CAM INGLES 1

ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES IN ORAL AGENT COMBINATION
THERAPY FOR TYPE 2 DIABETES (RECORD): A MULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL.
PHILIP D. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES. ROSIGLITAZONE IS AN INSULIN
SENSITIZER USED IN COMBINATION WITH METFORMIN, A SULFONYLUREA, OR BOTH, FOR
LOWERING BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. WE ASSESSED CARDIOVASCULAR
OUTCOMES AFTER ADDITION OF ROSIGLITAZONE TO EITHER METFORMIN OR SULFONYLUREA
COMPARED WITH THE COMBINATION OF THE OVER 5-7 YEARS OF FOLLOW-UP. WE ALSO ASSESSED
COMPARATIVE SAFETY METHODS. IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447 PATIENTS WITH
TYPE 2 DIABETES ON METFORMIN OR SULFONYLUREA MONOTHERAPY WITH MEAN
HAEMOGLOBIN A1C (HB A1C) OF 7-9% WERE RANDOMLY ASSIGNED TO THE ADDITION OF
ROZIGLITAZONE (N=2220) OR TO A COMBINATION OF METFORMIN AND SULFONYLUREA (ACTIVE
CONTROL GROUP, 2227). THE PRIMARY ENDPOINT WAS CARDIOVASCULAR HOSPITALISATION, OR
CARDIOVASCULAR DEATH, WITH A HAZARD RATIO (HR) NON-INFERIORITY MARGIN OF 1.20.
ANALYSIS WAS BY INTENTION TO TREAT. THIS STUDY IS REGISTERED WITH GOVERNMENT CLINICAL
TRIALS NUMBER NCT00379769. FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 IN
THE ACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOME DURING A MEAN DURING A
5.5 YEAR FOLLOW-UP, MEETING THE CRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-1.16).
HR WAS 0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-14 (0.80-1.63) FOR MYOCARDIAL
INFARCTION, AND 0.72 (0.49-1.06) FOR STROKE. HEART FAILURE CAUSING ADMISSION TO HOSPITAL
OR DEATH OCCURRED IN 61 PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE ACTIVE
CONTROL GROUP (HR 2.10, 1.35-3.27, RISK DIFFERENCE PER 1000 PERSON-YEARS 2.6, 1.1-4.1) UPPER
AND DISTAL LOWER LIMB FRACTURE RATES WERE INCREASED MAINLY IN WOMEN RANDOMLY
ASSIGNED TO ROSIGLITAZONE. MEAN HB A1C WAS LOWER IN THE ROSIGLITAZONE GROUP THAN IN
THE CONTROL GROUP AT 5 YEARS. INTERPRETATION. THE ADDITION OF ROSIGLITAZONE TO
GLUCOSE LOWERING THERAPY IN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO INCREASE THE
RISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN WOMEN. ALTHOUGH THE DATA ARE
INCONCLUSIVE ABOUT ANY POSSIBLE EFFECT ON MYOCARDIAL INFARCTION, ROSIGLITAZONE
DOES NOT INCREASE THE RISK OF OVERALL CARDIOVASCULAR MOBIDITY OR MORTALITY
COMPARED WITH STANDARD GLUCOSE-LOWERING DRUGS.

ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR OUTCOMES IN
ORAL AGENT COMBINATION THERAPY FOR TYPE 2 DIABETES
(RECORD): A MULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL. PHILIP
D. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES.
ROSIGLITAZONE IS AN INSULIN SENSITIZER USED IN COMBINATION
WITH METFORMIN, A SULFONYLUREA, OR BOTH, FOR LOWERING
BLOOD GLUCOSE IN PEOPLE WITH TYPE 2 DIABETES. WE ASSESSED
CARDIOVASCULAR OUTCOMES AFTER ADDITION OF ROSIGLITAZONE
TO EITHER METFORMIN OR SULFONYLUREA COMPARED WITH THE
COMBINATION OF THE OVER 5-7 YEARS OF FOLLOW-UP. WE ALSO
ASSESSED COMPARATIVE SAFETY METHODS. IN A MULTICENTRE, OPEN-
LABEL TRIAL, 4447 PATIENTS WITH TYPE 2 DIABETES ON METFORMIN
OR SULFONYLUREA MONOTHERAPY WITH MEAN HAEMOGLOBIN A1C
(HB A1C) OF 7-9% WERE RANDOMLY ASSIGNED TO THE ADDITION OF
ROZIGLITAZONE (N=2220) OR TO A COMBINATION OF METFORMIN AND
SULFONYLUREA (ACTIVE CONTROL GROUP, 2227). THE PRIMARY
ENDPOINT WAS CARDIOVASCULAR HOSPITALISATION, OR
CARDIOVASCULAR DEATH, WITH A HAZARD RATIO (HR) NON-
INFERIORITY MARGIN OF 1.20. ANALYSIS WAS BY INTENTION TO TREAT.
THIS STUDY IS REGISTERED WITH GOVERNMENT CLINICAL TRIALS
NUMBER NCT00379769.

FINDINGS. 321 PEOPLE IN THE ROSIGLITAZONE GROUP AND 323 IN THE
ACTIVE CONTROL GROUP EXPERIENCED THE PRIMARY OUTCOME
DURING A MEAN DURING A 5.5 YEAR FOLLOW-UP, MEETING THE
CRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-1.16). HR WAS
0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-14 (0.80-1.63) FOR
MYOCARDIAL INFARCTION, AND 0.72 (0.49-1.06) FOR STROKE. HEART
FAILAURE CAUSING ADMISSION TO HOSPITAL OR DEATH OCCURRED
IN 61 PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE ACTIVE
CONTROL GROUP (HR 2.10, 1.35-3.27, RISK DIFFERENCE PER 1000
PERSON-YEARS 2.6, 1.1-4.1) UPPER AND DISTAL LOWER LIMB FRACTURE
RATES WERE INCREASED MAINLY IN WOMEN RANDOMLY ASSIGNED TO
ROSIGLITAZONE. MEAN HB A1C WAS LOWER IN THE ROSIGLITAZONE
GROUP THAN IN THE CONTROL GROUP AT 5 YEARS. INTERPRETATION.
THE ADDITION OF ROSIGLITAZONE TO GLUCOSE LOWERING THERAPY
IN PEOPLE WITH TYPE 2 DIABETES IS CONFIRMED TO INCREASE THE
RISK OF HEART FAILURE AND OF SOME FRACTURES, MAINLY IN
WOMEN. ALTHOUGH THE DATA ARE INCONCLUSIVE ABOUT ANY
POSSIBLE EFFECT ON MYOCARDIAL INFARCTION, ROSIGLITAZONE
DOES NOT INCREASE THE RISK OF OVERALL CARDIOVASCULAR
MOBIDITY OR MORTALITY COMPARED WITH STANDARD GLUCOSE-
LOWERING DRUGS.

ROSIGLITAZONE EVALUATED FOR CARDIOVASCULAR
OUTCOMES IN ORAL AGENT COMBINATION THERAPY FOR
TYPE 2 DIABETES (RECORD): A
MULTICENTRE, RANDOMISED, OPEN-LABEL TRIAL. PHILIP
D. HOME MD, STUART J. POCOCK PHD, AND COLLEAGUES.
ROSIGLITAZONE IS AN INSULIN SENSITIZER USED IN
COMBINATION WITH METFORMIN, A SULFONYLUREA, OR
BOTH, FOR LOWERING BLOOD GLUCOSE IN PEOPLE WITH
TYPE 2 DIABETES. WE ASSESSED CARDIOVASCULAR
OUTCOMES AFTER ADDITION OF ROSIGLITAZONE TO
EITHER METFORMIN OR SULFONYLUREA COMPARED
WITH THE COMBINATION OF THE OVER 5-7 YEARS OF
FOLLOW-UP. WE ALSO ASSESSED COMPARATIVE SAFETY
METHODS. IN A MULTICENTRE, OPEN-LABEL TRIAL, 4447
PATIENTS WITH TYPE 2 DIABETES ON METFORMIN OR
SULFONYLUREA MONOTHERAPY WITH MEAN
HAEMOGLOBIN A1C (HB A1C) OF 7-9% WERE RANDOMLY
ASSIGNED TO THE ADDITION OF ROZIGLITAZONE (N=2220)
OR TO A COMBINATION OF METFORMIN AND
SULFONYLUREA (ACTIVE CONTROL GROUP, 2227).

THE PRIMARY ENDPOINT WAS CARDIOVASCULAR
HOSPITALISATION, OR CARDIOVASCULAR DEATH, WITH A
HAZARD RATIO (HR) NON-INFERIORITY MARGIN OF 1.20.
ANALYSIS WAS BY INTENTION TO TREAT. THIS STUDY IS
REGISTERED WITH GOVERNMENT CLINICAL TRIALS
NUMBER NCT00379769. FINDINGS. 321 PEOPLE IN THE
ROSIGLITAZONE GROUP AND 323 IN THE ACTIVE CONTROL
GROUP EXPERIENCED THE PRIMARY OUTCOME DURING A
MEAN DURING A 5.5 YEAR FOLLOW-UP, MEETING THE
CRITERION ON NON-INFERIORITY (HR 0.99, 95% CI O.85-
1.16). HR WAS 0-84 (O-59) FOR CARDIOVASCULAR DEATH, 1-
14 (0.80-1.63) FOR MYOCARDIAL INFARCTION, AND 0.72
(0.49-1.06) FOR STROKE. HEART FAILURE CAUSING
ADMISSION TO HOSPITAL OR DEATH OCCURRED IN 61
PEOPLE IN THE ROSIGLITAZONE GROUP AND 29 IN THE
ACTIVE CONTROL GROUP (HR 2.10, 1.35-3.27, RISK
DIFFERENCE PER 1000 PERSON-YEARS 2.6, 1.1-4.1).

UPPER AND DISTAL LOWER LIMB FRACTURE RATES
WERE INCREASED MAINLY IN WOMEN RANDOMLY
ASSIGNED TO ROSIGLITAZONE. MEAN HB A1C WAS
LOWER IN THE ROSIGLITAZONE GROUP THAN IN THE
CONTROL GROUP AT 5 YEARS. INTERPRETATION. THE
ADDITION OF ROSIGLITAZONE TO GLUCOSE
LOWERING THERAPY IN PEOPLE WITH TYPE 2
DIABETES IS CONFIRMED TO INCREASE THE RISK OF
HEART FAILURE AND OF SOME FRACTURES, MAINLY
IN WOMEN. ALTHOUGH THE DATA ARE
INCONCLUSIVE ABOUT ANY POSSIBLE EFFECT ON
MYOCARDIAL INFARCTION, ROSIGLITAZONE DOES
NOT INCREASE THE RISK OF OVERALL
CARDIOVASCULAR MORBIDITY OR MORTALITY
COMPARED WITH STANDARD GLUCOSE-LOWERING
DRUGS.

 1 WHAT WAS THE MAIN PURPOSE OF THE STUDY?
 A TO TREAT PATIENTS WITH TYPE 2 DIABETES.
 B TO DETERMINE THE INCIDENCE OF HOSPITALIZATION
IN PATIENTS TAKING ROSIGLITAZONE.
 C TO DISCOVER THE EFFECTS THAT ROSIGLITAZONE HAS
ON HEART FAILURE IN PATIENTS WITH TYPE 2 DIABETES.
 D TO GET GOVERNMENT APPROVAL FOR ROSIGLITAZONE.
 2 ROSIGLITAZONE IS AN INSULIN SENSITISER USED TO:
 A LOWER INSULIN IN PEOPLE WITH TYPE 2 DIABETES
 B LOWER BLOOD GLUCOSE IN PEOPLE WITH TYPE 2
DIABETES.
 C INCREASE BLOOD GLUCOSE IN PEOPLE WITH TYPE 2
DIABETES.
 D DIMINISH INSULIN IN PEOPLE WITH TYPE 1 DIABETES.

 3 WHAT DID THE TWO GROUPS HAVE IN COMMON?
 A PARTICIPANTS WERE GIVEN SULFONYLUREA.
 B PARTICIPANTS WERE GIVEN ROSIGLITAZONE.
 C PARTICIPANTS HAD NEARLY SIMILAR LEVELS OF HBA1C.
 D PARTICIPANTS WERE ALL FROM THE SAME CENTRE.
 4 WHAT DOES THE AUTHOR CONCLUDE REGARDING THE
SAFETY OF ROSIGLITAZONE IN GLUCOSE-LOWERING
THERAPY FOR PATIENTS WITH TYPE-2 DIABETES?
 A THE PERCENTAGE OF PATIENTS RESULTING IN HEART
FAILURE WAS VERY HIGH FOR BOTH GROUPS.
 B ROSIGLITAZONE, IN GENERAL, CAUSES HEART FAILURE.
 C ROSIGLITAZONE IS GENERALLY SAFE, BUT NOT FOR
WOMEN.
 D ROSIGLATAZONE SHOULD BE USED ONLY FOR MALE
PATIENTS.

5 THE ADDITION OF ROSIGLITAZONE TO GLUCOSE
LOWERING THERAPY IN PEOPLE WITH TYPE 2
DIABETES IS CONFIRMED TO:
A INCREASE THE RISK OF HEART FAILURE AND OF
SOME FRACTURES, MAINLY IN MEN.
B INCREASE THE RISK OF HEART FAILURE AND OF
SOME FRACTURES, MAINLY IN WOMEN.
C THE DATA ARE CONCLUSIVE ABOUT ANY
POSSIBLE EFFECT ON MYOCARDIAL INFARCTION,
D ROSIGLITAZONE INCREASES THE RISK OF
OVERALL CARDIOVASCULAR MORBIDITY.

1. C
2. B
3. C
4. C
5. B

 1. Rosiglitazone evaluated for cardiovascular
outcomes in oral agent combination therapy for
type 2 diabetes
 2. Rosiglitazone is an insulin sensitizer used ... for
lowering blood glucose in people with type 2
diabetes.
 3. ... 4447 patients with type 2 diabetes on
metformin or sulfonylurea monotherapy with
mean haemoglobin A1C (HBA1C) of 7-9% were
randomly assigned to addition of rosiglitazone ...
or to a combination of a metformin and
sulfonylurea ....

 4. Interpretation. The addition of
rosiglitazone to glucose lowering therapy for
people with type 2 diabetes is confirmed to
increase the risk of heart failure and of some
fractures, mainly in women. Although the
data are inconclusive about any possible
effect on myocardial
infarction, rosiglitazone does not increase
the risk of overall cardiovascular morbidity
or mortality compared with standard
glucose-lowering drugs.
 5. Idem

PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAEL DERMATOLOGIC CLINICS - VOLUME 25, ISSUE
3 W. B. SAUNDERS COMPANY JULY 2007 PITYRIASIS ALBA (PA) IS A COMMON DISORDER OBSERVED IN LATIN
AMERICAN PATIENTS. LESIONS DISCLOSE HYPOPIGMENTATION, MAINLY OBSERVED ON FACIAL AREAS AND
SUNLIGHT EXPOSED SURFACE OF ARMS AND FOREARMS; THOSE ON THE TRUNK AND LOWER EXTREMITIES ARE
LESS COMMON. AN ATOPIC DIATHESIS IS PRESENT IN MOST PATIENTS, AND THE CONDITION FREQUENTLY
DEVELOPS IN CHILDREN AND YOUNG ADULTS. THE AVERAGE LESION BEGINS WITH A SLIGHTLY
HYPOPIGMENTED MACULE THAT ENLARGES GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCE WITH
NEIGHBORING MACULES, RESULTING IN LARGER HYPOPIGMENTED DEFECTS. A FINE DESQUAMATION AND
DRYNESS OF SKIN ARE CHARACTERISTIC AND THE CLINICAL PICTURE USUALLY WORSENS DURING SUMMER OR
DURING FREQUENT WATERSPORT ACTIVITIES. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS AT THE
HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON HISTOLOGIC EXAMINATION, EPIDERMAL AND FOLLICULAR
SPONGIOSIS, FOCAL PARAKERATOSIS, SLIGHT ACANTHOSIS, AND MILD SUPERFICIAL PERIVASCULAR
INFILTRATES ARE SEEN. IN A STUDY, ULTRASTRUCTURAL EXAMINATION DISCLOSED SMALL AND REDUCED
NUMBERS OF MELANOCYTES AND MELANOSOMES. ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTER
PUBERTY, LOW POTENCY CORTICOSTEROIDS, SUCH AS 1% HYDROCORTISONE OR 0.5% DESONIDE, FREQUENT
EMOLLIENT APPLICATION, AND SUNLIGHT AVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THIS
DISORDER. SKIN CONTACT WITH DIVERSE CHEMICALS MAY INDUCE ACQUIRED HYPOPIGMENTATION, WHICH
MAY OCCUR EITHER DURING PROFESSIONAL ACTIVITIES OR AS AN INCIDENTAL EVENT. AREAS OF
CONTACT, SUCH AS HANDS AND FEET, MAY BECOME AFFECTED WITH OR WITHOUT INITIAL DERMATITIS, AND
THEREAFTER HYPOPIGMENTATION OCCURS. SOME OF THE INVOLVED CHEMICALS ARE CATECHOL AND
BENZENE DERIVATIVES USED AS ANTISEPTICS AND CLEANSERS, PESTICIDES, AND EPOXY RESINS COMMONLY
USED IN HOUSEHOLD WORK. MACULAR LESIONS SHOW DIFFERENT GRADES OF HYPOPIGMENTATION OR TRUE
DEPIGMENTATION INDISTINGUISHABLE FROM VITILIGO; A PREVIOUS HISTORY OF SUBSTANCE CONTACT AND
DERMATITIS ARE IN FAVOR OF THE CHEMICAL NATURE OF DEPIGMENTATION . ON HISTOLOGIC
EXAMINATION, JUST A FEW MELANOCYTES ARE PRESENT AND REDUCED OR ABSENT MELANIN IS OBSERVED.
TREATMENT OF DEPIGMENTATION IS DIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS ARE INVOLVED
AND MELANOCYTES IN AFFECTED AREAS ARE SCARCE. IF VITILIGO-LIKE DEPIGMENTATION BECOMES
REFRACTORY TO MEDICAL THERAPY, MELANOCYTE GRAFTING MAY BE AN IMPORTANT THERAPEUTIC
SOLUTION.

