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Because the ducts of sweat glands open on the tops of the epidermal ridges as sweat pores erectile dysfunction icd 9 code discount 25mg viagra with amex, the sweat and ridges form fingerprints (or footprints) upon touching a smooth object erectile dysfunction at age of 20 buy 25mg viagra. The epidermal ridge pattern is genetically determined and is unique for each individual impotence at 70 generic 75mg viagra fast delivery, and thus can serve as the basis for identification impotence natural treatments discount viagra 50mg amex. The second, deeper part of the skin, the dermis, is composed of dense irregular connective tissue containing a woven network of collagen and elastic fibers that provide great tensile strength (resistance to pulling or stretching forces). Because the dermis is typically thinner in women than in men, many women have the appearance of dimples in the skin, referred to as cellulite. Leather, which we use for belts, shoes, and basketballs, is the treated dermis of other animals. The dermis can be divided into a thin superficial papillary region and a thick deeper reticular region. The papillary region makes up about one-fifth of the thickness of the total dermis (see Figure 5. Dermal papillae contain capillary loops (blood capillaries) and can contain sensory receptors: Corpuscles of touch (Meissner corpuscles) that are sensitive to touch and/or free nerve endings, which initiate signals that produce sensations of warmth, coolness, pain, tickling, and itching. The reticular region (reticul- netlike) is attached to the hypodermis and contains bundles of thick collagen fibers, some elastic fibers, scattered fibroblasts and adipose cells, and various wandering cells (such as macrophages). Blood vessels, nerves, hair follicles, sebaceous (oil) glands, and sudoriferous (sweat) glands occupy the spaces between fibers. The doctor describes Richard as having two types of burns, "partial thickness" and "full thickness. His mother, father, and two sisters came to visit him in the burn unit every day, and his mother stayed overnight. Those burns are third-degree full thickness burns, involving all the layers of the skin down to the underlying subcutaneous layers. Carotene is stored in the stratum corneum and dermis after eating carotenerich foods. Dark-skinned individuals have large amounts of melanin in the epidermis, so their skin color ranges from yellow to reddishbrown to black. Light-skinned individuals have little melanin in the epidermis, making their epidermis appear translucent with a skin color ranging from pink to red depending on the level of oxygen in the blood moving through capillaries in the dermis. The red color is due to hemoglobin, the oxygen-carrying pigment in red blood cells. Melanin, carotene, and hemoglobin are three pigments that give skin a wide variety of colors. Because the number of melanocytes, the melanin-producing cells, is about the same in all people, differences in skin color are due mainly to the amount of melanin the melanocytes produce and transfer to keratinocytes. Freckles typically are reddish or brown and tend to be more visible in the summer than the winter. These flat blemishes look like freckles and range in color from light brown to black. Age spots are darker than freckles and build up over time due to exposure to sunlight. A tan is lost when the melanin-containing keratinocytes are shed from the stratum corneum. This condition gives a yellowish appearance to the skin and the whites of the eyes, and usually indicates liver disease. All skin color changes are observed most readily in people with lighter-colored skin and may be more difficult to discern in people with darker skin. However, examination of the nail beds and gums can provide some information about circulation in individuals with darker skin. The cuticle of the hair, the outermost layer, consists of a single layer of thin, flat cells that are arranged like shingles on the roof of a house, with their free edges pointing toward the distal end of the hair (Figure 5. The internal root sheath is produced by the hair matrix (described shortly) and forms a tubular sheath of epithelium between the external root sheath and the hair. The base of each hair follicle is enlarged into an onionshaped structure, the bulb (Figure 5. The bulb houses a nipple-shaped indentation, the papilla of the hair, which contains many blood vessels that nourish the growing hair follicle. The bulb also contains a germinal layer of cells called the hair matrix, the site of hair cell division. Hence, hair matrix cells are responsible for the growth of existing hairs, and they produce new hairs when old hairs are shed. Sebaceous (oil) glands (discussed shortly), smooth muscle cells, and sensory receptors are also associated with hairs (Figure 5. Under physiological or emotional stress, such as cold or fright, autonomic nerve endings stimulate the arrector pili to contract, which pulls the hair shafts perpendicular to the skin surface. This action causes "goose bumps" or "gooseflesh" as the skin around the shaft forms slight elevations. Surrounding each hair follicle is a hair root plexus, a sensory nerve ending that is sensitive to touch (Figure 5. The hair root plexuses generate impulses if the hair shaft is moved, which happens, for example, when an insect bumps into a hair as it crawls across your arm. The accessory structures of the skin-hair, skin glands, and nails-have a host of important functions. For example, hair and nails protect the body, and sweat glands help regulate body temperature. In adults, hair usually is most heavily distributed across the scalp, in the eyebrows, in the axillae (armpits), and around the external genitalia.

