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Seven points along the length of the fiber were tracked discount zebeta 10 mg overnight delivery. A stretch ratio was calculated assuming a straight line between adjacent points referenced against a no-load condition purchase zebeta 5mg with mastercard. Errors in the technique were quantified by imposing rigid body rotations and translations on the fiber. Any measured strain was then treated as an error in the measurement technique. The digitizing procedure for a single test was conducted seven times to measure the repeatability of the digitizing process. The standard deviation in determining the point positions was found to be 0. Lagrangian planar strains can be calculated directly from the initial and final lengths of the sides of the triangle. Measurement of the complete strain tensor is often achieved by examining three points placed in close proximity. Letting Pi′ and Pi denote the initial and final positions of three points undergoing a general planar deformation, as shown in Figure 5. Principal strains can be calculated solving the eigenvalue problem. With tissue property and geometry variations, uniform loads give rise to nonhomogenous strain fields. As a result, it often becomes necessary to determine the full-field strain distribution across the region of interest in the tissue. Further, tissue heterogeneity and the presence of an active component in muscle imply, when measuring isometric strains in a muscle tendon unit, that the strain within the structure may be changing. In an effort to improve accuracy and reduce noise in full-field strain measurement, investigators have fitted the surface displacement across the entire tissue surface with a function and then differentiated the function to attain the strain at each point. Image data were collected on a 1000 Hz, 238 × 192 pixel CCD camera. Strain was calculated using the Lagrangian formulation (Eq. While tensile axial defor- mations of the muscle were large, transverse deformations and the change in transverse deformation with respect to the initial position, x, were small. With this particular model, the structure had a gauge length of 6 cm, and failed when elongated to 9 cm. Given the limited spatial resolution of the imager, this resulted in a position resolution of approximately 0. Strains calculated using a central difference method from the noisy, discretized data produced errors on the order of the strain amplitude. Recognizing that discretization error is randomly distributed, fitting a function to a set of points decreases error by 1/ n where n is the number of points in the fitted curve. In these experiments, this resulted in a decrease in error by a factor of 6. While splines tended to have oscillations that produced negative strains when differentiated, polynomial functions were well- behaved and were insensitive to the order of the polynomial (Fig. The distal tendon, left, is inserted into the grip of a hydraulic actuator. Deflections in both the lateral and axial directions were quantified by digitizing the black surface marks. These data illustrate the decrease in quantization error associated by fitting the displacement field with a polynomial function. When fitting functions to multiple marker positions, a tradeoff between marker size and the number of markers occurs. While both reduce error, increasing marker size decreases the number of marks which can be placed on the surface. As the purpose of this technique is to minimize the error in the strain field and not the position of each spot, it becomes necessary to optimize the benefits of larger spot size with the benefits of greater numbers of spots. To that end, we generated numerical strain fields from previously performed experiments to assess the effect of spot radii and number of spots on strain measurement © 2001 by CRC Press LLC FIGURE 5.

As shown in the upper left image cheap zebeta 10mg fast delivery, the brainstem to the cerebellum via the pons (cortico-pontine discount zebeta 5 mg fast delivery, see Figure was sectioned at the level of the cerebral peduncles; the 48 and Figure 55), and to the spinal cord (cortico-spinal corresponding level is shown on a medial view of the tracts, see Figure 45 and Figure 48). Many of the structures visible on this “gross” midbrain region — the substantia nigra and the red specimen will be seen in more detail on the histological nucleus, both involved in motor control. The distinctive features identifying this section as • The substantia nigra is found throughout the midbrain are: midbrain and is located behind the cerebral peduncles. It derives its name from the dark • Anteriorly, the outline of the cerebral peduncles melanin-like pigment found (not in all species) with the fossa in between. The pigment is not retained when in the cell bodies. There- • A faint outline of the red nucleus can be seen fore, this nuclear area is clear (appearing white) in the tegmentum, which identifies this section in most photographs in atlases, despite its name. With myelin-type stains, the area will appear • In the middle toward the back of the specimen “empty”; with cell stains, the neuronal cell bod- is a narrow channel, which is the aqueduct of ies will be visible. Its function is related to the the midbrain, surrounded by the periaqueductal basal ganglia (see Figure 52 and Figure 53). The red nucleus is found at There are two levels presented for a study of the mid- the superior collicular level. Its function is dis- brain: cussed with the motor systems (see Figure 47). The periaqueductal gray, surrounding the aque- the decussation of the superior cerebellar duct, has been included as part of the reticular formation peduncles. The medial lemniscus, the ascending trigeminal pathway, and the fibers of the anterolateral system incor- CROSS-SECTION porated with them (see Figure 36 and Figure 40) are located in the outer part of the tegmentum, on their way The identifying features of this cross-section of the mid- to the nuclei of the thalamus (see Figure 63). The aqueduct is surrounded central region of the brainstem (the tegmentum); they are by the periaqueductal gray. The remainder of the midbrain functionally part of the ascending reticular activating sys- is the tegmentum, with nuclei and tracts. Dorsally, behind tem and play a significant role in consciousness (discussed the aqueduct, is a colliculus. The periaqueductal The descending fiber systems are segregated within gray surrounding the cerebral aqueduct is involved with the cerebral peduncles (see Figure 45, Figure 46, and