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Board Review Week 3 Test. Good luck!!. Question 1 of 40. B   Amygdaloid nuclei and lumbar system After the destruction of amygdaloid nucleus and lumbar system, the normal fear reaction is often absent.

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Board Review Week 3 Test


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slide3

B   Amygdaloid nuclei and lumbar system

After the destruction of amygdaloid nucleus and lumbar system, the normal fear reaction is often absent.

Mammillary bodies are part of the Papez circuit (of limbic system). Stimulation and ablation experiments indicate that in addition to its role in olfaction, the limbic system is concerned with feeding behavior. Along with the hypothalamus, it is also concerned with sexual behavior, the emotion of rage and fear, and motivation.

The functions of cerebral frontal lobes and cerebral motor cortex include initiating voluntary motor impulses for the movement of skeletal muscles, analyzing sensory experiences and providing responses relating to personality. The frontal lobes are also involved with responses related to memory, emotions, reasoning, judgment, planning and verbal communication. Lesions in cerebral frontal lobes and motor cortex may affect any or all of these functions.

Removal or lesions of neocortex will inhibit sexual behavior.

slide5

C   Meissner's corpuscles

Meissner's corpuscles are specialized receptors that lie in the papillary dermis, perpendicular to the surface of the skin. They are primarily found in hairless skin, particularly the fingers and toes. The capsule of the corpuscle is an elongated cone, within which an unmyelinated nerve ending spirals to the tip of the cone. As in the Pacinian corpuscle, the unmyelinated nerve ending is enclosed by Schwann cells.

slide7

B   Cholinergic sympathetic

The term cholinergic is used to describe any physiologic or pharmacologic relationship that involves acetylcholine (ACh). For example, cholinergic nerve fibers synthesize and release ACh, cholinergic receptors complex with ACh or synthetic analogs of ACh, and cholinergic drugs chemically resemble ACh or interfere with its inactivation. A sympathetic nerve fiber is part of the sympathetic division of the autonomic nervous system.

Autonomic control of the adrenal medulla involves single innervation via motor fibers of the sympathetic division of the autonomic nervous system (ANS). This unique arrangement of single innervation, rather than dual autonomic innervation through the two opposing ANS subdivisions requires sympathetic neurotransmission that is not dependent on norepinephrine (noradrenaline). The majority of postganglionic sympathetic fibers of the ANS release noradrenaline and are termed adrenergic , but the sympathetic preganglionic fibers that innervate the adrenal medulla release ACh, therefore, such fibers are designated as cholinergic sympathetic fibers.

The adrenal medulla has its embryological origins as a sympathetic ganglion that migrates to a location on the superior aspect of the kidney, but retains its connection with the sympathetic preganglionic fiber. (In this regard the cholinergic sympathetic classification of the autonomic fiber controlling the adrenal medulla is not unusual since all preganglionic fibers, both sympathetic and parasympathetic, are classified as cholinergic sympathetic fibers.)

slide9

B   Basement membrane

Type IV collagen is amorphous. It is abundant in the basement membrane. Distribution of collagen in different tissues is enumerated as follows:

Type I Skin, bone, tendons Type II Cartilage, vitreous humor Type III Blood vessels, skin, uterus Type IV Basement membrane Type V Interstitial tissue Type VII Dermal epidermal junction Type VIII Endothelium-descemet's membrane Type IX Cartilage Type X Cartilage Type XI Cartilage

slide11

D   Oral

Bioavailability (F) refers to the rate and extent to which a drug or a metabolite enters general circulation. From the bloodstream, the drug or metabolite is capable of reaching its site of action. Several variables affect bioavailability. For example, the formulation and pH of the drug can affect how rapidly the drug is absorbed through membranes. In addition, the route of administration influences bioavailability because bioavailability is determined by measuring either the amount of drug in circulation or the extent of the pharmacologic response produced by the drug. Either way, the route of administration plays a critical role.

In theory, the intravenous (IV) and intra-arterial (IA) routes deliver 100% of the administered dose to the bloodstream (F = 1). Other parenteral routes such as the intramuscular (IM) or subcutaneous (SC) routes deliver somewhat less than 100% of the administered dose (F < 1) due to pharmacokinetic factors such as tissue binding and relatively slow tissue clearance by the lymphatic system. The inhalational route, due to the extensive surface area of the alveolar-capillary interface, can provide a relatively high bioavailability measurement, although not as great as that attained through direct introduction of drug into the bloodstream. The route yielding relatively low bioavailability—a distinct disadvantage—is the oral route. The low bioavailability of drug is due to the action of gastric enzymes, gastrointestinal motility, and extensive hepatic first-pass metabolism effects. First-pass effects refer to the rapid inactivation of a drug by hepatic enzymes (e.g. mixed function oxidases) and the rapid elimination of drug metabolites via the biliary route of excretion. Drug metabolism also occurs within the intestinal lumen, the intestinal mucosal cells, and the hepatic portal system, but the majority of first-pass effects are due to the action of hepatic enzymes. (Although inhalational drugs are not directly affected by hepatic first-pass effects, they are subject to lung first-pass effects, including metabolism and excretion.) Passage through general circulation or through the kidney does not contribute to first-pass effects in pharmacokinetics.

