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A 30 years old female asymptomatic not requiring blood (a) Spectrin (b) Transferrin transfusion has Hb-13 gm% buy npxl 30caps amex herbals himalaya, HbF-95% discount npxl 30caps overnight delivery herbs life is feudal, HbA2 1 order 30 caps npxl with amex herbals ltd. Response of iron therapy in a patient with iron (b) Increased total iron binding capacity defciency anemia is denoted by: (c) Decreased serum ferritin (a) Restoration of enzymes (d) Increased mean corpuscular volume (b) Reticulocytosis 64 order 30 caps npxl mastercard wicked x herbal. Sideroblastic anemia is seen in chronic poisoning with: (c) Serum ferritin (a) Lead (b) Arsenic (d) Serum transferin (c) Copper (d) Mercury 65. Rate of iron uptake is regulated by which one of the fol- (c) Iron defciency anemia lowing: (d) Pernicious anemia (a) Mucosal cell iron stores 69. A 68 year-old man Babu Rao Apte presents with skin (b) Route of administration pigmentation, cirrhosis and diabetes mellitus. A 23-year-old female presented with jaundice and (b) Erythropoetic porphyria pallor for 2 months. The most relevant (d) Cutaneous porphyria investigation to arrive at a diagnosis is which of the 69. An abnormal Ham test is most likely associated with against malaria except: which of the following? A 5 year old male child presents with episodic anemia (c) Sickle cell disease and jaundice since birth. In hereditary spherocytosis an inherited abnormality is (d) Conjugated bilirubin seen in which of the following red blood cell compo- 80. A young male photographer Alok Nath from Bangalore (c) Defective hemoglobin synthesis is evaluated for recurrent episodes of jaundice. Not seen in paroxysmal nocturnal hemoglobinuria is: insignifcant and the person is not on any medication. His blood pressure is 120/80 mmHg, pulse is (c) Decreased leukocyte alkaline phosphatase 72/mm, temperature is 36. A 20-year-old man John Abraham is transported to the emergency department within 20 minutes of sustain- release hemoglobin. If it is presumed that he may have (a) Cirrhosis and hepatocellular carcinoma lost about 1. A 16-year-old female Gitika notices that her urine (b) Decreased hematocrit becomes red after she is given sulfonamides for (c) Decreased blood pressure treatment of a urinary tract infection. Both urine and (d) Decreased red blood cell count serum test positive for free hemoglobin, and the urine 95. The dis- smear shows normocytic and normochromic red cells trict has high endemicity of malaria. Dubey gives him primaquine chemoprophylaxis following substances is most likely responsible for for Plasmodium vivax malaria. Singh develops anemia, (a) Alpha-chain of hemoglobin hemoglobinemia, and hemoglobinuria. Special studies (b) Beta-chain of hemoglobin will likely reveal an abnormality in which of the fol- lowing? An infant presents with mild anemia, jaundice, and (c) Intrinsic factor splenomegaly. A 38-year-old male Kritesh presents to his physician The parents state that several relatives have also with the complaints of sudden onset of fever, chills suffered from a similar illness. A 6yrs old child belonging to Punjabi family with past history of blood transfusions presented with (b) Acute myelomonocytic leukemia hemoglobin 3. A 14-year-old male Kaalu is brought to the emergency (b) One altered peptide of HbS migrates faster towards room with high grade fever, chest pain, and dyspnea. Evaluation today the polymer and cause sickling of the red blood cells reveals a hematocrit of 23% and reticulocyte count of (d) Lowering the concentration of deoxygenated HbS 9%. Several hours after being admitted, the patient dies can prevent sickling in the hospital. At autopsy, the patient’s spleen is frm and brown; this fnding is most likely related to: 111. The hemoglobin electrophoresis shows (e) Target cell are present the following: Hb A 60% and Hb S 40%. Sickle cell anemia is the clinical manifestation of sickle cell anemia and thalassemia major? Hemoglobin H disease is caused by deletion of: Most Recent Questions (a) A single a globin gene (Karnataka 2009) (b) Two a globin genes 121. Which of the following regarding Bombay blood group (d) Relative excess of β, γ, and δ chains is false? In sickle cell anemia defect is in which chain: (b) Lack of H, A and B substance in saliva (a) Alpha chain (b) Beta chain (c) Lack of antigens of several blood group systems (c) Both the