SIMULADOR DE EXAMENProfra. Elvira Caballero García

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1.- ROSIGLIATAZONE EVALUATED FOR CARDIOVSCULAR OUTCOMES IN ORAL AGENT COMBINATION THERAPY FOR TYPE 2 DIABETES (RECORD): A MULTICENTRE, RANDOMISED, OPEN –LABEL TRIAL. PHILIP D HOME DM, STUART J POCOCK PHD. AND COLLEAGUES. ROSIGLITAZONE IS AN INSULIN SENSITISER USED IN COMBINATION WITH MEFORMIN, A SULFONYLUREA, OR BOTH, FOR LOWERING BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. WE ASSESSED CARDIOVASCULAR OUTCOMES AFTER ADDITION OF ROSIGLITAZONE TO EITHER METFORMIN OR SULFONYLUREA COMPARED WITH THE COMBINATION OF THE OVER 5-7 YEARS OF FOLLOW UP. WE ALSO ASSESSED COMPARATIVE SAFETY METHODS.

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IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447 PATIENTS WITH TYPE 2 DIABETES ON METFORMIN OR SULFONYLUREA MONOTHERAPY WITH MEAN HAEMOGLOBIN A1C (HB A1C) OF 7-9% WERE RANDOMLY ASSIGNED TO ADDITION OF ROSIGLITAZONE (N=2220) OR TO A COMBINATION OF METFORMIN AND SULFONYLUREA (ACTIVE CONTROL GROUP, N=2227). THE PRIMARY ENDPOINT WAS CARDIOVASCULAR HOSPITALISATION OR CARDIOVASCULAR DEATH, WITH A HAZARD RATIO (HR) NON INFERIORITY MARGIN OF 1.20. ANALYSIS WAS BY INTENTION TO TREAT. THIS STUDY IS REGISTERED WITH GOVERNMENT CLINICAL TRIALS NUMBER NCT00379769.

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FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 IN THE ACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOME DURING A MEAN 5-5 YEAR FOLLOW UP, MEETING THE CRITERION ON NON-INFERIORITY (HR 0.99, 95% CL 0.85-1.16). HR WAS 0-84 (0-59) FOR CARDOVASCULAR DEATH, 1-14 (0.80 – 1.63) FOR MYOCARDIAL INFARCTION, AND 0.72 (0.49-1.06) FOR STROKE. HEART FAILURE CAUSING ADMISSION TO HOSPITAL OR DEATH OCCURRED IN 61 PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE ACTIVE CONTROL GROUP (HR2.10, 1.35 – 3.27, RISK DIFFERENCE PER 1000 PERSON-YEARS 2.6, 1.1-4.1). UPPER AND DISTAL LOWER LIMB FRACTURE RATES WERE INCREASED MAINLY IN WOMEN RANDOMLY ASSIGNED TO RSIGLITAZONE. MEAN HBA1C WAS LOWER IN THE ROSIGLITAZONE GROUP THAN IN THE CONTROL GROUP AT 5 YEARS.

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INTERPRETATION. ADDITION ROSIGLITAZONE TO GLUCOSE LOWERING THERAPY IN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO INCREASE THE RISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN WOMEN. ALTHOUGH THE DATA ARE INCONCLUSIVE ABOUT ANY POSSIBLE EFFECT ON MYOCARDIAL INFARCTION, ROSIGLITAZONE DOES NOT INCREASE THE RISK OF OVERALL CARDIVASCULAR MORBIDITY OR MORTALITY COMPARED WITH STANDARD GLUCOSE –LOWERING DRUGS.

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WHAT WAS THE MAIN PURPOSE OF THE STUDY?

a) TO TREAT PATIENTS WITH TYPE 2 DIABETES.

b) TO DETERMINE THE INCIDENCE OF HOSPITALIZATION IN PATIENTS TAKING ROSIGLITAZONE.

c) TO DISCOVER THE EFFECTS THAT ROSIGLITAZONE HAS ON HEART FAILURE IN PATIENTS WITH TYPE 2 DIABETES

d) TO GET GOVERNMENT APPROVAL FOR ROSIGLITAZONE

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2. ROSIGLITAZONE IS AN INSULIN SENSITISER USED TO:

a) LOWER INSULINE IN PEOPLE WITH TYPE 2 DIABETES.

b) LOWER BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES.

c) INCREASE BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES.

d) DIMINISH INSULINE IN PEOPLE WITH TYPE 1 DIABETES.

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3. WHAT DID THE TWO GROUPS HAVE IN COMMON?

a) PARTICIPANTS WERE GIVEN SULFONYLUREA.

b) PARTICIPANTS WERE GIVEN ROSIGLITAZONE.

c) PARTICIPANTS HAD NEARLY SIMILAR LEVELS OF HBA1C.

d) PARTICIPANTS WERE ALL FROM THE SAME CENTRE.

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4.WHAT DOES THE AUTHOR CONCLUDE REGARDING THE SAFETY OF ROSIGLITAZONE IN GLUCOSE-LOWERING THERAPY FOR PATIENTS WITH TYPE-2 DIABETES?

a) THE PERCENTAGE OF PATIENTS RESULTING IN HEART FAILURE WAS VERY HIGH FOR BOTH GROUPS.

b) ROSIGLITAZONE, IN GENERAL, CAUSES HEART FAILURE.

c) ROSIGLITAZONE IS GENERALLY SAFE, BUT NOT FOR WOMEN.

d) ROSIGLATAZONE SHOULD BE USED ONLY FOR MALE PATIENTS.

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5. ADDITION ROSIGLITAZONE TO GLUCOSE LOWERING THERAPY IN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO:

a) INCREASE THE RISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN MEN.

b) INCREASE THE RISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN WOMEN.

c) THE DATA ARE CONCLUSIVE ABOUT ANY POSSIBLE EFFECT ON MYOCARDIAL INFARCTION.

d) ROSIGLITAZONE INCREASES THE RISK OF OVERALL CARDIVASCULAR MORBIDITY.

