Diagnoses Flashcards
(173 cards)
1
Q
What percentage of cancer patients will develop MDD?
A
> 10%
But ranges 2-50% depending on study. 10% is from a n = 9000 lit review
2
Q
What percentage of depressed cancer patients also suffer with clinically significant anxiety?
A
2/3
3
Q
Does depression worsen cancer prognoses?
A
Yes
25-40% higher mortality
4
Q
Which cancers are most likely to be associated with clinical depression?
A
Lung
Pancreatic
ENT
Lowest in localised skin ca
5
Q
What point in the cancer journey are depression diagnoses highest?
A
At cancer diagnosis
6
Q
What two features of a cancer are associated with higher clinical depression rates?
A
Metastases
Pain
7
Q
Which age group is least likely to be depressed in cancer?
A
Children and adolescents
8
Q
What two laboratory tests are altered in depressed cancer patients?
A
- IL-6 (high)
- Cortisol (less diurnal variation)
9
Q
What are possible biological (i.e. nonpsychosocial) causes of depression in cancer?
A
Tissue damage leading to inflammatory cytokine release, causing:
- Cytokine-mediated NE/serotonin uptake
- Increased cortisol levels
- Reduced neural growth factors
- Increased tryptophan catabolism
IL-1, TNF-a, IL-6, interferons
10
Q
What is the main external cause of poorer survival in cancer + depression?
A
Declining cancer treatment
11
Q
What side effect of SSRIs is especially concerning in patients on chemo?
A
NV
12
Q
What nonpharmacological factors help manage cancer + depression?
A
- Strong therapeutic relationship
- CBT
- ACT
- Relaxation techniques
- Exercise
13
Q
What demographic risk factors exist for depression in cancer?
A
- Female gender
- Older age (likely)
- Less education
- Lower income
- No intimate partner
- Distressed caregivers
14
Q
What psychological risk factors exist for depression in cancer?
A
- Preexisting depression
- Pessimism
- “Giving up”
- Neuroticism
- Rumination
- Disagreeable personality
- Avoidant/antisocial coping strategies
15
Q
Is suicidality solely found in cancer patients who are depressed (vs. not depressed)?
A
No–it is not diagnostic of depression
16
Q
What is a pheochromocytoma?
A
Catecholamine-secreting tumour of either the adrenal medulla or sympathetic ganglia.
Technically, the latter are “catecholamine-secreting paragangliomas”
17
Q
What percentage of pheochromocytomas are sporadic vs. genetic?
A
60% sporadic
40% familial
18
Q
What is the “classic” pheo presentation?
A
Episodic headache / sweating / tachycardia
19
Q
What is the most common presenting pheo symptom?
A
Hypertension
(paroxysmal or sustained)
85-95% at diagnosis
20
Q
What is a pheochromocytoma crisis?
A
Acute:
1. BP changes (high or low)
2. Hyperthermia >40 C
3. Cognitive changes
4. Organ failure
21
Q
What metabolic disorder can pheo induce/mimic?
A
T2DM
- catecholamines can cause insulin resistance
22
Q
What % of pheos are found incidentally?
A
60%
23
Q
What important treatment must be given before manipulating a pheochromocytoma?
A
Sympathetic antagonism
a-blockade
(phenoxybenzamine)
then
low-dose B-blockade w. nonspecific BB
never begin B-blockade before a
consider high-Na diet to maintain volume
24
Q
Are most catecholamine-secreting tumours benign?
A
Yes
90%
25
What is a hyperadrenergic spell?
Acute, self limited episode for:
- palpitations
- sweating
- HA
- tremor
- pallor
| MOST ARE NOT PHEO-RELATED
26
Which medications should be discontinued prior to pheochromocytoma investigations?
| (because they increase catecholamine levels)
1. TCAs
2. Decongestants
3. Amphetamines
4. Ethanol
5. L-dopa
6. Most psychoactive rx (not SSRIs)
27
What is the standard first test for suspected pheo?
24-hour urine catecholamines/metanephrins
28
Which 2 cancers are most associated with SCVO?
NHL
lung
29
What are the most common SVCO symptoms?
Dyspnea (most common)
Facial/upper limb edema
Chest pain
30
How is SVCO graded?
