LOs

Question 1

Define nephropathy.

Answer 1

Loss of >500mg/d of protein

Question 2

What is one sign of tubular and glomerular sclerosis as a result of nephropathy, other than pericyte loss and basement membrane thickening?

Answer 2

▪ Glomerular hyperfiltration which is associated with the expansion of the extracellular matrix
Albuminuria

Question 3

In addition to pericyte loss and BM thickening, what are the other pathological features of diabetic neuropathy.

Answer 3

• Attenuated perfusion of the nerves
  
  • Axonal thickening
    Neuron loss

Question 4

What therapies decrease the risk of macro and micro vascular complications?

Answer 4

• ACEi
  
  • Antiplatelet
    Statins

Question 5

Name the three principles governing current use of animals in research (Researchers should follow this In order to reduce the impact on animals).

Answer 5

▪ Reduction (reducing the number of animals used by improving experimental techniques, and data analysis techniques and sharing information with other researchers)
▪ Refinement (Refining the experiment or the way the animals are cared for so as to reduce their suffering - better houses, Living conditions, medical care etc.…)
▪ Replacement (replacing experiments on animals with alternative techniques like experimenting on cell cultures rather than full animals)

Question 6

What legislation Regulates animal research in the UK?

Answer 6

▪ Animals (Scientific Procedures) Act 1986 (ASPA) (the three R’s above come from this legislation!)

Question 7

What is the role of National Research Ethics Service (NRES) and Local Ethics committees in human research?

Answer 7

• National research ethics serves = regulates human research involving NHS staff, patients, or premises
• On a local level that is the NHS Research ethics committee
• On a local level not involving NHS = Research Ethics Comimittee

Question 8

What was the key point(s) in the Nuremberg Code

Answer 8

The voluntary consent of the subject is absolutely essential

Question 9

Name the 4 components of informed consent.

Answer 9

• Patient must have capacity
• Must give consent voluntarily
• Must be informed
• Consent must be continuing (can withdraw it at any time)

Question 10

List symptoms of hyperglycaemia.

Answer 10

• Passing a lot of urine
• Blurred vision
• Tiredness
• Extreme thirst
• Weight loss
• Itchy or sore genitals

Question 11

▪ How would you clinically differentiate between Type 1 and Type 2?

Answer 11

○ Presence of ketones, weight loss are more marked in type 1
○ FH or autoimmune disease more type 1 (e.g. Addison’s disease)
○ Antibody testing - GAD antibodies, islet cells antibodies, Anti ZnT8 ) but only for confirmation of clinical suspicion as they take up to 6 weeks so you would have treated the patient already + just because someone doesn’t have thee doesn’t mean they don’t have diabetes
○ C-Peptide levels has been increasing in use (C-peptide likely to be high in type 2 - be aware of honey moon)

Question 12

What medication you give if someone is diabetic and has protein in their urine

Answer 12

ACEi (Prevents nephropathy progression)

Question 13

what is the target BP for diabetic?

Answer 13

<130/80

Question 14

What does the Glycaemic index refer to?

Answer 14

Refers to how quickly carbohydrate is digested and absorbed as glucose into your blood stream

• Low = slowly absorbed
• High = quickly absorbed

Question 15

List the causes of acute Limb Ischaemia.

Answer 15

▪ Embolus (Cardiac - AF, Valvular heart disease, mural thrombus, endocarditis |Aortic and peripheral aneurysms | atherosclerotic plaque rupture)
▪ Thrombosis (plaque rupture and acute occlusion of pre-existing stenosis | background of PVD/Claudication)
▪ Trauma
▪ Dissection

Question 16

List the presentations of Acute Limb Ischaemia.

Answer 16

▪ 6 Ps (indicative of critical limb ischaemia):
		○ Pallor
		○ Paralysis
		○ Paraesthesia
		○ Pain
		○ Pulseless
		○ Polar (drop in temp) 
	▪ Elderly
	▪ Often new AF, not on coagulation
	▪ (Maybe irreversible muscle damage by 6 hours)

Question 17

Describe the investigations of an acute ischaemic leg.

