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By I. Iomar. West Virginia Wesleyan College.

Additionally cheap baclofen 25mg line muscle relaxant food, it is strongly recommended that no patient be discharged from an outpatient surgical facility until at least 3 hours have elapsed and there is evidence that all the local anesthetic effects have worn off purchase baclofen 25mg mastercard spasms poster. Rhinoseptoplasty Rhinoseptoplasty cases constitute approx 8% of the claims. Among the most common allegations are as listed here: • Unsatisfactory result: improper performance allegations. Of all the operations performed by plastic and reconstructive surgeons, this is regrettably the procedure with the highest degree of unpredictability. The problem is greatly aggravated by inappropriate patient-selection criteria. In these claims, there is almost universally a gap between the patient’s expectations and the results obtained, even when the surgical outcome appears excellent. The inappropriate use of imaging devices or the showing of “brag books” containing only excellent results often causes patients to have unrealistic expectations. The clear implication is “this is the kind of work that I do, and this is what you can expect. Abdominoplasty Abdominoplasty with or without suction-assisted lipectomy repre- sents approx 3% of claims. There is little question that the combination of suction-assisted lipoplasty prior to the actual abdominoplasty has significantly increased the morbidity of this operation and increased the number of claims in this category. There is a higher percentage of skin sloughs in those procedures when preceded by suction-assisted lipectomy. Chapter 14 / Plastic and Reconstructive Surgery 193 Suction-Assisted Lipectomy Suction-assisted lipectomy procedures, whether conventional or ultrasonic, have now become the single most requested elective aes- thetic procedures in the United States. Approximately 145,000 of these procedures were performed in the year 1997, according to ASPRS statistics (1). However, the rising popularity of this procedure has brought with it a host of problems. To begin with, because this is not a surgical procedure in the “traditional” sense, it is being performed by a wide variety of practitioners, some of them with no surgical back- ground or clear understanding of the surgical anatomy involved. Sec- ond, it is a procedure most commonly done on an outpatient basis outside of the control of any regulatory authorities (2). Additionally, with the advent of “tumescent” techniques, an unseemly race has developed to see who can suction out the most fat. The net result has been a dramatic rise in severe morbidity and fatal outcomes from high- volume liposuction. It is generally agreed that anything above 5000 cc of extracted fat constitutes high volume. The extraction of this amount of fat causes profound physiological changes, which in turn can lead to severe complications and/or fatal outcomes. The infusion of large amounts of fluid with even a weak concentration of lidocaine has also resulted in numerous fatal outcomes as a result of anesthetic overdose. To make matters worse, these procedures are often combined with other prolonged operations. Our experience clearly indicates that when a patient has been under anesthesia for more than 6 hours undergoing multiple procedures, the percentage of complications and/or fatal out- come rises dramatically. Overall, there are two categories of liability from conventional assisted lipectomy procedures: 1. Unrecognized abdominal perforation, resulting in disabling sec- ondary surgery or death b. Pulmonary embolism and death 194 Gorney The cavalier way in which this operation is sometimes performed requires rethinking, particularly when the amounts of fat extracted are major. In several venues in the United States, state medical regulatory authorities are beginning to take notice, and unless there is a significant downturn in the morbidity of this procedure, there will undoubtedly be some regulatory intervention to control the rising tide of misfortune. Skin Resurfacing Chemical peels and laser resurfacing constitute the next category of claims, constituting roughly 3%.

