Serophene

Emilio Bouza, M.D., Ph.D.

• Professor
• Clinical Microbiology
• University Complutense of Madrid
• Chief
• Clinical Microbiology and Infectious Diseases
• Hospital General Universitario Gregorio
• Mara?on (HGUGM)
• Madrid, Spain

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Which part of the cardiovascular system would often be adversly affected in this syndrome The extracellular matrix and the cytoskeleton communicate across the cell membrane through which of the following A pregnant 29-year-old woman diagnosed with type I diabetes 2 decades ago, taking Humulin three times per day, is referred to the oph thalmology clinic. Dilated indirect ophthalmoscopy coupled with biomi croscopy and fundus photography detect the presence of proliferative dia betic retinopathy with leaky retinal vessels indicative of increased vascular permeability, growth of new, fragile vessels on the retina and posterior sur face of the vitreous and macular edema. Overexpression of fibronectin is a histological marker of diabetic microangiopathy. Which of the following is the primary function of fibronectin in the basement membrane A 36-year-old man is referred by his family medicine physician to the pulmonary clinic. He complains of shortness of breath following physical activity and a decreased capacity for exercise. He says that strenuous exercise including yard work is impossible without sitting down and resting every few minutes. He is not a smoker and as an office worker he is not exposed to dust, fumes or other irritants at work. In the synthesis of collagen, the hydroxylation of proline and lysine occurs in which of the following The primary function of entactin (also known as nidogen) is to cross link which of the following A 14-year-old boy presents with thin, translucent skin, and a history of easy bruising. Imperfections in dentin formation (dentinogenesis imperfecta) 174 Anatomy, Histology, and Cell Biology 94. The tissue shown in the photomicrograph differs from white adipose tissue in which of the following ways Diseases in which there is a loss of function mutation in integrin expres sion on lymphocytes would most likely result in: a. A 33-year-old homeless woman has been living in an abandoned building eating dried meat, bread from the trash cans outside a bakery. She presents at the free clinic with bleeding under the skin particularly around hair follicles with bruises on her arms and legs. She is irritable, clinically depressed, and fatigued with general muscle weakness. She is afebrile and a glucose finger stick is nor mal and urine dipstick shows no sugar, protein or ketones. Which of the following is a major contributor to the tensile strength of collagen In adherence of epithelia to the basement membrane 176 Anatomy, Histology, and Cell Biology 99. A 40-year-old woman is referred to a dermatologist with more than 100 oval or round red-brown macules on her back. There are an excessive number of the metachromatically stained cells labeled with the arrows and shown in the inset to the lower left in the photomicrograph below. A 46-year-old woman who has been a type I diabetic for 35 years vis its your family medicine office. You prescribe Beclaperin gel, a prescription drug for the treat ment of diabetic foot ulcers. His physical examination reveals slight right-sided muscular weakness and a pulse of 78/min, regular; blood pressure 140/82 mm Hg. X-ray examina tion of the spine showed two wedged thoracic vertebrae, T7 and T8; no osteolytic lesions are observed. The bone marrow shows an increase in the cells shown in the accompany ing light micrograph. She works as a software developer and lives with her 52-year-old husband and 12-year-old daughter. She is a nonsmoker; and drinks an occasional glass of wine when she and her husband go out to din ner. On examination, the patients blood pressure is 155/100, pulse 84, weight 215 lb (increased from 180 3 years ago), height 5 ft 7 in. In this patient, dur ing the period of weight gain which of the following responses would be most expected in the cells shown in the photomicrograph Increased release of norepinephrine from nerve terminals in adipose tissue 180 Anatomy, Histology, and Cell Biology 103. A 65-year-old African-American man who has a history of both uri nary tract infections and urinary stones presents at the urology clinic with hematuria. He has a dietary history high in saturated fats and has been exposed to second-hand smoke both at home (his wife smokes) and at work where many of his coworkers smoke. Decreased elasticity of lung tissue causes an increased tendency toward spontaneous pneu mothorax, also known as a collapsed lung. The aorta is the most affected organ because of the extensive elastin in the wall, and dissecting aortic aneurysms are common in these patients. Marfan malformations include cardiovascular (valve problems as well as aortic aneurysm), skeletal (abnor mal height and severe chest deformities), and ocular systems. The result is the disloca tion of the lens because of loss of elasticity in the suspensory ligament. The receptor structure includes an intracytosolic portion that binds to the actin cytoskeleton through the attachment proteins talin or actinin. Proteoglycans (answer a) are located on the extracellular surface of the plasma membrane and throughout the extracellular matrix. The cadherins (answer c) function as transmembrane glycoproteins involved in the formation of parts of the intercellular junctional complexes. Intermediate filaments and micro tubules (answers d and e) are found intracellularly and constitute the cytoskeleton. It is important for modulation of cell migration in the adult and during development. Neural crest and other cells appear 181 182 Anatomy, Histology, and Cell Biology to be guided along fibronectin-coated pathways in the embryo. Fibronectin is found in three forms: a plasma form that is involved in blood clotting; a cell-surface form, which binds to the cell surface transiently; and a matrix form, which is fibrillar in arrangement. Cell-cell interactions involve both transient and more long-term, stable processes. Cell-cell adhesion is mediated by transmembrane proteins called cell adhesion mol ecules which include the calcium or magnesium-dependent selectins, inte grins, and cadherins (answers c and d) and the