ESAP 2015 Flashcards
Should adrenal venous sampling be done with or without ACTH stimulation?
Generally recommended that it be done with ACTH stimulation although there is no compelling evidence that it improves diagnostic accuracy.
What does addition of an ACE inhibitor do to the plasma renin activity in a patient with renal artery stenosis?
Increases plasma renin activity
What happens to the total testosterone level after weight loss due to gastric bypass surgery?
Significantly increases.
What happens to the free testosterone level after weight loss due to gastric bypass surgery?
Significantly increases.
What happens to the total testosterone level after weight loss due to calorie restriction?
Increases.
What happens to the free testosterone level after weight loss due to calorie restriction?
Increases.
Do serum sex hormone binding globulins increase or decrease with obesity?
They decrease.
What happens to the GFR in the early stages of treatment of primary hyperaldosteronism with mineralocorticoid receptor antagonists?
It decreases.
Aldosterone-induced hyper-filtration is blocked
Are insulinomas benign or malignant?
They can be either.
What are the two possibilities of there is a very marked elevation of beta cell polypeptides (insulin, pro-insulin, c-peptide) in a patient with hypoglycemia (and a pancreatic mass)?
- Insulin antibodies are present
- Insulinoma is malignant
Pancreatic procedures/surgeries in the presence of fatty infiltration may result in…?
High risk of complications such as pancreatic fistula or anastomotic breakdown.
If enucleation of an Insulinoma cannot be done because of location then what other non-medical management option is available?
Ethanol ablation under the guidance of endoscopic ultrasonography.
Name two drugs used in the medical management of insulinomas?
- Diazoxide
- Somatostatin
What is the ‘legacy effect’ in the DCCT (Diabetes Control and Complications Trial)?
The group of type 1 diabetics with intensified glucose control had prolonged reductions in cardiovascular risk.
Can statins reduce lifetime cardiovascular risk in teenagers?
Yes - if they have significant dyslipidemia with high LDL.
Is there data to demonstrate reduced risk of cardiovascular disease with low-fat diet alone?
No
What three tests should all women diagnosed with primary ovarian insufficiency have?
- Assessment of FMR1 repeat length
- Measurement of adrenal anti-bodies
- Karyotype analysis
What does hyperphosphatemia do to PTH levels?
Increases them.
In secondary hyperparathyroidism, what happens to the phosphorus levels?
Increased or upper-normal.
In secondary hyperparathyroidism, what happens to the calcium levels?
Normal or below normal
If calcium is 1 mg/dL above reference range persisting for more than 3 - 12 months after transplant, in a patient with tertiary hyperparathyroidism, then what further management should be done?
Either subtotal parathyroidectomy or 4-gland parathyroidectomy with auto-transplant.
In patients with high surgical risk, cinacalcet may be tried.
Do lifestyle changes (goal weight loss > 7% with calorie intake 1200 to 1800 kcal per day; and 175 minutes of moderate-intensity physical activity per week) cause reduction in cardiovascular events or mortality?
No
Look AHEAD trial
Do lifestyle changes (goal weight loss > 7% with calorie intake 1200 to 1800 kcal per day; and 175 minutes of moderate-intensity physical activity per week) cause reduction in diabetic complications?
This was not studied so data is not available to show this.
Look AHEAD trial
Do lifestyle changes (goal weight loss > 7% with calorie intake 1200 to 1800 kcal per day; and 175 minutes of moderate-intensity physical activity per week) cause decreased need for glucose-lowering therapy?
Yes
Look AHEAD trial
What is the mechanism of tumor-mediated hypoglycemia?
A circulating factor other than insulin stimulates the insulin receptor (insulin-like factor).
What happens to the endogenous production of beta-cell polypeptides in tumor-mediated hypoglycemia?
It ceases (because of the hypoglycemia)
What is the treatment of patients with non classical CAH who desire pregnancy?
Glucocorticoids (e.g. dexamethasone 250 mcg qHS)
What does pegvisomant do to HbA1c?
Lowers it.
What does pegvisomant do to insulin sensitivity?
Increases it.
What is the starting dose of pegvisomant?
10 mg daily
What is the risk of pituitary tumor enlargement over a 5-year period of a patient with residual tumor on pegvisomant for acromegaly?
3%
After parathyroidectomy, what site does bone density increase at most dramatically?
Lumber spine
Does bone density increase at the distal radius after parathyroidectomy?
Not significantly.
How can spermatogenesis be induced in men with secondary hypogonadism?
GnRH or gonadotropins.
How is GnRH administered?
Administered in a pulsatile fashion via an infusion pump that delivers a bolus every 90 to 120 minutes via a subcutaneous needle in the abdomen.
What does GnRH stimulate?
Pituitary gonadotropins i.e. LH and FSH.
What does LH stimulate in men?
