睿学教育Wisdome Education

Yeh-Chung Chang, MD

• Assistant Professor of Pediatrics
• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/yeh-chung-chang-md

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The proper energy (kVp) to cause the bones to slope (gradient) of a straight line joining absorb four times as many photons as the two points of specifed density on the char­ soft tissue medicine woman cast order persantine in india. This means that four times as acteristic curve is called the average gra­ many x-ray photons will reach the flm un­ dient symptoms 7 days pregnant buy 25 mg persantine otc. The average gradient is usually cal­ der soft tissues as will reach the flm under culated between density 0 symptoms pregnancy persantine 100mg buy amex. Such posure between bone and soft tissue reach­ a calculation is shown in Figure 11-8, ing the flm under the hand is 0. In calculat­ log relative exposure in the soft tissue area ing average gradient, D1 is always 0. A flm with average gradient of 1 range of 100:1 when the flm is transillu­ will not change subject contrast; a flm with minated and viewed (100 is the antilog of an average gradient of less than 1 will de­ 2. Because contrast is exposure range to the x-ray flm of 4: l has very important in radiology, x-ray flms all been exaggerated, or amplifed, in the have an average gradient of greater than viewed radiograph into a brightness range 1. As shown in Figure ll-10, this one will result in a density difference (contrast) of 0. Exposures producing density at the however, and can usually be ignored in level of 3 (0. Direct x-ray exposure light must be used to aid in viewing regions will produce a lower average gradient. In­ intensifying screens is exposed to x rays di­ creasing the time or temperature of de­ rectly, its characteristic curve has a consid­ velopment (or both) will, up to a point, in­ erably different shape than the curve ob­ crease the average gradient of a film (flm tained from exposure with screens. If development Remember, considerably more exposure time is only 40% of normal, the gradient (mAs) is required if no screens are used, will be reduced to about 60% of maximum. Automatic of 1; this value will rise to 30 mR or more film processing equipment has eliminated with direct x-ray exposure. To lower for a flm exposed to x rays only than summarize, increasing the time or temper­ for the same flm exposed by light from ature of development will intensifying screens. In addition, intensifying screens are rel­ Figure 11-11 shows the effect of devel­ atively more sensitive than film to higher opment time (or temperature) on average energy x rays. Scatter radiation decreases The speed of a flm-screen system is de­ contrast, as will be discussed in detail in fined as the reciprocal of the exposure in Chapter 14. Because intensifying screens roentgens required to produce a density of are relatively less sensitive to the lower en­ 1. X­ Roentgens ray film, because it is more sensitive to lower kVp x rays, may record the scatter As an example we will consider the speed radiation better than the higher energy, in­ of a commonly used film-screen system, Du formation-containing primary beam. The Pont Cronex 4 film combined with Du Pont variation in flm sensitivity to x rays be- Cronex Hi Plus (CaW04) screens. For medical x-ray characteristic curve varies with density, the flms, relative flm speed is usually com­ relative speed between two films will be pared at a density of 1. For example, if a low­ contrast and a high-contrast film are com­ Speed Class System pared for speed, as in Figure 11-14, the The measured speed of a flm-screen sys­ relative speed between the two films might tem depends on a number of variables, actually reverse with change in density. In such as the kVp, amount of scatter radia­ our example, speed calculated at a density tion, x-ray absorption by the cassette or x­ of 1. As things exist now, however, published measure­ > ments of speed must be used as approxi­ t 2. Table 11-3 lists the sequence from 100 to 1000 and gives the Figure 11-13 Film speed logarithm of each number. Note that the log of each number increases or decreases to standardize the way in which speed (and by 0. Thus, the ratio between numbers in test objects that are used to simulate radi­ the sequence is a constant. Table 11-3 does not list the sequence below 100, but simply divide by 10 to go on down (i. It is easy to multiply or divide by 10, the num­ bers increase or decrease by an easily de­ fined ratio, and a change in log of 0. The older films still accurately reflect relative intensifying screen speeds, which is the purpose of this table. Published values are accu­ within the accepted range for diagnostic rate for the conditions under which they radiology (usually considered to be density were determined, but such conditions vary. There are more than A will be limited to a log relative exposure 1000 flm-screen combinations on the mar­ ket today, so some "lumping" of an oth­ erwise enormous variety of expressions of speed seems necessary. Film B will remain in the designated emulsion is important only when the flm density values over a range of log relative is exposed with intensifying screens.

