Category: Anatomy

Introduction

Intracranial pressure (ICP) may be raised whenever there is an increase in brain tissue volume, blood volume, CSF volume, and due to other metabolic factors. A raised ICP has the potential to cause serious damage to the body by compressing vital structures in the brain stem, and is associated with a high mortality and morbidity. This is because unlike other organs like the kidney or liver, the brain can withstand ischaemia only for a short time.

This essay is based on the case history of Adam, a 50-year-old male, who has suffered a subarachnoid bleed. The purpose of the essay is to explore the pathophysiology of raised intracranial pressure and outline the importance of assessment of vital signs in a patient with raised intracranial pressure.

A brief analysis of the intracranial anatomy, CSF, and subarachnoid hemorrhage is followed by analysis of the pathophysiology of raised intracranial pressure and assessment of vital signs.

Intracranial anatomy

The cranium of the normal adult brain is a nondistensible structure. The components making up the volume within the cranium includes: brain tissue-1400 ml, blood-150 ml, and cerebrospinal fluid (CSF)-150 ml (Samuels, 2004).

The brain and spinal cord are covered by three meninges; dura mater, arachnoid mater, and the pia mater. These are protective in nature (McCaffrey, 2008).

The dura mater is a two-layered membrane, which lines the skull and is the most superior of the three meningeal layers. The space above the dura mater is called epidural space. The epidural space is a potential space; if there is bleeding in the brain, it may collect here (McCaffrey 2008).

The space between the dura mater and the arachnoid mater is called subdural space. It is also a potential space, and blood may collect here (McCaffrey, 2008).

The arachnoid mater is the middle layer, which has projections (arachnoid granulation or arachnoid villi) into the sinuses of the dura mater. These projections transfer CSF from the ventricles into the bloodstream (McCaffrey, 2008).

The subarachnoid space is present between the arachnoid and pia mater, and contains the CSF (McCaffrey 2008). The pia mater is the innermost layer of the meninges, which is closely attached to the brain (McCaffrey, 2008).

The arachnoid and the pia mater are very thin and are called leptomeninges (Greenberg, 2000).

Cerebrospinal Fluid

The CSF is principally produced in the choroid plexus of each lateral ventricle. It exits the brain via the foramina of Luschka and Magendi, and flows over the cortex to be absorbed into the venous system along the superior sagittal sinus (Ropper, 1998). A small amount of CSF is produced by the ependymal surfaces of the ventricles, and a minimal amount by the brain through the small perivascular spaces surrounding the blood vessels entering the brain substance (Reichman & Simon, 2003).

CSF is produced at a rate of 0.34 mL/min (Samuels, 2004). Approximately 150 mL of CSF is present within the ventricles and surrounding the brain and spinal cord (Ropper, 1998), and approximately 500 mL of CSF is produced each day (Reichman & Simon, 2003).

CSF supplies oxygen and vital nutrients to portions of the brain without an independent blood supply. The CSF also cushions the brain against traumatic injury to the head (Ropper, 1998).

Subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is the presence of blood within the subarachnoid space due to head trauma or nontraumatic causes. The nontraumatic causes include: rupture of a berry aneurysm or arteriovenous malformation (AVM) (Kazzi 2006). The mortality rate of SAH is 40% within the first week (Kazzi, 2006).

The symptoms of SAH include the acute onset of severe headache, and seizures (25%). Other signs and symptoms include: signs of meningeal irritation like neck stiffness, bilateral leg pain, and low back pain, nausea and/or vomiting, loss of consciousness, photophobia and visual changes (Kazzi, 2006).

Intracranial Pressure

The brain tissue, blood, and cerebral spinal fluid (CSF) all together, exert a pressure, which is known as the intracranial pressure (ICP) (Ropper, 1998). Normally, the ICP is maintained at a range of 2 to 12 mm Hg.

A volume change in any of the 3 intracranial components can cause abnormal variations in the intracranial volume with subsequent changes in the ICP. These volume changes include; increase in tissue volume (brain tumor, edema or bleeding), increased blood volume (vasodilatation of cerebral vessels or venous outflow obstruction), excess production, and decreased absorption or obstructed circulation of CSF (Porth, 2005).

The Initial increases in ICP are countered by a translocation of CSF to the spinal subarachnoid space and increased reabsorption of CSF. The small amount of blood in the cerebral circulation, however, limits the compensatory ability of the blood compartment. As the volume-buffering capacity of this compartment becomes exhausted, venous pressure increases, and cerebral blood volume and ICP rise (Porth, 2005).

Intracranial compliance

Since the cranial vault is a rigid and fixed structure, any additional intracranial volume can lead to increased ICP. According to the Monroe-Kellie doctrine “When the volume of any of the three cranial components increases, the volume of one or both of the others must decrease or the ICP will rise” (Samuels 2004).

Subsequent to an increase in the volume, the intracranial contents get displaced. As a mass lesion expands in the intracranial vault, there is only a minimal increase in ICP initially because the CSF and blood are displaced (Samuels 2004). Once these mechanisms get overwhelmed, the intracranial compliance (change in volume divided by the change in pressure) and further small increments in intracranial volume leads to dramatic elevations of ICP (Samuels, 2004).

Cerebral perfusion and autoregulation

There needs to be a state of constant perfusion of the brain tissue so that important substrates like oxygen and glucose can be delivered to the brain. In order to preserve perfusion across a wide range of systemic blood pressures, the brain has the capacity for an adequate hemodynamic response (Samuels, 2004).

The cerebral perfusion pressure (CPP) is the difference between the ICP and blood pressure in the major cerebral arteries. When the CPP is below 20-30 mmHg, the raised ICP becomes detrimental (Ropper, 1998).

The brain maintains a constant cerebral blood flow by a process called autoregulation. By this process, the brain adjusts the intracranial vascular resistance by altering vessel diameter and tone. After any severe cerebral insult like a subarachnoid hemorrhage, this ability of the brain to autoregulate is lost. The CPP now becomes dependent on the mean arterial pressure. Therefore, in order to maintain CPP in the presence of a raised ICP, the systemic blood pressure needs to be raised (Kaye, 2005).

Brain herniation

Brain herniae may be of 3 types, depending on the cause of raised ICP, or the position of the intracranial mass. They include: transtentorial, foramen magnum, and subfalcine types.

In transtentorial herniation, there is displacement of the brain and herniation of the uncus of the temporal lobe through the tentorial hiatus. This leads to compression of the 3rd cranial nerve and the midbrain (Kaye, 2005).

Because the brainstem and the reticular activating system get compressed, there is a deterioration of the conscious state leading to coma, hypertension, and bradycardia (Cushing response). In addition, there is respiratory failure, which is initially manifest by Cheyne-Stokes periodic breathing (Kaye, 2005).

Respiratory failure occurs when the medulla gets compressed. With a progressive increase in the ICP, there is further downward herniation of the brain stem into the foramen magnum or ‘coning.’ With further herniation and destruction in the brainstem, the pupils change from dilated and fixed to midsize and unreactive. These are irreversible events leading to brainstem death (Kaye, 2005).

Assessment of vital signs

By regular monitoring of the vital signs like pupillary reaction, blood pressure, pulse rate, respiratory rate, and temperature, it is possible to identify rising ICP.

Pupillary responses-in addition to being a sign of increasing ICP, the assessment of pupillary responses helps in identifying the location of an expanding mass (Brooker & Nicol, 2003). It is necessary to record the size, shape, and reaction to light of both the pupils (Brooker & Nicol, 2003).

A pupil that is becoming oval, enlarging or losing the ability to react to light may be an indication of rising ICP (Brooker & Nicol 2003). This will happen before the pupil becomes fixed and dilated. The pupillary responses are controlled by two cranial nerves: optic (III) and the oculomotor (III) (Brooker & Nicol, 2003).

If there is an expanding lesion in the right cerebral hemisphere, which causes herniation of part of the temporal lobe through the tentorium, then the right oculomotor nerve will be compressed, leading to a fixed and dilated pupil (Brooker & Nicol 2003). If the pressure is unrelieved and continues to increase, the oculomotor nerve on the opposite side will also become compressed and the contralateral pupil to the side of the lesion will become fixed and dilated (Brooker & Nicol, 2003).

