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Patients typically do not have renal insufficiency or hyper- tension buy 0.4mg flomax with mastercard. RVT can be diagnosed by computed tomography buy generic flomax 0.4 mg, magnetic resonance imaging purchase flomax 0.4 mg with mastercard, and contrast venography. Doppler ultrasound imaging is notoriously operator depend- ent and therefore should not be used for the diagnosis of RVT. Anticoagulation with warfarin is indicated for patients with RVT. The appropriate duration of therapy is likely lifelong. A 48-year-old white man with no significant medical history presents to your office with fever, weight loss, malaise, and arthralgia. Over the past few weeks, he has developed a purplish rash over his lower extremities and several sores on his toes. He is afebrile, but his blood pressure is 187/92 mm Hg and his heart rate is 97 beats/min. Livedo reticularis and digital ischemia are noted on examination. Laboratory results are significant for a potassium level of 3. Which of the following statements regarding polyarteritis nodosa (PAN) is true? Serologic tests for PAN are diagnostic; most patients exhibit a posi- tive enzyme-linked immunosorbent assay (ELISA) titer to antibodies against serine protease 3 and myeloperoxidase B. The pathogenesis of PAN is unclear, although there appears to be an association with hepatitis C infection C. ACE inhibitors and angiotensin receptor blockers (ARBs) should be used cautiously in patients with PAN because renal involvement may produce a functional equivalent of RAS D. In approximately 90% of patients with PAN, remission is achieved with high-dose steroids Key Concept/Objective: To understand the pathogenesis, diagnostic criteria, and treatment of PAN The pathogenesis of PAN is unclear. There appears to be an association with hepatitis B viral infection. The diagnosis of PAN is made by demonstration of the characteristic lesion in an artery. Serologic tests are not diagnostic in PAN, but low-titer antibodies to rheumatoid factor and nuclear antigen may be present. Immunofluorescence antibody staining for cytoplasmic and perinuclear antineutrophil cytoplasmic autoantibodies (ANCAs) may be positive, but the more specific test—serum ELISA titers for antibodies against both serine protease 3 (PR3) and myeloperoxidase—is negative. If left untreat- ed, patients with PAN have a poor prognosis. In such cases, patients are at risk for ischemia of numerous organ systems; the major causes of morbidity and mortality include renal failure, mesenteric ischemia, and cerebrovascular disease. Corticosteroids and cytotoxic agents have been the mainstays of therapy for idiopathic PAN, although the optimal therapy remains unknown. Approximately 50% of patients with idiopath- ic PAN achieve remission with high-dose steroids (e. ACE inhibitors and ARBs should be used cautiously in patients with PAN, because renal involvement may produce a func- tional equivalent of classic renal artery stenosis. A 54-year-old man presents with a 4-day history of low-grade fever and confusion. His physical examination is significant for pallor and ecchymoses. The peripheral blood smear shows schistocytes and a decreased number of platelets. For this patient, which of the following statements regarding thrombotic microangiopathies (TMAs) is true? When plasma activity of metalloprotease (ADAMTS-13) is elevated, von Willebrand antigens predominate; those antigens bind to platelets and cause aggregation and thrombi in the small vessels B. A presumptive diagnosis of thrombotic thrombocytopenic purpura (TTP) is often based on the presence of thrombocytopenia, schisto- cytes, and prolonged prothrombin time (PT) and partial thrombo- plastin time (PTT) C.

