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A 29-year-old man who emigrated from Scotland 3 years ago is brought to the emergency department because of severe shortness of breath for 2 hours 5 mg atorlip-5. He has a debilitating condition that began 2 years ago with an odd sticky feeling of his skin order atorlip-5 5 mg amex, but physical examination at that time showed no abnormalities buy atorlip-5 5 mg overnight delivery. His condition has progressed to include severe major depressive disorder, dementia, unsteady gait, difficulty walking, and impaired coordination. He now is confined to a wheelchair and has severe dementia and the inability to speak. A 52-year-old woman comes to the physician because of gradual loss of feeling in her feet during the past 6 months. She has a 23-year history of hypertension and a 20-year history of type 2 diabetes mellitus. Current medications include hormone replacement therapy, diuretics, and an oral hypoglycemic agent. Which of the following is the strongest predisposing risk factor of this new finding? A 49-year-old woman comes to the physician because of a 3-month history of waking at night because of pain and numbness of her right hand. Examination of the right hand shows tenderness with palpation and distal tingling on percussion of the volar wrist. A 65-year-old woman has had double vision, difficulty keeping her eyes open, and diffuse weakness for the past several months. She has bilateral ptosis that worsens with sustained upward gaze, limited horizontal and vertical movements in both eyes, and nasal speech. Her symptoms and signs improve transiently following intravenous injection of edrophonium. A 21-year-old woman comes to the physician 2 weeks after being involved in a motor vehicle collision that occurred when she fell asleep while driving. She says that during the past 2 years she has had several incidents of falling asleep at inappropriate times, including while walking. She also reports intermittent loss of muscle tone while awake and occasional sleep paralysis. B - 46 - Pathology Systems General Principles of Foundational Science 25%–30% Biology of cells Biology of tissue response to disease Immune System 5%–10% Blood & Lymphoreticular System 5%–10% Nervous System & Special Senses 1%–5% Skin & Subcutaneous Tissue 1%–5% Musculoskeletal System 1%–5% Cardiovascular System 5%–10% Respiratory System 5%–10% Gastrointestinal System 5%–10% Renal & Urinary System 5%–10% Pregnancy, Childbirth, & the Puerperium 1%–5% Female Reproductive System & Breast 1%–5% Male Reproductive System 1%–5% Endocrine System 5%–10% Multisystem Processes & Disorders 5%–10% - 47 - 1. Laboratory studies show normal hepatic enzyme activities, a negative direct antiglobulin (Coombs) test, increased mean corpuscular hemoglobin concentration, and increased osmotic fragility of erythrocytes. Which of the following types of erythrocyte is most likely to be seen on a peripheral blood smear? A 34-year-old woman is brought to the emergency department by her husband because of confusion for 2 hours. Her husband says that she has a 1-year history of episodes of nervousness, light-headedness, and dizziness that resolve after she eats a meal. Physical examination shows a round face, central obesity, excess fat over the posterior neck and back, and abdominal striae. A chest x-ray shows a 3-cm mass in the left upper lobe with enlargement of hilar nodes. Further serum studies are most likely to show an increased concentration of which of the following proteins? A 45-year-old man with chronic pancreatitis has a 9-kg (20-lb) weight loss and diarrhea. A 70-year-old man comes to the physician because of a 2-year history of shortness of breath and progressive chest pain. Physical examination shows absent breath sounds and dullness to percussion over the right lung base. A chest x-ray shows thickened pleura on the right side and a medium-sized pleural effusion. Microscopic examination of the kidneys shows intact nephrons interspersed between the cysts. The most likely cause of these changes in the kidneys involves which of the following modes of inheritance? An autopsy of a 24-year-old woman shows pleuritis, membranous thickening of glomerular capillary walls, concentric rings of collagen around splenic arterioles, and excrescences on the underside of the mitral valve. The external iliac arteries contain irregular, focal cystic areas within the media with pools of mucopolysaccharide and fraying fragmentation of the elastica. A 10-year-old boy is brought to the emergency department 15 minutes after he sustained abdominal injuries in a motor vehicle collision. The patient undergoes operative removal of a portion of the lower left lobe of the lung, the left lobe of the liver, half of the left kidney, half of the spleen, and a 2-foot section of the small intestine. Assuming survival of the acute trauma, which of the following organs is likely to have the most complete regeneration in this patient? A previously healthy 2-year-old boy is brought to the emergency department because of bloody stools for 2 days. Laboratory studies show: Hemoglobin 11 g/dL Hematocrit 37% Leukocyte count 9500/mm3 Platelet count 250,000/mm3 Test of the stool for occult blood is positive. During an emergency laparotomy, a 3 × 2-cm protrusion is found on the antimesenteric border of the small intestine approximately 50 cm proximal to the ileocecal valve. A 50-year-old man comes to the physician because of progressive fatigue and darkening of his skin during the past 2 years. A 69-year-old woman is brought to the emergency department because of progressive difficulty with her vision during the past day. She says, “This morning I had a blind spot in my left eye, and it just grew bigger as the day went on.

