By A. Julio. Reinhardt College. 2018.

Affected relatives must be on the same side of the family (maternal or paternal) 12 ONCOLOGY 9 Key Concept/Objective: To know the diagnostic criteria for HNPCC HNPCC is an autosomal dominant disorder associated with an unusually high frequency of cancers in the proximal large bowel order 250mg ceftin overnight delivery virus vodka. The median age at which adenocarcinomas appear in HNPCC is less than 50 years 500mg ceftin free shipping virus zero portable air sterilizer reviews, which is 10 to 15 years younger than the median age at which they appear in the general population. Also, families with HNPCC often include persons with multiple primary cancers; in women, an association between colorectal can- cer and either endometrial or ovarian carcinoma is especially prominent. Several sets of selection criteria have been developed for identifying patients with this syndrome. The Amsterdam-2 criteria comprise the following: histologically documented colorectal cancer (or other HNPCC-related tumor) in at least three relatives, one of whom is a first-degree rel- ative of the other two; a family history of one or more cases of colorectal cancer diagnosed before 50 years of age; and cases of colorectal cancer in at least two successive generations of the family. Affected relatives should be on the same side of the family (maternal or paternal), familial adenomatous polyposis (FAP) must be excluded in colorectal cancer cases, and tumors must be pathologically verified. A 50-year-old black male patient returns to your office for follow-up for hypertension. His hypertension is well controlled with hydrochlorothiazide and an angiotensin-converting enzyme inhibitor. Because the patient is 50 years old, you talk about colorectal cancer screening measures. 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.

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Explain to her that antihypertensive medication is effective in reducing hypertension cheap ceftin 250mg otc n-922 antimicrobial, making sodium reduction unnecessary Key Concept/Objective: To understand current evidence that supports the relationship between sodium and hypertension The Dietary Approaches to Stop Hypertension (DASH) trial1 demonstrated that the combi- nation of eating fruits ceftin 250 mg cheap necro hack infection, vegetables, and whole grains along with reducing fat and sodium levels can lower systolic blood pressure an average of 11. Reductions in dietary sodium can contribute to substantial reductions in the risk of stroke and coronary artery disease. In addition, for this patient, a reduction in sodium intake will decrease urinary calcium excretion and thus reduce her risk of osteoporosis. Because the patient has asked about putting salt on food, she should also be counseled that 80% of dietary sodium comes from processed food. It is important to review these hidden sources of salt with patients who would benefit from sodium restriction. The average American diet contains more than 4,000 mg of sodium a day. There is no recommended daily allowance for sodium, but the American Heart Association (AHA) recommends that daily consumption of sodium not exceed 2,400 mg, with substantially lower sodium intake for patients with hypertension. Sacks FM, Svetkey LP, Vollmer WM, et al: Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. A 64-year-old man comes to your clinic for a routine visit. He has a history of myocardial infarction, which was diagnosed 1 year ago. Since that time, he has been asymptomatic, and he has been taking all his medications and following an exercise program. He has been getting some information on the Internet about the use of omega-3 polyunsaturated fatty acids as part of a cardioprotective diet. CLINICAL ESSENTIALS 5 Which of the following statements is most accurate concerning the use of omega-3 fatty acids? Consumption of omega-3 polyunsaturated fatty acids has been shown to decrease the incidence of recurrent myocardial infarctions ❏ B. Omega-3 polyunsaturated fatty acids have been shown to decrease low- density lipoprotein (LDL) cholesterol levels ❏ C. Consumption of omega-3 polyunsaturated fatty acids is inversely related to the incidence of atherosclerosis and the risk of sudden death and stroke ❏ D. Omega-3 polyunsaturated fatty acids have been shown to elevate triglyc- eride levels Key Concept/Objective: To understand the benefits of omega-3 polyunsaturated fatty acids Omega-3 polyunsaturated fatty acids have been shown to have a cardioprotective effect. Consumption of omega-3 fatty acids is inversely related to the incidence of atherosclero- sis and the risk of sudden death and stroke. In high doses, omega-3 fatty acids may reduce blood triglyceride levels, but in dietary amounts, they have little effect on blood lipids. Even in modest amounts, however, omega-3 fatty acids reduce platelet aggregation, there- by impairing thrombogenesis. They may also have antiarrhythmic and plaque-stabilizing properties. A 52-year-old woman is diagnosed with diabetes on a blood sugar screening test. She is started on a diet and undergoes education about diabetes. After a month, she comes back for a follow-up visit and asks you why she should eat complex carbohydrates instead of simple carbohydrates if they are all the same. Which of the following statements about simple and complex carbohydrates is true? Simple and complex carbohydrates are indeed of the same caloric value, and there is no advantage in using one over the other ❏ B. Simple carbohydrates have a higher glycemic index than complex carbo- hydrates, and they may decrease high-density lipoprotein (HDL) choles- terol levels ❏ C. Simple carbohydrates have a higher glycemic index than complex carbo- hydrates, and they may increase HDL cholesterol levels ❏ D. Simple carbohydrates have a lower glycemic index than complex carbo- hydrates, and they may decrease HDL cholesterol levels Key Concept/Objective: To understand the difference between simple and complex carbohydrates Plants are the principal sources of carbohydrates.

