10/18/24, 9:18 PM Module 6

Module 6

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Module 6 Study Guide and Deliverables

Readings: Recommended Reading:

Anatomy and Physiology (Biga et. al., 2019)

Chapter 17: The Endocrine System

Chapter 27: The Sexual Systems
Chapter 28: Development and Inheritance

Hacking Healthcare (Trotter and Uhlman, 2011)

Chapter 9 - A selective history of EHR technology

Additional Resources:

Hiller-Sturmhöfel S, Bartke A. The Endocrine System: An Overview. Alcohol

Health and Research World. Vol. 22, No. 3, 1998
MedlinePlus Endocrine System
Lecture 44 Christian Bartley ([email protected]) Biology 101 & 102 - Class
Notes - PowerPoint Presentation

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Live Classroom: Tuesday, October 8 from 7:00-8:30 pm ET
Friday, October 11 from 7:00-8:30 pm ET

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Module Overview

The endocrine system is the grand communicator and coordinates with thenervous system to maintain homeostasis and internal function. The
endocrine system consists of a vast array of ductless glands that secrete chemical signals (hormones) that communicate between tissues. Hormones
control every major aspect of digestion, energy metabolism, reproduction, behavior, growth and development. The differing organs and tissues
responsible for hormone production will be described and the complex and remarkable pathologies that can develop will be examined. The hormonal
pathologies offer a fascinating insight into differential diagnosis and case studies will be presented for class analysis including approaches to assisted
reproduction.

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Learning Objectives

After completing this module, you will understand the basics of the endocrine system. The case study illustrates difficulties in implementation of radical
change and explore alternatives (incremental or step-shift change). This module will also provide a brief history of EHR and introduce basic
professional ethics and etiquette for health IT.

The Endocrine System

The Endocrine System

The endocrine system controls the way our body functions. The endocrine system includes eight major glands throughout our body, the hypothalamus
(posterior pituitary), pituitary (anterior pituitary), thyroid, parathyroids, adrenals, pineal body, and the reproductive organs (ovaries and testes). The
pancreas is also a part of the system because of its role in hormone production and in addition to its role in digestion (eMedicineHealth, 2014). The
endocrine system regulates (growth, development, digestion, excretion, breathing, heat rate, blood pressure, calcium absorption and storage,
metabolism and maintenance of body temperature, sexual function, reproduction, sleep, mood stability, among other things) through hormones. Table 1
shows several functions of the endocrine system and the hormones involved.

Most hormones have multiple effects, e.g. adrenaline (a hormone and a neurotransmitter) increases heart rate, constricts blood vessels, dilates air
passages and participates in the fight-or-flight response of the sympathetic nervous system. Most vital functions are influenced by multiple hormones,
e.g. glucose levels are controlled by insulin, glucagon, glucagon-like peptides, and cortisol among others. Most hormones are of two chemical types –
peptides that are based on chains of amino acids and usually bind to receptors on the target cell surface (e.g. insulin) and steroids that are derived from
cholesterol and can travel to the interior of the cell (hence it is membrane soluble), move to the nucleus, and activate or de-activate genes in the
chromosomal DNA (e.g. cortisol, testosterone, estrogen, vitamin D). Hormone synthesis and release are tightly controlled by negative (suppressive)
and positive (stimulatory) feedback loops. Hormones are often delivered directly by the blood to the target organ e.g. progesterone and estrogen
controlling Luteinizing hormone (LH) and Follicle-stimulating hormone (FSH).

Table 1. Principal functions of the endocrine system.

Function Examples

Growth and Development Growth hormone, testosterone, estrogen

Reproduction testosterone, estrogen

Maintenance of internal milieu:

Fluid balance
Electrolyte concentration
Blood pressure
Insulin, glucagon, cortisol, thyroxin, parathyroid hormones, growth hormone, aldosterone, antidiuretic hormone
Control of:

energy production
energy utilization
energy storage

As an example, the fight-or-flight response, regulated by multiple hormones, is a physiological reaction that occurs in response to a perceived harmful
event, attack, or threat to survival (Cannon, 1932). According to Cannon, animals react to threats with a general discharge of the “sympathetic” division
of the autonomic nervous system (the one we don’t think about), priming the animal for fighting or fleeing.

