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The transcribed region of a gene con- In bacteria female viagra 50mg with visa pregnancy quotes tumblr, a single RNA polymerase produces the primary transcript precur- tains the template for synthesis of an RNA buy discount female viagra 50 mg on-line menopause news, sors for all three major classes of RNA: messenger RNA (mRNA), ribosomal RNA which begins at the startpoint. Because bacteria do not contain nuclei, ribo- includes regions of DNA that regulate produc- tion of the encoded product, such as a pro- somes bind to mRNA as it is being transcribed, and protein synthesis occurs moter region. In a structural gene, the tran- simultaneously with transcription. The primary transcripts are modified and trimmed to produce the mature RNAs. The precursors of mRNA (called pre-mRNA) have a guanosine “cap” added at the 5 -end and a poly(A) “tail” at the 3 -end. Exons, which contain the coding sequences for the proteins, are separated in pre-mRNA by introns, regions that have no coding function. During splicing reactions, introns are removed and the exons connected to form the mature mRNA. In eukaryotes, tRNA and rRNA precursors are also modified and trimmed, although not as extensively as pre-mRNA. THE WAITING ROOM Anne Niemick is a 4-year-old girl of Mediterranean ancestry whose height and body weight are below the 20th percentile for girls of her age. She is listless, tires easily, and complains of loss of appetite and shortness of breath on exertion. A dull pain has been present in her right upper quadrant for 237 238 SECTION THREE / GENE EXPRESSION AND THE SYNTHESIS OF PROTEINS The thalassemias are a heteroge- the last 3 months. Initial labo- nous group of hereditary anemias ratory studies indicate a severe anemia (decreased red blood cell count) with a that constitute the most common hemoglobin of 6. A battery of additional hemato- gene disorder in the world, with a carrier logic tests shows that Anne has -thalassemia, intermediate type. The disease was first dis- covered in countries around the Mediter- Ivy Sharer, a patient with AIDS (see Chapters 12 and 13), has developed ranean Sea and was named for the Greek word “thalassa” meaning “sea”. However, it a cough that produces a gray, slightly blood-tinged sputum. A chest radi- is also present in areas extending into India ograph indicates infiltrates in the cavities of both upper lung fields (cavi- and China that are near the equator. A stain of sputum shows the presence of acid-fast bacilli, suggest- The thalassemia syndromes are caused ing a diagnosis of pulmonary tuberculosis caused by Mycobacterium tuberculosis. Individual syn- hours after eating one small mushroom, she experienced mild nausea and dromes are named according to the chain diarrhea. She brought a mushroom with her to the hospital emergency whose synthesis is affected and the severity 0 room. A poison expert identified it as Amanita phalloides (the “death cap”). Thus, in thalassemia, mushrooms contain the toxin -amanitin. More than 170 different mutations pleuritic chest pain, and a nonproductive cough. In addition, she com- have been identified that cause tha- plains of joint pains, especially in her hands. A rash on both cheeks and lassemia; most of these interfere with the the bridge of her nose (“butterfly rash”) has been present for the last 6 months. Ini- transcription of -globin mRNA or its pro- tial laboratory studies indicate a subnormal white blood cell count and a mild reduc- cessing or translation. Tests result in a diagnosis of systemic lupus erythematous (SLE) (frequently called lupus). ACTION OF RNA POLYMERASE Transcription, the synthesis of RNA from a DNA template, is carried out by RNA poly- merases (Fig. Like DNA polymerases, RNA polymerases catalyze the formation of ester bonds between nucleotides that base-pair with the complementary nucleotides on the DNA template. Unlike DNA polymerases, RNA polymerases can initiate the synthesis of new chains in the absence of primers. They also lack the 3 to 5 exonu- clease activity found in DNA polymerases.

