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By Z. Silvio. Concordia University, Chicago.

In function prinivil 5mg without a prescription, however, these glands are associated with the rated by varying amounts of adipose tissue. The amount of adi- reproductive system because they secrete milk for the nourish- pose tissue determines the size and shape of the breast but has ment of the young. The size and shape of the breasts vary consid- nothing to do with the ability of a woman to nurse. Each lobe is erably from person to person in accordance with genetic subdivided into lobules that contain the glandular mammary differences, age, percentage of body fat, or pregnancy. The mammary alveoli are the structures that berty, estrogen from the ovaries stimulates growth of the mam- produce the milk of a lactating female. Suspensory ligaments be- mary glands and the deposition of adipose tissue within the tween the lobules extend from the skin to the deep fascia overly- breasts. Mammary glands hypertrophy in pregnant and lactating ing the pectoralis major muscle and support the breasts. The lumen of each lactiferous duct expands near the Structure of the Breast nipple to form a lactiferous sinus. Milk is stored in the lactifer- ous sinuses before draining at the tip of the nipple. The surface of the areola may appear tions of the serratus anterior and external abdominal oblique bumpy because of the sebaceous areolar glands close to the sur- muscles (see figs. The breast overlies the lateral margin of the sternum, and the lateral color of the areola and nipple varies with the complexion of the margin of the breast follows the anterior border of the axilla. During pregnancy, the areola becomes darker in most axillary process of the breast extends upward and laterally toward women, and enlarges somewhat, presumably to become more the axilla, where it comes into close relationship with the axil- conspicuous to a nursing infant. This region of the breast is clinically significant be- Blood is supplied to the mammary gland through the perfo- cause of the high incidence of breast cancer within the rating branches of the internal thoracic artery, which enter the lymphatic drainage of the axillary process.

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Generally no change with SSRIs b-adrenoceptor-mediated ; Inconsistent changes with SSRIs cAMP response 5-HT1A receptor density ; (cerebral cortex) 5-HT2 receptor binding ; Increased with simulated ECT order prinivil 2.5 mg without a prescription. Species differences in change DA1 receptor-mediated ; responses DA2 receptor-mediated : responses NMDA receptor: affinity of glycine ; for strychnine-insensitive site attention has been devoted to the hypothalamic±pituitary±adrenocortical (HPA) axis (Mussleman and Nemeroff 1993). This is a complex system with many interlinked feedbackand feedforward controls. However, a key role is thought to be served by corticotropin-releasing factor (CRF) which is released from neurons in the para- ventricular nucleus (PVN) in the hypothalamus. From here, CRF is carried to the anterior pituitary where it triggers release of adrenocortical hormone (ACTH) into the systemic circulation. In turn, ACTH promotes release of glucocortioid hormones from the adrenal cortex. Not all CRF release is directed at the HPA system: extra- hypothalamic CRF is found in many limbic areas, including the locus coeruleus and Raphe nuclei (Fig. Normally, circulating glucocorticoids (of which cortisol is the most prominent in humans) cause feedbackinhibition of ACTH release so that cortisol secretion is, to some extent, self-limiting. However, many patients suffering from major depression have an increased concentration of plasma cortisol but reduced ACTH secretion. The latter abnormality seems to be partly due to a reduction in the number of CRF receptors in the pituitary, although it is thought that decreased ACTH secretion could provoke the adrenal hyperplasia which is common in depression. This would result in excessive secretion of cortisol and contribute to the inhibition of ACTH release (Musselman and Nemeroff 1993). Also, a high proportion of depressed patients do not show the reduction in cortisol secretion which is seen when normal subjects are challenged with the synthetic gluco- corticoid, dexamethasone, that normally decreases further release through feedback 448 NEUROTRANSMITTERS, DRUGS AND BRAIN FUNCTION Figure 20. This suggests that depression is associated with a defect in the regulation of glucocorticoid secretion and the locus of this disorder could be glucocorticoid receptors in the hippocampus. Evidence that CRF secretion is increased in depressives supports the idea that these receptors, which depress CRF secretion, are hypofunctional in depression (Ritchie and Nemeroff 1991). Also, transgenic mice which are deficient in glucocorticoid receptors exhibit many features of depression; these extend to disruption of feeding and cognitive deficits as well as abnormal HPA function. Antidepressant treatment causes a long-latency increase in hippocampal glucocorticoid receptor binding and the concentration of mRNA for these receptors.

