module nutrients uptake and metabolismjulivan/pbl - ii and iii year/nutrient uptake/nutrient...in...

Study Programme Medicine

MODULE Nutrients uptake and metabolism

Second year Spring semester

Faculty of Medicine LUHS

2014-2015

1. General information

Prior your studies of this and other modules you have to get acquainted with the main

document of study process at LUHS. This is The Regulation of Studies issued on June20, 2014

by LUHS Senate order Nr. 47-05. The booklet of the module is also available on www.personalas.ktu.lt/~julivan/PBL-II and III

year. On this web site you can also find information related with the module.

The main source of flexible information is provided by module organizers and contributors at

Intranet of LUHS – FC.

Supervisor of the module: prof. L.Ivanovienė ([email protected])

Coordinator of the module: prof. R. Morkūnienė ([email protected])

Departments

Institute of Human anatomy

Environmental and occupational medicine

Biochemistry

Institute of Physiology and Pharmacology

Human Histology and Embryology

Pathological anatomy

Internal Diseases

Subjects and teachers in charge:

Human anatomy (assoc. prof. V. Gedrimas; 327238; dr. I.Saburkina, [email protected])

Biochemistry (prof. L.Ivanovienė, 327323, [email protected]; prof. V.Borutaite;

[email protected] )

Pharmacology (lecturer, dr. R. Jankūnas, 327242)

Physiology (lecturer I. Korotkich, 327285, [email protected])

Human Histology and Embryology (prof. A. Valančiūtė, 327210, [email protected], doc.

K.Lasiene ,327235, [email protected] )

Pathological physiology (dr.D.Akramienė, 327285)

http://www.personalas.ktu.lt/~julivan/PBL

mailto:[email protected]



Pathological anatomy (Identified in the progress of the module)

Environmental and occupational medicine (assoc. prof. D. Lukšienė, 327360, [email protected])

Essentials of medical diagnosis (doc. dr. E. Mašanauskienė, 306093)

2. General content of the module In the module „Nutrients uptake and metabolism“, students study fundamental subjects, which are

essential to understand and know pathogenesis mechanisms, morphological aspects of pathology and to

have notion about common death causes. Analyzing the problems of this module the students gain new

knowledge and apply it to the following domains:

• Anatomic and histological structure of digestive system

• Mechanisms of digestion and uptake of nutrients

• Regulation of metabolism

• Relationship between metabolism and tissue function

• Relationship between disorders of metabolism and pathological processes

• Metabolic disorder-caused changes of digestive system morphology, the most common death

causes

• Clinical evaluation of metabolic disorders

• Prevalence and social aspects of most frequent metabolic disorders.

3. Aim of the Module The student after have studied this module should know how to define, analyze, explain and relate

phenomena to the cases analyzed in the module. Attaining this aim, students must gain knowledge

about:

• Anatomic and histological structure, function and embryogenesis of the digestive system

• Mechanisms, regulation and disorders of nutrients digestion and uptake

• Changes in morphology of digestive system caused by diseases of digestive system, metabolic

disorders, endoinfections and pancreatitis; causes of death in aforementioned conditions.

• Bile secretion, origin of bile pigments, enterohepatic circulation

• Cholestasis: ethiopathogenesis and impact to human health

• Mechanisms, regulation and disorders of synthesis, storage and breakdown of reserve

compounds (lipids)

• Epidemiology, ethiopathogenesis and principles of obesity treatment

• Integration of carbohydrate, lipid and protein metabolism in cells; disorders of integration

• Blood lipid metabolism and disorders; molecular causes of disorders, laboratory and clinical

diagnostics, principles of treatment

• Ethiopathogenesis and molecular mechanisms of atherosclerotic lesions; principles of

diagnostics and treatment

• Synthesis and regulation of pancreatic hormone secreation; mechanism of insulin action, tissue

and whole organism responses to insuline; causes of insuline hyposecretion and hypofunction

• Regulation of glucose metabolism and blood glucose concentration, disorders of glucose uptake

in tissues; diabetes mellitus: diagnostics, multiple lesions of organs and tissues, changes in

metabolism and ketogenesis, principles of patient observation and treatment

• Metabolism of nitrogenous compounds and it‘s regulation. Importance of imbalance of

synthesis and degradation of nucleotides in pathogenesis. Excretion of final products of

nucleotide degradation.

• Role of liver in detoxification of toxic metabolites and in xenobiotic metabolism. Liver damage:

morphological aspects and influence on the physiological and biochemical function.

Relationship between liver damage and functions of other organs.

• Principles of pancreas and digestive system clinical investigation

4. Tutorials 4.1. Case 1. Yellow lady A 40-year-old woman was healthy. Suddenly she felt very strong pain in the bottom of the navel and

her back. The pain had been continuing for 12 hours. She called for a doctor. The patient complained

about acute pain below navel during the last two days. Color of her excrements was whitish, color of

urine was brown. The woman complained of itchy skin. Her skin and eyes obtained yellow color. The

patient was obese, had a slight fever.

During physical examination it was observed: during palpation woman felt pain in the area of

epigastrium and below right rib arch. The blood tests were performed: level of hemoglobin was normal;

concentration of total bilirubin 290 µmol/l (normal 17 µmol/l); concentration of conjugated bilirubin

150 µmol/l (normal 5 µmol/l); activity of blood amylase 800 U/l (normal 70-235 U/l); activity of blood

lipase 1000 U/l (normal 0-200 U/l).

What do these alterations indicate?

How did these alterations appear?

Do these symptoms and patient‘s complains match?

Concept of problem: Relationship between disorders of metabolism and formation of bile stones and

outcome of this process.

Clinical symptoms: pains of abdomen, jaundice

Aim

To study mechanisms of bile and pancreas juice secretion, the structure of bile and pancreas ducts,

origin of bile components, degradation mechanisms of hemoproteins as main precursors of bile

pigments, role of bile in digestion, causes and clinical outcomes of obstruction of bile ducts.

Learning objectives and contents

To complete an analysis of this problem the students must know:

• Anatomy of digestive system components (digestive tract, major digestive glands). Anatomic

structure of major digestive glands - pancreas and liver; anatomic structure and topography of

bile ducts and gall bladder, to be able to recognize preparations of these organs.

Subject – Anatomy

Institute of Anatomy

References:

Supplementary readings:

1. Gray‘s anatomy, 39 ed., Elsevier, Churchill - Lvingstone, 2005.

• Features of histology of digestive system and liver Subject – Human Histology and Embryology

Department of Histology and Embryology

References:

Jungeira LC. et al. Basic Histology, 2010, p.p.281 – 339 Langman’s Medical Embryology,2006,p.p.203-226


Moore Persaud. Before we are born, 2003,p.p.201 - 227

• Main classes of nutrients and their digestion in different parts of digestive tract

Subject – Biochemistry

Department of Biochemistry

References:

1. Mark’s Basic medical biochemistry 2nd edition, 2005, p. 3-24, 493-503, 583-586, 687-690.

2. Harper’s biochemistry 23 edition, 1993, p. 599-614.

3. J.W.Baynes, M.H.Dominiczak Medical Biochemistry. 4th ed. Saunders, 2014, p.111-125.

4. Lippincott's Illustrated Reviews: Biochemistry, 3 edition, 2005, p. 83-88, 171-178, 243-246.

• Transport of digestion products through intestinal mucosa. Composition and role of gastric

juice in degradation of nutrients.



References:

1. Mark’s Basic medical biochemistry 2nd edition, 2005, p. 503-510, 586-593, 690-691.

2. Harper’s biochemistry 23 edition, 1993, p. 609-610, 614-620.

3. Lippincott's Illustrated Reviews: Biochemistry, 3 edition, 2005, p. 86, 247. 4. 3. J.W.Baynes, M.H.Dominiczak Medical Biochemistry. 4th ed. Saunders, 2014, p.111-125.

• Composition and role of bile. Mechanisms and regulation of bile acid synthesis; mechanisms

of gallstones formation.



References:

1. Mark’s Basic medical biochemistry 2nd edition, 2005, p. 585-587, 627-631,


3. Lippincott's Illustrated Reviews: Biochemistry, 3 edition, 2005, p. 222-224.


• Regulation of the secretion of pancreatic juice and bile. Role of gastrointestinal hormones.

Subject – Physiology


References:

1. Ganong WF. Review of medical physiology. 23nd ed. New York: Lange Medical Books /

McGraw-Hill; 2010, p. 435-436, 443-449, 485-486.


2. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books /

McGraw-Hill; 2005, p. 482-488, 497-498, 503.

• Pathological physiology of digestion. Jaundice; etiology, types and changes of body functions.

Subject – Pathological Physiology


References: Copstead L. E., Banasik J. L. Pathophysiology, Elsevier Saunders. 2013. p. 756 – 759.

McCance K., Huether S. E. Pathophysiology, Elsevier Mosby. 2010. p. 1485-1487.

• Characteristics and catabolic pathway of hemoproteins



References:

1. Mark’s Basic medical biochemistry 2nd edition, 2005, p. 812-815.

2. Harper’s biochemistry 23 edition, 1993, p. 337-338, 345-346.

• Bilirubin formation pathways. Transport of bilirubin to liver and bile. Urobilin formation in

intestine; diagnostic importance of heme catabolites.



References:

1. Mark’s Basic medical biochemistry 2nd edition, 2005, p. 812-815.


3. Lippincott's Illustrated Reviews: Biochemistry, 3 edition, 2005, p. 280-283.


• To understand clinical investigation of gall bladder and bile ducts, to understand cholestasis.

