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When the membrane po- 219 220 PART IV BLOOD AND CARDIOVASCULAR PHYSIOLOGY A Major Channels Involved in Purkinje and +20 1 2 TABLE 13 buy 60 mg orlistat otc weight loss yoga routine. The receptor includes the den- provides the mechanism for a rapid buy orlistat 60mg otc weight loss pills diabetics, automatic response to a po- drite of a sensory neuron and the place where the nerve impulse tentially threatening stimulus. Multiple Other Conditions of the Nervous System 105 sclerosis most often affects young adults resolved by the time the individual sees a between the ages of 20 and 40, with about physician. If a test is added at the end of a diagnostic work up to further classify disease (postaddition) all the designs presented in Figures 4. Thus, CRH not only stimulates ACTH secretion coids act directly on parvicellular neurons to inhibit CRH but also maintains the capacity of the corticotroph to syn- release, and indirectly through neurons in the hippocampus thesize the precursor for ACTH. When cells lose K (and accom- move out of cells and K , in exchange, to move into cells. Most ingested phosphate is Primarily by the Small Intestine absorbed from the GI tract, and the primary route of excre- Calcium absorption in the small intestine occurs by both tion of this phosphate is via the urine. One function of androgen-binding protein in the testis is to High levels of androgens have an anabolic effect on sequester testosterone, which significantly increases its lo- muscle tissue, leading to increased muscle mass, strength, cal concentration. Finally, the endogenous fatty acid amide, oleamide, has somnogenic effects. The head is larger than the trunk, and the brain is undergoing marked differentiation. CT shows a hemorrhage in the territory of the Which of the following vessels/segments are most likely involved? In 1973, an influential government inquiry into medical malpractice (32) led to the first efforts to evaluate the system’s efficacy from an epidemiologic perspective. Potentiation of a- or blockage of b- and g-secretase could reduce the production of Ab which becomes insoluble and is precipitated (see Hardy 1997). Index 279 INDEX A ALH, 162 Abdominal pain Allegations emergency room, 109–110 family physician risk manage- Abdominoplasty ment, 91–92 generating malpractice claims, 192 Allocated loss adjustment expense (ALAE), 206 Accelerated compensation events Alternative dispute resolution (ACEs), 273 (ADR), 266–268 proposals, 267 Ambiguous questions, 55–56 Access to health care, 218–222 American Academy of Actuaries evaluating, 219 effective medical malpractice MICRA, 221, 222 reforms, 215 Accident compensation systems American College of Emergency no-fault, 266–267 Physicians (ACEP) ACEP temporary holding orders, 106 temporary holding orders, 106 Anesthesiologists ACEs, 273 malpractice suits, 135–137 proposals, 267 Anesthesiology, 115–137 Actuarial science, 5–6 disasters, 126–132 ADH, 161–162 documentation, 120–121 Administrability injury prevention, 122–125 vs accountability, 267 dental, 122–125 Administrative compensation literature search, 136 schemes, 241 malpractice claims, 116–120 Admissible expert testimony, 28 newly identified risks, 132–135 ADR, 266–268 records, 120 Adversarial system risk management, 120–122 governing malpractice disputes, Anger 260 plastic and reconstructive sur- Adversarial witnesses, 27 gery medical liability, Adverse events 196–197 limited disclosure of, 271 Annual pap smear Affirmative duty, 182 importance, 170–171 Affordability, 219 Answers vs fairness, 267 physician witness, 61 Aftercare instructions Antibiotic-resistant infections, 95 emergency medicine, 105 Anticipation Agency for Healthcare Research physician witness, 61 and Quality Antishock trousers, 147 effective tort reforms, 219–220 Aortic aneurysm ALAE, 206 dissecting, 94 279 280 Index Appellate attorneys, 13 Atypical duct hyperplasia (ADH), Appellate practice, 13 161–162 Appendicitis Atypical lobular hyperplasia emergency room, 109–110 (ALH), 162 Arbitration, 239t Atypical squamous cells of undeter- Artificial blood vessels, 220 mined significance (ASC- Art of Cross-Examination, 46 US), 168 ASC-US, 168, 173–174 Authentication Assets online communications, 83 insurance companies, 7 Authoritative information Assimilation online communications, 84–85 pause for, 68 Authoritative sources, 56 Attendant costs, 202 Authoritative textbooks, 56 Attention Authority feigning, 66 physicians Attorney–client relationship, 25–26, erosion of, x 46–48 physician witness