Irene A. Weiss, MD
Fat in H & E stained section prepared by paraffin embedding technique appear non-staining vauloes because it is dissolved in alcohol ( erectile dysfunction at the age of 18 buy 80 mg top avana amex. Stromal Fatty Infiltration this form of lipid accumulation is quite different from fatty change just described impotence ring buy 80mg top avana visa. Stromal fatty infiltration is the deposition of mature adipose cells in the stromal connective tissue in contrast to intracellular deposition of fat in the parenchymal cells in fatty change erectile dysfunction frustration generic top avana 80 mg otc. Thus erectile dysfunction pill brands top avana 80 mg cheap, heart can be the site for intramyocardial fatty change as well as epicardial (stromal) fatty infiltration. The presence of mature adipose cells in the stroma generally does not produce any dysfunction. In the case of heart, stromal fatty infiltration is associated with increased adipose tissue in the epicardium. Sectioned slice of the liver shows pale yellow Pathologic accumulation of proteins in the cytoplasm of cells parenchyma with rounded borders. In proteinuria, there is excessive renal tubular reabsorp iv) Infrequently, lipogranulomas may appear consisting of tion of proteins by the proximal tubular epithelial cells which collections of lymphocytes, macrophages, and some multi show pink hyaline droplets in their cytoplasm. In antitrypsin deficiency, the cytoplasm of hepatocytes 1 shows eosinophilic globular deposits of a mutant protein. Many of the hepatocytes are distended with large fat vacuoles pushing the nuclei to the periphery (macrovesicles), while others show multiple small vacuoles in the cytoplasm (microvesicles). If the enzyme is present, Conditions associated with excessive accumulation of dark pigment is identified in pigment cells. In diabetes mellitus, there is intracellular accumulation of amelanotic melanoma from other anaplastic tumours. Glycogen deposits in diabetes mellitus generalised and localised hyperpigmentation and are seen in epithelium of distal portion of proximal convolu hypopigmentation: ted tubule and descending loop of Henle, in the hepatocytes, in beta cells of pancreatic islets, and in cardiac muscle cells. In glycogen storage diseases or glycogenosis, there is defec pigmentation on the skin of face, nipples, and genitalia and tive metabolism of glycogen due to genetic disorders. A similar appear conditions along with other similar genetic disorders are ance may be observed in women taking oral contraceptives. There are 2 broad categories of b) Peutz-Jeghers syndrome is characterised by focal peri-oral pigments: endogenous and exogenous (Table 3. Melanin f) Dermatopathic lymphadenitis is an example of deposition of melanin pigment in macrophages of the lymph nodes Melanin is the brown-black, non-haemoglobin-derived draining skin lesions. It is synthesised in the iii) Generalised hypopigmentation:Albinism is an extreme melanocytes and dendritic cells, both of which are present degree of generalised hypopigmentation in which tyrosinase in the basal cells of the epidermis and is stored in the form of activity of the melanocytes is genetically defective and no cytoplasmic granules in the phagocytic cells called the melanin is formed. Albinos have blond hair, poor vision and melanophores, present in the underlying dermis. However, sometimes tyrosinase is squamous and basal cell cancers of the skin in such present but is not active and hence no melanin pigment is individuals. In such cases, the presence of tyrosinase can be iv) Localised hypopigmentation: a) Leucoderma is a form of partial albinism and is an inherited disorder. Haemoprotein-derived pigments i) Haemosiderin Melanin-like Pigments ii) Acid haematin (Haemozoin) c. Lipofuscin (Wear and tear pigment) required for break-down of homogentisic acid which then B. Injected pigments (Tattooing) alkaptonuria, if allowed to stand for some hours in air, turns black due to oxidation of homogentisic acid. Hepatocytes in patients haemoglobin is liberated which is taken up by macrophages of Dubin-Johnson syndrome, an autosomal recessive form where it is degraded and stored as haemosiderin. A few of hereditary conjugated hyperbilirubinaemia, contain examples are as under: melain-like pigment in the cytoplasm (Chapter 21). The changing colours of a bruise or a black eye are caused by the pigments like biliverdin and bilirubin which are Haemoprotein-derived Pigments formed during transformation of haemoglobin into haemosiderin. Haemoproteins are the most important endogenous Brown induration in the lungs as a result of small haemor pigments derived from haemoglobin, cytochromes and their rhages as occur in mitral stenosis and left ventricular failure. In disordered iron