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By: William A. Weiss, MD, PhD
- Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
These genes produce proteins that normally Loss of differentiation oppose the action of an oncogene or inhibit cell divi sion discount terramycin 250 mg infection pathophysiology. Changes in gene regulation can affect not only single genes but entire networks of signaling buy terramycin 250 mg free shipping antibiotics for sinus infection and ear infection. Cells have a self-destruct mechanism cheap terramycin 250 mg visa antimicrobial yarn, known as apoptosis buy cheap terramycin 250 mg online virus vs virion, which is triggered by normal development Advanced tumor/malignant neoplasia and excessive growth. See Chapter 12 for Other than germ cells, cells in the body can divide agent exposures related to cancer. Cancer cells activate specific adhesion molecules, such as E-cadherin and telomerase to restore and maintain telomeres so cells can integrins. To transi mitosis or by external mutagens, multiple mechanisms tion from local to distant metastasis, the cancer cell have evolved to protect and repair the genome. These must be able to invade local blood vessels and lym repair mechanisms are directed by caretaker genes. Once in the circulation, metastatic cells must with the successful cancer cell divides rapidly and has a stand the stresses of travel in the blood and lym consequent need for building blocks for new cancerous phatic vessels, as well as exposure to immune cells. Also, cancer genes promote aerobic glycolysis and Metastatic cells must move to a distant site through high glucose utilization within the cell. Cancer cells arrive at a new location and attach therein to develop a new microenvironment. Identify the genetic events occurring within possible that successful metastatic tumor cells secrete cancer-prone families. These newly recruited stem cells then differentiate into tumor-supporting stroma and Most of the genetic and epigenetic alterations caus new blood vessels. Because they occur in the somatic cells rather than germline cells, they are not transmitted to future generations; they are not inher ited. It is possible, however, for cancer-producing Metastatic Sequence mutations to occur in germline cells. When muta tions are present in germline cells, transmission of Neoplastic cell multiplication cancer-causing genes occurs from one generation and to the next generation, producing families with a detachment/local invasion high incidence of specific cancers. Individuals who inherit the germline mutant Penetration allele will suffer loss of the normal allele by loss of Invasion heterozygosity or genetic silencing in some cells, and Efferent Cellular Blood the tumor develops. As this diversity increases, the number of cells in the cancer mass rises with new abilities that facilitate metastasis. Angiogenesis For cells to move from their normal, origi nal niche, they must detach from the stroma and migrate. To spread, many tumors and their associated Metastatic inflammatory cells secrete proteases and protease neoplasm activators. Another mediator Specific interactions between the cancer cells and receptors of cell detachment is the decrease in the cancer cell of on small blood vessels create the microenvironment (“soil”). Study pages 243 and 244; refer to Figure 9-20 and the majority of individuals with cancer have a mild ane Table 9-6. Chronic bleeding, severe malnutrition, med the diagnostic symptoms a cancer produces are as ical therapies, or malignancy in blood-forming organs may diverse as the types of cancer. The location of the cancer cause anemia by depleting erythrocyte building blocks or can determine symptoms by physical pressure, obstruc destroying the site for synthesis of erythrocytes. Cancer can cause Direct tumor invasion into the bone marrow causes problems far away from its source by pressing on nerves leukopenia and thrombocytopenia. Once the diagnosis of therapeutic drugs are toxic to the bone marrow and cancer is suspected or identified, tumor tissue must be cause granulocytopenia as well as thrombocytopenia. The incidence of system is used, with carcinoma in situ regarded as a spe hospital-related or nosocomial infections is increased cial case. Cancer confined to the site of origin is stage 1, in patients with cancer because of indwelling medical cancer that is locally invasive is stage 2, cancer that has devices, compromised wound care, and the introduction spread to regional structures such as lymph nodes is stage of microorganisms from visitors and other patients. The goal of chemotherapy is to kill cells that are undergoing mitosis and cytokinesis and those in Usually little or no pain is associated with the early interphase. Combination chemotherapy is the synergis stages of malignant disease, but pain will affect individu tic use of several agents, each with an effect against a als who are terminally ill with cancer. Cancer-associated certain cancer, used to avoid single-agent resistance and pain arises from multiple sources. Also, lower doses of each agent obstruction, invasion of sensitive structures, stretching may be used, causing fewer side effects and less toxicity. Induction chemotherapy seeks to cause site of the primary tumor or from a metastatic lesion. Adjuvant chemotherapy is given after Fatigue is the most frequently reported symptom of surgical excision of a cancerous lesion with the goal of cancer and cancer treatment. Neoadjuvant chemotherapy include sleep disturbance, biochemical changes, psy is given prior to localized surgery or radiation. Decreased muscle contractibility and function excessive toxicity and to avoid damage to normal are observed in individuals with cancer. Rapidly renewing and dividing cells Cachexia is a wasting, emaciation manifesting symp are generally more radiosensitive than other cells. Radiation therapy is well suited to Individuals show hyperinsulinemia, insulin resistance, treat localized disease in areas that are difficult to reach hyperglycemia, and abnormal blood glucose tests. A common radiation delivery system is a cancer, protein is used to meet energy needs rather than targeted external beam. Known routes of metastasis include: neoplasm is accessible and has not yet spread beyond a. Complete the following table by relating benign and malignant tumors to their sites of origin: Common Benign and Malignant Tumor Origin Sites Tissue Benign Tumor Malignant Tumor Connective/mesenchymal Fibroma Tissue Chondroma Osteoma Lipoma Leiomyoma Rhabdomyoma Hemangioma Hematopoietic Infectious mononucleosis Nerve Tissue Neuroma Neurilemmoma Epithelial Tissue Papilloma Adenoma 61 Copyright © 2012, 2008, 2004, 2000, 1996 by Mosby, an imprint of Elsevier Inc. Study pages 257 and 260; refer to Figure 10-1 and Study pages 253 and 257; refer to Table 10-1. At the cellular level, cancer is influences individual risk of cancer; however, it consti genetic.
