AIPGE 2011: All Questions With Options & References

Discussion in 'NEET 2013 All india Exam' started by Guest, Jan 10, 2011.

  1. Guest

    Guest Guest

    The Third Ventricle (ventriculus tertius) (Figs. 716, 720).—The third ventricle is a median cleft between the two thalami. Behind, it communicates with the fourth ventricle through the cerebral aqueduct, and in front with the lateral ventricles through the interventricular foramen. Somewhat triangular in shape, with the apex directed backward, it has a roof, a floor, an anterior and a posterior boundary and a pair of lateral walls.

    The roof (Fig. 723) is formed by a layer of epithelium, which stretches between the upper edges of the lateral walls of the cavity and is continuous with the epithelial lining of the ventricle. It is covered by and adherent to a fold of pia mater, named the tela chorioidea of the third ventricle, from the under surface of which a pair of vascular fringed processes, the choroid plexuses of the third ventricle, project downward, one on either side of the middle line, and invaginate the epithelial roof into the ventricular cavity.
    The floor slopes downward and forward and is formed mainly by the structures which constitute the hypothalamus: from before backward these are: the optic chiasma, the tuber cinereum and infundibulum, and the corpora mammillaria. Behind the last, the floor is formed by the interpeduncular fossa and the tegmenta of the cerebral peduncles.
    Interpeduncular Fossa (Fig. 724).—This is a somewhat lozenge-shaped area of the base of the brain, limited in front by the optic chiasma, behind by the antero-superior surface of the pons, antero-laterally by the converging optic tracts,and postero-laterally by the diverging cerebral peduncles. The structures contained in it have already been described; from behind forward, they are the posterior perforated substance, corpora mamillaria, tuber cinereum, infundibulum, and hypophysis.
  2. Guest

    Guest Guest

    19. Gun powder on clothing can be visualized by?
    A. Magnifying lens/spray
    B. UV rays
    C. Infrared photography
    D. X Ray
    Ans:infrared photography
    ref:GUNPOWDER RESIDUE ANALYSIS

    Powder is never totally burned when a gun is fired. Residues are thrown out quite some distance (as well as backwards in a cloud-like formation). By analyzing the presence or absence of powder residue thrown out forward towards the target, the analyst can determine muzzle to target distance, not an unimportant consideration with cases of self-defense pleas and alleged suicides. Distances and angles can also be determined by analyzing the halo, tattooing, or spotting around a bullet hole in a target's garments. Infrared photography will usually reveal even the most minute traces of powder residue. A halo of soot around the hole is usually 12-18 inches; a halo with specks usually 18-25 inches; and specks only 25-36+ inches. With shotguns, the general rule is that a one inch spread equals one yard, so a ten inch patter equals ten yards, for example.

    Gunshot holes or wounds usually fall into one of three categories: close range; distant; or contact. Distant shots are the most problematic. One of the oldest tests (1933) in existence was called the paraffin test, or dermal nitrate test. It was designed to check for residue on the hands (from the blown-back cloud-like formation). The suspect's hands were coated with paraffin or wax, and then the paraffin was tested with diphenylamine. If the wax turned blue, it indicated nitrates were present. Nitrates are the most common unburnt part of gunpowder residue. Unfortunately, the test fell out of popularity over the years because urine, tobacco, fertilizer, cosmetics, and other substances on the hands also yielded a blue color. Modern tests for hand residue look for primer substances such as barium on the thumbs and bullet-alloy substances such as antimony on the fingers.

    Another test for nitrates is called the Griess test which is designed to assist with measurement of distances and angles. The examiner presses a photographic paper onto surfaces near the target, and then sprays the paper with sodium rhodizonate and a pink to violet color appears if nitrates are present. Yet another test, called the Harrison-Gilroy test, doesn't check for nitrates at all, but for antimony, barium, and lead using the same paper color change indicator. There's some instability in the color changes of many of these tests, but there's the best thing to use when the crime scene is covered with bloodstains since the tests will activate only for gunshot residue. Many other tests exist, the most expensive ones involving neutron activation analysis and/or electron microscopes.

    214.Most common malignant TRANSFORMATION cauing bilateral proptosis in children?
    A. A. Cavernous haemangioma
    B. orbital Rhabdomyosarcoma
    C. ALL
    D. AML
    Ans:AML
    REFERNCE-INDIAN JOURNAL OF PEDIATRIC ONCOLOGY BY AIIMS CONSULTANT
    VOLUME 25 2004
    pls check to get ur doubt clears i am not able to paste it here....very clearly answer is aml and for the another similar question answer is chloroma(i.e granulocytic sarcoma of orbit)

    238. Late onset endophthalmitis after lens implantation is caused by?
    A. Staphylococcus epidermidis
    B. Pseudomonas
    C. Streptococcus pyogenes
    D. Propionibacterium acnes
    Ans is Staph epidermidis only......
    refernce----
    Late onset endophthalmitis associated with intraocular lens: a case of molecularly proved S. epidermidis aetiology.
    B. Jansen, C. Hartmann, F. Schumacher-Perdreau, and G. Peters
    Institute of Medical Microbiology and Hygiene, University of Cologne, Germany.
    This article has been cited by other articles in PMC.
    AbstractA case of severe endophthalmitis after cataract extraction followed by posterior chamber lens implantation is reported. Microbiological cultures from a tap of the patient's aqueous humour prior to lens explantation as well as from the explanted lens and aqueous and vitreous humour during operation yielded Staphylococcus epidermidis strictly. Scanning electron microscopy showed massive colonisation of the lens loop by staphylococci. Clonal identity of all isolates was demonstrated by plasmid DNA analysis and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) of extra-cellular products. This is strongly suggestive of the aetiological role of S. epidermidis in this case of late onset endophthalmitis.
    although popniobacterum is also one of the common agent but staph.epidermidis is most common to be isolated....

    263. Ophtalmoplegic migrain..
    A.Headache with reversible lose of ophthalmic nerve function
    B. recurrent transient 3rd nerve palsy after headache
    C. one option related to before or after aura
    ans is straight recurrent transient 3rd nerve palsy as i know this one so didnt see other option deeply....refernce---harrison and in mudit khanna med its given in a taable...

    48. A 65 yrs old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What
    is the ¡°BEST COURSE OF ACTION¡±?
    A. Conservative management (trial of conservative management)
    B. Arthroscopic washing
    C. Partial knee replacement
    D. Total knee replacement
    first make first option right it was trial of conservative management...
    according to campbell orthopedics general approach in case of osteoarthritis the first try is to manage patient conservatively by nsaids and intraarticular steroids and if not controlled then as per age and other factor surgical treatment is planned...........
    and course of action is the methodology how we proceed for treating a case and so best course will be to start with a trial of conservative treatment then approach surgically.....
  3. Guest

    Guest Guest

    249.ECG is poor at detecting ischaemia in areas supplied by?
    A. Left anterior descending
    B. Left circumflex
    C. Left coronary artery
    D. Right coronary artery

    Posterior ischemia or an ischemia in the region of the left circumflex artery are often not visible on a normal standard 12 lead ECG

    250.Which of the following is a contraindication for medical treatment in gallstones?
    A. Radio opaque stones
    B. Radiolucent stones
    C. Normal functioning gall bladder
    D. Small stones

    Bile acids help dissolve gall stones by decreasing the levels of cholesterol available for stone formation
    But radio opaque stones contain calcium in addition to cholesterol – dissolution of which is not possible
    Hence, bile acid therapy is contraindicated in radio opaque gall stones

    ref-Diseases of the liver and biliary system By Sheila Sherlock, Sheila Sherlock (Dame.), James Dooley

    251.Which among the following is preferred in a patient with decreased renal function to avoid contrast nephropathy?
    A. N acetylcysteine
    B. Fenoldopam
    C. Low osmolar contrast
    D. Mannitol

    a twisted repeat from aiims nov 10

    ans-N acetylcysteine>Low osmolar contrast

    The latest clinical trial, whose results were announced in November 2010, has found that acetylcysteine is ineffective for the prevention of contrast-induced nephropathy. This trial, involving 2,308 patients, found that acetylcysteine was no better than placebo; whether acetylcysteine or placebo was used, the incidence of nephropathy was the same—13%.[16][citation needed]

    Acetylcysteine continues to be commonly used in individuals with renal impairment to prevent the precipitation of acute renal failure

    Q252. Visceral larva migrans is seen in?
    A. Strongyloides
    B. Ancylostoma
    C. Toxocara canis
    D. Visceral leishmaniasis

    ans toxocara canis

    ref chatterjee 12th/206[/b]

    253.Regarding diabetes insipidus, all are true except?
    A. Water deprivation test is diagnostic
    B. Before doing test first correct hypoaldosteronism
    C. Hypothyroidism not affect the diagnostic test
    D. Pre test serum osmolarity 288, before giving vasopressin

    254.A young lady presents with fever, dysuria and pain abdomen. Uncomplicated acute cystitis was diagnosed. Which among the following is not true?
    A. Nitrate test positive
    B. E.coli count was < 10^3
    C. 1 pus cell per 7 fields
    D. 1 bacilli per field

    255.A patient presented with an abdominal injury with peritonitis and shock. Airway, breathing and IV fluids for circulation were taken care of. What is the next step of management?
    A. Take the patient for laparotomy under GA
    B. Take the patient go for a laparoscopy
    C. Insert an abdominal drain under LA and take up for surgery

    256.A investigator finds out that 5 independent factors influence the occurrence of a disease. Comprision of multiple factors responsible for a disease can be assessed by?
    A. ANOVA
    B multiple linear regression
    C. Chi square
    D. multiple logistic regression

    257.Not a part of national screening program?
    A. Diabetes mellitus
    B. Dental caries
    C. Breast cancer
    D. Carcinoma cervix

    258.Which of the following is true?
    A. Acetylcholinesterase inhibition by malathion can be reversed by increasing the level of acetylcholinesterase
    B. Sulphonilamide inhibits folate reductase irrevesibly
    C. Flouoroacetate competetively inhibits aconitase
    D. Ethanol inhibits aldehyde dehydrogenase when used in methanol poisoning

    259.Methods of producing monoclonal antibodies are all except?
    A. Attaching inactive viral particle on cell membrane
    B. Adding ethylene glycol
    C. Applying a small electric current
    D. Reducing the viscosity of the membrane

    260.All are true regarding phagocytosis by protozoa except?
    A. Amoeba n other unicellular org make their living out of it
    B. Phagocytose particles of < 5 microns size
    C. Phagocytose particles of > 5 microns size
    D. Digestion occurs within phagolysosomes
  4. Guest

    Guest Guest

    194. A 50 yr lady has history of sprained ankle 2 months back followed by recovery. She now complains of severe pain in that ankle with inability to flex that foot. Physician notes edema and shiny skin in local examination. What is the probable diagnosis:
    A. Fibromyalgia
    B. Complex regional pain syndrome 1
    C. Complex regional pain syndrome 2
    D. Peripheral neuropathy
    Ans:B Complex regional pain syndrome 1

    A 50 yr lady has history of sprained ankle 2 months back followed by recovery. She now complains of severe pain in that ankle with inability to flex that foot. Physician notes edema and shiny skin in local examination. What is the probable diagnosis:
    a. Fibromyalgia
    b. Complex regional pain syndrome 1
    c.Complex regional pain syndrome 2

    ANS:C>B
    A common problem for which patients consult neurologists like me is foot drop. As the name says, they have foot drop and hence are unable to dorsiflex their foot.
    As a result they are likely to catch their foot on the ground while walking and thus are prone to falls and this brings them to medical attention. Foot drop should be differentiated from frail foot. In foot drop, patients are unable to dorsiflex their foot while those who have a frail foot are unable to dorsiflex as well as unable to planter flex the foot (that is they are unable to pull their foot up or push down their foot as when you press down on a gas pedal).

    Foot drop might occur suddenly (acutely) or may be more insidious and the causes for both vary. Before we discuss the causes of foot drop, it is helpful to know a little about the relevant anatomy. The muscle which helps to dorsiflex the foot is called tibialis anterior and it is supplied by a nerve called the peroneal nerve. The peroneal nerve is a branch of the sciatic nerve. The sciatic nerve is formed by the lower lumbar and sacral nerve roots and forms a part of the lumbosacral plexus. The peroneal nerve in the knee area is quite superficial as it cross the neck of the fibula (fibula is one of the bones in the lower leg along with the larger tibia). As the nerve is superficial it is prone to compression across the neck of the fibula.

    So lets now discuss some of the common causes of foot drop. If suppose you suffer a fracture across the neck of the fibula, or have a gun shot wound to that area, or during knee surgery the peroneal nerve is accidently transected, you shall develop a foot drop. In all of the above the cause is injury to the peroneal nerve.

    But peroneal compression may also occur due to other more subtle causes. One of the most common causes of foot drop is habitual leg crossing. This is most commonly seen in obese persons or in diabetics who lose weight. After weight loss they can cross their legs more easily and may develop a foot drop. Why does this occur you may ask? Well the answer is simple, as I told you before the peroneal nerve is quite superficial and hence prone to compression. When you cross your leg, the nerve may get pinched against the other knee and if you do not relieve the pressure soon, you can develop a foot drop. A common scenario is that the person is sitting with his legs crossed on a long flight, or might have fallen asleep with his leg pressed against the side rails of the bed (this is common in hospitalized patients in the intensive care unit or also when patients are undergoing surgery in the OR), they wake up and find they have a foot drop. The good news is that the prognosis for this type of compression injury to the peroneal nerve is rather good. Once the pressure is released, these patients usually make a full recovery over a few days to weeks and their foot drop goes away.

    What is complex regional pain syndrome?

    Complex regional pain syndrome (CRPS) is a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems. Typical features include dramatic changes in the color and temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, and swelling. CRPS I is frequently triggered by tissue injury; the term describes all patients with the above symptoms but with no underlying nerve injury. Patients with CRPS II experience the same symptoms but their cases are clearly associated with a nerve injury.


    Older terms used to describe CRPS are "reflex sympathetic dystrophy syndrome" and "causalgia," a term first used during the Civil War to describe the intense, hot pain felt by some veterans long after their wounds had healed.

    CRPS can strike at any age and affects both men and women, although most experts agree that it is more common in young women.
  5. Guest

    Guest Guest

    All are true about Nesidioblastosis except ?
    1. Histopathology shows Hyperplasia of Islet cells
    2. Hypoglycemic Episodes are seen
    3. Occurs in adults more than child
    4. Diazoxide is used in treatment

    Ans-occurs in adults more than child.

    Nesidioblastoma – A Tumor of the Pancreas That What is it?

    Nesidioblastoma (also called “islet cell carcinoma”) is an uncommon cancer of the pancreas.

    Who gets it?

    Tumors of the endocrine pancreas (more about that word later) are pretty rare. In the US, they happen to 3-10 out of a million people per year.

    They are slightly more common in women than in men.

    In terms of age, they mostly present at ages 30-50.

    What causes it?

    The pancreas is a gland in our body. It has two types of cells:

    Endocrine cells: Make hormones (chemicals that control actions of other cells or organs in the body), like insulin.
    Exocrine cells: Make enzymes (proteins that have a function, like little machines) that are released into our intestines and help the body digest food.


    Islet cell tumors, like nesidioblastoma, arise from the endocrine part of the pancreas. This means that they secrete hormones. They may be functional (causing symptoms) or non-functional.

    An example would be a tumor that secretes insulin, like on the House episode. Insulin controls the amount of sugar in the blood. When insulin is high, sugar in the blood enters the cells, and there is less sugar in the blood.

    How does it feel?

    That depends on what the tumor secretes.

    If it secretes insulin, like was shown on the House episode, it will lead to low sugar levels in the blood. This means the brain will not get enough sugar, necessary for it to function properly. This will lead to headaches, blurry vision, changes in thinking and concentration, weakness. Also sweating, changes in the heart rhythm, and body tremors.

    Other hormones other than insulin can be secreted, and cause different symptoms.

    How is it discovered?

    There are different ways to discover different types of tumors arising from the pancreas.

    For an insulin secreting tumor, for example, glucose (blood sugar) and insulin in the blood can be measured.

    Another way of finding the tumor, which was shown on House, helps locate the tumor in the pancreas. In this method, calcium is injected into an artery that goes to one part of the pancreas. At the same time, a blood sample is taken from a blood vessel that comes out of the pancreas (a vein) to see if it secretes more hormones as a result. If there’s a tumor in the area the calcium reached, there will be an increase in the amount of hormone in the blood sample.

    How is it treated?

    Depending on the extent of the tumor, it can be removed from the body. Sometimes, other treatment measures are needed, if this is not enough.

    What happens after treatment?

    That depends on whether the tumor has spread to other areas of the body or not. If it has, chances of survival lower.
    an Secrete Hormones
  6. Guest

    Guest Guest

    Indications for aspiration of amoebic
    liver abscess
    J. DE LA REY NEL, A. E. SIMJEE, A. PATEL ................................... TABLE I. INDICATIONS FOR ASPIRATION
    Negative AGDTALA in the left lobe adjacent to the diaphragm
    ALA in the superficial anterior part 01 left lobe
    ALA in the right lobe adjacent to the diaphragm
    Any ALA above 10 cm in diamete

    TABLE IV. PATIENTS WITH INDICATIONS FOR ASPIRATION
    Remaining non-aspiration group
    1 adjacent to diaphragm
    Remaining aspiration group
    4 ALAs> 10 cm in diameter
    6 adjacent to diaphragm
    2 left lobe anterior superficial

    TABLE VII. MODIFIED INDICATIONSNo improvement clinically within 48 - 72 h
    Abscesses causing marked tenderness or severe pain
    All large abscesses (> 10 cm in any dimension)
    Superficial abscesses (anterior and inferior if > 10 cm in
    diameter)
    Marked elevation of the diaphragm (adjacent to the right
    dome of diaphragm)
    Left lobe abscesses (left lobe adjacent to the diaphragm or
    closer than 2 cm)
    Negative AGDT

    Causes of Orthopnea
    By Kay Wagers, eHow Contributor
    A person may sleep more comfortably with her head elevated by several pillows. In some people this is a preference; in others it is an indication that they suffer from orthopnea. The causes of orthopnea can be physical or psychological.



    TheFacts
    Orthopnea is a breathing problem characterized by difficulty breathing while lying down. Most patients who experience orthopnea wake up short of breath during the night. Some patients experience shortness of breath so acutely they need to sleep propped up in a sitting position rather than lying in bed to keep their head elevated in order to breath deeply. Orthopnea can be caused by heart, lung and sleep apnea problems..................................................................................................Cardiac........................................Orthopnea may be related to cardiac conditions, including hypertensive heart disease and congestive heart failure. A patient with hypertensive heart disease has a weakened heart that is less capable of pumping blood throughout the body. When he lies down, blood volume is redistributed throughout the body, making it more challenging for the heart to pump blood away from the lungs. This can cause shortness of breath. A patient with congestive heart failure may have a similar experience when lying down and can also awaken breathless because of orthopnea.
    Lung
    Pulmonary problems can also cause orthopnea, including chronic obstructive pulmonary disease -- COPD. A patient with COPD often experiences swelling of and increase mucus levels in the main airways of the lungs. Pulmonary congestion like that is usually relieved when a patient hold his body erect in a standing or sitting position. When he lies down in bed at night to sleep, congestion worsens, leading to trouble breathing and possibly triggering orthopnea.
    Anxiety Disorder
    Some patients with anxiety disorders characterized by panic attacks can also experience orthopnea. Symptoms of a panic attack include chest pain, intense feelings of fear, and the sensation that you cannot catch your breath. If a panic attack is triggered at night while a patient is asleep, she may awaken unable to breathe and experiencing orthopnea.
    Sleep Apnea
    Some of the causes of sleep apnea can also cause orthopnea. In sleep apnea, a patient experiences episodes of stopped breathing during sleep, often lasting longer than 10 seconds. Causes can include nasal obstruction, a narrow airway in the throat and large tonsils. These may also lead to difficulty breathing normally while lying down.


    .....................soooo its reservoir function pulmonary vessels during failing heart causes orthopnea...not reservoir function of legvains.....comments wellcome..
  7. Guest

    Guest Guest

    Compartment syndromes

    Increased pain with passive stretch of the involved muscles is a consistent diagnostic indicator of a compartment syndrome. Pain out of proportion to the injury usually is the initial presenting symptom. Paresthesias follow, but at this point, irreversible myoneural injury has likely occurred. Foot drop also may be noted; the time of presentation varies with the compartment involved.

    •Anterior compartment syndrome

    ◦Clinical presentation of an acute anterior compartment syndrome includes pain with passive toe flexion, some weakness of toe extension, and diminished sensation in the first web space because of deep peroneal nerve compression.
    ◦The extensor hallucis longus usually is the first muscle to show weakness.
    ◦Anterior compartment syndrome may follow trauma to the extremity but also can be observed in march gangrene. Local erythema, heat, and brawny edema over the anterior compartment are present.
    ◦Regardless of the cause, wide fasciotomy of the anterior compartment must be performed to salvage the ischemic muscles.

    •Deep posterior compartment syndrome

    ◦An acute deep posterior compartment syndrome presents as pain and some weakness of toe flexion and ankle inversion. Pain on passive toe extension is referred to the calf.
    ◦Diminished sensation over the sole of the foot especially on the medial side is noted, resulting from posterior tibial nerve compression.
    ◦Foot drop develops because of ischemic contracture of the posterior compartment and is seen if the acute syndrome is not treated.
    ◦Once again, wide fasciotomy of the involved compartment is mandatory at the time of acute presentation.

    •Chronic compartment syndrome

    ◦This occurs in athletes in their third or fourth decade who have exercise-induced pain in the lower leg or foot within 20-30 minutes of beginning to exercise. Often, this occurs after a recent increase in intensity or duration of training or after a change in the training routine.
    ◦The symptoms resolve after 15-30 minutes of rest; however, as the syndrome progresses, pain occurs earlier and takes longer to resolve.
    ◦The anterior compartment is the most commonly involved.
    ◦Unless the patient has been exercising just before being examined, the physical examination may be nonspecific or normal.
    ◦Patients with a chronic anterior compartment syndrome may have diminished sensation in the first dorsal web space.
    ◦Recording of intracompartmental pressures before, during, and after exercise can provide useful diagnostic information as to which compartments may be involved. The following are believed to be indicative of the syndrome: a resting pressure of 15 mm Hg or more and/or a pressure of 30 mm Hg or more 1 minute post exercise and/or a pressure of 20 mm Hg or more 5 minutes post exercise. A slit catheter may be used to measure these pressures with the understanding that accuracy of the readings is influenced by depth of needle insertion; position of the leg, ankle, and foot; and force of muscle contraction.
    ◦Some preliminary investigation has been completed of MRI as a potential test for chronic compartment syndrome.
    ◦Nonsurgical treatment of a chronic compartment syndrome is only successful if the patient is willing to discontinue the inciting activity. The surgical treatment of choice is fasciotomy of the involved compartment.
  8. Guest

    Guest Guest

    Medial circumflex femoral arteryFrom Wikipedia, the free encyclopediaJump to: navigation, search
    Artery: Medial circumflex femoral artery

    The profunda femoris artery, femoral artery and their major branches - right thigh, anterior view. Circumflex femoral arteries labeled.
    Latin arteria circumflexa femoris medialis
    Gray's subject #157 630
    Supplies thigh
    Source deep femoral artery, femoral artery

    The medial circumflex femoral artery (internal circumflex artery, medial femoral circumflex artery) is an artery in the upper thigh that helps supply blood to the neck of the femur.

    Contents
    1 Structure
    1.1 Branches
    2 See also
    3 External links

    StructureThe medial femoral circumflex artery arises from the medial and posterior aspect of the profunda femoris artery, and winds around the medial side of the femur, passing first between the pectineus and iliopsoas muscles, and then between the obturator externus and the adductor brevis muscles.

    The medial femoral circumflex artery may occasionally arise directly from the femoral artery.

    BranchesAt the upper border of the adductor brevis it gives off two branches:

    The ascending branch
    The descending branch descends beneath the adductor brevis, to supply it and the adductor magnus; the continuation of the vessel passes backward and divides into superficial, deep, and acetabular branches.
    The superficial branch
    The deep branch
    The acetabular branch
    See alsoLateral femoral circumflex artery
    External linksDuke Orthopedics medial_femoral_circumflex_artery
    medial+circumflex+femoral+artery at eMedicine Dictionary
    SUNY Figs 12:04-06 - "Arteries of the lower extremity shown in association with major landmarks."
    This article was originally based on an entry from a public domain edition of Gray's Anatomy. As such, some of the information contained within it may be outdated.