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These guidelines can be “projected” from the intelligent clinical management systems (the advanced electronic medical records sys- tems discussed Chapter 3) in the home discount 5 mg atorlip-5 overnight delivery, hospital buy discount atorlip-5 5 mg on line, or physician clinic in which the physician works buy atorlip-5 5 mg online. Rather than relying principally on direct contact through physi- cian visits, much of this monitoring and evaluation will be sup- ported from home by medical software that patients can access Physicians 79 through a web page maintained by the physician or by outside ven- dors or their hospital system. Thus, the physician’s protection and advice can be extended and strengthened by disease-management software that reaches into the patient’s home around the clock (24/7). Second Opinions and Other Consultations Internet connectivity through broadband will dramatically increase the ease with which medical consultation can take place throughout the world. Prior to the availability and extensive use of Internet, re- quests from physicians for specialty consultation were generated by telephone and were followed by paper medical records, x-rays, lab reports, and other information for consultation to take place. Some- times these records are hand carried by the patient to a scheduled appointment. With broadband Internet connections, it will be possible for complex patient records, including the medical record itself, digital radiological images, pathology reports, and even voice files to be sent instantaneously anywhere in the world as attachments to e-mail. Partners Health System (the Massachusetts General/Brigham and Women’s Hospitals in Boston) has allied itself with Duke Univer- sity Medical Center, Johns Hopkins University, and The Cleveland Clinic Foundation to create a consortium to provide international electronic second-opinion consultations. Although the Inter- net is completely oblivious to geographic and political boundaries, complex licensure issues will be problematic until telemedicine leg- islation is modified. It is still not clear at this writing, beyond teleradiology, how big an economic opportunity Internet-assisted telemedicine can 80 Digital Medicine become. At least for the foreseeable future, most of the economic opportunities for healthcare organizations will continue to be gen- erated by patient visits. Thus, information exchange, even consul- tation on the specifics of a patient’s problem, may be an important prelude to, but not a substitute for, the visit, during which some- thing is actually done to resolve the patient’s problem. Specialty societies have realized that they are trusted sources of medical knowledge and can leverage their prestige and legitimacy as representatives of their disciplines to create clinical content. These organizations, such as the American College of Cardiology and the American Academy of Orthopedic Surgeons, were traditionally re- luctant to foster consensus about best clinical practices for their members because of concerns about antitrust or competitive rela- tionships within or between disciplines (e. However, the ability to put the stamp of professional legitimacy on practice guidelines, based upon peer-reviewed research, puts these societies in the position of creating valuable content both for consumer and professional web sites, and for clinical operating systems like the intelligent electronic medical records discussed in the previous chapter. Connectivity is making it easier for colleagues to convene in cy- berspace, not only to consult on specific cases (as discussed above), but also to exchange ideas, collaborate in applying for grants, con- duct research activity, and organize to influence funding decisions Physicians 81 for research and for clinical care in Washington and state capitols. It is also enabling physicians to remain in contact with their chiefs and colleagues who trained them in medical school and residency training without having to travel. This is the ultimate source of competitive advantage of multispecialty physician organizations like the Mayo Clinic and the Permanente Medical Groups of Kaiser. The culture of successful multispecialty groups fosters easy interaction between physicians of different spe- cialties. This culture makes it possible for an internist to reach col- leagues in psychiatry, neurology, or infectious disease easily with patient-related questions that relate to their disciplines. Electronic connectivity will multiply these interactions by making it unneces- sary for both parties to be simultaneously connected or physically proximate. Relying on a trusted professional colleague to filter knowledge and focus it on a specific clinical problem is far more efficient than conducting one’s own literature search or sallying forth onto the Internet to find the answer. The