By H. Hamil. Lincoln University of Pennsylvania.
A 75-year-old man with a Gleason score of 4 Key Concept/Objective: To know the key prognostic factors for patients with prostate cancer The Gleason grading system is the most commonly used method of classifying prostate can- cers order 75 mg triamterene free shipping. Tumors are graded from 1 (least malignant) to 5 (most malignant) on the basis of his- tologic findings 75 mg triamterene. The two most common patterns observed are then added together to give a composite score. The majority of tumors are classified as Gleason 6 or 7, with grades of 7 or more considered high grade. In the Connecticut Tumor Registry, the two most important determinants of mortality from prostate cancer were age and Gleason grade. The patients at highest risk of dying of prostate cancer are those younger than 74 years and those with Gleason scores of 7 or higher. A 70-year-old patient has been seeing you for treatment of hypertension for several years. Recently, you referred him to a urologist after a prostatic nodule was discovered on DRE and his PSA level was found to be elevated. The urologist diagnosed the patient as having prostate cancer on the basis of the results of a biopsy. He has offered the patient the option of radical prostatectomy or external-beam radiation therapy. The patient asks you about the side effects of these treatments. Most patients undergoing radical prostatectomy will become impotent B. Erectile dysfunction occurs in a minority of patients undergoing exter- nal-beam radiation therapy C. Radical prostatectomy is more likely to produce urinary incontinence or impotence than is external-beam radiation therapy D.
If she is not treated for her HIV infection and gradually develops a low CD4+ T cell count without clinical manifestations of HIV generic triamterene 75 mg online, she has latent infection C buy discount triamterene 75mg on line. If she receives antiretroviral therapy and maintains an elevated CD4+ T cell count but maintains low but detectable plasma levels of HIV-1 RNA, she has persistent infection D. If she receives antiretroviral therapy and achieves an undetectable level of HIV-1 RNA, she has latent infection E. If she is also coinfected with HTLV-I and develops manifestations 40 years later, she can be said to have had chronic infection Key Concept/Objective: To understand the difference between latent, chronic, and persistent infection in the context of retroviral infection Three patterns of restricted viral expression are known; all three patterns are important for retroviral infections. Latent infection is characterized by intermittent episodes of acute or subclinical disease with no virus detected between episodes. For example, when HIV-1 RNA levels are suppressed below detectable levels with antiretroviral ther- apy, the infection is described as latent infection. This should be distinguished from clinical latency, in which manifestations of disease disappear in the setting of ongoing viral replication. Chronic infection implies that the virus is demonstrable but disease is absent. Persistent infection is associated with a long incubation period, slowly increas- ing amounts of virus, and, eventually, symptomatic disease. Thus, the asymptomatic patient who is receiving therapy but in whom viral RNA is still detectable has chronic infection, whereas the untreated patient who has slowly increasing amounts of virus and in whom clinical signs and symptoms will eventually manifest has persistent infec- tion. Which of the following statements regarding various clinical manifestations of HTLV-I infection is true? HTLV-I has a high disease penetrance, meaning that most infected patients will eventually show clinical manifestations of infection B. Patients with adult T cell leukemia (ATL) most commonly present with lymphadenopathy in the absence of circulating morphological- ly abnormal lymphocytes C. Patients with HTLV-I–associated myelopathy (HAM) characteristical- ly have hyperreflexia, ankle clonus, extensor plantar responses, and spastic paraparesis D. Hypocalcemia is a classic manifestation of acute and lymphomatous ATL E. HAM characteristically leads to a deterioration of cognitive function 7 INFECTIOUS DISEASE 97 Key Concept/Objective: To understand the various clinical manifestations of HTLV-I infection HTLV-I only infrequently becomes established as a latent infection with expression of viral gene products. The virus thus has a very low level of disease penetrance.
C Sacral herpes zoster 127 There are twelve pairs of truncal nerves cheap triamterene 75 mg free shipping, which innervate all the muscles and Anatomy skin of the trunk buy generic triamterene 75mg line. The dorsal rami separate immediately after the spinal nerves exit from the nerve root foramina. They pass through the paraspinal muscles, then divide into medial and lateral branches. T1 ventral ramus consists of a large branch that joins the C8 ventral ramus to form the lower trunk of the brachial plexus, and a smaller branch that becomes the first intercostal nerve. T2–T6 are intercostal nerves that pass around the chest wall in the intercostal spaces. Half-way around they give off branches to supply the lateral chest. They end by piercing the intercostal muscles near the sternum to form the medial anterior cutaneous nerve of the thorax. The T2 ventral ramus is unique in size and distribution, and called the intercostobrachial nerve. It supplies the skin of the medial wall and the abdom- inal floor of the axilla, then crosses to the upper arm and runs together with the posterior and medial nerves of the arm (branches of the radial medial cord). The second and third intercostobrachial nerves arise from the lateral cutane- ous branches of the third and fourth intercostal nerves. T7–T11 rami form the thoracoabdominal nerves, and continue beyond the intercostal spaces into the muscles of abdominal wall. They give off lateral cutaneous branches and medial anterior cutaneous branches. The eleventh and twelfth thoracic nerves, below the 12th rib, are called the subcostal nerve. The roots have a downward slant that increases through the thoracic region, such that there is a two-segment discrepancy with vertebral body and segmen- tal innervation. Pain and sensory symptoms at various locations (dorsal, ventral nerve). Muscle weakness only seen if bulging of abdominal muscles can be palpated.