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  <head>
    <title>024-02 Endocrine synthesis pathways, crisis physiology, and skeletal treatment sequencing</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Endocrine synthesis, crisis, and skeletal sequencing">
      <outline text="Thyroid synthesis and iodine effects">
        <outline text="Uptake, organification, coupling, storage, release"/>
        <outline text="Iodine effect is biphasic">
          <outline text="Deficiency raises stimulating hormone, goitre"/>
          <outline text="Acute load suppresses organification and release"/>
          <outline text="Autonomous tissue overproduces"/>
          <outline text="Autoimmune gland may become hypothyroid"/>
        </outline>
        <outline text="Most triiodothyronine made outside the gland">
          <outline text="Illness, fasting, drugs alter conversion"/>
        </outline>
      </outline>
      <outline text="Thyroid tests in context">
        <outline text="Stimulating hormone: sensitive primary screen">
          <outline text="Unreliable: central disease, recent change, illness"/>
        </outline>
        <outline text="Weeks to a new steady state">
          <outline text="Early testing causes dose oscillation"/>
        </outline>
        <outline text="Absorption: acidity, coeliac, iron, calcium">
          <outline text="Review administration before escalation"/>
        </outline>
      </outline>
      <outline text="Thyrotoxic mechanisms and emergencies">
        <outline text="Thyrotoxicosis: excess action from any source"/>
        <outline text="Hyperthyroidism: increased gland synthesis">
          <outline text="Thionamides cannot stop thyroiditis release"/>
        </outline>
        <outline text="More beta-adrenergic response and cardiac work"/>
        <outline text="Storm: clinical decompensation, not a threshold">
          <outline text="Triggers: infection, surgery, interruption, iodine"/>
          <outline text="Block adrenergic, synthesis, release, conversion"/>
        </outline>
        <outline text="Myxoedema coma often lacks coma">
          <outline text="Empirical glucocorticoid for hidden adrenal failure"/>
        </outline>
      </outline>
      <outline text="Adrenal steroid pathways">
        <outline text="All from cholesterol; zonal enzymes differ">
          <outline text="Glomerulosa lacks cortisol capacity"/>
          <outline text="Fasciculata cortisol, reticularis androgens"/>
        </outline>
        <outline text="Enzyme defects redirect precursors">
          <outline text="Low cortisol raises drive, causing hyperplasia"/>
          <outline text="Salt loss, hypertension, virilisation as clues"/>
        </outline>
        <outline text="Cortisol bound to binding globulin and albumin">
          <outline text="Oestrogen raises total cortisol"/>
        </outline>
      </outline>
      <outline text="Adrenal insufficiency and stress dosing">
        <outline text="Primary loses cortisol and often aldosterone"/>
        <outline text="Central keeps aldosterone via renin-angiotensin"/>
        <outline text="Exogenous glucocorticoids suppress drive">
          <outline text="Abrupt cessation can be dangerous"/>
        </outline>
        <outline text="Illness needs planned stress dosing">
          <outline text="Vomiting requires parenteral rescue"/>
        </outline>
        <outline text="Crisis: vasodilation, volume loss, hypoglycaemia"/>
      </outline>
      <outline text="Cortisol and aldosterone excess">
        <outline text="Glucocorticoid excess redistributes substrate">
          <outline text="Protein catabolism: weakness, thin skin"/>
          <outline text="Bone formation falls, resorption rises"/>
        </outline>
        <outline text="Establish autonomy, then localise dependence"/>
        <outline text="Aldosteronism: harm beyond pressure">
          <outline text="Potassium normal through intake and adaptation"/>
          <outline text="Posture, sodium, drugs affect the ratio"/>
        </outline>
        <outline text="Catecholamine tumours: receptor stimulation">
          <outline text="Biochemistry first; nodules are common"/>
          <outline text="Alpha before beta avoids unopposed constriction"/>
          <outline text="Restore volume before surgery"/>
        </outline>
      </outline>
      <outline text="Calcium sensing and phosphate balance">
        <outline text="Sensing receptor detects ionised calcium">
          <outline text="Falling calcium raises parathyroid hormone"/>
        </outline>
        <outline text="Kidney failure retains phosphate">
          <outline text="Less vitamin D activation"/>
          <outline text="Secondary hyperparathyroidism, may become autonomous"/>
          <outline text="Growth factor 23 rises early"/>
        </outline>
        <outline text="Magnesium: mild reduction stimulates">
          <outline text="Severe deficiency suppresses release"/>
          <outline text="Calcium fails until magnesium corrected"/>
        </outline>
      </outline>
      <outline text="Hypercalcaemia and hypocalcaemia logic">
        <outline text="First branch point: parathyroid hormone">
          <outline text="High or normal: primary, tertiary, lithium, familial"/>
          <outline text="Suppressed: malignancy, vitamin D, granulomas"/>
        </outline>
        <outline text="Volume depletion reduces calcium excretion">
          <outline text="Isotonic fluid limited by heart, kidney reserve"/>
        </outline>
        <outline text="Calcitonin fast but transient"/>
        <outline text="Confirm hypocalcaemia with ionised calcium"/>
      </outline>
      <outline text="Bone strength and treatment sequence">
        <outline text="Density is not strength">
          <outline text="Geometry, porosity, architecture, falls"/>
          <outline text="Fragility fracture establishes high risk"/>
        </outline>
        <outline text="Denosumab: reversible antibody pathway">
          <outline text="Stopping causes rebound vertebral fractures"/>
          <outline text="Plan a subsequent antiresorptive"/>
        </outline>
        <outline text="Anabolic therapy for very high risk">
          <outline text="Sequence affects gains and preservation"/>
        </outline>
      </outline>
      <outline text="Endocrine crisis support">
        <outline text="Organ support before hormones normalise"/>
        <outline text="Clinical recovery lags biochemistry"/>
        <outline text="Poor response: reconsider diagnosis, absorption">
          <outline text="Interactions, infection, heart failure, adrenal"/>
        </outline>
      </outline>
    </outline>
  </body>
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