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Te patient may be a Bombay A person who is group A may form anti-A buy indomethacin toronto arthritis in dogs exercise, but an 2 1 D purchase indomethacin with visa rheumatoid arthritis qualify for disability. Which typing results are most likely to occur when a patient has an acquired B antigen? Anti-A 4+ purchase indomethacin 25mg mastercard arthritis relief otc products, anti-B-3+ cheap indomethacin line arthritis pain onset, A1 cells neg, B cells neg the discrepancy is in forward grouping. Anti-A 3+, anti-B neg, A1 cells neg, B cells neg washed red cells at room temperature with anti-A C. Anti-A 4+, anti-B 1+, A1 cells neg, B cells 4+ and anti-A,B will enhance reactions. Which blood group has the least amount of This may be indicative of an acquired antigen. A1 caused by a mistyping or an antibody against Blood bank/Apply knowledge of fundamental antigens on reverse cells. Wash the cells with warm saline, autoadsorb the autoantibody, allowing a valid forward type to be serum at 4°C performed. Retype the sample using a diﬀerent lot number washed cells until the autocontrol is negative. B All negative results may be due to weakened Blood bank/Evaluate laboratory and clinical data to antigens or antibodies. Which of the following results is most likely carbohydrate that reacts with: discrepant? A stem cell transplant patient was retyped when Blood bank/Evaluate laboratory data to make she was transferred from another hospital. Patient cells: Anti-A, neg Anti-B, 4+ Answers to Questions 12–17 Patient serum: A1 cells, neg B cells, neg 12. Weak subgroup A subgroups may fail to react with anti-A and require Blood bank/Evaluate laboratory data to make additional testing techniques (e. C The reverse typing should agree with the forward for the following typing results? A positive reaction is expected Patient cells: Anti-A, neg Anti-B, neg with A1 cells in the reverse group. A 61-year-old male with a history of multiple Answer to Question 18 myeloma had a stem cell transplant 3 years ago. Typing results must rely on the patient history of donor type and reveal the following: recipient type, and the present serological picture. A complete Rh typing for antigens C, c, D, E, and Answers to Questions 1–5 e revealed negative results for C, D, and E. A This individual has the D antigen and is classiﬁed as Blood bank/Apply knowledge of fundamental Rh positive. Any genotype containing the D antigen biological characteristics/Rh typing/1 will be considered Rh positive. If a patient has a positive direct antiglobulin test, types contain the c antigen and could not be used should you perform a weak D test on the cells? Yes, Rh reagents are enhanced in protein media result from a larger quantity of precursors being Blood bank/Apply knowledge of fundamental available to the D genes because there is no biological characteristics/Rh typing/3 competition from other Rh genes. Most weak D individuals make anti-D agglutination usually requires a 37°C incubation C. Dce/dce both may be conducted at room temperature Blood bank/Evaluate laboratory data to verify test with no special enhancement needed for reaction results/Rh system/Paternity testing/2 Blood bank/Apply knowledge of fundamental biological characteristics/Rh system/1 Answers to Questions 6–11 7. What is one possible genotype for a patient who designation is not noted in the reporting of the develops anti-C antibody? B The genotype rr (dce/dce) lacks D, C, and E antigens Blood bank/Apply knowledge of fundamental and would be suitable for an individual who has biological characteristics/Rh typing/2 developed antibodies to all three antigens. A patient developed a combination of Rh most common Rh-negative genotype and is found in antibodies: anti-C, anti-E, and anti-D. If an individual lacks parts of C, E, and D antigens the antigen, he or she may make antibodies to the B. A DcE/DcE (R2R2) is not possible because R2 can be 0 0 antigens inherited only from the mother and is not present in D. Rh0 results in a fetal maternal bleed Blood bank/Apply knowledge of fundamental C. D antigen strength decreases during pregnancy biological principles/Rh typing/1 D. D antigen strength increases during pregnancy Blood bank/Apply knowledge of biological Answers to Questions 12–18 characteristics/Rh testing/3 12. What antibodies could an R1R1 make if exposed to with no previous history, a false-positive weak D test R2R2 blood? What