睿学教育Wisdome Education

Rajan A.G. Patel, MD

• Cardiology Fellow, Department of Medicine, Division of Cardiovascular
• Medicine, University of Virginia, Charlottesville, VA, USA

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This effect is rapid and does not require complex signaling pathways; however erectile dysfunction causes heart buy discount cialis soft 20 mg on line, the capacity is limited impotence at 43 best buy cialis soft, and the mechanism cannot serve a long-term role in calcium homeostasis impotence clinic cialis soft 40 mg purchase otc. Recall that ~99% of total body calcium is present in bones, and a healthy adult body has about 1 to 2 kg of calcium. Most of the calcium in bones exists as mature, hardened bone mineral that is not readily exchangeable but can be moved into the plasma via hormonal mechanisms (described below). However, ~1% (or 10 g) of the calcium in bones is in a simple chemical equilibrium with plasma calcium. This readily exchangeable calcium source is primarily located on the surface of newly formed bones. Any change in free calcium in the plasma or extracellular fluid results in a shift of calcium either into or out of the bone mineral until a new equilibrium is reached. Although this mechanism, like that described above, provides for a rapid defense against changes in free calcium concentrations, it is limited in capacity and can provide for only short-term adjustments. Long-term, hormonal regulation of plasma calcium and phosphate is under the control of parathyroid hormone, calcitonin, and 1,25- dihydroxycholecalciferol. Hormonal mechanisms have a large capacity and the ability to make long-term adjustments in calcium and phosphate fluxes, but they do not respond instantaneously. It may take several minutes or hours for the response to occur and adjustments to be made. Nevertheless, these are the principal mechanisms that regulate plasma calcium and phosphate concentrations. Synthetic peptides containing the first 34 amino terminal residues appear to be as active as the native hormone. There are two pairs of parathyroid glands, located on the dorsal surface of the left and right lobes of the thyroid gland. Because of this close proximity, a common cause of chronic hypocalcemia is postsurgical removal of all parathyroid tissue, either during a thyroidectomy and removal of neck-associated malignancies or after inadvertent interruption of blood supply to the parathyroid glands during head and neck surgery. Hypoparathyroidism is a rare complication of radioactive iodine ablation of the thyroid gland in Graves disease. The higher potency may be a result of a greater affinity for receptors and slower degradation by peripheral tissues. More precisely, a metabolite of vitamin D, 1,25-dihydroxycholecalciferol, serves as a3 hormone in calcium homeostasis. The D vitamins, a group of lipid-soluble compounds derived from cholesterol, have long been known to be effective in the prevention of certain bone diseases such as rickets (discussed below). Research during the past 30 years indicates that vitamin D exerts its effects through a hormonal mechanism. A related compound vitamin D2 (also known as ergocalciferol) is the form mainly found in plants and yeasts and is commonly used to supplement human foods because of its relative availability and low cost (see Fig. Although it is less potent on a mole-per-mole basis, vitamin D undergoes the same metabolic conversion steps and, ultimately2, produces the same biologic effects as vitamin D. Vitamin D can be provided by the diet or formed in the skin by the action of ultraviolet light on a3 precursor, 7-dehydrocholesterol, derived from cholesterol (see Fig. In many countries where food is not systematically supplemented with vitamin D, this pathway provides the major source of vitamin D. Because of the number of variables involved, it is difficult to specify a minimum exposure time. However, exposure to moderately bright sunlight for 30 to 120 min/d usually provides enough vitamin D to satisfy the body’s needs without any dietary supplementation. However, they undergo a series of3 2 transformations in the liver and kidneys that convert them into powerful calcium regulatory hormones (Fig. This reaction is largely unregulated, although certain drugs3 and liver diseases may affect this step. The product is 1,25-dihydroxycholecalciferol, also known as 1,25-dihydroxyvitamin D or calcitriol, the principal hormonally active form of the vitamin. The enzyme 1α-hydroxylase, which is located in tubule cells, catalyzes the reaction in the kidney3. In addition, enzyme activity increases in response to a decrease in plasma phosphate.