Therefore buy 500 mg ceftin with mastercard flagyl antibiotic for sinus infection, icits (see Figure 40 and discussed with Figure 67B) discount 500 mg ceftin with amex infection games. A these fibers decussate over a wide region and do not form lesion of the medial lemniscus above the mid-pontine level a compact bundle of crossing fibers; they also send col- will involve all trigeminal sensations on the opposite side. These trigeminal fibers Internal capsule and cortical lesions cause a loss of trigem- join with those carrying touch, forming the trigeminal inal sensations from the opposite side, as well as involving pathway in the mid-pons. The fibers are then found within SOMATOSENSORY AND TRIGEMINAL the white matter of the hemispheres. The somatosensory PATHWAYS information is distributed to the cortex along the postcen- tral gyrus (see the small diagrams of the brain above the This diagram presents all the somatosensory pathways, main illustration of Figure 36), also called S1. Precise the dorsal column-medial lemniscus, the anterolateral, and localization and two-point discrimination are cortical the trigeminal pathway as they pass through the midbrain functions. The view is The information from the face and hand is topograph- a dorsal perspective (as in Figure 10 and Figure 40). The information tion and information about joint position (as well as vibra- from the lower limb is localized along the continuation of tion) from the body is the medial lemniscus (see Figure this gyrus on the medial aspect of the hemispheres (see 33). The equivalent pathway for the face comes from the Figure 17). This cortical representation is called the sen- principal nucleus of the trigeminal, which is located at the sory “homunculus,” a distorted representation of the body mid-pontine level (see Figure 8B and Figure 35). The and face with the trunk and lower limbs having very little anterolateral pathway conveying pain and temperature area, whereas the face and fingers receive considerable from the body has joined up with the medial lemniscus representation. The trigeminal pain and Further elaboration of the sensory information occurs temperature fibers have likewise joined up with the other in the parietal association areas adjacent to the postcen- trigeminal fibers (see Figure 35). This allows us The various sensory pathways are all grouped together to learn to recognize objects by tactile sensations (e. These latter terminations may be involved with touch and position sense (and vibration) terminate in dif- the emotional correlates that accompany many sensory ferent specific relay nuclei of the thalamus (see Figure 12 experiences (e. The output from posteromedial nucleus the intralaminar nuclei of the thalamus goes to widespread cortical areas. Sensory modality and topographic information is retained in these nuclei. There is physiologic processing CLINICAL ASPECT of the sensory information, and some type of sensory “perception” likely occurs at the thalamic level. Lesions of the thalamus may sometimes give rise to pain syndromes (also discussed with Figure 63). Globus pallidus Trigeminal pathway Substantia nigra Medial lemniscus Red n. Substantia nigra Medial lemniscus Trigeminal pathway Anterolateral system FIGURE 36: Somatosensory and Trigeminal Pathways © 2006 by Taylor & Francis Group, LLC 100 Atlas of Functional Neutoanatomy minate or relay in these nuclei; the lateral lemnisci are FIGURE 37 interconnected across the midline (not shown). AUDITION 1 Almost all the axons of the lateral lemniscus terminate in the inferior colliculus (see Figure 9A and Figure 65B). The continuation of this pathway to the medial geniculate AUDITORY PATHWAY 1 nucleus of the thalamus is discussed in the following illus- tration. The auditory pathway is somewhat more complex, firstly In summary, audition is a complex pathway, with because it is bilateral, and secondly, because there are numerous opportunities for synapses. Even though named more synaptic stations (nuclei) along the way, with numer- a “lemniscus,” it does not transmit information in the ous connections across the midline. It also has a unique efficient manner seen with the medial lemniscus. It is feature — a feedback pathway from the CNS to cells in important to note that although the pathway is predomi- the receptor organ, the cochlea. There are also numerous interconnections imally to certain frequencies (pitch) in a tonotopic man- between the two sides. The peripheral ganglion colliculus to the superior olivary complex). The final link for these sensory fibers is the spiral ganglion. The central in this feedback is somewhat unique in the mammalian fibers from the ganglion project to the first brainstem CNS, for it influences the cells in the receptor organ itself. It has both a crossed and an uncrossed compo- After this, the pathway can follow a number of dif- nent. Its axons reach the hair cells of the cochlea by ferent routes.

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