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However erectile dysfunction treatment mumbai purchase suhagra no prescription, these methods are affected by dietary sources of vanillin; coffee erectile dysfunction statistics singapore cheap 100mg suhagra free shipping, chocolate erectile dysfunction doctors albany ny cheap suhagra 100 mg with mastercard, bananas bisoprolol causes erectile dysfunction purchase 50 mg suhagra free shipping, and vanilla must be excluded from the diet. Histidine Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/1 is true? Most of the T3 present in plasma is from its direct release from thyroid storage sites Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/2 thyroid hormones is true? An elevated serum total T4 and T3 is diagnostic of hyperthyroidism Chemistry/Apply knowledge of fundamental biological characteristics/Thyroid/2 39. C Thyroid hormones are derived from the enzymatic modification of tyrosine residues on thyroglobulin. Enzymatic coupling of these residues form T3 (3,5,3ґ-triiodothyronine) and T4 (3,5,3ґ,5ґ-tetraiodothyronine). Levels of T4 are about 50 times those of T3, but T3 is approximately 10 times more active physiologically. Eighty percent of circulating T3 is derived from enzymatic conversion of T4 by T4 5ґ-deiodinase. For this reason, free T3 and T4 are more specific indicators of thyroid function than are measurements of total hormone. Suitable assays are available that estimate free T4 and T3 and these should be used instead of total hormone assays. Euthyroid sick syndrome Chemistry/Correlate clinical and laboratory data/ Thyroid/1 45. In patients with primary hypothyroidism, there is an exaggerated response (>30 mU/L). Euthyroid sick syndrome Chemistry/Correlate clinical and laboratory data/ Thyroid/3 46. Reverse T3 is increased in acute and chronic illness and is used to identify patients with euthyroid sick syndrome. Subclinical hypothyroidism Chemistry/Correlate clinical and laboratory data/ Thyroid/3 5. After high-dose corticosteroid treatment Chemistry/Correlate clinical and laboratory data/ Thyroid/3 Answers to Questions 49­50 49. D the purpose of therapeutic drug monitoring is to achieve a therapeutic blood drug level rapidly and minimize the risk of drug toxicity caused by overdose. Therapeutic drug monitoring is a quantitative procedure performed for drugs with a narrow therapeutic index (ratio of the concentration producing the desired effect to the concentration producing toxicity). Drug groups that require monitoring because of high risk of toxicity include aminoglycoside antibiotics, anticonvulsants, antiarrhythmics, antiasthmatics, immunosuppressive agents used for transplant rejection, and psychoactive drugs. When testing for abuse substances, the goal is usually to determine whether the drug is present or absent. The most common approach is to compare the result to a cutoff determined by measuring a standard containing the lowest level of drug that is considered significant. To determine whether the dose of a drug with a low therapeutic index is likely to be toxic B. To determine whether the patient has been taking amphetamines Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug monitoring/1 2. The relationship between blood and tissue drug blood level therapeutic response levels Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug monitoring/1 3. A Pharmacokinetics is the mathematical expression of the relationship between drug dose and drug blood level. When the appropriate formula is applied to quantitative measures of drug dose, absorption, distribution, and elimination, the blood concentration can be accurately determined. Blood and tissue drug levels Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug monitoring/1 type of testing? Comparison of dose-response curves between family members Chemistry/Apply knowledge of fundamental biological characteristics/Therapeutic drug monitoring/1 3. B Pharmacodynamics is the relationship between the drug concentration at the receptor site (tissue concentration) and the response of the tissue to that drug. For example, the relationship between lidocaine concentration in the heart muscle and the duration of the action potential of Purkinje fibers. C Pharmacogenomics refers to the study of genes that affect the performance of a drug in an individual. Genetic variations of one such enzyme may account for individual pharmacokinetic differences and can be used to predict the efficacy of the drug.

