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Neuroanatomy: Magnetic Resonance Imaging and Computed To- Nelson BJ buy 50 mg quetiapine visa administering medications 7th edition answers, Mugnaini E discount quetiapine 100mg mastercard treatment 1st degree heart block. The Comparative Anatomy and Histology of the Exp Brain Res Ser 17:86–107). Cerebellum: The Human Cerebellum, Cerebellar Connections, and Newman DB, Hilleary SK, Ginsberg CY. The Central Nervous Sys- Schnitzlein HN, Hartley EW, Murtagh FR, Grundy L, Fargher JT. Computed Tomography of the Head and Spine: A Photographic Noback CR, Strominger NL, Demarest RJ. The Human Brain: An Introduction to its Functional A Photographic Color Atlas of MRI, CT, Gross, and Microscopic Anatomy, 5th ed. Inter- and intra-laminar dis- to the hippocampus mediated by stellate cells in the entorhinal cor- tribution of tectospinal neurons in 23 mammals. Baltimore: Urban & projections in primate as studied by retrograde double-labeling Schwarzenberg, 1981. Pernkopf Atlas of Topographic and Applied Human neurones of the substantia nigra receive a GABA-containing input Anatomy, 3rd ed. Atlas of Cross Section Anatomy of the Brain: Guide to anterograde tracing method. J Comp Neurol 1990;294: the Study of the Morphology and Fiber Tracts of the Human Brain. New York: Blakiston Division, McGraw-Hill Book Company, Inc, Strata P (ed). Illustrated Guide to the Central bulbospinal axons that contain serotonin and either enkephalin or Nervous System. Localization of enkephalin- Tatu L, Moulin T, Bogousslavsky J, Duvernoy H. Arterial territories ergic neurons in the dorsolateral pontine tegmentum projecting to of human brain: Brainstem and cerebellum. The posterior cranial fossa: Microsurgical anatomy and Terzian H, Ore GD. Neurosurgery 2000; 47 (Supplement); by bilateral removal of the temporal lobes. The supratentorial cranial space: Microsurgical Tieman SB, Butler K, Neale JH. Identification of cells of origin of non-pri- walk, CT: Appleton & Lange, 1995. Sylvian fissure morphology and asymmetry in munoreactive terminals synapse on primate spinothalamic tract men and women: Bilateral differences in relation to handedness in cells. Baltimore: Urban & Woolsey TA, Hanaway J, Gado MH: The Brain Atlas: A Visual Guide Schwarzenberg, 1982. The Pain System: The Neural Basis of Nociceptive Basal Cisterns and Vessels of the Brain, Diagnostic Studies, Gen- Transmission in the Mammalian Nervous System, Volume 8, Pain eral Operative Techniques and Pathological Considerations of and Headache. Bringing connection content into your WebCT courses As a first step, you will want to download from connection the files that you want to use in your courses. Please refer to the other Help information available at http://connection. Typically these files will be images, PowerPoint presentations, Word documents, and/or Adobe Acrobat (PDF) files. The steps below are also appropriate for bringing your own files into WebCT. Note: Spaces or punctuation characters other than the underscore in file names are not allowed in WebCT. Tip: If you are ever adding multiple files to WebCT during the same session, such as a group of images, or an HTML PowerPoint presentation, try zipping the files together. There are several products on the market, such as WinZip and StuffIt that can combine and compress several files into one. This means that you don’t need to upload each file separately, and your upload time may be reduced, if the files you are adding are compressible. Zipped files can be unzipped again using WebCT’s built- in Unzip utility within Manage Files.

