Dnb/Aipgmee Model Test 1

Secondary prevention involves the early identifications of a disorder to reduce its occurrence or duration. Thus early intervention programs for children with emotional disorders can reduce the likelihood that the problems will persist into adulthood.

• Typical cervical vertebrae - 3rd, 4th, 5th, 6th
• Atypical cervical vertebrae - 1st, 2nd, 7th
• Small triangular body
• Vertebral foramen -larger than body
• Transverse processes pierced by foramen transversarium
• The second part of the vertebral artery traverses the foramen transversarium of the 2nd to the 6th cervical vertebrae.
• Superior articular facet directed backwards & upwards. {These features are found in thoracic vertebrae also.}
• Inferior articular facet directed forwards & downwards
• Together they form the lateral pillars
• Anterior tubercle of 6th cervical vertebra - carotid tubercle
• Short & bifid spinous process

Review:GYNECOLOGY-GENITAL PROLAPSE-

The answer is c. (Tintinalli, 5/e, p 1827.) A fracture is a break or disruption in the
continuity of bone. A sprain is an injury to a ligament and may be classified as being: First-degree =
Microscopic tears and minimal swelling Second-degree = Pa

Caldesmon is a calmodulin binding protein (can bind to actin, tropomyosin, myosin and phospholipids also). Caldesmon tonically inhibits the ATPase activity of myosin in smooth muscle inhibiting calcium-dependent contraction of smooth muscle. It plays an essential role in the regulation of smooth muscle contraction and relaxation.

Rb proteins control any extremely important check point, the G1 to S transition during the cell cycle. The other checkpoints are regulated by a distinct set of proteins.

Malignant calcifications are cast and branching, dot dash linear calcifications. If dendritic means branching then they are malignant. Coarse calcifications are generally seen with benign processes. However, amorphous can be seen with malignancy. Clearly benign calcifications are popcorn or crescentic, egg shell, cyst fat necrosis, Arterial Calc, two parallel lines, duct ectasia oval/round, large oriented to nipple.

About phenylketonuria:
• AR inheritance
• Low levels of phenylalanine hydroxylase
• High levels of phenylpyruvic acid, phenyl lactic acid etc which are excreted in urine and give it a green colour with FeCI3.
Clinical features:
• Irritability, tremors, convulsions, hyperkinesis and muscle hypertonia.
• Lack of melanin causes blond hair, blue iris and fair skin.
Diagnosis:
• Increased phenylalanine levels> 20 mg/ dl/24hr
• Blood Tyrosinase levels> 5 mg/ dl
• Presence of abnormal urinary metabolite -phenylalanine (detected by ferric chloride test)
Treatment
• Low Phenylalanine diet (continued for 8-10 years).

Cortical Sensation
They are called cortical sensations because they require processing in the sensory cortex to be understood where as pure sensations like pain, temperature, touch pressure & vibration can be felt even in the absence of cortex although poorly. The most commonly used tests of cortical function are two-point discrimination, tactile localization, bilateral simultaneous stimulation and tests for graphesthesia & stereognosis. Abnormalities of these sensory tests, in the presence of primary sensation in an alert cooperative patient, signify a lesion of the parietal cortex or thalamocortical projections to the parietal lobe

Trauma Score - Injury Severity Score : TRISS
TRISS determines the probability of survival (Ps) of a patient from the ISS and RTS using the
following formulae:
Where 'b' is calculated from:
The TRISS calculator determines the probability of survival from the ISS, RTS and patient's age. ISS
and RTS scores can be inputted independently or calculated from their base parameters

Crossover study
A crossover study (also referred to as a crossover trial) is a longitudinal study in which subjects receive a sequence of different treatments (or exposures).
Randomized, controlled, crossover experiments are especially important in health-care. In a randomized clinical trial, the subjects are randomly assigned treatments. When the randomized clinical trial is a repeated measures design, the subjects are randomly assigned to a sequence of treatments. A crossover clinical trial is a repeated measures design in which each patient is randomly assigned to a sequence of treatments, including at least two treatments (of which one "treatment" may be a standard treatment or a placebo).
Nearly all crossover designs have "balance", which means that all subjects should receive the same number of treatments and that all subjects participate for the same number of periods. In most crossover trials, in fact, each subject receives all treatments.

Advantages
A crossover study has two advantages over a non-crossover longitudinal study. First, the influence of confounding covariates is reduced because each crossover patient serves as his or her own control. In a non-crossover study, even randomized, it is often the case that different treatment-groups are found to unbalanced on some covariates. In a controlled, randomized crossover designs, such in balances are implausible (unless covariates were to change systematically during the study).
Second, optimal crossover designs are statistically efficient and so require fewer subjects than do non-crossover designs (even other repeated measures designs).
Crossover studies often have two problems:
First is the issue of "order" effects, because it is possible that the order in which treatments are administered may affect the outcome.
Second is the issue of "carry-over" between treatments, which confounds the estimates of the treatment effects. In practice, "carry-over" effects can be avoided with a sufficiently long "wash-out" period between treatments. However, the planning for sufficiently long wash-out periods does require expert knowledge of the dynamics of the
treatment, which often is unknown, of course.

Superior gluteal nerve injuryTrendelenburg test tests for the stability of the hip joint and depends on integrity of
Femoral head = fulcrum
Femoral neck = lever arm
Effort = abductors (Gluteus medius and minimus)
The response is assessed by level of buttock folds positive Trendelenburg is seen in pain on weight bearing hip abductor weakness shortening of femoral neck dislocation/subluxation of hip
(a) The response is NORMAL (i.e. the test is "-negative") if the pelvis on the non-stance side can be elevated as high as hip abduction on the stance side will allow, and providing this posture can be maintained for 30 seconds with the vertebra prominens centered over the hip and foot.
(b) The response is ABNORMAL (i.e. the test is "positive) it' this cannot be done.
MRC Grade 5 abductor muscle strength is required to produce a normal response.

