#benign heme

[teachingrounds]

Q. What is ADAMTS13, anyway?

A. ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13), aka von Willebrand factor-cleaving protease (VWFCP) is a zinc-containing metalloprotease enzyme that degrades large vWF multimers -> reduced thrombus formation. Without it, vWF multimers persist -> increased consumption of platelets in the formation of thrombi. ADAMTS13 can be congenitally deficient (familial TTP) or targeted for destruction by IgG antibodies (acquired TTP).

Image: Pleiotrop on Wikipedia

[expertacademicassignmenthelp]

The Physiology Of The Liver

The liver is a vital organ responsible for numerous functions including metabolism, immunity, digestion, detoxification, and vitamin storage. It weighs around 2% of an adult’s body weight and is unique due to its dual blood supply from the portal vein (75%) and the hepatic artery (25%).

Cellular Structure

The liver’s functional unit is the lobule, which is hexagonal in shape. Each corner of the hexagon has a portal triad consisting of the portal vein, hepatic artery, and bile duct. The lobule is composed mainly of hepatocytes, which have distinct apical and basolateral membranes. Hepatocytes are categorized into three zones based on their function and blood supply:

Zone I (periportal region): Closest to the blood supply, involved in oxidative metabolism (e.g., gluconeogenesis, bile formation).

Zone II (pericentral region): Sits between Zones I and III.

Zone III: Farthest from the blood supply, primarily involved in detoxification and biotransformation.

Blood and bile flow in opposite directions within the liver. The space of Disse, between the hepatocytes and the sinusoidal lumen, contains Kupffer cells (macrophages) and Ito cells (fat-storing stellate cells).

Development

The liver develops from endodermal cells of the foregut as the hepatic diverticulum around the fourth week of embryonic development. It undergoes complex differentiation influenced by various pathways (e.g., Wnt/β-catenin, FGF). By the sixth week, the liver participates in hematopoiesis, and hepatocytes begin bile production by the 12th week.

Organ Systems and Functions

The liver interacts with multiple body systems:

Digestive and Metabolic Roles: Aids in digestion, stores fat-soluble vitamins, and handles cholesterol.

Hematological Functions: Produces clotting factors and proteins.

Detoxification: Metabolizes drugs and other xenobiotics through phase I (oxidation, reduction, hydrolysis) and phase II (conjugation) reactions.

Bilirubin Metabolism: Converts heme to unconjugated bilirubin, then conjugates it for excretion.

Hormonal and Protein Synthesis: Involved in thyroid hormone activation and synthesis of nearly all plasma proteins.

Related Testing

Liver function tests (LFTs), including ALT, AST, bilirubin, alkaline phosphatase, and gamma-glutamyl transpeptidase (GGT), help assess liver health. Imaging techniques like ultrasound, CT, and MRI are also employed to identify liver abnormalities.

Pathophysiology

Cirrhosis results from chronic liver injury (e.g., due to alcoholism, hepatitis B and C), leading to fibrosis and necrosis. It causes symptoms like portal hypertension, coagulopathy, and jaundice. Hepatitis viruses (A, B, C, D, E), autoimmune diseases (e.g., primary biliary cholangitis), and metabolic conditions (e.g., non-alcoholic fatty liver disease) also contribute to liver pathology.

Clinical Significance

Understanding liver physiology helps manage conditions like viral hepatitis, alcoholic liver disease, benign liver lesions, and liver cancers. Early detection through appropriate testing and management strategies is essential for preventing end-stage liver disease and improving patient outcomes

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[bluewindfall]

3 good things

The onc exam was pretty okay except for the last 4 benign heme questions XD

Have one last final tomorrow, which is kind of going to be the last final I take in college too

Managed to send an email I was avoiding

[ramrodd]

Duke Summer Faculty Reads: Nancy MacLean

Is describing oneself as a “classic liberal”, a 19th Century construct, an effort to avoid being thrown in with modern conservatism but still being conservative about a lot of issues?

