Chapter 1. The Runner's Experiment

1.1 Introduction Part 1

Lehninger Principles of Biochemistry
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The Runner's Experiment

By Justin Hines, Lafayette College and Marcy Osgood, University of New Mexico

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Instructor's Notes

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Topic Pre-requisites: Students should have exposure to the topics of Chapters 14–18 and ideally Sections 23.2 and 23.3 of Lehninger Principles of Biochemistry, 7th ed.

Overview

This capstone-type case is designed to help students understand the importance of gluconeogenic substrates in human metabolism and the interconnections between carbohydrate, fat, and protein metabolism in humans. Because the focus of this case is the integration of metabolic pathways, we recommend that students be exposed to the topics of Chapters 14–18 and ideally Sections 23.2 and 23.3 of the textbook (Lehninger Principles of Biochemistry, 7th ed.) before beginning this case. These latter two sections could be assigned as preliminary reading before initiating the case if they have not been explicitly covered in the class; in that case, we recommend allowing students additional time to complete this case study.

Students may work individually or in groups to complete this case study. Students are constantly encouraged to refer to their textbook throughout the case, and internet access is permitted, although it is not necessary for the completion of the case. Students are required to iteratively acquire, analyze, and integrate data as they progress through the case and answer assessment questions found throughout the case. All assessment questions are automatically scored.

For this case, students will need to explore all investigative options to complete the case, and so, unlike some other cases in this collection, the number of investigations that students make use of will not be reported.

Learning Objectives

This case is intended for remediating or extending student capabilities in these difficult topics:

  1. Real-world applications of the study of human metabolism. Students will:
    • utilize real biochemical tests to evaluate and “solve” a metabolic disorder case.
    • consider the importance of factors like personal and family history, diet, medications taken, and symptoms in solving a biochemical case.
  2. Critical and interrelated pathways in human central metabolism. Students will:
    • review carbohydrate, lipid, and amino acid metabolic pathways.
    • review fatty acid metabolism and recognize the distinctions between the oxidation of even- and odd-chain fatty acids.
  3. Connections between carbohydrate, fat, and protein metabolism in humans. Students should be able to:
    • outline and explain the importance of gluconeogenic substrates in human metabolism.
      • understand why the inability to convert acetyl-CoA to gluconeogenic substrates in humans leads to protein wasting.
      • explain the importance of ketone body formation and ammonia transport/disposal in human metabolism.
    • explain the important differences between the metabolic intermediates produced by the oxidation of even vs. odd-chain fatty acids.
  4. Practice critical thinking skills involving data. Students will:
    • evaluate data provided by metabolite and enzyme tests.
    • integrate multiple pieces of biochemical data.

Some questions are designed to address areas of difficulty for students

  • Students are often confused about the necessity to maintain glucose homeostasis, even in the presence of circulating ketone bodies… that is, the concept that glucose must always be exported from the liver under all circumstances in the fasted state is not clear to most students.
  • The significance of a fundamental disconnect in human metabolism--the absence of a metabolic pathway to convert acetyl-CoA ultimately to glucose--is often underappreciated or missed entirely by some students.
  • The role of protein wasting as a necessary, but unfortunate consequence of the need for gluconeogenic precursors in the absence of dietary carbohydrates or stored glycogen. It is both a critical aspect of human metabolism and a relevant real-world connection given the rise of protein-heavy diets in Western society (Atkins, etc.).
  • Author note: A common error is to jump immediately into testing a “pet” hypothesis by conducting laboratory tests (metabolite assays or enzyme assays) before exploring “data gathering” options like visual inspections or interviews with the person. This is an excellent and intentionally designed opportunity to point out a common mistake about the scientific method-- that is, it begins with making careful observations, rather than by immediately testing quickly formed hypotheses.

Suggested implementation

Below we describe two options for course implementation. The hybrid Online/In-class approach is recommended. Time required for students to complete the online case will vary by group depending on their level of discussion between each investigation. The case study can be started and stopped, and so it is recommended to give students a window of 3 to 5 days in which to complete the assignment.