Rouleaux formation refers to the stacking of red blood cells (RBCs) in a linear fashion, resembling a stack of coins. This occurs due to the presence of abnormal proteins in the blood, such as immunoglobulins, which cause the RBCs to stick together. In the context of multiple myeloma, a type of cancer that affects plasma cells, the abnormal proteins produced by the cancer cells can lead to rouleaux formation. This can result in impaired blood flow and oxygenation, leading to various symptoms and complications associated with multiple myeloma.

Schiller-Duval bodies are a characteristic feature of yolk sac tumors, a type of germ cell tumor that typically occurs in the ovaries or testes. These bodies are composed of a central blood vessel surrounded by tumor cells that form a glomerulus-like structure. The presence of Schiller-Duval bodies is highly specific for yolk sac tumors and can aid in their diagnosis.

No. of live birth during year
Crude birth rate = ---------------------------------- x 1000
Mid – year population
• Simplest measure of fertility.
{ Curde birth rate is 24.1
• India in year 2004 [
{ Curde death rate is 7.5
Mid year population: Refer to the population estimated as on the 1st July of an year.
Census: The census usually conducted at end of first quarter of first year in ach decade. Reason being most people are usually resident in their own homes in this period.
Mid year population – 1 July
Census - End of March Month

Despite the great length of the chromosomes of eukary¬otic DNA, the actual replication time is only minutes. This is because eukaryotic DNA is replicated bidirectionally from many points of origin. The hundreds of initiation sites for DNA replication on chromosomes share a consensus sequence called an autonomous replication sequence (ARS). Thus, while the process of DNA replication in mammals is similar to that in bacteria, with DNA polymerases of similar optimal temperatures and speed, the many replication forks allow for a rapid synthesis of chromoso¬mal DNA. Proteins such as histones, which are bound to mammalian chro¬mosomes, inhibit DNA replication or transcription. Dissociation of the protein-DNA complex (chromatin) and unwinding of DNA supercoils (fol¬lowed by chromatin reassembly) is part of the replication process.

Altitude insomnia describes a sleep disturbance that is a common consequence of exposure to high altitude. Periodic breathing of the Cheyne-Stokes type occurs during NREM sleep about half the time at high altitude, with restoration of a regular breathing pattern during REM sleep. Both hypoxia and hypocapnia are thought to be involved in the development of periodic breathing. Frequent awakenings and poor quality sleep characterize altitude insomnia, which is generally worse on the first few nights at high altitude but may persist. Treatment with acetazolamide can decrease time spent in periodic breathing and substantially reduce hypoxia during sleep

Review:Biochemistry

All the injuries would be associated with significant bleeding, but vascular constriction of healthy arteries in a young person would prevent exsanguination. However, if one artery is partially transected, complete constriction of injured arterial ends is not possible, and spontaneous cessation of bleeding doesn’t occurs.

Occurrence of clinical and subclinical infection in a community is responsible for herd immunity.
Herd immunity :
• It is the level of resistance of a community or group of people to a particular disease.
• Herd immunity provides an immunological barrier to the spread of disease in the human herd.
• The epidemic wave declined with a build-up of herd immunity following natural infection.
• It is neither possible nor necessary to achieve 100 per cent herd immunity in a population to halt an epidemic or control disease, as seen in SMALL POX eradication.
• Herd immunity implies group protection beyond that afforded by the protection of immunized individuals. It provides an immunological barrier to the spread of disease in the human herd.
• It may lead to elimination of the disease in due course (Eg. Poliomyelitis and Diphtheria).
• In the case of tetanus, however, herd immunity does not protect the individual.

There are two types of bacteriophages-"lytic" and "temperate." The distinction is made according to the life cycle of the bacteriophage. Upon entering a bacterium, lytic phages produce phage nucleic acids and proteins, assemble many new phage particles, lyse the cell, and release the progeny phage. Temperate phages, on the other hand, can penetrate the bacterium and enter a dormant state called "lysogeny" in which most viral genes are repressed. Bacterial functions re¬main active and the bacterium is not harmed. Some dormant phages replicate as plasmids, while others, such as phage lambda, become integrated into the host genome as "prophages." The prophage DNA is replicated along with the host DNA as the bacterium grows and divides.

• He is suffering form Adjustment of disorder (Depressive type)in this the symptoms of depression are there, however, the person does not meet full criteria of depression, i.e., Sadness of mood, Lack of interest and Suicide ideas, Death wishes, Hopelessness, hence the answer is Adjustment disorder.
The diagnostic criteria in the DSM-IV are:
1.The development of emotional or behavioral symptoms in response to an identifiable stressor(s)occurring within 3 months of the onset of the stressor(s).
2.These symptoms or behaviors are clinically significant as evidenced by either of the following:
a. Marked distress that is in excess of what would be expected from exposure to the stressor
b. Significant impairment in social or occupational (academic) functioning
The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
4.The symptoms do not represent Bereavement.
5.Once the stressor (or its consequences)has terminated, the symptoms do not persist for more than an additional 6 months.
• The primary treatment for adjustment disorder is talking. This reduces the pressure of the stressor and enhances coping.
• It allows the patient to put his or her rage into words rather than into destructive actions.
• Counseling, psychotherapy, crisis intervention, family therapy, and group treatment are often used to encourage the verbalization of fears, anxiety, rage, helplessness, and hopelessness.
• Sometimes small doses of antidepressants and anxiolytics are also used.
• In patients with severe life stresses and a significant anxious component, Benzodiazepines are used although, Tricyclic antidepressants or buspirone has been recommended for patients with current or past heavy alcohol use because of the greater risk of dependence.
• Tianeptine, alprazolam, and mianserin were found to be equally effective in patients with AD with anxiety.

