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Modify the response of the parasympathetic nervous system
Regulates the release of gonadotropic hormones (LH and FSH)
1. High nucleus to cytoplasmic ratio.
2. Prominent nucleoli
3. Many mitotic figures
4. Nuclear chromatin clumping
Epithelial tumors tend to spread via the lymphatics.
Common metastases to the liver:
Colon, stomach, breast, pancreas, lung.
Colon > stomach > pancreas
Common metastases to the brain:
Lung, Breast, Skin (melanoma), Kidney, GI cancers
Lung > Breast > Kidney > Skin (melanoma)
Common metastases to bone:
Prostate, Testes/Thyroid, Breast, Lung, Kidney
Prostate/Breast > lung > Thyroid/Testes
MOA: 1)Free radical generation
2) Intercalates in DNAToxicity: Cardiotoxic. Dexrazoxane can be used to prevent cardiotoxicity.
MOA: Free radical formation leading to DNA breaking
Treatment: Testicular cancer; Hodgkin's lymphoma
Side Effects: Pulmonary Toxicity
Etoposide, Bleomycin, Cisplatin.
These are all drugs used in the treatment of Testicular cancer.
1)Vinca alkyloids (Vincristine, Vinblastine)
2) Taxanes (Paclitaxel, Docitaxel)
3) Anti-helminthics (Bendazoles)
Vasculitis of medium arteries that affect very young children. The most serious complication is coronary artery involvement leading to coronary artery aneurysms. Symptoms are:
Fever, Bilateral conjunctivitis, Lympadenopathy, "strawberry" Tongue, erythema and edema. Also peeling of the hands/soles/fingertips.
Rule out Rickettsial diseases.
1. Transketolase - HMP Shunt
2. alpha-ketoglutarate dehydrogenase - TCA
3. Pyruvate Dehydrogenase - Glycolysis
4. Branched chain amino-acid dehydrogenase
Brief arrhytmic jerking movements, last <1 sec, usually occur in clusters for a few minutes; no loss of conciousness.
Treatment - 1st line: Valproic Acid
Typical Antipsychotic. Low potency.
Side effect: May cause retinal deposits that resemble retinitis pigmentosa.
1. Thickening and distortion of mitral valve leaflets.
2. Commissural fusion at the leaflet edges.
3. Stenosis of the mitral valve orifice.
Fibrosis of the valve leaflets follow acute rheumatic fever is the most common cause of mitral stenosis (up to 99% of cases). This can cause atrial enlargement which may lead to mural thromboses and then embolism.
Pemphigus vulgaris vs.
Bullous pemphigoid - autoantibodies against hemidesmosomal proteins. Bullae remain intact and mucosal involvement is uncommon. Negative for Nikolsky sign.
Pemphigus vulgaris - autoantibodies against desmosomal proteins 3 and 1 that result in painful, flaccid bullae and eruptions of skin and mucous membranes. They spread laterally with pressure (Asboe-Hansen sign), and new bullae form with gentle traction (Nikolsky sign).
ACTH -> Cushing's syndrome
PTH-related peptide -> Hypercalcemia
Erythropoetin -> Polycythemia
ADH -> SIADH
How standard deviations cover a Gaussian Curve
+/- 1 deviation - 68%
+/- 2 deviations - 95%
+/- 3 deviations - 99.7%
1. Medial hypertrophy
2. Sclerosis of the intima
PA02=Pi02 - (PaCO2/R)
PAO2 = 150 - (PaCO2/0.8)
A-a gradient = PA02 - PaO2
Normal range is typically between 10-15 mmHg
Increased gradient can occur in hypoxemia. Artifical increases come from delivering too much O2 (can't all be absorbed) and increasing age.
Pyruvate Dehydrogenase deficiency
Treatment: Increased intake of ketogenic nutrients
What is the main toxin of Clostridium perfringens?
PaCO2 = 1.5 X HCO3- +8 +/- 2
This is an equation that will predict respiratory compensation. If you see changes from this, then you can expect something helping the compensation.