0-5
1. Edema + vascular distension
2. Functional impairment from edema
3. Cerebral or laryngeal edema
4. Severe cerebral or laryngeal edema (stridor), or hemodynamic compromise (spontaneous syncope)
5. Death
| Most presente grade 1-2
31
What is the best imaging modality for SVCO?
CT w. contrast
32
What grade of SVCO is considered a medical emergency?
4
- severe laryngeal edema
- reduced LOC from cerebral edema
- central airway obstruction
33
What is the immediate approach to SVCO, grade 4 presentation?
ACLS to stabilise, then emergent stenting or thrombectomy
34
What is the approach to SVCO, grade 1-3 presentation?
1. Identify cause
2. Stent (esp. if chemo/radioresistant tumour)
3. Chemotherapy if lymphoma/SCLC
4. Radiotherapy if sensitive
5. Surgery (rare)
35
What two signs are indicative of inflammatory breast ca?
Skin erythema
Peau d'orange (edema)
| 1/3+ of breast
36
What are the diagnostic criteria for inflammatory breast ca?
1. Erythema or edema or warmth on 1/3+ of breast
2. Duration <6mo
3. Pathology+ breast ca
37
What percentage of breast ca are inflammatory?
1-2%
38
For which cancer is paracentesis not an ideal treatment for ascites?
Ovarian
| (tends to be mucinous)
39
In which population is diuresis the first-line treatment for ascites?
Portal hypertension
- cirrhosis
- large-volume liver disease
- HCC
40
What test distinguishes ascites likely to respond to diuresis?
Serum-ascites albumin gradient >11
this indicates transudative ascites
41
What is the usual dose ratio for diuretics in ascites?
5:2
Spironolactone 100mg + furosemide 40mg
42
What intervention for ascites has a poor risk:benefit ratio?
Peritoneovenous shunting
43
In which population are large-volume paracenteses *safer*, malignant- or portal-hypertention-related ascites?
Malignant ascites
44
Do patients with malignant ascites require post-para albumin?
Probably not
45
What volume of transudative ascites likely warrants albumin infusion?
>5L
46
What is the albumin dose post-paracentesis, if indicated?
6-8g per L of fluid, maybe lower
47
What is the most common cause of "malignant" or transudative ascites?
Peritoneal metastases
48
What is the first test for patients with restless leg syndrome?
iron studies
| (and workup of the cause of iron deficiency if present)
49
What substances can worsen the symptoms of restless leg syndrome?
1. EtOH
2. Caffeine
3. Dopamine antagonists
4. Antidepressants
5. First-gen antihistamines
50
List some nonpharm. options for managing restless leg syndrome.
1. Good sleep hygiene
2. Distractions when resting (e.g. games, work)
3. Regular exercise
4. Moist heat on legs
5. Leg massage
6. SCDs
51
What is the first prn drug for occasional RLS symptoms?
Sinemet
52
When is regular therapy indicated in RLS?
symptoms 2+ days/wk
symptoms impact QOL
53
What is the best class of drugs first-line for regular treatment of RLS?
HS gabapentinoids
54
What is the second-line drug class for RLS?
dopamine agonists
e.g. pramipexole, ropinirole, rotigotine
55
What is the third-line approach to RLS?
1. Combine gabapentinoid + dopamine agonist
2. Low-dose opioid
56
What are the core clinical features of Lewy Body Dementia?
1. Fluctuating attention/LOC
2. Well-formed visual hallucinations
3. REM sleep disorder
4. Bradykinesia or rigidity or resting tremor
57
What secondary features may develop in Lewy Body Dementia?
1. Profound sensitivity to antipsychotics
2. Parkinson-type symptoms
3. ANS dysfunction
4. Psychotic features
58
What class of drug is first-line treatment for LBD?
Cholinesterase inhibitors (e.g. donepezil, rivastigmine)
59
What are possible effects of antipsychotic medication in LBD?
1. Parkinsonian crisis
2. Severe ANS dysfunction
3. Confusion
4. Death
60
If using antipsychotics in LBD, name 2 options.
Quetiapine
Clozapine
61
What are the 3 realms of symptoms present in Huntington disease?
