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By F. Daro. Southern Illinois University Medical School at Springsfield. 2018.

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Itruns through the tympanic canaliculus into the tympanic cavity purchase clozaril 25 mg without prescription, where it receives fibers from the plexus of the internal carotid artery via the caroticotympanic nerve and forms the tym- panic plexus buy cheap clozaril 50mg line. It supplies sensory fibers to the mucosa of tympanic cavity and auditory (eustachian) tube (C) purchase clozaril 50mg line. The secretory fibers run as lesser petrosal nerve to the otic gan- glion (p order clozaril 25mg fast delivery. Apart from connections with the vagus nerve quality 50 mg clozaril, facial nerve, and sympathetic nervous system, the inferior ganglion gives off the (viscerosensory) branch of the carotid sinus (B13), which descends to the bifurca- tion of the common carotid artery and ter- minates in the wall of the carotid sinus (B14) and in the carotid glomus (B15) (see vol. Ninth Cranial Nerve 119 11 9 7 8 5 6 4 A Nuclear region of the glossopharyngeal nerve 7 C Sensory innervation of the middle ear 5 6 4 2 10 9 12 3 8 11 1 13 B Exit of the glossopharyngeal nerve 17 16 15 14 18 19 20 D Sensory innervation E Sensory innervation of of the tongue; taste the pharynx Kahle, Color Atlas of Human Anatomy, Vol. Only a small por- The eighth cranial nerve is an afferent tion reaches directly into the cerebellum via nerve consisting of two components, the the inferior cerebellar peduncle (restiform cochlear root for the organ of hearing and the body). The vestibular nuclei lie in the floor of the Cochlear Root (A) rhomboid fossa below the lateral recess: the superior nucleus (Bechterew’s nucleus) The nerve fibers originate from the bipolar (B14), the medial nucleus (Schwalbe’s nu- neurons of the spiral ganglion (A1), a band of cleus) (B15), the lateral nucleus (Deiters’ cells following the spiral course of the nucleus) (B16), and the inferior nucleus cochlea. The primary vestibular fibers termi- cells terminate at the hair cells of Corti’s nate mostly in the medial nucleus. Second- organ; the central processes form small ary fibers run from the vestibular nuclei to bundles that organize into the foraminous the cerebellum and into the spinal cord (ves- spiral tract (A2) and combine in the floor of tibulospinal tract) (B18). The The function of the vestibular apparatus plays latter extends, together with the vestibular an important role for balance and upright root (B) inside a common connective-tissue posture. Thetractstothecerebellumandthe sheath, through the internal acoustic meatus spinal cord serve this purpose. At the entrance of the bulospinal tract has an effect on muscular eighth cranial nerve into the medulla ob- tension in various parts of the body. The ves- longata at the cerebellopontine angle, the tibular apparatus controls especially move- cochlear component lies dorsally and the ments of the head and fixation of vision vestibular component ventrally. The cochlear fibers terminate in the ante- rior cochlear nucleus (A4) and in the pos- terior cochlear nucleus (A5). From the anterior nucleus, the fibers cross over to the opposite side (trapezoid body) (A6) (p. The fibers originating from the posterior cochlear nucleus cross partly as medullary striae (posterior acoustic striae) just below the rhomboid fossa; they ascend in the lateral lemniscus as well. Vestibular Root (B) The nerve fibers originate from bipolar neu- rons of the vestibularganglion (B9) which lies in the internal acoustic meatus. The periph- eral processes of these cells terminate at the sensory epithelia of the semicircular ducts (B10),thesaccule(B11),andtheutricle(B12) (p. Their central processes unite to form the vestibular root (B13) and terminate, after bifurcation into the ascending and de- Kahle, Color Atlas of Human Anatomy, Vol. Eighth Cranial Nerve 121 A Vestibulocochlear nerve, nuclear region, 5 and entrance of the cochlear root 4 8 6 7 3 5 2 4 1 B Vestibulocochlear nerve, nuclear region, and entrance of the vesti- bular root 14 16 15 13 14 10 16 15 9 17 18 12 11 Kahle, Color Atlas of Human Anatomy, Vol. The stapedius nerve The seventh cranial nerve supplies motor supplies the stapedius muscle in the middle fibers to the muscles of facial expression; in ear. The chorda tympani (BC14) branches off a nerve bundle emerging separately from above the stylomastoid foramen, runs the brain stem, called the intermediate beneath the mucosa through the tympanic nerve, it carries taste fibers and viscero- cavity (p. It contains taste fibers large, multipolar neurons in the nucleus of for the anterior two-thirds