Subject – Essentials of Medical Diagnostics

Clinic of Internal Diseases

References:

1. Epstein O, Perkin G.D., Cookson J. Clinical Examination edition 2008, 2012 p.186-221.

2. Kumar & Clark : Clinical Medicine, 2010, p.347- 419.

4.2. Case 2. Weak muscles.

The sixteen-year-old boy sought medical help for progressive muscle weakness. He experienced

painful muscle cramps on severe exercise but he could tolerate moderate exercise normally. The

exercise test was done and blood and urine was analysed biochemicaly. Results show, that severe

exercise was followed by dramatically elevated serum levels of lactate dehydrogenase, ceratine kinase

and aldolase. Myoglobinuria was also present. The blood glucose level was normal and could be

elevated by treatment with glucagon. Serum lactate concentration before exercise was 1,1 mM (normal

0,5-1,8 mM), after 5 min of severe exercise increased to 1,5 mM (normal 6,0-12,1 mM). It was decided

to do a muscle biopsy. The results of the biopsy analysis: the glycogen deposited in increased amounts

had a normal structure, concentration of glucose-6-phosphate was increased and fructose-1,6-phosphate

was decreased if compare to normal values.

What is the significance of his serum enzyme levels and the myoglobinuria after severe exercise test?

Why is there an increased deposition of muscle glycogen?

Why is patient able to tolerate moderate, but not severe, exercise?

What do the results of treating patient with glucagon indicate about his condition?

Concept of the problem. The supply of energy during muscle contraction

Clinical symptoms. Muscle cramps, myoglobinuria, intolerance of severe exercise

Aim To understand the main mechanisms of nutrients utilization and storage in muscle cells, the

principles of energy metabolism regulation, to relate processes of energy formation and transmission to

muscle contraction-relaxation, to evaluate the state of muscle and to interpret biochemical analysis data

for characterisation of pathological process.

Learning objectives and contents:

To complete an analysis of this problem the student must know:

• Histological features of digestive system implicated in digestion of carbohydrates

Subject – Histology


References:

Jungeira LC. et al. Basic Histology, 2010, p.p.281 – 339

Langman’s Medical Embryology,2006,p.p.203-226

• Principles, regulation, energy yield and biological importance of degradation of carbohydrates

(the main muscle energy substrate) in a cell under metabolism in anaerobic and aerobic

conditions


Unit - Department of Biochemistry

References:

1. CM Smith, A Marks, MA Lieberman. Marks' Basic Medical Biochemistry. A Clinical Approach. 2d

ed. Lippinkott Williams&Wilkins, 2005, p. 337-339, 341-358, 360-378, 380-389, 390-395, 399-416.

2. PC Champe, RA Harvey, DR Ferrier. Lippincott's Illustrated Reviews: Biochemistry. Ed.3. 2005, p.

69-114.

3. R.K.Muray, D.K. Granner, P.A. Mayes, V.W.Rodwell. Harper’s Biochemistry. 24th ed. A lange

medical book. Prentice-Hall International. 1996, p. 119-130, 164-171, 172-180.



1. Devlin M.D. Textbook of Biochemistry with Clinical Correlations. Wiley-liss, 6th ed., 2006.

• Structure of carbohydrates glycogen and glucose, principles, regulation and biological

importance of synthesis of glycogen and glucose



References:


ed. Lippinkott Williams&Wilkins, 2005, p. 58-63, 511-525, 556-577.


83-85, 115-134.


medical book. Prentice-Hall International. 1996, p. 131-141, 181-189, 190-200.



• To relate processes of energy formation and transmission to muscle contraction-relaxation



References:


ed. Lippinkott Williams&Wilkins, 2005, p. 862-876


323-324


medical book. Prentice-Hall International. 1996, p. 647-664.



• Repeat! Muscle contraction physiology from the module Locomotion.

4.3. Case 3. Obesity

A 48 years old man for several years has been willing to slim down. He was consulted by many

therapists, and various diets were recommended for him. Unfortunately nothing helped out. And

several days ago he decided to start starving and to get rid of several kilos. Therefore he consulted to

his doctor about the new diet, which lacks carbohydrates but is rich in fat.

It has turned out that this man has been having overweight since he was 15 or 16 years old. As he grew

up he always had not less than 100 kilograms. His father and his brother were also obese. At the

moment this man weighs 108 kilograms, and is 178 cm tall. The majority of fat are allocated in the

belly area. The concentration of blood glucose is at the normal level.

What mechanisms are responsible for the overweight of this man?

Is it an important problem?

What could you propose for this man?

Concept of the problem: the mechanisms of reserved fat accumulation and use.

Clinical symptoms: overweight

Aim

To investigate the structural features and transport, the mechanisms of accumulation and

assimilation of lipids and their components in tissues.

Learning objectives and contents By the time the students have solved this problem they will have been showing knowledge on or

known the following:

• The mechanisms of hydrolysis and synthesis of depot fats, and the regulation of these processes.



References:

1. Harper‘s Biochemistry, 23rd edition. R.K. Murray, D.K. Granner, P.A. Mayes, V.W. Rodwell.

Appleton and Lange, Norwalk, Connecticut, 1993, p. 142-153, 241-265.


• The biosynthesis of fatty acids in human body.



References:

1. Harper‘s Biochemistry, 23rd edition. R.K. Murray, D.K. Granner, P.A. Mayes, V.W. Rodwell.

Appleton and Lange, Norwalk, Connecticut, 1993, p. 212-219.


• The mechanisms of obesity resulting in the disproportion of accumulation and hydrolysis of fats

and the body-mass regulation principals.



References:

Harper‘s Biochemistry, 23 edition. R.K. Murray, D.K. Granner, P.A. Mayes, V.W. Rodwell.

Appleton and Lange, Norwalk, Connecticut, 1993, p. 258-260, 603.

Additional readings:

1. Lippincott‘s Illustrated Reviews: Biochemistry, 3rd edition. P.C. Champe, R.A. Harvey, D.R.

Ferrier. Lippincott Williams and Wilkins, 2005, p. 347-370.

2. Marks‘ Basic Medical Biochemistry: A Clinical Approach, 2nd edition. C. Smith, A.D.

Marks, M. Lieberman, 2005.

• Causes, morphology aspects and the most common death causes of obesity

Subject – Pathological Anatomy

Subdivision - Clinic of Pathological Anatomy

References:

I.L. Robbins and R.S. Cotran. Pathologic basis of disease, 7th ed., 2005, p. 461-465, 1207-1209.

• Clinical evaluation of obesity

Subject – Essentials of Medical Diagnosis

Subdivision – Clinic of Internal Diseases

References:

1. Lynn S. Bickley. Guide to physical examination and history taking. Lippincott Williams and

Wilkins, 2007, p. 90-96.

2. Parveen Kumar and Michael Clark. Clinical medicine. W.B. Saunders Company, 2005, p.

229-264.

• Prevention of obesity and evaluation of dietary on a caloric basis

Subject – Environmental and Occupational Medicine

Subdivision – Department of Environmental and Occupational Medicine

References:

1. Ustinavičienė R, Lukšienė DI. Human nutrition: [electronic book]. Kaunas: Lithuanian University

of Health Sciences, Lithuanian Academic e. library (eLABa), 20130522 , 2012. 65 p.

2. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev. 2007;29:1-5.

• Histological features of white and brown adipose tissue.

Subject - Histology

Subdivision – Department of Histology and embriology

4.4. Case 4. Worried about heart attack

A 38-year-old self-employer businessman, Brian C., went to his physician concerned about his

health. His business was doing badly and he was working long hours. He ate irregularly, smoked

heavily and drank substantial quantities of alcohol. He had notices a number of raised areas

(xanthomata) on his hands and legs. His doctor found by questioning that some members of his

family had died relatively young from heart attacks. Patient’s blood was taken and biochemical

analysis was performed. A fasting blood sample was assayed for plasma lipids (table 1).

Table 1. Plasma lipid analysis

The cholesterol content of each of the main plasma lipoproteins was detected in laboratory and

presented in the table 2.

Table 2. Cholesterol analysis of plasma electrophoretic components in mM

Fibroblasts were cultured from Brian’s skin. The ability to bind radiolabeled LDL was compared with

that of control fibroblasts (figure 2). After incubation with LDL their 3-hydroxy-3methylglutaryl-CoA

(HMG-CoA) reductase activity was also measured (figure 2).

Brian was given general advice about his life-style and put on a course of oral cholestyramide (a

synthetic anion-exchange compound which is not absorbed from the gut) and lovastatin (a competitive

inhibitor of HMG-CoA reductase). Four months later, his fasting plasma cholesterol has fallen by 30%.

Lipid Patient Normal TAG (mM) 1.7 0.6-3.2 Cholesterol (mM) 9.5 3.7-6.8

Subject β Pre-β α Normal 3.18 0.41 1.37 Patient 7.70 0.70 1.14

Figure 2. Effects of LDL concentration on binding of radiolabelled LDL to cultured fibroblasts

(a) and on the activity of HMG-CoA reductase (b).

Questions:

What is the origin of raised areas around muscle-tendon?

What is the rational for determination of blood lipids and lipoproteins?

How is the atheromatous plaque thought to arise?

If you had been Brian’s doctor what recommendations would you have made concerning his life-style?

Patient has a brother, a sister and a teenage son. Is it worth to examine them and how?

Concept of the problem: hypercholesterolemia and its consequences. Clinical symptoms: xanthomata on shin near Achil’s tendon. Aim:

To understand metabolism of cholesterol, the role of hypercholesterolemia in development of

atherosclerosis; to know molecular mechanisms of atherosclerotic injury to blood vessels.

Learning objectives and contents

At the end students must know:

• The role of cholesterol in human organism, biochemical pathways of its synthesis and

excretion.



