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The syndrome may follow spinal cord lesions at the T1 segment (tumour or syringomyelia), closed, penetrating or operative injuries to the stellate ganglion or the cervical sympathetic chain, or pressure on the chain or stellate ganglion produced by enlarged cervical lymph nodes, an upper mediastinal tumour, a carotid aneurysm or a malignant mass in the neck gastritis diet ютуб omeprazole 20 mg buy visa. The branchial system and its derivatives Six visceral arches form on the lateral aspects of the fetal head separated, on the outside, by ectodermal branchial clefts and, on the inside, by five endodermal pharyngeal pouches. In the human embryo the 5th and 6th arches do not appear externally and are represented only by a mesodermal core. Each arch has its own nerve supply, cartilage, muscle and artery, although considerable absorption and migration of these derivatives occur in development. The embryological significance of many of the branchial derivatives has already been discussed under appropriate headings (the development of the face, tongue, thyroid, parathyroid and aortic arch) but Table 4 serves conveniently to bring these various facts together. Branchial cyst and fistula the second branchial arch grows downwards to cover the remaining arches, leaving temporarily a space lined with squamous epithelium. This usually disappears but may persist and distend with cholesterol-containing fluid to form a branchial cyst. Another theory is that these cysts arise from squamous clefts in cervical lymph nodes. Revise on your own skull the position of: the external occipital protuberance (the apex of this is termed the inion), the nasion, which is the depression between the two supra-orbital margins, and the glabella, which is the ridge above the nasion. Feel the sharp edge of the lateral margin of the orbit that is formed by the frontal process of the zygomatic bone; behind the zygomatic bone is the zygomatic arch with the superficial temporal artery crossing its posterior extremity and forming a convenient pulse which the anaesthetist can reach. Rather less easily felt is the jugal point, the junction between the zygomatic bone and the zygomatic process of the frontal bone; it is the mass of bone encountered by the finger running forwards along the upper border of the zygomatic arch, and it is a surface marking for the middle meningeal artery (see below). The anterior edge of the mastoid is easily palpable but its posterior aspect and its tip are rather obscured by the insertion of the sternocleidomastoid. The whole of the superficial surface of the mandible is palpable apart from its coronoid process. The condyloid process can be felt by a finger placed immediately in front of, or within, the external auditory meatus while the mouth is opened and closed. When the teeth are clenched, masseter and the temporalis can be felt contracting, respectively, over the ramus of the mandible and above the zygomatic arch. The parotid duct can be rolled over the tensed masseter and its orifice seen within the mouth at the level of the 2nd upper molar tooth. The pulsation of the facial artery can be felt as it crosses the lower margin of the body of the mandible immediately in front of the masseter and again opposite the angle of the mouth. In the latter situation, if the cheek is gripped lightly with the finger placed within the mouth and the thumb placed on the skin surface, the pulse will be felt a little more than 0. A line drawn vertically between the first and second premolar teeth passes through the mental foramen, the infra-orbital foramen and the supra-orbital notch. Through these three orifices, lying in plumb-line, pass branches from each of the divisions of the trigeminal nerve; respectively, the mental branch of the inferior alveolar nerve (V), the infra-orbital nerve (V) and the supra-orbital nerve (V).
