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The monosaccharides are mainly hexoses (six-carbon sugars) order 60 caps confido amex prostate cancer 3 plus 3, and glucose is by far the most abundant of these buy confido 60 caps with visa prostate cancer 8-10. Glucose is obtained directly from the diet or from the digestion of dis- Carbohydrates Are Digested in Different Parts of accharides, oligosaccharides, or polysaccharides. The next the GI Tract most common monosaccharides are galactose, fructose, and The digestion of carbohydrates starts when food is mixed sorbitol. Galactose is present in the diet only as milk lactose, with saliva during chewing. The enzyme salivary amylase a disaccharide composed of galactose and glucose. Fructose acts on the -1,4-glycosidic linkage of amylose and amy- is present in abundance in fruit and honey and is usually lopectin of polysaccharides to release the disaccharide present as disaccharides or polysaccharides. Sorbitol is de- maltose and oligosaccharides maltotriose and -limit dex- rived from glucose and is almost as sweet as glucose, but sor- trins (Fig. Because salivary amylase works best at bitol is absorbed much more slowly and, thus, maintains a neutral pH, its digestive action terminates rapidly after the high blood sugar level for a longer period when similar amounts are ingested. It has been used as a weight-reduction bolus mixes with acid in the stomach. Sucrose, present in sugar cane and honey, is composed of glucose and fructose. Amylose The digestible polysaccharides are starch, dextrins, and glycogen. Starch, by far the most abundant carbohydrate in the human diet, is made of amylose and amylopectin. Amy- α-Amylase lose is composed of a straight chain of glucose units; amy- lopectin is composed of branched glucose units. Glycogen is a highly branched polysaccharide that stores carbohydrates in the body. Normally, about 300 to 1,6 Link 400 g of glycogen is stored in the liver and muscle, with more stored in muscle than in the liver. Muscle glycogen is 1,4 Link used exclusively by muscle, and liver glycogen is used to α-Amylase provide blood glucose during fasting. Dietary fiber is made of polysaccharides that are usually Maltotriose α-Limit dextrin Maltose poorly digested by the enzymes in the small intestine. They have an extremely important physiological function in that they provide the “bulk” that facilitates intestinal motility and function. Many vegetables and fruits are rich in fibers, The digestion products of starch after ex- FIGURE 27. CHAPTER 27 Gastrointestinal Secretion, Digestion, and Absorption 499 fore this point. Pancreatic amylase continues the digestion of the remaining carbohydrates. However, the chyme must first be neutralized by pancreatic secretions, since pancre- atic amylase works best at neutral pH. The products of pan- creatic amylase digestion of polysaccharides are also malt- ose, maltotriose, and -limit dextrins. The digestion products of starch and glycogen, to- gether with disaccharides (sucrose and lactose), are fur- ther digested by enzymes located at the brush border membrane. Enterocytes Play an Important Role in Carbohydrate Absorption and Metabolism Monosaccharides are absorbed by enterocytes either ac- tively or by facilitated transport. Glucose and galactose are absorbed via secondary active transport by a symporter (see FIGURE 27. The movement of Na into the cell, down concentration and electrical gradients, effects the uphill movement of glucose into the cell. The low intracellular Na concentration is maintained by the The sugars absorbed by enterocytes are transported by basolateral membrane the portal blood to the liver where they are converted to Na /K -ATPase. After a meal, the level of the Na /K -ATPase activity and the K conductance of blood glucose rises rapidly, usually peaking at 30 to 60 min- the basolateral membrane. The concentration of glucose can be as high as 150 a higher concentration than in plasma and leave the cell by mg/dL.