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However medications and grapefruit juice purchase persantine 100 mg free shipping, even when activity is optimal medicine doctor discount persantine 100 mg on line, genetic contributions to bone mass are greater than those of exercise treatment receding gums order genuine persantine online. Perhaps, 75% of the population variance is genetic, and 25% is a result of different levels of activity. In addition, the predominant contribution of estrogen to homeostasis of bone in young women is apparent when amenorrhea occurs secondary to chronic heavy exercise. These exceptionally active women are typically thin and exhibit low levels of circulating estrogens, low trabecular bone mass, and a high fracture risk (Fig. This graph shows spine bone density in young adult women who are nonathletes (controls), distance runners with regular menstrual cycles (cyclic runners), and distance runners with amenorrhea (amenorrheic runners). Differences from controls indicate the roles that exercise and estrogen play in determination of bone mineral density. Controlled clinical trials find that appropriate, regular exercise decreases joint pain and degree of disability, although it fails to influence the requirement for anti-inflammatory drug treatment. Regular exercise protects against type 2 diabetes through its positive effects on weight management and metabolic pathways involved in glycemic control that are independent of body weight. Increased physical activity is an effective strategy both for the prevention of type 2 diabetes and its management. It is also well known that aging lowers maximal dynamic and isometric exercise capacities. There is overwhelming evidence, however, that training can substantially mitigate declines in strength and endurance with advancing age. Changes in functional capacity, as well as protection against heart disease and diabetes, do increase longevity in active persons. However, it remains controversial whether chronic exercise enhances lifespan or whether exercise boosts the immune system, prevents insomnia, or enhances mood. In obese patients, chronic exercise preferentially increases caloric expenditures over increased appetite. Obesity increases the risk for hypertension, heart disease, and diabetes and is characterized, at a descriptive level, as an excess of caloric intake over energy expenditure. Because exercise enhances energy expenditure, increasing physical activity is a mainstay of treatment for obesity. For exceptionally active people, exercise expenditure can exceed 3,000 kcal/d, added to the basal energy expenditure, which for a 55-kg woman averages about 1,400 kcal/d. At high levels of activity, appetite and food intake match caloric expenditure, though the biologic factors that allow this precise balance have never been defined. In obese patients, modest increases in physical activity increase energy expenditure more than food intake, so progressive weight loss can be instituted if exercise can be regularized. This method of weight control is superior to dieting alone, because substantial caloric restriction (>500 kcal/d) results in both a lowered basal metabolic rate and a substantial loss of fat-free body mass. Exercise has other, more subtle, positive effects on the energy balance equation as well. A single exercise episode may increase basal energy expenditure for several hours and may increase the thermal effect of feeding. The greatest practical problem remains compliance with even the most precise exercise “prescription”; patient dropout rates from even short-term programs typically exceed 50%. Although skeletal muscle is omnivorous, its work intensity and duration, training status, inherent metabolic capacities, and substrate availability determine its energy sources. Even maximal efforts lasting 5 to 10 seconds require little or no glycolytic or oxidative energy production. The carbohydrate provided to glycolysis comes from stored, intramuscular glycogen or blood-borne glucose. Exhaustion from work in this intensity range (50% to 90% of the ) is associated with carbohydrate depletion. Accordingly, factors that increase carbohydrate availability improve fatigue resistance. These include prior high dietary carbohydrate, cellular training adaptations that increase the enzymatic potential for fatty acid oxidation (thereby sparing carbohydrate stores), and oral carbohydrate intake during exercise.

