Premature ovarian failure remains an important The most common acquired thrombophilia is the factor responsible for recurrent miscarriage order amoxicillin 500 mg without prescription schedule 8 medicines, owing to antiphospholipid antibody syndrome buy 500 mg amoxicillin free shipping medications vs grapefruit. Pregnancy in a rhesus-sensitised Anatomic abnormalities of the uterus and cervix are woman with a high titre of anti-D antibodies will also amenable to surgery amoxicillin 500mg low price medicine ball abs. Bacterial infec- and treated through in-vitro fertilisation and tions such as Brucella abortus also cause recurrent pre-implantation genetic diagnosis. Genital infections Genitourinary tuberculosis is classically associated References with infertility but latent infection can also cause 1. The antiphospholipid syndrome: Obesity is associated with increased risk of mis- ten years on. A cytogenetic study of repeated diation and anaesthetic gases, pesticides, and other spontaneous abortions. Implantation abnormalities in spontaneous abortions: is a complex process that involves synchronisation frequency, pathology and genetic counsel- of endometrial maturity with fertilisation, expres- ling. Structural rearrangements leukaemia inhibitory factor in the endometrium is of chromosomes in men. New out mouse model, but its exact role in humans is yet York: Academic Press, 1977: 81–97. Glycemic control and spontaneous abor- Mike Papesch and Eva Papesch tions in insulin dependent diabetic women. Spontaneous abortions in patients with Epidemiology insulin dependent diabetes mellitus: the Nosebleeds are common in children, nearly always effect of preconceptional diabetic control. Pregnancy in patients with mild thyroid Tey occur in about 15 per cent of the population, abnormalities: maternal and neonatal reper- and peak in childhood and late adult life. J Clin Endocrinol Metab 1991; 73: also occur in pregnancy in association with increased 421–27. Thyroid antibodies in euthyroid non-pregnant women with recur- Anatomy rent spontaneous abortions. Ultrasonographic examination of a confuence of blood vessels originating from both uterine cervix is better than cervical digi- the internal and external carotid arteries (Fig. Am J a terminal branch of the maxillary artery (external Obstet Gynecol 1994; 171: 956–64. Trauma: nose picking, nasal spray, cocaine, sur- The ulcerated surface of pyogenic granulomas gery, foreign bodies, nasal septal perforation ofen contains staphylococci or streptococci. One Nasal airfow/dry air: drying effect of septal devi- hypothesis has been that these organisms cause an ation, airline travel overgrowth of granulation tissue because of delayed Infective/infammatory: acute viral/bacterial rhi- re-epithelialisation of a wound. Circulating angiogenic nitis/sinusitis, fungal infection, factors also play a role, particularly in pregnancy. Drugs: anticoagulants (warfarin, aspirin,3 clopi- 4 Posterior nosebleeds are ofen severe. Tey present dogrel), non-steroidal anti-infammatory drugs with bilateral nasal bleeding, ofen with spitting up of Haemopoietic coagulopathies: blood dyscrasia, 18 blood. Severe nosebleeds present as any acute blood idiopathic thrombocytopenia purpura, haemo- philia, etc. Examination of the nose with a headlight may Pregnancy-related nosebleeds10 reveal a prominent anterior nasal septum vessel, with Pregnancy hormones afect the nasal mucosa, nasal associated dry crusted blood. Minor anterior nose- cycle, and mucociliary nasal transport time, pro- bleeds are managed with direct pressure over the sof ducing rhinorrhoea and nasal obstruction. Cotton wool and efects of oestrogen makes bleeding secondary to tissue nasal packs should be avoided, as these lead to minor trauma much more likely. Pyogenic granuloma gravidarum (a form of Vaseline or other ointments (Naseptin – exclude pea- lobular capillary haemangioma) occurs as oral nut allergy as this contains arachis oil) are applied to (gingivitis gravidarum) or nasal lesions in less than the nose afer the bleeding has stopped in order to aid 1 per cent of pregnant women. Ice is used to reduce nasal temperature and ter, present as an elevated red or purple mass with promote vasoconstriction of the nasal vessels. It is of a smooth, lobulated, ulcerative surface, and bleed more beneft to suck ice rather that apply ice to the easily with minimal trauma. If bleeding is