1
Q
Fetal hydronephrosis
A
Commonly detected in the second trimister during routine ultrasonographic anatomy survey.
- the finding is usually transient or clinically insignificant as the fetal renal pelvis has high compliance and can accomodate large volumes of urine.
- the most common pathologic cause of unilateral fetal hydronephrosis is a narrowing or kinking of the proximal ureter at uretopelvic junction.
- newborns presents with abdominal mass reflecting an enlarged kidney.
- the uteropelvic junction is the last segment of the fetal ureter to canalize. The pathogenesis of UPJ obstruction may involve failure of this canalization through abnormal development of circular musculature and/or collagen fibers.
2
Q
Infleuenza vaccines mechanism
A
They include inactivated( killed) vaccine administered by injection and a live attenuated vaccine given by nasal spray.
Each seasonal influenza vaccine contains antigens from 3 or 4 infleuenza A and B virus strains.
-inactivated version of infleuenza vaccine function mainly by inducing neutralizing antibodies against the hemagglutinin antigen in selected viral strains.
-upon subsequent exposure to infleuenza these antibodies inhibit binding of hemagglutinin to sialylated receptors on host cell membrane. This prevents the live virus from entering cells via endocytosis.
3
Q
Huntington pathogenesis
A
- transcriptional repression is one of the mechanism by which mutated huntington is thought to cause disease.
- regulation of transcription occurs in part due to the presence of histones, which can undergo variety of modifications that affects the accessibility of the genome for transcription.
- acetylation of histones weakens the DNA-histone bond and makes DNA segments more accessible for transcription factors and RNA polymerase, enhancing gene transcription.
- in huntington disease abnormal Huntington causes increased histone deacetylation, sliencing the genes necessary for neuronal survival.
- huntington is due to CAG repeats in the gene coding for huntington. Expansion of the protein polyglutamine region results in gain of function that leads to pathological interaction with other proteins including various transcription factors.
4
Q
Heme synthesis enzyme diseases
A
- Sideronlastic anemia —> ∂-aminolevulinic acid synthase
- Lead poisining : —> ∂-aminoluvulinic acid dehydratase and ferrochelatase.
- acute intermittent porphyria —> prophobilinogen deaminase
- Porphyria cutanea tarda —> uroporphyrinogen decarboxylase.
5
Q
Porphyria cutanea tarda
A
The most common disorder of porphyrin synthesis.
Its caused by uroporphtinogen decarboxylase deficiency, which is either inherited or acquired, manifesting in the presence of iron and of susceptibility factors.
-photosensetivity presents as vesicles and blister formation on sun exposed areas as well as edema, pruritus, pain and erythemia.
6
Q
Acute intermittent porphyria symptoms
A
- painful abdomen
- port wine colored urine
- polyneuropathy
- psychological disturbances
- precipitated by drugs (cp450 inducers), alcohol, starvation
7
Q
Common peroneal nerve injury is due to
A
Due to its superficial location its susceptible to injury .
-neck of the fibula fracture
8
Q
Pudendal nerve block location
A
When performing PN block , the ischial spines should be palpated intravaginally and the anesthetic should be injected medially in very close proximity to the ischial spine through sacrospinous ligament.-other important structure that are present in that area include the internal pudendal artery and inferior gluteal artery which run medial to the PN. Injection in one of those can lead to hematoma or arrythmia (if lidocaine is used)
9
Q
Lateral femoral cutaneous nerve (meralgia paresthetica)
A
Courses deep to the inguinal ligament to innervate the anterolateral thigh skin. Its commonly injured during hyperflexion of the thigh in the lithotomy position for pelvic surgery or vaginal delivery. Complications include anterior and lateral thigh numbness.
-meralgia paresthetica can be caused by obstruction of the LFCN in the inguinal ligament.
10
Q
PPI mechanism of action
A
It inhibit H/K ATPase > decreasing concentraion of HCL in gastic lumen
11
Q
Tetrodotoxin
A
Its a potent neurotoxin found in pufferfish, functions by blocking the voltage gated sodium channels in nerve cell membranes. Inhibits passive transport of sodium.
12
Q
Decreased physical workload at immobilzation leads to
A
-as a result, the skeletal muscle fibers in his leg decreased in size leading to disuse atrophy. Atrophy is tissue loss due to cellular death or reduced cell size.
13
Q
Nonreactive pupils to light stimulation following cardiac arrest indicates
A
-anoxic damage to the brainstem at the level of the upper midbrain.
