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Intra-aortic balloon pump (IABP) Key Concept/Objective: To understand that sudden cardiac death contributes significantly to the mortality of patients with heart failure The management of heart failure has evolved from primarily noninvasive medical thera- pies to include invasive medical devices buy diarex 30caps amex gastritis diet 6 days. In addition to contributing to worsening heart failure purchase diarex 30caps atrophic gastritis symptoms treatment, ventricular arrhythmias are a likely direct cause of death in many of these patients; the rate of sudden cardiac death in persons with heart failure is six to nine times that seen in the general population. The use of ICDs for the primary prevention of sudden death in patients with left ventricular dysfunction has grown enormously in recent years. There is increasing evidence that ICD placement reduces mortality in patients with ischemic car- diomyopathy, regardless of whether they have nonsustained ventricular arrhythmias. The role of these devices in patients with heart failure of a nonischemic cause has yet to be elu- cidated and is the subject of several ongoing trials. Biventricular pacing improves progno- sis in patients with severe CHF but has no role in the management of lethal arrhythmias. Both IABP and VAD are mechanical devices utilized as a bridge to cardiac transplantation for patients with very severe CHF. A 38-year-old man with stage C CHF remains symptomatic in spite of diuretic therapy. You are consid- ering adding a second and perhaps even a third agent to his regimen. Which of the following pharmacologic agents used in the management of heart failure lacks trial data indicating a mortality benefit and does not prevent maladaptive ventricular remodeling? ACE inhibitors or angiotensin receptor blockers (ARBs) ❏ B. Digoxin 1 CARDIOVASCULAR MEDICINE 3 Key Concept/Objective: To be aware of proven pharmacologic therapy aimed at counterbalancing the activation of the renin-angiotensin and sympathetic systems Left ventricular dysfunction begins with an injury to the myocardium. The unanswered question is why ventricular systolic dysfunction continues to worsen in the absence of recurrent insults. This pathologic process, which has been termed remodeling, is the struc- tural response to the initial injury. Mechanical, neurohormonal, and possibly genetic fac- tors alter ventricular size, shape, and function to decrease wall stress and compensate for the initial injury. Remodeling involves hypertrophy, loss of myocytes, and increased fibro- sis, and it is secondary to both neurohormonal activation and other mechanical factors. In patients with heart failure, ACE inhibitors have been shown to improve survival and car- diac performance, to decrease symptoms and hospitalizations, and to decrease or slow the remodeling process. ARBs block the effects of angiotensin II at the angiotensin II type 1 receptor site. ACC/AHA guidelines recommend the use of ARBs only in patients who can- not tolerate ACE inhibitors because of cough or angioedema; the guidelines stress that ARBs are comparable to ACE inhibitors but are not superior. Since publication of the guide- lines, however, several key trials have reported successful intervention with ARBs in patients in stage A and stage B. The primary action of beta blockers is to counteract the harmful effects of the increased sympathetic nervous system activity in heart failure. Beta blockers improve survival, ejection fraction, and quality of life; they also decrease mor- bidity, hospitalizations, sudden death, and the maladaptive effects of remodeling. Aldosterone also works locally within the myocardium, contributing to hypertrophy and fibrosis in the failing heart. A large randomized trial has shown that the addition of low- dose spironolactone (25 mg daily) to standard treatment reduces morbidity and mortality in patients with NYHA class III and IV heart failure (stage C and D patients). A large ran- domized study demonstrated that digoxin was successful in decreasing hospitalization for heart failure—an important clinical end point—but did not decrease mortality. It has no role in preventing maladaptive ventricular remodeling. A 60-year-old woman with a history of hypertension and mild chronic obstructive pulmonary disease (COPD) presents with a new complaint of progressive dyspnea. Grade IV to VI murmur at the apex that radiates to the axilla ❏ B.

