Year 2 MET2: Metabolism 2

Lecture: Met 2 Introduction

Lecture: Anterior Abdominal Wall & Inguinal Anatomy

1. Understand the anatomy of the anterior abdominal wall
2. Describe the basic anatomy of the inguinal ligament
3. Understand the origins of the layers of the spermatic cord
4. Explain where inguinal hernias commonly form and why

Lecture: Nutrition in Medicine

1. Describe how to identify those at risk of malnutrition
2. Explain the prevalence and causes of malnutrition in UK
3. Describe the physical and psychological consequences of under-nutrition.
4. Describe the different methods of nutritional assessment
5. Outline the role of doctors and other health professionals in identification of under-nutrition and delivery of nutrition support
6. Describe briefly the ethical and medico-legal aspects of artificial nutrition support

Lecture: Nutrition & Diet

1. Planning nutritional intervention
2. Reviewing outcome of nutritional intervention
3. Assessment of patient's nutritional status

Lecture: Liver Anatomy

1. Understand the relations and the basic structure of the liver.
2. Understand the peritoneal reflections surrounding the liver.
3. Describe the blood supply to the liver ( both systemic and portal ).
4. Describe the biliary tree.
5. Explain the clinical importance of porto-systemic anatomosis.

Lecture: Insulin

1. Define insulin resistance.
2. Describe the main features of the intracellular insulin signalling pathway.
3. Describe the main features of the insulin receptor.
4. Describe the main structural features of the insulin molecule.
5. Outline how insulin secretion is regulated.
6. Describe the molecular basis of insulin resistance at the level of the insulin receptor.
7. List the major metabolic actions of insulin on the metabolism of the major energy fuels, glucose and lipid, in the postprandial state.
8. Describe the structure of the pancreatic islet of Langerhans; list the major cell types and the hormones that they secrete.

Lecture: Clinical Skills - Abdomen

1. Demonstrate the appropriate techniques required to perform a holistic clinical examination of a patient with abdominal disease
2. How to gain consent to examine a person/patient's abdomen
3. The anatomical basis of the abdominal examination
4. How to identify the common clinical signs that signal a patient with abdominal disease is unwell.
5. How to position a patient/person correctly prior to examining their abdomen
6. How to perform a systematic examination of a patient with abdominal disease including some peripheral and central clinical signs
7. The associated clinical examination and investigations required to complete a clinical assessment of a patient with abdominal disease.
8. Be able to demonstrate the appropriate techniques required to perform an holistic clinical examination of a patient with abdominal disease.

Clinical Demonstration: Liver Disease

1. To appreciate the difference between liver failure, portal hypertension and cirrhosis.
2. To identify the important causes of acute and chronic liver disease.
3. To understand the different effects of alcohol on the liver.
4. To understand the natural history of Hepatitis B and C viruses and their presentation with acute and chronic liver disease
5. To recognise the features of biliary tract obstruction.
6. To understand the link between structure and function of the hepato-biliary tract and link this to clinical presentation

Lecture: Body Fluid Compartments & Water Balance

1. Distinguish between the terms 'osmolarity' and 'osmolality' and between the terms 'isosmotic' and 'isotonic'. State a normal value for plasma osmolality
2. Name the main fluid compartments of the body, commenting on their volumes and predominant cations.
3. Explain how total body water and total body sodium are regulated by mechanisms that are sensitive to plasma volume and plasma osmolality.
4. Quantify the factors that contribute to the water balance of the body.
5. By means of labelled diagrams, show the changes in volume and osmolality of tubular fluid along the length of the nephron, in the presence or absence of anti-diuretic hormone (ADH).
6. Explain how the thick-walled, ascending limb of the loop of Henle plays a key role (in conjunction with ADH) in the production of either dilute or concentrated urine to meet the requirements of water balance.
7. State the source, nature and mechanisms of release of ADH. Describe the stimuli for the release of ADH and explain how ADH controls urine volume and osmolality.

Lecture: Liver Cirrhosis and Metabolism

1. Understand the difference between compensated and decompensated cirrhosis.
2. Know the main causes of liver cirrhosis.
3. Know the symptoms (ascites, portal hypertension)
4. Know the tests used to diagnosed cirrhosis (in particular the significance of the metabolites used in the blood test)
5. Understand the complications of liver cirrhosis: hepatic encephalopathy and bacterial peritonitis
6. Understand the consequences of liver failure on the metabolic state
7. Explain the treatments for cirrhosis and their mechanism of action

Lecture: Insulin - Counter Regulatory Hormones

1. Describe the hepatic glucoregulatory actions of glucagon.
2. Summarise the physiological actions of the glucocorticoids on metabolism.
3. Describe the acute metabolic actions of adrenaline and noradrenaline.
4. Outline how glucagon opposes insulin action as glucose levels fall.
5. Outline the action of glucagon on hepatic lipid homeostasis during fasting.
6. List the symptoms, causes and consequences of hypoglycaemia.
7. Outline the metabolic effects of thyroid hormones.
8. Understand the regulation of thyroid pathophysiology.
9. Describe the actions of glucagon on glucose and lipid metabolism in the post absorptive and fasting states.

