Fall I – Summary Project

TABLE OF CONTENTS:
BLOCK I: CORE CONCEPTS

CHAPTER 1: MOLECULAR BIOLOGY CHAPTER 2: CELL BIOLOGY CHAPTER 3: GENETICS CHAPTER 4: GENERAL HISTOLOGY CHAPTER 5: MUSCLE CHAPTER 6: NERVOUS SYSTEM CHAPTER 7: INTRO TO EMBRYOLOGY CHAPTER 8: ANATOMY & RADIOLOGY OF EXTREMITIES
BLOCK 2: CARDIAC, RESPIRATORY, RENAL

CHAPTER 9: ANATOMY, EMBRYOLOGY, & RADIOLOGY OF THORAX CHAPTER 10: CARDIAC CYCLE CHAPTER 11: EKG CHAPTER 12: VASCULAR MICROANATOMY AND BIOPHYSICS CHAPTER 13: BLOOD & HEMOSTASIS CHAPTER 14: RESPIRATORY HISTOLOGY CHAPTER 15: RESPIRATORY PHYSIOLOGY CHAPTER 16: RENAL EMBRYOLOGY & RADIOLOGY CHAPTER 17: RENAL HISTOLOGY CHAPTER 18: RENAL PHYSIOLOGY
BLOCK 3: GI, METABOLISM, NUTRITION, ENDOCRINE, REPRODUCTION

CHAPTER 19: ANATOMY & EMBRYOLOGY OF GI TRACT CHAPTER 20: GI HISTOLOGY CHAPTER 21: GI PHYSIOLOGY CHAPTER 22: METABOLISM CHAPTER 23: NUTRITION CHAPTER 24: ENDOCRINE HISTOLOGY CHAPTER 25: ANATOMY & EMBRYOLOGY OF REPRODUCTION CHAPTER 26: MALE REPRODUCTION CHAPTER 27: FEMALE REPRODUCTION CHAPTER 28: INTEGRATIVE SEMESTER TOPICS

SChapter One - Molecular Biology
BLOCK I – CORE CONCEPTS THREAD: BIOCHEMISTRY & GENETICS
CONTRIBUTORS: ALEX SWEENEY, ELIZABETH MCQUITTY & ZAINA AL-MOHTASEB

TABLE OF CONTENTS: GENE I GENE II GENE III GENE IV GENE V GENE VI PROTEIN TAXONOMY PROTEIN II PROTEIN III PROTEIN IV PROTEIN V PROTEIN VI

RAM REDDY RAM REDDY RAM REDDY RAM REDDY RAM REDDY RAM REDDY MIKE SCHMID MIKE SCHMID MIKE SCHMID MIKE SCHMID MIKE SCHMID MIKE SCHMID

GENE I
DNA synthesis (semi-conservative replication) RNA synthesis (transcription – 5’-3’ with leading and lagging strand) protein synthesis (translation) C:G base pairs are harder to break because they are connected by 3 H-bonds. A:T pairs have 2 H-bonds…usually promoter regions/origins of replication are AT rich so that less energy is required to start replication. GC rich regions have a high melting temperature compared to AT rich regions DNA synthesis requires template, primer with 3-OH, building blocks (5’ dNTP’s), energy (p-p bonds), and DNA polymerase. 1. Mg and buffer also reqd. if done in a test tube. 2. 2 replication forks in prokaryotic replication (circular DNA). 3. DNA polymerase makes few mistakes due to 3’-5’ exonuclease activity a) Other polymerases: taq polymerase (heat stable, non-proof reading DNA dependent DNA polymerase), reverse transcriptase (RNA dependant DNA polymerase), telomerase (RNA dependant DNA polymerase) i. Telomerase: prevents telomere shortening. Cancer cells become immortal due to telomerase activity. It uses its own RNA template to elongate DNA 4. Topoisomerase I relieves strain due to supercoiling (gyrase in bacteria and Topo II in circular DNA) DNA is packaged into condensed chromatin (inactive genes) or extended chromatin (active genes) DNA is found in a: 1) B form (Biological form – right handed, 10bp/turn) 2) A form (right handed, 11bp/turn, ssDNA, DNA:RNA and RNA:RNA) 3) Z form (left handed 12bp/turn, active chromatin) -DNA repair can be achieved by endo and exo-nucleases - methylation is commonly used to distinguish the parent strands DNA can also be repaired by ligation of broken strands and using the second chromosome as a template. P53 prevents cell replication before DNA repair has occurred. Cells deficient in P53 can become cancerous.

-

GENE II
- siRNA’s are used as a defense mechanism in lower eukaryotes and plants - -Dicer cleaves 21 NT long dsRNA from foreign RNA. - -siRNA is amplified and spread - -RISC pairs siRNA with viral mRNA for clevage - -Host DNA is protected by methylation - -For more info on siRNA, go to www.fuzzymittens.com/ms1 , click on the link for core concepts, and find the iRNA ppt. in the cell bio folder - Plasmid cloning vectors - -Plasmid contains origin of replication, antibiotic resistance gene and polylinker region (site where polylinker DNA insertion occurs). - -New DNA, with sticky ends, is annealed to plasmid. - -Amplification occurs with antibiotic (the plasmid should be resistant) as the selection marker. - -You can prepare a genomic library in a plasmid vector. - Lambda phage cloning vectors and yeast artificial chromosomes - Both of these accommodate larger pieces of DNA. - Hybridization or antibody usage helps you to identify the specific DNA insert. - Genomic libraries vs. cDNA libraries vs. cDNA expression libraries: - Genomic libraries have introns, promoters, non-transcribed spacer DNA, etc. - cDNA contains only sequences complementary to post-modification mRNA (ready to be translated into protein) - cDNA expression libraries are composed of cDNA’s with the requisite DNA sequences for expression in an artificial system - DNA inserted into a cloning vector is isolated by using complimentary endonucleases

GENE III
2 ways to produce DNA probes: 1. Separate DNA strands and add radioactive dNTP’s 2. Use a polynucleotide kinase to transfer radioactive phosphate to the 5’ end of DNA. DNA sequencing 1. Chemical method (Maxam-Gilbert): • 4 tubes used (A, C, G, T) • Use a chemical that will attach to the designated nucleotide and break the strand • Result: a bunch of different sized strands that are sequenced • DNA footprinting also uses chemicals to determine where specific proteins bind 2. Enzymatic method (Sanger’s dideoxy) Make 4 different vials (same as above) and include specific dideoxy, “chain terminating” nucleotides in each vial. Result: same as chemical. Anti-viral drugs (AZT) can work by this same dideoxy method 3. Automated sequencing • Uses fluorescent tags on dideoxy nucleotides. The stability of a DNA hybrid is directly proportional to its base pair matching. More perfect hybrids are more stable, so you can separate less perfect hybrids with high temperature and NaCl concentration. Blots (Southern uses DNA, Northern uses RNA, and Western uses proteins) • Electrophoresis to separate different size fragments • Heat applied to denature and separate all fragments (i.e. dsDNA ssDNA) • Radioactive probe (complimentary to target sequence) added to the filter and hybridization occurs. • The sample is exposed to film so that you can identify hybrids. Restriction fragment length polymorphism is used to detect mutations in gene sequences. It involves cleavage of an isolated DNA fragment and identification of the digested pieces. 1. Southern blotting used 2. useful for prenatal screening, sickle cell detection and phenylketonuria PCR – polymerase chain reaction is used to make copies of genetic info. 1. Heat to separate strands 2. Add primers to hybridize and add dNTP’s 3. Heat and use Taq polymerase to transcribe 4. Repeat Variable numbers of tandem repeats (VNTR). Unique sequences outside of the coding regions of DNA are amplified for identification purposes

GENE IV
Transcription (5’-3’) • Synthesis of RNA from DNA templates. • Enzyme – RNA polymerase • Helicase and topo I are needed for accurate transcription • Promoters, enhancers, repressors and insulators are all used to regulate Most regulation occurs at the level of initiation. Regulation can be negative or positive. • • • • • • Prokaryotes have no nucleus so transcription and translation are coupled. 1 strand of Prokaryotic mRNA produces multiple proteins (polycistronic). Eukaryotic transcription and translation occur in nucleus and cytosol, respectively. Eukaryotic mRNA is monocystronic. All genes are present in every cell, but differential expression causes functional variation. Methylation on promoters causes inactivation Acetylation on histones causes activation Both demethylation of promoters and acetylation of histones are necessary to activate gene transcription

Steroids hormones alter gene expression (look at Block 3: Endocrine) Eukaryotic mRNA processing • Eukaryotic mRNA is capped (5’) and polyadenalted (3’). These modifications enable the mRNA to exit the nucleus. • Introns (70% of gene) are removed. Alternate and trans-splicing can give you many mRNA’s. • 7 subunits of snRNA come together to make snRNP which identifies the splicing site.

GENE V
Overall: Translation and Translation Control I. Translation = synthesis of proteins. a. mRNA to protein: need mRNA, ribosomes, tRNAs, amino acids, several protein factors, energy (ATP, GTP) b. tRNAs have 2 functions: 1. bind correct AA @ 3’ end; 2. bind triplet codon on mRNA using anti-codon segment. c. Wobble hypothesis: 3rd position in anti-codon pairs loosely, so imperfect pairing occurs. d. Eukaryotic vs bacterial ribosomes: Es are bigger! e. Positioning ribosome correctly on the mRNA: in bacteria, 16S segment binds 3’ end of mRNA; in eukaryotes, ribosome starts at 5’cap and scans for start codon (AUG) i. Sometimes start at IRES = internal ribosome entry site. f. Initiation: initiation factors aid small ribosomal subunit, with initiator tRNA bound (always Met for AUG site), to find start codon; then large ribosome subunit binds, then next tRNA; now AA can be transferred and translation begins. g. Elongation: each new AA residue gets transferred to growing chain. (believed to be catalyzed by rRNA: a rare ribozyme action). h. Termination: Release factors are like tRNA but without an AA attached: when RF binds to ribosome, protein is released. i. Polysomes – lots of ribosomes translating single mRNA at once; on RER surface (secretory proteins) or in cytosol (soluble proteins). II. Post-translation: proteins are folded as they come out of ribosome (see cell biology lectures) and proteins undergo post-translational modifications (see biochem lectures). III. mRNA stability and Translational Control a. mutations: i. silent – at protein level, no difference ii. missense – protein still translated but with an AA substituted. iii. nonsense – non-functional protein or truncated (mutation causes premature stop codon). iv. Addition/deletion – add or delete single nucleotide v. Frame-shift – generally results from addition or deletion. b. Stability: i. 5’cap: 5’-5’ linkage: protects mRNA ii. UTRs – UnTranslated Regions at 5’ or 3’ end of mRNA confer stability and places for regulatory proteins to bind. Eg: transferrin (5’UTR) and its receptor (3’UTR): aconitase (itself inhibited by Fe molecules) binds both UTR regions, so in low Fe, inhibits TR translation and stabilizes receptor mRNA to bring Fe into cell. Converse in Fe overload: TR translated and receptor mRNA degrades..

GENE VI
Overall: Biotechnology I. Recombinant proteins: (example: insulin) a. Use plasmid to clone insulin gene into bacteria. Cell culture makes insulin; once purified is perfect replacement therapy. b. Can get recombinant proteins in milk; expression of recombinant genes limited to mammary glands. Resolves some problems of making human genes ‘work’ in prokaryotes. These proteins get purified from the milk. c. Recomb proteins in use today: TPA (tissue plasminogen activator), blood clotting factors, interleukins, enzymes for research, safer vaccines. II. Use of transgenic mice in research a. Humans and mice have similar genes and similar development. b. Options: gene replacement, gene knock-out, gene addition. c. Accomplish by growing mouse stem cells in culture, altering DNA, then introducing stem cells into early embryo; breed 2nd generation to get purebreds. III. Genetic therapy a. ADA (adenosine deaminase) deficiency causes SCID (severe combined immune deficiency). Tx: take stem cells or Tcells from pt, add the ADA gene, then reintroduce patient’s cells into system. b. Portions of HIV genome used as very effective vector. (used for ADA) Viruses successful at incorporating into genome – randomly or at LTRs (long tandem repeat segments). c. Cloning sequence using viral vector: LTR – Enhancer – promoter – gene cDNA – poly(A) signal – LTR. (use promoter appropriate to target tissue). IV. Tailor-made anti-cancer drugs: a. Example is GLEEVAC: treats chronic myeloid leukemia. Disease caused by abnormal chromosome translocation resulting in a fusion kinase present only in cancer cells. GLEEVAC is tailor-made to inhibit this activity. Patient takes pill once a day until all blood cells should have turned over and all cells with mutation have died. Pt then cancer-free. V. Oncogene discovery – from cDNA library. Can note cell populations with over-growth phenotype. Led to discovery of Ras oncogene. VI. siRNAs a. The low-down: siRNAs are ‘small interference RNAs’. In plants, double stranded RNA is chopped by an RNase (dicer) into fragments 23nts long. These mark other incoming RNA that is complementary so that dicer can cut them as well. RNA – dep RNA polymerase makes more of these short fragments to function in future defense. Humans have dicer (but not the RNA-dep RNA polymerase). Research is ongoing to use dicer to chop up viral or cancer mRNAs in human disease.

PROTEIN TAXONOMY
Overall: Protein Structure I. Amino Acid structure a. All AAs are chiral with a side chain (giving specific AA), an amino group (NH2), a carboxy group (COO-) and an H. (exception is glcine with 2 Hs).
α carbon side chain

R-CH-CO2NH3+
carboxyl group

amino group

II.

b. Learn your amino acids – they’re in your syllabus. (note that categories such as non-polar vs. polar, aliphatic, aromatic, uncharged polar and charged polar actually matter and are worth learning also). Acid-Base behavior of AAs a. The charged AAs are acids and bases; usually they are on the surface of a protein and form salt-bridges with each other. b. Acid – proton donor; base – proton acceptor. c. Henderson-Hasselbach: relates the pKa of a buffer and the ratio of acid and base present to the resulting pH of the solution. pH = pKa + log ([A-]/[HA]) d. Titration curves: pKa = mid-point along the flat segment of these curves: at this point, half of the molar amount of titrated group is hydrogenated, half is de-hydrogenated. Work any problems from there, depending on where you start (pH) and whether you’re adding acid or base.

III.

IV.

V.

The peptide bond a. Peptide bond is planar; rotation only around alph-Carbon and side chain elements. Primary structure a. Each protein: unique number and sequence of amino acids coded from DNA to RNA to protein. b. Sequence conservation: percent identity across species. Interactions of side chains contributing to protein structure. water structure, hydrophobic interactions, Hbonds, electrostatic interactions, van der Waals interactions, molecular interaction.

PROTEIN II
Overall: More Protein Structure. I. Key concepts: a. Interactions between sidechains that are far apart in sequence cause protein to fold into compact shape. b. Inferior of protein typically hydrophobic, compact with few holes. c. Exterior typically hydrophilic and charged residues typ on surface. d. Majority of N-H and C=O are involved in hydrogen bonds which conver secondary structure. e. Specialized functional regions may form – catalytic sites. II. Secondary structure: - when sequence folds in regular, repeated fashion. a. Helix structures, sheets, turns, random structure. III. Super-secondary structure - Recognized sequences of known secondary structures. a. helix-turn-helix, beta-meander, beta-alph-beta structure. IV. Tertiary structure a. 3-D structure of single protein molecule; brings together different parts of primary and secondary structure. V. Quaternary structure - describes assembly of multiple enzyme subunits. a. Hydrophobic interactions important; also, charge and H bond interactions. b. Association of multiple subunits allows regulation of activity, info transmission (allostery and cooperativity), and creation of multiple assemblies using multiple subunit types. VI. Protein stability a. Proteins only marginally stable; this confers flexibility for enzyme activity. VII. Protein folding (key to Cystic Fibrosis and other diseases) a. Mechanism directing protein folding not known. b. Unfolded proteins will collapse then refold from compact structure. c. Not all proteins refold spontaneously. d. Molecular chaperones (bind unfolded proteins to prevent mis-folding) and Foldases (in ER; forms disulfide bonds) aid process. VIII. Post-translational Modifications: a. Disulfide bonds (2 Cys residues) – stabilize structure (eg: insulin has 3) b. Phosphorylation (Ser, Thr, Tyr) – think metabolism control mechanisms c. Hydroxylation d. Glycosylation – alters stability, signal recognition e. Carboxylation (like Acetyl CoA Carboxylase) f. Fatty acylation/prenylation – increases hydrophobicity of protein g. Proteolysis – all zymogens Protonation/deprotonation – changes in pH cause this

PROTEIN III & IV
HEMOGLOBIN: • Has heme group bound by hydrophobic interactions, and iron as Fe2+, which binds oxygen. • α2β2 tetramer. • Positive cooperativity in binding causes greater “steepness” about the P50 point; successive oxygens are easier to add. This increases the amount of oxygen bound in the lungs and the amount delivered in the tissues. The Bohr effect: decrease pH, decrease Oxygen binding to hemoglobin; Hemoglobin gives up oxygen more readily at low pH; saturation curve shifts to the right because it is less oxygen bound/saturated even at the same PO2. • H+ takes the place of oxygen; hemoglobin is a proton carrier between the lungs and the tissues, important buffer. • CO2 also binds deoxyhemoglobin in tissues and is carried to lungs. • BPG binds deoxy Hb and inhibits Oxygen binding in presence of BPG. Fetal HB doesn’t bind BPG as well. Therefore, higher oxygen affinity than adult Hb. • BPG is an intermediate in glycolysis, which indicates working tissue in need of oxygen for oxidative phosphorylation after glycolysis.

pH 7.4
Lower pH releases oxygen Higher oxygen releases protons

pH 7.0

MYOGLOBIN: • Monomer, similar to one of Hb’s subunits • Shows saturation behavior at Oxygen binding site; increases linearly to p50, then begins to level off. • Releases oxygen at lower pO2 than Hb; takes oxygen to very starved tissues, ex. Red/type I muscle. Enzyme kinetics: • Enzymes are catalysts to reach equilibrium faster. • Very specific-few substrates • Active site equals binding domain plus catalytic domain.

• • •

Enzymes are controlled by amount of enzyme, posttranslational modification, and quantity of substrates and products. Isozymes are different proteins from different genes that catalyze same reactions, often in different tissues. CPK found after heart attack (cardiac cells die or after muscle trauma); CPK-BB-brain and lungs. MB-heart MM-skeletal muscle (different isozymes can tell you which tissue has the problem).

At low substrate concentrations: • Velocity of enzyme reactivity is directly proportional to [S], then becomes limited by the concentration of the enzyme. • Km=[S] at ½ Vmax= Michaelis constant, perenzyme, sort of an indicator of enzyme’s affinity for its subsrate. Michaelis-Menten: • V=Vmax [S]/Km+[S] (Usually expressed in umol/minute of substrate consumed) • V or Vmax/[E] = specific activity of enzyme. • V varies the most in the range where [S] is less than Km; therefore most enzymes in the body have Km close to physiological [S], so their activity can be finely regulated by changing [S]. Lineweaver-Burk double reciprocal plot: Y intercept = 1/Vmax Slope = Km/Vmax Inhibition by products or product analogs gives reversible inhibition. Bind to active site/occupy it.

Competitive inhibitor: effector binds E. Can be fought off by increasing [S] and thus Vmax does not change. Changes slope, Km/Vmax, by increasing [S] required to reach Km. (Either substrate or inhibitor binds)

Non-competitive inhibitor: effector binds E and ES; cant be fought off by increasing [S] because inhibitors and substrates bind to different sites. Changes slope and intercept. Allostery: change enzyme function by changing enzyme shape Cooperativity: allostery via substrate; + or – Produces sigmoidal kinetics, see hemoglobin.

Phosphofructokinase: an example of allostery.

Term Cooperativity Comp. Inh.

Expt'l hallmark

Structural cause 'zif [S] "creates" new f'n enz.

"s-shaped curve" (n>1) Allostery (using substrate)

High [S] can overcome 1. S and I Bind at [I] "destroys" f'n enzyme it (1/vmax same) same site 2. allostery S and I bind at different sites Activator "converts" enz to f'n form

Non-comp. Inh. High [S] cannot overcome it Allosteric act. Allosteric inh.

Enzyme "works better" Allostery (using esp at low [S] activator)

Enzyme "works Allostery (as in 2.) "Bohr effect" or BPG worse" esp at low [S]

PROTEIN V & VI
Catalysts by enzymes: Specificity constant: efficiency of enzyme finding and converting substrate. Specificity constant = Vmax/Km Lock and key: specificity (the substrate fits specifically into the active site). Induced fit: binding substrate changes shape of enzyme and brings catalytic site into the right geometry for activity. Enzymes lower activation energy required for transition state. (∆Gact) (don’t change overall equilibrium)

Catalysis mechanisms: 1. Organization of substrates spatially:

2. 3. 4. 5.

Solvation effects/microenvironment excluding water Covalent catalysis/alternative mechanism Coenzymes/vitamins: Alternative (non-AA) side groups like aldehydes, ketones, metals, oxidizing and reducing agents. 6. Acid base catalysis

Rational Drug Design: The old way: • Accident • Screening The new way: • Isolate target enzyme or receptor first • Screen compounds for binding inhibitors and denerage lead compound • Determine lead compound’s structure and a synthetic strategy for compound. • Optimize structure (ex combining bits for greater inhibitor efficiency to make a multisubstrate analog). • Penicillin: Old way: Inhibited cell wall crosslinking but was susceptible to B lactatmase New way: Cephalosporins are inhibited but not susceptible to B lactamase. Substrate analogs: resemble substrates, 5 reactions. HIV blocked by dideoxy base which is incorporated into DNA and prevents further polymerization. Ex. AZT, DDI, DDC. These work because they don’t inhibit mammalian DNA polymerase, only RNA reverse transcriptase action.

AZT (azidothymidine), DDI (dideoxyinosine) and DDC (dideoxycytidine)

Multisubstrate analogs: More efficient. Cancer blocked by PALA, which inhibits pyramidine biosynthesis for DNA replication. Transition state analogs: Very specific, very tight binding to enzymes. AIDS protease that activates viral preprotein “protease inhibitors.” De novo design: • Get 3D structures (positive charge and hydrophobicity info) of target. • Use computer to screen known compounds, synthesize molecule.

Chapter Two – Cell Biology
BLOCK 1 – CORE CONCEPTS THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: LAURA HANSON, MICHAEL STEWART, LAURA GARCIA, SAGARI PONNURU, ADVA BUZI & ROBERT DOMINGO

TABLE OF CONTENTS: CELL MEMBRANES I CELL MEMBRANES II CELL MEMBRANES III CYTOSKELETON JUNCTIONAL COMPLEXES CELL ORGANELLES I CELL ORGANELLES II CELL ORGANELLES III CELL ORGANELLES IV CELL ORGANELLES V CELL SIGNALING I CELL SIGNALING II CELL SIGNALING III CELL SIGNALING IV CELL MOTILITY

JEANETTE KUNZ JEANETTE KUNZ JEANETTE KUNZ DAVID ROWLEY DAVID ROWLEY RICHARD SIFERS RICHARD SIFERS RICHARD SIFERS RICHARD SIFERS RICHARD SIFERS ERIC KLANN ERIC KLANN ERIC KLANN ERIC KLANN DAVID ROWLEY

CELL MEMBRANES I: STRUCTURE AND FUNCTION
PHOSPHOLIPIDS: BASIC STRUCTURE -most common kind is phosphoglyceride (aka glycerophospholipid) -is glycerol backbone + 2 fatty acids + [phosphate + head group]

WHY PHOSPHOLIPIDS ARE SUITABLE AS MAJOR COMPONENTS OF MEMB’S -amphipathic so in solution polar region is in contact with water, and non-polar region is away from water. -shape allows them to form monolayers, micelles, and bilayers -lateral fluidity HOW MEMBRANE FLUIDITY IS INFLUENCED 1. Longer acyl tail of fatty acids= increased Van der Waals interactions= higher Tm 2. More unsaturation= kinks that are harder to pack together= lower Tm 3. Cholesterol= bulky structure hard to pack and hard to move fast= wider range Tm DIFFERENT TYPES OF MEMBRANE PROTEINS Peripheral: Soluble proteins that associate with head groups of membrane or other proteins. • Electrostatic interactions that are easily dissociated with high salt or change in pH Integral: Insoluble proteins that penetrate or traverse the membrane. • Removed with detergents. May be single or multi pass (sequences of hydrophobic helices). Lipid-Anchored: Proteins with covalently attached lipid anchor in the bilayer • May be fatty acid or isoprenoid on the inner leaflet, or GPI on the outer FUNCTIONS OF MEMBRANE PROTEINS 1. Communication across membranes 2. Cell-cell and cell-matrix adhesion 3. Cell-cell recognition 4. Transport of compounds across membranes FACTORS AFFECTING PASSIVE DIFFUSION Membranes are differentially permeable and allow 1. Small nonpolar, 2. Hydrophobic, 3. Small polar uncharged molecules to pass through. 1. Flux is proportional to concentration difference across the membrane 2. Lipid solubility: partition coefficient= [concentration in bilayer]/[concentration in aq. soln.] 3. Membrane thickness and surface area (constant in animals) 4. Temp- higher temp= higher velocity of molecules 5. Size- bigger=slower Rate of passive diffusion is described by Fick’s Law: J=-P(Co-Ci) (doesn’t apply to charged molecules) WATER FLUX BY OSMOSIS REGULATES TONICITY Ingested water will distribute between extracellular and intracellular compartments. Water will flow from lower solute concentration to higher until the osmotic pressures on both sides of the membrane are equal. Donnan Effect: If a cell contains concentrated amounts of large molecules, water will tend to flow into the cell and change the volume. Water can flow across membranes through the membranes or by

facilitated diffusion through water pores. The large molecules can’t pass, but Na+ and K+ ions can, so cells regulate their volume by pumping ions in the direction that will reduce osmotic pressure.

CELL MEMBRANES II: TRANSPORT
FACILITATED DIFFUSION VS. ACTIVE TRANSPORT Facilitated Diffusion (Passive transport) Active Transport • Requires channels—simultaneously • Moves molecules UP conc. Grad. open to both sides; or carriers (permeases)—bind release • Energy utilized • No energy utilized • Saturable • Saturable • Specific • Selective • Used to generate a membrane potential • Multi-pass with hydrophilic residues • Uniport or Co-transport (sym or anti) towards the channels

PRIMARY ACTIVE TRANSPORT Uses the energy of ATP hydrolysis to make conformational change that transports the molecule through. #1 example: Na+/K+ ATPase • Pumps Na and K up their concentration gradients: 3 Na out for every 2 K in and every 1 ATP (antiport) • No ATP means Na and K gradients are lost (Ouabain, a steroid like drug, blocks the pump specifically and the gradients are lost) • Electrogenic (voltage gradient=stored energy) • Regulate osmotic balance, cell volume, and resting potential

SECONDARY ACTIVE TRANSPORT Uses energy to establish a concentration gradient, then uses that gradient to transport other molecules up their concentration gradient. #1 Example: Na+/Glucose cotransporter • First step is Na/K pump • Na+ gradient from step one is driving force to transport glucose into the cell • ATP is indirectly used • Gut epithelial cells use this • Na+ goes down its conc grad into the cell, and glucose goes up

MANY DISEASES ARE CAUSED BY TRANSPORT SYSTEM MALFUNCTION 1. Multi-drug resistance: ABC transporters that have highly conserved ATP binding domains, and are normally found in the liver, kidney, and intestine, and function to remove toxins. MDR gene is over expressed in certain cancers, and the ABC pumps pump out chemotherapeutic agents, causing drug resistance. 2. Cystic Fibrosis: ATP and cAMP sensitive Cl- channel becomes insensitive to cAMP. Cl- flux is disturbed in epithelia (eg lung). 3. Dropsy= Congestive Heart Failure: increasing intracellular Na+ will also increase Ca2+ levels which will increase force of contraction. Treatments will block or decrease the Na/K ATPase. Exs of drugs- Ouabain, Digitalis, Digoxin

CELL MEMBRANES III: ION CHANNELS
ION CHANNELS CAN SELECTIVELY ALTER MEMBRANE PERMEABILITY Non-gated channels are always open and are important in maintaining resting membrane potential. Gated channels are either open or closed in response to specific electrical, mechanical, or chemical signals. Ions flow rapidly when the channel is open (passive transport). Gated ion channels are categorized according to the kind of signal they respond to. The channels have specific amino acids that interact with the ions in solution and determine which ions will pass (this is called the selectivity filter). Specificity isn’t explained by ion size or charge alone. BASIC TYPES OF ION CHANNELS AND HOW THEY ARE GATED 1. Ligand-gated: non-covalent, reversible binding of a specific ligand will directly or indirectly cause conf. Change in the channel. Ligands can be NTs that bind the extracellular face, or can be second messengers or enzymes that act on the cytoplasmic face of the channel (by binding or changing phosphorylation state). Ligand-gated channels allow rapid communication. 2. Voltage-gated channels: change in memb potential causes movement of charged regions of the channel and opens or closes the channel. These channels propogate electrical impulses in nerve and muscle. 3. Mechanosensitive channels: stretching or deformation of PM induces a change in the shape of the channel and closes or opens it. IONIC BASIS OF MEMBRANE POTENTIAL AND ROLES OF ION CHANNELS Resting membrane potential = the difference in the ionic composition of the cytosol vs the surrounding fluid. (separation of charge=membrane potential). Interior Na=15 K=150 Cl=10 large anions=65 Exterior Na=150 K=5 Cl=110 large anions=.2 Ion channels allow the selective movement of the ions above (not the large anions) down their conc grad’s creating a difference in electrical potential between the inside and outside of the cell. Extent of the electrochemical gradient determines the direction and extent of net charge movement. Resting potential depends mainly on K+ leak channels (passive movement) and the K+ gradient MEMBRANE POTENTIAL VS. NERNST POTENTIAL VS. ACTION POTENTIAL Membrane potential= separation of charge/voltage difference b/w the inside and outside of the cell Nernst potential= equilibrium potential for any conc grad of a particular ion across a membrane, and is predicted by the Nernst Equation

Action potential= the membrane potential changes that occur during nerve impulse propogation

CYTOSKELETON
Cytoskeleton: Microtubules (MT) Location Cytoplasm, cilia, flagella Structure α & β tubulin subunit polymerizes to a helical MTs (13 units/turn) “soda-straw structure”. GTP cap at (+) end grows faster than (-) end. MTOC- microtubule organizing center directs polymerization. MAPsmicrotubule associated proteins stabilize MTs by cross-linking them into bundles Globular subunits (G- actin monomer) organize into a double stranded helix (F-actin polymer). Actively depolymerized and polymerized in non- muscle tissue. + end grows; - end disassembles; termed treadmilling. Capping actin w/ ATP stabilizes the polymer Function • Mitotic spindle: Roadway for motors; + end attaches Chromosomes; - at centriole. Kinesin (- to +) Dynein (+ to -) • Axon/Dendrites: Roadway for motor proteins to carry “cargo” • Cilia/Flagella: 9 +2 arrangement of MTs, Dynein on A tubule pushes B causing bending • Muscle: forms paracrystalline array with myosin for contraction • Cell cortex beneath membrane in most cells: aid endocytosis, exocytosis, and cell migration • Cytoplasmic streamingassociated with some organelle movement • Cytokinesis: associated with myosin in mitotic cells • Actin, like MTs, provide force and motion via motor proteins leading to contraction! Diameter 24nm

Microfilaments (actin filaments)

Present in every eukaryotic cell

5-7nm

Intermediate Filament:

Cell Type:

Keratin Vimentin Desmin Glial Fibrillary Acidic ProteinsGFAP Neurofilament

Helical monomer wraps around another to form a coiled-coil dimer. Two coiled-coils unite to form a staggered tetramer. Staggered tetramers can unite. Then 8 staggered tetramers twist into an intermediate filament. Epithelium Both Keratinized and Nonkeratinized epithelium Mesinchymal Fibroblasts, chondrocytes, macrophages, cells endothelial cells, vascular smooth muscle Contractile Striated & smooth muscle (except vascular cells smooth muscle) Glial cells Astrocytes

10-12nm

Neurons

Nerve cell body processes

Antimitotic Drugs Vinblastine: depolymerizes formed MTs, binds subunits of MTs and prevents polymerization by aggregating bound units into a paracrystalline array Taxol: accelerates formation of MTs and stabilizes them thus depleting the available tubulin for mitotic division Cochicine: colchicines-tubulin complex binds to growing (+) end of MT and stops MT growth.

JUNCTIONAL COMPLEXES
Gap Junction Structure: 6 connexins create a connexon which is a pore connecting adjacent cells (2nm diameter) Function: Allow ions and molecules up to 1500 D flow down a gradient. Ca2+ blocks gap junctions stopping flow Forms a seal around the cell which prevents flow of materials between epithelial cells (paracellular leakage) Provide firm adhesion between cells

Tight junction (Zonula Occludens)

Desmosome (Macula Adherens)

Hemidesomosome

Adherent Junction

Focal Contacts

multi-protein complex btwn cells that binds directly to the integral occludin proteins and to the cytoplasmic actin cytoskeleton 2 Disk shaped Cadherin transmembrane structures matched between cells. Attachment Plaque (12 proteins) located on cytosolic side where intermediate filaments insert. Ca2+ necessary. 1 Disk shaped integrin transmembrane structure that binds to the basal lamina (laminin and collagen type IV). Intermediate filaments attach to cytosolic side. Junctional complex with Cadherin trans-membrane protein. Inserts into the cytoplasmic actin of the Terminal web Junctional complex between cell and basal lamina. Integrin is the transmembrane protein. Actin is the cytoplasmic anchor

Bind the cell to the basal lamina

Encircles one cell and provides adhesion to neighbor.

Bind the cell to the basal lamina & ECM. Important for the motility of cells like fibroblasts. Not present in epithelial cells.

Facts to Know:
• • Desmosomes and hemidesmosomes attach to intermediate filaments like keratin, vimentin, or desmin; Tight junctions, adherent junctions, and focal contacts attach to actin. Desmosomes and adherent junctions use cadherins; hemidesmosomes and focal contacts use integrins.

CELL ORGANELLES I. THE NUCLEUS.
Heterochromatin-highly condensed / Euchromatin-less condensed (transcriptionally active) • Chromatin=complex of DNA, histones, and nonhistone proteins in eukaryotic cells. —the material of which chromosomes are made. • Histones = one of a group of small abundant proteins rich in positively-charges amino acids that form the nucleosome with the DNA of eukaryotes • Basic Unit of DNA packing is a Nucleosome: o consists of the core histones (H2A, H2B, H3, and H4), the linker histone (H1), and DNA • Making ribosomes: o Requires nuclear transport in two directions: (1) to bring ribosomal proteins to nucleolus (2) to export newly assembled ribosomal subunits o A lot of cellular machinery is devoted to making ribosomes • The nuclear pore complex mediates membrane permeablility o All movement of Nuclear macromolecules between the Import NLS importin nucleus and cytoplasm occurs through these structures. Because of its large size, the NPC allows free diffusion of macromolecules up to (45-60 kDa) o Signals mediate transport After import, importin recycles <<Nuclear localization back to cytoplasm for another round Sequence>> & <<Nuclear importin NLS of import. Export Sequence>> In cytoplasm, importin binds import cargo, carries it through o These targeting signals on the nuclear pore complex, and dissociates (releasing cargo) nuclear cargo are recognized in the nuclear interior. by soluble receptor/carriers called karyopherins (“nuclear carriers). <<Import karyopherins = importins>> <<export karyopherins= exportins>> o Over 20 karyopherins exist in human genome. Each receptor recognizes a different type of targeting signal. o mRNA export: very tight relationship between the splicing and processing of a newly transcribed mRNA and its export If one inhibits splicing, then export is inhibited also. In general mRNA export remains poorly understood because of complicated link between mRNA maturation and export • Relevance to disease: HIV Virus Life Cycle o Some HIV viral proteins contain NLSs. This allows viral nucleoprotein complexes to be actively imported into the nucleus of non-dividing cells. o Export of viral mRNA also uses host machinery. o Many viruses enter the nullius to gain access to the DNA replication machinery. The host machinery is used for the viral DNA to integrate into the genome. •

CELL ORGANELLES II: THE ENDOPLASMIC RETICULUM
• The rough endoplasmic reticulum: where proteins enter the secretory pathway • All ribosomes are equal. The translated mRNA determines the free vs. membrane bound state. <<Proteins contain targeting sequences or “zip codes” that mediate sorting to the correct internal organelle>> o Signal Sequence ER (Mediates translocation of nascent secretory and membrane proteins into the ER, the first compartment of the secretory pathway) o Signal sequences are stretches of 20 Three-dimensional reconstruction of a region of the smooth hydrophobic amino acids (# of AA and rough ER in a liver cell. required for a polypeptide to span a Alberts Fig. 12-38 lipid bilayer) • Covalent modifications assist protein folding (conformational maturation) and stabilize native structure o Asparagine-linked glycosylation o Disulfide bonds (do not form in cytoplasm because of the reduing atmosphere (glutathione). o Some membrane proteins lose their transmembrane domain and gain a GPI anchor • Final modification-protein folds (aided by chaperones of the ER lumen) <<Correct folding, and release form chaperones, is necessary for exit from the ER…FIRST HALF OF THE CHECKPOINT>> • Fxn’s for the smooth ER o Abundant in liver cells, because it contains some of the membrane-bound enzymes used to degrade certain hormones and to neutralize noxious substances such as alcohol and barbiturates o When large amounts of certain compounds, such as the drug Phenobarbital enter the system, the smooth ER in the liver doubles in surface area in a couple of days. (This change reflects rapid synthesis of detoxification enzymes, and the need for more membrane in which to place them.) o Synthesis nearly all of the major classes of lipids, including phospholipids and cholesterol, required of r the production of new cell membranes. o Most cellular lipids are synthesized on smooth ER. They reach the other membranes in the cell by one of three ways Vesicles bud off and move along cytoskeletal elements by motor proteins to other membranes with which they fuse Diffuse to the rough ER which is continuous with the smooth Er By transfer of proteins (to take lipids to organelles like mitochondria that don’t receive vesicular traffic from the ER • Smooth ER is common in cless engaged in steroid synthesis and lipid metalbolism because it contains some of the membrane bound enzymes required for these processes.

CELL ORGANELLES III: GOLGI & LYSOSOMES
Whether to release an ER-situated protein to the Golgi complex represents a crucial prosttranslational checkpoint. • The efficiency of protein clearance, underlies many loss-of-fxn and gain-of-toxic-fxn disorders o Cystic Fibrosis: Most common fatal genetic disease in the US today (1/3300 live births) o Repeated chest infections result in progressive loss of lung fxn, the major cause of premature death. o The most common mutation leading to cystic fibrosis results from deletion of Phe 508 in CFTR. o The mutant protein slightly misfolds, is trapped in the ER, and then degraded. o The mutation does not appear to affect the ability of the CFTR protein to transport ions, indication that the mutant protein would probably fxn if delivered to the plasma membrane/ o Alpha 1-antitrypsin deficiency: A genetic disease responsible for chronic obstructive lung emphysema o Also responsible for liver cirrhosis and is one of the most common genetic causes of childhood liver transplantation. o Both disorders are causes by mutations in the alpha 1-antitrypsin protein, Accumulation (in hepatocytes) of the undegraded mutant protein can lead to cirrhosis (gain-of-toxic-fxn disorder). Its hindered secretion is responsible for the lung disease (loss-of-fxn disorder). • Misfolded ER-situated proteins are dislocated into cytoplasm for degradation by proteosomes (prolonged duration of non-native structure = degradation). • Protein sorting signals specify: (1) ER retention (of native proteins) <<KDEL = retention signal>> (2) Golgi retention signal (different signals for cis, medial, & trans Golgi) (3) Signals for diverting secretory proteins to regulated secretory vesicles • Unless signals specify ER-retention, correctly folded proteins are delivered to the Golgi complex by default. • Golgi consists of flatted membrane-bound cisternae and resemble a stack of plates. • The tetanus toxin (protease) cleaves receptors used for the movement of synaptic vesicles in inhibitory neurons (blocks secretion of inhibitory NT = convulsive contractions of skeletal muscle lockjaw). Lysosomes. • Membrane bound organelle, acid pH (special coating on interior), degrades proteins, lipids, carbohydrates, DNA, RNA • The modifications of attached sugars divert most newly synthesized acid hydrolases out of the secretory pathway, and into lysosomes. (Mannose 6-phosphate (M6P) is a signal that targets newly synthesized proteins to lysosomes) • Lysosomal storage diseases: when a cell lacks one of the hydrolytic enzymes, lysosomes accumulate material that is normally destroyed o Tay-sachs disease is especially prevalent among Jews, particularly among those of Eastern European origin (1/30 reported chance) o Affected infants appear nml at birth (manifest relentless motor & mental deterioration & increasing dementia at 6 mths) death at 2-3 yrs o Results from an absence of hexoamionidase A (breaks down glycolipids) o Histological examination shows neurons ballooned with cytoplasmic vacuoles (distended lysosomes filled with glycolipid) >> progressive destruction of neurons •

CELL ORGANELLES IV: MITOCHONDRIA AND PEROXISOMES
• Mitochondria = generates cellular energy
Mitochondrial translocation machinery

Signal sequence for mitochondrial import “Translocator of Outer Membrane” (cytochrome oxidase) • Chaperones are required both in the cytosol and inside the mitochondria to achieve protein import • # and placement of sorting signals dictates site of protein residence “Translocator of Inner Membrane” • When mitochondria fail, less energy (ATP) is generated with the cell and cell death OXA complex mediates insertion into innermembrane. follows. • Damage is most notable in the following organs/tissues brain, heart, liver, skeletal muscle, kidney and endocrine system • Peroxisomes fxns = oxidation of fatty acids and other lipids, oxidation of purines, amino acids, hydroxyl acids, and other metabolites, biosynthesis of cholesterol, bile, acids, ether based lipids, contain large amounts of catalase which can convert excess hydrogen peroxide into water • Peroxisomal protein import (soluble matrix proteins only): 2 import signals (PTS1 and PTS2) [no detected targeting signal on some peroxisomal proteins = unknown mechansism] • Peroxisomal proteins are detected in vesicles that bud from the ER, and are claimed to represent immature peroxisomes • Multiple human diseases have been linked to peroxisomal disorders o Zellweger’s syndrome (inherited genetic disease): general defect in importing proteins into peroxisomes…exhibits “empty” peroxisomes…individuals die son after birth • Peroxisomal pathway is not completely understood o No chaperones exist in the peroxisomal matrix

CELL ORGANELLES V: ENDOCYTOSIS
o Protein trafficking from the plasma membrane o Phagocytosis “cell eating” (large particles) i.e antibody activated phagocytosis o Endocytosis (a) pinocytosis “cell drinking (b) Receptor mediated (active uptake of external & plasma membrane proteins) o Transcytosis (one side of cell to other) o Endocytosis: at the cell surface clathrin-coated pits and vesicles cycle between soluble (disassembled) and membrane-associated states. (adaptin proteins bind both clathrin, and the cytoplasmic tails of certain receptors clustering those receptors in coated pits. o Caveolae-another type of vesicle that buds from the plasma membrane that clusters GPI-linked membrane proteins o Transcytosis: In polarized cells, “tight junction” complexes are responsible for preventing the diffusion of membrane proteins between apical and basolateral surfaces limiting transcytosis to select substances. o Transcytosis is utilized for the uptake of maternal antibodies by nursing infants o Autophagy: protein trafficking distinct from plasma membrane that leads to lysosomal degradation. o General strategy used by cells to destroy their own organelles o Active in hepatocytes, but especially during period of amino acid starvation o The engulfing membrane may originate from ER or Golgi o Very little is known about the mechanics o also used in the destruction of proteins accumulating in the cytosol (aggressomes) that failed to be degraded by proteasomes (**potential modifier of the several gain-of-toxic-fxn diseases)

CELL SIGNALING I
Three basic categories of signaling molecules
Category Produced by Released Action Examples Time Endocrine islets or glands into blood diffusely throughout body Hormones Slow acting Paracrine many types of cells not in the blood locally at nearby target cells Growth factors, prostaglandins, FA derivatives Fast acting Chemical neurotransmitters neurons After action potential Locally at nearby neurons, gland, or muscle cells

Fast acting

Endocrine
Three different categories: 1. steroid (i.e. androgens, estrogens, glucocorticoids, mineralcorticoids, vit D) -small derivatives of cholesterol -hydrophobic so when in blood must be carried by carrier proteins -lipid soluble/ not water soluble -receptors are intracellular / bind the steroid and DNA 2. proteinaceous (proteins and polypeptides) -hydrophillic and water soluble -receptors on cell surface 3. amino acid related (i.e. epinephrine) -receptors on cell surface and have extracellular domain that bind hormone Neurosecretory cells in the hypothalamus couple the control of the nervous system to the endocrine system 1. Stimulating parvicellular neurons results in release of releasing and inhibiting factors from the hypothalamus that affects the secretions of the pituitary. 2. Magnocellular neurons extend axons to the posterior pituitary and release oxytocin and vasopression directly into circulation.

Paracrine
Growth factors: -small polypeptides with receptors on cell surface of target cell Functions: 1. Mitogenic: stimulate cell proliferation 2. trophic: stimulate cell survival and growth 3. chemoattractant: gradient of the factors will illicit cells to follow 4. pleiotropic: multiple effects Nerve growth factor: If there are too many neurons for the amount of target cells around, NGF will not be released by those cells and certain neurons will die resulting in a match in the number of neurons and cells. Histamine: -Example of a paracrine signaling molecule that is not a polypeptide. -IgE leads to histamine release (degranulation of mast cells); histamine is a vasodilator Eicosanoids -oxygenated bioactive derivatives of 20-carbon polyunsaturated fatty acids -diffuse across cell membrane and bind to surface receptors on nearby cells -an example is prostaglandins which when released from a damaged cell bind to nociceptors (sensory nerve endings which relay pain to the CNS), they do this by reducing depolarization necessary for an action potential Nitric Oxide (NO) -gas which can be extracellular messenged (diffuses across membrane) -vasodilator by relaxing smooth muscle of blood vessel wall (binds to guanylyl cyclase which converts GTP to cyclic GMP) Nitroglycerine is converted to NO in the body

Autocrine: cell responds to its own signaling molecules
Example: Activation of T-helper cells 1. Antigen bound to surface of Antigen Presenting cell binds to receptor on helper T cell 2. T Helper cell stimulates APC cell to secrete IL 1 3. IL 1 binds to receptor on T-helper cell which activate synthesis and secretion of IL 2 and expression of IL 2 receptors on its membrane 4. IL 2 binds to receptors and stimulates proliferation of same cell that secretes it

CELL SIGNALING II
Types of synaptic transmission:
1. 2. Electrical: ions travel through gap junctions (i.e. cardiac muscle and smooth muscle) Chemical: transmission between neurons (within the synapse)

Connections between neurons:

Criteria for true neurotransmitter:
1. 2. 3. 4. 5. 6. 7. found in presynaptic neuron enzymes required for its synthesis are found in the neuron stimulation of presynaptic neuron leads to NT in the cleft applying NT to postsynaptic neuron gives same result as stim of presynaptic neuron way to terminate the neuron must exist drugs that block synthesis of NT or its reaction should block the effects of stimulation drugs that block the degradation or reuptake of the NT must prolong the action of the NT

(a) Axodendritic (b) Axosomatic (c) Axoaxonic Not pictured: axosecretory (onto capillary) and neuromuscular (onto muscle)

Steps Involved in Synaptic Transmission

1. 2.

3.

4.

action potential drives down the axon Ca2+ channels open and Ca2+ enters the presynaptic terminal vessels fuse with presynaptic membrane NT is released and will have its effect on postsynaptic neuron

Postsynaptic potentials:
(EPSP = excitatory postsynaptic potential / IPSP = excitatory postsynaptic potential) 1. influx of Na+ - EPSP 2. influx of Cl- - IPSP 3. efflux of K+ - IPSP 4. influx of Ca2+ - EPSP Amplitude of these is relatively small and degrade across distance Spatial summation: summation from several sources Temporal summation: summation of potentials that follow each other in time

Ionotropic receptor – binding of the NT will allow passage of cations or anions Na+ channel: inflow of Na+ ions will cause postsynaptic cell to become positive or “excited” Cl- channel: inflow of Cl- ions will cause postsynaptic cell to become negative or “inhibited”

Metabotropic receptor– do not contain the ion channel Take longer to affect ion channels -G protein will be result in modulation of an ion channel that is close or far -Na+ and Cl- channels are the same as above; K+ channels will cause an outflow of K+ and the cell will become negative or “inhibited”

Removal of NT: either degraded in the cleft or reuptaken into the presynaptic neuron via pumps Other NT info:
1. 2. 3. 4. NT and receptor must match for result NT is synthesized from precursor molecules NT is packaged into vesicles Leaks of NT from vesicle is degraded

Other receptors:
Autoreceptors: receptors on neurons are activated by the NT that are released from themselves (usually feedback inhibition) Presynaptic: receptors located on axon terminals and activated by NT from another neuron (usually decrease release or synthesis of NT)

CELL SIGNALING III
Types of Receptors:
1) Steroid hormone receptor, composed of: 1. COOH-terminus domain – contains hormone binding site 2. NH2-terminus domain – involved in activation of transcription 3. middle-domain – contains DNA binding site *in inactive form, Hsp90 is bound to DNA binding site… when steroid hormone binds, Hsp90 dissociates and the complex can bind to specific DNA sequences 2) Adhesion molecules - activate cells through cell-cell or cell-matrix interactions; involves signal transduction cascades 3) Ion channel-linked receptors (Ex. Nicotinic Ach receptor, GABA, AMPA, and NMDA) - binding of NT causes an allosteric change in the receptor (channel) channel opens to allow ion flow • Nicotinic Ach: in neuromuscular jxn.; if Ach is bound for too long, channel will close (desensitization) • AMPA: permeable to Na and K; NMDA: permeable to Na, K, and Calcium also Glutamate binds to the AMPA receptor (ligand gated) Na comes in depolarization NMDA (ligand and voltage-gated) channel opens • GABA: GABA is the major inhibitory NT in CNS; receptor type A= ionotropic, type B= metabotrophic Other substances that affect GABA receptor (only when GABA is bound also!): 1. Barbiturates increase duration of channel opening 2. Benzodiazepines increase frequency of channel opening 3. Ethanol 4) G-protein-coupled receptors (7 transmembrane α-helices with G-protein α, β and gamma subunits) **slow response but good for signal amplification (1 NT can affect many channels) α subunit is most important binds GTP to carry out its function, hydrolyses GTP to GDP to turn off signal 5) Catalytic receptors (Ex. Receptor Tyrosine Kinase) Ligand binds conformational change in receptor autophosphorylation phosphorylate something else

now tyrosine kinase can

Protein Kinase (catalyze transfer of phosphate from ATP to substrate protein)
have regulatory and catalytic regions catalytic region has binding site for ATP; substrate has consensus sequence (signals kinase to phosphorylate) • regulatory domain often contains pseudosubstrate sequence (binds and inhibits catalytic domain) Protein Phosphatase (dephosphorylate proteins) • not as specific as kinases; do not have consensus sequence; can be inactivated by corresponding kinase to amplify phosphorylation Intracellular signaling Proteins: 1. adaptor molecules 2. anchoring proteins • •

bring 2 signaling molecules next to each other to facilitate the reaction help accomplish specificity

Concept of Divergence vs. Convergence • one NT could have multiple effects (divergence) OR several NTs could have the same end effect (convergence) • this means that there is a very complex circuitry of signaling

drugs can have wanted effects on one cell, but unwanted effects on another cell

CELL SIGNALING IV
Calcium as a 2nd messenger: - increases in [Ca] can cause dramatic changes within a cell - normally, [Ca] is low inside the cell (due to calcium pumps, which require ATP) - [Ca] can increase via: 1. activation of NMDA receptor 2. release from intracellular stores via activation of G-protein signaling cascade (involves Phospholipase C) Calmodulin (the principal Ca binding protein) - binding of Ca results in conformational change activates CamKII (calmodulin dependent protein kinase II) Diacylglycerol (DAG) - activates Protein Kinase C

Overall Pathway:
signal molecule G-protein receptor activates PLC PIP2 hydrolyzed to produce IP3 (which opens Ca channels on ER to increase [Ca]i) and DAG (which activates Protein Kinase C)

Role of Calcium in NT release:
Action potential arrives at pre-synaptic terminal voltage-gated Ca channels open Ca enters cell mobilizes vesicles for docking and release a) Synapsin binds vesicles to the cytoskeleton CamKII phosphorylates synapsin to release the vesicle from the cytoskeleton b) Synaptotagmin docks vesicles at the active zone Calcium has a direct effect on synaptotagmin, resulting in vesicle fusion & NT release Ca

**Ca channels are located very close to where synaptic vesicles need to be released, so NT release happens very quickly (200µs after Ca channel activation) ** [Ca]i can be altered by pre-synaptic inhibition (cell becomes more neg; inhibit Ca influx) or by presynaptic facilitation (depolarization increases Ca influx). ⇑Ca means ⇑signal transmission.

Calcium in Memory Formation (in Hippocampus)
Long Term Potentiation (LTP) = cellular event that is thought to contribute to memory formation • depends on activation of NMDA receptor (NMDA channel opens in response to glutamate binding AND strong depolarization of the post-synaptic cell) NMDA channel opens tyrosine kinase, etc) Calcium influx activation of numerous kinases (including PKC, CamKII,

Early phase LTP
Can result from: 1. more AMPA receptors on post-synaptic membrane 2. phosphorylation of receptors so that channel stays open for longer 3. more NT release 4. structural changes

Late phase LTP
* includes changes in gene expression Ca/calmodulin adenylyl cyclase cAMP cAMP kinase CREB-1 affects gene expression synthesis of effectors/ regulators that are responsible for long-term changes (i.e. creation of new synapses!)

CELL MOTILITY
• requires signaling, reorganizing of cell adhesion systems, and alterations in cytoskeleton

Signaling: chemotactic gradient Reorganization: cell polarity changes, lamellipodium – extension of migrating cell’scytoplasm, breaks in attachments to ECM Neutrophil Cell Motility 1. Chemotactic gradient signal neutrophil to reorganize 2. Neutrophil reorganization: triggered by surface receptors - polarization of cell organelles - Lamellipodia – actin filaments polymerized at cell edge to “reach”; serves as an extension 3. new membrane mass inserted at leading edge of lamellipodia 4. chemotactic receptors steer cell ex. F-MLP and f-met cause neutrophil to move towards these signals Diapedesis: passage of cell between endothelial cells into underlying connective tissue Margination: ex. Neutrophil attachment to inner vessel wall by binding selectin • binding increases increases calcium cascades inside endothelium Neutrophil’s integrins bind ICAMS to increase adhesion so can slow down to enter space between endothelial cells Movement across cell wall: • Focal adhesion – sites where integrins of neutrophil bind to vessel wall • Thrombin and histamine—released to increase permeability of endothelium • Act through CD31 that alters the cytoskeleton of the endothelial cells Regulatory Mechanisms: • inside-out signaling – change of conformation of integrins by phosphorylation that decreases binding • Receptor alterations:change in number of receptors, change receptor conformation Leukocyte Deficiency Disorder: - rare autosomal disorder - neutrophils not have adhesion molecules to follow chemotactic gradient to infection Type 1 LAD: cells not bind ICAM 1 on endothelial cells ecause cytoskeletal proteins not active —diapedesis not occur Type II LAD: neutrophils do not express ligands for E or P selectins on endothelial cells defect in cell rolling along vessel walls

Chapter Three – Genetics
BLOCK 1 – CORE CONCEPTS THREAD: BIOCHEMISTRY & GENETICS
CONTRIBUTORS: ANN MARSHBURN, MEGHA PATEL, THERESA WILLIS & ANNIE WEYAND

TABLE OF CONTENTS: MITOSIS MEIOSIS INTRO TO MEDICAL GENETICS MEDICAL GENETICS II MEDICAL GENETICS III MEDICAL GENETICS IV

CARLOS BACINO CARLOS BACINO LORRAINE POTOCKI LORRAINE POTOCKI LORRAINE POTOCKI LORRAINE POTOCKI

CYTOGENETICS I CYTOGENETICS II

CARLOS BACINO CARLOS BACINO

MITOSIS
Interphase G1 – machinery of cell prepares for division S – synthesis stage; DNA replication G2 – pre-mitosis; centrioles replicate Mitosis Prophase • Microtubule spindle forms • Chromatin condenses • Nuclear envelop disappears Prometaphase • Chromosomes begin to migrate • MTs begin to contact kinetochores Metaphase • Sister chromatids align at metaphasic plate • Force on kinetochores from each pole is equal and opposite Anaphase • Sister chromatids separate • Chromosomes migrate to opposite poles Telophase • Nuclear envelop reassembles • Cytoplasmic MTs reassemble Cytokinesis • Actin & myosin filaments make a contractile ring around cell • Division occurs equidistant from MT asters • Contractile ring disappears after mitosis CDK1 kinase Protein that signals mitosis to begin 3 Classes of Microtubules
1. astral: form an aster around centrosomes 2. kinetochore: attaches to and directs chromosome 3. spindle: overlap at metaphasic plate to form a skeleton

cut2 and PDS1 Proteins that, when degraded, signal anaphase to begin

Anaphase Lag
An abnormal separation of sister chromatids resulting in abnormal # of chromosomes in daughters

MEIOSIS
MEIOSIS: process of cell division in the maturation of sex cells Summary: replication of DNA (diploid with 2 chromatids per chromosome, or 2n and 4c), recombination (or crossing over) between homologues, followed by 2 divisions Result: generation of haploid gametes genetically distinct from each other and from the original parent cell Meiosis I: reduction division Result: The number of chromosomes (and DNA content) are reduced to 1n, 2c Sources of genetic diversity 1. genetic recombination, or crossing over, occurs during prophase I period and results in the actual physical exchange of portions of chromosomes between maternally and paternally derived chromosomes of a homologous pair 2. independent assortment: resulting gamete has varying ratio of maternal and paternally- derived chromosomes; 2n different types of gametes could be formed (where n is the haploid number of chromosomes) Stages of Prophase in Meiosis I: Leptotene: Chromosomes become visible Zygotene: chromosome pairs with homolog into a synaptonemal complex Pachytene: crossing over occurs Diplotene: The homologues repel; joined only at the chiasmata. Diakinesis: last stage of prophase I; crossing over has completed, nuclear envelope has completely disintegrated by this stage, centromeres attach to spindle fibers, chromosomes condensed Dictyotene: only in female meiosis; oocytes are frozen until puberty. Meiosis will be completed in the female only after fertilization with sperm. Meiosis II Result: No DNA replication and DNA is reduced to 1n, 1c

OOGENESIS: process of egg formation Result: mature ovum + 3 polar bodies Steps: 1. Primary oocyte is frozen in Meiosis I until stimulated for ovulation in puberty 2. Completion of Meiosis I forms secondary oocyte + 1st polar body 3. Secondary oocyte immediately begins Meiosis II and freezes at metaphase II by cytostatic factor 4. Meiosis II completes upon fertilization to form mature ovum + polar body Purpose of the asymmetric divisions: preserve the nutrient-rich cytoplasm necessary to sustain the egg until implantation into the uterus

SPERMATOGENESIS: process of spermatozoa formation Result: 4 functional haploid spermatids which later (inside the seminiferous tubules) differentiate to produce highly motile sperm. Differences from oogenesis: even divisions, meiosis begins at onset of puberty, process is continuous and never freezes *greater number of cell divisions of the male germline before the gamete formation leads to higher mutation rate in males than in females. FERTILIZATION 1. Capacitation: process that makes sperm capable of fusing to an egg; occurs as sperm migrate through the female reproductive tract 2. Binding of the sperm to the zona pellucida: induces the sperm to release digestive enzymes that enable the sperm to bore its way through; the plasma membranes of the sperm and egg then fuse, and the sperm nucleus enters the egg cytoplasm 3. Digestive enzymes: modify the glycoprotein network of the zona pellucida so additional sperm are no longer able to bind to the egg

NONDISJUNCTION: Failure of a pair of homologues fail to separate (disjoin) -In meiosis I, one daughter cell will have two of the chromosomes and the other will have none (2:0 segregation) -In meiosis II, at fertilization (if the other gamete is normal), the conceptus ends up trisomic or monosomic. -Trisomy 21, 18, 13 most common -Frequency of trisomies increases with advancing maternal age

INTRODUCTION TO MEDICAL GENETICS
Selected Single Gene Disorders: 1. Achondroplasia (ACH) - most common type of dwarfism. • Autosomal Dominant, 1:26,000-40,000 births • Traits include average-sized trunk, short arms and legs, lumbar lordosis, normal life span and intelligence. • Problems include compression of spinal cord and airway obstruction, apnea, and hydrocephalus. • Gene: 2 mutations on FGFR3 in >99% of ACH patients 2. Cystic Fibrosis (CF) - most common Autosomal Recessive disease in Caucasians. (1:25 are carriers of 1 copy of the gene) • Autosomal Recessive, 1:2,500 births • Most common fatal genetic disease in US today. • Problems include thick, sticky mucus that clogs lungs, infections, obstruction of pancreas. • Gene: CFTR (Na, Cl transporter), hundreds of mutations in this gene that lead to the disease 3. Sickle Cell Disease (SC) - most common inherited blood disorder in the US • Autosomal Recessive, 1:500 African Americans have the disease, 1:12 are carriers • Disorder of hemoglobin resulting in anemia, sickling crisis, risk of infection and organ damage. • Gene-Beta Hemoglobin, mutation causes structurally abnormal Hb, called HbS. (Substitution of valine for glutamic acid) 4. Breast Cancer - 2nd major cause of cancer death in American women. • Genes - BRCA1 on chromosome 17 and BRCA2 on Chromosome 13 • Mutations on these 2 genes leads to increased risk of developing breast and/or ovarian cancer. • These genes are thought to participate in repair of radiation-induced breaks in DNA strands and the mutations are thought to disable the mechanism. • Treatment includes careful monitoring and possibly drug or surgical therapies.