PIGMENTARY DISORDERS IN LATIN AMERICA FALABELLA, RAFAEL
DERMATOLOGIC CLINICS - VOLUME 25, ISSUE 3 W. B. SAUNDERS
COMPANY JULY 2007 PITYRIASIS ALBA (PA) IS A COMMON DISORDER
OBSERVED IN LATIN AMERICAN PATIENTS. LESIONS DISCLOSE
HYPOPIGMENTATION, MAINLY OBSERVED ON FACIAL AREAS AND
SUNLIGHT EXPOSED SURFACE OF ARMS AND FOREARMS; THOSE ON
THE TRUNK AND LOWER EXTREMITIES ARE LESS COMMON. AN ATOPIC
DIATHESIS IS PRESENT IN MOST PATIENTS, AND THE CONDITION
FREQUENTLY DEVELOPS IN CHILDREN AND YOUNG ADULTS. THE
AVERAGE LESION BEGINS WITH A SLIGHTLY HYPOPIGMENTED MACULE
THAT ENLARGES GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCE
WITH NEIGHBORING MACULES, RESULTING IN LARGER
HYPOPIGMENTED DEFECTS. A FINE DESQUAMATION AND DRYNESS OF
SKIN ARE CHARACTERISTIC AND THE CLINICAL PICTURE USUALLY
WORSENS DURING SUMMER OR DURING FREQUENT WATERSPORT
ACTIVITIES. A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS AT
THE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON HISTOLOGIC
EXAMINATION, EPIDERMAL AND FOLLICULAR SPONGIOSIS, FOCAL
PARAKERATOSIS, SLIGHT ACANTHOSIS, AND MILD SUPERFICIAL
PERIVASCULAR INFILTRATES ARE SEEN. IN A
STUDY, ULTRASTRUCTURAL EXAMINATION DISCLOSED SMALL AND
REDUCED NUMBERS OF MELANOCYTES AND MELANOSOMES.

ALTHOUGH PA IMPROVES SPONTANEOUSLY AFTER PUBERTY, LOW POTENCY
CORTICOSTEROIDS, SUCH AS 1% HYDROCORTISONE OR 0.5%
DESONIDE, FREQUENT EMOLLIENT APPLICATION, AND SUNLIGHT
AVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THIS DISORDER. SKIN
CONTACT WITH DIVERSE CHEMICALS MAY INDUCE ACQUIRED
HYPOPIGMENTATION, WHICH MAY OCCUR EITHER DURING PROFESSIONAL
ACTIVITIES OR AS AN INCIDENTAL EVENT. AREAS OF CONTACT, SUCH AS HANDS
AND FEET, MAY BECOME AFFECTED WITH OR WITHOUT INITIAL
DERMATITIS, AND THEREAFTER HYPOPIGMENTATION OCCURS. SOME OF THE
INVOLVED CHEMICALS ARE CATECHOL AND BENZENE DERIVATIVES USED AS
ANTISEPTICS AND CLEANSERS, PESTICIDES, AND EPOXY RESINS COMMONLY
USED IN HOUSEHOLD WORK. MACULAR LESIONS SHOW DIFFERENT GRADES OF
HYPOPIGMENTATION OR TRUE DEPIGMENTATION INDISTINGUISHABLE FROM
VITILIGO; A PREVIOUS HISTORY OF SUBSTANCE CONTACT AND DERMATITIS ARE
IN FAVOR OF THE CHEMICAL NATURE OF DEPIGMENTATION . ON HISTOLOGIC
EXAMINATION, JUST A FEW MELANOCYTES ARE PRESENT AND REDUCED OR
ABSENT MELANIN IS OBSERVED. TREATMENT OF DEPIGMENTATION IS
DIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS ARE INVOLVED AND
MELANOCYTES IN AFFECTED AREAS ARE SCARCE. IF VITILIGO-LIKE
DEPIGMENTATION BECOMES REFRACTORY TO MEDICAL THERAPY, MELANOCYTE
GRAFTING MAY BE AN IMPORTANT THERAPEUTIC SOLUTION.

PIGMENTARY DISORDERS IN LATIN AMERICA.
FALABELLA, RAFAEL; DERMATOLOGIC CLINICS - VOLUME
25, ISSUE 3 W. B. SAUNDERS COMPANY JULY 2007
PITYRIASIS ALBA (PA) IS A COMMON DISORDER
OBSERVED IN LATIN AMERICAN PATIENTS. LESIONS
DISCLOSE HYPOPIGMENTATION, MAINLY OBSERVED ON
FACIAL AREAS AND SUNLIGHT EXPOSED SURFACE OF
ARMS AND FOREARMS; THOSE ON THE TRUNK AND
LOWER EXTREMITIES ARE LESS COMMON. AN ATOPIC
DIATHESIS IS PRESENT IN MOST PATIENTS, AND THE
CONDITION FREQUENTLY DEVELOPS IN CHILDREN AND
YOUNG ADULTS. THE AVERAGE LESION BEGINS WITH A
SLIGHTLY HYPOPIGMENTED MACULE THAT ENLARGES
GRADUALLY FROM 1 CM TO 3 CM AND MAY COALESCE
WITH NEIGHBORING MACULES, RESULTING IN LARGER
HYPOPIGMENTED DEFECTS. A FINE DESQUAMATION AND
DRYNESS OF SKIN ARE CHARACTERISTIC AND THE
CLINICAL PICTURE USUALLY WORSENS DURING SUMMER
OR DURING FREQUENT WATERSPORT ACTIVITIES.

A FOLLICULAR VARIETY WITH MILD HYPERKERATOSIS AT
THE HAIR FOLLICLE OSTIUM FREQUENTLY OCCURS. ON
HISTOLOGIC EXAMINATION, EPIDERMAL AND FOLLICULAR
SPONGIOSIS, FOCAL PARAKERATOSIS, SLIGHT
ACANTHOSIS, AND MILD SUPERFICIAL PERIVASCULAR
INFILTRATES ARE SEEN. IN A STUDY, ULTRASTRUCTURAL
EXAMINATION DISCLOSED SMALL AND REDUCED NUMBERS
OF MELANOCYTES AND MELANOSOMES. ALTHOUGH PA
IMPROVES SPONTANEOUSLY AFTER PUBERTY, LOW
POTENCY CORTICOSTEROIDS, SUCH AS 1%
HYDROCORTISONE OR 0.5% DESONIDE, FREQUENT
EMOLLIENT APPLICATION, AND SUNLIGHT
AVOIDANCE/PROTECTION ARE USEFUL TO CONTROL THIS
DISORDER. SKIN CONTACT WITH DIVERSE CHEMICALS MAY
INDUCE ACQUIRED HYPOPIGMENTATION, WHICH MAY
OCCUR EITHER DURING PROFESSIONAL ACTIVITIES OR AS
AN INCIDENTAL EVENT. AREAS OF CONTACT, SUCH AS HANDS
AND FEET, MAY BECOME AFFECTED WITH OR WITHOUT
INITIAL DERMATITIS, AND THEREAFTER
HYPOPIGMENTATION OCCURS.

SOME OF THE INVOLVED CHEMICALS ARE CATECHOL
AND BENZENE DERIVATIVES USED AS ANTISEPTICS AND
CLEANSERS, PESTICIDES, AND EPOXY RESINS
COMMONLY USED IN HOUSEHOLD WORK. MACULAR
LESIONS SHOW DIFFERENT GRADES OF
HYPOPIGMENTATION OR TRUE DEPIGMENTATION
INDISTINGUISHABLE FROM VITILIGO; A PREVIOUS
HISTORY OF SUBSTANCE CONTACT AND DERMATITIS
ARE IN FAVOR OF THE CHEMICAL NATURE OF
DEPIGMENTATION. ON HISTOLOGIC
EXAMINATION, JUST A FEW MELANOCYTES ARE
PRESENT AND REDUCED OR ABSENT MELANIN IS
OBSERVED. TREATMENT OF DEPIGMENTATION IS
DIFFICULT, BECAUSE MOST OF THE TIME ACRAL AREAS
ARE INVOLVED AND MELANOCYTES IN AFFECTED AREAS
ARE SCARCE. IF VITILIGO-LIKE DEPIGMENTATION
BECOMES REFRACTORY TO MEDICAL
THERAPY, MELANOCYTE GRAFTING MAY BE AN
IMPORTANT THERAPEUTIC SOLUTION.

 6. PITYRIASIS ALBA IS A COMMON DISORDER
FREQUENTLY OBSERVED IN:
 A ARMS AND LEGS
 B FACE, ARMS AND FOREARMS
 C TRUNK AND LOWER EXTREMITIES.
 D FACE, ARMS AND LEGS
 7. THE AVERAGE LESION BEGINS WITH A
SLIGHTLY HYPOPIGMENTED SPOT THAT:
 A GROWS FROM 1 TO 3 CM.
 B REDUCES FROM 1 TO 3 CM
 C ENLARGES TO 5 CM. INDEPENDENTLY
 D CHANGES COLOR

 8. TO CONTROL THIS DISORDER IT IS USEFUL TO:
 A USE A FREQUENT EMOLLIENT APPLICATION
 B USE HIGH POTENCY CORTICOSTEROIDS
 C KEEP AWAY FROM THE SUN.
 D LACK THE PROTECTION OF THE SUN
 9. HYPOPIGMENTATION OCCURS WHEN:
 A SKIN HAS CONTACT WITH DIVERSE
CHEMICALS
 B WE HAVE INCIDENTAL ACTIVITIES
 C WE TAKE CORTISONE.
 D WE USE SUN PROTECTION.

 10. PITYRIASIS ALBA IS DANGEROUS BECAUSE:
 A PATIENTS BECOME INTOLERANT TO LIGHT
 B SOME OF THE TREATMENTS ARE TOXIC
C PRE-CANCEROUS LESIONS CAN FORM.
 D DELICATE SURGERY IS SOMETIMES REQUIRED.

6. B
7. A
8. A (y C)
9. A
10. D

Acral: Relating to or affecting the peripheral
parts, e.g., limbs, fingers, ears, etc.

 6. Pytiriasis alba (PA) is a common disorder
… mainly observed on facial areas and
sunlight exposed surface of arms and
forearms.
 7. The average lesion begins with a slightly
hypopigmented macule that enlarges
gradually from 1 cm to 3 cm.
 8. Frequent emollient application and
sunlight avoidance/protection are useful to
control this disorder.

 9. Skin contact with diverse chemicals may
induce acquired skin hypopigmentation …
 10. If vitiligo-like depigmentation becomes
refractory to medical therapy, melanocyte
grafting may be an important therapeutic
solution.

 A graft/ to graft/ grafting

 A graft/ to graft/ grafting

UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN ZORC, JOSEPH J. CLINICAL
PEDIATRIC EMERGENCY MEDICINE EL SERVIER DOI.10.1016.CPEM.209.03.008 MARCH
2009. UPPER RESPIRATORY TRACT INFECTIONS (INCLUDING OTITIS MEDIA) ARE
THE MOST COMMON ILLNESSES AFFECTING CHILDREN. ON AVERAGE, CHILDREN
EXPERIENCE AROUND SIX TO EIGHT UPPER RESPIRATORY TRACT INFECTIONS
(URTIS) EACH YEAR. ALTHOUGH THESE INFECTIONS USUALLY ARE MILD AND SELF
LIMITING, THEY OCCASIONALLY LEAD TO COMPLICATIONS THAT CAN BE LIFE
THREATENING. MOST URTIS CAN BE PLACED WITHIN THREE MAIN CATEGORIES OF
INFECTION: RHINOSINUSITIS, PHARYNGITIS, AND OTITIS MEDIA. WITHIN EACH
CATEGORY OF ILLNESS THERE IS A RANGE OF RELATED CONDITIONS THAT MAY
HAVE SIMILAR OR OVERLAPPING CLINICAL PRESENTATIONS. SOME JUDGMENT IS
REQUIRED IN DETERMINING WHICH PART OF THE RESPIRATORY MUCOSA IS MOST
AFFECTED. IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TO DESCRIBE
ILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS (INCLUDING THE COMMON
COLD, NASOPHARYNGITIS, AND SINUSITIS). THE TERM “PHARYNGITIS” IS USED TO
DESCRIBE ILLNESSES WHEN SORE THROAT IS MOST PROMINENT (INCLUDING
TONSILLITIS). THE TERM “OTITIS MEDIA” IS USED TO DESCRIBE ILLNESSES WITH
PREDOMINANTLY MIDDLE EAR SYMPTOMS (INCLUDING ACUTE OTITIS MEDIA
[AOM], OTITIS MEDIA WITH EFFUSION [OME], AND CHRONIC SUPPURATIVE OTITIS
MEDIA [CSOM]). CHILDREN WHO HAVE COUGH AS THE PREDOMINANT SYMPTOM
ARE CONSIDERED TO HAVE BRONCHITIS (A LOWER RESPIRATORY TRACT
INFECTION). TO MAKE MATTERS MORE COMPLICATED, ALL AREAS OF THE
RESPIRATORY MUCOSA MAY BE AFFECTED, SIMULTANEOUSLY OR AT DIFFERENT
TIMES, DURING ONE ILLNESS. THE CAUSE OF THESE RESPIRATORY MUCOSAL
INFECTIONS MOST COMMONLY IS VIRAL BUT CAN BE BACTERIAL AND MANY
INFECTIONS INVOLVE BOTH VIRUSES AND BACTERIA. IN DEVELOPED
COUNTRIES, BOTH VIRAL AND BACTERIAL INFECTIONS ARE LIKELY TO BE SELF
LIMITED. PERSISTENT DISEASE IS MOST LIKELY TO INDICATE A BACTERIAL
INFECTION.

UPPER RESPIRATORY TRACT INFECTIONS IN CHILDREN
ZORC, JOSEPH J. CLINICAL PEDIATRIC EMERGENCY
MEDICINE EL SERVIER DOI.10.1016.CPEM.209.03.008
MARCH 2009. UPPER RESPIRATORY TRACT INFECTIONS
(INCLUDING OTITIS MEDIA) ARE THE MOST COMMON
ILLNESSES AFFECTING CHILDREN. ON
AVERAGE, CHILDREN EXPERIENCE AROUND SIX TO EIGHT
UPPER RESPIRATORY TRACT INFECTIONS (URTIS) EACH
YEAR. ALTHOUGH THESE INFECTIONS USUALLY ARE MILD
AND SELF LIMITING, THEY OCCASIONALLY LEAD TO
COMPLICATIONS THAT CAN BE LIFE THREATENING. MOST
URTIS CAN BE PLACED WITHIN THREE MAIN CATEGORIES
OF INFECTION: RHINOSINUSITIS, PHARYNGITIS, AND
OTITIS MEDIA. WITHIN EACH CATEGORY OF ILLNESS
THERE IS A RANGE OF RELATED CONDITIONS THAT MAY
HAVE SIMILAR OR OVERLAPPING CLINICAL
PRESENTATIONS. SOME JUDGMENT IS REQUIRED IN
DETERMINING WHICH PART OF THE RESPIRATORY
MUCOSA IS MOST AFFECTED.

