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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

https://profiles.ucsf.edu/william.weiss

Review of systems is notable for intermittent cough discount 500mg calcium carbonate overnight delivery medicine vs surgery, increasing dyspnea on exertion discount 500 mg calcium carbonate treatment 3rd stage breast cancer, a 2 purchase calcium carbonate 500 mg without prescription medications ending in pril. Salah Mabrouk Khallaf smoked one pack of cigarettes per day for 49 years but quit smoking 2 years ago generic calcium carbonate 500 mg without prescription medications for bipolar disorder. On physical examination, distant breath sounds are audible in both lungs and there are scattered rhonchi. Ciprofloxacin, 500 mg every 12 hours, is administered for 10 days, but he notes little improvement in the swelling. She has just seen a television program on ovarian cancer, and is concerned because previous use of fertility drugs and a family history of ovarian cancer were mentioned as possible risk factors. Her mother developed endometrial cancer at 56 years, and a paternal uncle was diagnosed with a type of lymphoma at 60 years. She has one older sister with hypertension and one younger brother who is healthy. Results of her pelvic examination are unremarkable, but she asks what additional tests she should have to look for ovarian cancer in the early stages that cannot be detected by physical examination. Her periods cease while she is receiving chemotherapy, and she remains amenorrheic. Her hair is growing back and her energy is returning, but she is having severe hot flushes that keep her awake at night. She is so tired during the day that she is unable to perform her job in a satisfactory manner. She also relates that she and her husband have been unable to have satisfying sexual relations because intercourse is painful for her. A selective serotonin reuptake inhibitor and use of nonhormonal vaginal lubricating preparations B. Reassurance that these normal physiologic responses to menopause will resolve in time C. His digital rectal examination reveals a mildly enlarged prostate gland with no discrete nodules. A 58-year-old woman with a 60-pack-year smoking history is evaluated because of hemoptysis and weight loss. Examination of a specimen by bronchoscopic biopsy confirms small-cell lung cancer, and the findings suggest limited-stage disease. A 63-year-old man is evaluated because of a several-month history of increasing fatigue and some vague upper abdominal discomfort. His medical history includes gastroesophageal reflux disease, coronary artery disease, and clinical depression, all of which are well controlled with medications. Colonoscopy reveals a nonobstructing, non bleeding lesion; biopsy shows it to be poorly differentiated adenocarcinoma. Fine needle aspiration of one of the liver lesions confirms the presence of malignant cells consistent with a primary colon cancer. Exploratory laparotomy with resection of the primary tumor and placement of a hepatic arterial infusion pump D. He remains asymptomatic, and a recent bone scan revealed only degenerative disease. A 61-year-old man with a 120-pack-year smoking history is evaluated for a persistent and worsening cough and found to have a 3-cm mass in the right upper lobe on chest radiography. Positron emission tomography scan shows uptake only in the right upper lobe mass, and pulmonary function tests indicate that the patient has adequate pulmonary reserve to undergo resection. All margins are clear, and all peribronchial lymph nodes are negative for tumor within the resected specimen. Four cycles of combination chemotherapy including a taxane, followed by radiation therapy to the draining lymph node sites in the mediastinum C. Salah Mabrouk Khallaf cancer could be resected; the largest residual tumor was 3 cm in diameter. She is interested in pursuing aggressive therapy and wishes to be treated as soon as possible in her local community. The proposed systemic therapy will involve cisplatin or carboplatin and paclitaxel. A 62-year-old postmenopausal woman with a family history of breast cancer in two first-degree relatives wishes to consider taking tamoxifen to reduce her risk of breast cancer. Her baseline risk of breast cancer qualifies her for consideration of tamoxifen. Needle biopsy specimen shows adenocarcinoma; the tumor is found to be negative for hormone receptors. Her mother had breast cancer at 62 years and was treated by mastectomy; she is alive and healthy at the age of 80 years. The patients sister had breast cancer at 54 years and was treated by breast conservation therapy; 4 years later she died of a recurrence of breast cancer. The patient has seen two different surgeons with opposing viewpoints regarding the best treatment, and she has been reading extensively on the Internet and has become confused about her options. Chemotherapy, tamoxifen, and radiation therapy to the breast and axillary regions 55. A 32-year-old woman is evaluated because of a painless swelling in her lower neck. She has not had fever or unexplained weight loss, but has had night sweats twice in the past week. The remainder of her physical examination and results of a complete blood count are normal. Refer her to an otolaryngologist for a thorough search for a primary lesion of the oropharyngeal mucosa C.

