Bradley P. Kropp, MD

• Professor, Department of Urology,
• The University of Oklahoma Health Sciences Center, College
• of Medicine, Oklahoma University College of Medicine
• Attending Physician, Pediatric Urology,
• The Children? Hospital of Oklahoma,
• Oklahoma University Medical Center, Oklahoma City,
• Oklahoma

Many of the hepatocytes are distended with large fat vacuoles pushing the nuclei to the periphery (macrovesicles) arrhythmia monitoring device buy cheap terazosin 5mg, while others show multiple small vacuoles in the cytoplasm (microvesicles) hypertension risk factors generic 1mg terazosin otc. If the enzyme is present hypertension jnc 7 pdf terazosin 1 mg low price, Conditions associated with excessive accumulation of dark pigment is identified in pigment cells just started blood pressure medication order terazosin american express. In diabetes mellitus arteria coronaria buy terazosin with mastercard, there is intracellular accumulation of amelanotic melanoma from other anaplastic tumours arrhythmia institute discount generic terazosin canada. Glycogen deposits in diabetes mellitus generalised and localised hyperpigmentation and are seen in epithelium of distal portion of proximal convolu hypopigmentation: ted tubule and descending loop of Henle, in the hepatocytes, in beta cells of pancreatic islets, and in cardiac muscle cells. In glycogen storage diseases or glycogenosis, there is defec pigmentation on the skin of face, nipples, and genitalia and tive metabolism of glycogen due to genetic disorders. A similar appear conditions along with other similar genetic disorders are ance may be observed in women taking oral contraceptives. There are 2 broad categories of b) Peutz-Jeghers syndrome is characterised by focal peri-oral pigments: endogenous and exogenous (Table 3. Melanin f) Dermatopathic lymphadenitis is an example of deposition of melanin pigment in macrophages of the lymph nodes Melanin is the brown-black, non-haemoglobin-derived draining skin lesions. It is synthesised in the iii) Generalised hypopigmentation:Albinism is an extreme melanocytes and dendritic cells, both of which are present degree of generalised hypopigmentation in which tyrosinase in the basal cells of the epidermis and is stored in the form of activity of the melanocytes is genetically defective and no cytoplasmic granules in the phagocytic cells called the melanin is formed. Albinos have blond hair, poor vision and melanophores, present in the underlying dermis. However, sometimes tyrosinase is squamous and basal cell cancers of the skin in such present but is not active and hence no melanin pigment is individuals. In such cases, the presence of tyrosinase can be iv) Localised hypopigmentation: a) Leucoderma is a form of partial albinism and is an inherited disorder. Haemoprotein-derived pigments i) Haemosiderin Melanin-like Pigments ii) Acid haematin (Haemozoin) c. Lipofuscin (Wear and tear pigment) required for break-down of homogentisic acid which then B. Injected pigments (Tattooing) alkaptonuria, if allowed to stand for some hours in air, turns black due to oxidation of homogentisic acid. Hepatocytes in patients haemoglobin is liberated which is taken up by macrophages of Dubin-Johnson syndrome, an autosomal recessive form where it is degraded and stored as haemosiderin. A few of hereditary conjugated hyperbilirubinaemia, contain examples are as under: melain-like pigment in the cytoplasm (Chapter 21). The changing colours of a bruise or a black eye are caused by the pigments like biliverdin and bilirubin which are Haemoprotein-derived Pigments formed during transformation of haemoglobin into haemosiderin. Haemoproteins are the most important endogenous Brown induration in the lungs as a result of small haemor pigments derived from haemoglobin, cytochromes and their rhages as occur in mitral stenosis and left ventricular failure. In disordered iron metabolism and transport, Systemic overload with iron may result in generalised haemoprotein-derived pigments accumulate in the body. There can be two types of patterns: these pigments are haemosiderin, acid haematin (haemozoin), bilirubin, and porphyrins. Iron is stored in the tissues in 2 forms: Ferritin, which is iron complexed to apoferritin and can be identified by electron microscopy. Haemosiderin, which is formed by aggregates of ferritin and is identifiable by light microscopy as golden-yellow to brown, granular pigment, especially within the mononuclear phagocytes of the bone marrow, spleen and liver where break-down of senescent red cells takes place. In this reaction, colourless potassium ferrocyanide reacts with ferric ions of haemosiderin to form deep blue ferric-ferrocyanide (Fig. Excessive storage of haemosiderin occurs in situations when there is increased break-down of red cells, or systemic overload of iron due to primary (idiopathic, hereditary) haemochromatosis, and secondary (acquired) causes such as in thalassaemia, sideroblastic anaemia, alcoholic cirrhosis, Figure 3. Another variety of haematin pigment is formalin pigment formed in blood-rich tissues which have been preserved in acidic formalin solution. Excess of bilirubin or hyper bilirubinaemia causes an important clinical condition called jaundice. Normal bilirubin metabolism and pathogenesis of jaundice are described in Chapter 21. Hyperbilirubinaemia may be unconjugated or conjugated, and jaundice may appear in one of the following 3 ways: a) Prehepatic or haemolytic, when there is excessive destruc tion of red cells. Excessive accumulation of bilirubin pigment can be seen Parenchymatous deposition of haemosiderin occurs in the in different tissues and fluids of the body, especially in the parenchymal cells of the liver, pancreas, kidney, and heart. Skin and sclerae Reticuloendothelial deposition occurs in the liver, spleen, become distinctly yellow. Porphyrins are normal pigment present i) Increased erythropoietic activity: In various forms of in haemoglobin, myoglobin and cytochrome. Porphyria chronic haemolytic anaemia, there is excessive break-down refers to an uncommon disorder of inborn abnormality of of haemoglobin and hence iron overload. It results from genetic deficiency of further compounded by treating the condition with blood one of the enzymes required for the synthesis of haem, transfusions (transfusional haemosiderosis) or by parenteral resulting in excessive production of porphyrins. The deposits of iron in these cases, termed as genetic deficiency is precipitated