As those who have lived through malpractice litigation attest effective 10 mg baclofen muscle relaxant for pulled muscle, life goes on and operating room conversation ultimately shifts to more interesting topics generic baclofen 10mg amex yellow muscle relaxant 563. Rather than mulling over what they might have done wrong, anesthesiologists are encouraged to focus on the positive steps that can be taken to improve patient outcomes and enhance the defense of their own malpractice claims. Preparing and keeping a detailed narrative of what occurred and becoming familiar with the medical record will enable an anesthesi- ologist to explain relevant issues to a defense attorney and malpractice company claims representative. Researching topics relevant to the case in anesthesiology texts and in literature available through Internet medical search engines like Medline® can help an attorney establish the standard of care and identify appropriate experts. It can also help to avoid being surprised by information discovered by the plaintiffs. From a risk-management standpoint, anesthesiologists should ask Chapter 10 / Anesthesiology 137 themselves honestly whether changing any of their routine practices could avoid similar complications in the future. Changing techniques after an untoward event in no way implies that what was done previ- ously was substandard. Many anesthesiologists describe feelings of depression or shame after serious complications occur or after receiving notification of an impending malpractice claim. Although initially it can seem like things will only get worse, the vast majority of physicians report that the negative feelings pass with time and life does return to normal. Spend- ing time on outside activities they enjoy and avoiding overwork and sleep deprivation can only have positive effects on anesthesiologists’ mental state and job function (16). Guidelines for Risk Management in Anesthesiology, TDC Anesthesia Handbook, 1999. Lofsky AS: Labor and Delivery Disaster Claims, TDC Risk Management Bulletin, 2004. Anesthesiology: A Claims Review Panel on Epidural Anesthesia, TDC Anesthesia Handbook, 1999. Sleep Apnea and Narcotic Postoperative Pain Medication: A Morbid- ity and Mortality Risk, TDC Risk Management Bulletin, 2001. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Chapter 11 / Obstetrics and Gynecology 139 11 Malpractice and Medical Practice Obstetrics and Gynecology Jack M. Schneider, MD SUMMARY This chapter presents general and specialty-specific issues leading to malpractice litigation. Strategies for decreasing medical error and preventing malpractice litigation are outlined with emphasis on accurate documentation, review of clinical information, selec- tion and appropriate use of consultants, and above all, communi- cation to the patient and family. The need to continue learning from national care guidelines and specialty-specific publications is emphasized. Key Words: Labor; delivery; informed consent; maternal health care; Cesarean section; American College of Obstetrics and Gyne- cology Guidelines. INTRODUCTION Most cases of medical malpractice in obstetrics or gynecology follow from negligent performance of physician obligations that are not unique to this specialty. The physician must have the degree of learning and skill ordinarily possessed by reputable specialists practicing in the same field in the same or similar locality. Failure to meet these duties consti- tutes negligence, that is, the failure to meet the standard of care. Meeting the standard of care requires knowl- edge and application of national professional (e. With the exception of the emergency situation, informed consent must be obtained from the patient or legal guardian prior to providing treatment or performing a procedure. Appropriate alternatives must be disclosed and the risks of the proposed intervention discussed in detail. Although possible death or serious bodily harm must be addressed, it is wise to discuss more common complications of the specific treat- ment and to present them in terms of expected frequency of occurrence. One is failure to document the specific complications covered in the discussion (e. For example, the patient with pelvic pain often has the implied expectation of relief from the pain, but the physician knows this is possible but not certain. Refusal by the patient to consent to a plan of treatment must be made on an informed basis. The physician should thoroughly docu- ment the advice provided, the patient’s refusal to embrace the plan of care, and the potential consequences.

