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F. Hauke, MD

Clinical Director, Oregon Health & Science University School of Medicine

More commonly, patients present with testicular discomfort or swelling suggestive of epididymitis and/or orchitis. However, if symptoms persist or a residual abnormality remains, then testicular ultrasound examination is indicated. If a testicular mass is detected, a radical inguinal orchiectomy should be performed. Because the testis develops from the gonadal ridge, its blood supply and lymphatic drainage originate in the abdomen and descend with the testis into the scrotum. An inguinal approach is taken to avoid breaching anatomic barriers and permitting additional pathways of spread. Back pain from retroperitoneal metastases is common and must be distinguished from musculoskeletal pain. A delay in diagnosis is associated with a more advanced stage and possibly worse survival. The staging may be "clinical"-defined solely by physical examination, blood marker evaluation, and radiographs-or "pathologic"-defined by an operative procedure. The regional draining lymph nodes for the testis are in the retroperitoneum, and the vascular supply originates from the great vessels (for the right testis) or the renal vessels (for the left testis). As a result, the lymph nodes that are involved first by a right testicular tumor are the interaortocaval lymph nodes just below the renal vessels. For a left testicular tumor, the first involved lymph nodes are lateral to the aorta (para-aortic) and below the left renal vessels. In both cases, further nodal spread is inferior, contralateral, and, less commonly, above the renal hilum. Lymphatic involvement can extend cephalad to the retrocrural, posterior mediastinal, and supraclavicular lymph nodes. Treatment is determined by tumor histology (seminoma versus nonseminoma) and clinical stage (Table 9-1). This entity is composed of four histologies: embryonal carcinoma, teratoma, choriocarcinoma, and endodermal sinus (yolk sac) tumor. Teratoma is composed of somatic cell types derived from two or more germ layers (ectoderm, mesoderm, or endoderm). When a tumor contains both seminoma and nonseminoma components, patient management is directed by the more aggressive nonseminoma component. If the primary tumor shows no evidence for lymphatic or vascular invasion and is limited to the testis (T1), then either option is reasonable. If lymphatic or vascular invasion is present or the tumor extends into the tunica, spermatic cord, or scrotum (T2 through T4), then surveillance should not be offered. The operation removes the lymph nodes ipsilateral to the primary site and the nodal groups adjacent to the primary landing zone. The major long-term effect of this operation is retrograde ejaculation and infertility. Patients with pathologic stage I disease are observed, and only the <10% who relapse require additional therapy. Surveillance is an option in the management of clinical stage I disease when no vascular/lymphatic invasion is found (T1). The median time to relapse is about 7 months, and late relapses (>2 years) are rare. Surveillance is the preferred approach for patients with resected "low-volume" metastases (tumor nodes 2 cm in diameter and <6 nodes involved) because the probability of relapse is one-third or less. Because relapse occurs in 50% of patients with "high-volume" metastases (>6 nodes involved, or any involved node >2 cm in largest diameter, or extranodal tumor extension), two cycles of adjuvant chemotherapy should be considered, as it results in cure in 98% of patients. Surveillance has been proposed as an option, and studies have shown that about 15% of patients relapse.