• PTSD is characterized by recurrent and intrusive recollections of the stressful event either in flash-backs (images , thoughts, or perceptions) and/or in dreams.
• There is an associated sense of re-experiencing of the stressful event.
• There is marked avoidance of the events or situations that arouse recollections of the stressful event, along with marked symptoms of anxiety and increased arousal.
• The other important clinical features of PTSD include partial amnesia for some aspects of the stressful event, feeling of numbness, and anhedonia (inability to experience pleasure).

The hallmark symptom of delirium is an impairment of consciousness usually seen in association with impairments of cognitive functioning. Psychiatric symptoms include abnormalities of mood, perception, and behavior. Tremor, asterixis, nystagmus, incoordination, and incontinence are common neurologic symptoms. The classic presentation of delirium is a sudden onset, a fluctuating course, and a rapid recovery when the causative factor is identified and eliminated.

Normal-pressure hydrocephalus (NPH) results from failure of the arachnoid granulations to absorb normal amounts of cerebrospinal fluid (CSF) into the sagittal sinus and, in turn, into the venous circulation. Because there is no obstruction of the CSF flow from the ventricles through the aqueduct and basilar foramina, it is called "communicating" hydrocephalus. The imaging hallmark is large ventricles without atrophy. Large ventricles with atrophy can be seen in disorders that cause loss of brain volume; for example, the degenerative dementia of Alzheimer's disease. The idiopathic form of NPH is most likely the most common type seen clinically. This occurs when there is no known antecedent event contributing to the decreased function of arachnoid granulations.

Velpeau and sling Swathe bandages are used for
Acromio clavicular dislocation
Mode of injury is a direct fall onto the dome of the shoulder.
Rockwood classification is used to grade AC joint injuries.
This consists of 6 types. Treatment of type 1 to 3 is conservative and types 4 to 6 grades is essentially surgical duration of immobilization for any ligamentous injury is about 6 weeks most important ligament used for reconstruction in ac joint injuries is coracoacromial ligament nerves involved in this region -shoulder dislocation axillary 2nd common musculocutaneous fracture surgical neck humerus axillary

Urethral carcinoma refers to the development of cancerous cells in the urethra, the tube that carries urine from the bladder to the external body. The bulbomembranous urethra, also known as the membranous urethra, is the most common site for urethral carcinoma. This portion of the urethra is located between the prostatic urethra and the penile urethra. It is a narrow segment that passes through the urogenital diaphragm. Due to its location and structure, the bulbomembranous urethra is more susceptible to the development of carcinoma compared to other parts of the urethra.

Maraviroc is a drug used in the treatment of HIV infection.
Maraviroc is an entry inhibitor. Specifically, maraviroc blocks the chemokine receptor CCR5 which HIV uses as a coreceptor to bind and enter a human macrophage. Because HIV can also use another coreceptor, CXCR4, an HIV tropism test such as a trofile assay must be performed to determine if the drug will be effective.

A mature graffian follicle would be seen at midcycle and attains a size of approximately 20mm, but not infrequently, it achieves a size of 25 mm.

• Cooper's ligament (C) lies more superior to the Triangle of Doom, and is not in the boundary.
• Triangle of Doom is bounded by
– Vas deferens (A) medially
– Testicular vessels (B) laterally
– External iliac vessels covered by peritoneal fold (D) posteriorly/inferiorly
• The apex is directed towards the Deep Inguinal Ring.
• Contents: External iliac vessels
• Applied anatomy:
– During laparoscopic repair of inguinal hernia, application of staples is avoided in this triangle so as to prevent injury to the contents - external iliac vessels.
– Damage to these vessels may lead to uncontrolled bleeding and culminating fatally.
Ref: 1. Laparoscopic Surgery: Principles and Procedures; Daniel B. Jones, ISBN 0824746228, Pg. 305
2. Surgical Anatomy and Technique; Lee John, ISBN 0387987525; Pg. 154

Proinflammatory Antiinflammatory
IL – 1  /  IL – 4
IL – 2 IL – 10
IL – 6 IL – 13
IL – 8 IL – Ira
IFN PGE2
TNF TGF
PAF

Nicotinic acid (niacin), gives rise to NAD+ and NADP+. NAD+ is a cofactor required by all dehydrogenases. NADPH is a cofactor produced by the pen¬tose phosphate shunt. It is utilized in reductive synthesis of compounds such as fatty acids.

Death in blunt trauma chest is often due to tracheobronchial injury. Blunt trauma to the chest can cause severe damage to the trachea and bronchi, leading to airway obstruction, respiratory distress, and ultimately death. This type of injury can result from direct impact to the chest or from rapid deceleration forces. It can cause air leakage into the mediastinum, leading to tension pneumomediastinum or pneumothorax. Prompt recognition and management of tracheobronchial injuries are crucial to prevent fatal complications.

• When the foot is fixed (tibia stabilized) the femur rotates medially to lock the knee.
• Locking happens in the last 30 degree of extension and makes all the ligaments taut.
• This locked position is very stable and keeps the lower limbs like 2 pillars.
• Here the knee remains in full extension without much muscular efforts.
• Knee locking is carried out by the same muscle which has carried out extension, i.e., quadriceps femoris.
• Unlocking is carried out by the popliteus muscle, which moves femur laterally on stabilized tibia (fixed foot).
• Unlocking is needed to initiate flexion at the knee before we start walking from the knee locked position.

