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Injury to the gracile fasciculus on the right would result is other types of motor deficits cheap exelon 4.5mg overnight delivery medicine hollywood undead. The level of the cord damage is caudal to the cuneate fasciculi and the anterolateral system con- 38 buy exelon 6mg fast delivery medicine to calm nerves. Answer A: The exiting fibers of the abducens nerve (on the left) veys pain and thermal sensations. Answer A: The loss of pain and thermal sensations on the right Diplopia may result from lesions of the oculomotor and trochlear side of the body correlates with a lesion involving the anterolateral nerves, but these structures are not in the domain of the parame- system on the left side of the spinal cord. A lesion of the optic nerve results in blind- terolateral system would result in a left-sided deficit. The gracile ness in that eye and damage to the facial root does not affect eye and cuneate fasciculi convey discriminative touch, vibratory sen- movement but may cause a loss of view of the external world if the sation, and proprioception. The posterior spinocerebellar tract palpebral fissure is closed due to facial muscle weakness. Answer E: The substantia nigra contains a large population of dial lemniscus is located within the territory served by paramedian melanin-containing cells, is located in the midbrain just internal to branches of the basilar artery. Penetrating branches of the anterior the crus cerebri, and the loss of these cells gives rise to the motor spinal artery serve the hypoglossal nucleus. The neurotransmitter generally in the territories of short or long circumferential associated with these cells is dopamine. Answer D: Weakness of the extremities accompanied by paralysis cleus is in the midbrain, but its reddish tone is related to a rich vas- of the lateral rectus muscle (innervated by the abducens nerve) on the cular supply, not to cells containing a pigment. Answer E: The solitary nucleus is located immediately inferior middle alternating hemiplegia. Inferior alternating hemiplegia speci- (ventral) to the medial and spinal vestibular nuclei and is the only fies involvement of the hypoglossal root and the pyramid, and supe- nucleus in the choices to receive a general visceral afferent (GVA) rior alternating hemiplegia indicates damage to the oculomotor root and special visceral afferent (SVA-taste) input. Alternating (or alternate) hemianesthesia and tory nucleus and the nucleus ambiguus are visceromotor (general hemihypesthesia are sensory losses. Answer B: The prominent elevation formed on the caudal and (general somatic afferent [GSA] and special somatic afferent [SSA], medial wall of the third ventricle, at the general level of the pos- respectively). Answer E: The superior salivatory nucleus lies adjacent to the ignating the separation between the third ventricle (rostral to this exiting fibers of the facial nerve in a position just lateral to the ab- point on the midline) and the quadrigeminal cistern (caudal to this ducens nucleus in caudal levels of the pons. The pulvinar is lateral to the quadrigeminal cistern, the ons originating from these cells distribute on peripheral branches lamina terminalis forms the rostral wall of the third ventricle, and of the facial nerve. The dorsal motor and inferior salivatory nuclei the massa intermedia bridges the space of the third ventricle. The Edinger-Westphal nucleus is related pears as a shadow in T2-weighted MRI bridging the third ventri- to the oculomotor nucleus and the intermediolateral cell column cle. The superior colliculus is a mesencephalic structure found in is located primarily in thoracic levels of the spinal cord. Answer C: The oculomotor nucleus (containing general somatic nerve, portions of the corticospinal fibers in the crus cerebri, and efferent [GSE] cell bodies), along with the Edinger-Westphal (con- a number of other medially located structures are found in the ter- taining general visceral efferent [GVE] cell bodies) nucleus, is ritory of the penetrating branches of the basilar bifurcation. The found in the most anterior and medial portion of the periaqueduc- paramedian branches of the basilar artery and the corticospinal tal grey at the superior colliculus level. The trochlear nucleus is fibers in the pyramid serve the abducens nerve by branches of the found at a comparable position, but at the cross-sectional level of anterior spinal artery. The mesencephalic nucleus is found in the lemniscus are mainly, if not entirely, in the region of the midbrain lateral area of the periaqueductal grey, and the trigeminal and ab- served by branches of the quadrigeminal and posterior medial ducens nuclei are located in the pons. Answer D: The vocalis muscle (this muscle is actually the me- acterized by a loss of most eye movement (damage to oculomotor dial portion of the thyroarytenoid muscle) is innervated, via the nerve fibers) on the ipsilateral side and weakness of the upper and vagus nerve, by motor neurons located in the nucleus ambiguus. The abducens nerve is the cranial nerve in- spinal trigeminal nucleus relays sensory input from the face. The volved in a middle alternating hemiplegia and the hypoglossal is that hypoglossal nucleus is motor to the tongue and the facial nucleus nerve involved in an inferior alternating hemiplegia. Answer A: Fibers comprising the anterolateral system convey pain and thermal sensations from the body, excluding the face. Answer E: Motor neurons in the nucleus ambiguus innervate, These fibers are located in lateral portions of the medulla adjacent primarily through the vagus nerve, the muscles of the throat that to the spinal trigeminal tract; this latter tract relays pain and ther- move a bolus of food from the oral cavity to the esophagus. The gracile and cuneate fasciculi con- tongue, via the hypoglossal nucleus and nerve, may move food vey proprioception, discriminative touch, and vibratory sense in around in the mouth and toward the back of the oral cavity, but the spinal cord and the medial lemniscus conveys this same infor- the actual act of swallowing is through the action of pharyngeal and mation from the medulla to the dorsal thalamus.

