McNeil's notes - cardio, resp, gi, nephro, most cancer, radiation, chemo, transplant, pharmacology, infectious diseases Flashcards Preview

SF > McNeil's notes - cardio, resp, gi, nephro, most cancer, radiation, chemo, transplant, pharmacology, infectious diseases > Flashcards

Flashcards in McNeil's notes - cardio, resp, gi, nephro, most cancer, radiation, chemo, transplant, pharmacology, infectious diseases Deck (268):
1

Patient with acute right-sided M.I., what is the best course of action in managing this patient?
a. Volume resuscitation with N/S.
b. Inotropes are not indicated.
c. There is decreased right diastolic pressure once the pulmonary artery pressure is decreased.
d. EKG is often not diagnostic.
e. You should increase the right after load.

a. Volume resuscitation

The initial therapy for hypotension in patients with right ventricular infarction should almost always be volume expansion.
- Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, 6th ed., W. B. Saunders Company, p. 1181-1182.

a. Inotrops (yes if needed)
b. Reduce preload (opposite – want to increase preload)
c. IV fluid
d. Reduce afterload (yes, but most important is to give fluid to increase CO)

2

Post Operative MI, patients experiences cardiogenic shock. Which
is the best management?
a. Angioplasty
b. Intra-aortic balloon
c. Streptokinase
d. Decrease preload and afterload with an inotrope

a. Angioplasty

In the large randomized controlled SHOCK trial, investigators determined that patients with cardiogenic shock after acute myocardial infarction benefited if within 6 hours of the onset of shock they underwent an intervention that restored coronary blood flow, as opposed to medical stabilization and delayed intervention.[47] Two interventions used to restore coronary blood flow were immediate coronary artery bypass surgery and immediate percutaneous coronary interventions that included transluminal angioplasty and deployment of endoluminal stents to prevent reocclusion of the coronary artery.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

3

Two days post major bowel surgery, a patient develops dyspnea, left-sided chest pain and ECG changes in lateral leads. Immediate treatment should include:
a) heparin
b) O2

- Most common time for post-op MI is day 2-3 due to reabsorption of 3rd space volume and therefore volume overload on the heart
- Diagnosis of acute MI is based on 2 of 3 of the following:
o history and physical
o ECG changes (ST segment elevation, T wave inversion, significant Q waves)
o cardiac enzyme elevation
- management goal is to minimize the amount of infarcted myocardium and prevent complications
- immediate measures include:
o O2, sublingual NTG, morphine (pain relief, sedation), ASA, B-blocker (if not contraindicated), ACE I
o anticoagulation therapy - IV heparin to prevent extension of clot/thrombus
o thrombolytic therapy - this patient would not be a candidate since only POD #2, but criteria for review are:
 CP for 30+ minutes
 ECG changes:
• 1mm ST elevation in 2 limb leads OR
• 1mm ST elevation in 2 adjacent precordial leads OR
• new onset LBBB
 presentation within 12h of symptom onset
- Reference: MCCQE

4

Signs of cardiac tamponade include all of the following EXCEPT
A. Narrow pulse pressure
B. Pulsus alternans
C. Wide pulse pressure
D. Hypotension
E. Distended neck veins

C. Wide pulse pressure
This is also asked with "Right atrial pressure greater than the Leftatrial pressure"
This question was often asked, and basically the answer is usually you do NOT see WIDE pulse pressure. Also Left atrial pressure is normally greater than the right, but in cardiac tamponade they can equalize as fluid accumulates.

5

One week after undergoing tooth extraction, a patient develops fever, increased white count and SOB. On exam, the patient has systolic murmur at left sternal border with hypotension and increased pulse pressure. The likely diagnosis is:
a. tricuspid endocarditis with tricuspid regurg
b. pulmonary valve endocarditis with regurg
c. mitral valve endocarditis with regurg
d. aortic valve endocarditis with regurg

- d. aortic valve endocarditis with regurg

The most common causes of an ejection systolic murmur are aortic stenosis and aortic sclerosis

The valves most commonly infected are left-sided valves, with approximately equal frequency between the mitral and aortic valves (see the following images). Vegetations on the mitral valve can extend onto the noncoronary and left cusps of the aortic valve, as they are contiguous, and double aortic and mitral valve replacements are not rare. Left-sided valve endocarditis is more frequent, even in drug addicts, than right-sided endocarditis,[3] although infections of the tricuspid and pulmonary valves are highly suspicious of intravenous drug abuse.

Tricuspid valve endocarditis may occur in community-acquired infection, usually in intravenous drug addicts, or hospital-acquired infections from implanted devices. Isolated pulmonary valve endocarditis is rare (except in patients with congenital heart disease) and may cause confusing clinical symptoms

6

Which drug of the following if given to cardiac patient in non cardiac surgery will improve survival:
b. Metoprolol
c. Digoxin
d. ASA
e. Atropine

b. beta blocker

Perioperative B-blocker therapy and mortality after major noncardiac surgery reduced risk of in-hospital death among high risk, but not low risk patients.
- NEJM July 28, 2005
-article does not differentiate between atenolol and metoprolol
-extended release metoprolol reduces cardiac mortality but increases overall mortality

In patients scheduled for noncardiac surgery, including those at high risk, we recommend not starting perioperative beta blockade (Grade 1B). (See 'Patients not taking beta blockers' above.)
●In patients treated with long-term beta blockers for recommended indications, we suggest continuing beta blockade perioperatively (Grade 2B). (See 'Beta blockers' above.)

7

what is the mechanism of epinephrine during a cardiac arrest?

Answer given: increase cardiac inotropy

Epinephrine
Chronotropy 4+
Inotropy 4+
Vasoconstriction 4+
Vasodilatation 3+
- Piccini & Nilsson: The Osler Medical Handbook, 2nd ed.

8

Intraoperatively patient bradys down to 40 – drug to give

atropine

9

In hypertensive cardiomyopathy, which of the following is true regarding myocardial muscle cells?
a) there is an increase in the number of cells
b) the cells increase in size
c) the is an increase in both the size and number of cells

Histologically, individual muscle cells are hypertrophied, with a disorganized, characteristic whorled pattern.
- Marx: Rosen's Emergency Medicine, 7th ed.

10

Worst prognosis with severe CHF
a. hypotension
b. hypoxia

a. hypotension

The largest analysis[152] found that BUN, systolic blood pressure, heart rate, and age were the main multivariate predictors, and using a different statistical approach with dichotomous variables, suggests that the best single predictor was an elevated admission blood urea nitrogen (BUN ≤ 43 mg/dl), followed by low blood pressure (systolic blood pressure

11

All of the following are benefits of smoking cessation 6 weeks prior to surgery except
a. improved ciliary function
b. decreased airway reactivity
c. decreased co2 retention
d. increased secretion clearance
e. none of the above

Answer given: c. decreased co2 retention

Intermittent quitters had less loss of lung function at comparable cumulative cigarette doses than continuing smokers. Interestingly, the shorter-term improvement after quitting or the decrement after relapsing was significantly related to methacholine reactivity, [145] implying that acute airway inflammation contributes to the observed FEV1 fluctuations.
- Sethi JM - Clin Chest Med - 01-Mar-2000; 21(1): 67-86, viii

Cigarette smoking increases perioperative mortality probably because of the effects of smoking on both the cardiovascular and the respiratory systems.[100] Smokers may have increased levels of carboxyhemoglobin as a function of their brand of cigarette, how deeply they inhale, the number of puffs they take, and the level of ventilation present while they are smoking.[101] The level of carboxyhemoglobin in smokers usually ranges from 3% to 15%, and the major effects are to reduce the amount of hemoglobin available to bind with oxygen, thereby decreasing arterial oxygen content, and to shift the oxygen-hemoglobin saturation curve to the left. Smokers have a decreased oxygen delivery and an increased tissue oxygen extraction, manifested by a reduced mixed venous oxygen content.[102] Patients at greater risk for elevated carboxyhemoglobin levels are those who smoke avidly late at night and then undergo an early morning operation. Therefore, it is recommended that smokers stop smoking 12 to 18 hours preoperatively to allow sufficient time (three half-lives) for carboxyhemoglobin clearance.

Decreased CO2 retention. There were lots of references made to improving ciliary function, increasing secretion clearance and decreasing airway reactivity but I couldn't find anything about CO2 retention so I figured this is the answer.

12

You are called to see a patient after a blood gas that was ordered by the clinical clerk shows a PaO2 of 40mmHg. After 20 min of 100% O2 by face mask a CBC reveals a hematocrit of 0.65 and a repeat blood gas reveals values of 7.30/40/60/26 with a saturation of 88% on an FiO2 of 1.0. The likely diagnosis is:
a. polycythemia rubra vera
b. pulmonary fibrosis
c. COPD
d. Intrapulmonary shunt
e. Carbon monoxide poisoning

Answer given: b. pulmonary fibrosis

Carbon monoxide poisoning: “ arterial blood gases reveal metabolic acidosis, a normal PO2, decreased O2 saturation (by direct co-oximetry measurement rather than a calculated or pulse oximetry value) and a normal or slightly decreased PCO2”
- Harrison’s 13th ed

Polycythemia Vera: Normal arterial oxygen saturation (>92%)
- Ferri: Ferri's Clinical Advisor 2010, 1st ed.

DDX Polycythemia
Absolute
a) autonomous erythroid proliferation (polycythemia rubra vera)
b) secondary erythroid proliferation
I – Autonomous or inappropriate increase in erythropoiten eg neoplasm, renal lesions, familial
2- Secondary increase in erythropoiten
i – hypoxia (decrease PO2) – eg high altitude, alveolar hypoventilation, pulmonary disease, cardiac left to right shunt
ii – abnormal hemoglobin function (normal PO2) – eg high affinity genetic variants, congenital methemoglbinemia, carboxyhemoglobin (smoker’s polycythemia)
c) Hormonal stimulus to erythropoesis eg cushing sydrome, androgen or corticosteroid administration
Relative (reduced plasma volume, normal cell mass) eg dehydration, stress erythrocytosis
- Harrisons pg 180

Any pulmonary disease which produces chronic hypoxia may lead to erythrocytosis

13

Woman in third trimester of pregnancy is jaundiced which test would show hepatocellular damage
a) increased alk phos
b) increased unconjugated bili
c) increased conjugated bili
d) increased GGT
e) decreased urobilinogen

D. we agreed GGT is the answer at review week

Also known as intrahepatic cholestasis of pregnancy. Usually occures in thrid trimester but may develop any time after the 7th week of gestation. Clinical features include: pruritis and jaundice. Clinical and laboratory abnormalities include: elevated alkaline phosphatase (but during pregnancy, this is usually due to placental source rather than hepatic), elevated bilirubin (conjugated > unconjugated) and elevated GGT.

a) increased alk phos (post-hepatic and other sources)
b) increased unconjugated bili (pre-hepatic)
c) increased conjugated bili (hepatic and post-hepatic)
d) increased GGT (cholestatic but also from liver)
e) decreased urobilinogen (no conjugated bilirubin)

GGT is another enzyme found in hepatocytes and released
from the bile duct epithelium. Elevation of GGT is an early
marker and also a sensitive test for hepatobiliary disease. Like
AP elevation, however, it is nonspecific and can be produced by
a variety of disorders in the absence of liver disease. Increased
levels of GGT can be induced by certain medications, alcohol
abuse, pancreatic disease, myocardial infarction, renal failure,
and obstructive pulmonary disease. For this reason, elevated
GGT levels are often interpreted in conjunction with other
enzyme abnormalities. For example, a raised GGT level with
increased AP level supports a liver source.
Schwartz

14

A 58 y.o. M with cirrhosis presents with an UGI bleed. Initial resuscitation measures are carried out. What is the MOST helpful adjunct to treatment?
A. Synthetic vasopressin
B. Somatostatin (Octreotide)
C. Ranitidine
D. NG tube

- Somatostatin infusion

****if patient did not have a history of liver failure the diagnosis of duodenal or gastric ulcer is more likely , and treatment with PPI. PPI stablize the clot but does not speed clot resolution *******

Patients with evidence of liver disease (by history, physical examination, or laboratory data) who have active upper gastrointestinal bleeding should be started on pharmacologic therapy (e.g., intravenous octreotide) to lower portal venous pressure and stop the bleeding as soon as possible and then undergo urgent endoscopy.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

Somatostatin and octreotide have been studied in patients with ulcer-related upper gastrointestinal bleeding. A meta-analysis revealed a reduction in the rate of rebleeding in 1829 patients treated with somatostatin or octreotide, but mortality was not improved.[114] It is this author's opinion that these agents may be useful in some patients (e.g., those with severe bleeding who are awaiting endoscopy or surgery or those in whom other drug therapy is not possible) but are not indicated routinely.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

15

Patient with bleeding esophageal varices is started on vasopressin. What side effect should you watch for?
a. Coronary vasoconstriction
b. Decreased small bowel motility
c. Bronchial dilatation
d. Peripheral vasodilation

Answer: a. Coronary vasoconstriction

Vasopressin is an alternative pharmacotherapeutic agent but is used less frequently because of significant complications (including myocardial ischemia and infarction, ventricular arrhythmias, cardiac arrest, mesenteric ischemia and infarction, and cutaneous ischemic necrosis). In patients with vascular disease or coronary artery disease, vasopressin should be used with caution in an ICU setting with cardiac monitoring. The infusion should be reduced or terminated if chest pain, abdominal pain, or arrhythmias develop. Concomitant infusion of nitroglycerin may reduce undesirable cardiovascular side effects of vasopressin therapy and may provide more effective control of bleeding. Nitroglycerin is administered only if the systolic BP is greater than 100 mm Hg, at a dose of 10 mu g/minute IV, increased by 10 mu g/minute q10-15min until the systolic BP falls to 100 mm Hg or a maximum dose of 400 mu g/minute is reached.
- Washington Manual

In addition, vasospastic side effects are seen in approximately 25% of patients receiving vasopressin, with the risk of myocardial infarction being of greatest concern.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 6th ed., p.1299.

16

#1 cause of massive upper GI bleed

The most common causes of UGIB include the following (in approximate descending order of frequency) [3-5,8,9]:

●Gastric and/or duodenal ulcers
●Esophagogastric varices
●Severe or erosive esophagitis
●Severe or erosive gastritis/duodenitis
●Portal hypertensive gastropathy
●Angiodysplasia (also known as vascular ectasia)
●Mass lesions (polyps/cancers)
●Mallory-Weiss syndrome
●No lesion identified (10 to 15 percent of patients)

17

2L of diarrhea will result in all except:
a- decrease effective circulatory volume
b- decrease urine Na
c- increase thirst
d- increase ADH
e- decrease serum Cl

e. decreased serum Cl

Can easily answer this by process of elimination.

Remember: basically every fluid past the stomach is "high in bicarb"

Metabolic acidosis with normal anion gap results from a loss of fluid with a bicarbonate concentration greater than chloride concentration, the addition of acids with chloride as their associated anion, or the transient dilution of extracellular bicarbonate with nonbicarbonate solutions. To maintain electroneutrality, the decrease in serum bicarbonate is associated with a proportionate increase in the serum chloride level. For example, in diarrhea, bicarbonate loss is greater than chloride loss; thus, hyperchloremia develops.
- Shannon: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th ed.

18

Most sensitve test for pancreatitis
a-serum lipase
b-serum amylase
c- urine amylase

a. lipase

Although serum lipase is derived from pancreatic acinar cells, it rises slightly earlier than amylase, 4-8 hours after the onset of acute pancreatitis, and peaks earlier, at 24 hours ( Steinberg, 1985 ). The serum lipase also lasts longer in the serum, 8-14 days. For these reasons, serum lipase is more sensitive and specific than the serum amylase.
- McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed.

19

Pancreatitis causes all of the following except:
a) makes the patient delusional
b) fat necrosis
c) pleural effusion
d) dyspnea
e) pain

a) makes the patient delusional

The typical symptoms of acute pancreatitis are abdominal pain, nausea, and vomiting.
Examination of the skin may reveal tender areas of induration and erythema resulting from subcutaneous fat necrosis
- Goldman: Cecil Medicine, 23rd ed.

Tachypnea and shallow respirations may be present if subdiaphragmatic inflammatory exudate causes painful breathing. Dyspnea may accompany pleural effusions, atelectasis, congestive heart failure, or ARDS.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

Chronic pancreatitis indicates some degree of progressive and permanent damage to the pancreas, usually visualized as calcifications on radiographs and CT scans (Figs. 49-27 and 49-28 [27] [28]). This damage often leads to diabetes and pancreatic insufficiency, resulting in malabsorption with chronic diarrhea.
- Rakel: Textbook of Family Medicine, 7th ed.

Periostitis, nodular skin lesions, and synovial fat necrosis may develop as a result of lipases released during pancreatitis.
- Kliegman: Nelson Textbook of Pediatrics, 18th ed

Similarly asked question with choice diarrhea: answer is diarrhea (The question is likely ACUTE PANCREATITIS (which does not have diarrhea))

20

Hepatic dysfunction gives all except?
a. Decreased glucose
b. Increased bilirubin
c. Increased PT
d. Increased BUN
e. Altered circulating glucose profile

Glycogenesis, glycogen storage, glycogenolysis, and the conversion of
galactose into glucose all represent hepatic functions. Hypoglycemia is a rare accompaniment of extensive hepatic disease, but the amelioration of diabetes in patients with hemochromatosis is considered an indication of neoplastic change. The more common effect of hepatic disease is a deficiency of glycogenesis with resulting hyperglycemia. A hepatic enzyme system is responsible for the conversion of galactose into glucose, and abnormal galactose tolerance tests are seen in hepatitis and active cirrhosis.

Because urea is synthesized in the liver, hepatic dysfunction decreases urea production and, therefore, BUN concentration.
- Miller: Miller's Anesthesia, 7th ed.

21

Saliva is ineffective in digestion because
a) amylase deactivated by stomach ph
b) too small amount

Answer given: a) amylase deactivated by stomach ph

The function of saliva is to begin chemical digestion, for lubrication of the food, and for protection. Saliva contains mostly water and electrolytes, as well as amylase, lipase, mucin, immunoglobins and lysosymes. Amylase begins breakdown of carbohydrates and lipase begins breakdown of fats (but this is not significant).

22

Lower esophageal sphincter is affected by all of the following except:
a) caffeine
b) smoking
c) alcohol
d) impaired peristalsis of the esophagus

Peristaltic contractions alone do not generate enough force to open up the LES
- Townsend: Sabiston Textbook of Surgery, 18th ed.

23

63 year old male heavy drinker & smoker present with 8 week history of difficulty in swallowing and weight loss. The most appropriate next step is:
a. Esophagoscopy and biopsy
b. 24h PH study
c. motility study
d. CT Scan
e. OR

Esophagoscopy and biopsy

24

All of the following are cause of ileus except :
a. Hyperkalemia
b. Hypokalemia
c. Early post op
d. Intra abdominal sepsis
e. All of the above

- Hyperkalemia

Drugs
Narcotics, phenothiazines, diltiazem, anticholinergic agents, clozapine
Electrolyte abnormalities
Hypokalemia, hyponatremia, hypomagnesemia, hypermagnesemia, hypocalcemia, hypercalcemia
Intestinal ischemia
Mesenteric arterial embolus or thrombosis, mesenteric venous thrombosis, chronic mesenteric ischemia
Intra-abdominal inflammation
Appendicitis, diverticulitis, perforated duodenal ulcer
Iatrogenic
Laparotomy, laparoscopy
Retroperitoneal inflammation or hemorrhage
Lumbar compression fracture, acute pancreatitis, pyelonephritis
Infection
Intra-abdominal or systemic sepsis

Thoracic diseases
Lower rib fractures, lower lobe pneumonia, myocardial infarction
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

With severe hypothyroidism (i.e., myxedema), paralytic ileus and intestinal pseudo-obstruction can occur.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.;

Causes of Ileus
o Postlaparotomy
o Metabolic and electrolyte derangements (e.g., hypokalemia, hyponatremia, hypomagnesemia, uremia, diabetic coma)
o Drugs (e.g., opiates, psychotropic agents, anticholinergic agents)
o Intra-abdominal inflammation
o Retroperitoneal hemorrhage or inflammation
o Intestinal ischemia
o Systemic sepsis
- Townsend: Sabiston Textbook of Surgery, 16th ed

25

What is the cause of hyponatremia in liver disease?

A variety of factors can contribute to the development of hyponatremia in patients with cirrhosis. The most important factor is systemic vasodilation, which leads to activation of endogenous vasoconstrictors including antidiuretic hormone (ADH); ADH promotes the water retention that is responsible for the fall in serum sodium.
(uptodate)

26

Which form of hypertension is associated with low renin?
A. Renal artery stenosis
B. Primary hyperaldosteronism
C. CHF
D. Cirrhosis

B. Primary hyperaldosteronism

My simplified way to see it is that the kidneys produce renin when they aren't getting enough bloodflow in order to get more blood. So anything that would limit renal flow would cause increased renin. Primary hyperaldosteronism causes hypertension so kidneys are getting plenty of blood therefore don't need to secrete renin.

As diagnostic tests for quantifying the components of the renin-angiotensin-aldosterone system have become available, the syndrome of primary hyperaldosteronism (PAL) is now identified by hypertension, suppressed plasma renin activity (PRA), and high urine and plasma aldosterone levels.
- Wein: Campbell-Walsh Urology, 9th ed.

Decreased renin levels are found in the following conditions:
a Primary aldosteronism (98% of cases)
b Unilateral renal artery stenosis
c Administration of salt-retaining steroids
d Congenital adrenal hyperplasia with 17-hydroxylase deficiency
e Liddle's syndrome

Hyperaldosteronism > Increased sodium resorption at distal convoluted tubule > decreased renin release

27

Which of the factors below do not stimulate renin release by the kidney?
a) Epinephrine
b) Norepinephrine
c) Dopamine
d) Thromboxane A2
e) Leukotrienes

D and E

Renin is released in shock/hypoperfusion to the kidney.
- Stimulates: Catecholamines , also ACTH
- Does not stimulate: Thromboxane A2, Leukotrienes

28

Which of the following causes of polyuria is associated with a high urine specific gravity?
A. Diabetes Mellitus
B. SIADH
C. Acute non-oliguric renal failure
D. ATN

A. Diabetes Mellitus (increased, glucosuria and dehyrdation)


B. SIADH (increased retain H2O and concentrate urine)
C. Acute non-oliguric renal failure (decreased, lose both h20 and Na, osmols dilutes)
D. ATN (same as C)

Urine osmolality is determined by the number of particles in the urine (eg, urea, sodium, potassium), while the specific gravity is determined by both the number and size of the particles in the urine .

Notes: DI (high urine output – low specific gravity)

29

Which of the following drugs does not cause ARF?
a) NSAID.
b) ACE inhibitor.
c) Aminoglycosides.
d) Semi-synthetic penicillins.
e) Corticosteriods.

Answer: Corticosteroids.

30

Lab values in ATN, which is true:
a) Urine osmolality 600
b) Urine Na 80
c) FeNa

Answer: Urine Na of 80

Basically the kidney isn't able to concentrate urine

a) Urine osmolality 600 (250-300 is plasma) - so able to concentrate
b) Urine Na 80 (the answer)
c) FeNa 3% in ATN)
d) WBC casts and pyuria (AIN)

Test Prerenal Parenchymal
Urine osmolarity (mOsm) >500 250–350
U/P osmolality >1.5 20 40
FENa 3%
- Greenfield

FeNa is the fractional excretion of Na+. It is the most reliable for distinguishing prerenal azotemia from ATN (a measure of the kidney’s concentrating ability)

Hyaline casts: Low urine flow, concentrated urine, or an acidic environment can contribute to the formation of hyaline casts, and, as such, they may be seen in normal individuals in dehydration or vigorous exercise

31

Which of the following statements regarding Lasix is true:
a. Acts on the distal tubules
b. Increase urine out put in patient with decrease GFR
c. Acts on collecting tubules
d. Act on the loop of Henley
e. None of the above

d. Act on the loop of Henley

32

The best way to monitor the diet of renal failure patient is:
a. Urea level
b. Creatinine level
c. Sodium level
d. BMI
e. All of the above

a. urea

Understanding of urea metabolism is critical for prescribing the diet for patients with CKD because a goal is to reduce the accumulation of potential uremic toxins. This will require reducing dietary protein to minimize net urea nitrogen production (i.e., urea appearance).
- Brenner: Brenner and Rector's The Kidney, 8th ed.

