Q.Most common cause of renal artery stenosis is YOUNG patients less than 50yrs
a)DM
b)Atherosclerosis
c)HTN
d) Fibromuscular dysplasis

Answer:d) Fibromuscular dysplasis

Review: Renal artery stenosis is a narrowing or blockage of the artery that supplies blood to the kidney. It is caused by atherosclerosis, fibromuscular dysplasia of the renal artery wall, or scar formation in the artery.

Renal artery stenosis is caused when atheroembolic renal disease results in narrowing of the renal artery. Fibromuscular disease, a condition more common in young women in which fibrous tissue grows in the wall of the renal artery and narrows it, is a second cause. It may also be caused when scar tissue forms in the renal artery after acute arterial obstruction or traumatic injury to the kidney.

Renal artery stenosis often causes hypertension (high blood pressure) with no other signs of its presence, and it is usually discovered in investigation for the cause of hypertension that is difficult to control. Renal artery stenosis is, in fact, among the most common causes of secondary (caused by another condition) hypertension. The disorder may also be discovered when a bruit (loud whooshing sound) over the kidney is noted on examination with a stethoscope (auscultation).

In the elderly, renal artery stenosis is most commonly associated with atherosclerotic disorders, including atherosclerotic heart disease. Atherosclerotic plaque deposits within the renal artery and causes it to become stenosed (narrowed).

Fibromuscular dysplasia is a congenital disorder involving thickening of the arterial wall and is a cause of renal artery stenosis in younger adults, particularly women 20-40 years old.


Renal artery stenosis may cause chronic renal failure if it affects both renal arteries or if the high blood pressure associated with this condition is prolonged or severe.

Q.Life span of Cu-380A in years
a)2
b)1
c)5
d) 10

Answer:c) 5 years

Review: Tcu-380A device has approved life span of only 5 years but effective life is atleast 10 years. The Tcu-380A is now the most widely available used IUD distributed in more than 70 countries and one of the most effective methods of contraception ever developed (Schmidt et al, 1994).

Types

Unmedicated or inert

Medicated - copper bearing or hormone releasing
The majority of the IUDs now widely used are copper bearing

Progressing from stones in camels to insert devices, researchers have developed the second and third generation of medicated IUDs which are highly effective, long lasting, have fewer side effects than earlier models.

Actually the first modern IUDs, the Lippes Loop and the Margulies Spiral appeared in the early 1960s. They were made of polyethylene, biologically inert plastic (Zipper et al 1969). The first generation of copper IUDs, which included the Cu-7, the Tcu-200 and the Multiload-250, carried copper wire with a surface area of 200 to 250 mm2. it was thought that these IUDs would have to be replaced every few years therefore newer IUDs were developed including the Tcu-380A, the Tcu-220C, the Nova T, the Multiload-375 and others. IUDs that release a hormone in the uterus were developed in the 1970s (Luukkainen 1994). A smaller, lightweight and flexible T-shaped copper IUD, the Cu-SAFE 300, which can be inserted without a plunger and is designed to move towards the uterine fundus when the uterus contracts (Vankets et al 1995) is also being marketed. Others are frameless IUDs consisting of six copper sleeves on a surgical nylon thread called the FlexiGard 330, Gynefix TM, or Cufix PP 330 (Vankets et al, 1995, WHO 1995).

The hormone releasing LNG-20 IUD may be even more effective than copper IUDs. Also it reduces menstrual bleeding, while copper IUDs may increase it (Luukkainen and Trivonen 1995). The Progestasert which has been marketed since 1976, contains 38 mg of progesterone released at a rate to 65mg per day for one year. The LNG-20 IUD contains 52 mg of levonorgesterel released at a rate if 20 mg per day and lasts at least five years.

The other major types of unmedicated IUDs are flexible stainless steel rings (either round or of the shape of the uterine cavity and made with a single or double coil). These ring have been widely used in China but not elsewhere.


Mechanism of Action:

The precise mechanism of action of copper IUDs is still not certain, probably affect ova and sperm in various ways, most likely the primary action is altering the function or survival of sperms and ova before they can meet (Croxatto et al 1994). They stimulate a pronounced inflammatory reaction or foreign body response in the uterus. The concentration of various types of white blood cells postaglandins and enzymes in uterine- tubal fluids increases markedly (Sagiroglu 1971, WHO 1987). These changes may interfere with transport of sperms in the genital tract and may damage sperms and ova so that fertilization is impossible (WHO 1987). It has been reported that fewer sperms are found in the fallopian tubes in IUD users than in nonusers. Various types of white blood cells probably consume or damage many sperms in the uterus (Sagiroglu 1971). However, the LNG-20 IUD, although also prevent sperm and ova from joining, has a primarily hormonal mode of action, probably working chiefly by thickening cervical mucus so that sperms cannot pass through it (Luukkainon and Toivonen 1995). Prevention of implantation as a result of biochemical and histological changes in the endometrium as a result of biochemical and histological changes in the endometrium play only a minor role, specially in case of Cu ebaring or progesterone releasing IUDs.

Progesterone releasing IUD exerts no protective effect against ectopic pregnancy. Progesterone decreases tubal motility and this may be the reson for the progesterone releasing IUD failing to reduce the frequency of ectopic pregnancies. Rate of ectopic pregnancy with Levonogestrel releasing IUD is very low 0.02/100 women after 5 years of use (WHO 1997).

Q. Most common causee of Nephrotic syndrome in Adults:

1. FSGN
2. MPGN
   
3. MCD

Answer: ?
Review:
Minimal change disease: The most common cause (80%) of nephrotic syndrome in children. It is so called because on renal biopsy there is no change on light microscopy, only electron microscopy reveals fusion of foot processes.


Membranous glomerulonephritis: The most common primary renal cause of nephrotic syndrome in adults in developing countries

Focal glomerulosclerosis — Focal glomerulosclerosis (FGS) is the most common cause of the nephrotic syndrome in adults, accounting for 35 percent of all cases and over 50 percent of cases among blacks in western countries. FGS can present as a primary syndrome (primary FGS) or may be associated with other conditions (secondary FGS).

FGS is characterized on renal biopsy by the presence in some but not all glomeruli (hence the name focal) of collapse and scarring. The cause of primary disease is unknown, although a few cases appear to result from a genetic defect.

There is a subtype of FGS called collapsing FGS, which most often occurs in blacks. This disorder was first described in HIV-infected patients, but can occur in those without HIV infection.

Q.Acquired intrinsic hemolytic anemia is:

1. Hereditory spherocytosis
2. PNH
3. Thalassemia

Answer:PNH
Review:

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disease characterised by hemolytic anemia, thrombosis and red urine due to breakdown of red blood cells. PNH is the only hemolytic anemia caused by an acquired intrinsic defect in the cell membrane.

Signs and symptoms

• Quite paradoxically, the destruction of red blood cells (hemolysis) is neither paroxysmal or nocturnal the majority of the time (this constellation of symptoms is seen in only 25% of patients).
  
• On-going hemolysis is a more common characteristic.
• A common finding in PNH is the presence of breakdown products of RBCs (hemoglobin and hemosiderin) in the urine.
• An inconsistent, but potentially life-threatening, complication of PNH is the development of clot in the veins (venous thrombosis).
  