does the genotype —/— represent in the antibodies when exposed to R2R2 cells (DcE/DcE). Total Rh from either genetic suppression of the Rh genes or Blood bank/Evaluate laboratory data to make inheritance of amorphic genes at the Rh locus. A An Rh-negative control (patient cells in saline or procedures/Rh system/2 6% albumin) should be run if a sample appears to 16. The Wiener designation hr´ denotes c, hr˝ denotes e, and Blood bank/Evaluate laboratory data to verify test Rh0 is D. Tere are multiple alleles at a single complex locus that determine each Rh antigen D. Te antigens are named D, C, E, c, and e Blood bank/Apply knowledge of fundamental biological principles/Rh system/2 4. A physician orders 2 units of leukocyte-reduced Answers to Questions 19–20 red blood cells. What is the next blood because he is male, giving A negative would be the type that should be given? None of these options Blood bank/Apply knowledge of laboratory procedures/ Rh system/2 4. Which of the following statements is true antibody panel reveals the presence of anti-Lea. Antigens are destroyed using bleach-treated cells a positive antibody screen; however, a panel B. Should anti-Lea be antigens considered as a possibility for the patient with the C. Anti-Lea may be a possible antibody, but further Blood bank/Apply knowledge of fundamental studies are needed biological characteristics/Blood groups/2 C. Anti-Lea is not a likely antibody because even Leb individuals secrete some Lea Answers to Questions 1–4 D.
In the pediatric population discount indomethacin 25 mg otc arthritis diet webmd, children with vesi- coureteral reﬂux are at risk for pylonephritis and renal scarring purchase 75mg indomethacin mastercard arthritis in outer knee, since the kidney matures until approximately age 7 (Fig order 50 mg indomethacin with amex can you get arthritis in neck. The clinical onset of acute pyelonephritis can be sudden and dramatic; shaking chills with fevers of 38° to 40°C are not uncommon discount indomethacin 75 mg amex arthritis in dogs prednisone. Symptoms of lower urinary tract infection, such as frequency, urgency, and dysuria, may have preceded the acute event by several days. Costovertebral angle tenderness usually is severe due to inﬂammation of the kidney and surrounding anatomy. Risk Factors Risk factors for acute pyelonephritis include vesicoureteral reﬂux, obstruction of the urinary tract, and hematogenous infection. Reﬂux typically occurs in children, and, since their kidneys are still matur- ing, acute pyelonephritis can interfere with kidney growth and devel- opment. Obstructions can be caused by several factors, including stricture, stone, or pregnancy. Normally, bacteria in the urinary tract are washed out by ureteral peristalsis and proper bladder emptying; however, obstruction disables the former defense mechanism. Other risk factors include diabetes mellitus, since there is increased substrate availability in the kidney. Gas-forming organisms could result in emphysematous pyelonephritis, which may require nephrec- tomy. Patients with neurogenic bladder and the elderly also are at increased risk, since urinary emptying may not be complete in these patients. Finally, females are more prone to develop acute pyelonephri- tis due to their shorter urethral length compared to the male urethra. Management Treatment of pyelonephritis consists of intravenous ﬂuid hydration and antibiotic therapy. In mild cases, oral antibiotics can be considered; however, if a positive clinical response is not noted within 24 hours, hospitalization with intravenous antibiotics should be implemented. Following intravenous antibiotics, 75% to 80% of patients improve clinically and become afebrile within 72 hours. Once patients have been afebrile for 24 to 48 hours, they may be switched to oral antibiotics. A 14- to 21-day total course of antibiotics is recommended to ensure effective sterilization of the kidney and helps reduce the incidence of renal scarring. Urologic intervention is necessary if pyelonephritis occurs in the presence of an obstruction, such as a ureteral calculus. In this situa- tion, antibiotics are not effective until the purulent urine behind the obstruction is drained via nephrostomy or ureteral stent. In cases of renal abscess formation, percutaneous drainage and intravenous anti- biotic therapy usually are effective. Urinary Tract Tumors Urinary tract tumors, such as renal cell carcinomas, tumors of the urinary