Genetic diseases either follow a single gene disorder or a polygenic basis with multifactorial disorders generic 100mcg cytotec visa treatment 4 letter word. Metabolic diseases with a single gene disorder These metabolic diseases follow a Mendelian type of inheritance i purchase 200 mcg cytotec otc symptoms appendicitis. Phenylketonuria cytotec 100mcg lowest price medications not to mix, Galactosemia generic cytotec 200mcg line treatment diarrhea, Glycogen storage diseases); and x-linked recessive disorders (e. These are all rare Biochemical genetic diseases and they are beyond the scope of this lecture note. Metabolic disease with a polygenic disorder These metabolic diseases have multifactorial modes of inheritance. They are caused by the additive effects of two or more genes of small effect but conditioned by environmental, non-genetic influences. Example in these groups of metabolic diseases 213 includes Diabetes mellitus and Gout. As to the new classification there are four types of diabetes of which the first two are the major types. This can be sited as evidence that genetic factors are involved in the pathogenesis of the disease. In studies of identical (monozygotic) twins in which one or both were diabetic, both members of the pair were affected in approximately half of the cases [i. B these 50 % concordance rate shows that environmental factors contribute to the development of the disease on a heritable predisposition 3. Additional evidence came from studies of genes that code for antigens of the major Histocompatibilty complex. The above three genetic factors/ evidences show that there is a genetic factor that is/ are important for the susceptibly to the disease and environmental factors are required to the development of an autoimmune reaction on these susceptible individuals. Circulating auto- antibodies against components of the beta cells and against insulin were demonstrated in the large majority of all newly diagnosed children with diabetes. The destruction of beta cells by an immune response is also evidenced by the presence of mononuclear cell infiltrates in the pancreatic tissue of a patient with type 1 diabetes 216 Environmental factors As mentioned earlier, the fact that a significant proportion of monozygotic twins remain discordant for Diabetes suggests that non-genetic factors are required for development of diabetes. This is because milk proteins provide specific peptides that share antigenic sites (molecular mimicry) with human B cell surface proteins there by eliciting the production of auto reactive antibodies. The hyperinsulinemia inturn results in decreased insulin receptors peripherally in the muscle and adipose tissue. Increased hepatic glucose production 218 Impaired insulin secretion - The reason for the impairment of insulin secretion is not clear - Genetic defect, increased hyperglycemia (glucose toxicity), increased free fatty acid level (lipotoxicity)- all are suggested as a cause or factors which worsen beta cell failure to secrete insulin Increased hepatic glucose production - Insulin promotes storage of glucose as hepatic glycogen and suppresses gluconeogenesis. Type 2 No decrease is the number of beta cells and there is no morphologic lesion of these cells. Causes: May be caused by missing meals or doing unexpected exercise after taking insulin doses. In diabetic patients with autonomic neuropathy, there could be hypoglycemic unawareness. This is so because the patient doesnt have symptoms of hypoglycemia, and wont take appropriate measure. This oxidation produces ketone bodies (acetoacetic acid and Beta hydroxybutyric acid), which are released into the blood and lead to metabolic acidosis. Non-ketotic Hyperosmolar state Is usually a complication of Type 2 because there is enough insulin to prevent ketosis Patient present with profound dehydration resulting from a sustained hyperglycemic diuresis and finally goes to a comatose state B. Late complications of Diabetes Mechanisms of development of diabetic late complications: Long-term hyperglycemia is essential for the development of diabetic late complications. Many mechanisms linking hyperglycemia to the complications of long-standing diabetes have been explored. Hyperglycemia leads to increased intracellular glucose, which is then metabolized by aldose reductase to sorbitol, a polyol, and eventually to fructose. The accumulated sorbitol and fructose lead to increased intracellular osmolarity and influx of water, and eventually, to osmotic cell injury. In the lens, osmotically imbibed water causes