Staphylococcus saprophyticus Microbiology/Evaluate data for identification/ Gram-variable rods/3 41 erectile dysfunction quality of life discount 50mg suhagra with visa. Clue cells (vaginal epithelial cells with gram-variable coccobacilli on the cell margins) are seen in vaginal washings and the organism grows slowly on chocolate agar impotence with diabetes cheap suhagra 50mg fast delivery, 5% sheep blood agar erectile dysfunction getting pregnant suhagra 50 mg without prescription, and V-agar erectile dysfunction gif order discount suhagra on line. A 50-year-old male transplant patient was 487 experiencing neurological difficulties after a pulmonary infection. Microbiology/Evaluate data for identification/ Gram-positive bacilli/3 entered the emergency department complaining of diarrhea, fever, and other flulike symptoms. After 24 hours, the urine culture was negative, but the blood cultures revealed a gram-positive short rod that grew aerobically on blood agar. Motility = + (Wet mount = Tumbling) Glucose = + (Acid) Catalase = + Esculin hydrolysis = + 44. Anaerobic gram-positive, spore-forming bacilli were recovered from the feces of a chemotherapy patient with severe diarrhea. A 22-year-old pregnant woman (third trimester) What is the correct identification? Clostridium difficile Microbiology/Evaluate laboratory data for identification/Anaerobic gram-positive rods/3 Answers to Questions 42­44 42. Immunocompromised patients are susceptible to infections, especially pulmonary, which then disseminate to other organs, often proving fatal. If it is not detected and treated, infection of the fetus, resulting in stillbirth, abortion, or premature birth may result. Anaerobic gram-positive diphtheroids (nonspore formers) were cultured from two separate blood culture bottles (at 5 days) obtained from a 25-year-old patient admitted to the hospital with dehydration, diarrhea, and other flulike symptoms. Four other blood culture bottles did not grow any organisms at 7 days and were discarded. Anaerobic, nonpigmented, gram-negative rods were recovered from an anaerobic blood agar plate after 48 hours of incubation. The colonies on blood agar had the appearance of dry, irregular, white breadcrumb-like morphology with greening of the agar. The following reactions were noted: Kanamycin = Sensitive Colistin = Sensitive Indole = + Lipase = Neg Growth on 20% bile agar = Neg Vancomycin = Resistant Nitrate = Neg Catalase = Neg Urease = Neg What is the correct identification? Microbiology/Evaluate laboratory data for identification/Anaerobic gram-positive rods/3 46. Anaerobic gram-positive bacilli with subterminal What is the correct identification? Microbiology/Evaluate laboratory data for identification/Anaerobic gram-negative rods/3 Answers to Questions 45­48 45. It is one of the most common organisms isolated from blood cultures and is often a contaminant. The following results were recorded: Indole = Neg Urease = Neg Lipase = Neg Catalase = Neg Lecithinase = Neg Growth on blood agar = Swarming colonies What is the correct identification? Propionibacterium acnes Microbiology/Evaluate laboratory data for identification/Anaerobic gram-positive rods/3 47. The following test results were recorded: Kanamycin = Resistant Colistin = Resistant Growth on 20% bile plate = + Indole = V (Neg) Urease = Neg Pigment = Neg Nitrate = Neg Lipase = Neg 47. A A slender gram-negative rod with pointed ends that does not grow on 20% bile agar rules out B. Microbiology/Evaluate laboratory data for identification/Anaerobic gram-negative rods/3 7. A fungal culture was also ordered that grew the following on Sabouraud dextrose agar after 3 days: Hyphae = Septate with dichotomous branching Spores = Produced by conidial heads with numerous conidia Colonies = Velvety or powdery, white at first, then turning dark greenish to gray (reverse = white to tan) Vesicle = Holding phialides usually on upper two-thirds only What is the most likely identification? Aspergillus fumigatus Microbiology/Evaluate laboratory data to make identification/Mycology/3 Answers to Questions 49­50 49. This is called allergic aspergillosis and is characterized by a high titer of IgE antibody to Aspergillus. Invasive aspergillosis seen in neutropenic patients exhibits sinusitis, and is disseminated throughout the body.

Some have said erectile dysfunction vacuum pump purchase suhagra in united states online, "You either had the infection as a child erectile dysfunction treatment pumps order 50mg suhagra mastercard, have it now erectile dysfunction tampa generic 50mg suhagra amex, or will have it again when you have children erectile dysfunction 20 buy suhagra 100 mg fast delivery. Diphyllobothrium latum Microbiology/Apply knowledge of organism morphology/Parasitology/1 in infection? Opisthorchis sinensis Microbiology/Apply knowledge of life cycles/ Parasitology/2 65. These ascarid eggs of the dog can infect humans; the eggs hatch and the larvae wander through the deep tissues, occasionally the eye. The term internal autoinfection can be associated with the following parasites: A. Giardia lamblia and Cystoisospora belli Microbiology/Apply knowledge of life cycles/ Parasitology/2 severe diarrhea, disseminated disease in other body sites, and ocular infections. Ingestion, inhalation, and direct contamination Microbiology/Apply knowledge of life cycles/ Parasitology/2 to have diarrhea after repeated ova and parasites (O&P) examinations (sedimentation concentration, trichrome permanent stained smear) were reported as negative; organisms that might be responsible for the diarrhea include: A. Organisms stained with modified acid-fast stains Microbiology/Apply knowledge of life cycles and diagnostic procedures/Parasitology/3 Plasmodium knowlesi, resemble those of: A. Plasmodium vivax Microbiology/Apply knowledge of organism morphology/ Parasitology/3 73. Microsporidia have been identified as causing humans on passage from the gastrointestinal tract include: A. Plasmodium vivax Microbiology/Apply knowledge of organism morphology/ Parasitology/3 74. This means that the cycle and infection can continue even after the patient has left the endemic area. In the case of Cryptosporidium, the cycle continues in patients who are immunocompromised and unable to self-cure. D Infectious routes for microsporidial infections have