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What is the basis but also establishes as effective communication net on which the risk of exposure to these chemicals is work www.erectile dysfunction treatment order generic cialis soft online. The safety evaluation of chemicals has two important • Off site emergency: Off site emergency plans have interlinked components: to deal with identification of vulnerable Groups; their 1 impotence related to diabetes buy cialis soft toronto. Exposure assessment making estimates of the prompt evacuation if a recurrence of release of toxic chemical in the environment and in the target material is anticipated; mopping up of water and food organisms impotence in men buy genuine cialis soft online. The recent earthquake in Latur and • Do not allow children to play with matchboxes or Osmanabad districts of Maharashtra indicated that a lighters and electrical appliances like room heater, large number of casualties can take place even in a immersion heater, iron, hair dryers, etc. India with a wide range of climatic and topographical • Repair deep plaster cracks in ceilings and conditions is subject to various types of natural disasters. Expert advice should be sought if there In contrast, biological and chemical disasters take only are signs of structural defects. The extent and severity of natural • Do not stay close to glass, windows, outside doors disasters in India is briefly indicated below: and walls and anything that could fall such as lighting fixtures or furnitures. Flood is a common natural disaster during the later part • Switch off electrical gadgets and power supply. Statewise Analysis Drought By and large in India, all States/Union Territories are likely to face a disaster situation like drought, flood, Drought is also perennial feature in India. All 5 States, which are prone to only one type of disaster, face severe drought situation every The coastal area of the country experiences about two 1 year. Cancers of the head and neck-including cancers of the buccal cavity, head and neck subset, larynx, pharynx, thyroid, salivary glands, and nose/nasal passages-account for approximately 6 % of all malignancies in the United States [1]. Careful analysis of nodes in the neck and knowledge of the various compartments is critical in the assess- ment and staging of primary head and neck malignancies. Regardless of the site of the primary tumor, the presence of a single metastatic lymph node in either the ipsilateral or contralateral side of the neck reduces the 5-year survival rate by about 50 %. The risk of cervical metastasis depends on the site of origin of the primary tumor [2]. Classi fi cation The classification of cervical lymph nodes is complicated by the use of several dif- ferent systems and the rather loose intermixing of specific names for a particular node from one system to another [3]. Of the approximately 800 lymph nodes in the body, about 300 are located in the neck. Thus, between one fifth and one sixth of all the nodes in the body are located in either side of the neck, making development of a classification system very complex [4 ]. For nearly four decades, the most commonly used classification for the cervical lymph nodes was that developed by Rouvière in 1938 who described the “collar” (including occipital, mastoid, parotid, facial, retropharyngeal, submaxillary, submental, and sublingual nodes), anterior and lateral cervical groups. The direc- tion of nodal classification changed from that of a pure anatomic study to a nodal mapping guide for selecting the most appropriate surgical procedure among the various types of neck dissections [5 ]. Since then, a number of classifications have been proposed that use such level, region, or zone termi- nology. At the time of this writing, the criteria to define cervical lymphadenopathy are (1) a discrete mass great than 1. A nodal mass with central low density is specifically indicative of tumor necrosis [7, 9–11]. This is thought to be due to fibrosis of the lymphatic vessels in the irradiated regions resulting in diversion of lymph drainage to the submental nodes [14]. They drain lymph from oral cavity, nasal cavity, nasopharynx, oropharynx, hypopharynx, lar- ynx, and parotid gland (see Figs. Unusual Site of Metastasis Intraparotid lymph nodes may be involved by lymphoma or metastatic spread from tumors of the scalp and face region [17 ]. The tumor and the nodes are outlined in (b) 14 1 Head and Neck Lymph Node Anatomy a b Fig. Involvement of level V nodes precedes their involvement in thyroid malignancies (see Figs. Involvement of Virchow node in carcinoma stomach is attributed to the predominant drainage by thoracic duct and partial filtration by Virchow node. The tumor and the node are outlined in (b) 20 1 Head and Neck Lymph Node Anatomy Fig. Involvement of these nodes is considered as a bad prognostic sign in aerodigestive tract malignancies. These nodes are not included in the level system The facial, mastoid occipital, and retropharyngeal nodes (see Fig. Facial nodal group is a blanket term applied for nodes at mandibular, buccinators, infraorbital, retrozygomatic, and malar nodes.

Diseases

• Cote Katsantoni syndrome
• Navajo poikiloderma
• Dibasic aminoaciduria type 1
• Alves Dos Santos Castello syndrome
• Langdon Down
• Adenocarcinoma of lung
• Mental retardation, X-linked 14

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An extremely strong reaction called the cerebral ischemic response is triggered by inadequate brain blood flow (ischemia) and can produce a more intense sym­ pathetic vasoconstriction and cardiac stimulation than is elicited by any other infuence on the cardiovascular control centers erectile dysfunction 50 years old purchase cialis soft with paypal. However impotence 24-year-old purchase cialis soft once a day, if cere­ bral blood fow is severely inadequate for several minutes impotence 20 years old cialis soft 40 mg purchase without prescription, the cerebral ischemic response wanes and is replaced by marked loss of sympathetic activity. Presumably this situation results when function of the nerve cells in the cardiovascular centers becomes directly depressed by the unfavorable chemical conditions in the cere­ brospinal fuid. Whenever intracranial pressure is increased-for example, by tumor growth or trauma-induced bleeding within the rigid cranium-there is a parallel rise in arte­ rial pressure. This is called the Cushing rex and is a variant of the cerebral isch­ emic response. It can cause mean arterial pressures of more than 200 mm Hg in severe cases of intracranial pressure elevation. The obvious beneft of the Cushing refex is that it prevents collapse of cranial vessels and thus preserves adequate brain blood fow in the face of large increases in intracranial pressure. The early phase of the Cushing refex often includes tachycardia, whereas the late (and more dangerous) phase of this refex is accompanied by bradycardia (presumably resulting from elevated refex vagal activity from the arterial baroreceptor input). These pathways may be activated 2 Certain other reflexes originating from receptors in the cardiopulmonary region have been described that may be important in specifc pathological situations. For example, the Bezol-]arich reflex that involves marked bradycardia and hypotension is elicited by application of strong stimuli to coronary vessel (or myocardial) chemoreceptors concentrated primarily in the posterior wall of the lef ventricle. Activation of this refex causes certain myocardial infarction patients to present with bradycardia instead of the expected tachycardia. This input may contribute to the marked increase in blood pressure that accompanies such isometric efforts. It is uncer­ tain as to what extent this refex contributes to the cardiovascular responses to dynamic (rhythmic) muscle exercise. The response serves to allow prolonged submersion by limiting the rate of oxygen use and by directing blood fow to essential organs. A similar but less dramatic dive refex can be elicited in humans by simply immersing the face in water. This is a rare exception to the general rule that sympathetic and parasympathetic nerves are activated in recipro­ cal fashion. The dive refex is sometimes used clinically to refexly activate cardiac parasympathetic nerves for the purpose of interrupting atrial tachyarrhythmias. Another, but unrelated, clinical technique for activating parasympathetic nerves in an attempt to interrupt atrial tachyarrhythmias is called carotid mas­ sage. In essence, massage of the neck is done to cause physical deformation of the carotid sinuses and "trick" them into sending a "high-pressure" alarm to the medullary control centers. These responses originate in the cerebral cortex and reach the medullary cardio­ vascular centers through corticohypothalamic pathways. The least complicated of these responses is the blushing that is often detectable in individuals with lightly pigmented skin during states of embarrassment. The blushing response involves a loss of sympathetic vasoconstrictor activity onl to particular cutaneous vessels, and this produces the blushing by allowing engorgement of the cutaneous venous sinuses. Excitement or a sense of danger often elicits a complex behavioral pattern called the alrtng reacton (also called the "defense" or "fght or fight" response). The alerting reaction involves a host of responses such as pupillary dilation and increased skeletal muscle tenseness that are generally appropriate preparations for some form of intense physical activity. The cardiovascular component of the alert­ ing reaction is an increase in blood pressure caused by a general increase in cardio­ vascular sympathetic nervous activity and a decrease in cardiac parasympathetic activity. Centers in the posterior hypothalmus are presumed to be involved in the alerting reaction because many of the components of this multifaceted response can be experimentally reproduced by electrical stimulation of this area. The gen­ eral cardiovascular effects are mediated via hypothalamic communications with the medullary cardiovascular centers. The loss of consciousness is due to decreased cerebral blood flow that is itself produced by a sudden dramatic loss of arterial blood pressure that, in turn, occurs as a result of a sudden loss of sympathetic tone and a simultaneous large increase in parasympathetic tone and decrease in the heart rate. The infuences on the medullary cardiovascular centers that produce vasovagal syncope appear to come from the cortex via depressor centers in the anterior hypothalmus. It has been suggested that vasovagal syn­ cope is analogous to the "playing dead" response to peril used by some animals. Fortunately, unconsciousness (combined with becoming horizontal) seems to quickly remove this serious disturbance to the normal mechanisms of arterial pressure control in humans. The extent to which cardiovascular variables, in particular blood pressure, are normally affected by an emotional state is currently a topic of extreme interest and considerable research.