- Acute kidney failure
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Summary Acute viral hepatitis is usually a self-limited disease and in most cases requires supportive care only order 250 mg terramycin with visa antibiotics and drinking. For the few patients who develop fulminant liver failure order terramycin 250 mg visa bacteria zombie, liver transplantation will be the only treatment option generic 250mg terramycin free shipping antibiotic resistant bacteria in dogs. Introduction the term chronic hepatitis means active generic terramycin 250 mg visa virus 64, ongoing inflammation of the liver that persists for more than six months, being detected by biochemical and histologic means. Typically, biochemical tests are used to identify and follow patients with chronic hepatitis. Liver biopsies serve to define more precisely the nature of the chronic hepatitis, and to provide useful information regarding the extent of damage and prognosis. Histologically, chronic hepatitis is characterized by infiltration of the portal tracts by inflammatory cells. These cells are predominantly mononuclear, and include lymphocytes, monocytes and plasma cells. Liver biopsy is the gold standard to evaluate the grade (degree of inflammation) and stage (degree of fibrosis/cirrhosis) of chronic viral hepatitis. Histologic or inflammatory activity (A score) is determined by an algorithm incorporating the amount of portal and lobular inflammation and necrosis into a score from A0 A3. The degree of fibrosis (F score) is evaluated separately to obtain the stage of disease and ranges from F0-F4 (Figure 1-4). Other causes include autoimmune hepatitis, drug-induced hepatitis, Wilson’s disease, 1-antitrypsin deficiency, and steatohepatitis. Primary biliary cirrhosis and primary sclerosing cholangitis may occasionally mimic chronic hepatitis, but are not usually classified as such. Table 2 summarizes an approach to help determine the etiology of chronic hepatitis. A careful assessment of risk factors is helpful in determining the cause of chronic hepatitis (Table 2). The rate of transmission via needle stick injury varies with the type of virus exposure, bore size of the needle, and whether the needle is hollow or not (Table 3). In most cases, selected laboratory tests will provide confirmation of the diagnosis. This portal tract contains a chronic inflammatory infiltrate that is confined to the portal triad and does not extend past the limiting plate (arrowheads). Inflammatory cells are shown infiltrating and destroying the periportal hepatocytes (arrow) and disrupting the limiting plate (interface necrosis) (arrowheads). F1= Minimal fibrosis without bridging; F2/3= Bridging fibrosis in which fibrous tissue connects the joining triads; F4= Cirrhosis. The slide on the bottom right represents chronic hepatitis and a hepatocellular carcinoma. The histologic activity is dependent primarily on the degree of interface necrosis but lobular necroinflammatory foci are also included in grading. Shaffer 400 the clinical presentation of chronic hepatitis can include no symptoms, unexplained fatigue, or complications of cirrhosis including ascites, variceal bleeding and encephalopathy. General treatment considerations include counseling about reducing the risk of transmission, vaccination for hepatitis A and B if a patient is seronegative, and vaccination for pneumococcus and influenza in the presence of cirrhosis. Persons are screened for complications of chronic liver disease and co-existing causes of liver dysfunction. Complete abstinence or minimal alcohol intake is advised, because of the risk of accelerated progression of viral hepatitis in the person who consumes a hepatotoxin such as alcohol. Carrier rates in vertically infected newborns are greater than 90%, as compared to less than 1% in adult-acquired infection. Statistics Canada estimates that there are approximately 600,000 persons in Canada infected with Hepatitis B, with the majority of infections occurring in immigrants (6% rate of infection in ”new Canadians,” 1% in Canadian born individuals, and 4% rate of infection in First Nation Canadians). The immunologic status of the host is also important, as immunocompromised individuals. In general, the milder the acute illness, the more likely that progression to chronic liver disease will occur. Although different genotypes may play a role in altered natural history, disease activity and treatment efficacy, genotype testing is just beginning to have a role in treatment considerations. Genotype Geographic Range A North America, Europe, Africa B,C East Asia, North America D Worldwide Distribution E Africa F South America, Alaska G North America H Central America 3. This mutation is associated with genotypes B and D, and found most commonly in Mediterranean countries and in Asia. Presentation the majority of persons with chronic hepatitis B are asymptomatic or have only mild fatigue. They might give a history of parenteral exposure to blood or blood products, unprotected sex, or a family history of hepatitis B infection. Liver enzyme abnormalities, even when incidentally discovered, should raise the possibility of underlying viral infection. Screening of family and sexual contacts of known cases will often reveal additional cases. Diagnosis A summary of the interpretation of seromarkers of hepatitis B is provided in Table 9. Core antibody serology is not usually required in the routine assessment of chronic hepatitis B (Table 5). This acute phase is not often seen in chronically infected adults who have contracted the virus at birth or in early childhood. Chronic hepatitis has three phases, termed the “replicative”, “inflammatory” and “inactive” phases.
