Albendazole

Katharina M. Busl, MD

• Neurology Chief Resident
• Brigham and Women? Hospital
• Massachusetts General Hospital
• Harvard Medical School
• Boston, Massachusetts

The precise mode of action of alitretinoin in chronic hand eczema remains unclear antiviral purchase 400 mg albendazole overnight delivery, but retinoids are known to affect multiple processes at a cellular level including proliferation antiviral drugs youtube buy albendazole 400mg amex, differentiation and apop to sis the infection cycle of hiv includes buy albendazole 400 mg line. Alitretinoin has been shown to suppress the expression of co-stimula to ry molecules on the surface of antigen-presenting cells hiv infection with condom buy discount albendazole 400 mg, which may be of relevance to a therapeutic effect in contact dermatitis rate of hiv infection in jamaica best order for albendazole. In contrast to isotretinoin hiv infection news cheap 400 mg albendazole with visa, alitretinoin only has a minimal effect on sebum secretion. Both hyperkera to tic disease and pompholyx/fngertip variants of hand eczema were reported to respond. Smaller studies have reported beneft in palmoplantar psoriasis, chronic hyperkera to tic palmar psoriasis and chronic foot eczema. This raises the potential for prescribing and dispensing error with potentially serious consequences and litigation. Pharmacists who dispense alitretinoin should be alert to the potential for confusion. The capsule should be swallowed whole with/after a meal to maximize bioavailability. In patients with diabetes, hyperlipidaemia or risk fac to rs for cardiovascular disease, a lower starting dose of 10 mg once daily is recommended. It has been reported that some patients who have not responded by these time intervals may nevertheless beneft from more prolonged therapy. Treatment should be s to pped once an adequate clinical response (clear or almost clear) has been achieved. Relapse tends to occur slowly over several months and subsequent retreatment may be necessary. While soya beans and peanuts are both legumes, each of these foods stand alone in terms of immunogenicity and patients who are peanut allergic do not routinely need to avoid soya-containing products. In cases where the his to ry is unclear, immediate type allergy testing can be undertaken (skin prick tests or specifc immunoglobulin [Ig]E measurement) and if negative, a test dose given under clinical supervision. Blood donation: should be avoided during treatment and for at least 1 month after s to pping treatment. This is an important consideration as allergic contact dermatitis of the hands may be impossible to distinguish from an endogenous dermatitis on clinical grounds alone. Patients with diabetes, his to ry of hyperlipidaemia, or risk fac to rs for cardiovascular disease should be identifed and screened prior to commencing treatment and closely moni to red during treatment. In the absence of specifc advice from the manufacturers, testing every 3 months is reasonable. Monthly moni to ring may be indicated for those with diabetes, pre-existing hyperlipidaemia or risk fac to rs for cardiovascular disease. The moni to ring requirements are identical with those for oral isotretinoin (see Isotretinoin). This effect is usually dose related and reversible and usually responds to dosage reduction. If these measures fail and hyperlipidaemia is severe, treatment must be discontinued. Hypertriglyceridaemia is associated with an increased risk of pancreatitis, especially if levels exceed 9 mmol/L. They are a more frequent problem with alitretinoin than other systemic retinoids and tend to improve after several weeks of continued treatment. Cheilitis and alopecia are less common than with isotretinoin and acitretin respectively. Pho to sensitivity can occur during treatment with alitretinoin so patients should be advised to avoid use of sun beds and protect their skin against excessive sun exposure. Radiological changes with long-term retinoid therapy include hyperos to sis and spondylitis (rare). It is not yet clear if this applies to alitretinoin which has generally been used in older patients with a different psychosocial profle from those with acne. Very low amounts of alitretinoin have been detected in the semen of males taking alitretinoin. As with the other oral retinoids, isotretinoin and acitretin, these levels are to o low to pose a tera to genic risk to the unborn baby of a female partner. Lactation Alitretinoin is lipophilic and likely to be distributed to breast milk so it is contraindicated in breastfeeding females. There is insuffcient evidence at present to support use of alitretinoin in derma to logical disease in children. With acknowledgements to Raja Sivamani, Jillian Millsop and Vivian Shi who reviewed this chapter from an international perspective. Pharmacology of oral alitretinoin: a novel treatment for severe chronic hand eczema. Effcacy and safety of oral alitretinoin (9-cis-retinoic acid) in patients with severe chronic hand eczema refrac to ry to to pical corticosteroids: results of a randomized, double-blind, placebo controlled, multicentre trial. Anabolic steroids are sex hormones with some androgenic activity (increased skeletal muscle mass, increased organic mass of bone and retention of nitrogen). They cause less virilization than androgens in females and are helpful in some derma to logical conditions. The actions of anabolic steroids are similar to male sex hormones, with the possibility of causing serious disturbances of growth and sexual development if given to children. It is a weak androgen with additional antiproges to genic and antioestrogenic actions and interferes with gonadal steroid synthesis. It increases the proportion and concentration of tes to sterone carried unbound in plasma. In addition, danazol corrects partially or completely the primary biochemical abnormality of hereditary angioedema by increasing the levels of the defcient C1 esterase inhibi to r. As a result of this action, the serum levels of the C1 esterase inhibi to r and C4 component of the complement system are increased. Stanozolol is a synthetic derivative of tes to sterone and has more powerful androgenic effects, hence its use as a performance enhancing drug by bodybuilders. It suppresses the gonadotrophic functions of the pituitary and 23 Androgens may exert a direct effect upon the testes. It can increase collagen production and decrease the antianabolic action of cortisone. It corrects the formation of kinin or kinin-like fac to rs, which may be associated with oedema and swelling seen in hereditary angioedema. It has also been used for recalcitrant cholinergic urticaria and lividoid vasculopathy. The usage of these drugs for hereditary angioedema prophylaxis may decrease as on-demand self-administered therapy with C1 inhibi to r concentrate and bradykinin analogues becomes more widespread. Treatment is usually given continuously and dosage should be kept at the lowest effective level. In fertile females, treatment should be started during menstruation, preferably on the frst day of the cycle and adequate non-hormonal contraception used (see Use in special situations). Interactions with labora to ry function tests: danazol may interfere with labora to ry determination of tes to sterone or plasma proteins; stanozolol may interfere with thyroid function tests. Stanozolol is not recommended for use in pre-menopausal females, those with insulin dependent diabetes and hypercalcaemia/hypercalciuria. Menstrual irregularities, vaginal dryness, fushing, changes in libido and a reduction in breast size may also occur. Treatment should be discontinued if signs of virilization develop (hirsutism, pattern hair loss, voice change). Male fertility and sexual function may be affected (see Use in special situations). Isolated increases in serum transaminase levels, cholestatic jaundice and benign hepatic adenomata may also occur, so careful moni to ring is indicated. Peliosis hepatis has been reported (a condition in which hepatic and sometimes splenic tissue is replaced with blood-flled cysts). Benign intracranial hypertension has been reported (symp to ms include severe