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M2 Questions Webmaster: 2Lt David Lynch |
-Behavioral Medicine III-
Notes and Fact Recall: Social coherence is the meaningful link to society's dominant culture and values that sets up coping responses PER TIM are in nucleus at midnight, CLOCK, BMAL are on at noon clk mutation leads to bipolar disorder, reverses with lithium Inputs to SCN: Retinohypothalamic tract (glutamate) Median and Dorsal Raphe (serotonin) SCN projects GABA neurons zeitgeber - something external that entrains (changes phase, not period) sleep onset is active and rapid
Transference means patient views doctor as an expert Most important determinant of health? social class What increases during detraining? heart rate (max and resting) What increases during training? capillary density, mitochondrial density, citrate synthase activity Characteristics of an athlete's heart? sinus bradycardia, increased diastolic fill time, coronary blood flow, and stroke volume Initial increase in ventilation with exercise is from CNS, not a change in blood gases V/Q ratio increases and becomes more uniform in exercise Increase in VO2max with training comes from increased stroke volume and a-vO2 increase probits are used to linearize tox data: probit of 5 = 50% response, 1 probit = 1 standard deviation Therapeutic index = lethal dose 50 / effective dose 50 (LD50=concentration to kill half) Margin of safety = lethal dose 1 / effective dose 99 Ipecac contraindicated if patient ingested organic solvents or corrosive agents Rural populations have more unintentional poisoning mortalities Adverse effect of fenfluramine? 5-HT2B agonist → valve defects Other drugs that can act as 5-HT2B agonists? amphetamine, MDMA (ecstasy) Patient with sores from scratching on face and arm uses what? meth Difference between crystal meth and meth? crystal meth is cooked to remove impurities Exam is what kind of stress? brief naturalistic stressor ADH assay used to assess patients for what alcohol? ethanol Fastest way to see if patient injested antifreeze? urine will fluoresce under black light Treatment for fibromyalgia? SNRI's and TCA Treatment for depression in elderly? SSRIs Dementia = stable course, Delerium = fluctuating course Glomus body found where? apical skin Major way heat is lost when exercising? evaporation Major way heat is lost when resting? radiation Major way heat is lost on a cold windy day? convection Major way heat is lost when swimming? conduction Non-shivering thermiogenesis from what? brown fat What is effort-reward imbalance model? high stress + occupational instability leads to stress MOA of cyanide? cytochrome oxidase inhibitor (complex IV) What hepatic function decreases in old age? phase I (not phase II) When are people sleepiest? early AM hours Domoic acid is an analog of what? glutamate (causes excitotoxicity, stroke like symptoms) Ciguatoxin MOA? Na+ channel activation Treatment for opioid overdose? naloxone Treatment for ethylene glycol and methanol? fomepizole Treatment for ethanol? none, supportive only Why do opiates cause itching? local histamine release (not allergy!) Percent of body weight in interstitium? 9/60 or about 1/6 (3/5 water* 1/3ECF * 3/4 interstitial) Dehydration causes what? increase in core body temp, decrease stroke volume, increased HR How does trained athlete sweat differ from untrained? less NaCl lost to sweat in trained athlete Maximum fluid that can be absorbed from gut? ~1 to 1.5 L per hour What is the ideal sports drink? 6% carbs (different types), 250-350 mOsm Problem with a sports drink that is 450 mosm? causes secretion of H2O into gut Factors that affect gastric emptying? volume increases, calories decrease How do lung and heart change with aging? decreased compliance How do kidneys change with aging? decreased GFR, decreased ability to concentrate and dilute How does ADH change in old age? ↓ADH from hypotension, but relative excess → hyponatremia What is an instumental ADL? doing finances Cause for concern in elderly? BMI<20 or >10 lb weight loss in 6 months Definition of suffering? affective/emotional response from pain, nociception, or other input
