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C. Stejnar, M.B. B.CH., M.B.B.Ch., Ph.D.

Associate Professor, Western University of Health Sciences

Approximately 1 in every 100,000 to 1,000,000 bacteria will develop resistance to an antibiotic used for treatment. Large numbers of bacilli are typically present in an infection, so if a single antibiotic is used for treatment, resistant bacilli will be selected rapidly. Therefore multiple antibiotics prescribed over many months are commonly used to treat an infected patient. Blood cultures drawn at the time of admission were positive 10 hours later with gramnegative diplococci. This patient most likely has an infection with either Neisseria gonorrhoeae or Neisseria meningitidis, because no other gram-negative bacteria will look like this. Additional tests will be required to determine which bacterium is responsible for this infection. No other genera of bacteria resemble neisseriae, which appear as small, gram-negative diplococci. This property, combined with the microscopic morphology, permits a rapid preliminary diagnosis. Biochemical properties, specifically the ability to utilize specific carbohydrates such as glucose and maltose, are used to differentiate these two species. Although the meningococcal vaccine provides effective protection against serotypes A, C, Y, and W135, serotype B is not a good immunogen and is not included in the vaccine. This is problematic because serotype B is one of the common serotypes responsible for meningitis or meningococcemia in the Americas and Europe. Other genera in the family are rarely associated with human disease and will not be discussed in this chapter. The genus Neisseria consists of 29 species with two species, Neisseria gonorrhoeae and Neisseria meningitidis, strictly human pathogens. Additional species are commonly present on mucosal surfaces of the oropharynx and nasopharynx and occasionally colonize the anogenital mucosal membranes. Eikenella corrodens and Kingella kingae colonize the human oropharynx and are also opportunistic pathogens. T Physiology and Structure Neisseria species are aerobic gram-negative bacteria, typically coccoid shaped (0. All species are oxidase positive and most produce catalase, properties that combined with the Gram stain morphology allow a rapid, presumptive identification of a clinical isolate. Acid is produced by oxidation of carbohydrates (not by fermentation), a property that was historically used to differentiate Neisseria species. More rapid methods such as mass spectrometry are now used to identify these bacteria. Pathogenic and nonpathogenic species of Neisseria can also be differentiated by their growth on blood agar and nutrient agar. Soluble starch is added to the media to neutralize the toxic effect of the fatty acids. The optimum growth temperature is 35° C to 37° C, with poor survival of the organism at cooler temperatures. A humid atmosphere supplemented with 5% carbon dioxide is either required or enhances growth of N. These growth properties have practical importance: unless the specimen is processed on appropriate enriched media, N. Although the fastidious nature of this organism makes recovery from clinical specimens difficult, it is nevertheless easy for the organism to be transmitted sexually from person to person. Despite effective antibiotic therapy, gonorrhea is still one of the most common sexually transmitted diseases in the United States. The swift progression from good health to life-threatening disease produces fear and panic in communities, unlike the reaction to almost any other pathogen. Thirteen serogroups are currently recognized, with 6 serogroups (A, B, C, W135, X, and Y) associated with endemic and epidemic disease. Pathogenic and nonpathogenic strains of Neisseria have pili that extend from the cytoplasmic membrane through the outer membrane.

