At ground level women's health clinic jersey city order 20mg female cialis free shipping, the control firefighter inverts the hook and places the handle of the controlling nozzle onto the hook menstruation 15 days apart discount female cialis 10 mg without prescription. The member on the lowest balcony (door Firefighter) remains at this position to lighten up on the hose until sufficient hose is hoisted women's health usf order female cialis with a mastercard. Nozzle and back-up firefighters continually pass the hook up and move up until the nozzle reaches the balcony of the floor below the fire breast cancer 90 10 mg female cialis for sale. In both cases the control firefighter will remain at ground level and assist in hoisting and securing the line menopause signs order cheap female cialis line. Once sufficient line has been hoisted and the line has been charged women's health magazine old issues purchase 10 mg female cialis, the control firefighter can ascend the fire escape and join the nozzle team (see Fig menstruation fatigue cheap female cialis 20 mg mastercard. At this point the nozzleman pulls up sufficient hose to make entry on the fire floor above breast cancer virus generic 20mg female cialis otc. Once this hose is in place the nozzleman can position himself roughly half way up the steps to the fire floor landing to await water. When sufficient hose is pulled onto this balcony the back-up man will secure the line with a hose strap and then join the nozzleman. Once the backup man is done hoisting hose the doorman (if necessary) will secure the hose to the fire escape railing and then proceed up to flake out hose from the fire escape into a window on the floor below the fire. Knowledge of the building, the location of the fire, and availability of stair shaft windows will assist in making this determination. The nozzle firefighter attaches the rope to the nozzle, places the nozzle outside the window, then proceeds to the floor below the fire. The control firefighter must remain at the window until enough line is hoisted to ensure that the line does not get hung up. Once the line is charged, the control firefighter will check for kinks and join the nozzle team. Some windows will be secured closed and others may have stops which limit the raising of the sash only a few inches. The necessary amount of hose to reach the fire is removed and the pumper can be used to fill out the stretch. As the pumper proceeds to a hydrant the additional necessary hose peels off the rear of the hosebed. Steps: Pumper stops in vicinity of fire building so as not to impede the positioning of a truck company. Firefighter lays hose on ground about 15 feet from apparatus and slightly to side in direction of stretch. A third member lays the next three folds slightly to side away from direction of stretch. As they advance, hose is played out in a continuous line beginning with last firefighter. Another option would be to hand stretch the supply line from the operating point back to the hydrant. When intake pressure drops below 15 psi, the pump operator shall have his intake supply augmented. In order to prevent injuries or damage to hose or equipment, the supply line shall not be preconnected to an inlet of the pumper. Pumpers should not be positioned where they will prevent effective utilization of aerial and tower ladders. The method selected requires judgment based on fire conditions, location and location of apparatus. The following signals shall be sent from back step buzzer: One buzzer tone -Emergency stop. Three buzzer tones -Area to rear of pumper is clear for backing up operations and under proper supervision. The capacity of a hydrant is based on many variables (size of main, location within the system etc. Relay operations can complicate pumping operations because they require coordination between two or more pumpers (potentially accruing higher pressures) and two or more pump operators (necessitating more communication). In addition there is an increased possibility of introducing air into an operating pumper and losing prime. However, if a water relay is warranted, the following procedure shall be implemented. An exception to this is standpipe operations, where head pressure needs to be overcome. In this case, the operating pumper will operate with its pump in the Pressure configuration. Idle pressure is hydrant pressure plus pressure imparted by the pump at idle (typically 100-125 psi). The capacity of a hydrant is based on many variables size of main, location within the system etc. It is important for units to know the capabilities and limitations of hydrants in their response area. The requirement of standpipe systems is based on any of the following factors: building height, floor area, and/or fire department vehicle access. Stretch 3" hose line from pumper and connect to Siamese to supply standpipe siamese. The Nozzle, Back-up and Door Firefighters (if a five (5) fighter company) will proceed as follows: Place folded lengths on floor landing below standpipe outlet, or in hallway adjacent to stairway door containing standpipe, with straps facing up and male and female hose butts adjacent to each other. Length with nozzle is placed most distant from standpipe with nozzle facing in direction of stretch. If available and needed, place additional length(s) in the sequence before nozzle. The Nozzle firefighter may opt to take his length up to the fire floor before removing the strap. Hose plays out in the same manner as if it was stretched from the bed of the apparatus. Door firefighter (if present) monitors hose as it plays out to prevent kinks and snags. All hoselines stretched from standpipe shall be 2" hose with controlling nozzle and 1" Main Stream Tip. Always connect in-line pressure gauge to standpipe outlet to ensure correct nozzle pressure. Observe the color of siamese or outlet caps and indicating signs or plates before connecting hose lines. Color markings for the systems are: StandpipeRed Automatic Sprinkler. Yellow To supply the standpipe if the Siamese is inoperable (but the system is otherwise serviceable) or if the Siamese is supplied but further augmentation is required, this can be done by connecting and supplying water to the first floor outlet. Before water is started, member controlling supply must personally check connection of hose to proper siamese. If building is equipped with both standpipe and sprinkler systems and standpipe is to be used, the engine company first to arrive must connect first line to standpipe siamese and second line to sprinkler siamese. Another pumper must augment the supply to combination standpipe and sprinkler systems. During high-pressure pumping, members must not utilize stairways as staging or rest areas. Utilize minimum amount of personnel in stairways served by standpipes, during high-pressure operations. Photo 2 demonstrates how to carry folded lengths so as to protect the firefighter and others from the exposed hose butts. Note that the folded length is placed with the butts toward the body, minimizing the chance of the butts flopping around (especially in tight quarters like elevators). For narrow landings, folded lengths can be stacked on stairs, adjacent to each other. Placing hose under left arm and nozzle over right shoulder, nozzleman climbs the aerial. Nozzleman snaps life belt on top rung of aerial and passes nozzle and hose in over sill to officer who holds the line. Backup continues up, positions at top of the aerial, and snaps life belt on top