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For example generic cefixime 100 mg mastercard, the nucleus contains the enzymes for DNA and Veere’s cholera are gram-negative bacteria purchase 100mg cefixime free shipping. Their plasma membrane is surrounded by a Not all cells in the human are alike buy 100 mg cefixime free shipping. Different cell types differ quantitatively thin cell wall composed of a protein–polysac- in their organelle content purchase 200 mg cefixime with visa, or their organelles may contain vastly different charide structure called peptidoglycan and an outer membrane generic 100mg cefixime otc. In contrast, gram-positive amounts of a particular enzyme, consistent with the function of the cell. For bacteria have a plasma membrane and a thick example, liver mitochondria contain a key enzyme for synthesizing ketone bod- peptidoglycan cell wall that retains the Gram ies, but they lack a key enzyme for their use. Thus, the enzymic content of the organelles varies somewhat from cell tions, but also can grow under low oxygen type to cell type. They possess enzymes similar to those in human cells for glycolysis, the TCA cycle, and oxidative phosphorylation. PLASMA MEMBRANE have a low tolerance for acid, which partially A. Structure of the Plasma Membrane accounts for their presence in slightly basic seawater and shellfish. All mammalian cells are enclosed by a plasma membrane composed of a lipid bilayer (two layers) containing embedded proteins (Fig. The membranes The variable carbohydrate compo- are continuous and sealed so that the hydrophobic lipid bilayer selectively nents of the glycolipids on the cell restricts the exchange of polar compounds between the external fluid and the surface function as cell recognition intracellular compartment. The membrane is referred to as a fluid mosaic markers. For example, the A, B, or O blood because it consists of a mosaic of proteins and lipid molecules that can, for the groups are determined by the carbohydrate most part, move laterally in the plane of the membrane. The proteins are classi- composition of the glycolipids. Cell surface fied as integral proteins, which span the cell membrane, or peripheral proteins, glycolipids may also serve as binding sites which are attached to the membrane surface through electrostatic bonds to lipids for viruses and bacterial toxins before pene- or integral proteins. Many of the proteins and lipids on the external leaflet con- trating the cell. For example, the cholera AB tain covalently bound carbohydrate chains and therefore are glycoproteins and toxin binds to GM1-gangliosides on the sur- glycolipids. This layer of carbohydrate on the outer surface of the cell is called face of the intestinal epithelial cells. The toxin is then endocytosed in caveolae the glycocalyx. LIPIDS IN THE PLASMA MEMBRANE Each layer of the plasma membrane lipid bilayer is formed primarily by phos- One of the bacterial toxins secreted pholipids, which are arranged with their hydrophilic head groups facing the aque- by Clostridium perefringens, the ous medium and their fatty acyl tails forming a hydrophobic membrane core (see bacteria that cause gas gangrene, Fig. The principle phospholipids in the membrane are the glycerol lipids is a lipase that hydrolyzes phosphocholine phosphatidylcholine, phosphatidylethanolamine, and phosphatidylserine and the from phosphatidylcholine and from sphin- sphingolipid sphingomyelin (Fig. The resulting lysis of the cell ferent cell types, with phosphatidylcholine being the major plasma membrane lipid membrane releases intracellular contents in most cell types and sphingolipids the most variable. These bacteria are strict anaer- The lipid composition of the bilayer is asymmetric, with a higher content of phos- obes and grow only in the absence of oxy- phatidylcholine and sphingomyelin in the outer leaflet and a higher content of phos- gen. As their toxins lyse membranes in the phatidylserine and phosphatidylethanolamine in the inner leaflet. Phosphatidylserine endothelial cells of blood vessels, the capil- contains a net negative charge that contributes to the membrane potential and might be laries are destroyed, and the bacteria are important for binding positively charged molecules within the cell. Phosphatidylinosi- protected from oxygen transported by the tol, which is found only in the inner membrane, functions in the transfer of informa- red blood cells. They are also protected from tion from hormones and neurotransmitters across the cell membrane into the cell antibiotics and components of the immune (Fig. CH3 CH CH N+ CH 3 O 3 3 P + + o CH3 N CH3 NH3 C O— CH2 l + CCH2 CH2 H3N C H CH2 a r CH2 CH2 CH2 O O O O O — h e O P O— O P O— O P O— O a d O O O CH2 H2C CH CH2 HC NH Ethanolamine Serine C O C O HOCH C O CH2 CH2 HC CH2 CH2 CH2 CH CH2 H CH2 CH2 CH2 CH2 y CH CH CH CH d 2 2 2 2 r CH2 CH2 CH2 CH2 o p CH2 CH2 CH2 CH2 h CH CH CH CH o 2 2 2 2 b CH2 CH2 i c CH2 CH2 t CH2 CH2 a CH2 CH2 i l CH2 CH2 s CH CH 2 2 CH2 CH2 CH2 CH3 CH2 CH3 Phosphatidyl- Sphingomyelin choline Fig. Common phospholipids in the mammalian cell membrane. The polar head groups shown for ethanolamine and serine replace the choline in phosphatidylcholine to form phos- phatidylethanolamine and phosphatidylserine, respectively. Phosphatidylcholine, phos- phatidylethanolamine, and phosphatidylserine are phosphoacylglycerols.