14
Q
Pupillary reflex
A
during normal pupillary reflex, the retina as well as the optic nerve and tract transmit the light stimulus to the midbrain at the level of superior colliculus where its recieved by the pretectal nucleus and subsequently relayed to bilateral edinger westphal nuclei.
-these nuclei subsequently projects preganglionic parasympathetic fibers through the oculomotor nerve to the cilliary ganglion —> sphincter pupillae muscle
15
Q
During oophrectomy what ligament should be ligated
A
The suspensory ligament of the ovary (infundibulopelvic ligament). It contains the ovarian artery, vein, lymphatics and nerves.
16
Q
Increased myocardial oxygen during exercise can only be achieved through a corresponding increase in coronary blood flow.
A
The most important ones are adenosine and nitric oxide involved in coronary blood flow autoregulation
- adenosine, a product of ATP metabolism, acts as a vasodilatory element in the small coronary arterioles.
- nitric oxide is created by and released from the endothelial cells in the coronary vasculature. Its synthesized by arginine and O2 by endothelial NO synthase and is released from the coronary endothelium in response to neurotransmitters, platelt product, thrombin, histamine, bradykinin and endothillin.
- NO is also released in response to pulsatile stretch and flow shear stress in the coronary arteries. It is major regulator or flow mediated vasodilation in large arteries and periarteriolar vessels.
17
Q
Mannitol side effects
A
- mannitol works by rapidly increasing plasma or tubular fluid omolality which causes water to move from interstitial space into the vascular space or tubular lumen. In kidney it primarily acts on PCT.
- in the brain, water redistribution from the tissues into the plasma helps to reduce cerberal edema and intracranial pressure.
- overaggressive treatment with osmotic diuretics can lead to excessive volume depletion and eventual hypernatremia in certain patients. One of the more severe toxicities of aggressive osmotic diuretic therapy is pulmonary edema, caused by the rapid rise in volume that can also increase the overall hydrostatic pressure in the vasculature.
18
Q
Clumps of erythroid precurosr cells in liver and spleen is characterestic of
A
Chronic hemolysis- indicated extramedullary hematopoiesis due to hemolytic anemia (eg .ß-thalassemia)
19
Q
Maxillary overgrowth, frontal bossing and hepatosplenomegaly is seen in
A
ß-thalasemia
20
Q
Villous adenoma vs tubular
A
- villous Are often large, sessile and can have velvety or cauliflower like projections. It can secrete large quantities of watery mucus leading to secretory diarrhea, hypovolemia and electrolytes abnormalities.
- By contrast, tubular adenomas are composed of dysplastic colonic mucosal cells that form tube shaped glands and tend to be smaller and pudenculated.
- tubuvillous adenoma contains mixture of these 2 types
- villous adenoma are more likely to undergo malignant transformation.
21
Q
Metyhlmalonic acidemia
A
Autosomal recessive organic acidemia resulting from complete or partial deficiency of methylmalonyl CoA mutase.
- catabolism of isoleucine, valine theronine, methionine and odd chain fatty acid normally leads to propionyl CoA formation which is then converted to methylmalonyl CoA by biotin dependent carboxylation.
- methylmalonyl CoA is then converted to succinyl-coa and enter TCA.
- mutation in methylmalonyl CoA mutase results in buildup of methylmalonic acid leading to acidosis, hypoglycemia (increased metabolic rate leading to increased glucose utilization and inhibition of gluconeogenesis by organic acids).
- hypoglycemia leads to ketones formation.
- organic amino acid directly inhibit urea cycle leading to hyperammonemia.
- it manifest as hypotonia, lathergy, vomiting and respiratory distress in neonatal period.
- diagnosis is confirmed by the presence of elevated urine methylamlonic acid and propionic acid.
22
Q
Propionic acidemia
A
Deficiency in propionyl-CoA carboxylase, results in hyperammonemia, hypoglycemia and metabolic acidosis, although it doesnt display elevated levels of urine methylmalonic acid.
23
Q
Neuroblastoma
A
Pathogenesis: neural crest origin, involves adrenal medulla, sympathetic chain.
Clinical features:
1. Median age <2
2. Abdominal mass (most often involving adrenal galnd)
3. Periorbital ecchymosis
4. Spinal cord compression from epidural invasion “dumbbell tumor”
5. Opsoclonus-myoclonus syndrome(conjugate eye movements and involuntary jerking movements of the trunk and limbs)
Diagnostic findings:
Elevated catecholamines metabolites, small round blue cells on histology, N-myc gene amplification.
