內(nèi)分泌總論甲亢英文廖二元

1、A. The rapidity and extensiveness of advances in endocrinology have made it increasingly difficult for the students and physicians to take full advantage of information available for the understanding, diagnosis, and tre

2、atment of clinical disorders, not only of diseases in endocrinology, but also of that in all clinical specialties.,B. What easy to handle is that the general knowledge and the principles of endocrinology and metabolism

3、.C. For interest, be interested in the interesting medical branch.D. Main subjects,Regulation systems of extracellular communicationEndocrine gland and hormone-secreting cellsHormonesHormone secretion rhythm

4、sHormone synthases and its regulationEndocrine regulation axes,Mechanisms of hormone actionNutrient metabolismSystemic examinationLaboratory and special examinationsTherapeutic principles,Regulation Systems of Extr

5、a-Cellular Communication,nervous systemendocrine systemimmune system,Endocrine Gland and Hormone-Secreting Cells（激素分泌細(xì)胞）,A. Endocrine gland a. hypothalamus & posterior pituitary b. pineal gland (松果體)

6、 c. anterior and intermedial pituitary,d. thyroid e. parathyroid f. endocrine pancreas (內(nèi)分泌胰腺) g. adrenal cortex and medulla h. sexual gland (testis or ovary) i. others: thymus (胸腺)，placenta,B. Diffu

7、se neuro-endocrine cells APUD(amine precursor uptake and decarboxylation) cells in GI, pancreas, adrenal medulla, etc.)C. Hormone-secreting cells in tissues atrium, endothelium, fibroblast, lipocytes, lymphocytes,Str

8、ucture of hormone-secreting cells peptide/protein hormone-secreting cells: hormone-containing granules (激素顆粒) steroid hormone-secreting cells: lipid droplet (脂質(zhì)小滴),A. C

9、lassification a. as peptide/protein b. as derivatives of amino acid (catecholamine, 5-HT, melatonin, T3/T4) c. as derivates of cholesterol (cortisol, aldosterone, estrogen, androgen,

10、progesterone, 1, 25-(OH)2D3)B. Storage hormone granules thyroglobulin (甲狀腺球蛋白),Hormones,C. Types of hormone secretion,endocrine (內(nèi)分泌)paracrine (旁分泌)autocrine (自分泌)intracrine (胞內(nèi)分泌)neur

11、ocrine (神經(jīng)分泌)juxtacrine (并鄰分泌)solinocrine (腔分泌)amphicrine (雙重分泌),soluble hormone+binding protein: insulin, GH. IGF. Glucagon-like peptideinsoluble hormone+binding protein: T3, T4, sex steroids, co

12、rtisol, vitamin D.,D. Hormone transportation,half-life: peptides and protein: minutes steroids: variable, hrs degradation in liver, kedney, other tissues, or in hormone-secreting cells.,E. Hormone degradation and half-

13、life,A: Biological rhythms（生物節(jié)律） milliseconds: nerve impulse, membrane electrolytes. minutes: neurotransmitters hours: LH, TRH, testosterone, cortisol, GH, prolactin, TSH, etc d

14、ays: FSH peaks weeks: menorrhea months: T4, 1,25-(OH)2D3, pregnancy,Secretion Rhythms,B. Circadian rhythms (晝夜節(jié)律) biological “clock” in hypothalamus (melatonin), but lost in Cushing disease and psychosisC.

15、24-hr changes of serum and urine hormone (metabolic products),D. Heterogeneity of serum hormones hormone, pro-hormone (激素原), prepro-hormone (前激素原) monomer, dimer, trimer tetramer, etc. f

16、ragement of peptides.,A. Endocrine regulation active hormone molecule hormone-binding protein hormone receptor on membrane in cytoplasma in nucleolus (nucleoplasm) post-receptor trans

17、duction (cascade reaction) tropic-hormone (促激素) feedback cycle target cell reaction,Hormone Synthases and Its Regulation,B. Paracrine/autocrine regulation exist almost in all tissues. “point-line