COMMENARY:

“Classic liberal” is a  weasle word for the Public Choice agenda to replace the US Constitution with the Free Market Fascism of  Jefferson Davis’s States Rights theory of property, labor and the means of production

Meet the Economist Behind the One Percent’s Stealth Takeover of America

First of all, I recommend reading this article about James McGill Buchanan, a “classic liberal” economist behind the Public Choice economic agenda that has been driving Conservative politics since the Powell memo in 1972 that has shaped the thinking of the Kock brothers, Robert Mercer, Steve Bannon and Newt Gingrich. ‘

“The reason? Duke historian Nancy MacLean contends that his philosophy is so stark that even young libertarian acolytes are only introduced to it after they have accepted the relatively sunny perspective of Ayn Rand.” Lynne Parramore

Public Choice is basically a repackaged version of Jefferson Davis’s State’s Rights theory of property, labor and the means of production shared by Frederick Winslow Taylor, who created Scientific Management that is the core technology of the Harvard Business School (Scientific Management, in and of itself, is a perfectly valid performance technology, but is embedded in, a perverted by, the same theological context as Marxism: Harvard “capitalism” and Marxism are different sides of the same theological coin).

Public choice is American Tory Socialism based on Locre’s formulation of “life, liberty and property” that is a British legacy of the Magna Carta, property being the criteria for the franchise of King John at Runnymeade. This construct is reflected in the constitutional arrangements that established Thomas Jefferson’s property rights as being superior to Sally Heming’s human rights.

The purpose of the Public choice agenda is to restore this construct as the law of the land by constitutional convention arising from a referendum of 36 states.

The use of terms like “classic liberal” is part of the campaign to sow moral confusion by reframing what is fundamentally a venal agenda as benign, if not actually progressive. An example of this communication strategy is reflected in Lindsey Graham’s slander of the Squad as “communists”, etc, in support of Dumb Ass Donnie’s rancid bigotry. An Evangelical pastor just issued the opinion that the economics of Jesus is Free Market economics. Jesus existed in a global Free Market economic ecology that was mitigated somewhat by Pax Romana, but the actual economic dynamic was basically the kibbutz economics of pre-1947 Palestine, the community as a capitalist tool.

In contrast to the Tory Socialism of Public choice, the US Constitution is founded on the essential construct of Democratic Socialism: “Life,Liberty and the Pursuit of Happiness” that emerges from the Beatitudes and the economics of Jesus, as explicated by Adam Smith’s Wealth of Nations, the true source of “classic liberalism”.

In the final analysis, Public choice is just a pretty name for Free Market Fascism. Steve Bannon is the front man for a transnational criminal consortium committed to destabilizing constitutional authority, globablly, and dismantling the administrative state in order to replace it with the Free Market Fascism of Argintina under the Generals. As near as I can tell, all the astro-turf movements, globally, are within 3 degrees of organizations Steve Bannon has been coordinating since the Mercers began funding his activities.

Nancy McLean has a number of videos on YouTube that expand upon the Parramore article. This is a useful point of departure.

[drgirishbadarkhe]

Hematology Treatment Clinic Center In Nashik

Hematology is a branch of medicine that concerns itself with the study of blood, the blood-forming tissues, and its diseases. The word "heme" comes from the Greek for blood and the physicians working in this field are called hematologists. We started our adventure treating benign and malignant hematology in 2011. We are a team of super specialists specialized in the hematological treatment diseases with extensive experience in bone marrowtransplantation.

Contact details : 990-299-3531 email: haemgiri@gmail.com

Book an appointment: https://www.drgirishbadarkhe.com/appoinment.php

[mcatmemoranda]

I understand Gilbert's, Crigler-Najjar, and Dubin-Johnson syndromes. But I didn't when we took the first COMBANK test. Basically, if you just understand how bilirubin is processed, then you understand what happens in these diseases. In Gilbert's and Crigler-Najjar, you can't conjugate bilirubin, so you have high levels of unconjugated bilirubin. In Dubin-Johnson syndrome, you can conjugate bilirubin, but you can't transport it out of the liver, so you get increased levels of conjugated bilirubin. Gilbert's and Dubin-Johnson are benign conditions. Crigler-Najjar type I is fatal without a liver transplant and babies usually die within 18 months if not for the transplant. Crigler-Najjar type II is less severe and can be treated with phenobarbital. This was all in one of Dr. Plummer's recent pathology lectures...