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Acta Neurol Scand 80:151–156 treatment yeast infection women order genuine persantine line, 1989 sional football: reconstruction of game impacts and injuries symptoms of anxiety persantine 25mg purchase without a prescription. Victor M medicine hat mall purchase genuine persantine on line, Adams R, Collins G: The Wernicke Korsakoff and Re- Neurosurgery 53:799–812, 2003 lated Disorders Due to Alcoholism and Malnutrition. Arch Clin Neuropsychol 18:397–417, Putukian M, Echemendia R, Mackin S: Acute effects of heading in 2003 soccer: a prospective neuropsychological evaluation. Clin J World Medical Association: The World Medical Association Sport Med 10:104–109, 2000 statement on boxing. Available at: http:// Reeves D, Kane R, Winter K, et al: Automated Neuropsychological www. Arch Neurol 63:1277–1280, 2006 Roass A, Nilsson S: Major injuries in Norwegian football. Citations for re- rior temporal lobe; and isolated areas in more posterior areas view articles are provided on these topics for readers who (Levin et al. Skull fractures occur in approximately desire more in-depth reviews of each of these areas. Children more frequently present with diffuse injury and cerebral Epidemiology swelling (44%) resulting in intracranial hypertension than adults. Reviews of advances and challenges in the understand- stituting a major cause of death and disability in the United ing of the pathophysiology of pediatric brain injury as well as States (Langlois et al. The male-to-female incidence initial assessment, management, and treatment of pediatric rate ratio is approximately 1. Higher incidence rates higher in young children, among whom the incidence is ap- have been found to be related to median family income proximately 10% (Yablon 1993). Elevated rates of psychiatric disorder are consis- infant, toddler, and young child brain injury are related to tently found in cohorts of epilepsy individuals who have assaults or child abuse and falls. Antiepileptic drugs injury, by severity, ranges from 80% to 90% for mild, 7% to may positively influence behavioral or psychiatric presen- 8% for moderate, and 5% to 8% for severe brain injury. Etiology and Pathophysiology School Sequelae Focal injuries including subdural, epidural, and intracere- bral hematomas occur with a higher incidence in adults Academic functioning within the school environment is (30%–42%) than in children (15%–20%). There is an antero- the childhood equivalent of occupational functioning for 439 440 Textbook of Traumatic Brain Injury adults. Special ical study involved a birth cohort studied at age 5 and then education services are necessary for various problems in- again at age 10 (Bijur et al. The study found that cluding poor academic function related to 1) skill deficits children who went on to sustain injuries (e. The term novel psychiatric disorders has been coined to de- Psychiatric Disorders scribe two possible scenarios. These disorders are varied, thus demonstrating that behavioral outcome after brain in- Methodological Concerns jury is not a unitary construct. This categorical classifi- Study design is critical to the determination of the quality cation system of new/novel disorders has value because it and generalizability of data generated. The second stage in this evolution is the examination data from studies with major design flaws. Therefore, unless other- it is likely that different disorders will have different psy- wise indicated, this review refers only to accidental injury. In fact, understanding of phenotypically similar disorders in chil- there have only been two prospective studies of consecu- dren who have not experienced brain injury. The only prospective psychiatric predictor of novel psychiatric disorders in one study was studies that have used standardized psychiatric inter- preinjury family function (Max et al. Preinjury family life events Preinjury family function or stressors and immediate postinjury coping style emerge Socioeconomic status as significant variables later in the follow-up. The impor- Preinjury intellectual function tance of novel psychiatric disorders for family functioning is evident at 6, 12, and 24 months postinjury. The direc- whether these disorders were present before the injury can- tion of these effects is as expected (worse outcome with not be overstated. Furthermore, investigators have demonstrated ten- dren developed new-onset psychiatric disorder was simi- tative support for bidirectional influences of child behav- lar in one study (Brown et al. Table 28–2 provides a summary of current lesion-behavior 2002) rates of new-onset psychiatric disorder compared correlates for specific psychiatric disorders and symptom with uninjured control groups of children in four studies. The labile, aggressive, and disinhibited than the families of injured control children, and this was subtypes are common, whereas the apathetic and paranoid more closely linked with postconcussive symptoms than subtypes are uncommon (Max et al. Summary of lesion findings in psychiatric disturbances after pediatric traumatic brain injury Disorder Lesion correlate (timing of outcome) Source Attention-deficit/hyperactivity disorder Right putamen, thalamus (12 months) Gerring et al.

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Symptoms are often manifested 6 to 10 hours after ascent and generally subside in 1 to 2 days medicine 5325 25 mg persantine buy free shipping. In most cases symptoms als order persantine 100mg free shipping, the symptoms are only temporary and usually abate with time as altitude acclimation occurs treatment warts discount persantine master card. Exertion aggravates the situation, and in extreme cases, pulmonary edema and cerebral edema can occur, which can be fatal. The hypoxia-induced cerebral dilation accounts for the headache, dizziness, nausea, and sleep disturbance. The hypoxia-induced pulmonary vasoconstriction increases pulmonary vascular resistance. The heart trying to pump blood through “water-soaked lungs” further complicates the situation. As the lungs fill up with water, victims become increasingly short of breath and often spit up foamy blood. The third precaution of high-altitude climbing is to follow the climbers’ “golden rule”: climb high and sleep low, meaning that a climber should stay a few days at base camp to acclimatize, then climb slowly to a higher camp, and return to base camp for the night. This procedure is repeated a few times, each time extending the time spent at higher altitudes to let the body acclimatize to the lower oxygen tension. This means a climber can climb from 3,000 m (10,000 ft) to 4,500 m (15,000 ft) in 1 day, but then descend back to 3,300 m (11,000 ft) to sleep. This explains why climbers need to spend days and/or weeks at a time to acclimatize before they can reach a high peak. Acetazolamide may help speed up the acclimatization process and can treat mild cases of altitude sickness. The drug also forces the kidneys to excrete bicarbonate, the base form of carbon dioxide, thus counteracting the effects of hyperventilation that occurs at altitude. The sustained increased ventilation seen in the second stage is referred to as ventilatory acclimatization. Acclimatization occurs during prolonged exposure to hypoxia and is a physiologic response, as opposed to a genetic or evolutionary change over generations leading to a permanent adaptation. Ventilatory acclimatization is defined as a time-dependent increase in ventilation that occurs over hours to days of continuous exposure to hypoxia. Although the physiologic mechanisms responsible for ventilatory acclimatization are not completely understood, it is clear that two mechanisms are involved. Also, during prolonged hypoxia, the carotid bodies increase their sensitivity to PaO. The second mechanism responsible for ventilatory acclimatization involves the kidneys. The alkaline blood pH resulting from the hypoxia-induced hyperventilation is antagonistic to the hypoxic drive. The kidneys compensate by excreting more bicarbonate, which brings the ratio back to a normal 20:1 and a blood pH toward 7. This process occurs over a 2- to 3-day period, and the antagonistic effect resulting from the hypoxia-induced alkaline pH is minimized, allowing the hypoxic drive to increase minute ventilation further. In addition to ventilatory acclimatization, the body undergoes other physiologic changes to acclimatize to low-oxygen levels. These include increased pulmonary blood flow, increased red cell production, and improved oxygen and carbon dioxide transport. There is an increase in cardiac output at high altitude, resulting in increased blood flow to the lungs and other organs of the body. As mentioned previously, the increase in pulmonary blood flow reduces capillary transit time and improves the overall ventilation/perfusion ratio in the lungs, both of which result in an increase in oxygen uptake by the lungs. The increase in blood flow resulting from the2 combined increased vasodilation and increased cardiac output sustains oxygen delivery to the tissues at high altitude. Erythropoiesis is also increased at high altitude, which improves oxygen delivery to the tissues.

