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The postsy- sults in the secretion of a watery fluid metoclopramide 10mg fast delivery gastritis gallbladder removal, and evaporation then naptic axons from that ganglion innervate the lacrimal dissipates body heat. Constriction of the skin vasculature, gland and the glands of the nasal and palatal mucosa. Other concurrent with sweat gland activation, produces the cold, facial nerve presynaptic axons travel via the chorda tym- clammy skin of a frightened individual. These end sensations result from activation of the piloerector postsynaptic axons stimulate the production of saliva by muscles associated with hair follicles. Parasympathetic is likely a phylogenetic remnant from animals that use hair activation can also produce dilation of the vasculature erection for body temperature preservation or to enhance within the areas supplied by the facial nerve. The parasympathetic presynaptic ax- ons of the glossopharyngeal nerve arise from the inferior salivatory nuclei of the medulla. The axons follow a cir- THE PARASYMPATHETIC NERVOUS SYSTEM cuitous course through the lesser petrosal nerve to reach the otic ganglion, where they synapse. From the otic gan- The parasympathetic division is comprised of a cranial glion, the postsynaptic axons join the auriculotemporal portion, emanating from the brainstem, and a sacral por- branch of cranial nerve V and arrive at the parotid gland, tion, originating in the intermediate gray zone of the where they stimulate secretion of saliva. In contrast to the wide- Sensory axons that are important for autonomic func- spread activation pattern of the sympathetic division, the tion are also conveyed in cranial nerve IX. The carotid bod- neurons of the parasympathetic division are activated in a ies sense the concentrations of oxygen and carbon dioxide more localized fashion. There is also much less tendency in blood flowing in the carotid arteries and transmit that for divergence of the presynaptic influence to multiple chemosensory information to the medulla via glossopha- postsynaptic neurons—on average, one presynaptic ryngeal afferents. The carotid sinus, which is located in the parasympathetic neuron synapses with 15 to 20 postsy- proximal internal carotid artery, monitors blood pressure naptic neurons. An example of localized activation is seen and transmits this baroreceptor information to the tractus in the vagus nerve, where one portion of its outflow can solitarius in the medulla. It has ther close to the organ innervated or embedded within its been estimated that vagal output comprises up to 75% of walls. The organs of the gastrointestinal system demonstrate total parasympathetic activity. Because of this arrangement, pregan- travel in the vagus trunks to ganglia in the heart and lungs glionic axons are much longer than postganglionic axons. Sympathetic postsynaptic axons also intermingle with the parasympathetic presynaptic axons in these plexuses and Brainstem Parasympathetic Neurons Innervate travel together to the target tissues. Structures in the Head, Chest, and Abdomen The right vagus nerve supplies axons to the sinoatrial Four of the twelve cranial nerves—numbers III, VII, IX, and node of the heart, and the left vagus nerve supplies the atri- X—contain parasympathetic axons. Vagal activation slows the heart rate and nerves, which occupy areas of the tectum in the midbrain, reduces the force of contraction. The vagal efferents to the pons, and medulla, are the centers for the initiation and in- lung control smooth muscle that constricts bronchioles, tegration of autonomic reflexes for the organ systems they and also regulate the action of secretory cells. Parasympathetic and sympathetic activities are to the esophagus and stomach regulates motility and influ- coordinated by these nuclei. Acetylcholine plus vasoactive intestinal peptide (VIP) are the transmitters of the postsynaptic neurons. The oculomotor nerve originates from There is also vagal innervation to the kidneys, liver, nuclei in the tectum of the midbrain, where synaptic connec- spleen, and pancreas, but the role of these inputs is not yet tions with the axons of the optic nerves provide input for oc- fully established. The parasympathetic neurons are located in the Edinger-Westphal nucleus. The presynaptic axons travel in the superficial aspect of cranial nerve III to the ciliary gan- Sacral Spinal Cord Parasympathetic Neurons glion, located inside the orbit where the synapse occurs. The Innervate Structures in the Pelvis postganglionic axons enter the eyeball near the optic nerve and travel between the sclera and the choroid. These axons Preganglionic fibers of the sacral division originate in the supply the sphincter muscle of the iris; the ciliary muscle, intermediate gray matter of the sacral spinal cord, emerging which focuses the lens; and the choroidal blood vessels. These pregan- About 90% of the axons are destined for the ciliary muscle, glionic fibers synapse in ganglia in or near the pelvic or- while only about 3 to 4% innervate the iris sphincter. SPECIFIC ORGAN RESPONSES TO AUTONOMIC ACTIVITY CONTROL OF THE AUTONOMIC NERVOUS SYSTEM As noted earlier, most involuntary organs are dually inner- vated by the sympathetic and parasympathetic divisions, of- The autonomic nervous system utilizes a hierarchy of re- ten with opposing actions. A list of these organs and a sum- flexes to control the function of autonomic target organs.