Blood-borne phase - Suramin
CNS phase - melarsoprol
Cutaneous: Sodium stibogluconate
Visceral: Liposomal Amphotericin B
Schistosoma spp. (Blood)
Clonorchis sinensis (Biliary)
Paragonimus westermani (Lung)
Atopic diseases (allergy, asthma, Churg Strauss)
Acute interstitial nephritis
Collagen vascular diseases
Parasites (invasive typically)
3 forms (AR):
1. Cystathionine synthase deficiency - (Rx: decrease met, increase cys, give B12 and folate)
2. Decreased cystathionin synthase affinity for B6 - Rx: Give B6 in lots
3. Homocysteine methyltransferase deficiency - Rx: Give B12
Symptoms: Increased homocystine in urine, mental retardation, osteporosis, tall stature, kyphosis, lens subluxation and atherosclerosis (stroke and MI).
Defect in branched chain aminoacid metabolism (Ile, Leu, Val) from alpha-ketoacid dehydrogenase deficiency. This enzyme requires the same cofactor as pyruvate dehydrogenase.
Can cause CNS defects, mental retardation and death, also ketoacidosis and maple syrup smelling urine (hence the name).
X-ray often looks a lot worse than symptomsTreatment: Macrolides
coag negative staph
Strep bovis (in colon cancer)
1. Haemophilus influenza
2. E. coli and Enterococcus
4. Proteus mirabilis
5. Salmonella and Shigella
TCP or "Take care of pseudomonas"
Cefotetan, cefamandole, cefoperazone
1st generation sulfonylureas
B - Barbituates
C - Carbemazepine
G - Griseofulvin
P - Phenytoin
Q - Quinidine
R - Rifampin
S - St. John's Wort
P - Protease inhibitors
I - Isoniazid
C - Cimetidine
C - Ciprofloxacin
K - Ketoconazole
E - Erythromycin
G - Grapefruit juice
S - Sulfonamides
Viruses (mono, hepatitis)
Lupus and Leprosy
Verify actual syphillis infection with FTA-ABS test.
Glucokinase is a monitor of blood glucose for the beta-cells of the pancreas. Insufficient amounts of enzyme can result in insufficient insulin secretion in the face of larger glucose loads. This can be exacerbated by pregnancy.
Enteroviruses (over 90% of cases). These include:
MAP = 2/3 diastolic pressure + 1/3 systolic pressure
MAP = CO X Total Peripheral Resistance
Decreased G-6-PDH leads to less reduction of glutathione in RBCs which means there is an intravascular hemolysis when presented with oxidative stress. Common sources of oxidative stress are lima beans and many drugs.
Inherited as a recessive X-linked gene
Peripheral blood smear will show Heintz bodies and bite cells.
MoA: A sugar that is digested by bacteria in the stomach to create an acidic environment. This allows conversion of NH3 to NH4+. This traps ammonium in the colon for excretion.
Uses: Ammonia intoxication (like in urea cycle disorders)
Right - Systolic 25 / Diastolic 5
Left - Systolic 130 / Diastolic 10
Coxsackie Virus B myocarditis
Chronic Cocaine use
In IV drug users, suspect Staph aureus, Strep epidermidis, Pseudomonas aeruginosa, and Candida as causitive organisms.
IV drug users are also more likely to have involvement of the tricuspid valve leaflets. This can lead to PE from bacterial embolism.
J- Joints (Migratory polyarthritis)
O - Heart shaped O for pancarditis
N - Nodules (sub-cutaneous)
E - Erythema Migrans
S - Sydenham chorea/St. Vitus dance
Exaggerated decrease of systolic BP of >10mmHg upon inspiration.
Inspiration allows for greater venous return -> pushes the septum into the left ventricle -> less left ventricular filling and preload -> transiently lower SBP.
Seen in: Cardiac tamponade, asthma, obstructive sleep apnea, pericarditis and croup
Excess Vitamin A, tetracyclines, corticosteroid withdrawl.
