This document provides an overview of growth disorders including short and tall stature. It discusses the evaluation and causes of short stature such as growth hormone deficiency, Turner syndrome, and Prader-Willi syndrome. For growth hormone deficiency, it outlines the diagnostic process including stimulation tests and treatment with growth hormone. For tall stature, it reviews genetic, hormonal, and syndromic causes such as familial tall stature, precocious puberty, and Marfan syndrome.
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This is a series of lectures on general pathology useful for undergraduate and postgraduate pathology students. The ppts here have are enriched with explanatory pictures as well as useful video links.. hope you find them useful
It is the term used for people whose height is below the average compared to their peers’ height. This term is most commonly used for children, but also can be applied to adults. As children can be shorter than their friends or peers and still perfectly healthy. This case occur when the adult height is more than two standard deviations less than the known degree of shortness.
Causes and classification:
1- Structural growth delay:
Simply, in children the growth may be delayed than others, which are called late bloomers. They usually reach the puberty later than children of their age, and their growth will continue after others of the same age and the normal height rate.
2- Genetically:
It may called familial short stature or genetic short stature. In this case the person will have abnormal height rate lower than others at the same age throughout his life. . The bone age formation is with the chronological age. This is the most difference between the familial short stature and those of delayed growth.
3- Disease:
- Endocrine diseases: which will affect the production of hormones. Some of this hormones that affects the growth and the height are thyroxin (hypothyroidism), growth hormone (growth hormone deficiency), and Cushing’s disease.
- Chronic diseases: they effect on the overall health. Such as, kidney disease, heart problems, bronchial asthma, bowel inflammation, diabetes, rheumatoid arthritis, and sickle cell anaemia.
- Genetic conditions: Down syndrome, Williams syndrome, and turner syndrome.
- Skeletal and bone diseases: rickets, achondroplasia that change the structure by their effect on the growth of bones.
4
- Also some problems or diseases during pregnancy or malnutrition have effects on the height of the child. (Lacey et al, 1974)
4- Other normal and biological causes:
- According to Binder (2011), it is a case in which the person is 2 SD from the known normal ranges, and there is no evidence for endocrine problems or delayed growth. The short stature, in this case, occur due to some variations (genetic variations) which have large effects, such as SHOX gene. This gene is responsible for 1% to 4% of the cases of the short stature. This is known by Idiopathic short stature.
- Some causes of short stature cases may be because of the premature delivery of infants. Premature infants continue with this problem to the childhood, which is known by small for gestational age.
- Cartilage extracellular matrix as the collagen and another proteins that is responsible for the growth of cartilage.
- Control of growth plate function by the effect of cytokines, so the repeated inflammatory diseases cause slowing of the growth plate, because the catch up of the growth delayed after the effect of cytokines resolved.
Approach to Short Stature
Dr Raheel Ahmed
FCPS in Paediatric Medicine
Children Hospital, Chanka Medical College, Larkana
Topics
Definition.
Etiology
Measurements.
Examination.
Investigations.
Management.
Take home message.
Who is short child?
Short stature is defined as height that is two standard deviations below the mean height for age and sex (less than the third percentile).
OR
more than two standard deviations below the mid-parental height.
Etiology
Proportionate Short Stature
1) Normal Variants:
i) Familial
ii) Constitutional Growth Delay
2) Prenatal Causes:
i) Intra-uterine Growth Restriction-
Placental causes, Infections, Teratogens
ii) Intra-uterine Infections
iii) Genetic Disorders (Chromosomal
& Metabolic Disorders)
Postnatal Causes:
i) Undernutrition
ii) Chronic Systemic Illness
- Cardiopulmonary: CHD, Chronic Asthma,
Cystic Fibrosis
- Renal: RTA, CRF, Steroid dependent
Nephrotic Syndrome
- GI and Hepatic: Malabsorption, IBD, chronic
liver disease
- Chronic Severe Infections
- Hematological : Thalassemia, Sickle cell
anemia
iii) Psychosocial Short Stature
(emotional deprivation)
iv) Endocrine Causes:
- Growth Hormone Deficiency/ insensitivity
- Hypothyroidism
- hypopituitrism
- Diabetes Mellitus
- Cushing Syndrome
- Pseudohypoparathyroidism
- Precocious/ delayed puberty
Disproportionate Short Stature
1) With Short Limbs:
Achondroplasia,
Hypochondroplasia,
Chondrodysplasia punctata,
Chondroectodermal Dysplasia,
Diastrophic dysplasia,
Metaphyseal Chondrodysplasia
Osteogenesis Imperfecta,
Refractory Rickets
2) With Short Trunk:
Spondyloepiphyseal dysplasia,
Mucolipidosis
Mucopolysaccharidosis
Mid Parental Height
TCR
Calculated by MPH +-10
How to measure upper and lowersegments?
You should measure the upper segment( US ) then by using the total height you will obtain LS.
Upper segment is the sitting height.
Disproportionate short statue with short LS:-
Achondroplesia
Osteogenesis imperfecta.
Refractory rickets.
