Mayank V. Patel, MD

• Department of Surgery
• Our Lady of Mercy Medical Center
• Westchester Square Medical Center
• Bronx, New York

Other sagittal planes parallel to this (off center) divide the body into unequal portions pregnancy genetic testing order provera 10 mg fast delivery. A frontal (coronal) plane also extends vertically women's health health magazine buy provera 10 mg, but it is perpendicular to the sagittal plane and divides the body into anterior (front) and posterior (back) portions (fig recent women's health issues provera 5 mg purchase visa. Contents of the thoracic and abdominal cavities are most commonly shown as frontal sections pelvic floor disorders women's health issues 2.5 mg provera order mastercard. A transverse (horizontal) plane passes across the body or an organ perpendicular to its long axis; it divides the body or organ into superior (upper) and inferior (lower) portions (fig menstruation 6 days after ovulation buy 2.5 mg provera with mastercard. Directional Terms Words that describe the location of one structure relative to another are called the directional terms of anatomy. Most of these terms exist in pairs with opposite meanings: anterior versus posterior, rostral versus caudal, superior versus inferior, medial versus lateral, proximal versus distal, ipsilateral versus contralateral, and superficial versus deep. These terms do have some applications to anatomy of the trunk, however-for example, in referring to certain aspects of the intestines and microscopic anatomy of the kidneys. But when describing the trunk and referring to a structure that lies above or below another, superior and inferior are the preferred terms. Although it may be technically correct, one would not generally say that the elbow is superior to the wrist, but proximal to it. Because of the bipedal, upright stance of humans, some directional terms have different meanings for humans than they do for other animals. Anterior, for example, denotes the region of the body that leads the way in normal locomotion. For a four-legged animal such as a cat, this is the head end of the body; for a human, however, it is the front of the chest and abdomen. Posterior denotes the region of the body that comes last in normal locomotion-the tail end of a cat but the dorsal side (back) of a human. In the anatomy of most other animals, ventral denotes the surface of the body closest to the ground and dorsal denotes the surface farthest away from the ground. These two words are too entrenched in human anatomy to completely ignore them, but we will minimize their use in this book to avoid confusion. You must keep such differences in mind, however, when dissecting other animals for comparison to human anatomy. One vestige of the term dorsal is dorsum, used to denote the upper surface of the foot and the back of the hand. If you consider how a cat stands, the corresponding surfaces of its paws are uppermost, facing the same direction as the dorsal side of its trunk. Although these surfaces of the human hand and foot face entirely different directions in anatomical position, the term dorsum is still used. For purposes of study, the body is divided into two major regions called the axial and appendicular regions. Smaller areas within the major regions are described in the following paragraphs and illustrated in figure A. Axial Region the axial region consists of the head, neck (cervical3 region), and trunk. The trunk is further divided into the thoracic region above the diaphragm and the abdominal region below it. The quadrant scheme is often used to describe the site of an abdominal pain or abnormality. Each vertical line is called a midclavicular line because it passes through the midpoint of the clavicle (collarbone). The superior horizontal line is called the subcostal 4 line because it connects the inferior borders of the lowest costal cartilages (cartilage connecting the tenth rib on each side to the inferior end of the sternum). The inferior horizontal line is called the intertubercular 5 line because it passes from left to right between the tubercles (anterior superior spines) of the pelvis-two points of bone located about where the front pockets open on most pants. The three lateral regions of this grid, from upper to lower, are the hypochondriac,6 lumbar, and inguinal7 (iliac) regions. The three medial regions from upper to lower are the epigastric,8 umbilical, and hypogastric (pubic) regions. The arm, for example, is the segment between the shoulder and elbow joints, and the forearm is the segment between the elbow and wrist joints. Flexing your fingers, you can easily see that your thumb has two segments (proximal and distal), whereas the other four digits have three segments (proximal, middle, and distal). The segment concept is especially useful in describing the locations of bones and muscles and the movements of the joints. In strict anatomical terms, arm refers only to that part of the upper limb between the shoulder and elbow. Some of these membranes are two-layered, having one layer against the organ surface (such as the heart or lung) and one layer against a surrounding structure (forming, for example, the inner lining of the rib cage); there is only a thin film of liquid between them. The Cranial Cavity and Vertebral Canal the cranial cavity is enclosed by the cranium (braincase) and contains the brain. The vertebral canal is enclosed by the vertebral column (spine) and contains the spinal cord. Among other functions, the meninges protect the delicate nervous tissue from the hard protective bone that encloses it. It subsequently becomes partitioned by a muscular sheet, the diaphragm, into a superior thoracic cavity and an inferior abdominopelvic cavity. Both cavities are lined with thin serous membranes, which secrete a lubricating film of moisture similar to blood serum (hence their name). This is the region between the lungs, extending from the base of the neck to the diaphragm. It is occupied by the heart, the major blood vessels connected to it, the esophagus, the trachea and bronchi, and a gland called the thymus. It is separated from the visceral pericardium by a space called the pericardial cavity (fig. Like the pericardium, the pleura has visceral (inner) and parietal (outer) layers. The visceral pleura forms the external surface of the lung, and the parietal pleura lines the inside of the rib cage. Note that in both the pericardium and the pleura, the visceral layer of the membrane covers an organ surface and the parietal layer lines the inside of a body cavity. Shows the peritoneum, peritoneal cavity (with most viscera omitted), and some retroperitoneal organs. The Abdominopelvic Cavity the abdominopelvic cavity consists of the abdominal cavity superiorly and the pelvic cavity inferiorly. The abdominal cavity contains most of the digestive organs as well as the spleen, kidneys, and ureters. It extends inferiorly to the level of a bony landmark called the brim of the pelvis (see figs. The pelvic cavity, below the brim, is continuous with the abdominal cavity (no wall separates them), but it is markedly narrower and tilts posteriorly (see fig. Along the posterior midline, it turns inward and becomes another layer, the visceral peritoneum, suspending certain abdominal viscera from the body wall, covering their outer surfaces, and holding them in place. Some organs of the abdominal cavity lie against the posterior body wall and are covered by peritoneum only on the side facing the peritoneal cavity. These include the kidneys, ureters, adrenal glands, most of the pancreas, and