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METABOLISM OF GLUTAMINE IN THE BRAIN The brain is a net glutamine producer owing principally to the presence of gluta- mine synthetase in astroglial cells (see Chapter 47) kamagra effervescent 100mg free shipping. Glutamate and aspartate are synthesized in these cells generic 100 mg kamagra effervescent, using amino groups donated by the BCAA (principally valine) and TCA cycle intermediates formed from glucose and from the carbon skeletons of BCAA (Fig purchase 100mg kamagra effervescent fast delivery. This glu- tamine may efflux from the brain kamagra effervescent 100mg fast delivery, carrying excess NH4 into the blood discount 100 mg kamagra effervescent otc, or serve as a precursor of glutamate in neuronal cells. Blood- brain Blood barrier Astroglial cell Neurons BCAA BCAA α–KG Purine nucleotide BCKA Glutamate cycle GABA + + glutamine NH4 NH3 NH3 NH4 synthetase + CO2 NH4 Glutamine Glutamine Glutamate Fig. Glutamine serves as a nitrogen transporter in the brain for the synthesis of many different neurotransmitters. Different neurons convert glutamine to -aminobutyric acid (GABA) or to glutamate. Glutamine also transports excess NH from the brain into the blood. BCKA branched-chain keto acids; -KG 4 -ketoglutarate. CHAPTER 42 / INTERTISSUE RELATIONSHIPS IN THE METABOLISM OF AMINO ACIDS 775 Glutamine synthesized in the astroglial cells is a precursor of glutamate (an exci- During hyperammonemia, ammo- tatory neurotransmitter) and GABA (an inhibitory neurotransmitter) in the neuronal nia (NH3) can diffuse into the brain cells (see Fig. It is converted to glutamate by a neuronal glutaminase from the blood. The ammonia is able to inhibit the neural isozyme of glutam- isozyme. In GABAergic neurons, glutamate is then decarboxylated to GABA, inase, thereby decreasing additional ammo- which is released during excitation of the neuron. GABA is one of the neurotrans- nia formation in the brain and inhibiting the mitters that is recycled; a transaminase converts it to succinaldehyde, which is then formation of glutamate and its subsequent oxidized to succinate. This effect of ammo- nia might contribute to the lethargy associ- ated with the hyperammonemia found in III. CHANGES IN AMINO ACID METABOLISM WITH patients with hepatic disease. DIETARY AND PHYSIOLOGIC STATE The rate and pattern of amino acid utilization by different tissues change with dietary and physiologic state. Two such states, the postprandial period following a The levels of transthyretin (binds high-protein meal and the hypercatabolic state produced by sepsis or surgical to vitamin A and thyroid hormones trauma, differ from the postabsorptive state with respect to the availability of amino in the blood) and serum albumin in acids and other fuels and the levels of different hormones in the blood. As a result, the blood may be used as indicators of the the pattern of amino acid utilization is somewhat different. In the absence of hepatic disease, decreased levels A. A High-Protein Meal of these proteins in the blood indicate insuf- ficient availability of amino acids to the liver After the ingestion of a high-protein meal, the gut and the liver use most of the for synthesis of serum proteins. Glutamate and aspartate are used as fuels by the gut, and very little enters the portal vein. The In what ways does liver metabo- liver takes up 60 to 70% of the amino acids present in the portal vein. These amino lism after a high-protein meal acids, for the most part, are converted to glucose in the gluconeogenic pathway. Insulin release is also stimulated, but not nearly to the levels found after a high-carbohydrate meal. Skeletal muscle Protein synthesis + Insulin TCA [ATP] Alanine Glutamine BCAA Other amino acids Liver Protein + Glucagon Aspartate, Lactate, Glutamate, Citrulline, Amino acid Gluconeo- Glutamine, NH3 degradation genesis BCAA Urea [ATP] cycle Glucose CO2 Urea Gut TCA [ATP] CO2 Brain Fig. Glucagon stimulates gluconeogenesis in the liver is not inhibited. The higher the carbohydrate content of amino acid transport into the liver, stimu- the meal, the higher the insulin/glucagon ratio and the greater the shift of amino lates gluconeogenesis through decreasing acids away from gluconeogenesis into biosynthetic pathways in the liver such as the levels of fructose 2,6-bisphosphate, and synthesis of plasma proteins. The BCAA are slowly taken up by skeletal muscle and other tissues. These peripheral nonhepatic tissues use the amino The Atkins high-protein diet is acids derived from the diet principally for net protein synthesis. Hypercatabolic States meals will keep circulating insulin levels low, such that energy storage is not induced, Surgery, trauma, burns, and septic stress are examples of hypercatabolic states char- and glucagon release will point the acterized by increased fuel utilization and a negative nitrogen balance (Fig. The port the energy and amino acid requirements for the immune response and wound lack of energy storage, coupled with the loss healing.

