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Michael J. Paidas, MD

• Associate Professor
• Co-Director, Yale Women and Children? Center for Blood Disorders
• Co-Director, National Hemophilia Foundation?Baxter
• Clinical Fellowship Program at Yale
• Division of Maternal- Fetal Medicine
• Department of Obstetrics, Gynecology, and
• Reproductive Sciences
• Yale University School of Medicine
• New Haven, Connecticut

Barbara Ehrenreich and Dierdre English organic depression definition cheap 150 mg bupropion visa, Witches depression test german buy generic bupropion 150 mg on-line, Midwives and Nurses bipolar depression episode order genuine bupropion on line, Compendium anxiety 24 hours a day bupropion 150 mg line, London depression definition stock market order bupropion with visa, 1974 anxiety in dogs bupropion 150mg mastercard. She also uses this method in her discussion of the behaviour of eunuchs in history (p. Radicalesbians, Woman-Identifed Woman, In Notes from the 3rd Year, New York, 1971 17. This is not to say that the only ways that women can be oppressive are by internalizing male ways of thinking. As I remember, you have put down your older makeup clad sister as being kind of a nowhere person. If people are bisexual, and the sexes are to be judged equally, what exactly makes her inferior to a transvestite This scene could only appeal to someone who is absolutely terrifed of communicating with other people. If a man or woman is so tough that no pain gets through, I fear that the barriers are so high that no pleasure (probably sexual) can get through either. A person either represses all his emotions (good and bad) or he accepts all of them. Tat cow boy in me could only appear as a dress-up, a pretend, but it was so real to me somehow that fnally I was completely lost in it and scared someone might fnd out how deeply I felt it (at age 5 I had a Davy Crockett birthday party. To keep inside the closet, to only dress up alone in a locked room, hoping no one will ever see, afraid to open your mouth in regard to any topic coming close to your secret (What is beauty Lot and lots of gays go home from the bar alone cuz everyone there was a Gila monster, just like straights. Six or seven years ago Lou Reed was probably scared his fans would know him too well and that would be the end. Also might have kept my mouth shut if you showed any interest in female homosexuals. Tere is virtually no diference between men and women except a genital one, and anyone who limits and bases his life on his genitals is in a very bad way. But what are the fashy gays doing but imitating all the moronic frivolities that accrued around women in this unliberated stage Gays are maintaining the double-standard era stereotyped woman, and as a woman who is having one hell of a time becoming fully real as a person, I cannot encourage this at all. Why get hung up on changing your sexual orientation when no diference exists in reality You seemed to be spunkier than I was in many respects (biking up to Terre Andre; camping on the Mississippi) and I respected you for that. You never put me down at work, and fnally I even found out that you were as scared about phoning as I was! Well, I was trying to defend myself and my desires for sexual hipness disguised as sexual freedom. But til then, all I can say is that masculinity and femininity, when taken as mental properties rather than physical conditions must be dumped by anyone who cares about people. Maybe a person hates his trap, but will he be better of in a trap someone else just jumped out of because it was a killer How many people convince themselves to stay in a trap just because they tried to get into it so bad I felt I had to answer this letter also: Dear Dorothy: Your letter was unexpected and surprising. For too long my boyfriend and I hid out with each other (I remember well how much I wanted to literally lock us up together in our place, board up the windows from the outside world and save us from everything). Yesterday I came to the ofce to visit her and she refused to even acknowledge my presence, not even to as much as look at me. They are interested in transgender phenomena because they see them as special cases that make visible some of the routine social practices that everybody uses to construct gender on a day-to-day basis. In the selection below, Kessler and McKenna summarize their thoughts on how the gender attribu tion process works. They develop a series of transparencies depicting bodies with various physical characteristics or articles of clothing, which can be overlaid with one another in various combinations. By asking test participants to identity the gender of the various composite fgures, the authors are able to quantify the process of gender at tribution and to assign relative weights to particular elements involved in making the attribution.

