USMLE Q BANK: 2012

Monday, April 9, 2012

USMLE Review

Computation in your Nervous System.
Computation in this Nervous System.
Computation in your Nervous System.
Computation in your Nervous System.
NeuroAnatomy for Medical Students and Doctors

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The connections, or pathways, between groups of neurons in the CNS are in the form of fiber bundles, or tracts (fasciculi). Aggregates of tracts, as seen in the spinal cord, are referred to as columns (funiculi). Tracts may descend (eg, from the cerebrum to the brain stem or spinal cord) or ascend (eg, from the spinal cord to the cerebrum). These pathways are vertical connections that in their course may cross (decussate) from one side of the CNS to the other. Horizontal (lateral) connections are called commissures.

Multiple tracts connect many parts of the nervous system. For example, multiple ascending and descending tracts connect the PNS and lower spinal centers with the brain. This reflects the fact that the nervous system extracts different aspects of its sensory surround (eg, the shape, weight, and temperature of an object touching the body) and encodes them separately and that it controls specific aspects of motor behavior (posture, muscle tone, delicate movements) using different sets of neurons. The multiplicity of tracts also endows the nervous system with a degree of redundancy: After partial destruction of the nervous system, only some functions will be lost; other functions may be retained, increasing the probability that the organism will survive.

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Symmetry of the Nervous System

The nervous system is constructed with bilateral symmetry. This is most apparent in the cerebrum and cerebellum, which are organized into right and left hemispheres. On initial consideration, these hemispheres appear symmetric. Some higher cortical functions such as language are represented more strongly in one hemisphere than in the other, but to gross inspection, the hemispheres have a similar structure. Even in more caudal structures, such as the brain stem and spinal cord, which are not organized into hemispheres, there is bilateral symmetry.

Crossed Representation

Another general theme in the construction of the nervous system is decussation and crossed representation: The right side of the brain receives information about, and controls motor function pertaining to, the left side of the world and vice versa. Visual information about the right side of the world is processed in the visual cortex on the left. Similarly, sensation of touch, sensation of heat or cold, and joint position sense from the body's right side are processed in the somatosensory cortex in the left cerebral hemisphere. In terms of motor control, the motor cortex in the left cerebral hemisphere controls body movements that pertain to the right side of the external world. This includes, of course, control of the muscles of the right arm and leg, such as the biceps, triceps, hand muscles, and gastrocnemius. There are occasional exceptions to this pattern of "crossed innervation": For example, the left sternocleidomastoid muscle is controlled by the left cerebral cortex. However, even this exception makes functional sense: As a result of its unusual biomechanics, contraction of the left sternocleidomastoid rotates the neck to the right. Even for the anomalous muscle, then, control of movements relevant to the right side of the world originates in the contralateral left cerebral hemisphere, as predicted by the principle of crossed representation.

There is one major exception to the rule of crossed motor control: As a result of the organization of cerebellar inputs and outputs, each cerebellar hemisphere controls coordination and muscle tone on the ipsilateral side of the body

Computation in this Nervous System.

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Maps of the World Within the Brain

At each of many levels, the brain maps various aspects of the outside world. For example, consider the dorsal columns (which carry sensory information, particularly with respect to touch and vibration, from sensory endings on the body surface upward within the spinal cord). Axons within the dorsal columns are arranged in an orderly manner, with fibers from the arm, trunk, and leg forming a map that preserves the spatial relationship of these body parts. Within the cerebral cortex, there is also a sensory map (which has the form of a small man and is, therefore, called a homunculus), within the sensory cortex. There are multiple maps of the visual world within the occipital lobes and within the temporal and parietal lobes as well. These maps are called retinotopic because they preserve the geometrical relationships between objects imaged on the retina and thus provide spatial representations of the visual environment within the brain. Each map contains neurons that are devoted to extracting and analyzing information about one particular aspect (eg, form, color, or movement) of the stimulus.

Development

The earliest tracts of nerve fibers appear at about the second month of fetal life; major descending motor tracts appear at about the fifth month. Myelination (sheathing with myelin) of the spinal cord's nerve fibers begins about the middle of fetal life; some tracts are not completely myelinated for 20 years. The oldest tracts (those common to all animals) myelinate first; the corticospinal tracts myelinate largely during the first and second years after birth.

Growing axons are guided to the correct targets during development of the nervous system by extracellular guidance molecules (including the netrins and semaphorins). Some of these act as attractants for growing axons, guiding them toward a particular target.

Computation in your Nervous System.

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Tracts & Commissures

Visual information about the right side of the world is processed in the visual cortex on the left. Similarly, sensation of touch, sensation of heat or cold, and joint position sense from the body's right side are processed in the somatosensory cortex in the left cerebral hemisphere. In terms of motor control, the motor cortex in the left cerebral hemisphere controls body movements that pertain to the right side of the external world. This includes, of course, control of the muscles of the right arm and leg, such as the biceps, triceps, hand muscles, and gastrocnemius. There are occasional exceptions to this pattern of "crossed innervation": For example, the left sternocleidomastoid muscle is controlled by the left cerebral cortex. However, even this exception makes functional sense: As a result of its unusual biomechanics, contraction of the left sternocleidomastoid rotates the neck to the right. Even for the anomalous muscle, then, control of movements relevant to the right side of the world originates in the contralateral left cerebral hemisphere, as predicted by the principle of crossed representation.

Maps of the World Within the Brain

Computation in your Nervous System.

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These pathways are vertical connections that in their course may cross (decussate) from one side of the CNS to the other. Horizontal (lateral) connections are called commissures.

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Symmetry of the Nervous System

Crossed Representation

Maps of the World Within the Brain

NeuroAnatomy for Medical Students and Doctors

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Stroke, for example, is the third most frequent cause of death in industrialized societies; mood disorders such as depression affect more than one person in 10; and dysfunction of the nervous system can be seen in 25% of patients in most general hospitals at some time during their hospital stay. The neuroanatomic basis for many of these disorders is already known, and for other disorders it will soon be discovered.

