Session 1

Assignment: Discuss the difference between primary vs secondary vs tertiary hyperparathyroidism 

Hyperparathyroidism (HPT) is characterized by abnormally high parathyroid hormone (PTH) levels in the blood due to overactivity of the parathyroid glands. It is differentiated into three types based on the underlying cause: primary HPT (pHPT), secondary hyperparathyroidism (sHPT), and tertiary hyperparathyroidism (tHPT).

Primary hyperparathyroidism is characterized by elevated parathyroid hormone and calcium levels and is usually caused by parathyroid adenomas (or, in rare cases, by parathyroid carcinomas). Although often asymptomatic, symptoms such as bone pain, gastric ulcers, and/or kidney stones may emerge in severe cases. Associated conditions include osteitis fibrosa cystica in which there is high osteoclast activity at bone resulting in cystic bone spaces with brown fibrous tissue. This commonly occurs at the jaw. pHPT is also associated with multiple endocrine dysplasia (MEN) 1 and 2A.

Secondary hyperparathyroidism is characterized by high parathyroid hormone and low calcium levels and may be caused by kidney failure, vitamin D deficiency, or malabsorption. It is secondary parathyroid hyperplasia as a result of low Ca2+ absorption and/or high phosphate levels. sHPT is also called reactive HPT, as the increase in (parathyroid) hormone production is a physiological response to hypocalcemia and not caused by an abnormality of the parathyroid glands. Associated conditions include chronic renal disease since renal disease causes hypovitaminosis D, which leads to ↓ Ca2+ absorption. sHPT is also associated with renal osteodystrophy, where bone lesions are due to secondary hyperparathyroidism.

If sHPT and elevated parathyroid hormone blood levels persist, tHPT may develop, resulting in a shift from low to high calcium blood levels. tHPT is a dysregulation of parathyroid glands following chronic renal disease. The glands will secrete PTH regardless of Ca2+ levels.

Sources:

1. Amboss Knowledge
2. Pance Prep Pearls

 

 

Session 2

Assignment: Research Alkaline Phosphatase & GGT

Alkaline Phosphatase

ALP is an enzyme found in your bloodstream. It helps break down proteins in the body and exists in different forms, depending on where it originates.

Your liver is one of the main sources of ALP, but some is also made in your bones, intestines, pancreas, and kidneys. In pregnant women, ALP is made in the placenta.

The normal range of ALP varies from person to person and depends on your age, blood type, gender, and whether you’re pregnant.
The normal range for serum ALP level is 20 to 140 IU/L, but this can vary from laboratory to laboratory.
The normal range runs higher in children and decreases with age. Children and adolescents typically have higher blood ALP levels because their bones are still growing. As a result, the ALP test must be interpreted with different reference (normal) values for children and for adults.

Abnormal levels of ALP in your blood most often indicate a problem with your liver, gallbladder, or bones. However, they may also indicate malnutrition, kidney cancer tumors, intestinal issues, a pancreas problem, or a serious infection.

Liver and gallbladder
Checking ALP levels in the blood is a routine part of liver function and gallbladder tests. Symptoms such as jaundice, abdominal pain, nausea, and vomiting may lead your doctor to suspect something is wrong with your liver or gallbladder.
The ALP test can be helpful in identifying conditions such as:
• hepatitis (inflammation of the liver)
• cirrhosis (scarring of the liver)
• cholecystitis (inflammation of the gallbladder)
• blockage of bile ducts (from a gallstone, inflammation, or cancer)
You may also need an ALP test if you’re taking a medication that has the potential to damage your liver, such as acetaminophen (Tylenol). Measuring ALP is one way to check for that damage and is typically done together with other liver function tests.

Bones
The ALP test can be helpful in the diagnosis of bone problems such as:
• rickets, a weakening or softening of the bones in children that’s most commonly due to a significant deficiency of vitamin D or calcium
• osteomalacia, a softening of the bones in adults usually due to significant vitamin D deficiency, but also possibly due to the body’s inability to process and use vitamin D properly
• Paget’s disease of the bone, a disorder causing major problems with bone destruction and regrowth
ALP testing may also be helpful in investigating the presence of cancer tumors, unusual bone growth, or vitamin D deficiency. It can also be used to check the progress of treatment for any of the above conditions.

Results of the ALP test are typically interpreted along with gamma-glutamyl transferase (GGT) results and with other tests that may have been performed at the same time, such as a liver panel, as well as in the context of your medical history and physical exam.