Answer 17

▪ History
	▪ Examination
		○ Pulses (and contralateral)
		○ Cap refill/veins
		○ Sensation
		○ Motor Function 
		○ Squeeze calf
	▪ Ankle-Brachial Pressure Index (ABPI)
	▪ Arterial Doppler
	▪ Angiography (CT or MRI)

Question 18

Describe the management of Acute Limb Ischaemia.

Answer 18

▪ Analgesia 
	▪ Hydration 
	▪ LMWH or IV UF heparin
	▪ Imaging
	▪ Intervention
		○ Revascularisation
			§ Angioplasty and stenting (endovascular) - good for acute on chronic 
			§ Bypass surgery (open surgery) - acute on background of chronic disease, suitable if more extensive pattern of disease

Question 19

Define chronic Limb Ischaemia.

Answer 19

▪ Decrease in limb perfusion which may or may not threaten the viability of the limb
▪ Duration = >2 weeks

Question 20

State the cause of Chronic Limb Ischaemia.

Answer 20

▪ Atherosclerosis (build up of lipid, calcium, fibrous tissue within the intima of the arterial wall)
▪ >50% of diameter = flow limiting –> symptoms!
If plaques ruptures = thrombus = acute deterioration of symptoms!

(NOTE: So PVD causes the chronic limb ischaemia - so chronic limb ischaemia secondary to PVD)

Question 21

Define Intermittent Claudication.

Answer 21

▪ Most common presentation of PVD and chronic limb ischemia
▪ Pain or tightness, often in calves, on walking/exertion (the muscle group that is painful will be that supplied by narrow artery
Relieved by rest for 1-2minutes

Question 22

Describe the Examination of PVD.

Answer 22

• Inspection
  
  • Scars (remember groins)
  • Ulceration (between toes and on heel)
  • Colour
  • Venous guttering (occurs when the leg is elevated - if the arterial flow is sufficient veins should still fill, if they are empty and you can see shallow gutters where the veins have been this indicates fairly ischaemic limb)
• Palpation
  
  • Temperature
  • Cap refill time
  • Pulses – start with dorsalis pedis and posterior tibial pulse and work proximally
  • The aortic pulse is the most proximal of the lower limb pulses
• Ankle Brachial Pressure Index
  
  • Done in conjunction with examination
  • It is the rate of ankle to the brachial occlusion pressure (you divide the highest blood pressure of either dorsalis pedis or posterior tibial by brachial pressure which is measured by using BP cuff and doppler and seeing at which pressure the arteries occlude)
  • Normal is 0.8 - 1.2
  • Low ABPI usually due to lower limb peripheral arterial disease
  • Elevated ABPI due to calcified vessels - not reliable with diabetic with wide spread calcified arteries
  • This presumes arms vessels are normal

Other Investigations:
▪ Duplex ultra sound
▪ Angiography (CT or MR)
(Investigations only if intervention is planned)

Question 23

What is the most important intervention for claudication of the lower limbs?

Answer 23

▪ Risk Factor modification/management 
		○ Smoking cessation
		○ Hypertension control
		○ Good control of diabetes
		○ Supervised exercise (walking for 30-40 minutes 3 or 4 times a week (walking until you feel pain, push into it until you need to have rest, have rest then do it again)

Question 24

List the medications use to for chronic limb ischaemia/claudication.

Answer 24

▪ Aspirin or clopidogrel

▪ Statin

Question 25

Who are the patients that you should refer to secondary care? (these patients will benefit from further intervention as they are either at higher risk of limb threatning ischemia, or their claudication affects their daily life more.)

Answer 25

* Short distance claudication (<100m) * Sudden onset of symptoms * Lifestyle limiting * Threatening employment * Rapidly deteriorating * Especially if al risk factors addressed

Question 26

Define chronic limb threatening ischemia/critical limb ischemia.

