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169 Cards in this Set
- Front
- Back
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Deletion of chromosome 15 results in what obesity disorder?
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Prader Willi Syndrome - hypothalamic obesity results, due to intellectual disability, lack of satiety, hyperphagia. Also characterized by: inability to vomit, sensitivity to cold, hypotonia, hypogonadia, GH deficiency
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What is the name of the hypothalamic obesity syndrome which presents with polydactyly, and what is its inheritance pattern?
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Bardet Biedl, which is inherited autosomal recessively.
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What is the satiety centre of the hypothalamus, and what do lesions to the medial and lateral portions result in?
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Ventromedial nucleus of the hypothalamus. Lesions to the medial portion result in hyperphagia and obesity, while lesions to the lateral portion result in anorexia and death
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Name three anorexigenic factors released by the GI tract.
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Cholecystokinin (CCK), GLP-1, PYY
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Which is more common, pituitary adenomas or germ-cell tumours?
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Germ cell tumours are much more common
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What portion of adenomas are non-functioning?
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About 33% are non-functioning (most common type)
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If compression of the pituitary stalk occurs, what is the consequence?
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Hypopituitarism
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Adenoma: What is the typical sequence of hormonal deficiency?
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Gonadotropins, growth hormones, TSH, ACTH
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Intracranial Mass: Vomiting occurs when pressure is applied to what region?
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'area postrema'
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Squamous cell make up what commonly occurring growth from Rathke's pouch? How are they treated?
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Craniopharyngiomas. Usually with surgery, but regrowth is common.
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What markers can often be detected in blood with pituitary tumours?
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Alpha-fetoprotein and beta-human choriogonadotrophic hormone
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What is the most common way of treating adenomas?
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Chemotherapy, sometimes with (trans-sphenoidal) surgery as well
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What is the antifungal agent, ketoconazole, useful for treating?
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Inhibiting steroidogenesis of Cushing's Disease
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What’s the pattern of growth hormone secretion and what influences it?
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Pulsatile secretion from the pituitary, under the influence of somatostatin and GHRH (somatotropin)
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What are the 4 phases of linear growth?
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Prenatal, infantile, childhood, puberty.
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What happens to weight in all the post natal phases?
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increase in lean and fat body mass. Followed by increased bone mass.
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What is the average height difference between males and females and what growth pattern difference is it attributed to?
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13cm higher in males, due to delayed onset of pubertal growth (2 years), and extra 3cm growth in puberty.
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What is the average height gain in puberty?
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In females -25cm; males - 28cm.
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What is the difference between birth weight and 1 year of growth?
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Tripling of birth weight.
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The roof of the pituitary gland is....?
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The sellar diaphragm (sheet of dura mater stretched between the clinoid processes)
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The adenohypophysis is made up embryogically of…
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The roof of the embryonic pharynx
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The three divisions of the adenohypophysis are?
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Pars distalis, pars tuberalis, pars intermedia (between anterior and posterior)
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What are the two acidophil cell types in the pituitary?
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Lactotropes (mammotropes) and somatotropes
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What cell type produces LH and FSH?
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Gonadotropes
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What two nuclei of the hypothalamus project to the pituitary?
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The supraoptic and paraventricular nuclei
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True or false – the anterior pituitary has no direct blood supply?
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True. The superior hypophyseal arteries supply the infundibulum, which supplies the anterior pituitary through a portal system
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What percent of the population has a pituitary tumour (>3mm)?
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Between 6-23% (from random autopsies). Most are not clinically significant
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What is the definition of a microadenoma?
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Tumours that are less than 1cm in diameter
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What are 3 common mass effects of a pituitary tumour (eg. Macroadenomas)?
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Headache from stretching of dura mater; CSF obstruction and hydrocephalis; optic nerve compression (classically bitemporal hemianopia); CN III, IV, VI palsies; CSF rhinorrhoea; hypopituitarism (compression due to tumour)
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The typical order of loss of pituitary hormone secretion occurs …?