persistent, it is important to consider an underlying cause and to consider diferent treatments (see below). Ongoing use of simple moisturisers (E45 cream) or Vaseline can be useful to prevent dryness and bleeding from the anterior nasal septum. Management of severe nosebleeds History On arrival, make sure you are wearing appropriate protective clothing, including gloves, glasses, and a mask. Postnasal bleeding leads to signifcant cough- ing and vomiting of blood, with resultant blood Figure 2 Treatment of minor nosebleeds. Take note of the side of bleeding, the length and severity of the nose-bleed, and any precipitating Ongoing active bleeding not seen with this or exacerbating factors. Rigid nasendo- can require volume replacement and resuscitation scopes allow a more detailed view of the nasal cavity, (the Airways, Breathing and Circulation response), including the postnasal space. Coexisting coagulopathies need to Investigations be considered, as well as ruling out specifc under- Full blood count, clotting profle, and cross-match lying systemic illnesses, such as hereditary haemor- may be necessary. Local control meas- situ and appropriate investigations and fuid replace- ures as above are important, and packing of the nose ment achieved, the cause of the bleed should be with adrenaline-soaked gauze (with constriction of addressed. A good headlight, nasal speculum, and the nasal mucosa) and suction may allow identif- suction make examination easier. More examining the patient is on a bed with the head ele- severe nosebleeds will require defnite packing, and if vated about 70 degrees. Up to 90 per cent of nosebleeds bleeding is arrested, admission for observation for 24 can be seen originating from the anterior nasal septum hours. Severe nosebleeds may be associated the larger pack has expanded afer application of with bleeding from the mouth and haematemesis. Removal of clot from the front of the nose (blow- If bilateral nasal packs are used, monitoring of ing of the nose or use of suction) allows a better view pO is mandatory. On removal, the nose is again gauze, soaked with adrenaline and lignocaine, allows inspected for bleeding points and cauterised. If bleed- vasoconstriction of the mucosa and bleeding blood ing recurs or is continuous, early management in the vessel. Endoscopic bleeding, and provides anaesthesia to allow cautery (intranasal) ligation of the sphenopalatine artery, of particular blood vessels. Simple measures, such as appropri- ately applied pressure and cautery, with use of nasal creams usually treat most bleeds. Pyogenic gran- ulomas can occur in pregnancy and ofen require excision to control bleeding. Endoscopic ligation of the sphenopalatine artery is ofen required to control these bleeds. Life- Figure 3 Saline soaking of a nasal pack showing expansion of the threatening epistaxis associated with preg- pack. Arteriography and embolisation of the Hereditary haemorrhagic telangiectasia maxillary artery, in experienced hands, is an efective (Osler–Weber–Rendu syndrome): a view and safe technique, and should be considered, par- from the 21st century. Postgrad Med J ticularly if the epistaxis is severe and has been resist- 2003; 79: 18–24. A regional Extreme cases will require ligation of the external record linkage case control study.
Miscellaneous causes of bleeding from Non-vaginal bleeding the genital tract Non-vaginal bleeding could ofen be mistaken by Cervical lesions order amoxicillin 250 mg on line symptoms 2dp5dt, including severe cervicitis cheap amoxicillin 250mg medications you cant crush, cervi- women to be vaginal in origin generic 500 mg amoxicillin amex medicine for stomach pain. Surrounding struc- cal polyps, and carcinoma (squamous or adenoma- tures and problems that need to be considered from tous) of the cervix may also cause postmenopausal the urogenital part of the perineum are a bleeding bleeding. It is usually postcoital but may also occur urethral caruncle, haematuria from acute or chronic spontaneously without evident history of local cystitis, bladder polyp, and even neoplasia. Tese lesions are usually visible on a careful bleeding is usually painless, although occasionally is speculum examination, which must always be per- associated with local perineal or pelvic pain. Anorectal piles, fssures, lesions that inspection of the cervix fails to reveal and malignancy may be other ofending causes to be