References:

1. R.K. Murray, D.K. Granner, P.A. Mayes, V.W. Rodwell. Harper‘s Biochemistry, 23 ed., Appleton

and Lange, Norwalk, Connecticut, 1993, p. 271-276; 278

2. P.C. Champe, R.A. Harvey, D.R. Ferrier. Lippincott‘s Illustrated Reviews: Biochemistry, 3 ed.

Lippincott Williams and Wilkins, 2005, p. 217-222.


• Blood lipoproteins, their metabolism and role in the pathogenesis of atherosclerosis.

Biochemical analyses for evaluation of cholesterol metabolism, interpretation of the data of

such analyses.



References:


and Lange, Norwalk, Connecticut, 1993, p. 254-256, 276-278; 280-281.




• The role of hypercholesterolemia in the development of atherosclerosis and molecular

mechanisms of atherosclerotic injury to blood vessels.



References:

1. C. Smith, A.D. Marks, M. Lieberman. Mark‘s Basic Medical Biochemistry: A Clinical

Approach, 2 ed., 2005, p. 641-643.


• Metabolism of membrane phospholipids, possible damage to phospholipids and their

consequences.



References:

1. Harper‘s Biochemistry, 23 edition. R.K. Murray, D.K. Granner, P.A. Mayes, V.W. Rodwell.

Appleton and Lange, Norwalk, Connecticut, 1993, p. 245-251.




• Risk factors and development of atherosclerosis


Clinic of Pathological Anatomy

References:

I.L. Robbins and R.S. Cotran. Pathologic basis of disease, 7th ed., 2005, p. 516-524.

• Classification and mechanisms of action of antihyperlipidemic medicines, changes in plasma

lipoprotein levels, related theraputic effects and benefit-risk ratio.

Subject: Pharmacology

Unit: Institute of Physiology and Pharmacology

References:

1. Mysek MJ, Harvey RA, Champe PC. Lippincott‘s Illustrated Reviews: Pharmacology. 6th ed.

Philadelphia: Lippincott Williams & Wilkins; 2014.

2. Katzung BG. Basic and Clinical Pharmacology. 13th ed. Boston: McGraw-Hill; 2014.


Mutschler E, Geisslinger G, Kroemer HK, Ruth P., Shafer-Korting M. Arzneimittelwirkungen.

Lehrbuch der Pharmakologie und Toxikologie. 10 Aufl. Stuttgart; 2012.

4.5. Case 4. Persistent thirst

So far, a girl of 17 has been of good health. Today, however, she has visited her doctor because she had been

worrying about loosing weight despite of normal nutrition. Within 2 last months she has lost 5 kg of her body

weight. Now, she feels tired, has lost endurance (until recently she enjoyed walking), suffers of thirst constantly,

her mouth is dry and urination is frequent. During her medical examination, the doctor perceived a sharp odor of

girl’s breath. The doctor has sent specimens of the girl’s blood and urine for biochemical analysis. The analysis

of blood showed that glucose concentration was as high as 20 mmol/l (normal concentration is 3,3-5,5 mmol/l).

Glucose and ketone bodies were found in the urine.

How can you explain the presence of glucose and ketone bodies in girl’s urine?

Are these findings related to subjective sensations of this patient?

What additional examinations have to be performed to confirm diagnosis?

Concept of the problem: regulation of metabolism of carbohydrates, fats and proteins and

concequences of disturbances of this regulation.

Clinical symptoms: polydipsia, polyuria, hyperglycemia, ketonuria.

Aim

To understand principles of metabolism regulation by pancreatic hormones, ascertain concequences of

regulation disturbances on functioning of tissues and whole organism.

Learning objectives and contents For completion of the problem analysis, students should know:

• Features of external and internal structure of the pancreas as one of the biggest gland of

digestion, to define the pancreas as exocrine gland (characterisation of pancreatic duct system)

and as endocrine gland (know how to characterise pancreatic islets and their location in the

pancreas), know functions of the pancreas and other glands of digestion (liver), their agedependent

alterations.

Subject – Human anatomy


References:

1. Gray‘s anatomy, 39 ed., Elsevier, Churchill -Lvingstone, 2005, p. 179-180, 1231-1237.

• Histological structure of the pancreas; be able to recognise histological sections of the

pancreas, differentiate pancreatic islets and cell types.

Subject – Histology


References:

1. Jungeira L.C. et al. Basic Histology, 2005, p. 321 -339

• Principles of synthesis and secretion regulation of both insulin and glucagon.



References:


and Lange, Norwalk, Connecticut, 1993, p. 582-584; 585-586.; 595-596.


• Features of structure and molecular mechanisms of action of insulin and glucagon



References:


and Lange, Norwalk, Connecticut, 1993, p. 590-594.


• Regulation of metabolism of carbohydrates, fats and proteins by insulin.



References:




• Principles of diagnostics of diabetes mellitus; to have notion about complications of diabetes

mellitus and treatment.

Subject – Essentials of Medical Diagnostics


References:

1. Parveen Kumar and Michael Clark. Clinical medicine. W.B.Saunders Company, 2005, p. 1101-

1153.


1. Epstein P. et al. Clinical examination, 2003, p. 30-40.

• Mechanism of regulation of blood glucose concentration, biochemical markers of diabetes

mellitus, principles of glucose tolerance test and its interpretation.



References:




• Pathogenesis, morphology, complications and death causes in diabetes mellitus.



References:

I.L. Robbins and R.S. Cotran. Pathologic basis of disease, 7th ed., 2005, p. 1197-1201.

• Classification, pharmacological and clinical properties of antidiabetic agents.

Subject: Pharmacology


References:



2. Katzung BG. Basic and Clinical Pharmacology. 13th ed. Boston: McGraw-Hill; 2014. Supplementary readings:



• Abnormalities of carbohydrate metabolism, their etiology; etiology and pathogenesis of

diabetes mellitus.



References:

1. Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013. p. 816-826 2. Pathophysiology. The biologic basis for disease in adults and children; McCance K., Huether S. E.

Elsevier Mosby. 2010. p. 745 – 765.

4.6. Case 6. Dizziness A 55-year-old unemployed labourer man B.C., had been a heavy beer drinker for years and

was admitted to hospital after collapsing in the street. He was clearly unsteady on his feed, vomit,

confused and with strong smell of alcohol on his breach. His blood alcohol concentration was 78 mM.

Physical examination revealed tender enlargement of the liver. He complained on general loss of

appetite, fatigue, early-morning nausea and frequent gastrointestinal problems. Occasional vomiting of

blood had been reported and enlarged gastro-esophageal veins (verices) were detected.

His wife M.C., aged 42, also presented with gastrointestinal problems and frequent diarrhea.

She had been under considerable stress at work and admitted to concerns about her alcohol

consumption.

It was felt advisable to perform a set of liver function tests on both patients and the results are

shown in Table 1. The blood calcium and magnesium levels were low and man B.C. urinary urea

excretion was also low. In addition, his blood clotting time was found to be impaired.

Table 1. Biochemical tests of liver function Blood levels B.C. M.C. Normal range Total protein (g/l) Albumin (g/l) Total bilirubin (µM) Alkaline phosphatase (U/I) Alanin transaminase (U/I) Aspartate transaminase (U/I) γ-Glutamyl transferase (U/I)

68 31 58 725 35 42 790

77 39 15 339 94 177 463

60-84 35-50 3-15 100-300 5-35 10-40 7-45

What happens with alcohol in the liver?

What is significance of the biochemical test of liver function?

Which of the patient’s state is better and why?

Why alcoholism is not only medical but and social problem?

Concept of the problem: Disturbances of metabolism causes intoxication and after-effect of its

progression.

Clinical symptoms: confusion, unsteadying on his feed, nausea, vomiting, diarrhea, enlargement of the

liver, loss of appetite, fatigue

Aim To get knowledge’s about disturbances of metabolism, pathological and morphological alterations of

the liver and other organs in patients with alcoholism and psychosocial aspects of this problem.

Learning objectives and contents To complete an analysis of this problem the students must know:

To complete an analysis of this problem the students must know:

• Anatomy of the wall components of the digestive canal, structural and functional features.

Anatomic structure, topography and function of the liver; its intraorganic blood vessels.

Subject – Human Anatomy


References:

1. Gray‘s anatomy, 39 ed., Elsevier, Churchill -Lvingstone, 2005, p. 1213-1225

2. Atlases of anatomy

• Regulation and phases of gastric secretion. Role of gastrointestinal hormones.



References:

1. Ganong WF. Review of medical physiology. 23 ed. New York: Lange Medical Books / McGraw-

Hill; 2010, p. 431-435, 443-448.


Hill; 2005, p. 482-488, 491-495.

• Origin of gastointestinal motility. Motor functions of stomach and their regulation.



References:


Hill; 2010, p. 469-471, 473-475.


Hill; 2005, p. 480-482, 494-495.

• Functions of small and large intestine and their regulation. Role of enteric nervous system.

Mechanism of defecation.



References:


Hill. 2010, p. 448-449, 475-478.


Hill. 2005, p. 479, 504-511.

• Biochemical mechanisms of protein digestion. Mechanism of HCl synthesis in stomach.



References:

1. Murrey R.K., Granner D.K., Mayes P.A., Rodwell V.W. Harper‘s Biochemistry. 23nd ed.,

Appleton & Lange, 1993, p. 609- 621.

2. Champe P.C., Harvey R.A. Lippincott‘s illustrated reviews: Biochemistry 2nd ed, Lippincott-

Raven publishers, 1994, p. 229-233.

3. Smith C., Marks A.D., Lieberman M. Marks‘ Basic Medical Biochemistry: A Clinical

approach.2nd ed, Lippincot Williams & Wilkins, 2005, p. 687- 696.

4. J.W.Baynes, M.H.Dominiczak Medical Biochemistry. 4th ed. Saunders, 2014, p.122-125; 236-237.

• Liver failure, etiology, pathogenesis and changes of body functions. Portal hypertension.



