a = new Array(275);
var f = "<FONT FACE=ARIAL SIZE=2>"
a[0] = ""
a[1] = f + "(A) Incorrect. When parts of an organ undergo necrosis in a vascular distribution from loss of blood supply with resultant ischemia, then an infarct occurs."
a[2] = f + "(B) Incorrect. The loss of mitochondrial activity, as can occur with calcium influx with hypoxia, does not signal apoptosis."
a[3] = f + "(C) Incorrect. Phagocytosis is the process of cells or cellular debris being consumed by macrophages. Apoptotic bodies may be consumed in this fashion."
a[4] = f + "(D) Incorrect. Acute inflammatory cells (neutrophils) can release enzymes that destroy other cells and intracellular matrix, but this is a highly non-selective process."
a[5] = f + "(E) CORRECT. The induction of individual cell death occurs in the process of apoptosis. The drug effect is targeted primarily at neoplastic cells, not normal cells."
a[6] = f + "(A) Incorrect. Glycogen depletion within the cell can be reversed."
a[7] = f + "(B) Incorrect. An increase in cellular sodium (and the water that follows) produces edema with cellular swelling, but this is a potentially reversible form of injury."
a[8] = f + "(C) CORRECT. Chromatin clumping is reversible, but dissolution of the entire nucleus is not, and when the nucleus is lost, the cell will die."
a[9] = f + "(D) Incorrect. Acidosis by itself is reversible."
a[10] = f + "(E) Incorrect. Such membrane blebs constitute a reversible form of cellular injury."
a[11] = f + "(A) Incorrect. This 'wear and tear' pigment builds up in cells of tissues (such as myocardium and liver) over many years' time."
a[12] = f + "(B) Incorrect. A generalized yellow color, jaundice, can be the result of hyperbilirubinemia."
a[13] = f + "(C) Incorrect. Melanin pigment darkens the skin as concentrations of it increase from sunlight exposure (tanning)."
a[14] = f + "(D) CORRECT. The iron in the heme pigment from the red blood cells in the hemorrhage beneath the skin is incorporated into hemosiderin granules that impart the yellow to brown color of the healing bruise."
a[15] = f + "(E) Incorrect. Glycogen is stored in striated muscle and liver and imparts no grossly visible color change."
a[16] = f + "(A) CORRECT. The black color comes from carbon pigments in dust inhaled over the years, engulfed by macrophages, and sent via lymphatics to the nodes. It looks bad but does not compromise lung function. Smokers will have more anthracosis."
a[17] = f + "(B) Incorrect. Lipofuscin pigment builds up slowly withiin cell cytoplasm as a result of internal cellular changes. It is not an exogenous pigment."
a[18] = f + "(C) Incorrect. Melanin is made by cells (melanocytes) and is not an exogenous pigment."
a[19] = f + "(D) Incorrect. Hemosiderin is a storage form of iron and is not an exogenous pigment."
a[20] = f + "(E) Incorrect. Metastatic lesions are typically firm and white."
a[21] = f + "(A) Incorrect. Cytoskeletal abnormalities occur with ischemic injury, but do not worsen with reperfusion."
a[22] = f + "(B) Incorrect. Acidosis is part of ischemia, but does not specifically cause a reperfusion injury."
a[23] = f + "(C) CORRECT. Such toxic oxygen radicals are released from neutrophils when blood flow is restored following ischemia. This is a reperfusion injury. Overall, there is likely to be more good than harm to restoration of blood flow."
a[24] = f + "(D) Incorrect. Mitochondria swell with ischemic injury, but this is reversible."
a[25] = f + "(E) Incorrect. This is a reversible change that may occur with ischemia."
a[25.1] = f + "(F) Incorrect. This is a reversible change that may occur with ischemia."
a[26] = f + "(A) Incorrect. Accumulation of lipofuscin is not a function of hemorrhage, but of collection of cellular breakdown products, often seen with aging and in hepatocyte or myocardial fiber cytoplasm."
a[27] = f + "(B) Incorrect. Russell bodies are intracellular accumulations of immunoglobulins in plasma cells."
a[28] = f + "(C) Incorrect. Neutrophils suggest acute inflammation more typical for acute otitis media that accompanied each episode of acute otitis media, not the complication this boy now has."
a[29] = f + "(D) CORRECT. The lipid from the red cell membranes is broken down and cholesterol crystals form. The boy has the complication of otitis media known as a cholesteatoma"
a[30] = f + "(E) Incorrect. Anthracosis results from accumulation within the lung and lymph nodes of exogenous carbon pigment from dusts in the air that we all breath."
a[31] = f + "(A) Incorrect. The growth of the epithelial cells must become disordered in order to be dysplastic."
a[32] = f + "(B) Incorrect. Hyperplasia may occur with inflammation, as the number of cells increases, but hyperplasia does not explain the presence of the columnar cells."
a[33] = f + "(C) Incorrect. A carcinoma has the cellular atypia with hyperchromatism and pleomorphism. Goblet cells would not be seen."
a[34] = f + "(D) Incorrect. Ischemia would be unusual at this site and would be marked by coagulative necrosis."
a[35] = f + "(E) CORRECT. Metaplasia is the substitution of one tissue normally found at a site for another. The esophageal epithelium undergoes metaplasia in response to the ongoing inflammation from reflux of gastric contents. This is common in the lower esophagus with gastroesophageal reflux disease (GERD)."
