By P. Frithjof. College of Saint Elizabeth. 2018.

Asks what textbooks to which you commonly refer or recommend discount 50 mg viagra soft visa short term erectile dysfunction causes, so that if something is found within that text that conflicts with your testimony cheap 50 mg viagra soft with amex erectile dysfunction medication class, you can be made to look bad. The correct way to respond to this question is, “Nothing in its entirety is authoritative, but I would have to see specifically the sentence or sec- tion on a specific issue to see if I agree with that statement. Defending physician: Watch out for phrases such as, “Is it fair to say,” or, “Do you mean to say this? Specifically clarify any inaccuracies that he or she made in his or her summary. Plaintiff attorney: Quotes from a record or a document and asks you questions. Defending physician: To not misspeak, always ask to read the document before comment- ing on it. Plaintiff attorney: Asks questions that could be misleading if you answer them with a simple yes or no. For example, assume a case of prostatic atrophy misdiagnosed as adenocarcinoma. The attorney may ask, “When due skill and care are used by a pathologist, can he usually distinguish between atrophy and cancer? Rather, you should expand your answer by stating, “Although you can usually distinguish between the two processes, there are cases when it can be very difficult to tell them apart. All you can say is what is more probable than not, which is also known as a reasonable degree of medical certainty (>50%). Plaintiff attorney: Asks, “Are you sure that is all you have to say on the subject? Defending physician: Respond, “That is all that I can think of at the present time. Either he will let you finish your answer, or your lawyer will be able to ask you the question after the plaintiff attorney is finished. Plaintiff’s Goal: To Judge How Effective a Witness You Will Be at Trial How you do at deposition will be factored in as to whether the case may be settled or not. Lawyers can make outrageous claims against physicians in malprac- tice cases. As long as they make it in the setting of a court or deposition, they are immune against claims of defamation. TYPES OF PLAINTIFF ATTORNEYS AT DEPOSITION One author has aptly described plaintiff attorneys as “pals,” “freight trains,” “butterflies,” “time bombs,” or “ignoramuses”(8). Also, attorneys may be casually dressed, joking with each other, often including your lawyer in this banter before the deposition starts. Remember that the deposition is adversarial and that their role is to make you look bad. Do not let the “pal” plaintiff attorney disarm you with his or her friendliness. Freight Train The “freight train” plaintiff attorney will barrel along with rapid-fire questions, trying to make you speak before you think. The best way to handle this type of attorney is to hesitate before answering each question Chapter 5 / Discovery and Deposition 59 and to respond in complete sentences, which will slow down the process and ruin the timing of the plaintiff attorney. Butterfly The “butterfly” plaintiff attorney flips from one line of questioning to another in an attempt to confuse you. The goal of the plaintiff attor- ney is to make you give conflicting testimony. He or she will ask the same question in multiple ways over different points of time in the deposition, hoping for inconsistent answers. Do not worry about the apparent con- fusion in terms of the line of questioning. Concentrate on the questions at hand, and answer in a consistent manner.

