XY Chromosome in a Female With Secondary Amenorrhea

XY Chromosome in a Female With Secondary Amenorrhea Dania Al-Jaroudi, M.D Capsule A 17-year-old girl presented to our gynecology clinic with secondary amenorrhea. She had been diagnosed with ALL at the age of 5 years, she received chemotherapy and radiotherapy over the following years. Her chromosomal analysis showed a karyotype of 46, XY. Introduction Primary ovarian insufficiency is a disorder that is emotionally traumatic and bears lifelong consequences on fertility, bone and cardiovascular health (1,2), making it more challenging is its occurrence in adolescents. Previously the term premature menopause had been used and found to be incorrect; as about 50 % of women have intermittent ovarian function and may ovulate and conceive after this diagnosis (1,2,3). The diagnosis is made when women younger than 40 years, have four or more months of amenorrhea and two serum FSH levels taken one month apart in the menopausal range (2). Causes of primary ovarian insufficiency in adolescents include chromosomal abnormalities, premutation in the FMR1 gene for fragile X, or iatrogenic from chemotherapy or radiation therapy (1). Infiltrative, infectious processes and pelvic surgery are less common causes (1). Autoimmune disease is another cause, as around 4% of women will have adrenal or ovarian antibodies. Still the etiology remains unknown in many cases (3). Although advances in oncology treatments have improved survival of childhood cancer, this came at the expense of ovarian function, increasing the risk of ovarian insufficiency and infertility (4). Morse et. al showed in a prospective observational study of ovarian function during cancer treatment of females aged 0 to 18 years that ovarian insufficiency occurred in chemotherapy treated prepubertal and pubertal patients regardless of menarche, age, diagnosis or chemotherapy given (5). Furthermore, females receiving radiotherapy below the diaphragm and/or stem cell transplant (SCT) had no recovery in their ovarian function followed for one and a half years from the end of their treatment (5). Clinicians need to be sensitive in delivering the diagnosis of primary ovarian insufficiency to their patients (6). This diagnosis can be emotionally traumatic and emotional needs of the patient need to be addressed as should further support be available (6). Adequate information regarding the diagnosis should be given as according to Groff AA et al (6); most patients feel that inadequate information decreased their sense of control (6). Case Report Our patient is a17-year old single girl who presented to our clinic with secondary amenorrhea. She had been diagnosed with acute lymphocytic leukemia (ALL) in 2002 at 5 years of age. Therapy began with hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). She relapsed in 2007 and 2012 and was treated with methotrexate (MTX), dexamethasone (DEXA), vincristine, and L-asparagine. She then had total body radiation in 2012. In July 2012, patient was referred to King AbdulAziz medical city at 15 years of age with pancytopenia, she was again given hyperfractionated chemotherapy with two courses; course A: cyclophosphamide, vincristine, doxorubicin, and dexamethasone and Course B: methotrexate and cytarabine (HCVAD). After remission she was given busulfan/cyclophosphamide then she had stem cell transplant (SCT) from her full HLA matched sibling. Patient had menarche at 11 years, after which she had regular menstruations for 4 years before she developed secondary amenorrhea. Progesterone challenge test was done with no response. Hormonal profile showed hypergonadotropic hypogonadism, normal thyroid function