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J Neurol 243: 715–721 Brook JD generic cytotec 100mcg mastercard medicine x xtreme pastillas, McCurrach ME buy cytotec 100 mcg with visa treatment for shingles, Harley HG cheap cytotec 100 mcg amex symptoms 6dp5dt, et al (1992) Molecular basis of myotonic dystrophy: expansion of a trinucleotide (CTG) repeat at the 3 end of a transcript encoding a protein kinase family member. Cell 68: 799–808 Lieberman AP, Fischbeck KH (2000) Triple repeat expansion in neuromuscular disease. Muscle and Nerve 23: 843–846 Liquori CL, Ricker K, Moseley ML, et al (2001) Myotonic dystrophy type 2 caused by a CCTG expansion in intron 1 of ZNF9. Science 293: 864–867 Phillips MF, Steer HM, Soldan JR, et al (1999) Daytime somnolence in myotonic dystrophy. J Neurol 246: 275–282 388 Limb girdle muscular dystrophy Genetic testing NCV/EMG Laboratory Imaging Biopsy ++ ++ + – ++ Fig. There is an increase in connec- tive tissue (large arrow), the presence of nesting muscle fi- bers (arrow heads), muscle atro- phy (small arrow), and a hyper- trophied fiber (small arrow head) Distribution In approximately 50% of subjects with LGMD, weakness begins in the pelvic girdle musculature (the Leyden and Möbius type), then spreads to the pectoral musculature, and in 50% (the Erb type) starts first with the pectoral girdle musculature. Time course Generally most causes of LGMD are slowly progressive. Onset/age Age of onset is variable depending on the specific cause of the LGMD. The autosomal recessive forms are more severe and start early in life, whereas the autosomal dominant forms are milder and start later. The weakness is progres- sive, and eventually all muscles in the body are affected. Clinical syndrome LGMD is a very heterogenous disorder, where the clinical presentation depends on the gene defect. There is a characteristic clinical appearance: drooped shoulders, scapular winging, and “Popeye” arms (due to wasted arm muscles and spared deltoids). In the pelvic form of LGMD, sacrospinals, quadriceps, hamstrings, and hip muscles are especially involved, causing excessive lumbar lordosis and waddling gait. Facial muscles are uninvolved in LGMD until the patient is severely disabled from limb weakness. Muscle tendon reflexes are preserved in the early stages, but are lost as the disease progresses. As the disease progresses, there may be respiratory failure associat- ed with axial weakness and scoliosis. Specific types are characterized below: Autosomal dominant: 1A: Myotilin; 5q31 1B: Lamin A/C; 1q21 1C: Caveolin-3; 3p25 1D: 7q Bethlem myopathy: Collagen VI Autosomal recessive: 2A: Calpain-3; 15q15 2B: Dysferlin; 2p12 2C: gamma-sarcoglycan; 13q12 2D: alpha-sarcoglycan; 17q21 2E: beta-sarcoglycan; 4q12 2F: delta-sarcoglycan; 5q33 2G: Telethonin; 17q11–12 2H: TRIM32; 9q31–q33 2I: FKRP; 19q13. In rare cases distal muscles are affected, but cardiac and respiratory muscles are spared. Patient present early in childhood with a progressive aproximal muscle weakness, calf hypertrophy, cramping mus- cle pains, and a peculiar muscle rippling phenomenon. The clinical features resemble those of calpain3-associated LGMD. Characteristic clinical features include pelvic and pectoral girdle muscle involvement, weakness of neck flexor and facial muscles, dysarthria, tight heel cords, absent ankle jerks, and loss of ambulation at 40–50 years. Cognition is normal, but there is evidence of severe white matter changes on the MRI. A demyelinating neuropathy may be present, but is difficult to distinguish clinically from the severe myopathy. Onset is