GENETICS II, III & IV
Features of Transmission
• • • • Single allele is sufficient Vertical transmission patterns, with male-to-male transmission possible Number of affected males and females in population will be roughly equal Affected children born to non-affected parents may be explained by o differences in penetrance o variability of expression o new mutation in either the germ line or in somatic cells of the embryo o gonadal mosaicism. •

Representative Syndromes
Achondroplasia o Characterized by short stature, averagesized trunk, short arms and legs, and a slightly enlarged head with a prominent forehead. o 100% penetrance at birth o 80-90% are new mutations o Caused by mutation in the FGFR3 gene. Marfan Syndrome o Characterized by tall, thin body habitus, long fingers, extensible joints, aortic root dilation, floppy heart valves, and dislocated ocular lenses o 50% are new mutations o Caused by mutation in the fibrillin gene. Huntington Disease o Characterized by abnormal body movement (chorea), loss of cognitive skills, and psychiatric disturbances. o Disease is progressive and fatal. o Example of age-dependant penetrance. Affected individuals are normal through the first several decades of life, but disease shows 100% penetrance by age 65. Neurofibromatosis Type 1 o Characterized by tumor growth along peripheral nerves, patches of brown pigment on the skin, bone deformities, and learning disabilities o 50% caused by new mutations o Wide variability of expression

Autosomal Dominant

Autosomal Recessive

• • • • •

Two mutant alleles required, so both parents of affected child are considered obligate carriers Horizontal pattern of affected individuals, often with unaffected parents New mutations are very rare Number of affected males roughly equals number of affected females Consanguinity increases risk Majority of inborn errors of metabolism are AR conditions

• • • • • • • •

Cystic Fibrosis o Characterized by chronic infections, progressive lung damage and loss of functional lung tissue, failure to produce adequate pancreatic digestive enzymes, and progressive loss of pancreatic function o Most common AR condition in Caucasian population o Caused by mutation in CFTR gene. Tay-Sachs disease Gaucher disease Hereditary Hemochromatosis B-thalassemia Phenylketonuria Sickle Cell

• •

• •

No male-to-male transmission Generally more severe in hemizygous males than in heterozygous females One X-chromosome in each somatic cell in a female undergoes random inactivation, causing females to be functional mosaics In some disorders, inheritance of the mutant gene causes prenatal lethality in hemizygous males A new mutation can give rise to observable phenotype in both males and females

Incontinentia Pigmenti X-Linked Hypophospatemic Rickets

X-Linked Dominant

X-Linked Recessive

• • •

No male-to-male transmission Almost all affected individuals are male Females are obligate carriers if they bear more than one affected offspring, bear one affected offspring and have a male relatives with the same condition, or are the offspring of an affected male New mutations only give rise to observable phenotypes in the male

Duchenne and Becker Muscular Dystrophies o Caused by mutations in the dystrophin gene o Duchenne is considerably more severe o Characterized by ongoing muscle cell degeneration, which leads to elevated levels of CPK Fragile X Syndrome o Most common inherited cause of mental retardation o In families with fragile X syndrome, males in later generations are more likely to be affected -- anticipation Hemophilia A LHON MELAS MERRF NARP Keams-Sayre Syndrome

Mitochondrial

• •

Very wide variety in expression Exclusively maternal inheritance

• • • • •

Refers to genetic traits or disorders determined by combinations of multiple genes and their interactions with the environment and other factors such as DNA methylation Although these disorders are obviously familial, there is no distinct pattern of inheritance within a single family

• • • • • • • •

Neural tube defects Isolated cleft lip or cleft palate Pyloric stenosis Congenital heart defects Coronary heart disease Insulin dependent diabetes Schizophrenia Autism

Multifactorial

CYTOGENETICS I
Overview: Chromosomal abnormalities are more common than generally thought. They are present in over 50% of 1st trimester abortions and 7-10% of all clinically recognized pregnancies. These abnormalities are either constitutional (arise before/at conception) or acquired (in somatic cells after conception or birth). They are thought to play a key role in cancers. Mature human cells contain 23 pairs of homologous chromosomes, 22 pairs of autosomes and one pair of sex chromosomes. -Chromatin: condensed packaging of DNA seen in nuclei at interphase. -30,000-40,000 genes in humans, or about 3,000-4,000 genes per chromosome. Features of Chromosomes: Metaphase - chromosomes formed by 2 identical sister chromatids connected at a centromere. 2 arms, p is the short arm, q is the long arm. Metacentric - 2 arms same length Submetacentric - one arm distinctly shorter Acrocentric - very short p arms with specialized structure called a stalk. (stalks assoc. during interphase, called Nucleolar Organizing Regions. Satellites - distal to stalk, portions of highly repetitive DNA, no known coding sequence. Telomeres - telomeres are tandemly repetitive telomeric units that cap the ends of chromosomes. They play an essential role in the pairing of homologous chromosomes in prophase of meiosis. Examples of karyotype shorthand: 46, XX Normal female 45, X Turner Syndrome 47, XXY Klinefelter syndrome 47, XX, +21 Female with trisomy 21 46, XY, del(5p15.2) male with deletion on short arm of one chromosome 5 Clinical cytogenetics sample types: chromosomes can be studied from any cell actively dividing and where a nucleus is present. Bone Marrow - Rapid method for chromosome diagnosis. Used to diagnose newborns with suspected lethal disorders and when leukemia is suspected. Peripheral Blood - Analyses on lymphocytes from small blood sample. Must be stimulated to divide.

Fibroblast - Established from skin biopsy, abortus, or autopsy. Takes 1-2 weeks. Useful when blood tests are normal and mosiacism is suspected. Amniocentesis - Standard for prenatal diagnosis. Amniotic fluid collected at 16-18 weeks gestation. Results take 10-14 days. Chorionic Villus Sampling (CVS) - 1st trimester biopsy of placenta. 10-14 days, risk of miscarriage is about 1.0% Banding Methods: Q Banding- Quinacrine is fluorescent and stains A-T rich sequences. G-Banding- Most common stain in routine cytogenetics. Stain with Giemesa produces alternate light and dark bands. C-Banding- stains the constituitive heterochromatin darkly and euchromatin light. Used mainly to stain the centromeres. Fluorescence in situ hybridization (FISH)- application of a probe directly onto a metaphase chromosome spread or interphase nucleus. DNA probe is labeled with reporter molecule and detected with an antibody to that molecule. *Method of choice for detecting microdeletion syndromes. Probes: Single copy/Locus specific probes Sub-telomere-specific probes Alphoid or centromeric repeat probes Whole chromosome (painting) probes

CYTOGENETICS II
Numerical abnormalities - numerical errors due to nondisjunction include trisomies and monosomies. Other errors include triploidy (69 chromosomes) and tetraploidy (92). Most polyploid conceptuses are spontaneously aborted. Triploidy most often occurs when 1 normal egg is fertilized by 2 sperm. Tetraploidy occurs through a post-zygotic error of DNA replication, duplicating all the chromosomes. Mosaicism- resulting mixture of two or more cell lines in an individual that occurs very early in embryonic or pre-embryonic life. Ex: 45X/46XX Mosaic female with normal cell line and abnormal (45X) line. 46XY/47, XY, +21 Male with mosaic karyotype of a normal and trisomy 21 cell line. Gonadal Mosaicism- also called germinal mosaicism, affects organs involved in meiosis: ovaries and testes. Structural Chromosome Abnormalities: Terminal Deletions- result from one break in one chromosome arm. Segment containing the centromere is replicated and passed on to daughter cells. Accentric fragment is lost. Most common is the 5p- syndrome, cri-du-chat. Interstitial Deletions- 2 breaks in one chromosome arm. Accentric fragment between the two arms is lost. “sticky” ends rejoin. Includes Prader-Willi, DiGeorge, Williams, and Smith-Magenis syndromes. Reciprocal Translocations- 2 breaks occur in 2 different chromosomes at the same time. Broken ends exchange and rejoin and no material is lost. This is a balanced rearrangement. However, individuals are at risk or producing abnormal gametes through segregation errors during meiosis. Robertsonian Translocations- form between 2 acrocentric chromosomes (13, 14, 15, 21 & 22) Breaks occur in the short arm and the long arms fuse, forming a stable dicentric chromosome. Accentric fragments are lost. No phenotypic affect to losing the short arms. However, carriers are again at risk of abnormal segregation at meiosis. 5% of Downs cases are due to a Robertsonian Translocation. Inversions- form from 2 breaks in one chromosome. The piece between the breaks inverts and rejoins, thus a balanced rearrangement. During meiosis, however, a loop structure forms to accommodate the inverted segment, which may result in abnormalities if recombination occurs within the loop. 1-Paracentric inversion- inverted segment does not span centromere. (within one arm) Abnormalities from recombination result in dicentric and acentric chromosomes, which do not produce viable offspring. 2-Pericentric inversion- inverted segment spans and often displaces the centromere. Recombination results in deletions and duplications Cryptic chromosome abnormalities- submicroscopic subtelomeric chromosome defects found in 7.4% of children with moderate to severe mental retardation and in .5% of children with mild MR. Many of these families have a positive history for MR and early pregnancy losses. CHIP technology- Looking at small chromosomal regions and performing thousands of FISH assays at once to detect chromosome imbalances in one single experiment. Allows analysis of chromosome material at the 1-3 megabase level.

Chapter Four – General Histology
BLOCK 1 – CORE CONCEPTS THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: KATHARINE JONES, WALTER QUIROGA, VIKRAM SHENOY & GABRIEL DE LA GARZA

TABLE OF CONTENTS: SKIN I SKIN II CONNECTIVE TISSUE CARTILAGE & ADIPOSE BONE I BONE II JOINTS IMMUNE SYSTEM I IMMUNE SYSTEM II

SKIN I AND II
Six Functions of Skin: 1) Barrier 2) Sensory Organ 3) Thermoregulation 4) UV Protection 5) Immune (SALT: Skin Associated Lymphoid Tissue) 6) Sexuality (Apocrine and sebaceous glands in dermis secrete pheromones) Three Layers of Skin: 1) Epidermis: epithelial layer resting on basement membrane A) Thick skin—non hairy with very thick epidermis B) Thin skin—hairy with thin epidermis 2) Dermis: papilla project into epidermis to keep layers from sliding past each other, capillary beds, Meissner’s corpuscles A) Lower dermis—dense irregular connective tissue B) Upper dermis—loose connective tissue housing ecrine, apocrine and sebaceous glands 3) Hypodermis: dense irregular connective tissue with fat, Pacinian corpuscles Five Layers of the Epidermis: 1) Stratum Basale: Contacts basement membrane, consists of keratinocytes=STEM CELLS, mitotically active, desmosomes hold keratinocytes together, hemidesmosomes and focal contacts hold keratinocytes to basement membrane 2) Stratum Spinosum: A. Tons of DESMOSOMES for strong cohesion and barrier against friction, gives characteristic spiny appearance B. Filaggrin bundles intermediate filaments (cytokeratin—called tonofilaments in skin) into tonofibrils C. Mitotic in that some cells may divide to produce more spinosum cells 3) Stratum Granulosum: WATER BARRIER through Odland bodies containing phospholipids of skin’s water barrier, keratinohyalin formed into characteristic GRANULES of this layer 4) Stratum Lucidum: Cannot see histologically, LYSOZYMES BURST, nucleus and organelles dissolve, keratohyalin cements tonofibril bundles together, desmosomes still intact 5) Stratum Corneum: layer of DEAD keratinocytes A. stratum compactum—still desmosomes B. stratum disjunctum—upper most layer, no more desmosomes, desqamation (stem cell to desquamation = 30 days) Types of Secretion: 1) Merocrine: exocytosis into extracellular space 2) Apocrine: apical portion of cell ruptures but cell anneals and lives 3) Holocrine: cell death in secretion

Three Glands in Skin: 1) Sebaceous glands: acinar, NO lumen, secrete lipid pheromones by holocrine secretion, no myoepithelial cells, associate with every hair follicle and also without hair follicles in lips, glans penis, glans clitoris, areola of breasts, glands develop at puberty 2) Apocrine glands: coiled tubular (simple cuboidal or columnar), LARGE lumen, secrete proteinaceous pheromones by merocrine secretion, stratified cuboidal duct, myoepithelial cells, always associated with hair follicles but are only in circumanal region, genitalia, areola of breasts, axillae, develop at puberty 3) Ecrine glands: coiled tubular, SMALL lumen, light cells=ion pumpers, dark cells=secrete mucous by merocrine secretion, stratified cuboidal duct (basophilic), myoepithelial cells, important for thermoregulation Three Non-keratinocytes in Epidermis: 1) Merkel cell: sensory function 2) Melanocyte: NEURAL CREST ORIGIN!!, vimentin positive 3) Langerhans cell: MONOCYTE ORIGIN!!, vimentin positive **Pathology of Epidermis** Pemphigus (loss of adhesion between cells), Bullous pemphigus (loss of adhesion with basement membrane), Psoriasis (thickening of skin and subsequent cracking down to dermis), Squamous cell carcinoma, Basal cell carcinoma (neither are very invasive due to cell-cell junctions), Melanoma (extremely invasive because no cell-cell contacts)

CONNECTIVE TISSUE The 3 components of Connective Tissue (CT): cells, fibers, and ground substance. Extracellular Matrix (ECM) C E L L S Fibroblasts- synthesize the fibers (collagen, elastin) and ground substance (GAGs, proteoglycans, multiadhesive proteins) of the ECM. Also produce growth factors. Macrophages- are mature monocytes in the CT, which came from hematopoietic stem cells. Participate in phagocytosis, antigen-presentation, resistance to infections and tumors Mast Cells- stores chemical mediators (histamine [vsdln, bronchocxn], heparin [anticoagulates w/antithrombin], eosinophil chemotactic factor of anaphylaxis) of inflammatory response in basophilic secretory granules. 99.998% of IgE (from plasma cells) is bound to mast cell surface receptors and blood basophils. 2 populations: CT mast cells (skin, peritoneum) & mucosal mast cell (intestinal mucosa, lungs) Plasma Cells- come from B lymphocytes and synthesize antibodies. Adipose- store fat and produce heat Leukocytes- cross capillary walls from blood by diapedesis during inflammatory response (mediated by mast cells and basophils). None return to blood, EXCEPT for lymphocytes. Collagen- strength/organize ECM; generally found either as tropocollagen filaments < fibrils < fibers < bundles. A) Collagens forming Long Fibrils (aka Collagen Fibers) – forms bones, dentin, tendons, organ capsules, and dermis. Type 1 most abundant throughout body (point mutation leads to osteogenesis imperfecta); Type 2 unique to cartilage; Type 3 forms reticular fibers. (Types 1, 2, 3, 5, & 11) B) Fibril-associated Collagens – short collagens attaching collagen fibrils to each other and ECM. (Types 9, 12, & 14) C) Network-forming Collagen – forms meshwork unique to lamina densa of basal lamina. (Type 4) D) Collagen forming Anchoring Fibrils – anchors collagen fibers to basal lamina, e.g. hold epidermis (stratum basale) to dermis (lamina reticularis). (Type 7) Collagen Synthesis 1) α1, α2 chain translation into RER (preprocollagen→signal cleavage→procollagen) 2) Hydroxylation of proline & lysine (Vit. C dependent, lack of it leads to scurvy) 3) Glycosylation of hydroxylysine 4) Triple helix assembly of procollagens (α1, α1, α2) with registration peptides 5) Packaging and glycosylation in Golgi and eventual exocytosis into extracellular space 6) Procollagen registration peptide removal (at N- & C-termini) turns it into tropocollagen, which self assembles into polymeric collagen fibrils and fibers (fibril aggregates) Elastin- gives ECM resilience, stretches w/ tension, made of elastin & fibrillin, hydrolyzed by elastase, and mutation in elastin gene causes Marfan syndrome. Ground Substance – highly hydrated mix of GAGs, proteoglycans, and multiadhesive glycoproteins. Fills space b/w cells & fibers, has regulatory functions, acts as adhesive, lubricates, and is barrier to invaders. GAGs – linear, unbranched polymer of dissacharide units that are very hydrated and negatively charged; 5 types Proteoglycans – GAGs bonded to a protein core; proteoglycans attached to hyaluronic acid chain form proteoglycan aggregates, such as aggrecan in cartilage. Multiadhesive Glycoproteins – protein w/branched carbohydrate moiety; have role in cellular adhesion. A) Fibronectin – made chiefly by fibroblasts, has binding cites for cells, collagen, and GAGs. B) Laminin – participates in adhesion of epithelial cells to basal lamina, which is rich in laminin. *Cells use integrin to bind to collagen, fibronection & laminin extracellularly and with actin intracellularly THREE Loose (Areolar) CT Lots of cells Vascular Small Type I bundles in random Stroma Dense, regular CT Few cells Avascular Large Type I bundles in parallel Tendons MAJOR Dense, irregular CT Few cells Vascular Large Type I bundles in random Perichondrium, periosteum, TYPES epineurium, epimysium OF CT

F I B E R S

G R O U N D S.

CARTILAGE & ADIPOSE
CARTILAGE – 1) Dense, irregular CT perichondrium sheath provides vascularity, innervation, & lymph drainage. 2) Perichondrium has Type I collagen, fibroblasts, & chondroblasts. 3) Chondroblasts secrete collagen & ECM and become chondrocytes, which may divide into isogenous groups and use anaerobic glycolysis. Chondrocytes receive nutrients from perichondrium by diffusion and mechanical compression of tissue. 4) Articular cartilage at ends of bones is sustained by synovial fluid, NOT perichondrium. 5) Growth by 2 processes: interstitial growth (mitotic division of preexisting chondrocytes, important in articular cartilage) & appositional growth (differentiation of perichondrial cells, more important of the two). Type Hyaline Characteristics Chondrocytes arranged in groups within basophilic matrix of Type II collagen Chondrocytes within matrix of Type II collagen & elastic fibers. Chondrocytes arranged in rows in acidophilic matrix of Type I collagen bundles in rows Perichondrium Present except at articular surfaces Present Absent Locations Articular ends of long bones, ribs, templates for endochondral bone formation Pinna of ear, auditory canal, epiglottis, laryngeal cartilages Intervertebral discs, pubic symphysis.

Elastic Fibrocartilage
(intermediate b/w dense CT & hyaline)

ADIPOSE – 2 types Unilocular Adipose (yellow fat) – richly vascularized & innervated w/in reticular fiber network. 1) Stores liver-made triglycerides transported by VLDL and cholymicrons. Lipoprotein lipase (activated by insulin) releases FFA & glycerol for diffusion across capillary into adipocyte, where they are re-esterified to triglycerides. 2) Sympathetic NS indirectly innervates adipose tissue by releasing norepinephrine, which stimulates AC & cAMP to activate hormone-sensitive lipase. This hydrolizes TGs into FFA & glycerol, which are transported back to the liver. Multilocular Adipose (brown fat) – color due to capillaries and mitochondria 1) Important in first months of postnatal life b/c it produces heat through norepinephrine stimulation and thermogenin (ATP uncoupler) in mitochondria. 2) Sympathetic NS directly innervates this tissue.

BONE I & II AND JOINTS
Types of bone -Woven/primary(embryonic) – Random collagen I fibers - First bone formed in development, fracture repair and disease(padget’s, bone cancer) - Lamellar/secondary (adult) – Parallel collagen I fibers (woven bone is remodeled into Lamellar) ____________________________________________________ -Cortical / compact bone – high density -Trabecular / spongy / cancellous bone – Inner meshwork of bone struts. - histologically both have same structure Cell Types – Osteoblasts – deposition.inhibited by PTH, vit. D needed for synth. of osteoid glycoproteins, vit. C needed for collagen I synth. - Osteocytes- found in lacunae. Was previously an osteoblast, canaliculi connect adjacent lacunae. Osteocyte cell processes traverse canaliculi. - Osteoclasts – resorption of bone. Multinucleated, monocyte origin. Found in howship’s lacuna. PTH acts on osteoblast which stimulates osteoclast. Calcitonin inhibits indirectly. - Osteoprogenitor cell – Becomes osteoblast on activation. Lining cell found on endosteum (internal lining) or periosteum (external lining). Bundles of periosteal collagen fibers – Sharpey’s fibers.

Haversian system/osteon- complex of concentric lamellae surrounding haversian canal. Adjacent lamellae have collagen fibers perpendicular to each other. - Outer(near periosteum), Inner(around marrow cavity) and Interstitial (older lamellae after remodeling) lamellae - Volkmann’s canal- perforate the lamellae- lined with endosteum. Link haversian canals, periosteum and marrow cavity.

HistongenesisIntramembranous ossification - Source of flat bones, frontal & parietal bones, mandible, maxilla - Takes places within condensations of mesenchymal tissue in regions called primary ossification center. Cells differentiate into osteoblasts. Multiple ossification centers grow radially and fuse. Endochondral ossification - Forms long and short bones - Takes place within hyaline cartilage that resembles bone to be formed. Bone collar is formed first. - Primary ossification centers – in the diaphysis, after bone collar is formed and blood vessels penetrate. - Secondary ossification centers- In the epiphyses Epiphyseal cartilage (or plate) connects epiphyses to diaphysis – divided into 5 zones 1- Resting Zone, 2- Proliferative zone, 3- Hypertrophic cartilage zone, 4- calcified cartilage zone, 5ossification zone. (refer fig. 8-16 in junq) Joints 1- Diarthroses - Allows movement. - capsule and articular cavity.- synovial membrane, articular cartilage - synovial fluid- hyaluronic acid from cell of synovial layer. - fluid serves for exhange of nutrients and o2 and co2 - Negative charges of GAGs help bring H2O back in on release of pressure from joint. 2- Synarthroses – no movt. or very little. i- Synostosis- bones united by bone tissue- skull bones are typical ii- Synchondrosis- Bones united by cartilage- hyaline type. Eg- Epiphyseal plate, rib to sternum iii- Syndesmosis- Bones joined by dense connective tissue ligament- symphysis pubis. 3- Amphiarthroses- Intervertebral disc.

IMMUNE SYSTEM 1 AND 2
Reaction types • Innate mechanisms o barriers, mucous, protease inhibitors, etc. • Adaptive mechanisms o programmed cells with memory Two types of tissues • Primary lymphoid tissues-where immune cells are made and programmed o Bone marrow and Thymus • Secondary lymphoid tissues- where the immune response takes place o Lymph nodes, Spleen, Tonsils and diffuse lymphoid tissue Two Functional Divisions • Cellular Immunity Division o Programmed cells directly kill abnormal cells • Humoral Immunity Division o Circulating antibodies, the cells that produce them and the cells that respond to them
Antibodies Antibody - circulating glycoproteins that recognize and interact with specific antigens, binding to the epitope of the antigen on its Fab region and binds an immune cell at the Fc region Class Morphol. General Function Activates complement system, a 20 plasma P system that stim other N, giving rise to sets of P that opsonize (coat the outside of the pathogen) causing recognition by phagocytes and direct lysis Made By Location Fc Region Binds To Stuff that will activate the complement system Misc

IgM

pentamer

plasma cells

soluble in plasma and in the B lymphocyte membrane

1st class secreted into the blood in an immune resp.

IgG

monomer

Mainly stim. phagocytosis (make phagocytosis more appealing) by/to macphg and neutrophils but also aids activation of complement system

plasma cells

blood, lymph, intestinal lumen

Macrophages and neutrophils

• Major class in blood (75-80% of blood antibody) • only class that can pass to fetus via placenta • also in breast milk

IgA

dimer bound by protein J which also aids secretion

Agglutinates antigens/pathogens to prevent access to body (protects mucosas from proteosysis)

plasma cells

secretions (including breastmilk) released in lamina propria, transported across secretory epithelium

pathogens

principle class in secretions

IgE

monomer

Activates mast cells and basophils to trigger cytokine, histamine and heparin release. Activates eosinophils in response to a parasitic infection Receptor to antigens triggering B cell activation

plasma cells

Bound on cell surface

Mast cells, Basophils, Eosinophils

causes allergies

IgD

monomer

plasma cells

surface of B lymphocytes

expressed only expressed on developmentally after cell surface IgM on mature B cells

T lymphocytes - Develop and are selected in the thymus. They mediate cellular and cytotoxic immunity. T cells have cell surface receptors that recog antigen bound on a cell surface to a MHC complex of proteins. Also aid in the proliferation of other B and T lymphocytes to stimulate the humoral response Cells of the Immune System Activation Causes clonal expansion of other cytotoxic T cells, cytotoxic memory T lymphocytes, and perforin production

Cell Cytotoxic T cells (CD8+)

Function kill infected cells or cells expressing abnormal P by damaging the M with perforin

Activated By contact with an abnormal cell expressing MHC I

Activates

Origin

Misc

Bone Marrow

develop in the thymus

secretes cytokines (interleukins) and Antigens bound to MHC clonal expansion of growth factors to II class of surface P on Helper T, retainment of Helper T cells (CD4+) modulate the activity memory CD4+ and APCs (Dendritic cells of and aid in clonal and Langerhans cells) production of cytokines expansion of other T and B lymphocytes Clonal expansion and Antigens that bind to differentiation into mediate the humoral their IgM or IgD plasma cells (which B Lymphocytes response and ssecrete receotors, cytokines secrete lots of circulating antibodies secreted by Helper T in antibodies) and retain a close proximity some as memory B kill viral infected and Fc region of IgG release of perforins to Natural Killer cancer cells in a antibodies (and a lack of cause apoptosis and Lymphocytes nonspecific manner MHC I) lysis phagocytosis and lysis phagocytosis and lysis pathogen coated with Macrophages of pathogens coated by of pathogens coated IgG or complement P IgG ingest and destroy pathogen coated with ingest and destroy Neutrophils bacteria IgG or complement P bacteria Mast cells and Basophils mediate allergy/inflammatory responses histamine and heparin pathogen or allergen specific to their surface release and release of IgE chemoattractants

B and T cells via cytokine secreton

Bone Marrow

develop in the thymus

Bone Marrow

• Cell surface has IgD and IgM • some stick around as memory cells

nothing

Bone Marrow leave marrow as monocytes and mature in tissue Bone Marrow

Bone Marrow

have IgE rec

LYMPH TISSUES
Thymus - primary lymph tissue Cortex• tight tight tight blood-thymus barrier o consists of endothelial cells and their basal lamina epithelial reticular cells and their basal lamina fibroblasts and ECM o enables proper programming of T cells programming of T cellso positive selection for recognition of MHC complex o negative selection for recognition of self o 90% removed, remaining 10% move to medulla and exit via vasculature Medulla • epithelial reticular cells o highly branched w/ desmosomes o provide lattice for developing T cells o remnants form Hassall’s Corpuscles Lymph Nodes - secondary lipoid tissue • contain B lymphocytes, T lymphocytes, Plasma cells, and macrophages • Secondary nodules contain germinal centers w/ developing B lymphocytes • Lympocytes enter through High Endothelial Venules (HEV) Lymph Vessels • very leaky vessels with one-way valves •

Spleen – secondary lymphoid tissue • APCs, macrophages, reticular cells, lymphocytes • Blood enters open circulation via PALS in white pulp, traverses red pulp (Billroth’s cords) and exits into closed circulation • Note White pulp actually more basophilic, contains more red than red pulp • Also responsible for destruction of old red blood cells o Iron-free heme is metabolized to bilirubin

MALT Tonsils: secondary lymphoid tissue Skin: Langerhans, macrophages, lymphocytes, tight junctions Colon: Peyer’s patches Respiratory:
Immune System Components 2004 (Rowley)
Legend: = antigen = T cell receptor = major histocompatability complex final result “clock face nucleus” secretes antibodies Plasma Cell = antibody Memory T CD 4+ cells Helper CD 4+ T lymphocyte interleukins Memory T CD8+ cells

Study Guide
interleukins = cytokines

Cytotoxic CD 8+ T lymphocyte

+ +
Memory B cells proliferation

+

secrete perforins

proliferation proliferation IgA IgM + complement system IgG IgE + mast cells, basophils agglutinates antigen (secretions) B lymphocyte removes antigen IgD MHC-II phagocytosis of antigen, cell protease destroys antigen, cell vessel dilation and vascular permeability Inflamation to bring in more components Dendritic Follicular Cell (in lymph node) CD 4+ T lymphocyte CD 8+ T lymphocyte TCR TCR

kills the presenting cell

+ macrophage, neutrophil

protease cascade

Release of histamine, IgM heparin, chemotatic factors

MHC-I

Dendritic Antigen Presenting Cell (found everywhere) mononuclear phagocyte system

All nucleated cells

Chapter Five – Muscle
BLOCK ONE – CORE CONCEPTS THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: AMIT SINGH & SAMIT SONI

TABLE OF CONTENTS: MUSCLE STRUCTURE I MUSCLE STRUCTURE II MUSCLE FUNCTION I MUSCLE FUNCTION II MUSCLE FUNCTION III

MUSCLE STRUCTURE & FUNCTION
General Skeletal long cylinder, register, 2 peripheral nuclei epi,peri,endomysium, 2% mito, No lipid droplets, collagen type I, III, IV many peripherally located satellite, fibroblast, myofiber, endothelial myofibroblast focal contacts @ terminal z line post mitotic; limited w/ help of satellite cells no hyperplasia focal contact→ ECM Desmin α-actinin (Z line), actin, myosin, tropomyosin, troponin, dystrophin, nebulin, titin, cap z, creatine phosphate (M line), integrin neuromuscular jxn; motor unit=neuron+ fibers; triad @ A-I jxn type I- red: lots of mito & myoglobin (for marathons) type II- white: little mito & NO myoglobin (for sprinters) Cardiac boxcar, register, no epi/perimysium, lipid droplets, 40% mito, 1-2 central nuclei, collagen type I, III, IV 1-2 centrally located, with halos myofibers, endothelial, myofibroblast, fibroblast desmosomes, adherent jxns in transverse portion & gap jxn in lateral portion (intercalated disc) post mitotic→No regeneration intercalated disc (cell-cell) Desmin α-actinin, actin, myosin, tropomyosin, troponin, vinculin, integrin, cadherins, connexins, titin, cap z, creatine phosphate NO: nebulin→actin ( 1 micron avg ) varicosities (NT diffuses to pacer unit), Diad @ z line Smooth fusiform, 1 central nucleus, RER, mito, golgi, vesicles, ECM: collagen type I, III, IV No striations 1 centrally located myofibers, endothelial, myofibroblast, fibroblast focal contacts (focal densities @ membr) gap jxn mitotic→active regeneration, hyperplasia focal contacts (in all directions)→ECM Desmin NO: nebulin, titin, cap z, troponin YES: isofroms of tropomyosin, caldesmon, α-actinin, actin, myosin, vinculin, connexins, integrins unitary: as one unit, few varicosities (ex: uterus, bladder) multiunit: tremendous specificity, more varicosities (ex: iris, blood vessels) NT diffuses

Nuclei Cells Present Junctions Regeneration Force IF Proteins excluding Ca++ regulation Innervation

Calcium Regulation:
SKELETAL: - Here we have a TRIAD of T-tubule and terminal cisternae at A-I junction - Basically, two proteins here, Dihydropyridine and Ryanodine - What happens: 1. Get a depolarization that travels down T-Tubule System 2. Causes a conformational change in dihydropyridine which will… 3. Physically pry open ryanodine1 receptor located on Sarcoplasmic Reticulum membrane 4. Calcium (which was bound to Calsequestrin) is released through the Ryanodine 1 receptor. 5. Once out, Calcium can bind to troponin C to do its thang or Calcium can also cause Calcium induced Calcium release by interacting with the Ryanodine 1 receptors and opens them up to release Calcium from SR. -How to get rid of it: -Calcium can also come back into Sarcoplasmic Reticulum via Calcium ATPase TAKE HOME MESSAGE: ALL calcium in skeletal muscle comes INTRACELLULARLY!

CARDIAC - remember…here we have a DIAD at Z line - also, you have piss-poor Sarcoplasmic Reticulum here…why, you ask? Because the calcium here is mostly EXTRACELLULAR so you don’t need a GREAT sarcoplasmic reticulum - What happens: 1. Depolarization event travels through T-tubule system 2. Causes a conformational change of Dihydropyridine in T-Tubule which opens it allowing extracellular Ca2+ to enter 3. Once in, Ca2+ will bind Troponin C and do its “thang” 4. Calcium can also cause a small amount of Calcium induced Calcium release from SR via Ryanodine 2 but this is minimal and serves as a boost. - How to get rid of it: - by way of Ca2+ ATPase in SR or extracellularly

SMOOTH - 3 ways to raising Ca2+ levels, 2 of them are from extracellular sources, 1 is intracellular Extracellular: 1. Mechanosensitive receptor (unique calcium mechanical receptor) opens in response to stretching and allows extracellular Ca2+ in 2. Voltage sensitive receptor in Caveloa; in response to some electrical signal opens up and allows Ca2+ in - once inside this calcium will cause Calcium Induced Calcium Release from Ryanodine 3 receptors on Sarcoplasmic Reticulum (nonpinocytotic) Intracellular: 1. G-protein related: G-protein through signal transduction will cause release of IP3 which can bind to Ryanodine 3 receptor on SR membrane (nonpinocytotic) and cause Ca2+ induced Ca2+ release of intracellular calcium from remnant SR. How to get rid of it: - use Ca2+ ATPase in SR, tiny vesicles, or Na/Ca cotransport channel on smooth muscle membrane

Chapter Six – Nervous System
BLOCK 1 – CORE CONCEPTS THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: CARRIE ESHELBRENNER, LUCIA LIFSCHITZ, MICHELLE PHILLIPS & RENEA STRUM

TABLE OF CONTENTS: INTRODUCTION TO NERVOUS SYSTEM NERVOUS SYSTEM I NERVOUS SYSTEM II NERVOUS SYSTEM II AUTONOMIC NERVOUS SYSTEM I AUTONOMIC NERVOUS SYSTEM II

NERVOUS SYSTEM I-III
Embryonic Origin of Nervous System: ECTODERM (epithelial so has basal lamina) Neural Plate ⇒ (invaginates, becomes) Neural Groove ⇒ (pinches off to form) Neural Tube w/ tissue masses on both sides, the Neural Crest (Neural Crest is surrounded by basement membrane that becomes the Glia Limitans)

Neural Tube:

Becomes BRAIN and SPINAL CORD hollow portion ⇒ ventricles of brain central canal ⇒ spinal cord NEURONS: • Motor = VENTRAL (neurofilament) • PREganglionic Autonomics (Para/Sympa) (neurofilament) NEUROGLIA • Oligodendrocytes (GFAP) • Fibrous Astrocytes—mostly WHITE matter— (GFAP) • Protoplasmic Astrocytes—mostly GREY matter— (GFAP) • Ependymal cells (GFAP) OTHER CELLS FOUND in CNS (INVADERS) • Microglia (monocyte invaders) (vimentin) • Endothelium (vascular invaders) (vimentin) • Perivascular Macrophages (invader) (vimentin)

Neural Crest:
Gives rise to PERIPHERAL NERVOUS SYSTEM and the MENINGES (lining of the outer surface of the brain and spinal cord). People with defects in the neural crest will suffer from Prader-Willi Syndrome. NEURONS: • Sensory neurons = DORSAL (neurofilament) • POSTganglionic Autonomics (Para/Sympa) (neurofilament) VIMENTIN POSITIVE CELLS • Schwann cells • Satellite cells around sensory somas in DORSAL root ganglion • Pia Cells (meningothelial cells) • Arachnoid cells • Dura • Melanocytes (skin pigmentation)

Odontoblasts (enamel formation)

Parts of a Neuron
Part
Dendrite Soma/ Perikaryon Myelinating Cell Axon Nucleus Axon Hillock

Characteristics
Receive stimuli from the environment, sensory cells, other neurons; usually short; taper as they subdivide Contains nucleus and surrounding cytoplasm, exclusive of cell processes; Nissil bodies (RER); Golgi around periphery of nucleus; mitochondria scattered throughout; increasing lipofuscan (residue that builds up when lysozymes cannot digest all of the material) with aging; intermediate filament = neurofilament Large; circular; euchromatic; darkstaining nucleolus Carries signal to target cell; most neurons have only one; very long; constant diameter; little branching; diameter of axon α to propagation of action potential; may be myelinated (see below) Pyramidal shaped region where axon originates; determines diameter of axon Can transmit a chemical or electrical signal; contains synaptic vesicles; numerous mitochondria; types: (1) axodendritic (2) axosomatic (3) axoaxonic

Dendrite

Soma/Perikaryon
Synaptic Terminal/ Bouton

Nucleus

Axon

Axon Hillock

Synaptic Terminal/Bouton
Actual photomicrograph of motor neuron (PT stain); Schematic diagram of the ultrastructure of a neuron (see Junq 9-5 for labels)

Structure of Axon *Centrosome sits in axon hillock and gives rise to a bank of microtubules (10 microns) with + end pointing towards synapse *Similar backs arise down the length of the axon; no MTOC *Fast axonal transport – moves proteins along microtubules Anterograde – kinesin motor – 200 mm/day Retrograde – dynein motor – 300 mm/day *Slow axonal transport – carries actin and tubulin molecules to bouton Gel-sol transformation – 1 mm/day enzyme gelsolin momentarily cleaves actin filaments-creates area of low viscosity

Types of Neurons
Bipolar Neurons: • One dendrite, one axon • Found in cochlear ganglia, vestibular ganglia, retina, olfactory mucosa • Interneurons Multipolar Neurons: • More than two cell processes • Most neurons of the body • Motor efferents Pseudounipolat Neurons: • Dendrite fused to axon (wave of depolarization bypasses soma) • Found in spinal ganglia and most cranial ganglia

Myelination
General Process: • Microtubule polymerization causes myelinating cell to turn about the axon as lipid proliferates • E face fuses with E face to form intraperiod line • P face fuses with P face, squeezes cytoplasm out, forms main dense line • Cytoplasm percolates through the myelin as clefts of Schmidt-Lanterman – link remnant cytoplasm at rim of myelinating cell with that along the axon/myelinating cell interface (See Junq 9-30 for labels)

Myelinates Origin Intermediate Filament Mitotic? Number of Cells Myelinated Proteins of Fusion Node of Ranvier Basal Lamina?

Oligodendrocyte CNS Neural tube GFAP Yes Myelinates many axons simultaneously MBP (myelin basic protein) and PLP (proteolipid protein) No extra covering (no need for one because these axons are within the BBB) No (difficult to regenerate axon)

Schwann Cell Peripheral nervous system Neural Crest Vimentin Yes Myelinates only one neron PO and PP-22 Schwann cells send out paranodal processes to protect the nodes Yes-secreted by Schwann cells (allows for axonal regeneration)

AUTONOMIC NERVOUS SYSTEM I & II

INTRODUCTION TO EMBRYOLOGY
Week 1: Fertilization Blastocyst Clinical Correlations
Pelvic Inflammatory Disease • STD (gonorrhea or chlamydia) • Purulent infection in fallopian tubes can cause narrowing and prevent migration of fertilized egg Fertilization occurs in the ampullary region of the fallopian tube • Capacitation: sperm conditioning, enters zona radiata • Acrosome reaction: protein rxn after binding zona pellucida • Fusion: sperm + oocyte Cell divides, decreasing on size (blastomere) until reach 16 cells (morula) Morula travels to the uterus, fluid enters the zona pellucida and creates a cavity (blastocele) and the morula becomes a blastocyst. • Embryoblast: Inner cells • Trophoblast: Outer cells Blastocyst “hatches” from zona pellucida (ready to implant)

Abnormal Implantation • Ectopic: Fallopian tube • Placental Previa: near cervix (placenta will cover cervix) • Ovarian (rare) • Intra-abdominal (rare)

EARLY DEVELOPMENT
Week 2: The Week of Twos (Bilaminar Disc)
Trophoblast differentiates into 2 layers • Cytotrophoblast: inner layer, proliferates • Syncytiotrophoblast: outer later, invades endometrium and maternal capillarities and makes HCG*

Clinical Correlations
Hydatiform mole (benign) or Choriocarcinoma (malignant) • Abnormal growth of trophoblast without embryonic tissue • Fusion sperm to anucleate oocyte • High HCG (detected at Day 14)

Embryoblast differentiates into 2 layers • Hypoblast: next to blastocyst cavity • Epiblast: next to amniotic cavity Extra-embryonic mesoderm from new yolk sac cells from 2 layers • Extra-embryonic somatopleuric mesoderm: next to cytotrophoblast and amnion • Extra-embryonic splanchnopleuric

mesoderm: next to yolk sac
Two cavities form as a result of new mesoderm layers • Chorionic cavity: space between the splanchnopleuric and somatopleuric extraembryonic mesoderm • Amniotic cavity: between epiblsat and extra-

embryonic somatopleuric mesoderm
Secondary (Definitive) Yolk Sac: Hypoblast cells migrate along inside of exocoelomic cavity (along primary yolk sac) and pinch it off exocoelomic cysts

NEURULATION
Neurulation (begins on Day 18 thru Week 4)
Neural Plate: thickening of ectoderm (now called neuroectoderm) induced by notochord. This IS Neurulation Neural Folds: Elevation of neural plate edges and depression of mid region (neural groove) Neural tube: the edges to move towards the midline and fuse (starts at the 5th somite and progresses cranially and caudally) Neural crest cells: lateral border or crest of neural fold that migrate away to give rise to a variety of cells Crainial neural plate will become forebrain and midbrain Caudal neural plate will become hindbrain and spinal cord but needs Wnt-3a and FGF to activate Tube remains open until the cranial neuropore closes at day 25 and the caudal neuropore closes at day 27 (final step of neurulation!!) Clinical Correlations

Failure of caudal neuropore to close: • Spina bifida • Spina bifida occulta (covered by skin) Failure of cranial neuropore to close: • Encephalocele • Anencephaly

Chapter 8 – Anatomy & Radiology of the Extremities
BLOCK 1 – CORE CONCEPTS THREAD: ANATOMY/EMBRYOLOGY/RADIOLOGY
CONTRIBUTORS: TRAVIS TAYLOR, EDWIN BUTLER, ROHAN WAGLE, BO ALLAIRE & RYAN BOECK

TABLE OF CONTENTS: ANTERIOR CHEST WALL POSTERIOR CHEST WALL BRACHIAL PLEXUS ARM FOREARM HAND CLINICAL HAND HIP THIGH LEG FOOT CASES OF THE KNEE INTRO TO RADIOLOGY RADIOLOGY – UPPER EXTREMITY RADIOLOGY – LOWER EXTREMITY

CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON MICHAEL EPSTEIN CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON CASSIUS BORDELON ALFRED WATSON, JR. ALFRED WATSON, JR. ALFRED WATSON, JR.

Anterior Chest Wall
Muscle Pec minor Pec major Innervation Medial pec. n. Lateral & medial pec n. Major Action Depression of glenoid Adduction

Posterior Chest Wall
Muscle Trapezius Latissimus Dorsi Teres major Levator scapulae Rhomboid major & minor Innervation CN XI Subscapular n. Subscapular n. Dorsal scapular n. Dorsal scapular n. Major Action Elevation of shoulders Adduction Adduction Retraction of scapula Retraction of scapula

Shoulder
Muscle Innervation Major Action Serratus anterior Long thoracic n. Protraction of scapula Deltoid Axillary n. Abduction of shoulder Supraspinatus Suprascapular n. Abduction of shoulder Infraspinatus Suprascapular n. External rotation Teres minor Axillary n. External rotation Subscapularis Subscapular n. Medial rotation -Bursae: subdeltoid/subacromial allows the head of the humerus to slide under the deltoid and corachoacromial arch -Ligaments: coracoacromial, coracoclavicular, costoclavicular

BRACHIAL PLEXUS Proximal C5
Dorsal scapular suprascapular Lateral pectoral

Distal

Musculocutaneous

C6 C7

Axillary Radial Median subscapular

C8

Ulnar

T1 Roots (2 nerves) Real

Long thoracic

Medial pectoral

Trunks (1 nerve) Texans

Divisions (0 nerves) Drink

Cords (3 nerves) Cold

Branches (5 nerves) Beer

-Erb’s palsy = tearing of C5 -Klumpke’s palsy = tearing of T1 Arm
Muscle Coracobrachialis Biceps brachii Brachialis Triceps Innervation Musculocutaneous n. Musculocutaneous n. Musculocutaneous n. Radial n. Major Action Adduction Flexion of shoulder & elbow & supination Flexion of elbow Extension of elbow

-Ligaments: Transverse humearal -Quadrangular space: Axillary nerve & posterior humeral circumflex a. -Triangular space: circumflex scapular a. -“RUM @ West Coast Tequila Univ.” Radial -> Wrist drop; Ulnar -> Claw hand; Median -> Thenar atrophy & Ulnar deviation

Proximal Arm Subclavian 1) Transverse cervicle 2) Suprascapular Axillary 1) Lateral Thoracic 2) Subscapular a. Thoracodorsal b. Circumflex scapular (in triangular space) 3) Anterior humeral circumflex 4) Posterior humeral circumflex

Distal Arm Brachial 1) Profunda brachial

Forearm
Muscle Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris Extensor digitorum communis Extensor digiti minimi Extensor indicus proprius Extensor pollicis longus Extensor pollicis brevis Abductor pollicis longus Suppinator Flexor carpi radialis Flexor carpi ulnaris Extensors Innervation Radial n. Radial n. Radial n. Radial n. Radial n. Radial n. Radial n. Radial n. Radial n. Radial n. Flexors Median n. Median n. Major Action Extension of wrist Extension of wrist Extension of wrist Extension of digits 2 -5 Extension of digit 5 Extension of digit 2 Extension of digit 1 Extension of digit 1 Abduction of digit 1 Supination of forearm Flexion of wrist Flexion of wrist

Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Pronator teres Pronator quadratus

Median n. Median n. Median n. & ulnar n. Median n. Median n. Median n.

Flexion of wrist Flexion of digits 2 -5 Flexion of digits 2 -5 Flexion of digit 1 Pronation of forearm Pronation of forearm

-Ligaments: Annular, medial collateral -interosseus membrane: between radius and ulna

Hand
Muscle Flexor pollicis brevis Abductor pollicis brevis Opponens pollicis Adductor pollicis Interossei Lumbricals Innervation Median n. Median n. Median n. Ulnar n. Ulnar n. Ulnar n. & Median n. Major Action Flexion of digit 1 Abduction of digit 1 Opposition Adduction of digit 1 Flex the MPs & extend IPs Palmars = adduct (PAD), Dorsal = abuct (DAB)

-carpal tunnel covered by flexor retinaculum -palmar aponeurosis -Bones of wrist mnemonic: Some Lovers Try Positions That They Can’t Handle

CLINICAL ANATOMY OF HAND
Brachial Plexus Newborn Erbs C5-6 (Shoulder dysfunction) Klumpke C8-T1 (Horner’s sign) (Hand dysfunction) Adult Upper – downward tx Lower – abduction Shoulder Dislocation Axillary nerve (no shoulder abduction) Suprascapular nerve (Shoulder dysfunction) Rotator Cuff Ext. rotators (infraspinatus and teres minor) Int. rotators (subscapularis) Abduction (Supraspinatus) Impingement Syndrome (Supraspinatus) Biceps Rupture Long head (elderly) Distal insertion tears

no surgery surgery

Parsonage-Turner Acute brachial neuritis (caused by viral infection nerves) Tennis Elbow Lateral epicondylitis - responds to steroid injection Medial epicondylitis (responds to steroids)

impairment of radial and median

RUM/WCTU Radial Nerve: distal 1/3 humerus fracture can damage this unable to extend wrist Median Nerve Carpal Tunnel - roof = transverse flexor retinaculum - floor = carpal bones - 9 tendons and median nerve - syndrome numbness and tingling, thenar atrophy, weakness in grip Anterior interosseous paralysis - from anterior interosseous nerve that goes to pronator quadratus, thumb, and index finger can’t pinch finger to thumb

Hip
Muscle Gluteus maximus Gluteus medius Gluteus minimus Tensor fascia lata Biceps femoris Semitendinosus Semimembranosus Piriformis Obturator internus Quadratus femoris Innervation Inferior gluteal n. Superior gluteal n. Superior gluteal n. Superior gluteal n. Sciatic n. Sciatic n. Sciatic n. Nerve to piriformis Nerve to obturator internus Nerve to quadratus femoris Major Action Extension of hip Abduction Abduction Weak abduction Flexes knee & extends hip Flexes knee & extends hip Flexes knee & extends hip Weak external rotation of thigh External rotation of thigh External rotation of thigh

-Ligaments: sacrospinous, sacrotuberous, iliolumbar, iliofemoral (Y ligament of Bigalow), Transverse acetabular, round ligament (ligamentum teres), retinacular ligaments (carry blood supply to head of femur)

Thigh
Muscle Iliopsoas Sartorius Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Adductor magnus Adductor brevis Adductor longus Gracilis Pectineus Anterior compartment Innervation Femoral n. & lumbar plexus Femoral n. Femoral n. Femoral n. Femoral n. Femoral n. Adductor compartment Obturator n. & Sciatic n. Obturator n. Obturator n. Obturator n. Femoral n. Major Action Powerful flexion of hip Flexion of hip & knee Flexion of hip & Extension of knee Extension of knee Extension of knee Extension of knee Adduction of hip Adduction of hip Adduction of hip Adduction of hip Adduction of hip

-Pes anserina: “Say Grace before Tea” -> Sartorius, Gracilis, Semitendinosus -femoral triangle: NAVEL -> Nerve, Artery, Vein, Empty space, Lymphatics

Leg
Muscle Fibularis longus Fibularis brevis Tibialis anterior Extensor hallucis longus Extensor digitorum longus Gastrocnemius Soleus Popliteus Tibialis posterior Flexor digitorum longus Flexor hallucis longus Evertor compartment Innervation Superficial fibular n. Superficial fibular n. Extensors Deep fibular n. Deep fibular n. Deep fibular n. Flexors Tibial n. Tibial n. Tibial n. Tibial n. Tibial n. Tibial n. Major Action Eversion Eversion Extension of ankle & Inversion Extension of 1st toe & ankle Extension of toes 2-5 Flexion of knee & ankle Flexion of ankle Flexion of knee Flexion & Inversion Flexion of 1st toe Flexion of toes 2-5

-Popliteal fossa: 1) sciatic -> tibial & fibular n. 2) popliteal a. ->anterior & posterior tibial a.
-Tarsal tunnel: “Tom, Dick, & A Very Nervous Harry” -Greater Saphenous: from femoral vein to anterior foot surface -> used for coronary bypass -Ligaments of knee: ACL, PCL, lateral & medial collaterals -Lateral (O-shaped) & medial (C-shaped) meniscus of knee

Foot
-Ligaments: medial collateral (deltoid), lateral collateral (anterior fibulo-talar, posterior fibulo-talar, & lateral fibulocalcaneal), spring ligament (plantar calcaneal-navicular), long plantar -Stirrup of foot: Fibularis longus & Tibialis posterior -Bones of foot: Calcaneus (heel), Talus, Navicular (boat-shaped), Cuneiforms (lateral, medial, & intermediate), Cuboid, Metatarsals & phlanges

CASES OF THE KNEE
ACUTE
• • • • • • • • • • • • • • • distinct event audible pop sharp pain inability to continue marked swelling locking instability

CHRONIC
insidious onset non-painful popping dull ache and pain usually can continue may swell minimally stiffness giving way activity related

90% of acute cases deal with: • PCL • ACL • Medial Collateral ligament • Dislocated Patella (moreso in women due to wider hips, thus quadratus muscles have a wider starting point and pull the patella laterally; Vasus Medialus Obliques prevents against this action by stabilizing the patella medially) • Meniscus • Fracture Lateral Meniscus has 2 points of attachment, whereas Medial Meniscus has 3 points of attachment, therefore you are more likely to tear your Medial Meniscus.

INTRODUCTION TO RADIOLOGY
• • • • • • • X-ray - Excite phosphors on screen, which in turn provides 99% of film exposure Ranking of absorption of x-rays from least to most Air < Fat < Water < Barium Standard positions- Lateral, Oblique, and AP views Contrast studies—GI-barium, air, and water soluble (ex: iodine). Water soluble in GU and vascular as well Computed Tomography (CT)-x-rays at various angles with detectors, computer combines information to produce cross sections Interventional Procedures/Angiography-useful in imaging arteries/veins, atherosclerosis, tumors, traumas of organs/vessels Magnetic Resonance Imaging (MRI)-magnetic fields cause changes in magnetic spins of protons which can be measured, useful for CNS, musculoskeletal, abdomen, pelvis, vascular

RADIOLOGY OF THE UPPER EXTREMITY
• • • • • • • • Bone parts-epiphysis (head), metaphysis (region on diaphyseal side of epiphyseal plate), diaphysis (shaft), Growth is at epiphyseal plate, epiphysis growth is circumferential Metaphyseal growth is elongation of bone shaft, growth stops when epiphysis and metaphyses fuse Joint types- cartilaginous (ex: primary-rib/manubrium, secondary-manubrium/sternum), Fibrous (ex: Skull bones or Interosseus membrane), and synovial (ex: shoulder or knee) Radiographic points: Distal clavicle, acromion, coracoid process, glenoid fossa, greater and lesser tuberosities Differential diagnosis: Supposedly explains 95% of aberrant findings • C ongenital • I nfections • N eoplastic • T rauma Bone abnormalities: Trauma (fracture,dislocation), arthritis, tumors, infection, congenital Remainder of lecture was review of anatomy of upper extremity-see Harvey

RADIOLOGY OF THE LOWER EXTREMITY
• • • • • • • • • • • • • • Can’t break pelvis in just one place (pretzel example) Pubic symphysis-cartilage Nerves come out of arcuate lines of sacrum Dislocation-like femoral head coming out of ball and socket totally Sublexation-partially comes out, but still articular surface against articular surface Diastasis-two bones connected to each other split apart (like at pubic symphysis or sacro-iliac joint)— happens often with motorcycle accidents or delivery of large babies 120 to 130 degree angle between femur neck and shaft Condyle- epiphysis and metaphysic Blood from knee injury will collect in suprapatella bursa 2 cruciate ligaments keep tibia from going anteriorly or posteriorly relative to femur Fabella-normal variant bone at knee joint Infrapatellar ligament goes to tibial tuberosity FBI sign- if injure knee, blood and marrow come out, marrow (has lots of fat) floats to top, creates Fat/Blood Interface, seen with horizontal x-ray Fibula creates ankle joint, but doesn’t carry much weight Interrosseus membrane can transfer force and cause additional fractures

Chapter Nine – Anatomy, Embryology & Radiology of the Thorax
BLOCK 2 – CRR THREAD: ANATOMY/EMBRYOLOGY/RADIOLOGY
CONTRIBUTORS: WALTER QUIROGA, SANDIP PATEL, MUFADDAL GOMBERAWALLA, BARTLEY MITCHELL, STELLIOS KARNEZIS, JESS SOTELO & RYAN BOECK

TABLE OF CONTENTS: OVERVIEW OF HEART EMBRYOLOGY INTERNAL PARTITIONING OF THE HEART TUBE CARDIAC DEFECTS SURFACE ANATOMY OF HEART & ITS VASCULATURE INTERNAL GROSS ANATOMY OF THE HEART RADIOLOGICAL IMAGING OF THE HEART ECG IMAGING OF THE HEART VENOUS DEVELOPMENT ARTERIAL DEVELOPMENT DEVELOPMENT OF THE RESPIRATORY SYSTEM RESPIRATORY ANATOMY RADIOLOGY OF THE LUNG MEDIASTINUM

OVERVIEW OF CARDIAC EMBRYOLOGY
Origins of Cardiac Cells and Tissues
Cardiac Mesoderm (majority of cardiac mass)

Atrial & Ventricular Myocytes

Endocardium

Endocardial Cushions (partake in AV septation)

Purkinje cells (conduction system)

Cardiac Neural Crest

Aortic Wall (smooth muscle)

Neurons (Autonomic NS)

Outlet septation (AP septum)

Error! Proepicardium gives rise to a) coronary arteries (smooth muscle & endothelium) b) cardiac fibroblasts c) epicardium
DERIVATIVES OF PRIMITIVE HEART TUBE Truncus Arteriosus → Aorta & PA trunks Outlet Segment → RV apex & inlet, both outlets Inlet Segment → LV apex & inlet Primitive Atrium → Atrial appendages Sinus Venosus → SVC/IVC, smooth walls of atria GASTRULATION & PRECARDIAC MESODERM FORMATION

1) Starts in 3rd week (trilaminar germ disc, “week of threes”) 2) Cardiac progenitor cells in epiblast migrate through primitive streak to splanchnic layer of lateral plate mesoderm; those going first form cranial portions (outflow tract) & those going last form more caudal portions (RV, LV, Sinus Ven.) of heart 3) Pharyngeal endoderm induces those cells to form cardiac myoblasts; blood islands appear, unite, and form cardiogenic crescent, an endothelial-lined tube surrounded by myoblasts. 4) This eventually develops into the heart tube with cephalocaudal & lateral folding.

