Causes include trauma cheap cilostazol 50 mg on-line muscle relaxant side effects, physical defects in the labyrinthine system order cilostazol 50mg amex muscle relaxant magnesium, and pathologic syndromes such as Ménière disease cheap cilostazol 100 mg mastercard muscle relaxant blood pressure. As in the cochlea, aging produces considerable hair cell loss in the cristae and maculae of the vestibular system. Rotational or caloric stimulation can be used as an indicator of the degree of vestibular function. They are usually brought on by assuming a particular position of the head such as one might do when painting a ceiling. The offending particles are usually clumps of otoconia (otoliths) that have been shed from the maculae of the saccule and utricle, whose passages are connected to the semicircular canals. These clumps act as gravity-driven pistons in the canals, and their movement causes the endolymph to flow, producing the sensation of rotary motion. Because they are in the lowest position, the posterior canals are the most frequently affected. In addition to the rotating sensation, this input gives rise, via the vestibular system, to a pattern of nystagmus (eye movements) appropriate to the spurious input. The specific site of the problem can be determined by using the Dix–Hallpike maneuver, which is a series of physical maneuvers (changes in head and body position). By observing the resulting pattern of nystagmus and reported symptoms, the location of the defect can be deduced. Another set of maneuvers known as the canalith repositioning procedure of Epley can cause gravity to collect the loose canaliths and deposit them away from the lumen of the semicircular canal. Patients can be taught to perform the procedure on themselves if the problem returns. Ménière disease is a syndrome of uncertain (but peripheral) origin associated with vertigo. Typical associated findings include fluctuating hearing loss and tinnitus (ringing in the ears). Episodes involve increased fluid pressure in the labyrinthine system, and symptoms may decrease in response to salt restriction and diuretics. Other cases of peripheral vertigo may be caused by trauma (usually unilateral) or by toxins or drugs (such as some antibiotics); this type is often bilateral. Central and peripheral vertigo often may be differentiated on the basis of their specific symptoms. Peripheral vertigo is more severe, and its nystagmus shows a delay (latency) in appearing after a position change. Position-sensitive and of finite duration, the condition usually involves a horizontal orientation. Central vertigo, usually less severe, shows a vertically oriented nystagmus without latency and fatigability; it is not suppressed by visual fixation and may be of long duration. Treatment of vertigo, beyond that mentioned above, can involve bed rest and vestibular inhibiting drugs (such as some antihistamines). However, these treatments are not always effective and may delay the natural compensation that can be aided by physical motion such as walking (unpleasant as that may be). In severe cases that require surgical intervention (labyrinthectomy), patients can often achieve a workable position sense via the other sensory inputs involved in maintaining equilibrium. Some activities, such as underwater swimming, must be avoided by those with an impaired sense of orientation, because false cues may lead to moving in inappropriate directions and increase the risk of drowning. The sensation of taste and smell are two other sensory mechanisms that provide specific information about the external environment. In lower animals, the mechanisms of taste (gustation) and smell (olfaction) play a major role in finding food, seeking prey, finding directions, bonding with offspring and mates, and avoiding danger/predators. In the case of humans, most of these neural signals are associated with food, fragrance, and odors of our surrounding environment. Although our taste and smell are less sensitive than those of other species, millions of dollars are spent on additives to make our food taste better and on deodorants and perfumes to make us more desirable/attractive and sociable. Chemoreceptors are also found in areas of the body not normally associated with taste or smell. For example, cells expressing bitter taste receptors are found in the nose, airway, and digestive tract. When receptors in the nose are stimulated by irritants, protective reflexes like apnea, coughing, and sneezing are elicited to keep the irritant from entering the lungs. Taste is important for determining whether food in the mouth is a dangerous substance or safe to consume. The receptors for taste