test and prolactin levels. Pelvic ultrasound showed normal, but small sized uterus and ovaries. Chromosomal analysis showed 46, XY, this confused her primary physician was unsure about the best plan of management. On further review of her previous investigations, her chromosomal analysis one-year back had been a normal female genotype. So with the stem cell transplant (SCT) from her HLA matched sibling her genotype and her whole cell line had changed. With the impression of premature ovarian insufficiency as her primary diagnosis, patient was started on cyclical hormonal therapy; estradiol valerate 2 mg, norgestrel 500 mcg (progyluton ®, Bayer Health, Germany) for 6 months. On follow up after 2 months, she didn’t start progyluton because she thought she needs to start 5th day of cycle; proper counseling was done and patient was seen 2 months afterwards on hormonal therapy, calcium and vitamin D with withdrawal bleeds. Objective: To report a case of primary ovarian insufficiency in 17 year old, single girl, who had ALL and was treated with chemo and radiotherapy, followed by bone marrow transplant. Design: Case report. Setting: King Abdulaziz Medical City Patient(s): A patient diagnosed with primary ovarian insufficiency, after receiving chemo and radiotherapy for ALL. She later received bone marrow transplant from her HLA matched brother. Intervention(s): Hormone replacement therapy. Main Outcome Measure(s): After ruling out other causes, counseling and emotional support where given to the patient. She was then started on hormonal replacement therapy, calcium and vitamin D. Result(s): Patient started hormonal therapy and was followed in the clinic. Conclusion(s): This case describes a primary ovarian insufficiency in a girl post chemo and radiotherapy; it also describes a change in cell line following bone marrow transplant from her HLA matched brother. Key Words: Secondary amenorrhea, primary ovarian insufficiency, Hormonal replacement therapy, stem cell transplant. Acknowledgments: We would like to express our thanks to Dr. Hanan Dahlawi for providing care to the patient. Discussion: Conditioning with chemotherapy and radiotherapy prior to stem cell transplant (SCT) particularly with cyclophosphamide and total body irradiation will inevitably lead to primary ovarian insufficiency and infertility (7). The risk of primary ovarian insufficiency when patients receive busulfan and cyclophosphamide is about 100%, similar to what our patient has received (7). We report this case as this patient’s karyotype changed to a male karyotype following stem cell transplant (SCT) from her full HLA matched sibling. This led to a diagnostic confusion at first, and was later understood after her karyotype one year earlier was reviewed and genetist was consulted. There was no similar cases reported in the literature, although numerous cases where reported on primary ovarian insufficiency in adolescents, and successful pregnancy thereafter. Therefore, we recommend to educate physician on changes occurring after stem cell transplant. Unfortunately, this patient was not offered fertility preservation options prior to her treatment; this again is another area of awareness that needs to be raised in physicians. Nonetheless, this patient was offered counseling and hormonal therapy after she was referred to our out patient clinics. The aim of hormonal therapy in adolescents with primary ovarian insufficiency includes the relief of hypoestrogenic symptoms in addition to bone support, cardiovascular, and sexual health (8). Adolescents may need higher doses of estrogen than menopausal women to ensure adequate replacement and optimal bone health (8).

