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Monocytes/macrophages are also present in secretions and in most tissues cheap exelon 3mg visa, where they phagocytose unwanted microbes generic exelon 3 mg amex. Mucus itself is a protective film that traps organisms and debris generic 3 mg exelon visa; it also contains antibacterial substances. A 26-year-old female patient has had recurrent infections with pyogenic organisms. She has a follow-up appointment with you today to discuss her options. You remember that complement is a major mech- anism by which the innate immune system can act and that certain complement deficiencies can cause disease. Which of the following statements regarding the complement cascade is false? The alternative pathway requires antibodies for initiation B. The three complement pathways are the classical pathway, the alterna- tive pathway, and the lectin pathway C. The membrane attack complex (MAC) allows perforation via channel or pore formation into the foreign membrane D. C3 degradation occurs spontaneously all the time, and C3 fragments bind to host cells and foreign cells; however, regulatory proteins on host cells protect cells by inactivating such fragments Key Concept/Objective: To understand the complement system and its pathways The complement system lies at the interface between innate and acquired immunity. As a key component of innate immunity, it promotes the inflammatory response and attacks and destroys foreign substances. Inherited deficiencies of components in the activating cascade predispose to infectious diseases, primarily of a pyogenic type; surprisingly, such deficiencies also predispose to autoimmunity, especially systemic lupus erythematosus (SLE). The early part of the complement system is divided into three branches: the anti- body-initiated classical pathway; the antibody-independent (i. Although each branch is triggered differently, all share the common goal of depositing clusters of C3b on a target. This dep- osition results in the assembly of a common lytic mechanism called the MAC or C5b-9. The alternative pathway is an ancient pathway of innate immunity. Unlike the classical path- way, the alternative pathway does not require antibody for initiation. Rather, the natural breakdown (low-grade turnover) of plasma C3 via spontaneous cleavage of a highly reac- tive thioester bond allows such C3 to attach to any nearby host or foreign surface. Regulatory proteins on host cells protect cells by inactivating such fragments. However, foreign membranes usually do not possess such inhibitors, so amplification (the feedback loop of the alternative pathway) becomes engaged. As a further assault against a pathogen, the alternative pathway assembles the MAC. In this case, the C5 convertase (C3bBbC3bP) cleaves C5 to C5b. This promotes assembly of C6 + C7 + C8 and multiple C9s to allow per- foration (channel or pore formation) into the foreign membrane. A 32-year-old African-American woman with systemic lupus erythematosus (SLE) presents to your office for an examination. Her disease course has been complicated by hemolytic anemia, renal disease, syn- ovitis, and rash. Her current regimen consists of low-dose prednisone. During her visit, she says she has done some research on the Internet and wants to know if her SLE is caused by a problem with complement. Which of the following statements regarding complement is false?

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Local slowing and local impulse blockade of sensory fibers order 6mg exelon with amex, and decreased or absent sensory nerve action potentials with stimulation proximal and distal of a lesion can be observed generic exelon 1.5mg without a prescription. Several techniques are used to detect these changes cheap exelon 4.5mg amex, including stimulation at different sites, comparison of conduction properties in adjacent nerves (median/ulnar) and the “inching” technique. NCV can be used intraoperatively, mainly by orthopedic and neurosurgeons, to facilitate decisions in surgery and nerve surgery. While the measurement of motor nerves at the extremities is methodological- ly easy, the measurement of NCVs of proximal nerve segments is problematic. For some proximal motor nerves, like the long thoracic and femoral nerves, only the latencies can be assessed with certainty. Age, height, and temperature are also factors that have to be considered. Sensory NCV studies Unlike motor conduction, where a terminal branch and synapse contribute to latency, no synapse occurs between the stimulating site and recording site in a sensory nerve. Sensory nerve action potentials (SNAPs) can be measured in both the orthodromic and the antidromic direction. This means that stimulation of the main (mixed) nerve trunk results in a signal at the distal sensory nerve, or conversely stimulation of the distal sensory branch yields a signal at the nerve trunk. The studies can be done with surface recordings, or recording with needle electrodes using a near-nerve technique. Antidromic techniques with surface recording are commonly used. Near-nerve recordings are time-consuming but are able to pick up even low signals, and allow the assessment of several populations conducting at different velocities (dispersion), which may be nec- essary for diagnosis in sensory neuropathies. Sensory nerve studies are