Reactions of the adult humans in cold environment A) the increase heat production and B) the decrease heat loss Ad A) 1 cheap calcium carbonate 500mg with amex symptoms crohns disease. Food intake (specific dynamic action – the obligatory energy expenditure that occurs during its assimilation into the body) 3 discount 500 mg calcium carbonate fast delivery medications available in mexico. Muscular activity: a) Shivering – simultaneous contractions flexors and extensors muscles order calcium carbonate 500mg line medicine vicodin, heat production purchase calcium carbonate 500 mg without prescription symptoms copd. Vasoconstriction in the skin – alpha adrenergic sympathetic nerves – the decrease in heat loss Lewis reaction – during long-term cold application – vasodilatation – red color of the skin – warming up protective function 2. Position with the smallest body surface – quasi spheric shape Hormonal changes: the thyroid gland – in long-lasting stay in cold – calorigenic effect the adrenal medulla noradrenalin – vasoconstriction Hypothalamus – the posterior pituitary – vasopressin – vasoconstriction and water retention Reactions of the adult humans in hot environment A) the decrease heat production and B) the increase heat loss Ad A) 1. The decrease in metabolic rate – T = 25 – 30 C (higher temperatury – a rise of the metabolic rate) 2. Prevention of cold stress and hypothermic for neonatal care – clinical implications: Exposure to cool environment – cold stress often result in pathophysiological changes. Neutral Thermal Environment = a range of ambient temperatures within which the metabolic rate is minimal and thermoregulation is achieved by basal physical processes alone. Hyperthermia can exist when heat production exceeds heat dissipation = disequilibrium Variety of reasons: An increase in metabolic heat production, an impairment of heat dissipating mechanisms, a decrease in the heat –absorbing capacity of the environment due to high ambient temparture Exogenous hyperthermia, enormous physical effort. Humoral regulation in exercise Adrenal medulla: Catecholamines: Adrenaline – positive effects on heart and liver (mobilisation of glycogen and free fatty acids). Hypophysis (anterior pituitary): Increase (20 to 40 – fold after 20 min of exercise) in growth hormone secretion. Stimulation of anabolism – strengthening muscle ligaments and tendons, increasing bone thickness. Prolactin – increased blood levels following exercise –mobilizes fat + antidiuretic effect upon kidneys Endorphins: similarity to the opiates. Together with prolactin can be factor responsible for exercise-induced amenorrhoea. Limit for the sympathetics activation is individual – on average in exercise with 50 – 60 % of maximal oxygen consumption. Calculating Heart Rate Training Zones: There are a number of ways to estimate maximum heart rate. Realize that we are estimating maximum heart rate not measuring it so it is not an exact science. Reactivation of vagal nerves + progressive reduction of the sympathetic and hormonal activities. Tachycardia shortening of the diastole (ratio St:Dt at rest = 1:2, in maximal tachycardia up 1:1) = a decrease in diastolic refilling of the ventricles. The Starling relation curve is shifted to the left and up (effect of sympathetic stimulation, catecholamines). Blood Pressure Systemic: syst: rises sharply during isometric and sustained rhythmic exercise. Distribution of Blood Flow Muscle Blood Flow:At rest-open 200 capillaries/ mm2, in working muscle 10-15x more. Neural regulation through noradrenergic system (reduction of activity) and specific cholinergic sympathetic vasodilatory system. During heavy exercise – the ventilation is „overproportional“ – additive stimulus metabolic acidosis (lactic acid) via central chemoreceptors. Maximum aerobic capacity Increasing of a loading – a linear rise of oxygen consumption to a individual maximum – further increasing – disproportion between requirements and intake = exhaustion fatigue. The amount of extra O2 consumed is proportionate to the extent to which the energy demands during exercise exceeded the capacity for the aerobic synthesis of energy stores. The O2 debt is measured by determining O2 consumption after exercise until a constant, basal consumption of O2 is reached. Blood gasesBlood gases mild exercise – unchanged heavy – a decrease in paO2 (approx. By 10%) due to hyperventilation 27 Acid-base balance: -heavy exercise: metaboli acidosis partially compensated by hypocapnia (tendency to the respiratory alkalosis). Termoregulation Muscular work – increase in heat production central temperature. Long lasting sweating – fatigue of sweating glands – arrest of sweat production/evaporation – hyperthermia. If exercise/heavy muscular work is performed in hot environment – redistribution of blood to skin circulation – limited skeletal muscles perfusion and physical output. Hypertrophy of left ventricle, less of the right ventricle, atria and of pulmonary veins. O2 intake/consumption (from 3 to 7 l/min) Bone system Load – remodelation Activation of the osteoclasts and osteoblasts. Fatigue Limitation of the performances 1)Peripheral, physiological (in muscles): Exhaustion of metabolic reserves,accumulation of metabolites. Reactions to non-physical forms of loading Psychological and emotional load Reactions similar to physical exercise effects: Tachycardia, hyperventilation, sweating, cutaneous hyperperfusion, sympathoadrenal system activation, increasing of energetic substances concentration in plasma – without increased consumption. The T-system – is continuous with the sarcolemma = the transverse tubules – run transverse to the myofibrils, branch among themselves. Striations: Bands „I“ – light bands contain only actin filaments – isotropis Bands „A“ dark bands – myosin + actin filaments – anisotropic Zone „H“ – lighter band in the bands „A“ Line „Z“ – dark – in the bands „I“ the area between 2 „Z lines“ = sarcomere Biochemical characteristics the myosin filament – multiple myosin molecules–each m. Mechanisms of excitation and contraction of skeletal muscle 1) Mechanisms of excitation the skeletal muscle fibres are innervated by alpha – motoneurons (myelinated) – from the anterior horns of the spinal cord. Neuromuscular junction – the „motor end – plate“ Neurotransmitter Acetylcholine – synthesized in the cytoplasm of the terminal of an end – plate.