of the tongue (D) the facial nerve (AB2). They arch around and preganglionic fibers for the subman- the abducens nucleus (AB3) (internal genu of dibular and sublingual glands as well as the facial nerve) and emerge on the lateral various lingual glands. The cells of the Before it enters the parotid gland, the facial preganglionic secretory fibers (AB4) form the nerve gives off the posterior auricular nerve superior salivatory nucleus (AB5). The (E17) as well as branches to the posterior taste fibers (AB6) originate from the pseudo- belly of the digastric muscle (CE18) and to unipolar cells in the geniculateganglion (BC7) the stylohyoid muscle (C19). The parotid and terminate in the cranial section of the plexus gives off the temporal branches (E20), solitary nucleus (AB8). The visceroefferent the zygomatic branches (E21), the buccal and taste fibers do not arch around the ab- branches (E22), the marginal mandibular ducens nucleus but join the ascending limb branch (E23), and the cervical branch (E24) of the nerve and emerge as intermediate for the platysma (see vol. The branches nerve (B9) between the facial nerve and the provide innervation to all the muscles of fa- vestibulocochlear nerve. Both parts of the nerve pass through the Ramifications of the cervical branch lying inner auditory canal, the internal acoustic beneath the platysma form the superficial meatus (petrous part of temporal bone, in- cervical ansa by anastomosing with ternal acoustic pore, see vol. The small branches of the nerve in the petrous bone (external departing from the ansa are mixed sen- genu of the facial nerve) lies the geniculate sorimotor nerves.

It has sphincter-like properties and can Oocyte Arrested in Meiosis serve as a barrier to the passage of germ cells clozaril 100mg fast delivery. The oviducts transport the germ cells in two directions: sperm ascend to- Female germ cells develop in the embryonic yolk sac and ward the ampulla and the zygote descends toward the migrate to the genital ridge where they participate in the uterus purchase 25mg clozaril. This requires coordination between smooth muscle development of the ovary (Table 38 buy clozaril 25 mg fast delivery. Without germ contraction purchase clozaril 50mg with visa, ciliary movement order 100mg clozaril overnight delivery, and fluid secretion, all of cells, the ovary does not develop. Oogonia undergo mi- The uterus is situated between the urinary bladder and tosis only during the prenatal period. On each upper side, an oviduct opens into the uter- contain a finite number of oocytes, estimated to be about 1 ine lumen, and on the lower side, the uterus connects to the million. The puberty, only 200,000 oocytes remain; by age 30, only outer part is the myometrium, composed of multiple layers 26,000 remain; and by the time of menopause, the ovaries of smooth muscle. The inner part, lining the lumen of the are essentially devoid of oocytes. The stroma is permeated by spiral arteries and con- sis, to prepare for the production of a haploid ovum), become tains much connective tissue. The epithelial layer is inter- arrested in prophase of the first meiotic division, and remain rupted by uterine glands, which also penetrate the stromal arrested in that phase until they either die or grow into ma- layer and are lined by columnar secretory cells. The primordial follicle provides an environment for the developing fetus, and (Fig. When pregranulosa The cervix (neck) is a narrow muscular canal that con- cells surround the oocyte, a basement membrane develops, nects the vagina and the body (corpus) of the uterus. The cervix has numerous glands with a colum- A Graafian Follicle Is the Final Stage of nar epithelium that produces mucus under the control of Follicle Development estradiol. As more and more estradiol is produced during the follicular phase of the cycle, the cervical mucus changes Folliculogenesis (also called follicular development) is the from a scanty viscous material to a profuse watery and process by which follicles develop and mature (see Fig. Follicles are in one of the following physiological of the spinnbarkeit can be tested by touching it with a piece states: resting, growing, degenerating, or ready to ovulate. The mucus can form a thread During each menstrual cycle, the ovaries produce a group up to 6 cm under the influence of elevated estradiol. If a of growing follicles of which most will fail to grow to ma- drop of the cervical mucus is placed on a slide and allowed turity and will undergo follicular atresia (death) at some to dry, it will form a typical ferning pattern when under the stage of development. It is lined by several layers of epithelium that change Primordial follicles are