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The shared inheritance of genes leads to medicine yeast infection buy neurontin 100 mg mastercard an increased prevalence of disease among the relatives of affected individuals symptoms lactose intolerance purchase neurontin 400mg free shipping. This increased prevalence is most evident among first-degree relatives (hatched area) symptoms kennel cough discount neurontin 800mg on-line. If the frequency of a particular gene A is p, then that of its alternative allele is (1 - p) = q. An important consequence of this distribution is that irrespective of the initial frequency of the genes A and a in the population, the proportion of the three genotypes tends to remain constant in succeeding generations, provided that there is no difference in biologic fitness of any of the genotypes. If viability or fertility among the three genotypes is unequal, if individuals migrate into or out of the population, or if mating is not random, the frequency calculations require considerable correction. In small populations major changes in gene frequency can occur on the basis of chance alone. If the frequency of a recessive disease in a particular population is known, the frequency of heterozygous carriers and of the abnormal gene can be calculated. Thus, for a recessively inherited disease aa (q2) with a frequency of 1 per 10,000. Thus, in this particular example there are 200 clinically unaffected carriers of the abnormal gene for every affected individual. Cystic fibrosis, a recessively inherited disease, has a prevalence in the white population of about 1 per 2500 (q2); thus, the frequency of the gene (q) is 1 in 50 and of heterozygous carriers is approximately 1 in 25, or 4% of the white population. A similar calculation with respect to sickle cell anemia among African-Americans in the United States (q2 = 1/625) yields a frequency of heterozygous carriers of 1 in 12. When a gene is rare and severely disadvantageous, the rate of its introduction into a population by spontaneous mutation is balanced by the rate of elimination of the disadvantageous gene by natural selection. The frequency of the disadvantageous gene, however, can be stabilized at a high level if the heterozygotes are slightly favored (increased biologic fitness) and leave a greater number of progeny than does either homozygote. When a rare form of a species is present at a frequency that cannot be maintained by recurrent mutation alone, a balanced polymorphism is said to exist. Usually, this means that the rarer of two allelic forms occurs with a frequency of at least 1% of the population. An example of such a balanced polymorphism is the increased resistance of individuals heterozygous for the sickle cell trait to falciparum malaria. Death from falciparum malaria is much less frequent in carriers of the sickle cell trait than in non-carriers, and thus the heterozygote does have an advantage. Whether the extraordinary frequency of heterozygotes for the sickle cell gene in West Africa is due entirely to differential mortality or in part to differential fertility is uncertain, but this example suffices to illustrate that the effects of genes can be assessed only in relation to a particular environment. In most instances, however, a distinct advantage for the heterozygote of a polymorphic trait (of which there are many) cannot be demonstrated, and it is likely that certain polymorphic traits are genetically neutral. The term genetic load has been used to describe the total genetic disability of a population. It comprises both a mutational load, based on recurrent mutation of a normal gene to a lethal or sublethal gene, and a segregational load, resulting from segregation of the harmful gene from advantaged heterozygotes, as in the example of sickle cell heterozygotes discussed earlier. Each individual has been estimated to have three to eight genes, which, if homozygous instead of heterozygous, would be lethal. The relative contribution of the segregational and mutational loads to the total genetic load is uncertain. Knowledge of the genetic basis of susceptibility for specific diseases is likely to aid in disease prevention as well as therapy. Associated with these benefits, however, is the risk of discrimination against healthy at-risk individuals who may never develop a disorder. Thus, in addition to learning how to use this new knowledge for patient care, internists must gain the wisdom to use genetic information appropriately and confidentially. A historical perspective and summation of what we know about basic principles of human genetics, which emphasizes causes (mutations), pathogenesis, and therapy. A review of the hereditary basis of diseases with a prevalence of 1% or greater in the population. Authoritative discussions of all inborn errors of metabolism for which there is a substantial body of metabolic or biochemical information.