best clinical care can be found in institutions where peer communication is easy and open. It will be many years before the virtual version of this easy peer connection can be fostered in the medical part of the Internet, again in part due to medical-legal concerns. Medicine is so fragmented, and the knowledge base so diverse, that a workable peer-to-peer so- lution to locating and retrieving medical knowledge seems unlikely to appear any time soon. In the meantime, the Internet will make it easier for physicians to communicate with each other and foster network relationships that extend beyond the walls of the specific institutions in which physicians practice. Groupware like Lotus Notes has long made it possible for clinical and research teams that are dispersed geograph- ically to work on common projects. Physicians’ natural curiosity and gregariousness seem likely to find new outlets in virtual collab- oration on the Internet. Medical journals have raced to make their content available to physicians and other subscribers online. When physicians subscribe to their service, which is called Cog- niQ, they list all of the medical journals they follow. Physicians can scan the new articles and choose those of interest to be archived in their box on the Unbound Medicine server, in abstract or full-text form. Physicians 83 Thus, questions that would have been lost end up getting an- swered and stored in an easily retrievable fashion. Over time, the server retains the entire stream of answers to questions and relevant journal articles as a personalized “knowledge archive,” making it unnecessary for the physician to retain the new knowledge in his or her memory. This service will evolve from being modem dependent to being wireless as it becomes more widely available. As this occurs, physicians will be freed from the need to return telephone calls or to give verbal orders, enabling them to practice medicine “anytime, anywhere. In many institutions, physician mistrust of hospital motivations and strategies is a dominant theme. Mistrust Although competitive tensions between physician-sponsored enter- prises and hospitals have contributed to this problem, many physi- cians view the hospital as a battleship whose wake is sufficient to swamp the small boats it operates. The fact that hospitals and physi- cians have completely separate information domains complicates the ability to implement new clinical information systems. The Hospital as Potential Information Source Hospitals are presently committing major capital resources to com- puterize both operations and clinical services. As argued above, physician practices, even many large groups, are capital poor and thus lag in automating their processes and services. It is entirely possible given the present course that hospitals will complete this Physicians 85 process a decade or more ahead of physicians, leaving what physi- cians “know” about their patients locked up in paper records and their memories. When physicians do automate, if no compatibility standards are set in advance, they will use incompatible software and be unable to move clinical information between their systems and those of the hospital.

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Using the infant exclusively fed human milk as a model is in keeping with the basis for earlier recommendations for intake (e order 5 mg atorlip-5 amex. It also supports the recommenda- tion that exclusive intake of human milk is the preferred method of feed- ing for normal proven 5 mg atorlip-5, full-term infants for the first 4 to 6 months of life generic atorlip-5 5 mg with visa. In general, this report does not cover possible variations in physiologi- cal need during the first month after birth or the variations in intake of nutrients from human milk that result from differences in milk volume and nutrient concentration during early lactation. The use of formula intro- duces a large number of complex issues, one of which is the bioavailability of different forms of the nutrient in different formula types. Where data are available regarding adjustments that should be made for various for- mulas, they are included in the “Special Considerations” sections of the nutrient chapters. This volume was reported from studies that used test weighing of full-term infants. In this procedure, the infant is weighed before and after each feeding (Allen et al. Because there is variation in both the composition of milk and the volume consumed, the computed value represents the mean. It is assumed that infants will con- sume increased volumes of human milk during growth spurts to meet their needs for maintenance, as well as for growth. There is little evidence, however, of markedly different needs for carbo- hydrate, fat, and n-6 and n-3 polyunsaturated fatty acids. However, for the energy-yielding nutrients, these methods were not appropriate because