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Sub- periosteal dissection is undertaken around the inferior border of the lateral calcaneus cheap 100mg cefixime free shipping. A retractor is placed around the inferior border of the lateral calcaneus buy 200 mg cefixime amex. An oscillating saw is used and the calcaneus is transected in the trans- verse plane at the level just anterior to the middle facet (Figure S5 effective cefixime 100 mg. If the medial side of the calcaneus is not completely tran- sected with the saw cheap cefixime 200mg, it should be completed with an osteotomy (Fig- ure S5 buy cefixime 100mg online. The osteotomy now should be free and easy to be distracted, usually using a lamina spreader at the superior lateral corner of the osteotomy. The osteotomy is spread until the foot appears to be corrected. If the peroneus brevis is contracted limiting the amount of opening of the osteotomy, a separate incision is made 6 to 8 cm proximal to the tip of the lateral malleolus, and the peroneus tendon is exposed posterior to the fibula. If good muscle belly is present, a myofascial lengthening is made; however, if only tendon is encountered, a Z- lengthening of the peroneus brevis is performed. By spreading the osteotomy with a Cobb elevator or lamina spreader, the forefoot should swing into adduction and supination should cor- rect. The osteo- tomy is distracted until the forefoot adduction and supination have been corrected, usually requiring approximately 10 mm of lateral opening. Using the amount of distraction as a guide, bank bone or the patient’s iliac crest bone is harvested and shaped into a trapezoid with the wide area pointing lateral and superior in the osteotomy. Usually, the width of this graft is approximately 1 cm on the wide side and 5 mm on the narrow end, but the specific size should be determined by the amount of distraction needed (Figure S5. The osteotomy is fixed with a longitudinal K-wire or with a two-hole semitubular plate (Figure S5. The foot again is assessed carefully to determine if there is any first ray elevation of the medial column, especially to determine if first ray elevation occurs with dorsiflexor pressure on the plantar surface. Also, if dorsiflexor pressure causes forefoot abduction and dorsi- flexion through the lateral column at the calcaneocuboid joint, this deformity also needs to be corrected. Additional medial and lateral column correction is performed utilizing procedures discussed in cal- caneocuboid joint lengthening and forefoot supination and medial ray elevation procedures. Postoperative Care The foot is immobilized in a short-leg walking cast with a good mold to hold the foot in its corrected position and to mold in both medial and lateral lon- gitudinal arches. The toes are kept in the dorsiflexed position with a toe plate. The child is allowed weight bearing as tolerated, and the cast is required usu- 5. Following cast removal, the child is allowed to weight bear as tolerated, initially with- out the use of an orthotic. If the foot has a tendency to not be completely stable, an in-shoe orthotic, such as a supramalleolar orthotic, is prescribed. Lateral Column Lengthening Through the Calcaneocuboid Joint Indication Lateral column lengthening through the calcaneocuboid joint can be com- bined with subtalar fusion or can be performed as an isolated procedure. If lateral column lengthening through the calcaneocuboid joint is performed with a subtalar fusion, after the subtalar fusion has been performed the in- dication for lateral lengthening is determined by significant lateral subluxation and abduction of the forefoot when pressure is placed on the plantar surface of the forefoot. Calcaneocuboid joint fusion lengthening as an isolated pro- cedure is indicated when the child has substantial dorsiflexion through the midfoot with moderate hindfoot deformity. This procedure is performed typically as an isolated procedure only in adolescents or young adults. The exposure is via the distal end of the incision used for the subtalar fusion. The incision is carried anteriorly and curved toward the plan- tar aspect of the first metatarsal insertion of the area of the peroneus brevis. Subcutaneous incision is carried down to the calcaneocuboid joint, which is opened, and the capsule of the calcaneocuboid joint is removed along its whole lateral border and anterior border with good exposure. The calcaneocuboid joint usually demonstrates severe round- ing over the distal end of the calcaneus with lateral and superior sub- luxation of the cuboid.

