L\'entrainement en aérobie diminue l\'hyperréactivité bronchique (HRB) et l\'inflammation systémique chez les patients souffrant d\'asthme modéré à sévère: un essai randomisé contrôlé.
Prévalence de la bronchoconstriction induite par l’exercice (BIE) et de l’obstruction laryngée induite par l’exercice (OLIE) dans une population générale d’adolescents.
La liste des cours à préparer dans la biochimie et la biologie moléculaire:
Code
Biochemistry and molecular biology
• gene expression: DNA structure, replication, and exchange
– DNA structure: single- and double-stranded DNA, stabilizing forces, supercoiling
– analysis of DNA: sequencing, restriction analysis, PCR amplification, hybridization
– DNA replication, mutation, repair, degradation, and inactivation
– gene structure and organization; chromosomes; centromere, telomere
– recombination, insertion sequences, transposons
– mechanisms of genetic exchange, including transformation, transduction, conjugation, crossover,
recombination, linkage
– plasmids and bacteriophages
• gene expression: transcription, including defects
– transcription of DNA into RNA, enzymatic reactions, RNA, RNA degradation
– regulation: cis-regulatory elements, transcription factors, enhancers, promoters, silencers, repressants,
splicing
• gene expression: translation, including defects
– the genetic code
– structure and function of tRNA
– structure and function of ribosomes
– protein synthesis
– regulation of translation
– post-translational modifications, including phosphorylation, addition of CHO units
– protein degradation
• structure and function of proteins
– principles of protein structure and folding
– enzymes: kinetics, reaction mechanisms
– structural and regulatory proteins: ligand binding, self-assembly
– regulatory properties
• energy metabolism, including metabolic sequences and regulation
– generation of energy from carbohydrates, fatty acids, and essential amino acids; glycolysis, pentose
phosphate pathway, tricarboxylic acid cycle, ketogenesis, electron transport and oxidative phosphorylation,
glycogenolysis
– storage of energy: gluconeogenesis, glycogenesis, fatty acid and triglyceride synthesis
– thermodynamics: free energy, chemical equilibria and group transfer potential, energetics of ATP and
other high-energy compounds
• metabolic pathways of small molecules and associated diseases
– biosynthesis and degradation of amino acids (eg, homocystinuria, maple syrup urine disease)
– biosynthesis and degradation of purine and pyrimidine nucleotides
– biosynthesis and degradation of lipids (eg, dyslipidemias, carnitine deficiency, adrenogenital
syndromes)
– biosynthesis and degradation of porphyrins
– galactosemia and other small sugar disorders
– biosynthesis and degradation of alcohols and other small molecules
• biosynthesis and degradation of other macromolecules and associated abnormalities, complex
carbohydrates (eg, lysosomal storage disease), glycoproteins, and proteoglycans (eg, type II glycogen storage
disease)
A 32-year-old woman with type 1 diabetes
mellitus has had progressive renal failure over the
past 2 years. She has not yet started dialysis.
Examination shows no abnormalities. Her
hemoglobin concentration is 9 g/dL, hematocrit is
28%, and mean corpuscular volume is 94 μm3. A
blood smear shows normochromic, normocytic
cells. Which of the following is the most likely
cause?
(A) Acute blood loss
(B) Chronic lymphocytic leukemia
(C) Erythrocyte enzyme deficiency
(D) Erythropoietin deficiency
(E) Immunohemolysis
(F) Microangiopathic hemolysis
(G) Polycythemia vera
(H) Sickle cell disease
(I) Sideroblastic anemia
(J) β-Thalassemia trait
(Answer: D)
Partie1: Clinical Knowledge (CK)
Des QCM sur les connaissances cliniques, voici le programme :