-biopsy of the mass is diagnostic and reveals small round blue cell and homer wright rosettes.
24
Q
Acute hepatitis due to inhaled anesthetics
A
- halongenated anesthetics modulate various neuronal ion channels, leading to CNS depression. They are metabolized by hepatic CP450 system by which they are converted to reactive intermediates that can directly injure the liver of lead to immune mediated hepatocellular damage.
- halothone hepatitis typically present 2 days to 3 weeks after medication exposure with fever, nausea, jaundice, tender hepatomegaly and elevated aminotransferases and billirubin levels.
- liver can show centrilobular hepatic necrosis that indistingushible from viral hepatitis.
- drugs include (enflurane, isoflurane, sevoflurane, desflurane, halothane)
25
Analgesic nephropathy
- NSAIDs can cause renal failure if taken in large amounts over extended periods.
- affected patients typically have modest elevation in serum creatinine, mild proteinuria and evidence of tubular dysfunction( polyuria, nocturia)
- microscopic hematuria and sterile pyuria may also be seen on urinalysis.
- NSAIDs concentrates in the renal medulla along the medularry osmotic gradient with higher levels in the papillae.
- prolonged use leads to chronic interstitial nephritis seen as patchy interstitial inflammation with subsequent fibrosis, tubular atrophy, papillary necrosis and scarring, and caliceal architecture distortion.
- Ca+ may deposit in areas of chronic inflammation and this calcification is visible on renal imaging. NSAID also decrease prostaglandins synthesis causing constriction of medullary vasa recta and ischemic papillary necrosis.
26
Vascular endothelium secrete what substance to inhibit platelet aggregation
Prostacyclin (prostaglandin I2)
27
Erythema infectiosum
Benign childhood illness caused by parvovirus b19, SS DNA virus.
Lacy reticular rash follows the slapped cheeck rash, spreading over the trunk and extremities. The rash may result from immune complex deposition, the timing of which coincides with increasing levels of serum virus specific IgM and IgG.
-B19 replicates in erythrocytes precursor in the bone marrow. These cells express blood group P antigen.
28
Wound healing
3 phases
1. Inflammatory phase(24 hrs)
2. Proliferative phase(3-5 days)
3. Maturation phase.(scar formation)
During healing process, fibroblast migration and proliferation are controlled by multiple growth factors including PDGF and TGF-ß.
-hypertrophic or disfiguring scars can be caused by persistently elevated TGF-ß which leads to increased fibroblast proliferation and activity.
29
Persistant gallbladder outflow obstruction leads to
1. Hydrolysis of luminal lecithins to lysolecithins -> Disrupt the protective mucus layer.
2. The luminal epithelium is then exposed to the detergent action of bile salts resulting in chemical irritation and PG release.
3. Inflammation of the mucosa and deeper tissues causes gallbladder hypo-motility —> the increasing distension and internal pressure within the gallbladder results in ischemia.
4. Bacteria invade the injured and necrotic gallbladder.
30
Pathophysiology of Preeclampsia (PE)
Abnormal placentation is the most common cause
-abnormal placental vasculature leads to placental hypoxia and ischemia which in turn result in the release of antiangiogenic factors into maternal circulation. —
31
Fridreiech ataxia
Autsosomal recessive disorder caused by mutation of the frataxin (FXN) gene.
- this gene codes for an essential mitochondrial protein involved in assembly of iron sulfur enzymes.
- an increased number of trinucleatide repeats GAA is present in mutated gene, causing decreased FXN expression.
- this leads to decreased mitochondrial energy production and increased oxidative stress, resulting in degeneration of neural tracts and peripheral nerve. The following sites of involvement are characteristic:
1. Spinocerebellar and lateral corticospinal tract degeneration causes gait ataxia and spastic muscle weakness, respectively.
2. Degeneration of the dorsal coulmn and dorsal root ganglia causes loss of position and vibration sensation.
3. Kyphoscoliosis and foot (pes cavus) are characterestic skeletal deformities.
4. Heart involevement (hypertrophic cardiomyopathy).
5. D.M develops in 10% of patients.
32
Meniere disease
Disorder of the inner ear charactrized by increased volume and pressure of endolymph (endolymphatic hydrops) that is thought to be due to defective resorption of endolymph. The resultant distension of the endolymphatic system causes damage to the vestibular and cochlear components of the inner ear.