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Paracrine signaling factors affect only protein kinase buy generic viagra soft 50 mg on-line erectile dysfunction zyrtec, which phosphorylates target substrates buy 100 mg viagra soft fast delivery erectile dysfunction what doctor to see, leading to the immediate environment and bind with high specificity a decrease in cytoplasmic calcium and relaxation. They are also rapidly destroyed by extra- also be mediated by nitroglycerin, a pharmacological agent that is cellular enzymes or bound to extracellular matrix, thus pre- converted to NO in smooth muscle cells, which can then activate venting their widespread diffusion. G, G protein; PLC, phospholipase C; DAG, di- originally called “endothelium-derived relaxing factor acylglycerol; IP3, inositol trisphosphate. Second, specialized The nervous system provides for rapid communication be- nerve cells, called neuroendocrine cells, secrete hor- tween body parts, with conduction times measured in mil- mones. This system is also organized for discrete activi- liberate releasing factors that control secretion by the an- ties; it has an enormous number of “private lines” for sending terior pituitary gland, and the hypothalamic neurons, messages from one distinct locus to another. The conduction which secrete arginine vasopressin and oxytocin into the of information along nerves occurs via action potentials, and circulation. Third, many proven or potential neurotrans- signal transmission between nerves or between nerves and mitters found in nerve terminals are also well-known hor- effector structures takes place at a synapse. Synaptic trans- mones, including arginine vasopressin, cholecystokinin, mission is almost always mediated by the release of specific enkephalins, norepinephrine, secretin, and vasoactive in- chemicals or neurotransmitters from the nerve terminals testinal peptide. Innervated cells have specialized protein mol- classify a particular molecule as either a hormone or a ecules (receptors) in their cell membranes that selectively neurotransmitter. Chapter 3 discusses the actions of various neurotransmitters and how they are synthesized and degraded. Chapters 4 to 6 discuss the role of the nervous sys- tem in coordinating and controlling body functions. THE MOLECULAR BASIS OF CELLULAR SIGNALING Cells communicate with one another by many complex The Endocrine System Provides for Slower mechanisms. Even unicellular organisms, such as yeast and More Diffuse Communication cells, utilize small peptides called pheromones to coordi- The endocrine system produces hormones in response to a nate mating events that eventually result in haploid cells variety of stimuli. In contrast to the effects of nervous sys- with new assortments of genes. The study of intercellular tem stimulation, responses to hormones are much slower communication has led to the identification of many com- (seconds to hours) in onset, and the effects often last longer. A particular cell can respond to a hor- that these signaling pathways must be tightly regulated to mone only if it possesses the specific receptor (“receiver”) maintain cellular homeostasis. For ex- naling pathways can transform normal cellular growth into ample, arginine vasopressin increases the water permeability uncontrolled cellular proliferation or cancer (see Clinical of kidney collecting duct cells but does not change the wa- Focus Box 1. They may also be diffuse, in- Signaling systems consist of receptors that reside ei- fluencing practically every cell in the body. For example, ther in the plasma membrane or within cells and are acti- thyroxine has a general stimulatory effect on metabolism. Signaling special category of chemical messengers called tissue systems also include transducers and effectors that are growth factors. These growth factors are protein molecules involved in conversion of the signal into a physiological that influence cell division, differentiation, and cell sur- response. They may exert effects in an autocrine, paracrine, or lular messengers, called second messengers (Fig. Many growth factors have been identi- Examples of second messengers are cyclic nucleotides fied, and probably many more will be recognized in years such as cyclic adenosine monophosphate (cAMP) and to come. Nerve growth factor enhances nerve cell devel- cyclic guanosine monophosphate (cGMP), inositol opment and stimulates the growth of axons. Epidermal 1,4,5-trisphosphate (IP3) and diacylglycerol (DAG), and growth factor stimulates the growth of epithelial cells in calcium. Platelet-derived growth factor A general outline for a signaling system is as follows: stimulates the proliferation of vascular smooth muscle and The signaling cascade is initiated by binding of a hormone endothelial cells. Insulin-like growth factors stimulate the to its appropriate ligand-binding site on the outer surface proliferation of a wide variety of cells and mediate many of domain of its cognate membrane receptor. Growth factors appear to activation of the receptor; the receptor may adopt a new be important in the development of multicellular organisms conformation, form aggregates (multimerize), or become and in the regeneration and repair of damaged tissues. This change usually results in an associa- tion of adapter signaling molecules that transduce and am- plify the signal through the cell by activating specific ef- The Nervous and Endocrine fector molecules and generating a second messenger.