a[36] = f + "(A) CORRECT. She had a 'stroke' with loss of brain tissue. The brain undergoes liquefactive necrosis with infarction. As it resolves, macrophaes remove the dead cells and debria, leaving a cystic area that forms in the region of infarction."
a[37] = f + "(B) Incorrect. Atrophy would be a more generalized process, whereas a single cystic area in brain suggests a remote infarction."
a[38] = f + "(C) Incorrect. Coagulative necrosis is more typical of parenchymal organs such as kidney or spleen that do not have as high a lipid content as brain."
a[39] = f + "(D) Incorrect. Caseous necrosis is more typical of granulomatous inflammation with M. tuberculosis."
a[40] = f + "(E) Incorrect. This is single cell necrosis that does not result in a grossly visible cystic area."
a[41] = f + "(A) Incorrect. The stroma of the breast consists of connective tissue that provides structural support, but does not have cells that produce milk."
a[42] = f + "(B) Incorrect. Dysplasia in epithelia is a pre-malignant change not part of normal physiologic events. This would be a precursor to breast cancer. Pregnancy is a protective factor against breast cancer."
a[43] = f + "(C) Incorrect. With poor nutrition and weight loss, steatocytes can decrease in size. However, she loves her baby and will take care of herself."
a[44] = f + "(D) Incorrect. Metaplasia is the exchange of the normal epithelium for another in response to chronic irritation. Metaplasia is not a normal physiologic process."
a[45] = f + "(E) CORRECT. There is an increase in the breast lobules under hormonal influence with pregnancy to provide for lactation."
a[46] = f + "(A) Incorrect. Hemosiderosis is not a complication of aging."
a[47] = f + "(B) CORRECT. Lipochrome deposition is a very common finding, though ordinarily there are small amounts of it, and it has little effect upon cardiac function. The 'brown atrophy' of the heart in this case is a rare finding."
a[48] = f + "(C) Incorrect. Glycogen storage diseases are inherited conditions that usually appear early in life. Glycogen does not appear pigmented in H&E stained tissue sections."
a[49] = f + "(D) Incorrect. The cholesterol accumulates in atheromatous plaques in the arteries, not in myocardium."
a[50] = f + "(E) Incorrect. Calcium deposits appear as irregular dark blue areas and are not associated with aging of the myocardium."
a[51] = f + "(A) Incorrect. Cytoskeletal alterations occur with ischemia, but are not a useful marker for such an event."
a[52] = f + "(B) CORRECT. Carcinomas are derived from epithelium and contain cytokeratins, while sarcomas derived from mesenchymal cells contain vimentin."
a[53] = f + "(C) Incorrect. Many cell types contain intermediate filaments."
a[54] = f + "(D) Incorrect. Mallory's alcoholic hyaline can be observed by H&E staining. However, it is not entirely specific for alcoholism."
a[55] = f + "(E) Incorrect. Metaplasia and dysplasia are assessed by light microscopic appearances with H&E staining."
a[56] = f + "(A) CORRECT. The ongoing pressure load of the systemic hypertension led to myocardial fiber hypertrophy and a heart that increased to twice normal size."
a[57] = f + "(B) Incorrect. Fat in the heart does not increase in response to the increase in work load from hypertension."
a[58] = f + "(C) Incorrect. Myocardial fibers do not undergo a significant degree of hyperplasia."
a[59] = f + "(D) Incorrect. Fatty degeneration of myocardium is typically the result of a toxic or hypoxic injury."
a[60] = f + "(E) Incorrect. Myocardial edema is not a characteristic feature of myocardial injury or increased work load. However, heart failure could lead to peripheral edema."
a[61] = f + "(A) Incorrect. Heme containing iron as part of hemosiderin from breakdown of red blood cells can impart a brownish color, but this is typically local from trauma or more global as part of an iron storage disease such as hemochromatosis. Iron oxide is also used in tattoo pigments."
a[62] = f + "(B) Incorrect. Lipochrome (lipofuscin) is a 'wear and tear' pigment imparting a golden brown appearance to granules in cells (such as myocytes or hepatocytes), but this is not a feature of skin."
a[63] = f + "(C) CORRECT. The tanning process in skin is stimulated by ultraviolet light exposure. Melanocytes have the enzyme tyrosinase to oxidize tyrosine to dihydroxyphenylalanine in the pathway for melanin production."
a[64] = f + "(D) Incorrect. Homogentisic acid can be part of the process of the rare disease alkaptonuria, in which a black pigment is deposited in connective tissues."
a[65] = f + "(E) Incorrect. Glycogen in quantity is starch-like and imparts a paler color to organs in which it is stored in excess. It does not involve the skin."
a[66] = f + "(A) Incorrect. This physiologic event results from accumulation of melanin pigment. There is no change of one cell type to another involved."
a[67] = f + "(B) Incorrect. This is a form of physiologic hyperplasia of breast lobules from hormonal influence."
a[68] = f + "(C) CORRECT. Vitamin A is necessary to maintain epithelia, and squamous metaplasia of the respiratory tract may occur if there is a deficiency. The stratified squamous epithelium does not function as well as the normal pseudostratified columnar respiratory epithelium, and there is an increased risk for respiratory infections."
a[69] = f + "(D) Incorrect. An acute MI will lead to cardiac muscle fiber necrosis, which will heal with production of fibrous scar tissue, but this is not a reversible metaplasia."
