Growth hormone deficiency (GHD) is an important cause of short stature in children. Accurate diagnosis requires auxology, measurement of IGF1 and IGFBP3 levels, and GH stimulation tests. Recombinant human growth hormone therapy is effective and safe for treating GHD, but requires regular monitoring to ensure optimal results and growth responses.
A group of physiological abnormalities such as an increase in blood pressure, diabetes, increase in cholesterol levels and obesity is known as Metabolic Syndrome. Women in their pregnancy period are highly prone to this problem. Doctors are taking the issue of metabolic syndrome in obstetric practice seriously as it may risk the pregnancy.
A group of physiological abnormalities such as an increase in blood pressure, diabetes, increase in cholesterol levels and obesity is known as Metabolic Syndrome. Women in their pregnancy period are highly prone to this problem. Doctors are taking the issue of metabolic syndrome in obstetric practice seriously as it may risk the pregnancy.
IDD situation in our country has improved
A good number of thyroid disorder patients are either undiagnosed and or untreated
Thyroid disorder in pregnancy- Rate high
As a sound thyroid functioning status is crucial for growth, development in children; reproduction, psychological and general wellbeing in adults, we must be proactive in screening, diagnosing and treating our patients.
PCOS IS THE THIEF OF WOMENHOOD........an enigmatic condition must be understood and managed according to the age it presents.......contact dr jaideep at jaideep malhotraagra@gmail.com for CME AND WORKSHOPS IN YOUR CITY
IDD situation in our country has improved
A good number of thyroid disorder patients are either undiagnosed and or untreated
Thyroid disorder in pregnancy- Rate high
As a sound thyroid functioning status is crucial for growth, development in children; reproduction, psychological and general wellbeing in adults, we must be proactive in screening, diagnosing and treating our patients.
PCOS IS THE THIEF OF WOMENHOOD........an enigmatic condition must be understood and managed according to the age it presents.......contact dr jaideep at jaideep malhotraagra@gmail.com for CME AND WORKSHOPS IN YOUR CITY
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Growth Hormone therapy in
children with Growth Hormone
deficiency
Dr. Pranab Kumar Sahana
MBBS, M.D, D.M
Associate Professor,
Department of Endocrinology
NRS Medical College, Kolkata,W.B
2. Human Growth Hormone
Human GH is secreted by the somatotrophs of the
anterior pituitary gland under the control of—
• GH releasing hormone (GHRH)
• Somatostatin and
• Ghrelin
Potent stimulators of GH secretion—
• Exercise
• Stress
• High protein meals
• Prolonged fasting
3. Human Growth Hormone
(191 aminoacids)
• Under normal physiological conditions, GH is
secreted in approximately 6-10 secretary burts
each day
• GH secretion is very low in between pulses.
• Nearly 50 per cent of the daily GH secretion
occurs during the early hours of the night
following the onset of deep sleep (stage3 & 4).
• The growth promoting effects of GH are
mediated through a family of insulin-like
growth factors (principally IGF-1).
6. Effects of growth hormone
• Stimulation of linear growth
• Improves lean body mass
• Improves bone mineralisation and bone
density
• Reduction of fat mass and Lipolysis
• Stimulation of protein synthesis
• Altered insulin sensitivity
10. Classification based on growth velocity
Children who are short but growing with
a normal velocity
• Genetic short stature.
• Constitutional delay.
11. Children who are short and growing
with an abnormal growth velocity
• Hormonal abnormality.
• A dysmorphic syndrome .
• Small for gestational age.
• Systemic chronic illnesses.
12. Clinical features suggestive of GHD
• Most children with GHD have normal body
proportions and features
• Short stature
• Poor growth velocity
• Delayed bone age
• Immature facial appearance with a small midface
and frontal bossing (prominence)-chubby face
• Increased subcutaneous fat
• Delayed dentition
• Micropenis
• Sparse and thin hair
13. Developmental defects associated with
GHD
• Septo-Optic nerve hypoplasia
• Agenesis of corpus callosum
• Holoprosencephaly - a defect of the midline
cleavage of the forebrain
• Single central incisor
• Cleft lip and palate
• Hypospadias, microphallus,cryptorchidism -
GNRH deficiency
•
14. Features suggestive of GHD in neonate
• Hypoglycemia, prolonged jaundice,
microphallus, traumatic delivery
15. What is Growth failure
• 2-4 years : Height velocity less than 5.5
cm/rear
• 4-6 years: HV less than 5 cm/year
• 6-8 years: HV less than 4 cm/year for boys
HV less than 4.5 cm/year for girls
Normal Growth velocity = 6 cm /yr (4-10 years)
16. Auxology
• Compare child’s growth with established
norms.