more sensitive than motor studies at detecting nerve pathology. Sensory responses are more sensitive to temperature than motor responses in regard to conduction velocity, but not to nerve action potential amplitude. Correction factors or warming of the extremity must be considered. Radiculopathies do not affect the sensory potentials, as the dorsal root ganglion, which lies within or outside the neural foramen, is not affected. This can be useful if electrophysiology is needed to distinguish between radiculop- athy and plexopathy or neuropathy. References Kline DG, Hudson AR (1995) Nerve injuries. WB Saunders, Philadelphia Rivner MH, Swift TR, Malik K (2001) Influence of age and height on nerve conduction. Muscle Nerve 24: 1134–1141 Rutkove SB (2001) Effects of temperature on neuromuscular electrophysiology. Muscle Nerve 24: 867–882 Rutkove SB (2001) Focal cooling improves neuronal conduction block in peroneal neuro- pathy at the fibular neck. Muscle Nerve 24: 1622–1626 Late responses Late responses (e. F wave) are techniques to obtain information about the proximal portions of the nerve and nerve roots. This is important because few studies permit access to proximal parts of the PNS. It is generated by normal or pathologic axon branching. It may occur in neuropathies, possibly due to sprouting. It has a variable latency and amplitude and can be confused with A waves. It is clinically used to evaluate proximal portions of the nerves. The blink reflex has a reflex arc consisting of an orthodromic trigeminal nerve and an orthodromic motor facial nerve loop.

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Recent x-rays of the lumbar spine and pelvis were interpreted as being normal buy cheap exelon 6mg online. Of the following generic exelon 3mg on line, which is the best step to take next in the management of this patient? Perform bone scan of the spine and pelvis 12 BOARD REVIEW D 4.5 mg exelon fast delivery. Key Concept/Objective: To understand the diagnosis of ankylosing spondylitis This patient has classic inflammatory low back pain. In addition, he appears to have involvement of the hip and enthesitis (inflammation where connective tissue inserts into bone) of the heel. Analgesic doses of ibuprofen are minimally effective because anti- inflammatory dosages of NSAIDs (i. Determination of the erythrocyte sedimentation rate may confirm the inflam- matory nature of the symptoms; the presence of HLA-B27 is not diagnostic but might sug- gest the presence of a spondyloarthropathy. A bone scan is not specific, and the sacroiliac joints normally take up the radiotracer used in a bone scan. A CT scan of the sacroiliac joints can demonstrate early bony and cartilage changes not visible on regular x-rays—in this case, CT would be the best method of diagnosis. A 44-year-old woman complains of pain and swelling of the right ankle and foot. The symptoms have been present for 4 weeks and are generally worse in the morning. She had an episode of right knee swelling and pain 2 years ago that seemed to have responded to a course of NSAIDs. Her medical histo- ry is significant for hypertension, treated by hydrochlorothiazide, 25 mg/day, and mild scalp psoriasis, treated by tar shampoo. On physical examination, the blood pressure is 130/84 mm Hg, there are sev- eral small patches of hyperkeratosis in the scalp, the right ankle has a moderate effusion, and there is dactylitis of the second and fourth toes on the right foot. Which of the following should be the next step in treating this patient? Perform arthrocentesis of the right ankle and send fluid for culture B. Perform arthrocentesis of the right ankle and send fluid for crystal analysis C. Order x-rays of the foot and ankle to look for evidence of joint ero- sions D. Test for rheumatoid factor to evaluate for possible early rheumatoid arthritis E. Start the patient on piroxicam, 20 mg/day, and have her return in 1 month Key Concept/Objective: To be able to recognize psoriatic arthritis This patient has classic psoriatic arthritis. The diagnosis is based on clinical presentation, because there are no definitive diagnostic tests. The oligoarticular nature of this patient’s arthritis, along with the presence of dactylitis (sausage digits) and scalp psoriasis, makes the differential diagnosis short indeed. Piroxicam is a potent anti-inflammatory, and use of this agent is a reasonable first step in addressing the arthritis. A 30-year-old man who recently experienced an attack of uveitis is referred by an ophthalmologist for evaluation for possible underlying systemic disease. The patient’s episode of uveitis involved the left eye and lasted 3 weeks; the uveitis responded to topical corticosteroids. The patient denies having any pul- monary symptoms, diarrhea, urethritis, peripheral joint pain or swelling, or recent low back pain. When he was in his early 20s, he was involved in a car accident and for several years after experienced low back pain. He is an avid soccer player but has had to avoid playing recently because of plantar fasciitis of the right foot. On examination, the eyes are without inflammation, the lungs are clear, there is no periph- eral joint swelling and no tenderness over the sacroiliac joints, the Schober test demonstrates 3 cm of distraction, and there is tenderness in the right heel at the insertion of the plantar fascia.