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These loyal servants had trusted their king and queen erectile dysfunction brochure order viagra 50 mg without prescription, and then were brutally sacrificed to be the sentinels of this tomb erectile dysfunction medication options cheap viagra generic. Now that the tomb had been found erectile dysfunction treatment philadelphia purchase viagra uk, the ancient people would answer through their bones iief questionnaire erectile function purchase 50 mg viagra with mastercard. A sarcophagus was discovered immediately inside the entrance, with the image of a young woman holding a baby painted on its surface, along with a royal seal and a series of hieroglyphs. The land had been plagued by drought, famine, and disease, and the death of the princess is repeated through the scenes. Inside were two skeletons, a small, delicately framed woman with arms folded around what appeared to be a child. Because skeletal remains may persist for thousands of years, it is possible to trace patterns of disease and nutrition, evaluate the effects of social and economic changes, and deduce patterns of reproduction and mortality. In this chapter we will explore the anatomy of the appendicular skeleton and learn how understanding its structure can serve as a tool for medical science and other disciplines. The general function of the axial skeleton is the protection of internal organs; the primary function of the appendicular skeleton, the focus of this chapter, is movement. As you progress through this chapter, you will see how the bones of the appendicular skeleton are connected with one another and with skeletal muscles, making possible a wide array of movements. This arrangement permits you to do things such as walk, write, use a computer, dance, swim, and play a musical instrument. The appendicular skeleton includes the bones that make up the upper and lower limbs as well as the bones, arranged in formations called girdles that attach the limbs to the axial skeleton. The bone is S-shaped because the medial half of the clavicle is convex anteriorly (curves toward you when viewed in the anatomical position), and the lateral half is concave anteriorly (curves away from you). The clavicle, the anterior bone, articulates with the manubrium of the sternum; the scapula, the posterior bone, articulates with the clavicle and with the humerus. The pectoral girdles do not articulate (form joints) with the vertebral column and are held in position and stabilized by a group of large muscles that extend from the vertebral column and ribs to the scapula. A prominent ridge called the spine runs diagonally across the posterior surface of the scapula (Figure 8. Inferior to the acromion is a shallow depression, the glenoid cavity, that articulates with the head of the humerus (arm bone). The thin edge of the scapula closer to the vertebral column is called the medial border (Figure 8. The superior edge of the scapula, called the superior border, joins the medial border at the superior angle. If the force transmitted to the clavicle is excessive, as when you fall on your outstretched arm, a fractured clavicle may result. A fractured clavicle may also result from a blow to the superior part of the anterior thorax, for example, as a result of an impact following an automobile accident. Because the junction of the two curves of the clavicle is its weakest point, the clavicular midregion is the most frequent fracture site. Even in the absence of fracture, compression of the clavicle as a result of automobile accidents involving the use of shoulder harness seatbelts often causes damage to the brachial plexus (the network of nerves that enter the upper limb), which lies between the clavicle and the second rib. A fractured clavicle is usually treated with a figure-of-eight sling to keep the arm from moving outward. On the anterior surface is a slightly hollowed-out area called the subscapular fossa, also a surface of attachment for a shoulder muscle. It articulates proximally with the scapula and