-meniere is charactrized by : low frequency tinnitus or ringing, in the affected ear often accompanied by a feeling of fullness, vertigo: the subjective sensation of spining or motion and sensorineual hearing loss.
33
Mesothelioma
Rare malignant neoplasm arising from mesothelial cells which line body cavities.
Asbestos exposure is the primary risk factor.
Symptoms include dyspnea, and chest pain.
Hemorrhagic pleural effusions are frequently present
Nodular or smooth pleural thickening is the main finding on radiographic studies and macroscopic examination.
Histology shows: cells wtih numerous, long slender microbilli and abundant tonofilaments.
-pancytokeratin are useful for diagnosis (immunohistochemical markers).
34
Adenocarcinoma
- its the most common subtype overall, occuring most frequently in women and nonsmokers . In contrast squamous cell carcinoma and small cell lung carcinoma have strong association with smoking.
- small cell (oat cell) carcinoma is distinguished from the other types by its aggressive behavior. Its characterized by rapid growth, early local and distant spread and poor prognosis.
- clinical association: is clubbing and hypertrophic osteoarthropathy.
35
3rd pharyngeal pouch gives rise to
- thymus
| - inferior parathyroid gland (superior is from the 4th )
36
Panic attack
- typically accompanied by hyperventillation and decreased pCO2. Hypocapnia can cause decreased cerberal perfusion and thus neurological symptoms.
- its caused from decreased arterial partial CO2 tension.
37
Secondary Tb -surrounding cells CD marker
The ceseating granulomas of TB consist of large epitheloid macrophages with pale pink granular cytoplasm surrounding a central region of necrotic debris. CD14 is a surface marker of the monocyte macrophages linage.
38
Contact precautions in hospitals
Organism :
-MDR organism (MRSA, VRE) , enteric organisms (c.difficile), scabies.
Infection control measures:
-hand hygiene, nonsetrile gloves , gown, private room preferred.
39
Sickle cell disease vs HbS
- in sickle cell disease, the usual acidic glutamic acid residue at he sixth position on the beta globin chain is replaced by nonpolar valine residue forming hemoglobin S.
- this Glu-> val substitution leads to the formation of hydrophobic pocket on the beta globin surface that interacts with a complementery nonpolar residue on another hemoglobin molecule.
- the hydrophobic interaction causes polymerization of HbS molecules and subsequent erythrocytes sickling leading to membrane damage and permanent distortion of RBC, red cell sickling is promoted by low O2 levels, increased acidity and dehydration.
- in patients with HbC, glu is replace by a basic polar lysine residue. Because lys is charged there is no hydrophobic interaction between hemoglobin molecules and no polymerization/sickling. However the positive charge of lys causes HbC to have decreased mobility on electrophoresis.
40
Vasopressin effect on urea
Vasopressin produces V2 receptor mediated increase in water permability within the cortical and medullary collecting ducts. As water leaves the tubular fluid, urea concentration greatly increases in these tubular segments.
- although the cortical collecting duct is impermeable to urea, vasopressin activates urea transporters in the medullary collecting duct, increasing urea reabsorption and decreasing renal urea clearance.
- the passive reabsorption of urea into the medullary interstitial in the presence of ADH significantly increases the medullary osmotic gradient allowing the production of maximally concentrated urine.
41
Verapamil action on nodal cells
Class IV antiarrhytmics are comonly used to prevent recurrent nodal tachyarrhythmias such as PSVT. They work by blocking L-type caclcium channels in cardiac slow response tissues which causes slowing of phase 4 depolarization and reduced conduction velocity in the SA and AV nodes.
42
Severe hypoglycemia in a medical setting and nonmedical setting treated with
In a medical setting, its treated with IV glucose
In nonmedical settings, emergency glucagon kits may be needed for rapid correction of hypoglycemia. Glucagon can be injected I.M or subcutaneous by a caregiver or informed bystander.
-glucagon corrects hypoglycemia by increasing hepatic glycogenolysis and gluconeogenesis, and will typically cause a return to consiousness within 10-15 minutes of administration.
-if glucagon isnt available, buccal or sublingual glucose or sucrose may be attempted.
