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Site-specifc examination of the entire lumen, made possible by 4-way defection and fber optic lighting and imaging technology. The SpyGlass System addresses both of these limitations with a single-operator, single-use device that is redefning cholangioscopy with over 30,000 worldwide Laser Fiber cases completed to date. Irrigation: Flush and aspirate anatomy to clear the feld of view allows for a single physician to simultaneously operate both scopes and optimize visualization. The SpyGlass System has also been shown to be compatible using the Lumenis?SlimLine? 365 micron Laser probe (M0068408420) and the Lumenis?VersaPulse SpyScope PowerSuite 20 Watt Holmium Laser Generator (M0068408220). The SpyGlass Probe, when delivered through the SpyGlass Catheter, provides complete circumferential visualization in the pancreatico-biliary anatomy, which may expand options for visual diagnosis and targeted tissue acquisition, potentially leading Probe Connector to accelerated diagnosis and altered patient treatment. Optic Port the probe should be reprocessed and stored and protected in the large or small SpyGlass System storage tray. The camera head attaches to the camera control unit by a multi-pin cable connector on the proximal end and the ocular on the distal end. The ocular is an opto-mechanic coupler that facilitates focus and transmission of the image from the SpyGlass Probe. The light guide is composed of a fexible fber-optic bundle that attaches to the light source via a Wolf connector port and transmits the light to the SpyGlass Probe. The fow rate is adjustable and continuous fow can be controlled by the footswitch. Large Storage Trays are recommended whenever possible to maintain a larger loop radius for the coiled probe, which puts less strain on the probe fbers. SpyGlass Direct Visualization System Capital Components 8 Cart (3-Joint arm and isolation Transformer) Designed for easy transfer between rooms, the SpyGlass? System cart provides space for all required capital equipment along with two storage drawers to ft SpyGlass System storage trays, an isolation transformer (optional) to manage all electrical demands of the equipment on the cart, and fexible 3-joint arm to hold the camera in place and out of the way (also available separately with bedside attachment). This ensures electrical isolation and enables simple setup after moving from room to room requiring only the connection of the transformer power cable rather than 5 separate connections. The 3-Joint Arm with Clamp (M00546070) is useful if the account does not want to purchase the Travel Cart as it allows the account to mount the arm to another cart or table; 4For ordering information for 240 V transformer, please contact your local salesperson;5Large Storage Trays are recommended whenever possible to maintain a larger loop radius for the coiled probe, which puts less strain on the probe fbers. Indications, Contraindications, Warnings and Instructions for Use can be found in the product labeling supplied with each device. Other manifes sample population was a series of patients whose he tations include splenomegaly (50%), palatal petechiae, patic dysfunction was correlated with a documented hepatomegaly (more than 20%), and jaundice (5%). The study included nine patients (six men, hepatitis A, B, or C is that the former does not infect three women) with a mean age of 43. Five pa hepatocytes, gallbladder epithelium, or vascular endothe tients presented with recent clinical pictures sugges lium. Five patients began with a in the second or third week of symptomatic infection, as cholestatic pattern. Two patients required liver biop well as high serum alkaline phosphatase levels, whereas sies. This study was carried out at the Medica Sur Clinic Key words: Epstein-Barr virus infection, hepatic and Foundation in Mexico City, Mexico, from June 1, manifestations, cholestasis. Demo graphic data, family history, clinical presentation, labora 1 Departments of Biomedical Research and Gastroenterology & Liver tory test results, abdominal ultrasound, liver biopsy (if in Unit. The results are expressed as means, ranks, stan Address for correspondence: Nahum Mendez-Sanchez, M. Hepatic abnormalities, formed in patients for whom liver biopsies were indicat identified by elevated serum liver enzyme and/or biliru ed, including assessment of the expression of latent bin levels, were found in seven patients (77. Results Associated infections We included nine patients in the study, six of whom were male and three female. However, an acute process was con firmed by hepatic inflammation identified on biopsy. The Fatigue and adynamia were the most common clini remaining three patients (33. Gastrointestinal exception of patient 2 who had high levels of serum alka symptoms, including abdominal pain, nausea, and diar line phosphatase and gammaglutamyl transpeptidase rhea were noted in seven patients (77. Variables Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Sex M M F F F M M M M Age (yr) 41 33 23 57 44 46 19 56 73 Evolution (days) 3 7 15 7 5 3 30 43 30 Symptoms: Adynamia + + + + + + + + Anorexia + Abdominal pain + + + + + + Nausea + + + + + Diarrhea + + Upper respiratory tract infection + + + + Cephalalgia + + Fever + + + + + Jaundice + + + + + + Hepatodynia + + + + + + + Hepatomegaly + + + Splenomegaly + Rash + Paresthesia + Pruritus + M, male; F, female; Yr, years. Hepatitis A viral infection was found in patient 8, who Discussion presented one month earlier without complications.