• These clots (thrombi) are often found in the hepatic (causing Budd-Chiari syndrome), portal (causing portal vein thrombosis), and cerebral veins (causing cerebral venous thrombosis).
• Many patients with bone marrow failure (aplastic anemia) develop PNH (10-33%).
  
• Aplastic anemia can be caused by an attack by the immune system against the bone marrow.
  
• For this reason, drugs that suppress the immune system are being researched as a therapy for PNH.
  

Classification

PNH is classified:

Classic PNH. Evidence of PNH in the absence of another bone marrow disorder.
PNH in the setting of another specified bone marrow disorder.
Subclinical PNH. PNH abnormalities on flow cytometry without signs of hemolysis.

Pathophysiology
All cells have proteins attached to their membranes and they are responsible for performing a vast array of functions. There are several ways for proteins to be attached to a cell membrane. PNH occurs as a result of a defect in one of these mechanisms.

A molecule called PIGA (phosphatidylinositol glycan A) is needed to make a cell membrane anchor for proteins called GPI (glycosylphosphatidylinositol). The gene that codes for PIGA is inherited in an X-linked fashion, which means that only one active copy of the gene for PIGA may exist. If a mutation occurs in this gene then PIGA may be defective, which leads to a defect in the GPI anchor. When this mutation occurs in a bone marrow stem cell (which are used to make red blood cells as well as white blood cells and platelets), all of the cells it produces will also have the defect. Several of the proteins that anchor to GPI on the cell membrane are used to protect the cell from destruction by the complement system. The complement system is part of the immune system and helps to destroy invading microorganisms. Without the proteins that protect them from complement, red blood cells are destroyed. The main proteins which carry out this function are CD16, CD55 and CD59 (CD is an acronym for cluster of differentiation).

The increased destruction of red blood cells results in anemia. The increased rate of thrombosis is due to dysfunction of platelets. They are also made by the bone marrow stem cells and will have the same GPI anchor defect as the red blood cells. The proteins which use this anchor are needed for platelts to clot properly, and their absence leads to a hypercoagulable state.

Q. Most common TYPE of HEP B

1. adw
2. ayr
3. ada
4. ayw

Review:
Hepatitis B Virus

HBV, the only member of the family Hepadnaviridae that infects humans, has a diameter of 42 nm and consists of a 28 nm core surrounded by a protein coat; the core contains protein, circular double-stranded DNA, and DNA polymerase . Immunofluorescent antibody studies have detected HBV in the nuclei of infected liver cells. The core moves through the nuclear membrane into the cytoplasm, where it acquires its surface coat. HBV is found in the serum of almost all patients early in the course of acute HBV infection.

Two additional particles appear in the liver cell cytoplasm and serum of patients with HBV: a 22 nm-diameter sphere and a rod-shaped filament of the same diameter. These particles are found at the onset of jaundice in nearly all patients with acute HBV infection. The surface coat of the hepatitis B virion and the spheres and filaments are composed of pre-S1, pre-S2, and S polypeptides, in both glycosylated and unglycosylated forms. The S polypeptide is the major hepatitis B surface antigen (HBsAg).

Although there is only one major serotype of HBV, HBsAg has five major subtype determinants, termed a, d, y, w, and r, which are primarily of epidemiologic interest. All HBsAg-positive sera contain determinant a; determinants d and y are mutually exclusive, as are w and r. Hence, four subtype patterns are possible: adw, ayw, adr, and ayr. The first three subtype patterns occur frequently; ayr is rare. Many studies have attempted to correlate subtype with clinical course. It appears, however, that the subtypes are associated with different geographic distributions of HBV rather than with different degrees of virulence. Subtype adw is most common in the Americas and Europe; adr prevails in most of the Far East.


HBV can be classified into seven genotypes (A to G) on the basis of an intergroup divergence of 8% or more in the complete nucleotide sequence.

Genotypes A (serotype adw) and D (ayw) are most common in the United States and Europe;

genotypes B (adw) and C (adr) are most frequent in China and Southeast Asia.

There are also several variations or mutations in the nucleotide sequence of HBV. Core promoter and precore variants produce HBV virions that do not produce hepatitis B e antigen (HBeAg). These variants are most commonly seen in patients with genotypes B, C, and D. These differences in genotypes and the presence or absence of variants may account for variations in clinical manifestations of chronic HBV infection in the United States and other parts of the world.

Q Not a cause for Gastric cancer
a)Nitrates
b)Smoking
c)H.Pylori
d)Blood group B

Answer: ? Blood Group B

Review:

The cause of stomach cancer is unknown. Age and gender are risk factors and the disease is more common in men over the age of 55.

• A diet high in salt and nitrates and low in vitamins A and C increases the risk for stomach cancer.
  
• Other dietary risk factors include food preparation (e.g., preserving food by smoking, salt-curing, pickling, or drying) and environment (e.g., lack of refrigeration, poor drinking water).
  
• A diet high in raw fruits and vegetables, citrus fruits, and fiber may lower the risk for stomach cancer.

• Medical conditions that increase the risk for the disease include pernicious anemia (vitamin B-12 deficiency), chronic inflammation of the stomach (atrophic gastritis), and intestinal polyps (noncancerous growths).

• Genetic (hereditary) risk factors include hereditary nonpolyposis colon cancer (HNPCC) syndrome and Li-Fraumeni syndrome (conditions that result in a predisposition to cancer), and a family history of gastrointestinal cancer.
  
• People with type A blood also have an increased risk for stomach cancer.

Acquired (not present at birth) risk factors include the following:

• Cigarette smoking
• Infection with Heliobacter pylori bacteria (a bacteria related to stomach ulcers) or Epstein-Barr virus
• Obesity
• Occupational factors (e.g., working in rubber and coal industries)
• Personal history of gastrointestinal cancer, previous abdominal radiation, or stomach surgery

Which among the following mycobacteria does not produce pigment when grown In light or dark?

1. M. avium intracellulare complex
2. M. xenopi
3. M. scrofulaceum
4. M.marinum
   
   

Answer:M. avium intracellulare complex

Review:
A Quick Review of the Mycobacteria

All Mycobacteria share the following characteristics:

They are nonmotile, slim rod shaped organisms, 1-10 µm long.
They are obligate aerobes.
They grow very slowly when compared with conventional bacterial such as E. coli. They contain mycolic acid, a rare acid that is otherwise only found in Nocardia and Corynebacterium.
They stain Acid-fast with the Ziehl-Neelson stain.



A Quick Review of M. tuberculosis:
M. tuberculosis is a slender (1-4µm), unencapsulated, strongly acid-fast rod that frequently shows irregular beadingdue to vacuoles and polyphosphate content.

• M. tuberculosis has doubling time of 18 hours.
• M. tuberculosis multiplies intracellularly in phagosome and prevents phagolysosome fusion.
• M. tuberculosis produces large amounts of niacin, however, drug resistant strains can no longer do this.
• M. tuberculosis makes a heat sensitive catalase, unless it is INH resistant.
• M. tuberculosis reduces nitrate. (M. bovis does this too.)
• M. tuberculosis is virulent for Guinea pigs.