33

Post-operatively, a patient develops acute renal failure. Which of the following conditions is MOST consistent with a renal cause for the failure?
a. Urine osmolality equivalent to serum osmolality
b. Diuresis following 80mg IV lasix
c. Urine urea concentration one hundred times that of serum
d. Recent gram negative rod sepsis

Answer: a. Urine osmolality equivalent to serum osmolality

Test Prerenal Parenchymal
Urine osmolarity (mOsm) >500 250–350
U/P osmolality >1.5 20 40
FENa 3%
- Greenfield

34

The normal value of erythrocytes on urinalysis (> or = 3)

What is the cut-off number of RBC/HPF that is considered normal on urinalysis?
-0-2
-2-4
-5-10
-20
-50

0-2?

Hematuria is the presence of blood in the urine; greater than three red blood cells per high-power microscopic field (HPF) is significant.
- Wein: Campbell-Walsh Urology, 9th ed.

Normal urine should contain less than three red blood cells per HPF.
- Wein: Campbell-Walsh Urology, 9th ed.

Microscopic hematuria is a more commonly encountered entity. Various cutoff points defining microscopic hematuria exist in the literature. For adults, the American Urological Association Best Practice Policy has defined it as three or more red blood cells (RBCs)/hpf.
- Grossfeld et al, 2001a

35

A 35 year old female jogger has just is seen by her family doctor. A
urinalysis is done which reveals 8 rbc’s per hpf. She is sent to you. You should:
a) reassure and repeat urinalysis in 1 month
b) order a KUB roentogram
c) order an IVP
d) order a renal ultrasound
e) perform a cystoscopy

a) reassure and repeat urinalysis in 1 month

a) reassure and repeat urinalysis in 1 month

Exercise-induced hematuria is being observed with increasing frequency. It typically occurs in long-distance (>10km) runners, usually is noted at the conclusion of the run, and rapidly disappears upon rest. The hematuria may be of renal or bladder origin. An increased number of dysmorphic erythrocytes has been noted in some patients, which suggests a glomerular origin. Exercise-induced hematuria may be the first sign of underlying glomerular disease such as IgA nephropathy. Also, some patients with calculi in the renal pelvis may first develop hematuria when they run.
On the other hand, cystoscopy in patients with exercise-induced hematuria frequently reveals punctate hemorrhagic lesions in the bladder, which suggests that the hematuria is of bladder origin.
Vascular disease may also result in nonglomerular hematuria. Renal artery embolism and thrombosis, arteriovenous fistulas, and renal vein thrombosis all may result in hematuria. Physical examination may reveal severe hypertension, a flank or abdominal bruit, or atrial fibrillation.
In such patients, further evaluation for renal vascular disease
should be undertaken

36

Which is true regarding a patient with high output renal failure:
a. resolves spontaneously
b. responds to vasopressin
c. results in severe sodium depletion
d. secondary to contrast dye
e. treating with fluid restriction causes some resolution

b. responds to vasopressin: ? possible answer

37

Absolute indications for dialysis in patients with acute renal failure include all of the following except:
a. pH 500
d. Pericarditis
e. Encephalopathy

Answer: K100 mg/dl or a serum creatinine level of >10 mg/dl. However, we stress that in patients on a low-protein diet and/or possessing relatively little muscle mass, renal clearances of urea and creatinine are much lower for a given BUN or serum creatinine value.
- Walsh: Campbell's Urology, 7th ed.

Indications for and Frequency of Renal Replacement Therapy
The decision as to when to institute dialysis depends on the patient's signs and symptoms rather than an absolute level of blood urea nitrogen (BUN) or serum creatinine. The current opinion is that patients who begin dialysis at a relatively higher level of residual renal function have less morbidity and mortality. The benefits of early initiation include the avoidance of malnutrition, fluid overload, and the deleterious effects of prolonged exposure to the accumulation of phosphorus, β2-microglobulin, and other uremic toxins.
There is no question that hyperkalemia (unresponsive to diuretics, ion exchange resins, and dietary restriction) in the face of electrocardiographic changes is an absolute indication for dialysis to avoid life-threatening arrhythmias such as ventricular tachycardia, ventricular fibrillation, or asystole. Likewise, volume overload refractory to intravenous diuretics is an indication to start dialysis. Increasing lethargy, difficulty concentrating, nausea, and anorexia all may reflect advancing renal failure and may be manifestations of the uremic syndrome requiring dialytic therapy. Intervention should occur before the progression of uremic encephalopathy, seizures, and coma or the development of pericarditis or pericardial tamponade. Emergency hemodialysis is more costly, because the patients typically lack vascular access and are sicker, often requiring prolonged hospitalization.
- Goldman: Cecil Medicine, 23rd ed

38

1) What is the MOST likely electrolyte abnormality associated with adrenal insufficiency?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia

Answers:
1) Hyperkalemia

Basically you have low aldosterone, so you have low Na retention/LESS K+ excretion, so you get hyperK+

Aldosterone is a steroid hormone (mineralocorticoid family) produced by the outer-section (zona glomerulosa) of the adrenal cortex in the adrenal gland, and acts on the distal tubules and collecting ducts of the kidney to cause the conservation of sodium, secretion of potassium, increased water retention, and increased blood pressure. The overall effect of aldosterone is to increase reabsorption of ions and water in the kidney.
Its activity is reduced in Addison's disease and increased in Conn syndrome.
- http://en.wikipedia.org/wiki/Aldosterone

39

A 72 year old female with a longstanding history of rheumatoid arthritis and HTN presents to the ER. An X-ray shows a fracture of her left femoral head and profound osteopenia. She has had the flu for the past two days with nausea and vomiting and has not been taking her medication including ASA, prednisone, Imuran, and metoprolol. She is admitted and placed in Buck’s traction
Overnight she becomes hypotensive and unresponsive. Bloodwork on room air shows:
Na 129 mEq/L pH 7.1
K 7.1 mEq/L PO2 100 mmHg
Cl 91 mEq/L PCO2 55 mmHg
Glucose 0.3 mM HCO3 12 mEq/L

The likely diagnosis is:
a) myocardial infarction
b) fat embolus
c) addisonian crisis
d) sepsis
e) diabetic ketoacidosis

The immediate management of the above patient would include all EXCEPT:
a) Hydrocortisone 100mg IV q8h
b) Bicarbonate infusion
c) Fluid resuscitation and intubation
d) V/Q scan
e) Calcium gluconate 1g IV

Answers:
- addisonian crisis

Buzzwords: prednisone, not taking, + stressful situation = addisonian crisis

Adrenal Failure
I. Etiology. Adrenal failure may be due to disease of the adrenal glands (primary adrenal failure, Addison's disease), with deficiency of cortisol and aldosterone and elevated plasma adrenocorticotropic hormone (ACTH), or to ACTH deficiency caused by disorders of the pituitary or hypothalamus (secondary adrenal failure), with deficiency of cortisol alone (N Engl J Med 335:1206, 1996 ).
A. Primary adrenal failure most often is due to autoimmune adrenalitis, which may be associated with other endocrine deficits (e.g., hypothyroidism).
B. Secondary adrenal failure is due most often to glucocorticoid therapy; ACTH suppression may persist for a year after therapy is stopped. Any disorder of the pituitary or hypothalamus can cause ACTH deficiency, but usually other evidence of these disorders can be seen.
II. Clinical findings. Findings in adrenal failure are nonspecific, and, without a high index of suspicion, the diagnosis of this potentially lethal but readily treatable disease is missed easily. Symptoms include anorexia, nausea, vomiting, weight loss, weakness, and fatigue. Orthostatic hypotension and hyponatremia are common. Usually, symptoms are chronic, but shock may suddenly develop that is fatal unless treated promptly. Often, this adrenal crisis is triggered by illness, injury, or surgery. All these symptoms are due to cortisol deficiency and occur in primary and in secondary adrenal failure. Hyperpigmentation (due to marked ACTH excess) and hyperkalemia and volume depletion (due to aldosterone deficiency) occur only in primary adrenal failure.
- Washington Manual of Medical Therapeutics, 30th ed., Copyright © 2001 Department of Medicine, Washington University School of Medicine

Management of Acute Adrenal Insufficiency
Draw blood for measurement of cortisol and ACTH.
Infuse sufficient normal saline with 5% dextrose to restore normotension.
Administer 2 mg dexamethasone IV immediately (which will not interfere with further testing)
Give 250 mug Cortrosyn (ACTH) IV and measure 30-minute cortisol level.
Begin IV hydrocortisone as a continuous infusion to total 200 mg in 24 hours; or doses can be given in bolus form, 50 mg every 6 hours.
Investigate underlying etiology of adrenal insufficiency with plain film of abdomen to rule out adrenal calcification, tuberculosis testing, and evaluation of thyroid and gonadal status.
Chronic oral replacement therapy can begin as soon as the patient is medically stable and able to take medication orally
- Noble: Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc.

40

All the following are effects of adrenal hyperplasia EXCEPT:
A. Aseptic necrosis of bone
B. Fat redistribution
C. Delayed closure of growth plates
D. Peptic ulcer disease

C. Delayed closure of growth plates

Cushing’s: aseptic necrosis, fat redistribution, peptic ulcers
CAH: premature closure of growth plate.

Congenital Adrenal Hyperplasia: Both males and females may exhibit rapid growth in childhood (due to early epiphyseal closure, which then results in short stature in adulthood).
- Ferri: Ferri's Clinical Advisor 2010, 1st ed.

41

The most common cause of primary hyperaldosteronism:
a. Pituitary adenoma
b. Adrenal hyperplasia
c. Solitary adrenal adenoma
d. Bilateral adrenal adenomas

c. Solitary adrenal adenoma (Conn's disease, 65% according to Sabiston)

Diagnose by renin and aldosterone levels
Will be hypernatremic due to sodium resorption and potassium and hydrogen excretion, will be volume overloaded.
Aldosterone secretion will increase volume thus decrease renin
Primary: look for lesion
Secondary: (cirrhosis, ren art stenosis) will have high renin and high aldosterone

42

Adrenal medulla produces
a – aldosterone
b – ACTH
c – norepinephrine
d – cortisol

Answer: norepinepherine

Adrenal cortex - zona glomerulosa: aldosterone
- zona fasciculata: cortisol
- zona reticularis: androgens (mainly DHEA)
Adrenal medulla - epi and noreip

Cortex: salt, sugar, sex
Medulla: pump-up juice

43

Which of the following tumors MOST commonly produces SIADH?
A. Small cell lung cancer
B. Pancreatic cancer
C. Breast cancer
D. Lymphoma
E. Bronchogenic carcinoma

SCLC accounts for 15% to 20% of all lung cancers. This cell type has the strongest association with cigarette smoking, and is rarely observed in a never smoker. It is the cell type most commonly associated with paraneoplastic syndromes such as the syndrome of inappropriate (excessive) antidiuretic hormone secretion (SIADH), ectopic corticotropin secretion, Lambert-Eaton myasthenic syndrome (LEMS), and sensory neuropathy.
- Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.

44

2) All are seen in SIADH except:
a. Decrease urinary Na
b. Decrease urinary K
c. Hyponatremia
d. Increase urinary Osmolarity
e. Isovolemia

1) Hypernatremia

Potassium is actually normal (SIADH uses aquaporines, not Na/K pump)

45

3) SIADH; all true except?
a. Normal or low BUN
b. Decreased Na –where in the urine or serum?
c. Renal loss of Na
d. Urine osm > plasma osm
e. Renal loss of K

3) Renal loss of K
McNeil disagrees with this answer, but I think it's true. Aquaporine, no Na/K pump

The cardinal features of SIADH are hypotonicity with hyponatremia and an inappropriately concentrated urine. It is often unnecessary to measure serum osmolality directly in a hyponatremic patient, since the effective serum osmolality-- serum sodium (mmol/L) × 2 + glucose (mmol/L)--closely approximates direct measurements. [94] Any urinary osmolality greater than 50 to 60 mmol/L water is inappropriate in the setting of serum hypotonicity, which should inhibit the release of vasopressin and permit the excretion of a maximally dilute urine. The urinary osmolality in SIADH is often higher than the serum osmolality, but that is not a necessary feature of the syndrome.
SIADH has a number of other laboratory features that are helpful in diagnosis. The urinary sodium concentration is typically high, reflecting the natriuresis induced by expansion of extracellular fluid volume. However, the ability to conserve sodium in SIADH is usually unimpaired, [5] and the urinary sodium excretion can fall to low levels in the setting of reduced dietary sodium intakes. The blood urea nitrogen and serum uric acid levels are low, [95] again reflecting expanded extracellular fluid volumes and decreased tubular resorption of these solutes. Other electrolytes are diluted in proportion to the serum sodium, except for serum bicarbonate, which is normal.
- Wilson: Williams Textbook of Endocrinology, 9th ed

Hyponatremia caused by SIADH is characterized by a decrease in the plasma osmolality and inappropriately elevated urine osmolality. The urine osmolality is higher than 100 mOsmol/kg, and usually higher than 300 mOsmol/kg. The urine sodium is usually higher than 40 mEq/L, which is likely a consequence of increased levels of atrial natriuretic factor.
- Rakel: Textbook of Family Medicine, 7th ed

SIADH
Significant urinary losses of potassium, calcium, and magnesium may occur, so electrolyte levels should be monitored, with replacement accordingly.
- Rakel: Textbook of Family Medicine, 7th ed.

46

All are causes of hypernatremia except:
a. IV saline
b. Hyperaldosteronism
c. SIADH
d. DI

Answer: c. SIADH (inappropriate antidiuretic-->hyponatremic)

Decreased vasopressin release or decreased renal sensitivity to AVP leads to diabetes insipidus, a condition featuring hypernatremia (increased blood sodium concentration), polyuria (excess urine production), and polydipsia (thirst).
- http://en.wikipedia.org/wiki/Vasopressin

47

A 70kg male with peripheral edema, stable vital signs and a serum sodium of 120, is diagnosed with SIADH. Which of the following would be the MOST appropriate management?
A. Lasix, 40 mg IV
B. Restrict fluid to less than daily urine output
C. NS @ 150 cc/h
D. DDAVP
E. Desmocycline

What is the most appropriate treatment for SIADH?
a. Fluid restriction
b. DDAVP
c. IV D5
d. Lasix

Answer: a. Fluid restriction

Management (3):
1. For Na

48

What is the proper screen for familial medullary cancer?
a) CEA
b) Ret-oncogene
c) S-100

Answer: Ret-oncogene

For POS: MENII + Ret + Medullary cancer are friends

Because most familial cases have an identifiable RET mutation, as can occur in even apparently sporadic cases, screening should be vigorously pursued by routine testing of RET exons 10, 11, 13, 14, 15, and 16, with sequencing of the remaining 15 exons if indicated.
- Goldman: Cecil Medicine, 23rd ed.

49

MENII screening test for the siblings of affected adult is:
a. P53 protooncogene
b. RET oncogene
c. Ca levels
d. Parathyroid scan
e. CT scan

Answer: Ret-oncogene

Because most familial cases have an identifiable RET mutation, as can occur in even apparently sporadic cases, screening should be vigorously pursued by routine testing of RET exons 10, 11, 13, 14, 15, and 16, with sequencing of the remaining 15 exons if indicated.
- Goldman: Cecil Medicine, 23rd ed.

50

Which of the following is associated with an increased risk for developing thyroid cancer?
a. Smoking.
b. Dental radiography.
c. Medical treatment with I131
d. Child undergoing radiation therapy for a Wilms’ tumour.
e. None of the above.

I think the answer is D...

The association of irradiation and thyroid cancer has been known for years. The use of external beam irradiation in children and young adults in the 1950s and 1960s for acne and tonsillitis has been shown to result in an increased incidence of well-differentiated carcinoma (usually papillary) at any time, generally 5 years after exposure. Additionally, patients who have received external irradiation for soft tissue malignancy, such as Hodgkin's lymphoma, have an increased incidence of thyroid nodules and cancer (as many as 30%-35% of those exposed). Areas near known nuclear fallout contamination, such as Chernobyl in the former Soviet Union and areas of the southwest United States, have increased incidence rates of well-differentiated thyroid carcinoma
-Sabiston's

51

Squamous cell carcinoma of the central lip in a 85 year old man. Metastatic workup is negative (no nodes, no mets). The size measures 2.1cmx1cm. What is the best management?
a. excision only
b. excision and radiation
c. excision and chemotherapy
d. excision and bilateral neck dissection
e. excision and rad and chemo

A. excision

Early-stage lesions, surgery and rads equally effective
Recommended: surgery for stage I & II; post-op rads for III (T>4cm) & IV
Neck management
- Positive necks need treatment; SND I-III +/- rads
- Negative necks more controversial
- T1 has 3% risk of occult mets
- END if > 3 cm, thicker than 5 mm, recurrent or poorly differentiated

Like the rest of the oral cavity, staging of lip cancer is based on size at initial evaluation. Early-stage disease may be treated by surgery or radiation therapy with equal success. Local surgery (wide local excision) with negative margin control of at least 3 mm is the preferred treatment, with supraomohyoid neck dissection performed for tumors with clinically negative necks but deeper primary invasion or size greater than 3 cm. Neck dissection with postoperative radiation therapy for patients with clinically evident neck disease has an acceptable 91% regional control rate in the neck
- Townsend: Sabiston Textbook of Surgery, 18th ed.

52

60 year old male patient with bilateral painless parotid swelling:
a. Pleomorphic adenoma
b. Mixed tumor
c. Warthin tumor
d. Cystoadenosarcoma

Answer: Warthin tumor (10 % are bilateral)

Tip: It takes two sides to go to War (Warthin = bilateral)

Pleomorphic adenoma are benign, accounts for 80% of all parotid masses.
c. Warthin tumor = bilateral mass, male, 50-70 yo
a. Pleomorphic adenoma = painless isolated mass, female 30-60 yo, benign

53

what is the most common thyroid cancer:
a. papillary
b. follicular
c. medullary
d. anaplastic

Answer: papillary

Tip: Papillary is populary

180 cases of thyroid carcinoma dx 2006 (estim) 70-75% papillary, 10% follicular….. both are differtiated…..anaplastic (2-5%) undifferented/aggressive

54

What is the proper management of a 40 year old female with a previous history of head and neck irradiation for acne, who presents with a thyroid nodule?
a) Observation
b) Radioiodine
c) Thyroxine suppression
d) Excisional. Biopsy
e) Total thyroidectomy

The right answer is probably U/S guided FNA and CT with contrast. And she’ll get choice between diagnostic hemi or total thyroidectomy.

Neck irradiation for acne = stereotypical risk factor for thyroid cancer. Treat this person as if she had thyroid cancer.

Thyroid related history and PE are no different for exposed or nonexposed. FNA is the most informative method for charaterizing thyroid nodules. Accuracy of FNA appears to be similar for nodules in the general population and in patients exposed to radiation (Hatipoglu et al. FNA of thyroid nodule in radiation-exposed patients. Thyroid. 2000. Jan;10(1): 63-9)
However, hx of radiation is important b/c it affects treatment (as increased likelihood mass/nodule is cancer). If large nodules (>1.5cm) cannot be proven to be benign via FNA then indication for Sx. If nodule is cancer via FNA then would favor more extensive Sx (total lobectomy on side of dominant nodule and contralateral subtotal lobectomy) b/c high freq of multicentric cancer.
- Up to Date


-Total or near-total thyroidectomy is treatment of choice for most patients
-Lobectomy alone for papillary thyroid carcinomas

55

A 73 year old female is in the PACU following a total thyroidectomy. Her breathing is stridorous and she is complaining of dyspnea. Your initial management is:
a) observe and reassess
b) administer oxygen via a venturi mask
c) endotracheal intubation
d) aspirate the hematoma
e) open the wound and evacuate the clot

Post-op hematoma compromising airway – open wound and evacuate clot

56

Patient had SCC in the floor of the mouth which was resected and followed by radiotherapy. 1 year late, he came with painful ulcer in the floor of mouth with exposed mandible in the base of the ulcer. What is the diagnosis:
a. Recurrent SCC
b. Osteoradionecrosis
c. Osteosarcoma
d. Infection

Answer: Osteoradionecrosis

Guess it could be SCC too but.. I think they are trying to make us guess osteoradionecrosis. Depends on the stem I guess

Osteoradionecrosis is a possible complication following radiotherapy where an area of bone does not heal from irradiation. Irradiation of bones causes damage to osteocytes and impairs the blood supply. The affected hard tissues become hypovascular (reduced number of blood vessels), hypocellular (reduced number of cells) and hypoxic (low levels of oxygen). Osteoradionecrosis usually occurs in the mandible, and causes chronic pain and surface ulceration
Dr. Wikipedia

57

Patient with ulcerating lesion in the face (picture) with central keratin
crust and fleshy edges, what is the most appropriate management:
a. Excisional biopsy
b. Incisional biopsy
c. Excision with 1 cm margin
d. Excision with 2 cm margin

Hard to say what it is without seeing it.. but assuming it's BCC:

Clinical recognition of basal cell carcinoma is not difficult. Typically, there is a raised, nodular lesion with a smooth, clear (pearly) border and telangiectasia ( Plate 1, D ). The lesion can ulcerate and form a crust.

Biopsy to confirm diagnosis

Variable with tumor size, location, and cell type:
• Excision surgery: preferred method for large tumors with well-defined borders on the legs, cheeks, forehead, and trunk.
• Mohs' micrographic surgery: preferred for lesions in high-risk areas (e.g., nose, eyelid), very large primary tumors, recurrent basal cell carcinomas, and tumors with poorly defined clinical margins.
• Electrodesiccation and curettage: useful for small (

58

Patient had total thyroidectomy for papillary carcinoma, which marker will indicate recurrence:
a. TSH
b. T4
c. T3
d. Thyroglobulin

Answer: Thyroglobulin

Post-thyroidectomy Thyroglobulin levels are apparently associated with prognosis of papillary and follicular thyroid carcinomas and may predict tumor recurrence and metastastic potential. The detection of Thyroglobulin by biochemical and molecular means has important diagnostic significance due to its pleiotropic roles in identification of tissue of thyroid origin, differentiation, and post-operative follow-up.
- Lin JD (2007). "Thyroglobulin and human thyroid cancer". Clin Chim Acta 388: 15

59

The most important investigation of a solitary thyroid nodule is:
a) CT scan
b) Ultrasound
c) FNA

Answer: FNA

60

Middle aged male with a nodule in the left lower pole. Cold nodule. FNA shows thyroiditis. What do you do now?
a. I131 therapy
b. Thyroidectomy
c. Repeat FNA
d. Observe

Cold means higher risk of cancer. Likely repeat after 6-12 months.

Emedicine
Thyroid scintigraphy
In most centers, the routine initial diagnostic evaluation of a solitary thyroid nodule no longer includes imaging studies. In the past, radionuclide scanning was an important imaging study performed routinely in the initial assessment of a thyroid nodule. Nuclear imaging can be used to describe a nodule as hot, warm, or cold on the basis of its relative uptake of radioactive isotope. Hot nodules indicate autonomously functioning nodules, warm nodules suggest normal thyroid function, and cold nodules indicate hypofunctional or nonfunctional thyroid tissue. (Examples of hot and cold nodules are seen in the image below.) Hot nodules are rarely malignant; however, 5-8% of warm or cold nodules are malignant.[2]

61

What is the most common presentation of a nasopharyngeal carcinoma?
a) Neck mass
b) Decreased hearing
c) Nasal obstruction
d) Sore throat
e) New onset of cough

A.??