In hydronephrosis medications on nclex rn order 600mg neurontin free shipping, the central calyceal system is dilated and appears darker because it is filled with fluid (see Fig symptoms multiple myeloma buy genuine neurontin on-line. Classically treatment quotes and sayings order generic neurontin on-line, benign cysts do not need further evaluation, but cysts that do not meet these criteria need additional work-up. A small, echogenic kidney would indicate chronic renal disease (thus a renal biopsy would not be indicated), whereas large echogenic kidneys are seen with amyloidosis, human immunodeficiency virus infection, and acute glomerulonephritis. Primary renal carcinomas, renal metastases, lymphomas, and various benign tumors are not uniformly picked up until they are larger than 3 cm, and then their echogenicity is highly variable. After preliminary plain x-ray films, the radiologist injects one of various types of iodinated contrast materials, followed by serial x-rays. The contrast material is filtered by the glomeruli, after which it follows the normal flow of urine. Initial films (1 minute) after injecting the dye are known as "nephrograms," in which general radiopacity of the kidney is seen. Nephrograms initially can be used to measure the size of the kidney by measuring the maximum distance from the cephalad to the caudad margins. However, plain nephrotomography also can be used to estimate renal size without having to administer contrast material. The left kidney is normally somewhat larger than the right, with normal kidneys being somewhere between 11. However, because of size differences in patients, some investigators believe that expression of renal size with respect to vertebral height is a more accurate measure of normal renal size. After the nephrogram, calyces, pelvis, ureters, and bladder are sequentially viewed. The incidence of radiocontrast nephropathy is most frequent in patients with chronic renal failure, diabetes mellitus, or multiple myeloma. Regretfully, there are no proven methods to prevent prophylactically radiocontrast-induced nephropathy except volume repletion and good clinical judgment with respect to patients with risk factors for acute renal failure (see Chapter 103). In this technique, the ureters are catheterized by cystoscopy, and contrast material is injected. This technique does not give information concerning the renal parenchyma but is used to define anatomically the calyces, renal pelvis, and remainder of the excretory system. Renal arteriography may be performed by a skilled radiologist, introducing vascular catheters percutaneously into the femoral artery and advancing them above the renal arteries to indicate their exact number and takeoff points. Subsequently, the catheters may be selectively advanced into a specific renal artery under fluoroscopic control. Contrast dye then is injected into the renal artery, and the branches subsequently will be opacified. A number of magnification techniques can be used to improve visualization, and vasoconstrictive agents occasionally will be helpful to define normal vessels that constrict to epinephrine from tumors or inflammatory changes that are not as vigorously constricted by epinephrine. Renal arteriography is especially useful for defining the extent and type of fibromuscular dysplasia and is diagnostically helpful in differentiating other stenotic lesions such as arteriosclerosis, arteriodissections, emboli, thromboses, various types of vasculitides, and effects of trauma. There are no well-accepted criteria for choosing patients for renal arteriography, but the technique should be considered in those in whom therapeutically useful information is reasonably expected: patients with moderately severe hypertension, especially if they are young and have renal bruits on physical examination, and patients in whom renal arteriography can help define the nature of suspected tumors or help in the differential diagnosis of specific types of vasculitis. A modification of traditional renal arteriography is intravenous digital subtraction arteriography. In this technique, radiocontrast material is injected into either the inferior or superior vena cava, and digital subtraction imaging and filming are done later when the radiocontrast material circulates over the renal arteries. The technique has the advantage of using a lower contrast material dose, but the disadvantage is that it is mainly useful for diseases of the main renal artery and not its subsequent segments. The principle of this technique is that a computer constructs images mathematically from multiple x-ray absorption measurements from different projections of the body. To enhance the renal image, the studies are usually done with the aid of contrast material, except in circumstances in which the nature of renal calculi is being evaluated. These protons can absorb energy at only a very specific combination of local magnetic strength and the applied radiofrequency. Once the applied radiofrequency is stopped, the protons (small magnets) return to their previous lower-energy orientation in the magnetic field.
The most comprehensive textbook in English on polycystic and other cystic renal conditions treatment ulcerative colitis purchase 400 mg neurontin with visa. Many are asymptomatic and inconsequential medications dictionary discount 400 mg neurontin, but major malformations are important causes of early infantile death and later morbidity and renal failure treatment eating disorders purchase discount neurontin on-line. The congenital malformations that cause renal and urinary tract disease in adolescents and adults are the subject of this chapter. Renal agenesis is a failure of embryogenesis that, when unilateral, results in a solitary kidney. Renal hypoplasia signifies a small kidney with otherwise normally formed renal parenchyma that results from deficient nephrogenesis or reduced postnatal growth, whereas renal dysplasia, regardless of renal size, indicates abnormal metanephric differentiation resulting in abnormally and incompletely differentiated renal elements and in abnormal renal architecture. More than one third of patients with unilateral agenesis have other congenital defects. Because renal agenesis is a developmental field defect, unilateral agenesis is commonly associated with mullerian defects in women. A solitary kidney is not ordinarily at increased risk of acquired disease, except that one serious, but uncommon complication is compensatory hypertrophy with hyperfiltration, glomerular sclerosis, and eventual renal insufficiency. Unilateral agenesis in adults occurs as a component of several heritable disorders. Another syndrome is hereditary renal adysplasia, an autosomal dominant condition with variable penetrance. Unilateral and bilateral renal agenesis, renal dysplasia, and congenital hydronephrosis may all occur in a kindred, and the recurrence risk is for any of the defects. First-degree relatives of infants with bilateral renal agenesis carry a 12% risk