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2. PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAEL DERMATOLOGIC CLINICS - VOLUME 25, ISSUE 3 W. B. SAUNDERS COMPANY JULY 2007 PITYRIASIS ALBA (PA) IS A COMMON DISORDER OBSERVED IN LATIN AMERICAN PATIENTS. LESIONS DISCLOSE HYPOPIGMENTATION, MAINLY OBSERVED ON FACIAL AREAS AND SUNLIGHT EXPOSED SURFACE OF ARMS AND FOREARMS; THOSE ON THE TRUNK AND LOWER EXTREMITIES ARE LESS COMMON. AN ATOPIC DIATHESIS IS PRESENT IN MOST PATIENTS, AND THE CONDITION FREQUENTLY DEVELOPS IN CHILDREN AND YOUNG ADULTS. THE AVERAGE LESION BEGINS WITH A SLIGHTLY HYPOPIGMENTED MACULE THAT ENLARGES GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCE WITH NEIGHBORING MACULES,

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RESULTING IN LARGER HYPOPIGMENTED DEFECTS. A FINE DESQUAMATION AND DRYNESS OF SKIN ARE CHARACTERISTIC AND THE CLINICAL PICTURE USUALLY WORSENS DURING SUMMER OR DURING FREQUENT WATERSPORT ACTIVITIES. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS AT THE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON HISTOLOGIC EXAMINATION, EPIDERMAL AND FOLLICULAR SPONGIOSIS, FOCAL PARAKERATOSIS, SLIGHT ACANTHOSIS, AND MILD SUPERFICIAL PERIVASCULAR INFILTRATES ARE SEEN.

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IN A STUDY, ULTRASTRUCTURAL EXAMINATION DISCLOSED SMALL AND REDUCED NUMBERS OF MELANOCYTES AND MELANOSOMES. ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTER PUBERTY, LOW POTENCY CORTICOSTEROIDS, SUCH AS 1% HYDROCORTISONE OR 0.5% DESONIDE, FREQUENT EMOLLIENT APPLICATION, AND SUNLIGHT AVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THIS DISORDER. SKIN CONTACT WITH DIVERSE CHEMICALS MAY INDUCE ACQUIRED HYPOPIGMENTATION, WHICH MAY OCCUR EITHER DURING PROFESSIONAL ACTIVITIES OR AS AN INCIDENTAL EVENT.

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AREAS OF CONTACT, SUCH AS HANDS AND FEET, MAY BECOME AFFECTED WITH OR WITHOUT INITIAL DERMATITIS, AND THEREAFTER HYPOPIGMENTATION OCCURS. SOME OF THE INVOLVED CHEMICALS ARE CATECHOL AND BENZENE DERIVATIVES USED AS ANTISEPTICS AND CLEANSERS, PESTICIDES, AND EPOXY RESINS COMMONLY USED IN HOUSEHOLD WORK. MACULAR LESIONS SHOW DIFFERENT GRADES OF HYPOPIGMENTATION OR TRUE DEPIGMENTATION INDISTINGUISHABLE FROM VITILIGO; A PREVIOUS HISTORY OF SUBSTANCE CONTACT AND DERMATITIS ARE IN FAVOR OF THE CHEMICAL NATURE OF DEPIGMENTATION .

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ON HISTOLOGIC EXAMINATION, JUST A FEW MELANOCYTES ARE PRESENT AND REDUCED OR ABSENT MELANIN IS OBSERVED. TREATMENT OF DEPIGMENTATION IS DIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS ARE INVOLVED AND MELANOCYTES IN AFFECTED AREAS ARE SCARCE. IF VITILIGO-LIKE DEPIGMENTATION BECOMES REFRACTORY TO MEDICAL THERAPY, MELANOCYTE GRAFTING MAY BE AN IMPORTANT THERAPEUTIC SOLUTION.

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6.- PITYRIASIS ALBA IS A COMMON DISORDER FREQUENTLY OBSERVED IN:

a) ARMS AND LEGS

b) FACE, ARMS AND FOREARMS

c) TRUNK AND LOWER EXTREMITIES

d) FACE, ARMS AND LEGS

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7.-THE AVERAGE LESION BEGINS WITH A SLIGHTLY HYPOPIGMENTED SPOT THAT:

a) GROWS FROM 1 TO 3 CM.

b) REDUCES FROM 1 TO 3 CM

c) ENLARGES TO 5 CM. INDEPENDENTLY

d) CHANGES COLOR

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8.-TO CONTROL THIS DISORDER IT IS USEFUL TO:

a) USE ANON FREQUENT EMOLLIENT APPLICATION

b) USE HIGH POTENCY CORTICOSTEROIDS

c) KEEP AWAY FROM THE SUN.

d) LACK THE PROTECTION OF THE SUN

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9.-HYPOPIGMENTATION OCCURS WHEN:

a) SKIN HAS CONTACT WITH DIVERSE CHEMICALS

b) WE HAVE INCIDENTAL ACTIVITIES

c) WE TAKE CORTISONE

d) WE USE SUN PROTECTION

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10.-PITYRIASIS ALBA IS DANGEROUS BECAUSE:

a) PATIENTS BECOME INTOLERANT TO LIGHT

b) SOME OF THE TREATMENTS ARE TOXIC

c) PRE-CANCEROUS LESIONS CAN FORM

d) DELICATE SURGERY IS SOMETIMES REQUIRED

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3.- UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN ZORC, JOSEPH J. CLINICAL PEDIATRIC EMERGENCY MEDICINE EL SERVIER DOI.10.1016.CPEM.209.03.008 MARCH 2009. UPPER RESPIRATORY TRACT INFECTIONS (INCLUDING OTITIS MEDIA) ARE THE MOST COMMON ILLNESSES AFFECTING CHILDREN. ON AVERAGE, CHILDREN EXPERIENCE AROUND SIX TO EIGHT UPPER RESPIRATORY TRACT INFECTIONS (URTIS) EACH YEAR. ALTHOUGH THESE INFECTIONS USUALLY ARE MILD AND SELF LIMITING, THEY OCCASIONALLY LEAD TO COMPLICATIONS THAT CAN BE LIFE THREATENING. MOST URTIS CAN BE PLACED WITHIN THREE MAIN CATEGORIES OF INFECTION: RHINOSINUSITIS, PHARYNGITIS, AND OTITIS MEDIA.

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WITHIN EACH CATEGORY OF ILLNESS THERE IS A RANGE OF RELATED CONDITIONS THAT MAY HAVE SIMILAR OR OVERLAPPING CLINICAL PRESENTATIONS. SOME JUDGMENT IS REQUIRED IN DETERMINING WHICH PART OF THE RESPIRATORY MUCOSA IS MOST AFFECTED. IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TO DESCRIBE ILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS (INCLUDING THE COMMON COLD, NASOPHARYNGITIS, AND SINUSITIS). THE TERM “PHARYNGITIS” IS USED TO DESCRIBE ILLNESSES WHEN SORE THROAT IS MOST PROMINENT (INCLUDING TONSILLITIS).