International liver transplant society prac tice guidelines: diagnosis and management of hepatopulmonary syndrome and portopulmonary hypertension depression prevalence bupropion 150 mg with mastercard. Rebalanced hemostasis in patients with liver disease: evi dence and clinical consequences depression symptoms and treatment in hindi purchase bupropion 150 mg line. Hemostasis in liver transplantation: pathophys iology depression psychosis buy bupropion canada, monitoring anxiety zaps order bupropion without a prescription, and treatment depression youth purchase genuine bupropion online. Intraoperative hypercoagulability during liver transplantation as demonstrated by thromboelastography depression symptoms wikihow bupropion 150mg visa. The coagulopathy of chronic liver disease: is there a causal relationship with bleeding Transesophageal echocardiography during orthotopic liver transplantation: maximizing information without the distraction. Anesthesia for liver transplantation in United States academic centers: intraoperative practice. Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors. Effect of low central venous pressure andphlebotomy on blood product transfusion requirements during liver transplanta tions. Effects of continuous octreotide infusion on intraoperative transfusion requirements during orthotopic liver transplantation. The connecting segments and ventriculo-arterial connections are described separately. The Andersonian Approach to Cardiac Anatomy A different approach to describing cardiac anatomy was championed by Dr. If the right atrium connects to the right ventricle, and the left atrium connects to the left ventricle, this is described as atrioventricular concordance. If the pulmonary artery arises from the right ventricle and the aorta arises from the left ventricle, this is described as ventriculoarterial concordance. If the right atrium 4 connects to the left ventricle, this is termed atrioventricular discordance. If the pulmonary artery arises from the left ventricle, this is termed ventriculoarterial discordance. Assume the oxygen consumption is 150mL/min and pulmonary venous saturations are 100%. Assume the oxygen consumption is 120mL/min/m2 and pulmonary venous saturations are 100%. Moss and AdamsHeart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult. Nontraumatic chest pain in children and adolescents: Approach and initial management. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents, National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Half standard: amplitudes are displayed at half the size; must multiply by 2 to normalize them. There is usually a bimodal distribution, with peaks in the <1 year period, and again during adolescence. Also not tachycardia; can look similar acute bronchiolitis or amenable to ablation often. His breathing is unlabored, there is no hepatomegaly or splenomegaly, and the distal pulses are excellent. A chest X-ray demonstrates clear lung fields and a normal cardiac silhouette, but a narrowed mediastinal shadow. His mother reports that for the last week, he appears hungry, but fatigues with feeds and he now takes twice as long to complete a feeding as he did 1 week ago. Chapter 5: Initial Evaluation of the Newborn with Suspected Cardiovascular Disease; p. The increased oxygen content of blood flowing through the ductus promotes vasoconstriction of the smooth muscle and closure of the ductus. Anatomic Variations Ebstein anomaly develops from the failure of the septal and inferior leaflets of the tricuspid valve to fully delaminate, leading the attachments of the leaflets to be downward (apically) displaced from the annulus, and the leaflets to be abnormal. Since this blood is never oxygenated, leads to worsening cyanosis and decreased cardiac output. If a mother has a bicuspid aortic valve, is a fetal echo indicated during pregnancy Tetralogy of Fallot with Pulmonary Stenosis and Tetralogy of Fallot with Absent Pulmonary Valve. Early complete repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals. Usually occurs in isolation, but can be associated with 22q11 deletion or maternal diabetes. By definition the systemic, pulmonary, and coronary circulations arise from one ascending artery. Most have tachypnea, tachycardia, diaphoresis, and poor feeding as severe pulmonary overcirculation develops. In this, the majority of the conus sits below the aortic valve, pushing it anteriorly and superiorly, and the small amount of conus below the pulmonary valve causes it to slightly override the ventricular septum. In this lesion, there is more conus tissue underneath the pulmonary valve, but still enough under the aortic valve to push it rightward, though not anterior. Requires ductus arteriosus for systemic blood flow and is fatal without prostaglandin therapy and subsequent surgical palliation. Anatomic variations and clinical presentation Spectrum of lesions involving pulmonary atresia with variable degrees of hypoplasia of the right ventricle and