If men truly want to live in a more just and more peaceful world treatment narcissistic personality disorder cheap 3ml careprost mastercard, they have to challenge all forms of violence and oppression symptoms kidney careprost 3ml fast delivery, including those based on gender symptoms carpal tunnel buy cheap careprost. Often dependent on one salary 5 medications related to the lymphatic system purchase genuine careprost on-line, families may be unable to meet their needs beyond basic subsistence medicine valium discount 3 ml careprost visa. The research has repeatedly demonstrated that gender equality contributes to both economic growth and poverty reduction medicine evolution generic careprost 3ml mastercard. Investments in female education and health tend to increase family incomes 10 medications that cause memory loss cheap careprost 3 ml online, because educated medications emts can administer 3 ml careprost, healthy women are more able to engage in productive activities, find employment and earn higher incomes. Additionally, they place greater emphasis on the education and health of their children, thereby improving the productivity and quality of life for the next generation. Current constructs, for example, leave men and boys more free to express anger than any other emotion. There is, however, a growing awareness in men that they have lost an important part of their human experience, particularly in the emotional sphere. Less rigidity and stereotyping of masculinity will lead to increased options for men with likely benefits to their physical and mental health and psychological wellbeing. Leadership comes from teachers who nurture the dreams and aspirations of girls and from 19 doctors and nurses who listen and provide care without judgment. By focusing on masculinities, the concept of gender becomes visible to and relevant for men. Men, for example, need to understand that they are necessary partners with clear responsibilities in the struggle to eradicate violence against women and girls. They also need to understand that the promotion of gender equality is essential for the eradication of poverty and hunger and for the promotion of sustainable development. If women want men to change, women have to change their emotional and social expectations of men. Men, for example, respond better to messages about the positive aspects of masculinity rather than messages that point out the negative or assign blame. Opportunities, for example, should be provided for men and boys to share experiences with each other of gender roles and their impact within the safety of their own sex. The positive aspects of traditionally male roles can be drawn upon, such as strength, courage, leadership and protection. We need to emphasize the stake that men and boys have in gender equality, that is, the gains and potential benefits for men and boys. Men and male youth who understand the issues are a tremendous resource for initiating work with other men and can be a source of considerable influence. Seeing the effects of gender discrimination on people they are close to , like wives and daughters, is perhaps the most effective means of reaching and engaging men in the struggle for gender justice. Many men are involved in the fight for a more peaceful world and understand that this includes changing perceptions of masculinities and challenging gender roles. Men also serve as role models and mentors, demonstrating to boys and youth through their own behaviors and actions how men can be nonviolent, positive influences for all people, regardless of gender. The shift from a focus on women to a focus on gender creates an opportunity to give increased attention to men and boys. However, bringing men in must not mean replacing a focus on women with a focus on men, but rather developing a genuinely integrated approach. Involving men and boys in gender equality and creating interventions for their participation cannot be at the expense of the improvements in the lives of women and girls. It is important, however, to break down gender isolation and although some programs may need to target a singlegender group, programs should be planned by men and women in consultation. The emphasis should be on shared benefits and alliance building between men and women. Boys and girls need to learn respectful ways of dealing with each other on a basis of equality. Some of this could be taught via genderinclusive curricula (rather than genderbiased curricula) in the schools and in participatory lifeskills programs, from which both sexes would benefit. The role of education in the transformation of masculinity and male gender roles is vital. We must encourage more men to move beyond the confines of rigid gender divisions at home, at work and in the community. A focus on social justice, which de facto requires gender equality, may also be a less threatening entry point and allow for broadbased buyin as most people, men, women and adolescents, support a more socially just world. Interventions might include peer education, counseling, support services and rehabilitation for perpetrators of sexual violence, and advocacy for the adoption of equitable inheritance and property rights laws and practices. Attention must be focused on changing policies and practices and on transforming attitudes and behavior. More and more men are realizing that they have been absent parents and want a more active role in the rearing of their children. Real or perceived injustices in child custody issues in the West, for example, have led to male activism around the importance of male involvement in raising children. Research covering 16 rural communities where nongovernmental organizations had mainstreamed gender in their work documented dramatic economic, social and cultural changes as a result, including greater agricultural yield, improved sanitation, improved health status, sharing of agricultural and domestic chores, expanded school enrollment, especially for girls, and reduction in harmful traditional cultural practices, such as early marriage for girls and female genital mutilation. The organizations involved women and men working together, thereby addressing male resentment over a focus on women. With greater gender equality, there was more money in the family, greater respect between the sexes, and a reduction in domestic 20 violence in several communities. This research demonstrates that new forms of masculinities are emerging and that while the process of redefinition of female and male identities has been asymmetric, with women having made considerable progress, while with men it is beginning. The process of flight and displacement creates havoc with community structures and with cultural norms and traditions. Leadership structures, cultural practices, community coping mechanisms and shared moral standards break down. Women suffer most from situations of displacement as they continue to undertake most domestic labor and have to cope with many additional problems, such as inadequate shelter and inadequate food and the struggles to care for and maintain their families. Gender roles become more blurred as the struggle for survival takes precedence over more rigidly defined, traditional roles. Men often lose their means of livelihood, creating depression, despondency and withdrawal. Women, though, often benefit from the increased emphasis placed on them by international aid agencies. Suddenly they are being asked to participate in decisionmaking structures, in food distributions and in training and income generation programs. Women, as a result, may feel more empowered than previously; men may feel ever more emasculated. On the other hand, organizations assisting the displaced may fail to consider gender relations and inequalities, thereby overlooking potential resources or creating further tensions. Without a clear gender equality focus, outside agencies fail to capitalize on opportunities to support more equal gender relations and may even reinforce inequalities. When people believe that certain roles and activities are only appropriate for men or women, it can have negative consequences for the success of the skills training or livelihoods program. Even when they accompany their spouse or partner to the health clinic, there are usually no programs encouraging men to participate in reproductive health decisionmaking with their partner or programs to address their own reproductive and sexual health. Efforts to engage men more effectively in family planning and protection against sexually transmitted infections might require the establishment of separate clinics or separate clinic days for men and adolescent boys. While at times ignoring the particular needs of men, most aid agencies working with refugees and internally displaced persons do encourage female participation in decisionmaking structures and programs. This, too, creates challenges, male resistance, token female participation, female presence without real participation and the continuation of male domination. Strong female leaders may be marginalized by their communities and be targets of violence. Further, when women return to their communities of origin, they may be pressured back into more traditional roles and may be forced to give up previous gains. As we work toward gender inclusion and gender equity, the need to focus