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When considering a diagnosis of DCIS 100 mg lady era sale, LCIS lady era 100mg mastercard, or ADH buy lady era 100mg mastercard, it is important to keep these management differences in mind. Many primary care clinicians (and some surgeons) do not fully understand the terms DCIS, LCIS, ADH, and atypical lobular hyper- plasia (ALH). For this reason, the pathology report should include an explanation of the clinical significance of these terms, that is, that DCIS is a premalignant lesion placing the biopsied breast at risk, whereas LCIS and atypical hyperplasia are “markers” for risk in both breasts. It is also important to state clearly that there is no invasive carcinoma, because the “carcinoma” in DCIS or LCIS may be misun- derstood to mean the patient has “cancer. Nineteen percent of all breast biopsy claims involved large-core (cutting) needle biopsies of palpable breast masses or stereotaxic image-guided needle biopsies of nonpalpable lesions discovered on mammography. The following is a list of some diagnostic errors uncov- ered in a review of these claims: 1. The misdiagnosis of DCIS, sclerosing adenosis, and florid adenosis as invasive ductal carcinoma. Injury results if mastectomy is per- formed without first performing an excisional biopsy of the lesion or if axillary lymph nodes are sampled at the time an excisional biopsy is performed. Because LCIS is a “marker” for increased risk, whereas DCIS is a premalignant lesion, the management is totally different. Patient injury results if axillary lymph node sampling is performed at the time of excisional biopsy. The failure to recognize small, easily overlooked foci of invasive lobular carcinoma. These differential diagnostic possibilities need to be consciously considered when interpreting needle biopsies of breast lesions (18,19). If there are any reservations, then a definitive diagnosis should not be made and excisional biopsy should be recommended. When in situ carcinoma is diagnosed on needle biopsy, excisional biopsy should be performed because there may be invasive carcinoma as well. Biopsy Chapter 12 / Breast Cancer Litigation 163 is also recommended when ADH is diagnosed on needle biopsy, because there may be associated DCIS or invasive carcinoma (20,21). A study comparing the accuracy rates of breast biopsy techniques found that cutting needle biopsy without image guidance had a sensitivity of only 85%. This was considerably less than open breast biopsy (99%), FNA (96%), or cutting needle biopsy with image guidance (98%) (22). CONCLUSION Claims involving breast cancer are frequent and are less likely to be successfully defended than most other malpractice cases. Most women present with no signs or symptoms other than the breast mass itself. It is the patient, not the doctor, who usually finds a lump, and these cases bring higher average indemnities. Although these claims can involve physicians of any specialty, radiologists, pathologists and obstetrician/gynecologists are the most frequently targeted. Sur- prisingly, the problem is more likely to be a communication error resulting from failure to take appropriate action following a correctly read study than it is to be an interpretation error. One promising technique, computer-aided detection (CAD), offers the promise of reducing interpretation error and is just becoming more widely available. Mammogram films are taken in the usual manner and then scanned into a CAD system. The CAD system digitizes the mammogram and analyzes it for regions of interest, either clustered bright spots suggestive of microcalcification or dense regions sug- gesting a mass or architectural distortion. The radiologist first reads the film mammogram, then reviews the areas detected by the CAD system and evaluates them for clinical relevance. Published studies using blinded review of a prior “normal” mammogram in patients with newly diagnosed breast cancer showed that 23% of these films were, in fact, actionable. This 20% increase in the breast cancer detection rate is impressive and, if CAD is widely adopted, may reduce the frequency of breast cancer malpractice claims (23,24).