It presents as a rapidly progressive illness with symptoms of stridor, airway obstruction, drooling, and difficulty swallowing and signs of systemic toxicity (leukocytosis, fever, and/or tachycardia). It is the least invasive method to biopsy tissue but is more than adequate for identifying benign versus malignant tissue. In addition to lymphadenopathy, persistent lateral neck masses in adults may represent neuromas, neurofibromas, carotid body tumors, branchial cleft cysts, lipomas, sebaceous cysts, parathyroid cysts, or a primary soft tissue tumor. Midline neck masses may represent thyroglossal duct cysts, dermoid tumors, thyroid masses, lipomas, or sebaceous cysts. A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, genitourinary, or musculoskeletal anomalies. A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. Absence of ganglion cells on full-thickness rectal biopsy 2 cm above the dentate line b. Absence of ganglion cells on full-thickness rectal biopsy 1 cm above the dentate line c. Identification of a transition zone between the sigmoid colon and the distal rectum on barium enema. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4? A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice? Approximately 2 weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum. Diagnostic air enema with subsequent observation and serial abdominal examinations b. With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and a lesion 60 cm proximal to the ileocecal valve is identified (see photo). A newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. An x-ray of the abdomen shows gas in stomach and a nasogastric tube coiled in the esophagus. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. A Silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity. Enteral feeds for nutritional support should be initiated early prior to operative management. A 29-week-old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and ultrasound examination for possible necrotizing enterocolitis. Which of the following findings on imaging is an indication for surgical management? Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the right side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial management of the patient? Bowel rest with nasogastric tube decompression and broad-spectrum intravenous antibiotics c. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Fluid hydration and correction of electrolyte abnormalities prior to operative management. Administration of sodium bicarbonate to correct aciduria prior to operative management 505. A full-term male newborn experiences respiratory distress immediately after birth.

Positron emission tomography for target volume definition in the treatment of non-small cell lung cancer. Long-term observations of the patterns of failure in patients with unresectable non-oat cell carcinoma of the lung treated with definitive radiotherapy. Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. Palliative thoracic radiotherapy in lung cancer: An American Society for Radiation Oncology evidence-based clinical practice guideline. Prophylactic cranial irradiation for lung cancer patients at high risk for development of cerebral metastasis: results of a prospective randomized trial conducted by the Radiation Therapy Oncology Group. Twice daily compared to once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide. Solitary plasmacytomas of the bone generally involve the axial skeleton and account for almost seventy percent of clinical presentations. The remaining are extramedullary lesions generally presenting in the upper aerodigestive tract. The optimal radiation dose for the treatment of these lesions is not well known, with doses ranging from 30 Gy to 60 Gy in the published literature. The largest series, with 258 patients, reported is the European Multicenter Rare Cancer Network study (Ozsahin et © 2019 eviCore healthcare. Thirty-three were treated with a combination of radiation therapy and chemotherapy. Sixty percent of the patients who did not receive radiation therapy relapsed locally, while only 12% of the radiation therapy group experienced local relapse. A 10-year probability of disease progression to multiple myeloma was 36% for extramedullary plasmacytoma and 72% for solitary plasmacytoma of bone. Considerable care must be taken in the workup of a suspected solitary plasmacytoma to ensure that other lesions and hence, a diagnosis of multiple myeloma, are not present. Following a positive biopsy of the lesion, a full multiple myeloma evaluation should be performed. Bone marrow aspirate and biopsy are mandatory to document the lack of clonal cells for a diagnosis of solitary plasmacytoma. A variant of solitary plasmacytoma, when there are fewer than 10% of clonal plasma cells is termed solitary plasmacytoma with minimal bone marrow involvement. In addition to the previous workup, diagnostic imaging plays an important role in securing the diagnosis. Following confirmation of the diagnosis, surgery may play a role in certain definitive clinical presentations or is performed for clinical presentations requiring neurologic decompression or stabilization of a weight-bearing bone prior to the performance of radiation therapy. Lesions excised with positive margins or small, well-defined lesions may be treated with 40 Gy. Anatomic location, tumor size, surgical resection, older age at diagnosis and persistence of myeloma protein for one year post radiation treatment have all been postulated to be of prognostic significance but none have been definitely proven due to contrasting © 2019 eviCore healthcare. Multiple Myeloma and Other Plasma Cell Neoplasms (Chapter 78) in Gunderson L, Tepper J, editors. Outcomes and patterns of failure in solitary plamacytoma: a multicenter rare cancer network study of 258 patients. Radiation therapy for solitary plasmacytoma and multiple myeloma: guidelines from the International Lymphoma Radiation Oncology Group. Respiratory gating techniques and image guidance techniques may be appropriate to minimize the amount of critical tissue (such as lung) that is exposed to the full doses of radiation C. The treatment of lymphomas with radiation is generally done using relatively low doses in the range of 15 to 36 Gy at standard fractionation, sometimes with doses as low as 4 Gy in 2 fractions F. Complex or 3D techniques with image guidance © 2019 eviCore healthcare. Doses of 36 Gy to the original extent of disease for the following histologies: a. Directed at up to 4 separate sites in 1 phase a piece © 2019 eviCore healthcare. Sequential chemotherapy carries a high toxicity burden and requires substantial supportive care and the expertise of an experienced multidisciplinary team V1. In an individual with advanced or recurrent disease that is felt not to be curative and who is experiencing symptomatic local disease, photon and/or electron techniques are indicated for symptom control 1. Treatment decisions are preceded by workup and staging and planned in conjunction with the appropriate members of the multidisciplinary team.