Diseases

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Gastritis medications pain pills persantine 25mg order visa, duodenitis and non-ulcer Treatment dyspepsia Conservative treatment with intravenous fuids Tese conditions can present with dyspeptic symp- and analgesia medications requiring central line buy persantine 100 mg free shipping, particularly pethidine medicine shoppe persantine 100mg purchase overnight delivery, is the ini- toms of mild to moderate epigastric discomfort and a tial approach. Ideally this should be undertaken dur- ing the second trimester, which minimises the risks irritable bowel syndrome for premature delivery. Changes in bowel habit occur as a result of the increasing levels of serum progesterone, which acts to relax smooth muscle in the gut wall. Acute pancreatitis Initial management involves optimisation of lifestyle Tis occurs most commonly secondary to gallstones through dietary changes. Endoscopic retrograde cholangiopancreaticogram Eosinophilic oesophagitis (Eo) and sphincterotomy can be performed safely in patients found to have common bile duct stones as Eosinophilic oesophagitis is a chronic infamma- a cause for the pancreatitis. While epigastric pain and refux symptoms are features, patients typically present with dysphagia and food regurgitation. Treatment usually involves swallowing sents with epigastric pain afer eating, and is ofen inhaled corticosteroids, and this is considered to be associated with anorexia and weight loss. It is com- appropriate in pregnancy, provided a careful risk/ monly caused by Helicobacter pylori and diagnosed beneft assessment is performed. Probhodana Ranaweera 3 Radiological investigations are generally contraindicated during pregnancy unless there are extremely good introduction indications for using them. Ultrasound is widely used Postoperative fever is a common sign encountered in and is safe in pregnancy. Evaluating and managing 4 Gastro-oesophageal refux disease is very common in pregnancy and is consequently the commonest cause of a patient with a postoperative fever requires a sound epigastric pain. Many pancreatitis, and peptic ulceration, which may need a patients develop fever in the frst few days afer different management plan in pregnancy. Childhood and adult cancer after intrauterine exposure to ionizing Manifestation of fever is due to cytokine release in response to various stimuli. Medical versus surgical management cytokine most closely correlated with postopera- tive fever. For example, laparoscopic oopho- Gastrointest Endosc 2009; 69(3 Part 1): rectomy is associated with less tissue trauma and 453–61. Management of gastrointestinal and liver Importantly bacterial endotoxins and exotoxins diseases during pregnancy. Fever is defned time-related causes of postoperative as morning temperature exceeding 37. In clinical practice signifcant postoperative fever The time at which the fever begins will suggest its is defned as the presence of a temperature higher origin. Tere are no rigid demarcations The incidence of postoperative fever as published between the time frames described since, on many in the literature varies widely, from 14 to 91 per cent. Many patients with postoperative fever do not have Intraoperative causes of postoperative fever are: an underlying infectious cause. A total of 80–90 per pre-existing sepsis; cent of patients with fever on the frst postoperative intraoperative septicaemia; day usually have no infection, whereas 80–90 per transfusion reaction; cent of patients who develop fever on or afer the ffh heat stroke; postoperative day commonly have an identifable malignant hyperthermia. The causes of fever in the postoperative period are traditionally remembered using a simple mnemonic of fve W’s. Life-threatening causes of early postoperative fever Malignant hyperthermia is a rare autosomal, domi- nantly transmitted genetic disorder that is triggered Figure 2 Postoperative wound infection. It occurs within 30 minutes afer onset of Adrenal insufciency typically occurs in patients general anaesthesia but may even present 10 hours who have been on long-term steroids, and is due afer anaesthesia. Tachycardia develops, and the blood to iatrogenic suppression of the hypothalamic– pressure is unstable. Muscle rigidity sion may develop; steroid supplementation in time is develops with acidosis, hypoxia, and cardiac arrhyth- life saving. The treatment is to stop all anaesthetic drugs, Pulmonary embolism usually presents in a post- hyperventilate the patient with oxygen, give dantro- operative patient as sudden haemodynamic instabil- lene sodium and procainamide, and initiate cooling ity and collapse. Fever, although uncommon, may be and diuresis to prevent precipitation of myoglobin.

