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The middle piece contains spiral sheaths of mi- with this disorder have an accessory X chromosome caused tochondria that supply energy for sperm metabolism and lo- by meiotic nondisjunction buy cleocin 150 mg on line. The tail is composed of a 9 2 arrangement of XXY order cleocin 150mg with mastercard, but there are other chromosomal mosaics order 150mg cleocin free shipping. Testicular microtubules cheap cleocin 150mg online, which is typical of cilia and flagella buy cleocin 150 mg cheap, and is sur- volume is reduced more than 75% and ejaculates contain rounded by a fibrous sheath that provides some rigidity. Spermatogonic cell differentia- tail propels the sperm by a twisting motion, involving inter- tion beyond the primary spermatocyte stage is rare. The Formation of a Mature Spermatozoon Requires Extensive Cell Remodeling Testosterone Is Essential for Sperm Production and Maturation Spermatids are small, round, and nondistinctive cells. Dur- ing the second half of the spermatogenic cycle they un- Spermatogenesis requires high intratesticular levels of dergo considerable restructuring to form mature spermato- testosterone, secreted from the LH-stimulated Leydig cells. Notable changes include alterations in the nucleus, the The testosterone diffuses across the basement membrane of formation of a tail, and a massive loss of cytoplasm. The nu- the seminiferous tubule, crosses the blood-testis barrier, cleus becomes eccentric and decreases in size, and the and complexes with ABP. Sertoli cells some-like structure unique to spermatozoa, buds from the also contain FSH receptors. However, recent studies using Golgi apparatus, flattens, and covers most of the nucleus. The absolute requirement for FSH in sperm nine peripheral doublet microtubules surrounding a central production remains unknown. This becomes the axoneme or that testosterone may be sufficient for spermatogenesis. Throughout this reshaping The actions of FSH and testosterone at each point of process, the cytoplasmic content is redistributed and dis- sperm cell production are unknown. During spermiation, most of the remaining cyto- sis, spermatogenesis appears to depend on the availability plasm is shed in the form of residual bodies. In human males, FSH is thought The reasons for this lengthy and metabolically costly to be required for the initiation of spermatogenesis before process become apparent when the unique functions of puberty. Unlike other cells, the spermato- achieved, LH alone (through stimulation of testosterone zoon serves no apparent purpose in the organism. Its only production) or testosterone alone is sufficient to maintain function is to reach, recognize, and fertilize an egg; spermatogenesis. CHAPTER 37 The Male Reproductive System 659 TESTICULAR STEROIDOGENESIS hydrogenase), which substitutes the keto group in posi- tion 17 with a hydroxyl group. Unlike all the preceding Following spermatogenesis, the second primary function of enzymatic reactions, this is a reversible step but tends to the testes is steroidogenesis. Although estrogens are only minor products of testicu- Testosterone is then converted to dihydrotesterone lar steroidogenesis, they are normally found in low con- (DHT), the most biologically active androgen, and to centrations in men. Androgens (C19) are converted to es- estradiol, the most biologically estrogen. Aromatization involves the removal of Testosterone Production Requires Two the methyl group in position 19 and the rearrangement of Intracellular Compartments and Several Enzymes ring A into an unsaturated aromatic ring. The products of aromatization of testosterone and androstenedione are Steroid hormones are produced from cholesterol by the ad- estradiol and estrone, respectively (see Fig. Cholesterol, a testis, the Sertoli cell is the main site of aromatization, 27-carbon (C27) steroid, can be obtained from the diet or which is stimulated by FSH; however, aromatization may synthesized within the body from acetate. Each organ uses also occur in peripheral tissues that lack FSH receptors a similar steroid biosynthetic pathway, but the relative (e. The major steroid produced by the testis is Primarily Mediated by cAMP testosterone, but other androgens, such as androstenediol, androstenedione, and dehydroepiandrosterone (DHEA), as The action of LH on Leydig cells is mediated through spe- well as a small amount of estradiol, are also produced. A Leydig cell Cholesterol from low-density lipoprotein (LDL) and has about 15,000 LH receptors, and occupancy of less than high-density lipoprotein (HDL) is released in the Leydig 5% of these is sufficient for maximal steroidogenesis. This cell and transported from the outer mitochondrial mem- is an example of “spare receptors” (see Chapter 31). Excess brane to the inner mitochondrial membrane, a process reg- receptors increase target cell sensitivity to low circulating ulated by steroidogenic acute regulatory protein (StAR). After senger, cholesterol is converted to pregnenolone (C21) by exposure to a high LH concentration, the number of LH re- cholesterol side-chain cleavage enzyme (CYP11A1), which ceptors and testosterone production decrease.