usually before age 10 years, with a wide range of time before loss of ambulation and death. Shoulder and pelvic girdle muscles are affected, facial muscles are spared, calf muscle hypertro- phy is common, and the degree of clinical heterogeneity makes it difficult to distinguish from other forms of LGMD. There may be cardiac involvement and muscle hypertophy. Adhalin is primarily ex- pressed in skeletal muscle, but may also be found in heart muscle. The clinical severity of myopathy in patients with adhalin mutations varies considerably, and is most severe in patients homozygous for null mutations, who lack skeletal muscle adhalin expression. Missense mutations cause relatively milder phenotypes and variable residual adhalin expression. The clinical picture is very similar to other forms of LGMD. In addition, clinically indistinguishable secondary adhalin deficiency and LGMD may be associat- ed with loss of γ-sarcoglycan, coding to chromosome 13q12. It is associat- ed with flexion contractures of the ankles, elbows and fingers, and affects both sexes equally. The progression is very slow, and most patients remain ambulatory until late in life. Pathogenesis LGMD is a heterogenous disorder with a wide range of molecular defects. LGMD1A is associated with a a missense mutation of the myotilin gene on chromosome 5q. It is not clear why these patients develop LGMD, since it is difficult to demonstrate a reduction, or accumulation of myotilin. LGMD1B is due primarily to missense mutations of the gene for lamin A and C which play a critical role in the structure of the nuclear membrane and are involved in DNA replication, chromatin organization, regulation of the nuclear pore, and growth of the nucleus. LGMD1C is likely due to a dominant negative effect since transgenic mice expressing the P104L mutant caveolin protein develop LGMD whereas knockout animals do not. Caveolin-3 is part of caveolae membranes and is likely critical in controlling lipid and protein interaction in the caveolae membrane, and possible controlling T-tubule organization. Al- though collagen VI is ubiqitously expressed in the body, for unknown reasons only skeletal muscle and tendon are affected in patients with Bethlem myopa- 391 thy. LGMD2B substitutions or deletions of the dysferlin gene (DYSF) results in non-specific myopathic changes in skeletal muscle. The phenotypical variation suggests that additional factors to mutations in the DYSF gene account for the defect. Loss of sarcoglycan results in structural weakness of the muscle cytoskeleton resulting in a clinical picture similar to Becker’s muscular dystrophy. The pathological mechanisms are complex but likely involve several mechanisms including impaired mito- chondrial function with energy depletion, loss of calcium homeostasis, necrosis of affected fibers, and loss of fiber regeneration. LGMD2G is due to a mutation of the gene coding for telethonin found in the myofibrillar Z-discs. It likely plays a role in control of sarcomere assembly and disassembly. Laboratory: Diagnosis Serum CK is usually elevated especially in the autosomal recessive forms of LGMD. Electrophysiology: Nerve conduction studies are usually normal. The principal findings on needle EMG are short duration, low-amplitude motor unit potentials, increased polyphasic potentials, and early recruitment. Increased insertional activity is seen in more rapidly progressive autosomal recessive LGMD. Progressive muscle fibrosis may also result in decreased insertional activity. Muscle biopsy: The muscle biopsy is nonspecific and depends on the particular type of LGMD.