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This molecule is either isomerized to form glucose 6-phosphate or metabo- lized by the glycolytic pathway confido 60caps low cost man health medication. Fructose 1-phosphate is used by the glycolytic pathway more efficiently than glu- cose 6-phosphate generic confido 60caps with mastercard prostate cancer prognosis. Galactose is an important sugar used not only to provide energy but also in the biosynthesis of glycoproteins and glycolipids. When galactose is taken up by the liver, it is phosphorylated to form galactose 1-phosphate, which then reacts with uridine diphosphate-glucose, or UDP-glucose, to form UDP-galactose and glucose 1-phosphate. The UDP-galactose can be used for glycoprotein and glycolipid biosynthesis or converted to UDP-glucose, which can then be recycled. Gluconeogenesis is the production of very low density lipoprotein; TG, triglycerides; TCA, tricar- glucose from noncarbohydrate sources such as fat, amino boxylic acid. CHAPTER 28 The Physiology of the Liver 519 cible; the lipid droplets coalesce in an aqueous medium. The human liver normally has a consider- lipoprotein particles stabilize the hydrophobic triglyceride able capacity to produce VLDLs, but in acute or chronic center of the particle. During fasting, fatty acids are mobilized from adipose Liver VLDLs are associated with an important class of tissue and are taken up by the liver. The two forms of circulating hepatocytes to provide energy via -oxidation, for the gen- apo B are B48 and B100. The human liver makes only apo eration of ketone bodies, and to synthesize the triglyceride B100, which has a molecular weight of about 500,000. After feeding, chylomi- B100 is important for the hepatic secretion of VLDL. In crons from the small intestine are metabolized peripherally, abetalipoproteinemia, apo B synthesis and, therefore, the and the chylomicron remnants formed are rapidly taken up secretion of VLDLs is blocked. The fatty acids derived from the triglycerides seen in the cytoplasm of the hepatocytes of abetalipopro- of the chylomicron remnants are used for the formation teinemic patients. Although considerable amounts of circulating plasma LDLs and HDLs are produced in the plasma, the liver also Fatty Acid Oxidation and Synthesis. Fatty acids derived produces a small amount of these two cholesterol-rich from the plasma can be metabolized in the mitochondria of lipoproteins. LDLs are denser than VLDLs, and HDLs are hepatocytes by -oxidation to provide energy. The function of LDLs is to transport are broken down to form acetyl-CoA, which can be used in cholesterol ester from the liver to the other organs. HDLs the tricarboxylic acid cycle for ATP production, in the syn- are believed to remove cholesterol from the peripheral tis- thesis of fatty acids, and in the formation of ketone bodies. Because fatty acids are synthesized from acetyl-CoA, any The formation and secretion of lipoproteins by the liver substances that contribute to acetyl-CoA, such as carbohy- is regulated by precursors and hormones, such as estrogen drate and protein sources, enhance fatty acid synthesis. For instance, during fasting, the fatty The liver is one of the main organs involved in fatty acid acids in VLDLs are derived mainly from fatty acids mobi- synthesis. Palmitic acid is synthesized in the hepatocellular lized from adipose tissue. In contrast, during fat feeding, cytosol; the other fatty acids synthesized in the body are fatty acids in VLDLs produced by the liver are largely de- derived by shortening, elongating, or desaturating the rived from chylomicrons. As noted earlier, the fatty acids taken up by the liver can be used for -oxidation and ketone body formation. One of the major functions of the ative amounts of fatty acid channeled for these various pur- liver in lipid metabolism is lipoprotein synthesis. The four poses are largely dependent on the individual’s nutritional major classes of circulating plasma lipoproteins are chy- and hormonal status. More fatty acid is channeled to keto- lomicrons, very low density lipoproteins (VLDLs), low- genesis or -oxidation when the supply of carbohydrate is density lipoproteins (LDLs), and high-density lipoproteins short (during fasting) or under conditions of high circulating (HDLs) (Table 28. These lipoproteins, which differ in glucagon or low circulating insulin (diabetes mellitus). In chemical composition, are usually isolated from plasma ac- contrast, more of the fatty acid is used for synthesis of cording to their flotation properties.