1. Movement/neurological
2. Psychiatric
3. Cognitive
62
What is the defining cognitive impairment in Huntington disease?
Exective dysfunction
63
List some psychiatric symptoms of Huntington disease
1. Depression
2. Dysphoria
3. Apathy
4. Anxiety
5. Irritability
6. Agitation
7. Psychosis
64
What are the first- and second-line treatments for HD chorea?
1st line:
- vesicular monoamine transporter 2 (VMAT 2) inhibitors
- deu/tetrabenazine
- can cause depression
2nd line:
- atypical antipsychotics
- first line in patients with psychiatric disturbance
65
What is the currently accepted term for "complicated grief"?
Prolonged grief disorder
66
What is (probably) the general prevalence of prolonged grief disorder among the bereaved?
10%
| studies suck
67
What is the prevalence of prolonged grief disorder in those who have lost their SO?
10-20%
68
What is the prevalence of prolonged grief disorder in those who have lost a child?
60%
69
List 5 risk factors for prolonged grief disorder (9)
1. Age >60
2. Female
3. Low SES
4. Marginalised populations
5. Previous mood disorder
6. Loss of child or spouse
7. Young decedent
8. Death by trauma
9. Multiple losses
70
What are 3 characteristic features of grief in prolonged grief disorder?
1. "Separation distress": yearning/preoccupation with decedent
2. Loss of interest in the world/withdrawal
3. "Traumatic distress": disbelief, sense of being dazed, intrusive memories
| 6+ mo
71
What are 6 maladaptive cognitive patterns associated with prolonged grief disorder?
1. Denial
2. Ruminating on alternative versions of the death
3. Self-blame/anger
4. Intense reactions to reminders of decedent
5. "Shrine building" *or* extreme avoidance of reminders of decedent
6. Emotional dysregulation
| not inherently abnormal, but abnormal when prolonged
72
What is the rate of suicidal ideation in prolonged grief disorder?
40-60%
73
Name a screening tool for prolonged grief disorder and its 5 components.
Brief Grief Questionnaire
1. Difficulty accepting death
2. Grief impairs function
3. Disturbing thoughts about the death
4. Avoiding reminders of decedent
5. Feeling cut off from others
| each rated 0-2; 4+ is a positive screen
74
What is the three-part CSPCP mission statement?
To promote Palliative Medicine in Canada through advanced **education**, strengthening the **workforce**, and **advocacy**.
75
What is the four-part CHPCA mission?
The Canadian Hospice Palliative Care Association is the national voice for quality hospice palliative care in Canada by providing **education**, raising **awareness**, influencing public **policy**, and **collaborating** with provincial associations.
76
What % of patients with cancer will develop hypercalcemia?
20-30% (c. 1/4)
77
List 4 cancers in which hypercalcemia is common (6)
1. Lung
2. Breast
3. Renal cell
4. Myeloma
5. Lymphoma
6. Squamous cell
78
What are the 4 mechanisms of malignant hypercalcemia?
1. Humoral (PTHrP)
2. Ectopic PTH secretion
3. dihydroxy-Vitamin D secretion
4. Osteolytic metastases
79
List 2 cancers associated with humoral hypercalcemia.
1. Squamous cell
2. Renal cell
80
List 1 cancer and 1 noncancer entity associated with dihydroxy-Vitamin D secretion.
1. Lymphoma (all types)
2. Granulomatosis
81
List 3 cancers associated with osteolytic metastases leading to hyperCa.
1. Lymphoma
2. Myeloma
3. Leukemia
4. Breast
| (i.e. hematological malig + breast)
82
List 2 cancers associated with ectopic PTH secretion.
1. Lung
2. Ovarian
83
What tests, in order, could be ordered to determine the etiology of hyperCa of malignancy?
1. Ca++ with PTH
2. PTHrP and dihydroxyvitamin D
3. Myeloma workup
4. TSH + Vitamin A
84
List 3 medications that can cause hypercalcemia (5)
1. High-dose vitamin D
2. High-dose Ca salts + renal failure
3. Teriparatide (PTH) for osteoporosis
4. Thiazides
5. High-dose vitamin A or analogs
6. Lithium
85
What is the initial dose of calcitonin for hyperCa?
| What if the initial dose is ineffective?