Different routes of administration exhibit different advantages and disadvantages. The intravenous route delivers drug to the bloodstream nearly instantaneously as evidenced by the short time required to reach peak plasma concentration (Tmax) and maximal serum levels (Cmax). By contrast, the oral route requires a much longer time to reach Tmax and Cmax. The intravenous route provides precise control of dose via IV infusion and provides the means to deliver water-soluble drugs such as aminophylline in large volumes. A significant drawback to the rapid onset and distribution of drug through the IV route is the simple fact that the delivered dose is not retrievable should a dosage miscalculation or an unforeseen drug reaction occur. The enteral route, on the other hand, allows the retrieval of a portion of orally administered drug through induction of emesis or gastric lavage. In addition, orally administered drugs, because of their dosing convenience, are ideal for chronic outpatient use.

slide13

B   Delusions

A delusion is an idea that is not fixed in reality. A hallucination is a perception without a stimulus. Depression involves a depressed mood and lack of interest in life. Euphoria is an elevated mood. Delirium involves confusion and disorientation.

slide15

C   Respect her decision if she can demonstrate and communicate ability to reason

  • Competence is a legal term, capacity is a medical term. Physicians are often called on to make a determination of a patient's capacity to make medical decisions. The patient's primary care provider is an ideal person to make the assessment as they have background knowledge of the patient's educational level, values, and medical history.
  • A psychiatrist may be needed if overlying psychiatric problems make it difficult to determine capacity for judgment or ability to reason. Courts make the ultimate determination of competence, although there is usually concordance with the medical determination of capacity. Only lack of competence has legal ramifications, however.
  • A bedside mental status examination may help to determine capacity, but in and of itself does not determine competence. If the patient is deemed to have the capacity to make her own decisions, it may be detrimental to encourage family member involvement in the decision making process.
  • Adult protective services are usually called to investigate cases of abuse or neglect, not issues of capacity or competence. If still unclear, a psychiatrist or ethics board consultation could be utilized to help determine the patient's capacity to make her own decisions.
  • Four main criteria should be used to determine a patient's capacity to make medical decisions.
  • They can demonstrate understanding of the treatment options.
  • They can demonstrate understanding of how the different options affect their own individual situation.
  • 3) They can demonstrate ability to reason with the above information, using either evidence based in fact, or personal beliefs rooted in their value system.
  • 4) They are able to demonstrate 1-3 and can communicate a choice.
slide17

A   Frontal lobe

The brain, or cerebrum, is divided into two hemispheres: the right hemisphere and the left hemisphere. Connecting the two hemispheres are the corpus callosum, anterior commissure, hippocampal commissure, posterior commissure, and the habenular commissure.

The outermost portion of the brain, characterized by convolutions and grooves, is the cerebral cortex of which the right hemisphere controls the motor and sensory processes of the left side of the body and the left hemisphere controls the right side of the body (contralateral control).

The cerebral cortex may be anatomically divided into four lobes: the frontal, parietal, temporal and occipital lobes. The frontal lobe is responsible for planning and for motor functions. Specifically, the area within the frontal lobe that controls voluntary body movements is called the motor cortex. Thus, frontal lobe is the correct answer to the question.

The parietal lobe is largely concerned with somatic sensation (somatosensory cortex), the occipital lobe with vision, and the temporal lobe with audition as well as other functions. Thus, in the above question, these are incorrect answers.

The limbic lobe is a ring of cortical structures surrounding the central core of the brain and is itself encircled by the frontal, parietal, temporal and occipital lobes. It is part of the limbic system which is generally associated with emotion, learning and memory. As it is not associated with motor function, limbic lobe is an incorrect answer.

slide19

D   Spleen

Based upon their ultrastructural characteristics, capillary endothelia may be described as being continuous, fenestrated or discontinuous (sinusoidal). Discontinuous capillaries characteristically have larger diameter and more irregularly shaped lumen than that of other capillaries. Furthermore, these large diameter capillaries may have gaps between endothelial cells and have sparse or absent basal lamina underlying the endothelium. These types of capillaries are common to the spleen, but are also found in the liver and in bone marrow.

slide21

B   Anti-idiotype

Each immunoglobulin consists of light chains and heavy chains. Isotypic differences are those between types such as IgG and IgM, and allotypes are allelic variants in the individual C genes of antibodies. Idiotypes are antigenic determinants of the variable regions linked to the specificity towards the antigen. Long ago it was shown that the heterogeneity and average affinity of antibodies increase with time in response to an antigen. The population of idiotypes produced during an immune response evolves so that the response is more specific and more effective. The study of idiotypes is essential for the analysis of the genetic origin of variability.

slide23

A   Drug A

Dose-response curves that show the interaction between an agonist drug and an antagonist drug are those that compare the ED50 of the agonist alone with the ED50 of the agonist after an antagonist is added. In both the Drug A and Drug B graphs, it can be seen that the ED50 (median effective dose) of the agonist drug has increased from approximately 20 mg to approximately 50 mg. This increase in the median effective dose is due to the pharmacologic antagonism between agonist and antagonist as both drugs attempt to bind the same pharmacologic receptor.

A drug response is related to the number of complexes formed between receptor and agonist. An agonist exhibits affinity plus efficacy whereas an antagonist shows affinity for a receptor, or the ability to form a complex with it, but possesses no intrinsic activity, or efficacy.

