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Essential Study Partner for Anatomy and Physiology is a R&D Center is the opportunity to see what new text- complete generic 2.5mg nitroglycerin mastercard symptoms ms women, interactive student study tool packed with hun- books purchase nitroglycerin 2.5mg fast delivery medicine used to treat bv, animations, and simulations McGraw-Hill is work- dreds of animations and more than 800 learning activities. You can teractive diagrams and quizzes make learning core concepts also learn about other opportunities to review as well as stimulating and fun. This manual also includes a list- Human Anatomy, Sixth Edition ing of transparencies and multimedia resources that correlate with Kent Van De Graaff has authored a comprehensive laboratory each text chapter and provides answers to the Knowledge Check, manual specifically designed to accompany Human Anatomy, sixth Essay, and Critical Thinking questions that appear in the text. This laboratory manual emphasizes learning anatomical structures through visual observation, palpation, and knowledge of Test Item File the functional relationship of one body system to another. It fo- The Test Item File contains fill-in-the-blank, multiple choice, cuses primarily on the human organism, but also contains cat dis- and true/false questions specifically designed to complement sections and selected organ dissections. Instructors using WebCT, Blackboard, Human Anatomy text, the companion lab manual utilizes a well- or PageOut can access the Test Item File online. Coloring and labeling activities placed throughout the chapters reinforce recognition of anatomical structures, and labo- MicroTest is a computerized test generator that is free upon re- ratory reports at the end of each chapter encourage students to quest to qualified adopters. The test generator contains the com- synthesize concepts covered in both lab and lecture. MicroTest requires no programming experience and is designed to work on both Win- dows and Macintosh platforms. Instructor’s Manual ® for the Laboratory Manual This online manual is housed within the instructor Online Learning Center. It provides answers to the lab report questions, PageOut is McGraw-Hill’s exclusive tool for creating your own as well as overviews on how to present each laboratory exercise, website for your anatomy course. It requires no knowledge of materials lists, and additional topics for discussion. Transparencies This set of transparency acetates includes 200 full-color illustra- In addition to the materials specifically designed to accom- tions from the text that have been chosen for their value in rein- pany Human Anatomy, McGraw-Hill offers the following supple- forcing lecture presentations. Visual Resource Library Regional Human Anatomy: A Laboratory Workbook For Accessed through the instructor site at the Online Learning Use With Models and Prosections by Frederick E. Grine, Center and also available on CD-ROM, the Visual Resource Li- State University of New York—Stony Brook. Organized with a brary contains labeled and unlabeled versions of the key illustra- regional approach to human anatomy, this workbook utilizes tions and photos from the book, as well as all tables. You can coloring and labeling activities to simplify the learning of quickly preview images and incorporate them into PowerPoint or anatomy. Brief text descriptions of key anatomical structures other presentation programs to create your own multimedia pre- are grouped with detailed illustrations that can be colored and sentations. You can also remove and replace labels to suit your labeled to reinforce the material presented. Instructor’s Manual Anatomy and Physiology Laboratory Manual-Fetal Pig by Accessed via the Online Learning Center, the instructor’s manual Terry R. Prince provides in- color photos of the dissected fetal pig with corresponding labeled structional support in the use of the textbook. This online multimedia program contains vivid, high- emphasizes learning through the process of color association. The program helps The Coloring Guide provides a thorough review of anatomical students easily identify and review the corresponding struc- and physiological concepts. A set of two interactive CD- ROMs that cover each body system and demonstrate clinical ACKNOWLEDGMENTS concepts, histology, and physiology with animated three- Preparing a new edition of a text is a formidable task that in- dimensional and other images. And in the case of this text, even family members were Paolini, San Diego State University. My sincere gratitude is extended to faculty and stu- full-color, high-resolution light micrograph images and 35 scan- dents who have used previous editions of this text and have ning electron micrograph images of selected tissue sections typi- taken the time to suggest ways to improve it. Each image has labels thinking of others who will be using the text in the future, and at that can be clicked on or off, has full explanatory legends, offers the same time, ensuring a future for the text. Ronald Galli, colleagues at Weber State University, who were especially supportive of my efforts in preparing this edition. Feedback from conscientious students is espe- logical processes that are narrated and animated in vibrant cially useful and appreciated. Several physicians contributed clinical input to this edi- Life Science Animations (LSA) videotape series contains 53 tion. Prince animations on five VHS videocassettes: Chemistry, the Cell, and Karianne N.