IN THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS USED TO
DESCRIBE ILLNESSES WITH PREDOMINANTLY NASAL SYMPTOMS
(INCLUDING THE COMMON COLD, NASOPHARYNGITIS, AND
SINUSITIS). THE TERM “PHARYNGITIS” IS USED TO DESCRIBE
ILLNESSES WHEN SORE THROAT IS MOST PROMINENT
(INCLUDING TONSILLITIS). THE TERM “OTITIS MEDIA” IS USED
TO DESCRIBE ILLNESSES WITH PREDOMINANTLY MIDDLE EAR
SYMPTOMS (INCLUDING ACUTE OTITIS MEDIA [AOM], OTITIS
MEDIA WITH EFFUSION [OME], AND CHRONIC SUPPURATIVE
OTITIS MEDIA [CSOM]). CHILDREN WHO HAVE COUGH AS THE
PREDOMINANT SYMPTOM ARE CONSIDERED TO HAVE
BRONCHITIS (A LOWER RESPIRATORY TRACT INFECTION). TO
MAKE MATTERS MORE COMPLICATED, ALL AREAS OF THE
RESPIRATORY MUCOSA MAY BE AFFECTED, SIMULTANEOUSLY
OR AT DIFFERENT TIMES, DURING ONE ILLNESS. THE CAUSE OF
THESE RESPIRATORY MUCOSAL INFECTIONS MOST COMMONLY
IS VIRAL BUT CAN BE BACTERIAL AND MANY INFECTIONS
INVOLVE BOTH VIRUSES AND BACTERIA. IN DEVELOPED
COUNTRIES, BOTH VIRAL AND BACTERIAL INFECTIONS ARE
LIKELY TO BE SELF LIMITED. PERSISTENT DISEASE IS MOST
LIKELY TO INDICATE A BACTERIAL INFECTION.

UPPER RESPIRATORY TRACT INFECTIONS IN
CHILDREN. ZORC, JOSEPH J. CLINICAL PEDIATRIC
EMERGENCY MEDICINE; EL SERVIER
DOI.10.1016.CPEM.209.03.008 MARCH 2009. UPPER
RESPIRATORY TRACT INFECTIONS (INCLUDING OTITIS
MEDIA) ARE THE MOST COMMON ILLNESSES
AFFECTING CHILDREN. ON AVERAGE, CHILDREN
EXPERIENCE AROUND SIX TO EIGHT UPPER
RESPIRATORY TRACT INFECTIONS (URTIS) EACH YEAR.
ALTHOUGH THESE INFECTIONS USUALLY ARE MILD
AND SELF LIMITING, THEY OCCASIONALLY LEAD TO
COMPLICATIONS THAT CAN BE LIFE THREATENING.
MOST URTIS CAN BE PLACED WITHIN THREE MAIN
CATEGORIES OF INFECTION:
RHINOSINUSITIS, PHARYNGITIS, AND OTITIS MEDIA.
WITHIN EACH CATEGORY OF ILLNESS THERE IS A
RANGE OF RELATED CONDITIONS THAT MAY HAVE
SIMILAR OR OVERLAPPING CLINICAL PRESENTATIONS .

SOME JUDGMENT IS REQUIRED IN
DETERMINING WHICH PART OF THE
RESPIRATORY MUCOSA IS MOST AFFECTED. IN
THIS ARTICLE, THE TERM “RHINOSINUSITIS” IS
USED TO DESCRIBE ILLNESSES WITH
PREDOMINANTLY NASAL SYMPTOMS
(INCLUDING THE COMMON
COLD, NASOPHARYNGITIS, AND SINUSITIS). THE
TERM “PHARYNGITIS” IS USED TO DESCRIBE
ILLNESSES WHEN SORE THROAT IS MOST
PROMINENT (INCLUDING TONSILLITIS). THE
TERM “OTITIS MEDIA” IS USED TO DESCRIBE
ILLNESSES WITH PREDOMINANTLY MIDDLE EAR
SYMPTOMS (INCLUDING ACUTE OTITIS MEDIA
[AOM], OTITIS MEDIA WITH EFFUSION
[OME], AND CHRONIC SUPPURATIVE OTITIS
MEDIA [CSOM]).

CHILDREN WHO HAVE COUGH AS THE
PREDOMINANT SYMPTOM ARE CONSIDERED TO
HAVE BRONCHITIS (A LOWER RESPIRATORY
TRACT INFECTION). TO MAKE MATTERS MORE
COMPLICATED, ALL AREAS OF THE RESPIRATORY
MUCOSA MAY BE AFFECTED, SIMULTANEOUSLY OR
AT DIFFERENT TIMES, DURING ONE ILLNESS. THE
CAUSE OF THESE RESPIRATORY MUCOSAL
INFECTIONS MOST COMMONLY IS VIRAL BUT CAN
BE BACTERIAL AND MANY INFECTIONS INVOLVE
BOTH VIRUSES AND BACTERIA. IN DEVELOPED
COUNTRIES, BOTH VIRAL AND BACTERIAL
INFECTIONS ARE LIKELY TO BE SELF LIMITED.
PERSISTENT DISEASE IS MOST LIKELY TO
INDICATE A BACTERIAL INFECTION.

 11. WHY ARE UPPER RESPIRATORY TRACT INFECTIONS
SO DIFFICULT TO DIAGNOSE IN CHILDREN?
 A THEY GET MANY OF THEM.
 B THE SYMPTOMS OF DIFFERENT URTIS OVERLAP.
 C THERE ARE DIFFERENT KINDS OF URTIS.
 D VIRAL AND BACTERIAL INFECTIONS EXIST.
 12. AN EXAMPLE OF A LOWER RESPIRATORY
INFECTION IS:
 A NASOPHARYNGITIS.
 B BRONCHITIS.
 C SINUSITIS.
 D TONSILLITIS.

 13. THE CAUSE OF THE ILLNESS IN RESPIRATORY
INFECTIONS IS BEST DETERMINED BY THE:
 A SYMPTOMS.
 B PRESENCE OF A VIRAL INFECTION.
 C PRESENCE OF A BACTERIAL INFECTION.
 D AFFECTED PART OF THE RESPIRATORY
MUCOSA.
 14. THE MAIN AREA AFFECTED IN INFECTIONS
TERMED "OTITIS MEDIA" IS THE:
 A EYE
 B EAR
 C NOSE
 D THROAT

15. OME, AOM, AND SCOM ALL BELONG TO THE
FAMILY OF THE INFECTIONS CALLED:
A BRONCHITIS
B PHARYNGITIS
C RHINOSINUSITIS
D OTITIS MEDIA

11. B
12. B
13. A (D?)
14. B
15. D

 11. Within each category of illness, there is a
range of related conditions that may have
similar or overlapping clinical presentations.
 12. Children who have cough as the
predominant symptom are considered to have
bronchitis (a lower respiratory tract infection).
 13. Within each category of illness, there is a
range of related conditions that may have
similar or overlapping clinical presntations /
Some judgment is required in determining
which part of the respiratory mucosa is most
affected.

 14. The term “otitis media” is used to
describe illnesses of predominantly
middle ear symptoms
 15. …including acute otitis media
(AOM), otitis media with effusion
(AME), and chronic suppurative otitis
media (CSOM).

upper/lower respiratory tract infections/ up, low
… they may have overlapping clinical
presentations to
overlap/overlapping/overlapped
…, they occasionally lead to complications that
can be life threatening …
a threat/ to threaten/ threatening
Some judgment is required in determining which
part of the mucosa ...
to judge, a judge/ judgment, judgement
To make matters more complicated, …

FREQUENCY OF GERD SYMPTOMS IN ELDERLY PATIENTS WHO COME TO A FAMILY
MEDICINE CLINIC. OBJECTIVES: TO ASCERTAIN THE PREVALENCE OF
GASTROESOPHAGEAL REFLUX DISEASE (GERD) IN ELDERLY PEOPLE ATTENDING TO
FAMILY MEDICINE CLINICS. MATERIAL AND METHODS: THE STUDY WAS
CONDUCTED BY USING A PROSPECTIVE DESIGN IN WHICH PARTICIPANTS WERE
RANDOMLY SELECTED FROM A FAMILY MEDICINE CLINIC LOCATED IN MEXICO
CITY. THE STUDY WAS RUN FROM AUGUST TO SEPTEMBER 2003, AND INCLUDED
PATIENTS AGED SIXTY YEARS OR OLDER, REGARDLESS OF GENDER. THEY SHOULD
NOT HAVE COGNITIVE DAMAGE, WHICH WAS ASCERTAINED BY THE FOLSTEIN MINI
MENTAL STATE EXAMINATION. THOSE PATIENTS THAT DID NOT ACCEPT TO
PARTICIPATE AND THOSE HAVING INCOMPLETE OR ILLEGIBLE MEDICAL RECORDS
WERE EXCLUDED. THE SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST AND
CARLSSON-DENT TEST WERE APPLIED. THE INFORMATION ABOUT
DIAGNOSIS, DRUGS PRESCRIPTIONS, AND PHARMACOLOGICAL AND NO
PHARMACOLOGICAL GASTROESOPHAGEAL PROTECTION WAS OBTAINED FROM THE
MEDICAL CHARTS AND PRESCRIPTIONS. RESULTS: 400 ELDERLY PATIENTS WERE
EVALUATED BY USING THE CARLSSON-DENT TEST. GERD PREVALENCE WAS 25% (IC
95 % 21-29) THE AVERAGE AGE OF PATIENTS WITH AND WITHOUT GERD WAS 68 ± 7
YEARS AND 70 ± 7 YEARS RESPECTIVELY (P = .002). WOMEN SUFFERED GERD MORE
FREQUENTLY THAN MEN (P = 0.001). GERD DIAGNOSIS WAS NOT FOUND IN ANY OF
THE REVIEWED MEDICAL CHARTS. ANTACIDS, HISTAMINE- 2 RECEPTOR
ANTAGONISTS (H2 AS) AND WERE PRESCRIBED IN 39% (IC 95 % 34-44) OF PATIENTS
WITH GERD AND IN 18% (IC 95 % 15-21) WITHOUT GERD. CONCLUSIONS: ELDERLY
PATIENTS ATTENDING TO PRIMARY CARE FACILITIES OFTEN HAVE GERD
SYMPTOMS, BUT THEY ARE NOT PROPERLY DIAGNOSED OR FOLLOWED UP. THE
CARLSSON-DENT QUESTIONNAIRE IS AN ALTERNATIVE TO IDENTIFY GERD
PATIENTS.

FREQUENCY OF GERD SYMPTOMS IN ELDERLY
PATIENTS WHO COME TO A FAMILY MEDICINE
CLINIC. OBJECTIVES: TO ASCERTAIN THE
PREVALENCE OF GASTROESOPHAGEAL REFLUX
DISEASE (GERD) IN ELDERLY PEOPLE ATTENDING
TO FAMILY MEDICINE CLINICS. MATERIAL AND
METHODS: THE STUDY WAS CONDUCTED BY
USING A PROSPECTIVE DESIGN IN WHICH
PARTICIPANTS WERE RANDOMLY SELECTED FROM
A FAMILY MEDICINE CLINIC LOCATED IN MEXICO
CITY. THE STUDY WAS RUN FROM AUGUST TO
SEPTEMBER 2003, AND INCLUDED PATIENTS AGED
SIXTY YEARS OR OLDER, REGARDLESS OF GENDER.

THEY SHOULD NOT HAVE COGNITIVE
DAMAGE, WHICH WAS ASCERTAINED BY THE
FOLSTEIN MINI MENTAL STATE EXAMINATION.
THOSE PATIENTS THAT DID NOT ACCEPT TO
PARTICIPATE AND THOSE HAVING INCOMPLETE OR
ILLEGIBLE MEDICAL RECORDS WERE EXCLUDED.
THE SOCIO-DEMOGRAPHIC CHARACTERISTICS
TEST AND CARLSSON-DENT TEST WERE APPLIED.
THE INFORMATION ABOUT DIAGNOSIS, DRUGS
PRESCRIPTIONS, AND PHARMACOLOGICAL AND
NON PHARMACOLOGICAL GASTROESOPHAGEAL
PROTECTION WAS OBTAINED FROM THE MEDICAL
CHARTS AND PRESCRIPTIONS. RESULTS: 400
ELDERLY PATIENTS WERE EVALUATED BY USING
THE CARLSSON-DENT TEST.

GERD PREVALENCE WAS 25% (IC 95 % 21-29) THE
AVERAGE AGE OF PATIENTS WITH AND WITHOUT
GERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARS
RESPECTIVELY (P = .002). WOMEN SUFFERED GERD
MORE FREQUENTLY THAN MEN (P = 0.001). GERD
DIAGNOSIS WAS NOT FOUND IN ANY OF THE
REVIEWED MEDICAL CHARTS. ANTACIDS, HISTAMINE-
2 RECEPTOR ANTAGONISTS (H2 AS) AND WERE
PRESCRIBED IN 39% (IC 95 % 34-44) OF PATIENTS WITH
GERD AND IN 18% (IC 95 % 15-21) WITHOUT GERD.
CONCLUSIONS: ELDERLY PATIENTS ATTENDING TO
PRIMARY CARE FACILITIES OFTEN HAVE GERD
SYMPTOMS, BUT THEY ARE NOT PROPERLY
DIAGNOSED OR FOLLOWED UP. THE CARLSSON-DENT
QUESTIONNAIRE IS AN ALTERNATIVE TO IDENTIFY
GERD PATIENTS.

 16. ABOUT THE DESIGN OF THE STUDY:
 A RESEARCHERS USE A PROSPECTIVE
DESIGN, PARTICIPANTS WERE FAMILY MEDICINE
SPECIALISTS FROM MEXICO CITY SELECTED AT
RANDOM.
 B PARTICIPANTS ARE SELECTED AT RANDOM FROM A
FAMILY MEDICINE CLINIC FROM AN ELDERLY FEMALE
POPULATION.
 C ELDERLY PATIENTS WERE INCLUDED WITHOUT
CONSIDERING GENDER.
 D IT WAS ORIGINALLY PLANNED TO BE DONE IN
THREE MONTHS.
 17. THE INCLUSION OF PATIENT CRITERIA WAS:
 A CERTAINLY NOT TO HAVE ANY BRAIN DAMAGE.
 B TO HAVE COGNITIVE COMPETENCE PROVEN BY
THE FOLSTEIN MINI MENTAL STATE EXAMINATION.
 C NOT TO ACCEPT TO PARTICIPATE IN THE STUDY.
 D THERE WERE INCOMPLETE OR ILLEGIBLE MEDICAL
RECORDS.

 18 RESEARCHERS OBTAIN THE INFORMATION ABOUT
DIAGNOSIS, DRUGS PRESCRIPTIONS, AND
PHARMACOLOGICAL AND NON PHARMACOLOGICAL
GASTROESOPHAGEAL PROTECTION FROM:
 A A SOCIO-DEMOGRAPHIC CHARACTERISTICS TEST.
 B A CARLSSON-DENT TEST.
 C CLINIC DATABASES.
 D PATIENT RECORDS.
 19 THE AIM OF THE STUDY GAVE AS A RESULT:
 A GERD PREVALENCE WAS 25%.
 B AVERAGE AGE OF PATIENTS WITH AND WITHOUT
GERD WAS 68 ± 7 YEARS AND 70 ± 7 YEARS
RESPECTIVELY.
 C WOMEN SUFFERED GERD MORE FREQUENTLY
THAN MEN.
 D ANTACIDS, H2 AS AND WERE PRESCRIBED IN 39%
OF PATIENTS WITH GERD.

20 THE MAIN CONCLUSION OF THE STUDY WAS:
A PATIENTS WITHOUT GERD STILL RECEIVED
TREATMENT.
B PARTICIPANTS OFTEN HAD GERD SYMPTOMS.
C PATIENTS IDENTIFIED WITH GERD SYMPTOMS
WERE DIAGNOSED AND FOLLOWED UP CORRECTLY.
D THE CARLSSON-DENT QUESTIONNAIRE WAS THE
BEST ALTERNATIVE TO IDENTIFY GERD PATIENTS.

 16. The study … included patients aged sixty
and older, regardless of gender.
 17. They should not have cognitive
damage, which was ascertained by the
Folstein mini mental state examination.
 18. The information about diagnosis, drug
prescriptions, and pharmocological and
non pharmacological gastroesophageal
protection was obtained from the medical
charts and prescriptions.
 19. GERD prevalence was 25%.

 20. Elderly patients attending to primary
care facilities often have GERD
symptoms, but they are not properly
diagnosed or followed up.