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Gonadotropins, GH, TSH, ACTH
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Craniopharyngiomas arise from what embryological tissue? Are they malignant?
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Rathke's pouch (diverticulum of the mouth which forms anterior pituitary). They are benign, but commonly present as raised intracranial pressure from cystic growth.
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What are the top three tumour types in the pituitary?
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Non-functioning adenoma > prolactinoma > GH-producing adenoma
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How do prolactinomas present in women? Men?
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Women: galactorrhoea, menstrual irregularities, infertility. Men: sexual dysfunction.
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What would be the result of a growth hormone secreting tumour in children and adults?
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Children: gigantism. Adults: acromegaly
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How do gonadotrope adenomas present in women? Men? Children?
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Women: nothing. Men: sexual dysfunction or gynaecomastia. Children: precocious puberty.
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What is the classic triad of symptoms seen with raised intracranial pressure? Which symptom is harder to elicit in children?
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Headache, vomiting, papilloedema. Often children do not complain about visual disturbances and cues must be taken from their behaviour (ie. Sitting closer to the TV)
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Pressure inside the skull is based on the volume of what three things?
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The brain, blood and CSF.
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Headaches associated with raised ICP are associated with which structures?
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The headaches are thought to arise from tension on the dura mater or blood vessels
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At what time of day are headaches associated with ICP at their worst?
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Upon waking, when ICP is at its highest
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What is the cause of papilloedema?
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ICP transmission along the optic nerve sheath, though this does not happen in all individuals
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What is the cause of the vomiting with raised ICP?
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Distortion or ischemia of the vomit centre in the medulla
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What are some physical limitations to being short?
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Trouble reaching door handles, car pedals, etc.
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Does formal testing reflect the parents rating of child’s psychosocial problems associated with short stature?
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No, they usually show problems as lesser than what is interpreted by the parents and health care professionals
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What are some psychological complications of short stature?
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Significant school achievement problems, appropriate social skills, behavioural problems, lower IQ
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What are the three traits exhibited by late growing boys in adulthood?
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Less poised, relaxed and more restless.
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How does vasopressin exert its antidiuretic effect?
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Via V2 receptors in the common collecting ducts, which increase cAMP and brings aquaporin proteins to the apical surface and dilates the space between cells
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How does vasopressin exert its pressor effects?
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Via V1 receptors, which increase DAG/IP3 -> ↑Ca2+ in vascular smooth muscle -> ↑vascular resistance
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What triggers the release of vasopressin?
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(1) osmotic pressure of extracellular fluid signals SON and PVN; (2) high pressure detected in baroreceptors of carotid sinus and aortic arch
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What effect does nicotine have on secretion of ADH?
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Strong inhibitory effect
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What disorder arises from failure to produce/secrete VP?
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Diabetes insipitus
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What are the four actions of oxytocin?
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(1) uterine contraction at birth; (2) milk secretion; (3) uterine contractions during coitus help propel semen; (4) behavioural effect of bonding
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Octreotide is an analogue of what hormone, and is used to treat what kind of pituitary tumours?
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Analogue - somatostatin; tumours - Growth Hormone secreting tumours
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Pituitary tumours may obstruct CSF flow in which adjacent structure?
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Interventricular foramen (of Munro)
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Pituitary GCTs (germ-cell tumours) are more common than pituitary adenomas in children, and will result in a serum/CSF elevation of which two oncofetal tumour markers?
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alpha-fetoprotein (AFP) and beta-human choriogonadotrophic hormone (HCG)
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How are malignant GCTs primarily treated? What are the risks?
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By chemotherapy, and sometimes paired with surgery. The risk is whole brain exposure to radiation.
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A wait-and-watch approach is often used for what kind of pituitary adenomas?
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Minimal-symptom microadenomas (<10mm)
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Macroadenomas are treated using what options?
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Surgery, chemotherapy and medications, as they have demonstrated their potential for growth
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When is a tumour not excisable by a trans-sphenoidal route?
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Tumours which extend to subfrontal, retrochiasmatic or middle cranial fossae should be approached with a transcranial route.