headache, nausea and visual disturbance). Combined with the deleterious alterations in metabolic profle (see above) this may increase cardiovascular risk. Thrombotic events include sagittal sinus, cerebrovascular thrombosis and myocardial infarction. Lactation Androgens are contraindicated as it is not known whether they are excreted in human milk. Children the use of synthetic androgens is not recommended in pre-pubertal children. Risks include precocious sexual development in boys, virilization in girls and premature closure of the epiphyses in both sexes. If used in children, growth should be carefully moni to red with radiography if indicated to assess bone age. Symp to ms that may suggest a liver problem include persistent nausea and vomiting, abdominal pain, or the development of jaundice. Benefts and risks of danazol in hereditary angioedema: a long-term survey of 118 patients. Its mechanism of action is inhibiting androgen uptake and inhibiting nuclear binding of androgen in target tissues. These drugs were developed for the treatment of prostate cancer but at lower doses have been found to be effective in the treatment of females with hirsutism. Spironolac to ne is an aldosterone antagonist and acts as a potassium sparing diuretic. It inhibits the action of aldosterone on the distal renal tubule, increasing sodium and water excretion and reducing potassium excretion. Spironolac to ne is also a potent antagonist of the androgen recep to r as well as an inhibi to r of androgen production, hence its use to treat androgen related skin disease in females, namely hirsutism, androgenic alopecia and acne. It is used in combination with an oestrogen for hormonal oral contraception and hormone replacement therapy. Cyproterone acetate is a synthetic derivative of 17-hydroxyprogesterone, and acts primarily as an androgen recep to r antagonist. It also has weak progesterone agonist and glucocorticoid actions and inhibits androgen synthesis. Cyproterone acetate was the frst antiandrogen in clinical use and was introduced 1964. Males with a genetic defciency of type 2 5a-reductase do not suffer from male pattern hair loss. The enzyme 5a-reductase exists as two isoenzymes; type 1 is the dominant form in non-genital skin including the scalp and the sebaceous glands, while type 2 is the dominant form in genital skin, the prostate and hair follicles of the scalp, where miniaturization takes place. Finasteride selectively inhibits the type 2 isoenzyme whereas dutasteride inhibits both type 1 and type 2 5a-reductase. Other drugs with antiandrogenic effects include the corticosteroids, prednisolone and dexamethasone, which inhibit adrenal androgen secretion, particularly when given as a nocturnal dose (see Corticosteroids). Metformin, an insulin sensitizing agent, has been suggested to have direct antiandrogen actions on ovarian steroid synthesis as well as improving insulin sensitivity and reducing insulin levels, which leads to a reduction in circulating free androgens. The combined preparation also functions as a hormonal contraceptive, but is not licensed specifcally for this purpose. A higher daily dose (5 mg) is used for the treatment of benign prostatic hyperplasia but does not increase effcacy in hair loss. A placebo-controlled study reported that this dose had superior effects on hair growth and hair count to fnasteride. Capsules should be swallowed whole and not chewed or opened, as contact with the contents may cause irritation of the oropharyngeal mucosa. The onset of effect of these agents in male androgenic alopecia is slow and it usually takes 6 months to stabilize hair loss. Treatment arrests the progression of disease, but regrowth is partial at best and continued treatment is required to sustain beneft. At the recommended dose, fnasteride has been shown to improve the anagen (growing phase) follicle count in males with vertex baldness while those given placebo lost anagen hair. The majority of males continue to beneft from long-term 31 Antiandrogens treatment (up to 10 years).

Some causes of neutropenia also cause a decrease in the numbers of platelets and erythrocytes (pancy to penia) hiv infection numbers world cheap 400mg albendazole. In contrast to decreased production antivirus walmart order albendazole 400 mg with amex, neutropenia secondary to peripheral destruction causes a hyperplasia of the bone marrow hiv symptoms five months after infection cheap albendazole amex, with an increase in the number of granulocytic precursors antiviral untuk hepatitis cheap albendazole 400 mg without prescription. Causes of increased destruction of neu trophils include sequestration in the spleen due to hypersplenism (not splenic atrophy) primary hiv infection stories order albendazole 400mg overnight delivery, increased utilization hiv infection and blood type cheap 400 mg albendazole otc, such as with overwhelming infections, and immunologically mediated destruction (immune destruction). In the latter, antibodies are formed against neutrophils, and then these cells are destroyed peripher ally. The type of leuko cyte that is mainly increased may be an indica to r of the type of disease process present. The most common cause of eosinophilia is probably allergy to drugs such as iodides, aspirin, or sulfonamides, but eosinophilia is also seen in collagen vascular diseases. In contrast, neutrophilic leukocy to sis (neutrophilia) may be the result of acute bacterial infections or tissue necrosis, such as is present with myocardial infarction, trauma, or burns. Basophilia is most commonly seen in immediate type (type I) hypersensitivity reactions. Both eosinophils and basophils may be increased in patients with any of the chronic myeloproliferative syndromes. Monocy to sis is seen in chronic infections, such as tuberculosis, some collagen vascular diseases, neutropenic states, and some types of lymphomas. Lym phocy to sis (especially with increased numbers of T lymphocytes) may be seen along with monocy to sis in chronic inflamma to ry states or in acute viral infec tions, such as viral hepatitis or infectious mononucleosis. Acute reaction (acute non specific lymphadenitis) can result in focal or generalized lymphadenopathy. Focal lymph node enlargement is usually the result of bacterial infection (bac terial lymphadenitis). In contrast, generalized acute lymphadenopathy is usually the result of viral infections and usually produces a proliferation of reactive T lym phocytes called T immunoblasts. These reactive T cells tend to have promi nent nucleoli and can be easily mistaken for malignant lymphocytes or malignant Hodgkin cells. For example, reac tive T lymphocytes typically result in hyperplasia involving the T-cell areas of the lymph node, namely, the interfollicular regions and the paracortex. Examples of clinical situations associated with a T lymphocyte response include viral infections, vaccinations, use of some drugs (particularly Hema to logy Answers 281 Dilantin), and systemic lupus erythema to sus. Classic clinical symp to ms include fever, cervical lymphadenopathy, and pharyngitis. Atyp ical lymphocytes are usually found in the peripheral blood, and these same cells, which are reactive T immunoblasts cause enlargement of the cervical lymph nodes. In contrast to reactive T-cell processes, reactive B lymphocytes typically result in hyperplasia of the lymphoid follicles and germinal centers (follicular hyperplasia). His to logically these nodules somewhat resemble the germinal centers of lym phoid follicles, but instead they are characterized by increased numbers (crowding) of nodules, their location in both the cortex and the medulla, their uniform size, and their composition (a mono to nous proliferation of cells). This product is located on the outer mi to chondrial membrane, endoplasmic retic ulum, and nuclear envelope. It inhibits apop to sis by blocking bax channels and by binding to and sequestering apop to sis activating fac to r 1 (Apaf-1). This interferes with one mechanism of apop to sis that involves cy to chrome c being released in to the cy to plasm from mi to chondria via bax channels, these channels being upregulated by p53. Cy to chrome c then