a[70] = f + "(E) Incorrect. The enlarged prostate represents primarily glandular hyperplasia."
a[71] = f + "(A) CORRECT. Viral infection leads to apoptosis with individual hepatocyte necrosis, either from effects of viral replication or from the body's immune response."
a[72] = f + "(B) Incorrect. Brown atrophy of the heart results when there is marked lipofuscin deposition in the myocardium."
a[73] = f + "(C) Incorrect. Tissue destruction with transplant rejection is more widespread."
a[74] = f + "(D) Incorrect. Single cell necrosis is not evident in chronic alcoholic liver disease."
a[75] = f + "(E) Incorrect. This produces hypertrophy of smooth endoplasmic reticulum, not individual cell necrosis."
a[76] = f + "(A) CORRECT. This is gangrenous necrosis. Occlusive peripheral atherosclerotic vascular disease is typical for diabetes mellitus. Many arteries are involved, reducing collateral flow."
a[77] = f + "(B) Incorrect. Monckeberg's medial calcific arterial sclerosis does not typically produce ischemic changes."
a[78] = f + "(C) Incorrect. Such focal gangrenous necrosis is not typical for trauma, unless blood supply is disrupted, but then the necrosis should proceed quickly."
a[79] = f + "(D) Incorrect. The complications of AIDS are unlikely to lead to gangrenous necrosis."
a[80] = f + "(E) Incorrect. An abnormal immune reaction, such as a type III hypersensitivity reaction with antigen-antibody complex deposition, could produce focal vasculitis, but would not typically result in infarction of a large area or body part."
a[81] = f + "(A) CORRECT. This cellular hypertrophy with increase in cell size (not hyperplasia with increase in cell number) accounts for the marked increase in size of the uterus during pregnancy. Following pregnancy and reduction in hormonal stimulation, the uterus returns back to its normal size."
a[82] = f + "(B) Incorrect. This is a form of physiologic hyperplasia with proliferation of ducts and lobules leading to an increase in breast size."
a[83] = f + "(C) Incorrect. This is a form of compensatory hyperplasia."
a[84] = f + "(D) Incorrect. Following menopause, the ovary undergoes atrophy and decreases in size."
a[85] = f + "(E) Incorrect. The inflamed epithelium undergoes metaplasia."
a[86] = f + "(A) Incorrect. Germ cells are very radiosensitive."
a[87] = f + "(B) Incorrect. The intestinal mucosa is actively proliferating."
a[88] = f + "(C) Incorrect. RBC's are constantly being replaced by precursors that are proliferating."
a[89] = f + "(D) Incorrect. Germ cells are very radiosensitive."
a[90] = f + "(E) CORRECT. Neurons are terminally differentiated cells that do not actively divide or proliferate. However, at higher radiation doses, cerebral injury does occur from damage mainly to white matter and to the vasculature."
a[91] = f + "(A) Incorrect. An elevated troponin suggests acute to intermediate myocardial ischemic injury, but he does not have another myocardial infarction at this time."
a[92] = f + "(B) Incorrect. Sodium retention occurs with CHF, but the serum sodium is not significantly increased."
a[93] = f + "(C) CORRECT. Under conditions of poor tissue perfusion, there will be more anaerobic glycolysis and more acidosis in cells throughout the body. The blood lactate rises in this condition."
a[94] = f + "(D) Incorrect. Hypoxia can lead to an increased red blood cell mass over a long period of time, but this is not a typical adaptation to CHF."
a[95] = f + "(E) Incorrect. The sed rate increases with inflammatory conditions, not with CHF."
a[96] = f + "(A) Incorrect. This would more likely be a feature seen with ingestion of great amounts of alcohol."
a[97] = f + "(B) Incorrect. The accumulation of iron does not lead to biliary obstruction or dysfunction."
a[98] = f + "(C) CORRECT. There is 250 mg of iron in each unit of blood. The body has no mechanism for getting rid of excess iron. A small amount of iron is lost with normal desquamation of epithelia, and menstruating women will lose a bit more. The excess iron becomes storage iron, or hemosiderin. Over time, hemosiderosis involves more and more tissues of the body, particularly the liver."
a[99] = f + "(D) Incorrect. Glycogen accumulation can be seen in a variety of inherited glycogen storage diseases in which the lack of an enzyme leads to accumulation of a storage product."
a[100] = f + "(E) Incorrect. Amyloid deposition occurs when there is an excessive production of a protein that is broken down by proteases to an insoluble end product known as amyloid that can collect in various tissues."
a[101] = f + "(A) CORRECT. The skeletal muscle tissue is the least metabolically active of the ones listed, and is also able to function with anaerobic glycolysis."
a[102] = f + "(B) Incorrect. Shock can often lead to ischemic enteritis."
a[103] = f + "(C) Incorrect. The retinal neurons are very sensitive to hypoxia."
a[104] = f + "(D) Incorrect. The myocardium is very active metabolically."
a[105] = f + "(E) Incorrect. The neurons of the brain are very sensitive to hypoxia, and the hippocampal neurons in particular."
a[106] = f + "(A) Incorrect. Coagulative necrosis is a characteristic feature of ischemic injury to many organs such as heart, spleen, and liver."
a[107] = f + "(B) Incorrect. Gangrenous necrosis refers to destruction of an organ or body part. Dry gangrene typically describes a process involving an extremity such as the foot."