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Cabergoline is what type of agonist, and used to treat what kind of adenoma?
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A dopamine agonist, which is used to treat prolactinomas, as it inhibits the release of prolactin.
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If a patient is unsuitable for surgical removal of their corticotropin secreting tumour, what compound can be given to them and what is its MoA?
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The antifungal ketoconazole inhibits adrenal steroidogenesis
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What is the primary treatment for craniopharyngiomas?
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Surgical removal, though there is the risk of regrowth.
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The average natural circadian rhythm is chiefly determined by?
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The intrinsic activity of the SCN
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Which of the following does not contribute to the entraining of our natural circadian rhythm? Social cues, exercise, cortisol levels or melanopsin containing retinal cells
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Cortisol levels
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Name the structures in the pathway by which melatonin release is affected by light?
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Light -> Retinohypothalamic tract (RHT) -> SCN -> spinal cord -> PVN & superior cervical ganglion (SCG) -> (sympathetic innervation of) pineal gland: inhibition melatonin secretion
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Normal onset of melatonin release occurs at what time?
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Between 10PM and 12AM
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What 4 things is melatonin used to treat?
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(1) jetlag; (2) non-24 hour sleep-wake disorder; (3) delayed sleep-phase disorder; (4) insomnia
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What is Addison's disease?
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Autoimmunity which targets the adrenal cortex, resulting in hypoadrenalism
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What are the common targets of the autoimmune response in Addison's, and what general effect does this have on metabolism?
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17-hydroxylase or 21-hydroxylase. Unbalanced hormone production is seen: ↓corticosteroids and ↑androgens)
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What is the clinical presentation of adrenal underactivity?
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Hyperpigmentation (ACTH overdrive), postural hypotension (low Na), ↓cortisol/aldosterone/adrenal androgens
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What is the consequence of adrenal underactivity in infants?
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Can result in masculinization in females
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What are the main causes of adrenal overactivity?
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Primary hyperaldosteronism; tumours; hyperplasia
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What is produced in each 'zona' of the adrenal cortex?
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Z glomerulosa - aldosterone; Z fasiculata - cortisol; Z reticulatum - androgens
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What steroid is the precursor for all subsequent steroid hormones?
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Pregnenolone
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The two synthetic corticosteroids which have a strong affinity for MR, and thereby cause Na-retention and Ca/K-loss are?
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Hydrocortisone and prednisolone
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With cessation of excess steroid therapy, how long may it take to see adrenal atrophy resolve?
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Up to 36 months afterwards
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What type of muscle fibres atrophy in proximal myopathy? What doses of corticosteroids are required to see this?
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Type IIb muscle fibres (fast twitch). Doses exceeding 30mg prednisone
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What two hormones does the hypothalamus use to regulate growth hormone secretion from the pituitary?
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GHRH (aka. somatotropin) and somatostatin.
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What are three ways of increasing growth hormone release?
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High protein intake; early phase sleep; exercise; hypoglycemia; stress
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What are three ways of inhibiting growth hormone release?
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High glucose intake; REM sleep; malnutrition
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What disorder is seen with excessive HGH before bones plates fuse? After?
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Gigantism. Acromegaly.
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What are the major complications of acromegaly?
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Skeletal arthropathy (spine), and cardiomegaly/insufficiency. Diabetes is common. Increased risk of CRC
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What tissues does GH act directly upon? What tissue releases IGF-I and IGF-II, and what are their actions?
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GH acts up muscle, liver and adipose tissue. The liver releases both IGF-I and -II. IGF-I acts upon bone chondrocytes (↑collagen, protein, cell proliferation). IGF-II acts upon other tissues/organs (↑protein synthesis, RNA/DNA, cell proliferation)
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Besides GH (and IGF-I and -II), what other hormones contribute to growth?
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Thyroid hormone, androgens, estrogens, adrenal hormones
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What are some complications that occur with stunted growth?
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Poor self-esteem, depression, underachievement, lower IQ
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Prolactin stimulates secretion of milk. What are three ways of stimulating its release?