The noncompetitive nature of pharmacologic antagonism is seen in the graph of Drug A in which the potency and the efficacy of the agonist are both decreased. This type of interaction shows a sigmoid ED50 curve displaced downwards and to the right. The median effective dose increases from 20 mg to 50 mg, indicating a loss of agonist potency. In other words, more drug is required to bind available receptors and evoke a particular response. The maximal drug response, however, cannot be restored, no matter how high the dose of agonist drug administered. This decrease in effectiveness is visible graphically as a shift downwards in the ED50 curve and is typical of the irreversible competition occurring between an agonist drug and a noncompetitive antagonist. Each receptor bound by the noncompetitive antagonist is no longer available to the agonist, thereby decreasing agonist efficacy, or the ability to produce an effect relative to a given number of drug-receptor complexes.

In the Drug B graph the ED50 curve has undergone a parallel displacement to the right but no displacement downwards. This shift denotes a decrease in potency of the agonist but no change in its efficacy. Potency refers to the relative ability of a drug to produce a particular response at a given dose. It should be remembered that comparisons of potency are only useful if made at equieffective doses.

In competitive antagonism, an optimal number of agonist-receptor complexes can be formed and a maximal response (100%) can still be achieved, but the dose necessary to elicit this level of response is higher as evidenced by the increased median effective dose. The pharmacologic blocking effect of the competitive antagonist can be reversed by increasing the dose of the agonist. This provides additional agonist drug to bind available receptors as the competitive antagonist "uncouples" from them.

A classic example of this type of reversible pharmacologic antagonism is the competition for cholinergic receptors (N2-nicotinic) at motor end plates of neuromuscular junctions that occurs between acetylcholine acting as agonist and curarelike neuromuscular blockers acting as competitive antagonists.

slide25

B   Increase the morphine until she is comfortable, even if she dies in the process

Much literature has been published on the fact that terminal cancer patients are often inadequately treated when it comes to pain control. Many possible explanations have been proposed to explain this phenomenon. Some practitioners may fear they will be reprimanded by the Drug Enforcement Administration (DEA) for prescribing too many controlled substances. Some may believe that the patient really isn't in "that much" pain. Others fear that the side effects of the medication will cause further problems such as constipation, confusion, respiratory depression, or addiction (even in a patient that has days or weeks to live!) The literature emphasizes that narcotics can be dosed as high as it takes to achieve adequate pain control in terminally ill cancer patients. It is a common misconception that a practitioner will be criminally prosecuted when a terminal patient dies while receiving narcotics. If the patient in the aforementioned case inadvertently died while receiving high doses of morphine, it would not be considered murder or assisted suicide. The use of adequate pain medication for this patient is completely justified, especially in view of the patient's advanced directives, terminal diagnosis, and supportive family. An ethics consultation or risk management assessment would be an option if either the physician or the family were uncomfortable with the situation. Physician assisted suicide (the intentional administration of life-ending medication) is currently legal in Oregon, and other jurisdictions may legalize it or prohibit it in the future.

slide27

C   Schizoaffective disorder

Zelda's symptoms best describe the criteria for schizoaffective disorder. She presents with prominent schizophrenic and affective symptoms. As the name implies, schizoaffective disorder combines features of both disorders; a period where there is either a major depressive episode, a manic episode, or a mixed episode along with Criterion A symptoms for schizophrenia (i.e., delusions, hallucinations, etc.).

slide29

C   Duodenum

While villi, intestinal glands, and goblet cells might be found in the duodenum and ileum, submucosal glands, in combination with the former characteristics, could be found only in the duodenum. The submucosal glands, or Brunner's glands, secrete alkaline glycoproteins and bicarbonate ions to bring the pH of the intestinal contents to that optimal for action of the pancreatic enzymes.

The esophagus does not possess villi on the cells of the stratified squamous epithelium. It may have mucosal glands, however. The colon does not have villi or submucosal glands, but does have extensive numbers of goblet cells.

slide31

A   Blocking the release of acetylcholine at the synapse and thereby producing paralysis

Botulinum toxin produced by Clostridium botulinum is a neurotoxin that blocks the release of acetylcholine at the synapset , producing paralysis. The genes for this toxin are encoded by a temperate bacteriophage. It is composed of 2 polypeptide subunits held together by disulfide bonds and one of the subunits binds to a receptor on the neuron.

slide33

A   Liver and gall bladder

The photomicroscopic image depicts the histological appearance of two organs in close contact; the liver and gall bladder. Inspection of the epithelial lining of the gall bladder shows the presence of simple columnar cells.

Underlying the epithelium is a loose connective tissue core, the lamina propria, thrown into irregular folds. A fairly prominent layer of smooth muscle is seen underlying the lamina propria, forming the muscularis layer of the gall bladder. Glisson's capsule is absent at the position where the liver and gall bladder are in contact, however, the characteristic hepatic plates with intervening sinusoids can be seen.

The intervening area common to the liver and gall bladder is composed of connective tissue adventitia. Note that one of the folds of epithelium in the lumen of the gall bladder is pronounced and appears like a gland in the sectioned organ.

Without careful inspection of the image, the liver may appear similar to the cells of the parenchyma within the pars distalis of the pituitary gland, but the pars intermedia may contain what appear as colloid-filled cysts or follicles lined by simple squamous or cuboidal epithelium, not present in this image.