Blood pressure-unrelieved raised ICP causes brain hypoxia and compromises cerebral perfusion. The vasomotor center responds to this by attempting to increase cerebral blood flow by raising the mean arterial blood pressure (Brooker & Nicol, 2003).

Serial blood pressure monitoring will show an upward rise in both diastolic and systolic blood pressure, and because the mean arterial blood pressure is rising, there will be a widening gap between the diastolic and systolic pressures. It is more important to observe this widening gap than just a general blood pressure measurement (Brooker & Nicol, 2003).

Pulse rate-this usually falls with rising ICP. This is because the baroreceptors detect an abnormally rising blood pressure and attempts to reduce it by slowing the heart rate and therefore reducing the cardiac output (Brooker & Nicol, 2003).

Temperature-this usually increases in the end stages of unrelieved raised ICP. This is because of loss of temperature control due to compression of the hypothalamus (Brooker & Nicol, 2003).

Respiratory rate-this begins to decrease as the ICP rises, because there is cerebral hypoxia and compression of the respiratory center within the brain stem. In the end stages, the respiration will become shallow, slow, and irregular (Brooker & Nicol, 2003).

Conclusion

The cranium of the normal adult brain is a nondistensible structure inside which the brain tissue, blood, and cerebral spinal fluid all together, exert a pressure, which is known as the intracranial pressure. A volume change in any of the 3 intracranial components can cause abnormal variations in the intracranial volume with subsequent changes in the ICP.

Initially, as a mass lesion expands in the intracranial vault, there is only a minimal increase in ICP because the CSF and blood are displaced; later, these mechanisms get overwhelmed, and the intracranial compliance and further small increments in intracranial volume leads to higher rises in the ICP.

The cerebral perfusion pressure (CPP) is the difference between the ICP and blood pressure in the major cerebral arteries. A CPP below 20-30 mmHg, makes the raised ICP very dangerous. After a subarachnoid hemorrhage, the autoregulating ability of the brain is also lost.

Rising ICP leads to brain herniation, which is of three types: transtentorial, foramen magnum, and subfalcine types. When the herniating brain compresses

the brainstem and the reticular activating system, it leads to coma, hypertension, and bradycardia (Cushing response). In addition, respiratory failure also occurs.

In the given scenario, Adam has suffered a subarachnoid bleed. As a result of rising ICP, his heart rate dropped because the baroreceptors detected an abnormally rising blood pressure and attempted to reduce it by slowing the heart rate. His vasomotor center responded to the brain hypoxia by attempting to increase cerebral blood flow by raising the mean arterial blood pressure.

Initially, his right pupil dilated and did not react to light because herniation of part of the temporal lobe through the tentorium compressed the right oculomotor nerve. In a short while, the left pupil also became fixed and dilated due to compression of the oculomotor nerve on the opposite side.

With a progressive increase in the ICP, there was further downward herniation of the brain stem into the foramen magnum or ‘coning.’ Further herniation and destruction in the brainstem lead to brain stem death.

References

1. Brooker, C, & Nicol, M 2003, Nursing Adults: The Practice of Caring. Elsevier Health Sciences.
2. Greenberg, MS 2000, Handbook of Neurosurgery, 5th edn, Thieme Medical Publishers, New York.
3. Kaye, AH 2005, Essential Neurosurgery. Blackwell Publishing.
4. Kazzi, AA 2006. Subarachnoid Hemorrhage. Web.
5. McCaffrey, P 2008. The Meninges and Cerebrospinal Fluid.
6. Porth, CM 2005, Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins.
7. Ropper, AH, 1998, Harrison’s Principles of Internal Medicine. McGraw-Hill.
8. Reichman, E & Simon, RR 2003, Emergency Medicine Procedures. McGraw-Hill Professional.
9. Samuels, MA 2004, Manual of Neurologic Therapeutics. Lippincott Williams & Wilkins.

The External Anatomy of Kidney

Kidneys are the major organs of the renal system which perform vital homeostatic processes such as maintenance of water and ionic balance in the body. The kidneys’ primary function is waste removal through ultrafiltration, leading to urine formation. Moreover, they are actively involved in the reabsorption of amino acids, glucose, and water to achieve osmotic balance in the body (Wingerd & Taylor, 2020). In addition, hormones and enzymes are produced from the kidneys, stimulating, and catalysing physiological reactions in the body to achieve homeostasis.

A normal kidney is a brown organ, which has the shape of a bean seed. Each kidney is protected by a cushion called the renal capsule, a fibrous membrane having an irregular network of connecting tissue. The capsule is essential in holding kidneys in their positions within the abdominal cavity (Wingerd & Taylor, 2020). Moreover, it assists in maintaining the shape and responsible for protecting them from mechanical shock. The capsule is also overlayed by the renal fat pad, enhancing its efficacy in reducing the physical impact on the kidneys from an external force. The adipose tissues forming the fat pad are linked to the renal fascia, which in conjunction with the peritoneum, serves as anchorage surfaces for the kidneys to the posterior side of the abdominal cavity (Hickling et al., 2017). The hilum forms the entry point through which renal arteries and veins, and ureters serve the kidneys with fluids flowing in and out.

On top of the kidney is embedded an adrenal gland, which is responsible for modulating the organ’s physiological functions. However, the adrenal glands are part of the endocrine and not the renal system. The anterior interests of kidneys are protected by ribcages that curve into the lumbar region (Hickling et al., 2017). Kidneys are served by blood from the renal artery, which branches from the posterior side of the aorta. The flowing blood from the kidney is channelled into the inferior vena cava through the renal vein (Wingerd & Taylor, 2020). The excretory waste constituting the urine flows from the kidney into the bladder through the ureter. Thus, kidney serves in the purification of blood during the process of urine formation.

The Internal Anatomy of Kidney

The kidney comprises three primary internal layers: the cortex, medulla, and pelvis. The renal cortex is the region immediately after the capsule, and within it are the extended sections of the nephron to form the Bowman’s capsule (Lawrence et al., 2018). It is a granular tissue within the kidney, offering a space for the arterioles and venules emerging from the arteries and veins, respectively. Moreover, the glomerular capillaries, which permit filtration of the blood components, are embedded in the cortex (Wingerd & Taylor, 2020). It is in the renal cortex where erythropoietin hormone is secreted to stimulate erythrocyte formation.

The medulla is the parenchymatous region within the kidney, constituting the immediate layer after the cortex. It is composed of stacked masses of tissue defined as renal pyramids. Each pyramid is comprised of densely interwoven nephrons (Wingerd & Taylor, 2020). The basic unit by which a kidney executes homeostatic function is the nephron. The Bowman capsule located in the cortex connects to the proximal convoluted tubules through which the glomerular filtered plasma flows (Hickling et al., 2017). In the medulla pyramids, the loop of Henle and the distal convoluted tubules form part of the nephron channelling the purified plasma into the collecting ducts.

The renal pelvis is the innermost concaved region of the kidney. Every pyramid of the medulla ends in a renal papilla that supplies concentrated urine into the minor calyces. The pool formed by minor calyces from every renal pyramid constitutes the major calyx. All the significant calyces are consecrated into a single unit called the pelvis (Wingerd & Taylor, 2020). The pelvis connects the kidney to the ureter, thus directing the concentrated urine into the bladder.

Physiological Balancing in the Nephron

The Blood Supply Network

Kidneys are highly vascularized organs, receiving a quarter of the blood circulating within the body at a specific duration of time. The entry of blood into the two kidneys occurs via a pair of renal arteries extending from the aorta. On reaching the hilum of each kidney, the blood is channelled into segmental arteries, which branch into the interlobar arteries (Hickling et al., 2017). The interlobar vessels pass through the columns get into the cortex, in which they branch to form arcuate arteries. Further branching of the blood vessels leads to cortical radiate arteries, which supply their contents into the arterioles. Blood from the arterioles enters the glomerulus via the afferent arteriole. After glomerular filtration, the blood leaves the network of capillaries via the efferent arteriole (McDonald, 2019). Moreover, a portal of blood vessels extends from the afferent and efferent arterioles surrounding the proximal convoluted tubules, the loop of Henle, and the distal convoluted tubule to aid the urine concentration process.

