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The small intestine transports dietary petitively inhibits ACh at postganglionic sites infection game online sumycin 250 mg amex, inhibit- triglyceride as chylomicrons in lymph infection zombie movies generic sumycin 250mg on line. Aspirin is the most widely used analgesic (pain pathway for the transport of dietary lipids to the circu- reducer) xanthone antimicrobial buy sumycin 250mg with amex, antipyretic (fever reducer), and anti-inflam- lation by the small intestine. Omeprazole inhibits the H /K -ATPase crete LDLs, and although it does secrete HDLs, they and, thus, inhibits acid secretion. The chief cells of the stomach secrete to the blood by the small intestine. Amino acids, as well as dipeptides crete hydrochloric acid and intrinsic factor. Gastrin and tripeptides, use different brush border transporters and CCK are secreted by specialized endocrine cells. Histamine interacts with its receptor taken up passively by any part of the GI tract. Dietary protein is transported in the tamine does not cause an increase in intracellular portal blood as free amino acids. Although dipeptides sodium or cGMP or a decrease in intracellular calcium. When the pH of the stomach falls hydrolyzed by the brush border membrane, as well as below 3, the antrum secretes somatostatin, which acts by cytoplasmic peptidase to form free amino acids. Enterogastrones are Vitamins A, D, E, and K are all fat-soluble vitamins. Intrinsic factor is involved rect role in the absorption of calcium by the GI tract. Vitamin A is transported in chylomi- acidic chyme and is responsible for stimulating pancre- crons as ester. Vitamins D, E, and K are transported in APPENDIX A Answers to Review Questions 727 the free form associated with chylomicrons. Vitamin correct because the pancreas does not produce more B12,a water-soluble vitamin, is transported in the blood glucagon in portacaval shunt patients. The other choices do not apply to the ab- not nearly as important as the liver in removing sorption of potassium by the small intestine. Ascorbic acid enhances iron absorp- because the small intestine does not produce glucagon. Ascorbic acid does not enhance heme intestine is not compromised in portacaval shunt pa- iron absorption, nor does it affect heme oxygenase ac- tients. Hemosiderin is an intracellular com- Chapter 28 plex of ferric hydroxide, polysaccharides, and proteins. Alcohol dehydrogenase catalyzes the Ceruloplasmin is a circulating plasma protein involved conversion of alcohol to acetaldehyde, which is then in the transport of copper. Cytochrome P450 is a primary compo- and in neutrophil granules; it appears to contribute to nent of the oxidative enzyme system involved in the antimicrobial host defenses. Smokers inhale polycyclic aromatic ductase is an enzyme involved in phase I reactions of hydrocarbons, which stimulate drug-metabolizing en- drug metabolism. Glycogen phosphorylase is an enzyme in- patic drug-metabolizing enzymes than nonsmokers.

This chapter analyzes 100 con- secutive breast cancer claims from The Doctors Company antibiotics good or bad order sumycin master card, a large national medical malpractice insurer antibiotic that starts with l discount sumycin uk. Factors that contrib- ute to this high claims frequency include patient discovery of the breast mass antibiotic pneumonia order genuine sumycin online, delay in diagnosis, mammography communication errors, patient age, tumor size, and tumor stage. The potential for computer-aided detection to reduce mammography interpreta- tion errors is discussed. Finally, pathology claims involving breast biopsy and fine needle aspiration are analyzed and strat- egies are presented to minimize diagnostic error. Key Words: Breast cancer; breast cancer malpractice; breast can- cer claims; mammography error; breast biopsy error; breast fine needle aspiration. BREAST CANCER LITIGATION: THE CLINICAL CONTEXT Breast cancer is the most common diagnosis in malpractice claims in the United States. The magnitude of benefit is less clear in younger women, yet the majority of malpractice claims involve women younger than age 50. This chapter reviews the clinical circumstances surrounding breast cancer litigation. We then analyze in detail the liability faced by pathologists in dealing with breast biopsies. Although there is some comfort in the fact that few cases involve physician incompetence or technical inadequacy, this is no solace to the patient and does not form the basis of a strong defense in court. The vast majority of cases allege delay in diagnosis, and these claims may be divided into those involving diagnostic error and those involving poor communication. Additional claims arise from therapeutic acts of omis- sion or commission. Breast cancer is a common disease, and most women are familiar with the cumulative incidence figure that one in nine American women will have breast cancer in her lifetime. Although this figure is accu- rate, it is somewhat misleading because it includes precursor in situ lesions that have not yet become cancers and assumes that women will live to age 80 years or older and not die from other causes before that age. The prevalence of the disease is increasing because of the wide use of mammographic screening and the aging of the population (the incidence rises with age). Most breast cancers present without symp- toms, and it is the patient herself who most often discovers the tumor; therefore, any delay in diagnosis is both readily apparent and unlikely to be excused. The Doctors Company (TDC), a national physician-owned medical malpractice insurance company, analyzed 100 closed claims involving breast cancer in an attempt to identify repetitive problems (2–4). This is, to our knowledge, the largest single-source breast cancer claims study ever undertaken. Closed claims were reviewed to ensure the full range Chapter 12 / Breast Cancer Litigation 155 of outcome data would be available. Consecutive files were chosen to evaluate all actual case presentations independent of outcome. Overall Outcomes The 100 consecutive files involved 80 individual patients with breast cancer. In these cases, 127 physicians were defendants and 42 (33%) ultimately paid indemnity. Of the 80 women, 36 (45%) were successful against at least one defendant physician. Four claims went to trial and two resulted in a verdict for the plaintiff. Presenting Symptoms Clinical findings on presentation were documented in 71 cases. A palpable lump was found in 28 cases, pain was present in 8 cases, and there was nipple discharge in 1 case. Discovery of the Mass Frequently, the patient discovers her own breast cancer.