    This cardiovascular system article is a stub. You can help Wikipedia by expanding it.v · d · e
    v · d · eList of arteries of lower limbs / EIA (TA A12.2.16, GA 6.623)

    Inferior epigastric cremasteric ♂ / round ligament ♀

    Deep circumflex iliac ascending branch of deep circumflex
  9. Guest

    Guest Guest

    251. Which of the following is not supplied by the anterior division of mandibular nerve (V3) ?
    A. Temporalis
    B. Medial pterygoid
    C. Lateral pterygoid
    D. Masseter
    Ans:B. Medial pterygoid
    Reference: Wikipedia(shall search for better references)
    Branches

    Branches from the main trunk (except nervus spinosus) and the posterior division.
    The mandibular nerve gives off the following branches:
     From the main trunk of the nerve (before the division)
     nervus spinosus (meningeal branch)
     medial pterygoid nerve
     nerve to tensor tympani
     nerve to tensor veli palatini
     From the anterior division
     masseteric nerve
     deep temporal nerves (anterior and posterior)
     buccal nerve (a sensory nerve)
     lateral pterygoid nerve
  10. Guest

    Guest Guest

    257. During TURP, surgeon takes care to dissect above the verumontenum so as to prevent injury to?
    A. External urethral sphincter
    B. Urethral crest
    C. Prostatic utricle
    D. trigone of bladder

    Ans:A. External urethral sphincter
    Reference: Reoperative Pelvic Surgery By Richard P. Billingham
    “The veru montanum serves as the landmanrk in TURP as the External urethral sphincter lies just distal to it.â€
    “It is crucial to limit resection from bladder neck to veru montanumâ€

    259. Baby born at 33 weeks / 1.5 kg should be started on?
    A. Nil oral and IV fluids
    B. Oral nasogastric tube/alternate oral route
    C. IV fluids and oral feeding
    D. TPN
    Ans:B. Oral nasogastric tube/alternate oral route
    Reference:Nelson textbook of Pediatrics
    The method of feeding each LBW infant should be individualized. It is important to avoid fatigue and aspiration of food by regurgitation or by the feeding process. No feeding method averts these problems unless the person feeding the infant has been well trained in the method. Oral feeding (nipple) should not be initiated or should be discontinued in infants with respiratory distress, hypoxia, circulatory insufficiency, excessive secretions, gagging, sepsis, central nervous system depression, severe immaturity, or signs of serious illness.
    These high-risk infants require parenteral nutrition or gavage feeding to supply calories, fluid, and electrolytes. The process of oral alimentation requires, in addition to a strong cramming effort, coordination of swallowing, epiglottal and uvular closure of the larynx and nasal passages, and normal esophageal motility, a synchronized process that is usually absent before 34 wk of gestation.
    Preterm infants at 34 wk of gestation or more can often be fed by bottle or at the breast. Because the effort of cramming is usually the limiting factor, breast-feeding is less likely to succeed until the infant matures. Bottle-feeding of expressed breast milk may be a temporary alternative. In bottle-feeding, effort may be reduced by use of special small, soft pages with large holes. Smaller or less vigorous infants should be fed by gavage: A soft plastic tube with No. 5 French external and approximately 0.05 cm internal diameters and with a rounded atraumatic tip and two holes on alternate sides is preferable. The tube is passed through the nose until approximately 2.5 cm (1 inch) of the lower end is in the stomach. The free end of the tube has an adapter into which the tip of a syringe is fitted, and a measured amount of fluid is given by pump or by gravity. Such tubes may be left in place for 3–7 days before being replaced by a similar tube through the alternate nostril. Infants occasionally have enough local irritation from an indwelling tube that they may gag or troublesome secretions may gather around it in the nasopharynx. In such cases, a catheter may be passed through the mouth by a skilled person and removed at the end of each feeding.
    The LBW infant may be fed with intermittent bolus feedings or continuous feeding. In the occasional infant with feeding intolerance, nasojejunal feeding may be successful. Intestinal perforation is a risk with nasojejunal feeding. A change to breast- or bottle-feeding may be instituted gradually as soon as an infant displays general vigor adequate for oral feeding without fatigue.
    Gastrostomy feeding is not usually indicated in premature infants except as an adjunct to surgical management of specific gastrointestinal conditions or in permanently neurologically injured patients unable to ^*&^* and swallow normally.
    Initiation of Feeding.
    The optimal time to introduce enteral feeding to a sick LBW infant is controversial. Trophic feeding is the practice of feeding very small amounts of enteral nourishment to VLBW preterm infants to stimulate development of the immature gastrointestinal tract. The benefits of trophic feeding include enhanced gut motility, improved growth, decreased need for parenteral nutrition, fewer episodes of sepsis, and shortened hospital stays. Once the infant is stable, small-volume feedings are given in addition to intravenous fluids/nutrition. Feeding is gradually advanced and parenteral nutrition decreased. This approach may reduce the incidence of necrotizing enterocolitis. The main principle in feeding premature infants is to proceed cautiously and gradually. Careful early feeding of breast milk or formula tends to reduce the risk of hypoglycemia, dehydration, and hyperbilirubinemia without the additional risk of aspiration, provided that the presence of respiratory distress or other disorders does not present an indication for withholding oral feedings and administering electrolytes, fluids, and calories intravenously.
    If an infant is well, is making cramming movements, and is in no distress, oral feeding may be attempted, although most infants weighing <1,500 g require tube feeding because they are unable to coordinate breathing, cramming , and swallowing. Intestinal tract readiness for feeding may be determined by active bowel sounds, passage of meconium, and the absence of abdominal distention, bilious gastric aspirates, or emesis. For infants under 1,000 g, the initial feedings are either half- or full-strength breast milk or preterm formula at 10 mL/kg/24 hr as a continuous nasogastric tube drip (or given by intermittent gavage every 2–3 hr). If the initial feeding is tolerated, the volume is increased by 10–15 mL/kg/24 hr. The daily milk volume increment should not exceed 20–30 mL/kg/24 hr. Once a volume of 150 mL/kg/24 hr has been achieved, the caloric content may be increased to 24 or 27 kcal/oz. With high caloric density, infants are at risk for dehydration, edema, lactose intolerance, diarrhea, flatus, and delayed gastric emptying with emesis. Intravenous fluids are needed until feedings provide approximately 120 mL/kg/24 hr. The feeding protocol for premature infants weighing over 1,500 g is initiated at a volume of 20–25 mL/kg/24 hr of full-strength breast milk or preterm formula given as a bolus every 3 hr. Thereafter, increments in total daily formula volume should not exceed 20 mL/kg/24 hr. The expected weight increments for premature infants of various birthweights are projected from Figure 97-6 . Infants with IUGR may not demonstrate the initial weight loss noted in premature infants.

    266.
    Rise in end tidal CO2 during thyroid surgery can be due to all except:
    A. Anaphylaxis
    B. Malignant hyperthermia
    C. Thyroid storm
    D. Neuroleptic malignant syndrome
    Ans:A. Anaphylaxis
    Reference:

    Conditions That Can Increase End-tidal
    Carbon Dioxide
    External causes
    Alcohol therapy for limb arteriovenous malformation
    Contrast dye
    Drug toxicity or abuse
    Environmental heat gain more than loss
    Exercise hyperthermia
    Heat stroke
    Ventilation problems (kinked or blocked endotracheal tube)
    Equipment malfunction (faulty expiratory valve)
    Treatment of acidosis
    Tourniquet release
    Neuroleptic malignant syndrome
    Carbon dioxide insufflation
    Disease related
    Cystinosis
    Hypokalemic periodic paralysis
    Intracranial free blood
    Muscular dystrophies (Duchenne, Becker)
    Central core disease
    Myotonias
    Diabetic coma
    Freeman-Sheldon syndrome
    Hyperthyroidism
    Osteogenesis imperfecta
    Pheochromocytoma
    Prader-Willi syndrome
    Rhabdomyolysis
    Sepsis
    King Denborough disease
    Wolf-Hirschhorn syndrome
    Idiopathic hyperCKemia
    Malignant hyperthermia
  11. Guest

    Guest Guest

    249.ECG is poor at detecting ischaemia in areas supplied by?
    A. Left anterior descending
    B. Left circumflex
    C. Left coronary artery
    D. Right coronary artery

    Posterior ischemia or an ischemia in the region of the left circumflex artery are often not visible on a normal standard 12 lead ECG

    Ans-Left circumflex

    250.Which of the following is a contraindication for medical treatment in gallstones?
    A. Radio opaque stones
    B. Radiolucent stones
    C. Normal functioning gall bladder
    D. Small stones

    Bile acids help dissolve gall stones by decreasing the levels of cholesterol available for stone formation
    But radio opaque stones contain calcium in addition to cholesterol – dissolution of which is not possible
    Hence, bile acid therapy is contraindicated in radio opaque gall stones

    ref-Diseases of the liver and biliary system By Sheila Sherlock, Sheila Sherlock (Dame.), James Dooley

    ans-radio opaque stones

    251. Which of the following is not supplied by the anterior division of mandibular nerve (V3) ?
    A. Temporalis
    B. Medial pterygoid
    C. Lateral pterygoid
    D. Masseter
    Ans:B. Medial pterygoid
    Reference: Wikipedia(shall search for better references)

    Branches from the main trunk (except nervus spinosus) and the posterior division.
    The mandibular nerve gives off the following branches:
    From the main trunk of the nerve (before the division)
    nervus spinosus (meningeal branch)
    medial pterygoid nerve
    nerve to tensor tympani
    nerve to tensor veli palatini

    From the anterior division
    masseteric nerve
    deep temporal nerves (anterior and posterior)
    buccal nerve (a sensory nerve)
    lateral pterygoid nerve

    252. Drugs used in prophylaxis of migraine are all except?
    A. Propranolol
    B. Flunarizine
    C. Topiramate
    D. Levetiracetam
    Ans:D. Levetiracetam

    253.Most effective microbial killing system
    A.Reactive oxygen species
    B.Lysozymes
    C.Defensin
    D.Lactoferrin
    Ans:A.Reactive oxygen species

    254. Slide fixing in pathology most commonly done by
    A.formaldehyde
    B.alcohol
    C.picric acid
    D.glutraldehyde
    Ans:A.formaldehyde

    Reference: A Manual of Histology, General Anatomy, Embryology & Genetics
    “Formaldehyde is the most widely used fixative”

    255. Ophtalmoplegic migraine..
    A.Headache with reversible lose of ophthalmic nerve function
    B.Recurrent transient 3rd nerve palsy after headache
    C.
    D.
    Ans:B.Recurrent transient 3rd nerve palsy after headache (REPEAT)

    256. Patient having pain in epigastrium which radiates to back, serum amylase is normal, on x ray gall stone seen and pancrease appeares bulky..
    A.Acute Pancreatitis
    B.Acute cholecyctitis
    C.Duodenal ulcer
    D.
    Ans:A.Acute Pancreatitis

    257. During TURP, surgeon takes care to dissect above the verumontenum so as to prevent injury to?
    A. External urethral sphincter
    B. Urethral crest
    C. Prostatic utricle
    D. trigone of bladder
    Ans:A. External urethral sphincter
    Reference: Reoperative Pelvic Surgery By Richard P. Billingham
    “The veru montanum serves as the landmanrk in TURP as the External urethral sphincter lies just distal to it.”
    “It is crucial to limit resection from bladder neck to veru montanum”

    bailey and love..25th edition
    Strips of tissue are cut from the bladder neck down to the level
    of the verumontanum (Fig. 73.13). Cutting is performed by a
    high-frequency diathermy current, which is applied across a loop
    mounted on the hand-held trigger of the resectoscope.
    Coagulation of bleeding points can be accurately achieved, and
    damage to the external sphincter is avoided provided one uses
    the verumontanum as a guide to the most distal point of the
    resection.

    258. Which organ obtained from a cadaver is not used for transplantation?
    A. Blood vessel
    B. Lung
    C. Liver
    D. Bladder
    Ans:D. Bladder

    259. Baby born at 33 weeks / 1.5 kg should be started on?
    A. Nil oral and IV fluids
    B. Oral nasogastric tube/alternate oral route
    C. IV fluids and oral feeding
    D. TPN
    Ans:B. Oral nasogastric tube/alternate oral route
    Reference:Nelson textbook of Pediatrics

    260.Which of the following drug is not used for medical treatment of diabetic retinopathy?
    A.Tamoxifen
    B. --
    C. --
    D. --
    Ans:A.Tamoxifen

    261.Patient prestent with high TSH, low T4, what is the diagnosis?
    A.Grave's disease
    B.Hashimoto's disease
    C.Pituitary failure
    D.Hypothalamic failure

    Ans:B.Hashimoto's disease (ruling out the others)

    262.Pastient present with epigastric pain which radiates to the back and relieved by food, patient have history of such pain in past for which he was taking analgesics and in past 5 years 2 times operated for duodenal ulcer. What is the diagnosis
    A. Gastric ulcer
    B. Dudenal ulcer
    C. Chronic pancreatitis
    D.
    Ans:Duodenal Ulcer(??references)

    263. All are factors responsible for resurgence of malaria except?
    A. Drug resistance
    B. Use of bed nets
    C. Vector resistance
    D. Mutation in parasite
    Ans:B. Use of bed nets (modified REPEAT)

    264. What is false about lipoproteins.
    A.HDL inhibit oxidation of LDL
    B.Oxidize LDL not present in foam cells
    C.
    D.
    Ans:B.Oxidize LDL not present in foam cells

    265. 1yr old child present with growth failure,dry skin and palpable thyroid,with low thyroid harmones and a high TSH, what is cause?
    A.Dysharmonogenesis
    B.Dysgenesis
    C. Central Hypothyroidism
    D. TSH Receptor mutation(?)
    Ans:A Dysharmonogenesis(ruling out options)

    266.Rise in end tidal CO2 during thyroid surgery can be due to all except:
    A. Anaphylaxis
    B. Malignant hyperthermia
    C. Thyroid storm
    D. Neuroleptic malignant syndrome
    Ans:A. Anaphylaxis
    Reference:

    Conditions That Can Increase End-tidal
    Carbon Dioxide
    External causes
    Alcohol therapy for limb arteriovenous malformation
    Contrast dye
    Drug toxicity or abuse
    Environmental heat gain more than loss
    Exercise hyperthermia
    Heat stroke
    Ventilation problems (kinked or blocked endotracheal tube)
    Equipment malfunction (faulty expiratory valve)
    Neuroleptic malignant syndrome
    Carbon dioxide insufflation
    Diabetic coma
    Hyperthyroidism
    Pheochromocytoma
    Rhabdomyolysis
    Sepsis
    Malignant hyperthermia

    267. All are true except:
    A. Human anatomical waste is disposed in a yellow bag
    B. Red bag contents can be a source of contamination
    C. Black bag is used for incineration ash
    D. Blue bag contents are always disposed in secure landfill
    Ans:D. Blue bag contents are always disposed in secure landfill

    268.Which among the following is preferred in a patient with decreased renal functio to avoid contrast nephropathy?
    A. N acetylcysteine
    B. Fenoldopam
    C. Low osmolar contrast
    D. Mannitol
    Ans: A and C

    269. Which of the following is true?
    A. Acetylcholinesterase inhibition by malathion can be reversed by increasing the level of atropine
    B. Sulphonilamide inhibits folate reductase irrevesibly
    C. Flouoroacetate competetively inhibits aconitase
    D. Ethanol inhibits aldehyde dehydrogenase when used in methanol poisoning
    Ans:C. Flouoroacetate competetively inhibits aconitase???

    270. Small air way has laminar flow because?
    A. Reynold number more than 2000
    B. Diameter is very small
    C. Extremely low velocities
    D. Total cross sectional area low
    Ans: C. Extremely low velocities
    Reference: Essentials of Pathophysiology: Concepts of Altered Health States
    By Carol Mattson Porth, Glenn Matfin
  12. Guest

    Guest Guest

    226. Muscular component of dorsal aorta develops from?
    A. Axial mesoderm
    B. Paraxial mesoderm
    C. Intermediate mesoderm
    D. Lateral plate mesoderm

    According to this research,ans is paraxial mesoderm.Can't post the link.


    Smooth muscle of the dorsal aorta shares a common clonal origin with skeletal muscle of the myotome.

    We show that cells of the dorsal aorta, an early blood vessel, and of the myotome, the first skeletal muscle to form within the somite, derive from a common progenitor in the mouse embryo. This conclusion is based on a retrospective clonal analysis, using a nlaacZ reporter targeted to the alpha-cardiac actin gene. A rare intragenic recombination event results in a functional nlacZ sequence, giving rise to clones of beta-galactosidase-positive cells. Periendothelial and vascular smooth muscle cells of the dorsal aorta are the main cell types labelled, demonstrating that these are clonally related to the paraxial mesoderm-derived cells of skeletal muscle.
  13. Guest

    Guest Guest

    271. A neonate delivered at 38 weeks of gestation, birth weight of 2.2kg develops intolerance to feeds on 2nd day. Physical examination reveals no abnormalities. Sepsis screen in negative. And PCV is 70% What is the next step in management? (corrected by dr_sid4u)
    A. IV fluid
    B. Presumptive trearment of sepsis
    C. Exchange transfusion
    D. Repeat sepsis screen
    Ans:C Exchange transfusion
    Management of polycythemia is dependent upon two factors (Figure):
    1. Presence of symptoms suggestive of polycythemia and/or
    2. Absolute value of hematocrit
    (a) Symptomatic polycythemia
    The definitive treatment for polycythemia is to perform a partial exchange transfusion (PET). PET involves removing some of the blood volume and replacing it with fluids so as to decrease the hematocrit to a target packed cell volume of 55%.
  14. Guest

    Guest Guest

    CORRECTION:

    237. All are true about blood coagulation except?
    A. Factor 10 in a part of both intrinsic and extrinsic pathway
    B. Extrinsic pathway is activated by contact with plasma and negatively charged proteins
    C. Calcium is very important for coagulation
    D. Intrinsic pathway can be activated in vitro

    Ans: B. Extrinsic pathway is activated by contact with plasma and negatively charged proteins

    Reference:Robbins pathology 8th ed
    Clinical laboratories assess the function of the two arms of the coagulation pathway through two standard assays: prothrombin time (PT) and partial thromboplastin time (PTT). The PT assay assesses the function of the proteins in the extrinsic pathway (factors VII, X, II, V, and fibrinogen). This is accomplished by adding tissue factor and phospholipids to citrated plasma (sodium citrate chelates calcium and prevents spontaneous clotting). Coagulation is initiated by the addition of exogenous calcium and the time for a fibrin clot to form is recorded. The partial thromboplastin time (PTT) screens for the function of the proteins in the intrinsic pathway (factors XII, XI, IX, VIII, X, V, II, and fibrinogen). In this assay, clotting is initiated through the addition of negative charged particles (e.g., ground glass), which you will recall activates factor XII (Hageman factor), phospholipids, and calcium, and the time to fibrin clot formation is recorded.
  15. Guest

    Guest Guest

    answer for asymptomatic uncomplicated cystitis--latest guidelines
    Acute uncomplicated lower urinary tract infections (cystitis) in premenopausal, non pregnant womenThe most common cause of acute uncomplicated lower urinary tract infections (cystitis) in pre-menopausal, non pregnant women is E.coli (80% of cases). Staphylococcus saprophyticus is also recognized as a primary uropathogen in young women (5-10% of UTI in this population).32, 33 In Croatia, the incidence of S.
    Creatinine Clearance Dose (gentamicin, tobramycin)
    40-60 ml/min 1.2 - 1.5 mg/kg/dose IV q12h
    20-40 ml/min 1.2-1.5 mg/kg/dose IV q12-24h
    <20 ml/min 2 mg/kg loading dose

    saprophyticus is low (less than 5%).34 Other microorganisms (other enterobacteriaceae, enterococci) usually cause infection in the presence of underlying conditions.
    In women with clear symptoms of uncomplicated cystitis, ≥ 103 cfu/mL of uropathogens in midstream urine (MSU) is thought to be the best cut off for significant bacteriuria with sensitivity of approx. 80% and specificity of approx. 90%.5, 36, 37 (IV, C) In case the UTI symptoms are not clear it should be kept in mind that a low bacterial count (103 cfu/mL) is frequently found in healthy women as a consequence of urine contamination during voiding.
    Urine culture should not be performed in young women with sporadic uncomplicated cystitis as the causative agent is highly predictable.2, 3, 5, 6, 23 (IV, C) If the patient does not improve while on empirical therapy, a urine sample should be taken for culture.
    The diagnosis should be based on characteristic symptoms (described in table 3) and a dipstick test finding. According to literature, a positive nitrite test and/or leukocyte esterase test indicate the presence of an infection.38 (Ia). Therefore, the WG recommends the use of both - dipstick tests for leukocyte esterase as well as nitrite test (A).
    Although leukocyturia speaks in favor of infection diagnosis, positive finding does not always confirm infection, nor the lack of it rules it out.39 In laboratory practice, leukocyturia is detected most commonly through the detection of leukocytes in large visible urine sediment (magnification 10x40), where the finding od 5-10 leukocytes in large visible sediment is considered the upper limit of normal finding in urine of healthy individuals.40 By using this method for the detection of leukocyturia, a large number of patients with significant bacteriuria will have a negative finding, therefeore this method is considered not sensitive enough. The method of leukocyte counting in noncentrifuged urine is considered more sensitive, where the number of >10 leukocytes/mm3 presents a pathological finding.15 The simplest method for the detection of leukocyturia is the detection of leukocyte esterase. Leukocyte esterase test has a high sensitivity and specificity if performed in symptomatic patients (75- 96% sensitivity, 94-98% specificity).36, 37 Although the probability of UTI is reduced to a less than 20% by a negative dipstick test, UTI cannot be excluded in symptomatic women38, so clinical judgement should be used to decide whether to obtain urine for
    culture or invite the patient to a control visit, if symptoms persist or worsen. Increased number of leukocytes in urine is usually a sign of urinary tract infection, however it can also reflect some other factors such as the presence of a catheter, stones, vulvovaginitis, erosion of vaginal and cervical mucosa or dehydration. In such cases further investigation of sexually transmitted diseases or gynecological pathology should be indicated.
    The UTI WG has decided to use nitrofurantoin as the first choice therapy for acute uncomplicated lower urinary tract infections (cystitis) in pre-menopausal, non pregnant women since E.coli is still highly susceptible to this agent (97% in Croatia), the resistance to this agent seems to be developing slowly after many years of its clinical use13, its affordable price and low toxicity. There have been concerns about the toxicity of nitrofurantoin, acute and chronic pulmonary disease in particular. The incidence of these side effects seems to be low based on literature and personal experience of the members of the working group. Symptoms are reversible after the discontinuation of the drug. However, attention should be paid not to miss the symptoms of side effects and the drug should be stopped if they appear.
    The WG recommends nitrofrantoin to be administered twice daily because of drug efficacy and better patient compliance.
    Nitrofurantoin should be used for 7 days as there is no good evidence that shorter therapy is as effective. (IIb, B)
    There is no good evidence that shorter therapy is as effective as a 7-day therapy with co-amoxiclav, so the WG has accepted the general 7-day treatment for beta-lactam therapy for this indication.47, 48, 49, 50 (Ib, A)
    At present, the resistance of E.coli to fluoroquinolones in Croatia is 10% and fluoroquinolones should be saved for more serious infections.13 If used for uncomplicated cystitis norfloxacin should be used for no longer than 3 days, as this therapy is proved to be as effective as a 7-day therapy. Longer therapy is more likely to select resistance in a normal flora and therefore should be avoided.51, 52, 53, 54 (Ia, A)
    The resistance rates of E. coli to most commonly used antibiotics for the treatment of UTI in the period from 2001 to 2006 are shown in Table 4.2.
    Table 4.2. The resistance of E. coli to most common antibitiotics in Croatia in the period from 2002-200613
    Resistant Antibiotic (intermediate) %
    2002 2003 2004 2005 2006
    nitrofurantoin 4 (1) 3 (1) 3 (1) 3 (1) 2 (1)
    TMP/SMX 25 (0) 22
  16. Guest

    Guest Guest

    Surgical Therapy

    Surgical therapy in chronic pancreatitis is most commonly considered for intractable abdominal pain for which medical therapy has failed. Other indications for surgery in these patients are complications involving adjacent organs or structures (duodenal, splenic venous, or biliary complications), failure of endoscopic or radiologic management for pseudocysts, internal pancreatic fistulas, and exclusion of malignancy despite an extensive evaluation. The surgical approaches for these complications of chronic pancreatitis are discussed later. Surgical options for pain are pancreatic ductal drainage, resection of all or part of the pancreas, and both. The choice of surgical procedure depends in large part on the ductal anatomy, presumed pathogenesis of pain, and associated complications as well as local surgical preferences and expertise.[282-285]

    Ductal drainage procedures are the least technically demanding and preserve the most pancreatic parenchyma. The rationale for these procedures is to relieve ductal obstruction and reduce pancreatic pressures, thereby relieving pain. Pancreatic ductal drainage procedures generally require dilation of the pancreatic duct to more than 6 to 7 mm, a diameter that allows relatively easy identification and anastomosis. This operation is therefore considered in patients with big-duct chronic pancreatitis. The most commonly performed procedure is the lateral pancreaticojejunostomy or Partington-Rochelle modification of the Puestow procedure. In this procedure the pancreatic duct is opened longitudinally and anastomosed to a defunctionalized limb of small bowel, which is connected with a Roux-en-Y anastomosis. This limb also can be used to decompress any coexisting pseudocysts. At the time of the operation, ductal strictures can be incised and stones present can be readily removed as needed. The procedure also can be performed in the absence of a dilated pancreatic duct (normal duct Puestow procedure), but the efficacy for relieving pain is believed to be less. The procedure can be performed laparoscopically, although experience with this technique is limited. The operative mortality for a modified Puestow procedure is extremely low.[284-286]

    No randomized trials comparing a modified Puestow procedure with other surgical therapies have been conducted. Immediate pain relief is seen in approximately 80% of patients.[282-286] With long-term follow-up, only half continue to experience pain relief. The explanation for this decline in effectiveness is unknown but may reflect closure of the anastomosis, pain originating in the undrained segments of the head of the pancreas, or the development of other sources of pain (neural inflammation, central nervous system sensitization, duodenal or bile duct obstruction, etc.). There is thus a tradeoff between the simplicity and low risk of this procedure and the gradual deterioration of results over time. Exocrine and endocrine functions are generally unaffected by this surgical procedure per se but appear to continue to deteriorate as in unoperated patients.