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Conservative treatment consists of analgesia erectile dysfunction more causes risk factors cialis soft 20 mg online, anti-inflammatory medication impotence antonym 20 mg cialis soft buy visa, physiotherapy erectile dysfunction causes lower back pain order 20 mg cialis soft with visa, selective nerve root injections/caudal epidural, all of which aim to reduce the inflammation around the nerve root sheath. The risks of lumbar microdiscectomy are small but include infection (wound, pyogenic discitis and epidural abscess), dural tear, vascular injury and recurrent disc prolapse. The causes L3/4→compression of L4 root→pain in the can be classified as congenital (achondroplasia with posterolateral thigh region and anteromedial short pedicles or other skeletal dysplasia – rare) and aspect of the lower leg, motor weakness of the acquired (degenerative – common). The narrowing quadriceps (knee extension) and absence of the of the spinal canal is described as being either in the knee jerk. The abnormality begins as degenerative changes within the disc cause a reduction of the disc Imaging height and posterior bulging of the annulus. The The investigation of a patient with sciatic leg pain reduction in disc height causes infolding of the liga- consists of the following. Plain radiographs are obtained to assess abnor- Degenerative osteoarthritic changes (hypertrophy malities of segmentation (in particular lumbosacral and osteophyte formation) result from the increased transitional vertebrae) and detect evidence of a loading of the facet joints. The combination of spina bifida occulta if surgical intervention is being these changes results in the typical trefoil-shaped considered. Bone and calcium metabolism 227 Normal Ultrasound studies of the circulation may be needed to exclude peripheral vascular claudication. Severe cases who fail to respond to conservative Caude treatment can be managed surgically with decom- equina Normal pression, which may be either open or distractive. Disc protrusion There is considerable argument within the lit- erature about the role of fusion at the time of an Spinal stenosis open decompression (fusion may be posterolateral or interbody). The indications for fusion include a Bulging degenerative spondylolisthesis, recurrent stenosis disc and a severe stenosis requiring complete facet joint removal with a resulting potential for instability. Distractive decompression involves placing a Thickened spacer between the spinous processes in order to ligamentum Facet joint indirectly decompress the canal by distracting the flavum hypertrophy segment. Calcium is subsequently be difficult but there are certain defining differences excreted in the kidney. Vitamin D is acquired via two sources: diet (vita- The neurogenic claudication distance is variable but min D3) and the conversion of 7-dehydrocholesterol the vascular claudication distance is relatively constant. This active metabolite can then act on the gut to increase calcium and phosphate reabsorp- Imaging tion and within bone to cause osteoid mineralization. Parathyroid hormone acts to Screening blood tests increase reabsorption of calcium in the kidneys and Exclude hyperthyroidism, Cushing’s disease, hae- stimulates osteoclastic activity, resulting in release matological disorders and malignancy: thyroxine, of calcium from bone. Calcitonin is a 32 amino acid polypeptide from clear parafollicular cells in the thyroid gland. Imaging Calcitonin acts to reduce the serum calcium level and is secreted in response to raised serum calcium. It is bone mineral homeostasis include oestrogen, dual X-ray absorptiometry, which is performed on which prevents bone loss by inhibiting bone the spine and the hip. Risk factors include: genetics (ethnicity, family history, low body mass index) medical (rheumatoid arthritis, Cushing’s syndrome, chronic diseases) drugs (corticosteroids, anticonvulsants, chemotherapy, alcohol, smoking). The pathogenesis is an uncoupling of bone formation by osteoblasts and bone absorption by osteoclasts. Hip and distal radius fractures and vertebral compression fractures are the most common. They usually result in brain Spinal injuries are becoming increasingly common, stem and proximal spinal cord injury with loss of particularly in developed countries, because of the the breathing centres and death. They account for The majority of spinal injuries occur in the 10 per cent of all cervical spine injuries (Fig 10. The first two cervical vertebrae have a unique They have been classified by Anderson and anatomy. It is a ring structure with anterior and posterior Type I is an avulsion fracture of the tip of the arches and bulky lateral masses to support the peg and can be treated conservatively with weight of the head but has no vertebral body (this a collar. Its most distinctive feature is the tooth-like are often managed with a collar when painless process (the odontoid process) projecting from the non-union is acceptable. The odontoid process either a halo or surgical fixation is often (also known as the dens or peg) has two articulating indicated.