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THE TERM “OTITIS MEDIA” IS USED TO DESCRIBE ILLNESSES WITH PREDOMINANTLY MIDDLE EAR SYMPTOMS (INCLUDING ACUTE OTITIS MEDIA [AOM], OTITIS MEDIA WITH EFFUSION [OME], AND CHRONIC SUPPURATIVE OTITIS MEDIA [CSOM]). CHILDREN WHO HAVE COUGH AS THE PREDOMINANT SYMPTOM ARE CONSIDERED TO HAVE BRONCHITIS (A LOWER RESPIRATORY TRACT INFECTION).

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TO MAKE MATTERS MORE COMPLICATED, ALL AREAS OF THE RESPIRATORY MUCOSA MAY BE AFFECTED, SIMULTANEOUSLY OR AT DIFFERENT TIMES, DURING ONE ILLNESS. THE CAUSE OF THESE RESPIRATORY MUCOSAL INFECTIONS MOST COMMONLY IS VIRAL BUT CAN BE BACTERIAL AND MANY INFECTIONS INVOLVE BOTH VIRUSES AND BACTERIA. IN DEVELOPED COUNTRIES, BOTH VIRAL AND BACTERIAL INFECTIONS ARE LIKELY TO BE SELF LIMITED. PERSISTENT DISEASE IS MOST LIKELY TO INDICATE A BACTERIAL INFECTION.

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11.- WHY ARE UPPER RESPIRATORY TRACT INFECTIONS SO DIFFICULT TO DIAGNOSE IN CHILDREN?

a) THEY GET MANY OF THEM.

b) THE SYMPTOMS OF DIFFERENT URTIS OVERLAP.

c) THERE ARE DIFFERENT KINDS OF URTIS.

d) VIRAL AND BACTERIAL INFECTIONS EXIST.

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12.- AN EXAMPLE OF A LOWER RESPIRATORY INFECTION IS:

a) NASOPHARYNGITIS.

b) BRONCHITIS.

c) SINUSITIS.

d) TONSILLITIS.

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13.- THE CAUSE OF THE ILLNESS IN RESPIRATORY INFECTIONS IS BEST DETERMINED BY THE:

a) SYMPTOMS.

b) PRESENCE OF A VIRAL INFECTION.

c) PRESENCE OF A BACTERIAL INFECTION.

d) AFFECTED PART OF THE RESPIRATORY MUCOSA.

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14. THE MAIN AREA AFFECTED IN INFECTIONS TERMED "OTITIS MEDIA" IS THE:

a) EYE

b) EAR

c) NOSE

d) THROAT

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15.- OME, AOM, AND SCOM ALL BELONG TO THE FAMILY OF THE INFECTION CALLED:

a) BRONCHITIS

b) PHARYNGITIS

c) RHINOSINUSITUS

d) OTITIS MEDIA

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16.- ABOUT THE DESIGN OF THE STUDY:a) RESEARCHERS USE A PROSPECTIVE DESIGN,

PARTICIPANTS WERE FAMILY MEDICINE SPECIALIST FROM MEXICO CITY SELECTED AT RANDOM.

b) PARTICIPANTS ARE SELECTED AT RANDOM FROM A FAMILY MEDICINE CLINIC FROM AN ELDERLY FEMALE POPULATION.

c) ELDERLY PATIENTS WERE INCLUDED WITHOUT CONSIDERING GENDER.

d) IT WAS ORIGINALLY PLANNED TO BE DONE IN THREE MONTHS.

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17.- THE INCLUSION OF PATIENT CRITERIA WAS:a) CERTAINLY NOT TO HAVE ANY BRAIN DAMAGE.

b) TO HAVE COGNITIVE COMPETENCE PROVEN BY THE FOLSTEIN MINI MENTAL STATE EXAMINATION.

c) NOT TO ACCEPT TO PARTICIPATE IN THE STUDY

d) THERE WERE INCOMPLETE OR ILLEGIBLE MEDICAL RECORDS.

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18.-RESEARCHERS OBTAIN THE INFORMATION ABOUT DIAGNOSIS, DRUGS PRESCRIPTIONS, AND PHARMACOLOGICAL AND NO PHARMACOLOGICAL GASTROESOPHAGEAL PROTECTION FROM:a) A SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST.

b) A CARLSSON-DENT TEST.

c) CLINIC DATABASES.

d) PATIENT RECORDS.

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19.-THE AIM OF THE STUDY GAVE AS A RESULT:

a) GERD PREVALENCE WAS 25%.

b) AVERAGE AGE OF PATIENTS WITH AND WITHOUT GERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARS RESPECTIVELY.

c) WOMEN SUFFERED GERD MORE FREQUENTLY THAN MEN.

d) ANTACIDS, H2 AS AND WERE PRESCRIBED IN 39% OF PATIENTS WITH GERD.

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20.- THE MAIN CONCLUSION OF THE STUDY WAS:

a) PATIENTS WITHOUT GERD STILL RECEIVED TREATMENT.

b) PARTICIPANTS OFTEN HAD GERD SYMPTOMS.c) PATIENTS IDENTIFIED WITH GERD SYMPTOMS

WERE DIAGNOSED AND FOLLOWED UP CORRECTLY.

d) THE CARLSSON-DENT QUESTIONNAIRE WAS THE BEST ALTERNATIVE TO IDENTIFY GERD PATIENTS.

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4.- FREQUENCY OF GERD SYMPTOMS IN ELDERLY PATIENTS WHO COME TO A FAMILY MEDICINE CLINIC. OBJECTIVES: TO ASCERTAIN THE PREVALENCE OF GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN ELDERLY PEOPLE ATTENDING TO FAMILY MEDICINE CLINICS. MATERIAL AND METHODS: THE STUDY WAS CONDUCTED BY USING A PROSPECTIVE DESIGN IN WHICH PARTICIPANTS WERE RANDOMLY SELECTED FROM A FAMILY MEDICINE CLINIC LOCATED IN MEXICO CITY. THE STUDY WAS RUN FROM AUGUST TO SEPTEMBER 2003, AND INCLUDED PATIENTS AGED SIXTY YEARS OR OLDER,