by intake of some drugs. These have defective dominant disease associated with much more deposits of iron synthesis of haem in the red cell precursors in the bone than cases of acquired haemosiderosis. These may be further of 2 subtypes: by triad of pigmentary liver cirrhosis, pancreatic damage Congenital erythropoietic porphyria, in which the urine is resulting in diabetes mellitus, and skin pigmentation. On the basis of the last two features, the disease has come to be red due to the presence of uroporphyrin and coproporphyrin. Bones and iii) Excessive dietary intake of iron: A common example of skin show red brown discolouration. The excess of iron gets deposited in various organs a normal erythroid precursors but have a defect in synthesis including the liver causing pigment cirrhosis. Acid haematin or following: haemozoin is a haemoprotein-derived brown-black pigment Acute intermittent porphyria is characterised by acute containing haem iron in ferric form in acidic medium. But it episodes of 3 patterns: abdominal, neurological, and psycho differs from haemosiderin because it cannot be stained by tic. Haematin pigment is seen most commonly in chronic Porphyria cutanea tarda is the most common of all malaria and in mismatched blood transfusions. Porphyrins collect in the liver and small quantity malarial pigment can also be deposited in macrophages and is excreted in the urine. Most of the patients have associated Inhaled Pigments 43 haemosiderosis with cirrhosis which may eventually develop the lungs of most individuals, especially of those living in into hepatocellular carcinoma. The skin photosensitivity with acute abdominal and neurological most commonly inhaled substances are carbon or coal dust; manifestations. These substances may produce occupational lung diseases called pneumoconiosis Lipofuscin or lipochrome is yellowish-brown intracellular (Chapter 17). The pigment particles after inhalation are taken lipid pigment (lipo = fat, fuscus = brown). It is seen in the myocardial fibres, in the interstitial tissue of the lung and in the respiratory hepatocytes, Leydig cells of the testes and in neurons in senile bronchioles and pass into lymphatics to be deposited in the dementia. In the heart muscle, the change is provoke low grade inflammation, fibrosis and impaired associated with wasting of the muscle and is commonly respiratory function. The pigment Ingested Pigments can be stained by fat stains but differs from other lipids in being fluorescent and having acid-fastness. The examples are as under: By electron microscopy, lipofuscin appears as intralysoso i) Argyria is chronic ingestion of silver compounds and mal electron-dense granules in perinuclear location. These results in brownish pigmentation in the skin, bowel, and granules are composed of lipid-protein complexes. Lipofuscin represents the collection of indigestible material ii) Chronic lead poisoning may produce the characteristic blue in the lysosomes after intracellular lipid peroxidation and is lines on teeth at the gumline. Unlike in normal iii) Melanosis coli results from prolonged ingestion of certain cells, in aging or debilitating diseases the phospholipid end cathartics. The lipofuscin pigment granules are seen in the cytoplasm of the myocardial fibres, especially around the nuclei. There is presence of abundant coarse black carbon pigment in the septal walls and around the bronchiole. The examples of injected pigments are prolonged use of ointments containing mercury, dirt left accidentally in a wound, and tattooing by pricking the skin with dyes. Autolysis can occur in the living body when it is surrounded by inflammatory reaction (vital reaction), but the term is generally used for postmortem change in which there is complete absence of surrounding inflammatory response. Autolysis is rapid in some tissues rich in hydrolytic enzymes such as in the pancreas, and gastric mucosa; intermediate in tissues like the heart, liver and kidney; and slow in fibrous tissue. Morphologically, autolysis is identified by homogeneous and eosinophilic cytoplasm with loss of cellular details and remains of cell as debris. Necrosis can be caused by various agents such as hypoxia, chemical and physical agents, microbial agents, immunological injury, etc. A, Cell necrosis is identified irreversible cell injury in necrosis of all types (Fig. Morphologically this condensation of nuclear chromatin and fragmentation of the cell into change is identified as homogeneous and intensely membrane-bound apoptotic bodies which are engulfed by macrophages. The common examples are infarct brain 45 cytoplasmic vacuolation or dystrophic calcification. This process is morphologically Grossly, the affected area is soft with liquefied centre seen as characteristic nuclear changes in necrotic cell. Morphologically, there are five types of necrosis: coagulative, liquefaction (colliquative), caseous, fat, and fibrinoid necrosis. This appearance is partly attributed to the histotoxic effects of lipopolysaccharides present in the capsule of the Grossly, foci of coagulative necrosis in the early stage are tubercle bacilli, Mycobacterium tuberculosis. With progression, they Microscopically, the necrosed foci are structureless, become more yellowish, softer, and shrunken. Eventually, occurring at two anatomically different locations but the necrosed focus is infiltrated by inflammatory cells and morphologically similar lesions. These are: following acute the dead cells are phagocytosed leaving granular debris pancreatic necrosis, and traumatic fat necrosis commonly in and fragments of cells (Fig. Lique lipases from injured or inflamed tissue that results in necrosis faction or colliquative necrosis occurs commonly due to of the pancreas as well as of the fat depots throughout the ischaemic injury and bacterial or fungal infections. It occurs peritoneal cavity, and sometimes, even affecting the extra due to degradation of tissue by the action of powerful abdominal adipose tissue. The affected area on right shows cells with intensely eosinophilic cytoplasm of tubular cells but the outlines of tubules are still maintained. The interface between viable and non-viable area shows non specific chronic inflammation and proliferating vessels. The necrosed area on right side of the field shows a cystic space containing cell debris, while the surrounding zone shows granulation tissue and gliosis. Fat necrosis hydrolyses neutral fat present in adipose cells has the staining