Ultrafiltration in the Glomerulus

The formation of urine begins with the filtration process, which takes place in the glomerulus, a mesh of capillaries connected to the Bowman’s capsule. Ultrafiltration in the glomerulus does not require energy. However, it is accomplished through pressure build-up, which pushes the plasma and solute particles through the capillary walls. The process of filtration is aided through a three-layered membrane system (Lawrence et al., 2018). The fenestrated endothelia of capillaries in the permits plasma to pass through them, and not blood cells. Immediately, the negatively charged basement membrane blocks proteins from passing. Finally, the capsule of the capsule in the glomeruli develops a barrier that allows for the selected particles’ filtration. The efficiency of the filtration process is determined by the pressure create by the cardiac pumps of blood through the aorta, arteries, arterioles, and capillaries (Hickling et al., 2017). The net force for filtration generated in the glomeruli yields the glomerular filtrate channelled into the proximal convoluted tubule via the Bowman’s capsule.

Urine Concentration through Water and Ion Re-absorption

The kidney nephron is characterized by four tubular components in which reabsorption of water, ions, amino acids, and glucose takes place. The proximal convoluted tubule is attributed to the highest capacity of absorbing elements of the glomerular filtrate. From its lumen, sodium ions are taken back to the bloodstream by an active transport mechanism involving basolateral pumping of sodium-potassium ions (Lawrence et al., 2018). The secondary dynamic transport mechanism is involved in the reabsorption of amino acids, glucose, and vitamins. Moreover, water is reabsorbed by osmosis created by the ionic imbalance, which in turn drives the diffusion of lipids across the wall of proximal convoluted tubule into the bloodstream (Gupta & Sharma, 2020). The reabsorption of ions, sugar, amino acids, and lipids is essential in osmoregulation all over the body.

The glomerular filtrate moves into the loop of Henle, having the ascending and descending sections. The reabsorption of water through osmosis into the bloodstream main occurs in the descending spiral. On the other hand, potassium, sodium, and chloride ions are taken back to the bloodstream via the ascending loop of Henle (McDonald, 2019). The ATPase enzyme drives the process by creating an ionic gradient which makes the basolateral membrane of the symporter in the ascending loop to be functional in absorbing ions. Immediately after the loop of Henle, the filtrate enters the distal convoluted tubule where sodium ion absorption occurs. Mainly, active transport is involved in sodium-ion uptake via basolateral membrane (Lawrence et al., 2018). However, its passive absorption into the bloodstream occurs through sodium and chloride ion symporter on the apical plasmalemma. In the distal convoluted tubule, aldosterone hormone regulates sodium ion intake while parathyroid hormone controls the reabsorption of calcium ion (McDonald, 2019). Eventually, concentrated urine remaining in the lumen of the tubules moves into the collecting ducts, where final reabsorption occurs via active transport.

Conclusion

The concentrated urine is channelled into the pelvis; after that, it travels to the urinary bladder via the ureter. The kidney has two major homeostatic roles in the body, that is, maintenance of pH through balancing hydrogen ion concentration and osmoregulation. Moreover, it aids the purification of the blood by removing excess water, salts, and impurities. Its physiological functions encompass energy and the regulated hormonal process leading to the reabsorption of ions into the bloodstream. Thus, the structural and physiological function of the kidney allows urine formation and purification of blood.

References

Gupta, R., & Sharma, T. (2020). Review of urine formation in Ayurveda. Journal of Ayurveda and Integrated Medical Sciences, 5(1), 145-148.

Hickling, D. R., Sun, T. T., & Wu, X. R. (2017). Anatomy and physiology of the urinary tract: relation to host defence and microbial infection. In Urinary Tract Infections: Molecular Pathogenesis and Clinical Management (pp. 1-25).

Lawrence, E. A., Doherty, D., & Dhanda, R. (2018). Function of the nephron and the formation of urine. Anaesthesia and Intensive Care Medicine, 19(5), 249-253.

McDonald, M. D. (2019). The renal contribution to salt and water balance. In Fish Osmoregulation (pp. 309-331). CRC Press.

Wingerd, B., & Taylor, T. B. (2020). The Human Body: Concepts of Anatomy and Physiology. Jones & Bartlett Learning.

Introduction

Women’s breasts may not seem a rather essential part of their bodies. However, they indeed are because they let mothers feed their infants, and for many of them, these moments are unique and most valuable. Unfortunately, just like for any other body’s tissue, there are some dangerous conditions for breasts when special treatment and severe measures are required. The purpose of this paper is to discuss the anatomy of breasts and some common pathologies that may arise when a doctor is performing a mammogram.

Breast Anatomy

The breast is the special tissue that covers the pectoral (chest) muscles. It is made of fatty tissue and another particular tissue (glandular) that has the purpose of producing milk (“Picture of the breasts,” n.d.). Their size depends on the amount of fat, that is why if a woman loses weight, her breasts typically also become smaller. There are lymph nodes, lymph vessels, and blood vessels in the breast (“Picture of the breasts,” n.d.). Its milk-producing part is organized in about twenty sections – lobes, and each of them has lobules – smaller structures where milk is produced. In addition, there is a network of ducts that are tiny tubes through which milk travels.

Breast Pathologies Arising while Performing a Mammogram

Screening mammography is a unique tool used to look for unsuspected breast diseases when there are no evident symptoms. There are some malignant breast pathologies a mammogram can reveal, and most of them are at an early and potentially curable stage (“Picture of the breasts,” n.d.). Thus, screening mammography can see a breast lump before the client can feel it; micro-calcifications (tiny clusters of calcium); and specks or lumps caused by cysts, fatty cells, or cancer. In general, breast pathologies include:

• mastalgia – painful breasts
• breast lumps
• fibroadenomas – fibrous lump
• breast cysts
• benign fibrocystic disease
• nipple discharge
• mastitis – inflammation of the breast
• breast and nipple itchiness

Some types of breast cancer include:

• Metastatic Breast Cancer
• Phyllodes Tumors of the Breast
• Paget’s Disease of the Nipple
• Molecular Subtypes of Breast Cancer
• Male Breast Cancer
• Lobular Carcinoma in Situ
• Inflammatory Breast Cancer
• Invasive Lobular Carcinoma
• IDC Type: Papillary Carcinoma of the Breast
• Ductal Carcinoma in Situ (“Types of breast cancer,” 2018).

References

Picture of the breasts. (n.d.). WebMD. 2020, Web.

Types of breast cancer. (2018). Breastcancer.org. Web.

The knee joint is a rather necessary synovial joint that connects the tibia to the femur. In the knee, the tibiofemoral and the patellofemoral joints form a modified hinge joint, which lets the knee straighten, bend, and rotate from side to side. The purpose of the muscles surrounding the knee is to help keep it moving, well-aligned, and stable. The quadriceps femoris straightens the knee, and the hamstrings provide the opposite motion. Ligaments hold the bones stable, attach them, and give strength and stability to the knee joint. There are five knee ligaments: medial collateral, lateral collateral, anterior cruciate, posterior cruciate, and patellar.

Around the knee, there are four bones, and the femur (the thigh bone) is the longest one; it runs from the ankle to the knee. About 80-90% of the weight is carried by the tibia. Patella (knee cap) is a triangular semi-flat bone that has the purposes of increasing the force generated by the quadriceps muscle, moving the knee bends, and protecting the knee joint from trauma. The fibula helps to form the ankle joint and serves as an attachment for muscles like the lateral collateral ligament and biceps femoris.

The range of motion includes rotations (inward and outward), abduction (movement away from and towards the middle of the body), extension (straightening), and flexion (bending). Since the knee is a hinge joint, it primarily moves in one plane of movement, which is extension and flexion. The standard ROM measure includes 135° for a fully bent knee joint.

Spondylolisthesis

Classic Presentation

The patient, a female aged 67 years, presents with signs of stenosis coupled with pain over the fibrocartilaginous mass at the defect, and facet pathology at the L5 level of the lower spine. In addition, the patient seems to be symptomatic. The most presenting complaints include lateral recess stenosis and disk herniation, resulting in repeated instances of back pain, which worsens with activity but subsides with rest. According to the presentations compiled by Souza (2005), particularly the signs of stenosis, pain at the L4 or L5 joints, and the age factor, this may be a classical case of degenerative lumbar spondylolisthesis.

Cause

With the progression in age, bones, joints, and tendons supporting the spine tend to weaken and are no longer capable of embracing the spinal column in alignment (Yadla, 2008). As the facet joints (L4 or L5) age, they, on most occasions, become inept and permit too much flexion (the act of allowing the spine to bend forwards), giving rise to a situation where one vertebral body slips forwards onto the other (Yochum & Rowe, 1996).