43
Glucagonoma
Clinical:
-necrolytic migratory erythema (elevated painful and pruritic rash typically affecting the face, groin and extremities)
-lesions enlarge and coalesce leaving a central indurated area with peripheral blistering and scaling
-D.M/ hyperglycemia
-GI symptoms.
Diagnosis:
-markedly elevated glucagon levels.
44
Synaptophysin is present in which tumor
- transmembrane glycoprotein found in presynaptic vesicles of neurons, neurectodermal and neuroendocrine cells.
- immunoreactivity of CNS tumor for synaptophysin indicates a neuronal origin.
- less than 1% of CNS tumors. The majority of primary CNS tumors in adults are of glial origin, meningioma and pituitary adenomas er the next most common.
45
GFAP is positive in what tumors
1. Glioblastoma multiforme
2. Oligodendrogliomas
3. Ependymyoma
4. Peripheral neural sheath tumors.
46
Berger disease
The most common cause of GN.
- it typically affects older children and young adults and frequently present with painless hematuria within 5-7 days of an upper respiratory tract infection.
- the hematuria lasts for several days and then subside temporarily, returning every few months or with another upper respiratory infection.
- renal biopsy is performed in pts with severe or progressive disease and will show nonspecific mesangial hypercellularity and IgA deposits.
47
Purified RNA molecule induce viral protein synthesis and viral genome replication in human
-the purified RNA molecule must be single stranded and positive sense (SS +) in order to do this function(eg, rhinovirus, enterovirus,poliovirus,coxsackie virus, Hep A...) . In general only RNA molecules purified from SS(+) viruses are infection. purified SS (-) and DsRNA molecules requires more enzymes to be infection
48
Coronary dominance
Is determined by the coronary artery that supplies blood to the posterior descending artery( PDA, or posterior interventricular artery). The PDA originates from one of following.
- right coronary artery (approximately 70% of population)
- left circumflex artery in approximately 10% of the population
- both right coronary and left circumflex artery in 20% of population.
49
Foscarnet side effects
- it can chelate calcium —> ypocalcemia
- renal wasting of magnesium —> hypomagnesemia and a reduction in the release of PTH which contributes to the hypocalcemia state. Both hypocalcemia and hypomagnesemia can promote seizures .
50
Sofosbuvir
Inhibits nonstructual protein 5B (NS5B), an RNA-dependent RNA polymerase neede for HCV replication. Adverse effects associated with its use include fatigue and nausea.
51
Mayonnaise containing food lead to food posining with
S.aureus
52
Thiamine deficiency Tx
Always give thiamine supplementation with glucose in patients suspected of having thiamine deficiency (pts who abuse alcohol and pts with a poor diet)
53
High waist circumfrence is associated with
Insulin resistance , D.M and CAD
54
Antibiotics during pregnancy
1. Tetracyclines —> teeth staining
2. Chloramphenicol —> “gray baby” syndrome
3. TMP/SMX —> neural tube defects
4. Aminoglycosides —> ototoxicity, vestibulotoxicity.
55
Oseltamivir
Is neuroaminidase inhibitor, useful in the treatment of infleunza A and B infections.
- its required for the release of virus from infected cells and for the spread of virus within the respiratory tract.
- neuroaminidase inhibitors cause the newly synthesized virions to adhere to the host cell surface and form viral aggregates, thereby reducing the spread of virus to other host cells.
56
Metrandizole assocition with alcohol
Pts recieving metronidazole can develop disulfiram like reaction shortly after ethanol consumption. Its used to treat trichonoma vaginits and bacterial vaginosis.
-disulfiram inhibits acetyldehyde dehydrognase and cause actylaldehyde accumulation. Metranidazole interaction with alcohol is similar to that with disulfiram, exhibiting comparable systemic adverse effect such as headache, abdominal cramps, nausea and flushing.
57
Lateral epicondylitis
- its classically seen in casual tennis players in whom backhand strikes transmits sudden, extreme forces through the lateral epicondyle.
- the lateral epicondyle seves as the primary attachment point for the extensor carpi radilis brevis(ECRB) and extensor digitorum which are involved in wrist extension.
- overuse of ECRB can cause repetitive microtrauma of the ECRB tendon and lead to angiofibrioblastic tendiniosis at its origin on the lateral epicondyle.
58
Sheehan syndrome
In a setting of recent delivery the most likely represents ischemic necrosis of the pituitary gland.
During pregnancy the pituitary enlarges due to estrogen induced hyperplasia of the lactotrophs. However, the blood supply to the pituitary doesnt increase proportionally . As a result the enlarged pituitary is vulnerable to ischemia in case of systemic hypotension due to peripartum hemorrhage.