Unconjugated hyperbilirubinemia can result from increased production, impaired conjugation, or impaired hepatic uptake of bilirubin, a yellow bile pigment produced from hemoglobin during erythrocyte destruction. Under normal conditions, unconjugated bilirubin is transported in the plasma bound to albumin. At the sinusoidal surface of the liver, unconjugated bilirubin detaches from albumin and is transported through the hepatocyte membrane by facilitated diffusion. Within the hepatocyte, bilirubin is bound to two major intracellular proteins, which are cytosolic Y protein and cytosolic Z protein. Bilirubin must be made more soluble in order to be excreted into bile and eliminated from the body. This water-soluble, or conjugated, form of bilirubin is produced when glucuronic acid enzymatically is attached to one or both of the propionic side chains of bilirubin. Attachment of glucuronic acid to bilirubin occurs through an ester linkage and is called esterification. This esterification is catalyzed by microsomal bilirubin uridine diphosphate-glucuronosyltransferase (bilirubin-UGT), which is located in the endoplasmic reticulum of the hepatocyte. This reaction leads to the production of water-soluble bilirubin monoglucuronide and bilirubin diglucuronide. Deficiency of bilirubin-UGT leads to an ineffective esterification of bilirubin, which in turn results in an unconjugated hyperbilirubinemia.

Reduced bilirubin conjugation as a result of a decreased or absent UGT activity is found in several acquired conditions and inherited diseases, such as Crigler-Najjar syndrome (types I and II) and Gilbert syndrome. Impaired bilirubin conjugation can also result from other etiologies such as neonatal physiologic jaundice, breast milk jaundice, maternal serum jaundice, hypothyroidism/hyperthyroidism, Ethinyl estradiol, and liver diseases (chronic hepatitis, cirrhosis, and Wilson disease). The patient in this clinical scenario has no past medical history, takes no medications, and is asymptomatic. Therefore, he likely has Gilbert syndrome. Hepatic bilirubin UGT activity is consistently decreased to approximately 30% of normal in individuals with Gilbert syndrome reducing the ability of the liver to conjugate bilirubin. As a result, a patient will have isolated elevations in their unconjugated bilirubin. Gilbert syndrome may manifest only as jaundice on clinical examination. However, at least 30% of patients with Gilbert syndrome are asymptomatic.

Dubin-Johnson syndrome is an inherited, relapsing, benign disorder of bilirubin metabolism. This rare autosomal recessive condition is characterized by conjugated hyperbilirubinemia with normal liver transaminases, a unique pattern of urinary excretion of heme metabolites (coproporphyrins), and the deposition of a pigment that gives the liver a characteristic black color. Patients with Dubin-Johnson syndrome tend to develop nonpruritic jaundice during their teenage years. However, Dubin-Johnson syndrome is asymptomatic in most cases. The conjugated hyperbilirubinemia observed in Dubin-Johnson syndrome results from a defective transport of bilirubin glucuronide across the membrane that separates the hepatocyte from the bile canaliculi. The pigment that is not secreted from the hepatocyte is stored in the lysosome and causes the black liver color. Although the person in this clinical scenario is asymptomatic, it is his unconjugated bilirubin that is elevated, not his conjugated hyperbilirubinemia.

[soulbvrden]

Ʀᴡʙʏ ᴀᴇSᴛʜᴇᴛꞮᴄS

Repost. Do not Reblog. Bold what applies to your muse. Italicise what they don’t acknowledge. Feel free to add!