The virulence factors of M. tuberculosis include:

Waxes D, a heterogeneous group of peptidoglycolipids in cell wall with adjuvant activity.

Cord factor (Trehalose 6,6 dimycolate) which is a poorly understood determinant of pathogenicity that does manybad things in vitro.

Sulfatides which seem to be involved in the inhibition of phagolysomal fusion.

A Quick Review of the Nontuberculous Mycobacteria

The Nontuberculous Mycobacteria are soil and water organisms
The Nontuberculous Mycobacteria are noncommunicable. (i.e., There is no person to person spread.)
The Nontuberculous Mycobacteria prevents phagosome-lysosome fusion.
Disease usually develops in setting or trama/surgical disruption or immunosuppression.
The Nontuberculous Mycobacteria do not infect guinea pigs.
As a group, the Nontuberculous Mycobacteria are INH resistant. (M. kansasii is the exception to this rule.)
------------------------------------------------------------------------------------------------
Runyon Classification System of the Atypical Mycobacteria Runyon I Grown in the Dark.

Runyon I:

Members of Runyon I are slow growing.
Members of Runyon I produce a yellow-orange pigment when exposed to light.

A Few Interesting Facts About Runyon I Organisms:

M. kansasii

• On acid fast stain, M. kansasii appears as a long, banded, beaded, "barber pole", yellow bacillus due to beta carotene crystals.
• Some nonpathogenic strains of M. kansasii are catalase negative.
• M. kansasii reduces nitrate like M. tuberculosis.
• M. kansasii causes a lung disease that clinically resembles TB, especially in those with preexisting lung conditions such as COPD.
• Also males are affected more than females.

M.marinum

• Exposed to Light M. marinum causes swimming pool granulomas, and abscesses (fish fancier’s finger).
• Because M. marinum likes to grow at a lower than core body temperature, it causes disease at the site of abrasions.
• M. marinum inhabits both fresh and salt water, and infects a lot of marine organisms

-----------------------------------------------------------------------------------------------

Runyon II:
Members of Runyon II are slow growing.
Members of Runyon II produce yellow-orange pigment in light or dark.

Few Interesting Facts About Runyon II Organisms:

M. scrofulaceum

• M. scrofulaceum produces scrofula, a granulomatous cervical adenitis, usually in children.
• M. scrofulaceum enters through the oral pharynx and draining lymph nodes.

M. xenopi

• M. xenopi grows poorly at 37oC, but prefers temperatures of 42oC- 45oC.
• M. xenopi is isolated from water, hot and cold taps, and granulomatous lesions in swine

--------------------------------------------------------------------------------------------------
Runyon III

Members of Runyon III are slow growing
Members of Runyon III do not produce pigment.

A Few Interesting Facts About Runyon III Organisms:

M. avium intracellulare complex

M. avium intracellulare complex is often called MAC.
M. avium intracellulare complex is most common NTM infection in AIDS.
M. avium intracellulare complex causes:

• In middle-aged smokers with COPD or bronchiestasis, MAC can cause cough, weight loss, upperlobe x-ray changes, and cavities - all similar to TB.
• Patients with brochiectasis from old TB or cystic fibrosis can develop infiltrates from MAC infection inthe diseased lung areas.
• Non-smoking women over 50 who have a persistent cough and interstitial changes in their right middle lobe or lingula can have MAC infection.

The key to diagnosis is thinking to send sputum for AFB smear and culture. Whereas it used to be thought that these women were simply colonized with MAC, it is nowrealized that 20% will die within 5 years unless treatment is given.

• Scrofula, most common cause of cervical lymphadenitis in children. It must be treated by excision. M. avium intracellulare complex is highly drug resistant.

-------------------------------------------------------------------------------------------------

Runyon IV:

Members of Runyon IV are rapid growing.
They produce colonies in less than 5 days.
Members of Runyon IV do not produce pigment.
The production of arylsulfatase is used to distinguish the clinically significant rapid growers.
Members of Runyon IV have a positive test for iron uptake test


Few Interesting Facts About Runyon IV Organisms:

M. chelonei and M. fortuitum

M. chelonei and M. fortuitum cause infections in the immunocompromised (although disseminated-DZ is rare), and those with prosthetic implants.

Sometimes, M. chelonei and M. fortuitum infections can be traced to contaminated operating equipment (e.g., mammoplasty).

Areas infected by M. chelonei and M. fortuitum include soft tissue, lungs, bone, the CNS, and the eye (keratitis).

M. fortuitum reduces nitrate like M. tuberculosis

19) lepromin test all are true except

1. diagnostic of leprosy
2.for recruiting staff of leprosy sanatorium
3. used to classify leprosy


Answer: Diagnostic of leprosy


lepromin test

A test to evaluate leprosy using an intradermal injection of a lepromin; the test classifies the stage of leprosy based on reaction and differentiates tuberculoid leprosy, in which there is a positive delayed reaction at the injection site, from lepromatous leprosy, in which there is no reaction despite the active infection.

18) slapped cheek is seen in infection with
1. parvo virus
2. herpes
3. staph


Answer: Parvo Virus

Slapped cheek syndrome

Parvovirus B19 is a virus that only affects humans. The symptoms of infection varies from a very minor illness, possibly with headache, mild fever and sore throat to erythema infectiosum, which produces a typical rash that appears on the cheeks, hence its name Slapped Cheek Syndrome. The condition is also sometimes called Slap Cheek or Fifth Disease, being the fifth cause of common rash-associated diseases of childhood to be identified.

It is thought that 60% of all adults in the UK have been infected with Parvovirus at some point, usually between the ages of six and ten years old. An increase in the number of infections occurs every 3-4 years, largely in schoolchildren.

One infection is thought to confer lifelong immunity.

16.SSPE is a complication of
1. measles
2. varicella
3. rubella


Answer: Measles

Subacute Sclerosing Panencephalitis (SSPE) is a progressive neurological disorder characterized by inflammation of the brain (encephalitis). The disease may develop due to reactivation of the measles virus or an inappropriate immune response to the measles virus. SSPE usually develops 2 to 10 years after the original viral attack. Initial symptoms may include memory loss, irritability, seizures, involuntary muscle movements, and/or behavioral changes, leading to neurological deterioration. include memory loss, irritability, seizures, involuntary muscle movements, and/or behavioral changes, leading to neurological deterioration.

15. Most heat labile vaccine
1. OPV
2. measles
3. DPT
4. BCG


Answer: OPV

When the global network of developing country immunization programmes knownas the Expanded Programme on Immunization (EPI) was first established in the late1970’s, one of the greatest challenges was to ensure that the potency of vaccineswas maintained from the point of manufacture, usually in an industrialized country,to the point of administration in the field, under the harshest of climatic conditions.In addition to developing the technology needed to maintain this ‘cold chain’, theEPI also established a rigid set of parameters for the handling and storage ofvaccines. To maintain an operationally simple programme, at the peripheral levelthese parameters were defined by the most heat labile vaccine, oral polio vaccine(OPV).