A study conducted found that the most common presentations of NPC in patients are neck masses (commonly unilateral), followed by headache and epistaxis
Suzina SAH, Hamzah M. Clinical presentation of patients with NPC. Med J Malaysia. 2003;58(4):539–545

One study indicated the following symptoms:[4]
Nasal symptoms, including bleeding, obstruction, and discharge (78%)
Ear symptoms, including infection, deafness, and tinnitus (73%)
Headaches (61%)
Neck swelling (63%)

62

What is the most common gene responsible for nasopharyngeal cancer …
a) Epstein Barr virus
b) Retinoblastoma
c) P53
d) RB

Answer: Epstein Barr virus

The DNA of EBV has also been detected in pre-malignant lesions of the nasopharynx which further supports its role in the pathogenesis

ASIDE:
- other diseases associated with EBV infection include:
- lymphoproliferative disease in patients with HIV, immunosuppression
- chronic fatigue syndrome
- malignancies
- Burkitt lymphoma
- Hodgkin s disease, T-cell lymphoma
- tonsillar carcinoma, thymoma, gastric carcinoma
- Reference: MD Anderson

63

The most common cause of Tongue cancer is?
a) Adenocarcinoma
b) Squamous cell ca
c) Lymphoma
d) Adenoid cystic ca
e) Mucoepidermoid ca

b. SCC

Most cancers of the base of tongue are squamous cell carcinomas, which are typically poorly differentiated

Radiation therapy or surgery are equivalent treatments for patients with early-stage disease. Because both sides of the neck are at risk for nodal involvement and surgical treatment sometimes involves total laryngectomy, radiation therapy is usually recommended for early-stage patients. More advanced tumors (T3 and T4) are managed by radiation therapy alone, or by surgery with postoperative radiation.
Advanced tumors of the base of tongue and elsewhere in the oropharynx often require a "composite resection" (or jaw-neck resection/dissection), since large tumors involving the tongue and tonsil typically abut the inner table of the mandibular body and ramus and have often spread to the neck.
- Abeloff: Clinical Oncology, 2nd ed.,

64

Which of the following is not associated with a patient who has a Pancoast tumor?
1. Horner’s syndrome
2. Adrenal hyperplasia

Answer: Adrenal hyperplasia

Pancoast's syndrome is a constellation of symptoms and signs that include shoulder and arm pain along the distribution of the eighth cranial nerve trunk and first and second thoracic nerve trunks, Horner's syndrome, and weakness and atrophy of the hand. This most commonly is related to a local extension of an apical lung tumor located in the superior pulmonary sulcus (Pancoast's tumor). The most common cause of this symptom complex is NSCLC; however, SCLC and a number of other types of tumors and infections may rarely present in this manner.
- Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.

Infrequently, a patient with a Pancoast tumor may also have features of a paraneoplastic syndrome. Most of the metabolic manifestations are the result of the secretion of endocrine chemicals by the tumor. Manifestations encompass Cushing syndrome, excessive antidiuretic hormone secretion, hypercalcemia, myopathies, hematological problems, and hypertrophic osteoarthropathy.
- eMedicine

65

The MOST common cause of SVC syndrome is:
A. Lymphoma
B. Primary lung cancer
C. Mediastinal fibrosis
D. Tuberculosis

Answer: Primary lung cancer

The blockage of blood flow in the superior vena cava (SVC) results in SVC syndrome. Bronchogenic carcinoma accounts for the vast majority of these cases in older adults.[164][165] In teenagers and young adults, SVC syndrome is usually due to non-Hodgkin's lymphoma.
- Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed

Cancer is the most common cause of SVC syndrome. Lung cancer, lymphoma, and germ cell tumors of the chest are most commonly associated with SVC syndrome. Any cancer that has spread to the lymph nodes in the chest may cause compression of the superior vena cava. Some patients present with SVC syndrome as their first symptom of cancer. It can also be caused by some non-cancerous conditions including goiter, aortic aneurysm, and inflammation of the mediastinum. Rarely, central venous catheters can cause a blood clot to form and contribute to a SVC syndrome.

66

All are associated with mesothelioma Except:
a. Asbestos
b. Chest trauma
c. Hypoglycemia
d. Lethargy
e. Hypertrophic osteodystrophy

Chest trauma

Risk Factors: Asbestos (hydrated magnesium silicate fibrous minerals) exposure.10% lifetime risk of developing mesothelioma in asbestos workers! Also, will act syngeristically with cigarette smoking. Other Silicates (erionite).Viral (simian virus 40 – polyoma virus).

Radiation.
Symptoms: dyspnea, nonpleurtic chest pain, asymptomatic (pleural effusion on CXR) dysphagia, cough, horseness, wt loss, weakness, increase sputum, anorexia, nausea, abdo pain/mass, ascites cord compression, brachial plexopathy, Horner’s syndrome, SVC syndrome, Paraneoplastic syndromes (DIC, migratory thrombophlebitis, hypoglycemia, hypercalcemia (PTH-like peptide), thrombocytosis)

Note: found case report of mesothelioma diagnosised after chest trauma and persistent pulmonary symptoms (Machi et al. Malignant pleural mesothelioma diagnosed after chest trauma. Am Surg. 1997.)

67

13 year old boy presents with unilateral gynecomastia. What is the next appropriate step?
1. anti-estrogen therapy
2. unilateral mastectomy
3. observe

Answer: observe

Hypertrophy of breast tissue in men is a common clinical entity for which there is frequently no identifiable cause. Pubertal hypertrophy occurs in boys between the ages of 13 and early adulthood, and senescent hypertrophy is diagnosed in men older than 50 years. Gynecomastia in teenage boys is common and may be either bilateral or unilateral. Unless it is unilateral or painful, it may pass unnoticed and regress with adulthood. Pubertal hypertrophy is generally treated by reassurance without surgery. Both pubertal and senescent gynecomastia may be left untreated and do not require biopsy.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

68

A 58 year old Female presents with a chronic erythematous oozing eczematiod rash involving the right nipple and areola. There are not breast masses palpable, and her mammogram is normal. Which of the following recommendation is most appropriate?
a. Referral to a dermatologist
b. Oral Vitamin E and topical aloe and lanolin.
c. Biopsy.
d. Advise patient to wear nonallergenic brassiere.
e. Topical 5-FU.

Answer: Biopsy.

This is classic paget’s presentation

The disease [Paget's of the breast] begins insidiously in one breast with a small area of erythema on the nipple that drains serous fluid and forms a crust (Figures 21-55 and 21-56). The inflammation is usually attributed to trauma, and partial healing comforts the patient. Patients equate lumps rather than inflammatory changes with cancer and, consequently, the disease continues. Malignant cells migrate through the epidermis, and the disease becomes initially apparent on the areola and, at a much later date (1 year or more), on the surrounding skin (see Figure 21-55). The process appears eczematous, but the plaque is indurated and has sharp margins, which remain relatively fixed for weeks. Ulceration is a late finding.
A crucial point to note is that Paget’s disease of the breast is a rare, unilateral disease, whereas eczematous inflammation of the nipples is common and almost invariably bilateral. Cytologic diagnosis can be made from nipple scrape smears. A biopsy may be studied with conventional stains and immunohistochemistry
- Habif: Clinical Dermatology, 5th ed.

69

A 33 year old asymptomatic woman is referred to you with an abnormal mammogram. No masses are palpable in either breast. The mammogram shows a tight cluster of microcalcifications at the 2 o’clock position of the left breast. Magnification compression views show at least 20 tiny, irregular calcification in a 2 cm area, varying in shape and density with no associated mass lesion. There are no other calcifications present in either breast. Which of the following is the most likely diagnosis?
a. Lobular carcinoma in situ.
b. Fibroadenoma.
c. Infiltrating ductal carcinoma.
d. Ductal carcinoma in situ (DCIS).
e. Fibrocystic changes.

Answer: Ductal carcinoma in situ (DCIS).

Isolated clusters of tiny calcifications are the most common and important diagnostic sign of an early carcinoma. Calcifications are often smaller than 0.5 mm in diameter and thus must be identified by a magnifying lens. The presence of five or more calcifications within a volume of 1 cm3 is termed a cluster. Subsequent breast biopsies will find 25% of clusters associated with cancer and 75% with benign disease.
- Adam: Grainger & Allison's Diagnostic Radiology, 5th ed.

Between 20% and 25% of clustered microcalcifications are positive for cancer on biopsy. Benign calcifications usually are larger and coarser, and are often round, with smooth margins.
- Abeloff: Abeloff's Clinical Oncology, 4th ed.

HIGHER PROBABILITY OF MALIGNANCY
Pleomorphic or heterogeneous (granular) - Usually more conspicuous than the amorphic forms. They are neither typically benign nor typically malignant irregular calcifications. They vary in size and shape and are usually

70

A 39 year old woman underwent a lumpectomy and axillary dissection for a 2 cm moderately differentiated, ER negative infiltrating ductal carcinoma. Margins around primary tumour were free, and 1 of 19 lymph nodes was positive for carcinoma. Which of the following treatment plans is most appropriate?
a.Radiation therapy alone.
b.Radiation therapy and single drug chemotherapy for 3-6 months.
c.Radiation therapy and single drug chemotherapy for 1 year.
d.Radiation therapy and multiple drug chemotherapy for 1 year.
e.Radiation therapy and multiple drug chemotherapy for 3-6 months.

Answer: Radiation therapy and multiple drug chemotherapy for 3-6 months.

The concept of dose density has been tested in recent clinical trials. The U.S. Intergroup tested dose-dense versus conventionally scheduled combination chemotherapy in women with positive axillary lymph nodes as an adjuvant to surgery. In this study, patients were randomly assigned to multiple schedules of three chemotherapy drugs (doxorubicin, cyclophosphamide, and paclitaxel). Although it was a complicated study, the women receiving compressed schedules of the three drugs at higher doses were better off during follow-up than their counterparts who received so-called less dense treatment (disease-free survival rate at 4 years of 82% for the dose-dense group versus 75% for the other groups). In practice, the duration of adjuvant treatment for breast cancer may be shortened to even less than the usual 4 to 6 months.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Chemotherapy indications:
􏰂ER negative plus node-positive or high-risk node-negative
􏰂ER positive and young age
􏰂Stage I disease at high risk of recurrence (high grade, lymphovascular invasion) 􏰂palliation for metastatic disease

71

What is the most common benign breast lesion in women:
a. Fibroadenoma
b. Fibrocystic disease
c. Fat necrosis
d. Duct actasia

Answer: Fibrocystic disease

72

28 year old female presents with pain in Right upper outer quadrant of breast times months, on exam you find equal lumpiness to both upper outer quadrants, no distinct mass, and pain on exam only on right, what do you do
a) reassure and reexam in one month
b) bilateral mammogram
c) ultrasound
d) fine needle aspirate
e) bilateral mastectomy

Answer: reassure and reexam in one month

This is classic case of fibrocystic disease of the breast.
• breast pain, focal areas of nodularity or cysts often in the upper outer quadrant, frequently bilateral, mobile, varies with menstrual cycle, nipple discharge (straw-like, brown or green)

-mammography is not helpful in women under age 35 because the breast tissue is too dense for the mammographer to read clearly
-In a young woman with no physical findings indicating malignancy, it is reasonable to ask that the patient return 3 to 10 days after the next menstruation begins to determine if the lump regresses
-FNA can be performed if the lump remains easily palpable and feels cystic (round, smooth, and not hard) and the patient wants quick resolution of the issue.
-If fluid is obtained and is not bloody, the patient can be reassured and followed in 4 to 6 weeks to check for recurrence; a recurrence suggests the need for surgical referral.
-If bloody fluid is obtained it should be sent for cytology.
-If the lump does not feel cystic, the patient should be referred for ultrasound. If ultrasound shows a solid mass, the patient should undergo either FNAB, core needle biopsy, or excisional biopsy
-Ultrasonography can determine whether a breast mass is a simple or complex cyst or a solid tumor. It is most useful in the following circumstances:
• In women under age 35
• When a mass detected on screening mammography cannot be felt
• When the patient declines aspiration of a mass
• When the mass is too small or deep for aspiration

73

Adjuvant RT following mastectomy, which true
- Disease free survival improved
- Local recurrence reduced

Radiation indications:
decrease risk of local recurrence; almost always used after BCS, sometimes after mastectomy (is >4 nodes positive or tumour >5 cm)
inoperable locally advanced cancer
axillary nodal radiation may be added if nodal involvement

74

Colon cancer metastasizes by all of the following except:
a. Perinural invasion
b. Blood
c. Local invasion
d. Lymphatics
e. Trans peritoneal

Answer: Perinural invasion (???)

See TO notes
Spread: direct extension; lymphatic; hematogenous (liver most common, lung, rarely bone and brain); peritoneal seeding: ovary, Blumer’s shelf (pelvic cul-de-sac); intraluminal

75

Mass screening for colorectal carcinoma:
a) FOB is specific
b) CEA is as sensitive as FOB
c) Increased proportion of cases are detected earlier
d) Increased survival rates

??? I would say C?

TO notes
-carcinogenic embryonic antigen (CEA): to monitor for initial response to treatment, and to assess for recurrence q3 months (not a screening test)

76

Colonic adenomas are associated with malignancy. All of the following increase the risk of malignancy except:
a. sessile adenomas
b. multiple polyps
c. villous morphology
d. increased dysplasia
e. increasing size

Answer: sessile adenomas

The three principal features that correlate with malignant potential for an adenomatous polyp are size, histologic type, and degree of dysplasia. Although higher rates of malignant transformation are found when the source of the pathologic material is mainly from surgical polypectomies [7] rather than colonoscopic polypectomies, [8] the malignant potential is directly correlated with larger adenoma size, more villous histology, and higher degrees of dysplasia. To be sure, these three histopathologic criteria are usually interdependent so it is difficult to assign a primary premalignant role to any one of them. For example, although only 1.3% of all adenomas under 1 cm may harbor a cancer, if these small lesions have a predominant villous component or contain a focus of severe dysplasia, the cancer rate rises to 10% or 27%, respectively . Note, however, that a small (

77

Which of the following is TRUE with regards to multiple myeloma?
A. Commonly associated with hypocalcemia
B. Osteoblastic activity is increased
C. Associated with a monoclonal spike on protein electropheresis
D. Commonly presents with ↓ AlkP

Answer: Associated with a monoclonal spike on protein electropheresis

The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.

78

75 year old man presents with a pathologic fracture of left femur. Bloodwork shows hypercalcemia. X-rays show multiple lytic lesions. What is the likely diagnosis?
1. osteosarcoma
2. multiple myeloma
3. osteoporosis

Answer: multiple myeloma

The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.

79

75 year old man presents with a pathologic fracture of left femur. Bloodwork shows hypercalcemia. X-rays show multiple lytic lesions. What is the likely diagnosis?
1. osteosarcoma
2. multiple myeloma
3. osteoporosis

Answer: multiple myeloma

The lytic bone lesions, osteopenia, hypercalcemia, and pathologic fractures in patients with myeloma are a result of abnormal osteoclast activity induced by the neoplastic plasma cells and inhibition of osteoblast differentiation.
The serum alkaline phosphatase level may be increased.
With serum immunofixation, 93% of patients have detectable M protein.
- Goldman: Cecil Medicine, 23rd ed.

80

Which of the following entities is the most common childhood malignancy?
a. Lymphoma.
b. Leukemia.
c. Wilm’s Tumour
d. Neuroblastoma.
e. Rhabdomyosarcoma

Answer: Leukemia, ALL most common type of childhood tumours

Lymphohematopoietic cancers (i.e., acute lymphoblastic leukemia, lymphomas) account for approximately 40%, nervous system cancers for approximately 30%, and embryonal and sarcomas for approximately 10% each among the broad categories of childhood cancers.
- Kliegman: Nelson Textbook of Pediatrics, 18th ed.

81

What is the most common solid tumor in children younger than 4 years:
a. Eewing’s sarcoma
b. Neuroblastoma
c. Wilm’s tumor
d. Astrocytoma

Answer: Neuroblastoma

Neuroblastoma comprised 28% of infant cancer cases and was the most common malignancy among these young children (65 per million infants).
- Gurney JG, Smith MA, Ross JA (1999). "Cancer among infants". in Ries LAG, Smith MA, Gurney JG, Linet M, Tamra T, Young JL, Bunin GR (eds). Cancer Incidence and Survival among Children and Adolescents, United States SEER program 1975–1995. Bethesda, MD: National Cancer Institute, SEER Program. pp. 149–56.

Neuroblastoma>Wilms>Astrocytoma>retinoblastoma in this age group (leukemia is highest but this is not solid)

82

The most common pediatric tumor from sympathetic nerve origin is:
a. Neuroblastoma
b. Medulloblastoma.
c. Ganglioneuroma
d. Ganglioneuroblastoma

Sympathetic nervous system tumors accounted for 7.8% of all cancers among children younger than 15 years of age. Over 97% of sympathetic nervous system tumors are neuroblastomas, embryonal malignancies of the sympathetic nervous system that occur almost exclusively in infants and very young children.

Mediastinal tumors were more frequent in infants than in older children, while the opposite age pattern was observed for CNS tumors (Figure IV.1). The average age-adjusted annual incidence rate for all sympathetic nervous system cancers was 9.5 per million children. The occurrence of sympathetic nervous system malignancies was strongly
age-dependent (Figure IV.2). For neuroblastomas alone, the incidence rate for both sexes combined during the second year of life (29 per million) was less than half that of infancy (64 per million). Neuroblastomas were by far the most common cancer of infancy, with an incidence rate almost double that of leukemia, the next most common malignancy that occurred during the first year of life.

83

Which one is commonly associated with post chemo lymphoporliferative disease:
a. CMV
b. EBV
c. HCV

Infection with Epstein-Barr virus is associated with lymphoproliferative disorders, especially in immunocompromised hosts, and is associated with various tumors, including nasopharyngeal carcinoma and Burkitt lymphoma.
- http://emedicine.medscape.com/article/963894-overview

Majority >95% B-cell proliferation disorder associated with EBV
- Schwartz 2005

84

With respect to post-transplant lymphoproliferative disorders (PTLD), which is true …
a) B-cell lymphoma is the most common
b) Hodgkin s lymphoma is more common than non-Hodgkin s
c) T-cell lymphoma is more common than B-cell lymphoma
d) It is increased with OKT3

Answer: B-cell lymphoma is the most common

PTLD is a spectrum of B-cell abnormalities driven by EBV leading to the development of monoclonal B-cell lymphoma
- Schwartz

The majority of PTLDs are of B-cell origin and contain Epstein-Barr virus (EBV). However, PTLDs of T- or NK-cell origin have been described, and late-arising EBV-negative lymphoid tumors are becoming more frequently reported in this population.
- Transpl Infect Dis. 3(2):88-96, 2001 Jun.

85

Which does not lead to BCC
a-dysplastic Nevus
b-UV
c-Nevus Sebacous
d-xeroderma pigmentosum

Which one is not premalignant?

Answer: dysplastic Nevus

According to the National Cancer Institute, doctors believe that dysplastic nevi are more likely than ordinary moles to develop into a type of skin cancer called melanoma.
- http://en.wikipedia.org/wiki/Dysplastic_nevus

Multiple basal cell carcinomas (basaliomas) and other skin malignancies frequently occur at a young age in those with XP.
- http://en.wikipedia.org/wiki/Xeroderma_pigmentosum

The idea that a dysplastic nevus may transform itself into a malignant melanoma remains controversial.
- Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.

EPIDERMAL NEVUS SYNDROME
The syndrome name represents the predominant cell type of the nevus; for example, nevus verrucosus (keratinocytes), nevus comedonicus (hair follicles), and nevus sebaceous (sebaceous glands).
Tumors occur with moderate frequency in association with ENS. The nevus itself may undergo malignant transformation, often into a basal cell carcinoma.
- Bradley: Neurology in Clinical Practice, 5th ed

86

A biopsy of a lesion on the face reveals basal cell carcinoma. Repeat surgery is planned for complete excision. What is the acceptable margin of excision?
a) 2mm
b) 5mm
c) 1cm
d) 2cm
e) 5cm

Answer: 5mm

Although it is potentially dangerous to assign a "standard" margin, current surgical recommendations call for margins of 4 mm of healthy tissue in excision of nodular BCCs and more than 7 mm in aggressive BCCs.
- Townsend: Sabiston Textbook of Surgery, 16th ed., Copyright © 2001 W. B. Saunders Company

Most physicians recommend 0.5cm margins around basal cell carcinomas
- Schwartz

Cure rates for BCC and SCC treated with standard surgical excision approach 95%.[15] [21] Because BCCs and SCCs can extend unpredictably beyond the clinical border of the tumor, the recommended margin of normal skin to be included in the excision has ranged from 2 mm to over 10 mm.[23] The chances of incomplete excision and local recurrence rise as closer margins are obtained. [15] Ideally, margins should range from 4 to 6 mm with the understanding that micronodular, infiltrative, and morpheaform BCCs, basosquamous carcinomas, and poorly differentiated SCCs have a greater likelihood of tumor extension beyond the standard 4-mm margins.[8] [21] Tumors greater than 2 cm in size and recurrent tumors likely will have greater subclinical extension, and exact margins cannot be recommended.
- Cutaneous malignancies and their management. Padgett JK - Otolaryngol Clin North Am - 01-Jun-2001; 34(3): 523-53

87

62 year old man presents with a scaly, ulcerated lesion at the tip of left pinna. Biospy was done in suspicion of malignancy. Biospy results come back as a benign tumor. What is the likely diagnosis?
1. Merkel’s tumor
2. Keratoacanthoma
3. fibrodermosarcoma
4. squamous cell carcinoma

Answer: Keratoacanthoma (likely benign)

Merkel cell carcinoma is a particularly aggressive small cell tumor arising from the cutaneous nerve endings or Meissner's corpuscles
- Goldman: Cecil Medicine, 23rd ed.

Keratoacanthoma (KA) is a relatively common low-grade malignancy that originates in the pilosebaceous glands and closely and pathologically resembles squamous cell carcinoma (SCC). In fact, strong arguments support classifying keratoacanthoma as a variant of invasive SCC.1 Keratoacanthoma is characterized by rapid growth over a few weeks to months, followed by spontaneous resolution over 4-6 months in most cases. Keratoacanthoma reportedly progresses, although rarely, to invasive or metastatic carcinoma; therefore, aggressive surgical treatment often is advocated. Whether these cases were SCC or keratoacanthoma, the reports highlight the difficulty of distinctly classifying individual cases.
- http://emedicine.medscape.com/article/1100471-overview

Melanoma: Known risk factors for children are giant hairy nevus (>20 cm), dysplastic nevus syndrome, and xeroderma pigmentosum.
- Kliegman: Nelson Textbook of Pediatrics, 18th ed.