on masculinities again becomes apparent. Until male refugees see the advantage and rationale for gender mainstreaming, work toward gender equality will be stifled, impacting the potential gains for women both during displacement and following return. Gender equality work with men and boys must, however, be grounded in the context of local cultures and traditions. By starting with the local culture and traditions, we ground our work in a context that is understood and known. When men and boys reflect on the changes their own cultures have gone through over time, they begin to understand that change is a constant process and that culture is never static. Violence prevention efforts, for example, are most successful when they incorporate messages, strategies and models that make sense in a specific cultural context. Work with men and boys in situations of displacement means educating them on the cultural constructs of masculinities in the context of their own cultures and its impact on their lives and attitudes. Education leads to understanding, which opens avenues for work on gender equality. Female participation in decisionmaking structures will not be meaningful and significant unless men provide access and take seriously the input and ideas put forward by women. Further, the problem of genderbased violence will not be solved until men and boys actively participate in trying to eradicate it. It requires the inclusion of masculinities in gender training programs, in work with host governments and in work with partners. Too often we promote equal female beneficiary participation without promoting equal female staffing in our organizations and those of our partners. Too often we operate without any reference to the gender issues and roles in the host country and their impact on the displaced populations. Understanding local culture (both host society and that of the displaced community), practices, norms and policy visavis gender is imperative in the promotion of gender equality. We need to analyze and promote the powerful, but often informal, roles women have traditionally played while also seeking out those less traditional roles in which men have been engaged. Such information provides the building blocks for moving the gender mainstreaming efforts forward. Lastly, until we have gender balance and equality amongst our own staff, there is little likelihood we will succeed in demonstrating and promoting greater gender justice amongst the population with whom we work. Gender competence and commitment needs to be assessed during staff recruitment processes. Gendersensitive trainings, policies and programs need to be developed and supported. Report of the Expert Group Meeting, Male Roles and Masculinities in the Culture of Peace, Oslo, 24 28 September 1997. United Nations Commission on the Status of Women, the Role of Men and Boys in Achieving th Gender Equality, 48 session, Agreed Conclusions, 1 12 March 2004. The quiz is an excellent way of engaging men and women in the gender equality debate and raising awareness about the impact of gender inequality. What percentage of women worldwide are homeless or live in inadequate dwellings, such as slumsfi Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. Clinical data have shown that coadministration with saquinavir or erythromycin increased plasma levels of sildenafil by about 3 fold [see Drug Interactions (7. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely coadministered at this time point [see Dosage and Administration (2. Hypersensitivity reactions have been reported, including rash and urticaria [see Adverse Reactions (6. The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency could result. When vasodilators are used in combination, an additive effect on blood pressure may occur. In some patients, concomitant use of these two drug classes can lower blood pressure significantly [see Drug Interactions (7. Decreased blood pressure, syncope, and prolonged erection were reported in some healthy volunteers exposed to high doses of sildenafil (200800 mg). To decrease the chance of adverse reactions in patients taking ritonavir, a decrease in sildenafil dosage is recommended [see Dosage and Administration (2. However, in vitro studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium nitroprusside (a nitric oxide donor). The type of adverse reactions in flexibledose studies, which reflect the recommended dosage regimen, was similar to that for fixed dose studies. At doses above the recommended dose range, adverse reactions were similar to those detailed in Table 1 below but generally were reported more frequently. Reported events include those with a plausible relation to drug use; omitted are minor events and reports too imprecise to be meaningful: Body as a Whole: face edema, photosensitivity reaction, shock, asthenia, pain, chills, accidental fall, abdominal pain, allergic reaction, chest pain, accidental injury. Digestive: vomiting, glossitis, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, dry mouth, liver function tests abnormal, rectal hemorrhage, gingivitis. Metabolic and Nutritional: thirst, edema, gout, unstable diabetes, hyperglycemia, peripheral edema, hyperuricemia, hypoglycemic reaction, hypernatremia. Musculoskeletal: arthritis, arthrosis, myalgia, tendon rupture, tenosynovitis, bone pain, myasthenia, synovitis. Nervous: ataxia, hypertonia, neuralgia, neuropathy, paresthesia, tremor, vertigo, depression, insomnia, somnolence, abnormal dreams, reflexes decreased, hypesthesia.
After a long (D) the virus incorporates host cell proteases night of studies harrison internal medicine purchase generic careprost pills, he takes a particularly large into its genome in order to cleave and acti dose of aspirin; he later becomes disoriented treatment algorithm order cheap careprost on line, vate the viral polyprotein confused medications you can take while pregnant careprost 3ml on line, and then experiences a seizure symptoms yellow eyes discount careprost 3ml. He (E) Treatment with acyclovir is preventing the is brought to the emergency department by his virus from synthesizing its own guanine roommate treatment rheumatoid arthritis quality careprost 3ml, where his serum salicylate level is nucleotides 130 mg/dL symptoms 22 weeks pregnant order line careprost. A 4yearold girl is brought by her mother to the emergency department complaining of se (A) Protamine vere abdominal pain treatment 001 - b discount careprost 3ml on line. Physical examination suppressive therapy develops the tender red shows hypotension and tachycardia treatment water on the knee purchase careprost 3 ml amex. Class I antiarrhythmics are sodium channel gency department following a motor vehicle blockers that slow or block cardiac conduction, collision. Which of the cal injuries, but she appears drowsy and states following antiarrhythmics will increase both that she is feeling very sleepy. Emergency the action potential and the effective refractory medical staff collected several open medica periodfi Xray of (E) Physostigmine the chest shows cardiomegaly and pulmonary venous congestion. The image shows the doseresponse curves for severe left ventricular dilatation and global hy the agonist drug X administered alone, and pokinesis, with an ejection fraction of 25%. He several possible curves representing drug X is placed on a pharmacologic regimen includ administered with other agents. At which point in the image is di following curves, A through E, represents the goxin a direct inhibitorfi Answer E is compatible nonnucleoside reverse transcriptase inhibi with the effects of nitrates. It can sents with gastroparesis, specifcally esophageal cause pancreatitis in some individuals. Lamivudine is a causes of esophageal dysmotility include dia nucleoside reverse transcriptase inhibitor. It betic gastroparesis, Chagas disease, lupus, and functions by binding to the active site of the other collagen vascular diseases. Saquinavir is a protease the treatment for squamous cell carcinoma or inhibitor that blocks the enzyme necessary for adenocarcinoma of the esophagus or for high the creation of new viral proteins. It ton pump inhibitor used to treat gastroesopha functions by binding to the active site of the re geal refux disease, peptic ulcer disease, and verse transcriptase enzyme to inactivate it. Vagotomy is a treat contractility and heart rate (resulting in de ment option for peptic ulcer disease or acid hy creased oxygen consumption) by inhibiting persecretion states such as in ZollingerEllison b1 receptors in the heart. This agent decrease aldosterone by extension and further inhibits both the conversion of iodide to el reduce blood pressure. Answer A does not re duction of mono and diiodotyrosine within fect the effects of bblockers. Answer B does not re hibits the peripheral conversion of thyroxine fect the effects of bblockers. The majority of T3 is converted in the periph Chapter 7: Pharmacology Answers 149 eral tissue, liver, and kidneys. Dementia can be a re effect on the binding of T3 to the thyroid hor sult of neurotoxin exposures (eg, mercury). Also used in cytic type by showing abundant promyelocytes neonates with thyroid defciency, this medica with azurophilic granules. This describes radioac harbor a t(15;17) translocation, making the ret tive iodine, which is used patients >21 