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Evaluation studies should quality 100 mg clomid 1800 menstrual pads, on the one hand discount 100mg clomid free shipping pregnancy acne, aim as much as possible to objectify these subjective factors in a reproducible way. On the other hand, interindividual and even intraindividual differences will always play a part26 and should be acknowledged in the clinical decision making process. Observer variability and observer bias Variability between different observers, as well as for the same observer in reading and interpreting diagnostic data, should not only be acknowledged for “soft” diagnostics such as history taking and physical examination, but also for “harder” ones like x rays, CT scans and pathological slides. Even tests not involving any human factors show inter- and intrainstrument variability. Such variability should be limited if the diagnostic is to produce useful information. At the same time, evaluation studies should beware of systematic observer bias as a result of prior knowledge about the subjects examined. Clearly, if one wishes to evaluate whether a doctor can accurately diagnose an ankle fracture based on history and clinical examination, it must be certain that he is not aware of an available x ray result; and a pathologist making an independent final diagnosis should not be informed about the most likely clinical diagnosis. A different form of observer bias could occur if the diagnosticians are prejudiced in favour of one of the methods to be compared, as they may unconsciously put greater effort into that technique. A further challenge is that the experience and skill required should be equal for the methods compared, if these are to have a fair chance in the assessment. In this respect, new methods are at risk of being disadvantaged, especially shortly after being introduced. Discrimination does not mean usefulness For various reasons, a test with very good discrimination does not necessarily influence management. To begin with, a test may add too little to what is already known clinically to alter management. Furthermore, the physician may take insufficient 9 THE EVIDENCE BASE OF CLINICAL DIAGNOSIS account of the information provided by the test. For instance, studies of the consequences of routine blood testing have shown that in some cases an unaltered diagnosis still led to changes in the considered policy. For example, the MRI scan provides refined diagnostic information with regard to various brain conditions for which no therapy is yet in prospect. Finally, as discussed in the previous section, supplementary test results may not be relevant for treatment decisions. For this reason we strongly recommend that evaluation studies investigate both the discrimination of a test and its influence on management. Indication area and prior probability Whether a test can effectively detect or exclude a particular disorder is influenced by the prior probability of that disorder. A test is generally not useful if the prior probability is either very low or very high: not only will the result rarely influence patient management, but the risk of, respectively, a false positive or a false negative result is relatively high. In other words, there is an “indication area” for the test between these extremes of prior probability. For example, tests with a moderate specificity are not useful for screening in an asymptomatic population (with a low prior probability) because of the high risk of false positive results. Small steps and large numbers Compared with therapeutic effectiveness studies, evaluation studies of diagnostic procedures have often neglected the question of whether the sample size is adequate to provide the desired information with a sufficient degree of certainty. A problem is that progress in diagnostic decision making often takes the form of a series of small steps so as to gain in certainty, rather than one big breakthrough. Evaluating the importance of a small step, however, requires a relatively large study population. Changes over time and the mosaic of evidence Innovations in diagnostic technology may proceed at such a speed that a thorough evaluation may take longer than the development of even more advanced techniques. For example, the results of evaluation studies on the cost effectiveness of the CT scan had not yet crystallised when the MRI and PET scans appeared on the scene. So, the results of evaluation studies 10 EVALUATION OF DIAGNOSTIC PROCEDURES may already be lagging behind when they appear. Therefore, there is a need for general models (scenarios) for the evaluation of particular (types of) tests and test procedures, whose overall framework is relatively stable and into which information on new tests can be entered by substituting the relevant piece in the whole mosaic. This allows, for instance, a quick evaluation of the impact of new mammographic or DNA techniques with better discrimination on the cost effectiveness of breast cancer screening, if other pieces of the mosaic (such as treatment efficacy) have not changed. As discrimination itself can often be relatively rapidly assessed by means of a cross-sectional study, this may avoid new prospective studies.