The seminal vesicle may show irregular folds of the lamina propria, similar to the gall bladder, but the epithelium is predominantly pseudostratified columnar lining the lumen.

The prostate gland would show glands, whose lumen possibly contain concretions, lined by a variety of epithelia, usually pseudostratified columnar. Underlying the glands are a fibromuscular connective tissue.

The gall bladder also may be confused with the uterine tube, since the uterine tube is lined with a simple columnar epithelium, and has folds of lamina propria. However, many of the epithelial cells of the uterine tube are ciliated.

The ovary does not resemble the liver, since the parenchyma of the ovary contains ova in various stages of maturation interspersed throughout connective tissue.

slide35

B   Stage 2

Sleep comprises approximately 1/3 of our lives and its function is far from being completely understood. Normally, sleep is an active (not passive) process where the brain activity fluctuates over about 45 cycles per night. Distinct sleep stages can be measured by EEG as patients pass through stages 1-4 (non-REM) and then enter REM sleep. Patients enter REM sleep (dream sleep) approximately every 90 minutes and the duration of this stage lengthens as the night progresses.

The characteristic EEG pattern of the various sleep stages is listed below along with some physiological observations.

Waking - alpha waves (8-12 cps)

NREM Sleep - (Nonrapid eye movement) - low level of activity: lowered BP, heart rate, temperature, and respiratory rate. Good muscle tone and slow, drifting eye movements.

Stage 1 - lightest sleep, a transition stage; low voltage, desynchronized waves.

Stage 2 - sleep spindles, (13-15 cps) and high spikes (K complexes).

Stage 3 - some delta waves (high voltage at 0.5-2.5 cps).

Stage 4 - deepest sleep, mostly in first half of night; mostly delta waves.

REM Sleep - active sleep characterized by rapid synchronous eye movement, twitching of facial and extremity muscles, penile erections, and variation in pulse, BP, and respiratory rate. Muscular paralysis is present. Depth is similar to stage 2. Dreaming can occur in several stages but is most common in REM sleep.

slide37

D   Affect

Affect is the visible expression of emotions. In this patient the affect is inappropriate to the content of his speech.

Thought process denotes the connections between thoughts, and thought content is the actual thoughts themselves, which may be delusional or hallucinatory.

Mood is emotion that is pervasive and long-lasting. Mood is best described in the patient's own words.

Impulse control is a description of the patient's ability -or inability- to forego action in light of a particular feeling or urge.

slide39

B   Reversibility of effect can be rapidly achieved

Bioavailability (F) refers to the rate and extent to which a drug or a metabolite enters general circulation. From the bloodstream, the drug or metabolite is capable of reaching its site of action. Several variables affect bioavailability. For example, the formulation and pH of the drug can affect how rapidly the drug is absorbed through membranes. In addition, the route of administration influences bioavailability because bioavailability is determined by measuring either the amount of drug in circulation or the extent of the pharmacologic response produced by the drug. Either way, the route of administration plays a critical role.

In theory, the intravenous (IV) and intra-arterial (IA) routes deliver 100% of the administered dose to the bloodstream (F = 1). Other parenteral routes such as the intramuscular (IM) or subcutaneous (SC) routes deliver somewhat less than 100% of the administered dose (F < 1) due to pharmacokinetic factors such as tissue binding and relatively slow tissue clearance by the lymphatic system. The inhalational route, due to the extensive surface area of the alveolar-capillary interface, can provide a relatively high bioavailability measurement, although not as great as that attained through direct introduction of drug into the bloodstream. The route yielding relatively low bioavailability—a distinct disadvantage—is the oral route. The low bioavailability of drug is due to the action of gastric enzymes, gastrointestinal motility, and extensive hepatic first-pass metabolism effects. First-pass effects refer to the rapid inactivation of a drug by hepatic enzymes (e.g. mixed function oxidases) and the rapid elimination of drug metabolites via the biliary route of excretion. Drug metabolism also occurs within the intestinal lumen, the intestinal mucosal cells, and the hepatic portal system, but the majority of first-pass effects are due to the action of hepatic enzymes. (Although inhalational drugs are not directly affected by hepatic first-pass effects, they are subject to lung first-pass effects, including metabolism and excretion.) Passage through general circulation or through the kidney does not contribute to first-pass effects in pharmacokinetics.

Different routes of administration exhibit different advantages and disadvantages. The intravenous route delivers drug to the bloodstream nearly instantaneously as evidenced by the short time required to reach peak plasma concentration (Tmax) and maximal serum levels (Cmax). By contrast, the oral route requires a much longer time to reach Tmax and Cmax. The intravenous route provides precise control of dose via IV infusion and provides the means to deliver water-soluble drugs such as aminophylline in large volumes. A significant drawback to the rapid onset and distribution of drug through the IV route is the simple fact that the delivered dose is not retrievable should a dosage miscalculation or an unforeseen drug reaction occur. The enteral route, on the other hand, allows the retrieval of a portion of orally administered drug through induction of emesis or gastric lavage. In addition, orally administered drugs, because of their dosing convenience, are ideal for chronic outpatient use.

slide41

B   First node of Ranvier

Pacinian corpuscles, which are touch receptors, have been studied in detail. Because of their relatively large size and accessibility in the mesentery of experimental animals, they can be isolated, studied with microelectrodes, and subjected to microdissection. Each capsule consists of the straight, unmyelinated ending of a sensory nerve fiber, 2 µm in diameter, surrounded by concentric lamellas of connective tissue that give the organ the appearance of a minute cocktail onion. The myelin sheath of the sensory nerve begins inside the corpuscle. The first node of Ranvier is also located inside, whereas the second is usually near the point at which the nerve fiber leaves the corpuscle.

