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What are some research difficulties involved with alternative medicine practices?
- Challenging to apply conventional research methodologies like randomized controlled double blind studies
- Studies do not consider "the whole has value beyond the sum of its parts"
- Best treatment may be integrated with a combination of severl different interventions
A type of medicine where non conventional approaches are secondary to a primary western medicine treatment is called
____ or ____ medicine is a type of medicine that implies a balanced whole person centered approach. It involves synthesis of conventional medicine, CAM modalitites and/or traditional medical systems. Aim is prevention and healing
Holistic or integrative medicine
___ Medicine: is the changing of the focus of medicine to healing rather than disesae. It involves an understanding of the mind, spirit and community as well as teh body. it includes developing insight into the pts culture, beliefs, lifestyle that will help the provider understand how best to trigger the changes required to result in improved health
This act legally recognized botanicals as dietery supplements rather than drugs, described botanicals (gave them a deffinition), made it so that product lables can claim only general physiologic or theraputic effects rather than efficacy for special diseases
Dietary Supplement Health Education Act DSHEA
____ is herb extracted in alcohol or other solvent. it is concentrated 1 gm of herb to 5-10ml of solvent
___ is a more concentrated version of a tincture
___ is a liquid extract that then has the solvent removed creating a 4:1 concentration usually then combinded with a large amount of fillers
___ is a boiled herb for 10-15 mins then drank usually used for roots, Barks and berries
___ is when you add plant to hot water and steep it for 3-5 mins
Name two herbs contraindicated in pregnancy b/c of their effects of uterine vasoconstriciton
- Vinca major (periwinkle)
Name 2 herbs that are teratogenic if taken during pregnancy
- American mandrake
- Baptisia (wild indigo)
Best botanical for menopause is what?
Best dermatologic botanical/also helps with sleep
Best botanical for premenstural syndrome
Best botanical for flu or URI
Best botanical for circulatory disorders
Best botanical for circulatory or coginitive d/o
___ is an herbal that is described as a panex or heal all
Best botanical for BPH
most hepatoprotective botanical is
Herbal supplement for depression or emotional balance
St. John's wort
What are the components of a low glycemic index diet
lean protein, low fat, whol grains, legumes, nuts seeds dairy low glycemic vegitables (non starchy veggies), no artificial sweetners,
What are some indications for a low glycemic index diet?
- Breast Cancer
What are some indications for a paleolithic diet?
Obesity, NIDDM, hyperlipidemia, CV disease
What is a paleolithic diet
- Hunder gatherer diet (stone age diet)
- Lower total fat
- Hight in vitamin E, C, Ca and K and antioxidants and fiber
- Low in Na
- Very lean wild meat
- Green leafy veggies, fruits and nuts
- No dairy, grains, legumes, sugar, alcohol and processed foods
____ is a diet where disaccharides and polysaccarides are eliminated, people adhering to this diet cannot eat dairy, grains, legumes
Specific Carbohydrate diet
What is an indication for using the specific carbohydrate diet?
Irritable bowel disease (hypersensitiviety and cellular immune response to saccarides)
This diet has a modification of fat, sugar, antioxidants, allergic food and anti inflammaotyr culinary spices. It increases the omega-3 fatty acid intake and decreases the omega 6 fatty acids, saturated fats and trans fatty acids. It also eliminates foods high in glycemic index
Which diet features an increase in anit-inflammatory spices such as ginger, rosemary, tumeric oregano, cayenne, garlic onion clove and nutmeg?
This diet eliminates wheat, rye, barley and oats and replaces them with rice, corn, buckwheat
Gluten free/casien free/soy free diet
What is the indication for a gluten free diet?
Celiac disease, irritable bowel disease, inflammatory bowel disease
This alternative method technique practiced by chiropracters corrects misalignment of the vetebra
What are some contraindications to being treated by a chiropracter?
- Women with osteoporosis
- High risk pregnancy
- Bleeding disorders
- Bone fractures or metastases
What type of education do chiropracters recieve?
- 4-5 yrs of education
- first half is basic science then latter half is physical and lab dx with neuro, ortho, geri, peds, gyn, physiotherapy, radiology and nutrition
- Graducates recieve a Dr of chiropractic
- There is a board exam
- they take CMEs
- No Rx power
- NOT overseen by the AMA
What are some indications to see a chiropracter?
- Actue and chronic lower back pain
- lumbar disc herniation
- acute and chronic neck pain
- carpal tunnel syndrome
- cervicogenic HA
- Sinusitis/otitis media
- Regulations of autonomic nervous system
What are some possible adverse effects from chiropracting?
- Cauda equina syndrome after lumbar spine manipulation, neurogenic bowel and bladder, saddle anesthesia b/l leg weakness and sensory changes
- CVA after cervical manipulation
- spontaneous vetebral artery dissection
____ is the practice that involves stimulation of specific body pints by insertion and manipulation of fine needles
de Qi means what in chinese?
the chi has arrived it refers to the tingling sensation associated with accupuncutre
When recieving acupuncture these things are discouraged...
Alcohol, recreational drugs, heavy work, workouts, fasting, or feasting
What is "rational" for acupuncture?
Teh body has channels of streaming Qi which is the blood and fluid that carry out internal organ function, if the channels are obstructed ther is pain, congestion and illness, acutpuncure stimulats the flow and suplies where there is a dificency a drain for this fluid which facilitates ultimate healing
What are some indications for acupuncture?
- Nicotine/cocaine addition
- Stroke rehab
- Tension, migrain HA
- Pregnancy, nausea, back pain, shortens labor pain and labor
- Higher implantation rates for IVF
- Pain (tennis elbow neck shoulder rotator cuff knee osteoarthritis, LBP, carpal tunne syndorome)
T or F acupuncture providers have to be certified in clean needle training before becomming licenced
How many years of schooling are needed to become an acupunctureist
in the US 2-4 yrs of undergrad with 3 yrs of professional acupuncture training
___ is a subset of acupuncture where the skin is pressed in strokes by a round edged instrument resulting in red raised petichiae called sha
Adaptogenic therapy means what??