4u/kg q12h x maximum 48h
| 8u/kg q12h x 4 max
86
What is the typical onset of bisphosphonates for hyperCa?
2-4d
87
At 1 week, are bisphosphonates superior, inferior, or equal to Xgeva/denosumab?
Equal (response rates c. 90%)
88
What are the two most common causes of hypercalcemia of malignancy?
Humoral (c. 80%)
Osteolytic mets (c. 20%)
89
What are the two most common causes of hypercalcemia of malignancy?
Humoral (c. 80%)
Osteolytic mets (c. 20%)
90
What are the two most common causes of hypercalcemia of malignancy?
Humoral (c. 80%)
Osteolytic mets (c. 20%)
91
What level could be tested and supplemented (if necessary) prior to bisphosphonate therapy?
Vitamin D
92
Which bisphosphonate is superior for hypercalcemia of malignancy management?
Zolendronic acid
| (superior to pamidronate with response c. 90% vs. 70%)
93
What are the most common side effects of bisphosphonates?
1. Flu-like symptoms
2. HypoCa
3. HypoPO4
4. AKI
5. Uveitis
94
Which population is less likely to respond to pamidronate (vs. ZA)?
Humoral hypercalcemia (i.e. elevated PTHrP)
95
List 4 ways in which neuropathic pain differs from nociceptive
1. Related to direct nerve damage
2. Dermatomal/innervation involvement
3. Burning/tingling/shooting/electric quality
4. May have a central contribution
5. Presence of hyperalgesia/allodynia
96
List 3 ways in which visceral pain differs from somatic.
1. Poorly localised/large area
2. Cutaneous referral
3. Related to internal organ involvement
97
What percentage of cancer patients with pain have a neuropathic component?
40%
98
What is the midline retroperitoneal syndrome?
Tumour invasion of any midline abdominopelvic structure leading to posterior abdominal wall irritation/nerve plexus involvement.
Pain is epigastric/low thoracic
99
Give 4 examples of visceral pain as related to cancer.
1. Hepatic distension
2. Bowel obstruction
3. Peritoneal carcinomatosis
4. Ureteric obstruction
5. Retroperitoneal syndrome
6. Adrenal metastases
100
In order, list the pathways of a visceral nociceptive signal to the cortex.
1. Internal tissues/nerves (e.g. organs)
2. Local parasympathetic ganglia
3. Splanchnic nn.
4. Pre/paravertebral ganglia
5. Dorsal horn of ipsilateral spinal cord
6. Spinothalamic tract of the contralateral spinal cord
7. Reticular activating system (brainstem)
8. Thalamus
9. Cortex
101
In order, list the pathways of a somatic nociceptive signal to the cortex.
1. Peripheral tissues/nerves
2. Dorsal horn of ipsilateral spinal cord
3. Spinothalamic tract of the contralateral spinal cord
4. Reticular activating system (brainstem)
5. Thalamus
6. Cortex
102
List 4 peripheral pain mediators
1. Substance P
2. Serotonin
3. Prostaglandins
4. Histamine
5. Bradykinin
6. ACh
103
List 4 causes/risk settings of bleeding in palliative care (8)
1. Large ENT cancers
2. Large central lung ca
3. MDS --> thrombocytopenia
4. End-stage leukemias
5. Oral anticoagulants
6. Severe liver disease (metastatic or cirrhotic)
7. High-dose radiation
8. Fungating tumours
104
List 3 classes of drugs associated with increased bleeding risk (6)
1. Anticoagulants
2. Antiplatelets
3. Antidepresants, SNRI/SSRI
4. Corticosteroids
5. NSAIDs
6. Chemotherapy (many classes)
105
What 3 features of "hemoptysis" point away from UGIB?
1. Alkalinity
2. Foaminess
3. Purulence
106
What % of malignant spinal cord compressions are related to metastatic (vs. primary) disease?
90%
107
What are the 4 mechanisms of metastasis leading to SCC?
1. Arterial hematogenous spread to bone (most)
2. Venous hematogenous spread to bone (prostate ca only)
3. Ingrowth via neural foramen
4. (rare) Direct epidural spread
108
What is the order of pathophysiological events in the development of SCC?