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Nevertheless it is known from experimental studies purchase baclofen 10 mg with amex muscle relaxant lorazepam, after virtually complete destruction of the nigrostriatal tract order baclofen 10 mg with visa muscle relaxant definition, that systemic dopa can still increase striatal DA. Presumably conversion must take place in other neurons or as dopa crosses the blood-brain barrier. Whichever is correct, dopa will increase DA not only in the striatum but elsewhere in the brain and so side-effects occur such as vomiting (60% of patients), dyskinesia (80%), some psychoses (25%) and a reduction in prolactin secretion. Although some phasic hypertension may be seen, the dominant cardiovascular effects are cardiac arrythmias and hypotension (50%) probably through reduced sympathetic activity either due to DA displacing NA in peripheral sympathetic nerve terminals or a reduction in central sympathetic outflow. Unfortunately levodopa (only the levo form of dopa is active) has a very short plasma half-life (‰t) of 1‰±2 hours. Also it is estimated that only 30% of an oral dose reaches the circulation and less than 10% of that gets into the CNS. Blocking the conversion to DA would appear stupid unless this could be restricted to the periphery. More dopa would then be preserved for entry into the brain, where it could be decarboxylated to DA as usual. Drugs like carbidopa and benserazide do precisely that and are used successfully with levodopa. They are known as extracerebral dopa decarboxylase inhibitors (ExCDDIs). Carbidopa (a-methyldopa hydrazine) is structurally similar to dopa but its hydrazine group (NHNH2) reduces lipid solubility and CNS penetration (Fig. ExCDDIs certainly improve the efficacy and duration of action of levodopa so that it can be given in a smaller dose (e. As might be expected, some DA side-effects such as dyskinesia and psychoses are worse, but hypotension is less (no peripheral effects of DA) and vomiting is actually much reduced or abolished. This is because the chemoreceptor trigger zone of the vomiting centre while in the brain is on the blood side of the blood±brain barrier and will not be stimulated since no DA is formed peripherally (Fig. DA produces vomiting by acting on the chemo receptor trigger zone (CRTZ) of the vomiting centre (VC) outside, on the blood side, of the blood±brain barrier. When levodopa is given with an extracerebral dopa decarboxylase inhibitor like carbidopa it is not converted to DA peripherally and so there is no stimulation of the CRTZ. The emetic effect of a DA (D2) agonist can be prevented by a D2 antagonist like domperidone which acts only peripherally. This could also prevent the emetic effect of any DA formed peripherally from levodopa. Since neither carbidopa nor domperidone enter the CNS they do not modify the central effect of either levodopa or a DA agonist ExCDDI does reduce the peripheral metabolism of dopa in humans and increase the amount entering the brain in animals is shown in Fig. COMT inhibitors Levodopa is a better substrate for COMT than MAO and when given with an ExCDDI most of it is o-methylated to OMD (Fig. Recently COMT inhibitors have been developed which act either just peripherally (entacopone) or centrally as well DISEASES OF THE BASAL GANGLIA 309 Figure 15. Dopamine is not seen in either trace due to its rapid metabolism to DOPAC and HVA. Peaks for both these metabolites are seen in (i) but they are much reduced in (ii) indicating that in the presence of benserazide very little DA had been formed peripherally. The OMD peak is much greater after benserazide, which again indicates that dopa has been o-methylated (by COMT) rather than decarboxylated. Both have been tried clinically and shown to prolong the plasma half- life and effect of dopa (‡ExCDDI). Long-term effects After some 5 years of treatment, most patients show (1) Abnormal involuntary movements (AIMs), manifest mainly as dyskinesias at the peak plasma level of dopa. A patient may be walking fairly well but then become suddenly akinetic and fixed before quickly moving again. These effects could result from the progression of the disease but as they are a feature of levodopa therapy a change in the central response to levodopa or changes in its peripheral kinetics are more likely.