This book provides a concise but comprehensive and easy-to-remember synopsis of neuroanatomy and of its functional and clinical implications. In this new, 25th edition, each chapter has been extensively revised and carefully focused so that it emphasizes the most important concepts, facts, and structures. As a teacher, researcher, and clinician, I have tried to sculpt this book so that it will provide a resource and learning tool for busy medical students, residents, and students in health-related fields such as physical therapy; for graduate students who need an introduction to neuroanatomy; and for clinicians in practice, for whom minutes are precious. This book is not meant to supplant the longer, more encompassing, and comprehensive handbooks of neuroscience and neuroanatomy. On the contrary, it provides a more manageable and concise overview that presents the essential aspects of neuroanatomy and its functional and clinical correlations.

This book is unique in including a section entitled "Introduction to Clinical Thinking," which appears early in the text to introduce the reader to the logical processes involved in using neuroanatomy as a basis for thinking about the disordered nervous system. Recognizing that some students remember patients better than isolated facts, I have included discussions of clinical correlates and clinical illustrations that synthesize the most important characteristics of patients selected from an extensive clinical experience to help the reader interpret and remember neuroanatomic concepts in terms of function and clinical implications.

Because much of neuroanatomy has a spatial aspect, this book includes numerous figures. The illustrations have been designed to provide clear, explicit, and memorable representations of important pathways, structures, and mechanisms. Many tables are included, and they have been designed to be as clear and easy to remember as possible. These figures and tables incorporate feedback and suggestions from numerous trainees as well as teachers of neuroanatomy.

The advent of modern neuroimaging has revolutionized the clinical neurosciences, and this book takes full advantage of this technological advance by including numerous computed tomography (CT) and magnetic resonance images (MRIs) of the normal brain and spinal cord, together with functional magnetic resonance images (fMRI) which provides a noninvasive window on brain function. Also included are neuroimaging studies that illustrate common pathological entities that affect the nervous system, including stroke, intracerebral hemorrhage, and tumors of the brain and spinal cord.

As with past editions, I owe a debt of gratitude to many colleagues and friends, especially members of the Department of Neurology at Yale Medical School, who have liberally shared their insights and expertise and have helped to create an environment where learning is fun, a motif that I have woven into this book. I hope that readers of this site will join me in finding that neuroanatomy, which provides much of the foundation for both basic neuroscience and clinical medicine, can be enjoyable, memorable, and easily learned.

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Sunday, April 1, 2012

USMLE Review

Importance of Pharmacogenetics to help Variability in Narcotic Response.
Importance of Pharmacogenetics to Variability in Medication Response.
Importance of Pharmacogenetics to Variability in Meds Response.
Importance of Pharmacogenetics to Variability in Narcotic Response.
HOW HUMANS OVERCOME EXPOSURE TO XENOBIOTICS.

Importance of Pharmacogenetics to help Variability in Narcotic Response.

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The exaggerated responses are an inherited trait (Eichelbaum et al., 1975; Mahgoub et al., 1977). At present, a very large number of medications (estimated at 15% to 25% of all medicines in use) have been shown to be substrates for CYP2D6 (Table 4-3). The molecular and phenotypic characterization of multiple racial and ethnic groups has shown that seven variant alleles account for well over 90% of the "poor metabolizer" low-activity alleles for this gene in most racial groups; that the frequency of variant alleles varies with geographic origin; and that a small percentage of individuals carry stable duplications of CYP2D6, with "ultra-rapid" metabolizers having up to 13 copies of the active gene (Ingelman-Sundberg and Evans, 2001). Phenotypic consequences of the deficient CYP2D6 phenotype include increased risk of toxicity of antidepressants or antipsychotics (catabolized by the enzyme), and lack of analgesic effects of codeine (anabolized by the enzyme); conversely, the ultra-rapid phenotype is associated with extremely rapid clearance and thus inefficacy of med school antidepressants (Kirchheiner et al., 2001).

A promoter region variant in the enzyme UGT1A1, UGT1A1*28, which has an additional TA in comparison to the more common form of the gene, has been associated with a reduced medical video transcription rate of UGT1A1 and lower glucuronidation activity of the enzyme. This reduced activity has been associated with higher levels of the active metabolite of the cancer chemotherapeutic agent irinotecan (see Chapters 3 and 51). The metabolite, SN38, which is eliminated by glucuronidation, is associated with the risk of toxicity (Iyer et al., 2002), which will be more severe in individuals with genetically lower UGT1A1 activity. Medicine

CYP2C19 codes for a cytochrome P450, historically termed mephenytoin hydroxylase, that displays penetrant pharmacogenetic variability, with just a few SNPs accounting for the majority of the deficient, poor metabolizer phenotype (Mallal et al., 2002). The deficient phenotype is much more common in Chinese and Japanese populations. Several video odd proton pump inhibitors, including omeprazole and lansoprazole, are inactivated by CYP2C19. Thus, the deficient patients have higher exposure to active parent drug, a greater pharmacodynamic effect (higher gastric pH), and a higher probability of ulcer cure than heterozygotes or homozygous wild-type individuals (Figure 4-10).

The anticoagulant warfarin is catabolized by CYP2C9. Inactivating polymorphisms in CYP2C9 are common (Goldstein, 2001), with 2% to 10% of most populations being homozygous for low-activity variants, and are associated with lower warfarin clearance, a higher risk of bleeding complications, and lower dose requirements (Aithal et al., 1999).