1. Growth around thecal sac
2. White matter edema
3. Grey matter edema
4. Spinal infarction
109
What is the first-line imaging modality for malignant SCC?
MRI w/ and w/o contrast
| CT w contrast if MRI contraindicated
110
Describe the epidural-spinal-cord-compression scoring on MR
0: no SCC, tumour in adjacent bone
1. Epidural tumour without contact/just abutting
1a. No compression of sac
1b. Compression of sac but no cord contact
1c. Compression of sac and cord contact w/o compression
2. Compression of cord without circumferential involvement/still some CSF
3. Circumferential involvement or severe SCC
| 1 is "low grade"
2-3 are high grade
111
What uncommon test is the gold standard / alternative to MR?
CT myelography, with dye injection into intrathecal space
112
What are the 3 classic features of leptomeningeal disease?
Cranial nn palsies
Headache
Mental status changes
113
What is the defining neurological feature of ALS?
Upper + lower motor neuron involvment
114
What are the 2 most common patterns of ALS at presentation?
1. Asymmetric limb weakness (80%)
2. Bulbar sx (dysarthria or dysphagia) (20%)
115
List 5 good prognostic signs for ALS at diagnosis.
1. Younger age
2. Limb onset (vs. bulbar)
3. Longer duration of symptoms prior to diagnosis.
4. High FVC at diagnosis (>60% predicted)
5. Higher function at diagnosis
116
List 8 s/sx suggestive of respiratory failure in ALS
1. Dyspnea at rest/minimal exertion
2. Orthopnea
3. Nighttime waking with dyspnea
4. Daytime fatigue
5. Accessory muscle use
6. Paradoxical abdominal breathing
7. Cough weak / accumulating secretions
8. Hypophonia
117
List 3 indications for BiPAP in ALS
1. FVC <50% predicted
2. Nocturnal hypoventilation
3. Dyspnea at rest/minimal activity
118
What is the mean survival from onset of invasive ventilation in ALS?
30 months
119
What 3 vaccines should be offered to patients with ALS?
1. Flu shot
2. COVID
3. Pneumococcal
120
What are the indications for enteral feeding in ALS?
1. BEFORE FVC <50%
2. Near diagnosis
3. Dysphagia
4. Weight loss
121
What is the current evidence around life-prolongation with enteral feeding in ALS?
c. 6-month benefit, no QOL improvement
122
List 5 medication options for ALS related muscle spasticity/cramping
1. Mexiletine
2. Anticonvulsants
3. Tizanadine
4. Baclofen
5. Gabapentin
6. Botox
123
List 3 ways to manage thick secretions in ALS
1. Hydration
2. Mucolytics (NAC, guaifenesin)
3. Humidified air
4. Cough augmentation
5. Suction
124
What is the pseudobulbar affect?
Sudden uncontrolled episodes of laughter or crying.
Potentially related to impaired descending modulation of emotional expression.
| Also called emotional lability or incontinence
125
What is the standard pharmacological treatment for pseudobulbar affect?
Quinidine + dextromethorphan
30mg each bid (lower quinidine may work)
| Quinidine serves to reduce DM metabolism by CYP
126
What form of dementia are patients with ALS at higher risk for?
Frontotemporal
127
Which class of antidepressants should be considered first-line in ALS?
TCAs
| (they also treat sialorrhea, pseudobulbar affect, insomnia)
128
What is the main dividing line in neuroendocrine tumours, other than system of origin?
Well-differentiated vs. poorly
- affects prognosis/treatment
- aka "neuroendocrine tumour" vs. "NE carcinoma"
129
What is the alternative (old) name for well-differentiated neuroendocrine tumours of the hollow digestive organs?
Carcinoid tumours
130
What is a neuroendocrine tumour of the lung?
Small cell lung ca
131
What peptides cause symptoms of carcinoid syndrome?
1. Serotonin
2. Vasointestinal peptide (VIP
3. Gastrin
4. Histamine
5. Bradykinin
132
Neuroendocrine tumours of what embryological origin tend to cause carcinoid syndrome?
Midgut (small intestine + colon)
133
List 5 peptides secreted by functional pancreatic NETs.
