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Kathleen Costello quality zanaflex 2mg spasms calf muscles, RN order 2mg zanaflex overnight delivery muscle relaxant yellow pill v, 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. Dawson at the University of Edinburgh in Scotland used a microscope to describe inflammation around the blood vessels and the damage to the myelin with a clarity and thorough- ness that has never been improved. Little was known about the brain’s function, so the meaning of these changes was only a guess. The science of electro- physiology established techniques needed to study nerves. Rivers at the Rockefeller Institute in New York reproduced the autoimmune response classically seen in MS. An animal model for MS was developed called experimental allergic encephalomyelitis (EAE). Services and programs include a wide range of patient and family services, basic and psycho- social research, and MS education. NMSS and the Canadian MS Society cover North America with a wide range of programs and services. Lawry founded the International Federation of MS Societies, now the Multiple Sclerosis International Federation (MSIF). Patients were given ACTHIn the 1970s, research produced useful results. Scientists studying EAE suspected myelin protein fragments prevented the disease B. A mixture of the fragments was used to treat animals and then humans with MS (copolymer 1) C. In 1978, computed tomography (CAT) scanning was first used for patients with MS E. First experiments with interferons demonstrated their immune- modulating effectsThe 1980s saw the beginnings of major clinical trials in MS using immunomodulators, such as interferons and glatiramer acetate (copolymer 1). Young performed the first magnetic resonance imaging (MRI) on a patient with MS. The CMSC is the largest organization of MS health professionals in the world. It holds annual and regional meetings, consensus conferences, and training programs for MS profession- als. It has a journal (International Journal of MS Care) and a newsletter (The MS Exchange). The CMSC Foundation funds schol- arships and fellowships in MS training; the CMSC NARCOMS project has a large patient database to increase understanding of MS and its ramifications. The European Committee on Treatment and Research in MS (ECTRIMS) was founded shortly thereafter. ACTRIMS, the North American counterpart, was established fol- lowed by LACTRIMS, a Latin American organization representing Central and South America. Develop and maintain a mechanism by which members can share information on practice positions and resources 2.

Individuals who lack the intrinsic factor erating at varying degrees in different parts of the GI tract purchase zanaflex 2 mg with mastercard spasms stomach pain. When a meal that is hypotonic to plasma is ingested cheap 2 mg zanaflex with mastercard spasms with stretching, con- siderable absorption of water from the lumen to the blood takes place, predominantly through tight junctions and in- tercellular spaces between the enterocytes, resulting in the ELECTROLYTE AND MINERAL ABSORPTION absorption of small solutes such as Na and Cl ions. This Nearly all of the dietary nutrients and approximately 95 to mode of absorption, called solvent drag, is responsible for 98% of the water and electrolytes that enter the upper small a significant amount of the Na absorption by the duode- 508 PART VII GASTROINTESTINAL PHYSIOLOGY Stomach most of the monosaccharides and amino acids have already Parietal cell been absorbed by the small intestine (Fig. Sodium chloride is transported via two exchangers located at the brush border membrane. The downhill move- Vitamin B12 ment of Na into the cell provides the energy required for the uphill movement of the H from the cell to the lumen. Similarly, the downhill movement of HCO3 out of the cell provides the energy for the uphill entry of Cl into the Intrinsic enterocytes. The Cl then leaves the cell through facili- factor Intrinsic factor/ tated transport. This mode of Na uptake is called vitamin B12 Na /H -Cl /HCO3 countertransport. There is no sugar- or amino acid–coupled Na transport because most Ileum Lumen sugars and amino acids have already been absorbed. Sodium is also absorbed here via Na -selective ion channels in the apical cell membrane (electrogenic Na absorption). Absorption takes place throughout the intestine by passive H+ + HCO - H CO CO + H O Blood Vitamin B released into blood 3 2 3 2 2 12 Cl- Transcobalamin/ Glucose, + Na+ + Na H Transcobalamin