CD4+ (CD8+) T lymphocytes these T cells carry a marker on the surface known as a cluster of differentia- tion (CD) marker which can be either CD4 or CD8 cheap flomax 0.4mg on-line. The CD4+ T cells discount 0.4mg flomax with amex, also known as helper T cells buy cheap flomax 0.2mg online, help orchestrate the antibody responses, and the CD8+ T cells—also called cytotoxic (destructive to cells) or suppressor T cells—are involved in cell-mediated immunity that targets infected cells celiac disease inability to digest and absorb a protein found in wheat, resulting in poor absorption of nutri- ents from the foods because of damage to the lining of the small intestine; also called gluten intolerance or non-tropical sprue cervicitis inflammation of the cervix, the part of the uterus that protrudes into the vagina thefacts 155 AS-App 2(151-172) 5/29/02 5:56 PM Page 156 Ankylosing spondylitis: the facts chromosome a thread-like structure within the nucleus of a cell that contains the genes. There are 46 chromo- somes in the nucleus of a human cell; 22 of them are in pairs that are given the numbers 1–22, and the remain- ing two are the X or Y chromosomes (sex chromo- somes) that determine a person’s sex—males have one X and one Y chromosomes, and females have two X chromosomes Chlamydia trachomatis a bacterium that has a predilection to infect the genitourinary tract. Such an infection is the more commonly recognized initiator of reactive arthritis in the US Clostridium difficile bacteria that are normally present in the large intestine, can cause a serious illness called pseudo-membranous colitis in people taking anti- biotics, and can sometimes trigger reactive arthritis collagen and connective tissue a set of fibrous proteins and supporting framework that form the main building blocks of the body, including the internal organs, liga- ments, tendon, cartilage, bone, and skin conjunctivitis commonly known as pink eye; it is an inflammation of the delicate outer membrane that lines the inside of the eyelids and the white of the eye contracture arthritis or prolonged immobility can result in the involved joint becoming less freely moveable. Associated with shortening and wasting of muscles control group in clinical studies the control group, which is given either the standard treatment for a medical condition under study or an inactive substance (called a placebo), is compared with a group given an experimental treatment to find its efficacy for the disease under study coping the psychological processes following any stress- ful situation cortisone a natural hormone made by the adrenal gland. Sometimes wrongly used as a synonym for corti- costeroids 156 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 157 Appendix 2: Glossary corticosteroids a group of related compounds which, like cortisone, reduce inflammation and irritation caused by many disease processes, including many forms of arthritis, and skin and bowel diseases Crohn’s disease a chronic inflammatory bowel disease (also called ileitis or regional enteritis), that can affect the entire gastrointestinal tract, though it usually involves the lower small intestine, (the ileum) and the adjacent part of the colon C-reactive protein (CRP) its measurement in the blood can be used to detect or grade inflammation cytokine a soluble protein, produced by white blood cells, that acts as a messenger between cells, either stimulating or inhibiting the activity of various cells of the immune system. There is normally a very delicate balance among the various cytokines cytoplasm a liquid compartment in the cell, sur- rounding the central nucleus. The cytoplasm contains mitochondria and other structures or components responsible for normal protein formation, secretion and other cell functions DEXA bone scan a means of measuring the bone density to detect osteoporosis at a much earlier stage as compared to a standard X-ray. X-ray absorption at two different quantum energies or wavelengths disorder a synonym for disease disability in the context of health experience, a dis- ability is a restriction or lack (resulting from an impair- ment) of ability to perform an activity in the manner or within the range considered normal (see WHO, 1980) distal farther away from the trunk. The opposite is proximal DNA a double-stranded, helical molecule that carries genetic information, primarily present within the nucleus of each cell in plants and animals. It tells the cells exactly what to do and how to perform their functions thefacts 157 AS-App 2(151-172) 5/29/02 5:56 PM Page 158 Ankylosing spondylitis: the facts double-blinded a doubled-blinded trial produces more objective and unbiased results because neither the research investigators nor the study participants know who is receiving the investigational drug and who is receiving the placebo duodenum the first part of the small intestine. An ulcer on its inner lining is called a duodenal ulcer dowager’s hump