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The presence of a second carboxyl group on the glutamate (γ- 181 carboxy glutamate) side chain confers phospholipids binding properties on the Prothrombin in 2+ the presence of Ca trusted 20 mg levitra soft. However purchase levitra soft 20 mg with amex, it is found in patients suffering from Liver diseases (obstructive jaundice) discount 20 mg levitra soft, in new born infants and in patients with malabsorption generic levitra soft 20 mg visa. The placenta is inefficient at passing maternal Vit K to the fetus and immediately after birth the circulation concentration drops generic levitra soft 20mg with mastercard, 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. 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. Sodium and Potassium: They are important in cell, muscle physiology, transmission of messages and other biological processes. 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. Calcium and Phosphate: Major parts (90%) of them are found in the form of crystal lattice in the bone. People, who get enough sunlight, exercise regularly, on high protein diet, require 300- 400mgs per day. Clinical conditions: Hyper- calcemia; may be due to hyper parathyroidism, endocrine causes, renal failure and malignancies. Iron In body it is found in Haemoglobin, Myoglobin, ferritin, hemosiderin, transferrine and enzymes like cytochromes etc. Sources: cereals, legumes, raisins, nuts etc Functions: • Cofactor of enzymes like cytochrome oxidase, dopamine decarboxylase, tyrosinase, Cyt. Tyrosyl oxidase is important for collagen metabolism ++ +++ • Ceruloplasmin (serum ferroxidase) catalyses Fe to Fe , a pre requisite for the incorporation of iron into transferrin. Menke’s disease or Kinky hair syndrome: It is fatal sex linked recessive disorder in which there is cerebral and cerebellar degeneration, connective tissue abnormalities and kinky hair. Patient has normal absorption of iron but transport across the serosal aspect of mucosal membrane is defective. Sources: Widely distributed in vegetables, chlorophyll, cereals, beans, potatoes, cheese and animal tissues. Small quantities of it promotes bone development, increases retention of calcium and phosphate, prevent osteoporosis • High level of fluoride in bone causes abnormal rise in calcium deposition, increases bone density Flurosis is due to toxicity of fluoride. Zinc Sources are liver, milk, fish, dairy products, cereals, legumes, pulses, oil seeds, yeast and spinach etc. It is transported bound to a protein (α2-macroglobulin and transferrin) It is excreted in urine and feces. The body does not store Zinc to any appreciable extent in any organ, urinary excretion is fairly constant at 10 μmol/day. Deficiency of Zinc: Patients requiring total parentral nutration, pregnancy, lactation, old age and alcoholics have been reported as being associated with increased incidence of Zinc deficiency. Deficiency of selenium: • Liver cirrhosis • Pancreatic degeneration • Myopathy, infertility • Failure of growth Toxicity: - Selenium toxicity is called Selenosis - Toxic dose is 900micro gram/day - It is present in metal polishes and anti-rust compounds 191 - The Toxicity symptoms are Hair loss,failing of nails, diarrhea,weight loss and gaslicky odour in breath(due to the presence of dimethyl selenide in expired air). Introduction Hormones are responsible for monitoring changes in the internal and external environment. Tissue production (paracrine) of hormones is also possible Hormones and Central nervous system interact to shape up development, physiology, behaviour and cognition. The actions and interactions of the endocrine and nervous system control the neurological activities as well as endocrine functions. A messenger secreted by neurons is neurotransmitter while the secretion of endocrine is called hormone. Cellular functions are regulated by hormones, neurotransmitters and growth factors through their interaction with the receptors, located at the cell surface. The basic information provides a solid foundation from which to view the existing and future developments in the rapidly moving discipline. Hormones can be classified based on their structure, mechanism of action, based on their site of production etc.

