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By T. Jens. Connecticut College. 2019.

Increased lipolysis of fat stores order generic vardenafil erectile dysfunction injection, which can result from starvation buy cheap vardenafil on line occasional erectile dysfunction causes, dia- betes mellitus, or corticosteroid use, is most likely to cause steatosis (fatty liver) through which one of the listed mechanisms? Decreased free fatty acid excretion from the liver leads to free fatty acid accu- mulation in hepatocytes b. Increased free fatty acid delivery to the liver leads to triglyceride accumulation in hepatocytes d. Inhibition of apoprotein synthesis by the liver leads to phospholipid accumula- tion in hepatocytes e. Grossly, this individual’s stool has the appearance of “rice-water” because of the presence of flecks of mucus. Cultures of this patient’s stool grow Vibrio cholerae, a curved, gram-negative rod that secretes an enterotoxin consist- ing of a toxic A subunit and a binding B subunit. In an evaluation of an 8-year-old boy who has had recurrent infections since the first year of life, findings include enlargement of the liver and spleen, lymph node inflammation, and a superficial dermatitis resembling eczema. Microscopic examination of a series of peripheral blood smears taken during the course of a staphylococcal infection indicates that the bac- tericidal capacity of the boy’s neutrophils is impaired or absent. To treat her symptoms, you advise her to take indomethacin in the hopes that it will reduce her pain by interfering with the production of a. Which one of the listed statements is the best histologic definition of an abscess? A localized defect that results from the sloughing of necrotic inflammatory tis- sue from the surface of an organ c. A 25-year-old female presents with a history of losing four pregnancies in the past 5 years. She also has a history of recurrent pains in her legs sec- ondary to recurrent thrombosis. Evaluation of a pedigree for a certain abnormality reveals the following information: there are skipped generations with male-to-male transmis- sion; females are affected at the same rate as are males; and the disease is produced in the homozygous state, while heterozygous individuals are car- riers. You obtain a detailed family history from this patient and produce the associated pedigree (dark circles or squares indicate affected individu- als). Which of the following transmission patterns is most consistent with this patient’s family history? A 10-month-old baby is being evaluated for visual problems and motor incoordination. Examination of the child’s fundus reveals a bright “cherry red spot” at the macula. Talking to the family of this visually impaired 10-month-old infant, you find that they are Jewish and their family is from the eastern portion of Europe (Ashkenazi Jews). Based on this specific family history, which one of the following enzymes is most likely to be deficient in this infant? A 4-year-old male with mental retardation, self-mutilation, and hyper- uricemia is likely to have a deficiency of an enzyme involved in the a. A young boy is being evaluated for developmental delay, mild autism, and mental retardation. Physical examination reveals the boy to have large, everted ears and a long face with a large mandible. A biopsy of an enlarged salivary gland from an individual with Sjögren’s syndrome is most likely to histologically reveal an extensive infiltrate of a. An 8-month-old male infant is admitted to the hospital because of a bacterial respiratory infection. The infant responds to appropriate anti- biotic therapy, but is readmitted several weeks later because of severe otitis media. Over the next several months, the infant is admitted to the hospital multiple times for recurrent bacterial infections. During a routine physical examination, a 45-year-old male is found to have microscopic hematuria. This mass is resected and reveals a tumor composed of a uniform population of cells with clear cytoplasm. Based on all of these findings, which of the following best char- acterizes this tumor? Also assume that renal tumors composed of cells with clear cytoplasm that are larger than 2. A 35-year-old male living in a southern region of Africa presents with increasing abdominal pain and jaundice. He has worked as a farmer for many years, and sometimes his grain has become moldy. Physical exami- nation reveals a large mass involving the right side of his liver, and a biopsy specimen