properties of fibrin. The leaked out free fatty acids immune complex vasculitis, autoimmune diseases, complex with calcium to form calcium soaps (saponification) Arthus reaction etc), arterioles in hypertension, peptic discussed later under dystrophic calcification. Grossly, fat necrosis appears as yellowish-white and firm Microscopically, fibrinoid necrosis is identified by deposits. Formation of calcium soaps imparts the necrosed brightly eosinophilic, hyaline-like deposition in the vessel foci firmer and chalky white appearance. Necrotic focus is surrounded by nuclear debris of Microscopically, the necrosed fat cells have cloudy neutrophils (leucocytoclasis) (Fig. Local haemor appearance and are surrounded by an inflammatory rhage may occur due to rupture of the blood vessel. There is eosinophilic, amorphous, granular material, while the periphery shows granulomatous inflammation. The vessel appearance of adipocytes, coarse basophilic granular debris while the wall shows brightly pink amorphous material and nuclear fragments of periphery shows a few mixed inflammatory cells. Involvement of single cells or small clusters of cells in responsible for mediating cell death in a wide variety of the background of viable cells. The apoptotic cells are round to oval shrunken masses Physiologic Processes: of intensely eosinophilic cytoplasm (mummified cell) 1. Organised cell destruction in sculpting of tissues during containing shrunken or almost-normal organelles development of embryo. Normal cell destruction followed by replacement proliferation such as in intestinal epithelium. Cell death by cytotoxic T cells in immune mechanisms such as in graft-versus-host disease and rejection reactions. The nuclear chromatin is condensed or fragmented on the outer surface of apoptotic cell facilitates early (pyknosis or karyorrehexis). The cell membrane may show convolutions or projections appearance of inflammatory cells. Triggers for signalling program or loosely floating apoptotic cells after losing contact, with med cell death act at the cell membrane, either intra each other and basement membrane as single cells, or may cellularly or extracellularly. These include the following: result in major cell loss in the tissue without significant i) Withdrawal of signals required for normal cell survival change in the overall tissue structure.

The key anatomical substrates blood pressure medication with water pill discount 2mg terazosin fast delivery, damage to which causes the syndrome blood pressure pulse 90 5mg terazosin sale, are probably the intersti tial nucleus of Cajal and the nucleus of the posterior commissure and their projections hypertension kidney and dialysis specialists terazosin 1 mg discount. The incidence of parkinsonism increases dramatically with age; it is also associated with an increased risk of death blood pressure medication how it works purchase terazosin 2mg mastercard, particularly in the presence of a gait disturbance radial pulse blood pressure 90 buy terazosin paypal. Prevalence of parkinsonian signs and associated mortality in a community population of older people arrhythmia consultants of connecticut cheap terazosin 5mg free shipping. Cross References Apraxia; Blinking; Bradykinesia; Dysarthria; Dystonia; Hypokinesia; Hypomimia; Hypophonia; Mask-like facies; Micrographia; Orthostatic hypotension; Postural re exes; Rigidity; Seborrhoea; Sialorrhoea; Striatal toe; Supranuclear gaze palsy; Tremor Parosmia Parosmia is a false smell, i. Such smells are usually unpleasant (cacosmia), may be associated with a disagreeable taste (cacogeusia), and may be dif cult for the patient to de ne. Causes include purulent nasal infections or sinusitis and partial recovery following transection of olfactory nerve bres after head injury. Transient parosmia may presage epileptic seizures of temporal lobe corti cal origin (olfactory aura), particularly involving the medial (uncal) region. The clinical heterogeneity of hemifacial atrophy probably re ects patho genetic heterogeneity. The syndrome may result from maldevelopment of auto nomic innervation or vascular supply, or as an acquired feature following trauma, or a consequence of linear scleroderma (morphoea), in which case a coup de sabre may be seen. There may be a sense that the patient is strug gling against these displays of emotion, in contrast to the situation in other forms of emotional lability where there is said to be congruence of mood and affect, although sudden uctuations and exaggerated emotional expression are common to both, suggesting a degree of overlap. Pathological laughter and crying following stroke: validation of a measurement scale and a double-blind treatment study. Cross References Automatism; Emotionalism, Emotional lability; Pseudobulbar palsy Peduncular Hallucinosis Peduncular hallucinosis is a rare syndrome characterized by hallucinations and brainstem symptoms. Brainstem nd ings include oculomotor disturbances, dysarthria, ataxia, and impaired arousal. Peliopsia, Pelopsia Peliopsia or pelopsia is a form of metamorphopsia characterized by the misper ception of objects as closer to the observer than they really are (cf. Cross References Metamorphopsia; Porropsia Pelvic Thrusting Pelvic thrusting may be a feature of epileptic seizures of frontal lobe origin; occa sionally it may occur in temporal lobe seizures. Choreiform disorders may involve the pelvic region causing thrusting or rocking movements. Cross References Automatism; Chorea, Choreoathetosis; Seizure Pendular Nystagmus Pendular or undulatory nystagmus is characterized by eye movements which are more or less equal in amplitude and velocity (sinusoidal oscillations) about a central (null) point. In acquired causes such as multiple sclerosis, this may pro duce oscillopsia and blurred vision. Cross References Nystagmus; Oscillopsia Percussion Myotonia Percussion myotonia is the myotonic response of a muscle to a mechanical stim ulus. For example, a blow to the thenar eminence may produce involuntary and sustained exion of the thumb. This 273 P Periodic Alternating Nystagmus response, which may be seen in myotonic dystrophy, re ects the impaired muscle relaxation which characterizes myotonia. Cross Reference Myotonia Periodic Alternating Nystagmus Periodic alternating nystagmus is a horizontal jerk nystagmus, which damps or stops for a few seconds and then reverses direction. Periodic alternating nystagmus may be congenital or acquired, if the latter then its