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If in the lowest quartile discount cytotec 100mcg amex medications held before dialysis, or if she is at risk of a low peak bone mass cheap cytotec 200mcg on-line treatment jiggers, she receives anabolic therapy throughout the pubertal growth phase discount 200 mcg cytotec with visa medications errors pictures. G Zara and Brittney’s mother, Sarah, 35, is a smoker, exercises little, and an ultrasound at the supermarket shows her to be at risk of osteoporosis. Lifestyle modification is advised; if treatment is required, only 50% of the cost is borne by health insurance (because her risk factors are self-inflicted, her swipe card indicating no genetic or family risk). G Aunt Beth attends a compulsory well woman perimenopausal review, which includes ultrasound and bone turnover marker profile; together with the “high risk” profile on her swipe card, a coupon is issued for the private dual energy x ray absorptiometry facility. She joins others having self-funded dual energy x ray 95 BONE AND JOINT FUTURES absorptiometry (outside the National Health recommendations). Her genetic, physiological (turnover marker) and bone typing (density and stiffness index) are combined to issue the relevant section of the “GROT” (global recommendations for osteoporosis treatment)”, which obtains free medication. G Bone turnover is rechecked after six months, and one year of depot parathyroid analogue prescribed if increases in formation markers are suboptimal. If resorption markers fail to fall substantially, combination antiresorptive therapy is used (bisphosphonates given three monthly as intravenous bolus injections until sustained reduction is obtained, and in response to turnover markers thereafter). G If hormone replacement therapy or a selective oestrogen replacement modulator is prescribed for other indications (e. G NHS retirement screening (at age 70) offers measurement of hip dual energy x ray absorptiometry and biochemical markers of bone turnover, those with normal bone density and a normal rate of loss being reviewed 5 yearly. If formation markers are below the reference range or a further fracture occurs, anabolic therapy (parathyroid hormone or an osteospecific statin) will be prescribed. G Those who sustain osteoporotic fractures who failed to attend screening will be liable for the short term costs entailed. While some of these strategies are perhaps Orwellian, and some of the therapeutic interventions somewhat speculative, the scenario highlights the direction future developments might take. The ideal will surely be met when any name from any part of the world may be substituted, the programme perhaps supported by globally funded health care through the World Health Organization or similar bodies, and when people can continue to live a full and active life until their still inevitable death. Update on pharmacological interventions and an algorithm for management. Recommended reading Adachi JD, Olszynski WP, Hanley DA et al. Osteoporosis and Bone Biology: the state of the art. Monitoring of treatment with bone densitometry: misleading changes and regression towards the mean. Management of male osteoporosis: report of the UK consensus group. Interim report and recommendations of the WHO Task Force for Osteoporosis. Quantitative ultrasound techniques for the assessment of osteoporosis. Kanis JA, Gluer CC for the Committee of Scientific Advisors, International Osteoporosis Foundation. An update on the diagnosis and assessment of osteoporosis with densitometry. Birth and death of bone cells: basic regulatory mechanisms and implications for the pathogenesis and treatment of osteoporosis. Stimulation of bone formation in vitro and in rodents by statins. Basic principles and clinical applications of biochemical markers of bone metabolism. Von Mühlen D, Visby-Lunde A, Barrett-Connor E, Bettencourt R. Writing Group of the Bone and Tooth Society of Great Britain and the Royal College of Physicians. Update on pharmacological interventions and an algorithm for management. Osteoarthritis is the dominant problem in the elderly; in younger adults, low back pain, neck and upper limb pain, and chronic widespread pain occupy centre- stage. In many countries, these conditions are the leading cause of disability and of working days lost, and are one of the two or three most frequent reasons for seeking health care. Chronic musculoskeletal pain is prevalent throughout the world, but the frequency of seeking health care and the impact on systems of health and social care varies dramatically. This is partly a demographic issue – the greater the life expectancy, the proportionately higher proportion of the population will have such non-fatal problems – but is also related to cultural and social characteristics of different populations. Understanding chronic musculoskeletal pain I want to start by making a distinction between progress in “understanding” pain and likely developments in the practical “application” of new knowledge. There is a common assumption that the former will inevitably lead to the latter. A study might estimate the likely contribution of inheritance to spinal disc degeneration; the press release then gives a strong hint that this research will lead to cures for low back pain. The study is well performed and advances our understanding of spinal disc degeneration. However, other studies have established that most low back pain is unrelated to spinal disc disease, and knowing that disc disease is mostly an inherited genetic 98 MANAGEMENT OF CHRONIC MUSCULOSKELETAL PAIN problem does not mean that it can be or should be “reversed” or “treated”–a general problem for genetic studies at the current state of our knowledge – nor does it mean that this knowledge will have any relevance or applicability to the problem of chronic back pain. However, the last decades of the old millennium did bring clear advances in the science of pain. These are important in their own right but they also have profound implications for how we will conceive and understand chronic musculoskeletal pain in the future, regardless of whether or not they have obvious therapeutic applications. A brief summary is needed, with apologies to experts in the field for the crudeness of my exposition. The pain sensation can be blocked by analgesic drugs, but the cure for the pain depends on healing the damaged tissue. The new idea is that our nervous system is more dynamic and adaptable than this, and that it can change in response to pain stimuli in ways which can persist even when the source of pain has been removed and the site of injury repaired. This “plasticity” of the nervous system is affected by all sorts of influences – other pains for example or higher brain functions such as emotions and psychological states – and in turn can affect other parts of the ner- vous system, even the motor functions. This provides a biological explanation for the finding that pain can persist in the absence of continuing local damage and under the influence of, for example, anxiety. The original source of pain can disappear, and the pain continues as an active memory within the nervous system. This is the crucial, albeit over-simplified, picture of pain with which we enter the twenty-first century. There will be future refinements to this model, notably in the much broader field of understanding consciousness, but already it is clear that what follows from this development in neuroscience is going to shape our approach to and management of chronic musculoskeletal disease in the next decades. Will the medical perspective on chronic musculoskeletal pain change? The importance of traditional diagnosis will decline The first major implication of the new ideas is that they provide support for clinicians to advance out of their nineteenth-century view 99 BONE AND JOINT FUTURES of diagnosis, which is still concerned primarily with seeking a local pathology for chronic pain and making a diagnosis at the site of the pain as the end-point of their deliberations.

