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By C. Aidan. George Fox University. 2018.

If modifications cannot and attitudinal factors cheap zyban 150 mg without a prescription anxiety 411, as well as on the be made in these cases buy zyban 150 mg online anxiety meds, individuals must physical aspects of the illness or disabili- change employment. Accurately assessing individuals’ capac- must assume disability status because ity to return to work consists of more than appropriate modifications cannot be made evaluating physical factors. Job fear of reinjury, vocational dissatisfaction, stress or the attitudes of employers or or legal issues can also hamper return to coworkers can significantly interfere with work. Their ability to relate to and inter- individuals’ ability to return to the work act with others within the work environ- force. Interests, from work because of limitations caused aptitudes, and abilities are always pivotal by the condition may also make a return factors in determining vocational success, to work more difficult. Effective rehabil- the time required to carry out treatment itation that enables individuals to func- recommendations related to the condition tion effectively in their job often involves may make completing a full day at work the interdisciplinary efforts of many types virtually impossible. Interventions to improve antipsy- chotic medication adherence: Review of recent lit- Ben-Shlomo, Y. Journal of Clinical Psychopharmacology, What are the determinants of quality of life in 23(4), 389–399. Archives of Phys- rehabilitation counseling: Making the philosoph- ical Medicine and Rehabilitation, 83(2), 229–235. Effective patient education: A guide Journal of Consulting Clinical Psychology, 69, to increased compliance. Archives of Disease in awaiting lung transplant: Cystic fibrosis versus Childhood, 83(2), 104–110. Life satisfaction after trau- tered approach to sexuality in the face of life-lim- matic brain injury. Patient satisfaction with care and of Research and Personality, 34, 357–379. Neuropsychological sequelae in a series of patients with end-stage cystic fibro- Leplege, A. Moving beyond the illness: Factors con- ic illness and disability: A conceptual framework. Coping strate- gies as predictors and mediators of disability-relat- Cusack, L. Perceptions of body image: ed variables and psychosocial adaptation: An Implications for the workplace. Disability pliance in patients with chronic disease: Issues in Rehabilitation, 24(4), 185–195. The psycho- ence to antidepressants: A systematic review of logical effects of a skin disease. International clas- issues of women with physical disabilities: The sification of impairments, disabilities, and handicaps: continuing gender debate. Rehabilitation A manual of classification relating to the consequences Counseling Bulletin, 46(4), 224–233. A social psychol- Assessment of psychological factors associated ogy approach to measuring vocational rehabilita- with adherence to medication regimens among tion intervention effectiveness. American Journal of Promoting the importance of individual percep- Psychiatry, 159(10), 1653–1664. C HAPTER 2 Conditions of the Nervous System: Part I Conditions of the Brain NORMAL STRUCTURE AND FUNCTION as pulling away one’s hand from a OF THE NERVOUS SYSTEM hot surface as well as perceiving music being played in the next room. Monitoring and coordinating inter- tral nervous system and the peripheral nal body states so that internal or- nervous system (Table 2–1). The nervous gans function as a unit, internal body system is a complex network that serves constancy is maintained, and protec- as the communication center for the body. For example: in It controls and coordinates activities and response to lack of oxygen, breathing functions throughout the body by send- becomes more rapid; in response to ing, receiving, and sorting electrical cold, the body shivers; when threat impulses. Disruption of any part of the or danger is encountered, the heart nervous system affects body function in beats more rapidly. Specifically, functions of the nervous sys- tem include the following: Table 2–1 The Nervous System 1.