years inoic acid receptor responsible for their trans old who have hyperthyroidism. It is the pre formation, and the cells can be differentiated ferred drug to treat Graves disease that it is re using highdose alltrans retinoic acid. Irinotecan is a topo with endothelial damage results in plaque for isomerase I inhibitor, preventing ligation of mation over time. Consequently, graph shows KimmelstielWilson nodules, clozapine is reserved for schizophrenia that is which are pathognomonic for diabetic ne otherwise refractory to treatment. Even without recognizing this spe be regularly monitored for neutropenia for the cifc histopathology, however, one should be frst six months of treatment. Other adverse ef reminded of diabetes due to the combination fects include weight gain, hypotension, mild of renal and visual fndings (diabetic nephrop sedation, and, in some cases, extrapyramidal athy and retinopathy). Metronidazole is as tors have been conclusively shown to delay the sociated with disulframlike reactions and not time to endstage renal disease by 50% in type agranulocytosis. Polymyxins are associ should consider starting patients with diabetes ated with neurotoxicity and renal tubular aci on statins and lowdose aspirin as they are at a dosis, not agranulocytosis. Cyclophosphamide is him with a diuretic, intending to reduce his to often used in conjunction with prednisone to tal body fuids. When the amount of fuids in treat immunologically mediated kidney dis the body contracts, the body attempts to com ease. Prednisone is used to from losing its perfusion due to this vasocon treat immunemediated nephropathy, not dia striction, the kidney simultaneously releases betic nephropathy. However, they have not specifcally been enzymes, this patient blocked the pathway pro ducing the prostaglandins that were keeping Chapter 7: Pharmacology Answers 151 the afferent arterioles dilated and thus keeping tion leads to a reduction in the size of the pros his kidneys perfused. It is used to treat testicular production of prostaglandin E2 at both arteri tumors and lymphomas (especially Hodgkin), oles, but the constriction of the afferent arte not benign prostatic hypertrophy. Ibuprofen blocks the synthesis of prostaglandins, and thus a decrease Answer E is incorrect. Ketoconazole is an an in the prostaglandin level would be seen, not tifungal with antiandrogenic properties that an increase. Thus the increase in serum nasteride is most commonly used to treat this testosterone can overcome the androgen re condition. This scenario is com plasia along with promoting secondary sexual monly observed in cases of organophosphate characteristics (in men and women). Atropine, a muscarinic receptor CoA reductase, an essential step in the produc antagonist, is commonly added for sympto tion of cholesterol in the liver. Pancuronium is a long Dacarbazine) treatment regimen for Hodgkin lasting nicotinic receptor antagonist. Dactinomycin is used to treat Wilm increase acetylcholine levels in the neuromus tumor, germ cell tumors, rhabdomyosarcoma, cular junction and worsen the symptoms. It is used to treat tes peroxisome proliferatoractivated receptora ticular, bladder, ovarian, and lung carcinomas. Cyclophosphamide is increased clearance of triglyceriderich lipo an alkylating agent that acts by attaching alkyl proteins. There are no lipid Hemorrhagic cystitis is an adverse effect of cy lowering drugs that act at point A. Methotrexate inhib such as cholestyramine act at point B by block its the metabolism of folic acid by inhibiting ing the reabsorption of bile acids. The liver dihydrofolate reductase, thereby preventing must then metabolize more cholesterol to re the conversion of dihydrofolate to tetrahydro place the bile acids, thereby primarily lowering folate. Methotrexate Chapter 7: Pharmacology Answers 153 is used to treat many cancers including cho 16. Paclitaxel inhibits mi drugs such as oral contraceptives, warfarin, crotubule disassembly by binding to the b sub and ketoconazole may need to be given in unit of tubulin, which ultimately disrupts cel higher doses in order to be therapeutic. Other uses of chronic atrial fbrillation, which is a risk factor rifampin include treatment of leprosy, for me for clot formation and systemic embolization. Metronidazole forms cerebrovascular accidents or mesenteric infarc toxic metabolites that have a bactericidal ef tion. It is an effective antibiotic against amoe of vitamin Kdependent clotting factors and bae and anaerobes. The degree of adverse effects is a disulframlike reaction anticoagulation must be followed by measur when taken with ethanol. Phenytoin acts by pyretic, analgesic, and antiinfammatory ef blocking sodium channels, which inhibits fects. It has many used for rapid reversal of heparinization in the adverse effects, including induction of the setting of overzealous anticoagulation. Heparin is used for toin include gingival hyperplasia, megaloblas acute, not longterm, anticoagulation. Rearranging the formula yields: syndrome (prenatal growth defciency, mental Clearance = (0. It is used to terminate an ectopic preg neurotoxicity and acute renal tubular necrosis. Mifepristone is a partial do not cause orange bodily fuids, though it progesterone agonist that can be used alone does turn the skin bluish with chronic use. Hydrochlorothiazide uterine contractions and so is used in com causes decreased blood potassium and in bination with mifepristone to induce a frst creased urine potassium through loss of potas trimester medical abortion. It is used through volume contraction, loss of hydrogen to treat Mycobacterium tuberculosis infection, ion into cells in exchange for potassium, and to delay resistance to dapsone in patients with loss of hydrogen ion in the urine. Patients taking munized children exposed to Haemophilus in any type of diuretic, with the exception of fuenzae type B. Tamoxifen is a partial sodium, as they inhibit reuptake of sodium at estrogen agonist that is used to treat estrogen various points along the nephron. It is not indi diuretics inhibit sodium reuptake in the distal cated in the treatment of ectopic pregnancy or tubule. Administration of to loss of hydrogen ion in principle cells, and bicarbonate alkalinizes the urine, thereby pro potassium exiting cells into the blood in ex moting the excretion of acidic drugs such as as change for hydrogen ion going into cells. Methotrexate, a folic salicylates within the renal tubules, resulting acid analog, can be used as an immunosup in an ionic charge. In general, charged mol pressant, an abortifacient, or an antineoplastic ecules are cleared, while uncharged molecules Chapter 7: Pharmacology Answers 155 are easily reabsorbed from the tubules. Glucagon is used to that binds to both ferric and ferrous ions to treat bblocker toxicity. Deferoxamine can capture iron from ferritin and hemosiderin outside the Answer C is incorrect. Nacetylcysteine is bone marrow, but leaves iron in hemoglobin, used to treat acetaminophen toxicity. Vitamin K is used to though deferoxamine can effectively and rap treat warfarin toxicity. Herpes zoster is char histamine release, allergic reaction, and rare acterized by reactivation of a latent varicella cases of neural and renal toxicity. Aminocaproic acid is terized by chickenpox, after which the virus used in the treatment of tissue plasminogen ac lives in the ganglia of spinal nerve roots. Dimercaprol is used to cles develop in a dermatomal pattern and do treat poisoning by arsenic, mercury, and gold. Al inactive precursor that is activated by viral thy though this treatment may prevent iron from midine kinase when absorbed by infected cells. The patient has over tance to acyclovir by modifcations to the viral dosed on diazepam, a benzodiazepine. Curve B represents reverse the effects of opiates such as heroin or a drug with a lower effcacy but a greater po morphine. This could occur with a type of drug known as a partial agonist, which Answer E is incorrect. Physostigmine is used binds to the receptor as well as (or better than) to reverse the effects of anticholinergic agents. Potency is used to describe the drug with a decreased potency but the same amount of drug needed to produce a given ef effcacy. Remember that this at a lower dose to produce the same effect as antagonist would bind to the same receptor a drug with low potency. On the graph, more site as the agonist and take up its binding spots, potent drugs are located toward the left (indi effectively making it appear as though there is cating lower doses). This drug that is highly effcacious will better gen could occur with the addition of a partial an erate a response than the comparable quan tagonist, which operates with logic similar to tity of a less effcacious drug. They block tagonist indicates that it will decrease the eff sodium channels and thus slow conduction cacy of the drug in question. The fact that it is velocity in the atria, ventricles, and Purkinje noncompetitive means that it cannot be over fbers. It is not the site of Na+ indirectly inhibit the function of the Na+/ action for digoxin. This in turn results in the inotropic prop cium back into the sarcoplasmic reticulum. The drug commonly used to treat this by inhibiting the ratelimiting step in hepatic condition inhibits which of the followingfi A 64yearold woman with a history