Fear and paranoia created in the crucible Essay

The Crucible is full of heat, suspense, extramarital sex, public lies and ruthless prosecution, All of which add up to produce a book in which the theme of fear and paranoia is unquestionably a part in these small-town people’s lives. During the crucible, Miller tries to project a lot of fear and paranoia into his work, enabling the reader to physically and emotionally feel their part in Salem’s history. Salem is taken from the Hebrew Shalom meaning peace however from Millers part in the crucible; a darker, chaotic view is created for the readers, and the reality of peace is more shadowed by Salem and its characters dark paranoia. The overall effect that paranoia can set on a town is extraordinary, from being a small, well-known, blissful town; one mistake from a paranoid person can set off the whole town and can therefore disrupt and disturb it. Take Salem for example, a bunch of girls found dancing in the wood are immediately accused of doing witchcraft and trafficking with the devil, the paranoia of this town is really expressed by the fact that within the next day everybody knew about the â€Å"incident† and everybody except relatives had been quick to judge and had labelled them all witches, expressing the paranoia and fear among this small town. Miller’s attempts to create fear and paranoia are demonstrated in the way that he gives the readers and the characters something to be afraid of, fear must have a cause. Miller’s attempts at this are shown in the first scene as Parris questions and harasses Abigail because of his own paranoid ways that they were trafficking with the devil or even conjuring witchcraft in the woods, and the fear of his position and authority as reverend being taken from him and being thrown out of Salem. This fear is revealed as Parris says, â€Å"Now then, in the midst of such disruption, my own household is discovered to be the very centre of some obscene practice. † The life of many in Salem is orderly and controlled through religion fear of Gods might, not going to church could result in being sent into hell or purgatory after death. For example on page seventy three, as john proctor is quickly judged and damned and also accused by Cheever by saying â€Å"He plough on Sunday, sir†, thereby condemning proctor and heavily persuading Danforth to jail John Proctor. Fear for many of the characters is set by Miller on several different levels and so for a great number of people in the village, the churches power causes fear to do with the churches authority on how they have the power along with the law over witches, in the means of hangings, burnings and executions etc. The ordinary of the folk in the town have simple minds and can easily be manipulated or taken advantage over by the more superior of the town members, they can therefore easily be afraid of witches and their powers. These people also believed that their religion, Christianity was the only religion for the people, and straying from this religion was heresy. If a person tried to be an individual or â€Å"loner†, they were looked down upon, for that would mean they were leaving the community of belief that was supposed to be held by all members of the society. Salem was a theocracy, a type of government formed by combining the institutions of both state and church. When certain people began to be individualists, fear set into the community. It was this fear that prompted the Salem witch trials, the story that the play begins to tell. Because Salem’s inhabitants lived such ordinary lives, most of which were ruled or pressured intently by God, their lives became disorderly and the highers lose control, causing unrest among people’s lives for the reason that people need routine. However, once the highers lose control they therefore become afraid of losing their power and open to people becoming individuals and not being afraid to speak out or even proceed in the manner of life that they choose. As the play progresses, the church begins to lose power over individualists and rebels and consequently see people changing their ways of life because of the more recent happenings. This is shown in the way of the girls dancing in the woods. This act could possibly be taken as an act of witchcraft or possibly individualism; the girls (Betty, Mercy, Ruth, Mary, Abigail and Tituba) could have possibly been expressing their newfound uniqueness by dancing in the woods. In contrast to this lack of fear, the girls found dancing in the woods could possibly be taken as a taken as a very bold and daring act and an indication towards a desire for freedom or change and a desire to break control. This is indignation towards the church and their lives and is shown on page seven as she says, â€Å"Uncle, we did dance; let you tell them I confessed it – and I’ll be whipped if I must be. But they’re speakin’ of witchcraft. Betty’s not witched. † This quotation from Abigail is a suggestion to the rest of the town by expressing her point of not being witch, yet just dancing and symbolising their rebellious nature and newly found individualism. The townsfolk become confused with an alteration in the Status quo and are afraid of the unknown, so finally fear and paranoia sets in. Miller wrote the play from the stand point that people must not only be careful about how they react to certain situations, but that they also cannot avoid involvement in other issues, for that would mean to deny one’s own personal responsibility in the human race. Why are themes important to Miller? Themes are extremely and increasingly important to Miller as without these, plays or books are simply pieces of writing with no morale, theme or even point, and therefore the reader gains nothing from these books and feels no great need to read them, making them unsellable and pointless. Even the title plays a big part in the understanding of the book, for example in the crucible, this meaning a container which metals are heated to extract the poor element from dross or impurities, shows that this stands for the morale or point of the book that John Proctor is tested in a life-threatening ordeal and his death at the end rather than the betrayal of his confidence shows us that he too has come through the fire to be purified. Themes are important to Miller, the reader and the characters and this is shown in each of Millers books produced before he wrote and directed the crucible. In 1950, he wrote an adaptation of an enemy of the people, and the theme being the individual who insists he is right while the vast majority is absolutely wrong, this book even tying in with the crucible slightly. As well as all the other plays and books by Arthur Miller, like St. joan and the crucible and a man for all seasons, all his books are based on one similar thing and this is the overall main theme – a real historical happening, and this is the same case for the majority of his plays, all having a similar theme. In all three books in this case, the audience comes to value and applaud the stand made by the individual against the apparent vindictiveness of the law. From all of Millers books and plays, the crucible is renound for being the best and is shown and read all over the world, because of its meaning and theme of being somewhat different in different places and moments, giving information about the country it is being acted in, and so not only gives something extra to the reader but gives something back to the author each time it is acted out. The crucible is forever distinct of its time and maintains relevance because of its theme. The theme of the crucible however being of course, the conflict between a mans raw deeds and his conception of himself; the question of whether conscience is in fact an organic part of the human being, and what happens when it is handed over not merely to the state or the mores of the time but o one’s friend or wife. Overall, themes are important to Arthur Miller as it is shown in all of his other plays and that without one, a play is pointless and has no morale and is therefore not necessary to be produced as it is giving nothing to the human life, and is therefore extremely important to not only Arthur Millers plays but to every other playwrights plays throughout the world.