distally at the elbow joint with both the ulna and the radius. The proximal end of the humerus features a rounded head that articulates with the glenoid cavity of the scapula to form the shoulder joint (Figure 8. The surgical neck is a constriction in the humerus just distal to the tubercles, where the head tapers to the shaft; it is so named because fractures often occur here. The body (diaphysis) of the humerus contains a roughened, V-shaped area called the deltoid tuberosity. The radial fossa is an anterior depression above the capitulum that articulates with the head of the radius when the elbow joint is flexed (bent). The medial epicondyle and lateral epicondyle are rough projections on either side of the distal end of the humerus to which most muscles of the forearm are attached. The ulnar nerve may be palpated by rolling a finger over the skin surface above the posterior surface of the medial epicondyle. This superficial nerve makes you feel a severe pain when you hit your elbow, which for some reason is commonly referred to as the funny bone even though this event is anything but funny. Each upper limb consists of 30 bones: a humerus in each arm, ulna and radius in each forearm, 8 carpals in each wrist, 5 metacarpals in each palm, and 14 phalanges in the fingers of each hand (Figure 8. One such mnemonic to help you remember the location of the ulna in relation to the hand is "p. The distal end of the ulna consists of a head on the anterior side and a styloid process on the posterior side (Figure 8. The styloid process provides attachment for the ulnar collateral ligament to the wrist. The radius is located on the lateral aspect (thumb side) of the forearm (Figure 8. The proximal end of the radius has a disc-shaped head that articulates with the capitulum of the humerus (Figure 8. A roughened area inferior to the neck on the medial side, called the radial tuberosity, is a point of attachment for the biceps brachii muscle. The shaft of the radius widens distally where it contains a depression, the ulnar notch, on the medial side and a styloid process on the lateral side, which can be felt proximal to the thumb. The styloid process provides attachment for the brachioradialis muscle and wrist bones. Fracture of the distal end of the radius is the most common fracture in adults older than 50 years.

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In its course erectile dysfunction diabetes qof buy 50mg viagra fast delivery, the right subclavian artery may rise as high as 4 em above the clavicle erectile dysfunction treatment homeopathy viagra 75mg lowest price, depending on the level of brachiocephalic bifurcation erectile dysfunction doctor singapore 50mg viagra with amex. The subclavian artery may rarely be found anterior to the anterior scalene muscle together with the subclavian vein (occasionally the vein is found between the anterior and middle scalene muscles with the artery) impotence workup discount viagra 50 mg amex, may penetrate the middle scalene, or may pass between the middle and posterior scalene muscles. In rare instances, the subclavian artery may divide at the medial border of the scalene muscle into radial and ulnar arteries instead of continuing into the axillary artery. Arteries to the Head and Nedc Extemtll CtlrotldArtery There is great variability in the number and origins of external carotid artery branches. In addition, the vertebral artery may arise from the thyrocervical or costocervical trunk, from the left common carotid, or directly from the aorta in rare instances. The vertebral artery enters the sixth vertebral transverse foramen 88% of the time, the fifth and seventh with equal frequency (7%), and rarely even as high as the second foramen. The internal thoracic artery, like the vertebral artery, follows the usual pattern in a relatively high percentage of cases (79%). Several common variations include origin as a common trunk with the thyrocervical trunk and origin fi:om the suprascapular, inferior thyroid, transverse cervical, or a combination of these vessels. The