ᴡᴇᴀᴘᴏɴS

single part. multi-part. it’s also a gun. it’s surprisingly not a gun. bow. gatling. automatic. revolver. semi-automatic. rifle. machinegun. railgun. shotgun. handgun. flare gun. single barrel. double barrel. 3+ barrels. spring-loaded. single dust. multi-dust. combination dust. long range. short range. midrange. flexible. single blade. multiple blades. one edge. two edged. single hand. two-handed. dual wield. katana. spear. naginata. trident. nunchucks. staff. quarterstaff. bo staff, double-bladed. detachable. expandable. collapsible. sectional staff. knives. sai. wakizashi. tanto. daisho. battle fan. longsword. mace. spiked mace. flail. brass knuckles. gauntlets. greaves. dust. slingshot. camera. improbable weapon. hard light. shield. hammer. purse. claws. scythe. whip. cane.

ᴅᴜSᴛ

gravity. lightning. wind. fire. earth. volcanic. ash. ice. time. steam. plant. energy. protective. defensive. offensive. healing. infused. bullets. forged. cut. uncut. powder. combined.

ᴄᴏᴍʙᴀᴛ ɢᴇᴀƦ

boots. heels. wedges. combat boots. combat skirt. dress. shorts. miniskirt. cape. side cape. gloves. fingerless gloves. long gloves. mask. long sleeves. short sleeves. armor. sneakers. jeans. shorts. leggings. stockings. hoodie. formal wear. stealth gear. heavy combat gear.fashionable. utilitarian. comfortable. reduces friction. stamina building. neutral colors. bright colors. dark colors. pastels. layered. single layer. tight fit. loose fit. perfect fit. corset.t hemed. brand-name. handmade. knee-high socks. dust-infused. constant wardrobe changes. same (general) outfit with repairs. classy dresser. sloppy dresser.

ɢƦꞮᴍᴍ

with them. against them. flying. prowling. beowolves. ursa. two legged. four legged. multi-legged. old. young. sentient. aggressive. passive. ornate mask. simple mask. geist. arma gigas. multi-headed. griffon. seer. tentacles. wings. multiple wings. multiple limbs. humanoid. rational. grimmspawning. i’d rather not, thanks.

ᴜɴꞮǪᴜᴇ

wizard. maiden. winter. summer. fall. spring. inheritor. silver eyes. shapeshifter. faunus. human. grimmspawn. goddess. god. deity. messenger. fairy tale. myth. legend. historical figure. uninspired.

Sᴇᴍʙʟᴀɴᴄᴇ

elemental. enhances an internal trait. enhances an external trait. increases your power. increases another’s power. multiple people. one person. enhancement. enchantment. theft. death. luck. misfortune. emotional. stoic. glyphs. summoning. movement of objects. gained though sadness. gained through happiness. gained unexpectedly. so like you to gain. inherited power. first of its kind. nullifies something. nullifies someone else. self-harming. taxing. controllable. uncontrollable. attracts. repels. forceful. gentle. deadly. benign. explosive. implosive. manipulative. shadows. light. isolating. clones. travel. undiscovered. illusions.

ᴇʏᴇS

blue. green. gray. red. orange. multicolored. heterchromia. constantly changing. silver. yellow. purple. indigo. black. dualchrome. slitted pupils. unusual pupils. blind. odd sclera. no iris. no pupil.

ᴀᴜƦᴀ

infinite. unbound. deathless. protection. paragon. virtue. glory. sin. ruin. passing. immortal. bloody. growing. stagnant. renegade. finite. fated. destiny. shackled. pedestal. forgotten. hungry. wrathful. fractured. artificial. simple. complicated. mourned.

ƦᴇɢꞮᴏɴ

vale. atlas. vytal. vacuo. menagerie. mistral. mantle. patch. beacon. haven. shade. alsius. signal. unaffiliated. bandits. grimmlands.

ᴀʟʟꞮᴀɴᴄᴇ

humanity. destruction. survival. white fang. military. schnee. ozpin. salem. faunus.

Tagged: stole from @canefought Tagged: t-t-t-take it * blows airhorns *

[torchwiick]

RWBY Aesthetics Repost. Do not Reblog. Bold what applies to your muse. Italicise what they don’t acknowledge. Feel free to add!

