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Conversion of Fructose 6phosphate to Fructose 1 buy rogaine 5 60 ml otc, 6 bisphosphate The above reaction is followed by another phosphorylation order 60 ml rogaine 5 mastercard. A,B Aldolase B: occurs in liver and kidney • The fructose- 6-p exists in the cells in “furanose” form but they react with isomerase, phosphofructokinase-1 and aldolase in the open-chain configuration. Reactions of this type in which an aldehyde group is oxidized to an acid are accompanied by liberation of large amounts of potentially useful energy. Oxidation of Glyceraldehyde 3phosphate to 1,3 bis phosphoglycerate Glycolysis proceeds by the oxidation of glyceraldehde-3-phosphate,to form1,3-bis phosphoglycerate. Dihydroxyacetone phosphate also forms 1, 3 - bisphosphoglycerate via glyceraldehydes-3- phosphate shuttle. Conversion of 3- phosphoglycerate to 2- Phosphoglycerate 3-Phosphoglycerate formed by the above reaction is converted to 2-phosphoglycerate, catalyzed by the enzyme phosphoglycerate mutase. It is likely that 2,3 bisphosphoglycerate is an intermediate in the reaction and probably acts catalytically. Conversion of 2-phosphoglycerate to Phosphoenol pyruvate The reaction is catalyzed by the enzyme enolase, the enzyme requires the presence of ++ ++ either Mg or Mn for activity. Conversion of phosphoenol pyruvate to pyruvate Phosphoenol pyruvate is converted to ‘Enol’ pyruvate, the reaction is catalyzed by the enzyme pyruvate kinase. This is another example of “ substrate level phosphorylation “ in glycolytic pathway • “Enol“ pyruvate is converted to ‘ Keto’ pyruvate spontaneously. Clinical Importance • Tissues that function under hypoxic conditions will produce lactic acid from glucose oxidation. If lactate production is more it can produce metabolic acidosis • Vigorously contracting skeletal muscle will produce lactic acid. In liver fructose1-phosphate is split to glyceraldehyde and dihydroxy acetone phosophate by AldolaseB. Dihydroxy aceton phosphate and glyceraldehyde-3-P may be degraded via glycolysis or may be condensed to form glucose by aldolase. The reason being high concentration of Fructose 1 phosphate and fructose 1, 6 bis phosphate inhibit Liver phosphorylase by allosteric modulation. It is an inherited disorder that the defect may be in the galactokinase, uridlyl transferase or 4-epimerase. Shortening of chains Golycogen phosphorylase cleaves the α-1, 4 glycosidic bonds between the glucose residues at the non reducing ends of the glycogen by simple phosphorolysis. Removal of Branches A debranching enzyme also called Glucantransferase which contains two activities, Glucantransferase and Glucosidase. The transfer activity removes the terminal 3 glucose residues of one branch and attaches them to a free C4 end of the second branch. Lysosomal Degradation of Glycogen A small amount of glycogen is continuously degraded by the lysosomal enzyme α-(1, 4) glycosidase (acid maltase). The α-1,6 branches in glucose are produced by amylo-(1,4-1,6) transglycosylase,also termed as branching enzyme. This enzyme transfers a terminal fragment of 6 to 7 glucose residues(from a polymer of atleast 11 glucose residues long) to an internal glucose residue at the C-6 hydroxyl position. Glycogenesis Glycogen storage diseases These are a group of genetic diseases that result from a defect in an enzyme required for either glycogen synthesis or degradation. They result in either formation of glycogen that has an abnormal structure or the accumulation of excessive amounts of normal glycogen in specific tissues, A particular enzyme may be defective in a single tissue such as the liver or the defect may be more generalized, affecting muscle, kidney, intestine and myocardium. The severity of the diseases may range