Warming pts who have cold conditions and cooling pts who have warm conditions ( a component of gua sha)
___ ____ is when a vaccume is created in a glass, bamboo or gourd cup by lighting a ball of alcohol soaked cotton and passing it inside the cup which is placed on the skin
What is the rational behind cupping?
remove blood stasis
_____ is the buring of fiber precipitate of artemisia vulgaris (common mugwart) either directly on the skin or above the area
Direct and indirect moxibustion
____ is when a small electrical current is applied to the accupuncture needle to provide stimulation to the accupuncture site and enhance the effect
What is an indication for electrical stimulation accupuncture
acute and chronic MS
_____ is when a seven star needle is tapped with equal pressure into the skin, it is used "in the care of children" to treat eczema
____ involves the surface and musculoskeletal manipulation of musculoskeletal system. It is similar to western massage. The area is brushed, kneaded, rolled and pressed in areas between each fo the joints (known as the eight gates) to open the body s defensive (wei) chi and get the energy moving in teh meridians as well as the muscles
T or F herbalists are board certified by NCCAOM
___ is translated as "life knowledge" or "the science of life" and has a goal of balance in life with the belief that health is the state of enjoying uniterrupted physical, mental and spiritual happiness
____ is the branch of alternative medicine that stresses achievement of virtue (dharma), wealth (artha), enjoyment (kama), and salvation (moksha)
T or F in the US there is an official licening process with state certification board for people administering Ayurvedic medicine
In Ayurvedic medicine what is the dosha characterized by space/air, is respoinsible for mental creativity, imagination, indecisiveness, exhillaration, fear, insecurity and has a GI location in the colon?
In Ayurvedic medicine what is the dosha characterized by Fire/water, intelligence, confidence, leadership, excitement, anger, jeleousy, small intestine
In Ayurvedic medicine what is the dosha characterized by earth/water, memory, tranquility, devotion, love, patience, greed and is located in the stomach
What are the 5 panchakarma therapies?
- Emesis Tx
- Purgation tx (mild laxative to lubricate intestines)
- Enemat Tx (colon cleaning)
- Nasal Tx (nasal drops, lavage, medicated oils, inhialants)
- Bloodletting (by leach or venipuncture)
What are some indications for using Ayurvedic medicine?
Obestiy, HTN, CAD
____ yoga focuses on postures breathing exercies and meditation it was founded in 2,000 bc in india, and it focuses on self awareness with postures to purify the body in preparation for higher states of concious and medication
What are some indications for doing Hatha yoga?
Asthma, CV disease, BM, HTN, HA, mental disorders, OA, pain , RA, seizures, stress
___ ___ is a series of exercises that dates back to china 5,000 yrs ago and was originally a series of exercises to be practiced after a strenuous day it enhances teh flow of energy or Qi in the body and emphasisez balence and harmony through the continuous slow motions rhythmic flexion of the legs and extension of the arms and shifting of weight
In Tai Chi __ is the vital energy behind all processes pertainign to the body and midn and spirit. It is the energy amtter, vital energy or life force. It emanates through the energy pathways or meridians which cover the body like a network system
___ is part of chinese medicine is a part of chinese medicine that consits of medication physical movment and physical exercise
___ is the skill of working with Qi
What are some risk factors for PTSD?
- female gender
- adverse childhood experiences
- prior psychiatric problems
- lower level of eductation
- h/o previous psychiatric problems
- lower socioeconomic status
- minority race
- lenght spent in service
A soldier returns for Iraq with cc of sleeplessness he says his wife has complained that since coming home he has been angry, irritable and more aggressive than usual he says he has felt a sense of isolation/numbness what do you think he has?
What are some symptoms of PTSD?
- anger, irritability, aggressive/violent
- anxiety, startle reflex that is exaggerated
- sense of isolation
- emotionally numb
- Survior's guilt
- Avoidance of people places or things that serve as reminders of the incident
- difficulty on anniversary of incidents
- stituations smells and places that may trigger a flashback
What is the first criterion for PTSD? (criterion A)
exposure to a traumatic event in which both of the following have been present: experienced, witnessed, or ben confronted with an event or events that involve actual or threatened death or serious injury or a threat to the physical integrity of oneself or others, persons response involve intense fear helplessness or horror
What are the indications for practicing Qigong?
Effects on stroke, HTN, mortality decreased cholesterol levels, circulation, bone density, improved coagulation, fibrinolyiss, blood viscosity, RBC, potential effect on cancer, increased blood flow to the brain
Criterion B for PTSD is what?
What is intrusive recolection?
- Traumatic event is persitently re-experienced in at least one way
- Intense psychological distress at exposure to internal and external cues that symbolize/resemble an aspect of the traumatic event
- physicologic reactivity upon exposure to internal or external cues that symbolize or resemble an aspect of the truamatic event
What are some of the ways intrusive recollections can manifest?
- recurrent/intruisve distressing recollections
- recurrent distressing dreams or events
- acting out/ feeling recurrence of the event
- psychological distress with internal/external cues similar to event
- physiological reactivity
What is the third criterion (C) of PTSD??
Avoidance/numbing in PTSD is indicated by 3 of what occurences?
- Efforts to avoid thoughts, feeling or conversitons asociated with trauma
- efforts to avoid activities, places, or people who arous recollections of trauma
- Inability to recall an important aspect of the trauma
- markedly diminished interest or participation in significant activities
- feeling of detatchment or estrangement from others
- restricted range of affect
- sense of foreshortened future
What is the 4th/final criterion for PTSD (criterion D)
perisitent symptoms of increaseing arousal not present before the trauma
What are some manifestations of hyperarousal in PTSD?