Because it was not possible to precisely monitor the potency of anindividual vial, health workers would often have to destroy vaccines when theintegrity of the cold chain had been compromised.

13.Dysphagia lusoria is due to

1. Vascular anomaly
   
2. muscular anomaly
3. mucosal anomaly
4. carcinoma

Answer: Vascular anomaly

Dysphagia Lusoria

Explanation
A vascular ring is a developmental anomaly of the aortic arch. It occurs in about 0.3% of the population.

Failure of disappearance or development of one or more of the aortic arches results in constriction of the oesophagus and trachea between aberrant vessels.

It may be produced by:

an accessory aorta running anterior to the oesophagus and trachea with the 'normal aorta' running posteriorly. Often, the accessory aorta is the site of origin of the left common carotid and subclavian arteries.

the right common carotid artery arising directly from the arch of the aorta as its most proximal branch. The right subclavian artery arises from the arch distal to the left subclavian artery on the left side to pass posterior to the trachea and oesophagus across the posterior mediastinum. There is no brachiocephalic trunk.

a right-sided aortic arch due to regression of the left fourth branchial arch artery and dorsal aorta

The condition may be silent clinically or present at birth or the first few months of life with stridor and dysphagia. Gradually, these symptoms worsen as their is relatively greater growth of the trachea and oesophagus than vessels. The first anomaly - a double aorta - is more likely to produce symptoms than the abnormal origin of the right subclavian artery.

Diagnosis is by barium swallow.

Treatment is by surgical division of the ring.

14. Achalasia cardia is disorder of

1. ?
2. ?
3. ?
4. lower esophageal sphincter
   

Failure of relaxation of LES

Achalasia is a neuromuscular failure of relaxation at the lower end of the oesophagus with progressive dilatation, tortuosity, incoordination of peristalsis and often hypertrophy of the oesophagus above. There is effectively a functional obstruction at the lower end of the oesophagus.

Achalasia may occur at any age but particularly in the third to fourth decades. Males and females are affected equally.

Incidence is about 1 per 100,000 per year.


Achalasia primarily involves a neurological defect involving the ganglion cells of Auerbach's myenteric plexus in the lower oesophageal sphincter and oesophageal body. Abnormalities have also been reported in the vagal dorsal motor nucleus, the nucleus ambiguus, and in the smooth muscle of the oesophagus.

The damaging agent has been variously hypothesised as a neurotoxic virus, an autoimmune process, and a vitamin deficiency; none has been conclusively demonstrated.

At its most severe, aperistalsis occurs in the lower two thirds of the oesophagus with normal peristalsis above it. Thus, food accumulates in the oesophagus which then becomes dilated and atonic. The prolonged transit time may be a factor in the increased incidence of malignancy with achalasia - in up to 5% of cases.

It closely resembles changes seen in Chagas' disease.

12.Foot drop is due to paralysis of

• Common peroneal nerve
• Tibial nerve
• Sciatic nerve

Answer: Common peroneal nerve


Foot drop is a deceptively simple name for a potentially complex problem. Foot drop can be associated with a variety of conditions such as dorsiflexor injuries, peripheral nerve injuries, stroke, neuropathies, drug toxicities, or diabetes. The causes of foot drop may be divided into 3 general categories: (1) neurologic, (2) muscular, and (3) anatomic. These causes may overlap. Treatment is variable and is directed at the specific cause.


Peroneal nerve palsy may lead to severe disability w/ foot drop and paresthesias

11. Hypertrophic pulmonary osteoarthropathy is seen in

1. Scc lung
2. Anaplastic ca lung
3. Adeno ca lung
   

Answer: Adeno ca lung


"Symmetrical osteitis of the four limbs, chiefly localized to the phalanges and the terminal epiphyses of the long bones of the forearm and leg, sometimes extending to the proximal ends of the limbs and the flat bones, and accompanied by dorsal kyphosis and joint involvement. It is often secondary to chronic conditions of the lungs and heart. (Dorland, 27th ed)"

Hypertrophic pulmonary osteoarthropathy is a rare disorder that is associated with severe clubbing.

This disorder is characterised by:

• Subperiosteal new bone formation at the distal ends of long bones, metatarsals, metacarpals and proximal phalanges
• Symmetrical arthropathy of adjacent joints
• Clubbing of the fingers
• Gynaecomastia
• The patient may complain of dull aching and sometimes swelling of the wrist and ankles.

Paraneoplastic syndromes:

Gynecomastia - most commonly with large-cell
Hypercalcemia - most commonly with squamous cell
Hypertrophic pulmonary osteoarthropathy - presents as bilateral pain and tenderness in the legs, especially over the tibias.

Bone scan positive.
X-rays show elevated periosteum without cortical involvement. - most commonly with adenocarcinoma (secondary to PTHrp)
Clubbing of digits
Syndromes according to tumor location:

Pancoast syndrome (superior sulcus tumor) - lower brachial plexopathy,
Horner's syndrome,
shoulder/ulnar distribution of pain.

Horner's syndrome - enophthalmos, ptosis, miosis, ipsilateral loss of sweating, hoarseness due to recurrent laryngeal nerve involvement
Second primary: Patients treated for upper aerodigestive tract tumors (lung, H&N, esophagus) have a 3%/year risk of developing a subsequent cancer.

10. Foramen spinosum transmits

1. Accessory meningeal artery
2. Mandibular dvn of 5th nerve
3. Maxillary dvn of 5th nerve
4. Emissary vein

Answer : Foramen Spinosum Transmits the middle meningeal artery.

I guess the first option must be middle meningeal artery not accesory.

Wickham striae is seen in

1.Lichen planus
2. Psoriasis
3. Dermatophytic Infections
4. Eczema



Answer: Lichen planus shows Wickham striae (white, fine, reticular scales).


Lichen planus facts

• about one in 50 people affected
• ages 30 to 60
• women slightly more than men
• children or older people rarely affected
• cause unknown - not infectious
• often mistaken for other skin conditions
• flat-topped, pink-purple spots with a shiny surface that reflect light
• appear in groups or along the line of an injury
• irregular white streaks seen - Wickham's striae
• can cause mouth ulcers, hair-loss, nail damage

10) yellow coloured crusts are seen in
Impetigo


Well thats the answer...

Impetigo, a contagious skin infection that usually produces blisters or sores on the face and hands, is one of the most common skin infections among kids.

It is generally caused by one of two bacteria: group A streptococcus or staphylococcus aureus. Impetigo usually affects preschool and school-age children, especially in the summer months. A child may be more likely to develop impetigo if the skin has already been irritated or injured by other skin problems, such as eczema, poison ivy, insect bites, or a skin allergy to soap or makeup.

Good hygiene can help prevent impetigo, which often develops when there is a sore or a rash that has been scratched repetitively (for example, poison ivy can get infected and turn into impetigo). Impetigo is typically treated with antibiotics.

Signs and Symptoms
Impetigo may affect skin anywhere on the body but commonly occurs around the nose and mouth, hands, and forearms.