the descending pathway for the modulation of pain (see Figure 48). The substantia nigra consists, in fact, of two Figure 43). The pars reticulata lies adjacent to the tain visual movements (see Figure 41B). These nuclei give cerebral peduncle and contains some widely dispersed rise to a fiber tract, the tecto-spinal tract, a descending neurons; these neurons connect the basal ganglia to the pathway that is involved in the control of eye and neck thalamus as one of the output nuclei of the basal ganglia movements; it descends to the cervical spinal cord as part (similar to the globus pallidus internal segment, see Figure of the medial longitudinal fasciculus (MLF) (see Figure 53). The pars compacta is a cell-rich region, located more 51B). The MLF stains heavily with a myelin-type stain and These are the dopaminergic neurons that project to the is found anterior to the cranial nerve motor nucleus, next neostriatum (discussed with Figure 52). Loss of these to the midline, at this level as well as other levels of the neurons results in the clinical entity Parkinson’s disease brainstem. Also to be noted at this level is the brachium (discussed with Figure 52). With a section that has been stained for myelin, the nucleus is CLINICAL ASPECT seen as a clear zone. The red nucleus gives origin to a A specific lesion involving a thrombosis of the basilar descending pathway, the rubro-spinal tract, which is artery may destroy much of the brainstem yet leave the involved in motor control (see Figure 47 and Figure 48). Few people actually The oculomotor nucleus (CN III) is quite large and survive this cerebrovascular damage, but those that do are occupies the region in front of the periaqueductal gray, left in a suspended (rather tragic) state of living, known near the midline; this identifies the level as upper midbrain by the name “locked-in” syndrome. These motor neurons are large consciousness, with intellectual functions generally intact, in size and easily recognizable. The parasympathetic por- meaning that they can think and feel as before.

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Hemoglobin oxygen satura- tion on room air is 98% with a normal respiratory rate zebeta 10mg amex. Which of the following statements regarding basophils or basophilia is true? Thrombocytosis is commonly associated with splenectomy buy generic zebeta 10mg, but splenectomy has no association with basophilia B. Basophilia is defined as a basophil count greater than 500/mm3 C. Basophilia is seen in myeloproliferative disorders (MPDs) such as chronic myelogenous leukemia (CML), polycythemia vera (PV), and myeloid metaplasia, as well as in some hemolytic anemias and Hodgkin disease D. Granules in the basophil do not contain histamine Key Concept/Objective: To understand basophil physiology and the clinical significance of basophilia Basophilia (i. The basophil count can also be increased in patients with ulcerative coli- tis or varicella infection. Although basophils and mast cells are involved in immediate hypersensitivity reactions and basophils are often seen in areas of contact dermatitis, basophilia is not seen in patients with these disorders. Most, if not all, of the circulating his- tamine in the body is synthesized by the basophil and stored in its granules. Degranulation causes the release of histamine, which mediates many immediate hypersensitivity effects and which, because it is a potent eosinophil chemoattractant, draws eosinophils to the site of degranulation. Other substances that are released on basophil degranulation include additional eosinophil chemotactic factors and a variety of arachidonic acid metabolites, the most important of which is leukotriene C4. You are asked to consult on a case involving a 26-year-old man who developed leukocytosis after a motorcycle accident 3 days ago. The patient has multiple fractures of the pelvis and lower extremities, extensive soft-tissue injury, and aspiration pneumonia. His leukocyte count was 35,000 on admission and has subsequently ranged up to 50,000. Currently, the patient is sedated and is on a ventilator. Physical examination is remarkable for right lower lateral consolida- tion, ecchymoses of the lower extremities, and the absence of hepatosplenomegaly. No myelocytes or metamyelocytes are noted, and there is no elevation of the basophil or eosinophil count. The leukocyte alkaline phosphatase (LAP) score is 140 µm/L. Which of the following cannot be the cause of this patient’s elevated neutrophil count? Cytokine release Key Concept/Objective: To understand the causes of the leukemoid reaction and distinguish them from malignant causes The term leukemoid reaction is used to describe a profound leukocytosis (generally defined as a leukocyte count exceeding 25,000 to 30,000/mm3) that is not leukemic in eti- 20 BOARD REVIEW ology. Leukemoid reactions are the response of normal bone marrow to cytokine release by lymphocytes, macrophages, and other cells in response to infection or trauma. In a leukemoid reaction, the circulating neutrophils are usually mature and are not clonally derived. The major differential diagnosis is with regard to CML. Leukemoid reactions should also be distinguished from leukoerythroblastic reactions: the presence of immature white cells and nucleated red cells in the peripheral blood irrespective of the total leuko- cyte count. Although less common than leukemoid reactions in adults, leukoerythroblas- tosis reflects serious marrow stimulation or dysfunction and should prompt bone marrow aspiration and biopsy, unless it occurs in association with severe hemolytic anemia, sepsis in a patient with hyposplenism, or massive trauma. In such patients, trauma, hemorrhage, and infection all will contribute to a potent cytokine release and marrow stimulation. The absence of splenomegaly, leukocyte precursors (myelocytes, metamyelocytes), basophilia, or eosinophilia all point away from CML, and the elevated LAP score confirms the diag- nosis of a leukemoid reaction. On routine examination, a 45-year-old man is found to have a neutrophil count of 1,100/mm3. He feels well, takes no medications, and has no history of infection. His medical records reveal a persistent, asymptomatic neutropenia of 1,000 to 1,800 neutrophils/mm3 over the past 10 years. Which of the following ethnicities would help explain this patient’s low leukocyte count? Inuit Key Concept/Objective: To be able to recognize constitutional causes of neutropenia in certain populations Neutropenia is present when the peripheral neutrophil count is less than 1,000 to 2,000 cells/mm3.