Compensation strategies may be helpful for patients experiencing retropulsion or freezing order female viagra 100mg with visa women's health clinic bowling green ky. Thorough assessments of the home environment and the patient’s performance of daily living activities are also important in the fall- prevention plan order 100mg female viagra menstruation spotting. Home modifications and use of appropriate adaptive equipment can be best identified after evaluation and treatment by an Copyright 2003 by Marcel Dekker, Inc. Occupational therapy sessions may include practi- cing safety strategies in the kitchen, bathroom, and other areas in the home environment where falls are most likely to occur. Reduced cognitive skills may also impact patient safety and contribute to falls. Cognitive screening and assessment is recommended in order to tailor patient instruction and safety strategies to an appropriate level. Family or other caregivers may need to be involved in the education process to ensure that the recommendations are understood and utilized. An emergency plan should be devised for all patients who experience frequent falling. Caregivers should also be instructed in safe methods for helping patients get up from the ground after a fall, as they frequently provide primary assistance in these situations. CONTROLLING PAIN Complaints of pain are not uncommon in patients with PD and may be related to excessive rigidity, postural changes, inability to perform independent position change, dystonia, injuries sustained from falling, or other medical conditions. A complete assessment is needed to determine the source, frequency and intensity of pain. Instruction in recognizing pain behaviors (symptoms) may be required for caregivers as patients experien- cing significant cognitive changes may exhibit agitation, wandering, anxiety, or increased confusion as pain-related behaviors. While some patients require the use of prescribed medications or over- the-counter analgesics for pain control, there are a variety of other nonpharmacological interventions that may offer relief or reduce discom- fort. Many patients have reported improvements as a result of complemen- tary therapies, such as massage and acupuncture, though further research is required to assess the benefits of these treatments (13,14). Use of superficial heat, cold, or physical therapy modalities may also be effective in pain management. Instruction in proper positioning, seating systems, and posture principles is recommended to decrease discomfort resulting from improper postural alignment. Relaxation strategies and other forms of complementary medicine may also prove beneficial as part of a holistic approach to pain management. SPEECH/VOICE/COMMUNICATION An estimated 70–100% of people with PD experience changes in their ability to communicate effectively. Rarely, these changes are a first or very early Copyright 2003 by Marcel Dekker, Inc. The primary changes in speech and voice include soft or fading voice volume, monotone pitch, imprecise or slurred articulation of speech sounds, rapid and irregular rate of speech, ‘‘stutter- like’’ speech, and hoarse voice quality. The changes in speech and voice are caused by the physiological changes that occur with PD. Muscle rigidity, tremor, freezing, slowness, and diminished coordination of movements can all have an impact on the complicated coordinations of movement needed for clear, loud speech and voice. The emotional, social, and economic impact of this decreased vocal ability can be significant—reduced self-confidence, social isolation, frustra- tion related to communication breakdowns, and reduced ability to continue working. Medication management of PD, while extremely important and helpful in managing symptoms, does not typically improve speech and voice skills. Intervention by a speech language pathologist, initiated early in the disease process, offers the best possible outcomes of speech therapy. Traditional speech therapy techniques, such as practice on oral motor exercises, specific speech sound drills, and techniques to control speech rate and better coordinate breathing with voice, have been shown to be helpful. The most effective treatment, however, that has documented positive and long-lasting results is the Lee Silverman Intensive Voice Treatment (LSVT) (16,17). The treatment concepts are quite simple: ‘‘Think Loud/Think Shout. As PD progresses, it is sometimes necessary to ‘‘augment’’ speech and voice skills with devices such as personal amplifiers, word or picture boards, or computerized communication systems. Speech pathology intervention to maximize communication abilities may be needed at many different times during the course of PD as individual abilities change.

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Acute toxicity presenting as delirium (15) and psychosis (11) has been reported female viagra 50mg with mastercard womens health eugene oregon. Abrupt withdrawal has also been reported to produce delirium (29) as well as neuroleptic malignant syndrome (30) cheap female viagra 50mg otc womens health total body transformation. In many of these cases patients had either baseline cognitive deficits, psychiatric background, or excessive amantadine use. In general, the cognitive side effects such as confusion and concentration difficulties are more common in those with underlying, preexisting cognitive dysfunction. In advanced PD, amantadine may even carry comparable propensity for cognitive side effects to levodopa Copyright 2003 by Marcel Dekker, Inc. As such, conservative use in the elderly and avoidance of use even in the mildly cognitively impaired patient is necessary. Because of the renal predominant excretion of amantadine, patients with impaired kidney function carry a higher risk of toxicity. Dosing schedules have been developed for patients with poor renal function according to creatinine clearance (32). However, as a practical matter, with the availability of many other antiparkinsonian agents, it is best to avoid the use of amantadine in patients with poor renal clearance. In the event of suspected toxicity, dialysis is not helpful in decreasing toxic levels, probably due to extensive tissue binding (33). Mechanisms of Action Many studies have suggested putative mechanisms of action for amantadine that may explain antiparkinsonian effects, but the clinical significance of any given individual mechanism remains uncertain. It seems likely that amantadine has a combination of multiple effects on both dopaminergic and nondopaminergic systems. Dopaminergic mechanisms described for amantadine include findings of increased dopamine release (34), increased dopamine synthesis (35), inhibition of dopamine reuptake (36) and modulation of dopamine