subject to, 42 physician witnesses, 46–48 Autonomy Attorneys, 25–26 doctrine of, 141 appellate, 13 medical profession, xii–xiii Autopsy biographical information about, dead fetus, 144 26 Avoidability standard, 240 butterfly plaintiff, 59 Avoidable injuries, 255–256 client solicitation, 203 Awards doctors and, 249 caps on, 237 educating about case, 38–39 size of, 237 fee limits, 239t freight train plaintiff, 58–59 B ignoramus, 59 litigation, 25–26 Baby deliveries meeting with immediately, 31– cessation of, 220 33 Bad doctor fallacy, ix, 209–211 pal plaintiff, 58 Bad faith malpractice claims, 217 plaintiff Bedpan mutuals, 231 contingency fees, 18–19 Binding arbitration, 239t at deposition, 58–59 Birth injury compensation funds perspective on risk reduction, no-fault, 266–267 35–40 Blepharoplasty sliding contingency fee scale, generating malpractice claims, 18 191–192 provided by liability insurance Body dysmorphic disorder company, 25–26 plastic and reconstructive sur- time bomb, 59 gery medical liability, Atypical angina pectoris, 94 197–198 Index 281 Body language, 69–70, 141 effect on health care costs, Bowel injuries 221 during surgery, 149 noneconomic damage limit, Breach, 16–17 213–217 Breast augmentation periodic payments, 214 generating malpractice claims, provisions of, 213t 191 savings from, 215f Breast biopsy, 160–163 reforms, 214 malpractice claims, 161–163 Cancer diagnostic errors, 162 delayed diagnosis of, 143 Breast cancer Canons of statutory interpretation, delayed diagnosis of, 143 23 microscopic diagnosis of, 160– CAP, 168 163 Caps, 259 Breast cancer litigation, 153–165 Carefulness clinical context, 153–160 physician witness, 45 Breast cancer malpractice claims Cauda equina syndrome age, 159f, 159–160 emergency room, 111 diagnosis delay, 157–158 Causation, 16–17, 140 lymph node status, 159 legal, 16 mammography, 156–157 Centers for Medicare and Medicaid mass discovery, 155 Services (CMS), 273 overall outcomes, 155 Cephalosporin prophylaxis physician specialties, 155–156, for hysterectomies, 142–143 156f Cervical cancer presenting symptoms, 155 delayed diagnosis of, 143 tumor size, 158–159 Cervical spine Breast fine needle aspiration emergency room, 110 false-negative, 160–161 Cesarean sections (C-sections) malpractice claims, 160–163 rates of, 217–218 triple test strategy, 161 Change-of-shift Breast reduction emergency medicine, 106 generating malpractice claims, Charges 191 fee-based online consultation But for causation, 16 eRisk guidelines, 86 Butterfly plaintiff attorneys, 59 Charting anesthesiology, 120–121 C Chest pain California emergency room, 109 health care system, 221–222 Childhood vaccines MICRA, 201 cost affected by tort tax, 202 attorneys’ contingency fees Choice limit, 214 information, 269–272 caps, 213–217 Citing textbooks or journals collateral source rule, 214 physician witness, 43–44 282 Index Claims. Individuals’ per- uals with chronic illness or disability may ception or misperception of the reactions continue to perform the same work they of others in social groups may determine performed before the onset of the condi- the level of acceptance that they receive. Binding of the steroid hormone-re- lular metabolism with responses attributable to that partic- ceptor complex to the response element initiates transcription of ular steroid hormone. THE INCREASING IMPACT OF LAW AND REGULATION ON MEDICAL PRACTICE The legal context of medical practice has changed significantly in recent years. Sever’s disease (calcaneal apophysitis) can metaphyseal fractures of battered children the perichon- be diagnosed if there is soft tissue swelling on radi- drium retains a rim of juxtaphyseal cortex which is seen ographs or cross-sectional images or increased scinti- as a bucket handle or a corner fracture on radiographs. Spastic tone is antimotion sickness drugs would interfere with the natural most evident in the flexor muscles of the arm and the ex- neural compensation that would, it is hoped, reduce the tensor muscles of the leg. The posterior cord gives off the axil- gives off fine branches for sensory supply to lary nerve (B37) and continues as the radial the pericardium, the pericardiac branches nerve (B38). An epicanthic fold may also be present in some infants with Down syndrome. Different fiber systems terminate consists of three layers: at the smooth and spiny sections of the cell:! Noradrenaline and neuropeptide Y also have similar interactive effects on the vasculature. The anterior pole of the hemisphere is called the frontal pole (A5), the posterior one is called