    In an attempt to overcome the modest early and substantial late failure rates of simple drainage procedures, approaches combining resection of the pancreas with drainage of the pancreatic duct have been developed. These have focused particularly on the head of the pancreas because this is felt to be the pacemaker of the disease by many surgeons. A routine longitudinal pancreaticojejunostomy does not completely decompress the ducts in the head of the gland, the duct of Santorini, and the small ducts draining the uncinate process. Some patients may have an associated inflammatory mass of the head of the pancreas, making drainage of the pancreatic duct within the head of the pancreas more difficult. Options to deal with this problem include resection of the head of the pancreas (pancreaticoduodenectomy [Whipple operation], duodenum-preserving Whipple operation, or duodenum-preserving pancreatic head resections) and combinations of ductal drainage with local resection of all or part of the pancreatic head. It should be noted that improved pain relief after these surgical procedures involving pancreatic resection may be partially explained by the denervation of visceral pancreatic afferent nerves during more extensive dissection rather than better drainage of the pancreatic ducts in the head of the pancreas.

    Whipple resection or duodenum-preserving Whipple resection produces pain relief in 65% to 95% of patients.[282-286] Whipple operations are generally considered in patients with disease limited to the head of the pancreas, particularly those with a large inflammatory mass of the pancreas in whom malignancy is also being considered. Associated biliary or duodenal obstruction, seen more commonly in these patients with inflammatory masses of the head of the pancreas, can also be treated at the time of the resection. These operations have higher morbidity and mortality than simple ductal drainage operations. Although the mortality in high-volume centers is less than 3%, early postoperative complications (primarily disruptions of normal motility and pancreatic duct leaks) can occur in up to half of cases.[286] Surgical mortality is significantly higher if the inflammatory mass occludes or compresses major arteries or veins.[287,288]

    Three procedures have been developed to resect all or part of the head of the pancreas without the disruptions of gastrointestinal (GI) physiology seen with traditional Whipple operations and to limit the amount of pancreatic tissue removed, hopefully better preserving exocrine and endocrine function. The duodenum-preserving pancreatic head resection (DPPHR), developed by Beger, is performed by resecting the pancreatic head but sparing the duodenum, and covering the site with a defunctionalized Roux-en-Y jejunal limb to allow drainage of pancreatic and biliary secretions.[285,289] Modifications of this procedure were subsequently developed to avoid dissecting around the portal and superior mesenteric veins (and the associated bleeding risk) and to limit the amount of pancreatic tissue (in particular islet cells) that is removed. In one modification, developed by Frey, less of the head of the pancreas is cored out, leaving the bile duct and peripancreatic vessels undisturbed.[285,290] This approach is coupled with a longitudinal incision of the pancreatic duct in the body and tail of the pancreas and the overlaying of a long jejunal anastomosis covering both the opened duct and the cored-out head. A third operation, termed the Berne procedure, uses a pancreatic head resection without longitudinal duct incision, but leaves a narrow layer of pancreatic tissue against the duodenum and retropancreatic vessels.[287,291]

    There have been four randomized trials comparing one of the Whipple operations with DPPHR (either the Frey or Beger procedure).[285,292-294] In short-term follow-up, these procedures appear to have equivalent efficacy in relieving pain, with more diabetes seen in those undergoing Whipple procedures. In long-term follow-up this advantage of a DPPHR is lost.[294] Randomized trials comparing the Beger with the Frey operations show similar rates of postoperative complications, efficacy, and long-term quality of life.[285,293] Postoperative complications are more common than with a simple modified Puestow procedure, but both short- and long-term pain relief is superior. In the United States not many surgeons are trained in these variations of DPPHR, and the modified Puestow is done most commonly.

    More substantial pancreatic resection is rarely performed. In some patients with disease limited to the body and tail of the pancreas, typically after trauma to the pancreatic duct in the body of the pancreas with upstream obstructive chronic pancreatitis, resection of the body and tail may be considered. In patients with a nondilated pancreatic duct, a small V-shaped excision can be performed on the ventral surface of the pancreas over the pancreatic duct with an overlying pancreaticojejunostomy (similar to a modified Puestow operation) with acceptable results.[295] Total or near-total pancreatectomy has been only rarely performed in the past owing to unacceptable complications of severe brittle diabetes. Later studies using concomitant islet cell autotransplantation note insulin independence overall in about 40% of patients, with pain relief in 80% to 90% of patients. The risk of postoperative diabetes is dependent on the yield of islet cells at the time of the pancreatectomy. Islet yields are reduced in those patients with previous pancreatic surgery.[296,297] At the moment, total pancreatectomy should be regarded as a salvage operation for a small number of patients with overwhelming pain in whom all other options have failed.

    The complications occurring after surgery for chronic pancreatitis vary with the operation chosen. They include pancreatic fistula, wound infection, delayed gastric emptying, intra-abdominal abscess, pancreatitis, cholangitis, and bile leak.[282-286] The preoperative and perioperative uses of octreotide may reduce the risk of these postoperative complications, particularly pancreatic fistula.

    In the evaluation of patients who have undergone surgery for chronic pancreatitis, it is important to remember that exocrine insufficiency and endocrine insufficiency can develop as a consequence of the surgery as well as the ongoing disease process. Exocrine insufficiency in particular may escape detection because symptoms may be mild. Steatorrhea can develop in 30% to 40% of patients undergoing simple drainage procedures and in up to two thirds of those undergoing pancreatic resections.[282-286] The use of pancreatic enzyme supplements after pancreatic surgery leads to better absorption of nutrients and should be considered for most (or all) patients after surgery for chronic pancreatitis. The development of endocrine insufficiency after pancreatic surgery is also common but not invariable, and some series have even noted improvements in glucose tolerance in some patients after surgery. In general, however, diabetes mellitus still commonly occurs after surgery either as a consequence of pancreatic resection or from the ongoing ravages of the disease.
  17. Guest

    Guest Guest

    284. All are true regarding phagocytosis by protozoa except?
    A. Amoeba n other unicellular org make their living out of it
    B. Phagocytose particles of <0. 5 microns size
    C. Phagocytose particles of > 0.5 microns size
    D. Digestion occurs within phagolysosomes

    Here's a study acc to which answer is

    Phagocytose particles of > 0.5 microns size

    Don't know if this can be applied to the above question.

    Role of Particle Size in Phagocytosis of Polymeric Microspheres

    # Author:
    # Julie Champion 1
    # Amanda Walker 1
    # Samir Mitragotri

    Results

    Particles possessing diameters of 2–3 μm exhibited maximal phagocytosis and attachment. Rate of internalization, however, was not affected significantly by particle size. Maximal attachment of 2–3 μm microspheres is hypothesized to originate from the characteristic features of membrane ruffles in macrophages. Elimination of ruffles via osmotic swelling nearly eliminated the peculiar size-dependence of phagocytosis. A simple mathematical model is presented to describe the dependence of phagocytosis on particle size.
  18. Guest

    Guest Guest

    Depending on particle size, uptake may be subdivided in phagocytosis (all sizes) or pinocytosis (particles o150 nm) [52,55]. Large particles will be only removed by cells capable of phagocytosis, whereas smaller particles can be removed by all types of cells through pinocytosis (all cells are capable of pinocytosis). Phagocytotic activity increases with size of particles

    macrophages may ingest up to ~25% of their volume per hour [526]. For macrophages ranging from 25-30 microns in diameter [2844], these numbers imply a maximum particle-wrapping phagosomal membrane recycling rate of 1.1-4.4 micron2/sec and a maximum volumetric ingestion rate of 0.6-4.6 micron3/sec, which in turn suggests a theoretical maximum particle phagocytosis rate of one ~1-micron3 particle per second, per macrophage.

    The presence and activity of phagocytes is particularly related to the presence of small particles. For example, 0.325-micron PMMA particles stimulate cytokine release in vitro by human macrophages at concentrations exceeding 1010-1011 particles/cm3 [2864]. Maximum stimulus occurs at average particle sizes in the 0.1-2.0 micron range [234, 2865-2868], though phagocytosis is often said primarily to involve the uptake of particles >0.5 micron in size

    MacropinocytosisIt is a type of clathrin and caveolae independent endocytosis, occurring in many cells, including macrophages [39]. This also similar to that of phagocytosis by the protusions in the membrane driven by actin. But the difference is that the protusions do not zipper up along the ligand-coated particle, instead, they simply melt from the membrane to form vesicles termed as macropinosomes, which sample the extracellular milieu and having the size around 0.5-10 μm. The intracellular fate of macropinosomes varies depending on the cell type, but in most cases, they acidify and shrink. This endocytic pathway does not seem to display any selectivity, but is involved, among others, in the uptake of drug nanocarriers.

    Pinocytosis Endocytic mechanism for the cellular uptake of fluids and solutes, which is further subcategorized into macropinocytosis (endocytic vesicle (EV) size >1 μm); clathrin-mediated endocytosis (EV size 120nm); caveolin-mediated endocytosis (EV size ~60 nm) and clathrin- and caveolin-independentendocytosis (EV size ~90 nm); only acropinocytosis is actin-dependent, the three other pathways are actin-independent.
  19. Guest

    Guest Guest

    Deficiency---------->
    disease
    a-glucosidase-->gauchers
    a-1,4 glucosidase aka acid maltase-->pompes

    a-galactosidase-->f
    abry
    b-galactosidase-->morquio B
    b-galactosyl ceramidase aka b-galactosidase-->krabbes

    aryl sulfatase A-->metachromatic leukodystrophy
    aryl sulfatase B-->maroteau lamy

    ceramidase-->Farbers

    hexosaminidaseA-->tay sach
    hexosaminidaseA,B-->sandhoffs
  20. Guest

    Guest Guest

    Role of Helical CT in Diagnosis of Gallstone Ileus and Related Conditions
    Francesco Lassandro1, Stefania Romano1, Alfonso Ragozzino1, Giovanni Rossi2, Tullio Valente2, Ilaria Ferrara3, Lugia Romano1 and Roberto Grassi3

    Results

    Intestinal obstructions were detected in 32 patients, pneumobilia in 35, and air in the gallbladder in six (Fig. 1). In five patients, direct visualization of a biliary–enteric fistula was noted (Figs. 2A, 2B, 2C and 3A, 3B, 3C, 3D, 3E) (Table 1). In 35 patients, correct location of the stone was made at the first report; in five patients with partially calcified stone (12.5%), a retrospective review of the imaging findings (bulging of the intestinal loop or endoluminal calcifications) suggested their locations. In five patients, multiple endoluminal stones were detected (Fig. 2A, 2B, 2C). In eight patients, the evidence of pneumobilia and ectopic intestinal stones in the small bowel was not associated with findings of mechanical ileus. One patient (2.5%) had previously undergone cholecystectomy. Three cases of recurrence of gallstone ileus were noted in patients who previously underwent enterolithotomy without cholecystectomy. Diameter of the stones varied from 0.6 to 3.5 cm; the smallest impacted stone had a maximum diameter of 2.5 cm and the largest, 3.5 cm. In patients with no evidence of intestinal obstruction, the smallest stone size was 0.8 x 0.6 cm and the largest was 2.0 x 1.8 x 2.6 cm[/size]. In all patients at least two dimensions of the calculi were listed; in some patients the third dimension was difficult to see because of a partially calcified calculus or the presence of artifacts from patient movement. However, in 18 patients in whom MDCT was performed, three dimensions were obtained (Table 1).
  21. Guest

    Guest Guest

    Management of intra-tracheal fires
    Ignition of the tracheal tube and explosions, in
    addition to unintended facial burns, are the most
    common complications of the use of the CO2 laser
    [26, 32]. The paucity of reports of tracheal tube
    fires in conjunction with the use of the Nd-YAG
    laser may stem, in part, from different application
    techniques [19]. For an explosion to occur, there
    must be a source of ignition (the laser beam), a
    source of combustion (for example an elastomeric
    tracheal tube or cottonoids) and a medium which
    supports combustion (such as oxygen or nitrous
    oxide). A laser-ignited explosion may lead to
    serious injury to the patient and the experience
    can devastate the operating room team [74].
    A laser ignited explosion can cause a thermal
    and chemical injury. Thermal injury results from
    direct exposure to the flame. The severity of the
    burn depends on the duration of exposure and the
    heat intensity. The subglottic region, the epiglottis, the base of the tongue and the oropharynx
    are most likely to be affected. The flame may
    extend the length of the laryngoscope to burn the
    lips and face of the patient. Thermal injury can
    also result from heating of the tracheal tube, while
    burning tissue can be blasted into the distal
    airways. Inhalation of smoke may produce a
    chemical burn. Bronchospasm, intra-alveolar
    haemorrhage, oedema, and loss of surfactant may
    occur and lead to respiratory failure. Hydrogen
    chloride, a pulmonary toxin which produces a
    severe pneumonitis, is released when polyvinylchloride tubes burn [20, 99], while carbon
    monoxide is a decomposition product of burning Management of intra-tracheal fires
    Ignition of the tracheal tube and explosions, in
    addition to unintended facial burns, are the most
    common complications of the use of the CO2 laser
    [26, 32]. The paucity of reports of tracheal tube
    fires in conjunction with the use of the Nd-YAG
    laser may stem, in part, from different application
    techniques [19]. For an explosion to occur, there
    must be a source of ignition (the laser beam), a
    source of combustion (for example an elastomeric
    tracheal tube or cottonoids) and a medium which
    supports combustion (such as oxygen or nitrous
    oxide). A laser-ignited explosion may lead to
    serious injury to the patient and the experience
    can devastate the operating room team [74].
    A laser ignited explosion can cause a thermal
    and chemical injury. Thermal injury results from
    direct exposure to the flame. The severity of the
    burn depends on the duration of exposure and the
    heat intensity. The subglottic region, the epiglottis, the base of the tongue and the oropharynx
    are most likely to be affected. The flame may
    extend the length of the laryngoscope to burn the
    lips and face of the patient. Thermal injury can
    also result from heating of the tracheal tube, while
    burning tissue can be blasted into the distal
    airways. Inhalation of smoke may produce a
    chemical burn. Bronchospasm, intra-alveolar
    haemorrhage, oedema, and loss of surfactant may
    occur and lead to respiratory failure. Hydrogen
    chloride, a pulmonary toxin which produces a
    severe pneumonitis, is released when polyvinylchloride tubes burn [20, 99], while carbon
    monoxide is a decomposition product of burning rubber.

    The anaesthetic and surgical team should be
    well rehearsed in the management of sudden fire
    and appropriate equipment should be immediately available. Initially, the source of oxygen
    and nitrous oxide should be disconnected, the
    tracheal tube removed rapidly and the area flushed
    liberally with sterile water or normal saline. A
    new tracheal tube should be inserted and ventilation resumed with 100% oxygen as indicated
    clinically. This assumes that intubation is easy; if
    this is not the case, a long stylet can be passed
    through the existing tube before removing it in
    order to facilitate the passage of a new one. When
    the fire is extinguished and the airway secured,
    rigid bronchoscopy with a ventilating bronchoscope can be performed. The extent of injury
    can then be assessed, foreign bodies (pieces of
    tube, aluminium foil, pledgets) removed, and the
    large airways washed to remove carbonaceous
    deposit. Subsequent management depends on the
    severity of the burn. The decision to extubate the
    trachea depends on clinical judgement.
    Humidification of inspired gases is essential
    and a 24-h course of high dose steroids—methylprednisolone 5-7 mg kg"
    1
    or dexamethasone
    1-1.5 mg kg"
    1—is recommended, although their
    efficacy has not been proven [30]. It may be
    appropriate to administer a course of antibiotics.
    Recovery can be monitored by flexible or rigid
    bronchoscopy and this helps to determine the
    optimal time for extubation. Supportive measures,
    such as intermittent positive pressure ventilation
    and monitoring of pulmonary artery pressures,
    cardiac output and oxygenation (pulse oximetry),
    may be necessary. Tracheotomy may also be
    required.
  22. Guest

    Guest Guest

    The anaesthetic and surgical team should be
    well rehearsed in the management of sudden fire
    and appropriate equipment should be immediately available. Initially, the source of oxygen
    and nitrous oxide should be disconnected, the
    tracheal tube removed rapidly and the area flushed
    liberally with sterile water or normal saline. A
    new tracheal tube should be inserted and ventilation resumed with 100% oxygen as indicated
    clinically. This assumes that intubation is easy; if
    this is not the case, a long stylet can be passed
    through the existing tube before removing it in
    order to facilitate the passage of a new one. When
    the fire is extinguished and the airway secured,
    rigid bronchoscopy with a ventilating bronchoscope can be performed. The extent of injury
    can then be assessed, foreign bodies (pieces of
    tube, aluminium foil, pledgets) removed, and the
    large airways washed to remove carbonaceous
    deposit. Subsequent management depends on the
    severity of the burn. The decision to extubate the
    trachea depends on clinical judgement.
    Humidification of inspired gases is essential
    and a 24-h course of high dose steroids—methylprednisolone 5-7 mg kg"
    1
    or dexamethasone
    1-1.5 mg kg"
    1—is recommended, although their
    efficacy has not been proven. It may be

    All options seems right........but one thing odd was flodding of nasopharynx with sterile water.....
    i) is flushing and flodding are same or diff
    ii) if different...could flodding of nasopharynx be ans
    iii)if both are same what could be probable ans
  23. Guest

    Guest Guest

    With the availability of CT and its increasing use in the
    investigation of the acute abdomen, CT will be performed
    in some patients with gall stone ileus, and radiologists
    should be aware of the CT findings in gall stone ileus so
    that a prompt diagnosis is made. With its high contrast
    resolution, it is not surprising that CT can detect the three
    components of Rigler’s triad. HAVRILLAet al. (3) have confirmed
    the ability of CT to detect gall stones not visible on
    the conventional radiograph, and detection of pneumobilia
    by CT has also been reported (6). In our case, the conventional
    abdominal radiograph showed only small bowel obstruction,
    and CT provided the diagnosis of gall stone ileus
    by demonstrating the impacted gall stone and small bowel
    obstruction
  24. Guest

    Guest Guest

    Not a part of national screening program?
    A. Diabetes mellitus
    B. Dental caries
    C. Refractive error
    D. Carcinoma cervix
    ans-d


    Currently,
    cervical cytology is widely regarded as the gold standard for
    cervical cancer screening in all developed countries. It is
    however not feasible to implement a systematic cytology based
    screening programme in a country like India. This is mainly
    due to severe restrictions on the availability of infrastructure,
    resources, and funding.
  25. Guest

    Guest Guest

    Ministry of Health and Family Welfare, Govt. of India
    accepted in principle National Oral Health Policy in the year
    1995 to be included in National Health Policy. In pursuance to
    National Oral Health Policy 'National Oral Health Care
    Programme' has been launched as "Pilot Project" to cover five
    States (Delhi, Punjab, Maharashtra, Kerala and North eastern
    States) for its implementation.7 To begin with, one district in
    each of these States has been chosen to test run the strategies
    evolved through 2 national and 4 regional workshops
    organized in the country, to achieve the following goals7:
    1. Oral Health for all by the year 2010.
    2. To bring down the incidence of oral and dental diseases
    to less than 40% from the existing prevalence of 90%.
    3. To bring down the DMFT in school children between
    6-12 years of age to less than 2 which is approximately
    4 at present.
    4. To reduce high prevalence of periodontal diseases to
    lower prevalence.
    5. At the age of 18 years, 85% should retain all their teeth.
    6. To achieve 50% reduction in edentulousness between
    the age of 35-44 years.
    7. To achieve 25% reduction in edentulousness at the age
    of 65 years and above.
    8. To achieve 50% reduction in the present level of
    malocclusion and dento-facial deformities.
    9. To reduce the number of new cases of Oral Cancers and
    precancerous lesions from the existing levels
  26. Guest

    Guest Guest

    Summary
    In India Cervical Cancer Control Program is
    not yet implemented in spite of the formulation of
    national guidelines and availability of fund from the
    National Cancer Control Programme. The state health
    administrations have to be sensitized to launch the
    program using service delivery models most suitable to
    them. Launching community based low intensity cervical
    screening in combination with awareness campaign and
    monitoring system should be the priority of the cervical
    cancer control program. The HPV vaccine is a safe and
    effective option for cervical cancer prevention. The cost
    is prohibitive to consider it for a national program in India
    at this juncture. Experience gathered in terms of vaccine
    effectiveness, safety, acceptability, service delivery
    logistics and cost-effectiveness from demonstration
    programs will be useful to plan future vaccination
    strategies. Such demonstration programs with 100 per
    cent financing options for the vaccine should be the
    priority. The national consensus guidelines for vaccine
    administration in India should be formulated.
  27. Guest

    Guest Guest

    OVOALBUMIN was injected into a rabbit. What antibody will it produce initially?
    A. IgG
    B. IgM
    C. IgE
    D. IgD

    ANS -B

    IgM is the first immunoglobulin to appear during an immune response and is the first immunoglobulin one encounters as one ascends the phylogenetic tree.
    It is the most effective immunoglobulin at fixing complement and in aggregating targets. However, it does not serve as an opsonin. Because of its size, pentameric IgM is confined to the intact intravascular space but it is released during an inflammatory response. Its concentration in serum is about 125 mg% (range 65-120) for men and 160 mg% (80-320) for women. Its half-life is only about 5 days. Therefore, it is not nearly as important in host defense as IgG. However, monomeric IgM is the antigen receptor on B cells, thereby providing the specificity for the humoral immune response.

    They immunized rabbits with the protein ovalbumin (the albumin of egg whites) and then divided the immunized rabbits’ serum into two aliquots. Electrophoresis of one serum aliquot revealed four peaks corresponding to albumin and the alpha (a), beta (b), and gamma (g) globulins.
    The other serum aliquot was reacted with ovalbumin, and the precipitate that formed was removed; the remaining serum proteins, which did not react with the antigen, were then electrophoresed. A comparison of the electrophoretic profiles of these two serum aliquots revealed that there was a significant drop in the g-globulin peak in the aliquot that had been reacted with antigen. Thus, the g-globulin fraction was identified as containing serum antibodies, which were called immunoglobulins, to distinguish them from any other proteins that might be contained in the g-globulin fraction.

    Nomenclature

    Heavy chains are named by using the Greek letter that corresponds to the class name. Thus, the H chain of IgG is the gamma chain. The immunoglobulin molecule can be split into functional parts by various enzymes. This was important in establishing both the structure of the molecule and in assigning various functions to the different regions. In the 1950s and 1960s experiments by Rodney Porter and by Gerald Edelman elucidated the basic structure of immunoglobulin molecule which leads to get Nobel Prize in 1972. Porter cleaved the antibody molecule with enzymes to obtain fragments whereas Edelman dissociated the molecule by reducing the interchain disulfide bonds. The result attained by these two approaches complemented each other and allowed the basic structure of the antibody molecule to be elucidated.

    Using ultracentrifugation, both Porter and Edelman first separated the g-globin fraction of serum into a high molecular weight fraction with a sedimentation constant of 19S and a low molecular weight fraction with a sedimentation constant of 7S. They used the 7S fraction containing a 1, 50,000 MW g-globin designated as Ig G for their studies.