chains (d) None of these (d) H, A and B antibody will always be present in serum 121. Which of the following is the genotype of a person with (a) Altered stability blood group A? A 18 year old Afro American boy presenting with a non anticoagulant will you use for sending your sample? Most (c) Potassium oxalate + sodium fuoride likely cause is: (d) Tri Sodium citrate (a) Trinucleotide repeat 127. Molecular pathogenesis of α thalassemia involves (c) Polychromasia (a) Mutation in transcription sequence (d) Elliptocytosis (b) Gene deletion 128. One of the common variants of sickle cell anemia (d) Electrolyte imbalance frequently marked by lesser degree of haemolytic anemia and greater propensity for the development of 129. Stored plasma is defcient in (a) HbA (b) HbA (a) Factors 7 and 8 2 1 (c) HbA (d) HbA (b) Factors 5 and 7 1c 1b (c) Factors 5 and 8 141. Bence Jones protein in urine are due to the presence of (d) Factors 5, 7 and 8 (a) Light chain of monoclonal immunoglobulins (b) Heavy chain of monoclonal immunoglobulins 141. Carbohydrate present in blood group substance is (c) Light chain of polyclonal immunoglobulins (a) Fucose (b) Deoxyribose (d) Heavy chain of polyclonal immunoglobulins (c) Ribulose (d) Ribose 141. Erythropoietin is normally released from the kidney in response to hypoxic or anemic conditions. The proerythroblast (option c) is the frst recognizable cell in the red cell lineage. The reticulocyte (option d) is the enucleated cell just before the mature red blood cell. It is not directly stimulated by erythropoietin, but increases in number as a result of the increase in precursors. The commonest cause is metastatic cancer, most often carcinomas arising in the breast, lung, and prostate. This is due to disturbance of mechanisms regulating the egress of red cells and granulocytes from the marrow. Though it has the name purpura, but the platelet count in this condition is normal.

Proximal myotonic dystrophy

Some studies have shown a reduction in higher order aberrations after wavefront-guided ablations npxl 30 caps fast delivery quality herbals products pvt ltd, while others have shown an increase buy 30caps npxl with mastercard herbals that prevent pregnancy. Suspected etiologies include bacterial endotoxins cheap npxl 30caps with visa herbs chambers, meibomian secretions order npxl 30caps otc herbs thai bistro, oils from the microkeratome, and excessive laser energy from the IntraLase femtosecond laser. The excimer laser is then used to alter the shape of the cornea, after which the epithelial flap is repositioned. The femtosecond laser is a tool that uses ultrafast (15 kHz) pulses of energy to ablate tissue with extreme precision. The ultrashort pulses prevent heat buildup, thus allowing minimal to no damage to surrounding tissues. The potential advantages of using the femtosecond laser, or IntraLase, include greater safety, reproducibility of flap thickness, decreased flap complications, and decreased epithelial defects. Many physicians also feel the refractive outcome is improved especially in wavefront-guided procedures. Touboul D, Salin F, Mortemousque B, et al: Advantages and disadvantages of the femtosecond laser microkeratome. Corneal ectasia is progressive corneal thinning and steepening with irregular astigmatism that causes poor vision. Most surgeons believe that the stromal bed (calculated by taking the central corneal thickness minus the flap thickness minus the laser ablation) should be at least 250 mm to prevent corneal ectasia. However, other surgeons believe that the minimal stromal bed thickness should be greater. This procedure involves the placement of two 150-degree arc segments of polymethylmethacrylate plastic at two-thirds depths in the peripheral cornea. These lens implants are placed in the eye without the removal of the patient’s own crystalline lens. There are currently three main types: an anterior chamber lens clipped to the iris, an angle- supported anterior chamber lens, and a posterior chamber lens in the ciliary sulcus (just in front of the crystalline lens). In a worst case scenario (by adjusting for measurement inaccuracy), 9% of eyes would have been at risk for 10% loss of endothelial cells at 12 months. Several authors have reported that the iris-claw lenses do accelerate endothelial cell loss. Benedetti S, Whomsley R, Baltes E, Tonner F: Correction of myopia of 7 to 24 diopters with the Artisan