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A 70-year-old male patient who has diabetes and hypertension presents with a complaint of severe flank pain discount imipramine 75mg with mastercard. He was in his usual state of health until 5 days ago purchase imipramine 25mg without a prescription, when he developed intermittent order imipramine 25mg on-line, severe discount imipramine 75 mg on-line, lan- cinating pain that radiated from his midchest to his right flank and then to his right middle back generic 75 mg imipramine amex. He denies having undergone any trauma or having hematuria, dysuria, fever, chills, weight loss, or a histo- ry of renal stones. He also states that his shirt has been "sticking to his back" during this period. On phys- ical examination, the patient is afebrile and has a diffuse vesicular eruption in a T4 distribution with severe pain to palpation. Which of the following statements regarding varicella-zoster virus (VZV) infection is true? Primary varicella infection is communicable and can result in her- pes zoster infection in a contact B. Hospitalized patients with varicella or herpes zoster infection should be isolated to prevent spread of the virus to other susceptible persons C. There is no available medical therapy for herpes zoster eruptions D. Ramsay Hunt syndrome is a herpes zoster eruption in the first branch of the trigeminal nerve Key Concept/Objective: To know the clinical concepts and features of VZV infection Herpes zoster results from the reactivation of VZV infection. Varicella in one patient cannot produce herpes zoster in another; however, persons who are exposed to patients who have herpes zoster can contract varicella. Thus, hospitalized patients with varicella or herpes zoster should be iso- lated to prevent spread of the virus to other susceptible persons. High-dose oral acy- clovir (800 mg five times daily for 7 days), when begun early, may shorten the course and reduce the severity of herpes zoster in otherwise healthy hosts. Oral valacyclovir (1 g three times daily) or famciclovir (500 mg three times daily) may also be used. Ramsay Hunt syndrome is an infection of the geniculate ganglion of the seventh cranial nerve that produces facial paralysis; vesicles on the eardrum and side of the tongue can also occur. A 22-year-old man presents to your clinic with complaints of fever, sore throat, marked fatigue, and myalgias. He denies having had contact with anyone who was sick, and he denies ever having unprotected sexual intercourse. He has had only one sexual partner, with whom he has been having sexual relations for sever- al months. His sore throat has been improving, and he denies hav- ing cough or sputum production. On physical examination, mod- erate pharyngeal injection without exudates is noted, and the spleen tip is palpable and slightly tender. Laboratory testing shows a normal WBC, mild elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, a differential with 10% atypical lymphocytes, and a negative result on heterophil antibody screening. Which of the following statements regarding cytomegalovirus (CMV) infection is true? CMV pneumonitis is a common problem in patients during the first 4 months after organ transplantation 86 BOARD REVIEW B. Heterophil antibodies are formed in response to both CMV and Epstein-Barr virus (EBV) infections C. Despite profound immunosuppression, CMV is an uncommon cause of infection in patients with AIDS D. Detection of CMV in urine or saliva confirms active acute infection Key Concept/Objective: To know the clinical and diagnostic features of CMV infection This otherwise healthy young man has a mononucleosis-like illness and tests negative for heterophil antibodies. CMV mononucleosis occurs in patients of any age but is most common in sexually active young adults. Heterophil antibodies are not formed in response to CMV infection. CMV is recognized as an important pathogen in patients with AIDS. The virus often contributes to the immunosuppression observed in such patients and may cause disseminated disease affecting the eyes, the gastrointestinal tract, or the central nervous system. At least 50% of patients with AIDS have CMV viremia, and 90% or more have evidence of CMV infection at autopsy. Demonstration of viremia is a better indicator of acute infection than the detection of virus in urine or saliva.