from this mass confirms the diagnosis of liver cancer (hepatocel- lular carcinoma). A biopsy of this mass is diagnosed as a moderately differ- entiated squamous cell carcinoma. Workup reveals that no bone metastases are present, but laboratory examination reveals that the man’s serum cal- cium levels are 11. This patient’s paraneoplastic syndrome is most likely the result of ectopic production of a. A 22-year-old female presents with the sudden onset of a high fever, a diffuse erythematous skin rash, and shock. Which one of the following is the most likely diagnosis for this individual’s illness? Several days after exploring a cave in eastern Kentucky, a 39-year-old female develops shortness of breath and a low-grade fever. Chest x-rays reveal several irregular areas in both upper lung fields along with enlarged hilar and mediastinal lymph nodes. Which one of the following organisms is most likely responsible for this individual’s disease? The use of broad-spectrum antibiotics can produce a bleeding diathe- sis characterized by hematomas, hematuria, melena, and bleeding from the gums by decreasing the normal gut flora and inducing a deficiency of a. Which one of the listed changes will result from decreased function of this membrane ion pump? Decreased sodium ions inside Decreased potassium ions outside the cell the cell b. Decreased sodium ions inside Increased potassium ions outside the cell the cell c. Increased sodium ions inside Increased potassium ions outside the cell the cell d. Increased sodium ions outside Increased potassium ions inside the cell the cell e.

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The use of folic acid mouthwash is particularly indicated for pregnant women and women using birth control pills buy cheapest vardenafil and vardenafil best rated erectile dysfunction pills, in whom hormonal changes appear to reduce the amount of folic acid in the cells of the oral cavity purchase vardenafil master card impotence yoga postures. Botanical Medicines A number of botanical compounds have shown an ability to inhibit plaque formation, including green tea polyphenols and glycyrrhetinic acid from licorice, but the most extensively studied compound is an alcoholic extract of bloodroot. Bloodroot Bloodroot (Sanguinaria canadensis) contains a mixture of alkaloids, but chiefly sanguinarine, which is available in commercial toothpastes and mouth rinses. Sanguinarine demonstrates properties that are useful in preventing dental plaque formation. In vitro studies indicate that the antiplaque action of sanguinarine is due to its ability to prevent bacteria from adhering to tissue. Electron microscope studies demonstrate that bacteria exposed to sanguinarine aggregate and become morphologically irregular. These properties can be put to good use in treating severe periodontal disease or if surgery is required. One study demonstrated that gotu kola extract was quite helpful in speeding recovery after laser surgery for severe periodontal disease. Since there are as yet no clear guidelines for determining which factors are most important for any given person, a general approach is recommended here. If you are a smoker, we strongly encourage you to stop, as continued smoking greatly decreases the success of any therapy for periodontal disease. Diet A diet high in fiber may have a protective effect by increasing salivary secretion. For example, for an extract containing 6% triterpenoids, the dosage would be 500 mg twice daily. The menstrual cycle reflects the monthly rhythmic changes in the secretion rates of the female hormones and corresponding changes in the lining of the uterus and other female organs. The menstrual cycle is controlled by the complex interactions of the hypothalamus, pituitary, and ovaries. Each month during the reproductive years, the secretion of various hormones is designed to accomplish two primary goals: (1) ensure that only a single egg is released by the ovaries each month, and (2) prepare the lining of the uterus (the endometrium) for implantation of the fertilized egg. To accomplish these goals, the concentrations of the primary female sexual hormones, estrogen and progesterone, fluctuate during the menstrual cycle. The control center for the female hormonal system is the hypothalamus, a region of the brain roughly the size of a cherry, situated above the pituitary gland and below another area of the brain called the thalamus. The hypothalamus and pituitary gland are housed in the middle