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Hereditary hemochromatosis is not a risk factor for the development of HCC D generic cytotec 200 mcg line symptoms nausea headache. The presence of hepatitis infection and concomitant heavy alcohol consumption are synergistic in the development of HCC Key Concept/Objective: To understand the risk factors for HCC HCC is the most common primary malignant tumor of the liver cytotec 100mcg low cost treatment trichomoniasis. It is the fifth most com- mon malignancy in the world (564 cytotec 100 mcg without prescription schedule 6 medications,000 cases a year) and the third-highest cause of cancer- related deaths worldwide. HCC is most often a complication of liver cirrhosis caused by chronic infection by HBV, HCV, or alcohol. The incidence of HCC in the United States has increased from 1. This increase is considered to be primarily related to an increase in HCV infection. Hereditary hemochromatosis is also a risk factor for the development of HCC. Diabetes mellitus may be associated with HCC in patients with chronic HCV infection, and a significant synergy exists between heavy alcohol consump- tion, hepatitis virus infection (both HBV and HCV), and diabetes mellitus and the develop- ment of HCC. Patients with other metabolic disorders or conditions that may lead to cir- rhosis (e. Other risk factors include long-time ingestion of food contaminated with aflatoxins, metabolites of the mold Aspergillus flavus, exposure to oral contraceptives, and exogenous androgens. A 40-year-old African-American woman presents to your clinic for an annual health examination. She has hypertension and hyperlipidemia, for which she takes hydrochlorothiazide and a statin, respective- ly. Otherwise, she is in good health, and she exercises regularly. Her main concern today is her risk of 14 BOARD REVIEW breast cancer. She has a close friend who was recently diagnosed with breast cancer, and she is now very worried that she might one day get it. Which of the following statements regarding the risk factors for breast cancer is true? Because of germline mutations of either BRCA1 or BRCA2, the breast- ovarian cancer syndrome is inherited in an autosomal recessive fashion B. Reproductive risk factors include late menarche, early menopause, and increasing parity C. The diagnosis of breast cancer in first-degree relatives younger than 50 years is associated with a threefold to fourfold increased risk D. Women between the ages of 40 and 50 years are at greatest risk; 75% of all breast cancers are diagnosed in that age group Key Concept/Objective: To understand the risk factors for breast cancer In first-degree relatives younger than 50 years, the diagnosis of breast cancer is associated with a threefold to fourfold increased risk. Several familial breast cancer syndromes and their associated molecular abnormalities have been identified. These include the breast- ovarian cancer syndrome, which is attributed to germline mutations in either of two breast cancer susceptibility genes, BRCA1 and BRCA2. These mutations are inherited in an autosomal dominant fashion and can therefore be transmitted through both the maternal and the paternal lines. Reproductive risk factors include early menarche, late menopause, late first pregnancy, and nulliparity. All are felt to lead to a condition of prolonged estro- gen exposure to the breast. On clinical examination, a 54-year-old woman is noted to have a nontender mass in the upper outer quadrant of her left breast. There are no overlying skin changes, and there is no palpable adenopathy in the axilla. You immediately set up an appointment for mammography, but your patient is obviously disturbed. She has several questions regarding the therapy for breast cancer. Which of the following statements regarding breast cancer therapy is true? For women with stage I or II breast cancer, the survival rate with breast conservation therapy involving lumpectomy and radiotherapy is identical to the survival rate with modified radical mastectomy B. Sentinel lymph node mapping is difficult to perform and offers no benefit to axillary lymph node dissection C. The benefit of tamoxifen is limited to 5 years, and therefore, the rec- ommendation is to discontinue therapy after 5 