Code
Step 2 CK Content Outline
TABLE OF CONTENTS
1. General Principles
Infancy and Childhood
Adolescence
Senescence
Medical Ethics and Jurisprudence
Applied Biostatistics and Clinical Epidemiology
Systems-Based Practice and Patient Safety
2. Infectious and Parasitic Diseases
3. Neoplasms
4. Immunologic Disorders
5. Diseases of the Blood and Blood-forming Organs
6. Mental Disorders
7. Diseases of the Nervous System and Special Senses
8. Cardiovascular Disorders11
9. Diseases of the Respiratory System
10. Nutritional and Digestive Disorders.
11. Gynecologic Disorders
12. Renal, Urinary, and Male Reproductive Systems
13. Disorders of Pregnancy, Childbirth, and the Puerperium.
14. Disorders of the Skin and Subcutaneous Tissues.
15. Diseases of the Musculoskeletal System and Connective Tissue
16. Endocrine and Metabolic Disorders
17. Congenital Anomalies
18. Conditions Originating in the Perinatal Period
19. Symptoms, Signs, and Ill-defined Conditions
20. Injury and Poisoning
1.A 23-year-old female nursing student is brought to the emergency room by her parents after being found unconscious at home. She is noted to have a fingerstick glucose of 29 mg/dL. After administration of intravenous D50, she rapidly regains consciousness. Her parents state that this is the fourth time in a month that this has occurred. She is not taking any medications. The medical history is unremarkable except for a history of depression and a mother with diabetes mellitus. Examination is unremarkable. During an observed period in the hospital, the patient is noted to have a symptomatic glucose level of 31 mg/dL. Plasma insulin levels are elevated, and C-peptide levels are low. Which of the following is the most likely cause of her hypoglycemia?
Choose the one best response to this question.
A. Glipizide overdose
B. Surreptitious insulin use
C. Insulinoma
D. Glucagonoma
E. Diabetic ketoacidosis
Answer:
The answer is B.
>>> Factitious hypoglycemia from self-administration of insulin or ingestion of a sulfonylurea shares clinical and laboratory features with insulinoma. The absence of an elevated C peptide distinguishes exogenous insulin use from insulinoma. An undetectable sulfonylurea level works against a diagnosis of sulfonylurea toxicity. Factitious hypoglycemia is more common in health care workers, patients with diabetes and their relatives, and patients with psychiatric histories
Choose the one best response to this question : 2.A physician is deciding whether to use a new test to screen for disease X in his practice. The prevalence of disease X is 5%. The sensitivity of the test is 85%, and the specificity is 75%. In a population of 1000, how many patients will be erroneously told they have diagnosis X on the basis of the results of this test?
A. 713
B. 505
C. 237
D. 42
E. 8
Diagnosis = Diagnostic
how many patients will be erroneously told they have diagnosis X = Quel est le nombre des faux positifs (traduction du sens et non pas des mots)
Answer: Ps: It should be noted that the medical terms used in this case are the following : TP = True Positive and FP = False Positive TN = True Negative and FN = False Negative
The answer is C.
>>> In evaluating the usefulness of a test, it is imperative to understand the clinical implications of the sensitivity and specificity of that test. By obtaining information about the prevalence of the disease in the population—the specificity and sensitivity—one can generate a two-by-two table, as shown below. This table is used to generate the total number of patients in each group of the population.
The sensitivity of the test is TP/(TP + FN). The specificity is TN/(TN + FP). In this case the table is filled in as follows:
Notez bien: A physician c'est un médecin, un physicien en anglais c'est "a physicist"
This time we will provide you with two MCQs (Multiple Choice Questions) at a time! You have to choose the single best response to these questions : Question 01: Why is this infant's cough getting worse? A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination, he is in moderate respiratory distress with nasal flaring, hyperexpansion of the chest, and easily audible wheezing without rales. Which of the following is the most likely diagnosis?
runny nose = rhinorrhea = un nez qui coule
sneezing = eternuement
coughing = toux
respiratory distress = destresse respiratoire
nasal flaring = elargissement des narines
chest = thorax
Question 02 : What's wrong with this baby? You are asked to evaluate an infant born vaginally three hours previously to a mother whose only pregnancy complication was poorly controlled gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxygen and order a stat portable chest radiograph, which is normal. Which of the following tests is most likely to confirm your diagnosis?