Hybrid: Online/In-class: (recommended approach; ~30 minutes of class-time expected)

  1. Share the case study link with your students to work online outside of class, preferably in pairs or groups of three. Assign the case study to be due before your next class meeting. Students should be instructed to bring copies of notes and answers to assessment questions to the following class period.
  2. Review the online answers before the following class for difficult areas for students (see expected areas of difficulty above).
  3. Lead students in a discussion in pairs, groups, or as a class (depending upon class size and instructor preference) to address unresolved difficulties (~30 minutes in-class time).
  4. After using the case, we recommend that you select questions from the supplied assessment questions to use on exams or as homework assignments to reinforce the difficult concepts covered. Please see the document “Exam Questions for Case 4: Integration of Metabolism.”

Online only approach: (minimal in-class time required)

  1. Share the case study link with your students to work online, preferably in pairs or groups of three. Assign the case study to be due before your next class meeting.
  2. Review the online answers for difficult areas for students (see expected areas of difficulty above).
  3. Mention or remediate tough points during a portion of lecture.
  4. After using the case, we recommend that you select questions from the supplied assessment questions to use on exams or as homework assignments to reinforce the difficult concepts covered. Please see the document “Exam Questions for Case 4: Integration of Metabolism.”

Suggestions for in-class discussions (these questions may also be used in summative assessments-- i.e., exams, scored quizzes, etc.):

  • What were some of the most important facts in the initial presentation of Dave and Michael’s case and why were they important?
    • Students could be directed to brainstorm in groups or as a whole class.
  • What were some of the most important facts of Dave and Michael’s case that were revealed as a result of your investigations and why were they important?
    • Students could be directed to brainstorm in groups or as a whole class.
  • What are some issues associated with someone trying to do a diet that is completely based on one type of macronutrient, like fat in this case, or for example a diet entirely of protein?
    • Could be easily used as a think-pair-share exercise.
    • Alternatively, students could first answer this question in writing individually, and then those responses could be collected or discussed in groups and revised.
  • What was the relevance of the brothers being identical twins with respect to this case and to biochemistry in general--i.e., what might we have been concerned about if the brothers were not twins?
  • What is the significance of the two oils the brothers were eating?
  • What was the significance of Michael’s neurological issues?
  • Why did Michael have lower levels of immunoglobins and higher levels of ketone bodies than Dave?
  • Why are high levels of ketone bodies dangerous?

You are missing vital information

You may be missing vital information needed to sufficiently explain this incident. You must complete all investigations before proceeding to the final assessment questions.

You are missing vital information

You may be missing vital information needed to sufficiently explain this incident. You must complete all investigations before proceeding to the final assessment questions.

This activity has already been completed, however feel free to review the information contained within.

I am finished gathering information for this investigation and feel I am able to fully explain the reason(s) for Dave’s and Michael’s incidents in biochemical and physiological terms, including reasons for the significant differences between the two brothers’ conditions and I can fully justify and completely explain my reasoning based on the evidence I have gathered.

Figure 1.1

Race day had come. “Finally,” thought Michael. He was a marathon veteran, but this race was different. He felt terrible. “Probably a cold” he had told his girlfriend, but nothing was going to stop him today. Today was the day he would finally prove his brother Dave wrong, and he had 26.2 miles to do it.

The two young men shook hands shortly before the race started. Dave was thin, like Michael, but not “gaunt”. Michael’s girlfriend Jan had actually used that word to describe Michael a few days before. His cheeks had receded recently. “Seriously, you should stop this… you look terrible!” Jan said. “It’s just pre-race training… and of course, the experiment,” he thought. “I’ll be fine!” he assured her with a wink before leaving their apartment.

"Today is the day we settle this!"

“Today is the day we settle this!” he now called to Dave as they took off down the race route, but Dave only smiled and accelerated to leave Michael behind. As Dave disappeared into the crowd, Michael called out, “It’s not about speed! It’s about endurance dummy!”, but Dave was too far ahead to hear.