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This pattern is based on the or asymmetrically (involvement of a joint on one side Fig generic quetiapine 300 mg treatment pancreatitis. Sites and distribution of com- mon arthritides of the hand (A) and foot (B) cheap quetiapine 50 mg online medications for bipolar. The more common sites are encircled with thick lines and the less common sites with thin lines. Note the periosteal reaction or new-bone forma- tion classically identified in Reiter’s disease. Note also the potential for “sausage digit” dis- tribution in psoria- sis. When joints are encircled in isola- tion, the distribution is random and may be isolated to any joint 144 L. Resnik without simultaneous involvement of the corresponding The distribution of joint involvement is characteris- joint on the opposite side). The disease begins in the PIP, MCP, and carpal The specific radiographic characteristics of impor- joints with a more or less symmetrical distribution in tance in establishing or confirming the diagnosis often the right and left extremities. In some cases, the joints are the following: (1) whether the joint space narrowing of the hand and wrist are equally affected, but in others is symmetrical or asymmetrical; (2) whether soft-tissue the destructive process may be much more severe in the swelling is present and whether it is symmetrical (indi- hand than in the carpus. In still others, it may be more cating a joint effusion) or asymmetrical (indicating a pe- severe in the carpus than in the hand. In the foot, the riarticular mass); and the presence or absence of (3) pe- metatarsophalangeal (MTP) joints, particularly the riarticular osteoporosis, (4) periarticular erosions, and (5) fourth and fifth, are often involved in the initial stage spur formation. In fact, characteristic changes of Ancillary radiographic findings include the presence erosion may be present in the heads of the fourth or or absence of periosteal reaction of bones in the vicinity fifth metatarsal when the radiographic changes of the of the involved joint. Therefore, it is im- calcification within the joint cartilage (chondrocalci- portant to examine not only the hands but also the feet nosis) is to be noted. Laboratory values of importance are the erythro- granulation tissue (pannus) at the peripheral margin of cyte sedimentation rate; the presence or absence of serum the joint cartilage. These appear as small foci of destruc- rheumatoid factor; and the serum levels of uric acid. They may be very minute, but they represent one of the most significant roentgenographic observations of early Rheumatold Arthritis disease. The most common sites are the radial Rheumatoid arthritis typically begins in the peripheral sides of the heads of the first, second, and third joints, usually the proximal interphalangeal (PIP) and metacarpals; the heads of the fourth and fifth metatarsals; metacarpophalangeal (MCP) joints of the hand and the and the ulnar styloid. As the disease progresses, it affects more proxi- is more sensitive than plain radiography for detection of mal joints, advancing toward the trunk in all extremities early bone erosions. Characteristically, the distal inter- until finally almost every joint in the body is involved. In the early stages, there is edema and inflammation of the synovium and the subsynovial tissues. As the disease advances, the synovium becomes greatly thickened, 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.

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Decussating trigeminothalamic fibers are found in the corticospinal fibers order 300mg quetiapine overnight delivery symptoms quit drinking, medial lemniscus buy quetiapine 300mg free shipping xerogenic medications, and exiting fibers on the medulla and do not form a visible structure on the midline. Motor and sensory losses, without the cranial motor decussation is a compact bundle on the midline, but it is in nerve sign, could suggest a lesion at several different levels of the the medulla, not the midbrain. Answer B: All of the sensory deficits seen in this woman reflect a lesion in the medial lemniscus, which is located in the medial 55. Answer A: The anterolateral system is located just internal to medulla in the territory of the anterior spinal artery. The antero- the brachium of the inferior colliculus in the lateral portions of the lateral system and the spinal trigeminal tract convey pain and ther- midbrain tegmentum. This tract conveys pain and thermal sensa- mal sensations from the body (sans face) and face, respectively. The solitary tract is made up of the central processes of vis- Corticospinal fibers are located in the crus cerebri, the mesen- cerosensory fibers and the medial longitudinal fasciculus at this cephalic tract at the lateral edge of the periaqueductal (central) level contains descending fibers that influence spinal motor neu- grey, and the central tegmental tract is, as its name indicates, in rons. Oculomotor fibers within the midbrain leave the nucleus, arch through the tegmentum, and exit 61. A on the medial surface of the basis pedunculi into the interpedun- cavitation in this location may communicate with a cavity in cer- cular cistern. Hydromyelia refers to a cavity of the spinal cord that is lined with ependymal cells. Answer C: Fibers conveying discriminative touch, vibratory spinal cord that give rise to characteristic motor and sensory sensations, and proprioception are located in the lateral lemnis- losses. Answer A: The dentate nucleus appears as a long thin undulat- has difficulty walking due to a lesion of fibers conveying position ing line within the white matter core of the cerebellar hemisphere. Fibers of the an- a crumpled bag with its hilus (the opening of the bag) directed ros- terolateral system convey pain and thermal sensation. The other cerebellar nuclei (fastigial, globose, em- and