of hereditary renal adysplasia, and conversely the offspring of either affected or obligate heterozygotes carry a 15 to 20% empirical risk of bilateral renal maldevelopment. Bilateral hypoplasia, in which small kidneys contain a reduced complement of nephrons and in which the glomeruli and tubules individually undergo hypertrophy, has been called oligome gane phronie or oligonephronic hypoplasia. Patients typically survive into the second decade with slowly progressive renal insufficiency and are good candidates for renal transplantation. The abnormality is characterized by the early onset of a urinary concentrating defect, often with salt wasting, and hypertension occurs late if at all. Renal hypoplasia must be differentiated from acquired renal atrophy, particularly segmental atrophy in reflux nephropathy, and from nephronophthisis-medullary cystic disease. Unilateral hypoplasia is recognized in imaging studies that show unirenicular and birenicular kidneys, often with contralateral hypertrophy. Small aplastic and large multicystic dysplastic kidneys are non-functioning, but modern imaging studies differentiate these abnormalities from renal agenesis. The ipsilateral ureter is typically atretic, and contralateral malformations, among them obstruction and reflux, are common and increase morbidity if left untreated. Unilateral multicystic kidneys involute over time and sometimes disappear almost completely and become indistinguishable from renal agenesis. Unilateral aplasia and multicystic dysplasia may, as noted above, be manifestations of the hereditary renal adysplasia syndrome. Duplex kidneys with partial ureteral duplication are harmless, relatively common abnormalities. Renal duplication with complete ureteral duplication, on the other hand, is a more serious malformation because of associated ureteral ectopy (Fig. The ureter arising from the cephalad portion of the duplicated kidney typically enters the bladder below the normal position. Stenosis of the ectopic ureteral orifice results in varying degrees of urinary obstruction. High-grade obstruction causes maldevelopment and non-function of the upper part of the kidney, and enlargement of the ureterocele compresses and mildly obstructs the lower-pole ureter. This malformation, commonly discovered during childhood because of reflux and urinary tract infection, may not become symptomatic until adulthood, also because of urinary tract infection. Simple ureteral ectopy in the urethra or vagina is associated with incontinence and an increased risk of ascending infection. Ectopic ureters in the seminal vesicle become symptomatic at the onset of sexual activity.
Because the incidence of gallstones in patients with primary biliary cirrhosis is approximately 40% treatment 20 initiative cheap neurontin 800mg with visa, a positive mitochondrial antibody test does not reliably exclude coexistent treatment vaginal yeast infection purchase 100mg neurontin, clinically important extrahepatic obstruction medications neuropathy buy 600mg neurontin free shipping. Either or both of these tests are positive in a variable percentage of patients with chronic non-viral hepatitis. These antibodies also occur in a minority of patients with primary biliary cirrhosis. As is true of the mitochondrial antibody, these factors are neither organ nor species specific. Jaundice in the absence of bilirubinuria indicates an exclusively unconjugated hyperbilirubinemia, usually reflecting hemolysis, ineffective erythropoiesis, or an inherited disorder of bilirubin conjugation. Fecal occult blood tests may provide the first evidence of an alimentary tract lesion related to hepatobiliary disease. In certain clinical circumstances, stool culture or examination for ova and parasites may provide important information. In acute liver disease not associated with liver failure, major changes in the formed elements are uncommon and consist primarily of mild anemia, reflecting either low-grade hemolysis or marrow depression. Slight leukopenia is not uncommon and is often associated with atypical lymphocytes. In other forms of acute liver disease, hematologic abnormalities such as marrow suppression may be caused by ethanol or drugs. Severe aplastic anemia may sometimes complicate acute viral hepatitis, especially after liver transplantation for fulminant hepatitis C infection. Coagulopathy may complicate liver failure, owing to depressed hepatic synthesis of clotting factors and/or disseminated intravascular coagulation. In chronic liver disease, especially with cholestasis, erythrocytic target cells result from an expansion of the cell membrane with relative preservation of the cholesterol-phospholipid ratio. Spur cells (acanthocytes), most often found in advanced alcoholic cirrhosis, reflect a more profound relative and absolute increase in membrane cholesterol. Red blood cells, white blood cells, and platelets may be decreased in patients with portal hypertension, primarily because of hypersplenism (see Chapter 178). Iron deficiency, megaloblastic anemias, and sideroblastic anemias may be caused by associated nutritional, pathologic, or pharmacologic influences. It is commonly performed by the blind percutaneous technique but may be guided by ultrasonographic or radiologic studies or performed under direct visualization during laparoscopy or laparotomy when specific areas must be sampled. Because the histologic changes in acute hepatitis or acute cholestatic jaundice are usually non-specific, the value of liver biopsy in this setting is primarily prognostic. Relative or absolute contraindications include the presence of biliary sepsis, high-grade biliary obstruction, ascites, coagulopathy, and right pleural disease. Common causes of abnormal enzyme tests include obesity, alcohol consumption, chronic hepatitis C, bone disease, and muscle injury. Incidental discovery of mild to moderate elevation of transaminases is common among blood donors and others subjected to routine screening. Higher enzyme levels and the presence of other abnormal liver tests increase the probability of clinically significant liver disease. Further testing is generally indicated only in patients with persistent abnormalities. If these tests are negative, screening for alpha1 -antitrypsin deficiency is indicated. A substantial fraction of patients have fatty liver associated with non-alcoholic steatonecrosis, which often responds to weight loss or improved diabetic control. If the aminotransferase abnormality persists for 6 to 12 months in the absence of any apparent cause, liver biopsy may be warranted. Many patients with isolated elevation of the alkaline phosphatase have non-hepatic causes, including bone disease, rapid bone growth, and pregnancy. An abnormal alkaline phosphatase should be confirmed with the patient fasting, because intestinal alkaline phosphatase may be elevated after a meal. An hepatic source may be inferred if the serum gamma-glutamyl transpeptidase is abnormal or by fractionation of the alkaline phosphatase.