hump in the upper back (thoracic kyphosis) in an elderly woman with osteoporosis dysentery an infectious disease of the intestine that causes bloody, mucus-filled diarrhea, which can be accompanied by abdominal pain or cramps, fever, and dehydration from excessive diarrhea. It is caused by enteric infections, usually with Shigella, and can some- times trigger reactive arthritis elimination diet requirement that certain foods should not be eaten enteritis an inflammation (irritation) of the small intestine enthesis site of attachment of ligament or tendon to bone enthesitis inflammation of an enthesis enthesopathy an all-inclusive term that covers all abnormalities of an enthesis (e. It is the basic unit of heredity; all information in the genes (genetic information) is passed from parent to child generic name see brand name genetic counseling informing people about genetic facts that may guide them in making a decision based on a knowledge of disease risk. The word genetic refers to any characteristic that is inherited genetic marker a gene that is used to identify an indi- vidual disease or trait, or trace its inheritance within a family thefacts 159 AS-App 2(151-172) 5/29/02 5:56 PM Page 160 Ankylosing spondylitis: the facts genitourinary tract the genitalia, the bladder, and the urethral tube through which the bladder empties gut a word in common use to describe the large and small intestine (see bowel, large intestine; small intestine) handicap in the context of health experience, a handi- cap is a disadvantage for a given individual, resulting from an impairment or a disability, that limits or pre- vents the fulfillment of a role that is normal (depend- ing on age, sex, and social and cultural factors) for that individual (see WHO, 1980) H2-blockers medicines such as cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid), used to treat acid indigestion, heartburn, and ulcer pain. They are so called because they act by blocking histamine-2 signals to reduce the amount of acid produced by the stomach heartburn symptoms caused by stomach acid flowing back into the esophagus Helicobacter pylori a corkscrew-shaped bacterium found in the stomach that can predispose to stomach and duodenal ulcers. Previously called Campylobacter pylori heterozygote and homoozygote an individual inherits a set of two alleles for each HLA locus from his or her parents. For instance, an individual may inherit HLA- B27 from one parent and HLA-B8 from the other. Most individuals do not inherit the same gene (belong- ing to a locus) from both parents, and are said to be heterozygotes. HLA-B27, from both parents is homozygous for HLA-B27 HLA human leucocyte antigens. These are cell surface proteins, detected by blood testing, that vary from person to person. They are also called tissue antigens or histocompatibility antigens because ideally organ donors and recipients must have compatible HLA; 160 thefacts AS-App 2(151-172) 5/29/02 5:56 PM Page 161 Appendix 2: Glossary otherwise the transplanted organ is recognized as non- self (‘foreign’) and is rejected. HLA are related to the workings of the immune system; they present self- and foreign-derived (e. They are of two broad types, called class I and class II HLA. Their genes are located on chromosome 6; the loci are given the letters A, B, C, D, and so on HLA-B27 an HLA class I molecule that has been assigned the number 27; its gene is present at the B locus. There are quite a few HLA antigens that confer susceptibility to certain diseases: HLA-B27 to AS, and HLA-DR4 to rheumatoid arthritis, for example hydrotherapy physiotherapy in a pool (usually heated) idiopathic of unknown cause or explanation ileum the major part of the small intestine (see small intestine) ilium (or iliac bone) major bony component of the pelvis. There is one on each side, joined to the sacrum via the right and left sacroiliac joints impairment in the context of health experience, an impairment is any loss or abnormality of psychological, physiological or anatomical structure or function (WHO, 1980) incidence the rate of occurrence of some event, such as the number of individuals who get a disease divided by a total given population, per unit of time (usually per year). In contrast to prevalence, incidence describes the number of new cases of a disease among a certain group of people for a certain period of time, i. It may be acute (as in a burn or in gouty arthritis) or chronic (as in rheumatoid arthritis or chronic infections such as tuberculosis) thefacts 161 AS-App 2(151-172) 5/29/02 5:56 PM Page 162 Ankylosing spondylitis: the facts inflammatory bowel disease a chronic (long-lasting) inflammatory disease of the gut, e. Most joints are composed of cartilage, joint space, fibrous capsule, joint lining (synovium) and ligaments juvenile chronic arthritis arthritis in children 16 years of age or less, that has been present for at least 3 months, and for which no other cause is obvious.