metabolism and transport, Systemic overload with iron may result in generalised haemoprotein-derived pigments accumulate in the body. There can be two types of patterns: these pigments are haemosiderin, acid haematin (haemozoin), bilirubin, and porphyrins. Iron is stored in the tissues in 2 forms: Ferritin, which is iron complexed to apoferritin and can be identified by electron microscopy. Haemosiderin, which is formed by aggregates of ferritin and is identifiable by light microscopy as golden-yellow to brown, granular pigment, especially within the mononuclear phagocytes of the bone marrow, spleen and liver where break-down of senescent red cells takes place. In this reaction, colourless potassium ferrocyanide reacts with ferric ions of haemosiderin to form deep blue ferric-ferrocyanide (. Excessive storage of haemosiderin occurs in situations when there is increased break-down of red cells, or systemic overload of iron due to primary (idiopathic, hereditary) haemochromatosis, and secondary (acquired) causes such as in thalassaemia, sideroblastic anaemia, alcoholic cirrhosis, Figure 3. Another variety of haematin pigment is formalin pigment formed in blood-rich tissues which have been preserved in acidic formalin solution. Excess of bilirubin or hyper bilirubinaemia causes an important clinical condition called jaundice. Normal bilirubin metabolism and pathogenesis of jaundice are described in Chapter 21. Hyperbilirubinaemia may be unconjugated or conjugated, and jaundice may appear in one of the following 3 ways: a) Prehepatic or haemolytic, when there is excessive destruc tion of red cells. Excessive accumulation of bilirubin pigment can be seen Parenchymatous deposition of haemosiderin occurs in the in different tissues and fluids of the body, especially in the parenchymal cells of the liver, pancreas, kidney, and heart. Skin and sclerae Reticuloendothelial deposition occurs in the liver, spleen, become distinctly yellow. Porphyrins are normal pigment present i) Increased erythropoietic activity: In various forms of in haemoglobin, myoglobin and cytochrome. Porphyria chronic haemolytic anaemia, there is excessive break-down refers to an uncommon disorder of inborn abnormality of offi haemoglobin and hence iron overload. It results from genetic deficiency of further compounded by treating the condition with blood one of the enzymes required for the synthesis of haem, transfusions (transfusional haemosiderosis) or by parenteral resulting in excessive production of porphyrins. The deposits of iron in these cases, termed as genetic deficiency is precipitated by intake of some drugs. These have defective dominant disease associated with much more deposits of iron synthesis of haem in the red cell precursors in the bone than cases of acquired haemosiderosis. These may be further of 2 subtypes: by triad of pigmentary liver cirrhosis, pancreatic damage Congenital erythropoietic porphyria, in which the urine is resulting in diabetes mellitus, and skin pigmentation. On the basis of the last two features, the disease has come to be red due to the presence of uroporphyrin and coproporphyrin. Bones and iii) Excessive dietary intake of iron: A common example of skin show red brown discolouration. The excess of iron gets deposited in various organs a normal erythroid precursors but have a defect in synthesis including the liver causing pigment cirrhosis. Acid haematin or following: haemozoin is a haemoprotein-derived brown-black pigment Acute intermittent porphyria is characterised by acute containing haem iron in ferric form in acidic medium. But it episodes of 3 patterns: abdominal, neurological, and psycho differs from haemosiderin because it cannot be stained by tic. Haematin pigment is seen most commonly in chronic Porphyria cutanea tarda is the most common of all malaria and in mismatched blood transfusions. Porphyrins collect in the liver and small quantity malarial pigment can also be deposited in macrophages and is excreted in the urine. Most of the patients have associated Inhaled Pigments 43 haemosiderosis with cirrhosis which may eventually develop the lungs of most individuals, especially of those living in into hepatocellular carcinoma. Diseases