An actinic keratosis may follow 1 of 3 paths; it may regress, it may persist unchanged, or it may progress to invasive squamous cell carcinoma. The actual percentage that progress to invasive squamous cell carcinoma remains unknown, and estimates have varied from as low as 0.1% to as high as 10%.1,7 Furthermore, predicting which course each individual lesion will follow is impossible.
Early data suggest that actinic keratoses may also progress to basal cell carcinoma, a paradigm originally not considered in the actinic keratosis risk profile; further research is necessary to confirm this potential relationship. Overall, actinic keratoses can be safely and effectively eradicated; therefore, therapy is warranted.
- http://emedicine.medscape.com/article/1099775-overview

Causes of BCC
# UV radiation
# Other radiation: X-ray and grenz-ray exposure
# Arsenic exposure:
# Immunosuppression is associated with a modest increase in the risk of BCC.
# Xeroderma pigmentosum:
# Nevoid BCC syndrome
- http://emedicine.medscape.com/article/1100003-overview

88

Which of the following is the MOST sensitive indicator of malignancy in an incisional biopsy for an epithelial tumour?
A. Aneuploidy on flow cytometry
B. Positive stain for cytokeratin
C. Tumor cells breaking through the basement membrane layer
D. Multiple mitotic figures and prominent nucleoli

As compared with benign tumors and some well-differentiated malignant neoplasms, undifferentiated tumors usually possess large numbers of mitoses, reflecting the higher proliferative activity of the parenchymal cells. The presence of mitoses, however, does not necessarily indicate that a tumor is malignant or that the tissue is neoplastic. Many normal tissues exhibiting rapid turnover, such as bone marrow, have numerous mitoses, and non-neoplastic proliferations such as hyperplasias contain many cells in mitosis. More important as a morphologic feature of malignancy are atypical, bizarre mitotic figures, sometimes producing tripolar, quadripolar, or multipolar spindles

When dysplastic changes are marked and involve the entire thickness of the epithelium but the lesion remains confined by the basement membrane, it is considered a preinvasive neoplasm and is referred to as carcinoma in situ ( Fig. 7-10 ). Once the tumor cells breach the basement membrane, the tumor is said to be invasive.

In situ epithelial cancers display the cytologic features of malignancy without invasion of the basement membrane. They may be considered one step removed from invasive cancer; with time, most penetrate the basement membrane and invade the subepithelial stroma.

Lack of differentiation, or anaplasia, is often associated with [...] abnormal nuclear morphology. Characteristically the nuclei contain abundant chromatin and are dark staining (hyperchromatic). The nuclei are disproportionately large for the cell, and the nuclear-to-cytoplasm ratio may approach 1 : 1 instead of the normal 1 : 4 or 1 : 6. The nuclear shape is variable and often irregular, and the chromatin is often coarsely clumped and distributed along the nuclear membrane. Large nucleoli are usually present in these nuclei.
- Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.

If the mitotic figures are “atypical” and “bizarre”, I would say D, otherwise C.

NB: Cellular atypia is present in actinic keratosis as well. The distinguishing feature of SCC is that it invades the basement membrane.

89

With regards to the development of squamous cell skin cancer in the transplanted patients undergoing immunosuppressive therapy, which of the following is true?
a. Happens earlier
b. More aggressive
c. Sunlight protection decreases the chance of cancer
d. BCC is still more common in transplant recipients than SCC

D. SCC > BCC on immunosuppressives

Factors associated with SCC in OTRs (organ transplant recipients) include sun exposure, epidermodysplasia verruciformis-associated HPV types 5 and 8, fair skin, heart transplant, older age at transplant, male sex, and intense immunosuppression. Indeed, intensity and duration of immunosuppression have been associated with development of aggressive SCC. Studies suggest that antirejection therapies using tacrolimus, mycophenolate mofetil, or rapamycin versus cyclosporine, glucocorticoids, or azathioprine may decrease incidence of NMSC in OTRs.
- Abeloff: Abeloff's Clinical Oncology, 4th ed.

Answer: Transplant patients have an overall 5% to 6% incidence of malignancy, which is 100 times greater than the general population.[1,65] As many as 40% to 53% of all malignancies among transplant patients are skin cancers.[38,66] The incidence of skin cancer varies with the amount of sun exposure. In regions with limited sun exposure, such as the Netherlands, the risk of a skin tumor is 10% at 10 years after transplantation and 40% at 20 years.[67] In regions with high sun exposure, such as Australia, the incidence is 45% at 11 years after transplantation and 70% at 20 years.[68]
Under normal circumstances, basal cell carcinomas (BCC) are much more common than SCC. However, the incidence of SCC in transplant recipients is 40 to 250 times that of the general population, whereas the incidence of BCC is 10 times greater in transplant patients.[55,69] This results in a reversal of the BCC/SCC ratio. SCCs in transplant patients are much more aggressive and deadly.[78,79] They tend to recur locally even after surgical excision

90

Bowen’s disease is :
a. Squamous cell ca in situ
b. Basal cell ca in situ
c. Benign disease of the bone

Answer: Squamous cell ca in situ

91

Which is least likely to increase risk of melanoma :
a. Nevus sebaceous
b. Actinic keratosis
c. Xeroderma pigmentosa
d. Lentigo maligna

Answer: Actinic keratosis

A is premalignant for basal cell. No mention of melanoma in literature
B is premalignant for SCC. No evidence of melanoma transformation
C is a risk for melanoma for sure,
D is premalignant for melanoma

92

Malignant melanoma stage IV the treatment include all of the following except:
a. Surgery
b. Chemotherapy (cisplastin, decarpamazine)
c. Radiotherapy
d. Levosmil local chemo
e. Topical chemotherapy

Answer: Levosmil local chemo

The treatment of a patient with metastatic melanoma emphasizes palliation. No evidence indicates that treatment of metastatic melanoma has any impact on survival, which ranges from 5 to 11 months, with a median of 8.5 months. Treatment options include surgery for resection of solitary metastases, single-agent chemotherapy such as dacarbazine, temozolomide (an oral version of dacarbazine), combination chemotherapy, immunotherapy (vaccines, interleukin-2, interferon), or combined immunotherapy. Melanoma can metastasize to virtually any organ, especially the lung, skin, liver, and brain. Ongoing clinical trials are evaluating a molecularly targeted inhibitor of the RAF kinases.
- Goldman: Cecil Medicine, 23rd ed.

Symptomatic skeletal metastases can be effectively palliated with radiation. Metastases resulting in fractures of weight-bearing bones require internal fixation before radiation therapy.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Can't find anything in modern literature suggesting local or topical treatment of Stage IV melanoma.

stage I (T1, N0, M0 or T2, N0, M0);
stage II (T3, N0, M0 or T4, N0, M0);
stage III (any T, N1, M0 or any T, N2, M0);
stage IV (any T, any N, M1);
with distant metastases, surgical therapy is indicated for solitary lesions in brain/gut/skin if symptomatic; only adjuvant tx known to influence survival is INF alpha-2b (T4 or N1); radiation has been shown to be useful (symptomatic brain mets); hyperthermic regional limb perfusion with chemotx is used for patients with local recurrence or in-transit lesions (along lymphatics) on extremity or not amenable to excision; levamisole is an antihelmintic drug (used for colorectal CA; NO mention that it is used in melanoma)

93

8mm melanoma to be removed, what margins are appropriate
a-1 cm
b-2 cm
c-3 cm

According to the AAD's 2001 guidelines, surgical management of primary cutaneous melanoma should focus on obtaining an excision margin based on histologic confirmation of tumor-free margins.
1. Melanoma in situ: 0.5-cm margins
2. Melanoma with Breslow's thickness

94

A melanoma of 2.5mm thickness requires what margin?
A. 2mm
B. 5mm
C. 2cm
D. 5cm

According to the AAD's 2001 guidelines, surgical management of primary cutaneous melanoma should focus on obtaining an excision margin based on histologic confirmation of tumor-free margins.
1. Melanoma in situ: 0.5-cm margins
2. Melanoma with Breslow's thickness

95

Pigmented lesion beneath finger nail, most probably it will be:
a. Lentigo maligna
b. Superficial melanoma
c. Nodular melanoma
d. Acral melanoma

PICTURE: the picture is a toenail with a blue lesion underneath (African Canadian)

Acral lentiginous melanoma occurs on the palms, on the soles, or beneath the nail plate (subungual variant).
- http://emedicine.medscape.com/article/1100753-overview

Bob Marley

96

Melanoma in a black lady, which is true:
a. Nodular is the commonest
b. Commonest in hands and palms
c. F > M
d. Prognosis is not affected by grade

Answer: Commonest in hands and palms

Acral lentiginous melanoma characteristics are as follows:
* This is the least common subtype of melanoma (2-8% of melanoma cases in white persons).
* It accounts for 29-72% of melanoma cases in dark-skinned individuals (ie, African American, Asian, and Hispanic persons) and, because of delays in diagnosis, may be associated with a worse prognosis.22,23
* Acral lentiginous melanoma occurs on the palms, on the soles, or beneath the nail plate (subungual variant). See the image below.
* Subungual melanoma may manifest as diffuse nail discoloration or a longitudinal pigmented band within the nail plate.
* It must be differentiated from a benign junctional melanocytic nevus of the nail bed, which has a similar appearance.
* Pigment spread to the proximal or lateral nail folds is termed the Hutchinson sign, which is a hallmark for acral lentiginous melanoma.
- http://emedicine.medscape.com/article/1100753-overview

97

Which is MOST specific for melanocytic lineage
a. polymerase
b. tyrosinase
c. hydrogen peroxidase
d. HMB-45 Ag
e. S-100 protein

... This seems like incredibly low yield.

HMB-45, Melan-A, and Mitf demonstrated specificities of 97%. S-100 protein and tyrosinase were less specific. Sensitivity and specificity for the combination Mitf+/Melan-A+ were 95% and 100%, respectively, whereas they were 80% and 100%, respectively, for S-100+/HMB-45+. Mitf Melan-A, and tyrosinase are sensitive markersfor epithelioid melanoma. Mitf and Melan-A seem more specific than S-100 and tyrosinase. An antibody panel consisting of Mitf and Melan-A is superior to a panel of S-100 and HMB-45 in the diagnosis of melanoma in cytologic specimens.

98

All of the following are true about Melanoma EXCEPT?
a) the incidence is increasing
b) prognosis is based mainly on depth of invasion
c) sun exposure is a risk factor
d) the incidence is equal among black and white people

Easy.

Black people get far fewer melanomas than white (commonly acral lentiginous melanoma

99

Which of the following is not a side effect of Vincristine?
a) paralytic ileus
b) thrompocytopenia
c) Hypofibroginemia
d) leucopenia

Hypofibroginemia

Memorization. This question seemed to pop up pretty often though on old exams

100

A patient on Vinblastine develops a duodenal ulcer. Post-operatively one would expect which complication as a result of the medication?
a. hirsuitism
b. paralytic ileus

Answer: paralytic ileus

Toxic Effects: Vincristine's dose-limiting toxic effect is neurotoxicity, which appears to be related to its relative polarity. Peripheral neurotoxicity usually manifests as sensory impairment, decreased deep tendon reflexes, and paresthesias. Less commonly, severe painful dysesthesias, ataxia, foot drop, and cranial nerve palsy (eg, affecting the extraocular and laryngeal muscles) can occur. Autonomic neurotoxicities include constipation, abdominal cramps, and ileus, which may be prevented by use of mild laxatives. Alopecia occurs frequently, but myelosuppressive effects are minimal. Rare side effects include inappropriate secretion of antidiuretic hormone and ischemic cardiac toxicity. Vinblastine's dose-limiting toxic effect is myelosuppression, with leukopenia more pronounced than thrombocytopenia. Anemia is uncommon. Neurotoxicity can also occur but is significantly less common than with vincristine. Vinblastine is also a vesicant.
- Hoffman: Hematology: Basic Principles and Practice, 5th ed.

101

Of the list of chemotherapeutic agents listed below, which is not an alkylating agent:
a) cyclophosphamide
b) vincristine
c) chlorambucil
d) melphalan
e) ifosfamide

Answer: vincristine (Plant alkyloid)

Alkylating agents
Nitrogen mustards
o Cyclophosphamide
o Mechlorethamine or mustine (HN2)
o Uramustine or uracil mustard
o Melphalan
o Chlorambucil
o Ifosfamide
Nitrosoureas
o Carmustine
o Lomustine
o Streptozocin
Alkyl sulfonates
o Busulfan
- http://en.wikipedia.org/wiki/Alkylating_antineoplastic_agent

PLANT ALKYLOIDS
- Vincristine
- Vinblastine
- Paclitaxel
- Etoposide
Morell Notes

Vinblastine is a vinca alkaloid and a chemical analogue of vincristine.
- http://en.wikipedia.org/wiki/Vinblastine

102

Which of the following chemotherapeutics is an antimetabolite?
A. Chlorambucil
B. Gemcitabine
C. Vinblastine
D. Bleomycin

Gemcitabine

The “-abine” drugs are antimetabolites (cytarabine, fludarabine) plus 5-FU and methotrexate.

A. Chlorambucil (alkylating)
B. Gemcitabine
C. Vinblastine (anti-tublulin)
D. Bleomycin (anti-tumor antibody)

103

Which of the following is an antimetabolite:
a. Chlorambucil
b. vinblastin
c. cytarabin

c

The “-abine” drugs are antimetabolites (cytarabine, fludarabine) plus 5-FU and methotrexate.

104

What is the definition of neoadjuvant chemotherapy:
a. Chemotherapy pre op
b. Chemotherapy post op
c. Chemotherapy intra op
d. Chemo and radiotherapy
e. None of the above

Answer: Chemotherapy pre op

105

Which if the following is an antagonist to Methotrexate
a. Folic acid
b. Folinic acid

Answer: Folinic acid (leucovorin)

Folinic acid (INN) or leucovorin (USAN), generally administered as calcium or sodium folinate (or leucovorin calcium/sodium), is an adjuvant used in cancer chemotherapy involving the drug methotrexate.
Folinic acid is administered at the appropriate time following methotrexate as part of a total chemotherapeutic plan, where it may "rescue" bone marrow and gastrointestinal mucosa cells from methotrexate.
- http://en.wikipedia.org/wiki/Folinic_acid

Side effects:
Myelosuppression
Acute renal failure
elevation transaminases and bilirubin
pneumonitis
cerebral dysfunction

106

What is the dose limiting toxicity of Bleomycin?
a. myelosuppression
b. pulmonary fibrosis
c. cardiomyopathy
d. GI upset
e. peripheral neuropathy

Answer: pulmonary fibrosis

The two cytotoxic agents that commonly cause pulmonary damage are bleomycin and busulfan. The pulmonary damage caused by bleomycin is dose-related; patients who receive a cumulative dose of greater than 450 units show a higher incidence of toxicity than those who receive a lower cumulative dose.

107

Side effects of cisplatin

Name them all

lol

Nephrotoxicity
Ototoxicity
Myelosuppression ,thrombocytopenia, leukopenia
Hepatotoxicity
Gastrointestinal
Hyperuricemia
Neurotoxicity
Anaphylactic
Optic neuritis, papilledema

* Nephrotoxicity (kidney damage) is a major concern when cisplatin is given. The dose is reduced when the patient's creatinine clearance (a measure of renal function) is reduced. Adequate hydration and diuresis is used to prevent renal damage. The nephrotoxicity of platinum-class drugs seems to be related to reactive oxygen species and in animal models can be ameliorated by free radical scavenging agents (e.g., amifostine). This is a dose-limiting toxicity.
* Neurotoxicity (nerve damage) can be anticipated by performing nerve conduction studies before and after treatment.
* Nausea and vomiting: cisplatin is one of the most emetogenic chemotherapy agents, but this is managed with prophylactic antiemetics (ondansetron, gra3nisetron, etc.) in combination with corticosteroids. Aprepitant combined with ondansetron and dexamethasone has been shown to be better for highly emetogenic chemotherapy than just ondansetron and dexamethasone.
* Ototoxicity (hearing loss): unfortunately there is at present no effective treatment to prevent this side effect, which may be severe. Audiometric analysis may be necessary to assess the severity of ototoxicity. Other drugs (such as the aminoglycoside antibiotic class) may also cause ototoxicity, and the administration of this class of antibiotics in patients receiving cisplatin is generally avoided. The ototoxicity of both the aminoglycosides and cisplatin may be related to their ability to bind to melanin in the stria vascularis of the inner ear or the generation of reactive oxygen species.
* Alopecia (hair loss): this does not generally affect patients treated with cisplatin.
* Electrolyte disturbance: Cisplatin can cause hypomagnesaemia, hypokalaemia and hypocalcaemia. The hypocalcaemia seems to occur in those with low serum magnesium secondary to cisplatin, so it is not primarily due to the Cisplatin.

108

All could be used adjuvant therapy for malignant tumors except:
a. Monoclonal antibodies
b. Interferon
c. ???
d. BCG

Monoclonal antibodies (many, used for leptomeningocele and others)
Interferon (melanoma, lymphoma, BCC)
BCG (used for superficial transitional bladder CA)

109

Alkylating agents act by

Answer: crosslinking DNA

Alkylating agents are chemical compounds that facilitate the replacement of hydrogen for an alkyl group, potentially disrupting normal function of the altered molecule. As chemotherapeutic agents, alkylating agents interact directly with DNA by transferring positively charged alkyl groups to negatively charged chemical groups intrinsic to the DNA molecule. Examples of this class include cyclophosphamide and ifosfamide.
Cyclophosphamide and its structural analogue ifosfamide are bifunctional cyclic phosphamide esters of nitrogen mustard. Both drugs interact with the N7 position of guanine within the DNA helix to form cross-link bridges between the same strand of DNA (intrastrand), opposite strands of DNA (interstrand), and between DNA and cellular proteins.
- Katz: Comprehensive Gynecology, 5th ed.

110

Doxorubicin (adriamycin) is an antibiotic with anti-neoplastic properties. Which of the side effects listed below is associated with its use?
a) Nephrotoxicity
b) Perpipheral neuropathy
c) Myelosuppression
d) Cardiac toxicity
e) Stomatitis

Answer: Cardiac toxicity

Special attention must be given to the cardiotoxicity induced by doxorubicin. Irreversible myocardial toxicity, manifested in its most severe form by life-threatening or fatal congestive heart failure, may occur either during therapy or months to years after termination of therapy.
- Mosby's Drug Consult Copyright © 2002

111

3) The effect of radiation is/ are:
a. Immediate
b. Enhanced by the presence of O2
c. ????

Answer to 3): Enhanced by the presence of O2

Radiation deposition results in DNA damage manifested by single and double strand breaks in the sugar phosphate backbone of the DNA molecule. Cross linking between the DNA strands and chromosomal proteins also occurs. The mechanism of DNA damage differs by type of radiation delievered. Electromagnetic radiation is indirectly ionizing through short lived hydroxyl radicals produced primarily by the ionization of cellular hydrogen peroxide (H202). Protons and other heavy particles are directly ionizing and directly damage DNA.
Radiation damage is manifested primarily by the loss of cellular reproductive integrity. Most cell types to do not show signs of radiation damage until they attempt to divide, so slowly proliferating tumors may persist for months and appear viable. Some cell types, however, undergo apoptosis.
The extent of DNA damage following radiation is dependant on several factors. The most important of these is cellular oxygen. Hypoxic cells are significantly less radiosensitive then aerated cells. Since oxygen is thought to prolong the half-life of free radicals produced by the interaction of x-rays and cellular H202, indirectly ionizing radiation is less efficacious in tumors with areas of hypoxia. In contrast, radiation damage from directly ionizing radiation is independent of cellular oxygen levels.
The extent of DNA damage from indirectly ionizing radiation is dependent on the phase of the cell cycle. The most radiation sensitive phases are G2 and M; while G1 and late phase S are less sensitive. (where fractionation is important).
Several chemicals that can modify effects of radiation. Hypoxic cell sensitizers (metronidazole) which mimic oxygen and increase cell kill of hypoxic cells. Also radiation sensitizers that are thymidine analogues (iodoeoxyuridine and bromodeoxyuridine). These are incorporated into DNA in place of thymidine and render the cells more susceptible to radiation damage. Note: assoc. with severe acute toxicity.
- Schwartz 2006

112

What is the best skin sparing form of radiation?
a) Brachytherapy
b) Orthovoltage radiation
c) Gamma knife aka colbalt
d) Supravoltage radiation
e) Stereotactic radiation

a) Brachytherapy

This question seems to be asked every year.


b) Orthovoltage radiation (200 kV, no skin paring effect)
c) Gamma knife aka colbalt (1.25 MV = skin sparing effects)
d) Supravoltage radiation (???)
e) Stereotactic radiation (6MV = most skin sparing effect)

113

Patient treated with pelvic radiation for rectal carcinoma. Most likely late presentation with complication:
a. Diarrhea
b. Rectal bleeding
c. Pain
d. Bladder-anal fistula
e. Fecal incontinence

I don't know. a?

ENTERITIS — Radiation therapy (RT) can cause an acute injury to the small and large intestines that develops during or shortly after treatment of a variety of malignancies. The initial toxicity generally resolves within a matter of weeks, but chronic changes can develop months or years after therapy.

Pathogenesis — The gastrointestinal epithelium has a high proliferative rate, making it susceptible to injury from both radiation and chemotherapy. The primary effect of radiation is on mucosal stem cells within the crypts of Lieberkühn. Stem cell damage, either acutely as a direct consequence of radiation or subsequently as a result of microvascular damage, leads to a decrease in cellular reserves for the intestinal villi. This results in mucosal denudation with associated intestinal inflammation, edema, shortened villi, and decreased absorptive area.

The initial histologic evidence of damage is seen within hours of irradiation. This is followed by an infiltration of leukocytes with crypt abscess formation within two to four weeks; ulceration may also occur. Subsequent changes include a progressive occlusive vasculitis with foam cell invasion of the intima and hyaline thickening of the arteriolar walls, as well as collagen deposition and fibrosis, often in the submucosal layer [20].

The small bowel becomes thickened [21]. The vessel walls of small arterioles are obliterated, causing ischemia. Lymphatic damage results in constriction of the lymphatic channels, which contributes to mucosal edema and inflammation [22]. The mucosa is atrophied, with atypical hyperplastic glands and intestinal wall fibrosis [23]. Telangiectasias may be present and can cause bleeding. (See "Argon plasma coagulation in the management of gastrointestinal hemorrhage".)

Mucosal ulcerations can lead to perforation, fistulas, or abscess formation. As the ulcers heal, there can be fibrosis with narrowing of the intestinal lumen and stricture formation or even obstruction. Stasis can lead to small intestinal bacterial overgrowth. Even if the intestine appears normal, patients are at risk of spontaneous perforation [24].

These chronic changes can impair absorption of fats, carbohydrates, protein, bile salts, and vitamin B12, leading to loss of water, electrolytes, and protein in the small intestine [25,26]. Lactose degradation may be impaired, which can lead to increased bacterial fermentation and associated flatulence, abdominal distention, and diarrhea, possibly accompanied by bacterial overgrowth [27]. There is also evidence of altered gut motility acutely following RT. Bile salt resorption may be impaired, causing increased amounts of conjugated bile salts to enter the colon. These bile salts are then deconjugated by bacteria, resulting in intraluminal water retention with resultant diarrhea. The large intestine is generally believed to be less radiosensitive than the small intestine. When radiation injury does involve the colon, patients can develop a pancolitis that mimics inflammatory bowel disease (IBD).

114

What does radiation not inhibit in the cell?

Answer: apoptosis

Radiation induces direct DNA damage or indirect via generation of OH free radicles. This causes cell death (ie apoptosis)

Many stimuli activate the process of apoptosis (see Fig. 3-11 ), including DNA damage through ionizing radiation, growth factor and nutritional deprivation, activation of certain death receptors (e.g., Fas receptor [FasR] and tumor necrosis factor receptor [TNF-R1]), metabolic or cell cycle perturbations, oxidative stress, and many chemotherapeutic agents.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

DNA damage. Radiation, cytotoxic anticancer drugs, and hypoxia can damage DNA, either directly or via production of free radicals. If repair mechanisms cannot cope with the injury, the cell triggers intrinsic mechanisms that induce apoptosis.
- Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed.