swelling and opacity cataract formation. Sorbitol accumulation also impairs ion pumps and is believed to promote injury of schwann cells 222 and pericytes of retinal capillaries, with resultant peripheral neuropathy and retinal microaneurysms. Diabetic macrovascular disease: Atherosclerosis > The extent and severity of atherosclerotic lesions in large and medium sized arteries are increased in long standing diabetes, and their development tends to be accelerated. Atherosclerotic lesions in large blood vessels lead to vascular insufficiency and an ultimate production of ischemia in the organs supplied by the injured vessels. Myocardial infarction, Brain infarction (resulting in stroke), gangrene of the toes and feet. Non proliferative retinopathy Is characterized by retinal vascular micro aneurysms, blot hemorrhages, and cotton wool spots 2. Thickening of glomerular basement membrane which results in glumerulosclerosis, renal arteriosclerosis as part of the systemic Involvement of blood vessels, and pylonephritis. Polyneuropathy - The most common form of diabetic neuropathy is distal symmetric polyneuropathy. It most frequently presents with distal sensory loss, Hyperesthesia, paraesthesia and pain also occur. It is also characterized by long-term complication affecting the eyes, kidneys, Nerves and blood vessels. It also results from impaired insulin secretion, and increased glucose production. Gout Represents a heterogeneous group of diseases in which the common denominator is an increased serum uric acid level and the deposition of sodium urate crystals in joints, soft tissue around joints and kidneys. Pathogenesis of hyperuricemia: Uric acid is the end product of the catabolism of purines, derived either from the diet or synthesized de novo. Primary (idiopathic) Gout In this category the causes that result in hyperuricemia are unknown, Most cases (75-90%) of so- called idiopathic Gout result from an as yet unexplained impairment of uric acid excretion by the kidney. Conditions that result in over production of uric acid Most common cause of overproduction of uric acid is increased turn over of nucleic acids, as seen in leukemia and Lymphomas and after chemotherapy for cancer. Conditions that result in Decreased urinary excretion of uric acid - The most common cause of decreased urinary excretion of uric acid is chronic renal diseases that lead to renal failure. In renal failure the clearance of uric acid is decreased, and with a fall in the rate of Glomerular filtrates, hyperuricemia ensues. Pathology (Morphology): When a sodium urate crystal precipitates from super saturated body fluids, they absorb fibronectin, complement, and number of other proteins of their surfaces. In phagocytizing those protein coated crystals, Neutrophiles release inflammatory mediators resulting in local inflammatory reaction Uric acid crystals may be found intracellularly in leukocytes of the synovial fluid. Extra cellular soft tissue deposits of these crystals (tophi), are surrounded by foreign body giant cells and an associated inflammatory response of mononuclear cells. These granuloma like areas are found in the cartilages and in any soft tissue around the joints.
A repeat the above mentioned excersises 5 or 10 times on the incisions lay in different directions trusted 100 mcg cytotec medicine 3 times a day. The trainee should be able to tie 6 knots in 10 minutes to consider himself proficient in this excersise buy 200mcg cytotec with mastercard medications lisinopril. Maximal absorption of iron occurs in the duodenum Question 2 Which portion of the gastrointestinal tract is most responsible for the absorption of bile acids and folate? Ileum Question 3 Which of the following parts of the duodenum are not considered to be retroperitoneal? The proximal portion of the first part of the duodenum is intraperitoneal Question 4 All of the following are true regarding small bowel anatomy and physiology except: A generic 100mcg cytotec medications used for migraines. Gastrin is produced by the parietal cells in the stomach and are innervated by the vagus D cytotec 200 mcg with mastercard treatment questionnaire. The ileum is around 150 cm in length while the jejunum is about 100 cm Answer 4 C is false. It is unusual to see symptoms of hypoglycemia when serum glucose levels are above 25 mg/dL B. The concentration of the principal anions (bicarb and chloride) varies depending on pancreatic stimulation C. When the stimulus to secrete fluid is minimal, the chloride concentration is relatively high D. When the stimulus to