- Difficulty falling or staying asleep
- irritability or outbursts of anger
- difficulty concentrating
- exaggerated startle response
What are some common co-morbidities with PTSD?
Depression, suicidal intent, substance abuse, anxiety disorders, social problems
What are some PTSD treatments?
- Cognitive Behavioral Thearapy (CBT)
- Eye movement desensitization and reprocessing therapy (EMDR)
- Pharmacological treatments: SSRI, Other antidepresants, anticonvulsants (make sure you follow up closely with pharmacologic therapy in the initation phase of the perscription their mood can be more unstable)
What are some Pharmacological treatments for PTSD?
- Sertraline (zoloft) dose escalation effect must taper to d/c
- Paroxetine (Paxil) benifit over 20 mg? must taper to d/c
What is a of a TBI?
- Blow or "jolt" to the head: acceleration/deceleration force
- disrupts the normal function of the brain
- severity of TBI is determied at the time of the injury
- Classifications are mild, moderateor severe or by GCS
What is the eitiology of a TBI? What are the most common eitiologies in the military?
- head struck by solid object
- head strieks object
- brain acceleration/decelleration sans external force
- FB that penitrates brain
- force generate form an event a blast explosion etc
- Leading cause in military: Blasts, MVC, fragments, falls bullets
What are the symptoms of TBI?
- sleep disturbances
- balance problems
- visual distrubances/light sensitivity
- ringing in the ears
- Cognigitve signs:
- slowed thinking, poor concentration, memory/attention problems/ word finding problems
What are teh cognitive signs of TBI?
- Slowed thinking
- poor concentration
- memor/attention problems
- word finding problems
What are the emotional signs of TBI?
Anxiety, depression, irritability, mood swings
What are some concering signs and symptoms with a TBI?
- worsening headache
- worsening balance
- double vision or other vision changes
- decreaseing level of altertness
- increased disorientation
- repeated vomiting
- unusal behavior
- amnesia/memory problems
What 4 things are used to rate severity of a TBI?
- Loss of conciousness
- change in consciousness/mental state
- Post traumatic amnesia
- Glasgow coma scale
What are 4 considerations in TBI that you need to think about before you let them go back into play or into service?
- identification of neurologic emergencies
- identification fo high risk indivituals for second impact syndrome
- recognition and managment of neurologic sequelae
- prevention of cumulative and chronic brain injury
This imaging modality is best for normal brains, microbleeds, focal non-specific areas of subcortical white matter
This imaging modality is best/used for small contusions extra axial hematomas, subcortical hemmorhages
With a TBI what imaging study do you order first?
CT and then get an MRI if there are abnormal findings on CT
What are the first 3 prioities/goals in a TBI? especially with a blast injury
- ID other life threating injuries
- prevent further secondary brain injury
- treat identified mass lesions
How would you treat increased intracrainal pressure?
Mannitol or drain
What nonvisible part of the body do you HAVE to check on a pt who is brought in on a backboard?
the back! once it is safe to flip them you need to check it out back there and make sure nothing is wrong
What do you not want to do in a pt who may have increased intracranial pressure?
DO NOT hyperventilate
For every soldier who dies on the field how many will commit suicide?
This was a form of alternative medicine developed in germany in the 19th century by samuel Hahnenman, it emphasizes the holistic approach and offers indivicual approaches for specific complaints
What is the principle of simlar?
- a substane that can cause symptoms in the healthy person can stimulate self healing int eh person with similar response to an illness
- preparations are diulted in water initally b/c they may cause more of the same symptoms
What are the components of homeopathic evaluation?
- mental/emotional sx (mood, anxiety, fear)
- Sensation( character)
- location (side of body affected)
- direction (radiation)
- concomitant sx
- modalities (triggers aggrevating and alleviating factors)
- intensity (compared to the sx the pt has has before)
- onset (actual date and time of sx)
- sequence of events (circumstances before the pt has sx)
What are the indications for using homeopathic medicine?
- Otitis media
- allergic rhinitis
- acute diarrheal syndrome
Explain the pathophysiology of Primary hyperparathyroidism
- Mostly caused by adenomas but rarely caused by hyperplasia or cancer of the parathyroid
- Characterized by excess PTH secretion and a shift in the set point for the calcium's suppression fo the parathyroid gland
"Osteitis fibrosa cystica" is characteristic of what disorder?
On an x-ray of a pt with nonspecific bone pain and a small nodule near the thyroid you note a Brown tumor. What is your diagnosis
A 35 y.o male presents with extreame muscle fatigue that has been worsening for several weeks and has prevented him from going to the gym like usual. He has not changed his workout recently. On physical exam you note muscle atrophy from his last visit to you one year ago. You also note that he went to the ER since his last visit for a kidney stone that returned as calcium oxylate.What do you suspect is his diagnosis and how would you confirm it?
- Hypercalcemia secondary to Hyperparathyroidism
- Confirm with a serum calcium level and an immunoreactive PTH level
__ are tumors of bone that arise in settings of excess osteoclast activity, such as hyperparathyroidism, and consist of fibrous tissue, woven bone and supporting vasculature, but no matrix. They are radiolucent on x-ray.