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Bridging the gap between the tympanic membrane and the inner ear is a chain of three small bones impotence causes and cures cheap 20 mg cialis soft with amex, the ossicles (Fig female erectile dysfunction treatment generic cialis soft 40 mg on-line. The malleus (Latin for “hammer”) is attached to the eardrum in such a way that the back-and-forth movement of the eardrum causes a rocking movement of the malleus impotence tumblr discount cialis soft 40 mg with visa. The incus (Latin for “anvil”) connects the head of the malleus to the third bone, the stapes (Latin for “stirrup”). This last bone, through its oval footplate, connects to the oval window of the inner ear and is anchored there by an annular ligament. Vibrations from the eardrum are transmitted by the lever system formed by the ossicular chain to the oval window of the scala vestibuli. The anterior and posterior ligaments, part of the suspensory system for the ossicles, are not shown. The combination of the four suspensory ligaments produces a virtual pivot point (marked by a cross); its position varies with the frequency and intensity of the sound. The stapedius and tensor tympani muscles modify the lever function of the ossicular chain. Four separate suspensory ligaments hold the ossicles in position in the middle ear cavity. The superior and lateral ligaments lie roughly in the plane of the ossicular chain and anchor the head and shaft of the malleus. The anterior ligament attaches the head of the malleus to the anterior wall of the middle ear cavity, and the posterior ligament runs from the head of the incus to the posterior wall of the cavity. The suspensory ligaments allow the ossicles sufficient freedom to transmit the vibrations of the tympanic membrane to the oval window. This mechanism is especially important because, although the eardrum is suspended in air, the oval window seals off a fluid-filled chamber. When sound waves in air strike liquid, most of the energy (~99%) is reflected off the liquid and lost. The middle ear allows the impedance matching of sound traveling in air to acoustic waves traveling in a system of fluids and membranes in the inner ear. Two principles of mechanical advantage are used in the impedance matching, the hydraulic principle and the lever principle. The shape of the articulated ossicular chain is lever-like and has a lever ratio of about 1. In addition, the vibrating portion of the tympanic membrane is coupled to the smaller area of the oval window (~a 17:1 ratio). These conditions result in a pressure gain of around 25 dB, largely compensating for the energy loss going from an air to fluid environment. Although the efficiency depends on the frequency, approximately 60% of the sound energy that strikes the eardrum is transmitted to the oval window. The middle ear is also able to substantially dampen sound conduction when faced with very loud sounds by noise-induced reflex contraction of the middle-ear muscles. These small muscles are attached to the ossicular chain and help hold the bones in position and modify their function (see Fig. The tensor tympani muscle inserts on the malleus (near the center of the eardrum), passes diagonally through the middle ear cavity, and enters the tensor canal, in which it is anchored. Contraction of this muscle limits the vibration amplitude of the eardrum and makes sound transmission less efficient. The stapedius muscle attaches to the stapes near its connection to the incus and runs posteriorly to the mastoid bone. Its contraction changes the axis of oscillation of the ossicular chain and causes dissipation of excess movement before it reaches the oval window. These muscles are activated by a reflex (simultaneously in both ears) and contract in response to moderate and loud sounds. They act to reduce the transmission of sound to the inner ear, thereby protecting its delicate structures. Because this reflex requires up to 150 milliseconds to operate (depending on the loudness of the stimulus), it cannot provide protection from sharp or sudden bursts of sound. If a vibrating object, such as a tuning fork, is placed against a bone of the skull (typically the mastoid), the vibrations are transmitted mechanically to the fluid of the inner ear, where the normal processes act to complete the hearing process.

Syndromes

• Low blood volume (as with heavy bleeding or dehydration)
• Permanent vision loss in the affected eye
• Excessive bleeding
• Estrogen replacement therapy without the use of progesterone
• Low oxygen levels in the body
• Can count to four
• Collapse
• A high-calorie diet that supplies essential vitamins and minerals, as well as certain types of carbohydrates, proteins, and fats
• Convulsions