Evaluation

The patient experience elevated levels of back pain when a one-legged balance test is performed on her. According to Souza (2005), this physical examination test involves requesting the patient to balance on one leg and hyperextend at the lumbar area. Radiological evaluation reveals a slippage of the vertebrae of two-fourths the AP length, implying that the condition is at grade 2. Souza (2005) observes that “…each slip of one-forth the length of the anterior to the posterior body is considered a grade” (p. 60). Lastly, the patient is female and over 60 years old. Yochum & Rowe (1996) note that degenerative lumbar spondylolisthesis is three times more common in old women than in old men

Management

Physical/manipulative therapy involving stretching and strengthening coupled with a proactive aerobics program, such as biking or undertaking water exercises, may offer the much-needed reprieve (Yadla, 2008) Since the condition is at Level 2, there is no need for surgical consultation (Souza, 2005), therefore allopathic medicine can only prescribe epidural steroids for short-term relief.

Thoracic Compression Fracture

Classic Presentation

The patient, a male of 77 years, presents with mid-back pain, particularly after engaging in minor events such as coughing or sneezing. Spine experts reveal that this type of disorder affects the thoracic spine, which forms the back of the chest wall, and “…consists of 12 vertebras, 10 of which have ribs attached, intervertebral discs separating each vertebra, supporting soft tissue, and twelve thoracic nerves” (PainDoctor.com, 2010 para. 2).

Cause

According to Souza (2005), the fracture may be caused by weakness in bones, sufficient trauma to a bone, early menopause, sustained usage of corticosteroids, and hyperthyroidism. The risk factors include the age of 40 years or greater; history of injury and/or deformities; poor posture; heavy physical work, and; lack of exercise (PainDoctor.com, 2010).

Evaluation

When medical history is evaluated, evidence demonstrates that “…long-term corticosteroid use or age greater than 70 years is suggestive of a compression fracture in patients with thoracic or lumbar complaints” (Souza, 2005 p. 100). Upon physical examination, the patient experience acute pain when deep pressure is placed over the involved vertebral area. Radiographic images will characteristically reveal “… wedge-shaped defect, with the anterior height being lower than the posterior” (PainDoctor.com, 2010).

Management

This is a chiropractic case. In addition to encouraging the patient to avoid flexion exercises, a restrictive corset may be placed over the involved region to remind the patient not to bow forward or engage in making abrupt movements (Souza, 2005). In terms of Allopathic medicine, non-steroidal anti-inflammatory drugs can be used for short-term relief.

Rheumatoid Arthritis

Classic Presentation

The patient, a female of 52 years, presents with acute pain emanating from the hip coupled with periarticular soft tissue swelling, muscle pain, stiffness, fatigue, and flu-like symptoms. Souza (2005) observes that the presentation of pain over the hip may sometimes be bilateral.

Cause

According to Souza (2005), “…the cause is a synovial inflammatory process that creates a destructive pant” (p. 313). While genetic composition and a weak immune system do not cause rheumatoid arthritis, they can make individuals progressively more vulnerable to the environmental factors believed to either cause or exacerbate the condition.

Evaluation

Radiographic evaluation reveals consistent, symmetric joint space attenuation superiorly, which may over time become bilateral, leading to other negative conditions such as subchondral cysts and osseous destruction (Souza, 2005). According to this author, laboratory evaluations may reveal “…elevated erythrocyte sedimentation rate (ESR) and a positive rheumatoid factor” (p. 313). Physical examination may reveal enlarged liver and/or spleen, joint swelling and redness, and joint tenderness (Yochum & Lowe, 1996).

Management

Depending on the scope of severity, rheumatoid arthritis may either be a chiropractic case or a medical referral. For less acute cases, a chiropractor may perform physical therapy, warm compresses, encourage the patient to engage in mild, passive movements to maintain hip motion and reduce tenderness and swelling (Souza, 2005). For acute cases, as is witnessed here, allopathic medicine can be used to prescribe non-steroidal anti-inflammatory drugs, interleukin receptor inhibitors, immunomodulators, or, in extreme cases, prescribe joint replacement surgery.

Reference List

PainDoctor.com. (2010). Thoracic Pain (Mid-Back Pain). Web.

Souza, T.A. (2005). Differential diagnosis and management for the chiropractor: Protocols and Algorithms, 3^rd Ed. Sudbury, MA: Jones and Bartlett Publishers.

Yadla, S. (2008). Degenerative Lumber Spondylolisthesis. Web.

Yochum, T.R., & Rowe, L.J. (1996). Essentials of skeletal radiology, volume 1. Baltimore, MD: Lippincott Williams & Wilkins.

The brachial plexus (C5, 6, 7, 8, T1)

The brachial plexus is positioned to the side of the last four cervical vertebrae and the first thoracic vertebra. It is formed by the anterior rami of C5 through T1, with occasional contributions from C4 and T2. From its emergence, the brachial plexus extends onward and laterally, passes over the first rib behind the clavicle, and enters the axilla. Each brachial plexus innervates the entire upper extremity of one side, as well as a number of shoulder and neck muscles (Faiz, & Moffat, 2002). Brachial plexus is divided anatomically into roots, trunks, divisions, and cords. The roots of the brachial plexus are simply continuations of the anterior rami of the cervical nerves. The anterior rami of C5 and C6 converge to become the superior trunk, the C7 ramus becomes the middle trunk, and the ventral rami of C8 and T1 converge to become the inferior trunk. Each of the three trunks immediately divides into an anterior division and a posterior division. The divisions then converge to form three cords. The posterior cord is formed by the convergence of the posterior divisions of the upper, middle, and lower trunks; hence, it contains fibers from C5 through C8. The medial cord is an extension of the anterior division of the lower trunk and primarily contains fibers from C8 and T1. The lateral cord is formed by the convergence of the anterior division of the upper and middle trunk and consists of fibers from C5 through C7. In summary, the brachial plexus is composed of nerve fibers from the anterior branches of spinal nerves C5 through T1 and a few fibers from C4 and T2. Roots are continuations of the anterior rami. The roots converge to form trunks, and the trunks branch into divisions. The divisions in turn form cords, and the nerves of the upper extremity arise from the cords (Groff, 2001).

The axillary nerve (C5, 6): This is a mixed sensory and motor nerve that arises from the posterior cord of the brachial plexus. It passes through the quadrangular space with the posterior circumflex humeral artery. It provides: a motor supply to deltoid and teres minor; a sensory supply to the skin overlying deltoid; and an articular branch to the shoulder joint. The axillary nerve is particularly prone to injury from the downward displacement of the humeral head during shoulder dislocations. Motor deficit loss of deltoid abduction with rapid wasting of this muscle. Loss of teres minor function is not detectable clinically. Sensory deficit is limited to the ‘badge’ region overlying the lower half of deltoid (Ogla, 2006, Groff, 2001).

The radial nerve (C5, 6, 7, 8, T1): This is a mixed sensory and motor nerve which arises as a continuation of the posterior cord of the brachial plexus. It runs with the profunda brachii artery between the long and medial heads of triceps into the posterior compartment and down between the medial and lateral heads of triceps. At the midpoint of the arm it enters the anterior compartment by piercing the lateral intermuscular septum. In the region of the lateral epicondyle, the radial nerve lies under the cover of brachioradialis and divides into the superficial radial and posterior interosseous nerves. The branches of the radial nerve include: branches to triceps, brachioradialis and brachialis as well as some cutaneous branches. It terminates by dividing into two major nerves: The posterior interosseous nerve passes between the two heads of supinator at a point three fingerbreadths distal to the radial head thus passing into the posterior compartment. It supplies the extensor muscles of the forearm; the superficial radial nerve descends the forearm under the cover of brachioradialis with the radial artery on its medial side. It terminates as cutaneous branches supplying the skin of the back of the wrist and hand. Injury occurs when humeral shaft gets a fracture resulting in damage to the radial nerve in the spiral groove: Motor deficit loss of all forearm extensors- wrist drop; Sensory deficit usually small due to overlap: sensory loss over the anatomical snuffbox is usually constant (Ogla, 2006, Groff, 2001).