    Porter subjected Ig G to brief digestion with the enzyme papain and separated the fragments. Although papain has general, nonspecific proteolytic activity and will eventually digest the entire Ig G molecule, brief treatment cleaves only the most susceptible bonds. Papain digestion of Ig G produced two identical fragments called Fab fragments, because they retained their antigen binding activity, and one fragment called the Fc fragment because it was found to crystallize during cold storage.

    Similar experimental approach, but with the enzyme pepsin, was taken by Alfred Nisonoff. Brief pepsin digestion generated a single 1, 00,000 MW fragment composed of two Fab-like fragments and designated F(ab’)2. Like the Fab fragments, the F(ab’)2 fragment was also able to visibly precipitate antigens. However, after pepsin digestion, the Fc fragment was not recovered because it had been digested into multiple fragments. Porter subjected Ig G to mercaptoethanol reduction and alkylation, a chemical treatment that irreversibly cleaves disulfide bonds. The sample was then chromatographed on a column that separates molecules on the basis of size. This experiment revealed that the 1,50,000 MW Ig G molecule was composed of two 50,000 MW polypeptide chains, designated as heavy (H) chains and two 25,000 MW chains, designated as light (L) chains.
  28. Guest

    Guest Guest

    128 Alkalization of urine =methotrexate, cisplatin, ifosfamide
    ans-

    Position Paper on urine alkalinization. Proudfoot AT, Krenzelok EP, Vale JA.

    National Poisons Information Service (Birmingham Centre) and West Midlands Poisons Unit, City Hospital, Birmingham, UK.
    Abstract

    This Position Paper was prepared using the methodology agreed by the American Academy of Clinical Toxicology (AACT) and the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT). All relevant scientific literature was identified and reviewed critically by acknowledged experts using set criteria. Well-conducted clinical and experimental studies were given precedence over anecdotal case reports and abstracts were not considered. A draft Position Paper was then produced and presented at the North American Congress of Clinical Toxicology in October 2001 and at the EAPCCT Congress in May 2002 to allow participants to comment on the draft after which a revised draft was produced. The Position Paper was subjected to detailed peer review by an international group of clinical toxicologists chosen by the AACT and the EAPCCT, and a final draft was approved by the boards of the two societies. The Position Paper includes a summary statement (Position Statement) for ease of use, which will also be published separately, as well as the detailed scientific evidence on which the conclusions of the Position Paper are based. Urine alkalinization is a treatment regimen that increases poison elimination by the administration of intravenous sodium bicarbonate to produce urine with a pH > or = 7.5. The term urine alkalinization emphasizes that urine pH manipulation rather than a diuresis is the prime objective of treatment; the terms forced alkaline diuresis and alkaline diuresis should therefore be discontinued. Urine alkalinization increases the urine elimination of chlorpropamide, 2,4-dichlorophenoxyacetic acid, diflunisal, fluoride, mecoprop, methotrexate, phenobarbital, and salicylate. Based on volunteer and clinical studies, urine alkalinization should be considered as first line treatment for patients with moderately severe salicylate poisoning who do not meet the criteria for hemodialysis. Urine alkalinization cannot be recommended as first line treatment in cases of phenobarbital poisoning as multiple-dose activated charcoal is superior. Supportive care, including the infusion of dextrose, is invariably adequate in chlorpropamide poisoning. A substantial diuresis is required in addition to urine alkalinization in the chlorophenoxy herbicides, 2,4-dichlorophenoxyacetic acid, and mecoprop, if clinically important herbicide elimination is to be achieved. Volunteer studies strongly suggest that urine alkalinization increases fluoride elimination, but this is yet to be confirmed in clinical studies. Although urine alkalinization is employed clinically in methotrexate toxicity, currently there is only one study that supports its use. Urine alkalinization enhances diflunisal excretion, but this technique is unlikely to be of value in diflunisal poisoning. In conclusion, urine alkalinization should be considered first line treatment in patients with moderately severe salicylate poisoning who do not meet the criteria for hemodialysis. Urine alkalinization and high urine flow (approximately 600 mL/h) should also be considered in patients with severe 2,4-dichlorophenoxyacetic acid and mecoprop poisoning. Administration of bicarbonate to alkalinize the urine results in alkalemia (an increase in blood pH or reduction in its hydrogen ion concentration); pH values approaching 7.70 have been recorded. Hypokalemia is the most common complication but can be corrected by giving potassium supplements. Alkalotic tetany occurs occasionally, but hypocalcemia is rare. There is no evidence to suggest that relatively short-duration alkalemia (more than a few hours) poses a risk to life in normal individuals or in those with coronary and cerebral arterial disease.
  29. Guest

    Guest Guest

    ACOUSTIC NEUROMA
    Timothy C. Hain, MD DizzinessTumor index Page last modified: November 29, 2010


    Acoustic Neuroma (swelling of 8th nerve, just under Facial nerve)
    Main Points:
    1. Acoustic neuromas are a rare cause of unilateral hearing loss, dizziness, as well as other symptoms related to the brain.
    2. The best tests to diagnose acoustic neuroma are audiometry (hearing testing) and MRI scanning of the head with gadolinium contrast.
    3. About half of all acoustic neuromas are treated by surgery, about a quarter with radiation (this is increasing), and about a quarter are watched.
    4. No matter what method of treatment is used, hearing preservation is very unlikely.

    Acoustic neuromas, also known as vestibular schwannomas, are non-malignant tumors of the 8th cranial nerve. Most commonly they arise from the covering cells (Schwann cells) of the INFERIOR VESTIBULAR NERVE (Komatsuzaki and Tsunoda, 2001; Krais, 2007). They can also arise within the labyrinth (Neff et al, 2003).

    Acoustics comprise about 6 percent of all intracranial tumors, about 30% of brainstem tumors, and about 85% of tumors in the region of the cerebellopontine angle -- another 10% are meningiomas.

    Only about 10 tumors are newly diagnosed each year per million persons (Evans et al, 2005), corresponding to between 2000 and 3000 new cases each year in the US. Another way of looking at this is that an average person has a risk of about 1/1000 of developing an acoustic neuroma in their lifetime (Evans et al, 2005). In Denmark, the annual incidence was estimated to be 7.8 patients operated/year (Tos et al, 1992). As technology has improved, more small tumors have been diagnosed, resulting in a similar estimate of about 10 tumors/million/year.

    In patients with hearing asymmetry, it is believed that only about 1 in 1000 has acoustic neuroma (source: NIH), although some report prevalence as high as 2.5% (Baker et al. 2003). The higher prevalence does not correspond to our clinical experience in our practice in Chicago, common sense, or the findings of others. Tos et al (1992) observed that in a randomized Danish population of 40-60 year old men, asymmetrical hearing loss occurred in 8%. Simple math would suggest that if 8% of this group has asymmetrical hearing, there would be 80,000 such men among a million persons. Assuming that all tumors resulted in asymmetrical hearing, then the ratio would be 10/80,000 -- roughly 1/10,000.

    Acoustic neuromas occur largely in adults -- they are very uncommon in children. Only 39 cases in children had been reported in the literature as of 2001 (Pothula et al, 2001).

    Causes of Acoustic Neuroma
    Acoustic neuroma occurs in two forms: a sporadic form and a form associated with an inherited syndrome called neurofibromatosis type II (NF2). About 95 percent of all cases are sporadic.

    NF2 is rare; there are only several thousand affected individuals in the entire United States, corresponding to about 1 in 40,000 individuals (see image below). Roughly 5% of patients with acoustic neuroma have type II neurofibromatosis. More information about NF2 can be found at http://ghr.nlm.nih.gov/gene=nf2

    There is no credible evidence that radiation from cellular phones causes acoustic neuroma (Muscat et al, 2002).



    SIGNS AND SYMPTOMS:
    Diagnosis of an acoustic usually requires either a physician with otologic expertise who can integrate together the entire picture, or an MRI with gadolinium. Because acoustic neuromas are very rare, and MRI's are very expensive, in our opinion -- all patients with a substantial risk of having an acoustic should be evaluated by a medical doctor with otologic expertise. In other words, patients with unexplained stable asymmetrical hearing loss should generally all be evaluated by a physician with otologic expertise. The following text describes how this integration process can be done.

    Hearing Loss
    While hearing loss is common in acoustic neuroma (i.e. it is sensitive), there are myriads of other causes of hearing loss (i.e. hearing loss is very nonspecific). Roughly 20% of adults have hearing impairment of 25 db or more (Haggard et al, 1981). Because of the high sensitivity but low specificity, routine use of a very expensive diagnostic test such as a gad-MRI of the IAC's in all persons with asymmetrical hearing is not always justified. In other words, mistakes are justifiable on the basis of social cost/benefit ratio. While some clinicians "scan" all patients with asymmetrical hearing - -this is a very expensive way to "find" an acoustic.

    Hearing loss is the most frequent symptom of acoustic neuroma, occurring in more than 95 percent of patients. About 90 percent present with a one-sided, slowly progressive hearing impairment. An example is shown below.

    Clinicians often attempt to estimate the risk of an acoustic neuroma by looking at the pattern of hearing loss (see here for more about patterns). A high-frequency sensorineural pattern is the most common type, occurring in approximately two-thirds of patients. In the remaining third the next most common observation is hearing loss at low frequency (which would be more typical of Meniere's disease). Even less commonly, some have the "cookie bite" pattern (suggestive of congenital hearing loss or a noise notch).

    A sudden hearing loss occurs in about 25 percent of patients with acoustic neuroma. However, because acoustic neuroma is a rare condition, sudden hearing loss attributable to an acoustic tumor occurs in only 1-5 percent of patients with sudden hearing loss as there are many more common causes (Daniels et al, 2000). Even a sudden hearing loss with complete recovery can be caused by an acoustic(Nageris and Popovtzer, 2003).

    Cost of diagnosis to society
    Asymmetrical hearing is sensitive but extremely nonspecific for acoustic neuroma. The lack of specificity and rarity of acoustic neuromas compared to the myriad of other causes of asymmetrical hearing makes the "cost" of scanning every person with asymmetrical hearing to find an acoustic in 1/1000 persons (or even less) extremely high. The lack of specificity has been commented upon by Margolis and Saly (2008). This conclusion needs to be tempered by other clinical information - -someone with a progressive asymmetrical sensorineural hearing reduction would (in our opinion) be far more likely to have an acoustic than someone with a static or improving asymmetry. Nevertheless, if the chance of finding an acoustic in someone with asymmetrical hearing is between 1/1000 and 1/10,000 and the cost of an MRI is roughly $2000, then it costs between 2 million and 20 million $ in MRI studies to diagnose every acoustic neuroma.

    Specificity is another consideration. In this regard, some find that hearing is completely normal in as many as 11% of patients (Morrison and Sterkers, 1996). In our opinion, this percentage is high, but nevertheless certainly acoustic neuroma's can be found in persons with symmetrical hearing.

    Tinnitus
    Tinnitus is very common in acoustic neuroma, is usually unilateral and confined to the affected ear. Looking at things the other way, if you have tinnitus, it is very very unlikely that you have an acoustic neuroma, because these tumors are far rarer than other mechanisms of ear damage.

    Vertigo
    In spite of the usual origin of acoustics in the inferior vestibular nerve (Komatsuzaki and Tsunoda, 2001; Krais et al, 2007), vertigo (spinning) prior to surgery is not common, occurring in only about 20 percent of persons with acoustic neuroma. As the inferior vestibular nerve innervates the posterior semicircular canal and saccule, one might expect VEMP's, which test saccule function, to be uniformly abnormal in acoustic neuroma's, and in fact they are quite sensitive. Similarly, one might expect ipsilateral BPPV to be rare. This question has not been addressed. One might also expect abnormalities in OAE's as auditory efferents enter the cochlear area via the inferior division of the nerve. Again, this question has not been addressed.

    Vertigo is more common with smaller tumors. Unsteadiness is much more prevalent than vertigo, and approximately 70 percent of patients with large tumors have this symptom. Cerebellar symptoms (i.e. poor coordination of the arms) are unusual.

    Hyperventilation induced nystagmus is a little known physical sign that may be far more specific for acoustic neuroma. Evaluation of HVIN requires more sophisticated equipment than is available in most offices. It also requires the examiner to be familiar with this sign -- and it is somewhat obscure.

    Numbness in the face
    Facial sensory disturbances occurs only in large tumors (about 50 percent of those greater than 2 cm in size). The facial sensory disturbance may respond to carbamazepine or oxcarbamazine medication for neuralgia. Facial weakness is uncommon. Facial twitching, also known as facial synkinesis or hemifacial spasm, occurs in about 10 percent of patients. Headache prior to surgery occurs in roughly 40 percent of those with large tumors.

    DIAGNOSIS OF ACOUSTIC NEUROMA USING TESTS:
    As mentioned above -- acoustics can be diagnosed either by a medical doctor with otologic expertise who can integrate together the entire picture, or with an MRI scan with gadolinium of the brain. Because MRI's are so expensive, the most cost efficient method of diagnosis (at this writing - -in 2010), is to have all patients with unexplained asymmetrical hearing loss be evaluated by a medical doctor with otologic expertise.


    Typical audiogram for patient with an acoustic neuroma.



    Conventional audiometry is the most useful diagnostic test for acoustic neuroma. The most common abnormality is an asymmetrical high-frequency sensorineural hearing loss (see figure above). No more than 1 out of 20 patients with large tumors have symmetry within 15 db at 4000 hz. However, recall that only about 1 in 1000 patients with hearing asymmetry have acoustics. It has been estimated that 5 percent of persons with sensorineural hearing loss have acoustics (Daniels et al, 2000), but this estimate is suspect as it would imply a much higher prevalence of acoustic neuromas than are commonly accepted. Speech reception (SRT) is normal in many patients with small tumors. Excellent speech discrimination is found in about 50% of patients with small tumors, and one third of patients with large tumors still have near-normal (> 80%) speech discrimination. Because hearing asymmetry is mainly due to other conditions than acoustic neuromas, other pieces of information need to be integrated to make the clinical diagnosis of acoustic neuroma. Usually this integration process is done by a medical doctor with otologic expertise, and not by allied health persons such as audiologists.




    Audiogram of patient with large acoustic neuroma on left side, but (nearly) symmetrical hearing. This example shows that symmetrical hearing testing does not always exclude the diagnosis of an acoustic neuroma. See comment in text.

    Symmetrical hearing impairment or even normal hearing does not exclude an acoustic, but it is very rare.The author of this article has encountered several patients with symmetrical hearing but a large acoustic on one side. Above is an example of a man who had a large acoustic on the left side -- to be very sure one must do an MRI, and to be as sure as possible, one must do a high-field MRI of the IAC with gadolinium. Because this is terribly expensive (to screen everyone with hearing impairment of any type), mistakes are sometimes made. While this is really a decision for health care economists, it seems to us that occasional errors are overall permissible, when one considers what is best for the population at large..

    ABR testing
    When abnormal with a progressively worsening pattern, audiometry usually leads to further testing such as ABR (auditory brainstem response, also known as BAER for brainstem auditory evoked response) and gadolinium enhanced MRI (magnetic resonance imaging) which establishes the diagnosis. ABR testing is less sensitive than MRI (false negative rate about 33%), but it is considerably less expensive. A new technique called "summated ABR", essentially several ABRs compared over time, may provide better sensitivity. In our clinical context in Chicago, this technique is rarely relevant as the more sensitive test for acoustics (MRI) is so common. Nevertheless, this method might have utility in contexts where MRI's are difficult to access.

    A characteristic finding on ABR in a person with an acoustic neuroma would be a wave I with nothing after it -- no waves 3 or 5 (10-20% of cases). A wave I-III interval delay is common, and a wave V delay occurs in 40-60% of cases. ABR's have high false-positive as well as false negative rates. As many as 1/3 of patients with small tumors (on MRI) have normal ABR.

    ENG testing

    Electronystagmography, (ENG testing) is frequently abnormal in persons with acoustic neuromas and about 60 percent of all tumors are associated with unilateral loss of calorics (Hulshof et al, 1989). Nevertheless, ENG is not a reasonable diagnostic test because it is not specific, and also because there are far more other causes for caloric loss than acoustic neuromas. Rotatory chair testing is less sensitive than caloric testing. Posturography is insensitive to acoustic neuroma. Acoustic reflex decay is also insensitive (about 36%). Otoacoustic emissions are also considered a poor test for acoustic neuroma. As mentioned above, VEMP testing would be expected to be sensitive to acoustic neuroma's.




    MRI scan of brain (coronal) showing an acoustic neuroma (the white spot on the left side of the picture). MRI scan of brain (axial with contrast) showing a largely intracanalicular acoustic neuroma on right side of brain (left side of scan). Another intracanalicular acoustic on right side.

    Brain Imaging
    Although it is amazingly more costly compared to audiometry or ABR, the optimal test for excluding an acoustic neuroma is a gadolinium enhanced T1 MRI (see picture above).

    Parenthetically, it is puzzling that an old technology like MRI should keep increasing in cost every year. The stakes are enormous - -with facililities often charging $5000 for an hour long procedure. Lets see - -10 procedures/day -- 50,000. 200 days/year -- thats 10 million dollars. No wonder one see's MRI scanners sitting in shopping malls ! It seems to us that the the "free market" is somehow not working with MRI. It has been our observation that neuroradiology facilities often "bundle together" numerous MRI protocols that add to the time and expense of performing the test. Of course, one does get some added value here, but the cost differential can be gigantic.

    As an example, often MRI facilities perform diffusion imaging -- a protocol to detect a new stroke, in patients referred for evaluation of an acoustic. Similarly, often MRI facilities want to do both IAC and brain MRI, in patientswhere only the IAC was requested. This is also a problem with temporal bone CT's, where neuroradiologists seem to often use very creative protocols that they think might be interesting (but add to the bill and radiation load). We think that Neuroradiology facilities should just do what they are asked to do by referring doctors, and that insurance companies should refuse to pay for procedures that don't match up with the diagnosis. Well anyway --

    On MRI, acoustic neuromas are frequently uniformly enhanced and dense. The best protocol MRI protocol is generally a T1 with contrast (gadolinium) ot the IAC, in a closed MRI with the highest resolution available (3T is the best right now). One looks for lighting up of the tumor (enhancement) on the images with dye. A fast spin-echo T2 variant of MRI is very sensitive to acoustics, and in some clinical settings, can be done fairly inexpensively (but we don't know of anyone who does this in Chicago). If a person has a pacemaker or other metallic device, then they may have to have a CT scan with contrast instead of an MRI.

    CT scans with IV contrast are poor tests for diagnosis of acoustic neuromas, as they have a high false negative rate (about 37%). Once again, one looks for enhancement (lighting up of the tumor with contrast, and no lighting up without contrast). As CT scans show bone, another way to diagnose them is to see a process that expands the internal auditory meatus (canal) -- IAC. In persons with metal in vital places -- such as a pacemaker, sometimes CT scan is the only test available. As persons with pacemakers often have marginal kidney function, one must be careful here not to damage their kidneys with the CT scan dye. All in all, a much less satisfactory situation than when one has the option of using an MRI.

    While MRI's are the most sensitive test to acoustics, they also can make errors. False negative errors mainly occur in persons with very small tumors, or very bad scans (such as a scan done in a low-field unit, without contrast). False positive errors are very rare but also possible (House et a, 2008).

    Acoustic neuromas range in size up to 4 cm. The smallest, the intracanalicular acoustic (see above right), is measured in millimeters. A "small" acoustic is less than 1.5 cm (above left). A "moderate" acoustic is 1.5-3 cm, and a "large" acoustic is 3 cm or greater.

    Tumors are staged by a combination of their location and size. An "intracanalicular" is small and in the IAC (internal auditory canal). A "cisternal" tumor has extended outside the IAC. A "compressive" tumor is touching the cerebellum or brainstem, and a "hydrocephalus" tumor is obstructing CSF drainage pathways in the IV'th ventricle. Acoustic neuromas can extend from the nerve into the inner ear, which can make their removal more difficult (Falcioni et al, 2003). Intralabyrinthine schwannomas as well as intracochlear schwannoma's exist (Kennedy et al, 2004). The acoustic on the right upper panel has a small intracochlear extension.


    Axial image of patient with NF2 showing acoustic neuromas on both sides (Image courtesy of Dr. Richard Wiet). Higher image showing multiple meningiomas in same patient with NF2.



    Rarely, acoustic neuromas are inherited. Acoustic neuroma caused by type-II neurofibromatosis should be suspected in young patients and those with a family history of neural tumors. The figure above shows an example of such a person. It is common in this disease to become deaf due to bilateral acoustic neuromas. Genetic testing for NF1 and NF2 is available commercially, for example, from Athena Diagnostics.

    Differential diagnosis
    There are several other tumors that can occur in the same region of the brain, the cerebello-pontine angle or CPA, as acoustic neuromas. Of all lesions in the CPA, acoustic neuromas account for 70-90 percent. Meningiomas are second most common (10 percent), followed by epidermoids, and then lipomas. Occasionally tumors in other locations, such as the lung, can metastasize to the CPA. Metastatic tumors usually grow rapidly -- hearing goes down quickly, and often the facial nerve is involved with a Bells palsy, over a few weeks time.

    Acoustic Neuromas discovered by accident
    As CT and MRI scans become more commonly used, there are more acoustics being discovered accidentally -- serendipitously. For example, a person who has a migraine headache, might get an MRI which reveals an acoustic neuroma. Or someone who experienced an auto accident, might get an MRI which reveals an acoustic neuroma.

    This situation has considerable potential for trouble. It is not very likely that a previously silent acoustic neuroma, will suddenly manifest itself at the same time as another problem - -such as a minor head injury or migraine. Rather, it is commonly the case that the person will have one of the common causes of dizziness, and just happen to also have a silent acoustic.

    If someone in such a situation proceeds with surgery or radiation treatment, it is certain that the surgery or radiation will create a vestibular imbalance as well deafness. This will eventually occur anyway, but treatment of a tumor that is not growing will speed up the process. For this reason, extreme caution is suggested -- in our opinion, except for very large tumors, it is best to have objective evidence -- i.e. progression of hearing loss or a enlargement on MRI -- that the tumor is growing before embarking on surgery or radiation treatment. A second opinion is well worth obtaining.

    MANAGEMENT OF ACOUSTIC NEUROMAS
    Nikolopoulos and O'Donoghue recently reviewed 111 articles on acoustic neuroma treatment and stated that "well-designed comparisons between treatment methods do not exist, and therefore claims by clinicians favoring a particular treatment are unfounded" (2002). We do not think that clinical wisdom can be discounted to such a great degree, but certainly the present situation seems to be that acoustic neuroma treatment is an art.

    There are three distinct options:

    medical management or "wait and see" (conservative management)
    surgery to remove the tumor
    gamma-knife procedure or stereotactic radiotherapy.
    Medical Management: About 25% of all acoustic neuromas are treated with medical management. Medical management consists of periodic monitoring of the patient's neurological status, use of hearing aids when appropriate, and periodic imaging studies (such as MRI's). It is an appropriate method of management in some patients (Hoistad et al, 2001).

    There is no medication known to have a substantial effect on the growth of acoustic neuroma tumors. The tumors may grow very slowly, about 1 1/2 mm/year, and one may elect to follow a tumor with serial audiometry and/or MRI scans (Shin et al, 2000). In individuals of advanced age, a serious threat to life or bodily function from tumor growth may be judged unlikely in the remainder of a patient's expected lifespan, and for this reason, medical management may be elected (Perry et al, 2001). Once a tumor is diagnosed, a repeat scan is obtained at 6 months and then at yearly intervals (Perry et al, 2001).

    This procedure has its own risks. Even when the tumor is not growing on MRI, there is a risk of losing useful hearing in this situation, making the individual no longer a candidate for hearing preservation type surgery. Somewhere between 10 and 43% of patients followed for about 2 years lose "useful" hearing (Warrick et al, 1999; Shin et al, 2000; Lin et al, 2005).

    On the other hand, no matter what treatment procedure is used, surgical or not, in the long term, retention of "serviceable" hearing is very unlikely. The so-called "hearing preservation surgery" rarely preserves useful hearing, and it also tends to deteriorate fairly rapidly with time, with or without a tumor still being there. Because of this observation, some surgeons simply recommend taking out the entire 8th nerve when most convenient as this approach makes tumor recurrence very unlikely. In our opinion, this is should be a judgment call -- but not an unreasonable idea. A reasonable estimate is that over a year, about 75% of tumors will have visible enlargement, averaging 1.5 mm, and about 25% will not. Some variants grow much faster than others.

    In persons with neurofibromatosis, hearing is likely to remain stable in un operated ears for about 1-2 years (Masuda et al, 2004).