Answers: Answer 01
The answer is a, Bronchiolitis.
Of the choices given, bronchiolitis is the most likely, although asthma, pertussis, and bronchopneumonia can present similarly. The family history of upper respiratory infections, the previous upper respiratory illness in the patient, and signs of intrathoracic airway obstruction make the diagnosis of bronchiolitis more likely. Viral croup, epiglottitis, and diphtheria are not reasonable choices because there are no signs of extrathoracic airway obstruction.
The most likely cause of the illness is infection by respiratory syncytial virus, which causes outbreaks of bronchiolitis of varying severity, usually in the winter and spring. Other viruses, such as parainfluenza and the adenoviruses, have also been implicated in producing bronchiolitis. Treatment is generally supportive in this usually self-limited condition.
Supportive treatment = TRT symptomatique.
Answer 02 :
The answer is d, Chest ultrasound.
Infants born to mothers with gestational diabetes are at risk for being large for their gestational age and thus at increased risk for peripheral nerve injuries such as Erb-Duchenne and phrenic nerve paralysis. An ultrasound or fluoroscopy of the chest would reveal asymmetric diaphragmatic motion in a seesaw manner. With a negative chest radiograph, a chest CT would not be helpful at this point. Bronchoscopy would help delineate airway abnormalities and foreign bodies, but would not identify phrenic nerve paralysis
4. A 73-year-old female develops substernal chest pain, severe nausea, and vomiting while mowing the lawn. In the emergency department she has cool extremities, right arm and left arm blood pressure of 85/70 mmHg, heart rate of 65/min, clear lungs, and no murmurs. She has no urine output. A Swan-Ganz catheter is placed and reveals cardiac index of 1.1 L/min per m2, PA pressure of 20/14 mmHg, PCW pressure of 6 mmHg, and RA pressure of 24 mmHg. The patient most likely has:
A. gram-negative sepsis
B. occlusion of the left main coronary artery
C. occlusion of the right coronary artery
D. perforated duodenal ulcer
E. ruptured aortic aneurysm
PA pressure = Pulmonary Artery pressure
PCWP = Pulmonary Capillary Wedge Pressure = c'est la PCP ou la PAPO
RA pressure = Right Atrial pressure = pression de Oreillette Droite
Blood pressure = pression artérielle
Heart rate = pouls ( parfois ils parlent de "pulse" )
infarction = infarctus
Right ventricular failure = insuffisance ventriculaire droite
Answer: The answer is C.
This patient has a right ventricular infarction. The combination of findings consistent with bradycardia, cardiogenic shock, low normal left ventricular and PA pressures, and markedly elevated right atrial pressure is consistent with acute right ventricular (RV) failure. An acute pulmonary embolus may also cause acute RV failure, but the PA pressure is usually elevated. RV infarction is usually due to occlusion of the right coronary artery; the bradycardia is due to sinus or AV node ischemia. Right-sided precordial ECG will show ST-segment elevation. Occlusion of the left main artery will cause cardiogenic shock, but the PCW pressure will be elevated. Perforated duodenal ulcer and ruptured aortic aneurysm will cause hypovolemic shock with low RA and PCW pressures. Gram-negative sepsis will generally have an normal or increased cardiac index with normal filling pressures and low blood pressure
This time we've got 3 short and relatively easy questions :
As usual: Choose the best response for these questions :
Question 01 : What's Making this Girl's Mouth Droop?
Two weeks after a viral syndrome, a 9-year-old girl presents to your clinic with a complaint of several days of weakness of her mouth. In addition to the drooping of the left side of her mouth, you note that she is unable to completely shut her left eye. Her smile is asymmetric, but her examination is otherwise normal. Which of the following is the most likely diagnosis?