Weapons single part. multi-part. it’s also a gun. it’s surprisingly not a gun. bow. gatling. automatic. revolver. semi-automatic. rifle. machinegun. railgun. shotgun. handgun. flare gun. single barrel. double barrel. 3+ barrels. spring-loaded. single dust. multi-dust. combination dust. long range. short range. midrange. flexible. single blade. multiple blades. one edge. two edged. single hand. two-handed. dual wield. katana. spear. naginata. trident. nunchucks. staff. quarterstaff. bo staff, double-bladed. detachable. expandable. collapsible. sectional staff. knives. sai. wakizashi. tanto. daisho. battle fan. longsword. mace. spiked mace. flail. brass knuckles. gauntlets. greaves. dust. slingshot. camera. improbable weapon. hard light. shield. hammer. purse. claws. scythe. whip. cane.

Dust gravity. lightning. wind. fire. earth. volcanic. ash. ice. time. steam. plant. energy. protective. defensive. offensive. healing. infused. bullets. forged. cut. uncut. powder. combined.

Combat Gear boots. heels. wedges. combat boots. combat skirt. dress. shorts. miniskirt. cape. side cape. gloves. fingerless gloves. long gloves. mask. long sleeves. short sleeves. armor. sneakers. jeans. shorts. leggings. stockings. hoodie. formal wear. stealth gear. heavy combat gear.fashionable. utilitarian. comfortable. reduces friction. stamina building. neutral colors. bright colors. dark colors. pastels. layered. single layer. tight fit. loose fit. perfect fit. corset.t hemed. brand-name. handmade. knee-high socks. dust-infused. constant wardrobe changes. same (general) outfit with repairs. classy dresser. sloppy dresser.

Grimm with them. against them. flying. prowling. beowolves. ursa. two legged. four legged. multi-legged. old. young. sentient. aggressive. passive. ornate mask. simple mask. geist. arma gigas. multi-headed. griffon. seer. tentacles. wings. multiple wings. multiple limbs. humanoid. rational. grimmspawning. i’d rather not, thanks.

Unique wizard. maiden. winter. summer. fall. spring. inheritor. silver eyes. shapeshifter. faunus. human. grimmspawn. goddess. god. deity. messenger. fairy tale. myth. legend. historical figure. uninspired. criminal.

Semblance elemental. enhances an internal trait. enhances an external trait. increases your power. increases another’s power. multiple people. one person. enhancement. enchantment. theft. death. luck. misfortune. emotional. stoic. glyphs. summoning. movement of objects. gained though sadness. gained through happiness. gained unexpectedly. so like you to gain. inherited power. first of its kind. nullifies something. nullifies someone else. self-harming. taxing. controllable. uncontrollable. attracts. repels. forceful. gentle. deadly. benign. explosive. implosive. manipulative. shadows. light. isolating. clones. travel. undiscovered. illusions. unknown.

Eyes blue. green. gray. red. orange. multicolored. heterchromia. constantly changing. silver. yellow. purple. indigo. black. dualchrome. slitted pupils. unusual pupils. blind. odd sclera. no iris. no pupil.

Aura infinite. unbound. deathless. protection. paragon. virtue. glory. sin. ruin. passing. immortal. bloody. growing. stagnant. renegade. finite. fated. destiny. shackled. pedestal. forgotten. hungry. wrathful. fractured. artificial. simple. complicated. mourned.

Region vale. atlas. vytal. vacuo. menagerie. mistral. mantle. patch. beacon. haven. shade. alsius. signal. unaffiliated. bandits. grimmlands.

Alliance humanity. destruction. survival. white fang. military. schnee. ozpin. salem. faunus.