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Physical examination reveals numerous small red spots on the extremi ties and a stiff neck cheap terramycin 250mg mastercard antimicrobial therapy publisher. Lumbar puncture returns purulent fiuid order 250 mg terramycin antimicrobial office supplies, with segmented neutrophils and Gram-negative organisms resembling menin gococci buy discount terramycin 250mg line antibiotics for dogs canada. Severe endothelial injury in this patient is primarily mediated by which of the following proteinsfi On physical (B) Cardiogenic shock examination purchase 250 mg terramycin otc virus 2014 september, the patient is aphasic with a right-sided (C) Maternal-fetal histoincompatibility hemiplegia. You (D) Metastatic squamous cell carcinoma suspect that a thromboembolus coursed to the left middle (E) Pulmonary thromboembolism cerebral artery and smaller emboli traveled to the retinal arteries. Which of the following anatomic sites is the most likely source for these emboli in this patientfi Histologic examination of the lungs under (E) Septic shock polarized light is shown. Which of the following is the most likely cause of the birefringence observed in this pulmonary 13 A 68-year-old man with ischemic heart disease and a history lesionfi On physical examination, the patient has swollen legs, an enlarged liver, and fiuid in the pleural spaces (bubbly rales are heard on oscultation). Which of the following hemodynamic disorders explains the pathogenesis of hepatomegaly in this patientfi Microscopic examination of the liver at autopsy would most likely reveal which of the following his topathologic changesfi Labora (B) Hematocephalus tory studies demonstrate a hypochromic, microcytic anemia. Which of the (C) Maculopapular rash following best describes the stools in this patient with peptic (D) Petechiae ulcer diseasefi At bedtime, there are depressions in her (D) Melena legs at the location of the elastic in her socks. A percutaneous needle biopsy of the kidney establishes the diagnosis of minimal change neph 16 A 53-year-old man is hospitalized after injuring his neck in rotic syndrome. Doppler imaging discloses deep venous throm (B) Chronic passive congestion bosis. Which of the following is the most likely cause for the (C) Decreased intravascular oncotic pressure development of thrombosis in this patientfi At autopsy, the patient’s (E) Stasis protruding abdomen is found to contain a large volume of serous fiuid. What is the appropriate term used to describe 17 A 23-year-old man with hemophilia is recently wheelchair this fiuidfi Her tem 18 A 50-year-old fire fighter emerges from a burning house with perature is 38°C (101°F). Which of the following was the most likely most likely cause of increased hematocrit in this patientfi Ultrasound examination of term used to describe this form of superficial hemorrhagefi A liver biopsy discloses severe sinusoidal dilation within the centrilobular regions. Two days later, she presents for follow-up care with confiuent bluish hemorrhages in the skin around her eyes (“black eyes”). Which of the follow ing best describes this pattern of superficial skin hemorrhagefi His past medical history is signifi rupturing his spleen in a motorcycle accident. Analysis of arterial blood Which of the following is most likely responsible for develop gasses demonstrates metabolic acidosis. A Prussian blue stain of 29 A 72-year-old man is dead on arrival after collapsing at home. Which of the following is the most likely source of the atheroembolus occluding this arteryfi A thromboembolus at the bifurcation of the left and (E) Mesenteric artery right pulmonary arteries is noted at autopsy (shown in the image). Which of the following is the most likely cause of this 30 A 72-year-old woman complains of shortness of breath on patient’s pulmonary embolusfi She states that she also becomes short of breath at night unless she uses three pillows (orthopnea). Physical examination reveals mild obesity, bilateral pitting leg edema, an enlarged liver and spleen, and fine crackling sounds on inspiration (rales). At autopsy, the pathologist finds a laminated thrombus adher ent to the wall of the left ventricle (shown in the image). Hemodynamic Disorders 67 section of the left ventricle is examined at autopsy (shown in the image). Physical examination discloses bilateral pit (B) Hyalinization ting leg edema, hepatosplenomegaly, and rales at the bases of (C) Organization both lungs. Which of the following hemodynamic processes best explains 33 A 50-year-old woman presents with fatigue and shortness of this pathologic findingfi Physical examination shows evidence of pulmonary edema, enlargement of the left atrium, and calcification of the mitral valve. Before open heart surgery can be performed to remove the tumor, the patient suffers a stroke and expires.
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