Answer 26

▪ Chronic (>2weeks) ischemic at rest pain (pain particularly at night, they try to hang their leg out over the edge to improve supply), necrosis or ulceration as a result of proven arterial disease

Question 27

Describe the presentation of Chronic limb threatening ischemia.

Answer 27

▪ Ischaemic rest pain ▪ Gangrene, ulcers (neuropathic feet that rub on ill-fitting footwear with out the person realizing), non healing wounds ▪ May have background claudication (note: many patients present with chronic limb threatening ischemia as first presentation of PAD)

Question 28

Investigations for CLTI.

Answer 28

▪ Duplex US (allows us to see if a calcified plaque is actually affecting flow and general flow dynamics) --> CT angiography (gives cross sectional imaging) to delineate pattern of disease

Question 29

Initial management of CTLI.

Answer 29

▪ Address risk factors urgently ▪ Analgesia (often opiates, and also neuropathic pain with gabapentin or pregabalin) ▪ Refer early rather than urgently to vascular team ▪ Podiatry can help with wounds

Question 30

List the intervention management options for CLTI.

Answer 30

▪ Primary amputation (cannot revascularize or tissue loss is so extensive!) - either major (more proximal) or minor amputation (more distal like just the foot) ▪ Conservative treatment (No option for revascularization, or not fit for surgery, takes analgesia and lives with it!) Revascularization (Endovascular or open surgery) - aim is to prevent limb loss!

Question 31

Name the management of Intermittent Claudication.

Answer 31

▪ Revascularization (Endovascular or open surgery) - aim is to improve quality of life!

Question 32

Describe endovascular intervention (better for stenosis, short occlusions or less fitter patients than open)

Answer 32

▪ Usually angiography (inject dye/contrast and see any stenosis or occlusions) ▪ Allows for direct follow-up by angioplasty (insert a balloon and inflate it open up any stenosis or occlusions) then put a stent it (angioplasty + stent = PCI)

Question 33

Describe open surgery intervention. (Good for long occlusions, multilevel disease, and fit patients.

Answer 33

▪ Surgical bypass (use prosthetic graft or biological graft or another native vein to bypass the occluded segments of the artery) ▪ Frequently combined with endovascular interventions

Question 34

Describe the pathophysiology of Aortic Dissection.