Tagged: stole from @soulbirthed Tagged: Anyone, idc I just wanted to do it myself

[schpiedehl]

Reasons I hate the Hamilton fandom

Disclaimer: I’m a mod of one Hamilton fb group, an admin of another much smaller group, have seen the show twice, and a huge fan of many of the actors and creatives, not just the original cast. I am entrenched in the Hamilton fandom and have been for nearly 2 years so all of this comes from personal experiences with the fandom. I do not hate the actual musical and having talked to many folks and made friends through this fandom, I can confirm that it has had a positive effect on many people, especially aspiring actors of color. I had criticisms of the actual musical (reductive view of American history, perpetrates American exceptionalism, bootstraps narrative, not as feminist as fans insist, etc) but I’m mostly just addressing the issues within the fandom not within the media. The problems with the fandom is nebulous and manifold so I’m gonna try to be as thorough as possible here: - for those that don’t know, Hamilton is a show made by POC creatives for actors of color. The casting is not “color blind” it is racially conscious. All leads always, aside from the silly, villainous King George, are intended to be played by actors of color and the much of the fandom absolutely REFUSES TO ACKNOWLEDGE THIS. It ranges from the benign-seeing assertions that Hamilton is colorblind and therefore race of the actor doesn’t matter as much as talent (false, with the underlying belief that a white actor will somehow be better suited/more talented in a role that is literally not written for them) to petulant assertions that one white fan or another will be the first white actor to play x role, to erasing the racial identities of light-skinned black, latinx, and asian actors to fit the manufactured narrative that white actors can and have played principal roles and the show is therefore colorblind. Fans are quick to point out the ambiguous wording of “America then told by America now,” intended to subtly indicate POC, as meaning white folk, despite the continuous assertions by the creatives that this is simply not the case. - whitewashing in fan art. Hand in hand with the refusal by many white fans to acknowledge the fact that Hamilton the Musical is intended for POC, white fan artist almost universally draw the actors-as-characters with lighter skin, lighter eyes, and more typically European features. Lin, who played Hamilton in the original cast, is a Latino man of mixed race heritage with tan skin, black hair, and dark eyes yet fan art of him as Hamilton is nearly always pale, red haired, and sometimes even blue-eyed. Artists will defend this as interpretation and some will even indicate that Hamilton was white irl so this is more accurate but Hamilton irl and Lin were nothing alike and he presence of a goatee in Hamilton Fan art is an indisputable sign that the artist is drawing Lin, not the real life, baby faced Hamilton. Dark skinned actors like Okieriete Onaodowan (Hercules Mulligan in the original cast) are rarely drawn and when they are they tend to be heavily lightened. - characters deemed queer by the fandom - notably John Laurens who was thought to be gay or bi in real life by many historians - is often heavily feminized in fan art, despite the fact neither the character nor the actual figure are ever noted as being particularly effeminate. This is of course fetishization symptomatic of applying heteronormativity to gay relationships. - fans often reject and demonize female characters. This is not universal but many fans have negative reactions to Hamilton’s wife, Eliza (and ignore and/or demonize her in regards to the gay ship of Hamilton/Laurens, despite Laurens having died shortly after Hamilton married Eliza. Hamilton fans believe almost universally that Hamilton was bi irl, which is supported by historical consensus, but the notion of him actually being with a woman repulses much of the fandom. - basically standard biphobia). Fans are also extremely gross about Maria Reynolds. - a separate part of the fandom refuses to acknowledge both the historical consensus of the Hamilton/Laurens relationship and the fact that that musical contains several intentional references to it. I’ve been told many times to keep that “gay shit” out of the fandom. - shipping wars of course. - blind worship of the characters either without regard to their historical counterparts or