from fatal in infancy to mild disorders that are not life threatening some of the more prevalent glycogen storage diseases are the following. To provide the cell with ribose-5-phosphate (R5P) for the synthesis of the nucleotides and nucleic acids. The 3 carbon sugar generated is glyceraldehyde-3-phsphate which can be shunted to glycolysis and oxidized to pyruvate. Alternatively, it can be utilized by the gluconeogenic enzymes to generate more 6 carbon sugars (fructose-6-phosphate or glucose-6-phosphate). Although this bond plays a very important role in protein structure and function, inappropriately introduced disulfides can be detrimental. Oxidative stress also generates peroxides that in turn can be reduced by glutathione to generate water and an alcohol. Several deficiencies in the level of activity (not function) of glucose-6-phosphate dehydrogenase have been observed to be associated with resistance to the malarial parasite, Plasmodium falciparum, among individuals of Mediterranean and African descent. The basis for this resistance is the weakening of the red cell membrane (the erythrocyte is the host cell for the parasite) such that it cannot sustain the parasitic life cycle long enough for productive growth. Coris Cycle or Lactic Acid Cycle In an actively contracting muscle, only about 8% of the pyruvate is utilized by the citric acid cycle and the remaining is, therefore, reduced to lactate. The muscle cramps, often associated with strenuous muscular exercise are thought to be due to lactate accumulation. It is then taken up through gluconeogenesis pathway and becomes glucose, which can enter into blood and then taken to muscle. Significance of the cycle: Muscle cannot form glucose by gluconeogenesis process because glucose 6 phosphatase is absent.

Contact information Fill in details below: Country Name of programme Name of person completing the form Function E-mail Phone Fax 2 60 ml rogaine 5 with mastercard. Completeness of outpatient reporting in 2009 ealth ealth Type of facility included in outpatient reports 2009: centre post ospital polyclinic clinic Click boxes that apply overnment Mission Private ther (specify) Reporting completeness 2009: Of all health facilities supposed to report on outpatients each month cheap rogaine 5 60 ml with mastercard, what percentage actually do so? Total confirmed cases 2007 2008 2009 Microscopy (all ages, both active & passive Examined case detection, inpatients & Positive outpatients) P. Cases diagnosed in community 2007 2008 2009 2 Malaria cases detected by community based treatment programs R T examinations R Ts positive 2 Include both confirmed and clinically diagnosed cases. World Malaria Report 2010 questionnaire: Form for countries in pre-elimination and elimination phases (1) orld Malaria Report 20 0 orm for countries in pre elimination and elimination phases Please complete this form before 30 June 2010 and return to: Please note, empty cells will be treated as missing data. Contact information Fill in details below: Country: Name of programme: Name of person completing the form: Function: E-mail: Phone: Fax: 2. Reported cases and deat s 2007 2008 2009 Cases (All ages, both passive & lides examined active case detection) Positive P. World Malaria Report 2010 questionnaire: Form for countries in pre-elimination and elimination phases (2) 5. Completeness of reporting in 2009 ealth ealth Type of facility included in outpatient reports 2009: centre post ospital polyclinic clinic Click boxes that apply overnment Mission Private ther (specify) Please estimate reporting completeness for 2009: Monthly uartely Annually Fre uency of outpatient reporting: - Total number of health facilities expected to report (b) Total number of reports actually received in 2009 (c) Currently imple- ear 