The threshold for transfusing platelets varies.

Most clinicians provide platelet replacement in

nonbleeding patients if platelet counts drop below 20 × 109/L, though the exact levels at which platelets
should be transfused is a clinical decision based on each patient’s clinical condition.

During tissue expansion, what happens to the skin over the expander?

It only stretches.

It undergoes partial necrosis and then regenerates.

It generates new skin.

It undergoes de-epithelialization.

It undergoes columnar metaplasia.

Skin undergoing active expansion generates epidermal mitotic division and new skin formation. The
process of tissue expansion has provided plastic surgeons with an extremely useful option for a wide
range of cases requiring reconstruction. The first recorded use of a tissue expander occurred in 1957
when Neumann placed a rubber balloon in a subcutaneous pocket, gradually expanded it with air, and
used the newly generated skin to cover an ear defect. Now, expanders are available in different shapes
(round, rectangular, crescentic, and so on) and sizes to provide the required amount of skin for
adequate coverage while at the same time being in a position that allows the skin to be easily oriented
into the defect. Expanders can be placed either subcutaneously (wound coverage) or submuscularly
(breast reconstruction). For wound coverage, the diameter of the expander base should equal the
diameter of the wound.

Tissue expanders are made of a silicone shell and are intermittently filled with saline via an internal or
external port with patient discomfort being the usual indicator to stop filling. The expander should be
filled until enough skin is generated to cover two times the area of the wound as this will compensate
for the skin contracture that occurs after expander removal. Two terms associated with tissue expansion
are “creep” and “stress relaxation.” When the force of the growing expander causes the skin to stretch
via its viscoelastic properties, this is called “creep.” As the skin is stretched with a constant force, the
amount of force necessary to stretch the skin decreases over time and this is termed “stress relaxation.”
Concerning the vascular supply of the expanded skin, it’s actually increased because the process of
expansion acts as a delay. The capsule that forms on top of the expander adds to the vascular integrity
of the skin flap and therefore should be included during flap inset. The expanded skin has thickened
epidermis, thin dermis, atrophic, but functional muscle, and permanently atrophied fat. Complications
of tissue expanders include extrusion, infection, and flap necrosis. The expander should be removed in
these cases unless expansion is almost complete and the majority of the flap is not in jeopardy.

Bengtson B, Ringler S, George E, DeHaan M, Mills K. Capsular tissue: a new local flap. Plast Reconstr
Surg 1993;91(6):1073–1079.   [PubMed: 8479973]

70-year-old male underwent a total gastrectomy. His chances of developing wound dehiscence are
increased due to all of the following except:

decrease cellular migration and proliferation

decreased rate of wound capillary growth

decrease epithelialization

delayed wound contraction

decreased elastin degradation

Several studies have shown that the rate of wound dehiscence in patients over 70 years is two to three
times higher. Delayed wound contraction, decrease epithelialization, delayed cellular migration and
proliferation, decreased rate of wound capillary growth, decreased solubility and increased sclerotic
connective tissue are factors that lead to decreased wound breaking strength and increased dehiscence
rate.
Dermal changes that occur with aging include decreased cellularity (especially macrophages) and
decreased amounts of collagen and ground substance, leading to decreased dermal thickness. In
addition, dermal collagenase activity increases, and the appearance of the elastin fibers suggests
increased elastin degradation. These changes also contribute to impaired wound healing in the elderly.

Aging affects all stages of wound healing, but macrophages are particularly impacted.

Histologic features of skin aging include flattened dermal-epidermal junction, occasional nuclear atypia,
fewer melanocytes, fewer Langerhans cells, fewer fibroblasts, fewer mast cells, fewer blood vessels,
shortened capillary loops, abnormal nerve endings, depigmented hair, loss of hair, conversion of
terminal to vellus hair, abnormal nail plates, and fewer glands.

Mulder GD, et al. Factors complicating wound repair. In: McCulloch JM, Kloth LC, Feedar JA
(eds.), Wound Healing Alternatives in Management, 2nd ed. Philadelphia, PA: FA Davis, 1996, 51.

Yaar M, Gilchrest BA. Skin aging postulated mechanisms and consequent changes in structure and
function. Clin Geriatr Med 2001;17(4):661–672.

The gallbladder is lined by non-ciliated simple columnar epithelium or brush border columnar
epithelium that is lined by microvilli. 

So, the correct answer is 'brush border columnar epithelium'.