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Contraction of the papillary muscles prevents the mitral valve from everting into the left atrium and enables the valve to prevent the regurgitation of blood into the atrium as ventricular pressure rises proven lady era 100mg. The aortic valve does not open until left ventricular pressure exceeds aortic pres- sure discount 100 mg lady era visa. During the interval when both mitral and aortic valves 120 are closed cheap lady era 100 mg mastercard, the ventricle contracts isovolumetrically (i. The contraction Aortic 100 valve causes ventricular pressure to rise, and when ventricular opens pressure exceeds aortic pressure (at approximately 80 mm * Hg), the aortic valve opens and allows blood to flow from 80 * Aortic the ventricle into the aorta. At this point, ventricular mus- valve Aortic 60 closes cle begins to shorten, reducing the volume of the ventricle. Ventricular pressure actually decreases closes Left atrial 20 valve slightly below aortic pressure prior to closure of the aortic pressure v a cc opens valve, but flow continues through the aortic valve because * * 0 of the inertia imparted to the blood by ventricular contrac- tion. The ball continues to travel away from the paddle after you pull back because the inertial force on the 30 ball exceeds the force generated by the rubber band. Ventricular repolarization (produc- (ventricular outflow) ing the T wave) initiates ventricular relaxation or ventricu- 0 lar diastole. When the ventricular pressure drops below the atrial pressure, the mitral valve opens, allowing the blood 120 accumulated in the atrium during systole to flow rapidly into the ventricle; this is the rapid phase of ventricular fill- ing. Both pressures continue to decrease—the atrial pres- Ventricular volume sure because of emptying into the ventricle and the ven- 85 tricular pressure because of continued ventricular relaxation (which, in turn, draws more blood from the atrium). About midway through ventricular diastole, filling slows as ven- tricular and atrial pressures converge. S S2 S S4 1 3 S4 Pressures, Flows, and Volumes in the Cardiac R P T Electrocardiogram Chambers, Aorta, and Great Veins Can Be Matched With the ECG and Heart Sounds Q S The pressures, flows, and volumes in the cardiac chambers, 0 0. In electrical terms, ventricular systole is de- fined as the period between the QRS complex and the end of the T wave. In mechanical terms, it is the period between ously, blood enters the right atrium from the superior and the closure of the mitral valve and the subsequent closure of inferior vena cavae. In either case, ventricular diastole com- during atrial diastole produces the v wave and reflects its prises the remainder of the cycle. The small pressure oscillation early in atrial dias- The first (S1) and second (S2) heart sounds signal the be- tole, called the c wave, is caused by bulging of the mitral ginning and end of mechanical systole. The first heart sound valve and movements of the heart associated with ven- (usually described as a “lub”) occurs as the ventricle contracts tricular contraction. The relatively low- pitched sound associated with their closure is caused by vi- TABLE 14. Force of contraction tic and pulmonic valves close at the end of ventricular sys- 1. End-diastolic fiber length (Starling’s law, preload) tole, when the ventricles relax and pressures in the ventricles a. Contractility aortic and pulmonic valves produce the second heart sound, a. Sympathetic stimulation via norepinephrine acting on 1 which is relatively high-pitched (typically described as a receptors “dup”). Circulating epinephrine acting on 1 receptors (minor) and nearby structures contribute to these two sounds, espe- c. Intrinsic changes in contractility in response to changes cially S1; these factors include movement of the great vessels in heart rate and afterload and turbulence of the rapidly moving blood. Ventricular radius the rapid phase of ventricular filling and is associated with 2. Heart rate (and pattern of electrical excitation) heard in normal children and adolescents, its appearance in a patient older than age 35 usually signals the presence of a cardiac abnormality. It is caused by blood movement resulting from atrial contraction and, like S , is more com- Stroke Volume Is a Determinant 3 mon in patients with abnormal hearts.