• Length stadiometer: less than 2 years.
• Vertical Stadiometer: more than 2 years.
17. Technique for measuring erect height
(Herpenden Stadiometer)
• Child should be fully erect.
• Head in the Frankfurt plane.
• Back of the head, thoracic
spine, buttocks, heel should
touch the vertical axis of the
stadiometer.
• Should be measured in
triplicate and the mean
should be recorded.
19. Short stature
• Incidence of short stature due to Growth
Hormone deficieny is 1:4000 to 1:10000
• Short stature: a height of less than -2 standard
deviations (SDs) compared to the average
height at the corresponding sex and age.
20. Height SDS (Z Score)
• Child’s height- mean height for normal
children of the child’s age and gender divided
by the SD of the height for normal children of
this age and gender.
• Example- Child’s height= 121 cm
• Mean height= 140 cm
• SD= 6CM
• Z SCORE=19 divided by 6=-3.3 SDS.
22. Physical Examination
• Upper segment / lower segment ratio.
• Normal ratio: ~1.4 under 4yr, ~1.2 at 10yr, ~1.1
during puberty, 0.9 in adult.
• Short limbs: achondroplasia, hypochondroplasia,
multiple epiphyseal dysplasia.
• Short trunk: mucopolysaccharidoses,
spondyloepiphyseal dysplasia.
23. Definition of growth pattern
• Bone age- Age for which bone maturation is
average.
• Chronological age - calendar age.
• Height age- Age for which height is average.
• Weight age- Age for which weight is average.
24. Skeletal maturation /Bone age
• Mirror of tempo of growth and maturation
• Degree of growth plate senescence.
• X-ray of left wrist.
• Gruelich and Pyle.
• BA is a better predictor of pubertal milestones
than chronological age.
25. Bone age- importance in the diagnosis
of short stature
Type of growth
pattern
Bone age
approximates
Growth rate Differential
diagnoses
Intrinsic shortness Chronological age
BA=CA>HA
NORMAL FSS,CHROMOSOMAL
ABNORMALITIES,
BONE DYSPLASIA
Delayed growth Height age
BA=HA<CA
NORMAL CDGD,
CHRONIC DISEASE,
UNDERNUTRITION
Attenuated growth Height age
BA=HA<CA
ABNORMAL GHD
GHI
HYPOTHYROIISM
CUSHING
26. Parental Target height
• Midparental height =
Height of Father+ Mother /2+ 6.5 cm for boys
Height of Father+ Mother /2- 6.5 cm for boys
• Target Height: Within 10 cm of MPH
(Corrected)
27. Evaluation of growth failure- GH-IGF1 axis
Auxologic abnormalities:
• Severe short stature :Height SDS < -3
Severe growth deceleration:
• Height SDS < -2 and height velocity< -1.0 SD
over 2 years .
• Height SDS< -1.5 and height velocity <-1.5 SD
over 2 years.
28. Risk factors for GHD
• History of trauma, brain tumor, cranial
irradiation or organic or congenital
abnormalities of hypothalamic – pituitary
abnormalities (MRI)
29. Screening for IGF1 deficiency and
other diseases
A.
Free T3,Free T4,TSH, Cortisol (morning basal)
• Bone age (X-ray Wrist)
• Routine tests
• Anti TTG Ab, Anti Gliadin Ab
B.
• IGF1 and IGFBP3 : If <-2SD then proceed to GH
provocation tests.
• If MRI of HPT is abnormal then GH provocation
test is optional
31. Preconditions of GH testing
• Patients must be euthyroid and eucortisolemic
before tests.
• For prepubertal children pretreating with sex
steroids increases the specifity of the tests.
• 1-2 mg micronized estradiol or 50-100
microgram of ethinyl estradiol/day for 3 days
or 100 mg depot testosterone 3 days prior to
testing.
32. Limitations of GH stimulation tests
• Tests are non physiological.
• Cut off level is non uniform.
• Tests are expensive.
• GH assays are variable.
33. When GH stimulation test is not
necessary?