collecting system, and bladder tumors, can cause ﬂank pain when the tumor obstructs the urinary tract. These tumors also cause pain when they are large and stretch the ram capsule or when they invade surrounding structures (Fig. In this sit- uation, ﬂank pain could result from stretching of the renal capsule or direct invasion into surrounding tissues. There may be prior episodes of gross hematuria, ﬂank pain, or weight loss in patients with urologic malignancies. Renal cell tumors are relatively uncommon and account for 3% of adult malignancies. Most renal tumors (90%) are adenocarcinomas and originate from the cells of the proximal convoluted tubules. These tumors usually are unilateral and grow inwardly toward the medulla of the kidney. If gross hematuria is present, it indicates that the tumor has invaded the collecting system of the kidney. Only an advanced tumor would produce ﬂank pain, since a stage 1 tumor is conﬁned to the kidney. Tumors that penetrate the renal capsule but remain within Gerota’s fascia are considered grade 2. A grade 3 tumor has spread locally and can cause ﬂank pain, as can a grade 4 tumor, which is metastatic. Grade 4 tumors are treated with chemotherapy, but excision is sometimes necessary for relief of pain or to control bleeding. Tumors of the urinary collecting system, ureter, and bladder are most commonly transitional cell carcinomas. These tumors can cause ﬂank pain when they obstruct the urinary tract, and they commonly present with gross hematuria. About 30% of patients with a renal pelvic cancer complain of ﬂank pain, whereas only 15% of patients with a ureteral tumor experience ﬂank pain. Bladder tumors usually present with hematuria; however, when the tumor is located at the ureteral oriﬁce, it can cause ﬂank pain due to ureteral obstruction. Bladder tumors that obstruct the ureter tend to be advanced at the time of discovery, and prognosis is guarded. Urologic tumors rarely are palpable on physical examination unless they are large; however, most renal tumors are seen during 680 J. For this reason, all patients with ﬂank pain who also have gross hematuria require urologic consultation. Traumatic Flank Pain Flank pain due to trauma usually is obvious, given the clinical pre- sentation. In the trauma setting, imaging of the urinary system is nec- essary to exclude serious injury to the urinary tract, such as renal laceration, renal contusion, or ureteral avulsion (Table 38. In the pediatric population, a hydronephrotic kidney, due to a congenital ureteropelvic junction obstruction, can rupture from a rel- atively minor traumatic event. Also, the pediatric kidney is more prone to injury since it is not well protected. In the adult, a signiﬁ- cant amount of fat, muscle, and bone protect the kidney from injury, but this protective barrier is not well developed in children. Therefore, all children who present with ﬂank pain following a traumatic event require upper tract imaging. Injuries to the collecting system of the kidney usually are due to signiﬁcant trauma, except in the pediatric population for the reasons mentioned above. Administration of intravenous contrast often is nec- essary to document these injuries, since they usually are not seen on a plain abdominal x-ray or ultrasound examination and urinalysis may be normal (Table 38. Thus, a normal urinalysis in the trauma setting does not exclude serious urologic injury. Renal Artery Emboli Renal artery emboli can result secondary to mitral valve disease, atrial ﬁbrillation, acute myocardial infarction, endocarditis, and cardiac tumors. In addition, atherosclerotic aortic disease and thrombi originating in renal artery aneurysms have been known to cause renal artery emboli (Table 38.
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After a certain period of time indomethacin 50 mg cheap arthritis help, the cell layer is shaken off and the preparation is thoroughly washed cheap 50mg indomethacin amex arthritis in dogs hips treatment. The enzyme reaction generates spots of color purchase indomethacin from india arthritis foundation diet, each of which corresponds to a cell purchase cheapest indomethacin and indomethacin definition of arthritis flare, and which can be counted (Fig. By this means, the percen- tages of the subpopulations in the total population can be determined. By means of vibration, the cell stream is broken up into fine droplets which, depending on the fluorescence and sorting settings used, are