    Gamma Knife: When the risk of surgery is high because of other medical problems, or where the patient simply refuses surgery, the "gamma knife" procedure may be used. This is a method of irradiating the tumor, invented by Lars Leksell in 1971. This procedure avoids surgery with its attendant risks. In the past, this option was usually recommended only for higher risk surgical cases because of the possibilities of late radiation complications, and the need for ongoing MRI monitoring of the results of the procedure.

    The author of this review does not favor high-dose gamma knife because of the possibility of radiation complications at 2 years and beyond. However, low dose gamma knife is looking much better and there are certainly many times when it is the best option. Lower doses of radiation (e.g. 13 Gy) are presently advised because of the much lower risk of facial weakness and numbness (Wackym et al, 2004).

    An interesting consequence of the lower-dose radiation protocol is that patients are now seen who do not have complete loss of hearing or vestibular function after radiation. In some cases this can be very annoying as it may result in nerve irritability symptoms such as hyperventilation induced nystagmus. This is probably a consequence of using a treatment methodology that works more slowly than surgery. It seems likely that this complication is more common in persons who have small tumors.

    Hyperventilation induced nystagmus for this situation beats towards the lesion (unlike vibration induced nystagmus which beats away from the lesion). It is often very powerful. In persons with this sign, one can either wait for it to go away (this may take several years), try a medication that reduces nerve irritibility, or reconsider surgical treatment.

    Supplemental material on the site DVD: Video of hyperventilation induced nystagmus in patient with left sided acoustic neuroma

    Stereotactic radiotherapy. Radiation other than gamma rays can also be used to treat acoustic neuroma. They include linear accelerator (LINAC) and Cyberknife. These other modalities are similar to gamma knife in overall features. Long term hearing preservation is very rare in persons with stereotactic radiotherapy (6.7% according to Lin et al, 2005). In other words, although the "goal" is to preserve hearing, practically this is unrealistic. We see no particular reason to seek out stereotactic radiotherapy rather than gamma knife. The chance of recurrent tumor using current dose regimens is roughly 5-10%. Tumor growth is rare in patients who remain stable 6-7 years post therapy.

    Issues in radiotherapy are recurrence (5-10%), hearing loss (eventually 93%), risk of radiating large (>2 cm) tumors due to swelling of the tumor in the first year, risk for malignancy, hydrocephalus (rare), ruptured IAC aneurysm (rare), and accelerated vertebrobasilar atherosclerosis (e.g. Jackler, 2007).

    For larger tumors, cystic lesions, and neuromas with brainstem compression, according to the neurosurgeons, microsurgical resection in experienced neurosurgical centers is the preferred option (Unger et al, 2010).

    Very large acoustic neuroma (coronal view, the tumor is the large white blob). Source: Mayo Clinic Neuroscience Update.

    Surgical Treatment: About half of all acoustic neuromas are presently treated with surgery. This option will likely decline over the next few decades as use of gamma-knife and other radition based treatments grow. The figure above shows a large acoustic neuroma in which surgical management would generally be preferred. In most instances surgical removal of the tumor is the preferred option because it prevents potentially fatal complications of tumor growth (although this would be very unusual). Surgery may theoretically enable "preservation" of hearing, although it is very rare that hearing is actually serviceable after surgery. Usually the surgery is done at an academic center by a team of surgeons including a neurotologist (a specialized otolaryngologist) and a neurosurgeon. There are several operative approaches.

    Common surgical approaches to acoustic neuroma

    Translabyrinthine (through the inner ear). Hearing loss is expected and inevitable. Not appropriate for very large tumors.
    Retrosigmoid or suboccipital (through the skull behind the ear). Retraction of the cerebellum (part of the brain) is necessary. Headaches are common after this approach.
    (Image from Jackler R, Atlas of Neurotology and Skull Base Surgery (Mosby 1996, First edition, with permission).
  30. Guest

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    Complete response of deep neutrophilic dermatosis associated with myelodysplastic syndrome to 5-azacytidine

    Abstract Summary Cutaneous manifestations of myelodysplastic syndromes (MDS) may predict disease progression and a poorer prognosis. We describe a patient in whom a deep neutrophilic dermatosis preceded evolution of disease from refractory anaemia to RAEB (refractory anaemia with excess blasts) and resolved completely on treating the disease with 5-azacytidine. The dermatological response was accompanied by complete bone marrow remission and trilineage haematological improvement. We suggest that 5-azacytidine should be considered in the treatment of immune mediated cutaneous manifestations of MDS.

    Cutaneous manifestations of myelodysplastic syndromes (MDS) include infections, vasculitis, leukaemia cutis and neutrophilic dermatoses.1 The neutrophilic dermatoses are a group of inflammatory skin diseases characterized by sterile neutrophilic infiltrates of the dermis, epidermis or subcutaneous tissue. They are frequently associated with systemic disorders such as rheumatoid arthritis and Crohn disease but are well-recognized complications of haematological malignancies, particularly myelodysplasia and acute myeloid leukaemia.2,3

    Neutrophilic panniculitis has been described as a rare condition, characterized by plum-coloured plaques or nodules, systemic symptoms (fever, arthralgia and malaise), histological lobular infiltrate of neutrophils and a significant association with myelodysplasia.4,5 However, its definition as a distinct disease entity is debated and subcutaneous Sweet's syndrome should be considered in its differential diagnosis.6

    MDS are disorders of haemopoietic stem cells that manifest as peripheral blood cytopenias and predispose to acute leukaemia. Paraneoplastic cutaneous eruptions such as the neutrophilic dermatoses (Sweet's syndrome, pyoderma gangrenosum and neutrophilic panniculitis) frequently precede or accompany a diagnosis of MDS.7,8
    5-Azacytidine (Vidaza®; Pharmion Ltd, Windsor, Berks, U.K.) is a novel pyrimidine analogue and DNA demethylating agent that is effective in all subtypes of MDS and is the only drug that has been shown to prolong the time to leukaemic transformation.9 Recently, 5-azacytidine was licensed by the U.S. Food and Drug Administration (FDA) for the treatment of all subtypes of MDS.10 We describe the first case of deep neutrophilic dermatosis in a patient with MDS RAEB (refractory anaemia with excess blasts) II (> 10% bone marrow blasts) who responded completely to 5-azacytidine. Case report
    A 74-year-old male presented with MDS, refractory anaemia with trilineage dysplasia and diploid cytogenetics [haemoglobin 10·2 g L−1 (normal, 13–16·5 g L−1), white blood cells 4 × 109 L−1 (4–11 × 109 L−1), neutrophils 1·7 × 109 L−1 and platelets 89 × 109 L−1 (150–450 × 109 L−1)]. He was transfusion-dependent but responded well to treatment with granulocyte colony-stimulating factor (G-CSF) and erythropoietin (haemoglobin 12·8 × 109 L−1 and neutrophils 3·5 × 109 L−1). A year later he developed painless infiltrated violaceous plaques over his scalp, forehead, cheeks, neck and shoulders (Fig. 1a,b) and marked livedo reticularis on his pages . He simultaneously lost his response to erythropoietin and G-CSF, manifested as progressive anaemia and neutropenia (haemoglobin 6·97 g L−1 and neutrophils 0·59 × 109 L−1). Withholding G-CSF had no effect on the eruption. Investigations for autoantibodies, porphyrins and paroxysmal nocturnal haemoglobinuria screens were negative. Skin biopsies showed a deep neutrophilic dermatosis with inflammation centred on the superficial subcutaneous fat (Fig. 2a). The infiltrate was composed of a mixture of degenerate neutrophils and foamy macrophages with smaller numbers of lymphocytes and plasma cells). Immunohistochemical staining demonstrated the lymphocytes to be both B and T lymphocytes. There was no evidence of leukaemia cutis. Over the following 9 months the skin lesions persisted, his transfusion requirements increased and bone marrow blasts increased to 12% (normal < 5%). He commenced treatment with 5-azacytidine 75 mg m−2 subcutaneously for 7 days every 28 days. His skin lesions began to fade after 6 weeks of treatment and resolved completely by 2 months. This coincided with his becoming transfusion-independent. After 4 months of treatment the bone marrow showed < 5% blasts (bone marrow complete remission) and a trilineage major haematological response. At 23 months he continues to be in bone marrow remission and his rash has not recurred.

    Discussion
    Neutrophilic dermatoses are a spectrum of disorders that include Sweet syndrome, pyoderma gangrenosum and neutrophilic panniculitis. Their appearance may antedate or present simultaneously with the diagnosis of MDS and they are often associated with rapid disease progression.11 In addition to the prognostic implications, cutaneous manifestations can be both disabling and psychologically demanding. Oral steroids combined with chemotherapy to treat the underlying disease are often effective and lead to resolution of the cutaneous lesions. Treatments with ciclosporin,8 cyclophosphamide,12 thalidomide,13 infliximab (anti-TNF-),14 radiotherapy and immunosuppressive therapy have met with limited success and are associated with significant side-effects. In our patient, disease acceleration made treatment of the underlying MDS imperative. However, his general state was not robust enough for high-dose acute myeloid leukaemia-type combination chemotherapy and outpatient therapy with 5-azacytidine was the preferred option.
  31. Guest

    Guest Guest

    157. Not a disorder of protein misfolding ?
    A. Alzheimer's disease
    B. Tuberculosis
    C. Cystic fibrosis
    D. CJD

    Ans: B TB

    Reference:Robbins Pathology 8th edition
    The Cystic Fibrosis Gene: Mutational Spectra and Genotype-Phenotype Correlation.
    Since the CFTR gene was cloned in 1989, more than 1300 disease-associated mutations have been identified. Various mutations can be grouped into six “classes” based on their effect on the CFTR protein:

    • Class II: Abnormal protein folding, processing, and trafficking. These mutations result in defective processing of the protein from the endoplasmic reticulum to the Golgi apparatus; the protein does not become fully folded and glycosylated and is instead degraded before it reaches the cell surface. The most common class II mutation is a deletion of three nucleotides coding for phenylalanine at amino acid position 508 (ΔF508). Worldwide, this mutation can be found in approximately 70% of cystic fibrosis patients. Class II mutations are also associated with complete lack of CFTR protein at the apical surface of epithelial cells.


    Alzheimer's disease
    One of the main characteristics of Alzheimer�s disease is the accumulation of plaques of insoluble b-amyloid in the brain. It is still not certain whether these plaques are a cause or a consequence of the disease, but there is a lot of evidence for the former being the case. The b-amyloid plaques are formed by cleavage of amyloid-precursor protein (APP) by two different enzymatic activities, which release amyloid-b peptide fragments that are 40 or 42 amino acids long (Fig. 1). These then form fibrils, which aggregate into insoluble clumps of b-amyloid plaques that surround neurons and might cause damage.

    But this cleavage also occurs in healthy individuals and soluble b-amyloid proteins are normal constituents of brain tissue. How, then, do the plaques form in Alzheimer�s patients? It is thought that the misfolding of the protein dramatically alters its properties. In the normal protein, hydrophobic (water-repelling) amino acids bury themselves inside the protein right from the start of folding. However,********** if the protein folds wrongly, these hydrophobic amino acids are exposed and they rapidly seek out and bind to hydrophobic groups on other protein molecules, forming the insoluble aggregates or plaques that are found in Alzheimer's patients
  32. Guest

    Guest Guest

    Oral health is an important aspect of the overall health of an individual. Diseases such as dental caries and oral cancers are major public health issues in India. Dental caries, with a prevalence as high as 60-80% in children, is a major public health problem in India. Oral cancer has also long been a major problem in this country. Despite this, oral health has not been given sufficient importance in our country. Preventive dental care is almost nonexistent in the rural areas and very limited in urban areas. Although orodental problems may not be life threatening, their treatment is often expensive. They can be prevented and controlled to a large extent by health education and motivation. It is therefore essential that to combat oral diseases a preventive approach, with the focus on health education and promotion, be given prime importance.

    The National Oral Health Care Programme was launched as a pilot project in 1999 to reduce the increasing morbidity due to orodental problems in the country. To start with it was implemented in Maharashtra, Punjab, Delhi, Kerala, and the North-Eastern states. The main focus of this programme is on prevention through generation of awareness. Thus, the strategy has been oral health education of school children and the public, with extensive use of information, education and communication (IEC) materials for awareness generation. The project was reviewed by the National Institute of Health and Family Welfare in 2004.

    The strategies proposed for the eleventh 5-year plan include oral health education, formulation of a Basic Package on Oral Health (BPOC) for the country and its implementation, manpower and infrastructure development and capacity building, and monitoring of dental public health as well as research through National, State, and District Oral Health Cells. The total budget proposed for the National Oral Health Care Programme in the eleventh 5-year plan is Rs.182.09 crores.

    Apart from the National Oral Health Care Programme, the National Cancer Control Programme has also been given much importance in the eleventh 5-year plan. The problem of oral cancers will be dealt with under the National Cancer Control Programme at the national level. Apart from these initiatives there is the National Rural Health Mission's, School Health Programme, which includes an oral health awareness programme for children and also an oral/dental screening programme for early identification and prevention of orodental problems.

    Presently, oral health is being given immense importance at the national level. Most initiatives are aimed at the prevention of orodental disease, In the future, however, the curative aspects of oral health must also receive attention. Treatment of orodental disease is expensive and unaffordable for a large proportion of the country's population, especially for the rural poor. This issue must be addressed. Oral health is an integral part of the overall health of a person and the recent developments are therefore very heartening for those concerned about public health. Such initiatives by the government are always welcome.
  33. Guest

    Guest Guest

    274. In L5 root involvement, which among the following is not affected?
    A. Thigh adduction
    B. Knee flexion
    C. Knee extension
    D. Toe extension

    Ans:A Thigh Adduction

    Reference: Snell’s Clinical Anatomy by Regions

    Well both thigh adduction and knee extension are predominanly effected through L2-3-4...This question was a little tricky.......Read below

    The gluteus maximus is the largest muscle in the body. It lies superficial in the gluteal region and is largely responsible for the prominence of the buttock.
    The tensor fasciae latae runs downward and backward to its insertion in the iliotibial tract and thus assists the ******gluteus maximus muscle in maintaining the knee in the extended position.

    Now gluteus maximus has L5S12 supply ans snell clearly mentions it to do Knee extension....All standard books like Grey's anatomy and BDC have the same to sat and donot mention L5 involvement in thigh adduction though some internet sites mention it.......So going with the books Thigh Adduction seems to be the better answer....
  34. Guest

    Guest Guest

    "Increased level of the following - associated with atherosclerosis except?
    Choices including ApoE and alpha-2 macroglobulin"

    References:Low-density lipoprotein receptor-related protein (LRP) in atherosclerosis development: up-regulation of gene expression in patients with coronary obstruction
    Low-density lipoprotein receptor-related protein is "also known as alpha-2 macroglobulin receptor". Increased LRP is positively correlated with atherosclerosis.
    J. Mol. Med. 1998- 76: 596- 600.

    Presence of LDL receptor-related protein/alpha 2-macroglobulin receptors in macrophages of atherosclerotic lesions from cholesterol-fed New Zealand and heterozygous Watanabe heritable hyperlipidemic rabbits.
    Arteriosclerosis, thrombosis and vascular biology 1994 Dec;14(12):2017-24.


    Apolipoprotein E "Promotes the Regression of Atherosclerosis" Independently of Lowering Plasma Cholesterol Levels
    Arteriosclerosis, Thrombosis, and Vascular Biology. 2005;25:436

    Apolipoprotein (apo) E, which is present in plasma lipoproteins that carry dietary and liver-derived cholesterol, plays a protective role in atherosclerosisApoE in Atherosclerosis
    A Protein With Multiple Hats
    Arteriosclerosis, Thrombosis, and Vascular Biology. 2000;20:1852.

    ApoE gene therapy to treat hyperlipidaemia and atherosclerosis.
    Current opinion in molecular therapeutics- 2006- 8(4).



    Considering the above, the answer should be ApoE.
  35. Guest

    Guest Guest

    Which of the following is not associated with atherosclerotic plaque formation?
    A.Plasma ApoE
    B. alpha 2-macroglobulin
    C. Oxidised LDL
    D. Increased homocystiene

    Ans:A.Plasma ApoE

    Reference:
    The interface of atherosclerosis and thrombosis: basic mechanism

    Smooth muscle cell proliferation and extracellular matrix production---in Atherosclerosis


    The ability of smooth muscle cells to produce collagen is very important in maintaining cap integrity. Smooth muscle cells constitutively express collagen. Certain mediators found in atheroma, including platelet-derived growth factor (PDGF) and transforming growth factor-b induce cultured smooth muscle cells to increase collagen production.

    On the other hand, exposure to IFN-g causes cultured smooth muscle cells to decrease their production of collagen. This finding is important ince plaques contain numerous T lymphocytes, the principle source of IFN-g. Macrophages also release mediators that reduce collagen production by smooth muscle cells.

    Because they can either increase or decrease the amount of interstitial collagen in atheromatous fibrous cap, the relative number of smooth uscle cells influences plaque integrity. Several inflammatory mediators can affect smooth muscle cell numbers, including PDGF, which is both a chemoattractant and mitogen for smooth muscle cells.

    Another factor produced by platelets, transforming growth factor-b, has a mitogenic effect on smooth muscle cells that is ********potentiated by alpha 2-macroglobulin.

    Transforming growth factor-b also potently stimulates the synthesis of
    collagen by smooth muscle cells, as noted above.
  36. Guest

    Guest Guest

    ISOPRENALINE

    “ISOPROTERENOL; ISUPRELâ€

    1) Therapeutic drug action & mechanism(pharmacology)
    • Acts almost exclusively on b-adrenergic receptors
    • Causes i) Inotrope [b1-receptors]
    ii) Chronotrope [b1-receptors]
    iii) Vasodilator [b2-receptors]—potent effect
    iv) Bronchodilation [b2-receptors]
    • Reduces SVR & PVR via vasodilation & pulmonic vasodilation

    2) Indications
    • Ventricular dysfunction especially RV(combination of pulmonary dilation & inotropic support)
    • Bronchoconstriction
    • Bradycardias
    • Pulmonary hypertension (inotrope of choice if require inotropic support in such a patient)

    3) Effects on organs—side effects
    • Also increases venous return to heart

    4) Toxic effects/ precautions with administration
    • Tachycardias, dysrythmias (due to b1 effects)
    • Reduced coronary diastolic perfusion pressures (due to b2 effects)
    • Increased MVO2 (due to tachycardia) plus reduced myocardial O2 supply (due to reduced coronary diastolic perfusion pressures) may extend ischaemic areas

    5) Contraindications
    • Idiopathic hypertrophic subaortic stenosis
    • Tetralogy of Fallot with RV outflow tract obstruction (as may constrict pulmonary vasculature exacerbating preexisting pulmonary hypertension or right ventricular dysfunction

    7) Loading dose, maintenance dose, frequency & method of administration
    • 0.2 mg/ml; 1mg/5ml ampules
    • Dilute in 500 ml D5W
    • Run at 0.5 - 5 mg/min

    8) Drug’s metabolism—Drug’s excretion—Half life (pharmacokinetics)
    • 60 - 90 min duration of effect

    9) Important drug interactions
    • Should not be administered concommitantll with adrenaline as will dangerously exacerbate adrenergic effects resulting in arrythmias
    • Risk of arrythmias with volatile anaesthetics....doc not milrinone but isoprenaline correction please
  37. Guest

    Guest Guest

    CORRECTION ANSWER:

    236. A patient presents with fever and abdominal pain. Clinical examination reveals hepatomegaly extending 4 finger breadths below the costal margin. USG reveals a 5cm*5cm*4cm hypodense lesion 1cm deep to liver surface. Tests for hydatid disease were -ve. Best course of action is?
    A. Multiple aspirations,antiamebics and antibiotics
    B. Catheter drainage with antiamebics and antibiotics
    C .Hepatectomy(??)
    d.. Medical management with antiamebics and antibiotics
    Ans:A. Multiple aspirations,antiamebics and antibiotics

    Explanation:I m not pasting the references since the references of Sabiston and shwartz everyone may be knowing from previous threads......

    Coming to the Question straight...
    Lets split the Q into pieces...

    1. fever and abdominal pain--can be seen in both type of liver abscess.nothing much contributory
    2. hepatomegaly
    3. USG reveals a 5cm*5cm*4cm hypodense lesion---confirms an abscess
    4. 1cm deep to liver surface--little superficial
    5. Tests for hydatid disease were -ve.--so not hydatid for sure


    Now the catch is in the points 3 and 4

    Now for any solitary abcess--the first thing to be ruled out is a Amebic liver abscess..either do a amebic serology or aspirate and confirm..for us nothing about amebic serology was given and the diagnosis is in doubt.........Now the standard cut off size for aspiration as a treatment for amebic liver abcess is >5cm....but we have been given exact 5cm ..now wat to do?

    Point 4---wat is its significance.........after seraching books there was one paper which said within 2cm from surface is to be superficial......
    The indications for aspiration include superficial abcesses..........So we get a green signal to aspirate this abcess.

    Aspiration helps to confirm the diagnosis and serves to treat too....

    Now antiamebics are the sheet anchor for Amebic liver abscess..so we add them too.now antibiotics are also added for the bacterial spectrum........

    So thats the answer.......!!!!

    Ans:A. Multiple aspirations,antiamebics and antibiotics

    Well this is a synopsis in the light of references......If anyone has contrasting views can defenitely discuss........
  38. Guest

    Guest Guest

    Aromatase (P450arom or CYP19) is found in the ovary and placenta as well as in muscle, liver, hair follicles, adipose tissue, and brain. Placental aromatase converts the very abundant fetal adrenal androgens such as DHEA sulfate (DHEAS) and 16 -hydroxy DHEAS to estrogens (estrone, estradiol, and estriol). Under normal circumstances, none of the fetal androgen crosses into the maternal circulation and the efficiency of the aromatization is such that no testosterone accumulates. Placental aromatase deficiency[7,8]allows the fetal androgens and placentally derived testosterone to circulate freely so that both mother and fetus become virilized. If the fetus is genetically female, she will be born with clitoral enlargement and labial fusion. Sex differentiation proceeds normally in affected males. Theoretically, placental sulfatase deficiency would do the same thing to a female fetus because it also prevents placental estrogen synthesis, but it is an X-linked condition and therefore only males are affected.
  39. Guest