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This prominent line on the axial This chapter is also organized so that one can view structures in section represents the approximate plane of the sagittal section either the axial or the sagittal plane only discount baclofen 25mg line spasms from catheter. On the sagittal section this line signi- on left-hand pages and are sequenced from dorsal to ventral (odd- fies the approximate plane of the corresponding axial section buy discount baclofen 10mg online muscle relaxant reversals. Consequently, the user can cated either above or below that plane (axial to sagittal compar- identify and follow structures through an axial series by simply flip- ison) or medial or lateral to that plane (sagittal to axial ping through the left-hand pages or through a sagittal series by flip- comparison). This method of presentation provides a format for ping through the right-hand pages. The inherent flexibility in this reconstructing and understanding three-dimensional relation- chapter should prove useful in a wide variety of instructional/ ships within the central nervous system. The drawings shown in the following illustrate The magnetic resonance image (MRI) placed on every page the axial and sagittal planes of the photographs in this chapter. Many of the structures labeled in key thalamic nuclei (anterior, centromedian, pulvinar, habenular). The this photograph can be clearly identified in the adjacent T1-weighted heavy line represents the approximate plane of the sagittal section MRI. Abbreviations AntNu Anterior nucleus of thalamus HipCom Hippocampal commissure CaNu,H Caudate nucleus, head IntCap,AL Internal capsule, anterior limb CaNu,T Caudate nucleus, tail IntCap,G Internal capsule, genu CI Claustrum IntCap,PL Internal capsule, posterior limb CM Centromedial nucleus of thalamus OpRad Optic radiations CorCI Corpus callosum PulNu Pulvinar nuclear complex CP Choroid plexus Put Putamen DMNu Dorsomedial nucleus of thalamus Sep Septum pellucidum For Fornix, column StTer Stria terminalis Hab Habenular nucleus VA Ventral anterior nucleus of thalamus Hip Hippocampal formation VL Ventral lateral nucleus of thalamus Hip,F Hippocampus, fimbria VPL Ventral posterolateral nucleus Axial–Sagittal Correlations 163 AntNu For,B LDNu CorCl,Spl CorCl,G DMNu PrTecNu SMT Hab SC AC PoCom IC RNu For,Col HyTh MtTr TroNr MLF MB OcNr FNu OpNr SCP,Dec AbdNu BP ML Py NuGr PO HyNu LCSp 6-2 Sagittal section through the column of the fornix, anterior thalamic represents the approximate plane of the axial section shown in Figure nucleus, red nucleus, and medial portions of the pons (abducens nucleus), 6-1 (facing page). Many of the structures labeled in this photograph can cerebellum (fastigial nucleus), and medulla (nucleus gracilis). Abbreviations AbdNu Abducens nucleus MB Mammillary body AC Anterior commissure ML Medial lemniscus AntNu Anterior nucleus of thalamus MLF Medial longitudinal fasciculus BP Basilar pons MtTr Mammillothalamic tract CorCI,G Corpus callosum, genu NuGr Nucleus gracilis CorCI,Spl Corpus callosum, splenium OcNr Oculomotor nerve DMNu Dorsomedial nucleus of thalamus OpNr Optic nerve FNu Fastigial nucleus (medial cerebellar nucleus) PO Principal olivary nucleus For,B Fornix, body PoCom Posterior commissure For,Col Fornix, column PrTecNu Pretectal nuclei Hab Habenular nuclei Py Pyramid HyNu Hypoglossal nucleus RNu Red nucleus HyTh Hypothalamus SC Superior colliculus IC Inferior colliculus SCP,Dec Superior cerebellar peduncle, decussation LCsp Lateral corticospinal tract SMT Stria medullaris thalami LDNu Lateral dorsal nucleus TroNr Trochlear nerve 164 Internal Morphology of the Brain in Stained Sections Anterior horn of lateral ventricle Sep CaNu,H For,Col GPLGPL Ins Put VA MtTr IntCap,AL Cl DMNuDMNu ExtCap VL InTCap,PL CM VPM VPL HabCom MGNuMGNu SC,Br StTer SC PulNuPulNu CaNu, T OpRad Hip Tap 6-3 Axial section through the head of the caudate nucleus, centrome- ure 6-4 (facing page). Many of the structures labeled in this photograph dian nucleus, medial geniculate body, and superior colliculus. The heavy line can be clearly identified in the adjacent T2-weighted MRI. Many of the structures labeled in this photograph can