of the head just behind the eyes. It is called follicle-stimulating hormone because each egg within the ovary is housed inside an individual follicle. After ovulation, the eggless follicle is transformed into the corpus luteum, which functions primarily to secrete progesterone and estrogen to help a fertilized egg become well established in the uterine lining. If fertilization does not occur, the corpus luteum recedes, hormone production decreases, menstruation occurs approximately two weeks later, and the entire menstrual cycle begins anew. It is divided into three phases, in order of occurrence: follicular, ovulatory, and luteal. The follicular phase lasts for 10 to 14 days, the ovulatory phase lasts for about 36 hours and involves the release of the egg, and the luteal phase lasts for 14 days. Prolactin’s chief function is to promote the development of the mammary glands and milk secretion during pregnancy and nursing. Increased production of prolactin in lactating women can inhibit the maturation of the follicles in the ovaries, thus delaying the return of fertility after childbirth. The influence of serotonin on mood and behavior is fully discussed in the chapter “Depression. Estrogen excess is known to produce cholestasis (diminished bile flow or “sluggish liver”). Cholestasis reflects minimal impairment of liver function because normal indicators of liver status (such as concentrations of the liver enzymes in the blood) are not elevated. These enzyme measurements, the conventional means of assessing liver status, are not very useful, however, as they serve only to indicate liver damage, being elevated only when the liver cells are leaking enzymes. Because of the liver’s important role in numerous metabolic processes, even a minor impairment of liver function can have profound effects. The high incidence of gallstones and non-alcoholic fatty liver disease is a clear indication that many American women suffer from cholestasis. One study found a direct correlation between the estrogen/progesterone ratio and endorphin activity in the brain. This reduction is significant considering the known ability of endorphins to normalize or improve mood. The way in which estrogen levels during the luteal phase negatively affect neurotransmitter and endorphin levels may be connected to the way in which estrogen impairs the action of vitamin B6. Vitamin B6 levels are typically quite low in depressed patients, especially women taking estrogens (birth control pills or conjugated estrogens such as Premarin). Historically, this improvement was thought to be the result of a combination of a reduction in estrogen levels and an increase in progesterone levels in the mid-luteal phase. Now, however, the possible explanation centers on the influence of B6 on brain chemistry. Vitamin B6 has the ability to increase the synthesis of several neurotransmitters in the brain, including serotonin, dopamine, norepinephrine, epinephrine, taurine, and histamine. These produce a rapid increase in insulin, which then causes the retention of sodium and subsequent water retention, resulting in swelling in the hands and feet, abdominal bloating, and breast engorgement. Sugar, especially combined with caffeine, has a detrimental effect on mood (discussed later). Foods that can reduce inflammation include fresh fruits (especially berries), green leafy vegetables, fish, nuts, seeds, turmeric, garlic, and onions. Vegetarian women have been shown to excrete two to three times more estrogen in their feces and to have 50% lower levels of free estrogen in their blood than omnivores. Decreasing the percentage of calories as fat, in particular saturated fat, has dramatic effects on the reduction of circulating estrogen. Alcohol intake was negatively associated with anxiety, mood changes, and headaches. Exposure to cigarette smoke, whether passive or active, was associated with cramps and back pain. Ethnic differences in the reporting of symptoms and in associations with other medical conditions were observed as well. In particular, biofeedback and short-term individual counseling (especially cognitive therapy) have documented clinical efficacy. The regular exercisers had significantly lower scores for impaired concentration, negative mood, unwanted behavior changes, and pain. In another study, 143 women were monitored for 5 days in each of the three phases of their cycles. The high-frequency exercisers experienced the greatest positive mood scores and sedentary women the least.