been confirmed as ingestion and inhalation of the spores; direct transfer of infectious spores from environmental surfaces to the eyes has also been reported. D Routine O&P examinations usually do not allow the detection of Cryptosporidium spp. Modified acid-fast stains for coccidia and modified trichrome stains for the microsporidial spores are recommended. C Confirmation of an infection with microsporidial spores can be achieved by seeing evidence of the polar tubule within the spores (horizontal or diagonal line across/within the spore). A the older developmental stages of Plasmodium knowlesi (trophs, schizonts) resemble those seen in infections with P. Autofluorescence requires no stain and is 475 recommended for the identification of: A. Cyclospora cayetanensis oocysts Microbiology/Apply knowledge of organism morphology and diagnostic procedures/Parasitology/3 knowlesi include: A. Key characteristics of infection with Plasmodium holding the blood too long prior to preparation of thick and thin blood films include: A. Changes in parasite morphology, loss of organisms within several hours, and poor staining B. All of these options Microbiology/Apply knowledge of specimen collection and processing, organism morphology, and diagnostic procedures/Parasitology/3 Answers to Questions 75­79 75. D Autofluorescence requires no stain and is often recommended for confirmation of Cyclospora cayetanensis oocysts. Fluorescence microscopy and hematoxylin stains Microbiology/Apply knowledge of organism morphology and diagnostic procedures/Parasitology/3 78. A An infection with microsporidia can be confirmed using modified trichrome stains (10X the normal dye content found in routine trichrome stains) and light microscopy. The internal polar tubule will be visible within some of the spores; this will serve as confirmation of the infection. B the name Blastocystis hominis contains approximately 10 different strains/species that are morphologically identical; some are pathogenic and some are nonpathogenic. Because we cannot separate these organisms by morphology, this probably explains why some patients are symptomatic and some remain asymptomatic with this infection. Numerous strains/species are included in the name, some of which are pathogenic and some are nonpathogenic C. The number of organisms present determines pathogenicity Microbiology/Apply knowledge of organism life cycle and pathogenesis/Parasitology/3 79. D There are many changes that occur if blood is held longer than 1­2 hours prior to thick and thin blood film preparation.

It exists in the diet as a mixture of eight closely related compounds called Tocopherols impotence klonopin generic 50mg suhagra with mastercard. Functions the main function of Vit E is as an antioxidant doctor for erectile dysfunction in chennai 50 mg suhagra with mastercard, in particular a membrane antioxidant associated with lipid membrane structure erectile dysfunction 2 buy discount suhagra 50mg on-line. It provides protection from the action of peroxides by converting them to a product that is conjugating with glucuronic acid and excreted in bile erectile dysfunction drugs and infertility buy suhagra from india. Source: the richest source is vegetable oil, and nuts 180 Deficiency Vit E deficiency is a rare but found in complication of prolonged and severe steatorrhoea, and of prolonged parenteral nutrition. Deficiency of Vit E causes anemia in children with cystic fibrosis of pancreas are found to be tocopherol deficient as a result of stetorrhoea. There are three types, Menaquinone (K2)present in animals,Phylloquinone (K1) present in Plants. Like vit E, the absorption of Vitamin k is dependent on appropriate fat absorption. Functions It is the only one acting as co-enzyme from the group of Fat soluble vitamins. It is required for post translational modifications of several proteins required in the coagulation cascade. Activation is carried out by the carboxylation of specific glutamate residues on the prothrombin by Vit K dependent enzyme. The presence of a second carboxyl group on the glutamate (- 181 carboxy glutamate) side chain confers phospholipids binding properties on the Prothrombin in the presence of Ca2+. Deficiency It is widely distributed in nature and produced by the intestinal micro flora. However, it is found in patients suffering from Liver diseases (obstructive jaundice), in new born infants and in patients with malabsorption. The placenta is inefficient at passing maternal Vit K to the fetus and immediately after birth the circulation concentration drops, but recovers on absorption of foods. In addition the gut of the new born is sterile, so that the intestinal micro flora does not provide a source of vit K for several days after birth. This is the reason why adults who are on prolonged antibiotic treatment require supplementation of Vit. D dependent Carboxylation reactions are used in the treatment of thrombosis related diseases. Warfarin, which inhibit the action of Vit K - probably via the mechanisms involved in the regeneration of the active hydroquinone. Tests to asses Vitamin K status include the prothrombin time-an important test in the investigation and management of jaundiced patients and of those on anticoagulant treatment. Some elements are needed at high concentrations, required more than 100mg per day. Sodium and Potassium: They are important in cell, muscle physiology, transmission of messages and other biological processes. Since both are widely distributed, deficiency of the two elements is rarely found. It has a role, along with others, in the neuro muscular excitability Sodium is exchanged with Hydrogen in renal tubules to acidify urine. Sodium and Potassium maintain the degree of hydration of plasma proteins, and there by viscosity of blood. Hypernatremia: It occurs nearly always due to water deficiencies rather than Na2+ excess. It is usually seen in patients with dehydration, on steroid therapy or excess sodium intake. Hyponatremia: It is common in patients who are in diuretics or excessive sweating, kidney disease, diarrhea and congestive heart failure. Other causes are decreased excretion by the kidney, diseases like Anuria, tissue damage or Diabetes Mellitus. Hypokalemia: Low potassium is not due to dietary deficiency but due to conditions like vomiting, diarrhea.

