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1. Similarities n differences of

facilitated diffusion n active transport

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MUSCLES THAT MOVE THE ARM

MovementMovement Muscle InvolvedMuscle Involved

Flexion Pectoralis major

Deltoid (anterior fibres)

Coracobrachialis

Extension Latissimus dorsi

Deltoid (posterior fibres)

Teres major

Adduction Latissimus dorsi

Pectoralis major

Coracobrachialis

Teres major & minor

Infraspinatus

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MovementMovement Muscle InvolvedMuscle Involved

Abduction Deltoid (middle fibres)

Supraspinatus

Medial rotation Subscapularis

Deltoid (anterior fibres)

Latissimus dorsi

Pectoralis major

Teres major

Lateral rotation Infraspinatus

Teres minor

Deltoid (posterior fibres)

The prime mover is indicated in blue

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3a. Caring personality in

medicine

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Barriers in communication

Semantics

(Abstract Words, Concrete Words, Foreign Words, mismatch in body

language & message)

Psychological or Interpersonal barriers

(Attitudes & Values, Experiences, Halo effect, Psychological distance,

Dependency Syndrome, Filtering)

Physical Barriers

( Physical distance, time, setting, physical disturbance)

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Haemoglobin synthesis

Haem & globin produced at two different sites

in the cells

Haem in mitochondria

Globin in polyribosomes

Well synchronizedSynthesis begins in proerythroblast

65% at erythroblast stage

35% at reticulocyte stageMD Phase I Haematopoeitic & Lymphoid

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Requires the formation of the protoporphyrin IX and

availability of iron

All enzymatically directed

Take place in nucleated RBC

Initial & final steps mitochondria of NRBC

Intermediate step cell cytoplasm

Haemoglobin synthesis. Haem synthesis

MD Phase I Haematopoeitic & Lymphoid

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Haemoglobin synthesis. Haem synthesis

Requires:

Minerals iron,

- copper promote absorption, mobilization &

utilization of iron,

- cobalt B12 manufacturing

Vitamins B12, C, folate

Proteins

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A series of biochemical

reactions will follow.

Two molecules ofH-ALA

condense to form a pyrrolecalled porphobilinogen

(PBG)

Four PBG condense to form

a tetrapyrrole

uroporphyrinogen III.

UPG III is then converted to

coproporphyrinogen.

Haem synthesis starts with

the condensation of glycine

and succinyl coenzyme A

under the action of a ratelimiting enzyme H-

aminolaevulinic acid

synthase.

H-ALA will be formed.Pyridoxal phosphate (vit. B6)

is a coenzyme for this

reaction.

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Each molecule of haem

combines with a globin

chain.

A tetramer of four globinchains each with its own

haem group in a pocket is

formed to make up a

haemoglobin molecule.

CPG then changes toprotoporphyrin whichultimately combines with iron

in the ferrous state (Fe2+) toform haem.

Iron is brought to thedeveloping red cells by acarrier protein

( transferrin) which attaches tospecial binding sites on thesurface of these cells.

Transferrin releases iron andreturns back to circulation.

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Globin Synthesis

MD Phase I Haematopoeitic & Lymphoid

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The genes that encode the alpha globin chains are on

chromosome 16.

Those that encode the non-alpha globin chains are on

chromosome 11

Globin Synthesiscont

MD Phase I Haematopoeitic & Lymphoid

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A number of variables influence the nature of the non-alpha chain

in the hemoglobin molecule.

The fetus has a distinct non-alpha chain called gamma.

After birth, a different non-alpha globin chain, called beta, pairs

with the alpha chain.

The combination of two alpha chains and two non-alpha chainsproduces a complete hemoglobin molecule (a total of four chains

per molecule).

G

lobin Synthesiscont

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The combination of two alpha chains and two gamma chains form

"fetal" hemoglobin, termed "hemoglobin F".

With the exception of the first 10 to 12 weeks after conception, fetalhemoglobin is the primary hemoglobin in the developing fetus.

The combination of two alpha chains and two beta chains form

"adult" hemoglobin, also called "hemoglobin A".

Althoughhemoglobin A is called "adult", it becomes the predominate

hemoglobin within about 18 to 24 weeks of birth.

Globin Synthesiscont

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Retinol is transported to the retina via the circulation, where it moves into retinalpigment epithelial cells. There, retinol is esterified to form a retinyl ester that canbe stored. When needed, retinyl esters are broken apart (hydrolyzed) andisomerized to form 11-cis retinol, which can be oxidized to form 11-cis retinal. 11-cis Retinal can be shuttled to the rod cell, where it binds to a protein called opsinto form the visual pigment, rhodopsin (visual purple). Absorption of a photon oflight catalyzes the isomerization of 11-cis retinal to all-trans retinal and results in

its release. This isomerization triggers a cascade of events, leading to thegeneration of an electrical signal to the optic nerve. The nerve impulse generatedby the optic nerve is conveyed to the brain where it can be interpreted as vision.Once released all-trans retinal is converted to all-trans retinol, which can betransported across the interphotoreceptor matrix to the retinal epithelial cell tocomplete the visual cycle.

