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White and minority populations are affected with equal frequency E buy depakote 250 mg without prescription. Incidence rates are higher in inner-city populations than in rural ones Key Concept/Objective: To understand the epidemiology of syphilis Disease caused by the spirochete Treponema pallidum has been recognized for centuries buy depakote 500 mg. With advances in drug therapy and diagnostic methods cheap depakote 250 mg on-line, the control and, possibly, the eradication of syphilis in the United States have become realistic goals. Syphilis is transmitted through sexual contact primarily, with few cases associated with nonsexual exposure. The highest rates of infection occur in inner-city populations with lower socioeconomic status and are largely confined in the 22 BOARD REVIEW southeastern United States. Minorities are affected to a much higher degree than whites (25:1 in some studies). The high rates of new syphilis cases among inner-city popula- tions in the late 1980s and early 1990s has been linked strongly to the epidemic use of crack cocaine. Which of the following findings would NOT be consistent with the secondary stage of syphilis? Diffuse, painless lymphadenopathy and patchy alopecia B. A hyperpigmented maculopapular rash involving the trunk, extrem- ities, palms, and soles C. Signs and symptoms of meningitis (fever, stiff neck, photophobia) accompanied by abnormalities of the cerebrospinal fluid D. A single indurated and nontender ulcerative genital lesion accompa- nied by nonsuppurative regional lymphadenopathy E. Raised, moist, nontender plaques in intertriginous areas and on mucosal surfaces, the swabbing of which reveals spirochetes on darkfield microscopy Key Concept/Objective: To know the distinguishing features of secondary syphilis Once T. The characteristic lesion of primary syphilis is the chancre, an indurated, painless ulcer that can be up to 1 to 2 cm in size. Without treatment, the chancre typically resolves in 2 to 8 weeks; in a majority of cases, the chancre is not present by the time signs and symptoms of dissemination (secondary syphilis) develop. The clinical findings of secondary syphilis are varied but often include fever, malaise, diffuse lymphadenopathy, patchy alopecia, and a charac- teristic maculopapular rash, which involves the palms and soles. Condylomata lata, which are moist, indurated plaques (not truly ulcers) that occur primarily in intertrigi- nous areas, are typically seen in patients with secondary syphilis. They are teeming with organisms and are highly infectious. Although symptomatic parenchymal neu- rosyphilis is commonly associated with late-stage (tertiary) syphilis, up to 40% of patients with secondary disease have involvement of the CNS, manifested clinically as meningitis. A positive CSF–Venereal Disease Research Laboratory (CSF-VDRL) test result confirms neurosyphilis in this setting, but the sensitivity ranges only from 30% to 70%. A 32-year-old man presents to the health department to establish primary care. He has not seen a physi- cian since childhood and reports no chronic medical problems. On review of systems, he relates that approximately 1 year ago he developed an illness consisting of fever, "swollen glands," and a diffuse rash, which involved the palms. The illness resolved after a few weeks, and he did not seek medical care. Over the past 2 years, he has had several sexual partners, and he states he has not routinely used condoms. For this patient, which of the following findings would be most consistent with latent syphilis infection? Diffuse, painless lymphadenopathy and a faint, widespread macular rash B. A rapid plasma reagin (RPR) titer of 1:32 and negative results on flu- orescent treponemal antibody-absorption (FTA-ABS) testing C. An RPR titer of 1:16 and positive results on FTA-ABS testing D. An RPR titer of 1:256 and positive results on FTA-ABS testing E. Negative results on RPR and FTA-ABS testing 7 INFECTIOUS DISEASE 23 Key Concept/Objective: To know the clinical and laboratory findings of latent syphilis Latency refers to the period after resolution of secondary disease during which there are no signs or symptoms of disease: thus, by definition, there are no clinical findings to suggest active infection.