a[108] = f + "(C) CORRECT. The enzymes released from the pancreas with acute pancreatitis damage the surrounding fat and form soaps -- localized soft tan to yellow areas of fat necrosis. The damaged pancreatic exocrine cells release lipase and amylase as markers for their injury."
a[109] = f + "(D) Incorrect. Apoptosis describes destruction of single cells, not whole tissues."
a[110] = f + "(E) Incorrect. Liquefactive necrosis is more typical for damage to an organ such as the brain with abundant lipid. Liquefactive necrosis is seen in abscesses as well."
a[111] = f + "(A) CORRECT. The description is that of a typical infarct with vascular occlusion following embolization from vegetations of infective endocarditis."
a[112] = f + "(B) Incorrect. An abscess is a localized collection of pus with a soft yellow purulent center."
a[113] = f + "(C) Incorrect. Metaplasia, the replacement of one cell type with another, typically occurs on epithelial surfaces."
a[114] = f + "(D) Incorrect. Caseous necrosis is typically cheesy white and localized to the center of rounded granulomas."
a[115] = f + "(E) Incorrect. Liquefaction leads to soft areas of tissue necrosis that resolve leaving a space."
a[116] = f + "(A) Incorrect. Although fatty change in liver can occur with galactosemia, fibrosis is a prominent component, and such findings are typical in infants."
a[117] = f + "(B) Incorrect. Hemochromatosis with extensive iron deposition would give the liver a dark brown to orange color."
a[118] = f + "(C) Incorrect. Tuberculosis leads to granuloma formation. Granulomas tend to be focal areas of inflammation."
a[119] = f + "(D) CORRECT. The marked fatty change of the liver with hepatomegaly is a typical sequel of chronic alcohol abuse."
a[120] = f + "(E) Incorrect. The liver is not a major target of hypoxic injury because of its dual blood supply. Hypoxia would lead to necrosis with loss of parenchyma, not enlargement."
a[121] = f + "(A) Incorrect. The calcification of the coronary arteries is a complication of atherosclerosis and would make angioplasty to treat coronary occlusion difficult and complicated."
a[122] = f + "(B) Incorrect. Nephrocalcinosis could result in renal failure."
a[123] = f + "(C) Incorrect. This valvular calcification could lead to valvular dysfunction (stenosis or regurgitation) and heart failure."
a[124] = f + "(D) Incorrect. The metastatic calcification in lung from a high serum calcium levels with hyperparathyroidism or with metastatic disease could interfere with pulmonary function."
a[125] = f + "(E) CORRECT. Such calcification is commonly seen in adults, and though part of atherosclerosis, would not have major consequences if mild to moderate because the function of the aorta in carrying blood would not be seriously compromised."
a[126] = f + "(A) Incorrect. A neoplasm is a mass lesion."
a[127] = f + "(B) CORRECT. Gangrenous necrosis is a typical complication of diabetes mellitus with marked peripheral vascular disease. Gangrene is a form of coagulative necrosis that involves a body part, including several tissues. The infection adds an element of liquefactive necrosis, best described as 'wet gangrene.'"
a[128] = f + "(C) Incorrect. Such a disorder, with either thrombosis or hemorrhage, would be more likely manifested throughout the body. Coagulopathy is not a feature of diabetes mellitus."
a[129] = f + "(D) Incorrect. Hemosiderin may form locally from remote hemorrhage. With iron overload, it collects in tissues of the mononuclear phagocyte system."
a[130] = f + "(E) Incorrect. Caseation is a part of granulomatous inflammation. Caseating granulomas are soft, cheesy, and white."
a[131] = f + "(A) Incorrect. Fatty change in the liver is due to toxic and metabolic derangements, such as those that occur with malnutrition or alcoholism."
a[132] = f + "(B) Incorrect. Pancreatic fat necrosis may occur from injury from inflammation or trauma."
a[133] = f + "(C) Incorrect. Fatty change in the heart is a consequence of toxic or hypoxic events."
a[134] = f + "(D) CORRECT. The fat cells (adipocytes) increase in size (hypertrophy) with obesity in adults, and this is the predominant effect of weight gain."
a[135] = f + "(E) Incorrect. Muscle does not typically undergo metaplasia in response to weight gain. Adipocytes in fascial planes and around the muscle can increase in size. The muscle may atrophy in response to the sedentary lifestyle."
a[136] = f + "(A) CORRECT. The glutathione peroxidase system is designed to help break down free radicals generated from various forms of cell injury. This system works in the background with small numbers of free radicals. Disease processes with greater amounts of cell injury can overwhelm this system."
a[137] = f + "(B) Incorrect. Catalases decompose hydrogen peroxide, but they are not specifically designed to scavenge free radicals."
a[138] = f + "(C) Incorrect. Hydrogen peroxide is generated by some cells, such as neutrophils, in order to destroy phagocytized microbes."
a[139] = f + "(D) Incorrect. NADPH oxidase helps to generate free radicals within phagolysosomes in cells such as neutrophils."
a[140] = f + "(E) Incorrect. Myeloperoxidase within neutrophil granules helps in destruction of phagocytized microbes."
a[141] = f + "(A) Incorrect. Dysplasia refers to disordered epithelial cell growth and does not apply to soft tissues."