Normal wound healing follows a predictable pattern that can be divided into
a) Hemostosis and inflammation
b) Proliferation
c) Maturation and remodeling
The proliferative phase is the second phase of would healing and roughly spans day 4 through 12. it is during this phase that tissue continuity is re-established.

Review:GYNECOLOGY-GENITAL PROLAPSE-

Review:GYNECOLOGY-GENITAL PROLAPSE

Triflusal inhibit cyclooxygenase-2. It is the use as a prophylactic drug in cases of CAD, CVA.

Asymmetric tonic neck reflex: The baby is kept supine with the head in midline. Then the head is slowly turned to one side. This results in increased extensor tone in the arm on the side to which the head is turned and increased flexor tone in the arm on the opposite side.
Symmetric tonic neck reflex: appears after the disappearance of Asymmetric tonic neck reflex. It is elicited as: The head is extended on neck which leads to an increase in the tone of the upper limbs while the tone decreases when head is flexed on the neck. Rooting and crossed extensor reflexes are primitive reflexes present at the time of birth. These disappear as the infant grows.

The accessory optic system (AOS) is formed by a series of terminal nuclei receiving direct visual information from the retina via one or more accessory optic tracts. In addition to the retinal input there are now well-characterized afferent connections with pretectal nucleus and the ventral lateral geniculate nucleus. The efferent connections of the AOS are mainly to brainstem and other structures in support of visual-oculomotor events such as optokinetic reflex & nystagmus and visual-vestibular interaction (also called Vestibulo-ocular reflex) for Gaze stabilization.

The temporalis masseter, and medial and lateral pterygoid muscles attach to the mandible and are the major muscles involved in movements of the jaw The buccinator muscle, which controls the contents of the mouth during mastication, is innervated by the seventh cranial nerve and constitutes the chief muscle of facial expression. The lateral pterygoid muscles, acting bilaterally protract the jaw and, acting unilaterally rotate the jaw during chewing. Because the fibers of the superior head of the lateral pterygoid muscle insert onto the anterior aspect of the articular disk of the temporomandibular joint as well as onto the head of the mandible, spasm of this muscle, such as in a yawn, can result in dislocation of the mandible by pulling the disk anterior to the articular tubercle Reduction is accomplished by pushing the mandible downward and back, so that the head of the mandible reenters the mandibular fossa. The temporalis, medial pterygoid, and masseter muscles primarily elevate the jaw in molar occlusion

The inferior thyroid artery arises from the thyrocervical trunk, a branch of the subclavian artery. The superior thyroid artery arises from the external carotid artery. An inconsistent thyroid ima artery when present, may arise from the aortic arch, the innominate artery or the common carotid artery There are no branches of the internal carotid artery and infrequent branches of the common carotid artery in the neck. The transverse cervical artery supplies the posterior triangle of the neck. The vertebral arteries give off spinal and muscular branches in the neck.

Hereditary fructose intol¬erance is a defect in aldolase B. Fructokinase, triokinase, and aldolase A and C levels are unaffected. Fructose intake results in accumulation of fructose-I-phosphate. Hereditary fructose intolerance is an autosomal recessive disease that can be controlled by dietary changes.

EB Subtypes
Most forms of EB are inherited although it may also rarely arise as an acquired, autoimmune, bullous disease known as EB Aquisita. Our focus is on the inherited forms of EB, each of which range from mild to severe and can require major adjustments in the lifestyle of both the EB patient and his or her family.
There are three main forms of inherited EB: EB Simplex, Junctional EB and Dystrophic EB. These different subtypes are defined by the depth of blister location within the skin layers.

Blister formation of EB simplex is within the epidermis. Sometimes EB simplex is called epidermolytic. Blister formation in Junctional EB is seen at the level of the lamina lucida within the basement membrane zone. Dystrophic EB or dermolytic EB is a scarring form of EB which occurs in the deeper tissue at the level the lamina densa or upper dermis.
Testing for EB includes the following :
In order to appropriately identify the depth of blister location in the skin, a skin biopsy must be taken by a dermatologist. This procedure includes numbing an area and taking a small sample of skin (~4mm) for examination under a microscope.
Immunofluorescence antigenic mapping and monoclonal antibody studies.
Transmission electron microscopy
Molecular studies (DNA analysis) may be done to identify the specific genetic mutation and to determine the mode of inheritance (recessive vs dominant). This is helpful information in regard to future family planning.

Causes
Many stratified squamous epithelial tissues, such as the skin and oral mucosa, contain a complex BMZ. The BMZ is composed of many specialized components that combine to form anchoring complexes. At the superior aspect of the BMZ, keratin-containing intermediate filaments of the basal cell cytoskeleton insert on basal cell plasma membrane condensations termed hemidesmosomes. Anchoring filaments extend from the basal cell plasma membrane into the extracellular environment and span the lamina lucida, connecting hemidesmosomes with the lamina densa.
At the most inferior aspect of the BMZ, type VII collagen-containing anchoring fibrils extend from the lamina densa into the papillary dermis, connecting the lamina densa to anchoring plaques, trapping interstitial collagen fibrils. Thus, the cutaneous BMZ connects the extensive basal cell cytoskeletal network with the abundant network of interstitial collagen fibrils in the dermis.
• Molecular pathology of EBS
• Most cases of EBS are associated with mutations of the genes coding for keratins 5 and 14.
• Molecular pathology of JEB
• Mutations in genes coding for laminin 5 subunits (3 chain, laminin 3 chain, laminin 2 chain), collagen XVII (BP180), 6 integrin, and 4 integrin have been demonstrated.
• Contribute to the clinical manifestation of pyloric atresia.
• Molecular pathology of DEB
• DEB thus far has been associated in all cases with mutations of the gene coding for type VII collagen (COL7A1).

