PassNPLEX CONO Bridge

Logistics of the CONO Ontario Biomedical Examination

Where to find up to date information:

https://www.collegeofnaturopaths.on.ca/applicants/entry-to-practice-exam/
biomedical-exam/

At least a week before the exam, read over the rules and procedures and plan
what you will bring (ie ID, snacks, clear beverage container). Check the website
for updated rules:

https://www.collegeofnaturopaths.on.ca/resource-library/ontario-clinical-
sciences-and-ontario-biomedical-exam-handbook/

How the exam is administered:

3 hour exam with 150 multiple choice Q’s

= 1 min/question + 30 minutes to check your answers/answer difficult Q’s
*read the instructions/ask your proctor how to review your answers
before submitting so that you know before you begin

-Some Q’s are case-based, some are straight questions

-Administered on the computer at a testing centre
-During covid shutdowns, some exams were delivered at home using
online proctoring software.
-You will be able to book a location for the test centre or the at-home test
when you register for the exam depending on what’s available

Amount of overlap
-According to the blueprint for both exams, at least 90% overlap
-CONO blueprint is less specific than the NPLEX 1 blueprint

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Topics on CONO that are not on the NPLEX 1 blueprint:

1. Role of the microbiome in the processes of digestion, nutrient production, absorption,

and elimination.

2. Microbiome on the skin

3. Synthesis of Vitamin D in skin

4. Mechanisms of sexual arousal and response

5. Physiological adaptations related to pregnancy

6. Regulation of red blood cell production

7. Microscopic anatomy of nails

8. Comparison between Innate and Adaptive Immunity (self-study)

9. Classification of viruses, prions, bacteria, fungi, protozoa, and helminths based on

structural and biological characteristics (self-study)

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Role of the microbiome in the processes of digestion, nutrient

production, absorption, and elimination.
Composition of the Enteric Microbiome:

Composed of about 100 trillion bacteria, fungi and viruses.

Composition differs in longitude (lengthwise) and latitude (distance from the epithelium)

Most common to least common bacteria in the gut:

-Bacteroidetes and Firmicutes (Gram+ anaerobes)

-Proteobacteria (facultative anaerobes)

-Actinobacteria (diverse group)

Fermentation:

Bacteria in the large intestine ferment resistant starch into short chain fatty acids (SCFA).
The main SCFA’s are listed below:

• Butyrate is the preferred energy source of enterocytes.

• Propionate is transferred to the liver where it regulates gluconeogenesis and satiety

(makes animals feel more full)

• Acetate is the most abundant SCFA and is used in peripheral (human) tissue in
cholesterol metabolism and lipogenesis.

Carbohydrates (including starch, inulin, pectin and cellulose) that were not broken down in
the upper GI tract can be broken down in the colon by carbohydrate-active enzymes
(CAZymes). The amount of breakdown depends on which bacteria are present.

-Accounts for 10% of calories

Noteworthy fermentable starches: Fructooligosaccharides (FOS) and

galactooligosaccharides (GOS) are easily fermented by many different gut bacteria.

FOS are found in many plant products, see FODMAP diet

GOS are found in breastmilk.

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Vitamin Production in the GI tract:

Folate (B9) is produced by bifidobacteria and contributes to systemic folate status.

B12 can be produced in the large intestine by bacteria,

-however it needs intrinsic factor (IF) to be absorbed in the small intestine so the B12
produced by in a human’s large intestine is mostly used by other bacteria and excreted.

-NOTE: about 1% of oral B12 may be absorbed passively without IF

The following vitamins are produced in the large intestine, but their impact on systemic
status is unknown:

Vitamin K2

Vitamin A

riboflavin (B2)

biotin (B7)

pyridoxine (B6)

and thiamine (B1)

Microbiota can influence the amount of bioavailable hormones (ie. estrogen) and drugs (ie.
digitoxin) that are absorbed and recirculated from the intestines.

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Congugation or decongugation of bile acids

1. Bile acids produced from cholesterol in the liver.

2. The new bile acids and “recycled” ones are secreted via the gallbladder into the
duodenum. These are conjugated with glycine or taurine so that they can emulsify fats.

1. Function: In the small intestine bile acids emulsify fat into micelles that can more
easily be acted on by lipases and be absorbed at the brush border.

3. Further along in the small intestine, bile acids can undergo deconjugation/
dehydroxylation by intestinal bacteria.

4. At the terminal illeum, 90% of these are reabsorbed and brought back to the liver via
enterohepatic circulation (the portal vein). These become the “recycled” bile acids in
step (2). The remainder are excreted.

• Bile acids can kill bacteria by disrupting their lipid membranes so modifying them in
the GI tract is for self-preservation.

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Heme breakdown:

Heme

(heme oxygenase)

Biliverdin

(biliverdin reductase)

bilirubin ——-> bound to albumin and collected

in the liver hepatocytes

(congugated with glucuronic acid via UDP

image from: Wikipedia Commons
glucuronyl transferase)

congugated bilirubin ——> Excreted with bile into the

small intestine

(decongugated by intestinal bacteria)

urobiligen

some—-> reabsorbed into enterohepatic circulation and secreted into bile

some —-> excreted into urine as urobilin (turning it yellow)

most ——> further oxidized and excreted in feces as stercobilin

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The Microbiome on the skin

-Due to its expansion and renewal in the first years of life, the skin microbiome of adults
and children varies greatly.