charged just before they are se- parated and ideally contain one cell each. Certain parameters are measured for each cell with the help of a laser beam, where-upon the droplets are deflected into the intended containers by the + and – plate fields. Usage subject to terms and conditions of license 134 2 Basic Principles of Immunology Tetramer Assay Avidin with 4 Labeling of avidin binding sites for with fluorescein, biotin phycoerythrin, etc. The resulting tetrameric complexes are then incubated with a population of T cells. When the target cells are lysed chromium is released into the culture medium, following which it can be quantitatively measured. Following a brief stimulatory culture (six hours), the cells are rendered permeable using a mild detergent so that specifically labeled antibodies can diffuse into the cells. Usage subject to terms and conditions of license Immunological Test Methods 135 Table 2. Binds signal trans- tory T cells (about two-thirds ducers via cytoplasmic portion. Usage subject to terms and conditions of license 136 2 Basic Principles of Immunology Table 2. Usage subject to terms and conditions of license Immunological Test Methods 137 Table 2. Usage subject to terms and conditions of license 138 2 Basic Principles of Immunology Table 2. Atopic: Increased susceptibility tothe clin- Adjuvant: A substance which intensifies ical manifestations associated with the immune response against an anti- type I hypersensitivity (e. Affinity: A measure of binding strength Autosomes: All chromosomes other than between an antigen determinant (epi- the X or Y sex chromosomes. Allergy: An altered response following Bence-Jones proteins: Free light chains of secondary contact with the same anti- Ig present in the serum and urine of gen, also defined as type I hypersensi- multiple myeloma patients. Bursa fabricii: Lymphoepithelial organ ad- Allogeneic: Refers to the genetic variety jacent to the cloaca of birds, in which B contained within a species. Allotype: Different forms of a protein pro- C3b inactivator: A component of the duct, usually Ig, recognized as an anti- complement system, known as factor gen by another individual of the same I. Capping: Aggregation of surface mole- Alternative pathway: Activation of the cules on the cell membrane. Chemokines: Chemoattractant cytokines Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license 140 2 Basic Principles of Immunology Chimera: A single host bearing cells de- cells, on the way to the lymph nodes rived from genetically distinct indivi- veiled cells, and in the lymph nodes in- duals. Epitope: A special region within an anti- Cyclophosphamide: A toxic substance gen, which is recognized by an anti- frequently used to induce immuno- body binding site. Epstein-Barr virus: A herpes virus capable Cyclosporine A: An immunosuppressant of transforming human B cells, and for used for the prevention of rejection re- which B cells possess a special recep- actions. The causative agent of in- Cytophilic: Exhibiting an affinity towards fectious mononucleosis (Pfeiffer dis- cells (i. Fab: The part of the antibody molecule Cytotoxic: Exhibiting a destructive effect which contains the antigen-binding towards target cells. Dendritic cells Fc: Antibodies use the Fc fragment to bind are mobile and function to transport to cellular receptors (FcR) and C1q antigen into lymphoid organs. Usage subject to terms and conditions of license Glossary 141 Fractalkine: A chemokine expressed by Hinge region: The segment of an immu- endothelial cells; has effects on inflam- noglobulin heavy chain which lies be- mation and other processe. Contains all five classes of immunoglo- Humoral: Any factor present within extra- bulins. Rejection towards one another, forming a stain- of transplanted cells by host tissue. Mutations in the germ line, un- Hypervariable region: The three most like somatic mutations, are inherited variable segments present within the by progeny. Heterologous: Belonging to another spe- Immunity: Actively or passively acquired cies. High responder: Individuals (or inbred Immunofluorescence: Rendering certain strains) whichexhibit a strong immune antigens visible by binding of a specific response against a defined antigen. This gene complex codes for the Intron: The gene segment present be- most important transplantation anti- tween two exons. An in-vi- Low responder: Individuals (or inbred tro assay which measures the stimula- strains) which exhibit