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The differential diagnosis for proliferative glomerulonephritis includes connec- tive tissue diseases order finasteride 5 mg amex hair loss jak inhibitors, systemic vasculitis 5 mg finasteride amex hair loss cure thyroid, postinfectious glomerulonephritis, and other diseases. A 32-year-old woman presents to you after a recent hospital admission for flash pulmonary edema. She was diagnosed with hypertension several months ago. Her blood pressure remains poorly controlled despite compliance with a regimen of hydrochlorothiazide, amlodipine, and metoprolol. Her physical examination is remarkable for a blood pressure of 204/106 mm Hg in the left arm and bilateral abdominal bruits. You consider the diagnosis of renal artery steno- sis (RAS) secondary to fibromuscular dysplasia (FMD). Which of the following statements regarding RAS and FMD is true? Renal ultrasonography should be the first step in the evaluation of RAS because a finding of symmetrical kidneys precludes the need for further testing B. Angioplasty with stenting has become the most common method of managing FMD associated with hypertension and renal insufficien- cy; this procedure completely cures more then 50% of patients with hypertension and improves renal function in over one third C. The segmental nature of medial fibroplasia, the most common sub- type of FMD, results in the classic so-called beads-on-a-string appear- ance in the proximal third of the main renal artery D. Surgical repair of aneurysms is required if their diameter is greater than 1. It affects the distal two thirds of the main renal artery and its branches. In patients with a compatible clinical picture, evaluation for RAS starts with renal ultrasonography to measure kidney size. Even if the ultrasound scan shows that the kidneys are equal in size, further diagnostic testing is required. The choice of procedures is determined by the level of renal function: patients with a serum creati- nine level below 2 mg/dl should undergo renography; those with a serum creatinine above 2 mg/dl should undergo magnetic resonance angiography (MRA). The gold stan- dard for the diagnosis of RAS remains a renal arteriogram. Percutaneous intervention has been the standard of care, but large comparative trials are not feasible, given the relative rarity of these conditions. Angioplasty and stenting completely cure hypertension in about 22% of patients. Surgical repair of aneurysms (the “beads” seen on arteriography) is required if their diameter is greater than 1. A 58-year-old man known to have nephrotic syndrome presents to the emergency department. For sev- eral days, he has been experiencing low back pain and for the past several hours, he has been experi- encing hematuria and shortness of breath. The patient is tachypneic, with an oxygen saturation of 92% on 4 L of oxygen via nasal cannula. For this patient, which of the following statements regarding renal vein thrombosis (RVT) is true? RVT is most frequently associated with idiopathic and secondary membranous nephropathy; of these patients, 30% may have RVT 10 NEPHROLOGY 17 B. In addition to acute lower back pain and hematuria, most patients present with some degree of renal insufficiency C. Doppler ultrasonography is the most common modality used in the diagnosis of RVT D. For patients with RVT, a 6-month course of warfarin is indicated Key Concept/Objective: To understand the prevalence, clinical presentation, diagnostic modal- ities, and treatment of RVT RVT has been most frequently associated with idiopathic and secondary membranous nephropathy; 30% of these patients may have RVT. Pulmonary embolism may develop in up to 30% of patients with RVT, although alarmingly, the vast majority of these patients are asymptomatic. The classic clinical presentation of RVT is acute lower back pain and gross hematuria. Patients typically do not have renal insufficiency or hyper- tension.