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REGARDLESS OF GENDER. THEY SHOULD NOT HAVE COGNITIVE DAMAGE, WHICH WAS ASCERTAINED BY THE FOLSTEIN MINI MENTAL STATE EXAMINATION. THOSE PATIENTS THAT DID NOT ACCEPT TO PARTICIPATE AND THOSE HAVING INCOMPLETE OR ILLEGIBLE MEDICAL RECORDS WERE EXCLUDED. THE SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST AND CARLSSON-DENT TEST WERE APPLIED. THE INFORMATION ABOUT DIAGNOSIS, DRUGS PRESCRIPTIONS, AND PHARMACOLOGICAL AND NO PHARMACOLOGICAL GASTROESOPHAGEAL PROTECTION WAS OBTAINED FROM THE MEDICAL CHARTS AND PRESCRIPTIONS. RESULTS:

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400 ELDERLY PATIENTS WERE EVALUATED BY USING THE CARLSSON-DENT TEST. GERD PREVALENCE WAS 25% (IC 95 % 21-29) THE AVERAGE AGE OF PATIENTS WITH AND WITHOUT GERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARS RESPECTIVELY (P = .002). WOMEN SUFFERED GERD MORE FREQUENTLY THAN MEN (P = 0.001). GERD DIAGNOSIS WAS NOT FOUND IN ANY OF THE REVIEWED MEDICAL CHARTS. ANTACIDS, HISTAMINE- 2 RECEPTOR ANTAGONISTS (H2 AS) AND WERE PRESCRIBED IN 39% (IC 95 % 34-44) OF PATIENTS WITH GERD AND IN 18% (IC 95 % 15-21) WITHOUT GERD.

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CONCLUSIONS: ELDERLY PATIENTS ATTENDING TO PRIMARY CARE FACILITIES OFTEN HAVE GERD SYMPTOMS, BUT THEY ARE NOT PROPERLY DIAGNOSED OR FOLLOWED UP. THE CARLSSON-DENT QUESTIONNAIRE IS AN ALTERNATIVE TO IDENTIFY GERD PATIENTS.

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21.- ACCORDING TO THE ARTICLE, THE BEST WAY TO AVOID A HEART ATTACK IS:a) EATING A LOW FAT DIET AND EXERCISING

VIGOROUSLY.

b) HAVING A SURGERY.

c) CONTROLLING YOUR CRP

d) CONTROLLING YOUR CHOLESTEROL

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22.- ACCORDING TO THE ARTICLE, THE BEST DIET TO FOLLOW IS:a) A LOW-FAT DIET

b) SATURATED FATS

c) RED MEAT AND CHEESE

d) A MEDITERRANEAN DIET.

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23.- THE MEDITERRANEAN DIET CONSISTS MAINLY OF:a) LOW CARBOHYDRATES

b) RED MEAT AND CHEESE

c) UNSATURATED FATS

d) VEGETABLES

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24.- DRINKING RED WINE IS GOOD FOR YOU BECAUSE:a) IT MAKES YOU RELAX

b) HAS ANTIOXIDANT PROPERTIES

c) IT PREVENTS THE FORMATION OF CHOLESTEROL

d) IT’S EASY TO DIGEST

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25.-FROM THE ARTICLE WE CAN CONCLUDE THAT:

a) IF WE FOLLOW A LOW-FAT DIET AND EXERCISE VIGOROUSLY WE WILL AVOID HAVING A HEART ATTACK

b) IF WE FOLLOW A LOW-FAT DIET AND EXERCISE VIGOROUSLY WE WILL AVOID HAVING A HEART ATTACK

c) TAKING A VACATION, EXERCISING VIGOROUSLY AND FOLLOWING A MEDITERRANEAN DIET WE WILL AVOID HAVING A HEART ATTACK

d) PRACTICING THE RELAXATION RESPONSE ONCE OR TWICE A DAY BY BREATHING DEEPLY AND RHYTHMICALLY IN A QUIET PLACE WILL AVOID HAVING A HEART ATTACK.

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5.- NEW THINKING ON HOW TO PROTECT THE HEART BY JANE E. BRODY SURGERY MAY NOT BE THE BEST WAY TO AVOID A HEART ATTACK OR SUDDEN CARDIAC DEATH, THE NEXT STEP IS FINDING OUT WHAT CAN WORK AS WELL OR BETTER TO PROTECT YOUR HEART. MANY MEASURES ARE PROBABLY FAMILIAR: NOT SMOKING, CONTROLLING CHOLESTEROL AND BLOOD PRESSURE, EXERCISING REGULARLY AND STAYING AT A HEALTHY WEIGHT.

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BUT SOME NEWER SUGGESTIONS MAY SURPRISE YOU. IT IS NOT THAT THE OLD ADVICE, LIKE EATING A LOW-FAT DIET OR EXERCISING VIGOROUSLY, WAS BAD ADVICE; IT WAS BASED ON THE BEST AVAILABLE EVIDENCE OF THE TIME AND CAN STILL BE VERY HELPFUL. THE WELL-ESTABLISHED RISK FACTORS FOR HEART DISEASE REMAIN INTACT: HIGH CHOLESTEROL, HIGH BLOOD PRESSURE, SMOKING, DIABETES, ABDOMINAL OBESITY AND SEDENTARY LIVING.

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BUT BEHIND THEM A RELATIVELY NEW FACTOR HAS EMERGED THAT MAY BE EVEN MORE IMPORTANT AS A CAUSE OF HEART ATTACKS THAN, SAY, HIGH BLOOD LEVELS OF ARTERY-DAMAGING CHOLESTEROL. THAT FACTOR IS C-REACTIVE PROTEIN, OR CRP, A BLOOD-BORNE MARKER OF INFLAMMATION THAT, ALONG WITH COAGULATION FACTORS,

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Blood - borne A blood-borne disease is one that can be spread through contamination by blood.The most common examples are HIV, hepatitis B, hepatitis C and viral hemorrhagic fevers.Diseases that are not usually transmitted directly by blood contact, but rather by insect or other vector, are more usefully classified as vector-borne disease, even though the causative agent can be found in blood. Vector-borne diseases include West Nile virus and malaria.

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IS NOW INCREASINGLY RECOGNIZED AS THE DRIVING FORCE BEHIND CLOTS THAT BLOCK BLOOD FLOW TO THE HEART. EVEN IN PEOPLE WITH NORMAL CHOLESTEROL, IF CRP IS ELEVATED, THE RISK OF HEART ATTACK IS TOO. DIET REVISITED THE NEW DIETARY ADVICE IS ACTUALLY BASED ON A RATHER OLD FINDING THAT PREDATES THE MANTRA TO EAT A LOW-FAT DIET.