Cerebral vascular accident = AVC
Brainstem = Tronc cerebral
Bell palsy = Faites une petite recherche
Question 02 : An infant can move his head from side to side while following a moving object, can lift his head from a prone position 45° off the examining table, smiles when encouraged, and makes cooing sounds. He cannot maintain a seated position. Which of the following is the most likely age of the infant?
Question 03 : A child is brought to your clinic for a routine examination. She can dress with help, can ride a tricycle, knows her own age, and can speak in short sentences. She had difficulty in copying a square. Which of the following is the most likely age of this child?
a- 1 year
b- 2 years
c- 3 years
d- 4 years
e- 5 years
Answer to Question 01 :
The answer is e, Bell palsy.[1-3]
Bell palsy is an acute, unilateral facial nerve palsy that begins about 2 weeks after a viral infection. The exact pathophysiology is unknown, but it is thought to be immune or allergic. On the affected side, the upper and lower face are typically paretic, the mouth droops, and the patient cannot close the eye. Treatment consists of maintaining moisture to the affected eye (especially at night) to prevent keratitis. Complete, spontaneous resolution occurs in about 85% of cases, 10% of cases have mild residual disease, and about 5% of cases do not resolve. Occasionally infants will have a facial nerve palsy at birth; this is usually related to compression from forceps and spontaneously resolves over several weeks. As this is a compression neuropathy, it should not be called congenital Bell palsy.
Answer to Question 02 :
The answer is b, 3 months.[4-6]
By 8 weeks of age, infants who are developing normally should be able to smile and coo when smiled at or talked to. By 3 months of age, infants should be able to follow a moving toy not only from side to side but also in the vertical plane. When placed on his or her abdomen, a normal 3-month-old infant can raise his or her face 45° to 90° from the horizontal. Not until 6 to 8 months of age should an infant be able to maintain a seated position.
Answer to Question 03 :
The answer is c, 3 years.[4,5,7]
By 3 years of age, children become quite skilled in many areas. Most can say many words and speak in sentences. They can help dress and undress themselves, with the exception of shoelaces and sometimes buttons. They can ride a tricycle and can alternate feet when climbing stairs, although they still place both feet on each step when going down stairs. They can identify at least one color by name, know their age and gender, but have not progressed beyond copying a circle and a crude cross. Only at 4 to 5 years of age can a child copy a square.
Why is this patient fainting?
Choose the one best response to this question.
A 78-year-old male presents to the clinic complaining that every time he shaves with a straight razor, he passes out. His symptoms have been occurring for the last 2 months. Occasionally, when he puts on a tight collar, he passes out as well. The loss of consciousness is brief, he has no associated prodrome, and he feels well afterward. His past medical history is notable for hypertension and hypercholesterolemia. His only medication is hydrochlorothiazide. On physical exam his vital signs are normal, and his cardiac exam is normal with the exception of a fourth heart sound. Which of the following is the most appropriate next diagnostic test?
A. Stress echocardiography
B. Adenosine thallium scan
C. Computed tomogram of the neck
D. Carotid sinus massage
E. Tilt table test
Fourth heart sound = B4 (4ème bruit)
Answer:
The answer is D.
>>> The patient presents with carotid hypersensitivity syndrome in which pressure on the carotid sinus baroreceptors results in activation of the sympathetic nervous system with subsequent bradycardia caused by sinus arrest or atrioventricular block, vasodilation, or both. Generally, men older than 50 are at risk for this condition, and it classically presents with syncope in the setting of shaving, wearing a tight collar, or turning the head to one side. Diagnosis is suggested by carotid sinus massage with prolonged (more than 3 s) asystole.
Choose the one best response to this question, the answer is easy but the details are quite interesting..
All the following are features of lipoprotein lipase deficiency except:
A. low levels of plasma chylomicrons
B. acute pancreatitis
C. hepatosplenomegaly
D. xanthomas
E. autosomal recessive inheritance
The answer is A.