 Regardless/ regarding, in regards to

Regardless/regarding, in regards to

NEW THINKING ON HOW TO PROTECT THE HEART BY JANE E. BRODY SURGERY MAY NOT BE
THE BEST WAY TO AVOID A HEART ATTACK OR SUDDEN CARDIAC DEATH, THE NEXT STEP IS
FINDING OUT WHAT CAN WORK AS WELL OR BETTER TO PROTECT YOUR HEART. MANY
MEASURES ARE PROBABLY FAMILIAR: NOT SMOKING, CONTROLLING CHOLESTEROL AND
BLOOD PRESSURE, EXERCISING REGULARLY AND STAYING AT A HEALTHY WEIGHT. BUT SOME
NEWER SUGGESTIONS MAY SURPRISE YOU. IT IS NOT THAT THE OLD ADVICE, LIKE EATING A
LOW-FAT DIET OR EXERCISING VIGOROUSLY, WAS BAD ADVICE; IT WAS BASED ON THE BEST
AVAILABLE EVIDENCE OF THE TIME AND CAN STILL BE VERY HELPFUL. THE WELL-ESTABLISHED
RISK FACTORS FOR HEART DISEASE REMAIN INTACT: HIGH CHOLESTEROL, HIGH BLOOD
PRESSURE, SMOKING, DIABETES, ABDOMINAL OBESITY AND SEDENTARY LIVING. BUT BEHIND
THEM A RELATIVELY NEW FACTOR HAS EMERGED THAT MAY BE EVEN MORE IMPORTANT AS A
CAUSE OF HEART ATTACKS THAN, SAY, HIGH BLOOD LEVELS OF ARTERY-DAMAGING
CHOLESTEROL. THAT FACTOR IS C-REACTIVE PROTEIN, OR CRP, A BLOOD-BORNE MARKER OF
INFLAMMATION THAT, ALONG WITH COAGULATION FACTORS, IS NOW INCREASINGLY
RECOGNIZED AS THE DRIVING FORCE BEHIND CLOTS THAT BLOCK BLOOD FLOW TO THE
HEART. EVEN IN PEOPLE WITH NORMAL CHOLESTEROL, IF CRP IS ELEVATED, THE RISK OF
HEART ATTACK IS TOO. DIET REVISITED THE NEW DIETARY ADVICE IS ACTUALLY BASED ON A
RATHER OLD FINDING THAT PREDATES THE MANTRA TO EAT A LOW-FAT DIET. IN THE SEVEN
COUNTRIES STUDY STARTED IN 1958 FOUND THAT HEART DISEASE WAS RARE IN THE
MEDITERRANEAN AND ASIAN REGIONS WHERE VEGETABLES, GRAINS, FRUITS, BEANS AND FISH
WERE THE DIETARY MAINSTAYS. BUT IN COUNTRIES LIKE FINLAND AND THE UNITED STATES
WHERE PLATES WERE TYPICALLY FILLED WITH RED MEAT, CHEESE AND OTHER FOODS RICH IN
SATURATED FATS, HEART DISEASE AND CARDIAC DEATHS WERE EPIDEMIC. THE FINDING
RESULTED IN THE WELL-KNOWN ADVICE TO REDUCE DIETARY FAT AND ESPECIALLY
SATURATED FATS (THOSE THAT ARE FIRM AT ROOM TEMPERATURE), AND TO REPLACE THESE
HARMFUL FATS WITH UNSATURATED ONES LIKE VEGETABLE OILS. WHAT WAS MISSED AT THE
TIME AND HAS NOW BECOME INCREASINGLY APPARENT IS THAT THE HEART-HEALTHY
MEDITERRANEAN DIET IS NOT REALLY LOW IN FAT, BUT ITS MAIN SOURCES OF FAT — OLIVE
OIL AND OILY FISH AS WELL AS NUTS, SEEDS AND CERTAIN VEGETABLES — HELP TO PREVENT
HEART DISEASE BY IMPROVING CHOLESTEROL RATIOS AND REDUCING INFLAMMATION.

NEW THINKING ON HOW TO PROTECT THE HEART. BY
JANE E. BRODY. SURGERY MAY NOT BE THE BEST WAY
TO AVOID A HEART ATTACK OR SUDDEN CARDIAC
DEATH. THE NEXT STEP IS FINDING OUT WHAT CAN
WORK AS WELL OR BETTER TO PROTECT YOUR HEART.
MANY MEASURES ARE PROBABLY FAMILIAR: NOT
SMOKING, CONTROLLING CHOLESTEROL AND BLOOD
PRESSURE, EXERCISING REGULARLY AND STAYING AT A
HEALTHY WEIGHT. BUT SOME NEWER SUGGESTIONS
MAY SURPRISE YOU. IT IS NOT THAT THE OLD
ADVICE, LIKE EATING A LOW-FAT DIET OR EXERCISING
VIGOROUSLY, WAS BAD ADVICE; IT WAS BASED ON THE
BEST AVAILABLE EVIDENCE OF THE TIME AND CAN
STILL BE VERY HELPFUL. THE WELL-ESTABLISHED RISK
FACTORS FOR HEART DISEASE REMAIN INTACT: HIGH
CHOLESTEROL, HIGH BLOOD
PRESSURE, SMOKING, DIABETES, ABDOMINAL OBESITY
AND SEDENTARY LIVING.

BUT BEHIND THEM A RELATIVELY NEW FACTOR HAS
EMERGED THAT MAY BE EVEN MORE IMPORTANT AS A
CAUSE OF HEART ATTACKS THAN, SAY, HIGH BLOOD
LEVELS OF ARTERY-DAMAGING CHOLESTEROL. THAT
FACTOR IS C-REACTIVE PROTEIN, OR CRP, A BLOOD-
BORNE MARKER OF INFLAMMATION THAT, ALONG
WITH COAGULATION FACTORS, IS NOW INCREASINGLY
RECOGNIZED AS THE DRIVING FORCE BEHIND CLOTS
THAT BLOCK BLOOD FLOW TO THE HEART. EVEN IN
PEOPLE WITH NORMAL CHOLESTEROL, IF CRP IS
ELEVATED, THE RISK OF HEART ATTACK IS TOO. DIET
REVISITED THE NEW DIETARY ADVICE IS ACTUALLY
BASED ON A RATHER OLD FINDING THAT PREDATES
THE MANTRA TO EAT A LOW-FAT DIET. IN THE SEVEN
COUNTRIES STUDY STARTED IN 1958 FOUND THAT
HEART DISEASE WAS RARE IN THE MEDITERRANEAN
AND ASIAN REGIONS WHERE
VEGETABLES, GRAINS, FRUITS, BEANS AND FISH WERE

BUT IN COUNTRIES LIKE FINLAND AND THE UNITED
STATES WHERE PLATES WERE TYPICALLY FILLED WITH
RED MEAT, CHEESE AND OTHER FOODS RICH IN
SATURATED FATS, HEART DISEASE AND CARDIAC
DEATHS WERE EPIDEMIC. THE FINDING RESULTED IN
THE WELL-KNOWN ADVICE TO REDUCE DIETARY FAT
AND ESPECIALLY SATURATED FATS (THOSE THAT ARE
FIRM AT ROOM TEMPERATURE), AND TO REPLACE
THESE HARMFUL FATS WITH UNSATURATED ONES LIKE
VEGETABLE OILS. WHAT WAS MISSED AT THE TIME AND
HAS NOW BECOME INCREASINGLY APPARENT IS THAT
THE HEART-HEALTHY MEDITERRANEAN DIET IS NOT
REALLY LOW IN FAT, BUT ITS MAIN SOURCES OF FAT —
OLIVE OIL AND OILY FISH AS WELL AS NUTS, SEEDS
AND CERTAIN VEGETABLES — HELP TO PREVENT HEART
DISEASE BY IMPROVING CHOLESTEROL RATIOS AND
REDUCING INFLAMMATION.

 21. ACCORDING TO THE ARTICLE, THE BEST WAY
TO AVOID A HEART ATTACK IS:
 A EATING A LOW FAT DIET AND EXERCISING
VIGOROUSLY.
 B HAVING A SURGERY.
 C CONTROLLING YOUR CRP
 D CONTROLLING YOUR CHOLESTEROL
 22. ACCORDING TO THE ARTICLE, THE BEST DIET
TO FOLLOW IS:
 A A LOW-FAT DIET
 B SATURATED FATS
 C RED MEAT AND CHEESE
 D A MEDITERRANEAN DIET.

 23. THE MEDITERRANEAN DIET CONSISTS
MAINLY OF:
 A LOW CARBOHYDRATES
 B RED MEAT AND CHEESE
 C UNSATURATED FATS
 D VEGETABLES
 24. DRINKING RED WINE IS GOOD FOR YOU
BECAUSE:
 A IT MAKES YOU RELAX
 B IT HAS ANTIOXIDANT PROPERTIES
 C IT PREVENTS THE FORMATION OF
CHOLESTEROL
 D IT IS EASY TO DIGEST

 25. FROM THE ARTICLE WE CAN CONCLUDE THAT:
 A IF WE FOLLOW A LOW-FAT DIET AND EXERCISE
VIGOROUSLY, WE WILL AVOID HAVING A HEART
ATTACK
 B GOING TO THE PERIODONTIST, EXERCISING 15
MINUTES A DAY, RELAXING, AND FOLLOWING A
MEDITERRANEAN DIET, WE WILL AVOID HAVING A
HEART ATTACK
 C TAKING A VACATION, EXERCISING VIGOROUSLY
AND FOLLOWING A MEDITERRANEAN DIET, WE WILL
AVOID HAVING A HEART ATTACK
 D PRACTICING THE RELAXATION RESPONSE ONCE
OR TWICE A DAY BY BREATHING DEEPLY AND
RHYTHMICALLY IN A QUIET PLACE WILL AVOID
HAVING A HEART ATTACK.

21. C
22. D
23. C
24. B (Esta respuesta no está en la
lectura)
25. B

 21. But behind them, a relatively new factor
has emerged that may be even more
important as a cause of heart
attacks, than, say, high blood levels of
artery-damaging cholesterol. That factor is
C-reacting protein, or CRP.
 22. … the study … found that heart disease
was rare in the Mediterranean and Asian
regions where
vegetables, grains, fruits, beans, and fish
were the dietary mainstays.

 23. … the heart-healthy Mediterranean
diet is not really low in fat, but its main
source of fat – olive oil and oily fish as
well as nuts, seeds and certain
vegetables - help to prevent heart
disease by improving cholesterol ratios
and reducing inflammation.

 24. La respuesta no está en la lectura.
25. It is not that old advice, like eating
a low-fat diet or exercising vigorously
was bad advice; it was based on the best
available advice of the time and can still
be very helpful.

MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNAL
MORTALITY IS THE TIP OF THE MATERNAL MORBIDITY ICEBERG; SEVERAL
OBSETRIC, ANESTHETIC AND SOCIAL CHALLENGES IMPACT MORBIDITY
AND MORTALITY IN WOMEN. MATERNAL MORTALITY IS THE YARDSTICK
TO MEASURE WHEN HEALTH CARE PERSONNEL FAIL TO RECOGNIZE
RISKS, LACK INTERDISCIPLINARY COMMUNICATION, OR PROVIDE
SUBSTANDARD CARE, THUS RESULTING IN COMPLICATIONS DURING
PREGNACY, LABOR, OR DELIVERY. PREGNANCY-RELATED DEATH IS
DEFINED BY THE INTERNATIONAL CLASSIFICATION OF DISEASES, 10TH
REVISION (ICD-10) AS THE DEATH OF A WOMAN WHILE PREGNANT OR
WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE
OF DEATH. ALTHOUGH THE RISK FOR DEATH FROM COMPLICATIONS OF
PREGNANCY DECREASED DURING THE 20TH CENTURY IN THE UNITED
STATES, THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)
REPORTS A FAIRLY STATIC MATERNAL MORTALITY RATIO (MMR) OF
APPROXIMATELY 7.5 MATERNAL DEATHS PER 100,000 LIVE BIRTHS. IN THE
YEAR 2000, A COLLABORATIVE EFFORT INVOLVING WORLD HEALTH
ORGANIZATION (WHO), UNITED NATIONS CHILDREN’S FUND
(UNICEF), AND UNITED NATIONS POPULATION FUND (UNFPA) ESTIMATED
660 MATERNAL DEATHS, THUS AVERAGING 11 MATERNAL DEATHS PER
100,000 LIVE BIRTHS, PLACING THE MMR ABOVE THE STATISTICS
REPORTED BY THE CDC.

THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARE
LIMITED IN SCOPE BECAUSE THE INFORMATION IS OBTAINED FROM
DEATH CERTIFICATES, AND VARIOUS STATES OR ACADEMIC
INSTITUTIONS COULD BE UNDERREPORTING. ACCURATE STATISTICS ARE
LACKING, THUS RESULTING IN ONLY A SNAPSHOT OF THE ACTUAL
MATERNAL MORBIDITY AND MORTALITY. THE RECENT WHO ESTIMATE IN
THE UNITED STATES SHOWS THAT MATERNAL MORTALITY IS
APPROXIMATELY 17 IN 100,000 PREGNANCIES. THIS ESTIMATE IS
SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S. DEPARTMENT
OF HEALTH AND HUMAN SERVICES IN HEALTHY PEOPLE 2010, WHICH
SETS THE TARGET FOR MATERNAL MORTALITY AT LESS THAN 3.3 IN
100,000 LIVE BIRTHS. SOME REGIONAL REPORTS DOCUMENT RATIOS AS
HIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN UNACCEPTABLY HIGH
RATE. IN UNITED STATES, THE MOST COMMON CAUSES OF MATERNAL
DEATHS, ALTHOUGH THEY VARY AMONG STATES, INCLUDE
THROMBOEMBOLISM; AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;
COMPLICATIONS OF HYPERTENSION, INCLUDING PREECLAMPSIA AND
ECLAMPSIA; AND INFECTION, PULMONARY DISEASE, ANESTHESIA-
RELATED DEATHS, AND CARDIOMYOPATHY ARE ALSO SIGNIFICANT
CONTRIBUTORS TO MATERNAL MORBIDITY AND MORTALITY.

MATERNAL MORBIDITY, MORTALITY, AND RISK ASSESSMENT. MATERNAL MORTALITY IS THE TIP OF THE
MATERNAL MORBIDITY ICEBERG; SEVERAL OBSETRIC, ANESTHETIC AND SOCIAL CHALLENGES IMPACT
MORBIDITY AND MORTALITY IN WOMEN. MATERNAL MORTALITY IS THE YARDSTICK TO MEASURE
WHEN HEALTH CARE PERSONNEL FAIL TO RECOGNIZE RISKS, LACK INTERDISCIPLINARY
COMMUNICATION, OR PROVIDE SUBSTANDARD CARE, THUS RESULTING IN COMPLICATIONS DURING
PREGNACY, LABOR, OR DELIVERY. PREGNANCY-RELATED DEATH IS DEFINED BY THE INTERNATIONAL
CLASSIFICATION OF DISEASES, 10TH REVISION (ICD-10) AS THE DEATH OF A WOMAN WHILE PREGNANT
OR WITHIN 42 DAYS OF TERMINATION OF PREGNANCY, DESPITE THE CAUSE OF DEATH. ALTHOUGH THE
RISK FOR DEATH FROM COMPLICATIONS OF PREGNANCY DECREASED DURING THE 20TH CENTURY IN
THE UNITED STATES, THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) REPORTS A FAIRLY
STATIC MATERNAL MORTALITY RATIO (MMR) OF APPROXIMATELY 7.5 MATERNAL DEATHS PER 100,000
LIVE BIRTHS. IN THE YEAR 2000, A COLLABORATIVE EFFORT INVOLVING WORLD HEALTH
ORGANIZATION (WHO), UNITED NATIONS CHILDREN’S FUND (UNICEF), AND UNITED NATIONS
POPULATION FUND (UNFPA) ESTIMATED 660 MATERNAL DEATHS, THUS AVERAGING 11 MATERNAL
DEATHS PER 100,000 LIVE BIRTHS, PLACING THE MMR ABOVE THE STATISTICS REPORTED BY THE CDC.
THESE SURVEYS ON MATERNAL MORTALITY SURVEILLANCES ARE LIMITED IN SCOPE BECAUSE THE
INFORMATION IS OBTAINED FROM DEATH CERTIFICATES, AND VARIOUS STATES OR ACADEMIC
INSTITUTIONS COULD BE UNDERREPORTING. ACCURATE STATISTICS ARE LACKING, THUS RESULTING IN
ONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITY AND MORTALITY. THE RECENT WHO
ESTIMATE IN THE UNITED STATES SHOWS THAT MATERNAL MORTALITY IS APPROXIMATELY 17 IN 100,000
PREGNANCIES. THIS ESTIMATE IS SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES IN HEALTHY PEOPLE 2010, WHICH SETS THE TARGET
FOR MATERNAL MORTALITY AT LESS THAN 3.3 IN 100,000 LIVE BIRTHS. SOME REGIONAL REPORTS
DOCUMENT RATIOS AS HIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN UNACCEPTABLY HIGH RATE.
IN UNITED STATES, THE MOST COMMON CAUSES OF MATERNAL DEATHS, ALTHOUGH THEY VARY
AMONG STATES, INCLUDE THROMBOEMBOLISM; AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;
COMPLICATIONS OF HYPERTENSION, INCLUDING PREECLAMPSIA AND ECLAMPSIA; AND
INFECTION, PULMONARY DISEASE, ANESTHESIA-RELATED DEATHS, AND CARDIOMYOPATHY ARE ALSO
SIGNIFICANT CONTRIBUTORS TO MATERNAL MORBIDITY AND MORTALITY.