abdominal portions of two major blood vessels-the aorta and inferior vena cava (see fig. Organs that are encircled by peritoneum and connected to the posterior body wall by peritoneal sheets are described as intraperitoneal. The most serious cause of peritonitis is a perforation in the digestive tract, such as a ruptured appendix or a gunshot wound. Digestive juices cause immediate chemical inflammation of the peritoneum, followed by microbial inflammation as intestinal bacteria invade the body cavity. Anything that perforates the abdominal wall can also lead to peritonitis, such as abdominal trauma or surgery. So, too, can free blood in the abdominal cavity, as from a ruptured aneurysm (a weak point in a blood vessel) or ectopic pregnancy (implantation of an embryo anywhere other than the uterus); blood itself is a chemical irritant to the peritoneum. Death can follow within a few days from severe electrolyte imbalance, respiratory distress, kidney failure, and widespread blood clotting called disseminated intravascular coagulation. In some places, after wrapping around the intestines or other viscera, the mesentery continues toward the anterior body wall as the anterior mesentery. The most significant example of this is a fatty membrane called the greater omentum,19 which hangs like an apron from the inferolateral margin of the stomach and overlies the intestines (figs. The greater omentum is unattached at its inferior border and can be lifted to reveal the intestines. A smaller lesser omentum extends from the superomedial margin of the stomach to the liver. Mesenteries contain blood vessels, lymphatic vessels, and nerves supplying the viscera. The membranes are not physically attached, however, and under unusual conditions, they may separate and create a space filled with fluid or other matter. Thus there is normally no actual space, but only a potential for membranes to separate and create one. Normally the parietal and visceral pleurae are pressed together without a gap between them, but under pathological conditions, air or serous fluid can accumulate between the membranes and open up a space. In a nonpregnant uterus, the mucous membranes of opposite walls are pressed together so that there is no open space in the organ. In pregnancy, of course, a growing fetus occupies this space and pushes the mucous membranes apart. Systems of protection, support, and movement Integumentary system Skeletal system Muscular system Systems of internal communication and control Nervous system Endocrine system Systems of fluid transport Circulatory system Lymphatic system Systems of intake and output Respiratory system Urinary system Digestive system Systems of reproduction Male reproductive system Female reproductive system Some medical terms combine the names of two systems-for example, the musculoskeletal system, cardiopulmonary system, and urogenital (genitourinary) system. These terms serve to call attention to the close anatomical or physiological relationships between two systems, but these are not literally individual organ systems. The organ systems are classified in the following list by their principal functions, but this is an unavoidably flawed classification. Some organs belong to two or more systems- for example, the male urethra is part of both the urinary and reproductive systems; the pharynx is part of the respiratory and digestive systems; and the mammary glands can be considered part of the integumentary and female reproductive systems. Liver functions include metabolism of carbohydrates, lipids, proteins, vitamins, and minerals; synthesis of plasma proteins; disposal of drugs, toxins, and hormones; and cleansing of blood. The segments of the upper and lower limbs; how the anatomical meanings of arm and leg differ from the colloquial meanings A. Directions along which the body or an organ is divided by the sagittal, frontal, and transverse planes; how the median plane differs from other sagittal planes 3. Meanings of each of the following pairs or groups of terms, and the ability to describe the relative locations of two body parts using these terms: ventral and dorsal; anterior and posterior; cephalic, rostral, and caudal; superior and inferior; medial and lateral; proximal and distal; superficial and deep 4. Why the terms ventral and dorsal are ambiguous in human anatomy but less so in most other animals; what terms are used in their place in human anatomy; and reasons why they are occasionally appropriate or unavoidable in human anatomy A. Locations and contents of the cranial cavity, vertebral canal, thoracic cavity, and abdominopelvic cavity; the membranes that line them; and the main viscera contained in each 2. Contents of the mediastinum and its relationship to the thoracic cavity as a whole 3. The pericardium, its two layers, the space and fluid between the layers, and its function 4. The pleurae, their two layers, the space and fluid between the layers, and their function 5. The two subdivisions of the abdominopelvic cavity and the skeletal landmark that divides them 6. The peritoneum; its functions; its two layers and their relationship to the abdominal viscera; and the peritoneal fluid 7. Intraperitoneal versus retroperitoneal organs, examples of both, and how one would identify an organ as being intra- or retroperitoneal 9. The 11 organ systems, the functions of each, and the principal organs of each system Testing Your Recall 1. Which organ system regulates blood volume, controls acid­base balance, and stimulates red blood cell production The translucent membranes that suspend the intestines and hold them in place are called. The manual region is more commonly known as the and the pedal region is more commonly known as the. Organs that lie within the abdominal cavity but not within the peritoneal cavity are said to have a position. The anterior pit of the elbow is the region, and the corresponding (but posterior) pit of the knee is the region. The heart is in the space between the parietal and visceral pericardium, called the pericardial cavity. Identify which anatomical plane-sagittal, frontal, or transverse-is the only one that could not show (a) both the brain and tongue, (b) both eyes, (c) both the hypogastric and gluteal regions, (d) both kidneys, (e) both the sternum and vertebral column, and (f) both the heart and uterus. Name one structure or anatomical feature that could be found in each of the following locations relative to the ribs: medial, lateral, superior, inferior, deep, superficial, posterior, and anterior. Based on the illustrations in this atlas, identify an internal organ that is (a) in the upper left quadrant and retroperitoneal, (b) in the lower right quadrant of the peritoneal cavity, (c) in the hypogastric region, (d) in the right hypochondriac region, and (e) in the pectoral region. Why do you think people with imaginary illnesses came to be called hypochondriacs If you do not clearly remember these concepts, you may find that brushing up on them before you proceed will enable you to get more out of each new chapter. Here we will delve more deeply into metabolism and its two subdivisions, anabolism and catabolism. The Chemical Elements A chemical element is the simplest form of matter to have unique chemical properties. Water, for example, has unique properties, but it can be broken down into two elements, hydrogen and oxygen, that have unique chemical properties of their own. If we carry this process any further, however, we find that hydrogen and oxygen are made of protons, neutrons, and electrons-and none of these are unique.