115

Wound healing in radiated tissue is impaired MOST due to damage to which cell?
a. endothelials
b. neutrophils
c. macrophages
d. fibroblasts
e. lymphoblasts

a. endothelial

Seems like fibroblasts would be 2nd choice, but they have higher radiation resistance

Ionizing radiation causes endothelial cell injury with endarteritis and results in atrophy, fibrosis, and delayed tissue repair. Unlike most hypoxic wound beds, angiogenesis is not initiated. Because its greatest effect is on cells in the G2 through M phase, rapidly dividing cell populations are most sensitive to radiation. Such cells include keratinocytes and fibroblasts during wound healing, injury to which impairs epithelialization and the formation of granulation tissue.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

116

which cell is radio resistance
a- lymphocyte
b- epidemocyte
c- gut enterocyte
d- neural cell
e- spermatocyte

Answer: Neural cell.

Muscle and bone are also very resistant

Just think of cells that don't multiply much.

117

Early effects of radiation on the healing wound. All except
a) epilation
b) desquamation
c) sclerosis and stenosis of blood vessels
d) decreased fibroblasts

Blood vessel sclerosis and stenosis

This is late
This makes sense

IONIZING RADIATION
• Radiation causes endarteritis resulting in atrophy, fibrosis, and delayed tissue repair.
• Arterial fibrosis → impaired O2 delivery
• Progressive obliteration of blood vessels in the radiated area
(Morell Notes)

Acute radiation injury in mainfested by stasis and occlusion of small vessels, with a consequent decrease in wound tensile strength and total collagen deposition. Although decreased blood flow to the wound tissues certainly contributes to poor healing, there is strong evidence of a direct adverse effect of ionizing radiation on fibroblast proliferation, with possible permanent damage to the fibroblasts
- Sabiston

In the short term, most patients experience significant perineal skin reactions, often with confluent moist desquamation, such that a treatment break is necessary during most treatment courses.
- Abeloff: Abeloff's Clinical Oncology, 4th ed

Ionizing radiation causes endothelial cell injury with endarteritis and results in atrophy, fibrosis, and delayed tissue repair. Unlike most hypoxic wound beds, angiogenesis is not initiated. Because its greatest effect is on cells in the G2 through M phase, rapidly dividing cell populations are most sensitive to radiation. Such cells include keratinocytes and fibroblasts during wound healing, injury to which impairs epithelialization and the formation of granulation tissue.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

118

Radiation injury to skin all are true EXCEPT:
a. Fibroblasts change.
b. Hair follicles and sweat glands are not affected because they are deep to the surface
c. Skin reactions tend to be worse in skin folds
d. Skin erythema begins within a week of treatment

C???

119

Woman post neck surgery has a dehiscence and the carotid is exposed. What is the bets option for management?
a. Take back to O.R. and do a primary closure.
b. Let it heal by secondary intention.
c. Close with a myocutaneous flap.
d. Close with full thickness skin graft.
e. Close with a partial thickness skin graft.

Answer: Myocutaneous flap

The combination of infection and local ischemia of skin or mucosa may result in wound infection, suture line breakdown, flap necrosis, osteomyelitis, and osteoradionecrosis. Exposure of a previously irradiated carotid artery usually results in a bacterial infection and rupture and must be treated as a surgical emergency. Careful planning, meticulous attention to watertight closure of the pharynx and oral cavity, and provision of adequate independently well-vascularized tissue for reconstruction will minimize the likelihood of technical complications.
The pectoralis major musculocutaneous flap is a useful method of closing major fistulas and covering the great vessels at the same time.

120

Tests for the diagnosis of osteomyelitis

Sensitivity
PET = 96%
MR = 84%
Bone scan = 82%
Combined bone and leukocyte scintigraphy = 78%
Leukocyte scintigraphy = 61%

Specificity
PET 91%
Combined bone and leukocyte scintigraphy = 84%
Leukocyte scintigraphy = 77%
MR = 60%
Bone scintigraphy = 25%

121

If a dose of 200 eGy of Cobalt-60 radiation reduces the number of viable cells in a tumour from 100,000,000 to 60,000,000, then a subsequent dose of 200cGy will reduce the number of viable cells to:
a) 10,000,000
b) 16,000,000
c) 20,000,000
d) 24,000,000
e) 36,000,000

40% decrease + 40% decrease =
e. 36 000 000

Cell death following irradiation appears to be a complex exponential function of the dose- i.e. a specified radiation dose kills a constant fraction of irradiated cells. Thus, the dose required to kill a given number of tumour cells depends on the number of tumour cell initially present and is related to the tumour size. For densely ionizing radiation such as neutron the dose-response curve is straight.
Thus in the above case 100,000,000 cell go to 60,000,000 and these will go to 60X60/100= 36,000,000 viable cells
- Current surgical diagnosis and treatmen, 10th ed, P 1261

122

Intraoperative radiation decreases what stage of wound healing?
a) Decreased epithelialization
b) Proliferation
c) Inflammation
d) Maturation

Answer: Decreased epithelialization (???)

Ionizing radiation causes endothelial cell injury with endarteritis and results in atrophy, fibrosis, and delayed tissue repair. Unlike most hypoxic wound beds, angiogenesis is not initiated. Because its greatest effect is on cells in the G2 through M phase, rapidly dividing cell populations are most sensitive to radiation. Such cells include keratinocytes and fibroblasts during wound healing, injury to which impairs epithelialization and the formation of granulation tissue.
- Townsend: Sabiston Textbook of Surgery, 18th ed

123

A 55 year old female undergoes a left breast lumpectomy and axillary node dissection for invasive ductal cancer. She then receives chemotherapy and a 5 week course of 5000 cGy of external beam radiation to the breast and axilla. Late complications of irradiation include all of the following EXCEPT?
a) Brachial plexopathy
b) Rib fractures
c) Moist desquamation
d) Arm edema
e) Pneumonitis

Answer: Moist desquamation

Basically:
Early = early wound problems
Late = fibrosis and stuff

TABLE 75-23 -- COMPLICATIONS OF THERAPY
COMPLICATION FREQUENCY (% )
Arm edema 5-20
Rib fractures 5
Radiation pneumonitis 1
Brachial plexus damage

124

What is the most common type of heterotopic transplantation?
a. Kidney
b. liver
c. heart
d. Lung

Kidney

you put the kidney in the iliac fossa

heterotopic = put it where it anatomically normally isn't

125

The commonest infectious agent post transplant is:
a) HIV
b) HBV
c) HCV
d) CMV

As a result of immunosuppression to prevent rejection, transplant patients are at significant risk for viral infection, especially with cytomegalovirus
- Townsend: Sabiston Textbook of Surgery, 18th ed.

126

Which organ is the most immunogenic:
a) kidney
b) liver
c) heart
d) skin

D. skin

Decreasing order of tissue immunogenicity:
1) Bone marrow
2) Skin
3) Intestine
4) Islets of Langerhans
5) Heart
6) Kidney
7) Liver
- Medscape

127

When comparing kidney and cardiac transplants:
a. cardiac tx mortality 80% at one year
b. cardiac tx mortality 60% at two years
c. both cardiac and kidney organs have the same lifespan while on ice (between donor and recipient)
d. kidney tx has higher risk of chronic failure due to macrophages infiltrating the blood vessels
e. cardiac transplantation is contraindicated in patients with irreversible pulmonary hypertension

e. cardiac transplantation is contraindicated in patients with irreversible pulmonary hypertension

128

When comparing renal transplantation with cardiac transplantation, which of the following statements is MOST correct?
a. ABO compatibility is required for renal but not cardiac transplantation
b. Cold ischemia time is equivalent for both renal and cardiac transplantation
c. In the setting of cadaveric organs, the 5-year graft survival is equivalent
d. Chronic rejection does not occur in cardiac transplantation
e. T-cell mediated vascular fibrosis does not occur in cardiac transplantation

ABO compatibility is required for renal but not cardiac transplantation ?

"ABO incompatible (ABOi) heart transplantation is an accepted approach to increasing organ availability for young patients. Previous studies have suggested that early survival for ABOi transplants is similar to ABO compatible (ABOc) transplants"

a. ABO compatibility is required for renal but not cardiac transplantation (YES (see artcle)-cannot transplant kidney withour ABO compatibility; for heart, ideal to have match, but minor mismatches are accepted to help reduce waitlist without significant increase in hyperacute rejection)
b. Cold ischemia time is equivalent for both renal and cardiac transplantation – probably not
c. In the setting of cadaveric organs, the 5-year graft survival is equivalent
d. Chronic rejection does not occur in cardiac transplantation (NO)
e. T-cell mediated vascular fibrosis does not occur in cardiac transplantation (???) NO-T cells are involved in chronic rejection, and chronic rejection in the heart manifests as intimal hyperplasia and diffuse astherosclorsis

129

Renal transplant recipients lymphocytes are crossed matched with donor lymphocytes prior to transplantation. What property of lymphocytes is demonstrated????
a. increased amount of DNA
b. immunomodulation
c. involved in transplant rejection
d. involved in HLA presentation

d. involved in HLA presentation

In the case of HLA class II alleles, differences were originally detected using mixed lymphocyte responses. When T cells from a responder are mixed with lymphocytes from another individual, differences in HLA class II alleles cause the responder's T cells to proliferate. Data on mixed lymphocyte culture typing dominated the early HLA literature, and it was the method first used to detect the HLA class II associations with rheumatoid arthritis (RA).[21] Subsequently, serologic methods also were employed to detect class II polymorphisms.
- Firestein: Kelley's Textbook of Rheumatology, 8th ed.

130

what mediates hyperacute rejection:
a. IgG
b. IgM
c. T cell
d. B cell

IgG - preformed antibodies

IgM are first to be formed to a new antigen so they are created first upon new encounter, but IgG float around that were made from previous antigen, so they are there instantly

Hyperacute rejection is mediated by preformed antibodies that bind to endothelium and subsequently activate complement. This rejection is characterized by rapid thrombotic occlusion of the vasculature of the transplanted allograft. The thrombotic response occurs within minutes to hours after host blood vessels are anastomosed to donor vessels. Hyperacute rejection is mediated predominantly by IgG antibodies directed toward foreign protein molecules, such as MHC molecules. These IgG antibodies are the result of previous exposure to alloantigens from blood transfusions, pregnancy, or previous transplantation.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

T-cell: acute

131

What is the most common form of transplant rejection? (hyperacute, acute, chronic?)

Rejection typically occurs in three phases: hyperacute, acute, and chronic. Hyperacute rejection is rare with careful donor-recipient matching. It typically occurs in the immediate perioperative period. Acute rejection occurs within the first months after transplantation. It usually presents with constitutional symptoms and signs of transplant organ insufficiency. Expeditious laboratory assessment, including possible allograft biopsy, can confirm the diagnosis of rejection, and the appropriate adjustment can be made in the patient's immunosuppressant regimen. Acute rejection can occur at any time if immunosuppressants are stopped. Chronic rejection has a time course of years and results in the gradual failure of the transplanted organ.
- Marx: Rosen's Emergency Medicine, 7th ed.

Three types of graft rejection occur ( Fig. 27-15 ). Hyperacute rejection occurs within minutes to days after transplantation and is mediated primarily by preformed antibody. This type of rejection is prevented by screening the recipient for preformed antibodies, not by classic antirejection pharmaceuticals. Acute rejection is mediated primarily by T lymphocytes and first occurs between 1 and 3 weeks after solid organ transplantation without immunosuppression. Acute rejection episodes are most common in the first 3 to 6 months after transplantation but can occur at any time. Acute rejection can quickly destroy a graft if left untreated. The new immunosuppressive agents have made acute rejection increasingly less common. Chronic rejection occurs over a span of months to years and is the most common cause of graft loss after 1 year.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

132

With regard to heart transplantation, all of the following are true EXCEPT:
A. Infection is the # 1 cause of late death
B. 5 year survival is ~ 75%
C. Approximately half of patients undergoing heart Tx have underlying ischemic cardiomyopathy
D. Patients with HIV are not eligible for cardiac transplantation

Uptodate
Death after heart transplant
1) In the first 30 days: Graft failure (primary and non-specific) - 40 percent of deaths
2) Between 31 days and one year: Non-CMV infection - 33 percent
3) After 5 years: Allograft vasculopathy and late graft failure (likely due to allograft vasculopathy)I — 30 percent

133

All the following about chronic rejection in cardiac transplant are true except :
a. Commonest cause of death after 1 year
b. Usually associated with CMV infection
c. Characterised by multiple coronary atherosclerotic lesions
d. Present with arrythmias and heart failure

Answer given: b. Usually associated with CMV infection

Chronic rejection in cardiac transplantation is manifested as coronary vasculopathy. It usually presents as heart failure or arrhythmias rather than angina because of the persistent denervation of the allograft. It consists of diffuse concentric intimal hyperplasia of both epicardial and intramyocardial vessels. The consequences of acute myocardial infarction and ischemic myocardial dysfunction are the same as those of atherosclerotic coronary artery disease. Detection is usually by periodic coronary angiography or, more recently, intracoronary ultrasound.

Infection continues to be an important early and late cause of morbidity and mortality. The range and sites of opportunistic infections and the risk factors are quite similar to those seen with other solid-organ transplants. The allograft itself is fairly resistant to infection. Although CMV and toxoplasma will occasionally be identified in endocardial biopsies, serious bacterial and fungal infections seldom involve the heart except as a terminal event.

134

With regards to post heart transplant allograft vasculopathy, all of the following are true EXCEPT:
A. It is associated with CMV
B. It is the #1 cause of late death in heart transplant patients
C. It is characterized by proximal, discrete coronary lesions
D. It is associated with immune-related endothelial injury

C. It is characterized by proximal, discrete coronary lesions

The risk of transplant vasculopathy increases as the number of HLA mismatches and the number and duration of rejection episodes increase. CMV infection and ischemia-reperfusion injury also increase the risk, as do classic risk factors for atherosclerotic disease, such as smoking, obesity, diabetes, dyslipidemia, and hypertension. Transplant vasculopathy can develop as early as 3 months after transplantation and is detected angiographically in 20% of grafts at 1 year and in 40 to 50% at 5 years. In contrast to eccentric lesions seen in atheromatous disease, cardiac allograft vasculopathy produces concentric narrowing from neointimal proliferation of vascular smooth muscle cells and affects the entire length of the coronary tree, from the epicardial to the intramyocardial segments, leading to rapid tapering, pruning, and obliteration of third-order branch vessels.

Uptodate
CAV is a panarterial disease confined to the allograft and is characterized by diffuse concentric longitudinal intimal hyperplasia in the epicardial coronary arteries (figure 1) and concentric medial disease in the microvasculature. In contrast, traditional atherosclerosis is focal, noncircumferential, and most often observed proximally in the epicardial vessels. (See 'Pathology' above.)
Cardiac allograft vasculopathy appears to be multifactorial in origin with both immunologic and nonimmunologic factors implicated. Among the factors associated with vasculopathy are cellular and antibody mediated rejection, donor specific anti-HLA antibodies, cytomegalovirus infection, and hypercholesterolemia. Immunologic events appear to be most important, since CAV develops in the donor's but not the recipient's arteries. (See 'Pathogenesis' above.)

- Goldman: Cecil Medicine, 23rd ed.

135

Which of the following is most determinant for renal transplant success?
a) HLA
b) Cold ischemia time
c) Warm ischemia time
d) ABO

a. ABO

Need ABO compatibility or you'll get hyperacute rejection.
Second most important is HLA.

136

The most important predictor of good function of a transplanted kidney is:
a) Preoperative urine output by donor kidney
b) OR time
c) Cold ischemic time
d) Warm ischemic time

a) Preoperative urine output by donor kidney

137

HLA matching is routinely performed prior to transplants of the following organs:
a) lung
b) heart
c) kidney
d) liver

Answer: kidney

Renal Transplantation: Current practice is to select donors for recipients who are ABO-compatible, T-cell donor-specific crossmatch-negative with appropriate recipient sera, and the best available HLA match.
Survival of heart, liver, lung, and pancreas grafts is good, with between 58% and 67% of first grafts surviving at 5 years. Donors are not usually matched for HLA type, and a pretransplant donor crossmatch is not routinely performed.
Allogeneic hematopoietic progenitor cell transplantation is performed for hematologic malignancies and disorders, bone marrow failure, certain inherited metabolic disorders such as lipid storage diseases, and congenital immunodeficiency syndrome. Progenitor cells from an HLA-identical sibling donor are a frequent source.
- McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods, 21st ed.

138

All of the following HLA types are routinely checked prior to transplantation EXCEPT?
a. HLA A
b. HLA B
c. HLA C
d. HLA DR
e. HLA DQ

c. HLA-C

Renal Transplant = HLA – A, B, DR

Not sure what DQ is but ..

Potential donors and recipients are typed for HLA-A, HLA-B, and HLA-DR molecules. On close examination of graft survival, HLA matching is the best means of prolonging allograft survival. The larger the number of HLA-A, HLA-B, and HLA-DR alleles that are matched between both donor and recipient, the better the survival rate, particularly in the first year after transplantation.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Clinical data do not support the simple assumption that each mismatch for antigens of various loci has equal weight in causing graft loss. The major impact comes from the effects of B and DR antigens; little additional effect comes from the A locus.

139

A female patient in need of a kidney has 2 sisters. What is the chance that both sisters will be HLA non-identical?
a) 25%
b) 12.5%
c) 6.25%
d) 3.125%
e) 0%

Disagree. The stem must be wrong misworded.
The chance of both being non-identical (i.e. neither is identical) is 9/16.
For each sister, there are 4 possible genotypes. (AA, Aa, aA, and aa). So between the two sisters, there are 4x4=16 possible genotypes. In a quarter of each of the genotypes, one sister will match. But there is one case where both match. So chance of at least one match is 1/4 + 1/4 - 1/16 = 7/16. Chance of neither being match is 1 – (7/16) = 9/16.


140

All of the following are signs of renal transplant rejection except:
a) Fever
b) Hypotension
c) Pancytopenia
d) Graft tenderness
e) Increase graft size on ultrasound

Hypotension

Acute rejection typically occurs between 1 week and 3 months after transplantation. Decreased allograft function with rising serum creatinine values and diminished urine output are hallmarks of rejection. Additional signs and symptoms, such as low-grade fever, allograft tenderness, and hypertension may suggest the diagnosis.

Uptodate
CLINICAL MANIFESTATIONS — Patients with acute renal allograft rejection present with an acute rise in the serum creatinine, which suggests underlying renal allograft dysfunction. A rising serum creatinine level, however, is a relatively late development in the course of a rejection episode and usually indicates the presence of significant histological damage. Some additional clinical manifestations include decreased urine output, increased blood pressure, pyuria, and/or new or worsening proteinuria.

Many patients who have acute rejection episodes are asymptomatic. Fever, graft pain and/or tenderness, and graft swelling are currently uncommon with modern immunosuppressive drug therapy unless immunosuppression is completely discontinued

141

The cause of chronic rejection in renal transplant is:
a. Nonneculated cells +humoral
b. Humoral
c. Schwartzman phenomenon
d. All of the above
e. None of the above

Answer: antibodies (humoral)

Chronic rejection is characterized by a gradual decline in renal function associated with interstitial fibrosis, vascular changes, and minimal mononuclear cell infiltration. A positive B-cell crossmatch or a positive flow crossmatch against donor B or T cells is considered by some to be predictive of chronic rejection and poorer long-term graft survivals.
- Wein: Campbell-Walsh Urology, 9th ed

From an immunologic standpoint, chronic rejection is mediated by both T- and B-cell responses
- Sabiston

Hyperacute rejection: (minutes - hours)
o occurs when preformed antidonor Abs are present in the circulation of the recipient
o exposure occurs via: - prior transplant, prior blood transfusion, pregnancy
o mechanism: - Ab binds to donor Ag causing complement mediated lysis, then induction of a procoagulant state that causes immediate graft thrombosis
Acute rejection: (days - weeks, within first 6 months)
o causes primarily by cytotoxic T-cells (CD8) reacting against foreign Ag presented by MHC I molecules
o get cascade of events leading to massive attack of donor tissue causing destruction
o T-cell specific immunosuppression prevents acute rejection 90-95% of the time
Chronic rejection: (months - years)
o poorly understood and untreatable
o Ab mediated
o initiated by : - drug toxicity, recurrent infections, ischemia, age of organ
o histologically characterized by parenchymal replacement by fibrous tissue with little lymphocytic infiltrate
- Schwartz

142

ABO compatibility is important for which transplant :
a. Heart
b. Liver
c. Kidney
d. Lung
e. Intestinal

c. Kidney

143

The average half life of cadaveric kidney transplant with modern technique is:
a. 9years
b. 15 years
c. >20 years
d. 50 years
e. 40 years

a?

Living donor >20 years
Dead donor > 10

Although few organs are now lost to acute rejection, as a result of improvements in surgical techniques and immunosuppressive therapies, the long-term graft survival has altered little over the last decades, and the current mean half-life of cadaveric kidney transplants is only 10 years.
- Brenner: Brenner and Rector's The Kidney, 8th ed.

Recent data show that recipients of first deceased donor kidneys having no HLA-A, -B, or -DR antigen mismatches have graft half-lives of 14.5 years and a projected 73% chance of 5-year survival.
- Brenner: Brenner and Rector's The Kidney, 8th ed.

Cadaveric HLA-matched kidney transplant : half-life=16 yrs, survival rates 89 and 83% at one and 3 years post graft. If not HLA-matched, half-life=10years, survival 87 and 76%. Half-life increases with living donor and relatives (identical siblings being the best).
- UNOS scientific renal transplant registry

144

What is the expected half-life of a HLA matched transplanted cadaveric kidney?
a. >1 year
b. >2 years
c. >5 years
d. >10 years
e. >15 years

e?

Living donor >20 years
Dead donor > 10

Although few organs are now lost to acute rejection, as a result of improvements in surgical techniques and immunosuppressive therapies, the long-term graft survival has altered little over the last decades, and the current mean half-life of cadaveric kidney transplants is only 10 years.
- Brenner: Brenner and Rector's The Kidney, 8th ed.

Recent data show that recipients of first deceased donor kidneys having no HLA-A, -B, or -DR antigen mismatches have graft half-lives of 14.5 years and a projected 73% chance of 5-year survival.
- Brenner: Brenner and Rector's The Kidney, 8th ed.

Cadaveric HLA-matched kidney transplant : half-life=16 yrs, survival rates 89 and 83% at one and 3 years post graft. If not HLA-matched, half-life=10years, survival 87 and 76%. Half-life increases with living donor and relatives (identical siblings being the best).
- UNOS scientific renal transplant registry

145

Risk of chronic rejection of renal transplant increase in all except :
a. Increased ischemia time and reperfusion injury
b. Multiple previous acute rejections
c. Transplant between white and black American African origin

c. Transplant between white and black American African origin

146

All have favorable outcome after renal transplant except
- Non- diabetic pt
- Age

Previous transplant (if previous graft was lost due to rejection)

Uptodate
Patient survival after renal transplantation varies based upon the source of the allograft, patient age, and the presence and degree of severity of comorbid conditions. Other possible contributing factors include gender, race, and degree of immunosuppression. One European study evaluated the determinants of patient survival after renal transplantation among 86 living donor transplant recipients and 916 deceased donor recipients [8]. After the first year posttransplantation, an increased risk of death was observed among patients over the age of 40, men, deceased donor recipients, those with diabetes or hypertension, and smokers. Similar adverse outcomes with smoking, including those who have ever smoked, were noted in a second study

147

Renal transplant patients under immuno-suppression are at increased risk for which malignancy
a. breast cancer
b. colon cancer
c. lymphoma
d. lung cancer
e. kaposi’s sarcoma

c. lymphoma

148

What is the most common post transplant malignancy
A - lymphoma
b – epidermoid cancers
c – kaposi’s
d – cervical cancer

Cancer after transplantation is a particular concern: nonmelanoma skin cancer is prevalent, and there is a higher incidence of both solid organ cancers and lymphoma. Other complications include cardiovascular disease, which is the most common cause of patient death in those with a functioning kidney transplant.
- Walsh: Palliative Medicine , 1st ed.