Rx - Weight loss in obese, Acetazolamide, if refractory invasive serial lumbar puncture, LP shunt or optic nerve desheathing.
Urinary incontinence, ataxia, dementia
"Wet, Wobbly, Wacky"
This is a granulomatous vasculitis associated with eosinophilia and young asthmatics. Can present with sinusitis, palpable purpura, peripheral neuropathy, heart, GI and kidney abnormalities. p-ANCA positive.
Most common systemic vasculitis of children. Like to follow URIs.
1. Palpable pupura on buttocks/legs
3. GI: Ab pain, melena, lesions of the same age
Caused by IgA immune complexes and associated with IgA nephropathy
Prothrombin gene mutation G20210A
Associated with venous clotting
Caused by trinucleotide repeat of GAA in the frataxin gene. This results in mitochondrial dysfunction and loss of the spinocerebellar tract
Signs and symptoms: Ataxia, falling, nystagmus, dysarthria, pes cavus, hammer toes.
Cause of death: Hypertrophic cardiomyopathy
X-linked recessive defect causing progressive deletion of B and T cells.
Common triad is TIE: Thrombocytopenia, Infections, Eczema. Associated with increased IgA and IgE with decreased IgM
Insulin-like growth factor 1
Fibroblast growth factor
Platelet derived growth factor
All are lateral ankle ligaments. From most to least common (also most to least severe):
Anterior talofibular ligament
Posterior talofibular ligament
Posterior circumflex artery
Anterior glenohumeral ligaments and glenoid labrum separation from anterior glenoid neck (aka Bankart lesion)
Posterolateral humeral head defect (from abrasion to against anterior rim of the glenoid fossa. Aka Hill-Sachs lesion)
Supraspinatus - first 15 degrees of arm abduction
Infraspinatus - lateral rotation of arm
teres minor - lateral rotation of arm, adduction
Subscapularis - medial rotation of arm, adduciton
1. Strep pneumoniae
2. Haemophilus influenza
3. Morexella catarrhalis
Treat with amoxicillin, amoxicillin with clavulanate, cephalosporins or tympanostomy tubes for recurrant infection.
West Nile Virus
Inability to convert orotic acid to UMP via orotic acid phosphoribosyltransferase or orotidine 5-phosphate decarboxylase.
Findings are increased orotic acid in the urine, a megaloblastic anemia that does not correct with B12 or Folate, and failure to thrive. No hyperammonemia is seen. Treat with oral uridine.
Hereditary form due to a defect in delta-aminolevulinic acid leading to decreased heme synthesis. X-linked. Responds very well to B6 therapy.
Can also be caused by alcohol and lead injestion.
Symptoms: unilateral headache (often severe aching/boring in the periorbital/retro-orbital region) with partial Horner syndrome, ipsilateral nasal congestion, eye redness, rhinorrhea or tearing.
Rx - 100% oxygen supplementation helps allevaite symptoms.
B: bromocriptine (ergot), pramipexole, repinerole (Dopa receptor agonists)
A: Amantadine (Increases dopamine release)
L: Levodopa (given with carbodopa, is converted into dopamine
S: Segiline (MAO-B inhibitor), entacapone, tolcapone (COMT inhibitors - both prevent dopa degredation)
A: Antimuscarinics (Specifically benztropine)
Seizure meds (Ethosuximide, carbemazepine, lamotrigine, phenytoin, phenobarbital)
Fetal hydantoin syndrome
Drug induced lupus
A non-antibody binder of GP IIb/IIIa that will prevent platelet aggreation.
Side effects are bleeding and thrombocytopenia
Pathophys: Deficiency of ADAMTS 13 (vWF metalloprotease) leads to decrease degredation of vWF multimers. These large multimers cause increased platelet aggregation causing both thrombosis and thrombocytopenia.
Symptoms: Pentad of Thrombocytopenia, neurologic symptoms, fever, renal symptoms and microangiopathic hemolysis.
Note: HUS presents with Shiga-like toxin working by the same mechanism and has a triad that doesn not include the neural symptoms or fever.