localizing value is similar to that of downbeat nystagmus (with which it may coexist), especially for lesions at the cervico-medullary junction. Treatment of the associated lesion may be undertaken, otherwise periodic alternating nystagmus usually responds to baclofen, hence the importance of correctly identifying this particular form of nystagmus. Periodic respiration may be observed in unconscious patients with lesions of the deep cerebral hemispheres, diencephalon, or upper pons, or with central or tonsillar brain herniation; it has also been reported in multiple system atro phy. Cross References Coma Perseveration Perseveration refers to any continuation or recurrence of activity without appro priate stimulus (cf. Cross References Aphasia; Dysexecutive syndrome; Frontal lobe syndromes; Intrusion; Logoclonia; Palinopsia Personi cation of Paralyzed Limbs Critchley drew attention to the tendency observed in some hemiplegic patients to give their paralyzed limbs a name or nickname and to invest them with a per sonality or identity of their own. This sometimes follows a period of anosognosia and may coexist with a degree of anosodiaphoria; it is much more commonly seen with left hemiplegia. A similar phenomenon may occur with amputated limbs, and it has been reported in a functional limb weakness. Cross References Anosodiaphoria; Anosognosia Pes Cavus Pes cavus is a high-arched foot due to equinus (plantar exion) deformity of the rst ray, with secondary changes in the other rays. Surgical treatment of pes cavus may be necessary, espe cially if there are secondary deformities causing pain, skin breakdown, or gait problems. Patients may volunteer that they experience such symptoms when carrying heavy items such as shopping bags which puts the hand in a similar posture. These are signs of compression of the median nerve at the wrist (carpal tunnel syndrome). The term was coined by Weir Mitchell in the nineteenth century, but parts other than limbs (either congenitally absent or following amputation) may be affected by phantom phenomena, such as lips, tongue, nose, eye, penis, breast and nipple, teeth, and viscera. Phantom phenomena are perceived as real by the patient, may be subject to a wide range of sensations (pressure, tem perature, tickle, pain), and are perceived as an integral part of the self. Reorganization of cortical connections follow ing amputation may explain phantom phenomena such as representation of a hand on the chest or face, for which there is also evidence from functional brain imaging. Phantom Vision this name has been given to visual hallucinations following eye enucleation, by analogy with somaesthetic sensation experienced in a phantom limb after amputation. Similar phenomena may occur after acute visual loss and may over lap with phantom chromatopsia. Unformed or simple hallucinations are more common than formed or complex hallucinations. Phonagnosia is the equivalent in the auditory domain of prosopagnosia in the visual domain. Cross References Agnosia; Auditory agnosia; Prosopagnosia; Pure word deafness Phonemic Disintegration Phonemic disintegration refers to an impaired ability to organize phonemes, the smallest units in which spoken language may be sequentially described, resulting 277 P Phonetic Disintegration in substitutions, deletions, and misorderings of phonemes. Cross Reference Hyperacusis Phosphene Phosphenes are percepts in one modality induced by an inappropriate stimu lus. Noise-induced visual phosphenes have also been reported and may be equivalent to auditory-visual synaesthesia. Cross References Dazzle; Meningism; Retinitis pigmentosa Photopsia Photopsias are simple visual hallucinations consisting of ashes of light which often occur with a visual eld defect. They suggest dysfunction in the inferome dial occipital lobe, such as migraine or an epileptogenic lesion. Cross References Aura; Hallucination; Photism Physical Duality A rare somaesthetic metamorphopsia occurring as a migraine aura in which individuals feel as though they have two bodies. The rst response of the hallux is the critical observation, which may be facilitated by having ones line of vision directly above the axis of the toe. This normal plantar response is a super cial cutaneous re ex, analo gous to abdominal and cremasteric re exes, whereas the pathological response is often accompanied by activity in other exor muscles. Assessment of the response may be confounded by withdrawal of the foot in ticklish individuals. Differentiation from the striatal toe seen in parkinsonian syndromes is also important. The plantar response may be elicited in a variety of other ways which are not in routine clinical use. These may be helpful in ticklish patients who object to having their feet stroked. It is often dif cult to form a de nite judgment on the plantar response and reproducibility is also questionable. There remains a persistent belief, particularly amongst trainees, that an experienced neurologist can make the plantar response go which ever way s/he chooses. Cross Reference Dystonia Plexopathy Lesions con ned to the brachial, lumbar, or sacral plexi may produce a constella tion of motor and sensory signs (weakness, re ex diminution or loss, sensory loss) which cannot be ascribed to single or multiple roots (radiculopathy) or periph eral nerves (neuropathy). Polyopia may occur as part of the visual aura of migraine and has also been associated with occipital and occipito-parietal lesions, bilateral or con ned to the non-dominant hemisphere, and with drug abuse. It has also been described in disease of the retina and optic nerve and occasionally in normal individuals. The pathophysiology is unknown; suggestions include a defect of visual xation or of visual integration; the latter may re ect pure occipital cortical dysfunction. Cross Reference Winging of the scapula Poriomania A name sometimes given to prolonged wandering as an epileptic automatism, or a fugue state of non-convulsive status epilepticus. Cross References Automatism; Seizures Porropsia Porropsia, or teliopsia, is a form of metamorphopsia characterized by the mis perception of objects as farther away from the observer than they really are (cf. Postural and righting re exes depend not only on the integration of labyrinthine, proprioceptive, exteroceptive, and visual stimuli, mostly in the brainstem but also involve the cerebral cortex. However, abnormalities in these re exes are of relatively little diagnostic value except in infants.