a[142] = f + "(B) Incorrect. There are increased numbers of cells in this exaggerated healing process, but that does not account for the bright calcification."
a[143] = f + "(C) Incorrect. Though some cells may increase in size, the process is one of bone formation."
a[144] = f + "(D) CORRECT. The brightness on x-ray suggests calcification from osseous metaplasia of connective tissues that developed in the healing process. This condition is known as myositis ossificans, because there is bone formation in the injured muscle."
a[145] = f + "(E) Incorrect. This process is one of metaplastic bone formation as part of an exaggerated healing process, not the uncontrolled growth of a neoplasm."
a[146] = f + "(A) Incorrect. Metaplasia at this site does not occur."
a[147] = f + "(B) Incorrect. Depletion of lipid is usually part of a stress reaction in which the adrenals are increased in size."
a[148] = f + "(C) Incorrect. Diminished ACTH from the pituitary does not typically trigger the loss of adrenal cortical cells."
a[149] = f + "(D) CORRECT. The loss of ACTH leads to cortical atrophy from cellular downsizing, with the consequence of decreased glucocorticoid and mineralocorticoid production."
a[150] = f + "(E) Incorrect. Loss of ACTH does not lead to infarction of the adrenal. With three arterial blood supplies, the adrenal is very hard to infarct."
a[151] = f + "(A) Incorrect. Bile stasis may occur in the late stages of cirrhosis, or may be a function of biliary tract obstruction or liver cell injury."
a[152] = f + "(B) CORRECT. The toxic effects of the alcohol culminate in large lipid droplet accumulation within hepatocytes. Over time, more hepatocytes are affected and the liver is less able to compensate."
a[153] = f + "(C) Incorrect. Increased iron in the liver may occur in association with alcoholism, but is not nearly as common as fatty change."
a[154] = f + "(D) Incorrect. This is the result of chronic barbiturate ingestion."
a[155] = f + "(E) Incorrect. Liver infarction is rare because of the dual blood supply of oxygen through the hepatic artery and portal venous system."
a[156] = f + "(A) Incorrect. Excessive iron can be accumulated through increased absorbtion, increased intake, or prolonged transfusion therapy."
a[157] = f + "(B) Incorrect. Dystrophic calcification can occur in areas of tissue damage, as in granulomatous diseases. The liver is not a typical spot for metastatic calcification."
a[158] = f + "(C) Incorrect. Steatosis occurs with direct injury to hepatocytes, not biliary tract obstruction."
a[159] = f + "(D) CORRECT. She probably has a 'jaundiced' appearance to her sclerae and skin due to the increased amount of bilirubin. The bile pigments impart a yellow color to the tissues. She has biliary tract obstruction from cholelithiasis and choledocholithiasis."
a[160] = f + "(E) Incorrect. Fatty change is a process that occurs in the liver, and biliary tract obstruction does not typically cause it."
a[161] = f + "(A) Incorrect. Although dysplasia can be a premalignant condition, it is still reversible."
a[162] = f + "(B) Incorrect. Fatty change is potentially a reversible condition."
a[163] = f + "(C) CORRECT. The hypotension leads to diminished tissue perfusion with ischemic injury. Nuclear chromatin clumping is reversible, but nuclear pyknosis is not."
a[164] = f + "(D) Incorrect. 'Downsizing' of the cell in atrophy is reversible."
a[165] = f + "(E) Incorrect. A lack of sufficient oxygen may lead to anaerobic metabolism, but this can be temporary until the hypoxia is relieved."
a[165.1] = f + "(F) Incorrect. The cell 'downsizes' with autophagocytosis of cytoplasmic organelles, via its own lysosomes, but the cell does not die."
a[166] = f + "(A) CORRECT. Liquefactive necrosis typifies brain infarction. The brain tissue contains abundant lipid. After the initial softening, tissue macrophages will increase and clear the debris, leaving a cystic space. Since neurons cannot regenerate, the size of the infarct determines the amount of functional loss. The brain has some capacity for rewiring, but this diminishes with age."
a[167] = f + "(B) Incorrect. Infarction of most organs is accompanied by coagulative necrosis, but not the brain."
a[168] = f + "(C) Incorrect. Neurons are far more sensitive to hypoxia than glial cells."
a[169] = f + "(D) Incorrect. It is unlikely that the vascular supply can be reestablished in a matter of minutes."
a[170] = f + "(E) Incorrect. Gangrenous necrosis is more typical of a body part, such as a toe or a foot."
a[171] = f + "(A) Incorrect. At age 30 she is premenopausal."
a[172] = f + "(B) CORRECT. Fat necrosis is seen with trauma to the breast, and her lawyer will make good use of that documentation. The pattern of multiple injuries of differing ages at different sites suggests abuse."
a[173] = f + "(C) Incorrect. Lactation leads to a physiologic hyperplasia of the breast with increase in lobules."
a[174] = f + "(D) Incorrect. A variety of vascular and parenchymal changes can occur with radiation injury."
a[175] = f + "(E) Incorrect. The breast is not a site for hypoxic injury."
a[176] = f + "(A) Incorrect. Ischemia could lead to loss of cells, but the lung is hard to damage from ischemia because of its dual blood supply."