After all discount vardenafil 10mg with mastercard impotence pronunciation, the argument might go buy 10 mg vardenafil with amex erectile dysfunction quad mix, we allow patients to pursue cosmetic surgery, for the sake of nothing more medically urgent than vanity, even though there are some serious medical risks attached to some of those procedures. This question has a rhetorical ring to it, as if the answer were entirely obvious, but there is room for argument and judgment. To follow up further on that, we would have to specify a number of empirical facts, largely related to Donald’s ability to make decisions that were autonomous enough to warrant moral respect. The fourth ethical principle that has a bearing on our case is the principle of justice. As with the prior principle, there are several different construals we need to consider. Con- sider the case of a physician who has two patients with the same degree of coro- nary artery disease. However, the physician only refers the patient whom he really liked for the surgery. He does not refer the other whom he strongly disliked because the other patient had a history of noncompliance. This will mean that individuals who are financially more well off will have greater access to more expensive experimental therapies. The vast majority of goods and services are distributed in our society on the basis of an individual’s ability to pay. These sorts of consequences are generally not associated with access to other consumer goods, which is why health care might be seen as being morally special. Still, as we shall see below, very few would be prepared to argue that every- one in our society has a moral right to any or all of the health care they might want or need that would offer them any health benefits. Consequently, the most common justice arguments related to health care are that all in our society ought to have assured access to some basic package of health services, perhaps a fairly thick package of health services as proposed by the Clinton Administration in 1993. But even that more generous package would not have guaranteed anyone access to experimental medical therapies of the sort we are discussing. In his case, it would be fair to conclude that this would not be a matter of great moral consequence. In that period of time there is a reasonable chance these thera- peutic interventions will be perfected, which is to say they would become part of the standard medical armamentarium covered by health insurance. In the meantime the quality of his life will continue to be compromised; but he will not have been made worse off by this denial, so this would seem to be a morally tolerable outcome. Edward has some sort of cancer that has not been effectively treated by any current therapies. We have another gene therapy trial that is aimed at attacking the sort of cancer that Edward has. Edward will be dead in a year; he will have no opportunity to wait until the therapy is per- fected and disseminated. Still, he might argue that he has a just claim to at least a fair chance of access to such a trial. The argument might take this form: Gene therapy is not a product of the private effort and investment of some small group of individuals, as would be true with other consumer products. Rather, enormous public investments (tax dollars and university research facilities and training of the researchers them- selves) have made these successes possible. All in our society have contributed to the success of that effort; and consequently, all ought to have at least a fair chance to reap the rewards of that effort. It is unfair that only those who have been espe- cially economically fortunate already should have primary access to such tech- nologies, especially when life itself is at stake. For now it is sufficient to note that not all cases of access to experimental gene therapy are morally alike. There are subtle moral considerations that might tilt our judgment one way or another in a given case. Here is one more example of the sort of considerations that might raise issues of justice. Researchers want a therapeutic outcome for patients in these trials; this is the goal they share with standard medical practice. But they also seek to advance medical knowledge, which needs to be done very systematically. As a result, it will often be the case that patients will be denied access to one of these clinical trials if, in addition to their primary medical problem for which they are seeking entry to the trial, they have a serious co-morbid condition that could poten- tially compromise the quality of the clinical data they are seeking to gain. Is there any ethical justification for denying such patients an equal chance to be a participant in such a trial, especially if we have in mind an Edward-like patient as opposed to a Donald-like patient? To make certain that the ethical issue here is clear we need to emphasize that no matter what the co-morbid condition is that we imagine, those patients have just as good a chance of a successful therapeutic outcome in that trial as any other patient in the trial. That is, these researchers will claim that they are seeking to bring about the greatest good for the greatest number. More precisely, if the clinical data that is gathered in these trials is “tainted” through unknown effects associated with these co-morbid conditions, then there may be some tragic bad outcomes that come about when the results of these trials become part of standard clinical practice. So we have to imagine that there might be at some point in the future a large pool of potential patients who might be seriously harmed as a result of an incorrect clinical conclusion that we draw now. Researchers claim that they are morally obligated to do all in their power to prevent such possible future disasters. The whole point of both moral and political rights is to protect individuals against the encroachments of large and powerful social organizations, either in the private or public sector. Individuals may not have their deep moral rights violated for the sake of advancing some larger social good. The moral basis for this judgment is the Kantian principle of respect for persons we discussed earlier. Individuals cannot be simply used as mere things to advance even noble social goals without their free consent. A standard example in the ethics literature is the skid row bum who drunkenly stumbles in the street to be hit by a car. His head injuries are such that if surgery is done immediately he will likely be restored to something close to his former state of health. However, if surgery is delayed several hours, his con- dition will worsen and he will end up brain dead. His organs can then be used to save the lives of five other upstanding citizens who very much want to live but who otherwise would die of organ failure. We would certainly judge that any transplant surgeon who took advantage of a situation like this would be doing something grossly unethical. Someone might argue in response that there is a major disanalogy between this case and our Edward-like gene therapy case (where Edward is denied access to a clinical trial because of some co-morbid condition), namely, that our skid row bum is negligently harmed by delaying the surgery that will certainly benefit him. Edward is not treated negligently; he is simply being denied the opportunity to benefit from access to the trial. Edward will be denied access to the clinical trial because of a co-morbid condi- tion on the grounds that the quality of the clinical data might be corrupted by his participation. But the harm that we would hope to avoid there is potential, remote, maybe best described as “speculative” since we cannot assign any specific proba- bility to the likelihood of that occurring.