rung. Cellar Fires First Line the first line should be stretched to the cellar entrance door which is located inside the building, under the interior stairway on the first floor. This line should remain at this position to provide protection for people coming down the stairway, and to extinguish fire which may be extending upwards from the cellar via partitions, dumbwaiter shafts and other voids. This line should not be advanced down the cellar stairs if there is an outside entrance to the cellar at the front or rear of the building, unless of course, the fire is minor. Second Line the second hose line stretched should be advanced into the cellar by way of the front or rear entrance to the cellar. When assured that the second line is not needed on the first floor it may be advanced to the floor above the fire. Stairway Fires First Line the first hose line should be stretched up the stairway, operated to extinguish fire, shut down and advanced further up the stairway. When possible, the line should be operated up the well hole to cool off the hall and stairs above. Second Line A second line should follow to finish up extinguishing operations and to serve as protection for members advancing the first line. Air and Light and Dumbwaiter Shaft Fires First Line -The first hose line should be stretched to the nearest point from which water can be directed onto fire in the shaft. Second Line A second hose line may be necessary if it appears that fire might have extended into the adjoining building. For fires in rooms in the vicinity of a shaft, after the fire in the room has been controlled, the line should be operated up the shaft to extinguish fire and cool the shaft. Emphasis will be on the larger buildings, historically referred to as "H type" since they are our greatest problem. Although there are variations in the shapes of these buildings, such as "U", "O", "V", Double "E" and the newer, larger rectangular buildings, the problems and solutions are similar. A "worker" in an apartment of an "H type" building is of much greater potential than a similar fire in an apartment of a smaller building. An apartment in an "H type" building is usually larger, irregularly shaped and has long private halls. It is of vital importance that, before a line is committed in an "H" type building, the exact location of the fire be determined. There may be large courtyards, often with obstacles such as trees, benches, fences, shrubbery, etc. Every effort must be made to get the first line in operation before additional lines are stretched. Store Fires First Line the first line is stretched to the store and extinguishes fire. When it is obvious that the first line can control the store fire, the second line should be advanced to the floor above the fire. If two lines are needed in the store, the third line shall be stretched to the floor above. Cellar Fires First Line the first line is stretched by way of the usually numerous exterior approaches to seat of fire and extinguish. Fires in these buildings can be extensive, extremely hot, and depending on wind conditions and building air flow patterns, very difficult to extinguish. These fires require a coordinated effort from the designated attack stairway with 2" hose. If a second stairwell is required for attack and extinguishment, it should not be the stairwell designated as the evacuation stair. When the fire apartment door is left open; it will allow smoke and/or fire to vent out into the public hallway. If a window in the fire apartment fails, and wind is blowing into the fire apartment, an extreme condition may be created on that floor. This may negate the standard attack strategy; which is a direct frontal attack with a hose line from a stairwell, down the public hall and through the apartment door. Prior to advancing to the reported fire floor, members must gather information from the floor below, or two floors below if scissor stairs are present. Determine the location, letter designation and number of stairways serving the fire floor. Prior to the designation of the attack stairway, all members must access the fire floor from the same stairway. If the door to the fire apartment has been left open and size-up indicates that wind may impact fire conditions, the air flow paths must be controlled on the fire floor. Uncoordinated opening of apartment and stairway doors may cause fire conditions to dramatically increase with little or no warning. Initial hose lines stretched from a standpipe shall be from an outlet on a floor below the fire. The hoseline can be connected and stretched on the floor below and then up another stairway that is closer to the fire apartment to facilitate advance. The second line will be stretched via the attack stairway and this will be the factor in determining which standpipe outlet to use. Additional lengths of hose will probably be needed from the 2nd or 4th engine companies. The additional lengths should be added between the last length of the 2nd hose line and the standpipe outlet. This line should be charged at the stairway door to the fire floor depending on hallway conditions and size of the fire area. When the 2nd line is charged the pressure on the first line may drop; therefore, the control firefighter and officer of the first line should be notified. Second Line Second hose line stretched through the front door on the first floor to back up the first hose line. If the first line was used to secure first floor, second line will be stretched to cellar via interior cellar stair to extinguish the fire. First Floor Fires First Line First hose line stretched through the front door on the first floor to extinguish the fire. Second Line if not needed to back up the first hose line, shall be stretched through the front door on the second (parlor) floor to maintain the integrity of the interior stairs. Second Line -Second hose line stretched through the front door on the second (parlor) floor to back up the first hose line. If there is no fire in that exposure, stretch through an exposure to the rear yard of the fire building. They generally have three front windows per floor with one apartment going front to rear and no rear fire escape. The first line can be advanced to the top floor to cover any extension to that area or the cockloft after the cellar fire has been controlled by the second line. A member must be stationed on the landing to warn of any fire that may break out below them. If the first hose line has advanced into the cellar, and a backup line is not needed, the second hose line shall extinguish any fire on the first floor then proceed to the top floor as above. If the first hose line is used to cover the first floor public hall, and a backup line is not needed, the second hose line will be stretched into the cellar via the outside cellar entrance to extinguish the fire. First Floor Fires First Line the first hose line should be stretched to the location of the fire. Second Line the second hose line, if not needed to back up the first hose line, should be stretched to the floor above the fire. Second line the line should be stretched to the top floor or to the floor above. When a fire is reported in the exposure, the second line may be more effective being stretched to the exposure, with the third or fourth line stretched to back up line #l. When a building is fully involved with fire showing in exposure(s) the first arriving engine company should stretch one 3 " supply line for a tower ladder, and a hand line for entering the building.