Leydig cells of the testes resulting in synthesis and secretion of testosterone.
What does FSH stimulate in men?
Sertoli cells of seminiferous tubules to promote spermatogenesis.
What is the prerequisite for GnRH therapy in men?
Intactness of the pituitary gland.
When is hCG sufficient as mono therapy in the treatment of male infertility?
In men with testicular size larger than 8 mL.
What should the body fat composition be in men?
Less than 23.1%
What should the body fat composition be in women?
Less than 33.3%
Despite a normal BMI, increased adiposity confers an increased risk for metabolic complications and increased cardiovascular mortality, particularly for women.
True or false?
True
What should you add to abiraterone to resolve the hypermineralocorticoid state caused by the resultant elevated ACTH?
A non-mineralocorticoid steroid such as dexamethasone or prednisone.
What is the next step if FNA of the thyroid suggests lymphoma?
Core biopsy with repeated flow cytometry.
How many months before presentation do people with insulinomas typically have symptoms?
6 - 18 months
Do patients with insulinomas always have weight gain?
No
What does a response to glucagon indicate in hypoglycemic patients?
The presence of insulin or insulin-like factors.
What is the Rotterdam criteria for diagnosing polycystic ovary syndrome?
2 out of 3 of the following criteria:
- Hyperandrogenism, clinical (hirsutism or acne) or biochemical (elevated testosterone).
- Irregular menses.
- Polycystic ovaries on ultrasonography.
Which is higher in functional hypothalamic amenorrhea - LH or FSH?
FSH
Which type of amiodarone-induced thyrotoxicosis causes destructive thyroiditis?
Type 2 AIT
What is the half life of amiodarone and its metabolites?
Up to 100 days.
Where are amiodarone and its metabolites stored in the body?
Stored in tissues, notably fat, and released very slowly.
What diagnostic modality other than radio-iodine uptake scan can be used to distinguish between thyrotoxicosis secondary to thyroiditis or underlying auto-immunity?
High-resolution thyroid and color-flow Doppler ultrasonography.
What happens to the effectiveness of growth hormone therapy in patients taking oral estrogen replacement?
Decreases effectiveness.
What are two strategies to achieve satisfactory IGF-1 levels in patients taking growth hormone replacement as well as oral estrogen replacement?
- Transition to transdermal estrogen and progestin
OR - Increase dosage of GH replacement.
What is the most likely diagnosis in patients who present with primary adrenal insufficiency and pubertal delay?
Congenital adrenal hypoplasia
When does classic congenital adrenal hyperplasia due to 21 alpha-hydroxylase deficiency present?
During the neonatal period.
Are pregabalin and gabapentin drugs of the same class?
Yes
If diabetic neuropathic pain is not responding to a first-line agent then what is the next step?
Using a first line drug from a different class.
How long after pituitary surgery do IGF-1 levels continue to fall in patients with gigantism/acromegaly?
3 months or longer.
What should the glucose-suppressed GH level obtained 3 months after pituitary surgery be in patients who have been treated for acromegaly/gigantism?
Less than 0.5 ng/mL
What is the likely diagnosis in a patient presenting with fatigue, new-onset diabetes and osteoporosis (with low testosterone)?
Hemochromatosis
Which mutation can cause permanent neonatal diabetes?
KCNJ11 mutation (Gene encoding the ATP-sensitive potassium channel)
Which mutation can cause transient or permanent neonatal diabetes?
ABCC8
Gene encoding sulfonylurea receptor subunit
Which mutation causes IPEX syndrome?
IPEX: immune dysregulation, polyendocrinology, and enteropathy
FOXP3 mutation
X-linked disorder
What is the treatment for MODY 2?
Lifestyle modification.
What gene encodes MODY 2?
GCK gene
What is the mutation in DiGeorge syndrome?
22q11.2 deletion
How is DiGeorge syndrome inherited?
Autosomal dominant
Most new cases are de novo mutations
Developmental defect of third and four brachial pounches, leading to parathyroid aplasia or hypoplasia.
Diagnosis?
DoGeorge syndrome.
Is the PTH level high or low in pseudohypoparathyroidism?
High
Which gene is mutated in Wilson disease?
ATP7B gene
What is the first-line drug for infertility treatment in women with PCOS?
Clomiphene citrate
What is the second-line drug for infertility treatment in women with PCOS?
Recombinant human FSH
What off label drug has limited data showing better outcomes in infertility treatment of women with PCOS than clomiphene citrate?
Letrozole
Aromatase inhibitor
What’s the next step in an obese patient found to have low total testosterone?
Check free testosterone.
What is the central-to-peripheral gradient for a positive inferior petrosal sinus sampling?
Greater than 2 at baseline.
OR
Greater than 3 after corticotropin-releasing hormone stimulation
In non-classical congenital adrenal hyperplasia how are symptoms of the partial defect controlled, and ACTH suppressed?