Thiopurine methyltransferase (TPMT) where to get a physical exam methylates thiopurines such as mercaptopurine (an antileukemic drug that is also the product of azathioprine metabolism). One in 300 individuals is homozygous deficient, 10% are heterozygotes, and about 90% are homozygous for the wild-type alleles for TPMT (Weinshilboum and Sladek, 1980). Three SNPs account for over 90% of the inactivating alleles (Yates et al., 1997). Because methylation of mercaptopurine competes with activation of the drug to thioguanine nucleotides, the concentration of the active (but also toxic) thioguanine metabolites is inversely related to TPMT activity and directly related to the probability of pharmacologic effects.

Importance of Pharmacogenetics to Variability in Medication Response.

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If proportions of the observed three genotypes, which must add up to one, differ significantly from those predicted, it may indicate that a genotyping error Medical Books may be present.

Because polymorphisms are so common, haplotype (the allelic structure that indicates whether polymorphisms within a gene are on the same or different alleles) may also be important. Thus far, experimental methods to unambiguously confirm whether polymorphisms are allelic has proven to be feasible but technically challenging (McDonald et al., 2002). Most video odd investigators use statistical probability to assign putative or inferred haplotypes; e.g., because the two most common SNPs in TPMT (at 460 and 719) often are allelic, a genotyping result showing heterozygosity at both SNPs will have a >95% chance of reflecting one allele wild-type and one allele variant at both SNP positions (resulting in a "heterozygote" genotype for TPMT). However, the remote prospect that each of the two alleles carries a single SNP variant, thereby conferring a homozygous variant/deficient phenotype, is a theoretical possibility. Medicine

Candidate Gene versus Genome-Wide Approaches

Because medical mcq pathways involved in drug response are often known or at least partially known, pharmacogenetic studies are highly amenable to candidate gene association studies. After genes in drug response pathways are identified, the next step in the design of a candidate gene association pharmacogenetic study is to identify the genetic polymorphisms that are likely to contribute to the therapeutic and/or adverse responses to the drug. There are several databases that contain information on polymorphisms and mutations in human genes (Table 4-1), which allow the investigator to search by gene for polymorphisms that have been reported. Some of the databases, such as the Pharmacogenetics and Pharmacogenomics Knowledge Base (PharmGKB), include phenotypic as well as genotypic data.

Because it is currently not practical to what is a physical exam analyze all polymorphisms in a candidate gene association study, it is important to select polymorphisms that are likely to be associated with the drug-response phenotype. For this purpose, there are two categories of polymorphisms. The first are polymorphisms that do not, in and of themselves, cause altered function of the expressed protein (e.g., an enzyme that metabolizes the drug or the drug receptor). Rather, these polymorphisms are linked to the variant allele that produces the altered function. These polymorphisms serve as biomarkers for drug-response phenotype. However, their major shortcoming is that unless they are in 100% linkage with the causative polymorphism, they are not the best markers for the drug-response phenotype.

The second type of polymorphism is the causative polymorphism, which directly precipitates the phenotype. For example, a causative SNP may change an amino acid residue at a site that medical schools is highly conserved throughout evolution. This substitution may result in a protein that is nonfunctional or has reduced function. Whenever possible, it is desirable to select polymorphisms for pharmacogenetic studies that are likely to be causative (Tabor et al., 2002). If biological information indicates that a particular polymorphism alters function, for example, in cellular assays of nonsynonymous variants, this polymorphism is an excellent candidate to use in an association study.

Importance of Pharmacogenetics to Variability in Meds Response.

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New methods in comparative genomics are being refined to identify conserved elements in noncoding regions of genes that may be functionally important (Bejerano et al., 2004; Boffelli et al., 2004; Brudno et al., 2003). Medicine

Pharmacogenetic Phenotypes

Candidate genes for therapeutic and adverse response can be divided into three categories: pharmacokinetic, receptor/target, and disease-modifying.

Pharmacokinetics. what is a physical exam Germline variability in genes that encode determinants of the pharmacokinetics of a drug, in particular enzymes and transporters, affect drug concentrations, and are therefore major determinants of therapeutic and adverse drug response (Table 4-3; Nebert et al., 1996). Multiple enzymes and transporters may be involved in the pharmacokinetics of a single drug. Several polymorphisms in drug metabolizing enzymes were discovered as monogenic phenotypic trait variations, and thus may be referenced using their phenotypic designations (e.g., slow vs. fast acetylation, extensive vs. poor metabolizers of debrisoquine or sparteine) rather than their genotypic designations that reference the gene that is the target of polymorphisms in each case (NAT2 and CYP2D6 polymorphisms, respectively) (Grant et al., 1990). CYP2D6 is now known to catabolize the two initial probe drugs (sparteine and debrisoquine), each of which was associated with exaggerated responses in 5% to 10% of treated individuals. The exaggerated responses are an inherited trait (Eichelbaum et al., 1975; Mahgoub et al., 1977). At present, a very large number of medications (estimated at 15% to 25% of all medicines in use) have been shown to be substrates for CYP2D6 (Table 4-3). The molecular and phenotypic characterization of multiple racial and ethnic groups has shown that seven variant alleles account for well over 90% of the "poor metabolizer" low-activity alleles for this gene in most racial groups; that the frequency of variant alleles varies with geographic origin; and that a small percentage of individuals carry stable duplications of CYP2D6, with "ultra-rapid" metabolizers having up to 13 copies of the active gene (Ingelman-Sundberg and Evans, 2001). Phenotypic consequences of the deficient CYP2D6 phenotype include increased risk of toxicity of antidepressants or antipsychotics (catabolized by the enzyme), and lack of analgesic effects of codeine (anabolized by the enzyme); conversely, the ultra-rapid phenotype is associated with extremely rapid clearance and thus inefficacy of medical mcq antidepressants (Kirchheiner et al., 2001).

A promoter region variant in the enzyme UGT1A1, UGT1A1*28, which has an additional TA in comparison to the more common form of the gene, has been associated with a reduced videos medical transcription rate of UGT1A1 and lower glucuronidation activity of the enzyme. This reduced activity has been associated with higher levels of the active metabolite of the cancer chemotherapeutic agent irinotecan (see Chapters 3 and 51). The metabolite, SN38, which is eliminated by glucuronidation, is associated with the risk of toxicity (Iyer et al., 2002), which will be more severe in individuals with genetically lower UGT1A1 activity.

