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Co-Director, Louisiana State University School of Medicine in Shreveport

It derives its name from the dark • Anteriorly antibiotic resistance uk cipro 1000 mg, the outline of the cerebral peduncles melanin-like pigment found (not in all species) with the fossa in between antibiotics breastfeeding discount cipro 1000mg without a prescription. The pigment is not retained when in the cell bodies antibiotics starting with z buy cipro us. 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. However, tion of this nucleus is incorporated within it and is known usually, all voluntary movements are gone, except perhaps as the Edinger-Westphal (EW) nucleus (see Figure 8A). This means that they portion of the red nucleus and exit between the cerebral require a respirator to breathe and 24-hour total care. Between the LOWER MIDBRAIN: cerebral peduncles is a small nucleus, the interpeduncular nucleus, which belongs with the limbic system. The peri- CROSS-SECTION aqueductal gray surrounding the aqueduct of the midbrain is involved with pain and also with the descending path- This cross-section includes the cerebral peduncles, still way for the modulation of pain (see Figure 43).

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Diseases

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Duchenne muscular dystrophy

Although ductopenic rejection is a more indolent process antimicrobial testing generic cipro 1000mg on-line, it usually creates a need for retransplan- tation antibiotics for acne while breastfeeding purchase genuine cipro online. Hepatitis B is not cured by transplantation and can even cause rapidly progressive liver disease after transplantation antimicrobial lights cipro 1000 mg free shipping; however, aggressive antiviral therapy before and after transplantation has been associated with prolonged graft longevity. Approximately 10% of patients treated with the calcineurin inhibitors cyclosporine or tacrolimus develop renal failure after transplantation. Because of the strong immunosuppressive agents required, infections remain among the most serious complications, both short-term and long-term, after transplantation. A 37-year-old woman with a history of cryptogenic cirrhosis who underwent orthotopic liver transpla- nation 1 year ago asks you to assume her posttransplantation care. Which of the following is true regarding this patient? She can expect to return to work, but it is unlikely that she will be able to tolerate vigorous activity B. The phenytoin she takes for her seizure disorder may result in an ele- 4 GASTROENTEROLOGY 27 vation in serum cyclosporine level, leading to a need for lower doses of cyclosporine C. Infection is the leading cause of death in the posttransplantation pop- ulation D. Most transplant centers report 75% to 80% 5-year survival rates E. If she develops hyperlipidemia as a result of taking cyclosporine, she is unlikely to benefit from a change in immunosuppressive medications Key Concept/Objective: To understand the long-term prognosis of liver transplant recipients, in terms of both mortality and functional status Many posttransplantation patients not only return to work but are able to participate in such vigorous activities as marathon running. Phenytoin induces the cytochrome P-450 system, leading to decreased serum levels of cyclosporine. Age-related cardiovascular dis- ease is the leading cause of death in posttransplantation patients. Many patients receiving cyclosporine develop hyperlipidemia; some can be helped by changing this medication to tacrolimus. Because of advances in immunosuppressive medications and surgical tech- niques, most transplant centers report 5-year survival rates of 75% to 80%. A 28-year-old patient with type 1 diabetes mellitus of 5 years’ duration asks your opinion regarding pan- creas transplantation. He is concerned that in spite of his best efforts, it is very likely that he will devel- op both microvascular and macrovascular complications. Which of the following statements about pancreas transplantation is false? Recipients of pancreas transplantation usually have normal insulin levels after successful transplantation B. Pancreas transplantation can prevent or reduce nephropathy in diabet- ic patients with kidney transplants C. The graft pancreas is usually placed in the right lower quadrant, with vascular anastomoses to the common iliac artery and common iliac vein or portal vein D. Rejection is the leading cause of graft loss after transplantation E. A major difficulty with islet cell transplantation is that more than one pancreas is required to provide enough islets for the recipient to become euglycemic Key Concept/Objective: To understand the metabolic benefits of pancreas transplantation and the complications associated with this type of transplantation Pancreas transplantation has been shown to prevent or reduce the nephropathy that often develops in kidney grafts in diabetic patients. The favored placement of the graft is the right lower quadrant, with vascular anastomoses to the common iliac artery and the com- mon iliac vein or portal vein; in simultaneous pancreas and kidney transplantations, the preferred placement is the left lower quadrant. Rejection is the leading cause of graft loss; vascular thrombosis is the leading nonimmunologic cause. Glucose tolerance tests are usu- ally normal or near normal for pancreas transplant recipients. However, insulin levels are much higher than normal in these patients. Three months after liver transplantation for chronic hepatitis C infection, a 45-year-old man develops biochemical abnormalities suggestive of cholestatic hepatitis. Which of the following evaluation strategies is most important for this patient at this time? Hepatitis C virus (HCV) RNA levels 28 BOARD REVIEW C.