The musculocutaneous nerve (C5, 6, 7): This is a mixed sensory and motor nerve which arises from the lateral cord of the brachial plexus. It passes laterally through the two conjoined heads of coracobrachialis and then descends the arm between brachialis and biceps, supplying all three of these muscles en route. It pierces the deep fascia just below the elbow (and becomes the lateral cutaneous nerve of the forearm). Here it supplies the skin of the lateral forearm as far as the wrist.

The median nerve (C6, 7, 8, T1): This is a mixed sensory and motor nerve which arises from the confluence of two roots from the medial and lateral cords lateral to the axillary artery in the axilla. The median nerve initially lies lateral to the brachial artery but crosses it medially in the mid-arm. In the cubital fossa it lies medial to the brachial artery which lies medial to the bicipital tendon. The median nerve passes deep to the bicipital aponeurosis then between the two heads of pronator teres. A short distance below this the anterior interosseous branch is given off. This branch descends with the anterior interosseous artery to supply the deep muscles of the flexor compartment of the forearm except for the ulnar half of flexor digitorum profundus. In the forearm the median nerve lies between flexor digitorum superficialis and flexor digitorum profundus and supplies the remaining flexors except for flexor carpi ulnaris. A short distance above the wrist it emerges from the lateral side of flexor digitorum superficialis and gives off the palmar cutaneous branch which provides a sensory supply to the skin overlying the thenar eminence. At the wrist the median nerve passes beneath the flexor retinaculum (i.e. through the carpal tunnel) in the midline and divides here into its terminal branches: the recurrent branch to the muscles of the thenar eminence (but not adductor pollicis); the branches to the 1st and 2^nd lumbricals; and the cutaneous supply to the palmar skin of the thumb, index, middle and lateral half of the ring fingers (Scanlon, 2007).

Other branches of the brachial plexus

Supraclavicular branches: Suprascapular nerve (C5, 6) which passes through the suprascapular notch to supply supra- and infraspinatus muscles, and long thoracic nerve (of Bell) (C5, 6, 7) which supplies serratus anterior (Eder, 2003).

Infraclavicular branches: Medial and lateral pectoral nerves which supply pectoralis major and minor, medial cutaneous nerves of the arm and forearm, thoracodorsal nerve (C6, 7, 8) which supplies latissimus dorsi, and upper and lower subscapular nerves which supplies subscapularis and teres major.

Brachial Plexus Injuries

Erb–Duchenne paralysis: Excessive downward traction on the upper limb during birth can result in injury to the C5 and C6 roots. This results in paralysis of the deltoid, the short muscles of the shoulder, brachialis and biceps. The combined effect is that the arm hangs down by the side with the forearm pronated and the palm facing backwards. This has been termed the ‘waiter’s tip’ position (Scanlon, 2007).

Klumpke’s paralysis: Excessive upward traction on the upper limb can result in injury to the T1 root. As the latter is the nerve supply to the intrinsic muscles of the hand this injury results in ‘clawing’ (extension of the metacarpophalangeal joints and flexion of the interphalangeal joints) due to the unopposed action of the long flexors and extensors of the fingers. There is often an associated Horner’s syndrome (ptosis, pupillary constriction and ipsilateral anhidrosis) as the traction injury often involves the cervical sympathetic chain (Scanlon, 2007).

Crutch paralysis: The radial nerve is vulnerable to several types of trauma. Crutch paralysis may result when a person improperly supports the weight of the body for an extended period of time with a crutch pushed tightly into the axilla. Compression of the radial nerve between the top of the crutch and the humerus may result in radial nerve damage. Likewise, dislocation of the shoulder frequently traumatizes the radial nerve. Children are particularly at risk as adults yank on their arms. A fracture to the body of the humerus may damage the radial nerve, which parallels the bone at this point. The principal symptom of radial nerve damage is wrist drop, in which the extensor muscles of the fingers and wrist fail to function. As a result, the joints of the fingers, wrist, and elbow are in a constant state of flexion (Scanlon, 2007).

Ulnar Nerve Damage: The ulnar nerve can be palpated in the ulnar sulcus between the medial epicondyle of the humerus and the olecranon of the ulna. This area is commonly known as the “funny bone” or “crazy bone.” Ulnar nerve damage may occur as the medial side of the elbow is banged against a hard object. The immediate perception of this trauma is a painful tingling that extends down the ulnar side of the forearm and into the hand and medial two digits. Although common, ulnar nerve damage is generally not serious (Scanlon, 2007; Guyton, 1991).

References

1. Eder, C. (2003) Laboratory atlas of anatomy and physiology. 4^th ed., New York: McGraw-Hill.
2. Faiz, O., and Moffat, D. (2002) Anatomy at a glance. Oxford: Blackwell Science.
3. Groff, V. D. (2001) Human anatomy. 6^th Ed., New York: McGraw-Hill.
4. Scanlon, V. C., (2007) Essentials of anatomy and physiology. 5^th ed., Philadelphia: E. A. Davis Company.
5. Ogla, H. J. (2006) Principles of anatomy and physiology. 3^rd ed., Nairobi, Kenya: Paloma Publishers.
6. Guyton, A. C., (1991) Textbook of medical physiology. Philadelphia: W. B. Saunders.

Introduction

This paper is a review of the historic anatomy of the pancreas. The pancreas is one of the most important organs in the digestive system. The paper seeks to analyze the development and discovery of the pancreatic functions in the body. The paper seeks to elaborate clearly the anatomy and structure of the pancreas and the specialized functions it performs in the body.

The report seeks to identify the functions of other organs that help in the digestive process where the pancreas is dominantly involved. This paper seeks to unveil the historic discovery of the pancreas and to document the structural and functional aspect of the organ.

Anatomy

The pancreas was one of the last organs that were discovered in the research conducted to explain the digestion process. The development of the pancreas research continued from 200 AD until the final details where established in 1664. The functions of the pancreas were examined using the pancreatic fistula of dogs¹. Nonetheless, the digestive functions of the pancreas were not discovered until 1844.

Anatomists discover that the pancreas was excreting a juice that emulsifies fats and digests starch¹. During this period, a demonstration to show the digestive action of the pancreas juice on sugar, fats, and proteins was presented¹. This experiment was carried out using the pancreas fistula of a dog. Although in 1876 the pancreatic functions were believed to be driven by an enzyme, this was later disapproved after the discovery of secretin in the juice.

After researchers discovered secretin that was contained in the pancreatic juice, they disapproved the belief of enzymatic action¹. Its body is elongated towards the left within the aorta and attached on it by the peritoneum of the lesser sac. Its head is positioned on the right and it is placed at one end where the duodenum bends ¹. The pancreas is divided into three parts, a neck, body and a tail. The tail stretches all the way to the gastric face of the spleen¹. Here, the body of the pancreas stretches leftward on the outer side of the aorta. It is retroperitoneal and it is held against the aorta by the peritoneum of the lesser sac.

The pancreas is positioned at the back of the abdomen and other organs including the liver, the small intestines to mention, but a few engulf it¹. The pancreas is shaped like a flat pear but its two ends are not equal in size. The bigger side, which is normally on the right hand side, is called the head while the smaller end is the tail. Several blood vessels surround the pancreas. They include the superior mesenteric artery, the superior mesenteric vein, the portal vein, and the celiac axis ¹.

Structure

The body of the pancreas and its tail connect without a clearly protruding point of contact between them. One of the observable characteristics of the tail is its mobility as its tip stretches out to the spleen. The tail at this point is contained and held between the splenorenal ligaments by the spleen, artery, and vein¹.

The function of the splenocolic ligaments is to attach the splenic mobile characteristic of the colon to the spleen. This function brings the colon closer to the pancreas where its digestive functions begin to take place¹. The pancreas has very vital function on a number of abdominal structures.

Through the formation of unit by the bile duct, the duodenum, and the pancreas, digestion is enhanced in the stomach ¹. The bile duct can be found on the right hand side of the gastroduodenal artery in the inner walls of the stomach¹. All these veins supply blood not only to the pancreas but also to other vital abdominal organs in the body.

The excretion of exocrine glands is vital in the digestion process. The glands are the driving force that allows smooth and effective digestion. They are found in the pancreas. During digestion, food enters through the mouth and goes directly to the stomach. Here, the pancreatic juices are released into the systems of ducts that lead to the pancreatic duct¹.