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None the test order read from the specimen label was used to process the specimen menstrual depression cheap female cialis uk. Maximum number of Tube Position Id No Maximum number of Tube Position Id no read None Read reached menstrual headache relief buy cheap female cialis 20mg on-line. A report could not be generated: Could not log on to the database for None database log on failed women's health blood in the urine discount female cialis 10 mg fast delivery. A report did not contain an expected the report %1 did not contain the expected None image table menstrual juices 20mg female cialis with mastercard. An existing order was used for a Batch mode is enabled and a specimen None specimen menstruation pills generic 20mg female cialis with amex. None Configuration changed for automatic %1 Daily Checks or Shutdown maintenance None cycle on instrument %2 breast cancer walk nyc purchase on line female cialis. This event logs the changes to current configuration compared to the previously existed configuration womens health 7 buy generic female cialis line. TypeOfCycle: %1 CycleDateTime: %2 None Reason: %3 BackgroundCountData: %4 ReagentStatuses: %5 SubsystemStatuses: %6 UseTimeOfLastShutdown: %7 menopause the musical purchase female cialis 20 mg without prescription. None DataSummary SystemChecks test TypeOfCycle: %1 CycleDateTime: %2 None event. CycleTime: %3 Reason: %4 BackgroundCountData: %5 ReagentStatuses: %6 SubsystemStatuses: %7 UseTimeOfLastShutdown: %8. Operator access configuration created None for%1by%2Firstname:%3Lastname:%4 Access level: %5 Active status: %6. Operator access configuration modified None for %1 by %2 New first name: %3 Previous first name: %4 New last name: %5 Previous last name: %6 New access level: %7 Previous access level: %8 New active status: %9 Previous active status: %10. A prime occurs when transitioning from the None idle state to an operational state. None Specimen identifier was not submitted Identifier for manually presented specimen None on time. None the configuration has been successfully Configuration name: %1, items restored: %2. The destination printer did not support the printer %1 does not support the paper 1. Calibration is performed using materials based on or traceable to known reference preparations or materials. In the normal process of tracking data for an extended period of time, your laboratory can make a specific decision to recalibrate a given parameter. If the procedure indicates you need to calibrate, continue with the calibration procedure. You need enough of each to cycle three samples on the comparator instrument and three samples on the DxH 800. The System Manager assesses the calibration status, and indicates when calibration is recommended in the check boxes below the data. When all results are acceptable, the Edit System Recommendations button at the bottom right hand corner of the screen is enabled. This button allows to modify the calibration recommended by the system by selecting or deselecting check boxes. You can view a suggested reference range in the Performance Specifications and Characteristics section of the System Overview chapter. Repeatability 1 Ensure you have enough normal whole blood from a single donor for a minimum of 10 cycles. Repeatability in Single-tube Presentation Follow the instructions for Cassette Presentation Repeatability, using the Single-tube Presentation station to present each specimen tube. Repeatability Run Details When the Repeatability procedure is complete, the results display on the Repeatability Run Details screen. The system aspirates the bleach solution and draws it through the apertures and then drains the baths. Refer to the Dispense Diluent Procedure (Menu > Diagnostics > Dx Tools > Maintenance) section in the Troubleshooting chapter for instructions. If you find a filter that is torn or shredded, discard it and replace it with a new one. Push the connector into the port so that the pins in the port are inserted into the connector. Clean up spills immediately in accordance with your local regulations and acceptable laboratory procedures. Carefully align the threads on the vacuum trap jar with the threads on the vacuum trap assembly and screw the vacuum trap jar into place. Never use solvents (for example, acetone, benzene, ether, or phenol-based agents) on the housing or window. If the scan window is visibly dirty, or if the scanner is not scanning well, clean the scan window with a soft cloth or lens tissue dampened with water (or a mild detergent-water solution). If a detergent solution is used, rinse with a clean lens tissue dampened with water only. If in doubt as to how to proceed in any situation, contact your Beckman Coulter Representative. The Supplies alert status icon (see Alert Status Icons) displays the status of the supplies. Manage Supplies the system monitors the supplies status and provides you with a visual indication of their states through the Supplies alert indicator icon. While there is valid reagent usage remaining for all the supplies, the Supplies icon background is beige or neutral. A yellow background indicates a warning condition and a red background indicates an error condition. You can return the color to neutral by replacing the supplies that are low, depleted, or expired. To avoid injury and false hardware errors, do not remove the transport shield or lift the front cover until otherwise instructed. The aspiration probe and the associated tubing contain residual biohazardous material. This may include, but is not limited to , protective eyewear, gloves, and suitable laboratory attire. Removing and Replacing the Aspiration Probe 1 Select Menu > Diagnostics > Dx Tools. The front blood detector and the associated tubing can contain residual biohazardous material. Thread the tube through the holders on the side of the Probe Vertical Drive assembly. If the vacuum needs to be adjusted, turn the Count Regulator knob clockwise to increase the vacuum or counter-clockwise to decrease the vacuum. After you have verified that the vacuum is 6, select the Stop button on the Diagnostic Procedures Maintenance button to stop the Check Pneumatic Supply procedure. Adjust the Pneumatic Supply Regulator 1 Turn the knob on the Pneumatic Supply Module to adjust the Pneumatic Supply Regulator to 25 psi. Make sure that you position the containers correctly in the floor stand so that you do not crimp the tubes when they are inserted. Refer to Set Up Supplies (Menu > Supplies > Setup) in the Setup chapter of this manual. The contents of the old waste container and its associated tubing can include residual biological material and must be handled with care. If using this method of waste removal, Beckman Coulter recommends that you schedule routine maintenance of the laboratory drain pipes. The number of characters that can be read by the bar-code reader is limited to 22 characters or to that which can be printed in the viewable height, whichever is less. Approximately the bottom 10 mm and the top 10 mm of all tubes is not viewable by the bar-code reader. This is due to the curvature at the bottom of a rounded tube as well as to the cassette barcode window. If you need information on a tube not listed here, contact your Beckman Coulter Representative. Managing Supplies For information on replacement parts or consumable products, contact your Beckman Coulter Representative. If studies mode is enabled, the user also has privileges to configure the following settings for the way that studies mode will operate: Auto print for studies specimens, Auto transmit for studies specimens, Number of aspiration per tube for default test order. Deletion only of active test orders where all tests are pending for the entire test order. Deletion of any pending or completed test orders, except when a test order is in progress. The Log Type drop-down list on the History Logs screen allows you to view logs by type. Options on the Event Logs Screen Find Logs Select the Find button on the Event Logs screen to display the Find dialog box. Filter Logs Select the Filter button on