MATERNAL MORBIDITY, MORTALITY, AND RISK
ASSESSMENT. MATERNAL MORTALITY IS THE TIP OF
THE MATERNAL MORBIDITY ICEBERG; SEVERAL
OBSETRIC, ANESTHETIC AND SOCIAL CHALLENGES
IMPACT MORBIDITY AND MORTALITY IN WOMEN.
MATERNAL MORTALITY IS THE YARDSTICK TO
MEASURE WHEN HEALTH CARE PERSONNEL FAIL
TO RECOGNIZE RISKS, LACK INTERDISCIPLINARY
COMMUNICATION, OR PROVIDE SUBSTANDARD
CARE, THUS RESULTING IN COMPLICATIONS
DURING PREGNACY, LABOR, OR DELIVERY.
PREGNANCY-RELATED DEATH IS DEFINED BY THE
INTERNATIONAL CLASSIFICATION OF
DISEASES, 10TH REVISION (ICD-10) AS THE DEATH
OF A WOMAN WHILE PREGNANT OR WITHIN 42
DAYS OF TERMINATION OF PREGNANCY, DESPITE
THE CAUSE OF DEATH.

ALTHOUGH THE RISK FOR DEATH FROM
COMPLICATIONS OF PREGNANCY DECREASED DURING
THE 20TH CENTURY IN THE UNITED STATES, THE
CENTERS FOR DISEASE CONTROL AND PREVENTION
(CDC) REPORTS A FAIRLY STATIC MATERNAL
MORTALITY RATIO (MMR) OF APPROXIMATELY 7.5
MATERNAL DEATHS PER 100,000 LIVE BIRTHS. IN THE
YEAR 2000, A COLLABORATIVE EFFORT INVOLVING
WORLD HEALTH ORGANIZATION (WHO), UNITED
NATIONS CHILDREN’S FUND (UNICEF), AND UNITED
NATIONS POPULATION FUND (UNFPA) ESTIMATED 660
MATERNAL DEATHS, THUS AVERAGING 11 MATERNAL
DEATHS PER 100,000 LIVE BIRTHS, PLACING THE MMR
ABOVE THE STATISTICS REPORTED BY THE CDC. THESE
SURVEYS ON MATERNAL MORTALITY SURVEILLANCES
ARE LIMITED IN SCOPE BECAUSE THE INFORMATION IS
OBTAINED FROM DEATH CERTIFICATES, AND VARIOUS
STATES OR ACADEMIC INSTITUTIONS COULD BE
UNDERREPORTING.

ACCURATE STATISTICS ARE LACKING, THUS RESULTING IN
ONLY A SNAPSHOT OF THE ACTUAL MATERNAL MORBIDITY
AND MORTALITY. THE RECENT WHO ESTIMATE IN THE
UNITED STATES SHOWS THAT MATERNAL MORTALITY IS
APPROXIMATELY 17 IN 100,000 PREGNANCIES. THIS ESTIMATE
IS SIGNIFICANTLY HIGHER THAN THE GOAL SET BY THE U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES IN
HEALTHY PEOPLE FOR 2010, WHICH SETS THE TARGET FOR
MATERNAL MORTALITY AT LESS THAN 3.3 IN 100,000 LIVE
BIRTHS. SOME REGIONAL REPORTS DOCUMENT RATIOS AS
HIGH AS 22.8 PER 100,000 LIVE BIRTHS, WHICH IS AN
UNACCEPTABLY HIGH RATE. IN UNITED STATES, THE MOST
COMMON CAUSES OF MATERNAL DEATHS, ALTHOUGH THEY
VARY AMONG STATES, INCLUDE THROMBOEMBOLISM;
AMNIOTIC FLUID EMBOLISM; HEMORRHAGE;
COMPLICATIONS OF HYPERTENSION, INCLUDING
PREECLAMPSIA AND ECLAMPSIA; AND
INFECTION, PULMONARY DISEASE, ANESTHESIA-RELATED
DEATHS, AND CARDIOMYOPATHY ARE ALSO SIGNIFICANT
CONTRIBUTORS TO MATERNAL MORBIDITY AND

 26. FOR MATERNAL MORTALITY, A RISK FACTOR COULD
BE:
 A EXCESIVE INTERDISCIPLINARY COMMUNICATION BY
HEALTH CARE PERSONNEL.
 B FAILURE TO RECOGNIZE RISKS BY HEALTH CARE
PERSONNEL .
 C HEALTH CARE PERSONNEL PROVIDE STANDARD CARE.
 D ALL THE ABOVE ARE RISK FACTORS.
 27. THE MAIN REASON WHY THE MATERNAL MORTALITY
SURVEILLANCES ARE LIMITED IN SCOPE WOULD BE:
 A BECAUSE THE INFORMATION IS OBTAINED FROM
DEATH CERTIFICATES.
 B A SITUATION OF UNDERREPORTING.
 C BECAUSE VARIOUS STATES OR ACADEMIC INSTITUTIONS
COULD BE OVERREPORTING.
 D THE MATERNAL MORTALITY SURVEILLANCES ARE
ACCURATE.

 28. ACCORDING TO THE FINDINGS FROM THE
STUDY CONDUCTED BY WHO, UNICEF AND THE
UNFPA, WHAT IS THE CONCLUSION?:
 A PREGNANCY RELATED DEATH IS THE DEATH OF
A PREGNANT WOMAN .
 B PREGNANCY RELATED DEATH IS THE DEATH
OF A WOMAN WITHIN 42 DAYS OF TERMINATION
OF PREGNANCY, DESPITE THE CAUSE OF DEATH.
 C THE RISK OF DEATH FROM COMPLICATIONS
OF PREGNANCY DECREASED DRAMATICALLY
DURING THE 20TH CENTURY IN THE UNITED
STATES.
 D THE MMR STATISTICS ARE ABOVE THE CDC
STATISTICS.

 29. ALTHOUGH THE U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES HAS PROJECTED GOALS FOR 2010, WHAT IS
THE ACTUAL RATIO?:
 A MATERNAL MORTALITY IS APPROXIMATELY 17 IN 100,000
PREGNANCIES.
B MATERNAL MORTALITY IS AT LESS THAN 3.3 IN 100,000 LIVE
BIRTHS.
C THE RESULTS HAVE NOT BEEN WHAT THEY EXPECTED.
 D MATERNAL MORTALITY IS 22.8 PER 100,000 LIVE BIRTHS.
30. ABOUT THE CAUSES OF MATERNAL DEATHS, WHICH
WOULD BE CONSIDERED A CONTRIBUTOR FROM THE
FOLLOWING?:
A THROMBOEMBOLISM.
B AMNIOTIC FLUID EMBOLISM.
C PREECLAMPSIA AND ECLAMPSIA.
D CARDIOMYOPATHY.

 26. Maternal mortality is the yardstick to
measure when health care personnel fail to
recognize risks, lack interdisciplinary
communication, or provide substandard
care.
 27. These surveys on maternal mortality
surveillances are limited in scope because
the information is obtained from death
certificates, and various states or academic
institutions could be underreporting.

 28. A collaborative effort involving World
Health Organization (WHO), United
Nations Children’s Fund (UNICEF), and
United Nations Population Fund(UNFPA)
estimated 660 maternal deaths, thus
averaging 11 maternal deaths per 100,000 live
births, placing the MMR above the statistics
by the CDC.
 29. The recent WHO estimate in the United
States shows that maternal mortality is
approximately 17 in 100,000 pregnancies.

 30. … and cardiomyopathy are also
significant contributors to maternal
mortality and morbidity.
 (A, B y C son causas. La D es el único
contribuyente de los mencionados en el
texto.)

actual, actually/current, currently

VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTS WITH HYPERTENSION HAVE
INADEQUATE CONTROL OF BLOOD PRESSURE BECAUSE THEY ARE NOT CONSISTENTLY ADHERENT IN
TAKING THEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN THE FORM OF A VACCINE THAT
LOWERS BLOOD PRESSURE BY CONTROLLING ANGIOTENSIN II, SUGGEST FINDINGS FROM A SMALL
SAFETY STUDY PRESENTED AT THE SCIENTIFIC SESSIONS OF THE AMERICAN HEART ASSOCIATION IN
NOVEMBER. THE STUDY OF 72 PATIENTS WITH MILD-TO-MODERATE HYPERTENSION PRESENTED BY
JURG NUSSBERGER, MD, PROFESSOR OF MEDICINE AT THE UNIVERSITY HOSPITAL OF THE CANTON OF
VAUD, LAUSANNE, SWITZERLAND, FOUND THAT AT 14 WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB
(AT 0, 4 AND 12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THAT WAS 5.6 MM HG LOWER AND A
DIASTOLIC BLOOD PRESSURE 2.8 MM HG LOWER THAN THOSE OF PATIENTS WHO RECEIVED PLACEBO.
CYTOO6-ANGQB, WHICH IS UNDER DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG
(ZURICH, SWITZERLAND), IS A VIRUS-SHAPED NONINFECTIOUS PARTICLE THAT IS COUPLED WITH
ANGIOTENSIN II, AN OCTAPEPTIDE VASOCONSTRICTOR. SUCH COUPLING INDUCES THE BODY TO
PRODUCE ANTIBODIES AGAINST THIS SMALL MOLECULE TO MINIMIZE ITS EFFECTS ON CONSTRICTING
BLOOD VESSELS. NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHT CAUSE
HYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASE SHORTLY AFTER THE BOOSTER OF
TWELVE WEEKS INDUCED PEAK ANTIBODY LEVELS. HE ALSO SAID THE LIKELIHOOD OF VACCINE-
INDUCED ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS WAS MINIMAL BECAUSE THE SMALL
SIZE OF THE TARGET MOLECULE LIMITS THE NUMBER OF EPITOPES THAT COULD BE AFFECTED.
NUSSBERGER SPECULATED THAT IF THE CYTOO6-ANGQB VACCINE IS ULTIMATELY APPROVED, PATIENTS
WOULD BE ABLE TO AVOID THE NEED FOR MEDICATION BUT WOULD REQUIRE A BOOSTER SHOT 2 0R 3
TIMES A YEAR. HE SAID THE NEXT STEP IN STUDYING THE VACCINE WILL BE TO CONDUCT ANOTHER
SMALL TRIAL TO DETERMINE THE APPRPRIATE DOSING TO CREATE THE LARGEST ANTIBODY RESPONSE
AND GREATEST REDUCTIONS IN BLOOD PRESSURE. MORRIS J. BROWN, MD, PROFESSOR OF CLINICAL
PHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE IN ENGLAND AND PAST PRESIDENT OF THE
BRITISH HYPERTENSION SOCIETY, SAID THE FINDINGS OF THE STUDY (WHICH WAS FUNDED BY CYTOS)
ARE “INTRIGUING” BUT OFFERED A CAVEAT. “I AM A LITTLE WARY OF TOP-LINE RESULTS FROM
BIOTECHS, ESPECIALLY SECONDARY EFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID.
BROWN HAS ALSO HAD A HAND IN ATTEMPTS TO CREATE A HYPERTENSION VACCINE, PMD3117, UNDER
DEVELOPMENT BY PROTHERICS PLC IN RUNCORN, ENGLAND (BROWN MJ ET AL. CLIN SCI).

VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA. SOME PATIENTS
WITH HYPERTENSION HAVE INADEQUATE CONTROL OF BLOOD
PRESSURE BECAUSE THEY ARE NOT CONSISTENTLY ADHERENT IN TAKING
THEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN THE FORM OF A
VACCINE THAT LOWERS BLOOD PRESSURE BY CONTROLLING
ANGIOTENSIN II, SUGGEST FINDINGS FROM A SMALL SAFETY STUDY
PRESENTED AT THE SCIENTIFIC SESSIONS OF THE AMERICAN HEART
ASSOCIATION IN NOVEMBER. THE STUDY OF 72 PATIENTS WITH MILD-TO-
MODERATE HYPERTENSION PRESENTED BY JURG
NUSSBERGER, MD, PROFESSOR OF MEDICINE AT THE UNIVERSITY
HOSPITAL OF THE CANTON OF VAUD, LAUSANNE, SWITZERLAND, FOUND
THAT AT 14 WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB (AT 0, 4 AND
12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THAT WAS 5.6 MM HG
LOWER AND A DIASTOLIC BLOOD PRESSURE 2.8 MM HG LOWER THAN
THOSE OF PATIENTS WHO RECEIVED PLACEBO. CYTOO6-ANGQB, WHICH
IS UNDER DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG
(ZURICH, SWITZERLAND), IS A VIRUS-SHAPED NONINFECTIOUS PARTICLE
THAT IS COUPLED WITH ANGIOTENSIN II, AN OCTAPEPTIDE
VASOCONSTRICTOR. SUCH COUPLING INDUCES THE BODY TO PRODUCE
ANTIBODIES AGAINST THIS SMALL MOLECULE TO MINIMIZE ITS EFFECTS
ON CONSTRICTING BLOOD VESSELS.

NUSSBERGER SAID HE IS NOT CONCERNED THAT THE VACCINE MIGHT
CAUSE HYPOTENSION BECAUSE ANTIBODY TITERS STARTED TO DECREASE
SHORTLY AFTER THE BOOSTER OF TWELVE WEEKS INDUCED PEAK
ANTIBODY LEVELS. HE ALSO SAID THE LIKELIHOOD OF VACCINE-
INDUCED ANTIBODIES CROSS-REACTING WITH OTHER PROTEINS WAS
MINIMAL BECAUSE THE SMALL SIZE OF THE TARGET MOLECULE LIMITS
THE NUMBER OF EPITOPES THAT COULD BE AFFECTED. NUSSBERGER
SPECULATED THAT IF THE CYTOO6-ANGQB VACCINE IS ULTIMATELY
APPROVED, PATIENTS WOULD BE ABLE TO AVOID THE NEED FOR
MEDICATION BUT WOULD REQUIRE A BOOSTER SHOT 2 0R 3 TIMES A
YEAR. HE SAID THE NEXT STEP IN STUDYING THE VACCINE WILL BE TO
CONDUCT ANOTHER SMALL TRIAL TO DETERMINE THE APPROPRIATE
DOSING TO CREATE THE LARGEST ANTIBODY RESPONSE AND GREATEST
REDUCTIONS IN BLOOD PRESSURE. MORRIS J. BROWN, MD, PROFESSOR
OF CLINICAL PHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE IN
ENGLAND AND PAST PRESIDENT OF THE BRITISH HYPERTENSION
SOCIETY, SAID THE FINDINGS OF THE STUDY (WHICH WAS FUNDED BY
CYTOS) ARE “INTRIGUING” BUT OFFERED A CAVEAT. “I AM A LITTLE WARY
OF TOP-LINE RESULTS FROM BIOTECHS, ESPECIALLY SECONDARY
EFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID. BROWN HAS
ALSO HAD A HAND IN ATTEMPTS TO CREATE A HYPERTENSION
VACCINE, PMD3117, UNDER DEVELOPMENT BY PROTHERICS PLC IN
RUNCORN, ENGLAND (BROWN MJ ET AL. CLIN SCI).

VACCINE TAKES AIM AT HYPERTENSION. ORLANDO, FLA.
SOME PATIENTS WITH HYPERTENSION HAVE
INADEQUATE CONTROL OF BLOOD PRESSURE BECAUSE
THEY ARE NOT CONSISTENTLY ADHERENT IN TAKING
THEIR MEDICATIONS. BUT HELP MAY BE ON THE WAY IN
THE FORM OF A VACCINE THAT LOWERS BLOOD
PRESSURE BY CONTROLLING ANGIOTENSIN II, SUGGEST
FINDINGS FROM A SMALL SAFETY STUDY PRESENTED AT
THE SCIENTIFIC SESSIONS OF THE AMERICAN HEART
ASSOCIATION IN NOVEMBER. THE STUDY OF 72 PATIENTS
WITH MILD-TO-MODERATE HYPERTENSION PRESENTED
BY JURG NUSSBERGER, MD, PROFESSOR OF MEDICINE AT
THE UNIVERSITY HOSPITAL OF THE CANTON OF
VAUD, LAUSANNE, SWITZERLAND, FOUND THAT AT 14
WEEKS, THOSE INJECTED WITH CYTOO6-ANGQB (AT 0, 4
AND 12 WEEKS) HAD A SYSTOLIC BLOOD PRESSURE THAT
WAS 5.6 MM HG LOWER AND A DIASTOLIC BLOOD
PRESSURE 2.8 MM HG LOWER THAN THOSE OF PATIENTS
WHO RECEIVED PLACEBO.

CYTOO6-ANGQB, WHICH IS UNDER
DEVELOPMENT BY CYTOS BIOTECHNOLOGY AG
(ZURICH, SWITZERLAND), IS A VIRUS-SHAPED
NONINFECTIOUS PARTICLE THAT IS COUPLED
WITH ANGIOTENSIN II, AN OCTAPEPTIDE
VASOCONSTRICTOR. SUCH COUPLING INDUCES
THE BODY TO PRODUCE ANTIBODIES AGAINST
THIS SMALL MOLECULE TO MINIMIZE ITS EFFECTS
ON CONSTRICTING BLOOD VESSELS. NUSSBERGER
SAID HE IS NOT CONCERNED THAT THE VACCINE
MIGHT CAUSE HYPOTENSION BECAUSE ANTIBODY
TITERS STARTED TO DECREASE SHORTLY AFTER
THE BOOSTER OF TWELVE WEEKS INDUCED PEAK
ANTIBODY LEVELS. HE ALSO SAID THE
LIKELIHOOD OF VACCINE-INDUCED ANTIBODIES
CROSS-REACTING WITH OTHER PROTEINS WAS
MINIMAL BECAUSE THE SMALL SIZE OF THE
TARGET MOLECULE LIMITS THE NUMBER OF
EPITOPES THAT COULD BE AFFECTED.