____ is the pathopneumonic feature of hyperparathyroidism and is characterized by an increase in the giant multinucleated osteoclasts in scalloped areas on the surface of the bone and the replacement of normal cellular and marrow elements with fibrous tissue. X-ray changes include resorption of the phylangial tufts and replacement of the usually sharp cortical outline of teh bone in the digits with an irregular outine
Osteitis fibro cystica
You have a pt with PMH of Zollinger ellison syndrome who presents to you with muscle fatigue and a high blood serum calcium. You diagnose them with ___ and should further work them up for a possible diagonosis of ____
- Diagnose with hyperparathyroid
- work up for MEN1
Diagnostic test of choice for hyperparathyroidism
What is the typical treatment for primary hyperparathyroidism
Surgeons take out 3-3.5 of the parathyroid glands and leave the rest tagged with a metal tag just in case they need to be removed at a later date
What are some indications for surgery to fix hyperparahthyroidism?
- Serum calcium > 1mg/dL above normal
- creatinine clearance < 60 ml/min
- overt clinical manifestations: kidney stones, osteitis fibrosa cystica, neuromuscular disease, symptomatic hypercalcermia
- BMD T score <2.5 or fragility fracture
- age <50 y.o.
- Inadequate follow up
Acidosis (decreases or increases) binding of calcium to proteins like albumin, while alkalosis (increases or decreases) it
- Acidosis reduces binding
- Alkalosis increases binding
What is a normal total calcium value
What is a normal value range for ionized calcium?
How do you adjust the total calcium level for high or low albumin?
- for every 1g/dl of albumine below or above 4.0, then add or subtract 0.8mg/dl of calcium fromt the total calcium
- for example if the total calcium is 8.0 with an albumine of 2.0 then 4-2 = 2 and 2* 0.8 = 1.6 add this to the total calcium and you get 9.6 for the true calcium
Calcium and PTH are (inversely or directly) proportional
How does the body correct a low serum calcium?
- Low serum calcium
- stimulates the release of PTH from the parathyroid glands
- PTH acts on teh bone to release calcium and phosphate from the skeleton
- PTH enhances calcium reabsorbtion fromt eh kidney and inhibits phosphate reabsorbtion producing phosphaturia
- PTH stiulates the conversion of 25 OHD to 1,25 OH 2 D which enhances intestinal calcium absorbtion
- the overall result is a return to normal calcemia
How does the body correct an elevation in serum calcium?
- Decreased PTH and 1,25 OH 2 D secretion, stimulates calcium sensing receptors to decreases renal calcium absorbtion
- Net result
- Decreased skeletal calcium release
- Decreased intestinal calcium absorbtion
- Decreased renal calcium resorbtion
What is the most common cause of hypercalcemia in the outpatient setting?
What is the most common cause of hypercalcemia in inpatients?
Name some causes of hypercalcemia
- Parathyroid horomone related: primary hyperparathyroidism, tertiary hyperparathyroidism, familal hypocalciuric hypercalcemia, lithium
- Vitamin D related: Vitamin D intoxication, granulomatous disease like sarcoidosis, TB, IBD b/c they create their own vitamin D
- Malignancy related: pTHrP producing squamous cell tumors, osteolytic metastases (multiple myeloma and breast cancer), PTH producing tumor, Other humoral factors (lymphoma, leukemia, multiple myeloma)
- Other Causes: milk alkali syndrome Immobilization, vitamin A toxicity, aluminum intoxication, hyperthyroidism, thiazide use, adrenal insufficency, pheochromocytoma
- Vitamin D toxicity
What malignancies elevates serum calcium via PTHrP?
- Squamous cell lung cancer
What types of calcium elevate serum calcium by elevation in 1,25 D?
Hodgkin's and other lymphomas
How does vitamin D toxicity/granulomatous disease increase calcium level?
Activated macrophages and lymphoid cells within granulomatous tissues induce the conversion of 25 vitamin D to 1,25 vitamin D. Mechanisms invovle both increased calcium absorbtion from the gut and increased bone resorbtion
What are some acute kidney findings consistend with hypercalcemia?
- renal failure
What are some acute neuropsychiatric symptoms consitent with hypercalcemia?
T or F hypercalcemia can be related to pancreatitis
True mechanism unknown
What are some symptoms of chronic hypercalcemia?
- bone disease
- general osteopenia
- cortical osteopenia
- mild reduction in GFR
- Subtle mental impairement
- Soft tissue calcifications
What is the treatment for hypercalcemia?
- Hydration oral or IV
- Forced hydration either NS 200-300ml/hr this depends on their levels and symptoms caution with heart disease due tot the increase in volume
- Furosemide 20-40mg after hydration to increase Ca+ excretion
- IV bisphosphonates: zoledronic acid 4mg, pamidoronate 60-90 mg
- Dialysis (if all else fails)
What are some causes of hypocalcemia?
- Inadequate PTH produciton (hypoparathyroidism often due to surgery or diGeorge Syndrome)
- Impaired PTH secretion: due to hypomagnessemia, respiratory alkylosis, activating mutation calcium receptor
- Targe organ resistance: Hypomagnesemia, pseudohypoparathyroidism
- Vitamin D related: malabsorbtion and poor diet, impaired 25 hydroxylation (as with liver disease), Impaired 1 alpha hydroxylation (as with renal disease), Vitamin D dependent rickets, Oncogenic osteomalacia,
- Excessive skeletal depostion: osteoblastic metastases like prostate cancer, Hungry bone syndrome (bone disease in hyperparathyroid syndrome, can have severely low calcium until it is fixed)
- Chelation: phosphate, citrated blood products
- Critical illness: Pancreatitis, ICU pts
What are the symptoms of hypocalcemia?
- paresthesias (lips, distal fingers and toes)
- Increased neuromuscular irritability (tetany, muscle cramkps, twitching)
- altered CNS function seizures AMS
- Generalized fatigue
- Trousseu's sign
- Chvostecks sign
- prolonged QT interval
- basal ganglia
- intracerebral calcifications
Trousseaus sign is a sign of what?
Chvosteck's sign is a sign of ___
What is the treatment for hypocalcemia?