the History Logs Event Logs screen to filter events. Delete Logs Select the Delete button on the History Logs Event Logs screen to display the Delete dialog box. Autoprint Refer to the, Auto Print History Log Configuration section of the Setup chapter for instructions on setting up Autoprint for History Logs. The Data Summary Log screen displays two tabs of History Logs: Supplies and Daily Checks. The second line of the footer, left hand side, represents the algorithm revision and, in brackets, the variable flagging sensitivity. If a term has more than one meaning, all meanings relevant to this manual are included. Sometimes specified as the difference of the means of a sample to the assay or expected value (mean difference) or the percent difference of the means of a sample to the assay or expected value (percent mean difference). An alert occurs when a condition exists on the system for which corrective actions must be taken in order for specimen results to be reported. This condition has no immediate effect on the system operation as the system does not stop. The system alerts the operator by triggering visual alarms, and if applicable, audible alarms. All alerts require operator review; however, the method of review is specific to the individual event. The components do not have to be related functionally and may not qualify as a sub-system (completeness of functionality). Backups can be done completely, meaning that all of the selected data is backed up, or incrementally, meaning that only the changes are backed up. Some examples are: cerebrospinal fluid (brain and spinal cord), pericardial fluid (heart), peritoneal dialysis fluid (abdomen), peritoneal lavage fluid (abdomen), peritoneal tap fluid (abdomen), pleural fluid (lungs), and synovial fluid (joints). Low-to-high carryover is the amount of sample with low cell concentrations carried over to samples with high cell concentration, such as diluent to blood. High-to-low carryover is the amount of samples with high cell concentrations carried over to samples with low cell concentrations, such as blood to diluent. It comprises the Reagent Services, Pneumatic Services, Pneumatic Supply and Electronic Supply. Each control file contains results from a single instrument and a single control lot or specimen. The tests on the order will depend on the method of presentation (Cassette or Single-Tube). That is, the Test Order is no longer available on either the active or inactive Test Order lists. Furthermore, if there were any results associated with the test order, they are no longer available. On dataplots, as more cells appear in a particular region, the color of the region gets brighter. An error occurs when a condition exists on the system for which the operator must take corrective action. Operation of the system or a component was affected or may have been halted, and action is required in order to recover the situation. Action may be unrecoverable and may consist of contacting your Beckman Coulter Representative. The system alerts you of an error by displaying messages and triggering visual and audible alarms. All errors require acknowledgement or review; however, how each error is acknowledged or reviewed is specific to the event. Indicates that messages posted to the Event Log are intended to alert the operator of an error. The operator is required to review or acknowledge the message in order to clear the Event Log visual indicator. On screens and printouts, the letters, such as H, L, and R appear next to parameter results to indicate specific conditions. Gaussian distribution A normal or symmetrical distribution; for example, a bell-shaped curve. H&H HgB/Hct hardware modules Replaceable, testable units that comprise multiple components and/or assemblies. An information event is logged to the Event Log by filter category and does not require operator acknowledgement or review. It allows a laboratory to compare its performance to all other laboratories in the program that use the same or similar instrument category and control products. On dataplots, membership is represented showing different types of cells in different colors. Electrical signals and laser light are passed through the flow cell such that particles flowing through the flow cell will perturb the signals listed above and cause a variety of transducers (antennas, light sensors) to produce other electrical signals which are then measured to produce raw data. Opacity has the effect of removing the size component, yielding a measurement that is more closely related to the internal contents of the cell. Operator (Level I) Normal operator has low level privileges to the system software. Operator (System) Default operator the system uses this operator when no one is logged in to the system software, but the system is processing specimens. Operator (Temp Admin) Temporary administrator operator has full level privileges to the system software, to all system service tools and the full operating system for one day only. The name comes from pleura, the serous membrane that enfolds the lungs and is folded back upon the walls of the thorax and upon the diaphragm. If any test value exceeds the reference value by 1% or more, the test value appears in red on the Daily Checks screen and is flagged with an H (high) or L (low). If any test value exceeds the reference value, the test value appears in red on the System Manager screen and is flagged with an H (high) and L (low). The opposite of batch processing, where specimens must be grouped according to tests ordered. Also known as reproducibility, precision, within-run precision, within-assay, within-run, intra-assay, and intra-run precision. It consists of extracting a sample from a specimen container, segmenting the required sample volume, then combining it with conditioning reagents to enhance specific discrimination characteristics for measuring and analysis. Also, the volume of a specimen that is conditioned for a specific measuring function. When the volume removed from a specimen container exceeds the conditioning requirement and a portion is discarded, or when portions of the sample are allocated to several conditioning processes, the sample may be called an intermediate sample volume. The screen returns to its normal view when the System Manager receives sample data or when you interact with the System Manager by pressing a key on the keyboard. This is used for procedures where specific specimens are designated for delivery and no other specimens can be scheduled for delivery during the procedure. A study might be used to do things such as validating a new instrument, performing accuracy studies, or evaluating performance, etc. This interaction can include, but is not limited to: ordering tests, reviewing test results, reviewing quality control results, making log entries, and responding to system errors. The aperture counts for the three apertures were too far apart to give a reliable average parameter value. It consists of values for volume, conductivity, and light scatter for multiple angles. A warning occurs when a condition exists on the system for which the operator needs to be alerted. This condition has no immediate effect on the system operation, however an action may be needed in order to avoid problems in the future.