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Pregnancy; estrogen; nursing (PRF, prolactoliberin); sleep; stress; TRH; dopamine antagonists, such as antipsychotics; histamine antagonists (H2); adrenergic antagonists
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What inhibits prolactin's release?
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Dopamine; prolactin (feedback)
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FSH stimulates what in males? Females?
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(males) spermatogenesis. (females) maturation of follicles
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LH stimulates what in males? Females?
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(males) testosterone release from Leydig cells. (females) estrogen release from ovaries, ovulation, formation of corpus luteum.
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Name the four phases of normal growth
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Prenatal, infantile, childhood, pubertal
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What effect does GH have on fat stores?
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It stimulates lipolysis
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What is the pattern of bone density growth seen?
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It lags behind height and weight growth.
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What is the Jansen's metaphyseal condrodysplasia, and what are the consequences?
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Constitutive activation of the PTH receptors, which results in short stature
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What is the most common STI at the moment, in developed countries? What does it commonly co-occur with?
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Chlamydia trachomatis. N. Gonorrhoea
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What is the most common cause of genital ulceration?
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HSV (herpes), which is the case 70-80% of the time!
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What percent of women are asymptomatic with chlamydia?
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80% of women
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What is the name of the liver capsule infection, resulting from chlamydia infection?
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Fitz-Hugh-Curtis syndrome
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Which antibiotics are first used for chlamydia infections? Which is used during pregnancy?
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Doxycycline OR azithromycin (latter used in pregnancy)
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How does perinatal chlamydia infection present in the child?
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Pneumonia and conjunctivitis.
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How does Gonorrhoea appear under a microscope?
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Gm negative, diplococci. Intracellular.
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What antibiotics are used to treat gonorrhoea? What is used in pregnancy?
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Ceftriaxone OR cefixime OR ciprofloxacin. None of those are used in pregnancy: use cephalosporin OR spectinomycin
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What is the organism responsible for syphilis?
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Treponema pallidum
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When is primary syphilitic infection seen after contraction, and how does it present?
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3-4 weeks post exposure. It presents as painless inguinal lymphadenopathy and chancres. Serological tests will still be negative.
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Condylomata lata and maculopapular rash (palms, trunks, soles) are seen when in syphilitic infection? What are other systemic effects?
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2-6 months in to syphilitic infection (though may spontaneously resolve before this). Malaise, anorexia, headache, diffuse lymphadenopathy are also seen
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What are the neurological manifestation of tertiary syphilitic infection?
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Tabes dorsalis (slow degeneration of dorsal column) and general paresis
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What is the gold standard investigation for diagnosis of syphilis?
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Darkfield microscopy, looking for spirochetes
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What is the antibiotic used for syphilis?
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(benzathine) penicillin
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What STI presents with itching, tingling or burning 2-21 days after exposure?
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Herpes Simplex Virus
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How soon is one infectious after exposure to HSV?
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7-10 days, when the lesions appear
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How is diagnosis of genital herpes made?
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With viral culture, cytologic smear, antibody tests or PCR
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How is genital herpes treated?
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With acyclovir until it is in remission. Educate patient about transmission.
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What are some theories about the aetiology of endometriosis?
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Retrograde menstruation; lymphatic flow; metaplasia; extrapelvic disease
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What percentage of women are affected by endometriosis? How is it affected by menopause?
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15-30% of premenopausal women. Regression is common after menopause.
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When is the mean age of onset of endometriosis?
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Age 25-30
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Family history increases the risk of endometriosis by how much?
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Ten-fold.
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What are other risk factors for endometriosis?
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Genital tract obstructions. Nulliparity. Age > 25
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Where is the most common site to find endometriosis? Where are some sites outside of the genital tract?
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Ovaries are affected in 60% of cases. Other sites include: rectosigmoid colon and appendix
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If not asymptomatic, how does endometriosis typically present?
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Sacral pain with menses, deep dyspareunia, dysmenorrhea. Sometimes persistent pain. Pre-/Post-menstrual spotting. Bowel or bladder dysfunction.