are packaged primarily in taste buds that are distributed across the upper alimentary canal with the majority of human taste buds located in the oral cavity (~5,000). The largest numbers are located on the dorsal portion of the tongue with smaller populations found in the epithelium of the soft palate, upper esophagus, epiglottis, and upper larynx. Taste receptor cells are modified epithelial cells that extend from the basal lamina to the epithelial surface where their apical microvilli extend into an opening in the epithelium, the taste pore, to sample chemical compounds that are dissolved in saliva (Fig. Only food that is dissolved in saliva can attach to taste receptor cells and evoke a neural sensation of taste. Type I cells act like glial cells providing support and maintaining the extracellular environment within the taste bud. Although this cell type is in close apposition with numerous afferent fibers, they do not make traditional synaptic contacts with these fibers. This cell type releases several transmitters that interact with sensory nerve endings and other cells in the taste bud. The fourth cell type, the basal cell, acts as a precursor cell able to differentiate into new taste cells. They are continually replenished by new sensory cells formed from the basal cells. When a sensory cell is replaced by a maturing basal cell, the old synaptic connections are broken, and new ones must be formed. Taste buds consist of taste cells surrounded by supporting epithelial cells and basal cells. Stimulating the taste cells alters the cell’s ion channels producing a depolarizing potential. Similar to other sensory receptors, a depolarizing potential leads to neurotransmitter release. The neurotransmitter, in turn, triggers action potentials in the afferent nerve fibers that are sent to the solitary nucleus in the brainstem via the seventh, ninth, and tenth cranial nerves. From the solitary nucleus, information is distributed to cell groups that are involved in feeding and digestive-related functions like salivary and gastrointestinal secretions, and swallowing. Taste information is also relayed, via the thalamus, to cortical structures responsible for the appreciation of taste quality and intensity as well as to cortical areas where multisensory integration of taste, smell, tactile, and temperature cues occurs to produce the experience we call flavor. Among thousands of different taste sensations, humans can discriminate between five specific tastes received by the gustatory receptors. These are salty, sweet, bitter, sour, and umami, which means “savory” or “meaty” in Japanese.
Initial treatment comprises They are often painless but those that form because resting the foot in a boot purchase cilostazol cheap muscle relaxant safe in breastfeeding, hard-soled shoe or a cast cilostazol 100 mg with visa spasms colon symptoms. Corns often form as a result of irritation An open debridement of the joint and a simple from tight shoes order cilostazol master card muscle relaxant herbal supplement. Hard corns may form on the top realignment osteotomy of the metatarsal head can of structural problems and at the sides of toes, soft be performed if these measures fail to relieve the corns form between the toes. This shortens and decompresses the joint and rotates the good cartilage upwards can treat the Management pain successfully. Treatment starts by removing the cause, initially by advising shoe wear adjustments. A similar condition occurs on the palms Redistributing foot pressure away from the area of the hands (Dupuytren’s contracture) and on the of callus by a custom insole may also help. Thickened second and third metatarsals, may be treated surgi- nodules develop along the course of the plantar fascia cally by a shortening osteotomy of the metatarsals which may invade the overlying dermis and some- to redistribute load around the foot more evenly. It is commoner in men and 25 per cent of If conservative measures fail to remove the pain cases are bilateral. This is Typically, patients present more out of con- not a straightforward procedure. Recurrence is high cern about the lump than pain, but the lumps can as, unlike in the hand, all the diseased tissue cannot become painful. Also as the incision usually has to be on the Management bottom of the foot the patient may exchange the If the nodules are not painful the treatment of fibroma for a painful scar that hurts just as much to choice is to leave them alone. Infections of the spine usually affect either the ver- As the endplate infection progresses it eventu- tebral body or the intervertebral disc, but infections ally involves the disc space itself