binds to and acti vates Apaf-1, which then stimulates a caspase cascade. These cases are thought to have arisen from prior follic ular lymphomas that became diffuse in appearance. Finally, the Rappaport classification is an old classification (developed in 1966) that was based on the microscopic appearance of tumor cells. That is, the size of the malignant cells was classified as being either lymphocytic or Hema to logy Answers 283 histiocytic, while the tumor growth pattern was nodular or diffuse. Also this classification is called well-differentiated cells being similar to lymphocytes and poorly differentiated cells being angulated (cleaved) or having nucleoli. The cells are often mixed with macrophages in biopsy, giv ing a starry sky appearance. The cy to plasmic vacuoles of the lymphoma cells contain lipid, and this would be reflected by a positive oil red O reaction. These unique lymphomas are characterized by rapid cell growth and spread in to the circulation, where they produce elevated to tal white counts reflected by circulating lymphoma cells. Young adults are classically affected and the disease typically involves the cervical, supraclavicular, or mediastinal lymph nodes. The leukemias are divided in to acute and chronic forms, and then further subdi vided based on lymphocytic or myelocytic (myelogenous) forms. Acute leukemias are characterized by a decrease in the mature forms of cells and an increase in the immature forms (leukemic blasts). Symp to ms include fever (secondary to infection), easy fatigability (due to anemia), and bleeding (due to thrombocy to penia). The peripheral smear in patients with acute leukemia usually reveals the white cell count to be increased. The diagnosis of acute leukemia is made by finding more than 30% blasts in the bone marrow. Myeloblasts, charac terized by their delicate nuclear chromatin, may contain three to five nucleoli. These are abnormal lysoso mal structures (primary granules) that are considered pathognomonic of myeloblasts. There are numerous abnormal promyelocytes present that contain numerous cy to plasmic granules and numerous Auer rods. This 286 Pathology abnormality is characterized by increased fibrin degradation products in the blood. This produces an abnor mal retinoic acid recep to r and provides the basis for treatment of these patients with all-trans-retinoic acid. This characteristic translocation, which involves the oncogene c-abl on chromosome 9 and the breakpoint cluster region on chromosome 22, results in the formation of a new fusion protein (P210) that is a nonrecep to r tyrosine kinase. The most com mon sign in these patients is splenomegaly, which is due to leukemic cells infiltrating the red pulp, which is unusual considering that most leukemias preferentially infiltrate the white pulp. Because these neoplastic cells prolifer ate in the spleen, splenec to my may be a treatment choice. Another treatment option is interferon-alpha and pen to statin; the latter blocks adenine deami nase. His to logical examination of the periph eral smear reveals a marked increase in the number of mature-appearing lymphocytes. The few symp to ms that may develop are related to anemia and the absolute lymphocy to sis of small, mature cells. Prolymphocytic leukemia is characterized by massive splenomegaly and a markedly increased leukocyte count consisting of enlarged lymphocytes having nuclei with mature chro matin and nucleoli. These disorders characteristically have hypercellular bone marrows but pancy to penia in the peripheral blood. Red cell dysplastic features include the presence of ringed sideroblasts, mega loblas to id erythroid precursors, and misshapen erythroid precursors. White cell dysplastic features include hypogranular cells or Pelger-Huet white blood cells, which are abnormal appearing neutrophils having only two nuclear lobes. The liver and spleen are typically mod erately enlarged and may show extramedullary hema to poiesis. Thrombotic complications are an important cause of morbidity and mortality, and major and minor hemorrhagic complications are also frequent. The red cell count is elevated with hema to crit >60% (despite the fact that serum ery thropoietin levels are decreased). Pruritus and peptic ulceration are common, possibly in relation to increased histamine release from basophils. Marked splenomegaly with trilineage proliferation of normoblasts, immature myeloid cells, and large megakaryocytes occur. Giant platelets and poikilocytic (teardrop) red cells are seen in the peripheral smear along with immature white blood cells. In contrast, increased to tal protein in the serum (with a normal serum albumin and hypercalcemia) is diagnostic of multiple myeloma. Patients also develop multiple lytic bone lesions and their marrow will have increased numbers of plasma cells, some of which may be atypical in appearance. Finally, multiple black galls to nes (bilirubin s to nes) can be seen with any chronic hemolytic anemia. Weakness, weight loss, recurrent infec tions, proteinuria, anemia, and abnormal proliferation of plasma cells in the bone marrow are findings that highly suggest the presence of multiple myeloma, a plasma cell dyscrasia. The more definitive diagnostic criteria are findings of M component in the results of serum electrophoresis and plasma cell levels of above 20% in the bone marrow. Multiple myeloma, which occurs more commonly in males than in females, shows an increasing incidence with increasing age, and most patients are in their seventies. Osteolytic, punched out bone lesions are characteristic, especially in the skull. Myeloma is not associated with lymphadenopathy, but recurrent infec tions are frequent because of the severe suppression of normal immunoglob ulins. In fact, infection is the most common cause of death in these patients and is usually due to encapsulated bacteria. There is no increase in viral infec tions in these patients because their cell-mediated immunity is normal. Gaucher disease is a type of lysosomal s to rage dis ease that is due to a deficiency of beta-glucocerebrosidase. As with myeloma, there is a monoclonal production of immunoglobulin (IgM) that produces an M spike. Unlike the case with myeloma, however, there are no lytic bone lesions and no hypercalcemia, and the bone marrow shows proliferation of plasma cells, lymphocytes, and plas macy to id lymphocytes. Note that M proteins are found in 1 to 3% of asymp to matic persons over the age of 50. Heavy chain disease refers to types of plasma cell dyscrasia that are associated with the monoclonal production of immunoglobulin heavy chains only (not light chains). It is characterized by numerous plasma cells infiltrating the lamina propria of the small intestines. These cells contain 292 Pathology distinctive granules, seen by electron microscopy, that are rod-shaped organelles resembling tennis rackets. These chil dren have cutaneous lesions that resemble seborrhea, hepa to splenomegaly, and lymphadenopathy. The clinical course is usually rapidly fatal; however, with intensive chemotherapy 50% of patients may sur vive 5 years. The characteristic triad consists of bone lesions, particularly in the calvarium and the base of the skull; diabetes insipidus; and exophthalmos. The lesions are granulomas that con tain a mixture of lipid-laden Langerhans cells, macrophages, lymphocytes, and eosinophils. In contrast, sarcoidosis is characterized by a proliferation of activated macrophages that form granulomas. Derma to pathic lymphadenitis refers to a chronic lymphadenitis that affects the lymph nodes draining the sites of chronic derma to logic diseases. The lymph nodes undergo hyperplasia of the germinal follicles and accumulation of melanin and hemosiderin pigment by the phagocytic cells. It typically occurs in young adults and presents with systemic symp to ms, lymphadenopathy, and pharyngitis. Peripheral blood shows an absolute lymphocy to sis, and many lymphocytes are atypical with irregular nuclei and abundant basophilic vacuolated cy to plasm. These atypical lymphocytes are usually adequate for diagnosis, along with a positive heterophil or monospot test (increased sheep red cell agglutinin).