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What percentage of infertility cases does endometriosis account for?
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Upwards of 30% of infertility cases
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The differential diagnosis for endometriosis should include?
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Ectopic pregnancy, recurrent salpingitis, haemorrhagic corpus luteum, ovarian neoplasm, chronic PID
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How is diagnosis of endometriosis made? What biomarker is used to confirm?
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By direct visualization with a laparoscope, and biopsying growths. On visualization, will have chocolate cysts (endometriomas) or mulberry spots, sometimes with a 'powder burn' appearance on the surface. Biomarker CA-125 is used.
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What medical treatment is used for endometriosis, and what are the goals of it?
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The goals are to minimize discomfort (with NSAIDs) and regress growth (pseudopregnancy with OCPs)
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What is the recurrence rate of endometriosis after medical treatment? Surgical?
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Both have recurrence rates of up to 40%
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With Polycystic Ovarian Syndrome, what is the typical age of onset? What is the clinical picture?
|
Age 15-35. Virilization: anovulation, hirsutism, infertility, obesity. Also acanthosis nigricans
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How PCOS appear on ultrasound? What biomarkers are used for diagnosis? Other tests?
|
As a string of pearls. Biomarkers: LH:FSH > 2:1. OGTT are also done, to determine insulin resistance
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How is the menstrual cycle managed in PCOS? Menorrhagia?
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Weight loss, and OCP (or Provera). Menorrhagia is treated with transexamic acid
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How is infertility treated, in PCOS?
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Medically induced ovulation: human menopausal gonadotropins, LHRH, recombinant LSH, metformin. Can also use ovarian drilling
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How is hursuitism treated, in PCOS?
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OCPs. Finesteride. Glutamide (androgen reuptake inhibitor). Mechanical removal.
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What symptoms are commonly reported by persons with anxiety?
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Shaking, flushes/chills, sweating, nausea, palpitations
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What changes to BGLs, TGs and hormones (CRH, ACTH, cortisol, adrenalin, PRL, ADH) are seen in anxiety?
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All are increased
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Outflow/tone from what component of the nervous system is increased in anxiety?
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Sympathetic nervous system
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Which hormone levels are increased in the anxious state due to SNS stimulation?
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CRH (ACTH, cortisol), PRL, ADH, adrenalin
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How does SNS stimulation result in increased availability of glucose for muscle action?
|
Cortisol and adrenalin counteract insulin, and stimulate glycogenolysis and gluconeogenesis
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What change occurs to blood volume, in response to SNS stimulation, and why?
|
Vasoconstriction (cortisol, adrenalin, vasopressin) causes reduced blood flow to the kidneys, which increases RAAS activity, increasing blood volume.
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Why does thyrotoxicosis result in anxiety?
|
Thyroid hormones potentiate actions of catecholamines.
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What tumour may result in anxiety?
|
Phaeochromocytoma (of the adrenal medulla; PCC)
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Define basal metabolic rate (BMR)
|
Energy expenditure when body is at rest (not asleep), with no muscle movement or SNS arousal
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Resting metabolic rate is how much higher than BMR?
|
10-15%
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BMR is primarily determined by what?
|
Lean body mass (LBM). Therefore it is higher in obese persons, who have greater muscle mass to support their fat mass.
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What are three means of decreasing BMR?
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Fasting, caloric restriction, weight loss, hypothyroid state
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What are the 3 catecholamines in the body?