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Un número relativamente pequeño de pacientes necesitarán unos pocos complementarios “habituales” discount levitra soft 20mg, como un hemograma levitra soft 20 mg free shipping, un análisis de orina o una radiografía de tórax generic 20 mg levitra soft visa. Finalmente cheap 20mg levitra soft, un paciente en un grupo numeroso de enfermos levitra soft 20mg without a prescription, no completamente cuantificado, necesitará de algún complementario sustentado por alta tecnología, que no debemos desgastar innecesariamente por comodidad, superficialidad o complacencia. Para completar esta relativa cuenta, puede decirse que los complementarios aportan 5 % del proceso diagnóstico. En el caso de las inferiores debemos conocer que son las “dos columnas” en las que se erige “el edificio” corporal. El cuerpo humano es el único edificio levantado sobre dos columnas y la posición erecta no es para nada el resultado estático de dos cilindros sustentando uno mayor, sino una combinación sutil de estructuras y funciones que se ponen de acuerdo mediante contracciones agónicas y antagónicas que de forma imperceptible, automática y casi desconocida logran la bipedestación. En esta mirada general deben coincidir en altura y casi tocarse: tobillos, pantorrillas y rodillas. Luego precisamos los hallazgos de abajo hacia arriba: El pie El pie es una compleja estructura de sostén y marcha. Estos dedos mal denominados “artejos” por la práctica diaria, pueden estar en “gatillo”, engarrotados. En este caso la superficie de su última falange apoya con gran fricción sobre el zapato en ocasión de la marcha y la trastornan, al tiempo que se lesionan. Su base articula con la cabeza del primer metatarsiano que es el punto de apoyo común para ambos arcos del pie, el transversal y el longitudinal. Su base, al ser punto de apoyo, es particularmente resentida por las neuropatías, con mayor frecuencia la diabética. Proporcionalmente recibe menos sangre que los restantes que la reciben también desde los lados. Al estar en el extremo interno, los zapatos nuevos, o apretados, lo erosionan, en ocasiones gravemente. Los 3 puntos de apoyo son: las cabezas de los metatarsianos 1ro y 5to y el calcáneo. Los 2 arcos son: transversal entre las cabezas, longitudinal entre la cabeza del 1ro y el calcáneo. Esta configuración, de la que no dispone quien tiene el pie plano, asegura una marcha mullida, elástica y elegante. Aumento de volumen Si al examen físico una extremidad, solo una, está aumentada de volumen, entonces sin lugar a dudas, tiene: 1. Trastorno en el retorno venoso o linfático o ambos Si son las dos extremidades las aumentadas de volumen, entonces esta posibilidad pasa al quinto lugar: 1. Trastorno en el retorno venoso o linfático o ambos Cambios de coloración ¾ Palidez En una extremidad: sugiere enfermedad arterial. El sistema venoso de las extremidades tiene un componente profundo y otro superficial En los miembros inferiores, cuando se afecta el sistema profundo es en general por las trombosis. En las trombosis venosas profundas el aumento de volumen de la pierna o de toda la extremidad es el signo más frecuente y evidente. A partir de este párrafo hacemos nuestro juramento ético: “Juro por mi honor de médico que nunca más inventaré los pulsos arteriales” El sistema arterial se explora con el paciente acostado. La mano derecha del explorador sobre la pedia derecha, la mano izquierda sobre la pedia izquierda. La arteria pedia se busca en el dorso del pie, hacia su porción superior, por fuera del tendón del extensor del dedo grueso. Más bien es que su tronco se divide en las ramas terminales antes de alcanzar el dorso del pie. Arteria poplítea Es la estructura más profunda en el hueco poplíteo y resulta muy difícil su palpación. De todas maneras, con el paciente con su rodilla flexionada y el pie apoyado en la cama se intentará palparla en la profundidad del hueco, hacia el cóndilo femoral interno. Si resulta muy fácil su palpación debemos presumir que está dilatada, pues es la segunda arteria proclive al aneurisma, después del sector aortoilíaco. Arteria cubital Si bien tiene un calibre un tanto mayor que la radial es más profunda y más incierta su palpación, que se hará en la propia muñeca, hacia su porción interna. Dada esta circunstancia, Allen describió su prueba: ¾ Prueba de Allen El médico comprime la arteria radial sobre su latido. Luego comprime la arteria cubital en el lugar que se supone esté, después el paciente abre y cierra su mano, lenta y fuertemente una y otra vez.