(Its not to hemorrhage rather due to ischemic necrosis)
59
Short gastric arteries arises from
Splenic artery
60
TTP clinical
Low hb, low platelt, high bun and creatinine
Normal PT and PTT
Shistocytes present
Hematuria and proteinuria
61
Kimmelstiel wilson nodules
Diabetic nephropathy
62
Muscular dystrophy
| Duchenne muscular dystophy
- Is a term that applies to the various diseases that manifests with progressive muscular weakness.
- Deletion of the dystrophin gene that encodes the dystrophin protein on X chromosome P21 are the most common mutation in duchene muscular dystrophy(DMD) and becker muscular dystophy (BMD)
- framshift mutation which result in a nonfunctional protein and severe clinical manifestation in DMD
- in contrast deletion that are multiple of 3 base pairs (in-shift mutation), resulting in a truncated but functional protein and milder clinical phenotype (BMD).
- dystophin is a structual component of skeletal muscle fibers that provide mechanical stability to the sarcolemma. It links a component of the cytoskeleton (actin) to the transmembrane proteins that are connected to the extracellular matrix.
- loss of ystrophin results in cellular injury (myonecrosis). On light microscopy there is segmental degeneration and regeneration of the myofibers with marked variation in size. Over time, the muscle tissue undergoes progressive fatty replacement.”
63
Pemphigus vulgaris
- autoimmune bullous disease charactrized by painful flaccid bullae and erosions of skin and mucosal membranes.
- any mucosal site can be involved but most commonly oral mucosa.
- bullae are weak and often rupture prior to presentation with only erosions remaining.
- autoantibodies against desmosomes, sepcifically desmogleins 1 and 3 are the characterestic for this lesion.
- biopsy shows intraepithelial cleavage with detached keratinocytes.
- IF of the unaffected skin adjacent to PV shows epidermal intercellular IgG and C3 deposits.
64
How to differentiate between TTP and DIC
DIC usually have high PT and PTT while in TTP the PT and PTT are normal (problem is in platelet) .
TTP is due to impaired cleavage of vWF.
65
Kimmelstiel wilson nodules
1. Loacted in peripheral mesangium
2. Ovoid or spherical in shape
3. Lamellated appearance
4. Eosinophilic on hematoxylin and eosin stain
5. PAS + stain
66
Vareniciline in smoking cessation
The reinforcing effects of nicotine is caused by stimulation of å4ß2 nicotinic recptor in CNS. Varenciline is a partial agonist of this receptor that competes with nicotine and prevents it from binding. BCZ varenicline is partial agonist, it helps reduce the symptoms of nicotine withdrawl by mildely stimulating the receptor.
-its partial agonist activity inly causes limited downstream release of dopamine, resulting in less stimulation of the reward pathway than nicotine.
67
Ansa cervicalis
Arises from C1-C3, innervates sternohyoid, sternothyroidm and omyhyoid muscles of the anterior neck. Penetrating trauma to the neck above the cricoid cartilage can injure this nerve.
68
Subacute endocarditis
- the mitral valve is the most common valve affected by IE
- MVP is the most common underlying valvular disease predisposing to the development of IE in developed countries, particularly when its associated with coexistent mitral regurgitation.
- embolic stroke can arise from it
- risk factors include MVP, valvular sclerosis and mechanical valves.
- large friable irregular masses seen on autopsy are most likely vegitations and are the most probable source of emoblus if stroke occur.
Usmle
flashcards
Decks in class (45)
# Cards
-
Uworld- block 198
-
UWorld Block 2136
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Block 399
-
Block 482
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Block 596
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Block 691
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Block 788
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Block 969
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Block 1060
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Block 1159
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Block 1248
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Block 1352
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Block 1445
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Block 1551
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Block 1641
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Block 1745
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Block 1844
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Block 1933
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Block 2138
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Block 2235
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Block 2338
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Block 2434
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Block 2540
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Block 2657
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Block 2752
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Block 2837
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Block 2933
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Block 3037
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Block 3155
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Block 3248
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Block 3350
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Block 3445
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Block 3535
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Block 3636
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Block 3735
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Block 3828
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Block 3931
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Block 4022
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Block 4268
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Block 4358
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Block 4471
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Block 45106
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Block 4652
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Block 870
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block 2040