the amount of energy required per body weight is significantly lower dur- ing the second 6 months, due largely to the slower rate of weight gain/kg of body weight. The amounts of fat and carbohydrate consumed from complementary foods were determined by using data from the Third National Health and Nutrition Examination Survey. One problem encountered in deriving intake data in infants was the lack of available data on total nutrient intake from a combination of human milk and solid foods in the second 6 months of life. Most intake survey data do not identify the milk source, but the published values indicate that cow milk and cow milk formula were most likely consumed. For determining estimated energy requirements using a doubly labeled water database, equations using stepwise multiple linear regressions were generated to predict total energy expenditure based on age, gender, height, and weight. Methods to Determine Increased Needs for Pregnancy It is known that the placenta actively transports certain nutrients from the mother to the fetus against a concentration gradient (Hay, 1994). In these cases, the potential for increased need for these nutrients during pregnancy is based on theoretical considerations, including obligatory fetal transfer, if data are available, and on increased maternal needs related to increases in energy or protein metabolism, as applicable. Methods to Determine Increased Needs for Lactation For the nutrients under study, it is assumed that the total requirement of lactating women equals the requirement for the nonpregnant, non- lactating woman of similar age plus an increment to cover the amount needed for milk production. To allow for inefficiencies in use of certain nutrients, the increment may be greater than the amount of the nutrient contained in the milk produced. While data regarding total fat, cholesterol, protein, and amino acid content of various foods have been available for many years, data for individual fatty acids have only recently been available. For nutrients such as energy, fiber, and trans fatty acids, analytical methods to determine the content of the nutrient in food have serious limitations. Methodological Considerations The quality of nutrient intake data varies widely across studies. The most valid intake data are those collected from the metabolic study proto- cols in which all food is provided by the researchers, amounts consumed are measured accurately, and the nutrient composition of the food is determined by reliable and valid laboratory analyses. It is well known that energy intake is underreported in national surveys (Cook et al. Estimates of underreporting of energy intake in the Third National Health and Nutri- tion Examination Survey were 18 percent of the adult men and 28 percent of the adult women participating (Briefel et al. In addition, alcohol intake, which accounted for approximately 4 percent of the total energy intake in men and 2 percent in women, is thought to be routinely underreported as well (McDowell et al. Adjusting for Day-to-Day Variation Because of day-to-day variation in dietary intakes, the distribution of 1-day (or 2-day) intakes for a group is wider than the distribution of usual intakes, even though the mean of the intakes may be the same (for further elaboration, see Chapter 13). However, no accepted method is available to adjust for the underreporting of intake, which may average as much as 18 to 28 percent for energy (Briefel et al. A second recall was collected for a 5 percent nonrandom subsample to allow adjustment of intake estimates for day-to-day variation. Survey data from 1990 to 1997 for several Canadian provinces are available for energy, carbohydrate, fat, saturated fat, and protein intake (Appendix F). Food Sources For some nutrients, two types of information are provided about food sources: identification of the foods that are the major contributors of the nutrients to diets in the United States, and the food sources that have the highest content of the nutrient. The determination of foods that are major contributors depends on both nutrient content of a food and the total consumption of the food (amount and frequency). Therefore, a food that has a relatively low concentration of a nutrient might still be a large con- tributor to total intake if that food is consumed in relatively large amounts. Studies in human lactation: Milk composition and daily secretion rates of macronutrients in the first year of lactation. Dietary methods research in the Third National Health and Nutrition Examination Survey: Underreporting of energy intake. Feinleib M, Rifkind B, Sempos C, Johnson C, Bachorik P, Lippel K, Carroll M, Ingster-Moore L, Murphy R. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chro- mium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Discrepancy between self-reported and actual caloric intake and exercise in obese subjects.