Deformation of the capsule causes a sudden change in the membrane potential by increasing its permeability and allowing positively charged sodium ions to leak to the interior of the fiber. This change in local potential causes a local circuit of current flow that spreads along the nerve fiber to its myelinated portion. At the first node of Ranvier the local current flow initiates action potentials in the nerve fiber.

slide43

C   IgG1

Opsonization is an enhancement of phagocytosis through the binding to the surface of a pathogen. IgG antibodies, in particular IgG1 are very effective opsonins. Phagocytes express Fcg receptors on their surface. These receptors bind IgG antibodies, especially IgG1. Phagocytes also distinguish between free antibodies, to which they do not bind, and aggregated or multimeric antibodies on the surfaces of bacteria and viruses, to which they do bind.

slide45

B   Interval shorter than T1/2

The T1/2 is the time required to reduce the blood level of a drug by one half, thus after one T1/2 only 50% of the drug remains. After two T1/2 intervals only 25% of the drug remains. If the dosage interval is more frequent than the T1/2 time, accumulation is guaranteed.

The Kel is the elimination constant in concentration units eliminated per each time unit. This value cannot be used to assure accumulation since the starting blood level is not known.

Four half-times will reduce the beginning blood concentration to about 6% of the starting concentration.

slide47

B   Inhibition of acetylcholinesterase

Of the above only the inhibition of acetylcholinesterase, the enzyme that breaks down acetylcholine into acetate and choline and effectively stops cholinergic signaling between two cells, would increase levels of acetylcholine in the synaptic cleft.

slide49

A   Gunshot wounds

Physicians in most jurisdictions are obligated to violate patient confidentiality when it is for the greater good or is required by law. The most common circumstances included are gunshot wounds, wounds secondary to crimes, communicable diseases, including venereal diseases and tuberculosis, child abuse, elder abuse, abuse of the mentally impaired, animal abuse, and driving impairment secondary to physical conditions. A notable exception to these rules is AIDS, despite the fact that it is a communicable disease, and that lack of notification of exposed individuals may result in more people contracting this disease. The reasons for this are social and political, and the devastating effect on the individual that would result from having his or her AIDS status become public knowledge are felt, at this time, to outweigh the rights of others to be protected from exposure. Obviously, this subject is quite controversial and not likely to be resolved in the near future. Other conditions that are generally not reported in violation of patient confidentially are intravenous drug abuse, spousal abuse, and psychosis.

slide51

A   Schizophrenia

Schizophrenia is characterized by psychotic disturbances that affect such areas of functioning as thought content (e.g., delusions), form of thought (e.g., bizarre or unfocussed thoughts), perception (e.g., hallucinations), affect (e.g., labile mood, flat affect), identity (e.g., confusion regarding self, poor boundaries between self and external world), volition (e.g., loss of motivation), interpersonal relationships (e.g., social withdrawal), and psychomotor behavior (e.g., rigidity, hyperactivity). The diagnosis of schizophrenia requires that the characteristic symptoms be present for at least 1 month (e.g., that there be an active phase) and that functioning be impaired with respect to premorbid functioning for a period of at least 6 months. DSM-IV identifies 5 types of schizophrenia: paranoid, disorganized, catatonic, undifferentiated, and residual, based on their respective prominent features. Onset of schizophrenia is usually in the late teens to mid-30s, and the course of the disease is normally chronic. If an acute first episode occurs and lasts less than 6 months, the diagnosis of Schizophreniform disorder must be made. If the course continues beyond 6 months and all other criteria are met, the diagnosis may be the changed to Schizophrenia of the appropriate subtype.

Schizophreniform disorder is identical in presentation to Schizophrenia, however Schizophreniform disorder, by definition, lasts less than 6 months. The prognosis of Schizophreniform disorder is therefore better than that of Schizophrenia because the former is an acute, rather than chronic, condition.

Childhood schizophrenia is similar to schizophrenia but it has an earlier onset. In addition, a significant difference is that children do not have to specifically show a sustained deterioration from a previous level of functioning to partially fulfill the diagnostic criteria for Schizophrenia. Rather, children must demonstrate a failure to develop normally in social, interpersonal, or affective areas and fulfill the remaining diagnostic criteria for Schizophrenia in order to qualify for a diagnosis of Childhood Schizophrenia.

Schizo-affective disorder is characterized by a combination of the symptoms of a Mood disorder (e.g., depression) and Schizophrenia, in individuals who do not meet the full diagnostic criteria of either disorder. Individuals who are suspected to be suffering from a form a Schizophrenia on first glance, therefore, but who have significant symptoms related to mood, might be more accurately diagnosed as having Schizo-affective disorder. The psychotic features of Schizo-affective disorder are generally more prominent than would be seen in an individual diagnosed with a Mood Disorder with Psychotic Features, and the diagnosis requires that the psychotic symptoms be present for at least 2 weeks during which time there are no mood symptoms. Mood symptoms are, however, required to be present for most of the duration of the illness.