Because the patient is 50 years old buy cheap diarex 30caps line gastritis diet ���, you talk about colorectal cancer screening measures buy 30caps diarex otc gastritis diet lunch. Which of the following statements regarding colorectal cancer screening is false? A fecal occult blood test (FOBT) is equally useful at detecting adeno- mas and early-stage cancers B. A case-control study demonstrated a risk reduction of 70% for death from cancers within reach of the sigmoidoscope C. Colonoscopic polypectomy lowers the incidence of colorectal cancers by 50% to 90%, and the American Cancer Society currently recom- mends colonoscopy every 10 years, starting at age 50, for asympto- matic adults at average risk for colorectal cancer D. There has not been a formal trial of double-contrast barium enema (DCBE) as a screening test for colorectal neoplasia in a general population Key Concept/Objective: To understand colorectal cancer screening tests Screening and early detection (secondary prevention) are important in influencing the outcome in patients with colorectal neoplasia. Many deaths from colorectal cancers could probably be averted by appropriate use of screening. The rationale for screening for col- orectal neoplasia is twofold: First, detection of adenomas and their removal will prevent subsequent development of colorectal cancer. Second, detection of localized, superficial tumors in asymptomatic individuals will increase the surgical cure rate. The rationale for screening for the presence of blood in the stool is that large adenomas and most cancers bleed intermittently. Annual testing may allow detection of disease that, although unde- tected on previous occasions, has not yet reached an advanced and perhaps incurable stage. Compared with endoscopic tests, FOBT detects relatively few adenomas; the princi- pal benefit of an FOBT program is to increase detection of early-stage cancers. A case-con- trol study demonstrated a risk reduction of 70% for death from cancers within reach of the sigmoidoscope; the data suggested that the benefit may last as long as 10 years. The effec- tiveness of colonoscopy has been demonstrated by several studies. Observational, case-con- trol, and prospective, randomized trials have shown that colonoscopic polypectomy low- ers the incidence of colorectal cancers by 50% to 90%. The American Cancer Society cur- rently recommends colonoscopy every 10 years, starting at age 50, for asymptomatic adults at average risk for colorectal cancer. Repeat examinations at more frequent intervals are indicated for patients at increased or high risk. There has not been a formal trial of DCBE as a screening test for colorectal neoplasia in a general population. A comparison study in patients who have undergone colonoscopic polypectomy found colonoscopy to be a more effective method of surveillance than DCBE. A 62-year-old black male patient is in the hospital for evaluation of anemia with associated fatigue and weight loss. He was found to be heme-positive on rectal examination, and a colonoscopy was performed. A mass was found in his ascending colon; biopsy revealed adenocarcinoma. A CT scan of his chest, abdomen, and pelvis revealed a 3 cm mass in his ascending colon; there were no liver lesions or other metastatic disease and no intraperitoneal lymphadenopathy. Surgical pathology revealed invasive adenocarcinoma extending into the serosa, but no lymph node involvement. The patient has stage B disease because no lymph nodes are involved and no distant metastasis was found B. Because most recurrences after resection occur within 3 to 4 years, the cure rate is reasonably estimated by 5-year survival rates D. Postoperatively, the carcinoembryonic antigen (CEA) level may serve as a measure of the completeness of tumor resection Key Concept/Objective: To understand the staging and prognosis of colorectal carcinoma The prognosis for patients with adenocarcinoma of the colorectum is closely associated with the depth of tumor penetration into the bowel wall and the presence or absence of regional lymph node involvement and distant metastases. The Dukes system has been applied to the TNM classification method, in which T represents the depth of tumor pen- etration; N, the presence or absence of lymph node involvement; and M, the presence or absence of distant metastases. Stage A (T1N0M0) cancers are superficial lesions that do not penetrate the muscularis and do not involve regional lymph nodes. Stage B cancers pene- trate more deeply into the bowel wall without lymph node involvement. Stage D cancers have metastasized to liver, lung, bone, or other anatomically distant sites. Because most recurrences after resection occur within 3 to 4 years, the cure rate is reasonably estimated by 5-year survival rates.