Missense mutations are those in which a single base change (point mutation) results in a codon that encodes for a different amino acid residue. The effects of these types of mutations can range from very minor or even undetectable to major, depending on the importance of the altered residue to protein folding and function. Nonsense mutations are also point mutations in which the affected codon is altered to a stop (nonsense) codon, resulting in a truncated protein. Frame shift mutations are due to one or two base "pair insertions or deletions such that the reading frame is altered. These mutations generally lead to truncated proteins as well, since in most protein coding regions the unused reading frames contain numerous stop codons.

CCK or CCK-PZ (cholecystokinin)¬
Function of CCK
(a) Contraction of gall bladder
(b) Secretion of the pancreatic juice rich in enzyme
(c) Augments the action of secretin producing secretion an alkaline pancreatic juice.
(d) Inhibits gastric emptying
(e) Exerts a trophic effect on the pancreas
(f) Causes the secretion of enterokinase
(g) Enhance, the motility of the small intestine
(h) Augments the contraction of pyloric sphincter

The reduction of rhodopsin and cone pigments by light decreases the concentrations of photosensitive chemicals in rods and cones. Thus, the sensitivity of the eye to light is correspondingly reduced. This is called light adaptation.

The class of drugs that is least likely to cause sexual sysfunciton (e.g., erctile disorder) are antiparkinson drugs, such as L-dopa. Dopamine has a stimulatory effect on sexuality. Drugs like L-dopa, which increase dopamine levels, may stimulate sexually Similarly antidopaminergic agents (i.e.,antipsychotics) decrease sexuality. Because serotonin has negative effects on sexuality, MAO inhibitors, tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) are all more likely than antiparkinson drugs to cause sexual dysfunction.

Review:GYNECOLOGY-GENITAL PROLAPSE-

The exotoxins of enteric bacteria consist primarily of proteins that, following secretion into the sutrounding milieu, exert their effects by binding to specific recep¬tor molecules on the surface of mammalian cells.
Exotoxins often consist of an A subunit and one or more B subunits that are linked together by disulfide bonds. The effects of the toxins are mediated by the A subunit in a dose-dependent manner, whereas the B subunits bind to cells and facilitate entry of the A subunit. The genes encoding the exotoxins are often on plasmids rather than on chromosomes (i.e., they are extrachromosomal).

Echinococcus granulosus (dog tapeworm) larvae cause unilocular hydatid cyst disease. Dogs are the most important definitive hosts (contain adult worm). Hu¬mans are almost always dead-end intermediate hosts that can contain the larval forms of this tapeworm, which is one of the smallest. Worms in the dog's intestine liberate thousands of eggs, which are ingested by sheep (or humans). The embryos emerge in the small intestine, penetrate the intestinal wall, and mi¬grate primarily to the liver (but also to the lungs, bones and brain). The embryos develop in one, large fluid-filled hydatid cyst (unilocular). The inner germi¬nal layer of the cyst generates many protoscoleces within "brood capsules." Hydatid sand is a term ap¬plied to the individual scolices in hydatid cyst fluid. The life cycle is completed when sheep entrails are eaten by dogs. Rupture of the cyst can produce anaphy¬lactic shock.

In dermatomyositis classic rash takes the form of a liliac or heliotrope discoloration of the upper eyelids with periorbital edema, and scaling erythematous eruption or dusky red patches over the knuckles, elbows and knees (Gottron lesions). Muscle weakness is bilaterally symmetric and typically affects the proximal muscles first.
In polymyositis muscle involvement is similar to dermatomyositis but there is no cutaneous involvement.
Inclusion body myositis begins with the involvement of distal muscles, involvement may be asyndetic.

Explanation:
*Right broncho-mediastinal lymphatic trunk (4) drains into right lymphatic duct (and not thoracic duct).
*THEME: Right half of the body above diaphragm (right superior quadrant) drains into the right lymphatic duct.

-Right lymphatic duct receives the lymphatic drainage from the right half of the head& neck (Jugular lymphatic trunk); right upper limb (right subclavian lymphatic trunk) and the right thoracic cavity (right broncho-mediastinal lymphatic trunk & the right upper intercostal ducts).

-Thoracic duct drains the body below the diaphragm and also the remaining left superior quadrant of the body. Hence, it receives the left sided jugular, subclavian and broncho-mediastinal lymphatic trunks). It also receives Left upper intercostal ducts (3) whereas, right upper intercostal ducts empty into the right lymphatic duct.
* Thoracic duct receives three major lymphatic vessels at its commencement: Bilateral ascending lumbar ducts (1);
Bilateral descending thoracic ducts (2) and Intestinal lymphatic trunks.
*Bilateral descending thoracic ducts (2) drain the lower 6 intercostal spaces (embryologically this region comes below diaphragm) and empty into the thoracic duct. As noted above upper 6 intercostal spaces on the right drain into the right lymphatic duct and left upper intercostals (3) into thoracic duct accordingly.
*Important: Right thoracic duct not only receives the lymphatics of right lung (lungs lie above diaphragm) but also lower lobe of left lung ! Upper lobe of left lung drains into the thoracic duct only.
*Externally umbilicus (in place of diaphragm) is taken to be the watershed line i.e., skin above the umbilicus on right side of the body drains into the right lymphatic duct.
References:
1. Pg. 984-986; Gray's Anatomy (39th Ed.)
2. Pg. 272; B D Chaurasia (4th Ed.); Vol-1.
3. Pg. 217; Last’s Anatomy (11th Ed.)