CYP2C19 codes for a cytochrome P450, historically termed mephenytoin hydroxylase, that displays penetrant pharmacogenetic variability, with just a few SNPs accounting for the majority of the deficient, poor metabolizer phenotype (Mallal et al., 2002). The deficient phenotype is much more common in Chinese and Japanese populations.

Importance of Pharmacogenetics to Variability in Narcotic Response.

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For some multigenic phenotypes, such as response to antihypertensives, the large numbers of candidate genes will necessitate a large patient sample size to produce the statistical power required to solve the "multigene" problem. Medicine

GENOMIC BASIS OF PHARMACOGENETICS

Phenotype-Driven Terminology

Because initial discoveries in osce medical pharmacogenetics were driven by variable phenotypes and defined by family and twin studies, the classic genetic terms for monogenic traits apply to some pharmacogenetic polymorphisms. A trait (e.g., CYP2D6 "poor metabolism") is deemed autosomal recessive if the responsible gene is located on an autosome (i.e., it is not sex-linked) and a distinct phenotype is evident only with nonfunctional alleles on both the maternal and paternal chromosomes. For many of the earliest identified pharmacogenetic polymorphisms, phenotype did not differ enough between heterozygotes and homozygous "wild-type" individuals to distinguish that heterozygotes exhibited an intermediate (or codominant) phenotype (e.g., for CYP2D6-mediated debrisoquine metabolism). Other traits, such as TPMT, exhibit three relatively distinct phenotypes, and thus were deemed codominant even in the premolecular era. With the advances in molecular characterization of polymorphisms and a genotype-to-phenotype approach, additional polymorphic traits (e.g., CYP2C19 metabolism of drugs such as mephenytoin and omeprazole) are now recognized to exhibit some degree of codominance. Some pharmacogenetic traits, such as the long QT syndrome, segregate as dominant traits; the long QT syndrome is associated with heterozygous loss-of-function mutations of ion channels. A prolonged QT interval is seen on the electrocardiogram, either basally or in the presence of certain drugs, and the individual is predisposed to cardiac video odd arrhythmias

In an era of detailed molecular characterization, two major factors complicate the historical designation of recessive, codominant, and dominant traits. First, even within a single gene, a medical mcqs vast array of polymorphisms (promoter, coding, noncoding, completely inactivating, or modestly modifying) are possible, making the assignment of "variant"vs. "wild-type" to an allele a designation that depends upon a complete survey of the gene's polymorphisms and is not necessarily easily assigned. Secondly, most traits (pharmacogenetic and otherwise) are multigenic, not monogenic. Thus, even if the designations of recessive, codominant, and dominant are informative for a given gene, their utility in describing the genetic variability that underlies variability in drug response phenotype is diminished, because most phenotypic variability is likely to be multigenic.

Types of Genetic Variants

A polymorphism is a variation in the DNA sequence that is present at an allele frequency of 1% or greater in a population. Two major types of sequence variation have been associated with variation in human reading ecg phenotype: single nucleotide polymorphisms (SNPs) and insertions/deletions (indels) (Figure 4-3). In comparison to base pair substitutions, indels are much less frequent in the genome and are of particularly low frequency in coding regions of genes (Cargill et al., 1999; Stephens et al., 2001). Single base pair substitutions that are present at frequencies of 1% or greater in a population are termed single nucleotide polymorphisms (SNPs) and are present in the human genome at approximately 1 SNP every few hundred to a thousand base pairs, depending on the gene region (Stephens et al., 2001).

HOW HUMANS OVERCOME EXPOSURE TO XENOBIOTICS.

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Metabolism by the phase 1 cytochrome P450 isoenzymes (CYPs) followed by phase 2 uridine diphosphate-glucuronosyltransferase (UGT) enzymes produces a metabolite that is highly water soluble and readily eliminated from the body (Figure 3-1). Metabolism also terminates the biological activity of the drug. In the case of phenytoin, metabolism also increases the molecular weight of the compound, which allows it to medical lecture be eliminated more efficiently in the bile. Medicine

While xenobiotic-metabolizing ekg ecg enzymes are responsible for facilitating the elimination of chemicals from the body, paradoxically these same enzymes can also convert certain chemicals to highly reactive toxic and carcinogenic metabolites. This occurs when an unstable intermediate is formed that has reactivity toward other compounds found in the cell. Chemicals that can be converted by xenobiotic metabolism to cancer-causing derivatives are called carcinogens. Depending on the structure of the chemical substrate, xenobiotic-metabolizing enzymes produce electrophilic metabolites that can react with nucleophilic cellular macromolecules such as DNA, RNA, and protein. This can cause cell death and organ toxicity. Reaction of these electrophiles with DNA can sometimes result in cancer through the mutation of genes such as oncogenes or tumor suppressor genes. It is generally believed that most human cancers are due to exposure to chemical carcinogens. This potential for carcinogenic activity makes testing the safety of drug candidates of vital importance. Testing for potential cancer-causing activity is particularly critical for drugs that will be used for the treatment of chronic diseases. Since each species has evolved a unique combination of xenobiotic-metabolizing enzymes, nonprimate rodent models cannot be solely used during drug development for testing the safety of new drug candidates targeted for human diseases. Nevertheless, testing in rodent models such as mice and rats can usually identify potential mcq medical carcinogens.