phakic intraocular lens: Two-year follow-up. Pop M, Payette Y: Initial results of endothelial cell counts after Artisan lens for phakic eyes: An evaluation of the United States Food and Drug Administration Ophtec Study. Because the crystalline lens adds about 18 D of power to the optical system, clear lens extraction may be used in patients with a comparable level of myopia. However, performing intraocular surgery for a purely refractive goal is controversial. In addition, highly myopic eyes carry a moderate risk of retinal detachment, which is increased after lens extraction. The correction of astigmatism is slightly more forgiving than the correction of myopia. Each of the procedures for myopia has adaptations to address astigmatism alone or simultaneously with myopia. Epithelial ingrowth into the stroma, healing difficulties, and significant scarring may result. If compound myopic astigmatism is present, a combination of spherical and cylindrical patterns results in correction of both myopia and astigmatism. Whichever procedure isemployed, the axisof the astigmatism shouldbe marked with the patient seated, because it may shift when the patient reclines. A rigid gas-permeable contact lens may be especially effective in alleviating irregular astigmatism. However, many patients do not tolerate or desire contact lenses after corneal transplant surgery. Once all sutures are out and the refraction is stable, arcuate relaxing incisions may be performed in the donor cornea along the steep meridian to reduce astigmatism. An alternative technique involves using a blade to open the wound partially and relax several clock hours of the graft-host junction as opposed to creating incisions in the donor tissue. As described above, the excimer laser also has been used to correct postcorneal transplant astigmatism. Relaxing incisions combined with compression sutures (across the graft-host interface) have been used successfully to correct astigmatism of 5–10 D by causing steepening of the cornea in the sutured median (Fig. Treatment for postcorneal transplant greater than 10 D, a wedge resection astigmatism. Compression sutures were placed in the flat meridians (1:00–3:00 and 6:30–8:00), and (of corneal tissue followed by sutured relaxing incisions were performed in the graft wound closure of the wound) may be 90 degrees away. A 40-year-old Olympic ski coach desires refractive surgery so that he may see distance clearly. When a transverse incision causes corneal flattening in one meridian, there is a compensatory steepening of the unincised corneal meridian 90 degrees away. In the case above, the coupling effect of the incised and unincised meridians (90 degrees apart) should have been anticipated. In general, short incisions tend to cause less steepening of the unincised meridian than longer incisions. Of the available options, none is as effective or reliable as the procedures for myopia. For low levels of hyperopia, holmium laser thermokeratoplasty has been used with some success. Eight (or 16) peripheral laser spots are placed in a ring (or two), each spot causing shrinkage of the stromal collagen and resulting in steepening of the central cornea. The heat generated causes collagen shrinkage, allowing the central cornea to steepen. The procedure is effective for low to moderate hyperopia, but the trend is for regression over several years. The laser is used to create a large, donut-shaped ablation that requires a generous epithelial defect (often 9 mm or more). Performing the laser ablation under a corneal flap has the theoretical advantage of decreased haze (ablation performed deep to Bowman’s layer) and faster healing response (no large epithelial defect). Moreover, the risks of intraocular surgery, including endophthalmitis, are difficult to justify in eyes without organic disease. What are the effects of refractive surgical procedures on corneal endothelial cells? After excimer laser treatment of myopia, studies in animals and humans suggest a small, insignificant loss of endothelial cells that diminishes over time. As the treated population grows older, patients eventually will require cataract surgery. Is corneal decompensation in Fuchs’ endothelial dystrophy accelerated by previous refractive surgery? Effects of the laser itself, the inflammatory response, and toxicity of topically applied drugs may contribute to endothelial cell loss and require further study.