generally considered the non- histologically during the menstrual cycle. When estradiol growing resting pool of follicles, which gets progressively levels are low, as during the prepubertal or post- depleted throughout life; by the time of menopause, the menopausal periods, the vaginal epithelium is thin and the ovaries are essentially devoid of all follicles. Primordial fol- secretions are scanty, resulting in a dry and infection-sus- licles are located in the ovarian cortex (peripheral regions ceptible area. Estradiol induces proliferation and cornifi- of the ovary) beneath the tunica albuginea. The theca externa remains fibroblastic constant rate throughout fetal, juvenile, prepubertal, and and provides structural support to the developing follicle. Once primary follicles leave the resting pool, Development beyond the primary follicle is go- they are committed to further development or atresia. Most nadotropin-dependent, begins at puberty, and continues in become atretic, and typically only one fully developed fol- a cyclic manner throughout the reproductive years. The conversion from primordial to pri- follicle continues to grow, theca layers expand, and fluid- mary follicles is believed to be independent of pituitary go- filled spaces or antra begin to develop around the granulosa nadotropins. This early antral stage of follicle development is re- resting to a growing pool is unknown; it could be pro- ferred to as the tertiary follicular stage (see Fig. The grammed by the cell genome or influenced by local ovarian critical hormone responsible for progression from the pre- growth regulators. Mitosis of the granulosa The first sign that a primordial follicle is entering the cells is stimulated by FSH. As the number of granulosa cells growth phase is a morphological change of the flattened increases, the production of estrogens, the binding capac- pregranulosa cells into cuboidal granulosa cells.

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The heel is the back of the foot order clozaril 50mg on line, and the sole of and the thigh and leg purchase 50mg clozaril fast delivery. Explain how knowledge of the body regions is applied in a clinical setting buy clozaril 100mg otc. Body Organization and © The McGraw−Hill Anatomy clozaril 50 mg lowest price, Sixth Edition Organization generic clozaril 50 mg, and the Anatomical Nomenclature Companies, 2001 Human Organism Chapter 2 Body Organization and Anatomical Nomenclature 41 Mediastinum (contains esophagus, major vessels, and certain nerves) Thoracic Pleural cavities cavity (surround lungs) Pericardial cavity (surrounds heart) Abdominal cavity (contains abdominal viscera) Abdominopelvic Pelvic cavity cavity (contains pelvic viscera) Paras FIGURE 2. The For functional and protective purposes, the viscera are compart- coelom is lined with a membrane that secretes a lubricating fluid. The abdominopelvic cavity consists of an upper abdominal Body Cavities cavity and a lower pelvic cavity. The abdominal cavity contains Body cavities are confined spaces within the body. They contain the stomach, small intestine, large intestine, liver, gallbladder, organs that are protected, compartmentalized, and supported by pancreas, spleen, and kidneys. There are two principal body cavities: the posterior (dorsal) body cavity and the larger anterior (ventral) body cavity. Body Organization and © The McGraw−Hill Anatomy, Sixth Edition Organization, and the Anatomical Nomenclature Companies, 2001 Human Organism 42 Unit 2 Terminology, Organization, and the Human Organism Lesser omentum Diaphragm (supports stomach (muscular partition between to liver) thoracic and abdominal cavities) Pancreas (retroperitoneal Liver to parietal peritoneum) Stomach Duodenum (covered by visceral peritoneum) (retroperitoneal to parietal peritoneum) Large intestine (covered by visceral peritoneum) Mesentery (supports intestines) Parietal peritoneum (lines abdominopelvic cavity) Small intestine Greater omentum Visceral (protective, fatty serous membrane peritoneum attached to stomach and transverse (covers abdominal colon of large intestine) viscera) Peritoneal cavity Rectum (space created by the parietal peritoneum lining the wall of the abdominopelvic cavity) Urinary bladder FIGURE 2. There are two orbits, each of which houses an eye- and certain reproductive organs (uterus, uterine tubes, and ball and its associated muscles, vessels, and nerves. Likewise, ovaries in the female; seminal vesicles and prostate in the male). Body cavities serve to confine organs and systems that have related functions. The major portion of the nervous system oc- cupies the posterior cavity; the principal organs of the respiratory Body Membranes and