When impetigo is caused by group A streptococcus, it begins as tiny blisters. These blisters eventually burst and leave small wet patches of red skin that may weep fluid. Gradually, a tan or yellowish-brown crust covers the affected area, making it look like it has been coated with honey or brown sugar.

Impetigo that is caused by staphylococcus aureus triggers larger fluid-containing blisters that appear clear, then cloudy. These blisters are more likely to stay intact longer on the skin without bursting.

Contagiousness
Impetigo may itch and can be spread by scratching. Kids can spread the infection by scratching it and then touching other parts of the body.

Impetigo is contagious and can spread to anyone who comes into contact with infected skin or other items, such as clothing, towels, and bed linens, that have been touched by infected skin.

9) strep viridans causes
1. erysipelas
2. endocarditis
3. impetigo

Answer : Endocarditis

Many bacteria can cause endocarditis, but an organism commonly found in the mouth, Streptococcus viridans, is responsible for approximately half of all bacterial endocarditis. Other common organisms include Staphylococcus and Group D streptococcus. Less common organisms include Pseudomonas, Serratia, Candida, and many others

8 ) ultras sonic feature of impending fetal death
• Brady cardia
• Altered fetal tone
.Absent fetal respiration

Answer: Bradycardia?
Fetal Monitoring
Monitoring consists of measuring uterine contractions with a tocometer, fetal HR with a Doppler transducer, and fetal movement and tone with ultrasonography. Together, these measurements yield a good indication of fetal health. Preoperative ultrasonography can also approximate gestational age when an accurate history cannot be obtained. Gestational age plays a pivotal role in all surgical decision making for a pregnant patient.

The fetal HR is routinely measured both preoperatively and postoperatively. Though the fetal HR can be heard 14 weeks after conception, it serves as an indicator of fetal oxygenation only after week 26. Specific fetal HR abnormalities—absence of variability, late or variable decelerations, and bradycardia—are predictive of impending fetal hypoxia, physical damage, or death. In the absence of these extreme (and hence obvious) fetalHR patterns, interpretation of fetal tracings can be complex. There are no conclusive data to suggest that any single monitoring technique reflects fetal outcome.Optimization of maternal physiologic status is more important than any mode of fetal monitoring.

5)sympatic ophthalmitis is seen in
• Blunt unjury
• Penetrating injury

Answer Penetrating injury


Underlying condition causes of Sympathetic ophthalmitis:

Eye injury
Penetrating eye injury
Autoimmune disease


Sympathetic ophthalmia, a rare bilateral granulomatous panuveitis, presumably arises following penetrating ocular injury and surgery as a result of lymphatic exposure to a previously sequestered antigen.

4) crystalline lens of eye develops from
• Surface ectoderm
• Nero ectoderm
• Mesoderm

Answer surface ectoderm

*lens placode
--->lens pit
--->lens vesicle
--->lens fibres
--->lens capsule
--->embryonic/fetal nucleus

3) a child is able to skip by
• 48months
• 54 months
• 60months
• 72 months

Answer 60 Months

Infant -- birth to 1 year

Displays social smile
Rolls over by self
Able to sit alone, without support
Babbling
Plays peek-a-boo
Eruption of 1st tooth
Pulls self to standing position
Walks while holding on to furniture or other support
Says mama and dada, using terms appropriately
Able to drink from a cup
Understands "NO" and will stop activity in response
Walks without support


Toddler -- 1 to 3 years
Masters walking
Recognizes gender differences
Uses up to 8 words and understands simple commands
Able to run, pivot, and walk backwards
Uses spoon to feed self
Can name pictures of common objects and point to body parts
Able to walk up and down stairs
Imitates speech of others, "echoing" word back
Begins pedaling tricycle
Learns to take turns (if directed) while playing with other children
Able to feed self neatly, with minimal spilling
Able to state first and last name
Recognizes and labels colors appropriately
Able to draw a line (when shown one)
Dresses self with only minimal help
Learns to share toys (without adult direction)


Preschooler -- 3 to 6 years
Rides tricycle well
Able to draw a circle
Able to draw stick figures with 2 to 3 features for people
Hops on one foot
Catches a bounced ball
Understands size concepts
Enjoys rhymes and word play
Able to skip
Enjoys doing most things independently, without help
Balances better, may begin to ride a bicycle
Understands time concepts
Begins to recognize written words -- reading skills start
Starts school


School-age child -- 6 to 12 years
Understands and able to follow sequential directions
Beginning skills for team sports (soccer, T-ball, etc.)
Begins to lose "baby" teeth and erupt permanent teeth
Routines important for daytime activities
Reading skills develop further
Peer recognition begins to become important
Girls begin to show growth of armpit and pubic hair, breast development
Menarche (1st menstrual period) may occur in girls


Adolescent -- 12 to 18 years
Boys show growth of armpit, chest, and pubic hair; voice changes; and testicular/penile enlargement
Girls show growth of armpit and pubic hair; breast development; menstrual periods
Adult height, weight, sexual maturity
Understands abstract concepts
Peer acceptance and recognition is of vital importance



Physical Milestones of a Five to Six Year Old

Child will be more in control of his or her body.
Child will have a marked increase in stamina and coordination.
Child can throw and catch a ball with practice.
Child may start to loose baby teeth as permanent teeth start emerging.
Child will show a preference to their right or left hand.
Child will be able to skip.
Child will be able to master buttons.
Child will show an interest in learning how to lace and tie his or her own shoes.
Child will be able to write the alphabet, though the letters may not be neat or precise.
Child is usually worn out from a day of play and learning and goes to bed easier. However, many children in this age group do not like being awakened in the morning and may be fussy.

2) carbon atom of the purine ring from co2 is
• c2
• C6
• C8

Answer C6

De Novo Synthesis of Purine Nucleotides

We use for purine nucleotides the entire glycine molecule (atoms 4, 5,7), the amino nitrogen of aspartate (atom 1), amide nitrogen of glutamine (atoms 3, 9), components of the folate-one-carbon pool(atoms 2, 8), carbon dioxide, ribose 5-P from glucose and a great deal of energy in the form of ATP. In de novo synthesis, IMP is the first nucleotide formed. It is then converted to either AMP or GMP.

PRPP
Since the purines are synthesized as the ribonucleotides, (not as the free bases) a necessary prerequisite is the synthesis of the activated form of ribose 5-phosphate. Ribose 5-phosphate reacts with ATP to form 5-Phosphoribosyl-1-pyrophosphate (PRPP).

This reaction occurs in many tissues because PRPP has a number of roles - purine and pyrimidine nucleotide synthesis, salvage pathways, NAD and NADP formation. The enzyme is heavily controlled by a variety of compounds (di- and tri-phosphates, 2,3-DPG ), presumably to try to match the synthesis of PRPP to a need for the products in which it ultimately appears.

Commitment Step

De novo purine nucleotide synthesis occurs actively in the cytosol of the liver where all of the necessary enzymes are present as a macro-molecular aggregate. The first step is a replacement of the pyrophosphate of PRPP by the amide group of glutamine. The product of this reaction is 5-Phosphoribosylamine. The amine group that has been placed on carbon 1 of the sugar becomes nitrogen 9 of the ultimate purine ring. This is the commitment and rate-limiting step of the pathway.