of diabe tes, hypertension, and congestive heart failure was brought to the emergency department af ter she complained of a headache and blurred vision and was found to have a blood pressure of 220/95 mm Hg. What is the mechanism of ac (B) High K+, low Na+, low urine volume tion of drug Xfi Following the administration of drug X, there (C) Patent ductus arteriosus is an increase in systolic, diastolic, and mean (D) Pulmonary stenosis arterial pressures. After the effect of drug (E) Ventricular septal defect X has worn off completely, drug Y is then added, resulting in little or no change to the 6. When drug X is re scribed an antiarrhythmic agent that alters the administered, there is a net decrease in blood fow of cations in myocardial tissue. Which of the following would be affected by an agent that affects phase 0 of the myocardial action X Y X potentialfi A 56yearold woman arrives in the emer gency department complaining of dizziness and headache. She is currently not taking any med (B) Ligandgated potassium channels closing ications and has not seen a doctor for several (C) Ligandgated sodium channels opening years. The physician decides to address her (D) Voltagegated calcium channels opening hypertension urgently. Which of the following (E) Voltagegated potassium channels closing drugs is contraindicated in this patientfi A 64yearold man is brought to the emergency (D) Protein deposits such as transthyretin department for chest pain. A 72yearold AfricanAmerican man under tial management, he is admitted to the critical goes hip surgery. On the ffth hospital develops chest pain, tachycardia, dyspnea, and day, he experiences a sudden onset of dyspnea a lowgrade fever. An echocardiogram shows arrest and efforts to resuscitate him are unsuc severe mitral regurgitation. Which of the following would most likely predispose the patient to this (A) Left anterior descending artery eventfi A 17yearold boy dies suddenly while playing (E) Von Willebrand factor defciency basketball for his high school team. The physician diagno ses her with a disorder that is characterized by thickening of the great vessels. Which of the following signs and symptoms most likely will be detected on history and physical examina tionfi A 67yearold woman presents to the emer gency department complaining of dizziness. Atherosclerosis is associated with numerous wellknown risk factors, such as age, smoking, diabetes, hyperlipidemia, and a family history of atherosclerosis. What is most likely the frst step in the patho genesis of atherosclerosis caused by hyperlipid emiafi A 65yearold AfricanAmerican man is ad mitted to the hospital for severe shortness of 18. He states that he has been having in signed to show the pressure changes that nor creased diffculty breathing when performing mally take place in the right atrium through physical activity. His blood pressure is 125/85 two, or sometimes three, positive waves and mm Hg, and his heart rate is 85/min. A 25yearold pregnant woman goes to her Jugular x y gynecologist for her 36week checkup. A 56yearold Asian man with hypertension, hypercholesterolemia, and type 2 diabetes mel litus comes to a physician for a checkup. His past medical history is signifcant for an acute illness at the age of nine, which involved a high fever, pleuritic chest pain, mi grating joint pain, and a pink, nonpruritic rash on his torso. Auscultation of the heart reveals a lowpitched diastolic rum ble heard best at the apex. A common location for an abdominal aortic (E) Hypertension aneurysm is inferior to the renal arteries and extending to the bifurcation of the common 22. On gross physical ex diseased portion of the aorta and replacing it amination, the infant appears normal, but on with a synthetic graft. Based on anatomic con cardiac examination is found to have a con siderations, which structure is most at risk of tinuous murmur in both systole and diastole.
The contrast may be less real than we care to think; lently inflicted through magic or spells treatment naive definition generic careprost 3ml visa. It is targeted against magic of the placebo pill through which Western doctors a specific individual symptoms constipation order careprost 3 ml without a prescription, family treatment arthritis order careprost paypal, or tribe symptoms type 2 diabetes generic careprost 3ml on-line, reassure and even fob off patients for whom they may be in retribution for some act of able to do remarkably little medications given before surgery purchase 3 ml careprost overnight delivery. Illness is or sorcerers were entrusted with the rituals of diagnosis thus a reprisal or and cure medicine grapefruit interaction purchase careprost without prescription. Medical magic was then explicit within folklore medications you can crush discount careprost line, the and beyond medicine naproxen 500mg discount careprost 3 ml online, Christianity Church, and learned medicine alike. But the Old (being literate and analytical) has also developed demarcations between the body Testament figure of Job struck on the one hand and, on the other, the soul, mind, or spirit. Such distinctions have or seventeenthcentury wood cut, served as an illustration been contested, and physic and faith have continually crisscrossed or collided, of how the Lord might visit engaging in border disputes. Although often complementary, there remains the righteous with afflictions potential for conflict; while separate, there remains scope for unification. Pain was broadly lished by the Church (until quite recently, medicine remained a junior, subaltern viewed as the inevitable state of fallen man, whose body profession, less prestigious than the cloth). Spirit is immortal; the flesh, by contrast, is weak and corruptible, and, thanks to Original Sin, theologically depraved. Cleanliness had to be defended against such defiling pollutions as the blood of a menstruating woman, ft was a Talmudic requirement that Jews should not live in a city without a physician. Mistrusting the fallen body, early Christians responded with defences of their own. In the Middle Ages, chastity, fasting, and selfflagellation became hallmarks of holiness. God has an only son, who is born in the flesh, before being crucified in bodily agony. Through divine propitiation, believers are promised bodily resurrection at the Last Judgment. While abhorring the flesh because tainted by sin, Christianity, in short, also emphasized a certain sanctity immanent within it. While asceticism was prized, mortification was never to be pursued to the point of selfdestruction. The man in the street has been less enthusiastic about pain Christian zealotry may seem to verge on masochism and philosophers have felt obliged to confront the problem of pain. A prime aim, for example, of the Epicureans (followers of the Greek philosopher, Epicurus) lay in devising damage limitation, designed to curb selfinflicted exposure to agonies: the simple life would avoid giving hostages to fortune. Stoicism similarly recommended soaring above wordly passions, for they brought disappointment not pleasure. Since the time of the Desert Fathers in early strued pain as the penalty for disobedience a notion reinforced by etymology, the Christianity, holy individuals word pain being derived from poena (the Latin for punishment). Especially at lence, while chosen individuals were devoutly to rejoice in the Cross of illness. Martyrdom to disease in this vale of tears might be as glorious as martyrdom tion, flagellating themselves to the infidel. Thus Christian doctrine regarding welfare, philanthropy, and tom of collective religious medicine grew extremely complex. Nevertheless, the miracle was painted by main Christian churches have routinely accepted that medicine has a valid role. The Fourth Lateran Council (1215) in Rome forebade clerics to shed blood through the practice of surgery, and warned against immoderate involvement of clerics in treating physical complaints. For one thing, Catholicism energetically involved itself in healing rituals, championing recourse to relics, offerings made in fulfilment of vows, pilgrimages, holy waters, and, above all, shrines and cults. Saints won reputations for special healing powers: for example, to cure toothache, you prayed to St Apollonia (d. Epidemics often excited confrontations between the Church and the medical profession, public authorities and the people, as to the meaning of diseases and the measures required. Laden like leprosy with Scriptural associations and moral metaphors, plague was typically interpreted as a visitation, requiring public atonement. Faced with plague, Church authorities in Renaissance Italy proclaimed mass intercessions and propitiatory prayers. The municipalities, for their part, counterordered quarantine and isolation, sometimes banning religious processions. In Tudor and Stuart times, plague led to tussles in England between royal health policy and protesting Puritans. The Crown and city corporations responded to epidemics by containment, bolting city gates, banning markets, and quarantining sufferers and suspects. Solomon ions could wreak bodily evil: sickness and death were indices of such diabolical Eccles (or Eagles) was a power. When someone fell ill without obvious cause, accusations of maleficium Quaker fanatic who ran naked through the streets of London (malice) might