Quinine causes fewer arrhythmias and hypotension with infusion than quinidine, but it is often not available in U. Chloroquine is only effective for Plasmodium vivax and in Plasmodium ovale and Plasmodium falciparum infection in certain pockets of the Middle East and Caribbean where resistance has not yet developed. It is most commonly used as a prophylactic agent but is also used for treatment of multidrug-resistant malaria. Thick smears take a longer time to process but increase sensitivity in the setting of low parasitemia. Thin smears are more likely to allow for precise morphologic evaluation to differentiate among the four different types of Plasmodium infection and to allow for prognostic calculation of parasitemia. If clinical suspicion is high, repeat smears should be performed if the results are initially negative. If personnel are not available to rapidly interpret a smear, empirical therapy should be strongly considered to ward off the most severe manifestation of Plasmodium falciparum infection. The results will remain positive for weeks after infection and do not allow quantification of parasitemia. Patients generally present with these symptoms or occasionally neck stiffness, sore, throat abdominal pain, and weight loss. The presence of erythema chronicum migrans suggests concurrent Lyme disease because a rash is not a feature of babesiosis. The ring forms are distinguished from Plasmodium falciparum by the absence of central brownish deposit seen in malarial disease. Babesia duncani is typically found on the West Coast of the United States, and Babesia divergens have been reported sporadically in Washington state, Missouri, and Kentucky. Therapy for severe Babesia microti disease in adults is clindamycin with additional quinine. The most commonly used technique for diagnosis of visceral leishmaniasis (kala azar) is a rapid immunochromatographic test for recombinant antigen rK39 from Leishmania infantum. This is widely available, rapid, and safe, requiring only a fingerprick of blood with results available in approximately 15 minutes. Although splenic aspiration with demonstration of amastigotes in tissue smear is the gold standard for the diagnosis of visceral leishmaniasis and culture may increase the sensitivity, the test is invasive and may be dangerous in inexperienced hands. Polymerase chain reaction for the leishmaniasis nucleic acid is only available at specialized laboratories and is not routinely used clinically. The protozoa is transmitted to mammalian hosts by the reduviid bugs, which become infected by sucking blood from animals or humans with circulating protozoa. Infection has also been transmitted from blood transfusion, organ transplant, and ingestion of contaminated food or drink. Acute Chagas disease is typically a mild febrile illness followed by a chronic phase characterized by subpatent parasitemia, antibodies to T. About 10% to 30% of patients with chronic Chagas disease develop symptoms, usually related to cardiac or gastrointestinal lesions. Chagas disease is a health problem in rural Mexico, Central America, and South America. Most acute cases occur in children, but the epidemiology is uncertain because most cases go undiagnosed. Chronic Chagas disease is diagnosed by demonstration of specific immunoglobulin G antibodies to Trypanosoma cruzi antigens. False-positive results may occur in patients with other parasitic infections or autoimmune disease. The World Health Organization recommends a positive test be confirmed with a separate assay. Right heart catheterization with placement of a Swan-Ganz catheter could quantify left and right heart pressures and cardiac output. Constrictive pericarditis could also be evaluated, but this diagnosis is less likely with the presence of signs of left heart failure. Unfortunately, the only available drugs, benznidazole and nifurtimox, lack efficacy and have notable side effects. In acute Chagas disease, nifurtimox reduces the duration of symptoms and parasitemia and decreases the acute mortality Rate. However, only approximately 70% of acute infections are cured by a full course of treatment.

G/A the tumour is characteristically diffuse, forming a thick, white, fleshy coating over the parietal and visceral surfaces. The tumour cells are usually welldifferentiated, cuboidal, flattened or columnar cells. Usually, there are slit-like or gland-like spaces lined by neoplastic mesothelial cells separated by proliferating spindle-shaped tumour cells. The most frequent primary malignant tumours metastasising to the pleura are of the lung and breast through lymphatics, and ovarian cancers via haematogenous route. Pulmonary hypertension is defined as systolic blood pressure in the pulmonary arterial circulation above the following cut off figure: A. Reid index used as a criteria of quantitation in chronic bronchitis is the ratio of thickness of: A. Classic a-1 antitrypsin deficiency in emphysema has the following phenotype of protease inhibitor: A. The extent of damage to pulmonary parenchyma is severest in the following type of emphysema: A. Bronchiectasis commonly develops in the following microanatomic zone of bronchial tree: A. Inhaled dust particles of the following size are generally eliminated by expectoration: A. Bronchogenic carcinoma has increased incidence in the following pneumoconiosis: A. Chapter 15 the Respiratory System 312 Silicosis occurs in following occupational exposure except: A. Out of various forms of asbestos, the following type is implicated in etiology of malignant pleural tumour: A. The following histologic types of bronchogenic carcinoma have strong association with cigarette smoking except: A. The following tumour does not have association with occupational exposure to asbestosis: A. Which of the following mutation is being used to develop targeted molecular therapy in non-small cell cancer of lung? Which of the following histologic types of carcinomas is most likely to be found at the periphery of the lung preceded by healed lung lesions? The lacrimal glands which are compound racemose glands are situated at the outer upper angle of the orbit. The globe of the eye is composed of 3 layers: the cornea-sclera, choroid-iris, and retina. The cornea is covered by stratified epithelium which may be regarded as continuation of the conjunctiva over the cornea. The sclera is composed of dense fibrous tissue which is thickest at the back of the eyeball. The uveal tract consists of 3 parts-the choroid and ciliary body posteriorly, and the iris anteriorly. The retina is part of the central nervous system and corresponds in extent to the choroid which it lines internally. The retina is composed of a number of layers of cells and their synapses which are of 3 types-external photoreceptor cells (rods and cones), intermediate relay layer of bipolar cells, and internal layer of ganglion cells with their axons running into the central nervous system. The lens is the biconvex mass of laminated transparent tissue with elastic capsule. The anterior chamber is the space filled with the aqueous humour, and is bounded by the cornea in front and the iris behind, with anterior surface of the lens exposed in the pupil. The posterior chamber containing aqueous humour is the triangular space between the back of the iris, the anterior surface of the lens and the ciliary body forming its apex at the pupillary margin. The vitreous chamber is the large space behind the lens containing gelatinous material, the vitreous humour. The main function of the eye is visual acuity which depends upon a transparent focussing system comprised by the cornea, lens, transparent media consisting of aqueous and vitreous humours, and a normal retinal and neural conduction system.