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The receptors for the pharyngeal dilator reflex appear to be located in the nose, mouth, and upper airways; the afferent pathways appear to be in the trigeminal, laryngeal, and glossopharyngeal nerves gastritis diet зурхай cheap 20 mg omeprazole fast delivery. This reflex may be very important in maintaining the patency of the upper airway during strong inspiratory efforts and during sleep. Mechanical or chemical irritation of the airways (and possibly the alveoli) can elicit a reflex cough or sneeze, or it can cause hyperpnea, bronchoconstriction, and increased blood pressure. The receptors are located in the nasal mucosa, upper airways, tracheobronchial tree, and possibly the alveoli themselves. Those in the larger airways of the tracheobronchial tree, which also respond to stretch, are sometimes referred to as rapidly adapting pulmonary stretch receptors because their activity decreases rapidly during a sustained stimulus. The afferent pathways are the vagus nerves for all but the receptors located in the nasal mucosa, which send information centrally via the trigeminal and olfactory tracts. These receptors may play an important role in adjusting the ventilatory effort to elevated workloads and may help minimize the work of breathing. They may also participate in initiating and maintaining the elevated ventilation that occurs during exercise, as will be discussed in Chapter 72. Somatic pain generally causes hyperpnea; visceral pain generally causes apnea or decreased ventilation. The receptors responsible for initiating these responses are located in the walls of the pulmonary capillaries or in the interstitium; therefore, they are called J (for juxtapulmonary capillary) receptors. These receptors may also be responsible for the dyspnea (a feeling of difficult or labored breathing) encountered during the pulmonary vascular congestion and edema secondary to left ventricular failure or even the dyspnea that healthy people feel at the onset of exercise. The afferent pathway of these reflexes is slow-conducting nonmyelinated vagal fibers. Other receptors that may contribute to the sensation of dyspnea include the arterial chemoreceptors, stretch receptors in the heart and blood vessels, and receptors in the respiratory muscles. Changes in the Pco2, pH, and Po2 result in alterations in alveolar ventilation designed to return these variables to their normal values. Chemoreceptors alter their activity when their own local chemical environment changes and can therefore supply the central respiratory controller with the afferent information necessary to make the appropriate adjustments in alveolar ventilation to change the whole-body Pco2, pH, and Po2. The respiratory control system therefore functions as a negative-feedback system as discussed in Chapter 1. The arterial and cerebrospinal fluid partial pressures of carbon dioxide are probably the most important inputs to the ventilatory control system in establishing the breath-to-breath levels of tidal volume and ventilatory frequency. Acutely increasing the level of carbon dioxide in the inspired air (the Fico2) increases minute ventilation.
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In our institution, most patients who require initial therapy and who cannot, or do not want, to be enrolled in clinical trials, are treated with the combination of rituximab, cyclophosphamide, and dexamethasone gastritis symptoms throat discount 40 mg omeprazole with visa. This is a very well-tolerated regimen that will not interfere with subsequent collection of stem cells. In some rare instances, the use of single-agent rituximab can be considered, but in the majority of cases, combination therapy is indicated. In elderly patients who have significant comorbidities or limited mobility, single-agent chlorambucil can be considered as well. Plasma exchange is only indicated in cases of symptomatic hyperviscosity, and is used only as a "bridge" procedure until effective cytotoxic therapy is instituted. Issues to be considered when selecting therapy include factors associated with the disease, such as tumor bulk, hyperviscosity, and cytopenias, as well as patient-related factors, such as comorbid diseases and prior therapy. For some patients, achieving rapid cytoreduction of tumor may be important (and may favor a combination therapy approach), but for most, this is not necessary and single-agent therapy may be more appropriate. It is also important to remember that there may be a long latent period before one observes the full clinical benefit of the selected treatment. Based on the small population of patients with this disease and the paucity of information available regarding the best therapy, however, patients should be considered for clinical trials whenever possible. Immune-related and inflammatory conditions and risk of lymphoplasmacytic lymphoma or Waldenstrom macroglobulinemia. Genomewide linkage screen for Waldenstrom macroglobulinemia susceptibility loci in high-risk families. Risk of lymphoproliferative disorders among first-degree relatives of lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia patients: a population-based study in Sweden. Prognostic factors and response to fludarabine therapy in patients with Waldenstrom macroglobulinemia: results of United States intergroup trial (Southwest Oncology Group S9003). Waldenstrom macroglobulinaemia: presenting features and outcome in a series with 217 cases. The role of serum immunoglobulin free light chain in response and progression in Waldenstrom macroglobulinemia. Prognostic validation of the international classification of immunoglobulin M gammopathies: a survival advantage for patients with immunoglobulin M monoclonal gammopathy of undetermined significance Clinical characteristics and factors predicting evolution of asymptomatic IgM monoclonal gammopathies and IgMrelated disorders. Prognostic model for diseasespecific and overall mortality in newly diagnosed symptomatic patients with Waldenstrom macroglobulinaemia. Proceedings from the annual meeting of the Am Soci Hematol 1998;92:184b, Abstract 3776. Chromosomal abnormalities are associated with the polymorphous subtype and an aggressive clinical course. Waldenstrom macroglobulinemia neoplastic cells lack immunoglobulin heavy chain locus translocations but have frequent 6q deletions. Gene-expression profiling of Waldenstrom macroglobulinemia reveals a phenotype more similar to chronic lymphocytic leukemia than multiple myeloma.
