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CAUSE WHAT IS IT YPICAL SYMPTOMS Anxiety or Chronic feelings of a low Numbness in both hands buy discount zoloft 25 mg online depression symptoms thoughts of death, depression (See mood or anxiety faintness order zoloft 25mg overnight delivery mood disorder questionnaire for children, pins and needles chapter on around lips, trouble breath- Depression, ing, occurs in people con- Suicidal cerned about their heart Thoughts, or health, can be a “panic Anxiety. If you are experiencing chest pain other than heartburn, refer to the chapter on Chest Pain for more information. If your pain is centered more in your abdomen, see the chapter on Abdominal Pain for more information. Your Doctor Visit What your doctor will ask you about: anxiety, depression, weight loss, weakness, abdominal pain, nausea, vomiting blood, tarry stools, results of any recent tests of the insides of your stomach, any suc- cesses with previous treatments or diets. Your doctor will want to know if you or anyone in your family has had any of these conditions: abdominal surgery, liver disease, arthritis, chronic lung disease, alcoholism, ulcer disease. Your doctor will want to know when and how you first noticed your heartburn, and how many times it has recurred. Some important factors to consider with ulcers caused by heartburn: • Ulcers are caused by the movement of stomach acid up into and through the esophagus, which connects the throat to the stom- ach. Over time, this movement of acid can lead to ulcer, or irri- tation of the stomach or intestinal lining. To keep this from happening, your doc- tor may ask you to: • Limit your intake of caffeine, cigarettes, alcohol, and cer- tain medications. Heatstroke What it feels like: collapse during extreme heat, sometimes leading to delirium or coma. Someone with a mild form of heatstroke, known as heat prostration, will appear faint, have cold and clammy skin, and have a slight fever. If a person with heatstroke falls into a coma, becomes delirious, or has hot and dry skin and a temperature of more than 103 degrees F, seek medical help immediately. Your Doctor Visit What your doctor will ask you about: headache, changes in think- ing, loss of consciousness, nausea, vomiting, diarrhea, decreased urine output, sweating, cold skin, muscle cramps, bleeding. Your doctor will want to know if you or anyone in your family has had any of these conditions: alcoholism, heart disease, high blood pressure, diabetes. Your doctor will want to know how long you were in a hot environ- ment, the temperature of the environment, your temperature at the time of collapse, and what you were doing when you collapsed. Your doctor will do a physical examination including the fol- lowing: temperature, breathing rate, blood pressure, pulse, thorough exam of your reflexes and movement, checking skin for sweating, color, and warmth. RISK FACTOR WHAT IS IT YPICAL SYMPTOMS Dehydration Not drinking enough Dry mouth, producing little water or no urine, sunken eyes, more common in people taking blood pressure med- ication or drinking alcohol Inadequate An inability to cool Lack of sweating when hot, sweating down by sweating more common in the eld- erly, diabetics, those with high cholesterol, people wearing too much clothing or engaging in excessive exercise, or people taking anticholinergic medica- tions such as Benadryl and Cogentin, or phenoth- iazines such as the antipsy- chotic Haldol Heavy Drinking (Alcohol) What it is: your drinking patterns become a problem when you expe- rience withdrawal if you stop drinking alcohol (see below), you devel- op an illness related to drinking, or it interferes with your social or work life; drinking to excess – a six-pack of beer in one sitting, or a fifth of a gallon of whiskey, for example, without becoming drunk – is also probably a sign of problem drinking. For example, if you answer “yes” to any of the following ques- tions, you may have a drinking problem: 1. Have you ever had a drink when you wake up, to “steady your nerves” or cure a hangover? Your doctor will also want to know if you or anyone in your fam- ily has had any of these conditions: seizures, delirium after cutting 119 Copyright © 2004 by The McGraw-Hill Companies, Inc. Your doctor will do a physical examination including the fol- lowing: temperature, pulse, blood pressure, thorough skin examina- tion, tests of memory, pushing on your abdomen, checking your limbs for tremors or shakiness, tests of brain function involving bal- ance, eye movements, and reflexes. PROBLEM WHAT IS IT YPICAL SYMPTOMS Tremulousness Trembling or shaking Irritability, flushed skin, stomach upset, sleepiness, occurs after several days of drinking Delirium Delirium that occurs Fever, confusion, tremor, tremens when you stop drinking