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Studies on the elastic properties of human iso- cuff is not fully transmitted to the underlying artery buy confido 60 caps line prostate 3 biopsies. In older adults (or those serving a profile of the pressure drop along the vascular tree who have “stiff” or hard-to-compress blood vessels from (Fig generic confido 60caps on-line prostate cancer untreated. Little change in pressure occurs in the aorta and other causes, such as arteriosclerosis), additional external large arteries. Approximately 70% of the pressure drop oc- pressure may be required to compress the blood vessels and curs in the small arteries and arterioles, and another 20% stop the flow. This extra pressure gives a falsely high estimate occurs in the capillaries. Obesity may contribute to an inaccurate smooth muscle in the walls of small arteries and arterioles assessment if the cuff used is too small. When medium and large arteries are affected by disease, THE NORMAL RANGE OF ARTERIAL PRESSURE they may become major sources of increased resistance and significantly reduce blood flow to regions of the body (see As with all physiological variables, values for individuals are Clinical Focus Box 15. Although the range of blood pressures in the population as a whole is rather broad, changes in a given patient are of diagnostic impor- Blood Viscosity, Vessel Length, and Vessel tance. Normal arterial blood pressure in adults is approxi- Radius Affect Resistance mately 120 mm Hg systolic and 80 mm Hg diastolic (usu- To understand the importance of smooth muscle in the ally written 120/80). An increase in viscosity raises vascular resist- blood pressure rises until the sixth decade of life after which ance and, thereby, limits flow. Blood pressure is higher among pends on blood flow as well as blood oxygen content, a lim- African Americans than Caucasian Americans. Blood pres- ited flow can negate the increase in oxygen content sure is higher among men than among women with func- resulting from the increased number of red blood cells. Dietary fat and salt, as well as obesity, are as- individuals with polycythemia (an increased number of red sociated with higher blood pressures. Other factors that blood cells), less oxygen may actually be delivered to tis- affect blood pressure are excessive alcohol intake, physical sues because of increased viscosity; this occurs despite the activity, psychosocial stress, potassium and calcium intake, enhanced oxygen-carrying capacity provided by the extra and socioeconomic status. A normal hematocrit reflects a good bal- ance between sufficient red blood cells for oxygen trans- port and the viscosity caused by red blood cells. Hypertension Is a Sustained Elevation in Blood Pressure Epidemiological data show that chronically elevated blood 120 pressure is associated with excess cardiovascular morbidity and mortality. In adults, hypertension is defined as sustained 100 systolic blood pressure of 140 mm Hg or higher, sustained diastolic blood pressure of 90 mm Hg or higher, or taking 80 antihypertensive medication. Hypertension causes damage 60 to the arterial system, the myocardium, the kidneys, and the nervous system, including the retinas. Medical treatment 40 that lowers blood pressure to normal values significantly re- duces the risk of damage of these target tissues. Pulse pressure is greatest in The relative importance of the various segments contribut- the aorta and large arteries. The greatest drop in pressure occurs ing to the systemic vascular resistance is appreciated by ob- in the arterioles. Strokes are the third leading from atherosclerotic disease depend on which arteries are cause of death in the United States and a leading cause of stenotic (narrowed) and the severity of the reduction in significant disability. Regions commonly affected by atherosclerosis As with the heart, mild arterial disease involving the include the heart, brain, and legs. Muscle ischemia produces pain sions are relatively mild, blood flow may be inadequate called claudication, which typically resolves rapidly only when the myocardial demand is high, such as during when the patient rests. If blood flow is inadequate to meet the metabolic vere, symptoms may progress to include rest pain and, needs of a particular tissue, the tissue is said to be is- chemic. In the heart, short periods of ischemia may pro- ultimately, limb infarction with gangrene. As the disease pro- In all of these cases, blood flow to the affected organ gresses and the coronary stenosis becomes more severe, may be preserved by the development of collateral arter- ischemia tends to occur at increasingly lower cardiac work- ies, which can carry blood around the stenotic or occluded loads, eventually resulting in angina at rest. When collateral flow is inadequate to vere stenosis and/or complete occlusion of the coronary meet needs, blood flow may be improved with angio- arteries, blood flow may become inadequate to maintain plasty (using a balloon catheter, laser, etc. Millions of people in the United States are affected route blood around a blockage). More than 1 million revas- by coronary disease, with more than 1 million experienc- cularization procedures using these techniques are per- ing myocardial infarction each year and 700,000 ultimately formed in the United States annually. Returning to equation 3, despite the potential effect of growth) and is, therefore, not important as a physiological blood viscosity on resistance, hematocrit normally does not determinant of vascular resistance.