the occipital pole (A6). I believe that this is a very important question with information that is important for the jury to have. Large proteins, in- villi are confined to the area of the decidua basalis. Complex partial seizures manifest themselves as bizarre behaviours which are also known as psychomotor or temporal lobe epilepsy, since a lesion (focus) is often found in that brain area. They are abundant in areas Knowledge Check of high metabolism within bone, such as under the periosteum and 6. Overall Outcomes The 100 consecutive files involved 80 individual patients with breast cancer. The hilum is also the site for drainage of lymph vessels and Renal Blood Vessels innervation of the kidney. Free radicals and peroxides are highly reactive substances and can damage DNA, membrane lipid and cell protein and initiate lipid peroxidation to destroy all mem- branes. Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis. Answer E: Excessive eating (gluttony), which may include a ated with the facial [VII] nerve) and send, to the lacrimal, sub- propensity to attempt to eat things not considered food items, is mandibular, and sublingual glands, respectively. A wide variety of health profes- extremities) placed into an upright posi- sionals are usually involved in this phase tion as soon as possible to prevent com- of rehabilitation, including physiatrists, plications such as respiratory problems physical therapists, rehabilitation nurses, from occurring. IfD2 antagonism is considered necessary, or at least desirable, for counteracting positive symptoms it is surprising that a relatively weak D2 antagonist like clozapine should not only be so effective but also prove successful in patients who have not responded to other neuroleptics more potent at D2 receptors.

INTRODUCTION From a plaintiff attorney’s perspective purchase orlistat 60 mg weight loss pills on facebook, risk reduction for a physician named in a malpractice claim is based on that physician’s understanding of the way an experienced attorney approaches a potential medical neg- ligence case buy discount orlistat 120mg line weight loss zach galifianakis. The ways in which logical deficits and diseases relate to damage in specific parts these clinical correlations can be used to enrich the learning of the nervous system. The cubital fossa is the depressed anterior portion of the cubital region. In these instances, a subtotal thyroidec- with hypothyroidism need to remain on tomy, which involves the removal of this medication for life. They may also lead to poor circulation in the extremities (peripheral vascular in- sufficiency; see Chapter 11), so that even Psychosocial Issues in Diabetes Mellitus minor injuries are prone to become infect- ed and may become so severely infected Diabetes mellitus not only involves life- that amputation (see Chapter 14) is nec- long multifaceted treatment, but it also essary. Spectrum bias in the evaluation of diagnostic tests: lessons from the rapid dipstick test for urinary tract infection. Even worse, many efforts at self-protection, such as avoiding poor patients or patients with terminal diseases, have no plausible liability-reducing effect and merely reinforce stereotypes that already burden vulnerable populations (23). The primary vestibular fibers termi- cells terminate at the hair cells of Corti’s nate mostly in the medial nucleus. Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ skeleton is the prime target, but the organism also has an (2003) Radionuclide bone imaging: an illustrative review. The results of a number of studies manipulating the levels of the gas show that NO plays a role as a neuronal communicator. The cerebrum is divided into two halves, The parietal lobe is located in the middle called hemispheres: the right hemisphere of each hemisphere and is primarily the and the left hemisphere. In curve allows large quantities of oxygen to be released or un- tissue capillaries, where PO2 is low, the reaction is shifted to loaded from hemoglobin in the tissue capillaries where a the left; oxygen is unloaded from hemoglobin and becomes lower capillary PO prevails. C, The perfusion of three phases can be altered in a way that diffusion in the extra- capillaries around the cell increases concentrations of bloodborne cellular space is changed. Al- cele may have residual effects result- though the condition itself is not progres- ing from spinal cord damage. CHAPTER 13 The Electrical Activity of the Heart 225 The combination of two poles that are equal in magnitude and opposite in charge and