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IN THE SEVEN COUNTRIES STUDY STARTED IN 1958 FOUND THAT HEART DISEASE WAS RARE IN THE MEDITERRANEAN AND ASIAN REGIONS WHERE VEGETABLES, GRAINS, FRUITS, BEANS AND FISH WERE THE DIETARY MAINSTAYS. BUT IN COUNTRIES LIKE FINLAND AND THE UNITED STATES WHERE PLATES WERE TYPICALLY FILLED WITH RED MEAT, CHEESE AND OTHER FOODS RICH IN SATURATED FATS,

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HEART DISEASE AND CARDIAC DEATHS WERE EPIDEMIC. THE FINDING RESULTED IN THE WELL-KNOWN ADVICE TO REDUCE DIETARY FAT AND ESPECIALLY SATURATED FATS (THOSE THAT ARE FIRM AT ROOM TEMPERATURE), AND TO REPLACE THESE HARMFUL FATS WITH UNSATURATED ONES LIKE VEGETABLE OILS. WHAT WAS MISSED AT THE TIME AND HAS NOW BECOME INCREASINGLY APPARENT IS THAT THE HEART-HEALTHY MEDITERRANEAN DIET IS NOT REALLY LOW IN FAT,

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BUT ITS MAIN SOURCES OF FAT — OLIVE OIL AND OILY FISH AS WELL AS NUTS, SEEDS AND CERTAIN VEGETABLES — HELP TO PREVENT HEART DISEASE BY IMPROVING CHOLESTEROL RATIOS AND REDUCING INFLAMMATION.

CASO 6

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26.-FOR MATERNAL MORTALITY A RISK FACTOR COULD BE:a) EXCESIVE INTERDISCIPLINARY

COMMUNICATION BY HEALTH CARE PERSONNEL.

b) FAILURE TO RECOGNIZE RISKS BY HEALTH CARE PERSONNEL .

c) HEALTH CARE PERSONNEL PROVIDE STANDARD CARE.

d) ALL ABOVE ARE RISK FACTORS.

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27.- THE MAIN REASON WHY THE MATERNAL MORTALITY SURVEILLANCES ARE LIMITED IN SCOPE WOULD BE:a) BECAUSE THE INFORMATION IS OBTAINED OF

DEATH CERTIFICATES.b) A SITUATION OF UNDERREPORTING.c) BECAUSE VARIOUS STATES OR ACADEMIC

INSTITUTIONS COULD BE OVERREPORTING.d) THE MATERNAL MORTALITY SURVEILLANCES

ARE ACCURATE.

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28.-ACCORDING TO THE FINDINGS FROM THE STUDY CONDUCTED BY WHO, UNICEF AND THE UNFPA WHAT IS THE CONCLUSION:a) PREGNANCY RELATED DEATH IS THE DEATH OF A

PREGNANT WOMAN .b) PREGNANCY REALTED DEATH IS THE DEATH OF A WOMAN

WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE OF DEATH.

c) THE RISK OF DEATH FROM COMPLICATIONS OF PREGNANCY DECREASED DRAMATICALLY DURING THE 20TH CENTURY IN THE UNITED STATES.

d) THE MMR STATISTICS ARE ABOVE THE CDC STATISTICS.

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29.- ALTHOUGH THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES HAS PROJECTED GOALS FOR 2010, WHAT IS THE ACTUAL RATIO:a) MATERNAL MORTALITY IS APPROXIMATELY 17 IN

100,000 PREGNANCIES.b) MATERNAL MORTALITY IS AT LESS 3.3 IN 100,000

LIVE BIRTHS.c) THE RESULTS HAVE NOT BEEN WHAT THEY

EXPECTED.d) MATERNAL MORTALITY IS 22.8 PER 100,000 LIVE

BIRTHS.

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30.- ABOUT THE CAUSES OF MATERNAL DEATHS WHICH WOULD BE CONSIDERED A CONTRIBUTOR FROM THE FOLLOWING:a) THROMBOEMBOLISM.b) AMNIOTIC FLUID EMBOLISM.c) PREECLAMPSIA AND ECLAMPSIA.d) CARDIOMYOPATHY.

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6.- MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT MATERNAL MORTALITY IS THE TIP OF THE MATERNAL MORBIDITY ICEBERG; SEVERAL OBSTETRIC, ANESTHETIC, AND SOCIAL CHALLENGES IMPACT MORBIDITY AND MORTALITY IN WOMEN. MATERNAL MORTALITY IS THE YARDSTICK TO MEASURE WHEN HEALTH CARE PERSONNEL FAIL TO RECOGNIZE RISKS, LACK INTERDISCIPLINARY COMMUNICATION, OR PROVIDE SUBSTANDARD CARE, THUS RESULTING IN COMPLICATIONS DURING PREGNANCY, LABOR, OR DELIVERY.

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PREGNANCY-RELATED DEATH IS DEFINED BY THE INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) AS THE DEATH OF A WOMAN WHILE PREGNANT OR WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE OF DEATH. ALTHOUGH THE RISK FOR DEATH FROM COMPLICATIONS OF PREGNANCY DECREASED DRAMATICALLY DURING THE 20TH CENTURY IN THE UNITED STATES,

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THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) REPORTS A FAIRLY STATIC MATERNAL MORTALITY RATIO (MMR), OF APPROXIMATELY 7.5 MATERNAL DEATHS PER 100,000 LIVE BIRTHS. IN THE YEAR 2000, A COLLABORATIVE EFFORT INVOLVING WORLD HEALTH ORGANIZATION (WHO), UNITED NATIONS CHILDREN'S FUND (UNICEF), AND UNITED NATIONS POPULATION FUND (UNFPA) ESTIMATED 660 MATERNAL DEATHS, THUS AVERAGING 11 MATERNAL DEATHS PER 100,000 LIVE BIRTHS, PLACING THE MMR ABOVE THE STATISTICS REPORTED BY THE CDC.

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THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARE LIMITED IN SCOPE BECAUSE THE INFORMATION IS OBTAINED FROM DEATH CERTIFICATES, AND VARIOUS STATES OR ACADEMIC INSTITUTIONS COULD BE UNDERREPORTING. ACCURATE STATISTICS ARE LACKING, THUS RESULTING IN ONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITY AND MORTALITY. THE RECENT WHO ESTIMATE IN THE UNITED STATES SHOW THAT MATERNAL MORTALITY IS APPROXIMATELY 17 IN 100,000 PREGNANCIES.