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In some instances cheap cleocin 150 mg on line, seizures may be able to scrape a food particle off occurring in the immediate postdamage their teeth with their tongue order cleocin 150 mg visa, but they phase resolve after swelling of the brain may be unable to coordinate the muscles recedes discount 150 mg cleocin amex. In many other cases cheap 150mg cleocin with visa, however order 150mg cleocin amex, indi- that move the tongue to produce a pho- viduals continue to have seizures, a condi- netic sound. It results from dysfunc- Language impairment may differ tion of the language centers in the brain, depending on the area of the brain dam- rather than impairment in the muscu- aged. Individuals may nitive skills: be able to understand and read simple material; however, as the complexity or • Memory length of the message increases, difficul- • Attention and concentration ty becomes more apparent. Although • Self-awareness they are able to comprehend, they may • Problem solving and decision making have difficulty expressing thoughts in • Information processing and concept speech and writing because of difficulty formation putting words and sentences together log- • Judgment ically. Speech may be labored, slow, and/or difficult to Memory encompasses the ability to understand, and small connecting words, store and retrieve information. Memory and increased verbal output, but with for both new and old information may be reduced information content, so that affected. Immediate memory lasts only sec- Wernicke’s aphasia are typically unaware onds or minutes unless converted in- of their communication difficulties. An example In some instances individuals may ex- of immediate memory is remember- perience global aphasia, in which there ing a phone number long enough to is severe difficulty communicating because dial the number, but then not com- of both the inability to use language (to mitting it to memory for later use. Short-term memory lasts from min- to wipe the same spot on a counter until utes to hours, but it is then lost if not someone intervenes. An Individuals with brain damage may be example of short-term memory may unable to remember skills that were once be learning facts for a test but not very familiar. For instance, they may be committing the facts to long-term unable to complete simple daily tasks, memory for continued use. Long-term memory is memories that to remember the steps involved or are stored and are able to be retrieved because, after completing the first steps of in the future, whether after weeks or the task, they forget their original goal. Memory problems can be the most lim- iting of all of the potential cognitive con- A variety of memory problems may be sequences of brain damage because they experienced after brain damage. Some affect the individual’s ability to learn, individuals may be able to remember facts store, and retrieve information. The abil- but are unable to remember how to do ity to profit from experience is often specific tasks. Consequently, individuals may be able to remember the names and may continue to make the same mistakes birthdates of family members but be un- over and over, since the ability to apply able to remember how to operate a wash- what was learned from past experience is ing machine. The ability to gener- retrograde amnesia in which they are alize from one situation to another may unable to remember things that occurred also be impaired. For example, an ments may have forgotten their own per- individual who has learned a skill in a sonal history so they do not recognize rehabilitation setting may be unable family members, or they may not be able to perform that skill in his or her own to remember what type of work they had home. After brain damage individuals can Attention and Concentration have difficulty remembering or learning new information so that they are unable After brain damage individuals may find to acquire new memories or recall recent it difficult to focus attention and to con- conversations and events. Conse- stances individuals make up answers to quently, they may be unable to follow a questions, or make up situations or events train of thought or perform multiple step (confabulation). They may have difficulty faulty memory but from the tendency to focusing on one task, may be easily dis- juxtapose unrelated memories together. At tracted, or may be unable to “shift gears” other times, in conversation, individuals from one task to another. Individuals with may get stuck on one theme, repeating a brain damage may find it difficult to per- question, phrase, or concept again and form multiple tasks at one time, such as again (perseveration). Perseveration can writing down messages or notes while also pertain to tasks that the individual talking on the phone, or carrying on a repeats over and over, such as continuing conversation while polishing furniture. For example, if they want to visit a friend in another city, they may recog- Individuals with brain damage may nize that they can take a train to get there, have limited ability to recognize or under- but they may not be able to consider how stand the limitations they are experienc- they would obtain money for the train ing. They may lack insight into the fare, how they would obtain a ticket, or appropriateness of their behavior and may how they would get to the train station. There may also be an inability to There may also be lack of ability to ini- monitor and adjust their own actions tiate and sustain activity. When become inconsistent, so that tasks per- they do receive feedback, they may dis- formed well on one day may not be count it because they disagree with oth- performed well on subsequent days. Indi- ers’ observations regarding their behavior viduals with damage to the left side of the or performance.