18、” (點-線式) regulation network,A. Hormone regulationA: ultra-short feedback (超短反饋) B: short feedback (短反饋)C: positive feedback (正反饋) D: long negative feedback (負(fù)反饋) : stimulating;

19、 : inhibitory,,,A,nerve impulses/cytokines,CNS,hypothalamus,pituitary gland,target gland,,,,,,D,B,,,,Endocrine Regulation Axes,,,,,,,,,B. Regulation axes (調(diào)節(jié)軸) a. hypothalamus-pituitary-thyroid (adrenal

20、 cortex, sexual gland) b. GIH/GHRH-GH/GHBP-IGFs/IGFBPS- IGFBP/IGFBPase c. renin-AT-ALD involved in renin, AT, ALD, ANP, AVP, AM (adrenomedullin, 腎上腺髓質(zhì)素),d. axis of endocrine panc

21、reas-energy metabolism and body weight involved in insulin, glucagon, glucagon-like peptide-1, somatostatin, leptin, etc.e. PTH-CT-1,25-(OH)2D3 involved in PTH, CT,1,25-(OH)2D3, serum Ca2+, Pi3-f.

22、 AVP-AVP receptor-AQP (aquaporin, 水孔蛋白) V1 receptor: related to regulation of BP V2 receptor: related to H2O reabsorption,A. Acted as transcription- regulatory factors steroid hormone bindin with recep

23、tor (cytoplasm or nucleoplasm) H-R complex+DNA binding domain gene expression protein,,,,,Mechanisms of Hormone Action,B. Acte

24、d at cell surface a. peptide hormone + membrane R postreceptor cascade reaction b. types of membrane RG-protein coupled receptor (transmenbrane 7 times) involved in PTH, AT, glucagon, LH, FSH,

25、 TSH, AVP, CT, HCG, etc.receptor kinases (transmembrane 1 time), with tyrosine kinase (activity), involved in insulin, IGF, EGF, etc.receptor-linked kinases, involved in GH, PRL, leptinreceptors of ligand-gated ion ch

26、annels (transmembrane 4 or 6 times), involved in 5-HT, GABA, etc.,,metabolism, anabolism and catabolismmetabolic diseases (related to enzymes, hormones, or ion channels, etc).macroelement and microelement (traced eleme

27、nt)micronutrient (Fe, F, Zn, Cu, Mn, I, Cr, Co, etc)vitamins,Nutrient Metabolism,A. General concepts:,A. Symptom and signs a. body height (genetic factors, GH, TH, sex hormones, IGF-1, nutrition, systemic

28、 diseases) b. obesity and weigh loss (genetic constitution, nutrition, systemic disease, GH, TH, insulin, leptin, cortisol, sex hormones) c. polydipsia and polyuria (DM, ALD ,

29、 hyperparathyroidism, DI),,Systemic Examination,d. hypertension with hypokalemia (primary hyperaldosteronism, reninoma, Cushing syndrome) e. hyperpigmentation (ACTH, MSH, estrogen, progester

30、one, androgen) f. hair loss or hypertrichosis (hairy, 多毛癥) genetics, race, androgen. hypertrichosis: PCOS, congenital adrenal hyperplasia, Cushing disease, ovarian tumors,

31、hypothyroidism, drugs.,hair loss: cortisol , androgen , g. gynecomastia (男性乳腺發(fā)育): Klinefelter syndrome, testicular tumors, drugs.) h. exophthalmos (突眼)：Graves disease, chronic lymphoc

32、ytic thyroiditis, eye diseases.) i. bone pain and fractures (osteoporosis, hyperparathyroidisim, bone or hematologic diseases),,,A. hormones and biomarkers (生化標(biāo)志物) in serum and urine: hormones,

33、 electrolytes, sugarB. hormone derivatives: VMA, 17-OHCS, 17-KS,Laboratory and Special Examinations,C. Dynemic tests (動態(tài)試驗) stimulation test (興奮試驗)： hypofunction (hypocortisolism) inhibi

34、tory states (TSH in GD) suppression test (抑制試驗)： hyperfunction (DXM for Cushing disease) therapeutic test (治療試驗): (spironolactone treatment in suspected hyperaldosteronism),