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A transjugular liver biopsy is preferable to transcutaneous biopsy, as portal pressures can be measured gastritis eating before bed order discount omeprazole. As the disease progresses beyond day 100 post-transplant, portal fibrosis is seen with increasing bile duct dropout. A maculopapular rash is characteristic and may be described as a painful or pruritic sunburn. Characteristically involved sites include the back of the neck, palms, soles, dorsal surfaces of the extremities, and ears, although the rash can spread quickly to include the entire body. Although oral and liver toxicity can be severe and preclude up to 40% of patients from receiving a full course of therapy, methotrexate remains widely in use, now typically in combination with a calcineurin inhibitor. This lack of survival advantage propagated the use of both combination regimens at the discretion of individual transplant centers. Mycophenolate mofetil is a prodrug of mycophenolic acid, an inhibitor of de novo synthesis of purines in lymphocytes required for lymphocyte proliferation. Mycophenolate mofetil has been examined in combination with cyclosporine or tacrolimus. Single-center randomized studies of mycophenolate mofetil suggest greater safety but not greater efficacy over methotrexate. One study was stopped early as cyclosporine/mycophenolate mofetil showed a clear advantage over cyclosporine/methotrexate in regard to decreased mucositis (21% vs. Sirolimus is associated with the risk of endothelial damage such as in sinusoidal obstructive syndrome. For cord blood transplants, cyclosporine has been the drug primarily utilized as a prophylaxis backbone. Endoscopy with biopsies of the upper and/or lower tract should be obtained for persistent symptoms, inasmuch as histology provides critical information. Upper or lower endoscopy affords both a visual examination of the mucosa which may exhibit edema, erythema, ulceration, and mucosal sloughing, as well as the opportunity to obtain tissue for histology. Classic microscopic findings include epithelial crypt apoptotic bodies and lymphocytic infiltration. Involved mucosa can be noncontinuous and a lack of findings or a low degree of severity at one level does not rule out other areas or degrees of involvement. Infections and pulmonary embolism should always be entertained in the differential diagnosis of a transplant patient with shortness of breath, hypoxia, or new infiltrate. Volume overload and cardiogenic pulmonary edema is another mechanism of respiratory distress. Diffuse alveolar hemorrhage has long been recognized as a post-transplant complication and occurs in approximately 10% of patients, with myeloablative regimens associated with a higher incidence. Patients manifest with dyspnea (92%) accompanied with mild to severe bleeding into the alveoli, although hemoptysis is seen in a minority (15%) of cases.
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Some practitioners utilize differential subset response rates from differing agents to inform selection of agents gastritis diet gastritis symptoms cheapest generic omeprazole uk. At least one series showed intestinal involvement predicted for response, although this was not supported in the other series. Thrombotic microangiopathy has been observed in up to 35% of patients when used in combination with calcineurin inhibitors. The following sections review major progress in our understanding of the pathobiology, clinical advances in the management of the syndrome, and remaining challenges for future research. Understanding of the hospital and community bacterial resistance patterns is essential to select appropriate prophylactic antibiotics. Patients on high-dose steroids are at high risk for contraction of fungal pneumonia and appropriate coverage with antifungal medication is warranted. Thus, in normal immunity, naive T cells are educated in the thymus, and autoreactive cells are deleted. The resulting phenotype includes sclerodermatous (Scl) skin changes, weight loss, bile duct loss, mononuclear cell infiltration of the salivary glands, and mortality. Evidence of impaired thymic negative selection has not been observed in other murine models. Experimental models have suggested benefit of keratinocyte growth factor to prevent thymic injury, however, this strategy was not successful in human clinical investigation. The advent of improved prophylactic regimens has led to decreases in the rates and severity, although the most effective primary therapy remains steroids. The most commonly occurring manifestations arise in the skin, eyes, mouth, and liver. Common skin manifestations include pigmentation changes, lichen planuslike changes, poikiloderma, as well as more advanced cutaneous and subcutaneous sclerosis. Oral findings include lichen planuslike changes, hyperkeratotic plaques, or decreased oral range of motion. Patients can suffer from oral and ocular sicca symptoms, including dry mouth and dry or gritty eyes. Once the syndrome is recognized, it should be classified appropriately, and severity assessed; these data together provide both prognostic information, as well as indications for topical or systemic therapy. The individual organ scores are then summarized for an overall global severity score of mild, moderate, or severe. A global severity score of mild encompasses no more than 2 organs, with severity of 1 each; moderate global severity indicates any organ site with a score of 2 (or lung score of 1), or involvement of 3 or more organ sites; finally, the severe category results from either any individual organ site score of 3, or a lung score of 2. From these data, six risk groups were identified based on the number of risk factors present. Nonrelapse mortality at 5 years ranged from 5% in the lowest risk group to 72% in those with greatest risk.
