Revision Flashcards
1
Q
What do intercalated and principle cells do in the DCT?
A
Intercalated:
- H+ secretion
- K+ resorption
Principle cells:
- Na resorption
- K+ secretion
2
Q
Acid- Base Balance: In the Kidneys how is HCO3 reabsorpbed and where?
A
PCT:
- Carbonic anhydrase
- Na reabsoprbed & H+ excretion
DCT:
- Intercalated cell: (both on tubular membrane)
- H+ ATPase
- K/H ATPase (H out, K in)
3
Q
Acid Base Balance: How is H+ secreted in the Kidneys
A
Late DCT:
Intercalated cell A:
- H+ ATPase
- K/H ATPase
However this is not sufficient on its own so you need: URINARY BUFFERS- as both below processes occur HCO3- is made and being added to blood
Phospahte:
(I think anywhere this can happen)
- Na/ H exchanger (Na in and H out)
- NaHPO4- combines with H+
Ammonia:
- In PCT Glutamine synthesied to form NH4+
- In CCT: NH3 secreted. H+ATPase secretes H+ which combine to make NH4+
4
Q
a) Where does Gluconeogenesis occur?
b) Where do glycogenolysis occur?
A
a) Liver & Kidneys
b) Liver & Skeletal muscle
5
Q
What transports Iodide into the follicular cell?
A
Na/ I symporter
6
Q
What converts iodide into iodine?
A
Thryoid peroxidase
7
Q
What take iodine from the follicular cells –> Colloid?
A
Pendrin
8
Q
Where is thyroglobulin synthesised?
A
In the follicular cell
9
Q
Why type of hormone is the thyroid hormone?
Therefore how does it travel in blood?
A
Steroid hormone
70% Thyroid Binding Globulin
30% Albumin
10
Q
What does thyroid binding globulin have a higher affinity for?
A
T4
11
Q
How does T3 have an action on target cells?
A
T3/ T4 enters cell via: Diffuse/ Transported MCT 8(10)
T4 –> T3 via deiodinases
T3 binds to intracellular receptors (alpha or beta)
Interacts and binds w/ DNA and changes protein synthesis
12
Q
Describe the types of deiodinases- where are they found?
A
Type 1: T4 –> T3 Activates inner and outter ring. Found on most cells- liver, kidney, brain, thryoid
Type 2: T4 –> T3 Activates outter ring. Intracellular raise- CNS, brown fat, placenta, MSK, SK/ Cardiac muscle
Type 3: T3–> T2 or T4 –> rT3. Remove T2- placenta/ CNS
13
Q
What are the physiological actions of T3?
A
- Metabolism (increase BMR)
- Maturation & Differentiation- Bone, lungs & Brain
- Neurological Function- Synapse formation, myelinogenesis, Neuronal outgrowth
-
Growth: CNS/ Skeletal development
- Regulated by GH but T3/T4 needed
- By 12 week of gestation gland makes/ secretes t3/t4 so need suficient iodine from mother
14
Q
Beyond insulin and glucagon give some hormonal examples of glucose control
A
- Adrenaline- increase glucose production and lipolysis
- Cortisol- increase glucose production and lipolysis
- Growth Hormone- increase glucose production and lipolysis
- FFA- increase glucose production
- Incretins eg: GLP-1
15
Q
Describe how insulin is secreted
A
1) Extracellular glucose is transported into B cells via GLUT 2
2) Metabolised to ATP which increases the ATP: ADP ratio in cell
3) Cause closure of ATP dependant K+ channels
4) –> Depolarisation of cell membrane
5) –> Influx of caclium via voltage gated calcium channels
6) –> Exocytosis of insulin from stored vesicles
16
Q
Talk about the stages of biphasic insulin secretion:
A
Stage I: Rapid onset and lasts 10 mins
Release of pre-docked & primed vesicles
Stage II: Prolonged plateau. As long as hyperglycaemia exists
Transport –> Dock –> Prime –> Fusion
17
Q
Talk about how insulin promotes glucose –> Cell
A
Anabolic (Promote Glycogen synthase, Lipogenesis, Protein synthesis & Mitogenesis. Prevent Protein and lipid breakdown)
Bind to GLUT 4 receptor on cell membrane
GLUT 4 stored in IC vesicles. Insulin promotes vesicular fusion & transportation and insertion into the wall. Causing glucose –> cell
18
Q
Fed State: Entero-Insular Axis:
What are the two hormones produced?