Antibodies to the malignant tumor cross-react with native antigen generic diarex 30caps visa gastritis diet of worms, giving rise to these clinical syndromes generic diarex 30 caps with mastercard gastritis newborn. It is well recognized that paraneo- plastic syndromes can precede by weeks to months the clinical presentation of the under- lying primary malignancy. As such, awareness of these syndromes is of great importance, and maintaining a high index of suspicion could lead to an earlier diagnosis. Patients with Lambert-Eaton syndrome present with weakness. The symptoms get bet- ter during the day (unlike the symptoms of myasthenia), and repetitive use of the affect- ed limb increases the strength of that limb. An antibody against the acetylcholine recep- tor is responsible for this paraneoplastic syndrome. Small cell carcinoma is most often found to be the underlying tumor. The peripheral nervous system is affected by two different sets of antibodies. Both peripheral neuropathies are predominantly sensory. In patients with lymphoma and Waldenström disease, myelin-associated glycoprotein antibodies (anti-MAG) are produced. Anti-Hu antibodies are found in patients with peripheral neuropathy and encephalo- myelitis associated with small cell carcinoma of the lung. This patient has clear cerebellar signs and symptoms. A main characteristic that points toward a paraneoplastic syndrome is the bilateral nature of the findings. Furthermore, cerebellar changes in imaging were detected several months after the onset of symptoms. Patients with cerebellar tumors tend to present with unilateral signs and symptoms and abnormal neuroimaging studies. Cerebellar hemorrhage presents in a more acute manner. Alcohol abuse is associated with bilateral findings, although truncal ataxia frequently dominates the clinical picture. The fact that this patient does not use alcohol and the normal findings on MRI argue strongly against this diagnosis. Because of the clear relationship between ovarian cancer and paraneoplastic cerebellar degeneration, this patient should undergo evaluation for this malignancy. A 45-year-old man with a history of hypertension and alcohol abuse and dependence presented to the emergency department with confusion. The patient was oriented only to person and was easily distract- ed. Results of physical examination were as follows: temperature, 99. On questioning, the patient was confused and mildly agitated. The remainder of the physical examination was largely unre- vealing; there were no signs of chronic liver disease and no focal neurologic findings. Laboratory evalu- ation was significant for a serum sodium level of 112 mEq/L and a normal serum ammonia level. The patient was admitted for further evaluation, and 3% NaCl was initiated to correct his hyponatremia. The following day, the serum sodium level was 135 mEq/L. After showing initial clinical improvement in alertness and cognition, the patient’s clinical status declined on hospital day 4. He has become obtund- ed and has developed flaccid quadraparesis and extensor plantar responses.

The knee typically pops as a consequence of the presence of a pathologic plica between 60 degrees and 45 degrees of flexion discount diarex 30caps with visa gastritis diet kits. Arthroscopic finding of the pathologic MPP through the popping disappears during the day superolateral view generic 30 caps diarex with amex gastritis diet �������. Using the thumb, manual force was applied to press the inferomedial portion of the patellofemoral joint. The knee is held in the fully tained over the plica, the knee is passively extended position. The examiner flexes the flexed no more than 6 times. The test is posi- knee against patient’s extension with the patella tive when the patient experiences pain or dis- pushed medially. Knee pain with or without a comfort that corresponds to their presenting palpable click of the shelf is a positive sign. The examiner flexes the patient’s knee and forces it into a valgus posi- Management tion, with the patella pushed medially and the Suspected diagnosis of MPP syndrome should be lower leg internally or externally rotated. Conservative therapy is Knee pain with or without a palpable click of especially effective in younger patients with short the shelf is a positive sign. Arthroscopic findings during the MPP test through superolateral view. Patella Plica Syndrome 249 Arthroscopic Technique Two portals are used: high anterolateral portal and superolateral portal. For the diagnosis of associated intra-articular pathological condi- tions and pathologic MPP, the arthroscope is positioned through a high anterolateral portal. Then the arthroscope is moved into superolat- eral portal, allowing the plica to be viewed from above. While viewing through the superolateral portal, the MPP test was done without overdis- tension of the knee joint. After pathologic MPP was confirmed, total arthroscopic excision was performed using basket forceps and motorized shaver. Infrapatellar Plica The infrapatellar plica is the vestigial remnant of Figure 14. At 90˚ of flexion, the plica slipped away from the medial femoral condyle. It is a synovial fold that originates from the inter- condylar notch, runs parallel to and above the anterior cruciate ligament, and attaches to the infrapatellar fat pad. Posteriorly, the plica is sep- include rest, nonsteroidal anti-inflammatory arated from the anterior cruciate ligament, but it agents, hamstring stretches, and quadriceps- may be attached to the anterior cruciate liga- strengthening exercise. If the clinical syndrome ment either completely or partially. Illustrations for patterns of infrapatellar plica in the right knee. The plica divides the anterior joint cavity into the medial and lateral compartments. Distribution of patterns of infrapatellar plica related to sex, side, and age. It is then responsible for the so-called plica syndrome. When a plica of the synovial membrane loses its normal elasticity and becomes fibrotic, it can be a cause of dynamic derangement of the knee. The thickened fibrotic infrapatellar plica impinged to the the thigh musculature. Two patients’ cases were intercondylar trochlea, resulting in limitation of extension of the knee. After teus hiatus or manipulation of the arthroscope arthroscopic excision and immediate postopera- from the anterolateral portal into the lateral tive exercise, full active range of motion of the gutter.