Patients with aplastic anemia generally have symptoms characteristic of a particular cellular deficiency women's health clinic vernon bc generic female cialis 10mg online. Those with anemia may be fatigued or short of breath menstrual quotes purchase cheap female cialis line, those with neutropenia may manifest serious infection women's health nz order female cialis with paypal, and those with thrombocytopenia may demonstrate petechiae or bleeding women's health clinic utah discount female cialis online mastercard. A low reticulocyte count suggests underproduction rather than increased loss or destruction of red cells menopause lower back pain buy 10 mg female cialis with amex. The diagnosis is confirmed with a bone marrow biopsy that shows a substantial decrease in the number of red cell pregnancy 29 weeks female cialis 20 mg amex, white cell menstruation yahoo answers cheap female cialis 10 mg without a prescription, and platelet precursors menopause quiz buy female cialis online now, and replacement of the usually cellular bone marrow with fat. Aplastic anemia can be mild or severe, and the 272 Hematology management of the patient depends on the severity of the illness. Failure of the pluripotential stem cells of the bone marrow to maintain bone marrow cellularity and the production of normal numbers of mature red cells, neutrophils, and platelets characterizes aplastic anemia. Failure of the pluripotential stem cell can be caused by many different factors (Table 17. Many agents that cause aplastic anemia, such as benzene and radiation, can on occasion precipitate malignant transformation of the damaged bone marrow stem cells, resulting in the development of acute leukemia. Pure Red cell Aplasia Acquired pure red cell aplasia is a rare disorder, usually immunologically mediated, in which there is a specific failure of production of red cells. The bone marrow biopsy shows a selective absence of red blood cell precursors, whereas white cell and platelet precursors are present in normal numbers. Anemia of Renal Failure Patients with significant renal disease almost always have anemia. Patients who require dialysis are almost always severely anemic and need repeated transfusions. The primary cause of the anemia is a lack of erythropoietin, a hormone necessary for red cell growth and development in the bone marrow. The anemia is usually normocytic and normochromic with a normal reticulocyte percentage. About 40 percent of the time, the anemia is microcytic and hypochromic, usually only mildly so, but occasionally sufficient to cause confusion with iron deficiency anemia. Inspection of the bone marrow usually shows abundant iron in reticuloendothelial cells, but little or no iron in red cell precursors. Thus, the patient has adequate iron stores, but is unable to transfer iron from the reticuloendothelial system storage cells to the red cell precursors that need it to form hemoglobin. The cause of this block in iron reutilization is uncertain, and there is no effective treatment other than to correct the 276 Hematology underlying chronic disease. Myelophthisic anemia Neoplasms, granulomatous infections, or a fibrotic process can directly replace the bone marrow. Anemias Associated with Endocrine Abnormalities [Hypothyroidism, Hypopituitarism] A mild anemia is commonly associated with hypothyroidism. The reticulocyte count is low, demonstrating that this is a hypoproliferative anemia, through the actual mechanism is not known. In hemolytic disorders, red cells are destroyed prematurely, usually in a random fashion. If the red blood cell life span is only moderately shortened, the patient will usually have little, if any, anemia because the bone marrow is capable of increasing the rate of new red blood cell production by a factor of 4 to 8. Red cell metabolism gradually deteriorates as enzymes are degraded and not replaced, until the cells become non-viable, but the exact reason why the red cells die is obscure. The breakdown of red cells liberates iron for recirculation via plasma transferrin to marrow erythroblasts, and protoporphyrin which is broken down to bilirubin. This circulates to the liver 278 Hematology where it is conjugated to glucuronides which are excreted into the gut via bile and converted to stercobilinogen and stercobilin (excreted in feces). Stercobilinogen and stercobilin are partly reabsorbed and excreted in urine as urobilinogen and urobilin. Globin chains are broken down to amino acids which are reutilized for general protein synthesis in the body. Intravascular hemolysis (breakdown of red cells within blood vessels) plays little or no part in normal red cell destruction. Extravascular Versus intravascular hemolysis There are two general sites in which hemolysis may take place (Table 17. In intravascular hemolysis, which is uncommon, red blood cells are destroyed directly within the circulatory system. Extravascular hemolysis is more common than intravascular hemolysis and involves the destruction of red blood cells within mononuclear phagocytic cells, often in the spleen. They are usually inherited, and generally (but not always) the abnormality is observable in the peripheral blood smear. Extracorpuscular defects refer to problems in the environment of the red blood cell, not in the red blood cell itself (Table 17. Extracorpuscular hemolysis is usually acquired and is often but not always discernible in the form of morphologic abnormalities in the peripheral blood smear. For example, many spherocytes suggest hereditary spherocytosis or immunohemolytic anemia and sickle cells suggest one of the sick cell syndromes. In the majority of cases hematocrit levels are normal or near normal with minimal hemolysis; greater than 25 percent (often 75%) of red cells are elliptocytes. It should be noted that some elliptical cells also occur in thalassemia, iron deficiency, myelophthisic anemias, sickle cell disease, and megaloblastic anemia. These disorders, however, are accompanied by other characteristic morphologic changes as well. Erythrocyte enzyme deficiencies Hereditary hemolytic anemia has been associated with 284 Hematology at least ten red cell enzyme deficiencies. Because of the X-linkage, male patients are more severely affected than female patients. The deficiency is not limited to any particular racial or geographically defined population. Rather than producing acute hemolysis in association with drug ingestion, it causes a chronic congenital nonspherocytic hemolytic anemia. Generally the term hemoglobinopathy is used to signify a structurally abnormal hemoglobin with at least one amino acid substitution. Structural abnormalities may cause premature red cell destruction; easily denatured hemoglobins; hemoglobins with abnormal oxygen affinity; altered hemoglobin solubility; and, in a few instances, reduced globin synthesis. In this topic only the few clinically significant hemoglobinopathies are discussed. Hemoglobin S By far the most important hemoglobinopathies are those related to the presence of sickle hemoglobin (HbS). Sickle hemoglobin results form replacement 287 Hematology of the sixth amino acid form the N-terminal end of the chain, glutamic acid, by valine. Invariably sickle cells are typically seen on Wright-stained peripheral blood smears from patients. Hemoglobin C syndromes Hemoglobin C (HbC) is probably the second most common hemoglobinopathy (2-3% gene frequency in black populations). HbC is caused by substitution of lysine for glutamic acid in the sixth position form the N terminal end of the -hemoglobin chain (same location as the substitution in HbS). A variety of acquired clinical conditions result in shortened survival of previously normal red cells. These include immune-mediated destruction, red cell fragmentation disorders, acquired membrane defects, splenic effects, and the results of infections and environmental toxins. Immunohemolytic anemia 288 Hematology Immunohemolytic anemias are the result of the binding of antibody, complement, or antibody plus complement to red cells. Antibodies formed against erythrocyte antigens may be either warm (active at 37oC) or cold (active at room temperature and below). In some cases, these antibodies activate a series of proteins, referred to collectively as complement; in others, the red cells are coated with antibody alone. As a result of complement activation by hemolytic antibodies, intravascular red cell lysis and release of hemoglobin may occur. The red cells are usually coated with IgG alone, IgG and complement or complement alone, but a minority of cases show IgA or IgM coating alone or combined with IgG antibody. Part of the coated membrane is lost so the cell becomes 290 Hematology progressively more spherical to maintain the same volume and is ultimately prematurely destroyed, usually predominantly in the spleen. The disease may occur at any age in either sex and presents as a hemolytic anemia of varying severity. Laboratory findings the hematological