and subsequently in the epidural space, paraspinal soft tissues and causes the typical ‘spondylo-discitis’ that is seen in occasionally the posterior elements of the spinal adults, i. This may Spinal infections may be pyogenic (bacterial) be accompanied by the presence of an epidural or non-pyogenic (often referred to as atypical and abscess (spread of infective material into the spinal which include tuberculosis and fungal infections). Pyogenic infections Non-pyogenic infections: tuberculosis Most arise following the haematogenous spread Tuberculosis is increasing in many areas because (a bacteraemia) of a urological, respiratory or skin of the increased incidence of immunosuppression infection but contiguous (direct) spread can also (e. The commonest infecting organism in more than (1) It is an acid-fast bacillus and is able to resist 50 per cent of cases is Staphylococcus aureus but decolorization with strong acids. Half of all spinal infections occur in the lumbar The mycobacteria family include M. The primary infection is usually caused to develop an infection within the disc space itself by inhalation of aerosolized organisms, which (a discitis) via haematogenous spread. The patient usu- less vascular disc is less amenable to the spread ally quickly recovers from what is often a relatively of infection via the blood stream and therefore minor respiratory infection but years later a reac- infection typically starts as a vertebral endplate tivation may occur with presentation of secondary 212 The spine extrapulmonary metastases, which are most com- T1 as it is mainly made up of fat) becomes replaced monly seen in the vertebral bodies. The granulomatous identifying the presence of epidural abscess (results response involves the accumulation of monocytes, in ring enhancement of the abscess). With gadolinium there may result in a kyphotic deformity and neurologi- is an absence of rim enhancement as the infecting cal sequelae. It con- Investigation firms the diagnosis in both pyogenic infections and Clinical diagnostic indicators tuberculosis. Children usually present with either non-specific back pain or difficulty or refusal to walk. Management of pyogenic infections Adults typically present with non-specific back The mainstay of treatment is the intravenous pain and may also have constitutional symptoms administration of an appropriate antibiotic. Adults require longer treatment with antibiotics as The presence of neurological abnormalities is their discs are avascular. Progressive the failure of medical management, progressive kyphosis can result in neurological sequelae (Pott’s spinal deformity, neurological compromise or sig- paraplegia). Management of non-pyogenic Imaging infections Plain radiographs are often unhelpful as visible The pharmacotherapeutic treatment of tuber- change can take up to 12 weeks to develop. There is an increased signal include isoniazid, rifampicin, pyrazinamide and intensity on T2 weighted images caused by the pres- streptomycin. Early-onset scoliosis differs from late-onset scoliosis in that it is more common in boys, and Spinal deformity can occur in the coronal plane (sco- left thoracic curves predominate. Some of these liosis – a lateral curvature of the spine) and the sagit- children have associated abnormalities, such as tal plane (kyphosis, lordosis and spondylolisthesis). Rarer causes include The prevalence of adolescent idiopathic scoliosis infection, tumour, degeneration and trauma. It is four times more common in girls (and for those Congenital scoliosis requiring intervention the ratio is 9:1). Congenital scoliosis is a lateral curvature of the spine caused by developmental vertebral anomalies Management that result in an imbalance in the lateral longitudi- The management of early and late onset scoliosis nal growth of the spine. These osteogenic anomalies differ as the early onset group are too young to can be classified as failures of formation (hemiver- undergo definitive fusion (as this would restrict tebrae, see Figure 10. This disorders of the homeobox genes during the first is achieved by the use of serial plaster jackets, spinal trimester of pregnancy and is associated with a high braces and in the cases that are progressive the use incidence (up to 60 per cent) of other abnormalities of growing rod constructs that can be lengthened as within or outside the spine, particularly in those the child grows. Plaster jackets are used for progressive cures in the genitourinary system and the heart. Older children can have thermo- per cent also have intraspinal anomalies, including plastic braces to try and control curve progression. The objectives of