A Brief Psychotic disorder is characterized by the sudden onset of at least 1 psychotic symptom, which lasts for up to, but not exceeding, 1 month. When the symptoms subside, the individual returns to his or her full premorbid level of functioning. Onset of Brief Psychotic disorder frequently occurs after a severe stressor in which case the stressor should be noted, and in cases related to childbirth, symptoms must occur within 4 weeks postpartum. The absence of the recent or heavy use of alcohol or other drugs distinguishes Brief Psychotic disorder from Substance-Induced Psychotic disorder.

slide53

E   Determine whether she is competent to understand the ramifications of her refusal for screening

Hereditary syndromes with a greatly increased risk for adenomatous polyps and colon cancer include familial polyposis, Gardner's syndrome, and Peutz-Jeghers syndrome. These patients need careful follow-up, with family and genetic counseling so they understand the risks of their condition for them and their family.

In familial polyposis, there is a mutation on chromosome 5 (the FAP gene), which is transmitted in an autosomal dominant pattern. Nearly all untreated patients will develop colon cancer before age 40. These individuals are treated with surgical removal of the colon; if they choose to have a subtotal colectomy, they require aggressive surveillance of the rectal remnant every 3 to 6 months to have new polyps removed.

Gardner's syndrome is a variant of family polyposis. It is associated with sebaceous cysts, desmoid tumors, and osteomas of the skull or mandible. Peutz-Jeghers syndrome is an autosomal dominant disease associated with pigmentation of the skin and mucous membranes, as well as multiple hamartomatous polyps in the stomach and small and large intestines.

Patients with familial polyposis syndromes, like those with any condition increasing the risk for malignancy, must have adequate surveillance to try and identify pre-malignant polyps before they develop into cancer. However, patient autonomy allows patients to refuse care, if they are competent to make decisions for themselves. The clinician must determine (with the assistance of other professionals if needed) the patient's competence before trying to force or coerce her compliance. Additionally it would be very useful to spend time to educate her further about the importance for colonoscopic surveillance, particularly given her learning disability. If she is in fact determined to be incompetent to make decisions about her own care, then other tactics may be employed to care for her as needed.

slide55

B   Pharmacokinetic phase

  • The sequence of events set in motion following introduction of a drug into the body is commonly divided into three phases:
  • The pharmaceutical phase of drug action is concerned with the various formulations of drugs and the different routes of administration available for their introduction. Formulations, or forms of drugs, often influence how readily a drug becomes available or how quickly it is absorbed across cell membranes. The route of administration determines, in part, how rapidly a drug is introduced to the body.
  • (2) Following introduction of a drug, movement of the drug through cell membranes from one body compartment to another normally occurs. This pharmacokinetic phase is responsible for the movement of drugs from a plasma protein-bound state to a free state in the plasma, and from the plasma into cell and tissue depot sites and into organs such as the liver and kidneys. Pharmacokinetics deals with the rate of drug metabolism in organs of biotransformation such as the liver and with the rate of clearance by organs of excretion such as the kidneys. The complex interplay of absorption mechanisms (e.g. aqueous, lipid, and facilitated diffusion, endocytosis, pH of fluids), storage (e.g. plasma-binding, tissue-binding, or cellular-binding), distribution systems (e.g. blood, lymph, cerebrospinal fluid), enzymes (e.g. gastrointestinal, hepatic, pulmonary), and hemodynamics (e.g. glomerular filtration pressure) contributes to the plasma half-life of drugs (t 1/2 ) and their ultimate clearance from the body. In short, pharmacokinetics is concerned with the "fate of drugs" after they have been introduced to the body.
  • (3) The pharmacodynamic phase is concerned with the physiologic and biochemical mechanisms of action of drugs. This final phase of drug action is initiated by drug molecules that have "survived" the different mechanisms of pharmacokinetics such as storage, biotransformation, and elimination. The remaining drug molecules are free to interact at specific target sites such as membrane, enzyme, cytoplasmic, or nuclear receptors.
slide57

B   IgM and IgA

The immunoglobulins include IgG, IgM, IgA, IgE, and IgD. Certain groups of streptococci secrete a variety of streptolysins or hemolysins that lyse red blood cells and are much more active weight for weight than hemolysins such as bile salts or saponin, but which have a more important toxic action on polymorphs and macrophages. Various hemolysins are released also by pathogenic staphylococci, and these can kill phagocytes.

The immunophilins are a family of intracellular proteins that bind to certain compounds forming complexes that interfere with signaling pathways important for the clonal expansion of lymphocytes.

Endotoxins are part of the outer membrane of Gram-negative bacteria. Some of the diseases in which endotoxins may play a part are typhoid fever, tularemia, plague and brucellosis, and a variety of hospital-acquired infections caused by opportunistic Gram-negative pathogens. Endotoxin is a complex lipopolysaccharide that displays a large array of biological effects.