6. World Malaria Report 2010 questionnaire: Form for countries in pre-elimination and elimination phases (3). It highlights continued progress made towards reaching international targets for malaria control by 2010 and by 2015. Since 2008, more than 289 million insecticide-treated mosquito nets have been delivered to sub-Saharan Africa, enough to protect three quarters of the 765 million people at risk of the disease. Malaria control is making an important contribution to attaining the health-related Millennium Development Goals. It contains the esophagus, trachea, primary bronchi, thymus gland, heart (pericardial cavity), large blood vessels and lymphatic vessels. It contains stomach, spleen, liver, gallbladder, pancreas, most of the small intestine, most of the large intestine, kidneys, adrenal glands, ureters, and many major blood vessels. Remaining 4% of living matter is composed of: potassium (K), sulfur (S), sodium (Na), chlorine (Cl), magnesium (Mg) and trace elements. Electrical energy: energy of charged particle stored in a particular location, for example a battery 2. First law of thermodynamics: Energy can be neither created nor destroyed, but it can be converted from one form to another. Second law of thermodynamics: As energy forms convert from one form to another, the universe increases in disorder. Atom: smallest possible unit of matter that retains the physical and chemical properties of that element. Atomic number: the number of protons an element contains (this is Page 2-2 equal to the number of electrons in a neutral atom) 3. Second electron shell: (1) further from the nucleus that the first electron shell (2) can hold a maximum of 8 electrons e. Third electron shell: (1) further from the nucleus that the second electron shell (2) can hold a maximum of 8 electrons f. The atomic number tells the number of protons in an atom’s nucleus, which is equal to the number of electrons in the Page 2-3 electron shells. Isotope: atoms of an element the have the same number of protons, but different numbers of neutrons 1. Anion: an atom that has gained one or more electrons from another - atom and has become negatively charged. Ionic bond: bond formed by the attraction between an atom with a positive electrical charge (cation) and an atom of a negative electrical charge (anion). Hydrogen bond: bond formed when a covalently bonded hydrogen acquires a slight positive charge and becomes attracted to negatively charged atoms nearby. Synthesis reactions = Anabolism: combining 2 or more atoms or molecules to form a more complex molecule. Hydrogen bonding occurs in water due to the polar covalent bonds formed between the 2 hydrogen atoms and the oxygen atom in a water molecule. Buffers: chemical substances that regulate the changes in pH and therefore in the body help maintain homeostasis. Examples: Sucrose (table sugar) is glucose + fructose Maltose (malt sugar) is 2 glucose molecules Lactose (milk sugar) is glucose + galactose C. Carbohydrates are catabolized from polysaccharides -->disaccharides--> monosaccharides with the use of enzymes at each step. Triglycerides are the most abundant form of lipids, both in the Page 2-12 diet and stored in the body. Composed of: (1) Glycerol, a 3 carbon molecule (2) 3 fatty acids (a) Saturated fatty acids: i) have no carbon to carbon double bonds ii) solid at room temperature iii) found in animal fat iv) Examples: lard, butter (b) Unsaturated fatty acids: i) have one or more carbon to carbon double bond ii) liquid at room temperature iii) Examples: vegetable oil, corn oil 2. Examples: cholesterol, bile salts, testosterone, estrogen, progesterone and corticosteroid hormones 4. Proteins: composed of carbon, hydrogen, oxygen and always nitrogen, any may contain sulfur, phosphorous and iron.

