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In: Porte Jr D buy finasteride 1mg cheap japanese hair loss cure, Sherwin RS generic 5mg finasteride hair loss in men wear, Baron A (eds) Ellenberg and Rifkin’s diabetes mellitus, 6th edition. McGraw Hill, pp 789–804 258 Diabetic mononeuritis multiplex and diabetic polyradiculopathy (amyotrophy) Genetic testing NCV/EMG Laboratory Imaging Biopsy ++ ++ ++ Anatomy/distribution Diabetic mononeuritis multiplex (DMM) and diabetic polyradiculopathy (DPR) are due to the loss of motor and sensory axons in one or more named nerves or nerve roots. The term mononeuritis multiplex refers to multiple mononeuro- pathies in conjunction with polyneuropathy. Symptoms Patients experience proximal and distal weakness and sensory loss in specific named peripheral nerves (including cranial or truncal nerves) or nerve roots. The onset is sudden and usually extremely painful in the sensory distribution of the nerve/nerve root. In DMM, the most commonly involved named nerves include the median, radial and femoral nerve and cranial nerve III. In DPR, thoracic and high lumbar nerve roots are frequently affected, initially unilater- ally, but frequently with later bilateral involvement. Clinical syndrome/ DMM and DPR are sudden in onset, often self-limited, and occur primarily in signs older, poorly controlled type 2 patients. In DMM, patients experience sudden pain, weakness and sensory loss in a named peripheral nerve. Patients with DMM of cranial nerve III, present with unilateral pain, diplopia, and ptosis with pupillary sparing. In DPR, involvement of thoracic nerve roots presents as band-like abdominal pain that is often misdiagnosed as an acute intraabdomi- nal emergency. L2-L4 DPR is often confused with a pure femoral neuropathy; the former is common while the later is rare. Patients are weak in hip flexion and knee extension with an absent knee reflex; frequently weakness will spread to involve L5-S1 anterior myotomes. Pathogenesis Unlike DPN or DAN, DMM and DPR are due to discreet infarcts in nerves due to vascular occlusions. Epineural vessels are inflamed with IgM and comple- ment deposition. Diagnosis Laboratory: It is essential to exclude vasculitis by appropriate serological screening (see p. Electrophysiology: NCV reveals loss of sensory and in advanced cases motor amplitude and mildly slowed conduction velocities in distinct nerves. EMG reveals denervation in myotomes corresponding with the named nerves. Abdominal and lumbosacral plexus CAT scans are routine to rule out intraabdominal pathology in patients with diabetic thoracic radiculopathy and a mass lesion in the lumbosacral plexus in patients with diabetic lumbar polyradiculopathy. Glycemic control is essen- Therapy tial to prevent reoccurrence. Physical therapy and supportive care help accel- erate recovery. There are reports of using intravenous gammaglobulin (IVIG) in DPR, but efficacy remains unproven. DMM and DPR improve spontaneously in most cases, but may leave mild Prognosis residual deficits. It is essential to achieve improved glycemic control in affected patients; if not, it is highly likely that the patient will experience recurrent episodes. Dyck JB, Norell JE, Dyck PJ (1999) Microvasculitis and ischemia in diabetic lumbosacral References radiculoplexus neuropathy. Neurology 53: 2113–2121 Feldman EL, Stevens MJ, Russell JW, Greene DA (2001) Diabetic neuropathy. In: Becker KL (ed) Principles and practice of endocrinology and metabolism, 3rd edition. Lippincott, Williams & Wilkins, pp 1391–1399 Simmons Z, Feldman EL (2002) Update on diabetic neuropathy. Curr Opin Neurol 15: 595–603 Windebank AJ, Feldman EL (2001) Diabetes and the nervous system.