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The length of the digestive system is approximately 5 times greater than one’s height generic 500mg calcium carbonate otc symptoms with twins. This helps digestion by allowing time and space to generic calcium carbonate 500mg on line medications of the same type are known as break down food cheap 500 mg calcium carbonate fast delivery symptoms in early pregnancy, absorb nutrients 500 mg calcium carbonate amex treatment h pylori, and absorb water. The time it takes to digest food from the time you eat it to the time you excrete it is about one to three days. Introduction: In this part of the lab, you will work in groups and use real food to simulate what happens to the food you eat as it travels along your digestive system. We will pause at each section of the digestive system to identify any unique features and to try to better understand how these features contribute to the digestive process. Remind students about the mechanical and chemical digestion taking place in the mouth. Try to “swallow”, or pass the corn flake mixture through the straw esophagus by cutting a small hole in one corner of the bag and squeezing the mixture into the straw. Hold the gallon ziplock bag under the straw to catch anything that comes through the straw. This is really hard to do, so just do a little to demonstrate peristalsis (muscles squeezing the food down into the stomach). Yes, if someone tries to swallow a cracker lying down they should be able to do it. Remind students about the mechanical and chemical digestion occurring in the stomach. There is a mucous membrane (very similar to mucous, or snot, in your nose) which protects our stomach from the acid. Your real stomach secretes hydrochloric acid (not lemon juice), which has a very low pH. Have someone in your group hold the roll at a 45 degree angle over the plastic cup. Before pouring the mixture through the tube, add some food coloring to your gallon ziplock bag. This food coloring represents other digestive juices from the liver, gallbladder, and pancreas that are required to complete chemical digestion of food. Once you’ve added food coloring, pour your corn flakes mixture from the 1 gallon ziplock bag into the top end of the roll. The other digestive juices are bile (produced in the liver and stored in the gallbladder) and enzymes produced in the pancreas. Remind students about the important nutrient adsorption occurring in the small intestine. If we couldn’t absorb the nutrients from our food, digestion would be a futile endeavor. What do you notice about the food that emerges from the other end of the paper towel roll The small intestine has some interesting features which make it highly specialized for maximizing nutrient absorption. Although our paper towel roll intestine has smooth walls, your real small intestine has many folds, big folds you can see, and tiny folds that are only visible under the microscope. The formula we will use is for calculating the surface area of a tube is: 2 x x radius x length. Let’s simplify by approximating with 3, and the radius as 2 cm, which makes the formula: 2 x 3 x 2 cm x length. Using the length of your small intestine you just calculated, what is the surface area of your small intestine The microscopic folds (called villi) increase the surface area further by another ten times. Pour the cornflake mixture that you collected in your cup (after being passed through the paper towel roll) into the pantyhose (on the open end). Let everyone in your group squeeze the corn flake mixture part of the way through the pantyhose. Cut a small hole (representing the anus/rectum) to release the corn-flake mixture. What happens if your large intestine isn’t working to absorb the water from your food Some animals eat all at once (lions) and some animals eat a little bit throughout the day (cows) and the different digestive systems accommodate this. Why can some animals survive eating only plants and some can survive eating only meat Their bodies are designed to use the nutrients they get (from plants or meat) to make energy, build muscle, etc. Are foods that are higher in calories healthier for you and foods that are lower in calories less healthy for you Some things are very calorie dense (for example with low water content) and some things are not very calorie dense (for example high water content). The number of calories does not correlate to how healthy or nutritious the food is (think of a Twinkie versus lettuce). The number of calories you need everyday depends on your size, how much exercise you get, your metabolism, and your age. The number of calories you need everyday is somewhere between 1,500 and 3,000 calories. There are other parts of your digestive system that food doesn’t pass through, such as the liver, the gallbladder, and the pancreas.

