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The persistent headache is due to the pressure of the tumorous mass on the meninges buy 130mg malegra dxt with mastercard, which are heavily sensory innervated effective malegra dxt 130mg. Alzheimer’s disease: from Alois Alzheimer purchase malegra dxt 130mg free shipping, German neurologist discount malegra dxt 130mg amex, 1864–1915 CLINICAL PRACTICUM 11 generic malegra dxt 130 mg amex. Her father says the girl You call for the neurosurgeon and arrange was hit in the side of the head by a baseball. She was knocked unconscious for about 30 seconds, but then she awakened and seemed QUESTIONS: fine except for a big bruise with swelling over her right temporal area and a slight 1. However, about an hour later she in the adjacent CT scan have such became very drowsy and was soon comatose. Why did the patient become comatose You see the bruised and swollen tempo- after she appeared to be fine? Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 Chapter 11 Nervous Tissue and the Central Nervous System 397 Chapter Summary Organization and Functions of the Transmission of Impulses (pp. The central nervous system (CNS) of neurons that permit transmission of quadrigemina, the cerebral peduncles, and consists of the brain and spinal cord action potentials. The functions of the nervous system General Features of the Brain reflexes and the inferior colliculi are include orientation, coordination, (pp. The pons consists of fiber tracts functional units of the nervous system. The cerebrum, consisting of two The pons also contains nuclei for certain activities of neurons. A neuron contains dendrites, a cell body, with higher brain functions, such as the respiration. The cerebellum consists of two (a) The cell body contains the nucleus, instigation of voluntary movement, the hemispheres connected by the vermis and chromatophilic substances, storage of memory, thought processes, and supported by three paired cerebellar neurofibrils, and other organelles. The cerebral cortex is convoluted with (a) The cerebellum is composed of a axon conducts action potentials away gyri and sulci. Neuroglia are of six types: frontal, parietal, temporal, and occipital convoluted cortex of gray matter. The insula lies deep within the (b) The cerebellum is concerned with around axons in the PNS; cerebrum and cannot be seen in an coordinated contractions of skeletal oligodendrocytes form myelin layers external view. Brain waves generated by the cerebral perform a phagocytic function in the cortex are recorded as an Myelencephalon (pp. The medulla oblongata is composed of the substances from the blood to the CNS; valuable diagnostic information. The white matter of the cerebrum consists spinal cord and contains nuclei for several cerebrospinal fluid in the CNS; and of association, commissural, and autonomic functions. Basal nuclei are specialized masses of gray reticular activating system in arousing the (a) The neuroglia that surround an axon matter located within the white matter of cerebrum. The diencephalon is a major autonomic outer periosteal layer and an inner 4. The thalamus is an ovoid mass of gray a single layer surrounded by the vascular (a) Sensory (afferent) neurons are matter that functions as a relay center for epidural space. The hypothalamus is an aggregation of surrounding the subarachnoid space, multipolar. The epithalamus contains the pineal smooth muscle, cardiac muscle, gland and the vascular choroid plexus and glands. Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 398 Unit 5 Integration and Coordination Ventricles and Cerebrospinal Fluid 4. The blood-brain barrier determines which (b) The conus medullaris is the terminal (pp. The lateral (first and second), third, and the extracellular fluid of the brain. Ascending and descending spinal cord continuous with the central canal of the 1. Cerebrospinal fluid is continuously formed and two longitudinal grooves that decussate (cross over) in the spinal by the choroid plexuses from blood plasma partially divide it into right and left cord or in the medulla oblongata of and is returned to the blood at the halves. Beside each Match the following structures of the brain to (d) the vermis.

