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By A. Mine-Boss. Valdosta State University.

The degree of visu- using the appropriate technique for clean- al loss that results from an eye injury is a ing and applying contact lenses purchase viagra soft 50mg on line impotence treatment devices. Using Glaucoma is a condition involving in- appropriate eye protection for work viagra soft 50mg on line vacuum pump for erectile dysfunction in pakistan, creased intraocular pressure. If left untreat- home, and sports activities that carry a risk ed, permanent damage to the optic nerve of eye injury is one of the major forms of can result, causing blindness. Glaucoma The most common eye disease is con- occurs when the amount of aqueous junctivitis (inflammation of the mem- humor produced exceeds the amount brane that lines the eye, the conjunctiva. In most instances, even though the drainage pipe is blocked, conjunctivitis is easily treated, is self-lim- resulting in overaccumulation of water in iting, and has no permanent effects. Some types of infectious conjunctivitis, such as gonococcal conjunctivitis, or tra- Types of Glaucoma choma, however, can cause ulceration of the cornea and subsequent blindness. Uveitis is an inflammation of the uveal Broad categories are based on the reason tract (iris, ciliary body, choroid). Because the outflow no longer equals the inflow, the amount of Treatment of glaucoma is directed to- aqueous humor builds and pressure in the ward reducing the intraocular pressure by eye increases. Open-angle glaucoma gen- decreasing the amount of aqueous humor erally progresses slowly over many years, produced or by increasing its outflow. This producing no symptoms until the optic can be accomplished with medication or nerve is sufficiently damaged to reduce through surgically creating a new pathway visual acuity and visual field. Vision loss gen- Medication for the treatment of glauco- erally begins with the loss of peripheral ma, whether eye drops or oral medication, (side) vision so that individuals can see must be used daily throughout life to con- only straight ahead, as if looking through trol eye pressure and prevent further dam- a tunnel (tunnel vision). In either type of glaucoma, peripheral vision is often gradual, individ- early detection and treatment are critical uals may be unaware of the problem until to prevent irreversible damage to the optic advanced stages of the condition. Regard- treated, the field of vision continues to less of the type of glaucoma, lifetime med- narrow until all vision is lost. Treatment of Chronic Acute Closed-Angle Glaucoma Open-Angle Glaucoma Acute closed-angle glaucoma develops Chronic open-angle glaucoma may be much more rapidly than chronic open- controlled with medication in the form of angle glaucoma and is a medical emer- eye drops alone to decrease production of gency. Symptoms include sudden severe aqueous humor or in combination with pain, sharply decreased vision, nausea and oral medication that reduces pressure in vomiting, and rapid damage to the optic the eye, thus halting progression of the nerve with associated vision loss. Because eye drops are absorbed closed-angle glaucoma results from an into the bloodstream, they may affect oth- abrupt blockage and obstruction of the er body functions and cause systemic side canal of Schlemm so that aqueous humor effects ranging from generalized weakness rapidly accumulates in the anterior to central nervous system, cardiovascular, chamber of the eye. Oral med- angle glaucoma is much less common ications for the treatment of glaucoma than chronic open-angle glaucoma, it is work by decreasing the production of a medical emergency and must be treat- aqueous humor. For example, arteriosclerot- medical supervision, not only to monitor ic retinopathy is due to changes that occur the condition itself but also to identify any in blood vessels in the retina because of side effects of the medication. Hypertensive retinopathy is When intraocular pressure cannot be due to changes that occur in blood vessels successfully controlled with medication, in the retina because of high blood pres- individuals with chronic open-angle glau- sure. In both instances, treatment of the coma may have a surgical procedure primary underlying condition can control called trabeculectomy that relieves pressure the progress of retinopathy. Individuals may also need and the most common cause of blindness, to continue using eye drops or oral med- is diabetic retinopathy. Diabetic retinopathy ication after surgery to control pressure; is the result of damage to the retina and is however, in some instances surgery may a complication of diabetes mellitus (see eliminate the need for medication. Treatment of Acute Closed-Angle Glaucoma Consequently, regular comprehensive eye examinations by a physician are impor- Acute closed-angle glaucoma results tant in helping to prevent visual loss. Nonproliferative diabetic retinopathy miotics constrict the pupil, thus enlarging 2. Proliferative diabetic retinopathy the drainage passageway and facilitating the outflow of aqueous humor. Because of Nonproliferative diabetic retinopathy is the emergency nature of acute closed- caused by changes in blood vessel walls angle glaucoma, oral or intravenous med- that allow fluids to leak into retinal tissue. As a rior chamber of the eye, thus preventing result, retinal tissues receive too little oxy- further eye damage by relieving built-up gen (ischemia) and growth of new vessels pressure. At times iridotomy abnormally fragile and prone to bleed, may also be performed prophylactically in causing hemorrhage into the vitreous the unaffected eye after an acute attack.