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Superior surface The triangular superior surface is bounded by lateral borders from the apex to the ureteric entrances

and by a posterior borderjoining them.

In males the superior surface is completely covered by peritoneum, extending slightly on to the baseand continued posteriorly into the rectovesical pouch, laterally into the paravesical fossae andanteriorly into the median umbilical fold.

It is in contact with the sigmoid colon and the terminal coils of the ileum.Inferolateral surfaces Each inferolateral surface in males is separated anteriorly from the pubis and puboprostatic ligaments

by an adipose retropubic pad and posteriorly by fascia from the levator ani and obturator internus.

The inferolateral surfaces are not covered by peritoneum.

Fundus (base)

is triangular and located postero-inferiorly.

in males, it is related to the rectum although separated from it above by the rectovesical pouch and below that by theseminal vesicles and deferent ducts .

In a triangular area between the deferent ducts, the bladder and rectum are separated only by rectovesical fascia

Neck. the neck is the lowest part of urinary bladder and is also the most fixed;

It is pierced by the internal urethral orifice

In males the neck rests on, and is in direct continuity with, the base of the prostate;

from it the median umbilical ligament (urachus,) ascends behind the anterior abdominal wall to the umbilicus, theperitoneum over it being the median umbilical fold.

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Arterial supply

The principal arteries of supply to the urinary

bladder are:

1. the superior vesical and

2. inferior vesical, derived from the anteriortrunk of the internal iliac artery.

3.Th

e obturator and 4. inferior gluteal arteries also send small

branches to it

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Nerve Supply of the BladderThe nerves supplying the bladder form the vesical plexus

and consist ofboth sympathetic and parasympathetic components,

each of which contains both efferent and afferent fibres.

Efferent Fibres Parasympathetic fibres arise from the second to the fourth sacral segments of the spinal cord (nervi erigentes);

Sympathetic fibres are derived from the lower two thoracic and upper two lumbar segments of the spinal cord.

In addition to the branches from the vesical plexus, small groups of autonomic neurons occur throughout all regions

of the bladder wall. These multipolar intramural neurons are rich in acetyl cholinesterase (AChE) and occur in ganglia

consisting of 5 to 20 nerve cell bodies.

Noradrenergic terminals also relay on cell bodies in the pelvic plexus although it is unknown whether similar nerves

synapse on intramural bladder ganglia.

The urinary bladder (including the trigonal detrusor muscle) is profusely supplied with nerves which form a dense

plexus among the detrusor smooth muscle cells.

Majority of these nerves contain AChE and occur in abundance throughout the muscle coat of the bladder.

The human detrusor muscle possesses a sparse supply of sympathetic noradrenergic nerves. Nerves of this type

generally accompany the vascular supply and only rarely extend among the nonstriated myocytes of the urinary bladder.

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Nerve Supply of the Bladder (continued)Efferent fibres (continued)

In bladder neck of the male, nonstriated muscle is sparsely supplied with cholinergic (parasympathetic)

nerves but possesses a rich noradrenergic (sympathetic) innervation A similar distribution of autonomic

nerves also occurs in the nonstriated muscle of the prostate gland, seminal vesicles and ducti deferentes.

From a functional standpoint, sympathetic nerves on stimulation cause contraction of nonstriated muscle in

the wall of the genital tract resulting in seminal emission. Concomitant sympathetic stimulation of the

proximal urethral muscle causes sphincteric closure of the bladder neck, thereby preventing reflux of

ejaculate into the bladder.

Afferent Fibres

Vesical nerves are also concerned withpain and awareness of distension.

Pain fibres are stimulated by distension or spasm due to a stone, inflammation or malignant disease;

they are found in sympathetic and parasympathetic nerves, predominantly the latter.

The spinal path for pain is in the anterolateral white columns and considerable relief follows bilateral

anterolateral cordotomy.

Since nerve fibres mediating awareness of distension are in the posterior columns (fasciculus gracilis),

after anterolateral cordotomy the patient still retains awareness of the need to micturate.

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Catabolism ofamino acid

Removal ofE-amino

group

Metabolism of carbon skeletons

Seven products

AcetylC

oAAcetoacetyl

CoA

Pyruvate

Oxaloacetate

Fumarate

E-ketoglutarate

Succinyl CoA

Lipids

Energy

Lipids

Energy

Glucose

Ketogenic Glucogenic

Disposal of

Nitrogen

involves

Converges to produce

Classified as

Classified as

provide provide

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Relationship between various amino acids

Oxaloacetate

Fumarate

Succinyl CoA

E-ketoglutarate

Acetyl CoAGlucose

Pyruvate

PhenylalanineTyrosine

Tryptophan

Leucine

Lysine

Glutamate

GlutamineHistidine

Arginine

ProlineValine

Isoleucine

Threonine

Methionine

Phenylalanine

Tyrosine

Asparagine

Aspartate

Tryptophan

Cysteine

Glycine

Serine

Alanine

TCA CYCLE