Let's see the important difference between case control study and cohort study then we can conclude the answer.
Case control study
• Proceed from "effect to cause"
• Start with the disease
• Involve fewer number of subject
• Yield relatively quick result
• Identification of several Risk factor about the one disease in question
• Suitable for study of rare disease
• By it one can calculate odd ratio (do not provide incidence ratio RR)
• Relatively Inexpensive
• More chance of Bias
Cohort study
• Proceed from "cause to effect"
• Start with Risk factor or suspected cause
• Involve larger number of subject
• Long follow up period needed
• Allow identification of several disease from single risk factor in question
• Inappropriate when disease are exposure under investigation.
• Yield Incidence rate, relative risk as well as attributed risk
• Expensive
• Less chance of Biased
It may lead to elimination of the disease in due course (e.g. Poliomyelitis and Diphtheria)

Warfarin inhibits epoxide reductase, thus inactivating vitamin K and the vitamin K-dependent factors: prothrombin (II),VII, IX, X, protein C, and protein S. The prothrombin time (PT) measures the extrinsic system down to the formation of a clot (VII, X, V, II, fibrinogen --7 clot), whereas the partial thromboplastin time (PTT) is a measure of the intrinsic system down to the formation of a clot (XII, XI, IX, VIII, X, V, II, fibrinogen --7 clot). Therefore, both the PT and PIT are prolonged in a patient on a warfarin deriva¬tive, but the deficiency in factor IX is only measured in the PTT, not the PT. Protein C and S are not measured in either the PT or the PTT.

Pramlintide is an analogue of amylin, a small peptide hormone that is released into the blood stream by the β-cells of the pancreas along with insulin, after a meal. Like insulin, amylin is deficient in individuals with diabetes.
By augmenting endogenous amylin, pramlintide aids in the absorption of glucose by slowing gastric emptying, promoting satiety via hypothalamic receptors (different receptors than for GLP-1), and inhibiting inappropriate secretion of glucagon, a catabolic hormone that opposes the effects of insulin and amylin. It can be given in both type 1 and type 2diabetes.

Paneth (Zymogen) cells reside at the base of crypts and are the only cell type to undergo downward migra¬tion from the proliferation zone. The principal defense molecules secreted by Paneth cells are alpha-defensins, also known as Cryptdins. These peptides have hydrophobic and positively-charged domains that can interact with phospholipids in cell membranes. This structure allows defensins to insert into membranes to form pores that disrupt membrane function, leading to cell lysis. Due to the higher concentration of negatively-charged phospholipids in bacterial than vertebrate cell membranes, defensins preferentially bind to and disrupt bacterial cells, sparing the cells they are functioning to protect. In addition to defensins, Paneth cells secrete zinc, lysozyme and phospholipase A2

The answer is c. (Ludman, pp 12, 20.) Most tuning forks are lowfrequency and the
majority of hearing loss is above their frequencies. Variability among observers in the whispered voice
test does not make this a reliable method to detect hearing loss

American society of anesthesiologist has classified patients in five categories.
GRADES
1 - Normal healthy patient.
2 - Patient having mild systemic disease that does not limit functional activity.
3 - Severe systemic disease that limits functional activity but not incapacitating.
4 - Incapacitating disease that is constant threat to life. 5 - Morbid patient. 6 - Brain dead.

Review:Biochemistry

CF an autosomal recessive disorder. Approximately 50% will survive to the age of25. In 1989, the CF gene was found to be located on the long arm of chromosome 7. The CF protein is called the cystic fibrosis transmembrane regulatory protein (CFTR). The most common mutation is the three-base deletion removing a phenylalanine residue at position 508 of CFTR, called the F508 mutation. The basic defect is due to a defect in chloride permeability, which can result in the accumulation of mucus and can lead to stasis and obstruction. Both the upper and lower airways can be involved, and they can lead to frequent bronchial infections predominated early by Staphylococcus aureus and Hemophilus influenzae and in late disease by Pseudomonas aeruginosa. The diagnosis is usually made by the sweat test performed by quantitative pilocarpine iontophoresis. CF diagnosis is confirmed by an elevated sweat chloride concentration greater than 60 mEq/L.

There are two types of heat treatments:
Superficial (Surface) and deep.
Superficial heat therapy applies heat to the outside of the body. Deep heat therapy direct heat toward specific inner tissues through ultrasound or by electric current. Heat therapies are beneficial prior to exercise, providing a warm-up effect to the soft tissues involved.
Surface heat
1. Hot water bottle
2. Warm bath
3. Hot socks or compressor
4. Infrared lamp
5. Wax bath.
Deep Heat
1. Shortwave diathermy (heat produced by high frequency alternative current).
2. Ultra sonic therapy
3. Microwave
• Heat produces a soothing effect on many aches and pains, by increasing the blood flow.
• Heat must not be applied to insensitive or ischaemic skin and if there is underlying acute infection or neoplastic tissue.
• Superficial heat - only the skin and subcutaneous tissue are heated
• Deep heat - deeper Structures are heated
• The ultrasonic waves and microwaves penetrate to a considerable depth.
• When the, wave strike the tissue the energy is converted into heat. It is most useful for localised tender fibrous nodules.

Injuries of the trachea are repaired using running 3-0 absorbable monofilament suture.

Most interstitial lung diseases have a predilection for the lower lung zones, including idiopathic pulmonary fibrosis. However, there are several diseases that tend to present predominantly in the upper lung zones, including silicosis, berylliosis, coal worker's pneumoconiosis, cystic fibrosis, eosinophilic granuloma, ankylosing spondylitis, nodular rheumatoid arthritis, late stages of sarcoidosis, lymphan¬gioleiomyomatosis, mycosis, Mycobacterium, and Pneumocystis carinii pneumonia (PCP) found in AIDS patients who are on inhaled pentamidine prophylaxis.