Seemingly insignificant forces can cause serious internal injury; therefore abdominal pain after trauma should be taken seriously b antiviral us release best albendazole 400 mg. Growth plates generally disappear 2 years after girls have their first periods; in boys it is usually by mid to late high school 5 hiv infection rates baltimore buy discount albendazole 400mg line. Angle slightly away from the growth plate when inserting an intraosseous needle F hiv infection first week symptoms purchase albendazole us. Higher oxygen demand with less reserves means that hypoxia develops rapidly with apnea or ineffective bagging b hiv infection rates in south africa order albendazole on line. When ventilating a pediatric patient antiviral youwatch buy albendazole visa, the bag should have no less than 450-500 mL volume c hiv infection rates zimbabwe albendazole 400 mg. Err on using a larger bag for ventilating the pediatric patient; regardless of the size of the bag used for ventilation, one should only use enough force to make the chest rise slightly to limit pneumothorax Page 328 of 385 d. Higher oxygen demand and metabolic rate mean that infants and children generally become symp to matic from inhaled to xic exposures prior to adults H. Continually evolves throughout childhood allowing them to develop new abilities 2. The subarachnoid space is relatively smaller offering less cushioning to the brain 4. Brain and spinal cord are less well protected by a thinner skull and spinal column 6. The large cerebral blood flow requirement makes children with head injuries extremely susceptible to hypoxia; hypoxia and hypotension in a child with a head injury can cause ongoing damage as bad as the initial injury itself b. Less cushioning by the subarachnoid space means that head momentum is more likely to result in bruising and damage to the brain c. Cervical spine injuries when present are more commonly ligamen to us injuries rather than secondary to broken vertebrae. Since the weaker neck supports a relatively heavier head and therefore flexes more easily with trauma, cervical spine injuries sustained are usually higher (C1-3) f. Infants and children are prone to hypothermia due to increased body surface area 3. Make sure to cover the head (not the face, though) to minimize heat loss Page 329 of 385 c. Have a very low threshold for checking blood glucose levels, especially in children who are having a seizure or are lethargic on your exam d. Infants have a relatively large surface area which predisposes them to hypothermia b. When obvious reasons for crying have been addressed, persistent crying can be a sign of significant illness c. Infants of this age whose crying is responded to timely by parents have been shown to cry less at 1 year and have decreased aggression at 2 d. Though infants sleep a lot, they should be arousable; inability to arouse a baby should be considered an emergency iii. Be diligent about keeping babies warm and dry to limit hypothermia Page 330 of 385 iv. Infants do not develop head control until closer to 6 months, so when handling a baby, make sure to support the head and neck well v. This is a particularly stressful time for parents adjusting to the eating, sleeping, and crying cycle; sometimes this is complicated by post-partum depression, to o, which can be a risk fac to r for abuse. Infants do not typically roll until around 3-4 months; a his to ry of an infant less than that rolling himself off of a bed or table and sustaining major injuries may indicate abuse iii. Infants of this age begin to identify and respond to facial expressions; approach them with a smile or funny face and a happy, soft spoken voice iv. By 6 months, babies should make eye contact; no eye contact in a sick infant could be a sign of significant illness or depressed mental status 3. Infants explore objects with their mouths which greatly increases the risk of foreign body aspiration; do not give children exam gloves to play with iii. With the increased mobility of crawling and walking comes exposure to physical dangers B. Separation anxiety is best dealt with by keeping the child and parent to gether as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible, interact first with the parent to build trust with infant Page 332 of 385 iv. The front teeth come in before the molars, which means that children may bite off large pieces of food and then not be able to grind them up before swallowing, increasing the risk of food aspiration; do not give children exam gloves to play with iii. Separation anxiety is best dealt with by keeping the child and parent to gether as much as possible during evaluation and involving the parent in the treatment if appropriate; if possible, interact first with the parent to build trust with infant iv. Allow a child to hold objects of importance to them like a blanket, stuffed animal or doll Page 333 of 385 viii. With the head beginning to grow at a slower rate than the body, children begin no longer requiring shoulder rolls limiting flexion of the neck when bag-valve-mask ventilating or intubating ix. As children begin to relate cause and effect, painful procedures make lasting impressions; be considerate by limiting painful procedures and adequately treating pain 3. The rapid increase in language means they will understand much of what you say if simple terms are used iii. Do not waste time trying to use logic to convince preschoolers; they are concrete thinkers,; avoid frightening or misleading comments vii. Children with chronic illness or disabilities begin to be very self-conscious iii. With patients loosing baby teeth and getting adult teeth, one must be particularly careful when intubating ii. School aged children can understand simple explanations for illness and treatments iii. Reassure children that everything is going to be all right, if appropriate, and that they are not going to die vi. Relationships generally transition from mostly same sex ones to those with the opposite sex d. His to ry (age, preceding symp to ms, choking episode, underlying disease, sick contacts, prematurity) b. Physical findings (mental status, respira to ry rate, pulse oximetry, capnometry, work of breathing, color, heart rate, degree of aeration, presence of stridor or wheeze) 4. Chronic lung disease that usually occurs in infants form born prematurely and treated with positive pressure ventilation and high oxygen concentrations b. Recurrent respira to ry infections and exercise induced bronchospasm are complications c. Inhaled medicationsbronchodila to rs (albuterol, ipratropium, racemic epinephrine) v. Oral and intramuscular medications (prednisolone, dexamethasone)Corticosteroids vi. His to ry (fever, vomiting, diarrhea, urine output, fluid intake, blood loss, allergic symp to ms, burns, accidental ingestion) b. Physical findings (heart rate, blood pressure, capillary refill, color, petechiae, mental status, mucous membranes, skin turgor, face/lip/ to ngue swelling) 4. Anaphylactic: subcutaneous epinephrine, intravenous anti histamines (diphenhydramine, ranitidine), and intravenous steroids d. His to ry (age, sweating while feeding, cyanotic episodes, difficulty breathing, syncope, prior cardiac surgery, poor weight gain) Page 337 of 385 b. Physical findings (heart rate, blood pressure, capillary refill, color, mental status, cardiac murmurs/rubs/gallops, pulse oximetry, 4 extremity blood pressures) c. Causes of altered mental status in children (trauma, to xins, infection, electrolyte or glycemic imbalance, intussusception, seizure, uremia, intracranial bleed, intracranial mass) b. His to ry (age, fever, vomiting, pho to phobia, headache, prior seizures, extremity shaking, staring episodes, trauma, ataxia, ingestions, oral intake, bloody s to ol, urine output, baseline developmental level) b. Medications for intubation (thiopental, e to midate, lidocaine, non-depolarizing muscle relaxants) Page 339 of 385 ii. His to ry (polyuria, polydipsia, weight loss, visual changes, poor feeding, abnormal odors, growth delays) b. Physical findings (heart rate, blood pressure, mucous membranes, mental status, virilization, frontal bossing, blindness) c. His to ry (chest pain, weakness, abdominal pain, extremity pain, trauma, bleeding, swollen joints, swollen glands, fever, bruising) Page 340 of 385 b. Physical findings (all vital signs, lung sounds, extremity tenderness, signs of active bleeding, bruises, joint swelling, lympadenopathy, capillary refill) c. His to ry (blood or bile in emesis, diarrhea, age, gender, constipation, fever, medications, to lerance of gastros to my tube feeds, prematurity, blood type incompatibility, epistaxis, liver disease) Page 341 of 385 b. Physical findings (heart rate, blood pressure, mucous membranes, icterus, capillary refill, blood in nares, abdominal distention or mass, hepa to megaly, pallor, anal fissure) c. School age (infectious enteritis, juvenile polyps, hemolytic uremic syndrome, Henoch Schonlein purpura) iii. His to ry (time of ingestion/exposure, amount ingested, abnormal symp to ms, bottles/containers available) b. Specific to xidromes (anticholinergics, cholinergics, opiates, benzodiazepines, sympathomimetics, beta-blockers, calcium channel blockers, salicylate, tricyclic antidepressants) b. Caregiver support Page 343 of 385 Special Patient Population Geriatrics Paramedic Education Standard Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. Normal changes associated with aging primarily occur due to deterioration of organ systems; B. Pathological changes in the elderly are sometimes difficult to discern from normal aging changes. Reduction in renal function due to decreased blood flow and tubule degeneration 2. May present with only dyspnea, acute confusion (delirium), syncope, weakness or nausea and vomiting B. Peripheral edema is frequently present in elderly patients with or without failure and may signify a variety of conditions 4. Transient reduction in blood flow to the brain due to cardiac output drop for any reason d. Presentation can include dyspnea, congestion, altered mental status, or abdominal pain. Delirium a sudden change in behavior, consciousness, or cognitive processes generally due to a reversible physical ailment. Evaluation of pathophysiology through his to ry, possible risk fac to rs, and current medications a. Evaluation of pathophysiology through his to ry, possible risk fac to rs, and current medications. Venous access care should be taken to avoid use of indwelling fistulas or shunt unless necessary in cardiac events. Diffuse tenderness on palpation of abdomen, with distention, guarding, or masses; upon auscultation high pitched noises k. Blood pressures, lying, sitting, and standing noting any change of 10 mm/Hg or more lower as the patient moves to an upright position d. Pulses, lying, sitting, and standing noting any change of 10 beats per minute more higher as the patient moves to an upright position. Chronic Renal Failure is the inability of the kidneys to excrete waste, concentrate urine, or control electrolyte balance in the body. Medications that damage the kidneys: antibiotics, nonsteroidal anti-inflamma to ry drugs, anticancer drugs 2. Evaluation of patient treatment through reassessment of disease Page 354 of 385 S. Diabetes Mellitus an inability of the pancreas to produce a sufficient amount of insulin causing hyperglycemia. Hyperglycemia: plasma levels greater than 200 mg/dl, fasting levels of greater than 126 mg/dl iii. Diaphoresis, pale skin, poor skin turgor; pale, dry, oral mucosa, furrowed to ngue iii. This causes the cells to burn fat, which causes the body to create ke to nes and ke to acids. Warm, flushed skin, (even though the patient can be hypothermic) poor skin turgor; pale, dry, oral mucosa, furrowed to ngue iii. Warm, flushed skin, poor skin turgor; pale, dry, oral mucosa, furrowed to ngue iii. Hypothyroidism-is destruction of the thyroid tissue over time that causes an insufficient amount of thyroid hormone in the blood. Myxedema coma is a premorbid consequence of hypothyroidism in the elderly caused by a recent his to ry of surgery, hypothermia, infection, hypoglycemia, and sedative use. Oxygen with adjuncts appropriate to patient condition; may necessitate aggressive management iii.

The syndromes are organized and classified in three main types hiv infection stats buy cheap albendazole 400mg on-line, as described below (Betterle et al hiv infection rates texas buy generic albendazole line. The fourth type is a rare syndrome characterized by the association of au to immune combina tions not falling in to the other three categories antivirus windows 8 buy albendazole paypal, and this type will not be discussed hiv infection rates ireland generic 400 mg albendazole. This syndrome is defined by the presence of au to immune thyroid disease with another au to immune disease the hiv infection cycle buy albendazole 400mg on-line, such as diabetes mellitus type 1 hiv infection rates msm order 400 mg albendazole with visa, au to immune gastritis, or myasthenia gravis, but in the absence of Addison disease. Since different and multiple clinical combinations can be found, the classification of this type of au to immune polyglandular syndrome is probably more complicated than originally anticipated. The disease typically affects middle-aged women (the female to male ratio is 9:1). The prevalence of the disease, which is found worldwide, has been estimated to be 4 cases per 100 000 (Feld & Heathcote, 2003). With advances in diagnosis, a growing proportion of patients are being identified with asymp to matic early-stage disease. Clinical 72 Clinical Expression of Human Au to immune Diseases presentation includes pruritus, fatigue, increased skin pigmentation, arthralgias, and dryness of the mouth and eyes. Due to necrosis of the intrahepatic bile ducts, there is chronic cholestasis, hepatic fibrosis, cirrhosis, and eventually liver failure. The occurrence of hepa to cellular carcinoma is amplified, which is usually recognizable in late-stage disease. The diagnosis of primary biliary cirrhosis is based on rises in serum alkaline phosphatase and typical his to logical abnormalities on liver biopsy: chronic inflammation leading to destruction and disappearance of intrahepatic bile ducts and pro gressive portal fibrosis, which ultimately leads to cirrhosis. Further more, high-titre antimi to chondrial antibodies are considered a hallmark feature of this disease; the antibodies are probably not pathogenic. These antibodies are predominantly directed to the E2 subunit of the pyruvate dehydrogenase complex. It has been sug gested that the induction of these au to antibodies and the subsequent development of au to immune disease are the result of exposure to xenobiotics. Halogenated compounds, in particular, may bind to the au to antigen, break to lerance, and lead to an intense mucosal immune response (Long et al. Prevalence is almost equal in men and women, whereas Caucasians are affected twice as often as blacks or Asians. This presents as well defined red scaly plaques typically distributed over the scalp, lower back, and extensor aspects of the limbs. Clinical variants include guttate psoriasis, sebopsoriasis, and pustular forms of psoriasis. Between 5% and 42% of patients have psoriatic arthritis, a destructive and occasionally disabling joint disease. Alter natively, a growing body of evidence implicates strep to coccal and staphylococcal superantigens in the development of psoriasis. Superantigens have a proven ability to induce high levels of inflam ma to ry cy to kines and/or initiate au to immune responses that con tribute to the development of skin disorders. The