NUSSBERGER SPECULATED THAT IF THE CYTOO6-ANGQB
VACCINE IS ULTIMATELY APPROVED, PATIENTS WOULD BE
ABLE TO AVOID THE NEED FOR MEDICATION BUT WOULD
REQUIRE A BOOSTER SHOT 2 0R 3 TIMES A YEAR. HE SAID
THE NEXT STEP IN STUDYING THE VACCINE WILL BE TO
CONDUCT ANOTHER SMALL TRIAL TO DETERMINE THE
APPROPRIATE DOSING TO CREATE THE LARGEST ANTIBODY
RESPONSE AND GREATEST REDUCTIONS IN BLOOD
PRESSURE. MORRIS J. BROWN, MD, PROFESSOR OF CLINICAL
PHARMACOLOGY AT THE UNIVERSITY OF CAMBRIGE IN
ENGLAND AND PAST PRESIDENT OF THE BRITISH
HYPERTENSION SOCIETY, SAID THE FINDINGS OF THE
STUDY (WHICH WAS FUNDED BY CYTOS) ARE “INTRIGUING”
BUT OFFERED A CAVEAT. “I AM A LITTLE WARY OF TOP-LINE
RESULTS FROM BIOTECHS, ESPECIALLY SECONDARY
EFFICACY VARIABLES IN A PRIMARY SAFETY STUDY,” HE SAID.
BROWN HAS ALSO HAD A HAND IN ATTEMPTS TO CREATE A
HYPERTENSION VACCINE, PMD3117, UNDER DEVELOPMENT
BY PROTHERICS PLC IN RUNCORN, ENGLAND (BROWN MJ ET
AL. CLIN SCI).

 31 ABOUT PATIENTS WHO DO NOT TAKE THEIR TREATMENT
REGULARY:
 A THESE PATIENTS HAVE AN ADEQUATE CONTROL OF
BLOOD PRESSURE.
 B THEY ARE CONSISTENTLY ADHERENT IN TAKING THEIR
MEDICATIONS.
 C THEY MUST HAVE A REGULAR DIET CONTROL.
 D THEY HAVE AN INADEQUATE CONTROL OF BLOOD
PRESSURE.
 32 ABOUT THE WORKING MECHANISM OF THE VACCINE:
 A ITS WORKING MECHANISM IS BY CONTROLLING
ANGIOTENSIN I.
 B ITS WORKING MECHANISM IS BY CONTROLLING
ANGIOTENSIN II.
 C ITS WORKING MECHANISM IS BY CONSTRICTING BLOOD
VESSELS.
 D IT INDUCES ANTIBODIES CROSS-REACTING WITH OTHER
PROTEINS.

 33 WITH RESPECT TO THE CYT006-ANGQB
VACCINE, CONSIDERATIONS HAVE BEEN MADE THAT:
 A THE VACCINE MAY PRODUCE HYPERTENSION.
 B THE VACCINE DOES NOT INDUCE ANTIBODIES
CROSS-REACTING WITH PROTEINS.
 C THE VACCINE MAY CAUSE HYPOTENSION.
 D THE VACCINE MIGHT CAUSE IMPOTENCY.
 34 WHAT IS THE REASON OF THE REDUCED NUMBER
OF AFFECTED EPITOPES ?
 A BECAUSE OF THE SMALL SIZE OF THE EPITOPES.
 B BECAUSE OF THE SMALL SIZE OF THE TARGET
MOLECULE.
 C BECAUSE ANTIBODY TITERS STARTED TO DECREASE.
 D THE NUMBER OF EPITOPES WAS NEVER AFFECTED.

35 WHAT SHALL BE DONE TO DETERMINE THE
LARGEST ANTIBODY RESPONSE AND GREATEST
REDUCTIONS IN BLOOD PRESSURE?
A A SMALL TRIAL TO DETERMINE THE RIGHT
DOSING HAD TO BE CONDUCTED.
B A BOOSTER SHOT 2 OR 3 TIMES A YEAR.
C ANGIOTENSIN II AND OCTAPEPTIDE
VASOCONSTRICTOR INDUCE THE BODY TO
PRODUCE ANTIBODIES.
D ANGIOTENSIN II WOULD ALONE REGULATE THE
BLOOD PRESSURE.

31. D
32. B
33. C (B?)
34. B
35. A

 31. Some patients with hypertension
have inadequate control of their blood
pressure because they are not
consistently adherent in taking their
medications.
 32. But help may be on the way in the
form of a vaccine that lowers blood
pressure by controlling angiotensin
II, …

 33. Nussberger said he is not concerned
that the vaccine might cause
hypotension because antibody titers
started to decrease shortly after the
booster of twelve weeks induced peak
antibody levels. He also said the
likelihood of vaccine-induced
antibodies cross-reacting with other
proteins was minimal because …

 3 4. … the small size of the target molecule
limits the number of epitopes that could be
affected.
 35. He said the next step in studying the
vaccine will be to conduct another small
trial to determine the appropriate dosing to
create the largest antibody response and
greatest reductions in blood pressure.

 A booster/ to boost, a boost/ a booster shot

 A booster/ to boost, a boost/ a booster
shot

 Adherent=compliant
 Adherence=compliance
 To adhere=to comply

WILLIAM THOMAS GREEN MORTON ON OCTOBER 16, 1846, DEMONSTRATED THAT ETHER COULD INDUCE
INSENSIBILITY TO THE SURGEON’S KNIFE. A JAW TUMOR WAS REMOVED FROM GILBERT ABBOT BY JOHN
COLLINS WARREN AT THE MASSACHUSETTS GENERAL HOSPITAL IN FRONT OF AN AUDIENCE OF MEDICAL
PROFESSIONALS. THE NEWS OF THIS PUBLIC DEMONSTRATION TRAVELED QUICKLY, GIVEN THE NATURE OF
COMMUNICATION IN THE 184Os. ON DECEMBER 16, 1846, THE INFORMATION IN THE FORM OF A LETTER
ARRIVED IN LONDON. ON DECEMBER 19, THE FIRST ETHER ANESTHETIC WAS GIVEN IN THE UNITED
KINGDOM FOR THE REMOVAL OF A TOOTH. ON DECEMBER 21, THE FAMOUS SURGEON ROBERT LISTON
AMPUTATED THE LEG OF A BUTLER, AND UTTERED THE FAMOUS WORDS, “THIS YANKEE DODGE BEATS
MESMERISM HOLLOW.” JAMES YOUNG SIMPSON, THE PROFESSOR OF MIDWIFERY IN
EDINBURGH, SCOTLAND, WAS AMONG THE FIRST TO USE ETHER FOR THE RELIEF OF LABOR PAIN. ON
JANUARY 19, 1847, HE USED ETHER TO AMELIORATE THE PAIN OF LABOR. THIS FIRST CASE, THAT OF A
YOUNG WOMAN WITH RICKETS AND SEVERELY DEFORMED PELVIS, WAS AT GRAVE RISK OF DYING AND
THERE WAS NO HOPE FOR A LIVE BIRTH. BY USING ETHER, THE MOTHER SURVIVED THE COMPLICATED
DELIVERY PAIN-FREE. THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’S PHYSICIAN IN
SCOTLAND. SIMPSON CONTINUED TO PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATED
AND NORMAL DELIVERIES; HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITH ETHER AND SOUGHT A
MORE PLEASANT, RAPID-ACTING ANESTHETIC. AT THE SUGGESTION OF DAVID WALDIE, HE EXPERIMENTED
WITH CHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN 1831. ON THE EVENING OF NOVEMBER
4, 1847, SIMPSON AND HIS FRIENDS INHALED IT AFTER DINNER AT A PARTY IN SIMPSON’S HOME. THEY
PROMPTLY FELL UNCONSCIOUS AND, WHEN THEY AWOKE UNDER THE TABLE AND CLEARLY OFF THEIR
DINING ROOM CHAIRS, WERE DELIGHTED WITH THEIR SUCCESS. WITHIN 2 WEEKS, SIMPSON SUBMITTED
HIS FIRST ACCOUNT OF THE CHLOROFORM’S USE TO THE LANCET. IN THE NINETEENTH CENTURY, THE
RELIEF OF OBSTETRIC PAIN HAD SIGNIFICANT SOCIAL AND RELIGIOUS CONSEQUENCES, WHICH MADE
ANESTHESIA DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THE BATTLE CENTERED ON WHETHER
RELIEVING LABOR PAIN WAS CONTRARY TO GOD’S WILL. THE PAIN ASSOCIATED WITH CHILDBIRTH WAS
BELIEVED TO BE A DEVINE PUNISHMENT FOR ORIGINAL SIN. SHORTLY AFTER GIVING HIS FIRST
OBSTERTRIC ANESTHETICS, SIMPSON PUBLISHED A PAMPHLET ENTITLED “ANSWERS TO THE RELIGIOUS
OBJECTIONS ADVANCED AGAINST THE EMPLOYMENT OF ANESTHETIC AGENTS IN
MIDWIFERY, SURGERY, AND OBSTETRICS,” WHICH ARGUED AGAINST THESE RELIGIOUS PROHIBITIONS.

WILLIAM THOMAS GREEN MORTON ON OCTOBER
16, 1846, DEMONSTRATED THAT ETHER COULD INDUCE
INSENSIBILITY TO THE SURGEON’S KNIFE. A JAW TUMOR WAS
REMOVED FROM GILBERT ABBOT BY JOHN COLLINS WARREN AT
THE MASSACHUSETTS GENERAL HOSPITAL IN FRONT OF AN
AUDIENCE OF MEDICAL PROFESSIONALS. THE NEWS OF THIS
PUBLIC DEMONSTRATION TRAVELED QUICKLY, GIVEN THE NATURE
OF COMMUNICATION IN THE 184Os. ON DECEMBER 16, 1846, THE
INFORMATION IN THE FORM OF A LETTER ARRIVED IN LONDON.
ON DECEMBER 19, THE FIRST ETHER ANESTHETIC WAS GIVEN IN
THE UNITED KINGDOM FOR THE REMOVAL OF A TOOTH. ON
DECEMBER 21, THE FAMOUS SURGEON ROBERT LISTON
AMPUTATED THE LEG OF A BUTLER, AND UTTERED THE FAMOUS
WORDS, “THIS YANKEE DODGE BEATS MESMERISM HOLLOW.”
JAMES YOUNG SIMPSON, THE PROFESSOR OF MIDWIFERY IN
EDINBURGH, SCOTLAND, WAS AMONG THE FIRST TO USE ETHER
FOR THE RELIEF OF LABOR PAIN. ON JANUARY 19, 1847, HE USED
ETHER TO AMELIORATE THE PAIN OF LABOR. THIS FIRST
CASE, THAT OF A YOUNG WOMAN WITH RICKETS AND SEVERELY
DEFORMED PELVIS, WAS AT GRAVE RISK OF DYING AND THERE WAS
NO HOPE FOR A LIVE BIRTH. BY USING ETHER, THE MOTHER
SURVIVED THE COMPLICATED DELIVERY PAIN-FREE.

THAT SAME JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’S
PHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TO PROVIDE
ANESTHESIA IN CHILDBIRTH FOR BOTH COMPLICATED AND NORMAL
DELIVERIES; HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITH
ETHER AND SOUGHT A MORE PLEASANT, RAPID-ACTING ANESTHETIC.
AT THE SUGGESTION OF DAVID WALDIE, HE EXPERIMENTED WITH
CHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN 1831. ON THE
EVENING OF NOVEMBER 4, 1847, SIMPSON AND HIS FRIENDS INHALED
IT AFTER DINNER AT A PARTY IN SIMPSON’S HOME. THEY PROMPTLY
FELL UNCONSCIOUS AND, WHEN THEY AWOKE UNDER THE TABLE AND
CLEARLY OFF THEIR DINING ROOM CHAIRS, WERE DELIGHTED WITH
THEIR SUCCESS. WITHIN 2 WEEKS, SIMPSON SUBMITTED HIS FIRST
ACCOUNT OF THE CHLOROFORM’S USE TO THE LANCET. IN THE
NINETEENTH CENTURY, THE RELIEF OF OBSTETRIC PAIN HAD
SIGNIFICANT SOCIAL AND RELIGIOUS CONSEQUENCES, WHICH MADE
ANESTHESIA DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THE
BATTLE CENTERED ON WHETHER RELIEVING LABOR PAIN WAS
CONTRARY TO GOD’S WILL. THE PAIN ASSOCIATED WITH CHILDBIRTH
WAS BELIEVED TO BE A DEVINE PUNISHMENT FOR ORIGINAL SIN.
SHORTLY AFTER GIVING HIS FIRST OBSTERTRIC
ANESTHETICS, SIMPSON PUBLISHED A PAMPHLET ENTITLED “ANSWERS
TO THE RELIGIOUS OBJECTIONS ADVANCED AGAINST THE
EMPLOYMENT OF ANESTHETIC AGENTS IN MIDWIFERY, SURGERY, AND
OBSTETRICS,” WHICH ARGUED AGAINST THESE RELIGIOUS

WILLIAM THOMAS GREEN MORTON ON OCTOBER
16, 1846, DEMONSTRATED THAT ETHER COULD
INDUCE INSENSIBILITY TO THE SURGEON’S KNIFE. A
JAW TUMOR WAS REMOVED FROM GILBERT ABBOT
BY JOHN COLLINS WARREN AT THE MASSACHUSETTS
GENERAL HOSPITAL IN FRONT OF AN AUDIENCE OF
MEDICAL PROFESSIONALS. THE NEWS OF THIS
PUBLIC DEMONSTRATION TRAVELED
QUICKLY, GIVEN THE NATURE OF COMMUNICATION
IN THE 184Os. ON DECEMBER 16, 1846, THE
INFORMATION IN THE FORM OF A LETTER ARRIVED
IN LONDON. ON DECEMBER 19, THE FIRST ETHER
ANESTHETIC WAS GIVEN IN THE UNITED KINGDOM
FOR THE REMOVAL OF A TOOTH. ON DECEMBER
21, THE FAMOUS SURGEON ROBERT LISTON
AMPUTATED THE LEG OF A BUTLER, AND UTTERED
THE FAMOUS WORDS, “THIS YANKEE DODGE BEATS
MESMERISM HOLLOW.”

JAMES YOUNG SIMPSON, THE PROFESSOR OF
MIDWIFERY IN EDINBURGH, SCOTLAND, WAS AMONG
THE FIRST TO USE ETHER FOR THE RELIEF OF LABOR
PAIN. ON JANUARY 19, 1847, HE USED ETHER TO
AMELIORATE THE PAIN OF LABOR. THIS FIRST
CASE, THAT OF A YOUNG WOMAN WITH RICKETS AND
SEVERELY DEFORMED PELVIS, WAS AT GRAVE RISK OF
DYING AND THERE WAS NO HOPE FOR A LIVE BIRTH. BY
USING ETHER, THE MOTHER SURVIVED THE
COMPLICATED DELIVERY PAIN-FREE. THAT SAME
JANUARY DAY, SIMPSON WAS APPOINTED THE QUEEN’S
PHYSICIAN IN SCOTLAND. SIMPSON CONTINUED TO
PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH
COMPLICATED AND NORMAL DELIVERIES;
HOWEVER, HE RAPIDLY BECAME DISSATISFIED WITH
ETHER AND SOUGHT A MORE PLEASANT, RAPID-ACTING
ANESTHETIC. AT THE SUGGESTION OF DAVID
WALDIE, HE EXPERIMENTED WITH
CHLOROFORM, WHICH HAD FIRST BEEN PREPARED IN

ON THE EVENING OF NOVEMBER 4, 1847, SIMPSON AND HIS
FRIENDS INHALED IT AFTER DINNER AT A PARTY IN
SIMPSON’S HOME. THEY PROMPTLY FELL UNCONSCIOUS
AND, WHEN THEY AWOKE UNDER THE TABLE AND CLEARLY
OFF THEIR DINING ROOM CHAIRS, WERE DELIGHTED
WITH THEIR SUCCESS. WITHIN 2 WEEKS, SIMPSON
SUBMITTED HIS FIRST ACCOUNT OF THE CHLOROFORM’S
USE TO THE LANCET. IN THE NINETEENTH CENTURY, THE
RELIEF OF OBSTETRIC PAIN HAD SIGNIFICANT SOCIAL AND
RELIGIOUS CONSEQUENCES, WHICH MADE ANESTHESIA
DURING CHILDBIRTH A CONTENTIOUS SUBJECT. THE
BATTLE CENTERED ON WHETHER RELIEVING LABOR PAIN
WAS CONTRARY TO GOD’S WILL. THE PAIN ASSOCIATED
WITH CHILDBIRTH WAS BELIEVED TO BE A DEVINE
PUNISHMENT FOR ORIGINAL SIN. SHORTLY AFTER GIVING
HIS FIRST OBSTERTRIC ANESTHETICS, SIMPSON
PUBLISHED A PAMPHLET ENTITLED “ANSWERS TO THE
RELIGIOUS OBJECTIONS ADVANCED AGAINST THE
EMPLOYMENT OF ANESTHETIC AGENTS IN
MIDWIFERY, SURGERY, AND OBSTETRICS,” WHICH ARGUED
AGAINST THESE RELIGIOUS PROHIBITIONS.