References:

• 1. Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013. p. 756-767

• 2. Pathophysiology. The biologic basis for disease in adults and children; McCance K., Huether

S. E. Elsevier Mosby. 2010. p. 1482 - 1494.

• Etiology and pathogenesis of the alcoholism, morphological alterations of the pancreas, liver

and gastrointestinal canal and death causes in patients with this disease. Endoinfectional

processes of digestive canal and pancreatitis.



References:

1. I.L. Robbins and R.S. Cotran. Pathologic Basis of Disease, 7th ed., 2005, p. 421-424, 812-815,

816-819, 870-871..

• Metabolism of amino acids, detoxification of ammonia and subsequences of the disturbance of

this process.



References:

1. Murrey R.K., Granner D.K., Mayes P.A., Rodwell V.W. Harper‘s Biochemistry. 23nd ed., Appleton

& Lange, 1993, p. 287-352.

2. Champe P.C., Harvey R.A. Lippincott‘s illustrated reviews: Biochemistry 2nd ed, Lippincott-

Raven publishers, 1994, p. 229-268.

3. Smith C., Marks A.D., Lieberman M. Marks‘ Basic Medical Biochemistry: A Clinical

approach.2nd ed, Lippincot Williams & Wilkins, 2005, p. 683- 746.



Devlin MD. Textbook of Biochemistry with Clinical Correlations. Wiley-Liss; 6th ed., 2006, p. 743-

787.

• Role of the liver in detoxification processes, its molecular mechanisms.



References:

1. Gibson G.G., Skett P. Introduction to drug metabolism, 3 ed., Nelson Thornes publishers,

2001, p. 1-84.

2. Coleman M.D. Human drug metabolism. John Wiley & Sons, Ltd, 2005, p. 1-127.

3. J.W.Baynes, M.H.Dominiczak Medical Biochemistry. 4th ed. Saunders, 2014, p.395;398-404.


1. Devlin M.D. Textbook of biochemistry with clinical correlations. Wiley-Liss; 6th ed, 2006,

p. 414-432.

2. Marshal W.J., Bangert S.K. Clinical chemistry, 5th ed. Mosby, 2004, p. 85-103.

3. McPhee S.J., Lingappa V.R., Ganong W.F. Pathophysiology of disease; an introduction to

clinical medicine, 4th ed., Lange medical books/McGraw-Hill, 2003, p. 380-419.

• Clinical assessment, complications and treatment of the disturbances of the liver and

gastrointestinal canal.

Subject – Essentials of Medical Diagnostic


References:

1. Lynn S. Bickley .Guide to physical examination and history taking. Lippincott Williams and

Wilkins, 2007, p. 359-409.

2. Parveen Kumar and Michael Clark. Clinical medicine .W.B.Saunders Company, 2005, p. 265-

418.

• Psychosocial aspects of alcoholism

Subject – Environment Medicine

Department of Environment and Occupational Medicine

References:

1. Telksnienė R., Lukauskas A. Readings in healthy nutrition, 2002, Kaunas, p. 18-20.

2. Gurr M. Healthy lifestyles. Nutrition and physical activity. ILSI Press, 1998, p. 35-39.


http://www.who.int/topics/alcohol_drinking/en/

5. Lectures

5.1. Biochemical mechanisms of nutrients digestion. Regulation of digestion. (2 h) Department of Biochemistry

In charge – professor L. Ivanovienė

Description

Main classes of nutrients. Differences in their structure. Essential nutrients (essential fatty acids,

minerals, vitamins). Degradation of nutrients in mouth: role of salivary enzymes - α-amylase and

lysocime in digestion of carbohydrates. Degradation of nutrients in stomach: mechanism of formation

and action of hydrochloric acid, mechanism of action of proteolytic enzymes. Role of lingual and

gastric lipase in degradation of lipids in stomach. Digestion of nutrients in duodenum: specificity of

pancreatic enzymes. Role of bile acids in degradation of lipids. Mechanism of activation of pancreas

enzymes. Absorption of digestion products. Putrefaction.

5.2. Heme catabolism: relationship to formation of bile pigments. (2 h)


In charge – professor V.Borutaitė

Description

Characteristics of hemoproteins, their catabolic pathways. Pathways bilirubin formation. Transport of

bilirubin to liver and bile. Composition and function of bile. Synthesis of bile acids its regulation. Role

of cholesterol in metabolism of bile acids. Bile as main form of elimination of cholesterol. Formation

of urobilins in intestine. Jaundice.

5.3. Histologic structure of digestive system. (2 h) Department of Histology and Embriology

In charge – professor A.Valančiūtė

Description

Embryological origin and main developmental stages of special parts of digestive system. Histologic

structure of the oral cavity: lips, tongue, hard and soft palate, teeth, minor and major salivary glands.

Common and special points of structure of the digestive tube: esophagus, stomach, small and large

intestines. Major glands in digestive system: pancreas and liver. Microscopic structure of liver lobulae,

liver blood circulation, ultrastructure of hepatocytes, bile excretion. Structure of pancreas exocrine and

endocrine parts, secretion of hormones.

5.4. Pathological physiology of digestion. The disorders of liver functions (2 h.) Institute of Physiology and pharmaology (Pathological Physiology) In charge - lect. D. Akramienė Description Disorders of motor (vomiting, hiccup, eructation) and secretory (hyper- and hypiacidity) functions of

the stomach and consequences of stomach resection. Their etiology, pathogenesis, disorders of body

functions. Peptic ulcer disease, etiology, pathogenesis. Diarrhea and constipation, their etiology,

pathogenesis, disorders of organism functions. Liver failure, etiology, pathogenesis and changes of

body functions. Portal hypertension, etiology, pathogenesis, disorders of body functions. Jaundice,

etiology, pathogenesis, disorders of body functions.

5.5. The understanding of clinical analysis data for diagnosis of digestive system and liver diseases. (2 h) Clinic of Internal Diseases

In charge – lect. E .Mašanauskienė

Description

Examination of main symptoms of patients suffering from digestive system and liver diseases (pain,

nausea, vomit, waterbrash, disorder of swallow, distension, diarrhoea, constipation, haemorrhage, pain

in the right side, jaundice, itch). Analysis of digestive system and liver: analysis of faeces, H. Pylori

diagnosis, pH-metry, fibroesophagogastroduodenoscopy, endoscopic and echoscopic analysis, bilirubin

and liver enzymes tests. Syndromes: acute abdominal pain, GERL syndrome, syndromes of

haemorrhage, malabsorbtion. Understanding of liver cirrhosis and alcoholic liver diseases.

5.6. Gastrointestinal functions and their regulation (2h)


Responsible person – lect. I. Korotkich

Description

Swallowing. Nervous and humoral regulation of secretory and motor functions of the stomach.

Regulation of the secretion of pancreatic juice and bile. Regulation of functions of small and large

intestines. Defecation.

5.7. Metabolism of triacylglycerols and phospholipids. (2 h) Department of Biochemistry

Responsible persons – prof. L.Ivanovienė

Description

Mechanism of the synthesis of triacylglycerols: substrates, their origin, and the synthesis enzymes.

Mechanisms of the degradation of triacylglycerols (tissue lipolysis): enzymes and the ways of control.

Hormonal regulation of the degradation and synthesis of triacylglycerols. Connection between the

synthesis of phospholipids and triacylglycerols, and intercompetition. The synthesis of triacylglycerols

from phosphatidic acid. Compounds activating the synthesis of phospholipids. The biosynthesis of

sphingolipids. Plasmalogen – a platelet-activating factor. The consequences of defects in

phospholipids.

5.8. Disorders of carbohydrate metabolism: Hyperglycaemia and hypoglyceamia. Diabetes mellitus, its etiology, mechanisms of pathogenesis, changes of body functions. (2 h) Institute Physiology and Pharmacology (subject Pathological Physiology) In charge - lect. D. Akramienė Description: Causes of disturbances in carbohydrate metabolism. Hyperglycaemia and hypoglycemia; causes and

and pathogenesis. Etiology and pathogenesis of diabetes mellitus, changes in metabolism, its acute and

chronic complications.

5.9. Metabolism and transport of cholesterol. (2 h) Department – Biochemistry

In charge – prof. L.Ivanoviene

Description:

Cholesterol and products of its metabolism. Biosynthesis of cholesterol, its regulation. Isoprenoid

compounds. Formation of esters of cholesterol. Transport of cholesterol: from intestine, liver,

extrahepatic tissues. LDL and HDL metabolism. LDL receptors. Coefficient of atherogenecity. HDL.

Lecitin:cholesterol-acetiltransferase and apoD (cholesterol transport protein). Excretion of cholesterol.

Hypercholesterolemia, its causes.

5.10. Antidiabetic and antihyperlipidemic agents (2 hours) Unit: Institute of Physiology and Pharmacology

In charge: dr. R.Jankūnas

Description:

Insulin preparations: classification, pharmacodynamics, pharmacokinetics, indications for use, routes of

administration and adverse reactions. GLP-1 analogues: pharmacodynamics and adverse reactions. Oral

hypoglycemic agents (metformin, sulfonylureas, meglitinides, pioglitazone, alpha-glucosidase

inhibitors, DPP-4 inhibitors and SGLT-2 inhibitors): pharmacodynamics and adverse reactions.

Precautions to avoid hypoglycemia, warning signs and agents administered for its therapy. Role of

antihyperlipidemic agents in multifactor intervention strategy to reduce cardiovascular risk.

5.11. Regulation of metabolism by hormones of pancreas: molecular mechanism of

action and signs of insufficiency. (2 h)


In charge – professor L. Ivanovienė

Description

Regulation of secretion of glucagon and insulin. Mechanism of glucagon action: target cells,

transduction of glucagone signal to the cell, effects of glucagon on carbohydrate and lipid metabolism.