-Vaginally vs. Cesarean-section delivered babies have different skin microbiomes initially:
Lactobacillus sp. are prevalent in vaginally-delivered and Staphylococcus sp. in C-section
babies.

-At 3 months of age, site-specific communities are established on the skin

Organisms:

• Staphylococci Epidermis is most common. May protect against colonization of Staph

aureus

• Staphylococci Aureus colonizations associated with infections and atopic dermatitis

• Propionibacterium acnes secretes enzymes that injure pilosebaceous glands which

exacerbates acne vulgaris.


Synthesis of Vitamin D in skin:

1. UVB light from the sun lyses 7-dehydrocholesterol (provitamin D 3) -> previtamin D 3
(cholecalciferol) in the plasma membrane of skin cells

2. previtamin D3 has an unstable cis isomer shape -> it rearranges to form double bonds
and create vitamin D3 within several hours

3. Vit D3 is then attracted to a binding protein in the extracellular space and enters
capillaries/circulation

4. If it doesn’t enter into circulation Vit D3 can absorb more UVB radiation and isomerize
into other biologically inactive photoisomers.

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Mechanisms of sexual arousal and response

Physiological sexual responses in men and women has been divided classically into
four phases:

1. Excitement

1. physical and/or psychological stimulation resulting in clitoral or penile tumescence

and vaginal lubrication

1. Penile tumescence is the result of increased blood flow into the corpora
cavernosa (arterial flow > venous return). Nitric oxide is responsible for
increases of blood flow. Peripheral parasympathetic innervation from S2-S4
segments is involved in addition to sympathetic innervation from T11-L2.

2. Less is known about female sexual response, but similar parasympathetic and
sympathetic innervation similarly applies and blood flow to the vagina and
clitoris are increased. Lubrication is a result of transudation of fluid through the
vaginal walls from the Bartholin glands.

2. Plateau

3. Orgasm

1. Sensory event associated with the repeated contraction of the pelvic floor and
ejaculation in men

1. Ejaculation occurs as a reflex from cutaneous stimulation. It involves the

emission of semen from the vas and seminal vesicles into the posterior urethra
and the closure of the bladder neck.

4. Resolution

1. Increased genital blood flow resolves

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Physiological adaptations related to pregnancy

-Human chorionic gonadotropin (hCG) is produced by the trophoblast at implantation.

-Changes in maternal metabolism prioritize fetal growth: hyperinsulinemia, insulin

resistance, increased plasma lipids, and more efficient plasma amino acid transport.

-maternal energy requirements are mostly met by lipolysis while carbohydrates

supply the fetus

-increased LDL and VLDL supply steroid hormone production in the placenta

-Blood volume and cardiac demand increase. This may cause a relative anemia (low
RBC concentration) for the mother or exacerbate preexisting heart disease.

-Heart rate increases 10-15 bpm

-Cardiac Output increases 30-50%

-Diastolic BP reduces 10-15mmHg due to less peripheral vascular resistance

(systolic remains the same)

-The increase in blood volume and glomerular filtration rate (GFR) will alter the
clearance rate of some medications.

-Pulmonary:

-pulmonary vascular resistance is reduced 30%

-pulmonary tidal volume increases 30%

-no changes in respiratory rate, maximum capacity or vital capacity

- 40% reduction in expiratory reserve because of the elevation of the diaphragm

by the enlarged uterus.

-Gastrointestinal:

-the lower esophageal sphincter (LES) reduces in tone and the stomach is
pressed upwards by the enlarged uterus causing GERD.

-intestinal motility is reduced, contributing to nausea, vomiting and constipation.

-nausea is also caused by low blood sugar assoc. with hyperinsulinemia

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-gallbladder release is decreased leading to increased risk of gallstones.

-Weight gain is expected in the second and third trimester averaging 1lb/week for
women who were previously normal and underweight and 0.5 lb/week for women that
were overweight or obese before pregnancy. A small percent of this weight gain is
increased adipose stores.

-Endocrine:

-Anterior pituitary gland increases to produce more prolactin and the size of the
posterior pituitary diminishes. The thyroid gland also enlarges during pregnancy.

-Oxytocin levels progressively increase along side serum estradiol (E2) and
progesterone. At birth, oxytocin stimulates contractions.

image from: Wikipedia Commons

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Regulation of red blood cell production

-The number or RBC’s is tightly regulated so enough oxygen can be transported to tissues
and there are not a mass of cells that may impede flow

-Erythropoietin is the main factor that increases RBC production

-90% of erythropoietin is formed in the kidneys

image from: Joy Dertinger PassNPLEX CC 2021

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Anatomy of a human nail

A. Nail plate

A. composed onychocytes:
keratinocytes that have lost their
nuclei and have less fat and
water and more cysteine = many
strong disulfide bonds. They do
not desquamate

B. lunula

A. the distal, visible end of the nail

image from: Wikipedia Commons
matrix (E)

C. root

D. sinus

E. matrix

A. where cells for the nail plate are formed by keratinocytes that flatten and loose their
nuclei. Also includes melanocytes, Langerhans and Merkel cells.

F. nail bed

A. does not contain stratum granulosum

B. Contains a rich vascular network

G. hyponychium

A. the epidermis underlying the free margin of the nail

H. free margin.

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Self Study:
Comparison between Innate and Adaptive Immunity

-Understand the differences and similarities in cells, function and location of their
components

Classification of viruses, prions, bacteria, fungi, protozoa, and helminths based on

structural and biological characteristics.


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