There are considerable data that a $250 purchase viagra soft 50mg overnight delivery erectile dysfunction drugs list,000 cap on noneconomic damages reduces malpractice premiums by 25 to 30% (2 buy viagra soft 50mg cheap psychological erectile dysfunction drugs,28,36), and experience in California, Colorado, and other states is confirmatory. The mirror image of the positive effect of real reform can be seen in the experience of states that had caps on noneconomic damages that were invalidated by their state supreme courts. Ohio enacted MICRA- like reforms in 1975, but the Ohio Supreme Court nullified these in 1985. Malpractice insurance rates fell steadily until 1982, when the law was challenged in the courts. Since 1985, Ohio malpractice premiums have once again increased significantly and the state is dealing with a Chapter 15 / The Case for Legal Reform 215 Fig. In 2003, Ohio approved a new set of reforms in an effort to ameliorate the growing problem. By 2000, malpractice indem- nities in the state had increased 400% compared to 1998 (38). Alabama, Georgia, Illinois, Kansas, New Hampshire, North Dakota, and Washington have also had tort reforms nullified by their state supreme courts (4). Today, Georgia, Illinois, Oregon, and Washington are among the 19 states facing a professional liability crisis (4). New York did so in 1975, 1981, and 1986 with no observable improve- ment in the malpractice insurance situation (33). Florida and Texas have repeated similar experiences (24), and in 2003 both state legis- latures attempted to remedy the deteriorating medical-legal climate in their state with new reforms that do include caps on noneconomic damages. A work group of the American Academy of Actuaries concluded that to be effective, a package of medical malpractice reforms must include a $250,000 per injury limit on noneconomic damages and a collateral source offset (33). They found that reforms worked best when imple- mented together as a comprehensive program. Most significantly, they confirmed that porous caps with built-in exceptions or multipliers and peripheral reforms that do not include the fundamental elements of MICRA are predictably ineffective. States with $250,000 or $350,000 limits on noneconomic damages had average premium increases only one-third as large as those in states without caps between 2000 and 2001 (2,39). California’s experience over the preceding quarter century stands as firm testimony to these data. In 2002, the nonpartisan Congressional Budget Office estimated that the MICRA-based reforms contained in House Resolution 4600 (which failed to pass the Senate) would have lowered malpractice insurance premiums by 25 to 30% (40). Milliman USA analyzed medical malpractice claims in the 15 largest states from 1990 to 2001 and concluded that caps on noneconomic damages reduced medical malpractice loss costs for physicians (41). In this study, reform states like California and Colorado saw loss costs reduced 48 and 31%, respectively. In contrast, New York’s loss cost per physician stood at 300% compared to California, and Pennsylvania’s stood at 328%. In an earlier study, Milliman had estimated that a $250,000 cap on noneconomic damages in New York would reduce premium levels by 29% (32). Perhaps the most comprehensive study of this issue ever undertaken was that delivered by the Governor’s Select Task Force on Healthcare Professional Liability Insurance in Florida in 2002 (22). Testimony ran to 13 volumes and included physicians, lawyers, insurance industry representatives, regulators, legal scholars, professional organizations, and concerned citizens. The final report exceeds 300 pages and contains more than 1300 citations. The report takes note of Florida’s past history of unsuccessful reform and concludes that: “A cap on non-economic damages of $250,000 per incident limited only to healthcare professional liability cases is the only available remedy that can produce a necessary level of predictability... The authors noted that Florida’s unsuccessful previous attempts at reforms that did not include such a cap “are nothing more than a failed litany of alternatives” (22). Chapter 15 / The Case for Legal Reform 217 The National Association of Insurance Commissioners (NAIC) stud- ied the market for medical malpractice insurance to evaluate the current crisis in 2003 (28). Its conclusions, made independently and with access to the considerable state statutory data and experience, are in accord with those detailed previously. It found rising premium rates to be pri- marily a function of increasing claims costs. In addition, they found these problems were impeding public access to essential health care.