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Two-year-old In adolescents and young adults with undetected hip dys- girl with an abscess plasia generic metoclopramide 10mg with amex atrophische gastritis definition, CT with 3D reconstructions demonstrates the con- in the soft tissues of figuration and containment of the femoral head, acetabu- the thigh. Sagittal post-gadolinium lar architecture, and narrowing of the joint space. In the T1-weighted image spine, vertebral abnormalities and fusions between verte- shows enhancement brae or ribs are easily demonstrated with CT. Frontal and posterior oblique 3D surface renderings of the spine of a 3-month-old girl with a severe defect of the bony thorax. The study was performed using a multi-detector CT, without need for sedation. Multiple tarsal ing treatment for developmental dysplasia of the hip coalitions may occur in up to 20% of cases and not (DDH) [31, 32]. Although accuracy for Calvé-Perthes disease, and with femoral ischemia of detecting tarsal coalitions is comparable for CT and MR other etiologies, MR imaging will demonstrate marrow imaging, CT allows easier evaluation of both feet, edema and lack of gadolinium enhancement of the and it is less expensive, and more readily available. MR imaging can also images demonstrate a complete osseous fusion if the depict associated physeal and metaphyseal abnormali- coalition is bony, or irregularity of the articular surfaces of ties and the extent of marrow involvement [36, 37]. In more advanced disease, MR imaging shows the con- tainment of the femoral head and the congruity of the MR Imaging articular surfaces. MR imaging is crucial for evaluating spinal os- MR imaging is the modality of choice for assessing spinal teomyelitis, by depicting epidural abscess and extension abnormalities. In infants, MR imaging evaluates abnor- of the infection into the paraspinal soft tissues. It is also malities of vertebral segmentation, and the location of the very useful in pelvic osteomyelitis, where bony geometry conus medullaris (normally at L2 level, more caudal if the is complex and soft tissue involvement is often the most cord is tethered). In older children, MRI is optimal for important component of the infection; and in patients evaluating protrusion or herniation of the discs, spinal who do not respond after 48 hours of antibiotic therapy stenosis, and nerve root compression. MR mors involving the epidural and subarachnoid spaces are imaging is useful in osteomyelitis involving the physis, best demonstrated with gadolinium-enhanced imaging. MR imaging respond to standard therapeutic measures, MR imaging of osteomyelitis should always include gadolinium en- depicts the position of the femoral head before and af- hancement to ascertain whether the infected volume con- ter reduction and detects obstacles to reduction (pulv- tains drainable pus. Septic arthritis and femoral head ischemia in an 11-year-old boy who had osteomyelitis of the ischium. Tibial torsion is determined by the angle between a physeal widening and sometimes transphyseal bridging. External tibial torsion determined by tients in whom impaired sensation and continued motion physical examination is normally 4° at birth, and 14° at result in repeated physeal damage. A 3D fat-suppressed spoiled gradient-recalled Sonography is the main study in infants younger than 6 echo sequence provides most, if not all, of the informa- months with a question of hip dysplasia because it al- tion required to assess growth arrest [52, 53]. It depicts: the injuries have a similar MR imaging appearance in chil- hypoechoic cartilages of the proximal femoral epiphysis dren and adults. In Coventry, T1-weighted images also depict skip lesions and metas- England, screening of more than 14 000 newborns de- tases or multifocal disease in the contralateral extremity tected a 6% incidence of sonographic abnormalities. In children it is particularly important to evaluate these, nearly 80% were normal by 4 weeks and 90% by extension of tumor into the epiphysis, which occurs in 8 weeks. In the United States, however, hip sonog- Cross-sectional Measurements raphy is usually performed when the physical examina- tion is abnormal or when there are risk factors; Glenoid version is the angle between the main axis of the these include a positive family history, breech delivery, scapula