non-calcium-dependent immunoglobulin (Ig) superfamily. The stable adhesion junction, known as the zonula adherens, links the cytoskeleton of adjacent cells through cad herins (transmembrane linker proteins) to actin filaments inside the cell [answer e (see feedback for question 199)]. Desmosine and isodesmosine are amino acids unique to elastin and responsible for the covalent binding of elastin fibers to each other. Microfibrils, composed of fibrillin, facilitate for mation of the elastin molecules, but are not directly involved in cross-linking. One third of elastin is composed of the hydrophobic amino acid glycine, which is randomly distributed throughout the elastin molecule. The overall hydrophobicity of elastin molecules allows for their distensibility and facilitates their capacity to slide over one another. Hydroxyproline, which constitutes 10% of collagen, is often used to determine the collagen content of various tis sues. Hydroxylation of proline stabilizes the triple helix through interchain hydrogen bonds, and hydroxylation of lysine is critical for the cross-linking stage of collagen assembly. Procollagen is sub sequently transported in transfer vesicles to the Golgi for packaging into secretory vesicles. Transport of secretory vesicles is an energy and micro tubule-dependent process. Outside of the cell, N-terminal and C-terminal specific procollagen peptidases cleave the nonhelical registration peptides, which results in the formation of tropocollagen. Tropocollagen sponta neously assembles in a staggered array to form collagen fibrils. Lysyl oxi dase (answer a) is an extracellular enzyme responsible for the formation of covalent cross-links between tropocollagen molecules. Fibrils form colla gen fibers under the influence of other extracellular matrix constituents, such as proteoglycans and glycoproteins. Collagenases (answer d) specifi cally cleave tropocollagen in the extracellular matrix. Integrins like laminin receptors (answer b) bind cells to the basal lamina; fibronectin receptors bind cells to the extracellular matrix (answer c). Laminin receptors in the cell mem brane also organize the assembly of the basal lamina. Collagen (answer d) is cross-linked by covalent intramolecular and intermolecular cross-links that form primarily between the nonhelical segments at the ends of the collagen molecules. Lysyl oxidase is a key enzyme in the cross-linking process; it deaminates lysine and hydroxylysine to form aldehyde groups that react with each other to form the covalent bonds. Actin is cross-linked 184 Anatomy, Histology, and Cell Biology (answer e) into bundles by actin-binding proteins such as the bundling protein actinin and the gel-forming protein (fimbrin). This results from a genetic mutation that alters the propeptide sequence in such a way that the molecular orientation and cross-linking are adversely affected. Both types of fat tissue (brown and white) are highly vascularized and function in protection from the cold. Brown fat specifically is involved in heat production, whereas white fat is a true thermal insulator. Brown fat is involved in nonshiver ing thermogenesis and generates heat (answer c), probably as a protective device for developing organs in the fetus and neonate. White adipose tissue is specialized for lipid storage and functions as a thermal insulator (answer b) and shock absorber. White adipose tissue is unilocular, and the cells have a single, large lipid droplet in the cytoplasm that provides the signet-ring appearance often described for fat cells. Brown adipose tissue has a multiloc ular appearance and is brown because of numerous mitochondria. In white adipocytes, the released fatty acids and glycerol are exported from the cells. Heat is transferred to the blood by the extensive capillary networks found in brown adipose tissue. Shivering (answer e) initiates the mobilization of lipid in white adi pose tissue because shivering requires energy. E and P-selectins bind reversibly to glycoproteins on leukocytes causing them to roll along the endothelial surface. Adhesion of leukocytes results in arrest of leukocyte motion, allowing secreted proteases to disrupt endothelial tight junctions and the basement membrane, subsequently resulting in diapedesis. Lymphocyte apoptosis (answer d) is not regulated directly by integrins and plasma cells do not normally enter the blood (answer e). The leukocyte adhesion cascade involves several precise ordered steps: rolling, integrin activation and firm adhesion of the leuko cytes, all necessary prerequisites to transendothelial migration. The woman in the scenario is pregnant, smokes, and has a diet deficient in fresh fruits and vegetables. Scurvy, or vitamin C deficiency, results in an inability to form normal collagen triple helices. In scurvy, the resulting collagen is less stable and is subject to denaturation and proteolytic breakdown (answer a). The collagen formed is not normally hydroxylated at proline and lysine residues because of the absence of vitamin C, which is a specific cofactor for hydroxylation of pro line and lysine (answer b). Bone structure and the dentition may be abnor mal and wound and fracture healing delayed (answer d). General tissue instability may occur because collagen synthesis is necessary for mainte nance of structural support (answer e). The organization of collagen in tissues also varies, depending on function, from the layered appearance in bone to the axial parallel bundles in tendons and the wickered pattern in skin. The interac tions with fibril-associated collagens (with interrupted triple helices) regulate 188 Anatomy, Histology, and Cell Biology orientation and are also important in establishing tissue organization and flexibility (answer a). Electrostatic interactions (answer c) do not play a significant role in maintenance of collagen tensile strength. Lysine, along with hydroxylysine, is the substrate for lysyl oxidase that catalyzes the for mation of cross-links (answer e). Laminin in the lamina rara (lucida) of the basal lamina binds to the laminin receptor (integrin) on the epithelial cell (answer a). Cell-cell interactions (answer b) are modulated by the cell adhesion molecules [e. The highly charged glycosaminoglycans are responsible for the filtration characteris tics (answer d) of the basement membrane.