Cell targets of insulin. Receptors of insulin. Intracellular signal transduction pathway of insulin.

Mechanism of catabolic and anabolic insuline effects. Deficiency of insulin secretion and action.

Somatostatin and other peptides, which regulate pancreatic secretion.

5.12. Mechanisms of regulation of blood glucose concentration. (2 h)


In charge – prof. V.Borutaite

Description

Mechanisms of glucose uptake from blood to tissues: Insulin as an essential factor of glucose uptake

from blood. Role of glucagon in maintainance of stabile blood glucose concentration under short

periods of starvation, e.g. night-fast. Maintainance of constant blood glucose concentration under long-

lasting starvation. Glucocorticoids: synthesis and scretion, regulation of aforementioned precesses,

molecular mechanisms of glucocorticoid action. Hyper- and hypocorticism.

5.13. Diabetes mellitus, its pathogenesis and morphology, complications and death

causes. (2 h)

Clinic of Pathological anatomy

In charge – prof. R. Gailys and prof. V.Lesauskaitė

Description

Morphological changes of the pancreas. Classification of diabetes. Pathogenesis of diabetical macro-

and microangiopathies, localisation and outcomes of the most common alterations. The most common

complications and death causes in diabetes mellitus.

5.14. Notion of metabolic endocrine diseases. (2 h) Clinic of Internal diseases In charge – lect. E .Mašanauskienė Description Clinical examinations implicated in diagnosis of endocrine diseases that manifest as striking metabolic

abnormalities. Complains: weakness, obesity, thirst, polyphagia, plyuria. Clinical examinations:

anthropometry, glucose tolerance test, examination of glycemia. The main symptoms of diabetes

mellitus are revise as well as diagnostic criteria, complications, notion about treatment of diabetes

mellitus.

5.15. Amino acid metabolism. Ammonia detoxication. (2 h) Department of Biochemistry

In charge – professor V. Borutaitė

Description

Stages of amino acid catabolism. Types and main enzymes of amino acid deamination in human body.

Aminotransferases, diagnostic value of plasma aminotransferases. Transport of ammonia in the

circulation and detoxication of ammonia. Mechanism of urea synthesis and disorder consequences.

Amino acid decarboxylation. Biogenic amines. Detoxication of products of protein putrefaction in large

intestine. Metabolism of carbon skeletons of amino acids. Synthesis of creatinine, biological

importance. Regulation of amino acid metabolism. Parenteral nutrition. Amino acids – drugs.

5.16. Pathologic anatomy of alcoholism. General endoinfectional processes and

pacreatites. (2 h)


In charge – prof. R.Gailys, prof. V.Lesauskaitė

Description

General morphological manifestations of alcoholism, its complications and reasons of death.

Endoinfections of digestive tract and ulcer disease. Bellary stones and pancreatities.

5.17. Liver role in detoxification processes. Molecular mechanisms of the

biotransformation of xenobiotics and autobiotics. (2 h)


In charge – prof. L.Ivanovienė

Description

Liver role in the metabolism of carbohydrates, lipids and proteins. Liver role in detoxification of

xenobiotics and autobiotics. Metabolism of the xenobiotics in the liver: three phases of

biotransformation; role of cytochrome P450 in biotransformation; I phase biotransformation reactions –

oxidation, reduction, hydrolysis reactions; II phase reactions – conjugation with glucuronic acid,

sulphuric acid, acetic acid, thiosulphates, α-amino acids, glutathione, double conjugation; methylation.

Metabolism of alcohol (ethanol). Detoxification of protein decay products appeared in large intestine.

5.17. Pathologic anatomy of alcoholism. General endoinfectional processes and

pacreatites. (2 h)


In charge – prof. R.Gailys, prof. V.Lesauskaitė

Description

General morphological manifestations of alcoholism, its complications and reasons of death.

Endoinfections of digestive tract and ulcer disease. Bellary stones and pancreatities.

5. 18. Psychosocial aspects of alcoholism. (2h) Department of Environment and Occupational Medicine

Responsible person – Prof. R. Radišauskas

Description

Harm of alcoholism: influence on physical and mental efficiency – attention, thinking, orientation,

mobility of intracentral communication, sensomotoric rate of response and other alteration of

psychophysiological functions. Quality of work, productivity, industrial and home traumatism. Alcohol

and traffic causalities. Alcohol and psychosocial climate within the family. Alcohol, criminality and

suicide. Influence of alcohol on health (short accents): central nervous, analyzers, heart and vessels,

breeching, digestive, endocrine and other systems. Alcohol and cancer.

6. Practicals 6.1. Anatomic structure of major digestive glands. Intraorganic and extrahepatic

ducts of bile. Anatomy of gall bladder. Morphofunctional features of pancreas as

major digestive gland. (3 h)

Unit– Institute of Anatomy

In charge – associate professor V. Gedrimas

Aim: to learn in details anatomy of major digestive glands, macroanatomic and internal structure of

liver and pancreas, anatomic parts and location of gall bladder, peritonisation, vascularisation, bladder

duct and its connection to liver ducts, formation of common bile duct, variations of connection,

positioning of duct in ligament of duodenum in liver, connection to pancreas duct, anatomy of opening

of bile duct major duodenal papilla. To study in details structure, topography, vascularisation of

pancreas, to be able to define pancreas as gland of external secretion, to know its ducts and their

location including variations, connection to bile ducts, to define pancreas as endocrine gland: structure,

location and function of pancreas islets.

Objectives: to study external anatomy of liver. To better understand internal structure of liver, to

describe segments, lobules. To study anatomic museum preparations, which illustrate anatomic

structure, position, size, and visible parts of gall bladder duct, and to characterise pecularities of its

positioning, and their clinical anatomy, to understand anatomy of other extrahepatic bile ducts. To

revise anatomy of duodenum, to find longitudinal wrinkle by using sections of this organ, to find major

mammilla in it. To discuss flow of bile and pancreas juices by inserting a thin flexible probe into major

mammilla.

To be able to show anatomic parts, structural components, ducts of pancreas in anatomic preparations,

models, pictures and sets of internal organs, prepared for dissection. To understand location of pancreas

islets, describe vascularisation, frequent variations and anomalies of pancreas.

References: Gray‘s anatomy, 39 ed., Elsevier, Churchill-Lvingstone, 2005

6.2. Digestion of lipids. Effect of bile on pancreatic lipase activity. (3 h) Department of Biochemistry

In charge – prof.L.Ivanoviene; prof. R.Morkuniene; prof. V.Borutaite The aim:

To evaluate the effect of bile on digestion of dietary lipids

Objectives:

1. To investigate digestion of lipids by pancreas enzymes

2. To evaluate the effect of bile acids on digestion of lipids by pancreas enzymes

3. To discuss the molecular mechanism of effect of bile acids on digestion of lipids

References:

Nutrient uptake. Laboratory manual on biochemistry. FC

1. To get knowledge on liver cirrhosis and alcoholic liver diseases.

6.3. Structure of the wall of digestive tract (3 hr.). Department of Histology and Embryology In charge – prof. A.Valančiūtė

Aim

To know and to understand the general structure of digestive canal and the structural differences of its

separate parts.

Objectives. To comprehend the histological structure of different parts of the digestive canal, and the

importance of epithelial cells, glands of the wall of digestive canal, and smooth muscles in the process

of digestion and absorption of nutrients.

Acquired competence: To be able to distinguish under the microscope the following histological

preparations: oesophagus, cardia, fundus of the stomach, pylorus, duodenum, jejunum, ileum, large

intestine, vermiform appendix. It is acquired to recognize different structural elements in every

histological preparation and to explain the purpose of these structural elements. To acquire general

40

knowledge on the embryological origin of digestive system: the time of germ appearance and the

sources of development.

Questions:

1. General characterization of the histological structure of the digestive canal wall and the

structural differences of its separate parts. Structural features related to the function.

2. Types and role of the epithelial cells of digestive canal.

3. Glands in the wall of digestive canal.

4. Elements of the immune defence system in the wall of digestive canal.

In the esophagus preparation to be able to distinguish the main layers of oesophagus wall: mucous with

squamous stratified non keratinized epithelium, subepithelial connective tissue with the esophageal

cardiac glands near the stomach, submucous connective tissue with mucous glands and large vascular

net, muscular layer, nerve plexuses.

In the transition between esophagus and stomach preparation to be able to find the transition place from

esophagus into the stomach, to recognise all layers of the oesophagus wall, cardiac glands in the

esophagus and columnar gastric epithelial cells, epithelium covering the gastric mucous membrane and

its pits, the subepithelial layer of the cardia with the glands of the mucous membrane.

In the fundus of the stomach preparation to be able to distinguish all layers of the gastric mucous

membrane: mucous, submucous layer, muscular layer and seruos covering. In the subepithelial

connective tissue to recognise gastric(fundic) glands and four types of cells: mucocytes of the gland

neck; chief (zymogenic) cells; parietal cells, gastric endocrine cells.

In the pylorus preparation to distinguish mucous, submucous and muscular layers, serous covering and

pylorus glands.

In the duodenum preparation to distinguish the mucous membrane and villi, subepithelial connective

tissue, glands of the submucous layer, blood-vessels of the submucous layer and intramural nerve

ganglia in the muscular wall.

In the jejunum preparation to be able to recognise the structural differences between jejunum and

duodenum, to distinguish the mucous membrane, submucous, muscular and serous layers.

In the ileum preparation to recognise low and sparce villi and abundant grouped lymph nodes (Peyer’s

patches) in the intestine wall. To distinguish all layers of the ileum preparation.