For weeks they had been talking about their plan, the experiment, and how much money they were going to make. Michael smiled to himself and then put his head down to focus on the run. Dave was long gone but Michael was certain that he would see him again soon enough… that is, until he started to feel dizzy…

Juan had worked at several marathon medical tents before. It was always the same: people try to run the race without training properly, and they end up at the tents. Most are dehydrated and exhausted, others just “hit the wall,” when their bodies run out of glycogen, and some even have heart attacks, mainly due to poor training. This particular day wasn’t very hot, but it didn’t take much to overwhelm people during a marathon. Working the races was a nice excuse for an ER doctor to get out in the sun for a few hours on the weekend and a chance to help some people… for Juan that was as addicting as running.

Two hours in and Juan was bored. The chatter on the radio was the same as always: dehydrated runners at both tents, and one elderly person from the crowd had to be treated for heat exhaustion, though it was really just from standing too long… so far it was a slow day.

1.2 Introduction Part 2

Figure 1.2

Suddenly the radio chatter picked up. The ambulance from the medical tent at the 10-mile mark was headed in to his location at the finish line with a young man who was non-responsive. The incoming call was interrupted by a second voice: the ambulance from the medical tent at the 20-mile mark ALSO had a non-responsive man. ‘What are the odds?’ Juan thought. The two ambulances arrived simultaneously. Runner ID tags identified both subjects immediately: Michael and Dave Gard, two brothers! Dave was unconscious, but otherwise looked OK. When Juan saw Michael, however, he was startled into action; he would not have guessed that the two men were brothers!

You are a biochemistry student and you are shadowing an ER doctor who has just admitted two young males. One man, Dave, regained consciousness before arrival, whereas the other, Michael, regained consciousness only after arriving at the hospital and is still delirious. Neither man was particularly dehydrated, having drunk water during the race. Both have been stabilized, but blood and urine samples from before they were treated are available for you to test. It is up to you to discover what might be the problem with the two brothers.

Consider that there are two primary questions to answer:

What caused both brothers to lose consciousness during the race? Here are some potential biochemical hypotheses for you to consider:

  1. Ketoacidosis
  2. Lactic acidosis
  3. Ammonia toxicity
  4. Mercury poisoning
  5. Acute hyperglycemia due to type II diabetes
  6. Hypoglycemia
  7. Phenylketonuria
  8. Maple-syrup urine disease

What is the biochemical explanation for the differences in the conditions of the two brothers?

You may now conduct additional investigations to explore the details of this case and to test hypotheses so that you can eventually answer both questions. Note: for this case, you are encouraged to explore ALL possible investigations to gather as much information as possible to explain the case before finishing the case by continuing to the final case assessments.

1.3 Investigation Options

RECOMMENDED INITIAL INVESTIGATIONS

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Evaluate the overall physical appearance of the two brothers, including insect bites or other injuries.

Results: The men are identical in height. Dave has a lean, athletic build, but is not unusually thin for a long-distance runner. Michael, on the other hand, appears to be severely emaciated. You note sunken eyes and cheek bones and protruding ribs, indicating a lack of not only body fat but also muscle tone. No injuries or other abnormalities are apparent.

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Investigate past medical history, including current medications.

Results: Neither man smokes, drinks, or uses illegal drugs. They are not on any medications. Dave reports that Michael had not been feeling well prior to the race, but had thought that he was “just coming down with a cold or something”. Given that the men were both avid marathoners, no one apart from Michael’s girlfriend Jan had been concerned about Michael’s recent and rapid weight-loss.

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Investigate the relationship between the two brothers in greater detail.

Results: Dave explains that the two men are not just brothers, they are best friends and despite their grossly different appearances at the moment, they are identical twins! He says, “Before we started our experiment just a few weeks ago, most people couldn’t tell us apart!”

Dave mentioned something about an experiment; you could ask him more about this. The following is now a new investigation option:

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Ask Dave about “The Experiment”.