Lecture: Clinical Acid / Base

1. Know the methods available for the assessment of acid-base balance in patients.

Lecture: Acid - Base Regulation

1. Learn the relationship between pH, HCO3 and pCO2
2. Learn how cell metabolism and environment are constantly challenging the pH of the human body
3. Learn which organs are involved in pH regulation and by which mechanisms
4. Learn the four forms of Acid-Base disturbance
5. Learn the how to calculate the anion gap and what type of metabolic disorders it is associated with
6. Understand why Acid-Base homeostasis is essential for human physiology

Lecture: Liver Disease

1. To understand the link between structure and function of the hepato-biliary tract and link this to clinical presentation
2. To identify the important causes of acute and chronic liver disease.
3. To appreciate the difference between liver failure, portal hypertension and cirrhosis.
4. To understand the different effects of alcohol on the liver.
5. To understand the natural history of Hepatitis B and C viruses and their presentation with acute and chronic liver disease
6. To recognise the features of biliary tract obstruction.

Lecture: Diabetes Mellitus

1. Outline the potential abnormalities of glucose homeostasis in diabetes mellitus.
2. Describe the principal forms of diabetes mellitus.
3. List mechanisms that can amplify insulin secretion
4. Describe advanced glycation end products (AGEs) and AGE receptors (RAGEs)
5. Summarise the effects of inadequate insulin secretion or action upon carbohydrate and fat metabolism, including the etiology of diabetic ketoacidosis.
6. Outline how increased AGE promote atherosclerosis via low density lipoproteins (LDL).
7. Outline how glucose tolerance can be maintained by the balance between insulin secretion and action.
8. Describe the Hb A1c test.
9. Outline the effects of persistent hyperglycaemia.
10. Outline the changes in glucose and insulin during an oral glucose tolerance test in normal, insulin resistant and diabetic subjects.
11. Describe how beta-cell mass changes in type 2 diabetes
12. Outline the macrovascular complications of diabetes mellitus.
13. List the long-term complications of diabetes mellitus.

Lecture: Nausea and Vomiting

1. There are different classes of anti-emetic drugs with different actions; no drug is effective against all types of emesis
2. Many different causes (pregnancy, motion, drugs, gastrointestinal/ painful conditions, surgery). Can be especially severe during cancer chemotherapy and palliative medicine
3. Antagonists at 5-HT3 and NK1 receptors are used to inhibit severe emesis often in combination with the steroid, dexamethasone
4. Old, 'established' anti-emetic drugs are commonly used, often with a 'mixed pharmacology' (antagonise at M1, H1 and/ or D2 receptors) and side-effects
5. Emesis (nausea + vomiting) is a normal defensive reflex which becomes a medical issue if induced by drugs or disease
6. Nausea is not the same as vomiting and is more difficult to treat

Lecture: Thyroid

1. Describe the detection and treatment of hyperthyroidism and hypothyroidism
2. Outline the synthesis, storage and release of thyroid hormones
3. List the effects of excess and deficiency of thyroid hormones
4. Briefly explain the pathophysiology of hypo- and hyperthyroidism
5. Outline the actions of thyroid hormones
6. Describe the effects of thyroid stimulating hormone on the thyroid gland

Lecture: Endocrine Anatomy

1. Understand the anatomy and the blood supply of the adrenal glands.
2. Describe the structural and functional relationships between the hypothalamus and the pituitary gland.
3. Describe the anatomy and the blood supply of the thyroid gland and surrounding structures.
4. Understand the contents and the clinical importance of the cavernous sinus.
5. Understand the anatomy and the blood supply of the pancreas and its relations.