The beating of the heart is affected is the thickest layer and pumps blood through the ves- by the emotions buy discount cefixime 100 mg line, which may explain the frequent refer- sels purchase cefixime 200 mg with mastercard. Cardiac muscle’s unique structure is described in ences to it in song and poetry buy cefixime 100mg with mastercard. Location of the Heart The heart is slightly bigger than a person’s fist buy cefixime 200 mg with amex. This organ The Pericardium is located between the lungs in the center and a bit to the The pericardium (per-ih-KAR-de-um) is the sac that en- left of the midline of the body (Fig 200mg cefixime for sale. The formation of most of the mediastinum, the central region of the thorax. The broad, superior base is the area of at- outermost and heaviest layer of this sac is the fibrous tachment for the large vessels carrying blood into and out pericardium. Connective tissue anchors this pericardial of the heart. A serous membrane lines this fi- Thyroid gland brous sac and folds back at the base to Trachea Base of heart cover the heart’s surface. Anatomi- cally, the outer layer of this serous membrane is called the parietal layer, and the inner layer is the visceral layer, Right Left also known as the epicardium, as pre- lung lung viously noted. A thin film of fluid be- tween these two layers reduces friction as the heart moves within the peri- Ribs (cut) cardium. Normally the visceral and parietal layers are very close together, but fluid may accumulate in the region between them, the pericardial cavity, under certain disease conditions. Checkpoint 14-1 What are the names of the innermost, middle, and outermost lay- ers of the heart? Diaphragm Pericardium Apex of heart Checkpoint 14-2 What is the name of the Figure 14-1 The heart in position in the thorax (anterior view). THE HEART AND HEART DISEASE 285 Table 14•1 Layers of the Heart Wall LAYER LOCATION DESCRIPTION FUNCTION Endocardium Innermost layer of the Thin, smooth layer of epithelial Lines the interior of the chambers and heart wall cells covers the heart valves Myocardium Middle layer of the heart Thick layer of cardiac muscle Contracts to pump blood into the arteries wall Epicardium Outermost layer of the Thin serous membrane Covers the heart and forms the visceral heart wall layer of the serous pericardium Heart wall Epicardium (visceral pericardium) Myocardium Endocardium 14 Visceral pericardium Pericardial cavity Serous pericardium Parietal pericardium Fibrous pericardium Figure 14-2 Layers of the heart wall and pericardium. The serous pericardium covers the heart and lines the fibrous pericardium. ZOOMING IN Which layer of the heart wall is the thickest? Table 14•2 Layers of the Pericardium LAYER LOCATION DESCRIPTION FUNCTION Fibrous pericardium Outermost layer Fibrous sac Encloses and protects the heart; anchors heart to surrounding structures Serous pericardium Between the fibrous Doubled membranous sac with fluid Fluid reduces friction within the pericardium and the between layers pericardium as the heart functions myocardium Parietal layer Lines the fibrous Serous membrane Forms the outer layer of the serous pericardium pericardium Visceral layer Surface of the heart Serous membrane Forms the inner layer of the serous pericardium; also called the epi- cardium 286 CHAPTER FOURTEEN the human heart is really a double pump (Fig. The right side pumps blood low in oxygen to the lungs through the pulmonary circuit. The left side pumps oxygenated Intercalated disk blood to the remainder of the body through the systemic circuit. Each side of the heart is divided into two chambers. Nucleus Four Chambers The upper chambers on the right and left sides, the atria (A-tre-ah), are mainly blood-receiving chambers (Fig. The lower chambers on the right and left side, the ventricles (VEN-trih-klz) are forceful pumps. The chambers, listed in the order in which blood flows through them, are as follows: Figure 14-3 Cardiac muscle tissue viewed under the mi- 1. The right atrium (A-tre-um) is a thin-walled chamber croscope ( 540). The sample shows light striations (arrow- that receives the blood returning from the body tis- heads), intercalated disks, and branching fibers (arrow). This blood, which is low in oxygen, is carried in Atlas of Histology. Philadelphia: Lippincott Williams & veins, the blood vessels leading back to the heart from Wilkins, 2000. The superior vena cava brings blood Special Features of the Myocardium Head and arms Cardiac muscle cells are lightly stri- Superior Left ated (striped) based on alternating vena cava pulmonary actin and myosin filaments, as seen in artery skeletal muscle cells (see Chapter 8). Unlike skeletal muscle cells, however, Aorta cardiac muscle cells have a single nu- cleus instead of multiple nuclei. Also, cardiac muscle tissue is involuntarily Right Left controlled. There are specialized parti- lung lung tions between cardiac muscle cells that show faintly under a microscope (Fig. These intercalated (in-TER- atrium cah-la-ted) disks are actually modified Left plasma membranes that firmly attach atrium adjacent cells to each other but allow for rapid transfer of electrical impulses Left between them.