The vaginal wall is composed of three layers: an inner mu- cosal layer zyban 150 mg without a prescription mood disorder emotion, a middle muscularis layer buy 150 mg zyban fast delivery depression symptoms shortness of breath, and an outer fibrous layer. Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 Chapter 21 Female Reproductive System 737 FIGURE 21. They also provide friction ridges for stimulation of the penis dur- ing coitus. The additives within semen, however, temporarily neutralize the acidity of the vagina to assist the survival of the spermatozoa deposited within the vagina. The mons pubis is the subcutaneous pad of adipose con- The muscularis layer consists of longitudinal and circular nective tissue covering the symphysis pubis. At puberty, the bands of smooth muscle interlaced with distensible connective mons pubis becomes covered with coarse pubic hair in a some- tissue. The distension of this layer is especially important during what triangular pattern, usually with a horizontal upper border. Skeletal muscle strands near the vaginal orifice, in- The elevated and padded mons pubis cushions the symphysis cluding the levator ani muscle, partially constrict this opening. This layer consists of dense regular con- are two thickened longitudinal folds of skin that contain loose nective tissue interlaced with strands of elastic fibers. The labia majora contain numerous sebaceous and sweat course of the arteries. They are homologous to the scrotum of the male and The vagina has sympathetic innervation from the hypogas- function to enclose and protect the other organs of the vulva. An episiotomy may be done during parturition to facilitate delivery and accommodate the head of an emerging fetus when lac- eration seems imminent. Vulva Medial to the labia majora are two smaller longitudinal The external genitalia of the female are referred to collectively as folds called the labia minora (singular, labium minus). The structures of the vulva sur- minora are hairless but do contain sebaceous glands. This increased blood flow causes the ture and origin to the penis in the male; it is, however, much erectile tissues to swell. The unexposed portion of the clitoris is vestibular glands to secrete mucus near the vaginal orifice. The composed of two columns of erectile tissue called the corpora vestibular secretion moistens and lubricates the tissues of the cavernosa that diverge posteriorly to form the crura and attach vaginal vestibule, thus facilitating the penetration of the erect to the sides of the pubic arch. Mucus continues to be secreted during The vaginal vestibule is the longitudinal cleft enclosed by coitus so that the male and female genitalia do not become irri- the labia minora. The openings for the urethra and vagina are lo- tated, as they would if the vagina became dry. If stimulation of the clitoris is of suffi- ately in front of the vaginal orifice. The vaginal orifice is lubri- cient intensity and duration, a woman will usually experience a cated during sexual excitement by secretions from paired major culmination of pleasurable psychological and physiological re- and minor vestibular glands (Bartholin’s glands) located within lease called orgasm. The Associated with orgasm is a rhythmic contraction of the ducts from these glands open into the vaginal vestibule near the muscles of the perineum and the muscular walls of the uterus and lateral margins of the vaginal orifice. These reflexive muscular actions are thought to sue, called vestibular bulbs, are located immediately below the aid the movement of spermatozoa through the female reproduc- skin forming the lateral walls of the vaginal vestibule. The vestibu- tive tract toward the upper end of a uterine tube, where an ovum lar bulbs are separated from each other by the vagina and urethra, might be located. Following orgasm or completion of the sexual act,sym- The vulva is highly vascular and is supplied with arterial pathetic impulses cause a reduction in arterial flow to the blood from internal pudendal branches of the internal iliac arter- erectile tissues,and their size diminishes to that prior to sex- ies and external pudendal branches from the femoral arteries. The venous return is through vessels that correspond Knowledge Check in name and position to the arteries. Describe the structure and position of the uterine tubes During pregnancy, the vulva becomes swollen and bluish— and explain how an ovum is transported through a uterine especially the labia minora—because of increased vascularity tube to the uterus. Describe the histological structure of the uterine wall and comes more apparent as pregnancy progresses.