In the large intestine preparation to distinguish all main layers of the wall: mucous membrane,

subepithelial mucous layer, muscular mucous layer, submucous layer, muscular layer and serous

covering.

In the vermiform appendix preparation to recognise mucous membrane, much thinner crypts, lymph

nodes.

References:

1. Jungeira LC. et al. Basic Histology, 2005, p. 287 -316

2. Langman’s Medical Embryology, 2001, p. 270-285

6.4. Clinical analysis of digestive system and liver. Syndromes of injury. (3 h)


In charge – lect. E .Mašanauskienė

Aim:

to analyse clinical data of digestive system and liver and syndromes of injury.

Objectives:

1. Clinical data analysis

2. Analysis of main clinical syndromes

Skills:

1. To interpret clinical analysis data for diagnosis of digestive system and liver diseases.

2. To understand main syndromes of digestive system and liver injury.

Questions analysed:

1. Complaints of the patients suffering from digestive system and liver diseases.

2. Clinical analysis of diagnosis of digestive system and liver diseases.

3. Main clinical syndromes: acute abdominal pain, dispeption, GERL, malabsorbtion,

haemorrhage, jaundice, portal hypertension, liver deficiency.

4. To get knowledge on liver cirrhosis and alcoholic liver diseases.

References:

1. Parveen Kumar and Michael Clark. Clinical medicine. W.B.Saunders Company, 2005, p. 347- 419.

Aim: to analyze clinical data of digestive system and liver and syndromes of injury.

6.5. Histological structure of oral cavity organs (3 hr.) Department of Histology and Embriology

In charge– prof. A.Valančiūtė

Aim: To analyse the histological structure of oral cavity, salivary glands and their ducts.

Objectives: To comprehend the importance of different parts of digestive system: teeth and salivary glands in the process of digestion and absorption of nutrients. Acquired competence: To be able to distinguish under the microscope the following histological preparations: a lip, parotid salivary gland, sublingual salivary gland, submaxillary salivary gland, teeth, tongue. Questions: Embryological origin of different parts of digestive system. Oral cavity and the structures

therein. General characterization of the histological structure of the digestive canal wall and the

structural differences of its separate parts. Structural features related to the function.

In the lip preparation to be able to recognize the skin area, transitional and mucous parts. In the skin

area to distinguish stratified squamous keratinized epithelium, hair roots, sabeceous and sweat glands,

and connective tissue with the blood-vessels. In the transitional part to distinguish the epidermic

granular and thin non keratinized layers, subepithelial connective tissue with high papillae and

capillaries imparting the reddish colour to the lips. In the mucous part to distinguish the stratified

squamous non keratinized (possessing lower papillae of the connective tissue) epithelium, mucous and

serous glands, striated muscles.

In the parotid salivary gland preparation to be able to recognize the parenchyma and stroma of the

glands, lobules, serous alveoli, secretory ducts, connective tissue.

In the sublingual salivary gland preparation to be able to recognize the mixed terminal parts of

secretory gland, acinus, predominant mucous cells and demilunes of serous cells within and in a

connective tissue – secretory ducts.

In the submaxillary salivary gland preparation to be able to recognize the serous (proteinaceous) and

mixed (mucoserous) alveoli of the glands, in the connective tissue between lobules – ducts and

bloodvessels.

In the tooth preparation to recognize the stages of the tooth development: Irst - bud , IInd – cap, and

IIIrd – belland crown stages of the development.

In the tongue preparation to recognize the foliate papillae covered by the stratified squamous non

keratinized epithelium, and the connective tissue papillae with the blood-vessels therein. In the lateral

surface of epithelium to recognize the taste buds. Also to recognize filiform papillae covered with

squamous stratified keratinized epithelium.

References:

Jungeira LC. et al. Basic Histology, 2005, p. 281 –286, 317 -321

6.6. Determination of creatinine in urine. Determination of carbamide (urea) in urine. (3 h)


In charge – prof.L.Ivanoviene; prof. R.Morkuniene; prof. V.Borutaite

Aims:

1. To quantify the daily amount of creatinine excreted with urine, to use data obtained to evaluate

functional state of skeletal muscle and kidney.

2. To determine the amount of carbamide in urine.

3. To be able to interpret data obtained and to evaluate the efficiency of processes of amonia

detoxification.

Objectives:

1. To learn how to determine the amount of creatinine in urea and to calculate daily amount of

excreated creatinine in urine.

2. To get knowledge on metabolism of creatine and creatinine and their biological significance.

3. To practice in interpretation of changes in creatine and creatinine concentrations and realation

to physiological and pathological processes.

4. To be able to evaluate changes in creatine and creatinine concentrations and in activity of

isoenzymes of creatine kinase in biological samples during pathological or physiological

processes.

5. To get knowledge on metabolic production of ammonia, its toxicity and ways of detoxification

in human organism.

6. To skill in determination of the main product of ammonia detoxification – carbamide in

biological fluids.

7. To be able to evaluate changes in carbamide concentrations in biological fluids during various

pathological processes.

References:


6.7. Structure and histophysiology of large digestive glands (3 h) Department of Histology and Embryology

In charge – prof. A.Valančiūtė

Aim:

To learn histological structure of the liver, ultrastructure of hepatocytes, system of blood supply to the

liver, histological structure of the exocrine part of pancreas and pancreatic ducts.

Objectives:

During studies of structure of liver and ultrastructure of hepatocytes, to understand bile secretion,

significance of blood circulation system, the role of phagocytic cells in immune response. To study

structure of exocrine part of pancreas, ultrastructure of secreting cells, histological structure of ducts of

the pancreas.

Skills:

Students will learn to distinguish histological preparations by microscope, to identify structural

elements in the histological preparations and to explain their significance.

Questions:

1. Structure of pancreas exocrine part, ducts, significance of exocrine part of pancreas for

digestion.

2. Histology of the liver and blood supply system.

3. Macrophagocytes in the liver and their significance.

In pancreas preparation to identify acini lined by conus-form cells – exocrinocytes of pancreas with

acidophylic apical parts (zymogen granules) and basophylic basal parts, septa of connective tissue with

capillaries, intercalated and intralobular ducts, islets of pancreas.

In human liver preparation to identify lobules of the liver, central vein of the lobule, portal spaces with

bile ducts, lymphatics nerves, blood vessels in the corners, plates of multi-angular hepatocytes,

sinusoidal capillaries between them.

In preparations of pig liver, to identify lobules surrounded by connective tissue between lobules, central

vein and plates of hepatocytes, bile ducts, arteries, veins and nerves in the corners of the lobule.

Gallbladder preparation – to distinguish layers of gallbladder wall: epithelial lining, folds of mucosa,

muscles and adventitia.

References: Jungeira LC. et al. Basic Histology, 2005, p. 321 -339

6.8. Clinical evaluation of obesity. Diabetes mellitus. Fundamentals of diagnostics,

complications, notion of treatment. (3 h)

Clinic of Internal diseases

In charge – lect. E .Mašanauskienė, prof. A.Naudžiūnas

Aim: To analyse clinical evaluation of obesity and principles of diabetes mellitus diagnosis; to have a notion

of diabetes mellitus complications and treatment

Objectives: to analyze types of obesity and clinical diagnostics; to know principles of diabetes mellitus

diagnostics; to have a notion of diabetes mellitus complications and treatment.

Skills gained:

1. To be able to rate normal body mass and obesity.

2. To know clinical and laboratory signs of diabetes mellitus.

Questions analysed

1. Causes of body mass gain and appetite.

2. Rates and types of obesity.

3. Estimation of normal body mass.

4. Clinical symptoms of obesity and notion of treatment.

5. Causes of diabetes mellitus.

6. Glucose tolerance test.

7. Diabetic and hypoglycemic coma.

8. Fundamentals of clinical and laboratory diagnostics of diabetes mellitus.

9. Notion of diabetes mellitus complications.

10. Notion of treatment of diabetes mellitus, diabetic and hypoglycemic coma.

References: Epstein P. et al. Clinical examination, 2003, p. 30-40.

6.9. Determination of cholesterol concentration in blood serem. Determination of

cholesterol, high density lipoproteins, low density lipoproteins and tiacylglycerols by

automatic analyzer Cardio-Check. ( 3 h)


In charge – prof.L.Ivanoviene; prof. R.Morkuniene; prof. V.Borutaite

Aim

To learn how to determine and to calculate cholesterol and its transfering lipoprotein concentrations in

human blood sereum as well as to interpret obtained results.

Objectives:

1. To determine concentration of cholesterol in human blood plasma by Ilck.

2. To calculate concentration of colesterol in both systemic and non-systemic units.

3. To determine concentrations of cholesterol, high density lipoproteins, low density lipoproteins

and triacelglycerols in blood serum by automatic analyzer.

4. To evaluate the reasults and to interpert them.

References: Nutrient uptake. Laboratory manual on biochemistry. FC

6.10. Pathological anatomy of diabetes mellitus and obesity. (3 h) Clinic of Pathological Anatomy In charge – prof. R. Gailys, prof. V. Lesauskaitė Aim: To identify macro and micro preparations with macro and micro angiopathies and to indicate possible causes of death; to study pathological anatomy of the obesity; solve morphologic diagnostic tasks. Nephroangiosclerosis diabetica histological slide (H+E ir PAS reaction). Pay attention to thick walls of the loops of glomerular capillaries. There are PAS positive deposits in the walls glomerular capillaries and the mesangium as well. Some glomeruli are atrophic and sclerotic, surrounded by connective tissue. References: 1. I.L. Robbins, R.S. Cotran. Pathologic basis of Disease, 7 th edition, 2005, p. 461-465, 1197- 1201, 1209 2. R. Butkus, J. Čeponis, R. Gailys, v. Lesauskaitė. Manual to laboratory practice in general and special pathological anatomy.