Results: Dave tells you that the two brothers had been planning to start a new dietary supplement company, Gard Nutraceuticals, selling purified fish oil, which they believe is a health panacea. They disagreed on the best fish oil to bring to market however, so the men had been conducting an experiment to settle this disagreement. Both had been taking fish-oil pills along with a multi-vitamin for the past three weeks while they tapered back their training runs dramatically. When you press Dave about what else he and Michael were eating, shockingly he says “nothing”. They had been eating enough fish oil to consume 3000 Calories per day, which is normal for marathon training (approximately 330 grams of fish oil per day). Each brother had been touting a different product: Michael was taking oil from wild-caught salmon, while Dave was taking oil from a flathead (striped) mullet. The bet was to determine whether fish oil was an adequate caloric-replacement supplement for athletes, and whose product was better. To make the decision unambiguous, the pair was going to use the marathon to decide the winner since the boys had nearly identical marathon times in previous races.

The details of this fish-oil experiment may merit further investigation. In particular, some fish contain high levels of mercury, which could be toxic if consumed in large quantities. You now have the following two new investigation options available to you:

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Test hair for common toxins (heavy metals and narcotics) and ask Dave about mercury contamination in the supplements.

Results: Dave immediately points out that they worked with a chemist to extensively purify the fish oils to remove any mercury contamination. An independent laboratory verified that there are only trace levels of mercury left in their formulations, and Dave brings up the documentation on his smart-phone, showing that the analysis is good. Mercury toxicity will be negligible regardless of how much oil is consumed. Also, no heavy metals or narcotics were detected in hair samples from either brother.

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Investigate the composition of the dietary supplements the subjects were eating.

Results: Complete hydrolysis followed by esterification of the triacylglycerols (TAGs) in the two fish oil samples allowed fatty acid composition to be analyzed by gas chromatography.

The oil consumed by Dave (from the striped mullet Mugil cephalus) contained:

  • 11% 16:0
  • 5% 16:1(Δ7)
  • 15% 18:1(Δ9)
  • 36% 20-, 22-, or 24-carbon omega-3 or omega-6
  • 25% 15-, 17-, 19-, and 21-carbon fatty acids
  • 6% 12- or 14-carbon fatty acids
  • 2% unidentified

The oil consumed by Michael (from Atlantic salmon Salmo salar) contained:

  • 16% 16:0
  • 6% 16:1(Δ7)
  • 20% 18:1(Δ9)
  • 45% 20-, 22-, or 24-carbon omega-3 or omega-6
  • 4% 15-, 17-, 19-, and 21-carbon fatty acids
  • 7% 12- or 14-carbon fatty acids
  • 2% unidentified
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Question 1.1

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5
Correct.
Incorrect.
true
inv102
true

Question 1.2

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
4
Correct.
Incorrect.
Incorrect.
inv103
true

Question 1.3

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
3
Correct.
Incorrect.
true
inv104
true