The squamous part is the flattened plate of bone at the sides of the skull buy 150 mg zyban visa depression symptoms negative thinking. On the inferior surface of the The two parietal bones form the upper sides and roof of the cra- squamous part is the cuplike mandibular fossa generic zyban 150 mg depression test hospital, which nium (figs. The coronal suture separates the forms a joint with the condyle of the mandible. This artic- frontal bone from the parietal bones, and the sagittal suture ulation is the temporomandibular joint. The inner concave surface of each parietal bone, as well as the inner concave surfaces of other cranial bones, is marked by shallow impressions from convolutions of the brain and vessels serving the brain. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 147 Frontal bone Parietal bone Temporal bone Lacrimal bone Nasal bone Zygomatic bone Inferior nasal concha Maxilla Vomer Mandible FIGURE 6. Coronal suture Parietal bone Frontal bone Lambdoid suture Sphenoid bone Squamous suture Ethmoid bone Temporal bone Lacrimal bone Occipital bone Nasal bone Zygomatic bone External acoustic meatus Infraorbital foramen Mastoid process Maxilla Condylar process Coronoid process of mandible of mandible Styloid process Zygomatic process Mental foramen Mandibular notch Mandible Angle of mandible Creek FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 148 Unit 4 Support and Movement Incisors Premolars Canine Incisive foramen Molars Median palatine suture Zygomatic bone Palatine process of maxilla Palatine bone Sphenoid bone Greater palatine foramen Medial and lateral Zygomatic process pterygoid processes of sphenoid bone Vomer Foramen ovale Mandibular fossa Foramen lacerum External acoustic meatus Carotid canal Jugular fossa Styloid process Stylomastoid foramen Mastoid process Foramen magnum Occipital condyle Mastoid foramen Temporal bone Parietal bone Superior nuchal line Condyloid canal Occipital bone External occipital protuberance Creek FIGURE 6. Parietal bone Frontal Temporal bone bone Occipital bone Nasal bone Maxilla Mandible Palatine bone Vomer FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 149 Squamous suture Supraorbital margin Mandibular condyle Mandibular fossa Zygomatic arch External acoustic meatus Coronoid process of mandible Mastoid process of temporal bone Styloid process Ramus of mandible of temporal bone Jugular foramen Mental protuberance Lambdoid suture Angle of mandible Occipitomastoid suture Condyloid canal Digastric fossa Occipital condyle Mandibular foramen Foramen magnum FIGURE 6. Frontal bone Sphenoid bone Temporal bone Parietal bone Occipital bone FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 150 Unit 4 Support and Movement Frontal bone Ethmoid bone Zygomatic bone Middle nasal concha Maxilla Inferior nasal concha Vomer FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 151 Ethmoidal Frontal sinus sinus Sphenoidal sinus Frontal sinus Ethmoidal sinuses Sphenoidal sinus Maxillary sinus Maxillary sinus (a) (b) FIGURE 6. The structures of the middle ear and inner ear are housed in this dense part of Region of the Orbit Contributing Bones the temporal bone. Floor (inferior) Maxilla; zygomatic bone; palatine bone The carotid canal allows blood into the brain via the inter- Lateral wall Zygomatic bone nal carotid artery, and the jugular foramen lets blood drain Posterior wall Greater wing of sphenoid bone from the brain via the internal jugular vein. Three cranial Medial wall Maxilla; lacrimal bone; ethmoid bone nerves also pass through the jugular foramen (see table 6. Superior margin Frontal bone Lateral margin Zygomatic bone The mastoid process of the temporal bone can be easily pal- Medial margin Maxilla pated as a bony knob immediately behind the earlobe. This process contains a number of small air-filled spaces called mastoid cells that can become infected in mastoiditis, as a result, for exam- ple, of a prolonged middle-ear infection. A thin, The occipital bone forms the posterior and most of the base of pointed styloid process (figs. It articulates with the parietal bones at the lambdoid inferiorly from the tympanic part. The mastoid process, a rounded projection bone through which the spinal cord passes to attach to the brain posterior to the external acoustic meatus, accounts for the stem. On each side of the foramen magnum are the occipital mass of the mastoid part. At the anterolateral edge of the toid foramen, located between the mastoid and styloid occipital condyle is the hypoglossal canal (fig. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 152 Unit 4 Support and Movement (a) (b) FIGURE 6. The optic canal is a large opening through the lesser wing tion on the occipital bone that can be felt as a definite bump just into the back of the orbit that provides passage for the under the skin. The superior orbital fissure is a triangular opening be- mastoid part of the temporal bone. Sutural bones are small clus- tween the wings of the sphenoid bone that provides pas- ters of irregularly shaped bones that frequently occur along the sage for the ophthalmic nerve, a branch of the trigeminal lambdoid suture. This bone has a somewhat mothlike shape angle of the sphenoid bone that provides passage for the (fig. It consists of a body and laterally projecting greater middle meningeal vessels. Commonly through which the internal carotid artery and the called “Turk’s saddle,” the sella turcica houses the pituitary meningeal branch of the ascending pharyngeal artery pass. The foramen rotundum is an opening just posterior to the the nasal cavity.

