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By M. Muntasir. Antioch College. 2018.

Glucose Glycine Serine also can undergo -elimination of its hydroxyl group order 10mg fluoxetine with mastercard women's health clinic tweed heads, catalyzed by serine dehydratase buy fluoxetine 10 mg free shipping women's health issues mayo clinic, to form pyruvate. Regulatory mechanisms maintain serine levels in the body. When serine levels fall, 3-Phosphoglycerate Serine serine synthesis is increased by induction of 3-phosphoglycerate dehydrogenase and by release of the feedback inhibition of phosphoserine phosphatase (caused by higher lev- els of serine). When serine levels rise, synthesis of serine decreases because synthesis 2-Phosphoglycerate Cysteine of the dehydrogenase is repressed and the phosphatase is inhibited (see Fig. Glycine Pyruvate SO4 Glycine can be synthesized from serine and, to a minor extent, threonine. The major route from serine is by a reversible reaction that involves FH4 and pyridoxal phos- Alanine phate (Fig. Tetrahydrofolate is a coenzyme that transfers one-carbon groups Fig. Amino acids derived from interme- at different levels of oxidation. It is derived from the vitamin folate and is discussed diates of glycolysis. These amino acids can be in more detail in Chapter 40. The minor pathway for glycine production involves synthesized from glucose. Their carbons can threonine degradation (this is an aldolase-like reaction because threonine contains a be reconverted to glucose in the liver. CHAPTER 39 / SYNTHESIS AND DEGRADATION OF AMINO ACIDS 717 CH2 O P CH2OH Glycolysis Glucose HO P O C H PEP Pyruvate – – COO COO 3-Phosphoglycerate 2-Phosphoglycerate NAD+ ADP 3-phosphoglycerate dehydrogenase NADH ATP CH O P COO– 2 C C – COO CH2OH 3–Phospho- Glycerate hydroxypyruvate Glutamate NAD+ PLP α-Ketoglutarate NADH CH2 O P CH2OH + H 3 – – COO COO 3-Phospho-L-serine Hydroxypyruvate phosphoserine – PLP phosphatase Alanine Pi CH2 OH Pyruvate + H 3 COO– Serine Fig. The major pathway for serine synthesis from glucose is on the left, and for serine degradation on the right. Serine levels are main- tained because serine causes repression (circled T) of 3-phosphoglycerate dehydrogenase synthesis. Serine also inhibits (circled - ) phosphoser- ine phosphatase. CH3 H O H C O– + OH NH4 Threonine O PLP CH3 C serine H hydroxymethyl H O COO– O 2 2 + transferase 2 NH 4 O – PLP + D-amino acid 2 COO H2C NH3 H C O Serine oxidase Oxalate COO– COO– FH4 N5,N10–CH2–FH4 Glycine transaminase Glyoxylate TPP CO2 – – + COO COO FH4 NAD Pyruvate Alanine C H N5,N10–CH2–FH4 NADH CH2 glycine CO2 + H2O + cleavage CH2 NH4 CH2 CO enzyme 2 – CH2 COO α-Keto- – COO glutarate α-Hydroxy- β-ketoadipate Fig. Glycine can be synthesized from serine (major route) or threonine. Glycine forms serine or CO and NH by 2 4 reactions that require tetrahydrofolate (FH4). Glycine also forms glyoxylate, which is converted to oxalate or to CO2 and H2O. Kidney formed, it can be oxidized to oxalate, which is sparingly soluble and tends to pre- stones (renal calculi) are often composed of cipitate in kidney tubules, leading to kidney stone formation. A lack of the transaminase of oxalate formation in the liver comes from glycine metabolism. Dietary oxalate that can convert glyoxylate to glycine (see accumulation has been estimated to be a low contributor to excreted oxalate in the Fig 39. This disease has a consequence urine because of poor absorption of oxalate in the intestine. Generation of energy from glycine occurs through a dehydrogenase (glycine Cystathionuria, the presence of cys- cleavage enzyme) that oxidizes glycine to CO2, ammonia, and a carbon that is tathionine in the urine, is relatively donated to FH. As they mature, cystathionase levels rise, and the C. Cysteine levels of cystathionine in the urine decrease. In adults, a genetic deficiency of cys- The carbons and nitrogen for cysteine synthesis are provided by serine, and the sulfur tathionase causes cystathionuria. Serine reacts with homocysteine (which is als with a genetically normal cystathionase produced from methionine) to form cystathionine. This reaction is catalyzed by cys- can also develop cystathionuria from a tathionine -synthase. Cleavage of cystathionine by cystathionase produces cysteine dietary deficiency of pyridoxine (vitamin B6), and -ketobutyrate, which forms succinyl CoA via propionyl CoA.