35、provocation test (glucagon test for diagnosis of pheochromocytoma)X-ray film (bone diseases, kedney stones)CT&MRI (morphologic changes)radionuclear tomography (thyroid, pancreas, adrenal cortex and medulla, parath

36、yroid, etc)type B US (thyroid, adrenal cortex, ovary, testis),A. Pathogenic therapy: supplement of nutrients, gene treatment.B. Hypofunction: 1. hormone replacement therapy (Addison disease, hyp

37、othyroidism; hypogonadism) 2. drugs to stimulate hormone secretion (sulfonylurea for type 2 DM) 3. transplantation (organ, tissue, cells),Therapeutic Principles,C. Hyperfunction 1. drugs to suppre

38、ss hormone secretion (iodide for GD, spironolactone for hyperaldosteronism. SS for insulinoma) 2. radioactive therapy (131I for GD, γ- knife for pituitary tumors),HYPERTHYROIDISM (THYR

39、OTOXICOSIS, 甲亢),Hyperthyroidism is only a diagnosis of excessive thyroid hormone status, not a concrete disease or a syndrome.It is wrong to say “Graves disease (Graves病)” as “hyperthyroidism (甲亢)” in brief.,Thyroidal o

40、rigin Graves disease multiple nodular thyrotoxicosis (多結(jié)節(jié)性毒性甲狀腺腫)Plummer disease (toxic thyroid adenoma)automatic hyperfunctional thyroid nodules (自主 功能性甲狀腺結(jié)節(jié))multiple au

41、toimune endocrine syndrome with hyperthyroidism (多發(fā)性自身免疫性內(nèi)分泌腺 病伴甲亢)thyroid carcinomasneonatal hyperthyroidismgenetic toxic thyroid hyperplasia/goiteriodine-induced hyperthyroid

42、ism (碘甲亢),Pathogenesis of Hyperthyroidism,Pituitary origin pituitary TSHoma thyroid hormone insensitivity syndrome (pituitary type, 垂體型TH不敏感綜合征) paracarcinoma syndrome HCG-related hyperthyroidism carc

43、inomas (lung, GI, pancreas) with hyperthyroidism Ovarian goiter with hyperthyroidism Iatrogenic hyperthyroidism (醫(yī)源性甲亢),Transient hyperthyroidismSubacute de Quervian thyroiditis (肉芽腫性甲狀腺炎) hymp

44、hocytic thyroiditis (postpartum, IFN, IL, Li) trumatic thyroiditis radioactive thyroiditisChronic chronic lymphocytic thyroiditis,PathogenesisHistopathologyClinical presentationLaboratory and special exa

45、msDiagnosis and differential diagnosisTreatment,GRAVES DISEASE (GD),GD is also called: diffuse toxic goiter Basedow diseaseSubclinical hyperthyroidism is usually referred to a GD state with (ab)normal T3,

46、T4, decreased TSH, and no clinical symptoms of hyperthyroidism,Graves Disease (GD),A. Abnormalities of immune system a. TSH-R-Ab + TSH-R mimic the action of TSH hyperfunction and goiter. b

47、. functioning of Ig Th hypersensitivity + IL-1, IL-2 B cells produce TSH-R-Ab (TRAb),Pathogenesis,stimulating IgG hyperfunction(TSAb) c. TRAbinhibitory IgG hypofunction and anta

48、gonistof TSHR andTSAb (TF1Ab, TGBAb)growth-stimulating IgG (TGI),,,,,,,B. Other factors genetic factors infective factors stress (physical or emotional),C. Thyroid-associated ophthalmopathy

49、 (TAO) unknown GAG (葡萄聚糖) accumulation, T cell infiltration, edema, fibrosis and sight loss.,A. Thyroid goiter: symmetrical, diffuse, soft enlarged after treatment:

50、lobular follicles: hyperplastic column with scant colloid, papillary projections, vascularity increased lymphocytes and plasma cells infiltration,Histopathology,B. Eyes orbital contents incre

51、ased, containing mucoprotein, GAG (glycosaminoglycan, 葡糖聚糖), lymphocytes.C. Skin (dermopathy) hyaluronic acid (透明質(zhì)酸), chondroitin sulfates (硫酸軟骨素) increased, collagen fibers separated nodular an