Lecture: Micronutrients

1. List the principal causes of vitamin deficiencies in developed countries.
2. Give examples of the fat-soluble vitamins and describe their function within the context of clinical features of their deficiencies.
3. Discuss the role of vitamins (and trace elements) as antioxidants
4. Give examples of water-soluble vitamins and list the principal function common to B vitamins
5. Describe the clinical syndromes associated with deficiencies of the water-soluble vitamins B1 (thiamin), B6, B12 and folate
6. Give examples of important trace elements present in the diet within the context of clinical features of their deficiencies

Lecture: Diet and Coronary Heart Disease

1. Differentiate between types of lipids in relation to protection from and contribution to cardiovascular disease
2. List the major risk factors for cardiovascular disease
3. Outline evidence that the risk of cardiovascular disease may be modified by environmental influences in early life.
4. Review the main dietary factors that influence the development of coronary heart disease and hypertension
5. Understand how salt and alcohol influence cardiovascular function
6. Be aware of key epidemiological studies of risk factors for cardiovascular disease

Lecture: Obesity

1. Describe the prevalence of obesity in the UK and its relationship with the population's intake of fat and carbohydrate and trends in physical exercise.
2. Discuss the pathological and psychosocial consequences of obesity.
3. Explain the links between obesity, insulin resistance and diabetes.

Lecture: Appetite Regulation

1. Outline the role of serotonin in the regulation of appetite.
2. Summarise how hormones from the gut, in particular ghrelin, affect food intake.
3. Define the terms anorexigen and orexigen.
4. Outline the control of food intake by the hypothalamic leptin-melanocortin pathway.
5. Understand the significance of leptin resistance in obesity.
6. Describe the role of malonyl-CoA in the hypothalamus as a regulator of food intake.
7. Summarise the impact of insulin on satiety.

Clinical Demonstration: Acromegaly

1. Anatomical relations of the pituitary gland and the surgical anatomy of a pituitary mass
2. Origin and natural history of pituitary adenomas
3. Signs and symptoms of acromegaly (consequences of growth hormone over-secretion)
4. Social and emotional impact of pituitary disease
5. Physiology of the growth hormone axis and the pathophysiology of over-secretion of growth hormone
6. Principles of diagnostic endocrine and radiological tests for Acromegaly
7. Principles, benefits and risks of medical, surgical and radiotherapy treatments for Acromegaly
8. Effect of a pituitary mass on normal pituitary physiology

Lecture: Steroids

1. Describe other unwanted effects arising from long-term therapy with glucocorticoids
2. Clinical uses of corticosteroids
3. Explain how long-term corticosteroid therapy disrupts endogenous corticosteroid secretion
4. List some synthetic steroids with mainly glucocorticoid activity. Explain the reason for the development of such compounds.
5. Describe the mechanisms of action contributing to anti-inflammatory and immunosuppressive effects of corticosteroids.

Lecture: Hypothalamus and Pituitary

1. Describe the structure and origins of the pituitary gland and explain the relationship between the hypothalamus and both the anterior and posterior pituitary.
2. Briefly outline the actions of the hormones of the posterior and anterior pituitary.
3. Use the concept of negative feedback to explain the principles underlying clinical tests for pituitary hormone secretion
4. List the hormones secreted by both the anterior and posterior pituitary and in each case explain the role of the hypothalamus in regulating their secretion

Lecture: Defecation & Anal Anatomy

1. Understand the embryonic development of the anorectum.
2. Know the functional anatomy of the anorectum: muscles, vascular and nerve supplies.
3. Outline the investigations available to investigate anorectal disorders.
4. Understand the physiological mechanisms of defecation.
5. Understand how developmental errors lead to anorectal birth defects.

Lecture: Acid-Base

1. Know the methods available for the assessment of acid-base balance in patients
2. To understand the pathogenesis and common causes of: a) respiratory acidosis b) respiratory alkalosis c) metabolic acidosis d) metabolic alkalosis
3. To recognise the biochemical changes associated with the above disorders and how the body attempts to compensate

Lecture: Renal Excretory Function

1. Compare the reabsorption of sodium, glucose, amino acids and hydrogencarbonate in the proximal tubule of the nephron.
2. Show the effects of molecular size and charge on the composition of glomerular filtrate.
3. Outline renal handling of important electrolytes
4. With reference to the renal reabsorption of glucose,define the terms:'renal threshold' and 'transport maximum'. What may be the effects of glucose presence in the final urine?