Although all immunoglobulin molecules are constructed from a basic unit of two heavy and two light chains, both IgM and IgA can form multimers. IgM molecules are found as pentamers, and occasionally hexamers, in plasma, and IgA is found in mucous secretions, but not plasma, as a dimer. IgM and IgA C regions contain a "tailpiece" of 18 amino acids that contains a cysteine residue essential for polymerization. In the case of IgA, polymerization is required for transport through epithelia.

slide59

D   REM

Sleep comprises approximately 1/3 of our lives and its function is far from being completely understood. Normally, sleep is an active (not passive) process where the brain activity fluctuates over about 45 cycles per night. Distinct sleep stages can be measured by EEG as patients pass through stages 1-4 (non-REM) and then enter REM sleep. Patients enter REM sleep (dream sleep) approximately every 90 minutes and the duration of this stage lengthens as the night progresses.

The characteristic EEG pattern of the various sleep stages is listed below along with some physiological observations.

Waking - alpha waves (8-12 cps)

NREM Sleep - (Nonrapid eye movement) - low level of activity: lowered BP, heart rate, temperature, and respiratory rate. Good muscle tone and slow, drifting eye movements.

Stage 1 - lightest sleep, a transition stage; low voltage, desynchronized waves.

Stage 2 - sleep spindles, (13-15 cps) and high spikes (K complexes).

Stage 3 - some delta waves (high voltage at 0.5-2.5 cps).

Stage 4 - deepest sleep, mostly in first half of night; mostly delta waves.

REM Sleep - active sleep characterized by rapid synchronous eye movement, twitching of facial and extremity muscles, penile erections, and variation in pulse, BP, and respiratory rate. Muscular paralysis is present. Depth is similar to stage 2. Dreaming can occur in several stages but is most common in REM sleep.

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D   A measure of the maximal agonist effect

Efficacy is a term used to describe the ability of an agonist to elicit a maximal response. It is a pharmacological parameter used to signify the relation between occupancy of receptor sites and the pharmacological response. Drugs may have any degree of efficacy greater than zero, with zero efficacy denoting an antagonist. Full agonists have higher efficacy than partial agonists because the latter do not elicit the maximal response of full agonists occupying the same number of receptor sites.

Potency is the relative amount of a drug required to produce a given response. It is usually illustrated by a graph of ED50 values of two agonists. The smaller the ED50, the more potent the drug.

The therapeutic index is a measure used to relate the dose of a drug needed to produce a desired effect to that which produces an undesired effect. It evaluates the safety and usefulness of a drug and is the ratio of the LD50/ED50.

Affinity is term denoting the ability of a drug to bind to a receptor. A drug can bind to a receptor and not produce a pharmacological response.

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E   Direct causation of effect by the defendant's negligence

Negligence torts against health care providers must fulfill four criteria for success. A duty, or obligation, by the defendant (health care provider) must be owed to the plaintiff (patient). Dereliction of duty, or performance significantly below the standard of care, must have occurred. The plaintiff must have been damaged by the action in a physical or psychological manner, or via loss of reputation. Economic losses are not generally recoverable. The defendant's negligence must be the direct and proximate cause of the plaintiff's injuries. Fraud or deceit on the part of the defendant is grounds for deliberate torts. Other types of deliberate torts are battery, assault, breach of confidentiality, and bad faith breach of contract.

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C   Cloned hybridoma cell are of a single class and directed towards the same epitope in the protein

Monoclonal antibodies are antibodies produced by a cloned hybridoma cell in culture. Therefore, each antibody is identical and directed towards the same epitope of the antigen. An epitope is the antigenic determinant. A protein can have many epitopes. In contrast, polyclonal antibodies, such as those obtained after injection of the protein into a rabbit or a goat, are heterogeneous. These antibody molecules are produced by different B-lymphocytes in the animal in response to the antigen. This represents a mixture of different antibodies each of which recognizes different epitopes on the antigen.

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C   Glomerular basement membrane

The basement membrane of the glomerulus is formed by the fused basal lamina of the podocyte foot processes and the endothelial cells of the glomerulus. The membrane contains Type IV collagen which acts as a physical barrier to large particles such as proteins or albumen during filtration. In addition to size of the molecule, glycosaminoglycans associated with the basement membrane restrict the movement of smaller sized cationic molecules across the membrane.

Podocytes are modified simple squamous cells that comprise the visceral layer of Bowman's capsule. These cells also possess foot processes, or pedicels that extend around the glomerular capillaries and interdigitate with the pedicels of neighboring podocytes.

Capillary endothelial cells line the glomerular capillary upon which the podocytes reside.

The outer layer of simple squamous epithelial cells of Bowman's capsule comprise the parietal layer, which is continuous with the cuboidal epithelium of the proximal convoluted tubule at the urinary pole.

Mesangial cells also are found in association with the renal corpuscle; most within the corpuscle as intraglomerular mesangial cells, but some outside of the corpuscle along the vascular pole. The mesangial cells function as phagocytic cells and provide structural support for podocytes.

Smooth muscle cells circling the afferent arteriole of the glomerulus are modified and contain secretory granules of renin. These modified muscle cells are called the juxtaglomerular cells and are best visualized with histochemical stain for the renin.

