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Rather generic levitra super active 20mg with mastercard impotence guide, this volume is meant to provide much of the knowledge content demanded of the clerkship participant as well as the non-surgical buy 40mg levitra super active otc erectile dysfunction performance anxiety, referring physician purchase levitra super active now erectile dysfunction treatment after radical prostatectomy. First, we have emphasized evidence-based approaches to surgical practice throughout the text. For this purpose, we have liberally (and literally) adapted evidence-based tables from the ﬁrst edition of the compre- hensive textbook Surgery: Basic Science and Clinical Evidence which I was privileged to be a coeditor with my colleagues: Drs. Jeff Norton, Randy Bollinger, Fred Chang, Sean Mulvihill, Harvey Pass, and Rob Thompson. Second, we have adapted many of the learning objectives deﬁned by the Association for Surgical Education and outlined these at the beginning of each chapter. Many chapters are presentation focused rather than bearing the more traditional disease or organ system orientation. Each chapter is introduced by one or more brief case studies that focus upon key concepts and common presentations of the illnesses under discussion. Finally, diagnosis and management algorithms are included in most chapters to guide both the learning and doing processes. I express my gratitude for the efforts of my colleagues in the Depart- ment of Surgery at Robert Wood Johnson Medical School who have contributed unselﬁshly of their knowledge in the construct of this edition. I hope the reader can share in this wisdom as well as their commitment to learning surgery. Barbara Chernow has, as always, provided us with her expert guidance and unwavering standard of excellence. The editors of Surgery: Basic Science and Clinical Evidence provided constant support and encouragement and the contributors to the ﬁrst edition of this textbook set the stan- dard for documenting the evidence-based practice of surgery. Burd xi xii Contents 10 Clerkship Survival Skills: Speed Reading and Successful Examination Strategies. Rettie, PhD Department of Surgery, Division of Vascular Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey Scott R. To describe features of a patient’s clinical history that inﬂuence surgical decision making. During a rather cursory initial physical examination, the emergency room physi- cian palpates a ﬁrm, slightly tender mass in the patient’s right upper quadrant. Introduction One might wonder what is unique in the surgical assessment of a patient that differentiates it from any other medical evaluation. Ciocca A good medical evaluation and a good surgical evaluation really should contain many of the same components. Close attention to the patient’s underlying medical conditions is critical and comes into play when the surgeon is trying to assess the risks for a given patient of a particular operation. This is particularly pertinent when evaluat- ing the 87-year-old patient in the case presented here. The main differences between the two types of evaluations are acuity and the need to frequently make a difﬁcult decision with limited data in the surgical scenario. The decisions made by a surgeon frequently involve subjecting patients to a procedure that may either save their life or hasten their demise. A great deal can be said for experience and time, and few would argue that the more experience one has the better one’s judgment becomes. Education begets experience to some degree, and therefore it is incumbent on the budding physician to read and absorb as much material as possible. Therefore, the art of medicine is a constant learning and rereading of given topics. Since patients’ presentations can be confusing, it is necessary for the physician to develop a systematic evaluation of a patient. This sys- tematic organized approach, in fact, forms the essence of the surgical approach. As a surgical resident frequently called to the emergency room or clinic to evaluate a patient with a “surgical” problem, always approach the patient with the following questions in mind: (1) Does the patient need to be operated on? If the answer is no, then the problem is not sur- gical and appropriate medical therapy or consultation can be set up. This leads to the next question: (2) Does the patient need to be admitted to the hospital? If the answer is yes, then the appropriate therapy needs to be started (intravenous ﬂuid, antibiotics, standard preoperative testing) (See Algorithm 1. History and Physical Examination The foundation of both medicine and surgery begins with a thorough history and physical examination. We have become dependent on myriad diagnostic studies that, while at times helpful, are sometimes unnecessary, expensive, overutilized, time-consuming, and, occasionally, dangerous. Perioperative Care of the Surgery Patient 5 History and Physical Exam Nonsurgical Problem Surgical Problem Needs hospital admit Does not need hospital admit Appropriate medical referral Needs emergent Needs nonemergent Outpatient— surgery surgery referred to surgeon for workup Minimal diagnostic Tests and workup O. While speciﬁcs of the history and physical exam differ depending on the speciﬁc complaint of the patient and are discussed in greater detail in the ensuing chapters, there are a few constants to keep in mind. As simple and as seemingly easy as this is to do, it is something that all physi- cians, on occasion, fail to do. It can be time-consuming, since patients do not always clearly and concisely articulate their problem. Based on the chief complaint or complaints, the physician then can ask more directed questions to illuminate the problem further. Very often, the physician needs to act like a good newspaper reporter, concisely obtaining the What, Where, When, and How of a problem: What is the problem? Another critically important component of the patients’ history includes a listing of their past medical history, usually starting with whether or not they have ever experienced earlier episodes of their current problem. If they have, then a description of the type and success of the therapy may be helpful. One should inquire, in a systematic manner, about any history of major medical illnesses. The patient’s past medical history in the case presented at the beginning of this chapter is critically important. This certainly will give the examiner a clearer understanding of what the patient does and what sort of familial or social support the patient may have. Always inquire, in as nonjudgmental manner as pos- sible, about social habits such as smoking, alcohol intake, illegal drug 6 R. As delicate and uncomfortable as these ques- tions may be to both the patient and examiner, the answers are clini- cally and at times critically important. A thorough listing, including dosages, of medications is necessary and frequently provides insight into the patient’s underlying medical conditions. Inclusion of any adverse reactions or allergies to medications is of obvious import. This so-called “eyeball” test, while difﬁcult to scientiﬁcally validate, can be helpful, particularly when the patient’s presenting problem requires urgent or emergent surgical intervention. This makes intuitive sense, and, if one performs the examination in the same order each time, the likelihood of missing an important physical ﬁnding decreases. Avoid the tendency to examine ﬁrst, and sometimes only, the body area for which the patient has a complaint.