Where are the produced from?
What are they produced in response to?
What are they degraded by?
A
Gastrointestinal Insulinotropic Peptides: Gastric Inhibitory Peptide, Glucagon Like Peptide
Produced by L cells of SI
Produced in response to oral glucose load to augment insulin secretions
Degraded by: Dipeptidyl-peptidase 4
19
Q
What causes DMT1?
What are the 4 Cardinal symptoms?
What is DKA caused by? Symptoms? Causes?
A
AI disease, selective destruction on pancreatic B cells –> complete insulin deficiency
Symptoms: Weight loss (unopposed proteolysis & lipolysis), Polydyspia, Polyuria, Hyperglycaemia
DKA: Production of KB (from b oxidation of FA) as alternative energy source. Symptoms: High RR, Abdo pain. Causes: Preceed illness/ missed insulin dose
20
Q
What are the complications (bar hyperglycaemia) of DM. Split into Macrovascular and Microvascular
A
Macrovascular:
- Nephropathy
- Retinopathy
- Neuropathy
Microvascular:
- IHD
- PVD
- Cerebrovascular disease
21
Q
What type of hormone is insulin?
A
Peptide hormone
22
Q
GLUT 1:
Affinity
Specificity
Tissue Distribution
Notes:
A
Affinity: 1.5mM
Specificity: Glucose, Galactose, Mannose
Tissue Distribution: Ubiqutos, RBC, Brain
Notes: low affinity increase basal uptake
23
Q
GLUT 2:
Affinity
Specificity
Tissue Distribution
Notes:
A
Affinity: 15mM
Specificity: Glucose, Fructose
Tissue Distribution: Pancreatic B cells, Liver
Notes: high affinity therfore low basal uptake
24
Q
GLUT 3:
Affinity
Specificity
Tissue Distribution
Notes:
A
Affinity: 1.8mM
Specificity: Glucose
Tissue Distribution: Brain, intestine, placenta
Notes:
25
GLUT 4
Affinity
Specificity
Tissue Distribution
Notes:
Affinity: 5mM
Specificity: Glucose
Tissue Distribution: Muscle, Adipose
Notes: **INSULIN SENSITIVE**
26
GLUT 5:
## Footnote
Affinity
Specificity
Tissue Distribution
Notes:
Affinity: 10mM
Specificity: **Fructose**
Tissue Distribution: Intestine
Notes:
27
SGLT 1
## Footnote
Affinity
Specificity
Tissue Distribution
Notes:
Affinity: 0.3
Specificity: 2 Glucose: 1 Sodium (and galactose)
Tissue Distribution: **Intestine** & Kidney
Notes:
28
SGLT 2:
Affinity: 1.5mM
Specificity: 2 Glucose: 1Sodium
Tissue Distribution: **Kidney**
Notes:
29
Rectus Abdominus:
Attachments
Nerve supply
Function
Pubic bone --\> Xiphoid process & CC of ribs 5-7
Nerve: T7-T11
Functions: Compress abdominal viscera, stabilse pelvis during walking, Depress ribs
30
What is the rectus abdominus covered in? And what is this structure called?
What does it contain? Why is this important?
Arcuate line- talk about the what happens to the strucutre ^?
Aponeurosis of the flat abdo muscles forming the rectus sheath
Rectus sheath contains the inferior epigastric artery & vein. THe superior & inferior epigastric artery unite in the rectus sheath blood flow via subclavian to external iliac
At arcuate line the rectus sheath only surrounds the RA anterirly so posteriorly RA are in direct contact with the transversalis fascia
31
External obliques:
Attachment
Nerves
Functions
Attachment: **Ribs 5-12 --\> Iliac crest & Pubic tubercle**
Nerves: T7-T12 (Subcostal)
Functions: Contralateral rotation of torso
32
Internal obliques:
## Footnote
Attachment
Nerves
Functions
Attachment: Inguinal ligament, Inguinal canal & Lumbodorsal fascia --\> Ribs 10-12
Nerves: T7-T12 plus ilioinguinal & iliohypogastric
Functions: Bilateral contraction compresses abdo, Ipsilateral contraction --\> Ipsilateral rotation of torso
33
Transverse Abdominus
Attachment
Nerves
Functions
Attachment: Inguinal ligament lateral 1/3, Costal Cartilages 7-12 --\> Aponeurosis linea alba, pubic crest and pectinate line
Nerves: T7-L1
Functions: Compress abdominal contents
34
What are the collective functions of the Anterior Abdominal muscles?