    Guest Guest

    ALL INDIA POST GRADUATE MEDICAL EXAMINATION-----2011-MD/MS

    TOTAL NO. OF QUESTION---------300

    1. Most common nerve injured in supracondylar fracture humerus?---RADIAL NERVE(MAHESWARI,B&L)
    2. Earliest symptom of GERD which becomes pathological in an infant is? Respiratory distress
    3. Basal metabolic rate is closely associated with?-----Lean Body mass
    4. A girl presented with recurrent occipital headache associated with ataxia and vertigo. There is history of Mother having similar complaints.Most probable diagnosis WRONG
    5. Drug of choice for central Diabetes Insipidus is? Desmopressin
    6. A 32 year old mountaineer has a hematocrit of 70%.---Polycythemia with relative dehydration
    7. Tetracycline is used in the prophylaxis of which of the following diseases?---- Cholera
    8. A 7 month old child presents with complaints of recurrent bouts of cough.-A. Nasophayngeal swab
    9. Aflatoxin is produced by?------Aspergillus flavus
    10. Most important prognostic factor in congenital diaphragmatic hernia?---AGE OF SURGERY
    11. A surgeon removed the part of liver to the left of the falciform ligament. ------Ans: B 2 & 3
    12. Punnett square is used for---Finding genotype of offspring
    13. Cavitation in lungs is seen in?---Ans: D Staphylococcal Pneumonia
    14. All are false with respect to PSUDOHYPOPARATHYROIDISM except?---N/A
    15. Difference between follicular carcinoma and follicular adenoma is-: A Vascular invasion
    16. Antidepressant drug that can be used in nocturnal eneuresis?--Ans: A Imipramine
    17. A 40yr old female patient presented with depressed mood, loss of appetite and no interest in surroundings for the past 1yr. There is associated insomnia. These symptoms followed soon after a business loss 1yr back.Which of the following statements is true regarding the management of this patient?---:B--SSRI
    18. An Infant is brought to the casualty with reports of violent shaking by parents. Most characteristic injury is?----:C Subdural hematoma
    19. Gun powder on clothing can be visualized by------C. Infrared rays
    20. All have polysaccharide capsule related antigen antibody response except? C Bordetella pertusis
    21. Signature fracture refers to?------ Depressed fracture
    22. Which among the following is most frequently seen in anti phospholipid antibody syndrome?(Pls CORRECT Q)----Ans: D Anti beta 2 GP Ab
    23. What factor is responsible for deciding whether an antibody will remain membrane bound or get secreted?-----C Differential RNA Processing--N/A
    24. Blood Chimerism is associated with?-------B Monochorionic diamniotic twins
    25. In expectant management of placenta praevia, all are done except?----A Cervical encirclage
    26. Whichdrugisnot in the conduct of labour inawoman with rheumatic heart diseaseMethylergometrine
    27. Which is not an autoimmune disease?----Sickle Cell Disease
    28. All are true regarding selective estrogen receptor downregulator (SERD),fulvestrant except?
    Ans: C It’s slower acting and less efficacious than SERM
    29. A farmer developed swellings in the inguinal region which later ulcerated and associated with constitutional symptoms. What stain can be used to detect the bipolar stained organisms?B. Waysons stain
    30. An 8 year old boy completed 8 out of 10 day course of cefaclor. Now he developed a generalized erythmatic rash which is mildly pruritic and associated lymphadenopathy. Diagnosis is?---KAWASAKI
    31. Rave drug is?--------------- WRONG
    32. How to differentiate ASD from VSD in X-ray?-------PULMONARY CONGE.
    33. Regarding an imbecile, all are true except?----------------: A IQ is 50-60
    34. Which is not true regarding diet modificat recomnded in high cardiovascular risk group?-Cholesterol less then 100 mg/1000kcal/day
    35. Maintenance dose of which of the following drugs is used worldwide for opioid dependence?-Methadone
    36. Best test/Gold standard test for assessing betaHCG function/action?----- Radioimmunoassay
    37. Vitamin K is involved in the posttranswerlational modification of?------A Glutamate
    38. Spinal anaesthesia is given at which level?------- L2-4
    39. A child presented with mild fever little breathlessness was treated and she improved over 4 days but later deteriorated again with fever and more breathlessness. x ray showed hyperlucency. diagnosis?
    Ans: A Bronchiolitis obliterans(REPEAT)
    40. Which of the following passes through foramen magnum?-----Vertebral artery
    41. McKeon's theory on reduced prevalence of TB?----Medical advancement
    42. Which among the following is not a cause of fasting hypoglycemia?---- Glucagon excess
    43. Mineralocorticoid receptor is not present in?---------- Liver
    44. Prolonged treatment with INH leads to deficiency of?--------------- Pyridoxine
    45. Which is the most reliable objective sign of identifying pulmonary plethora in chest X-ray?
    Ans: C Diameter of the decending Rt pulmonay artery >16mm
    46. Necrotizing lymphadenitis is seen in?----Kikuchi disease
    47. NARP syndrome is seen in?---- Mitochondrial disorder
    48. A 65 yrs old lady presented with a swollen and painful knee. On examination, she was found to have grade III osteoarthritic changes. What--------B. Arthroscopic washing
    49. Causes of primary amenorrhoea are all except?----C Sheehan syndrome
    50. Integrase inhibitor approved for treatment of HIV is?---A. Raltegravir
    51. Deoxygenated blood is not seen in----- Umbilical vein
    52. All of the following are pneumatic bones except?------ Mandible
    53. Which of the following is not a contraindication for pregnancy?--- WPW syndrome
    54. Which of the following antihypertensive drugs is contraindicated in a patient on Lithium in order to prevent toxicity?-----Diuretics
    55. Superior vena caval syndrome is most commonly caused by?----C. Non small cell lung ca
    56. Which of the following is not an adverse effect of thalidomide?--------Diarrhea
    57. Blount’s disease is: N/A
    58. A teenaged girl complains of pain in knee on climbing stairs and on getting up after sitting for a long time. What is the probable diagnosis?------ Chondromalacia patellae
    59. Which of the following is not included in parenteral nutrition?-------C Fibre
    60. Sparrow marks are seen in?------- WRONG
    61. Amphotericin B causes deficiency of?------WRONG
    62. All are seen in injury to common peroneal nerve except?----- loss of sensation over the sole
    63. Cause of premature death in schizophrenia?------ Suicide
    64. Epileptic potential is present in---------WRONG
    65. Which of the following anesthetic drugs is contraindicated in a patient with hypertension?--- WRONG
    66. All of the following decrease bone resorption in osteoporosis except?---- Teripartide
    67.OndonicellsandHallercellsareassociatedwiththefollowingstructuresrespectivel?Optic nerve and Orbital floor
    68. Pain sensation from the ethmoid sinus is carried by---------- Nasociliary nerve
    69.-Which among the following is not used to treat alcohol dependence?----- Disulfiram
    70. A 40yr old patient has a single kidney with an exophytic mass of 4 cm size at it’s lower pole. Which among the following is the best course of action?A Partial nephrectomy
    71. 29-Which among the following is the most common fungal infection seen in immuno competent patients?
    B. Candida
    72. All are seen in Argyl Robertson pupil except?---- C Consensual reflex is normal
    73. -A 5 year old boy while having dinner suddenly becomes aphonic and is brought to the casulty for the complaint of respiratory distress. What should be
    the appropriate management?----A. Cricothyroidotomy
    74.Which among the following is a branch from the trunk of brachial plexus?---- WRONG
    75.Orthotolidine test is used for detecting:------------- Chlorine
    76. Which among the following is the most common tumour associated with neurofibromatosis in a child?
    Ans: Juvenile myelomonocytic leukemia
    77. Diaphragm develops from all except:-----D. Cervical myotomes
    78. Erythema nodosum is seen in all except:---- WRONG
    79. Posterior relations of head of pancreas are all except?----- B First part of Duodenum
    80. Multiple sebaceous cysts seen in:----Gardner’s syndrome
    81. Whichamongthefollowingisthehallmarkofacuteinflammation?Vasodilatationandincreasedvascular permeability
    82.True about epidural opioids are all except?-----A. Acts on dorsal horn substantia gelatinosa
    82. Which among the following does not cause hyperpyrexia?----- Alcohol
    83. Allaretrue aboutpheochromocytomaexcept?A 90% are malignant.as per the rule of 10only 10% are malignant
    84. Campylobacter jejuni false is:-------c.humans are reservoir
    85. Which of the following does not cause indoor air pollution? WRONG
    86. Most important and potential agent that can be used in bioterrorism: D. Clostridium botulinum
    87. Earliest to be diagnosed by antenatal USG is?-------Anencephaly
    88. 151. Dose of radiation required for development of haematological syndrome is?-----2.5-5 Gy
    89. Intraoperative myocardial infarction is best diagnosed by:----- TEE
    90. Pseudoisomorphic phenomenon seen in-------- WRONG
    91. A fire breaks out during laser vocal cord surgery. What is not to be done? N/A
    92. Ovoalbumin was injected into a rabbit. What antibody will it produce initially?-----B. IgM
    93. Which insect among the following is not resistant to DDT?------ Phlebotomus
    94. Which virus among the following is least likely to cross placenta?-----B. Herpes simplex
    95. About yaws all are true except:------C. Secondary yaws can involve bones
    96. Weight gain in pregnancy is related to all except?------------------- B Smoking
    97. A3.8 kgbabyofadiabeticmotherdevelopedseizures16hours after birth. Most probable cause isHypoglycemia
    [98 . Regarding PCOD, all are true except?----C Very high prolactin
    99. Which anesthetic modality is to be avoided in sickle cell disease? IV regional anesthesia(REPEAT)
    100. Best marker for intrahepatic cholestasis of pregnancy is?------- B Bile acids
    101. Which of the following is the most probable diagnosis in a young patient with loss of central vision and a normal ERG with no family history?----- BEST disease
    102. Renal calculi associated with proteus infection is:Triple phosphate
    103. The primary action of NO in git is?---:C GI smooth muscle inhibition
    104. A 40 year old female underwent surgery. Post operatively she told the anaesthetist that she was aware of per-operative events. Individual intraoperative awareness is evaluated by (to prevent such instances from occurring)?---:C BIS
    105. All of the following helps in generating oxygen burst for killing bacteria within neurophils except?
    A. NO SYNTHESE
    106. Most common cause of meningoencephalitis in children? Enterovirus
    107. Principle orgenelle involved in the execution of apoptosis is? Mitochondria(REPEAT)
    108. Feature of obstructive azoospermia is? NORMAL Testosterone and FSH(REPEAT)
    109. 'C' in C reactive protein stands for:----WRONG
    110. Buprenorphine is?---- Partial agonist of mu receptor
    111.All are true about aprepitant except? N/A
    112. Time of occurrence of secondary haemorrhage after tonsillectomy? 6 Days
    113. A patient with head injury on examination revealed eye opening in response to pain, inappropriate words and pain localisation. Calculate GCS?--WRONG
    114. A primigravida in 1st trimester had sputum positive for acid fast bacillus. What is the preferred treatment?
    Category 1 DOTS(REPEAT)
    115. HbH is seen in?Deletion of 3 alpha genes
    116. Which among the following is a cardioprotective fatty acid?. Omega-3 fatty acid
    117. What will you give to treat hypothyroidism in a patient with ischemic heart disease? Low dose of levothyroxine
    118. Carrier state is not important in transmission of: Measles(REPEAT)
    119. A schizophrenic patient started on haloperidol 2 days back, comes with complaints of torticollis and orofaciolingual movements. What is the diagnosis? Acute Dystonia
    120. All are true about parvovirus b19 except <10% spread by transplacental route(REPEAT)
    121. Sterile pyuria is present in?-----Renal tuberculosis
    122. A 35 year old female has proximal weakness of muscles, ptosis and easy fatiguability. The best test to Edrophonium test
    123. Denominator in Maternal Mortality Rate? Total live births(REPEAT)
    124. Psammoma bodies are seen in all except? Follicular carcinoma thyroid(REPEAT)
    125. Visceral larva migranswer is seen in? Toxocara canis
    126. Urethral crest is situated in:A Prostatic urethra
    127. People were separated into relevant 5 sub groups. People were selected randomly from these sub groups. What type of sampling was done?A CLUSTER sampling
    128. All of the following are true about erlotinib except? Food decreases its absorption
    129Best marker for open nural tube defect. A Acetylcholinesterase(REPEAT)
    130. Arthropod transmitted disease not found in India?----------------Yellow fever
    131. A 55 year old man presents with history of 5 episodes of hematuria each lasting for about 4-5 days in the past 5 years. What will be the best investigation to arrive at a diagnosis?-----C. Abdominal USG
    132. A graph of Normal blood sugar level curve and Diabetic blood sugar level curve was shown. An area was seen overlapping towards the normal gycemic curve. A point at 120 mg/dl was shown too. Question : What does that area represent?---------B. False positive
    133. Which among the following not used in diagnosis of insulinoma?----- xylose test
    134. All are true about Nesidioblastosis except ? N/A
    135. Gold standard test for diagnosis of laryngopharyngeal reflux? WRONG
    136. Acoustic neuroma involvesI
    137. A patient had running nose and pain over medical aspect of eye. He later developed chemosis,protosis and diplopia on abduction of right eye with---- Cavernous sinus thrombosis(REPEAT)
    138. An anesthesia resident was giving spinal anaesthesia when the patient had sudden aphonia and loss of consciousness. What could have happened? VASOVAGAL
    139. Urea cycle occurs in:-----A. Liver
    140. Right isomerism is?---------------WRONG
    141. Definitive airway is all except?------ LMA
    142. A primigravida at 37 weeks of gestation with loss of engagement and Cervix 1cm dilated for the past 10hrs. What is management? WRONG
    143. Regarding anterior choroidal artery syndrome, all are true except?---------------N/A
    144. A 15 day old baby came with history of seizures. Blood tests revealed Ca 5mg/dl, PO4 9mg/dl, PTH 30pg/ml (n=10-60). What is the most probablendiagnosis?----WRONG
    145. Thiamine deficiency causes decreased energy production because?D It is a co-enzyme for pyruvate dehydrogenase & alpha ketoglutarate dehydrogenase
    146. Mother to baby transmission of HIV can be minimised by all except?Vaginal delivery(REPEAT)
    147. True regarding leptospirosis is Ans: C? Rats are the only reservoirs
    148. 18 year old male presents with hemetemesis, melena and splenomegaly. What is the probable initial diagnosis?NCPF(REPEAT)
    149. Following are true about carbohydrate antigen except?-------------------N/A
    150. Ideal age for surgery in unilateral undescended testis is? 12months
    151. A 45 year old lady presented with DUB & USG finding of 8mm thick endometrium. What is the next step?Endometrial histopathology(REPEAT)
    152. Fallopian tube immotility is seen in? Karteagener syndrome(REPEAT)
    153. First structure to be fixed after amputation is? Bone fixing
    154. Poor prognostic factor for ALL is? t(9;22) t(4;11)
    155. Most potent activator of T cells? Mature dendritic cells(REPEAT)
    156.Not a disorder of protein misfolding ? WRONG
    157. Aortic knuckle shadow on PA CXR, obliterated by consolidation of which portion of lung? Posterior part of upper lobe. (reference is still inadequate)
    158. CT least accurate for:
    159.Best investigation for bone metastases: Bone scan
    160. Compliance is decreased in all except? Chronic bronchitis
    161. A 70yr old presents with intemittent jerks of recent origin, EEG showing bilateral periodic spikes. What is the most probable diagnosis? CJD
    162. Pulmonary toxicity is seen with? Bleomycin
    163. 92 young male presented with history of fever and a nodule in the leg. Histopathology of the nodule revealed foamyhistiocytesandneutrophillic infiltratein the dermis. Most probable diagnosis is?Sweet syndrome
    164. Medical treatment for variceal bleed is by? Octreotide
    165. All are true statements regarding use of sodium fluoride in the treatment of otosclerosis except?
    Ans:A inhibits osteblastic activity(REPEAT)
    166. A patient who was given primaquin develops hemolysis. Diagnosis is G6PD deficiency
    167. true regarding ranula?--- It is a cystic swelling in the floor of mouth
    168.Which of the following is not an evidence based treatment for menorrhagia?Ethamsylate(REPEAT)
    169. A 3.8 kg baby of a diabetic mother developed seizures 16 hours after birth. Most probable cause is?
    Hypoglycemia(REPEAT)
    170. 74 coarctation of aorta mc asso with------ Bicuspid aortic valve(REPEAT)
    171. Anaesthetic agent with vasoconstrictor is contraindicated in? Finger block(REPEAT)
    172. 63Auto-Rikshaw ran over a child’s thigh, there is a mark of the tyre tracks, it is an Imprint abrasion
    173. Tolerance in opioids develops to all except? WRONG
    174. The bifurcation of Common carotid artery is palpated at? Upper border of thyroid cartilage
    175. Pregnant mother at 35 weeks of gestation. What drug can you not give her for treatment of SLE?
    Methotrexate(REPEAT)
    176. All are true about xanthogranulomatous inflammation except? Associated with TB
    177. Clue Cells are seen in : Bacterial Vaginosis (REPEAT)
    178. Which complement component is involved in both classical and alternate pathway? C3(REPEAT)
    179. Which of the following are not associated with menstrual cycle? Estrous Profile
    180. Alkalanization of Urine is done during administration of which of the following chemotherapeutic drugs?
    Ans:A CISPLETIN
    181. The Progesterone in low dose OCP is? -------B.Levonegestrol
    182. Test of Pasterurized milk is performed by:------ Phosphatase test(REPEAT)
    183. All are true about delirium tremens except?--WRONG
    184. Main site of water absorption is:-------Jejunum (REPEAT)
    185. Pentalogy of fallot has which one of following extra entities: ASD(REPEAT)
    186. All of the following are done in management of shoulder dystocia except? Fundal pressure(REPEAT)
    187. About Human Development Index, all are true except? . Life expectancy at 1 year of age(REPEAT)
    188.A 50yr old patient presents with 2 yrs h/o recurrent abdominal pain, radiating to back, relived only by parenteral analgesic. USG & CT confirmed the diagnosis ,appropriate procedure is? Longitudinal Pacreaticojejunostomy
    189. A young lady presents with fever , dysuria and pain abdomen . Uncomplicated acute cystitis was diagnosed . Which of these is false ?----C.1 pus cell per 7 field
    190. In a 5 year old child the burn area corresponding to thesize of palm is equal to WRONG
    191 What is the type of joint seen in the growth plate? Primary cartilaginous joint
    192.The acid base status of a patient is as follows : pH - 7.45, pCO2 - 30 mm of Hg, pO2 - 105 mm of Hg.--------WRONG
    193 A female presents with sings of meningitis. CSF shows gram positive bacilli. It is most probably?
    Ans:A Listeria
    194.A 50 yr lady has history of sprained ankle 2 months back followed by recovery. She now complains of severe pain in that ankle with inability to flex that foot. Physician notes edema and shiny skin in local examination. What is the probable diagnosis:Complex regional pain syndrome 1
    195.Drug given for bone megakaryocyte stimulation in patient of thrombocytopenia..? Oprelvekin
    196. A man presents with maculopapular rash 2weeks after having a painless genital.Causative organism of the condition is: WRONG
    197. A patient with stab injury presents with with omentum protruding in the umbilical area ,vitals stable.The next step in the management of the patient is:-------A.FAST
    198 . Site not affected in posterior cerebral artery infarct is?-----B Pons(Not referenced)
    199. A poison Illuminous, translucent, waxy A Yellow phosphorous
    200 . A pt comes with history of unresponsive fever n cough. xray shows pneumonia,sputum reveals aerobic, gram positive and partially acid fast branching filaments.Causative organism is? Nocardiosis
    201. Which among the following is the best inotrope drug for use in right heart failure with primary pulmonary hypertension? Milrinone
    202. Which of the following helps in generating oxygen burst for killing bacteria within neurophils ?Oxidase
    203. Main blood supply of neck of femur? PROFUNDA FEMORIS
    204. All are actions of muscarinic antagonist except? Contraction of radial muscles of Iris
    205. All are used in the treatment of hot flushes except?------------------N/A
    206. OPTIONS UNCLEAR SO 2 VERSIONS HAVE BEEN PUT UP:
    207. Best treatment option for genuine stress incontinence?.Tension free vaginal taping
    208. Lines of blaschko are: D Lines of development
    209. All are true about meglitinides except?----- WRONG
    210. All are true regarding serotonin syndrome except? Dantrolene is the drug of choice for the condition
    211 All of the following are neuronal tumours except? WRONG
    212. Orthopnoea in right heart failure develops due to?
    A. Reservoir function of pulmonary veins
    213. Commonest cause for bilateral proptosis in children? :CAV.HAEMANGIMA
    214.Most common malignant cause of proptosis in children? Rhabdomyosarcoma
    215. Blood examination of a patient revealed Ca 12.5 and Alkaline Po4 900IU/L. Which of the following investigations need not be done? Urine microscopy
    216. Most useful indicator for acute illness Case fatality rate
    217.Endolymphatic Hydrops is seen in Meniere’s disease
    218. About contrast radiography true is Test dose should be performed if a contrast reaction is suspected
    219. A female with XO genotype and Primary amenorrhoea most likely diagnosis is? Gonadal dysgenesis
    220. 1.Cicatrising alopecia with perifolicular blue-gray pathches (??) is most commonly associated with
    Whitish lesion in the buccal mucosa
    221.Transfer of an amino group from an amino acid to an alpha keto acid is done by?Transaminases
    222. True about gastric carcinoma is? Often associated with achlorhydria/hypochlorhydria
    223. A boy gets hit by a tennis ball in the eye following which he has complaints of decreased vision. Which of the following tells that blunt injury is due to the ball.--WRONG
    224. False about C.diphtheriae is? Toxin production is chromosome mediated
    225. True regarding drug resistance of MRSA? Due to change in penicillin binding receptors
    226. Muscular component of dorsal aorta develops from? B. Paraxial mesoderm
    227. Dental numbering is done by all except?------------------N/A
    228. False about pneumococcus is? Meningitis caused by it is milder than other organisms
    229. False regarding Japanese encephalitis is:------A. Epidemic is 2-3 cases in a village
    230. True in keto acidosis is..------- Decreased Hco3
    231. A 6 week old male infant was brought in a state of dehydration and shock. Examination revealed hyper pigmentation over the body with normal external genitalia. Blood tests revealed hypoglycemia, Na - 124 mEq/L and K - 7 mEq/L. What is the probable diagnosis ?----A. Congenital adrenal hyperplasia
    232. All of the following are true regarding diabetes mellitus except? Insulin is not used in type 2 DM
    233. Which among the following is an early sign of magnesium toxicity? Loss of DTR
    234. All of the following are affected in low radial nerve palsy except? WRONG
    235. A man connected to a body plethysmograph exhales against a closed glottis. What will be the finding?
    C. The pressure in the lungs decreases, but that in the box increases
    236. A patient presents with fever and abdominal pain. Clinical examination reveals hepatomegaly extending 4 finger breadths below the costal margin. USG reveals a 5cm*5cm*4cm hypodense lesion 1cm deep to liver surface. Tests for hydatid disease were -ve. Best course of action is?--B. Catheter drainage with antiamebics and antibiotics
    237. All are true about blood coagulation except?---Intrinsic pathway can be activated in vitro
    238. Late onset endophthalmitis after lens implantation is caused by?---PSEUDO
    239. All are seen in the floor of 3rd ventricle except? N/A
    240. Which among the following is not a component of hypogastric sheath?Broad ligamnent of uterus
    241. A patient presents with signs of pneumonia. The bacterium obtained from sputum was gram positive cocci which grew on sheep agar. What test is used to identify the type of organism?(Question stem incomplete---though it seemed like pneumococcal pneumonia) WRONG
    242. True about platelet function defect? . Normal platelet count with prolonged bleeding time
    243. After removal of pituitary for craniopharyngioma, first drug given is? Cortisone
    244. A 5 year old child presented with ballooning of perpuce while micturition. Perpuce adhesions were present. What is the best treatment for him? Circumscision
    245. Which of the following process in a vector is used to increase the yield of protein produced in recombinant protein synthesis? Promoter induction-------------N/A
    246. Which of the following is not associated with atherosclerotic plaque formation? WRONG
    247. Least common cause of ambiguous genitalia in a female child----w4 MUTATION
    248.A patient presented to the with bluish pigmentation of conjunctiva, mucous membranes, nails. What is the poison:------ARSENIC
    249.ECG is poor at detecting ischaemia in areas supplied by?----Left circumflex
    250.Which of the following is a contraindication for medical treatment in gallstones?--Radio opaque stones
    251. Which of the following is not supplied by the anterior division of mandibular nerve (V3) ?WRONG
    252. Drugs used in prophylaxis of migraine are all except?----- Levetiracetam
    253.Most effective microbial killing system-------Reactive oxygen species
    254. Slide fixing in pathology most commonly done by-----WRONG
    255. Ophtalmoplegic migraine..--Ans:B.Recurrent transient 3rd nerve palsy after headache
    256. Patient having pain in epigastrium which radiates to back, serum amylase is normal, on x ray gall stone seen and pancrease appeares bulky...Acute Pancreatitis
    257. During TURP, surgeon takes care to dissect above the verumontenum so as to prevent injury to?
    WRONG
    258. Which organ obtained from a cadaver is not used for transplantation?----Bladder
    259. Baby born at 33 weeks / 1.5 kg should be started on?--Oral nasogastric tube/alternate oral route
    260.Which of the following drug is not used for medical treatment of diabetic retinopathy?---.Tamoxifen
    261.Patient prestent with high TSH, low T4, what is the diagnosis?-WRONG
    262.Pastient present with epigastric pain which radiates to the back and relieved by food, patient have history of such pain in past for which he was taking analgesics and in past 5 years 2 times operated for duodenal ulcer. What is the diagnosis------Duodenal Ulcer
    263. All are factors responsible for resurgence of malaria except-----Ans:B. Use of bed nets
    264. What is false about lipoproteins.---Oxidize LDL not present in foam cells
    265. 1yr old child present with growth failure,dry skin and palpable thyroid,with low thyroid harmones and a high TSH, what is cause?----D. TSH Receptor mutation(?)
    266.Rise in end tidal CO2 during thyroid surgery can be due to all except:-----Anaphylaxis
    267. All are true except:-----Ans:D. Blue bag contents are always disposed in secure landfill
    268. Most common site of obstruction after TURP?-----C. Prostatic membranous urethra
    269. Which of the following is true?--- Ethanol inhibits aldehyde dehydrogenase when used in methanol poisoning
    270. Small air way has laminar flow because?-------Extremely low velocities
    271. A neonate delivered at 38 weeks of gestation, birth weight of 2.2kg develops intolerance to feeds on 2nd day. Physical examination reveals no abnormalities. Sepsis screen in negative. And PCV is 70% What is the next step in management?
    B. Presumptive trearment of sepsis
    272.Not a part of national screening program?------B. Dental caries
    273.All are true regarding phagocytosis by protozoa except?--Phagocytose particles of <0. 5 mic size
    274. In L5 root involvement, which among the following is not affected?---A. Thigh adduction
    275. 14.A sewer worker presented with fever. Lab findings revealed renal failure with increased BUN and serum creatinine. What is the most appropriate drug to give him?---- Benzyl penicillin
    276. All are true about ranalozine except?N/A
    277. A lady who presented with hematuria on evaluation was found to have stage 2 transweritional cell carcinoma of bladder. Which of the following is true?--70% chance of requiring cystectomy in 5 yrs
    278.Which is not seen in digoxin toxicity?----D. Regularisation of AF
    279. A 6 year old child presents with pain and tenderness in hip in femoral triangle region.limitation of movements, X-ray does not reveal any abnormality. What is the next step?-----C. Aspiration
    280. All are true about world health report 2008 except?----Ans:D Economic reforms
    281. Regarding Clostridium tetani, all are true except?----. Spores are resistant to heat
    282.A child presents with abdominal pain only during passage of stools. No other symptoms like vomiting or blood in stools. There are no signs of intestinal obstruction. Most probable diagnosis is?
    Ans: Most probable answer A Rectal polyp
    283. True regarding chlamydia trachomatis is? A. Culture of purulent endocervical discharge is used for isolation of organism
    284.A 5 yr old boy presented with leukocoria in right eye ball, while other eye had 2-3 small lesions in the periphery. What will be the ideal management for this patient?-----B. Enucleation of right eye & conservative management for the other eye
    285. A patient presented with an abdominal injury with peritonitis and shock. Airway, breathing and IV fluids for circulation were taken care of. What is the next step of management----. Take the patient for laparotomy under GA
    286.Two plants are grown. One genetically endowed with ability to produce a green fluorescent pigment and the other with firefly luciferase.Which plant will glow in the dark?----A. Both plants will glow
    .287.Mr X is a chronic smoker. His family insists on quitting smoking. He is thinking about quitting, but is reluctant to do so because he is worried that on quitting he will become irritable. This is?
    A. Precontemplation and preparation
    288.Which of the following is Contra indicated in a patient with seizures/epilepsy?-- OCP
    289.8 yr old with sign of meningitis and ear infections with ring enhancement in the fronto temporal lobe all can cause it except------Ans:A STREPTO
    290.Vectors don't transmit infection by?----Ans: A Ingestion
    291.A investigator finds out that 5 independent factors influence the occurrence of a disease. Comprision of multiple factors responsible for a disease can be assessed by?
    A. ANOVA
    292.About diabetes insipidus all true except D.Pre test serum osmolarity >288, before giving vasopressin.
    293.All are non delmeas for control of mosquito except?WRONG
    294.In superior oblique palsy diplopia is :-----Ans: C.HORIZ. and down
    295.Ttrue about prion------a.catalyses folding of other proteins
    296. Methods of fusing two cells in genetic recombination techniques are all except?N/A
    297. Which among the following does not cause hyperpyrexia?---B. Alcohol
    298 . Arthropod transmitted disease not found in India?----C Yellow fever
    299.Direct standardisation is used to compare the mortality rates between two countries.This is done because of the difference in:---C Age distributions
    300. Which among the following is preferred in a patient with decreased renal functio to avoid contrast nephropathy?----N acetylcysteine
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    Indications for aspiration of amoebic
    liver abscess
    J. DE LA REY NEL, A. E. SIMJEE, A. PATEL ..
    TABLE I. INDICATIONS FOR ASPIRATION
    Negative AGDTALA in the left lobe adjacent to the diaphragm
    ALA in the superficial anterior part in left lobe
    ALA in the right lobe adjacent to the diaphragm
    Any ALA above 10 cm in diamete