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Triple Test Strategy Every breast FNA report should include a statement reminding the clinician that breast FNA has a false-negative rate of 3–5% and a false- positive rate of 0 cheap 130mg malegra dxt free shipping. The consequences of these errors can be mini- mized by applying the triple test strategy purchase 130 mg malegra dxt free shipping, that is cheap malegra dxt 130 mg mastercard, correlating the FNA results with the mammogram/ultrasound findings and the clinical breast examination and performing a biopsy if these are discordant generic 130 mg malegra dxt overnight delivery. Whenever possible purchase malegra dxt 130 mg free shipping, the pathologist should review the mammogram and ultrasound reports and discuss the physical findings with the cli- nician before releasing the FNA report. If the pathologist knows there is triple test discordance, then this should be stated in the report and biopsy recommended. This strategy would eliminate most liability claims for breast FNA and result in improved clinical outcomes. Claims resulting from false-positive FNAs usually are caused by interpretation errors. Most commonly, an FNA diagnosis of carcinoma is made on a mass subsequently shown to be a fibroadenoma. The claim results from either unnecessary mastectomy or axillary node sampling if breast conservation is elected. In almost every instance, these claims would have been prevented if the triple test strategy had been applied. Breast Biopsy Some breast biopsy claims involve the differentiation of low-grade ductal carcinoma in situ (DCIS) from ductal involvement by lobular carcinoma in situ (LCIS). It is hoped that the use of immunostains for E-cadherin will add objectivity to this distinction (13,14). Occasional claims involve the differentiation of DCIS from atypical duct hyper- plasia (ADH). This is not surprising, because poor interobserver repro- ducibility in the diagnosis of ductal proliferative lesions is well documented even among experts (15–17). DCIS is a premalignant lesion that may be treated surgically to obtain negative margins and sometimes with radiation therapy or mastectomy. In contrast, LCIS and ADH are regarded as “markers” for increased risk involving both breasts and are usually managed conservatively by sur- veillance alone. When considering a diagnosis of DCIS, LCIS, or ADH, it is important to keep these management differences in mind. Many primary care clinicians (and some surgeons) do not fully understand the terms DCIS, LCIS, ADH, and atypical lobular hyper- plasia (ALH). For this reason, the pathology report should include an explanation of the clinical significance of these terms, that is, that DCIS is a premalignant lesion placing the biopsied breast at risk, whereas LCIS and atypical hyperplasia are “markers” for risk in both breasts. It is also important to state clearly that there is no invasive carcinoma, because the “carcinoma” in DCIS or LCIS may be misun- derstood to mean the patient has “cancer. Nineteen percent of all breast biopsy claims involved large-core (cutting) needle biopsies of palpable breast masses or stereotaxic image-guided needle biopsies of nonpalpable lesions discovered on mammography. The following is a list of some diagnostic errors uncov- ered in a review of these claims: 1. The misdiagnosis of DCIS, sclerosing adenosis, and florid adenosis as invasive ductal carcinoma. Injury results if mastectomy is per- formed without first performing an excisional biopsy of the lesion or if axillary lymph nodes are sampled at the time an excisional biopsy is performed. Because LCIS is a “marker” for increased risk, whereas DCIS is a premalignant lesion, the management is totally different. Patient injury results if axillary lymph node sampling is performed at the time of excisional biopsy. The failure to recognize small, easily overlooked foci of invasive lobular carcinoma. These differential diagnostic possibilities need to be consciously considered when interpreting needle biopsies of breast lesions (18,19). If there are any reservations, then a definitive diagnosis should not be made and excisional biopsy should be recommended. When in situ carcinoma is diagnosed on needle biopsy, excisional biopsy should be performed because there may be invasive carcinoma as well. Biopsy Chapter 12 / Breast Cancer Litigation 163 is also recommended when ADH is diagnosed on needle biopsy, because there may be associated DCIS or invasive carcinoma (20,21).