THE PHASES OF DRUG METABOLISM

Xenobiotic metabolizing video odd enzymes have historically been grouped into the phase 1 reactions, in which enzymes carry out oxidation, reduction, or hydrolytic reactions, and the phase 2 reactions, in which enzymes form a conjugate of the substrate (the phase 1 product) (Table 3-1). The phase 1 enzymes lead to the introduction of what are called functional groups, resulting in a modification of the drug, such that it now carries an -OH, -COOH, -SH, -O- or NH2 group. The addition of functional groups does little to increase the water solubility of the drug, but can dramatically alter the biological properties of the drug. Phase 1 metabolism is classified as the functionalization phase of drug metabolism; reactions carried out by phase 1 enzymes usually lead to the inactivation of an active drug. In certain instances, metabolism, usually the hydrolysis of an ester or amide linkage, results in bioactivation of a drug. Inactive drugs that undergo metabolism to an active drug are called prodrugs. An example is the antitumor drug cyclophosphamide, which is bioactivated to a cell-killing electrophilic derivative (see Chapter 51). Phase 2 enzymes facilitate the elimination of drugs and the inactivation of electrophilic and potentially toxic metabolites produced by oxidation. While many phase 1 reactions result in the biological inactivation of the drug, phase 2 reactions produce a metabolite with improved water solubility and increased molecular weight, which serves to facilitate the elimination of the drug from medical surgical the tissue.

Sunday, March 25, 2012

USMLE Review

Cancer is the other leading cause involving death in women and is the commonest cause of early death.
Cancer is the other leading cause with death in females and is the most common cause of premature death.
Cancer is the second leading cause with death in females and is the most common cause of unplanned death.
Cancer is the second leading cause associated with death in females and is the commonest cause of premature death.
Introduction to Women??´s Health: The Primary Treatment of Women
Introduction to Women??´s Health: The Primary Treatment of Women
Introduction to Women??´s Wellness: The Primary Care of Women
Introduction to Women??´s Wellness: The Primary Treatment of Women

Cancer is the other leading cause involving death in women and is the commonest cause of early death.

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According to findings from the 2003 Youth Chance Behavior Surveillance System developed by the Centers with regard to Disease Control and Prevention, during the month prior to the survey, 56% involving adolescent women possessed attempted dieting, 18% had opted more than day without eating, 11% had taken diet helps without professional assistance, and 8% had induced Medicine
vomiting or taken laxatives for weight control. 12
The female lifespan number of 15 to 44 yrs . old delineates the reproductive years. In addition to having the traditional childbearing and family responsibilities, females are increasingly accepting new, additional roles. The effect of multiple and often conflicting roles with women's mental together with physical health remains to remain determined, but it can be almost certainly closely linked to reproductive freedom together with health. Thus, clinicians ought to understand the protection and effectiveness of current types of contraception, including longer oral contraception together with emergency contraception, along with the acceptability of these techniques to women of various cultures. 13, 16, Medical BooksMany common symptoms of reproductive function are certainly not exclusively gynecologic troubles. For example, polycystic ovary syndrome is linked to insulin resistance and a better risk of diabetes and cardiovascular disease16 [see 04: V Polycystic Ovary Syndrome].
Autoimmunity is a common theme in many of the medical disorders that contain the highest frequency in women 15 to 44 years of age. Most of your autoimmune diseases occur on a regular basis, as well since cause greater morbidity, in women than within men. Many these diseases are stimulated by changes with estrogen levels, particularly during pregnancy. The prevalence rates of collagen vascular diseases like rheumatoid arthritis, systemic lupus erythematosus, and scleroderma are three to nine times higher in a lot of women than in males. Many autoimmune-related endocrinopathies, such as Hashimoto thyroiditis together with Graves disease, have a female-to-male ratio up to 10: 1. Less famous is the role of autoimmunity within recurrent pregnancy loss and infertility in women.
Among that mental disorders, depressive illnesses are twice as common in women as in men. Each season, an estimated 6. 5% of women experience a significant depressive episode, and twice that a lot of have chronic low-grade depression. The increased associated risk of depression with women begins with puberty and declines following your menopause. In addition, many women experience mood, cognitive, or behavioral changes associated with cyclic where to get a physical exam changes in hormone levels in the menstrual
cycle or while using the marked changes with hormone levels that occur during the postpartum period and the menopausal transition. The genetic, biologic, and environmental contributions to women's susceptibility to depression are not fully understood; nevertheless, hormonal factors are believed to play a significant role. Women are also twice as probable as men being diagnosed with an anxiety disorder, including panic disorder, posttraumatic stress disorder, generalized anxiety condition, agoraphobia, and very simple ecg tutorial
A major cause of psychosocial morbidity with women is real bodily and sexual abuse. According to your National Violence With Women Survey conducted by the National Institute of Justice and the Centers for Disease Control and Prevention in 1998, 52% of women have been physically assaulted at some time during their existence, and 18% experienced a rape. 17 Young women are at certain risk for rape; of those women who've been raped, more than half were newer than 18 years when rape primary occurred.

Cancer is the other leading cause with death in females and is the most common cause of premature death.