point of origin from the subclavian artery also varies fi:om proximal to distal. The origins and branching patterns of the thyrocervical and costocervical trunks are so highly variable among individuals and between sides that the most common pattern for each is found in less than half ofthe population. The branches of the axillary artery, conversely, are so variable that the most common pattern occurred in only 20 of 47 bodies studied by Hitzrot. BtarhllllAttfry Major variations of the brachial artery have been found in 20% to 25% of individuals. Two-thirds of these are unilateml, and most of the remaining bilateral anomalies were different from side to side. There are minor variations among the profunda, superior, and inferior ulnar collateral branches of the brachial artery in which they may arise from each other, share a common trunk, or replace each other. The common interosseous artery and its volar and dorsal branches are variable in their origins, size, and terminations. When this occurs, the vessels in the forearm often lie in a more superficial plane than normal, usually just beneath the deep antebrachial Art. Coleman and Anson,10 in fact, found that an incomplete ulna-based arch is more common than the normal textbook description of a complete arch. In addition, a median artery Superficial arch 34% 13% 4% Deepan::h 36% 13% 1%. The princeps pollicis and radial indicis arteries, in particular, may arise from either or both arches. The inferior phrenic arteries may arise independently or from a common stem, may have supernumerary branches, and may arise from the aorta or from the celiac artery or its branches. The visceral branches of the abdominal aorta are so highly variable that Nelson et al. These include variations in the level ofbifurcation, tortuosity, and direct origin of normally secondary visceral branches. The most clinically significant abdominal aortic anomaly is the rare occurrence of coarctation (0. The secondary branches ofthe abdominal the typical three-branched celiac trunk has been found in 60% to 89% of bodies. In rare instances, the superior mesenteric artery is combined with the celiac trunk. The left gastric arteJ:y is relatively constant in its origin from the celiac trunk. The most frequent and significant variation of the left gastric artery is the origin ofa branch to the left lobe ofthe liver in as many as one-fourth of specimens. This may supplement or replace the left hepatic branch ofthe proper hepatic arteJ:y. The common hepatic artery arose from the celiac trunk more than 80% of the time in the series of Daseler et al. The most frequent variation of the common hepatic artery in this series was its absence in 12% of cases. When the common hepatic artery is absent, the right and left hepatic arteries arise independently from the celiac trunk or its branches, the aorta, or the superior mesenteric artery. Most often the aberrant vessel replaces the standard branch offthe proper hepatic artery, and the remaining aberrant vessels are accessory branches. In addition, accessory cystic arteries, also arising most often from the right hepatic artery, were found 11% ofthe time by Daseler et al. The tortuous splenic artery exhibits several variations in addition to the permutations of celiac branching discussed previously. It may arise from the superior mesenteric artery, and it may give rise to the left gastric, middle colic, or left hepatic artery. There may be two splenic arteries, with one or both arising directly from the aorta. It may give rise to the splenic, right, left, or common hepatic artery or a combination of these vessels. A right hepatic artery from the superior mesenteric artery has been found in 12% to 20% of cases and may replace or supplement the usual right hepatic. The superior mesenteric artery may also provide accessory branches to the stomach, pancreas, or spleen. It may also provide left colic and superior rectal branches that replace the inferior mesenteric artery. The greatest variability in the superior mesenteric artery is found in its colic branches.