and biochemical finding are typical of a hemolytic anemia with spherocytosis prominent in the peripheral blood. The antibodies both on the cell surface and free in serum are best detected at 37oC. In these syndromes the autoantibody, whether monoclonal (as in the idiopathic cold hemeagglutinin syndrome or associated with 291 Hematology lymphoprolifertative disorders) or polyclonal (as following infection. Hemolytic syndromes of varying severity may occur depending on the titer of the antibody in the serum, its affinity for red cells, its ability to bind complement, and its thermal amplitude (whether or not it bids to red cells at 37oC). Agglutination of red cells by the antibody often causes peripheral circulation abnormalities. Intravascular hemolysis occurs in some of the syndromes, in which the complement sequence is completed on the red cell surface. Low serum levels of complement in other case may help to protect the patient from a more sever clinical disease. Paroxysmal cold hemoglobinuria this rare disease, characterized by hemoglobinuria following cold exposure, is caused by an IgG autoantibody to the red cell antigen P. This Donath Landsteiner autoantibody is unique in that it binds to red cells at cold temperatures, in contrast to other IgG antibodies. Furthermore, it binds complement well, and brisk hemolysis results when the cells are warmed and the complement sequence proceeds to completion. Drug induced immune hemolytic anemias Four pathophysiologic mechanisms account for most cases of drug-induced red cell sensitization and positive 293 Hematology direct Coombs test. The drug-induced problem may result in serious hemolytic anemia on the one hand, or a laboratory abnormality without clinical sequelae on the other. Although the drug coating by itself is not harmful, some patients develop high-titer antipenicillin IgG antibodies, which can react with the coated red cells. The coombs test is positive due to the presence of IgG; complement is not usually found. The immune complexes often activate complement, and an abrupt and life threatening intravascular hemolytic anemia may 294 Hematology develop. The coombs test is positive for complement; the immune complexes themselves do not bind firmly to the cell. The direct Coombs test is usually strongly positive with IgG; complement is rarely found. Cephalosporins: Membrane modification these drugs cause a positive direct Coombs test through a non-immunologic mechanism. Cephalothin and other cephalosporins are capable of altering the red cell membrane so that proteins, including complement and an assortment of -globulins, are nonspecifically adsorbed. As a result of the presence of these proteins, the direct antiglboulin test is positive. However, the red cell eluate does not react with any other cells, because 295 Hematology the mixture of -globulins does not include any predominantly red cell antigen-specific antibody. The antibody screen is negative because no unusually drug related antibodies are present. Hemolytic transfusion reactions the differential diagnosis of a positive direct antiglobulin test includes not just red cell autoantibodies but also alloantibodies-antibodies in the patient directed against foreign red cell antigens. For example, a patient whose red cells are group O has anti-A and anti-B in his or her serum. Like many other IgM antibodies, these isoagglutinins are potent complement fixers. The direct Coombs test is positive due complement fixation, but may become negative within hours to days, depending on how rapidly the group a cells are destroyed. The presence of urine hemosiderin beginning 3 to 5 days after the transfusion attests to the recent presence of hemoglobinemia. If the patient then receives an antigen positive unit, an anamnestic rise in antibody occurs over the next 3 to 21 days. Here, red cell destruction is usually leisurely, since the cells are eliminated only after they are coated with sufficient antibody, which depends on the rapidity with which it is produced. The direct Coombs test on a posttransfusion blood specimen is positive due to IgG coated transfused red cells. The test becomes negative as the antibody-coated cells are removed from the circulation. Hemolytic disease of the newborn this hemolytic process actually begins in utero to the baby of a mother with IgG red cell antibodies. IgG antibodies readily cross the placenta, as opposed to IgM antibodies, which cannot. In the past, many Rh(D) negative women became sensitized to the red cell antigen D at the time of birth of a first Rh-positive child, because at birth it is common for a small volume of fetal cells to enter the maternal circulation. Rh-positive fetuses carried by a sensitized Rh-negative mother can be severely affected by the IgG anti-D. Some babies develop profound in utero anemia with congestive heat failure (hydrops fetalis), leading to stillbirth. Over time, some patients develop hypochromic microcytic red cells due to progressive iron deficiency, resulting form hemoglobinuria and hemosiderinuria. Since occasional false positives occur, positive results require confirmation with the more complex and rigorous Ham test. Explain in brief microcytic anemia and the different forms included in this category 4. Leukemia the leukemias are a group of disorders characterized by the accumulation of abnormal white cells in the bone marrow. These abnormal cells may cause bone marrow failure, a raised circulating white cell count and infiltrate organs. Thus common but not essential features include abnormal white cells in the peripheral blood, a raise total white cell count, evidence of bone marrow failure. Other chronic types include hairy cell leukemia, prolymphocytic leukemia and various leukemia/lymphoma syndromes. In acute leukemia, in which there are over 50% myeloblasts or lymphoblasts in the bone marrow at clinical presentation, the blast cells fail to differentiate normally but are capable of further divisions. Their accumulation results in replacement of the normal hemopoietic precursor cells of the bone marrow by myeloblasts or lymphoblasts and, ultimately in bone marrow failure. The clinical condition of the patient can be correlated with the total number of leukemic cells in the body. When the abnormal cell number approaches 1012 the patient is usually gravely ill with severe bone marrow failure. Peripheral blood involvement by the leukemic cells and infiltration of organs such as the spleen, liver and lymph nodes may not occur until the leukemic cell population comprised 60% or more of the marrow cell total. The clinical presentation and mortality in acute leukemia arises mainly from neutropenia, thrombocytopenia and anemia because of bone marrow failure and, less commonly, from organ infiltration. In over 95% of patients there is a replacement of normal bone marrow by cells with an abnormal chromosome the Philadelphia or Ph chromosome. This is an abnormal chromosome 22 due to the translocation of part of a long (q) arm of chromosome 22 to another chromosome, usually 9, with translocation of part of chromosome 9 to chromosome 22. It is an acquired abnormality of hemopoietic stem cells that is present in all dividing granulocytic, erythyroid and megakaryocytic cells in the marrow and also in some B and probably a minority of T lymphocytes. A great increase in total body granulocyte mass is responsible for most of the clinical features. In at least 70% of patients there is a terminal metamorphosis to 308 Hematology acute leukemia (myeloblastic or lymphoblastic) with an increase of blast cells n the marrow to 50% or more. It most cases there are no predisposing factors but the incidence was increased n survivors of the atom bomb exposures in Japan. The levels of neutrophils and myelocytes exceed those of blast cells and promyelocytes. The accumulation of large numbers of lymphocytes to 50-100 times the normal lymphoid mass in the blood, bone marrow, spleen, lymph nodes and liver may be related to immunological non-reactivity and excessive lifespan. Between 70% and 99% of white cells in the blood 310 Hematology film appear as small lymphocytes.