• •

INTERNAL PARTITIONING OF THE HEART TUBE
Prior to septation, the early heart tube undergoes looping to create left-right axis. During week 4 of development, there are 4 concurrent steps in internal septation of the heart tube: 1. atrial septation 2. endocardial cushions and atrioventricular canal septation 3. ventricular septation and chamber formation 4. truncal (truncus arteriosus) septation • 1. Atrial Septation • Simultaneously involves asymmetry of system venous drainage (rightsided) by degeneration of left-sided venous system • 4 embryonic structures form foramen ovale (fossa ovalis in adults) 1. Septum primum- flat valve/wall that guards fossa ovalis 2. Ostium primum- residual opening between septum primum and endocardial cushions. The EC cushion can fail to close this gap resulting in patent foramen ovale. 3. Septum secundum- forms on the right atrial side of the septum, becomes limbic region of the fossa ovalis 4. Ostium secundum- forms in septum primum • • • Foramen ovale closes after placental flow shuts off and fetal lungs become active. Fetal lung activation increases left atrial pressure, closing the FO. 2. Endocardial cushion growth is the primary determinant of septation. EC cushion cells are mesodermal origin (endocardial endothelial cells) AV valves form from this AV myocardium, and the failure of tricuspid valve formation leads to a common pediatric defect- Ebstein’s anomaly.

3. Ventricular septation and chamber formation o left ventricle opens to inlet, right ventricle opens to outlet o muscular septum grows upward and fuses with endocardial cushions for ventricular septation o failure of this septa to form results in ventricular septal defect 4. Outlet septum and septation of truncus arteriosus o conus of the outlet septum fuse with spiral septum of the truncus, which extends downwards o spiral septum of truncus arteriosus delineates aorta and pulmonary artery o the spiral septation is of neural crest origin, and thus children with DiGeorge’s and Prader-Willi might have aorticopulomary defects

Aortic Arch Derivatives: o Left aortic arch (Left side, 4th arch) o Pulmonary Arteries (6th arch) o Patent Ductus Arteriosus (Left side, 6th arch)

CARDIAC DEFECTS
Ventricular Septal Defects Types: • Perimembranous- membranous septal defect • Muscular- muscular septal defect • EC cushion defect- AV canal defect • Multiple Physiology: • Dependent on defect size and pulmonary resistance • In general, ventricular left to right shunting (LV pressure > RV pressure) and elevated pulmonary vascular resistance • Causes: edema in adults, pulmonary overcirculation and left-side overdilation in chidren. Presentation: • Adults get congestive heart failure, kids get pulmonary overcirculation • Symptoms in kids: tachypnea, tachycardia, diaphoresis, failure to thrive • If not corrected, can result in irreversible pulmonary vascular disease creating permanent left to right shunt (Eisemenger’s Syndrome) Treatment: • Medical: high caloric food, diuretics, ACE inhibitors, digoxin • Surgical: transcatheter closure Other defects with similar physiology: truncus arteriosus septation defects, patent ductus arteriosus TETRALOGY OF FALLOT Intraventricular septal defect (outlet and muscular septum don’t fuse) Hypertrophy of the right ventricle Override of the aorta Pulmonary stenosis

1. 2. 3. 4.

Physiology: • Decreased pulmonary blood flow, large right to left shunt causes severe cyanosis Presentation: • Tet spells: hypercyanosis, decreased systemic vascular resistance, decreased right ventricular filling, tachycardia, increased right ventricle outflow tract obstruction • No stethoscope “wooshing” sound heard since RV and LV pressures are both equally high and since blood moves slowly. Will hear ejection murmur of pulmonary valve due to stenosis. Treatment: • Beta-blockers, peripheral vasoconstrictors, rehydration

Surgical intervention: anatomical correction, can induce ductus arteriosus to bypass obstruction

SURFACE ANATOMY OF THE HEART AND ITS VASCULATURE
In these notes I’ve presented the most clinically relevant information that would help the most for Thursday. You will find accompanying Netter’s Diagrams towards the end. Surface Anatomy The heart is surrounded by a pericardium made of two parts – fibrous (external) and serous (internal). The bottom of the pericardium is attached to the diaphragm via the central tendon. The phrenic nerve passes bilaterally along the pericardium, which should be handled with particular care when opening the pericardial sac in cardiothoracic surgery. Behind the heart are two important sinuses, Transverse and Oblique. The transverse sinus, formed behind the Aorta and Pulmonary Artery, can be clamped to stop blood flow in trauma procedures and during cardiopulmonary bypass during cardiothoracic surgery.

The Coronaries There are normally two branches (the first branches) off the aorta that give the heart’s blood supply – the right coronary and left coronary. The left coronary divides and gives rise to the Left Anterior Descending (LAD) artery, which supplies the left ventricle. I am sure everyone knows that blockage in the coronaries can lead to ischemia, heart attack, and even cardiac arrest. Dr. Cooley refers to a block in the left coronary trunk as “the widowmaker” On the posterior side of the heart, the “dominance” is determined by which coronary supplies the branch that becomes the posterior inter-ventricular artery. It is normally the right coronary (i.e. a right dominant heart) but it is not uncommon to see left dominance. 40% of venous blood returns to the heart directly through the chambers. The remaining blood returns from veins that come together to form the large coronary sinus, which articulates the left atrio-ventricular space, and drains into the right atrium.

INTERNAL GROSS ANATOMY OF THE HEART
(You should know most of this, it doesn’t get interesting till the Auricles…) Right Atrium Note there are 3 veins into which venous blood returns to the RA: SVC, IVC, and Coronary Sinus. The opening of the IVC is covered by the Eustacian valve.

The anterior wall is covered with bands of muscle called Pectinate, while the rest of the RA is smooth. The junction between pectinate muscle and the smooth portion is called the crista terminalis. In the atrial septal wall you can see the fossa ovalis, surrounded by its limbus, a remnant of the foramen ovalis. This is often the site for Atrial Septal Defects (ASD) Also note the right auricle, a pouch found to the right of the RA – more on the auricles later Guarding the passage to the right ventricle is the tricuspid valve – which takes us to the: Right Ventricle The three flaps (hence tricuspid) of the tricuspid valve are held down by chordae tendineae (or heart strings) which attach via Papillary muscles to the ventricular myocardium. Analogous to the pectinate muscles, the ridges of muscles here are called trabeculae carneae, whose ridge along the smooth part of the ventricle is called the crista supraventricularis. Blood leaves the RV through the Pulmonic valve. It is composed of the cusps, like shirt pockets, which prevent backflow. The Pulmonic valve is at the trunk of the Pulmonary artery, the pathway to the relatively low pressure pulmonary circulation. Note late closing of this valve causes the split S2 on inspiration. Left Atrium Oxygenated blood returns to the heart via 4 (2 bilaterally) pulmonary veins to the left atrium. Besides the left auricle, the left ventricle is rather, well, boring. Here is where we’ll discuss the auricles. Blood can build up in either the right or left auricle, since they are basically out-pouches of each atria. If blood is allowed to just sit there, it will form a clot, which is no big deal. Until the clot comes loose. Then it will enter either one of the two circulations, and can block pulmonic arteries (pulmonary embolism), or a systemic artery, like the aorta. Not good. Blood leaves the left ventricle via the mitral valve to the: Left Ventricle This is the main meat of the heart. You can always tell this ventricle from the right by the thickness in its wall. The mitral valve here is similar to the tricuspid, held down by chordae tendineae attached to papillary muscles. Except this time the valve only has two cusps.

Blood leaves the left ventricle via the aortic valves (same design as pulmonic) destined for systemic circulation. Note the Inter-ventricular septum dividing the two ventricles is prone to numerous septal defects, known as ventricular septal defects (VSD) Great Anatomy plates for the Heart from Netter’s:

RADIOLOGICAL IMAGING OF THE HEART
Surface borders of the heart Right: Right Atrium Left: Left Ventricle Diaphragm: Right and Left Ventricle Apex: Left Ventricle Posterior: Left Atrium (not normally seen anteriorly) Cardiomegaly The heart is considered enlarged if it is wider than half the width of the chest. Valves of the heart In a lateral radiograph, you draw a line (dotted line as seen below) through the anterior posterior border of the diaphragm towards the lower of two halos seen in the middle (the bronchii). If this sounds confusing (its harder to say in words), just look at the pictures below. The line simply helps orient yourself within the radiograph.

TV: Tricuspid valve (most anterior) AV: Aortic Valve (most superior to the dotted line) MV: Mitral Valve (inferior to line and AV)

ECG IMAGING OF THE HEART
ECG works by directing a high frequency sound towards an object. The sound is then either reflected, retracted, or absorbed. The amount of time it takes for reflected sound determines how far the object is away from the ultrasound probe. This is then reconstructed in a 2-d plane. Doppler uses the Doppler Effect to measure bloodflow and blood velocity, this is particularly useful for measuring ventricular ejection. Ventricular Volume can be measured using Volume = (3.42*Length*Width)-6.4 Ejection Fraction (EF), a common measure used to gauge LV function, is measured as the Stroke Volume/End Diastolic Volume. The fraction shortening (FS) of the size of the LV can also be used to determine using EF=1.7(FS) In clinical cases, when something is wrong, go through Preload, Afterload, and Contractility to see where the problem may occur.

Right Ventricle Interventricular septum Left ventricle

Pericardium

Aortic valve Ascending Aorta Anterior Mitral valve

Posterior wall left ventricle Posterior Mitral valve Descending Aorta

Left Atrium

VENOUS SYSTEM
Hepatic portal system-btw liver and GI Middle of 4th week-sinus venosus receives blood from right/left sinus horns VITELLINE VEINS-1st veins formed [RIGHT STAYS-LEFT REGRESSES] Carries blood from Yolk sac to sinus venosus • • •

RIGHT VITELLINE VEIN
Hepatic sinusoids Rt inferior vitelline veins at duodenum become Portal vein & superior mesenteric vein Right hepatochardiac becomes the terminal IVC

• Left hepatic vein remains; otherwise regresses NOTE: liver buds grow into vitelline and umbilical veins UMBILICAL VEINS [LEFT STAYS-RIGHT REGRESSES] Originate in chorionic villi, carry oxygenated blood from placenta to sinus venosus Left Umbilical Vein-carries blood from placenta to liver • Ductus Venosus-to shunt blood around liver to right hepatochardiac channel • DV becomes ligamentum venosum after birth • remainder becomes ligamentum teres completely regresses NO MAJOR DERIVATIVES OF UMBILICAL VEINS AFTER BIRTH! CARDINAL VEINS [RIGHT STAYS-LEFT REGRESSES] carries blood from fetal body to sinus venosus Anterior (superior): Right and Left anterior cardinal veins anastomose to form brachiocephalic vein •

LEFT VITELLINE VEIN

RIGHT UMBILICAL VEIN

RIGHT CARDINAL VEIN
-Anterior distal portion becomes right internal jugular -Anterior proximal/common cardinal after brachiocephalic becomes SVC

LEFT CARDINAL VEIN
-Anterior distal becomes left internal jugular -Anterior proximal regresses along with left sinus horn Remnant of left sinus horn/left anterior cardinal vein becomes coronary sinus Posterior (inferior)-supplemented and replaced by supra- and sub- cardinal veins Supracardinal (body wall) -sprout from base of posterior cardinal veins caudally and medially to subcardinal veins -Drain blood from intercostal veins Abdominal Supracardinal -Right supracardinal anastomoses with right subcardinal to form IVC below kidneys -Left supracardinal in abdomen obliterates Thoracic Supracardinal -Right supracardinal anastamoses with the right anterior cardinal (SVC), becomes azygous vein -Left supracardinal remains patent as well and becomes the hemiazygous vein once it separates From the posterior cardinal and anastamoses with the right supracardinal Subcardinal (kidneys and gonads) -sprout caudally from base of posterior cardinal veins laterally to supracardinal veins -Anastamosis btw left and right subcardinal forms left renal vein prior to left subcardinal regression -Left and right adrenal and gonadal veins are derived from the subcardinal veins (this is why the left adrenal and gonadal veins join left renal as opposed to IVC like right side) Left subcardinal vein regresses Rt subcardinal vein joins rt vitelline to become the portion of the IVC btw liver & kidney Sacrocardinal Veins (legs) -Fusion of right and left posterior veins gives rise to sacral segment of IVC -Most caudal portion of posterior veins persists to become common iliac veins

ARTERIAL SYSTEM
Truncus arteriosus (TA) divides into ventral aorta and pulmonary artery. Aortic sac from TA forms aortic arches (into pharyngeal pouches) Aortic Arches-1,2,3,4,6 (5th never completely forms) 4th-7th week -Right and left vagus form right and left recurrent laryngeal nerves—hook around 6th aortic arch early on -6th aortic arch remains attached to aorta on L (ductus arteriosus) and loses its connection on the R, so recurrent laryngeal hooks around ductus arteriosus on 6th arch on L and 4th arch on R -right recurrent laryngeal under subclavian (right 4th aortic arch) -left recurrent laryngeal under ductus arteriosus (fusion of left sixth with dorsal aorta (AA)) 1st Arch (22-24 day; gone by 27th day) Remnants are maxillary artery 2nd arch (26th day, gone by 28th) Remnants are hyoid and stapedial arteries 3rd , 4th, and 6th arches (Day 29) -3rd arch: common carotid arteries internal and external carotid arteries -4th arch: froms aortic arch on left, brachiocephalic artery on right Left carotid and subclavian come off of aortic arch -Right side: Brachiocephalic trunk, with carotids (3rd arch) and subclavian (continuation of 4th arch) Subclavian -Right: Derived from right brachicephalic from right 4th arch -Left: Left seventh intersegmental off aortic arch Aortic Arch Order: Right brachicephalic (to right subclavian/right carotid) Left carotid Left subclavian 5th arch never completely forms -6th arch: (becomes continuous with pulmonary trunk as truncoarterial sac divides [spiral septum]) Breaks off forming right and left pulmonary arteries -Right side: right pulmonary artery no fusion with dorsal aorta since it has disappered -Left side: left pulmonary artery fusion with dorsal aorta (distal AA) to form Ductus Arteriosus

FETAL CIRCULATION Oxygenated blood from left umbilical vein (80% saturation) through ductus venosus to right hepatochardiac vein (IVC) to truncus venosus. Straight into right atrium, then through foramen ovale, and into left atrium. Then to left ventricle to body via aorta-some blood is delivered from RA to RV to PA through PDA to aorta (none through lungs) [now 58% saturated] -since no pulmonary circulation coming from right ventricle right ventricular pressure is much higher than left resulting in the right to left shunt through the foramen ovale Venous system brings some deoxygenated blood back to right atrium Two umbilical arteries take remaining deoxygenated blood off aorta back to placenta NeonatalCoughing clears lungs clearing the pulmonary circulation resulting in higher left sided pressure closing the flap and hence eliminating the right to left shunt resulting in proper circulation. Musculature closes off ductus arteriosus forming ligamentum arteriosus. CLINICAL Venous UMBILICAL Premature baby ductus venosus might not close after birth and must be closed invasively Post natal ductus venosus is best place for intravenous catheter-closes once removed CARDINAL: If left anterior did not regress double SVC if no brachiocephalic left SVC if brachicephalic via coronary sinus Failure of left supracardinal vein to involute Double IVC Failure of right subcardinal to connect to right vitelline (liver) absent IVC btw kidney and liver blood travels from IVC through azygous to SVC Arterial RIGHT SUBCLAVIAN If right subclavian did not detach from dorsal aortic arch to join with 7th intersegmental Right 7th intersegmental would come off aorta behind esophagus and distal to left subclavian Becoming the right subclavian (on left side) and resulting in a vascular ring COARCTATION OF AORTA Deoxygenated blood supplied to lower left extremity from pulmonary artery Alleviation via maintaining patent ductus arteriosus to bring in some deoxygenated blood If it’s preductal coarct and not postductal coarct DOUBLE AORTIC ARCH If right 4th aortic arch does not form asymmetrically smaller double aortic arch vascular ring PATENT DUCTUS ARTERIOSUS Prevalent in premature babies whose musculature is not well developed enough to constrict PDA NEONATAL PULMONARY HYPERTENSION Maintain the right to left shunt LYMPHATICS Develop from splanchnopleuric mesoderm like blood vessels 5th week-jugular lymph sacs 6th week-4 additional lymph sacs develop -retroperitoneal lymph sacs -cisterna chili -posterior lymph sacs NOTE: There is much more to lymphatics and obviously arterial development in the rest of the body; however, we did not go over it in class, and hence, it can’t be covered. If you know all this junk, you’re set for vascular embryology.

DEVELOPMENT OF THE RESPIRATORY SYSTEM
• • • • • • Lung bud (respiratory diverticulum) appears as outgrowth from ventral wall of foregut at 4 weeks. Location of lung bud determined by signals from surrounding mesenchyme (FGF’s). Epithelium of larynx, trachea, bronchi, and lungs is of endodermal origin Cartilaginous, muscular, and connective tissue components of lungs & trachea are of splanchnic mesoderm origin Lung bud initially still patent with foregut, but is separated by the tracheoesophogeal septum in the 4th week. Lung buds expand into pericardioperitoneal canals, forming visceral and parietal pleura (both of mesodermal origin) Branching of buds goes thru ~17 generations to the 6th month, and another 6 divisions during postnatal life. Postnatal growth is primarily due to increase in number of bronchioles and alveoli, not an increase in alveolar size.

RESPIRATORY ANATOMY
Innervation: Visceral Pleura- autonomic nerves (sympathetic chain and vagus nerve) Parietal Pleura- somatic nerves Mediastinal & Diaphramatic-phrenic nerves Costal pleura- intercostals nerves Passing through hilum- sympathetics from thoracic chain & parasympathetics from vagus Blood vessels: Pulmonary artery-through hilum, continues with bronchus into segment Pulmonary vein-through hilum, travels between lobes and branches in Bronchial vessels (oxygenated separate vessel source) Bronchial arteries-from aorta on left and intercostals on right Bronchial veins-to azygous on right and hemiazygous on left Contents of hilum: Pulmonary veins (most anterior and inferior structures) Pulmonary artery Bronchus Pulmonary Ligament Hilar lymph nodes and lymphatics Sympathetics from thoracic chain, parasympathetics from vagus Lymph drainage-Important in lungs, most common site of carcinoma (Harvey’s p.14) Miscellaneous: • Incorrect subclavian puncture can hit cupola as this section extends 1” over clavicle • 17 lung bud divisions prenatally, 6 additional divisions postnatally • 3 lobes right side, two lobes left side (with lingual) • Inferior lobe is mostly posterior, middle lobe of right side not heard well posteriorly • Middle lobe superior border located just below nipple (4th rib) • Path to right bronchus is straighter and therefore default path for scopes • Saddle embolisms in pulmonary artery occur at bifurcation of bronchi (carina)

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LUNG RADIOLOGY

Remember ALPS for lower lobe pulmonary artery divisions PA ex-ray so heart is closer to film, less magnification (done farther away to also reduce angle and magnification). Lateral done right/left for same reason. Bronchiograms not done much any more, CTs used instead. Right bronchi stems off higher from trachea Pulmonary artery should be same size as bronchus or smaller In addition to air, alveolar sacs can fill with transudate, blood, pus, or tumor, when fill up-coalesce and become white-airspace disease Air in between pleura causes lung collapse Azygous fissure from azygous vein coming down late into lungs, only area that has four layers of pleura Middle lobe, heart and lingula in same plain Posterior to heart, lower lobes Tb is often found in upper lobes Superior artery of lower lobe is only major branch not touching diaphragm To see bottom of inferior lobe, need to look through diaphragm in AP and PA views and through lateral view because diaphragm is anterior to it.

MEDIASTINUM

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Chapter Ten – Cardiac Cycle
BLOCK 2 – CRR THREAD: PHYSIOLOGY
CONTRIBUTORS: JENNIFER LIN, SANDIP PATEL, & ROHIT PUSKOOR

TABLE OF CONTENTS: CARDIAC CYCLE INTERPRETING HEART SOUNDS SYSTOLIC FUNCTION OF THE MYOCARDIUM DIASTOLIC CARDIAC FUNCTION NEURO-HORMONAL REGULATION OF THE CARDIOVASCULAR SYSTEM

VINAY THOHAN VINAY THOHAN JOHN FARMER JOHN FARMER JOHN FARMER

CARDIAC CYCLE
Electrical impulse precedes mechanical event

Event Atrial systole Isovolumic vent contration Vent ejection Isovolumic vent relaxation Late diastole

Ventricular diastole Ventricular systole (Atrial diastole) Ventricular diastole (atrial diastole)

time 0.1 sec 0.3 sec 0.4 sec

description Atrial contraction squeezes a bit more blood into vents Push AV valves close, but not enough pressure to open semilunar valves Vent pressure > aortic pressure, blood ejected Vents relax, vent pressure < aortic, blood flows back into cups of semilunar valves and closes them Atria and vents relaxed, passive vent filling

Valves open Tricuspid, mitral none Aortic, pulmonic none Tricuspid/mitral

Phases 1 2 3 4 1

Pulse pressure = systolic P – diastolic P EDV (end diastolic volume) = max amount of blood in ventricles at end of vent relaxation (~135 ml) ESV (end systolic volume) = min amount of blood in vents after vent ejection (~65 ml) SV (Stroke volume) = EDV – ESV (~70 ml) EF (Ejection fraction) = SV/EDV (nl 50-55%) Echocardiography Volume = (3.42*L*W)- 6.4 FS Fractional shortening = [internal diameter ID diastolic – ID systolic]/ ID diastolic EF = 1.7* FS Impact of physiologic variables on cardiac performance Cardiac Output (L/min) = HR * SV Cardiac Output Heart Rate Automaticity Preload (EDV) Parasym – ACh - ↓ HR Frank Starling – as Sym – NE - ↑ HR preload ↑, SV ↑ ↑ preload: inspiration, exercise, aortic regurg, system shunt ↓ preload: valsalva, dehydration, atrial fib, meds

Stroke volume Afterload (ESV) As afterload ↑, SV ↓ Force that ventricle must overcome to eject blood (mean arterial P)

Contractility As contractility ↑, SV ↑ Intrinsic capacity of heart to generate force indep of extrinsic factors. Sym – NE on Beta1 ↑ contractility

HEART SOUNDS
Normal valve opening= silent, only heart in pathology. Normal valve closing= lub-dub Murmurs are caused by turbulent flow, which themselves are caused by pressure gradients Can time heart sounds in relation to events of cardiac cycle by feeling the carotid upstroke S1= lub= AV valves closing for systole S2= dub= Semilunar valves closing for diastole (can accentuate split S2 by breathing in which will expand the right side of the heart due to increased venous return, this split is physiologically normal) S3= poor contractility (poor contractility= less squeezing so extra blood left in LA leaks into LV when mitral valve opens) S4= a stiff heart (left ventricle already full, can hear overflow of blood in late diastole) Summation gallop= all 4 sounds are heart, generally associated with weak heart and high blood pressure --S4—S1-----S2---S3-------S4---S1----S2—S3— Electrical activity in the heart precedes physical manifestation Timing of Heart Murmurs Systolic: aortic stenosis, pulmonary stenosis Holosystolic: Mitral regurgitation, Tricuspid regurgitation, Ventricular Septal Defect Diastolic: Aortic regurgitation, Mitral stenosis Differentials Location of heart sound Tricuspid regurgitation will increase during inhalation, mitral regurgitation will not Ventricular septal defect can be felt on patient’s chest (thrill due to turbulent blood flow) Ask yourself when listening: 1. Where you are listening and with what part of the stethoscope 2. Systolic or Diastolic (feel carotid pulse as a pacemaker) Holosystolic vs Crescendo-Decrescendo

SYSTOLIC FUNCTION OF THE MYOCARDIUM
*Mechanisms of myocardial contraction - 3 component model of muscle contraction -contractile element CE: dvlps shortening F -series elastic element SE: passively stretched by CE -parallel elastic element PE: supports resting tension, doesn’t shorten - isotonic contraction: CE initially contract, stretches SE, dvlps F as great as afterload and then shortening occurs - isometric contraction: CE and SE don’t shorten following stimulation (occurs during isovolumic contraction phase) - excitation-contraction coupling: contraction and relaxation BOTH promoted by beta stimulation major contractile proteins: actin, myosin, tropomyosin, troponin *Determinants of Cardiac Output - HR: ACh, beta stim - Preload: venous return, Starling law - Afterload: peripheral resistance, blood pressure - Contractility: beta stim, inherent properties of myocardium Ohm’s law: I = V/R CO = BP/SVR CO = HR*SV Heart is pump in series so Left Vent CO = Right Vent CO Systemic Resistance high and pulmonic Resistance low so LV and RV contraction dynamics differ *Concept of Afterload (force that heart must overcome to eject blood from ventricles into aorta) Clinical causes of ↑ed afterload -Hypertension (HTN) -Aortic stenosis -aging -Hypertrophic cardiomyopathy Internal determinants -Viscous resistance (minor) -Inertial components (minor) -Wall stress** Law of Laplace WS = P*R/2h External determinants -Impedance -Arterial compliance ** -Vascular resistance **

- Pressure loads (HTN & valvular aortic stenosis) => thickened myocyte (↑ volume) => concentric hypertrophy - Volume loads (regurgitant valve lesions) => ↑ EDV (↑ length) => eccentric hypertrophy *Concept of Preload - Starling’s law: force of contraction is function of initial length of muscle fiber - ↑ intracardiac P in diastole stretches muscle fibers more, which increases EDV, contraction, and stroke volume - as preload ↑, SV ↑ and ventricular performance ↑

CARDIAC DIASTOLIC FUNCTION
*Mechanisms and Evaluation of Diastolic Function - passive elastic properties: recoil, titin (noncontractile, highly elastic) - active energy requiring process: ATP hydrolysis to detach actin from myosin -> Ca++ dissociation from TropC -> SERCA activated by ↑ Ca++ -> Ca++ sequestered back by SR Pressure-Volume loops diastolic heart failure => ↑ Pressure systolic heart failure => ↑ volume combined heart failure => ↑ pressure and volume -Compliance: measure of diastolic fxn = dV/dP - reduction may occur in conditions that impair O2 delivery to heart - pressure-vol curve steeper when impaired, so that small change in vol gives huge change in P -impaired diastolic fxn => reduced LV/RV filling => central, peripheral vascular congestion => backflow so RA/LA P ↑ (edema) =>release ANP to vdltn (reduce Na+ and vol retention) [usually inadequate to restore homeostatis] *Phases of Diastole Isovol relaxation Energy dependent, LV not filling Impaired in coronary artery disease, CHF Rapid filling Rate dependent on P gradient and suction effect via active relaxation (titin) 80% vent filling Diastasis Slow fill rate, from blood flow directly from veins to ventricles (just pass through atria) 5% vent filling Atrial systole Booster pump, ↑ in diastolic disfxn, lost in atrial fibrillation 15% vent filling

*Factors affecting Diastolic Function Extracellular matrix -Fibrillar proteins (collagen I, elastin): ↑ collagen, ↓ ability to relax NE, Ang II stim synthesis of collagen Matrix metalloproteinase degrade -basement membrane proteins -proteoglycans

Cardiac myocyte Intrinsic properties -Troponin T, C, I -Tropomyosin -Titin -Phospholamban: Ca++ uptake by SR causes of dysfxn -Sarcolemma channel defects -SR uptake of Ca++ defect in ATPase -protein phosphorylation defects

Extrinsic causes of dysfxn -pericardial disease: prevents distention -restrictive cardiomyopathy: deposition of iron, granules (also pericarditis) - neurohumoral activation: ↑ NE and Ang II => P overload and ↑ EC matrix deposition

Neurohormones -NE -Ang II -Aldosterone -endothelin NE, Ang II ↑ collagen => ↑ stiffness, ↓ ability to relax, vent hypertrophy => dsyfxn Beta stim ↑ force of contraction (inotropy) AND ↑ rate of relaxation (lusitropy)

Macrophage ↓ Non ACE │ │ │ ────→ ↓─────── Fibroblast ↑ collagen synthesis

microvasculature mast cell ↓ ↓ Ang I chymase ↓ ACE │ Ang II │ ↓ │ TISSUE ANG II ←───── ↓ ───────↓ myocyte nerve endings ↑ contractility ↑ fibrosis ↑ hypertrophy ↑ apoptosis ↓ diastolic fxn NE

NEURO-HORMONAL REGULATION OF THE CARDIOVASCULAR SYSTEM
BASIC CONTROL OF CARDIOVASCULAR FUNCTION CV System Physiologic function controlled by: 1.Inherent contractile properties of the myocyte 2.Circulating neurohormones 3.ANS – myocardium and conduction system is richly innervated by ANS fibers
Neurohormones maintain a baseline vascular tone and may be activated during periods of stress. Persistent elevations are maladaptations, and are associated with ischemia, hypertrophy and fibrosis. Elevated levels of NE and AngII play major roles in:

1)CHF 2)post-MI ventricular remodeling a)hypertrophy of noninfarcted segment b)expansion of infracted segment c)occur due to increased wall stress from increased LVEDV and LVEDP; will cause CHF 3)Atherosclerosis
MEDULLARY CONTROL CENTERS 1.Sympathetic nucleus – activated by the hypothalamuαs in response to exercise, stress, hypertension input; increases adrenergic outflow 2.Vagal nucleus (parasympathetic) 3.Nucleus solitarius (part of the medulla oblongata) • Along with hypothalamus, is one of the primary medullary autonomic control centers • Modulates sympathetic and vagal outflow to the periphery • Baroreceptors are sensory nerves in the cardiac atria, vena cava, aortic arch, and carotid sinus that are sensitive to stretching of the wall due to increased pressure from within; they function as receptors for CNS reflex stimuli that tend to ⇓ pressure. • Excessive elevation of BP stimulates baroreceptors in carotid and aortic arch, which ⇑ afferent vagal stimuli to the solitarius. • Solitarius inhibits sympathetic nucleus and activates vagal nucleus in response to vagal inflow • Vagal nucleus sends efferent vagal stimuli to reduce heart rate (SA node) and contractility (minor effect). • Net result: reduced CO, HR and BP

RENIN-ANGIOTENSIN SYSTEM 1)Vasoconstrictor • reduces coronary flow 2)Procoagulant 3)Inflammation 4)Impairs fibrinolysis • inhibits tPA; thrombosis • Works with SNS to maintain BP, HR and organ perfusion • AngII generated from mast cells, macrophages and endothelial cells (90% tissue/10% plasma) • ACE generates AngII from AngI; also degrades bradykinin (BK), a vasodilator • Tissue AngII stimulates NE secretion and collagen production in fibroblasts • AngII is overproduced in hypertension • Reduction of AngII by inhibiting ACE will improve O2 delivery to the myocardium

PARASYMPATHETIC NS Distributed mainly to the atria and have major effects on reduction of HR • Vagal nerves go to SA node and AV node • Decreases CO • Ach interacts with M2 muscarinic receptor, activates Gi • Atropine comp. inhibits Ach • Muscarinic receptors in arterioles: inhibits NE release and stimulates endothelium to produce NO vasodilation • Muscarinic receptors in K+ channels in SA and AV nodes: downregulate cAMP 1. Inhibits SA node: lowers HR 2. Inhibits AV node: causes AV block (“athlete’s heart”) 3. Reduces contractility (modest effect) • Stimulated by rest, sleep, trained state

Sympathetic Nervous System Significant distribution in the ventricle. Can increase both HR and systolic function. Normal sympathetic stimulation maintains CO. • Activate after a reduction in LVCO to maintain blood pressure and organ perfusion • Long-term activation is detrimental due to direct toxic effect on myocyte with decreased inotropy • Downregulation of β-receptors will occur with secondary decrease in ventricular function despite high NE levels (high sympathetic activation will increase CHF mortality) Norepinephrine (NE) • Resultant vasoconstriction after binding to α1 receptor • β1 > α1 > β2 • Inhibited by vagal stimulation, NO, adenosine, α2 receptor • Upregulated by β2 (?), AngII, adrenergic depolarization • NE will initially increase CO, which may later decrease due to baroreflex Epinephrine (EP) • Resultant vasodilation after binding to β2 receptor • β1=β2 > α1; mixed β effects with α effects achieved at high doses • Increases CO Dopamine • β1 > β2 > α • Activates DA1 and DA2 for peripheral vasodilation • Activates β1 for inotropic effects on the heart • High dose – activates α1 for vasoconstriction α1 receptor • Vasoconstriction α2 receptor • Feedback inhibition and reuptake pump for NE β1 receptor • Located primarily in the myocardium • Agonists cause increase in chronotropy (heart rate) and force of heart contraction (inotropy) and relaxation (lusitropy) • Inotropy – activation of PKA phosphorylates SERCA • Lusitropy - increases phosphorylation of phospholamban β2 receptor • Located predominantly in the periphery • Agonists cause vasodilation and bronchodilation • Decrease in PVR causes increased venous return (preload)

Chapter Eleven – EKG
BLOCK 2 – CRR THREAD: PHYSIOLOGY
CONTRIBUTORS: ANNIE WHITNEY AND BETH ZARNOW

TABLE OF CONTENTS: EKG VOL. 1 EKG VOL. 2

HUE-TEH SHIH HUE-TEH SHIH

EKG VOL. 1
NOTE: Use at your own risk. I didn’t include EVERY single detail because this is meant to be a broad, big ideas kind of review. I included things that have been tested before in the interim and the final and that contribute to a good “big picture” of the topic at hand. Enjoy! ☺

CARDIAC ELECTROPHYSIOLOGY -The normal cardiac rhythm originates from the sinoatrial (SA) node -nodal cells depolarize spontaneously at a rate of 60-100 beats per minute at rest -about .1 second after origination at the SA node, the electrical impulse arrives at the atrioventricular (AV) node -fibrous atrioventricular ring insulates the ventricles from the atria, so the only way the impulse can travel from the AV node is down the Hisbundle-Purkinje fiber system, which carries the impulse to the muscle cells of both ventricles -different sites along the cardiac conduction system exhibit distinctive shapes of action potentials, depending on the composition of their ion currents -the electrical impulse travels from one cardiac cell to the next; the electrical influence of one cardiac cell on another depends on: 1) the voltage difference between the cells 2) the resistance of the gap junction between the cells (when the cells are tightly coupled, the resistance is low, and the gap junctions are minimal barriers to the flow of depolarizing current) -the intracellular and extracellular currents are equal and opposite; it is the extracellular current that gives rise to the electrocardiogram (ECG or EKG) -there are several different cardiac membrane currents that are caused by the influx or efflux of various ions; they are time dependent and voltage gated. Important things to remember about each current: INa – responsible for rapid depolarization in muscle and Purkinje fibers, NOT present in SA or AV nodal cells ICa – responsible for rapid depolarization in SA and AV nodes; also triggers contraction in all cardiac myocytes IK – responsible for repolarization in ALL cardiac myoctes If – pacemaker current; responsible, in part, for pacemaker activity in SA node, AV node, and Purkinje fibers *primary pacemaker = SA node *secondary pacemaker = AV node *tertiary pacemaker = Purkinje fibers -the cardiac action potential is divided into several phases; again, important things to remember about each: Phase 0 – the upstroke of the action potential; where depolarization occurs (is slow in SA and AV nodal cells because they lack the INa current) Phase 1 – the rapid repolarization component (when it exists) Phase 2 – the plateau phase

Phase 3 – the repolarization component; IK dependent Phase 4 – the electrical diastolic phase; pacemaker activity occurs here -the refractory period prevents extraneous pacemakers from triggering ectopic beats and tetanus -effective refractory period: same as “absolute refractory period”; electrical extrastimulus has no effect -relative refractory period: electrical extrastimulus can produce an action potential that is smaller in magnitude -when comparing the conduction velocity in various cardiac tissues, we find that the SA and AV nodal cells are the slowest conductors, while the Purkinje system is the fastest -atrial conduction pathways include Bachman’s bundle (carries electrical wave from SA node to the left atrium) and internodal pathways (from SA to AV node) -normal cardiac tissue depolarizes in a specific order: 1) atrial depolarization from R to L and downward 2) interventricular septum depolarization from L to R 3) depolarization of anteroseptal region toward apex 4) depolarization of ventricular myocardium, always from the endocardium toward the epicardium 5) spreading of depolarization from apex to base (carried by Purkinje fibers) *the last region to depolarize is the posterobasal region of the left ventricle -Acetylcholine and Catecholamines modulate pacemaker activity, conduction velocity, and contractility -ACh is released from the vagus onto the SA and AV nodes and slows intrinsic pacemaker activity; it also slows conduction velocity in the AV node -Catecholamines, via B1 adrenergic receptors, increase heart rate and contractility ELECTROCARDIOGRAM -a lead is made up of 2 electrodes; one serves as the positive pole, the other serves as the negative pole -the lead records fluctuations in voltage difference between the positive and negative pole; these fluctuations are called waves *William Einthoven discovered the mechanism of the EKG -different waves have different letters of the alphabet! P wave – depolarization of the atria QRS complex – depolarization of the ventricles Q = initial downward deflection R = upward deflection S = late downward deflection T wave – repolarization of the ventricles *we cannot see the repolarization of the atria because it is buried within the QRS complex -the standard surface ECG is usually composed of 12 leads

-the frontal plane (aka Einthoven’s triangle) is composed of 6 limb leads: 3 standard: I, II, III 3 augmented: aVR, aVL, aVF -the transverse plane consists of 6 precordial leads: V1, V2, V3, V4, V5, V6 -the pattern we see on the ECG is created by -if a lead (the line between 2 electrodes) is perpendicular to the wave of depolarization, the measured deflection would be isoelectric

EKG VOL. 2
I made this as concise as possible. Sorry, there’s no easy way around it. The last page of Shih’s notes does have a good diagram from the book showing simple examples of nodal block, WPW, and fib EKGs. Basics to Reading EKG: 1) Locate P wave and determine relationship (ratio) to QRS complex. 2) Identify pacemaker (which wave initiates full complex) and measure heart rate based on various intervals (ex P-P and R-R). 3) Classify QRS shape (ex narrow vs wide) and note distinguishing features of ST (ex depressed or elevated) 4) Estimate mean QRS axis. 5) Examine rhythm for regularity or pathology (ex fibrillation). Determining heart rate from EKG: Rate = (paper/sec)*(beat/paper) ex rate = (1box/.2s)/(1beat/4boxes) *measure paper in mm or marked boxes. The paper speed will be given, but don’t forget to correct for seconds to minutes at the end. Find mean QRS axis: Geometric method: Draw a line perpendicular to two axes, the intersection of the is the mean axis. Inspection method: Identify isoelectric lead (no wave for that portion), and the mean axis is perpendicular to it. **For all the abnormalities, I’ve tried to focus on just a couple key signs. This is not a complete listing of all indications, but I’ve tried to demonstrate trends without including exactly what happens on each lead. Abnormal EKG findings Axis Deviation: Normal P = 0-90o QRS = -30 – 100 o Right axis deviation = 90-180 o Left axis deviation = 0- -90 o Northwest deviation is area between RAD and LAD Hypertrophy is responsible for shifting the heart and determining the zone of transition. Atrial enlargement: Right: exaggerated P-wave (Lead II), extended (+) P in V1 Left: exaggerated P-wave (Lead II), extended (-) P in V1 Right ventricular hypertrophy is indicated by: 1) right axis deviation (RAD) 2) right bundle branch block (RBBB), complete or incomplete 3) R>S in right-sided leads

Left ventricular hypertrophy is indicated by: 1) large R or deep S in V1-6 2) QRS axis left of -15 o and/or duration of >0.04s 3) ST opposite direction of QRS 4) LAD Myocardial Infarction *The progression of myocardial ischemia to injury to infarction is indicated by 1) peaking of T wave followed by 2) T-wave inversion followed by 3) ST elevation, often accompanied by Q wave formation When viewing signs of infarction on EKG read-out, look for reciprocal effects in a lead placed on the opposite side of the body. (ex, elevation of ST segment will look like depression if measured on the opposite side of the infarct) To determine location of MI, a Q wave in… 1) lead V1 or V2 indicates MI over the ventricular septum (anteroseptal) 2) lead V3 or V4 indicates MI of the anterior myocardium 3) lead V5 or V6 indicates MI of the lateral myocardium So, by knowing which lead you are looking at, you can determine from what area the abnormal wave is coming. Bundle branch block Main signals of… 1) Right BBB – normal axis, but presence of R and R’, wide QRS 2) Left BBB – presence of R in left sided-leads with wide QRS *incomplete R or LBBB has the same signs as complete BBB but without the extended QRS 3) Left anterior fascicular block – LAD, narrow QRS, q (small vs normal-Q) in Leads I and aVL 4) Left posterior fascicular block – RAD, notched R, exaggerated S in Lead I Conduction abnormalities Abnormal (de)polarization or anatomy can cause arrhythmias. Sinus pause/arrest involves escape from the SA node to a secondary pacemaker, usually the AV node. This abnormality is usually functional. There are three types of heart block: 1 o – prolonged conduction but with 1:1 P:QRS 2 o – Mobitz I presents as intermittent dropped beats with gradually prolonged conduction (PR gets longer before drop). Mobitz II is the same intermittent dropped beats but with a fixed PR interval. 3 o – complete block, no QRS following P

SA and AV block refer to dropping P and R waves, respectively. SA block indicates that the signal is not being generated in the normal node, and AV block would suggest that the impulse is being produced but not transmitted. Mechanisms of arrhythmia: Circus movements (aka re-entry) are 1) closed conduction loops with 2) unidirectional block in a 3) this one’s important… slow conduction zone!!! Prolonged depolarization can trigger early after-depolarization (EAD, phase 2 or 3) or late after-depolarization (phase 4). This appears as a “hiccup” on the downstroke. bradycardia < 60bpm vs tachycardia > 100 bpm A wandering atrial pacemaker is indicated by tachycardia with multiple P wave morphologies. Atrial flutter is much less common than ventricular flutter (very rapid but regular incomplete firing) or fibrillation (irregular rapid activity, with or without pattern). All are due to erratic electrical activities. Wolff-Parkinson-White Syndrome Is a pre-excitation syndrome characterized by an accessory (extra) AV pathway, known as the bundle of Kent. The accessory pathway results in a delta wave, which is a “blip” in the PR interval that obstructs the Q wave. This syndrome is often associated with tachycardia, a narrow QRS and atrial fibrillation. Note: Ca++ entry bockers given to treat the atrial fib can trigger ventricular fib with WPW. Effects of drugs and electrolytes Digitalis gives various EKG abnormalities, from ST depression to SA/AV nodal block and tachycardia. hypercalcemia- shortened QT and exaggerated T (too much action) hypocalcemia – prolonged QT and flat T (not enough Ca++ to get full contraction) hyperkalemia – depressed activity, nodal block, prolonged intervals (too much K+ prevents proper depolarization) hypokalemia – ventricular arrhythmias (not enough K+ to suppress overactivity) Congrats if you’ve made it to the end!

Chapter Twelve – Vascular Microanatomy & Biophysics
BLOCK 2 – CRR THREAD: CELL BIOLOGY/HISTOLOGY & PHYSIOLOGY
CONTRIBUTORS: STEPHANIE WUEST, LARRY PUTHENPARAMBIL, MATT REHRER & ANDREW THURSTON

TABLE OF CONTENTS: MICROANATOMY OF VASCULAR I & II BLOOD PRESSURE, BLOOD FLOW & THEIR MEASUREMENT BIOPHYSICS OF ARTERIES AND VEINS VASCULAR REGULATION OF PRESSURE AND FLOW VASCULAR REGULATION II

MICROANATOMY OF BLOOD VASCULATURE
5 Fxns: 1. 2. 3. 4. 5. Withstand High Pressure Smooth out flow Regulate flow Exchange Materials Return blood to heart

Structure: Tunica Intima: inner most layer with flat attenuated endothelial cells; contains subendothelial space Tunica Media: Concentric layers of smooth muscle Tunica Adventitia: Layers of connective tissue with vasa vasorum. Arteries: -Elastic Large vessels Tunica Intima: Thick; big subendothelial space for distortion Tunica Media: 40-70 layers of muscle Tunica Adventitia: Thin; Vasa Vasorum -Muscular Arteries Fxn: to conduct blood t oreional areas Tunica Intima: Subendothelial space = thinner than Elastic arteries Tunica Media: Thickest tunic has external elastic lamina Tunica Adventitia: Thicker than Elastic Arteries -Arterioles Fxn: to conduct blood from muscular arteries to capillary beds Tunica Intima: very thin; no subendothelial space Tunica Media: 1-3 layers of smooth muscle Tunica Adventitia: very thin Terminal Ends are called metarterioles which are useful to regulate flow through the capillary beds -Capillaries Fxn: Gas and nutrient exchange Only has an endothelial cell layer and pericytes There are 4 types of capillaries: 1. Continuous Non-fenestrated 2. Continuous Fenestrated 3. Continuous fenestrated w/no diaphragm 4. Discontinuous sinusoidal -Venules 3 types: 1. Postcapillary Venules Identical to capillaries but has more pericytes still no media or adventitia 2. Collecting Venules Pericyte layer becomes continuous and there is a beginning adventitia 3. Muscular Venules No pericytes and have beginning media and fibrous adventitia -Veins Fxn: Capacitance vessels with low hydrostatic pressure Have large lumen and thinner walls Semilunar valves derives from tunica intima to help flow back to heart Some smooth muscle in media is arranged longitudinally Adventitia is thicker than media and has higher density of vasa vasorum. -Lymphatics - have semilunar valves like veins

Microanatomy of Vasculature Tunica Intima- Nutrient exchange, pressure accommodation Composed of Endothelial cells and subendothelial layer. Endothelial cells may be fenestrated. Loose connective tissue has longitudinal orientation in the subendothelial layer. The subendothelial space is well developed in elastic arteries, and contains an internal elastic lamina in muscular arteries. In smaller vessels, the tunica intima is just an endothelial cell and basal lamina. Folds of intima create the valves of veins. Tunica Media- Provides elasticity, regulates vessel diameter. Composed of concentric layers of smooth muscle, elastic and reticular fibers. Reticular fibers bind smooth muscle cells to the elastic fibers. The force of contraction of the smooth muscle is transmitted to the fibers. Fibers are secreted by smooth muscle cells. In elastic arteries, the tunica media contains 40-70 elastic layers. Muscular arteries have 3-30 layers, with fewer elastic fibers. Arterioles have 1-3 layers of smooth muscle in the media. Capillaries and small venules do not have a tunica media (replaced by pericytes). The smooth muscle of the tunica media in veins is longitudinally oriented. Tunica Adventitia- Volume accommodation/Capacitance Composed of Collagen Type I and elastic fibers in longitudinal orientation, with vaso vasorum. Adventitia also contains sympathetic nerve endings. Adventitia is better developed in veins than arteries, and tends to be thicker than the tunica media in veins. Vaso vasorum penetrates deeper into vessel walls in veins. Special Vessels: Pulmonary arteries-Elastic arteries with no subendothelial space. Elastic fibers are in longitudinal orientation to stretch with the act of breathing. Lymphatic- Endothelial lined tubes with blind endings. No media or adventitia. Venules are sensitive to histamines, serotonin and bradykinins which induce leakage of fluid in inflammation. Vessel Diseases/Reasonable Places for “Integration”Atheroma formation- Fatty streaks in Tunica Intima, accumulation of macrophages, calcification/stiffening of arterial wall, formation of fibrous cap, cap rupture, platelet plug formation. Risk Factors include diabetes, hypertension, high cholesterol and homocysteine. Thrombus- blood clot in blood vessel. Can occlude pulmonary vessels, creating “dead space.” Aneurysm

Layers (from inside out) Tunica Intima

Function Constituents exchange and cushion under high pressure Endothelial cell attenuated flat cell; selective fluid barrier; regulatory functions longitudinal orientation; some (stores factor VIII); offers friction free are fenestrated service (negative charge) Subendothelial space loose connective allows for distortion collagen type I and elastic fibers tissue; longitudinal of endothelial cell during systole; orientation smooths out flow elastin Internal Elastic Lamina fenestrated allow diffusion of substances to nourish cells deep in vessel wall elastic fibers; Tunica Media concentric layers regulation of flow; reticular fibers reticular fibers of helically arranged smooth transmit force from (collagen type III) muscle cells; gap smooth muscle to elastic fibers junctions (not every cell innervated) containment collagen type I and Tunica Adventitia longitudinal elastic fibers orientation of fibers; DICT

Structure

Cell types

Misc

endothelial cells

vimentin positive; secrete basal lamina

fibroblasts and few smooth muscle cells

none

synthetic smooth muscle cells

basal lamina (anchored to elastic and reticular fibers)

fibroblast, some smooth muscle cells, adipocytes (with age)

vasa vasorum (nourishment); sympathetic nerve endings

Vessel Elastic Arteries

Size Lumen large (1-3 cm) large

Tunica Intima thick; well-developed subendothelial space; prominent internal elastic lamina

Tunica Media Tunica Adventitia thick (40-70 elastic relatively thin layers); high content of elastic fibers

Function maintain diastolic pressure; receive main output of heart; withstand pressure

Misc examples: Aorta, Pulmonary, Carotid, Subclavian, Common Iliac

Muscular Arteries medium (0.5mm-1cm)

thin (less rebound)

thickest layer; thicker than elastic higher content of artieries smooth muscle cells (3-30 layers) 1-3 layers smooth muscles cells little to none

conduct blood to regional areas; regulate lumen diameter regulate flow and pressure to capillary sympathetic innervation to stimulate vasoconstriction (unmyelinated); skeletal muscle also has cholinergic nerves for vasodilation; terminal ends are metarterioles (fine tuning)

Arterioles

small (0.4 mm) reduced to 0.5 thin with essentially no µm in subendothelial space; metarteriole little or no internal elastic lamina

Capillaries

very small (5- allows 10 µm) passage of single RBC

discontinuous layers of none pericytes; only endothelial cells and basal lamina

none

exchange of gas and nutrients

forces: hydrostatic, osmotic, conc gradients; active transport (transcytosis); continuous (muscle, CT, exocrine, nervous) vs. fenestrated (kidney, intestine, endocrine)

Venules

Postcapillary small (10-20 µm) Collecting Muscular Veins small (20-50 µm) small (50-100 µm) medium (1mm-4cm) large

more pericytes than capillaries continuous pericyte layer no pericytes

none

none

sensitive to histamines, serotonin, and bradykinins (induce leakage of fluid) net fluid movement identical to capillaries but larger back into venule diameter; active during inflammation and edema

none

some surrounding collagen smooth muscle cells fibrous (1-2 layers thick) irregular shape (no hydrostatic well-developed; rhythmic smooth muscle contraction propels pressure); well developed vasa vasorum (de-oxy blood) oriented longitudinally blood to heart; valves prevent backflow

valves; subendothelial smooth muscles space with poorly oriented formed internal elastic longitudinally lamina (medium sized)

BP, BLOOD FLOW AND THEIR MEASUREMENT
Resistance and Pressure Relationships Systemic resistance > pulmonary resistance Systemic pressure > pulmonary pressure Systemic vascular volume > pulmonary vascular volume Venous volume > arterial volume Pressure in arteries > pressure in veins Series Circuits: R(total) = R1 + R2 + … Local change in resistance dramatically effects R (total) Parallel Circuits: 1/R(total) = 1/R1 + 1/R2 + … Local change has minimal impact on R (total) Application of Circuits Output of two ventricles must be equal since they are in series, but LV pumps against a greater resistance of systemic circuit than RV. One organ regulating BP in capillary bed on a local level does not effect other organs blood flow since organs are in parallel, not a dramatic effect on MAP Poiseuille’s Law: Q (flow) = ∆P (pressure) / R (resistance) Resistance Determined by: R = 8ηL / πr^4 L =Vessel length: increase length, increase resistance, decrease flow η = Blood viscosity: increase viscosity, increase resistance, decrease flow r = Vessel Radius: increase radius, decrease resistance, increase flow CO (Cardiac Output) = SV (stroke volume) x HR (heart rate) Flow Laminar Flow: velocity in middle of vessel faster, resistance (adhesion) as you move out towards vessel wall, energy effective, parabolic shape Turbulent Flow: results in murmur, critical velocity (Reynold’s number) where flow transitions to turbulent, inefficient flow with greater resistance Blood Pressure Systolic Pressure: maximum pressure of aorta following contraction, first tapping sound heard Diastolic Pressure: minimum pressure of aorta following relaxation, muffling of sounds Aortic Regurgitation An inadequate aortic valve leads to lowered diastolic pressure, backflow of blood increases the workload of the left ventricle 3 Types of Pressures Driving Pressure: along length of the vessel Transmural Pressure: difference between intravascular pressure pusing out and tissue pressure on vessel wall pushing in, prevents vessel collapse Hydrostatic Pressure: refers to pressure that blood exerts as a fluid on its container (vessel walls)

BIOPHYSICS
Capillaries: take sum of all cross-sectional areas (large radius), slowest blood flow, facilitates increased absorption, Slow blood flow made possible arterioles that regulate pressure in capillaries downstream and are site of greatest resistance. Controls of Capillary Pressure ↑ Rpre (arteriolar resistance) = ↓ capillary pressure characteristic of venous pressure ↓ Rpre = ↑ Capillary pressure ↑ Rpost (venous resistance) = ↑ capillary pressure characteristic of arterial pressure ↓ Rpost = ↓ capillary pressure Arteriolar Constriction = ↑ P in Arteries; ↓ P in veins Arteriolar Dilation = ↓ P in Arteries; ↑ P in veins Application with Chronic Disease: ↑ venous pressure when you stand up, ↑ Capillary Pressure, ↑ Fluid Filtration (exits capillaries), ↑ Fluid filtration into interstitial spaces, Edema in the ankles Normal person: ↑ Rpre to compensate, ↓ Capillary Pressure C (Compliance): ∆V (volume) / ∆P (transmural pressure) Prevents arterial pressure from falling to zero between each heart beat Arteries compliance < venous compliance Arteries: linear compliance, only slight ↓ in compliance w/ unphysiologically high transmural pressure Aorta: stiffens with aging, same volume of blood must pass through and will thus have a higher pressure as aorta cannot expand, blood goes right downstream as aorta no longer is able to rebound, less blood diffuses to coronary arteries in diastole Veins: At low transmural pressure, apparent compliance is extremely high, however as vein becomes rounded (stores blood) and undergoes geometric changes the compliance lowers. At unphysiologically high pressure, compliance greatly decreases, veins resist deformation

WALL TENSION: amount of pressure needed to push together an imaginary slit in wall of vessel
Elastic Fibers play a role early on as tension ↑. Collagen plays a later role when vessel reaches threshold b/c it has slack ends that are pulled tight, small changes in radius from this point on have a dramatic change in tension. Law of Laplace: T = ∆P x radius Aorta: largest # of elastic fibers, highest wall tension Vena Cava: lower # elastic fibers, lower wall tension Aneurysm: Decreased production of elastic fibers, collagen increases production initially to compensate but levels out, smooth muscle cells also degrade, collagen prevents bursting

VASCULAR ROLE IN REGULATION OF PRESSURE AND FLOW
Objectives 1&2: Describe the distribution of total blood V in major portions of the cardiovascular system. Why are arterial and venous V not equal? A: 65% of systemic blood is on the venous side (which mean, yes... 35% in arteries). This is due to the high compliance of veins. Objective 3: What is CVP? A: Central venous pressure; estimates CBV = venous blood in the left heart + pulmonary. CVP is the main determinant of RA filling. Its pressure changes are sensed by the atrial baroreceptors. Changes in CBV change CO by affecting EDV Objective 4: Describe 3 mechanisms by which arteriolar resistance is altered to meet local tissue blood flow needs.

Central Factors
- sympathetics (+) vscxn - always some chronic background vscxn - sympathetic changes designed to keep MAP constant

Local Factors - affect arteriolar diameter - no dramatic change in MAP - modulate the sympathetic nerve stimulation EXAMPLES:

General Equations:
MAP = CO x TPR CO = SV x HR SV = EDV - ESV therefore, MAP = (EDV-ESV) x HR x TPR

1) Active Hyperemia - increased flow due to increased metabolism 2) Reactive Hyperemia - increased flow after a period of arrested blood flow 3) Autoregulation - increased pressure = increased resistance, so flow is carefully controlled

Objective 5: Describe the physical forces operating across the capillary wall and predict how a change in these forces alters net fluid movement across the wall.

Starling’s Equation: Jv = Lp [(Pc - Pif) Hydrostatic Pressure (P): a) Capillary Pc b) Tissue Pif Osmotic Pressue ( ): a) Blood c b) Tissue if Physical Properties: a) Hydraulic conductivity Lp b) Reflection coefficient (btw 0 & 1) - 0 means total protein diffusion - 1 means no protein diffusion

(

c

-

if)]

Filtration Reabsorption

If Pc - Pif > If Pc - Pif <

cc-

if, net FILTRATION and Jv EQ will be POSITIVE if, net REABSORPTION and Jv EQ will be NEGATIVE

In Pulmonary Edema, get pulmonary hypertension and high LA pressure resulting in high Pc with net filtration.