An infant present with gastroschisis at birth. Which of the following applies to this condition?
A. It is also seen in patients with aganglionic megacolon
B. It results from herniation at the site of regression of the right umbilical vein
C. It is caused by a failure of recanalization of the midgut part of the duodenum
D. It is caused by failure of the midgut to return to the abdominal cavity after herniation into the umbilical stalk
E. It is associated with hernial sac

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DMA's ANATOMY PG Q&A 15-12-2017

Published on Dec. 15, 2017, 5:23 p.m. MIQ OF THE DAY

1) An infant presents with gastroschisis at birth. Which of the following applies to this condition

A) It is also seen in patients with aganglionic megacolon

B) It results from herniation at the site of regression of the right umbilical vein

C) It is caused by a failure of recanalization of the midgut part of the duodenum

D) It is caused by failure of the midgut to return to the abdominal cavity after herniation into the
umbilical stalk

2) Which of the following structure in glomerulus has pores?

A) Parietal epithelial cell

B) Basement membrane

C) Capillary endothelium

D) B + C
3) Untrue about Hirschsprung disease

A) Occurs due to non-migration of neural crest cells

B) Developmental failure Auerbach and Meissner’s plexus in the gut

C) Distal large intestine is aperistaltic and spastic

D) Absent sympathetic activity in the affected region

4) Untrue about ureteric bud

A) Endodermal derivative

B) Arises from Wolffian duct

C) Forms collecting tubules

D) Penetrates metanephric tissue

5) Following statements describe the development of diaphragm. Choose the incorrect statement

A) The dorsal mesentery of the oesophagus gives rise to the crura

B) Defect in the pleuro-peritoneal membrane leads to Morgagni’s hernia

C) Body wall contributes for the peripheral muscular component

D) The septum transversum descends to T8 from C3-5 following rapid growth of neural tube

6) Following are the boundaries of epiploic foramen except

A) Free margin of lesser omentum

B) Inferior vena cava

C) Quadrate lobe of liver

D) Right adrenal

7) A 38-year-old woman with a history of heartburn suddenly experiences excruciating pain in the
epigastric region of the abdomen. Surgery is performed immediately upon admission to the emergency
room. There is evidence of a ruptured ulcer in the posterior wall of the stomach. Where will a surgeon
first find the stomach contents

A) Pouch of Morrison

B) Cul-de-sac of Douglas

C) Omental bursa
D) Paracolic gutter

8) Most common muscle to be congenitally absent is

A) Pectoralis major

B) Teres minor

C) Semimembranosus

D) Gastrocnemius

9) All is true about Trochlear nerve except

A) Longest intracranial course

B) Arise from dorsal aspect

C) Supplies ipsilateral superior oblique

D) Arises from out side the common tendinous ring

10) Urogenital diaphragm is contributed by all except

A) Sphincter urethra
B) Perineal body

C) Colles’ fascia

D) Perineal membrane

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1. Ans. (B) It results from herniation at the site of regression of the right umbilical vein

o Herniation at the site of regression of the right umbilical vein (2): Gastroschisis
o Failure of recanalization of the midgut part of the duodenum (3): Duodenal atresia

o failure of the midgut to return to the abdominal cavity after herniation into the umbilical stalk(4):
Omphalocele

o Infants with Down syndrome may show omphalocele (4) & congenital aganglionic megacolon (1)

o Hirschsprung's disease is congenital aganglionic megacolon due to absence of myenteric (or

Auerbach's plexus) ganglion cells (disturbed migration of neural crest cells) in a distal segment of the
large intestine.

2. Ans. C. Capillary endothelium

Pores are present only in capillary endotheli

ght occulomotor nucleus will paralyse the left superior oblique.

o Superior rectus muscle is also supplied contralaterally by the occulomotor nerve. Left occulomotor
nucleus supplies the right superior rectus.

o Trochlear nerve is the only cranial nerve which exits dorsally (b) from the brainstem.

o -This nerve exits dorsally/ posteriorly, loops around the brainstem and turns anteriorly to move
along with other cranial nerves - which all exit the brainstem anteriorly.

o -Trochlear nerve gains additional length as it goes dorsal and then comes ventral, whereas other
nerves were simply exiting ventrally. Thus the nerve has the longest intracranial course (a).

o -It is also having the longest intracranial (subarachnoid) course.

o Abducent nerve has the longest intracranial (intradural) course.

o -Because of the long course, it is often stretched when intracranial pressure rises and presents with
lateral rectus palsy- Medial squint.

o Trochlear nerve passes through the superior orbital fissure to reach the orbit and supply superior
oblique muscle. It passes outside (d) the common tendinous ring of Zinn.

o -Occulomotor & Abducent nerves also pass through the superior orbital fissure, but they pass inside
the CTR of Zinn.