circulatory systems are in the thoracic cavity; the primary organs of digestion are in the abdominal cavity; and the reproductive organs Body membranes are composed of thin layers of connective and are in the pelvic cavity. Not only do these cavities house and support epithelial tissue that cover, separate, and support visceral organs various body organs, they also effectively compartmentalize them so and line body cavities. There are two basic types of body mem- that infections and diseases cannot spread from one compartment to another. Mucus generally lubricates or protects the associated or- In addition to the large anterior and posterior cavities, there are gans where it is secreted. Mucous membranes line various cavi- several smaller cavities and spaces within the head. The oral cavity functions primarily in digestion and secondarily in respira- tion. The nasal cavity, which is part of the respiratory system, has two chambers created by a orbital: L. Body Organization and © The McGraw−Hill Anatomy, Sixth Edition Organization, and the Anatomical Nomenclature Companies, 2001 Human Organism Chapter 2 Body Organization and Anatomical Nomenclature 43 Parietal pleura (lines inside of body wall) Visceral pleura (covers surface of lung) Pleural cavity (contains pleural fluid) Diaphragm (a) Parietal pericardium (forms sac surrounding heart) Visceral pericardium (covers surface of heart) Pericardial cavity (contains pericardial fluid) (b) FIGURE 2. The space nasal cavities and the tubes of the respiratory, reproductive, uri- between these two membranes is called the pericardial cavity. The parietal peritoneum ities and cover visceral organs, secreting a watery lubricant called lines the abdominal wall, and the visceral peritoneum covers serous fluid. The peritoneal cavity is the potential Each pleura (pleura of right lung and pleura of left lung) has two space within the abdominopelvic cavity between the parietal parts. The visceral pleura adheres to the outer surface of the lung, and visceral peritoneal membranes. The moistened space be- tween the two pleurae is known as the pleural cavity (fig. A thin visceral pericardium covers the surface of the heart, peritoneum: Gk. Body Organization and © The McGraw−Hill Anatomy, Sixth Edition Organization, and the Anatomical Nomenclature Companies, 2001 Human Organism 44 Unit 2 Terminology, Organization, and the Human Organism Body cavities Differentiate during development Anterior (ventral) Posterior (dorsal) cavity (coelom) cavity Protects visceral Protects the brain and organs; permits organ spinal cord; contains movement during buoyant cerebrospinal peristalsis; contains fluid lubricating serous fluid Separated Subdivided into into Thoracic cavity Abdominopelvic Cranial cavity Spinal cavity cavity Contains and protects Maintains consistency Maintains consistency of heart, lungs, trachea, Contains peritoneal of brain while keeping spinal cord while esophagus, major cavity and its contents it immobile allowing it to be flexible vessels, and nerves Subdivided into Separated into Abdominal cavity Pelvic cavity Right pleural Mediastinum Left pleural cavity Contains abdominal Contains some urinary cavity viscera and lubricating and reproductive Contains trachea, Surrounds left lung and peritoneal fluid organs, terminal Surrounds right lung esophagus, major contains lubricating portion of digestive and contains vessels, and nerves pleural fluid tract, and lubricating lubricating pleural peritoneal fluid fluid Also contains Pericardial cavity Surrounds heart and contains lubricating pericardial fluid FIGURE 2. Body Organization and © The McGraw−Hill Anatomy, Sixth Edition Organization, and the Anatomical Nomenclature Companies, 2001 Human Organism Chapter 2 Body Organization and Anatomical Nomenclature 45 Cranial cavity (contains brain) Sphenoidal sinus (contains mucous membrane) Frontal sinus (contains mucous membrane) Orbit (contains eye) Nasal cavity (contains mucous membrane and olfactory receptors) Middle ear Oral cavity cavity (contains teeth, (contains tongue, and taste auditory buds) ossicles) FIGURE 2. Certain organs, such as the kidneys, adrenal Clinical Case Study Answer glands, and the medial portion of the pancreas, which are Normally, the thoracic cavity is effectively separated from the ab- within the abdominopelvic cavity, are positioned behind the dominopelvic cavity by the diaphragm, peritoneum, and pleura. The blow would have produced sudden upward pressure against the diaphragm, causing it to rupture. These organs are not located within the peritoneal cavity; body cavity and list the major organs contained within rather they are retroperitoneal, or fully posterior to the peritoneal each division.