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The resulting clone of cells can recognize the same antigen as the original lymphocyte (see Figure 21 erectile dysfunction statistics 2014 buy cheapest viagra and viagra. Some of the cells of a T cell clone become effector cells erectile dysfunction meaning cheap 50mg viagra free shipping, while other cells of the clone become memory cells erectile dysfunction when drunk buy viagra overnight delivery. The effector cells Activation of T Cells At any given time erectile dysfunction treatment time buy generic viagra 75mg on line, most T cells are inactive. A T cell becomes activated only if it binds to the foreign antigen and at the same time receives a second signal, a process known as costimulation. The need for two signals to activate a T cell is a little like starting and driving a car: When you insert the correct key (antigen) in the ignition (T cell receptor) and turn it, the car starts (recognition of specific antigen), but it cannot move forward until you move the gear shift into drive (costimulation). The need for costimulation may prevent immune responses from occurring accidentally. Different costimulators affect the activated T cell in different ways, just as shifting a car into reverse has a different effect than shifting it into drive. Once a T cell has received these two signals (antigen recognition and costimulation), it is activated. The result is the formation of a clone of helper T cells that consists of active helper T cells and memory helper T cells. Within hours after costimulation, active helper T cells start secreting a variety of cytokines. However, if the same antigen enters the body again in the future, memory helper T cells can quickly proliferate and differentiate into more active helper T cells and more memory helper T cells. Following antigenic recognition, costimulation occurs with interleukin-2 or other cytokines produced by helper T cells. The result is the formation of a clone of cytotoxic T cells that consists of active cytotoxic T cells and memory cytotoxic T cells. Active cytotoxic T cells are the effector cells of a T cell clone; they attack other body cells that have been infected with the antigen. Instead, they can quickly proliferate and differentiate into more active cytotoxic T cells and more memory cytotoxic T cells if the same antigen enters the body at a future time. Elimination of Invaders Cytotoxic T cells are the soldiers that march forth to do battle with foreign invaders in cell-mediated immune responses. They leave lymphatic organs and tissues and migrate to seek out and destroy infected target cells, cancer cells, and transplanted cells (Figure 21. After delivering a "lethal hit," a cytotoxic T cell can detach and attack another infected target cell displaying the same antigen. The major difference is that cytotoxic T cells have receptors specific for a particular microbe and thus kill only target body cells infected with one particular type of microbe. In contrast, natural killer cells can destroy a wide variety of microbe-infected body cells. After binding to infected target cells that have microbial antigens displayed on their surface, cytotoxic T cells kill the infected cell with various lethal substances. In addition, cytotoxic T cells secrete substances that attract and activate phagocytic cells and prevent migration of phagocytes away from the infection site. After detaching from a target cell, a cytotoxic T cell can seek out and destroy another target cell. Besides cells infected by microbes, which other types of cells do cytotoxic T cells attack In the presence of a foreign antigen, a specific B cell forms plasma cells that secrete specific antibodies, which circulate in the lymph and blood to reach the site of invasion and disable the antigen. The body contains not only millions of different T cells but also millions of different B cells, each capable of responding to a specific antigen. Cytotoxic T cells leave lymphatic tissues to seek out and destroy a foreign antigen, but B cells stay put within a 767 Activation and Clonal Selection of B Cells During activation of a B cell, an antigen binds to B cell receptors (Figure 21. B cell antigen receptors are chemically similar to the antibodies that eventually are secreted by the plasma cells. B cells can respond to an unprocessed antigen, but their response is much more intense when they process the antigen first. The helper T cell produces interleukin-2 and other cytokines, which function as costimulators to activate B cells. Once activated, a B cell undergoes clonal selection, forming a clone of plasma cells and memory B cells (Figure 21. Plasma cells are the effector cells of a B cell clone; they secrete specific antibodies. A few days after exposure to an antigen, a plasma cell secretes hundreds of millions of antibodies each day for about 4 or 5 days, until the plasma cell dies. Interleukins produced by helper T cells enhance B cell division into plasma cells and secretion of antibodies by plasma cells. Instead, they can quickly divide and differentiate into more plasma cells and more memory B cells should the same antigen reappear at a future time. Different antigens stimulate different B cells to develop into plasma cells and their accompanying memory B cells. All of the B cells of a particular clone are capable of secreting only one type of antibody, which is identical to the antigen receptor displayed by the B cell that first responded. It occurs mainly in children and young adults, and more often in females than in males. The virus most commonly enters the body through intimate oral contact such as kissing, which accounts for its common name, the "kissing disease. Because of this infection, the B cells become so enlarged and abnormal in appearance that they resemble monocytes, the primary reason for the term mononucleosis. In addition to an elevated white blood cell count with an abnormally high percentage of lymphocytes, signs and symptoms include fatigue, headache, dizziness, sore throat, enlarged and tender lymph nodes, and fever.

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