Tonometers Abnormal lens findings associated with glau As the Goldmann applanation tonometer is coma include abnormal size or shape of the lens the most clinically accurate device erectile dysfunction at age 26 purchase top avana 80 mg mastercard, this tonome (lens swelling erectile dysfunction gene therapy purchase top avana 80mg fast delivery, spherophakia erectile dysfunction doctors in navi mumbai generic top avana 80mg with amex, etc impotence jelqing purchase top avana without a prescription. Abnormalities of the ciliary zonule (con applanation tonometer, unlike applanation genital anomalies, trauma, exfoliative glaucoma, tonometers such as the Schiotz tonometer, has etc. The Tono-Pen lens thickness due to the progression of cataracts and the Perkins applanation tonometer are porta may result in angle closure. Observation ment procedures and should ordinarily be used of the anterior surface of the lens is also impor only for screening purposes. It is known that the tant, and following laser iridotomy and peripher physical properties of the cornea have an effect al iridectomy, posterior synechiae may occur. Gonioscopy the scleral spur is observed as a white line between the ciliary band and the trabecular 1. Iridial protrusions are frequently seen Gonioscopy is indispensable in the treatment on the surface thereof. In gonioscopy, it is tal glaucoma, the iris shows synechiae anterior to important to properly recognize the various struc the scleral spur, and the scleral spur cannot be tures composing the anterior chamber angle, observed. Pathological surface of the ciliary body, and it is observed as a gonioscopic findings include ocular ischemic grayish-black band. Gonioscopic observation methods and neovascularization may also occur in the Gonioscopy may be conducted either directly anterior chamber angle. From a physiological or indirectly, and gonioscopes can be classified standpoint, neovascularization may be observed as either direct and indirect. An example of a in the anterior chamber angle, with these blood direct gonioscope is the Koeppe lens, and exam vessels following a concentrical or radiating reg ples of indirect gonioscopes include the ular course. Pathological neovascularization Goldmann gonioscope and the Zeiss 4-mirror involves an irregular curved course, with multi gonioscope. Compression gonioscopes In the case of active uveitis, nodules may also be Compression gonioscopes are useful for distin observed in the form of inflammatory exudates in guishing between a simple narrow anterior the anterior chamber angle, and this may also be chamber angle or functional closure and organic accompanied by peripheral anterior synechiae. Compression gonioscopy is useful lar meshwork, the scleral spur side is equivalent in accurately determining the pathology of angle to the functional trabecular meshwork and is closure glaucoma. Test equipment used in auxiliary diagnosis pigment dispersion syndrome, a pronounced Ultrasound biomicroscopy is a diagnostic 21 procedure that allows sectional observation of elliptical shape, and with respect to the fixation the microstructure of the anterior ocular tissue, point, it measures 60 degrees superiorly and including the anterior chamber angle, and this medially, 70-75 degrees inferiorly, and 100-110 technique has been reported to be useful in the degrees temporally. In diagnosing glaucoma, the detection of morphological changes in the optic disc or ret 2. The Goldmann perimeter is in standard inter Although pathologic findings of the optic disc national use. Its background luminance is set at or retinal nerve fiber layer are related to the 31. In (1/16 mm2), (1/4 mm), 2 (1 mm), 2 (4 mm), 2 normal-tension glaucoma in particular, the dis (16 mm2), and (64 mm2), and target brightness ease is frequently discovered when optic nerve ranges from 1a (12. Static visual field ophthalmoscopic observation of the optic Generally speaking, static visual field mea nerve, the recommended technique is stereo surement is more sensitive in detecting visual scopic examination, with three-dimensional field anomalies in the early stages of glaucoma observation of optic disc cupping, and the than dynamic visual field measurement. The method of using a slit-lamp microscope and an most commonly-used perimeters for this purpose auxiliary lens (non-contact lens or Goldmann are the Humphrey and Octopus perimeters. In these stat the above four methods of observing the ic visual fields, precise measurements are mainly fundus oculi are used as appropriate in order carried out within 30 degrees from the center. For further details on this subject, please refer Measurement results are affected by factors such to Appendix 2, "Guideline for Detecting as blepharoptosis, refractive error, opacity of the Glaucomatous Abnormalities in Optic Disc and intermediate transparent tissue, pupil diameter, Retinal Nerve Giber Layer. Fixation status, frequency of occur rence of false-negatives and false-positives, and. Perim etry short-term fluctuations are useful indicators in evaluating the reliability of measurement results. Test results are expressed using threshold values, Gray scale (shades of grey of actual threshold values), total deviation (deviation from normal values according to age), and pattern deviation (devia tion from the predicted normal visual field of the test subject). Assessment