located close to one another, is called a dipole. The ureters enter the base of the bladder obliquely, Micturition is fortunately under voluntary control in forming a valvular flap that passively prevents the reflux of healthy adults. The effect of gravity on the (D) Zone 4 ONE lettered answer or completion that is pulmonary circulation in an upright 6. Second, the present crisis occurs in the shadow of the new patient safety movement (65). In a caudal-to-rostral sequence, the more rostral it is brain called circumventricular organs, which are adjacent placed, the greater the complexity of the neural network. Melancholy is a term used to describe Alexander, who later became known as Alexander the Great. The embryoblast of the implanted (b) By the end of the fourth week, the adulthood. How does the hypodermis of the skin differ in males and fe- the functioning of internal organs, take radiographs, and perform males? In a healthy adult, a drop in ventilatory acclimatization are not completely understood, alveolar PO2 to 60 mm Hg occurs at an altitude of approxi- it is clear that two mechanisms are involved. In a basic physical examination, only the reflexes and sensory functions are assessed. Note functional importance of these shifts is that an exercising the leftward shift of the oxyhemoglobin equilibrium curve when muscle is warm and acidic and produces large amounts of CO binds with hemoglobin. Blood pressure is higher among pends on blood flow as well as blood oxygen content, a lim- African Americans than Caucasian Americans. This work led to the proposal that anxiety was due to (or exacerbated by) excessive ANXIETY 411 Figure 19. Without my having returned an angry comment to his opener, he dropped that line of questioning with a look of disgust (duly noted by the jury and even the judge). A base load, by raising pH, stimulates buffers, however, are present and active. Knowledge Check Objective 18 Describe the venous drainage of the head, 17. Keeping pace with ever-expanding medical knowledge is a daunting task, but physicians must practice “under significantly expanded legal obligations, face stricter standards of professional accountability for medical negligence, and no longer enjoy exemption from the laws of competition” (13). Answer D: The rostral edge of the striae medullares (of the Review and Study Questions for fourth ventricle) is regarded as the border between the pontine Chapters 3 and 4 and medullary portions of the fourth ventricle. If sev- system is also an important component of erance is not complete (incomplete spinal sexual arousal in both males and females.

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Capillaries in these re- encephalon and telencephalon discount 60 mg orlistat mastercard weight loss games, where emotionally moti- gions discount 60mg orlistat free shipping weight loss 4 pills reviews, like those in other organs, are fenestrated (“leaky”), vated behavior, appetitive drive, consciousness, sleep, lan- allowing the cells of hypothalamic nuclei to sample freely, guage, memory, and cognition are coordinated. ACTION POTENTIAL, AND ELECTRICAL The binding of a neurotransmitter to its receptor typi- cally causes a flow of ions across the membrane of the post- SIGNALING BY NEURONS synaptic cell. Developmental © The McGraw−Hill Anatomy, Sixth Edition Development Anatomy, Postnatal Companies, 2001 Growth, and Inheritance Chapter 22 Developmental Anatomy, Postnatal Growth, and Inheritance 767 Uterine wall Intervillous space Chorion Uterine cavity Villous chorion Yolk sac Connecting stalk Umbilical cord Amnion Chorionic cavity Amnion Smooth chorion Internal os Cervix Vagina (a) (b) Placenta Villous chorion Amnion Uterine cavity Umbilical vein Smooth chorion Mucoid connective tissue Umbilical arteries Yolk sac Amnion (c) (d) FIGURE 22. The input is roughly so- GPe-subthalamic nucleus-GPi circuit has been termed the matotopic and is via neurons that use glutamate as the neu- indirect pathway in contrast to the direct pathway of stria- rotransmitter. 