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It is an integral part of the Reproductive and has been extended to all Category ‘C’ districts in all Child Health Program medications zithromax purchase discount persantine on line. Investment Program medicine wheel purchase persantine 100 mg free shipping, which has received approval • Integrated financial envelop: Flexibility has been in Nov 1999 medicine woman dr quinn order cheap persantine online. This will be extended to 60 districts granted to 6 States to design a package of interven- in these states or other states as may be mutually tions to address Maternal Health Care. The Government of India launched the National Rural • Improving outreach services: A new scheme has Health Mission in 2005. Measles Delivery care services include skilled birth attendance vaccine was included instead of typhoid vaccine. Close for all deliveries and provision of emergency obstetric monitoring was done in less than 1 year of age group. It is Program error: An event caused by an error in vaccine recommended that the first dose be given on first preparation, handling or administration. The most contact during pregnancy, the second dose being given common program error is infection as a result of nonsterile not earlier than one month after the first. Use of reconstituted vaccines beyond the In India, children get the diseases at an early age. Coincidental: An event that occurs after immunization However, if the child is brought later than the due date but is not caused by the vaccine. This is due to a chance for the next dose, it can still be given without starting temporal association. Malnutrition, low grade fever, mild evidence that the event is not related to immunization. Examples being common, minor vaccine reactions like local reaction (pain, swelling, redness), fever and systemic symptoms (e. An The cold chain is a system of transportation and storage 596 ideal vaccine reduces these reactions to a minimum while of vaccine at recommended temperature from the producing the best possible immunity. Current recommendation • Personnel: to organize and manage vaccine distribution is to store all vaccines on the basket. Domestic Refrigerators Whenever a thick layer of ice is formed inside the They also maintain a cabinet temperature between freezer, the inside temperature goes up, thus +2ºC to +8ºC with a holdover time of only 4 hours. Therefore, they are not recommended for common use • A paper should be pasted outside the refrigerator in the national program. However, they are used in containing the name and contact number of the urban dispensaries and by private practitioners in urban concerned person in case of a problem or failure. Ice lined refrigerators are lined with tubes or ice packs filled with water which freezes and keeps the internal Cold Boxes temperature at a safe level despite electricity failure. Conditioned ice packs are placed at the top-opening, they can hold the cold air inside better bottom and sides of the cold box before loading the than a front-opening refrigerator. A thermometer 597 Ice lined refrigerator has two sections-top and is also kept in the cold box. Thus Hep B is It is also a thermally insulated box, to carry small most sensitive to freezing. Response Time should be These are flat plastic containers filled with water, up to 48 hours for plains and 72 hours for hilly terrain. These are frozen in the • Down time refers to the time between breakdown deep freezer and when placed in nonelectrical cold of equipment and its repair or the period for which chain equipments such as vaccine carriers and cold an equipment remains out of service. The down time should be less than 2 weeks for plains and 3 weeks Thermometers for hilly terrain. Either dial or stem (alcohol) thermometers are used to • Bundling is the simultaneous availability of a measure the temperature during storage of vaccines. It is sent for of vaccines kept inside with adequate space between the next immunization session, but has to be the boxes, exposure to direct sunlight, different discarded after unopened more than thrice. Once the vaccine is frozen 598 enough to allow the temperature of the ice at the it tends to form flakes which gradually settle to the core of the icepack to rise to 0°C. It prevents freezing of freeze- occurs faster in a vaccine vial which has been frozen as compared to a vaccine vial which has not been Warm Chain frozen. It is an interlinked procedure minimizing the risk of Test: Shake test is conducted when one suspect that hypothermia of newborn babies. At first a vaccine vial training all persons, provision of clean, warm surface and of the same batch number and from the same drying, wrapping material, immediate drying, wrapping manufacturer is taken and is freezed until the and putting the baby to breast, warm cap, covering contents are solid (at least 8 hours at – 18°C). Now this False contraindications to immunization: control vial and test vial (suspect vial) are taken • Minor illness, chronic diseases (heart, lung, kidney).