 36. WILLIAM THOMAS GREEN MORTON USED
 A ETHER ON A PATIENT SO THERE WOULD BE NO
SENSIBILITY IN THE OPERATION.
 B ETHER ON A PATIENT TO REDUCE THE SENSIBILITY
DURING THE OPERATION
 C ETHER TO DISINFECT THE KNIFE IN THE
OPERATION AND OTHER OPERATING EQUIPMENT
 D ETHER INSTEAD OF AN ANESTHETIC.
 37. JAMES YOUNG SIMPSON WAS THE FIRST TO USE
ETHER FOR
 A CURING A PATIENT WHO HAD RICKETS
 B REDUCING THE LABOR PAIN OF A WOMAN WHEN
GIVING BIRTH WITH A DEFORMED PELVIS
 C REDUCING THE PAIN OF SURGERY
 D SAVING THE NEWBORN FROM DYING IN
CHILDBIRTH

 38. SIMPSON PREFERRED TO CONTINUE
 A USING ETHER FOR CHILDBIRTH
 B USING ETHER AND CHLOROFORM FOR CHILDBIRTH
 C TO ONLY USE CHLOROFORM FOR CHILDBIRTH
 D PROVIDE ANESTHESIA IN CHILDBIRTH FOR BOTH
COMPLICATED AND NORMAL DELIVERIES
 39. IT IS EVIDENT THAT THIS NEW PRACTICE OF USING
ANESTHESIA IN CHILDBIRTH HAD SOCIAL AND RELIGIOUS
CONSEQUENCES
 A SIMPSON WAS IN FAVOR OF RELIGIOUS BELIEFS IN
CHILDBIRTH PRACTICE
 B SIMPSON WAS IN FAVOR OF SOCIAL BELIEFS ABOUT
CHILDBIRTH PRACTICE
 C SIMPSON WAS AGAINST RELIGIOUS BELIEFS IN
CHILDBIRTH PRACTICE
 D SIMPSON WAS AGAINST THESE RELIGIOUS
PROHIBITIONS

40. THE PAIN ASSOCIATED WITH CHILDBIRTH WAS
BELIEVED TO BE CAUSED AS
A A CONSEQUENCE OF A DEFORMED PELVIS.
B A DEVINE PUNISHMENT FOR ORIGINAL SIN.
C BECAUSE OF LACK OF ANESTHETICS.
D AN OVERSIZED PRODUCT.

 36. William Thomas Green Morton on
October 16, 1846, demonstrated that ether
could induce insensibility to the surgeon’s
knife.
 37. James Young Simpson, the professor of
midwifery in Edinburgh, Scotland, was
among the first to use ether for the relief of
labor pain.
 38. Simpson continued to provide
anesthesia in deliveries for both
complicated and normal deliveries.

 39. ,… Simpson published a pamphlet entitled
“Answers to the Religious Objections Advanced
against the Employment of Anesthetic Agents
in Midwifery and Surgery and Obstetrics,”
which argued against these religious
prohibitions.
 40. The pain associated with childbirth was
believed to be a devine punishment for original
sin.
 Midwifery/midwife
 delivery=childbirth

A 71-YEAR-OLD MAN PRESENTED WITH A 2-WEEK HISTORY OF PAIN AND
SWELLING OF HIS LEFT ARM. EXAMINATION REVEALED A
CRAGGY, MOBILE MASS WITH IRREGULAR BORDERS IN THE EXTENSOR
COMPARTMENT OF THE LEFT ARM MEASURING 6 × 4 CM.
ULTRASONOGRAPHY OF THE LEFT ARM DEMONSTRATED THE PRESENCE
OF DEEP OVOID HYPERECHOIC MASS LOCATED IN THE LONG AXIS OF
THE LEFT TRICEPS MUSCLE, MEASURING 5 × 3 CM. THIS LED TO FURTHER
RADIOLOGIC EVALUATION IN THE FORM OF MRI OF THE LEFT ARM. MRI
SHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPS MUSCULATURE
ON T1-WEIGHTED IMAGES WITH FAT SATURATION. THIS LESION IS
CONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. A
PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA WAS MADE. AN
INCISIONAL BIOPSY WAS PERFORMED. THIS WAS FOUND TO BE
CONSISTENT WITH METASTATIC SQUAMOUS CELL CARCINOMA WITH A
POSSIBLE LUNG PRIMARY, FURTHER SUPPORTED DUE TO A POSITIVE
CK7 AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY. CT SCAN
OF THE CHEST REVEALED A LESION MEASURING 4 × 2 CM IN THE LEFT
UPPER LOBE. FIBER-OPTIC BRONCHOSCOPY AND BIOPSY CONFIRMED
THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL CARCINOMA OF THE
LUNG. HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THE MASS IN
THE ARM, 20 GY IN 4 FRACTIONS. THIS PROVIDED GOOD RELIEF FROM
PAIN AND SWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT.

SYSTEMIC THERAPY WAS NOT OFFERED ON THE BASIS OF POOR AND
DETERIORATING PERFORMANCE STATUS. UNFORTUNATELY, THE
PATIENT DIED WITHIN 10 WEEKS OF PRESENTATION. INTRAMUSCULAR
METASTASES IN CANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITE
PECULIAR BECAUSE MUSCULAR MASS ACCOUNTS FOR APPROXIMATELY
50% OF TOTAL BODY WEIGHT. IT IS THOUGHT THAT MUSCULAR
CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, AND ACCUMULATION
OF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO THE RARE
OCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OF
MUSCULAR METASTASIS REMAINS UNKNOWN, BUT AN AUTOPSY SERIES
SUGGESTS THAT ITS INCIDENCE COULD BE AS LOW AS 0.8%. LUNG
CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOST
OF THESE CASES. MANY OTHER TUMORS, SUCH AS
KIDNEY, STOMACH, PANCREAS, THYROID
GLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE ALSO
BEEN SPORADICALLY DESCRIBED IN ASSOCIATION WITH
INTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARY PRESENTATION
OF AN INTRAMUSCULAR METASTASIS, SUCH AS DEMONSTRATED BY OUR
PATIENT, REMAINS AN EXCEPTIONALLY UNUSUAL OCCURRENCE. THE
MOST FREQUENT PRESENTATION OF MUSCULAR METASTASIS IS PAIN
WITH OR WITHOUT SWELLING. DIAGNOSIS, EVEN WITH RADIOLOGIC
IMAGING IS OFTEN TRICKY BECAUSE IT CAN BE CONFUSED WITH AN
ABSCESS OR SOFT TISSUE TUMORS.

A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORY OF A
HARD, PAINFUL, NONPULSATILE MASS IN HIS LEFT UPPER ARM. EXAMINATION REVEALED A
CRAGGY, MOBILE MASS OF IRREGULAR BORDERS IN THE LEFT ARM MEASURING 6 × 4 CM.
ULTRASONOGRAPHY OF THE LEFT ARM DEMONSTRATED A DEEP OVOID HYPERECHOIC MASS
LOCATED IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE. MRI SHOWED INTERMEDIATE
SIGNAL MASS IN THE TRICEPS MUSCULATURE ON T1-WEIGHTED IMAGES WITH FAT
SATURATION. THIS LESION WAS CONFINED TO THE EXTENSOR COMPARTMENT OF THE ARM. A
PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE SARCOMA WAS CONSIDERED. AN INCISIONAL BIOPSY
REPORTED METASTATIC SQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNG
PRIMARY, FURTHER SUPPORTED DUE TO A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON
IMMUNOHISTOCHEMISTRY. CT SCAN OF THE CHEST REVEALED A LEFT UPPER LOBE LESION
MEASURING 4 × 2 CM. FIBER-OPTIC BRONCHOSCOPY AND BIOPSY CONFIRMED THE DIAGNOSIS
OF STAGE IV SQUAMOUS CELL LUNG CARCINOMA. HE UNDERWENT PALLIATIVE
RADIOTHERAPY TO THE MASS IN THE ARM. THIS PROVIDED GOOD RELIEF FROM PAIN AND
SWELLING WITHIN 2 WEEKS OF COMPLETING TREATMENT. SYSTEMIC THERAPY WAS NOT
OFFERED ON THE BASIS OF POOR AND DETERIORATING PERFORMANCE STATUS.
UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKS OF PRESENTATION. INTRAMUSCULAR
METASTASES IN CANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITE PECULIAR BECAUSE
MUSCULAR MASS ACCOUNTS FOR APPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT IS
THOUGHT THAT MUSCULAR CONTRACTILE ACTIONS, LOCAL PH ENVIRONMENT, AND
ACCUMULATION OF LACTIC ACID AND OTHER METABOLITES CONTRIBUTE TO THE RARE
OCCURRENCE OF THIS PHENOMENON. THE TRUE INCIDENCE OF MUSCULAR METASTASIS
REMAINS UNKNOWN, BUT AN AUTOPSY SERIES SUGGESTS THAT ITS INCIDENCE COULD BE AS
LOW AS 0.8%. LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY CANCER IN MOST OF
THESE CASES. MANY OTHER TUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROID
GLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS HAVE BEEN SPORADICALLY
DESCRIBED IN ASSOCIATION WITH INTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARY
PRESENTATION OF AN INTRAMUSCULAR METASTASIS, SUCH AS DEMONSTRATED BY OUR
PATIENT, REMAINS AN EXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOST FREQUENT
PRESENTATION OF MUSCULAR METASTASIS IS PAIN WITH OR WITHOUT SWELLING. DIAGNOSIS
OF THIS CONDITION, EVEN WITH RADIOLOGIC IMAGING IS OFTEN TRICKY BECAUSE IT CAN BE
CONFUSED WITH AN ABSCESS OR SOFT TISSUE TUMORS, HIGHLIGHTING THE VALUE OF
HISTOLOGIC DIAGNOSIS. TREATMENT IN THE FORM OF RADIOTHERAPY, CHEMOTHERAPY, OR
EVEN METASTASECTOMY OFTEN PROVIDES PALLIATION ONLY. MOST PATIENTS DIE IN LESS
THAN A YEAR FROM DIAGNOSIS.

A 71-YEAR-OLD MALE PRESENTED WITH A 2-WEEK HISTORY
OF A HARD, PAINFUL, NONPULSATILE MASS IN HIS LEFT
UPPER ARM. EXAMINATION REVEALED A CRAGGY, MOBILE
MASS OF IRREGULAR BORDERS IN THE LEFT ARM
MEASURING 6 × 4 CM. ULTRASONOGRAPHY OF THE LEFT
ARM DEMONSTRATED A DEEP OVOID HYPERECHOIC MASS
LOCATED IN THE LONG AXIS OF THE LEFT TRICEPS MUSCLE.
MRI SHOWED INTERMEDIATE SIGNAL MASS IN THE TRICEPS
MUSCULATURE ON T1-WEIGHTED IMAGES WITH FAT
SATURATION. THIS LESION WAS CONFINED TO THE
EXTENSOR COMPARTMENT OF THE ARM. A PRESUMPTIVE
DIAGNOSIS OF SOFT TISSUE SARCOMA WAS CONSIDERED.
AN INCISIONAL BIOPSY REPORTED METASTATIC
SQUAMOUS CELL CARCINOMA WITH A POSSIBLE LUNG
PRIMARY, FURTHER SUPPORTED DUE TO A POSITIVE CK7
AND NEGATIVE CK20 STAIN ON IMMUNOHISTOCHEMISTRY.
CT SCAN OF THE CHEST REVEALED A LEFT UPPER LOBE
LESION MEASURING 4 × 2 CM. FIBER-OPTIC
BRONCHOSCOPY AND BIOPSY CONFIRMED THE DIAGNOSIS
OF STAGE IV SQUAMOUS CELL LUNG CARCINOMA.

HE UNDERWENT PALLIATIVE RADIOTHERAPY TO THE
MASS IN THE ARM. THIS PROVIDED GOOD RELIEF FROM
PAIN AND SWELLING WITHIN 2 WEEKS OF
COMPLETING TREATMENT. SYSTEMIC THERAPY WAS
NOT OFFERED ON THE BASIS OF POOR AND
DETERIORATING PERFORMANCE STATUS.
UNFORTUNATELY, THE PATIENT DIED WITHIN 10 WEEKS
OF PRESENTATION. INTRAMUSCULAR METASTASES IN
CANCER PATIENTS ARE RARE. THIS IN ITSELF IS QUITE
PECULIAR BECAUSE MUSCULAR MASS ACCOUNTS FOR
APPROXIMATELY 50% OF TOTAL BODY WEIGHT. IT IS
THOUGHT THAT MUSCULAR CONTRACTILE
ACTIONS, LOCAL PH ENVIRONMENT, AND
ACCUMULATION OF LACTIC ACID AND OTHER
METABOLITES CONTRIBUTE TO THE RARE
OCCURRENCE OF THIS PHENOMENON. THE TRUE
INCIDENCE OF MUSCULAR METASTASIS REMAINS
UNKNOWN, BUT AN AUTOPSY SERIES SUGGESTS THAT
ITS INCIDENCE COULD BE AS LOW AS 0.8%

LUNG CARCINOMA SEEMS TO BE THE UNDERLYING PRIMARY
CANCER IN MOST OF THESE CASES. MANY OTHER
TUMORS, SUCH AS KIDNEY, STOMACH, PANCREAS, THYROID
GLAND, BREAST, OVARY, PROSTATE, AND BLADDER CANCERS
HAVE BEEN SPORADICALLY DESCRIBED IN ASSOCIATION
WITH INTRAMUSCULAR SECONDARIES. HOWEVER, PRIMARY
PRESENTATION OF AN INTRAMUSCULAR METASTASIS, SUCH
AS DEMONSTRATED BY OUR PATIENT, REMAINS AN
EXCEPTIONALLY UNUSUAL OCCURRENCE. THE MOST
FREQUENT PRESENTATION OF MUSCULAR METASTASIS IS
PAIN WITH OR WITHOUT SWELLING. DIAGNOSIS OF THIS
CONDITION, EVEN WITH RADIOLOGIC IMAGING IS OFTEN
TRICKY BECAUSE IT CAN BE CONFUSED WITH AN ABSCESS
OR SOFT TISSUE TUMORS, HIGHLIGHTING THE VALUE OF
HISTOLOGIC DIAGNOSIS. TREATMENT IN THE FORM OF
RADIOTHERAPY, CHEMOTHERAPY, OR EVEN
METASTASECTOMY OFTEN PROVIDES PALLIATION ONLY.
MOST PATIENTS DIE IN LESS THAN A YEAR FROM
DIAGNOSIS.

 41. BASED ON THE CLINICAL AND THE DIVERSE
IMAGING STUDY’S FINDINGS, WHICH OF THE
FOLLOWING WAS THE PRESUMPTIVE DIAGNOSIS
OF THE ATTENDING MEDICAL TEAM?
 A A DEEP OVOID MASS LOCATED IN THE LEFT
TRICEPS MUSCLE CONSIDERED A PROBABLE
STAPHYLOCOCCUS AUREUS ABSCESS.
 B A MASS OF FAT SATURATION OBSERVED ON MRI
ON T1-WEIGHTED IMAGES.
 C A PRESUMPTIVE DIAGNOSIS OF SOFT TISSUE
SARCOMA LOCATED IN THE LEFT TRICEPS MUSCLE.
 D A DIAGNOSIS OF METASTATIC SQUAMOUS CELL
CARCINOMA, WITH A POSSIBLE PRIMARY OF THE
LUNG.

 42. THE PATIENT WAS SUBMITTED TO PALLIATIVE
CARE AND NON SYSTEMIC THERAPY BASED ON WHAT
REASON?
 A A POSITIVE CK7 AND NEGATIVE CK20 STAIN ON
IMMUNOHISTOCHEMISTRY IS OF POOR PROGNOSIS.
 B THE DIAGNOSIS OF STAGE IV SQUAMOUS CELL
LUNG CARCINOMA WAS NOT CONFIRMED ON FIBER-
OPTIC BRONCHOSCOPY.
 C HE ONLY UNDERWENT PALLIATIVE RADIOTHERAPY
BECAUSE OF COST-BENEFIT REASONS.
 D BASED ON A POOR AND DETERIORATING
PERFORMANCE STATUS SYSTEMIC THERAPY WAS
DEFERRED FOR QUALITY OF LIFE PALLIATIVE
THERAPY.