Furthermore, when disk #1 is replaced, its chances of failing are probably higher than usual for the first few weeks. In the real world, if we stock enough spares that we run out only once every 10 years and have to wait for a shipment from the factory, but doing a replacement happens to run us out of stock today, we will probably still be out of stock tomorrow and the next day. Because the error is transient, the subsequent behavior of the supermodule is as if repair happened by the next operation cycle. The reason things seem so good is that we are evaluating the chance that two transient errors occur in the same operation cycle. This effect is powerful, but the leverage works in both directions, thereby creating a potential hazard: it is especially important to keep track of the rate at which transient errors actually occur. Create a fail-fast module by taking two replicas, giving them the same inputs, and connecting a simple comparator to their outputs. As long as the comparator reports that the two replicas of a pair agree, the next stage of the system accepts the output. The major attraction of pair-and-compare is that it can be used to create fail-fast modules starting with easily available commercial, off-the-shelf components, rather than commissioning specialized fail-fast versions. Special high-reliability components typically have a cost that is much higher than off-the shelf designs, for two reasons. Second, they are usually low-volume products that cannot take advantage of economies of large-scale production. These considerations also conspire to produce long delivery cycles, making it harder to keep spares in stock. If each of the replicas is itself a fail-fast design (perhaps using pair-and-compare internally), then a voter can restrict its attention to the outputs of only those replicas that claim to be producing good results and ignore those that are reporting that their outputs are questionable. But if that fail-fast replica is actually a pair-and-compare module, it might be more accurate to say that there are two still-working replicas at that point. Another technique that takes advantage of repair, can improve availability, and can degrade gracefully (in other words, it can be fail-soft) is called partition. An electric power company, rather than installing a single generator of capac ity K megawatts, may install N generators of capacity K/N megawatts each. When equivalent modules can easily share a load, partition can extend to what is called N + 1 redundancy. Suppose a system has a load that would require the capacity of N equivalent modules. Then, if any one of the modules fails, the system can carry on at full capacity until the failed module can be repaired. N + 1 redundancy is most applicable to modules that are completely interchangeable, can be dynamically allocated, and are not used as storage devices. When modules are not completely equivalent (for example, electric generators come in a range of capac ities, but can still be interconnected to share load), the design must ensure that the spare capacity is greater than the capacity of the largest individual module. For some applications an occasional interruption of availability is acceptable, while in others every interruption causes a major problem. When repair is part of the fault toler ance plan, it is sometimes possible, with extra care and added complexity, to design a system to provide continuous operation. Adding this feature requires that when failures occur, one can quickly identify the failing component, remove it from the system, repair it, and reinstall it (or a replacement part) all without halting operation of the system. The design required for continuous operation of computer hardware involves connecting and disconnecting cables and turning off power to some components but not others, without damaging anything. When hardware is designed to allow connection and disconnection from a system that continues to operate, it is said to allow hot swap. In a computer system, continuous operation also has significant implications for the software. Configuration management software must anticipate hot swap so that it can stop using hardware components that are about to be disconnected, as well as discover newly attached components and put them to work. If there are periodic consistency checks on data, those checks (and repairs to data when the checks reveal inconsistencies) must be designed to work correctly even though the system is in operation and the data is perhaps being read and updated by other users at the same time. Overall, continuous operation is not a feature that should be casually added to a list of system requirements. When someone suggests it, it may be helpful to point out that it is much like trying to keep an airplane flying indefinitely.