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Cushing disease and excess growth hormone will result in elevated blood glucose levels and diabetes (not decreased glucose values) hypertension with pregnancy purchase 5 mg terazosin visa. Red cells are not involved arteria ovarica cheap 2mg terazosin with mastercard, and involvement of the thyroid blood pressure medication kidney 1 mg terazosin with amex, liver arteria facial cheap terazosin 5mg on line, and pancreas is usually asymptomatic blood pressure ranges hypotension order 2mg terazosin fast delivery. It is the first counterregulatory hormone to respond to hypoglycemia arteria arcuata safe terazosin 1mg, and it does this by increasing glycogenolysis and gluconeogenesis. In mild cases, dietary therapy may suffice, but the vast majority of patients require drug therapy. Statins are clearly the most effective medications available, but the majority of patients will not have optimal cholesterol control, even with maximum doses of a statin. Polyendocrine adenomatosis, type I, frequently includes islet cell tumors of the pancreas, leading to the Zollinger-Ellison syndrome, insulinomas, and glucagonomas. Estrogens cause thickening of vaginal mucosa and can improve urogenital and post-menopausal symptoms. Initially, strength may be increased, but this is transient, and a third of patients will experience weakness, likely secondary to myopathy. Muscle spasm and rhythmic contraction (fasciculation) are not clinical features of growth hormone excess. Vitamin D-resistant rickets is a familial disorder, with an X-linked recessive pattern, treated with pharmacologic doses of vitamin D. Risk of death in anorexia nervosa is also associated with hypothermia, suicide, or pneumonia with emaciation. In addition, severe weight loss can lead to both systolic and diastolic dysfunction of the ventricles. Diabetes is not a feature of eating disorders and acute kidney injury can sometimes develop in severe volume depletion states, but not typically seen. More commonly impaired uric acid excretion is an important risk factor for developing gout in patients with chronic kidney disease. The association of cardiovascular disease, hypertension, pyelonephritis, and hyperlipoproteinemia with gout contributes to the high prevalence of renal disease in these individuals. In severe osteomalacia, there is bowing of the long bones, inward deformity of the long bones, and wide osteoid borders on bone surfaces. Hypocalcemia is characteristic of osteomalacia; however, secondary hyper-parathyroidism often raises the serum calcium to low normal levels. Although it can develop gradually, acute renal failure can also be precipitated by hemodynamic stresses (bleeding, diuresis). The earliest manifestations are intrarenal vasoconstriction and avid sodium retention. Potassium retention is not a feature of the hepatorenal syndrome and oligoria occurs, not polyuria. In some cases, it is possible to identify carrier states and make prenatal diagnoses. The relationship between the abnormal gene and the metabolic defect (inability to regulate copper balance) is unclear. Other stimulators of protein kinases include platelet-derived growth factor and epidermal growth factor. Insulin-resistant states can be caused by prereceptor resistance (mutated insulin, anti-insulin antibodies) or receptor and postreceptor resistance. The action of insulin involves all three major metabolic fuels (carbohydrate, protein, fat). Radioactive iodine treatment or abrupt withdrawal of antithyroid medications is also implicated. The key diagnostic features are fever, tachycardia, and central nervous system dysfunction. In these individuals, bone age often correlates better with the onset and progression of puberty than does chronologic age. Approximately, one-third of unselected women with metastatic breast cancer will respond to tamoxifen. Androgen receptors on the tumor cells and premenopausal status do not affect response to tamoxifen therapy. A history of maternal breast cancer is also a risk factor for developing breast cancer. Calcium deposits are seen in the periarticular areas of the fourth and fifth metacar pophalangeal, third proximal interphalangeal, and fourth distal interphalangeal joints. There is slight soft tissue swelling, especially of the fourth and fifth metacarpophalangeal joints. In Cushing syndrome, secondary to an autonomous adrenal tumor, onset is usually gradual, and hirsutism, other androgenic effects, and hyperpigmentation are absent. The classic presenting symptoms are increased thirst, polyuria, polyphagia, and weight loss. In type 2 diabetes, the presentation can be more subtle and is often made when the patient is asymptomatic. Hypothyroidism can cause some of the symptoms experienced by this patient but not the weight loss, frequent yeast infections, or nocturia. Perineal pruritus in a diabetic is almost always associated with Candida albicans. It is caused by Pseudomonas aeruginosa and is characterized by ear pain, drainage, fever, and leukocytosis. Microaneurysms, dilated veins, dot and blot hemorrhages, cotton-wool spots, and hard exudates are common findings. Loss of desire can also be caused by psychologic disturbance, but may indicate androgen deficiency or drug effect. The lesions can be in large vessels (aortic occlusion, Leriche syndrome), small arteries, or even in the sinusoidal spaces. It is diagnosed by demonstrating minimal elevation of androgens and exclusion of other causes. Management is primarily by cosmetic therapy, although drugs to suppress androgen production and/or androgen effects on the