The enzyme is under tight allosteric control by FEEDBACK inhibition. Either AMP, GMP, or IMP alone will inhibit the amidotransferase while AMP + GMP or AMP + IMP together act synergistically. This is a fine control and probably the major factor in minute by minute regulation of the enzyme. The nucleotides inhibit the enzyme by causing the small active molecules to aggregate to larger inactive molecules.

[PRPP] also can play a role in regulating the rate. Normal intracellular concentrations of PRPP (which can and do fluctuate) are below the KM of the enzyme for PRPP so there is great potential for increasing the rate of the reaction by increasing the substrate concentration. The kinetics are sigmoidal. The enzyme is not particularly sensitive to changes in [Gln] (Kinetics are hyperbolic and [gln] approximates KM). Very high [PRPP] also overcomes the normal nucleotide FEEDBACK inhibition by causing the large, inactive aggregates to dissociate back to the small active molecules.

Purine de novo synthesis is a complex, energy-expensive pathway. It should be, and is, carefully controlled.


Formation of IMP
Once the commitment step has produced the 5-phosphoribosyl amine, the rest of the molecule is formed by a series of additions to make first the 5- and then the 6-membered ring. (Note: the numbers given to the atoms are those of the completed purine ring and names, etc. of the intermediate compounds are not given.) The whole glycine molecule, at the expense of ATP adds to the amino group to provide what will eventually be atoms 4, 5, and 7 of the purine ring (The amino group of 5-phosphoribosyl amine becomes nitrogen N of the purine ring.) One more atom is needed to complete the five-membered ring portion and that is supplied as 5, 10-Methenyl tetrahydrofolate.

Before ring closure occurs, however, the amide of glutamine adds to carbon 4 to start the six-membered ring portion (becomes nitrogen 3). This addition requires ATP. Another ATP is required to join carbon 8 and nitrogen 9 to form the five-membered ring.

The next step is the addition of carbon dioxide (as a carboxyl group) to form carbon 6 of the ring. The amine group of aspartate adds to the carboxyl group with a subsequent removal of fumarate. The amino group is now nitrogen 1 of the final ring. This process, which is typical for the use of the amino group of aspartate, requires ATP. The final atom of the purine ring, carbon 2, is supplied by 10-Formyl tetrahydrofolate. Ring closure produces the purine nucleotide, IMP.

Note that at least 4 ATPs are required in this part of the process. At no time do we have either a free base or a nucleotide.

Formation of AMP and GMP

IMP can then become either AMP or GMP. GMP formation requires that IMP be first oxidized to XMP using NAD. The oxygen at position 2 is substituted by the amide N of glutamine at the expense of ATP. Similarly, GTP provides the energy to convert IMP to AMP. The amino group is provided by aspartate in a mechanism similar to that used in forming nitrogen 1 of the ring. Removal of the carbons of aspartate as fumarate leaves the nitrigen behind as the 6-amino group of the adenine ring. The monophosphates are readily converted to the di- and tri-phosphates.


Control of De Novo Synthesis

Control of purine nucleotide synthesis has two phases. Control of the synthesis as a whole occurs at the amidotransferase step by nucleotide inhibition and/or [PRPP]. The second phase of control is involved with maintaining an appropriate balance (not equality) between ATP and GTP. Each one stimulates the synthesis of the other by providing the energy. FEEDBACK inhibition also controls the branched portion as GMP inhibits the conversion of IMP to XMP and AMP inhibits the conversion of IMP to adenylosuccinate.

1) Shield ulcer is seen in
• Plycten
• Spring catarrh
• Conjunctivitis

Vernal Keratoconjunctivitis (VKC) - Spring Catarrh


A classic presentation of VKC.

Signs and symptoms: VKC is a chronic, bilateral inflammation of the superior and limbal palpebral conjunctiva. The warmer the climate, the greater its prevalence. Onset typically occurs between ages 3 and 25 years. Males typically are affected more than females.
Symptoms often include severe itching with thick, ropy discharge. In most cases, patients have a history of allergies or infantile eczema.

important clinical signs

*large conjunctival papillae on the back of the superior tarsus;
*raised Horner-Trantas dots (gelatinous, white clumps of degenerated eosinophils usually located at the superior limbus);
*superficial punctate keratitis (SPK) and,
*in severe cases, well-demarcated, sterile corneal shield ulcers, located superiorly.

Vernal shield ulcers develop in the upper regions of the cornea. The base of the ulcer is composed of abnormal mucus, fibrin and serum, deposited as a gray plaque. Friction secondary to the roughened superior conjunctiva erodes the corneal epithelium.

The correct answer is E.

DIC in a patient with probable leukemia strongly suggests Acute Promyelocytic leukemia. which is characterized by a t( 15,17) translocation. This translocation results in the fusion of a truncated retinoic acid receptor -alpha (RAR-alpha) gene on chromosome 17 to the promyelocyte -leukemia transcriptor unit on chromosome 15.

The Correct Answer is E

Osteoarthritis

• Patient usually over age 50
• Morning stiffness less than 30 min
• Crepitus in joint, with or without inflammation
• Bony enlargement or tenderness
• Rheumatoid Factor is low
• Synovial fluid is non-inflammatory

Positively birefringent crystals on polarizing light microscopy are commonly seen with pseudogout and gout.

The Correct Answer is B

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disorder that may affect many tissues and organs but particularly the joints often progressing to destruction of the articular cartilage and ankylosis of the joints . Due to its physical, social and psychological burden, patients are often faced with many difficulties in various aspects of their lives. The main cause of functional disability in RA is synovitis which leads to erosive joint damage . Many variables such as age , sex , duration of illness, number of affected joints , education, psychological factors and certain laboratory values can contribute to the sequela of functional disability.

The Correct Answer is B

Osteoarthritis

• DEGENERATIVE JOINT DISEASE (DJD)
• Disease of older patients
• Loss of articular joint cartilage
• Narrowing of joint space
• Osteophytes
• Bony sclerosis around joint
• Usually secondary to weight-bearing, chronic wear and tear
• Affects hips, knees, spine most frequently

The Correct Answer is B

Osteoporosis

Represent a decrease in bone mass, making bones more susceptible to Compression and fracture

30-50% of bone density must be lost to be seen by plain x-rays

Caused by

• senile postmenopausal hormonal changes
• Steroids
• Malnutrition
  
• Certain inherited conditions
• Leukemia, multiple myeloma

The Correct Answer is D

Metastases to bone are more common than primary bone tumors.

Common tumors which metastasize to bone include prostate, breast, lung and Kidney

Carcinomas

• Common sites for metastatic disease are spine, skull, ribs, pelvis, and proximal Extremities
• Most mets are lytic causing destruction of bone
• More uncommonly, mets are blastic or mixed
• Metastases from prostate and breast carcinomas often are blastic or sclerotic
• Plain films or bone scans (Nuclear medicine) are ways to assess for metastatic Bone disease
• MR can show marrow involvement best.
  

The correct answer is D.