surgery in these children is The failure of formation most commonly seen to maintain growth and control the curve. Several is the hemivertebra (unilateral complete failure of techniques have been described but none is perfect. The hemivertebra may be Many advocate the use of a posterior growth rod described as fully segmented (with a disc above and technique, which allows for longitudinal growth below), semi-segmented (a single disc either above while maintaining distraction across the curvature or below) or unsegmented (fused above and below). Adolescent idiopathic scoliosis A failure of segmentation results in the forma- Adolescent idiopathic scoliosis is much more com- tion of a bony bar that tethers the growth of a mon in girls, and typically results in the formation vertebral segment, resulting in differential growth of a right thoracic curvature. There is occasionally a family history, and most severe risk of curve progression. These children are essentially normal, but during periods of sig- Idiopathic scoliosis is classified as early onset (less nificant spinal growth the vertebrae rotate resulting than 5 years old) or late onset (more than 5 years in the typical thoracic rib hump deformity. Factors associated with a high risk of curve progression are a young age at diagnosis, female sex, double major curves, left-sided curves and the curve magnitude at diagnosis. Imaging When viewing a plain radiograph, the curves are described as if one is looking at them from behind in the same way as one views the child clinically. On reaching skeletal maturity, a curve of less than 40 degrees is unlikely to progress further. Such curves are unlikely to be cosmetically troublesome and therefore can be managed conservatively. Curves that are greater than 50 degrees on attainment of skeletal maturity have the poten- tial to continue to progress at an expected rate of 1–2 degrees per year. These curves must be managed on an individual basis and the degree of cosmetic deformity also taken into account. If conservatively managed, it is imperative that these curves are monitored for evidence of late progression.
All of the following are true of familial cancers except (b) Number of mitosis (a) Early age of onset (c) Basement membrane invasion (b) Arises in 2 or more relatives of index case (d) Pleomorphism (c) Sometimes multiple tumors are present (d) Present with specifc marker phenotype 20 order 50 mg cilostazol spasms in 7 month old. A 58 year old smoker Babu Bhai presents with long (a) Mitoses standing epigastric pain buy generic cilostazol 100mg on line muscle relaxant drug test, occasional vomiting and (b) Polychromasia signifcant weight loss purchase cilostazol 50 mg on line muscle relaxant knots. A biopsy and other studies (d) Metastasis confrmed that he has gastric cancer at a stage that is 20. Bimodality of incidence occurs in all, except associated with a very poor prognosis. Which of the following criteria can be used to determine if a pheochromocytoma lesion is benign or malignant? Ionizing radiation affects which stage of cell cycle (a) Blood vessel invasion (a) G2 S (b) Cannot be determined by microscopic examination (b) G1 G2 (c) Hemorrhage and necrosis (c) G2 M (d) Nuclear pleomorphism (d) G0 G1 Most Recent Questions 22. Which of the following is most reliable feature of (b) G0-G1-G2-S-M malignant transformation of pheochromocytoma? Overgrowth of a skin structure at a localised region is: (b) G1 phase (a) Hamartoma (c) G2 phase (b) Malignant tumor (d) S phase (c) Choristoma 24. Which of the following mutations in a tumor suppressor (a) Promotion of cell cycle progression agent causes breast carcinoma? Which of the following is known as the “guardian of (b) Base excision repair the genome”? Proto-oncogene erb-B is not related to: (Kolkata 2003) (b) Repair by connective tissues (a) Breast carcinoma (c) Formation of the blood clot (b) Small cell lung carcinoma (d) All of the above (c) Non-small cell lung carcinoma 57. Which of the following genes is most likely marked in (c) Receptor tyrosine kinase the fowchart depiction as ‘X’? A patient Madhu undergoes total thyroidectomy for (b) K-ras a mass lesion of the thyroid. During the surgery it is (c) Cyclin D found that the parathyroid glands appeared enlarged. This boy may have a (d) p53 propensity to develop tumors in which of the following structures? Aisha, a 51 year old woman discovers a lump in her left (a) Bladder (b) Colon breast on a weekly self-examination. Mammography is performed which confrms the presence of a suspicious (c) Peripheral nerve (d) Skin “mass”, and needle core biopsy is performed to determine whether the mass is