6.11. Antidiabetic agents (2 hours)


In charge: dr. R.Jankūnas

Aim: To gain basic knowledge on classification, pharmacological and clinical properties of antidiabetic agents.

Objectives:

1. Desribe and compare mechanisms of action and effects of antidiabetic agents on target

tissues/enzymes including pancreas, hepatocytes, muscles, adipose tissue, kidneys, SGLT-2, DPP-4

etc.

2. List and compare most important adverse reactions of antidiabetic agents.

3. Explain pharmacodynamic basis of most important adverse reactions of antidiabetic agents.

4. Desribe major risks of insulin therapy.

5. Explain relation of pharmacokinetic properties to timing of administration (dosage interval and

relation to meals) of insulin preparations.

6. Relate pharmacodynamic properties of antidiabetic agents to their use depending on the diabetes

type.

References:







6.12. Protein digestion. Effect of pepsin. Analysis of gastric juice. Patological components of gastric juice. (3h) Department of Biochemistry In charge – prof.L.Ivanoviene; prof. R.Morkuniene; prof. V.Borutaite Aim

To understand mechanism of protein digestion by pepsin.

Subjectives

1. Evaluate effect of hydrochloric acid on pepsin action.

2. Evaluate factors that arouse pepsin inactivation.

3. To know molecular mechanism of pepsin action. Perform quantitative analysis of gastric juice.

4. Calculate acidity of gastric juice.

5. Acquit with essential types of gastric juice and its clinical importance. Determine pathological

compounds of gastric juice.

References:


6.13. Alcoholism. Diseases and syndromes of digestive system. (3 h) Clinic of Pathological Anatomy In charge– prof. R. Gailys, prof. V. Lesauskaitė Aim: To help students to get theoretical knowledge’s and practical skills to evaluate morphology of alcohol-

induced injury of digestive canal, pancreas and liver, study pathology of the endoinfective processes.

Objectives:

To isolate preparation that illustrate morphology of alcoholism and preparations that illustrate colitis,

appendicitis, candidosis, bile stone disease and acute necrosis of pancreas and ulcer disease; dissolve

morphological diagnostic tasks.

Hepatocyte in case of alcoholism. Electron micrograph (x30 000). Pay attention and draw alcoholic

“hyaline” (Mallory bodies) within the cytoplasm of hepatocytes.

Alcoholismus: lipidosis hepatocytorum et cirrhosis hepatis. Histological slide (H+E). Pay attention to

fat hepatocytes and to the changed architecture of the liver, which is caused by the proliferation of

connective tissue and regenerating hepatocytes. Find out so called untrue liver lobules (pseudolobuli)

with proliferating small bile ducts and interstitial infiltration by immune cells.

References:

1. I.L. Robbins, R.S. Cotran. Pathologic basis of Disease, 7 th edition, 2005, p. 421-424, 812-819,

870-871, 928-933.

2. R. Butkus, J. Čeponis, R. Gailys, v. Lesauskaitė. Manual to laboratory practice in general and special

pathological anatomy.

6.14. Changes of plasma glucose level during diabetes mellitus Instutute of Physiology and Pharmacology Subject Pathological physiology

In charge– dr. D.Akramienė Objectives: 1. To understand the use of the terms insulin, Type I diabetes mellitus, Type II diabetes mellitus.

2. To understand how fasting plasma glucose levels are used to diagnose diabetes mellitus.

3. To understand the assay that is used to measure plasma glucose

Description: The simulatory laboratory work will be performed. You will develop a Glucose Standard Curve and

measure fasting plasma glucose levels in the blood samples from different patients.

Literature: Pathophysiology; Lee-Ellen C. Copstead and J.L. Banasik, 5th ed. Saunders Elsevier 2013. p. 816-826

7. Seminars 7.1. Features of structure of the digestive canal wall and liver (2 h) Institute of Anatomy In charge – associate professor V.Gedrimas, dr. I.Saburkina Aim: To know structure and localisation of the digestive canal parts such as mouth, fauces, oesophagus,

stomach, small and large intestine; to know structural principles of food stuff digestion and absorption

(structure of mucosa, features of blood and lymph circulation).

Objectives:

At the end of your independent studies (preparing for a seminar), using material of dissection and

preparations, under instructor supervision structures of parts of the digestive canal – mouth, fauces,

oesophagus, stomach, and gut wall (structure of mucosa, its folds, glands and etc.), collocation of

blood and lymph vessels under mucosa, muscular layers, process of peristalsis are ascertained.

Structures, implicated in absorption of components from mash moving along the digestive canal, and

their transfer by blood of portal vein into liver are being discussed. Hepatic porta, and their structures –

hepatic artery, portal vein, bile ducts are being demonstrated. Anatomy of intraorganic circulation as

well as collocation of portal vein, hepatic vein, bile duct and role of liver in utilization of absorbed

nutrients are ascertained.

References. 1. Gray‘s anatomy, 39 ed., Elsevier, Churchill - Lvingstone, 2005, p. 581-633, 986-990, 1143- 1157, 1139-1143. 2. Anatomy atlases 7.2. Obesity evaluation and prevention. Evaluation of diet caloric content. (2 h) Department of Environmental and Occupational Medicine In charge – assoc. prof. D. Lukšienė Aim: To get acquainted to principles of healthy nutrition and to distribution, epidemiology and prophylaxis

of obesity.

Objectives:

1. To analyse causes of obesity and to determine main principles of obesity prophylaxis.

2. To discuss distribution of obesity and its social-economical conditions.

3. To determine main principles of obesity prophylaxis.

4. To evaluate dietary caloric content and to compose dietary daily needs.

References: 1.Ustinavičienė R, Lukšienė DI. Human nutrition: [electronic book]. Kaunas: Lithuanian University of Health Sciences, Lithuanian Academic e. library (eLABa), 20130522 , 2012. 65 p. Supplementary readings:

1. http://www.who.int/nutrition/publications/obesity/en/index.html 2. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev. 2007;29:1-5.

7.3. Antihyperlipidemic agents (2 hours) Institute of Physiology and Pharmacology

In charge – dr. R. Jankūnas

Aims:

1. To consider the role of the antihyperlipidemic agents as multifactor intervention strategy to

reduce cardiovascular risk.

2. To describe the pharmacological and clinical properties of antihyperlipidemic agents.

Objectives:

1. List non-pharmacological interventions to correct hyperlipidemia.

2. Describe mechanism of action of statins; relate it to changes in plasma lipoprotein levels.

3. List and describe indications for use of statins.

4. List and describe major adverse reactions of statins.

5. Provide quantitavive estimation of benefit-risk ratio of statins.

6. Describe mechanism of action of bile acid-binding resins; relate it to changes in plasma

lipoprotein levels, indications for use and adverse reactions.

7. Describe mechanism of action of fibrates; relate it to to changes in plasma lipoprotein levels

and indications for use; list their adverse reactions.

8. Describe mechanism of action of niacin; relate it to changes in plasma lipoprotein levels; list its

adverse reactions.

9. Explain why niacin has not currently been used as anyihyperlipidemic agent.

References: 1. Mysek MJ, Harvey RA, Champe PC. Lippincott‘s Illustrated Reviews: Pharmacology. 6th ed.



3. http://www.ncbi.nlm.nih.gov/pubmed/

4. http://www.compendium.uk




. 7.4. Analysis of amino acid metabolism using metabolic pathways (2 h) Department of Biochemistry In charge – prof.L.Ivanoviene; prof. R.Morkuniene; prof. V.Borutaite Aim: To know amino acid and nucleotide metabolic pathways and understand possible subsequences of metabolism disturbances. Objectives: 1. To be able to characterize types of amino acid deamination, to relate changes in aminotransferase

(transferase) amounts in blood serum and pathents‘ clinical condition.

2. To be able to follow up amino groups transfer from amino acids to the ammonia ions and its

conversion to urea. To be able to describe sourcesof ammonia in the organism and mechanism of it’s

toxically action.

3. To get used in analyzing of metabolic pathways for identification of glucogenic amino acid and

ketogenic amino acids. To get ability evaluate production of energy during amino acid metabolism.

References: 1. http://www.sigmaaldrich.com/life-science/metabolomics/learning-center/metabolic-pathways.html 2. Murrey RK, Granner DK, Mayes PA, Rodwell VW. Harper‘s Biochemistry. 23nd ed., Appleton & Lange, 1993, p. 353-377. 3. Champe PC, Harvey RA. Lippincott‘s illustrated reviews: Biochemistry 2nd ed, Lippincott-Raven publichers, 1994, p. 243-356. 4. Smith C, Marks AD, Lieberman M. Marks‘ Basic Medical Biochemistry: A Clinical approach.2nd

ed, Lippincot Williams & Wilkins, 2005, p. 747- 780. Supplementary readings: 1. Devlin MD. Textbook of biochemistry with clinical correlations. Wiley-Liss; 6th ed, 2006, p. 743- 787.

8.Examination programme 8.1. Human anatomy

1. Connection between the structure and function of the intestine wall layers.

2. Classification of the salivary glands according their size, location in the body and salivary content.

The ducts of large salivary glands, and their release places in the mouth.

3. Structural and functional differences of the anatomical pharynx elements.

4. Structural components of the gastric mucous and submucous membranes, and their structural

relationship with the function of stomach.

5. Characterization of liver intraorganic blood circulatory system.

6. Structural and functional features of the bile ducts.

7. Structural components of the pancreas functioning as exocrine gland.

8.2. Physiology 1. Factors affecting secretion of hydrocloric acid in stomach. Machnisms of their action.

2. Phases of gastric juice secretion and their features.

3. Regulation of gastric motility and emptying. Vomiting.

4. Nervous and humoral regulation of the secretion of pancreatic juice and bile.

5. Regulation of functions of small and lage intestines. Defecation.

8.3. Human histology and embryology 1. Embryologic origin of the digestive system, main stages of development.

2. Histological structure of the teeth.

3. Embriological origin of the teeth and main stages of the development.

4. Histology of the oesophagus.

5. Similarities and differences of histological structure of small and large intestine. Types of epithelial cells in different parts of intestine.