years D. Aromatase inhibitors offer a viable alternative to tamoxifen therapy for premenopausal women Key Concept/Objective: To understand the basic principles of breast cancer therapy Breast conservation therapy that involves lumpectomy with radiotherapy and modified radical mastectomy that involves removal of the breast and axillary nodes provide identi- cal survival rates for women with stage I or II breast cancer. Sentinel lymph node mapping involves injection of a radioactive tracer, vital blue dye, or both into the area around the primary breast tumor. The injected substance tracks rapidly to the dominant axillary lymph node—the so-called sentinel lymph node. This node can be located by use of a small axillary incision and visual inspection or by use of a handheld counter. If the sentinel node is tumor free, the remaining lymph nodes are likely to be tumor free as well, and further axillary surgery can be avoided. The benefit of tamoxifen increases with the duration of treatment; the proportional reductions in 10-year recurrence and mortality were 47% and 26%, respectively, with 5-year regimens of tamoxifen therapy. The aromatase inhibitors specifically inhibit this conversion, leading to further estrogen deprivation in older women. Randomized trials have shown that the aromatase inhibitors (e. Given their mechanism of action, aromatase inhibitors should not be used for treatment in premenopausal women. A 42-year-old woman presents for a routine health maintenance visit. She underwent menarche at age 13 and is still menstruating. There is no history of breast cancer in her fam- ily. Several of her friends have recently been diagnosed with breast cancer, and she is concerned about developing it herself. She performs monthly breast self-examinations and has noted no abnormalities. Which of the following statements regarding breast cancer screening is true? Mammography will detect more than 95% of breast cancers C. The combination of clinical breast examination and mammography improves survival D. Mammography is recommended by several professional organizations but has not been shown to improve survival E.

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Physical examination is significant for marked ascites effective cytotec 200 mcg medicine 360, tender hepatomegaly 100 mcg cytotec visa medicine zolpidem, and 3+ bilateral lower extremity pit- ting edema generic cytotec 200 mcg mastercard symptoms questionnaire. You order magnetic resonance imaging of the abdomen, which reveals the presence of a hepatic vein thrombosis. Which of the following statements regarding paroxysmal nocturnal hemoglobinuria (PNH) is true? PNH is the result of a mutation that causes a deficiency of a mem- brane-anchoring protein, which in turn results in an inability to prop- erly modulate complement attack B. PNH causes anemia but has no effect on other cell lines C. PNH can cause thromboses in unusual sites, such as in the mesenteric or hepatic vein; however, lower extremity thromboses and associated pulmonary emboli are not seen D. The diagnosis of PNH is a diagnosis of exclusion because there are no specific tests available for PNH Key Concept/Objective: To know the clinical characteristics of PNH The mutation associated with PNH results in a deficiency of the membrane-anchoring pro- tein phosphatidylinositol glycan class A. Normal human erythrocytes, and probably platelets and neutrophils, modulate complement attack by at least three glycosylphos- phatidylinositol (GPI) membrane-bound proteins: DAF (CD55), C8-binding protein (C8BP), and MIRL (CD59). Because the defective synthesis of GPI affects all hematopoietic cells, patients with PNH may have variable degrees of anemia, neutropenia, or thrombo- cytopenia, or they may have complete bone marrow failure. Recurrent venous occlusions lead to pulmonary embolism and hepatic and mesenteric vein thrombosis, possibly result- 5 HEMATOLOGY 11 ing from the release of procoagulant microparticles derived from platelets. Diagnosis is made by specific tests based on fluorescence-activated cell sorter analysis using antibodies that quantitatively assess DAF (CD55) and particularly MIRL (CD59) on the erythrocyte or on the leukocyte surface. A 48-year-old black man presents to the emergency