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The patient typically presents with back pain generic 150mg cleocin otc, often thoracic cleocin 150mg otc, but with mini- mal findings on exam of either musculoskeletal or neurologic impair- ment order cleocin 150mg visa. Repeat visits to the ED for back pain should raise your suspicion of this disorder buy generic cleocin 150 mg online. Epidural abscess is a special danger in illicit needle users discount 150mg cleocin amex, precisely the population who may be faking or exaggerating illness to obtain narcotics. Thus, you should be very cautious in dis- missing a complaint of severe back pain in needle users. If there is a possibility of epidural abscess, an MRI is usually diagnostic. Endotracheal Intubation Inadvertent esophageal intubation may result in good breath sounds. Even if you place the tube correctly, it can become dislodged as the patient is moved or manipulated for X-rays. At least several of the following methods should be used to confirm correct tube position. Be sure the tube is secured correctly, even if performed by a respi- ratory therapist. Drug Addicts May Also Be Sick Drug-seeking behavior, with false claims of illness, is common in EDs. However, drug abusers, especially illicit needle users, are more prone to true illness than the general population. Illicit drug users frequently exhibit tachyphylaxis to narcotic analgesics. Do Not Lose Your Patient in X-Ray One last thing to remember: it is easy to forget patients sent out of the ED for studies. CONCLUSION Malpractice litigation and the fear of being sued are unfortunate aspects of practicing medicine in American culture. Never forget the importance of good documentation in the medical record. It is often said that physicians have already lost just by being sued, even if they ultimately win the case. It is an agonizing experience to be called a bad doctor when you know that you did not commit mal- practice. And if you think that you really did do something suboptimal, then you have to deal with your own guilt. I would strongly suggest availing yourself of professional counsel- ing if depression, guilt, or anger are significant. Many local and state medical associations have support groups for doctors involved in malpractice litigation. It is important to realize that no matter what happens in the legal case in question, it is an aberration. Physicians treat thousands of patients in their careers, and far more than 99% of patients are helped by their physicians’ care. Chapter 9 / Emergency Medicine 113 In the end, the best defense against being sued is to practice good medicine. If you are a good doctor, communicate well with your patients, and pay attention to documentation, you will have gone a long way toward not only preventing lawsuits but also truly helping the people who come to you for care. Malpractice litigation fear and risk management beliefs among teaching hospital physicians. Relation between negligent adverse events and the outcomes of medical malpractice litigation. The relationship between physicians’ malpractice claims history and later claims: does the past predict the future? Preventability of malpractice claims in emergency medicine: A closed claims study. Conflicts between managed care organizations and emer- gency departments in California. The impact of health maintenance organization care authorization policy on an emergency department before California’s new man- aged care law. Emergency department patient literacy and the readability of patient- directed materials. Does determining serum alcohol concentrations in emer- gency department patients influence physicians’ civil suit liability? Lofsky, MD SUMMARY This chapter reviews the leading causes for anesthesiology mal- practice claims and the indemnity payments that result from dif- ferent patient injuries.

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