10. Ans. (C) Colles’ fascia

o Urogenital diaphragm contains the deep perineal pouch and is lined inferiorly by the perineal
membrane (d) and not Colles’ fascia (c).

o -Colles’ fascia actually is the inferior lining of superficial perineal pouch.

o Urogenital diaphragm is a triangular musculo-fascial diaphragm in the anterior part of perineum. It is

contributed by mainly two muscles: sphincter urethrae (a) and deep transverse perinei.

o -These muscles are enclosed within a superior and inferior fascia. The inferior fascia is also called as
perineal membrane.

o Perineal body (b) is a fibromuscular body attached at the posterior border of perineal membrane in
the midline. Both the fascia of urogenital diaphragm are attached to the perineal body.

o Perineal body is a good support of pelvic viscera and is contributed by many muscles of the perineum
including the muscles of urogenital diaphragm – deep transverse perinei & sphincter urethrae.

o Damage to the perineal body or urogenital diaphragm results in prolapse of the pelvic viscera.

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Carcinoid syndrome (CS) is a life-threatening medical condition that affects approximately 10% of
patients with carcinoid tumors (8,9). Carcinoid tumors are slow-growing benign lesions of
enterochromaffin or Kulchitsky cells that are derived from the neuroendocrine lineage and have a low
incidence rate of 1.9 per 100,000 (10–16). Patients with carcinoid tumors are usually asymptomatic or
may have vague gastrointestinal complaints. However, patients with CS typically present with flushing
that is often times accompanied by diarrhea, abdominal cramping, and fatigue. In the majority of
patients (approximately 50%), particularly males, tumors are located in the small bowel or proximal
colon, and rarely in the stomach, bronchus or appendix (3,8,17). CS may rarely arise from ovarian
teratomas, tumors of the uterine cervix, glomus jugulare, and thyroid gland or present with right-sided
cardiac failure from valvular disease or severe bronchoconstriction 

Essentials of Clinical Immunology (Sixth Edition)

Helen Chapel, Mansel Haeney, Siraj Misbah, Neil Snowden

HOMEE-TEXT INSTRUCTIONSMULTIPLE CHOICECASESFIGURESUSEFUL LINKSYOUR FEEDBACKBECOME A

REVIEWERESSENTIALS SERIESWILEY STUDENT BOOKSSTUDENT APPSCLINICAL AND EXPERIMENTAL
IMMUNOLOGY - CONTENTREVIEW ARTICLES

Multiple Choice Questions

Question 1. Which one group of the following cells is NOT phagocytic in nature?

A Neutrophil polymorphonuclear leucocytes.B B lymphocytes.C Microglial cells.D Macrophages.E 

Kupffer cells.

Well done, you have selected the right answer.

Secrete antibodies and cytokines and are responsible for antigen specific humoral responses. They can
process and digest antigens (particularly in secondary immune responses but do not have a major
phagocytic role).

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‫اليخفاكم الخبر ان تم ايقاف مستحقاتنا من البترول منذو شهر يونيو حتى االن رغم التزامنا بواجباتنا ودوام النوبات وحرصنا الشديد على‬
‫تغطية العمل على اكمل وجه ولم يبدر منا اي تقصير حسب مانستطيع ان نقدم لخدمة الجرحى‬

‫ولكن تفاجئنا بقطع مستحقات` البترول التي هي الشي اليسير كي يخفف علينا أعباء المواصالت والحضور باكرا للمستشفى‬

‫وكي ال ننقطع عن المجئ الى المستشفى‬

‫نرفع لكم هذا الطلب بالتوجيه الى من يلزم بصرف المستحقات` من شهر يونيو وحتى اآلن‬

‫ولكم جزيل الشكر‬

Two thousand two hundred forty-three patients met criteria for inclusion in the study. Six hundred ten
patients (27%) underwent immediate splenectomy, splenorrhaphy, or splenic embolization (within 4
hours). Of the remaining 1633 patients who were admitted with planned nonoperative management,
252 patients (15%) failed. Of the injury and patient characteristics reviewed, being older than 55 years
and having an ISS higher than 25 were significantly associated with failure. Risk of failure also increased
with admission to a level III or IV trauma hospital compared with a level I trauma hospital.