Try to Fly High:
More likely to have EPS
Low potency typical antipsychotics are more likely to have anticholinergic, antihistimine and alpha blockade side effects.
Use: Mood stabilizer for bipolar disorder. Control of mania.
Side effects: Tremor, sedation, heart block, hypothyroidism, Polyuria (nephrogenic Diabetes Insipidus is a possible side effect), Teratogen (particularly Ebstein's anomal and great vessel malformations).
Olanzapine (side effect of weight gain and danger of diabetes)
Clozapine (monitor "clozely" for aplastic anemia)
5-HT1b/1d agonist that causes vasoconstriction.
Uses: Control of migraines and other headaches.
Contraindicated in populations where vasoconstriction is unwanted: Coronary artery disease, Prinzmetal's angina, Pregnancy (use opioids instead)
Increased pressure on the baroreceptors (by either increase in MAP or physical massage), increases the amount of firing carried up to the brainstem. This results in the sending of a parasympathetic signal that will slow the heart by increasing the refractory periods in the SA and AV node.
In decreases of pressure, the brainstem will send sympathetic signals down due to a decrease in firing from the baroreceptors.
Remember, this information is carried from the aortic baroreceptors in the Vagus nerve and from the Carotid sinus in the glossopharyngeal nerve.
Cauda equina syndrome.
This is compression of the nerve roots in the cauda equina either by a mass or a massive disk herniation. This results in a "saddle anesthesia" and loss of the anocutaneous reflex. The affect nerves are S2-S4.
The picture is of Gottron papules which are flat-topped violaceous papules over the joints and fingers. This with a heliotrope rash and progressive muscle weakness via muscle cell destruction is typical for dermatomyositis. This disease carries an increased risk of cancer.
Odd-chain fatty acid
Cholesterol side chains
Not used very often because of dietary restrictions, drug-drug interactions and lengthy side effect profiles. However, they are good in the use of atypical depression (eg. hyperphagia, hypersomnia and weight gain) as well as resistant depression.
PTU and Methimizole
Polyarteritis nodosa (PAN).
This is a segmental, transmural, necrotizing inflammation of medium to small sized arteries in any organ except for the lung. This typically presents with fever, ab pain, neuropathy, weakness and weight loss. This is also associated with Hep B infections and can be seen in 10-30% of cases.
Medullary Sponge Kidney (MSK)
Mostly benign condition involving the dilation of medullary collecting ducts and is only associated with Kidney stones. It is often an incidental finding.
What bedside maneuver exaggerates the murmur of mitral regurgitation and VSD?
Fluoxetine, Paroxetine, sertraline, fluvoxamine, citalopram
Low overdose risk. Used for depression, OCD, bulimia, social phobias and PTSD
Side effects: GI distress, sexual dysfunction.
"Serotonin Syndrome" - usually requires the use of another serotonin increasing drug. You se myoclonus, hyperthermia, diarrhea, flushing, cardiovascular collapse and seixure.
Venlafaxine, duloxetine, nefazodone, miilnacipran
Used for Depression, generalized anxiety disorder (Venlafaxine), Diabetic peripheral nephropathy (duloxetine).
Side effects: Increased BP, stimulant, sedation, nausea.
RBF = RPF/(1-Hct)
RPF = C of PAH
C = UV/P
Zona occludens (Tight junctions)
Zona adherens (Intermediate junctions)
Macula adherense (Desmosomes)
Paraldehyde or phenformin
Isoniazid or irontablets
Wilms' tumor, Aniridia, Genitourinary malformation, mental-motor Retardation.
Associated with a mutation in the WT-1 gene on chromosome 11p
Defects in the ATM gene which codes for DNA repair enzymes.
Triad: Cerebellar defects (ataxia), spider angiomas (telangiectasia), IgA deficiencyPredisposition for Lymphomas and Leukemias
Widening of the mediastinum due to aortic dissection.