a[177] = f + "(B) CORRECT. The irritant effect, such as the various chemicals in cigarette smoke, leads to replacement of the normal epithelium with another (such as squamous epithelium replacing respiratory epithelium). This metaplastic process is the first step that could lead to dysplasia and then to neoplasia. Note that histologists call any flattened epithelium a 'squamous' epithelium, but pathologists refer to specific cell types, and consider a true squamous epithelium to be a stratified squamous epithelium."
a[178] = f + "(C) Incorrect. Although there can be a natural history of progression from metaplasia to dysplasia to carcinoma, most metaplasias do not become cancers, and metaplasia by itself is not cancer."
a[179] = f + "(D) Incorrect. Chronic viral infection is not likely to lead to metaplasia."
a[180] = f + "(E) Incorrect. Metaplasias are typically not congenital, but acquired. Hint: the pediatric term 'dysplasia' refers to disordered development of a tissue, including cell types that ordinarily are not present. In adults, dysplasia refers to an abnormal change in an epithelium, beyond physiologic alteration, that is starting down the road to cancer."
a[181] = f + "(A) Incorrect. The heart failure would be mainly left-sided, with pulmonary congestion as a consequence."
a[182] = f + "(B) CORRECT. Friable mitral valvular vegetations from infective endocarditis can embolize into the systemic circulation. Occlusion of a branch of the arterial supply to an organ can result in an infarction, which is characterized by the appearance of coagulative necrosis in most visceral organs."
a[183] = f + "(C) Incorrect. Edema is not likely to occur at this location. There can be pulmonary congestion and edema from left-sided heart failure."
a[184] = f + "(D) Incorrect. Granulomatous inflammation is more typical for infection with mycobacteria and fungi, not bacteria."
a[185] = f + "(E) Incorrect. Gangrenous necrosis would imply destruction of most of the kidney; the emboli would lead to focal infarctions."
a[186] = f + "(A) Incorrect. The state of nutrition can play a role in survival, but does not put an upper limit on doublings."
a[187] = f + "(B) Incorrect. Mutations occur over time, but overall are uncommon and have more to do with appearance of neoplasms."
a[188] = f + "(C) Incorrect. Apoptosis is programmed cell death that is controlled by a variety of factors which should not affect cells growing in culture."
a[189] = f + "(D) CORRECT. A number of factors play a role in aging, but the lack of immortality of individual cells is one feature. The lack of telomerase activity in most cells prevents repeated division. Stem cells have greater replicative capacity."
a[190] = f + "(E) Incorrect. Cellular damage from oxidation--such as free radical damage--contributes to aging but does not limit the number of generations."
a[191] = f + "(A) Incorrect. An elevated total serum cholesterol, particularly if it is over 200 mg/dl, will suggest an increased risk for a myocardial infarction, but will not help to diagnose an acute event."
a[192] = f + "(B) CORRECT. The CK will be elevated with myocardial ischemic injury. The CK-MB isoenzyme fraction is most specific for cardiac muscle, while CK-MM is most specific for skeletal muscle. Another very specific analyte for cardiac striated muscle injury is troponin. Myoglobin is a sensitive, but not specific marker for myocardial injury, because it could also be released from skeletal muscle."
a[193] = f + "(C) Incorrect. Hypertriglyceridemia suggests an increased risk for coronary atherosclerosis and its complications, but a triglyceride level will not predict an acute event, nor change because of that event."
a[194] = f + "(D) Incorrect. Amylase can be increased with injury to the pancreas, not cardiac muscle."
a[195] = f + "(E) Incorrect. The sed rate is a very non-specific indicator for inflammation and infection. It essentially measure 'acute phase proteins' such as fibrinogen that increase with acute tissue injuries."
a[196] = f + "(A) Incorrect. An increased serum cholesterol leads to complications of atherosclerosis, with the possibility of infarctions in various organs, but not disturbances of bilirubin metabolism."
a[197] = f + "(B) Incorrect. A low platelet count will lead to a coagulopathy marked by petechiae and purpura, but the bilirubin is not recycled fast enough to produce jaundice."
a[198] = f + "(C) Incorrect. Even metastases to the liver are unlikely to produce obstructive jaundice, because of the focal nature of the masses."
a[199] = f + "(D) CORRECT. Hepatitis, most often an infectious viral hepatitis, leads to liver cell dysfunction with impaired uptake, conjugation, and excretion of bilirubin. As a result there is an increasing serum bilirubin that produces the jaundice (icterus)."
a[200] = f + "(E) Incorrect. Diabetes mellitus has a variety of complications, mainly from accelerated atherosclerosis, but liver failure is not common. Liver has a dual blood supply."
a[201] = f + "(A) Incorrect. Normal aging does not lead to metaplastic changes in epithelium. Epithelia may become thinner with aging."
a[202] = f + "(B) Incorrect. Epithelial metaplasia is a reversible process, but may progress to dysplasia."
a[203] = f + "(C) Incorrect. A metastasis would be composed of malignant cells. Metaplasia is one step on the way to malignancy, but is, by itself, not malignant."
a[204] = f + "(D) CORRECT. The loss of normal functioning respiratory epithelium means that the normal barrier to infection has been weakened."
a[205] = f + "(E) Incorrect. Pulmonary infarctions are not accompanied by squamous metaplasia."
a[206] = f + "(A) Incorrect. Pyknosis involves cell death with destruction of the nucleus."
a[207] = f + "(B) Incorrect. Hypertrophy is an increase in cell size, with an increased amount of normal cellular components."