VASCULAR REGULATION II
Mechanisms of Vascular Regulation

Vasoconstriction
1) Increase intracellular Ca2+ 2+ - ↑ [Ca ]i → Ca2+/CaM → ↑ MLCK → ↑ MLC-P → actin/myosin binding - Open Ca/Na channels, 1 receptors, endothelin 2) Increase myosin light chain phosphorylation - ↓ MLCK-P → ↑ MLCK → ↑ MLC-P → actin/myosin binding - Muscarinic M2 receptor

Vasodilation
1) Decrease intracellular Ca2+ - ↓ [Ca2+]i → ↓ Ca2+/CaM → ↓ MLCK → ↓ MLC-P → ↓ actin/myosin binding - Open K channels, NO, purigenic adennosine rcptr 2) Decrease myosin light chain phosphorylation - ↑ MLCK-P → ↓ MLCK → ↓ MLC-P → ↓ actin/myosin binding - B2 receptor, prostacyclin, histamine

Short Term Regulation NT Mediated 1) Baroreflex - neural feedback loops 2) Sympathetics - vscxn via NE, acts on VSMC adrenoreceptors - eg. ↓ MAP → vscxn → ↑ TPR/↓ Pcap → ↑ MAP 3) Parasympathetics - vsdltn, but less common - Ach acts on the heart 4) Adrenal Medulla - vsdltn Vascular Receptors 1) Adrenergic (catecholamines) - 1 (vscxn) ; 2 (vsdltn) - NE1 via G-q & IP3 ; EPI 2 via ↑ cAMP & PKA 2) Cholinergic (muscarinic) - ACh = indirect vsdltn, direct smooth muscle ctxn - M2 receptor on symp neurons (-) NE release - M3 on endothelia ↑ IP3 → ↑ NO and vsdltn 3) Non-adrenergic non-cholinergic (NANC) - parasymp releases NT (ACh and NO) = vsdltn

Long Term Regulation Vasoactive 1) Amines: - EPI (adrenal medulla) - vscxn via 1 - 5-HT (platelets/mast cells) - vscxn via 5-HT2B - Histamine (mast cells) - vsdltn via B2 2) Peptides: - Ang II - AT1 = vscxn ; AT2 = vsdltn - Endothelin (endothelia) - ETa/b2 = high P vscxn - ETb1 = low P vsdltn - AVP aka ADH (pituitary) - vscxn - ANP (atria) - vsdltn - Bradykinin - vsdltn with NO 3) Arachadonic Acid Metabolites: - Prostacyclin (endothelia) - vsdltn - Prostaglandin E2 - vsdltn - Thromboxane A2 - vscxn via TxA2tau receptor 4) Gases: - NO - vsdltn (like 2 but with G instead of A) - Superoxide (O2-) - vscxn via many prtn oxidations Non-Vasoactive 1) Changes in Extracellular Fluid (ECF) - ECF = plasma volume and interstitial fluid - ↑ PV → ↑ arterial P → ↑ filtration - regulated by Kidney via Na+ ouput/retention: - RAS regulation - AngII, aldosterone - Autonomic Nervous System - AVP - ANP

In Hypertension - 3 theories: 1) ↑ vscxn and/or ↓ vsdltn 2) all Kidney regulated: ↑ Na+ retention = ↑V = ↑BP 3) all neural: ↑symp vscxn = ↑MAP Vascular remodeling in hypertension: - VSMC with chronic ↑BP: lumen same, wall thicker

α1 → Gαq → ↑ PLC → ↑ IP3 and DAG → ↑ IP3R → ↑ [Ca2+]i = VSCXN 2 → Gαs → ↑ cAMP → ↑ PKA → ↑ MLCK-P → ↓ MLCK → ↓ MLC-P → ↓ actin/myosin binding = VSDLTN

Chapter Thirteen – Blood & Hemostasis
BLOCK 2 – CRR THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: MADHU REDDY & VANESSA SALINAS

TABLE OF CONTENTS: BLOOD I BLOOD II HEMOSTASIS I HEMOSTASIS II

FRANK KRETZER FRANK KRETZER JUN TERUYA JUN TERUYA

BLOOD I & II
Cell Type
Erytrhocyte

Size
7.5µm across, .8µm thick at center, 2.6µm thick at outer rim

Number
Male: 4 million Female: 5 million

Comments
- Biconcave anucleate cells with no organelles - Energy from hexose monophosphate shunt - Live of about 120 days, removed from circ. by spleen and liver when surface oligosaccharides are altered or cytoskeleton changes. - Polycythemia = Increased hematocrit (RBC volume) - Anemia = Pathologically low Hb - Macrocyte = RBC > 9µm in diameter, lack of B12 may cause this - Microcyte = RBC < 6µm in diameter, iron deficiency may cause it - Hypochromatic anemia – not enough hemoglobin in red blood cells. Dis (the pale zone) gets bigger. - Heriditary Spherocytosis = Pts. have fragile, convex RBCs, caused by mutation in cytoskeletal protein. May lead to anemia. Most common mutation is in ankyrin; can sometimes also have a mutation in spectrin. - Reticulocyte = RBC w/ small amount of mRNA and ribosomes. If greater than 1% of RBC’s are reticulocytes, patient is “reticking.” - Picture shows normal RBCs and in center a nucleated RBC that can be seen in newborns. - Crenation – blebbling that comes off of blood cells; is an artifact AKA: WBC’s, consist of granulocytes and agranulocytes. Granulocytes = Neutrophils, Eosinophils, and Basophils; contain specific granules for each cell type and non specific azurophilic granules; differentiated on basis of nuclear morphology Agranulocytes = Lympocytes and Monocytes AKA: polymorphonuclear cells (PMNs), Polys, Segs. - Nucleus normally has 3 lobes, but can be more (>5 = hypersegmentation) - May show Barr bodies in females = inactivated X chromosome - Circulate in blood 6-7hrs and enter CT and live approx 1-4 days. - Anaerobic metabolism of glycogen and hexose monophosphate shunt. - Activated when they encounter IgG coated bacteria - Specific granules and azurophillic granules(lysozomes) fuse with phagosome - Specific granules give off O2- radical -when you have an infection, have a “left shift” where more band cells (precursor neutrophils – before nucleus undergoes segmentation) are seen; nucleus looks “horseshoe-shaped,” still has no mitochondria or RER (so terminal cell) - Nuclei have two, small delicate lobes connected by nuclear strand. - Specific granules have externum and internum by TEM. - Internum has major basic protein (MBP) which stains red. - Eosinophils modulate inflammation by counterbalancing basophils secretions. - Nuclei have two bulky lobes very close together. - Specific granules contain heparin (anti-clotting), histamine (increases permeability of capillaries), and eosinophil chemotactic factor. -Granules take up hemotoxylin and azure results in black appearance - Medeate inflammatory response - Perform many of same functions as mast cells

Leukocyte

6,000-10,000/µL

Neutrophil

12-15µm

60-70%

Eosinophil

12-15µm

2-4%

Basophil

12-15µm

0-1%

Lymphocyte

6-8µm

20-30%

Monocyte

20µm

3-8%

- B & T Cells - Have large spherical nucleus, sometimes w/ indentation - Small amount of basophilic cytoplasm - Only blood cells that can enter tissue and return back to blood - Has small ring of cytoplasm under light microscopy - Nucleus is oval, horseshoe, or kidney shaped. - Nucleus is eccentrically placed. - Enter tissues and become macrophages and numerous other cell types. - Largest blood cell - Anucleated disc like fragments - Removed from circulation by spleen after 10 days - Originate from polyploid megakaryocytes in bone marrow - External rim (hyalomere) of microtubules that does not stain well - Does not contain an MTOC - Middle of platelet is hyalomere which stains more heavily than hyalomere -By TEM: Lambda granules = lysomoes; Delta granules = dense bodies (ATP, ADP, and serotonin); and Alpha granules = fibrinogen, platelet recruiting factures, and platelet derived growth factor - Contain an open CANALICULAR system, which increases surface area for granule fusion (release of granule products) - Thryombocytopenia = too few platelets - Picture shows two platelets and some RBCs, note that platelets are smallest blood cell

Platelet

2-4µm

200,000-400,000/µL

RBC Cytoskeleton:

QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture.

HEMOSTASIS I
Primary HS: von Willebrand factor agglutinates plates → platelets activated → platelets aggregate • Secondary HS: coagulation factors activated → form cross-linked fibrin • Coagulation Cascade: Intrinsic Extrinsic 12 7 11 9 8 10 5 2 I II III IV V VII Fibrinogen Prothrombin Tissue F. Calcium ions Proaccelerin Proconvertin VIII IX X XI XII XIII Antihemophilic F. Christmas F. Stuart F. Plasma Thromboplastin Antecedent Hageman F. Fibrin Stabilizing F. •

• •

1 * Hemophilia A: not enough 8: * Hemophilia B: not enough 9 Activated Partial Thromboplastin Time (PTT) o Tests the intrinsic coagulation pathway o Measures clotting time of plasma, after activating factor XII and adding phospholipids and calcium o Reagents: PTT reagent, Factor XII activator, phospholipids, calcium o Method: 0.1 ml plasma & 0.1 ml reagent → incubate 3-5 mins → + 0.1 ml Ca2+ → note clotting time; Normal range: 24-35 sec o Abnormal PTT: deficiency of one or more c. factors of intrinsic pathway; inhibitors: heparin, antibodies to c. factors or phospholipids (lupus anticoagulants) Prothrombin Time (PT) o Tests the extrinsic coagulation pathway o Measures clotting time after addition of thromboplastin with calcium o Reagent: PT reagent o Method: 0.1 ml plasma & 0.2 ml PT reagent; Normal Range: 11.5-14.5 sec o Abnormal PT: warfarin therapy, vitamin K deficiency, liver disease, deficiency of factors, inhibitors: factor specific inhibitor, lupus anticoagulant PT INR o Designed to monitor patients who take warfarin as an anticoagulant o Formula: INR = (PTpatient/PTcontrol)ISI: Normal Range: 1.00 Anticoagulant (treat & prevent thrombosis): Heparin (makes complex w/ antithrombin → inhibits thrombin and F. X; monitored by PTT; neutralized by protamine), Warfarin (taken after MI/stroke, inhibits vitamin K synthesis(dependent: F. II, VII, IX, X; protein C & S); dose monitored by PT INR-2.0-3.0)

Chapter Fourteen – Respiratory histology
BLOCK 2 – CRR THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: ANGELA HEAPE AND JAN KEMNADE

TABLE OF CONTENTS: HISTOLOGY OF THE AIRWAYS MICROANATOMY OF THE ALVEOLI & VASCULATURE CILIA STRUCTURE IMMOTILE/LABILE CILIA SYNDROME

HISTOLOGY OF THE AIRWAYS
Trachea Bronchi (Regular) Bronchiole Terminal Bronchiole Respiratory Bronchiole Alveolar Ducts Alveolar Sacs Alveoli (Proper)

Simple Squamous Epithelium
protease Alveolar macrophage

nucleus

Pseudostratified Ciliated Columnar

Simple Ciliated Columnar

Simple Ciliated Cuboidal & Simple Cuboidal

Simple Squamous

Conductive: clean, warm, moisten
Pseudostratified Ciliated Columnar Epithelium (Respiratory Epithelium)

Respiratory: gaseous exchange
Simple Ciliated Cuboidal Epithelium hypophase GAGs antiprotease Clara cell hypophase

Epi: nucleus/organelles to side w/ thin cytoplasmic projection at capillary Alveolar macrophages: crawl on alveolar surface  phagocytize/digest bacteria, dump lysosomal enzymes (protease, lysozyme, trypsinogen, collagase, elastase)

Direction of mucus escalator & cilia beats Mucus globs

Carcinoma Metaplasia

Ciliated columnar cell

Goblet cell

Brush cell

Clara Cell: stem cell, secrete GAGs for hypophase (prevents desiccation), secrete oxidases (kill pollutants/bacteria) & antiproteases (neutralize macrophage secretion of proteases), starts in terminal bronchiole

Basal lamina Basal lamina

Basal lamina Intermediate cell Stem cell Small Granule cell Sensory neuron

Metaplasia: reversible plasticity from resp. epi. to nonkeratinized strat. Sq. w/ environ. Stress Smoker Changes: pollutantsneed mucusstem cell makes goblet cells (limited space, ciliated cells elim.)XS mucus falls distallymorning hacking coughdownstream too much mucusmore ciliated cells made, less claramacrophage proteases go uncheckeddigest alveolar wallemphysema

Carcinoma: no longer plastic, can’t change back and forth, lost contact inhib., take over tissue, breaks BL, metastases

1. Ciliated Columnar Cell: mucus escalater, 300 million cilia on apical surface beating proximally 2. Goblet Cell: basal nucleus, synth. RER/Golgi, mucus secretory granules (for hypophase), pale 3. Brush Cell: apical microvilli, sense air speed & control via sensory neuron at basal surface 4. Small Granule Cell: DNES, basally secretes vesicles, affects glands and smooth muscle 5. Stem Cell: can divide and replace any of the cells 6. Intermediate Cell: seen in state of differentiation to one of these cells Stains: RED – ion pumper, denatured + mitochondria bind to – eosin BLUE – protein sec., – RER / P groups from ribosome backbone / mRNA bind to + hemotoxylin PALE – mucus sec., mucus fails to take up H&E stain

MICROANATOMY OF THE ALVEOLI & VASCULATURE
Trachea Cartilage keeping airways open 16-20 C-shaped hyaline cartilage rings Bronchi Regular Bronchioles Conducting Portion (moisten, warm, clean) Histology of the Respiratory Tract Terminal Bronchioles Respiratory Bronchioles Alveoli Respiratory Portion (gas exchange)

Patches of hyaline cartilage islands to prevent collapse Right & left spiral twists in lamina Linking cartilage Smooth Muscle Dominant, continuous, circular feature in lamina propria (cxn in asthma) propria, rings posteriorly hypertrophy in chronic bronchitis Respiratory Epithelium: Pseudostratified Ciliated Columnar Epithelium (which Epithelial Type will convert to nonkeratininzed stratified squamous, metaplasia in situ then - tight junctions, Ciliated Simple Columnar Ciliated Simple Cuboidal metastasis via vasculature of lamina propria) - respiratory surfactant/mucus basal lamina elevator Ciliated columnar cells Ciliated cuboidal cells Clara cells, stem cells that secrete GAGS (bronchiolar surfactant), Goblet cells, frothy appearing mucus producers, decreasingly oxidases, antiproteases (to balance macrophages) Brush cells, sensory cells detecting airspeed Basal cells, stem cells Cells Small granule cells, part of DNES, controlling serous and mucus secretion, cxn of myoepithelial cells, smooth muscle tone; aggregate into neuroepithelial bodies in bronchi & reg b's; recruit mast cells? Intermediate cells, histologically indistinguishable cells in the process of differentiation Seromucus in lamina propria, releasing Glands proteins and mucus c via myoepithelial cell cxn, duct to lumen Fibers - keeping Increasing elastic (elastic & fibrillin) and reticular fibers (III) produced by fibroblasts as lumen decreases in size Hyaline cartilage is coll type II airways open fibroblasts will wall off infected areas with coll infiltrate MALT (also nose hairs, tonsils, BALT, lymphoid nodules present at branch points; prolif in circulating antibodies, lymphocytes, chronic bronchitis (germinal centers, cytokine action) and leukocytes) Type 2 = stem cell, “great cell”, “MVC”, “septal cell”, frothy, thick wall, makes surfactant Type 1 = alveolar pneumocyte, cytokeratin +, thick alveolar walll endothelial cells, macrophages

Simple Squamous 97% Type I, attenuated epithelial cells 3% Type II, great cell, septal cell, multivesicular cell, stem cell secreting alveolar/ pulmonary surfactant of multivesicular bodies' SPA, SPB, SPC,SPD + lamellar bodies' lipid monolayer Alveolar macrophages from interstitium, secreting lysozymes, collagenase, elastase, lactoferrin, migrating up to APC at BALT or coughed up or swallowed; digest alveoli walls when Clara cells lost to differentiation

Reticular fibers (coll III) are structural support, prevent overextension; trace elastic provide recoil

CILIA STRUCTURE & IMMOTILE AND LABILE CILIA SYNDROMES
Microtubule Singlets Structure-(see pages 44&47 of Junq) • A spiral of Alpha and beta subunits • One alpha joined to one beta=protofilament • 13 protofilaments=one turn of the spiral o each protofilament is aligned so that all alpha subunits are next to other alpha subunits and all beta subunits are next to other beta’s • positive end=end with beta subunits exposed=facing towards plasma membrane • negative end=end with alpha sub. Exposed=facing towards pericentiolar protein (made of tau protein and gamma-tubilin) “Unipolar configuration”=microtubules extend from centrosome (negative end) to periphery (positive end) Dynamics • Polymerization=rescue • Depolymerization=catastophe • Both controlled by: o GTP-GDP caps (GTP pro rescue) o Monomer binding proteins o Positive end cap proteins • Interrupted by drugs: o Taxol-stablizes singlets so no new monomer available in cytosol o Vinblastin-binds monomer into paracristalline complexes FACT-microtubule most labile component of cytoskeleton FACT-microtubules link to intermediate filaments via MAPS FACT-microtubules affect: o Cell shape o Placement of organelles o Directed vesicle migration o Chromosome alignment and movement Motor Proteins-power stroke occurs upon release of ADP o Dynein (nein means “no” in german which is synonomous with negative) o Movement towards negative end o Proximal o Similar in Aa makeup to myosin o Kinesin

o Movement towards positive end o Distal o No similarities with any protein Microtubules and Nerve axon o Axons have a series of microtubules all facing with positive end towards synaptic terminal o Only the first microtubule comes from the centrosome, the rest have no known MTOC o FACT-these microtubules have a 100 day dynamic instability o Fast anterograde axonal transport due to kinesin (400mm/day) o Fast retrograde axonal transport due to dynein (300mm/day) o Slow anterograde axonal transport o Due to actin microfilaments o Actin gets cleaved near soma by gelsolin which then carries these actin molecules (and other enzymes) towards terminal end of axon where they elongate the microfilament (1mm/day) o Responsible for axon regeneration and growth FACT : It is the cytoplasm with has solidity and the plasma membrane which is fluid! Microtubules and Nerve Dendrites o Parallel Microtubules in antiparallel polarity o No known MTOC Centrioles of the Centrosome o o o o o One centrosome during interphase Two centrioles at ninety degree angle make on e centrosome Surrounded by pericentiolar protein During S phase each centriole replicates Structure of Centriole o Nine peripheral triplets called A,B, and C o NO internal amorphous protein in central area (as opposed to basal bodies)

Ultrastructure of Axoneme o Made up of 9+2 microtubules-with positive end distally o 9 peripheral microtubule doublets made of an A and a B subfiber  A subfiber=complete microtubule with 13 protofilaments  B subfiber=shares 3 protofilaments with the A fiber  Tektin lines this wall and controls the doublet length (similar to nebulin in muscle)  Each A subfiber has 2 inner and 3 outer dynein arms

These arms are used to beat cilia (see Ciliary Motion below)  Each doublet connected to the next via nexin (similar to titin in muscle) o 2 inner microtubule singlets-C1&C2  linked to each other via bridge (without bridge cilia are immotile)  inner sheath surrounds the two singlets  C1 marked with three tubular projections o Each A subfiber connected to inner sheath via a radial spoke and spokeheads  Control how many arms of dynein attach to B subfiber and therefore control cilia beat  Compared to tropomyosin, calmodulin, Troponin T, troponin C, and troponin I o Since all of these proteins (dynein, nexin, radial spokes and inner sheath are uniquely spaced at different intervals, their relation to each other determines their specific binding o 173 motor proteins control bending o 131 stability proteins control stability Ciliary Motion  Consists of: o Power stroke (bend) towards 1 and 9 doublets o Recovery stroke towars 5 and 6 doublets  Cilia always bend perpendicular to plane on central singlet bridge protein  The way it works o In the presence of ATP, the dynein arms of the A subfiber of one doublet interact with the tubulin of the B subfiber of the adjacent doublet. o Once ATP is cleaved to ADP+Pi (with both ADP and Pi still attached to Dynein) Dynein binds to the B subfiber at 90 degrees o Then Pi and soon after ADP is released causing the power stroke towards a 45 degree angle o then ATP binds again, is hydrolyzed to ADP+Pi which causes dynein to go back towards 90 degrees and the cycle starts over again  As this occurs, one doublet is trying to slide upward past another. However, this is impossible since the doublets are connected to each other via nexin and to the inner sheath via radial spokes  As a result bending of the entire cilia occurs towards the side where the tension between doublets originated (1 and 9 side for bend)  This translates to cilia beating in propagated waves o IN RESPERITORY TREE, CILIA BEAT MUCOUS ALONG THE DISTAL TO THE PROXIMAL ESCALATOR  BIG QUESTION: Why are there no cilia in the alveoli extending from the apical surfaces of Type I and Type II alveolar cells? o Because the separation between the alveolar cells and the capillaries must be kept as thin as possible to allow for maximum gas exchange. •

Axoneme singlet

Basal Bodies o Lie underneath cilia and form support structure o Have 9 peripheral triplet microtubules with a core of amorphous protein (gamma tubulin and tau protein) o Basal bodies are created by replication of centrioles during ciligenesis o Each basal body gives rise to 1 cilia o The A and B subfiber of the triplet give rise the A and B subfiber of the doublet, respectively (C stops at transition zone (see below)) o The central amorphous protein gives rise to the 2 central sinlgets o RULE (in eukaryotes): Amorphous protein gives rise to singlets; Triplets give rise to doublets o FACT: Basal bodies do not give rise to cytoplasmic microtubules sine they lack pericentriolar protein

AB axoneme doublet ABC basal body triplet
Amorphous protein

Transition zone CBA ABC

Immotile Cilia Syndrome o Due to: o Mutation in motor protein  Causes inability to bend or recovery bend  Called immotile cilia syndrome o Mutation in stability protein  Causes cilia to fall apart with time • Very bad if this happens in postmitotic cell • Called labile cilia syndrome • Control affected by way more than GTP-GDP caps, monomer binding protein, and positive end protein caps o Approx. 200 to 300 cilia per cell o Places cilia are found and their associated clinical condition if faulty: o Nasal mucosa and respiratory epithelium-massive respiratory infections o Ependymal cells-low grade headaches o Oviduct-extopic pregnancy, inability of oviduct to capture egg o Ductili efferentes of testicles-low grade testicular ache (feels similar to blue balls), inability of sperm to get to epididymis: infertility o Sperm tail-immotile sperm, infertility o Middle ear-frequent otitis media

Quick Reference Tektin=nebulin Nexin=titin Radial spoke and spokeheads= tropomyosin, calmodulin, Troponin T, troponin C, and troponin I Dynein= “-“ Kinesin=”+” Axoneme=9doublets+2singlets Basal body=9triplets+amorphous protein

• • • • • • •

Chapter Fifteen – Respiratory Physiology
BLOCK 2 – CRR THREAD: PHYSIOLOGY
CONTRIBUTORS: MICHELLE PHILLIPS, RAJ CHINNAPAN, ALAP JANI, REN WEIDMAN, CAMILLE MCCORMICK, & MATT COPE

TABLE OF CONTENTS RESPIRATORY EQUATIONS INTRO & MECHANICS OF RESPIRATION MECHANICS OF RESPIRATION AND DETERMINANTS OF MOVING CAPACITY TRANSPORT OF O2 AND CO2 IN THE BLOOD GAS EXCHANGE IN THE LUNGS INTRO TO ACID-BASE PHYSIOLOGY ACID/BASE MAINTENANCE OF NORMAL PH – RENAL & RESPIRATORY RESPONSES VENTILATION & PERFUSION I VENTILATION & PERFUSION II MATCHING VENTILATION & PERFUSION CONTROL OF VENTILATION CLINICAL PULMONARY PROCEDURES

RESPIRATORY EQUATIONS Be familiar with equation, abbreviations, and underlying concept
Equations Tidal Volume VT = VA + VD Fick’s Law of Diffusion Vgas = (A x D x ∆P) / T [Normal Values] [VT = 500 mL]
Air moved with normal respiration = alveolar volume + ‘dead space’ volume.

solubility /

Volume of gas diffused across blood-gas barrier = (area * diffusion coefficient (α sq. root of mw) * partial-pressure difference) / thickness.

Dalton’s Law of Partial Pressures PB = PX + PY + PZ Total pressure (e.g. Barometric) of a mix of gases = sum of partial pressure of
each gas.

PZ = PB x FZ PZ = (PB –PH20) x FZ
alv = (total

Thus, the partial pressure of any gas = total pressure * fraction (%) of total. Effect of water vapor pressure on inspired gases: partial pressure of any gas at pressure – H20 vapor pressure) * gas fraction (%) of total.

Transmural vs. Transpulmonary Pressure PTM = PAW – PIP The force responsible for distending an airway; the radial pressure difference
across the fishnet tethering of airways. wall at any point along the tracheobronchial tree. Recall

conditions, with to PIP.

PTP = PA – PIP

A special case of transmural pressure, across the alveolar wall. At static glottis open and no air movement, PTP is equal and opposite

Compliance C = ∆V / ∆P
change in compliant (steep compliance slope).

[0.2 L/mmHg]
Compliance is determined by the relationship of the change in volume and the pressure; if a small ∆P gives a large ∆V, you’re highly Emphysema↑; fibrosis↓. Stiffness = 1/C. lungs inward after inhalation).

↓compliance, ↑elastic recoil (force bringing Note: airways are more compliant at lower volumes.

alveolar

Airway Resistance RAW = (PB – PA) / V* V* = (PB – PA) / RAW
52% ↑R.

[R = 1.5 cm H2O]
Ventilation α driving pressure (the difference between barometric pressure and pressure) and inv. α airway resistance. Note effect of radius: R α 1/r ; 10% ↓r,
4

oxygen CO2)

Alveolar Gas Equation [PAO2 = 100 mm Hg] [PaCO2 = 35-40 mm Hg] [FO2 = .21] [R = .8] PA02 = (PB– PH20)(F02) – PaC02 / R Available O2 at alveolar level = (total air pressure less water vapor pressure) * PA02 = 150 – PaC02 / 0.8
fraction – arterial pressure of CO2 given by ABG (equal to alveolar pressure of / respiratory quotient.

Respiratory Quotient R = VC02 / V02 Minute Ventilation V*E = VT x f Alveolar Ventilation V*A = (VT – VD) x f
improving VA. space; all = (exhaled CO2* correction

[R = .8] [200 CO2 exhaled / 250 O2 inhaled]
Amount of carbon dioxide produced per oxygen consumed; related to diet.

[V*E = 7.5 L/min]
Expired ventilation = tidal volume * frequency of respiration.

[V*A = 5.25 L/min] [VECO2 = 0.2 L/min] [PaCO2 = 35-40 mm Hg]
Alveolar ventilation = (tidal volume less dead space) * frequency of respiration. This equation illustrates the advantage of hyperpnea over tachypnea in An easy way to measure alveolar ventilation and detect physiological dead exhaled CO2 comes from alveolar gas. Alveolar ventilation factor for measuring outside of the warmer, wetter

V*A = (VECO2 x 0.863) / PaCO2

lungs) / arterial CO2 from ABG. This is inversely proportional to CO2 ventilation.

equation shows that alveolar ventilation

Dead Space Ventilation [anatomic VD = 150 mL] [VD / VE = .3, or ≈ (200 – 250) / 200 mL] VD / VE = (PACO2 – PECO2) / PACO2 Dead space volume / exhaled volume = (alveolar CO2– exhaled CO2) / alveolar
CO2. anatomic VD admixture. Recall that arterial CO2 is used to measure alveolar CO2. Physiological VD = + alveolar VD due to normal physiological shunting/venous

A-a difference or gradient PA02 – Pa02
between create an A-a mismatches widen this.

[A-a = 5-15 (14) mmHg] [PAO2 = 100 mm Hg]
Calculate PAO2 by Alveolar Gas Equation; get PaO2 from ABG. The difference mean systemic arterial O2 and alveolar O2; normal physiological shunts difference of 5-15 mmHg. Ventilation/perfusion (V*/Q*)

Note: V* is ventilation, or volume of air moved in a unit of time, or ‘airflow’; V* = V / t, or V* = V * f, in all of the above equations. It’s the V with the dot on top in the text.

Acid-Base Anion Gap AG = Na+ - (Cl- + HCO3-) Resp Comp for Met Ac/Alk PCO2 = 1.5 * [HCO3-] + 8, +/-2

[AG = 12, +/- 4] [PCO2 ∆ 12 – 55 mmHg] [HCO3- 22-26 (24) mM]

Met Comp for Resp Ac/Alk [pH = 7.35 – 7.45 (7.40)] [PCO2 = 40 mmHg] Acute, < 24 hrs: ∆ PCO210 mmHg = ∆ pH .08 Chronic, > 24 hrs: ∆ PCO210 mmHg = ∆ pH .03 pH α [HCO3-] / [CO2]
Resp Ac Primary defect Clinical causes ↑ PCO2, ↓ pH, ↑ [HCO3 ] ↓ CO2 clearance; ↓ V* Emphysema/COPD; drug overdose, apnea, asphyxia, V*/Q* mismatch
-

Resp Alk ↓ PCO2, ↑ pH, ↓ [HCO3 ] ↑ CO2 clearance; ↑ V* Hypoxia, panting, aspirin, sepsis, pulm edema, PE
-

Met Alk ↑ [HCO3 ] Addn of alk; loss of acid NG suction, vomiting, hypovolemia (diuretics), + steroids, Cl / K depletion
-

Met Ac ↓ [HCO3 ] + Failure to secrete H ; addn of acid; loss of alk Non-AG Met Ac/hyperchloremic, hypokalemic (diarrhea, PRT acidosis), hyper/normokalemic (renal tubule acidosis, acid ingestion) AG Met Ac: AMUDPILES*
-

Working through acid-base problems Normal values to know: pH = 7.35 – 7.45 (7.40) PCO2 = 40 mmHg PO2 = 100 mmHg [HCO3-] = 22-26 (24) mM AG = 12, +/- 4 Blood glucose = 110 mg/dL Plasma creatinine = 1 mg/dL Questions to ask: Acidemic or alkalotic? Primary disorder? Met Ac – AG or non-AG? Met Ac - simple AG Ac? Mixed disorder? ∆ pH ∆ PCO2, [HCO3-] ∆ AG ∆ AG = ∆ [HCO3-] Normal pH; ∆ PCO2, [HCO3-] in opposite directions; ∆ pH in wrong direction for primary disorder ∆AG >> ∆[HCO3-], high AG ac + primary met alk ∆AG << ∆[HCO3-], AG ac + non-AG ac, or AG ac + chronic resp alk, e.g. pulm edema in CHF Resp for Met, PCO2 = 1.5 * [HCO3-] + 8, +/-2 Met for Resp, Acute, < 24 hrs: ∆ PCO210 mmHg = ∆ pH .08 Met for Resp, Chronic, > 24 hrs: ∆ PCO210 mmHg = ∆ pH .03 ∆ V*, V*/Q* mismatch, acid or alkali loss or load, diabetes, AMUDPILES*

Compensation? Hx - clinical problems/clues? kidney failure,

*AMUDPILES: Aspirin, uremia (renal failure), DKA (diabetic ketoacidosis), paraldehyde, ischemia/infarct, lactic acidosis, ethanol/ethylene glycol, starvation/sepsis.

Determined Decrease below 0.8 indicates perfuse

Ventilation/Perfusion V*/Q* = FEV1 / FVC

[V*/Q* = .8, or 4L/min VA / 5L/min CO] [FEV1 / FVC = .8]
Varies regionally (higher at apex as Q increases faster than V towards base). via imaging (Xe for V*, radiolabeling for Q*) or spirometry. severity of obstructive disorder. Alveolar dead space = ↓Q*, or ↑V*/Q*; remember that dead space = you don’t Shunt = ↓V*, or ↓V*/Q*; remember that shunt = choking (inhaled nut)

HISTOLOGY OF THE URINARY SYSTEM
Trace sequentially the renal vasculature from renal artery to renal vein. State the exact capillary type for each of the unique capillary beds. Renal artery off aorta anterior and posterior renal artery interlobar arteries between lobes/pyramids arcuate arteries at the corticomedullary interface interlobular arteries between lobules at the dense c.t. capsule as stellate vasculature afferent arterioles 2-5 capillary tufts of glomerulus (continuous fenestrated s diaphragms for filtration) efferent arterioles peritubular capillary network (fenestrated c diaphragms for nourishment). From the efferent arterioles or arcuate arteries and returning to the arcuate veins are the vasa recta (descending v.r., continuous non-fenestrated.; ascending v.r., continuous fenestrated c diaphragms for water resorption) The stellate vasculature, peritubular capillary network, and ascending vasa recta give off veins that retrace the course of the arteries and return via the renal vein out through the hilum to the IVC. Trace sequentially the epithelial tubules and ducts from Bowman’s capsule to the large collecting ducts of Bellini at the area cribrosa. Classify the epithelium and draw the ultrastructure of each. Bowman’s capsule (visceral layer, podocytes over glom capillaries; parietal layer, simple squamous) PCT & proximal straight / th.d.LOH, simple cuboidal/low columnar t.d. & t.a. LOH, simple squamous distal straight / th.a.LOH & DCT simple cuboidal collecting tubules & cortical collecting duct, simple cuboidal medullary collecting duct & medullary collecting duct of Bellini, simple cuboidal /low columnar. List the seven physical filtration structures operant across the glomerular capillaries into the urinary space (Bowman’s space). Capillary endothelium fenestrae s diaphragms Basal lamina lamina rara interna, with fibronectin Basal lamina lamina densa, with coll type IV, laminin, (-) charged heparin sulfate Basal lamina lamina rara externa, with fibronectin Podocytes’ pedicels’ 25 nm filtration slits Filtration slit protein diaphragms Podicels’ (-) charged podocalyxin List the tubules and ducts that create the gross image of medullary rays extending from the base of the medullary pyramids into the cortex. Proximal straight / th.d.LOH t.d. and t.a.LOH, distal straight / th.a.LOH, cortical collecting duct. (Entire LOH + cortical collecting duct.) Precisely define and differentiate these terms: glomerulus vs. corpuscle, visceral layer of Bowman’s capsule vs. parietal layer of Bowman’s capsule; nephron vs. uriniferous system. Corpuscle includes glomerulus plus Bowman’s capsule. The visceral layer of Bowman’s capsule is made of podocytes and mesangial cells; the parietal layer is a simple squamous epithelium continuous with the cuboidal/low columnar epithelium of the PCT. Some argue that a nephron ends with the DCT, not including the collecting tubules; all nephrons emptying into a given cortical collecting duct form a uriniferous system. List the sites where urothelium (transitional) epithelium is found. What is so unique about urothelium? Minor calyx – major calyx – renal pelvis – ureter – urinary bladder – prostratic urethra in males. Urothelium, a.k.a. transitional epithelium (not to be confused with metaplasia in situ), features:

Reversible desmosomes let cells tumble (but hemi-desmosomes anchor each to basal lamina) Protein plaque plates that form an osmotic barrier against urine in the full bladder and are vesiculate when bladder is empty Occasional multinucleate / polyploid cells! Note: the distal portions of the urethra are [m: pseudostratified columnar for prostatic, membranous, and some penile urethra] non-keratinizing stratified squamous epithelium. Know the differences in the lengths of the thin loops of Henle in cortical vs. juxtamedullary nephrons. Juxtamedullary nephrons (1/7 total) have very long tLOH, creating the hypertonic medullary gradient. List four functions of mesangial cells. Argue that they are vimentin positive macrophages of monocyte origin. Then argue that they are desmin positive highly differentiated pericytes. Contractility in response to ANG II & relaxation in response to ANP, to change flow rate and capillary surface area and thereby change GFR and blood pressure. Structural support of glomerulus, via ECM secretion Phagocytosis Sampling of lumen solute content, especially glucose Contractile cells ought to be desmin positive, as are all contractile cells of mesenchymal origin. Phagocytic cells ought to be vimentin positive, as are all cells of monocyte origin. Mesangial cells are both! They have desmin and vimentin intermediate filaments. List the three cells that comprise the juxtaglomerular apparatus. What is the function of each? DCT macula densa cells sense solute content of tubular fluid and react within seconds to autoregulate GFR at the level of the individual nephron. Their cumulative action powerfully affects blood pressure. Lacis cells ? Juxtaglomerular (JG) cells, modified smc’s in tunica media of afferent arteriole contain secretory granules full of renin for merocrine, regulated secretion; renin activates angiotensinogen to ANG I; subsequently ACE activates ANG I to ANG II. Explain why there is higher resolution in epoxy resin infiltrated tissue stained with toluidine blue as compared to paraffin infiltrated tissue stained with hematoxylin and eosin. Epoxy resin fixates the tissues better because there is less shrinkage, deformity, and dehydration. It is possible to get thinner (1 µm) sections, and even thinner sections for use in TEM. Paraffin infiltrated tissue is more susceptible to deformation and gives thicker sections (8-10 µm), which doesn’t allow the dyes to penetrate the tissues as well. Paraffin sections are not usable for TEM. Compare & Contrast the two systems in the human body which involve the fusion of common basement membranes from two cell types: the thin interalveolar septum as the air-blood barrier in the alveoli, vs. the glomerulus filtration apparatus in the renal corpuscle. We see these are cell fusion products with different purposes: the alveolus is optimized for gas exchange, and the glomerulus is optimized for physical filtration of the blood plasma. To that end we see marked attenuation of the basement membrane in the alveoli, to absolutely reduce the thickness of the diffusion membrane and increase flow per Fick’s equation. We see specialized use of the basement membrane in the glomeruli, with fibronectin in the lamina rara interna and externa, as well as laminin in the lamina densa, acting as physical filtration meshworks, along with negatively charged heparin sulfate in the lamina densa acting as a barrier to cation loss. Write: which of the following three systems best captures the biologic interpretation of “the more the less”: blood vessel structure, the respiratory tree, or the renal capillary/tubule/duct system?

INTRODUCTION AND MECHANICS OF RESPIRATION
Fick’s Law of Diffusion: V of gas diffused = A/T x D x (P1 – P2) A = area, T = thickness, D = diffusion coefficient (specific for each gas), P1 – P2 = partial pressure difference across membrane Dalton’s Law: total pressure of a mixture of gases = sum of individual partial pressures (Partial Pressure of a Gas = Fraction of that Gas in Air x Total Pressure) Alveoli (polyhedral) – Atmospheric Pressure = 760 mm Hg type I (gas exchange, 90%) Water vapor pressure = 47 mm Hg type II (produces surfactant, 10%) Intrapleural Pressure = 5 cm H2O Stabilized by surfactant Trachea --> Terminal bronchioles = Anatomic Dead Space; No Alveol – 150 mL. Air flows inward through conducting airways by bulk flow. Protection: Removal of inhaled particles – • upper airways (nasal hair) • conducting airways (mucous/cilia) • alveoli (macrophages, cytokines) Inspiration: • Active process • Prim. Muscle - Diaphragm (C3-C5) • Forced inspiration requires secondary muscles – scalenes, sternocleidomastoids, neck / back, upper airway Expiration: • No primary muscles • Active expiration from exercise or voluntary hyperventilation from disease requires abdominal muscles and internal intercostals muscles RV not measured by spirometry.(nor are FRC & TLC.
To measure RV: Volume of Distribution Approach: Helium Dilution & Nitrogen Washout Plethysmography: Subject in airtight box has pressure and volume changes measur PTP = PA – Ppl (or PIP) – across alveolar wall (PA = alveolar pressure) PTM = Paw – Ppl (or PIP) – across airway (Paw = airway pressure)

MECHANICS OF RESPIRATION AND DETERMINANTS OF AIR MOVING CAPACITY

Transmural Pressure distends the airways (PTM = PAW – PIP). Transpulmonary Pressure drives movement of air / det. lung vol. PTP = PA – PIP Pneumothorax (PTP = PA) • Can decrease PIP (suction tube) • Can increase PA (mech. vent.) Compliance = ∆V / ∆PTP High compliance low recoil Low compliance high recoil (0.2 / cm H2O) = normal compliance. Increased Compliance: • Emphysema • Aging Decreased compliance: • Pulmonary Fibrosis • Pulmonary Edema • Inc. Pulm. Venuous Pressure • Acute Resp. Distress Syndrome

Laplace’s Law P = (2T / r) = 2 x surface tension / radius Hysterexis – a greater pressure is required to open a closed airways than to keep an open airway (surface tension); not present in a saline solution. Loss of surfactant: Surfactant produced by type II pneumocytes: • stiff lungs (loss of compliance) • 90% lipid / 10% apoproteins • areas of atelectasis (collapse due to loss of stability) • Smaller alveolar have greater reduction of surface area. • “wet” (alveoli filled with fluid Airflow = (PA – PB) / R Laminar flow – small airways Transitional flow - branching airways Turbulent flow - trachea PA is + and glottis open air flows out PA is (-) air flows in PA is 0 NO AIR is moving A – Change in Lung Volume B – Pressure C – Alveolar Pressure D – Flow Transmural pressure can cause airway to dilate (inspiration) or collapse (expiration) • Cartilage and “tethering” tend to oppose this tendency Expiration usually passive, but flow is effort dependent at higher volume

Graphs to Left:

TRANSPORT OF O2 AND CO2 IN THE BLOOD

O2 Transport in the Blood
• O2 dissolved = solubility constant O2 x PO2 o 0.3 ml O2 / 100 ml blood o minor role in O2 transport → would not get enough O2 for consumption Hemoglobin (Hb) o 96% of O2 delivered to tissues by hemoglobin o Tetramer with 4 binding sites (2α subunits, 2β subunits [fetal Hb has 2γ subunits instead], with Fe2+ NOT Fe3+) o O2 pulls down the Fe2+ and histidine group attached → goes from tensed state to the relaxed state (cooperativity– all four subunits snap into relaxed state and have a higher (150x) affinity for O2 – this is also the cause of the sigmoidal shape of the binding curve) o O2 carrying capacity = 20 ml O2 / 100 ml blood = 1.34ml O2/gHb x 15gHb/100ml *Note: need to have more than 10 g Hb / 100 ml blood o Saturation measured by pulse oximeter (note: CO bound same as O2 bound)

Altered Hemoglobin Affinity for O2 o Terms: P50 = PO2 at which ½ of Hb is saturated (normal = 27)

o o

o o

Shift to the left = increased O2 affinity, lower P50 → holds on to O2 Shift to the right = decreased O2 affinity, higher P50 → releases O2 ↑PCO2 – shift to the right ↓pH – shift to the right Note: the effects of CO2 and pH allow for delivery of O2 to the tissues *Bohr Effect* ↑temp. – shift to the right ↑2,3 DPG (chronic hypoxia, anemia, altitude) – shift to the right

CO2 Transport in the Blood
• •

In plasma (11%) o 6% dissolved o 5% bicarbonate ions (HCO3-) In RBC (89%) o Hb acts as a buffer binding to H+ and needing to release O2, so ↑Hb means ↑CO2 capacity Note: thus if there is no O2 on Hb (low PO2), the RBC is able to pick up much more CO2 and vice versa (high O2 = low CO2 capacity) *Haldane Effect* o 4% dissolved o 21% carbamino proteins (Hb – NH – COO-) o 64% HCO3 – Carbonic Anhydrase (CA) accelerates CO2 → HCO3- + H+ HCO3 then leaves through Cl-HCO3 exchanger leading to a Cl shift into the RBC

GAS EXCHANGE IN THE LUNGS
DIFFUSION • NOT bulk flow (gas from trachea to alveoli by pressure difference/driving P = PB – PA) • • Gas transfer across the alveolar-capillary membrane DETERMINED BY 5 PROPERTIES o Molecular weight o Solubility o Area of membrane o Thickness of membrane o Proportionality Constant – describes interaction between membrane & gas FICK’S LAW o Vgas = As x D x ∆P T *NOTE: the V should have a dot above it

D (Diffusion Coefficient) = Solubility / square root of the molecular weight Thus CO2 diffuses 20x greater than O2 • • There are temporal and spatial variations (think ventilation and perfusion) Diffusion Limited o Example: CO o Due to Hb affinity – the blood acts as a sinkhole, so there is always a driving pressure (∆P between Alveoli and capillary), and it never reaches equilibrium – i.e. there is always a capacity for more CO o Doesn’t depend on speed of blood o Just waits on CO to diffuse across – thus it is diffusion limited Perfusion Limited o Example: N2O o Not bound to Hb, thus after going through 10% of capillary, equilibrium is met and there is no more driving pressure o Only way to get more N2O is to get new blood o Thus the amount of exchange depends on the speed of the blood flow (more diffusion with higher blood flow o Note: CO2 and O2 are normally perfusion limited O2 and CO2 vary depending on the diffusing capacity (DL) and the blood flow (Q), but are normally only diffusion limited in diseased states – extreme cases DLCO o o o Use CO to measure the diffusing capacity (DLCO) because it’s only limited by diffusion, venous CO = 0, and Hb has a 210 times greater affinity for CO than O2 This looks at the membrane and general diffusion properties Increased DLCO is caused by:

• •

o

• Body size (↑ A, ↑ VC) • Male • Exercise (↑Q & A, VC) • ↑PACO Decreased DLCO is caused by: • Age (lose 2% each year after age 20) • ↓PACO • Diseased states: • Pulmonary fibrosis (↑thickness of wall) • COPD (↓ in capillary area) • Anemia (↓ Hb) Uptake – diffuses and binds to Hb, but low affinity Usually perfusion limited Increases with increased cardiac output Equilibrates (normally) in 1/3 of the passage A – a gradient is normally approx. 14 mmHg (Alveolar O2 – arterial O2) Varies with exercise and disease states – see CO2 Differences with CO Hb is preloaded with O2 (venous blood has 75% sat.) Hb has a reduced affinity to O2 PAO2 (Alveolar O2 pressure) is greater Equilibrates before end of capillary (perfusion limited) Differences ∆P is less for CO2 (only 6 mmHg) Diffuses faster than O2 (2-3x) Greater carrying capacity CO2 is more likely to become diffusion limited than O2 in diseased/problem states. This will occur when DL is low and Q is high because decreased diffusion and increased blood flow means that is more likely that the blood won’t be equilibrated by the end of the capillary – thus it would be diffusion limited. Examples: Exercise • Takes longer to equilibrate • ↑ CO2 causes it to take even longer • In diseased states with poor diffusion – there is no equilibration High Altitude • O2 on tops out at 60 mmHg, venous return at 20 mmHg • Can cause problems when exercising because the increased CO2/decreased O2 means that the lungs can’t meet the requirement and the blood doesn’t equilibrate

O2 o

o

CO2 o

o

o

ACID-BASE
Alkalosis (pH > 7.40)

pH?

Acidosis (pH < 7.35)

Respiratory/Metabolic? Respiratory/Metabolic?
Abnormal pCO2 levels = respiratory alkalosis. Abnormal HCO3 levels = metabolic alkalosis. [HCO3] < 22 [HCO3] > 26 Abnormal pCO2 levels = respiratory acidosis. Abnormal HCO3 levels = metabolic acidosis.

pCO2 > 40 mmHg

Metabolic Alkalosis
-Causes: Vomiting, diuretics, volume depletion, steroid abnormalities. NG suction. -Compensatory Changes: decreased ventilation to increase blood CO2 levels. pCO2 < 35 mmHg

Metabolic Acidosis
-Main causes of metabolic acidosis in general are diarrhea, DKA, renal failure, and lactic acidosis (from shock).

Respiratory Acidosis
-Causes: Any pulmonary disease that would decrease CO2 clearance, CNS depression, neuromuscular disease. -Compensatory Changes: same as in respiratory alkalosis, except renal response in the case of acidosis is to increase [HCO3].

Anion Gap?
-AG = [Na] – ([Cl] + [HCO3]) Normal AG range is 12 +/- 4 (8-16)

Respiratory Alkalosis
-Causes: Hypoxia, pulmonary edema, pulmonary embolism, CNS problems, drugs, liver failure, early sepsis. -Compensatory Changes: (Most well compensated condition) Acute (<24 hrs) – No renal compensation. So for every 10 mmHg change in pCO2, expect a 0.08 change in pH. Chronic (>24 hrs) – Renal response is to decrease [HCO3]. For every 10 mmHg change in pCO2, expect a 0.03 change in pH.

-Compensatory Changes: increased ventilation to lower blood CO2 levels. Adequate compensation can be determined by the equation: pCO2 = 1.5([HCO3]) + 8 (+/-2)

AG not between 8 and 16 AG between 8 and 16

AG Metabolic Acidosis
-Check ∆AG = (AG – 12). If ∆AG ≠ ∆[HCO3] (apx.), good indication of a complex acid-base problem. ∆ [HCO3] = 24 - [HCO3].

Other Things to Remember:
-Lungs compensate immediately. Kidneys take 12-24 hrs before their compensatory effect is noticed. -Hyperkalemia causes acidosis. Conversely, acidosis causes hyperkalemia. -CO2 + H2O ↔ H2CO3 ↔ HCO3- + H+ -Carbonic anhydrase is the enzyme that catalyzes the reaction regulating blood pH (above equation). -pH = pKa + log([HCO3]/[CO2]) where pKa is 6.1 for this equation. -However, pH is ultimately dependant on the ratio HCO3/CO2 Normal Values: pH = 7.40 (7.35–7.40) pCO2 = 40 mmHg (35-40) HCO3 = 24 (22-26) AG = 12 (8-16)

Non-AG Metabolic Acidosis
-Also called Hyperchloremic Acidosis -Causes: If potassium levels are low (hypokalemia): diarrhea, ileal loop, proximal RTA. If potassium levels are high (hyperkalemia): HCl ingestion, type IV RTA.

-Causes: AMUDPILES Aspirin Methanol Uremia DKA Paraldehyde Ischemia/infarct Lactic acidosis Ethanol Sepsis/starvation

Mixed Disorder Indications: -Normal pH, except other values are off (often indicative of chronic respiratory alkalosis). -pCO2 and [HCO3] deviate in opposite directions. -pH change is in opposite direction than expected for a known disorder. -When ∆AG ≠ ∆[HCO3] If ∆AG >> ∆[HCO3], you have a mixed high AG acidosis and a primary metabolic alkalosis If ∆AG << ∆[HCO3], there are two possibilities. -mixed high AG acidosis and chronic respiratory alkalosis -mixed AG acidosis and non-AG acidosis

VENTILATION AND PERFUSION I
Parameters that determine minute ventilation VE = VT x f where VE = expired minute ventilation, VT = tidal volume, & f = frequency of respiration Normally in the range of 7500ml (500 x 15) • • Anatomic dead space occurs in the conducting airways through which air moves, but no exchange occurs Physiologic (“functional”) dead space is anatomic dead space + alveolar dead space (occurs in variety of disease states where alveolar tissue does not function well—gas exchange is reduced or absent) o Normal, healthy individuals: physiologic dead space = anatomic dead space (~150ml or 0.3 VT) Wasted ventilation is ventilation in areas that are not well perfused or receive no perfusion at all (occurs in all dead space) Alveolar ventilation is actual amount of air that is ventilated in a minute: VA = (VT - VD) x f o normal ~ (500-150) x 15 = 5250 ml/min (5.25 L/min) to (500-150) x 12 = 4200 ml/min (4.2 L/min) Partial pressure is the measured pressure of a gas in the air o Dalton’s Law: the sum of all the partial pressures of each gas present will equal the barometric pressure (Pb = Px + Py + Pz…etc.) o Partial pressure will vary with barometric pressure (eg. changes in altitude) Fractional concentration is the percentage of a gas present in the air – it is not affected by barometric pressure

• • •

Alveolar ventilation and the arterial blood gases PCO2 and PO2 • Alveolar O2 and CO2 vary in a reciprocal fashion (Dalton’s law) because partial pressures of N2 and H2O are constant • In steady state the production of CO2 (VCO2) is relatively constant @ 200ml/min and is expired, maintaining PA(alveolar)CO2 (~PaCO2) at 40 mmHg • There is a very strong correlation of VA and PACO2 (measured in ABG as PaCO2) : o VA = (VECO2 x 0.863)/PaCO2 VA = (200ml/min x 0.863)/40= 4.315 L/min o Rearranging this equation, we can calculate PACO2 (PaCO2): PaCO2=0.863 x VCO2 / VA o If VCO2 is constant (200 ml/min), then PACO2 (~PaCO2) is inversely proportional to alveolar ventilation: Double ventilation reduce PACO2 by ½ Reducing ventilation increases PACO2 • O2 exchange less sensitive to VA – affected in that as VA increases, PACO2 decreases, hence the partial pressure of O2 must increase • Hypoventilation: increased alveolar CO2 (decreased O2) • Hyperventilation: decreased alveolar CO2 (increased O2) o Note: what we typically think of “hyperventilation” is really panting or moving air up and down through dead space – no actual ventilation takes place • Hypercapnea: increased arterial CO2 (based on blood gases) • Hypocapnea: decreased arterial CO2 Hypernea: increased depth of breathing • • Tachypnea: increased rate of breathing

VENTILATION AND PERFUSION II
Pulmonary Circulation
Low pressure Net driving pressure (∆P between pul artery &left atrium) = 7 mmHg Highly compliant (gets entire cardiac output) Thin wall w/ little smooth muscle Hypoxia (low O2), hypercarbia (low pCO2), and acidosis (low pH) cause vasoCONSTRICTION in pulmonary circulation (trying to redistribute blood to areas of the lung that are functional Autonomic nervous system (sympathetic and parasympathetic) innervation plays MINOR role in vascular tone Hormones also play MINIMAL role in pulmonary vascular system

Systemic Circulation
High pressure Net driving pressure (∆P between aorta &right atrium) = 93 mmHg Hypoxia, hypercarbia, and acidosis cause vasoDILATION in systemic circulation (trying to get more blood to the tissue)

Influences on the pulmonary vascular bed LA pressure Cardiac Output Changes in lung volume Body position Alveolar pressure

Neurogenic stimuli (active) Humoral/chemical (active) Alveolar hypoxemia & hypercapnea (active)

Resistance decreases as cardiac output increases via recruitment & distention w/o PVR change: Recruitment – opening of previously closed vessels and flow through previously open but unperfused vessels Distension – increase in caliber of vessels Benefits of recruitment and distention – reduces capillary pressure: minimize right ventricle load maintain transit time (increases in minimize pulmonary edema transit time decreases in increase capillary surface area diffusion) Notes on recruitment and distention Pulmonary circulation can handle a cardiac output of 5L (normal) up to 20L (w/ exercise) Capillary blood volume can increase from 75ml to 200ml with exercise In order for the pulmonary circulation to handle this increased flow, resistance in the vessels must go down (remember V = ∆P/R) However, too much distension/recruitment can smush capillaries closed (increased resistance) Lung volume effects on pulmonary vascular bed:: Alveolar vessels (pulmonary capillaries, arterioles, and small veins) surrounded by gas thus their caliber is affected by transmural pressure (Tm = PA – PIP) Extra-alveolar vessels (arteries/veins) increase their caliber w/ lung inflation secondary to radial traction Hypoxic Vasoconstriction effects on pulmonary vascular bed: If alveoli not getting enough oxygen, the smooth muscle surrounding the LOCAL pulmonary vessels contract in an effort to redistribute blood to areas of the lung that are not hypoxic. This is a good example of trying to match perfusion (Q) to ventilation (P) Prolonged hypoxia can lead to changes in the vasculature and pulmonary hypertension the mechanism of this response is poorly understood

Nitric Oxide effects on pulmonary vascular bed: Nitric oxide is a vasodilator thus, breathing NO would decrease pulmonary vascular resistance thereby increasing perfusion Hypoxia in the lungs vasoconstriction. Inspiration of nitric oxide would of course reverse these affects because of its action as a vasodilator Starling forces effects on pulmonary vascular bed: Hydrostatic pressure (like that found in systemic circulation) Oncotic pressure (like that found in systemic circulation Surface tension – inward pull of fluids into interstitium/alveolus (does not affect systemic circulation) Alveolar pressure – compresses interstitium and favors movement into capillary (does not affect systemic circulation) Causes of Pulmonary Edema Pulmonary edema occurs if filtration is greater than fluid removal Inc in fluid in the interstitium increases the distance gas must travel across the alveoli impairs gas exchange (decreased diffusion), & increases the work of breathing Increase in hydrostatic pressure and capillary permeability lead to increased filtration out of the capillary and into interstitium of the lung. If this increased filtration overwhelms the lymphatic systems ability to carry away this extra fluid edema Impaired lymphatic outflow increased fluid in lung interstitium edema Increase in central venous pressure (the pressure within the SVC and the IVC) increase in venous return increased pressure in pulmonary circulation increased filtration Increased central venous pressure may cause backup of flow from lymphatic system (remember, lymphatic system dumps fluid into the venous system up near the heart) thus, high venous pressure could increase lymphatic pressure impair fluid uptake by lymphatic system edema Hemodilution (an increase in the volume of plasma in relation to red blood cells in the blood) An increase in plasma would decrease the oncotic pressure within the capillary (oncotic pressure is what is pulling fluid back into the capillary). Thus a decrease in oncotic pressure would lead to an increase in net filtration edema Diseases associated w/ Pulmonary Edema Heart failure Lung injury ARDS Starvation

MATCHING VENTILATION & PERFUSION
Zones I, II, and III in the lung, with respect to pulmonary vascular pressure and airway pressure: • Zone 1 (PA > PPA > PPV) – Conditions occur only when alveolar pressure (PA) is high or when pulmonary arteriole pressure (PPA) is low ex. hemorrhages Zone 2 (PPA > PA > PPV) – condition prevails at the apex to the middle of the lung; Pulmonary artery pressure increases progressively toward the base secondary to hydrostatic pressure and exceeds alveolar pressure. Blood flow is determined by difference of Pa and PA. Zone 3 - (PPA > PPV > PA) – conditions prevail in the middle to lower lung – Distention causes a gradual decrease in resistance of the capillaries as your move downward in zone 3 (increase in blood flow) Zone 4 - (PPA > PPV > PA) - Occurs only in the most dependent portion of the erect lung and though hydrostatic pressure is high, blood flow is diminished due to narrowing of the extra-alveolar vessels at low lung volume.

How V/Q is affected by the vertical distribution of ventilation and perfusion in the lung: • Ventilation increases slowly from the apex to the base; Perfusion - blood flow increases more rapidly from the apex to the base, • Supine: base = apex; posterior>anterior • These differences dec w/ exercise. • V/Q is abnormally high at the apex, and V/Q is lower towards the base o Normal VQ is 0.8 (4L/min VA) (5L/min Q) o Proportionately Q > V at base and V > Q at apex.

Airway and vascular control mechanisms which help maintain a normal ventilation/perfusion ratio: • Airway control mechanisms – bronchiolar constriction partially diverts airflow away from unperfused alveoli and toward normal alveoli in order to correct a VA/Q shift (precise mechanism is unknown) • Vascular control mechanisms – Vascular smooth muscle cells (VSMCs) sense a decrease in PO2, an increase in PCO2, and a fall in pH o Decrease sin local alveolar PO2 triggers a compensatory hypoxic pulmonary vasoconstriction; diverts blood flow away from unventilated alveoli toward normal alveoli Right-to-left shunts vs physiologic dead space (wasted ventilation): • Shunt occurs when a portion of Cardiac Output is not normally oxygenated through the pulmonary system (the elimination of airflow to a group of alveoli – alveoli are perfused but not ventilated) o Anatomic shunt (bypasses pulmonary circulation) – Septal Defect results in a right to left shunt o Alveolar shunt (goes through the pulmonary system but doesn’t come into contact with alveolar air) o Hypoxia in the systemic arteries due to lack of O2 exchange • Physiologic dead space or alveolar dead space ventilation – the elimination of blood flow to a group of alveoli ex. Pulmonary embolism o No exchange of O2 and CO2 occurs between unperfused alveoli and pulmonary capillary blood; Alveolar gas gradually achieves the composition of moist inspired air PO2 149 mmHg and PCO2 approx. 0 mmHg Abnormal ventilation/perfusion ratios influence on local oxygen and carbon dioxide pressures: Alveolar Dead Space Ventilation and Shunt

Major functions of the bronchial circulation. The function of bronchial circulation is to nourish conducting airways as well as warm and humidify air.

CONTROL OF VENTILATION
• Medulla—Central control; generates rhythm; (Higher CNS can take over) -DRG (Dorsal Respiratory Group)—only inspiration control; afferent role -VRG—inspiration and expiration; efferent role -Central Chemoreceptors—Respond to PCO2 (major) and pH (minor) NOT to O2! Blood-brain barrier not very permeable to H+. See Note 1. Pons—Modulates rhythm Proprioreceptors—muscles of respiration, receptors in tendons and joints 3 Major Types of Pulmonary Receptors 1. Slowly Adapting Receptors—pulmonary stretch receptors (mechanoreceptors) within parenchyma; myelinated fibers in Vagus 2. Rapidly Adapting Receptors (Irritant Receptors)—Chemo- and MechanoReceptors; Located in conducting pathways; lead to asthma-like effects: bronchoconstriction, hyperpnea, low compliance; myelinated fibers in Vagus 3. C Fibers—Chemo- and Mechano-Receptors; located in alveolar wall and bronchi; lead to rapid, shallow breathing, bronchoconstriction, mucus secretion; unmyelinated fibers in Vagus Peripheral Chemoreceptors: 1. Carotid Bodies—sense C02, pH, and 02 (most important effect and only site of 02 detection); most perfused organ of body (See Note 2) 2. Aortic Bodies—Not important in humans Lung Volume Patterns: -Apneusis: Prolonged inspiration, short expiration -Cheyne-Stokes—crescendo/decrescendo pattern. Occurs in Congestive Heart Failure, Bilateral Cortical Disorders, and high altitude. -Ataxic: Irregular

• • •

Note 1: This explains why there is a rapid response to respiratory acidosis and not metabolic acidosis. CO2 can rapidly affect ventilation, but H+ alone cannot (even though H+ can affect the peripheral chemoreceptors (20% of total response), but they are just not as important as the central chemoreceptors. (80%). Note 2: Mechanism of action: 1. Hypoxia inhibits K+ channels; 2. Depolarization opens Ca+ channels; 3. Release NTs (dopamine); 4. Send action potential to DRG

CLINICAL PULMONARY PROCEDURES
• • • • • • • • • • • • • • • FEV1/FVC should be 80%. If less, then obstruction (e.g. COPD, asthma) FEV1 (amount you can breathe out in 1s) determines the severity of obstruction TLC determines severity of restriction (non-compliance) for stiff lung problems Pleural effusion—accumulation of fluid in pleural sac X-ray while laying on side and while sitting determines whether fluid in pleural space or a mass (because if fluid it will move) For removal of fluid, insert needle above the rib to avoid vein, artery, and nerve Deep Venous Thrombosis can lead to pulmonary embolism Pulmonary Embolism leads to problems such as hypoxia, but doesn’t show up well on X-ray For perfusion scan, lungs should look super imposable Saddle embolism—large embolus in pulmonary artery; catastrophic Lung masses on X-ray: if acute, then probably pneumonia With right risk factors, might think cancer. “If tumor is the rumor, tissue is the issue.” Nice one, Dr. G-W. COPD—severity determined by FEV1; flat diaphragms. Lung volume reduction surgery—shortens lungs, diaphragm can raise up.