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Tethered spinal cord disease

Insulin promotes glucose uptake into target tissues generic npxl 30caps with visa herbals on york carlisle pa, stimulates glycogen synthesis purchase 30 caps npxl with visa mobu herbals x-tracting balm reviews, and inhibits glycogenolysis buy 30 caps npxl fast delivery himalaya herbals 100 tabletas. Bold arrows indicate processes stimulated by insulin; light arrows indicate processes inhibited by insulin buy npxl 30 caps low price herbals dario. In addition to increasing glucose uptake and providing a mass action stimulus for glycolysis, insulin activates the enzymes glucokinase (liver), hexokinase (muscle), phosphofructokinase, pyruvate kinase, and pyruvate dehydrogenase of the glycolytic pathway (see Fig. Also shown is the inhibition of gluconeogenesis by insulin inhibition of fructose-1,6-diphosphatase, phosphoenolpyruvate carboxylase, and pyruvate carboxylase. In adipose tissue and the liver, insulin promotes lipogenesis and inhibits lipolysis (Fig. Insulin has similar actions in muscle, but because muscle is not a major site of lipid storage, the discussion here focuses on actions in adipose tissue and the liver. By promoting the flow of intermediates through glycolysis, insulin promotes the formation of α-glycerol phosphate and fatty acids necessary for triglyceride formation. In addition, it stimulates fatty acid synthase, leading directly to increased fatty acid synthesis. Insulin inhibits the breakdown of triglycerides by inhibiting hormone-sensitive lipase, which is activated by many counterregulatory hormones, such as epinephrine and adrenal glucocorticoids. By inhibiting this enzyme, insulin promotes the accumulation of triglycerides in adipose tissue. Insulin promotes the accumulation of lipid (triglycerides) in adipocytes by stimulating the processes shown by the bold arrows and inhibiting the processes shown by the light arrows. In addition to promoting de novo fatty acid synthesis in adipose tissue, insulin increases the activity of lipoprotein lipase, which plays a role in the uptake of fatty acids from the blood into adipose tissue. As a result, adipose tissue takes up lipoproteins synthesized in the liver, and fatty acids are ultimately stored as triglycerides. Insulin promotes protein accumulation in its primary target tissues-liver, adipose tissue, and muscle-in three specific ways. Second, it increases the activity of several factors involved in protein synthesis. For example, it increases the activity of protein synthesis initiation factors, promoting the start of translation and increasing the efficiency of protein synthesis. Insulin also increases the amount of protein synthesis machinery in cells by promoting ribosome synthesis. Third, insulin inhibits protein degradation by reducing lysosome activity and possibly other mechanisms as well. Numerous effects of glucagon have been documented in several tissues, primarily adipose tissue, when the hormone has been added at high, nonphysiologic concentrations in experimental situations. Although these effects may play a role in certain abnormal situations, the normal daily effects of glucagon occur primarily in the liver. Glucagon initiates its biologic effects by interacting with one or more types of cell membrane receptors. Similarly, glucagon promotes the net breakdown of glycogen by inactivating glycogen synthase. Glucagon also stimulates amino acid transport into liver cells and the degradation of hepatic proteins, helping provide substrates for gluconeogenesis (see Fig. The glucagon-enhanced conversion of amino acids into glucose leads to increased formation of ammonia that glucagon alleviates by increasing the activity of the urea cycle enzymes and ureagenesis. Bold arrows indicate processes stimulated by glucagon; the light arrows indicate a process inhibited by glucagon. If the rate of fatty acid transport into the mitochondria exceeds the energy needs of the liver, the fatty acids are used in the production of ketones. Ketones are an important source of fuel for muscle and heart cells during times of starvation, sparing blood glucose for other tissues that are obligated glucose users, such as the central nervous system. During prolonged starvation, the brain adapts its metabolism to use ketones as a fuel source, lessening the overall need for hepatic glucose production. Bold arrows indicate processes stimulated by glucagon; light arrows indicate processes inhibited by glucagon. Therefore, the relative level of both hormones in the blood plasma, the insulin/glucagon ratio (I/G ratio), determines the net physiologic response. The I/G ratio can vary 100-fold or more because the plasma concentration of each hormone can vary considerably in different nutritional