Actos

By Y. Rozhov. Robert Morris College, Illinois.

These considerations impli- cate the HPA axis in the neuroendocrinologic and autonomic manifestations of emotion associated with tissue trauma buy actos 45 mg fast delivery diabetes test nhs. In addition to controlling neuroendocrine and autonomic nervous sys- tem reactivity discount actos 30 mg with mastercard diabetes type 1 blood pressure, the HPA axis coordinates emotional arousal with behavior (Panksepp, 1986). As noted earlier, stimulation of the hypothalamus can elicit well-organized action patterns, including defensive threat behaviors and autonomic arousal (Jänig, 1985). The existence of demonstrable behav- ioral subroutines in animals suggests that the hypothalamus plays a key role in matching behavioral reactions and bodily adjustments to challeng- ing circumstances or biologically relevant stimuli. Moreover, stress hor- mones at high levels, especially glucocorticoids, may affect central emo- tional arousal, lowering startle thresholds and influencing cognition (Sapolsky, 1992). Saphier (1987) observed that cortisol altered the firing rate of neurons in limbic forebrain. Clearly, stress regulation is a complex, feedback-dependent, and coordinated process. The hypothalamus appears to take executive responsibility for coordinating behavioral readiness with physiological capability, awareness, and cognitive function. Chapman and Gavrin (1999) suggested that prolonged nociception may cause a sustained, maladaptive stress response in patients. Signs of this in- clude fatigue, dysphoria, myalgia, nonrestorative sleep, somatic hyper- vigilance, reduced appetite and libido, impaired physical functioning, and impaired concentration. In this way, the emotional dimension of persisting pain may, through its physiological manifestation, contribute heavily to the disability associated with chronic or unrelieved cancer pain. Central Serotonergic Pathways The serotonergic system is the most extensive monoaminergic system in the brain. It originates in the raphé nuclei of the medulla, the pons, and the mesencephalon (Grove, Coplan, & Hollander, 1997; Watson, Khachaturian, Lewis, & Akil, 1986). Descending projections from the raphé nuclei modu- late nociceptive traffic at laminae I and II in the spinal cord and also motor neurons. The raphé nuclei of the midbrain and upper pons project via the medial forebrain bundle to multiple limbic sites such as hypothalamus, sep- tum and hippocampus, cingulate cortex, and cerebral cortex, including frontal cortex. The potential role of serotonergic mechanisms in affective disorders, particularly depression and panic disorder, continues to receive a great 76 CHAPMAN deal of attention (Grove et al. These are important for pain perception because descending endogenous modulatory pathways from the nucleus raphé magnus, the solitary nucleus, and other mesen- cephalic structures can attenuate or gate nociceptive signaling at the level of the dorsal horn, and these pathways are largely serotonergic. Longstand- ing, but thinly supported, speculation holds that depletion of serotonin may result in diminished endogenous modulation of nociception and hypersen- sitivity to noxious events. Currently, the major antidepressant medications are selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors, often called SSRIs (Asberg & Martensson, 1993). Increased receptor selectivity in the newer drugs helps to maximize benefit and minimize side effects of these medications. It is now clear that the older assumptions of simple bioamine deficiency are insufficient to account for the role of serotonin in affective disorders. Al- though a definitive understanding is still at issue, it has become clear that the serotonergic system influences the actions of the HPA axis, particularly by augmenting cortisol-induced feedback inhibition (Bagdy, Calogero, Mur- phy, & Szemeredi, 1989; Dinan, 1996; Korte, Van, Bouws, Koolhaas, & Bohus, 1991). Moreover, it interacts with noradrenergic pathways in complex ways, including attenuation of firing in LC neurons (Aston-Jones et al. The interdependence of the monoamine systems and the HPA axis indicates that we cannot hope to account for complex patterns of brain or behavioral responses by considering these elements individually. They appear to be components of a larger system that we have yet to conceptualize. TWO STAGES IN THE EMOTIONAL ASPECT OF PAIN The physiology of emotion suggests that the affective dimension of pain in- volves a two-stage mechanism. The primary mechanism generates an im- mediate experience akin to hypervigilance or fear; put simply, it is threat. In nature, this rapid response to injury serves to disrupt ongoing attentional and behavioral patterns. At the same time, efferent messages from the hy- pothalamus, amygdala, and other limbic structures excite the autonomic nervous system, which in turn alters bodily states. Cardiac function, muscle tension, altered visceral function, respiration rate, and trembling all occur, and awareness of these reactions creates a strong negative subjective expe- rience. This body state awareness is the second mechanism of the affective dimension of pain.

But depending upon the loca- tion of emergency rooms cheap actos 45mg with mastercard blood sugar pendulum lyrics, physicians also see major trauma like gunshot wounds and the results of bad car accidents quality actos 30 mg diabetes mellitus with neuropathy. In 2002 there were 3,846 residents in 127 accredited training programs in emergency medicine. Neurology Neurologists diagnose and treat all types of diseases of the brain, spinal cord, peripheral nerves and muscles, and the nervous system. They work with people who have epilepsy, cerebral palsy, retarda- tion, stroke, Parkinson’s disease, muscular dystrophy, multiple sclerosis, Alzheimer’s disease, and serious headaches. Neurologists use medication and other non- invasive procedures to treat their patients; neurosurgeons use surgery to treat some of the same illnesses. Neurologists often have long-term relationships with their patients, as most of the diseases Other Specialties 77 they treat are chronic ones. Great strides are being made in the treatment of some diseases such as Parkinson’s and stroke, so this work can be very rewarding. In the subspecialty of pediatric neurology, physicians work with children. Other neurologists may have mostly elderly patients with Alzheimer’s and Parkinson’s. While this is considerably less than what neurosurgeons earn, liability insurance premiums are much lower for neurologists since their work is less invasive. In 2002 there were 1,291 residents in 119 accredited training programs for neurologists. Pathology The medical specialty of pathology deals with the causes, mani- festations, and diagnoses of diseases. One is in a hospital, investigating the effects of disease on the human body. These pathologists perform autopsies and examine tissues removed from patients in biopsies or surgical procedures. Now more than ever, pathologists can make significant contributions to medicine. Pathology is a laboratory-oriented discipline, and there is little patient contact. Pathology is diverse, since it spans all medical special- 78 Opportunities in Physician Careers ties. There is a need for manage- ment skills in pathology because some pathologists run large labs. Average salaries in this field range from $167,000 to $294,500 and liability insurance premiums are low. In 2002 there were 2,289 residents in 153 accredited programs in pathology. The American Board of Pathology offers certification in either anatomic or clinical pathology or both. Subspecialties of pathology include the following fields: Blood banking. A physician specializing in blood banking is responsible for the maintenance of an adequate blood supply, blood donor and patient-recipient safety, and appropriate blood utiliza- tion. The blood-banking specialist directs the preparation and safe use of specially prepared blood components, including red blood cells, white blood cells, platelets, and plasma constituents. This specialty deals with the biochem- istry of the body as it applies to the cause and progress of disease. This specialty includes the application of biochemical data to the detection, confirmation, or monitoring of a disease. The chemical pathologist often serves as a consultant in the diagnosis and treat- ment of disease. The dermopathologist often serves as a clini- cal consultant and must have in-depth knowledge of dermatology, microbiology, parasitology, new technology, and laboratory management. This specialty investigates cases of sudden, unexpected, suspicious, or violent death as well as other specific classes of death defined by law. The forensic pathologist Other Specialties 79 sometimes serves the public by becoming a coroner or medical examiner. This specialty deals with diseases that affect the bone marrow, blood cells, blood clotting mecha- nisms, and lymph nodes.