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It is insensitive to physical or chemical treatments that inactivate all known viruses buy discount levitra soft 20 mg on line. Formalin fixation does not destroy infectivity order levitra soft 20 mg fast delivery, but exposure to Clorox generic 20mg levitra soft visa, formic acid or stringent autoclaving does cheap levitra soft 20mg with amex. Two isoforms of the Prion protein (PrP) have been hypothesized: a normal discount levitra soft 20 mg on-line, cellular form (PrP-C) and a modified infectious form (PrP-Sc). The incidence of Kuru has dropped precipitously since the suppression of ritual cannibalism. All three diseases are transmissible by intracerebral injection of infected nervous tissue into experimental animals. By six months dementia is profound and myoclonic jerking is evident as the individual becomes vegetative, mute and bedfast. Accidental transmission of the disease with corneal graft and with intracerebral electrode implantation has been reported. It is also important to remember that the tissues remain ‘infective’ after formalin fixation for a year or two. The x-ray source rotates around the patient’s head and divides the x-ray attenuation into compartments called pixels. From about 800,000 measurements, the computer assigns a number to each pixel and, by using a gray scale, reconstructs an image. Scan times can be shortened to less than 1 second to minimize motion artifact when the patient is restless. Iodinated water-soluble contrast agents can be given intravenously to enhance differences in tissue density. Following the pulse, the relaxation of these protons back to their original energy state is accompanied by emission of radiowaves that are characteristic of the particular tissue. Two tissue-specific relaxation constants, known as T1 and T2, as well as proton density can be measured. These different weightings are produced by varying 1) the imaging techniques (spin-echo, fast spin-echo, gradient-echo, inversion-recovery or echo- planar), 2) the repetition time (interval between repetitions of the pulse sequence), and 3) the echo time (the interval between radiofrequency excitation and measurement of the radiowave emission or signal). The time required for obtaining conventional spin-echo images ranges from 4 to 7 minutes for T1-weighted images to 8 to 12 minutes for both proton density and T2-weighted images. Fast spin-echo images allow similar images to be obtained in as little as 2 to 3 minutes. An even newer technique known as echo-planar imaging allows images to be obtained in a matter of seconds; these include “fast T2-weighted images” and diffusion-weighted images. Other advantages include better visualization of the posterior fossa and spinal cord, and the lack of ionizing radiation. The accumulation of Gd-media within a specific region of the brain shortens both T1 and T2 relaxation times, and appears as an area of increased signal intensity on T1-weighted images, even when precontrast images show no evidence of abnormal signal. The earliest changes of cerebral infarction may be seen within the first three hours after the onset of stroke on diffusion-weighted images; this is related to the visualization of cytotoxic edema within affected cells in the zone of acute infarction. During the first 5 days after stroke onset, Gd-enhancement may be seen within the small arteries of the ischemic cerebral territory, with gyral enhancement present 5 days to several months after onset. Additional lesions within the optic nerves, brainstem, and spinal cord may also be detected. If multiple small enhancing nodules were found, the diagnosis of cerebral toxoplasmosis or other granulomatous infection would be favored. These include patients with complex partial seizures, headache, dementia, head trauma, psychosis and congenital craniospinal anomalies. A gradient-echo pulse sequence enables visualization of flowing blood as areas of increased signal intensity. After obtaining a series of contiguous thin sections with gradient-echo techniques, a map of the blood vessels is reconstructed as a set of projection angiograms that can be viewed in any orientation. The relative regional selective vulnerability within the brain causes atrophy, which can be detected intra vitam using neuroimaging techniques (radiologic evaluation). The selective vulnerability of one or more systems may cause specific symptoms such as dementia or movement disorder or both (clinical evaluation). The neuropathological examination determines the type, distribution and extent of the abnormal changes involving the brain (biopsy or postmortem evaluation). The integration of the neuroimaging, clinical, and pathologic findings leads to a definitive diagnosis of neurodegenerative diseases. Neurodegenerative diseases encompass a group of chronic, progressive disorders usually involving the elderly. Neurodegenerative disorders of childhood are generally considered in separate categories.

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