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Cardiovascular System Answers 199 Other common complications of myocardial infarction include arrhythmias such as heart block menopause age range buy raloxifene 60mg low price, sinus arrhythmias pregnancy qa order cheap raloxifene, or ventricular tachycardia or fibrillation womens health 2013 order raloxifene 60 mg line. Next in importance pregnancy 5 weeks ultrasound photos buy raloxifene with american express, but not in frequency (only 10%), is cardiogenic shock from severe left ventricular contractile incompetence. Milder left ventricular failure with lung edema occurs in 60% of these cases, while mural thrombosis with peripheral emboli may occur in up to 40%. Ventricular aneurysm forms a "bulge" of the left ventricular chamber; it consists of scar tissue and does not rupture, but may contain a thrombus. Sudden cardiac death occurs within 2 h in 20% of patients with acute myocardial infarction. Patients develop severe retrosternal chest pain that is typically worse with deep inspiration or coughing. Pericarditis developing after a myocardial infarct is usually either serous or serofibrinous. Serofibrinous pericarditis has a fibrinous exudate mixed with the serous fluid and may result from uremia or viral infections. Other types of pericarditis include purulent (suppurative) pericarditis with many inflammatory cells (seen with bacterial infections) or hemorrhagic pericarditis (seen with carcinoma or tuberculosis). Pulmonary diseases that can cause cor pulmonale include diseases of the lung parenchyma, such as chronic obstructive pulmonary disease and interstitial fibrosis, and diseases of the pulmonary vessels, such as multiple pulmonary emboli and pulmonary vascular sclerosis. The latter has been associated with the use of the combination of diet drugs fenfluramine and phentermine. Patients with aortic stenosis may present with angina (chest pain), syncopal episodes with exertion, and heart failure. Much less frequently it is due to syphilis, ankylosing spondylitis (rarely), infective endocarditis, aortic dissection, or aortic dilation from cystic medial necrosis. A blowing diastolic murmur is heard Cardiovascular System Answers 201 along the left sternal border. Volume overload of the heart is the basic defect and results in left ventricular dilation and hypertrophy. The hypertrophied left atrium may also compress the esophagus (resulting in dysphagia, or problems swallowing food) or irritate the recurrent laryngeal nerve (producing hoarseness). In the lungs this produces venous congestion and hemorrhage, which cause dyspnea, fatigue, and hemoptysis. Rheumatic nodules may develop over pressure points during the later stages and seldom occur in cases without cardiac involvement. Immunofluorescence shows immunoglobulins and complement along sarcolemmal 202 Pathology sheaths of cardiac myofibers, but Aschoff bodies seldom contain immunoglobulins or complement. It is manifested by myocarditis, which is characterized histologically by the Aschoff body; pericarditis, which is referred to as "bread-and-butter" pericarditis; and verrucous endocarditis. In contrast, organisms of low virulence, such as -hemolytic viridans streptococci and Staphylococcus epidermidis, infect previously damaged valves, such as valves damaged by rheumatic fever. Symptoms in patients with infective endocarditis are the result of bacteremia, emboli from the vegetations, immune complexes, and valvular disease. Bacteremia produces fever, positive blood cultures (several of which may be needed for confirmation), abscesses, and osteomyelitis. Embolization of parts of the large, friable vegetations can produce Roth spots in the retina, splinter hemorrhages in nail beds, and infarcts of the brain, heart, and spleen. The most common viral causes are coxsackieviruses A and B, echovirus, and influenza virus. Most patients recover from the acute myocarditis, but a few may die from congestive heart failure or arrhythmias. Sections of the heart show patchy or diffuse interstitial infiltrates composed of T lymphocytes and macrophages. Bacterial infections of the myocardium produce multiple foci of inflammation composed mainly of neutrophils.