- Calcium administration oral or IV depends on condition and underlying cause
- Vitamin D or 1,25 (OH)2 Vitamin D
- Hydrochlorothiazide prevents excretion
This drug prevents calcium excretion and is indicated for hypocalcemia but contraindicated for hypercalcemia (and may in fact cause hypercalcemia)
___ is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fractures
Osteopenia is a T score of __ to __ std deviations below normal on a DEXA scan
-1 to -2.5
Osteoporosis is defined as a T score ___ std devations below normal on a DEXA scan
more than -2.5
Bone quality is based on what three factors?
- Bone quality: achitecture/geometry, damage, mineralization
- Bone mineral density
- bone strength
Explain the pathophysiology of osteoporosis
osteoblast and osteoclasts naturally resorbe and remodel bone all the time with osteoporosis the osteoblastic remodling remodles the bone with less and less bone density than you started with
What are some Secondary causes of osteoporosis?
- Endocrine: primary hyperthyroidism, hypercortisolism, hyperthyroidism, hypogonadism
- Nutritional: alcoholism, calcium or vitamin D deficiency, Anorexa nervosa
- Gastrointestinal: malabsorbtion, celiac disease, chron's disease, gastric resection or bypass
- Medications: aromatase inhibitors for breast cancer, androgen deprivation therapy, chemotherapy/immunosupressants, glucocorticoids, anticonvulsants, proton pump inhibitors, selective serotonin reuptake inhibitors
- Collagen disorders: Ehlers Danlos syndrome, osteogenesis imperfecta
- Other: immobilization, Rheumatoid arthritis, multiple myeloma, Organ transplant, hypercalcemia
What are some risk factors for osteoporosis?
- Advanced age
- low body weight
- low calcium and vitamin D intake
- Menopausal status
What are some risk factors for ostoeporotic fracture?
- Advanced age
- prior fragility fracture
- low bone mineral density
- low body weight
- parental history of hip fractures
- use of glucocorticoids
- cigarette smoking
- excessive alcohol consumption
- secondary causes
What are some symptoms you would expect to find with osteoporotic vertebral fractures?
- acute and chronic pain in the back
- kyphosis and height loss
- respiratory and abdominal problems (breathing, constipation and bloating)
- Impaired function
- Increased morbidity and mortality
- Increased fracture risk
what are some diagnostic evaluations for Osteoporosis workup?
- Diagnosis of postmenopausal osteoporosis (PMO) primarily clinical daignosis with med history, PE, lab tests for menopause, bone mineral density
- Bone Density Scan (DEXA)
- Central DXA measurement
- Biochemical markers for bone turnover
What are the biochemical markers for bone formation?
- Bone specific alkaline phosphatase (BSAP)
- Osteocalcin (OC)
- Propeptide of type 1 collagen (P1NP)
What are the biochemical markers for bone resorption?
- N-telopeptide of type 1 collagen (NTX)
- C-telopeptide of type 1 collagen (CTX)
When would you perscribe ET or HRT for osteopenia osteoporosis? and how would you manage a pt on this therapy?
- prescribe to decrease the risk of hip and vertebral fractures in post menopausal osteoporosis
- individualize therapy based on each pts risk benifit profile
- prescribe lowest effective dose to shortest duration
- re-evluate frequently
What are the SEs of SERMs?
hot flashes, muscle and joint aches and increased risk of phlebitis
How do SERMs work
- bind to estrogen receptors and have estrogen like effects in some tissues but not others
- Raloxifene is indicated for breast cancer and the remodling and redtuion of osteopenia and ostoporosis in PMO
Ebondromate has a reduction of __ fractures but not __ fractures
reduction of spine but not hip
What are the two types of bisphosphonates?
N-containing bisphosphonates and non-N-containing Bisphosphonates
The bisphosphonate family of drugs all have this ending ___
What are some SEs of bisphosphonates?
- Osteonecrosis of the jaw
- Atypical subtrochanteric femur fractures
- Less severe: esophagitis, dyspepsia, musculoskeletal
___ is a drug/horomone given as an anabolic agent for osteoporosis that peaks and then comes back down to baseline within 4 hrs. It is indicated for SEVERE osteoporosis
What is the black box warning on PTH used for osteoporosis
How do RANK ligand inhibitors work?
in menopause decreased estrogen causes an increase in the RANK ligand causing incresaed osteoclastic activity RANK ligand inihibitors inhibit this by occupying the RANK ligand
How must you instruct a pt on bisphosphonates to take their meds?
- Must take with 6-8 oz of water
- must fast (eat nothing!) for 30-60 mins after taking
- remain upright for at least 30 mins and 60 for ibandronate
What two bisphosphonates can be given IV
Zolendronic (reclast) and Ibandronate (Boniva)
What are the SEs of of RANKL inhibitors? (denosumab)
- muscle and joint aches, small increase in skin infections
- (monoclonal antibody for RANKL, given subQ, can give to pts with decresaed renal function, decrease in hip frax with tx)
What are some general recomendations for the prevention of osteoporosis?
- Calcium supplement
- Vitamin D supplement
- Exercise that is weight bearing
- fall prevention
a group of health care professionals from diverse fields working in a coordianted way towards a common goal for a patient
the ___ approach to care is where one practitioner retains central responsibility for the pt and consults others as needed
What are some benifits to the health care delivery of interdiciplinary medicine?
- more efficient delivery of care
- maximize resources and facilities
- decrease burden on acute care facilities
- increased preventative care
- facilitates ongoing quality improvement efforts
What are some benifits for patients from interdiciplinary medicine
- improves care by increaseing coordinatino of services especially for complex problems
- Integrates health care for wide range of problems and needs
- Can serve pts of more diverse cultural backgrounds
- Uses time more efficiently
What are the benifits of interdiciplinary teams for healt care providers?