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Acute manifestations of splenectomy include leukocytosis (up to 25000/µl) and thrombocytosis (up to 1 × 106/µl) but return back to normal levels within 2-3 weeks erectile dysfunction from nerve damage cialis soft 20 mg purchase with amex. Chronic Manifestations of splenectomy include: • Anisocytosis and poikilocytosis • Howell-Jolly bodies (nuclear remnants) • Heinz bodies (denatured hemoglobin) • Basophilic stippling • Target cells • Pappenheimer bodies (contain sideroblastic granules) • Irregular contracted red cells erectile dysfunction protocol discount cialis soft 20 mg order on line. When such erythrocyte abnormalities are seen without splenectomy erectile dysfunction treatment hong kong discount cialis soft 20 mg without prescription, splenic infltration by tumor should be suspected. This condition is similar to endometriosis (presence of endometrial tissue at non- endometrial sites). Which of the following surface glycoproteins is most (b) Spherocytosis often expressed in human hematopoietic stem cell? Burr cell is seen in: (Jharkhand 2003) (d) Howell-Jolly bodies (a) Uremia (e) Cabot ring (b) Hepatocellular carcinoma (c) Gastric carcinoma 6. Which of the following surface glycoproteins is most (d) Ovarian carcinoma often expressed in human hematopoietic stem cell? A 74 year-old female Lajo Devi with renal failure (a) Renal cell carcinoma presents for hemodialysis. On further (c) High altitude investigations, she is found to be anemic and is given a (d) Benign liver tumor dose of erythropoietin. Normal platelet count is found in: (a) Methyl violet (a) Wiskott Aldrich syndrome (b) Brilliant Cresyl blue (b) Henoch Schonlein purpura (c) Sudan black (c) Immune thrombocytopenia (d) Indigo carmine (d) Dengue fever 16. In an adult man, there is about how much grams of (c) Mild splenomegaly hemoglobin in the circulating blood? Hypersegmented neutrophils are present in which of (b) Myelodysplastic anemia the following anemia? All of the following can cause reticulocytosis except and ataxia is given radiolabeled cobalamin by mouth (a) Aplastic anemia followed by an intramuscular injection of unlabeled (b) Thalassemia cobalamin. The urine radioactivity level measured (c) Sickle cell anemia afterwards is determined to be normal. Which of the (d) Chronic blood loss following is the most likely cause of this patient’s 39. Upper gastrointestinal endoscopy is (a) Rubella (b) Human parvo virus B19 consistent with atrophic gastritis. Some blood parameter (c) Measles (d) Dengue virus changes after the frst dose of cyanocobalamin are shown in the graph on the left side of the page. A 60-year old male patient with history of rheumatoid (c) Haptoglobin (d) Gastrin arthritis presents with the following: Hb:4. A 13 yr girl with fatigue and weakness was found to be (a) Beta thalassemia trait having reduced hemoglobin. Schilling test is used for identifcation of which of the (d) Thalassemia major following? The condition which does not cause microcytic hypo- (b) Binding of lead to transferrin, inhibiting the trans- chromic anemia is: (Karnataka 2008) port of iron (a) Iron defciency (c) Binding of lead to cell membrane of erythroid pre- (b) Hookworm infestation cursors. Lead poisoning is associated with: (d) Thalassemia minor (a) Microcytic hypochromic anemia 47. Microspherocytes in peripheral blood smear are seen (d) Bone marrow hypoplasia in: (Karnataka 2005) (e) Iron defciency (a) Congenital spherocytosis 48. Anemia of chronic disease is characterized by of all (c) Anemia in chronic disease. A 30 years old female asymptomatic not requiring blood (a) Spectrin (b) Transferrin transfusion has Hb-13 gm%, HbF-95%, HbA2 1. Response of iron therapy in a patient with iron (b) Increased total iron binding capacity defciency anemia is denoted by: (c) Decreased serum ferritin (a) Restoration of enzymes (d) Increased mean corpuscular volume (b) Reticulocytosis 64. Sideroblastic anemia is seen in chronic poisoning with: (c) Serum ferritin (a) Lead (b) Arsenic (d) Serum transferin (c) Copper (d) Mercury 65. Rate of iron uptake is regulated by which one of the fol- (c) Iron defciency anemia lowing: (d) Pernicious anemia (a) Mucosal cell iron stores 69. A 68 year-old man Babu Rao Apte presents with skin (b) Route of administration pigmentation, cirrhosis and diabetes mellitus. A 23-year-old female presented with jaundice and (b) Erythropoetic porphyria pallor for 2 months. The most relevant (d) Cutaneous porphyria investigation to arrive at a diagnosis is which of the 69. An abnormal Ham test is most likely associated with against malaria except: which of the following?

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In other words erectile dysfunction medications injection order cialis soft 20 mg amex, pumping against a high pressure is more oxygen costly erectile dysfunction new treatments order 20 mg cialis soft free shipping, than pumping a high flow output erectile dysfunction doctors in el paso tx cheap cialis soft 40 mg line, even if the total work is the same in both situations. Consequently, changes in cardiac work are poor quantitative indicators of myocardial oxygen demand. Beyond the basal O consumption needed to run membrane pumps and basic cellular activity2, four major determinants of increased O demand in the heart have been identified; these are (1) increased2 systolic pressure (or, more accurately, ventricular wall stress), (2) increased extent of muscle shortening (or stroke volume), (3) increased heart rate, and (4) positive inotropic stimuli. Combinations of hemodynamic variables have been used as estimators of O demand in the heart. The2 double product or systolic pressure × heart rate and the tension–time index (the area under the left ventricular systolic pressure curve) have been used as predictors of cardiac O demand. Changes in these2 indices reflect changes in the oxygen needs of the heart caused by changes in heart rate and force generation, but they often fail in instances in which certain drugs, such as β-adrenergic agonists, produce positive inotropic and chronotropic (heart rate) effects on the heart at the same time that their vasodilator effects cause a drop in blood pressure. Even without a good index available as a predictor of cardiac oxygen demand, it is useful to simply recognize factors proven to alter myocardial O demand. For example, hypertension, or high blood2 pressure, greatly increases the stress load on the heart and thus increases O demand. Similarly2, exercise increases heart rate, myocardial contractility, and, in unconditioned people, blood pressure as well, all of which synergize to create greatly increase myocardial O demand. In patients who have compromised2 coronary circulations resulting from atherosclerosis, it is thus helpful to realize that decreasing blood pressure and heart rate will lessen the possibility that cardiac oxygen demand will exceed cardiac oxygen supply. Ejection fraction and hemodynamic evaluations are used as simple clinical indices of myocardial performance. Clinical evaluation of the condition of the heart in patients is technologically demanding. Although many technologies and devices are available to evaluate the heart, their implementation requires specialized skills in cardiology. Nevertheless, there are some relatively simple means of estimating cardiac performance available to the clinician. Clinicians can obtain a two-dimensional view of changes in the size of the ventricular chambers during the cardiac cycle through the use of ultrasound images employed in echocardiography. Ventricular chamber cross-sectional area during systole and diastole can be estimated from these real-time images and used to estimate stroke volume in the heart. The change in areas between diastole and systole is expressed as a percentage of the area during diastole and is called the ejection fraction. In normal hearts, the ejection fraction is 45% to 67%; values ≤40% indicate impaired performance. Variables that reflect changes in the inotropic state of the heart have proven difficult to develop and are often used on the basis of what works reasonably well in the clinic. For example, the peak rate of rise of pressure in the left ventricle during isovolumic contraction (peak dP/dt) has been shown to reflect alterations in myocardial contractility and to be affected little by changes in preload or afterload. For example, the only way a patient’s stroke volume can decrease or remain unchanged in the face of an increased ventricular preload is if the patient’s heart is experiencing a negative inotropic influence. Conversely, increased stroke volume in the face of an unchanged or decreased preload indicates that the heart is under a positive inotropic influence. There are certain physiologic and pathologic conditions that are known to change loading conditions and the inotropic state of the heart. For example, drugs that relax venous smooth muscle lower central venous and ultimately right atrial pressure, thereby reducing the filling of the heart and ventricular preload. Standing causes pooling of blood in the lower extremities and also decreases pressure in the right atrium with a similar effect unless the body corrects for this by activation of sympathetic nerves to veins (see Chapter 17). However, drugs used to treat certain cardiovascular diseases such as hypertension and myocardial ischemia can counteract this corrective reflex by directly relaxing vascular smooth muscle. Such an effect in veins causes a drop in preload when the patient taking such medications rises from a supine to standing position. Nitroglycerin in particular, which is used to treat angina, preferentially dilates veins over arteries. People taking these medications are susceptible to fainting on standing as a result of excess pooling of blood in the veins.