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ERCP is the gold standard for diagnosing chronic pancreatitis on the basis of ductal abnormalities buy imipramine 75 mg on line; the degree of duc- tal abnormalities correlates roughly with exocrine dysfunction purchase 75 mg imipramine free shipping. The secretin test discount 50mg imipramine fast delivery, in which duodenal contents are sampled before and after secretin is administered intravenously purchase imipramine 50 mg mastercard, is probably the most sensitive direct assessment of pancreatic exocrine function purchase 75 mg imipramine with visa, but because of improvement in imaging tests, the secretin test is used infrequently. A 15-year-old girl presents to the emergency department complaining of right upper quadrant pain. She has had two similar episodes in the past 3 months. The pain is located in the epigastrium and radiates to the right shoulder. The patient is also complaining of nausea and vomiting. At presentation, she says the pain is starting to disappear. On physical exami- nation, the patient has tenderness to palpation in the right upper quadrant. Laboratory testing shows a white cell count of 7,000, a hematocrit of 26%, and a normal platelet count. Her liver function test results are significant only for an indirect bilirubin of 2 mg/dl. Ultrasonography shows three stones in the gall- bladder, no pericholecystic fluid, and no gallbladder wall edema. The patient should be started on antibiotic therapy; in 2 to 3 days, after this acute process resolves, a cholecystectomy should be per- formed B. The patient has acute viral hepatitis; the gallstones are an incidental finding C. If the patient undergoes a cholecystectomy, an analysis of the gall- stones is likely to show black pigment stones D. An endoscopic retrograde cholangiopancreatography (ERCP) should be done, because it is likely that a stone has passed to the common bile duct and is now causing obstruction Key Concept/Objective: To understand the processes that lead to the formation of gallstones Two principal types of stone, the cholesterol stone and the pigment stone, form in the gall- bladder and biliary tract. The cholesterol stone is composed mainly of cholesterol (> 50% of the stone) and comprises multiple layers of cholesterol crystals and mucin glycopro- teins. The pigment stones contain a vari- ety of organic and inorganic components, including calcium bilirubinate (40% to 50% of dry weight). Black pigment stones are most often seen in patients with cirrhosis or hemolytic anemia and are found predominantly in the gallbladder. This patient likely has biliary colic secondary to gallstones. Her laboratory results show evidence of hemolysis (low hematocrit, increased indirect bilirubin). Acute cholecystitis is unlikely in this clini- cal scenario because the pain is starting to disappear after 3 hours, there is no fever, and there is no evidence of leukocytosis on complete blood count. Also, ultrasonography did not show evidence of acute cholecystitis, such as the presence of pericholecystic fluid or edema of the gallbladder. Acute viral hepatitis can present as right upper quadrant pain; however, it is unlikely in this case because the pain is acute and is starting to resolve, and the only abnormal liver function test result is the indirect bilirubin value, suggesting hemolysis. An ERCP is not indicated because there is no evidence of obstruction or cholestasis, such as an elevation in the direct bilirubin level or the alkaline phosphatase level or a finding of a dilated common bile duct on ultrasound. You are asked to consult regarding a 52-year-old man with fever who is in the surgical intensive care unit. The patient has been in the hospital for 6 weeks after being injured in a car accident. He had a cranial fracture and multiple rib fractures; three feet of his jejunum were surgically removed, and he has had multiple complications since then, including pneumonia, sinusitis, and coagulase-negative Staphylococcus bacteremia. All of these complications seem to have resolved with adequate treatment. Over the past 2 days, he has developed increasing fever. He is still intubated and on total parenteral nutri- tion. On physical examination, the patient’s temperature is 102° F (38. The patient has jaundice, and there is tenderness in the right upper quadrant. The examination is otherwise unchanged from previous notes in the chart.

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The process of osteocon- duction involves the scaffold that provides the necessary support on which new bone can grow to fill the defect area buy imipramine 75 mg with mastercard. As new bone continues to grow to fill the defect area buy imipramine 75 mg without prescription, the process of resorption and remodeling occurs generic imipramine 25 mg online. The development of synthetic materials that can extend the limited supply of natural bone grafts while providing these critical elements has been the focus of much research purchase 50 mg imipramine. One synthetic material that shows promise in this regard is a porous formulation based on the biopolymer poly(propylene glycol-co-fumaric acid) (PPF) order 50mg imipramine fast delivery. This polymer can be crosslinked in the presence of effervescent agents and osteoconductive filler to create a scaffold that mimics the physical and chemical properties of human cancellous bone. A combination of this formulation and an osteoinductive material, such as morselized cancellous autograft, venous blood, or bone marrow, comprises a material with improved handling characteristics and the potential for improved clinical results relative to other composite materials. This paper reviews a series of in vitro and in vivo studies on the use of a PPF-based material as a bone graft extender for use in clinically relevant repair scenarios. AUTOGRAFT BONE Iliac crest autograft is the gold standard for bone graft material. Autograft bone provides the critical elements required for bone growth. The material is also able to maintain the strength and structural integrity of the defect area. Despite these advantages, the material suffers from several disadvantages. The primary disadvantage is the need for a secondary surgical site. Autografts are predominantly removed from the iliac crest of the patient. The procedure of harvesting material from the iliac crest has been shown to cause complications in 4–49% of patients. These complications can range from increased pain—observed in 25% of patients—to infection, sensory loss, and neurologi- cal and vascular injury. Further complications include increased anesthesia time and operative blood loss as well as prolonged recovery time. In addition to the procedural complications, the supply of bone available for harvest is limited. These complications, along with the risk of donor site morbidity and the limited supply of material available for harvest, have pushed the search for alternative materials. ALLOGRAFT BONE Allograft bone is the substitute most often used for autograft bone. It is typically available fresh, frozen, or freeze-dried. This material undergoes extensive processing and donor screening in an effort to reduce the risk of disease transmission. This processing decreases but does not eliminate the risk of disease transmission. In addition, the processing decreases the mechanical and biological properties of the bone, while adding to the cost of the material. In summary, although a viable alternative to autograft bone, allograft bone suffers from concerns of possible disease transmission, recipient rejection, increased cost, and limited availability. SUBSTITUE BONE GRAFT MATERIALS The problems associated with autograft and allograft materials described above, not the least of which is the increasing demand for a limited supply, have acted to fuel the development of substitute materials. Substitute materials have primarily been developed as a replacement for graft materials and currently are used in approximately 10% of the bone graft procedures per- formed worldwide. Calcium salt ceramics and glasses, such as calcium phosphates and hydroxyapatites, are widely used synthetics. Demineralized bone and collagen-based materials have also been used as substitute bone graft materials. Calcium phosphate materials such as tricalcium phosphate (TCP) and hydroxyapatite (HA) are among the most common synthetics. These materials have been successfully applied in orthopedic and dental applications for decades. Calcium salt materials have compositions similar to that of native bone and provide osteoconductive surfaces on which new bone can form. Although somewhat similar in composition, the materials elicit different biological responses.

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