Disproportionate short stature with short US:-
Spondyloepiphysial dysplasia.
Mucopolysaccharidosis.
Growth velocity
0-1 year : 25cm/year
1-2 year: 12cm/year
2-3 year: 8cm/year
3-4 year: 7cm/year
4-9 year : 5-6 cm/year
As a rule any growth rate <4.5cm/year between 2-12 year is pathological.
Contrast induced nephropathy (CIN) is agenerally reversible form of acute kidney injury (AKI) that occurs soon after the administration of radiocontrast media.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
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Transition to Acting
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Fitness Regimen
Workout Routine
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Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
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8. Short stature /Growth failure
height below 3rd percentile (-2SD for age
and gender)
• height significantly below genetic potentials
(-2SD below mid-parental target)
• abnormally slow growth velocity
• downwardly crossing percentile channels on
growth chart (> 18 months age)
9.
10. NORMAL GROWTH VELOCITY
- prenatal growth : 1.2 -1.5 cm / week
- infancy : 23 - 28 cm / year
- childhood : 5 - 6.5 cm / year
- puberty : 8.3 cm / year (girls), 9.5 cm / year (boys)
11. Evaluation
Is Is child short ?
child short ?
velocity impaired
Any dysmorphic features or
disproportionate ?
12. Is child short ?
Plotted on an appropriate growth chart.
Length is measured lying down and
should be used for infants and children up
to 24 months of age .
Height is measured standing and should
be used for children 2 years and above.
13.
14.
15. velocity impaired?
Accurate height measurements performed at 6-month
intervals and plotted to the year and month of age on
the growth curve
If the growth velocity is subnormal (below the 25th
percentile for age) without alternative physiological
explanations, the child should be thoroughly
investigated
22. Initial screening evaluation of growth failure
General tests
- CBC with differentials, renal profile, liver function test, ESR,
Urinalysis, serum ca ,ph, TTG
• chromosomal analysis in every short girl
Endocrine tests
- thyroid function tests
- growth factors: IGF-1, IGFBP-3
- growth hormone stimulation tests if growth hormone deficiency is
strongly suspected.
Imaging studies
- bone age : anteroposterior radiograph of left hand and wrist
- CT / MRI brain ( if hypopituitarism is suspected)
Other investigations depends on clinical suspicion
- blood gas analysis
- radiograph of the spine
23. BONE AGE
X ray left hand wrist to tips of fingers
TW3 (Tanner Whitehouse)
GP( Greulich-Pyle )ATLAS
GILSANZ and RATIB
WHY BONE AGE ?
Skeletal maturity
Correlates closely with SMR(sexual maturity rating)
predict for remaining growth potential
Helps in adult height prediction
28. Familial short stature
One of the MC cause of short stature
Ht <3rd percentile but N against MPH
GV normal, growth curve follows parallel to 3rd centile
line
BA= CA, with N body proportion
Child achieve puberty at appropriate age
Adult stature is below normal
29. Constitutional delay of growth and
puberty (CDGP)
More frequently encountered in boys
Born with normal weight and length
Grow normally in the 1st year, decelerates during 2nd -
3rd year to reach just below 3rd percentile
Continue to grow parallel to 3rd percentile with normal
GV throughout the childhood
Puberty delayed with growth spurt delayed and
attenuated
BA< CA
H/O delayed puberty in either parent often
32. seckel syndrome
Inheritance is autosomal recessive
Caused by defects of genes on chromosome 3 and 18
Mental retardation (more than half of the patients have an IQ below
50)
Microcephaly
Sometimes pancytopenia
Cryptorchidism
Low birth weight
Dislocations of pelvis and elbow
Unusually large eyes
Low ears
Small chin
35. Presentation
genetic disorder in which seven genes (or some subset thereof)
on chromosome 15 (q 11–13) are deleted or unexpressed
Cryptorchidism
Speech delay
Poor physical coordination
Hyperphagia (over-eating
Excessive weight gain
Sleep disorders
Delayed puberty
Short stature
Obesity
Extreme flexibility
Infertility (males and females)
Hypogonadism
Sparse pubic hair
36. Achondroplasia
Autosomal dominant genetic disorder
mutation in Fibroblast growth factor receptor 3 (FGFR3)
Improportionate dwarfism
Shortening of the proximal limbs
Short fingers and toes
Large head with prominent forehead
Small midface with a flattened nasal bridge
Spinal kyphosis
38. Growth hormone deficiency
epidemiology
The incidence :about 1:4000 to 1:10000
3 to 30 percent of children with growth hormone
deficiency (GHD) have an affected parent, sibling, or
child.
40. congenital
The first pattern is related to perinatal asphyxia e.g a
history of perinatal distress, breech delivery, cesarean
section, and low Apgar scores.
The second pattern of GHD presenting in infancy is
associated with early prenatal embryologic
malformations, including central nervous system
(CNS) malformations (eg, septo-optic dysplasia),
midface abnormalities (eg, coloboma of the eye,
midface hypoplasia, cleft palate and lip, median cleft
face, and single central incisors),and in males,
micropenis.