the problem. Chronic endometritis of tuberculosis has also Timely diagnosis is therefore important, and women been known to cause postmenopausal bleeding. The accuracy of endometrial At times these methods can yield insufcient sampling in the diagnosis of patients with sampling, and hysteroscopy will be necessary. Direct vis- diagnosis of endometrial cancer and hyper- ualisation of the endometrial cavity enables the diag- plasia: a systematic quantitative review. Most patients tolerate the procedure well, particu- larly with the use of ‘no touch’ techniques. Diagnostic accuracy of hysteroscopy for endome- Kirana Arambage and Dilip Visvanathan trial cancer is high, owing to the abnormal appear- ance of the endometrium. However, pre-malignant Rectal bleeding usually occurs from diseases involv- change such as hyperplasia may not be so easy to ing the colon, rectum, and anus (Box 1). Bleeding detect visually, and biopsy via curettage is the rec- from the upper gastrointestinal tract, the oesophagus ommended gold standard for arriving at a tissue and stomach, and from the small intestine usually diagnosis. However, massive upper gas- trointestinal bleeding can present as dark red blood loss per rectum owing to a rapid transit time. Investigation of post menopausal with an iron defciency anaemia blood detectable bleeding. Accuracy of transvaginal ultrasonography in diabetic or obese women with Box 1 Causes of rectal bleeding in postmenopausal bleeding. Overcoming resistance and Anorectal conditions barriers to the use of local estrogen therapy Haemorrhoids for the treatment of vaginal atrophy. Ultrasonographic endometrial thick- Infammatory bowel disease ness for diagnosing endometrial pathology Adenomatous polyps in women with postmenopausal bleeding: a Carcinoma meta- analysis. History and evaluation Obstet Gynecol 2009 Feb; 113(2 Pt 1): A detailed history from the patient may give clues to 462–64. Selecting a method A digital examination and proctosigmoidoscopy can of treating the condition that could achieve optimal help diagnose an anorectal condition. A colonoscopy, clinical results with the least pain and inconvenience though difcult in the bleeding patient, will help at to the patient has always posed a challenge to the least identify the segment involved. While acute fssures can be managed with ography may be helpful in diagnosis if radiological medical therapy alone, chronic fssures do need some expertise is present. In the event of a woman who form of manipulation or surgery to relieve internal presents with acute rectal bleeding and haemody- sphincter spasm. If a lower Trauma gastrointestinal cause cannot be found, then inves- Rectal bleeding may occur secondary to trauma. Prompt diagnosis and involvement of the Anorectal disease colorectal surgeon allows for optimal results. Haemorrhoids and anal fssures are the commonest anorectal conditions that present during pregnancy Infammatory bowel disease and may cause signifcant distress. The real incidence Most pregnant women with a history of infamma- of these lesions is unknown2 and they tend to be tory bowel disease have uneventful pregnancies, and inadequately investigated and treated. It is rare for infammatory bowel dis- Haemorrhoids ease to present for the frst time in pregnancy. When Haemorrhoids in pregnancy are due to increased cir- relapses of Crohn’s disease do occur during preg- culating volume, increased venous congestion caused nancy, they usually present in the frst trimester. Most by compression of the superior rectal veins by the patients are already on some form of medical therapy. Long-term outcomes of symptoms such as infammatory bowel disease, anal pregnancy and vaginal delivery in such patients are fssure, and carcinoma of the colon, rectum, or anus. Colorectal cancer Treatment during pregnancy is directed mainly Colon cancer during pregnancy is very rare and the at relieving symptoms, especially pain control. The diagnosis fre- fcations, increased fuid intake, stool sofeners, and quently is delayed because symptoms of colorectal analgesics. For many women, symptoms will resolve cancer, such as rectal bleeding, nausea and vomiting, spontaneously soon afer birth. Defnitive treatments and constipation are usually attributed to symptoms are therefore deferred to some time afer delivery. Digital rectal examination, tests for Rubber band ligation can be safely performed in