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In practical terms buy rogaine 5 60 ml visa, safe food can be defined as food that generic 60 ml rogaine 5 visa, after being consumed, causes no adverse health effects (19). The government is responsible for the establishment of standards or codes of practice as well as the enforcement of laws and regulations. Furthermore, it should encourage the food industry to undertake voluntary measures to improve food safety. Consumers in turn should be well aware of the quality of the food they buy, prepare and consume and should adopt appropriate practices of food handling at home. At the industry level, all segments, including agriculture, should establish some system for safety assurance of their products and employ appropriate procedures and technologies (19). But, it is critical that preventive measures for ensuring food safety should be given great attention to prevent and or reduce food borne diseases. Production of raw materials: To ensure safe food production, it is important to look at the agricultural level, where foods are initially produced, and improve the hygienic quality of raw foods. By improving the conditions under which crops, fruits, vegetables and food animals are raised, the hygienic quality of raw food products can be significantly improved. Furthermore, use of both pesticides and fertilizers should be reduced, and residue levels of toxic chemicals used to improve crop production should be systematically monitored. Prohibition of use of untreated sewage water for irrigation of vegetable fields is also an area of attention. Food safety at this stage can also be improved through measures 97 aimed at reduction of industrial and vehicle emissions and disposal of hazardous waste materials that can enter the food chain. Food Processing: Greater demands are being made on the food-processing industry as a result of increasing urbanization. As consumers continue to move further a way from the sources of production, they will require an effective and safe food distribution system. This separation of the customer from the production sector means a loss of the traditional methods used by the consumer to ensure, the safety of food. Substantial losses of food by contamination and spoilage can be prevented through the use of carefully controlled technology and well designed food-processing infrastructure (19). Inspection programs have serious limitations, however, as they sometimes over look critical factors that are not part of the inspection protocol. Inspection services are usually inadequate or non-existent in many developing countries in which Ethiopia is inclusive. Hazard:Means the unacceptable contamination, growth or survival of microorganisms of concern to safety or persistence in foods of products of microbial metabolism (E. Toxins, enzymes, histamine) or the presence of chemicals of a harmful level of concentration or of a potential risk to health (4). Critical control Point: Is a location, practice, procedure, or process at or by which control can be exercised overall or more factors that, if controlled, could minimize or prevent the hazard (4). Food Preservation and Storage The aim of food preservation is to eradicate or prevent the growth of pathogens during manufacturing, processing and preparation of food so that it will remain, safe to eat for longer periods of time. Bacterial growth is enabled by a number of conditions, the most important being the presence of a good substrate (in this case a food item); an infection with viable organisms; a temperature that allows growth of bacteria; proper pH; and sufficient water for growth. Food Preparation in the Home: The household is perhaps the most relevant place for developing strategies to combat food borne illness, as it is the location where the consumers, can exert the most control over what they eat. Clearly, one of the most significant components of keeping food pathogen–free in the household is maintaining a clean and hygienic environment in the kitchen or other food preparation areas. Proper sanitation facilities, cleanliness of household members who prepare the food, and control of pests are all essential for the presentation of acceptable food. Many bacterial pathogens are able to multiply in food because of the temperature at which the food is stored. Food preparation in the food service industry: The consequences of improper food preparation in food services such as canteens and restaurants can be much greater than that in the household, simply because a large number of individuals may be simultaneously exposed to unsafe food items. It is essential to have a quality control program (inspection) that will ensure the maintenance of food product standards during all stages of handling, processing and preparation; it must also be applied to all areas and equipment that come into contact with food and beverages. Street foods are particularly prone to lapses in safe food preparation, hence requiring stringent control measures (19). The different methods for applying the above principles are discussed below: Methods to keep food safe The art of keeping food safe and preservation requires knowledge of bacteria and the effect of the environment on microorganisms. Methods of keeping food safe and preservation include modern innovations such as vacuuming and filtration techniques, pressure canning and radiation processes. The primary objective of keeping food safe is to prevent food from acquiring hazardous properties during preparation, shipment, or storage. The principal methods and the techniques used to keep food safe include temperature control (including pasteurization, cooking, canning, refrigeration, freezing and drying), fermentation and pickling, chemical treatment and irradiation (2, 3, 4, 6, 7).