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Right: During inspiration, contraction of the muscles of inspiration causes intrapleural pressure to become more negative gastritis diet oatmeal purchase discount omeprazole online. The transmural pressure gradient increases and the alveoli are distended, decreasing alveolar pressure below atmospheric pressure, which causes air to flow into the alveoli. They expand passively in response to an increased distending pressure across the alveolar wall. This increased transmural pressure gradient, generated by the muscles of inspiration, further opens the highly distensible alveoli and thus decreases the alveolar pressure. The transmural pressure gradient is conventionally calculated by subtracting the outside pressure (in this case, the intrapleural pressure) from the inside pressure (in this case, the alveolar pressure). The pressure in the thin, liquid-filled space between the visceral and parietal pleura is normally slightly less than atmospheric pressure, even when no inspiratory muscles are contracting. At the end of expiration, when all the respiratory muscles are relaxed, the lung and the chest wall are acting on each other in opposite directions. The lung is tending to decrease its volume because of the inward elastic recoil of the distended alveolar walls; the chest wall is tending to increase its volume because of its outward elastic recoil. Thus, the chest wall is acting to hold the alveoli open in opposition to their elastic recoil. Initially, before any airflow occurs, the pressure inside the alveoli is the same as atmospheric pressure-by convention 0 cm H2O. Alveolar pressure is greater than intrapleural pressure because it represents the sum of the intrapleural pressure plus the alveolar elastic recoil pressure: Alveolar pressure = Intrapleural pressure + Alveolar elastic recoil pressure (1) the muscles of inspiration act to increase the volume of the thoracic cavity. As the inspiratory muscles contract, expanding the thoracic volume and increasing the outward stress on the lung, the intrapleural pressure becomes more negative. Increasing alveolar volume lowers alveolar pressure and establishes the pressure gradient for airflow into the lung. The pressure gradient across the outermost alveoli is transmitted mechanically through the lung via the alveolar septa. In negative-pressure breathing (inset A), the mechanical stress would likely be transmitted from the more exterior alveoli (those closest to the chest wall) to more interior alveoli, so the exterior alveoli might be more distended.
Syndromes
- Have others avoid contact with the baby if they have a cold or fever. If necessary, have them wear a mask.
- Delusions
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Carbonic acid is therefore said to be a volatile acid because it can be converted into a gas and then removed from an open system such as the body gastritis tratamiento buy generic omeprazole 10 mg. A much smaller quantity of fixed or nonvolatile acids is also normally produced during the course of the metabolism of foodstuffs. The fixed acids produced by the body include sulfuric acid, which originates from the oxidation of sulfurcontaining amino acids such as cysteine; phosphoric acid from the oxidation of phospholipids and phosphoproteins; hydrochloric acid, which is produced during the conversion of ingested ammonium chloride to urea and by other reactions; and lactic acid from the anaerobic metabolism of glucose. Other fixed acids may be ingested accidentally or formed in abnormally large quantities by disease processes, such as the acetoacetic and butyric acid formed during diabetic ketoacidosis (see Chapter 66). A vegetarian diet may produce significantly less fixed acid and may even result in no net production of fixed acids. The removal of fixed acids is accomplished mainly by the kidneys, as will be discussed in Chapter 47. The body contains a variety of substances that can act as buffers in the physiologic pH range. These include bicarbonate, phosphate, and proteins in the blood, the interstitial fluid, and inside cells (discussed in greater detail in Chapter 47). The isohydric principle states that all the buffer pairs in a homogeneous solution are in equilibrium with the same hydrogen ion concentration. For this reason, all the buffer pairs in the plasma behave similarly, so that the detailed analysis of a single buffer pair, like the bicarbonate buffer system, can reveal a great deal about the chemistry of all the plasma buffers. The bicarbonate buffer system consists of the buffer pair of the weak acid, carbonic acid, and its conjugate base, bicarbonate. The ability of the bicarbonate system to function as a buffer of fixed acids in the body is largely due to the ability of the lungs to remove carbon dioxide from the body. At body temperature in the plasma, the equilibrium of the reaction is such that there is roughly 1,000 times more carbon dioxide physically dissolved in the plasma than there is in the form of carbonic acid. Under pathologic conditions, the extremes of arterial blood pH have been noted to range as high as 7. Note that the pH scale is "inverted" by the negative sign and is also logarithmic as it is defined. Hydrogen ions are the most reactive cations in body fluids, and they interact with negatively charged regions of other molecules, such as those of body proteins.