52、d plaque formation lymphatic drainage decreased,A. General considerations male: female ≈ 1: 4~6, common in 30~40yrs.B. Hypermetabolic states nervousness (99%). irritability (90%), palpatation (88%),

53、 tachycardia (82%), insomnia (60%), fatigue (70%), heat intolerance (70%), excessive sweating (40%), weight loss (75%), with voracious appetite (65%), menstrual pattern changed (50%),Clinical Presentation,C. Thy

54、roid diffuse goiter: absent in the elderly, consistency: soft, firm, rubbery, symmetrical enlarged, surface: smooth, lobular, thrill with audible bruit

55、 eyelid spasm or retraction,D. Eyes a. non-infiltrative orbitopathy: fissure widened, sclera exposed, lid retraction, lid trem

56、or, lid lay, globe lay.,b. infiltrative orbitopathy: excessive tearingexophthalmos (asymmetrical)eyelids unclosedblurred visiondouble visionvisual acuity decreasedcorneas ulcerated, infectedsight

57、loss,,,,c. Classification of Graves orbitopathy: NOSPECS (from: American Thyroid Association)ClassDefinition0No physical signs or symptoms1Only signs, no symptoms (signs limited to upper lid retraction,

58、 stare, lid lag, and proptosis to 22mm)2Soft tissue involvement (symptom and sign)3Proptosis>22mm4Extraocular muscle involvement5Corneal involvement6Sight loss (optic nerve involvement),E. Others tre

59、mor of the hands and tongue muscle wasting rapid reflex response diarrhea liver function wbc , and anemia, vitiligo (白癜風(fēng)), hair loss pretibial myxedema (脛前粘液性水腫),,,F. Complications

60、 a. cardiopathy and heart failurethyrotoxicosis ,arrhythmia, heart enlargement and heart failure, and all disappeared after treatment b. Thyrotoxic crisissymptoms and signs exaggerated abruptlyprecipitating f

61、actors: infection, trauma, surgeryradiation thyroiditis, DKA, parturtionAdditional pictures: arrhythmias, pulmonary edema,congestive heart failure, restlessness, delirium,nausea, vomiting, abdominal pain, apathy,

62、 stupor,coma, hypotension, shock, etc.,c. hypokalemic periodic paralysismore common in Asiaabruptly paralysis with hypokalemiaprecipitated by dextrose, oral carbohydrateor vigorous exercise.attacks last 7-27

63、 hrs.some companied by myasthenia gravis.,A. Serum TH and TSH a. FT3 and FT4 b. TT3 and TT4 c. rT3 d. TSHB. TSH receptor antibodies,Laboratory and Special Exams,C. TRH stimulation testeuthyroid G

64、raves ophthalmopathyGD medicationD. 131I uptake and T3 suppression testE. pathological exams,A. Functional diagnosis GD suspected: (1)weight loss; (2)slight fever; (3)diarrhea; (4)tachycardia; (5)atrial fibrillat

65、ion; (6)fatigue; (7)dysmenorrhea; (8)with difficult in control of DM, TB, heart failure, CHD, liver disease,Diagnosis and Differential Diagnosis,B. TypesFT3 、FT4 , sTSH (uTSH) : hyperthyroidismFT3(orTT3) , FT4(TT4

66、) normal, sTSH : T3 hyperthyroidism FT4(orTT4) , FT3 (TT3) normal, sTSH : T4 hyperthyroidismFT3 and FT4 (ab)normal, sTSH : subclinical hyperthyroidism,C. Pathogenic diagnosis TRAb, TgAb, TPOAb, HCG, 131

67、I uptake, TSH,A. General management rest enough, energy and nutrients supplement, sedatives for restlessness and insomnia.B. Management of hyperthyroidism a. medical antithyroid agents: methylthiou

68、racil (MTU) or propylthiouracil (PTU) 300~600mg/d methimazole (MM) or carbimazole (CMZ) 30~60mg/d,Treatment,b. dosage and course1st stage (ca.6 wks):