a weak immune tion response of lymphocytes as allor- response against a given antigen. Usage subject to terms and conditions of license Glossary 143 that are either virally infected or tu- Pseudoalleles: Tandem variants of a gene, morous. Paratope: The part of an antibody mole- Recombination: A process by which ge- cule which contacts the antigenic de- netic information is rearranged during terminant (epitope); the antigen-bind- meiosis. Secretory piece: An IgA-associated poly- Primary lymphoid tissues: Thymus, bur- peptide produced by epithelial cells, sa of Fabricius (in birds), bone marrow. Suppressor cell: A proposed antigen-spe- Thy: A cell surface antigen of mouse T cific T-cell subpopulation which acts to cells; there are several allelic variants reduce the immune responses of other of this marker. Tolerance: A state of specific immunologi- Syngeneic: Animals produced by re- cal unresponsiveness. Kayser The Morphology and Fine Structure of Bacteria 3 & Bacterial cells are between 0. The cytoplasmic membrane harbors numerous proteins such as permeases, cell wall synthesis enzymes, sensor proteins, secretion system proteins, and, in aerobic bacteria, respiratory chain enzymes. The membrane is surrounded by the cell wall, the most important element of which is the supporting murein skeleton. The cell wall of Gram-negative bac- teria features a porous outer membrane into the outer surface of which the lipopolysaccharide responsible for the pathogenesis of Gram-negative infec- tions is integrated. Its murein layer is thicker and contains teichoic acids and wall-associated proteins that contribute to the pathogenic process in Gram-positive infections. Many bacteria have capsules made of polysac- charides that protect them from phagocytosis. Foreign body infections are caused by bacteria that form a biofilm on inert surfaces. Some bacteria produce spores, dormant forms that are highly resistant to chemical and physical noxae. Magnifications of 500– 1000Â—close to the resolution limits of light microscopy—are required to obtain useful images of bacteria. Another problem is that the structures of objects the size of bacteria offer little visual contrast.
It is uncommon to discover a palpable ﬂank mass proven indomethacin 75mg arthritis relief in back, unless there is a large renal tumor present purchase indomethacin online from canada tricompartmental arthritis definition. Patients with acute pyelonephritis or obstructing renal calculi complain of severe pain when the ﬂank is percussed order indomethacin with a visa arthritis in pointer fingers, so it is important to tap lightly in order to maintain patient conﬁdence cheap 75 mg indomethacin with amex arthritis mutilans definition. To rule out a musculoskeletal etiology for the ﬂank pain, the lower extremities should be examined for motor and sensory function. Laboratory and Diagnostic Studies Laboratory Studies The history and physical examination help determine the most probable etiology of the ﬂank pain and guide the clinician toward the selection of the most appropriate laboratory and diagnostic tests. Evaluation of Flank Pain 689 In almost all cases, a urinalysis should be performed as the initial diagnostic test. In contrast, patients with uric acid stones tend to have an acidic urine, since these stones do not form when the urine is alkaline. A Gram stain should be done in the emergency room or clinic and can help determine if infection is present. The shape of the crystal can be used by the laboratory technician to help identify its composition. The urinalysis may be normal if the etiology of the ﬂank pain is due to cardiac, intraabdominal, musculoskeletal, or psychological problems. Anemia and a low or high platelet count might be seen in the presence of bleeding urologic tumors. The impaired function could be due to dehydration, obstruction, tumor, infarct, or medical renal disease. Moreover, an elevated serum creati- nine indicates bilateral renal disease or disease involving a solitary kidney, since only one healthy kidney is required to maintain a normal serum creatinine. In long-standing renal compromise, it is not un- common to see a fall in serum bicarbonate along with hyperkalemia. Hyponatremia results from volume overload and can cause nausea, vomiting, and seizures. Hyperkalemia especially is dangerous, since it could result in cardiac arrhythmias. Other useful tests might include a serum uric acid level and serum calcium level, if a