How to manage chronic pain? plan contingent behavior (not pain contingent!) Chronic pain is not a medical emergency Def of catastrophizing? exaggerated negative orientation toward actual/anticipated pain experiences Role of physiatrist? diagnose and treat musculoskeletal and neurologic conditions Physiatrist modes of treatment? therapy, medications, injections Def of acute inpatient rehab? >3hrs per day Goal of physiatrist? improve QOL MC occupational disease? repeated trauma (skin disorders is #2) Antidote for acetaminophen overdose? acetylcysteine Smoking causes what percent of lung cancers? 80-90% Toxicity of organophosphates? inhibitors of cholinesterases Long term problem with herbicides? malignancies Problem with excessive radar exposure? cataracts Subclinical level of radiation? <200Gy (imminent death if >1000) Lead toxicity? Blocks ferrochetalase action, microcytic anemia, encephalopathy, hyperdense bones, basophilic stippling, precipitates gout attacks Toxicity of EtOH? affects microtubule fomation, mitochondrial function Result of radiation exposure? short term fibrosis, long term cancer Difference between Mallory body and Councilman body? Mallory body has a nucleus Patient in ER with confabulation may have what vitamin deficiency? B1 thiamine (alcoholic) Cirrhosis of liver leads to what cancer? hepatocellular? Atrophy of cerebellar vermis from EtOH abuse causes what? truncal ataxia How long before rigor mortis starts to form? 2-4 hours How fast is body heat lost? about 1.5 degrees F per hour In what year was homosexuality removed from disorders in DSM? 1973 Critical temperature for heat stroke? 106 (if CNS symptoms, heat stroke until proven otherwise) Critical temperature for heat exhaustion? 101 When should an autopsy be done? after body cools, bruises show up better Stippling from gunshot occurs at what range? less that 2 ft Cone of damage from gunshot is caused by what? high velocity rounds How can you determine drowning? no absolute test, need complete history and autopsy Lupus like syndrome caused by what drugs? hydralozine and procainamide Approximate age diurnal cycle is apparent? 3 months old What is consistent in parasomnias? always found in same sleep state (ie: night terrors in IV) What treatment for night terrors? afternoon nap reduces stage IV sleep at night 5 year old with nocturnal enuresis? reassure parents 9 year old with nocturnal enuresis? if never been dry (ie: primary) then do UA; if secondary wake up child to pee Problem with intranasal Desmopressin? hyponatremia and seizures Periodic Limb Movement Disorder? strong familial component, treat with dopamine agonist Restless Leg Syndrome? Dopamine agonist to treat (may need Fe therapy from these drugs) Pramipexole and Ropinirole are non-ergoline dopamine agonists (also used to treat Parkinson's) Diagnose RLS by history, diagnose PLMS by electromyographic findings 80% of patients with RLS have PLMS Treatment for sleep phase delay? no exercise after 6pm, no caffeine after 3pm Child who 'always has a cold'? Possible obstructive sleep apnea (OSA) How to differentiate from OSA and snoring? need polysomnography Factors that reduce SIDS? sleeping on back, pacifiers, breastfed Regulation center for circadian rhythm? suprachiasmatic nucleus of hypothalamus Bright light late is day does what to circadian rhythm? phase delayed, no change in period Lesion at rostral midbrain? constant slow wave sleep from reticular formation Lesion at midpons? constant wakefulness Neurotransmitters role in sleep? serotonin promotes sleep, ACh is alerting Affects of sleep deprivation? slowed thinking, temporal dissociation, visual misperception Fundamental problem in narcolepsy? REM inclusions in awake state Overnight polysomnogram in narcolepsy? normal Tetrad of narcolepsy? excessive daytime sleepiness, cataplexy, hypnogogic/hypnopompic hallucinations, sleep paralysis Genes linked to narcolepsy? hypocretin 1 deficiency, (aka: orestin A) in lateral hypothalamu Diagnosis of narcolepsy? polysomnography and multiple sleep latency test Treatment of narcolepsy? modafinil, socium oxybate Characteristics of REM sleep? atonia
Stimulant medications? methylphenidate, pemoline, dextroamphetamine sulfate, modafinil The above treat ADHD and narcolepsy, except modafinil is for narcolepsy, OSA, shift sleep DOs Cataplexy medication? SSRIs and TCA suppress REM Sleep changes in depression? decreased REM latency, more total REM sleep, less slow wave sleep (ie: less refreshing sleep), more awakenings, early morning awakenings Depressed patients have increased REM, Manic patients have decreased REM Sleepwalking occurs in what stage of sleep? III Sleeptalking occurs in what stages of sleep? I, II Miliaria caused by what? occlusion of eccrine sweat glands after heat exposure Miliaria indicates inability to cool skin properly. Need to avoid heat and sweating if possible. Affects of cold? ↓ADH (cold diuresis), O2 dissociation curve shifts left, increase serum glucose, but less is available to cells, J waves on EKG Apathy and sleepiness in cold = hypothermia Temperature for cardiac arrest? 