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This is because wild type-2 strains are al- ready eradicated and not circulating in the community since 1999 erectile dysfunction medication side effects 40 mg cialis soft purchase. Manifestations Most human coronaviruses are widespread affecting people of most part of the world and produce mild respiratory tract infection latest erectile dysfunction drugs order cialis soft 20 mg otc. It is inaffective for Coxiella burnettii At 80ºC for 30 min for 3 – Vaccine bath: 60ºC for 1 hr erectile dysfunction uptodate cheap 20 mg cialis soft overnight delivery. Sterilization at a Temperature of 100ºC: – Boiling, Koch’s or Arnold’s steam sterilizer – Tyndalisation (Intermittent sterilization)-100 c for 20 min for 3 days. Used 0 for Sugar solution, gelatin Sterilization and Disinfection, Hospital Waste Management, Bacteriology of Water, Milk and Air 3. Filtration • Bacteriological flters: Excellent way to reduce the – Candle flters -Diatomaceous earth (e. Chamberland flters) of heat-labile materials- like – Asbestos flters (Seitz and Sterimat flters), vaccine, antibiotics, toxin, – Sintered glass flters serum and sugar. Ionizing Radiation is also called as Cold Radiation sterilization Types Used for Sterilization of Ionizing radiation Disposable rubber or plastic syringes, infusion Example- Cobalt 60, X-rays, gamma rays sets, catheters, catgut sutures, bone & tissue and cosmic rays grafts & adhesive dressings. Typhi in a given time divided • O- Phthalic acid, Peracetic acid by the dilution of phenol which sterilizes the suspension in the • Autoclave, Hot air oven, Plasma sterilization same time. Biological Sterilization Indicator Hot air oven Clostridium tetani non toxigenic strain, B. Stethoscope, thermometer or low level disinfectant Medical equipments Does not come in direct Examination table, computers Low level disinfectant contact with patient Hospital Waste Management Biomedical waste • A vast amount of waste is generated in the process of health care, research, testing, or related procedures on human beings or animals conducted in hospitals, clinics, labs. Category No 2 Animal waste (animal tissues, organs, body parts carcasses, bleeding parts, fuid, blood and experimental animals used in research, waste generated by veterinary hospitals/ colleges, discharge from hospitals, animal houses). Category No 3 Microbiology and biotechnology waste (wastes from laboratory cultures, stocks or specimens of micro-organisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production of biological, toxins, dishes and devices used for transfer of cultures). Category No 5 Discarded medicines and cytotoxic drugs (wastes comprising of outdated contaminated and discarded medicines). Category No 6 Solid waste (items contaminated with blood and body fuids including cotton, dressings, soiled plaster casts, line beddings, other material contaminated with blood). Category No 7 Solid waste (disposable items other than the waste sharps such as tubing, catheters, intravenous sets etc. Category No 8 Liquid waste (waste generated from laboratory and washing, cleaning, house-keeping and disinfecting activities). Category No 10 Chemical waste (chemicals used in production of biological, chemicals, used in disinfection, as insecticides, etc). Presence of Corynebacterium indicates recent for incineration in appropriate bag contamination 39. Ans (a) (b) (Prions, Coxiella) Ref: Ananthnarayan 9th /p30 Holder’s method of Pasteurization(Heating at 63°C for 30 min) is ineffective for Coxiella burnettii, spores and prions. The dye changes colour to green after a defned period of time at a certain temperature. Typhi in a given time divided by the dilution of phenol which sterilizes the suspension in the same time. Lawn Culture • It provides uniform surface of growth of the bacterium on the solid medium. Pour-Plate Culture Stroke Culture Used to quantitate bacteria in urine cultures • This provides a pure growth of bacteria for carrying out diagnostic tests. I • For demonstration of oxygen requirement of the bacteria Stab Culture • Example where stab culture is used- mannitol motility medium, Triple sugar iron Stab culture is used for test. Liquid Culture • Used for blood culture and for sterility tests, where, the concentration of bacteria is small. The use of agar to use as solid media was suggested by Frau Hesse, the wife of one of the Robert Koch’ assistant. Lysogenic conversion: Bacteriophage when integrated with the bacterial chromosome, this stage is called as lysogenic conversion.