vitamin B amino 12 complex acids H2CO3 Cl- HCO - FIGURE 27. CO2 + H2O 3 Na+ Metabolism ATP K+ A num and jejunum, but it probably plays a minor role in Na absorption by the ileum and colon because more distal re- Blood gions of the intestine are lined by a “tight” epithelium (see Chapter 2). CO + H O H CO In the jejunum, Na is actively pumped out of the baso- 2 2 2 3 lateral surface of enterocytes by a Na /K -ATPase (Fig. The result is low intracellular Na concentration, and the luminal Na enters enterocytes down the electro- chemical gradient, providing energy for the extrusion of H into the lumen (via a Na /H exchanger). The H + + - - Cl- Na+ Na H HCO3 Cl then reacts with HCO3 in bile and pancreatic secretions in the intestinal lumen to form H2CO3. The CO2 readily diffuses H CO 2 3 across the small intestine into the blood. Another mode of Cl- Na uptake is via a carrier located in the enterocyte brush CO + H O 2 2 + + border membrane, which transports Na together with a Na Na monosaccharide (e. K+ K+ B In the ileum, the presence of a Na /K -ATPase at the basolateral membrane also creates a low intracellular Na Blood concentration, and luminal Na enters enterocytes down the electrochemical gradient. B, Na ab- coupled symporters is not as great as in the jejunum because sorption by the ileum. CHAPTER 27 Gastrointestinal Secretion, Digestion, and Absorption 509 diffusion through the tight junctions and lateral intercellu- increased by 1,25-dihydroxy vitamin D3. The driving force for K ab- cell, the Ca ions are sequestered in the ER and Golgi sorption is the difference between luminal and blood K membranes by binding to the CaBP in these organelles. The absorption of water results in an in- Calcium absorption by the small intestine is regulated by 2 crease in luminal K concentration, resulting in K ab- the circulating plasma Ca concentration. In the colon, K can be absorbed Ca concentration stimulates the release of parathyroid or secreted depending on the luminal K concentration. Prolonged di- its active metabolite—1,25-dihydroxy vitamin D3—in the arrhea can be life-threatening, because the dramatic fall in kidney. This in turn stimulates the synthesis of CaBP and 2 extracellular K concentration can cause complications the Ca -ATPase by the enterocytes (Fig. Most of the Cl ions added to the GI tract from 2 the diet and from the various secretions of the GI system increase in Ca absorption by the enterocytes. Intestinal chloride absorption involves both passive and active processes. The absorption of Mg seems to take place along intestinal mucosa, with the serosal side more positive than the entire small intestine, and the mechanism involved the lumen. The average daily zinc intake is 10 to 15 mg, about taken up actively by enterocytes via Cl /HCO3 ex- half of which is absorbed primarily in the ileum. This absorption of Cl is in- cated in the brush border membrane actively transports zinc hibited by the presence of other halides.

Sympathetic fibers from the carotid The ciliary ganglion (AB1) is a small zanaflex 2 mg fast delivery zerodol muscle relaxant, flat plexus form the deep petrosal nerve (AB15) body lying laterally to the optical nerve in (sympathetic root) and join the greater the orbit cheap zanaflex 2 mg spasms left upper abdomen. Its parasympathetic fibers from petrosal nerve to form the nerve of the ptery- the Edinger–Westphal nucleus run in the goid canal (AB16). The para- pathetic fibers originate from the lateral sympathetic fibers (B17) for the lacrimal horn of the spinal cord C8–T2 (ciliospinal gland (AB18) synapse in the ganglion. The center) (B4) and synapse in the superior cer- postganglionic fibers run in the ganglionic vical ganglion (B5). The postganglionic branches (AB12) to the maxillary nerve fibers ascend in the carotid plexus (B6) as (AB11) and reach the lacrimal gland via the sympathetic root (B7) to the ciliary ganglion. The remaining parasympathetic secretory Theshortciliarynerves (AB9)extendfrom the fibers run in the orbital branches (B22) to the ganglion to the eyeball and penetrate the posterior ethmoidal cells, in the lateralposte- sclera to enter the interior of the eyeball. The taste fibers (B25) for the soft palate run Clinical Note: The pupil is antagonistically in- in the palatine nerves and in the greater nervated by parasympathetic fibers (constriction petrosal nerve. Injury to the ciliospinal center or the spi- nal roots C8, T1 (paralysis of the lower brachial plexus, p. Ciliary Ganglion, Pterygopalatine Ganglion 