follow. Priests had trials of their own: how did the victim respond to prayer, Poole (180779). In 1602, Mary Glover fell sick with fits and Elizabeth Jackson, a London char 90 The Cam bridge Illustrated H istory of M edicine woman, was accused of bewitching her. Testifying in court, the physician, Edward Jorden, contended that her disorder was organic. Puritan counterwitnesses protested that this was a case of demonism, a view upheld by the judge, Sir Edmund Anderson, a noted hammer of witches. Jorden did not deny the reality of diabolism in general, he merely claimed that it did not apply to Glover. Leading Anglican ecclesiastics supported Jorden, for the bishops wanted to put a damper on witchcraft accusations, which they saw as being exploited by Roman Catholics and Puritans alike in their battles against the Church of England. The boy is to be by Hippocrates of Cos (see page 58), insisted that sickness was of the body, undergoing an epileptic and that the body formed part of the comprehensive economy of Nature (physis): seizure; Jesus as the source of healing floats in a sea of light. In early Greece, there were no state privileges or Christendom many religious cures were attempted. It was legal safeguards for the medical art, and anybody was free to jockey for trade in the widely believed that St medical marketplace. In such circumstances, the Hippocratic doctors strove in Valentine, St Sebastian, and St various ways witness the celebrated Hippocratic Oath (see page 59) to elevate Vitus assisted epileptics. Yet, as emphasized in Chapter 2, if GraecoRoman medicine was secular and naturalistic, it was also holistic. It focused upon what it called the humours, those fluids whose equilibrium was vital for life: the the healing god Asclepius (or body must not become too hot or too cold, too wet or too dry. It did not see illness as typically caused by invasive (a cast of the original) was pathogens: the cause of sickness was largely internal. In reality, they argued, Nature was made up of particles or corpuscles of inert matter. Dissection and experimentation spurred inspection of muscles, cartilage, mind and matter. They had the profoundest implications for conceptions of health and disease: wellbeing became compared to the running of a welltuned, welloiled machine, and sickness was depicted as a mechanical breakdown, due perhaps to a blockage, fuel shortage, or excessive friction. Knowledge of anatomy (structure) paved the way for a better grasp of physiology (function). Moreover, if the flesh truly were a machine no more, no less it should prove as comprehensible as the workings of a clock. The mechanical worldview with its attendant mindbody dualism unleashed an extraordinarily productive programme of anatomical and physiological research that bore exceptional fruit, in the nineteenth century, with experimental physiology and cell biology and, in the twentieth, with molecular biology. Such developments imparted a new scientific aura to nineteenthcentury professional medicine. Proponents of scientific medicine, such as the German bacteriologist Robert Koch, discoverer of the cholera bacillus, believed they had cracked the secret of disease. So the core medical project over the past two centuries has lain in exploring the workings and the malfunctions of bodily tissues and cells. Chapter 5 examines the role in this of the laboratory and the medical specialisms it has sustained.
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Chocolate agar with Fortunately, the disease rarely results in death factor V and X is used to culture Haemophilus and patients are often asymptomatic; however, infuenzae. Loeffer medium is quelae, specifc symptoms depend on the loca needed to culture Corynebacterium diphthe tion of the cysts. This describes all tosomiasis is a parasite that commonly invades sporeforming bacteria, which include Bacil the bladder. About duces the symptoms seen in this baby and 60% of these infections cause no symptoms, also fts the mode of transmission. C botuli and in the remaining 40% of cases, the symp num causes botulism via the production of a toms can range from mild to severe. Severe heatlabile toxin that inhibits the release of forms of the infection can present with blood acetylcholine into the neuromuscular junc tinged sputum, loss of appetite, weight loss, tion. Infants may initially become constipated a painful red rash on the legs, and change in and then develop generalized muscle weak mental status. IgA protease is pro duced by some bacteria so they can cleave Answer A is incorrect. In a patient with fever, secretory IgA and colonize mucosal areas; chills, and fulike symptoms who has recently Neisseria gonorrhoeae, Neisseria meningitidis, returned from Namibia, there is concern for Streptococcus pneumoniae, and Haemophilus infection by Plasmodium species, which cause infuenzae are the most well known. Malaria is transmitted by the female none of these are typically transmitted via food, Anopheles mosquito. Exotoxin A is produced Treatment is tailored to the geographic area by Pseudomonas aeruginosa as well as some of infection and the Plasmodium species in Streptococcus species. Exotoxin A has been as volved; agents include chloroquine, hydroxy sociated with toxic shock syndrome and scarlet chloroquine, and atovaquoneproguanil. However, none of these organisms pro larial infection would be evident on a blood duce the symptoms seen in this case or is trans smear. Lecithinase is pro to the Mississippi and Ohio River valleys is duced by Clostridium perfringens and is re suggestive of histoplasmosis. Although histo sponsible for the development of gas gangrene, plasmosis typically does not present symptom cellulitis, and diarrhea. It is highly anti spleen, adrenal glands, mucosal surfaces, and genic and can cause sepsis in severe infections. On microscopy, histoplasmosis ap However, generalized muscle weakness is not pears as spherules flled with endospores, as characteristic of sepsis. Recent hiking in and sputum culture are suggestive of coccidi wooded areas carries the risk of contracting oidomycosis, a fungal infection caused by the tickborne illnesses, such as those carried by inhalation of Coccidioides immitis or Coccidi the Ixodes tick: Babesia microti, a protozoon oides posadasii. These organisms are found in that causes babesiosis; Borrelia burgdorferi, a soil in dry areas of the southwestern United spirochete that causes Lyme disease; and Ehr States, Mexico, and Central and South Amer lichia chaffeensis, a rickettsial bacterium that ica. Coccidioidomycosis is the second most 90 Section I: General Principles Answers causes erlichiosis. This fungus can chial rashes, jaundice, hepatosplenomegaly, be found in various environments, including and sensorineural hearing loss. Cardiovascular sphagnum moss, decaying vegetation, hay, abnormalities are not features of congenital and soil. Congenital herpes in nodules along the draining lymphatics (as fection most often either affects skin, eyes, and cending lymphangitis). If the include chorioretinitis, hydrocephalus, and mother becomes infected during pregnancy, intracranial calcifcations. Early symptoms can the pathogens can cross the placenta and in include a maculopapular rash, jaundice, and fect the fetus. The virus crosses the placenta in the the infection is not treated soon after birth. Newborns with con malities that range from deafness to cataracts genital syphilis normally are asymptomatic to cardiovascular abnormalities. Because blood is shunted, there is a with infection by the organism Helicobacter widening of pulse pressure (the difference be pylori. The S2 sound is protonpump inhibitors is often suffcient to a composite of two distinct heart valves. This pattern is seen in is forced to stay open longer than the aortic benign fora such as the lactobacilli. This pattern would be Moreover, an invasive process by the organism commonly seen in streptococcal species such would likely take >4 hours to produce symp as Streptococcus pneumoniae. Vibrio cholerae causes is commonly seen in facultative anaerobes largevolume, watery diarrhea. This pattern represents for treatment, tetracyclines have been shown Pseudomonas aeruginosa, an opportunistic to reduce the course of the disease. This patient presents Proteus mirabilis, a common cause of urinary with classic symptoms of hepatocellular carci tract infection. Approximately 1%5% of these patients the major cause of illness in this patient, and develop hepatocellular carcinoma. These organisms are typically found in specifc types of food, and B cereus is Answer A is incorrect. Campylobacter jejuni transplantation, but it does not cause a chronic enterocolitis can be treated with erythromy hepatitis or cirrhosis. Hepatitis E is transmit ism is not associated with eating reheated rice ted via the fecaloral route and has been linked and would typically result in bloody diarrhea. It does not 92 Section I: General Principles Answers cause chronic hepatitis except very rarely in 21. This boy is suffering patients who have previously received solid or from the classic hemolyticuremic syndrome gan transplants. It is caused ins that are released bind to a molecule within by a doublestranded virus (reovirus). It is typi the desmosome called desmoglein 1, thereby cally spread throughout daycare centers but disrupting