Fever & hyperglycemia both worsen experimental ischemia & have been associated with
worsened clinical outcome after stroke & head trauma. – H17/1722

Anemia associated with a corrected reticulocyte count less than 2% would most likely be seen in a patient with anemia of chronic inflammation (ACD) who is taking iron. In ACD, iron is blockaded in macro phages and is unavailable for hemoglobin synthesis. Iron ther¬apy does not produce any reticulocyte response.
A patient with rheumatoid arthritis who has a nor¬mocytic anemia and a positive direct Coombs test has an autoimmune hemolytic anemia. The corrected reticulocyte count is increased in hemolytic anemias. A patient who received an intramuscular injection of B12 for treatment of pernicious anemia one week ago will have an increased reticulocyte response because the missing raw material for DNA synthesis is now available. A patient with a gastrointestinal bleed 6 days ago will have an increased reticulocyte response because the marrow has had enough time for acceler¬ated erythropoiesis. However, if the bleed was less than 5 days ago, the reticulocyte count would not be increased because the marrow has not had time to produce and release RBCs. A patient with agnogenic myeloid metaplasia has an inappropriate increase in the reticulocyte count because it is not related to eryth¬ropoietin stimulation of the bone marrow.

TOF consists of Right ventricular outflow tract obstruction (infundibular stenosis),
Large Perimembranous VSD, Overriding of aorta and RVH.

• Areas 3, 1 & 2 - Primary Somatosensory Cortex
• Area 4 - Primary Motor Cortex
• Area 5 - Somatosensory Association Cortex
• Area 6 - Premotor cortex and Supplementary Motor Cortex (Secondary Motor Cortex
• Area 7 - Somatosensory Association Cortex
• Area 8 - Includes Frontal eye fields
• Area 17 - Primary visual cortex (V1)
• Area 18 - Secondary visual cortex (V2)
• Area 19 - Associative visual cortex (V3)
• Area 22 - Superior temporal gyrus, caudal part contain the Wernicke's area
• Area 23 & 24 – Ventral cingulate cortex
• Area 29,30,31,32,33 – Ant. and Post. Cingulate cortex
• Area 39 - Angular gyrus, considered to be part of Wernicke's area
• Areas 41 & 42 - Primary and Auditory Association Cortex
• Area 44 - pars opercularis, part of Broca's area
• Area 45 - pars triangularis part of Broca's area

Review:GYNECOLOGY-GENITAL PROLAPSE-

Mafenide acetate is the antibiotic agent that penetrates burn eschar to reach the interface with the patient’s viable tissue. This agent has the disadvantage that it is quite painful on any partial thickness areas & it is a carbonic anhydrase that interferes with renal buffering mechanism. Chloride is retained, and metabolic acidosis results. For these reasons, the silver sulfadiazine is more commonly used in burn centres.

Captopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II. Because angiotensin II acts directly on the adrenal cortex to stimulate the synthesis and release of aldosterone, ACE inhibitors lower both se¬rum angiotensin II and aldosterone levels. The reduction in aldosterone causes a secondary elevation of serum potassium, because aldosterone increases renal sodium retention potassium excretion. Renin levels increase after ACE inhibitors, diuretics, or vasodilators are administered because these agents lower blood pressure, which activates renin secretion. l3-blockers (e.g., propranolol) block the sympathetic component of renin secretion and lower plasma renin levels. Thia¬zide diuretics often decrease serum potassium. Spiro¬nolactone antagonizes aldosterone and may increase serum potassium, but it does not decrease aldosterone serum levels.

All clinical suspected cases should preferably be investigated for malaria by Microscopy or Rapid Diagnostic Kit (RDK).
2. The first line of treatment is chloroquine and the ACT (Artesunate + Sulpha Pyrimethamine) combination is recommended for the treatment of Pf cases in qualified areas like chloroquine resistant areas, cluster of Blocks and identified districts on the basis of epidemiological situation.
3. Pf cases should be treated with chloroquine in therapeutic dose of 25 mg/kg body weight divided over three days. This practice is to be followed at all levels including VHWs like FTDs/ASHA as well in chloroquine sensitive areas. In high risk area in addition to chloroquine, single dose of Primaquine 0.75 mg/kg bw should be given on first day.
4. Microscopically positive Pv cases should be treated with chloroquine in full therapeutic dose of 25 mg/kg body weight divided over three days. This practice is to be followed at all levels including VHWs like FTDs/ASHA etc. Primaquine should be given in dose of 0.25mg/kg bw daily for 14 days as per prescribed guidelines only to prevent relapse except in contraindicated patients which include G6PD patients, infants and pregnant women.
5. Artesunate tablets should not be administered as mono therapy. It should invariably be combined with sulpha pyrimethamine tablets in prescribed dosages.
6. Resistance should also be suspected if in spite of full treatment with no history of vomiting, diarrhea, patient does not respond within 72 hours parasitologically. Such individual patients should be reported to concerned District Malaria /State Malaria Officer/ROHFW Pf monitoring teams for monitoring of drug sensitivity status.
7. In cases resistant to chloroquine and SP-ACT, oral quinine with tetracycline or doxycline can be prescribed.
8. In severe and complicated P. falciparum malaria cases intra-venous Quinine/ parenteral Artemisinine derivatives are to be given irrespective of chloroquine resistance status. This treatment may continue till such time oral Quinine/Artemesinine derivatives become available.