anomalies of the coronary arteries. Inlet portion of the right ventricle is absent and often there is a dimple in the floor of the right atrium where the valve would have been. If there are normally related great arteries, this causes pulmonary obstruction and increasing hypoxemia. If patients have pulmonary atresia, may show diminished lung markings, or if unobstructed, may have pulmonary edema. There is obligate right to left flow at the atrial septum in order to allow for any blood to enter the left ventricle and provide cardiac output. Semilunar valve Replacement with Decellularized Homograft after Damus Kaye-Stansel Anastomosis and Fontan Procedure. Rastelli operation, 1969 Originally used for transposition of the great arteries, now used for numerous complex repairs, including truncus arteriosus. The two most common cardiomyopathies in pediatric patients are Hypertrophic Cardiomyopathy and Dilated cardiomyopathy, so those are discussed here. For further information on other types of cardiomyopathies, see the References section. Hypertrophic Cardiomyopathy Most frequently occurring cardiomyopathy (1:500 of general population) and has an autosomal dominant pattern of inheritance. Most common cause of sudden cardiac death in young people and competitive athletes. Subtle diastolic changes can be appreciated before objective hypertrophy with careful echocardiography. Ventricular tachycardia and fibrillation can occur in patients without significant obstruction and cause sudden death. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task Force 3: hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy and other cardiomyopathies, and myocarditis. International Society for heart and Lung Transplantation: Practice Guidelines for Management of heart Failure in Children. Evaluation, Risk Stratification and Management of Pulmonary Hypertension in Patients with Congenital Heart Disease. Endocarditis: infection of the endocardial surface of the heart, including native or prosthetic heart valves, septal defects, the mural endocardium, foreign devices or patches, surgical shunts and indwelling central venous catheters. They often do not have fever and may present with only generalized sepsis or focal neurologic findings from emboli to the brain. Clinical manifestations and evaluation of adults with suspected native valve endocarditis. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Diagnosis, Treatment and Long-Term Management of Kawasaki Disease: A statement for health professional from the committee on rheumatic fever, endocarditis and Kawasaki disease, Council on Cardiovascular Disease in the Young, American Heart Association. S y n th e siz e fin d in g s in to a C re a the a d iffe re n tia llistfo r R e fin e a d ia g n o stic p la n to c o n firm o r b rie f su m m a ry o f le sio n s e a c h le sio n. R ib fra c tu re s (c h ro n ic, se ve re a irw a y d ise a se h e a le d) M e d ia stin u m (in c lu d in g h e a rt): 5. V e n tra lto h e a rt (m e ta sta tic o rin filtra tive ro u n d p a tte rn (w ith n o d u le s) + U A c e ll) 2.

The ends of the bone (D) are covered by hyaline cartilage that lacks a perichondrium anxiety 7 months pregnant order discount bupropion. Synovial fluid nber depression definition discount bupropion 150 mg fast delivery, which differs from blood serum in its reduced protein content depression side effects bupropion 150mg visa, acts as a lubricant and becomes more viscous with age depression vs recession order bupropion us. Rheuma toid arthritis is an autoimmune disease in which infiltration of cells from the immune system leads to the destruction of the synovial capsule and the artic ular cartilages postpartum depression definition medical dictionary purchase 150 mg bupropion fast delivery. Inflammation of the synovium leads to the formation of a pan nus and eventually to changes in the articular cartilage converting it into a fibrocollagenous structure bipolar depression 2 buy bupropion 150 mg overnight delivery. Bisphosphonate treatment is the most effective current treatment for osteo porosis. Bisphosphonates are analogues of the pyrophosphates and suppress bone resorption by osteoclasts. Some of the bisphosphonates are metabolized to a toxic analogue that targets mitochondria and apoptosis of the osteoclasts. The osteosarcoma cells synthesize bone and function similarly to osteoblasts, from which they are derived. Osteoblasts and osteosarcoma cells synthesize alkaline phos phatase, which is critical in increasing the local calcium: phosphate ratio, thereby inducing the calcification of osteoid (prebone) to form bone. Acid phosphatase (answer c) is synthesized by osteoclasts and is essential for the dissolution of bone and its subsequent resorption. Elastin (answer e) is synthesized by smooth muscle cells, endothelial and microvascular cells, chondrocytes, and fibroblasts. Downregulation of the anti-angiogenic peptides, angiostatin and endostain, would enhance tumor growth (answer e). Enhancement