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The stroma—the material of the ovary in which folli- OF THE OVARIES cles and blood vessels are embedded—lies in both the cortical The ovary contains a large number of follicles cheap clomid 25 mg online geriatric women's health issues, each of which en- and medullary layers purchase clomid 25mg with mastercard pregnancy yoga. Some of these follicles mature during the ovarian cycle, and the ova they contain progress to the secondary oocyte Blood Supply and Innervation stage of meiosis. During ovulation, the largest follicle ruptures and releases its secondary oocyte. The ruptured follicle becomes a Blood is supplied by ovarian arteries that arise from the lateral corpus luteum and regresses to become a corpus albicans. These sides of the abdominal aorta,just below the origin of the renal ar- cyclic changes in follicular development are accompanied by teries. An additional supply comes from the ovarian branches of changes in hormone levels. The right ovarian vein empties into the inferior vena cava, Objective 4 Describe the position of the ovaries and the whereas the left ovarian vein drains into the left renal vein. Objective 5 Describe the structural changes in the ovaries that lead to and follow ovulation. Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 Chapter 21 Female Reproductive System 729 Ampulla Uterine tube of uterine Suspensory Ovarian ligament tube ligament of Body of uterus ovary Mesovarium Fundus of uterus Ovary Infundibulum of uterine tube Round Fimbriae ligament Egg cell Broad Follicle Endometrium ligament of uterus Myometrium Perimetrium Fornix of vagina Cervix of uterus Vagina Waldrop FIGURE 21. The ovaries have both sympathetic and parasympathetic a newborn girl contain about 2 million oocytes, this number de- innervation from the ovarian plexus. Innervation to the ovaries, clines to 300,000 to 400,000 by the time she enters puberty. On however, is only to the vascular networks and not to the follicu- average, 400 oocytes are ovulated during a woman’s reproductive lar substance within the stroma. Follicle Formation Normal, healthy ovaries usually cannot be palpated either by Primary oocytes that are not stimulated to complete the first vaginal or abdominal examination. If the ovaries become meiotic division are contained within tiny follicles called pri- swollen or displaced, however, they are palpable through the vagina. There are many types of nonmalignant tumors of the ovaries, most of mordial follicles. In response to stimulation by gonadotropic which cause swelling and some localized tenderness. The ovaries at- hormones, some of these oocytes and follicles get larger, and the rophy during menopause, and ovarian enlargement in post- follicular cells divide to produce the follicular epithelium that menopausal women is usually cause for concern. At The germ cells that migrate into the ovaries during early embry- this point, they are called secondary follicles (fig. The mound is called the cumulus oogonia stops at this point and never resumes. Under stimulation of follicle-stimulating of the first meiotic division, and therefore the primary oocytes are still diploid (have 46 chromosomes). Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 730 Unit 7 Reproduction and Development Primary follicles Vesicle Secondary follicle (a) Granulosa cells Antrum Corona radiata Secondary oocyte Zona pellucida Cumulus oophorus Theca interna (b) FIGURE 21. In- By about the tenth to the fourteenth day following day 1 of a terestingly, the follicular cells produce estrogen from its precursor menstrual period, usually just one follicle has matured fully to be- testosterone, which is supplied by a layer of cells immediately come a vesicular ovarian (graafian) follicle (fig. This does not form two complete cells, that it forms a bulge on the surface of the ovary. Under proper however, because only one cell—the secondary oocyte—gets al- hormonal stimulation (a sudden burst of luteinizing hormone most all of the cytoplasm. The other cell formed at this time be- from the anterior pituitary, triggered by a peak level of estrogen), comes a small polar body (fig. The secondary oocyte enters the second meiotic and extrude its secondary oocyte into the peritoneal cavity near division, but meiosis is arrested at metaphase II and is never the opening of the uterine tube in the process of ovulation (ov-yu˘- completed unless fertilization occurs. Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 Chapter 21 Female Reproductive System 731 (a) (b) FIGURE 21. Ovarian cortex Tunica albuginea Ovarian medulla Primordial Maturing follicles follicle Broad ligament FIGURE 21. Female Reproductive © The McGraw−Hill Anatomy, Sixth Edition Development System Companies, 2001 732 Unit 7 Reproduction and Development Fimbriae of uterine tube Knowledge Check 4. Describe the position of the ovaries relative to the uterine tubes and describe the position and functions of the broad Oocyte ligament and mesovarium.