- Increase professional satisfaction
- shifts emphasis from acute episodic care to long term preventative care
- enables the practitioner to learn new skills and approaches
- encourages innovation
- allows provider to focus on individual areas of expertise
What are some general benifits to interdiciplinary medicine teams
- improved cost effectiveness
- increased quality of health care services
- pts with higher satisfaction and adherence
- fewer ER visits
- Pt empowerment
- Elderly population lower mortality rates
What are the drawbacks to interdiciplinary care?
- interprofesional conflicts
- Physician responsible for the actions of other health care professionals on the team
- Regulations for collaborative practice
- Clarify roles/accountability for non-physician members for the team performing shared tasks
What are the components of Active listening?
- Empathetic listening- other directed and non-defensive want to understand perspective life and experiences of the pt
- Skills: attending, acknowlaging, restating, paraphrasing, reflecting, interpreteing, sumarizing, probing, giving feedback, supporting, checkign perception, being quiet
- Listening skills: verbal attending, minimal encouragers, being present
- Questions: open ended, closed, why
- Summarizing: shows understanding, checks for accuracy, ends conversation and moves forward
Pt presents with PMH of existing pituitary adenoma presents with headache, visual field defects and N, V and hemiparesis. What does he likely have?
What are the symptoms of pituitary apoplexy
Headache, Visual field defects, ocular palseys, AMS, N, V, meningismus and hemiparesis
73 y.o. m is admitted with abdominal pain, nausea, vomiting, fever, HA and hypotension he is given IV fluids and antibotics IV fluids and pressors, he developed obtundation, hyponatremia, meningismus and cranial nerve III and IV and VI palsies What do you think might be his diagnosis?
What are some of the eitiologies of hypopituitarism?
- Suprasellar/hypothalamic tumors (craniopharyngioma)
- Infiltrative disease- sarcoid or lymphocytic hypophysitis
- Infacrtion: Sheehan�s syndrome, apoplexy
____ is a decreased secretion of one or more anterior pituitary hormones (GH, ACTH, TSH, FSH, LH, PRL)
A deficiency of the posterior pituitary hormone ADH leads to what syndrome?
Are deficiencies of posterior pituitary secretion of ADH usually associated with benign or malignant pituitary tumors?
43 y.o. F presents with cc of being really thirsty and peeing a lot she says that she gets up several times a night to drink cold water and go to the bathroom. Upon checking her serum you find that she has hyponatremia. Do you treat for Diabetes insipidus?
No because she has hyponatremia you can rule out diabetes insipidus which would present with normal or hypernatremia. If you treat this pt they will end up with profound hyponatremia
26 y.o. male presents with cc of excessive thirst and urination. He says he has to go several times during class and that he wakes up to 4 times during the night to pee and drink. He thought this was due to dehydration from sports but noticed that it persisted on his week off from training. You check his sodium and he is hypernatremic
- Diabetes insipidus
- You suspect a pt has diabetes insipidus based on their symptoms and a chem. 7, what other diagnostic test should you do? What are you looking for?
- MRI the brain for Craniopharyngioma, lymphocytic hypophysitis, germinoma, metastasis
What is the treatment for diabetes insipidus?
- 1 puff DDAVP nasal spray before bed
- transphenoidal excision of tumor
What is the most important SE of DDAVP?
Hyponatremia pt must protect against this by intermittent sodium checks and close body monitoring for feeing the drug wear off
T or F diagnosis of hypopituitarism can be made by measuring the serum levels of TSH and ACTH
No They can be falsely normal
Pt presents with cc of fatigue. She also describes having apathy cold intolerenc and recent weight gain. On PE she has no goiter of the thyroid. You order a TSH and find it to be normal. What do you need to order next? What are you looking for?
Free T4 you are looking for an inappropriately low T4 which would indicate a central hypothyroidism
What is the treatment for central hypothyroidism?
In a pt with adrenal insufficiency and hypothyroidism from central hypopitutarism what must you treat first and why?
Treat the adrenal insufficiency before the hypothyroidism because Lthyroxine increases the metabolism of cortisol and can precipitate an adrenal crisis in a pt with adrenal insufficiency
This disease is due to abnormal CRH or ACTH production which results in decreased cortisol production
Central Adrenal insufficiency
What are the signs and sx of Central adrenal insufficiency?
Weakness, orthostatic hypotension anorexia, vomiting, wt loss, muscle or joint aches, hyponatremia
ACTH secretion peaks at what time of the day?
42y.o. F presents with fatigue, anorexia, nausea, and hypoglycemia that is mild. When you question her you find she has a PMH of lupus for which she just had been on a dose of Prednisone 30mg. She decided to discontinue it 2 days ago because she said it made her feel fat. Now she thinks she has the flu. What do you think she has?
Secondary adrenal insufficiency due to withdrawl from glucocorticoid treatment
What is the Tx for ACTH deficiency?
Glucocorticoid replacement therapy.
How does central adrenal insufficiency differ from primary symptom wise? (what symptoms does primary have that secondary does not?)
Secondary does not have: salt craving or hyperkalemia from abnormal aldosterone secretion and it does not have hyperpigmentation (b/c ACTH is not elevated)
Which is least concerning a low level of cortisol at 7am, 10am or 3pm?
3pm because levels are normally low in the afternoon
T or F a low level of ACTH during stress like infection during hospitalization may be concerning for Adrenal insufficiency
Do pts on OCT have a lower or higher cortisol level? Why?
Estrogen helps make cortisol binding globulin which increases the binding of free cortisol in the blood falsely lowering the levels of free cortisol. So people on OCT will have a falsely low free cortisol
What is the gold standard test for central adrenal insufficiency?
Insulin tolerence test
What are some tests you could do for central adrenal insufficiency?