1. Keep abdo viscera in abdo cavity
2. Assist viscera in maintaing position
3. Protect abdo viscera from injury
4. Assist in forcefull expiration- push abdo viscera upwards
5. Increase intra abdo pressure: coughing, vomiting, defecation
35
Name the 5 abdominal incisions
Median
Paramedian
Subcostal
Pfannestiel (suprapubic)
Gridiron @ McBurney's Point
36
Why is the rectus muscle displaced laterally in an paramedian scar?
So you go towards the nerve supply
37
Why is a Gridion incision made?
Which nerve is at risk?
@ McBurney point 1/3 way from ASIS to umbilicus
Damage to the iliinguinal / iliohypogastric nerve
38
Where is a Pfannestil scar?
What nerve is ar risk of damage?
Suprapubic
Ilioinguinal nerve @ risk
39
Where is a subcostal incision made?
What must you preserve?
2 finger bredth below the costal margin & lateral to the linea alba
Preserve T9, superior epigastric artery and thoracoabdominal nerves
40
Which part of the pancreas is NOT retroperitoneal?
Tail of Pancreas
41
Where is the lesser omentum? What is it made of?
What does it contain?
Between the liver & stomach
From Ventral mesentary
Portal triad- Portal vein, Hepatic Artery & Common Bile duct
42
What are the 3 main branches of the Coeliac Trunk?
Common hepatic
Left gastric
Splenich vein
43
Where is the root of the mesentery?
What does it divide?
Origin of the mesentry from the SI (Jejunum and Ilium)
Divies the Infracolic sac into Left & Right
44
What is the greater oemntum made of?
Dorsal mesentary
45
What cells are found in gastric glands?
Parietal cells (IF & HCL)
Chief cells (Pepsinogen)
G Cells (Gastrin)
Mucus surface/ neck cells
46
What cells make somatostain?
D cells
47
Where are parietal cells found (Aside from gastric glands)?
Oxyntic Gland area- proximal 80% stomach
48
Where are G cells found (aside from gastric glands)?
Pyloric Gland area- Antrum region
49
What are the hormones released by the enteric plexus during receptive relaxation?
NO
Seratonin
50
Give an example of Cocci
a) -ve
b) +ve
a) Neisseria menigitidis, Haemophiulus influenzae
b) Strep/ Staph species
51
Give an example of a Bacillus
a) -ve
b) +ve
a) Samlonella, Escherichia Coli
b) Lactobacilli species or Bacillus Anthracis
52
Give some differences between bacteria & human cells
* Bacteria has Pilli/ Flagella
* Bacteria x10 bigger
* Bacteria is prokaryote
53
Give some differences between virus and bacteria
* Virus have envelope stolen from host cell
* Virus only have RNA (bacteria = DNA in single strand)
* Bacteria: Flagella, Pilli, Chromosome, Cell Wall
54
Define GORD
Reflux of acid contents through LOS
55
Define Reflux Oesophagitis
Caused by persistant reflux episodes
Damage of oesophageal mucosa/ inflammation
56
What are the types of incontinence?
* Stress
* Functional
* Overflow
* Urgency
57
58
What planes and what way does the stomach rotate?
Stomach rotates to the right around longitudinal axis and clockwise around saggital axis
59
What structures in the abdomen become secondarily retroperitoneal during development?
Pancreas and duodenum
60
What does greater and lesser omentum develop from?
Greater omentum from Ventral Mesentry
Lesser omentrum from Dorsal Mesentry (is the periotneum between the stomach & liver)
61
Explain the divisions of the greater sac?
Supracolic: Superior to TC and Anterior to Greater Omentum
Infracolic: Inferior to TC and Posterior to Greater Omentum
62
Where does the liver grow out from?
What holds it in the adult position? What is the exception?
Ventral mesentary
Peritoneum holds it in position but there is a bare area where the top of the liver touches the diaphragm
63
What does the Falciform Ligament contain? What was it embryologially?