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THIS ESTIMATE IS SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES IN HEALTHY PEOPLE 2010, WHICH SETS THE TARGET FOR MATERNAL MORTALITY AT LESS THAN 3.3 IN 100,000 LIVE BIRTHS. SOME REGIONAL REPORTS DOCUMENT RATIOS AS HIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN UNACCEPTABLY HIGH RATE.

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IN UNITED STATES, THE MOST COMMON CAUSES OF MATERNAL DEATHS, ALTHOUGH THEY VARY AMONG STATES, INCLUDE THROMBOEMBOLISM; AMNIOTIC FLUID EMBOLISM; HEMORRHAGE; COMPLICATIONS OF HYPERTENSION, INCLUDING PREECLAMPSIA AND ECLAMPSIA; AND INFECTION. PULMONARY DISEASE, ANESTHESIA-RELATED DEATHS, AND CARDIOMYOPATHY ARE ALSO SIGNIFICANT CONTRIBUTORS TO MATERNAL MORBIDITY AND MORTALITY

CASO 7

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31.-ABOUT PATIENTS THAT DON`T TAKE THEIR TREATMENT REGULARY:a) THIS PATIENTS HAVE AN ADEQUATE CONTROL OF

BLOOD PRESSURE.b) THEY ARE CONSISTENTLY ADHERENT IN TAKING

THEIR MEDICATIONS.c) THEY MUST HAVE A REGULAR DIET CONTROL.d) THEY HAVE AN INADEQUATE CONTROL OF BLOOD

PRESSURE.

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32.- ABOUT THE WORKING MECHANISM OF THE VACCINE:a) IT`S WORKING MECHANISM IS BY CONTROLLING

THE ANGIOTENSIN I.b) IT`S WORKING MECHANISM IS BY CONTROLLING

THE ANGIOTENSIN II.c) IT`S WORKING MECHANISM IS BY

CONSTRICTING BLOOD VESSELS.d) IT INDUCES ANTIBODIES CROSS-REACTION WITH

OTHER PROTEINS.

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33.-WITH RESPECT TO THE CYT006-ANGQB VACCINE, CONSIDERATION HAVE BEEN MADE THAT:a) THE VACCINE MAY PRODUCE HYPERTENSION.b) THE VACCINE DOES NOT INDUCE ANTIBODIES

CROSS-REACTION WITH PROTEINS.c) THE VACCINE MAY CAUSE HYPOTENSION.d) THE VACCINE MIGHT CAUSE IMPOTENCY.

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34.- WHAT IS THE REASON OF THE REDUCED NUMBER OF AFFECTED EPITOPES ?a) BECAUSE OF THE SMALL SIZE OF THE EPITOPES.b) BECAUSE OF THE SMALL SIZE OF THE TARGET

MOLECULE.c) BECAUSE ANTIBODY TITERS STARTED TO

DECREASE.d) THE NUMBER OF EPITOPES WAS NEVER

AFFECTED.

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35.- WHAT SHALL BE DONE TO DETERMINE THE LARGEST ANTIBODY RESPONSE AND GREATEST REDUCTIONS IN BLOOD PRESSURE:a) A SMALL TRIAL TO DETERMINE THE RIGHT

DOSING HAD TO BE CONDUCTED.b) BOOSTER SHOT 2 OR 3 TIMES A YEAR.c) ANGIOTENSIN II AND OCTAPEPTIDE

VASOCONSTRICTOR INDUCE THE BODY TO PRODUCE ANTIBODIES.

d) ANGIOTENSIN II WOULD ALONE REGULATE THE BLOOD PRESSURE.

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7.-VACCINE TAKES AIM AT HYPERTENSION ORLANDO, FLA: SOME PATIENTS WITH HYPERTENSION HAVE INADEQUATE CONTROL OF BLOOD PRESSURE BECAUSE THEY ARE NOT CONSISTENTLY ADHERENT IN TAKING THEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN THE FORM OF A VACCINE THAT LOWERS BLOOD PRESSURE BY CONTROLLING ANGIOSTENSIN II, SUGGEST FINDINGS FROM A SMALL SAFETY STUDY PRESENTED AT THE SCIENTIFIC SESSIONS OF THE AMERICAN HEART ASSOCIATION IN NOVEMBER.

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THE STUDY OF 72 PATIENTS WITH MILD-TO-MODERATE HYPERTENSION, PRESENTED BY JURG NUSSBERGER, MD, PROFESSOR OF MEDICINE AT THE UNIVERSITY HOSPITAL OF THE CANTON OF VAUD, LAUSANNE, SWITZERLAND, FOUND THAT AT 14 WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB (AT 0,4, AND 12 WEEKS) HAD A DAYTIME SYSTOLIC BLOOD PRESSURE THAT WAS 5.6 MM HG LOWER AND A DIASTOLIC BLOOD PRESSURE 2.8 MM HG LOWER THAN THOSE OF PATIENTS WHO RECEIVED PLACEBO.

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CYT006-ANGQB, WHICH IS UNDER DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG (ZURICH, SWITZERLAND), IS A VIRUS-SHAPED NONINFECTIOUS PARTICLE THAT IS CHEMICALLY COUPLED WITH ANGIOTENSIN II, AND OCTAPEPTIDE VASOCONSTRICTOR. SUCH COUPLING INDUCES THE BODY TO PRODUCE ANTIBODIES AGAINST THIS SMALL MOLECULE TOP MINIMIZE ITS EFFECTS ON CONSTRICTING BLOOD VESSELS. NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHT CAUSE HYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASE SHORTLY AFTER THE BOOSTER OF TWELVE WEEKS INDUCED PEAK ANTIBODY LEVELS.

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HE ALSO SAID THE LIKELIHOOD OF VACCINE-INDUCED ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS WAS MINIMAL BECAUSE THE SMALL SIZE OF THE TARGET MOLECULE LIMITS THE NUMBER OF EPITOPES THAT COULD BE AFFECTED. NUSSBERGER SPECULATED THAT IF THE CYT006-ANGQB VACCINE IS ULTIMATELY APPROVED, PATIENTS WOULD BE ABLE TO AVOID THE NEED FOR MEDICATION BUT WOULD REQUIRE A BOOSTER SHOT 2 OR 3 TIMES A YEAR. HE SAID THE NEXT STEP IN STUDYING THE VACCINE WILL BE TO CONDUCT ANOTHER SMALL TRIAL TO DETERMINE THE APPROPRIATE DOSING TO CREATE THE LARGEST ANTIBODY RESPONSE AND GREATEST REDUCTIONS IN BLOOD PRESSURE.