secrete is maximal, the chloride concentration is relatively high Answer 8 D is incorrect. Gram positive septicemia usually has a poorer prognosis than gram negative infection B. The operation took around 4 hours and at the end of the case, his abdomen was slightly difficult to close. He developed an ileus post-op, a wound dehiscence requiring takeback, and then on day 9 started draining succus from his midline excision. High output fistula are more likely to be from the proximal bowel and less likely to close with conservative management. Iatrogenic enterocutaneous fistulas are more common than spontaneous fistulas from inflammatory bowel disease Answer 10 C. The most common cause of colonic obstruction without previous surgery is cancer B. Coagulation mode generates less heat on a slower frequency causing tissue dehydration and vessel thrombosis Question 14 Which of the following types of cautery leads to heat being generated over the target area quickly with minimum lateral spread? This best describes the cutting mode Question 15 Which of the following types of cautery is the safest because it disperses energy only between its tips? She states that she has one child and would like to try to have another within the next year. There is an outpouching of the bowel is markedly inflamed circumferentially at this point. It inhibits the activation of resting T lymphocytes Question 23 Which of the following would you least likely expect as a side-effect? Most non-protein calories are provided by (D- choose from lipids, glucose, or alcohol). Anal disease can be manifested as large skin tags and should be treated with Flagyl, not excision C. Perirectal disease may respond to resection of diseased small bowel Answer 28 C is false- most patients with Crohns ultimately need an operation Crohn Disease The most commonly involved bowel segment is the terminal ileum Anal disease can be manifested as large skin tags and should be treated with Flagyl, not excision 90% of these patients eventually need an operation Perirectal disease may respond to resection of diseased small bowel Intermittent abdominal pain, n/v/d/f, weight loss Even after resection, recurrence rate is around 50% Question 29 Which of the following characteristics are not consistent with Crohns Disease? All of the above are sequlae of extensive ileal resection Crohn Disease Surgical indications- Obstruction- partial can be tx conservatively Abscess- sometimes tx with perc drainage Megacolon- 15% perforation, usually contained Blind loop obstruction Fissures- Setons and conservative measures preferable; do not do lateral internal sphincerotomy Enterocutaneous fistula Anorectal/ vaginal fistulas- may need advancement flap or diversion Do not need clear margins, just get 2 cm away from gross disease Crohn Disease Complications from terminal ileum removal: Megaloblastic anemia from decreased B12 uptake Decrease bile salt uptake- increased bile salt delivery to colon-> steatorrhea Decrease oxalate binding- increased intraluminal fat binds calcium & allows for oxalate absorption Gallstones (calcium bilirubinate) from malabsorption of bile acids Question 32 A 45 yo male presents with right lower quadrant pain; you end up exploring him & find a 2cm carcinoid that is close to the appendiceal base. Cholecystectomy should be performed in case he needs embolization in the future C. It is caused by a pulsion diverticulum that arises adjacent to the inferior pharyngeal constrictor B. Gastrograffin swallow (instead of barium) should be performed because gastrograffin is inert if aspirated C. Surgical intervention is indicated in symptomatic patients with this condition regardless of size D. Open repair is performed through the left neck and always involves a myotomy through the cricopharyngeus and thyropharyngeus muscles Answer 34 B. Cystic Hygromas Occasionally grows suddenly as a result of an upper respiratory tract infection, infection of the hygroma itself, or hemorrhage into the tissues Can compress the trachea and cause dysphagia. You suspect that it is somewhere in the head or neck given his long smoking history but despite extensive workup, you cant find the primary. The G1 phase determines how long the cell cycle will take Question 2 Which of the following correctly describes the Cori cycle? Vascular dilation Question 4 Which of the following factors is degraded by plasmin? Question 7 You are performing an axillary dissection and take only level 1 nodes. Question 8 A 56 yo female presents with a sore, inflamed appearing right breast that has puckering