 43. WHICH OF THE FOLLOWING IS NOT
DESCRIBED IN THE PRESENT ARTICLE AS A
FACTOR THAT CONTRIBUTES TO THE RARE
OCCURRENCE OF INTRAMUSCULAR
METASTASES?
 A THE MUSCULAR MASS ACCOUNTS FOR
APPROXIMATELY 50% OF TOTAL BODY
WEIGHT.
 B MUSCULAR CONTRACTILE ACTIONS.
 C LOCAL PH ENVIRONMENT.
 D ACCUMULATION OF LACTIC ACID AND
OTHER METABOLITES.

 44. WHICH IS THE PRIMARY UNDERLYING CANCER IN
MOST CASES OF INTRAMUSCULAR METASTASES?
 A LUNG CARCINOMA.
 B KIDNEY AND BLADDER CANCER.
 C STOMACH AND PANCREATIC CARCINOMA.
 D BREAST AND OVARIAN CANCER.
45. THE MOST FREQUENT PRESENTATION OF
INTRAMUSCULAR METASTASES SEEN IS?
A PRESENTATION OF THE AFFECTED SITE WITH
PAIN, WITH OR WITHOUT SWELLING.
B THROMBOSIS OF THE AFFECTED EXTREMITY.
C FEVER AND SEPSIS.
D USUALLY INDOLENT AND ONLY FOUND AT AUTOPSY

41. C
42. D
43. A
44. A
45. A

Craggy: riscoso, escarpado

 41. Ultrasonography of the left arm
demonstrated … a mass … located in …
the left triceps muscle. A presumptive
diagnosis of soft tissue sarcoma was
made.
 42. Systemic therapy was not offered on
the basis of poor and deteriorating
performance status.

 43. Intramuscular metastases in cancer
patients are rare. It is thought that
muscular contractile functions, local
pH environment, and accumulation of
lactic acid and other metabolites
contribute to the rare occurrence of
this phenomenon.

 44. Lung carcinoma seems to be the
underlying primary cancer in most of
these cases.
 45. The most frequent presentation of
muscular metastasis is pain, with or
without swelling.

MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NO
LONG-TERM CONSEQUENCES. HOWEVER, RECENT STUDIES SUGGEST
THAT MIGRAINE ATTACKS MAY BE ASSOCIATED WITH PATHOLOGICAL
CHANGES IN THE BRAIN, PARTICULARLY IN THE CEREBELLUM. THE
OBJECTIVE OF THE PRESENT STUDY WAS TO DETERMINE WHETHER
INDIVIDUALS NOT REPORTING HEADACHE COMPARED WITH
INDIVIDUALS REPORTING MIGRAINE SYMPTOMS, PARTICULARLY
AURA, IN MIDLIFE ARE AT INCREASED RISK OF LATE-LIFE INFARCT-LIKE
LESIONS FOUND ON MAGNETIC RESONANCE IMAGING (MRI) WITHOUT
CONSIDERATION OF CLINICAL SYMPTOMS. A POPULATION-BASED STUDY
OF MEN AND WOMEN IN REYKJAVIC, ICELAND (COHORT BORN 1907-1935;
RANGE, N=4689; 57% WOMEN) WERE FOLLOWED UP SINCE
1967, EXAMINED AND INTERVIEWED ABOUT MIGRAINE SYMTPOMS IN
MIDLIFE (MEAN AGE, 51 YEARS; RANGE, 33-65). BETWEEN 2002 AND
2006, MORE THAN 26 YEARS LATER, BRAIN MRIs WERE PERFORMED.
PARTICIPANTS REPORTING HEADACHES ONCE OR MORE PER MONTH
WERE ASKED ABOUT MIGRAINE SYMPTOMS, INCLUDING
NAUSEA, UNILATERAL LOCATION, PHOTOPHOBIA, AND NUMBNESS.
THESE INDIVIDUALS WITH HEADACHE WERE CLASSIFIED AS HAVING
MIGRAINE WITHOUT AURA, MIGRAINE WITH AURA, OR NONMIGRAINE
HEADACHE. A COMPREHENSIVE CARDIOVASCULAR RISK ASSESSMENT
WAS PERFORMED AT BOTH EXAMINATIONS.

THE PRESENCE OF INFARCT-LIKE LESIONS (TOTAL) AND
SPECIFICALLY LOCATED IN THE CORTICAL, SUBCORTICAL, AND
CEREBELLAR REGIONS WERE THE MAIN OUTCOME MEASURE.
INFARCT-LIKE LESIONS WERE PRESENT IN 39.3% OF MEN AND
24.6% OF WOMEN. AFTER ADJUSTING FOR AGE, SEX, AND
FOLLOW-UP TIME, COMPARED WITH THOSE NOT REPORTING
HEADACHES ONCE OR MORE PER MONTH (N=3243), THOSE WITH
MIDLIFE MIGRAINE WITH AURA (N=361) HAD AN INCREASED RISK
OF LATE-LIFE INFARCT-LIKE LESIONS (ADJUSTED ODDS RATIO
OR , 1.4 CONFIDENCE INTERVAL CI , 1.1-I.8) THAT SPECIFICALLY
REFLECTED AN ASSOCIATION WITH CEREBELLAR LESIONS IN
WOMEN (PREVALENCE OF INFARCTS 23.05% FOR WOMEN WITH
MIGRAINE WITH AURA VS 14.5% FOR WOMEN NOT REPORTING
HEADACHES; ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3%
PREVALENCE OF INFARCTS FOR MEN WITH MIGRAINE WITH
AURA VS 21.3% FOR MEN NOT REPORTING HEADACHES; ADJUSTED
OR, 1.0; 95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINE
WITHOUT AURA AND NONMIGRAINE HEADACHE WERE NOT
ASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITH AURA
IN MIDLIFE WAS ASSOCIATED WITH LATE-LIFE CEREBELLAR
INFARCT-LIKE LESIONS ON MRI. THIS ASSOCIATION WAS
STATISTICALLY SIGNIFICANT ONLY FOR WOMEN.

MIGRAINE IS CONSIDERED TO BE AN EPISODIC CONDITION WITH NO LONG-TERM CONSEQUENCES.
HOWEVER, RECENT STUDIES SUGGEST THAT MIGRAINE ATTACKS MAY BE ASSOCIATED WITH
PATHOLOGICAL CHANGES IN THE BRAIN, PARTICULARLY IN THE CEREBELLUM. THE OBJECTIVE OF THE
PRESENT STUDY WAS TO DETERMINE WHETHER INDIVIDUALS NOT REPORTING HEADACHE COMPARED
WITH INDIVIDUALS REPORTING MIGRAINE SYMPTOMS, PARTICULARLY AURA, IN MIDLIFE ARE AT
INCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONS FOUND ON MAGNETIC RESONANCE IMAGING
(MRI) WITHOUT CONSIDERATION OF CLINICAL SYMPTOMS. A POPULATION-BASED STUDY OF MEN
AND WOMEN IN REYKJAVIC, ICELAND (COHORT BORN 1907-1935; RANGE, N=4689; 57% WOMEN) WERE
FOLLOWED UP SINCE 1967, EXAMINED AND INTERVIEWED ABOUT MIGRAINE SYMTPOMS IN MIDLIFE
(MEAN AGE, 51 YEARS; RANGE, 33-65). BETWEEN 2002 AND 2006, MORE THAN 26 YEARS LATER, BRAIN
MRIs WERE PERFORMED. PARTICIPANTS REPORTING HEADACHES ONCE OR MORE PER MONTH WERE
ASKED ABOUT MIGRAINE SYMPTOMS, INCLUDING NAUSEA, UNILATERAL
LOCATION, PHOTOPHOBIA, AND NUMBNESS. THESE INDIVIDUALS WITH HEADACHE WERE CLASSIFIED
AS HAVING MIGRAINE WITHOUT AURA, MIGRAINE WITH AURA, OR NONMIGRAINE HEADACHE. A
COMPREHENSIVE CARDIOVASCULAR RISK ASSESSMENT WAS PERFORMED AT BOTH EXAMINATIONS.
THE PRESENCE OF INFARCT-LIKE LESIONS (TOTAL) AND SPECIFICALLY LOCATED IN THE
CORTICAL, SUBCORTICAL, AND CEREBELLAR REGIONS WERE THE MAIN OUTCOME MEASURE. INFARCT-
LIKE LESIONS WERE PRESENT IN 39.3% OF MEN AND 24.6% OF WOMEN. AFTER ADJUSTING FOR
AGE, SEX, AND FOLLOW-UP TIME, COMPARED WITH THOSE NOT REPORTING HEADACHES ONCE OR
MORE PER MONTH (N=3243), THOSE WITH MIDLIFE MIGRAINE WITH AURA (N=361) HAD AN INCREASED
RISK OF LATE-LIFE INFARCT-LIKE LESIONS (ADJUSTED ODDS RATIO OR , 1.4 CONFIDENCE INTERVAL
CI , 1.1-I.8) THAT SPECIFICALLY REFLECTED AN ASSOCIATION WITH CEREBELLAR LESIONS IN WOMEN
(PREVALENCE OF INFARCTS 23.05% FOR WOMEN WITH MIGRAINE WITH AURA VS 14.5% FOR WOMEN
NOT REPORTING HEADACHES; ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3% PREVALENCE OF INFARCTS
FOR MEN WITH MIGRAINE WITH AURA VS 21.3% FOR MEN NOT REPORTING HEADACHES; ADJUSTED
OR, 1.0; 95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINE WITHOUT AURA AND
NONMIGRAINE HEADACHE WERE NOT ASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITH AURA
IN MIDLIFE WAS ASSOCIATED WITH LATE-LIFE CEREBELLAR INFARCT-LIKE LESIONS ON MRI. THIS
ASSOCIATION WAS STATISTICALLY SIGNIFICANT ONLY FOR WOMEN.

MIGRAINE IS CONSIDERED TO BE AN EPISODIC
CONDITION WITH NO LONG-TERM CONSEQUENCES.
HOWEVER, RECENT STUDIES SUGGEST THAT MIGRAINE
ATTACKS MAY BE ASSOCIATED WITH PATHOLOGICAL
CHANGES IN THE BRAIN, PARTICULARLY IN THE
CEREBELLUM. THE OBJECTIVE OF THE PRESENT STUDY
WAS TO DETERMINE WHETHER INDIVIDUALS NOT
REPORTING HEADACHE COMPARED WITH
INDIVIDUALS REPORTING MIGRAINE
SYMPTOMS, PARTICULARLY AURA, IN MIDLIFE ARE AT
INCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONS
FOUND ON MAGNETIC RESONANCE IMAGING (MRI)
WITHOUT CONSIDERATION OF CLINICAL SYMPTOMS.
A POPULATION-BASED STUDY OF MEN AND WOMEN IN
REYKJAVIC, ICELAND (COHORT BORN 1907-1935;
RANGE, N=4689; 57% WOMEN) WERE FOLLOWED UP
SINCE 1967, EXAMINED AND INTERVIEWED ABOUT
MIGRAINE SYMTPOMS IN MIDLIFE (MEAN AGE, 51
YEARS; RANGE, 33-65).

BETWEEN 2002 AND 2006, MORE THAN 26 YEARS
LATER, BRAIN MRIs WERE PERFORMED.
PARTICIPANTS REPORTING HEADACHES ONCE OR
MORE PER MONTH WERE ASKED ABOUT MIGRAINE
SYMPTOMS, INCLUDING NAUSEA, UNILATERAL
LOCATION, PHOTOPHOBIA, AND NUMBNESS.
THESE INDIVIDUALS WITH HEADACHE WERE
CLASSIFIED AS HAVING MIGRAINE WITHOUT
AURA, MIGRAINE WITH AURA, OR NONMIGRAINE
HEADACHE. A COMPREHENSIVE CARDIOVASCULAR
RISK ASSESSMENT WAS PERFORMED AT BOTH
EXAMINATIONS. THE PRESENCE OF INFARCT-LIKE
LESIONS (TOTAL) AND SPECIFICALLY LOCATED IN
THE CORTICAL, SUBCORTICAL, AND CEREBELLAR
REGIONS WERE THE MAIN OUTCOME MEASURE.
INFARCT-LIKE LESIONS WERE PRESENT IN 39.3% OF
MEN AND 24.6% OF WOMEN.

AFTER ADJUSTING FOR AGE, SEX, AND FOLLOW-UP
TIME, COMPARED WITH THOSE NOT REPORTING
HEADACHES ONCE OR MORE PER MONTH (N=3243), THOSE
WITH MIDLIFE MIGRAINE WITH AURA (N=361) HAD AN
INCREASED RISK OF LATE-LIFE INFARCT-LIKE LESIONS
(ADJUSTED ODDS RATIO OR , 1.4 CONFIDENCE INTERVAL
CI , 1.1-I.8) THAT SPECIFICALLY REFLECTED AN ASSOCIATION
WITH CEREBELLAR LESIONS IN WOMEN (PREVALENCE OF
INFARCTS 23.05% FOR WOMEN WITH MIGRAINE WITH AURA
VS 14.5% FOR WOMEN NOT REPORTING HEADACHES;
ADJUSTED OR, 1.9; 95% CI, 1.4-2.6 VS A 19.3% PREVALENCE OF
INFARCTS FOR MEN WITH MIGRAINE WITH AURA VS 21.3%
FOR MEN NOT REPORTING HEADACHES; ADJUSTED OR, 1.0;
95% CI, 0.6-1.8, P 0.4 FOR INTERACTION BY SEX). MIGRAINE
WITHOUT AURA AND NONMIGRAINE HEADACHE WERE NOT
ASSOCIATED WITH AN INCREASED RISK. MIGRAINE WITH
AURA IN MIDLIFE WAS ASSOCIATED WITH LATE-LIFE
CEREBELLAR INFARCT-LIKE LESIONS ON MRI. THIS
ASSOCIATION WAS STATISTICALLY SIGNIFICANT ONLY FOR
WOMEN.

 46 RECENT STUDIES SUGGEST THAT MIGRAINE
ATTACKS MAY BE ASSOCIATED WITH PATHOLOGIC
CHANGES IN THE BRAIN. WHICH LOCALIZATION IN
PARTICULAR IS CONSIDERED?
 A THE CEREBELLUM.
 B THE WHITE MATTER.
 C THE HYPOCAMPUS.
 D THE FRONTAL LOBE.
 47 IN THE POPULATION-BASED STUDY OF MEN AND
WOMEN IN REYKJAVIK, ICELAND, WITH A MEAN AGE
OF 51 YEARS AND RANGING FROM 33-65 YEARS, WHAT
STUDY WAS CONDUCTED APPROXIMATELY 26 YEARS
LATER?
 A BRAIN COMPUTERIZED AXIAL TOMOGRAPHY.
 B BRAIN BIOPSY.
 C BRAIN MAGNETIC RESONANCE IMAGING.
 D ELECTROENCEPHALOGRAM

 48 THOSE WITH MIDLIFE MIGRAINE WITH AURA HAD AN
ODDS RATIO OF 1.4 OF LATE-LIFE INFARCT-LIKE LESIONS.
THIS WAS MORE SPECIFICALLY OBSERVED IN WHICH
GROUP?
 A CEREBELLAR LESIONS IN WOMEN.
 B CEREBELLAR LESIONS IN MEN.
 C CORTICAL LESIONS IN WOMEN.
 D SUBCORTICAL LESIONS IN MEN.
 49 THE MAIN OUTCOME MEASURES OF THE STUDY WERE
THE PRESENCE OF INFARCT-LIKE LESIONS SPECIFICALLY
LOCATED IN WHICH REGIONS?
 A CORTICAL, CEREBELLAR AND MEDULLA OBLONGATA
REGIONS.
 B CORTICAL, SUBCORTICAL, AND CEREBELLAR REGIONS.
 C CEREBELLAR, SUBCORTICAL AND WHITE MATTER
REGIONS.
 D PERIVENTRICULAR, HYPOCAMPUS AND OCCIPITAL
REGIONS.

 50 WHICH OF THE FOLLOWING TYPES OF
HEADACHES WERE NOT ASSOCIATED WITH AN
INCREASED RISK OF INFARCT-LIKE LESIONS AT
FOLLOW-UP?
 A POST-TRAUMATIC HEADACHE
 B HEADACHE AND MIGRAINE WITH AURA.
 C MIGRAINE WITHOUT AURA AND NON-
MIGRAINE HEADACHE.
 D SINUSITIS AND MIGRAINE

 46. However, recent studies suggest that
migraine attacks may be associated with
patological changes in the
brain, particularly in the cerebellum.
 47. … more than 26 years later, brain MRIs
were performed.
 48. …, those with midlife migraine with aura
… had an increased risk of late-life infarct-
like lesions … that specifically reflected an
association with cerebellar lesions in women
….

 49. … and specifically located in the
cortical, subcortical, and cerebellar
regions were the main outcome
measure.
 50. …, migraine without aura and
non-migraine headache were not
associated with an increased risk.

a CT scan/ a CAT scan

CAM INGLES 1

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CAM INGLES 1