Although the test can detect lower levels physician who suspected a molar pregnancy order levitra super active with amex impotence effects on relationships. Serum is preferred over urine because sample was diluted 10-fold and the assay was serum levels are more consistently above the cutoﬀ repeated levitra super active 40mg sale erectile dysfunction funny images. Te result was found to be grossly point than random urine in very early pregnancy buy levitra super active 40 mg online erectile dysfunction gluten. A pipeting error was made in the ﬁrst analysis α subunit and the other with the β subunit. Antigen excess caused a falsely low result in the where both antibodies are added together, a process undiluted sample called the “hook eﬀect” is known to occur. Most cases of Down syndrome are the result of: or isochromosome formation, but most cases arise A. Nondisjunction of an E chromosome (E trisomy) from nondisjunction of chromosome 21 during B. Deletion of the long arm of chromosome 21 estriol is used to screen for Down syndrome during Body ﬂuids/Apply knowledge of fundamental biological the second trimester. Which assay result is often approximately 25% below the expected level in pregnancies associated 10. Amniotic ﬂuid bilirubin (free) estriol is almost all derived from the fetus and is D. Urinary chorionic gonadotropin a direct reﬂection of current fetal placental function. When all four assays are combined with adjustments for maternal age, gestational age, race, maternal weight, and diabetes, the detection rate is approximately 70–80% and the false-positive rate 7%. Elevated levels in amniotic ﬂuid are speciﬁc for dependent upon gestational age, upper reference spina biﬁda limits depend upon last menstrual period dating. When Body ﬂuids/Apply principles of special procedures/ serum levels are high, ultrasound is used to Alpha fetoprotein/2 determine fetal age and rule out twins. When performing marker screening tests for and estriol do not discriminate well between Down syndrome, why are results expressed in 21 trisomy and normal pregnancy before the multiples of the median (MoM) rather than second trimester. MoM normalizes for gestational age (almost twofold higher in Down syndrome) and C. Mean cannot be determined accurately for these which has a median in Down syndrome less than analytes half of that seen in normal pregnancy. These two markers used together with high-resolution Body ﬂuids/Apply knowledge of special procedures/ ultrasound to determine nuchal fold thickness Trisomy screening/1 (swelling at the base of the neck) have a sensitivity of 85%–90%. It eliminates interlaboratory variation in reference ranges seen when concentration units are reported. Laboratories using diﬀerent methods (antibodies or calibrators) may have signiﬁcantly diﬀerent mass unit results for the same sample, necessitating diﬀerent reference ranges. The reference range in concentration units is also dependent upon the gestational age at the time of sample collection; however, the average result for normals is always 1. Use of MoM obviates the need to report speciﬁc reference ranges based on method or gestational age and makes calculation of risk less complicated. Which statement regarding the fetal ﬁbronectin Answers to Questions 14–17 test is true? B The fetal ﬁbronectin test is used mainly to rule of delivery within 14 days out the likelihood of preterm delivery in high-risk B. Te test should not be performed before pregnancies or in women with signs of preterm labor. Te test is used to identify amniotic ﬂuid after cervical secretions in early pregnancy but disappears rupture of the fetal membranes by about week 20. When there is inﬂammation to the membranes preceding delivery, ﬁbronectin is released Body ﬂuids/Apply principles of special laboratory and can be found in cervicovaginal secretions. A procedures/Fetal ﬁbronectins/1 positive test (>50 ng/mL) has a sensitivity of about 15. Vaginal Body ﬂuids/Apply knowledge of fundamental biological ﬂuid is normally acidic, with a pH between 5. What is the most common cause of male Nitrazine paper or a swab containing Nitrazine yellow. Body ﬂuids/Correlate clinical and laboratory data/ The tail is divided into the midpiece, principal piece Seminal ﬂuid/2 (mainpiece), and endpiece. Which of the following values is the lower anterior end of approximately 5 μ containing a 9 + 2 limit of normal for sperm concentration? It is thinner than the midpiece and lacks the health and disease states/Seminal ﬂuid/2 outer radial ﬁbers. Mumps, Klinefelter’s syndrome, and malignancy cause testicular failure which accounts for about 10% of infertility cases in men. The sperm concentration is multiplied by the seminal ﬂuid volume to determine the sperm count. This often results from obstruction of the ejaculatory duct or testicular failure. Which morphological abnormality of sperm is Answers to Questions 18–21 most often associated with varicocele? Cytoplasmic droplet below the neckpiece lengthened neckpiece are the most common C. Sperm morphology should be evaluated by classifying 200 Body ﬂuids/Correlate