Sperm can be cryopreserved for years buy nitroglycerin 2.5mg treatment 2 prostate cancer, if agents such as glycerol are Sperm deposited in the female reproductive tract swim up used to prevent ice crystal formation during freezing cheap 6.5 mg nitroglycerin free shipping symptoms after embryo transfer. During maturation in the epididymis, the sperm ac- enters the uterus, and implants into the endometrium. To bind to and penetrate the zona pellucida, the sperm must undergo ca- The Egg and Sperm Enter the Oviduct pacitation, an irreversible process that involves an increase A meiotically active egg is released from the ovary in a in sperm motility, the removal of surface proteins, a loss of cyclical manner in response to the LH surge. For a suc- lipids, and merging of the acrosomal and plasma mem- cessful fertilization, fresh sperm must be present at the branes of the sperm head. To increase the proba- branes and change in acrosomal structure is called the acro- bility that the sperm and egg will meet at an optimal time, some reaction. The reaction occurs when the sperm cell the female reproductive tract facilitates sperm transport binds to the zona pellucida of the egg. It involves a redis- during the follicular phase of the menstrual cycle, prior to tribution of membrane constituents, increased membrane ovulation (see Chapter 38). However, during the luteal fluidity, and a rise in calcium permeability. Capacitation phase, after ovulation, sperm survival and access to the takes place along the female genital tract and lasts 1 hour to oviduct are decreased. Sperm can be capacitated in a chemically de- egg and sperm begin to exhibit signs of degeneration fined medium, a fact that has enabled in vitro fertilization within 24 hours after release. In vitro fertilization may be The volume of semen (ejaculatory fluids and sperm) in used in female infertility as well. The liquid component of the semen, called semi- The ovum is grasped by the fimbria, ciliated finger-like nal plasma, coagulates after ejaculation but liquefies projects of the oviducts. The grasping of the egg is facili- within 20 to 30 minutes from the action of proteolytic en- tated by ciliary movement and muscle contractions, under zymes secreted by the prostate gland. The coagulum the influence of estrogen secreted during the periovulatory forms a temporary reservoir of sperm, minimizing the ex- period. Because the oviduct opens into the peritoneal cav- pulsion of semen from the vagina. During intercourse, ity, eggs that are not picked up by the oviducts can enter some sperm cells are immediately propelled into the cer- the abdominal cavity. Those remaining in the vagina do not survive an abdominal ovum is fertilized. The cervical canal constitutes a more on the presence of granulosa cells surrounding the egg. Oocyte maturity is judged from the Candidates for in vitro fertilization (IVF) are women with dis- morphology of the cumulus (granulosa) cells and the pres- ease of the oviducts, unexplained infertility, or endometrio- ence of the germinal vesicle and first polar body. The ma- sis (occurrence of endometrial tissue outside the endome- ture oocytes are then placed in culture media. About Follicular development is induced with one or a combina- 100,000 spermatozoa are added for each oocyte. After 24 tion of GnRH analogs, clomiphene, recombinant FSH, and hours, the eggs are examined for the presence of two menopausal gonadotropins (a combination of LH and FSH). Embryos are grown to the Follicular growth is monitored by measuring serum estra- four- to eight-cell stage, about 60 to 70 hours after their re- diol concentration and by ultrasound imaging of the devel- trieval from the follicles. When the leading follicle is 16 to 17 mm in di- often deposited in the uterine lumen in order to increase ameter and/or the estradiol level is greater than 300 pg/mL, the chance for a successful pregnancy. To ensure a recep- hCG is injected to mimic an LH surge and induce final follic- tive endometrium, daily progesterone administrations be- ular maturation, including maturation of the oocyte. A successful pregnancy rate of proximately, 34 to 36 hours later, oocytes are retrieved from 15 to 25% has been reported by many groups, which com- the larger follicles by aspiration using laparoscopy or a pares favorably with that of natural human pregnancy. The fertilizable life of the human ovum is about 24 head becomes anchored to the membrane surface of the hours, and fertilization occurs usually by 2 days after ovu- egg, and microvilli protruding from the oolemma (plasma lation. The fertilized ovum remains in the oviduct for 2 to membrane of the egg) extend and clasp the sperm. The 3 days, develops into a solid ball of cells called a morula, oolemma engulfs the sperm, and eventually, the whole and by day 3 or 4 enters the uterus.