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Consider, for instance, the case of Kim Peek, who was the inspiration for the Academy Award winning film Rain Man (see Figure 5. The Russian psychologist Luria (2004) has described the abilities of a man known as S, who seems to have unlimited memory. He remembered strings of hundreds of random letters for years at a time, and seemed to never forget anything. Explain the progression from sensory memory to short-term memory to long-term memory 4. Describe the following methods of measuring memory: Recall, free recall, cued recall, recognition, and relearning. Describe the ways in which long-term memory organizes information, and the impact those organization strategies have on memory. Encoding is the process by which we place the things that we experience into memory. You could not remember the name, probably because you were distracted and never encoded the name to begin with. Some memories we will hold for years, other memories we hold only long enough to use the information, such as looking up a phone number and retaining it long enough to place the call. Memory would be useless without the ability to retrieve the memories that we have created. Retrieval is not a simple process and many factors can influence the ease with which we can locate a memory. We tend to have poor memory for things that do not matter, even if we see them frequently. Research has found that we are better able to remember information if we encode it in a meaningful way. When we engage in elaborative rehearsal or elaborative encoding, we process new information in ways that make it more relevant or meaningful (Craik & Lockhart, 1972; Harris & Qualls, 2000). Ineffective encoding, or an encoding failure, is an important cause of memory failure and forgetting in humans. If you do not make the correct association between memories, for example, you will not be able to retrieve a memory when cued. Whether you are trying to learn names or definitions for psychology, it is important to make useful associations when you encode or memorize the information. Rather than simply trying to remember the perspectives and their characteristics, you might try to relate the information to things you already know. For instance, you might try to remember the fundamentals of cognitive psychology by linking the characteristics to the computer model. The cognitive perspective focuses on how information is inputed, processed, and retrieved, and you might think about how computers do pretty much the same thing. For instance, you might link the cognitive perspective to structuralism because both were concerned with mental processes. That image might help you remember that childhood experiences were an important part of Freudian theory. Research Focus: Elaboration and Memory In an important study showing the effectiveness of elaborative encoding, Rogers, Kuiper, and Kirker (1977) studied how people recalled information that they had learned under different processing conditions. In the semantic task condition, the participants were asked if the word was a synonym of another word, and in the self-reference task condition, participants were asked to indicate whether or not the given adjective was or was not true of themselves. After completing the specified task, each participant was asked to recall as many adjectives as he or she could remember. This finding, known as the self-reference effect, is powerful evidence that the self-concept helps us organize and remember information. The next time you are studying for an exam, you might try relating the material to your own experiences. The self-reference effect suggests that doing so will help you better remember the information (Symons & Johnson, 1997). Whether the information moves from shorter duration memory into longer-duration memory or whether it is lost from memory entirely depends on how the information is attended to and processed. Unless it is attended to and passed on for more processing, the memory is quickly forgotten.

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Bilirubin Metabolism and Icterus Bilirubin is the pigment that gives bile its yellow-brown color. Heme resides in red cell hemoglobin and in many enzyme systems, which are preferentially localized in the liver (cytochromes, catalase, and peroxidase). Although the pool size of hemoproteins in the liver is small compared with the hemoglobin pool, the production of bilirubin from hepatic heme accounts for 30% of the total production, because the hepatic heme turnover rate is much higher (2 hours to 4 days versus 98 days for hemoglobin). Bilirubin is cleared from the plasma by the liver, and has to be conjugated by the hepatocytes preceding biliary excretion. The unconjugated form is stringently hydrophobic and bound to albumin in the circulation. On conjugation, bilirubin is excreted into bile and the conju gate is not reabsorbed from the intestines. Rarely, in cases of bacterial overgrowth, bilirubin is deconjugated by bacterial enzymes and the unconjugated pigment is reab sorbed in the small intestines into an enterohepatic cycle. Bacterial degradation of bili rubin in the colon produces stercobilins, black and brown pigments that give feces its normal color. Cholestasis causes accumulation of conjugated bilirubin in plasma, which is not only re-excreted by the liver but may also be excreted by the kidneys in the urine. However, the kidney in dogs, particularly males, has all the enzymes to produce bilirubin out of heme and to conjugate it, so that it can be excreted into urine. Therefore, the urine of healthy male dogs may contain detectable concentrations of bilirubin. Urobilinogen is a colorless product, a small fraction of which is absorbed into the portal blood. Most of it is cleared by the liver, but a minor part reaches the systemic circulation and can be excreted by the kidneys. Measurement of urobilinogen in urine has been used to differentiate between different forms of icterus and cholestasis. However, due to many physiologic variations and technical errors, this parameter has no clinical value. Bilirubin is cleared from the blood, conjugated, and excreted