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Dopamine, adrenalin, noradrenalin
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Where is adrenaline secreted?
|
Secreted by the adrenal medulla
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What is the adrenalin synthesis pathway? What enzyme is involved?
|
Tyrosine -> DOPA -> dopamine -> noradrenaline -> adrenalin. The enzyme involved is tyrosine hydroxylase
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What are the subtypes of adrenalin receptors and their general mechanism of action?
|
Alpha and beta-adrenoreceptors: Alpha adrenoreceptors inhibit adenyl cyclase and decrease cAMP; activate phospholipase C and increase Ca2+ levels; Beta-receptors work on GPCRs, stimulating adenylate cyclase, converting ATP to cAMP
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What tissues are beta-adrenoreceptors present in and what is the effect on them?
|
(heart) increase force of contraction, and AV node conduction; (kidney, JGA) release renin; (smooth muscle) relaxation of bronchi, gut, genitourinary systems; (skeletal muscle/liver) glycogenolysis; (adipose) lipolysis
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How would one diagnose PCC (Phaeochromocytoma)?
|
By measurement of catecholamines (and metabolites) in urine, and visualization of the tumour on CT scan
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How can one manage the symptoms of thyrotoxicosis?
|
By blockade of beta-adrenoreceptors, which are overstimulated
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What is the most common cause of goitre in the world?
|
Iodine deficiency
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What are 2 ways goitres can be classified, how are they further classified?
|
Structure (nodular or diffuse) or functional (toxic or non-toxic)
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What is the grading system used for goitres?
|
Grade 0-3. 0 = not visible/palpable; 1a = only palpable; 1b = visible on neck extension; 2 = visible when neck normal; 3 = large; detectable from distance
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|
What hormones (in addition to TSH) may stimulate thyroid growth, or modulate TSH's effects?
|
Insulin, insulin-like growth factor, human chorionic gonadotropin
|
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What kind of goitre will be seen in Graves?
|
Diffuse, toxic (generally)
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Why does thyrotoxicosis result in feeling tiredness, despite increased mobilization of energy stores?
|
Mismanagement of energy means that much is depleted, and muscles also become wasted.
|
|
Describe lid lag.
|
Descent of the eyelid lags behind descent of the eyeball.
|
|
What are some muscle signs seen in hypothyroidism?
|
Muscle pain, delayed reflexes
|
|
Where does the puffy look in the face, hands and supraclavicular fossa come from, in hypothyroidism?
|
Increased deposition of glycosaminoglycans
|
|
Discolouration occurs in skin (palms) due to what in hypothyroidism?
|
Hypercarotonemia (yellow colour)
|
|
Effusion, in hypothyroidism, may be found where?
|
Pleural, pericardial and ascites.
|
|
In what condition are thyroid bruits common?
|
Graves, where there is increased vascularity
|
|
Binding of autoimmune antibodies to the thyroid causes hypothyroidism – T/F?
|
TRUE
|
|
Which antibody is implicated in Graves disease?
|
TSH-R stimulating antibodies.
|
|
If TSH levels are high the patient is most likely suffering from: A – thyrotoxicosis, B – primary hypothyroism, C – pituitary tumour
|
B - primary hypothyroidism, as the pituitary is attempting to compensate
|
|
How long does TSH take to re-equilibrate after a change in thyroid status?
|
Approximately 4 weeks
|
|
What would you expect to see with iodine isotope (technetium pertechnetate) uptake in a patient with Graves disease, why?
|
Increased uptake, due to increased TSH-R stimulation
|
|
What are the drugs carbimazole and propyl-thiouracil (PTU) used for in Graves disease?
|
For blocking the (peroxidase activity) synthesis of triiodothyronine and thyroxine hormones
|
|
What are some serious complications of antithyroid drugs?
|
Agranulocytosis (rare) and liver function abnormalities. Neomercazole (NMZ ) is preferred unless in first trimester of pregnancy
|
|
With pharmacotherapy, how long does a remission of Graves take?
|
12-18 months of therapy
|
|
What is the main indications for thyroidectomy? qualifying factor?
|
In the case of thyroid tumour or obstruction. The patient should be made euthyroid with antithyroid drugs beforehand.
|
|
What is the treatment for hypothyroidism?
|
Oral thyroxine (start low). Re-evaluate dose every 4 weeks until TSH is stable
|
|
Thyroid carcinomas – what are the stages of treatment, what marker do you need to monitor?
|
Total thyroidectomy, followed by 131I. Thyroxine is given for 6-12 months, to suppress TSH release and reduce chance of reoccurrence.
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