cell adhesion. Vibrio cholerae causes cular intercellular contact areas that permit massive watery diarrhea by secreting cholera the passage of small molecules between adja toxin. The most common causes serve to connect epithelial cells to the underly of urethritis in males are Chlamydia tracho ing extracellular matrix. Intermediate junctions shows intracellular inclusions consistent with lie deep to tight junctions, comprised of actin infection by C trachomatis. While they may be flaments forming a continuous band around diffcult to differentiate, C trachomatis infec the cell, providing structural support just be tion induces a predominantly immunologic low tight junctions. The columnar epithelium (eg, intestinal lining) antibiotic of choice for chlamydia urethritis is and seal the intercellular space to prevent dif azithromycin (macrolide) or doxycycline (tet fusion between cells. Ceftriaxone is an effec tor of recent disease, given that IgM is the frst tive treatment for gonorrhea, but the cephalo antibody produced in response to an antigen. This patient likely has pertussis, or whooping cough, which is Answer C is incorrect. Fluconazole inhibits caused by the gramnegative rod Bordetella fungal steroid synthesis. This organism has four virulence fac ment of fungal infections, such as Candida al tors, including pertussis toxin. Penicillin has been Gai proteins, which ultimately results in the shown to suppress chlamydial multiplication. The effects of this ac However, it does not eradicate the organ cumulation include histamine sensitization, ism and thus is not the best treatment for this increased insulin synthesis, lymphocytosis, and type of infection. Vancomycin has not released by Clostridium botulinum prevents been shown to be effective in the treatment of the release of acetylcholine into the synaptic chlamydial infection. It is used to treat drug cleft, resulting in muscle weakness and paraly resistant Staphylococcus aureus and Clostrid sis. The cytokine this results in extremely watery diarrhea ac interleukin1, released by macrophages acti companied by electrolyte imbalances. This is a characteristic of Shiga toxin, which typically leads to bloody Answer F is incorrect. Diphtheria toxin and ture a throat swab from patients with suspected exotoxin A from Pseudomonas inactivate elon Corynebacterium diphtheriae infection. This gation factor 2, but neither is a likely cause of organism causes symptoms of pseudomembra watery diarrhea. Rapid treatment with diphtheria pertussis causes whooping cough, not severe antitoxin, penicillin, or erythromycin and the watery diarrhea. BordetGengou agar is tamines, serotonins, and other compounds used to culture Bordetella pertussis, the etio stored in the granules of these immune cells. Chocolate agar with ceptors present on these cells causes the activa factors V and X is used to culture Haemophilus tion of these cell types. This organism typically causes up reaction, the anaphylactic pathway can be sty per respiratory infections but is not responsible mied. Neisseria gonorrhoeae duced by T lymphocytes and, among other is cultured on ThayerMartin media. Az negative bacterium carried by the American treonam is a potent antipseudomonal agent in dog tick (Dermacentor variabilis). Amoxicillin is an ami southeastern United States than in the Rocky nopenicillin antibiotic that interferes with cell Mountains. The WeilFelix assay re cocci), it does not provide antipseudomonal action is the classic test for rickettsial disease. Aminoglycosides are effective against tibiotic used for serious multidrugresistant, many gramnegative bacteria and some strains grampositive infections. It is also used as methicillinresistant Staphylococcus aureus broadspectrum therapy when combined with and moderate to severe Clostridium diffcile in a penicillin or metronidazole. Nystatin is used in the cell wall mucopeptide formation by binding treatment of fungal infections such as oral can the DalaDala portion of cell wall precursors. Penicillin is not effec by warfarin overdose is reversed by pharma tive against Rickettsia rickettsii. The vulva and vagina are right upper quadrant pain), along with the frequently infamed. The cervix and vagina ominous sign of hypotension, a clear clini may develop small, red, punctate lesions, caus cal picture of cholecystitis. Entamoeba histolytica smelling vaginal discharge suggest a vaginal infection presents with bloody diarrhea (dysen foreign body. E histolyt dominal pain with an abnormal, foulsmelling ica is transmitted via cysts in water (fecaloral vaginal discharge is suggestive of pelvic infam transmission). Treatment for metrium, fallopian tubes, ovaries, and peri E histolytica infection includes metronidazole toneum. The typical organisms involved are Neisseria gonorrhoeae and Chlamydia tracho Answer C is incorrect. Mi cally cause intense pruritus and a thick, odor croscopically, macrophages containing amas less, white, cottage cheeselike vaginal dis tigotes are observed. The Plasmodium falci parum parasite is responsible for causing ma Answer E is incorrect. Naegleria fowleri matic heart disease can develop due to calcif presents with a rapidly progressing meningoen cation of warty vegetations on fbrotic healing, cephalitis that can progress to coma or death most commonly on the mitral valve. Other symptoms include nau sult, it most commonly causes mitral stenosis, sea, vomiting, and irrational behavior. Trans which in mild disease causes a late diastolic mission occurs through swimming in fresh murmur heard best at the apex. Microscopic analysis will reveal incidence of this mitral stenosis secondary to amebas in the spinal fuid. Unfortunately, rheumatic fever is low given the widespread there is no treatment for N fowleri. Cryptosporidium spe to pericarditis, an infammation of the pericar cies are transmitted via cysts in water (fecal dial sac that leads to friction with an expanding oral transmission). Rather, is no treatment available for Cryptosporidium a friction rub may be associated with malig species infection; however, in healthy patients, nancy, uremia, active infections such as viral cryptosporidiosis is selfresolving. Arboviruses and favi gitation and ultimately valve surgery may be ruses can be transmitted through mosquito required, but typically it is followed by a car bites. These viruses cause tropical diseases diologist with serial exams and echocardiogra such as dengue fever and yellow fever, but not phy. It also can be caused by diastolic heart failure because the left ventricle is not as 34. The exam fnding is stellation of symptoms and prior hospitaliza due to turbulent blood fow caused by blood tion points toward pseudomembranous coli flling a stiff ventricle. Antibi Burkitt lymphoma, a lymphoma endemic otic treatments suppress the normal fora of to Africa. Always consider C diffcile in patients normality associated with Burkitt lymphoma is with gastroenteritis and recent antibiotic use. This describes how the drome in young adults similarly characterized Norwalk virus can cause gastroenteritis charac by fever and pharyngitis. Both cause pericardi terized by nausea, vomiting, and diarrhea that this only rarely. Members of this toxin produced by Shigella species, which can family include rotavirus, which is responsible cause a bloody and mucusrich diarrhea. This describes the exotoxin produced by Vibrio cholerae, which Answer D is incorrect. This answer choice de causes a large volume of watery diarrhea de scribes the structure of Coronaviridae. This pain clude elevated gammaglobulin, decreased is relieved when leaning forward and worsens nerve conduction velocity indicative of demy with inspiration. The most common cause pericarditis, coxsackie B is the most epidemiologic associations involve infections common cause of infammation of the pericar with Campylobacter jejuni, a commashaped, dial membrane. Herpesvirus is char moniae is an ahemolytic, encapsulated, gram acterized by multinucleated giant syncytial positive coccus that produces an IgA protease. It can be a cause of osteomyelitis, is a rodshaped, grampositive, sporeforming, but this is more common after implantation anaerobe that produces a heatlabile toxin that with orthopedic appliances. Salmonella species are lism, therefore, does not lead to sensory fnd oxidasenegative, gramnegative bacilli. The patient is now the causative agent of syphilis, is a spiral in the secondary stage of a syphilis infection, shaped bacterium with axial flaments, visu characterized by wartlike lesions known as alized using darkfeld microscopy. Tertiary condylomata lata, generalized rash, and sys syphilis causes sensory defcits rather than temic symptoms such as lymphadenopathy, muscle weakness and is preceded by a painless weight loss, and fever. Tzanck preparation grampositive, coagulasepositive coccus that using Giemsa stain reveals multinucleated gi occurs in clusters. Acidfast bacilli such were infected with Rickettsia rickettsii (Rocky as Mycobacterium tuberculosis are found in Mountain spotted fever). This infant is show used to stain acidfast mycobacteria such as ing signs of neonatal sepsis and meningitis. The most common cause of neonatal sep sis and meningitis is group B Streptococcus 39. Metronidazole has good activity terial enteritis), pulmonary symptoms, or ad against protozoans and anaerobic organisms. Actinomyces israelii is a Fluoroquinolones have good coverage against bacterial pathogen with a fungallike morphol gramnegative and select grampositive organ ogy. Additionally, fuoroquinolones are a class num is a species native to freshwater and salt C substance, as they have the potential to water environments. Giv neous wound infection in anglers, swimmers, ing fuoroquinolones during pregnancy is not and aquarium owners. It is not commonly as recommended unless the benefts justify the sociated with disseminated infection in immu potential risks to the fetus. Although Nocardia otics, or had an allergy that prevented the use can stain weakly acidfast, they demonstrate of other agents. Chapter 5 Immunology 101 102 Section I: General Principles Questions Questions 1. He does not experience dysuria, (E) Tumor necrosis factorb and urinalysis shows no bacteria or crystals. What is a (A) Kupffer cell, dendritic cell possible mechanism accounting for his symp (B) Kupffer cell, macrophage tomsfi She is diagnosed with a would be correct to conclude which of the fol condition associated with the release of proin lowingfi