Cardiac muscle fibers synthesize specific proteins (troponin for example) that can be assessed in blood following muscle cell injury women's health center keokuk ia purchase raloxifene discount. Cardiac dysfunction involves many parts of the heart and can begin in an area other than the heart itself menstrual pain generic 60mg raloxifene visa. Heart failure takes many forms breast cancer quotes and poems discount 60mg raloxifene amex, such as congestive heart failure title x women's health purchase raloxifene 60mg mastercard, coronary artery disease, and myocardial infarction (heart attack). These include valine, leucine, isoleucine, methionine, tryptophan, phenylalanine, threonine, lysine, and histidine. Homocystinuria is caused by impaired enzyme activity, which results in elevated levels of homocysteine and methionine in plasma and urine. Albumin is responsible for the osmotic pressure of plasma and serves as a transport protein. Prealbumin migrates ahead of albumin during electrophoresis and transports thyroid hormones. Protein disintegrates into constituent amino acids, which are further deaminated into ketoacids and ammonia. Conjugated proteins are composed of protein (apoprotein) and a nonprotein substance (referred to as prosthetic groups), such as lipid (forms lipoproteins), carbohydrate (forms glycoproteins), or metals (form metalloproteins). Functions of protein include tissue nutrition, water distribution, plasma buffer, substance transport, and structural support. Protein analysis determines either the total nitrogen content of the sample or the total protein. Refractometry methods use the refractive index of a solution in the determination of solute concentration. Therefore, the refractive index of water increases proportionally to the concentration of a solute in solution. Therefore, this method provides an approximation useful as a rapid test, but error can occur in patients with hyperglycemia, lipemia, or azotemia. When albumin is positively charged, it binds to certain dyes, causing a shift in absorbance from free dye. Brom-cresol green is the most widely used dye, although brom-cresol purple is considered more specific in binding albumin. This separates the protein fractions in serum when an electrical field is applied. Macromolecules, such as immunoglobulins, in solution may remain immobile or even be swept back toward the opposite pole if they are insufficiently charged. Endosmosis is minimal in systems that use purified agarose, starch or polyacrylamide. Changes in pH will cause proteins to lose amphotericity and migration will be affected. Capillary electrophoresis is a method in which the techniques of electrophoresis are carried out in a small-bore, fused silica capillary tube. This capillary tube serves as an electrophoresis chamber that is connected to a detector at its terminal end and to a power supply. Capillary zone electrophoresis is the simplest form of electrophoresis and is able to resolve many analytes such as proteins, peptides, and amino acids. At the point where antigen and antibody concentration are equal, a precipitin ring forms. Measurement of the diameter of the precipitin ring squared is compared with a standard curve of antigen concentration. Then, monospecific antiserum is added, and the support medium is stained for visual interpretation of bands.

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Purkinje cells ofthe cerebellum and neurons of the hippocam pus are more susceptible to hypoxic injury than are other neurons women's health clinic in sacramento buy raloxifene 60mg mastercard. Examples include the activated products of oxygen reduction women's health center bethlehem pa purchase raloxifene 60mg fast delivery, such as the superoxide B pregnancy 10 weeks cheap raloxifene 60 mg mastercard. Oxygen toxicity women's health clinic dr gray's elgin order 60 mg raloxifene with visa, such as in the alveolar damage that can cause adult respiratory distress jiJ 3. Intracellular enzymes, such as glutathione peroxidase, catalase, or superoxide dismutase jiJ 2. Exogenous and endogenous antioxidants, such as vitamin A, vitamin C, vitamin E, cysteine, glutathione, selenium, ceruloplasmin, or transferrin 3. Widespread injury results, including: Failure of the cell to synthesize the apoprotein moiety of lipoproteins causes an accumulation of intracellu lar lipids (fatty change). Plasma membrane damage, caused by products of lipid peroxidation in the smooth endo plasmic reticulum, resulting in cellular swelling and massive influx of calcium, with resultant mitochondrial damage, denaturation of cell proteins, and cell death v. Necrosis is the sum of the degradative and inflammatory reactions occurring after tissue death caused by injury. In pathologic specimens, fixed cells with well-preserved morphology are dead but not necrotic. Autolysis refers to degradative reactions in cells caused by intracellular enzymes indige nous to the cell. Postmortem autolysis occurs after the death of the entire organism and is not necrosis. Heterolysis refers to cellular degradation by enzymes derived from sources extrinsic to the cell. Coagulative necrosis Coagulative necrosis results most often from a sudden cutoff of blood supply to an organ (ischemia), particularly the heart and kidney. General preservation of tissue architecture is characteristic in the early stages. Nuclear changes, the morphologic hallmark of irreversible cell injury and necrosis, are characteristic. Suppurative infections characterized by the formation of pus (liquefied tissue debris and neutrophils) by heterolytic mechanisms involve liquefactive necrosis. Caseous necrosis combines features of both coagulative necrosis and liquefactive necrosis. This type of necrosis most often affects the lower extremities or bowel and is secondalY to vascular occlusion. When complicated by infective heterolysis and consequent liquefactive necrosis, gan grenous necrosis is called wet gangrene. When characterized primarily by coagulative necrosis without liquefaction, gangrenous necrosis is called dry gangrene. This deposition of fibrin-like proteinaceous material in the arterial walls appears smudgy and acidophilic. Traumatic fat necrosis, which occurs af ter a severe injury to tissue with high fat content, such as the breast b. Enzymatic fat necrosis, which is a complication of acute hemorrhagic pancreatitis, a severe inflammatory disorder of the pancreas (1) Proteolytic and lipolytic pancreatic enzymes diffuse into inflamed tissue and lit erally digest the parenchyma. In addition, apoptosis is an important mechanism for physiologic cell removal dur 4, ing embryogenesis and in programmed cell cycling. This involutional process is similar to the physiologic loss of leaves from a tree; apopto sis is a Greek term for "falling away from. A tendency to involve single isolated cells or small clusters of cells within a tissue 2. Progression through a series of changes marked by a lack of inflammatory response a. Involution and shrinkage of affected cells and cell fragments, resulting in small round eosinophilic masses often containing chromatin remnants, exemplified by Councilman bodies in viral hepatitis C. Caspases are aspartate-specif cysteine ic proteases that have been referred to as "major executioners" or "molecular gUillotines. The initial activating caspases are caspase-8 and caspase-9, and the terminal caspases (executioners) include caspase-3 and caspase-6 (among other proteases).