    TABLE IV. PATIENTS WITH INDICATIONS FOR ASPIRATION
    Remaining non-aspiration group
    1 adjacent to diaphragm
    Remaining aspiration group
    ALAs> 10 cm in diameter
    adjacent to diaphragm
    left lobe anterior superficial

    TABLE VII. MODIFIED INDICATIONS
    No improvement clinically within 48 - 72 h
    Abscesses causing marked tenderness or severe pain
    All large abscesses (> 10 cm in any dimension)
    Superficial abscesses (anterior and inferior if > 10 cm in diameter)
    Marked elevation of the diaphragm (adjacent to the right dome of diaphragm)
    Left lobe abscesses (left lobe adjacent to the diaphragm or closer than 2 cm)
    Negative AGDT
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    Oculomotor nucleusFrom Wikipedia, the free encyclopediaJump to: navigation, search
    Brain: Oculomotor nucleus

    Section through superior colliculus showing path of oculomotor nerve.

    The cranial nerve nuclei schematically represented; dorsal view. Motor nuclei in red; sensory in blue. (Oculomotor is "III")
    Latin nucleus nervi oculomotorii
    Gray's subject #188 807
    NeuroNames hier-483

    The fibers of the oculomotor nerve arise from a nucleus in the midbrain, which lies in the gray substance of the floor of the cerebral aqueduct and extends in front of the aqueduct for a short distance into the floor of the third ventricle. From this nucleus the fibers pass forward through the tegmentum, the red nucleus, and the medial part of the substantia nigra, forming a series of curves with a lateral convexity, and emerge from the oculomotor sulcus on the medial side of the cerebral peduncle.

    The nucleus of the oculomotor nerve does not consist of a continuous column of cells, but is broken up into a number of smaller nuclei, which are arranged in two groups, anterior and posterior. Those of the posterior group are six in number, five of which are symmetrical on the two sides of the middle line, while the sixth is centrally placed and is common to the nerves of both sides. The anterior group consists of two nuclei, an antero-medial and an antero-lateral .

    The nucleus of the oculomotor nerve, considered from a physiological standpoint, can be subdivided into several smaller groups of cells, each group controlling a particular muscle.

    A nearby nucleus, the Edinger-Westphal nucleus, is responsible for the autonomic functions of the oculomotor nerve, including pupillary constriction and lens accommodation.
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    Discuss the monitoring of virus infections in pregnancy

    Several viruses from different virus families can cross the placenta to cause congenital infection in the fetus, or infect the baby perinatally as it passes through the birth canal of the mother. Occasionally, this may result in severe consequences for the baby. Therefore, it is essential to investigate any febrile diseases or those with a rash during pregnancy, so that appropriate steps may be taken. The following virus infections may be transmitted vertically from the mother to child.

    Rubella

    Cytomegalovirus

    Herpes Simplex

    Varicella Zoster

    Enteroviruses

    Parvovirus

    HIV

    HBV

    Others eg. HCV, LCM

    Rubella

    Primary maternal rubella infection in the first trimester of pregnancy carries devastating consequences for the fetus. There is almost a 100% chance of developing severe congenital malformations if the infection occurred within the first eight weeks of pregnancy. Fortunately, primary rubella infection in the mother is usually symptomatic, presenting with a maculopapular rash, fever, and possibly arthralgia. Therefore, medical opinion is usually sought and the illness investigated by the laboratory. Termination of pregnancy is the usual recommendation for any laboratory confirmed cases of primary maternal rubella occurring in the first trimester of pregnancy.

    Since primary rubella infection is usually symptomatic, there is little justification in the routine screening of the mother's blood for the presence of acute rubella infection in the first trimester of pregnancy. All suspected contacts with rubella in early pregnancy should be investigated. In many countries including the UK, the mother's blood which is taken at the antenatal booking clinic is screened for the presence of rubella antibodies and hence past immunity, and so that non-immune women may be offered rubella vaccination after birth.

    CMV

    In countries with a successful immunization policy against rubella, CMV has replaced rubella as the leading viral cause of mental handicap. Congenital infection may follow primary or recurrent CMV infection during any stage of pregnancy. Most congenital infections are asymptomatic. A minority (5-10%) of congenitally infected infants present with symptoms of cytomegalic inclusion disease. A further 5-10% of asymptomatic infants will develop late sequelae such as hearing defects later on. There is a 1 in 25 chance of an infant born with cytomegalic inclusion disease if the mother contracts a primary CMV infection during pregnancy. The actual figure for recurrent infection is unknown but the incidence of cytomegalic inclusion disease is much higher in infants congenitally infected following primary CMV infection than recurrent CMV infection.

    Unlike rubella, most CMV infections, whether primary or recurrent, are asymptomatic. Occasionally, primary CMV infection may result in an infectious mononucleosis like syndrome. Therefore, in order to monitor for active CMV infection, one would have to take repeated urine specimens throughout pregnancy for CMV culture. Alternatively, one may screen for primary maternal infection only. A primary infection may be diagnosed in hitherto known seronegative women by carrying out repeated IgM tests throughout pregnancy. Both screening policies would involve a lot of manpower and resources and are not justifiable, unless one is prepared to recommend termination of pregnancy to all diagnosed cases of CMV infection during pregnancy.

    HSV

    Neonatal HSV infections occurs at an incidence of between 1 in 2500 to 1 in 10000 live births. Most infections are acquired by the infant as it passes through the birth canal of the mother. Genital herpes in the mother is an obvious predisposing factor, although the majority of infected infants are born to mothers who have no signs or symptoms of active infection at the time of delivery but in whom asymptomatic shredding of HSV occurs. Premature rupture of the membranes is also a risk factor. The indications for an elective caesarean section are controversial but the majority of obstetricians would recommend it in the presence of a florid primary maternal infection at the time of labour. Recurrence of genital herpes is not an indication for caesarean section. Since shredding of HSV from the genital tract is common and neonatal HSV is rare, there is no justification for the routine screening for HSV shredding in pregnant women. Florid primary genital herpes infection can be diagnosed by clinical recognition with or without laboratory confirmation.

    Varicella-Zoster

    Very rarely, varicella infection in early pregnancy may result in the virus crossing the placenta to cause a severe characteristic congenital varicella syndrome in the fetus. VZV may also cross the placenta in the end-stage of pregnancy to cause neonatal varicella, which may range from mild to severe. Varicella in the mother usually presents with a characteristic rash which could be confirmed by laboratory investigations. Contacts with known cases of varicella during pregnancy should be investigated by screening the mother for immunity against VZV. Non-immune mothers should be offered varicella-zoster immunoglobulin as a prophylaxis against infection.

    Enteroviruses

    Like VZV, enteroviruses can cross the placenta in the end-stage of pregnancy to cause a potentially severe disease in the neonate. Typically, the mother presents with a fever a few days before delivery. In this cause, faecal and other specimens from the mother should be cultured for enteroviruses. If enterovirus infection is confirmed, it may be opportune to give human normal immunoglobulin to the baby to reduce the severity of the infection.

    Parvovirus

    Parvovirus infection during pregnancy, especially the second trimester of pregnancy may lead to fetal distress and natural abortion by causing hydrops fetalis in the fetus. Parvovirus is not associated with any congenital defects and therefore there are no indications for the routine screening of parvovirus infection in pregnancy. Since parvovirus cause a similar clinical picture to rubella, it is important to exclude rubella infection.

    HIV

    The rate of vertical transmission of HIV varies from around 15% in Europe to up to 50% in some countries in Africa. The question of whether to or not to screen for HIV antibodies in women attending antenatal clinics is a very difficult one as it involves ethical and legal considerations. Such a policy would probably not be justified in low prevalence areas such as the U.K., where anonymous studies carried out on pregnant women showed a low prevalence. Antenatal screening may be justified in high prevalence areas such as Central Africa. Another argument in favour of screening is that anti-HIV agents given to the mother has now been shown to be effective in preventing the transmission of HIV to the infant.

    HBV

    There is a 80% chance of transmission of hepatitis B virus vertically from mother to child if the mother is an e antigen positive carrier. Most infected infants will become carriers and thus liable to develop cirrhosis and hepatocellular carcinoma later on in life. Most vertical infections occur perinatally and postexposure prophylaxis is possible with hepatitis B vaccine and immunoglobulin. Vertical transmission is the main mechanism for the maintenance of the high prevalence of hepatitis B in areas of high endemicity. Therefore, antenatal screening for hepatitis B surface antigen in pregnant women would be justified in areas of high prevalence. However, even in areas of low prevalence such as the U.K., there is movement towards the implementation of antenatal screening, so that infants of mothers who are hepatitis B positive may be protected by prophylaxis.

    Others

    Other viruses such as hepatitis C, Japanese B encephalitis, LCM virus and lassa fever have rarely been reported to cause congenital infections. Since such occurrences are rare, there are no indications for antenatal screening. One should however be aware of the possible effects on the fetus if such infections were diagnosed during pregnancy. HTLV-I may be transmitted vertically from the mother to child, usually via breast milk. In countries where HTLV-I infection is prevalent such as Japan, it may be beneficial to screen all pregnant women so that seropositive women can be advised against breast feeding once the child is born.

    To conclude, the detection and monitoring of some virus infections in pregnancy such as HBV and HIV may lead to reduced chances of transmission of the virus to the fetus. However, in other cases such as CMV, the need for monitoring is less clear-cut as nothing could be done to stop transmission except by the termination of pregnancy.
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    Causes of Orthopnea
    By Kay Wagers, eHow Contributor
    A person may sleep more comfortably with her head elevated by several pillows. In some people this is a preference; in others it is an indication that they suffer from orthopnea. The causes of orthopnea can be physical or psychological.



    TheFacts
    Orthopnea is a breathing problem characterized by difficulty breathing while lying down. Most patients who experience orthopnea wake up short of breath during the night. Some patients experience shortness of breath so acutely they need to sleep propped up in a sitting position rather than lying in bed to keep their head elevated in order to breath deeply. Orthopnea can be caused by heart, lung and sleep apnea problems[/b
    Cardiac
    Orthopnea may be related to cardiac conditions, including hypertensive heart disease and congestive heart failure. A patient with hypertensive heart disease has a weakened heart that is less capable of pumping blood throughout the body. When he lies down, blood volume is redistributed throughout the body, making it more challenging for the heart to pump blood away from the lungs. This can cause shortness of breath. A patient with congestive heart failure may have a similar experience when lying down and can also awaken breathless because of orthopnea.
    Lung
    Pulmonary problems can also cause orthopnea, including chronic obstructive pulmonary disease -- COPD. A patient with COPD often experiences swelling of and increase mucus levels in the main airways of the lungs. Pulmonary congestion like that is usually relieved when a patient hold his body erect in a standing or sitting position. When he lies down in bed at night to sleep, congestion worsens, leading to trouble breathing and possibly triggering orthopnea.
    Anxiety Disorder
    Some patients with anxiety disorders characterized by panic attacks can also experience orthopnea. Symptoms of a panic attack include chest pain, intense feelings of fear, and the sensation that you cannot catch your breath. If a panic attack is triggered at night while a patient is asleep, she may awaken unable to breathe and experiencing orthopnea.
    Sleep Apnea
    Some of the causes of sleep apnea can also cause orthopnea. In sleep apnea, a patient experiences episodes of stopped breathing during sleep, often lasting longer than 10 seconds. Causes can include nasal obstruction, a narrow airway in the throat and large tonsils. These may also lead to difficulty breathing normally while lying down.
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    MTX (methotrexate, MTX for the anti-tumor, anti-folate chemotherapy drugs, a larger amount of treated tumors, a higher incidence of adverse reactions, 20% to 30%. We use a small dose of a single injection of MTX , the number of small, less adverse reactions. MTX major adverse reactions: gastrointestinal reactions: oral mucosal erosion, ulcers, vomiting; suppression of bone marrow granulocyte; long-term use of large doses can damage the liver; occasional hair loss, rashes, irregular menstruation; liver renal insufficiency disabled. mifepristone does not increase the compatibility of its adverse effects. mifepristone treatment of ectopic pregnancy is the mechanism of competitive progesterone receptor, progesterone inhibited the activity of the degenerative villi, decidua atrophy necrosis. It is also acting on the hypothalamus-pituitary, inhibition of FSH, LH secretion, progesterone-dependent maintenance of pregnancy termination, accelerated degeneration and necrosis of villi, fetal death. synergistic effect of both good successful rate. Practice has proved that Early diagnosis of ectopic pregnancy is critical, MTX with mifepristone for small mass, blood HCG low, mild clinical symptoms in patients with ectopic pregnancy. conservative treatment for young women of childbearing requirements, in particular, the contralateral fallopian tube had been resection or significant lesions. In recent years the rate of early diagnosis of ectopic pregnancy increased, the common ruptured tubal pregnancy in abortion were increased before the diagnosis, conservative surgical treatment to reduce pain and improve the chances of another pregnancy
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    Mefipristone, a Medical Treatment for Fibroids, is Not Looking Good
    Low-dose mifepristone in treatment of uterine leiomyoma: a randomised double-blind placebo-controlled clinical trial.

    Authors: Bagaria M, Suneja A, Vaid NB, Guleria K, Mishra K.

    Study from: Department of Obstetrics and Gynaecology, University College of Medical Sciences, Delhi, India.

    Problem: So far, no medication has worked to relieve symptoms of fibroids. In early studies, one drug that appeared to be promising was Mefipristone (RU-486). Progesterone causes fibroid cells to grow and Mefipristone blocks this effect.

    Study: The study included 40 women with bothersome symptoms from fibroids; 20 women were taking mifepristone and 20 were taking a placebo. None of the women or their doctors knew what pill they were taking.

    Fibroid-related symptoms, the size of the uterus and size of the largest fibroid were measured with ultrasound at the beginning of the study and every month for three months. A biopsy of the uterine lining cells was done at the beginning and again at the end of treatment.

    Results: Women who were taking Mefipristone had a 95% decrease in menstrual blood loss after three months Complete relief of menstrual cramping occurred in 80%, but only 33% patients were free of pelvic pain. Women taking the placebo pills had no change in any symptoms. Backache, bladder problems and pain with intercourse were not better in either group.

    The size of the uterus and size of the largest fibroid were about 30% smaller by the end of the third month of therapy. Women taking Mefipristone had an increase in haemoglobin (red blood cells) from 9.5 to 11.2 . However, 63% of women taking mefipristone had benign overgrowth of the uterine lining cells (endometrial hyperplasia without atypia).


    Authors’ Conclusions: A low dose of mifepristone taken for three months is effective in reducing menstrual bleeding and reducing uterine and fibroid sizes, but has the side-effect of causing uterine lining cell overgrowth.
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    Malartic and associates (2008) stated that mifepristone can reduce uterine fibroid tumors' growth by several pathways. Its efficiency has been widely evaluated in symptomatic patients for more than 10 years. A significant decrease in fibroid tumors and uterine volume concomitant with better quality of life scores can be obtained with the administration of 5-mg daily doses of mifepristone. Mifepristone can be compared with gonadotropin-releasing hormone agonists in terms of efficiency. Observed adverse outcomes are hot flushes (38 %), elevated hepatic enzymes (4 %) and benign endometrial hyperplasia (28 %). Hot flushes and endometrial hyperplasia are not observed with 5-mg daily doses. Data suggest that many invasive procedures could be avoided with the routine use of mifepristone for fibroid tumors care. However, the authors noted that published study periods are only 3 to 12 months; long lasting evaluation in larger groups of patients seems necessary before this treatment could be proposed as routine care.

    In a review on medical management of fibroids, Sankaran and Manyonda (2008) stated that two progesterone antagonists, mifepristone and asoprisnil, have shown significant promise and warrant further research. This is in agreement with the observations of Lethaby and Vollenhoven (2008) who noted that limited short-term evidence of 2 progestogenic therapies indicates that low-dose mifepristone may improve quality of life and bleeding in the short-term, and asoprisinil may improve bleeding and fibroid-related symptoms. They stated that more research is needed on the role of hormonal therapies for women with fibroids
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    HBV is present in high concentrations in blood, serum, and serous exudates and in moderate concentrations in saliva, vaginal fluid, and semen; efficient transmission occurs through blood exposure and sexual contact. Risk factors for HBV infection in children and adolescents include intravenous acquisition by drugs or blood products, acupuncture or tattoos, sexual contact, institutional care, and intimate contact with carriers. No risk factors are identified in ≈40% of cases. HBV is not thought to be transmitted via indirect exposure such as sharing toys. In children, the most important risk factor for acquisition of HBV remains perinatal exposure to an HBsAg-positive mother. The risk of transmission is greatest if the mother is also HBeAg positive; up to 90% of their infants become chronically infected if untreated; intrauterine infection occurs in 2.5% of their infants. In most cases, serologic markers of infection and antigenemia appear 1–3 mo after birth, suggesting that transmission occurred at the time of delivery; virus contained in amniotic fluid or in maternal feces or blood may be the source. Immunoprophylaxis of those infants is very effective in preventing infection and protects >95% of neonates. Of the 22,000 infants born each year to HBsAg-positive mothers in the United States, >98% receive immunoprophylaxis and are thus protected.

    Nelson Textbook of Pediatrics, 18th ed
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    williams gyni
    Treatment

    Suction curettage is the preferred method of evacuation regardless of uterine size in patients who wish to remain fertile (Tidy, 2000). Other surgical procedures, however, may be employed for specific indications. For example, hysterectomy may be performed with preservation of the ovaries if a woman wishes surgical sterilization. Additionally, theca-lutein ovarian cysts regress after delivery but may be aspirated if symptomatic (Berkowitz, 1996). Oophorectomy, however, should not be performed except for rare circumstances when torsion of an ovary enlarged by theca-lutein cysts leads to extensive ovarian infarction (Mungan, 1996).

    Prior to surgery, patients are evaluated for the presence of associated medical complications. Fortunately, thyroid storm from untreated hyperthyroidism, respiratory insufficiency from trophoblastic emboli, and other severe coexisting conditions are rare. Because of the tremendous vascularity of these placentas, blood products should be available prior to the evacuation of larger moles, and adequate infusion lines should be established.

    At the beginning of the evacuation, the cervix is dilated to admit a 10- to 12-mm plastic Karmen suction cannula (see Fig. 41-17.3). As aspiration of molar tissues ensues, intravenous oxytocin is given. At our institution, 20 units of synthetic oxytocin is mixed with 1 L of crystalloid and infused at rates to achieve uterine contraction. Finally, a thorough, gentle curettage is performed (see Section 41-17, Suction Dilatation and Curettage). Intraoperative sonography may assist in documenting complete evacuation.

    Following curettage, because of the possibility of partial mole and its attendant fetal tissue, Rh immune globulin should be given to nonsensitized RhD-negative women. Rh immune globulin, however, may be withheld if the diagnosis of complete mole is certain (Fung Kee, 2003).

    Hydatidiform Mole (Molar Pregnancy)

    Hydatidiform moles are abnormal pregnancies characterized histologically by aberrant changes within the placenta. Specifically, the chorionic villi in these placentas show varying degrees of trophoblastic proliferation and edema of the villous stroma. Based on the degree and extent of these tissue changes, hydatidiform moles are categorized as either complete hydatidiform moles or partial hydatidiform moles (Table 37-2). Cytogenetic studies have shown that chromosomal abnormalities play an integral role in the development of hydatidiform moles (Lage, 1992). Overall survival from these potentially malignant conditions has been virtually 100 percent for the past few decades (Lurain, 1983).Table 37-2 Features of Complete and Partial Hydatidiform Moles


    Feature
    Complete Mole
    Partial Mole

    Karyotype
    46,XX or 46,XY
    69,XXX or 69,XXY

    Pathology

    Fetus/embryo
    Absent
    Present

    Villous edema
    Diffuse
    Focal

    Trophoblastic proliferation
    Variable, may be marked
    Focal and minimal

    p57Kip2 immunostaining
    Negative
    Positive

    Clinical presentation

    Typical Diagnosis
    Molar gestation
    Missed abortion

    Postmolar malignant sequelae
    15–20%
    2–4%


    Complete Hydatidiform Mole

    Karyotype and Histology

    Classically, these molar pregnancies differ from partial moles with regard to their karyotype, their histologic appearance, and their clinical presentation. Complete moles typically have a complete diploid karyotype, and 85 percent of these are 46,XX. The chromosomes, however, in these pregnancies are entirely of paternal origin. In a process termed androgenesis, the ovum is fertilized by a haploid sperm, which then duplicates its own chromosomes after meiosis (Fig. 37-1) (Fan, 2002; Kajii, 1977). Although most of these moles are 46,XX, dispermic fertilization of a single ovum can produce a 46,XY karyotype (Lawler, 1987).

    Pathogenesis of complete and partial moles. A. A 46,XX complete mole may be formed if a 23,X-bearing sperm penetrates a 23,X-containing egg whose genes have become "inactive". Paternal chromosomes then duplicate to create a 46,XX chromosomal complement solely of paternal origin. Alternatively, this same type of egg can be fertilized independently by two sperm, either 23,X- or 23,Y-bearing, to create a 46,XX or 46,XY chromosomal complement, again of paternal origin only. B. A partial mole may be formed if two sperm, either 23,X- or 23,Y-bearing, both fertilize a 23,X-containing egg. The resulting fertilized egg is triploid. Alternatively, a similar haploid egg may be fertilized by an unreduced diploid 46,XY sperm.

    Microscopically, complete moles display enlarged, edematous villi and abnormal trophoblastic proliferation that diffusely involve the entire placenta (Fig. 37-2). Macroscopically, these changes transform the chorionic villi into clusters of vesicles with variable dimensions. Indeed, the name hydatidiform mole stems from this "bunch of grapes" appearance. In these pregnancies, no fetal tissue or amnion is produced. As a result, this mass of placental tissue completely fills the endometrial cavity.