• Pituitary abnormalitity- hypoplasia, ectopic
posterior pituitary, abnormal stalk
• Severe short stature (Height<-3SD) with
significantly reduced IGF1 and IGFBP3 with
normal nutrition
34. Inerpretaion of GH stimulation test
• If peak GH < 10ng/ml: GHD .
• If peak GH < 5ng/ml: Complete GHD
• then MRI of pituitary hypothalamic area
• Test for other pituitary hormones if not done
already.
• Molecular genetics:
GH,GHR,GHRHR,PROP1,POU1F1,HESX1,LHX3/4.
35. IGF1
• Advantage:
• Reflects integrated growth hormone secretion
• Stable concentrations throughout the day
• Disadvantage:
• Age and sex dependent ranges
• Nutrition dependent
• Difficult to assay- small molecule
• Costly
• Unreliable in <5 years children
36. IGFBP3
• Simple to measure – large molecule
• Independent on age, gender and nutrition
• Better screening test.
37. Growth charts
• Compare individual children with the
3rd,10th,25th,50th,75th,97th percentiles of
normal children.
• Limitations:
1. do not define children below 3rd or above
97th percentile.
2. Less applicable in adolescence than in
infancy and childhood
44. Dosage and method of
administration
• 0.18-0.35 mg/kg/week administered in 7 daily
doses in the evening.
• In puberty: dose can be increased
Usual Growth responses to hGH:
• 1st year: 10-12 cm.
• 2nd and 3rd year: 7-9 cm.
45. Annual growth velocity in prepubertal children
with GHD(QD vs. TIW)
J Clin Endocrinol Metab 1996;81:1806-1809
46. Height gain with HGH in GHD
J Clin Endocrinol Metab 2006;91:2047-2054
Study Gender N GH
dose(mg/
kg/wk)
Duration(
Yrs)
Age
(yrs)
Height
SDS
Change
in
height
SDS
Height
vs.MPH
KIGS M 351 0.22 7.5 18.2 -0.8 +1.6 -0.2
F 200 0.20 6.9 16.6 -1.0 +1.6 -0.5
NCGS M 2095 0.28 5.2 18.2 -1.1 +1.4 -0.7
F 1116 0.29 5.0 16.7 -1.3 +1.6 -0.9
KIGS- Kabi Internaational Growth Study
NCGS- National Cooperative Growth Study
47. Monitoring of GHT
• Height velocity every 6months
• IGF1 and IGFBP3 after 1 month then every 6
months
• Target IGF1= Upper half of the normal range.(0 to
+2SD)
• Free T4 - periodical
• Cortisol – periodical (MPHD)
• Adherence
• Adverse effects
48. Predictors of response to GHT
• Age at start of treatment.
• Severity of GHD.
• Dose and frequency of administration.
• Genetic potential.
• Bone age.
49. Inadequate growth response on GHT
• Poor adherence.
• Subtherapeutic dose.
• Concurrent GHI.
• Development of neutralising antibodies.
• Development of central hypothyroidism.
• Comorbid disease.
• Incorrect diagnosis.
50. Potential side effects of GH treatment
Salt and water
retention
Possible glucose
intolerance and
hyperinsulinism
Pseudotumor
cerebri
Antibody
formation and
growth
attenuation
Hypothyroidism
Acute
pancreatitis
Slipped capital
femoral
epiphysis
51. Adverse effects of GHT
• Prepubertal gynaecomastia
• Growth of naevi
• Worsening of neurofibromatosis
• Hypertrophy of tonsils and adenoids ,sleep apnea
• Cancer: no increased risk in IGHD,ISS
• For patients with primary cancer diagnosis that
led to GHT – increased risk of secondary cancer.
52. Duration of GHT in children with GHD
• GHT is continued till GV < 2.5 cm/year.
• 2/3rd of IGHD will be growth hormone
sufficient at adult age.
• Genetic or organic causes of GHD is usually
permanent.
54. Case
• 6 years girl
• Height SDS= -3.18
• Target height= 156.2 cm
• Wt=10 kg
• Wt. SDS= -2.5
• Bone age= 4 years
• 3 years boy
• Height SDS= -3.23
• Weight SDS= -2.53
• Bone age 2 years.
55.
56.
57. Summary
• GHD is an important cause of short stature.
• Accurate diagnosis is essential.
• Auxology,IGF1,IGFBP3 and stimulated GH are
cornerstones of diagnosis.
• Recombinant human growth hormone is
efficacious and safe.
• Regular monitoring is essential to have
optimum results.