Question 1.4

oEiPFXxTcSsE4IYyJ1OsIrl9XTI0X8ajCpd9jH2XDZednq8v/kgFXo5ITZhsswfSvRUIMsTzDIZLoGEVblFlcXUVm7z5KoKH+8bopKM/C0EeOgHx7jqNPGVkIDNShzsjuixOTE5fNaHVOYeUmov3hCI/J8OjBoX4RuL4X0OqcuN/w1vsm+i605C3VyZdOVzqxNN8+jkD9m19X56nyTV6yZA1QCZAyJgaCgPhrxyJsyRg2iMMRppA8uNYzoiWL3AXJqf1VJn8RCYg2NVqzzoHz8A9rac6zKsr+8PIlGbSfUfdUgrQA6DlUHsJfCNoGKEUZ3uyfnZvK3sUmR1WcKa8pJO2ABVeSA/HhR24649U27/68/Rs4jv5P9p8QEah0VmCI3Hvfyj5YUAKjgkS/m8oNoTcRmy12t1cN42mcf5F+oXpcTaMSjb1vVBm/Tsl923GPv0oUhphqKhU6kMiRftldm5B2mg80Y8dPxz5tvEV+y2LSxldh5v+/016LKEMg1y2C97PgSeoUj4SK973R39yvtJlapyclZ/L7OlBITDtOFukikttflT6F7czeyzPshxKGRinXpDvbpPNOcBrecAnYjZ5LETKunKsFfro0QlZtB/rJ6G3jNQ+J8aFFmda5H0ASTqLcDwVtUHWiLKA9mSN1WBJ0rGyQiJaj2HIimj41y+yPeMrOvAfJNTRYhakjfVu2v2Xk3MXXLVBZSYoM4mLHKEpNXkkAlqm6v6CNvk+xIpKiUmIsnBA/BMU5729W0Ga5L4CBjbCH4R3ROKSjdMVOLCaHJWepDA/ZO9EjKX4FoF3YHFOMwWJMnJjNfDe93ieD4Z9sghh/qt1JArsN8//sselrr7rdVtirr0HrKXoJRuQ+JthIYoaPcwFUCXWW/pEjfUJ10jydfEJZ7dDj+Q1ObJ5LV1fqiEcCFR6zMvnfKic4VfTGmrTeJSE99Hn1HEduaHcpFxpU5n6lSlu9E0hZ4/rNs5Ms1nrr18W4JBrmvXoK5o7eNDwpZq+ZfthUcSUgxfUIfHxg0aNPEJrSr1lGZB7M1Wu6lMO0EWv87WcaZbi7zIethQMkWW5hPGmKrI67zEh6EsploHAlcMdFiFpp3m8cTRMhT/LhI6ySe/8ITh1u0vVwVxLkQrChcouIUbjSFm8OygVkHTf9luS8xE+7eJ61xgmGAgP2V4TaOub4jh8ywu5YVJtLqvra+hWTQsdAIeeX9nHD7d+oq6GxWC5tpHGn70HSYovt9W0aMN5ZandW9TV4uN6jALibjN777YOHSZdiLEk9y8tNGMcLSNRNTVBKRdgdyaOVEeMG+l8Wl+IORkB2BrjRmSM3pKS+TH27ohYC8dQvuGLegQxbWGHpFqwul4lhQ/Hz19oxuqKCPFIar2YCYhZPl+j4yshF8JK/REFQ1otbBfjLF5wYieqYyzT575As+/lp/SiIxof0k81aMBG12iMHHBlcDRn0eTfH8OY3Eri+7fmpjtRTHSo2Pey9E7lRU3oYQ/Zczgj285sR0/cMZZKy2DGzNIVCJD9MSb5IZ0GDl18vLFciVmY02fK6n2VteVDT8jBR+Kavso6FnnH5Z5nE6od82+sfWO6/9mAwhbrTpJiHJw1be6Fr3fnrmVwvRxUDhspYGyuy70kK3BhlVPXQ2TestevuCVyUbV0FWBkXeXgjVCROnBQTRm0ELXkuPsPwv+jfK7pRTX7a1/AA9/iddFgG0zrcXAG4NjTBjExqqc3dN8E4HiucwQZGeeiP6+fsXC0Ap/nhZgYtFQ47XluT9Lp9USiV3G/QniZ6J9fbALtCgCwurPF7oMwndiaN1ZaUjKHyRmhQjzj+tzVY6QhY7RtQA3j26DhrD9DagVvFWcoeTph/DTpYjxW0J9ctJ5l5A0afBojdjJgs3e4Xm94BIkpZDCcaHfeFk7OoGPVoIQOksnHdDWJ/MejjHqTKYPDgA/V2EdYHP+qEjszRq281twjeSqVmlhIRunNFP21JY1yRlXbWUXjilINYTNkHR6AhoYym0YsY/W6+ZSZh0keWcSLUQSDjUCntW+79tZB4JEt21YTYN9n597eno43avDQq3Y7syK13AHUOwTPmkrt8ScHySHI2GWcyeWvI7E9Bf9m5vCVLOj5/OcminI51AGut8iYgeUhWR/Y4FzuPfSC67jMyOzkUBEYl34hp9f0gE5kyCcTzR8Nx9HculqVderAgyIznp+CRG+VcV8rLUPe2TD/BJ0VQfIwNpb0ULK9XX/pe0jI
5
Correct. You have uncovered a critically important aspect of this case. As you continue exploring more investigations, consider what biochemical consequences might occur when someone is not consuming glucose and cannot convert the food that they are eating into glucose.
Incorrect. As you continue exploring more investigations, consider what biochemical consequences might occur when someone is not consuming glucose and cannot convert the food that they are eating into glucose.
true