(Ref. Park PSM 19th ed. 205)
A “problem village” has been defined as one where no source of safe water is available within a distance of 1.6 km Q,
or where water is available at depth of more than 15 meters Q,
or water source has excess salinity, iron, fluorides Q and other toxic elements Q
or where water is exposed to the risk of cholera. Q

Even after extensive search in Physiology, Ophthalmology, Biochemistry books and on internet I couldn't get the exact reference for this one. All that I got was:
• 2 vitamin C transporters SVCT -1 and SVCT -2 are Na+ dependent
• Choline and taurine are linked with bile acid.
• No relation has been mentioned any where with vitamin C.
• Myoinositol was also found not to be associated with Vit C
• You can go with Na+-K+ ATPase (TPO).

Culture-negative pulmonary infiltrates may occur in patients with neutrophilic dermatoses
Pyoderma gangrenosum is an uncommon ulcerative skin disorder characterized by rapidly enlarging necrotic ulceration with a muco¬purulent base and violaceous undermined border. It is generally associated with inflammatory bowel disease, arthritis, and immunologic and hematologic disorder; but can also occur in normal persons. The lesions are generally limited to the skin but there may be multisystem involvement such as lungs, heart, joints, eyes, gastrointestinal tract and central nervous system. Pyoderma gangrenosum is characterized by sterile neutrophilic infiltrations of the tissues. The condition is rare in children. Pyoderma gangrenosum is a multisystem neutrophilic disease which requires aggressive treatment with systemic corticosteroids and other immunosuppressive agents.

Retropharyngeal abscess presents with cough, drooling of saliva, respiratory distress, stridor and a bulge in the lateral side of neck. The stridor decreases on lying down owing to the presence of abscess behind the pharyngeal wall which gives way for air to enter or escape in lying down position.
In the rest of the conditions, stridor will not decrease with lying down.

[Scott- Brown’s Otorhinolaryngology Head and Neck Surgery 7th Edition Volume 3 Page 3572]
• Ototoxicity is one of the unwanted side-effects of a number of medical drugs. As ototoxicity appears to be most pronounced in the higher frequencies, it can be assessed at an earlier stage by using high-frequency audiometry from 8 to 20 kHz.
• As a consequence of the cochlear sensitivity for drugs such as the aminoglycosides or cisplatin , ototoxicity presents as sensorineural hearing loss, from higher-frequency first to lower frequencies over time. Therefore, the key is to monitor the highest frequencies possible, either by ultra-high (up to 12 kHz) frequency pure-tone audio¬metry or otoacoustic emissions.
• Otoacoustic emissions are more sensitive at detecting auditory dysfunction than high-frequency pure-tone audiometry during treatment with aminoglycoside or cisplatin.
• They also have the advantages of being practical at the bedside and do not require a soundproofed room.
• Distortion-product otoacoustic emissions are more sen¬sitive than transient-evoked otoacoustic emissions for the detection of early signs of ototoxicity.
• When using audiometry to monitor hearing during treatment with aminoglycosides, it is necessary to monitor both the conventional ( 8 kHz range will only detect around 80 percent of cases of hearing loss.
• The rate of detection of ototoxicity from monitoring ultra-high frequencies alone is around 95 percent during treatment with cisplatin.
• Ultra¬high frequency pure-tone audiometry is technically not possible at the bedside, limiting its clinical utility for non ambulant patients.
• Regular monitoring of auditory function is recom-mended for all patients exposed to oto toxins (aminoglycosides) , particularly groups at high risk, is ¬necessary to detect the earliest signs of ototoxicity. If a high-frequency sensorineural hearing loss is recognized, attempts should be made to modify the patient's chemotherapeutic regime in order to minimize further injury to the cochlea

Review:GYNECOLOGY-GENITAL PROLAPSE-

Ancylostoma braziliense
Most common cause of cutaneous larva migrans common in Central and Southern America
Strongyloides stercoralis
• Acquired percutaneously (e.g. walking barefoot)
• Causes pruritus and larva currens - this has a similar appearance to cutaneous larva migrans but Moves through the skin at a far greater rate
• Abdo pain, diarrhoea, pneumonitis
• May cause Gram negative septicaemia due carrying of bacteria into bloodstream
• Eosinophilia sometimes seen
Management: thiabendazole, albendazole. Ivermectin also used, particularly in chronic infections

Elastic Arteries
• Aorta, pulmonary artery and major branches
• Diameter = 1-2 cm
• Tunica media is rich in elastin (extensible)
• Collagen (prevents overdistension)
Conduit (Muscular) Arteries
• Diameter = 1mm-1cm
• Popliteal, radial, cerebral, coronary arteries
• Tunica media is thicker, contains more smooth muscle
• Rich autonomic nerve supply (contraction and relaxation)
Resistance Vessels
• Main resistance to blood flow resides in the;
• Smallest, terminal arteries (diameter = 100-500mm)
• Arterioles ( • Richly innervated by vasoconstrictor nerve fibres
• Actively regulate local blood flow to match local demand
Capillaries (Exchange vessels)
• Diameter: 4-7mm
• Wall: single layer of endothelial cells
• Wall thickness = 0.5mm
• Large cross-sectional area
• Slow blood velocity
• Red cell transit time = 1-2 sec
Arteriovenous Anastomosis (Shunt vessels)
• Shunt vessels ( diameter = 20-135mm)
• Connect arterioles to venules, bypassing the capillaries
• Present in skin, nasal mucosa
• Temperature regulation
The Veins - “Capacitance Vessels”
• Diameter 50-200mm
• Thin wall
• In limb veins, intima possesses pairs of valves
• Low resistance to flow
• Storing large volumes of blood under low pressure
• ~ 60-70% of the circulating blood volume