department for evaluation of severe fatigue. He reports that his last known CD4+ T cell count was “around 100. He was in his usual state of moderate health until 2 days ago. His only complaints are severe fatigue and some dys- pnea on exertion. He denies having fever, chills, cough, abdominal pain, or dysuria. He states that his doctor recently changed his “PCP pill” because of a persistent rash. Laboratory values are remarkable for a hematocrit of 22% and a urinalysis that shows 4+ blood and 0–2 RBCs. Which of the following statements regarding glucose-6-phosphate dehydrogenase (G6PD) deficiency is true? G6PD is an enzyme that catalyzes the conversion of adenosine diphos- phate (ADP) to adenosine triphosphate (ATP), a powerful reducing agent B. G6PD deficiency is very rare in the United States C. G6PD deficiency occurs with equal frequency in males and females D. Potential users of dapsone should be screened for G6PD deficiency Key Concept/Objective: To understand the function of G6PD and the epidemiology of G6PD deficiency G6PD is the first enzyme in the pentose phosphate pathway, or hexose monophosphate shunt. It catalyzes the conversion of the oxidized form of nicotinamide-adenine dinu- cleotide phosphate (NADP+) to the reduced form (NADPH), which is a powerful reducing agent. NADPH is a cofactor for glutathione reductase and thus plays a role in protecting the cell against oxidative attack. G6PD deficiency is one of the most common disorders in the world; approximately 10% of male blacks in the United States are affected. The gene for G6PD is on the X chromosome at band q28; males carry only one gene for this enzyme, so those males that are affected by the disorder are hemizygous. Females are affected much less frequently because they would have to carry two defective G6PD genes to show clini- cal disease of the same severity as that in males. Dapsone, which is capable of inducing oxidant-type hemolysis, has increasingly come into use as prophylaxis for PCP in patients infected with HIV. Therefore, it is important to screen potential users of dapsone for G6PD deficiency with the standard enzymatic tests. A 25-year-old black man comes for a routine office visit. You have followed the patient for many years for his sickle cell disease. The patient takes very good care of himself and has only required hospital admission four times in the past 5 years. Two of these admissions occurred in the past 6 months. You feel that the patient’s clinical course is worsening. He has recently required the addition of narcotics to his home regimen of nonsteroidal anti-inflammatory drug therapy. The patient states that he now has moderately severe pain in long bones two to three times monthly. He has also developed worsening left hip pain over the past month. Which of the following statements regarding sickle cell disease is true? In patients with homozygous sickle cell disease, roughly 50% of total hemoglobin is hemoglobin S B. Risk factors that predispose to painful crises include a hemoglobin level greater than 8. The most definitive test for the diagnosis of sickle cell anemia is the sodium metabisulfite test D. Hydroxyurea has never been shown to be of benefit in the therapy of sickle cell disease Key Concept/Objective: To know the clinical features of sickle cell disease Sickle cell disease develops in persons who are homozygous for the sickle gene (HbSS), in whom 70% to 98% of hemoglobin is of the S type. Risk factors that predispose to painful crises include a hemoglobin level greater than 8. Conversely, the low hematocrit in sickle cell anemia reduces blood viscosity and is protective. The most definitive tests for sickle cell anemia are hemoglobin electrophoresis or high-per- formance liquid chromatography, which indicate the relative percentages of HbS and HbF. Hydroxyurea produces an increase in F reticulocyte and HbF levels. In a phase III trial, patients treated with hydroxyurea (starting dosage, 15 mg/kg/day) had fewer painful crises, fewer admissions for crisis, and fewer episodes of acute chest syndrome and required fewer transfusions than patients given a placebo. There was no effect on stroke; however, after 8 years of follow-up, mortality was reduced by 40%.

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