Results of CSF analysis are as follows: 370 WBC/mm3 buy 1 mg finasteride amex hair loss real cure, with 70% neutrophils buy 1 mg finasteride otc hair loss in men 39; protein, 95 mg/dl; glucose, 68 mg/dl, with simultaneous serum glucose, 110 mg/dl. T2-weighted MRI images reveal increased signal intensity in the basal ganglia and thalami. Which of the following statements regarding this patient’s disease is true? The disease spreads primarily via the fecal-oral route B. Neutrophilic CSF pleocytosis is distinctly unusual early in the course of this disease C. Using sentinel chickens to detect viral infection is important in con- trolling outbreaks E. The mortality from this disease is less than 20% E. The disease is caused by an arenavirus Key Concept/Objective: To be familiar with the presentation of an arboviral encephalitis and the means to detect the mosquito vectors Rapid alteration in mental status associated with fevers should raise suspicion for viral encephalitis. Of the various types of viral encephalitides, Eastern equine encephalitis (EEE), in a recent review, was found to have distinctive basal ganglion and thalamus involvement on MRI scan. It is one of the arboviral (arthropod-borne) encephalitides and is spread by mosquito bite rather than a fecal-oral route. Neutrophilic CSF pleocytosis would not be unusual early in the course of any acute viral CNS infection and is common in EEE. Control of outbreaks comes from monitoring and controlling the mosquito vectors. Presence of the virus in swampy habitats can be detect- ed by recovering virus from mosquitoes or by measuring serum antibodies in wild passer- ine birds or caged sentinel birds (chickens). The are- naviruses are endemic in rodents, with lymphocytic choriomeningitis virus being most common in the United States. A 59-year-old woman from Missouri has a 20-year history of systemic lupus erythematosus, for which she is taking corticosteroids. One day before admission, the patient started taking ibuprofen for a flare in arthralgias. Chest x-ray, complete blood count, and urinalysis are normal. CSF analysis shows 400 WBC/mm3, with 51% monocytes, normal glucose, slightly elevated protein, and negative Gram stain for bacteria. Without therapy, she becomes fully alert and afebrile within 24 hours. At this point, she relates that she had two identical episodes within the past 5 years, each after ibuprofen use. Systemic lupus erythematosus cerebritis 50 BOARD REVIEW C. Louis encephalitis Key Concept/Objective: To be aware that both infectious and noninfectious processes can present as an aseptic meningitis or meningoencephalitis syndrome The patient has evidence of CNS inflammation with a mononuclear CSF pleocytosis. Enteroviruses commonly cause acute viral meningitis, but recurrent acute infections would be very unlikely. Louis encephalitis—the other “SLE”—is an arboviral encephali- tis that would neither resolve clinically within 24 hours nor recur. Mollaret recurrent meningitis might have a herpesvirus origin, but there is a more likely explanation in this patient. Cerebritis can be part of active systemic lupus erythematosus, but rapid resolution and no other manifestations of active disease argue against the diagnosis. Nonsteroidal anti-inflammatory drugs can cause a meningoencephalitis, especially in patients with underlying collagen vascular diseases. Three identical episodes occurring immediately after the use of ibuprofen, with rapid improvement after its removal, argue for this diag- nosis. Eight weeks ago, a 26-year-old woman with Hodgkin disease developed a zosteriform eruption of the left periorbital and left forehead regions. The skin lesions resolved, and apart from episodic neuralgic pains, the patient was doing well until today, when she experienced the sudden development of right hemi- plegia. On examination, the patient is awake, afebrile, and aphasic; residual small scabs are noted on the left side of the face, and she has a dense right hemiplegia. For this patient, which of the following diagnostic test results is most likely?

Creatine kinase and lactose dehydrogenase (LDH) levels are elevated at 12 finasteride 5mg without prescription hair loss in men jobs,000 U/L and 475 U/L discount finasteride 1mg free shipping lakme prevention shampoo hair loss, respectively. Urinalysis shows reddish urine with a specific gravity of 1. Microscopic examination of urine sediment demonstrates 0 to 2 red cells and 0 to 5 white cells per high-powered field; hyaline casts are also observed. The urinary findings are suggestive of which of the following conditions? Myoglobinuria Key Concept/Objective: To recognize the findings associated with myoglobinuria 8 BOARD REVIEW This patient presents with rhabdomyolysis related to alcohol intoxication and pro- longed immobilization. Myoglobin released from the breakdown of skeletal muscle is an endogenous nephrotoxin that can induce acute renal failure (ARF) by direct injury to tubular epithelial cells. ARF is a complication in up to one third of patients with rhabdomyolysis; factors that predispose to ARF in this setting include hypovolemia and acidosis. The prompt recognition of myoglobinuria is thus of paramount importance in this clinical setting and can be aided greatly by careful examination of the urine. Both myoglobin and hemoglobin (released from the breakdown of red cells in hemolytic processes) will react with the urine dipstick test for blood. The presence of pigments in the urine should be suspected when the results of dipstick testing are strongly positive for blood in the absence of red cells on microscopic examination. Acute glomeru- lonephritis is characterized by the finding of red cells and red cell casts on urinalysis. Acute (allergic) interstitial nephritis is suggested by the presence of white cell casts and nonpigmented granular casts. Eosinophiluria is an additional finding that suggests interstitial nephritis, though a finding of eosinophiluria is not highly sensitive. A 57-year-old woman with hypertension, mitral valve prolapse with regurgitation, asthma, and a histo- ry of alcoholism presents to your office to establish primary care. Because the patient has hypertension, you order a basic metabolic profile and urinalysis as a part of your initial evaluation. The laboratory calls to notify you that the patient’s serum creatinine level is 2. Which of the following statements regarding chronic kidney disease (CKD) is true? CKD is defined as a glomerular filtration rate (GFR) of less than 30 ml/min/1. Persistently increased proteinuria in the setting of a normal or increased GFR signifies the presence of stage 1 CKD C. Measurement of 24-hour creatinine clearance to assess GFR is more accurate than estimating GFR from the Modification of Diet in Renal Disease (MDRD) equation D. Treatment of comorbid conditions, interventions to slow progres- sion of kidney disease, and measures to reduce cardiovascular dis- ease should begin during CKD stage 3 Key Concept/Objective: To understand the basic principles of the diagnosis and treatment of CKD CKD is defined as either kidney damage or a GFR of less than 60 ml/min/1. The MDRD and Cockcroft-Gault equations provide useful esti- mates of GFR in adults. Clinical practice guidelines point out that clinicians should not use serum creatinine concentration as the sole means of assessing the level of kidney function. In addition, measurement of 24-hour creatinine clearance to assess GFR is not more accurate than estimating GFR from the MDRD equation. Evaluation of all patients with CKD should include testing for proteinuria. Persistently increased proteinuria is usually a marker of kidney damage; in the setting of a normal or increased GFR, it sig- nifies the presence of stage 1 CKD. Treatment of comorbid conditions, interventions to slow progression of kidney disease, and measures to reduce cardiovascular disease should begin during stages 1 and 2. A 46-year-old male patient with long-standing CKD, diabetes, and hypertension presents for routine fol- low-up. Which of the following statements regarding the management of complications associated with CKD is false?