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For example, polycystic ovary syndrome is linked to insulin resistance and a heightened risk of diabetes together with cardiovascular disease16 [see 06: V Polycystic Ovary Syndrome].
Autoimmunity is a typical theme in most of the medical disorders that contain the highest prevalence in women 15 to 44 years of age. Most of your autoimmune diseases occur more often, as well since cause greater morbidity, with women than in men. Many of these diseases are affected by changes with estrogen levels, particularly during pregnancy. The prevalence costs of collagen vascular diseases such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma are three to nine times higher in females than in males. Many autoimmune-related endocrinopathies, such as Hashimoto thyroiditis together with Graves disease, have a female-to-male ratio up to 10: 1. Less well recognized is the purpose of autoimmunity in recurrent pregnancy deprivation and infertility within women.
Among that mental disorders, depressive illnesses are twice as common in women as in men. Each 12 months, an estimated 6. 5% of women experience a major depressive episode, and twice that many have chronic low-grade despression symptoms. The increased risk of depression with women begins with puberty and declines following your menopause. In add-on, many women encounter mood, cognitive, or behavioral changes associated with cyclic video odd changes with hormone levels in the menstrual Medicine
cycle or while using the marked changes in hormone levels that occur through the postpartum period along with the menopausal transition. Your genetic, biologic, and environmental contributions to women's susceptibility to depression may not be fully understood; nevertheless, hormonal factors are believed to play a leading role. Women are also twice as likely as men to remain diagnosed with an anxiety disorder, including panic disorder, posttraumatic stress disorder, generalized anxiety disorder, agoraphobia, and simple medical entrance
A significant cause of psychosocial morbidity within women is actual and sexual abuse. According to that National Violence With Women Survey conducted by the National Institute of Justice and also the Centers for Disease Control and Deterrence in 1998, 52% of women have been completely physically assaulted at some time during their lifetime, and 18% experienced a rape. 17 Young women are at particular risk for rape; of those women who've been raped, more as compared to half were younger than 18 a long time when rape first occurred. 17
Physical and erectile assault of a lot of women is primarily an issue of partner physical violence. Three fourths with women who experience physical or sexual abuse after 18 years of age are assaulted by a current or former spouse or maybe a male intimate. Unfortunately, clinicians often omit to recognize or address symptoms of use, whether because of inadequate familiarity with physical and sexual violence, misconceptions about it, or inadequate learning its management. Adequate screening tools are specially crucial in this emergency department, where up one third of women who have been assaulted seek treatment.
45 to sixty-four Years
Death rates for ladies 45 to 64 yrs . old have declined by 30% in the past 25 years. Previously, the leading reason for death in this generation was heart disease; however, cancer has become ranked number an individual.

Cancer is the second leading cause with death in females and is the most common cause of unplanned death.

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As women improvement through this age group, cancers of the breast and reproductive tract emerge as being the leading cause involving death, followed by unintentional injury and cardiovascular disease. Of the unintentional and intentional injuries, motor vehicle incidents, homicide, and suicide account for three fourths off injury-related deaths. 6 Death costs from homicide and suicide have shown a downward trend in young women. Nevertheless, black females, like black males, are more likely than members involving other races to be homicide victims, and firearms are used in over fifty percent of those fatalities. Intimate partners play a substantial role in physical violence against women; 1 / 3 of murders involving women are perpetrated by an intimate partner medical osces
The most dramatic trend with this age group, beginning in the 1980s and peaking inside mid-1990s, was the emergence and rapid increase of HIV infection for a major cause associated with death. Although entire AIDS incidence together with death rates get decreased yearly due to the fact 1996, the rate of decline has been smaller in a lot of women. The consequences about this disease for gynecologic treatment and reproductive counseling for ladies are unique. Because HIV can be transmitted during pregnancy plus more than 40% with pregnancies are accidental, routine medical care should include discussions about successful contraceptive methods, the consequences of pregnancy on HIV infection and treatment, and the potential for perinatal transmission involving HIV. entrance for medical Treatment strategies for ladies who may become or who ? re pregnant should to consider regimens that maximally curb maternal viral download and reduce transmission to your fetus while reducing toxicity. A three-part strategy of zidovudine (AZT) reduces second hand smoke of perinatal transmission by 70% and it is effective even with women with sophisticated disease. 10 United Advises Public Health Service ideas for antiretroviral Medicine
chemoprophylaxis to cut back perinatal HIV transmission are evolving rapidly and take into consideration the now standard usage of more aggressive blend drug therapies to deal with HIV, as well for the reason that clinical status together with antiviral drug history with the woman. Zidovudine should be part of the antepartum drug regimen in all of the pregnant HIV-infected females, if feasible. Treatment guidelines are updated periodically and are available online (http: //AIDSinfo. nih. gov). health video
An important role of clinicians in the care of younger ladies is to know and reduce risk-taking and also other unhealthy behaviors. For example, early or unprotected sex increases women's chance for sexually carried diseases (STDs). But not just are these diseases transmitted quicker from men to help women, but women are generally disproportionately affected because of infectious complications that can result in disorders of reproductive function, such as pelvic inflammatory disease and subsequent ectopic pregnancy or infertility. Regretably, efforts at chance reduction, particularly in the use of harmful substances, are hampered by industry and market forces and other social factors which influence women's activities. For example, the adverse effects of cigarette smoking on lung cancer and also other respiratory diseases, heart disease, osteoporosis, and pregnancy are well discussed, yet 20% of women pursue to smoke and 18% of teenage mothers smoke cigarettes during pregnancy. 6
Social and cultural factors also have contributed to your increasing prevalence of dieting and taking in disorders.

Cancer is the second leading cause associated with death in females and is the commonest cause of premature death.