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The nitrogen from amino acid degradation appears in the urine primarily as urea or NH quality 100 mg kamagra effervescent, the ammonium ion cheap kamagra effervescent 100 mg. Ammo- 4 nia excretion is necessary to maintain the pH of the blood buy generic kamagra effervescent 100 mg line. Amino acids are used as fuels either directly or after being converted to glucose by gluconeogenesis buy cheap kamagra effervescent 100mg. Some amino acids can be synthesized in the human generic kamagra effervescent 100 mg without prescription, provided that glucose and a nitrogen source are available. Net degradation of labile protein occurs in skeletal muscle (which contains the body’s largest protein mass) and other tissues. RELEASE OF AMINO ACIDS FROM SKELETAL MUSCLE DURING FASTING The efflux of amino acids from skeletal muscle supports the essential amino acid pool in the blood (see Fig. Skeletal muscle oxidizes the BCAA (valine, leucine, isoleucine) to produce energy and glutamine. The amino groups of the BCAA, and of aspartate and glutamate, are transferred out of skeletal muscle in ala- nine and glutamine. Alanine and glutamine account for approximately 50% of the total -amino nitrogen released by skeletal muscle (Fig. The release of amino acids from skeletal muscle is stimulated during an overnight fast by the decrease of insulin and increase of glucocorticoid levels in the blood (see Chapters 31 and 43). Insulin promotes the uptake of amino acids and the general synthesis of proteins. The mechanisms for the stimulation of protein syn- thesis in human skeletal muscle are not all known, but probably include an activa- tion of the A system for amino acid transport (a modest effect), a general effect on initiation of translation, and an inhibition of lysosomal proteolysis. The fall of blood insulin levels during an overnight fast results in net proteolysis and release of amino acids. As glucocorticoid release from the adrenal cortex increases, an induction of ubiquitin synthesis and an increase of ubiquitin-dependent proteolysis also occur. AMINO ACID METABOLISM IN LIVER DURING FASTING The major site of alanine uptake is the liver, which disposes of the amino nitrogen by incorporating it into urea (see Fig. The liver also extracts free amino acids, CHAPTER 42 / INTERTISSUE RELATIONSHIPS IN THE METABOLISM OF AMINO ACIDS 765 Kidney NH3 Brain NH+ 4 Glutamine Urea Valine, Isoleucine Gut Alanine Alanine Glutamine Lactate BCAA Skeletal Urea Liver muscle Cells of the Glucose Lactate immune system Amino acids α-Keto acids Alanine Fig. Interorgan amino acid exchange after an overnight fast. After an overnight fast (the postabsorptive state), the utilization of amino acids for protein synthesis, for fuels, and for the synthesis of essential functional compounds continues. The free amino acid pool is supported largely by net degradation of skeletal muscle protein. Glutamine and alanine serve as amino group carriers from skeletal muscle to other tissues. Glut- amine brings NH to the kidney for the excretion of protons and serves as a fuel for the kidney, gut, and cells of the immune system. Alanine 4 transfers amino groups from skeletal muscle, the kidney, and the gut to the liver, where they are converted to urea for excretion. The brain con- tinues to use amino acids for neurotransmitter synthesis. Amino acid release from human forearm Composition of average protein 25 20 15 10 5 0 Alanine Glutamine Branched- chain amino acids Fig. The arteriovenous difference (concentration in arterial blood minus the concentration in venous blood) across the human forearm has been measured for many amino acids. This graph compares the amount of alanine, glutamine, and BCAA released with their composition in the average protein. Alanine and glutamine represent a much higher percentage of total nitrogen released than originally present in the degraded protein, evidence that they are being synthesized in the skeletal muscle. The BCAA (leucine, valine, and isoleucine) are released in much lower amounts than those present in the degraded protein, evidence that they are being catabolized. Aspartate and glutamate also contribute nitrogen to the formation of alanine and glutamine 766 SECTION SEVEN / NITROGEN METABOLISM Glucose -keto acids, and some glutamine from the blood. Alanine and other amino acids are oxidized and their carbon skeletons converted principally to glucose.