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For example impotence over 60 purchase cialis soft without prescription, stool culture minerals are absorbed from the large intestine doctor for erectile dysfunction philippines cialis soft 20 mg order overnight delivery, permits identification of pathogens in the feces erectile dysfunction watermelon cialis soft 20 mg order on line. Many abnormalities and infections can be diag- In this chapter, the diseases of each part of nosed using blood tests. These include tests for liver enzymes are used to detect liver diseases of the mouth, esophagus, stomach, abnormalities and liver infections. Biopsy is small and large intestines, pancreas, liver, and used to identify several diseases. Malabsorption syndrome can also be identified through biopsy of the intestine’s lining. Chapter Nine Diseases and Disorders of the Gastrointestinal System L 171 Mesenteric artery and vein Plica Mesentery Muscularis Visceral externa Mucosal epithelium peritoneum Submucosa (serosa) Mucosa Villi Longitudinal muscle layer Plica Circular muscle layer Submucosal gland Muscularis mucosae Myenteric plexus Mucosal glands Lymphatic vessel Artery and vein Submucosal plexus Figure 9–5  Mucosal surface of the small intestine. These imag- Complete coverage of diseases of the mouth ing techniques and endoscopy have many appli- is beyond the scope of this book. This chapter cations and will be discussed throughout this focuses instead on the major oral inflammatory chapter. Removing can adversely affect the ability to taste, chew, the white patches leaves a raw, damaged muco- moisten, and swallow food. Antibiotics and antiviral medications are not effective treat- Oral Inflammation and Infection ments for fungal infections. Oral candidiasis is Oral inflammation, or stomatitis, is the inflam- treated with oral antifungal agents. Depending on the cause, stomatitis may appear as patches, ulcers, red- Cancer of the Mouth ness, bleeding, or necrosis. It occurs mostly among Oral cancer is a malignant tumor originating those with risk factors such as immune defi- within the oral tissues, most often a squamous ciency and long-term antibiotic use. How- 11th among the leading causes of cancer death ever, stomatitis may also be caused by bacte- worldwide. Most of these cancers appear on ria and fungi, or it may be a sign of a systemic the floor of the mouth, tongue, and lower lip. Streptococci are a common cause of An aggressive form of the cancer occurs on the oral and throat bacterial infections, resulting in upper lip. Bacteria also cause canker it is clear that tobacco, smokeless tobacco, and sores, small circular lesions with a red border. Treatment for lip and tongue sexually transmitted disease gonorrhea, causes cancer includes surgical removal. The therapy may be used to treat local cancers on sexually transmitted bacterium Treponema palli- the floor of the mouth. This cancer cannot be dum causes syphilis, which causes oral chancres prevented, but people can eliminate known risk (small sores associated with the onset of syph- factors such as smoking and alcohol use. Herpes simplex is a common cause of oral virus Diseases of the Esophagus infections. Transmitted by genital–oral contact, The function of the esophagus is the controlled herpes simplex type 2 causes vesicles that rupture passage of food to the stomach. These lesions can appear inside ease manifests itself as dysphagia, difficult or and outside the mouth. Pain from herpes lesions makes eating, drinking, Cancer of the Esophagus and swallowing difficult. The symptoms typically Cancer of the esophagus is a malignant tumor subside within 2 weeks when the viruses move that arises within its tissues. The disease ranks from the area of the lesion to nerve tissue known sixth among leading causes of cancer death as ganglia. Cancer of the esophagus occurs lowing stressful events or suppression of immune most commonly in men over age 60 and is nearly function. Like mouth cancer, tobacco and mation and pain with systemic anti-inflammatory alcohol use are major risk factors. The cancer narrows the esophageal lumen, The fungus Candida albicans is normally causing the principal symptom of dysphagia. The present in the mouth in low levels but can grow obstruction causes vomiting, a bad taste in the excessively in newborns or those with immune mouth, and bad breath.

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The patient presents with a chronic condition and hematuria but the urinary blood loss is not usually signifcant enough to produce an anemic state erectile dysfunction drug companies buy cialis soft overnight delivery. Hyperaldosteronism (option D) results in potassium depletion erectile dysfunction 27 discount cialis soft 20 mg visa, sodium retention lovastatin causes erectile dysfunction discount cialis soft 40 mg with amex, and hypertension. Primary hyperaldos- teronism (Conn’s syndrome) is associated with adrenocortical adenomas in 90% of patients and is characterized by decreased renin. The patients usually have severe headache, anxiety, increased sweating, tachycardia, palpitations and hypertensive episodes. Features of ‘rule of 10’s’in pheochromocytoma • 10% are bilateralQ • 10% are extra-adrenalQ • 10% are malignant Q • 10% occur in children Q • 10% are not associated with hypertensionQ Please note Earlier, it was mentioned that 10% are pheochromocytoma are familialQ but latest Robbins says “25% of the individuals with pheochromocytoma and paraganglioma have a germline mutation” 40. Idiopathic atrophy due to autoimmune adrenalitis is the most common cause of Addison’s disease in the worldwhereas tuberculosis is the most common cause of the same in India. The tumors are composed of polygonal to spindle- shaped chromaffn cells, clustered with their supporting cells into small nests or alveoli (Zellballen), by a rich vascular network. Therefore the diagnosis of malignancy in pheochromocytoma is based exclusively on the presence of metastases. These may involve regional lymph nodes as well as more distant sites, including liver, lung and bone. While the acute effect of cortisol is to produce lipolysis, patients with chronically increased cortisol levels develop a characteristic central obesity and buffalo hump. The mechanism for the redistribution of body fat is an interaction between cortisol and insulin. Cortisol excess causes protein catabolism, which leads to poor wound healing, decreased connective tissue, and fragile blood vessels. The combination of thin skin and fragile blood vessels leads to abdominal stretch marks (striae) the are characteristically purple in color. Increased gluconeogenesis and decreased peripheral insulin sensitivity lead to elevated blood glucose. To distinguish between these two, we administer high doses of the potent synthetic glucocorticoid, dexamethasone. In Cushing’s disease, it is due in part to the mineralocorticoid-like effects of high plasma cortisol. Approximately two thirds of patients with hypertension demonstrate paroxysmal episodes, which are described as an abrupt, precipitous elevation in blood pressure, associated with tachycardia, palpitations, headache, sweating, tremor, and a sense of apprehension. Edema is not seen because of the escape mechanism: escape from the sodium retaining effects of hyperaldosteronism. First of all, read both assertion (A) and reason (R) carefully and independently analyse whether they are true or false. If both A and R are ture, then we have to know whether R is correctly explaining A [answer is (a)] or it is not the explanation of assertion [answer is (b)] 1. Both are stored in secretory granules and equimolar quantities are secreted after β cell simulation. It is associated with the following: • 10% are bilateralQ • 10% are extra-adrenalQ • 10% are malignant Q • 10% occur in children Q • 10% are not associated with hypertensionQ Most of the earlier texts mention that 10% of these tumors are familialQ but Robbins 8th/1159 clearly says that it has been modifed. The most reliable feature of follicular cancer is demonstration of capsular invasion or vascular invasion. It presents as a painless enlargement of the thyroid and transient hyperthyroidism (lasting about 2-8 weeks). Clinical features are pain in neck, sore throat, fever, fatigue, anorexia, myalgia, enlarged thyroid and the presence of transient hyperthyroidism lasting for 2-6 weeks. It may be followed by asymptomatic hypothyroidism but recovery is seen in most of the patients. Capillary dysfunction in target organs leads to microvascular disease (not macrovascular disease) leading to diabetic retin- opathy, neuropathy and nephropathy. These patients don’t develop ketoacidosis and its symptoms (nausea, vomiting, respiratory diffculties) because of elevated portal insulin levels. The ‘fat sparing’ effect of insulin prevents the formation of ketone bodies by inhibiting the fatty acid oxidation in the liver. It is because of the deposition of the altered form of calcitonin which gets deposited in the thyroid stroma.