86 F Frequently comorbid with fibromyalgia? chronic fatigue, irritable bowel syndrome, temporal mandibular joint disorder, depression Moms with depression put child at increased risk for behavior disorders. Benzodiazepines MOA? allosteric modulators of GABA-A receptor, makes the receptor more likely to open when GABA is present Benzodiazepines metabolized by CP450 by oxidation and/or conjugation Benzodiazepines cross the placenta, unknown significance on fetus. GABA-A receptor is a pentamer of 2 α, 2 β, and 1 γ unit. It binds GABA to open its Cl- channel. Antidote for benzodiazepine overdose? flumazenil (competitive antagonist of BDZ receptor) Effects of SSRIs on sleep? decreased REM latency and duration Effects of benzodiazepines on sleep? ↓REM sleep, ↓slow wave sleep, more stage 2 sleep, less awakenings, less latency Long acting benzodiazepines? chlordiazepoxeide, diazepam, clobazam Intermediate acting benzodiazepines (5-25hrs)? estazolam, lorazepam, temazepam Zolpidem MOA? same as benzodiazepines, although they are structurally unrelated
Test to rule in methanol toxicity? gas chromatography MOA of fomepizole? ADH inhibitor How does methanol damage optic nerve? metabolized to formic acid, which is toxic to optic n. How much does one drink raise BAC? .02mg/dl per drink Where is most EtOH absorbed? small bowel Denial is the major component of which stage of change? precontemplation Preparation? action within one month Special considerations in exercise testing: diabetes don't test until blood sugar is 100mg/dL, if >300 check with physician. COPD monitor O2 sat, may need supplemental oxygen. Arthritis avoid exercise in joints where active inflammation is present. Hypertension avoid high intensity exercise and heavy lifting, straining, breath holding. Obesity avoid high intensity, use weight bearing activities. PAD walk until unable to tolerate discomfort CDC/AHA recommendations for exercise? 30 min of moderate intensity exercise, preferably daily What heart rate is needed for best cardioprotective effects? 70-90% of max What initiates sleep? serotonergic predominance of raphe nucleus What causes eye movements in REM? paramedian pontine reticular formation PPRF REM has same waves as what? awake state (beta waves, aka sawtooth waves)
Def Compliance? patient obeys/follows directions - passive recipient Def Adherence? patient actively involved in health care Nonadherence causes increased morbidity, mortality, costs, decreased QOL Maintenance? pt has incorporated change into daily life, is confident Termination? Patient has maintained for >1yr, avoids relapses, is confident lapses do not have to become relapses Examples of upstream approaches? National public education, tax incentive, policies Examples of midstream approaches? community, worksite, school programs for at risk populations Examples of downstream approaches? treatment of those with problem (drugs, education, etc) Most common reason for patient dismissal? noncompliance Time period before patient must secure care from another physician after dismissal? 30 days May have to contact Medicaid before dismissing patient.
Documentation is critical for terminating patient. Percent of gay and bisexual males who attempt suicide? 30% Percent of suicides completed by gay youth? 30% Preventive test for gay men at risk for anal cancer? anal Pap smear + anoscopy Gay men have increased risk of HIV, Hep B, anal cancer, proctitis, anal syphilis How to treat methanol poisoning if no fomepizole or dialysis available? ethanol (competes for ADH) Acidic arterial pH in methanol poisoning from what? formic acid Indications for fomepizole? serum methanol >20mg/dl or known injestion + osm gap>10 Isopropanol injestion? fruity breath, ketonemia, NO acidemia (b/c metabolized to acetone) Traumatic brain injuries (TBI) most often from what? motor vehicle accidents 80% TBI are mild (loss of consciousness less than 30 min, post traumatic amnesia < 24min, Glascow coma scale 13-15 after 30 min) TBI is any disruption of brain function (loss of consciousness, memory, Glascow coma scale measures what? eye, motor, verbal response (max score 15) DAI (diffuse axonal injury) symptoms? slow thinking, general slowing Frontal lobe dysfunction? difficulty planning, disinhibition, amotivation, no concrete thinking Right temporal dysfunction? Visual memory impairment Left temporal dysfuncion? verbal memory impairment Right parietal dysfunction? visuospacial processing impaired, get lost easily Left parietal dysfunction? language comprehension