The latest tort crisis is characterized by both the decreasing availabil- ity of insurance coverage generic 150mg zyban otc anxiety 38 weeks pregnant, as insurers exit the market in response to 234 Studdert buy cheap zyban 150 mg online depression risk factors, Mello, and Brennan deteriorating loss ratios, and decreasing affordability of policies offered by the remaining insurers. As we noted in an earlier report (59), the genesis of the current crisis is best characterized as multifactorial. Three factors that have almost certainly played a role are: (a) dramatic in- creases in payouts to plaintiffs since 1999—a 60% increase in the aver- age award (unadjusted for inflation) and a doubling of the percentage of payouts of $1 million or more during the 1997–2001 period, according to the Physician Insurers Association of America (60); (b) moderate increases in the frequency of claims in some states (31); and (c) the wider downturn in the economy, which tends to be reflected in lower stock values and bond interest rates, affecting insurers’ investment re- turns (30,31). Some also argue that imprudent business decisions by insurers during the 1990s have contributed to their present difficulties (e. The causes of increases in claims frequency and severity are unclear, but plausible arguments can be made for at least five factors: (1) greater public awareness of medical error; (2) lower levels of patient confi- dence and trust following the negative experience with managed care; (3) advances in medical innovation, particularly diagnostic technology, and increases in the intensity of medical services (61); (4) rising public expectations about medical care; and (5) a greater reluctance among plaintiffs’ attorneys to accept offers that historically would have closed cases. The last factor may be explained in part by the first two factors if public skepticism about error has infiltrated jury attitudes and deci- sion making. As in past crises, the medical community asserts that it must adopt defensive practices to avoid lawsuits, such as ordering unnecessary tests and procedures and turning away high-risk cases (57). A related claim is that rising insurance costs are endangering patient care by forcing physicians in high-risk specialties to leave practice or move to more hospitable jurisdictions and by forcing hospitals to close high-risk ser- vices such as obstetrics and emergency departments (62). Plaintiff attor- neys dispute the claims of compromised access and deny that defensive medicine imperils patient care; therefore, the malpractice debate at state and national levels proceeds along a well-worn path. However, the familiar rancor should not lull observers into a sense of déjà vu. Two critical policy issues distinguish the current malprac- tice crisis from previous eras. First, the health care industry today has less capacity to absorb sudden increases in insurance premiums. In the 1980s, hospitals and physicians could generally pass a significant Chapter 16 / Health Policy Review 235 portion of such costs to payers (63). The spread of managed care, the advent of strong price controls in Medicare (with very little adjust- ment, especially recently), and the widespread adoption of fee sched- ules by private insurers have lowered net incomes (64), rendering physicians less able to cope with hikes in practice costs than in earlier tort crises. Second, the present crisis occurs in the shadow of the new patient safety movement (65). The Institute of Medicine’s 2000 Report on medical error (66) galvanized public attention; almost overnight, it catapulted medical injury from a relatively obscure topic in health ser- vices research to the forefront of the nation’s health policy agenda. Although the report skirted the topic of liability, the interconnectedness of patient safety and malpractice is increasingly apparent. THE “TWO CULTURES” PROBLEM: MALPRACTICE LAW AND PATIENT SAFETY The malpractice system lies in deep tension with the goals and initia- tives of the patient safety movement. At root, there is a problem of two cultures (67): trial attorneys believe that the threat of litigation makes doctors practice more safely, but tort law’s punitive, individualistic, adversarial approach is antithetical to the nonpunitive, systems-oriented, cooperative strategies promoted by patient safety leaders. To learn from errors, we must first identify them; to identify them, we must foster an atmosphere conducive to openness about mistakes (68). Hospitals and physicians are urged to be honest with patients about injury and medical error, to report such events to one another and to regulators, and to address methods of prevention openly (69). To nurture openness, experts stress that most errors arise from proficient clinicians working in faulty systems, not from incompetence or carelessness (66). In sharp contrast, tort law targets individuals, assigning blame and compensation based on proof of negligence. Before, during, and after litigation, information about injuries and their surrounding circum- stances is kept hidden. Risk-management activities typically are divorced from quality improvement (70). The clash between tort and patient safety cultures acts as a drag on efforts to improve quality. Concerns about malpractice exposure dimin- ish the health care industry’s appetite for patient safety activities (71– 73). The reluctance of physicians to buy into such activities stems from the perception that they are being asked to be open about errors with 236 Studdert, Mello, and Brennan little or no assurance of legal protection at a time when litigation is on the rise, malpractice insurance is increasingly expensive and difficult to find, and claims history bears significantly on insurance prospects.