The "tearing pain radiating to the back" is a classic presentation of aortic dissection. Risk factors for aortic dissection are chronic hypertenion and cystic medial necrosis (seen in Marfan's)
3. Intracranial calcifications
You can also see pulmonary stenosis and "blueberry muffin" rash
VANC can cause flushing:
Calcium channel blockers
Drugs that can cause torsade de points
K+ channel blockers, Type IA antiarrhythmics, macrolides, haloperidol, chloroquine, protease inhibitors
Treat with Mg++ push
Amanita phalloides toxin
Amanita phalloides toxin
"STOP making New Thrombi"
1. Owl's Eyes inclusion?
2. Owl's eyes nucleus?
3. Owl's eyes Protozoan?
1. CMV infection
2. Hodgekin's lymphoma
HPV 16 has an E6 gene product that supresses p53.HPV 18 has an E7 gene product that supresses RB.
Doxepin, amoxapine, Amitriptyline (-iptyline), Imipramine (-ipramine)
Uses: Depression, Bedwetting (imipramine), OCD (Clomipramine), fibromyalgia
Toxicities: Anticholinergic, alpha-blocking, Sedation. Tertiary (amitriptyline) have more anticholinergic effects than secondary (nortriptylin) TCAs. Tri-C: Convulsions, Coma, Cardiotoxicity (arrhythmias)
Coxsackie A virus (hand-foot-mouth disease)
Rocky Mountains Spotted Fever (Rickettsia rickettsii)
Hypokalemia, hypertension, metabolic alkalosis.
Remember, this is primary hyperaldosteronism.
Subacute combined degeneration.
This combination is degeneration of both the dorsal columns as well as the descending lateral corticospinal tracts. This can also include a peripheral neuropathy.
This presents as loss of position sense and vibration, ataxia and spastic paresis.
Unconjugated (indirect) bilirubin is taken up by a passive organic anion transport protein (OATP).
Conjugated (direct) bilirubin is secreted into the biliary system by an energy dependant ATP-binding cassette protein MRP2 (an ATP depending organic anion transporter).
Chronic Granulomatous disease; a NADPH oxidase deficieny.
Remember, this is the condition where you get repeated infections from catalase positive organisms due to a lack of NADPH producing sufficient reactive oxygen to kill them off. X-linked disorder.
Vitamin D deficiency (Rickets/Osteomalacia)
Clinical features include bowing of legs, the "rachitic rosary" or bony prominences at the costochondral junction of the chest, Harrison's sulci (indentation in the lower ribs, craniotabes (softening of the skull), and growth retardation.
High frequency sound is best heard near the base of the cochlea, near the round and oval windows (remember that the stapes presses on the oval window to create sound).
Low frequencies are best picked up at the apex of the cochlea near the helicotrema.
Findings: Progressive neurodegeneration, hepatosplenomegaly, cherry-red spot on macula, foam cells
Deficient enzyme: Sphingomyelinase
Findings: Progressive neurodegeneration, developmental delay, cherry-red spot on macula, lysosomes with onion skin, no hepatosplenomegaly.
Deficient enzyme: Hexosaminidase A
Accumulation: GM2 ganglioside
AR inherited. Sandhoff's is Hexoasaminidase B and really bad/fast Tay-Sachs
Findings: Peripheral neuropathy, developmental delay, optic atrophy, globoid cells.
Deficient enzyme: beta-galactocerebrosidase
Findings: Central and peripheral demyelination with ataxia, dementia.
Deficient enzyme: Arulsulfatase A
Accumulation: Cerebrosde sulfate
Findings: Developmental delay, gargoylism, airway obstruction, corneal clouding, hepatosplenomegaly.
Deficient enzyme: alpha-L-iduronidase
Accumulation: Heparan/Dermatan sulfate
Scheie is like this without mental retardation. AR inheritance.
Findings: A mild presentation of Hurler's syndrome + aggressive behavior, no corneal clouding.
Deficient enzyme: Iduronate sulfatase
Accumulation: Heparan/Dermatan sulfate
X-linked recessive inheritance
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