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Protein-bound calcium viagra soft 50 mg lowest price erectile dysfunction caused by vasectomy, therefore generic viagra soft 50mg with visa erectile dysfunction 47 years old, has the capacity to serve as a buffer of free plasma calcium concentrations. This effect 3,000 600 is rapid and does not require complex signaling pathways; however, the capacity is limited, and the mechanism cannot 500 serve a long-term role in calcium homeostasis. Recall that approximately 99% of total body calcium is 300 present in bones, and a healthy adult body has about 1 to 2 kg of calcium. Most of the calcium in bones exists as 1,000 200 mature, hardened bone mineral that is not readily ex- changeable but can be moved into the plasma via hor- monal mechanisms (described below). However, approx- imately 1% (or 10 g) of the calcium in bones is in a simple chemical equilibrium with plasma calcium. This readily 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 exchangeable calcium source is primarily located on the Serum calcium (mg/dL) surface of newly formed bones. Any change in free cal- cium in the plasma or extracellular fluid results in a shift FIGURE 36. Simultaneous measurements of calcitonin and parathyroid against changes in free calcium concentrations, it is lim- hormone in the pig. Proceedings of ited in capacity and can provide for only short-term ad- the Symposium on Calcitonin and C Cells. However, exposure to moderately bright sunlight for 30 to Calcitonin (CT) is a 32-amino acid polypeptide. Also 120 min/day usually provides enough vitamin D to satisfy known as thyrocalcitonin, CT is produced by parafollicu- the body’s needs without any dietary supplementation. The first step occurs in amino acid residues and is 10 times more potent than hu- the liver and involves addition of a hydroxyl group to carbon man CT in its hypocalcemic effect. This re- may be due to a greater affinity for receptors and slower action is largely unregulated, although certain drugs and liver degradation by peripheral tissues. Next, 25-hydroxycholecalcif- cally as a synthetic peptide matching the sequence of erol is released into the blood, and it undergoes a second hy- salmon calcitonin. The product In contrast to PTH, CT secretion is stimulated by an in- is 1,25-dihydroxycholecalciferol, also known as 1,25-dihy- crease in plasma calcium (see Fig. Hormones of the droxyvitamin D3 or calcitriol, the principal hormonally ac- GI tract, especially gastrin, also promote CT secretion. The biological activity of 1,25-di- cause the net effect of CT is to promote calcium deposition hydroxycholecalciferol is approximately 100 to 500 times in bone, the stimulation of CT secretion by GI hormones greater than that of 25-hydroxycholecalciferol. The reaction provides an additional mechanism for facilitating the up- in the kidney is catalyzed by the enzyme 1 -hydroxylase, take of calcium into bone after the ingestion of a meal. The third key hormone involved in regulating plasma The final step in 1,25-dihydroxycholecalciferol forma- calcium is vitamin D3 (cholecalciferol). The activity of 1 -hydroxylase is metabolite of vitamin D3 serves as a hormone in calcium regulated primarily by PTH, which stimulates its activity. The D vitamins, a group of lipid-soluble com- Therefore, if plasma calcium levels fall, PTH secretion in- pounds derived from cholesterol, have long been known to creases; in turn, PTH promotes the formation of 1,25-di- be effective in the prevention of rickets. In addition, enzyme activity in- the past 30 years indicates that vitamin D exerts it effects creases in response to a decrease in plasma phosphate. Both a de- is the form principally found in plants and yeasts and is crease in plasma calcium, which triggers PTH secretion, commonly used to supplement human foods because of its and a decrease in circulating phosphate result in the activa- relative availability and low cost. Although it is less potent tion of 1 -hydroxylase and an increase in 1,25-dihydroxy- on a mole-per-mole basis, vitamin D2 undergoes the same cholecalciferol synthesis. The physiological ac- The Actions of Parathyroid Hormone, Calcitonin, and tions of vitamin D3 also apply to vitamin D2. Most hormones gener- Vitamin D3 can be provided by the diet or formed in the ally improve the quality of life and the chance for survival skin by the action of ultraviolet light on a precursor, 7-de- when an animal is placed in a physiologically challenging hydrocholesterol, derived from cholesterol (Fig. The complete many countries where food is not systematically supple- absence of PTH causes death from hypocalcemic tetany mented with vitamin D, this pathway provides the major within just a few days. The net effects of PTH on plasma calcium and phos- phate and its sites of action are shown in Figure 36. PTH causes an increase in plasma calcium concentration while decreasing plasma phosphate. This decrease in phosphate concentration is important with regard to calcium home- ostasis.