SECONDARY INVESTIGATIONS

true

Determine Blood Serum Concentrations

inv7
true

Common immunoglobins (IgG, IgA, IgM) and ammonium (NH4+) levels

Results for Dave: All values for immunoglobin concentrations are at the low end of the normal ranges, which is normal for someone finishing a marathon. (normal ranges: [IgG] = 560–1800 mg/dL; [IgM] = 45–250 mg/dL; [IgA] = 100–400 mg/dL); [NH4+] = 20 mmol/L (normal range: 12–48 mmol/L)

Results for Michael Severely low levels of IgG, IgM, and IgA. [NH4+] = 67 mmol/L (normal range: 12–48 mmol/L)

inv105
true

Question 1.5

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
5
Correct.
Incorrect.
Incorrect.
inv8
true

Free fatty acids (FFAs) and triacylglycerols (TAGs)

Results for Dave: 500 mg/dL FFAs (normal range: 190–420 mg/dL); 190 mg/dL TAGs (normal range: 40–150 mg/dL)

Results for Michael: 660 mg/dL FFAs (normal range: 190–420 mg/dL); 230 mg/dL TAGs (normal range: 40–150 mg/dL)

inv9
true

Glucose and glycated hemoglobin (HbA1c as a marker)

Results for Dave: [Glc] = 39 mg/dL (normal range: 70–110 mg/dL) Note: This value indicates severe hypoglycemia. HbA1c = 4.4% (normal range: 4–6.5%)

Results for Michael: [Glc] = 31 mg/dL (normal range: 70–110 mg/dL) Note: This value indicates severe hypoglycemia. HbA1c = 3.2% (normal range: 4–6.5%)

inv106
true

Question 1.6

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
4
Correct.
Incorrect.
Incorrect.
inv106b
true

Question 1.7

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
3
Correct.
Incorrect.
inv10
true

H3O+ ions: blood pH

Results for Dave: pH = 7.31 (normal range: 7.35–7.45)

Results for Michael: pH = 7.2 (normal range: 7.35–7.45) The physician you are shadowing tells you that a value of 7.31 indicates acidosis but that this value will not normally cause a loss of consciousness. A pH value of 7.2 indicates severe acidosis and could result in neurological problems.

inv11
true

Ketone bodies (acetoacetate and acetone)

Results for Dave: low but detectable levels (normal range: undetectable)

Results for Michael: dangerously high levels of both found

inv107
true

Question 1.8

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
Incorrect.
4
Correct.
Incorrect.
true
inv108
true

Question 1.9

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
Incorrect.
4
Correct.
Incorrect.
true
inv12
true

Lactate and pyruvate

Results for Dave: [lactate] = 2.0 meq/L (normal range: 0.5-2.2 meq/L); [pyruvate] = 0.05 meq/L (normal range: 0–0.11 meq/L)

Results for Michael: [lactate] = 0.7 meq/L (normal range: 0.5–2.2 meq/L); [pyruvate] = 0.02 meq/L (normal range: 0–0.11 meq/L)

true

Determine Urine Concentrations

inv13
true

Branched-chain α-keto acids

Results for both Dave and Michael: undetectable levels (normal range: undetectable)