Malignancy is common in long-term renal transplant survivors despite improvements in post-transplant management. In a recent survey of 43 renal transplant recipients with allografts lasting 19 or more years, 30% (13) developed a malignancy. [750] The chronic use of immunosuppressive agents increases the risk of neoplasms after transplantation. The types of cancers encountered in transplant recipients are very different from the normal population, with a higher incidence of squamous cell carcinomas of the skin, non-Hodgkin's lymphoma, Kaposi's sarcoma, in situ carcinomas of the uterine cervix, carcinomas of the vulva and perineum, hepatobiliary carcinomas, and a variety of sarcomas. [751]
Although the overall incidence of tumors in the transplant population is 100 times higher than in the general population, the incidence of tumors seen commonly in the general population (lung, breast, prostate, colon, and invasive uterine carcinomas) does not increase and may in fact be even lower after transplantation. If all cancers are considered, the average time of their appearance is 61 months. It is clear that some neoplasms appear at distinct time intervals after transplantation. For instance, Kaposi's sarcoma is the first to appear (average of 21 months) and then lymphomas (average 32 months), epithelial cancers (69 months), and cancer of the vulva and perineum (112 months). [99]
- Brenner & Rector's The Kidney, 6th ed., Copyright © 2000

Most PTLDs manifest as non-Hodgkin's lymphomas arising from B lymphocytes. The cumulative incidence of PTLD is approximately 1% after renal transplantation, but it may be as high as 10% in children.
The incidence of KS (Kaposi’s Sarcoma) is around 0.4% for transplant patients in Northern and Western countries but is as high as 5% in Arab, Jewish, and Mediterranean patients.
Skin cancers are very common in renal transplant recipients and include squamous cell and basal cell carcinomas and malignant melanomas.[139-141] Up to half of all posttransplant malignancies are skin cancers.[140] The incidence varies with the amount of sun exposure and the duration of follow-up. In The Netherlands, for example, up to 10% of renal transplant recipients develop skin cancer by 10 years, 40% by 20 years
Carcinomas of the vulva, anus, perianal region, penis, perineum, and scrotum are common after renal transplantation.[141] Compared with the general population, there is a 100-fold increase in the incidence of anogenital malignancies.
The incidence of breast cancer is high after renal transplantation; indeed, it is the most common posttransplant malignancy among women.
The risk of colon cancer appears to be similar in renal transplant recipients and in the general population.
The incidence of lung cancer after transplantation is similar to that in the general population.
- http://cme.medscape.com/viewarticle/418437_5

149

What is the leading cause of late death (>1 year post transplant) in kidney transplant recipients?
a. sepsis
b. chronic rejection
c. malignancy
d. cardiovascular disease
e. senesence

D

Hypertension after renal transplantation is common. Causes of this include medications (glucocorticoids, cyclosporine, and tacrolimus), intrinsic renal disease, and rejection. In spite of aggressive preoperative assessment and treatment, myocardial infarction and stroke continue to be leading causes of death in these patients. Prednisone and cyclosporine increase cardiovascular risk because of associated hyperlipidemia, and post-transplantation hyperlipidemia should be treated with dietary changes and, if necessary, antilipid medications.
- Walsh: Campbell's Urology, 7th ed., pg 524

150

Which of the following is associated coronary artery disease:
a. tacrolimus
b. cyclosporin
c. azathioprine
d. MMF

b. cyclosporin

These pretransplant risk factors are amplified by post-transplant immunosuppression. Cyclosporine and corticosteroids, in particular, are associated with increased coronary artery disease. Adequate pretransplant assessment for coronary artery disease, including liberal use of coronary angiography, can help identify patients at risk. Post-transplant manipulation of immunosuppression in high-risk recipients needs to be undertaken. For instance, switching from cyclosporine to tacrolimus is considered, as well as avoidance or withdrawal of steroids in selected patients.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

151

1) All of the following are side effects or complications of cyclosporine EXCEPT:
a) Nephrotoxicity
b) Tremor
c) Hyperuricemia
d) Teratogenicity
e) Hypercholesterolemia

Hypercholesterolemia

Toxicity (3 Ns/7 Hs):
Nephrotoxicity by ↓ GFR, usually reversible with dose reduction (additive nephrotoxicity with NSAIDs and Cipro)
Neoplasia
Neurotoxic (tremor, paraesthesia)
Hyperuricemia
Hypertension
Hyperglycemia
Hyperkalemia
Hyperplasia of the gingiva
Hepatotoxic
Hirsutism
(Note the absence of myelosuppression)

152

1) Mechanism of action of cyclosporine is:
a. Inhibit B cell lymphocyte
b. Inhibit IL-2 activated T cell and cytotoxic T cell
c. Inhibit IL-6 activated T cell
d. Inhibit macrophage

b. Inhibit IL-2 activated T cell and cytotoxic T cell

153

2) Cyclosporine immunosuppression occurs by neutralizing which cell type
a. macrophages
b. PMNs
c. B-cells
d. T-cells
e. Plasma cells

d. T-cells

154

All of the following are true regarding Cyclosporin EXCEPT:
a. Inhibition of IL-2 gene expression
b. Stimulates B-lymphocyte IgG production
c. Inhibits T-Lymphocyte activation by mitogens
d. Was first isolated from the fungus Tolypocladium inflatum
e. Is a less powerful immunosuppressant the FK-506 (Tacrolimus)

Answer given: b. Stimulates B-lymphocyte IgG production


Calcineurin inhibitors bind to immunophilins (intracellular binding proteins). The calcineurin inhibitor-immunophilin complex inhibits a key phosphatase that is involved in transducing the signal from the T-cell receptor to the nucleus. The net effect is blockade of interleukin-2 and other cytokine transcription, leading to inhibition of T-lymphocyte activation and proliferation.
Cyclosporine A (CsA) is a cyclic 11-amino acid peptide derived from a fungus. Its major nonimmune side effect is nephrotoxicity due to afferent arteriolar vasoconstriction. Angiotensin-converting enzyme inhibitors, volume depletion, and other nephrotoxins may potentiate this toxicity. Acute nephrotoxicity is reversible with dose reduction; chronic nephrotoxicity is generally irreversible. Other adverse effects include gingival hyperplasia, hirsutism, tremor, hypertension, glucose intolerance, hyperlipidemia, hyperkalemia, and rarely thrombotic thrombocytopenic purpura.
CsA has a narrow therapeutic window, and doses are adjusted based on blood levels (recommended maintenance trough levels of 100-300 ng/ml and 2-hour peak levels

155

Which drug is not used in immunosupression post cardiac transplant:
a. Methotrexate
b. Steroids
c. OKT-3
d. Cyclosporine
e. Azathioprene

A. Methotrexate

Common question

The goal of perioperative induction therapy is to inhibit only those T cells that respond to donor antigen, thus achieving immunologic unresponsiveness to the transplant in the face of a fully functioning immune system, called donor-specific tolerance. Agents include the anti-CD3 antibody OKT3 and the interleukin-2 receptor antagonists daclizumab and basiliximab.
Patients initially receive high doses of intravenous corticosteroids (e.g., 500 mg of IV methylprednisolone at the end of cardiopulmonary bypass, followed by 150 mg IV every 8 hours for three additional doses), then oral steroids that are gradually tapered during the next 6 months in an attempt to minimize side effects ( Chapter 33 ). Corticosteroids also are usually the drug of first choice to treat acute rejection.
The calcineurin inhibitors cyclosporine and tacrolimus act specifically on the immune system and do not affect other rapidly proliferating cells. Important and often limiting side effects include nephrotoxicity, which occurs in up to 40 to 70% of patients, and hypertension. Target therapeutic levels 2 hours after a dose improve outcome.
Mycophenolate mofetil has replaced azathioprine as the first-line antiproliferative drug, with several randomized trials demonstrating superiority to azathioprine.[1] Mycophenolate mofetil may cause leukopenia, debilitating diarrhea, and nausea.
Sirolimus (often called rapamycin) and everolimus are complementary to calcineurin inhibitors, and both drugs have been used as alternatives to standard maintenance immunosuppression and as rescue drugs for rejection. In one randomized trial using cyclosporine and steroids, addition of sirolimus halved the number of patients with acute rejection and reduced the development of vasculopathy in the donor heart compared with addition of azathioprine.[2]
- Goldman: Cecil Medicine, 23rd ed.

Special aspects of posttransplant care involve the prevention of graft rejection through immunosuppression. Standard triple therapy is usually used (steroids, cyclosporine, and azathioprine). Some centers favor a steroid-free regimen for chronic immunosuppression, if feasible. Newer immunosuppressives (mycophenolate and tacrolimus [FK-506]) are also used in the pediatric group. Immunosuppression may result in infectious complications that are often more severe and may sometimes be fatal in the pediatric population.
- Townsend: Sabiston Textbook of Surgery, 16th ed.,

156

Which of the following drugs is used in the treatment of pulmonary hypertension post heart transplant:
a. Prostacyclin
b. Histamine
c. Epinephrine
d. Metoprolol
e. None of the above

Answer: Prostacyclin vs none of the above.

Beginning in the past decade, several potent therapies for pulmonary hypertension have evolved. [207] [208] A continuous intravenous infusion of prostacyclin improves pulmonary vascular hemodynamics, exercise tolerance, and survival in pulmonary hypertension.
- Miller: Miller's Anesthesia, 7th ed.

Inhaled nitric oxide, in a usual dose of 20 to 60 parts per million, is a potent vasodilator that has a selective effect on the pulmonary vasculature, reduces pulmonary vascular resistance, and improves right ventricular function in patients with pulmonary hypertension. Intravenous epoprostenol, an alternative, is typically used at 5 to 50 ng/kg/min.
- Goldman: Cecil Medicine, 23rd ed.

These sources are not heart transplant specific.

157

Azathioprine is a(n):
a. Antibiotic
b. Purine analogue
c. Alkylating agent

Azathioprine is used in organ transplantation and autoimmune disease. Some of the autoimmune diseases are rheumatoid arthritis, pemphigus, Inflammatory Bowel Disease (such as Crohn's disease and Ulcerative Colitis), multiple sclerosis, autoimmune hepatitis and restrictive lung disease.
Azathioprine interferes with the synthesis of purines (adenine and guanine), which is required for DNA synthesis. Fast-growing cells, including T-cells and B-cells, are particularly affected by the inhibition of purine synthesis.
It is a pro-drug, converted in the body to the active metabolites 6-mercaptopurine (6-MP) and 6-thioinosinic acid.
- http://en.wikipedia.org/wiki/Azathioprine

158

Which immunosuppressant causes cholestasis?
a) OKT3
b) Azathioprine
c) Prednisone
d) Cyclosporine A
e) Mycophenolate mofentil

Azathioprine is associated with an extraordinary range of hepatic disorders, including liver biochemical test abnormalities in asymptomatic patients, bland cholestasis, cholestatic hepatitis, bile duct injury, and vascular injury. Cholestatic hepatitis probably is the most common presentation; several cases have been associated with zone 3 necrosis and congestion, suggesting acute vascular injury, and azathioprine shares the vascular toxicity of other thiopurines.
- Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed.

Occasionally, cyclosporin A causes cholestatic liver chemistry tests.
The most common toxicities of azathioprine are hematologic. Occasionally, it has been associated with cholestatic jaundice, hepatitis, or both.
Diarrhea and abdominal discomfort are the most common gastrointestinal side effects of mycophenolate mofetil (MMF)
OKT3 increases the risk of bacterial, fungal, and viral infection and the development of posttransplant lymphoproliferative disorder (PTLD)
- Gastrointestinal complications of immunosuppression. Gastroenterology Clinics. Volume 28 • Number 1 • March 1999

159

Woman comes in to office, is being treated with azothioprine, cyclosporine and some other immunosuppressant (can’t remember) Has WBC of 1.5 and platelets of 75,000. What do you do:
a) discontinue all immunosuppressant
b) treat empirically with IV antibiotics
c) discontinue azothioprine until WBC>3.0

Answer: discontinue azothioprine until WBC>3.0

Sounds like a renal transplant patient based on this combo.
Azathioprine is mercaptopurine class→inhibits nucleic acid synthesis
Patients are maintained on 1mg/kg or less, adjusted based on WBC. The drug causes suppression of done marrow (esp platelets and WBC) and may cause jaundice. If severe AE or infection, temporarily discontinue the drug. Not give in increased amounts for acute rejection.
Cyclosporin is hepato and nephrotoxic and may increase incidence of neoplasms, esp lymphoma.

160

A patient with renal transplant is being treated for rejection with OKT3 and develops a fever. Blood and urine cultures are sent. The most appropriate management is?
a) stop OKT3
b) reduce OKT3
c) continue OKT3 and await culture results

Representative Agents That Cause Serum Sickness
Heterologous (animal-derived) antisera:
Mouse: monoclonal antibodies (muromonab-CD3 [Orthoclone OKT3], rituximab [Rituxan], infliximab [Remicade])
Stoppage of the culprit agent, when identified, is recommended. Serum sickness is usually self-limited and rarely life threatening when the offending drug or protein is stopped or removed. Symptoms generally improve over 2 to 4 weeks as patients clear their immune complexes. Fever and arthralgias typically resolve within 48 to 72 hours of treatment, and the formation of new cutaneous eruptions usually ceases within the same time frame.
- Bope: Conn's Current Therapy 2010, 1st ed.

161

Drug adjustment in elderly patients is due to:
a. Decrease GFR
b. Increase total body water
c. Increase total body fat
d. Old age
e. None of the above

Answer: Decrease GFR

162

Why we should adjust drug dose in children:
a. Reduced GFR
b. Immature liver glucourinide enzyme
c. High risk of side effect

Answer: Immature liver glucourinide enzyme / Hepatic glucuronidation

Common question. Tip to remember: babies are often born jaundiced

Although a normal, healthy neonate is born with the same hepatic enzymes important for drug metabolism that an adult has, a reduced ability to metabolize drugs is present in the postnatal period. Hepatic enzyme activity is generally reduced in the neonate. As the
infant ages, his or her ability to metabolize medications increases. It is interesting to note that, although total metabolic capacity is reduced in neonates and infants, certain metabolic pathways may actually be much more active than in adults and some medications may
be metabolized through alternative pathways. Nevertheless, care should be taken during the postnatal period when using medications, such as
phenytoin, phenobarbital, and diazepam, that are primarily hepatically
metabolized.
- Current Pediatrics

Neonates:
Nephrogenesis is complete by 34 weeks' gestational age in the fetus. Fetal urine production is normally 10 to 20 mL/kg/hr by the end of gestation. Regardless of gestational age, all infants normally void within the first 24 hours of birth. Neonatal GFR is dependent on gestational age and doubles in the first 2 weeks of life.
In very low birth weight infants, GFR at birth is normally below 10 mL/min/1.73 m2. Renal concentrating and acidifying capacity are reduced in the first 2 months of life.
- Wein: Campbell-Walsh Urology, 9th ed.

163

All the following herbal medicine predispose to bleeding EXCEPT:
a. Kava.
b. Ginseng.
c. Garlic.
d. Ginkgo biloba

Kava screws with sedation, not with bleeding

G's of bleeding:
Ginkgo
Garlic
Ginseng

164

Which of the following is an IRREVERSIBLE inhibitor of the enzyme COX-1:
a. clopedriogel (Plavix)
b. Ticlopidine
c. Aspirin
d. Indomethacin
e. Warfarin

Answer: Aspirin (irreversible inhibitor of COX 1 and COX 2)

165

Which of the following is LEAST likely to cause an upper GI bleed?
a. celecoxib
b. ibuprofen
c. naproxen
d. voltaren
e. ASA

Answer: celecoxib

Coxibs have been tested extensively to establish their enhanced gastrointestinal safety compared with nonselective NSAIDs.
The Celecoxib Long-Term Arthritis Safety Study (CLASS) was a 6-month trial comparing the incidence of upper gastrointestinal ulcers in arthritis patients receiving celecoxib (400 mg twice daily), ibuprofen (800 mg three times daily), or diclofenac (75 mg twice daily); low-dose ASA therapy was allowed during the study.[112] Upper gastrointestinal ulcer incidence alone or combined with symptoms comparing celecoxib with conventional NSAIDs was 0.76% or 1.45% (P = .092) for celecoxib and 2.08% or 3.54% (P = .023) for conventional NSAIDs.
- Firestein: Kelley's Textbook of Rheumatology, 8th ed.

166

Norepinephrine works predominantly through which receptors:
a) Alpha
b) Beta-1
c) Beta-2
d) Alpha and beta-1

1) Alpha and beta-1

Norepinephrine (Levophed).
This drug has both alpha- and beta-adrenergic activity, resulting in extremely potent vasoconstriction and an increase in cardiac output. Therefore it does have arrhythmogenic potential. Observational studies suggest that, compared with patients treated with dopamine, patients treated with norepinephrine have better hemodynamics and lower mortality.
- Piccini & Nilsson: The Osler Medical Handbook, 2nd ed.

167

Levophed acts via which receptors:
a. Alpha.
b. Alpha – 1.
c. Alpha – 2.
d. Beta – 1.
e. Beta – 2

Alpha – 1

168

Which decreases cardiac output
a-Levophed
b-Dopamine
c-Propranalol

The mechanism of the antihypertensive effects of propranolol has not been established. Among the factors that may be involved are decreased cardiac output, inhibition of renin release by the kidneys, and diminution of tonic sympathetic nerve outflow from vasomotor centers in the brain.
- http://www.mentalhealth.com/drug/p30-i02.html

169

Metoprolol mechanism of action
a. selective BB
b. increases dP/dt

Metoprolol is a selective β1 receptor blocker used in treatment of several diseases of the cardiovascular system, especially hypertension.
- http://en.wikipedia.org/wiki/Metoprolol

170

Which Herbal Medication Decreases Tylenol Activity?

St. John’s Wart, any other Liver damaging substance (ETOH, Barbiturates, Carbamazepine, Rifampin), Cholestyramine also decreased effect via chelating.

171

Most common needle stick injury occurs in
a) PGY 1
b) PGY-2
c) PGY-3
d) PGY-4
e) PGY-5

Answer: PGY5

A survey performed among 699 surgeons in training at 17 medical centers found that the mean number of needlestick injuries increased according to the postgraduate year (PGY); by the final year of training, 99 percent of residents had a history of needlestick injury [9]. Furthermore, more than half of the most recent injuries had not been reported; the most common reason for not reporting the exposure was lack of time

172

All of the following are important when investigating needle-stick injury, EXCEPT:
a) Depth of injury
b) Type of needle (e.g. Hollow bore, etc)
c) Level of contamination
d) Viral load of patient

Answer: Depth of injury

173

Most common anaerobic organism in abdominal infections:

Answer: Bacteroides

174

Which of the following is not a commensal on human skin
a) staph aureus
b) strep
c) staph epidermitis
d) corinebacteium
e) proplysomething

Answer: staph aureus
Commensal = This normally means a microorganism that lives in close contact with a human or animal, doing neither harm nor good.

The majority of skin microorganisms are found in the most superficial layers of the epidermis and the upper parts of the hair follicles. They consist largely of micrococci (Staphylococcus epidermidis and Micrococcus sp.) and corynebacteria. These are generally nonpathogenic and considered to be commensal, although mutualistic and parasitic roles have been assigned to them.

Frequency of the best studied skin microbes[4]
Organism observations
Staphylococcus epidermidis Common, occasionally pathogenic
Staphylococcus aureus Infrequent, usually pathogenic
Staphylococcus warneri Infrequent, occasionally pathogenic
Streptococcus pyogenes Infrequent, usually pathogenic
Streptococcus mitis Frequent, occasionally pathogenic
Propionibacterium acnes Frequent, occasionally pathogenic
Corynebacterium spp. Frequent, occasionally pathogenic
Acinetobacter johnsonii Frequent, occasionally pathogenic
Pseudomonas aeruginosa Infrequent, occasionally pathogenic
- Cogen AL, Nizet V, Gallo RL. (2008). Skin microbiota: a source of disease or defence? Br J Dermatol. 158(3):442-55.

175

A 20 year old man presents to the ER with a 1.5 cm deep and 5 cm long laceration to his forearm after being cut by a lawnmower blade. He has lived in Canada his whole life and had all of his childhood immunizations. The wound is full of dirt and grease. He is not sure of his tetanus status. What is the most appropriate treatment plan:
a) tetanus toxoid
b) tetanus immunoglobin
c) tetanus toxoid and immunoglobin
d) antibiotics for 10 days and then a tetanus toxoid

c) tetanus toxoid and immunoglobin

176

A 23 year old, foreign sailor sustains an open fracture to his right tibia along with numerous abrasions to both hands. This was done after falling from the upper deck of a ship while unloading cargo approximately 7 hours ago. The ER physician that saw him ha splinted his leg and started IV antibiotics. You, the orthopedic resident on call have seen him and booked the OR.
His tetanus immunization status is not known. You will:
a) adminster human tetanus immunoglobulin
b) adminster tetanus absorbed toxoid
c) adminster both human tetanus immunoglobulin and tetanus toxoid
d) adminster both human tetanus imunoglobulin and the first of 3 doses of tetanus absorbed toxoid
e)none of the above

Answer: adminster both human tetanus imunoglobulin and the first of 3 doses of tetanus absorbed toxoid.

Td should be given to a pt with an open fracture even if the patients tetanus status is known to be up to date. In somebody with an unkown tetanus status he should be given Td and TIG (Tetanus Immune Globulin) 250 –500mg IM/IV in the limb away from the one receiving the Td.

Because of widespread vaccination programs, tetanus is a rare complication of open fractures in most developed countries.
When actively immunized with tetanus toxoid, patients require only a booster dose.
The second dose of tetanus toxoid should be given 4 weeks after the initial one, and a third dose should be given 6 to 12 months later.
- Canale & Beaty: Campbell's Operative Orthopaedics, 11th ed.

177

man steps on a nail and shows up 2 days later with headache, back spasm and neck pain. What does he have
a – botilism
b- meningitis
c – tetanus
d- migrane

c – tetanus

178

A foreign body is more prone to infections because:
a) it suppresses T-cell activation
b) It suppresses B-cell activation
c) It forms a glycocalyx to which bacteria can attach

c) It forms a glycocalyx to which bacteria can attach

In the presence of prosthetic devices, many bacteria elaborate a fibrous exopolysaccharide material called glycocalyx. Organisms can grow within this matrix and form thick biofilms that protect the pathogens at least in part from host defense mechanisms (phagocytes, antibodies and complement) and are barriers against the penetration of many antibiotics.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

179

Toxic shock syndrome is caused by:
A. Staph aureus septiciemia
B. Staph aureus toxin
C. Streptococcus septicemia
D. Streptococcus toxin

Answer: Staph aureus toxin

Toxic Shock Syndrome (CDC Case Definition)
Fever (>38.9), Hypotension (SBP15mmHg or orthostatic syncope or dizziness), Rash –diffuse macular erythoderma, Desquamation (1-2 weeks after onset of illness, particularly involves palms and soles, Multisystem involvement (3 or more of the following organ systems): GI: Vx or diarrhea, Muscular: severe myalgia or CPK elevation >2 times the normal upper limit, MM: vaginal, oropharyngeal, or conjunctival hyperemia, Renal: 2x normal BUN or Cr or pyuria, Hepatic: bilirubin or transaminases > 2x normal, Hematologic: plts

180

Risk of post op pneumonia is increased most by:
a) Diabetes.
b) Renal failure.
c) Corticosteroid use.
d) CHF.
e) Ascites.