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MORRIS J. BROWN, MD, PROFESSOR OF CLINICAL PHARMACOLOGY AT THE UNIVERSITY OF CAMBRIDGE IN ENGLAND AND PAST PRESIDENT OF THE BRITISH HYPERTENSION SOCIETY, SAID THE FINDINGS OF THE STUDY (WHICH WAS FUNDED BY CYTOS) ARESULTS FROM BOITECHS, ESPECIALLY SECONDARY EFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,”

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HE SAID. BROWN HAS ALSO HAD A HAND IN ATTEMPTS TO CREATE A HYPERTENSION VACCINE, PMD3117, UNDER DEVELOPMENT BY PROTHERICS PLC IN RUNCORN, ENGLAND (BROWN MJ ET AL. CLIN SCI.

CASO 8

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WILLIAM THOMAS GREEN MORTON ON OCTOBER 16, 1846, DEMONSTRATED THAT ETHER COULD INDUCE INSENSIBILITY TO THE SURGEON'S KNIFE. A JAW TUMOR WAS REMOVED FROM GILBERT ABBOT BY JOHN COLLINS WARREN AT THE MASSACHUSETTS GENERAL HOSPITAL IN FRONT OF AN AUDIENCE OF MEDICAL PROFESSIONALS. THE NEWS OF THIS PUBLIC DEMONSTRATION TRAVELED QUICKLY, GIVEN THE NATURE OF COMMUNICATION IN THE 1840S.

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ON DECEMBER 16, 1846, THE INFORMATION IN THE FORM OF A LETTER ARRIVED IN LONDON. ON DECEMBER 19, THE FIRST ETHER ANESTHETIC WAS GIVEN IN THE UNITED KINGDOM FOR THE REMOVAL OF A TOOTH. ON DECEMBER 21, THE FAMOUS SURGEON ROBERT LISTON AMPUTATED THE LEG OF A BUTLER, AND UTTERED THE FAMOUS WORDS, “THIS YANKEE DODGE BEATS MESMERISM HOLLOW” .

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JAMES YOUNG SIMPSON, THE PROFESSOR OF MIDWIFERY IN EDINBURGH, SCOTLAND, WAS AMONG THE FIRST TO USE ETHER FOR THE RELIEF OF LABOR PAIN. ON JANUARY 19, 1847, HE USED ETHER TO AMELIORATE THE PAIN OF LABOR. THIS FIRST CASE, THAT OF A YOUNG WOMAN WITH RICKETS AND A SEVERELY DEFORMED PELVIS, WAS AT GRAVE RISK OF DYING AND THERE WAS NO HOPE FOR A LIVE BIRTH.

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BY USING ETHER, THE MOTHER SURVIVED THE COMPLICATED DELIVERY PAIN-FREE. THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN'S PHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TO PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATED AND NORMAL DELIVERIES; HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITH ETHER AND SOUGHT A MORE PLEASANT, RAPID-ACTING ANESTHETIC.

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AT THE SUGGESTION OF DAVID WALDIE, HE EXPERIMENTED WITH CHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN 1831. ON THE EVENING OF NOVEMBER 4, 1847, SIMPSON AND HIS FRIENDS INHALED IT AFTER DINNER AT A PARTY IN SIMPSON'S HOME. THEY PROMPTLY FELL UNCONSCIOUS AND, WHEN THEY AWOKE UNDER THE TABLE AND CLEARLY OFF THEIR DINING ROOM CHAIRS, WERE DELIGHTED WITH THEIR SUCCESS.

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WITHIN 2 WEEKS, SIMPSON SUBMITTED HIS FIRST ACCOUNT OF CHLOROFORM'S USE TO THE LANCET.IN THE NINETEENTH CENTURY, THE RELIEF OF OBSTETRIC PAIN HAD SIGNIFICANT SOCIAL AND RELIGIOUS CONSEQUENCES, WHICH MADE ANESTHESIA DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THE BATTLE CENTERED ON WHETHER RELIEVING LABOR PAIN WAS CONTRARY TO GOD'S WILL.

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THE PAIN ASSOCIATED WITH CHILDBIRTH WAS BELIEVED TO BE A DEVINE PUNISHMENT FOR ORIGINAL SIN. SHORTLY AFTER GIVING HIS FIRST OBSTETRIC ANESTHETICS, SIMPSON PUBLISHED A PAMPHLET ENTITLED ANSWERS TO THE RELIGIOUS OBJECTIONS ADVANCED AGAINST THE EMPLOYMENT OF ANESTHETIC AGENTS IN MIDWIFERY AND SURGERY AND OBSTETRICS, WHICH ARGUED AGAINST THESE RELIGIOUS PROHIBITIONS.

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36.-. WILLIAM THOMAS GREEN MORTON USED:

a) ETHER ON A PATIENT SO THERE WOULD BE NO SENSIBILITY IN THE OPERATION.

b) ETHER ON A PATIENT TO REDUCE THE SENSIBILITY DURING THE OPERATION.

c) ETHER TO DISINFECT THE KNIFE IN THE OPERATION AND OTHER OPERATING EQUIPMENT.

d) ETHER INSTEAD OF AN ANESTHETIC.

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37.- AMES YOUNG SIMPSON WAS THE FIRST TO USE ETHER FOR

a) CURING A PATIENT WHO HAD RICKETS.b) REDUCING THE LABOR PAIN OF A WOMEN

WHEN GIVING BIRTH WITH A DEFORMED PELVIS.

c) REDUCING THE PAIN OF SURGERY.d) SAVING THE NEWBORN FROM DYEING IN

CHILDBIRTH.

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38.-SIMPSON PREFERRED TO CONTINUE.a) USING ETHER FOR CHILDBIRTH.b) TO CONTINUE USING ETHER AND

CHLOROFORM FOR CHILDBIRTH.c) TO ONLY USE CHLOROFORM FOR CHILDBIRTHd) PROVIDE ANESTHESIA IN CHILDBIRTH FOR

BOTH COMPLICATED AND NORMAL DELIVERIES

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39.-IT IS EVIDENT THAT THIS NEW PRACTICE OF USING ANESTHESIA IN CHILDBIRTH HAD SOCIAL AND RELIGIOUS CONSEQUENCES:a) SIMPSON WAS IN FAVOR OF RELIGIOUS BELIEFS

IN CHILDBIRTH PRACTICEb) SIMPSON WAS IN FAVOR OF SOCIAL BELIEFS

ABOUT CHILDBIRTH PRACTICEc) SIMPSON WAS AGAINST RELIGIOUS BELIEFS IN

CHILDBIRTH PRACTICEd) SIMPSON WAS AGAINST THESE RELIGIOUS

PROHIBITIONS

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40.- THE PAIN ASSOCIATED WITH CHILDBIRTH WAS BELIEVED TO BE CAUSED AS:a) CONSEQUENCE OF DEFORMED PELVIS.b) A DEVINE PUNISHMENT FOR ORIGINAL

SIN.c) BECAUSE OF LACK OF ANESTHETICS.d) AN OVERSIZED PRODUCT

CASO 9

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A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORY OF A HARD, PAINFUL, NONPULSATILE MASS IN HIS LEFT UPPER ARM. EXAMINATION REVEALED A CRAGGY, MOBILE MASS OF IRREGULAR BORDERS IN THE LEFT ARM MEASURING 6 × 4 CM. ULTRASONOGRAPHY OF THE LEFT ARM DEMONSTRATED A DEEP OVOID HYPERECHOIC MASS LOCATED IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE.