clinical and laboratory data/ mature sperm in duplicate by strict criteria. A Eosin Y is excluded by living sperm and is used Body ﬂuids/Apply principles of special procedures/ to determine the percentage of living cells. Which of the following semen analysis results is are used to evaluate sperm morphology. Motility 50% progressive movement count (sperm/mL × volume) and can be caused by Body ﬂuids/Evaluate data to recognize abnormal absence of the seminal vesicles or prostate, ductal results/Seminal ﬂuid/2 obstruction, or retrograde ejaculation of seminal ﬂuid into the urinary bladder. Which of the following sample collection and coagulate within 5 minutes after ejaculation owing processing conditions will lead to inaccurate to secretions of the seminal vesicles. Sample stored at room temperature for 1 hour causing liquefaction to occur within 1 hour at room before testing temperature. Sample collected without an anticoagulant grading the movement of 2 replicates of 200 sperm D. It is normal when ≥ 32% show Body ﬂuids/Apply knowledge to recognize sources of progressive movement or when ≥ 40% show error/Seminal ﬂuid/2 progressive and nonprogressive movement. The patient should abstain from ejaculation for at least 2 days but no more than 7 days prior to submitting the sample. The sample should be collected at the testing site in a sterile jar with a wide opening, and stored at room temperature. Motility should be determined as soon as the fluid has liquefied (maximum storage time is 1 hour). Anticoagulants are not used; if the sample fails to liquefy, it can be treated with chymotrypsin before analysis. This is Body ﬂuids/Evaluate laboratory data to recognize multiplied by the sperm concentration to give the health and disease states/Seminal ﬂuid/2 absolute count per mL. Pernicious anemia duodenal ulcers, which are associated with discomfort, Body ﬂuids/Gastric/Correlate clinical and laboratory hyperacidity, and bleeding.
A Robertsonian translocation (choice B) would result in fusion of q arms from two acro- centric chromosomes buy levitra super active 20 mg with amex impotence early 30s. Isochromosome 18(p) indicates levitra super active 20mg on-line impotence cream, a chromosome 18 with two p arms and no q arms (choice C) buy levitra super active on line amex impotence age 45. Nondisjunction during either meiosis 1 or meiosis 2 (choices D and E) would produce a full trisomy. Chromosomal abnormalities are responsible for about 50% of spontaneous abortions, and of these the most common cause is trisomy (52%). All other listed causes can also cause miscarriage; however, these problems are less common than chromosomal anomalies. These diseases tend to cluster in families (familial), but they do not conform to mendelian pedigree patterns. This chapter reviews some basic principles of the genetics of common, complex diseases. Because several genes and influential environmental factors contribute to the liability, its distri- bution in the population can be represented as a Gaussian ("bell-shaped") curve. Multifactorial Threshold Model Unlike liability for a disease, the multifactorial diseases themselves are not continuous traits. Expression of the disease phenotype occurs only when a certain threshold of liability is reached. As a simple example, obesity is a complex, multifactorial condition in which excess body fat may put a person at risk for a variety of other conditions, including type 2 diabetes and cardiovascular disease (see below). In contrast, the genes and environmental factors underlying multifactorial traits have not been identified specifically. For example, if we wish to know the recurrence risk for sib- lings of individuals with cleft lip and/or palate, we ascertain a large cohort of individu- " als with cleft lip and/or palate and then measure the proportion of their siblings who are also affected with cleft lip and/or palate (in this case, the sibling recurrence risk is approximately 3%, which is considerably higher than the general population preva- lence of 0. Recurrence risks for single- gene traits remain the same regardless of the number of affected individuals in the family (e. This does not mean that the true risk has changed; rather, it reflects the fact that additional affected individuals provide more information about the true risk. The presence of multiple affected individuals indicates that thefamily is located higher on the liability distribu- tion (i. For example, one study showed that sibling recurrence risk for a neural tube defect (spina bifida or anencephaly; see Clinical Correlate) was 3% if one sibling was affected, 12% if two were affected, and 25% if three were affected. Again, this reflects the fact that the individual and his or her relatives are located higher on the liability distribution. For example, the prevalence of pyloric stenosis (congenital constric- Multifactorial Diseases tion of the pylorus) is approximately 111,000 for females and 1/200 for males. Thus, • Are estimated empirically the average affected female is likely to be located higher on the liability distribution