Bone mineral density was found to be lower when metallic screws were used to fix distal femoral osteotomies in rabbits buy cheap finasteride 1 mg hair loss in men 70s clothing, compared with bioabsorb- able screws buy finasteride 1 mg with visa hair loss cure prostaglandin d2. In experimental studies, stress shielding has been shown to occur in grafted mandibular bone [25,26], and bone resorption has been reported clinically in association with the use of rigid plate fixation. However, the clinical significance of this problem remains unclear. Radio-opacity The radio-opacity of metals can lead to obliteration of the view of tissues lying behind them, interfering with adequate radiological evaluation [27–31] such as CT scanning [32,33] and MRI. This is a disadvantage in the field of CMF surgery, where neuroimaging is needed, e. In addition, radio-opacity of metals may interfere with radiotherapy used in the treatment of cancer patients. Infection Implants may be colonized by bacteria that can form a biofilm, as may occur with Staphylococcus epidermidis. A biofilm is known to interfere with the reach of antibodies and phagocytes to the residing bacteria, and with antibiotic sensitivity [37–39,42], leading to a status of persistent Bioabsorbable Devices in CMF Surgery 171 infection. Various solutions are being explored to enhance the resistance of biomaterials to bacterial adhesion. Corrosion Stainless steel may suffer from corrosion in body fluids. With titanium, corrosion is limited by the formation of an oxide film, but titanium particles have been reported to be found at distant locations. Corrosion products can accumulate in tissues encapsulating the implant [3,43] or in the draining lymph nodes. The effect of metal ions on osteoblasts has been investigated and it was found that they may alter osteoblast behavior even at subtoxic concentrations. These effects may not be very apparent clinically, but it is a matter of concern and there is a need to develop better and ‘‘smarter’’ materials. Costs As mentioned earlier, in pediatric CMF surgery, the problems of implant pseudomigration and interference with growth of the skull warrant the removal of metal implants. Removal operations are associated with potential complications and extra costs, for obvious reasons, as the second operation is usually technically more difficult, consumes more time, and requires more facilities. DEVELOPMENT OF BIOABSORBABLE OSTEOFIXATION DEVICES A. General Research has focused on a class of aliphatic polymers called poly- -hydroxy acids. This class has been under intensive research in the development of osteosynthesis devices since the 1960s [46–57]. Devices made of polyglycolide (PGA) or polylactide (PLA) are the strongest obtained in this class. Bioabsorbable polyesters are broken down by hydrolysis, with progressive attack on their ester bonds, leading ultimately to release of monomers. In vivo, their degradation may also be accelerated due to the effect of enzymes. The resulting monomers are metabolized and eliminated without the risk of toxic organ accumulation. An important polymer that is used for manufacturing surgical devices is the polymer of glycolic ( -hydroxy acetic) acid. The polymer is manufactured by ring opening of the dimer (glycolide) [54,59] hence the name polyglycolide. Both names, polyglycolic acid and polyglycol- ide, are used interchangeably. Glycolide, the cyclic dimer condensation product, is formed by dehydrating glycolic acid. PGA of high molecular weight (20, 000 to 145, 000) is a hard, tough, crystalline polymer melting at about 224–228 C, with a glass transition temperature (Tg) of 36 C. PGA can be spun into fibers which increase the strength properties of the polymer because of higher preferred molecular orientation of the polymer in the fiber [46,61]. The other important polymer used in manufacturing surgical devices is the polymer of lactic ( -hydroxycarboxylic) acid.