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D   Dopamine beta-hydroxylase

Monoamine oxidase (MAO) and catechol-O-methyltransferase (COMT) are involved in the degradation of catecholamines. MAO is present in the mitochondria of several tissues and catalyzes the oxidative deamination of catecholamines and other biogenic amines. COMT metabolizes catecholamines by transferring a methyl group from S-adenosylmethionine to its substrate. COMT is mainly found in the liver and the kidney. Dopamine beta-hydroxylase and phenethanolamine-N-methyltransferase (PNMT) are involved in the synthesis of catecholamines. Dopamine beta-hydroxylase forms norepinephrine and norepinephrine is converted to epinephrine by the action of PNMT, an enzyme which is exclusively found in the adrenal medulla.

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D   The essential elements of informed consent are the patient's autonomy and comprehension

The ethical elements of informed consent require that the patient be adequately informed about the proposed treatment, its risks and benefits, as well as the risks and benefits of alternatives, to include no treatment at all. It further requires that she give her consent freely.

The ethical basis of informed consent is that it is a process that recognizes that patient's benefit from participating in making decisions about their healthcare. It recognizes that each person has the right of self-determination (autonomy). In addition to autonomy, human beings exist in a variety of relationships with others. The physician-patient relationship has a powerful effect upon how the patient makes healthcare decisions. A relationship of trust, mutual respect, and equality will provide the context for decisions that contribute positively to the patient's well being.

The physician must not coerce the patient into accepting the treatment that (s)he favors by counseling in a deceptive or biased manner. However, the physician may give reasons why one medical option is favored over another. And there is room for disagreement among the medical community with regards to which option is most appropriate. A second opinion may be desirable when faced with a serious decision, but it is not a requirement.

The legal criteria for informed consent varies from state to state. Documentation may have legal significance, but it does not necessarily protect against medical liability claims. Neither does simply obtaining a signature fulfill the ethical principle of respect for persons.

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B   Schizophrenia, paranoid type

Patients with schizophrenia, paranoid type usually appear normal in that disorganized speech, disorganized behavior, flat affect, and catatonic behavior are not prominent. However, they are usually able to take care of themselves and their daily lives are not very disruptive. They do, however, present with a theme of suspiciousness or paranoia and have delusions of persecution that someone is trying to do harm, poisoning their food, following them, or trying to kill them.

Schizophrenia, disorganized type has prominent symptoms of disorganized speech and behavior. They usually talk gibberish, and are not usually able to take care of themselves. They have very poor personal hygiene and appearance. Again, hallucinations and delusions are not prominent.

Schizophrenia, catatonic type patients have the stupor or retarded immobility and are sometimes mute, or display very negative speech. They have bizarre posturing and grimacing.

Schizophrenia, undifferentiated type, does not meet the criteria for the other types and it is a diagnosis of exclusion. It is for patients that do not have the prominent symptoms of catatonic, paranoia, or disorganized behaviors.

Schizophrenia, residual type is a diagnosis that is given to patients who at one time had one of the other types but have been treated and whose symptoms are no further pronounced. It often is applied to patients who have been treated and now they are in the process of partial remission.

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D   It is in the differential diagnosis for diarrhea

The definition of stress is an individual's negative emotional response to a perceived inability to meet demands place on him or her. It may express itself as anger, hostility, or feelings of helplessness, loss of control, or victimization. It is believed to be a factor in 60-80% of all health problems, and is the leading cause of disability claims in California. Major symptoms include fatigue, exhaustion, tight back and shoulders, insomnia, anxiety, anger, headaches, depression, sadness, hopelessness, colds, indigestion, diarrhea, and ulcer symptoms. Effective prevention and avoidance techniques include assertiveness training and the development of communication skills. Treatment methods include relaxation techniques, meditation, exercise, and participation in enjoyable activities.

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A   Glycogen metabolism

Smooth ER (sER), when viewed by an electron microscope, appears as a complex system of anastomosing or dilated tubules, but without association with ribosomes. Cells which contain substantial amounts of SER in the cytoplasm are associated with functions relating to glycogen metabolism, steroid synthesis, or drug metabolism. Cells associated with muscle contraction may contain small amounts of SER in the cytoplasm, but the predominant intracellular feature of these cells are actin and myosin filaments. Similarly, nerve cells, or their processes, may contain SER, but the predominant form of ER present in cells associated with depolarization and conduction would be rough endoplasmic reticulum (RER). Antibody synthesis, such as performed by a plasma cell, shows extensive RER in the cytoplasm. A cell that is associated with oxygen transport, such as the erythrocyte, would have few cytoplasmic organelles.

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C   Light chain has one variable and one constant region

  • The basic unit of an antibody is made up of two light chain and two heavy chains.
  • Equal number of heavy and light chain polypeptides are present in every immunoglobulin molecule and can be represented by the formula:- (H2L2)n. The polypeptide chains are linked covalently by disulfide bonds. Additional characteristics of structure of an antibody molecule are as follows:
    • Consists of light chain that is common to all class
    • Heavy chain is different for each class and subclass
    • Light chain has one variable and one constant region
    • Fc fragment is on carboxy terminal
    • Antigen binding site is present on carboxy terminal of the antibody molecule
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B   Sympathetic cholinergic postganglionic fibers

Although most of the sympathetic postganglionic fibers are adrenergic, the fibers to the sweat glands, piloerector muscles and a few blood vessels are cholinergic. The parasympathetic nervous system does not innervate sweat glands.