In a subsequent examination of the same database menstruation blood 5 mg provera sale, 610 prospectively identified pregnancies exposed to olanzapine resulted in 10% premature births pregnancy 25 weeks belly discount 10 mg provera visa, 9% spontaneous abortions women's health center of chicago generic provera 10 mg buy on line, 8% perinatal conditions menstrual vs ovarian cycle buy cheap provera. In a study of antipsychotic placental passage rates and neonatal outcomes (Newport et al women's health daily tips order provera 10 mg line. Case reports of 39 infants exposed to olanzapine during lactation with no evidence of infant toxicity currently appear in the literature (Croke et al. The Lilly Safety Database reported on 62 breast-feeding mother­infant dyads with a 15. Pharmacokinetic studies of olanzapine exposure during lactation have reported that plasma concentrations were undetectable in infants during nursing (Gardiner et al. An additional study in 68 women with first-trimester exposure and known outcomes reported 9 (13. No data on the neurodevelopmental effects of risperidone exposure during pregnancy or lactation are available. Pharmacokinetic studies have reported placental passage concentrations among neonates (n=6) of 49. Quetiapine the reproductive safety literature for first-trimester quetiapine exposure is limited to a case series of two successive pregnancies (Grover and Madan 2012), which reported healthy, full-term deliveries, and the McKenna et al. To our knowledge, this is the lowest placental passage rate ever reported for a psychotropic agent. No data are available on the neurodevelopmental effects of quetiapine exposure during pregnancy or lactation. Three cases of quetiapine use during lactation following use during pregnancy estimated the nursing infant dosage at 0. Aripiprazole Reproductive safety data for aripiprazole include a case series of 86 mother­ infant dyads that showed an increased risk of premature birth and fetal growth retardation but no increased risk of congenital malformations, miscarriages, preeclampsia, or gestational diabetes (Bellet et al. Of the three case reports of aripiprazole use during lactation, the milk excretion profiles were questionable in two (Lutz et al. Use of ziprasidone, brexpiprazole, lurasidone, iloperidone, or asenapine during pregnancy has not been reported. A lone case report of use of paliperidone palmitate, the longacting injectable formulation of paliperidone, during pregnancy (haloperidol was also used) indicated no adverse obstetrical outcomes (Özdemir et al. Data concerning lactation were limited to a single case report of ziprasidone use during lactation that reported a milk-to-plasma ratio of 0. Furthermore, the historical use of phenothiazine antipsychotics to treat pregnancy-associated emesis aids in separating the effects of psychiatric illness and antipsychotic drugs on pregnancy outcome. Chlorpromazine, haloperidol, and perphenazine have received the greatest scrutiny, with no significant associations between these compounds and major malformations (Goldberg and DiMascio 1978; Hill and Stern 1979; Nurnberg and Prudic 1984). In a prospective study encompassing nearly 20,000 women receiving primarily phenothiazines for emesis, Milkovich and van den Berg (1976) found no significant association with neonatal survival rates or severe anomalies after controlling for maternal age, medication, and gestational age at exposure. Similar results have been obtained in several retrospective studies of women taking trifluoperazine for repeated abortions and emesis (Moriarty and Nance 1963; Rawlings et al. Reanalysis of the data obtained by Milkovich and van den Berg (1976) did find a significant risk of malformations associated with phenothiazine exposure in weeks 4 through 10 of gestation (Edlund and Craig 1984). In our study of antipsychotic placental passage, neonatal haloperidol (n=13) concentrations were 66% of maternal concentrations (Newport et al. In lactation, chlorpromazine is the most widely studied typical antipsychotic, with 7 infants exposed to chlorpromazine during nursing showing no developmental deficits at 16-month and 5-year follow-up evaluations (Kris and Carmichael 1957). However, 3 infants in another study whose mothers were prescribed both chlorpromazine and haloperidol showed evidence of developmental delay at 12­18 months (Yoshida et al. One group postulated that the physicochemical properties of perphenazine could lead it to become "trapped" in breast milk (Wilson et al. Results of the Collaborative Perinatal Project indicated that first-trimester exposure to diphenhydramine, the best studied of these medications, was associated with major and minor congenital anomalies (Miller 1991; Wisner and Perel 1988). A case­control study found a significantly higher rate of prenatal diphenhydramine exposure among 599 infants with oral clefts than among 590 control infants (Saxén 1974). Clinical studies of the teratogenic potential of benztropine and amantadine are lacking, although laboratory animal studies indicated that amantadine is associated with an elevated risk of congenital malformations (Hirsch and Swartz 1980). Perinatal toxicities, including neonatal intestinal obstruction after gestational exposure to benztropine (Falterman and Richardson 1980) and a possible neonatal diphenhydramine withdrawal syndrome manifested by tremulousness and diarrhea (Parkin 1974), also warrant concern. Anxiolytics Pharmacotherapy for anxiety disorders includes antidepressants, benzodiazepines, buspirone, and certain atypical antipsychotics. Benzodiazepines A retrospective analysis of more than 100,000 women found that at least 2% were prescribed a benzodiazepine during gestation (Bergman et al. The earliest benzodiazepine teratogenicity studies reported an increased risk of oral clefts after in utero diazepam exposure (Aarskog 1975; Saxén 1975; Saxén and Saxén 1975), but later studies failed to confirm this association (Ban et al. Prospective studies of first-trimester alprazolam exposure encompassing approximately 1,300 pregnancies indicated no excess of oral clefts or other birth defects (Barry and St Clair 1987; Schick-Boschetto and Zuber 1992; St Clair and Schirmer 1992), and a recent study of first-trimester exposure to diazepam and temazepam echoed this finding (Ban et al. A meta-analysis found that prenatal benzodiazepine exposure does confer an increased risk of oral clefts, although the absolute risk increased by only 0. This conclusion is consistent with the findings of a later case­control study that found no difference in rates of prenatal benzodiazepine exposure between more than 38,000 infants with congenital anomalies and nearly 23,000 control children (Eros et al. Although benzodiazepine teratogenicity data are somewhat mixed, benzodiazepine neonatal syndromes are well documented. Numerous groups have described a floppy infant syndrome characterized by hypothermia, lethargy, poor respiratory effort, and feeding difficulties following benzodiazepine exposure in late pregnancy (Erkkola et al. In a study of 53 infants with late-pregnancy lorazepam exposure, term infants whose mothers had taken oral lorazepam showed no evidence of toxicity other than a brief delay in establishing feeding, whereas preterm infants and term infants whose mothers had received larger intravenous doses of lorazepam had symptoms consistent with floppy infant syndrome (Whitelaw et al. Neonatal withdrawal syndromes, characterized by restlessness, hypertonia, hyperreflexia, tremulousness, apnea, diarrhea, and vomiting, have been described in infants whose mothers were taking alprazolam (Barry and