Physical ex (C) Sjogren syndrome amination of the skin reveals the lesion seen (D) Systemic lupus erythematosus in the image 2c19 medications buy 3 ml careprost amex. Treatment in from rejection of his recently transplanted cludes bone marrow transplantation treatment 4 water discount careprost 3ml online. A hyperacute and fourth pharyngeal pouches to descend is rejection is mediated by preformed antibod known as DiGeorge syndrome treatment 360 buy careprost 3ml overnight delivery, and results in ies to the transplanted organ medicine 8 capital rocka buy careprost australia. Chromo it can be observed while still in the operating some 22q11 deletions are associated with Di theater medicine cabinet with lights discount 3ml careprost with amex. Tetany from hypocalcemia but is most likely in the frst three months after and viral and fungal infections are common transplantation symptoms 2 year molars buy careprost 3 ml free shipping. It is due to human leukocyte due to the lack of T lymphocytes treatment juvenile arthritis generic careprost 3ml on line, while nor antigen discrepancies between host and graft medications interactions purchase careprost 3 ml overnight delivery, mal B lymphocytes are present. Plasma cells are responsible for Escherichia coli, and Aspergillus are common antibody production and therefore would be pathogens. They are the cell type that leads to activity, and thus cannot have chronic granulo chronic rejection of the graft. They do not attack pathogens kinase defect causes Bruton agammaglobulin or tissues and are not implicated in the pathol emia, resulting in decreased levels of all im ogy of acute rejection and negative selection. This defect in early stem cell differ allel and sequential events occur within the entiation results in a lack of T and B lympho synovium to cause joint destruction, includ cytes. Kupffer cells are tissue torb plays a role in dampening the immune resident macrophages; the image depicts a response, and in the case of rheumatoid ar Langerhans cell. Langerhans cells are ing T lymphocyte activation and proliferation, specialized, tissueresident dendritic cells, not inhibiting biosynthesis of metalloproteinases, macrophages. When an Rh by helper T lymphocytes and helps stimulate negative mother gives birth to an Rhpositive macrophages. Thus, the indirect Coombs test is an important laboratory tool to monitor Answer D is incorrect. Tumor necrosis for Rh incompatibilities that may complicate factora is one of the main cytokines involved fetal health. The test result given in this ques in mounting an acutephase response; it is se tion indicates that the patient possesses antiRh creted by macrophages. Tumor necrosis fac be logical for the clinician to suspect previous torb has functions similar to tumor necrosis pregnancy with an Rhpositive fetus. The results of the test granules is unknown, but they are present only cannot be used to determine the Rh status of a with Langerhans cells. Upon antigen encoun current fetus; only direct typing of fetal blood ter, Langerhans cells upregulate costimulatory can determine its Rh status. Agglutination occurs when the tegral part in the activation of T lymphocytes antiIgG antibody binds to the antiRh antibod and the subsequent induction of an adaptive ies that are already bound to the Rhpositive immune response. The inci toms also may be consistent with anaphylaxis, dence of this illness has decreased drastically the patient has never been exposed to vanco in recent years because of immunization ef mycin; therefore, she would not have pre forts. By the bacterial capsule antigen and diphtheria contrast, a vancomycininduced anaphylactic toxoid protein. Because the bacterial capsule reaction involves histamine release from mast is a polysaccharide, it alone will not generate a cells and basophils without binding of pre suffcient immune response. Another method of prevention is pre pili are an important virulence factor of H in treatment with antihistamine. It does not, how reactions are mediated by preformed IgE anti ever, play a role in vaccination. H infuenzae does not of the antigenIgE complexes to Fc receptors generate protein A. This is a virulence factor on mast cells results in degranulation and re found in Staphylococcus aureus that binds the lease of vasoactive substances such as hista Fc portion of IgG and thus helps prevent opso mine. This clinical scenario would result in hyperacute rejection (within Answer C is incorrect. Macrophages provide a secondary immune response in this situation Answer E is incorrect. The medullary cords but are not initially involved in acute or hyper contain lymphocytes and plasma cells, and are acute reactions. The smear would is typically mediated by preformed antidonor have a hypersegmented neutrophil, classically antibodies that are possessed by the recipient. Serum levels of homocysteine and pouches, and thus the thymus and parathyroid methylmalonic acid can be elevated, and a glands. The recurrent viral and fungal infec complete blood cell count can show thrombo tions are caused by a Tlymphocyte defciency. Vitamin B12 defciency also causes In lymph nodes, T lymphocytes are found in a megaloblastic anemia with hypersegmented the paracortical region, thus this region is of neutrophils on peripheral blood smear. Folate ten underdeveloped in patients with DiGeorge defciency also results in a similar megaloblas syndrome. The medullary sinuses However, this patient shows signs of vitamin contain macrophages and communicate with B defciency, which would result in a macro 12 lymphatics. Pyridoxine defciency (vitamin B), often caused by isoniazid ther Answer A is incorrect. The cell on the left Note that urethritis, conjunctivitis/anterior is a macrophage and the cell on the right is uveitis, and arthritis make up the classic triad a helper T cell. This patient most important mechanism for increasing killing of likely has hyperIgM syndrome, which is intracellular pathogens such as mycobacteria. Since IgM is initially of eosinophils increase in hypersensitivity dis created and subsequently switched to the other eases such as asthma and in parasitic infection. Basophils and mast Two prominent clinical problems are Pneumo cells are the primary mediators of the immedi cystis jiroveci and neutropenia. The disease is associated with an IgA def 114 Section I: General Principles Answers ciency. The typical presentation of the disease body titer is usually a good indicator of disease is given away by the name, as symptoms in severity, particularly in Wegener granulomato clude cerebellar problems (ataxia) and spider sis, for which specifcity and sensitivity of anti angiomas (telangiectasia). Since neutrophils are unable to adhere to the endothelium and transmigrate into tis Answer D is incorrect. The image reveals Job syndrome presents with recurrent staphy ReedSternberg cells, which are found in lococcal abscesses, eczema, and high levels of Hodgkin lymphoma and can be identifed by IgE. In thymic aplasia (Di Most studies support a Blymphocyte origin for George syndrome), the third and fourth pha ReedSternberg cells. Evidence supporting this ryngeal pouches, and thus the thymus and includes rearrangements at immunoglobulin parathyroid glands, fail to develop. Neutrophil levels are which stains in a cytoplasmic distribution and elevated in acute infection and infammation. Opsonins adhere to microor evated in Tlymphocyte leukemias such as ganisms and promote leukocyte chemoattrac Tcell acute lymphocytic leukemia and Tcell tion, antigen binding and phagocytosis, and chronic lymphocytic leukemia. IgA patrols mucosal years and must include arthritis in at least one barriers and prevents attachment of bacteria joint for at least six weeks. It does not fx complement, nor is morphologic joint pathology is similar to that it an opsonin. However, there are several signs and symptoms that occur more com Answer B is incorrect. IgE mediates immedi adenopathy, and hepatomegaly), largejoint in ate (type I) hypersensitivity and immunity to volvement, and antinuclear antibody seroposi helminths by facilitating the activation of eo tivity. IgM fxes (activates) complement but does not function by opso Answer A is