129 21 9 1 3 8 2 26 14 13 18 20 11 15 19 12 16 24 10 A Topographical arrangement of the ciliary ganglion and the ptery- gopalatine ganglion 18 2 9 1 3 7 26 8 14 19 12 17 11 22 13 10 16 25 15 23 24 6 5 B Pathways of the ciliary ganglion and the pterygopalatine ganglion 4 Kahle, Color Atlas of Human Anatomy, Vol. Its pregan- glionic parasympathetic fibers originate glionic parasympathetic fibers (B21) origi- from the inferior salivatory nucleus. They nate from the superior salivatory nucleus, run in the glossopharyngeal nerve and run in the facial nerve (intermediate nerve), branch off, together with the tympanic and leave the nerve together with the taste nerve,fromtheinferiorganglionoftheglos- fibers (B22) in the chorda tympani (AB9). In sopharyngeal nerve in the petrous fossula to the latter, the fibers reach the lingual nerve the tympanic cavity. The fibers leave the (AB20) and extend in it to the floor of the tympanic cavity through the hiatus for the mouth where they cross over into the gan- lesser petrosal nerve as a fine branch, the glion (AB18). Postganglionic sympathetic lesser petrosal nerve (AB4) (parasympathetic fibers from the plexus of the external carotid root). The nerve runs beneath the dura artery reach the ganglion via the sympa- mater along the surface of the petrous bone theticbranch(B23)givenoffbytheplexusof and reaches the otic ganglion after passing the facial artery; they pass through the gan- through the foramen lacerum. They pass through without synapsing and enter via a com- municating branch (A11) the greater petrosal nerve (A12), in which they reach the pterygopalatine ganglion (A13). The postganglionic secretory (parasympa- thetic) fibers together with sympathetic fibers enter the auriculotemporal nerve (AB15) via a communicating branch and from here into the facial nerve (AB16) via another anastomosis. The fibers then ramify in the parotid gland (AB17) together with branches of the facial nerve. Apart from the parotid gland, they supply the buccal and labial glands via the buccal nerve and the in- ferior alveolar nerve. Otic Ganglion, Submandibular Ganglion 131 12 4 15 26 25 2 13 11 9 3 1 10 14 5 16 17 20 18 A Topographical arrangement of 24 the otic ganglion and the sub- mandibular ganglion 19 3 VII 8 1 4 9 7 6 22 10 21 5 20 15 B Pathways of the otic ganglion and 16 the submandibular ganglion 17 18 23 24 19 Kahle, Color Atlas of Human Anatomy, Vol. Further lateral are the Apart from certain modifications in the cells of the locus ceruleus (D18) (the pontine medulla oblongata (A1), pons (A2), and respiratory center reaching into the mid- mesencephalon (A3), the brain stem has a brain; it contains noradrenergic neurons, uniform structure. The relatively large, scattered part of the brain stem, which is common to cells dorsal to the locus ceruleus form the all three parts and contains the cranial mesencephalic nucleus of the trigeminal nerve nuclei, is the tegmentum (A4). The lateral field is occupied by level of the medulla oblongata and the pons, the pedunculopontine tegmental nucleus it is overlain by the cerebellum and in the (D20). At the ventral margin of the tegmen- mesencephalon by the tectum (quadrigemi- tum lies the interpeduncular nucleus (D21), nal plate) (A5). The ventral part of the brain which is rich in peptidergic neurons (pre- stem mainly contains the large tracts de- dominantly enkephalin). The habenulo in- scending from the telencephalon; they form terpeduncular tract (fasciculus retroflexus, the pyramids (A6) in the medulla oblongata, Meynert’s bundle) (p. The lateral lemniscus (D22) radiates ven- The ventricular system undergoes consider- trally into the nucleus of the inferior col- able narrowing in the midbrain, the aque- liculus (D14) (p. The fibers of the duct of the mesencephalon (cerebral aqueduct, peduncle of the inferior colliculus (D23) aqueduct of Sylvius) (A–D9). During aggregateatthelateralaspectandruntothe development, the lumen of the neural tube medial geniculate body (central auditory becomes increasingly narrowed as the teg- pathway, p. In the medial field lie the mentum of the midbrain increases in medial longitudinal fasciculus (D24) (p. The fiber plate of the basal plate lie ventrally: the nucleus of of the medial lemniscus (D26) (p. The fibers of the cerebral peduncle nucleus (eye muscles), the red nucleus (C11), (D27) are cut transversely and are inter- and the substantia nigra (C12) (consisting of spersed with a few pontine fibers running anouterreticularpartandaninnercompact across.