urinary calculus is suspected. Barone Diagnostic Studies Following the history, physical exam, and laboratory analysis, a plain ﬁlm of the abdomen can help identify urinary calculi (Fig. The entire ﬁlm should be viewed for intestinal gas pattern, gallstones, bony structure, and free air, which may provide insight into the etiology of the pain. Renal cell carcinomas are osteolytic tumors, and this can be seen radiographically in metastatic disease. An abnormal intestinal gas pattern, gallstones, or free air suggest intraabdominal pathology. Aortic calciﬁcations and aneurysms should be determined, since they might suggest renal artery disease as the etiology of the ﬂank pain. Urinary calculi typically are seen as calciﬁcations overlying the kidney shadow or along the course of the ureter (Fig. Small stones, 1 to 2mm in size, can cause severe ﬂank pain if they obstruct the ﬂow of urine into the bladder. Following the history, physical examination, urinalysis, and abdom- inal plain ﬁlm, a preliminary diagnosis is possible in most instances. However, more detailed imaging studies often are performed to conﬁrm the diagnosis and to help plan appropriate therapy. These reactions can be severe and have resulted in hemodynamic and respiratory collapse. These tests demonstrate anatomy, not function, and this con- sideration may be important in a patient’s evaluation. In this instance, the kidney looks normal; however, it is no longer functioning due to the recent infarct. Summary The urologist frequently evaluates patients with ﬂank pain and diag- noses and treats conditions that may have local or systemic ramiﬁca- tions. Nonurologic causes for the pain always are considered during the initial evaluation. Although the history and physical examination are the most important aspect of the evaluation, laboratory and diag- nostic tests help conﬁrm the diagnosis. Since this is a commonly encountered clinical problem, all practitioners should have some famil- iarity with the diagnosis and management of ﬂank pain. To generate a list of potential diagnoses for the patient who presents with pain or a mass in the scrotum. Be sure to: • Discuss testicular versus extratesticular origins • Discuss benign versus malignant causes • Discuss emergent versus nonemergent causes 3. Be sure to discuss the following issues: • Pain—presence, absence, onset, severity • Palpation—distinguish testicular from extrates- ticular (adnexal) mass • Transillumination 4. Cases Case 1 A mother brought her 15-month-old son in for evaluation because he has “only one testicle. Weiss Case 2 A 15-year-old boy presented to the emergency department with acute testis pain and nausea. Testicular development and descent are controlled intricately by the hypothalamus-pituitary-gonad axis (Fig. Testosterone regulates its own production by regaling feedback on the hypothalmus and pituitary. Scrotal development in males is a result of the testis and epididymis descending, causing the skin to stretch. Sperm fertility is enhanced by being stored in a cooler region within the scrotum rather than in the abdomen. Cryptorchid or “undescended testis” results in infertility if the testis is not placed in the scrotum. Scrotal Disorders 695 During early development, the testes originates in the abdomen near the kidney. During early embryologic development, the processus vaginalis is an invagination at the inguinal ring. The gubernac- ulum attaches superiorly onto the Wolfﬁan duct and inferiorly into the inguinal canal. This descent from abdomen to scrotum explains why the testis lymphatic drainage is to the nodes below the renal hilum and the venous drainage is to the vena cava on the right and to the renal vein on the left. Cryptorchidism Cryptorchidism or undescended testis is deﬁned as an abnormal descent of the testis and can be unilateral or bilateral. Two thirds of the cases are unilateral, while one third of the cases are bilat- eral. Initial visual inspection should reveal a scrotum that is devel- oped bilaterally. Often, slight groin pressure with the foreﬁnger brings the testis down into the scrotum. If the testis is not palpated in the scrotum or groin, ultrasonography may be necessary to locate it above the inter- nal inguinal ring or within the abdomen. If the testis does not appear to be descending properly, surgical orchiopexy is the necessary treatment to place the testis in the scrotum, which allows appropriate testis maturation and eventual fertility.