hair follicle can be used. The spectrum of disease, however, is quite wide, and some patients have only mild hirsutism. When onset of hair growth (with or without frank virilization) is very rapid, a neoplastic source of androgen is suggested. In addition to ovarian tumors, the potential neoplasms include adenomas and carcinomas of the adrenal gland. Elevated levels of a precursor of cortisol biosynthesis such as 17 hydroxyprogesterone, 17-hydroxypregnenolone, or 11-deoxycortisol can present. Poor metabolic control is probably a major factor in the progression of diabetic nephropathy. Similar diets are often prescribed for diverticulitis or other conditions associated with a narrowed or stenosed colon. When acute symptoms subside, however, restrictions concerning dietary fiber should be stopped. Most patients should be referred to a dietician to help construct a diet appropriate in caloric intake. Early dumping occurs within 30 minutes of eating and is characterized by vasomotor symptoms such as palpitations, tachycardia, lightheadedness, and diaphoresis. Late dumping includes similar symptoms plus dizziness, confusion, and even syncope. It is presumed that this results in lower levels of serum ammonia, but other substances in the serum may be implicated. Chronic encephalopathy can be controlled with restricting protein intake and taking lactulose (osmotic laxative). Restricting daytime protein intake in patients with Parkinson disease may improve the efficacy of levodopa therapy. The peak incidence in the United States is in poor and elderly people and alcoholics. It is common in children in developing countries and is a major cause of blindness. Asthma may be aggravated, acanthosis nigricans can occur, and in high doses, elevation of uric acid and fasting blood sugar can occur. Hepatic toxicity, including cholestatic jaundice, has been described with large doses. In North America, thiamine deficiency occurs in alcoholics or those with chronic disease. In alcoholics, deficiency is secondary to low intake, impaired absorption and storage, and accelerated destruction. Genetic factors are important as clinical manifestations occur only in a small proportion of chronically malnourished individuals. The diagnosis is based on clinical suspicion and response to therapy, and can be confirmed by demonstrating low levels of the urinary metabolites 2-methylnicotinamide and 2-pyridone. Small doses of niacin (10 mg/day) with adequate dietary tryptophan will cure pellagra secondary to nutritional deficiency. Questions 1 through 6: For each patient with a small bowel tumor, select the most likely diagnosis. A small bowel x-ray reveals an area of narrowing and the lesion is surgically resected. His colonoscopy is negative for any obvious sources of bleeding, but upper endoscopy reveals ulceration in the distal duodenum that is biopsied. The pathology report shows this to be the most common primary malignancy of the small bowel. A 23-year-old man of Middle-Eastern decent is investigated for symptoms of chronic diarrhea, vomiting, and abdominal cramps. This form of small bowel tumor can be treated with antibiotics in its early stages. A 21-year-old woman develops acute perium-bilical pain that localizes to the right lower quadrant. She appears unwell, and on examination, there is tenderness and guarding in the right lower quadrant. A pregnancy test is negative and a pelvic examination rules out pelvic inflammatory disease. A clinical diagnosis of acute appendicitis is made and she has an uncomplicated laparoscopic appendectomy. The pathology report notes acute inflammation and a tumor for which the appendix is a very common site of involvement. A 57-year-old woman with a 20-year history of celiac disease now presents with weight loss, cramps, and abdominal discomfort. On examination, her abdomen is soft and there is fullness in the right lower quadrant. A small bowel x-ray reveals an area of narrowing in the distal ileum, and there is thickening and nodularity of the mucosal folds. A 48-year-old man presents with periumbilical pain made worse by eating and weight loss. The differen tial diagnosis includes tumors that most commonly involve the distal part of the small bowel. A 19-year-old man has a long history of weight loss, abdominal distention, bloating, and diarrhea. Investigation reveals steatorrhea, and a small bowel biopsy reveals blunting and flattening of villi. She has had ulcers at multiple sites of the small bowel including the distal duodenum and jejunum. She also has chronic diarrhea, but not enough fat to make the diagnosis of steatorrhea. She reports no weight loss, but does notice occasional bright red bleeding with bowel movements. Her family history is negative for colon cancer and she has never had screening colonoscopy. She is referred for colonoscopy and the only abnormal finding is multiple diverticuli. A 77-year-old woman is brought to the emergency room because of symptoms of nonspecific abdominal discomfort. On physical examination, the vital signs are normal, the abdomen is soft and nontender with no masses or organomegaly palpated. Abdominal x-rays show lots of stool in the colon, but no free air or air fluid levels. Which of the following conditions can cause a false-positive elevation in the serum amylase A 71-year-old man presents to the clinic for evaluation of progressive weight loss and dysphagia over a 3-month period. The symptoms of dysphagia are getting worse and seem to be more pronounced with solid foods than liquids. His past medical history includes coronary artery disease, hypertension, and dyslipidemia.