Diseases

• Cryptorchidism arachnodactyly mental retardation
• Collagen disorder
• Arthrogryposis due to muscular dystrophy
• Marfan-like syndrome, Boileau type
• Mental retardation X linked Atkin type
• Achondrogenesis Kozlowski type
• Chorea minor
• Umbilical cord ulceration intestinal atresia
• Shwachman Bodian Diamond syndrome
• Rubinstein Taybi like syndrome

The adopted amend General Counsel ments replace the term "Medical Review Division" with "Commis Texas Workers Compensation Commission sion" in subsection (f) because other divisions within the commis Effective date: April 28 menopause research purchase serophene online pills, 2005 sion may order medical providers to reimburse insurance carri Proposal publication date: February 4 womens health kaiser roseville generic 100 mg serophene with visa, 2005 ers menstruation for 2 weeks buy serophene 50mg amex. Commenter stated the move to electronic bill submis the proposed text as published in the February 25 women's health questions to ask your doctor discount 100mg serophene otc, 2005 women's health clinic midland tx buy 100mg serophene overnight delivery, issue sions and reimbursement data will result in significant improve of the Texas Register (30TexReg1028) menstruation unclean bible buy serophene in india. The amendment is necessary because there menters actually opposed remote-controlled hunting and did not is no way for the department to verify compliance with hunting understand that the proposal would prohibit, rather than allow, license laws if the participating party is not physically present remote-controlled hunting. The current rule prohibits the use of a motor adoption of the portion of the proposed rule addressing remote ized conveyance to locate or hunt desert bighorn sheep. The commenters did not elaborate upon their til recently, the hunting of bighorn sheep was conducted exclu rationale for opposition. The department disagrees with the com sively on department lands, where the department has the au ments. However, in recent years the department has issued permits that authorize the hunting of the department received 320 comments supporting adoption of bighorn sheep on private property. The proposed amendment would make the reg the Texas Wildlife Association and the Texas Deer Association ulation consistent with the statute. The department tion by making the rules governing the hunting of desert bighorn disagrees with the comments and responds that hunting from sheep consistent with statutory provisions. No changes were made as a result of the com adoption of the portion of the rule governing remote-controlled ments. Ten of those commenting provided an elaboration of the amendment is adopted under the authority of Parks and the reasons for opposing adoption. The departments response Wildlife Code, Chapter 61, Uniform Wildlife Regulatory Act to those comments is as follows. The commenter went on to say that license data or aquatic animal life and the means, methods, and places in could be required to be entered prior to the system allowing which it is lawful to hunt, take, or possess game animals, game control of the firearm, followed by a simple validation scheme birds, or aquatic animal life. The commenter further this agency hereby certifies that the adoption has been reviewed stated that the departments position was like saying that a store by legal counsel and found to be a valid exercise of the agencys cant validate a credit card number and balance if the customer legal authority. The department disagrees with the commenter and responds that license validation isnt the issue; Filed with the Office of the Secretary of State on April 8, 2005. The department also Chief of Staff responds that the credit card analogy is not apposite, since the Texas Parks and Wildlife Commission validation of a credit card establishes only whether the card is Effective date: April 28, 2005 valid and the account balance is sufficient, not the identity of Proposal publication date: February 25, 2005 the person presenting the card. The department also responds For further information, please call: (512) 389-4775 that even if license compliance could be verified via electronic means, the cost to the department could not be justified given the minuscule number of persons likely to use such systems. Adoption is without change from the 30 TexReg 2400 April 22, 2005 Texas Register proposed text as published in the February 18, 2005, issue of Filed with the Office of the Secretary of State on April 11, 2005. Martin Cherry this amended rule adoption will allow the State Board, on Chief Deputy General Counsel a case-by-case basis, to grant a waiver to allow an eligible Comptroller of Public Accounts landowner to receive another cost-share under specific circum Effective date: May 1, 2005 stances. Determinations for another cost-share will be made Proposal publication date: February 11, 2005 for continued implementation of best management practices For further information, please call: (512) 475-0387 to adress nonpoint source pollution in areas of the state with potential and/or identified problems. The amendment specifically addresses the penalty and interest Filed with the Office of the Secretary of State on April 6, 2005. Mel Davis No comments were received regarding adoption of the amend Special Projects Coordinator ment. Notice of adoption of the new rule can be found in the Texas Youth Commission (the commission) adopts an this issue of the Texas Register. Effective date: April 27, 2005 this agency hereby certifies that the adoption has been reviewed Proposal publication date: February 18, 2005 by legal counsel and found to be a valid exercise of the agencys For further information, please call: (512) 424-6014 legal authority. Proposal publication date: February 18, 2005 the new rule will provide greater consistency and clarity re For further information, please call: (512) 424-6014 garding the process for admitting youth to the Medical Recovery Dorm at the Al Price State Juvenile correctional facility. This agency hereby certifies that the adoption has been reviewed Filed with the Office of the Secretary of State on April 7, 2005. Notice of Public Hearing the deadline for questions is May 4, 2005 and the deadline for pro the Texas Department of Agriculture (department) will hold a public posals is May 11, 2005 at 3:00 P. The hearing will be held on Wednesday, April 27, 2005, beginning at Parties interested in submitting a proposal may obtain in 1:30 p. A copy of For more information, please contact Karl Young, Texas Department downloaded from the Electronic State Business Daily at of Agriculture, P. This activity consists of the permanent placement of a sumer1/Agricultural/Commercial2/credit thru $250,000. Note: the con meets or exceeds teacher standards required for special and general ed sistency review for this project may be conducted by the Texas Com ucation. Funds are awarded on an annual to submit comments on whether a proposed action is or is not consis basis with continuation funding evaluated yearly. Non-federal match tent with the Texas Coastal Management Program