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Often the injury will be confined to one bouts of exercise are tolerated increasingly well and are muscle of a group used to perform a specific action order viagra soft 50mg fast delivery erectile dysfunction cure. Injury associated with the hypertrophy of the muscle; hence discount viagra soft 50mg otc erectile dysfunction q and a, the can occur to a muscle that is overstretched while unstimu- familiar phrase, “No pain, no gain. They include the application of ice packs and enforced rest Under such circumstances, the force in the muscle may of the injured muscle. Nonsteroidal anti-inflammatory rise to a level considerably higher than could be attained in drugs (NSAIDs) can lessen the pain, but they also appear an isometric contraction; relatively few injuries occur un- to delay healing somewhat. For injuries in which an actual der isometric or isotonic (concentric) contraction condi- separation of the muscle and tendon occurs, surgical re- tions. Massaging of an injured muscle does not junction, a location that can be determined by physical ex- appear to be as beneficial as light exercise, which may help amination and confirmed by magnetic resonance imaging to increase blood flow and promote healing. There may from strain injury is associated with the gradual regaining also be extensive damage throughout the muscle itself. In of strength, which will eventually reach near-normal levels some cases, there is complete disruption of the muscle if reinjury is avoided. Some muscle tissue is permanently (avulsion), although usually separation is not complete. Most recovered muscles will have a some- ness, weakness, delayed swelling, and “bunching up” in what increased susceptibility to injury for an extended pe- extreme cases. Several predisposing factors may cause a muscle strain Precautions for avoiding strain injury include adequate injury, including relative weakness of a given muscle, result- physical conditioning and practiced expertise at the task at ing from a lack of training early in a sports season, and fa- hand. Preexercise stretching and warm-up may be of some tigue, which leads to increased injury late in an athletic value in preventing strain injury, although the experimen- event. In general, factors that make a muscle less able to con- tal evidence is equivocal. Among muscle fibers, the relative fast-twitch fibers on the basis of their contraction speed importance of each pathway and the presence or absence of (see Table 9. The differences in rates of contraction associated supporting organelles and structures vary. These (shortening velocity or force development) arise from dif- variations form the basis for the classification of skeletal ferences in actomyosin ATPase activity (i. Mitochondria are abundant in usually contains a mixture of fiber types, but in most mus- these fibers because they contain the enzymes involved in cles a particular type predominates. White which dyes for specific enzymatic reactions are used to muscle fibers, which contain little myoglobin, are fast- identify individual fibers in a muscle cross section. They contain significant amounts of stored glycogen, Red Muscle Fibers and Aerobic Metabolism. The color which can be broken down rapidly to provide a quick differences of skeletal muscles arise from differences in the source of energy. Although they contract rapidly and pow- amount of myoglobin they contain. Similar to the related erfully, their endurance is limited by their ability to sustain red blood cell protein hemoglobin, myoglobin can bind, an oxygen deficit (i. They require a period of recovery (and a supply of that depend heavily on aerobic metabolism for their ATP oxygen) after heavy use. White muscle fibers have fewer CHAPTER 9 Skeletal Muscle and Smooth Muscle 165 TABLE 9. There are indica- tigue resistance, chemical measurements of fatigued skele- tions that enzymes of the glycolytic pathway may be tal muscle specimens have shown that the ATP content, closely associated with the thin filament array. In well-moti- vated subjects, CNS factors do not appear to play an im- Red and White Fibers and Muscle Function. The relative portant role in fatigue, and transmission at the neuromus- proportions of red and white muscle fibers fit muscles for cular junction has such a large safety factor that impaired different uses in the body. Muscles containing primarily transmission also does not contribute to fatigue.

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