Variation of the pancreas

The size of the pancreas is not constant in all mammals. It differs depending on the embryological development of one individual to another. The pancreas develops in the form of two buds embroiled on the duodenum¹. The ventral bud is supposed to rotate fully under normal circumstances but in some cases, it may not complete a full cycle. This may lead to a situation called pancreatic divism.

Histological structure

The pancreas is made up of tissues that contain endocrine and exocrine functions, and this separation is observable when the pancreas is placed under a microscope¹. The tissues that contain endocrine functions are observed under the microscope as lightly stained groups of cells, and their scientific name is islets of Langerhans¹. The darker stains seen under the microscope form another group of cells that are called Acini. These groups of cells are set in lobes at odds by an emaciated tough wall.

The secretory cells of each group of tissues surround a small-intercalated canal¹. To perform their functions effectively, these cells are made up of many small granules of zymogens can be seen. A solitary sheet of columnar cells shapes the ducts. Since they are large, several layers of columnar cells can be clearly seen¹.

Ductal structure

Near the tail of the pancreas, a duct is formed from other ductile that helps in drainage. These ducts are responsible for draining the lobules of the glands¹. The pancreas has accessesory ducts that help it to communicate with the main duct. These ducts are located in the bile duct and in the minor papilla, which is situated in close proximity to the second duodenum¹. This close proximity allows efficient communication during digestion within the duodenum. The pancreas plays a major role in this process.

Conclusion

This research has reviewed clearly and efficiently the discovery of the pancreas. The paper has started by outlining the history and foundation of pancreatic discovery from the 200 AD. The development and experiments that led to the discovery of the pancreas and its functions have been chronologically presented.

The paper further outlines the anatomy of the pancreas in a detailed manner to explain its function in the digestion process. Several other organs that are related to the pancreas and its functions have also been discussed including the duodenum, the intestines, and the bile duct. This paper has explicitly discussed the histological structure of the pancreas in detail. The ductal structure of the pancreas has also been studied and outlined in this comprehensive research work.

References

Anatomy and Histology of the Pancreas. Jpck. 2013; 1(1): 1-8. Web.

By any standards, the functioning of the human body still remains a puzzling and complex experience. After several thousand years of intricate study, civilizations are yet to unearth all their mysteries. However, as a direct result of joint efforts by scientists, researchers and other theorists, a great deal of knowledge about how our body systems operate has been brought into the light. For example, we now have a more profound understanding of how the association between the Central Nervous System (CNS) and the Peripheral Nervous System (PNS) assist in the preservation of musculoskeletal integrity (Tortora & Derrickson, 2006). This section aims at discussing the functions and interactions of the structures of the nervous, skeletal and muscular systems involved in the movement of climbing a stairway to answer a phone call.

It is imperative to start the discussion at the peripheral nervous system (PNS), the conduit used by the body to relay sensory and motor signals between the CNS on the one hand and the body organs, body surface and musculoskeletal sections on the other hand (Tortora & Derrickson, 2006). The PNS also provides the body with a link to the external environment, not only in terms of reception of external stimuli such as a ringing telephone but also in responding to the stimuli. To climb upstairs to pick the phone, the sensory (afferent) division of PNS must relay signals to the CNS via sensory neurons, and use the spinal cord as the major conduit between the body and the CNS. The brain will then process the information and relay it back via the motor (efferent) division of the PNS to the affected effector organs. In the afferent division, the dendrites function to receive signals from other neurons and pass over the same information to the cell body, while axons fibers functions to conduct the signals from the cell body to other nerve fibers through the discharge of neurotransmitters known as acetylcholine (Tortora & Derrickson, 2006).

The semicircular canals and the otolith organs, classified as vestibular apparatuses in the afferent division, will definitely assist the person in terms of deciphering the position of the phone, not mentioning the fact that these structures will assist him to sustain positional equilibrium and balance while climbing up the stairs. The eyes will provide important information about the position of the phone relative to environment (Tortora & Derrickson, 2006). The proprioceptive fibers functions to supervise the stretch or contraction of the muscles involved in climbing up the stairs to pick up the phone. For example, they will monitor the tension within the anterior trunk muscles or rectus femoris and relay the signals to the CNS for processing.

The signals transmitted by the motor neurons of the efferent division stimulate various muscles used in the movement to contract or relax (Tortora & Derrickson, 2006). The effector organs found in the muscles functions to respond to the efferent impulse. In movement, most reflex activities occasioned by the efferent division are somatic reflexes, meaning that they have the capacity to activate skeletal muscles such as the quadratus femoris, tibialis, soleus, and bicep femoris (Blakey, 2006).

In climbing up the stairs to pick the phone, the skeletal system serves two fundamental functions – provide support for tissues and underlying muscles, and facilitate movement through the use of bones and appended muscles (Tortora & Derrickson, 2006). According to the authors, the mostly utilized bones in movement comes from the hip joint (femur and pelvic girdle), knee joint (femur and tibia), and ankle joint (tibia and calcaneus). Joints make it possible for one to accomplish a multiplicity of coordinated movements in diverse parts of the body. In climbing up the stairs, each of these joints generates two phases – the driving phase (leg is in direct contact with the ground) and the recovery phase (leg is in the air).

The musculoskeletal system makes use of the lever principle to make the muscles pull the affected bones so that the movement of climbing up the stairs to pick the phone is attained. While in the driving phase, mentioned above, the hip area utilizes gluteal and hamstring muscles such as biceps femoris and semitendinosus, while the ankle utilizes gastrocnemius muscle. The knee joint utilizes such muscles as rectus femoris, vastus lateralis and vastus intermedialis (Tortora & Derrickson, 2006). While in the recovery phase, the hip utilizes the iliopsoas muscles; the knee uses the hamstrings; and the ankle makes use of the tibialis anterior muscles. Muscles such as the trapezius and stemocleidomastoid, found within the neck region, assists the person to maintain the head in position while climbing the stairs, while others such as the rectus abdominus assists in maintaining an upright posture and body position. It is important to note that sensory (afferent) receptors of the PNS rooted in the muscles constantly relay information about the position of the muscles to the CNS, effectively enabling movement to be made without straining the muscles (Mcardle & Katch, 2005).

The physiology on body movements can never be possibly exhausted. However, by viewing body movements, scientists, sports personalities, trainers and other interested parties are able to critically appraise how one body movements influences and are influenced by another via a chain reaction involving the nervous systems, muscles, skeletons and joints (Mcardle & Katch, 2005). This is an important discovery for the posterity of mankind.

Reference List

Blakey, P. (2006). The muscle book. Bethany Turnpike Honesdale, PA: Himalayan Institute Press.

Mcardle, W.D., & Katch, V.L. (2005). Essentials of exercise physiology, (3^rd Ed), Lippincott Williams & Wilkins.

Tortora, G.J., & Derrickson, B.H. (2006). Principles of anatomy and physiology. River street, Hoboken, NJ: John Wiley & Sons, Inc.

Introduction

It is imperative to note that type-2 diabetes is a significant problem that affects an enormous percentage of the population, and many resources have been devoted to research and development of measures that would help to address this issue. The understanding of the way a particular disease affects the anatomy and living functions is vital because the knowledge that is gained may be utilized in studies. Moreover, it is necessary to understand that research in this area is highly important because the introduction of new ways of treatment may be vital, and some of the approaches that are currently used may not be regarded as efficient.

Body

The problem is that endocrine functions of the pancreas are affected most of the time. Alpha cells are vital because they help the body to create a hormone that is known as glucagon that increases the level of blood sugar. Moreover, it ensures that the amount is sufficient for the human brain to function efficiently. On the other hand, insulin is produced by beta cells that help to reduce these levels and control the use of sugar by a human body. However, possible changes to insulin levels can be particularly dangerous because the function of the endocrine system is affected. The production of insulin may be slowed down significantly, or it can be stopped. Also, it may be caused by the fact that a body may struggle to deal with functions of insulin in some cases. Elevated levels of glucose can be incredibly dangerous because vital aspects of the body are affected. Another aspect that needs to be discussed is that cells may not be capable of holding together if the condition is not controlled. Symptoms that are frequently associated with this disease also should be noted. Frequent urination is one of the issues that are noticed the most.