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In the urban cycle purchase flomax 0.2 mg, humans are the vertebrate host and the Aedes aegypti mosquito is the principal vector generic 0.4mg flomax otc. In dry areas and urban centers where water storage practices promote the breeding of Aedes aegypti flomax 0.2 mg fast delivery, this mosquito is responsible for epidemic transmission. Several hundred thousand people are infected yearly, and outbreaks are frequent. Yellow fever causes a full spectrum of disease, from subclinical infection to fatal, fulminant dis- ease. Three common stages of the disease are noted (all of which were experienced by this patient): infection, remission, and intoxication. Bradycardia relative to fever is a nonspecific sign associated with yellow fever. Aedes aegypti is also the primary vector for Dengue fever; however, this patient did not exhibit the characteristic symptoms of myalgias, arthralgias, retroorbital pain, and rash. Haemaphysalis spinigera tick is the vector for Kyasanur Forest disease virus, which is found primarily in Mysore, India. The Hyalomma tick is the vector for Crimean-Congo hemorrhagic fever, which is found in sub-Saharan Africa, Eastern Europe, Russia, the Middle East, and western China. Finally, the Dermacentor pictus tick is the vector for Omsk hemorrhagic fever virus, which is found primarily in western Siberia. A young woman presents to your office with concerns about HIV infection because of previous I. Results of enzyme-linked immunosorbent assay (ELISA) and Western blot assay are positive for HIV. If she is not treated for her HIV infection and gradually develops a low CD4+ T cell count with clinical manifestations of HIV, she has chronic infection B. If she is not treated for her HIV infection and gradually develops a low CD4+ T cell count without clinical manifestations of HIV, she has latent infection C. If she receives antiretroviral therapy and maintains an elevated CD4+ T cell count but maintains low but detectable plasma levels of HIV-1 RNA, she has persistent infection D. If she receives antiretroviral therapy and achieves an undetectable level of HIV-1 RNA, she has latent infection E. If she is also coinfected with HTLV-I and develops manifestations 40 years later, she can be said to have had chronic infection Key Concept/Objective: To understand the difference between latent, chronic, and persistent infection in the context of retroviral infection Three patterns of restricted viral expression are known; all three patterns are important for retroviral infections. Latent infection is characterized by intermittent episodes of acute or subclinical disease with no virus detected between episodes. For example, when HIV-1 RNA levels are suppressed below detectable levels with antiretroviral ther- apy, the infection is described as latent infection. This should be distinguished from clinical latency, in which manifestations of disease disappear in the setting of ongoing viral replication. Chronic infection implies that the virus is demonstrable but disease is absent. Persistent infection is associated with a long incubation period, slowly increas- ing amounts of virus, and, eventually, symptomatic disease. Thus, the asymptomatic patient who is receiving therapy but in whom viral RNA is still detectable has chronic infection, whereas the untreated patient who has slowly increasing amounts of virus and in whom clinical signs and symptoms will eventually manifest has persistent infec- tion. Which of the following statements regarding various clinical manifestations of HTLV-I infection is true? HTLV-I has a high disease penetrance, meaning that most infected patients will eventually show clinical manifestations of infection B. Patients with adult T cell leukemia (ATL) most commonly present with lymphadenopathy in the absence of circulating morphological- ly abnormal lymphocytes C. Patients with HTLV-I–associated myelopathy (HAM) characteristical- ly have hyperreflexia, ankle clonus, extensor plantar responses, and spastic paraparesis D. Hypocalcemia is a classic manifestation of acute and lymphomatous ATL E. HAM characteristically leads to a deterioration of cognitive function 7 INFECTIOUS DISEASE 97 Key Concept/Objective: To understand the various clinical manifestations of HTLV-I infection HTLV-I only infrequently becomes established as a latent infection with expression of viral gene products. The virus thus has a very low level of disease penetrance.

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Many of these people are now being referred to transmission of the pain afferents entering the spinal cord “pain clinics generic flomax 0.2mg without prescription,” where a team of physicians and other health from peripheral pain receptors generic 0.4mg flomax mastercard. The large neurons of the motor strip (in the deeper cortical layers) send their axons as INTRODUCTION projection fibers to form the cortico- bulbar and There are multiple areas involved in motor control cheap 0.2mg flomax visa, which cortico-spinal tracts. It is this cortical strip that is the reason for the title Motor Systems (plural). This cortical nucleus), the cerebellum (with its functional subdivisions), area sends its axons to the motor cortex as well nuclei of the brainstem including portions of the reticular as to the cortico-spinal tract, and its function formation, and finally the output motor neurons of the likely has more to do with proximal joint con- cranial nerve motor nuclei and the spinal cord (the anterior trol and postural adjustments needed for move- horn cells, also known as the lower motor neurons). One way of approaching this complexity is to separate • The supplementary motor cortex is