of integrin-integrin receptor interactions would facil itate metastasis (answers a and b). Overexpression of selectins (answer c) on endothelial cells could enhance sticking of tumor cells to the endothelium and eventual extravasation. A 5-year-old boy sustains a tear in his gastrocnemius muscle when he is involved in a bicycle accident. Contraction of that muscle fiber results in a 10% shortening of the length of the sarcomere. What is the length of the A band after the shortening produced by the muscle contraction A 66-year-old man who lives alone has a severe myocardial infarction and dies during the night. Inhibition of Ca++leakage from the extracellular fluid and sarcoplasmic reticulum b. The sarcoplasmic reticulum of skeletal muscle functions in which of the following Observation of a histologic preparation of muscle reveals cross striations and peripherally located nuclei. The use of histochemistry shows a strong staining reaction for succinic dehydrogenase. The same tissue pre pared for electron microscopy shows many mitochondria in rows between myofibrils and underneath the sarcolemma. Fibers that contract rapidly but are incapable of sustaining continuous heavy work c. In muscular dystrophy, the actin-binding protein dystrophin is absent or defective. Loss of integrity of the desmosomal components of the intercalated discs of cardiac muscle Muscle and Cell Motility 219 130. Which of the following is absent in smooth-muscle cells compared to skeletal muscle cells In the transmission electron micrograph of skeletal muscle shown below, which of the following is true of the zone labeled C This structure bisects the H band and is formed predominantly of creatine kinase d. The mechanochemical enzyme that can be found on the surfaces of cellular organelles where it mediates movement toward the plus end of microtubules is which of the following They are supportive cells for maintenance of muscle and a source of new myofibers after injury or after increased load. There is no ded ifferentiation of myocytes into myoblasts (answer b), or fusion of damaged myofibers to form new myotubes (answer c). Hypertrophy, not hyperplasia (answer d), occurs in existing myofibers in response to increased load. Pro liferation of fibroblasts may occur in the damaged area but leads to fibrosis, not repair of skeletal muscle. In the development of skeletal muscle, myoblasts of mesodermal origin undergo cell proliferation. Myoblasts, which are mononucleate cells, fuse with each other end to end to form myotubes. This process requires cell recognition between myoblasts, align ment, and subsequent fusion. However, as the degree of overlap of thick and thin filaments is altered, the thin filaments, which form the I band and are anchored to the Z line, are pulled toward the center of the sarcomere. As this occurs, the I band decreases in length and the H band is no longer visible. The filaments themselves do not decrease in length; they slide past one another in the sliding-filament model of muscle contraction. If there is a 20% contraction of the muscle (contraction to 80% of its length), then the sar comere is reduced in length from 2. The size of the A band 221 222 Anatomy, Histology, and Cell Biology remains unchanged. The I bands are not shown completely on the figure (see High-Yield Facts) because they are found between adjacent A bands. Ca2+ions continue to leak from the extracellular fluid and the sarcoplasmic reticulum (answer a), however, the sarcoplasmic reticulum is no longer able to retrieve the Ca2+ ions (answer b). The high levels of lactic acid cause deteriora tion of the skeletal muscle and end the state of rigor mortis (answer e). When Ca2+ in the muscle cell cyto plasm is high, the Ca2+ binds to the troponin complex. The binding of Ca2+ to the troponin complex results in a conformational change in the com plex, thereby allowing myosin to interact with actin. The troponin complex subse quently reverts to the conformational state in which the troponin complex blocks the interaction of myosin with actin (answer b). Glycogen is stored as particles or droplets in the cytoplasm, which contains the enzymes required for the synthesis and breakdown of glycogen (answer c). The transverse tubule system, or T system, is an extension of the plasma mem brane of the myofiber (sarcolemma). The T system allows for simultaneous contraction of all myofibrils since it encircles the A-I bands in each sarcom ere of every myofibril. In combination with the paired terminal cisternae, the transverse tubules form a triad. Depolarization of the T system during contraction is transmitted to the sar coplasmic reticulum at the triad (answers d and e). It is important to note that cardiac muscle also has a T system, although it is not as elaborate and well organized as that found in skeletal muscle. The deductive process is based on the fact that the sample must be skeletal or cardiac muscle due to the pres ence of cross-striations (answer e). The presence