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Controversy with organizational skills and may be eas- continues cheap 100 mg viagra soft erectile dysfunction and diabetes, however buy generic viagra soft 50 mg on-line impotence lab tests, regarding the extent ily distracted. In social situations, they may to which Asperger’s disorder differs from appear to not be listening to what others autism (Macintosh & Dissanayake, 2004; say, changing the subject of conversation Mayes, Calhoun, & Crites, 2001). Individuals may have difficul- with Asperger’s disorder show core symp- ty sitting still, with frequent fidgeting and toms of autism in the presence of high squirming, and difficulty remaining seat- verbal intelligence (Frith, 2004), and some ed. They may also have difficulty remain- question whether the disorder (sometimes ing quiet when appropriate, instead talk- called “high-functioning” autism) neces- ing excessively, blurting out responses at sarily leads to disability (Baron-Cohen, 2000). Individuals with ADHD usually have no significant language de- may appear impatient, careless, and disor- lays or delays in cognitive development, ganized. As they reach adulthood, symp- age-appropriate self-help skills, or adaptive toms may become less conspicuous. Diagnosis is often not made Delirium and Dementia until children enter school and have dif- ficulties with social interaction. Although Delirium and dementia have in com- cognitive function is normal, adults with mon symptoms in which there is a de- Asperger’s disorder may continue to have crease in cognitive ability or memory from difficulty with social interaction. These condi- 180 CHAPTER 6 PSYCHIATRIC DISABILITIES tions are characterized by alteration of of cognitive processes over time, such as brain function and are often caused by an symptoms occurring with arteriosclerosis identifiable organic factor. These disorders can occur at any age and Mental conditions in this category may can be secondary to another medical con- be reversible or irreversible. Manifestations of these conditions may affect psychological, Delirium cognitive, or behavioral function. In previ- Delirium is characterized by difficulty in ous editions of the DSM, these conditions sustaining attention to external stimuli, were classified as organic mental disorders. These conditions affect a variety of cog- • infection nitive abilities, such as: • the consequences of another medical condition • memory • medication side effects or drug inter- • orientation judgment action effects • attention • substance intoxication or substance • computational and organizational skills withdrawal There may also be associated psychomo- • a combination of causes tor or language impairments, sleep distur- If the cause of delirium can be identi- bances, and other behavioral manifestations. Conditions classified in this DSM cate- Dementia gory can be acute or chronic. Symptoms of acute disorders are sudden in onset, such Dementia is a global deterioration of as symptoms caused by generalized infec- multiple intellectual abilities, including tion or intoxication. There are also impairments in ic disorders generally occur more slowly other higher intellectual functions, such and are characterized by the deterioration as the ability to abstract or make judg- Common Psychiatric Disabilities 181 ments, and personality variables. There are Dementias such as those in Alzheimer’s many causes of dementia, some of which disease, multi-infarct dementia, or arterio- are listed in Table 6–3. Some conditions responsible for irreversible dementia are described below. Table 6–3 Potential Causes of Dementia Alzheimer’s Disease Alzheimer’s disease Anemia Alzheimer’s disease is a progressive, Anoxia degenerative type of dementia. Onset is Binswanger’s disease generally insidious, with gradual deterio- Brain tumor ration of cognitive function, eventually Chronic alcohol/drug use/abuse resulting in death. Alzheimer’s disease ac- Chronic liver disease counts for 50 to 75 percent of all cases of Chronic lung disease dementia (Kawas, 2003). Although it has Communicating hydrocephalus commonly been thought of as a condition Creutzfeld-Jakob disease that occurs in older age groups, it may Depression occur as early as middle life. HIV infection Although there are identifiable, structur- Huntington’s disease al changes of the brain characteristic of Infections of the central nervous system Alzheimer’s disease, there is currently no Metabolic disorders definitive way to make the diagnosis ex- Multicerebral infarcts cept by direct examination of the brain it- Multiple demyelinating lesions self at autopsy. Diagnosis is based on docu- Parkinson’s disease mentation of memory impairment, thor- Pick’s disease ough cognitive testing, a detailed person- Subdural hematoma al and social history, a description of the Syphilis progression of symptoms, drug evalua- Systemic lupus erythematosus tion, and elimination of other causes of Thyroid disorders symptoms through laboratory, physical, Uremia and neurological examinations. Vitamin B12 deficiency The progression of the condition and the severity of symptoms at different stages vary from individual to individual. Al- though several drugs to help symptoms are Table 6–4 Potential Reversible Causes of currently on the market, there is no cure Dementia for the disease. Treatment is directed to helping individuals maintain their gener- Thyroid disorder al health, well-being, and functional capa- Anemia city as long as possible and to supporting Nutritional deficiencies the family responsible for their care. Depression Multi-Infarct Dementia Some types of dementia are reversible, and some are not. Some potentially reversi- Multi-infarct dementia refers to condi- ble dementias are listed in Table 6–4.