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Energy metabolism increases safe clomid 25 mg menstrual 2 weeks, as Less common conditions that cause chronic elevations does appetite clomid 50 mg cheap menstruation problems. However, despite the increase in food in- in circulating thyroid hormones include adenomas of the take, a net degradation of protein and lipid stores occurs, thyroid gland that secrete thyroid hormones and excessive resulting in weight loss. All of these changes can be re- TSH secretion caused by malfunctions of the hypothala- versed by reducing the rate of thyroid hormone secretion mic-pituitary-thyroid axis. The disease state that develops with drugs or by removal of the thyroid gland by radioac- in response to excessive thyroid hormone secretion, called tive ablation or surgery. REVIEW QUESTIONS DIRECTIONS: Each of the numbered (A) Stimulation of endocytosis of (E) Stimulation of the binding of T4 items or incomplete statements in this thyroglobulin stored in the colloid and T3 to thyroxine-binding globulin section is followed by answers or by (B) Release of a large pool of T4 and (F) Increased cAMP hydrolysis completions of the statement. A child is born with a rare disorder in ONE lettered answer or completion that is cell which the thyroid gland does not the BEST in each case. What would be the from the thyroglobulin stored in the predicted effects on mental ability, body 1. The effects of TSH on thyroid colloid growth rate, and thyroid gland size follicular cells include (D) Increase in perfusion by the blood when the child reaches 6 years of age? A 25-year-old woman complains of than normal generate heat weight loss, heat intolerance, excessive (B) Mental ability would be unaffected, (D) Are present exclusively in brown fat sweating, and weakness. TSH and body growth rate would be slowed, (E) Uncouple fatty acid oxidation from thyroid hormones are elevated, goiter and thyroid gland size would be glucose oxidation in mitochondria is present, but no antithyroid smaller than normal (F) Are essential for maintaining body antibodies are detected. Which of the (C) Mental ability would be impaired, temperature in mammals following diagnoses is consistent with body growth rate would be slowed, 5. Molecular and structural biology of and thyroid gland size would be deiodination of T4 in pituitary thyroid hormone receptors. Philadelphia: Lippincott Williams & Laboratory findings include TSH 10 (A) Mental ability would remain Wilkins, 2000. These improved, and thyroid gland size thyroid hormones at the cellular level: findings are most consistent with a would be smaller than normal The mitochondrial target. FEBS Lett diagnosis of (B) Mental ability would be improved, 1999;452:115–120. The thy- hypothalamic-pituitary defect and thyroid gland size would be (B) Hyperthyroidism secondary to a roid gland. In: Wilson JD, Foster DW, normal hypothalamic-pituitary defect Kronenberg HM, Larsen PR, eds: (C) Mental ability would remain (C) Hyperthyroidism as a result of Williams Textbook of Endocrinology. Philadelphia: WB Saunders, improved, and thyroid gland size (D) Hypothyroidism as a result of 1998. Thyroid hormone and develop- (D) Mental ability would remain (E) Hypothyroidism as a result of ment: Brain and peripheral tissue In: impaired, body growth rate would be iodine deficiency Hauser P, Rovet J, eds. Thyroid Dis- improved, and thyroid gland size (F) Hyperthyroidism as a result of eases of Infancy and Childhood. Wash- would be larger than normal autoimmune thyroid disease ington, DC: American Psychiatric (E) Mental ability would be improved, 7. Mechanisms of slowed, and thyroid gland size would (A) Produces hydrogen peroxide as an thyroid hormone action. Biological activities of body growth rate would remain to form an iodothyronine residue thyroid hormone receptors. Eur J En- slowed, and thyroid gland size would (C) Occurs on the basal membrane of docrinol 1997;137:433–445. Uncoupling proteins (D) Catalyzes the release of thyroid hormone and other regulators of un- (A) Utilize the proton gradient across hormones into the circulation coupling proteins. Int J Obes Relat the mitochondrial membrane to (E) Couples MIT and DIT to Metab Disord 1999;23(Suppl facilitate ATP synthesis thyroglobulin 6):S56–S59. The adrenal gland is comprised of an outer cortex sur- ularis by increasing intracellular cAMP. Angiotensin II and angiotensin III stimulate aldosterone glomerulosa, zona fasciculata, and zona reticularis. Hormones secreted by the adrenal cortex include glucocor- ing cytosolic calcium and activating protein kinase C. The glucocorticoids cortisol and corticosterone are synthe- tosol of target cells.