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The hypothalamus is a region of the forebrain below the thalamus that coordinates both the autonomic nervous system and the activity of the pituitary,
controlling body temperature, thirst, hunger, and other homeostatic systems, and involved in sleep and emotional activity as shown in Figure 3. First,
the amygdale (fear center) initiates the reaction by triggering a neural response in the hypothalamus. Then the pituitary gland is activated and secrets
the hormone Adreno-Cortico-Tropic-Hormone (ACTH). The adrenal gland is activated almost simultaneously and releases the
hormone/neurotransmitter epinephrine also known as adrenaline. This results in the production of the hormone cortisol, which increases blood
pressure, blood sugar, and suppresses the immune system (Padgett and Glaser, 2003). The initial response and subsequent reactions are triggered to
create a boost of energy, which is activated by epinephrine binding to liver cells and the subsequent production of glucose. Catecholamine hormones,
such as adrenaline (epinephrine) or noradrenaline (norepinephrine), facilitate immediate physical reactions associated with a preparation for violent
muscular action (Figure 4). The body reactions include:

Breathing rate increases

Heart beats faster and with greater contraction
Blood pressure may rise
Muscles tense for action
Skin may feel clammy consequent to vasoconstriction in the periphery
Pupils dilate
Blood glucose rises
Mental function changes – focus only on the big picture (the threat), difficult to focus on fine details

Figure 3. The hypothalamus determines whether or not and how much each of those glands or body parts secretes their own hormones in order to
keep your body in balance (/).

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Figure 4. The fight-or-flight response.

Endocrine diseases are disorders of the endocrine system: Endocrinology is the branch of medicine associated with endocrine disorders. Broadly
speaking, endocrine disorders may be subdivided into three groups (WebMD, n.d.):

Endocrine gland hyposecretion (leading to hormone deficiency)

Endocrine gland hypersecretion (leading to hormone excess)
Tumours (benign or malignant) of endocrine glands

In the United States, the most common endocrine disease is diabetes (MedlinePlus, 2014). The blood glucose (blood sugar) level in human body is
often maintained in a very narrow range by hormones, i.e. insulin and glucagon. Both insulin and glucagon are secreted from the endocrice part of the
pancreas (specifically the islets of Langerhans as shown in Figure 5) in response to blood sugar levels, but in opposite fashion as shown in Figure 6.
Insulin and glucagon are normally secreted by the beta cells and the alpha cells of the pancreas respectively. A common theme in endocrinology is that
the paired hormones with opposite effects controlled by negative feedback loops.

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Encyclopaedia Britannica, Inc.

Encyclopaedia Britannica, Inc.

Figure 5. The Islet of Langerhans and the cells constituting it.

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Figure 6. The roles played by pancreas, insulin, and glucagon in regulating blood glucose levels (Endocrineweb, n.d.).

Type 1 diabetes is caused by a deficiency or complete loss of the beta-cells of the pancreas, either by aging/genetic factors, a viral infection or an
autoimmune disease, which results in a total lack of insulin. It is treated by injections of insulin. Type 2 diabetes occurs when the body stops responding
to insulin due to a problem with the insulin receptors. In Type 2 diabetes, the insulin is produced and released as normal, but it has less of an effect. It
often occurs in obese patients and can be controlled by diet and exercise.

Figure 7. How blood glucose levels change over time for people with and without diabetes.
For more details on the endocrine system, refer to http://www.nlm.nih.gov/medlineplus/endocrinesystem.html.

References

Cannon, Walter (1932). Wisdom of the Body. United States: W.W. Norton & Company.