goals and policies ing funds of at least 10% of total project costs are required for projects and whether the action should be referred to the Coastal Coordination in federally designated poverty areas. Tammy Brooks, Program Specialist, Coastal Coordi Additional information concerning this request for proposal or more nation Council, P. All questions pertaining to Brooks at the above address or by fax at (512) 475-0680. In addition, answers to frequently asked questions will be ucation service centers as partners. The grant project timeline for professional development must address time East Texas Council of Governments allocated for progress monitoring to ensure teacher implementation of training received. Professional development activities should vision of the State of Texas governing the 14 county Uniform Planning Region 6, is soliciting proposals for independent audit services for fis be planned and implemented based on a comprehensive assessment of cal year 2004 2005. Audit will cover federal and state grants and all other programs admin Dates of Project. Audit must comply with the Single Audit Act and related through Professional Development Partnerships Grants will be imple amendments as well as applicable Office of Management and Budget mented during the 2005-2006 school year. Applicants should plan for a starting date of no earlier than August 15, 2005, and an ending date Circulars. Applications will be selected based on the indepen quest by letter, email or by phone. Reviewers will evaluate applica tions based on the overall quality and validity of the proposed grant be made to (903) 984-8641 or email at judy. An eligible partnership shall include 1) a mathe by faxing (512) 463-9811; or by e-mailing dcc@tea. Thepartnershipmayalsoin complete mailing address, and phone number including area code. Copies of all by contacting Becky Petty, Staff Attorney at 512/239-3693, Texas such inquiries and the written answers thereto will be posted on the Commission on Environmental Quality, P. Texas Education Agency Filed: April 13, 2005 An agreed order was entered regarding Deer Creek Ranch, Inc. Texas Commission on Environmental Quality Information concerning any aspect of this order may be obtained by Enforcement Orders contacting Lindsay Andrus, Staff Attorney at 512/239-4761, Texas Commission on Environmental Quality, P. Box 13087, Austin, An order was entered regarding Midway Armadillo Corporation and Texas 78711-3087. Box 13087, Austin, An agreed order was entered regarding City of Marlin, Docket No. Information concerning any aspect of this order may be ob An agreed order was entered regarding Frank Pokluda dba Time Mart tained by contacting Mauricio Olaya, Enforcement Coordinator at No. Information concerning any aspect of this order may be obtained by An agreed order was entered regarding Mary and Rick Hooper dba contacting Lindsay Andrus, Staff Attorney at 512/239-4761, Texas Seven Oaks Motel Complex Sewage Treatment Plant, Docket No. Box 13087, Austin, Information concerning any aspect of this order may be obtained by Texas 78711-3087. Information concerning any aspect of this order may be obtained by contacting Wendy Cooper, Staff Attorney at 817/588-5867, Texas An agreed order was entered regarding Duke Energy Field Services, Commission on Environmental Quality, P. Information concerning any aspect of this order may be obtained by contacting Tel Croston, Enforcement Coordinator at 512/239-5717, 30 TexReg 2436 April 22, 2005 Texas Register Texas Commission on Environmental Quality, P. Information concerning any aspect of this order may be ob Information concerning any aspect of this order may be obtained by tained by contacting Mauricio Olaya, Enforcement Coordinator at contacting Carolyn Lind, Enforcement Coordinator at 903/535-5145, 915/834-4967, Texas Commission on Environmental Quality, P. An agreed order was entered regarding La Gloria Oil And Gas An agreed order was entered regarding Joey Claybar and Ambrose Company, Docket No. Information concerning any aspect of this order may be obtained by contacting Alfred Okpohworho, Staff Attorney at 713/422-8918, Texas Information concerning any aspect of this order may be obtained by Commission on Environmental Quality, P. Box 13087, Austin, Texas contacting John Barry, Enforcement Coordinator at 409/899-8781, 78711-3087. Information concerning any aspect of this order may be obtained by contacting Audra Ruble, Enforcement Coordinator at 361/825-3126, Information concerning any aspect of this order may be obtained by Texas Commission on Environmental Quality, P. Box 13087, Austin, contacting Cari Bing, Enforcement Coordinator at 512/239-1445, Texas 78711-3087. A default order was entered regarding Kourosh Khabazian and Mil lennium Car Care and Sales, Inc. Information concerning any aspect of this order may be obtained by contacting Barbara Klein, Staff Attorney at 512/239-1320, Texas Information concerning any aspect of this order may be obtained by Commission on Environmental Quality, P. Box 13087, Austin, contacting Steven Lopez, Enforcement Coordinator at 512/239-1896, Texas 78711-3087. Information concerning any aspect of this order may be obtained by contacting Lori Thompson, Enforcement Coordinator at 903/535-5116, Information concerning any aspect of this order may be obtained Texas Commission on Environmental Quality, P. Box 13087, Austin, by contacting Rebecca Johnson, Enforcement Coordinator at Texas 78711-3087. Information concerning any aspect of this order may be obtained by contacting Trina Grieco, Enforcement Coordinator at 713/767-3607, Information concerning any aspect of this order may be ob Texas Commission on Environmental Quality, P. Box 13087, Austin, tained by contacting Mauricio Olaya, Enforcement Coordinator at Texas 78711-3087. An agreed order was entered regarding Harriet McDaniel dba Break Away Airport, Docket No. Information concerning any aspect of this order may be obtained by contacting Leila Pezeshki, Enforcement Coordinator at 210/403-4080, Information concerning any aspect of this order may be ob Texas Commission on Environmental Quality, P. Box 13087, Austin, tained by contacting Kensley Greuter, Enforcement Coordinator at Texas 78711-3087. Information concerning any aspect of this order may be obtained Information concerning any aspect of this order may be obtained by by contacting David Van Soest, Enforcement Coordinator at contacting Erika Fair, Enforcement Coordinator at 512/239-6673, 512/239-0468, Texas Commission on Environmental Quality, P. An agreed order was entered regarding Noemi Salinas dba El Alto An agreed order was entered regarding Robbins Chevrolet Company, Country Store, Docket No. Information concerning any aspect of this order may be obtained by Information concerning any aspect of this order may be obtained by contacting Jaime Garza, Enforcement Coordinator at 956/430-6030, contacting Kimberly Morales, Enforcement Coordinator at 713/422 Texas Commission on Environmental Quality, P. Information concerning any aspect of this order may be ob tained by contacting Mauricio Olaya, Enforcement Coordinator at Information