located motor activity into a voluntary system and a nonvoluntary on the dorsolateral surface and mostly on the system. This is an organizing area for • Voluntary motor control involves both direct movements and its axons are sent to the premo- and indirect pathways: tor and motor cortex. These two important large areas of the brain are continuation in the spinal cord, the lateral “working behind the scenes” to adjust and calibrate the cortico-spinal tract. All these areas also receive input from other parts system for the control of proximal joint of the cerebral cortex, particularly from the sensory post- movements and axial musculature, involves central gyrus, as well as from the parietal lobe. Therefore, there are several path- and gravitational changes, as well as visual ways that “descend” through the spinal cord — each with input. The various nuclei of the brainstem (the its own crossing (decussation) and each of which may red nucleus, the vestibular nuclei, and the retic- result in a functional loss of the control of movement, with ular formation) are regulated by older func- a change in responsiveness of the stretch (deep tendon) tional parts of the cerebellum but may be reflexes. This system The motor pathways (tracts) are called descending also controls muscle tone and the deep tendon because they commence in the cortex or brainstem and reflex, the reactivity of the muscle (stretch) influence motor cells lower down in the neuraxis, either in reflex. Those neurons in the cortex or brainstem (including the reticular formation) giving rise There are three areas of the cerebral cortex directly to these pathways are collectively called the upper motor involved in motor control (see Figure 14A, Figure 17, neurons. The motor neurons in the spinal cord or brainstem Figure 53, and Figure 60): that give origin to the peripheral efferent fibers (spinal and cranial nerves) are often called collectively the lower motor • The motor cortex is the precentral gyrus ana- neuron (discussed with Figure 44). The various portions of the body are function- LEARNING PLAN ally represented along this gyrus; the fingers This section will consider the motor areas of the cerebral and particularly the thumb, as well as the cortex, the basal ganglia, the cerebellum, the motor nuclei tongue and lips are heavily represented on the of the thalamus, and the nuclei of the brainstem and retic- dorsolateral surface, with the lower limb on the ular formation involved in motor regulation. This motor standardized diagram of the nervous system will be used “homunculus” is not unlike the sensory homun- © 2006 by Taylor & Francis Group, LLC Functional Systems 121 as with the sensory systems, as well as the inclusion of upper spinal cord that serves to coordinate var- select X-sections of the spinal cord and brainstem. There are both The descending tracts or pathways that will be con- ascending and descending fibers within the sidered include: MLF, from vestibular and other nuclei. The cor- on the dominant side on the dorsolateral surface, a little tico-spinal tract, from cortex to spinal cord, is anterior to the lower portions of the motor areas (see a relatively new tract and the most important Figure 14A). The frontal eye field, in front of the pre- for voluntary movements in humans, particu- motor area, controls voluntary eye movements (see Fig- larly of the hand and digits — the direct volun- ure 14A). A typical human fibers that go to the reticular formation include those that form part of the indirect voluntary lesion of the brain (e. The cortico-pontine fibers are affects cortical and subcortical areas, and several of the described with the cerebellum. Its or spasticity) and an alteration of the stretch reflexes (dis- connections are such that it may play a role in cussed with Figure 49B). The reflex in the indirect voluntary pathways and in non- involves stroking the lateral aspect of the bottom of the voluntary motor regulation, as well as in the foot (a most uncomfortable sensation for most people). Testing this same reflex after a lesion interrupts the reticular formation, one from the pontine region, cortico-spinal pathway results in an upward movement of the medial reticulo-spinal tract, and one from the the big toe (extension) and a fanning apart of the other medulla, the lateral reticulo-spinal tract. The abnormal response is called a Babinski sign — • Lateral vestibulo-spinal tract: The lateral ves- not reflex — and it can be elicited almost immediately tibular nucleus of the pons gives rise to the after any lesion that interrupts any part of the cortico- lateral vestibulo-spinal tract. This nucleus plays spinal pathway, from cortex through to spinal cord (except an important role in the regulation of our spinal shock, see Figure 5). It is Most interestingly, this Babinski sign is normally therefore a nonvoluntary pathway. It is under present in the infant and disappears somewhere in the control of the cerebellum, not the cerebral cor- second year of life, concurrent with the myelination that tex. SPINAL CORD CROSS- Recent studies indicate that complex motor patterns are present in the spinal cord, such as stepping movements SECTION with alternating movements of the limbs, and that influ- ences from higher centers provide the organization for MOTOR-ASSOCIATED NUCLEI these built-in patterns of activity. CLINICAL ASPECT UPPER ILLUSTRATION The deep tendon reflex is a monosynaptic reflex and per- The motor regions of the spinal cord in the ventral horn haps the most important for a neurological examination. The lateral motor nuclei supply The degree of reactivity of the lower motor neuron is the distal musculature (e.

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