The purpose of the time out is to remove the girl from stimuli to facilitate the extinction of unwanted behavior. To be effective, time out must be used consistently and predictably. If the child protests during a time out, as in this case, additional time is added to the period to extinguish the protest behaviors. The goal is to convey the clear message that the time out will be ended only when unacceptable behaviors are ended.

To impact behavior, the intervention must be closely associated with the behavior. To delay in responding to the girl's protests (choice A) makes it harder for her to realize that the additional time is a direct consequence of her behavior.

At age 3, reasoned, rational explanations (choice B) are unlikely to have any impact on the child's behavior. The child probably lacks the cognitive capacity to grasp the abstract rationale for why she is being disciplined.

Paddling (choice C) is a type of attention, and can actually reinforce the behavior the parents are trying to extinguish. The child learns that protestation will bring the parents and their attention, even if it is negative attention. In addition, as a general rule, any response option on the USMLE exam that has someone hitting a child will almost certainly be scored as a wrong answer!

This option encourages the child to cry and then demand a treat to become quiet (choice E), a kind of juvenile blackmail. Avoiding bad behavior is a baseline and need not be specially rewarded.

The correct answer is C.

This is a classic presentation of a patient with carpal tunnel syndrome, which typically affects females between the ages of 40 and 60 who chronically perform repetitive tasks that involve movement of the structures that pass through the carpal tunnel. One important structure that passes through the carpal tunnel is the median nerve. Patients often note a tingling, a loss of sensation, or diminished sensation in the digits. There is also often a loss of coordination and strength in the thumb, because the median nerve also sends fibers to the abductor pollicis brevis, flexor pollicis brevis, and the opponens pollicis. A final function of the median nerve distal to the carpal tunnel is control of the first and second lumbricals which function to flex digits two and three at the metacarpophalangeal joints and extend interphalangeal joints of the same digits.

Abduction of the fifth digit (choice A) is a function controlled by the ulnar nerve, which does not pass through the carpal tunnel.

Adduction of the thumb (choice B) is a function of the adductor pollicis, which is the only short thumb muscle that is not innervated by the median nerve, but rather by the deep branch of the ulnar nerve.

Sensation of the lateral half of the dorsum of the hand (choice D) is mediated by the radial nerve, which also does not pass through the carpal tunnel.

Sensation over the lateral aspect of the palm (choice E) is mediated by the median nerve, however the branch innervating the palm (palmar cutaneous branch of the median nerve) passes superficial to the carpal tunnel.

Sensation over the medial aspect of the dorsum of the hand (choice F) is mediated by the ulnar nerve.

Sensation over the medial aspect of the palm (choice G) is mediated by the ulnar nerve.

The correct answer is C.

Wine and cheese (and many other fermented foods) contain tyramine, an indirect sympathomimetic that can trigger excess catecholamine release and lead to a hypertensive crisis when ingested by patients taking MAO inhibitors. The only such drug listed among the answer choices is phenelzine. Other MAO inhibitors with similar effects include tranylcypromine, isocarboxazid, and iproniazid. Whenever this particular drug class is mentioned in a question stem, consider the possibility of interactions with foods or other medications the patient may have taken.

Amitriptyline (choice A) is a tricyclic antidepressant. Tricyclic antidepressant drugs (particularly amitriptyline) are known for their anticholinergic side effects. They also produce postural hypotension (because they block alpha-adrenergic receptors) and are sedative.

Fluoxetine and sertraline (choices B and D) are antidepressants that are selective serotonin reuptake inhibitors (SSRIs). Fluoxetine is also useful in treatment of obsessive-compulsive disorders.

Trazodone (choice E) is an atypical antidepressant with substantial sedative side effects. Its most serious side effect is priapism, a medical emergency.

The correct answer is B. The Stanford-Binet scale is best for younger children (2-4 years old), since it does not rely exclusively on language.

The Denver Developmental Scale (choice A) is used to assess the attainment of developmental milestones in children under 2.

The WAIS-R (Wechsler Adult Intelligence Scale; choice C) is used for individuals aged 17 and over. (Just think, the WAIS-R is rated "R").

The WISC III (Wechsler Intelligence Scale for Children; choice D) is useful for evaluating children aged 6-16.

The WPPSI (Wechsler Preschool and Primary Scale of Intelligence; choice E) is used for children aged 4-6.

The correct answer is E.

The disease is myotonic dystrophy, which is an autosomal dominant disease; the affected gene has been localized to chromosome 19. Myotonic dystrophy is relatively common and is best thought of as a systemic disease, since it causes cataracts, testicular atrophy, heart disease, dementia, and baldness in addition to muscular weakness.

A mutation on the X chromosome (choice A) causes Duchenne muscular dystrophy.

None of the muscle diseases are known to be related to defects on the Y chromosome (choice B).

Facioscapulohumeral dystrophy is associated with a defective gene on chromosome 4 (choice C).

Infantile hypotonia has been related to defective genes on chromosome 5 (choice D).

The Correct Answer is B

Gram Negative Bacteria

· THE CELL WALL of Gram-negative bacteria is a thinner structure with distinct layers.

· There is an outer layer which is more like a cytoplasmic membrane in composition with the typical trilaminar structure.

· THE MAIN COMPONENT of the Gram-negative cell wall is lipopolysaccharide.

· Additionally there is present phospholipid, protein, lipoprotein and a small amount of peptidoglycan.

· The lipopolysaccharide consists of a core region to which are attached repeating units of polysaccharide moieties.

· A component of the cell wall of most Gram-negative bacteria is associated with endotoxic activity, with which are associated the pyrogenic effects of Gram-negative infections.

· On the side-chains are carried the bases for the somatic antigen specifity of these organisms.

· The chemical composition of these side chains both with respect to components as well as arrangement of the different sugars determines the nature of the somatic or O antigen determinants, which are such important means of serologically classifying many Gram-negative species.

· In many cases it has been shown that the reason for certain organisms belonging to quite different species, giving strong serological cross-reactivity is due their having chemically similar carbohydrate moieties as part of their lipopolysaccharide side chains, which generally have about 30 repeating units.

THESE SIDE CHAINS have as part of their structure frequently quite common hexoses, but in many cases there are also present some unusual hexoses, such as 6-deoxyhexoses and 3,6-dideoxyhexoses. Also O -methyl sugars may be part of these side chain structures.

• WHILE THERE IS a great deal of variation among these side chains, the composition of the core region is much more conserved among many Gram-negative groups of bacteria.
• Characteristic of the core region of many of the Enterobacteriaceae is phophorylated 2-keto-3-deoxyoctonoate, phosphorylated L-glycero-D-mannoheptose, D-galactose, D-glucose and N -acetyl-glucosamine.
• The first two are by far the most widespread components of the core region of many species.
• The lipid component of the lipopolysaccharide, known as lipid A is predominantly associated with the endotoxic activity.
• It is the most conserved part of the Gram-negative cell wall and the basis of its structure is a beta-1,6-linked D-glucosamine disaccharide.
• In some Pseudomonas and Rhodopseudomonas strains this is replaced by 2,3-diamino-2,3-dideoxy-D-glucose.
• This has phosphate residues in positions 1 and 4. To both the amino and hydroxyl groups of the glucosamine moieties are linked long-chain fatty acids. Among the enterobacterial lipopolysaccharides the N -acyl residues are frequently fatty acids like beta-hydroxymyristic acid or similar 3-hydroxyalkanoic acids. Some Gram-negative bacteria lack phosphate in their lipid A and some types contain other carbohydrates 2,3-diamino-2,3-dideoxy-D-glucose.