Many chicks seem suicidal purchase discount vardenafil erectile dysfunction pills natural, and pebbles or marbles must be added to the water container to prevent drowning order generic vardenafil on-line erectile dysfunction low libido. Chicks have been known to get stuck between the food container and a wall, and they may also jump out of the brooder and become chilled. The room has a control system that allows heating, cooling and adequate ventilation. A metal rack is attached to the wall to suspend individual containers off the floor for easy cleaning. The bottom is made of one-fourth inch by one-half inch vinylized wirec and the removable top is made of one-fourth inch by one-fourth inch hardware cloth in a wood frame that is hinged in the middle for access to both the front and back of the brooder. These chicks are standing together for security but are not huddled, which would indicate chilling. Shallow pools, three-fourths inch deep, are used in- itially to acclimate young ducklings to the water. A double sink is A 150-watt infrared heat lamp is placed over each box effective for cleaning pans and a hose is used for on an extendable cord so that the heat can vary from cleaning the wall-mounted brooder boxes. Various directly over the enclosure to 32 inches above the disinfectants can be used. Room temperature is main- changed several times a day as needed, and enclo- tained at 76 to 82°F while the box temperatures are 81 sures are cleaned once a day. A poultry water bottle is used 3 on brooder room set-ups may be found in Brown and in each box with pebbles in the troughs so that young 45 Hyde. The water bottle and food pan are positioned away from the wall at the opposite end of The ducklings are ready for outside pens at two to the heat source. It is preferable to use an interme- diate facility to acclimate the ducklings to the differ- For younger birds, it is advisable to use a vinyl b ence between the very controlled environment of the turf-type mat or towel under the heat source to make brooder room and the limited control of outside pens. Outside enclosures approxi- sorbent materials used for bedding may be consumed mately eight feet square with concrete floors and a by some ducklings and cause impactions. The room gently sloping pool covering about half of the floor should have a treatment area with a counter, scale space are ideal. Simulating the natural conditions that a free-rang- ing hatchling would encounter may stimulate feed- ing behavior. Newly hatched Mandarin Ducks and Wood Ducks tend to calm down in the brooder and begin to eat after they have been tossed in the air and allowed to drop to the ground. Neonates are best raised in groups chicks feed best if a cotton floor mop is hung in the of similarly sized individuals. This lone neonate was provided a stuffed toy for company (1994 Busch Gardens Tampa. Ducklings may become wet and chilled in a brooder or when moved to an outdoor area and exposed to gradual, and vinyl mats should be placed on the edge heavy rains. Their undeveloped feathers lack the of the pool and on some of the dry areas to prevent natural oils and proper structure to repel water. A heat lamp should be avail- Weaker ducklings that are not competing effectively able for each pen. All pools should have overflows and with other chicks for food may become hypoglycemic, good drainage for easy cleaning. A hair dryer can be used to dry the the outdoors, the birds can be moved to larger grow- feathers and warm the body. Steroids, subcutane- Neonatal Problems ous fluids and antibiotics may prevent secondary problems. Large doses of rapidly metabolized ster- The majority of losses during the first two weeks of life are associated with the poorly understood diagnosis of starveout. Starveout is a term coined by poultry pathologists to describe a condition of turkey poults wherein birds never start to eat; they starve after their yolk stores are depleted. Charac- teristically, deaths