- Morning serum cortisol level
- Cort stim test
- Insulin tolerance test
What is a morning serum cortisol level and what do you use it for?
- Endogenous levels of cortosol are highest in the morning so it is the most reliable measure of ACTH production
- Less than 3mcg/dl in the am is adrenal insufficiency
- >18 mcg/dl in the morning is normal function
- you have the pt collect 3 morning urine samples and if any of the 3 are over 18 adrenal insufficnecy is unlikely
What is a cort stim test?
- Blood test for central adrenal insuffiency
- Performed by: 1) take blood sample for a baseline cortisol level, 2) give ACTH 3) take cortisol at 30 mins, 4) take cortisol at 60 mins
- It is not helpful in an acute setting (like after apoplexy surgery) and it is not reliable with oral contraceptives
- Peak >18 is normal
What is an Insulin tolerence test
- Gold standard for diagnosis of Central adrenal insufficiency
- Hypoglycemia stimulates the entire HPA axis, which is useful to diagnose actue and chronic AI as well as GHD
- Contraindicated in the elderly CV disease, seizures, and serious psychiatric disease
- Physician must be present
- Administer insulin and look for hypothalamic pituitary response
What types of people are contradindicated from doing an insulin tolerence test?
Elderly, CV disease, seizures, serious psychiatric disease
T or F ACTH levels are useful to determine the cause of adrenal insufficiency but not to determine whether adrenal insufficiency is present
What is the most common cause of central adrenal insufficiency?
Withdrawl from glucocoticoid therapy
If you determine someone to have central adrenal insufficiency and you rule out hx of glucocorticoid use what is your next diagnostic procedure?
MRI of the pituitary
Why should you not exceed a normal physiologic dose of glucocorticoid replacement when treating a pt with adrenal insufficiency?
- Cushing syndrome will ensue in a mild to moderate form if there is too
After establishing labs consistent with primary adrenal insufficiency what is the next diagnostic step?
What are the eitiologies fo primary adrenal insufficiency?
- Metatstatic cancer
- Adrenal infarction or hemorrhage
If you have a pt in whom you supect primary adrenal insufficiency due to autoimmune etiology what other labs should you check?
- Consider the possibility of polyglandular autimmune syndromes
- Check Calcium, phosphorus, glucose, TSH, testosterone, FSH
In boys under 15 y.o. with primary adrenal inufficency you should rule out adrenoleukokydtrophy What is this disease?
Abnormal fatty acid accumulations in the adrenals and the brain causing cognitive neurologic and behavioral problems. You can combat it early in the course of the disease but only if you catch it!
When treating a pt with primary adrenal insufficiency what are the sick rule guidelines for increasing or decreasing treatment?
Double or triple glucocorticoid replacement dose for physical illness. (this includes operation or when they need extra but not for minor illness or emotional stress)
If a pt with primary adrenal insufficiency is in the ER with severe vomiting and diarrhea and is unable to keep food liquid or pills down how should you manage their condition?
- IV glucocorticoids and fluids in the ER, stress does is typically 100mg IV every 6-8 hours. No IV mineralocorticoids available 100mg of hydrocortisone has sufficient mineralocorticoid activity
- (pts with central hypoadrenalism do not need mineralocorticoids)
Serum cortisol levels while hypotensive equal to ____ mcg/dl are diagnostic of adrenal insufficiency
___ is a disorder due to abnormal GnRH, LH or FSH secretion, resulting in a decreased production of gonadal steroids
What are some sx of hypogonadism in women?
Amenorrhea, infertility, dyspareunia
What are some sx of hypogonadism in men?
- Decreased libido and increased impotence and infertility
- Men tend to loose their sex drive before they loose their erections this means men usually go longer without diagnosis than women (who miss their period)
Treatment for central hypogonadism in men
- Testosterone (IM testosterone esters for men peak serum T supraphysiologic increase in HCT and prostate stimulation)
- Testosterone patches and gels are a bit better because they provide a more stable horomone replacement
- Gonadotropin therapy if fertility is desired (LH to the testes to testosterone to spermatogenesis)
Treatment for central hypogonadism in women
- Estrogen/progestin replacement for women of reproductive age
- No data, WHI results cannot be extrapolated to women of reproductive age.
- Goal: restoration of normal hormone level
- Gonadotropin therapy if fertility desired
- For women who are post menopauseal: HRT similar as for eupitutitary women but hot flashes are rare and some intracranial tumors have estrogen receptors
What are the benefits to replacing GH in adults with central hypopituitarism?
Increase bone density, increased muscle, decreased fat and improves cardiovascular and blood glucose with some benefits to quality of life
Name some questions you should ask a pt when deciding with them on a type of birth control?
- Sexually active?
- Number of lifetime partners or current partners?
- Men, women or both?
- Where do you have sex most often
- In what kind of sex do they engage? Vaginal, oral, anal?
- Medical history? STIs, Meds?, Age?, Smoker?
- Family history
What are some pros of the Pill as oral contraception?
- decreased risk of ovarian cancer and endometrial cancer
- anemia, PID, ectopic pregnancy
What are some cons of pill oral contraception?
- Decreased effectiveness when interaction with other meds (PCN, tetracycline, sulfonamides, rifampin, phenytoin, barbituates) Antibiotics may be myth
- Hypercoaguability: PE, MI, CVA thromboembolism
What are some ABSOLUTE contraindications for using the pill.
- Smoker over age 35 (if greater than 1/2 per day)
- History of PE, CVA, MI or thromboembolism (but can take progesterone pill only)
- Breast or endometrial cancer (if estrogen receptor positive)
- Hepatic tumor with abnormal LFTs (due to CYP enzyme)
What are some relative contraindications to the pill?