A weight change can also be extremely problematic and should be viewed as a worrying sign. Excessive thirst is also a significant problem that is worth mentioning. Also, it is necessary to mention that this form of this condition is the most common among the population. Another aspect that is worth noting is that it is necessary to have an understanding of risk factors that lead to the development of this condition. Obesity is regarded as the biggest problem, and many individuals do not have an understanding of the fact that it is a severe risk factor, and their behavior needs to be changed (Gower 2011). Insulin resistance that is frequently related to obesity is also incredibly problematic, and a wide range of measurement techniques have been developed. Also, a relationship between this aspect and obesity is still debated by scientists (Sinaiko & Caprio 2012). The fatigue that is caused by this illness also needs to be discussed. The problem is that such blood sugar levels reduce the circulation of the blood and cells are not provided with sufficient levels of oxygen and nutrients. The fact that kidneys have to produce much more urine than usual also needs to e mentioned. It is imperative to understand that it causes too much pressure, and it may lead to many complications. Chronic kidney disease is especially worrying because it may cause a failure of the organ, and a significant percentage of individual that was diagnosed with type-2 diabetes have to deal with this condition. Individuals that suffer from this condition are recommended to make changes to their diet, and some of the approaches that are suggested are incredibly efficient. Also, lifestyle changes are recommended in most cases, and health care professionals suggest that it helps to reduce possible risks. The need to lose weight may be viewed as one of the core aspects of the treatment, and this is a factor that needs to be taken into account.

The fact that those who suffer from type-2 diabetes are more likely to get infected is especially worrying. The most significant problem that individuals have to deal with is an understanding of the fact that this condition cannot be completely healed, and it frequently leads to depression and other psychological problems. However, one of the studies suggests that some of the issues that are caused by this illness may be reversed. It is also suggested that genetic and environmental factors may play a vital role (Taylor 2011). Moreover, the issue is that many individuals are under constant pressure because they have to manage their level of sugar in the blood, and it may limit some activities. Metabolic changes that individuals have to deal with are quite significant most of the time. The blood vessel and nerve damage also should be noted because it leads to severe consequences such as the development of diseases that are related to the cardiovascular system. It is paramount to understand that the risks that are associated with infections are also significantly increased, and it may be necessary to be much more careful and pay significant attention to such aspects as hygiene. It is paramount to understand that the impact on the body is quite significant if the condition is not treated promptly, and people that suffer from this condition are more likely to have to deal with such problems as amputation and others. Another aspect that is worth mentioning is that one of the recent studies suggests that type-2 diabetes is one of the risk factors that are associated with bone fractures because it is stated that material and dynamic abnormalities may be noted. For instance, high levels of glucose in blood may lead to nonenzymatic glycation (Leslie et al. 2012).

However, there is a need for future research because this is an area that is not yet fully explored. Issues with the vision that are caused by this disease should be regarded as especially problematic. Diabetic macular edema is a severe complication that is caused by the fact that significant amounts of fluid are accumulated in the central region of an eye. Nerve cells that are present in the macula control an ability of an individual to sense light, and any changes can lead to severe consequences, and blurred vision is a significant issue. Studies suggest that close to thirty per cent of individuals that have suffered from type-2 diabetes for more than twenty years develop this condition, and it indicates that the long-term impact of this disease is tremendous. Diabetic retinopathy is a complication that is especially worrying because blood vessels in this organ are damaged, and the severity of this problem may vary in some cases. Furthermore, it is imperative to understand that hypertension and hyperlipidemia are worrying factors that may cause many complications. Understandably, microvascular damage that is caused cannot be avoided in some cases, but necessary measures should be taken to prevent possible issues (Jaime et al. 2010).

The biggest problem that needs to be discussed is that individuals that suffer from this condition have to deal with comorbidities, and it complicates the treatment most of the time. Obesity should be viewed as especially problematic because it may lead to the development of many other dangerous illnesses. Metabolic syndrome is problematic because several risks are present, and it may not be an easy task to address all of the issues at once. It is imperative to understand that insulin sensitivity is reduced significantly, and function of beta cells is affected as well. Such significant changes lead to the development of this condition. The connection between coronary artery disease and type-2 diabetes has been established. The problem is that a presence of high levels of blood sugar leads to increased blood pressure. High cholesterol is also frequently related to this illness, and it is one of the core factors that are associated with cardiovascular diseases and such issues as heart attacks. The possibility of a cerebral infarction is a significant problem because the risks are much higher for individuals that are affected by this condition. Moreover, it is noted that the number of patients that have suffered a stroke in the past and are diabetic has been increasing over the years. Also, it is paramount to mention that such individuals have to deal with poorer outcomes because of unique aspects of this condition (Bejot & Giroud 2010).

Another problem that is worthy of a discussion is that patients that have to deal with this illness are more likely to suffer from inflammation processes, and it is noted that tumor necrosis factor is a marker that is frequently related to type-2 diabetes (Calle & Fernandez 2012). It is also stated that adiponectin that is manufactured by adipose tissue has an enormous impact on insulin sensitivity. The issue is that genetic and other reasons for such processes are not yet fully understood, but it is expected that the situation is going to be improved in the future because enormous amounts of resources are devoted to the research (). One of the studies suggests that the most attention should be paid to beta-cell function because it determines glucose cases most of the time. Kahn states that it is entirely possible that body-fat distribution is one of the core factors that lead to insulin resistance, and intro-abdominal fat should be analyzed (Kahn 2003). Dysfunction of beta cells is especially problematic because the body cannot produce sufficient amounts. Results of another study suggest that some genetic variants can be related to fasting protein, and the information that is received is truly fascinating (Strawbridge et al. 2011).

Conclusion

In conclusion, it is paramount to mention to understand that the impact of this condition on the body of an individual is quite significant, and it leads to the development of many other conditions if not controlled. It is necessary to mention that this disease is incredibly problematic because it affects an enormous percentage of the population and is much harder to manage than many other illnesses. It is suggested that many cases could have been prevented if individuals have paid attention to some of the factors and taken necessary measures that would help to reduce any possible risks that are related to this illness. The most attention should be devoted to preventive measures, and the population should be educated about the impact of this disease on the body of an individual and what course of action needs to be taken if someone suspects that he or she suffers from this condition. The problem is that some of the medicines that are currently used have numerous side-effects that may lead to severe complications, and management of type-2 diabetes is still viewed as a significant problem. Overall, it is evident that this condition affects almost every single system in the human body, but some of them are much more susceptible than others because of many factors, and it is necessary to have an understanding of possible risks.

Reference List

Ahlqvist, E, Ahluwalia, T & Groop, L 2011, ‘Genetics of Type 2 Diabetes’ Clinical Chemistry, vol. 57, no. 2, pp. 241-255.

Béjot, Y & Giroud, M. 2010, ‘Stroke in diabetic patients’, Diabetes & Metabolism, vol. 36, no. 1, pp. s84-87.

Calle, M & Fernandez, M 2012, ‘Inflammation and type 2 diabetes’, Diabetes & Metabolism, vol. 38, no. 3, pp. 183-191.

Gower, A 2011, ‘Type 2 diabetes’, Nursing Standard, vol. 25, no. 41, pp. 59.

Jaime, D, Thomas, C, Janet, M, Keri, K & Pamela, A 2007, ‘How the diabetic eye loses vision’, Endocrine, vol. 32, no. 1, pp. 107-116.

Kahn, S 2003, ‘The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of Type 2 diabetes’, Diabetologia, vol. 46, no. 1, pp. 3-19.

Leslie, W, Rubin, M, Schwartz, A & Kanis, J 2012, ‘Type 2 diabetes and bone’, Journal of Bone and Mineral Research, vol. 27, no. 11, pp. 2231-2237.

Sinaiko, A & Caprio, S 2012, ‘Insulin Resistance’, The Journal of Pediatrics, vol. 161, no. 1, pp. 11-15.

Strawbridge, RJ, Dupuis, J, Prokopenko, I, Barker, A, Ahlqvist, E, Rybin, D et al. 2011, ‘Genome-wide association identifies nine common variants associated with fasting proinsulin levels and provides new insights into the pathophysiology of type 2 diabetes’, Diabetes, vol. 60, no. 10, pp. 2624-2634.

Taylor, R 2011, ‘Reversing type 2 diabetes’, Practical Diabetes, vol. 28, no. 9, pp. 377-379.