a[208] = f + "(C) Incorrect. Cell death occurs with coagulative necrosis."
a[209] = f + "(D) CORRECT. The lipochrome represents the residual debris of organelles and appears with increased frequency with aging, particularly in heart and liver."
a[210] = f + "(E) Incorrect. With reduced oxygen, many cells can switch to the glycolytic pathway to produce ATP, but this does not generate lipofuscin."
a[211] = f + "(A) Incorrect. Glutathione is part of the protective antioxidant mechanism."
a[212] = f + "(B) Incorrect. Ionized calcium does not directly participate in lipid damage. Calcium influx into mitochondria is an irreversible cellular injury."
a[213] = f + "(C) Incorrect. Under conditions of hypoxia, cellular respiration becomes anaerobic, with lactic acid production."
a[214] = f + "(D) CORRECT. Ferric ion is needed for reduced oxygen species to injure cells. Hydroxyl radicals initiate lipid peroxidation."
a[215] = f + "(E) Incorrect. Lipase is a digestive enzyme that is formed in the pancreatic acinar parenchyma and excreted into the pancreatic duct system and conveyed to the small intestine."
a[216] = f + "(A) Incorrect. The CO2 is increased with respiratory acidosis, but this does not lead to precipitation of calcium."
a[217] = f + "(B) CORRECT. Metastatic calcification occurs as a result of a high serum calcium, which in the case of hyperparathyroidism is accompanied by a low serum phosphorus."
a[218] = f + "(C) Incorrect. Uric acid may contribute to formation of uric acid calculi, but does not play a role in hyperparathyroidism and hypercalcemia."
a[219] = f + "(D) Incorrect. Hyponatremia could result from excessive antidiuretic hormone, but is not part of hyperparathyroidism."
a[220] = f + "(E) Incorrect. A low serum calcium may occur when the serum phosphorus rises with renal failure, not with hyperparathyroidism."
a[221] = f + "(A) CORRECT. Disordered growth of an epithelium is seen in dysplasia, which can be a precursor to neoplasia. When the term 'dysplasia' is used in pediatric conditions, it refers to disordered development of a tissue, including cell types that ordinarily are not present. In adults, dysplasia refers to an abnormal change in an epithelium, beyond physiologic alteration, that is starting down the road to cancer."
a[222] = f + "(B) Incorrect. Metaplasia refers to exchange of one type of epithelium to another not typically found there. The endocervix, which normally has columnar epithelium, may undergo squamous metaplasia with persistent cervicitis."
a[223] = f + "(C) Incorrect. Anaplasia refers to such an irregular appearance of cells in a neoplasm that it cannot be determined what kind of cell is present."
a[224] = f + "(D) Incorrect. Hyperplasia refers to an increased number of cells."
a[225] = f + "(E) Incorrect. Aplasia refers to absence of growth--lack of development, which is typically a congenital problem."
a[226] = f + "(A) CORRECT. Calcium is deposited in and around the granuloma as a reaction to injury with necrosis. Most pulmonary granulomas are the result of infection, typically tuberculosis."
a[227] = f + "(B) Incorrect. Apoptosis refers to single cell necrosis, not a process that occur with the focal tissue destruction seen in  a granuloma."
a[228] = f + "(C) Incorrect. High calcium levels, such as can occur with hyperparathyroidism, may lead to calcium deposition, even in normal tissues, and this is called metastatic calcification."
a[229] = f + "(D) Incorrect. Metastatic calcification can be seen with hyperparathyroidism and a high serum calcium. The calcification occurs in normal tissues."
a[230] = f + "(E) Incorrect. Calcium homeostasis is normally regulated by vitamin D and parathormone and has little to do with the amount of ingested calcium, unless a very large amount is ingested, which happens rarely. Excess calcium is typically not absorbed or is excreted."
a[231] = f + "(A) Incorrect. Metaplasia refers to the exchange of one epithelial cell type for another."
a[232] = f + "(B) Incorrect. Dysplasia in cellular terms refers to disordered cell growth in an epithelium."
a[233] = f + "(C) CORRECT. After removal of part of the liver, remaining liver can undergo hyperplasia to compensate. Hepatocytes are stable cells that are able to re-enter the cell cycle."
a[234] = f + "(D) Incorrect. Anaplasia refers to cells of a neoplasm that are so poorly differentiated that it is impossible to tell from what cell type they arose."
a[235] = f + "(E) Incorrect. Neoplasia refers to the process of new, uncontrolled growth that forms a tumor mass growing without physiologic control."
a[236] = f + "(A) Incorrect. Steatosis refers to the intracellular accumulation of lipid, either as small (micro) or large (macro) droplets (vesicles). This process occurs in hepatocytes."
a[237] = f + "(B) Incorrect. Fatty, or lipid, degeneration is a rare phenomenon in which small lipid droplets may accumulate within myocardial fibers under conditions of severe hypoxia."
a[238] = f + "(C) CORRECT. The adipocytes are normal fat cells. Obese persons just have more of them, and the individual cells are larger, making them more obvious and prominent on examination. Their presence in the superficial myocardium is more a marker of obesity than a risk for myocardial failure."
a[239] = f + "(D) Incorrect. Cholesterolosis refers to lipid accumulation (including cholesterol esters) in macrophages in an epithelium. The term is generally applied to the gallbladder."