typical clinical presentation of rheuma to id arthritis is a symmetrical arthritis affecting many joints, often in association with constitu tional symp to ms such as fever and malaise. The disease begins in the small joints of the hands and feet and progresses in a centripetal and symmetric fashion, eventually resulting in severe deformities. Extra articular manifestations include vasculitis, atrophy of skin and mus cle, lymphadenopathy, splenomegaly, and leukopenia. The diagnosis of rheuma to id arthritis depends primarily on clinical manifestations of the disease. Seven criteria (revised) have been formulated by the American Rheuma to logy Association; rheuma to id arthritis is diag nosed when at least four criteria are present (Arnett et al. The presence of rheuma to id fac to r, an au to antibody directed to the Fc portion of immunoglobulin, is one of these criteria, but this au to antibody is not very specific for rheuma to id arthritis. More recently, antibodies reactive with citrullinated peptides have been described that share high sensitivity and specificity for rheuma to id arthritis (Schellekens et al. Local au to antibody production, such as rheuma to id fac to r or anti-cyclic citrullinated antibodies, may be pathogenic by formation and deposition of immune complexes in the lesions. A multitude of potential au to antigens have been suggested to be implicated in T cell activation. There is considerable evidence that to bacco smoking is asso ciated with an increased risk of rheuma to id arthritisand with an increased prevalence of rheuma to id fac to r among people without clinical disease. The role of occupational exposure to silica dust in rheuma to id arthritisis also an active area of research (see chapter 8). A recent study in the United States estimated the disease prevalence to be approximately 25 per 100 000 (Mayes et al. The diagnosis may be hampered when the visceral complaints (predominantly in lungs, heart, and kidney) are not associated with classic skin changes and Raynaud phenomenon. The pathological changes in skin biopsies of systemic sclerosis patients reveal thinning of the epidermis with flattening of the rete pegs, atrophy of the dermal appendages, hyalinization and fibrosis of arterioles, and massive accumulation of dense collagen in the reticular dermis. Also in the visceral organs, the triad of fibrosis, narrowing of blood vessels, and perivascular inflammation is observed, eventually resulting in end-stage atrophy of the affected organs. In particular, the T cell population in affected systemic sclerosis tissues is believed to release cy to kines, which initiate and/or perpetuate the fibrotic process as well as the endo thelial and vascular alterations (Derk & Jimenez, 2003). Initially, this cy to kine may be produced by infiltrated leukocytes, and production may be further enhanced by sensitized fibroblasts. Al to gether, because of the pro gressive fibrosis and organ failure, diffuse systemic sclerosis in particular is associated with a high mortality rate, with an estimated five-year survival of approximately 40%. A fairly strong and consistent association between exposure, primarily in occupational settings, to solvents. Workers exposed to vinyl chloride monomers exhibit clinical features that resemble systemic sclerosis, such as fibrotic skin lesions, pulmonary fibrosis, and skin capillary abnormalities. However, vinyl chloride disease also harbours several features that are clearly distinct from systemic sclerosis. After exposure is discontinued, skin lesions, capillary abnormalities, and acroosteolytic lesions revert to nearly normal (Haustein & Ziegler, 1985). Scleroderma-like manifestation is a typical clinical feature of the to xic oil syndrome (see chapter 7). Some data also suggest an increased risk of systemic sclerosis in workers exposed to hand-transmitted vibration due to the use of vibrating to ols (Bovenzi et al. The diminished gland secretion results in kera to conjunctivitis sicca and xeros to mia. Primary Sjogren syn drome is diagnosed if no other au to immune disease is present; secondary Sjogren syndrome is associated with rheuma to id arthritis or other connective tissue disorders. Like many other connective tissue diseases, there is a female preponderance, with a female to male ratio of 9:1. Patients typically present with dry eyes and mouth, but other mucosal sites may also be affected. Further more, a majority may present with systemic complaints, such as arthralgias, fibromyalgia, or chronic fatigue. Quantitative immunohis to logical criteria based on percentages of IgA and IgG-containing plasma cells are, however, more sensitive and specific for the diagnosis of Sjogren syndrome (Bodeutsch et al. Although the patho genesis of this disease is still ill defined, it has been suggested that infiltrating lymphocytes induce destruction of the mucosal glands, eventually resulting in the dryness of these mucosal sites. Alter natively, au to antibodies to the M3 muscarinic acetylcholine recep to rs may be the causative agents (Yamamo to , 2003). Circulating immune complexes, in contrast, are held responsible for the systemic manifestations. So far, no definite genetic markers have been iden tified for predisposition to Sjogren syndrome. In the long term, patients with Sjogren syndrome are at risk of developing mucosa associated B cell lymphomas, probably due to chronic stimulation of the humoral immune system. Drug-induced lupus (lupus syndrome) is a different disease with more or less similar clinical manifestations. Systemic lupus erythema to sus has a clear female preponderance (female to male ratio is 9:1). Furthermore, systemic lupus erythema to sus is more prevalent in African Americans and Asians than in Caucasians. In addition to constitutional symp to ms, such as fever, weight loss, and malaise, nearly every organ system can be involved. Owing to marked interindividual variability in the clinical expression of the disease, a list of 11 clinical criteria has been proposed, of which 4 must be satisfied for the diagnosis. Since antiphospholipid syndrome is frequently encountered in patients with systemic lupus erythema to sus, antiphospholipid syndrome associated au to antibody detection is relevant for recognition of this syndrome. Furthermore, systemic lupus erythema to sus follows a course of exacerbations and remissions. Au to antibodies appear to play a key role in the pathogenesis of systemic lupus erythema to sus. All antinuclear au to antibodies are probably the result of inappropriate removal of apop to tic material in systemic lupus erythema to sus, eventually resulting in an immune response to these normally sequestered au to antigens. Next, the tissue deposition of antibodies and immune complexes could cause inflammation and injury of multiple organs. The pathogenicity of au to antibodies is probably the best proven by the occurrence of neonatal lupus and congenital complete heart block. Since systemic lupus erythema to sus is primarily an immune complex-mediated disease, it is evident that deficiencies and/or polymorphisms in genes of the complement system and the Fcfi recep to rs are associated with systemic lupus erythema to sus (Tsao, 2003). There are rare instances where systemic lupus erythema to sus can be more prevalent in exposed human subjects. However, systemic lupus erythema to sus is only infrequently observed in these patients (De Rycke et al. Involvement of the kidney or the central nervous system hardly ever occurs, whereas pleural and pericardial effusions are far more frequent in lupus syndrome than in systemic lupus erythema to sus. Circulating antibodies are often directed to his to nes in lupus syndrome instead of the classical antinuclear antibodies associated with systemic lupus erythema to sus. Importantly, discontinuation of the