The extracellular plaque (10±50 mm diameter) consists of a central core of amyloid surrounded by glial processes and a number of neurites in a ring formation discount 6.5 mg nitroglycerin free shipping premonitory symptoms. The intracellular cytoplasmic tangle is composed of helical filaments in a paired format generic nitroglycerin 6.5mg otc treatment trichomoniasis. SENILE PLAQUES Appropriate silver staining and immunohistochemical localisation of b-amyloid show these to be extracellular lesions which in their typical neurite form are roughly spherical in shape (10±50 mm diameter) with a central core of amyloid surrounded by glial processes and a rim of neurites. The amyloid can sometimes exist alone (compact plaque), when the neurites no longer react to silver staining or in a diffuse state (primary plaque) before neurites have formed. It is unclear whether the development of neuritic from diffuse plaques causes neurofibrillary pathology and neuronal dysfunction or results from those processes. Plaques are, however, indices of neuronal death, generally of large pyramidal cells. They are found mostly in the cerebral cortex, especially the hippocampus and frontal temporal area, and while most common in AzD brain they also occur in Down Syndrome and in pugilistic (brain damage) dementia and can even be found sparsely in the normal ageing brain. The tangles are composed of tau1 protein, which normally promotes polymerisation of the microtubules that maintain cell structure, but for some reason has become hyperphosphorylated and deposited as helical filaments in a characteristic entwined paired format which disrupts neuron function. Hirano bodies, which are intraneuronal eosinophile inclusions, are also seen in AzD. FORMATION OF -AMYLOID AND ITS EFFECTS Most cases of AzD show cerebrovascular amyloid deposits and the amyloid protein of senile plaques is the same as that found in blood vessels. It is referred to as b-amyloid protein and is part of a 695, 751 or 770 amino-acid amyloid precursor protein APP, which is a transmembrane protein and although its precise function is not clear, it is widely distributed and APP knock-out mice show reduced motor function. Normally so-called short 40 amino-acid-soluble derivatives of APP are produced by proteolytic cleavage of APP within the b (A4) amino-acid sequence but APP can also be cleaved Figure 18. Amyloid b4 protein (b/A4) is part of a 695, 751 or 770 amino-acid amyloid precursor protein APP. This is a transmembrane protein which is normally cleared within the b/A4 amino acid sequence to give short 40 amino- acid soluble derivatives. One possibility is that in AzD this process is excessive and the insoluble amyloid b protein (Ab) aggregates to form the amyloid fibrils and core of the senile plaques. The protein may also stimulate the phosphorylation of tau and the production of neurofibrillary tangles. Suggestions include the production of free radicals, sensitisation to glutamate and increased Ca2‡ influx. The last has been shown in in vitro studies but these tend to use concentrations in excess of those found in the brain and often with shorter and soluble synthetic forms of Ab. Certainly the direct injection of b-amyloid or neurotic plaques into rat brain does not appear to kill neurons but continuous infusion of Ab (1±40) into the cerebral ventricles of rats does lead to impairment of learning and memory (Nitta et al. In fact no consistent correlation has been found between the appearance, distribution and number of amyloid plaques and either neuronal loss or the degree of dementia, although the latter correlates with the number of neurofibrillary tangles, which tend to precede plaques in appearance by some years. Also cortical amyloid deposits can be found in non-demented elderly patients. Thus the basic question appears to be: does the disease process, whatever that is, cause the development of AzD as well as the pro- duction of b-amyloid or is there production of b-amyloid, which then causes AzD? AETIOLOGY If b-amyloid deposition is responsible for AzD, it is important to know what causes its production. Since AzD is most common in the elderly and as b-amyloid is found in the normal aged brain, it is likely that AzD depends on some predisposing factor that increases amyloid production and which may strike early in life but is more likely to become apparent during ageing. Mutations of the APP gene on chromosome 21, the apolipoprotein E (ApoE) gene on chromosome 19, the presenilin 1 (Ps1) gene on chromosome 14 and presenilin 2 (Ps2) gene on chromosome 1 have all been implicated in AzD. GENETIC MUTATION A number of family mutations of the APP gene on chromosome 21 have been found, generally in early-onset AzD patients in different countries, all of which lead to increased b-amyloid production. Also chromosome 21 is abnormally trisomic in Down Syndrome and most Down sufferers develop AzD if they reach 40 years. In transgenic mice, expressing familial AzD mutations of APP, the overexpression of APP is accompanied by increased amyloid deposition but whether this is due to the mutation or overexpression of APP is uncertain. Also not all the animals show memory loss and that tends to precede the amyloid disposition. Three distinct forms of ApoE, E2, E3 and E4 are encoded on chromosome 19 but it is the ApoE, E4 allele that occurs at a much higher frequency in late-onset AzD patients (50%) compared with controls (16%) and binds to and possibly increases the formation of b-amyloid. The precise physiological role of these 463 and 448 amino-acid transmembrane proteins is unclear but plasma and brain tissue from patients with PS mutations contain above-normal levels of the b-amyloid protein as do transgenic mice expressing PS mutations and cells transfected with mutant PS.