He has in excess of 150 scientific publications in the fields of toxicology and risk assessment buy atorlip-5 5 mg with visa. Munro formerly held senior posi- tions at Health and Welfare Canada as director of the Bureau of Chemical Safety and director general of the Food Directorate cheap 5 mg atorlip-5 with visa, Health Protection Branch buy 5 mg atorlip-5 visa. He was responsible for research and standard setting activities related to microbial and chemical hazards in food and the nutritional quality of the Canadian food supply. He has contributed significantly to the development of risk assessment procedures in the field of public health, both nationally and internationally, through membership on various committees dealing with the regulatory aspects of risk assessment and risk management of public health hazards. He is a graduate of McGill University in biochemistry and nutrition and holds a Ph. Murphy’s research interests include dietary assess- ment methodology, development of food composition databases, and nutritional epidemiology. She served as a member of the National Nutri- tion Monitoring Advisory Council and the 2000 Dietary Guidelines Advi- sory Committee, and is currently on editorial boards for the Journal of Food Composition and Analysis and Nutrition Today. Murphy is a member of numerous professional organizations including the American Dietetic Association, the American Society for Nutritional Sciences, the American Public Health Association, the American Society for Clinical Nutrition, and the Society for Nutrition Education. She has over 50 publications on dietary assessment methodology and has lectured nationally and inter- nationally on this subject. Nuttall is a member of the American Diabetes Association, the Endocrine Society, and the Ameri- can Society of Biological Chemists and is a fellow of the American College of Physicians and the American College of Nutrition. His research interests include diabetes mellitus, control of glycogen metabolism, and glycogen synthase and phosphorylase systems. Previously, he was chair and a professor of the Depart- ment of Biostatistics and Epidemiology at the School of Public Health and Health Sciences at the University of Massachusetts at Amherst. Pastides is a consultant to the World Health Organization’s Program in Environ- mental Health and is a fellow of the American College of Epidemiology. He was a Fulbright Senior Research Fellow and visiting professor at the University of Athens Medical School in Greece from 1987 to 1988. Pastides has been a principal investigator or coinvestigator on over 30 externally-funded research grants, results of which have been published in numerous peer-reviewed journals. He is the recipient of several prestigious awards such as the Borden Award in Nutrition of the Canadian Society for Nutritional Sciences, the Sandoz Award of the Clinical Research Society of Toronto, the Agnes Higgins Award of the March of Dimes, the Osborne Mendel Award of the American Society for Nutrition Sciences, and the Nutrition Award of the American Academy of Pediatrics. Pencharz has served on the grant review boards for the Medical Research Council, the National Institutes of Health, the U. His research expertise is protein, amino acid, and energy metabolism in neonates and young adults, especially in patients suffering from cystic fibrosis. Luke’s– Roosevelt Hospital Center, and a professor of medicine at the College of Physicians and Surgeons, Columbia University. His research interests are in the hormonal control of carbohydrate metabolism, diabetes mellitus, obesity, and food intake regulation. Pi-Sunyer is a past president of the American Diabetes Association, the American Society for Clinical Nutri- tion, and the North American Association for the Study of Obesity. Pi-Sunyer is editor-in- chief of Obesity Research and associate editor of the International Journal of Obesity. Rand’s general expertise is in statistical modeling and application of statistics to biomedical problems. He was the recipient of several honors and awards and has served on many journal editorial boards. Reeds served as a permanent member of the Nutrition Study Section, National Institutes of Health and the International Review Panel, United Kingdom Agricultural and Food Research Council. Reeds’ research expertise was protein metabolism and amino acid requirements, specifically the regula- tion of growth and protein deposition by diet and other environmental variables such as stress and infection. Rimm is project director of a National Heart, Lung, and Blood Institute- and National Cancer Institute-funded prospective study of diet and chronic disease among men, as well as the principal investigator of a National Institute on Alcoholism and Alcohol Abuse study. Memberships include the Executive Committee of the Epidemiology and Prevention Council of the American Heart Asso- ciation and the Society for Epidemiologic Research. He has authored over 150 papers with a main research focus on the associations between diet and other lifestyle characteristics and the risk of obesity, diabetes, and cardiovascular disease. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University. She is also a professor of nutrition in the School of Nutrition Science and Policy at Tufts and a professor of psychiatry and a scientific staff member in the Department of Pediatrics at Tufts University Medical School. Her research focus is infant and adult obesity, infant nutrient requirements, breastfeeding, and nutri- tion and aging. She chairs national meetings on dietary prevention of obesity and sits on international committees for evaluation of nutritional requirements. He has more than 100 scientific publications on food safety and risk assessment and has lectured nationally and internationally on these subjects. Rodricks is the author of Calculated Risks, a nontechnical introduction to toxicology and risk assessment. Her laboratory is actively involved in research on dietary fiber, phytoestrogens from flax and soy, and whole grains. Slavin has published more than 100 reviewed research articles and has given hundreds of nutrition semi- nars for professional and lay audiences. She is a science communicator for the Institute of Food Technologists and a member of numerous scientific societies, including the America Dietetic Association, the American Soci- ety for Nutritional Sciences, and the American Association for Cancer Research. She is a frequent source for the media on topics ranging from functional foods to sports nutrition. Her research interests are human nutrition, dietary fiber, nutrient bioavailability, sports nutrition, carbo- hydrate metabolism, and the role of diet in cancer prevention. He has served on the editorial board of the Journal of Nutrition, as program manager of the U.

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