and the glenoid. Femoral anteversion is de- oligohydramnios and conditions sometimes caused by termined by obtaining slices from the femoral head to the uterine crowding, such as torticollis, clubfoot, or lesser trochanter, and slices through the distal femoral metatarsus adductus. A line through the main axis of the femoral The coronal view, oriented like a frontal radiograph, neck and another along the posterior surfaces of the distal shows acetabular morphology. The angle between Special Aspects of Musculoskeletal Imaging in Children 153 the iliac wing and the bony acetabulum (the alpha an- presenting with a limp. Skeletal scintigraphy is also high- gle) is approximately 60° in normal newborns. The ly sensitive for evaluation of avascular necrosis, detection sonolucent cartilaginous acetabulum is more concave of skeletal metastases, and early identification of trau- than the bony roof and it is in direct contact with the matic injuries, such as lower extremity injuries of tod- cartilaginous epiphysis. Ossification of the proximal dlers and stress injuries of young athletes. In child abuse, femoral epiphysis is detected sonographically several skeletal scintigraphy complements the radiographic weeks earlier than with radiographs. The trans- skeletal survey [74, 75] particularly when radiographic verse view serves to examine hip motion and detect findings are negative or uncertain. The femoro-acetabular sensitive for rib fractures and diaphyseal fractures, but it relationships can be assessed during abduction and ad- often fails to detect linear skull fractures and certain duction and during the Barlow maneuver.

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The ischial tuberosity is the bony projection that supports the weight of the body in the Thigh sitting position metoclopramide 10mg without prescription gastritis diet 13. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 184 Unit 4 Support and Movement Head of femur Greater trochanter Greater trochanter Fovea capitis femoris Intertrochanteric crest Intertrochanteric line Neck of femur Gluteal tuberosity Lesser trochanter Linea aspera Body of femur Lateral epicondyle Lateral epicondyle Medial epicondyle Intercondylar fossa Patellar surface Medial condyle Lateral condyle (a) (b) FIGURE 7. Femur The body of the femur has a slight medial curve to bring the knee joint in line with the body’s plane of gravity. The body of the femur has several distinguishing features femur articulates with the acetabulum of the os coxae. On the proximolateral side of the body is roughened shallow pit, the fovea capitis femoris, is present in the greater trochanter, and on the medial side is the lesser the lower center of the head of the femur. It Lateral also articulates both proximally and distally with the fibula. Two epicondyle of femur slightly concave surfaces on the proximal end of the tibia, the medial and lateral condyles (fig. The condyles are separated by a slight up- Patella ward projection called the intercondylar eminence, which pro- vides attachment for the cruciate ligaments of the knee joint (see Head of figs. The tibial tuberosity, for attachment of the tibia patellar ligament, is located on the proximoanterior part of the Tibia body of the tibia. The anterior crest, commonly called the “shin,” is a sharp ridge along the anterior surface of the body. A fibu- lar notch, for articulation with the fibula, is located on the disto- FIGURE 7. In that the tibia is the weight-bearing bone of the leg, it is much larger than the fibula. The patellar surface is located between the condyles on fibula articulates with the proximolateral end of the tibia. Above the condyles on the lateral and medial distal end has a prominent knob called the lateral malleolus. Both processes can be seen as prominent surface features and are easily palpated. Fractures to the fibula above the lateral malleolus are common in Patella skiers. Articular facets on the articular surface of the patella ar- The foot contains 26 bones, grouped into the tarsus, metatarsus, ticulate with the medial and lateral condyles of the femur. Although similar to the bones of the The functions of the patella are to protect the knee joint hand, the bones of the foot have distinct structural differences in and to strengthen the patellar tendon. It also increases the lever- order to support the weight of the body and provide leverage and age of the quadriceps femoris muscle as it extends (straightens) mobility during walking. It usually does Tarsus not fragment, however, because it is confined within the patel- lar tendon. Dislocations of the patella may result from injury or from There are seven tarsal bones. The most superior in position is the underdevelopment of the lateral condyle of the femur. Leg It has a large posterior extension, called the tuberosity of the Technically speaking, leg refers only to that portion of the lower limb between the knee and foot. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 186 Unit 4 Support and Movement Base of patella Articular surface Anterior surface Medial Apex of patella condyle Intercondylar eminence Intercondylar eminence Lateral condyle Articular surface of fibular head Head of fibula Tibial tuberosity Fibular articular Neck of fibula surface Anterior border Body of Body of tibia fibula Patella Tibia Fibula Medial malleolus Lateral malleolus Lateral malleolus (a) (b) FIGURE 7. Anterior to differ in shape, however, because of their load-bearing role. The remaining four The metatarsal bones are numbered I to V, starting with the tarsal bones form a distal series that articulate with the medial (great toe) side of the foot. The proximal bases of the first, second, and third metatarsals ar- Metatarsus ticulate proximally with the cuneiform bones. The heads of the metatarsals articulate distally with the proximal phalanges.

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 buy generic metoclopramide 10mg on line chronic gastritis rheumatoid arthritis. 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). A study comparing the accuracy rates of breast biopsy techniques found that cutting needle biopsy without image guidance had a sensitivity of only 85%. This was considerably less than open breast biopsy (99%), FNA (96%), or cutting needle biopsy with image guidance (98%) (22). CONCLUSION Claims involving breast cancer are frequent and are less likely to be successfully defended than most other malpractice cases. Most women present with no signs or symptoms other than the breast mass itself. It is the patient, not the doctor, who usually finds a lump, and these cases bring higher average indemnities. Although these claims can involve physicians of any specialty, radiologists, pathologists and obstetrician/gynecologists are the most frequently targeted. Sur- prisingly, the problem is more likely to be a communication error resulting from failure to take appropriate action following a correctly read study than it is to be an interpretation error. One promising technique, computer-aided detection (CAD), offers the promise of reducing interpretation error and is just becoming more widely available. Mammogram films are taken in the usual manner and then scanned into a CAD system. The CAD system digitizes the mammogram and analyzes it for regions of interest, either clustered bright spots suggestive of microcalcification or dense regions sug- gesting a mass or architectural distortion. The radiologist first reads the film mammogram, then reviews the areas detected by the CAD system and evaluates them for clinical relevance. Published studies using blinded review of a prior “normal” mammogram in patients with newly diagnosed breast cancer showed that 23% of these films were, in fact, actionable. This 20% increase in the breast cancer detection rate is impressive and, if CAD is widely adopted, may reduce the frequency of breast cancer malpractice claims (23,24). In cases where medical care has been suboptimal, the errors are usually obvious and most involve a short-circuiting of the diagnostic process or poor communi- cation among physicians or between doctor and patient. Allowing a negative physical examination to delay biopsy in a patient with a suspicious mammogram. Believing that the absence of “grave signs” of cancer is evidence against the presence of breast cancer. Failure to document the history, physical examination findings, and a plan for follow-up. Failure to order a diagnostic study, or order one but fail to assure it is completed. Telling a patient not to worry about a mass she brings to your attention. Failure to assure that breast cancer screening includes both a physi- cal examination and a mammogram.

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