Answer 34

``` ▪ Tear in the intima ▪ Blood enters the media of aortic wall ▪ Propagates proximally and distally ▪ This dissect the layers of the wall ▪ Causes false lumen or channel to form with the blood flowing within the wall ```

Question 35

List risk factors for AD.

Answer 35

▪ Hypertension ▪ Common in men aged 65-75 ▪ Associated with marfans syndrome

Question 36

Describe the presentation of Aortic Dissection.

Answer 36

▪ Sudden tearing chest pain ▪ Radiates to the back ▪ Hypertension ▪ Hypotension as the dissection becomes more severe

Question 37

Describe the management of Aortic Dissection

Answer 37

▪ Resuscitation ▪ Confirmation by immediate imaging (Ultrasound, CT or MRI angiogram) ▪ Urgent vascular input and surgical repair ▪ Manage hypertension (beta blockers) ▪ Urgent surgical stenting or repair (time critical – each passing hour increases mortality)

Question 38

Describe the difference between Type A and Type B aortic dissection.

Answer 38

▪ A ▪ Affects ascending aorta ▪ Sudden tearing anterior chest pain ▪ Associated cardiac complications = acute mitral regurgitation, MI, cardiac tamponade, stroke as it backs up into carotid ▪ Surgical Tx by cardiothoracic - replacement of arch ▪ B ▪ Affect descending aorta ▪ Sudden onset intrascapular pain ▪ Mx: pain control and urgent BP control (aim for BP <110 to minimise dissection) ▪ Surgery if there Uncontrolled pain and end organ hypoperfusion, ongoing dilatation and dissection despite BP control - usually endovascular unless that’s nor possible then it is open ▪ If dissection managed medically through BP control and pain settles, then no surgery, need life long follow-up

Question 39

Define aneurysm.

Answer 39

▪ Full thickness dilatation of an artery by more than 50% of its normal diameter (Normal aortic diameter = 2cm, so anything over 3cm is aneurysm) - risk of rupture increases as they expand

Question 40

Describe the difference between true aneurysms and false aneurysms.

Answer 40

▪ True = involve dilatation of all the layers of the arterial wall (atherosclerotic aneurysms) ▪ False = do not involve all the layers of the arterial wall (e.g. iatrogenic)

Question 41

List three types of aneurysms.

Answer 41

▪ Saccular(form on the side of the wall rather than circumferential dilatation) ▪ Fusiform ▪ Ruptured Aneurysm

Question 42

Describe the presentation of Aortic Aneurysms.

Answer 42

▪ Majority Asymptomatic (Incidental findings) ▪ Symptomatic with no rupture ▪ Pain (Non-specific abdominal pain) or tenderness with no evidence of rupture on CT ▪ Acute Limb Ischaemia/Symptoms of peripheral vascular disease - thrombus forms inside then embolising into the lower limbs ▪ Inflammatory aneurysms ▪ Pain ▪ Local symptoms - hydronephrosis due to ureteric involvement in inflammation ▪ Local pain and other symptoms indicate management ▪ Pulsatile expansible pulsation in the abdomen ▪ Ruptured abdominal aneurysm (high mortality 75-80%) ▪ Typical § Back pain § Abdominal pain § Hypotension § Collapse ▪ Atypical § Left renal angle pain radiating to groin (the first presentation of renal colic in a man over 60) § RIF pain ▪ Haemodynamic unstable (straight to theatre), BUT if stable can check by CT (however don’t be fooled they become unstable after a while)

Question 43

Describe the aneurysm screening programme.

Answer 43

▪ All men >65 ▪ Abdominal US ▪ >3cm = on-going follow up and monitoring ▪ >5.5cm refer to surgical clinic for Ix and Tx

Question 44

A) At what size do you usually intervene with asymptomatic aortic aneurysms? B) Describe management.

Answer 44

A) >5.5cm (does not mean it ruptures at this but it is safer to operate than to leave it - other people may have to be bigger than this as an operation is riskier than leaving it) B) ▪ Referred ▪ CT angiogram to outline anatomy and clarify what option available ▪ Anaesthetic assessment to assess anaesthetic risk ▪ MDT discussion ▪ Surgery

Question 45

Describe the management of symptomatic/Asymptomatic/ruptured aneurysms.

Answer 45

▪ Symptoms indicate repair no matter that size! ▪ Treat reversible risk factors ▪ Treat peripheral vascular disease if there is any (in symptomatic) ▪ Surgical ▪ Endovascular stenting (EVAR) - aneurysm is relined from the inside with a metal stent, arteries accessed via femoral artery ▪ Laparoscopic repair ▪ Open surgical repair - clamp the aorta to stop the blood to the legs, open it, synthetic graft is sew to the inside then it is closed over it

Question 46

Describe management of rAAA.

Answer 46

1- ABC approach 2- Call for help - senior and vascular team early 3- Oxygen 4- IV access - bloods, G and S, major haemorrhage protocol 5- Fluids 6- CT Angiogram 7- Vascular team will alert theatre and anaesthetic early for surgery (if the person has co-morbidities and may not be able to handle the surgery discussion need to be had about palliative care etc..)

Question 47

Explain the concept of permissive hypotension in relation to intraabdominal bleed.

Answer 47

▪ Hypotension can be useful in the setting of intraabdominal bleed ▪ Permissive hypotension refers to the concept of managing trauma patients by restricting the amount of fluid resuscitation and maintaining blood pressure in the lower than normal range if there is continuing bleed (it is getting the balance between organ perfusion and haemostasis) ▪ If BP is increased rapidly then it may destabilise retroperitoneal haematoma and cause bleeding to worsen ▪ The aim is always to perfuse the brain, measure this by talking to the patient and ask them questions and see if they answer - if the patient is orientated and able to talk then blood pressure is sufficient ▪ If disorientated and confused = transfuse!