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Women are twice as probable as men to become diagnosed with an anxiety disorder, including panic disorder, posttraumatic stress condition, generalized anxiety condition, agoraphobia, and basic video odd
A major cause of psychosocial morbidity in women is actual physical and sexual neglect. According to that National Violence With Women Survey conducted through the National Institute of Justice and also the Centers for Condition Control and Prevention in 1998, 52% of women are generally physically assaulted at some time during their lifetime, and 18% have experienced a rape. 17 Young women are at particular risk for rape; of those women who have been raped, more as compared to half were younger than 18 years when rape first occurred. 17
Physical and sexual assault of women is primarily a problem of partner physical violence. Three fourths of women who encounter physical or erectile abuse after 18 years of age are assaulted by a current or former spouse or maybe a male intimate. Sorry to say, clinicians often fail to recognize or home address symptoms of neglect, whether because of inadequate knowledge of physical and sexual violence, misconceptions about it, or inadequate training in its management. Adequate screening tools are specially crucial in your emergency department, where up to one third of women who've been assaulted seek treatment.
45 to sixty-four Years
Death rates for women 45 to 64 years of age have declined by 30% in earlier times 25 years. Prior to this, the leading trigger of death in this age group was heart condition; however, cancer is right now ranked number an individual. This shift with mortality reflects mostly a decline within death rates with regard to heart diseaseâ??????a decline that has been observed in both sexes and that is attributed to changes in lifestyle, far better control of hypertension, together with lower blood cholesterol levels.
Many of giving her a very chronic conditions in women first can be purchased in this age group; some of these, such as cardiovascular disease, osteoporosis, and cancer, are inextricably linked to the menopause and the associated marked drop in estrogen concentrations. Hormone replacement is the most beneficial therapy for vasomotor together with vaginal symptoms from the menopause; in addition, hormone therapy (HT) decreases bone loss along with the risk of osteoporotic cracks and colon tumor. However, because of the adverse effects involving HT shown inside Women's Health Gumption Trial (as i. e., an improved incidence of chest cancer, heart disease, stroke, dementia, together with urinary problems), eighteen, 19, 20, twenty one, 22, 23, 24 HT really should not be used as precautionary therapy in postmenopausal a lot of women entrance for medical
Although the menopause encompasses most of the physiologic changes that define this period, females also experience significant transitions in social roles and life circumstances that greatly affect their physical and mental health: children leave property; many women end up widowed or Medical Books divorced; parenting roles switch as women are called upon to care for aging parents; together with disabilities increase, making it feel like difficult for some women to operate within and away from the home. An knowledge of these life events is important to the comprehensive care of adult women.

Introduction to Women??´s Health: The Primary Treatment of Women

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A dominant theme in women's health is a effect of proclaimed changes in endogenous hormone grades that occur throughout a woman's lifetime. A health-issue category unique to women could be the influence, during this reproductive Medical Books years, with sex hormones with sexual development and reproductive function. As women grow older and sex hormone degrees decrease with menopause, women's risk factors for many diseases increase dramatically and become more similar to help those of males. Although women develop the same diseases that have an impact on men, biologic mechanisms together with psychosocial factors influence the span of disease differently with women.
Social Variables
One of the important social trends within the last 50 years is the increasing participation of women in the workforce. Currently, around 59% of women 16 years of age and older will be in the workforceâ??????including 71% with women with children younger than eighteen yearsâ??????and 60% involving working women are applied full time throughout the year. 5 The cumulative side effects of playing several roles, work stress, and new green exposures on women's health and reproductive status are largely unknown, but they are certain to have important health and social ramifications.
Paralleling the growing numbers of women in Medicine
workforce could be the increasing number of single-parent families headed by women, especially minority women. Several families live with poverty. Increasing evidence suggests that socioeconomic variables are major indicators of health insurance and that, video odd for some health outcomes, poverty and lack of education are more important determinants of health than ethnicity. 6 Nevertheless, socioeconomic status can't wholly explain significant ethnic and racial differences that maintain women's susceptibility and reaction to certain diseases. For instance, the mortalities with coronary heart condition (CHD), stroke, and breast tumor are higher with black women as compared to in white females, whereas the mortality linked to lung cancer is actually higher in white women. 6 Irrespective of their racial and ethnic designation, minority-group women have a lower life requirement than white females and experience greater health problems. The differences are generally most pronounced in areas associated with reproductive issues and childbearing, the occurrence and course of chronic disease, the incidence and upshot of cancer, and the chance of interpersonal physical violence. 6
Morbidity and Mortality in Females
At the beginning of the 20th century, the average lifespan of women in the usa was 48 a long time, compared with forty six years for males. Since then, everything expectancy for women has increased a lot more than 30 years and it is currently ecg test close to help 80 years, compared with 74 years for men. 6 The striking increase in overall life span is thought to be related to lower infant mortality, control of infectious health conditions, and progress in the relief chronic diseases, such as diabetes and cardiovascular disease.
Despite a dramatic decline in mortality from heart disease that has occured in both sexes within the last 2 decades, heart disease remains the leading trigger of death for females, accounting for 30% off deaths in a lot of women [see Table 1].

Introduction to Women??´s Health: The Primary Treatment of Women

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As women grow old and sex hormone grades decrease with menopause, women's risk factors for certain diseases increase dramatically and be more similar to help those of males. Although women develop the same diseases that have an impact on men, biologic mechanisms together with psychosocial factors influence the course of disease differently with women.
Social Factors
One of the important social trends over the past 50 years is a increasing participation of women in the workforce. Currently, around 59% of women 16 years of age and older are in the workforceâ??????including 71% with women with little ones younger than 18 yearsâ??????and 60% associated with working women are employed full time throughout every season. 5 The cumulative effects of playing multiple roles, work stress, and new environmental exposures on women's health insurance and reproductive status are generally largely unknown, but they will have important health insurance and social ramifications.
Paralleling the growing amounts of women in Medicine
workforce could be the increasing number involving single-parent families advancing by women, especially minority women. Many of these families live with poverty. Increasing evidence suggests that socioeconomic elements are major indicators of health insurance and that, medical surgical for a few health outcomes, poverty and lack of education are even more important determinants with health than ethnicity. 6 However, socioeconomic status can not wholly explain significant ethnic and racial differences that remain in women's susceptibility and reaction to certain diseases. For instance, the mortalities associated with coronary heart disease (CHD), action, and breast melanoma are higher within black women than in white females, whereas the mortality with lung cancer is usually higher in white-colored women. 6 Irrespective of their racial or even ethnic designation, minority-group women possess a lower life requirement than white women and experience greater health conditions. The differences are generally most pronounced in areas associated with reproductive issues and childbearing, the occurrence and course of chronic disease, the incidence and upshot of cancer, and the chance of interpersonal violence. 6
Morbidity and Mortality in Women
At the beginning of the 20th century, the average life-span of women in the united states was 48 a long time, compared with 46 years for men. Since then, everything expectancy for females has increased more than 30 years and is currently video odd close to help 80 years, compared with 74 years for men. 6 The striking increase in overall life expectancy is thought to be related to lower infant mortality, control of infectious diseases, and progress in dealing chronic diseases, like diabetes and coronary disease.
Despite a stunning decline in mortality from cardiovascular disease that has occured in both sexes within the last 2 decades, heart disease remains the leading cause of death for women, accounting for 30% of all deaths in a lot of women [see Table 1]. Cardiovascular disease occurs in females 10 to 15 a long time later than it does in men. This delayed onset, which is attributed primarily to the protective effect of estrogen, accounts for the reality that 90% of heart disease-related mortality within women pg entrance medical occurs after the menopause. Evidence shows that heart disease within women is more serious than that with men, resulting within higher mortality.