If the affected testicle is nonviable, orchiectomy is performed with orchiopexy of the nonaffected testicle. Manual detorsion can be attempted by external rotation of the testicle toward the thigh, but the patient still needs to be taken to surgery following the initial presentation of testicular torsion. If left untreated, testicular torsion leads to strangulation of the blood supply to the testicle. The underlying pathology is secondary to an abnormally narrowed testicular mesentery with tunica vaginalis surrounding the testis and epididymis in a bell clapper deformity. Diagnosis of testicular torsion is mainly made with clinical presentation and examination. A technetium 99m (99mTc) pertechnetate scan or Doppler ultrasound may be helpful in making the diagnosis if clinical suspicion of torsion is low; however, operation should not be delayed in order to maximize testicular salvage. If treated within the first 4 to 6 hours of onset of symptoms, the chance of saving the testicle is high. A radical nephrectomy should be offered as a possible curative procedure in this patient because many nodes initially suspected of having metastatic disease on imaging are enlarged due to reactive inflammation. Most early prostate cancers are slow-growing tumors and will remain confined to the prostate gland for a significant length of time. Active surveillance involves frequent visits to the doctor (every 3-6 months) with questions about new or worsening symptoms and digital rectal examinations for any change in the prostate gland. Chemotherapy is not indicated in the treatment of early-stage prostate cancer and is most often given to patients with metastatic disease who no longer respond to hormonal therapy. Medical management consists of -Adrenergic antagonists and/or 5-alpha reductase inhibitor. In the middle third of the ureter, this will usually consist of ureteroureterostomy (primary anastamosis) using absorbable sutures over a stent. In the lower third, ureteral implantation into the bladder using a tunneling technique is preferred. The creation of a watertight seal is difficult and nephrectomy may be required if the injury occurs during a procedure in which a vascular prosthesis is being implanted (eg, an aortic reconstructive procedure) and contamination of the foreign body by urine must be avoided. If there is incomplete disruption of the urethra, a transurethral Foley catheter can be cautiously placed across the injury. However, if there is complete disruption, a suprapubic catheter is placed temporarily and definitive repair is delayed 4 to 6 months, at which time the hematoma will have resolved and the prostate will have descended into the proximity of the urogenital diaphragm. On rectal examination, the prostate is extremely tender to palpation and it should be performed gently to prevent releasing bacteria into the blood stream. A urinary tract infection also presents with the same complaints of frequency, urgency, dysuria, and decreased urinary stream, but it is not associated with perineal pain or pain on rectal examination. An 18-year-old football player is seen in the emergency ward with severe knee pain incurred after being hit by a tackler while running. Which of the following findings on physical examination is most sensitive for an anterior cruciate ligament injury? A 34-year-old man is extricated from an automobile after a motor vehicle collision. The patient has an obvious deformity of his right thigh consistent with a femur fracture. Upon closer examination of the right thigh, there is bone visible through an open wound. Which of the following is the most appropriate management of his open femur fracture? A 6-year-old boy is brought into the emergency room by his mother for walking with a limp for several weeks. On examination, the patient has tenderness over his right thigh without evidence of external trauma. An x-ray of the pelvis shows a right femoral head that is small and denser than normal.