states. After an overnight fast, it may fall to about two, and with prolonged fasting, it may fall to as low as 0. A good example of the profound influence of the I/G ratio on metabolic status is in T1D (see below). Insulin levels are low, so pathways that insulin stimulates operate at a reduced level. However, insulin is also necessary for α cells to sense blood glucose appropriately; in the absence of insulin, the secretion of glucagon is inappropriately elevated. The result is an imbalance in the I/G ratio and an accentuation of glucagon effects well above what would be seen in normal states of low insulin, such as in fasting. In addition to abnormal glucose metabolism, disorders in the metabolism of lipid and protein intensify the seriousness of the disease. Superimposed on the disorders of carbohydrate, fat, and protein metabolism are diabetic-specific microvascular lesions in the retinas, renal glomeruli, and peripheral nerves. Diabetes, if untreated, leads to renal failure, erectile dysfunction, blindness, coronary arterial disease, and increased risk of cancer. In fact, adults with diabetes have heart disease death rates about two to four times higher than adults without diabetes. Also, stroke accounts for ~20% of diabetes-related deaths, and the risk for stroke is also two to four times higher among people with diabetes. The cause of diabetes continues to be a mystery, although both genetics and environmental factors such as obesity and lack of exercise appear to play significant roles. Data from the National Diabetes Statistical Report released in 2014 reported that there are 29. Diabetes has several clinical forms, each of which has a distinct etiology, clinical presentation, and course. Symptoms usually include frequent urination, increased thirst, increased food consumption, and weight loss. There are four main type of diabetes: (1) Type 1 diabetes (T1D) results from the body failure to produce insulin, (2) prediabetes results from insulin resistance, (3) Type 2 diabetes (T2D) results from insulin resistance and β-cell failure, and (4) gestational diabetes results from insulin resistance during pregnancy. Although most cases of T1D are a consequence of an inappropriate autoimmune destruction of the β cell, an autoimmune-independent subtype of T1D has recently been described, and recommendations have been put forth to divide T1D into type 1A (immune mediated) and type 1B (other forms of diabetes with severe insulin deficiency). Type 1B diabetes appears to be a rare form of T1D in which histologic examination of pancreatic sections demonstrates inflammation but no anti-islet autoantibodies. Whereas studies to gain deeper insight into type 1B diabetes are currently underway, it is known that type 1A diabetes results from a selective destruction of the β cells within the islets. A subtype of type 1A diabetes that has a latent onset in adults also exists, and recent findings suggest that its correct diagnosis and tailored insulin therapy may delay the progression and worsening of the disease (see Clinical Focus 34. The development of type 1A diabetes is usually divided into a series of stages, beginning with genetic susceptibility and ending with essentially complete β-cell destruction.

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In the dye disappearance test quality npxl 30caps quality herbals, a drop of fluorescein is placed in the inferior conjunctival fornix effective 30 caps npxl kan herbals relaxed wanderer. After 5 minutes generic 30caps npxl with mastercard herbs pool, the amount present in the tear lake is assessed using a cobalt-blue light order 30 caps npxl visa ridgecrest herbals anxiety free. A primary Jones dye test involves placing fluorescein in the inferior conjunctival fornix. In a secondary Jones dye test the inferior fornix is first irrigated to remove all residual fluorescein from the primary test. If fluorescein-stained fluid is recovered from the nose, the fluorescein must have passed freely through the punctum, canaliculus, and to the lacrimal sac during the primary Jones test, indicating a partial block of the nasolacrimal duct. If clear fluid is recovered, a partial obstruction or functional disorder of the punctum or canaliculus is indicated. If no fluid is recovered from the nose but instead regurgitates from the adjacent punctum, an obstruction at or distal to the common canaliculus is present. When the punctum is not patent, this can frequently be opened with a sharp probe or cut-down procedure to find the proximal canaliculus. In most patients, placement of a temporary silicone stent is helpful to prevent the punctum from reclosing. In this surgery a fistula is created between the caruncle and the nasal mucosa and a permanent glass tube (Jones tube) is placed in this tract to