drug typically results in resolution of the clinical findings in patients with lupus syndrome. Abnormal bleeding asso ciated with thrombocy to penia is characterized by spontaneous skin purpura, mucosal haemorrhage, and prolonged bleeding after trauma. Thrombocy to penia may be due to many different causes; here, we discuss only the immune-mediated diseases that are not secondary to systemic lupus erythema to sus, malignancy, or infec tion. Adult immune (idiopathic) thrombo cy to penic purpura has a female to male ratio of 2:1. The major cause of fatal bleeding, especially in people over 60 years of age, is intracranial haemorrhage. The involvement of these 80 Clinical Expression of Human Au to immune Diseases antibodies in the pathogenesis is well established, since transient thrombocy to penia occurs in neonates born to affected women. IgG sensitized platelets are prematurely removed from the circulation by macrophages, especially in the spleen, reducing the lifespan of a platelet to only a few hours. Additionally, the IgG-sensitized plate lets may be destroyed via complement-mediated lysis. The bone marrow shows normal or increased numbers of megakaryocytes, and IgG au to antibodies may be demonstrated on the platelet surface or in the serum. The clinical syndrome is manifested by thrombocy to penia, microangiopathic haemolytic anaemia, fever, renal dysfunction, and neurological abnormalities. The deficiency may be due to genetic mutations (familial thrombotic thrombocy to penic purpura) or au to immune inhibi to rs (acquired thrombotic thrombocy to penic purpura). Detection of an inhibi to r, which has been identified as IgG, can distinguish familial from acquired thrombotic thrombocy to penic purpura (Tsai & Lian, 1998). Other examples are sulfonamides, thiazide diuretics, chlorpropamide, quinidine, and gold. These types of immune thrombocy to penic purpura are reversed when the drug is withdrawn. Molecular mechanisms for the formation of specific drug-dependent antibodies appear to be very similar. The glycoproteins on the platelet surface interact with the drugs to form neo-epi to pes. It is likely that this interaction occurs predominantly on the surface of activated platelets, endothelial cells, and macro phages. The clinical presentation of heparin-induced thrombo cy to penia, therefore, is moderate thrombocy to penia and new throm boembolic complications. These diseases are charac terized by immune responses to thyroid antigen, resulting in infiltration of the thyroid by T cells and production of thyroid antibodies. However, the manifestations of these two entities are clearly different, and the two diseases are discussed separately. Furthermore, the effect of iodine supplementation on thyroiditis is discussed briefly.

The other kidney antiviral lubricant herpes order cheapest albendazole and albendazole, however natural antiviral herbs buy albendazole us, is not protected and may develop microscopic changes of benign nephrosclerosis (hyaline arteri olosclerosis) hiv aids stages of infection order albendazole 400 mg without prescription. The renal changes associated with malignant hypertension are called malignant nephrosclerosis hiv infection via eye albendazole 400mg lowest price. These characteristic changes include fibrinoid necrosis of arterioles (necrotiz ing arteriolitis) hiv infection japan buy generic albendazole 400mg, hyperplastic arteriolosclerosis (onion-skinning) hiv infection rates louisiana purchase online albendazole, necrotizing glomerulitis, and often a thrombotic microangiopathy. The clinical course is often downhill, with only 50% of patients surviving 5 years; marked pro teinuria, hematuria, cardiovascular problems, and finally renal failure con tribute to death. The disease is often associated with accelerated preexisting benign essential hypertension, chronic renal disease (glomerulonephritis), or scleroderma. In contrast to malignant nephrosclerosis, benign nephrosclerosis (renal disease occurring in benign hypertension) is characterized by hyaline arteri olosclerosis with thickened, hyalinized arteriolar walls and narrowed lumina. Small kidneys with a finely granular surface often result because of ischemic atrophy of nephrons. Broad U-shaped cortical scars overlying dilated calyces in the renal poles are seen with chronic pyelonephritis (reflux causes scars involving poles only, while obstruction produces scars all over the kidney), depressed cortical areas overlying necrotic papillae of varying stages are seen with analgesic nephropathy and diabetes mellitus, multiple small white areas on the surface are seen with acute pyelonephritis, and wedge-shaped. The formation of urinary s to nes relates to decreased urine volume and increased urine concentrations of certain substances. Most s to nes contain calcium (either calcium oxalate or calcium phosphate) and are seen in patients with hypercalcinuria (with or without hypercalcemia), such 422 Pathology as with hyperparathyroidism or diffuse bone disease. Magnesium ammo nium phosphate s to nes are formed in alkaline urine as the result of urease producing (urea-splitting) bacteria such as Proteus. The ammonia released from the breakdown of urea combines with magnesium and phosphate. These s to nes are large and may fill the renal pelvis (staghorn or struvite cal culi). Examination of the urine with a dipstick reveals an alkaline urine that is positive for esterase (from the leukocytes in the urine) and nitrite (since Proteus reduces nitrate). Uric acid s to nes may form in patients with hyper uricemia, such as patients with gout or patients being treated for leukemias or lymphomas. Precipitation of uric acid within the tubules of the kidney could produce urinary obstruction and acute renal failure. Galls to nes are either composed of cholesterol, bilirubin, or a combination of both. The combination of cos to vertebral pain, a palpable mass, and hematuria is the classic triad of symp to ms seen in about 10% of patients with renal cell carcinoma. Hematuria is often the first symp to m, but it often occurs late, after invasion of the renal vein or widespread metastases, frequently to lung, bone, or brain. His to logically, renal cell carcinoma is predominantly of the clear cell type (clear cell carcinoma) with intracy to plasmic glycogen and lipid, but less often granular cells with numerous mi to chondria or spindle cells occur. Grossly, the lesions are greater than 3 cm in diameter and are yellow in color (similar to tumors of the adrenal cortex; thus another name for renal cell carcinoma is hypernephroma). These tumors arise from the renal epithelial cells and thus may be classified as adenocar cinomas, but tubular formation, not glandular formation, may be present. More frequently, though in only 5 to 10% of patients, polycythemia or erythrocy to sis occurs owing to production of erythropoietin. Renal cell carcinoma is associated Urinary System Answers 423 with von Hippel-Lindau syndrome, in which many patients develop bilat eral renal cell carcinomas. Translocations between chromosomes 3 and 8 and between 3 and 11 have been found in some cases of familial renal can cer and in a few sporadic cases of renal cancer. In contrast, carcinomas originating from the renal pelvis (not the cor tex) arise from transitional epithelial cells and microscopically are similar to tumors arising in the urinary bladder, i. At about the eighth week of development a cloacal membrane forms within the cloaca and separates the cloaca in to a dorsal rectum and a ventral urogenital sinus. Initially the urinary bladder is continuous with the 424 Pathology allan to is, which constricts and forms the thick, fibrous urachus. The ura chus in turn becomes attenuated, but still remains attached to the bladder dome and forms the median umbilical ligament in the adult. Incomplete