concerning any aspect of this order may be obtained by 915/834-4967, Texas Commission on Environmental Quality, P. Information concerning any aspect of this order may be ob tained by contacting Mauricio Olaya, Enforcement Coordinator at Information concerning any aspect of this order may be obtained 915/834-4967, Texas Commission on Environmental Quality, P. Information concerning any aspect of this order may be obtained by contacting Jaime Garza, Enforcement Coordinator at 956/430-6030, Information concerning any aspect of this order may be obtained by Texas Commission on Environmental Quality, P. Box 13087, Austin, contacting Jill Reed, Enforcement Coordinator at 432/620-6132, Texas Texas 78711-3087. Information concerning any aspect of this order may be obtained by contacting Mac Vilas, Enforcement Coordinator at 512/239-2557, Information concerning any aspect of this order may be obtained by Texas Commission on Environmental Quality, P. Box 13087, contacting Chris Friesenhahn, Enforcement Coordinator at 210/403 Austin, Texas 78711-3087. Information concerning any aspect of this order may be obtained by contacting Daniel Siringi, Enforcement Coordinator at 409/899-8799, Information concerning any aspect of this order may be obtained by Texas Commission on Environmental Quality, P. Box 13087, Austin, contacting Harvey Wilson, Enforcement Coordinator at 512/239-0321, Texas 78711-3087. Box 13087, Austin, and operate additional facilities, systems, plants, and enterprises con Texas 78711-3087. According to the petition, the Petitioner has conducted An agreed order was entered regarding Mission Resources Corpora a preliminary investigation to determine the cost of the project, and tion, Docket No. To request a contested case hearing, you must submit the An agreed order was entered regarding Dos Investment, Inc. Box 13087, way not common to the general public; and (5) the location of your Austin, Texas 78711-3087. The Executive Director may approve a petition unless a written request Information concerning any aspect of this order may be obtained by for a contested case hearing is filed within 30 days after the newspaper contacting Jill Reed, Enforcement Coordinator at 432/620-6132, Texas publication of the notice. If a hearing request is filed, the Executive Commission on Environmental Quality, P. Box 13087, Austin, Texas Director will not approve the petition and will forward the petition and 78711-3087. If a contested case hearing is held, LaDonna Castanuela it will be a legal proceeding similar to a civil trial in state district court. For additional informa tion, individual members of the general public may contact the Office Notice of District Petition of Public Assistance, at 1-800-687 4040.

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Clas does not produce urine (which is a component sically, a regular and symmetric 3-Hz spike is of amniotic fuid), there is a smaller volume of found on electroencephalography. This is described mide is the primary treatment option in cases by the term oligohydramnios. Carbamazepine has nary hypoplasia, fetal compression with altered been associated with the exacerbation of ab facies, and positioning defects of hands and sence seizures. These adjunctive therapies, however, is a connection between the pulmonary artery have limited effcacy. This pathway should associated with the exacerbation of absence be open during gestation and is not an abnor seizures. The teachers concerns increase in oxygen content causes a decrease in regarding the boy are quite common in the prostaglandins, resulting in closure of the con case of absence seizures. If the ductus arteriosus remains patent will be incorrectly attributed to inattentiveness after birth, the baby can be given indomethacin to help stimulate the vessel to close. They are abundant in cells that require a large amount of energy, such as myocytes. Secondary lysosomes multiple myeloma, a neoplastic proliferation are formed when a primary lysosome, with its of plasma cells in the bone marrow that often hydrolytic enzymes, fuses with materials for leads to lytic bone lesions and pathological degradation. Cells B lymphocyte that can produce and secrete such as macrophages, which are responsible large amounts of antibody specifc to a par for phagocytosis of cell debris, may contain ticular antigen. Areas of rough endo of one isotype and antigen specifcally, which plasmic reticulum in neurons are called Nissl can be detected as an M spike by serum pro bodies. A 41-year-old man is admitted to the hospital sician by her distraught parents because of a for progressive obtundation. On admission the sore throat, diffculty breathing, and a barking patients serum sodium level is 114 mEq/L. On physical examina Treatment is initiated, and seven hours later tion, the toddler is found to have some respi the patients serum sodium level is 134 mEq/L. The rest of the examination is worsens with the development of dysarthria, unremarkable. A 32-year-old woman presents to her family doctor complaining of fatigue, myalgia, and 4. Labo nation reveals cervical lymphadenopathy and ratory analysis reveals: the rash seen in the image. Parathyroid hormone: 750 pg/mL Which of the following most likely contributes to the pathogenesis of this mans bone disease Colonoscopy of one of the af fected patients reveals colonic infamma tion with exudates and necrosis of the muco Courtesy of Dr. Which of the following is the micro biology laboratory likely to isolate from the af (A) Aortic aneurysm fected patients A 68-year-old woman presents to the emer (E) A gram-positive anaerobe gency department with altered mental status. A 9-year-old boy is brought to the emergency rate is 116/min, respiratory rate is 23/min, department with a two-day history of abdomi and blood pressure is 132/87 mm Hg. Which of the follow diffuse abdominal tenderness and a rash over ing is the most accurate description of the pa the arms and the legs. What is the most likely etiology (C) Metabolic acidosis with respiratory com of this patients symptoms A renal biopsy specimen is obtained and reveals a focal proliferative glo merulonephritis, characterized by linear stain ing of the basement membrane on immuno fuorescence for IgG. He is subsequently found to have an eye tumor that is caused by dysfunction of a spe B cifc cell-cycle regulatory gene product. A biopsy is taken, and fever, diaphoresis, mydriasis, and severe agita the results are shown in the image. When asked, his mother states that her the following is the most likely diagnosis A 64-year-old man with a history of hyper tension, coronary artery disease, and type 2 diabetes presents to his physician because he has trouble seeing. A 28-year-old woman with a past medical his with sparing of Meyers loop tory signifcant for pelvic infammatory dis (E) Right posterior cerebral artery infarction ease presents to the emergency department with sparing of the occipital pole with right lower quadrant abdominal pain. A 60-year-old woman is receiving chemother sistently localized to the right lower quadrant apy for breast cancer. She presents to