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The disease can adversely impact the roles of provider order 60 caps confido with amex androgen hormone supplements, spouse quality confido 60caps mens health 8 week program, parent, friend, and employee. There are emotional consequences of the disease as well as physical ones. As the disease is one for life, individuals and families will have multiple needs throughout their lives. They will need emotional support, education, symptom management, adaptation to changes, adaptive equipment, supportive care, and perhaps even end of life care. Nursing is a critical element in meeting the multiple needs of the MS patient and family. MS nurses have evolved from home-based care providers giving support to the disabled person to certified MS nurs- es and advanced practice nurses who must be well educated in the disease process and the available treatments. In addition, MS nurses must be sensitive to and supportive of the emotional needs of those affected by the disease. MS nurses must provide appropriate educa- v vi PREFACE tion regarding the disease process, treatment regimes, symptom man- agement, and community resources. Nurses need to share experiences and knowledge to support MS patients and families as well as each other. Through the vision of June Halper, MSCN, ANP, FAAN, the International Organization of Multiple Sclerosis Nurses (IOMSN) was founded in 1997. Its mission is to establish and perpetuate a specialized branch of nursing in mul- tiple sclerosis; to establish standards of nursing care in multiple scle- rosis; to support multiple sclerosis nursing research; to educate the healthcare community about the disease; and to disseminate this knowledge throughout the world. The ultimate goal of the IOMSN is to improve the lives of everyone affected by multiple sclerosis through the provision of appropriate healthcare services. This IOMSN determined that the expertise of the MS nurse need- ed to be developed and recognized. To that end an international cer- tification board, separate from the IOMSN, was established and a cer- tification process was developed. The first MS nursing certification exam was given on June 5, 2002 in Chicago, Illinois. Prior to the exam several review courses were held in various locations. It was clear following the review courses that a tremendous amount of knowledge is need- ed to be an “expert” in MS nursing. This core curriculum summarizes in outline form the basic con- cepts of multiple sclerosis and MS nursing. Each chapter provides rel- evant information as well as references for further study. Readers will learn about the history of MS, as well as the current theories regard- ing the immunologic basis for the disease. Pharmacologic strategies that include treatment for acute attacks, immunomodulating thera- pies, and symptomatic therapies are discussed, as are nonpharmaco- logic interventions. This text provides the reader with essential information about mul- tiple sclerosis and its management. It is an excellent review for those interested in MS nursing certification, and an excellent resource and reference for the MS nurse. Through the dedicated efforts of June Halper, this core curriculum is available to all of us involved with the care of persons with MS. Kathleen Costello, RN, MS, CRNP, MSCN President, International Organization of Multiple Sclerosis Nurses (IOMSN) Chapter 1 The History of Multiple Sclerosis Care Objectives: Upon completion of this chapter, the learner will: Identify the evolution of knowledge that has impacted the care of people with multiple sclerosis (MS) Discuss turning points in the definition of MS Describe the networks in MS careMultiple sclerosis (MS) is a common neurologic disease of young adults. It affects people in the prime of their lives with unpredictability and uncertainty. Margaret Gatty 1 2 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM F. BarbellionAn early monograph on MS was written by Charles Prosper Ollivier. These included anatomic depictions of autopsy findings and the description included a clinical history. He added to the observations of Carswell, Cruveilhier, and the German physician von Frerichs with his own, calling the disease le sclerose en plaques or scarring in patches. Theories of causation ranged from infection to genetics, vascular problems, and immunologic deficits.

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