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Cortical nephrons have efferent arterioles that give rise to peritubular capillaries, and they have short loops of Henle gastritis symptoms australia order 40 mg omeprazole visa. In contrast, juxtamedullary nephrons have efferent arterioles that descend into the medulla to form vasa recta, and they have long loops of Henle. The macula densa marks the end of the thick ascending limb and the beginning of the distal convoluted tubule. This is followed by the con- necting tubule, which leads to the cortical collecting tubule, the first portion of which is called the initial collecting tubule. Interspersed among the segment-specific cells in each of these three segments are individual cells of the second type, called intercalated cells. The last portion of the medullary collecting duct contains neither principal cells nor intercalated cells but is composed entirely of a distinct cell type called the inner medullary collecting duct cells. The granular cells are named because they contain secretory vesicles that appear granular in light micrographs. It is made up of (1) juxtaglomerular cells (granular cells), which are specialized smooth muscle cells surrounding the afferent arteriole, (2) extraglomerular mesangial cells, and (3) cells of the macula densa, which are part of the tubule. The close proximity of these components to each other permits chemical mediators released from one cell to easily diffuse to other components. All the cortical collecting ducts then run downward to enter the medulla and become outer medullary collecting ducts, and then inner medullary collecting ducts. The latter merge to form several hundred large ducts, the last portions of which are called papillary collecting ducts, each of which empties into a calyx of the renal pelvis. Each renal calyx is continuous with the ureter, which empties into the urinary bladder, where urine is temporarily stored and from which it is intermittently eliminated. From this point on, the remainder of the urinary system serves only to maintain the composition of the tubular fluid established by the kidney. Up to the distal convoluted tubule, the epithelial cells forming the wall of a nephron in any given segment are homogeneous and distinct for that segment. However, beginning in the second half of the distal convoluted tubule, two cell types are found intermingled in most of the remaining segments. Secretion is the process of moving substances into the tubular lumen from the cytosol of epithelial cells that form the walls of the nephron. Secreted substances may originate by synthesis within the epithelial cells or, more often, by crossing the epithelial layer from the surrounding renal interstitium. Reabsorption is the process of moving substances from the lumen across the epithelial layer into the surrounding interstitium. Contrast this value with the net filtration of fluid across all the other capillaries in the body: approximately 4 L per day. When we recall that the average total volume of plasma in humans is approximately 3 L, it follows that the entire plasma volume is filtered by the kidneys some 60 times a day. The opportunity to filter such huge volumes of plasma enables the kidneys to excrete large quantities of waste products and to regulate the constituents of the internal environment very precisely.