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As the disease advances cheap exelon 6mg free shipping medicine reminder alarm, the synovium becomes greatly thickened cheap 1.5mg exelon visa medicine in ancient egypt, Ulnar deviation of the phalanges with or without asso- with enlargement of the synovial villi. The by proliferation of fibrovascular connective tissue distal phalanx of the thumb is characteristically hyper- known as pannus. Pannus is responsible for the charac- extended, giving rise to the “hitchhiker thumb” defor- teristic marginal erosions that first occur in the so- mity. The carpus is characteristically rotated towards called bare areas between the peripheral edge of the the ulna. Ultimately, pannus grows over and destroys the surface of the articular cartilage. Juvenile Rheumatoid Arthritis (Still’s Disease) In general, the younger the patient, the more likely the Roentgenographic Observations disease is monoarticular, particularly involving a large joint such as the knee, ankle, or wrist. The disease may The initial manifestations are soft-tissue swelling, sym- be limited to a few major joints. If it begins in an old- metrical narrowing of the joints, periarticular osteoporo- er child, there is more likely to be symmetrical in- sis, and marginal erosions. Radiographic manifestations volvement of the smaller peripheral joints, as in an of the disease are present in 66% of patients 3 to 6 adult. There is interference with skeletal maturation, months after the onset of disease and in 85% of those af- usually manifested as acceleration of maturation, with fected for 1 year. The pre- Peripheral Arthritis 145 mature fusion leads to shortening of the digits. Reiter’s Syndrome Involvement of the spine is much more common in children than in adults. The involvement may be mani- Reiter’s syndrome is characterized by urethritis, conjunc- fested by atlantoaxial subluxation and erosions and tivitis, and mucocutaneous lesions in the oropharynx, eventually by bony ankylosis of the facet joints in the tongue, glans penis, and skin, as well as arthritis. The major joint involvement is the lower ex- Spondyloarthropathies) tremities, particularly the feet. The term rheumatoid variants refers to inflammatory The most dramatic radiographic finding is usually pe- riostitis, particularly the exuberant, fluffy, or whiskerlike arthritides that differ immunologically, clinically, and ra- periostitis at the site of tendon insertions, most frequent- diographically from rheumatoid arthritis. The diseases ly at the attachment of the plantar fascia, which forms a are ankylosing spondylitis, psoriatic arthritis, Reiter’s dis- poorly defined spur on the plantar surface of the calca- ease, and colitic arthritis. Periosteal reaction is also found in metatarsal shafts a negative rheumatoid factor, but a significant percentage and on the surfaces of the tarsal bones in the distal tibia have the HLA-B27 antigen. The IP, MTP, and tarsal joints are most often mon in men and usually cause symptoms in the axial affected. This is in contrast to rheumatoid arthritis, which is more common in females and involves the distal ap- pendicular skeleton. Radiographically, these diseases dif- Colitic Arthritis fer from rheumatoid arthritis in the absence or mild na- ture of periarticular osteoporosis or demineralization, the Arthritis occurs in approximately 10% of patients with frequent occurrence of periostitis or periosteal new-bone chronic inflammatory bowel disease, more commonly formation, and the asymmetrical involvement of the pe- in patients with ulcerative colitis than in those with ripheral skeleton. The most common manifestation is sacroiliitis, which is similar to but not as extensive as Psoriatic Arthritis in ankylosing spondylitis and is usually symmetrical. Patients are rarely symptomatic, and the radiographic Fewer than 10% of patients with psoriasis develop a pe- findings of sacroiliitis are often noted incidentally on culiar form of arthritis, a smaller percentage develop abdominal radiographs obtained as part of a small bow- classic rheumatoid arthritis, and an even smaller number el or colon examination. In some cases, the arthritis may even precede the skin manifestations by several years. Systemic Lupus Erythematosus Psoriatic arthritis tends to involve the small joints of the hands and feet. The process is characteristically Arthralgia is a very common complaint in systemic lu- asymmetrical and is not associated with periarticular os- pus erythematosus (SLE), but radiographic findings oc- teoporosis. The most characteristic involvement is in the cur in only one third of patients, and these are usually DIP joints of the hands and toes, usually in association nonspecific changes of soft-tissue atrophy and osteo- with psoriatic changes of the nails. The most characteristic radiologic finding is an metrical involvement is confined to a single digit, some- abnormality of joint alignment without articular ero- times referred to as a “sausage digit”, with involvement sions: Involvement of the IP joints results in either a of both IP joints and occasionally the MCP joint of one “swan neck” or “boutonniere” deformity of the digit. Ankylosis of the IP joints is also com- Many patients are able to correct their deformities vol- mon. Sacroiliitis is common and resembles that seen in Degenerative Joint Disease (Osteoarthritis) ankylosing spondylitis except that it is often asymmetri- cal; spondylitic changes are less common. The syn- Pathologically degenerative joint disease is characterized desmophytes in psoriatic spondylitis are typically broad, by degeneration and shredding of articular cartilage.

