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76 Cards in this Set

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  • Back
What cytokine made by macrophages in inflammation elicits production of acute phase reactants by the liver?
IL-6
negative APR:

APR:
Albumin, prealbumin, RBP, transferrin

C3, MBP, CRP, a-1-at, a2mg, ceruloplasmin, fibrinogen, F8, haptoglobin, SAA, fibronectin...
What is the fastest migrating protein on SPEP?
Prealbumin = transthyretin

Rarely seen as such small quantities
What is the amyloid precursor protein in senile cardiac amyloidosis?
prealbumin
half life of albumin? prealbumin?
alb: 17d

prealb: 2d
Name 2 causes of truly elevated prealbumin

fake elevation?
chronic alcohol; corticosteroid therapy

falsely elevated in heparin therapy: alters beta-lipoprotein (LDL) such that it migrates in the prealbumin range
hallmark of CSF-PEP?
sharp prealbumin band. crosses BBB & is actively secreted.

also: double transferrin peak (beta region). BBB transports transferrin but modifies some to Tau protein
What migrates to the prealbumin region?
prealbumin / transthyretin

RBP (retinol binding protein - Vit A)
what regions INCREASE in inflammation?

decrease?
a1 : a1at (and orosomucoid = a1-acid-gp)
a2: haptoglobin, ceruloplasmin
gamma1: gamma globulins
gamma2: CRP

decreased: albumin, prealbumin, transferrin (beta1)
the greatest decreases in serum albumin are seen in?
protein-losing conditions (nephrotic syndrome)
classic pattern in nephrosis
low albumin
high a2 (a2macroglobulin)
low gamma globulin
normal spep. 
where is the "origin" located?
Which is the anode & which is the cathode?
normal spep.
where is the "origin" located?
Which is the anode & which is the cathode?
origin in located in the gamma region
the anode is on the left, it is + charged, and most proteins are - charged

the cathode is on the right and is - charged, gamma globulins are weakly negative so they don't move far from the application site
What is the most common defect in HyperIgM Syndrome?
defect in a Th2 cell protein (CD40 ligand). The disorder causes immunodeficiencies, including a higher than normal susceptibility to various types of infections.

Can't class switch!
What are the 2 most obvious bands that are present in PLASMA but not SERUM?
Prothrombin (alpha 1 region)

Fibrinogen (Beta-gamma region)(can misinterpret as an M protein) (Ethanol can precipitate this out in vitro!)
beta-gamma bridging is the hallmark of?
cirrhosis
Features of tubular proteinura UPEP?

glomerular?
Tubular - weak albumin band, strong a1, b. impaired tubular reabsorption

glom - Strong albumin band, strong a1, b. Very large and very small proteins are conserved in the kidney
Type I cryoglobulins
monoclonal. myeloma or waldenstroms
Type 2 cryo
monoclonal IgM (RF activity - anti-IgG)
AND
polyclonal IgG

most common
Type 3 cryo
mixture 2 polyclonal
#1 cause of mixed cryoglobulinemia (types 2 & 3)
HCV
clinical sx of cryoglobulinemia?

Most common renal finding?
PURPURA (leukocytoclastic vasculitis)
arthralgia
HSG
LAD
anemia
sensorineural deficits
glomerulonephritis

MPGN2
what cardiac marker rises the most compared to normal, following an MI?

What cardiac marker stays elevated the longest following an MI?
Troponins. 50x normal levels. Most assays measure cardiac troponin I, though there's not much difference with T.

Troponins. Up to 10 days.
Troponins. 50x normal levels. Most assays measure cardiac troponin I, though there's not much difference with T.

Troponins. Up to 10 days.
What conditions can show a "flipped" LDH ratio, where LDH1 > LDH2?
Hemolysis, AMI, renal infarct

..since LDH1 is found in RBCs, heart, and kidney
What is LDH-6 and what does it mean in terms of prognosis?
LDH6 is not a true isoenzyme of LDH but a mimic that is seen predominantly in alcohol use and indicates hepatic vascular insufficiency in the setting of shock

BAD px
What is macro-CK-2?
aka mitochondrial CK
a normal variant of CK that is found in mitochondria, however its presence is a BAD finding and is usually seen in advanced disseminated malignancies
What is macro-CK-1?
An Ig-CK complex that is not cleared readily from the circulation and persists. Autoimmune. Can lead to a chronically elevated CK level, but has no other clinical significance.
AST:ALT in EtOH?

viral hepatitis?
>2

<1
what is the Regan isoenzyme?
form of placental alkaline phosphatase seen in 5% pts with carcinoma
What is the affect of heparin on ALT & AST?
Renal failure?
Heparin can INCREASE these

Renal failure DECREASES them (cause is unknown)
acid phosphatase found most in?
RBCs, prostate, bone
How to tell RBC acid phosphatase from others?
RBC is RESISTANT to tartrate (=TRAP, same as hairy cell leuk)
What blood groups have higher NONFASTING alkaline phosphatase?
Lewis + group B & O
What form of bilirubin is found in the urine?

What form is responsive to phototherapy?
Urine only has CONJUGATED

UNconjugated responds to phototherapy
autoimmune hepatitis shows polyclonal increase in what globulins?

primary biliary cirrhosis?
ai: IgG

PBC: IgM
Causes of UNconjugated hyperbili?
Crigler Najar
Gilbert
Bowel obstruction
Hemolysis
Physiologic jaundice, breast milk jaundice
Causes of conjugated hyperbili?
Dubin Johnson
Rotor
Biliary obstruction
Sepsis
neonatal hepatitis
TPN
When to worry about neonatal jaundice:

Threshold for exchange transfusion?
- 1st 24h of life
- continuing to rise after 1 week
- Total bili > 12, conj>2, or increase of >5 in one day

exchange transfusion when bili >20
Persistently elevated serum amylase concerning for?