Ligamentum Teres- remnent of umbilical vein
64
What are the 4 lobes of the liver from the posterior view?
Right, Left, Caudate, Quadrate
65
What is the Caudate lobe bound by?
One of the features is an embryological remanent of something- name it
IVC and Ligamentum Venosum- embryological remnant of Ductus Venosum
66
Label
What is the function of these?
Right and Left Triangular ligament and Coronary ligaments attach the liver to diaphragm
67
Describe the blood supply to the liver
Where does this run?
In the free edge of the lesser omentum
68
What does the free edge of the lesser omentum contain?
Portal triad- Common bile duct, Hepatic artery, Portal Vein
69
What is the pringle manoeuvre?
Pinch the free edge to cut off blood supply to the liver
70
Describe the regions of the gall bladder and any surface anatomy
Fundus (at top) 9th CC which is L1
Body
Neck (at bottom)
71
Describe the duct system of the gall bladder
CD= Cystic Duct
72
What can refer pain to the Right shoulder?
Gall bladder/ Liver via phrenic nerve
73
Describe the surface anatomy of the pancreas
Epigastric region- head nestles in the C of the duodenum (L1-L3) and extends into left hypochondrium.
Pancreatic neck sits on transpyloric plane
Pancreatic tail sits near splenic hilum
74
What organs are foregut derivates?
Liver and Pancreas
75
What is the sphincter that guards the entrace into the duodenum from the Ampulla of Vata?
Hepato-pancreatic sphincter
76
Where can pancreatitis cause pain?
Where can fluid accumulate?
Epigastric/ Back pain
Fluid accumulation in lesser sac
77
What is the blood supply of the pancreas?
CT- Superior pancreaticoduodenal artery
SMA: Inferior pancreaticoduodenal artery
Splenic Artery Branches
78
What is the lymph drainage of the pancreas?
Coeliac nodes --\> Thoracic Duct --\> Supraclavicular
79
What is the surface anatomy of the spleen?
Ribs 9-11 or Ribs 10-12
80
Describe antigen detection testing?
Monoclonal antibodies produced against antigen
81
Describe and define PCR Testing
Exponential replication of specific DNA or RNA sequence
Prime produced against a DNA/ RNA sequence
* Denaturation
* Annealing
* Extension
82
Define Serology
Detection of an antibody against a speific pathogen
83
Describe ELISA
| (Enzyme Linked Immuno-sorbent Assay)
(Specific antigens are produced from pathogens and used to detect antibodies)
1) Antigen specific for \_\_\_\_
2) Serum mixed with fixed antigen and patient's antibodies- these will bind if present
3) An antibody with an enzyme attached if used to bind the patient's antibody
3) Unbound antigens are washed off
5) Colourless substrates are added and converted to coloured products by enzymes
6) Coloured product indicated postive test result
84
What are the sympathetic exceptions of receptor type?
* Chromaffin cells of Adrenal Medulla
* Sweat Glands
Ach Muscarinic receptors
85
Describe how the sympathetic chain communicates with spinal nerves
White Ramus Communicans:
* Only leaving T1-L2 spinal nerves
* Pre-ganglionic sympathetic neurones go into sympathetic chain
Grey Ramus Communicans:
* At all spinal levels
* Post-ganglionic sympathetic neurones pass into spinal nerves
Splanchinic
* Take sympathetic nerves to organs of the body
86
What can cause Horner's Syndrome?
* Pancoast tumour
* Iatrogenic
* IJV canulation
* Cervical cord damage (Reticulospinal neurones innervate preganglionic sympathetic fibres in the lateral grey horn) (Medullary tract)
87
Name the sympathetic Ganglia in the neck
* Stallate (near lung apex)
* Middle cervical
* Superior cervical (near skull base)
88
When may you conduct a sympathectomy?
* Raynauds
* Hyperhidrosis
89
Name the pre-aortic ganglia
* Coeliac (T5-T9)
* Aorticorenal
* Superior mesenteric (T10-T11)
* Inferior mesenteric (T12-L1)
They supply the gut tube
90
Draw out how parasympathetics travel with CNX to an organ
Dorsal Nuclei of Vagus, travel with CNX and synapse at organ specific ganglia
(Forgut and Midgut supplied by this, Hindgut supplied by S2-S4)
91
How do the other parasympathetics (not CNX) travel to organs?