Lipoprotein lipase (LPL) and its cofactor apo CII are required for the hydrolysis of triglycerides in chylomicrons and very low density lipoproteins (VLDLs). A genetic deficiency of either protein impairs lipolysis and results in an elevation in plasma chylomicrons. VLDL is also elevated. The triglyceride-rich proteins persist for days in the circulation, causing fasting levels higher than 1000 mg/dL. The inheritance pattern is autosomal recessive. Heterozygotes have normal or mildly elevated plasma triglyceride levels. Clinically, these patients may have repeated episodes of pancreatitis secondary to hypertriglyceridemia. Eruptive xanthomas may appear on the back, the buttocks, and the extensor surfaces of the arms and legs.
Hepatosplenomegaly may result from the uptake of circulating chylomicrons by the reticuloendothelial cells. The diagnosis is made by assaying triglyceride lipolytic activity in plasma. Dietary fat restriction is the treatment of choice.
Choose the one best response to this question.
A 28-year-old female complains of chronic diarrhea. After a lengthy history and a negative physical examination, you suspect surreptitious laxative abuse. Which of the following tests would be most consistent with this hypothesis?
A. Elevated stool osmotic gap
B. Fecal leukocytes on stool examination
C. Excess stool fat
D. Charcot-Leyden crystals on stool examination
E. Inflammatory cells on small bowel biopsy
Stool = les selles
Bowel = intestins
The answeris A.
>>> Chronic diarrhea (lasting more than 4 weeks) may be due to a host of causes, including medications [especially habitual use of laxatives, which may be stimulant (senna, castor oil) or osmotic (e.g., Mg-containing) in nature], enterocolic fistulas, hormones (from certain endocrine tumors, such as carcinoid, VIPoma, and medullary carcinoma of the thyroid), carbohydrate malabsorption (e.g., lactase deficiency, which leads to a low stool pH), fat malabsorption, pancreatic exocrine insufficiency, mucosal malabsorption (e.g., celiac sprue, seen on small-bowel biopsy), or IBD. Diarrhea can result from invasion of the small bowel with lymphoma cells or eosinophils in which the Charcot-Leyden crystals from extruded eosinophils may be seen. If inflammation or infection is the cause, fecal leukocytes will usually be found. Laxative use is consistent with an osmotic gap: 2([Na] + [K]) <290 mosmol/kg. However, certain anionic laxatives containing sulfates or phosphates produce diarrhea without an osmotic gap, since sodium secretion occurs in response. In these cases direct measurement of the laxative in the stool is required to confirm the suspicion of laxative abuse.
IBD = Inflammatory Bowel Disease = MICI (Maladie Inflammatoire Chronique de l'Intestin)
Choose the one best response to this question.
All the following therapies have been shown to reduce the risk of hip fractures in postmenopausal women with osteoporosis except :
A. alendronate
B. estrogen
C. parathyroid hormone
D. raloxifene
E. risedronate
F. vitamin D plus calcium
The answer is D.
>>> The selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene act in a fashion similar to that of estrogen in decreasing bone turnover and bone loss in postmenopausal women. These agents have been shown to decrease the risk of invasive breast cancer. Raloxifene, which is approved for the prevention of osteoporosis, reduces the risk of vertebral fractures by 30 to 50%. There are no data confirming a similar effect on nonvertebral fractures. Optimal calcium intake reduces bone loss and suppresses bone turnover. Vitamin D plus calcium supplements have been shown to reduce the risk of hip fractures by 20 to 30%. The bisphosphonates alendronate and risedronate are structurally related to pyrophosphate and are incorporated into bone matrix. They reduce the number of osteoclasts and impair the function of those already present. Both have been shown to reduce the risk of vertebral and hip fractures by 40 to 50%. One trial found that risedronate reduced hip fractures in osteoporotic women in their seventies but not in older women without osteoporosis. Risedronate may be administered weekly. The newer bisphosphonates zoledronate and ibandronate may be dosed yearly or monthly. A daily injection of exogenous parathyroid hormone analogue superimposed on estrogen therapy produced increases in bone mass and decreased vertebral and nonvertebral fractures by 45 to 65%. There are no published studies of combinations of parathyroid hormone and SERMs or bisphosphonates.