Probably the most common causes are chronic heart failure and cirrhosis of the liver with ascites buy depakote 500 mg mastercard. A 54-year-old woman comes to your clinic for a routine visit buy generic depakote 500mg line. Her medical history is positive only for mild asthma and arterial hypertension best depakote 250 mg. Her only medications are albuterol, which she administers with a measured-dose inhaler as needed, and an angiotensin-converting enzyme inhibitor. You have a discussion with her regarding her risk of osteoporo- sis, and you decide to obtain a dual-energy x-ray absorptiometry (DEXA) scan for screening. Her creatinine and albumin levels are normal, her liver function tests are normal except for a slightly elevated alkaline phosphatase level, and her calcium level is 11 mg/dl. What is the most appropriate step to take next in the treatment of this patient? Start bisphosphonate, calcium, and vitamin D, and reassess in 6 months 6 BOARD REVIEW B. Measure the parathyroid hormone (PTH) level with a two-site immunoradiometric assay (IRMA, or so-called intact PTH) and assess 24-hour urinary calcium output C. Order CT scans of the chest and abdomen to look for an occult malignancy D. Start hormone replacement therapy with estrogens and progestins Key Concept/Objective: To understand the appropriate initial evaluation of a patient with hyper- calcemia This patient presents with mild, asymptomatic hypercalcemia. The most common cause of hypercalcemia in outpatients is hyperparathyroidism. The differential diagnosis of hypercalcemia is extensive. Once hypercalcemia is confirmed, the next step is to measure the serum PTH concentration. Other helpful tests include blood urea nitrogen (BUN), serum creatinine, alkaline phosphatase, and serum inorganic phosphorus assays; an electrolyte panel; and an assessment of 24-hour urinary calcium output. If the levels of PTH are elevated or inappropriately normal, the hypercalcemia is said to be PTH mediat- ed. When PTH levels are suppressed, the hypercalcemia is said to be non–PTH mediated. Patients with hyperparathyroidism typically have a serum calcium concentration of less than 12 mg/dl; mild to moderate hypophosphatemia; and non–anion gap acidosis (from renal tubular acidosis). Urinary calcium excretion is usually increased; in these patients, the reduction of fractional calcium excretion by PTH is overcome by the high filtered cal- cium load, which may result in nephrolithiasis. The levels of alkaline phosphatase can be elevated as well. Before starting a more extensive evaluation in this patient, it is necessary to exclude the possibility of primary hyperparathyroidism. A 45-year-old man with a history of primary hyperparathyroidism comes to your clinic for a follow-up visit. He was diagnosed 3 years ago after routine blood tests revealed an elevation in calcium level. Review of systems is negative, and his physical examination is unremarkable. His family history is negative for similar problems. What is the most appropriate treatment regimen for this patient? Observation, with routine follow-up visits that include assessment of calcium levels and DEXA scans B. Refer to an experienced surgeon for parathyroid surgery D. Administer calcium, 1,000 to 1,500 mg/day, and vitamin D, 400 to 800 IU/day Key Concept/Objective: To understand the surgical indications for hyperparathyroidism Treatment of the patient with hyperparathyroidism must take into account the degree of the hypercalcemia, the presence of symptoms, and the severity of any end-organ damage. Because many patients with hyperparathyroidism are either asymptomatic or minimally symptomatic, there is controversy over which patients require definitive therapy with sur- gery. The 2002 National Institutes of Health Workshop on Asymptomatic Primary Hyperparathyroidism defined the following indications for surgical intervention: (1) sig- nificant bone, renal, gastrointestinal, or neuromuscular symptoms typical of primary hyperparathyroidism; (2) elevation of serum calcium by 1 mg/dl or more above the nor- mal range; (3) marked elevation of 24-hour urine calcium excretion (> 400 mg); (4) decreased creatinine clearance (reduced by 30%); (5) significant reduction in bone density (T score < –2.