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However discount 100 mg lady era, because it increases active vitamin calcium from plasma into bone discount 100mg lady era overnight delivery. Calcitonin has little or no D formation purchase lady era 100 mg line, it ultimately increases the absorption of both direct effect on the GI tract. The net effect of 1,25-dihydroxycholecalciferol is to in- Calcitonin is important in several lower vertebrates, but crease both calcium and phosphate concentrations in despite its many demonstrated biological effects in humans, plasma (Fig. The activated form of vitamin D prima- it appears to play only a minor role in calcium homeostasis. First, CT loss following surgical removal of the thyroid In the kidneys, 1,25-dihydroxycholecalciferol increases gland (and, therefore, removal of CT-secreting parafollicu- the tubular reabsorption of calcium and phosphate, pro- 642 PART IX ENDOCRINE PHYSIOLOGY Plasma calcium Parathyroid glands PTH secretion Plasma PTH Kidneys Phosphate 1,25-(OH)2 D3 Bone reabsorption formation resorption Calcium reabsorption Urinary excretion Plasma of phosphate 1,25-(OH)2 D3 Urinary excretion Release of calcium of calcium into plasma Intestine Calcium absorption FIGURE 36. Plasma calcium Parafollicular cells CT secretion Plasma CT Kidneys Phosphate Calcium Bone reabsorption reabsorption resorption Urinary excretion Urinary excretion Calcium of phosphate of calcium release FIGURE 36. CHAPTER 36 Endocrine Regulation of Calcium, Phosphate, and Bone Metabolism 643 Plasma calcium Plasma PTH Renal 1α-hydroxylase activity 1,25-(OH)2 D3 formation Plasma 1,25-(OH)2 D3 Kidneys Bone Phosphate Calcium promotes PTH reabsorption reabsorption action Intestine Urinary excretion Phosphate Calcium of phosphate absorption absorption Urinary excretion of calcium FIGURE 36. Osteoporosis involves a reduction in total this is a weak and probably only minor effect of the hor- bone mass with an equal loss of both bone mineral and or- mone. Several factors are known to contribute di- osteoclasts, increasing bone resorption (see Fig. Long-term dietary calcium defi- In the gastrointestinal tract, 1,25-dihydroxycholecalcif- ciency can lead to osteoporosis because bone mineral is erol stimulates calcium and phosphate absorption by the mobilized to maintain plasma calcium levels. Vitamin C de- small intestine, increasing plasma concentrations of both ficiency also can result in a net loss of bone because vitamin ions. This effect is mediated by increased production of cal- C is required for normal collagen synthesis to occur. A de- cium transport proteins resulting from gene transcription fect in matrix production and the inability to produce new events and usually requires several hours to appear. For reasons that are not entirely understood, a reduction in the me- chanical stress placed on bone can lead to bone loss. Im- ABNORMALITIES OF BONE mobilization or disuse of a limb, such as with a cast or paral- MINERAL METABOLISM ysis, can result in localized osteoporosis of the affected limb. Space flight can produce a type of disuse osteoporo- There are several metabolic bone diseases, all typified by sis resulting from the condition of weightlessness. The conditions most fre- vancing age in both men and women, and it cannot be as- quently encountered clinically are osteoporosis, osteomala- signed to any specific definable cause. Osteoporosis Is a Reduction in Bone Mass Until about the time of puberty, males and females have Osteoporosis is a major health problem, particularly be- similar bone mineral content. However, at puberty, males cause older adults are more prone to this disorder and the begin to acquire bone mineral at a greater rate; peak bone average age of the population is increasing (see Clinical Fo- mass may be approximately 20% greater than that of 644 PART IX ENDOCRINE PHYSIOLOGY CLINICAL FOCUS BOX 36. While it is known that a diet bone loss initially occurs without symptoms. People may low in calcium or vitamin D, certain medications such as not know that they have significant bone loss until their glucocorticoids and anticonvulsants, and excessive inges- bones become so weak that a sudden strain, bump, or fall tion of aluminum-containing antacids can cause osteo- causes a fracture. Osteoporosis is a major public health porosis, in most cases, the exact cause is unknown. How- threat in the United States because it affects some 28 mil- ever, several identified risk factors associated with the lion Americans. Some 10 million individuals have been di- disease are being a woman (especially a postmenopausal agnosed with the disease and another 18 million have low woman); being Caucasian or Asian; being of advanced bone mass, placing them at increased risk for osteoporo- age; having a family history of the disease; having low sis. Approximately 80% of those affected by osteoporosis testosterone levels (in men); having an inactive lifestyle; are women.

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