Practice problems were handed out after this lecture, so don’t forget to look at those.

Chapter Sixteen – Embryology and Radiology of the Kidney
BLOCK 2 – CRR THREAD: ANATOMY/EMBRYOLOGY/RADIOLOGY
CONTRIBUTORS: JESS SOTELO, BARTLEY MITCHELL & ROHIT PUSKOOR

TABLE OF CONTENTS: EMBRYOLOGY OF THE KIDNEY RADIOLOGY OF THE KIDNEY

DEVELOPMENT OF THE KIDNEY
Development begins in 4th week Pronephros—rudimentary and non functional Mesonephros—functions for short time in early fetal period • Forms lateral to developing gonads • Mesonephric duct (arising laterally) forms Wolffian Duct • Males: Wolffian duct forms epidiymus, ductus deferens, seminal vescicles, and ejaculatory duct; degenerates in females • Paramesonephric (Mullerian) ducts arises from invagination of urogenital ridge • Paramesonephric ducts (@ 9wks) form uterine (fallopian) tubes, fusing to form the uterine canal, uterus, cervix, fornix, and top portion of vagina

Metanephros—forms definitive/permanent kidney
• • • Appears in 5th week Excretory system develops from metanephric mesoderm Ureteric bud develops as outgrowth from mesonephric duct, penetrates metanephric tissue, and forms collecting tubules/ureters Metanephric tissue caps induced by collecting tubules (WT1 expression in mesenchyme) Metanephric tissue caps form bowman’s capsules, proximal and distal CT’s, and loops of henle. 1-million nephrons in each kidney at birth urine production from 10th week ascent of kidneys—shift to more cranial position; vascularization by arteries from aorta at continuously higher levels

• • • • •

Bladder and Urethra • derive from cloaca in wks 4-7 • cloaca divides into urogenital sinus anteriorly, anal canal posteriorly • mesonephric duct absorbs into posterior bladder, ureter rises as kidneys ascend, • Trigone lining initially mesodermal in origin become replaced by endodermal lining.

Developmental abnormalities
Wilm’s tumor Age < 5yrs Mutations in WT1 or WT2 Associated with other anomalies (aniridia, GU anomalies, retardation) 90% cure rate with surgery, chemo, radiation multicystic dysplastic kidney— numerous ducts, but only undifferentiated mesenchyme no nephrons, renal agenesis Potter sequence Anuria, oligohydramnnia (less amniotic fluid), pulmonary hypoplasia, GU anomalies

RADIOLOGY OF THE KIDNEY
Kidney location: 1) between T12 and L1 2) obliquely along psoas muscle surrounded by fat and fascia Anatomy: • Composed of distinct but fused lobes (428, usually 14) • Septum of Bertin, a downgrowth of cortical tissue, separates the lobes

Imaging the GU System by Intravenous Urogram (IVU) 1.Inject contrast (usually iodine) into venous system 2.Kidneys excrete iodine 3.Image of kidneys and ureters and to some degree bladder Can do linear tomograms to better see the kidneys
Horseshoe kidney (image) – kidneys are connected across the midline (like a horseshoe); more prone to injury because they sit anteriorly to spine; in blunt trauma, can be fractured more easily
Stones like to stick in certain places: 1) uretopelvic junction 2) uretovesicular junction 3) ureter crossing over iliac artery Ureters – transitional cell epithelium; can get stones or tumors Abnormal location of kidneys (if stop during ascent): 1) pelvic 2) horseshoe (internal fusion across midline) 3) crossed-fused ectopia (both kidneys are on one side of abdomen, fused together) 4) thoracic (ascend into chest) 5) agenesis (only 1 unilateraly kidney) 6) no kidney (fetus dies)

Response to stone: 1) increase in peristalsis initially as stone tries to pass 2) after an amount of time, peristalsis decreases and have an increase in hydrostatic pressure 3) prostaglandins are released, which increases blood flow 4) eventually, have atonic hydronephrosis – increased GFR, decreased blood flow

hemorrhagic cystitis – can be due to bacterial/viral infection; chemicals and radiation can cause; can cause large blood clot to form in bladder, which appears as filling defect without contrast; very distended, irregular appearing bladder; usually see in patients with long-standing paralysis or severe BPH or static hypertrophy , where you have urinary outlet obstruction; black line around bladder represents air within walls of bladder – consequence of very severe infection
Bladder Problems: 1) Stones – usually arise in patients where urine is sitting for a long time, unable to flow; it precipitates to cause stones; looks like vague lucency (“filling defect” of a stone) 2) Tumors – transitional cell carcinoma; soft tissue protruding into the bladder (same as ureters) – most common bladder cancer 3) Foreign bodies 4) Infections 5) Anatomic anomalies

Male Urethra Posterior Urethra: 1) prostatic – part of urethra within prostate; leads to bladder; sometimes have filling defect that causes ovalshaped lucency 2) membranous – level of the external sphincter; gets very thin as you go through the UG diaphragm Anterior urethra: 3) bulbous – penile-scrotal junction is the delineation between penile and bulbous urethra; bulbous is more dilated compared to penile 4) penile

Male Gonorrhea Multiple areas of irregularity and stricture along urethra, typical of infectious process involving urethra. Diastasis - widening of symphysis pubis Straddle injury – fall that injures juncture between anterior, posterior urethra In cases of UTI, want to make sure: 1) no reflux from bladder up into kidneys (if have reflux, infection can go to kidneys – more severe infection) 2) in male, no evidence of prosto-urethral valve – sometimes these valves can cause functional obstruction and the bladder can be very enlarged

Miscellaneous: • Retrograde urethrogram – inject contrast in urethra • Staghorn calculi (very large calcifications filling entire collecting systems of renal pelvis) – do surgery, open collecting system to pull these calcifications out • diverticulum of the bladder 1) also caused by long-standing obstruction 2) P builds up, have weaknesses in the wall 3) have these outpouchings/protrusions of bladder 4) when smaller, called sacules

Chapter 17 – Renal Histology
BLOCK 2 – CRR THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: STEPHANIE WUEST & DAVID MURDOCK

TABLE OF CONTENTS: MICROANATOMY OF RENAL VASCULATURE HISTOLOGY OF THE GLOMERULUS HISTOLOGY OF THE RENAL TUBULES AND BLADDER

HISTOLOGY OF RENAL VASCULATURE
Renal artery branches into anterior and posterior renal arteries. Interlobar arteries branch off and go between lobes. The arcuate arteries run between the medulla and the cortex. Interlobular arteries branch off of the arcuate arteries and extend through cortex. Afferent arterioles branch off of the interlobular arteries and enter the glomerulus. Efferent arterioles leave glomerulus and become the peritubular capillary network (restricted to the cortex). Peritubular capillaries are fenestrated with diaphragms. The vasa recta supplies the medulla and can branch off of the arcuate arteries or efferent arteriole. Descending vasa recta is continuous nonfenestrated, while the ascending vasa recta is continuous fenestrated with diaphragms. Veins arise in the stellate vasculature and retrace the course of arteries.

Remember: Increased filtration at the glomerulus increases osmotic pressure of the peritubular capillaries and increases reabsorption. This is the principle behind glomerulotubular balance. Also, the rate of renal plasma flow to the glomerulus affects glomerular filtration rate by preventing equilibration of osmotic and hydrostatic forces in the glomerulus.

HISTOLOGY OF THE GLOMERULUS
Bowman’s Capusle-Parietal (simple squames) and Visceral Layer (podocytes) Podocytes- Nucleus floats in urinary space. Pedicles touch the basal lamina and interdigitate with pedicles from other cells. Pedicles have lots of microtubules. Podocalyxin is a negatively charged protein surrounding pedicles. Glomerulus Enothelial Cells-Continuous fenestrated, no diaphragms. Continuous basal lamina. Mesangial Cells- Cover the vascular pole of the glomerulus. Proliferate in many renal diseases. Dual Origin Phagocytic (monocyte origin)->Vimentin Positive Contractile->Desmin positive. Sample Glucose-cytoplasmic processes reach into capillary lumens. Contractile- contract in response to angiotensin II, relax in response to atrionatriuretic factor. Phagotcytic – clean up debris of filtration Secrete matrix- supports capillary tufts.

Filtration Barrier Endothelial Fenestra->lamina rara interna (contains fibronectin)->lamina densa (fusion product of basal laminas)->lamina rara externa (fibronectin)->filtration slits->slit diaphragms->podocalyxin. Result is that large proteins and erythrocytes are usually not filtered through the barrier.

HISTOLOGY OF RENAL TUBULES AND BLADDER
Proximal Convoluted Tubule
●continuous with squamous epithelium of Bowman's capsule ●much longer than DCT ●cuboidal (low columnar) epithelium with brush border reabsorption ●basal PM infoldings with mitochondria ion transport ●central nuclei, 3-5 surround PCT ●apical canalliculi between microvilli endocytotic peptide uptake for digestion ●ANF acts on PCT, creatinine & penicillin secreted here

Distal Convoluted Tubule
●shorter than PCT ●simple cuboidal epithelium ●apical nuclei, many pale cells surround large lumen ●basal PM infoldings with mitochondria (like PCT) ion transport ●aldosterone acts here

Urothelium
● reversible desmosomes cells can roll over each other if epithelium is stretched/shortened ● dense plaques on P face of plasma membrane protect from caustic urine ● epithelial cells are nonpathologically binucleate & polyploid ● minor/major calyx, renal pelvis, ureters, bladder, prostatic urethra

urotheliu Juxtaglomelular Apparatus
1. Macula Densa ● tall narrow cells with closely packed nuclei ● chemoreceptors for Na+ in DCT filtrate; pass info to smooth muscle in tunica media of afferent arteriole 2. Juxtaglomelular (JG) cells ● modified smooth muscle of afferent arteriole ● synthesize and secrete renin (PAS+) Adventitia ● stimulated by macula densa and sympathetic neuronal inputs to secrete renin into blood stream ● renin cleave angiotensinogen (from liver) angiotensin I (inactive) ● ACE (from lungs) cleaves angiotensin I angiotensin II ●angiotensin II: afferent arteriole and mesangial cell constriction less blood flow through glomerulus, BP increases +

Bladd er
Urothelium thickness Lamina Propria Smooth muscle 5-6 cells highly elastic 3 layers in all directions

Ureter s
3-4 cells highly elastic bundled by CT, inner long. & outer circ., peristalsis +

Collecting Tubules &
●composed of pale principal cells (aldosterone sensitive) and dark intercalated cells (unknown function) ●as cortex medulla, epithelium transitions from cuboidal to columnar with no intercalated cells ●medullary collecting ducts respond to ADH

Male Urethra
● carries urine & ejaculate ● long compared to female 1. prostatic - urothelium 2. membranous pseudostratified columnar 3. spongy (penile) pseudostratified columnar with mucous glands stratified squamous near tip

Loop of Henle
●creates hypertonic osmotic gradient within medullary interstitium ●juxtamedullary nephrons: long loops that penetrate deeply into medulla ●cortical nephrons: loops in cortex only; short thin descending limb; no thin ascending ●ascending/descending thin limbs: simple squamous ●ascending/descending thick limbs: simple cuboidal 3. Lacis cells ● carry info between macula densa and JG cells of afferent arteriole

MD JC

Female Urethra
● stratified squamous ● 2 inches - prone to bladder infection ● no subdivisions

Glomerul

Chapter 18 – Renal Physiology
BLOCK 2 – CRR THREAD: PHYSIOLOGY
CONTRIBUTORS: NIKHIL DHAWAN, PAVAN JHAVERI, BANI MAHESHWARI, MONICA DANDONA, & ROHIT PUSKOOR

TABLE OF CONTENTS: GFR & RPF: DEFINITION AND INTERRELATIONSHIP CLEARANCE: CONCEPT APPLICATION RENAL HANDLING OF NA, CL, AND H20 RENAL HANDLING OF UREA, GLUCOSE, AMINO ACIDS, PHOSPHATE AND CA RENAL COUNTER-CURRENT EXCHANGE RENAL HANDLING OF H AND HCO3 RENAL HANDLING OF POTASSIUM BODY FLUID COMPARTMENTS & EXCHANGE REGULATION OF EXTRACELLULAR VOLUME AND OSMOLES DIALYSIS

GFR & RPF
Blood flows to the kidneys and is filtered. The amount filtered is the GFR (Glomerular Filtration Rate) ; the amount of plasma that reaches the kidney is the RPF (Renal Plasma Flow). RPF = (1 – Hct) x RBF Glomerular Filtration Barrier: 1) endothelial cells that line glomerular capillaries 2) the glomerular basement membrane 3) epithelial cells (or podocytes) that line Bowman’s capsule. The Sieving coefficient(SC) quantifies the ability different solutes to pass the glomerular filtration barrier at different rates. A sieving coefficient of 1 means that the substance will totally cross the glomerular filtration barrier. A molecule with a sieving coefficient of 1 is freely filtered The Sieving coefficient depends on the the following characteristics: 1. Size – solutes less than 5,500 daltons have SC close to 1. 2. Charge – Cations have advantage because the glomerular basement membrane is negative and podocytes are negative. GFR = (Ux*V) / (Px*1440). Common Markers of GFR: Inulin – not used anymore because it had to be injected in. Creatinine – A metabolite of creatinine phosphate in muscle. Creatinine is partially secreted, but the way creatinine is measured overestimates by the same amount (20%) that was secreted. There are three instances when creatinine is not a good measure. When GFR is changing rapidly, with significant muscle damage, and when GFR is significantly depressed, creatinine is not a good measure of GFR. What determines GFR? The hydrostatic pressure and the osmotic pressure and Kf. Kf is the product of the hydraulic permeability of the capillary (Lp) and the surface area available for filtration (Sf). GFR = (Kf) (Puf). The formula for Puf is the following: Puf = (Pgc – Pbs) – (Πgc - Πbs) with the hydrostatic pressure in the glomerular capillary (Pgc) and in Bowman’s space (Pbs) and the oncotic pressure in the glomerular capillary (Πgc) and in Bowman’s space (Πbs). Remember that a hydrostatic pressure will push a solution out and that an osmotic pressure will pull a solution in. That is why Puf is a substraction between the two forces. Renal Plasma Flow: this is the amount of plasma that hits the glomerulus. We saw the equation above RPF = (1-Hct)RBF. However this equation isn’t very useful clinically. In order to measure renal plasma flow we have to measure a substance in the urine that is

completely excreted in one pass. The formula then is the same as GFR, but with this new substance. (RPF) x (Px) = (Ux) x (V) , rearranging, RPF = [(Ux) x (V)] / (Px). To measure RPF clinicians use Para-aminohippuric acid (PAH) which is removed in one pass. After leaving the glomerulus, the efferent arteriole gives rise to a second renal capillary network, the peritubular capillaries. These capillaries provide nutrients for the tubules and remove fluid and solutes reabsorbed by the tubules. The peritubular capillaries have a low hydrostatic pressure compared to other systemic capillaries and a high oncotic pressure (owing to the high protein concentration caused by glomerular filtration). This situation leads to a favorable pressure gradient for fluid reabsorption along the entire length of the peritubular capillary. Changes in RPF and glomerular filtration have direct effects on peritubular fluid reabsorption. For example, if a subject is administered a large volume of intravenous fluid, RPF and GFR increase. Concomitantly, afferent and efferent arteriolar resistances decrease due to suppression of angiotensin II. In this situation, peritubular capillary oncotic pressure is lower than normal and thus there is less capacity to accommodate tubular fluid reabsorption; tubular reabsorption decreases and renal fluid and solute excretion increases. This process, in which changes in RPF and GFR lead to parallel changes in fluid and solute excretion, is referred to as glomerulotubular balance. Cells of the macula densa sense increases in GFR (by changes in solute concentrations) and signals (decrease in angiotensin II) increases arteriolar resistance decreasing GFR to normal. Sympathetic nervous system activation leads to release of norepinephrine, which has multiple effects on the kidney. These include afferent and efferent arteriolar vasoconstriction, stimulation of angiotensin II production, and direct stimulation of tubular sodium reabsorption. Atrial natriuretic peptide causes marked vasodilation of afferent and efferent arterioles, increasing cortical and medullary blood flow and lowering the sensitivity of tubuloglomerular feedback. This results in an increase in RPF and GFR. It also decreases angiotensin II and arginine vasopressin levels. Other vasoactive substances serve as counter-regulatory agents or modify the effects of major regulatory hormones. These include epinephrine, endothelins, leukotrienes (all renal vasoconstrictors), dopamine, and nitric oxide (renal vasodilators).

CLEARANCE
Cx = [(Ux)(V)]/(Px) Units = ml/min. • Rate of plasma that would account for the urine concentration of a particular solute, if all the plasma was cleared of that solute. Does clearance usually overestimate or underestimate blood volume that is cleared in reality? Underestimate Exception? PAH, because it is all cleared from the plasma on the first pass through the kidneys

Excretion = Filtration + Secretion – Reabsorption
• If filtration = excretion, you can use that substance for GFR (creatinine, inulin)

Fractional excretion (FEx)
Excretion of X/filtered load of X = [(Ux)(V)]/[(GFR)(Px)] = Cx/GFR If a given solute is excreted totally and only by filtration, then what will its clearance and FE be? Clearance will be GFR, and FE will be 1.00 (100%) What does and FE >1 and FE<1 mean? Net secretion of solute and net reabsorption of solute, respectively. Fractional reabsorption: FRx = 1 – FEx FEx = [(Ux)(Pcr)]/[(Ucr)(Px)] • Which means that fractional solute excretion is independent of time and can be done at anytime (just need plasma and urine concentrations and flows)

SNGFR = (TFin)(V)/(Pin) SNGFR is single nephron glomerular filtration rate TFin is tubular fluid conc. of inulin Pin is plasma conc. of inulin. • Only done in lab animals by inserting a small pipette into a single renal tubule. • Rat kidney has SNGFR of 30nl/min • Useful for calculating number of nephrons in a kidney: # of nephrons = GFR/SNGFR

Proximal Convoluted Tubule Histology Simple low columnar epithelium, lots of apical microvilli (PAS+) with canaliculi between, basal infoldings with mitochondria Central nuclei Large cells (3-5 nuclei around lumen); much longer than DCT 67% reabsorbed Apical: Na-H exchanger; cotransport w/ glucose, aa, PO4 (creates negative S1 lumen) Basolateral: Na,K ATPase Paracellular transport esp. in S2, S3 segments (positive lumen) Significant backleak in S1

Na+ (freely filtered)

Descending Ascending Thin Limb Thin Limb Squamous Squamous epithelium epithelium Can tell difference from vasa recta capillaries because vasa recta are thinner, vimentin positive, and contain erythrocytes and plasma proteins. Impermeable Reabsorption passive and paracellular

Thick Ascending Limb Similar in structure to distal convoluted tubule

Distal Convoluted Tubule Simple cuboidal epithelium NO microvilli (no PAS+) Basal infoldings with mitochondria Apical nuclei Pale compared to PCT 5% reabsorbed Little Paracellular; Apical: Na/Cl cotransporter (inhibited by diuretics thiazides) Basolateral: Na,K ATPase

Collecting Ducts Pale principal cells and dark intercalated cells. As progresses into medulla, becomes taller and taller columnar cells with no intercalated cells 3% reabsorbed by principal cells Apical: epithelial Na channels create negative lumen (channels blocked by diuretic amiloride) Basolateral: Na,K ATPase

Other information Basal mitochondria – typical of ion-pumpers (eosinophilic). All the epithelium will be cytokeratin positive.

Cl- (freely filtered)

Water

Potassium (freely filtered)

Reabsorption: Early PCT – paracellular dominates because of (-) lumen gradient of Na+ Late PCT – trans. dominates Apical: Countertransport with another anion Basolateral: Cl- channels or K/Cl cotransporter Paracellular reabsorption through ‘leaky’ tight junctions; Trancellular through aquaporins transcellular > paracellular 80% reabsorbed Early PCT – normal lumen negative impairs somewhat Late PCT – positive lumen enhances Passive and paracellular via solvent drag

Impermeable

Reabsorption passive and paracellular

25% reabsorbed Apical: Na/K/Cl cotransporter, NaH exchanger; Basolateral: Na,K ATPase; Paracellular transport also (loop diuretics – comp. inhibitors of Na/K/Cl) Reabsorption: Apical: Na/K/Cl cotransporter Basolateral: Cl channels and ClHCO3 exchanger

Reabsorption: Apical: Na/Cl cotransporter Basolateral: Clchannels

Moderately permeable

Impermeable

Impermeable

Impermeable

Reabsorption: Principal cells – paracellular (negative lumen from Na) Beta-intercalated cells – transcellular using apical Cl-HCO3 exchanger, basolateral Cl channels Increased permeability with ADH (vasopressin)

1) Principal determinant of ECF volume 2) Reabsorption closely coupled with water in PCT; dissociated in distal segments 3) Basolateral exit always via Na,K ATPase 4) Urinary Excretion – 100mmole/day (0.4%) Most filtered sodium is reabsorbed with chloride.

Water transport always passive 1) Urinary excretion from 1-3% to 150% 2) Medullary recycling: K reabsorbed in IMCD and thin and thick ascending exceeds K secreted in descending; K trapped in interstitum - secreted in K overload 3) Imp. For intracellular pH and regulation of ICF volume

Used for solute reabsorption 10% reabsorbed in Loop of Henle Reabsorption High luminal Passive (+) lumen drives K drives paracellular paracellular; passive secretion driven by Transcellular via paracellular high K in apical Na/K/Cl reabsorption medullary cotransporter and interstitium basolateral K channels Beyond LOH, depends on overall K balance 6% reabsorped during 2% reabsorbed K depletion in IMCD; during K depletion IMCD reabsorbs regardless of overall K balance. α-intercalated - reabsorb K by H,K ATPase with exit through K channels principal – secrete via K channels and K/Cl cotransport

Proximal Convoluted Tubule Urea (freely filtered) Reabsorption (50% remains) Paracellular – mainly by solvent drag Some transcellular

Descending Thin Limb UT2 – secretes urea taken up in IMCD

Ascending Thick Ascending Distal Convoluted Thin Limb Limb Tubule More urea secretion (urea delivery to the initial portions of the collecting ducts – 110% remains)

Collecting Ducts Reabsorption – apical uptake via UT1 transporter and basolateral exit via UT4 40% remains

Other information At low rates of urine flow, reabsorption increases and secretion decreases Diabetes – glucose may rise too high to be all reabsorbed and glucose will be excreted. (Filtered load – excretion = glucose reabsorbed)

Glucose (freely filtered)

Completely reabsorbed (98% in PCT and remaining 2% in rest of nephron) S1 - SGLT2 (Na-glucose co-transporter apically) and GLUT2 (facilitated diffusion basolaterally) Takes up glucose until ratio inside to out is 70 to 1 (high capacity- low affinity) S3 – SGLT1 (uses 2 Na+ to take in glucose) and GLUT1 (facilitated diffusion basolaterally) Scavenges glucose – ratio inside out is 4900/1 (high affinity – low capacity)

Amino Acid (freely filtered) Oligo Peptides/ Proteins Phosphate (not freely filtered – 10% bound to proteins) Calcium (not freely filtered – 40% bound to proteins)

H+/HCO3

Completely reabsorbed (>98% in proximal tubule and rest in remaining nephron) Not individual transporters – Cysteine (basic) transporters (w/o get cystinuria) and neutral AA transporter (w/o get Hartnup’s disease) Apical uptake – with sodium or AA channels (facilitated diffusion); Basolateral – facilitated diffusion + Na/AA cotransport or countertransport Completely reabsorbed (>98% in proximal tubule and rest in remaining nephron) Small oligopeptides filterable and most hydrolyzed by peptidases on the luminal membrane of proximal tubular cells. Some oligopeptides resistant to hydrolysis and enter proximal cells via H-oligopeptide cotransporter. Larger proteins can either undergo endocytosis (break down because of vesicle fusion lysosome) or transcytosis (not degraded). 80% reabsorbed 10% reabsorbed – Apical – Na/PO4 transport mechanism unknown which makes lumen more negative (2 Na+ for 1 PO4-) (PTH downregulate expression) Basolateral – not understood by passive 1.5 % reabsorbed 8% reabsorbed 65% reabsorbed 25% reabsorbed predominantly Majority solvent drag – induced ½ paracellular; ½ transcellular, by Na and water reabsorption transcellular qualitatively like thick Voltage driven in S2 and S3 Apical – ascending limb Apical through Ca channel; epithelium Ca Basolateral – Na-Ca channels; countertransport & Ca,HBasolaterally – ATPase same as PCT Reabsorbs remaining 10% Reabsorbs 80% of HCO3Reabsorbs 10% HCO3- comes in through CAIV; Apical: H+ secretion through H-ATPase pumps of HCO3 Apical: H+ Secretion: Na-H Apical: H+ and/or H/K ATPase pumps exchange, H-ATPase pumps Secretion: Na-H Basolateral: Cl-HCO3 exchanger exchange, HAldosterone – 1) Stimulates Na reabsorption in Basolateral: HCO3- reabsorped: ATPase pumps Na-HCO3 transport (early); Clcollecting ducts – (-) lumen favors H+ secretion HCO3- exchanger (late) 2) Stimulates H-ATPase Basolateral: Aldosterone independent – Acidosis stimulates HCO3 exits in ClHigh intracellular HCO3- drives HCO3- out of cell HCO3 exchanger insertion of H-ATPase (alkalosis inhibits)

10% excreted Balances with amount absorbed in the gut.

O.5% excreted Uptake closely related to Na uptake

H+ secretion and HCO3 reabsorption always take place together in kidney Net acid excretion = (Titrable acidity +Ammoniagenesis) – HCO3 secretion

Proximal Convoluted Tubule Ammonia Most NH3 does not come from glomerular filtration – generated in PCT. For each molecule of glutamine consumed, you secrete 2 molecules of NH4 and reabsorb 2 molecules of HCO3-

Descending Ascending Thin Limb Thin Limb Secretion of NH4 in cortical thin descending limb. Medullary portion of descending limb and thin ascending limb – net passive NH3 reabsorption into interstitium (combine with H+ to form NH4) NH4 recycling is occurring because NH4 from medullary interstitium can also be secreted

Thick Ascending Limb Reabsorption Apical NH4 uptake through Na/K/Cl cotransporter or K channels (NH4 substitutes for K) Basolateral NH4 exit through nonionic diffusion

Distal Convoluted Tubule

Collecting Ducts NH4 enters basolaterally by non-ionic diffusion or Na/K ATPase – then secreted into lumen and excreted. Lateral transport from LOH to medullary collecting ducts allows some to bypass cortical collecting ducts.

Other information If taken up by vasa recta, it is detoxified in the liver, which eventually depletes HCO3. Don’t want this – that is why NH4 is removed in thick ascending limb. 60% of net acid excreted through NH4

Hormones

ANF – increases RPF and GFR, increases Na excretion, increases PO4 excretion Sympathetic Nerve activity – stimulation of Na-H exchanger enhances Na reabsorption via Na/K ATPase AngII – stimulates Na-H countertransport, stimulates Na and water reabsorption Parathyroid Hormone (PTH) decrease PO4 reabsorption and increase excretion by downregulating apical transporter expression * Ca handling in proximal tubule is not subject to hormonal control.

Aldosterone stimulates Na/K/Cl cotransporter PTH stimulates apical Ca uptake

Aldosterone stimulates Na/Cl transporter PTH stimulates apical Ca uptake

Collecting Ducts ANF – inhibits Na reabsorption in IMCD ADH (vasopressin) – increases # of open Na channels in apical principal cells, stimulates insertion of UT1; increase water reabsorption with insertion of aquaporins Aldosterone stimulates Na and Cl reabsorption and K secretion in the principal cells by activation of apical sodium channels and basolateral Na.KATPase PTH stimulates apical Ca uptake

Aldosterone stimulates Na+ reabsorption and K+ excretion by the renal tubule Renin-Angiotensin and increase in plama K+ stimulate aldosterone secretion. Angiotensin II causes renal vasoconstriction, particularly of the arteriole (efferent>afferent). It also causes contraction of the renal mesangial cells leading to a decrease in glomerular surface and hence lower GFR. It also decreases renal blood flow and increases the sensitivity of tubuloglomerular feedback. Atrial Natriuretic Peptide is a powerful vasodilator and causes diuresis by enhancing the renal excretion of Na+. Lowers effective circulating volume. It increases cortical and medullary blood flow and lowers the sensitivity of tubuloglomerular feedback (macula densa). Increase in GFR and RFP. Decreases AngII and ADH. ADH (vasopressin) increases water reabsorption in medullary collecting ducts. Although it regulates plasma osmolarity as its primary function, it also increases renal vascular resistance, particularly in medullary vessels. Decreases urine flow, so decreases K secretion BUT also increases Na and K permeability so increases K secretion. Sympathetic nervous system – norepinephrine – 1) afferent and efferent arteriolar vasoconstriction, 2) stimulation of AngII, 3)direct stimulation of Na reasbsorption Anti-Natriuretic Factors: Aldosterone, Sympathetic Nervous System, ADH (vasopressin); Natriuretic Factors: ANF, endogenous ATP inhibitors, Dopamine, Bradykinins Clearance of PAH approximates RPF (at low PAH concentration) Clearance of inulin approximates GFR Criteria for USE of a substance to measure GFR: 1) freely filtered in glomeruli; 2) neither secreted nor reabsorped; 3) neither metabolized or produced 4) physiologically inert

Thick Ascending Distal Convoluted Collecting Ducts Other information Limb Tubule Tubular fluid Everything reabsorbed except Principal Cells – Reabsorption Summary maximally dilute ammonia produced and secreted reabsorb Na, reabsorb through Na/Cl/K (diluting segment) Cl, secrete K, cotransporter. Intercalated Cells – beta Also reabsorbs absorbs Cl; alpha HCO3, Ca, and absorbs K NH3…causes Can secrete NH4, K medullary based on needs interstitial osmolarity Reabsorbs urea, Ca, PO4 (concentrating Very dependent on segment – allows outside conditions and for excretion of aldosterone concentrated urine) • BODY RATHER MAINTAIN ECF VOLUME THAN DEAL WITH HYPOOSMOLARITY • Water homeostasis does not equal volume homeostasis (change in water balance refers to change in osmolarity, while change in volume balance refers to change in Na) • Na only changes ECF volume b/c it cannot readily diffuse into the cell and a large uptake of sodium stimulates thirst which will put back any water taken out of the cell • Water does not affect ECF volume (plasma volume particularly) because it distributes throughout the cell and has a much larger effect on ICF volume (67% of fluid in body) than ECF volume (33% of which plasma is 20% and interstitial fluid is 75%) • ICF is more acidic than ECF; pH of any body fluid is determined by the ratio of bicarbonate to carbon dioxide • Decreased ECF volume leads to decreased blood pressure and hypotension; increased ECF volume does the opposite • Most dangerous consequence of ECF volume overload is fluid accumulation in the pulmonary interstitium with subsequent impairment of gas exchange • STEADY STATE – if you expand a person’s ECF volume with addition of sodium, you have a linear increase in sodium excretion from kidneys • ADH (arginine vasopressin) not only increases water permeability but also upregulates solute reabsorption (urea and Na/K/Cl), notably in the thick ascending limb and the medullary collecting ducts to create hypertonic medullary interstitium that is necessary for water reabsorption. Main stiumulus from pituitary is plasma hyperosmolarity. • Creation of medullary hyperosmolarity – countercurrent multiplier (descending limb permeable to water – ascending limb permeable to solutes – increases osmolarity of interstitium) • Maintainence of medullary hyperosmolarity – countercurrent exchanger (VASA RECTA – descending absorbs solutes, ascending gives solutes back to interstitium; descending gives out water to interstitium, ascending takes water back in – net removal of solutes and water from the interstitium with a slight preference for solute removal over water removal) • Regulation of Water Balance: 1) Solute Reabsorption in LOH – increase NaCl transport + increase GFR increases urinary concentrating capacity; 2) Dietary Protein Intake – high protein – high urea synthesis – high urine concentrating; 3) Medullary Blood flow – High blood flow rate washes out and low medullary blood flow preserves urinary concentrating capacity; 4) Tubular flow rate – high tubular flow rate impairs concentrating capacity because leaves less time for urea and water reabsorption to equilibrate; 5) Arginine Vasopressin (ADH) • ACID/BASE – since there is an obligatory loss of alkali in the stool, very important to get rid of the acid through kidneys • Excrete buffers that act as sponges that permit excretion of a relatively large amount of non-volatile acids with low free H+ excretion in the urine (NET ACID EXCRETION = Titratable acidity + Ammoniagenesis – HCO3 excretion) • Titratable acidity depends on 1) amount of buffer in glomerular filtrate, 2) pK of buffer (should be in between plasma and urine in order to bind H+), 3) pH of the urine (lower the pH, more protonated the buffer – greater amount of acid excreted with the buffer) • If just looking at pK, phosphate is better buffer – but more bicarbonate present and is open system – that is why CO2/HCO3 is better buffer system for human body • Hemoglobin – important ICF buffer – deoxyhemoglobin pH increases, thus is better acceptor of H+ at the tissues • H+ dissolves bone – give phosphate which is used as a titrable acid. This is why people with chronic acidosis either have short stature or osteoporosis.

Proximal Convoluted Tubule

Descending Thin Limb Takes up water and secretes urea and potassium that is high in med. interstium

Ascending Thin Limb Passive and paracellular reabsorption of Na, Cl, K, and NH3

DIALYSIS
Dialysis involves bringing blood into contact with semi-permeable membrane on the other side of which is dialysate. Solute passively transported across membrane by:
1)diffusion – driven by transmembrane concentration gradients • Remove largest possible quanitity of solute (urea, creatinine) – dialysate has no solute • Remove some (but not all) of solute (K+) – dialysate has low concentration of solute • Raise plasma concentration of solute (HCO3-) – dialysate has high concentration of solute 2)convection – small solutes have high permeability across dialysate membrane; imposition of hydrostatic or osmotic pressure will cause water transport; solute flux occurs by solvent drag • Remove some solutes WITHOUT CHANGING PLASMA CONCENTRATION (Na+)

Small solutes may be removed by:
1)convection – if concentration gradient is low 2)diffusion – if concentration gradient is high 3)both contribute to net transport for most small molecules Goals of Dialysis:
1.removal of uremic toxins 2.removal of fluid (ultrafiltration) 3.removal of solutes (i.e. K+ and phosphate) normally excreted largely/exclusively by kidneys 4.replacement of solutes (i.e. Ca2+, HCO3) that are deficient in patients w/kidney failure

URR = ([ureapre] – [ureapost]) / [ureapre] x 100%
dialysis is adequate when URR > 65-70% Factors Influencing Dialysis Adequacy:

1)higher blood and/or dialysate flow rates higher URR 2)larger surface area dialyzers and more permeable membranes higher URR 3)increasing dialysis duration improves clearance 4)patients of larger size or on high protein diets require more intensive dialysis Why same patient survival rates/quality of life for PD and HD? 1)selection bias (healthier patients on PD) 2)residual renal function may be better preserved in patients on PD 3)biocompatibility issues (HD patients regularly exposed to artificial membrane) 4)short, intense HD procedure may have more cardiovascular complications than long, gentle PD procedure 5)PD patients have better clearance of middle MW molecules (0.35-10 kDa) than HD counterparts because receive continuous dialysis (these molecules can be responsible for aspects of morbidity in dialysis patients)

Peritoneal Dialysis (PD) Hemodialysis (HD) • Artificial membrane, packaged in a dialyzer • Peritoneal membrane • Osmotic pressure gradient determines • Hydrostatic pressure gradient determines ultrafiltration; changes in osmolarity of ultrafiltration; PD and PB can be adjusted reliably for HD only to achieve wide range of TM pressures dialysate (usually by glucose) are used to adjust ultrafiltration rate • 4 hours a day, 3 days a week • Osmotic gradient is highest at start of single • amount of solute entering dialyzer must equal amount of PD treatment; intraperitoneal osmolarity solute leaving dialyzer drops until plasma and IP osmolarities • if no net fluid removal occurs, change in blood solute equilibrate and ultrafiltration stops content equals change in dialysate solute content • 24/7 process; dialysate instilled through • much lower clearance rates than PD catheter into IP cavity for “viable amount of Ideal Membrane Qualities: time” before being withdrawn and replaced 1)high permeability to low, middle MW solutes • limit of viable time is when net fluid 2)minimal loss of vital solutes (aa, proteins) 3)performs UF over wide range of TM pressures reabsorption begins due to net glucose 4)composed of non-toxic materials not prone to thrombosis transport from dialysate to plasma Formulas QP = KUF (PB – PD) – calculates fluid flux (QIB x CIB) + (QID x CID) = (QOB x COB) + (QOD x COD) – solute entry = solute exit D = (QB x (CIB – COB)) / (CIB – CID) – change in solute content of blood / driving force C = [(QB) (CIB – COB)] / (CIB) = (QD x COD) / CIB – dialysis clearance = dialysance (when CID = 0)

Chapter Nineteen – Anatomy/Embryology – GI Tract
BLOCK 3 – GIMNER THREAD – ANATOMY/EMBRYOLOGY/RADIOLOGY
CONTRIBUTORS: JESS SOTELO, JOHN PITCHER & ANTHONY CARTER

TABLE OF CONTENTS: DEVELOPMENT OF GIT & MESENTERIES I DEVELOPMENT OF GIT & MESENTERIES II GROSS ANATOMY OF THE GI TRACT UNDISTURBED VISCERA UPPER GIT SMALL & LARGE INTESTINE BLOOD SUPPLY AND LYMPHATICS OF GI

EMBRYOLOGY OF THE GI TRACT I & II
Endodermal origin – depends on: 1) cranial-caudal folding (NS) 2) lateral folding (somites) Foregut – anterior portion of endoderm (esophagus to ligament of Treitz) celiac artery Hindgut – posterior portion of endoderm (mid-transverse colon to anux) inferior mesenteric artery Midgut – everything in between (ligament of Treitz to mid-transverse colon) –-> superior mensenteric artery Gut: Buccopharyngeal membrane (mouth) cloacal membrane (anus) Initially a straight tube suspended by dorsal mesentery – stomach is suspsended by ventral mesentery as well Peritoneal cavity is formed by coalescence of coelomic cavity (lateral plate mesoderm with lateral folding) -foregut -4th week – tube begins to enlarge -5th week – dorsal portion enlarges more than ventral (greater curvature) -superior portion enlarges fundus -7th-8th week – rotation 90° around cranial caudal axis; dorsal L (greater curvature); ventral R (lesser curvature) -vagus nerve rotrates with it – left vagus is anterior, right vagus is posterior Duodenum -pushed posteriorly (retroperitoneal) and right into a C-loop -space between stomach and duodenum is lesser sac (rest of peritoneal cavity is greater sac) Stomach

Epiploic foramen of Winslow – only connection between greater sac and lesser sac Lesser Sac – enlarges because dorsal mesogastrium expands and becomes redundant; folds on itself and hangs below stomach greater sac (inside is lesser sac) Small Intestine -rotation is key -ileum grows fastest, abdominal cavity can’t handle it – buckles into umbilical cord (as a loop) Stage I (first rotation): - 90° counterclockwise (as viewed from front of embryo) - cranial limb caudally and to the embryo’s right (ileum) - caudal limb cranially and to the embryo’s left (ascending and transverse colon)

-

10th-11th week, get return to abdomen from umbilical cord

Stage II (second rotation)

- 180° counterclockwise turn (appendix has now traveled 270°) -fixation of rotated intestine

Stage III:

Malrotation Stage I (herniation) – premature fixation of duodenum (isolated duodenal malrotation) - failure to progress to Stage II (omphalocele) – occurs with cardiac syndrome/defects - Pentralogy of Cantrell (omphalocele, diaphragmatic hernia, sternal cleft, ectopia cordis, cardiac anomalies) -congenital diaphragmatic hernia – failure of pleuroperitoneal canal to close pulmonary hypoplasia and distress omphalocele – through umbilical cord; covering over intestines; common associated anomalies gastroschisis – defect lateral to umbilical cord (usually right, because of umbilical vein regression); no covering over intestines; associated conditions rare; occurs later in development Stage II -nonrotation - 90° instead of 270° (no rotation and/or return to abdomen; colon on left, small bowel on right) -malrotation - 180° instead of 270° cecum fixes to a wall (Ladd’s bands) and obstructs duodenum (volvulus) -reversed rotation – rare - 90° CCW, then 180° CW -hyperrotation – rare – greater than 270° rotation (dangerous because it twists on itself when not fixed – volvulus cuts off blood supply)

Stage III (fixation) – undescended colon (@ liver); inverted cecum; retroperitoneal cecum; lack of duodenal/colic function (internal hernia) Meckel’s diverticulum - vitelline duct does not regress between 5th and 8th weeks -see it in 2% of the population; it’s 2 inches long; 2 feet from the ileocecal valve; and there are 2 abnormal tissues (gastric (provides H+ for ulcer and pancreas) - around ileum - torsion, ulcers - variety of ways it can fail to close - remnants of yolk sac connection is called omphalomesenteric remnant

Liver – 3rd week; outgrowth of primitive foregut penetrates septum transversum as it rapidly proliferates -10th week – liver represents 10% of body weight; @ birth, represents 5% of body weight -hematopoietic cells – RBCs and WBCs in last 2% of gestation Septum Transversum becomes: 1) peritoneal surface of liver – except for cranial portion, which becomes the bare zone/central tendon 2) falciform ligament – helps suspend umbilical vein from umbilicus; inferior edge will become the ligamentum teres 3) lesser omentum (hepatogastric) – free margin is the hepatoduodenal or hepatogastric ligament; it is the roof of the epiploic foramen of Winslow Biliary System: -connection between liver and foregut narrows and becomes the bile duct; it splits into right and left hepatic ducts -ventral outgrowth becomes gall bladder; anomalies are common -diverticulum becomes liver, gall bladder, and ventral pancreas Spleen -starts in dorsal mesentery of stomach, rotation of stomach moves spleen to the left -dorsal mesogastrium lengthens, and part between spleen and body wall will fuse with the peritoneum (lienorenal ligament) -Wandering Spleen – failure of spleen to attach; presents as abdominal pass causing pain and torsion (cuts off blood supply enlarged!) -accessory spleens – occurs in 10% of population; don’t all fuse at hilum; gonadal desc -important to remove all in a splenectomy Pancreas -ventral bud (near biliary system) uncinate process – inferior portion of head of pancreas; main pancreatic duct of Wirsung -dorsal bud (in dorsal mesentery) remainder of gland, tail; persistent duct can be accessory duct of Santorini -rotation of stomach and duodenum brings two buds together -Annular Pancreas – forms around duodenum during rotation due to bilobed neutral pancreas -Pancreatic Divisum- failure of ducts to fuse; accessory duct can be dominant; this can lead to pancreatitis; can also result in side effecs including starvation -lengthening of the mesentery and pancreas along the posterior abdominal wall retroperitoneal position along with C loop of duodenum 2°

Hindgut -distal 1/3 of transverse colon to rectum/anal canal -4th week – cloaca: 1) anterior UG sinus bladder and GU structures 2) posterior primitive anorectal canal anus and rectum The anterior and posterior cloaca are divided by the urorectal septum (mesoderm). -lined by endoderm, meets the ectoderm of the outside at cloacal membrane (dentate or pectinate line marks the end between ectoderm and the start of endoderm; it is extremely sensitive on the casino side of the tube -7th week -9th week -cloacal membrane ruptures (if not, you get imperforate anus) -ectoderm proliferation covers the anal canal -anal membrane canalizes

proximal anorectal – endoderm – superior rectal artery (from IMA) distal anorectal canal – ectoderm – inferior rectal artery (pupendal) Pectinate = intersection of anal ectoderm and anal endoderm. Anomalies 1) Urorectal fistula 2) Imperforate anus a. low lesion – just a problem with opening; well formed buttocks and anus b. high lesion – less developed or visible anus region (worse than low lesion); treat with colostomy to stop colon and prevent urogenital-GI contamination; do an anoplasty to fix at 6-8 weeks

GI TRACT
Definitions/Boundaries
--Retroperitoneal: Not suspended in a mesentery --Greater omentum: watchdog of peritoneal cavity (can seal off infections if given enough time i.e. appendix rupture) Undersurface fused with transverse mesocolon --Epiploic foramen: superior: caudate liver lobe inferior: 1st stage duodenum posterior: IVC anterior: lesser omentum edge --Triangle of Calot: liver, common hepatic duct, cystic duct; significant because cystic artery found within --Foregut: Upper esophagus to Lig. of Treitz Midgut: Lig. of Treitz to mid-transverse colon Hindgut: mid-transverse colon to anus --Innervation: fore/midgut = vagus; hindgut = sacral (S2, S3, & S4)

Clinical Correlates
--Ascites: Excess fluid in peritoneal cavity caused by hypertension impeding venous flow --Visceral (internal) pain caused by (1) stretch (2) ischemia --Appendicitis --Diverticulosis: herniation of mucosa of appendices epiploica; Diverticulitis: inflammation of diverticula --Cholecystectomy: removal of gallbladder Stomach Duodenum

--Angularis incisura: junction of body/pyloric antrum --When empty, fluids flow along lesser curvature --Empty stomach’s inner mucosa = rugae (folds) which flatten as stomach fills

--Point of fore/midgut junction --Second stage contains ampulla of Vater

Jejunum/Ileum --Plicae circularis = Valves of Kerckring = valvula coniventes to ↑ surface area --Lymphatic nodules = Peyer’s patches --Passing from jejunum to ileum: wall becomes thinner, plicae ↓, arterial arcades ↑ Colon Liver

--Teniae coli—outer longitudinal muscle arranged in 3 bands --Outer wall puckered into haustra --Appendices epiploica—peritoneum cystic duct → covered fat pads that ↑ distally duodenum

--Bare area in contact --Covered by Glisson’s capsule with diaphragm --Functional division = gallbladder Anatomic division = falciform ligament --Path of bile: Right and left hepatic ducts → common hepatic duct → gallbladder (stored)→ common bile duct → Ampulla of Vater →

--Blood supply: hepatic artery, portal vein emptying into IVC Spleen --Bound within gastrosplenic/lienorenal ligaments & lesser sac --Located behind ribs 9, 10, and 11

BLOOD SUPPLY OF GI TRACT
Celiac Axis Inferior Mesenteric Axis

--Celiac = Artery of foregut --Superior mesenteric = artery of midgut; suspended in mesentery of small intestine Hepatic Portal system

--Inferior mesenteric = artery of hindgut

Venous drainage of GI collected in portal system and sent to liver before IVC Areas of Portal-Systemic venous anastomoses 1. Lower end of esophagus 2. Rectum 3. Umbilicus 4. Retroperitoneal portions of gut

--Lymph nodes situated along mesenteric borders of organs & arteries supplying them --Lymph flows back along arteries to 3 main branches (Celiac/SMA/IMA) & into cisterna chyli

CHAPTER TWENTY – GI Histology
BLOCK 3 – GIMNER THREAD: CELL BIOLOGY/HISTOLOGY
CONTRIBUTORS: GEOFF PREIDIS, DANNY BANG, VAFA BAYAT, SARAH BOHN CHRISTENSEN & ROHIT PUSKOOR

TABLE OF CONTENTS MICROANATOMY OVERVIEW OF THE GI TRACT HISTOLOGY OF THE ESOPHAGUS HISTOLOGY OF THE STOMACH HISTOLOGY OF THE SMALL INTESTINE HISTOLOGY OF THE LARGE INTESTINE HISTOLOGY OF THE LIVER I HISTOLOGY OF THE LIVER II CASE BASED TEACHING I CASE BASED TEACHING II

MICROANATOMY OVERVIEW OF GI TRACT
LAMINA PROPRIA – loose connective tissue with many lymphocytes GLANDS – most gut glands are invaginations of epithelium that penetrate the lamina propria and stop at the muscularis mucosa (exceptions – esophagus and duodenum) MUSCULARIS MUCOSA – separates lamina propria from submucosa; very small 1) mucosal flutter 2) mucosal squeeze • INNER CIRCULAR LAYER • OUTER LONGITUDINAL LAYER ADVENTITIA/SEROSA – loose connective tissue; if has flat mesothelial cells covering, then it is called the serosa SUBMUCOSA • Dense irregular connective tissue • Mucus glands will sit in this layer in esophagus and duodenum (very unusual) • Submucosal/Meissner’s plexus – neural crest origin; part of ENS; multipolar somas; handles mucosal flutter and mucosal squeeze MUSCULARIS EXTERNA (MUSCULARIS PROPER, MUSCULARIS) • Big muscular layer which handles all major gut movements • INNER CIRCULAR LAYER • Myenteric/Auerbach’s plexus – multipolar somas; much larger than Meissner’s; gut movement (7): peristalsis, receptive relaxation, pyloric grind, segmentation, saculation/haustration, MMC, mass movement • OUTER LONGITUDINAL LAYER • 3RD OBLIQUE LAYER (only in pyloric stomach, for pyloric grind) MOUTH & ESOPHAGUS Peristalsis Digestion Stratified squamous non-keratinized epithelium STOMACH 1.cardiac 2.fundic 3.pyloric Salivary Glands 1.parotid 2.submandular 3.sublingual Lower Esophageal Sphincter (LES) – must open to get food into cardiac stomach; can’t swallow food if haven’t relaxed LES; if open too often, can get acid reflux Enzymes 1.lactoferrin (keeps iron low) 2.lysozyme (degrades gram (-) walls) 3.sIgA 4.salivary amylase 5.salivary lipase (breaks down to monoglyceride and two free fatty acids) M U C O S A

Functions 1.receptive relaxation (~ 1 hr) 2.pyloric grind, simultaneous with pH drop 3.pyloric sphincter opening

Enzymes 1.pepsins - break down proteins 2.gastric intrinsic factor – binds B12; deficiency will cause megacytic anemia

SMALL INTESTINE 1.duodenum 2.jejunum 3.ileum 4.ileocecal valve

Entero-endocrine Cells (DNES) – hormone secretors 1)open configuration 2)closed configuration Controlled by: • autonomic system • motor patterns • Meissner’s

IN THE DUODENUM… A) Ampulla of Vader 1.exocrine pancreas – enzymes for further break down of chyme; has bicarbonate wash 2.gall bladder – empties through Sphincter of Odi; bile salts for emulsifying fats (come from liver through cystic duct) Must happen simultaneously: • Gall bladder contracts • Sphincter of Odi opens • Pancreatic enzyme secreted • Acidic chyme delivered B) Bruer’s glands – make highly alkaline mucus to neutralize acidic chyme

LARGE INTESTINE/COLON Cecum Asc. Transv. (with colon colon appendix attached)

Desc. colon

Sigmoid Colon

Rectum 1.internal sphincter (smooth musc.) 2.external sphincter (skeletal musc.)

Anal canal Stratified squmaous non-keratinized

Anus

Histology of the Esophagus
Function: Bulk transport—peristalsis linked to opening of LES. Epithelium: Stratified squamous non-keratinized (all cells nucleated, get thinner away from BL, toward lumen). Lamina Propria: --Esophageal cardiac glands in the lower regions only (provide extra protection against gastric juices). --Occasional lymphocyte aggregations around ducts (GALT). --Minor capillary bed—but vessels are huge & dilated near the cardiac region. Related to Melanoma and Portal Hypertension (see below). --Huge invaginations with epithelium to combat friction. Muscularis Mucosa: None, until lower esophagus, where you find a few longitudinal fibers (you don’t need the mucosal squeeze and flutter here; this organ is for bulk transport only). Submucosa: --Esophageal glands—facilitate transport, protection from food. --HUGE vessels. --A few mucus glands (salivary glands make most of the mucus) --Hardly any lymphatic nodules (not much GALT needed here). Muscularis Externa: Upper 1/3 striated, lower 2/3 smooth. Other Histological Features: --Very dark spots are Glycogen granules. --Pale cells w/ halo are Melanocytes (paleness = extracted GLY) NOTE: this is the only Junq image of esophagus—know it!! Key Facts: • Desquamation: stratified cells’ desmosomes oxidize, cells slough off far from BL. --happens in the esophagus; turnover rate is 15d. • Exfoliation: simple epithelium loses its hemi-desmosomes & focal contacts, detach from BL. • Why is Glycogen found in some esophageal epithelial cells? Another part of GALT: when cells desquamate, bacteria metabolize GLY, converting it to Lactic Acid (pH drop kills bacteria). --also occurs in vagina (thus antibiotics that kill off bacteria = no more LAC = no pH drop = yeast infections). • Why are Melanocytes found in the esophagus? As bacteria die (a good thing), they release O2- radicals (a bad thing). Melanin is a sink/neutralizer for radicals. However, cells can develop: • Melanomas: in distal 1/3 of esophagus (the highly vascularized region); easy metastasis. • Portal Hypertension: In chronic alcoholics, liver is constantly destroyed and regenerated, but with fibrotic masses (cirrhosis). Portal blood can’t get through liver to hepatic vein, so anastomosing vessels in the esophagus proliferate, burst, yield torrential vomiting of blood. • Vegetarians: fiber leaves abrasions, so epithelium responds by making keratohyalin (not nearly as elaborate as the keratin pattern seen in skin; esophageal cells never enucleate). • GERD: with acid reflux, the stratified, squamous, non-keratinized epithelium undergoes metaplasia into simple columnar epithelium, producing mucus. • Barrett’s Esophagus: with GERD, acid hits esophagus, which undergoes metaplasia. Additionally, only 1 type of stomach mucus is produced, lacking bicarb wash = even more acid hitting esophagus, leading to malignancy and metastasis in these huge dilated vessels in the cardiac region. Then comes massive ulcer formation, swelling, hypertrophy of LES, and achylasia. • GALT in esophagus: lactoferrin, lysozyme, and sIgA from saliva; low pH (due to glycogen granules consumed by bacteria which release lactic acid); a few lymphocytes (around ducts).

HISTOLOGY OF THE STOMACH Sources: Kretzer lectures 11/3, 11/8; Junq p299-308. Function: --reservoir (receptive relaxation). When empty = rugae. --pyloric grind (propulsion and retropulsion, coordinated by ICCs on greater curvature); --secretions (pepsinogen, gastric lipase, GIF, gastrin) --pH drop (for GALT, and to activate pepsins). Epithelium: Homogenous. --simple columnar; all cells secrete mucus (using apical bicarbonate pumps), forms the… -- Gastric mucosal barrier: 4 types of mucus (cardiac, fundic, pyloric, surface mucus), 1mm, mixed by the mucosal flutter (originating in muscularis mucosa). Expelled by mucosal squeeze (extensions of smooth muscularis mucosa fibers up into the Lamina Propria). --3 types of glands: Cardiac, Fundic, Pyloric. Muscularis Externa: 3 layers (out long, circ, inner oblique

Fundic Gland: note red chief cells and light parietal cells. TEM: canaliculi & mitoch. = parietal cell; RER = chief cell Key Facts: • Cardiac glands: tubular, coiled glands down to muscularis mucosa; secrete cardiac mucus, lactoferrin, lysozyme. • Pyloric glands: very deep pits, shorter coiled secretory portion; secrete pyloric mucus, lactoferrin, lysozyme. • Fundic glands: tubular, straight ducts to muscularis mucosa. Parietal, chief, enteroendocrine (at base), neck mucus, stem cells --Chief cells: basophilic, lower gland. Gastric lipase, pepsinogen. Regulated merocrine secretion, stim by gastrin, Ach, H+. --Parietal cells: eosinophilic. HCl, intrinsic factor (if not reabsorbed in ileum, you get pernicious/macrocytic anemia). Resting state: intracellular canaliculi holding H/K-ATPase, ready to fuse with tubulovesicles to make 1 big PM. Activated: via Histamine secreted from Enterocromaffin-Like Cell (an enteroendocrine cell) = fusion into PM. --Stem cells: few, in neck region. Bidirectional differentiation (up= mucus cells; down= chief, parietal, enteroendocrine cells). --Neck mucus cells: misnomer, not exclusively in the neck of the gland. --Enteroendocrine cells: in bases of glands. G cells = gastrin; D cells = somatostatin (inhibits release of gastrin & others) • Pepsinogen: precursor to pepsins, a protease family—minor digestion. Most takes place in sm. intestine, with bile & pancreas. This minor digestion plays 2 key roles: o making the chyme small enough to pass through Pyloric sphincter. o creating small peptide “signals” for enteroendocrince cells in duodenum to stim. pancreas • Mucus: tetramer of glycosylated glycoproteins. Destroyed by pepsins, so constantly produced. • Gastric Lipase: takes over for salivary lipase, which is inactivated below pH 7. Cleaves TGs into FFAs. • Gastrin Intrinsic Factor (GIF): binds Vitamin B12, to be reabsorbed in intestine. • Gastrin: secreted by enterendocrine cells enriched in antrum & pylorus; yolked to motor patterns. Communicates between pyloric grind of Meissners / Auerbach’s and pepsinogen / acid secretion. • Cell turnover: 4-7 days. Exfoliation, followed by expulsion from glands by mucosal squeeze, then digested by gastric juices. • GALT in stomach: salivary lactoferrin, salivary lysozyme, salivary sIgA, stomach lactoferrin & lysozyme, pH drop, 4 types of mucus in gastric mucosal barrier. • Proton pump inhibitors (PPIs): block Parietal cells’ acid pumps, AND histamine receptor antagonist; trx for gastric ulcers. • Aspirin: breaks down punctate spots in gastric mucosal barrier, so H+ ions free to erode epithelial cells. If gastric ulcers penetrate to serosa (highly vascularized), then you get bleeding into peritoneal cavity. • Alcohol: like aspirin. And ruins parietal cells = less intrinsic factor = pernicious anemia. And, less pH drop = bacteria. And weak pyloric sphincter = bile backwash into stomach = bile-induced gastric ulcers, the worst kind. • Stress: Sympathetic NS turns off the bicarb pump, making you more prone to gastric ulcers.

H. Pylori: live under gastric mucosa, secreting enzymes that block mucus formation & bicarb pump, letting acid eat mucosa. HISTOLOGY OF THE SMALL INTESTINE Sources: Kretzer lectures 11/8, 11/9, Junq p307-321. Function: --digestion (inflow from Vater, Wirsung, Santorini), with enteroendocrine cells’ CCK, secretin, motilin. --absorption (huge SA w/ valves, villi, microvilli) --motility: segmentation, peristalsis, MMC. --hormones; --mucus (protection); --GALT Epithelium: Mixed. Maturing Goblet cells and Enterocytes. Submucosa: Brunner’s glands, large blood vessel plexus. Serosa: thin connective tissue layer covered by mesothelium.