maintain its patency. The majority of lacrimal system obstructions occur in the nasolacrimal duct, which connects the lacrimal sac to the nose. In this procedure the lacrimal sac is marsupialized to the nasal passages, so the tears can bypass the blocked nasolacrimal duct and drain directly from the lacrimal sac into the nose. A purulent discharge from the punctum may be seen with gentle pressure on the lacrimal sac. Appropriate systemic antibiotics should be given, and warm compresses should be applied to the medial canthus. Approximately 6% of newborns have a congenital obstruction of the nasolacrimal system. Infants may present with epiphora, conjunctivitis, amniocele formation, or a dacryocystitis. The lacrimal drainage system begins embryologically as a cord in the medial canthus that expands laterally to the punctum and inferiorly to the nasal mucosa of the inferior meatus. The lumen also forms first in the medial canthus, and canalization develops laterally and inferiorly. This may not yet be patent at birth and is the most common site of congenital obstructions. Then undertake probing of the nasal lacrimal duct under anesthesia, often with balloon dacryoplasty. Most clinicians recommend massaging the infant’s lacrimal sac (in the medial canthus) in an inferior direction to increase the hydrostatic pressure in the nasolacrimal duct and hopefully force open any obstruction. If there is an associated conjunctivitis or discharge, topical antibiotics are also used. If a child has a persistent tearing because of blockage of the nasolacrimal duct, a probing of the system should be performed in the first 13 months of life. Katowitz and Welsh have shown that the success rates of probing drop significantly if performed after 13 months of age. In this procedure the child is placed under general anesthesia and a Bowman probe is passed into the punctum, through the lacrimal system, and out through the nasolacrimal duct. Some surgeons elect to perform a balloon dacryoplasty at the time of the initial probing. In this procedure a deflated balloon is passed into the duct and then inflated to dilate the duct and the ostium. Approximately 90–95% of infants who undergo a probing enjoy a resolution of their symptoms. Tubes are generally left in place for approximately 6 months and serve to keep the passageway open. Unilateral proptosis is frequently defined as asymmetric protrusion of one eye by at least 2 mm. Normal upper limits for proptosis are approximately 22 mm in Caucasians and 24 mm in African Americans. Clinically, proptosis can be recognized by observing the globes from above, over the patient’s forehead. It is measured with an exophthalmometer, which is usually based at the lateral orbital rim. Computed tomographic scan demonstrating proptosis of the right globe symptoms of irritation and foreign secondary to thyroid-related enlargement of the body sensation, or they may rectus muscles. Indications of nerve compression include decreased visual acuity, relative afferent pupillary defect, color vision deficit, and visual field defect of the affected eye. Severe conjunctival chemosis with prompt therapeutic intervention, corneal erosion secondary to proptosis caused by surgically or medically. This eye secondary to old trauma, which is causing often coexists in cases of thyroid apparent proptosis of the right eye. Which clinical entity is frequently associated with unilateral or bilateral painless proptosis, eyelid retraction, eyelid lag on downward gaze, and motility disturbances? Patients can be hyperthyroid, hypothyroid, or euthyroid when manifesting ophthalmic symptoms. Proptosis and eyelid retraction caused various extraocular muscles (most by thyroid ophthalmopathy. Proptosis and eyelid retraction cause corneal problems, and muscle enlargement in the orbit causes diplopia and possibly optic nerve compression. Which clinical entity is frequently associated with unilateral proptosis, pain, conjunctival injection, and motility disturbances in an adult? Orbital inflammatory pseudotumor is a nonspecific idiopathic inflammatory disease of the orbit. Inflammation may be localized to a muscle, the lacrimal gland, or sclera, or may be diffuse. Other possible signs include eyelid erythema or edema, palpable mass, decreased vision, uveitis, hyperopic shift, and optic nerve edema. Which clinical entity is characterized by unilateral proptosis, pain, fever, decreased ocular motility, erythema, and edema of the eyelids? Infectious orbital cellulitis involves an infection (usually bacterial) that has extended posterior to the orbital septum. Once past the orbital septum barrier, infection can spread rapidly and cause serious complications such as meningitis or cavernous sinus thrombosis.

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