D2 receptors producing a high affinity state (37). This latter effect may speculatively play a role in modulating levodopa-induced dyskinesias. The relevance of these dopaminergic mechanisms is uncertain given that studies have demonstrated that the antiparkinsonian effects can occur without changes in brain concentrations of dopamine or its metabolites (38) and without evidence for dopamine synthesis or release (39). Other neurotransmitter effects reported with amantadine include serotonergic, noradrenergic, anticholinergic, and antiglutaminergic proper- ties (40). The anticholinergic properties suggest a well-described antipar- kinsonian interaction (41,42). Renewed interest has arisen in the antiglutamate properties of amantadine. These can be attributed to two important clinical implications. First, it may provide a putative neuropro- tective mechanism and be added to the list of drugs that may be examined for such clinical effects. Second, converging lines of evidence provide support to the idea that the antiglutamate properties of amantadine may be important for modulating motor complications in late-stage PD. Amantadine possesses mild anti-NMDA properties that have led to the suggestion that the drug may contribute to a possible neuroprotective effect in PD (43,44). Glutamate excitotoxicity, mediated via persistent or sustained activation of NMDA receptors, produces an excess calcium influx activating a cascade of molecular events leading to the common final Copyright 2003 by Marcel Dekker, Inc. Blockade of NMDA glutamate receptors has been shown to experimentally diminish the excitotoxic effects of this cascade of reactions (45,46). In cell cultures, preexposure of substantia nigra dopaminergic neurons to glutamate antagonists provided protection when þ subsequently exposed to MPP (1-methyl-4-phenyl-pyridium ion, the active metabolite of MPTP), a common specific nigral toxin used to produce animal models of PD (47). Extension of these preclinical findings to clinical applicability in PD patients remains speculative, but probably best serves a role to stimulate future studies. The anti-NMDA properties of amantadine have also been implicated in its role modulating motor complications. Evidence has accumulated that glutamate NMDA receptors may play a significant role in the pathogenesis of motor complications. Loss of striatal dopamine and nonphysiological stimulation by extrinsic levodopa both cause sensitization of NMDA receptors on striatal medium spiny neurons in animal models (22). This sensitization may play a key role in altering normal basal ganglia responses to cortical glutaminergic input and produce the disordered motor output that leads to motor complications. Recent studies have reported that striatal injection or systemic administration of glutamate antagonists in primate and rodent models of PD can decrease levodopa motor complications without decreasing benefits of dopaminergic treatment (7,48–51). Summary With improved management options for PD, patients are living longer, and, as a result, more are suffering from long-term complications of disease and therapy.

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Which of the following best describes a mother with galactosemia caused by a deficiency of galactose 1-phosphate uridylyl transferase? CHAPTER 30 / SYNTHESIS OF GLYCOSIDES purchase 50 mg female viagra otc pregnancy upper back pain, LACTOSE cheap female viagra 100mg on line menopause 60, GLYCOPROTEINS AND GLYCOLIPIDS 555 2. The immediate carbohydrate precursors for glycolipid and glycoprotein synthesis are which of the following? In this patient, the bilirubin produced lacks which of the following carbohy- drates? The nitrogen donor for the formation of amino sugars is which of the following? Which of the following glycolipids would accumulate in a patient with Sandhoff’s disease? This process of glucose produc- tion is called gluconeogenesis. Gluconeogenesis, which occurs primarily in the liver, is the pathway for the synthesis of glucose from compounds other than carbohydrates. In humans, the major precursors of glucose are lactate, glycerol, and amino acids, particularly alanine. Except for three key sequences, the reactions of gluconeogenesis are reversals of the steps of glycolysis (Fig. The sequences of gluconeogenesis that do not use enzymes of glycolysis involve the irreversible, regulated steps of glycolysis. These three steps are the conversion of (a) pyruvate to phospho- enolpyruvate, (b) fructose 1,6-bisphosphate to fructose 6-phosphate, and (c) glu- cose 6-phosphate to glucose. Some tissues of the body, such as the brain and red blood cells, cannot synthe- size glucose on their own, yet depend on glucose for energy. On a long-term basis, most tissues also require glucose for other functions such as the synthesis of the ribose moiety of nucleotides or the carbohydrate portion of glycoproteins and glycolipids. Therefore, to survive, humans must have mechanisms for maintaining blood glucose levels. After a meal containing carbohydrates, blood glucose levels rise (Fig. Some of the glucose from the diet is stored in the liver as glycogen. After 2 or 3 hours of fasting, this glycogen begins to be degraded by the process of glycogenolysis, and glucose is released into the blood. As glycogen stores decrease, adipose triacylglycerols are also degraded, providing fatty acids as an alternative fuel and glycerol for the synthesis of glucose by gluconeogenesis. Amino acids are also released from the muscle to serve as gluconeogenic precur- sors. During an overnight fast, blood glucose levels are maintained by both glycogenolysis and gluconeogenesis. However, after approximately 30 hours of fasting, liver glycogen stores are mostly depleted. Subsequently, gluconeogenesis is the only source of blood glucose. Changes in the metabolism of glucose that occur during the switch from the fed to the fasting state are regulated by the hormones insulin and glucagon. Insulin is elevated in the fed state, and glucagon is elevated during fasting. Insulin stimu- lates the transport of glucose into certain cells such as those in muscle and adi- pose tissue. Insulin also alters the activity of key enzymes that regulate metabo- lism, stimulating the storage of fuels. Glucagon counters the effects of insulin, stimulating the release of stored fuels and the conversion of lactate, amino acids, and glycerol to glucose. The gluconeogenic pathway is almost the reverse of the glycolytic pathway, except for three reaction sequences. At these three steps, the reactions are catalyzed by different enzymes. The energy requirements of these reactions differ, and one pathway can be activated while the other is inhibited.

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