be duncle), and medulla (solitary nuclei and tract). Note the position of the clearly identified in the adjacent T1-weighted MRI. The heavy line repre- Abbreviations AC Anterior commissure LDNu Lateral dorsal nucleus AnLen Ansa lenticularis ML Medial lemniscus AntNu Anterior nucleus of thalamus MtTr Mammillothalamic tract BP Basilar pons NuCu Nucleus cuneatus CC Crus cerebri NuGr Nucleus gracilis CM Centromedian nucleus OlfTr Olfactory tract CorCl,B Corpus callosum, body OpTr Optic tract CorCl, Spl Corpus callosum, splenium PO Principal olivary nucleus DMNu Dorsomedial nucleus of thalamus PulNu Pulvinar nuclear complex FacNu Facial nucleus RNu Red nucleus For,B Fornix, body SC Superior colliculus ForVen Fourth ventricle SCP Superior cerebellar peduncle (brachium H Prerubral field conjunctivum) HyTh Hypothalamus SN Substantia nigra IC Inferior colliculus SolNu&Tr Solitary nuclei and tract LatVen,AH Lateral ventricle, anterior horn ThFas Thalamic fasciculus LenFas Lenticular fasciculus VA Ventral anterior nucleus of thalamus 166 Internal Morphology of the Brain in Stained Sections AC CaNu,HCaNu,H LT GPL Put For,Col GPM Hyth MtTr IntCap,AL VL Cl VPM SC IntCap: CM VPL PL RL MGNuMGNu CeGy SCSC PulNu Hip,F OpRad Hip CP ALV 6-5 Axial section through the head of the caudate nucleus, ventral post- shown in Figure 6-6 (facing page). Many of the structures labeled in eromedial nucleus, medial geniculate body, and ventral parts of the pulvinar. Abbreviations AC Anterior commissure IntCap,AL Internal capsule, anterior limb ALV Atrium of lateral ventricle IntCap,Pl Internal capsule, posterior limb CaNu,H Caudate nucleus, head IntCap,RL Internal capsule, retrolenticular limb CeGy Central gray (periaqueductal gray) LT Lamina terminalis CI Claustrum MGNu Medial geniculate nucleus CM Centromedian nucleus of thalamus MtTr Mammillothalamic tract CP Choroid plexus OpRad Optic radiations For,Col Fornix, column PulNu Pulvinar nuclear complex GPL Globus pallidus, lateral segment Put Putamen GPM Globus pallidus, medial segment SC Superior colliculus Hip Hippocampal formation VL Ventral lateral nucleus of thalamus Hip,F Hippocampus, fimbria VPL Ventral posterolateral nucleus of thalamus HyTh Hypothalamus VPM Ventral posteromedial nucleus of thalamus Axial–Sagittal Correlations 167 CorCl,G LDNu CorCl,Spl DMNu VLVL PulNu CaNu,H VAVA CMCM SCSC H RNu IC LL AC SN SCP ENu OpTr CC AnLen SOpNu LenFas CSNu ML TriMoNu FacNr OCblF NuCu 6-6 Sagittal section through central regions of the diencephalon (cen- heavy line represents the approximate plane of the axial section shown tromedian nucleus) and midbrain (red nucleus), and through lateral areas of in Figure 6-5 (facing page). Many of the structures labeled in this pho- the pons (trigeminal motor nucleus) and medulla (nucleus cuneatus). Abbreviations AC Anterior commissure LL Lateral lemniscus AnLen Ansa lenticularis ML Medial lemniscus CaNu,H Caudate nucleus, head NuCu Nucleus cuneatus CC Crus cerebri OCblF Olivocerebellar fibers CM Centromedian nucleus of thalamus OpTr Optic tract CorCl,G Corpus callosum, genu PulNu Pulvinar nuclear complex CorCl,Spl Corpus callosum, splenium RNu Red nucleus CSNu Chief (prinicipal) sensory nucleus of trigeminal nerve SC Superior colliculus DMNU Dorsomedial nucleus of thalamus SCP Superior cerebellar peduncle (brachium con- ENu Emboliform nucleus (anterior interposed cerebellar nucleus) junctivum) FacNr Facial nerve SN Substantia nigra H Field of Forel (prerubral field) SOpNu Supraoptic nucleus IC Inferior colliculus TriMoNu Trigeminal motor nucleus LenFas Lenticular fasciculus VA Ventral anterior nucleus of thalamus LDNu Lateral dorsal nucleus of thalamus VL Ventral lateral nucleus of thalamus 168 Internal Morphology of the Brain in Stained Sections CaNu Ins LT HyTh For MtTr AC RNu OpTr LGNuLGNu CC ML StTer IC,Br CaNu,T Hip MGNu IC OpRad 6-7 Axial section through the hypothalamus, red nucleus, inferior col- the midbrain, represents a slightly oblique section through the mesen- liculus, and lateral geniculate body. The position of the lamina terminalis is indicated by the dou- proximate plane of the sagittal section shown in Figure 6-8 (facing ble-dashed lines. The axial plane through the hemisphere, when continued into be clearly identified in the adjacent T1-weighted MRI. Abbreviations AC Anterior commissure LGNu Lateral geniculate nucleus CaNu Caudate nucleus