1. Insulin
2. Somatostatin
3. VIP
4. Gastrin
5. Glucagon
134
Describe the carcinoid syndrome.
1. Chronic episodic flushing
2. Chronic episodic hypotn/tachycardia
2. Chronic episodic diarrhea
3. +/- R sided heart valve failure
4. +/- Chronic episodic bronchospasm
135
What is the classic triad of a functional somatostatinoma?
1. Diarrhea/steatorrhea
2. Cholelithiasis
3. T2DM
136
What is the mechanism of paraneoplastic syndromes of the nervous system?
Antibody/humoral immunity cross-reactivity between tumour and nervous system antigens.
137
What areas of the nervous system can be affected by paraneoplastic syndromes?
All!
- CNS
- PNS
- neuromuscular junctions
- muscle tissue directly
- retinas
138
What percentage of lung ca are associated with paraneoplastic hyperCa?
6%
139
What cancer accounts for 75% of malignant SIADH?
SCLC
| 10% of SCLC cause SIADH
140
What are the symptoms of malignant SIADH?
1. Confusion
2. Anorexia/NV
3. Cerebral edema (if acute)
141
What is the mechanism of Lambert-Eaton syndrome?
Autoantibodies targeting voltage-gated-Ca-channels
- reduced ACh release at NMJ
142
What is the presentation of Lambert-Eaton syndrome?
1. Progressive proximal muscle weakness (esp. legs)
2. Reduced DTRs
3. Ptosis and/or diplopia
4. Recovery of reflexes/strength with brief vigorous exercise (unique to LES)
5. Limited respiratory muscle involvement
143
What hematological changes are commonly found in lung cancer?
1. Anemia (40%)
2. Leukocytosis (15%)
3. Thrombocytosis (15%)
144
What bony paraneoplastic syndrome can be seen in lung ca?
Hypertrophic osteoarthropathy
- clubbing of nails
- symmetrical pain in joints/long bones
- esp. distal joints (elbows/knees down)
- treated with steroids/NSAIDs/cancer treatment
145
What 3 features point away from a rheumatoid arthritis diagnosis and toward paraneoplastic polyarthritis?
1. Male sex
2. Asymmetry
3. High serum inflammatory markers
146
What three cancer types are most associated with paraneoplastic syndromes?
1. Lung
2. Gyne
3. Lymphoma
147
Do the majority of paraneoplastic syndromes present before or after cancer diagnosis?
Before (60%)
148
What % of patients in PC struggle with sexuality?
50-70%
149
List 3 common barriers to assessing sexuality in PC patients.
1. Inadequate training
2. Clinician discomfort
3. Assuming old people don't have sex
4. Assuming sex is only intercourse
5. Assuming treatments are not available
6. Assuming other providers will ask
7. Assuming single people don't have sex
8. Discomfort with nontraditional sexualities (heterosexism)
150
List 3 sample questions in a PC sexual history.
1. Many of my patients have challenges with sexuality. Do you have any?
2. Treatment may impact intimacy. Has it affected you?
3. Is your physical relationship important? Has your illness impacted it?
4. Does your living situation affect intimacy?
5. Can we help you reestablish physical intimacy?
6. Would you like help talking about this with your partner?
151
List 3 issues that impact female sexuality in PC.
1. Libido loss
2. Vaginal dryness
3. Dyspareunia
4. Vaginismus
5. Pelvic floor dysfunction
152
List 3 issues that impact male sexuality in PC.
1. Libido loss / ED
2. Urinary incontinence
3. Vasomotor symptoms
4. Penile shortening d/t treatment
153
List 8 non-symptom topics to discuss with families at the deathbed.
1. DNR/ACP
2. Funeral home
3. SDM
4. Encourage them to talk/touch
5. Prognosis
6. Educate around thirst/hunger/oral care
7. Explain/provide plans for any crises
8. Discuss any culturally relevant EOL/postmortem needs (e.g. lying in state, family washing body)
154
What is the survival curve post-dialysis withdrawal?
1. 10 days: 70% dead
2. 30 days: 97% dead
3. 100 days: 99%
155
List 5 factors that predict earlier mortality after dialysis is d/c
1. Male sex
2. White
3. Hospital inpatient
4. Lower PPS
5. O2 needs
6. Peripheral edema
7. Reduced oral intake
8. DNR
156
List 5 symptoms expected after dialysis withdrawal.