occult blood, and fexible sigmoidoscopy followed pregnancy for internal haemorrhoids. If the haem- by colonoscopy should be performed for complaints orrhoids are severely prolapsed or have associated consistent with or suggestive of colonic disease. Later in pregnancy, it is pref- fssure, and carcinoma of the colon, rec- erable to delay surgery to allow fetal maturation and tum, and anus during pregnancy. Surgical treatment of frst half of the pregnancy because delaying treat- acute manifestations of Crohn’s disease ment until afer delivery may result in tumour spread. Initial presentation presenting in pregnancy is managed somewhat difer- of Crohn’s disease in pregnancy: report of a ently from colon cancer. If the patient chooses after ileal pouch-anal anastomosis for to terminate the pregnancy, she may be managed as a infammatory bowel disease: immediate and non-pregnant patient afer therapeutic termination. Dis During pregnancy, a variety of colorectal condi- Colon Rectum 2004; 47: 1127–35. Colorectal cancer complicating to the safety and timeliness of the operation while pregnancy. A multidisciplinary team approach is a reminder and updated treatment pro- recommended with close collaboration between the tocols. Eur J Obstet Gynecol Reprod Biol obstetrician, surgeon, oncologist, neonatologist, and 2000; 91: 201–202. The safety and effcacy of gas- nasal congestion present for 6 weeks or more during trointestinal endoscopy during pregnancy. Congenital It is caused by the continual use (beyond 1 week) of Choanal atresia, septal deviation topical nasal vasoconstrictors such as xylometazoline or pseudoephedrine. It is similarly seen in nasal blockage associated with the menstrual Allergy cycle. Topically applied oestrogens have produced Allergic rhinitis congestion of the nasal mucosa and increased nasal Autoimmune resistance. However, increased levels of oestradiol Wegener’s granulomatosis, sarcoidosis, atrophic and progesterone were not found in a study of preg- rhinitis nant women with nasal congestion compared with a control group of women without nasal congestion,2 iatrogenic Surgical, drug induced and the regular use of the combined oral contra- ceptive pill has not been associated with increasing Foreign body 9 symptoms.
In some instances cheap amoxicillin 250 mg online symptoms 2 dpo, the joint above a Methods of reduction fracture can be left free while a plaster still provides support order amoxicillin toronto symptoms diagnosis, e buy amoxicillin 500 mg without prescription medications 126. Traction was traditionally the mainstay in frac- Gravity is used, particularly for treatment of ture management to maintain reduction (Fig 7. Nevertheless, it still can provide an The former are most often used in the important treatment option. If a fracture cannot be reduced by closed methods Balanced traction is achieved on a limb by an open surgical procedure will be required. The applying a force in one direction, either with skin General management of fractures 149 place screws in the bone, each side of the fracture, and hold them in place with an external frame (a fixator). The screws may be inserted into the injured bone which has sustained the fracture or in other bones on either side of the fractured bone. In the latter case, ligamentotaxis (tension in the soft tissues) may be employed to reduce the injury, e. In the last case, wires rather than screws are utilized and a frame is constructed resembling Meccano (the Ilizarov frame). It can also be used for severely comminuted or unstable fractures where internal fixation may not be possible. The advantage of Resultant external fixation is that it allows access to the soft tissues, allowing interventions such as skin or soft X tissue grafting. Extramedullary fixation includes the use of X pins, plates, screws and wires (Fig 7. The objective of this type of fixation aims to achieve anatomical reduction of the fracture fragments and hold them in position. Effort should be made to preserve the bone fragments and the soft tissue by means of an ‘atraumatic’ surgical traction or skeletal traction, which is counteracted technique. This should be followed by early active by the patient’s body weight, usually by raising the pain-free mobilization of the muscles and joints end of the bed. Pulleys can be used to ensure the adjacent to the fracture to prevent the development correct line of pull. Fixed traction