International student essay Essay

The relations between the representatives of various cultures, either social or economical grow stronger with each passing year due to the globalization. In my opinion, the opportunity to get to know the other cultures and lifestyles through communication with its representatives is invaluable, as no books, movies or reports about the chosen country, can present such complete and accurate information, as people can. The circumstances were that China became the country were I got my first serious working experience, after graduating with a major in Chinese and English from the acclaimed Daewon Foreign Language High School. I spent two years working in this country, and that was when I became interested in China, in the opportunities that the diverse and multiple populations of these state presents to the businessman, in the peculiarities and technologies of its fast-growing economy. That was when I felt that Chinese economics was growing, and I realized it had the potential for becoming the world’s biggest and most powerful one. It was than that I felt I was interested in establishing business relationships and working in that country. Considering these facts, I feel I would like to study with a person who grew up in China, in a state, whose social system and economy are very different from that in my country of origin. My opinion is that for to work successfully in a foreign country, you should be well acquainted with its language, cultural patterns, and the way of life, as they influence business directly. Communication with the person who spent his/her childhood and youth in the country of my interest would help me to have an insight into the specifics of life in China. Unfortunately, in the present time I have little opportunities of practicing Chinese, and studying with a person of Chinese origin would also improve my language skills. I believe that people can and, moreover, should study from each other, share their experiences, as it is the most convenient way to get the most valuable practical knowledge. I hope that while studying in the University of Texas in Austin both my classmates and I will have a chance to benefit from communication with students with various cultural and academic backgrounds.

