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NEET MDS Synopsis

Nucleic Acids
Physiology

Nucleic Acids:


Two major types: DNA
RNA (including mRNA, tRNA, & rRNA) 

Both types have code which specifies the sequence of amino acids in proteins
DNA = archival copy of genetic code, kept in nucleus, protected
RNA = working copy of code, used to translate a specific gene into a protein, goes into cytoplasm & to ribosomes, rapidly broken down


Nucleic acids are made of 5 nucleotide bases, sugars and phosphate groups
The bases make up the genetic code ; the phosphate and sugar make up the backbone
RNA is a molecule with a single strand
DNA is a double strand (a double helix) held together by hydrogen bonds between the bases

A = T; C= G because:

A must always hydrogen bond to T






C must always hydrogen bond to G

Radiological Signs
Oral and Maxillofacial Surgery

Radiological Signs Indicating Relationship Between Mandibular Third Molars
and the Inferior Alveolar Canal
In 1960, Howe and Payton identified seven radiological signs that suggest a
close relationship between the mandibular third molar (wisdom tooth) and the
inferior alveolar canal (IAC). Recognizing these signs is crucial for dental
practitioners, especially when planning for the extraction of impacted third
molars, as they can indicate potential complications such as nerve injury. Below
are the seven signs explained in detail:
1. Darkening of the Root

This sign appears as a radiolucent area at
the root of the mandibular third molar, indicating that the root is in close
proximity to the IAC.
Clinical Significance: Darkening suggests that the root
may be in contact with or resorbing against the canal, which can increase
the risk of nerve damage during extraction.

2. Deflected Root

This sign is characterized by a deviation
or angulation of the root of the mandibular third molar.
Clinical Significance: A deflected root may indicate
that the tooth is pushing against the IAC, suggesting a close anatomical
relationship that could complicate surgical extraction.

3. Narrowing of the Root

This sign is observed as a reduction in
the width of the root, often seen on radiographs.
Clinical Significance: Narrowing may indicate that the
root is being resorbed or is in close contact with the IAC, which can pose a
risk during extraction.

4. Interruption of the White Line(s)

The white line refers to the radiopaque
outline of the IAC. An interruption in this line can be seen on radiographs.
Clinical Significance: This interruption suggests that
the canal may be displaced or affected by the root of the third molar,
indicating a potential risk for nerve injury.

5. Diversion of the Inferior Alveolar Canal

This sign is characterized by a noticeable
change in the path of the IAC, which may appear to be deflected or diverted
around the root of the third molar.
Clinical Significance: Diversion of the canal indicates
that the root is in close proximity to the IAC, which can complicate
surgical procedures and increase the risk of nerve damage.

6. Narrowing of the Inferior Alveolar Canal (IAC)

 This sign appears as a reduction in the
width of the IAC on radiographs.
Clinical Significance: Narrowing of the canal may
suggest that the root of the third molar is encroaching upon the canal,
indicating a close relationship that could lead to complications during
extraction.

7. Hourglass Form

This sign indicates a partial or complete
encirclement of the IAC by the root of the mandibular third molar,
resembling an hourglass shape on radiographs.
Clinical Significance: An hourglass form suggests that
the root may be significantly impinging on the IAC, which poses a high risk
for nerve injury during extraction.

Leukaemias
General Pathology

Leukaemias
Uncontrolled proliferation of leukocyte precursors (may be with associated red cell and platelet series proliferation).

Factors which may playa causal role are.
- Viral
- Radiation.
- Genetic.

Classification

1. Acule leukaemia:

a. Lymphocytic (lymphoblastic).
b. Myelocytic and promyelocytic (myeloblastic).
c. Monocytic.
d. Myelomonocytic.
e. Undifferentiated (Stem cell).

2. Chronic leukaemia:

a. Lymphocytic
b. Myelocytic

3. Miscellaneous:
a. Erythroleukaemia (De Guglielmo's disease).
b. Eosinophilic leukaemia.
c. Megakaryocytic leukaemia.



Pheochromocytoma
General Pathology

Pheochromocytoma

Pheochromocytomas are neoplasms composed of chromaffin cells, which as their normal counterparts synthesize and release catecholamines. 

1. Arise in association with one of several familial syndromes such as MEN syndromes, type 1 neurofibromatosis, von Hippel-Lindau disease, and Sturge-Weber syndrome. 
2. Are extra-adrenal, occurring in sites such as the organ of Zuckerkandl and the carotid body, where they are usually called paragangliomas rather than pheochromocytomas. 
3. Are bilateral; but in association with familial syndromes, this figure may rise to 50%. 
4. Are malignant; frank malignancy, however, is more common in extra-adrenal tumors.  

Gross features

- The size of these tumors is quite variable ranging from small to huge masses. 
- Sectioning shows yellow-tan, well-defined tumor that compress the adjacent adrenal. Large lesions display areas of hemorrhage, necrosis, and cystic degeneration.  
- Incubation of the fresh tissue with potassium dichromate solutions converts the tumor a dark brown color.