including their historical counterparts. - slavery apologism. Comparing slaves to modern consumer items and/or farm animals to demonstrate the ubiquity of slavery and/or people’s mindset regarding it. While it is true that people are the product of their time, “everyone owned slaves” and “you cannot judge them by the Norms of our culture” are common silencing/apologist techniques which both lack nuance and perpetuate racist ideals. It also erases the fact that abolitionism and moral opposition to slavery existed not only in post-revolution society but also within the very people who owned slaves. Thomas Jefferson wrote that slavery was the worst evil while simultaneously owning and raping slaves. - I’ve encountered at least one person with a bona fide slavery fetish. That’s not the fandom as a whole but it is worth noting. - abhorrent beliefs are common re: Thomas Jefferson’s relationship with Sally Hemings. - this has basically been covered above but rampant racism is not uncommon in this fandom. You get the distinct feeling that a sizeable portion has never once interacted with a person of color before, based on the ways they claim ownership over the actors, portray the characters, talk about racial issues, etc - speaking of the actors: fans are very gross toward the actors in a variety of different ways. - fans fetishize the fuck out of Daveed Diggs, who played Jefferson in the original cast. Diggs, for reference is a biracial black Jewish man, a rapper, actor, and activist best known outside of Hamilton for his work with clipping., which includes an extremely politically charged afrofuturist space rap opera. Fans tend to do a couple things in regards to Diggs. One, they conflate him with irl Jefferson leading so some really and truly bizarre headcanons and fan interpretations. Diggs himself has no love for irl Jefferson and has - along with the rest of the cast - cautioned fans against romanticizing the real figures, apparently to limited success. More heinously, however, I have seen people claiming ownership of Digg’s body and hair (claiming they would be upset if his cut it, or would stop being his fan even), made comments about keeping him as a sex slave, fetishizing his ethnic features, or even denying his blackness in favor of fetishizing his white, Jewish heritage. I’ve even seen a white woman comment that she wanted to kill diggs’ black girlfriend, skin her, and wear her as a suit to attract Diggs. No fucking joke. Diggs work as a musician is loved by many fans but others reject it as “scary black music.” - this happens with other actors tho not as much as Diggs. Fans have made plenty of comments about Okieriete Onaodowan’s “big black spy on the inside,” for instance, showing further capacity to fetishize black bodies. - for many fans, the original cast can do no wrong. They will go out of their way to justify and forgive anything that can be seen as problematic rather than acknowledging that they can still like a person that has problematic aspects. - or conversely, they gang up on actors on twitter, or tag them in hate/undeservedly negative critique. - replacements and non-OBC casts are largely ignored and several of the actors have been trolled or sent hate simply because they are not the originals. There is also the mindset that no one could ever be better than the original and the show is not worth seeing without the originals which is extremely disrespectful toward the replacement actors. - a large portion of the fandom claims that Hamilton is the only rap they like, or that they don’t like hip hop at all. When the Hamilton mixtape - and album featuring inspired-bys and covers of Hamilton songs by contemporary singers and rappers, was released fans HATED IT, many pointed out that they hated the hip hop sound and the “bastardization” of the music. Many of the songs on the Mixtape were by artists which inspired Hamilton in the first place. - a lot of the fans are just plain cringey. Bad head canons which become more ubiquitous than the actual canon portrayals, extremely forceful when it comes to trying to “convert” people, extremely adverse to any kind of criticism of the musical, history, or the actors, obnoxious at cons, etc. - art theft is rampant - extreme classism re: bootlegs especially - older fans have a tendency to be extremely abusive toward younger fans. Not all young fans are bad but bad memes and stupid references are met with extreme, quick, and unwarranted vitriol.