The Objective 15 Identify the regions of the large intestine and colon then angles medially from the brim of the pelvis to form an describe its gross and histological structure antibiotics nursing order 500mg sumycin with amex. Objective 16 Describe the functions of the large intestine and explain how defecation is accomplished antimicrobial infections buy sumycin with a visa. Digestive System © The McGraw−Hill Anatomy antibiotic resistance threats in the united states cdc purchase generic sumycin pills, Sixth Edition Body Companies, 2001 Chapter 18 Digestive System 657 Transverse colon Hepatic flexure Splenic flexure Mesocolon Ascending colon Taeniae coli Descending colon Epiploic appendage Ileum Ileocecal valve Orifice of appendix Haustrum Cecum Appendix Sigmoid colon Rectum Anal canal FIGURE 18. A third-degree hemorrhoid remains pro- and the last 2 to 3 cm of the rectum is referred to as the anal lapsed through the anal orifice. The rectum lies anterior to the sacrum, where mon medical treatment for a prolapsed hemorrhoid. The anus is the external a rubber band is tied around the hemorrhoid, constricting its blood supply, so that the tissue dries and falls off. Two sphincter muscles guard the anal ment, infrared photocoagulation, a high-energy light beam coagu- opening: the internal anal sphincter, which is composed of lates the hemorrhoid. The mucous membrane of the anal Although the large intestine consists of the same tunics as canal is arranged in highly vascular, longitudinal folds called the small intestine, there are some structural differences. A series of rhoids, in reference to the condition in which such masses occur, are also called piles. A first-degree hemorrhoid is contained within the bulges in the walls of the large intestine form sacculations, or haustra anal canal. Digestive System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 658 Unit 6 Maintenance of the Body Rectum Levator ani Hemorrhoidal muscle vessels Anal canal External anal Anal columns sphincter Internal anal sphincter Anus Loechel FIGURE 18. Submucosa Mucosa Center of Columnar lymphatic epithelium with nodule goblet cells Intestinal (a) glands Lumen Tunica muscularis Submucosa Serosa FIGURE 18. The arrow indicates the opening of a goblet cell into the intestinal lumen. Tissues and Organs: A Text-Atlas of Scanning Electron Microscopy, © 1979 W. Digestive System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 18 Digestive System 659 TABLE 18. The parasympathetic innervation arises from peristaltic wave, involving the action of the taeniae coli, which the paired pelvic splanchnic and vagus nerves. Mass movements from the large intestine respond to bowel pressure and signal the generally occur only two or three times a day, usually during or need to defecate. This response to eating, called the gastro- branches from the superior mesenteric and inferior mesenteric colic reflex, can best be observed in infants who have a bowel arteries. Venous blood is returned through the superior and infe- movement during or shortly after feeding. It has been estimated that an average volume of 850 ml of water per day is absorbed across the mucosa of the colon. The fecal material that is left then passes to the rectum, leading to Mechanical Activities of the Large Intestine an increase in rectal pressure and the urge to defecate. If the urge to defecate is denied, feces are prevented from entering the anal canal Chyme enters the large intestine through the ileocecal valve. In this case, the feces remain in the 15 ml of pasty material enters the cecum with each rhythmic open- rectum and may even back up into the sigmoid colon. The ingestion of food intensifies peristalsis of the The defecation reflex normally occurs when the rectal ileum and increases the frequency with which the ileocecal valve pressure rises to a particular level that is determined largely by opens; this is called the gastroileal reflex. At this point, the internal anal sphincter relaxes to admit large intestine accumulates in the cecum and ascending colon. Three types of movements occur throughout the large in- During the act of defecation, the longitudinal rectal mus- testine: peristalsis, haustral churning, and mass movement. Peri- cles contract to increase rectal pressure, and the internal and ex- staltic movements of the colon are similar to those of the small ternal anal sphincter muscles relax.

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