Microscopic features
- These tumors are composed of polygonal to spindle-shaped chromaffin cells and their supporting sustentacular cells, arranged in well-defined small nests (Zellballen)," rimmed by a rich vascular network.
- The cytoplasm is often finely granular (catecholamine-containing granules) 
- The nuclei are often quite pleomorphic. 
- Both capsular and vascular invasion may be encountered in benign lesions, and the presence of mitotic figures per se does not imply malignancy. Therefore, the definitive diagnosis of malignancy in pheochromocytomas is based exclusively on the presence of metastases. These may involve regional lymph nodes as well as more distant sites, including liver, lung, and bone. 

The laboratory diagnosis of pheochromocytoma is based on demonstration of increased urinary excretion of free catecholamines and their metabolites, such as vanillylmandelic acid (VMA)&  metanephrines.

Immunoglobulin
General Microbiology

Immunoglobulin (Ig)

Immunoglobulins are glycoprotein molecules that are produced by plasma cells in response to an immunogen and which function as antibodies. The immunoglobulins derive their name from the finding that they migrate with globular proteins when antibody-containing serum is placed in an electrical field

FUNCTION
1. Immunoglobulins bind specifically to one or a few closely related antigens. Each immunoglobulin actually binds to a specific antigenic determinant. Antigen binding by antibodies is the primary function of antibodies and can result in protection of the host.

2. The significant biological effects are a consequence of secondary "effector functions" of antibodies.Phagocytic cells, lymphocytes, platelets, mast cells, and basophils have receptors that bind immunoglobulins. This binding can activate the cells to perform some function. Some immunoglobulins also bind to receptors on placental trophoblasts, which results in transfer of the immunoglobulin across the placenta. As a result, the transferred maternal antibodies provide immunity to the fetus and newborn.

STRUCTURE OF IMMUNOGLOBULINS

The basic structure of the immunoglobulins is illustrated in figure 2. Although different immunoglobulins can differ structurally, they all are built from the same basic units.

A. Heavy and Light Chains

All immunoglobulins have a four chain structure as their basic unit. They are composed of two identical light chains (23kD) and two identical heavy chains (50-70kD)

B. Disulfide bonds

1. Inter-chain disulfide bonds - The heavy and light chains and the two heavy chains are held together by inter-chain disulfide bonds and by non-covalent interactions The number of inter-chain disulfide bonds varies among different immunoglobulin molecules.

2. Intra-chain disulfide binds - Within each of the polypeptide chains there are also intra-chain disulfide bonds.

C. Variable (V) and Constant (C) Regions

When the amino acid sequences of many different heavy chains and light chains were compared, it became clear that both the heavy and light chain could be divided into two regions based on variability in the amino acid sequences. These are the:

1. Light Chain - VL (110 amino acids) and CL (110 amino acids)

2. Heavy Chain - VH (110 amino acids) and CH (330-440 amino acids)\(x = {-b \pm \sqrt{b^2-4ac} \over 2a}\)h the arms of the antibody molecule forms a Y. It is called the hinge region because there is some flexibility in the molecule at this point.

E. Domains

Three dimensional images of the immunoglobulin molecule show that it is not straight as depicted in figure 2A. Rather, it is folded into globular regions each of which contains an intra-chain disulfide bond (figure 2B-D). These regions are called domains.

1. Light Chain Domains - VL and CL

2. Heavy Chain Domains - VH, CH1 - CH3 (or CH4)

F. Oligosaccharides

Carbohydrates are attached to the CH2 domain in most immunoglobulins. However, in some cases carbohydrates may also be attached at other locations. 

IMMUNOGLOBULIN FRAGMENTS: STRUCTURE/FUNCTION RELATIONSHIPS

Immunoglobulin fragments produced by proteolytic digestion –

A.  Fab 
Digestion with papain breaks the immunoglobulin molecule in the hinge region before the H-H inter-chain disulfide bond Figure 6. This results in the formation of two identical fragments that contain the light chain and the VH and CH1 domains of the heavy chain.

Antigen binding – These fragments are  called the Fab fragments because they contained the antigen binding sites of the antibody. Each Fab fragment is monovalent whereas the original molecule was divalent. The combining site of the antibody is created by both VH and VL. 

B. Fc 
Digestion with papain also produces a fragment that contains the remainder of the two heavy chains each containing a CH2 and CH3 domain. This fragment was called Fc because it was easily crystallized.

Effector functions – The effector functions of immunoglobulins are mediated by this part of the molecule. Different functions are mediated by the different domains in this fragment . 

Treatment of immunoglobulins with pepsin results in cleavage of the heavy chain after the H-H inter-chain disulfide bonds resulting in a fragment that contains both antigen binding sites . This fragment is called F(ab’)2because it is divalent. The Fc region of the molecule is digested into small peptides by pepsin. The F(ab’)2binds antigen but it does not mediate the effector functions of antibodies.
 