uses the same principle, but the Internal fixation is indicated lower limb is placed in a Thomas splint so the trac- tion, which is applied to the distal part of the limb when long-lasting immobilization of the soft and connected to the end of the splint, is counter- tissues, especially around joints, may result in acted by the proximal ring of the splint pressing pain and stiffness; against the pelvis. Precise reconstruction of these surfaces is important, as any incongruity of Surgical interventions the articulating surfaces will give rise to areas Surgical intervention may be required to reduce of high stress and the risk of developing post- the fracture to a satisfactory position and hold the traumatic arthritis; fracture in an acceptable position by external or when recovery of function of long bones internal fixation and intramedullary or extramed- is dependent on early exact and stable ullary techniques. The nail may to have a hemiarthroplasty (replacement of the either be solid or flexible. Solid nails are secured femoral or humeral head) or a total joint replace- with locking screws at each end. Flexible An open or compound fracture is an orthopaedic nails are sometimes used in childhood fractures. Some wounds are known to be On arrival in the Accident and Emergency tetanus-prone, e. The fracture will have been temporarily splinted Those patients with an unknown tetanus status and any wound covered at the scene of the incident or those who have not had recent immunization (see Chapter 6). Intravenous flucloxacillin The neurovascular status of the limb should be and amoxicillin or cefuroxime are currently ascertained and recorded. Flucloxacillin and penicillin applied over the wound and should not be can be used in combination or a second-generation removed once an accurate description of the cephalosporin, such as cefuroxime. If heavily contaminated, metronidazole may be added possible, this should be supplemented with a to prevent infection by Gram-negative and anaero- photograph. The Gustilo classification of open wounds (see Once the patient has been anaesthetized, atten- below) can be used to record and assess the degree tion can be directed towards the wound, the frac- of soft tissue damage. Gustilo classification category to ‘increase’ with The dressings are removed before the skin is time as the patient receives treatment. The wound should be irri- Typ e I Open fractures with a small, 1 cm, clean gated with normal saline. A minimum of 6L of wound with minimal injury to the musculature fluid is usually needed, depending on the size of the and no significant stripping of the periosteum wound. Careful assessment associated extensive injury to the muscle, peri- and the excision of unhealthy tissue may involve osteum and bone which is often associated with extending the wound in the knowledge that subse- significant contamination of the wound. Such injuries can be better to have a zone of clean healthy tissue around subdivided into: the fracture. This is called a degloving bone and neurovascular structures with- injury and is most commonly seen inassociation out muscle transfer. Contraction The category of Gustilo injury generally reflects the Circulation velocity of the trauma sustained by the patient: remembered as the four Cs. They usually take well but the cosmetic do so may result in increasing pressure within the result is often poor. All these full thickness grafts are less reliable and The management of devascularized bone frag- leave a significant scar at the donor site, but when ments is controversial. If the Primary closure of the wound can be per- fracture is not stabilized further soft tissue damage formed after the removal of all the dead tissue and may occur, which increases the risk of developing washout provided there is negligible skin loss, the infection. This consists of a tissues, neurovascular structures and any adjacent polyurethane sponge with transparent self-adhesive joint. The vacuum draws fluid from the zone of injury blood loss and promotes wound healing. Complications of fractures 155 The immediate complications of fractures are: the femoral artery in a supracondylar fracture of the femur bleeding (haemorrhage) the internal iliac and superior gluteal arteries in vascular injury association with pelvic fractures. In pelvic fractures the haemorrhage is often from injured veins and retroperitoneal blood