What is the most common cause of a normal amylase in the setting of acute pancreatitis?
pseudocyst

hypertriglyceridemia (TG inhibit the amylase assay)
# isoenzymes of amylase & what are they
6
first 3 are salivary on electrophoresis
last 3 are pancreatic

salivary is inhibited by wheat germ lectin (triticum vulgaris

amylase is cleared by the kidneys
how do amylase, CEA, CA19-9 vary among pancreatic cysts?
pseudocyst has elevated amylase

CEA is elevated in mucinous (mucinous cystadenoma has only CEA elevated, IPMN has all 3 elevated)

serous and solid-pseudopapillary have decreased all 3
what is delta-bilirubin?
conjugated bili covalently linked to albumin, cannot be readily excreted. thus conjugated bili measurements may persist after treatment
palpable purpura (leukocytoclastic vasculitis)
arthralgia
HSG
anemia
sensorineural deficits
glomerulonephritis (most commonly?)
cryoglobulinemia

MPGN2
Rapid correction of hyponatremia can lead to?
Slow correction?
CPM
cerebral edema
Normal BUN:Cr ratio?
10:1

Increased: poor renal perfusion (BUN reabsorbed)

Decreased: rare: liver disease, poor intake
What 4 hormones share the same alpha subunit?
hcg
TSH
FSH
LH
When does hcg peak?
end of first trimester
increased hcg & inhibin
decreased AFP & uE
Trisomy 21
decreased AFP, uE, hcg
Trisomy 18
increased AFP only
neural tube defect
notable drugs eliminated by zero-order kinetics (most drugs are eliminated by first-order = proportional to drug concentration)
EtOH
ASA
phenytoin
what two toxins will give an osmol gap on the commonly used platform of freezing point depression, but not with the less commonly used vapor pressure osmometry?
Ethanol & methanol
Metabolites of methanol? source?
formate & formaldehyde
windshield washer fluid
Metabolites of ethylene glycol? source?

clues in lab?
oxalate & glycolate
antifreeze

calcium oxalate crystals!
What 2 alcohols do not cause acidosis but do produce an OSMOL gap?
Ethanol
Isopropanol
Treatment of methanol or ethylene glycol OD?
Ethanol! competitively inhibits the enzyme alcohol dehydrogenase, which is responsible for producing the toxic metabolites of these drugs
abdominal pain and bilateral wrist drop
long-term lead poisoning
How does Fe deficiency perpetuate Pb toxicity (2 ways)?
1. Can't make heme molecules so protoporphyrins are increased (precursor)

2. Increased GI uptake of Fe also increased uptake of Pb
Elevated free erythrocyte protoporphyrin (FEP) and zinc-protoporphyrin (ZPP) are elevated in what 2 conditions?
lead poisoning
iron deficiency
What levels of CO are seen in smokers?

Severe symptoms with lethargy, LOC?
2-6%

20-50%
Time from ingestion for full acetaminophen absorption?

antidote?
4 hours

N-acetylcysteine (promotes metabolism via conjugation and decreased production of toxic NAPQI)
Why do alcoholics have a higher risk of hepatic injury from acetaminophen toxicity?

what zone of the liver shows acetaminophen toxicity?
Alcohol induces the P450 system in the liver, wchih increases the amount of acetaminophen metabolized to NAPQI

Zone 3 (centrilobular)
Bitter almond odor in breath
Cyanide toxicity
Clues to cyanide toxicity

mechanism?
almond breath
cherry red skin
severe anion gap metabolic acidosis (LACTATE)
inhalation of smoke (insulation) or pesticide
increased THIOCYANATE (metabolite)

CN binds cytochrome a3 and leads to decreased oxygen-dependent metabolism
treatment of CN tox
nitrites (form met-hgb) and sodium thiosulfate (forms thiocyanate, harmless compound eliminated by kidneys)
Earliest signs of ASA OD?
tinnitus & dizziness
Mortality in aspirin OD is best correlated with the ___-hr plasma salicylate concentration, with values >___mg/dL having a high fatality rate
6
130
what are the crazy stages of metabolic / respiratory / acidosis / alkalosis in ASA toxicity?
1. Respiratory alkalosis, 3-8h post ingestion, from direct stimulation of respiratory center

2. Compensatory metabolic acidosis, 12-24h, where patients usually present

3. Increased anion gap metabolic acidosis, through metabolic effects such as Krebs cycle inhibition

4. respiratory acidosis from CNS depression
Ingested arsenic is largely excreted in the ____ with most of the remainder distributed into ____, _____, and ____.
urine

skin, nails, and hair
Sx arsenic toxicity
vomiting, bloody diarrhea, abdominal pain
cytopenias with basophilic stippling
peripheral neuropathy, nephropathy, skin hyperpigmentation and hyperkeratosis
2 characteristic syndromes with weird names associated with chronic mercury toxicity
1. Acrodynia / Feer syndrome
-autonomic manifestatsions and desquamative erythematous rash palms & soles.
- increased urinary catecholamines ~ pheo!

2. Erethism
- CNS d/o with personality changes, irritability, fine motor disturbances
name 2 toxins that are best screened for with 24-hour urine levels
arsenic & elemental mercury
what drug, when taken with digoxin, enhances its toxicity?
quinidine
best test of quinidine toxicity
EKG (prolonged QT interval, torsades de pointes)
digoxin t 1/2
36h
warfarin dosing in a patient with mutations in:

VKORC1

CYP2C9
VKORC1: confers warfarin resistance & requires INCREASED dose

CYP2C9: Leads to DECREASED warfarin metabolism, and increased serum levels, so DECREASED dosage is needed
Tangier disease
AR
Absent Apo-A1, no HDL