Using Peer-Learning to Create a Case Archive of Common Diagnostic Errors Monday arteriogram discount terazosin uk, Nov blood pressure problems effective terazosin 1 mg. Radiologists frequently encounter cases in their daily workflow that present opportunities for learning hypertension of chronic kidney disease is medicated with purchase terazosin 1 mg with amex, feedback blood pressure chart according to age and weight 2 mg terazosin otc, and improvement which could benefit not just the original interpreting radiologist but others at the same institution prehypertension blood pressure treatment buy discount terazosin 5mg on line. Recognizing the need to provide the best possible service to our patients and to promote a culture of continuous learning within our department arteria descendente anterior discount terazosin, our quality committee worked to identify these cases and improve peer learning opportunities for our radiologists. Radiology departments are increasingly transitioning from peer review systems to environments that promote peer learning. We discuss the implementation of a successful case archive methodology that is well received by participants and has potential to benefit all individuals in the department. Radiologists identify eligible cases during daily reading, multi-disciplinary patient conference participation, requests from referring clinical services, and other available avenues. Submitted cases are categorized by our quality committee on the basis of subspecialty, anatomy, and type of pathology. The archive is used by section heads to review areas of education need in the department and for potential inclusion at monthly peer learning conferences. A searchable version available to all radiologists is undergoing user testing by interested individuals. The conferences are advertised to division members, radiology residents, and visiting trainees in graduate and undergraduate medical education as well as technologists. The 5 most common topics by frequency were fracture 44 (17%), missed diagnosis 32 (12%), missed priors 18 (7%), lesion/mass (7%), and infarct 10 (4%). The greatest volume of cases identified in abdominal imaging 66 (25%), cardiothoracic imaging 63 (24%), and neuroradiology 53 (20%). The system provides learning opportunities to all of our radiologists and should help to monitor future trends in department and division performance. Univariate and multivariate analyses were performed to reveal the potential risk factors of radionecrosis, including dosimetric data, clinicopathologic characteristics of patients, prior whole brain irradiation and the delivery of chemotherapy and/or targeted therapy. After a median radiologic follow-up of 8 months, the two-year cumulative incidences of radiologic and symptomatic radionecrosis were 20. Patients were at higher risk of radiologic radionecrosis if the ratio of in-field maximum point dose (Dmax) to prescribed dose exceeded 1. Peripheral blood samples were collected pre-radiotherapy and weekly during radiotherapy. All patients had squamous cell carcinomas and all received concurrent chemotherapy. Three patients had oropharyngeal, 2 had laryngeal and 1 with nasopharyngeal tumors. Review of anatomical relationship of the ligamentum teres and obliterated umbilical arteries B. The aim of this study is to report the impact of percutaneous image-guided bone biopsy on antibiotic therapy and the rate of amputations. A total of 98 patients underwent bone biopsy, and 87 patients were included in the study. Procedure indication, pre-procedure imaging, bone specimen pathology and culture results, antibiotic therapy prior to biopsy and changes in the antibiotic regimen after biopsy were recorded. Patients with radiographic evidence of osteomyelitis were more likely to have positive biopsy culture (p<0. Prior antibiotic therapy was not associated with positive bone biopsy culture results. Positive bone biopsy cultures were associated with a change in the antibiotic regimen. Positive bone biopsy cultures were associated with changes to the antibiotic regimen. Positive cultures did not have a significant impact on the rate of future amputation. In 6 patients, not reaching the hemodynamic target the stent was dilated to 10 mm of diameter during the same session. Overall clinical success was achieved in 66/75 (88%) patients (82% in refractory ascites, 95% variceal bleeding, 100% other). Patient characteristics, imaging and pathology results, and follow up clinic notes were reviewed. Technical success was defined as the ability to perform an aspiration, collect samples for biopsy, or place a drain. Clinical success was defined as a diagnostic pathology sample from a biopsy or resolution of symptoms related to the indication for aspiration/drain without the need for additional interventions. The most common presenting pelvic pathologies for aspiration/drain placement were tubo-ovarian abscess and pyosalpinx whereas a pelvic mass in the setting of history of current or prior malignancy was the primary indication for biopsy. Of the 28 patients, 13 underwent biopsies, 14 underwent aspirations, and one patient underwent drain placement. Of the biopsies, 12/13 (92%) were technically successful and all were diagnostic on pathology. Of these 14 patients, two required additional drain placement due to re-accumulation of fluid and one underwent surgical management. The remaining one patient underwent successful drain placement that was removed 12 days later without need for additional intervention. This study suggests that anxiety management is important to radiologists and the most preferred practices to reduce pre-procedural anxiety include patient education, anxiolytic medications, and empathetic care. Characteristical imaging parameters like contrast-media amount, number of needed series (projections), dose-area-product in total and overall fluoroscopy time were analyzed and compared. For statistical evaluation the median values were calculated and compared with student s 2-sided t-test. Increased likelihood of treatment via interventional oncology was observed for younger male patients, those with Medicare or private insurance, higher income and education, lower comorbidities and cancer stage, and patients treated at academic centers compared to other treatment approaches (p<0. A significant interaction term between treatment year and approach was evident (p<0. Interventional oncology demonstrated superior overall survival compared to other non-surgical treatment options. Healthcare access and utilization must be targeted to address outcome discrepancies, potentially providing interventional oncology to a broader patient population. Background the wide application of diagnostic imaging methods in recent years has lead to an increasing number of incidental tumors, including kidney tumors. These lesions are often presented as early-stage localized renal malignancies, which has possibly contributed to the reduced mortality and morbidity of renal cancer as a whole due to its early detection. In addition, while the standard care for these patients is excision, nephron sparing surgery has emerged as an oncologically equivalent alternative to radical nephrectomy in most cases of localized renal cell carcinoma, reducing the negative sequelae of traditional surgical