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Patients develop hematuria pregnancy quizzes purchase 60 mg raloxifene mastercard, red cell casts womens health imaging effective raloxifene 60mg, 374 Pathology mild periorbital edema menstrual relief purchase raloxifene with american express, and increased blood pressure women's health york pa discount raloxifene online american express. Electron microscopy reveals the mesangial deposits and large, hump-shaped subepithelial deposits in peripheral capillary loops that are characteristic. Immunofluorescence shows granular deposits containing IgG, C3, and often fibrin in glomerular capillary walls and mesangium. Children with poststreptococcal glomerulonephritis usually recover, and therapy is supportive only. In both types there is mesangial proliferation accompanied by thickening of the glomerular basement membranes, and a special finding that often supports the diagnosis of membranoproliferative glomerulonephritis is the presence of actual splitting of the glomerular basement membranes. The hematuria may become recurrent, with proteinuria that may approach nephrotic syndrome proportions. A small percentage of patients may progress to renal failure over a period of years. There are focal interruptions of the glomerular basement membrane as well, along with deposits of fibrin, as seen with electron microscopy. The pathogenesis of this same lesion in diabetes mellitus and renal vein thrombosis is unknown. Electron-dense deposits are classically seen in a subendothelial position on the glomerular basement membrane but may be subepithelial as well in some cases. This can be quite variable, however, and certain causes may be associated with damage to specific portions of the kidney. Both ischemia and heavy metals primarily damage the epithelial cells of the proximal straight tubules, while aminoglycosides primarily affect the proximal convoluted tubule. Chronic pyelonephritis is an asymmetric, irregularly scarring process that may be unilateral or bilateral. Microscopically, there is atrophy and dilation of tubules with colloid in some tubules. Chronic glomerulonephritis causes bilat- 378 Pathology eral symmetrically shrunken and scarred kidneys. Cystic dysplasia is characterized by undifferentiated mesenchyme and immature cartilage and collecting ductules. The former is more common in elderly men, while the latter is more common in young women. This produces increased secretion of angiotensin and aldosterone, which leads to retention of sodium and water and produces hypertension. The kidney with stenosis of the renal artery becomes small and shrunken due to the effects of chronic ischemia, but the stenosis protects this kidney from the effects of the increased blood pressure. The other kidney, however, is not protected and may develop microscopic changes of benign nephrosclerosis (hyaline arteriolosclerosis). Grossly, multiple small petechial hemorrhages are found on the surface of the kidneys. The clinical course is often downhill, with only 50% of patients surviving 5 years; marked proteinuria, hematuria, cardiovascular problems, and finally renal failure contribute to death. The disease is often associated with accelerated preexisting benign essential hypertension, chronic renal disease (glomerulonephritis), or scleroderma. In contrast, benign nephrosclerosis (renal disease occurring in benign hypertension) is characterized by hyaline arteriolosclerosis with thickened, hyalinized arteriolar walls and narrowed lumina. Small kidneys with a finely granular surface often result because of ischemic atrophy of nephrons. Broad Ushaped cortical scars overlying dilated calyces in the renal poles are seen with chronic pyelonephritis (reflux causes scars involving poles only, while Urinary System Answers 379 obstruction produces scars all over the kidney), depressed cortical areas overlying necrotic papillae of varying stages are seen with analgesic nephropathy and diabetes mellitus, multiple small white areas on the surface are seen with acute pyelonephritis, and wedge-shaped. The formation of urinary stones relates to decreased urine volume and increased urine concentrations of certain substances. Most stones contain calcium (either calcium oxalate or calcium phosphate) and are seen in patients with hypercalcinuria (with or without hypercalcemia), such as with hyperparathyroidism or diffuse bone disease. Magnesium ammonium phosphate stones are formed in alkaline urine as the result of ureaseproducing (urea-splitting) bacteria such as Proteus. The ammonia released from the breakdown of urea combines with magnesium and phosphate. These stones are large and may fill the renal pelvis (staghorn or struvite calculi). Examination of the urine with a dipstick reveals an alkaline urine that is positive for esterase (from the leukocytes in the urine) and nitrite (since Proteus reduces nitrate).