a[240] = f + "(E) Incorrect. Xanthomas are accumulations of macrophages filled with lipid that form a mass effect."
a[241] = f + "(A) CORRECT. Elevations in troponin I or T and in the creatine kinase (CK) enzymes, particularly CK-MB fraction, as well as serum myoglobin, are going to be seen acutely with a myocardial infarction."
a[242] = f + "(B) Incorrect. A remote myocardial infarct of several months age consists mainly of a collagenous scar, and the complications depend upon the size of the scar."
a[243] = f + "(C) Incorrect. A large myocardial infarct could reduce cardiac function with resultant congestive heart failure that leads to chronic passive congestion."
a[244] = f + "(D) Incorrect. In this case, the myocardial infarct was so large that healing resulted in an aneurysm. The abnormal blood flow resulting from aneurysmal dilation favors thrombus formation on the wall of the ventricle in the aneurysm."
a[245] = f + "(E) Incorrect. If a thrombus were present to produce the original myocardial infarction, which is often the case, then survival results in time for recanalization of the thrombus to increase blood flow through the coronary artery."
a[246] = f + "(A) Incorrect. Apoptosis is single cell necrosis that is not the major mechanism of cell death from ischemic injury."
a[247] = f + "(B) CORRECT. The ischemia during the cardiac arrest followed by reperfusion established following successful resuscitation will generate activated oxygen species to produce free radical injury."
a[248] = f + "(C) Incorrect. Heterophagocytosis by macrophages is a way of clearing debris from dead cells following infarction."
a[249] = f + "(D) Incorrect. There is no epithelium in the myocardium to undergo metaplasia, and such metaplasia is not a consequence of ischemic injury."
a[250] = f + "(E) Incorrect. Such cytokeratin accumulation is a long-term process, as is seen with neurofibrillary tangles in Alzheimer's disease. This is not part of an ischemic injury."
a[251] = f + "(A) Incorrect. An increased ALT suggests hepatocyte injury."
a[252] = f + "(B) Incorrect. Hypercholesterolemia is not associated with pancreatitis, but marked hypertriglyceridemia (>1g/dL) can be associated with pancreatitis."
a[253] = f + "(C) Incorrect. An elevated CK suggests injury to striated muscle."
a[254] = f + "(D) Incorrect. An elevated urea nitrogen suggests renal failure."
a[255] = f + "(E) CORRECT. There is evidence for acute pancreatitis with edema and necrosis. The necrosis is typically fat necrosis with grossly visible focal chalky-white deposits representing areas of saponification as a consequence of release of pancreatic enzymes (lipase and amylase) with acute inflammation."
a[256] = f + "(A) Incorrect. Hypertension leads to vascular changes in arteries, but not to hemolysis with icterus."
a[257] = f + "(B) Incorrect. With hemolysis, the iron is recycled and neither lost nor gained."
a[258] = f + "(C) Incorrect. Diabetes mellitus is not associated with red blood cell destruction."
a[259] = f + "(D) CORRECT. The increased turnover of red blood cells leads to increased bilirubin production to cause the icterus, as the amount of bilirubin generated exceeds the capacity of the liver to conjugate and excrete it into the bile. This also explains his anemia."
a[260] = f + "(E) Incorrect. Neoplasms such as carcinomas are unlikely to lead to hemolysis, though some (leukemias, lymphomas) are associated with autoimmune phenomena that include antibodies directed at red blood cells."
a[261] = f + "(A) Incorrect. Thin actin filaments and thick myosin filaments are components of muscle tissue."
a[262] = f + "(B) Incorrect. Cholesterol esterified to long chain fatty acids can be a transport form of cholesterol utilized in building cell membranes. Cholesterol may also collect to form deposits that are a component of atheromas."
a[263] = f + "(C) Incorrect. Fatty acids can be taken up by a variety of cells for lipid biosynthetic pathways; they may be used in energy pathways. They may be taken up by fat cells for lipid storage."
a[264] = f + "(D) Incorrect. Fibronectin is a component of the extracellular matrix."
a[265] = f + "(E) CORRECT. Intermediate filaments may collect in the damaged hepatocytes as the globular hyaline known as Mallory hyaline. It is characteristic for alcoholic liver disease, but not pathognomic for it."
a[265.1] = f + "(F) Incorrect. Microtubules are a structural component of cells."
a[266] = f + "(A) Incorrect. Basophils are few in number in the blood and are not often seen in effusions."
a[267] = f + "(B) Incorrect. Ciliated columnar cells form the lining of the bronchial tree are would be sloughed off into the sputum, not into the pleural cavity."
a[268] = f + "(C) Incorrect. Eosinophils may participate in inflammatory reactions that are most often allergic or parasitic."
a[269] = f + "(D) Incorrect. Fibroblasts are part of an inflammatory process with healing and collagen deposition, typical of a resolving inflammatory process leading to pleural adhesions."
a[270] = f + "(E) Incorrect. Langhans giant cells are aggregated activated macrophages in a granulomatous response. If the pleura were involved, the cell count would be higher."
a[270.1] = f + "(E) CORRECT. Small numbers of lymphocytes may be present with this serous effusion, typical for autoimmune diseases that include serositis."
a[270.2] = f + "(E) Incorrect. Neutrophils are characteristic for exudates containing many cells and protein, not transudates with few cells and protein. Neutrophils are more characteristic of acute inflammatory processes, such as bacterial infections."