Answer key: CHF

Risk Factors for the Development of Postoperative Pneumonia and Respiratory Failure
Condition Odds Ratio (pneumonia)
History of CHF -
DM—insulin treated -
Chronic Steroid Use 1.33 (1.12-1.58)
CRF -
Alcohol—>2 drinks/d 1.24 (1.08-1.42)
History of COPD 1.72 (1.55-1.91)
Current smoker 1.28 (1.17-1.42)
History of CVA 1.47 (1.28-1.68)
- Townsend: Sabiston Textbook of Surgery, 18th ed.

181

Within the NICU, a newborn develops osteomyelitis (hematogenous) of many joints. The causative agent is likely to be:
a. GBS
b. GAS
c. Staph
d. E coli
e. H influenza

Answer: S. Aureus

Common question. The answer is NOT GBS. GBS is a less cause of OM and causes FOCAL osteomyelitis

Osteomyelitis is uncommon in the neonatal period. The incidence is unknown but is estimated to be approximately 1 to 3 cases for every 1000 intensive-care nursery admissions.
Associated risk factors include prematurity, low birthweight, preceding infection, bacteremia, exchange transfusion, and the presence of an intravenous or umbilical catheter. Osteomyelitis of the skull secondary to contiguous spread of infection has occurred as a complication of fetal scalp electrode monitoring and in association with infected cephalohematoma. Osteomyelitis of the calcaneus has complicated heel lancet puncture
Approximately 20% to 50% of neonates with osteomyelitis have infection of multiple bones, and about 75% have suppurative arthritis of contiguous joints.
Staphylococcus aureus (60%), GBS, and enteric gram-negative bacilli are the most common causes
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

S. aureus recovered in more than ½ of cases of osteomyelitis in both infants and children
- Up to Date

182

The most common organism in nosocomial pneumonia is :
a. Staph aureus
b. Serritia
c. Pseudomonas
d. S.pneumonia
e. None of the above

Answer key: Coliforms or pseudomonas. Depends on the answers provided. I would say coliforms > s. aureus > pseudomonas

Most patients who acquire nosocomial pneumonia have been maintained on mechanical ventilators in an ICU. The most frequent microbial agents causing these kinds of health care–associated pulmonary infections, according to NNIS data, are S. aureus, P. aeruginosa, Enterobacter species, K. pneumoniae, and E. coli (in decreasing order of relative frequency).
- Goldman: Cecil Medicine, 23rd ed.

Common bacteria involved in nosocomial pneumonia include the following:
* P aeruginosa
* Klebsiella species
* Escherichia coli
* Acinetobacter species (Acinetobacter species commonly colonize the respiratory tract secretions in patients in the ICU. Care must be exercised in interpretation of culture data.)
* Staphylococcus aureus, especially methicillin-resistant S aureus (MRSA)
* Streptococcus pneumoniae (should be considered in early-onset HAP; causes up to 9% of pneumonias in elderly patients in nursing homes)
* Haemophilus influenzae (should be considered in early-onset HAP)
- http://emedicine.medscape.com/article/234753-overview

The etiologic agents responsible for HAP have been elucidated in numerous studies. Gram-negative bacteria, including Pseudomonas aeruginosa, Enterobacter, Acinetobacter, and enteric Gram-negative rods, are implicated in 55 to 85% of HAP cases; Gram-positive cocci (particularly Staphylococcus aureus) account for 20 to 30%; and 40 to 60% of cases are polymicrobial. Acuity and severity of illness, duration of hospitalization, and prior antibiotic exposure are major determinants of likely pathogens. In critically ill patients requiring prolonged mechanical ventilation (MV) in ICUs, P aeruginosa and Acinetobacter (eg, Acinetobacter calcoaceticus and Acinetobacter baumannii), which are resistant to many antibiotics, account for 30 to 50% of HAP; these pathogens are uncommon in non-ICU settings.
- Hospital-acquired pneumonia: risk factors, microbiology, and treatment. Chest Volume 119 • Number 2 • February 2001

183

Patient post nasopharyngeal resection, patient gets pneumonia, the most common causative agent is?
a) Staph aureus
b) Strep
c) Pseudomonas
d) H. flu

Answer key: Strep

As with many other microorganisms, S. pneumoniae finds its ecologic niche in colonizing the nasopharynx. On a single occasion, appropriate culturing yields pneumococci in 5 to 10% of healthy adults and 20 to 40% of healthy children. With repeated attempts at culture, the percentage increases in all age groups, rising to 40 to 60% in toddlers and young children in daycare.

184

Candida infection is associated with all of the following except:
a. Single +ve blood culture is significant
b. Can be diagnosed by ocular lesion
c. Need aggressive treatment
d. +ve urine culture is diagnostic

Answer: Urine culture is diagnostic

Often asymptomatic bacteruria

The presence of typical retinal lesions may be useful in diagnosis.
A definitive diagnosis of invasive candidiasis requires isolation of the organism from an otherwise sterile body fluid or tissue (eg, blood, cerebrospinal fluid, bone marrow, or biopsy specimen) or demonstration of organisms in a tissue biopsy specimen. Cultures that are negative for Candida species, however, do not exclude invasive infection in immunocompromised hosts.
- AAP 2000 Red Book: Report of the Committee on Infectious Diseases, 25th ed., p.198.

185

Which of the following is true re: skin infections?
a. mupirocin has a broad spectrum of activity and is considered to be the first line treatment with wound with a locally infected wound
b. Clindamycin is effective against pseudomonas
c. Fucidin is to be used in leg ulcers
d. Topical antibiotics are sufficient in wound with cellulitis

Answer: mupirocin

Not sure if this is still true in 2016..

First-line treatment of limited impetigo (superficial bacterial skin infection) is with topical mupirocin or fusidic acid.
- Marx: Rosen's Emergency Medicine, 7th ed.

Most aerobic Gram-negative bacteria (such as Pseudomonas, Legionella, Haemophilus influenzae and Moraxella) are resistant to clindamycin.
- http://en.wikipedia.org/wiki/Clindamycin

Adverse Reactions: The application of fusidic acid to deep leg ulcers has been associated with pain.
- www.rxmed.com

186

Regarding clostridium difficle, which one is false:
a – asympotmatic carrier state is possible
b – affects small bowel
c – psudeomembranes may be absent on colonoscopy

Answer: effects small bowel

C. difficile is a gram +ve anaerobe; 3-5% of the population are carriers; can be found in 15-20% of asymptomatic patients treated with Abx; affects the colon because Abx affect normal colonic bacteria; pseudomembranes usually cannot be seen if not fulminant colitis.

187

Post antibiotic colitis is best diagnosed by (assuming that C. diff leads to post antibiotic colits)
a. C. diff culture in stool
b. C. diff culture in blood
c. Identification of c. diff toxin in stool
d. Pseudomembranes on colonoscopy

The most widely utilized means of diagnosing C. difficile-associated diarrhea and colitis clinically is detection of C. difficile toxins in stool specimens. Used in the appropriate clinical setting, this test is both sensitive and specific. More than 90% of patients with pseudomembranous colitis have cytotoxic activity in their stools detected by this assay
- Mandell: Principles and Practice of Infectious Diseases, 5th ed

188

The action of BCG is best described as
1- passive, specific
2- passive, non-specific
3- active, specific
4- active, nonspecific

Abbreviation for Bacille bilié de Calmette-Guérin; Bacille Calmette-Guerin, a live vaccine which has lost its virulence because of multiple cultivations in labs. It causes a person to convert to tuberculin positive on the screening test and is not administered in the Western world. However, where TB is endemic it is used, although its efficacy is questionable.
- Mechanisms of Microbial Disease. 3rd edition. Schaechter p. 239

In the past two decades, the most successful immunotherapy in man probably consisted of non-specific immunotherapy with BCG for superficial bladder cancer.
- A P M Van Der Meijden. Non-specific immunotherapy with bacille Calmette–Guérin (BCG). Clin Exp Immunol. 2001 February; 123(2): 179–180.

189

The part of endotoxin most responsible for its effects
a) O antigen
b) Core polypeptide
c) TCR recepor
d) 2 other choices

Answer: Core polypeptide.
But if Lipid A was a possible answer, it would be better (see next question)

Bacterial endotoxin is a lipopolysaccharide that is a structural component in the outer cell wall of gram-negative bacteria. Lipopolysaccharide is composed of a long-chain fatty acid anchor (lipid A) connected to a core sugar chain, both of which are the same in all gram-negative bacteria. Attached to the core sugar is a variable carbohydrate chain (O antigen), which is used to serotype and discriminate different bacteria. Most biologic activities of lipopolysaccharide, including the induction of fever, macrophage activation, and B-cell mitogenicity, come from lipid A and the core sugars and are mediated by induction of host cytokines, including tumor necrosis factor (TNF) and IL-1 (Chapters 3 and 5) . [29]
- Robbins Pathologic Basis of Disease, 6th ed.

190

Which of the following structures corresponds to gram negative endotoxin the most?
a) Lipid A
b) Major basic protein

Answer: Lipid A

Endotoxins are part of the outer membrane of the cell wall of Gram-negative bacteria. Endotoxin is invariably associated with Gram-negative bacteria whether the organisms are pathogenic or not. Although the term "endotoxin" is occasionally used to refer to any cell-associated bacterial toxin, in bacteriology it is properly reserved to refer to the lipopolysaccharide complex associated with the outer membrane of Gram-negative pathogens such as Escherichia coli, Salmonella, Shigella, Pseudomonas, Neisseria, Haemophilus influenzae, Bordetella pertussis and Vibrio cholerae.
The biological activity of endotoxin is associated with the lipopolysaccharide (LPS). Toxicity is associated with the lipid component (Lipid A) and immunogenicity is associated with the polysaccharide components. The cell wall antigens (O antigens) of Gram-negative bacteria are components of LPS. LPS elicits a variety of inflammatory responses in an animal and it activates complement by the alternative (properdin) pathway, so it may be a part of the pathology of Gram-negative bacterial infections.
- http://www.textbookofbacteriology.net/endotoxin.html

191

Which of the following organisms has demonstrated to be a recently increasing pathogen in the ICU
a. enterobacter
b. enterococcus
c. methicillin resistant S. Aureus (MRSA)
d. pseudomonas
e. streptococcus

Answer: methicillin resistant S. Aureus (MRSA)

This must be an old question.. "recently"

In the 1990s, vancomycin-resistant enterococci emerged and have become endemic in many American hospitals. Patients infected or colonized with these pathogens should be placed under contact precautions. The increasing prevalence of vancomycin resistance among the enterococci coupled with the experimental transfer of vancomycin resistance genetic elements to S. aureus in both in vitro and in vivo models raised concerns that vancomycin-resistant S. aureus strains would emerge in the clinical setting. Fortunately, such vanA strains have not been detected to date, but S. aureus strains with intermediate susceptibility to vancomycin have emerged in Japan and the United States.
- Mandell…

192

Hand washing among healthcare staff is most important in preventing the spread of:
a. Hepatitis B
b. Hepatitis C
c. HIV
d. MRSA
e. Rubella

Of the above pathogens, the only one that could be transmitted by hand/skin contact is MRSA. If Hepatitis A was an option, this would also be a correct choice.

193

PICTURE: infected sternal wound, how would you let this heal? (flap, primary, secondary closure?)

Wound infection and dehiscence occur in about 2% of median sternotomies and increase morbidity for cardiothoracic patients. These wounds can be successfully managed with removal of sternal wires, generous dé-bridement of necrotic bone and cartilage, culture-based antimicrobial therapy, and flap closure. In addition to providing soft tissue coverage, a muscle flap will also recruit much needed blood supply to the area to assist in healing and controlling infection. Muscle flaps most frequently used for closure of sternal wounds include the pectoralis major or rectus abdominis. Release of sternal wire fixation has not been shown to result in chest wall instability and is generally well tolerated.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

194

Which is true of bite infections?
a-Most infections are caused by B-lactamase producing bugs
b-Pasturella is a major component of human bites
c-Eikenella is a major component of Cat bites
d-Most are gram negative

Answer: Most infections are caused by B-lactamase producing bugs

Nearly 50% of the anaerobic gram-negative bacilli isolated from human bite wounds may be penicillin resistant and beta-lactamase positive
- Ferri: Ferri's Clinical Advisor 2010, 1st ed.

195

Which of the following is true when comparing an animal vs. human bite:
a) animal bites have more anaerobic organisms
b) human bites have greater beta-lactamase bacteria
c) Eikenella is in higher concentration in animal bites
d) Pasteurella multocida is in higher concentration in human bites

b) human bites have greater beta-lactamase bacteria

Humans harbor more pathogens than animals. S. aureus, Eikenella corrodens, Haemophilus species, and (in more than 50% of cases) anaerobic bacteria infect human bites
- Habif: Clinical Dermatology, 5th ed.

a) animal bites have more anaerobic organisms (animal bites have a mix of anerobic and aerobic organism)
b) human bites have greater beta-lactamase bacteria (yes)
c) Eikenella is in higher concentration in animal bites (no, Pasteurella)
d) Pasteurella multocida is in higher concentration in human bites (no, Eikenella)

The incidence of Eikenella corrodens in human bite infections of the hand has been reported to vary between 7% and 29%. Most commonly isolated organisms from infected human bite wounds are, as in animal bites, α-hemolytic streptococcus and S. aureus, β-lactamase-producing strains of S. aureus, and Bacteroides species. Anaerobic bacteria are more prevalent in human bite infections than previously recognized, including Bacteroides, Clostridium, Peptococcus, and Veillonella. Most studies of animal bite wounds are focused on the isolation of Pasteurella multocida, disregarding the role of anaerobes. Recent studies show that dog bite wounds point toward multiple organisms, with P. multocida being isolated from only 26% of dog bite wounds in adults. Most animal bites cause mixed infections of both aerobic and anaerobic bacteria.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

196

Which of the following would you not expect to culture from a human bite?
a. staph aureus
b. strept
c. eikanella
d. pseudomonas

Answer: pseudomonas

197

The most common bacteria found in a human bite infection in order from MOST common to LEAST common is:
a. Bacteroides, S. aureus, Streptococccus, Eikenella
b. S. aureus, Streptococccus, Bacteroides, Eikenella (see TO notes)
c. S. aureus, Streptococcus, Bacterioides, Pasteurella multicida
d. Bacteroides, Eikanella, S. aureus, Streptococcus
e. Eikanella, S. aureus, Streptococcus, Bacteroides

This is kind of a silly question.. It's most usually polymicrobial

Information on the bacteriology of human bites comes almost exclusively from hand bites, with the vast majority of these being CFIs. Infected wounds are polymicrobial, with an average of five organisms per wound. Streptococci and S. aureus are the most common aerobic pathogens. Gram-negative rods and anaerobes are more frequently isolated from infected human bites than other types of hand infections, including those from animal bites. The presence of anaerobes in mixed infection may be associated with a worse outcome.
Eikenella corrodens, a facultatively anaerobic gram-negative rod harbored in human dental plaque, is found in 25% to 29% of CFI infections. It acts synergistically with aerobic organisms, most frequently streptococci, and is thought to account for greater morbidity in these wounds.
- Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th Edition, Copyright © 2002, pg 781

198

Most common cause of infection after a cat bite
a – Eikenella
b – Staph
c – Strep
d – Pasturella

Answer key: pasteurella

Tip: you pasturize milk, and cats like milk

Pasteurella species are isolated from 50 percent of dog bite wounds and 75 percent of cat bite wounds (figure 1) [9]. Capnocytophaga canimorsus, a fastidious gram-negative rod, can cause bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease. Anaerobes isolated from dog and cat bite wounds include Bacteroides, fusobacteria, Porphyromonas, Prevotella, propionibacteria and peptostreptococci [11]. (See "Pasteurella infections" and "Clinical features and management of sepsis in the asplenic patient".)

199

What type of organism is Pasturella? (gram neg or positive, cocci vs rods)

Pasteurella is a genus of Gram-negative, facultatively anaerobic bacteria.

200

A child had domestic dog bite. What should you do regarding rabies:
a. Observe the dog for 10 days. Give nothing to the child
b. Observe the dog for 10 days. Give antirabies serum
c. Observe the dog for 10 days. Give antirabies serum and vaccine
d. Observe the dog for 10 days. Give the vaccine

a. Observe the dog for 10 days. Give nothing to the child

From best to worst (less chance to high chance infection):
dog > cat > human

Bite wound infection microbiology: usually polymicrobial with aerobes and anaerobes.
Usual ones are staph, strept, and anaerobes in most infections.
Pasteurella multocida is the primary one in cat infections, and occasionally dogs.
E. corrodens has been isolated from human bites.
Most common in humans: strept, staph aureus, H. parainfluenza, klebsiella pneumon, eikenella, bacteroides, fusobacterium, and anaerobic cocci (peptostreptococci).
Dogs: Pasteurella, staph, strept, fusobacterium
Prophylactic Abx are recommended for patients with high-risk bites.
Punctures from cats → pen + dicloxacillin (will cover pasteurella)
Dog bites → nothing unless to hand then dicloxacillin or cephalexin (incidence of pasteurella is low)
Alternative for dog and cat bites in pen allergic patients → TMP-SMX
Human bites → 2nd or 3rd generation cephalosporin or diclox + amp
Alternative for all bites: cefuroxime or clavulin
Presents after 24 hrs: usually don’t need abx.

201

A lumberjack is working in the wood of northern New Brunswick, and is bitten by a raccoon. The animal escapes. The lumberjack presents to the ER 2 hours later. He has never been bitten before nor immunized against rabies. You should:
a) observe him and treat him only if he develops symptoms of rabies
b) give rabies immune globulin (RIG) at the bite site
c) give rabies immune globulin (RIG), ½ at the bite site, and ½ removed from the bite site
d) give rabies immune globulin (RIG) at the bite site, and give the first of 5 doses of human diploid cell vaccine (HDCV)
e) give rabies immune globulin (RIG), ½ at the bite site, and ½ at another site removed from the bite, followed by the first of 5 doses of human diploid cell vaccine (HDCV)

Answer: E

Unprovoked attacks by an animal may indicate that the animal may be rabid and hence is an indication for treatment.
Domestic animals that bite human should be captured and observed for 10 days for signs of rabies. If the animal dies or is killed its head should be examined for the virus.
Postexposure prophylaxis includes :
a) Immediate and thorough cleansing of all wound with soap and water
b)For pts not previously vaccinated, give 20 IU/kg of human rabies immune rabies immune globulin (HRIG). If anatomically feasible up to one half the dose should be infiltrated around the wound, and the rest should be administered IM in the gluteal area. HRIG should not be administered in the same syringe or into the same anatomic site as vaccine. Because HRIG may partially suppress active production of antibody, no more than the recommended dose should be given. These pts should also be given the rabies vaccine. There are two rabies vaccines available; the human diploid cell rabies vaccine (HDCV) or rabies vaccine adsorbed (RVA)(Imovax). A regimen of five 1 ml doses of HDCV or RVA is given IM (deltoid) on days 0, 3, 7, 14, and 28.
c) For pts who were previously vaccinated, treatment includes in addition to local wound care, the adminstration of HDCV or RVA vaccine, 1 ml, IM (deltoid) on days 0 and 3. HRIG should not be administered.
- Schwartz, Trauma, P207-209

202

Six hours after insertion of a foley, a patient develops fevers and chills. Which is the most appropriate next step?
a) Start antibiotics
b) Urine culture
c) Blood culture
d) Take out the foley
e) get serum Cr + WBC

???

The symptoms of UTI usually develop 24 to 48 hours after the Foley catheter is removed. Of interest, the signs and symptoms associated with a catheter-acquired lower UTI are not nearly as pronounced or as specific as those associated with cystitis unrelated to catheter use. Patients with lower UTIs usually do not have fever but experience urinary frequency and mild dysuria, which are difficult to distinguish from normal postoperative discomfort.
- Katz: Comprehensive Gynecology, 5th ed.

203

Number one bacteria isolated from catheterized UTI patient is:
a-E.Coli
b-Pseudomonas
c-Staph A.
d-Enterococcis

Answer: E. Coli.

UTIs are common; 150 million people are diagnosed annually.[22] Catheter-associated UTIs are the most common nosocomial infections, accounting for 40% of all hospital-acquired infections.[22] More than 95% of UTIs are monomicrobial. E. coli is the most common microorganism .
- Walsh: Palliative Medicine , 1st ed.

For patients who have an indwelling urinary catheter, the risk of infection remains relatively constant at about 3 to 6% per catheter day (higher for female than for male patients and increased by manipulation of the catheter). After 10 to 14 days, about half of catheterized patients have bacteriuria.
According to data from the CDC's NNIS, the pathogens most frequently responsible for health care–associated urinary tract infections are (in order of decreasing relative frequency) Escherichia coli, Enterococcus species, P. aeruginosa, Candida species, Klebsiella pneumoniae, Entero-bacter species, Proteus mirabilis, coagulase-negative staphylococci, other fungi,
- Goldman: Cecil Medicine, 23rd ed.

204

Sepsis following a blood transfusion is most likely from what organism?
a. Syphilis.
b. Yersina.
c. E. coli.
d. Enterococcus.
e. Pseudomonas.

The answer seems to be Yersinia for RBC (cold-thriving bacteria)

For platelets, skin (staph epi, bacilus) cause stored at room temperature

The cold storage conditions of RBCs provide an environment conducive to the survival of cryophilic organisms, such as Yersinia enterocolitica and some Pseudomonas spp. (especially Pseudomonas fluorescens); these gram-negative bacteria account for more than half of all episodes of RBC-associated transfusion BSI.
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

Gram-negative bacteria, including Yersinia enterocolitica, Pseudomonas fluorescens, Serratia marcescens, and Serratia liquefaciens, accounted for most of the reported cases of transfusion-transmitted infection caused by contaminated RBCs historically.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Gram-negative bacteria, including Pseudomonas, Yersinia, Enterobacter, and Flavobacterium, are organisms commonly associated with a contaminated unit of refrigerated blood.
- Hoffman: Hematology: Basic Principles and Practice, 5th ed.

205

Which of the following is the most infectious agent for a blood transfusion?
a) HAV
b) HBV
c) HCV
d) CMV
e) HIV
f) Toxo

CMV
Answer: CMV > HBV > HCV > HAV > HIV

a) HAV – rare; established in plasma tranfusion for hemophiliacs
b) HBV – 1:80 000
c) HCV - 1:225 000
d) CMV (most common)
e) HIV (1: more than 1 million)
f) Toxo risk is very low

CMV infection is endemic, so routine screening is not performed in the United States. About 20% of blood donors are infected with CMV by 20 years of age, and approximately 70% are infected by the age of 70. The infection is carried in white blood cells. Most patients who encounter problems with CMV are immunocompromised, especially transplant recipients taking immunosuppressive drugs. Such patients require transfusion with blood products that have reduced risk for CMV infection (leukocyte reduced or seronegative) to avoid transmission of this viral infection. Human herpesvirus 8 causes Kaposi's sarcoma and lymphoma in patients with acquired immunodeficiency syndrome and other immunosuppressed states such as transplantation.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

206

The risk of HCV infection from one unit of PRBC is: (see above)
a. 1 in 3.
b. 1 in 3000.
c. 1 in 300,000.
d. 1 in 3,000,000

Answer: (1 in 3,000,000)

1 in 3.7 million

HCV (1:872,000-1:1,700,000)

207

Which cannot be transmitted by blood transmission
a. malaria
b. cryptococcus
c. HIV
d. HCV
e. HBV

Answer: Cryptococcus

Blood transmitted virus obviously include HIV, Hep B, and Hep C. Although many other infectious diseases can theoretically be transmitted by blood transfusion, only a few are of real concern. They include Y. enterocolitica infection, syphilis, and malaria. Other significant but rarely known infections include Yersinia and other GNB whose growth is actually enhanced by storage with the CPD buffer at 4 oC.
Post-transfusion syphilis is unlikely because the infective agent cannot survive during storage at 1° to 6°C. The only blood products that have the potential to transmit syphilis are those stored at room temperature. Platelet concentrates are the blood component most likely to be implicated because they commonly are stored at room temperature.
Several other diseases have also been reported to be transmitted by blood transfusion, including herpes virus infections, infectious mononucleosis (Epstein-Barr virus), toxoplasmosis, trypanosomiasis, leishmaniasis, brucellosis, typhus, filariasis, measles, salmonellosis, and Colorado tick fever.
- Miller Anesthesia pp 1631 on MDCONSULT

Malaria is undoubtedly the most common transfusion-transmitted infection in the world.
- Hoffman: Hematology: Basic Principles and Practice, 5th ed.