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Mycophenolate mofetil can cause vasoconstriction and worsen hypertension C 10 mg zebeta amex. Graft dysfunction causes worsening of hypotension D buy discount zebeta 5mg. Cyclosporine commonly induces a volume-dependent form of hypertension Key Concept/Objective: To understand the relationship between immunosuppressive medica- tions and hypertension 30 BOARD REVIEW With the goal of graft survival in mind, the long-term follow-up of patients undergoing renal transplantation should focus on management of the major causes of morbidity and mortality. Cardiovascular disease, specifically hypertension, is one of the most common posttransplantation complications, affecting 80% to 90% of these patients. The etiology of hypertension in this population is multifactorial but includes diseased native kidneys, use of immunosuppressive medications, graft dysfunction, and, rarely, transplant renal artery stenosis. Although calcineurin inhibitors are the cornerstones of immunosuppression, as a class, these agents commonly cause hypertension. Specifical- ly, cyclosporine causes direct vasoconstriction and induces preglomerular vasoconstric- tion, resulting in a volume-dependent form of high blood pressure. Other classes of immunosuppressants that cause hypertension are corticosteroids and TOR (target of rapamycin) inhibitors. Antimetabolites, however, such as azathioprine and mycophe- nolate mofetil, are important in immunosuppressive agents because of their lack of nephrotoxicity and because they have little effect on blood pressure. A 43-year-old woman with end-stage renal disease (ESRD) presents to your clinic for renal transplant evaluation. She has focal segmental glomerular sclerosis and has been doing well for some time on hemodialysis, but she is concerned about "losing the transplanted kidney" because of her original disease. Which of the following statements regarding recurrence and graft loss associated with her primary renal disease is false? Primary glomerular diseases frequently recur and are commonly associated with graft loss B. Lupus nephritis rarely recurs after transplantation C. Type II membranoproliferative glomerulosclerosis has a high recur- rence rate, but only one fifth of those patients have graft loss D. Patients with Alport syndrome can develop anti-glomerular base- ment membrane (anti-GBM) disease in the allograft Key Concept/Objective: To understand the risk of disease recurrence in patients with primary glomerular disease The recurrence rates of different primary renal diseases vary. Primary glomerular dis- eases frequently recur in the transplanted kidney; however, graft loss secondary to recurrence is uncommon. The patients who are at greatest risk of graft loss are those in whom renal function deteriorated rapidly and aggressively. In these patients, trans- plantation may be relatively contraindicated. Lupus nephritis, anti-GBM disease, and membranous nephropathy have low recurrence rates and are rarely associated with graft loss. Type II membranoproliferative disease has a high recurrence rate (80% to 90%); however, it too is associated with a low incidence of graft loss. Patients with Alport syndrome can develop anti-GBM disease in the allograft, although this is uncom- mon, and Alport syndrome is not a contraindication to transplantation. A 39-year-old black woman with ESRD secondary to membranous nephropathy presents to your clinic for routine follow-up. She underwent renal transplantatation 3 months ago and is doing well on a regi- men of steroids, sirolimus, and cyclosporine. On reviewing results of routine laboratory studies, you note that her total cholesterol level is elevated to 246 mg/dl. Her immunosuppresion is unrelated to the elevated cholesterol level B. Her hyperlipidemia is likely characterized by a low level of low-den- sity lipoprotein (LDL) but a high level of high-density lipoprotein (HDL) C. Diet and exercise will be sufficient to control her lipid abnormalities D. Her lipid abnormalities will probably improve within 6 months after transplantation 10 NEPHROLOGY 31 Key Concept/Objective: To understand the treatment of the patient with coexisting diseases Of the cardiovascular diseases that affect the renal transplant population, hyperlipi- demia is one of the most common.

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