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The parafollicular cell is usually embedded in the wall of the follicle purchase 50 mg clozaril amex, inside the basal lamina surrounding the follicle clozaril 50 mg low cost. However buy clozaril 50 mg on-line, its plasma mem- brane does not form part of the wall of the lumen safe 100mg clozaril. Parafol- Follicular licular cells produce and secrete the hormone calcitonin buy clozaril 25mg low price. SYNTHESIS, SECRETION, AND METABOLISM OF THE THYROID HORMONES T4 and T3 are not directly synthesized by the thyroid folli- cle in their final form. Instead, they are formed by the chemical modification of tyrosine residues in the peptide Capillary structure of thyroglobulin as it is secreted by the follicular cells into the lumen of the follicle. Therefore, the T4 and T3 formed by this chemical modification are actually part of the amino acid sequence of thyroglobulin. The high concentration of thyroglobulin in the colloid provides a large reservoir of stored thyroid hormones for Parafollicular cell later processing and secretion by the follicle. The synthesis of T4 and T3 is completed when thyroglobulin is retrieved A cross-sectional view through a portion of through pinocytosis of the colloid by the follicular cells. Once inside follicular cells, the io- HO O COOH dide ions diffuse rapidly to the apical membrane, where they are used for iodination of the thyroglobulin precursor. A typical thyroglobulin molecule contains only H H 20 to 30 atoms of iodine. The iodination of thyroglobulin is catalyzed by the en- HO O C C COOH zyme thyroid peroxidase, which is bound to the apical membranes of follicular cells. Thyroid peroxidase binds H NH2 an iodide ion and a tyrosine residue in the thyroglobulin 5 precursor, bringing them in close proximity. The enzyme oxidizes the iodide ion and the tyrosine residue to short- Triiodothyronine (T3) lived free radicals, using hydrogen peroxide that has been generated within the mitochondria of follicular cells. The numbering of the iodine atoms on free radicals then undergo addition. A second iodine atom may be added to a MIT residue by this same to its constituent amino acids, releasing T4 and T3 mole- enzymatic process, forming a diiodotyrosine (DIT) cules from their peptide linkage. Iodinated tyrosine residues that are close together in the thyroglobulin precursor molecule undergo a coupling reaction, which forms the iodothyronine structure. Thy- Follicular Cells Synthesize roid peroxidase, the same enzyme that initially oxidizes Iodinated Thyroglobulin iodine, is believed to catalyze the coupling reaction The steps involved in the synthesis of iodinated thyroglob- through the oxidation of neighboring iodinated tyrosine ulin are shown in Figure 33. These free radicals synthesis of a thyroglobulin precursor, the uptake of io- undergo addition, as shown in Figure 33. For example, when two The synthesis of the protein precursor for thyroglobulin is neighboring DIT residues couple by this mechanism, T4 is the first step in the formation of T and T. After being iodinated, the thy- 4 3 is a 660-kDa glycoprotein composed of two similar 330- roglobulin molecule is stored as part of the colloid in the kDa subunits held together by disulfide bridges. For example, a typical thyroglobulin mol- vesicles by the Golgi apparatus. These vesicles migrate to ecule contains five to six uncoupled residues of DIT and the apical membrane of the follicular cell and fuse with it. However, T3 is formed in only The thyroglobulin precursor protein is then extruded onto about one of three thyroglobulin molecules. As a result, the the apical surface of the cell, where iodination takes place. The iodide used for iodination of the thy- Thyroid Hormones Are Formed From the roglobulin precursor protein comes from the blood perfus- Hydrolysis of Thyroglobulin ing the thyroid gland. The basal plasma membranes of fol- licular cells, which are near the capillaries that supply the When the thyroid gland is stimulated to secrete thyroid follicle, contain iodide transporters. These transporters hormones, vigorous pinocytosis occurs at the apical mem- move iodide across the basal membrane and into the cy- branes of follicular cells. The iodide transporter is an ac- brane reach into the lumen of the follicle, engulfing bits of tive transport mechanism that requires ATP, is saturable, the colloid (see Fig. Endocytotic vesicles or colloid and can also transport certain other anions, such as bro- droplets formed by this pinocytotic activity migrate to- mide, thiocyanate, and perchlorate.