her on without migration, and has been associated cologist complaining of fatigue and dyspnea with nausea and vomiting. Physical examination reveals an ods are usually regular, her last menstruation elevated jugular venous pressure, crackles, and was approximately six weeks ago. X-ray of the chest tion, she is found to be afebrile with a blood shows an enlarged cardiac silhouette. Her on pressure of 90/60 mm Hg, a pulse of 110/min, cologist believes her chemotherapeutic agent and a respiratory rate of 26/min. What is the examination shows localized tenderness with mechanism of the chemotherapeutic agent she guarding in the right lower quadrant. Laboratory stud (B) Inhibition of dihydrofolate reductase ies show a hematocrit of 29. Which of the following is the most likely (E) Selective estrogen receptor modulator etiology of this patients illness A 22-year-old woman comes to your offce Glucose: 96 mg/dL complaining of vaginal itching and burn Serum osmolality: 250 mOsm/kg ing. She says she feels as if she has the fu Which of the following is the most likely cause and has had intermittent fevers and muscle of this patients condition Vaginal examina tion reveals the lesion seen in the image, and (A) Excessive fuid intake treatment is started. The patient subsequently (B) Glioblastoma multiforme develops elevated levels of blood urea nitro (C) Metastatic breast cancer gen and creatinine in addition to a tremor and (D) Small cell lung cancer mental status changes. Which of the following (E) Squamous cell lung cancer agents did this patient most likely receive A 33-year-old man from upstate New York comes to his physician because of fu-like symptoms after a camping trip one week ago. He also notes a troubling rash on his leg that has moved slowly from his ankle to his midthigh over the past several days. The patient recently lost his pre scription benefts through his health insurance plan, so he uses an old bottle of tetracycline from his medicine cabinet at home. One week later the man presents to the emergency de partment with signs of dehydration and a cre atinine level of 3. When asked about into the emergency department after having a her sleeping habits in greater depth, she re witnessed tonic-clonic seizure lasting two min ports sleeping for seven-nine hours per night, utes. Throughout the veals no abnormalities, and the patients vital course of the visit, the patient becomes pro signs are all within normal limits. Laboratory gressively more animated and begins making tests show: aggressive sexual advances toward the physi cian and the staff. She reports that her mood Na+: 123 mEq/L has been good, but not overly elevated, expan K+: 3. The following graph is a depiction of the Star (E) Schizotypal personality disorder ling curve showing the relationship between cardiac output and ventricular end diastolic 21. A 37-year-old man complains of an unsteady volume in a patient with congestive heart fail gait when he walks. If this patient is treated with a positive abuse, alcohol abuse, and numerous sex part inotropic agent, the Starling curve would do ners. A 16-year-old girl visits her family physician (E) Treponema pallidum with complaints of amenorrhea. A 2-year-old boy presents to his pediatrician expected for her height, she doesnt think she with hepatosplenomegaly, failure to thrive, and is skinny enough. After breaking up with her progressive central nervous system deteriora boyfriend a year ago, she dropped out of cheer tion. Liver biopsy shows that hepatocytes and leading and has been struggling with school, Kupffer cells have a foamy, vacuolated appear although she used to be an honors student. The pediatrician suspects that the boy She admits to crying spells, feeling guilty, and will die by age three. Which of the following is the function of the metabolic enzyme def medications is contraindicated in this patient A patient with adult T-lymphocyte leukemia receives a bone marrow transplant from an un related donor. Despite an immunosuppressive p55 post-transplant treatment regimen, over the course of several weeks the patient develops a severe cutaneous rash and intractable diarrhea. Blood tests were normal except for alanine aminotransferase (1032 U/L), aspartate ami p24 notransferase (829 U/L), lactate dehydrogen gag ase (634 U/L), and alkaline phosphatase (446 U/L). Which of the following is the most likely p18 etiology of the patients current symptoms The motherapeutic agents that are used for the image shows the results: tube 1 is the control treatment of choriocarcinoma as a part of the for positives, tube 2 is the control for negatives, mechlorethamine/Oncovin/procarbazine/pred and tube 3 is the patients sample. Vincristines mechanism of the following is the most appropriate next step action makes the drug specifc for which phase for the clinician A 3-year-old boy is brought to the pediatrician fce three months after a diffcult delivery. She because of decreased vision and pain in his describes constant fatigue and recent weight right eye. She has the diagnosis of glaucoma shortly after birth been bottle-feeding, because breastfeeding did that has been refractory to standard medical not work. Which of the following abnormalities would support the most likely additional signs is most likely on physical ex diagnosis On fur mL ther questioning, the patients parents say that (D) Total serum thyroxine, 1. Which of the following laboratory test abnormal facies becomes cyanotic and hypoxic results corresponds to the patients disorder On physical examination, the neonatologist hears a crescendo-decrescendo Partial Choice Platelet Bleeding Prothrombin thromboplastin murmur with a harsh systolic ejection. Exami A normal normal normal nation of this patients serum is likely to reveal B normal normal normal which of the following An obese 32-year-old man presents at the (A) Cimetidine clinic complaining of increasing diffculty (B) Magnesium hydroxide catching his breath. He also reports that he has (C) Misoprostol been wheezing and has a productive cough. A 43-year-old man with a history of hypercal smoking cigarettes for the past 15 years. Fam cemia and bitemporal hemianopsia presents ily history is signifcant for a father with sig to the emergency department with muscle nifcant lung disease. He re basilar hyperlucency that is localized solely to ports brief episodes of complete paralysis in his the lung bases and not the apices. The pH of the patients na is also at increased risk for which other condi sogastric suction fuid is increased. The patients family history is positive for numerous endo (A) Cor pulmonale crine organ abnormalities. Which of the fol (B) Liver cirrhosis lowing is the most likely cause of this patients (C) Pseudomonal pneumonia symptoms A 32-year-old woman presents to the emer (B) Gastrinoma gency department with mental status changes, (C) Insulinoma severe weakness, and multiple petechiae evolv (D) Pheochromocytoma ing over the past three weeks. Patients with Paget disease of the bone usually studies show a severe anemia, thrombocyto have serum calcium levels between 8. During the second phase of