malignant. Devesh, Most Recent Questions the pathologist confrmed the mass to be malignant and 66. Endometrial carcinoma is associated with which of the (a) Medulloblastoma following tumor suppression gene mutation? Which of the following statements about carcinogenesis (a) Beta-2 macroglobulin is false? An example of a tumor suppressor gene is: (c) Exposure to aniline dyes predisposes to cancer of the (a) Myc urinary bladder (b) Fos (c) Ras (d) Hepatitis B virus has been implicated in hepatocel- (d) Rb lular carcinoma 66. Radiation exposure during infancy has been linked to which one of the following carcinoma? Which among the following is not a neoplastic virus: (a) Cytomegalovirus (Bihar 2006) (c) Clonorchiasis (b) Hepatitis B virus (d) Schistosomiasis (c) Human papilloma virus 82. Physical examination reveals a large mass involving (a) Prevents formation of pyrimidine dimers the right side of his liver, and a biopsy specimen (b) Stimulates formation of pyrimidine dimers from this mass confrms the diagnosis of liver cancer (c) Prevents formation of purine dimers (hepatocellular carcinoma). Which of the following (d) All of the above substances is most closely associated with the pathogenesis of this tumor? The most radiosensitive cells are: (a) Afaxotin B1 (a) Neutrophils (b) Lymphocytes (b) Direct-acting alkylating agents (c) Erythrocytes (d) Megakaryocytes (c) Vinyl chloride 82. One of the following leukemia almost never develops smoker Akki demonstrates glands containing cells with after radiation? With (b) Chronic myeloid leukemia which of the following infectious agents has this type (c) Acute lumphoblastic leukemia of lesion been most strongly associated? Which of the following bio markers he develops generalized lymphadenopathy with would be most useful for follow-up of patient? Which of the following tumors have an increased (d) Chondroblastoma elevation of placental alkaline phosphatase in the serum as well as a positive immunohistochemical staining for 86. An undifferentiated malignant tumor on (d) Pelvic immunohistochemical stain shows cytoplasmic (e) Vertebrae positivity of most of the tumor cells for cytokeratin. A 65 years old male diagnosed by biopsy a case of lung carcinoma, with paraneoplastic syndrome and 115. Which one of the following is a frequent cause of serum (c) Calcitonin alpha- fetoprotein level greater than 10 times the normal (d) Calcitonin related peptide upper limit? Workup reveals that no bone (c) Submucosa metastases are present, but laboratory examination (d) Appendix reveals that the man’s serum calcium levels are 11. Marker for ovarian carcinoma in serum is: woman Nusheen is noted to have a ruddy complexion. Which of the following is a marker for carcinoma of (a) Breast (b) Colon lung and breast? Secondaries of all the following cause osteolytic lesions and alternating diarrhea and constipation. Physical examination demonstrates hyperpigmentation of except: skin, even in areas protected from the sun. Tumor (a) Prostate (b) Kidney involvement of which endocrine organ is most strongly (c) Bronchus (d) Thyroid suggested by this patient’s presentation? Which of the following mutation is seen in malignant abdominal and back pain, malaise, nausea, 8 kg weight melanoma? Which of the following is a special stain for emergency room with a pathologic fracture of the shaft rhabdomyosarcoma? X-ray studies demonstrate multiple (a) Cytokeratin (b) Synaptophysin lytic and blastic bone lesions. Biopsy of one of these (c) Desmin (d) Myeloperoxidase lesions shows adenocarcinoma. The most common cause of malignant adrenal mass is (a) Breast (b) Colon (a) Adrenocortical carcinoma (c) Kidney (d) Lung (b) Malignant Phaeochromocytoma (c) Lymphoma Most Recent Questions (d) Metastasis from another solid tissue tumor 123. Tumor that follows rule of 10 is: brain in (a) Pheochromocytoma (a) Breast (b) Lung (b) Oncocytoma (c) Kidney (d) Intestines (c) Lymphoma (d) Renal cell carcinoma 123. The latter are sharply demarcated lesions that may be impossible to distinguish from follicular adenomas on gross examination. This distinction requires extensive histologic sampling of the tumor-capsule-thyroid interface, to exclude capsular and/or vascular invasion. Extensive invasion of adjacent thyroid parenchyma makes the diagnosis of carcinoma obvious in some cases’. Follicular Carcinoma: brushing up key points • It is the 2nd most common form of thyroid cancer • Seen in women of older age (40-50 yrs. Uncommonly, cells have abundant, eosinophilic cytoplasm called as Hurthle cellsQ • Differentiation from follicular adenoma is based on the presence of capsular invasion preferably and not on vascular invasionQ.