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- With that knowledge let's get back to the case. This young man with a history of abnormal
cholesterol suddenly developed massive elevations of both cholesterol and TG. Something sure
turned on his lipogenic genes. That something is the fairly acute onset of type 2 diabetes mellitus.
As the lipid levels became grossly pathological, the first manifestation was not the pancreatitis but
rather the deposition of the TG into the dermis causing eruptive xanthomas. Tragically that
diagnosis was missed and that could have had lethal consequences (pancreatitis can be fatal).
When you see rapid onset of papulovesiclular lesions on trunks and extremities, eruptive
xanthomas have to be in the differential diagnosis. They are often quite pruritic. It takes 5 minutes
to make the diagnosis: draw a red top tube, spin it and you will see "milk" not clear yellow serum.
Or pick up and ophthalmoscope and glance at the retina where you might see white rather
than red arterial vessels (lipemia retinalis). Both FA and cholesterol lipogenic genes (influenced
by the nuclear transcription factors (NTF) sterol regulatory element binding proteins (SREBP) 2
and 1C can go crazy when the glycemia onset is sudden in insulin resistant and/or insulin
deficient patients developing T2DM. These NTF or genes cause synthesis of enzymes
(lipogenic) that create lipids: such as DGAT, HMGCoA reductase) The FA are rapidly converted
to TG which utilizing MTP joins lots of newly synthesized FC, and CE forming chylomicra and
VLDLs. As one would expect in someone with extreme hypercholesterolemia and
hypertriglyceridemia, there is a massive increase in large TG-rich lipoproteins as evidenced by
the VLDL-P (147 nmol/L). In this case they are both chylos and VLDLs. One cannot differentiate
between chylomicra and VLDL using NMR -- they are simply both very large TG trafficking
particles and reported as large VLDL-P.
The acute onset of T2DM (due to IR and insulin - It was the change in my own attitude toward the game that was of supreme importance to me. It taught me, little by little, the essential difference between betting on fluctuations and anticipating inevitable advances and declines, between gambling and speculating. I think it was a long step forward in my trading education when I realized at last that when old Mr. Partridge kept on telling the other customers, "Well, you know this is a bull market!" he really meant to tell them that the big money was not in the individual fluctuations but in the main movements that is, not in reading the tape but in sizing up the entire market and its trend. And right here let me say one thing: After spending many years in Wall Street and after making and losing millions of dollars I want to tell you this: It never was my thinking that made the big money for me. It always was my sitting. Got that? My sitting tight! It is no trick at all to be right on the market. You always find lots of early bulls in bull markets and early bears in bear markets. I’ve known many men who were right at exactly the right time, and began buying or selling stocks when prices were at the very level which should show the greatest profit. And their experience invariably matched mine that is, they made no real money out of it. Men who can both be right and sit tight are uncommon. I found it one of the hardest things to learn. But it is only after a stock operator has firmly grasped this that he can make big money. It is literally true that millions come easier to a trader after he knows how to trade than hundreds did in the days of his ignorance. – Jesse Livermore
Sunday, 6 May 2012
May 2012 resources
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