Clinical Demonstration: Type 1 Diabetes (IDDM)

1. To add a clinical context to the lectures on diabetes

Clinical Demonstration: Obesity

1. Discuss the possible approaches to the treatment of obesity
2. Describe the physical, psychological social and emotional problems which may confront obese patients
3. Discuss the important problems in obtaining a reliable nutritional history from obese patients
4. Enumerate the clinical signs which are relevant to the aetiology or complications of obesity

Lecture: Renal Anatomy

1. Describe the gross anatomy of the urinary system and relations of kidneys and adrenal glands
2. Describe the course of the ureters and the position and relations of the urinary bladder in both sexes
3. Understand the blood supply to the kidneys and adrenals and the distribution of the arteries within the kidney
4. Discuss the structure, position and importance of urinary sphincter muscles

Clinical Skills - Thyroid Exam

1. Be able to carry out a clinical examination of a patient with reference to thyroid disease, including relevant parts of the general examination: demeanour, feet to face, hands (including pulse), mouth, eyes (including thyroid features), neck, neurology.
2. Recognise the features of the thyroid diseases named in the lecture so that they can be recognised from the clinical findings & biochemical tests.

Lecture: Kidney Histology

1. Describe the vasculature of the kidney, relating its unique features to the physiology of urine production and nourishment of the nephron.
2. Identify the components of the juxtaglomerular apparatus and describe its role in regulation of blood and urine volumes and renal homeostasis.
3. Outline the general organisation of the urinary system including the kidney, ureter, bladder and urethra.
4. Identify the parts of the nephron and describe the role of each component in the physiologic processes involved in urine production.
5. Outline the structural components of the urinary passageways and bladder and describe how micturition is controlled.

Lecture: Kidney Embryology

1. Know that the kidney is composed of the collecting system and excretory system
2. Understand from their knowledge of kidney development how some of the common defects in kidney development can arise
3. Describe the ascent of the kidney
4. Describe the development of zonation within the adrenal gland
5. That the embryonic origin of the collecting system is the ureteric bud
6. Appreciate the basic anatomy of the intermediate mesoderm, mesonephric and metanephric systems
7. The origin of the excretory system is the metanephric mesoderm
8. Appreciate during development how these tissue combine to give rise to the fully developed kidney
9. Understand the embryonic origin of the adrenal medulla and cortex and how they give rise to the adrenal gland

Lecture: Transplantation Immunology

1. Understanding the difference between types of rejection: hyperacute, acute and chronic.
2. Understanding how we can disrupt the immune response to transplanted tissue therapeutically.
3. Understanding how the recognition of transplanted tissue is compatible with our understanding of how the immune system differentiates self from non-self.
4. Understanding non-immunological processes that damage transplanted organs, including "ischaemia-reperfusion injury".
5. Understanding the mechanisms that are important in mediating immunological rejection: lymphocytes, antibodies, complement and coagulation cascade.

Clinical Demonstration: Renal Dialysis

1. Be aware of the limitations, advantages and disadvantages of haemodialysis
2. Understand the principles and practical aspects of haemodialysis
3. Be aware of the limitations, advantages and disadvantages of peritoneal dialysis
4. Understand the principles and practical aspects of peritoneal dialysis in its many forms

Clinical Demonstration: Renal Transplantation

1. Describe the complications associated with antirejection therapy
2. Be aware of the prognosis, advantages and disadvantages of transplantation
3. Describe the basic principles of tissue typing and lymphocytotoxic cross matching

Lecture: Micturition

1. Distinguish between urge incontinence, stress incontinence, overflow incontinence and leak incontinence
2. Describe the anatomy of the bladder, prostate and urethra
3. Explain the most common causes for each of the above.
4. Describe treatments available for disorders of micturition.
5. Describe the reservoir and emptying functions of the bladder and outline the neurological control of each
6. Outline the investigations available to distinguish the cause of incontinence in an individual.

Lecture: Imaging & Endoscopy of the Urinary Tract

1. Understand the main imaging techniques used for investigation of urinary tract disorders.
2. Understand how endoscopy of the urinary tract is performed.
3. Know which investigation technique is most appropriate for each region of the urinary tract.

Lecture: Calcium

1. Describe the source of parathyroid hormone and explain how its secretion is regulated.
2. Explain the relationship between the various forms of circulating calcium in blood
3. Briefly explain how the body excretes excess calcium
4. Describe the transformation of vitamin D3 into an active hormone and explain how this is regulated
5. Recognise the structure of vitamin D3 and describe the sources of this vitamin in the body
6. Outline the source and actions of calcitonin and explain its role in calcium metabolism.
7. Describe the actions of parathyroid hormone and 1, 25-dihydroxyvitamin D3 and account for the effects of vitamin D3 deficiency, and for hypo- and hyper-secretion of parathyroid hormone.
8. Briefly explain the relationship between calcium and phosphate metabolism.