On examination purchase 5mg finasteride with mastercard hair loss icd 9, you note synovitis of the left knee and right ankle purchase 5 mg finasteride mastercard hair loss network. Aspiration of the knee synovial fluid reveals no crystals. Which of the following statements regarding gram-positive bacteria and septic arthritis is false? Staphylococcal species are more common than streptococcal species as a cause of septic arthritis B. Group B streptococcal infection may be particularly virulent in dia- betic patients and may involve the axial joints (i. Gram stain is a reliable tool to differentiate between Staphylococcus and Streptococcus, because Staphylococcus appears as clusters in bio- logic smears D. Initial therapy for suspected staphylococcal or streptococcal septic arthritis should be vancomycin Key Concept/Objective: To understand the presentation and treatment of septic arthritis caused by gram-positive bacteria Gram-positive bacteria remain the most common cause of septic arthritis, accounting for 70% to 80% of cases. Staphylococcal arthritis was particularly frequent in a series of patients with endocarditis related to intravenous drug abuse. Gram stain cannot be relied on to differentiate between Staphylococcus and Streptococcus, because in biologic smears, Staphylococcus may not exhibit the clusters seen when grown in vitro. Suspected staphylococcal joint infection should be treated initially with vancomycin until methi- cillin resistance can be excluded. Non-group A, α-hemolytic streptococci are the second most common cause of septic arthritis, accounting for 10% to 21% of culture-positive cases. The number of reported group B (and to a lesser extent, groups C and G) strepto- coccal infections has been increasing. Group B streptococcal infection may be particu- larly virulent in diabetic patients and may involve axial joints (e. Other manifestations of group B streptococcal sepsis include myositis, fasci- itis, and endophthalmitis. For initial therapy, vancomycin is a reasonable choice. Definitive therapy should be made on the basis of culture results. Which of the following statements about septic (bacterial) arthritis is true? Local inoculation of organisms into the joint space is the most com- mon route of acquisition B. The finger joints are the most commonly involved site E. Most cases are polyarticular Key Concept/Objective: To understand the epidemiology and pathogenesis of bacterial arthritis 48 BOARD REVIEW Patients with underlying joint damage from any cause (e. In the majority of cases, bacte- ria are presumed to reach the joint space via the bloodstream rather than by direct inoc- ulation (as would occur with postarthroplasty infections or with infections associated with trauma). The knee and hip are the most commonly involved joints; bacterial arthritis of the small finger joints is uncommon. Only 10% to 15% of cases of septic arthritis are polyarticular. HIV infection has not been identified as a risk factor for sep- tic arthritis. A 23-year-old sexually active woman presents with left knee and wrist pain. She initially experienced polyarthralgias and low-grade fevers for several days, after which she developed progressive left knee pain. On examination, she is febrile and has a significant effusion and pain with passive range of motion of the left knee. A few scattered necrotic pustular lesions are present on the extremities. The rest of the examination (including pelvic examination) is negative. Appropriate cultures are obtained, and a diagnostic aspirate of the knee joint reveals a WBC count of 45,000/mm3 (predominantly polymorphonuclear leukocytes), but the Gram stain is negative. Cultures of the joint fluid eventually yield Neisseria gonorrhoeae.

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The secondary sensory neurons buy cheap finasteride 5mg online hair loss cure columbia university, whose cell bodies form the vestibular nuclei generic finasteride 1mg fast delivery hair loss cure eczema, send axons mainly to the cerbellum and lower motor neurons of brain stem and spinal cord (modulating muscle activation for keeping balance). In the lateral vestibular nucleus, axons project ipsilateral and caudal into the spinal cord and vestibulospinal tract (to lower motor neurons for the control of antigravity muscles). The medial and inferior vestibular nuclei have reciprocal connections with the cerebellum (vestibulocerebellar tract), which allows the cerebellum to coordinate balance during movement. All nuclei in the vestibular complex send fibers into the medial longitudinal fasciculus (MLF), which serves to maintain orientation in space. Connections between CN III, IV, and VI allow the eyes to fixate on an object while the head is moving. Vestibular axons in the descending part of the MLF are referred to as the medial vestibulospinal tract, and influence lower motor neurons in the cervical spinal cord bilaterally. Symptoms Patients experience dizziness, falling, vertigo, and nausea/vomiting. Signs Lesions result in abnormal eye movements, and problems with stance, gait, and equilibrium. Pathogenesis Metabolic: Diabetes, uremia 65 Toxic: Alcohol Aminoglycosides Cytostatic drugs: cisplatin, cyclophosphamide, hydroxurea, vinblastine Heavy metals Lead Mercury Quinine, salicylates Vascular: Anterior inferior cerebellar artery (AICA) Posterior communicating artery aneurysm Unruptured aneurysms, large vascular loops Vascular lesions of the spiral ganglion Vertebrobasilar circulation (history of hypertension, diabetes) Infection: Labyrinthitis: specific and unspecific: Suppuration reaches inner ear by either blood, or direct