Which of the following statements regarding AT-III deficiency is false? AT-III deficiency causes severe arterial thrombosis D purchase exelon 3mg with mastercard. For patients with AT-III deficiency 3mg exelon for sale, the risk of thrombosis increases with age Key Concept/Objective: To understand AT-III deficiency AT-III deficiency is an autosomal dominant trait that affects nearly 1 in 2 order exelon 1.5 mg without prescription,000 people. There are two types of AT-III deficiency: inherited and acquired. The inherited form has two subsets: quantitative deficiency and qualitative deficiency. In some cases, AT-III defi- ciency may be acquired, as with disseminated intravascular coagulation or severe liver dis- ease or through the administration of I. AT-III normally inactivates factor Xa and thrombin; patients with AT-III deficiency show evidence of continuous factor X acti- vation and thrombin generation. The typical presentation of AT-III deficiency is similar to that of other hypercoagulable states. There is no evidence that AT-III deficiency increases the risk of arterial thrombosis. The two hypercoagulable states more closely related to arte- rial thrombosis are the antiphospholipid syndrome and hyperhomocystinemia. A 26-year-old man presents with new-onset left lower extremity swelling and pain of 6 hours’ duration. He takes no medications and has no history of trauma, immobilization, or prior thrombosis. His family history is remarkable for two “blood clots” in his mother. Compression ultrasonography confirms occlu- sive thrombus in the left superficial femoral vein. Which of the following is the most appropriate sequence of interventions for this patient? Start heparin and warfarin immediately, send tests for the hypercoagu- lable state before warfarin reaches therapeutic levels, and discontinue heparin after the international normalized ratio (INR) reaches thera- peutic levels B. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin after 5 days’ overlap C. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin when the INR reaches therapeutic levels D. Start heparin and warfarin immediately, discontinue heparin after 5 days’ overlap, and evaluate for the hypercoagulable state after warfarin therapy is completed E. Evaluate for the hypercoagulable state, but no anticoagulation is indi- cated for superficial thrombophlebitis Key Concept/Objective: To understand the timing of workup and duration of therapy for patients presenting with a new DVT 5 HEMATOLOGY 39 A 26-year-old man presenting with new-onset thrombosis and a positive family history is highly suspicious for a hereditary hypercoagulable state and should be worked up for this. Because the levels of protein C and antithrombin III can be diminished in the setting of acute thrombosis and because heparin and warfarin also alter these levels, the optimal time for the workup is after the patient has completed therapy. Exceptions to this rule include the antiphospholipid antibody syndrome, in which early diagnosis can affect ther- apy and disorders for which specific genotypic tests are available (e. Because the INR (prothrombin time) is heavily depend- ent on factor VII, which has a short half-life, it rises fairly quickly after warfarin is begun. However, therapeutic anticoagulation may take several days longer because of the persist- ence of factor X and prothrombin. Overlapping heparin and warfarin by 5 days is thought to limit the risk of propagation of thrombus caused by delayed therapeutic anticoagula- tion. The confusingly named superficial femoral vein is in fact in the deep system and war- rants therapy. A 58-year-old woman is 2 days’ status post–total hip replacement. She has been receiving subcutaneous heparin as prophylaxis for DVT. You are asked to see the patient to evaluate new-onset dyspnea. On examination, the patient is tachypneic, tachycardic, and diaphoretic. She is agitated and complains of substernal chest pain.

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