TEMS: Epithelium; enteric cell; lipid-absorption phase; Paneth’s cell; BM under Peyer’s patches. Key Facts: • Brunner’s glands: in duodenal submucosa (only other GI glands in submucosa are tiny esophageal glands). Secrete alkaline mucus to neutralize chyme. • Valves of Kerckring: (aka plicae circularis), 1cm; most are found in jejunum. Submucosa core. • Villi: 1mm, velvety appearance. Lamina propria core. Mixed epithelium: maturing goblet cells / enterocytes. • Crypts of Leiberkuhn: go downward from villi to meet muscularis mucosa. • Microvilli: 1um, true actin core. • Goblet cells (pale, frothy) secrete mucus for protection. Enterocytes (stain dark): absorbtive, secrete sIgA. --Goblet:Enterocyte ratio increases toward ileocecal valve (mucus protection from hardening fecal mass) • Paneth’s cells: make lactoferrin, lysozyme, defensins (bacterial-killing proteins). Never found in colon. --LM: Eosinophilic; stain for lysozyme (secretory granules). --TEM: protein secretor (defensins). Tons of RER, dark secretory vesicles, escape crypts in mucosal squeeze • Stem cells: lower half of crypts (not in neck, as in gastric glands). As new cells migrate to surface, they also differentiate independent of mitosis. They work for a day, then exfoliate. Unidirectional migration. • Enteroendocrine cells/ DNES: both open and closed types. • M cells: no microvilli, just microfolds housing antigen and APCs (macrophages, lymphocytes). Fragmented BM allows easy access. Highest conc. in ileum: tons of lymphatic nodules grouped into a Peyer’s patch. • Microvillar twitch: enterocytes’ microvilli (3000/cell) have real actin core, linked to myosin for motility. o Actin in microvilli bundled by fimbrin and filamen, linked to PM by linker proteins. o actin bundles fray into the terminal web, stuck to adherent junctions containing myosin & villin. • Glycocalyx,/ Enteric coat: very thick, traps pancreatic enzymes and food particles. Enzymes: carboxypeptidases, aminopeptidases, endopeptidases. Both cytosolic and membrane-bound work together • Lipid Assimilation: Lipase (in lumen) hydrolyzes lipids to MG + FFA. Bile acids then create a stable emulsion, which passively crosses microvillar membranes, collected in SER, resynthesized to TGs, packaged into chylomicrons. Most of these go to lymph; some to blood vessels. • Lacteals: lymph vessels; larger than capillaries, but rarely seen in section. Drain to submucosa, where they make many anastomoses and surround lymphoid nodules. • Villar pump: contraction of villus by smooth muscle; shoots 3-5 times per minute. 2 key functions: o Mixes pancreatic enzymes with substrate in the enteric coat. o Squeezes TGs in a lacteal downward, into a lymphatic nodule in the Lamina Propria. • Capillary bed (fenestrated w/diaphragms) densest at tip of villus, where all the mature enterocytes are found, while a less dense bed of non-fenestrated capillaries lies at base of crypts (around stem cells, Paneth’s cells).

• •

GALT in small intestine: some salivary sIgA (preserved by secretory piece); tons of enterocyte sIgA; MMC; secretins; Paneth’s cells; M cell and its associated APCs. Carcinoids: tumor of enteroendocrine cells (clinically, presents as an endocrine problem)

Histology of the Large Intestine
Sources: Kretzer lecture 11/9; Junq p320-324. Function: absorption of water, formation of fecal mass, production of mucus. Epithelium: --Goblet cells more abundant than enterocytes (more mucus needed here). --Enterocytes are columnar with poor microvilli (little absorption needed). --no folds except in rectal region (villi would get ripped off). Lamina Propria: rich in lymphoid cells and nodules (GALT). Large vessel plexus Muscularis Externa: longitudinal fibers reduced to teniae coli. Serosa: contains appendices epiploica of adipose tissue Key Facts: • • • • Haustrations, aka Saculations: the equivalent of segmentation in the small intestine. Together with peristalsis and mass movement, makes up the motor patterns in colon. Stem cells: located in bottom third of crypts of Leiberkuhn. Paneth’s cells: DO NOT EXIST HERE; bacteria is too important. Histology of Appendix: evagination of cecum; narrow irregular lumen caused by abundant lymphoid follicles in its wall. Fewer and shorter glands than in colon. No teniae coli. Appendicitis: frequent because organ is closed-ended: contents not rapidly renewed, thus susceptible to inflammation. Anal region: longitudinal folds of mucusa = rectal columns of Morgagni. Then, 2cm above anus, GI epithelium gives way to stratified squamous epithelium. Hemorrhoids: plexus of large veins in Lamina Propria, become excessively dilated, varicose.


• •

GOBLET CELLS SECRETING INTO THE LARGE INTESTINAL GLAND. MICROVILLI OF ENTEROCYTES HELP IN WATER REABSORPTION.

LIVER HISTOLOGY I&II § Portal Triad

►DUAL BLOOD SUPPLY [1] 80% nutritional; portal vein—intestine (amino acids, sugars, sIgA, B12), spleen (bilirubin), pancreas (hormones), ileum (bile salts); lymphatics (triglycerides) [2] 20% hepatic artery—oxygen rich [3] Two sources mix in liver sinusoids, drains into central / hepatic / collecting venule ►DIVERSE CELL POPULATION [1] 80% hepatocytes—normal aging leads to ↓ hepatocyte density [2] Hepatocyte mitotic activity with damaged lobe, repair via chalones and gap junctions; lifetime 150 days [2] Rest are Ito cells, fibroblasts, Kupffer cells, endothelial cells § Classic Liver Lobule

►DIFFERENTIAL ID VIA LUMEN & WALL THICKNESS [1] Portal venule—may contain erythrocytes, low wall thickness : lumen ratio, squamous endothelial lining + ↑ adventitia; ↑ nutrition, toxics, & metabolites [2] Bile duct—simple cuboidal epithelium, medium wall thickness; new bile from canals of Hering empty here [3] Hepatic arteriole— squamous endothelial lining + ↑ intima media; high wall thickness : lumen ratio; oxygenated blood [4] Sinusoid (not shown)—big lumen, discontinuous, endothelial monolayer ► UNIDIRECTIONAL BILE FLOW [1] Unidirectional pulsation of bile canaliculi from central vein to portal area [2] Canal of Hering bridges bile canaliculi over terminal hepatocyte plate into bile ductule [3] Bile ductule consists of simple cuboidal epithelium; proliferation in biliary disease → cholangials [4] Bile ducts join to become right and left hepatic ducts, which join the cystic duct → common bile duct to ampulla of Vater § Clinical Correlation: Alcoholism

Mallory stain ►HEXAGONAL STRUCTURE [1] Demonstrates vascular blood flow—collecting venule @ center draining blood from 6 spaces of Moll [2] Space of Moll contains triad—portal venule, hepatic arteriole, bile duct, as well as invisible lymphatic vessel and unmyelinated nerves, surrounded by terminal hepatocytes [3] Gradient of detoxification—highest @ perilobular, cleanest @ centrolobular [4] Liver sinusoids—fenestrated w/o diaphragms, no basal lamina, large lumen

►5 SITES OF FIBROSIS IN CIRRHOSIS (2° ALCOHOLISM) [1] periphery of classic liver lobule [2] space of Disse (↓ Ito cells, ↓ hepatocyte microvilli) causing ↓ vitamins (A, D, E, K), ↓ sinusoidal sampling & ↓ detox [3] bile duct causing bile insufficiency and obstruction [4] obliteration of space of Moll [5] around central vein causing portal hypertension

►OTHER SX OF ALCOHOLIC LIVER [1] pernicious anemia 2° vitamin B12 malabsorption [2] poor nutritional habits lead to ↓ glucose metabolism & ketosis [3] bile insufficiency & poor bilirubin breakdown leads to ↑ fat & ↓ urobilin in pale, floating stool § Hepatic Acinus (of Rappaport)

[5] SER damaged by barbiturates, underdeveloped in neonate; responsible for detox [6] SER site of de novo bile acid synthesis (10%), rest is recycled from portal circulation [7] 3 distinct plasma membrane surfaces facing: the space of Disse, adjacent hepatocytes, & bile canaliculus

►3 ZONES OF DECREASING TOXICITY [1] Diamond shaped acinar view demonstrates effect of incoming blood flow on liver tissue [2] Perilobular hepatocytes most affected by toxic substances (zone I) followed by mid-central (zone II), centrolobular last (zone III). § Hepatocyte, Kupffer, & Bile

►BILE & BILIRUBIN MANAGEMENT [1] Bile canaliculus (EM above) is central gutter isolated from sinusoid by tight junction, closed off from central venule. Contains actin filaments around cytoplasmic side → contract in a wave to move bile towards portal area [2] Bile acids in canaliculi are primary bile acids—maximally hydroxylated & conjugated to taurine and glycine [3] Bile canaliculi contain primary bile salts, bilirubin glucuronide, sIgA, bicarbonate, cholesterol [3] Hydrophobic bilirubin is formed in macrophages in spleen, bone marrow, and Kupffer cells; passed to hepatocytes and transformed to bilirubin glucuronide, which is secreted into bile to be passed in stool [4] Blocked or deficient bilirubin management causes jaundice and pale stool ►KUPFFER: SYNTHESIS AND DEGRADATION [1] Responsible for 5% of plasma protein synthesis [2] Derived from monocytes, like Ito cells [3] Ability to degrade aged erythrocytes and hemoglobin into bilirubin

► STRUCTURE/FUNCTION: SINUSOIDAL SAMPLING [1] Perisinusoidal space of Disse (1) between discontinuous, singlelayer sinusoidal endothelium (2) and hepatocyte [2] Microvillous (not true microvilli) extensions of hepatocyte lie in space of Disse, stretching to sample sinusoidal blood [3] Trace reticular fibers from scarce fibroblasts support hepatocytes, keep sinusoids open, provide scaffolding for orderly hepatocyte regeneration [4] Ito cells of monocyte origin reside in space of Disse storing vitamins A, B12, D, E, K [5] Structure features allowing above function include: gaps in endothelium, endothelial fenestrae arranged into extensive sieve plates, no diaphragms, no basal lamina, scarce reticular scaffolding ►HEPATOCYTE EM: EXTENSIVE METABOLIC PROCESSING [1] EM: look for rod-like mitochondria, stacked RER, lysosomes; black irregular clusters of glycogen; nucleus (3) very euchromatic with gaps along nuclear envelope. [2] Lysosomes needed for protein, bacteria degradation, peroxisomes for lipid metabolism and ß oxidation; peroxisomal dysfunction—adrenoleukodystrophy [3] Glycogen granules collect near SER, reflective of nutritional state [4] RER makes blood plasma proteins (constituitive, merocrine, endocrine liver): albumin, fibrinogen, prothrombin, transferrin, lipoproteins, angiotensinogen

CASE-BASED TEACHING I & II
• 20 million adults in U.S. / 4-11% • 0.15-1.4% in children / more in infants, adolescents Bile = water, bilirubin, bile pigments, cholesterol, phospholipids 2 Types of gallstones: black (bile pigments), cholesterol Gallstones require: supersaturation, stasis/still environment, nucleation Black stones Radiopaque, equal gender, any age; assoc. w/ hemolysis, cirrhosis, TPN, Ileal disease, Ceftriaxone Cholesterol stones White to yellow, more female, puberty onset; assoc. w/ obesity, birth control pills, pregnancy, c.f.

GALLSTONES

Endoscopic retrograde cholangiopancreatography (ERCP)—uses a dye and X-Rays to outline gallbladder, pancreas; uses general anesthesia, experienced biliary endoscopist, staff Extracorporeal Shockwave Lithotripsy (ESWL)—powerful shock waves produced by a medical instrument to break up gallstones Choledocholithiasis—gallstone in the bile duct—Sx=jaundice, RUQ pain, fever identified: leukocytosis (↑WBCs), ↑LFTs (Liver Function Tests), ↑GGT (Gamma glutamyl transpeptidase), ↑alkaline phosphatase, ↑conjugated bilirubin, MRI, ultrasound • • • • • • • • • • • • • • HELICOBACTER PYLORI—MARK GILGER Only recently identified conclusively; 40 strains; potentially serious consequences Gram-neg., microaerophilic, spiral, 4-6 sheathed flagella, lives sub-mucus, urease producer One of the most common infections ≈ 3 billion; humans only reservoir; small children (hi re-infection rate) may be key to human transmission; vaccine proving difficult Person-person transmission (unknown mode), common in underdeveloped nations, low socioeconomic, crowded; more in African-American, Hispanic Risks: peptic ulcer (17-20%), gastric adenocarcinoma (1%) – both declining for 40 yrs Computer trending disappear in U.S. in 100 yrs w/o intervention Pathogenesis: ingestion, swim thru mucus, attach to mucosa (adhesion molecules), acute inflammatory response (acute gastritis), chronic inflammatory response 80-90% = mixed/mild gastritis = asymptomatic = normal acid secretion 10-20% = antral gastritis = ↑acid, peptic ulcers, (less cancer risk) 1-3% = corporal/fundic gastritis = ↓acid, gastric atrophy, (more cancer risk) Suggestive: epigastric pain, hematemesis (upper GI bleeding), halitosis (bad breath) In children: acute, chronic (most common) infections, gastric, duodenal ulcers, cancer: maltoma, adenocarcinoma Tests: serology, urea breath test, fecal antigen, saliva, upper endoscopy with gastric biopsy & culture, silver stain Triple therapy—2 weeks—proton pump inhibitor + 2 antibiotics, 68-95% success

CELIAC DISEASE Definition: immune-mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. May be associated with family history of other autoimmune disorders such as type 1 diabetes. • Gluten – found in wheat, rye and barley • Classic gastrointestinal manifestation: age 6-24 months correlating with end to breast feeding, chronic diarrhea, abdominal distention and pain, anorexia, irritability, failure to thrive. • Diagnosis: o Serologic test: best one is anti-tissue transglutaminase antibodies TTG (IgA) o Upper GI endoscopy: scalloped appearance and mucosal nodularity in duodenal folds o Histologic section: villi disappear, tissue becomes more cellular and flat (note: Kretzer had a slide of this on the last practical) • Treatment: Lifelong strict gluten-free diet.

Chapter Twenty-One – Gut Physiology
BLOCK 3 – GIMNER THREAD: PHYSIOLOGY
CONTRIBUTORS: MATT DRISCOLL, CRYSTAL WHITE & ROHIT PUSKOOR

TABLE OF CONTENTS: GUT NEUROPHYSIOLOGY GUT MOTILITY I GUT MOTILITY II GUT MOTILITY III GUT SECRETIONS I GUT SECRETIONS II GUT SECRETIONS III

MARELLA DEBIASI MARELLA DEBIASI MARELLA DEBIASI MARELLA DEBIASI MARELLA DEBIASI MARELLA DEBIASI MARELLA DEBIASI

GUT NEUROPHYSIOLOGY
Gut Innervation Together Controls: 1.muscle contraction 2.secretion 3.blood flow 4.absorption of nutrients from digesta INTRINSIC INNERVATION EXTRINSIC INNERVATION (long-distance) (local) SYMPATHETIC: PARASYMPATHETIC: ENTERIC NS: 1.submucosal/Meissner’s • Long preganglionics • Short preganglionics 2.myenteric/Auerbach’s originating from dorsal from T1-L4 release Ach motor nucleus of onto nicotinic receptors in 3.subepithelial plexus – vagus with ganglion ganglia outside the organ very small, very few neurons; important for inside innervated organ • Decreased motility and mucosal flutter and • Lower esophagus secretions (stress squeeze through intestine – response or exercise) vagus nerve (CN X) ENS Neurons: Three Gut Ganglia (parallels • Anal portion of 1.secretomotor (efferent) arteries): intestine (S2-S4) 2.interneurons (can be 1.celiac • Increased motility and excitatory or inhibitory) 2.superior mesenteric secretions 3.sensory (afferent) 3.inferior mesenteric a)mechanoreceptors Postganglionics release: b)osmoreceptors Postganglionics release NE: 1.Ach and SubP (excitatory) c)chemoreceptors 1.inhibitory to non-sphincter 2.NO (activates cGMP); VIP muscle (β-adrenergic) (decreases net IC Ca++); and 2.excitatory to sphincter muscle ATP (inhibitory) (α-adrenergic) Gut Reflexes: Short range reflexes Controls: 1.muscle activity 2.fluid and electrolyte exchange between lumen and tissue 3.vascular control Examples: 1.Enteric reflex – allows gut to sense bolus, produce contraction in one gut segment and relaxation in another 2.Secretory reflex – same as enteric, but output is secretion Long range reflexes Allows gut function to be controlled not only locally, but over distal/proximal portions of the GI 1.vago-vagal reflex – NTS has the ability to adjust efferent output at the level of the dorsal motor nucleus of the vagus in response to sensory input 2.gastro-enteric EXCITATORY (4) – 3.gastro-ileal as food comes into 4.gastro-colic stomach, have reflex 5.duodeno-colic to move digesta further down the line 6.intesto-intestinal INHIBITORY(2) – 7.ileogastric slow down motility and contractions

CLINICAL CORRELATIONS Chronic Constipation: Irritable Bowel Syndrome: caused by progressive • Bouts of constipation alternating with bouts of diarrhea degeneration of ENS, • Gut neurons don’t work well causing slower transit • Emotional component (emotions sent by CNS to PNS 11.through GI will also travel through ANS to gut)

GUT MOTILITY I - GENERAL COMPONENTS OF MOTILITY
o Gut motility is controlled by 3 types of input: myogenic, neuronal, and hormonal. o Slow waves and Spike Potentials 1. Slow waves - myogenic, Basic Electric Rhythm (BER) Rhythmic calcium influx followed by efflux of potassium. Initiated by Interstitial Cells of Cajal - modified smc's • ICCMY's - ICC's located in myenteric region (near myenteric plexus) • ICCIM's - intermuscular ICC's - individual ICC's located within the layers of smc's (mixed in with the muscle). Not AP's, but have graded intensity. • Intensity and level of depolarization depends on extrinsic input (stretch, Ach, parasympathetic all increase/ NE, sympathetic, NO all decrease) o i.e. A bolus of food will stretch the gut and increase slow wave intensity Contraction will occur even without action potential when the slow wave rises above "contractile threshold". • Spike potentials will not occur until wave rises above "electrical threshold". 2. Spike Potentials Frequency ↑ w/ ↑ depolarization of slow waves until membrane potential reaches -20 at which point tonic contraction occurs. Spike potentials only occur w/ depolarization greater than ELECTRICAL threshold They are a non-graded contraction (all or nothing) o General Types of Communication 1. Chemical (neurotransmitters) vs Electrical (gap junctions) 2. Multiunit (electrical isolation, finely controlled movements) vs Single Unit/Unitary Smooth Muscle (electrically connected, coordinated K) o Fundamental Motor Patterns 1. Peristalsis: propulsion, moves food forward. 2. Mixing Movements: churning, mixing, back and forth. 3. Accommodation: Reservoir function. o ICC and GI Pathologies: ICC density is reduced in the following diseases: 1. Slow Transit Constipation 2. Diabetes Mellitus

GUT MOTILITY II - ESOPHAGUS AND STOMACH
o Peristalsis in Esophagus o Primary - Initiated by Nucleus Ambiguous and carried out by vagal motor neurons. Upper esophageal sphincter (UES) and proximal esophagus are skeletal muscle. Distal esophagus is smooth muscle. As the peristaltic wave moves distally, more is initiated by ENS and less by vagus (vagus still modulates). o Secondary - Not normally initiated by routine swallowing. Used instead when additional peristalsis waves are necessary (i.e.: something is stuck, reflux, etc.) Activated by Mechanoreceptors, acid receptors, and osmoreceptors. Occurs only in distal, smooth muscle portion of the esophagus o LES relaxes to allow bolus to pass. Normally, tone is maintained by Ach NO normally produces relaxation for swallowing (deglutition) Achalasia - inability to swallow caused by either loss of inhibitory neurons or loss of all myenteric neurons (no excitatory nor inhibitory) • Associated with GERD. o GERD - Flow of Gastric juices from stomach to esophagus. o 4 Normal Barriers: LES pressure (most important), Esophageal Mucus, Clearing of acid by Secondary Peristalsis, and Normal gastric motility. 3 things may reflux: Acid, Pepsin, and Bile (requires Pyloric Sphincter reflux) o Stomach Motility o Physiologists divide into proximal (inactive) and distal (active) Motor Functions of the Stomach include MMC, Reservoir, Mixing, Grinding, and Gastric Emptying o BER originates in pace setter region along greater curvature (3 cpm). Fundus has no rhythmic electrical activity o Fasting State - only low amplitude slow waves. No contractions. o Fed State - Action potentials accompany amplified slow waves causing waves of contraction = peristalsis. o Motility Patterns of Stomach: Fasting Eat Receptive Relaxation in proximal stomach Peristalsis moves food toward pyloric sphincter Antral Systole and mixes food as it refluxes back toward proximal stomach • Proximal stomach regulates intragastric pressure. • Only particles < or = 1-2mm may pass pyloric sphincter. o Gastric Emptying Times o Esophagus - 10 sec, Stomach - 3h, SI - 7-9h, LI 25-30h, Rectum 30-120h o Factors that slow Fed State Motility High fat, sugar, and protein content Low pH, solid foods, lying down, large quantity of food Some hormones - Progesterone (pregnant women) o Diabetic Gastropathy o Hyperglycemia decrease number of ICC's Decreases Motility o Ketoacidosis Ileus (paralysis gut), including gastroparesis (stomach paralysis) o Gastrectomy - w/ severe obesity or gastric tumors o Billroth I - ligate remaining stomach to beginning of duodenum o Billroth II - bypasses some of proximal duodenum w/ re-attachment of remaining stomach

GUT MOTILITY III - SMALL INTESTINE TO RECTUM
o Small Intestine Motility o Major Functions = digestion and absorption. o Motor Patterns Fed • Mixing - "segmentation" - circular segmental contractions simultaneous w/ longitudinal contractions • Propulsion - peristalsis - ENS sensory neuron at site of bolus causes contractions of circular muscle behind bolus and relaxation in front. Opposite for longitudinal muscle. Carried out by ENS. Modulated by ANS. o Initiated by pressure dependent release of 5-HT from enterochromafin cells into lamina propria sensory neurons Fasting - MMC - 3 phases, 90 minutes total • BER w/o contractions - 60 min • Irregular Motor activity-random spike potentials on top of waves-20 min • Regular contractions w/ propulsion - 10 min o Colon/Large Intestine Motility o Functions: Absorption of water and electrolytes, Mixing, Propulsion, Storage of fecal matter until expulsion o Motor Patterns - not as organized as SI (no distinct fed/fasting patterns). Haustrations - similar to segmentation - creates haustra (baggy appearance) as some sections are relaxed and others are contracted. Mass Movement (aka - power propulsion) - 2-3/day - 20cm movements of fecal matter toward rectum. • Contraction of circular muscle in a distended area of colon longitudinal muscle contraction follows LI folds up like an accordion in front of the ring of contraction, moving chyme analward • "Long Duration" contractions move digesta away from proximal transverse colon in either direction • "High Amplitude” contractions move digesta a long distance from proximal transverse colon toward anus o Defecation - Rectum is usually empty because of a "functional" internal anal sphincter distention of rectal wall by fecal matter in the rectum initiates the Defecation Reflex: Intrinsic Defecation Reflex – initiated by ENS (myenteric plexus) • Peristalsis in descending, sigmoid, and rectum • Intrinsic Defecation Reflex is weak on its own Parasympathetic Defecation Reflex • Increases peristalsis via pelvic nerve reflex • Strengthened peristalsis generated by ENS o Hirshprung's disease (aganglionic megacolon) -Lack of neurons on distal colon - present @ birth Retarded bowel function, Distended distal colon and abdomen, Gradual onset of vomiting, and Fever

GUT SECRETIONS I
Saliva Functions Lubricate and bind food/solubize dry food Alkaline buffering Initial starch digestion Initial lipid digestion (medium chain TG) Antibacterial Saliva Contents Mucin-glycoprotein Bicarb secreted into ducts Alpha-amylase Lingual lipase (secreted by von Ebners glands) Muramidase-gram positive bacteria Lactoferrin-binds Fe ions sIgA Growth factors Types of Salivary gland • Parotid-serous, water secretions • Submaxillary(mandibular)-mixed • Sublingual-mucous secretions In acini: -fluid similar in ion concentration to plasma is secreted -serous acini=water secretion -mucous acini=mucus-rich secretion In salivary duct (impermeable to H20): -Na+ & Cl- absorbed -K+ & HCO3+ secreted Resutlt: Hypotonic saliva ↑ flow->↓time in duct-> ↑ Na+ & Cl-, ↓ K+ & bicarb

Growth of mucosa & autonomic neurons

Control of Saliva flow: PNS increases blood flow ->increased saliva production Gastric Secreting Cells Surface Epithelium -produce mucous containg mucin and bicarb (protect from low pH) -tight junctions contribute to protective gastric mucosal barrier Oxyntic (Parietal) cells -secrete HCl and intrinsic factor -low pH activates pepsin -intrinsic factor necessary for B12 absoption in ileum -stim by Ach, histamine, gastrin Enterochromaffin-like cells (ECL) -enteroendocrine cells -produce histamine which stimulates acid secretion -stim by Ach and gastrin Actions of Gastric Secretions -digestion: pepsin (protein) and lipase (TG) -protection: low pH (kill bacteria) -antianemic: intrinsic factor (absorption of vitamin B12) -stimulatory: bile and pancreatic juices Gastric Mucosal Barrier -protective barrier -damaging factors: H. pylori, acid, pepsin, NSAIDs, smoking, alcohol, bile acids, ischemia, hypoxia -protective factors: bicarb, mucus, blood flow, frowth factors, cell renewal, prostaglandins -when damaging factors increase of protective decrease damage results (erosion is superficial to muscularis mucosa while an ulcer penetrates muscularis mucosa)

Chief (peptic) cells -pepsin (secreted as inactive pepsinogen) G-cells -secrete gastrin (peptide synthesized as preprohormone and cleaved) -stim by food digestion products (peptides, AA, Ca+) -inhibited by very low pH D-cell -secretes somatostatin -inhibits parietal cell and histamine release -“senses” lumen acid Phases of Gastric Secretion Cephalic (10-20% of secretions) Gastric (50-60% of secretions) -Stim by sight/smell/taste of food, -Stim by distention of stomach, digestion of chewing swallowing or hypoglycemia protein -Regulated by vagus nerve -Regulated by local ENS and vagovagal -Ach, Gastrin & histamine stim parietal reflexes cells -Ach, Gastrin & histamine stim parietal cells

Intestinal (10-15% of secretions) -Stim by protein digestion products (vagovagal response) -involves endocrine and G-cells

GUT SECRETIONS II
Hormones Secretin -stim by acid (in duodenum) -stim HCO3- secretion from exocrine pancreas and inhibits gastric emptying -synthesized as preprohomone, cleaved to peptide CCK -stim by AA, FA -stim enzymes from pancreas and gallbladder contraction GIP -stim by glucose, FA -inhibits gastric emptying and acid secretion Motilin -peptide seceted by endocrinocytes of proximal small intestine -controls smooth muscle contraction in upper GI tract Factors preventing autodigestion of pancreas: -trypsin inhibitors in panreatic tissue and secretions -secretion of zymogens (inactive enzyme) -enzymes in membrane bound granules -pressure gradient favoring unidirection flow from pancreas to duodenum

Exocrine Pancreas-bicarb and digestive enzymes -secreted from acinar cells, carried in ducts

Endocrine Pancreas -insulin and glucagon

Pancreatic Acinar Secretions (most secreted as inactive proenzyme) -Proteolytic: trypsinogen, chymotrypsinogen, procarboxypeptidase, proaminopeptidase -Amylolitic: alpha-amylase -Lypolytic: lipase, prophospholipase, procolipase -Nucleolytic: ribonuclease, deoxyribonuclease

Pancreatic acinar secretions become more alkaline traveling through ducts -bicarb secreted into lumen of duct -creates acid tide in blood -cystic fibrosis transmembrane regulator important for bicarb secretion: patients w/ CF → high protein concentration in pancreatic ducts occludes ducts → pancreatic insufficiency and diabetes **Other effects of cystic fibrosis** -clogged airways and respiratory infection Phases of pancreatic excretions -plugged small bile ducts of liver impede Cephalic and Gastric: release Ach to stim secretions and digestion gastrin which stim CCK (which stim secretion) and liver function Intestinal: most important phase for pancreatic secretion, -obstruction of gut by thick stools secretin stimulates bicarb, major effect from direct stim -absence of vas deferens renders 95% of males of CCK by AA and FA in intestine infertile -excessive NaCl in sweat Bile Formation *Hepatocytes secrete bile into canaliculi *Intrahepatic and extrahepatic ducts secrete a watery, HCO3 rich fluid into bile *Between meals parto fbile goes into glallbladder which removes H2O and electrolytes *Bile that reaches the duodenum is a mixtere of diluted hepatic bile and concentrated gallbladder bile Gallbladder Contraction Phase 1. Fasting (late phase 2 MMC) (25%) 2. Cephalic (15-25%) 3. Gastrointestinal (>50%)
Factors affecting chyme composition: -rate of gastric emptying -rate of pancratic fluid secretion -rate of gallbladder emptying

Bile acids and salts *Amphipathic to solubilize fat *Reabsorbed by the gut to be reused *Chenodeoxycholic acid and cholic acid are most abundant *Form micelles w/ FA and deliver FA to enterocytes for absorption

Factors controlling bile secretion CCK- ↑ secretion Secretin- ↑ HCO3 secretion Gastrin- stim via secretin and direct stim Motilin- ↑ secretion PNS-gallbladder contraction and sphincter of Oddi relaxation SNS- gallbladder relaxation and ↓ secretion

Mechanism 1. Vagal cholinergic, motilin, and other neuropeptides 2. Vagal cholinergic 3. CCK, cholinergic, hormonal

-rate of transport of chyme ouot of proximal duodenum (intestinal motility)

GUT SECRETIONS III
Fluid In -1500 mL from diet -7000 mL from secretions of stomach, small intestine, pancreas and billiary tree Passive Transport -solute moves down its electrochemical gradient Passive Diffusion -no protein necessary Ion-specific Channels -pore that allows rapid passive diffusion Secondary Active Transport -use electrochemical gradient of one solute to move another against its gradient paracellular 1)GLUT-2 facillitates glucose transport across basolateral membrane of enterocyte 2)Na+ channels *electrogenic (net transfer of charge across epithelium) *amiloride-inhibitable channels in colon are responsive to mineralocorticoids *maintains lumen-negative potential diff across gut mucosa 1)Nutrient specific absorption of Na+ *SGLT-1 receptor on apical surface of enterocytes *Na+ transported into cell down its gradient, carrying glucose against its gradient (Na+ gradient set up by Na-K ATPase) 2)Na-H exchange & Na-Cl absorption *Na-H antiporter transports Na+ into cell (down gradient) and H+ (up gradient) *Cl-HCO3 exhanger transports HCO3-(down) & Cl- (up) *Na-H antiporter throughout small intestine, Cl-HCO3 only in ileum → neutral NaCl absoprtion in ileum, luminal acidification in jejunum Na-K ATPase creates low concentration Na+ & low K+ in cells-gradients often used for secondary active transport Absorption/Excretion -7000 mL absorbed in small intestine -1400 mL absorbed in colon -100 mL excreted in feces

Active Transport -solute moves up electrochemical gradient

Pumps -use ATP to move solute against gradient Mechanism of Cholera

*classic cholera toxin (CT) stimulates enteric neurons (altering moter function) and endocrine cells which secrete prostaglandins, serotonin and VIP → activate adenylate cyclase → increase cAMP → activating Clrelease into lumen and inhibiting Na+ absorption *zona occludens toxin (ZOT) loosens tight junctions allowing water to leak back into lumen *accessory cholera toxin (ACE) has unknown function *actions combine to give secretory diahrrea → dehydration

Treatment of Cholera (Oral Rehydration Therapy) *glucose rich fluids *Na-glucose symporter unaffected by cholera toxin → Na+ will be absorbed with glucose creating hypertonic basolateral space → water is also reabsorbed bring Na+ and Cl- (via solvent drag) and further increasing hypertonicity of basolateral space

Absorption and secretion of electrolytes

Chapter Twenty-Two – Metabolism
BLOCK 1 – CORE CONCEPTS & BLOCK 3 – GIMNER THREAD: BIOCHEMISTRY & GENETICS
CONTRIBUTORS: ELLEN HAMMER, LIVIA VAN, BEN MCARTHUR, MICHAEL PIRICS, THELMA GAYTAN, NICHOLETTE LAWSON, AARON CARDON, BRYAN CHAMBERLAIN, CHRIS KAUFMANN, MARISA RODRIGUEZ & VAFA BAYAT

TABLE OF CONTENTS: ENERGY METABOLISM I ENERGY METABOLISM II ENERGY METABOLISM III METABOLISM IN THE FED STATE CARBOHYDRATE METABOLISM IN THE FED STATE PROTEIN METABOLISM IN THE FED STATE FAT METABOLISM IN THE FED STATE REGULATION IN THE FED STATE METABOLISM IN THE FASTED STATE CARBOHYDRATE METABOLISM IN THE FASTED STATE PROTEIN METABOLISM IN THE FASTED STATE FAT METABOLISM IN THE FASTED STATE REGULATION IN THE FASTED STATE GUT DIGESTION GUT ABSORPTION CHOLESTEROL METABOLISM CHOLESTEROL & ATHEROSCLEROSIS BIOPRODUCT METABOLISM PURINE/PYRIMIDINE METABOLISM METABOLISM IN THE STRESSED STATE METABOLISM IN STARVATION & EXERCISE

Energy Metabolism I: citric acid cycle
Acetyl CoA - Fat, Protein, and CHO metabolism all converge on Acetyl CoA (requires pantotheine, B5) Mitochondria Outer membrane: not very important, all metabolites past through freely Inner membrane: where energy generation occurs Mitochondrial matrix: all entry controlled by inner membrane transporters o Pyruvate made in cytosol o Conversion to Acetyl CoA (in matrix, catalyzed by PDH complex) Pyruvate Dehydrogenase Complex (PDH) Key regulatory enzyme components o TPP: Thiamin pyrophosphate (B1, thiamin) o Lipoic acid o FAD (B2, riboflavin) o NAD (B3, niacin) Converts pyruvate to AcetylCoA, releasing 1 NADH Citric Acid Cycle key regulatory enzymes o citrate synthase o isocitrate dehydrogenase o _-ketoglutarate substrate level phosphorylation o 1GTP generated directly from succinyl CoA o other ATP is from NAD and FAD in ox. phos. yield: o o 3 NADH,1 FADH, 1 GTP (and 1 NADH from PDH) Total = 12.5 ATP/pyruvate or 10 ATP/AcetylCoA

-

Pyruvate carboxylase TCA cycle intermediates are entry points for a lot of other metabolic pathways. To replenish this drain on TCA intermediates, pyruvate carboxylase uses biotin, B7 to drive: PYR  OAA (stimulated by Acetyl CoA) Biotin is involved with most carboxylation reactions. Regulation of the TCA Cycle Signal metabolites o AMP-like (ADP, AMP, CoASH, NAD+, Ca2+) ---- drives PDH reaction and TCA cycle forward o ATP-like (ATP, AcCoA, citrate, NADH) ----------- inhibits Regulatory phosphorylations o PDH complex - (P) = ACTIVE o PDH complex + (P) = INACTIVE Cofactor cycling o NAD and FAD must be available for reaction to move forward. o The availability of these cofactors is also a regulation

-

Energy Metabolism II: oxidative phosphorylation
Energy from electron transport is used to drive a proton pump in the inner mitochondrial membrane. The proton pump creates an electrochemical gradient with more H+ in the cytosol and less in the matrix. This proton motive force drives protons back into the matrix through ATP synthase, catalyzing ATP synthesis.

Electron transport chain Membrane bound components o Complex I: NADH dehydrogenase o Complex II: cytochrome b-c1 reductase o Complex III: cytochrome oxidase Mobile components o Coenzyme Q: ubiquinone o Cytochrome c NADH enters at Complex I and yields 2.5 ATP FADH enters at coQ and yields 1.5 ATP Electron Carriers Each of these complexes come with their own unique set of electron carrers. Examples of components include heme, copper, flavins (FMN), iron….) Semiquinone Intermediates Electron carriers (CoQ and flavin mononucleotide FMN) that can accept or donate one electron at a time can form semiquinone intermediates. As a result, they can scavenge free radicals. Reactive Oxygen Species (ROS) Oxygen radicals can sometimes escape the mitochondria before they are fully reduced to water. These superoxide anion radicals can form 1. hydrogen peroxide Reactive oxygen species 2. hydroxyl radicals 1. 2. Superoxide dismutase Glutathione peroxidoes

Detoxifies ROS

Inhibitors Used to study and elucidate the order of the complexes of the electron transport chain 1. antimycin Block respiration: the transfer of electrons to oxygen 2. cyanide 3. oligomycin – blocks ATP synthesis 4. atractyloside, bongkrektate – inhibit ADP recycling (needed to make ATP) Uncouplers Respiratory control is the coupling of electron flow to O2 and the synthesis of ATP. Uncouplers collapse the proton gradient so no ATP synthesis occurs even though respiration continues and even increases. 1. 2. Diseases 1. 2. UCP (mitochondrial uncoupling protein) – brown fat in mammals in response to cold, generates heat from uncoupling gradient. DNP (dinitrophenol) – will carrier H+ across the membrane, collapsing the gradient. most present as muscle myopathies and neurological symptoms MELAS, MERRF – maternally inherited defects in mitochondrial tRNA’s

ENERGY METABOLISM III- GLYCOLYSIS
Objectives: I. Metabolic Function of muscle and how it cooperates with other organs - muscle serves as major reservoir for protein (used for gluconeogenesis) and glycogen (used strictly for muscle energy needs) - glucose in muscle is only used by the muscle because once hexokinase converts glucose into glucose-6-phosphate, there is no phosphatase to convert it back to glucose - ATP is needed for contraction, two ways of getting ATP 1) anaerobic: phophocreatine => creatine, glycolysis (4 ATP/ glucose molecule) 2) aerobic: glycogen (immediate needs) and fat II. Understand how glycolysis generates energy aerobically and anaerobically - aerobically, glycolysis serves to generate pyruvate which will be converted to acetyl CoA, which enters into the TCA cycle in the mitochodria and then ATP is generated in the electron transport chain via oxidative phosphorylation (32 ATP are generated) -anaerobically, glycolysis yields two pyruvate, two ATP, and two NADH, which are converted back to NAD+ by lactate dehydrogenase (producing lactic acid byproduct) III. Know how glycolysis in muscle behaves under different metabolic states -when food is available 1) storage occurs: 1) G6P => glycogen, 2) pyruvate => protein, 3) AcCoa => fat 2) glycolysis and TCA cycle are run for muscle energy needs -when energy is need 1) glycogen is converted to G6P, which enters glycolysis 2) protein is converted to pyruvate to be used in TCA cycle and amino acids are transported to the liver to be converted to glucose via gluconeogenesis 3) Fatty acids are converted to ACoA to enter the TCA cycle * if oxygen not available, glycolysis runs only, making lactic acid (converted to glucose by the liver via the Cori Cycle)

IV. Control points of glycolysis
enzyme glycogen synthase glycogen phosporylase hexokinase Phosphofructokinase Fructose Bisphosphatates Pyruvate Kinase Activation G6P Low energy signals: AMP, Ca+2, cCMP Low energy signals: AMP, F26P High energy signals: ATP, citrate F16P Deactivation ATP, G6P G6P High energy signals: ATP, citrate Low energy signals: AMP, F26P ATP Substrate G1P Glycogen Glucose Fructose 6 P F 1,6 P PEP Product Glycogen G16 G6P Fructose 1, 6 P F6P Pyruvate

-Ca +2 and PKA phosphorylates: activates phosphorylase kinase and inactivates phosphatase - PFK2 in liver can be inactivated by phosphorylation, but can’t be inactivated by muscle. This enables muscle to continue to use glucose when energy is low, but liver will perform gluconeogenesis V. Function of Creatine Kinase and sources of energy available for muscle - phosphocreatine + ADP converted to creatine + ATP, buffers ATP concentration during anaerobic exercise - sources of energy for muscle, listed from the least amount of ATP generated to the greatest amount: Muscle ATP < Creatine phosphate < glycogen to lactate < muscle glycogen to CO2 < liver glycogen to CO2 < adipose tissue FA to CO2

METABOLISM IN THE FED STATE
Be familiar with the role the intestine plays in the Fed State The primary role of the intestine in this state is digestion of food and absorption of nutrients for use in storage molecule synthesis. The fed state is the time during and shortly after eating; the energy consumed exceeds the requirements of the body. Food is digested and used to synthesize storage molecules. Carbohydrates are broken down into glucose, fructose, and galactose. Proteins are broken down into amino acids. Fats are broken down into fatty acids which are transported as chylomicrons.
INTESTINAL LUMEN BLOOD INTESTINAL LUMEN LYMPHATIC SYSTEM

Proteases

Amino Acids

Amino Acids

Amin o Acids

Fatty Acids
Lipases

FA TG Chylo

Proteins
Peptides

Peptidases

Triglycerides
Monoglycerides MG

Peptides

Intestinal Epithelial Cell

Intestinal Epithelial Cell

Begin to learn the fates of carbohydrates, fats, and proteins in the diet In the fed state, the primary goal is storage of energy in the form of storage molecules. Macromolecule Storage Molecule Organ of Storage Carbohydrate Glycogen LIVER, muscle* Protein Proteins MUSCLE, liver Fat Triglycerides ADIPOSE *Glycogen stores in muscle cells can only be used by the cell that stores them since it has no glucose-6-phosphorylase Become familiar with the cellular diagrams and patterns of metabolite flow in energy metabolism These will be on the next lectures in more detail Understand the metabolic roles of liver, adipose, muscle, brain, kidney, intestine, and anaerobic tissues in the overall coordination of energy metabolism in humans Kidney Liver Muscle Secretes nitrogen Stores glycogen Major protein storage Some protein storage Stores some fat Major glycogen storage Minor glycogen storage Stores some protein Provides movement Intestine Makes glucose Can function anaerobically Food digestion Detoxifies Brain Food absorption Major biosynthesis organ Major fuel is glucose Red Blood Cells Adipose Requires glucose Fat storage Anaerobic metabolism

CARBOHYDRATE METABOLISM IN THE FED STATE
Be familiar with the glycolytic pathway and the purposes it serves in liver, muscle, and adipose The process of glycolysis is described in Core Concepts lectures. All cells utilize glycolysis to meet their immediate energy needs. Different cell types convert glucose into storage molecules as below:
liver

GLC GLC

insulin

muscle

GLC GLC

insulin

adipose

GLC GLC

insulin

PRO AA KB AA KB

G6P PYR AcCoA CO2

GLY LAC FA TG LAC FA VLDL AA KB

PRO AA KB

G6P PYR AcCoA CO2

GLY LAC FA TG LAC FA VLDL AA KB

PRO AA KB

G6P PYR AcCoA CO2

GLY LAC FA TG LAC FA VLDL

Know the patterns of glucose utilization in aerobic and anaerobic tissues Since anaerobic tissues lack mitochondria, these tissues convert carbohydrates to lactate to meet their immediate energy needs. The liver can utilize this lactate to create storage molecules. Anaerobic tissues also have no means for creating storage molecules on their own, and rely on other sources (mostly blood glucose) in the fed state. Brain tissue also utilizes blood glucose as its primary source of energy in the fed state. Be familiar with the various glucose transporters and the significance of their tissue-specific distribution Glucose requires a transporter to traverse the cell membrane. One type of glucose transporter, SGLT1, is a symport transporter with Na+ found in the duodenum, jejunum, and renal tubules. Other transporters are simply glucose channels that allow movement across the membrane by facilitated diffusion. Glucose Transport Protein Tissue KM* GLUT1 Erythrocytes, placenta, fetal tissue 5-7mM GLUT2 Kidney, liver, intestine, _-cells of pancreas 7-20mM GLUT3 Brain 1.6mM GLUT4 (insulin-sensitive) Adipose, muscle 5mM *Don’t memorize these values. Just remember that a low KM represents the concentration of substrate required to achieve 50% enzyme activity. In this case, the lower number means the protein is a more efficient channel. Be familiar with the pathways for glycogen synthesis in liver and muscle
HO
CH2OH CH2OH CH2OH CH2OH CH2OH CH
2

6 O 1 O
OH

O 4

HO

OH OH

1 O P-P-Rib-U

+

O 4
OH OH

O 1 O
OH

O
1 O

4

4

OH

H O

Glycogen

HO

OH OH

1 O

+
P-P-Rib-U

O 4
OH OH

1 O

4

HO

O H

Glycogen

Glycogen Synthase
6
CH2OH CH2OH CH2OH

6 CH2OH O 4 1
OH CH2OH

Glycogen branching enzyme
O
2

O 4

O 1 4
OH OH

O 1 O
OH

HO

OH OH

4

OH

1 O

HO

OH

New Bond
CH

O

Glycogen + UDP
4

6 O 1 O
OH

New Bond
O

O
OH OH

1 O

4

OH

_1-4 glycosidic linkages, with _1-6 branches

Glycogen + UDP

Glycogen storage diseases – von Gierke’s – glucose-6-phosphatase deficiency causes glycogen accumulation and massive hepatomegaly; Andersen – glycogen branching enzyme deficiency causes long chains with few branches (fatal by age 2); McArdle’s (muscle, not fatal) and Hers (liver, fatal) – glycogen phosphorylase deficiency causes glycogen accumulation – fatal in liver since liver will not be able to produce glucose for other tissues

PROTEIN METABOLISM IN THE FED STATE
Understand how the liver metabolizes excess amino acids and disposes of amino groups
liver

GLC GLC

insulin

PRO AA KB AA KB

G6P PYR AcCoA CO2

GLY LAC FA TG LAC FA VLDL

All organs will take up amino acids to create proteins in the fed state. Insulin stimulates protein synthesis. The liver creates storage molecules from excess amino acids as shown in the diagram to the left. Amino acids fall into two categories, glucogenic and ketogenic. Ketogenic – L, K Glucogenic – A, C, D, E, G, H, M, N, P, Q, R, S, T, V Both Glucogenic and Ketogenic – F, I, W, Y Amino groups are disposed of in one of two ways. The first is transamination. Various transaminases move amino groups in a B6-dependent reaction from an amino acid to _-KG, forming glutamate, which can be deaminated by glutamate dehydrogenase, forming ammonium and α-KG. Ammonium is dealt with in the urea cycle, the second method of disposal. TCA cycle
NH3 Transamination R C COO amino acid H
+

R C COO- Carbon Backbone
Keto Acid

Be familiar with the urea cycle
2 ATP + CO2 + H4N
glutamate dehydrogenase carbamoyl phosphate synthetase

Pyridoxal phosphate – B6

Glutamate
transaminases

α-keto acid

-

NH3 OOC-CH2-CH2 C COO OOC-CH2-CH2 C COO α-KG Glutamate H Glutamate
Dehydrogenase

O

Various Transaminases

=

O

+

α-keto glutarate
H2N-C-OP carbamoyl
phosphate CP

Amino Acid
Deamination

=

O

+ + NH4 NADH NAD

Pi

UREA

NH
C=O
2

ORN

orinthine transcarbamoylase

CIT
ATP

NH
2 UREA arginase arginosuccinate synthetase

Aspartate
aspartate transcarbamoylase

α-keto acid

There are diseases associated with each enzyme in the cycle as well as in carbamoyl phosphate synthetase. Arginosuccinate lyase deficiency is treated with low protein intake with arginine supplementation. One nitrogen in urea comes from glutamate via glutamate dehydrogenase. The other comes from aspartate via aspartate transcarbamolyase. Other amino acids contribute through one of these entry points.

Oxaloacetate

Amino Acid

ARG

AMP + PPi
arginosuccinate lyase

ASA

This cycle takes place in the mitochondrial matrix and the cytosol. The ornithine transcarbamolyase reaction takes place in the matrix, the product, citrulline, is transferred to the cytosol via the ornithine-citrulline antiport transporter. The cycle continues in the cytosol until returning to the matrix as ornithine. The urea cycle takes place mainly in the liver. Nitrogen from other organs are transported to the liver via the alanine cycle (similar to the Cori cycle for lactate recycling). Know the essential and nonessential amino acids Essential amino acids are those that are required in the diet since they cannot be synthesized. Essential – Leu, Ile, Val, His, Lys, Arg*, Thr, Met, Phe, Trp Nonessential – all the rest can be made from the essential amino acids or other metabolites *Arginine is essential for neonates. Later in life, arginine can be synthesized from the urea cycle.

REGULATION OF METABOLISM IN THE FED STATE
• Insulin increases in response to elevated blood glucose levels after a meal. o In the Beta cells of the pancreas, increased glucose increases the concentration of ATP. This blocks potassium efflux leading to membrane depolarization. This causes calcium influx that leads to insulin being exocytosed via secretory granules. o Sulfonylurea (type 2 diabetes drug) functions like ATP to block potassium influx Insulin regulates energy metabolism in 3 general ways: o 1. Reversible Phosphorylation  Insulin dephosphorylates enzymes, Glucagon phosphorylates enzymes o 2. Signal Metabolites (increases F2,6BP [glycolysis] and malonyl CoA [FA synthesis]) o 3. Enzyme Levels o Also: activates protein synthesis, activates phosphatases, GLUT4 in membranes of muscle and adipose) Insulin and Glycogen Enzyme Phosphorylation o Insulin signals high glucose and favors dephosphorylation o Glycogen synthase is activated by insulin, Glycogen phosphorylase is inhibited by insulin Insulin and Signal Metabolites o PFK2/FBP2 complex can be phosphorylated by glucagon in liver (not in muscle). Thus, only liver undergoes gluconeogenesis (not muscle) o F2,6BP is the product of PFK2/FBP2 and stimulates glycolysis and inhibits gluconeogenesis at the level of PFK1 o Malonyl coA causes inhibition of beta oxidation of fatty acids, leading to increased storage  Malonyl coA is the product of ACC2 (reactant is acetyl coA)  Malonyl coA blocks the carnitine shuttle which transports fatty acids into the mitochondrion for beta-oxidation  ACC2 knockout mice are skinny since no block on the carnitine shuttle, so fatty acids constantly are beta-oxidized • Insulin and Enzyme Levels o Liver  Insulin increases glucokinase (increasing glycolysis); and decreases glucose-6phosphatase and PEPCK (blocking gluconeogenesis) o Adipose  Insulin increases the amount of lipoprotein lipase in adipose, increasing influx of dietary fat for storage  Insulin also increases glucose influx via GLUT4

METABOLISM IN FASTED STATE
I. Average person can go about 50-60 days w/out eating, w/water. Once about 50% protein in body broken down, death will result. I. Metabolic patterns change in response to changing hormone levels A. ↑glucagon affects liver B. ↓insulin affects liver, muscle and adipose C. ↑norepinephrine affects adipose II. Processes During Fasting A. Glycogenolysis: occurs in liver, glucose goes to brain, anaerobic tissues and muscle (small amount), *glycogen reserves only last about 1 day* B. Gluconeogenesis: occurs in liver, precursors are glycerol (from triglycerides), alanine (from proteins) and lactic acid (from anerobic tissues) C. Lipolysis: occurs in adipose, most tissues begin to use fatty acids as fuel source w/exception of anaerobic tissues and brain (fatty acids cannot pass blood/brain barrier) D. Ketone Body Synthesis: occurs in liver, converts fatty acids to soluble, 4-carbon ketone bodies 1. All tissues can use ketone bodies as fuel source except liver and anaerobic tissues 2. This spares proteins from being degraded because brain relies less on glucose * Liver also repackages fatty acids into triglycerides and exports them as VLDL which is used as energy source mainly in muscle (liver does this because too much fatty acids can be toxic)

CARBOHYDRATE METABOLISM IN THE FASTED STATE
I. Liver supplies glucose to brain(70%), anaerobic tissue(20%) and muscle(10%) by breaking down glycogen in response to rise in glucagon. Glycogen is a SHORT-TERM fuel reserve, meant only for brief fast. (Muscle stores it also but uses supply for itself.) II. Liver - ↑glucagon triggers conversion of glycogen→glucose Brain - continues to use glucose as fuel Anaerobic tissues - continue to use glucose as fuel and release lactic acid III. Important Enzymes in Glycogen Synthesis/Degradation A. Glycogen Synthase - makes glycogen, turned off by glucagon, see fed state lectures for more info B. Glycogen Phosphorylase - Signaled by glucagon, degrades glycogen by adding a phosphate group to terminal glucose residues, releasing them as G1P. (Deficiency of this enzyme in McArdle and Hers Diseases). G1P then converted to G6P. C. Branching Enzyme - transfers a 7 unit segment from chain to form a branch using α1-6 linkage D. Debranching Enzyme - when glycogen phosphorylase gets to 4 residues before a branch point, it stops. The debranching enzyme then transfers a 3 unit segment to the main chain. It then removes the remaining glucose at the branch and releases it as free glucose. E. Glucose-6-phosphatase - converts G6P to glucose in ER, is turned on by ↓insulin, is only found in liver, kidney and intestine (why muscle glycogen can only be used by muscle). (Deficiency in Von Gierke Disease). IV. Gluconeogenesis A. Liver - makes glucose from 3 noncarbohydrate precursors. 1. lactic acid (from anaerobic tissues) joins glycolytic pathway at pyruvate 2. alanine (from muscle) joins glycolytic pathway at pyruvate 3. glycerol (from adipose) joins glycolytic pathway at DHAP, requires least amount of energy to be converted to glucose B. Kidneys - make glucose from glutamine (from muscle), but usually low except during extended fast V. Regulation - gluconeogenesis and glycolysis differ at 3 pts, each of which is a site of regulation in the liver (some directly turned on/off by glucagon) A. ↑G6phosphatase: more G6P→glucose ↓glucokinase: less glucose→G6P B. FBP1 turned on: more FBP→F6P PFK1 inhibited: less F6P→FBP C. ↑PEPCK: more OAA→PEP (OAA made from Pyruvate) Pyruvate Kinase inhibited: less PEP→Pyruvate VI. Cori Cycle - cycling of lactate and glucose between liver and anaerobic tissues

Diagrams for Carb. Met. In Fasted State

FASTED STATE

ANAEROBIC

ENERGY

LAC
BRAIN

CO2

70%

20% GLC
LIVER

MUSCLE

10%

CO2

glucagon

GLY

KIDNEY

ADIPOSE

INTESTINE

FASTED STATE

GLC
glucokinase glucose 6-phosphatase

CORI CYCLE
LIVER ANAEROBIC

LIVER
glucagon - insulin

G6P F6P
PFK1 FBP1

F1,6BP

GOL
PEP
pyruvate kinase PEPCK

6 ~P

2 ~P

OAA PYR AcCoA
Stryer

Ala

LAC

PROTEIN METABOLISM IN FASTED STATE
I. Muscle breaks down protein to amino acids due to decreased insulin in first few days of fasting (muscle is largest mass of protein in body) A. Alanine - used by liver to make glucose, disposes of nitrogen as urea B. Glutamine - used by kidneys to make glucose, dispose of N as NH4+ II. Muscle - ↓insulin leads to ↑breakdown of protein to amino acids, which are then transported out of muscle (pyruvate can also be converted to amino acids) Liver - ↑glucagon leads to ↑alanine→amino acids→pyruvate Kidneys - ↑glutamine→amino acids→pyruvate Intestine - ↑glutamine→amino acids→pyruvate→lactic acid III. Proteins to be degraded are tagged w/ubiquitin, then hydrolyzed to amino acids in cell's proteasome IV. Amino acids are converted to Ala and Gln A. Early step: remove Nitrogen from amino acids as NH3 B. Carbon backbones shuffled to Pyruvate and αketoglutarate C. Re-add NH3 1.Pyr→Ala via transamination rxn 2.αKG→Gln via transamination and/or amination D. αketoacids generated by transamination rxns are converted to Pyr and αKG to make more Ala and Gln V. Glucose Synthesis from Amino Acids A. Liver (alanine): -14 ATP B. Kidneys (glutamine): +11 ATP VI. Urea Cycle in the Liver A. Under the influence of glucagon, most nitrogen for urea cycle comes from Ala and NH4+ from other tissues. B. Some NH4+ also made IN liver because Gln is deaminated during conversion of Ala→Pyruvate. C. Contrast this to fed state where most N for urea cycle is from: 1. excess dietary amino acids 2. NH4+ released by intestine due to oxidation of nonessential amino acids for energy

Diagrams for Prtn. Met. in Fasted State
FASTED STATE
ANAEROBIC

ENERGY - insulin

BRAIN

MUSCLE

CO2
LIVER

PRO GLC Ala Gln

KIDNEY

LAC Ala

ADIPOSE

INTESTINE

FAT METABOLISM IN THE FASTED STATE
• • • • • Adipose stores fat as triglycerides All tissues can oxidize fat except the brain and anaerobic tissues A drop in insulin triggers fat oxidation; adipose is INSENSITIVE TO GLUCAGON, but. . . Norepinephrine and epinephrine trigger fatty acid mobilization Fatty acids are ONLY MOBILIZED FROM ADIPOSE

OVERVIEW (See Lecture notes for diagrams): Adipose—Releases fatty acids in the the blood as insulin _ and norepinephrine _ Liver—Makes fatty acids into ketone bodies, also re-releases some FAs as triglyceride (carried by VLDL) as glucagon _ Muscle—takes in triglyceride and ketone bodies from liver and burns them as insulin _ Brain—Takes in any available glucose and ketone bodies as insulin _ FAT METABOLISM • Norepinephrine activates phosphorylation cascade for hormone sensitive lipase (HSL) • HSL oxidizes fatty acids for export to bloodstream • _ insulin keeps HSL phosphorylated and depletes DHAP (precursor for triglyceride synthesis) • FAs are carried by albumn in the blood—conentration up to 2mM • Unbound FAs may for micelles in the blood and contribute to sudden death in runners • Once inside the cell, FAs are converted to fatty acyl CoA in order to put them into the carnitine shuttle (which transports them to the mitochondrial matrix) o Carnitine shuttle (CS) diseases exist!  Defective CS in muscle—nonlethal; leads to cramping because muscles can only use glycogen and glucose for energy and run out of these things quickly when worked hard  Defective CS in liver—lethal; liver uses FAs for its own fuel and dies without them • In the matrix, FAs are cleaved through β oxidation (which is just like reverse fatty acid synthesis) down to acetyl CoA and may then enter the Krebs cycle • FAs yield more energy per carbon; are also a relatively lightweight storage form (no hydration) Palmitate + 8HSCoA + 7FAD + 7NAD + ATP _ 8AcCoA + 7FADH2 + 7NADH + AMP + 2Pi Total=106 ATP ALL ABOUT KETONE BODIES • Ketone bodies are made by the liver from circulating fatty acids • All aerobic tissues may use them (EXCEPT the liver)—liver has no CoA transferase • Brain derives 30% of energy from ketone bodies after about 3 days of starvation • Ketone bodies help preserve muscle proteins • Major ketone bodies=acetoacetate and β-hydroxybutyrate • The conversion of acetoacetate to β-hydroxybutyrate using NADH gives a 10% energy boost to the molecule • The spontaneous breakdown of acetoacetate to acetone is what accounts for the “fruity” breath of patients in DKA • The breakdown of one molecule of acetoacetate gives 2 acetyl CoA (20 ATP total)