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. Gap junctions are pores composed of paired con- would increase the problem, causing an undesired ef- nexons that allow the passage of ions, nucleotides, and fect. Within the hour, he develops blurry vision, ex- cessive salivation, and a runny nose. In Hashimoto’s disease, the thy- pothyroidism alone, and the remaining 25% have both roid gland is infiltrated by lymphocytes, and elevated lev- phases of the disease. Which of the following types of teeth are What are the biomechanical movements found in the permanent but not in the Essay Questions of the large intestine that make these deciduous dentition? Plaintiff attorneys say they carefully screen malpractice claims before filing, yet 70–80% of these claims are still found to be without merit (12). Dealing with heterogeneity In many cases the interpretation of present heterogeneity is the most fascinating and productive part of a meta-analysis. Skeletal Radiol 24(5):325-330 between septic arthritis and transient synovitis of the hip in 43. This process is also favoured by the high levels of free iron in the substantia nigra which are augmented in PD patients. A continuous test may have equivalent ROCs and diagnostic ORs in two different settings, but very different likelihood ratios (LRs). The structure of the cell membrane is molecules into and out of the cell and separates the cell’s not fully understood, but most cytologists believe that it consists internal structures from the extracellular environment. This requires that all the compounds must have a similar chance of reaching the CNS, or at least of providing appropriate plasma levels, and also that compounds with little or no clinical efficacy in the disorder do not modify the NTin the same way as effective drugs. Osteochondral injuries of the femoral condyles displacement of the medial fragment. TSH would also not be able to the thyroglobulin molecule to form MIT and DIT. Therefore, there is a need for general models (scenarios) for the evaluation of particular (types of) tests and test procedures, whose overall framework is relatively stable and into which information on new tests can be entered by substituting the relevant piece in the whole mosaic. Select the in skeletal muscle (B) Treatment with exogenous insulin ONE lettered answer or completion that is (D) Stimulation of hormone-sensitive (C) Sulfonylurea treatment BEST in each case. Stanford, SC (1999) SSRI-induced changes in catecholaminergic transmission. Radiology 204(1):185-189 a result of repeated pronation, forearm extension, and 12. Mesentery Parietal peritoneum Gut Peritoneal cavity Layers of the Gastrointestinal Tract Liver Visceral peritoneum The GI tract from the esophagus to the anal canal is composed of four layers, or tunics. Bone Fractures CASE STUDY FOR CHAPTER 35 A 38-year-old Caucasian man recently came to the atten- tion of his physician when he suffered the second of two Type 2 Diabetes bone fractures in the past year and a half. If a patient is either a minor or incompetent (and the parent or guard- ian refuses treatment), and you know serious consequences will ensue if appropriate tests and/or treatment are not undertaken, then your legal and moral obligations change. Sweat glands become coiled as the secretory portion of the developing gland proliferates into the dermal mesenchyme. Muscles with a large amount of series elasticity have a large tetanus-twitch ratio. Its N-terminal signal peptide sequence limiting step in gonadotropin synthesis. Excretion of phenobarbital is pro- fluid volumes can be determined from the volume of moted by increasing urine output and making the urine distribution of a single indicator, such as radioactive more alkaline. Supraspinal morphine is thought to reduce these controls so blurring the perception of pain. Frequent source of health insuranceFactors that influence unemployment A. Selection ma of the subcutaneous fat, showing swelling, in- of the optimal techniques for each individual patient is creased echogenicity of the subcutaneous fat with de- essential, and factors such as cost, radiation dose and creased acoustic transmission, blurring of tissue planes, need for sedation should all be considered. The left testicular vein transports nutrient-rich blood from the small intestine for process- (or left ovarian vein) and the left suprarenal vein, by contrast, ing. For example, the uterine tube does Many couples avoid them, however, because they detract from not expand well to accommodate a growing embryo, nor does it possess the spontaneity of sexual intercourse. This organ stores and concen- The liver lobules have numerous functions, including syn- trates bile. The data from such a study can be used to calculate and compare the prognostic value of each test, using conventional measures of diagnostic accuracy. Hypovolemia cially in debilitated patients, may be accompanied by hy- contributes if the patient is dehydrated, but heat exhaustion pothermia, instead of the usual febrile response to infec- often occurs without significant dehydration.

