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The testicular ar- teries in the male and the ovarian arteries in the female are small FIGURE 16 depakote 250 mg generic. The inferior mesenteric artery is the last major branch of the abdominal portion of the aorta cheap 250mg depakote with amex. It is an unpaired anterior ves- The ulnar artery extends down the medial, or ulnar, side of sel that arises just before the iliac bifurcation. The inferior the forearm and gives off many small branches to the muscles on mesenteric supplies blood to the distal one-third of the transverse that side. It, too, has an initial large branch, the ulnar recurrent colon, the descending colon, the sigmoid colon, and the rectum. At Several lumbar arteries branch posteriorly from the ab- the wrist, the ulnar and radial arteries anastomose to form the su- dominal portion of the aorta throughout its length and serve the perficial and deep palmar arches. The metacarpal arteries of the muscles and the spinal cord in the lumbar region. In addition, an hand (not shown) arise from the deep palmar arch, and the digital unpaired middle sacral artery (fig. Branches of the Thoracic Portion of the Aorta Arteries of the Pelvis and Lower Extremity The thoracic portion of the aorta is a continuation of the aortic arch as it descends through the thoracic cavity to the diaphragm. The abdominal portion of the aorta terminates in the posterior This large vessel gives off branches to the organs and muscles of pelvic area as it bifurcates into the right and left common iliac the thoracic region. Circulatory System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 16 Circulatory System 567 Ribs FIGURE 16. Pericardium of heart cecum, appendix, of aorta ascending colon, and Posterior intercostal aa. Intercostal and thoracic transverse colon muscles, and pleurae Suprarenal aa.

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Point of departure can be the size of the before–after difference in estimated disease probability or other effectiveness parameters buy 125 mg depakote amex, for example buy 125 mg depakote with amex, the decrease in the rate of (diagnostic) referrals, which would be sufficiently relevant to be detected. If the basic phenomenon to be studied is the clinical assessment of doctors, the latter are the units of analysis. When the consequences for the patients are considered the main outcome, their number is of specific interest. The data analysis of the basic before–after comparison can follow the principles of the analysis of paired data. In view of the relevance of evaluating differences of test impact in various subgroups of patients, and given the observational nature of the before–after study, studying the effect of effect modifying variables and adjusting for confounding factors using multivariable analytical methods, may add to the value of the study. When the clinician and patient “levels” are to be considered simultaneously, multilevel analysis can be used. As it is often difficult to reach sufficient statistical power in studies with doctors as the units of analysis, and because of the expected heterogeneity in observational clinical studies, before–after studies are more appropriate to confirm or exclude a substantial clinical impact than to find subtle differences. Modified approaches Given the potential sources of uncontrollable bias in all phases of the study, investigators may choose to use “paper” or videotaped patients or clinical vignettes, interactive computer simulated cases, or “standardised patients” especially trained to simulate a specific role consistently over time. The limitations of such approaches are that they do not always sufficiently reflect clinical reality, are less suitable (vignettes) for an interactive diagnostic work up, cannot be used to evaluate more invasive diagnostics (standardised patients), and are not appropriate for additionally assessing diagnostic accuracy. A before–after comparison in a group of doctors applying the test to an indicated patient population can be extended with a concurrent observational control group of doctors assessing indicated patients, without receiving the test information (quasi experimental comparison). However, given the substantial risk of clinical and prognostic incomparability of the participating doctors and patients in the parallel groups compared, and of possibly incorrectable extraneous influences, this will often not strengthen the design substantially. If a controlled design is considered, a randomised trial is to be preferred (Chapter 4). First, we have to deal with problems for which, in principle, reasonable solutions can be found in order to optimise the study design. Examples are appropriate specifications of the clinical problem to be studied and the candidate patient population, and the concomitant documentation of test accuracy. Second, the before–after design has inherent limitations that cannot be avoided nor solved.

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Skeletal System: © The McGraw−Hill Anatomy cheap 500 mg depakote otc, Sixth Edition Introduction and the Axial Companies generic 125 mg depakote amex, 2001 Skeleton 146 Unit 4 Support and Movement TABLE 6. Slightly medial to its midpoint Temporal Bone is an opening called the supraorbital foramen, which provides pas- The two temporal bones form the lower sides of the cranium sage for a nerve,artery,and veins. Each temporal bone is joined to The frontal bone also contains frontal sinuses, which are its adjacent parietal bone by the squamous suture. The squamous part is the flattened plate of bone at the sides of the skull. On the inferior surface of the The two parietal bones form the upper sides and roof of the cra- squamous part is the cuplike mandibular fossa, which nium (figs. The coronal suture separates the forms a joint with the condyle of the mandible. This artic- frontal bone from the parietal bones, and the sagittal suture ulation is the temporomandibular joint. The inner concave surface of each parietal bone, as well as the inner concave surfaces of other cranial bones, is marked by shallow impressions from convolutions of the brain and vessels serving the brain. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 147 Frontal bone Parietal bone Temporal bone Lacrimal bone Nasal bone Zygomatic bone Inferior nasal concha Maxilla Vomer Mandible FIGURE 6. Coronal suture Parietal bone Frontal bone Lambdoid suture Sphenoid bone Squamous suture Ethmoid bone Temporal bone Lacrimal bone Occipital bone Nasal bone Zygomatic bone External acoustic meatus Infraorbital foramen Mastoid process Maxilla Condylar process Coronoid process of mandible of mandible Styloid process Zygomatic process Mental foramen Mandibular notch Mandible Angle of mandible Creek FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 148 Unit 4 Support and Movement Incisors Premolars Canine Incisive foramen Molars Median palatine suture Zygomatic bone Palatine process of maxilla Palatine bone Sphenoid bone Greater palatine foramen Medial and lateral Zygomatic process pterygoid processes of sphenoid bone Vomer Foramen ovale Mandibular fossa Foramen lacerum External acoustic meatus Carotid canal Jugular fossa Styloid process Stylomastoid foramen Mastoid process Foramen magnum Occipital condyle Mastoid foramen Temporal bone Parietal bone Superior nuchal line Condyloid canal Occipital bone External occipital protuberance Creek FIGURE 6. Parietal bone Frontal Temporal bone bone Occipital bone Nasal bone Maxilla Mandible Palatine bone Vomer FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 149 Squamous suture Supraorbital margin Mandibular condyle Mandibular fossa Zygomatic arch External acoustic meatus Coronoid process of mandible Mastoid process of temporal bone Styloid process Ramus of mandible of temporal bone Jugular foramen Mental protuberance Lambdoid suture Angle of mandible Occipitomastoid suture Condyloid canal Digastric fossa Occipital condyle Mandibular foramen Foramen magnum FIGURE 6. Frontal bone Sphenoid bone Temporal bone Parietal bone Occipital bone FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 150 Unit 4 Support and Movement Frontal bone Ethmoid bone Zygomatic bone Middle nasal concha Maxilla Inferior nasal concha Vomer FIGURE 6. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 151 Ethmoidal Frontal sinus sinus Sphenoidal sinus Frontal sinus Ethmoidal sinuses Sphenoidal sinus Maxillary sinus Maxillary sinus (a) (b) FIGURE 6.