incorrect. This patient has be creased likelihood of antinuclear antibody se come susceptible to opportunistic disease ropositivity. This patient should be started on highly active antiretroviral therapy, which commonly 17. This patient has al includes the nucleoside reverse transcriptase ready had several bacterial infections, most inhibitor zidovudine. Specifcally, the protein C3b is respon sible for the opsonization of bacteria, and is Answer C is incorrect. It is due to a are particularly susceptible to extracellular sensitivity to gluten, which is found in wheat, pyogenic bacterial infections with organisms grains, and many cereals. Biopsy shows marked such as Haemophilus infuenzae, Streptococ atrophy, total loss, or fattening of the villi of cus pyogenes, Staphylococcus aureus, and the small bowel. Abetalipoproteinemia fnding for Bruton patients is the absence, or is an autosomal recessive disease that causes a near absence, of tonsils and adenoids, which defect in the synthesis and export of lipids by are Bcellrich tissues. Patients diagnosed with mucosal cells because of the inability to syn Bruton will need to be treated with replace thesize apolipoprotein B. However, the clinical cytes would result in a defect in cellmediated time course, suggested gluten sensitivity, and immunity, and the patient would be more fndings on biopsy make viral enteritis unlikely. Decreased T cells are ally presents in middleaged men who have seen in DiGeorge syndrome because of ab malabsorptive diarrhea, and the hallmark is the sence of thymus. Rodshaped nation and family and patient history are all bacilli of the causal agent, Tropheryma whip highly suggestive of an immunoglobulin def pelii, are found on electron microscopy. This clinician is are suggestive of selective IgA defciency, the concerned that the fetus may have erythro most common inherited immunodefciency blastosis fetalis (hemolytic disease of the new in the European population and, interestingly born). This disease is mediated by maternally enough, one that appears to have no striking derived IgG antiRh antibodies developed in disease associations. If the mother transfused with normal blood products con possesses the antibodies developed from a pre taining IgA. Graftversushost dis athy is a heterogeneous renal disease that is a ease is a potentially lethal side effect of bone consequence of immune complexes deposited marrow transplantation. Examples include anaphy general, immunosuppressants are used to mini laxis, asthma, hives, and local wheal and fare. Lupus nephritis is con ity reactions are a group of Tcellmediated sidered a heterogeneous renal disease that can pathologies. Examples include the tuberculin have a variety of presentations including active skin test, transplant rejection, and contact der or inactive diffuse, segmental, or global glo matitis. Hypocalcemia is char infected bite, patients may develop erythema acteristic of thymic aplasia (DiGeorge syn migrans at the site of the bite and additional drome), in which the third and fourth pha annular lesions. They may also display symp ryngeal pouches, and thus the thymus and toms of cardiac and neurologic involvement, parathyroid glands, fail to develop. As a result including frstdegree heart block, myopericar patients may experience tetany. Thymic apla ditis, meningitis, cerebellar ataxia, and seventh sia often presents with congenital defects such nerve facial palsy. In addition, patients often as cardiac abnormalities, cleft palate, and ab experience a migratory musculoskeletal pain. Pneumonia is an infec in hyperIgM syndrome, ataxiatelangiectasia, tion of the lung involving the alveoli, intersti and in selective IgA defciency. They are low fever, cough, and an increased respiratory in hyperIgM syndrome, in which B cells are rate, as this patient does. However, physical unable to class switch because of a defect in exam would display fndings of dullness to per helper T cells; these patients have high levels cussion in a lobar distribution in addition to of IgM and low IgG, IgA and IgE levels. Neurologic symptoms include temic infammatory process that involves an headache, cognitive dysfunction, seizures, and exaggerated Th1 immune response of un myelopathy, but seventh nerve involvement is known etiology. Pulmonary symp symptoms, with the appearance of hilar lymph toms usually manifest as a pleuritis with or adenopathy and noncaseating granulomas without pleural effusion, but one would not in the lungs, but can affect any organ system. Acute sarcoidosis can develop suddenly over a period of weeks, with both constitutional and Answer E is incorrect. The HeerfordtWalden acidfast bacterium Mycobacterium tuberculo strom syndrome of acute sarcoidosis includes sis, which produces a primary infection of the the development of fever, parotid enlargement, lungs. Symptoms include fever, night sweats, anterior uveitis, and facial nerve palsy, as seen malaise, weakness, and dry cough. Of the neurologic symptoms phy may reveal paratracheal or hilar lymph seen in sarcoidosis, seventh nerve involvement adenopathy, as in this patient. Lyme disease is a multi fed protein derivative test is negative, making system infection caused by the spirochete Bor it less likely that she has been exposed to the relia burgdorferi, carried by the Ixodes scapu bacterium. This patient is likely normal IgG level is characteristic of Wiskott presenting with renal amyloidosis. WiskottAldrich syndrome ber, amyloid deposits show applegreen bire is an Xlinked disorder that results in a reduced fringence in polarized light). The cells express abnormal amounts of light chain triad of symptoms consists of recurrent pyo protein. The organs most affected are the kid genic infections, eczema, and thrombocytope neys and the heart. C2 is a complement dye reduction test are characteristic of chronic protein; complement is a system of proteins granulomatous disease. It is not involved in amyloidosis patho defciency that reduces the ability of phago genesis. The defnitive test for this disorder is a on cytotoxic T lymphocytes and is involved in negative nitroblue tetrazolium dye reduction immune response. The Fab fragment is ulin levels can be seen in thymic aplasia (Di the part of the antibody that binds to the anti George syndrome). They may also It is not involved in amyloid protein deposi have disorders of the great vessels and heart tion. IgA defciency is sitivity reactions (also known as delayedtype the most common of these. Because IgA is the hypersensitivity) are mediated by previously most prominent immunoglobulin found in activated Thelper 1 (Th) cells. These Th cells become 1 activated to secrete interferonfi and tumor Answer A is incorrect. A very high IgE level necrosis factorb, which mediate a local in and normal levels of all other immunoglobu fammatory response within 2448 hours after lins are characteristic of Job syndrome. These Th1 ef syndrome is a disorder of the immune system fector cells are present only in individuals who that involves the failure of helper T cells to have previously been exposed to Mycobacte produce interferonfi. A low IgM level in tions include celiac disease and contact hyper conjunction with an elevated IgA level and a sensitivities such as poison ivy. It manifests as a variable combination of progressive neurologic Answer B is incorrect. Th2 cells are those interferonfi leads to the failure of the neutro that help the humoral (antibodymediated) phil response to chemotactic stimuli. Cleft palate is a com is characterized by ptosis, limb weakness, and mon feature of thymic aplasia (DiGeorge syn diffculty breathing. Thymic aplasia results from failure of autoantibody to the acetylcholine receptor on the third and fourth pharyngeal pouches (and the postsynaptic membrane. All antibody mol thus the thymus and parathyroid glands) to de ecules consist of two identical heavy chains velop. The disease often presents with congeni and two identical light chains that are held to tal defects such as cardiac abnormalities, cleft gether by disulfde bonds. Hydrogen bonds are can also present with tetany due to hypocalce weaker than disulfde bonds and do not con mia. Ionic bonds are found lections of cells seen in (among other things) in chemicals such as sodium chloride but are chronic granulomatous disease. This disease not responsible for holding antibody chains to is caused by an inability of neutrophils to kill gether. Visual hallucinations are seen between some atoms, such as nitro are not a symptom of any of the known im gen, but are not responsible for holding the mune defciencies. Infammation of the pulmonary capillaries, Chapter 5: Immunology Answers 121 which can lead to hemoptysis, is common in Answer D is incorrect. This page intentionally left blank Chapter 6 Pathology 123 124 Section I: General Principles Questions QuestionsQuestions 1. A 19yearold college student is admitted to the (C) Pseudopalisading tumor cells surrounding hospital for bacterial meningitis. A 43yearold woman presents to her primary mechanisms is most likely responsible for the care physician for a regular checkup. When the patient looks to the (C) Fusion of the cranial sutures right, both eyes seem to move appropriately. A 41yearold man visits his physician because (A) Lesion of the left medial longitudinal fas of increasingly painful headaches.