invasion (meningoencephalitis). Bacterial: streptococcus pneumoniae, hemophilus Syphilis Lyme disease Petrositis Viral: Ramsey Hunt syndrome Herpes zoster oticus Vestibular neuronitis HIV may cause sensoneurial hearing loss Mycotic: Coccidiomycosis, cryptococcosis Rickettsial infection Immunologic disorders: Hashimoto’s thyroiditis MS, leukodystrophies, Demyelinating neuropathies Periarteritis nodosa Sarcoidosis Trauma Blunt-, penetrating-, or barotrauma Transverse fractures are often associated with CN VII lesion. The less common transverse fractures damage both facial and vestibulocochlear nerves. These fractures involve the otic capsule, passing through the vestibule of the inner ear, tearing the membranous labyrinth, and lacerating both vestibular and cochlear nerves. Vertigo is the most common neurological sequel to head injury and it is positional. References Kovar M, Waltner JG (1971) Radiation effects on the middle and inner ear. Pract Otorhino- laryng 33: 233–242 Luxon LM (1993) Diseases of the eighth cranial nerve. In: Dyck PJ, Thomas PK, Griffin JP, Low PA, Podusl JF (eds) Peripheral neuropathies. Saunders, Philadelphia, pp 836–868 Scherer H (1986) Nervus vestibulocochlearis. In: Schmidt D, Malin JC (eds) Erkrankungen der Hirnnerven. Thieme, Stuttgart, pp 186–218 67 Glossopharyngeal nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Branchial motor: stylopharyngeus muscle. Quality Visceral motor: otic ganglion, fibers to stimulate the parotid gland. General sensory: posterior one third of the tongue, skin of the external ear, and the internal surface of the tympanic membrane. Special sensory: taste, from the posterior third of the tongue. The nuclei consist of: the nucleus ambiguus, inferior salivatory nucleus, and Anatomy nucleus solitarius. The nerve emerges from the medulla oblongata at the dorsal border of the inferior olive. A dural isthmus separates the nerve from the vagus nerve. It leaves the cranial vault through the jugular foramen (jointly with the vagus and accessory nerves), and passes in the upper neck between the carotid artery and jugular vein. Then it passes superficially to the internal carotid artery behind the styloid process. The nerve follows the posterior inferior part of the stylopharyn- geus muscle, between the constrictors of the pharynx, and finally reaches the deep hypoglossus muscle. Its extracranial course includes several ganglia (superior and petrous ganglia).

Thin filaments were observed to connect to the Z-line and make up the I-band buy finasteride 5 mg with amex hair loss in men 50th. Thick filaments were observed to compose the A-band with thick and thin filaments having a region of overlap order 5mg finasteride with visa hair loss guinea pig. High magnification electron micrographs showed connec- tions between thick and thin filaments in the overlap zone. These connections were referred to as cross- bridges. EM, in combination with techniques such as freeze-fracture and protein purification, has pro- vided much of what we know about the structure of contractile proteins, the membrane networks, and the neural innervation zones. A diffraction pattern arises whenever a beam of electromagnetic radiation passes through a narrow slit or a small hole. The hole or slit causes the beam to spread and acquire regions of destructive interference such that a banding pattern or a series of concentric rings results. When monochromatic light is used to illuminate muscle, the striation pattern within muscle gives rise to an optical diffraction pattern. The distance between fringes can be used to calculate sarcomere length. A major advantage of diffraction studies is that they can be applied to thin sections of living tissues. A variety of other techniques have been used to identify the molecular structure of muscle. Thick and thin filament composition were determined through extraction/aggregation studies. Selective extraction of A- and I-bands with salt solutions revealed that thick filaments are composed mainly of myosin and thin filaments are composed mainly of actin. Evidence indicating that the cross-bridges represent the HMM end of myosin came from aggregation studies. When intact myosin molecules aggregated they formed a large number of projections. Different myo- fibrillar isoforms have been identified using peptide finger printing, monoclonal antibodies, and the application of recombinant DNA procedures. Chemical techniques have been used to determine its protein and molecular components. Light microscopy and tissue staining techniques have revealed the vascular, neural, and fiber structures within tendon as well as the locations of fibroblast cells. Polarization microscopy in combination with special stains has been used to isolate the fibrous elements of collagen, elastin, and reticulin. Electron microscopy has been used to determine the organization of collagen molecules. Summary of Approaches Used to Determine Muscle-Tendon Structures Approach Employed Examples of Structures Identified I. Muscle-tendon attachments and gross, architecture, blood vessels, nerves II. Axial repeat spacing of myosin heads, myofilament spacing IV. Contractile proteins and sub-fragments electron microscopy B. Contractile proteins and sub-fragments combined with electron microscopy C. Functions of Specific Structures Nuclei dictate cell material and distribution. Nuclei communicate with other nuclei within a cell to maintain some consistency of regulation. The amount and type of protein to be produced are defined by a nucleus and carried out by the ribosomes in response to mRNA.

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