Ossification
Anatomy



Ossification

Intramembranous-found in the flat bones of the face

Mesenchymal cells cluster and form strands
Strands are cemented in a uniform network. Which is known as osteoid
Calcium salts are deposited; osteoid is converted to bone
Trabeculae are formed and make cancellous bone with open spaces known as marrow cavities
Periosteum forms on the inner and outer surfaces of the ossification centers
Surface bone becomes compact bone


Endochondral-primary type of ossification In the human

Endotracheal intubation (ETI)
Oral and Maxillofacial Surgery

Endotracheal intubation (ETI) is critical in trauma patients for securing the
airway, especially in cases of severe head injury or altered consciousness.
Statistics indicate that approximately 15% of major trauma patients require
urgent intubation, with rates varying widely from 2% to 37% depending on the
setting. Proper airway management is vital to prevent respiratory failure and
improve outcomes.
 Importance of Endotracheal Intubation in Trauma Care


 Endotracheal intubation (ETI) involves
placing a cuffed tube into the trachea to secure the airway, ensuring
adequate ventilation and oxygenation.


Prevalence: Studies show that between 9% and 28% of
trauma patients undergo ETI, highlighting its significance in emergency
medical care.


Consequences of Failure: The inability to secure a
definitive airway is a leading cause of preventable death in trauma cases.
Effective airway management is crucial for survival.


Indications for Endotracheal Intubation


Clinical Criteria: ETI is indicated in various
scenarios, including:

Severe head injuries with altered consciousness.
Respiratory distress or failure.
Hypoxia despite supplemental oxygen.
Hemodynamic instability (e.g., shock).



Guideline Recommendations: Current guidelines suggest
that ETI should be performed when specific clinical criteria are met, such
as:

Glasgow Coma Scale (GCS) < 9.
Persistent hypotension (systolic blood pressure < 90 mmHg).
Severe respiratory distress.



Challenges in Decision-Making


Complexity of Situations: The decision to intubate is
often complicated by factors such as:

The patient's overall condition and injury severity.
The presence of multiple indications for intubation.
The potential risks associated with the procedure, including
complications like hypoxemia and cardiovascular instability.



Variability in Practice: Despite established guidelines,
the actual intubation rates can vary significantly based on clinical
judgment and the specific circumstances of each case.


Outcomes Associated with Endotracheal Intubation


Impact on Mortality: Research indicates that patients
who undergo ETI may experience higher mortality rates, particularly if
intubation is performed in the absence of other indications. This suggests
that isolated shock may not be a sufficient criterion for intubation.


Length of Stay: Patients requiring ETI often have longer
stays in intensive care units (ICUs) and may experience more complications,
such as coagulopathy and multiple organ failure.


GENERAL SOMATIC AFFERENT (GSA) PATHWAYS FROM THE FACE
Physiology

 Pain, Temperature, and Crude Touch and Pressure

General somatic nociceptors, thermoreceptors, and mechanoreceptors sensitive to crude touch and pressure from the face conduct signals to the brainstem over GSA fibers of cranial nerves V, VII, IX, and X.

The afferent fibers involved are processes of monopolar neurons with cell bodies in the semilunar, geniculate, petrosal, and nodose ganglia, respectively.

The central processes of these neurons enter the spinal tract of V, where they descend through the brainstem for a short distance before terminating in the spinal nucleus of V.

Second-order neurons then cross over the opposite side of the brainstem at various levels to enter the ventral trigeminothalamic tract, where they ascend to the VPM of the thalamus.

Finally, third-order neurons project to the "face" area of the cerebral cortex in areas 3, 1, and 2 .

Discriminating Touch and Pressure

Signals are conducted from general somatic mechanoreceptors over GSA fibers of the trigeminal nerve into the principal sensory nucleus of V, located in the middle pons.

Second-order neurons then conduct the signals to the opposite side of the brainstem, where they ascend in the medial lemniscus to the VPM of the thalamus.

 Thalamic neurons then project to the "face" region of areas 3, I, and 2 of the cerebral cortex.

 Kinesthesia and Subconscious Proprioception

Proprioceptive input from the face is primarily conducted over GSA fibers of the trigeminal nerve.

The peripheral endings of these neurons are the general somatic mechanoreceptors sensitive to both conscious (kinesthetic) and subconscious proprioceptive input.

Their central processes extend from the mesencephalic nucleus to the principal sensory nucleus of V in the pons

The subconscious component is conducted to the cerebellum, while the conscious component travels to the cerebral cortex.

Certain second-order neurons from the principal sensory nucleus relay proprioceptive information concerning subconscious evaluation and integration into the ipsilateral cerebellum.

Other second-order neurons project to the opposite side of the pons and ascend to the VPM of the thalamus as the dorsal trigeminothalamic tract.

Thalamic projections terminate in the face area of the cerebral cortex.

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