hallucinations, sweating, dilated pupils Seizures Convulsions Occur within 2 days of when you stop drinking Cerebellar A type of brain disorder Unsteadiness, abnormal degeneration eyeball movements, unco- ordinated gait Wernicke- A brain disorder caused Confusion, memory loss, Korsakoff by a lack of thiamine disorientation, abnormal psychosis (vitamin B1) eyeball movements Neuropathy Nerve damage in the Unsteadiness, numbness or extremities burning in feet or hands Hiccough What it feels like: an involuntary and rapid intake of breath accom- panied by tightness in the abdomen, often persistent. Most cases of hiccoughs occur in people who are in otherwise perfect health, often the result of eating too quickly. Your Doctor Visit What your doctor will ask you about: abdominal pain, weakness, chest pain, new cough or change in cough pattern, trouble swallow- ing, anxiety. Your doctor will want to know if you or anyone in your family has had any of these conditions: alcoholism, kidney disease, liver disease, nervous system disease. CAUSE WHAT IS IT YPICAL SYMPTOMS Rapid eating Eating too quickly Otherwise healthy Gastroenteritis Infection of the stomach Nausea, vomiting, diar- rhea, cramping, muscle aches, slight fever Gastric An expansion of the “Gas,” discomfort distention (see stomach, either by food chapter on or gas Bloating) Lung tumor Unchecked, abnormal Change in cough patterns, growth of cells in the coughing up blood, chest lungs ache, more common in cigarette smokers Advanced renal Inability of the kidneys Pallor, gradual lapse into failure to function properly coma, history of kidney disease Encephalitis Inflammation or infection Fever, nausea, vomiting, of the brain stiff neck, headache, grad- ual lapse into coma Hoarseness What it feels like: a dry, scratchy voice. The most common cause of hoarseness that has lasted less than 2 weeks is inflammation in the voice box, often accompanied by a cold and sore throat. Your Doctor Visit What your doctor will ask you about: cough, fever, sore throat, trouble breathing, wheezing, weight loss, coughing up blood, neck or chest pain, trouble swallowing, thickening of hair, cold intolerance. Your doctor will want to know if you or anyone in your family has had any of these conditions: any chronic disease, alcoholism. Your doctor will want to know if you smoke cigarettes, drink alcohol, or sing professionally.

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The other principal medical image registration category is based on corresponding features that can be extracted manually or automatically 25 mg zoloft overnight delivery depression symptoms tiredness. The feature-based medical image registration methods can be classified into point-based approaches buy zoloft 25mg with mastercard mood disorder 311, for example, Besl and MaKey (1992); Bookstein (1992); and Fitzpatrick, West, and Maurer (1998); curve-based algorithms, for example, Maintz, van den Elsen, and Viergever (1996) and Subsol (1999); and surface-based methods, for example, Audette, Ferrie and Peters (2000) and Thompson and Toga (1996). One main advantage of feature-based registration is that the transformation can be stated in analytic form, which leads to efficient computational schemes. However, in the feature-based registration methodologies, a preprocessing step of detecting the features is needed and the registration results are highly dependent on the result of this preprocessing. In medical image registration, a transformation which maps datasets obtained from different times, different viewpoints, and different sensors, must be determined. Depend- ing on the characteristics of the differences between the medical images to be registered, generally, the registration transformations can be divided into rigid and non-rigid transformations. The rigid transformations can be used to cope with rotation and translation differences between the images. But usually, patient postures, tissue struc- tures, and the shapes of the organs cannot always remain the same when they are imaged with different imaging devices or at different times, therefore, elastic or non-rigid registrations are required to cope with these differences between the images (Rohr, 2000). As a challenging and active research topic, elastic medical image registration has attracted extensive attentions of researchers and a number of novel methods have been proposed; for example, a block matching strategy was used by Lin et al. Elastic biomedi- cal image registration is still an ongoing and challenging research topic and a lot of efforts are needed in this area. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Biomedical image registration is the primary tool for comparing two or more medical images to discover the differences in the images or to combine information from multimodality medical images to reveal knowledge not accessible from individual images. Its main task is to determine a mapping to relate the pixels of one image to the corresponding pixels of a second image with respect to both space and intensity. Figure 3 illustrates the basic registration steps and the corresponding functions of each step. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Biomedical Image Registration 165 Biomedical Registration Transformations Biomedical image distortions must be taken into consideration when two sets of medical images are to be registered. There are many factors that can result in medical image distortions, for example, different underlying physics of imaging sensors, inter-subject differences, voluntary and involuntary movements of the subject during imaging. These distortions impose many challenges for biomedical image registration because image characteristics and distortions determine the registration transformations. For more details on medical imaging deformation characteristics and registration transformations, please refer to Bankman (2000); Fitzpatrick, Hill, and Maurer (2000); Turner and Ordidge (2000). According to its transformation type, biomedical image registration can be divided into rigid registration and non-rigid registration. The rigid registration is used to correct the simplest distortions caused by rotation and translation. Because of the rigid structure of the skull, the distortions of the brain images are often assumed as rigid distortions. When the brain image registration is carried out, the rigid transformation, which preserves the lengths and angle measures, is often used to correct these translation and rotation displacements. Affine transformation, which maps parallel lines into parallel lines, is used for the correction of translation, rotation, scaling, and skewing of the coordinate space. For example, affine transformation is useful for the correction of skewing distortion in CT caused by tilted gantry. Non-rigid medical image deformations can be caused by the dramatic changes of the subject positions, tissue structures, and the shapes of the organs when the subject is imaged with different imaging devices or at different times. Usually, different imaging devices require the subject to pose differently to get optimal imaging results, therefore, rigid and affine transformations are not sufficient for correcting these non-rigid defor- mations. The involuntary motions of the lung and the heart lead to elastic deformations which cannot be registered using rigid and affine transformations as well. Even brain structure cannot always be considered as the same over time because of the differences between pre-operation and post-operation.

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Skeletal muscle These studies reveal that each skeletal muscle fiber fiber (cell) Motor axon contains many threads buy generic zoloft 50 mg on-line depression definition emedicine, or filaments buy cheap zoloft 50 mg online depression definition social studies, made of two kinds of proteins, called actin (AK-tin) and myosin (MI-o-sin). In movement, the myosin filaments Neuromuscular Axon branches “latch on” to the actin filaments in their overlapping region junction by means of many paddlelike extensions called myosin heads. Using the energy of ATP for repeated move- The point of contact between the neuron and the muscle cell is ments, the myosin heads, like the oars of a boat moving the neuromuscular junction. As the overlapping filaments slide together, the THE MUSCULAR SYSTEM ✦ 155 8 Axon of motor neuron Synaptic vesicle Mitochondrion Synaptic cleft Neurotransmitter (acetylcholine) A Axon Muscle Muscle fiber B Motor end plate branches fiber nucleus Vesicle releasing acetylcholine Receptor binds acetylcholine C Axon Mitochondria D Vesicles with Folds in motor end plate neurotransmitter of muscle cell Figure 8-3 Neuromuscular junction (NMJ). Once the filaments cross-bridges form, the myosin heads move the actin fila- ments forward, then they detach and move back to posi- tion for another “power stroke. In resting mus- Myosin head ADP ADP cles, the calcium is not available because it is stored P Binding site P within the endoplasmic reticulum (ER) of the muscle covered cell. Muscle relaxes when stimulation ends and the calcium Ca2+ Ca2+ is pumped back into the ER Box 8-1, Muscle Contraction and Energy, has addi- tional details on skeletal muscle contraction. The source of this energy is the oxidation ponin and tropomyosin away from binding sites so cross-bridges (commonly called “burning”) of nutrients within the cells. When cal- there is no ATP to disengage the filaments, so they remain cium shifts these proteins away from the binding sites, the fol- locked in a contracted state. The circulating blood constantly