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eMedicineHealth (2014) Endocrine System Introduction. Retrieved 9/10/2015 from
http://www.emedicinehealth.com/anatomy_of_the_endocrine_system/article_em.htm#endocrine_system_introduction.

Endocrineweb (n.d.) Normal Regulation of Blood Glucose. Retrieved 9/10/2015 from http://www.endocrineweb.com/conditions/diabetes/normal-
regulation-blood-glucose.

MedlinePlus (2014) Endocrine Diseases. Retrieved 9/10/2015 from https://www.nlm.nih.gov/medlineplus/endocrinediseases.html.

Padgett, David and Glaser, R (2003). How stress influences the immune response. Trends in Immunology 24 (8): 444–448.

WebMD (n.d.) Endocrine Disorders. Retrieved 9/10/2015 from http://www.webmd.com/diabetes/endocrine-system-disorders

A Brief History of EHR Technology

A Brief History of EHR Technology

MUMPS stands for Massachusetts General Hospital Utility Multi-programming System, later “Multi-User Multi-Programming System”, or alternatively M
language. It is a programming language, database, and operating system rolled into one. It was developed by Neil Pappalardo, Robert Greenes, and
Curt Marble in Dr. Octo Barnett's animal lab at the MGH Boston during 1966 and 1967. The M database is a key-value database engine optimized for
high-throughput transaction processing. It is in the class of "schema-less", "schema-free," or NoSQL databases. MUMPS is very different from C-based
language. The syntax is much terser and it is not whitespace-invariant. At one point, MUMPS was commonly used in finances and healthcare.
Eventually financial industry moved away from MUMPS. It remains to be the programming language for healthcare. In 1977, ANSI Standardization of
MUMPS was blessed by a Federal agency then called the National Bureau of Standard. At least 3 of the most important health IT systems are based
on MUMPS: MEDITECH, Epic, and VA VistA (Wikipedia, 2015; Trotter and Uhlman, 2011).

VistA (Veterans Health Information Systems and Technology Architecture) is an enterprise-wide information system built around an EHR, used
throughout the VA medical system. It consists of nearly 160 integrated software modules for clinical care, financial functions, and infrastructure. Over
60% of all physicians trained in the U.S. rotate through the VHA on clinical electives, making VistA the most familiar and widely used EHR in the U.S.

In late 1970s, two key players behind the standardization of MUMPS, Joseph O'Neill and Marty Johnson, moved into an office called "CASS"
(Computer Assisted System Staff") within the VA's Department of Medicine and Surgery. They had the vision that MUMPS could be brought into the VA
hospitals nationwide and located a group of programmers working at VA hospitals to develop software called Decentralized Hospital Computer Program
(DHCP).

The movement didn’t get official support and the effort moved underground and is known as the Underground Railroad of the VA. In early 1980s,
leadership eventually found that DHCP can provide the skeleton of a system that could fully computerize healthcare delivery at the VA. DHCP was
renamed VistA (Wikipedia, 2015a; Hardhats, n.d.). An important detail about VistaA is that it is available for download under the Freedom of Information
Act (FOIA) as it was developed by federal employees. This makes the source code for VistA available in the public domain (Trotter and Uhlman, 2011)

Professional Ethics and Etiquette for Health IT

One might assume that professional ethics and a certain standard of etiquette exist in any place of business. Many places of business have policies
regarding disclosure of information and dress codes. However, there are a number of factors that may be unique to healthcare, such as access to
personal medical information.

With the exception of handling of protected health information, working in the IT department in a healthcare facility that does not directly deal with
patients may not be much different in regards to professional ethics and etiquette from other business environments. If you work in a facility where
direct patient care occurs, you may encounter patients and/or their families. Patients may have very serious illnesses. Families may be visiting
patients that are very sick or dying. Even if you do not work in direct patient care areas, these encounters could occur in common areas such as
lobbies, elevators, and cafeterias. Care and sensitivity regarding your actions that goes beyond not discussing or disclosing protected health
information may be prudent in these and other areas.