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Grossly medicine used during the civil war order persantine toronto, testis is (most commonly seminoma) occurs with undescended testes small symptoms non hodgkins lymphoma persantine 100 mg buy without prescription, brown and atrophic symptoms bone cancer generic persantine 100 mg otc. Microscopically, tubules are atrophic with thickened (more for abdominal than for basement membranes. Smaller but defnite Review of Pathology risk of malignancy is present for contra-lateral, correctly placed testis. Difference of ectopic testis from undescended testis is that former is fully developed and hence has normal Gonorrhea and tuberculosis spermatogenesis whereas latter lacks spermatogenesis. Neonatal torsion lacks any associated scrotal sac causes: anatomical defect whereas adult torsion results from a bilateral anatomical defect in ↑ pain in torsion: ↓ pain in orchitis. To prevent subsequent torsion, contralateral normal testis is fxed to scrotum [orchiopexy]. Note: Doppler fow studies and testicular scintigraphy are useful if testicular torsion is ex- Concept pected clinically. Transillumination is helpful in differentiation of cysts (which • Benign scrotal cysts may form from abnormalities of tunica vaginalis. Processus transilluminate) and tumors vaginalis is an outpouching of the peritoneum that enters into the scrotum. Varicocele results from dilatation of testicular veins in Sertoli cell only syndrome: Absence of germ cells pampiniform plexus. It is associated with oligospermia (< 20 million spermatozoa/ Results in infertility due to ml of semen) and is most common cause of infertility. Yolk sac tumor is the commo- nest testicular tumor in infants and children up to 3 years of age. Spermatocytic seminoma is a distinctive tumor characterized by being found in old age and having excellent prognosis [do not metastasize]. Histologically, it is characterized by maturation of tumor cells, some of which resemble secondary spermatocytes. Malignant teratomas have tissue derived from all three germ layers with scattered immature neural elements. In children, differentiated mature teratomas are considered benign whereas in post- Yolk sac tumor are charac- pubertal males, all teratomas are regarded as malignant. Half of tumors show Schiller-Duval bodies or glomeruloid Concept structures [structures resembling endodermal sinuses]. Localized to testes for long duration (70% Early dissemination (60% present in sumption of malignancy. Tunica albuginea spared Tunica breached mostly Extragonadal site of germ cell tumors include mediastinum (commonest), retroperitoneum Important points about germ cell tumors and pineal gland. It is divided into peripheral, central, transitional zones and the region of anterior fbromuscular stroma. Characteristically, the glands are lined by two layer of cells, basal layer of cuboidal cells covered by a layer of columnar secretory cells. Infammation of prostate (prostatitis) It is characterized by fnding at least 15 leukocytes per high power feld in prostatic secretions. Sharply demarcated spherical structures with concentric owl eye (known peripheral zone. Glands consist of two layer of cells; cuboidal and columnar [in carcinoma single layers of cells are present 5-a-reductase inhibitors (e. In addition to mechanical effects of enlarged prostate, clinical symptoms are also due to smooth muscle mediated contraction of prostate by a1A receptors. Most of the prostatic carcinomas are acinar adenocarcinoma and Note: In some cases, nodular enlargement may project up into the foor of urethra as a hemispherical arise in peripheral zone, classi- mass, which is termed as “median lobe hypertrophy”. Advancing age, race (more in American blacks, least in Asians), dietary factors (increases with more fat consumption, Concept decreases with lycopene, vitamin A, vitamin E, selenium and soy products), androgens and Feature that differentiate benign genetic factors are implicated in pathogenesis of prostate cancer. Local absent in cancer [single layered extension most commonly involves seminal vesicles and later base of bladder; Fascia of cells]. Hematogenous spread occur chiefy to bones (osteoblastic secondaries) most commonly to lumbar spine. Lymphatic 554 Genital System and Breast spread occurs initially to obturator nodes. Histologically, most lesions are adenocarcinomas characterized by small glands that appear “back to back” without intervening stroma or that appear to be infltrating beyond the normal prostate lobules. Most prostate cancers arise peripherally, away from urethra; therefore urinary symptoms occur late.

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The most pylori infection except (Karnataka 2008) appropriate marker for this tumor would be which of (a) Chronic gastritis the following? Sister Mary Joseph nodule is most commonly seen in (b) Mucosa and submucosa with which of the following? In pernicious anemia symptoms 2dp5dt generic 25mg persantine otc, antibody is formed against: (c) Colon cancer (a) G-cell (Bihar 2006) (d) Pancreatic cancer (b) Parietal cell (c) Stem cell 17 medicine 4839 persantine 25mg order without prescription. Upper gastrointestinal radiographs 502 Gastrointestinal Tract show that the stomach is small and shrunken symptoms vaginal cancer order persantine 100 mg otc. One of the following can have malignant transforma- the following is the likely microscopic fnding in this tion: man? The man subsequently (a) Parietal cells complains of heartburn and nausea, and gives a history (b) Chief cells that he has been vomiting each morning for the last few (c) Neuroendocrine cells days. Which of the following forms of gastritis would (d) Interstitial cells of Cajal most likely be found in this patient? Which of the following artery is responsible for (b) Chronic antral gastritis duodenal ulcer hemorrhage? Which of the following conditions would mostly likely (d) Left gastric artery be associated with chronic gastritis (Type A) resulting from autoimmune destruction of parietal cells? The best prognosis is gastric carcinoma is in type: (a) Decreased growth of luminal bacteria (a) Linitis plastic (b) Decreased likelihood of developing gastric carcino- (b) Polypoidal growth ma (c) Ulcerative (c) Decreased plasma concentration of gastrin (d) Superfcial spreading (d) Increased production of macrocytic red blood cells 30. An endoscopy is performed and (b) Megaloblastic after thorough microscopic examination, her diet is (c) Sideroblastic modifed. She is started on a special diet with no wheat (d) Normocytic Normochromic or barley grain products. Which of the following organs is not involved in (c) Atrophy of the villi with blunting and fatterning Whipple’s disease? The (a) Increase in intraepithelial lymphocytes patient was stabilized by the health care team but after (b) Increase in crypt: villous ratio 15 days, he passed altered colored (black) stools. The patient worsened within a short time and (d) Elongated hyperplastic and tortuous crypts eventually expired. If an autopsy is conducted, which of the following organs would show the presence of 41. A complete endoscopic examination is performed on a middle aged female Bebo having abdominal pain and 42. Which of the following is most (c) Agammaglobulinemia likely to have been picked up by her physician? She has (a) Perforation (b) Stricture formation no fever, nausea, vomiting or abdominal pain but has (c) Hemorrhage (d) Sepsis lost 3. Endoscopy is performed and the biopsy from associated with pseudomyxoma peritonei? Which (c) Stomach (d) Pancreas of the following antibodies is likely to be seen in this 47. She also had weight loss of 4 kg over last 5 who observes that she is afebrile and has scleral icterus months. Her blood investigations 504 Gastrointestinal Tract reveal total serum bilirubin of 9. Diverticulum most common site is: microscopic examination shows sclerosing cholangitis. Which of the followingis the commonest site of (a) Chronic pancreatitis intestinal tuberculosis? A patient who recently underwent a gastrectomy (a) Sigmoid colon (b) Transverse colon procedure complains of nausea, diarrhea, sweating, (c) Cecum (d) Liver palpitations, and fushing soon after eating a meal. Anti-gliadin antibodies are detectable in: patient should be instructed to (a) Tropical sprue (a) eat less frequent, larger meals that are high in carbo- (b) Whipple’s disease hydrates (c) Celiac disease (b) eat more frequent, smaller meals that are high in (d) Intestinal lymphoma fat (c) eat more frequent, larger meals that are high in protein 57. Which of the following is not associated with celiac (d) eat more frequent, smaller meals that are high in car- sprue? A female patient has severe arthritis involving the (c) Klinefeter syndrome lower back. Before making a diagnosis of ankylosing (d) Type 1 diabetes spondylitis, the patient should be questioned by the 57.