This allows the cell to gain sodium and reduces the steepness of the sodium 2 gradient discount 120 mg orlistat with visa weight loss young living. The inner mucosal layer lease of glycogen; synthesis of blood proteins; phagocytosis of old of the gallbladder is thrown into folds similar to the gastric folds red blood cells and certain bacteria; removal of toxic substances; of the stomach buy 60 mg orlistat amex weight loss pills 375mg. Leptic means to activate (take hold of) and in animals these compounds produce a state of maintained motor tone known as catalepsy. In a second study of 33 patients with osteogenic methylene diphosphonate uptake in primary osteosarcoma. The axons follow a cir- THE PARASYMPATHETIC NERVOUS SYSTEM cuitous course through the lesser petrosal nerve to reach the otic ganglion, where they synapse. Marrow edema without a fracture line in a patient with a history of chronic repeti- Replacement tive injury represents a “stress reaction. Treatment may sue may form, causing varying degrees of be instituted prior to surgery to prevent functional loss. By offering medical advice on the phone, you can legally become the attending physician for a 72 Gorney patient you have never seen. The mAChR agonist muscarine (10 mM) does not affect the Ca2‡ rise but inhibits the subsequent opening of the SKCa channels. See Attorneys facilities, 260 LCIS, 161–162 vicarious misdiagnosis, 162 doctrine of, 90–91 Legal causation, 16 Liability crisis Legal defense professional estimating costs, 5 states facing, 215 as insurance company expenses, Liability insurance, 260–262 4 byproduct of, 262 Legal doctrine professional, 4 impact of changes in, 230 Liability insurance company Legal process, 257–260 providing attorneys, 25–26 Legal reform Liability law case for, 201–223 expansion of, 202 medical context of, 204 Liability reform value of, 213–214 and patient safety, 255 290 Index Liability rule of negligence LSIL, 171 substantive, 15–17 Lump sum judgment rule, 20–22 MICRA, 18 Liability rules M modification of, 236 MAC, 116 Libby Zion case, 271 Malpractice, 248 Licensing jurisdiction expert driven cases, 28 online communications, 84 gynecology and obstetrics, 139– Limitations period, 18–19 150 Limiting access to court, 236 Malpractice claims. All three r subunits have been identified in brain,but their precise location and the functional significance of this expression is unclear. Very similar to LH, hCG has a molecular weight of concentrations of hCG follow a similar pattern. The long skele- Knowledge Check tal muscle fibers contain so much cytoplasm that several govern- 9. As a result, a diagnostic sign of real value in primary care (LR of 8, LR of 0. The muscles of the buttock are femoral triangle on the upper medial portion of the thigh served by the superior and inferior gluteal arteries. These events make it possible and the digestive, urinary, respiratory, and meiotic development is completed and a for morphogenesis to continue. Dalley, JW, Mason, K and Stanford, SC (1996) Increased levels of extracellular noradrenaline in the frontal cortex of rats exposed to naturalistic environmental stimuli: modulation by acute systemic administration of diazepam or buspirone. Hajdu noted that, in desmoid tumor should be regarded as a second desmoid tu- the United States, the incidence is about the same as that of mor until proven otherwise [8-10]. New normal abnormal in a degenerative disease that York: McGraw-Hill, 2000. Turn to face the lawyer when he or she poses a question and then turn to the jury to answer the question. In fact after a MAOI, tryptamine produces a behavioural response in rats similar to that of tryptophan apart from the absence of certain features like tremor and wet-dog shake. A familiar example of denaturation by tion of temperature (T); increasing T by 10 C increases the heat is the coagulation of albumin in the white of a cooked reaction rate by a factor of 2 to 3. Although most erythrocytes are body’s first line of defense against foreign released into the blood, some are taken up material is called nonspecific or innate im- by the spleen to be stored for emergency munity. There Muscles swell as they shorten, and this compresses adjacent are two reasons. The patellae (“kneecaps”) are two OF THE SKELETAL SYSTEM sesamoid bones all people have. Surgical treatment in- teoarthritis (OA) of the hip has long been debated. In the body, synovial joints usually serve as the fulcra (F), forward provide the effort. Certainly if this is how neuroleptics work it cannot be claimed that they have returned brain function to normal. Single-Unit and Multiunit Smooth Muscles Furthermore, whereas skeletal muscle fibers require stimu- Smooth muscles are often grouped into two functional cate- lation by action potentials through somatic motor neurons before gories: single-unit and multiunit. Anger can also be the result of frustra- Guilt can be described as self-criticism tion. Increased signal is seen on T2-weighted alterations in the muscle morphology. Special senses are localized spinal cord or brain stem, they may initiate a reflexive motor re- in complex receptor organs and have extensive neural pathways sponse but not a conscious awareness. Certificates of merit exist in about one-third of states and require plaintiff attorneys to obtain expert assessments that claims are warranted before filing them.

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