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This area is visualized under fluoroscopy and a transverse drillhole is placed to fenestrate the tibia safe 200 mg cefixime. A standard exposure is made to the anterior medial aspect of the tibia for intramedullary nailing generic 200 mg cefixime with mastercard. The guidewire is inserted into the tibia cheap 100 mg cefixime fast delivery, the tibia is reamed in the standard fashion proven cefixime 100mg, and an intramedullary nail of the appropriate size is chosen and driven into the tibia just proximal to where the initial drillhole was placed cefixime 200mg for sale. Utilizing the drill in a fan-shaped fashion, multiple holes are made at this level of the tibia (Figure S4. The tibia is fractured with manual force concentrated at this area. The tibial nail is driven across the osteotomy site and into the distal fragment to just proximal to the tibial plafond. While the tibial nail is introduced, care is taken to make sure that there is no varus or valgus deformity of the distal fragment. Proximal and distal transfixion screws are applied (Figures S4. Postoperative Care The wounds are covered with waterproof dressings. The child then is mo- bilized with weight bearing as tolerated, encouraging full weight bearing as quickly as possible. If additional foot procedures or other soft-tissue proce- dures about the foot were performed, a short-leg walking cast may be needed. The intramedullary nail or transfixion screws are removed postoperatively only if they cause discomfort. Patellar Advancement Patellar advancement is primarily an operative procedure that is performed only in combination with distal femoral osteotomy, either concomitantly or, if it has been overlooked, as a follow-up operative procedure. For this reason, patellar advancement is presented as part of the distal femoral osteotomy procedure. However, if the procedure is to be performed as an independent procedure, it can be done through a transverse incision at the distal pole of the patella (Figures S4. Distal Femoral Osteotomy Indication Distal femoral osteotomy is required for knee flexion contractures that are greater than 30°. Derotation and varus-valgus realignment also may be per- formed at the same time. This osteotomy may be performed with open or closed growth plates, although the fixation is easier if the growth plates are closed. The incision is made along the lateral aspect of the distal thigh and carried anterior to the middle of the patellar ligament. The incision needs to extend proximally to approximately the junction of the mid- dle and distal third of the thigh (Figure S4. The incision is carried down to the knee capsule, which is opened all the way anteriorly to the patellar ligament. The incision then is car- ried proximally and posteriorly along the edge of the vastus lateralis (Figure S4. Incision in the periosteum is performed, and sub- periosteal dissection allows full exposure of the lateral and anterior femur. Subperiosteal dissection also can be extended circumferentially around the femur in the distal third above the metaphysis. Then, the patella can be dislocated or subluxated to the medial side, exposing the whole distal femur. Insertion of a guidewire at the level of the blade plate is a helpful step. The guidewire is inserted parallel to the distal femoral condyle and parallel to the anterior femur. This guidewire is inserted with visual inspection, but also can be checked with fluoroscopic control (Figure S4. After insertion of the guidewire, the guidewire should be cut off to allow approximately 3 to 4 cm of wire to be exposed laterally. The blade plate chisel then is inserted just proximal to this wire in the plane parallel to the tibia, with the tibia in maximum extension. The chisel for the blade plate is inserted under visual control and can be checked with the fluoroscope.

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