LT Lamina terminalis CaNu,T Caudate nucleus, tail MGNu Medial geniculate nucleus CC Crus cerebri ML Medial lemniscus For Fornix MtTr Mammillothalamic tract Hip Hippocampal formation OpRad Optic radiation (geniculocalcarine fibers) HyTh Hypothalamus OpTr Optic tract IC Inferior colliculus RNu Red nucleus IC,Br Inferior colliculus, brachium StTer Stria terminalis Ins Insula Axial–Sagittal Correlations 169 Zl AC ThFas Lenfas VPM CaNu BrSC VLVL PulNuPulNu SThNu GPL GPM MGNu Put SN Hip OpTr AmyNu CC DNu MCP PCNu 6-8 Sagittal section through the caudate nucleus, central parts of the proximate plane of the axial section shown in Figure 6-7 (facing page). The heavy line represents the ap- tified in the adjacent T1-weighted MRI. Abbreviations AC Anterior commissure MGNu Medial geniculate nucleus AmyNu Amygdaloid nucleus (complex) OpTr Optic tract BrSC Brachium of superior colliculus PCNu Posterior cochlear nucleus CaNu Caudate nucleus PulNu Pulvinar nuclear complex CC Crus cerebri Put Putamen DNu Dentate nucleus (lateral cerebellar nucleus) SN Substantia nigra GPL Globus pallidus, lateral segment SThNu Subthalamic nucleus GPM Globus pallidus, medial segment ThFas Thalamic fasciculus Hip Hippocampal formation VL Ventral lateral nucleus of thalamus LenFas Lenticular fasciculus VPM Ventral posteromedial nucleus of thalamus MCP Middle cerebellar peduncle (brachium pontis) ZI Zona incerta 170 Internal Morphology of the Brain in Stained Sections LT SOR OpTr IR HyTh AmyNu MB CC CP SN ML Hip CaNu,T SCP,Dec FHip LatVen,IH MLF LL DenGy SCP OpRad 6-9 Axial section through ventral portions of the hypothalamus hemisphere, when continued into the midbrain, represents a slightly (supraoptic recess and mammillary body) and forebrain (amygdaloid nu- oblique section through the mesencephalon. Many of the structures la- cleus), and through the superior cerebellar peduncle decussation in the mid- beled in this photograph can be clearly identified in the adjacent T1- brain. The heavy line represents the approximate plane of the sagittal weighted MRI. The axial plane through the Abbreviations AmyNu Amygdaloid nucleus (complex) LT Lamina terminalis CaNu,T Caudate nucleus, tail MB Mammillary body CC Crus cerebri ML Medial lemniscus CP Choroid plexus MLF Medial longitudinal fasciculus DenGy Dentate gyrus OpRad Optic radiations FHip Fimbria of hippocampus OpTr Optic tract Hip Hippocampal formation SCP Superior cerebellar peduncle (brachium HyTh Hypothalamus conjunctivum) IR Infundibular recess of third ventricle SCP,Dec Superior cerebellar peduncle, decussation LatVen,lH Lateral ventricle, inferior (temporal) horn SN Sustantia nigra LL Lateral lemniscus SOR Supraoptic recess of third ventricle Axial–Sagittal Correlations 171 VL + VPL CaNu,B EML + ThRetNu OpTr OpRad AC PulNu CalSul ALV Hip GPL LGNu Put GPMGPM CP FHip DenGy Hip DNu AmyNu LatVen,IH 6-10 Sagittal section through the putamen, amygdaloid nucleus, and line represents the approximate plane of the axial section shown in Fig- hippocampus and through the most lateral portions of the diencephalon ure 6-9 (facing page). Many of the structures labeled in this photograph (external medullary lamina and ventral posterolateral nucleus). Abbreviations AC Anterior commissure GPM Globus pallidus, medial segment ALV Atrium of lateral ventricle Hip Hippocampal formation AmyNu Amygdaloid nucleus (complex) LatVen,lH Lateral ventricle, inferior (temporal) horn CalSul Calcarine sulcus LGNu Lateral geniculate nucleus CaNu,B Caudate nucleus, body OpRad Optic radiations CP Choroid plexus OpTr Optic tract DenGy Dentate gyrus PulNu Pulvinar nuclear complex DNu Dentate nucleus Put Putamen EML External medullary lamina ThRetNu Thalamic reticular nuclei FHip Fimbria of hippocampus VL Ventral lateral nucleus of thalamus GPL Globus pallidus, lateral segment VPL Ventral posterolateral nucleus of thalamus CHAPTER 7 Synopsis of Functional Components, Tracts, Pathways, and Systems The study of regional neurobiology (brain structures in gross spec- the CD that comes with this atlas; these are taken from the cur- imens, in brain slices, in stained sections, and in MRI and CT) is rent edition of Stedman’s Medical Dictionary. In this respect, the the basis for the study of systems neurobiology (tracts, pathways, full definitions are actually available in this book.

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