corticospinal are motor in function; however this man has no boliform) are small clumps of cells, and the red nucleus is found weakness. Answer C: The inferior salivatory nucleus is located in the ros- tral medulla, medial to the solitary tract and nuclei and inferior to the medial vestibular nucleus. Preganglionic axons that orig- Review and Study Questions for inate from these cells distribute on branches of the glossopha- Chapter 6 ryngeal nerve. The dorsal motor nucleus is in the medulla, its ax- ons travel on the vagus nerve. Cells located in the lateral wall of the atrium of the lateral ventricle. Answer C: Weakness of the extremities accompanied by (D) Pulvinar nucleus paralysis of muscles on the contralateral side of the tongue (seen (E) Splenium of the corpus callosum as a deviation of the tongue to that side on protrusion) indicates a lesion in the medulla involving the corticospinal fibers in the 2. Which of the following structures is clearly seen in coronal and ax- pyramid and the exiting hypoglossal roots. This is an inferior al- ial brain slices, and in many MRIs, in planes extending from the ternating hemiplegia. Middle alternating hemiplegia refers to a midline laterally through the basal nuclei? Alternating (B) Column of the fornix (alternate) hemianesthesia and hemihypesthesia are sensory (C) Genu of the internal capsule losses. Which of the following nuclei is located within the internal disorders and with cognitive dysfunction shows a large anterior medullary lamina and may be visible in an axial MRI in either T1- horn of the lateral ventricle. A loss of which of the following structures would (B) Dorsomedial result in this portion of the ventricular system being enlarged? The sagittal MRI of a 23-year-old woman shows a mass in the right (E) Septum pellucidum and fornix interventricular foramen (possibly a colloid cyst); the right lateral ventricle is enlarged. The axial MRI of a 54-year-old man shows an arteriovenous mal- impinging on which of the following structures? Which of the following structures is probably most affected (B) Posterior limb of internal capsule by this malformation? The sagittal MRI of a 42-year-old woman taken adjacent to the (E) Posterior limb of the internal capsule midline shows a round structure immediately rostral to the in- terpeduncular fossa on the inferior surface of the hemisphere. In a sagittal MRI, and in a sagittal brain slice, both taken just off Which of the following most likely represents this elevation?

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Four claims involved women in their 20s buy generic quetiapine 200mg on line treatment zenkers diverticulum, an age when breast cancer may not be the first diagnosis that comes to mind and when screening mammography is infrequently performed buy quetiapine 300 mg online medications for ibs. The younger the patient, the easier it is to demonstrate significant damages from lost wages, the costs of raising young children, and lost child- bearing potential. Although the index of suspicion for breast cancer in very young women may be lower, the impact of missing the diagnosis is especially high. Because the insensitivity of mammography in women younger than age 40 is well-recognized, clinical follow-up is mandatory and making a definitive diagnosis is essential. There were fewer claims for older women, but 10 of 17 (59%) paid indemnity. BREAST BIOPSY AND THE MICROSCOPIC DIAGNOSIS OF BREAST CANCER We turn now to an analysis of the clinical and medical-legal issues surrounding the microscopic diagnosis of breast cancer. In a separate study of pathology claims, TDC reviewed 218 con- secutive surgical pathology and fine needle aspiration (FNA) claims from 1995 to 1997 (7–9). Breast FNA accounted for 6% of these claims and breast biopsy accounted for another 14%. When claims involving breast FNA, breast biopsy, and breast frozen section were combined, breast specimens accounted for 22% of all pathology claims. Fifty- four percent of breast biopsy claims involved the false-negative diag- nosis of breast carcinoma, whereas 35% were for the false-positive diagnosis of carcinoma. Breast Fine Needle Aspiration A false-negative breast FNA usually results from the failure to adequately sample a breast mass (sampling error) and is responsible for the majority of claims. Often, these claims involve a woman with a palpable breast mass, in whom an FNA is negative, and who is subsequently diagnosed with carcinoma. In many of these cases, an FNA diagnosis of “fibrocystic change” or “negative” was made on sparsely cellular smears. Although the definition of breast FNA speci- men adequacy is controversial (10–12), it is important to remember that many physicians perform FNA procedures infrequently and lack formal training in smear preparation technique. For this reason, they are often unable to reliably assess whether or not the mass was adequately sampled. Therefore, when the slides have only a few cells, Chapter 12 / Breast Cancer Litigation 161 it is hazardous for a pathologist to assume that the specimen is a rep- resentative sample and proceed to make a diagnosis of fibrocystic change or negative. This is a special problem in a managed care envi- ronment where patients frequently change health plans—and physi- cians—and are often lost to follow-up. Most of these claims could have been prevented if the diagnosis had been “nondiagnostic because of sparse cellularity, additional diagnostic studies recommended. 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. The consequences of these errors can be mini- mized by applying the triple test strategy, that is, correlating the FNA results with the mammogram/ultrasound findings and the clinical breast examination and performing a biopsy if these are discordant. Whenever possible, 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).

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