CN 3,7,9
* Preganglion parasympathetics travel with CN 3,7,9
* Synapse @ peripheral ganglia
* Then post-ganglionic travel with branches of CN V
92
What is Frey Baillarger Syndrome?
* **Gustatory sweating of face** post parotid surgery/ injury
* **PS nerve regrow to innervate muscarininc receptors of sweat glands** (normally sympathetic innervated)
93
Coeliac Disease
Where is the site of Pathology?
What is the Defect in Absorption/ Digestion?
a) Duodenum & Jejunum- damage to mucosa
b) Fats and Lactose Hydrolysis
94
Pancreatitis
## Footnote
Where is the site of Pathology?
What is the Defect in Absorption/ Digestion?
a) Pancrease
b) Fat digestion
95
Surgical resection Ilium/ Chron's
## Footnote
Where is the site of Pathology?
What is the Defect in Absorption/ Digestion?
a) Terminal Ilium
b) B12 deficiency, Bile salts/ Bile acid absorption
96
Lactase Deficiency
## Footnote
Where is the site of Pathology?
What is the Defect in Absorption/ Digestion?
a) Small intestine
b) Lactase hydrolysis
(Lactose passes into LI where its broken down by gut bacteria then fermented. Gases, Organic acids, other osmotically active particles are made --\> Bloating and Increased Motility)
97
Describe how B12 is absorbed
Stomach: Binds to **R protein**
Duodenum/ Jejunum: Bind to **IF**
Terminal Ilium: Absorbed by **receptor mediated endocytosis**
Mucosal Cell Ilium: B12 released from IF
B12 released into blood & carried by **B12 binding protein**
98
Describe the Gastrocolic reflex
Mediated by Gastrin & Autonomic nerves
Initiate Colonic Mass movements (peristalsis)
Colonic contents --\> Rectum --\> Defeacation (via defeacation reflex)
99
Describe the Defecation reflex
1. Contraction of the rectum.
2. Relaxation of the internal anal sphincter.
3. An initial contraction of the external anal sphincter.
4. Increased peristaltic activity in the sigmoid colon.
5. Relaxation of the external anal sphincter.
6. Expulsion of faeces.
100
Describe the valsalva manouvre
1. Full inspiration followed by forced expiration against a closed glottis causes the diaphragm to move downwards.
2. The abdominal and thoracic muscles are contracted.
3. Increased pressure in the abdomen forces faecal contents into the rectum.
4. The defaecation reflex is initiated.
101
What does the posterior RAMUS supply?
How may it be injured?
Adjacent uscles of the back and overylying dermatome
Injury via: Facet Joint Pathology
102
Describe IV disc degeneration stages
* Degenration
* Prolapse
* Extrusion
* Sequestration
103
What nerves are included in cauda equina?
L3-S5
104
Where are the sacral spinal nerves in the cauda equina?
S1-S5 are centrally
105
Where does the Filum Terminale begin and end?
L4-Terminates @ Coccyx
106
# Define cauda equina syndrome
Compression of the sacral spinal nerves
107
Causes of cauda equina syndrome?
* **IV disc herniation**
* **Tumour**
* **Spinal stenosis**
* **Spondylolithesis**
* Vertebral canal stenosis
108
Symptoms/ signs of cauda equina
* Cannot feel self going to toilet
* Loss of Ankle Jerk Reflex
* Lower limb sensory change
109
What are the red flags for cauda equina syndrome?
* Saddle anaesthesia
* Incontinence/ Urinary retention
* Reduced anal tone
* Loss of sensation/ Paralysis
110
Lumbar Puncture:
a) Where do you perform it
b) What layers do you go through?
c) How should the patient be positioned?
d) Where do you put the needle?
e) How do you angle the needle?
Want to access CSF in the subarachnoid space
a) Adults: L3/4. Children L4/5. L4= Highest point of Iliac crest
b) Skin, Supraspinous ligaments, Infraspinous ligament, Ligamentum Flavum
c) Flexed- opens up the spaces between spinous processes
d) In between the spinous processes
e) Antero-superiorly so you don't hit the lamina
111
What technique do you use for an epidural?
Same route as LP
ONLY into Epidural space
112
What does the ligamentum flavum bind?
Lamina of adjacent Verberae
113
What do the supraspinous and infraspinous ligaments bind?