occur in water- fowl at 7 to 14 days of age; the birds have an empty, contracted gastroin- testinal tract, a small yellow liver, a distended gall bladder and no fat stores. It has been shown that many species, especially in captive situ- ations, require specific stimuli and encouragement to begin self-feed- ing,64 and a lack of these stimuli may contribute to the problem. Tile floors quire food for the first 24 to 48 hours and walls are easy to clean, and the brooder boxes can be removed for cleaning and while the yolk sac is being absorbed. Heat lamps are placed on retractable extension cords to allow changes in the Scoters, Harlequins, Oldsquaw duck- amount of heat provided to an individual brood box. Clinical signs sug- should be repeated every 15 minutes (some chicks gesting that surgery is necessary include swollen may require four or five doses) until the chick is abdomen, dyspnea, exercise intolerance, inability to warm and stabilized (Harrison G, unpublished). For surgery, birds are anesthetized with isoflu- Gastrointestinal disorders seem to be particularly rane and placed in dorsal recumbency with the legs common in neonatal birds. Feathers on the abdomen are ment and the need to establish a resident flora in plucked from flank to flank and from the keel to the what is a sterile environment at hatching probably cloaca, and the skin is surgically prepped (see Figure account for many of these problems. Impac- broad-spectrum antibiotics postoperatively pending tions lead to putrefaction of the gastrointestinal con- results of a yolk sac culture. Some chicks will require tents causing inflammation of the gastrointestinal tube-feeding for several days before they will resume mucosa and frequently systemic intoxication. A second syndrome, rupture of the yolk sac, can occur At necropsy, affected birds have a moderate-to-large as a sequela to yolk sac retention or yolk sacculitis unabsorbed yolk sac in the abdominal cavity that is (the third yolk sac-related syndrome). No also occur following traumatic events in two- to other abnormalities are noted. Yolk Similar data are not available for most aviary species, sacculitis and omphalitis can occur separately or but, in general, persistence of the yolk past two weeks concurrently in a bird and are most frequently asso- of age is abnormal and detrimental. Causes for non- ciated with gram-negative organisms, especiallySal- absorption are unknown, as are the events that lead monella sp. Neonates depend characterized by edema and inflammation of the ab- on the yolk sac for the first two to three days of life dominal wall surrounding the umbilicus. Yolk saccu- and if the yolk is not absorbed, the birds will be litis is characterized by enlargement, hyperemia and malnourished. Maternal immunoglobulins, specifi- petechiation of the wall and greenish discoloration cally IgG, are absorbed with the yolk. In most cases, om- sorption of the yolk could result in the same immu- phalitis and yolk sacculitis arise from contamination nosuppression seen in mammals that do not ingest of the umbilicus. Temperature and humidity during incubation affect Miscellaneous Microbial Infections: Bacterial infec- yolk sac development. High humidity or low tem- tions in neonates usually cause a multisystemic, fatal perature may cause a failure to retract the yolk sac septicemia. Infected yolk appears as a thick often subtle: splenomegaly, hyperemia and petechia- brownish or yellow coagulated mass compared to tion of the lung and gastrointestinal serosa, and normal yolk, which is a greenish-yellow liquid (see congestion or focal necrosis of the liver. The incidence of bacterial showed that yolk sacs in precocial species ranged septicemia can be reduced through sound brooder from 12 to 25% of the body weight. The majority of hygiene and by identifying and controlling infections the yolk sac should be absorbed within a week.

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