Conversely treatment 2 degree burns purchase neurontin with mastercard, the presence of hyperuricemia suggests effective arterial volume contraction treatment emergent adverse event order generic neurontin line. The urinary sodium concentration is usually greater than 30 mEq/L medicine 6 year program purchase discount neurontin on line, and the fractional excretion of sodium is greater than 1%. Moreover, as noted previously (see Volume Depletion), the blood pressure and pulse may be normal in states of modest volume contraction. A useful diagnostic and therapeutic maneuver in this situation is to observe the results of water restriction. Neurologic symptoms secondary to osmotic swelling of the brain are much more common when hyponatremia develops rapidly in menstruant women and prepubescent children. These histologic findings may occur in any part of the brain but are more common in the central areas of the pons. The symptoms of osmotic demyelinating syndrome often occur several days after too-rapid hyponatremia correction and include behavioral disturbances, fluctuating levels of consciousness, ataxia, pseudo-bulbar palsy, difficulty in speaking, and other varying features. In non-fatal cases, the recovery is slow, often taking weeks, and recovery may not be complete with residual sequelae. The rate and magnitude of this correction can be considered conveniently as a two-step process: acute correction of symptomatic hyponatremia and chronic correction of asymptomatic or residual hyponatremia. Although the development of osmotic demyelination syndrome is quite rare, failure to correct symptomatic hyponatremia is associated with unacceptable morbidity and mortality rates. In volume-contracted states, the treatment of choice is to raise the serum sodium concentration by 10 mEq/L or to levels of 120 to 125 mEq/L over a 6-hour interval by administering hypertonic 3 to 5% saline. As was discussed, elevating serum sodium too quickly to values more than 125 mEq/L may be hazardous. Because the desired effect is to correct total body water osmolality, the amount of sodium administered must be sufficient to raise total body water osmolality to approximately 250 mOsm/kg H2 O, that is, to approximately twice the desired serum sodium concentration. A convenient formula for calculating this sodium requirement is as follows: [125 - measured serum Na+] Ч 0. Because 60% of body weight is water, the formula allows an estimate of the amount of sodium required to raise total body water osmolality to 250 mOsm/kg H2 O. However, if one cannot remember this formula, a useful practice is to administer 250 mL of either 3 or 5% saline over 4 to 6 hours. This will usually raise the serum sodium concentration by 10 to 15 mEq/L and abate the neurologic symptoms. Once the acute corrective phase of hyponatremia is complete, one can initiate the principle of chronic correction of hyponatremia. The most important aspect in managing asymptomatic, non-volume-depleted hyponatremia is to restrict electrolyte-free water intake. If water intake is restricted to less than 1 L/d, the serum sodium concentration will rise regardless of its cause. Because this approach is clinically unacceptably slow in certain patients, an alternative is to use normal saline in combination with a loop diuretic. Thus, one must use a loop diuretic with intravenous saline if this approach is taken. However, both these drugs may have complications and should only be used if the patient cannot adequately comply with water restriction and high dietary salt intake. A hypertonic disorder is one in which the ratio of solutes to water in total body water is increased. Hypernatremia develops whenever water intake is less than the sum of renal and extrarenal water losses; in chronic hypertonic states, net water balance may be zero. The most common causes of clinically significant hypernatremia occur as a consequence of three pathogenic mechanisms: impaired thirst, solute or osmotic diuresis, excessive losses of water, either through the kidneys or extrarenally, and combinations of these derangements. These disorders are grouped in Table 102-10 according to the primary pathogenic mechanism. These disorders rarely cause significant hypernatremia and are not discussed further. This problem occurs in patients who are comatose or who are otherwise unable to communicate thirst.
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