into bile by the liver. The clearance is not an efficient process18,19 in contrast to the hepatic clearance of bile acids. Whereas bile acids are nearly completely cleared during the first passage, bilirubin requires many passages to become cleared completely (Fig. As a conse quence, bilirubin is equally distributed over the entire circulation, but bile acids are highly concentrated in the portal blood and have a low concentration in the systemic circulation. This explains the differences in the reaction pattern of bilirubin and bile Clinical Syndromes Associated with Liver Disease 423 Ineffective clearance and recirculation Complete clearance bilirubin in 1 circulation Bile acids gut Fig. Bile acids are reabsorbed and undergo an enterohepatic circulation, which is maintained by an efficient clearance of bile acids from the portal vein. Bilirubin is not absorbed from the small intestines and its hepatic clearance from the blood has low efficiency. Consequently, there is a high gradient between the portal and systemic concentrations of bile acids, but not of bilirubin. Furthermore, systemic bile acids are increased due to portosystemic shunting and cholestasis; bilirubin is only increased due to cholestasis (or increased production in case of severe hemolysis). In diseases with cholestasis, all bile components including bilirubin and bile acids gain entry to the systemic circulation with the hepatic lymph. This process is not related to hepatic clearance or portal perfusion of the liver. Conversely, in diseases characterized by portosystemic shunting (congenital porto systemic shunts, portal hypertension, acquired collateral circulation, and so forth), the high portal bile acid concentration reaches the systemic circulation giving a high plasma bile acid concentration. However, the bilirubin concentration is not influenced by abnormal liver perfusion.

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Noting that funding is tied to attendance, Portantino said California school districts would also benefit with the later start time. Senator By Jessica Rice Some California middle school and high school students may get a little more sleep under a bill introduced by California Senator Anthony Portantino, D-La Canada Flintridge. In a statement Monday, Portantino referenced a policy statement from the American Academy of Pediatrics from 2014, in which the organization advised school districts to change start times to 8:30 in the morning or later. The lead author of the statement, pediatrician Judith Owens, said students who get enough sleep are less likely to be overweight, suffer from depression, become involved in car accidents, and are also more likely to experience positive effects including better grades and standardized test scores. During multiple studies at schools that delayed start times, at least nine benefits were observed, according to the American Psychological Association. Portantino said his favorite benefit was "increase in quality of student-family interaction. Another one of the benefits observed was increased attendance at schools that made the shift. Stemming from that observation, Portantino believes later start times will improve attendance at schools, and thus funding for those schools. If the current attendance rate were improved by one percent, the district would gain an added $40 million a year, Portantino said, citing the Los Angeles Unified School District. Portantino said they have not come to a conclusion about zero period, and said it was left out of 186 the bill on purpose because they would like to hear from educators and school districts in the state before a decision is made. Additionally, studies also found decreases in student involved car accidents, disciplinary actions, and decrease in student sleeping during lectures. California school districts would benefit with later school day start times as funding is tied to attendance. Anthony Portantino, D-La Canada Flintridge, introduced a bill Monday that would prohibit middle and high schools from starting classes before 8:30 a. Citing a recommendation from the American Academy of Pediatrics, Portantino says school districts that push back the school day start see an increase in attendance rates, grade point averages and test scores, among other benefits. The science and research are clear: Our kids will do better if we start the school day later. She pointed out that an earlier start time may create problems for parents who drop their kids off before heading to work in the morning, he said. The average start time for middle and high school students in California during the 2011 to 2012 school year was 8:07 a. Portantino said he drafted the bill without an implementation date to gather feedback from stakeholders and give parents time to adjust. He believes the benefits for children will outweigh a schedule disruption to parents. Beyond health effects, Portantino argues that Senate Bill 328 will increase funding for schools, which is often tied to attendance. The Los Angeles Unified School District, for example, estimates that a 1 percent bump in attendance could bring an additional $40 million in funding to the district. Evidence is piling up that the sleep deprivation resulting from adolescents? early start times takes a mental, physical and emotional toll, and a new bill by state Sen. Anthony Portantino, D-La Canada Flintridge, amounts to a wake-up call about wake-up calls. Introducing it, he cited a 2014 American Academy of Pediatrics study that reported that on school nights, 87 percent of high school students and 59 percent of middle school students slept less than the 8. Specific examples of how students are helped by later school starts are easy to find. At Nauset Regional High School in Eastham, Massachusetts, for instance, D and F grades plunged by half after the start of school was changed from 7:35 a. Zoe Lofgren, D-San Jose, has sought to draw attention to sleep deprivation among students since 1998. About 1,000 schools in 70 districts have switched to later starts in recent years, with public high schools in Seattle the highest-profile example.

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