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Approximately 80–90% of the average malpractice carrier’s portfolio is invested in investment grade bonds buy discount exelon 1.5mg symptoms 0f parkinson disease, so investment income is heavily dependent on prevailing interest rates (5 generic exelon 6mg free shipping medicine 666 colds,23). These have fallen considerably over the same period of time claims losses have been increasing. Therefore, there has been reduced income from Chapter 15 / The Case for Legal Reform 209 investments to subsidize the cost of claims. Although virtually no malpractice insurer has suffered net negative investment returns, reduced investment income means that premium must cover a greater share of insurers’ costs. The GAO has calculated that in the period from 2000 to 2002, premium rates would need to rise approx 7. However, this is a small percentage of overall rate increases, emphasizing the primary role played by rising claims losses. In fact, the high returns of the 1990s enabled insurers to sell coverage for less than its actual cost by making up the difference with investment income. This worked well for the companies, which were able to grow despite intense price competition, and directly benefited policyholders, who received their insurance for less than cost. Unfortunately, when interest rates declined, the deficit created by the lost investment income added to premium increases necessitated by the rising cost of claims. Faced with large losses, a number of malpractice insurers were forced into bankruptcy (notably PHICO, PIE, and Frontier, among others), and many more electively withdrew from the market, refusing to offer pro- fessional liability coverage at any price. Paul, a market leader in this field for more than two decades, was the largest and most important of these (2). This shrank the capacity of the market as a whole to provide insurance for physicians and other health care providers. Another factor adding to the upward pressure on malpractice premi- ums was a changed reinsurance market. Insurance companies buy rein- surance to prevent individual large losses from distorting results and to further spread the risk inherent in providing professional liability cov- erage in the first place. After September 11, the cost of this reinsurance rose significantly as reinsurers sought to recover from the estimated $75- to $100-billion cost of the tragic event. This meant that reinsurers demanded higher profit margins and more restricted coverages before they were willing to accept risk. Finally, judicial nullification and threats to existing legal reforms contributed to the problem. State supreme courts in approximately a dozen states held the tort reforms approved by their respective state legislatures unconstitutional (24). The loss of these reforms worsened the medical-legal environment for physicians and their insurers and is still another factor contributing to the rise in severity. The Fallacy of the Bad Doctor There would be less concern over the increase in malpractice pre- miums if the additional costs were born only by unqualified or negli- 210 Anderson gent physicians. Indeed, one of the arguments for preserving the cur- rent system is that malpractice suits accurately identify these substan- dard doctors, thus performing an important societal function. First, 70 to 80% of all malpractice claims today are found to be without merit (i. So it cannot be reasonably argued that the existence of claims against a doctor is evidence of poor medical practice. Expressed differently, the majority of malpractice claims in the United States today are filed against good doctors. Further evidence that rising malpractice premiums are not caused by bad doctors can be found in a review of additional data. It is a reasonable rule of thumb in any given year that about 2% of physician- policyholders will account for approx 50% of the claims losses (16). This leads some to argue that eliminating these offenders would dra- matically reduce premium rates. For this to be true, the same 2% of doctors would have to account for half the losses in succeeding years, and this is not the case.