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The ventral respiratory groups are located bilaterally in the retrofacial nucleus, the nucleus ambiguus, the nucleus para-ambigualis, and the nucleus retroambigualis gastritis polyps omeprazole 10 mg low cost. The neurons in the nucleus ambiguus are primarily vagal motor neurons that innervate the ipsilateral laryngeal, pharyngeal, and tongue muscles involved in breathing and in maintaining the patency of the upper airway. Other neurons from the ventral respiratory groups mainly project contralaterally to innervate inspiratory muscles and the expiratory muscles. An area in the in the pons (the part of the brainstem just rostral to the medulla) called the apneustic center appears to be an integration site for afferent information that can terminate inspiration. The specific group of neurons that function as the apneustic center has not been identified. The pontine respiratory groups may also modulate the respiratory control system response to stimuli such as lung inflation, hypercapnia, and hypoxia. There is integration of descending influences as well as the presence of local spinal reflexes that can affect these motor neurons. Descending axons with inspiratory activity excite phrenic and external intercostal motor neurons and also inhibit internal intercostal motor neurons by exciting spinal inhibitory interneurons. Ascending pathways in the spinal cord, carrying information from pain, touch, and temperature receptors, as well as from proprioceptors, can also influence breathing, as will be discussed in the next section. The spontaneous rhythmicity generated in the medullary respiratory center can be completely overridden (at least temporarily) by influences from higher brain centers. In fact, the greatest minute ventilations obtainable from healthy conscious human subjects can be attained voluntarily, exceeding those obtained with the stimuli of severe exercise, hypercapnia, or hypoxia. Conversely, the respiratory rhythm can be completely suppressed for several minutes by voluntary breath holding, until the chemical drive to breath (high Pco2 and low Po2 and pH) overrides the voluntary suppression of breathing at the breakpoint. The sensors are stretch receptors located within the smooth muscle of large and small airways. They are sometimes referred to as slowly adapting pulmonary stretch receptors because their activity is maintained with sustained stretches.
Roland, 49 years: The apex of the axilla is truncated and is, in fact, the gap between the middle third of the clavicle and the outer edge of the first rib.
Sanford, 43 years: Sophisticated optical and genetic techniques allow imaging of microglia in vivo, thus providing insight into the morphological and motile reactivity of microglia in the living animal (Exner 1894, Davalos et al 2005).
Musan, 54 years: They are enzymatically degraded into their constituent amino acids, which are then returned to the blood.
Thordir, 56 years: The diaphragm is a large (about 250 cm2 in surface area), domeshaped muscle that separates the thorax from the abdominal cavity.
Larson, 21 years: Many of these receptors, including 7 of the 13 known toll-like receptors, are present in sensory neurons (OchoaCortes et al 2010), and although the second-messenger pathways activated by these receptors could result in a generator potential, these receptors appear to be responsible primarily for afferent sensitization rather than activation.
Masil, 28 years: From its nucleus, which lies in the floor of the 4th ventricle, a series of about a dozen rootlets leave the side of the medulla in the groove between the pyramid and the olive.
Sulfock, 34 years: Only on extremely rare occasions are the glands actually completely buried within thyroid tissue.
Tukash, 36 years: There may be an extensive obstruction of the aorta from the left subclavian artery to the ductus, which is widely patent and maintains the circulation to the lower parts of the body; often, there are multiple other defects and frequently infants so afflicted die at an early age.
Esiel, 50 years: Following injury or disease, keratinocytes can release an array of cytokines, chemokines, and growth factors (Pastore et al 2006, Li et al 2011), which can have sensitizing actions on nociceptors, as well as endogenous opioids, which can have an analgesic action (Khodorova et al 2003).
Finley, 41 years: When the mouth is widely open, the condylar process of the mandible slides forwards onto the articular eminence; thence, a blow, or even a yawn, may cause forward dislocation into the infratemporal fossa on one or both sides.
Darmok, 31 years: Islet cells are there is good evidence that it is present at much higher concentration in glycinergic neurons than in other cell types.
Aidan, 60 years: In nulliparous women the vaginal wall is rugose, but it becomes smoother after childbirth.
Kerth, 55 years: The bile ductules are lined by cholangiocytes, which are columnar epithelial cells specialized to modify bile composition.
Volkar, 32 years: Its floor consists of iliacus, the tendon of psoas, pectineus and adductor longus.
Chris, 52 years: The nasopharynx the nasopharynx lies above the soft palate, which cuts it off from the rest of the pharynx during deglutition and therefore prevents regurgitation of food through the nose.
Navaras, 63 years: The tubular cells possess a complement of aquaporins (water channels) in both the apical and basolateral membranes, and the tight junctions are also permeable to water.
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