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Diseases

  • Tethered spinal cord disease
  • Pyruvate dehydrogenase deficiency
  • Aspiration pneumonia
  • Gonadal dysgenesis
  • AIDS dysmorphic syndrome
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  • Pitt Hopkins syndrome
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Blepharophimosis syndrome Ohdo type

EJ bacterial nanowires discount cipro 500 mg mastercard, Gerlinger C antibiotic 8 weeks pregnant cheap cipro online master card, Heithecker R: The effect of 2 tol Venereol 2002 popular antibiotics for sinus infection cheap cipro 500 mg with visa;129:S382. TM, Stewart DM, Jarratt MT, Katz I, Pariser terium acnes. Dermatology 2002;204:277– 65 Vartiainen M, de Gezelle H, Broekmeulen CJ: DM, Pariser RJ, Tschen E, Chalker DK, Rafal 280. Comparison of the effect on acne with a combi- ES, Savin RP, Roth HL, Chang LK, Baginski 92 Inui S, Nakajima T, Fukuzato Y, Fujimoto N, phasic desogestrel-containing oral contracep- DJ, Kempers S, McLane J, Eberhardt D, Leach Chang C, Yoshikawa K, Itami S: Potential anti- tive and a preparation containing cyproterone EE, Bryce G, Hong J: A randomized trial of the androgenic activity of roxithromycin in skin. Eur J Contracept Reprod Health Care efficacy of a new micronized formulation ver- Dermatol Sci 2001;27:147–151. J Dermatol single-blind, randomized, controlled, parallel 82 Strauss JS, Leyden JJ, Lucky AW, Lookingbill 2001;28:1–4. Dermatology 2001;203: TM, Stewart DM, Jarratt MT, Katz I, Pariser is effective for inflammatory acne and achieves 38–44. DM, Pariser RJ, Tschen E, Chalker DK, Rafal high levels in the lesions: An open study. Der- 67 Thiboutot D: Acne and rosacea: New and ES, Savin RP, Roth HL, Chang LK, Baginski matology 2002;204:301–302. Dermatol Clin 2000;18: DJ, Kempers S, McLane J, Eberhardt D, Leach 95 Soto P, Cunliffe W, Meynadier J, Alirezai M, 63–71. EE, Bryce G, Hong J: Safety of a new micron- George S, Couttes I, Roseeuw D, Briantais P: 68 Brache V, Faundes A, Alvarez F, Cochon L: ized formulation of isotretinoin in patients Efficacy and safety of combined treatment of Nonmenstrual adverse events during use of im- with severe recalcitrant nodular acne: A ran- acne vulgaris with adapalane and lymecycline. J Am Acad 96 Lemay A, Dewailly SD, Grenier R, Huard J: 69 Lubbos HG, Hasinski S, Rose LI, Pollock J: Dermatol 2001;45:196–207. Attenuation of mild hyperandrogenic activity Adverse effects of spironolactone therapy in 83 Allenby G, Bocquel MT, Saunders M, Kazmer in postpubertal acne by a triphasic oral contra- women with acne. Arch Dermatol 1998;134: S, Speck J, Rosenberger M, Lovey A, Kastner ceptive containing low doses of ethynyl estra- 1162–1163. P, Grippo JF, Chambon P, et al: Retinoic acid diol and d,l-norgestrel. J Clin Endocrinol Me- 70 Schmidt JB: Other antiandrogens. Dermatolo- receptors and retinoid X receptors: Interac- tabolism 1990;71:8–14. Proc Natl 97 Thiboutot D, Archer DF, Lemay A, Washenik 71 Dodin S, Faure N, Cedrin I, Mechain C, Tur- Acad Sci USA 1993;90:30–34. K, Roberts J, Harrison DD: A randomized, cot-Lemay L, Guy J, Lemay A: Clinical efficacy 84 Sitzmann JH, Bauer FW, Cunliffe WJ, Holland controlled trial of a low-dose contraceptive and safety of low-dose flutamide alone and DB, Lemotte PK: In situ 13-cis-hybridization containing 20 microg of ethinyl estradiol and combined with an oral contraceptive for the analysis of CRABP II expression in sebaceous 100 microgram of levonorgestrel for acne treat- treatment of idiopathic hirsutism. Clin Endo- follicles from retinoic acid-treated acne pa- ment. Ann Dermatol Venereol combiphasic oral contraceptive in Germany. Eur J Contracept Reprod Health Care 2001;6: for chronic inflammation acne. Infect Immun 117 Pugeat M, Ducluzeau PH: Insulin resistance, 108–114. J Cutan Med Surg treatment of moderate acne vulgaris. Clin J expression in human sebocytes and IL8 regu- 2001;5:231–243. Arch Dermatol letti N: Rat preputial sebocyte differentiation Lebwohl M, Swinyer L: Effectiveness of nor- Res 2002;294:33. J Invest Dermatol 1999;112:226– moderate acne vulgaris. J Am Acad Dermatol Uematsu S, Legaspi AJ, Brightbill HD, Hol- 232. J Immunol 2002;169: androgen-dependent skin disorders. Derma- of acne vulgaris: A randomized, placebo-con- 1535–1541. Obstet Gynecol 1997;89:615– 110 Oeff MK, Seltmann H, Hakiy N, Bogdanoff 121 Cilotti A, Danza G, Serio M: Clinical applica- 622.