6. Similarities and differences of histological structure of major salivary glands.

7. Histological structure of cardiac, fundic and pyloric parts of the stomach. Role of stomach fundic glands in digestive process.

8. Structure of clasical hepatic lobule. Blood circulation in the lobule. Ultrastructure of hepatocytes, secretion of bile.

9. Structure of exocrine and endocrine part of the pancreas.

10. Elements of organism‘s immune defense system in digestive system.

11. Glands in different parts of digestive tract and their role in digestive process.

12. Histological structure of the tongue.

13. Histological structure of the lips.

8.4. Pathological anatomy. This is a preliminary programme of exam on pathological anatomy course

1. Lipidosis, its kinds, causative factors, morphogenesis, morphology, outcome and signifficance. Lipidic tezaurismoses, local accumulation of cholesterol and cholesterol esters. 2. Pathological anatomy and complications of the obesity. 3. Disorders of bilirubin metabolism. Jaundice, its mechanisms of development. 4. Calculi (stones), its mechanisms of formation, localisation and morphology. Disorders of urates metabolism. 5. Cholelithiasis and cholecystitis, its morphology and complications. 6. Diabetes mellitus, its classification, pathogenesis, morphology, complications and causes of death. 7. Alcoholism, its pathogenesis, morphology, complications and causes of death. 8. Nonspecific immune responce, its morphogenesis, morphology, cursus, outcome and functional signifficance. 9. Pathogenesis, morphology and complications of appendicitis. 10. Pathogenesis, morphology and complications of peritonitis. 11. Pathogenesis, morphology and complications of ulcer disease. 12. Benign and malignant tumors of esophagus and stomach, its kind of growing, morphology, complications and causes of death. 13. Tumors of intestines, its morphology, complications and causes of death. 14. Tumors of liver, gallbladder, bile ducts and pancreas, its morphology, complications and causes of death.

8.5. Pathological physiology 1. Disorders of motor (vomiting, hiccup, eructation) and secretory (hyper- and hypiacidity)

functions of the stomach and consequences of stomach resection. Their etiology, pathogenesis,

disorders of body functions. Peptic ulcer disease, etiology, pathogenesis.

2. Diarrhea and constipation, their etiology, pathogenesis, disorders of organism functions.

3. Liver failure, etiology, pathogenesis and changes of body functions. Portal hypertension,

etiology, pathogenesis, disorders of body functions.

4. Jaundice, etiology, pathogenesis, disorders of body functions.

5. Carbohydrate metabolism disorders (hyperglycemia, hypoglycaemia, and diabetes mellitus.

Their etiology, pathogenesis, disorders of body functions.

8.6. Essentials of Medical Diagnostics

1. Obesity. The clinical signs and di agnostics.

2. Characteristics of symptoms of diabetes mellitus.

3. Glucose tolerance test. Indications for application. Interpretation of test results.

4. Criteria of diagnostic of type 1, type 2 and gestacional diabetes mellitus and understanding about treatment.

5. Complications of acute and chronic diabetes mellitus.

6. Symptoms of gastrointestinal (GI) and liver diseases.

7. Instrumental invetigations applied for diagnosis of gastrointestinal and liver deseases.

8. Examination of stool, meanings of patological findings.

9. Examination of clinical, biochemical enzymes analysis of liver.

10. Main gastrointestinal syndroms: abdominal pain , dyspepsion, GERD, malabsorption, bleeding from GI tract.

11. Main liver syndroms: jaundice, portal hypertension, liver failure.

12. Understanding of liver cirrhosis and alcoholic liver disease.

8.7. Biochemistry

8.7. Biochemistry 1. Digestion of polysaccharides, absorption of products of digestion. 2. Digestion of lipids (TAG, phospholipids, cholestrol esters), absorption of products of

digestion. 3. Digestion of proteins, absorption of products of digestion. 4. Biosynthesis of hydrochloric acid in the stomach and its functions. Determination of acidity

of gastric juice. 5. Structure of bile acids, role of bile in nutrient digestion. 6. Metabolism of hemoproteins. 7. Bile: main components; pigments and their metabolism. 8. Bile acids: origin, sites of production, characterization of structure, importance of bile in

digestion. 9. Reaction sequence of glycogen breakdown, enzymes, regulation, energy value,

physiological significance. 10. Reaction sequence of glycogen synthesis, enzymes, regulation, physiological significance.

11. Metabolism of acetyl-CoA produced in beta-oxidation; ketogenesis (production of ketone bodies): substrates, reaction, enzymes, products, transportation and consumption of keton bodies.

12. Synthesis of triacylglycerols in tissues (tissue lipolysis) and its regulation. 13. Breakdown of triacylglycerols in tissues (tissue lipolysis) and its regulation. 14. Biological significance of cholesterol. Origin of cholesterol in human organism. The main

stages of cholesterol synthesis. Regulation of cholesterol synthesis. 15. Approximate composition of chylomicrons, chylomicron formation and metabolism. 16. Approximate composition of very low density lipoproteins (VLDL), VLDL formation and

metabolism. 17. Approximate composition of high density lipoproteins (HDL). HDL formation and

metabolism. 18. General pathways of amino acid catabolism. Deamination of amino acids: ways of

deamination, enzymes, their specificity, coenzymes, products and their metabolism. Diagnostic significance of aminotransferases.

19. Formation of ammonia and its detoxication in human organism. 20. Metabolism and elimination of xenobiotics. 21. Metabolism of ethanol. Mechanisms of ethanol toxicity. 22. Synthesis of insulin, secretion and its regulation in human organism. Target cells of insulin.

Structure of insulin receptors, mechanism of intracellular signal transduction. Physiological effects of insulin.

23. Synthesis of glucagon, secretion and its regulation in human organism. Target cells of glucagons. Location of glucagons receptors, mechanism of intracellular signal transduction. Physiological effects of glucagon.

24. Mechanisms of regulation of glucose concentration in blood: role of glucagon, glucocorticoids and insulin.

8.4. Pharmacology 1. Classification, common features and differences of antidiabetic agents.

2. Preparations of insulin: classification, pharmacodynamics, relation of timing of administration with pharmacokinetic properties, indications for use, adverse reactions.

3. GLP-1 analogues: pharmacodynamics, indications for use, adverse reactions.

4. Sulfonilkarbamidai: pharmacodynamics, indications for use, adverse reactions.

5. Meglitinidai: pharmacodynamics, indications for use, adverse reactions.

6. Metformin: pharmacodynamics, indications for use, adverse reactions.

7. Rosiglitazone: pharmacodynamics, indications for use, adverse reactions.

8. α-glycosidase inhibitors: pharmacodynamics, indications for use, adverse reactions.

9. DPP-4 inhibitors: pharmacodynamics, indications for use, adverse reactions.

10. SGLT-2 inhibitors: pharmacodynamics, indications for use, adverse reactions.

11. Adverse reactions of antidiabetic agents. Hypoglycemia: prevention, warning signs and agents administered for its treatment.

12. Statins: pharmacodynamics, indications for use, adverse reactions.

13. Bile acid binding resins: pharmacodynamics, indications for use, adverse reactions.

14. Fibrates: pharmacodynamics, indications for use, adverse reactions.

15. Niacine: pharmacodynamics, adverse reactions.

8.9. Environmental and occupational medicine 1. Obesity, its definition, prevalence and causes.

2. Body mass index, its evaluation.

3. Daily energy requirement (DER) and dietary composition assessment.

4. Main principles of obesity prophylaxis.

5. Psychological reasons of alcoholism.

6. Social and economic reasons of alcoholism.

7. Psychosocial damage of alcoholism.

8. Prevention of alcoholism.

Process of examination and evaluation.

1. Examination conditions and rules are set by a document The Regulation of studies issued on June

20, 2014. LUHS Senate order Nr. 47-05. Student rights and duties are under full regulation of this

document.

2. The exam on NUTRIENT UPTAKE is organized by the Department of Biochemistry. Date and time of

the exam are scheduled. The information is available at:

http://pm.lsmuni.lt/tvarkarasciai/show.php?a=semester&sem=MF4sem20142015.

3. Instructions about student allocation in examination rooms are available at Intranet of the University

FC as much as 3 days before the exam.

4. Composition of the exam. The exam is composed of 9 subjects. Format of subject-based questions is

MCQ and short answer questions. The content of questions comme from the module programme (see

above). Total value of exam questions make 100%. Contribution of specific subjects to the total

depends on their complexity and the duration of studies (contact and independent work h). In the

auditoria, you will be provided by a set of processed questions. Guestions of a particular subject are

http://pm.lsmuni.lt/tvarkarasciai/show.php?a=semester&sem=MF4sem20142015

printed out on separate pages which are cliped together. Numbering of subject-based questions starts at

1. Instructions how to make your answers are provided at the first subject- approached page.

5. Evaluation. Each department and institute which contributes to the module makes evaluations on

specific subject-based questions. The departments receive student papers in anonimous way (without

names and groups but with particular code). Common grade is composed by the department of

biochemistry after decoding of evaluation data. Student grades are posted on electronic register

http://pm.lsmuni.lt/pazangumas/login.php.

6. Feedback. Students can get familiar with their mistakes only after anouncement of all grades in

electronic register. Therefore they should know their individual code numbers from the exam

organizing department. Knowing the code numbers, other departments can provide you with needed

information.

http://pm.lsmuni.lt/pazangumas/login.php

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