, which now are called daughter chromosomes, is an active, dynamic process, but the mechanisms by which the movement is effected are not certain. When the nuclear envelope has been reformed completely, the chromosomes uncoil and become indistinct, and the two nuclei reassume the interphase configuration. Their development is associated with specific nucleolus-organizing regions present on certain chromosomes. The mitotic spindle is a somewhat diffuse body formed mainly of microtubules; those which pass from pole to pole of the spindle are called continuous fibers. Other microtubules extend from the poles of the spindle to attach to the centromere of each chromosome and form the chromosomal fibers. Protein complexes known as kinetochores assemble at the centromere and bind to the microtubules of the mitotic spindle. The fibers between the two forming nuclei appear stretched and often are called interzonal fibers.
The patient is unable to respond appropriately to visual or verbal commands during the seizure hypertension of pregnancy generic altace 5 mg line, and has impaired recollection or awareness of ictal phase hypertension with cardiac involvement discount altace 1.25mg otc. These are usually tonic-clonic type and difficult to differentiate from primary generalized tonic-clonic seizure blood pressure medication for diabetics order 2.5mg altace with amex. Generalized seizures There are seizure disorders which arise from both cerebral hemispheres simultaneously blood pressure chart for senior citizens cheap altace 10 mg on line, with without any detectable focal onset. The seizure typically lasts for only few seconds, consciousness returns as sudden as it was lost. It usually manifests with blank staring and they may have also subtle motor manifestations like blinking of the eyes, chewing movements. The seizure may occur as many as hundreds of times per day It is usually detected by unexplained daydreaming and decline in school performance. It usually begins in childhood (4- 8 yrs), and it often has a good prognosis, with 60-70 5 of such patients will have spontaneous remission during adolescence. The seizure usually begins abruptly without warning (no aura or focal manifestations. Patients gradually regain consciousness over minutes to hours, and during this transition there is typically a period of postictal confusion, headache, muscle ache and fatigue that can last for many hours. A normal common physiologic form of myoclonus is sudden jerking movement observed while falling asleep. Urinalysis, serum glucose, liver function test, renal function test electrolytes, toxicological screening). Avoidance of precipitating factor Maintain normal sleep schedule Avoid taking excess alcohol Reduce stresses using, physical Exercise, meditation or counseling 3. The drugs should be administered in progressive dose until seizure control has been achieved or until drug toxicity occurs. The addition of a second drug is associated with worsening of adverse effects; hence care should be taken, before one decides to add a second drug to the original regimen. Phenytoin: is the usual prescribed as a second line drug in resource limited settings like ours mainly because of its availability and cost. It is often given for the treatment of partial seizure Dosage: a low initial dosage with gradual increase is advised. Managing psychosocial issues Social stigma: avoid misconceptions in the public through health education Psychiatric problems: depression, psychosis,anxiety should be treated Social problems (education, employment, marriage): encourage patients to go school /work to get married and establish family. Educate Patients and families: about the diseases and what precautions patient should take. Patients may have mild clonic movement of only the fingers, or fine, rapid movement of the eyes.
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