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The stimulating effect of hypoxia is blunted mainly The response of peripheral chemoreceptors to oxygen by the central chemoreceptors prinivil 10 mg without a prescription, which respond more po- depends on arterial PaO2, and not oxygen content. For example, if 100% oxygen is given to the response curve is not linear; instead, hypoxia is of in- an individual newly arrived at high altitude, ventilation is creasing effectiveness as PO2 falls below about 90 mm Hg. During the next few The behavior of the receptors is reflected in the ventilatory days, ventilation in the absence of supplemental oxygen response to hypoxia illustrated in Figure 22. The shape of progressively rises further, but it is no longer restored to sea the curve relating ventilatory response to PO2 resembles level value by breathing oxygen. Rising ventilation while that of the oxyhemoglobin equilibrium curve when plotted acclimatizing to altitude could be explained by a reduction upside down (see Chapter 21). As a result, the ventilatory of blood and CSF bicarbonate concentrations. This would response is inversely related in an approximately linear reduce the initial increase in pH created by the increased fashion to arterial blood oxygen saturation. However, this mechanism is not the full and pH, and the relatively low sensitivity across the normal explanation of altitude acclimatization. Cerebrospinal fluid ranges of these variables, cause ventilatory changes to be pH is not fully restored to normal, and the increasing ven- apparent only when PO2 and pH deviate significantly from tilation raises PaO2 while further lowering PaCO2, changes the normal range, especially toward hypoxemia or that should inhibit the stimulus to breathe. By contrast, ventilation is sensitive to PCO2 inquiry, the reason for persistent hyperventilation in alti- within the normal range, and carbon dioxide is normally tude-acclimatized subjects, the full explanation for altitude the dominant chemical regulator of breathing through the acclimatization, and the explanation for the failure of in- use of both central and peripheral chemoreceptors (com- creased ventilation in acclimatized subjects to be relieved pare Figs. There is a strong interaction among stimuli, which Metabolic acidosis is caused by an accumulation of non- causes the slope of the carbon dioxide response curve to in- volatile acids. The increase in blood [H ] initiates and sus- crease if determined under hypoxic conditions (see Fig. Because of the restricted movement of H lated to the prevailing PCO2 and pH (see Fig. As dis- into CSF, the fall in blood pH cannot directly stimulate the cussed in the next section, these interactions, and interac- central chemoreceptors.

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Circulatory System © The McGraw−Hill Anatomy purchase prinivil 10mg with visa, Sixth Edition Body Companies, 2001 546 Unit 6 Maintenance of the Body FIGURE 16. The parietal pericardium is actually The wall of the heart is composed of three distinct layers composed of an outer fibrous pericardium and an inner serous (table 16. It is the serous pericardium that produces the lu- visceral pericardium. The space between this layer and the parietal bricating pericardial fluid that allows the heart to beat in a pericardium is the pericardial cavity, just described. It is composed of cardiac muscle tissue (see chapter 4) and arranged Pericarditis is an inflammation of the parietal pericardium in such a way that the contraction of the muscle bundles results that results in an increased secretion of fluid into the pericar- dial cavity. Because the tough, fibrous portion of the parietal peri- in squeezing or wringing of the heart chambers. The thickness of cardium is inelastic, an increase in fluid pressure impairs the the myocardium varies in accordance with the force needed to movement of blood into and out of the chambers of the heart. Thus, the thickest por- Some of the pericardial fluid may be withdrawn for analysis by in- tion of the myocardium surrounds the left ventricle and the atrial jecting a needle to the left of the xiphoid process to pierce the pari- etal pericardium. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 16 Circulatory System 547 TABLE 16. In- separated from each other by the thin, muscular interatrial sep- flammation of the endocardium is called endocarditis. Atrioventricular valves (AV valves) lie between the atria and ventricles, and semilunar valves are located at the bases of the two large vessels leaving the heart. The atria contract and empty simultaneously into vessels that supply blood to the muscular wall of the heart. The most prominent groove is the coronary sulcus that encircles the walls of the atria are reinforced with latticelike pestinate mus- heart and marks the division between the atria and ventricles.

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Moreover discount prinivil 2.5 mg with amex, a system that provided immediate information and prompt compensation would have substantial advantages over conventional litigation for elderly claimants. EMPLOYER-SPONSORED HEALTH CARE AND THE WORKERS COMPENSATION ANALOGY Employer-sponsored private health insurance covers most Ameri- cans. Therefore, the current malpractice crisis affects the ability of businesses to attract and retain workers. Active involvement in health care purchasing also has made business better attuned to employees’ experiences as users of medical services. Moreover, industry’s contin- ued tolerance of avoidable physical harm in the health care system, especially when it is traceable to faulty systems design, contrasts sharply with general regulatory and self-regulatory changes since the 1960s, which have created a corporate culture exquisitely sensitive to health and safety issues and their relationship to productivity. Finally, health care is an economic engine throughout the country; liability crises reduce present-day prosperity and jeopardize future prospects. To address these issues, the business community could broker a com- promise approach to malpractice mirroring workers’ compensation, that limits liability but retains incentives for safety and assures prompt, reasonable payment in the event of injury. To accomplish this, employ- ers would need to set aside their parochial interests in using the mal- practice crisis as a poster child for general business tort reform to further their workers’ interests in safe, reliable health care. CONCLUSION This chapter analyzes the first medical malpractice insurance crisis of the 21st century in light of significant changes that have occurred in the health care system since previous crises. It concludes that the established debate over traditional tort reform incompletely defines current problems and leads to ineffective solutions. The chapter began by analogizing the malpractice crisis to the legend of Rip van Winkle and concludes with a different literary parallel. In the 1993 movie Groundhog Day, a retelling of Charles Dickens’ Christmas classic using a different holiday, actor Bill Murray plays a local weatherman assigned to cover the early February festivities in Punxatawny, Penn- sylvania. To his astonishment, he awakens each morning and finds Chapter 17 / New Directions in Liability Reform 275 himself reliving the day before, but he is the only person aware that the day’s events have already happened many times. Health care provid- ers, payers, and policymakers are experiencing a similar phenomenon in the current reiteration of the medical malpractice crisis and can profit from following the progression of Murray’s cinematic charac- ter.

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