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Complications of spinal anesthesia and measures to take • Drop in blood pressure-due to high spinal block - Give Oxygen - Make faster the drip if that does not help order rogaine 5 60 ml mastercard. Commonly performed nerve blocks: o Digital nerve block o Axillary block of the brachial plexus o Wrist-block 122 C) Field block Field block is injection of local analgesic so as to create a zone of analgesia around the operative field order rogaine 5 60 ml on-line. It can be used for: o Repair of an inguinal hernia o Caesarean section o Circumcision D) Infiltration Infiltration is direct injection of drugs into the area to be incised and between bone ends in fractures. E) Topical anesthesia This can be performed simply by applying 4% lidocaine to the mucus membrane, for minor surgery and instrumentation of: o Nose o Mouth o Eye o Pharynx and larynx o Urethral procedures 123 Review Questions 1. After evaluation by the surgeon, it is decided to take him to the operating theater. A 17 year old girl is brought to the Emergency department with polytrauma after a car accident. L Bartholomeusz: Safe Anesthesia: A Training manual, where facilities are limited. Outline management options for thyroid carcinomas Thyroid Enlargement: Goiter Goiter refers to a generalized enlargement of the thyroid gland which is normally impalpable. Inflammatory • Autoimmune (chronic lymphocyte thyroiditis, Hashimoto’s disease) • Infectious • Acute (bacterial thyroiditis, viral,) • Chronic (tuberculous, syphilitic) 126 Simple Goiter Patho-physiology: Simple Goiter is enlargement of the thyroid gland as a result of stimulation of the thyroid gland by high levels of circulating thyroid stimulating hormone. Defective hormone synthesis also cause goiter and it accounts for many sporadic goiters. In endemic goiter, it usually occurs at puberty when metabolic demands are high, this is reversible if stimulations cease. As a result of fluctuating stimulation of the thyroid gland, areas of active lobule and inactive lobules will develop. Active lobules become more vascular and hyperplasic until hemorrhage occurs causing necrosis. These necrotic lobules coalesce to form nodules filled with either iodine free colloid or inactive follicles. Secondary changes like cystic degeneration, hemorrhage and calcification occur at late stages. Diagnosis Clinical presentation: Discrete swelling in one lobe with no palpable abnormality else where is called solitary (isolated) nodule. The Goiter is painless and freely moves with swallowing and usually patients are euthyroid. Complications • Tracheal obstruction can occur due to gross lateral displacement or compression. Prevention and treatment Prevention In endemic areas the incidence of goiter can be significantly reduced by the introduction of iodized salt. In early stages, a hyper-plastic goiter may regress if thyroxin is given in a dose of 0. Operation might be indicated • On cosmetic grounds • Tracheal compression and • When malignancy cannot be excluded The options of surgical treatment are • Near total thyroidectomy • Subtotal thyroidectomy Toxic goiters Thyrotoxicosis - is a condition in which there is increased metabolic rate due to high level of circulating thyroid hormone. Clinical features The most significant symptoms are • Loss of weight in spite of good appetite, • A recent preference of cold • Palpitation. The most important clinical signs of thyrotoxicosis commonly seen are • excitability of the patient, • the presence of goiter, • hot and moist palms, • exophthalmus in primary type • tachycardia with cardiac arrhythmia 128 • Weakness of the proximal limb muscles • The goiter in primary thyrotoxicosis (Grave’s disease) is diffuse and vascular, it may be large or small, firm or soft and bruit may be present. Diffuse toxic goiter: Primary toxic goiter or Grave’s disease is a diffuse vascular goiter appearing at the same time as symptoms of hyperthyroidism. The hypertrophy and hyperplasia are due to abnormal thyroid stimulating antibodies Toxic nodular goiter: A simple nodular goiter is present for a long time before the hyperthyroidism, and hence termed secondary thyrotoxicosis. It is usually seen in middle aged or elderly people and less frequently associated with eye signs. In many cases of toxic nodular goiter, the nodules are inactive and it is the intermediate thyroid tissue that is involved in hyper secretion. Toxic nodule: This is a solitary hyperactive nodule which may be part of a generalized nodularity or a true toxic adenoma. It is autonomous and its hypertrophy and hyperplasia are not due to thyroid stimulating antibodies. Diagnosis of thyrotoxicosis • Most cases are easily diagnosed by the clinical picture. This helps to determine the functional activity relative to the surrounding gland according to isotope uptake. Treatment of thyrotoxicosis Treatment of thyrotoxicosis includes specific and non-specific measures. The specific measures are • the use of antithyroid drugs • surgery • radioiodine The nonspecific measures which include rest and sedation are not commonly recommended.

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