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MRI SHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPS MUSCULATURE ON T1-WEIGHTED IMAGES WITH FAT SATURATION. THIS LESION WAS CONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. A PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA WAS CONSIDERED. AN INCISIONAL BIOPSY REPORTED METASTATIC SQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNG PRIMARY,

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FURTHER SUPPORTED DUE TO A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY. CT SCAN OF THE CHEST REVEALED A LEFT UPPER LOBE LESION MEASURING 4 × 2 CM. FIBER-OPTIC BRONCHOSCOPY AND BIOPSY CONFIRMED THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL LUNG CARCINOMA. HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THE MASS IN THE ARM.

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THIS PROVIDED GOOD RELIEF FROM PAIN AND SWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT. SYSTEMIC THERAPY WAS NOT OFFERED ON THE BASIS OF POOR AND DETERIORATING PERFORMANCE STATUS. UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKS OF PRESENTATION. INTRAMUSCULAR METASTASES IN CANCER PATIENTS ARE RARE.

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THIS IN ITSELF IS QUITE PECULIAR BECAUSE MUSCULAR MASS ACCOUNTS FOR APPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT IS THOUGHT THAT MUSCULAR CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, AND ACCUMULATION OF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO THE RARE OCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OF MUSCULAR METASTASIS REMAINS UNKNOWN,

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BUT AN AUTOPSY SERIES SUGGESTS THAT ITS INCIDENCE COULD BE AS LOW AS 0.8%. LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOST OF THESE CASES. MANY OTHER TUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROID GLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE BEEN SPORADICALLY DESCRIBED IN ASSOCIATION WITH INTRAMUSCULAR SECONDARIES.

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HOWEVER, PRIMARY PRESENTATION OF AN INTRAMUSCULAR METASTASIS, SUCH AS DEMONSTRATED BY OUR PATIENT, REMAINS AN EXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOST FREQUENT PRESENTATION OF MUSCULAR METASTASIS IS PAIN WITH OR WITHOUT SWELLING. DIAGNOSIS OF THIS CONDITION,

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EVEN WITH RADIOLOGIC IMAGING IS OFTEN TRICKY BECAUSE IT CAN BE CONFUSED WITH AN ABSCESS OR SOFT TISSUE TUMORS, HIGHLIGHTING THE VALUE OF HISTOLOGIC DIAGNOSIS. TREATMENT IN THE FORM OF RADIOTHERAPY, CHEMOTHERAPY, OR EVEN METASTASECTOMY OFTEN PROVIDES PALLIATION ONLY. MOST PATIENTS DIE IN LESS THAN A YEAR FROM DIAGNOSIS.

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41.-BASED ON THE CLINICAL AND THE DIVERSE IMAGING STUDY’S FINDINGS WHICH OF THE FOLLOWING WAS THE PRESUMPTIVE DIAGNOSIS OF THE ATTENDING MEDICAL TEAM:a) A DEEP OVOID MASS LOCATED IN THE LEFT TRICEPS

MUSCLE CONSIDERED A PROBABLE STAPHYLOCOCCUS AUREUS ABSCESS.

b) A MASS OF FAT SATURATION OBSERVED ON MRI ON T1-WEIGHTED IMAGES.

c) A PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA LOCATED IN THE LEFT TRICEPS MUSCLE.

d) A DIAGNOSIS OF METASTATIC SQUAMOUS CELL CARCINOMA, WITH A POSSIBLE PRIMARY OF THE LUNG.

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42.- THE PATIENT WAS SUBMITTED TO PALLIATIVE CARE AND NOT SYSTEMIC THERAPY BASED ON WHAT REASON?a) A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON

IMMUNOHISTOCHEMISTRY IS OF POOR PROGNOSIS.b) THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL LUNG

CARCINOMA WAS NOT CONFIRMED ON FIBER-OPTIC BRONCHOSCOPY.

c) HE ONLY UNDERWENT PALLIATIVE RADIOTHERAPY BECAUSE OF COST-BENEFIT REASONS.

d) BASED ON A POOR AND DETERIORATING PERFORMANCE STATUS SYSTEMIC THERAPY WAS DEFERRED FOR QUALITY OF LIFE PALLIATIVE THERAPY.

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43.- WHICH OF THE FOLLOWING IS NOT DESCRIBED IN THE PRESENT ARTICLE AS A FACTOR THAT CONTRIBUTES TO THE RARE OCCURRENCE OF INTRAMUSCULAR METASTASES?a) THE MUSCULAR MASS ACCOUNTS FOR

APPROXIMATELY 50% OF TOTAL BODY WEIGHT.b) MUSCULAR CONTRACTILE ACTIONS.c) LOCAL PH ENVIRONMENT.d) ACCUMULATION OF LACTIC ACID AND OTHER

METABOLITES.

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44.- WHICH IS THE PRIMARY UNDERLYING CANCER IN MOST CASES OF INTRAMUSCULAR METASTASES?a) LUNG CARCINOMA.b) KIDNEY AND BLADDER CANCER.c) STOMACH AND PANCREATIC CARCINOMA.d) BREAST AND OVARIAN CANCER.

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45.-THE MOST FREQUENT PRESENTATION OF INTRAMUSCULAR METASTASES SEEN IS?

a) PRESENTATION OF THE AFFECTED SITE WITH PAIN, WITH OR WITHOUT SWELLING.

b) THROMBOSIS OF THE AFFECTED EXTREMITY.c) FEVER AND SEPSIS.d) USUALLY INDOLENT AND ONLY FOUND AT

AUTOPSY.

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