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They increase breathing and heart rate generic viagra soft 100 mg with amex erectile dysfunction more causes risk factors, lessen appetite and dilate the pupils buy viagra soft 50mg low price over the counter erectile dysfunction pills uk. Users tend to feel more alert, energetic, confident and cheerful and less bored or tired. With high doses people often experience a rapid flow of ideas and feel they have increased physical and mental powers although this is usually manifest as talking non-stop. Taking a lot, especially over a few days, can produce a temporary panic and paranoia and with high doses the amphetamine psychosis is like a transient episode of schizophrenia. The effects of a single dose last for about 3±4 h and tend to leave the user feeling tired. Users may feel depressed, lethargic, lacking in energy and incredibly hungry without taking the drug. Tolerance also develops with regular use so more is needed to get the same effect. Heavy, regular use often leads to lack of sleep and food and lowers resistance to disease. Eating disorders, such as anorexia nervosa, may become a problem, especially among women users and work and domestic routines may be disturbed. Many heavy users become very run down and alternate between periods of feeling good and energetic then feeling depressed and low. Some users experience violent mood swings and can become very aggressive. Mode of action The effects of the amphetamines are discussed in detail in Chapter 7 and are thought to be due to changes in the catecholamines, noradrenaline and dopamine. The peripheral 514 NEUROTRANSMITTERS, DRUGS AND BRAIN FUNCTION cardiovascular effects probably follow elevated (released) noradrenaline levels in sympathetic neurons while the central effects result from an increased noradrenaline release (anxiety, restlessness) or dopamine (motor stimulation, psychosis). How this is achieved is not absolutely clear but it seems that due to the similarity in structure of amphetamines and catecholamines, amphetamine can enter the nerve terminal by the NA/DA transporter. By so doing, it reduces uptake of the monoamines but more importantly, it causes release of extra NA and DA. This is the result of reverse transport of elevated cytoplasmic monoamines caused by both an inhibition of MAO and a reduction in vesicular uptake of the transmitters. COCAINE General Cocaine comes from the Coca plant, grown in the high arid, mountainous areas of South America. It is usually extracted from the leaves of the plant but the leaves themselves can be chewed and a smokable paste made from the leaves is mainly used in countries where the plant grows. In Britain and America the most common form of cocaine is as a white crystalline powder. Most users sniff it up the nose, often through a rolled banknote or straw, but it can also be made into a solution and injected. Because it is such a fast-acting drug and the powerful effects wear off quickly, repeated use is common, and since cocaine is a relatively expensive drug it has become closely associated with a rich lifestyle. Large amounts of cocaine are seized in the UK, but relatively few people present themselves for treatment of dependency. There may be many reasons for this including the fact that those who can afford to have a cocaine problem can afford to attend a private clinic and so are unavailable to researchers and those agencies who collect information about drug use. However, there does seem to be some increase in more general use of the drug. It is appearing in more clubs around the dance/rave scene alongside Ecstasy even though cocaine powder costs more. Crack is around £20±25 for a small rock the size of a sultana, but a rock may have slivers cut from it which are sold for perhaps £10. Although the UK crack problem has not turned out to be as significant as predicted some years ago, crack use has increased in certain inner-city areas bringing with it reports of problems of dependence, drug-related crime and violence. Coca leaf chewing as an aid to work may have been common among South American Indians as long ago as 250 BC. Cocaine was first extracted from the leaves in 1855 and by the 1870s it was a popular stimulant and tonic and used in a range of patent medicines for all sorts of ailments. Sigmund Freud recommended its use for a range of medical and psychological problems, including alcohol and morphine addiction. Sherlock Holmes, the fictional detective created by Arthur Conan Doyle, was a regular cocaine user while coca-laced wines were enjoyed by popes and royalty in the nineteenth century. At the turn of the DRUG DEPENDENCE AND ABUSE 515 twentieth century doctors began to warn of possible dependence and problems with its use.

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