following chromosomal translocations is most the disease, which of the following laboratory likely involved in this disorder A 17-year-old girl who is six weeks pregnant presents to the emergency department be B 50 5. Physical examination (A) Menopause shows that the patient is breathing abnormally (B) Parkinson disease fast, and the tips of his fngers have a slight (C) Schizophrenia bluish tinge. X-ray of the chest reveals diffuse (D) Turner syndrome interstitial pneumonia with a ground-glass ap (E) Type 2 diabetes mellitus pearance. A 37-year-old man with end-stage liver disease secondary to hepatitis C presents to the emer (A) Fluconazole or ketoconazole gency department confused and lethargic. He (B) Itraconazole or potassium iodide has ascites, spider angiomata, and asterixis. Laboratory studies (D) Topical miconazole or selenium sulfde show the following results: (E) Trimethoprim-sulfamethoxazole Aspartate aminotransferase: 46 U/L 40. A 17-year-old girl with type 1 diabetes mellitus Alanine aminotransferase: 55 U/L gives birth to a baby boy at 37 weeks gestation Alkaline phosphatase: 100 U/L by cesarean section. His Prothrombin time: 38 seconds heart rate is 80/min, and he does not respond Albumin: 2. Muscle tone is absent, and Which of the following is the mechanism of his cry is weak. A 60-year-old Scandinavian woman presents a show large pleural-based mass in the right to her doctor with a two-month history of pro lower lung.

From Murthy L (2006) Implications of dirty and wet rags womens health 7 day detox 50mg serophene overnight delivery, 34 Bangladesh Monira used to rinse her rags in water from the well without using soap women's health center centrastate buy serophene 100 mg cheap, and hide them behind beams in the house or in the roof thatch where they grew mould women's health boca raton fl order serophene with amex, "I put the rags in any crack where no-one would see them breast cancer 900 serophene 100 mg otc. One in three girls fail to change their cloths frequently or wash them with soap after use womens health quiz serophene 25 mg lowest price. A number of alternative methods used However menstruation tracker order serophene now, once the rainy session arrived, the girls returned by women and girls have been documented. There was just not enough sunlight these practical measures do not all meet basic each day to fully dry the rags. Washing, drying and storing cloths in emergency contexts poses additional challenges. It also has an impact on the sustainability of supply, such as in Disposal of sanitary products into latrines emergency situations. When there is no convenient established method for the the waste disposal chain disposal of sanitary products, girls and women often dispose of their pads or cloths into latrines. In principle, the rate at which pit contents break down through biological activity should be similar to the rate of flling, thus providing a long service for the pit. This is the case of much household waste disposed of into the latrine, such as plastics, glass, cans and fabrics. Once a latrine is full, it can no longer fulfl its function to provide safe, hygienic and dignifed sanitation for its owners. The costs of dealing with full pit latrines are high, comparable in many instances to the costs of installing new pit latrines. There are not many studies available about degradation processes happening inside latrines, and even less, if any, regarding decomposition of menstrual hygiene materials inside latrines. It is very probable that pads and cloths are not easily biodegradable, and can contribute to increasing the flling rates of pit latrines41. Disposal of blood from menstrual cups Care should be taken for the safe disposal of blood from menstrual cups. It can be poured safely into a pour fush or pit latrine, or disposed of in a pit and covered with a layer of soil. Modifying latrines to be menstrual hygiene-friendly Latrines in Afghanistan traditionally have a urine diversion channel, which goes through a hole to the outside of the latrine, then drips down the outside wall or through a pipe that pours into the open. These designs may cause women and girls who are menstruating to not want to use the latrine. A small adaption can be made by adding an external pipe to direct the urine into the ground rather than exposing it and blood to the environment. Girls latrines with an integral incinerator, Tamil Nadu, India Disposal shoot inside the latrine Fire grill inside incinerator External view of the latrine and incin erator (All photos: Ministry of Rural Development, Government of India) Refer to Toolkit 3. There are also locally adapted methods of using low-cost products made 11 2011 conversion rates used. The LaunchPad is expected to be in 15 National Rural Health Mission (no date) Operational production in 2012 in Rwanda. Module four Working with communities on menstrual hygiene Part of Menstrual hygiene matters; A resource for improving menstrual hygiene around the world, written by Sarah House, Therese Mahon and Sue Cavill (2012). Benefts of good menstrual hygiene Sometimes community programmes can be linked into schools menstrual hygiene activities. Amina Khatum began working with the girls at the Char Bramagacha school a few months ago. The programme is working Community channels can be particularly important to reach in 68 upazilas (districts) in low-lying areas and the girls who dont attend school. The module on schools and Chittagong Hill Tracts to assist the installation of menstrual hygiene (Module 5) provides some ideas that drinking water and sanitation facilities, and ensure could also be adapted for use in community settings to that knowledge of good hygiene enables people to reach girls not in school. Educating mother[s] who could be the main source of information to pass out to their young girls should be taken seriously. This approach is intended not only to educate mothers to improve their own health, but also to help them overcome shyness and pass on accurate information to their daughters. Currently female relatives sometimes pass on unhealthy practices, because they are not properly educated or confdent talking about menstrual hygiene themselves. Top right: Not disposing of used sanitary materials hygienically can dirty the environment. Opposite: Safe disposal of used sanitary napkins in an appropriate place can prevent environmental waste problems. The most important step in establishing access to affordable and appropriate sanitary materials is the involvement of women and girls in the selection process, and in the design and planning of interventions. The following example indicates the various responsibilities of different actors in the programme. Water, sanitation and hygiene facilities in the household As the women and girls in a household may not control the family fnances, men and boys may need to be engaged to help improve the water, sanitation and hygiene situation at household level. Module fve Working with schools on menstrual hygiene Part of Menstrual hygiene matters; A resource for improving menstrual hygiene around the world, written by Sarah