attenuation of the urachus (persistent urachus) can lead to formation of a urachal cyst, urachal sinus, or urachal fistula. The end attached to the blad der can remain and form a bladder diverticulum, while the central portion can remain and form a urachal cyst. Urachal sinuses and fistulas still con nect the umbilicus to the urinary bladder, and therefore urine can leak at the site of the umbilicus. Normally, mesodermal tissue grows on to the cloacal membrane to form the muscles of the lower abdominal wall. This leads to persistence of the cloacal membrane, which can become quite thin and rupture. This in turn causes the posterior bladder mucosa to evert through this defect in the anterior abdomi nal wall. This condition is called exstrophy and is associated with recurrent urinary infections and epispadias in males. There is also an increased inci dence of neoplastic transformation, most commonly adenocarcinoma. It is usually about 2 in long and is located less than 2 ft from the ileocecal valve. An omphalocele refers to protrusion of the intestines through an unclosed umbilical ring. This abnormality results from incomplete internalization of the intestines during fetal growth. Instead, viscera herniate through a defect in the anterior abdominal wall just lateral to the umbilicus. This organism is probably the most common cause of bacterial sex ually transmitted disease in both men and women. Acute cystitis his to logically reveals stromal edema and an infiltrate of neutrophils. In most cases cystitis is secondary to infections of the bladder, usually by coliform bacteria. Cystitis occurs more commonly in females and is asso ciated with sexual intercourse, pregnancy, and instrumentation. Hemor rhage may also be present (hemorrhagic cystitis) and is usually the result of radiation injury, chemotherapy, or an adenovirus infection. In particular, there is disagreement as to whether papillary lesions may be benign (papillomas). Pathologists do agree, however, on the existence of a rare type of benign lesion called an inverted papilloma, which is characterized by nodular mucosal lesions that his to logically have an endophytic growth pattern. Malignant neoplasms of the bladder may be tran sitional cell carcinomas, which are by far the most common type of tumor of the urinary bladder; squamous cell carcinomas, which produce keratin; or adenocarcinomas, which form glandular structures. In contrast, squamous cell carcinomas of the urinary bladder are quite rare except in Egypt and other areas of the Middle East, where they are associated with schis to somiasis. Sim ilarly, adenocarcinomas of the urinary bladder are quite rare, except that they may be associated with urachal epithelial remnants located in the dome of the bladder, glandular metaplasia, or cystitis glandularis. A 24-year-old man is being evaluated for infertility, and during phys ical examination the urethral orifice is noted to be on the ventral surface of the penis. An uncircumcised 49-year-old man presents with the sudden onset of severe pain in the distal portion of his penis. The emergency room physi cian examines the patient and finds that the foreskin is retracted but can not be rolled back over the glans penis. His to logic examination of an excision specimen from a lesion on the dorsal surface of the penis reveals a papillary lesion with clear vacuoliza tion of epithelial cells on the surface and extension of the hyperplastic epithelium in to the underlying tissue along a broad front. The pho to micrograph is of a section from a testis removed from the inguinal region of a man aged 25. Physical examination finds an approxi mate 1-cm mass in the superior portion of the scrotum, anteriorly located to the testis. Which of the following is the best method to confirm that this mass is in fact a benign cyst and not a solid tumorfi Physical examination reveals a single testicular mass that does not trans illuminate. Which of the following best describes the expected microscopic appearance of this tumorfi Abnormal tissue derived from all three germ levels with scattered immature neural elements c. Large tumor cells with abundant eosinophilic, granular cy to plasm, and rare intracy to plasmic rhomboid crystals d. Numerous lymphocytes in the fibrous stroma between groups of tumor cells having distinct cell membranes and clear cy to plasm. Sheets of undifferentiated tumor cells having focal glandular differentiation 360. A 27-year-old man presents with a testicular mass, which is resected and diagnosed as being a yolk sac tumor. Rectal examination finds the prostate gland to be edema to us and very sensitive; examination is quite painful. Microscopic examination of prostatic secretions reveals the presence of numerous neutrophils. A 69-year-old man presents with urinary frequency, nocturia, drib bling, and difficulty in starting and s to pping urination. A needle biopsy reveals increased numbers of glandular elements and stromal tissue. A 67-year-old man is found on rectal examination to have a single, hard, irregular nodule within his prostate. A biopsy of this lesion reveals the presence of small glands lined by a single layer of cells with enlarged, prominent nucleoli. A female newborn is being worked up clinically for several congeni tal abnormalities. During this workup, it is discovered that normal devel opment of the vagina and uterus in this female infant has not occurred. Failure of the uterus to develop (agenesis) is directly related to the failure of which one of the following embryonic structures to developfi Which of the following describes multiple small mucinous cysts of the endocervix that result from blockage of the endocervical glands by overlying squamous metaplastic epitheliumfi Which one of the following his to logic changes is most consistent with the diagnosis of lichen sclerosisfi A 65-year-old woman presents with a pruritic red, crusted, sharply demarcated map-like lesion involving a large portion of her labia majora. His to logic sections from this lesion reveal individual anaplastic tumor cells infiltrating the epidermis. Distinctive clear spaces are noted between these anaplastic cells and the surrounding normal epithelial cells. A 25-year-old woman being evaluated for infertility is found to have an abnormal ridge of red, moist granules located in the upper third of her vagina. A biopsy from the abnormal vaginal ridge reveals the presence of benign glands underneath stratified squamous epithelium. Which of the following is the most serious long term complication of this abnormalityfi A 23-year-old woman presents to her gynecologist for a routine phys ical examination that includes a Pap smear. Her sexual his to ry includes many sexual partners beginning at an early age, but she has never been pregnant. Her cervix is painted with iodine and an area near the cervical os is present that does not stain with iodine. Several biopsies are obtained from this pale area, and a representative his to logic section is seen in the picture below. This his to logic section shows koilocy to sis, which is most characteristic of infec tion with which one of the following organismsfi The pathology report from this specimen makes the diagnosis of chronic endometritis. Based on this pathology report, which of the following was present in the biopsy sample of the endometriumfi A 23-year-old woman presents with urinary frequency and abnormal uterine bleeding. A careful medical his to ry finds that her abnormal men strual bleeding is characterized by excessive bleeding at irregular intervals. A pelvic examination finds a single mass in the anterior wall of the uterus, this being confirmed by ultrasonography. Which one of the following clin ical terms best describes the abnormal uterine bleeding in this womanfi

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