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The contents of the granules are extruded into cholamines also activate glycogen phosphorylase in the interstitial fluid discount exelon 4.5mg visa medicine you cant take with grapefruit. The catecholamines diffuse into capil- skeletal muscle and adipose cells by interacting with re- laries and are transported in the bloodstream buy cheap exelon 3mg line symptoms xxy. The elevated cAMP activates glycogen phos- fibers that innervate chromaffin cells triggers the secretion phorylase. Stimuli such as injury, anger, anxiety, cells is metabolized, although glucose is not released into pain, cold, strenuous exercise, and hypoglycemia generate the blood, since the cells lack glucose-6-phosphatase. The impulses in these fibers, causing a rapid discharge of the glucose 6-phosphate in muscle is converted by glycolysis catecholamines into the bloodstream. The lactate taken up by the liver is converted to glucose via glu- coneogenesis and returned to the blood. Catecholamines Have Rapid, Widespread Effects In adipose cells, the rise in cAMP produced by cate- cholamines activates hormone-sensitive lipase, causing the Most cells of the body have receptors for catecholamines hydrolysis of triglycerides and the release of fatty acids and and, thus, are their target cells. These fatty acids provide an related forms of catecholamine receptors, all of which are alternative substrate for energy metabolism in other tissues, transmembrane proteins: 1, 2, 1, and 2. All can bind primarily skeletal muscle, and block the phosphorylation epinephrine or NE, to varying extents (see Chapter 3). During profound hypoglycemia, the rapid rise in blood Fight-or-Flight Response. Epinephrine and NE produce catecholamine levels triggers some of the same metabolic widespread effects on the cardiovascular system, muscular adjustments that occur more slowly during fasting. During system, and carbohydrate and lipid metabolism in liver, fasting, these adjustments are triggered mainly in response muscle, and adipose tissues. In response to a sudden rise in to the gradual rise in the ratio of glucagon to insulin in the catecholamines in the blood, the heart rate accelerates, blood. The ratio also rises during profound hypoglycemia, coronary blood vessels dilate, and blood flow to the skele- reinforcing the actions of the catecholamines on tal muscles is increased as a result of vasodilation (but vaso- glycogenolysis, gluconeogenesis, and lipolysis. Smooth muscles in the air- cholamines released during hypoglycemia are thought to ways of the lungs, gastrointestinal tract, and urinary be partly responsible for the rise in the glucagon-to-insulin bladder relax. Muscles in the hair follicles contract, causing ratio by directly influencing the secretion of these hor- piloerection. Catecholamines stimulate the se- action to the sudden release of catecholamines is known as cretion of glucagon by the alpha cells and inhibit the se- the fight-or-flight response (see Chapter 6). These catecholamine-mediated responses to hypoglycemia are Catecholamines and the Metabolic Response to Hypo- summarized in Table 34. Catecholamines secreted by the adrenal medulla and NE released from sympathetic postganglionic nerve terminals are key agents in the body’s defense against hypoglycemia. Catecholamine release usually Catecholamine-Mediated Responses starts when the blood glucose concentration falls to the TABLE 34. A fur- ther decline in blood glucose concentration into the hy- Liver Stimulation of glycogenolysis poglycemic range produces marked catecholamine release. Stimulation of gluconeogenesis Hypoglycemia can result from a variety of situations, such Skeletal muscle Simulation of glycogenolysis as insulin overdosing, catecholamine antagonists, or drugs Adipose tissue Simulation of glycogenolysis that block fatty acid oxidation. Hypoglycemia is always a Stimulation of triglyceride lipolysis Pancreatic islets Inhibition of insulin secretion by beta cells dangerous condition because the CNS will die of ATP Stimulation of glucagon secretion by alpha cells deprivation in extended cases. The length of time pro- CHAPTER 34 The Adrenal Gland 621 REVIEW QUESTIONS DIRECTIONS: Each of the numbered (F) Defects in aldosterone synthase (C) Cholesterol side-chain cleavage items or incomplete statements in this 4. What is the mechanism through which enzyme section is followed by answers or by catecholamines stabilize blood glucose (D) 11 -Hydroxylase completions of the statement. Select the concentration in response to (E) 3-Hydroxy-3-methylglutaryl CoA ONE lettered answer or completion that is hypoglycemia? Which of the following sources of muscle weakness and fatigue, anorexia, and cholesterol is most important for (B) Catecholamines inhibit weight loss associated with sustaining adrenal steroidogenesis glycogenolysis in the liver gastrointestinal symptoms (nausea, when it occurs at a high rate for a long (C) Catecholamines stimulate the vomiting). A patient receiving long-term (D) Congenital adrenal hyperplasia (E) Cholesterol from the endoplasmic glucocorticoid therapy plans to (E) Hypopituitarism reticulum undergo hip replacement surgery. A 7-year-old boy comes to the (A) Glucocorticoids should be glucocorticoids accelerate pediatric endocrine unit for evaluation decreased to prevent serious gluconeogenesis during fasting? Review of his hypoglycemia during recovery (A) Glucocorticoids stimulate the growth charts indicates substantial (B) Glucocorticoids should be secretion of insulin, which activates weight gain over the previous 3 years increased to stimulate immune function gluconeogenic enzymes in the liver but little increase in height. To and prevent possible infection (B) Glucocorticoids inhibit the use of differentiate between the development (C) Glucocorticoids should be glucose by skeletal muscle of obesity and Cushing’s disease, blood decreased to minimize potential (C) Glucocorticoids maintain the and urine samples are taken.

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