brings these substances to the cells, but muscle cells also store a small reserve Checkpoint 8-9 When muscles work without oxygen, a com- supply of each to be used when needed, during vigorous pound is produced that causes muscle fatigue. When muscles are stretched, they contract more it can be broken down into glucose when needed by the forcefully, as the internal filaments can interact over a muscle cells. Aerobic exercise, that is, compound similar to ATP, in that it has a high energy exercise that increases oxygen consumption, such as run- bond that releases energy when it is broken. During strenuous activity, tine phosphate to promote endurance however, a person may not be able to breathe in oxygen An exercise program should include all three meth- rapidly enough to meet the needs of the hard-working ods—stretching, aerobic exercise, and resistance train- muscles. At first, the myoglobin, glycogen, and creatine ing—with periods of warm-up and cool-down before and phosphate stored in the tissues meet the increased de- after working out. The vasodilation (vas-o-di- process generates ATP rapidly and permits greater magni- LA-shun), or widening of blood vessel diameter, that oc- tude of activity than would otherwise be possible, as, for curs during exercise allows blood to flow more easily to example, allowing sprinting instead of jogging. The Anaerobic metabolism can continue only until the buildup resting heart rate of a trained athlete is lower than the av- of lactic acid causes the muscles to fatigue. Circulation in the capillaries surrounding to take in extra oxygen by continued rapid breathing the alveoli (air sacs) is increased, and this brings about (panting) until the debt is paid in full. In ad- moderate regular exercise has the additional benefits of dition, the glycogen, myoglobin, and creatine phosphate weight control, strengthening of the bones, decreased that are stored in the cells must be replenished. The after strenuous exercise during which extra oxygen is effects of exercise on the body are studied in the fields of THE MUSCULAR SYSTEM ✦ 159 8 Box 8-2 Hot Topics Anabolic Steroids: Winning at All Costs? Steroids damage the liver, making it more susceptible Amone testosterone by promoting metabolism and stimu- to disease and cancer, and suppress the immune system, in- lating growth. However, athletes also purchase them illegally, using tility, and the development of female sex characteristics such them to increase muscle size and strength and improve en- as breasts (gynecomastia). They increase blood cholesterol levels, which may increase the risk for baldness and, especially in men, cause lead to atherosclerosis, heart disease, kidney failure, and mood swings, depression, and violence. Types of Muscle Contractions ◗ Isometric (i-so-MET-rik) contractions are those in which there is no change in muscle length but there is Muscle tone refers to a partially contracted state of the a great increase in muscle tension. The maintenance of this tone, or tonus (TO-nus), is For example, if you push the palms of your hands hard due to the action of the nervous system in keeping the against each other, there is no movement, but you can muscles in a constant state of readiness for action. When walking, sible for muscle tone, there are two other types of con- for example, some muscles contract isotonically to propel tractions on which the body depends: the body forward, but at the same time, other muscles are contracting isometrically to keep your body in position. All of the connective tissue within and around Insertion the muscle merges to form the tendon, which then at- taches directly to the periosteum of the bone (see Fig. Radius In moving the bones, one end of a muscle is attached to Ulna a more freely movable part of the skeleton, and the other Humerus end is attached to a relatively stable part. The less movable Tendon (more fixed) attachment is called the origin; the attachment to the part of the body that the muscle puts into action is Figure 8-7 Muscle attachments to bones. Figure 8-7 shows the action of the biceps sistance and the effort; a see-saw or a scissors is an exam- brachii (in the upper arm) in flexing the arm at the elbow. The second-class lever has the The insertion on the radius of the forearm is brought to- resistance located between the fulcrum and the effort; a ward the origin at the scapula of the shoulder girdle.