St Clair 1987), chlordiazepoxide (Athinarayanan et al. Benzodiazepine neonatal syndromes have been reported to persist for as long as 3 months after delivery (for a review, see Miller 1991). Pharmacokinetic studies during pregnancy indicate that benzodiazepines readily traverse the placenta and with prolonged administration may accumulate in the fetus (Mandelli et al. For example, fetal concentrations of diazepam at delivery are typically higher than maternal concentrations (Erkkola et al. Because benzodiazepine metabolism is slower in the fetus than in the mother, it is understandable that an agent like diazepam (which has multiple active metabolites) might accumulate in the fetus. In addition, high concentrations of diazepam are sequestered in lipophilic fetal tissues, such as the brain, lungs, and heart (Mandelli et al. In contrast, fetal-to-maternal ratios of lorazepam (which has no active metabolites) are typically less than 1. Yet neonatal clearance of lorazepam is slow, with detectable levels evident 8 days after delivery (Whitelaw et al. Studies evaluating the neurobehavioral effects of prenatal benzodiazepine exposure are needed. A benzodiazepine exposure syndrome-consisting of growth retardation, dysmorphism, and mental and psychomotor retardation in infants (Laegreid et al. Nevertheless, a series of laboratory animal studies raised concerns that prenatal benzodiazepine exposure may produce deficits in memory and learning ability (Frieder et al. Infants with impaired metabolic capacity may show sedation and poor feeding even with low maternal dosages (Wesson et al. Overall, benzodiazepines are associated with lower milk-to-plasma ratios than are other classes of psychotropics. The percentage of the maternal dosage of lorazepam to which a nursing infant is exposed has been estimated to be 2. In summary, benzodiazepines do not appear to carry a significant risk of somatic teratogenesis, but neurobehavioral sequelae remain obscure. Because benzodiazepines are associated with neonatal risks, they should be used judiciously and tapered before delivery if possible. Because lorazepam and oxazepam are less dependent on hepatic metabolism, they theoretically have less potential for fetal accumulation during pregnancy. Finally, benzodiazepines can be safely administered, in judicious doses, during lactation. However, breast feeding should be discontinued if an infant experiences sedation or other signs of benzodiazepine toxicity. Buspirone Buspirone Buspirone has garnered a unique, and arguably illogical, position within the psychotropic armamentarium. The only report of prenatal administration of buspirone identified 1 infant born with a major malformation among 14 infants with first-trimester buspirone exposure (Wilton et al. Future Directions and General Recommendations the development of prenatal and postnatal treatment guidelines is hampered by the haphazard accrual of clinical research data with inconsistent methodologies. Whereas clinical data have confirmed the teratogenic potential for only a few psychotropic agents, animal studies, which commonly use maternal concentrations exponentially higher than those seen in clinical care, show clear somatic and neurobehavioral teratogenicity (Elia et al. Such inconsistencies between clinical and preclinical data further confound efforts to construct reliable treatment recommendations. Similarly, advances in statistical methods and the accrual of data from a variety of sources have identified statistical findings that may have limited relevance to clinical decision making (Ranganathan et al. Because pregnant and nursing women are generally excluded from clinical trials of pharmacological agents, definitive clarification with proper control groups is unlikely to be forthcoming in the near future. Consequently, clinical treatment decisions are made on the basis of incomplete or uncertain information. Informed Consent Obtaining informed consent in the clinical decision cannot overemphasized. Informed consent should include the following: be Agreement on the primary treatment objective, which typically is to minimize potential harm to the fetus (Acceptance of and adherence to this objective will help reduce the potential for subsequent maternal selfrecrimination. Good evidence indicates that concomitant exposures, such as to tobacco, increase both obstetrical and neonatal risk. Nonpsychotropic treatment strategies also include psychotherapy alternatives appropriate during pregnancy and the postpartum period. Initial treatment planning for reproductive-age women with mental illness should include the potential pregnancy and future family planning. Notably, more than 45% of the pregnancies in the United States are unplanned, and knowledge of conception is often well into the organogenesis (Finer and Zolna 2016; Kost 2015). Choosing initial pharmacotherapy with this in mind supports "new and improved=limited data. Consequently, both the safety and the efficacy of the psychotropic regimen are important considerations. A psychotropic agent is preferred if 1) it has previously been effective for the patient; 2) it has previously been well tolerated by the patient; 3) the fetus has already been exposed to it. It is important to emphasize the potential hazards of switching agents during pregnancy or lactation. Dosage Management Maintaining maternal emotional well-being is the goal of psychotropic treatment in the antepartum and postpartum periods. Partial or subtherapeutic treatment heightens risk by continuing to expose the mother and infant to both illness and medications. The minimum effective dosage should be maintained throughout treatment, and the clinician should remain mindful that dosage requirements may change during pregnancy. Similarly, clinicians and patients should be aware that dosage adjustment may not significantly alter fetal exposure during pregnancy. To minimize the potential for neonatal withdrawal and maternal toxicity after delivery, careful monitoring of side effects and serum concentrations may be indicated. Monitoring of Nursing Infants Because clinical laboratory assays typically lack the sensitivity to detect the serum concentrations of nursing infants, infant plasma monitoring for psychotropic medications is not routinely indicated. If there is an index of suspicion that a child is experiencing an adverse effect from nursing exposure to a psychotropic medication, breast feeding should be discontinued. Resources For clinicians involved in the care of numerous women in their reproductive years, a valuable resource that includes an interactive e-book is Drugs in Pregnancy and Lactation by G. Lancet 2(7941):921, 1975 53396 Adab N, Jacoby A, Smith D, et al: Additional educational needs in children born to mothers with epilepsy. Arch Dis Child 54(3):240, 1979 373647 Allen S: A quantitative analysis of the process, mediating variables, and impact of traumatic childbirth. N Engl J Med 356(26):2684­2692, 2007 17596602 Ambresin G, Berney P, Schulz P, et al: Olanzapine excretion into breast milk: a case report. J Clin Psychopharmacol 24(1):93­95, 2004 14709955 American Academy of Pediatrics Committee on Drugs: Transfer of drugs and other chemicals into human milk. Semin Perinatol 39(7):508­511, 2015 26358804 Aydin B, Nayir T, Sahin S, et al: Olanzapine and quetiapine use during breastfeeding: excretion into breast milk and safe breastfeeding strategy. New York, Raven, 1982b, pp 141­145 Barnas C, Bergant A, Hummer M, et al: Clozapine concentrations in maternal and fetal plasma, amniotic fluid, and breast milk (abstract). New York, Raven, 1982, pp 147­154 Bellantuono C, Marini A, Lucarelli C: Infant health and neurodevelopmental outcomes following prenatal exposure to duloxetine. Schizophr Res 47(2­3):167­175, 2001 11278134 Bérard A, Ramos E, Rey E, et al: First trimester exposure to paroxetine and risk of cardiac malformations in infants: the importance of dosage. Lancet 340(8821):694­696, 1992 1355799 Bertossi M, Virgintino D, Errede M, et al: Immunohistochemical and ultrastructural characterization of cortical plate microvasculature in the human fetus telencephalon. Microvasc Res 58(1):49­61, 1999 10388603 Bescoby-Chambers N, Forster P, Bates G: Foetal valproate syndrome and autism: additional evidence of an association. Pediatrics 104(1):e11, 1999 10390297 Bitnun S: Possible effect of chlordiazepoxide on the fetus. Arch Women Ment Health 15(1):69­72, 2012 22277970 Bologa M, Tang B, Klein J, et al: Pregnancy-induced changes in drug metabolism in epileptic women. Eur J Clin Pharmacol 59(10):767­773, 2003 14615857 Boukhris T, Sheehy O, Mottron L, et al: Antidepressant use during pregnancy and the risk of autism spectrum disorder in children. J Pediatr 97(2):332­333, 1980 6772753 Dallemagne G, Weiss B: Altered adult behavior of mice following postnatal treatment with haloperidol.

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The hand consists of the carpal50 region pregnancy 5 weeks 3 days order provera without prescription, with 8 small carpal bones arranged in two rows in the base of the hand; the metacarpal region in the palm breast cancer football socks cheap provera 2.5 mg online, with 5 bones; and the fingers (digits) menstrual nausea relief provera 10 mg order free shipping, with 14 bones mensis buy genuine provera on line. Note that what we colloquially call the wrist-the narrow region where one might wear a bracelet or wristwatch-is not what anatomists call the wrist (carpal region): the thick menopause belly buy provera line, fleshy base of the hand proximal to the hollow of the palm. The Humerus the humerus has a hemispherical head that articulates with the glenoid cavity of the scapula (fig. The smooth surface of the head (covered with articular cartilage in the living state) is bordered by a groove called the anatomical neck. Other prominent features of the proximal end are muscle attachments called the greater and 48 49 lesser tubercles and an intertubercular sulcus between them that accommodates a tendon of the biceps muscle. The surgical neck, a common fracture site, is a narrowing of the bone just distal to the tubercles, at the transition from the head to the shaft. Immediately proximal to these condyles, the humerus flares out to form two bony processes, the lateral and medial epicondyles, the widest points felt when you palpate your elbow. The medial epicondyle protects the ulnar nerve, which passes close to the surface across the back of the elbow. This epicondyle is popularly known as the "funny bone" because striking the elbow on the edge of a table stimulates the ulnar nerve and produces a sharp tingling sensation. Immediately proximal to the epicondyles, the margins of the humerus are called the lateral and medial supracondylar ridges. The distal end of the humerus also shows three deep pits: two anterior and one posterior. On the anterior surface, a medial pit called the coronoid fossa accommodates the coronoid process of the ulna when the forearm is flexed. When the forearm is rotated so the palm turns forward and back, the circular superior surface of this disc spins on the capitulum of the humerus, and the edge of the disc spins on the radial notch of the ulna. Immediately distal to the head, the radius has a narrower neck and then widens to a rough prominence, the radial tuberosity, on its medial surface. The distal end of the radius has the following features, from lateral to medial: 1. The posterior side of this notch is formed by a prominent olecranon-the bony point where you rest your elbow on a table. Laterally, the head of the ulna has a less conspicuous radial notch, which accommodates the edge of the head of the radius. The bony lumps you can palpate on each side of your wrist are the styloid processes of the radius and ulna. Notice that the "heads" of the radius and ulna are at opposite ends-the proximal end of the radius but distal end of the ulna. The anterior (palmar) surface of a phalanx is slightly concave from end to end and flattened from side to side; the posterior surface is rounder and slightly convex. Describe how to distinguish the medial and lateral ends of the clavicle from each other, and how to distinguish its superior and inferior surfaces. Identify the fossae, articular surfaces, and processes of this joint and state to which bone each of these features belongs. Name the four carpal bones of the proximal row from lateral to medial, then the four bones of the distal row in the same order. The Carpal Bones the carpal bones are arranged in two rows of four bones each (fig. Although they are colloquially called wrist bones, the narrow point where one might wear a wristwatch is at the distal end of the radius and ulna. The short carpal bones allow movements of the hand from side to side and anterior to posterior. Unlike the other carpal bones, the pisiform is a sesamoid bone; it is not present at birth but develops around the age of 9 to 12 years within the tendon of the flexor carpi ulnaris muscle. The bones of the distal row, again starting on the lateral side, are the trapezium,53 trapezoid, capitate,54 and hamate. The hamulus is an attachment for the flexor retinaculum, a fibrous sheet in the wrist that covers the carpal tunnel (see fig. On a skeleton, the metacarpals look like extensions of the fingers, making the fingers seem much longer than they really are. The proximal end of a metacarpal bone is called the base, the shaft is called the body, and the distal end is called the head. There are two phalanges in the pollex (thumb) and three in each of the other digits. Phalanges are identified by roman numerals preceded by proximal, middle, and distal. The three parts of a phalanx are the Pelvic Girdle the terms pelvis and pelvic girdle are used in contradictory ways by various anatomical authorities. Some people remember the names of the carpal bones with the mnemonic, "Sally left the party to take Charlie home. This unique bone is a useful landmark for locating the others when studying the skeleton. Identify the unlabeled bones in the X-ray by comparing it with the drawing in part (a). The pelvis59 is a bowl-shaped structure composed of these bones as well as the ligaments and muscles that line the pelvic cavity and form its floor. The pelvic girdle supports the trunk on the lower limbs and encloses and protects the viscera of the pelvic cavity-mainly the lower colon, urinary bladder, and internal reproductive organs. Each hip bone is joined to the vertebral column at one point, the sacroiliac joint, where its auricular surface matches the auricular surface of the sacrum. The two hip bones articulate with each other on the anterior side of the pelvis, where they are joined by a pad of fibrocartilage called the interpubic disc. The disc and the adjacent region of each pubic bone constitute the pubic 59 symphysis,60 which can be palpated as a hard prominence immediately above the genitalia. The pelvis has a bowl-like shape with the broad greater (false) pelvis between the flare of the hips, and the narrower lesser (true) pelvis below. The hip bones have three distinctive features that will serve as landmarks for further description. The largest of these is the ilium, which extends from the iliac crest to the center of the acetabulum. The iliac crest extends from an anterior