Free Essays on Midsummer Nights Dream

The role of women and the supernatural are obvious themes present in the Shakespeare play, A Midsummer Night’s Dream. These themes are used currently as well; however during the Elizabethan Era they had very different understandings. The role of women was used in a more negative context and the supernatural was more commonly believed than it is today. Compared to men, women were treated as a lower society of persons during the Elizabethan time. They were expected to cook, clean, care for the children, while look beautiful if in a upper class family and be hard working if in a lower class family. Women were not ranked how men were. They were characterized based on their sexual background or their marital status. The father was the head of the household; so whatever he said was the law of the house. The wives could not disagreed or question a decision her husband made unless she did it with humility and meekness. If the father sticks with what he has already said, his wife must accept this and forget about it. The wife is the rock of the family. She must make sure her family is always stabile, emotionally and morally. In the family daughters must be well mannered, good-looking, and pure. Also, she must marry a man that will benefit the social position of her entire family. The daughters cannot even think about marriage unless her parents, mostly her father has approved. Man is considered to be the top ruler in the family, as well as outside the family. The Elizabethans had many reasons why the man, particularly the husband was the top authority. One reason was that God appointed him to this position when man and woman were created. Women were expected to do and say what their husbands wished of them, whether it went against their beliefs and feelings or not. As long as she doesn’t go against God’s will, she can go against herself as often as needed to. Another theme is the supernatural, particularl... Free Essays on Midsummer Night's Dream Free Essays on Midsummer Night's Dream Shakespeare’s play, A Midsummer Night’s Dream, is a humorous and imaginative comedy. One main theme Shakespeare includes in his play is transformation. In order to understand the many transformations, one must have a close following and understanding of the play. One transformation, which happens to three people, is due to Oberon and Puck’s flower juice. The juice is a love potion, which is applied to a person’s eyelids when he or she is sleeping. When the person awakens, he or she will fall in love with the first person they see. The first love transformation occurs when Lysander awakens to Helena, his soon-to-be wife’s good friend (Act II, scene ii, lines 103-107). The second transformation occurs when Titania awakens to see Bottom, who has undergone a transformation of his own (Act III, scene i, lines 129-224). The third transformation occurs when Demetrius also awakens to see Helena, whom he had earlier claimed to be sickened by (Act III, scene ii, lines 137-144). Another type of transformation occurs between Hermia and Helena. At the beginning of the play, both Demetrius and Lysander were in love with Hermia, although she was only in love with Lysander (Act I, scene i, lines 22-45). Helena, was in love with Demetrius, but he did not like heart all (Act II, scene i, lines 188-194). By the middle of Act II, because of the love potion, Lysander had fallen in love with Helena. By Act III, Demetrius had also fallen in love with her, for the same reason. Neither Demetrius nor Lysander loved Hermia anymore, but both loved Helena. This is the opposite scenario of what the play opened with. A physical transformation occurs when the mischievous Puck oversees the craftsmen rehearsing their play. He decides to play a joke and transforms Bottom’s head into that of an ass’s (Act III, scene I, lines 102-105). When the other craftsmen see Bottom’s head, they are scared and run away, leaving puck v... Free Essays on Midsummer Night's Dream The role of women and the supernatural are obvious themes present in the Shakespeare play, A Midsummer Night’s Dream. These themes are used currently as well; however during the Elizabethan Era they had very different understandings. The role of women was used in a more negative context and the supernatural was more commonly believed than it is today. Compared to men, women were treated as a lower society of persons during the Elizabethan time. They were expected to cook, clean, care for the children, while look beautiful if in a upper class family and be hard working if in a lower class family. Women were not ranked how men were. They were characterized based on their sexual background or their marital status. The father was the head of the household; so whatever he said was the law of the house. The wives could not disagreed or question a decision her husband made unless she did it with humility and meekness. If the father sticks with what he has already said, his wife must accept this and forget about it. The wife is the rock of the family. She must make sure her family is always stabile, emotionally and morally. In the family daughters must be well mannered, good-looking, and pure. Also, she must marry a man that will benefit the social position of her entire family. The daughters cannot even think about marriage unless her parents, mostly her father has approved. Man is considered to be the top ruler in the family, as well as outside the family. The Elizabethans had many reasons why the man, particularly the husband was the top authority. One reason was that God appointed him to this position when man and woman were created. Women were expected to do and say what their husbands wished of them, whether it went against their beliefs and feelings or not. As long as she doesn’t go against God’s will, she can go against herself as often as needed to. Another theme is the supernatural, particularl... Free Essays on Midsummer Night's Dream Midsummer night's Dream A Midsummer Night’s Dream; Theme of Love In Shakespeare’s play A Midsummer Night’s Dream, one of the main reoccurring themes is love. Shakespeare writes of love that is passionate and impulsive, or sensible and reasonable. In Act three, Bottom, a crude commoner states on opinion of love. "And Yet, to say the truth, reason and love keep little company together now-a-days; the more pity, that some honest neighbors will not make them friends." (Act III, Scene i, line 136) However, in many ways, reason and love are already much more closely linked in their society than the modern day reader is used to. Shakespeare has one example of real love in this play: Hermia and Lysander^s. Their love is pure and simple. They have no reason to be in love with each other, but yet have hopelessly fallen so. This is Shakespeare^s symbol of ultimate innocence. However, often with innocence comes abuse of that quality, as in A Midsummer Night^s Dream. Egeus, Hermia^s father, feels th at Hermia is too innocent to choose her own husband, and that it is his place to choose one for her. Although perhaps he is only doing this to ^protect^ her, it shows his opinion of Hermia^s incompetence. He illustrates this value system when explains to Theseus "And, my gracious duke, This man hath bewitch^d the bosom of my child. Thou, thou, Lysander, thou hast given her rhymes, And interchanged love-tokens with my child^ With cunning hast thou filch^d my daughter^s heart, Turn^d her obedience, which is due to me, To stubborn harshness." (Act I, Scene I, line 27) In many ways the opposite of real love, Hermia and Demetrius^ relationship is symbolic for practicality and sensibility. Hermia does not love Demetrius and refuses to marry him. It is not even clear what Demetrius^ motives are. One can speculate, however, that he desires to marry Hermia for her money or respectable family. Whatever the reasons, it is apparent that this relationship is...