House, Therese Mahon and Sue Cavill (2012). Step-by-step approach to supporting menstrual 2007-8 Education civil engineers trained on girl hygiene in schools friendly toilet designs. Steps included training engineers, building the capacity of teachers and exchanging learning, 2007-8 Student assemblies established to look all of which has increased the knowledge and confdence of after use and maintenance [of facilities]. Eforts were made to integrate issues relating to both accessibility and menstrual hygiene throughout, including into school management, infrastructure, the curriculum and monitoring routines. This was to develop teacher training guidance notes to assist them in supporting girls with their menstrual hygiene learning using a Tanzanian girls menstrual hygiene booklet2. Trials were also undertaken to distribute the girls menstrual hygiene book at scale, to every girl in the last three years of primary school across four districts of Tanzania. This was a learning process for a possible national scale-up to all districts and to investigate the options for menstrual protection disposal methods, including incineration. The fndings from this research will be incorporated into the fnal version of the national school water, sanitation and (Picture: Government of the United Republic of Tanzania/ Rashid Mbago, reproduced directly from the Tanzania girls hygiene guidelines. Somewhat There is some smell and/or some sign of fecal matter and/or some flies and/or Clean some litter. Not Clean There is a strong smell and/or presence fecal matter and/or a significant fly problem and/or a large amount of litter. What facilities and programmes are there in the school for promoting safe and private menstrual hygiene for older girls Yes No 8 Is there any operation and maintenance mechanism Yes No for the designed latrine Hygiene (menstrual) 1 Have any staff members been trained on menstrual Yes No health and hygiene education/promotion Yes No Napkin 1 Are napkins available in the school office for Yes No emergency need of the girls Dustbin 1 Is there dustbin available for disposal of napkins in Yes No the toilet Yes No 5 Is napkin and solid waste disposal system in place Yes No and functioning Note that menstrual hygiene interventions are needed in both primary and secondary schools, because girls can start their period at primary school age. Female teachers or other trusted female adults can play an important role in ensuring girls have the information they need on adolescence and how to look after themselves during menstruation. An increasing number of booklets for girls on menstrual hygiene are being developed (see Toolkit 1. Schools be taught without reference to the biology, where strict also provide the opportunity of reaching large numbers of religious or traditional beliefs restrict the teachings due to boys with information on adolescence (see Module 1. Involving parents in menstrual hygiene Materials are increasingly being developed to help girls learn about menstrual hygiene, and these can be Schools also offer opportunities to engage parents in used, along with additional guidance, by teachers as menstrual hygiene, which can improve support for girls at learning resources (refer to Toolkit 5. More work is needed to Teacher Associations can be involved in monitoring how incorporate these resources into the curriculum and teacher menstrual hygiene-friendly the school environment is, and training, and have them approved by the relevant ministry making improvements and providing additional resources of education. This will require engaging curriculum where governments are unable or unwilling to do so. For example, girls may be taught the undertaken in Africa and Asia to supply commercially biology of the process without learning how they will feel produced disposable or re-usable pads to girls in school or how they should look after themselves. While this can feel uncomfortable teaching the subject and therefore will certainly have a positive impact on girls education and may skip over the subject quickly. Where harmful cultural wellbeing, further attention is needed on the mechanisms myths exist (eg girls and women not being allowed to bathe for providing longer-term access to pads, whether during their period) the teacher may also not have the disposable or re-usable (which will also need replacing correct information to counteract such beliefs. Together they have been supporting womens self-help the condition of the water, sanitation and hygiene facilities groups and girls in residential schools to make their own in schools is frequently recognised as a major challenge for re-usable sanitary pads, as well as establishing a supply schoolgirls and staff in managing their menstrual hygiene. Refer to Module 3 and Toolkit 3 for details on all aspects of sanitary product selection, production and the supply chain. In this conditions of hygiene and their state was one of secondary school, at least half of the students would be the main issues discussed by all girls. Assuming that most girls menstruate girls were proud of their toilet and had a supervisor for fve days of the month, we calculated that at least responsible for their maintenance. In the focus group discussions, of sanitation was not evident at the other two schools. None of the three schools had soap available for of the problematic schools was toilet paper available at hand-washing in the toilets. Instead, many girls described using all supervisor, soap was only available on special occasions kinds of other types of paper including text books and when the school had visitors. A few girls brought their toilet paper researcher for not having soap and said, I did not know from home while others tried not to use the school toilet you were coming, nobody told me. In the boarding schools the showers were open-plan and girls rose at 4am to shower and wash the majority changed their pads or cloths three to four menstrual cloths before anybody could see. Insufcient time at break or no washing observed that the showers ran with blood as girls had facilities were major concerns voiced. All girls hated the possibility of anybody seeing their menstrual blood in the toilet. Washable containers with themselves, their hands, their cloths and their clothing, a close-ftting lid should be located inside the latrines. Ideally, there should be a water supply inside latrine units, whether from A trial of constructing incinerators in schools in Tanzania10 a tap or a bucket that is routinely flled. This design feature meets the Tanzanian girls concerns, the girls in Malawi reported changing their sanitary as sanitary materials can be inserted directly into the protection materials one to four times a day, highlighting incinerator from the latrine cubicle. School latrines need to be in a safe Whichever method or design is adopted, a management location (chosen in collaboration with female students), system needs to be established to sustain operation and private, and have water, soap and materials to wrap used maintenance over the longer-term.

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