point or angle called the anterior superior iliac spine to a sharp posterior angle called the posterior superior iliac spine. In a lean person, the anterior superior spines form visible anterior protrusions at a point where the front pockets usually open on a pair of pants, and the posterior superior spines are sometimes marked by dimples above the buttocks where connective tissue attached to the spines pulls inward on the skin (see atlas B, fig. The posterolateral surface of the ilium is relatively rough-textured because it serves for attachment of several muscles of the buttocks and thighs. The anteromedial surface, by contrast, is the smooth, slightly concave iliac fossa, covered in life by the broad iliacus muscle. Medially, the ilium exhibits an auricular surface that matches the one on the sacrum, so that the two bones form the sacroiliac joint. Inferior to the spine is a slight indentation, the lesser sciatic notch, and then the thick, rough-surfaced ischial tuberosity, which supports your body when you are sitting. The three childhood bones that fuse to form the 63 obtur = to close, stop up; ator = that which adult hip bone are identified by color according to the key at the top. In anatomical position, it is nearly horizontal and serves as a platform for the urinary bladder. The pubis is often fractured when the pelvis is subjected to violent anteroposterior compression, as in seat-belt injuries. The pelvis is the most sexually dimorphic part of the skeleton-that is, the one whose anatomy most differs between the sexes. In identifying the sex of skeletal remains, forensic scientists focus especially on the pelvis but on many other bones as well. The Lower Limb the number and arrangement of bones in the lower limb are similar to those of the upper limb. In the lower limb, however, they are adapted for weight bearing and locomotion and are therefore shaped and articulated differently. The femur and tibia are essentially pillars for supporting the weight of the body. The patella (kneecap) is a sesamoid bone at the junction of the femoral and crural regions. The leg proper (crural region) extends from knee to ankle and contains two bones, the medial tibia and lateral fibula. The foot consists of the tarsal region, with 7 tarsal bones extending from the heel to the midpoint of the foot arch; metatarsal region, with 5 bones extending from there to the "balls" of the feet just proximal to the toes; and toes (digits), with 14 bones. As with the colloquial versus anatomical meaning of wrist, the colloquial meaning of ankle (the narrow point where one might wear an ankle bracelet) is different from the anatomical meaning: the posterior half of the foot containing the seven tarsal (ankle) bones. In anatomical terms, the wrist is part of the hand and the ankle is part (indeed, about half) of the foot. The trochanters are connected on the posterior side by a thick oblique ridge of bone, the intertrochanteric crest, and on the anterior side by a more delicate intertrochanteric line. At its upper end, the linea aspera forks into a medial spiral (pectineal) line and a lateral gluteal tuberosity. The gluteal tuberosity is a rough ridge (sometimes a depression) that serves for attachment of the powerful gluteus maximus muscle of the buttock. At its lower end, the linea aspera forks into medial and lateral supracondylar lines, which continue down to the respective epicondyles. The medial and lateral epicondyles are the widest points of the femur, easily palpated at the knee. These and the supracondylar lines are attachments for certain thigh and leg muscles and knee ligaments. During knee flexion and extension, the condyles rock on the superior surface of the tibia. On the anterior side of the femur, a smooth medial depression called the patellar surface articulates with the patella. On the posterior side is a flat or slightly depressed area called the popliteal surface. It has a broad superior base, a pointed inferior apex, and a pair of shallow articular facets on its posterior surface where it articulates with the femur. The quadriceps femoris tendon extends from the anterior quadriceps femoris muscle of the thigh to the patella, and it continues as the patellar ligament from the patella to the tibia. This is a change in terminology more than a change in structure or function, as a tendon connects muscle to bone and a ligament connects bone to bone. Because of the way the quadriceps tendon loops over the patella, the patella modifies the direction of pull by the quadriceps muscle and improves its efficiency in extending the knee, hence the efficiency of walking and running. Its broad superior head has two fairly flat articular surfaces, the medial and lateral condyles, separated by a ridge called the intercondylar eminence. The rough anterior surface of the upper tibia, the tibial tuberosity, can be palpated just below the patella. This is an attachment for the powerful thigh muscles that extend (straighten) the knee. Distal to this, the shaft has a sharply angular anterior border, which can be palpated in the shin. It has a hemispherical head that articulates with the acetabulum of the pelvis, forming a quintessential ball-and-socket joint. The medial malleolus is part of the tibia, and the lateral malleolus is the part of the fibula. The Ankle and Foot the tarsal bones of the ankle are arranged in proximal and distal groups somewhat like the carpal bones of the wrist (fig. Because of the load-bearing role of the ankle, however, their shapes and arrangement are conspicuously different from those of the carpal bones, and they are fully integrated into the structure of the foot. Its posterior end is the point of attachment for the calcaneal (Achilles) tendon from the calf muscles. It has three articular surfaces: an inferoposterior one 69 the Fibula the fibula (fig. The fibula is somewhat thicker and broader at its proximal end, the head, than at the distal end. The remaining bones of the foot are similar in arrangement and name to those of the hand. They are metatarsals I through V 70 71 navi = boat; cul = little; ar = like cunei = wedge; form = in the shape of 72 meta = beyond; tars = ankle from medial to lateral, metatarsal I being proximal to the great toe. The great toe is the hallux and contains only two bones, the proximal and distal phalanx I. The metatarsal and phalangeal bones each have a base, body, and head, like the bones of the hand. All of them, especially the phalanges, are slightly concave on the inferior (plantar) side. Note that roman numeral I represents the medial group of bones in the foot but the lateral group in the hand. The reason for the difference between the hand and foot lies in a rotation of the limbs that occurs in the seventh week of embryonic development. Early in the seventh week, the limbs extend anteriorly from the body, the foot is a paddlelike foot plate, and the hand plate is also more or less paddlelike with the finger buds showing early separation (fig. The future thumb and great toe are both directed superiorly, and the future palms and soles face each other medially. Thumb Elbow Knee Great toe (b) Eight weeks out in front of you with the palms facing each other as if you were about to clap. Then rotate your forearms so the thumbs face away from each other (laterally) and the palms face upward. The lower limbs rotate in the opposite direction, medially, so that the soles face downward and the great toes become medial. So even though the thumb and great toe (digit I of the hand and foot) start out facing in the same direction, these opposite rotations result in their being on opposite sides of the hand and foot (fig.