inv109
true

Question 1.10

6nUk1fzBz9ThPNuw1CPLuddKP/KIj4KgteSMB5CD6+y1urz5dpztLvxaULO846Cpri309ysVltHEuR5p/SJf0o/CK+MJ9VwOuIPo61EcpmVn5KttbDEoBMJuPDAx1ncC/HyNu+dNfxylApFMn1DcjhLfcmDrGnbGzwo3Pb9Lf2jhZ3mB175K7cjXDiIFrCH+OpJFTCs4zFSYQLytK14ta4sUsDI0FxdHL1cHShDLK/N1+K/1XuxQCz/AMWtb8rZShLNADGTjQagyHVFQw0SL7EvpdyxRhDIT7YW/FgjbblS0raPUgVLmIkPrvHIz633Pq+SS97pqBDe+3RxmBQHLGsnk/TC9xczYekFLAzurL06HbIwsqG2EM3ULbp0r5WvkOy2CYL2cDEyHIi66He3CKUAI5HOJKqV/g33lId9zh7bXQ4e0VrHtxwzqU8H1VBV7DnNPwYMzhlY2SGMvVKvuwit+YJFPCHcx4FOtkJZ85v4YOJS6Xds3BRGWBLKuypMDnwiPedSbkZms6KZrJaYUwtje3vO+hp/EUQpsYO5795zFU3t/csm+ECATA4lFvjCLfPU9hEvZw1gLVeSnqq+gFfwlX13/Zzr/cJ7ni6LgGbnyUt88XsNyixoiFzYae5A+y8k1xGvsOGIeDllpGWatpeh4Rj9c39yWsbOEzJ/vekTr1sZCIvuUoFDuk95+GX5Iay+ZsYlDZa3nnUZhjUZ/aEM6gSPme+/pTWCgXrTOzagXORhaeQBwAIhV/4PpokhwHWGDU1lSZHV9Xs7cn7eXzEEgCqxtk5I2fC88EEVLNTV9SHKNgv9Df/OCIvOyKQd61BLbgC/DHXhxERKKCQjHPnd5e6qKQOndB3GReapZgUIRguRAohlCmD18mx4QTEk8QDLBHI5cAEu+rrOt+Xp6qvqbrTCBcC5K26LS1WmpDAQnNgac97ASkDFgWJ32mFL5wcwOfahDNOiKtO0a31Muf0h19jKIXeFs/WkkOGBY2egFoTQpbk3yASp4CeAcBGj6qhqwfoJ3Naoas66YE+vq0ErkUr10aOKVVsTViy8c/i5cPf8fg0d92jDWeuQW43jSYJFYk55XcvdPJJ3CAPRkyDtnEmIARItxZwftP/6GiXq3pZCRd2BlkmXoNLX9DwrxlfY6tqlbtc9DCZQf6g8xFRVRB4306FbLdv5WEkGvlqjle9/QU+TTvWI09ZO7GJf6ENOjmWIQK07t5GCfMTjlFk/yC6TEEgFuQ+xnqYtcK6cnbn/348u6Vf3bNyqkCyuYeumARgihsaNzDVIcQS86RLGFqFT1z+NlJKbDIskPhVYsIhHw0hTPKDcB/yBcWc5TMhQcZLURFErfa9LWsYp2gz3RQXLJtVj9abFR/h6La/QRemUywUFYh8Cs2QxqxuAgsGQZoJ5IOGy3snFCjp7GiFwrXgVzRja0Ggqejw+l+goQgb6ZUyspl9OAnGFd3hlDCnbjF7SY/HsBq0FPeJk9Q+PeanD9mprRkYZCubt9yJS5Zyj5eaGUJ/D2uBJE51fAczIXc6AFbSnPRTAxahBG+TlhKTuTXLsLKvxjroLQcUVBXt8TT7ArxNyYG5Z26Mv2
5
Correct.
Incorrect.
Incorrect.
inv14
true

Phenylpyruvate (a phenylketone)

Results for both Dave and Michael: undetectable levels (normal range: undetectable)

inv110
true

Question 1.11

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
5
Correct.
Incorrect.
Incorrect.
true

Specific Enzyme Tests

inv15
true

Lactate dehydrogenase (LDH)

Results for both Dave and Michael: [LDH] = 150 U/L (normal range: 110–210 U/L)

inv16
true

Liver Asp aminotransferase (AST) and Ala aminotransferase (ALT)

Results for Dave: Both enzymes are within the normal range (normal range: 7–55 U/L)

Results for Michael: Both enzyme levels are elevated.

inv17
true

Pyruvate dehydrogenase (PDH)

Results for both Dave and Michael: PDH complex activity = 2.5 nmol/min*mg (normal range: 2–2.5 nmol/min*mg)

inv18
true

Test cells for electron transport chain enzyme activities

Results for both Dave and Michael: ETC enzyme activities were normal.

1.4 Case Summary

Congratulations on completing this Case Study!

If your instructor has assigned the graded assessment for this case study, you can find it on the homepage of your Sapling course site.