Introduction to Women??´s Wellness: The Primary Care of Women

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Currently, it is estimated that 59% of women 16 years of age and older are in the workforceâ??????including 71% associated with women with children younger than 18 yearsâ??????and 60% with working women are employed full time throughout every season. 5 The cumulative effects of playing several roles, work stress, and new environmental exposures on women's health insurance and reproductive status are largely unknown, but they are certain to have important health insurance and social ramifications.
Paralleling the growing numbers of women in Medicine
workforce is a increasing number involving single-parent families advancing by women, especially minority women. Several families live in poverty. Increasing evidence indicates that socioeconomic aspects are major indicators of health and that, video odd for a few health outcomes, poverty and not enough education are more important determinants involving health than ethnicity. 6 However, socioeconomic status is unable to wholly explain significant ethnic and racial differences that remain in women's susceptibility and reaction to certain diseases. For example, the mortalities linked to coronary heart condition (CHD), stroke, and breast tumor are higher in black women as compared to in white females, whereas the mortality associated with lung cancer is usually higher in white-colored women. 6 Regardless of their racial or even ethnic designation, minority-group women have a lower life expectancy than white a lot of women and experience greater health conditions. The differences are generally most pronounced in areas linked to reproductive issues together with childbearing, the occurrence and course of chronic disease, the incidence and outcome of cancer, and the risk of interpersonal physical violence. 6
Morbidity together with Mortality in Females
At the start of the 20th century, the average life-span of women in the was 48 a long time, compared with forty six years for men. Since then, the life expectancy for a lot of women has increased a lot more than 30 years and it is currently ekg interpretation close to help 80 years, weighed against 74 years for men. 6 The striking increase in overall life expectancy is thought to be related to reduced infant mortality, regulate of infectious diseases, and progress in the relief chronic diseases, like diabetes and cardiovascular disease.
Despite a stunning decline in mortality from cardiovascular disease that has occured in both sexes over the past 2 decades, heart disease remains the leading reason for death for women, accounting for 30% of all deaths in females [see Table 1]. Heart disease occurs in females 10 to 15 years later than it can do in men. This delayed onset, that's attributed primarily on the protective effect involving estrogen, accounts for the fact that 90% of center disease-related mortality in women medical entrance occurs following your menopause. Evidence suggests that heart disease in women is more serious than that with men, resulting within higher mortality. And also affected by biologic factors, the poorer survival of women may stem from the older age together with increased prevalence involving comorbid conditions in women at the time of diagnosis, as well as to less well identified social factors that influence the examination and treatment of cardiovascular disease in women.

Introduction to Women??´s Wellness: The Primary Treatment of Women

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This chapter contains additional information on these topics, as properly as links to help other chapters in ACP Medicine addressing important women's wellness topics.
Factors Which Influence Women's Health
Hormonal Influences
A dominant idea in women's health may be the effect of proclaimed changes in endogenous hormone concentrations that occur throughout a woman's lifetime. A health-issue category unique to women is a influence, during that reproductive Medical Books years, involving sex hormones on sexual development and reproductive function. As women grow older and sex hormone degrees decrease with menopause, women's risk factors for certain diseases increase dramatically and become more similar to those of men. Although women develop the same diseases that affect men, biologic mechanisms together with psychosocial factors influence the course of disease differently within women.
Social Aspects
One of delivering social trends over the past 50 years could be the increasing participation of women in the workforce. Currently, it is estimated that 59% of women 16 yrs . old and older will be in the workforceâ??????including 71% of women with children younger than 18 yearsâ??????and 60% associated with working women are applied full time throughout every season. 5 The cumulative side effects of playing multiple roles, work stress, and new green exposures on women's health and reproductive status are largely unknown, but they will have important health and social ramifications.
Paralleling the growing numbers of women in Medicine
workforce is a increasing number involving single-parent families advancing by women, especially minority women. Many of these families live within poverty. Increasing evidence suggests that socioeconomic aspects are major indicators of health insurance and that, video medical for some health outcomes, poverty and not enough education are much more important determinants associated with health than ethnicity. 6 Nevertheless, socioeconomic status is unable to wholly explain fundamental ethnic and racial differences that maintain women's susceptibility and reaction to certain diseases. For instance, the mortalities linked to coronary heart disease (CHD), stroke, and breast melanoma are higher with black women as compared to in white females, whereas the mortality linked to lung cancer is actually higher in white women. 6 Regardless of their racial and also ethnic designation, minority-group women have a lower life expectancy than white a lot of women and experience greater health conditions. The differences are generally most pronounced in areas associated with reproductive issues together with childbearing, the occurrence and course of chronic disease, the incidence and outcome of cancer, and the risk of interpersonal physical violence. 6
Morbidity together with Mortality in A lot of women
At the beginning of the 20th century, the average life-span of women in the country was 48 many years, compared with forty six years for males. Since then, everything expectancy for women has increased more than 30 years and it is currently ecg test close to help 80 years, compared with 74 years with regard to men. 6 The dramatic increase in overall life span is thought to be related to reduced infant mortality, control of infectious health conditions, and progress in dealing with chronic diseases, like diabetes and cardiovascular disease.