Titrating the dose of a long-acting glucocorticoid like dexamethasone.
What is Bruns-Garland syndrome?
Diabetic amyotrophy
Which part of the nervous system is affected in diabetic amyotrophy?
- Lumbosacral nerve roots
- Peripheral nerves
Meralgia paresthetica has neuropathic symptoms in the distribution of which nerve?
Lateral femoral cutaneous nerve
How much grapefruit juice affects drug metabolism of statins?
More than 500 mL a day
Which is affected by grapefruit juice more…
Simvastatin or atorvastatin?
Simvastatin
The prescribing information for statins raises concerns with excessive grapefruit juice consumption…
What is considered excessive?
> 1.2 liters/day
Which three statins are not metabolized by CYP3A4 and therefore not affected by grapefruit juice?
- Pravastatin
- Rosuvastatin
- Pitavastatin
Which two molecular tests are currently in the market for assessing for malignancy in thyroid nodules?
- Gene expression classifiers
- Mutation analysis panels
Are gene expression classifiers used to identify nodules that are benign or those that are malignant?
Benign
It’s a ‘rule out’ test to identify benign nodules.
Can a mutation analysis test reliably exclude malignancy in thyroid nodules with indeterminate cytology?
No.
Because approximately 40% of malignant nodules with indeterminate cytology do not harbor these genetic mutations.
Is mutation analysis a good test to confirm the presence of malignancy in thyroid nodules with pathology that is suspicious for malignancy?
Yes.
They are good ‘rule in’ tests.
If there is low risk of disease recurrence for thyroid cancer and microscopic disease is found after the surgery then what is the next step?
Suppressing the TSH to the lower range of normal.
What else is needed to interpret the results of a selective arterial calcium stimulation test?
Knowledge of the particular arterial anatomy of the patient’s pancreas…
So the angiogram should be reviewed with the radiologist.
What two hormone levels does drospirenone increase?
- Aldosterone (both plasma and urine)
- Plasma renin activity
What enzyme does licorice inhibit?
11-beta-hydroxysteroid dehydrogenase type II
What happens to the aldosterone level after ingesting licorice?
It deceases.
What happens to the plasma renin activity after ingesting licorice?
It decreases.
What is the target TSH for people aged 70 - 80 years?
4 - 6 mIU/L
When is a referral for bariatric surgery indicated?
- BMI > or = 40
OR
- BMI > or = 35 with an obesity related co-morbidity
What happens to urinary calcium when PTHrP increases?
It increases
How does B-cell lymphoma usually cause hypercalcemia?
Mediated by excess 1,25-dihydroxyvitamin D (calcitriol)
What happens to PTHrP when there is hypercalcemia secondary to excess 1,25-dihydroxyvitamin D (such as in lymphoma)?
It is suppressed.
In a male-to-female transgender patient what should you do if the estrogen levels are still on the lower side but the patient’s triglycerides are high?
Start fibrates
What should you consider in a patient with type 1 diabetes with an atypical presentation and family history of the same?
Genetic testing for MODY
Parenteral nutrition can also exacerbate renal magnesium wasting.
True or false?
True
What happens to the PTH levels with chronic magnesium deficiency?
Levels are low or inappropriately normal compared to the degree of hypocalcemia.
What two things related to PTH can severe magnesium depletion produce?
- PTH resistance
- Decrease in PTH secretion
Exogenous PTH injections can have a blunted response when used to treat hypocalcemia in what circumstances?
Magnesium deficiency
In case of hypocalcemia and hypomagnesemia - which should be treated first?
Hypomagnesemia
When hypocalcemia and hypomagnesemia coexist then how long should magnesium therapy continue for?
Until hypocalcemia resolves
The attenuation values of pheochromocytomas are always greater than ____ Hounsfield units.
15
What is elevated carbohydrate antigen 19-9 (CA 19-9) suggestive of?
Cholangiocarcinoma
Cholangiocarcinoma can cause hypercalcemia by which two mechanisms?
- PTHrP mediated
- Local destruction and release of calcium from bone
Does excess 24,25-dihydroxyvitamin D cause hypercalcemia?
No
Inactive metabolite of vitamin D
What are elevated fibroblast growth factor 23 levels associated with?
Tumor-induced osteomalacia
Acquired disorder with renal phosphate wasting that typically occurs with mesenchymal tumours
Is tumour-induced osteomalacia associated with hypercalcemia?
No
Does hypercortisolism cause hypercalcemia?
No
What patient group did not benefit from statin use (no cardiovascular risk reduction)?
Patients with end-stage renal disease.
What is the treatment of choice for hirsuitism in women with congenital adrenal hyperplasia?
Hormonal contraception
What is statistically the most likely cause of primary adrenal failure in children?