A 55-year-old white male with a history of diabetes presents to your office with complaints of generalized weakness, weight loss, nonspecific diffuse abdominal pain, and erectile dysfunction. The examination is significant for hepatomegaly without tenderness, testicular atrophy, and gynecomastia. Skin examination shows a diffuse slate-gray hue slightly more pronounced on the face and neck. Joint examination shows mild swelling of the second and third metacarpophalangeal joints on the right hand. What is the recommended test for diagnosis?
A. Serum ferritin
B. Serum iron studies, including transferrin saturation
C. Urinary iron quantification in 24-h collection
D. Genetic screen for HFE gene mutation (C282Y and H63D)
E. Liver biopsy
weight loss = perte de poids
hepatomegaly without tenderness = HPM non douloureuse
hue = coloration
Joint examination = l'examen des articulations
swelling = tumefaction
liver biopsy = biopsie du foie
The answer is D.
>>> Hemochromatosis is a common disorder of iron storage in which inappropriate increases in intestinal iron absorption result in excessive deposition in multiple organs but predominantly in the liver.
There are two forms: (1) hereditary hemochromatosis, in which the majority of cases are associated with mutations of the HFE gene, and (2) secondary iron overload, which usually is associated with iron-loading anemias such as thalassemia and sideroblastic anemia.
Serum ferritin testing and plasma iron studies can be very suggestive of the diagnosis, with the ferritin often >500 g/L and transferrin saturation of 50 to 100%. However, these tests are not conclusive, and further testing is still required for the diagnosis.
Although liver biopsy and evaluation for iron deposition or a hepatic iron index > 2 is the definitive diagnosis, genetic testing is widely available today, and because of the high prevalence of HFE gene mutations associated with hereditary hemochromatosis, it is recommended for diagnostic evaluation. If the genetic testing is inconclusive, the invasive liver biopsy evaluation may be indicated
The parents of a 2-month-old boy are concerned about his risk of coronary artery disease because of the recent death of his 40-year-old maternal uncle from a myocardial infarction. Which of the following is the most appropriate management in this situation?
a- Screen the parents for total cholesterol
b- Counsel the parents regarding appropriate dietary practices for a 2-month-old infant and test him for total cholesterol at 6 months of age
c- Reduce the infant's dietary fat to less than 30% of his calories by giving him skim milk
d- Initiate lipid-lowering agents
e- Recommend yearly ECGs for the patient
The answer is a, Screen the parents for total cholesterol.[1-2]
>>> Identification of those with a genetic predisposition to hypercholesterolemia and of the factors that increase the risk of the condition is recommended so that dietary and other measures to reduce serum lipids can be introduced if indicated. Children with a first- or second-degree relative with early onset of coronary heart disease should be evaluated early in life but after 2 years of age. Other known risk factors include obesity, diabetes, hypertension, and smoking. No change in current infant dietary practice is recommended for children under 2 years of age. The high total fat content of the infant diet is considered to be biologically sound, given the need for lipid for a developing nervous system and the infant's limited capacity for an intake of high volume during this period of rapid growth. It is generally agreed that a dietary fat intake of 40% of calories is excessive over the age of 2 years. There is, however, concern about the potential loss of minerals such as iron, zinc, and calcium when dietary fat is reduced below 30% of calories in children 2 to 18 years of age. Principal sources of fat in the American diet are meat and milk, which are also sources of minerals such as iron and calcium. Simple modifications in the current U.S. diet of children of these ages (trimming excess fat from meat and drinking 1% fat milk) would effect a reduction of fat intake by 5% of calories without the risk of lowering mineral intake. It would be helpful in this situation to determine whether the uncle had hypercholesterolemia. Yearly ECGs and lipid-lowering agents are not indicated in this situation.
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