criteria and severity classification for glaucomatous visual field abnormalities See Appendix 1 [4, 5] 23 24 Section 4 Principles of Treatm ent for Glaucom a. Principles of glaucom a therapy but the principle of drug treatment of the disease lies in obtaining the maximum effect with the 1. However, in providing treatment, compliance must also be taken into consider one must not only bear in mind possible adverse ation. As the therapeutic options in glaucoma include drug treatment, laser treatment, and sur 2. The most reliable method of treatment is gical treatment, the appropriate therapeutic reduction of intraocular pressure modality must be selected based on the individu At present, based on the evidence, the only al patient and the disease stage and type. Baseline data determination glaucoma, and discontinuation of steroid admin Patient status prior to treatment is important istration in steroid glaucoma. Early detection is vital level at which damage will continue to prog At present, once visual function has been lost ress. In assessing therapeutic effect as well, it in glaucoma, there is no way to regain it. Accordingly, early detec not only in determining the therapeutic tion and treatment of glaucoma are of primary approach, but in detecting the progression of importance. Moreover, based on the results of various ran domized comparative studies2-7), it is recommend 2. The patient should be 26 questioned about his or her awareness of the 5) Carbonic anhydrase inhibitors current situation and course and what difficulties (1) Systemic he or she is experiencing in everyday life. Non-compliance is an important factor parasympathomimetics have been used as the in the progression of glaucomatous visual field drugs of choice. Therefore, compliance issues must be taken into account when the type of treatment is 3. When monotherapy with glaucoma treatment agents does not produce a sufficient effect, these 6. In order to increase efficacy by improving Although combinations of adrenergic blockers intraocular penetration, while minimizing and sympathomimetics or combinations of pros adverse effects by reducing systemic absorption taglandin analogues, which increase the uveo of eye drops, and also in order to improve com scleral outflow, and pilocarpine, which decreases pliance, it is important to guide patients in the uveoscleral outflow, appear to be unsuitable proper administration method as follows. To relieve pupillary block, equalize pressure (3) If the cornea is edematous, drugs such as differential between the anterior and posterior carbonic anhydrase inhibitors or hyperos chambers, and open the anterior chamber angle. It may also be performed 4) Contact lens in patients with suspected plateau iris syndrome Contact lenses such as the Abraham or Wise 29 contact lens for iridotomy are used. Among these, bullous keratopa A contact lens for iridotomy is used, and irra thy is serious, and this complication has been diation is conducted on the periphery of the iris reported to occur frequently in Japan. The occur on the superior temporal and superior nasal sides rence of bullous keratopathy is thought to be under the eyelid (in order to prevent monocular related with factors such as the condition of the diplopia). However, a transparent site on the corneal endothelium and the total laser irradia cornea is selected, taking care to avoid areas of tion energy. As the plasma generation energy differs Corneal opacity depending on the unit used, the energy must Bullous keratopathy be selected according to the model used. The beam is focused not on the surface of Focal cataracts the iris, but on the stroma of the iris. In order to prevent iridial hemorrhage, Posterior synechia the planned penetration site is pre-irradiated Late closure of the iridotomy using an argon laser, etc. Unintended retinal irradiation (2) Thermal laser iridotomy using an argon laser, etc. Spot size: 200-500 m (2) Carbonic anhydrase inhibitors or hyperos Power: 200 mW motics are administered as needed. Stage (perforation irradiation) limiting, but depending on the extent of the Spot size: 50 m inflammation, it may be necessary to Power: 1000 mW administer topical steroids. Laser trabeculoplasty site like gun-smoke when perforation is 1) Purpose achieved, further irradiation is carried out in the trabecular meshwork is irradiated with a order to expand the hole so that it will be suf laser in order to improve aqueous outflow. However, this procedure is ineffective in sites Approximately 25 applications are placed per where peripheral anterior synechia has already quadrant at uniform intervals along 90 to 180 of developed. Power: 400-800 mW (allows transient blanch (2) the procedure is carried out under topical ing without small bubbles formation) anesthesia.