High ALP usually means that either the liver has been damaged or a condition causing increased bone cell activity is present.
• If other liver tests such as bilirubin, aspartate aminotransferase (AST), or alanine aminotransferase (ALT) are also high, usually the increased ALP is caused by liver damage or disease. If GGT is also increased, then the high ALP is likely due to liver disease. Significantly elevated ALP, often more than 4 times what is normal, may indicate bile duct obstruction and/or gallbladder inflammation.
• If liver tests and GGT are normal, then the high ALP is likely caused by bone diseases. Likewise, if calcium and/or phosphorus measurements are abnormal, usually the ALP is coming from bone.
If it is not clear from signs and symptoms or from other routine tests whether the high ALP is from liver or bone, then a test for ALP isoenzymes may be necessary to distinguish between bone and liver ALP.

ALP in liver disease
ALP results are usually evaluated along with other tests for liver disease. In some forms of liver disease, such as hepatitis, ALP is usually much less elevated than AST and ALT. When the bile ducts are blocked (usually by gallstones, scars from previous gallstones or surgery, or by cancers), ALP and bilirubin may be increased much more than AST or ALT. ALP may also be increased in liver cancer.

ALP in bone disease
In some bone diseases, such as Paget disease, where bones become enlarged and deformed, or in certain cancers that spread to bone, ALP may be increased.

If you are being successfully treated for Paget disease, then ALP levels will decrease or return to normal over time. If you have bone or liver cancer that responds to treatment, ALP levels should decrease.

Moderately elevated ALP may result from other conditions, such as Hodgkin lymphoma, congestive heart failure, ulcerative colitis, and certain bacterial infections.

Low levels of ALP may be seen temporarily after blood transfusions or heart bypass surgery. A deficiency in zinc may cause decreased levels. A rare genetic disorder of bone metabolism called hypophosphatasia can cause severe, long-term low levels of ALP. Malnutrition may lower serum ALP activity.

 

Gamma-glutamyltransferase (GGT) 

Gamma glutamyl transferase (GGT) is an abundant enzyme found in cell membranes of many tissues mainly in the liver, kidney, and pancreas with the highest concentrations being in the liver and kidney. It is made in the liver and is one of the 4 liver enzymes that is tested in order to evaluate liver and bile duct function.
GGT functions in the body as a transport molecule, helping to move other molecules around the body. It plays a significant role in helping the liver metabolize drugs and other toxins.

The normal range for GGT levels is 9–48 units per liter (U/L). Normal values can vary due to age and sex. (M 9-50 and F 8-40)

GGT is elevated in the blood in most diseases that cause damage to the liver or bile ducts.
Normally, GGT is present in low levels, but when the liver is injured, the GGT level can rise. GGT is usually the first liver enzyme to rise in the blood when any of the bile ducts that carry bile from the liver to the intestines become obstructed, for example, by tumors or stones. This makes it the most sensitive liver enzyme test for detecting bile duct problems and compared with other liver enzymes, it persists longer. Generally, the higher the GGT level the greater the damage to the liver.

However, the GGT test is not very specific and is not useful in differentiating between various causes of liver damage because it can be elevated with many types of liver diseases, such as liver cancer and viral hepatitis, as well as other non-hepatic conditions, such as acute coronary syndrome. For this reason, the GGT test is not recommended for routine use by itself. However, it can be useful in conjunction with other tests and in determining the cause of a high alkaline phosphatase (ALP) level, another enzyme found in the liver.
Only modest elevations (2-5 times normal) occur in infectious hepatitis, and in this condition, GGT determinations are less useful diagnostically than are measurements of the transaminases.

Both GGT and ALP are increased in liver diseases, but only ALP will be increased with diseases affecting bone tissue. Therefore, GGT can be used as a follow up to an elevated ALP to help determine if the high ALP result is due to liver or bone disease.

GGT levels are sometimes increased with consumption of even small amounts of alcohol. Higher levels are found more commonly in chronic heavy drinkers than in people who consume less than 2 to 3 drinks per day or who only drink heavily on occasion (binge drinkers). The GGT test may be used in evaluating someone for acute or chronic alcohol abuse. GGT can be used to screen for chronic alcohol abuse (it will be elevated in about 75% of chronic drinkers) and to monitor for alcohol use and/or abuse in people who are receiving treatment for alcoholism or alcoholic hepatitis.
A low or normal GGT test result indicates that it is unlikely that you have liver disease or have consumed any alcohol.

Sources:

1. https://labtestsonline.org/tests/alkaline-phosphatase-alp
2. https://www.healthline.com/health/alp#uses
3. https://labtestsonline.org/tests/gamma-glutamyl-transferase-ggt
4. https://www.healthline.com/health/gamma-glutamyl-transpeptidase#results
5. https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/8677

 

 

Session 3

Assignment: If you were stranded on an island and left in charge of a hospital there and could only pick 5 antibiotics to cover everything, which 5 antibiotics would you chose?

Surgery- 5 Abx