Mutations: Prop-1 . POU1F1 . Pit-1
41. acquired
most commonly Idiopathic
Head trauma
Tumor
Inflammatory (Histiocytosis X, autoimmune)
CNS radiation
Surgical damage to the pituitary and hypothalamus
42. CLINICAL PRESENTATION
The single most important clinical manifestation of
GHD is growth failure.
Congenital :
Breech presentation and perinatal asphyxia.
Hypoglycemia and prolonged jaundice.
The penis may be small.
Higher male : female ratio 3 : 1.
47. Management
treat underlying cause.
psychological support for non-treatable causes.
48. Indications For GH Treatment
Paediatric GH deficiency.
• Turner syndrome.
• Small for gestational age.
• Chronic renal insufficiency.
• Idiopathic short stature.
• Prader–Willi syndrome .
• AIDS cachexia
49. GH treatment
GH dose: 0.025 - 0.05 mg/kg/day(0.5 - 1.0
units/kg/wk) at night SC.
GH treatment should start with low doses and be
titrated according to clinical response, side effects,
and growth factor levels
patients should be monitored at 3-month intervals
50. When to stop
Continue treatment till child reaches near final height.
Height velocity of < 2cm / year over at least 9 months .
Bone age >13 years in girls and >14 years in boys
59. Familial or genetic tall stature
most common cause of tall stature.
These children are usually tall from early childhood
and have tall parents.
Genetically tall children have a high normal growth
rate, normal results from physical examination, and a
bone age that is compatible with chronologic age.
Comparing the growth of the patient and the parents
on a growth chart reveals that the tall stature is
appropriate for that family.
60.
61. Constitutional tall stature.
Is the second most common cause of tall stature.
They have a normal length at birth. The growth velocity
accelerates in early childhood, and the tall stature is usually
evident by the age of 3 to 4 years Growth velocity slows
down after the child reaches 4 or 5 years; thereafter the
growth curve is parallel to and above the normal curve.
slightly or moderately advanced bone age.
Puberty usually develops in the early range of normal, and
final adult height is in the upper range of normal.
There is usually a family history of a similar growth pattern
62.
63. Precocious puberty.
Acceleration of linear growth invariably occurs
simultaneously with signs of premature sexual
development or inappropriate virilization.
Osseous maturation(BA) that is greater than expected
for the chronologic age.
The ultimate height is less than it would have been
otherwise due to early epiphyseal closure.
64. Pituitary growth hormone excess.
Growth hormone-producing or null cell adenoma of
the pituitary gland Before the epiphyses close.
Bone age is often advanced.
65. Marfan's syndrome.
Autosomal dominant trait.
Arachnodactyly, tall stature, superior lens subluxation
or dislocation, and aortic or mitral regurgitation.“
The arm span is greater than height, and the
Upper to lower body segment ratio is diminished
joint hyperextension,
Inguinal or femoral hernia, pectus excavatum, scoliosis,
megalocornea, and myopia." Retinal detachment
Aortic aneurysm and rupture
66. Homocystinuna.
Autosomal recessive disorder caused by a deficiency of
cystathionine P-synthase with resultant excretion of
large amounts of homocystine in urine
Phenotypic appearance similar to those with Marfan's
syndrome
Mental retardation, malar flush,
Inferior lens subluxation or dislocation,
Increased incidence of seizures,
Arterial and venous thrombosis, osteoporosis,
vertebral collapse
67.
68. Weaver syndrome.
Accelerated linear growth, advanced bone age,
Campylodactyly , mild mental retardation.
small jaw, widely separated eyes, large and dysplastic
ears,
broad forehead, long philtrum, megacephaly.
strabismus, depressed nasal bridge, and flat occiput.
69.
70. Klinefelter's syndrome.
abnormal karyotype is 47 XXY.
Affected children are tall and have eunuchoid proportions
with a long arm span and legs and a decreased upper to
lower body segment ratio.
Genital abnormalities, such as hypogonadism,
cryptorchidism, and a small phallus, are sometimes
present.
Gynecomastia is common during adolescence.
Mental retardation and behavioural difficulties,
such as excessive shyness, aggressiveness, and antisocial
behaviour, are often present.
71. Diagnostic imaging studies and laboratory tests helpful
for evaluating a child with tall stature
SUSPECTED DIAGNOSIS SUGGESTED TESTS
Serum FSH-LH, estradiol or testosterone;
skull x-ray, or MRI
True precocious puberty
Serum estradiol or testosterone; abdominal
ultrasonography or CT
Ovarian or adrenal tumour
Serum electrolytes; plasma 1 7-
hydroxyprogesterone; urinary pregnanetriol;
dexamethasone suppression test
Congenital adrenal
hyperplasia
Pituitary growth hormone
excess
Cerebral gigantism Skull x-ray, CT, or MRI; electroencephalography
Klinefelter's syndrome Chromosome study
Serum growth hormone or somatomedin C; skull x-ray,
CT, or MRI
Plasma cystine, homocystine, and methionine;
urinary homocystine
Homocystinuria
Hypogonadal syndromes Serum FSH, LH, estradiol or testosterone