Occipital dysfunction? cortical blindness - you can 'see', but you're still blind Cerebellum dysfunction? tremors, nystagmus, ataxia Most mild TBIs recover completely within 3 months Mild TBI becomes post concussion syndrome (PCS) when? after 1 month What are the aspects of PCS? medical (headache), cognitive (memory), psychological (irritability) No memory of time immediately after trauma? post traumatic amnesia Decline in memory after TBI? anterograde amnesia Treatment after TBI? REST (avoid phone calls, etc), educate pt, validate sxs Treatment for frontal lobe emotional dysregulation? valproate Replicative senescence from what? telomere shortening Genes upregulated in response to oxidative stress? MSRA, p66shc, Thdx1 (loss will increase aging) Trigger for increased SIRT1 activity? increase in NAD/NADH ratio SIRT1 is master regulator of aging Excess insulin and IGF1 increases aging by inhibiting FOXO1 Werner Syndrome: RecQ helicase mutation, telomere shortening, replicative senescence, no adolescent growth spurt. Hutchinson-Gilford: de novo mutation in Lamin A/C, a nuclear intermediate filament involved in nuclear and chromatin structure. Growth retardation, connective tissue probs, death by 13 Ataxia Telangiectasia: AT mutation leads to DNA repair deficiency. Cerebellar degeneration, hypersensitivity to oxidative stress, immunodeficiency Berardinelli-Seip Syndrome: congenital liprodystrophy - accelerated growth, metabolic abnormalities in adipocytes from deficiency in an acyltransferase or Seipin. Familial Alzheimer's: point mutation in beta amyloid locus Familial Parkinson's: misfolded and aggregate proteins, PARK2 E3 UB ligase Characteristics of skin thermoreceptors: free nerve endings, small myelinated Aδ or C fibers which send info to cortex and hypothalamus At comfortable skin temperature (ie 34 C), both cold and warm fibers are firing. Temperature sensing area in hypthalamus is preoptic area/anterior hypothalamus - spontaneously firing warm sensing fibers Response to a cold environment: vasoconstriction via sympathetics releasing NE, mostly behavioral, also shivering initiated by dorsal medial portion of hypothalamus Apical skin (hairless skin) has glomus body (arteriovenous anastoamosis) under tonic sympathetic vasoconstriction. Sympathetics are removed to open glomus body and release heat (ie: your earlobes burn after being out in cold) Bigger effect on heat transfer from vasodilation than vasoconstriction Rise in temperature from exercise is not a resetting of thermostat, just temporary buildup of heat Glucocorticoids suppress inflammatory cytokines IL-1, IL-2, IL-6, TNF Glucocorticoids upregulated antiinflammatory cytokines IL-4, IL-10 Glucocorticoids shift response decrease TH1 response, increase B cell response Glucocorticoids act through glucocorticoid receptor which affects AP1 and NFκB Systems stimulated by stress: Sympathetic-Adrenal-Medullary (SAM), Hypothalamic-Pituitary- Adrenal (HPA) Systems inhibited by stress: parasympathetics, GNRH, (therefore LH, FSH) Gonadal steroids, GH Ways in which nervous system affects immune function: sympathetic innervation, catecholamines, endorphins, enkephalins, GH, corticosteroids, et al. HPA Axis: hypothalamus releases CRH, pituitary releases ACTH, Adrenal gland releases epinephrine and corticosteroids Where can ACTH be produced other than pituitary gland? activated lymphocytes Infection → IL-1 production → HPA axis stimulated Stress initially raises cortisol, over time cortisol levels decrease below normal Chronic stress shortens telomeres, higher oxidative stress Affected by glucocorticoids: cytokines, leukocyte migration, apoptosis Percent of people ready for the Action phase of change? 20% Main issue with Precontemplation and Contemplation phases? Importance Main issue with Action and Maintenance phases? Confidence Consciousness raising most important for Precontemplation → Contemplation Self liberation most important for Preparation → Action Social capital: level of interpersonal trust, associational memberships, allows collective action Best health quality in US is Asian-Americans followed by Caucasians Melatonin produced by the pineal gland Things to check with problem sleeper? BMI>30, neck circumference, airway, pupils, neuro, vascular, thyroid Abnormal sleep latency is <5 min, normal is >10 Disuse syndrome: cardiovascular vulnerability, depression, etc. Normal time of sleep cycle? ~90 minutes Sodium oxybate is a REM suppressant Step 2 treatment for moderate pain? mild opioids like codeine Sawtooth = REM
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