Anesthesia is one of the most important inventions made by man. It is hard to imagine a world where there is no way to deal with the pain caused by surgery and other related medical procedures. Complicated medical procedures such as surgery require the application of appropriate anesthetic. But even with expert knowledge about anesthesia and the skills necessary to perform complex dental procedures, the patient can still suffer from unbearable pain if the dentist does not understand the complex nature of dealing with the inferior alveolar nerve or IAN. It is the responsibility of the dentist or surgeon to be familiar with these anatomical variations.

The IAN is a mixed nerve and the main reason why people have the ability to have sensory perception in the lower teeth, lower lip and buccal mucosa (Sandoval, Lopez, & Suazo 51). The IAN is the largest branch of the mandibular nerve (Pai, Swamy, & Prabhu 93). It represents a direct continuation of its posterior trunk and carries sensory and motor fibers (Lang 119). The IAN descends behind and positions itself lateral to the lingual nerve in the interpterygoid fascia between the pterygoid muscles (Lang 119). The IAN enters the mandibular foramen through the pterygomandibula space (Lang 119).

In addition, the IAN “supplies the mandibular teeth, a portion of its fibers exiting at the mental foramen as the mental nerve (Lang 119). This is the basic description of the IAN. But it is common knowledge among experts that the IAN can be observed as having different anatomical variations. These variations can have significant implications when it comes to oral healthcare especially in the context of surgery and other complex dental works.

Anatomical Variations

The IAN may form a single trunk with the lingual nerve and this extends as far as the mandibular foramen (Bergman, Afifi, & Miyauchi, 18) In another type of variation, the IAN can be separated from the lingual nerve by an accessory ligament that extends “from the lateral pterygoid plate and spine of the sphenoid to the lateral side of the pterygospinous ligament” (Bergman, Afifi, & Miyauchi, 18). In another case the IAN can be perforated by the internal maxillary artery (Manikandhan, Naveenkuma, & Anantanarayanan 185). In another kind of variation, the IAN may have accessory roots connected to the mandibular nerve.

In another type of variation, the IAN mylohyoid branch can be the reason why there is a branch that goes through the mylohyoid muscle and joins the lingual nerve. In other cases, it was observed that these branches that arise from the mylohyoid branch and communicates with the depressor anguli oris as well as parts of the platysma (Sandoval, Lopez, & Suazo 51). It is interesting to note that this section is usually supplied by the facial nerve but in this case the IAN figured prominently in how the person perceives pain if the dentist fails to appreciate the variations that exist in the relation to this particular nerve and where its anatomical branches are located.

In other cases it was discovered that the IAN formed several connections with the auriculotemporal nerve (Bergman, Afifi, & Miyauchi, 18). But in a rare case that was documented, the roots of the third lower molar tooth surrounded the IAN (Sandoval, Lopez, & Suazo 52). It has to be made clear that the infratemporal fossa “consists of two pterygoid muscles, maxillary vessels and mandibular nerves and its branches (Pai, Swamy, & Prabhu 93). It is the site where surgery is usually performed. Therefore, it is of primary importance that surgeon, neurosurgeon, maxillofacial surgeon and even radiologist must be aware of the fact that variations do exist. Specialists may be unaware of the variation or simply could not accept the fact that the occurrence may not be as rare as they thought.

In another type of variation, researchers were able to discover the close interrelationship of the lingual nerve and IAN. Due to the variation, researchers were able to establish that these two types of nerves were able to communicate to each other (Sandoval, Lopez, & Suazo 51). This was made possible because according to the report, the IAN was “origin by two roots and the second portion of the maxillary artery passed through the two roots of the IAN (Sandoval, Lopez, & Suazo, 51). This conclusion was partly based on the findings made by other researchers. After examining the lingual nerves in 48 hemisectioned human heads, they were able to discover that there were communications or bridges between the lingual nerve and IAN (Sandoval, Lopez, & Suazo, 52).

A more detailed explanation was given by the researchers and they wrote: “The maxillary artery was observed along the nerve juncture produced between the IAN and the lingual never and the nervous bridge between the two, located 5.4mm from the foramen ovale, passing between the lingual nerve and the IAN (Salvador, Lopez, & Suazo, 52). It is of grave importance that healthcare providers must be aware of the details pertaining to the infratemporal fossa and the common variations especially when it comes to the IAN.

Importance of Understanding Anatomical Variations

Any variation in the IAN can give rise to “neurovascular compression causing numbness, regional pain and headache” as a direct result of the inadequate application of anesthesia (Manikandhan, Naveenkuma, & Anantanarayanan 185). But the root cause is the inability to deal correctly with the effect of the variations in the IAN and other related nerves and artery. Consider for instance the impact of the following discovery when an adult male cadaver, who was about forty years old, was dissected. During the dissection, the ramus was excised above the mandibular foramen and this is what the researchers found out:

In the right infratemporal fossa, the inferior alveolar nerve was seen to emerge from three different roots instead of a single root from the posterior division of the mandibular nerve. These variant roots emerged from the posterior division of the mandibular nerve, and the lingual nerve (Pai, Swamy, & Prabhu 93).

Based on these findings, specialists urged one another to keep in mind the impact of variations in the IAN. One practical application of this discovery is the need to determine how to deliver the correct dosage when it comes to the use of anesthesia. In another case, the variation of the IAN was made possible by the rare variation in the inferior alveolar artery. This is significant because the IAN descends into the mandibular foramen together with the inferior alveolar artery. Thus, the researcher who discovered this anomaly made a report regarding their find as they completed their examination of a 63-year old cadaver (Khaki et al. 345). After they detached the coronoid process and removed the ramus of the left mandible of the said cadaver, they found out that the inferior alveolar artery originated from the external carotid artery (Khaki et al. 345). In addition it was also discovered that the location of the artery was 3.5 cm inferior to its terminal bifurcation into the maxillary and superficial temporal arteries (Khaki et al. 345).

This variation is significant because the dentist has to be aware of these anomalies when it comes to dental, oral and maxillofacial surgery. Since the IAN is the largest branch of the mandibular nerve, it is the target in the event of dental procedures and the goal is to achieve mandibular anesthesia (Khaki et al. 346). Therefore, there is potential hazard to cause vascular trauma. It has been reported that arterial penetration can reach as high as 20% and so the variation can negatively affect the health of the patient.

Another example of variation was discovered when doctors attempted to perform surgery on a 20 year old Indian female. The specialists wanted to operate on the said individual because she was diagnosed with hemifacial microsomia but they found out that the IAN perforated the ramus of the mandible “with a very short intra-bony course and exiting laterally” (Manikandhan, Naveenkuma, & Anantanarayanan 185). This again is another proof that variations come in different forms but the more important thing to remember is that it occurs frequently.

Conclusion

In the case of dental or maxillofacial, the specialist must not underestimate the importance of variation. In most anatomical variations of the IAN, the obvious consequence is the failure of the anesthesiologist when it comes to pain management. But in other forms of variation, such as those that are brought about by variations in other major artery or nerve the consequence can be as simple as vascular trauma or death. It is therefore important that healthcare providers must be knowledgeable about this particular anatomical variation.

Works Cited

Bergman, Ronald, Adel Afifi, and Ryosuke Miyauchi. Illustrated Encyclopedia of Human Anatomic Variation. IA: University of Iowa Press, 1996. Print.

Khaki, Amir et al. “A Rare Variation of the Inferior Alveolar Artery with Potential Clinical Consequences.” Folia Morphology 64.4 (2005): 345-346. Print.

Lang, Johannes. Clinical Anatomy of the Masticatory Apparatus Peripharyngeal Spaces. New York: Thieme Publishers, 1995. Print.

Manikandhan, R., J. Naveenkuma, and P. Anantanarayanan. “A Rare Variation in the Course of the Inferior Alveolar Nerve.” International Journal of Oral & Maxillofacial Surgery 39.2 (2010): 185-187. Print.

Pai, Mangala, Ravindar Swamy and Latha Prabhu. “A Variation in the Morphology of the Inferior Alveolar Nerve with Potential Clinical Significance.” Biomedical International 1 (2010): 93-95. Print.

Sandoval, Catherine, Bernarda Lopez, and Ivan Suazo. “An Unusual Relationship Between the Inferior Alveolar Nerve, Lingual Nerve and Maxillary Artery.” International Journal of Odontostomatol 3.1 (2009): 51-53. Print.