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They reported that if she did not move of the pain discount 100 mg kamagra effervescent amex, and the radiograph was consistent (Figure she would be quiet order kamagra effervescent 100mg with visa; however cheap 100 mg kamagra effervescent with amex, any movement would cause C10 order kamagra effervescent 100mg without prescription. A reconstruction was performed with an ad- her to cry out buy 100 mg kamagra effervescent visa. She was fed by ductor lengthening on the left and bilateral femoral varus gastrostomy tube, took medication to control seizures, and derotation shortening osteotomy with a peri-ilial pelvic had chronic constipation. She was mobilized immedi- On physical examination she had good head control but ately, and by 3 months all the preoperative pain had re- could not prop-sit, she did not weight bear, and had mild solved. She was sitting all day and not crying with dress- scoliosis. The left hip lacked 20° to come to neutral ab- ing and other position changes. The right hip abducted 70° but could not be 20 years, 11 years after reconstruction, the hips had sym- brought to the neutral adduction. The popliteal angle on metric range of motion with full extension and flexion, the left was 90° and on the right it was 60°. The feet were abduction to 20°, but rotation limited to 20° internally in severe planovalgus. On physical examination she cried and 30° externally (Figure C10. No hip pain was with attempted left hip abduction and all attempts to sit, present, and the hip appeared to have a nearly normal stand, or change her position. In general, younger children, between 6 and 12 years of age, who are having pain from a severely subluxated or dislocated hip can have the reconstructive treatment indications pushed harder because more remodeling capability remains (Case 10. Conversely, fully mature children with a sub- stantial triangular-shaped femoral head have very little possibility of getting a good result from reconstruction because of limited ability for remodeling. She had been sent as a second opinion from a physi- walking decreased related to both her increased size and cian who had recommended a proximal femoral resection. Her parents wanted to try to get her back to ambulating One year prior she had undergone a dorsal rhizotomy with a walker again and were very hesitant to have a re- because of increased hip pain. After an extensive discussion in which her parents she had never been able to stand. She had mild mental re- stated that they were willing to risk a second operation tardation, fed herself, and was very clear that her hip hurt if reconstruction failed, a reconstruction was performed. On physical examination she After the reconstruction, the hip subluxated inferiorly was noted to be somewhat overweight at 70 kg and was due to no muscle tone (Figure C10. However, imme- extremely hesitant about all aspects of the examination. By a 6-year follow-up at age 21 years, could not be obtained; however, the left lower extremity she had painless free motion of the hip except for very had no spasticity and no apparent contractures. She still could not stand hip caused pain with motion but also had no spasticity. First, it is important to correct the pathomechanics, which is the original eti- ology. The abnormal hip joint reactor force vector has to be corrected by ad- equate lengthening of the hip adductor muscles. The high-force environment that has caused this should be treated by adequate femoral shortening so that the hip joint is no longer under high force after reconstruction. The second major aspect of a reconstructive procedure is correction of the acetabular de- formity, which is of such severity that it will not be able to remodel and needs to be corrected directly. The third major aspect of a reconstruction is mak- ing all attempts to leave children with symmetric movement of the hips and symmetric limb lengths. The standard hip reconstruction involves open adductor lengthening, followed by a varus shortening derotational osteotomy of the femur and a reconstruction of the acetabulum using a peri-ilial acetabular osteotomy. The peri-ilial osteotomy and the Dega osteotomy are somewhat confusing, and the use of the Dega osteotomy for spastic hip disease was initially described as extending posteriorly into the sciatic notch. The San Diego osteotomy continues to use the anterior approach to the hip capsule rather than the medial approach, which is ad- vocated in the peri-ilial approach. Cast immobilization continues to be used after the pelvic osteotomy by some, as opposed to the immediate mobilization used after the peri-ilial osteotomy. However, outcomes of both procedures are very similar.