Instead of speculating that strains below a certain threshold are “trivial” and evoke no adaptive response buy cheap depakote 250mg on line, Frost suggests that a range of strain values elicits no response discount 500 mg depakote. The aforementioned FNT proposed by Frost generic 250mg depakote mastercard, however, has been criticized on the basis that bones are naturally curved, and need be. It must be kept in mind that Frost’s theory concerns load-induced changes in surface curvature rather than absolute curvature. Martin22 suggests that if Frost originally expressed his theory in terms of a variable more directly related to strain and divorced from notions of local © 2001 by CRC Press LLC anatomic conformation, the confusion and debate may have been reduced. All controversy aside, Frost is commonly credited with providing the conceptual framework from which many of the current mechan- ical theories have been guided. Pauwels’ Stress Magnitude Theory Pauwels62 proposed a model for predicting the cortical thickness of diaphyseal bone as a function of the axial stresses due to bending. Accurate predictions were attained with respect to distortions in the cross- sectional geometry of a rachitic femur, through simplified assumptions relating surface remodeling to stress. Simplifying the initial femoral cross-section to a hollow elliptical geometrical configuration, the surface stress, σs, was calculated as a function of a simulated hip load. Alterations were made to the cortical thickness (Tc) via the following power function: T = a + bσ n (2. Following an iterative process, the final stage (considered an equilibrium point) closely resembled the geometrical configuration of the actual bone. The rationale for the algorithm defining his model was not explained in detail; nonetheless, his efforts established the capabilities of a simplistic model to predict generalized adaptive geometries. Kummer63 advanced a concrete form of Pauwels’ theory which has been carefully reviewed by Firoozbakhsh and Cowin. The cubic relationships developed by Kummer accounted for the adaptive changes associated with pressure necrosis, but neglected those associated with disuse atrophy. Cowin’s Adaptive Elasticity Theory The mathematically rigorous and potentially powerful theory proposed by Cowin and colleagues,56,65-67 was developed to describe the physiological adaptive behavior of bone. The basic hypothesis governing the thermomechanical continuum theory of adaptive elasticity is that the load-adapting properties of living bone can be modeled by a chemically reacting porous medium in which the rate of reaction is strain controlled. The objective was to model bone as a porous elastic solid and to model the normal adaptive processes that occur in bone remodeling as strain controlled mass deposition or resorption processes which modify the porosity of the porous elastic solid. In addition, it was shown that remodeling will not occur in a long bone, such as the femur, as a result of a purely torsional load about its long axis. In the years that followed, Cowin and Firoozbakhsh68 presented a somewhat less rigorous surface adaptation model in which bone assumed a site-specific homeostatic equilibrium strain state. Control equations, in which the rate of remodeling is proportional to the deviation from a reference (homeostatic) value were developed. Consequently, any aberrant strain state would influence bone remodeling in an attempt to reinstate homeostatic conditions via the following formula: o U ij ij ij (2. The Cij establishes a generalized matrix of remodeling coefficients. It should © 2001 by CRC Press LLC be noted that the authors relied on generality for the choice of Cij, without reference to a biological basis. The values of the remodeling rate coefficients are necessary for a model to prove biologically useful, as the Cij tensors contain coefficients for each component of strain. Experimental procedures indicate that the coefficients vary with each test model, consequently eliminating the ability to describe adaptation in a generalized sense. Cowin and associates64 performed cubic approximations of the theory of internal remod- eling, and performed numerous studies attempting to establish possible values of the remodeling coeffi- cients. Cowin and associates6 also described a computational approach to the theory of surface remodeling enroute to predicting in vivo values for surface remodeling rate coefficients. Employing the surface remodeling theory established by Cowin and Van Buskirk,67 Cowin and Firoozbakhsh68 presented a variety of theoretical predictions of surface remodeling in the diaphysis of long bones. For example, both endosteal and periosteal surfaces can move in either direction, in or out, in the same or opposing directions. It is possible for the medullary canal to fill completely, subsequently causing the endosteal surface to vanish.

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