- Uterine fibroids (myth b/c probably doesn't actually make them worse and the pill can help decrease bleeding)
- Lactation, DM, HTN: pill does not affect glucose metabolism, should not be on estrogen immediatly postpartum for 3-4 wks due to hypercoaguable state
- myth that estrogen can decrease milk volume
How long must a woman wait postpartum before starting the pill?
3-4 wks b/c of hypercoaguability
What are some drawbacks to using the patch (hormonal contraception)
- Changed weekly
- Patch affected by weight; obese pts have lower level of estrogen circulating
- High dose in the patch circulating levels of estrogen are higher
- Skin irritation
How long can the ring sit in the vaginal vault?
What is the major drawback to the ring?
- It can be expelled, especially in women who have had children already
- they must make sure the ring is still there periodically
- can be out for a few hours before it is an issue
- can be rinsed off
- ring cannot absorb any other fluids
What is the max amount of time the ring is effective for?
What group of women benifit most from Depo Provera injections for birth control?
Women with husbands awaiting vasectomy b/c inject and by the time it wears off he should be aspermia
What are some drawbacks to Depo Provera?
- Irregular vaginal bleeding
- Breast tenderness
- Weight gain if greater than 10% in 3 months the stop! Increases hunger
- Long term use- loss of bone mineral density, osteoporosis and osteoporotic fracture (reversible within 6 mo of stopping med)
- Can worsen clinical depression
- Significant delay in the return of normal ovulation
- cannot remove once they have injected so adverse reactions are here to stay
- Every 12 wks needs a new injection
What is Nexplanon? what are its pros? and cons?
- Implant depot of horomones for birth control
- Pros: good for three years, progesterone only, "get it and forget it"
- Cons: similar to depo provera, No STI protection, risk of irregular bleeding
What is the MOI of IUD?
irritates the uterine lining, this way the embryo will not be able to attach to the uterine lining, changes cervical mucous which prevents sperm from passin and Mirena also has a drug eluting action as well
What are the Pros of IUD
- progesterone only
- works directly on the uterine lining to prevent buildup so no periods
- Lasts for 5 years
What are the Cons of an IUD
- may be moral contraindications for some patients
- Can spot every day for the first 3-6 months
- Vasovagal respons during implantation proceedure is common (can give anesthesia to the cervix to prevent this)
What is the MOA of a spermicide?
put into vagina in an ovule cream or film, then it disrupts the cell membrane of the sperm, acts as a mechanical barrier
What are the pros to spermacides?
no horomones, should be used in addition to condoms = good effect, cheap
What are the Cons to spermicides
- only 82% effective with 70% effective in reality
- Irritation and allergic reaction occur frequenly
- Leaks out after sex
What are a few things you should counsel your pt on about using male condoms?
- Most effective barrier method
- one size does not fit all
- check expiration date before using
- store packaging in adequate places
- Make room for semen at the top before use
- 85-90% effective in real like use
Are female condoms more or less effective than male condoms?
less male is 85-90% while female is only 80%
What are the pros to using male condoms
- no horomones
- prevents STIs
- can use water based lubricants
What are the Cons to using male condoms?
- Can break
- latex allergies, spermicide reactions,lubricant reactions
- can decrease sensation and pleasure
T or F diaphragm is one size fits all and can be bought OTC
no must be sized in the office
How long must a diaphragm with spermicide be kept in post coitus
How effective is the diaphragm or cervical cap?
94% in studies but only 84% in real life
What are the drawbacks to using a diaphragm
- may lead to bladder irritation or cystitis
- if left in too long may colonize with S aureus and develope toxic shock syndome
- replace every 5 years or with weight change of more than 10 pounds
- cap has to be changed every 2 years
How often must you change a diaphragm? how about a cap?
What is the name of the IUD that is non horomone eluting on the US market?
Can the male feel the string of an IUD?
What are the drawbacks to ParaGuard
- cramping pain during proceedure (pretreat with NSAIDs)
- get periods like normal but they will be crampier and heavier
- may be hard to get in a woman who has not had children yet
What are some ABSOLUTE contraindications to using an IUD?
- Current pregnancy
- abnormal vaginal bleeding diagnose first
- GYN Cancer
- acute cervical or uterine infection
- history of PID if recent make sure it is treated properly and can treat while the IUD is in
What are the relative contraindications to using an IUD
- Nulliparity: not really a contraindication
- Prior ectopic pregnancy
- History of STI
- moderate to severe dysmenorrhea
What is the failure rate for vasectomy?
less than 1%
What are the pros of vasectomy?
- It happens to the guy!!!! : )
- local anesthesia
- rare complications (bleeiding and infection)
- Re-anastomosis success rates are 60-70% if changed their mind
What are the cons of vasectomy?
- Should not be seen as reversible
- must use backup until azoospermia is confirmed
Explain how Tubal sterilization is done, its pros and cons
- Goagulation, banding or ligation
- clip or cauterize the tube
- intraabdominal surgery
- Essure: trans vaginally inserted metal coil into both tubes takes 3 months to scar and form blockage
- Pros: low rate of ectopic, reversal rate up to 80%
- Cons: General anestheis except fo essure
- should not be considered reversible
How effective is coitus interruptus
96% effective but 73% effective in actual use
What are the pros and cons to coitus interruptus?
- Pros: no horomones, don't need any other devices
- Cons: self control, some sperm is present in pre-ejaculatory fluid
- After delivery ovulation is delayed due to hypothalamus supression of ovulation seconday to breast feeding
- useful for a max of 6 months post partum
- effectiveness 45-98%
What are the options for Contraceptive failure?
- Plan B: levonorgestril, taken immediatly upt o 72 hrs after if BMI is over 26 it is completely ineffective, one step, don't need a prescription
- Ella: non hormonal emergency contraceptive, Effective in BMI less than 30, need a prescription
- ParaGard insertion is the most effective