of peripherally placed nuclei eliminates cardiac muscle as a possibility (answer d). Skeletal mus cle may be subclassified into three muscle fiber types: red, white, and 224 Anatomy, Histology, and Cell Biology intermediate fibers. Red muscle fibers have a high content of cytochrome and myoglobin and, beneath the plasmalemma, contain many mitochon dria required for the high metabolism of these cells. The presence of numerous mitochondria provides a strong staining reaction with the use of cytochemical stains such as that for succinic dehydrogenase. White fibers are capable of rapid contraction but are unable to sustain continuous heavy work. Human skeletal muscle fibers are composed of red, white, and intermediate-type fibers. The intermediate fibers contain a concentration of myoglobin between white and red muscle fibers. This walking process is unidirec tional and is based on the polarity of the actin filament. In skeletal muscle, phosphorylation of the light chain is not required for binding to actin (answer e). It binds actin to the skeletal muscle membrane and therefore binds the I and M bands to the cell membrane. The inability to bind actin to the plasma membrane of skeletal muscle leads to disruption of the contraction process, weakness of muscle, and abnormal running, hopping, and jump ing. The Gower maneuver is the method used by persons suffering from muscular dystrophy to stand from a sitting position. Respiratory failure occurs in those persons because of disruption of diaphragmatic function. Dys trophin is found in all muscle types and is part of a complex that regulates interactions of the sarcolemma with the extracellular matrix through associ ated glycoproteins (dystrophin-glycoprotein complex). Therefore, loss of dystrophin causes destabilization and decreased contractility (answer a). Muscular dystrophy refers to a group of progressive hereditary disorders (1/3500 male births) that involve mutations in the dystrophin gene. Becker muscular dystrophy is a less severe dystrophy in which dystrophin is defective. Synthesis of actin (answer b) is not reduced in skeletal muscle from these patients; in fact, hypertrophy and pseudohypertrophy (replacement of muscle with connec tive tissue and fat) occurs. Microtubules perform vesicular and organelle transport functions (answer d), and intermediate filaments, not actin, form the intracellular connection in desmosomes (answer e). Actin maintains the mechanical strength of the cytoplasm of the cell and is essential for cellular functions that require surface motility. Although movement of vesicles along filaments is regulated by minimyosins (myosin I), movement of vesicles and organelles is predominantly a func tion of microtubules (answers b and c) under the influence of the unidi rectional motors kinesin and dynein. The movements of chromosomes (answer d) as well as the cilia and flagella (answer e) are driven by dynein, and chromosomal movements occur through microtubular kinetics. The contractile process is similar to the actin-myosin interactions that occur in motility of nonmus cle cells. In the smooth-muscle cell, actin and myosin are attached to inter mediate filaments at dense bodies in the sarcolemma and cytoplasm. Dense bodies contain actinin and, therefore, resemble the Z-lines of skeletal muscle. Contraction causes cell shortening and a change in shape from elongate to globular. Contraction occurs by a sliding filament action analo gous to the mechanism used by thick and thin filaments in striated muscle. The connections to the plasma membrane allow all the smooth-muscle cells in the same region to act as a functional unit. The sarcoplasmic reticulum is not as well developed as that in the striated muscles. There are no T tubules present; however, endocytic vesicles called caveolae are believed to function in a fashion similar to the T tubule system of skeletal muscle. When intracellular calcium levels increase, the calcium is bound to the Ca2+-binding protein, calmodulin. Ca2+-calmodulin (answers b and c) is required and is bound to myosin light-chain kinase (answer d) to form a Ca2+-calmodulin-kinase complex. This complex catlayzes the phosphoryla tion of one of the two myosin light chains on the myosin heads. A specific phosphatase dephosphorylates the myosin light chain, which returns the actin and myosin to the inactive, resting state. The actin-tropomyosin interactions (answer e) are similar in smooth and skeletal muscle. At the center of the myofibril and consisting of thick filaments is the A band, which interdigitates with the I band. The Z disk is composed mostly of the intermediate filament protein desmin and other proteins such as actinin, filamin, and amorphin, as well as Z Muscle and Cell Motility Answers 227 protein. Cytoplasmic dynein is respon sible for movement toward the minus end of the microtubules. Remember kinesin kicks out and dynein drags them in (see feedback to question 41).

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