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If the foot is externally rotated relative to the knee joint axis generic kamagra effervescent 100 mg visa, the extension moment arm shortens and the knee valgus moment arm lengthens generic kamagra effervescent 100mg without prescription. Therefore cheap 100mg kamagra effervescent overnight delivery, the gastrocsoleus is less effective in controlling the knee joint in flexion- extension discount kamagra effervescent 100mg with mastercard, and it places an increased valgus stress on the knee best 100 mg kamagra effervescent. This knee flexion is passively produced by momentum of the for- ward movement of the hip joint, the vertical vector of the plantar flexors push-off burst, and the initiation of the hip flexor power burst. All hamstring muscles are quiet during this aspect of toe-off, except for some mild variable contraction of the gracilis and the sartorius, and sometimes with the short head of the biceps. These muscles are the only ones that normally can pro- vide active knee flexion in late stance phase, which is a period of time when the hip is flexing as well. As the knee flexion velocity increases, the rectus femoris starts contracting in preswing phase, with most activity at toe-off and the first 20% of swing phase. The rectus has an eccentric contraction to slow the velocity of knee flexion and transfer this momentum into hip flex- ion. At the time of peak knee flexion, the rectus muscle turns off and the knee extension begins as a passive motion of gravity working on the elevated foot and shank segment, as well as the momentum of active hip flexion. Enough knee flexion has to occur so the limb is shortened so that the foot will not strike the ground as it swings under the body segment. In terminal swing phase, the passive knee extension is increasing rapidly and the velocity of the knee extension has to be decelerated by an eccentric contraction of the semitendinosus, semimembranosus, and biceps femoris, which also act as hip extensors. These hamstring muscles now transfer force from the forward swinging foot and shank segment into hip extension. The hamstring muscles guide the hip and knee into proper alignment for initial contact. It is at this period of time where control of hip and knee flexion by the hamstring mus- cles is crucial in the control of step length. There are some other secondary muscles functioning at the knee, such as the fascia latae and the biceps femoris, which assist with rotational control and valgus stability. The semimembranosus and the semitendinosus with the gracilis may assist in controlling internal rotation of the tibia and varus in- stability. However, most of these forces are controlled by the ligamentous restraints in the knee joint. Hip The hip joint is the only joint with significant motion in all three planes dur- ing gait. The hip is also a principal power output joint along with the ankle 7. Complete control of the knee in- cludes stabilizing function of the hamstrings and quadriceps, especially at foot contact, which is provided by isometric contraction, a hip extensor that uses momentum to ex- tend the hip and knee at the same time. In mid- stance and terminal stance phase, the gastro- csoleus is the primary controller of the knee position. In swing phase, the rectus initially controls knee flexion through an eccentric contraction and the hamstrings use an ec- centric contraction to decelerate the forward swing of the foot, thereby limiting knee ex- tension (A). These motions are well demon- strated on the knee kinematics along with the normal moments and power absorption at the knee. Significantly more power is absorbed at the knee than is generated, demonstrating the fact that the knee’s primary function is to provide stability and change the limb’s length between stance and swing phase (B). The position of hip flexion at initial contact significantly contributes to step length along with knee extension. At initial contact, the hip starts into extension under the influence of strong gluteus maximus con- traction. Additionally, all of the hamstring muscles plus the adductors are active at initial contact and remain active during weight acceptance phase. This forceful hip extension provides a large hip extension moment in early stance phase and a power output to lift the forward falling of the body. Also, at initial contact and in weight acceptance, the abductor muscles are active to contract and hold the center of gravity in the midline. There is an initial hip adduction motion in weight acceptance followed in midstance and terminal stance with gradual abduction.

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