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One of the major barriers for using the data in such ways is the inaccessible and often unstructured nature of the paper record 50mg clozaril for sale. The introduction of computer based medical records to a large degree buy 25 mg clozaril visa, removes that barrier purchase clozaril 25 mg with amex. Recent decades have seen a rapid increase in the role of computers in medical record keeping purchase 25mg clozaril mastercard, and professional organisations have started to play an active role in the introduction of electronic records clozaril 100mg on line. For example, in 1978 the first Dutch general practitioners started using personal computers in their practices. In 1990, 35% of Dutch GPs were using one or more computer applications; although the majority of these are administrative, an increasing number of clinicians use computer stored medical records. Other countries, such as the United Kingdom, have also witnessed a rapid introduction of electronic records into primary care. In secondary care, although progress has been made, the introduction of electronic records is slower. The explicit purpose of automating medical records is to use the data in those records to support not only the care of individual patients, but also applications such as decision support, quality control, cost control, or epidemiology. The reliability of clinical data, for example, has long been questioned, and tensions between reimbursement schemes and coding schemes have been discussed. Some researchers argue that the process of automation may further reduce the reliability of data. Burnum,4 for example, states: “With the advent of the information era in medicine, we are pouring out a torrent of medical record misinformation”. Although we disagree with this pessimistic view, we acknowledge that medical data are recorded for a specific purpose and that this purpose has an influence on what data are recorded and how. In developing systems that record medical data, designers make decisions about how to model those data in order to perform a given task. For example, in designing the computer based medical record system Elias,3 the designers focused on issues such as ease of data entry and emulating existing paper records. The same designers 170 DIAGNOSTIC DECISION SUPPORT subsequently discovered significant limitations in the Elias records when they developed a decision support system that uses these records as a data source. First, data recorded on computer can be readily retrieved and reused for a variety of purposes. As a result, databases containing data on millions of patients are available. Although the subsequent analysis of the data may prove difficult, both clinicians and researchers are moving from a period of “data starvation” to “data overload”. Second, once data are available in this way, they can easily be transported. The result is that processes that interpret the data (for example diagnosis or consultation) are no longer closely associated with the physical location where they were collected. Data can be collected in one place and processed in another (for example telediagnosis). Third, as clinicians (and patients) are using computers to record medical data, the same electronic record can be used to introduce other computer programs that interact with the user. Electronic medical records require both an extensive ICT infrastructure and clinicians experienced in using that infrastructure. Once that infrastructure is operational, other applications (such as decision support or access to literature) are much easier to introduce. Electronic medical records will stimulate and enable other developments. We will discuss two of them: the development and use of integrated decision support systems, and the creation of observational databases. Clinical decision support systems A number of definitions for clinical decision support systems have been proposed. Shortliffe,1 for example, defines a clinical decision support system as: “any computer program designed to help health professionals make clinical decisions”. The disadvantage of such a broad definition is that it includes any program that stores, retrieves or displays medical data or knowledge. To further specify what we mean by the term clinical decision support system, we use the definition proposed by Wyatt and Spiegelhalter1: “active knowledge systems that use two or more items of patient data to generate case specific advice”. This definition captures the main components of a clinical decision support system: medical knowledge, patient data, and patient specific advice.

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