Mazin, 52 years: Mature (Benign) Teratomas: – Cystic teratomas are usually found in young women during the active repro- ductive years. Arch Neurol 51:177–186, 1994 Eames P: Behavior disorders after severe head injury: their nature, References causes, and strategies for management. What is the most often used alternative to enucleation for a medium-sized melanoma located posterior to the equator?

Brant, 41 years: Gastric Diagnosis with at least 5 cm clearance on either side, N 1 carcinoma ofen presents with recurrent and N2 nodes, greater and lesser omentum Diagnostic Test superfcial thrombophlebitis. The term hermaphrodite is reserved for the very rare cases in which both ovarian and testicular tissues are present. If there is a central catheter then one culture India are Gram-negative pathogens including Klebsiella, should be sent from the catheter lumen and the other from E.

Snorre, 31 years: If the patient is seeing well with the sutures in place, the sutures (most commonly 10–0 nylon) are left undisturbed and tend to disintegrate spontaneously over a few years. Chronic exposure of cells to a hormone may cause the cells to become less responsive to subsequent exposure to the hormone by a process termed desensitization. Interstitial cells of Cajal are the pacemaker cells that generate electrical slow waves.

Harek, 24 years: Interstitial nephritis ing the arterial pH to nearly normal Preparation of the Recipient 6. Furthermore, women live decades past menopause, and during that time, many do not take any hormonal replacement therapy. Calluses usually form affect the epidermis; the epidermis is red, swol- on feet and hands over bony prominences.

Sinikar, 36 years: Tere is no visible swelling in the preau- cells resembles cords, sheets or glandular On examination, a swelling is palpable in ricular region. Pizzillo’s method of palpation – Tis is (A) Inspection: The gland is inspected from indicated in short neck obese patients as the front. The latter gets coagulated • Meat, fish, poultry during the process of curd formation.

Roland, 64 years: Coronary (c) Liver (d) Spleen arteriography demonstrates signifcant atherosclerotic 384 Cardiovascular System 74. The rare cases that become chronic carriers may be infective for six months or more. Depth perception Depth perception is the visual ability to see the world in three dimensions (“3D”) and arises from binocular depth cues that require input from both eyes.

Cronos, 54 years: Structure and Function of the Heart The heart is a hollow muscular organ located in the center of the chest. This last bone, through its oval footplate, connects to the oval window of the inner ear and is anchored there by an annular ligament. This condition, more properly called ankyloglos- sia, is caused by a congenital shortening of the Traumatic ulcer of the tongue lingual frenulum.

Gnar, 29 years: Pathology cial fascia are incised, instead of a stab inci­ Tissue destruction and ulceration may follow sion, so as to avoid damage to vital structures Ischiorectal Abscess due to release of exotoxins like streptokinase, like vessels and nerves, e. The protein-rich oedema fluid causes a the skin in the interdigital clefts where infection secondary proliferation of fibroblasts and epithelial might enter. Imaging Urine analysis Diagnostic imaging allows differentiation of acute Urine microscopy demonstrates, in most cases, the bacterial pyelonephritis from pyonephrosis.

Riordian, 61 years: Although 53 may sometimes be detected in normal children, it is heard more commonly in patients with left ven­ tricular failure. Cutting the 11:00 suture will relax the wound and decrease the amount of astigmatism. J Neuropsychiatry Clin Neurosci trauma exposure and posttraumatic stress disorder.

Kurt, 23 years: Occlusion of the iridotomy with debris or a membrane may cause a recurrent episode of pupillary block angle closure. Hypernatremic dehydration promotes the development of high core temperature in multiple ways through the combination of hypernatremia and reduced plasma volume. Patients near presbyopia may need reading glasses when using their contacts but can read without a bifocal lens in their glasses (see question 45).

Anog, 53 years: Tese neo- sarcoma sues and persists in the same excessive man- plasms infltrate the surrounding tissues and ner even afer cessation of the stimuli, which metastasize through lymphatics or blood. If they enter the glass obliquely, their paths are bent in proportion to how much their speed is slowed. Because sperm cells are rapidly dividing and undergoing meiosis, they are sensitive to external agents that alter cell division.

Miguel, 37 years: Be- are affected when structural damage is detected with cause of the water content of blood and the makeup of ce- structural imaging techniques. Tuberculosis Tuberculosis can present with lower abdominal and right iliac fossa pain, ascites, weight loss and small bowel obstruction. Peripheral smear shows microcytic, hypochromic cells with basophilic stippling and presence of target cells.

Campa, 51 years: Pharmacological agents may include disorders and the remainder (60 per cent) are from vaginal lubricants and the use of androgenic proges- developmental abnormalities. Unlike the skeletal muscle, the cardiac muscle can utilize lactate as an energy source, which is benefcial during strenuous exercise when skeletal muscles are producing lactate. Treatment will kill the syphilis bacte- numbness, gradual blindness, and dementia.

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