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A7 discount zoloft 100mg amex depression symptoms breathlessness, A8) discount zoloft 100 mg with amex anxiety nausea, and the direction of HCO3–/Cl– ex- HCO3– + H+ CO2 + H O2 change reverses (! Because it acceler- toOxy-Hbinthelungpromotesthisprocessby ates the establishment of equilibrium, the increasing the supply of H+ ions (Haldane ef- short contact time (! CO2 distribution in blood (mmol/L blood, CO2 diffusing from the peripheral cells (! The HCO3– Mixed venous blood: concentration in erythrocytes therefore be- Plasma* 0. Percentage of total arteriovenous difference H+ ions are liberated when CO2 in red cells 9% 78% 13% 100% circulating in the periphery is converted to * Approx 0. Since the removal of H+ ions Despopoulos, Color Atlas of Physiology © 2003 Thieme All rights reserved. CO2 transport in blood Expelled from lung 8 Oxy- Hb CO Hb 2 NH COO– NH2 CO2 Alveolus H+ O2 Hb Oxy- H Hb H In lung H O + 2 H 7 – 9 – CO HCO3 HCO3 2 Carbonic anhydrase Cl– Erythrocyte In plasma In periphery 5 Carbonic anhydrase HCO– HCO– CO2 3 3 Bicarbonate formation 2 – 4 Cl H2O H+ 6 Hb Hemoglobin Oxy- H as buffer Hb H O2 H+ Hemoglobin carbamate Oxy- Hb formation Hb 3 NH2 NH COO– Hemoglobin CO2 CO2 carbamate 1 Tissue 125 Metabolism Despopoulos, Color Atlas of Physiology © 2003 Thieme All rights reserved. TheCO2dis- CO2 in Cerebrospinal Fluid sociation curve illustrates how the total CO2 concentration depends on PCO (! Unlike HCO3– and H, CO+ 2 can cross the blood- 2 TheconcentrationofdissolvedCO2,[CO2],in cerebrospinal fluid (CSF) barrier with relative plasma is directly proportional to the PCO2 in ease (! The PCO2 in CSF there- plasma and can be calculated as follows: fore adapts quickly to acute changes in the PCO2 [CO ] =2 αCO2! The dissociation curve for total CO2 is The concentration of non-bicarbonate calculated from the sum of dissolved and buffers in blood (hemoglobin, plasma pro- bound CO2 (! When the CO2 concentration in- CO2 binding with hemoglobin depends on creases, the liberated H+ ions are therefore ef- the degree of oxygen saturation (SO2) of fectively buffered in the blood. Blood completely saturated with HCO3– concentration in blood then rises rela- O2 is not able to bind as much CO2 as O -free2 tively slowly, to ultimately become higher blood at equal PCO levels (! B2), result- loaded with O,2 the buffer capacity of ing in a renewed increase in the pH of the hemoglobin and, consequently, the levels of CSF because the HCO3–/CO2 ratio increases chemical CO2 binding decrease due to the Hal- (! Venous blood is never respiratory activity (via central chemosen- completely void of O, but is always O -satu-2 2 sors), a process enhanced by renal compensa- rated to a certain degree, depending on the tion, i. The SO2 of mixed venous blood is ultimately adapts to chronic elevation in PCO2— about 0. The normal range of CO2 Despopoulos, Color Atlas of Physiology © 2003 Thieme All rights reserved. Effect of CO2 on pH of CSF Example: 1 Acute Respiratory acidosis 2 Chronic Renal compensation CO2 HCO3– CO2 HCO3– H2O H+ Blood H2O H+ Blood-CSF NBB barrier pH NBB pH CO2 HCO3– CO2 HCO3– H O H+ 2 CSF H2O H+ pH NBB pH ( ) Central chemoreceptors Central chemoreceptors Strong signal for 127 respiratory regulation Weak signal (adaptation) Despopoulos, Color Atlas of Physiology © 2003 Thieme All rights reserved. Shifts to Hb is also involved in CO2 transport and is an the left are caused by increases in pH (with or important blood pH buffer (! Hb is a tetramer with 4 subunits PCO2, temperature and 2,3-bisphosphoglyc- (adults: 98%: 2α + 2" = HbA; 2% 2α +2δ = erate (BPG; normally 1mol/mol Hb tetramer). Each of the and/or increases in PCO2, temperature and 2,3- four Fe(II) atoms (each linked with one his- BPG(! Displacementof Hb depends on the partial pressure of O2 (PO2): the O2 dissociation curve due to changes in pH oxygen dissociation curve (! A shift to the curve has a sigmoid shape, because initially right means that, in the periphery (pH#, bound O2 molecules change the conformation PCO2"), larger quantities of O2 can be absorbed of the Hb tetramer (positive cooperativity) and from the blood without decreasing the PO2, thereby increase hemoglobin-O2 affinity. A shift to the left is useful when Thus, 1g Hb can theoretically transport the PAO2 is decreased (e. This oxygen-carrying capacity is a func- (no positive cooperativity), its O2 dissociation tion of [Hb]total (! A, yellow and purple curves curve at low PO2 is much steeper than that of as compared to the red curve). Since the O2 dissociation curve of The O2 content of blood is virtually equivalent to fetal Hb (2α+2γ = HbF) is also steeper, SO2 the amount of O2 bound by Hb since only 1. The solubility coefficient (αO2), which is 22–30mmHg) of maternal placental blood. This is sufficient, because the fetal [Hb]total is CO2 Oxygen saturation (SO ) is the fraction of 180g/L. The carbon monoxide (CO) dissocia- 2 Oxy-Hb relative to [Hb]total, or the ratio of ac- tion curve is extremely steep. Methemoglobin O2 dissociation is independent of total Hb if reductase reduces Fe(III) of Met-Hb back to plottedasafunctionofSO (!

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