In addition erectile dysfunction medications cost buy generic suhagra pills, these investigators described the cases of four children with a mean age of 3 impotence caused by diabetes purchase 100 mg suhagra amex. These were specifically optic nerve tumors impotence juice recipe generic suhagra 50 mg free shipping, as opposed to chiasmal tumors erectile dysfunction generics 50mg suhagra visa, with proptosis as the primary initial symptom. Sixteen (48%) of the tumors have never caused any clinical symptoms or signs; they were all discovered by screening neuroimaging in asymptomatic children. Most important, of the 17 children who had symptomatic tumors, there was demonstrable growth of the tumor on neuroimaging or progression of visual disturbances in only three children. Even tumors that had undergone rapid growth with proptosis before diagnosis failed to progress during the follow-up period. The three children who had progressive disease all had chiasmal involvement; two of these children experienced only minimal progression. Perhaps the most dramatic symptom of optic pathway glioma is progressive proptosis over a relatively short period of time. Most studies document proptosis in approximately 30% of the children with symptomatic tumors [Listernick et al. Clearly, these tumors are biologically distinct from the quiescent optic nerve tumors seen in other patients. The majority of children with symptomatic optic pathway glioma will have visual abnormalities at the time of diagnosis. Signs may include an afferent pupillary defect, optic nerve atrophy, papilledema, strabismus, or defects in color vision. Children with optic pathway gliomas involving the optic chiasm are at risk of precocious puberty, which was the initial complaint in 30% of the patients with tumors in one series [Listernick et al. The second group of tumors undergoes a period of growth culminating in visual symptoms In addition, the period of greatest risk for the development of symptomatic tumors is during the first 6 years of life, and significant tumor growth after this age is unusual. Once these tumors are detected, they rarely progress or cause any subsequent problems. In addition, the period of greatest risk for the development of symptomatic tumors is during the first 6 years of life, and significant tumor growth after this age is unusual. Precocious Puberty Children with optic pathway gliomas are at risk of precocious puberty. The currently accepted theory is that lesions located near the hypothalamus interfere with tonic central nervous system inhibition of the hypothalamic-pituitarygonadal axis, resulting in the premature onset of puberty. Early detection is important, since both the accelerated linear growth and the development of secondary sexual characteristics can be managed well with a long-acting luteinizing hormone­releasing hormone agonist. Routine screening would be important if it led to early detection of optic pathway gliomas and if early initiation of therapy prevented complica- tions. Although many asymptomatic tumors might be identified through such an approach, the vast majority would not progress to the point of requiring treatment. More than half of the detected tumors never grew or caused any symptoms, and the vast majority of symptomatic optic pathway gliomas never required treatment. Overall, only three of 26 children showed any evidence of tumor progression after diagnosis and only two required treatment. Both of these children had abnormal eye examinations and would have been identified even if screening neuroimaging had not been performed. It is also recommended that ocular alignment and rotations, pupillary light responses, and refractive status with cycloplegia be assessed. Magnetic resonance imaging scan, axial inversion recovery sequence of head and orbits, demonstrates a large left-sided intraorbital optic nerve glioma and proptosis of the globe. They will have large intraorbital tumors, perhaps with involvement of the intracranial optic nerve but without evidence of chiasmal symptoms. The main concern in these patients is retrograde spread of the tumor to the optic chiasm, with associated decreased vision in the contralateral eye. However, there is no evidence that surgical removal of tumor is effective in preventing spread. Treatment may be considered for those few patients who have intraorbital gliomas with either residual useful vision and/or evidence of radiologic or ophthalmologic progression.

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