If a test has not yet been introduced buy discount nitroglycerin 6.5 mg on line medicine world, the prospects for a good evaluation are better than if it is already in general use buy nitroglycerin 2.5mg on line medicine clip art. It is then, for example, still possible to define an appropriate control group to whom the test is not applied, so that its influence on the prognosis can be investigated. In addition, at such an early stage the conclusion of the analysis can still be used in the decision regarding introduction. Furthermore, it is possible to plan a procedure for monitoring and evaluation after introduction. All of this emphasises the importance of developing an evaluation programme before a test is introduced. A common misunderstanding is that only expensive, advanced diagnostic technology cause unacceptable increases in healthcare costs; in fact, cheap but very frequently used (routine) tests account for a major part of direct costs. Moreover, these tests greatly influence other costs, as they often preselect patients for more expensive procedures. Yet the performance of such low-threshold diagnostics has often not been adequately evaluated. Examples include many applications of haematological, clinicochemical, and urine tests. Complex relations Most diagnostics have more than one indication or are relevant for more than one nosological outcome. In addition, tests are often not applied in isolation but in combinations, for instance in the context of protocols. Ideally, diagnostic research should reflect the healthcare context,17 but it is generally impossible to investigate all aspects in one study. Therefore, 6 EVALUATION OF DIAGNOSTIC PROCEDURES choices must be made as to which issues are the most important. Multivariable statistical techniques are available to allow for the (added) value of various diagnostic data, both separately and in combination, and also in the form of diagnostic prediction rules. Diagnostic analysis aims to specify test performance in clinical subgroups or to identify the set of variables that yield the best individual diagnostic prediction, which is a completely different perspective. Much work remains to be done to improve the methodology of diagnostic data analysis. The “gold” standard problem To evaluate the discriminatory power of a test, its results must be compared with an independently established standard diagnosis. However, a “gold” standard, providing full certainty on the health status, rarely exists. Even x rays, CT scans and pathological preparations may produce false positive and false negative results. The aim must then be to define an adequate reference standard that approximates the “gold” standard as closely as possible. Sometimes one is faced with the question whether any appropriate reference standard procedure exists at all. For example, in determining the discrimination of liver tests for diagnosing liver pathology, neither imaging techniques nor biopsies can detect all abnormalities. In addition, as a liver biopsy is an invasive procedure it is unsuitable for use as a standard in an evaluation study. A useful independent standard diagnosis may not even exist conceptually, for example when determining the predictive value of symptoms that are themselves part of the disease definition, as in migraine, or when the symptoms and functionality are more important for management decisions than the anatomical status, as in prostatism. Also, in studying the diagnostic value of clinical examination to detect severe pathology in non-acute abdominal complaints, a comprehensive invasive standard diagnostic screening, if at all possible or ethically allowed, would yield many irrelevant findings and not all relevant pathology would be immediately found. An option, then, is diagnostic assessment after a follow up period by an independent panel of experts, representing a “delayed type” cross-sectional study. For example, as long as classic angiography is considered the standard when validating new vascular imaging techniques, the latter will always seem less valid because perfect agreement is never attainable. However, as soon as the new method comes to be regarded as sufficiently valid to be accepted as the 7 THE EVIDENCE BASE OF CLINICAL DIAGNOSIS standard, the difference will from then on be explained in favour of this new method. In addition, when comparing advanced ultrasound measurements in blood vessels with angiography, one must accept that the two methods actually measure different concepts: the first measures blood flow, relevant to explain the symptoms clinically, whereas the second reflects the anatomical situation, which is important for the surgeon.