REGULATION OF METABOLISM IN THE FASTED STATE
Draw the flow of metabolites in liver, adipose, muscle, and brain in the Fasted State.
Explanation of some of the more cryptic slides from this lecture: 13) Depending on the particular signal metabolite that is present, a particular protein may be activated or inactivated, based on whether it gets phosphorylated or not. 14, 15, 16) For instance, in the fasted state IN THE LIVER insulin is low and glucagon is high (liver responds ONLY to glucagon, though). Via a signaling pathway, glucagon signals the phosphorylation of glycogen phosphorylase (activating it) and the dephosphorylation of glycogen synthase (inactivating it) 17, 18) Glucagon does this through a cAMP mediated G-protein mechanism 20) In the presence of glucagon, the gluconeogenic enzymes that make pyruvate into G6P are upregulated, while the glycolytic enzyme (PFK1) that makes G6P into pyruvate is both downregulated and shut off. Meanwhile, the enzyme responsible for making the precursor to fatty acid synthesis (Acetyl Coa carboxylase) is shut off while the carnitine shuttle is working to make fatty acids into Acetyl CoA. 21) Glucagon causes the phosphorylation and thus the shut-down of Acetyl CoA carboxylase, thereby depleting the supply of Malonyl Coa. This causes the carnitine shuttle to be switched on. 22) In the absence of Malonyl CoA, the Fatty Acyl CoA is shipped out of the mitochondrial matrix and into the cytosol where it can take part in gluconeogenesis 24) Each enzyme shown is either turned off or on as indicated by the particular substrate: hexokinase—switched off by high G6P levels PFK1—switched off by high citrate levels (in the Krebs cycle) pyruvate carboxylase—switched on by high levels of Acetyl CoA pyruvate dehydrogenase—switched off by high levels of Acetyl CoA

Know how the flow through different pathways serves the particular functions of each tissue • Adipose o Releases fatty acids and glycerol into the the blood as insulin _ and norepinephrine _ in order to provide energy to the other organs and to provide a substrate for ketone body genesis to the liver • Liver o Makes fatty acids into ketone bodies; o Re-releases some FAs as triglyceride for oxidation by muscle (carried by VLDL) as glucagon_; o Breaks down glycogen and ships it out into the bloodstream in the form of glucose via the action of glucose-6-phosphatase (which muscle does not have); o Takes in amino acids from muscle breakdown and shuttles them into the glycolytic pathway via pyruvate • Muscle o takes in triglyceride and ketone bodies from liver and burns them as insulin _ • Brain o Takes in any available glucose and ketone bodies as insulin _; VERY LOW Km FOR GLUCOSE Understand the strategies for regulation of glucose in the fasted state 1)Changes in enzyme levels (see lectures on fed state) 2)Cofactor cycling—ensures that oxidation of foodstuffs is in sync at all points along the pathway (cofactors=NAD+, ATP, HSCoA, etc.) 3) Phosphorylation—(see diagram) various enzymes are turned off and on via phosphorylation. Usually if one enzyme is active when phosphorylated, its counterpart going the opposite direction is inactive when phosphorylated 4) Signal metabolites—may be AMP-like (low energy) or ATP-like (high energy) and give very precise control over metabolic pathways; change Km and Vmax of enzymes; allosteric 5) Substrate cycles—uses opposing enzymes to turn products into reactants. Allows sets of enzymes to work as ON/OFF switches to decrease backleak through a pathway (i.e. glycogen synthase and glycogen phosphorylase work opposite each other and are never active at the same time)

protein kinase
P
ADP ATP

ON

OFF
Pi

protein kinase
ATP ADP

ON
Pi

P

OFF

GUT DIGESTION & ABSORPTION
• • • • • • Digestion- Lumenal processing of food into chemical form that can be absorbed Absorption- Moving of components across gut epithelium 45% of Western Diet, Recommended 60% Vast majority derived from plants; exceptions: Small glycogen stores in meat, Lactose in milk Complete digestion to monosaccharides required for absorption Pre-Intestinal: Starch hydrolysis by salivary _ amylase, minor significance Inactivated by low stomach pH Stabilized by association with food particles Intestine Lumen: Starch hydrolysis by pancreatic _ amylase Amylase is far in excess of that required Completeness of digestion dependent on properties of food (amount of mastication, physiochemical properties) Brush Border Hydrolysis: Membrane proteins with enzymatic activity Examples include Sucrase-Isomaltase, Lactase-phlorizin hydrolase, Maltaseglucoamylase, Trehalase (yeast, mushrooms) Completeness of digestion dependent on properties of food (amount of mastication, physiochemical properties) Apical /Basolateral - Membrane Bound Transporters
Transporter SGLT1 GLUT1 GLUT2 GLUT3 GLUT4 GLUT5 Details Sodium Dependent (apical surfaces only) Basal Surfaces only Low affinity transport Basal Surfaces only Insulin dependent Fructose Location Intestine, Kidney Many tissues Liver, pancreas, kidney, small instestine Many tissues Skeletal, cardiac muscle, adipose Small intestine, kidney, testes, adipose, skeletal muscle

CARBOHYDRATES

Digestion

Absorption

• • • • •

Paracellur/Transcellular Transport (Contribution unknown)

PROTEIN
15% of Western diet; Recommended 10% Digestion is incomplete; Can be absorbed as either amino acids or peptides Source of protein is both ingested and endogenous (Secreted enzymes, desquamated cells) Gastric: Pepsin produces large peptide fragments Secreted by chief cells as pepsinogen and activated by low stomach pH Intestinal Lumen: Pancrease secretes pro-enzymes Trypsin activated by brush border enteropeptidases

Digestion

-

Fellow pancreatic enzymes activated by Trypsin: Chymotrypsin, Elastase, Carboxypeptidases A & B Apical membrane enzymes also cleave proteins: Aminopeptidases N &A, Dipeptidylcarboxypeptidase Intracellular Metabolism: Di, tri, and tetra peptides converted to amino acids by intracellular peptidases Apical Transport H+ / oligopeptide cotransporters (Coupled with H+/Na countertransporters to displace H+) Amino acid membrane transporters Basolateral Transport - 3 amino acid transporters moving AA out of cell into blood (Sodium independent) - 2 amino acid transporters moving AA out of blooell into cell (Sodium dependent) 40% of Western diet; Recommended 30% Source of protein is both ingested and endogenous (Bile, desquamated cells, bacteria) Pre-Intestinal: Lypolysis by acid lipases Lingual Lipase (salivary) and Gastric Lipase (Chief cells) 15-30% of digestion and absorption occurs in stomach Intestinal Lumen: Pancreatic Lipases Lipase, Collpase, Phospholipase A2, Cholesterolesterase Products are 2-monoglycerides and fatty acids Micellar Uptake Products solubilized by Bile Salts (liver) Spontaneous aggregation into negatively charged Micelle Micelles carry lipids to enterocytes thru acidic microenvironment created by H+ pumps Lipids leave micelle and enter enterocytes by diffusion Lipid Reassembly - Lipids re-esterfied in the Smooth ER to Triglycerides, Phospholipids, and Cholesterol Esters forming Chylomicrons Chylomicrons enter lymph

Absorption

Lipid
• • • •

Digestion

Absorption

CHOLESTEROL METABOLISM
There are 2 sources of cholesterol in the body: 1) Dietary 2) Endogenously Produced • Acetyl CoA = Precursor • *** The rate limiting step in cholesterol synthesis is HMG-CoA  Mevalonate, catalyzed by HMG-CoA Reductase. HMG-CoA Reductase inhibitors are called statins and are hugely important in cardiovascular medicine (Zocor, Lipitor, etc.) Cholesterol’s Uses in the Body (not a complete list): 1) Cell membrane: keeps membranes stable at high temp, fluid at low temp 2) Bile salts: addition of 7-hydroxyl group is crucial step in bile acid synthesis, then conjugation to glycine or taurine (taurine is an amino acid but isn’t used in proteins). Bile salts form micelles and solubulize lipids in intestinal lumen 3) Steroid hormone precursors Lipid Trafficking: • Triglycerides and cholesterol are packaged into chylomicrons and lipoproteins for transit, using various Apo proteins • Chylomicrons are produced by enterocytes (jejeunum), from dietary triglycerides, and secreted into lymph (***Remember: lymph re-enters venous system via thoracic duct). Lipoprotein ApoB-48 is a specific marker for chylomicrons. • Chylomicrons are taken up into liver. The liver repackages TG’s and cholesterol as VLDL’s, and secretes them into blood to send TG’s to tissues. At muscle and adipose, free fatty acids are released via lipoprotein lipase and are taken up into cells. • VLDL is converted to LDL (the “bad” cholesterol), which is smaller and denser, via the removal of triglycerides leaving a higher density of cholesterol esters. Both VLDL and LDL contain one molecule of ApoB100. LDL can be trafficked back to liver or peripheral cells. • Caveolae are special cell membrane domains where cholesterol efflux can occur • Cellular LDL uptake occurs via LDL Receptor, which binds certain Apo proteins (ApoB-48, ApoB100, ApoE, etc), and the whole complex is endocytosed via clathrin-coated pits

CHOLESTEROL & ATHEROSCLEROSIS Atherosclerosis is bad. It proceeds in stages: 1. Intimal thickening 2. Fatty Streak (i.e. a yellow patch on the endothelium) 3. “Fibroatheroma,” which means: complex nasty plaque within the wall of the artery. It has a lipid core, cholesterol crystals, and a fibrous cap covering the plaque and keeping it from rupturing. They can have intra-plaque hemmorage, i.e. clot formation inside the plaque due to blood leaking in. Clots would form because these plaques are loaded with tissue factor and other nasty stuff that initiates the clotting cascade (extrinsic, anyone?). 4. “Vulnerable Plaque” is a catch-all term for a plaque that sucks so bad it’s going to rupture. The difference between this and fibroatheroma is semantic. 5. Fibrous Cap Rupture. The fibrous cap is degraded by macrophages until it spills all the thrombogenic material inside the plaque into the lumen, where massive clotting occurs. If this happens in your carotid it’s a stroke. If it happens in a coronary it’s a myocardial infarction. ***Note the “healed ruptured plaque” in the image, which is also called a fibrous plaque. These are very common and can constrict bloodflow, but because they have no lipid core they cannot rupture and thus are not dangerous. These plaques show up very well on any imaging technique because they narrow the vessel lumen, but are usually not worth treating. This is why it is important for an imaging technique to distinguish different types of plaque by composition, i.e. to be able to distinguish a dangerous fibroatheroma from some other less-dangerous fibrous or calcified plaques.
Cardiovascular Imaging: 1. Angiography = Gold Standard. You pump iodinated die through an arterial tree and take xray movies. You see the lumen of the vessel and can see plaques that impede blood flow or plaques that have ruptured. Cannot distinguish plaque types, cannot see outer wall. 2. B-Mode Ultrasound. Bmode is done from outside the body (on the skin), so only the carotids (which are superficial and large) can be analyzed meaningfully. Lumen yes, outer wall yes, plaque type no. 3. Intravascular Ultrasound (IVUS). This is done via a catheter inserted into an artery, and enables visualization of lumen, wall, and plaque type. 4. CT. CT’s advantages for visualizing arteries are that it’s noninvasive and fast, but uses radiation and is not able to distinguish plaque types. Lumen = yes, outer wall = Dr Morrisett didn’t say.

IVUS

Angiography

5. MRI. MRI provides much better images of arteries, and can distinguish plaque types, but takes forever. Lumen yes, outer wall = Dr. Morrisett didn’t say.

Purine & pyrimidine metabolism

Disorders
Gout - uric acid is circulating in the blood at concentrations right below the solubility limit of 6.5mg/dl - elevated levels of circulating uric acid  urate crystal precipitation, especially in the extremities (cooler temperatures), characteristically the big toe. - Painful, arthritic joint inflammation - Treatment: allopurinol – hypoxanthine analog, inhibits xanthine oxidase Lesch – Nyhan syndrome - defects in HPRT - has gout, self-destructive behavior, other neurological disorders von Gierke’s syndrome - missing G6Pase - everything stuck at G6P, spills into hexose monophosphate shunt  R5P  drives purine synthesis  elevated uric acid severe combined immunodeficiency disorder (SCID) - deficient ADA - accumulation of dATP which is toxic to T and B cells deficiency in PNP - accumulation of dGTP which is toxic to T cells (lesser severe than SCID)

Drug Targets
Cancer chemotherapy - mostly in dTMP synthesis pathway - hydroxyurea: blocks ribonucleotide reductase - 5-fluorouracil: blocks thymidylate synthase - methotrexate: blocks dihydrofolate reductase (DHF reductase) Nucleotide Analogs - taken up by cells and incorporated in salvage pathways - araA: interferes with herpes virus DNA polymerase - araC: cancer treatment, interferes with human DNA polymerase - AZT: interferes with HIV DNA polymerase

M ETABOLISM IN THE S TRESSED S T A T E
• • (Experimental) Stress = hypoglycemia (e.g. infusion of insulin) Hypothalamus senses hypoglycemia; sympathetic nervous system activation causes sequential release of (Bala Blood Glucose Homeostasis): 1. Epinephrine: released from chromaffin cells of adrenal medulla 2. Growth hormone: from anterior pituitary 3. Cortisol: ACTH from anterior pituitary Goal: produce glucose from energy stores – like fasted except: o Doesn’t involve ketone bodies o Epinephrine/growth hormone inhibit protein breakdown o Epinephrine alters enzyme activity instead of levels. Amplify fasted state effects, counteract fed state effects. Cortisol “prepares” cellular metabolism; EPI/glucagons “act on” preparation.

• •

Stress + Adrenal Medulla
+

+ Hypothalamus
GHRH CRH +

Somatotrophs

Corticotrophs
ACTH +

+ Epinephrine Liver Adipose Muscle
Stimulates _-1 (IP3), _-2 (cAMP) receptors Stimulates _-2 receptors Stimulates _-2 receptors

+ Growth Hormone
Gluconeogenesis, PRO synthesis, IGF-1 production Increased CHO/fat catabolism Increase PRO synthesis, CHO/fat catabolism

Adrenal Cortex + Cortisol
Upregulates PEPCK

Upregulates HSL Increases PRO breakdown

Stressed Metabolism Questions
1) In order of appearance in blood, which three hormones are released in response to stress? 2) Which hormone(s) is(are) fast-acting? Slow-acting? Why? 3) When (in a 24-hr cycle) is growth hormone released in adulthood? How does it act anabolically? 4) Adrenergic receptor activation (alpha and beta) converges on activation of which enzyme? 5) Which tissue has both types of adrenergic receptors? a. Which metabolic enzymes are activated there by epinephrine? b. Inhibited? 6) Activation of fat stores in liver provides energy for _______ in the form of _______, whereas ___________ provides the energy used in gluconeogenesis. 7) Under maximum stress, glycogen phosphorylase in muscle is allosterically activated by epinephrine through ____________ and further by _____________. Which of these effects would be greater in liver and why? 8) Cortisol upregulates _______ in liver, ________ in adipose, and stimulates _________ in muscle

Answers
1) 2) 3) 4) 5) Epinephrine from adrenal medulla, growth hormone from adenohypophysis, and cortisol from adrenal cortex. Epinephrine is fast-acting (enzymatic activation through phosphorylation) whereas cortisol and growth hormone are slow-acting (nuclear transcription factors). A spike of GH is released in the middle of the sleep cycle (possibly to protect protein stores during the overnight fast). Phosphorylase kinase: alpha through an IP3 pathway, beta through a cAMP pathway. Liver a. Glycogen phosphorylase and hormone-sensitive lipase are directly activated; b. glycogen synthase and FA synthase are directly inhibited c. gluconeogenesis and fatty acid catabolism are indirectly activated through substrate availability (“signal metabolites”). Acetyl-CoA from fatty acid breakdown supplies liver with its own energy requirements, whereas glycogen mobilization supplies gluconeogenesis (along with glycerol and lactate). Phosphorylation by phosphorylase kinase and signal metabolites combine to maximally activate glycogen phosphorylase. In liver, both cAMP and IP3 mechanisms act to make phosphorylase kinase maximally active. PEPCK in liver, HSL in adipose, and protein breakdown in muscle are increased by cortisol.

6) 7)

8)

Metabolism in the S TRESSED S T A T E
Stressed State: overlays fed or fasted state – goal is to increase available energy to respond to stress
Cortisol: steroid Transcription ctrl. – since it only increases enyme levels, it may not have big effect. Phosphorylation also required to activate the enzymes – “permissive effect”_____________ Growth Hormone: incr. glucose, incr. lipolysis, decr. protein breakdown Epinephrine- binds to 2 rcptrs, activates 2 pathways – _-adrenergic IP3/Ca+, only in liver, _-adrenergic cAMP, muscle, liver, and adipose – both pathways activate protein kinases (which activate some enzymes, deactivate others – the IP3 pathway can increase the activity of phosphorylase kinase by adding a Ca- in muscle this same effect is achieved by endogenous protein binding_________________________

Chapter Twenty-Three – Nutrition
BLOCK 3 – GIMNER THREAD: BIOCHEMISTRY & GENETICS
CONTRIBUTORS: NIRAJ PATEL, PAVAN JHAVERI, DHRUVIL SHAH, & CHRIS JOHNSON

TABLE OF CONTENTS: NUTRITIONAL GUIDELINES NUTRITIONAL ASPECTS OF PROTEINS, CARBS, LIPIDS I NUTRIONAL ASPECTS II VITAMINS & SUPPLEMENTS MINERAL NUTRITION ENERGY BALANCE AND OBESITY EXERCISE NUTRITION NUTRITION DURING PREGNANCY AND LACTATION

NUTRITIONAL GUIDELINES
I. Nutrient Specific Recommendations A. Recommended Daily Allowance (RDA) – intake meeting needs of all healthy people. B. Estimated Average Requirement (EAR) – intake adequate for 50% of people. C. Adequate Intake (AI) – intake appears sufficient, but insufficient data for est. EAR. D. Tolerable Upper Limit (UL)- highest daily intake likely to pose no adverse risks. E. Estimated Energy Requirements (EER’s) – require special attention because they vary by gender and stage of development. II. Establishing Dietary Reference Intakes A. Animal Models – limited by relevance to free-living humans. B. Human feeding studies – limited by inability to measure long term outcomes and relevance to free-living humans. C. Observation Studies – can’t show causal relationships due to diet complexity, variation in nutrient intake and bias/errors in reporting nutrient intake. D. Randomized Clinical Trials – only a small number of nutrients or nutrient combos can be studied, and can’t determine effects of chronic intake due to short follow-up period. III. General Dietary Guidelines A. Aim for fitness -increase physical activity B. Build a healthy base -use Food pyramid and eat variety of fruits and vegetables. 1. 25% of Americans get 5 servings a day. 2. Older people eat the most. C. Choose well -decrease fat, cholesterol, sodium, and sugar intake. D. General agreement across countries regarding food recommendations.

NUTRITIONAL ASPECTS I & II
• • Energy Intake = energy expenditure + energy excretion + energy storage Biological fuel values o Fat = 9 kcal/gm o Carb = 4 kcal/gm o Prot = 4 kcal/gm o EtOH = 7 kcal/gm

Respiratory Quotient – CO2 production/O2 consumption (F = .71, P = .85, C = 1, lipolysis); Good to know when you have patients in which you want to keep CO2 levels as low as possible Proteins: • There are no “inert” protein stores, every protein has a fnxnl role • Rates of protein synthesis will be limited by the least concentrated aa. • You can get complete protein from complementary protein sources (lentil + Wheat, etc) Carbs: • Lactose (glu + gala), sucrose (glu + fru) • Hereditary fructose intolerance – rare, hepatic pathology • Upside: water soluble, good for brain fnxn • Downside: High RQ vs. fat; glycogen much less calorically dense than fat Fat: • Upside: Lower RQ vs fat; calorically dense • Downside: water insoluble; overconsumption is easy; not glucogenic • Polyunsaturated fatty acids are essential. o Linoleic acid (LA; omega-6) and alpha-linoleic acid (ALA; omega-3) are 18 C parent fatty acids o LA can go to arachidonic acid and ALA can go to eicosapentaenoic acid and docosahexaenoic acid o PUFA deficiency leads to skin changes (dry, scaly skin followed by desquamation) • Monounsaturated fatty acids o Oleic acid is most important MUFA o Beneficial impact on lipid profile • Saturated fatty acids o Adverse effect on lipid profile o May be less well-absorbed than unsaturated fatty acids • Trans fatty acids are evil Diet Recommendations: • Normal Diet is recommended to be 45-65% carbs, 20-35% fats, 10-35% proteins o At least 130 grams of carbs o MUFA and PUFA should take place of sat. fats as much as possible With Low Fuel Supply: • Depeletion of glycogen stores • Gluconeogenesis • Ketone body formation • Cori cycling

Reduced energy expenditure

VITAMINS AND SUPPLEMENTS
-Developed countries get enough -The question that is being asked is if there is any added benefit to using vitamins above the RDA, or is it detrimental -Bottom line – eat a wide variety of colored foods and beware of pill supplementation. People who use vitamins are often the people that need them the least (most athletic, healthy, etc) Antioxidants -Scavenge free radicals from O2-, OH, H2O2 -Antioxidant provitamins (carotenes) -Antioxidant vitamins (C/E) -Non-vitamin antioxidants Vitamin A Good sources: fish oils, liver, organ meats, egg yolks, colored veggies. RED YELLOW ORANGE Usual sources: veggies, meats, fish, and poultry Deficiencies in US are rare, in developing countries lead to problems with blindness, measles, diarrhea, and pneumonia -Visual function – rhopsidin conformational change -Maintenance of mucus secreting epithelium -Gene Expression -Cellular differentiation -Immune Response Vitamin E Good sources: oils, margarines Usual sources: grains, fruits/veggies, and fats/oils Epidemiological studies are based on people eating lots of food that contains Vitamin A and Vitamin E. the results show beneficial effects of excess Vitamin A and E. Interventional studies give excesses of just the vitamins themselves, and the results appear to be detrimental effects. Vitamin B12 Nothing grown contains B12. Get it from meats, dairy, fortified grains. -Binds intrinsic factor, absorbed in ileum -Gastritis, Pancreatitis, malabsorption all prevent absorption of B12. Poor absorption is common in elderly and alcoholics. -Deviancies cause increased plasma homocystiene, pernicious anemia, and neurological symptoms Folate Good sources: Dark greens, fortified grains, and tomato/orange juice Usual sources: grains, fruits/veggies -Deficiencies cause increased plasma homocystiene, pernicious anemia, few neurological symptoms in adults, neural tube defects in embryo. -Neural tube defects – prevented by 400 micrograms of folic acid a day. All women of childbearing age should be taking this because defects occur before the woman knows she is pregnant. Homocystiene Promote endothelial cell injury, proliferation of smooth muscle, procoagulant properties, and platelet aggregation Heart disease, stroke and osteoporosis all decrease when homocystiene decreases Beware of fallacies and rip-offs

MINERAL NUTRITION
Iodine -Deficiency rare in US, but common in other places -Deficiency can lead to goiter, cretinism, hyperthyroidism, and growth retardation -Found in seafood, iodinated salt Iron -Used in heme, enzymes, cofactor -Deficiencies are more common – almost half of world’s population is deficient -Women more likely to be deficient than men (due to menses) -RDA for women is higher, but they eat less iron than men Nonheme iron: plant/dairy sources. Poor bioavailability, but makes up 90% of iron intake Heme iron: meat sources. Good bioavailability, but only 10% of iron intake. Heme iron increases the bioavailability of nonheme iron Type I Hematochromatosis – autosomal recessive disorder manifest when there is excess iron in the body. One of the reasons why we can’t fortify things with iron like we do with iodine, etc. Iron Overload Disease. Zinc -Cofactor, gene expression, numerous other things -Deficiency leads to lots of bad things, including growth and poor infection recovery -No way to test zinc deficiency, no way to observe effects of zinc deficiency -Developed world gets enough, but undeveloped world struggles Osteoporosis -Low bone density – prone to fracture -Common in white, elderly women -20% mortality in 1st year after fracture -Big healthcare cost -Calcium and mineral absorption occurs during adolescence. That is when adequate Ca and minerals is important. By the time you get osteoporosis, not a lot you can do to cure it. -Mechanical loading and weight bearing exercise increase bone mass density -Intense exercise too young leads to poor bone health/growth Bad factors: genetics, smoking, aging, steroids, and homocystiene Good Factors: estrogen, exercise, alcohol, and obesity Bone Health -Genetics, nutrition, exercise, gonadal steroid status, not drinking excess or smoking all important -Everyone falls short on adequate Ca intake – but women do worse than men. Could be to diet soft drinks and body image issues. -Once you have osteoporosis, Ca and Vitamin D are important, but not as much as meds (Hormone Replacement Therapy), which has more significant effects Salt -More consumption than we metabolically need -One third from food, one third form processing, one third from the salt shaker -Significant component of hypertension

OBESITY/ENERGY BALANCE
-No routine clinical method for measuring body fat, and no definition of obesity based on body fat -BMI – surrogate marker – weight (kg) / height (m) squared. Or in lbs over inches times 704. <18 underweight 18-25 lean 25-30 overweight >30 obese -Human system is evolutionary built to conserve body weight -Genetics have some part, but obesity has increased rapidly lately, suggesting a larger cultural component Daily Intake – Energy Expenditure = Stores -Daily intake has increased due to increased portion sizes, increase in energy dense foods (fat), and increased availability -Expenditure has decreased with physical activity -Expenditure is easier, more accurate to measure than intake -Obese burn more calories than lean people. This kind of debunks the idea that obese people are obese because they have a slow metabolism. In order to be obese, you have to have a faster metabolism. -Eating (intake) is more time efficient than expenditure – it takes longer to burn x amount of calories than ingest them. -In a controlled calorie setting, the composition (fats to carbs to proteins) doesn’t matter. Energy intake (i.e. calories) is key -Fat is more energy dense than carbs. Most likely, you are going to eat the same amount of food (weight). The more fats you eat the more calories you get per unit weight of food. Thus, high fat diets lead to weight gain. Fats are passively over consumed. For a diet to work needs to be -Hypocaloric -Stuck to -Instill permanent lifestyle changes

EXERCISE NUTRITION
I. Anaerobic vs. Aerobic Exercise A. Anaerobic – without oxygen i.e. glycolysis only, no oxidative phosphorylation. a. Main energy source during high intensity, short duration exercises i.e. sprinting. b. primarily in Type II, FT, (White) Muscle. 1. high conc. of myosin bound to ATPase at baseline. 2. low fatigue resistance. B. Aerobic - requires oxidative phosphorylation for energy. a. Main energy source during prolonged exercises i.e jogging for 20min. b. primarily in Type I, ST (Red) Muscle fibers. 1. low baseline ATPase bound to myosin. 2. tons of mitochondria, high myoglobin and capillary density. C. During exercise, 0-2 min. most energy is from anaerobic processes; at 2 min. approximately equal contribution by both anaerobic and aerobic; 2-60 min. most energy from aerobic. D. VO2 max (max. oxygen uptake) is gold standard in measuring cardiovascular fitness. a. VO2 max = max SV x max HR x (arterialO2 – venousO2)max (Fick eq.) b. As age increases VO2max decreases. E. To burn fat, exercise at 30-50% of VO2 max as fat is main energy source; as intensity increases greater percent of energy comes from CHO’s. F. % of ST and FT fibers doesn’t change. II. Nutrition and Exercise Capacity A. Basal metabolic expenditure – minimum energy needed while at rest and fasting. a. Est. by for Males: (106 kcals/1st 5ft. + 6kcals/each inch after)*10. Females: (100 kcals/1st 5ft. + 6kcals/each inch after)*10. b. Harris Benedict equation. B. Overweight individuals should consume cal. equal to BMR. C. Glycogen loading only useful in sports with mostly aerobic demands.

NUTRITION DURING PREGNANCY AND LACTATION
Anabolic state (e.g., for milk production) requires more nutrients, and in general nutrition is important for pregnancy & lactation. Nutrient deficiencies come from substance abuse, vegetarianism, eating disorders, obesity & under nutrition. Must do nutritional assessment of mothers. Four basic points: (1) history, (2) dietary evaluation, (3) physical exam & (4) lab tests. Additionally, ask mother about the following conditions: medical (e.g., diabetes mellitus, PKU, eating disorders), gynecologic (e.g., young age), obstetric (e.g., weight gain), drug (legit & illicit) and socioeconomic status. Then perform a dietary assessment to determine appetite, meal patterns, cultural practices, food cravings & aversions, and whether she has pica (phenomenon where women eat dirt because of minerals in soil). The ideal techniques are to take 72-hour diet records & to give a food frequency questionnaire; they are impractical. The new USRDA food pyramid (2005) will likely be more inverted, with vegetables & fruits as the base and less grain products (the vegetarian pyramid is the same accepts that nuts & legumes substitute for meats). The two factors used to determine the viability of the baby are: pre-pregnancy weight (special concerns for over/underweight ♀) and the trajectory of her weight as the pregnancy progresses. “What you see in the mom is what you see in the child.” Lab evaluations are done to see levels for Hgb (hemoglobin), Hct (hematocrit), serum ferritis, serum glucose & urinary ketones and glucose (to determine if mother has secondary diabetes). Metabolic changes in the ♀ during pregnancy are caused by: growth of placenta, ↑ blood volume, ↑ fat, breast development, delayed GI motility (caused by progesterone) & ↑ insulin resistance to ↑ glucose level in bloodstream primarily for developing fetus. Dietary considerations for pregnant ♀ are: Energy: increase diet by 300 kcal/d in the 2nd & 3rd trimesters. “One peanut butter & jelly sandwich plus a glass of milk over what is her normal diet constitutes 500 calories & 30 g protein.” Protein: increase by 20 g/d Ca2+: increase by 1000-2000 mg/d; causes ↓ PIH, preeclampsia, LBW; source is dairy products Vitamin A: supplements not needed; teratogenic Folic acid: 0.4 mg/d (400 µg/d) before & during at least the 1st trimester; causes ↓ neural tube defect; 4 mg/d must be prescribed if ♀ is high risk (e.g., mothers who had encephalic baby); source is green leafy vegetables & fruit; 50% destroyed by cooking Zinc: supplements cause ↓ in prematurity & perinatal mortality Alcohol: contraindicated (fetal alcohol syndrome) Caffeine: controversial Artificial sweeteners: aspartame contraindicated if PKU Risk factors for nutrient deficiencies: multiple gestations (twins), substance abuse, hyperemesis gravidarum (excessive vomiting that kills hunger), eating disorders or obesity, vegetarian diet (Fe, Zn, Ca2+, Vitamin D, B12 & folate). Medical conditions requiring therapeutic diets: diabetes mellitus, sickle cell anemia, PKU, hypertension, chronic renal disease, malabsorptive disease & poverty. Management of vomiting, reflux, constipation: eat slow & small meals, avoid citrus, spicy foods, spearmint, caffeine; eat high fiber cereals & veggies; drink fluids between meals; avoid lying down after eating; wear loose clothes Growth & maturation of breasts: ductular elongation & alveolar multiplication. Initiation & maintenance of milk production: ↓ estrogen & progesterone while ↑ prolactin at parturition; ↑ prolactin & ↑ oxytocin with suckling. Factors that influence milk production are nutritional status, dietary intake, feeding schedule, infant weigh & maturity, infant/maternal illness, age & parity, stress & postpartum depression, and cigarettes, alcohol & contraceptives. Physical exams of breasts look for asymmetry, nodules, inflammation & cracked nipple. Look for latching on, feeding position, soft breast & audible swallow in breastfeeding baby. Test for Na+1 in milk because high Na+1 is a sign of weaning or poor milk production. The comparison between human milk & cow milk: both have lactose & fat amount is nearly same (though structurally different); as for the differences, cow milk is low in carbohydrates (4.8 g/dl vs. 7.2) and high in protein (3.3 g/dl vs. 0.9), whey is more predominant in human milk (and whey contained good proteins for immunocompetence), and while human milk is low in Na, K, Ca, P, Fe, and Vitamin D, cow milk is only low in Fe & Vitamin D. “Formulas are in between.” The benefits of breastfeeding in the first 3 months are for the infant (nutritional, immunological, psychological & allergic) and maternal (convenience, cost, contraception, cancer & +/- weight loss). Contraindications to breastfeeding are maternal infections (HIV; herpes & hepatitis), metabolic diseases (galactosemia; PKU & MSMD) & maternal medications (chemotherapy, illicit drugs, etc.)

Chapter Twenty-Four – Endocrine Histophysiology
BLOCK 3 – GIMNER THREADS: CELL BIOLOGY/HISTOLOGY PHYSIOLOGY
CONTRIBUTORS: ROHIT PUSKOOR, VIVEK MALLADI, SARAH CHRISTENSEN, MATT BROWN, SANIA RAHIM, & MITALI BANERJEE

TABLE OF CONTENTS: STRUCTURE/FUNCTION OF THE ENDOCRINE SYSTEM I STRUCTURE/FUNCTION OF THE ENDOCRINE SYSTEM II GENERAL PRINCIPLES OF ENDOCRINOLOGY HYPOTHALAMUS & POSTERIOR PITUITARY ANTERIOR PITUITARY THYROID I CALCIUM METABOLISM I CALCIUM METABOLISM II ADRENAL GLANDS SALIVARY GLANDS & PANCREAS PANCREAS BLOOD GLUCOSE HOMEOSTASIS GLUCOSE METABOLISM

ENDOCRINE STRUCTURE/FUNCTION I
ALL ENDOCRINE TISSUES, EXCEPT FOR THE THYROID, HAVE A COMMON STRUCTURE OF CORDS AND SHEETS OF CELLS WITH ASSOCIATED LARGE-BORE FENESTRATED CAPILLARIES. SOME FIBROBLASTS AND RETICULAR FIBERS. PITUITARY DEVELOPMENT Mallory’s trichome 1) 2) H&E 1) 2) 1) 2) HISTOPHYSIOLOGY blood vessels are visualized as yellow, because erythrocytes are yellow-stained pars nervosa stains less darkly than the pars distalis chromophobes take up no dye basophils are more granular and have larger nuclei (than acidophils) acidophils appear yellow basophils are orange and more granular

PASOrange C

HYPOTHALAMUS Median Eminence – nerve endings here release hormones that regulate anterior pituitary; leaky blood-brain barrier Infundibular Stem – nuclei here will make small stimulating, inhibiting, & releasing hypothalamic molecules released at median eminence POSTERIOR PITUITARY (pars nervosa or neurophysis) caudal invagination of diencephalons (CNS derivative) composed of pituicytes (neuroglial-like support cells) and hypothalamic axon endings close to capillaries connected to short portal vessels (leaky blood-brain barrier) nerve endings are dilated and have Herring bodies (stored secretory product) makes small hormones, attached to carrier proteins called neurophysin Supraoptic nuclei ADH/AVP -makes collecting duct more permeable to water so kidney can retain more water -diabetes insipidus – loss of ADH action -increase in plasma osmolarity or decrease in blood volume will stimulate ADH release -can stimulate Prl synthesis and release (through short portals) -stimulates mammary gland myoepithelial cell contraction  milk ejection (spinal reflex arc-activated by suckling)

• • • •

Paraventricular (parvicellular) nuclei

Oxytocin

A D E N O P H Y S I S

Made up of secreting epithelial cells. Formed by the upward and anterior invag. of oral ectoderm of roof of mouth, which pinches off from oral ectoderm and wraps around pars nervosa. Rathke’s pouch – pouch that remains in cranial invaginations of oral ectoderm after the invaginations meet

PARS TUBERALIS is a collar of cells (mostly basophils) around the infundibular stem. Gonadotropic cell FSH_ LH_ F: stimulates follicle dev, secretion of estrogen M: stimulates spermatogenesis_ F: stimulates follicle maturation, ovulation and production of progesterone M: stimulates Leydig cells (androgen synth.)_ GnRH (+)

PARS INTERMEDIUS is low in hormones and lies between the pars nervosa and the pars distalis. It’s mostly basophils (most of which are corticotropes). ANTERIOR PITUITARY (pars distalis) 1)chromophobes – don’t take up dye 2)chromophils – take up acidic or basic dye; subdivided into: a)acidophils – simple hormones Somatotropic cell GH_ Stimulates growth of long bone via somatomedin C SRH/GHRH (+) (lateral location)_ (low GH causes pit. dwarfism)_ Somatostatin (-) _ Mammotropic cell Prl_ -regulates mammary gland development PIH, dopamine (-) (dispersed -regulates lactation_ throughout)_ PRH, TRH, oxytocin (+) _ b) basophils – GP hormones Thyrotropic cell (central anterior region, opposite from pars nervosa)_ Corticotropic cell (located centrally, straddle thyrotropes)_

TSH_

ACTH_

-regulates how much TH made -important for regulating basal metabolic rate -thyroid is also important for development_ Stimulates adrenal cortex to make glucocorticoids_

TRH (+) _

CRH (+) _

INFERIOR HYPOPHYSEAL ARTERY Capillary plexus at pars nervosa.

Capillary plexus in anterior pituitary.

SUPERIOR HYPOPHYSEAL ARTERY Capillary plexus at median eminence

Short portal veins connect the capillary bodies in the pars nervosa and the adenohypophysis.

Long portal veins connect the capillary beds in the median eminence and the adenohypophysis.

ENDOCRINE STRUCTURE/FUNCTION II
ADRENAL GLANDS • Located at superior poles of the kidney • Cortex is derived from moderm; medulla is of neural crest origin Subcapsular plexus (made from superior and middle adrenal arteries) • See little arches of cells CORTEX – regulated Zona by pituitary Glomerulosa • ALDOSTERONE (mineralcorticoid released in response to AngII) corticotropes making • Increases renal reabsorp. of Na and ACTH and by reninexcretion of K angiotensin system • Long, almost straight fascicles of Zona cells Fasiculata • CORTISOL (some made in ZR as well) • Most common steroid • Increases blood glucose by stimulating gluconeogen. and decreasing glycogen synth and storage in liver • Helps breakdown proteins and fats in other tissues • Anti-inflammatory effects • Aids NE, EP production in medulla; permissive to NE effects on carb metabolism • Chords of cells  reticular network Zona • ANDROGENS (mainly DHEA and Reticularis androstenedione) - pre-androgens which can be converted to testosterone in peripheral tissues • Hirsutism in women

Cortical arteries form fenestrated capillary networks that serve ZG and ZF. These anastomose to form…

MEDULLA – regulated by sympathetic nerves (T8-T11) and steroids from the adrenal cortex

Adrenal Medulla

• •

Makes CATECHOLAMINES (80% EP/20% EP); released into fenestrated medullary capillaries Conversion of NE to EP is mediated by PNMT; PNMT synthesis is induced by cotrisol Made of chromaffin tissue “Fight or flight” response

…another network that supplies the ZR (where all the blood from the adrenal cortex drains). Medulla has dual blood supply: 1)oxygenated blood from medullary artery 2)blood drained from adrenal cortex (esp. ZR)

Blood from medulla collects in medullary venous sinuses and exits via the adrenal vein.
Steroid cells have a very obvious morphology (COMMON BOARD QUESTION) • a lot of lipid because it’s a substrate for steroid synthesis • lots of smooth ER – where acetone is converted to cholesterol and where pregnenalone is converted to various steroid hormones • lots of mitochondria, with lots of tubular round cristae – where cholesterol is converted to pregnenalone • cells are foamy because of lipid storage; no secretory granules because steroid hormones are made on demand

PANCREATIC ISLETS – comprise 2% of pancreas; 2K-3K of cells per islet β cells Insulin (look 1)stimulates uptake and utilization of for insulin glucose vesicles) 2)lowers blood glucose 3)has anabolic effects on protein and triglyceride synthesis

ISLET HISTO

α cells

Glucagon

1) stimulates glycogenolysis and gluconeogenesis 2) increases blood glucose

PINEAL GLAND

Delta cells

F cells

Stimulates exocrine pancreas Somatostatin 1)Inhibits insulin and glucagon (paracrine) 2)Inhibits exocrine pancreas Stimulates production Gastrin of HCl by parietal cells Inhibits secretion of Pancreatic polypeptide somatostatin and pancreatic enzymes

VIP

Located at back of 3rd ventricle, connected to roof of diencephalons Comprised of pinealocytes and astroglial cells which support the gland Secretes melatonin in 24 hour cycles; affected if sleep cycle is screwed up

Brain sand – concretion made of hydroxypatite crystals. Important radiological landmark used to find pineal gland (and other brain structures from there). Increases with age.

Adrenal/Pancreatic Islet Mediate all of Stress Response: Epinephrine Heart rate

Mental alertness Blood glucose Glucose uptake Stimulate pituitary (ACTH) Stimulate adrenal medulla Blood delivery Blood pressure

Epinephrine Cortisol Glucagon Epinephrine Insulin Epinephrine (stimulates pituitary to make more ACTH – positive feedback) Sympathetics Cortisol Epinephrine Epinephrine Aldosterone ADH Cortisol

THYROID GLAND - Thyroid controls basal metabolic rate and calcium regulation. Located in cervical region of the neck, anterior to the larynx. Composed of two lobes, separated by an isthmus. Cells are not in standard chord pattern. TSH: 1) stimulates follicular cells to synthesize colloid material and process to make hormones 2) stimulates uptake of iodide, oxidation to iodine, and release into lumen with iodinating enzymes
3) stimulates reuptake of iodinated thyroglobulin back into the follicular cell, where it will be processed by lysosomic enzymes to mono, di, tri and tetra iodothyronine. T3 (18-hr half-life) and T4 (5-7 day half-life) are active; T1 and T2 are recycled.

T4 is metabolized to T3 at end-organ; stimulates mitochondrial respiration and ox phos, increasing metabolic rate. Also increase # of mitochondria and cristae.
Follicular cells secrete colloid into a lumen, where it is stored, until they need to take it back up and process it to make thyroid hormone (TH). • Columnar – no secretory material in lumen  active thyroid • Cuboidal/squamous – lumen filled w/colloid  inactive Parafollicular cells are on basal side of follicular cells (farther away from lumen) – called C cells (because they’re clear). They make calcitonin (which inhibits osteoclast action).
Iodine Deficiency (Goiter) • • • • • • • • • • • diet low in iodine thyroglobulin is not iodinated properly (and thus it is not taken back up and processed properly) increase in TSH stimulates thyroid to make more colloid leads to hypertrophy of the gland (goiter) adult hypothyroidism (hypothermia, cold intolerance) cutaneous vasoconstriction gives myxedema reduced CO PG and fluid retention in dermis Hyperthyroidism Antibodies (TSIs) which mimic TSH (autoimmune effect – cause hyperactivity of thyroid gland) Exophthalmos, tachycardia, warm skin, tremors

Myxedema

Graves’ disease

PARATHYROID GLAND - Parathyroid gland controls calcium regulation and has other unknown effects. 1) oxyphil cells – more eosinophilic; larger with larger nuclei; appears in clusters of 2-3 cells; loaded with mitochondria; may be preformed cell that differentiates to chief cell 2) chief cells – smaller and make PTH which stimulate osteoclast activity by stimulating osteoblasts to decrease activity and release rank ligand; also decrease calcium excretion in kidneys and increase calcium absorption in intestines Hyperparathyroidism • Excessive production of PTH • Multiple sites of bone deposition (bone cysts) • Calcium deposits in kidney (stones) • Usually caused by adenoma in parathyroid gland • Can mimic Padgett’s disease Hypoparathyroidism • Rare • Lower production of PTH, causing low serum calcium • Muscle spasms and convulsions • Unknown mechanisms

GENERAL PRINCIPLES OF ENDOCRINOLOGY
Relationship Between Endocrine and Neural Systems 1) The communication between the two systems is highly regulated 2) Two examples to show the coordinated response to stimuli First Ex: ⇓ Glucose gives two responses; both serve to ⇑ glucose: 1) Neural ANS (Sympathetic) Response - ⇑ glycogenolysis 2) Endocrine Response: a. ⇑ ACTH -> ⇑ cortisol production -> ⇑ gluconeogenesis, glycogenolysis b. ⇑ GH - > ⇑ gluconeogenesis, glycogenolysis Second Ex: ⇓ Blood Volume gives two responses; both serve to restore Blood Volume: 1) Neural ANS (Sympathetic) Response - ⇑ vasoconstriction 2) Endocrine Response a. ⇑ ACTH -> ⇑ cortisol -> Reabsorb Na and Water b. ⇑ Renin/AT Fxn -> Reabsorb Na and Water c. ⇑ ADH -> Reabsorb Water Hormones Versus NT’s (Take Home Point: You can’t use generalizations to distinguish between neural inputs and endocrine hormones) 1) Secretion into blood – Normally an endocrine trait, but Adrenal Medulla uses neural input through blood. 2) Electrical Potentials – β cells use electrical potentials causing hormone release. 3) Bifunctional molecules – Dopamine serves as neural input or endocrine hormone. 4) Co-secretion/Co-transcription – POMC’s post-translational modifications can give NT or hormone Hormone Synthesis (Take Home Point: Regulation occurs everywhere) 1) Alternative transcription gives different products 2) mRNA has signal exon used for processing 3) Hormone is cleaved in ER and in Golgi to give final product Feedback (Take Home Pt: Product buildup from target cell deactivates endocrine cell.) 1) Example – PT glands release PTH -> acts on bone to release calcium into plasma -> calcium acts on gland to suppress further PTH secretion Regulation of Circulating Hormones (Take Home Pt: Binding proteins, once attached to hormones, have 2 effects: 1) ⇑ Half life of hormone; 2) Serve as reservoir for hormones) 1) Thyroid Hormones typically are highly bound to proteins (usually TGB) 2) The free hormones in plasma are the active ones Receptors (Take Home Point: Hormones are not all or nothing like NTs; the 1) number of receptors and 2) affinity of receptor help determine the intensity of effect. 1) Receptors can be in two states, productive and non productive. This allows a receptor to downregulate in the face of a tumor or upregulate in the face of hormone deficiency.

HYPOTHALAMUS & POSTERIOR PITUITARY
Receptor Systems (Take Home Point: There are many, and they cause diffuse effects in many different ways) 1) cAMP-mediated phosphorylation - cAMP can activate PKA, which will phosphorylate proteins that may have many biological effects. Conversely, the cAMP can go straight to nucleus to be a direct activator to gene transcription. 2) Lipid 2nd messengers – PLC is activated on plasma membrane, creating IP3 and DAG. IP3 releases calcium, allowing it to perform various functions. 3) Receptor-Hormone complex – A steroid hormone can enter the cell, attach to a steroid hormone receptor, and directly mediate gene transcription through its complex. These effects are delayed, but the duration of effect is longer. Posterior Pituitary (Take Home Point: ADH is constitutively released, and because they have no binding proteins, they have a neurophysin protein that accompanies hormone through the stalk and into the posterior pituitary.) 1) Neurophysin is created w/ the prohormone in the hypothalamus. Cleavage in the stalk area leaves the hormone coupled w/ free Neurophysin. ADH Release (Take Home Point: ADH is mostly stimulated by shrinkage of osmoreceptors in hypothalamus and disruption of baroreceptors) 1) If blood is hypotonic, water flows into it from osmoreceptors, causing them to shrink. This shrinkage causes a neural firing which allows the release of ADH from nuclei. 2) Baroreceptors are normally giving out inhibitory stimuli to hypothalamus nuclei. A drop in blood pressure removes inhibitory signal, allowing release of ADH. Response to Osmolality & BV (Take Home Point: ADH responds quickly and linearly to an increase in plasma osmolality, but it responds very slowly to even a large decrease in blood volume) 1) A 1% change in osmolality can cause ADH release. 2) Through ADH release and the delayed thirst response, body fluids are diluted, which will then cause the two responses to shut off. 3) Possible reason for slow ADH response to _ BV is pure water isn’t best thing for increasing blood volume; water not isotonic to blood plasma Regulation of Hypothalamic-Pituitary-End Organs Axis (Take Home Pt: Feedback Regulations comes in many forms) 1) Pituitary hormone and end-organ product inhibits hypothalamus-releasing hormone and activates hypothalamus-inhibiting hormone. Fun Facts About Hypothalamus, Anterior Pituitary, and Posterior Pituitary 1) Hypothalamus is the cntrl center: it takes neural inputs and funnels them to pituitary 2) Anterior pituitary: True gland that makes hormones and gets signals to secrete them. a. These hypothalamic signals are picked up by a capillary plexus in the median eminence. They are then carried down to the anterior pituitary by portal vessels. b. These anterior pituitary hormones serve to 1) Initiate a release of product at the target organ and 2) Help nutrition of the target gland. 3) Posterior Pituitary – Not really a gland. Actually a collection of axons that stem from hypothalamus which contain secretory products (ADH, oxytocin)

ANTERIOR PITUITARY Oxytocin (Take Home Point: Its function is to cause milk ejection through the neuroendocrine reflex as well as contraction of the uterus (one of the few examples of positive feedback) Growth Hormone (Take Home Point: Hormone works on all cells and is responsible for metabolism and growth, both of soft tissue and bone. It can have a direct effect on gene transcription via a receptor, or it can act indirectly through a second messenger) 1) Regulation a. GHRH (positive feedback) b. Somatostatin (Negative feedback) c. Developmentally (As a child, you have many more spikes in GH secretion than as an adult, the biggest spike being during sleep) 2) How it acts a. Cytokine receptor family which has a direct effect on gene regulation i. Once hormone is attached to receptor, JAK kinase is recruited ii. This kinase phosphorylates transcription factor STAT5 iii. STAT5 immediately goes to nucleus and transcribes genes b. IGF-1 also acts as a second messenger i. It mainly acts as a growth factor ii. It is also closely related to insulin 3) Feedback (End products inhibit upstream secretion or activate inhibiting factors) a. GH inhibits release of GHRH, while IGF-1 inhibits both GHRH and GH release. GH and IGF-1 also activate somatostatin, an inhibiting factor. 4) GHRH, like other trophic hormones, have two effects on the anterior pituitary: 1) Release secretory granules into blood w/ Ca+2 help, and 2) Cause the synthesis of more GH by upregulating gene transcription 5) GH and IGF-1 have slightly different functions a. GH has mostly metabolic effects. It acts to _ Adiposity, _ glucose levels, and _ lean body mass. b. IGF has mostly growth effects. It acts to regulate organ size and fxn by making nucleic acids and proteins. 6) Stimulation and inhibition of GH and IGF-1 a. GH is stimulated by a decrease in glucose levels and inhibited by an increase in glucose, GH, or IGF-1. The stimulation could also be caused by _ FFA, fasting, or exercise. The one odd exception is GH is stimulated by _ AA content. b. In a nutshell, IGF-1 is stimulated by GH with insulin acting as an accessory. It is inhibited by fasting or by _ protein levels, and these effects may overcome the stimulatory effects of GH. Prolactin (Take Home Pt: Hormone similar to GH causing milk synthesis and secretion) 1) It’s stimulated by the neuroendocrine reflex (ie suckling of the baby) and inhibited by dopamine. 2) The neuroendocrine reflex causes dopamine to be inhibited, allowing the anterior pituitary to secrete prolactin and inc. alveolar secretion. Oxytocin is also secreted, allowing alveolar ejection to coordinate with the secretion.

THYROID
TH: metabolism, growth, thermogenesis.
TRH: causes release of preformed hormones, synthesis of new hormones TSH is secretory and trophic; it acts through both GS/AC/cAMP and PLC/IP/Ca pathways in follicular cells. TH made in follicles: Iodine actively transported from blood to lumen (colloid), thyroglobulin precursors secreted into lumen; thyroid peroxidase oxidizes I- to I, 3’,5’ locations on tyrosine residues (to make MIT, DIT), and couples these residues to make T3, T4 and inert stuff. These are transported from colloid to blood through pinocytosis. Iodine uptake: need based. Too much iodine: uptake decreases (Wolff-Chaikoff, avoids hyperthyroidism). If this continues, uptake resumes anyway (Jod-Basedow, avoids hypothyroidism [but can lead to pathologic hyperthyroidism]).

99.7% of TH is bound, ensures a steady reserve The thyroid makes more T4 (thyroxine, not very active) than T3 (triiodothyronine, active). Target organs convert incoming T4 based on their needs: 5’ deiodination (via 5’deiodinase)  T3 (active) 5 deiodination (via 5 deiodinase)  reverse T3 (rT3, inactive) after a hormone is thus made (and used), it is further deiodinated by whatever enzyme didn’t act on it in the first place, converting it to 3,3’-Diiodothyronine whether it was T3 or rT3 End organ effects: (T3+receptor) ⇑ gene expression for Na-K ATPase, mitochondrial enzymes. These increase 02 use and BMR; must increase cardiac fxn and ventilation, food intake and processing to support BMR. Byproducts: heat, CO2, urea, protein/fat use. Systemic needs for TH: Growth: CP in muscle, maturation/elongation/remodeling bone, teeth, fibronectin synthesis inhibition in skin Cardiovascular: T3  catecholamine receptors  ⇑ α-myosin heavy chain  ⇑ HR , contractility CNS: Growth of cortices, neuron proliferation in utero. More T4/T3 receptors and converters in infancy  Memory, alertness, emotion, reflexes Thyroid pathology: (think of systemic needs and metabolic effects) Hyperthyroidism- hypertension, tachycardia, weight loss (but increased appetite), diarrhea, nervousness/tremors, fatigue, insomnia, exopthalmos. Graves disease: stimulator antibodies act like TSH, ⇑hormones, goiter (trophic

effect). Actual TSH levels low (appropriate (-) feedback by T3) Hypothyroidsm- opposite of above- low energy, slow reflexes, weight gain, cold intolerance, mental slowness, constipation Hashimoto thyroiditis: autoimmune destruction of follicular cells and some blocking of remaining TSH receptors by antibodies. Tx: exogenous TH Iodine Deficiency: [endemic] goiter- low I, low T3, no (-) feedback for TSH  ⇑TSH_trophic effect Cretinism: low iodine in pregnancy, low thyroid hormones_improper fetal development_mental retardation, improper bone development.

CALCIUM METABOLISM I/II
Biological functions Ca2+: NT release, signaling, cofactor, contraction, bone. Tight control between bound/ionized forms; binding affected by pH P: buffer, phosphorylation, nucleic acids, bone. Present as orthophosphate; variable. *P and Ca2+ crudely regulate each other Calcium balance: Most Ca2+ is in bone, release/deposition regulated by calcitonin/ PTH (most important). Range is very tight: often a complete shut-off of one or the other occurs (due to Ca2+ sensors-lots of calcium prevents PTH transcription/release, preventing a further rise in serum calcium). Calcium and phosphate reabsorption and excretion by the kidneys are also regulated by both PTH and calcitonin; PTH levels have a greater effect, but calcitonin is antagonistic to PTH for Ca2+ reabsorption. Calcium absorption is regulated by 1,25-(OH)2 D3 levels (7-dehydrocholesterol + UV light in skin_cholecalciferol, made active through 25-hydroxylase activity in liver and 1α-hydroxylase activity in kidney (kidney action based on need)) ⇑D3  ⇑Ca2+ binding protein, Ca2+ ATPase expression on enterocyte ⇑Ca2+ absorption.
*D3 ALSO AFFECTS OTHER REGULATORY MECHANISMS BESIDES Ca2+ABSORPTION

STATE ⇑plasma Ca2+

HORMONE KIDNEYS INTESTINE BONE 1)Prevents PTH ⇑ P reabsorption Nothing direct; ⇓ reabsorption translation/release; (NOT PTH absorption of P, (PTH PTH effects Ca2+decreased antagonist) antagonist) 2+ lessened due to ⇓ PTH ⇓ Ca 2)⇑ Calcitonin reabsorption from parafollicular (PTH cells antagonist) ⇓ plasma ⇑ PTH from ⇑ 1α⇑ P, Ca2+ ⇑ reabsorption, 2+ Ca parathyroid glands hydroxylase  absorption(thanks improved even (calcium is not ⇑ 1,25 (OH)2D3, to ⇑D3 from more by preventing ⇑ PTH action ⇑P, Ca2+ kidney) translation/release) reabsorption (thanks to ⇑D3) * Urinary excretion changes inversely with renal reabsorption; take note of P/ Ca2+ trends. Bone reabsorption/mineralization is mediated by osteoblast/clast activity Bone activity factors: CaPO4 in (hydroxyapatite), osteoid, osteoblasts/clasts Epiphyseal plate growth/maturation: IGF-1, Insulin, T3 Remodeling (complete turnover every 7-9yrs): PTH/Calcitonin, cytokines, sex steroids. Osteoblasts control osteoclast proliferation/activity: RANK ligand  ⇑ osteoclast activity; osteoprotegerin prevents RANK interaction  prevents osteoclast activity Pathological states of calcium metabolism Hyperparathyroidism-hyperplasia or tumors.“Bones, stones, moans, groans:”

Bone loss, pain, ⇓ height, ⇑ Ca2+, ⇑renal stones (overloads Ca2+ reabsorption), psychosis Hypoparathyroidism Low plasma calcium. Renal stones (⇓ Ca2+ reabsorption), parasthesias, muscle cramps, seizures, altered mental status, prolonged QT interval (remember minutia of EKG lectures) Pseudo(n)hypoparathyroidism- varying end organ resistance; some of above symptoms Osteomalacia (adults)/rickets (kids)- low vitamin D availability (or malabsorption/lack of sunlight); liver/kidney disease/drugs  Vitamin D not activated; D can’t act on end organs (due to uremia, anticonvulsants) Osteoporosis-bone mineral loss (thought due to ⇓ sex steroids, esp. after menopause. Tx: hormone replacement therapy) Paget’s disease of bone- ⇑ osteoclasts AND ⇑ osteoblasts: mosaic density pattern on Xrays, esp. skull, spine, femur, tibia. Predisposition to Fx, pain, cardiac failure (lesions highly vascular), osteosarcoma in 1% *note: this was on his slides, but not reviewed in great detail in class. This data taken from Pathophysiology for the Boards and Wards.