Lecture: Adrenals

1. Explain the effects of both excess and deficiency of adrenal hormones
2. Describe the structure of the adrenal gland and relate the zones to production of hormones.
3. Describe the regulation of hormone secretion by each zone
4. Describe the physiological actions of the adrenal hormones

Lecture: Diuretics

1. Compare the different mechanisms for sodium re-absorption found in different parts of the nephron.
2. Explain why diuretics increase potassium excretion, and how this may be reduced.
3. Show, by means of a labelled diagram, the proportions of sodium reabsorbed from tubular fluid in: the proximal tubule; the loop of Henle; the distal tubule; the collecting duct.
4. List the major clinical indications of the uses of a diuretic.
5. Give the primary sites of action of thiazide, loop diuretics, and spironolactone, and rank them in order of their efficacy.
6. Explain the use of mannitol as a 'diuretic'.
7. Describe the actions of aldosterone on the distal tubule and collecting duct which maintain the sodium balance of the body. State the fraction of the total sodium re-absorption which is subject to regulation by aldosterone.

Lecture: Formative Assessment Endocrine

Practical: Urine

Clinical Demonstration: Nutrition and Diet

1. Using a case study to consider:
2. Assessment of patient's nutritional status
3. Planning nutritional intervention
4. Reviewing outcome of nutritional intervention

Practical 1: Alimentary Canal

1. Describe the general arrangement of the gastrointestinal tract and associated viscera
2. Outline the extent and the subdivisions of the peritoneal cavity
3. Describe the difference between retroperitoneal organs and intraperitoneal organs
4. Describe hiatus hernia and know the common causes of this condition
5. Know the anatomy of the inguinal region
6. Describe inguinal hernias and know the common causes of these hernias
7. Know the anatomy of the sigmoid, rectum, anal canal and sphincter
8. Know the symptoms and causes of haemorrhoids

Practical 2: Endocrine System

1. Describe the position and anatomical relationships of the pituitary gland
2. Understand the cavernous sinus and its contents
3. Describe the position and anatomical relationships of the thyroid gland
4. Describe the blood supply to the thyroid gland
5. Identify the strap muscles and understand their function.
6. Describe the position and anatomical relationships of the pancreas
7. Compare the position and anatomical relationships of the suprarenal glands
8. Describe the components, course and relations of the biliary tree (tract).
9. Describe the termination of the bile duct and pancreatic duct.
10. Revise the normal structure and blood supply of the liver.
11. Describe some important pathologies of the liver.

Practical 3: Renal System

1. List the components of the urinary system.
2. Describe the position and relations of the kidneys
3. Describe the blood supply to the kidneys and recognise on CT/MRI
4. Describe the structure of the kidney
5. Describe the course of the ureters.
6. Describe the anatomical relationships of the urinary bladder in both genders
7. Describe the course of the urethra in both genders
8. Demonstrate the anatomy of kidneys, ureters and bladder using radiological imaging: CT MRI and IV pyelograms

Microanatomy 1: The Endocrine System

1. Describe the general organisation of endocrine tissues in the pituitary gland, thyroid and parathyroid glands, adrenal gland and Islets of Langerhans of the pancreas.
2. Recognise and name the cell types found in these endocrine tissues.
3. Describe the blood supply to the pituitary gland and its relevance to anterior pituitary function.
4. Describe the blood supply to the adrenal gland and the functional relationship between the adrenal medulla and the nervous system.
5. Recognise and describe specific disease processes that affect the glands of the endocrine system.

Microanatomy 2: The Renal System

1. Describe the basic structural organisation of the kidney, including its vasculature.
2. Describe the structure of the nephron.
3. Relate the structure of the glomerulus to its role in the filtration of blood.
4. List the causes of impaired glomerular filtration and the clinical consequences of this.
5. Describe the structure and microanatomy of the urinary tract, including the bladder.
6. Describe common pathologies involving the urinary tract and be able to recognise them in pathology specimens .

Microanatomy 3: The Liver

1. Describe the architecture and blood supply of the liver.
2. Recognise and name the cell types found in normal liver.
3. Recognise and describe specific disease processes that affect the liver.
4. Understand how liver disease affects the function of the liver and/or other systems.

PBL 1: EXTREMES OF THE FOOD WORLD

PBL 2: ONE FOR THE ROAD

PBL 3: UNDERSTANDING YOUR ILLNESS

PBL 4: GENES & JEANS

PBL 5: A COMPLICATION OF DIABETES

PBL 6: A SLOWED-DOWN TEACHER

PBL 7: SARAH TAYLOR

PBL 8: NOCTURIA WITHOUT HIGH FLUID INTAKE