There is a positive feedback loop resulting in increased oral amylase secretion in people consuming diets high in carbohydrates purchase calcium carbonate 500mg on-line treatment wasp stings. Amylase is sensitive to cheap calcium carbonate 500mg symptoms vitamin b deficiency pH and thus is inhibited in the acidic environment of the stomach order calcium carbonate 500 mg otc medicine keychain. Salivary amylase has increased importance in two groups; infants with decreased pancreatic amylase production in the first 9 months and children with pancreatic insufficiency from cystic fibrosis or other etiologies generic 500 mg calcium carbonate fast delivery symptoms 24 hour flu. Minimal carbohydrate digestion occurs in the stomach due to the inactivation of amylase in the acidic environment. Amylase targets the 1,4 bonds of complex carbohydrates and is unable to break terminal bonds or 1,6 bonds. Starch is digested in the small intestine to simple components derived from branched amylopectin (maltose, maltotriose and limit dextrins). Oligosaccharides and disaccharides are digested by specific enzymes in the microvillus membrane (brush border). Brush border enzymes are synthesized in the endoplasmic reticulum and glycosylated in the Golgi apparatus of the enterocyte. They are then trafficked to the apical membrane where they are anchored at the surface by a transmembrane segment. The anchored enzymes are active following cleavage of a small residue at the extracellular N-terminal end. Disaccharidases are protected from proteolysis by glycosylation and are found in higher concentration in villus enterocytes of the proximal small bowel. These enzymes include maltase (digests maltose to glucose and glucose), sucrase (digests sucrose to fructose and glucose), trehalase (digests trehalose to glucose and glucose), lactase (digests lactose to galactose and glucose) and isomaltase (de-branching enzyme digests 1,6 bonds of limit dextrin to produce glucose). Sucrose uptake is regulated after hydrolysis by the apical membrane uptake rate of fructose and glucose, whereas lactose absorption is limited by the rate of hydrolysis. However, disaccharidase levels vary during gestation: sucrase appears early (by about 20 weeks), while lactase does not achieve “normal” levels until the 3rd trimester. In most humans, lactase decreases with age starting at about 3-5 years or earlier depending on the population. However, in people of Northern European ancestry and other population groups in small areas elsewhere in the world, lactase activity remains at the infantile level. Lactase non-persistence is found in the United States mainly in African-Americans, Asians, and Native Americans, although people of Southern European ancestry can also exhibit lactase non persistence. Lactase activity is “hard wired” genetically; lactase is not inducible, and lactose restriction does not lower lactase levels. Carbohydrates not digested in the small intestine pass into the large intestine where they are digested by colonic bacteria. Absorption: Once carbohydrates are digested, the products must be absorbed and transported to the portal circulation. Digestion and absorption are typically coupled, with the enzymes closely located to the appropriate transporters. The two Na+ ions and the glucose molecule are then transferred to the cytoplasmic side of the membrane following another conformational change that involves rotation of the receptor. The sodium is transported from high to low concentration (with concentration gradient) and at the same time allows the carrier to transport glucose against its concentration gradient. Sodium ions and accompanying anions and water follow the glucose, maintaining iso-osmolarity. Facilitated diffusion utilizes a carrier protein to achieve transport at rates greater than simple diffusion and does not rely on concentration gradients. Fructose malabsorption can be minimized by simultaneous glucose administration suggesting there is another glucose responsive system in the enterocytes. Recent data suggests passive glucose absorption does exist, but that it is a facilitated system mediated by glucose-dependent activation. Hormonal influences have also been proposed and are currently being studied further. A distal promoter region has been identified and is currently being characterized. It has also been proposed that a repressor region exists that down regulates lactase expression. Treatment requires dietary elimination of sucrose and occasionally initially a starch free diet. Diagnosis may be made by clinical history and supported by breath testing, although the sensitivity and specificity of this test is approximately 60%. Due to decreased enzyme release there is inadequate carbohydrate digestion resulting in malabsorption. Only 10% of baseline quantities of amylase are needed to avoid symptoms of malabsorption. Failure to alkalinize fluid in small intestine and therefore inactivation of the pancreatic enzymes may also result in functional pancreatic insufficiency; this may occur when there is villus atrophy as in celiac disease. Once a gluten free diet produces mucosal healing, disaccharidase deficiency abates. They report that he has had Formatted: List Paragraph, Numbered + Level: 1 + worsening diarrhea for the past 6 months following a viral acute gastroenteritis. What is Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0. Lactose Non-persistence Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0. Infection Formatted: List Paragraph, Indent: Left: 1" Answer: Lactose Intolerance 2. What enzymes involved in carbohydrate digestion are induced by increasing dietary Formatted: List Paragraph, Numbered + Level: 1 + intake Sucrase-isomaltase Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + c.