than is an affected male (i. In contrast, the risk of carrying a single-gene mutation decreases by only • Increase if the proband 1/2 with each successive degree of relationship (i. Although the recurrence risk for a single-gene disorder remains the same regardless of the preva-, • Decrease very rapidly for lence of the disease in a population, the empirical risk for multifactorial diseases more remotely related increases as the population prevalence increases. This is because populations with relatives higher prevalence rates have a higher preponderance of genetic and errvironmental Increase as the prevalence risk factors. Anencephaly (partial or complete absence of the brain) usually leads to a stillbirth, and anencephalies that survive to term do not live for more than a few days. Spina bifida, a protrusion of spinal tissue through the vertebral column, produces secondary hydrocephalus in 75% of cases and often produces some degree of paralysis. Improved intervention strategies have increased survival rates substantially for this condition, with more than two thirds of patients now surviving beyond 10 years of age. However, there is also evidence for genetic variation in the abilily to metabolize folic acid. Assessing the Contribution of Genes Versus Environment A very simple definition of heritability is the contribution of genetic variability (or more spe- cifically, variance) to the liability curve. These studies include: Twin studies Adoption studies • Statistical studies on populations Because the third type of study is beyond the scope of the exam, only the first two will be " I discussed. Twin studies It is a major challenge to disentangle the effects of common genes and common environment when studying the causes of multifactorial diseases. If we wish to gauge the relative effect of genetic inheritance on a trait, we can compare the con- Note cordance of the trait in monozygotic versus dizygotic twins (two individuals are concordant if they share the same trait; if they do not share the trait, they are discordant). As this table demonstrates, twin studies indicate that genes playa role in the causation of most common diseases. There is a formal equation that can be used to calculate heritability by using the I data from twin studies. Adoption studies Another way of assessing the relative effects of genes and environment is to measure the preva- lence of a trait in individuals who had one biologic parent with the trait b~t who were adopted by parents ~ho do not have the trait. Children of a parent with schizophrenia raised by I 10% Oncogenes and Tumor schizophrenic parent I Suppressor Genes I Children of a parent with schizophrenia raised by 80A I Oncogenes generally L~~schizophrenic p~n~ __. In this study proteins that are more population, when one parent has schizophrenia, the risk of schizophrenia in an offspring is active than the normal about 8 to 10 times higher than the risk in the general population. Because the general population is so much larger than the function; one hit) population with familial cases, a physician is more likely to encounter sporadic cases. In other instances, different genes are apparently major contributors I: to the familial cases versus the sporadic cases. Development of the cancer may depend not only on inheritance of the with significantly reduced mutant allele but also on contributions from other genes and environmental factors. Typically, mutation penetrance of inherited forms of cancer is usually less than 100%. If, during their lifetime, they incur • Rhabdomyosarcoma a loss-of-function somatic mutation ~na <;ell(a second hit), it leads to cancer. Although the study of inherited cancer syndromes has led to the identification of a number of tumor suppressor genes and oncogenes, the inherited can- • Adrenocortical carcinoma cer syndromes are thought to account for only about 1% of all cancers. However, somatic (as opposed to germ-line) mutations in many of these tumor suppressor genes and proto-onco- • Lymphocytic or histiocytic genes playa key role in the causation of noninherited, common cancers such as most breast lymphoma and colon tumors. It is important to keep in mind that many of these somatic mutations can Lung adenocarcinoma be caused by environmental factors. This example illustrates the link between • Gonadal germ cell tumors genes, environment, and cancer. Other common multifactorial diseases Many other common diseases may occur as both sporadic and familial cases. In some instances, similar to the situation with Li-Fraumeni syndrome, studying the familial cases allows identifi- cation of the gene(s) involved. Sometimes, the same genes are found to be involved in sporadic cases of the disease. Genetics of Common Diseases: Summary of Principles Several key principles should emerge from this review of the genetics of common diseases: Common diseases generally have both genetic and environmental liability factors. Liability for common diseases in a population can be represented by a normal (Gaussian) distribution.
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