[teachingrounds]

Q. What's on the differential for quantitative platelet disorders, separated by disease mechanism?

A. DDx: Decreased production: • Aplastic anemia • Infectious diseases: HIV, hepatitis C, varicella, rubella • Liquid malignancies: leukemia and lymphoma • Myelodysplastic syndromes • Marrow infiltration from solid tumors in bone • Nutritional deficiencies: copper, folate, B12 • Radiotherapy or chemotherapy treatments

Increased destruction: • DIC = Disseminated intravascular coagulation • DTIP = Drug-induced Immune ThrombocytoPenia • HELLP syndrome = Hemolysis, Elevated Liver enzymes, Low Platelets • HIT = Heparin-Induced Thrombycytopenia • HUS = Hemolytic Uremic Syndrome • ITP = Immune ThrombocytoPenia aka Idiopathic Thrombocytopenic Purpura • TTP = Thrombotic Thrombocytopenic Purpura

Image: Platelet-Chan by Maxibillity, Deviant Art

[smarmykemetic]

Arensnuphis An anthropomorphic deity of Merotic Nubia, Arensnuphis' origins are unclear, but the god seems to have been indigenous to the area to the south of Egypt. Unfortunately, the Egyptian interpretation of his name as Iry-hemes-nefer -'the good companion'- suggests only a benign deity, and provides no real indication of his origins or essential nature. In the temple of Arensnuphis at Philae the god is called the 'companion' of Isis, but this title does not seem to be based in any mythological background. It is more important that he was equated with the Egyptian gods Onuris and Shu, sometimes being merged with the latter as the syncretic deity Shu-Arensnuphis. Arensnuphis was usually depicted in the form of a man wearing a feathered crown, sometimes holding a spear. His association with Shu and Onuris probably led to similarities of iconography shared by these gods. Arensnuphis could also be depicted in the form of a lion, though in this form he may not be distinguishable from other lion gods. The cult of Arensnuphis first attested in Nubia at Musawwarat el-Sufra east of the Nile's sixth cataract in the 3rd century BC. The god's worship spread into Egyptian Nubia during the Graeco-Roman Period, and a small kiosk was jointly built and decorated for him on the island of Philae by Ptolemy IV (c. 221-205 BC) and the Meroitic king Arqamani (c. 218-200 BC). Arensnuphis was also depicted in the temple of Dendur near the first cataract of the Nile where he is shown worshipped by the Roman emperor Augustus.

The Complete Gods and Goddesses of Ancient Egypt By Richard H. Wilkinson

[teachingrounds]

Q. What is a "normal" number of platelets?

A. The bone marrow produces ~10 to the power of 11 platelets every day (100,000,000,000!). Measured in the volume of blood, a "normal" number is 150-400 x10^6. More than that is thrombocytosis, and less than that is thrombocytopenia.

[teachingrounds]

Q. What is Thrombotic Thrombocytopenia (TTP)?

A. Recall that TTP presents with microangiopathic hemolytic anemia (MAHA) + thrombocytopenia + negative Coombs + normal coags (PT/INR). TTP can be nonspecific, so clinical suspicion must be high to diagnose it. Consider it if platelets and haptoglobin are very low, hemoglobin is low, and bilirubin and serum LDH are high.

Image: Thrombocytopenia, Libertas Academica, Flickr. You'll have to imagine the schistocytes.

[teachingrounds]

Q. What's on the differential for quantitative platelet disorders?

A. DDx: • Aplastic anemia • DIC = Disseminated intravascular coagulation • DTIP = Drug-induced Immune ThrombocytoPenia • HELLP syndrome = Hemolysis, Elevated Liver enzymes, Low Platelets • HIT = Heparin-Induced Thrombocytopenia • HUS = Hemolytic Uremic Syndrome • Infectious diseases: HIV, hepatitis C, varicella, rubella • ITP = Immune ThrombocytoPenia aka Idiopathic Thrombocytopenic Purpura • Liquid malignancies (leukemia and lymphoma) • Marrow infiltration from solid tumors in bone • Myelodysplastic syndromes • Nutritional deficiencies: copper, folate, B12 • Radiotherapy or chemotherapy treatments • TTP = Thrombotic Thrombocytopenic Purpura

Quantitative platelet disorders have two broad mechanisms: decreased production or increased destruction. Can you reorganize this list into two by mechanism?

Image: Platelet-Chan by Maxibillity, Deviant Art

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Q. Are platelets cells?

A. Not exactly. Platelets are fragments of megakaryocytes, multi-nucleated cells in the bone marrow that respond to thrombopoietin to release non-nucleated extensions of their cytoplasm into the blood. Each megakaryocyte can "birth" 1-3,000 platelets, which "live" for 7-10 days before being used up or undergoing apoptosis.

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Q. What is the PLASMIC score good for in a patient with (suspected) Thrombotic Thrombocytopenia (TTP)?

A. The PLASMIC Score predicts ADAMTS13 deficiency and therefore the likelihood of a diagnosis of TTP. Use in adult inpatients who might benefit from early initiation of plasma exchange while awaiting test results. Plasma exchange should be strongly considered for intermediate and high-risk patients (PLASMIC scores of 5 and 6-7, respectively) as the mortality for untreated TTP is >90%.

Pro-Tip: An ADAMTS13 level should be obtained before plasma exchange is started but should not delay starting treatment in high-risk patients!