interventions, such as chronic kidney disease. Evaluation this retrospective study was approved by our institutional review board, and written informed consent was waived. A total of 73 anonymized abdominal computed tomography studies were selected based on the hospital records. Kidney images were cropped from these studies in axial, coronal and sagittal axis, yielding 951 normal kidney images and 888 solid renal tumor images. This dataset was randomized in the patient level into training (65%), validation (15%) and test (20%) subsets. Discussion In the present study, our model achieved up to 79% accuracy for differentiating normal kidneys from solid renal tumors, with a precision of 91. Using machine learning with large predictor sets significantly improved the prediction quality. Our approach can be easily replicated at other facilities to provide patients with the most accurate wait time information. Background Radiology patients can be frustrated by the seemingly opaque experience of waiting for their exams as daily wait time patterns can change significantly. Previously, to address this problem at Massachusetts General Hospital, a simple 3-predictor linear regression model was made to display estimated patient wait times. After training each, the model with the least error is chosen to predict wait times. To display real time predictions, models are stored in the database with expiration dates. The expired models are retrained, enabling capture of any changes in patient workflow. Thus, the algorithm was optimized to automatically choose which model to use and when to retrain, completely unsupervised. Additionally, our algorithm provides an interactive display of recent prediction history, where less accurate predictions can be investigated. We develop a universal lesion detector that covers all kinds of lesions in one framework. It includes a variety of lesions such as lung nodules, liver tumors, adenopathy, bone lesions, etc. The central slice contains the ground-truth bounding-box and the other slices provide the 3D context. We combine this fused feature map and the lesion proposals generated by a region proposal network to obtain the final detection results. Smaller lesions and bone lesions benefit more from 3D information (5% and 8% improvement). The universal lesion detector can help radiologists find all types of lesions, which is more useful than single-purpose detectors in practice. Fracture morphology heterogeneity in the setting of skeletal immaturity with variable appearances of physes and apophyses are a challenge for automatic classification. Fracture locations were recorded in image coordinates for further dataset generation. Patches were automatically generated in a random fashion along the calculated centerline of the long bone. Training set including 256000 patches with fractures and the same number showing normal bone. Transfer learning networks Xception and DenseNet (126 and 201 layers respectively) resulted in 71. The majority of the false negative exams included indistinct fracture lines or were one of the fracture types not well represented in the training set. The false positive exams were all not well represented in the training set and constituted fractures near a joint line of the lower extremity. The automated patch approach eliminated image scaling, and allowed localization of the classified fracture within a relatively narrow spatial domain. We expect that with the larger representation of each fracture type accuracy will improve. The Delphi technique is a methodologically approved consensus driven process used to synthesize and validate expert opinion when evidence is not available. Machado, Botucatu, Brazil (Abstract Co-Author) Nothing to Disclose Ana Carolina D. To demonstrate an association between the molecular subtype and ultrasound images. To discuss some cases that we chose to do the biopsy in more than one location because ultrasound characteristics showed different patterns in the same patient and the histopathology confirmed different results. Show cases that we chose to do the biopsy in more than one location because the image characteristics showed different patterns in the same patient. To discuss about possibility of choosing biopsy in two different locations and whether these radiological changes showed different histopathological characteristics in our cases. Case based review of diseases (A) Diffuse breast enlargement Infection Mastitis Hormonal disturbance Gynecomastia Other cause Edema caused by extramammary origin Edema caused by mammary procedure (B) Neoplasm Benign Hamartoma Fibroadenoma Giant juvenile fibroadenoma Fibrocystic disease Benign phyllodes tumor Malignant Invasive ductal cancer Inflammatory breast cancer Malignant phyllodes tumor (C) Extrammamary location of mass: Chest wall Lipoma Malignant fibrous histiocytoma 4. Ultrasound is the most commonly used modality for axillary evaluation given its wide availability. Current debate questions whether there is a benefit to diagnosing metastasis with ultrasound-guided needle biopsy as this may lead to more axillary node dissections in an era of its decreasing role. Eaverage values were significantly higher in breast cancers with positive lymph node, negative hormone receptor, high Ki67, and high grade (P<0. Eaverage values were different according to molecular subtypes of breast cancer (P=0. Eaverage values were significantly higher in triple negative cancers than those in luminal A cancers (P=0. For qualitative data, two breast radiologists independently interpreted and decided the findings by consensus reading. Each binary group of quantitative data was designated by a cutoff value decided by receiver-operating characteristic analysis. Logistic regression was used to evaluate associations between factors and plaintiff award. Named defendants were radiologists (43%), surgeons (27%), obstetrician/gynecologists (26%), and internal medicine/family practice (15%). Age, defendant type, and cancer stage were not significant predictors of case outcome. Breast cancer-related suits involve physicians from multiple specialties, radiology being the most common. Delay in diagnosis, lack of surgeon referral, and lack of recommended follow-up are related to plaintiff payments and may be areas of professional practice to target to prevent over and misuse of the medical malpractice system. A better understanding of factors and trends in malpractice litigation can lead to medical malpractice system improvement. Davies, Manchester, United Kingdom (Abstract Co-Author) Nothing to Disclose Josh W.

References

• Ledezma CJ, Hoh BL, Carter BS, et al. Complications of cerebral arteriovenous malformation embolization: multivariate analysis of predictive factors. Neurosurgery. 2006;58(4):602-611; discussion 602-611.
• Brookes MJ, Bourke AG (2008). Radiological appearances of papillary breast lesions. Clin Radiol 63: 1265-1273.
• Bushby K, Anderson LV, Pollitt C, Naom I, Muntoni F, Bindoff L. Abnormal merosin in adults. A new form of late onset muscular dystrophy not linked to chromosome 6 q2.
• Tincello DG, Kenyon S, Abrams KR, et al: Botulinum toxin A versus placebo for refractory detrusor overactivity in women: a randomised blinded placebocontrolled trial of 240 women (the RELAX study), Eur Urol 62(3):507n514, 2012.