1. Fatigue
2. Pruritus
3. Drowsiness
4. Dyspnea
5. Edema
6. Agitation
7. Pain
8. Nausea/vomiting
157
Define "frailty"
**Age-related** syndrome of physiological decline, characterised by **vulnerability** to complications from medical and surgical treament.
Other features include:
- weakness/fatigue
- multimorbidity
158
What is the prevalence of frailty?
Difficult to say--definitions vary.
c. 10-15% of >65
c. 45% of >65 + cancer
c. 40% >95
159
What three major outcomes does frailty increase one's risk for?
| (outcomes not related to comorbidities)
1. Hip #
2. Disability/institutionalisation
3. Hospitalisatiom
160
What are the 2 main conceptual frameworks of frailty?
*Syndromic/phenotypical frailty*: based on symptoms and signs such as wakness, slow gait, and fatigue.
Index frailty: based on the accumulation of comorbidities/insults resulting in frailty.
161
Name a simple 5-part frailty screening scale and its components.
FRAIL scale
1. Fatigue (most/all of the past 30d)
2. Resistance (difficulty on 1 flight of stairs)
3. Ambulation (difficulty walking 1 block)
4. Illnesses (5+ of a list I won't include)
5. Loss of weight (5%+ in past year)
Each scored 0-1
0 = robust
1-2 = pre-frail
3-5 = frail
162
What is the key physiological aspect of frailty?
Senile sarcopenia
163
At diagnosis of frailty, what is an essential intervention?
Goals of care!
- tests and interventions are often less beneficial
- frail patients at higher risk of complications
164
List 4 interventions for frailty with evidence for efficacy
1. Group (but not individual) exercise
2. Nutritional enhancement (diet, SLP, dental, mood, medication s/e)
3. Cognitive training
4. OT assessment for ADLs
5. Vitamin D (maybe)
6. Deprescribing
165
What are the cytokines associated
with tumour-related fever?
1. IL-1
2. IL-6
3. TNF-a
4. Interferons
166
Which cancer types are most ass’d with fever?
* RCC
* Lymphomas
* HCC
167
Define febrile neutropenia
1. Neutrophils <0.5 (ANC <500)
AND
2. 1 temp 38.5+ or 2 temps 38.0+ in 24h
168
Which two populations suffer
from iatrogenic hot flashes in PC?
Women in ovarian failure/post TSO
Men on estrogens/GnRH agonists
169
What are the core elements
of clinically diagnosing brain death?
1. GCS 3
a. No movement in response to stimuli
b. No seizures
2. Absent cranial nerve reflexes
a. Pupillary response
b. Corneal reflex
c. Neg- caloric testing
d. No gag/cough with deep suction
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What are invx to support a
brain death diagnosis?
1. No vagal nerve response to atropine
a. i.e. HR changes <10bpm
2. Absent central respiratory drive
a. Ventilate on 100% O2 x 20 min.
b. ABG
c. Stop ventilation
d. Repeat ABG in 10 minutes
e. If PaCO2 is >60mmHg, brain dead
f. Stop early if hypoxemic
3. Cerebral perfusion imaging
4. EEG (isoelectric = brain dead)
5. Transcranial Doppler (no diastolic drop)
6. ICP = SBP
171
Describe key aspects of preparing
to withdraw a ventilator support
1. Close contact with family
a. Encourage comforting rituals
b. Describe what will/may happen in explicit and simple terms
c. Describe your plan for comfort care
2. Ensure family can be present
3. Document GOC, plan, outcome
4. Reduce medications/tubes/restraints
5. Stop paralytics
6. Ensure sedation before/during/after
172
Describe an approach to sedation
during ventilator withdrawal
1. Sedate all patients, even comatose
2. Physician present until stable sx
3. Ideally use IV > subq route
4. Midazolam 5mg bolus then 1-5mg/h
5. Phenobarb bolus, 1-2mg/kg at 50mg/h rate
a. Then infuse 2mg/kg/h
b. Superior if patient more wakeful
6. Consider propofol (req. anesthesia)
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