Spinous processes of the adjacent vertebrae
114
Spinal anaesthesia
Access Subarachnoid Space (remember this finished at S2)
Children: L5/S1 and Adults L3/L4
Bathes the spinal nerves of **cauda equina**
Levels of anaesthesia can be adjusted by: density/ volume and position
115
Caudal Anaesthesia
Via Sacral Hiatus (Equilateral triangle between PSIS which is just above S2 spinous process) and Upper Part of Natal Cleft where Sacral Hiatus sits
Insert needle at oblique angle through ligament & advanced towards the head
Targets **sacral spinal nerves**
eg: Below Pelvic Pain Line S2-S4
116
Describe the arterial supply of the spinal cord
Anterior (Vertebral artery) and x2 Posterior Spinal arteries (PICA and Vertebral)
Give rise to Intervertebral arteries
Gives rise to Radicular arteries supply roots and rootlets
117
Venous drainage of spinal cord, meninges and vertberal bodies
Spinal veins --\> Intervertebral veins
Radicular veins
Intervertebral veins --\> Venous Plexus (valveless and can spread cancer from prostate --\> vertebral bodies) which is in Epidural space
118
What is the femoral artery felt?
What is this a marker of?
Midinguinal Point +/-1cm
Marks entrance to deep inguinal ring
119
Describe the location of an inferior lumbar triangle hernia
Who is this most common in?
Males aged 50-70yrs
External Obliques (T7-T12), Iliac Crest, Latismus Dorsi (Thoracodorsal nerve)
120
Superior Lumbar Triangle Herniation
Rib 12, Internal Oblique, Quadratus Lumborum
121
Surface anatomy of the superficial inguinal ring
Superolateral to the pubic tubercle in the External Oblique Aponeurosis
122
Femal contents of the inguinal canal
* Ilioinguinal nerve
* Genital Branch of the Genitofemoral nerve
* Round Ligament of Uterus
* Lymphatics from Uterus
123
Inguinal Canal Contents Male
* Spermatic cord
* Ilioinguinal nerve
* Genital branch of the Genitofemoral nerve
124
Describe the walls of the inguinal canal
Anterior: EO muscle
Roof: IO muscle and Aponeurosis of IO and TA
Aponeurosis of IO and TA form the Conjoint tendon which sits behind superficial ring
Posterior: Transversalis Fascia
Floor: Inguinal ligament
125
What causes a direct inguinal hernia?
Weakness of conjoint tendon/ abdo wall muscles
126
Direct and Indirect Hernia in relation to INFERIOR Epigastric artery
Direct: Medial
Indirect: Lateral
127
Describe the boarders of Hesselbach's Triangle
Medial: RA
Lateral: Inferior Epigastric
Inferior: Inguinal ligament
128
Nerves at risk of damage during inguinal canal region surgery
Iliohypogastric
Ilioinguinal (sensory to anterior scrotum and root penis)
129
Define AKI
A **significant deterioration in renal function,** which is potentially reversible, over a period of hours or days.
130
Define CKD
Abnormalities of kidney function or structure present for more than 3 months, with implications for health.
131
Define ESKD
The stage of chronic kidney disease where **renal replacement therapy (RRT) is required to safely sustain life**
132
Complications of CKD
* **Cardiovascular disease**
* **Hypertension**
* **Anaemia**
* **Bone-mineral metabolism**
**•Poor nutritional and functional status**
* **Progression of CKD**
* **AKI**
133
AKI Management
1) Keep the patient alive
2) Generic management of AKI
* -**Review medication**: dose reduction, toxic drugs to the kidney
* -Close observation: **Fluid balance** and **GFR monitor**
* -**Fluid management**/ **Electrolyte management**
3) Diagnose cause of AKI & treat; often requires specialist input . Know your limitations.
134
Angiotensin II- What are the effects?
* Vasoconstriction
* Increase Na absorption on renal tubule cells (PCT, Thick AOL, DCT/CCT)
Indirectly:
* Thirst
* Alsoterone
* ADH
135
Vasodilation of Efferent Arteriole
Angiotensin II Blocker
136
Vasoconstriction of Afferent Arterioles
* **Endothelin**
* **Noradrenaline**
* **Adrenaline**
* **Adenosine**
137
Vasodilation of Afferent Arterioles
* Prostaglandins
* ANP