Strongest and Weakest Parts of a Magnet

Strongest and Weakest Parts of a Magnet Did you know that the magnetic field of a magnet is not uniform? The strength of the field varies depending on its location around the magnet. The magnetic field of a bar magnet is strongest at either pole of the magnet. It is equally strong at the north pole when compared with the south pole. The force is weaker in the middle of the magnet and halfway between the pole and the center. If you were to sprinkle iron filings on a piece of paper and place the magnet beneath it, you could see the path of the magnetic field lines. The field lines are closely packed at either pole of the magnet, widening as they get farther from the pole and connecting to the opposite pole of the magnet. The magnetic field lines emerge from the north pole and enter the south pole. The magnetic field gets weaker the farther you get from either pole, so a bar magnet is only useful for picking up small items over short distances. Where Is the Magnetic Field Strongest? Iron filings make a pattern tracing field lines because each bit of iron is itself a tiny dipole (the separation between magnetic fields). The force the dipole experiences is proportional to the strength of the dipole and proportional to the rate at which the magnetic field changes. The dipole tries to align itself with a magnetic field, but at the ends of a bar magnet, the field lines are very close together. What this indicates is that the magnetic field varies strongly over a short distance compared to the variation closer to the middle of the magnet. Because the magnetic field changes so dramatically, a dipole feels more force.

Industrial Structure of Banking Essay Example | Topics and Well Written Essays - 1750 words

Industrial Structure of Banking - Essay Example Fourth, the relationships between the banks and the financial markets have also proven important determinants of the financial stability of the economy. Financial markets refer to the entity where stocks and other securities are traded(Anon., 2010). Banks are custodians of the investors’ funds. The financial markets generate prices whenever securities are bought and/or sold. When these banks want to make loans to the investors, they value these financial assets whereby the valuation and pricing of these financial assets are the main determinants of the financial stability of the economy. When prices are high, the banks are willing to lend more in the economy and this leads to the financial crisis in the economy since there is more money chasing few assets in the economy. On the other hand, when the prices are determined to be low in the financial markets, there will be a little amount borrowed hence high financial stability in the economy. Therefore, this links the relationshi p between the banks and the behavior of securities in the financial markets and how the relationship affects the financial stability. The other market structure is a cross-border listing, which refers to the process where banks stocks are listed in the securities market of other countries where it was not incorporated. These banks which are listed in other countries enhance the capital inflow to the economy. Too much inflow of these funds into the economy can lead to financial instability if not well monitored.

Invasion of Privacy in the Business World Research Paper

Invasion of Privacy in the Business World - Research Paper Example In business, there are two approaches to privacy; consumer protection and free market. In free market, commercial organizations are allowed to make the major business decisions based on idea that the consumers will do business within the desired degree of privacy (Francis, 1991). If some organizations do not sufficiently maintain privacy of their operations, then they lose competitive advantage and ultimately lose the market share. This occurs when an organization fails to offer favorable privacy option to its clients or by failing to provide sufficient information of the privacy practices that it carries out. Usually consumers are unable to claim the violation of privacy made by organizations. The consumer protection approach advocates more defined protection policies and heir enforcement by the government (Rosen, 2010). The reason is based on the idea that individuals do not have time or the knowledge to make decisive choices or they are not aware of alternatives available.In the U nited States privacy is not explicitly guaranteed by the Constitution. It has been implicitly mentioned in the 4th, 5th and 14th amendments of fundamental freedom right that ensures protection of citizen from government intrusion and interference. In addition, Common Law appears to recognize some degree of protection of privacy of information.In 1970, the Fair Credit Reporting Act was passed to law, to ensure that customers were protected from information gathered from them by the private sector.