The entry of air into the connective tissue framework of cases develop it before the age of 10 years erectile dysfunction treatment manila best buy top avana. The sexes are affected equally but in children there is 2:1 male usual sources of entry of air into stroma of the lung are female ratio injections for erectile dysfunction that truly work generic top avana 80 mg free shipping. Most of these septa of the lung impotence lifestyle changes generic 80 mg top avana free shipping, into the mediastinum erectile dysfunction most effective treatment buy top avana 80 mg low price, the pleura, and even allergens cause ill-effects by inhalation. Collection of small quantities of stimulated by fumes, gases and organic and chemical dusts air is generally harmless and is resorbed. There are increased levels of accumulation of air in surgical emphysema may produce IgE in the serum and positive skin test with the specific impaired blood flow in the lungs. Pneumo-mediastinum may offending inhaled antigen representing an IgE-mediated type produce symptoms resembling myocardial infarction. These result in further release of mediators oedema and inflammatory infiltrate consisting of which accentuate the above-mentioned effects. In addition, lymphocytes and plasma cells with prominence of eosino inflammatory injury is caused by neutrophils and by major phils. Changes of bronchitis and emphysema may super of asthma develops later in adult life with negative personal vene, especially in intrinsic asthma. Asthmatic patients suffer from symptom-complex after an upper respiratory tract infection episodes of acute exacerbations interspersed with symptom by viruses. Most attacks typically but about 10% of patients become hypersensitive to drugs, last for a few minutes to hours. When attacks occur most notably to small doses of aspirin (aspirin-sensitive continuously it may result in more serious condition called asthma). The clinical diagnosis is supported by demonstration of circulation eosinophilia and sputum 3. The pathologic changes in diameter) developing secondary to inflammatory are similar in both major types of asthma. The most characteristic material examined is generally autopsy of lungs in clinical manifestation of bronchiectasis is persistent cough patients dying of status asthmaticus but the changes are with expectoration of copious amounts of foul-smelling, expected to be similar in non-fatal cases. Post-infectious cases commonly develop Grossly, the lungs are overdistended due to over-inflation. The origin of inflammatory destruc bronchi and bronchioles by viscid mucus plugs. The bronchial wall shows thickened basement growth, or infection may be a primary event i. Several hereditary and congenital factors may result secondarily in diffuse bronchiectasis: i) Congenital bronchiectasis caused by developmental defect of the bronchial system. The disease charac teristically affects distal bronchi and bronchioles beyond the segmental bronchi. More vertical air passages of left lower lobe are more often involved than the right. The dilated airways, depending upon their gross or bronchographic appearance, have been subclassified into the following different types (. Cut surface of the affected lobes, generally the lower zones, shows characteristic honey-combed appearance. The bronchi are extensively dilated nearly to the pleura, their walls are thickened and the lumina are filled with mucus or Figure 17. The chronic inflammatory cells and destruction of normal causes of endobronchial obstruction include foreign bodies, muscle and elastic tissue with replacement by fibrosis. Necrotising pneumonias such bands of fibrous tissue between the bronchus and the as in staphylococcal suppurative pneumonia and tuberculosis pleura. Sectioned surface shows honey-combed appearance of the lung in the lower lobe where many thick walled dilated cavities with cartilaginous wall are seen (arrow). The bronchial wall is thickened and infiltrated by acute and chronic inflammatory cells. The mucosa is sloughed off at places with exudate of muco-pus in the lumen (arrow). Sinusitis is a common accompaniment of diffuse expansion of lungs due to alterations in chest wall, pleura bronchiectasis. Late complications occurring in cases and neuromuscular apparatus, but are primarily not lung uncontrolled for years include development of clubbing of parenchymal diseases. Airways Obstructed at any level from Reduced expansion of lung parenchyma trachea to respiratory bronchiole 2. Pulmonary Increased pulmonary resistance and Decreased total lung capacity function test obstruction of maximal expiratory airflow 3. X-ray chest Variable appearance depending Typically bilateral infiltrates giving ground-glass upon the cause shadows 4. The major common clinical manifestations of restrictive 487 lung diseases are exertional dyspnoea, non-persistent I. Connective tissue diseases by inhalation of dust, mostly at work (pneumo = lung; conis = 8. Sarcoidosis (Chapter 6) the type of lung disease varies according to the nature 2. Pulmonary Langerhans cell histiocytosis (eosinophilic 5 m reach the terminal airways where they are ingested by granuloma of the lung) and morbidity. Beryllium Acute berylliosis implicated in this transformation as follows: Chronic berylliosis 1. Cotton, flax, hemp dust Byssinosis significant role in the pathogenesis of progressive massive 4. Mouldy maple bark Maple-bark disease tissues by these inflammatory cells which on activation cause 8. Most of these too are eliminated by due to proliferation of fibroblasts at the damaged tissue site. Grossly, the lung parenchyma shows small, black focal Hypersensitivity reaction. Similar blackish pigmentations are found particles, especially in coal-miners engaged in handling soft on the pleural surface and in the regional lymph nodes bituminous coal for a number of years, often 20 to 30 years.
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