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VLDL is processed in the Golgi complex and secreted into the blood by the liver (Figs order fluoxetine 10 mg line breast cancer vaccine. The fatty acid residues of the triacylglycerols ultimately are Why do some alcoholics have high stored in the triacylglycerols of adipose cells cheap 20mg fluoxetine visa menopause 2014. Similar to chylomicrons, VLDL particles are first synthesized in a nascent form, and on entering the circulation they acquire apoproteins CII and E from HDL particles to become mature VLDL particles. This 60 TG diagnostic impression is further supported by the finding that Cora’s profile of lipid abnormalities appeared to change somewhat from one determination to the next, a 40 characteristic of FCH. This hereditary disorder of lipid metabolism is believed to be quite common, with an estimated prevalence of about 1 per 100 population. As a result, packaging of 0 VLDL is increased, and blood VLDL levels may be elevated. Depending on the efficiency of lipolysis of VLDL by LPL, VLDL levels may be normal and LDL levels may be elevated, Fig. Composition of a typical VLDL or both VLDL and LDL levels may be high. In addition, the phenotypic expression of FCH particle. The major component is triacylglyc- in any given family member may be determined by the degree of associated obesity, the erol (TG). C cholesterol; CE cholesterol diet, the use of specific drugs, or other factors that change over time. G-6-P glucose 6-phosphate; complex F-6-P fructose 6-phosphate; F-1,6-BP fructose 1,6-bisphosphate; FA fatty acyl Secretory group; TG triacylglycerol. FATE OF VLDL TRIACYLGLYCEROL Liver cell Lipoprotein lipase (LPL), which is attached to the basement membrane proteoglycans of capillary endothelial cells, cleaves the triacylglycerols in both VLDL and chylomi- VLDL crons, forming fatty acids and glycerol. The C-II apoprotein, which these lipoproteins obtain from HDL, activates LPL. The low Km of the muscle LPL isozyme permits Phospholipid muscle to use the fatty acids of chylomicrons and VLDL as a source of fuel even when Cholesterol the blood concentration of these lipoproteins is very low. The isozyme in adipose tis- sue has a high Km and is most active after a meal, when blood levels of chylomicrons and VLDL are elevated. The fate of the VLDL particle after triglyceride has been removed by LPL is the generation of an IDL particle (intermediate-density lipopro- tein), which can further lose triglyceride to become an LDL particle (low-density lipoprotein). The fate of the IDL and LDL particles is discussed in Chapter 34. Fatty acids for VLDL synthesis in the liver may be obtained from the blood or they may be synthesized from glucose. In a healthy individual, the major source of the Apoprotein B–100 Triacylglycerol fatty acids of VLDL triacylglycerol is excess dietary glucose. In individuals with diabetes mellitus, fatty acids mobilized from adipose triacylglycerols in excess of the oxida- Fig. Synthesis, processing, and secre- tive capacity of tissues are a major source of the fatty acids re-esterified in liver to VLDL tri- tion of VLDL. These individuals frequently have elevated levels of blood triacylglycerols. VLDL are transported els of NADH inhibit the oxidation of fatty acids. Therefore, fatty acids, mobilized to the cell membrane in secretory vesicles and from adipose tissue, are re-esterified to glycerol in the liver, forming triacyl- secreted by endocytosis. Blue dots represent glycerols, which are packaged into VLDL and secreted into the blood. An enlarged VLDL particle is frequently associated with chronic alcoholism. As alcohol-induced liver disease pro- depicted at the bottom of the figure.