Classic congenital adrenal hyperplasia.
What is the most common mutation causing classic congenital adrenal hyperplasia?
CYP21A2
Primary adrenal insufficiency in a child (not neonate/infant) with a behavioral disorder and mildly abnormal neurologic findings.
Diagnosis?
Adrenoleukodystrophy (ALD)
Mutations in which gene causes adrenoleukodystrophy (ALD)?
ABCD1
What is the most common cause of perioperative mortality associated with bariatric surgery?
Thromboembolic disease, particularly pulmonary embolism.
What is the second most common cause of perioperative mortality associated with bariatric surgery?
Anastomotic leaks
Is treated sleep apnea a cause of perioperative mortality associated with bariatric surgery?
No, only untreated sleep apnea.
How should you treat patients with a TSH-secreting pituitary tumor who are not cured by the surgery?
Depot somatostatin analogue (octreotide or lanreotide)
This is usually effective in controlling TSH hypersecretion.
What would be the first choice medication for osteoporosis in patients with active upper gastrointestinal problems (Barrett esophagitis, gastritis, duodenitis, ulcers etc)?
Intravenous bisphosphonates
What is the Jod-Basedow phenomenon?
Iodine-induced hyperthyroidism in individuals with pre-existing autoimmunity because of supra-physiologic iodine loads (e.g. CT and coronary angiography).
What is the Wolff-Chaikoff effect?
Inhibition of iodine organification in the presence of iodine overload leading to reduced formation and release of thyroid hormones.
What is the escape phenomenon after the Wolff-Chaikoff effect?
Presence of autonomous thyroid function permits synthesis and release of excess quantities of thyroid hormone resulting in iodine-induced thyrotoxicosis about 8 - 10 days after the iodine load.
This is a response to the low inorganic iodine concentration which is a consequence of down-regulation of the sodium-iodide symporter on the basolateral membrane of follicular thyroid cells.
What happens if there is failure to escape from the Wolff-Chaikoff effect after an iodine load?
Results in iodine-induced hypothyroidism.
What should the TSH be in order to consider prophylactic anti-thyroidal medications before iodine loads (contrast studies) in patients thought to be high risk for iodine-contrast-media-induced hyperthyroidism?
Undetectable
What does icodextrin metabolise to?
Maltose
Which other sugars to glucose meters detect?
- xylose
- maltose
- galactose
What kind of glucose meter (and strips) should a patient on peritoneal dialysis with icodextrin use?
Glucose-specific monitors and strips.
www.glucosesafety.com
How long does it take for icodextrin and maltose metabolites to be cleared in patients with significant renal dysfunction?
2 weeks or more.
What is the recommended range of TSH in the first trimester of pregnancy?
0.1 - 2.5 mIU/L
What is the recommended range of TSH in the second trimester of pregnancy?
0.2 - 3 mIU/L
What is the recommended range of TSH in the third trimester of pregnancy?
0.3 - 3 mIU/L
Which anti-hypertensives not affecting the renin-angiotensin-aldosterone system have the greatest protein lowering effect?
- verapamil
- diltiazem
What happens to methylmalonic acid and homocysteine levels in the setting of vitamin B12 deficiency?
They are elevated.
What is necessary to protect the uterus from endometrial hyperplasia and cancer when estrogen is taken for menopausal symptoms in a women with an intact uterus?
Progesterone
Which has less adverse effect on lipids - micronized progesterone or medroxyprogesterone?
Micronized progesterone.
What dosage and regimen of medroxyprogesterone acetate has been demonstrated to prevent endometrial hyperplasia?
- 5 - 10 mg for 12 days a month.
- 2.5 mg daily
What can be considered to protect the uterus from endometrial hyperplasia and cancer when estrogen is taken for menopausal symptoms in a woman with an intact uterus if the patient cannot take any type of progesterone by mouth?
- Levonorgestrel-coated intrauterine device
Which is more effective at alleviating hot flashes in menopause - estradiol or venlafaxine?
Estradiol
Which statins have the greatest triglyceride-lowering effect?
(Two)
- High dose atorvastatin
- Rosuvastatin
Has lowering triglycerides with prandial insulin been shown to reduce cardiovascular risk?
No
If the PSA increases by more than ____ when a patient is on testosterone - then he should be referred to a urologist?
1.4 mg/mL
What is the most likely location of an ectopic ACTH-secreting tumor in a young man?
In the thorax
How would you screen for type 1 diabetes in a healthy patient who is concerned about her/his family history of type 1diabetes?
Referral to clinical research study that performs type 1 diabetes screening.
Which opioid does not affect the gonadal axis?
Buprenorphine
If there is marked thickening of the pituitary stalk on MRI then what hormone deficiency does the patient probably have?
Anti-diuretic hormone
Diabetes insipidus