Bleeding vessels. An artery may appear normal externally, but fol- Although a fracture may be associated with an injury lowing a blunt injury may contain an intimal tear or to a major blood vessel, the local soft tissue trauma flap which restricts blood flow causing intravascu- and, indeed, bleeding from the bone itself can lead to lar thrombus formation leading to distal embolism significant blood loss. The degree of blood loss varies with the bones Arterial injuries are suspected on clinical exami- involved: nation and are confirmed by measuring doppler pressures. Treatment is dependent on the nature of the vascu- The significance of such fractures must never be lar injury. If an angiography shows the vessels are underestimated, especially if there are other injuries. Thrombosed vessels can It is crucial to anticipate these requirements and be cleared by a balloon catheter. When an arterial repair is performed the frac- ture must be stabilized simultaneously to prevent Vascular injuries further injury to the blood vessel. Arteries and veins may be damaged by sharp or Nerve injuries blunt trauma (see Chapter 6 and 11). An artery may be cut, torn, contused, compressed or simply go The effects of a nerve injury are seen in the ana- into spasm, in association with a fracture. This may tomical distribution of the nerve, and may include result in haemorrhage, thrombosis or both. Arterial Sensory, Motor, Autonomic, Reflex and Trophic bleeding is generally pulsatile and can be torrential.
Delayed wound healing: Due to foreign body amoxicillin 500 mg fast delivery medications ending in zole, ischemia buy amoxicillin toronto medications vitamins, diabetes cheap amoxicillin 250 mg online medicine man dr dre, malnutrition, hormones (glucocorticoids), infection or scurvy. Ascorbic acid defciency causes reduced cross linking of tropocollagen to collagen and so, in this condition the patient has increased bleeding tendencies and poor wound healing. Dehiscence or rupture of a wound is most common after abdominal surgery and is due to increased abdominal pressure. Excessive formation of the repair components: Certain conditions may arise because of increased granulation tissue or excessive collagen leading to keloid, hypertrophic scar and ‘proud fesh’. Incisional scars or traumatic injuries may be followed by exuberant proliferation of fbroblasts and other connective tissue elements called desmoids or aggressive fbromatoses. Formation of contractures: Contractures are particularly prone to develop on the palms, the soles, and the anterior aspect of the thorax. Self-renewal can be achieved in two ways: asymmetric cell division symmetric cell division In human embryo in about 3rd • Produces one daughter cell that is identical • Produces two identical daughter cells week of development stem cells to the parental cell and one daughter cell appear in yolk sac. Self-renewal In adults, most of the stem cells alone cannot defne stem cells, because any established cell line, e. Potency is used to indicate a cell’s ability to differentiate into specialized cell types. This can be classifed as: totipotent cells Multipotent cells oligopotent cells uni/Mono potent cells Can form an Can form multiple Can form more than Can form a single entire organism cell lineages but one cell lineage but are differentiated cell lineage. Embryonic stem cells are pluripotent, that is, they are capable of forming all the tissues of the body Adult stem cells are usually only able to differentiate into a particular tissue. However, a number of reports have shown that tissue stem cells, which are thought to be lineage-committed multipotent cells, possess the capacity to differentiate into cell types outside their lineage restrictions (called trans-differentiation). For example, hematopoietic stem cells may be converted into neurons as well as germ cells. After binding of complement and antibody on the (c) Monocytosis surface of encapsulated bacteria, the process of (d) Lymphocytosis phagocytosis by polymorphonuclear leukocytes involves which of the following? Which of the following helps in generating reactive O (a) Phagocytes 2 intermediates in the neutrophils? In acute infammation due to the contraction of endothelial cell cytoskeleton, which of the following 8. After extravasation, leukocytes emigrate in the tissue towards the site of injury. All of the following are signs of infammation except (c) It affects venules, capillaries and arterioles commonly. A 14 month old boy Chunnu is being evaluated for recurrent, indolent skin infections and gingivitis. Endogenous chemoattractant is: (Bihar 2004) taking a detailed history from the mother, she tells very (a) C5a valuable point that he had delayed separation of the (b) Bacterial products umbilical cord which occurred around 9-10 weeks after (c) Lipopolysaccharide A his birth. Which of the following proteins is most likely (d) C8 under-expressed in this boy? A 5-year-old female Sukanya is hospitalized with fever (c) It causes formation of a more important bactericidal and hemorrhagic skin lesions on her lower extremities. All of the following are true in respect of angioneurotic (d) Inability to form the membrane-attack complex edema except? A 3-year-old boy, Krish presents with recurrent (b) It is more common in females bacterial and fungal infections primarily involving his (c) It manifests as pitting edema skin and respiratory tract. Physical examination reveals (d) It is an autosomal dominant disorder the presence of oculocutan-eous albinism. Which of the following complement component can be activated is both common as well as alternative within neutrophils, lymphocytes, and monocytes. Further (a) C1 workup reveals ineffective bactericidal capabilities (b) C2 of neutrophils due to defective fusion of phagosomes (c) C3 with lysosomes. The function common to neutrophils, monocytes, and (a) Vasoconstriction macrophages is (b) Pain at the site of infammation (a) Immune response is reduced (c) Bronchodilation (b) Phagocytosis (d) Decreased vascular permeability (c) Liberation of histamine 40. Both antibody dependent and independent complement (d) C3a and C5a pathway converge on which complement component? Which of the following is secondary mediator of the in the pathogenesis of her condition. In Lipooxygenase pathway of the arachidonic acid metabolism, which of the following products helps to promote the platelet aggregation and vasoconstriction? Digital rectal examination reveals an enlarged (d) C3b prostate with irregular surface. In infammatory process, the prostaglandin E1and E2 and X ray spine shows osteoblastic lesions. Mr Lal also (a) Vasodilatation complaints of signifcant weight loss, loss of appetite (b) Increased gastric output (c) Decreased body temperature and loss of energy over the past 45 days. His current (d) Vasoconstriction complaints can be attributed to which of the following? Jeeva Roy who orders for some blood infammation is: (Kolkata 2002) investigations. An 8 year old girl Geetu presents to the physician with wheezing and diffculty in breathing. Her blood contains higher than fnd the cause of her urine turning a dark brown color normal concentration of IgE. She has the cell shown in the photograph below is implicated been otherwise symptomatic, and her blood pressure 50 Infammation has been within normal limits. The most important source of histamine: moderate blood present with red cells and red cell casts. These (c) Neutrophil clinical fndings suggest that her disorder is associated (d) Macrophages with activation of the alternate complement system. Following injury to a blood vessel, immediate is the most suggestive of activation of the alternate haemostasis is achieved by which of the following? Both antibody dependent and independent comple- following substances is most likely to be associated ment pathway converge on which complement compo- with these clinical fndings? E cadherin gene defciency is seen in: (a) Linoleic acid (a) Gastric cancer (b) Linolenic acid (b) Intestinal cancer (c) Arachidonic acid (c) Thyroid cancer (d) Butyric acid (d) Pancreatic cancer 75. Which of the following is the most characteristic of (d) Tuberculosis granuloma: (Kolkata 2003) (a) Epithelioid cell 80. The fgure (b) Secretory shows a very important step in the pathogenesis of this (c) Antigenic condition. A 45-year-old poor man Teja has a chronic cough, a (a) Remnant skin appendages cavitary lesion of the lung, and is sputum positive for (b) Underlying connective tissues acid-fast bacilli. Which of the following is the principle (c) Minimal edema and erythema form of defense by which the patient’s body fghts (d) Granulation tissue against this infection? A 36-year-old man, Avnish presents with a cough, fever, night sweats, and weight loss.
V. Narkam. Eastern Washington University.