Diseases
Alpha-mannosidosis
Malakoplakia
Chromosome 2, monosomy 2q
Lymphoid hamartoma
Cloverleaf skull bone dysplasia
Hepatitis D
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Obesity Although at the peak of physical health women's health clinic midland tx discount 20 mg female cialis with mastercard, a concern for early adults is the current rate of obesity. Results from the National Center for Health Statistics indicated that an estimated 70. The current statistics are an increase from the 2013-2014 statistics that indicated that an estimated 35. The average man in his 20s weighs around 185 pounds and by his 30s weighs approximately 200 pounds. The average American woman weighs 162 pounds in her 20s and 170 pounds in her 30s. This translates to 266 million obese men and 375 million obese women in the world, and more people were identified as obese than underweight. Societal factors include culture, education, food marketing and promotion, the quality of food, and the physical activity environment available. Behaviors leading to obesity include diet, the amount of physical activity, and medication use. Rather, research has identified variants in several genes that may contribute to obesity by increasing hunger and food intake. The genes that helped our ancestors survive occasional famines are now being challenged by environments in which food is plentiful all the time. Overall, obesity most likely results from complex interactions among the environment and multiple genes. Additionally, the medical care costs of obesity in the United States were estimated to be $147 billion in 2008. However, the top five causes of death in emerging and early adulthood are non-intentional injury (including motor vehicle accidents), homicide, and suicide with cancer and heart disease completing the list (Heron, & Smith, 2007). Rates of violent death (homicide, suicide, and accidents) are highest among young adult males, and vary by race and ethnicity. Rates of violent death are higher in the United States than in Canada, Mexico, Japan, and other selected countries. Males are 3 times more likely to die in auto accidents than are females (Frieden, 2011). Heavy drinking is defined as drinking five or more drinks on the same occasion on each of five or more days in the past 30 days. Nearly 88,000 people (approximately 62,000 men and 26,000 women) die from alcohol-related causes annually, making it the fourth leading preventable cause of death in the United States. In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31% of overall driving fatalities). This typically occurs after four drinks for women and five drinks for men in approximately two hours. In 2014, 25% of people ages 18 or older reported that they engaged in binge drinking in the past month. The role alcohol plays in predicting acquaintance rape on college campuses is of particular concern. Krebs, Lindquist, Warner, Fisher and Martin (2009) found that over 80% of sexual assaults on college campuses involved alcohol. Females are more likely to blame themselves and to be blamed by others if they were intoxicated when raped. College students view perpetrators who were drinking as less responsible, and victims who were drinking as more responsible for the assaults (Untied, Orchowski, Mastroleo, & Gidycz, 2012). These include the pervasive availability of alcohol, inconsistent enforcement of underage drinking laws, unstructured time, coping with stressors, and limited interactions with parents and other adults. Due to social pressures to conform and expectations when entering college, the first six weeks of Source freshman year are an especially susceptible time for students. Additionally, more drinking occurs in colleges with active Greek systems and athletic programs. Alcohol consumption is lowest among students living with their families and commuting, while it is highest among those living in fraternities and sororities. College Strategies to Curb Drinking: Strategies to address college drinking involve the individual-level and campus community as a whole. Interventions include education and awareness programs, as well as intervention by health professionals. At the college-level, reducing the availability of alcohol has proven effective by decreasing both consumption and negative consequences. Additionally, 25% of those who smoke cigarettes, 33% of those who smoke marijuana, and 70% of those who abuse cocaine began using after age 17 (Volkow, 2004). Emerging adults (18 to 25) are the largest abusers of prescription opioid pain relievers, anti-anxiety medications, and Attention Deficit Hyperactivity Disorder medication (National Institute on Drug Abuse, 2015). For those in college, 2014 data indicate that 6% of college students smoke marijuana daily, while only 2% smoked daily in 1994. For noncollege students of the same age, the daily percentage is twice as high (approximately 12%). Additionally, according to a recent survey by the National Institute of Drug Abuse (2018), daily cigarette smoking is lower for those in college in comparison to non-college groups (see Figure 7. Rates of violent death are influenced by substance use which peaks during emerging Source and early adulthood. Drugs impair judgment, reduce inhibitions, and alter mood, all of which can lead to dangerous behavior. Reckless driving, violent altercations, and forced sexual encounters are some examples. Drug and alcohol use increase the risk of sexually transmitted infections because people are more likely to engage in risky sexual behavior when under the influence. This includes having sex with someone who has had multiple partners, having anal sex without the use of a condom, having multiple partners, or having sex with someone whose history is unknown. Lastly, as previously discussed, drugs and alcohol ingested during pregnancy have a teratogenic effect on the developing embryo and fetus. Because gender is considered a social construct, meaning that it does not exist naturally, but is instead a concept that is created by cultural and societal norms, there are cultural variations on how people express their gender identity. For example, in American culture, it is considered feminine to wear a dress or skirt. However, in many Middle Eastern, Asian, and African cultures, dresses or skirts (often referred to as sarongs, robes, or gowns) can be considered masculine. Similarly, the kilt worn by a Scottish male does not make him appear feminine in his culture. For many adults, the drive to adhere to masculine and feminine gender roles, or the societal expectations associated with being male or female, continues throughout life. In American culture, masculine roles have traditionally been associated with strength, aggression, and dominance, while feminine roles have traditionally been associated with passivity, nurturing, and subordination. Men tend to outnumber women in professions such as law enforcement, the military, and politics, while women tend to outnumber men in care-related occupations such as childcare, healthcare, and social work. Adherence to these roles may demonstrate fulfillment of social expectations, however, not necessarily personal preferences (Diamond, 2002). Consequently, many adults are challenging gender labels and roles, and the long-standing gender binary; that is, categorinzing humans as only female and male, has been undermined by current psychological research (Hyde, Bigler, Joel, Tate, & van Anders, 2019). The term gender now encompasses a wide range of possible identities, including cisgender, transgender, agender, genderfluid, genderqueer, gender nonconforming, bigender, pangender, ambigender, non gendered, intergender, and Two-spirit which is a modern umbrella term used by some indigenous North Americans to describe gender-variant individuals in their communities (Carroll, 2016). Gender Minority Discrimination: Gender nonconforming people are much more likely to Figure 7. Transgender individuals of color face additional financial, social, and interpersonal challenges, in comparison to the transgender community as a whole, as a result of structural racism. Black Source transgender people reported the highest level of 257 discrimination among all transgender individuals of color. As members of several intersecting minority groups, transgender people of color, and transgender women of color in particular, are especially vulnerable to employment discrimination, poor health outcomes, harassment, and violence. Consequently, they face even greater obstacles than white transgender individuals and cisgender members of their own race. Results indicated that participants who identified as transgender and gender nonconforming had significantly higher levels of anxiety and depression than those identifying as cisgender. The transgender children discussed in chapter 4 may, when they become an adult, alter their bodies through medical