Nasib, 53 years: Neuropathol Appl Neurobiol 26:448–453, 2000b thology and Genetics: Cerebrovascular Disease. These include caffeine, the stimulant in coffee, and nicotine, the addictive compound in cigarettes. These zones might differ in size and/or pattern2 in a patient with certain types of anemias, during acute inflammation, or in the presence of an autoimmune disease. Mitchell P, Smith W, Attebo K, et al: Prevalence of open-angle glaucoma in Australia.

Gorn, 62 years: The elbow is pronated and extended with the wrists flexed, adopting a waiter’s tip position. Tere is hematogenous spread to lungs, liver, Increased serum calcium and serum spleen and other bones. The sugar laden tissues serve as a chance of complications and it gives more liteal fossa. Blood displaced from the skeletal muscle into the central venous pool is an important factor in the hemodynamics of strenuous whole body exercise.

Marik, 29 years: Miles 1892) recognized that the injurious effects of tissue where a vessel is embedded using standard imaging stretching brain tissue were central to understanding the sequences. Tese lesions are usually visible on a careful bleeding is usually painless, although occasionally is speculum examination, which must always be per- associated with local perineal or pelvic pain. Two types of Higher incidence of leprosy is seen in some hilly, tribal reactions are seen. For example, Rapo- deceleration injuries that are most common in motor vehi- port et al.

Yokian, 50 years: Plastic reconstruction is needed in skin, fat, fbrous tissue, muscles, blood Blood spread is rare. This can occur from dehydration as a result of severe vomiting, sweating, or diarrhea, as well as from decreased fluid and electrolyte intake, kidney damage, or adrenal cortical destruction (i. The insertion chest infection of closed suction drainage systems into cavities Cardiac problems that cannot be obliterated after surgery reduces the Mental confusion incidence of haematomata. First of all, read both assertion (A) and reason (R) carefully and independently analyse whether they are true or false.

Agenak, 27 years: The duration of immobilization is the Most cases settle with medical treatment with same. The Covering the emulsion is a thin layer, amount of blackening (density) on the de- commonly gelatin, that serves to protect the emulsion from mechanical damage. What are the premalignant lesions of are not palpable, the treatment of urethra is excised keeping 1. This explains why the distal nephron can establish steep gradients for small ions and water, whereas the proximal tubule cannot.

Rasul, 64 years: New York, Guil- Masanic C, Bayley M, VanReekum R, et al: Open-label study of ford, 2007, pp 345–360 donepezil in traumatic brain injury. In addition, aerobically trained humans are capable of higher sweat production rates than normal, which accelerates heat loss from the surface of the skin (see Chapter 28). Moreover, ice–cold is projectile, copious, self-induced and the following are important clinically. Blood flow in the skeletal muscle can increase 20-fold during a bout of strenuous exercise.

Ramirez, 37 years: The health of the host and the composition of the gut microbiota are intimately linked through the interactions that occur between the gut microbiome and the host’s innate and adaptive immune systems. The latter takes the form of reduced arm swing and lack of truncal swagger when walking. J Int Neuropsychol Soc Ghaffar O, McCullagh S, Ouchterlony D, et al: Randomized treat- 16:401–411, 2010 ment trial in mild traumatic brain injury. What are the clinical fndings of fracture the forearm (at the same or different ‡—” ȋ ‹‰Ǥ ͳͲ͵Ǥʹ͹Ȍ patella?