concerning for inflammatory breast cancer. You confirm this on biopsy and her other films are otherwise negative for metastatic disease. Primary therapy should not be wedge resection Pyogenic liver abscess Primary causes are biliary infection (cholecystitis/cholangitis) or seeding from portal vein drainage (appendicitis/diverticulitis) E. Scan reveals an abscess and cultures show Entameoba histolytica, Which of the following should you recommended for treatment? Question 12 A 65 yo female has a new diagnosis of a right colon adenocarcinoma and 2 hepatic tumors involving segments 1 and 2. Right hemicolectomy and left hepatic resection Colon Cancer with Hepatic Mets Remember the anatomy: Seg 1 = caudate 2-4 = left lobe (2/3 compose left lat segment) 5-8 =right lobe. Protein C is a hepatically made product and it has a relatively short half life B. Protein C has a relatively long half life and is produced mostly in the peripheral tissues C. Coumadin is a vitamin K antagonist that can produce a transient hypercoagulable state cue to the coagulation inhibition normally provided by the short-half life Protein C B. You can expect that a patient on anabolic steroids may be particularly sensitive to coumadin C. A person taking corticosteroids may be less sensitive to the effects of coumadin D. A person with Crohns disease that has multiple bowel resection and clinically has short bowel syndrome D. All of the above may be deficient in vitamin K Question 16 Which of the following correctly states the mechanism of coumadin? It causes anticoagulation by breaking down fully formed factors 2, 7, 9, and 10 B. It affects the gamma carboxylation of the precursor proteins of the clotting cascade C. The process is a competitive inhibition and can be overcome by administering vitamin K D.
In addition buy cheap cytotec 200 mcg on-line symptoms ear infection, they are characteristically hypointense encephalitis in infants and young children: a separate pat- on T2-weighted images; however 100mcg cytotec sale brazilian keratin treatment, imaging characteris- tern of fndings cytotec 200mcg cheap symptoms 6 year molars. In: Pe- gitis virus syndrome: a disease that mimicks congenital diatric Neuroimaging discount cytotec 200 mcg without prescription medicine identifier pill identification. The b-value is a sequence-specifc factor that determines the sensitivity for the water difusion. Tus, the dephasation efects are emphasized with an extreme reduction of the T2 relaxation time. Bound and free protons interact via a chemical exchange and dipoldipol interactions and have a dif- ferent resonance width, but the same mean resonance frequency. Via a high frequency pulse, which is placed difusion, whereas vasogenous edema comes along with outside the resonance of free water, the protons bound elevated difusion. In addition, the so-called cross relaxation also rections, while in anisotropic difusion it is greater in results in a reduction of the T1 time. Here the difusion parallel to the direc- tion of the fber bundles is greater than vertical to this 14. Choline is an ity in not more than 8 min; thus, it can also be used in integral part of the cellular membranes. Lactate serves as marker of resonances among each other and relative to the refer- the anaerobic glycolysis. At an echo time of 135 ms lip- ence substance are specifed as parts per million (ppm), ids (Lip) can ofen be defned between 0. T1 hypointense plaques with con- appearing white matter correlates with the grade of trast enhancement show increased values for choline clinical impairment. The subcallosal line joins the undersurface of the front (rostrum) and back (splenium) of the corpus callosum 218 A. Moreover, this increase in the Cho/Cr ratio cor- dation of proteins by macrophages in the pus. So far, it has not been examined system- especially in the periphery or near the skull base. Cerebritis is the earliest form of manifestation of a The choline and creatine peaks are moderately in- pyogenic cerebral infection and shows restricted water creased. In contrast to bacterial abscesses tuberculous examinations of the pulvinar sign demonstrate an in- abscesses do not normally show amino-acid resonances crease in myoinositol in the posterior thalamic nuclei. Lympho- pathogenetically explained by the angioinvasivity of the mas also show a high lipid peak, which is, however, of- aspergilli. J Magn Reson Imag- weighted imaging and apparent difusion coefcient map- ing 24(4):817824 ping of the normal-appearing brain. 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