interventions, such as surgery and hormonal therapy, so that their physical being is better aligned with gender identity. However, not all transgender individuals choose to alter their bodies or physically transition. Many will maintain their original anatomy but may present themselves to society as a different gender, often by adopting the dress, hairstyle, mannerisms, or other characteristics typically assigned to a certain gender. It is important to note that people who cross-dress, or wear clothing that is traditionally assigned to the opposite gender, such as transvestites, drag kings, and drag queens, do not necessarily identify as transgender (though some do). Sexuality may be experienced and expressed in a variety of ways, including thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles, and relationships. These may manifest themselves in biological, physical, emotional, social, or spiritual aspects. The biological and physical aspects of sexuality largely concern the human reproductive functions, including the human sexual-response cycle and the basic biological drive that exists in all species. Emotional aspects of sexuality include bonds between individuals that are expressed through profound feelings or physical manifestations of 258 love, trust, and care. Sexuality also impacts, and is impacted by cultural, political, legal, philosophical, moral, ethical, and religious aspects of life. In most mammalian species, sex hormones control the ability to engage in sexual behaviors. However, sex hormones do not directly regulate the ability to copulate in primates (including humans); rather, they are only one influence on the motivation to engage in sexual behaviors. Social factors, such as work and family, also have an impact, as do internal psychological factors like personality and stress. Sex drive may also be affected by hormones, medical conditions, medications, lifestyle stress, pregnancy, and relationship issues. The sexual response cycle is a model that describes the physiological responses that take place during sexual activity. According to Kinsey, Pomeroy, and Martin (1948), the cycle consists of four phases: excitement, plateau, orgasm, and resolution. The excitement phase is the phase in which the intrinsic (inner) motivation to pursue sex arises. The plateau phase is the period of sexual excitement with increased heart rate and circulation that sets the stage for orgasm. Orgasm is the release of tension, and the resolution period is the unaroused state before the cycle begins again. The Brain and Sex: the brain is the structure that translates the nerve impulses from the skin into pleasurable sensations. The brain regulates the release of hormones, which are believed to be the physiological origin of sexual desire. The cerebral cortex, which is the outer layer of the brain that allows for thinking and reasoning, is believed to be the origin of sexual thoughts and fantasies. Beneath the cortex is the limbic system, which consists of the amygdala, hippocampus, cingulate gyrus, and septal area. These structures are where emotions and feelings are believed to originate, and they are important for sexual behavior. This is the small area at the base of the brain consisting of several groups of nerve-cell bodies that receives input from the limbic system. Studies with lab animals have shown that destruction of certain areas of the hypothalamus causes complete elimination of sexual behavior. One of the reasons for the importance of the hypothalamus is that it controls the pituitary gland, which secretes hormones that control the other glands of the body. Oxytocin, also known as the hormone of love, is released during sexual intercourse when an orgasm is achieved. Oxytocin is also released in females when they give birth or are breast feeding; it is believed that oxytocin is involved with maintaining close relationships. In males, testosterone appears to be a major contributing factor to sexual motivation. Vasopressin is involved in the male arousal phase, and the increase of vasopressin during erectile response may be directly associated with increased motivation to engage in sexual behavior. The relationship between hormones and female sexual motivation is not as well understood, largely due to the overemphasis on male sexuality in Western research. Estrogen and progesterone typically regulate motivation to engage in sexual behavior for females, with estrogen increasing motivation and progesterone decreasing it. Research suggests that testosterone, oxytocin, and vasopressin are also implicated in female sexual motivation in similar ways as they are in males, but more research is needed to understand these relationships. Sexual Responsiveness Peak: Men and women tend to reach their peak of sexual responsiveness at different ages. For men, sexual responsiveness tends to peak in the late teens and early twenties. Sexual arousal can easily occur in response to physical stimulation or fantasizing. Sexual responsiveness begins a slow decline in the late twenties and into the thirties, 260 although a man may continue to be sexually active. Through time, a man may require more intense stimulation in order to become aroused. Women often find that they become more sexually responsive throughout their 20s and 30s and may peak in the late 30s or early 40s. This is likely due to greater self-confidence and reduced inhibitions about sexuality. Proper use of safe-sex supplies (such as male condoms, female condoms, gloves, or dental dams) reduces contact and risk and can be effective in limiting exposure; however, some disease transmission may occur even with these barriers. Historically, religion has been the greatest influence on sexual behavior in the United States; however, in more recent years, peers and the media have emerged as two of the strongest influences, particularly among American teens (Potard, Courtois, & Rusch, 2008). Mass media in the form of television, magazines, movies, and music continues to shape what is deemed appropriate or normal sexuality, targeting everything from body image to products meant to enhance sex appeal. Cultural Differences: In the West, premarital sex is normative by the late teens, more than a decade before most people enter marriage. In the United States and Canada, and in northern and eastern Europe, cohabitation is also normative; most people have at least one cohabiting 261 partnership before marriage. In southern Europe, cohabiting is still taboo, but premarital sex is tolerated in emerging adulthood. In contrast, both premarital sex and cohabitation remain rare and forbidden throughout Asia. Even dating is discouraged until the late twenties, when it would be a prelude to a serious relationship leading to marriage. In cross-cultural comparisons, about three fourths of emerging adults in the United States and Europe report having had premarital sexual relations by age 20, versus less than one fifth in Japan and South Korea (Hatfield & Rapson, 2006). It is a personal quality that inclines people to feel romantic or sexual attraction (or a combination of these) to persons of a given sex or gender. Sexual orientation is independent of gender; for example, a transgender person may identify as heterosexual, homosexual, bisexual, pansexual, polysexual, asexual, or any other kind of sexuality, just like a cisgender person. Research done over several decades has supported this idea that sexual orientation ranges along a continuum, from exclusive attraction to the opposite sex/gender to exclusive attraction to the same sex/gender (Carroll, 2016). Bisexuality was a term traditionally used to refer to attraction to individuals of either male or female sex, but it has recently been used in nonbinary models of sex and gender. Alternative terms such as pansexuality and polysexuality have also been developed, referring to attraction to all sexes/genders and attraction to multiple sexes/genders, respectively (Carroll, 2016). Being asexual is not due to any physical 262 problems, and the lack of interest in sex does not cause the individual any distress. Development of Sexual Orientation: According to current scientific understanding, individuals are usually aware of their sexual orientation between middle childhood and early adolescence. However, this is not always the case, and some do not become aware of their sexual orientation until much later in life. It is not necessary to participate in sexual activity to be aware of these emotional, romantic, and physical attractions; people can be celibate and still recognize their sexual orientation. Some researchers argue that sexual orientation is not static and inborn but is instead fluid and changeable throughout the lifespan. There is no scientific consensus regarding the exact reasons why an individual holds a particular sexual orientation.
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