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Although severity has not characterized plastic surgery’s loss experience in the past 50mg clomid for sale menstruation at 9, the trend is toward larger awards discount clomid 100 mg amex women's health issues in developing countries, particularly in those cases where an elective pro- cedure has resulted in a fatal outcome. An important example is the claims arising out of large-volume suction-assisted lipectomy. This category of claims will be more carefully examined toward the conclu- sion of this chapter. Scarring in General Most surgeons assume the patient understands that healing entails formation of scar. Unfortunately, it is seldom discussed in the preop- erative consultation. In plastic and reconstructive surgery, the appear- ance of the resulting scar can be the major genesis of dissatisfaction. It is imperative that the plastic surgeon obtains from the patient clear evidence of his or her comprehension that without scarring, there is no healing. The patient must be made to understand that healing qualities Chapter 14 / Plastic and Reconstructive Surgery 191 are as individual as the texture of one’s hair or the color of one’s eyes; it is built into genetic programming. Documentation of such conver- sation in the preoperative chart is most important. Breast Reduction The genesis of dissatisfaction most often involves the following: • Unsatisfactory scar. Approximately 44% of all elective aesthetic surgery claims involve augmentation. Setting aside for the moment breast implants and autoimmune disease, the most frequent causes of dissatisfaction are as follow: • Encapsulation with distortion and firmness. Facelift/Blepharoplasty Facelift and blepharoplasty account for approx 11% of claims. The most common allegations are listed here: • Excessive skin removal, resulting in a “stary” look. The trend toward doing the vast majority of these patients on an outpatient basis deserves some comment. In a survey of blindness after blepharoplasty carried out by the author at The Doctors Company in 1999, it was discovered that the only trait all cases had in common was the fact that they were discharged very shortly after the termination of the outpatient surgery. Upon arrival at home, each did something to generate a sudden rise in blood pressure at the time of maximal reactive hyperemia as the epinephrine in the local anesthetic wore off (e. It is imperative that all patients under- going outpatient surgery involving undermining of heavily vascular- 192 Gorney ized tissues be strictly warned not to undertake any maneuvers that will generate sudden elevations in blood pressure. Additionally, it is strongly recommended that no patient be discharged from an outpatient surgical facility until at least 3 hours have elapsed and there is evidence that all the local anesthetic effects have worn off. Rhinoseptoplasty Rhinoseptoplasty cases constitute approx 8% of the claims. Among the most common allegations are as listed here: • Unsatisfactory result: improper performance allegations. Of all the operations performed by plastic and reconstructive surgeons, this is regrettably the procedure with the highest degree of unpredictability. The problem is greatly aggravated by inappropriate patient-selection criteria. In these claims, there is almost universally a gap between the patient’s expectations and the results obtained, even when the surgical outcome appears excellent. The inappropriate use of imaging devices or the showing of “brag books” containing only excellent results often causes patients to have unrealistic expectations. The clear implication is “this is the kind of work that I do, and this is what you can expect. Abdominoplasty Abdominoplasty with or without suction-assisted lipectomy repre- sents approx 3% of claims. There is little question that the combination of suction-assisted lipoplasty prior to the actual abdominoplasty has significantly increased the morbidity of this operation and increased the number of claims in this category. There is a higher percentage of skin sloughs in those procedures when preceded by suction-assisted lipectomy. Chapter 14 / Plastic and Reconstructive Surgery 193 Suction-Assisted Lipectomy Suction-assisted lipectomy procedures, whether conventional or ultrasonic, have now become the single most requested elective aes- thetic procedures in the United States.

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