Chapter Twenty-Five: Reproductive Endocrinology & Pelvis Anatomy
BLOCK 3 – GIMNER THREAD: ANATOMY/EMBRYOLOGY/RADIOLOGY
CONTRIBUTORS: LAUREN RAIMER, LAUREN ALEXANDER, NISHA VARGHESE & CANDACE HURST

TABLE OF CONTENTS: DEVELOPMENT OF THE GENITAL SYSTEM DEVELOPMENT OF THE EXTERNAL GENITALIA PELVIC ANATOMY OVERVIEW RECTUM AND LATERAL PELVIC WALL MALE PELVIC ANATOMY PERINEUM INTERNAL FEMALE GENITALIA

DEVELOPMENT OF THE GENITAL SYSTEM I
Intermediate mesoderm Weeks 4-6 Week 6 genitourinary system Formation of the genital ridge- condensation of mesenchyme, proliferation of epithelium near the developing kidney • Migration of germ cells (not of genital ridge origin) • First near the endodermal cells in the wall of the yolk sac close to the allantois • Migrate along dorsal mesentery of the hindgut • Induce the development of the gonad into ovary or testis but up until the 6th week the sex cords are indifferent and bipotential Beginning of male or female differentiation

Differentiation of Indifferent Gonad
SRY Present = testes Development of medullary cords No cortical cords Develops thick tunica albuginea SRY TDF (testis determining factor) MIS (mullerian inhibiting substance) and testosterone regression of Mullerian ducts

Week 7 SRY Absent = ovary Development of cortical cords No medullary cords No think tunica albuginea develops No MIS, the mullerian ducts develop into uterus and uterine tubes

by 4th month

Genital ducts

testis cords =horseshoe shaped contain Primitive germ cells Sertoli- from surface epithelium produce MIS Leydig- from mesenchyme Secrete testosterone at 8th wk Testis cords are solid until puberty when acquire lumen and become seminferous tubules Mesonephric ducts (Wollfian ) • As mesonephros regresses, epigenital tubules establish contact with cords of the rete testis (become ductuli efferentes • Elongation of tubules below ductuli efferentes becomes the epididymis • Wall thickens around more distal tubule to become the vas deferens

cortical cords ( 2 generation cords) split into clusters cluster of epithelial cells surround a primitive germ cell Oogonia= germ cells Follicular cells= surrounding epithelium Medullary cords degenerate No connection to mesonephric duct Paramesonephric ducts (Mullerian) • Longitudinal invagination of the epithelium • Three parts initially 1) Cranial vertical portion 2) Horizontal portion 3) Caudal vertical portion 1 and 2 the uterine tube while 3 uterine canal folding of the embryo towards the midline moves the mullerian ducts together and forms the broad ligament

Testosterone • Produced by interstitial cells of Leydig • Testosterone mediates virilization (masculinization) of the mesonephric • Converted to dihydrotestosterone (DHT) by 5a reductase –DHT makes external genitalia male Androgen Insensitivity Syndrome “Testicular Feminization Syndrome” • Failure of tissues to respond to DHT • Genotype = 46 XY • Phenotype = female, MIS present = no uterus, short blind vagina

DEVELOPMENT OF THE EXTERNAL GENITALIA

~ solid tip of paramesonephric ducts meet urogenital sinus ~2 evaginations from urogenital sinuses (sinovaginal bulbs) form vaginal plate ~grows cranially ~ canalization by 5th month Anomalies: uterus didiphys w/ double vagina, uterus arcuatus (top indented), uterus bicornis with or without 1 rudimentary horn, atresia of cervix or vagina Structure Uterus, cervix, fornix Vagina Hymen Origin Mullerian/Paramesonephric duct Vaginal plate from urogenital sinus Separation of vaginal from urogenital tissues (failure = imperforate hymen)

Early/Indifferent External Genitalia Week 3: cells from primitive streak migrate to cloacal membrane to form cloacal folds. Cranial fusion genital tubercle. Cloacal folds divide into urethral and anal folds. Swellings on sides labioscrotal swellings. Anomalies: hermaphrodites – both testicular and ovarian tissue present. 70% 46XX. usually have a uterus with ambiguous external genitalia pseudohermaphrodites – genotype and phenotype don’t match, usually a receptor/hormone abnormality. Male: low MIS or androgenic hormones, receptor insensitivity, Androgen Insensitivity Syndrome most common. Kleinfelter syndrome 47XXY, 1/500 males, infertility, gynecomastia, impaired maturation, underandrogenization Female: less common, usually due to absence of enzyme. Congenital Adrenal Hyperplasia, increased androgens -> virilization, life threatening electrolyte imbalance. Turner’s syndrome: 45XO, female, no sexual maturation, high oocyte loss, short webbed neck, high arched palate, shield chest, cardiac and renal anomalies, inverted nipples. Male External Genitalia Development: androgen mediated Genital Tubercle elongates phallus Urethral fold urethral groove close to form penile urethra by 3rd month, lined by endoderm. Does NOT extend into glans. Distal portion forms in 4th month Ectodermal cells form glans solid epithelial cord extends internally, joins penile urethra, develops lumen external urethral meatus Genital swellings scrotum Anomalies: Hypospadias (glandular, penile or scrotal) – ureteral tube fails to close, 3/1000 births Epispadias – genital tubercle forms on caudal rather than cranial side, ureteral tube opens on top, 3/10,000 births Bifid or double penis – genital tubercle splits, rare Penile agenesis – genital tubercle fails to form, very very rare Testicular Descent: Testes start attached to retroperitoneum. Gubernaculum – mesenchymal condensation on base of testes, elongates and attaches adjacent to labioscrotal swellings between internal and external obliques. Outgrowth of G. starts descent, increase in intraabdominal pressure pushes testes into inguinal canal, regression of G. pulls testes into scrotum Transversalis fascia internal spermatic fascia Internal oblique cremaster External oblique external spermatic fascia Female External Genitalia Development: Genital tubercle elongates slightly clitoris Urethral folds do not fuse labia minora Genital swellings enlarge labia majora Urogenital groove stays open vestibule

Anomalies: Extremely rare

Ovarian gubernaculum does not shorten or regress. Inferior portion round ligament. Superior portion ovarian ligament

PELVIC ANATOMY OVERVIEW
Muscles 1. Coccygeus – ischial spine to side of sacrum and coccyx. From a posterior view, its called the sacrospinous ligament (orange) Levator ani (4 parts) 2. Iliococcygeus – obturator interna fascia to sacrum, coccyx, anococcygeal body, external sphincter of anus, and perineal body. (purple) 3. Pubococcygus – pubis to coccyx and anococcygeal body. (red) 4. Puborectalis – loops anal canal and acts as a sphincter. (gray) 5. Levator prostatae (pubovaginalis) – attaches into perineal body; acts as a sphincter. (blue)

Boundaries of Perineum (and pelvic outlet) 1. Tip of coccyx 2. Sacrotuberous ligament covered by the gluteus maximus. 3. The ischiopubic rami. 4. The undersurface of the symphysis pubis. Nerves and Vessels The pudendal nerve (S 2,3,4) and the internal pudendal artery (a branch of the internal iliac), exit the pelvic cavity by passing through the greater sciatic notch. Then, they go over the ischial spine and through the lesser sciatic notch, entering the ischioanal fossa through the pudendal canal.

RECTUM AND LATERAL PELVIC WALL
General Features of Rectum 1. Not straight. 2. About 5 inches. 3. Begins at S3. 4. No tenia coli, appendices epiploica, or sacculations. 5. Both circular and longitudinal muscle. Anal Canal 1. Portion of gut below the pelvic diaphragm. 2. About 1 ½ inches 3. Between perineal body and anococcygeal body. 4. Surrounded by three parts of external sphincter: Subcutaneous portion, superficial portion, and Deep portion. Blood Supply 1. Superior rectal 2. Internal iliac 3. Middle rectal 4. Internal pudendal 5. Inferior rectal Lymphatic Drainage (just follow arterial blood except for anal part which drains to node of cloquet). 1. Most of rectum drains to paracolic nodes and thus into the inferior mesenteric. 2. Lower rectum and upper anal canal drain to internal iliac nodes and nodes anterior to sacrum 3. Area below pectinate drains along pudendal to internal iliac nodes. 4. Lowest portion of anal canal may drain to inguinal nodes. Branches of the Internal Iliac Artery Intervertebral Joints / Ligaments

MALE PELVIC ANATOMY
Female Pelvis Subpubic arch greater than 90* Oval-shaped Pelvic inlet All diameters greater than in male. Ala of sacrum wider than promontory. Ischial spine and tuberosity turned outward Bone is thinner than males. v. Male Pelvis Subpubic arch less than 90*. Heart shaped inlet. All diameters less than female. Promontory wider than ala of sacrum. Ischial spine turned inward. Bone coarser and thicker.

Scarpa’s fascia becomes Colle’s fascia, which 1. separates the urogenital triangle contents from the anal triangle (therefore, a urethra rupture will NOT allow urine to pass into the anal triangle or down into the thighs) & 2. creates a septum between the two testes.

Erectile Structures in Males

• • • • •

Each structure is surrounded by the tunica albuginea (a dense connective tissue sheath). Note the 90* angle in the urethra. This is important to remember when passing a catheter. The corpus spongiosum is not as turgid as the cavernosum so the urethra is not compressed. Denonvillier’s fascia is between the rectum and the prostate. Erection occurs when parasympathetics cause vasodilation so increased blood flow exceeds venous drainage.

PERINEUM

Perineum – Diamond shaped area enclosing external genitalia and the anus. Divided
by a line between the ischial tuberosities into a urogenital triangle (lying anteriorly) and an anal triangle (lying posteriorly). Boundaries of the perineum are the tip of coccyx, sacrotuberous ligament, ischiopubic rami, undersurface of pubic symphysis. • Scarpa’s fascia separates both triangles by passing into the perineum and fusing along the ischiopubic ramus and posterior edge of perineal membrane. • Colle’s fascia is split by the opening of the vagina and fuses to vaginal walls Contents of the Urogenital Triangle (structures lie in the superficial perineal pouch) Mons pubis, labia majora (fat-filled) and labia minora (fat-free), fourchette (area where labia minora come together), urethral opening, ischiocavernosus muscle (striated muscle covering crus of clitoris), bulbospongiosus muscle (striated muscle covering bulb of vestibule), Bartholin’s glands, perineal membrane, superficial transverse perinei. The opening between the labia minora is called the vestibule. The vaginal opening is the largest opening into the vestibule; a hymen (mucous membrane projection) can surround and even completely cover vaginal opening. Clitoris does not contain a corpus spongiosum. Contents of the Anal Triangle Anococcygeal body, anus and external sphincter, and levator ani

Innervation and Blood Supply of Perineum
Pudendal nerve (S 2,3,4) lies in the pudendal canal (Alcock’s canal) after exiting the pelvic cavity and passing through greater and lesser sciatic notch, respectively. Branches of the pudendal nerve are: perineal nerve (innervates labia and striated muscles of urogenital area), dorsal nerve (skin and erectile tissue of clitoris), and inferior rectal (skin around anus, mucous membrane up to pectinate line, and external sphincter). Labia

majora receives sensory fibers from ilioinguinal and genitofemoral and the posterior cutaneous of the thigh. The internal pudendal artery (branch of the internal iliac) also lies in the canal, in between the dorsal and the perineal nerve. It has 5 branches: inferior rectal, posterior labial, artery to the bulb, deep artery to the clitoris, and dorsal artery of clitoris. The inferior rectal nerve and vessels cross the fat-filled fossa on either side of the anal canal called the ischioancal fossa, a site prone to infections.

Female vestibular bulbs

Male corpus spongiosum

greater vestibular bulbourethral glands glands urethral and paraurethral glands glans clitoris prepuce of clitoris corpus of clitoris labia minora labia majora prostate gland glans penis prepuce of penis corpus (shaft) of penis penoscrotal raphe scrotum

Table 1:Homologus structures in the male and female genitalia

(Paraurethral glands or Glands of Skene are tiny glands surrounding urethral opening; they represent the homologue of the prostate) Erectile tissue in the female is the clitoris, which is surrounded by dense connective tissue, the tunica albuginea. Its blood supply is the helicine or coiled arteries. The clitoris is not traversed by the urethra, so it has no corpus spongiosum extending from the bulb of the vestibule. Motor innervation of erectile tissue is via sacral parasympathetics via pudendal nerve.

Embryological Origins of Genitalia
Clitoris develops from genital tubercle. Labia minora from the genital folds; labia majora from the genital swellings. Vestibule develops from lower part of urogenital sinus.

INTERNAL FEMALE GENITALIA

1. UTERUS Usual position of the uterus is said to be anteverted and anteflexed. Both the round ligament (runs in the inguinal canal with the genitofemoral nerve) and the ligament of the ovary are derived from the gubernaculum. The uterus is supported by the broad ligament (double fold of peritoneum attaching to lateral pelvic walls), fibrous ligaments, and the pressure of other pelvic organs. Its major support are the pelvic diaphragm muscles. Parts of the broad ligament: mesosalpinx (above ovary containing fallopian tube), mesovarium (short portion attached to ovary), and mesometrium (major part attaching uterus to lateral pelvic wall). Uterine artery, supplying the uterus, crosses over the ureter in the base of the broad ligament. (Water flows under the bridge analogy)

The cervical ligaments include (see Harvey’s page 141) uterosacral, pubocervical, and the cardinal ligament of Mackenrodt, which contains the ureter, uterine artery and the nerves to the uterus. The internal and external iliac nodes receive most of the lymph from the uterus. The para-aortic nodes drain the ovary. 2. OVARY • • • Main source of estrogen Lies very close to the obturator nerve Egg ruptures onto the ovarian surface and thus into the peritoneal cavity

The attachments of the ovary are mesovarium (suspends ovary to posterior surface of broad ligament), ligament of ovary (attaches ovary to uterus at same point as round ligament), ovarian fimbrium (attaching ovary to tube), and the suspensory ligament. Ovary is supplied by the ovarian artery (arises from abdominal aortabelow renal vessels) and ovarian vein (which forms the pampiniform plexus which coalesces into a single ovarian vein draining into the IVC on the right and renal veoin on left). Ovary is innervated by sensory fibers arising from T 10. 3. VAGINA • • • • 3 inch long fibrous sheath Terminal part of vagina is attached to perineal body Cervix projects into upper anterior wall Lumen is a horizontal slit due to pull of transverse perinei muscles and cervcal ligament

Because cervix projects into the vagina, a shallow groove occurs around its end, called the fornix, which is divided into the anterior, posterior and lateral fornices. Blood supply of uterus is from the uterine artery. Lymph drains to iliac nodes with uterus; lowest portion to the superficial inguinal. Nerve supply is from uterine plexus. Lowest portion innervated by pudendal branches.

Chapter Twenty-Six – Male Reproduction
BLOCK 3 – GIMNER THREADS: ANATOMY/EMBRYOLOGY/RADIOLOGY CELL BIOLOGY/HISTOLOGY PHYSIOLOGY
CONTRIBUTORS: C.J. LEE, CALEB CAMPBELL, & BRYAN CHAMBERLAIN

TABLE OF CONTENTS: ANATOMY OF MALE REPRODUCTION MALE REPRODUCTIVE PHYSIOLOGY MALE GAMETOGENESIS & REPRODUCTION

MALE REPRODUCTIVE ANATOMY
PENIS - Corpus Cavernosum: dual fused columns of erectile tissue dorsal surface of penis - Corpus Spongiosum: single column of erectile tissue ventral surface of penis in which the urethra runs - Tunica Albuginea: dense connective tissue capsule around the erectile tissue in the penis (often pinned as white line between c. spongiosum and c. cavernosum in a longitudinal section of the penis) - Erectile tissue is ensheathed by Buck’s fascia (deep fascia of the penis) - Corpus spongiosum with urethra lead into the Glans (head) of the penis, which is an expansion of the spongiosum and is covered by the foreskin or prepuce - Origin of the c. cavernsoum is called the Crus (crura) is found on either side of the bulb of the penis - Cowper’s Glands (bulbourethral glands) enter the urethra at the bulb of the penis; located in the deep perineal space of the urogenital diaphragm BLOOD SUPPLY - Arteries: artery to the bulb, artery to the crus, dorsal artery o The branches of these vessels in the trabeculae of the erectile tissue = trabecular and coiled helicine arteries o Parasympathetic stimulation will lead to vasodilation of helicine and trabecular arteries and, therefore, erection - Veins: mostly drained to pudendal veins, but the body of the penis (erectile tissue) will drain via dorsal vein, under the pubic arch to the prostatic plexus LYMPHATIC DRAINAGE - mainly to superficial inguinals, especially the gland of Cloquet in the femoral canal FOUNDATION OF PENIS - Ischiocavernosus muscle: tentlike flaps of muscle extending on either side of penis from perineal membrane to the body of the penis - Bulbospongiosus muscle: wraps circumferentially around the bulb of the penis at its base - Perineal membrane: membrane of connective tissue surrounding bulb of penis; bottom (inferior boundary) of urogential triangle (superior border is urogenital diaphragm) EPIDIDYMIS - Posterolateral testis => head of ep. => body of ep. => tail of ep. => vas deferens - Small cyst called the appendix epididymis often found at the head of the epididymis (remnant of the mesonphros that may enlarge or twist the testes) VAS DEFERENS - Runs posterior to testes in scrotum and is easily palpated in scrotum/spermatic cord - Artery from superior vesicular as it crosses - Turns medially to back of bladder at level of ischial spine - Runs through external inguinal ring and deep inguinal ring around inferior epigastric artery SEMINAL VESICLES - Don’t store sperm, but secrete high fructose/prostaglandin mix that comprises ~70% of ejaculate - On posterior surface of bladder, just lateral to ampulla of vas - Possible to palpate rectally only if bladder is full - Joins with VD to form 1” ejaculatory duct in prostate PROSTATE GLAND - Partly muscular and partly glandular - Apex = between edges of anterior levator ani, inferior = on urogenital diaphragm - Contains remnant of paramesonephric duct = prostatic utricle (a small diverticulum of the urethra) - Peripheral lobes (lateral to ejaculatory ducts) are prone to cancer - Median lobe can hypertrophy (difficult to pee) - Blood supply from inferior vesicular and middle rectal arteries - Venous Drainage through extensive venous plexus outside capsule o Receives dorsal vein of penis + veins from the prostate o Drains to internal iliac o Has extensive connections with vertebral plexus => prostate cancer commonly metastasizes to bodies of vertebrae

MALE URETHRA - Membranous urethra is portion that departs prostate and passes through urogenital diaphragm o Most easily ruptured portion o Contains voluntary urinary sphincter - Navicular fossa: dilation of urethra at its termination in the Glans of the penis NERVE SUPPLY OF MALE SYSTEM - Sympathetic: mainly from T10 via hypogastric plexus o Cause all portions of the male system to contract (epididymis, vas, seminal vesicles, prostate, bladder) - Parasympathetic: from sacral plexus o Causes vasodilatio of arteries in penis (trabecular and helicine) => erection - Cutaneous: skin of penis from dorsal nerve of pudendal; skin of scrotum from perineal branch of pudendal (post), ilioinguinal and genitofemoral nerves (ant) SCROTUM - Layers (from outside to testicle): skin, dartos muscle, colle’s fascia, external spermatic fascia, cremastric fascia, internal spermatic fascia, scrotal space, parietal tunica vaginalis, visceral tunica vaginalis, tunica albuginea - Testicles guided to scrotum by gubernaculums - Divided (outside) by pigmented line called scrotal raphe - Divided (inside) by scrotal septum from scrotal muscle

QuickTime™ and a TIFF (LZW) decompressor are needed to see this picture.

MALE REPRODUCTIVE HISTOLOGY

KRETZER + LAMB’S LECTURES = KRAM(B) LECTURES! GOALS: 1. Be able to describe histology of the tissue 2. Know what these cells do—the process and the regulation of the process OBJECTIVES: HISTOLOGY OF THE TESTIS: 1. Overview of Structure A. Organization of testis: Scrotal location keeps testis 2-3 degrees lower than body temperature (req. for spermatogenesis). Suspended by spermatic cord (vas deferens, spermatic artery, vein, lymphatic plexus). B. Tunica albuginea (by rete testis) mediastinum testis (on posterior) septates testis into communicating lobules containing: 1-4 seminiferous tubules, blood/lymph vessels, nerves, Leydig cells, macrophages. C. Fibroblasts + Peritubular myoid cells (like smooth muscle) basement membrane Seminiferous tubule (Sertoli and pre-sperm cells) Tubuli recti Rete testis Ductuli efferentes Epididymis 2. Leydig cell A. Histology: Eosinophilic/red cells in the interstitium. Lots of SER, lipid droplets in cytoplasm, and mitochondria with tubular cristae. Located in interstitial space, close to blood vessels and lymphatics. B. Function: Signalled by LH to produce& release steroid testosterone constitutively. LH is present only during 8-18 weeks gestation and after puberty. 3. Myoid cell A. Histology: On the outer side of the basement membrane, surround seminiferous epithelium. B. Function: Shakes Sertoli cell to release mature spermatids from Sertoli cells into lumen during spermiation. 4. Sertoli (nurse) cell A. Histology: Long, pale, triangular nucleus w/ invaginations, a prominent nucleolus and little heterochromatin. Luminal folds. Lots of cytoplasm (envelops the germ cells) & SER, some RER, well developed Golgi, mitochondria and lysosomes. Post mitotic after puberty. B. Function: Tight/occluding junctions between Sertoli cells make the blood-testis barrier that protects all sperm precursors in adluminal compartment (except for spermatagonia which are in the basal compartment) from blood proteins and antibodies. Supports, protects, and nourishes developing germ cells. Stimulated by FSH and testosterone—affects spermatogenesis. Makes up the seminiferous tubules. Digests spermatid residual bodies by phagocytosis then lysosomal digestion. Secretes proteins, ions, inhibin, Mullerian Inhibiting Hormone (MIH) and Androgen Binding Protein (concentrates testosterone in the lumen). 5. Sperm Maturation

A. Spermatogonia (stem cells): Along basal lamina, haloed nucleus (hematoxylin and eosin stain). Type A dark (putative) Type B (more differentiated) Primary Spermatocytes. Begins mitosis at puberty, called proliferative stage of spermatogenesis; ineffective since many cells apoptose. They can re-establish spermatogenesis after treatment with toxic agents or radiation. B. Primary Spermatocytes: Located in adluminal compartment. 4N nucleus is distinct with compact DNA in various coiling stages 4stages of prophase (leptotene zygotene pachytene diplotene) takes more than 22 days (so most primary spermatocytes seen in prophase). Largest spermatogenic cells. C. First Meiotic Division Prophase: Leptotene (homologous chromosomes attach to inner membrane of nuclear envelope) Zygotene (Synaptoneal complex between homologous chromosomes forms) Pachytene (Homologous recombination/crossing over begins) Diplotene (Crossing over ends with chromosomes attached at chiasmata; chance for non-disjunction) Diakinesis (Chromosomes detach from membrane and condense, synaptonemal complex disassembles, MT spindle formed) D. Consequences of Meiosis: i) Haploid chromosomal complement ii) Random mixing of paternal & maternal genes from homologous recombination iii) Crossing over increases genetic variation E. Secondary Spermatocyte: 2N. Quick second meiosis (6-7 hours), so hardly ever see this stage. No S phase between first and second meiotic division. All divided cells remain attached by intercellular cytoplasmic bridges until spermiogenesis. F. Spermatid: 1N, small, with areas of condensed chromatin in a large, round nucleus. Last stage of spermatogenesis; begins spermiogenesis (spermatid differentiation). G. Spermiogenesis: Differentiation of haploid spermatid into mature spermatozoa. Golgi phase—spermatid has mitochondria, a pair of centrioles, free ribosomes, and tubules of SER; it begins to form PAS+ granules (in Golgi) that aggregate into an acrosomal granule. Acrosome vesicle moves toward cell surface, centrioles move to opposite surface. Cap phase Acrosomal Phase— Acrosome (hyaluronidase, neuraminidase, acid phosphatase, trypsin-like protease) enlarges. Acrosomal sac/cap must digest through egg’s zona pellucida and corona radiata to fertilize. Cell reverses orientation so acrosome faces basally. Nucleus condenses (arginine and lysine-rich protamines replace histones) to increase mobility and decrease shearing against sperm head during ejaculation; transcriptional activity ceases. One centriole forms a flagellum (9+2 MT axoneme); mitochondria migrate along axoneme to middle piece. Maturation Phase—nucleus continues to elongate and condense. Cytoplasmic bridges and residual body cytoplasm left to be digested by Sertoli cell. Detaches from Sertoli cell and enters lumen (spermiation). H. Spermatazoa: Head (condensed nuclear chromatin + acrosome) is 5µm, connecting piece (centriole pair, distal one gives rise to the axoneme), and tail (5µm middle piece with helical mitochondrial sheath to provide energy, axoneme, and nine outer keratin-containing, dense fibers; 50µm principal piece with seven

outer fibers and keratin fibrous sheath; 5µm end piece with only the axoneme and no sheath). Entire spermatogenesis = about 64 days. Each lobule is at different stages of spermatogenesis, so at any one time all spermatogenic forms are present. HISTOLOGY OF THE MALE GENITAL TRACT 1. Overview A. Seminiferous tubule Tubuli recti Rete testis Ductuli efferentes Epididymis Vas Deferens (Seminal Vesicle and Prostate Gland) Ejaculatory duct Prostatic Urethra Membranous Urethra Penile Urethra 2. Tubuli recti: Straight tubules lined by simple cuboidal epithelium 3. Rete testis: Anastomosing channels that collect sperm. Absorbs seminiferous fluid (secretory proteins and ions). 4. Ductuli efferentes: Lined by columnar epithelium (10-20 of the ducts have cilia that beat sperm towards epididymis). Surrounded by large lymphatic channels and blood vessels, and large clusters of Leydig cells. Absorbs seminiferous fluids. 5. Epididymis: A. Histology: 3 regions—head/caput, body/corpus, tail/cauda. Epithelium increases in thickness from from head to tail. Scalloped outline. Walls made of pseudostratified columnar cells (principal cells), basal cells (pyramidal precursor principal cells), apical cells (rich in mitochondria), clear cells (in the tail of the epididymis), and intraepithelial lymphocytes. Spermatazoa in lumen. B. Function: Surrounding smooth muscle cells support epididymis, and produce peristaltic contractions that move sperm along; ciliated cells also help move the sperm. Stereocilia (microvilli w/out actin or MTs) absorb seminiferous fluid. Digests residual bodies from spermiogenesis. Secondary maturation of sperm (gains motility, stabalization of condensed chromatin, changes surface charge of plasma membrane, gets new surface proteins—takes 2-12 days). Epididymus stores sperm. 6. Vas Deferens: A. Histology: Pseudostratified columnar epithelium and an inner and outer longitudinal smooth muscle with a circular layer between. Inside of the spermatic cord—includes cremaster muscle and pampiniform plexus. Enlarges into ampulla ejaculatory duct prostate prostatic urethra. 7. Seminal Vesicles A. Histology: Tortuous tubules surrounded by two longitudinal and one circular (in the middle) layer of smooth muscle—like the Vas. Inner folded mucosa lined by simple cuboidal to pseudostratified columnar epithelium—large Golgi + secretory granules. Viscous produce in lumen. B. Function: Smooth muscle contracts at ejaculation to secrete: Fructose (sperm’s food), Prostaglandin (causes vagina to contract & pull sperm in), Inositol, and Citrate. 50-70% of seminal fluid and activates spermatazoa. 8. Prostate A. Histology: Pseudostratified or simple columnar epithelium. Tons of smooth muscle in stroma. Glycoprotein + Calcium form concretions in

lumen. Peripheral zone (70% of gland, major site of prostatic cancer), Transition zone (5% of gland, site of benign prostatic hyperplasia), Central zone (25% of gland), and Prostatic Urethra B. Glands: Periurethral Mucosal Glands, Periurethral submucosal glands, Peripheral compound glands (main) stored empty into prostatic urethra during ejaculation. Acidic (pH 6.5) secretion: prostate-specific acid phosphatase, prostate-specific antigen-amylase and fibrinolysin (for liquefaction of viscous seminal fluid).
STRUCTURE OF THE PENIS

1. Urethra: 20cm long A. Prostatic Urethra—Receives fluid from ejaculatory and prostate ducts. B. Membranous Urethra—Shortest segment. Has involuntary smooth muscle and voluntary striated muscle sphincters controls urine/semen flow. C. Penile Urethra—Receives Bulbourethral/Cowper glands (secrete: galactose, sialic acid, mucus {lubrication function}—generally precedes sperm emission) 2. Penis A. Erectile Tissue = Corpora cavernosa (connected blood sinusoids) + Ventral corpus spongiosum (surrounds the penile urethra; tip of spongiosum is the Glans penis)
STEPS TO ERECTION AND EJACULATION

1. Erection: Cerebral cortex + hypothalamus stimulate autonomic penile dorsal nerve branches (from pundential nerve) Nitric oxide produced stimulates cGMP (to convert GTP GMP in smooth muscle) [[if phosphodiesterase is around it will destroy cGMP and terminate the erection]] cGMP induces Calcium smooth muscle relaxes helicine arteries open blood fills and enlarges sinusoids of the Corpora cavernosa, which compress venous channels blood in > blood out engorged penis 2. Ejaculation: thought to be a reflax stimulated by distention of post. urethra A. Sequence: Seminal fluid deposited in posterior urethra. Increased pressure closes bladder neck. Rhythmic contractions of periurethral + pelvic floor muscles seminal fluid propelled to urethral meatus. B. Control: i) CNS: dopaminergic facilitates, serotonergic inhibits ii) PNS: Efferent nerves from cerebral cortex hypothalamus/spniothalamic centers anterolateral columns (grey matter) thoracolumbar sympathetic outflow (T10-L3) some synpse in paravertebral symp ganglia while others just pass thru wind around lower aorta superior hypogastric ganglion superior hypogastric nerves innervation of end organs. 3. THE BOTTOM LINE: Parasympathetic nerves stimulate vasodilation & erection and sympathetic nerves stimulate ejaculation.

TESTIS FUNCTION/HORMONE PRODUCTION: 1. In the Sertoli Cell:

A. Regulation by hypothalamic (release GnRH)/pituitary (release FSH and LH)/gonadal axis. B. FSH—receptors on Sertoli cell, stimulates release of: inhibin (alpha and beta subunit) inhibits GnRH & FSH release; activin (homodimers of either of inhibins subunits) simulates FSH release stimulates Androgen Binding Protein release into lumen. C. Androgens—necessary for development of sexual differentiation of the brain and behavior. Receptors are detectable during perinatal period and are located on cell nuclei of brain, accessory sex glands, sweat glands, and hair follicles. Receptors on Sertoli cell (not on germ cells); androgens are necessary for normal spermatogenesis. D. Growth factors—evidence for local control of spermatogenesis. 2. In the Leydig Cell A. Leydig cells have LH receptors that stimulate steroidogenesis through camp mediated signal transduction pathway. Steroidogenesis occurs 8-18 weeks of gestation and after puberty. B. Regulated by LH (stimulates testosterone biosynthesis) and Prolactin (induces expression of LH receptor). C. Testosterone maintains spermatogenesis (by acting on Sertoli cell), male libido, and the function of male accessory glands.

Libido Control Upregulators Downregulators Androgens Prescription Drugs Estrogen Stress Progesterone Steroid Recep. Defects Neurosteroids Hypogonadism NT/Dopamine Aging Genetics Neurogenic Psychological Vasculogenic

Tissue N Seminiferous Epithelium Leydig Cells Myoid Cells Basement Membrane Seminiferous Tubule 2N 2N

divisions Mitotic 8-18 wks gestation & post puberty

cell type

Secretion Seminiferous fluid Testosterone

Sertoli & pre-sperm cells mitotic Stem cell mitotic Progenitor cell post-mitotic after puberty meiosis I meiosis II

Sperm, secretory proteins, ions, Inhibin, Activin, MIH

Spermatagonium Type A 2N Spermatagonium Type B 2N Sertoli Cells 2N 4N Primary Spermatocyte Secondary Spermatocyte 2N 1N Spermatid 1N Spermatazoa Tubuli Recti Rete Testis Ductuli Efferentes Epididymis Vas/Ductus Deferens Seminal Vessicle Prostate Gland

Androgen binding protein (ABP)

Prostatic Urethra Membranous Urethra Penile Urethra Glans Penis Bulbourethral Glands

Simple cuboidal Lined only by Sertoli-->ABP Simple cuboidal Absorb Seminif. fluid Columnar Absorb Seminif. fluid Pseudo-strat columnar Absorb Seminif. fluid Pseudo-strat columnar Simp. Cub.-->Strat. Columnar Prostaglandin & Fructose Simple/pseudo strat columnar Pros. Spec. antigen-amylase Pros. Spec. acid phosphatase Fibrinolysin (liquifaction) Transitional Urothelium Receive Ejac. Duct + Prostate Duct Psuedostrat Columnar Receive Bulbourethral Ducts Psuedostrat Columnar Stratified Squamous Mucus-secreting epithelium Bulb.: Mucus/Galactose/Sialic Acid

Physiology of Male Reproduction
Hypothalamo-Pituitary-Gonadal Axis • GnRH Neurons of Hypothalamus o Scattered throughout hypothalamus, but function as unit - Originate in Olfactory Placode o Start firing at puberty in response to “Pulse Generator” phenomenon o Pulse frequency and amplitude are of critical importance: Entrainment - Frequency is matched at sequential steps - Amplitude (Changes in concentration) decreases in sequential steps o Feedback is under Tonic Control by products Bolus injections of GnRH, LH or FSH would shut of axis • Anterior Pituitary o Hormones stored in vesicles and released by exocytosis under influence of high intracellular Calcium levels o G-Protien Coupled receptors receive GnRH and cause Opening of Ca2+ channels (Tonic control) Activation of PIP3-PKC series resulting in additional opening of Ca2+ channels and synthesis of hormone (FSH or LH) • Gonadal Response o Leydig cells produce testosterone in response to Luteinizing Hormone cAMP mediated mechanism regulates steroidal cascade Leydig cell stores testosterone precursors (mainly cholesterol), not actual hormone Rate limiting step: Cholesterol → Pregnenolone (mitochondria) Subsequent step: Pregnenolone → Testosterone (SER) o Testosterone promotes sperm maturation Diffusion through basal lamina of seminiferous tubule allows for testosterone to reach most basal cells Sertoli cells transport testosterone to luminal cells, bypassing tight junctions with Androgen Binding protein o Testosterone serves as precursor to Dihydrotestosterone and Estrogen DHT responsible for development of prostate, scrotum, urethra, penis, and bone Estrogen conversion by Sertoli cells but unknown function in testis; Conversion in liver & adipocytes eases process of binding up excess androgens

Chapter Twenty-Seven – Female Reproduction
BLOCK 3 – GIMNER THREADS: ANATOMY/EMBRYOLOGY/RADIOLOGY CELL BIOLOGY/HISTOLOGY PHYSIOLOGY
CONTRIBUTORS: RAHEL SELASSIE SCOTT, TAMELA MCCLAM AND RESHMA BRAHMBHATT

TABLE OF CONTENTS: ANATOMY OF FEMALE REPRODUCTION I ANATOMY OF FEMALE REPRODUCTION II OVARY GAMETOGENESIS HISTOLOGY OF FEMALE REPRODUCTIVE TRACT FERTILIZATION, IMPLANTATION & PLACENTAL FUNCTION PHYSIOLOGY OF FEMALE REPRODUCTION ENDOCRINE ASPECTS OF PREGNANCY PHYSIOLOGIC EFFECTS OF PREGNANCY

ANATOMY OF FEMALE REPRODUCTION I & II

I.

Female External Genitalia a. Crus of clitoris: covered by ischiocavernosus muscle b. Clitoris: 2 columns of corpus carvernosus (homologue penis) c. Prepuce: fusion of labia minora in front d. Vestibule: opening between two labia majora e. Fourchette: union of 2 labia minora, covers perineal body f. Bulb of vestibule: 2 columns to erectile tissue on either side of vagina, covered by bulbiospongiosus muscle g. Bartholin’s glands: 2 glands under portion of vestibule bulb h. Glands of Skene: ting glands surrounding urethral opening (homologue prostate) i. Hymen: projections of mucus membrane around vaginal opening j. Nerves: Pudendal S2, 3, 4 & labia majora: ilioinguinal, genitofemoral & posterior cutaneous of thigh k. Usual position of uterus: Anteverted & anteflexed l. Gubernaculums: origin of ovarian ligament & round ligament of the uterus 4 things cause female belly pain a. Gall bladder b. Tubule pregnancy c. Endometriosis d. Appendicitis e. Ruptured ovarian cysts Uterine Supports a. Broad ligament: double fold of peritoneum, attaches uterus & fallopian tubes to lateral pelvic wall i. Mesosalphinx: above ovary with fallopian tube ii. Mesovarian: short portion attached to ovary iii. Mesometruim: attaches uterus to lateral pelvic wall b. Fibrous ligaments c. Pressure from other pelvic organs d. Pubic bones e. Most important: pelvic diaphragm muscles f. “Water under Bridge” Ureter passes underneath uterine artery g. Round ligament of Uterus i. Attaches to uterus under fallopian tube ii. In inguinal canal with genitofemoral nerve & attaches into labia majora fascia h. Cervical ligaments: uterosacral, pubocervical i. Cardinal Ligament of Mackenrodt: contains nerves to uterus, ureter & uterine artery Ovary a. Vessels: ovarian arteries & veins pampiniform plexus b. Nerve supply T10 c. Rectouterine Pouch of Douglas i. Between uterus & rectum Pelvis a. Skeleton: 2 hip bones (os coxae) & sacrum (5 fused vertebrae) b. Pectinate Line: where pectinate muscle fuses to pelvic bones c. Ala of sacrum: wings, on either side of L5 d. Lesser sciatic foramen: 2 things pass obturator tendon & pudenal nerve bundle e. Diagonal obstetrical conjugate diameter: Undersurface of pubis promontory of sacrum f. Sexual Characteristics Male Subpubic arch < 90 degrees Female Subpubic Arch > 90 degrees

II.

III.

IV.

V.

Heart shaped inlet Promontory > Ala sacrum Ischial spine inward Course thicker bones

Oval shaped inlet Ala sacrum > Promotory Ischial spine outward Thinner bones

VI.

Pelvic Diaphragm a. Muscle that closes off pelvic outlet, separates pelvic cavity from perineum b. Perineal body: mass of CT ant. To anal canal c. Anococcygeal body: post. To anal canal d. Levator ani muscles i. Iliococcygeous: inferior to pubococcygeus ii. Pubococcygeus iii. Puborectialis: loops anal canal sphincter iv. Levator Prostatae (Pubovaginalis) urethral sphincter e. Nerve: S4 & Pudendal Nerve S2, 3, 4 Urogenital Diaphragm a. Inf. To pelvic diaphragm b. Post. Edge deep transverse perinea c. Ant. Urethral sphincter d. Thick external surface perineal membrane Perineum a. Encloses external genitalia & anus b. Boundaries i. Coccyx tip ii. Sacrotuberous ligaments iii. Ischiopublic rami iv. Symphysis pubis c. Ischioanal fossa: Deep fat filled fossa, deep to skin on either side of anus in posterior triangle, prone to infections Female Perineum a. Fatty abdominal wall laver: forms labia & mons pubis b. Scarpa’s fascia: Separates urogenital triangle from anal triangle c. Colle’s fascia: split at vaginal opening d. Fourchette: where labia minor join e. Ishciocavernosus Muscle: covers crus of clitoris f. Bulbiosphongiousus muscle: covers bulb of vestiuble

VII.

VIII.

IX.

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OVARY GAMETOGENESIS
Basic anatomical development: @ 5 weeks, the gonads are undifferentiated. Without SRY and MIF, an ovary forms Mullerian ducts oviducts, uterus, upper vagina Urogenital sinus lower 2/3 vagina, bladder, urethra, vestibular glands, hymen Genital tubercle clitoris Urogenital folds labia minora Labioscrotal swellings labia majora Random information from lecture: Ovulation is the only time that estrogen sends positive feedback to the pituitary (releasing more estrogen) During pregnancy, hCG maintains the corpus luteum on the ovary, allowing the high levels of progesterone required for a successful pregnancy

Oocyte Mitosis/Meiosis Mitosis: occurs in fetus Meiosis I: o partly occurs in fetus, partly after birth o eggs frozen in diplotene stage @ birth and called primary oocytes o @ ovulation, meiosis I is completed and first polar body is discarded Meiosis II: o completed at fertilization o second polar body discarded Follicular development/characteristics It takes ~90 days for a follicle to mature. Many reach maturity at the same time, but only the dominant follicle actually releases its egg for ovulation. Stages of development: - Primordial follicle: single layer squamous granulosa/follicular cells - Primary follicle (unilaminar): simple cuboidal granulosa cells - Primary follicle (multilaminar): stratified cuboidal granulosa cells, zona pellucida forms - Antral: antrum (cyst-like structure within follicle filled with follicular fluid – FSH and LH) - Mature: thin granulosa on wall, theca cells, oocyte on one side, cumulus cells (mound of granulosa cells) Granulosa/Follicular cells These cells surround the oocyte within the follicle. They protect and nourish the oocyte. More importantly, under the signal of FSH, they synthesize aromatase, which converts androstenedione into estrogen. Theca cells Theca cells are differentiated fibroblasts of the stroma surrounding the follicle. They separate into a theca interna and theca externa. Theca interna: make androstenedione, which is sent to the granulosa cells to be converted into estrogen. This layer has the most blood supply and has rounder cells than the theca externa. There is a basement membrane between the theca interna and the granulosa layer on which it lies, forming a distinct boundary Theca externa: spindle shaped cells, fibroblasts. No clear boundary between theca externa and interna. Both granulosa and theca layers have a large number of LH receptors. The granulosa and theca interna layers also give rise to the corpus luteum. Follicular Atresia Most oocytes die by apoptosis, which can occur in any stage of follicular development Oocytes decline rapidly: 8 million (20 wks) > 2 million (birth) > 400,000 (puberty) ~450 ovulations in a lifetime Menopause: oocyte depletion Without pregnancy, the corpus luteum degenerates into a corpus albicans (scar of dense connective tissue) with lots of collagen

-

HISTOLOGY OF FEMALE REPRODUCTIVE TRACT

Fallopian tube Layers (inside to outside): Mucosa: simple columnar, some ciliated cells Muscularis: inner circular/spiral, outer longitudinal Serosa: visceral peritoneum

Many folds, especially in ampulla

Uterus Corpus Layers (inside to outside): o Endometrium: ciliated and secretory simple columnar epithelium, ciliated rare in glands Basalis: adjacent to myometrium, contains lamina propria and beginning of uterine glands, doesn’t change during menstrual cycle. Blood supply: straight arteries (from arcuate arteries) Functionalis: remainder of lamina propria and glands and surface epithelium, changes during menstruation. Blood supply: spiral arteries (from arcuate arteries) o Myometrium: 4 poorly defined layers of smooth muscle. Inner and outer layers are longitudinal, middle layers have the vessels. During pregnancy, the myometrium undergoes hyperplasia and hypertrophy o Adventita (connective tissue) or serosa (connective tissue and mesothelium) Cervix: 85% dense connective tissue Exocervix: stratified squamous epithelium Endocervix: simple columnar epithelium Most cancers occur at squamocolumnar junction (where exo- and endocervix meet)

Menstrual cycle and Uterine glands Proliferative phase: after shedding of lining to ovulation. Glands are straight and narrow. There is dense stroma. Estrogen involved. Luteal phase: after ovulation to shedding of lining. Glands are twisted, cells are less dense. Progesterone involved. Menstruation: no hormones

Vagina Layers (inside to outside): Mucosa: - Stratified squamous epithelium - No glands or nerve tissues - Epithelium has some keratohyalin - Under the influence of estrogen, glycogen accumulates in epithelium lower pH (think esophagus) - Lamina propria is loose connective tissue with lots of elastic fibers, many lymphocytes and neutrophils that can pass into the lumen of the vagina during certain phases of the menstrual cycle. Muscularis: mostly longitudinal bundles of smooth muscle, some circular muscle close to mucosa Adventitia

External genitalia Labia majora and minora, vestibular/bartholin’s glands, clitoris Many nerve endings, including meissner’s and pacinian corpuscles

FERTILIZATION, IMPLANTATION & PLACENTAL FUNCTION
Timetable Fertilization occurs 24-48 hours after ovulation in the fallopian tubes Zygote becomes morula in the fallopian tube and travels to the uterus 2-3 after fertilization Blastocyst “hatches” from zona pellucida ~72 hrs after entering uterine cavity Implantation: 6-7 days after fertilization Apposition: loose relationship b/tw blastocyst and endometrium Adhesion: invasive implantation (invasion of myometrium and uterine vessels by syncitiotrophoblast) Decidualization of endometrial stroma: see adjacent box Placenta Functions: Gas exchange (umbilical arteries carry deoxy blood, umbilical vein carries oxy blood) Transfer of maternal IgA Steroid hormone production (progesterone and estrogen from androgen precursors) Protein hormone production Active transport of glucose and ions Placental Villi: Circulation: Fetal circulation is in the villi Maternal circulation in intervillar spaces Syncitiotrophoblast (multinucleated) and cytotrophoblast (one nucleus) surround fetal capillaries As pregnancy progresses, syncitiotrophoblast > cytotrophoblast Fetal side of the placenta: chorion or chorionic plate Maternal side of the placenta: decidua basalis Pathology Ectopic pregnancy: implantation of blastocyst anywhere outside uterus ~95% occur in fallopian tubes Risks: Pelvic Inflammatory Disease, pelvic surgery Sxs: pain, amenorrhea, vaginal bleeding Placental abruption: premature separation of normally implanted placenta occurs late in pregnancy causes: ↑ BP (pre-eclampsia), trauma, clotting disorders, cocaine Sxs: spontaneous painful bleeding, uterine contractions Placenta acreta: abnormal attachment of the placenta to the uterine lining, invades and does not separate from uterine wall Placenta increta: invasion of placental villi into uterine muscle Placenta percreta: invasion into the serosa of the uterus (through the muscle into the peritoneum) Dx usually at time of delivery Placenta previa: placenta partially or completely covers cervical os Sx: painless vaginal bleeding Dx: ultrasound Gestational trophoblastic disease: Hydatiform mole: partial or complete replacement of normal trophoblastic tissue by dialated/edematous villi o Complete mole: 46, XX – paternal origin o Partial mole: 69, XXY – one maternal and two paternal sets of chromosomes o Extremely high levels of hCG o Choriocarcinoma: occurs in 20% of patients with molar pregnancies o Sx: bleeding, very high hCG o Dx: ultrasound Decidualization: maternal contribution to placenta Decidua basalis: under fetus Decidua capsularis: around fetus Decidua parietalis: around uterine wall

PHYSIOLOGY OF FEMALE REPRODUCTION
Hpg Axis Ovary Endocrinology Follicle→Steroid synthesis→ovulation→corp.lut. Follicle Formation Primordial→1 follicle NON hormonal 1 follicle→antral follicle –FSH (granulose) LH (theca+granulosa) Microenv: Pit horms, growth fxr, activin, inhibin

Phase Follicular Ovulatory Luteal Menstrual

Puls. Mode Tonic, ↑f SURGE Tonic, ↑A Tonic-inhib

Regulation: HT pulse generator, NT and opioids, Ovarian steroid feedback

Female Sex Steroids and Synthesis Origin Types FXN Estrogen Follicle Estradiol (E2) potent, estrone, estriol breast/reprod tract maturation, bones(osteoblastic), ↓cholesterol, skin/sebaceous glands Progesterone Corpus Luteum, placenta Progesterone, 17-OH progesterone cyclical secretory activity, antagonizes estrogen, breast lobules, thermoregulation Androgens adrenals, ovaries Androstenedione, DHEA, testosterone. Hair patterns

Menstruation: ↓estrogen/progesterone→↑lysosomal enzymes (phospholipase)→arachidonic acid→prostaglandins→ vasoconstriction locally→ischemia/necrosis→endometrial desquamation (bleeding) Ovulation: Atresia- Non-dom. follicle FSH DHT

Before LH surge FSH priming E2 feedback

During LH surge (14days) Biochem/cellular events Meiosis resumes Vasc/plasmin→rupture and release

After LH surge Corp Lut forms Progesterone

Menopause (age=48-52, only humans) ↑↑FSH, LH, and androgens Sx: hot flashes, bone loss, cardiovascular risk, atrophy of reprod orgs, skin/mucosal ∆s, psychological issues Rx: Estrogens

ENDOCRINE ASPECTS OF PREGNANCY
Fertilization • • • • • • Need: timing, egg, sperm, factors determining egg/sperm transport and maturation Egg/sperm fuse, sperm enters, prevent addtl sperm entry, 2nd meiosis completion, pronucleus fusion, cell division Division and differentiation, attachment, decidual reaction, formation of differentiated cell layers GnRH, estrogen, progesterone, hCG, hPL, CRH, IGF-1, IGF-11 hCG (made by trophopblast)- P production by CL, fetal Leydig cell, ↓immunoreactivity hPL (made by trophoblast) – differentiation of mammary glands, fuel balance

Implantation Placenta l Hormones

FETO-Placental unit and steroid metabolism By 8wks-Mom+fetus adrenal glands, placenta cooperate Maternal Endocrine ∆s ↓HPG axis Lactotroph hyperplasia ↑cortisol Parathyroid hyperplasia ↑PRL secretion ↑PTH ↑fat stores ↑insulin resistance

Fetal Growth • Insulin is growth factor • Diabetic mother→↑glucose to fetus→↑growth • No MIF=female. 8-10weeks= reproductive tract. 12-14weeks=external genitalia (DHT→male, Estradiol→female) Partrurition ↓P Prostaglandins E2, F2α Oxytocin Relaxin Fetus: ↑HPA Lactation ↓P Neurohormonal suckling reflex

• • • •

• •

PHYSIOLOGIC EFFECTS OF PREGNANCY
Reproductive Organs • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • ↑vasc, engorgement genital organs ↑breast size (estrogen). ↓estrogen→lactation ↑estrogen, progesterone→↑pigmentation (skin, areolas, linea alba) Relaxin→ligament flexibility Avg = 24lbs. +300kcal/day for fetus. Peripheral resistance to insulin due to hPL. ↑cholesterol and triglycerides hormones→nausea. Hyperemesis gravidarum=sever vomiting→dehydration ↓Motility bc ↓P→↓motilin→↑reabsorption→constipation ↑Gastrin→↑stomach vol→↓pH. ↓esophageal peristalsis. GERD due to esoph peristalsis, sphincter relaxation, ↑Pressure from uterus, hiatal hernia Bowel moved up, lateral. Appendix moved superiorly into right flank ↓albumin:globulin kidneys, renal pelvis, ureters dilate. ↑P→smc relax; hyperplasia of smc can cause ↑urinary resid. vol ↑body water Renal-↑adrenal, placental hormones, ↑plasma vol → ↑GFR, ↑RPF. Urine volume ↑slightly→urinary system more efficient (↑creatinine clearance) No vasoconstriction in pregnancy Bladder capacity increases, more pressure from uterus→frequent urination ↑↑Blood volume (20-100%) ↑RBC→↑iron requirement (fetus gets 1st)→iron deficiency anemia in mother ↑WBC (PMNs primarily) ↑platelet, ↑fibrinogen and ↑F8 ♥ moves up and to left, ↑size (12%). ↑cardiac capacity (70-80nml). Potential systolic ejection murmurs. ↑CO (40%) (mostly stroke volume↑, some ↑HR) ↓BP(systemic) due to ↓SVR possibly bc placental “shunt” and vasoactive substances (NO, ANH) ↓PVR Diaphragm elevated, rib cage up/out Nasopharynx, larynx, trachea, and bronchi engorged due to cap dilation ↑dead space, tidal volume →↑Alveolar ventilation ↓FRC, RV, ERV ↑20% O2 utilization Hyperventilation of pregnancy due to ↑TV→↓pCO2 tension, while maintaining alveolar O2 tension ↑Respiratory Rate

Weight Gain

GI Motility Stom/Esoph Bowel Liver Kidney

Hematologic

Cardio

Pulmonary

Chapter Twenty-Eight - Integrative Topics
ALL BLOCKS ALL THREADS
CONTRIBUTORS: GABRIEL DE LA GARZA, DREW JUERGENS & ROHIT PUSKOOR

TABLE OF CONTENTS: RENIN-ANGIOTENSIN-ALDOSTERONE AXIS NEURAL CREST CELLS POLYPLOID CELLS MULTI-NUCLEATED CELLS CELLS WITH HALOS CANALICULI CELLS OF MONOCYTE ORIGIN MALT GALT IMMOTILE CILIA SYNDROME MYOEPITHELIAL CELLS PANCREAS VS. SUBMANDIBULAR GLAND

THE RENIN-ANGIOTENSIN-ALDOSTERONE AXIS
In general: The renin-angiotensin-aldosterone axis is a major player in the maintenance of blood volume and fluid homeostasis. In conjunction with ADH from the posterior pituitary, it is activated by a loss of blood volume and causes the retention of Na and H20, thus returning blood volume back toward normal. Activated by: Loss of blood volume Inhibited by: Normal or high blood volume Note: Renin-angiotensin-aldosterone is triggered mostly by loss of blood volume (and not a so much change in osmolarity). ADH is triggered by both, but is more sensitive to changes in osmolarity. (ADH should be covered more in-depth elsewhere.)

Angiotensinogen: Location: Angiotensinogen is a plasma protein in circulation (comes from hepatocytes in liver) Renin: Secreted by: The granular cells of the juxtaglomerular apparatus (JGA). The specialized cells of the macula densa sense Na concentration and renal perfusion pressure. The lacis cells (next to the macula densa) transfer information to the juxtaglomerular cells, which secrete renin into the adjacent capillaries. Acts on: Converts Angiotensinogen to Angiotensin I in the plasma Angiotensin I: Comes from: The blood (that’s where angiotensinogen is converted to angiotensin I by renin) Acts on: NOTHING (it’s inactive) Angiotensin converting enzyme (ACE): Located in: The lungs or endothelial lining (depending on whether you believe Cassius or Farmer) 10% is in plasma and 90% tissue, according to Farmer. Acts on: Angiotensin I to convert it to Angiotensin II (active)

Angiotensin II: Comes from: The blood after being converted from Angiotensin I by ACE in the lungs and/or blood vessels. Acts on: 1. The zona glomerulosa of the adrenal cortex to stimulate the synthesis of aldosterone. (ACTH also does this to a lesser degree.) 2. The smooth muscle of arterioles, causing them to vasoconstrict, thus increasing total peripheral resistance (TPR) and mean arterial pressure. Aldosterone: Secreted by: The zona glomerulosa of the adrenal cortex Acts on: The collecting tubules of the kidneys (and to some extent the salivary and sweat glands) to increase Na reabsorption. This, in turn causes water retention in the kidneys and increases blood volume.

The pathway: (Sorry, it would have arrows, but they didn’t work for some reason.) Lowered Arterial pressure
Which leads to…

Lowered Renal perfusion pressure
Which leads to…

Increased Renin secretion
Which converts…

Angiotensinogen to Angiotensin I
And then…

ACE converts Angiotensin I to Angiotensin II
And then…

Angiotensin II
Has a double effect on…

1. Constriction of arterioles
Which leads to...

2. Secretion of Aldosterone
Which leads to…

Increased Total Peripheral Resistance
Which leads to…

Na and H2O reabsorption
Which leads to…

Increased Arterial pressure

NEURAL CREST CELLS
1.sensory neurons (neurofilament) 2.postganglionic sympathetics (neurofilament) 3.postganglionic parasympathetics (neurofilament) 4.Schwann cells (vimentin) 5.satellite cells around sensory somas in DRG (vimentin) 6.pia cells (meningothelial cells) (vimentin) 7.arachnoid cells (vimentin) 8.dura (vimentin) 9.melanocytes (vimentin) 10.odontoblasts (vimentin) 11.Outlet septum (divides aorta and pulmonary trunk) 12.thymus 13.parathymus 14.Maintenance of aortic blood vessels (main arterial vessels branching off the aorta) 15.Autonomic innervation of the heart 16.Maintenance of aortic smooth muscle 17.Wall of the aorta 18.Enteric nervous system 19.Adrenal medulla 20.parafollicular cells in thyroid gland

POLYPLOID CELLS
1.megakaryocytes 2.aged hepatocytes

MULTINUCLEATED CELLS
1.megakaryocytes 2.aged hepatocytes 3.cardiac muscle 4.skeletal muscle 5.osteoclast 6.synctitiotrophoblast

CELLS WITH HALOS
1) Melanocytes 2) Spermatogonia

CANALICULI
Bone- w/ gap junctions Apical PCT- ion pumping Platelet- open system for alpha, delta, and lambda vesicle fusion Serous salivary cells- increases surface area to allow for secretion Parietal cells

CELLS OF MONOCYTE ORIGIN
Microglia of brain Langerhans of skin Macrophage anywhere Mesangial in kidney Osteoclast of bone Perivascular macrophage in brain Pulmonary macrophage in lung Lipocyte cells in liver (Ito cells in space of Disse) Kupffer cells (near endothelial cells in liver)

MALT
• • • • • • • • • • • • • • • • • • • alveolar macrophage (proteases, lysozymes) Goblet cells ciliated cells modified M cells epithelial antigen presenting cells Clara cells- release oxidases to neutralize persistent invaders lymphocytes and leukocytes in thick alveolar wall DNES (paracrine signals to seromucous glands to release hydrolytic enzymes into hypophase) ex: small granule cells lymphoid nodules at bifurcation of bronchi granulocytes in lamina propria tight junctions surfactant antibodies/antigen complexes cytokines complement system basal lamina nose hairs cough reflex mucus escalator

GALT
esophagus • sIgA (and also cervix… as in opening of uterus) • lactoferrin • lysozyme • glycogen built up and release w/ desquamating cells • thick epithelium w/ tight junctions • melanocytes- neutralize O2- radicals made by dying bacteria stomach • sIgA • lactoferrin

• lysozyme • muramidase • cardiac and pyloric mucus • low pH • intraepithelial lymphocytes small intestine • Paneth cells (defensins, lactoferrin, lysozyme) • sIgA • plasma cells • macrophages • lymphocytes • Peyer’s patches w/ M cells in ileum Colon • Lymph nodules • Peyer’s patches • lots of goblet cells and mucus appendix • lots of goblet cells and mucus • large lymphatic nodules

IMMOTILE/LABILE CILIA SYNDROME AFFECTS…
Brain (ependymal) Epididymis Oviduct Inner ear Bronchi Salivary Sperm

MYOEPITHELIAL CELLS
Eccrine and apocrine sweat glands mammary glands surround acinar cells surround intercalated ducts (NOT striated ducts) of salivary glands
Submandibular Gland α-amylase (pH ~7) none none none (Von Ebner's glands under tounge) none Pancreas pancreatic amylase deoxyribonuclease, ribonuclease trypsinogen, chymotrypsinogen, proelastase,procarboxypeptidase (A and B), proaminopeptidase procolipase, prophospholipase A2, procholesterol esterase yes

Amylase Nucleases Proteases

Lipase Pacinian Corpuscles

Islets of Langerhans Zymogen Tight Junctions Glands (acinar cells) Myoepithelial cells Intercalated duct Secretin/HCO3 wash Solution

none no basal in acini (intercellular canniliculi) serous (demilunes), mucous around acinar cells and intercalated ducts do not go into acinar cells none hypotonic (↑K and Ca, ↓ Na) changes with amount of time in intecalated duct oral cavity, ciliated simple columnar sym: ↑ protein, low H20 volume - dry mouth parasym: ↓ protein - tons of volume aldosterone (retain Na) kallikrein (vdltn) Intercalated and striated ducts (eosinophilic b/c of palisades of mitochondria) stratified cuboidal → stratified columnar → stratified squamous non-keratinized lysozyme (gram -), muramidase (gram +), lactoferrin (binds Fe), sIgA large capillary bed in connective tissue stroma around acinar cells (?) fenestrated with diaphragms

endocrine fxn. (α outside, everything else inside) secretions as zymogens apical in acini - caustic secretions protein secretors: basophilic base and eosinophilic apicies (denatured zymogens) none - use muscularis mucosa and perstalsis to secrete go into acinar cells - centroacinar cells (release HCO3) present to neutralize acidic chyme hyper or isotonic, caustic meets common bile duct @ ampulla of Vater vagus (ACh)

Duct Opening Nervous stimulation

Hormonal stimulation Intralobular ducts

chyme causes release of CCK (zymogen release) and secretin (HCO3 wash) intercalated duct only simple columnar, some goblet and enteroendocrine cells maybe even mucus glands none First: continuous fenestrated capillaries with diaphragms in Islets of Langerhans Second: continuous non-fenestrated capillaries around pancreatic acinar cells α: glucagon β: insulin δ/D: somatostatin (antagonistic to CCK, secretin, ACh) D1: VIP F: Pancreatic polypeptide (antagonistic to CCK) large with activity, small when fasting pyrimidal acinar none

Interlobular ducts

Antibacterial

Blood flow

Endocrine function

no DNES cells, VERY limited endocrine fxn. converts bradykinin to kininogen using kallikrein, causing vdltn, increased flow and saliva

Lumen size Shape Pellicle Protein

tiny round acinar yes - protects Ca on teeth

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