The correct answer is E.

Urinary tract infections are the most common bacterial infections encountered during pregnancy, and Escherichia coli is the most commonly isolated organism. 70% of cases in the U.S. are caused by P pili-positive strains.

Bundle-forming pili (choice A) are found in enteroaggregative E. coli (EAEC).

GVVPQ fimbriae (choice B) are found in EAEC.

Heat labile toxins (choice C) are pathogenic factors in enterotoxic strains (ETEC).

Heat stable toxins (choice D) are pathogenic factors in ETEC or EAEC.

Type 1 pili (choice F) are a major pathogenic factor in ETEC.

The correct answer is A.

Anthrax forms extremely stable spores and has, in fact, been encountered in very old (i.e., deep) dirt in Israeli and Arabian excavation sites. The causative organism, Bacillus anthracis, is found in many animal species, and humans can acquire the organism either through contact with the animals or from locally contaminated soil. The pustule described in the question stem is called a "malignant pustule" and may be accompanied by lymphadenopathy. Most cases remain localized, but death can occur as the result of complications such as bacteremia, meningitis, and pneumonia.

Borrelia burgdorferi (choice B) causes Lyme disease. In the first stage of this disease, there is a localized expanding erythematous rash rather than an eschar. Furthermore, Lyme disease occurs in the U.S., Europe, and Asia, corresponding to the distribution of Ixodid ticks, which spread the infection.

Francisella tularensis (choice C) causes tularemia. The organism can persist for weeks to months but does not form spores that could survive for hundreds or thousands of years. Also, most human cases occur in the endemic areas of the U.S.

Spirillium minus (choice D) is one of the causes of rat-bite fever. There is no indication the man was bitten by a rat.

Yersinia pestis (choice E) causes bubonic plague. This organism does not form stable spores that could survive for extended periods of time.

The correct answer is B.

Hyperlipidemia has been subclassified based on the lipid and lipoprotein profiles. Type 2a, which this patient has, can be seen in a hereditary form, known as familial hypercholesterolemia, and also in secondary, acquired forms related to nephritic syndrome and hyperthyroidism. The root problem appears to be a deficiency of LDL receptors, which leads to a specific elevation of cholesterol in the form of increased LDL.

Heterozygotes for the hereditary form generally develop cardiovascular disease from 30 to 50 years of age. Homozygotes may have cardiovascular disease in childhood.

Type 1 (choice A) is characterized by isolated elevation of chylomicrons.

Type 2b (choice C) is characterized by elevations of both cholesterol and triglycerides in the form of LDL and VLDL.

Type 3 (choice D) is characterized by elevations of triglycerides and cholesterol in the form of chylomicron remnants and IDL.

Type 5 (choice E) is characterized by elevations of triglycerides and cholesterol in the form of VLDL and chylomicrons.

The correct answer is D.

Wernicke-Korsakoff syndrome refers to the constellation of neurologic symptoms caused by thiamine deficiency. Among these, a severe memory deficit, which the patient may attempt to cover by making up bizarre explanations (confabulation), is prominent. Anatomical damage to the mamillary bodies and periventricular structures has been postulated as the cause. In the U.S., severe thiamine deficiency is seen most commonly in chronic alcoholics. Thiamine deficiency can also damage peripheral nerves ("dry" beriberi) and the heart ("wet" beriberi).

Folic acid deficiency (choice A) produces megaloblastic anemia without neurologic symptoms.

Niacin deficiency (choice B) produces pellagra, characterized by depigmenting dermatitis, chronic diarrhea, and anemia.

Riboflavin deficiency (choice C) produces ariboflavinosis, characterized by glossitis, corneal opacities, dermatitis, and erythroid hyperplasia.

Vitamin B12 deficiency (choice E) produces megaloblastic anemia accompanied by degeneration of the posterolateral spinal cord.

The correct answer is B.

One of the most common side effects of any antineoplastic therapy is weight loss secondary to decreased appetite and/or nausea and vomiting. Furthermore, weight loss due to decreased food intake tends to occur more frequently in elderly patients receiving antineoplastic therapy. One medication that has consistently helped to increase appetite in such patients is megestrol acetate. This agent is a progestational hormone with antineoplastic properties used in the treatment of advanced carcinoma of the breast and endometrium. Megestrol, when given in relatively high doses, can substantially increase the appetite in most individuals, even those with advanced cancer

The correct answer is E.

Arrow E points to a smooth muscle cell in the media of the arteriole. Alpha1 agonists stimulate alpha1 receptors present on the smooth muscle, which leads to an increase in intracellular calcium via phosphatidylinositol hydrolysis. This increase in calcium is necessary for smooth muscle contraction. Arrow A indicates an endothelial cell located in the intima of the arteriole.

Nitric oxide, also known as endothelial cell relaxing factor (EDRF), is produced from arginine by endothelial cells. A muscarinic agonist can lead to the evolution of NO, producing vasodilatation.

Arrow B indicates a polymorphonuclear leukocyte in the bloodstream.

Arrow C indicates the basal lamina underlying the endothelium.

Arrow D indicates the arteriolar adventitia.

The correct answer is E.

Beta-adrenergic blockade may blunt or prevent the premonitory signs and symptoms (e.g., tachycardia, blood pressure changes) of acute episodes of hypoglycemia. Non-selective beta-blockers, such as propranolol, may even potentiate insulin-induced hypoglycemia. Even though this effect is less likely with cardioselective agents, the use of either cardioselective or non-selective beta-blockers in diabetics is not recommended due to their "masking" effect of the normal warning signs and symptoms of hypoglycemia. None of the drugs listed in the other choices will blunt the premonitory signs and symptoms of hypoglycemia.

Captopril (choice A) is an angiotensin-converting enzyme (ACE) inhibitor that can be safely used for the treatment of hypertension in diabetic patients.

Diltiazem (choice B) is a calcium channel blocker that is also considered to be safe and effective for the treatment of hypertension in diabetic patients.

Both methyldopa (choice C), a centrally acting alpha-adrenergic agonist , and prazosin (choice D), an alpha1-adrenergic antagonist, can be safely used to treat hypertension in diabetic patients. However, due to the side effect profile of these medications, they are generally used only in diabetic patients who are unresponsive to ACE inhibitors and calcium channel blockers.

The Correct Answer- A

An incidence rate is found by dividing the number of newly diagnosed cases in a period of time by the number of persons in the population who are at risk of getting the illness. If we assume that the 200 students who had the illness at the outset of the study are not at risk of getting the illness, that leaves 150 new cases among the 1000 remaining students.

The correct Answer- C

One should use adjustment of rates when comparing the rates from two different populations. When the age distributions are known for each of the two populations, direct adjustment of the rates can be used. The other choices do not provide any appropriate means for comparing the two death rate