    Histologic photograph of a complete hydatidiform mole. Villi have extensive stromal edema. (Courtesy of Dr. Raheela Ashfaq.)


    Photograph of gross complete hydatidiform mole specimen. Note the grape-like fluid filled clusters of chorionic villi. (Courtesy of Dr. Raheela Ashfaq.)

    Clinical Findings

    The clinical presentation of a complete mole has changed considerably over the past few decades. More than half of patients diagnosed in the 1960s and 1970s had anemia and uterine sizes in excess of that predicted for their gestational age. In addition, hyperemesis gravidarum, preeclampsia, and theca-lutein cysts developed in approximately one quarter of women (Montz, 1988; Soto-Wright, 1995).

    Complete moles, however, present infrequently today with these traditional signs and symptoms (Coukos, 1999). As a result of -hCG testing and sonography, the mean gestational age at evacuation currently approximates 12 weeks, compared with 16 to 17 weeks in the 1960s and 1970s (Drake, 2006; Soto-Wright, 1995). Vaginal bleeding remains the most common symptom and still occurs in virtually all patients. One quarter of women will present with a uterine size greater than dates, but the incidence of anemia is less than 10 percent. Moreover, hyperemesis gravidarum, preeclampsia, and symptomatic theca-lutein cysts are observed rarely (Lazarus, 1999; Mosher, 1998; Soto-Wright, 1995). Currently, these sequelae typically occur chiefly in patients without early prenatal care who present with a more advanced gestational age and markedly elevated serum -hCG levels (Osathanondh, 1986).

    Plasma thyroxine levels are often elevated in women with complete moles, but clinical hyperthyroidism is unusual and is identified in only approximately 5 percent of patients (Amir, 1984; Berkowitz, 1987). In these circumstances, serum free thryoxine levels are elevated as a consequence of the thyrotropin-like effect of -hCG (see Chap. 15, Peptide Hormones in Reproduction) (Hershman, 2004).

    Partial Hydatidiform Mole

    These moles vary from complete hydatidiform moles clinically, genetically, and histologically. The degree and extent of trophoblastic proliferation and villous edema are decreased compared with that in complete moles. Moreover, most partial moles contain fetal tissue and amnion in addition to placental tissues.

    As a result, patients with partial moles typically present with signs and symptoms of an incomplete or missed abortion. Most women will have vaginal bleeding, but because trophoblastic proliferation is slight and only focal, uterine enlargement in excess of gestational age is uncommon. Similarly, preeclampsia, theca-lutein cysts, hyperthyroidism, and other dramatic clinical features are rare (Stefos, 2002). Pre-evacuation -hCG levels are lower than those for complete moles and often do not exceed 100,000 mIU/mL. For this reason, partial moles are often not identified until after a histologic review of a curettage specimen.

    Partial moles have a triploid karyotype (69,XXX, 69,XXY, or less commonly, 69,XYY) that is composed of one maternal and two paternal haploid sets of chromosomes (see Fig. 37-1) (Lawler, 1991). Nontriploid partial moles have been reported, but probably do not actually exist (Genest, 2002b). The coexisting fetus present with a partial mole is nonviable and typically has multiple malformations with abnormal growth (Jauniaux, 1999).

    Differential Diagnosis

    In reproductive-aged women with vaginal bleeding, diagnoses may include gynecologic causes of bleeding and complications of first-trimester pregnancy (see Chaps. 6, Threatened Abortion, and 8, Diagnosis). Therefore, initial urine or serum -hCG measurement is invaluable in guiding the diagnostic evaluation.

    Diagnosis of Hydatidiform Mole

    First-trimester diagnosis of hydatidiform mole is now common because of the routine use of serum -hCG measurements and transvaginal sonography. An important characteristic of molar pregnancy is its tendency to produce excess -hCG due to trophoblastic proliferation. As a result, serum -hCG levels commonly are greater than that expected for the gestational age (Sasaki, 2003).

    Although -hCG levels are helpful, the diagnosis of molar pregnancy more frequently is found sonographically because of the identifiable diffuse swelling and enlargement of the chorionic villi. Most first-trimester complete moles demonstrate a typical sonographic appearance: a complex, echogenic intrauterine mass containing many small cystic spaces. Fetal tissues and amnionic sac are absent (Fig. 37-4) (Benson, 2000). In contrast, sonographic features of a partial molar pregnancy include a thickened, hydropic placenta with a concomitant fetus (Zhou, 2005).

    Sonogram of complete hydatidiform mole. The classic "snowstorm" appearance is created by the multiple placental vesicles, which completely fill this uterine cavity. (Courtesy of Dr. Elysia Moschos.)

    Despite the utility of these tools, there are diagnostic limitations. For example, Lazarus and colleagues (1999) reported that -hCG levels in early molar pregnancies may not always be elevated in the first trimester. These same investigators also found that sonography could lead to a false-negative diagnosis if performed at very early gestational ages, before the chorionic villi have attained the characteristic vesicular pattern (Lazarus, 1999). For example, only 20 to 30 percent of patients may have sonographic evidence suggestive of a partial mole (Johns, 2005; Lindholm, 1999; Sebire, 2001). Consequently, the preoperative diagnosis in early gestations is usually difficult and commonly not made until after a histologic review of the abortal specimen.

    Pathologic Diagnosis

    Histopathology

    The histopathologic changes typical of a complete and partial mole are listed in Table 37-2. There is no single criterion that distinguishes these hydatidiform moles from each other or from nonmolar gestations.

    Complete moles characteristically have two prominent features: (1) trophoblastic proliferation and (2) hydropic villi. In gestations younger than 10 weeks, there are striking differences, however, from these classic findings. In these early gestations, hydropic villi may not be apparent, and molar stroma still may be vascular (Paradinas, 1997). As a result, complete moles now often must be characterized by more subtle morphologic alterations. Unfortunately, this can result in their misclassification as partial moles or nonmolar spontaneous abortions (Fukunaga, 2005; Mosher, 1998).

    Partial moles are reliably diagnosed when three or four major diagnostic criteria are demonstrated: (1) two populations of villi, (2) enlarged, irregular, dysmorphic villi (with trophoblast inclusions), (3) enlarged, cavitated villi (3 to 4 mm), and (4) syncytiotrophoblast hyperplasia/atypia (Chew, 2000). Good diagnostic reproducibility still can be achieved in most circumstances using these histologic distinctions of complete and partial mole.

    Ploidy Determination

    Determination of the type of molar gestation clearly can be enhanced by combining histopathology with ploidy determination. Flow cytometry is a technique for counting, examining, and sorting cells that are suspended in a stream of fluid. With this tool, multiple physical or chemical characteristics of single cells can be analyzed simultaneously as they flow through an optical electronic detection apparatus. A second cytometry method, automated image cytometry, uses optical images of several hundred cell nuclei to identify subtle morphologic changes within tissues. Both techniques can analyze cellular ploidy and can be used to distinguish complete moles (diploid) from partial moles (triploid) (Fig. 37-5). Automated image cytometry, however, has been shown to be more sensitive than flow cytometry in making this distinction (Crisp, 2003a).

    Composite diagram of differences between normal hydropic products and partial or complete hydatidiform moles. Tissues that are negative for staining are blue, whereas those positive for staining are brown. The extent (percent cells staining) equates to low, medium, or high expression. Note the progressive increase in Ki-67 and a progressive reduction in p57KIP2 (p57) staining when comparing normal hydropic products of conception with partial and complete moles. First, KI-67 is a proliferation marker and is most prominently expressed in complete moles. In contrast, p57 is a nuclear protein whose gene is paternally imprinted and maternally expressed, meaning that the gene product is produced only in tissues containing a maternal allele. Because complete moles contain only paternal genes, the p57 protein is absent in complete moles. However, this nuclear protein is strongly expressed in spontaneous pregnancy losses with hydropic change. Finally, the DNA ploidy graphs show normal diploid pattern in hydropic contents and in complete moles, whereas the DNA peak is triploid (DNA index 1.5) in partial moles. (Courtesy of Dr. Raheela Ashfaq.)


    Immunostaining

    In addition to ploidy analysis, histologic immunostaining techniques also can clarify the diagnosis. p57KIP2 is a nuclear protein whose gene is paternally imprinted and maternally expressed, meaning that the gene product is produced only in tissues containing a maternal allele. Because complete moles contain only paternal genes, the p57KIP2 protein is absent in complete moles (Merchant, 2005). In contrast, this nuclear protein is strongly expressed in normal placentas, spontaneous pregnancy losses with hydropic change, and partial hydatidiform moles (Castrillon, 2001). Accordingly, immunostaining for this nuclear protein is a practical and accurate adjunct to ploidy analysis in the pathologic classification of hydatidiform moles (Castrillon, 2001; Genest, 2002a). p57KIP2 staining has the additional advantage of differentiating hydropic abortuses from complete moles, a distinction not made by ploidy analysis (Merchant, 2005). As a result, complementary use of ploidy analysis and p57KIP2 status now can help to distinguish among a diploid hydropic spontaneous abortion (p57KIP2-positive), a diploid complete mole (p57KIP2-negative), and a triploid partial mole (p57KIP2-positive) (Fig. 37-5) (Crisp, 2003).

    In summary, most complete and partial moles are readily identifiable and present little diagnostic difficulty. Those with borderline histology can be resampled in an attempt to confirm the classic features shown in Table 37-2. Ancillary testing with ploidy analysis or p57KIP2 staining is useful for diagnostic, educational, and quality assurance purposes, but these adjunctive tests should not become the mandatory "gold standard" for routine clinical practice because they are neither perfect nor universally available (Genest, 2001).

    Treatment

    Suction curettage is the preferred method of evacuation regardless of uterine size in patients who wish to remain fertile (Tidy, 2000). Other surgical procedures, however, may be employed for specific indications. For example, hysterectomy may be performed with preservation of the ovaries if a woman wishes surgical sterilization. Additionally, theca-lutein ovarian cysts regress after delivery but may be aspirated if symptomatic (Berkowitz, 1996). Oophorectomy, however, should not be performed except for rare circumstances when torsion of an ovary enlarged by theca-lutein cysts leads to extensive ovarian infarction (Mungan, 1996).

    Prior to surgery, patients are evaluated for the presence of associated medical complications. Fortunately, thyroid storm from untreated hyperthyroidism, respiratory insufficiency from trophoblastic emboli, and other severe coexisting conditions are rare. Because of the tremendous vascularity of these placentas, blood products should be available prior to the evacuation of larger moles, and adequate infusion lines should be established.

    At the beginning of the evacuation, the cervix is dilated to admit a 10- to 12-mm plastic Karmen suction cannula (see Fig. 41-17.3). As aspiration of molar tissues ensues, intravenous oxytocin is given. At our institution, 20 units of synthetic oxytocin is mixed with 1 L of crystalloid and infused at rates to achieve uterine contraction. Finally, a thorough, gentle curettage is performed (see Section 41-17, Suction Dilatation and Curettage). Intraoperative sonography may assist in documenting complete evacuation.

    Following curettage, because of the possibility of partial mole and its attendant fetal tissue, Rh immune globulin should be given to nonsensitized RhD-negative women. Rh immune globulin, however, may be withheld if the diagnosis of complete mole is certain (Fung Kee, 2003).

    Postmolar Surveillance

    Incidence of Gestational Trophoblastic Neoplasia Following Hydatidiform Mole

    Gestational trophoblastic neoplasia (GTN) develops after approximately 15 to 20 percent of complete moles (Soto-Wright, 1995; Wolfberg, 2004). Despite the trend of diagnosing these abnormal pregnancies at earlier gestational ages, this incidence has not decreased (Seckl, 2004; Soto-Wright, 1995). Of those women who develop GTN, three quarters have locally invasive molar disease, and the remaining one quarter develop metastases.

    In contrast, GTN develops in only 2 to 4 percent of partial moles following evacuation (Goto, 1993; Lavie, 2005). A lower reported incidence (0.5 percent) of GTN following partial mole in the United Kingdom may reflect more stringent diagnostic criteria (Bagshawe, 1990; Seckl, 2000). Malignant transformation into metastastic choriocarcinoma does occur but fortunately is exceedingly rare (0.1 percent) (Cheung, 2004; Seckl, 2000).

    Beta-Human Chorionic Gonadotropin Levels

    There are no pathologic or clinical features at presentation that accurately predict which patients ultimately will develop GTN (Rice, 1990). Because of the trophoblastic proliferation that characterizes these neoplasms, serial serum -hCG levels following evacuation can be used to effectively monitor patients for development of GTN. Therefore, postmolar surveillance with serial quantitative serum -hCG levels should be the standard. Titers should be monitored following uterine evacuation at least every 1 to 2 weeks until they become undetectable.

    Historically, 6 months of surveillance after achieving an undetectable -hCG levels was recommended for all patients with molar gestation. Unfortunately, poor compliance with 6 months of monitoring has been reported—especially among indigent women and certain ethnic groups (Allen, 2003; Massad, 2000). In addition, pregnancies conceived within 6 months of achieving undetectable -hCG levels complicate the monitoring schedule but are otherwise uneventful (Tuncer, 1999). As a result, several studies have evaluated and recent data support the safety of significantly shortening the duration of surveillance. It appears that a single blood sample demonstrating an undetectable level of -hCG following molar evacuation is sufficient to exclude the possibility of progression to GTN. Patients may then be discharged safely from routine surveillance thereafter (Batorfi, 2004; Feltmate, 2003; Lavie, 2005; Wolfberg, 2004).

    Pregnancies can occur during the monitoring period, and the resulting -hCG production can hinder detection of progression to GTN (Allen, 2003). For this reason, women are encouraged to use effective contraception until achieving a -hCG titer of less than 5 mIU/mL or the threshold of the individual assay. Oral contraceptive pills decrease the likelihood of pregnancy compared with less effective barrier contraception and do not increase the risk of GTN (Curry, 1989). Injectable medroxyprogesterone acetate is particularly useful when poor compliance is anticipated (Massad, 2000). In contrast, intrauterine devices are not to be inserted until the -hCG level is undetectable because of the risk of uterine perforation if an invasive mole is present.

    Prophylactic Chemotherapy

    The purpose of administering chemotherapy at the time of molar evacuation is to prevent the development of GTN in high-risk patients who are unlikely to be compliant with -hCG surveillance. For example, in a prospective, double-blind clinical trial of 60 women who had high-risk complete moles, Limpongsanurak (2001) randomly assigned women to receive either dactinomycin or placebo at the time of evacuation. Prophylactic chemotherapy reduced the incidence of GTN from 50 to 14 percent, but toxicity was significant. In clinical practice, the correct classification of high-risk complete moles, however, is extremely difficult because there is no universally accepted combination of risk factors that accurately predicts GTN development. Moreover, regardless of how a high-risk complete mole is defined, few women ultimately will be assigned to this group. Thus, identification at diagnosis of the women who potentially could benefit from prophylactic chemotherapy is of little overall clinical importance (Parazzini, 1988b).

    As a result, the indications for prophylactic chemotherapy remain controversial (Murad, 1990). Rarely, this strategy may be considered in patients with complete moles and multiple risk factors (age greater than 40 years, previous history of molar pregnancy, and excessively high -hCG titer), particularly if postevacuation -hCG testing is unavailable or poor compliance during surveillance is expected (Berkowitz, 1996). For this reason, prophylactic chemotherapy is not offered routinely and typically is practiced outside the United States and Europe (Uberti, 2006).
  49. Guest

    Guest Guest

    Lung compliance

    Describe the factors that affect lung compliance. (03A14, 1990)
    Definition of compliance
    Compliance
    the slope of the pressure-volume curve at a particular lung volume
    => i.e. volume change per unit of pressure change (mL/cmH2O)
    normal value = 200mLs/cmH2O
    Lower compliance = more effort of breathing
    Specific compliance
    = compliance divided by FRC (/cmH2O)
    normal value = 0.05/cmH2O
    similar values in both sexs and all ages including neonates
    measurement of the intrinsic elastic property of the lung tissue
    Dynamic compliance vs static compliance
    Static compliance is the compliance measured when there is no gas flow into or out of the lung.
    Lung compliance and chest wall compliance
    Compliance is made up of lung compliance and chest compliance
    => 1/Ct = 1/Cl + 1/Ccw
    (Ct = total compliance, Cl = lung compliance, Ccw = chest wall compliance)

    Factors affecting compliance
    Lung elastic recoil
    Lung volume
    Pulmonary blood flow
    History of recent ventilatory
    Bronchial smooth muscle tone
    Disease
    Lung's elastic recoil
    Due to:
    Surface tension in the alveoli
    Stretched elastic fibres in the lung parenchyma
    Surface tension accounts for 70% of the elastic recoil

    Lung volume
    The slope of the P-V curve is not constant across different lung volumes.
    At high lung volumes, compliance is reduced because more pressure is required to stretch the already stretched elastic tissues further.
    At very low volumes, compliance is reduced because of closed airway and collapsed alveoli
    => increased surface tension
    => increased pressure is needed to re-open the airway/alveoli
    => reduced compliance
    At the base of the lung, at very low volumes, compliance is even more reduced because of positive intrapleural pressure

    Posture affects compliance by affecting the lung volume.
    Restriction of chest expansion also affect lung volmen and chest wall compliance.
    Pulmonary blood flow
    Contributes to stiffness of the lung, especially in the case of pulmonary congestion
    History of recent ventilation
    Prolonged periods of hypoventilation without periodic deep breath may lead to reduced compliance.
    Maybe related to atelectasis.
    Bronchial smooth muscle tone
    In animal studies, increased bronchocontriction can lower time constant and reduced dynamic compliance.
    Static compliance is probably not affected.
    Disease
    In diseased lungs, where time constant for the alveolis are different, units with higher time constants are slow to fill and empty.
    With higher respiratory rate, the problem worsens:
    => units with high time constant hypoventilates
    => less lung units participate in volume changes
    => dynamic compliance reduced.
    With collapsed alveoli
    => greatly increased surface tension
    => very high pressure is required to re-open airway/alveoli
    Diseases that REDUCE compliance:
    Fibrosis
    Pulmonary hypertension/congestion
    Alveolar atelectasis
    Reduced surfactant (increased surface tension)
    e.g. artificial ventilation, prematurity
    Diseases that INCREASE compliance:
    Pulmonary emphysema (alteration in elastic tissue)
    -> static compliance is reduced but dynamic compliance is reduced.
    Normal ageing (alteration in elastic tissue)
    Asthma (reason unknown)
    (see West p97)

    Additional notes
    NB: 1/compliance = elastance

    Recoil pressure of the lung (transpulmonary) = alveolar pressure - intrapleural pressure
    Recoil pressure of the chest = intrapleural pressure - atmospheric pressure
    Examiner's comments
    Definition with correct units
    Compliance equation of total lung, chest walls and lung
    Surfactant and its role on surface tension
    Laplace law
    elastic forces and disease states
    lung size
    lung volume and compliance (and FRC)
    Effect of gravity on lung and on compliance
    (extra) other types of compliance: dynamic, static, specific
    (extra) diagrams showing pressure volume loop, hysteresis, compliance curve
    (extra) restrictive lung disease, obstructive lung disease, pulmonary emphysema, pleural effusion
    (extra) differentiation effects of emphysema on dynamic vs static compliance

    To be added later
    Measurement of compliance see Nunn p54
    Elastic forces - lung vs chest wall (20050121-10)

    ? is compliance highest at FRC
    ? diagram of pressure volume loop
    Please don't talk illogogically
  50. Guest

    Guest Guest

    ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery
    A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)


    8.4. Use of TEE
    Class IIa


    The emergency use of intraoperative or perioperative TEE is reasonable to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality. (Level of Evidence: C)

    Transesophageal echocardiography has become increasingly common in the operating room for cardiac surgery but is less frequently used in noncardiac surgery. Multiple investigations have documented the improved sensitivity of TEE for detection of myocardial ischemia compared with ECG or pulmonary capillary wedge pressure measurements. Most studies have used offline analysis of the TEE images, however, and automated, online detection may increase its value.

    There are few data regarding the value of TEE-detected wall-motion abnormalities to predict cardiac morbidity in noncardiac surgical patients. In 2 studies from the same group, intraoperative wall-motion abnormalities were poor predictors of cardiac morbidity. In 1 study involving 322 men undergoing noncardiac surgeries, TEE demonstrated an OR of 2.6 (95% CI: 1.2 to 5.7) for predicting perioperative cardiac events.487 Although regional wall-motion abnormalities in a high-risk patient suggest myocardial ischemia, resolution of myocardial ischemia may not result in improvement of wall motion.

    There is emerging evidence demonstrating the utility of TEE to alter the management of patients undergoing cardiac surgery; however, interpretation of TEE requires additional education. Many anesthesiologists are expert in this technique, but others have limited or no training. Currently, there is insufficient evidence to determine the cost-effectiveness of TEE for its use as a diagnostic monitor or to guide therapy during noncardiac surgery; therefore, the routine use of TEE in noncardiac surgery does not appear warranted. In contrast, emergent use of intraoperative or perioperative TEE to determine the cause of an acute, persistent, and life-threatening hemodynamic abnormality is indicated. Guidelines for the appropriate use of TEE have been developed by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologist


    9.2. Intraoperative and Postoperative Use of ST-Segment Monitoring
    Class IIa


    Intraoperative and postoperative ST-segment monitoring can be useful to monitor patients with known CAD or those undergoing vascular surgery, with computerized ST-segment analysis, when available, used to detect myocardial ischemia during the perioperative period. (Level of Evidence: B)

    Class IIb


    Intraoperative and postoperative ST-segment monitoring may be considered in patients with single or multiple risk factors for CAD who are undergoing noncardiac surgery. (Level of Evidence: B)

    The presence of intraoperative and postoperative ST-segment changes has been associated with cardiac morbidity and mortality in high-risk patients undergoing noncardiac surgery. Most contemporary operating rooms and ICU monitors incorporate algorithms that perform real-time analysis of the ST segment. Numerous studies have demonstrated the limited ability of physicians to detect significant ST-segment changes compared with computerized or offline analysis. Computerized ST-segment trending is superior to visual interpretation in the identification of ST-segment changes. Because the algorithms used to measure ST-segment shifts are proprietary, variability in accuracy between the different monitors has been evaluated in several studies compared with offline analysis of standard Holter recordings. ST-segment trending monitors were found to have an average sensitivity and specificity of 74% (range 60% to 78%) and 73% (range 69% to 89%), respectively, compared with Holter ECG recordings.529 Several factors have been identified that decreased the accuracy of the monitors and have been discussed in detail elsewhere. Additionally, the lead system used affects the incidence of ischemia detected, with leads II and V5 detecting only 80% of all episodes detected by a 12-lead ECG in 1 study, whereas another study found that V4 was the most sensitive lead (83.3%).

    Virtually all studies examining the predictive value of intraoperative and postoperative ST-segment changes have been performed with ambulatory ECG recorders. Using retrospective analysis, investigators have found postoperative ST-segment changes indicative of myocardial ischemia, primarily ST-segment depression, to be an independent predictor of perioperative cardiac events in high-risk noncardiac surgery patients in multiple studies, with changes of prolonged duration (greater than 30 minutes per episode or greater than 2 hours cumulative duration in different studies) being particularly associated with increased risk. In a review of studies involving more than 2400 patients between the years 1990 and 2003, Landesberg reported a sensitivity of perioperative ischemia in predicting postoperative cardiac events of 55% to 100%; the specificity was 37% to 85%, the positive predictive value was 7% to 57%, the negative predictive value was 89% to 100%, and the relative risk of suffering a postoperative cardiac event, including cardiac death, in patients with ischemia ranged between 2.2% and 73%. Postoperative ST-segment changes, particularly of a prolonged duration, have been shown to predict worse long-term survival in high-risk patients.

    In a cohort of patients older than 45 years with 1 risk factor but without known CAD, the presence of intraoperative and postoperative ST-segment changes was not associated with either ischemia on an exercise stress test or cardiac events within 1 year.536 The total cohort of patients was small, which may limit the ability to generalize these findings.

    Intraoperative ST-segment changes may also occur in low-risk populations. ST-segment depression has been shown to occur during elective cesarean sections in healthy patients.537,538 Because these changes were not associated with regional wall-motion abnormalities on precordial echocardiography, in this low-risk population, such ST-segment changes may not be indicative of myocardial ischemia and CAD.

    Thus, although there are data to support the contention that ST-segment monitoring detects ischemia, no studies have addressed the issue of the effect on outcome when therapy is based on the results of ST-segment monitoring. However, general consensus is that early treatment, such as control of tachycardia, could lead to a reduction in cardiac morbidity.

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