The innermost osteocytes around each central canal receive nutrients from these blood vessels and pass them along through their gap junctions to neighboring osteocytes breast cancer 5k in washington dc buy provera 2.5 mg with amex. They also receive wastes from their neighbors and convey them to the central canal for removal by the bloodstream breast cancer under arm discount provera 2.5 mg without prescription. Thus women's health center williamsport pa cheap 5 mg provera with amex, the cytoplasmic processes of the osteocytes maintain a two-way flow of nutrients and wastes between the central canal and the outermost cells of the osteon women's health clinic denton tx order cheap provera. The inner and outer boundaries of dense bone are arranged in circumferential lamellae that run parallel to the bone surface pregnancy 0-2 weeks 5 mg provera overnight delivery. Between osteons, we can find irregular regions called interstitial lamellae, the remains of old osteons that broke down as the bone grew and remodeled itself. For example, factories employed women to paint luminous numbers on watch and clock dials with radium paint. The women moistened their paint brushes with their tongues to keep them finely pointed and ingested radium in the process. The radium accumulated in their bones and caused many of them to develop a bone cancer called osteosarcoma. Even more horrific, in the wisdom of hindsight, was a deadly health fad in which people drank "tonics" made of radium-enriched water. One famous enthusiast was the millionaire playboy and championship golfer Eben Byers (1880­1932), who drank several bottles of radium tonic each day and praised its virtues as a wonder drug and aphrodisiac. By the time of his death, holes had formed in his skull and doctors had removed his entire upper jaw and most of his mandible in an effort to halt the spreading cancer. Brain damage left him unable to speak, but he remained mentally alert to the bitter end. His tragic decline and death shocked the world and helped put an end to the radium tonic fad. Lamellae of one osteon are telescoped to show their alternating arrangement of collagen fibers. The art inset relates osteocyte structure to the shapes of the lacunae and canaliculi of the bone. The matrix is arranged in lamellae like those of compact bone, but there are few osteons. Central canals are not needed here because no osteocyte is very far from the marrow. Spongy bone is well designed to impart strength to a bone while adding a minimum of weight. Spongy bone has much more surface area exposed to osteoclast action than compact bone does. Therefore, when osteoclasts resorb bone tissue, it comes largely from the spongy bone, as we see in osteoporosis (see Deeper Insight 7. Head Trabeculae of spongy bone Compact bone Lines of stress Shaft (diaphysis) Bone Marrow Bone marrow is a general term for soft tissue that occupies the marrow cavity of a long bone, the spaces amid the trabeculae of spongy bone, and the larger central canals. In a child, the marrow cavity of nearly every bone is filled with red bone marrow (myeloid tissue). In adults, most of the red marrow turns to fatty yellow bone marrow, like the fat at the center of a ham bone. Red marrow is then limited to the skull, vertebrae, ribs, sternum, part of the pelvic (hip) girdle, and the proximal heads of the humerus and femur (fig. Yellow bone marrow no longer produces blood, although in the event of severe or chronic anemia, it can transform back into red marrow and resume its hemopoietic function. Suppose you had unlabeled electron micrographs of the four kinds of bone cells and their neighboring tissues. Name the four cells and explain how you could visually distinguish each one from the other three. In this frontal section of the femur, the trabeculae of spongy bone can be seen oriented along lines of mechanical stress applied by the weight of the body or the pull of a muscle. As osteoblasts become trapped in their own hardening matrix, they become osteocytes. At the surfaces, osteoblasts beneath the periosteum deposit layers of bone, fill in the spaces between trabeculae, and create a zone of compact bone on each side as well as thicken the bone overall. This process gives rise to the sandwichlike structure typical of a flat cranial bone-a layer of spongy bone between two layers of compact bone. Throughout the skeleton, it is the method of depositing new tissue on the bone surface even past the age where the bones can no longer grow in length. Most bones of the body develop in this way, including the vertebrae, ribs, sternum, scapula, pelvic girdle, and bones of the limbs. This figure uses a metacarpal bone from the palmar region of the hand as an example because of its relative simplicity, having only one epiphyseal plate (growth center). Many other bones develop in more complex ways, having an epiphyseal plate at both ends or multiple plates at each end, but the basic process is the same. Red bone marrow occupies the marrow cavities of the axial skeleton and proximal heads of the humerus and femur. Mesenchyme develops into a body of hyaline cartilage, covered with a fibrous perichondrium, in the location of a future bone. For a time, the perichondrium produces chondrocytes and the cartilage model grows in thickness. In a primary ossification center near the middle of this cartilage, chondrocytes begin to inflate and die, while the thin walls between them calcify. These deposit a thin collar of bone around the middle of the cartilage model, reinforcing it like a napkin ring. As chondrocytes in the middle of the model die, their lacunae merge into a single cavity. Osteoclasts arrive in the blood and digest calcified tissue in the shaft, hollowing it out and creating the primary marrow cavity. Osteoblasts also arrive and deposit layers of bone lining the cavity, thickening the shaft. As the bony collar under the periosteum thickens and elongates, a wave 2 1 Mesenchyme first condenses into a soft sheet of tissue permeated with blood vessels-the membrane to which intramembranous refers. Mesenchymal cells line up along the blood vessels, become osteoblasts, and secrete a soft collagenous osteoid19 tissue (prebone) (fig. Calcium phosphate and other minerals crystallize on the collagen fibers of the osteoid tissue and harden the matrix. The figures are drawn to different scales, with the highest magnification and detail at the beginning and backing off for a broader overview at the end of the process. With the aid of chapter 8, name at least two specific bones other than the clavicle that would form by this process. Periosteum: Fibrous layer Osteogenic layer Osteoid tissue Osseous tissue (bone) Osteoblasts Osteocytes 4 death occur in the epiphysis of the model as well, creating a secondary ossification