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Some of the transmitter in neurons are therefore also called electri- molecules return into the bouton by reup- cal synapses in contradistinction to the take (D5) buy malegra dxt 130mg cheap. Electrical coupling via gap junctions occurs not only between neurons but also between glial cells purchase malegra dxt 130 mg on-line. Neurotransmitters (C generic malegra dxt 130 mg without prescription, D) Transmission of impulses at the chemical synapses is mediated by neurotransmitters buy cheap malegra dxt 130 mg online. The most widely distributed transmitter substances in the nervous system are acetylcholine (ACh) purchase 130mg malegra dxt with mastercard, glutamate, gamma- aminobutyric acid (GABA), and glycine. Glutamate is the most common excitatory transmitter, GABA is a transmitter of the in- Kahle, Color Atlas of Human Anatomy, Vol. Types of Synapses, Neurotransmitters 27 2 1 B Complex synapse A Parallel contact (1) and spinous synapse (2) 6 C Different types of synaptic vesicles 5 3 4 D Model of a synapse (according to Akert, Pfenniger, Sandri and Moor) Kahle, Color Atlas of Human Anatomy, Vol. Many neurons, perhaps most of them, pro- The retrograde transport (in the direction of duce more than one transmitter substance. The catecholaminergic and vesicles are endowed with several motor serotoninergic neurons can be identified proteins, the ATP-binding heads of which by fluorescence microscopy because their interact with the surface of the microtubule transmitters show a green-yellow fluores- inanalternatingandreversiblefashion. This cence following exposure to formalin vapor results in ATP being hydrolyzed, and the re- (A, B). It is thus possible to trace the axon leased energy is converted into molecular and to recognize the perikaryon and the movement that causes the vesicles to roll outline of its nonfluorescent nucleus. The along the microtubules in the target direc- fluorescence is very faint in the axon, more tion. The velocity of the rapid intra-axonal distinct in the perikaryon, and most intense transport has been calculated at 200– in the axon terminals. Proteins, viruses, and tox- highest concentration of transmitters oc- ins reach the perikaryon by retrograde curs. Since this port, there is also a continuous flow of axo- enzyme is also produced by noncholinergic plasm which is much slower, namely, neurons, the proper assay is by immunocy- 1–5mm per day. It can be demonstrated by tochemistry using antibodies against choline ligating a single axon (E); proximal to the acetyltransferase, the acetylcholine-synthe- constricted site, the axoplasm is held back sizing enzyme. It has been shown mechanisms are used in neuroanatomy to by double-labeling that many neuropep- study connecting tracts (see p. Axonal Transport (D, E) The transmitter substances or their synthe- sizing enzymes are produced in the peri- karyon and must be transported to the axon terminal. The microtubules of the neuron, neurotubules (D1), play a key role in this transport mechanism. If they are destroyed by applying the mitotic poison colchicine, the intra-axonal transport stops. Neurotransmitters, Axonal Transport 29 C Peptidergic neuron, immunoperoxidase reaction (according to Star, Stumpf, et al. The main difference cellular guanosine triphosphate-(GTP-) between the two types of receptors is in the binding protein (G protein). In the case of ligand-gated ion channels, the activation Ligand-gated Ion Channels causes a rapid synaptic potential lasting only for milliseconds. Activation of G pro- Ligand-gated ion channels consist of differ- tein-coupled receptors results in responses ent subunits (A1) that are inserted into the that last seconds or minutes. Binding of the neu- regulate enzymes that produce intracellular rotransmitter to the specific receptor causes messenger substances. These have an effect the channel to become permeable to certain on ion channels or, via regulatory proteins, ions (B). Recep- tors for the excitatory transmitter glutamate Synaptic Transmission (C) are classified according to the synthetic li- gands binding to them. There are three The synaptic transmission is essentially types of glutamate-gated ion channels: the characterized by three processes: AMPA (aminohydroxymethylisoxazole- 1 Conversion of the action potential arriv- propionic acid) receptor (C3), the NMDA (N- ing at the axon terminal into a chemical methyl-D-aspartate) receptor (C4), and the signal. Binding to the AMPA re- opening of calcium channels (C5) and in ceptor causes an influx of sodium ions, thus the influx of calcium, which, mediated by leading to depolarization of the cell. Simi- certain proteins, causes fusion of synaptic larly, activation of the NMDA receptor vesicles (C6) with the presynaptic mem- causes an influx of both Na+ and Ca2+. Under brane and release of the transmitter into conditions of resting potential, the NMDA the cleft (C7). This tem- 3 In the case of ligand-gated ion channels, poral shift in activities of the AMPA and this results in their opening for certain NMDA receptors results in a graduated re- ions. In the case of glutamatergic recep- sponse of the postsynaptic neurons to the tors, the influx of Na+ or Ca2+ causes neurotransmitter glutamate. In the case of GABA and glycine re- ceptors, the influx of Cl– causes hyper- mitter in the brain, and glycine in the spinal cord.

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