Hanson, 56 years: Patients with double vision in their functional field of vision require muscle surgery. Reservoirs include humans, animals, virus infection, and giardiasis are transmitted insects, soil, and water. What are the two most likely congenital defects in adrenal steroidogenic enzymes that could explain the findings in this child? Note that in Figure 3-3, each major phase of the ventricular cardiac cycle has a corresponding phase of cardiac muscle length and tension change.

Riordian, 34 years: Active transport of phosphate is coupled to calcium transport, and thus, when active transport of calcium is low, as with vitamin D deficiency, phosphate absorption is also low. Its action is terminated by uptake via an excitatory amino acid transporter back into the presynaptic terminal or into glial cells where it is converted to glutamine by the enzyme glutamine synthase. Skin wettedness depends on the hydration of the epidermis and the fraction of the skin surface that is wet. Reducing emissions may This has already been discussed in Chapter 9 (Occu- be achieved through multiple clean energy initiatives.

Kamak, 46 years: Thus from gatherer, man became a classification of disease than in the real cause or producer. With aging comes a natural loss of bone due to many endo- Hashimoto Thyroiditis Is More Frequent than Expected When crine changes. However, veins in the skeletal muscle are rather sparsely innervated with sympathetic vasoconstrictor fibers, and the rather small volume of blood that can be mobilized from the skeletal muscle by sympathetic nerve activation is probably not of much significance to total body hemodynamics. Linolenic acid is an omega-3 fatty acid, and linoleic and arachidonic both omega-6 fatty acids.

Pakwan, 36 years: Other than insulin administration and strict adherence to diet regimens, there is little that pharmacotherapy can do in type 1 diabetes because of the loss of pancreatic beta cells. Vein superior to artery On occasion it may also be possible to pick up pericardial pathology such as a pericardial effusion, Vein inferior R to artery prompting the need for echocardiogram. General symptoms like fever, anorexia Stage 1: (Stage of synovitis or Stage of sinus and wasting of muscles. By pumping protons into the lumen of the stomach in exchange for potassium ions, this pump maintains the low pH in the stomach that is necessary for proper digestion.

Grok, 25 years: Microbiologists refer to these bacteria as the microbiome, which is defined as the genetic material within a microbial community. J Abnorm Child Psy- depth review of neuropsychological outcome of pediatric chol 20:233–246, 1992 traumatic brain injury. However, surgical patients do share a common thread and that is the pharmacological management of postoperative pain. The estimated resemble small pencil erasers with flat lifetime risk of acquiring a fungal skin infection tops, and can be pink, light brown, or light is between 10 and 20%.

Berek, 41 years: According to the cases the nose may grow swollen and bumpy National Psoriasis Foundation, psoriasis affects from excess tissue. Fresh frozen plasma and platelet preparations patients have often lost a large volume of blood, are may also be required to correct coagulation after hypothermic and coagulopathic. Each ear contains three semicircular canals and two otolithic organs, the utricle and the saccule (Fig. For example, a heart may be so weakened by disease that it cannot provide adequate blood flow to the muscle tissue of the heart.

Umul, 35 years: This change is under complex reflex control, and bright light entering just one eye will cause the appropriate constriction response in both eyes. Magnetic resonance imaging is most useful for evaluating tumor invasion into the optic nerve or orbit as well as assessment of the brain for related intracranial neuroblastic malignancy (trilateral retinoblastoma; pinealoblastoma). Because exercise may also improve gait, balance, coordination, proprioception, and reaction time, even in older and frail persons, chronic activity reduces the risks of falls and osteoporosis. Diseases and Disorders of the Inner Ear Hearing Loss Presbycusis is age-related hearing Diseases and Disorders loss and is the most common cause of hearing of the Middle Ear loss in adults.

Shakyor, 21 years: It involves the systematic tensing and relaxing of various muscle groups to elicit a deepening relaxation response, usually with combination of muscle groups and addition of diaphragmatic breathing to shorten the protocol. In this context, the term selectively permeable means that the membrane is permeable to water but not solutes. This approach to the bile ducts oscopy fails, usually because of a tortuous sigmoid may also be used therapeutically to insert stents colon or severe diverticular disease. The proximal tubule epithelium 2+ 2+ is rather impermeable to Mg under normal conditions, and so there is little passive Mg reabsorption.

Tjalf, 61 years: The blood pressure exerted against the walls of an artery and the energy required to move blood at a certain velocity are interrelated by the Bernoulli principle. These defects are not limited to red blood cells, as defcient platelets and granulocytes are also more sensitive to lysis by complement. The prevalence of epidermoid cysts is not tigo is staphylococcal or streptococcal bacteria known, but they are the most common cutane- that enter through a break in the skin. The Lauge – Hansen classifcation of ankle It should either be done within a few tibia cannot be moved.

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