center. In the metacarpal bones, as illustrated in the figure, this occurs in only one epiphysis. The secondary ossification center hollows out by the same process as the diaphysis, generating a secondary marrow cavity in the epiphysis. In bones with two secondary ossification centers, one center lags behind the other, so at birth there is a secondary marrow cavity at one end while chondrocyte growth has just begun at the other. The joints of the limbs are still cartilaginous at birth, much as they are in the 12-week fetus in figure 7. The plate persists through childhood and adolescence and serves as a growth zone for bone elongation. Note the layers of osteoid tissue, osteoblasts, and fibrous periosteum on both sides of the bone. Osteoclasts in the marrow cavity follow this wave, dissolving calcified cartilage remnants and enlarging the marrow cavity of the diaphysis. The region of transition from cartilage to bone at each end of the primary marrow cavity is called a metaphysis. With the aid of chapter 8, name at least two specific bones that would have two epiphyseal plates (proximal and distal) at stage 5. Cranial bones Mandible Bone Growth and Remodeling Ossification does not end at birth, but continues throughout life with the growth and remodeling of bones. Humerus Radius Ulna Vertebrae Scapula Ribs Bone Elongation To understand growth in length, we must return to the epiphyseal plates mentioned earlier (see fig. From infancy through adolescence, an epiphyseal plate is present at one or both ends of a long bone, at the junction between the diaphysis and epiphysis. On X-rays, it appears as a translucent line across the end of a bone, since it is not yet ossified (fig. The epiphyseal plate is a region of transition from cartilage to bone, and functions as a growth zone where the bones elongate. The red- stained regions are calcified at this age, whereas the elbow, wrist, knee, and ankle joints appear translucent because they are still cartilaginous. This region, farthest from the marrow cavity, consists of typical hyaline cartilage with resting chondrocytes, not yet showing any sign of transformation into bone. A little closer to the marrow cavity, chondrocytes multiply and arrange themselves into longitudinal columns of flattened lacunae. Next, the chondrocytes cease to multiply and begin to hypertrophy (enlarge), much like they do in the primary ossification center of the fetus. Minerals are deposited in the matrix between the columns of lacunae and calcify the cartilage. Within each column, the walls between the lacunae break down and the chondrocytes die. This converts each column into a longitudinal channel (clear spaces in the figure), which is immediately invaded by blood vessels and marrow from the marrow cavity. Osteoblasts line up along the walls of these channels and begin depositing concentric lamellae of matrix, while osteoclasts dissolve the temporarily calcified cartilage. But around the perimeter of the marrow cavity, continuing ossification converts this spongy bone to compact bone. Osteoblasts lining the aforementioned channels deposit layer after layer of bone matrix, so the channel grows narrower and narrower. By adulthood, these will disappear and the epiphyses will fuse with the diaphyses. Chondrocyte multiplication in zone 2 and hypertrophy in zone 3 continually push the zone of reserve cartilage (1) toward the ends of the bone, so the bone elongates. In the lower limbs, this process causes a person to grow in height, while bones of the upper limbs grow proportionately. Cartilage growth from within, by the multiplication of chondrocytes and deposition of new matrix in the interior, is called interstitial21 growth. The most common form of dwarfism results from a failure of cartilage growth in the long bones (see Deeper Insight 7. In the late teens to early twenties, all the cartilage of the epiphyseal plate is depleted. The junctional region where they meet is filled with spongy bone, and the site of the original epiphyseal plate is marked with a line of slightly denser spongy bone called the epiphyseal line (see figs. When the epiphyseal plate is depleted, we say that the epiphyses have "closed" because no gap between the epiphysis and diaphysis is visible on an X-ray. Once the epiphyses have all closed in the lower limbs, a person can grow no taller. This micrograph shows the transition from cartilage to bone in the growth zone of a long bone. Bone Widening and Thickening Bones also continually grow in diameter and thickness. This involves a process called appositional growth,22 the deposition of new tissue at the surface. In bone, however, osteocytes embedded in calcified matrix have little room to spare for the deposition of more matrix internally. Osteoblasts in the inner layer of periosteum deposit osteoid tissue on the bone surface, calcify it, and become trapped in it as osteocytes-much like the process in figure 7. They lay down matrix in layers parallel to the surface, not in 22 cylindrical osteons like those deeper in the bone. This process produces the surface layers of bone called circumferential lamellae, described earlier. This is achieved by osteoclasts of the endosteum dissolving tissue on the inner bone surface. Thus, flat bones develop by intramembranous ossificaton alone, whereas long bones develop by a combination of the intramembranous and endochondral methods. Bone Remodeling In addition to their growth, bones are continually remodeled throughout life by the absorption of old bone and deposition of new. It repairs microfractures, releases minerals into the blood, and reshapes bones in response to use and disuse. As its name implies, achondroplastic dwarfism results from a failure of cartilage growth-specifically, failure of the chondrocytes in zones 2 and 3 of the metaphysis to multiply and enlarge. This is different from pituitary dwarfism, in which a deficiency of growth hormone stunts the growth of all of the bones, and a person has short stature but normal proportions throughout the skeletal system. Two people of normal height with no family history of dwarfism can therefore have a child with achondroplastic dwarfism. The mutant allele is dominant, so the offspring of a heterozygous achondroplastic dwarf have at least a 50% chance of exhibiting dwarfism, depending on the genotype of the other parent. Persons homozygous for the trait (those who inherit it from both parents) are usually stillborn or die soon after birth. Wolff observed that these stress lines were very similar to the ones that engineers knew of in mechanical cranes. The effect of stress on bone development is quite evident in tennis players, in whom the bones of the racket arm are more robust than those of the other arm.

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