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Platelet activation in response to endothelial injury causes 2 imately the 8-nucleus stage purchase fluoxetine 10mg free shipping menopause levels, the cytoplasm Ca -dependent changes in the contractile elements 10 mg fluoxetine for sale womens health kaiser roseville, which, in turn, substantially becomes granular, and the platelets are bud- change the architecture of the plasma membrane. Long pseudopodia are generated, ded off the cytoplasm. A single megakary- increasing the surface area of the membrane as clot formation is initiated. The second type of granule is the granule, which contains a heparin antagonist (heparin interferes with blood clotting; see biochemical com- Idiopathic thrombocytopenic pur- ments), platelet-derived growth factor, -thromboglobulin, fibrinogen, von Wille- pura (ITP) is an autoimmune dis- brand factor (vWF), and other clotting factors. The third type of granule is the lyso- ease in which antibodies to platelet somal granule, which contains hydrolytic enzymes. During activation, the contents glycoproteins are produced. Antibody bind- of these granules, which modulate platelet aggregation and clotting, are secreted. PLATELET ACTIVATION is the appearance of small red spots on the skin (petechial hemorrhages) caused by Three fundamental mechanisms are involved in platelet function during blood coag- blood leakage from capillaries. Minor dam- ulation: adhesion, aggregation, and secretion. Adhesion sets off a series of reactions age to vascular endothelial cells is constantly termed platelet activation, which leads to platelet aggregation and secretion of being caused by mechanical forces related to platelet granule contents. In patients with ITP, few platelets The adhesion step refers primarily to the platelet–subendothelial interaction that are available to repair the damage. Blood vessel injury exposes collagen, subendothelial matrix-bound vWF, and other matrix components. The platelet cell membrane contains glycoproteins (GPs) that bind to collagen and to vWF, causing the platelet Von Willebrand factor is a large multimeric glycoprotein with a GPIb GPIIb GPIIIa GPIa subunit molecular weight of 220,000 daltons. Its size in the circulation Platelet ranges between 500 and 20,000 kDa, and its membrane role in circulation is to stabilize Factor VIII and protect it from degradation. The high- 2 3 1 molecular-weight forms are concentrated in Adhesion VWF Exposed by Adhesion the endothelium of blood vessels and are initial adhesion released in response to stress hormones and events endothelial damage. High-molecular-weight Subendothelial vWF released by the endothelium is cleaved collagen by a specific metalloprotease in the serum, reducing the size of the circulating vWF. Adhesion of platelets to the subendothelial cell layer. GPIa initially binds to the Large vWF multimers are more effective at exposed collagen, which results in changes in the three-dimensional configuration of forming complexes with platelets than are the complex, allowing GPIb to bind to vWF (2). This second binding event exposes the small vWF multimers. GPIIb/GPIIIa complex, which also can bind to vWF and fibrinogen. CHAPTER 45 / BLOOD PLASMA PROTEINS, COAGULATION AND FIBRINOLYSIS 831 to adhere to the subendothelium. Binding to collagen by GPIa (integrin 2 1) vWF deficiency is the most com- mon cause of inherited bleeding causes the platelet to change its shape from a flat disc to a spherical cell. Both platelet adherence extrudes long pseudopods, which promote platelet/platelet interactions. Binding of and the clotting cascade are affected subendothelial vWF by GPIb causes changes in the platelet membrane that expose because levels of Factor VIII are low. In the GPIIb/IIIa (integrin IIb 3) binding sites to fibrinogen and vWF. The vWF gene is large, cov- that results in more platelets being recruited and aggregated at the site of injury. Multiple mutations are known, with granules and their granules, with ADP release being of particular importance varying clinical presentations. ADP released from the platelets and from damaged red blood cells binds to a receptor on the platelet membrane, which leads to the further unmasking of GPIIb/IIIa binding sites.

The incision needs to extend proximally to approximately the junction of the mid- dle and distal third of the thigh (Figure S4 fluoxetine 20 mg cheap women's health clinic greenville sc. The incision is carried down to the knee capsule fluoxetine 10 mg with amex women's health clinic ballarat, which is opened all the way anteriorly to the patellar ligament. The incision then is car- ried proximally and posteriorly along the edge of the vastus lateralis (Figure S4. Incision in the periosteum is performed, and sub- periosteal dissection allows full exposure of the lateral and anterior femur. Subperiosteal dissection also can be extended circumferentially around the femur in the distal third above the metaphysis. Then, the patella can be dislocated or subluxated to the medial side, exposing the whole distal femur. Insertion of a guidewire at the level of the blade plate is a helpful step. The guidewire is inserted parallel to the distal femoral condyle and parallel to the anterior femur. This guidewire is inserted with visual inspection, but also can be checked with fluoroscopic control (Figure S4. After insertion of the guidewire, the guidewire should be cut off to allow approximately 3 to 4 cm of wire to be exposed laterally. The blade plate chisel then is inserted just proximal to this wire in the plane parallel to the tibia, with the tibia in maximum extension. The chisel for the blade plate is inserted under visual control and can be checked with the fluoroscope. The level of the chisel insertion should be immediately proximal to the growth plate if the child still has an open growth plate, or should be inserted so that it will be just above the notch of the femoral condyles if the growth plate is closed. Medial lateral insertion should be parallel to the distal femoral 974 Surgical Techniques Figure S4. If varus-valgus correction is desired, the chisel is still inserted parallel to the distal femoral condyles. With the knee in maximum extension, the flat side of the chisel should be at a right angle (Fig- ure S4. Then, the chisel is introduced from lateral to medial until it just can be palpated on the medial side. Utilizing an oscillating saw, the distal osteotomy is made parallel to the inserted chisel 12 to 15 mm proximal to the chisel (Figure S4. The proximal osteotomy is made transverse to the proximal femur at the level where the distal osteotomy ends (Figure S4. This osteotomy will now remove a significant anterior wedge from the femur (Figure S4. After removal of this wedge, full extension of the knee should be possible with minimal tension. If full extension is still not possible, additional transverse resections of the proximal femur should be performed. In some severe contractures, an addi- tional several centimeters of resected femur may be required. After the correct amount of femur has been resected, and due to the obliquity of the distal osteotomy, a large posterior spike will be pres- ent on the distal fragment. This large posterior fragment can be tran- sected; however, care should be taken not to remove an excessive amount because it will cause weakening of the distal fixation (Figures S4. The chisel is removed and the blade plate will be inserted. Blade plate size typically is chosen as an offset right-angle hip plate. Because of the shortening, the distal femoral osteotomy configuration causes the bone surface on the distal end to be larger than the proximal end.

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