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Good natured joking or unprofessional comments overheard by patients or patients’ families may have unintended consequences. For example,
making a joke to a surgeon who drops his or her pen in the elevator implying clumsiness may seem funny to you and the surgeon. However, if a patient
scheduled to undergo a procedure performed by that surgeon overhears this, the patient may experience increased anxiety regarding that procedure.

Case Study

Two adult brothers had a similar medical problem. They both developed a new onset loss of hearing in one ear. Brother A’s problem occurred a couple
of years before Brother B’s problem.

Brother A was about 40 years old when he noticed a loss of hearing in one ear. He went to his physician who was a family practice specialist. A
hearing test was performed using a small portable piece of equipment in an exam room. Brother A was referred to an otolaryngologist. Diagnostic
testing including an MRI did not reveal direct evidence of any particular cause of the problem. Viral infection was considered as a likely cause of the
problem. The otolaryngologist treated Brother A with an oral course of corticosteroids. This did not change Brother A’s hearing. The otolaryngologist
offered Brother A further treatment with a procedure in which a corticosteroid is injected through the tympanic membrane of the affected ear. After an
in-depth discussion with the otolaryngologist regarding the likelihood of improvement after this treatment, Brother A decided not to have this procedure.
To date, Brother A’s hearing in the affected ear has not improved.

Brother B was about 35 years old when he noticed a loss of hearing in one ear. He went to an otolaryngologist and had a hearing test. Diagnostic
testing including an MRI did not reveal direct evidence of any particular cause of the problem. Viral infection was considered as a likely cause of the
problem. The otolaryngologist treated Brother B with an oral course of corticosteroids. This did not change Brother B’s hearing. Brother B went to see
two other otolaryngologists for additional opinions. Brother B was offered further treatment with a procedure in which a corticosteroid is injected
through the tympanic membrane of the affected ear. After multiple in-depth discussions regarding the likelihood of improvement after this treatment,
Brother B decided to undergo this procedure. The procedure was repeated multiple times over several weeks. To date, Brother B’s hearing in the
affected ear has not improved.

Brother A had medical insurance at the time through his employer. He contributed part of the cost of this insurance through deductions from his
paycheck. The insurance coverage was a “high deductible” plan. The deductible was about $2,000.

Brother B had medical insurance at the time through his employer. He did not directly contribute to the cost of this insurance. There was no deductible
and no co-pay.

Questions Related to Case Study

These questions are provided for thought or discussion. You are not required to turn in answers to these questions.
The questions may not have an easy answer or a correct answer, but might help you understand some of the issues facing healthcare in the U.S. today.

1. Should patients pay some or all of the cost of their healthcare?

2. Should cost play a role in healthcare decisions?
3. Is more expensive healthcare better than less expensive healthcare?
4. Should difficulty or inability to pay prevent someone from obtaining healthcare?
5. Should people be able to obtain unlimited healthcare if they are not directly paying for it?
6. Does the presence of a life-threatening medical problem change the answers to any of the above questions?
7. If the patient is a child, would the answers to any of the above questions change?
8. If the patient is obtaining healthcare in the U.S. and is not a U.S. citizen, would the answers to any of the above questions change?
9. If the patient is close to death, but could be kept alive for a short period of time at a high financial cost, would the answers to any of the above
questions change?
10. If the patient had an earlier opportunity to purchase health insurance, but declined to do so and later developed a medical problem, would the
answers to any of the above questions change?

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References

Trotter F and Uhlman D (2011). Hacking healthcare: A guide to standards, workflows, and meaningful use. Chapter 9 A selective History of EHR
Technology.

Wikipedia (2015) MUMPS. Retrieved 9/10/2015 from http://en.wikipedia.org/wiki/MUMPS.

Wikipedia (2015a) VistA. Retrieved 9/10/2015 http://en.wikipedia.org/wiki/VistA

Hardhats (n.d.)The History of the Hardhats. Retrieved 9/10/2015 from http://hardhats.org/history/hardhats.html.

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