Cryptococcus seen after transplant.

208

Hemophilia patient needs factor VIII. What is risk of developing a viral disease?
a) Same as that of blood transfusion
b) Less than platelet transfusion
c) More than a blood transfusion
d) Equal to FFP

Answer: Less than platelet transfusion

“The answer for this depends on what was given to the patient. It seems that FFP would be inappropriate, given the large volume needed. Cryo would be ok, and it can be treated to kill off viruses. Irregardless, platelet transfusions require many donors, so the risk for this would be higher.”

A number of blood products contain factor VIII coagulant activity. FFP contains approximately 200 units of factor VIII per bag, but is not suitable for replacement therapy because of the large volume needed to raise the recipient's factor VIII activity to hemostatically effective levels. Cryo is a single-donor product, containing at least 80 IU of factor VIII and 150 mg of fibrinogen. Factor VIII concentrates may be prepared by various techniques, generally beginning with cryoprecipitation, subsequent purification by chemical or other treatment, and heat or solvent-detergent treatment to inactivate viruses.
- Lee: Wintrobe's Clinical Hematology, 10th ed., Copyright © 1999

Frozen plasma prepared from freshly donated blood or fresh plasma is necessary to provide factors V and VIII. The other plasma clotting factors are present in banked preparations. The risk of infectious disease is the same whether fresh frozen plasma or whole blood/red cells is administered. Antihemophilic concentrates are prepared from plasma and are available for the treatment of factor VIII deficiency. Some of these concentrates are twenty to thirty times as potent as an equal volume of fresh frozen plasma. The simplest factor VIII concentrate is the plasma cryoprecipitate.
A variety of factor VIII concentrates are available. Wet-frozen cryoprecipitate is preferred for replacement in patients with mild hemophilia since the risk of hepatitis is less than it is with factor VIII concentrates. The latter are preferred for major replacement problems.
- Schwartz, Chapter 3.

209

Which of the following is LEAST likely to cause neurologic abnormalities in an AIDS patient?
a) pneumocystis carinii
b) direct invasion by HIV
c) multifocal leukencephlopathy
d) toxoplasmosis
e) CNS lymphoma

Pneumocystis carinii ?

Although B makes no sense to me

HIV-1 enters the CNS soon after primary infection. CNS penetration may occur either via infected monocytes or lymphocytes or via cell-free mechanisms. [11] [12] Macrophages and microglial cells are the predominant cells infected within the CNS and are largely responsible for virus replication within the brain

Studies in animal models have demonstrated P. carinii outside the lungs histologically.
Extrapulmonary pneumocystosis occurs mainly in patients with advanced HIV infection who are taking no prophylaxis or only aerosolized pentamidine. The main sites of involvement are lymph nodes, spleen, liver, bone marrow, gastrointestinal tract, eyes, thyroid, adrenal glands, and kidneys

AIDS is characterized by specific illnesses in people with HIV infection and CD4 counts of less than 200 cells/μL (or CD4 percentage

210

Young male with HIV could have all except:
a. hairy leukoplakia
b. mycoplasma pneumonia
c. kaposi’s sarcoma

None of the above?

Oral Hairy Leukoplakia: Its presence in an otherwise asymptomatic patient is a strong indicator of a diagnosis of HIV
- Cummings: Otolaryngology: Head & Neck Surgery, 4th ed.

Conditions which may be caused or influenced by Mycoplasma or for which Mycoplasma becomes an opportunistic infection include AIDS/HIV.

The vast majority of Kaposi Sarcoma cases have developed in association with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS),

Mycoplasma pneumonia is the least likely

211

Which of the following malignancies IS NOT increased in AIDS patients?
a. Non-Hodgkin's lymphoma
b. Squamous cell carcinoma
c. Myelogenous leukemias
d. Kaposi's sarcoma
e. None of the above

Answer: Myelogenous leukemias

HIV-1: Kaposi’s sarcoma, non-Hodgkin’s lymphoma, Hodgkin’s lymphoma, anal SCC
- Schwartz p.306 table 9-4

212

Surgeon gets poked with a needle from a person with HIV. What is the chance of contracting HIV
a. 1 in 20
b. 1 in 200
c. 1 in 2000
d. 1 in 20000

Answer: 1 in 200

0.3% (1/300)

Pooled data from multiple studies demonstrated HIV transmission in 20 health care workers, out of more than 6000 workers who sustained a needlestick injury from an HIV-infected patient, yielding a transmission rate of 0.33%.
- Bope: Conn's Current Therapy 2010, 1st ed.

The overall risk of seroconversion after a percutaneous needlestick from a known HIV-positive source is 0.3% per exposure.
- Goldman: Cecil Medicine, 23rd ed.

213

Post needle stick injury from a patient with known HIV, prophylaxis is
a) AZT alone
b) AZT + 3TC
c) Protease inhibitor (Rotonovir)
d) Septra

Answer: AZT + 3TC (may also add protease inhibitor ex indinavir)

2016: Triple therapy is the gold standard now.

For HCP who are offered and agree to take PEP, we suggest a three rather than a two-drug regimen, regardless of the severity of the exposure (Grade 2C). We typically use tenofovir-emtricitabine combined with raltegravir or dolutegravir. Alternative regimens that are also acceptable are tenofovir-emtricitabine combined with ritonavir-boosted atazanavir, or ritonavir-boosted darunavir. We prefer ritonavir-boosted darunavir as it may be better tolerated. (See 'Selection of antiretroviral therapy' above.)
uptodate 2016

old stuff:
Zidovudine (INN) or azidothymidine (AZT) (also called ZDV) is a nucleoside analog reverse transcriptase inhibitor (NRTI), a type of antiretroviral drug.

New treatment guidelines recommend use of combinations of two or more antiviral drugs.(1, 2, 3, 4) Treatment with zidovudine (AZT) AND lamivudine (3TC) is currently advised for most HIV exposures conferring a risk of transmission. A protease inhibitor or a non-nucleoside reverse transcriptase inhibitor is added when the exposure is especially high risk and/or the source patient has recently taken both zidovudine and lamivudine.
- http://hivinsite.ucsf.edu/InSite.jsp?page=KB

Despite poorly characterized risks and benefits, postexposure prophylaxis with ART is recommended for health care workers sustaining percutaneous, mucus membrane, or nonintact skin exposure to an HIV-infected source. HIV antibody testing of the worker should be done at the time of exposure and repeated at 6 weeks, 12 weeks, and 6 months after exposure. If given, prophylaxis should be administered as soon as possible, preferably within hours after the exposure. Recommended prophylactic regimens typically contain a two-drug combination of NRTIs; coformulations of zidovudine plus lamivudine (Combivir) and emtricitabine plus tenofovir (Truvada) are used extensively and have good tolerability. Three-drug HAART regimens including a PI are recommended for more severe exposures.
- Bope: Conn's Current Therapy 2010, 1st ed.

214

Which of the following markers is the most clinically useful for following the course of a person infected with the human immunodeficiency virus (HIV)
a. Plasma viral load.
b. CD4 cell count.
c. Serum neopterin.
d. Serum β2-microglobulin.
e. P24 antigen level.

We do HIV RNA testing two weeks after the initiation of Answer: CD4 cell count

I've seen this answered plasma viral load as well.. Not sure what the correct answer is. Probably CD4 count cause it's "clinically" correlated with AIDS

ART, and then every four to eight weeks until the level falls below the assay's limit of detection (below 20 to 75 copies/mL by most commercial assays). At that point, the viral load can be measured every three to six months to confirm ongoing viral suppression.

●CD4 cell counts should be monitored every three to six months initially and then every 6 to 12 months once viral suppression has been confirmed. (See 'CD4 cell count monitoring' above.)

●For patients who have suppressed viral loads for more than two years, and whose CD4 counts remains above 300 cells/microL, viral load testing can be performed every six months and CD4 cell counts can be checked annually. If the CD4 cell count is >500 cells/microL, CD4 cell count monitoring is optional. However, more frequent testing should be resumed if there is a change in the patient’s clinical status or if there is a change in regimen. (

215

Which is not beta-lactam?
a. Carbipenim
b. Penicillin
c. Cephalosporin
d. Macrolides

Answer: Macrolides

Carbapenems (imipenem, meropenem) are a class of beta-lactam antibiotics with a broad spectrum of antibacterial activity.
- http://en.wikipedia.org/wiki/Carbapenem

216

Penicillins most sensitive to pencillinase(B lactamase)
- ampicillin
- Oxacillin
- Naficllin

Answer: ampicillin

Penicillinase resistant penicillins:
Cloxacillin
Dicloxacillin
Methicillin
Nafcillin
Oxacillin
- DrDrugs handbook

217

Which antibiotic would be best to treat enterococcus
a. Flagyl
b. Penicillin
c. Cefazolin
d. Gentamycin
e. Ciprofloxacin

Answer: penicillin (likely older answer … more likely ampicillin)

2016: amp, pen, or vanco as per uptodate
enterococcus is impermeable to aminoglycosides, and gent can be used for synergy but not alone

A single agent can generally be used to treat enterococcal UTIs, including ampicillin (1 g every 6 hours), amoxicillin (500 mg every 8 hours), or intravenous vancomycin (1 g every 12 hours). Vancomycin is typically reserved for penicillin-allergic patients or if the strain has high-level penicillin resistance.
Many cases of enterococcal bacteremia are transient or self-limited, yet antibiotic therapy with penicillin or ampicillin has been shown to improve outcomes.
Combination therapy (intravenous penicillin, ampicillin, or vancomycin plus an aminoglycoside) is the standard therapy for enterococcal endocarditis
- Goldman: Cecil Medicine, 23rd ed

Treatment Strategies
In the normal host, minor localized infections due to enterococci can generally be treated with ampicillin alone. Antibiotics containing β-lactamase inhibitors (clavulanate or sulbactam) only provide advantage for the few organisms that have high-level resistance due to production of β-lactamase. Most species are susceptible to nitrofurantoin, and this agent is an alternative to penicillins for uncomplicated UTIs.
Systemic infections such as BSI, endocarditis, and meningitis are usually treated with a combination of penicillin or ampicillin and an aminoglycoside if the organism is susceptible to both. Vancomycin can be substituted for the penicillins but should be used with an aminoglycoside, because its action alone is only bacteriostatic.
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

218

A patient presents with an empyema and a culture comes back showing Fusobacterium. Which of the following is the LEAST appropriate antibiotic?
A. Cloxacillin (penicillin)
B. Amoxicillin/clavulin
C. Imipenim
D. Clarithromycin

Clarithromycin

Macrolides (ie clarithromycin) have minimal activity against Fusobacterium (table).
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

Further explanation if you want:

Fusobacterium is a genus of filamentous, anaerobic, Gram-negative bacteria, similar to Bacteroides.[1] Fusobacterium contribute to several human diseases, including periodontal diseases, Lemierre's syndrome, and topical skin ulcers. Although older resources have stated that Fusobacterium is a common occurrence in the human oropharynx, the current consensus is that Fusobacterium should always be treated as a pathogen.
- http://en.wikipedia.org/wiki/Fusobacterium

Beta-lactam antibiotics in conjunction with beta-lactamase inhibitors—for example, ticarcillin-clavulanate or piperacillin-tazobactam—show excellent activity against B. fragilis group members, as well as Prevotella, Porphyromonas, Fusobacterium, Bilophila, and Sutterella spp.
Fusobacterium is sensitive to penicillin (table)
The carbapenems are a highly effective class of antibiotics for the GNAR, and several have broad-spectrum activity against both aerobic and anaerobic bacteria. Imipenem, meropenem, ertapenem, and doripenem are all FDA-approved carbapenems.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Penicillin was previously regarded as the drug of choice for oral and dental infections involving anaerobic bacteria; however, increasing resistance has been noted among these organisms, principally with beta-lactamase production by Bacteroides, Prevotella, and Fusobacterium spp [23,24]. For infections that are serious, the preferred drugs for oral use are clindamycin, metronidazole, metronidazole plus penicillin, and amoxicillin-clavulanate. Macrolides and ketolides are usually active against oral anaerobes in vitro with the exception of Fusobacteria, which are usually resistant [25]. Ciprofloxacin, trimethoprim-sulfamethoxazole, tetracyclines, oral cephalosporins, and antistaphylococcal penicillins are not active or are less predictably active against anaerobic species.

219

A patient is in a motorcycle accident and sustains an open fracture. What antibiotics would you give?

Gustillo I: ancef
Gustillo II: ancef
Gustillo III: Ancef + gent
Farmyard: Add penicillin (for clostridium/anaerobe)
Injury in water: add aminoglycoside

Above is probably true for 2016 exam. Things may change as evidence comes out..

There is sufficient Class I and II data to recommend preoperative dosing of prophylactic antibiotics for coverage of gram positive organisms in trauma patients with open fractures as a standard of care. For Grade III fractures (an open segmental fracture, an open fracture with extensive soft tissue damage or a traumatic amputation), additional coverage for gram negative organisms should be given. High dose penicillin should be added to the antibiotic regimen for barnyard wounds

depends on the grade of fracture. Extensive soft tissue involvement or exposed bone requires adding gram negative coverage

220

How to you treat MRSA osteomyelitis?
a. Cloxacillin
b. Vancomycin
c. Ancef

Answer: Vancomycin
..

221

All of the following are inactivated by MRSA except?
nafcillin, carbenicillin were listed. I don't think vanco was.


See uptodate
IV: vanco, dapsone, tigecycline, linezolid
Oral: clindamycin, Septra, tetracycline (minocycline, doxycycline), linezolid

DO NOT USE: fluoroquinolones, all b-lactam agents

Treatment options for MRSA
- Nafcillin (Nafcil, Unipen, Nallpen)
- Vancomycin (Vancocin, Vancoled)
- Telavancin (Vibativ)
- Minocycline (Minocin)
- Linezolid (Zyvox)
- Quinupristin/dalfopristin (Synercid)
- Daptomycin (Cubicin)
- Tigecycline (Tygacil)

222

When comparing 3rd generation cephalosporins with 1st or 2nd generation cephalosporins, which of the following statements is MOST accurate?
a. Much more effective Enterobacter coverage
b. Much more effective coverage vs. anaerobes
c. Better coverage vs. gram positive aerobes
d. Less resistance because of branched amino side chain
e. Less effect on PT/INR

Answer: Much more effective Enterobacter coverage

The third-generation cephalosporins have greatly expanded activity against gram-negative rods, including many resistant strains, and rival the aminoglycosides in their coverage while having a much more favorable safety profile. In exchange for this gram-negative coverage, most members of this group have significantly less activity against staphylococcal and streptococcal species than first- and second-generation cephalosporins do. Anaerobic coverage is generally rather poor as well. The important distinction in the third-generation cephalosporins is between those with significant activity against Pseudomonas species (cefoperazone, ceftazidime, and cefepime) and those without (cefotaxime, ceftizoxime, and ceftriaxone).
- Townsend: Sabiston Textbook of Surgery, 18th ed.

First-generation cephalosporins have activity against staphylococci, streptococci, and community-acquired Escherichia coli, Klebsiella, and Proteus species. They have limited efficacy against the other enteric gram-negative rods and anaerobes. These agents are commonly used for treating OSSA osteomyelitis, pharyngitis, UTIs, and skin/soft-tissue infections.
Third-generation cephalosporins have the broadest coverage for enteric, aerobic gram-negative rods and retain good activity against streptococci other than enterococci. They have moderate anaerobic activity but do not cover B. fragilis. Ceftazidime is the only third-generation cephalosporin that is useful for treating serious P. aeruginosa infections. Several of these agents have good CNS penetration and are useful in treating. Third-generation cephalosporins are not reliable for treatment of organisms with the AmpC-inducible beta-lactamases regardless of the results of susceptibility testing. These microbes should be treated with cefepime, carbapenems, or quinolones.
- Washington Manual

223

Abx that doesn’t cover pseudomonas
a. cefoxitin
b. carbenicillin
c. ticarcillin
d. tobra

Answer: cefoxitin

Cefoxitin is a cephamycin antibiotic developed by Merck & Co., Inc., often grouped with the second−generation cephalosporins. Cefoxitin acts by interfering with cell wall synthesis. Its activity spectrum includes a broad range of gram-negative and gram-positive bacteria including anaerobes. It is inactive in vitro to most strains of Pseudomonas aeruginosa and enterococci and many strains of Enterobacter cloacae.
- http://en.wikipedia.org/wiki/Cefoxitin

Treatment of pseudomonas
aminoglycosides (gentamicin, amikacin, tobramycin);
quinolones (ciprofloxacin, levofloxacin, and moxifloxacin)
cephalosporins (ceftazidime, cefepime, cefoperazone, cefpirome, but not cefuroxime, ceftriaxone, cefotaxime)
antipseudomonal penicillins: ureidopenicillins and carboxypenicillins (piperacillin, ticarcillin: P. aeruginosa is intrinsically resistant to all other penicillins)
carbapenems (meropenem, imipenem, doripenem, but not ertapenem)
polymyxins (polymyxin B and colistin)[28]
monobactams (aztreonam)
- http://en.wikipedia.org/wiki/Pseudomonas_aeruginosa#Treatment

After the introduction of carbenicillin, there were continuous improvements in the development of antipseudomonal agents that more or less ceased after the release of the fourth-generation agent cefepime and the carbapenem meropenem.
Some aminoglycoside resistance may also be encoded by genes that modify these agents,[282] especially in the case of gentamicin and tobramycin. Thus, multiple mechanisms of bacteria resistance also exist for these agents.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Ticarcillin (see Fig. 21-7) is no longer available as a single agent. It is susceptible to hydrolysis by class A β-lactamases and is used as a fixed combination of ticarcillin-clavulanate. It is less active than aminopenicillins against penicillin-resistant streptococci and relatively inactive against enterococci but is more active against many gram-negative species, including Pseudomonas aeruginosa.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Used to cover pseudomonas:
1. Ceftazidime (3rd gen)
2. Imipenem, meropenem
3. Cipro
4. Aminoglycoside
5. Aztreonam
6. Acylureidopenicillin
- Morell Notes

224

First line Abx in Rx of C. diff colitis
The standard treatment for C.diff colitis is:
a. PO flagyl
b. IV flagyl
c. PO vanco
d. IV vanco

Answer: PO flagyl

Basically:
mild : PO flagyl
moderate: PO vanco
severe: IV flagyl +/- PO vanco
IV vanco does nothing


Prescribe specific therapy if symptoms are severe or persistent:
- Metronidazole orally for 10-14 days (drug of choice)
- Vancomycin orally for 10-14 days if
Diarrhea does not improve during metronidazole treatment
Patient cannot tolerate metronidazole
Patient is pregnant or

225

which is a good prophylactic antibiotic for G+ve, G-ve and anerobes:
a. cefoxitine
b. ceftriaxone
c. vanco
d. flagyl

Answer: cefoxitine

Cefoxitin is a cephamycin antibiotic developed by Merck & Co., Inc., often grouped with the second−generation cephalosporins. Cefoxitin acts by interfering with cell wall synthesis. Its activity spectrum includes a broad range of gram-negative and gram-positive bacteria including anaerobes. It is inactive in vitro to most strains of Pseudomonas aeruginosa and enterococci and many strains of Enterobacter cloacae.
- http://en.wikipedia.org/wiki/Cefoxitin

Cefotetan, and ceftizoxime have fairly good activity against anaerobes, but ceftriaxone, cefoperazone, and cefotaxime are not reliable enough against gram-negative anaerobes to be useful, and ceftazidime and cefepime have poor activity against both gram-positive and gram-negative anaerobes.
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

cefoxitine (2nd gen, good gram positive, some gram neg and anaerobic)
ceftriaxone (3rd gen, gram + and gram -)
vanco (gram +)
flagyl (anaerobes)

226

All of these have significant activity vs anaerobes except?
a. Metronidazol
b. Ceftriaxone
c. Imipene
d. Penicillin
e. Erythromycin

Answer: Erythromycin
Or ceftriaxone??

Breakpoint interpretive criteria for macrolide activity against anaerobic bacteria have not been established, but erythromycin generally has moderate activity against some species of gram-negative anaerobes, such as Prevotella and Porphyromonas, whereas B. fragilis strains are usually resistant.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

The activity of clarithromycin is superior generally compared with erythromycin and azithromycin against anaerobes but is reliable only for some Prevotella, Porphyromonas, Propionibacterium, and Eubacterium spp
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

Cefotetan, and ceftizoxime have fairly good activity against anaerobes, but ceftriaxone, cefoperazone, and cefotaxime are not reliable enough against gram-negative anaerobes to be useful, and ceftazidime and cefepime have poor activity against both gram-positive and gram-negative anaerobes.
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

Neither erythromycin or ceftriaxone have significant anaerobic coverage.

227

The most common side effect of cephalothin:
a. Hypersensitivity
b. Skin rash
c. Renal toxicity

Answer: Hypersensitivity

Cephalothin is the oldest of the first-generation cephalosporins and was previously used as the prototype of this group. Active against most gm+ve cocci (including penicillinase-producing staphylococci) but does not have clincally useful activity against enterococci, Listeria, oxacillin-resistant staphylococci. Hypersensitivity Reactions
Hypersensitivity reactions are the most common systemic adverse events encountered with cephalosporin treatment. Nevertheless, immediate (30 to 60 minutes after administration) and accelerated (1 to 72 hours after administration) immunoglobulin E (IgE)-mediated anaphylactic or urticarial reactions are rare (especially with second- and third-generation compounds) relative to the frequency of 0.01% associated with penicillin. [63] [64] Skin rash with or without fever and eosinophilia occurs in 1 to 3% of patients after variable periods of cephalosporin therapy. [64] [65] [66] [67] With the exception of an apparent increased incidence of a serum sickness syndrome in children receiving cefaclor, there are no data to indicate that hypersensitivity reactions are more common with any individual cephalosporin.
- Mandell: Principles and Practice of Infectious Diseases, 5th ed.,

228

A patient in renal failure needs dose adjustment for all of the following antibiotics EXCEPT:
a) ampicillin
b) cefazolin
c) metronidazole
d) Septra
e) tobramcin

Answer: metronidazole

ampicillin – primary excretion by tubular secretion and glomerular filtration, therefore needs dose adjustment
cefazolin - elimination occurs by tubular secretion and glomerular filtration, therefore needs dose adjustment
metronidazole – metabolized by the liver, excreted in the urine. No note made of dose adjustment required in renal failure
Septra – in patients with renal failure, sulfamethoxazole excretion is only slightly decreased whereas trimethoprim excretion is markedly decreased, therefore Septra needs dose adjustment
Tobramycin – high concentrations can accumulate in renal cortex and therefore has nephrotoxic potential. Accumulation occurs in patients with ARF, therefore needs dose adjustment
- Reference: Lippincott Pharmacology, CPS

229

Patient on Cipro, which other drug to you adjust?
a) Digoxin
b) Theophylline
c) Propranolol
d) Vitamin E

Answer: Theophylline

Probably old question - who even uses theophylline anymore?

SERIOUS AND FATAL REACTIONS HAVE BEEN REPORTED IN PATIENTS RECEIVING CONCURRENT ADMINISTRATION OF CIPROFLOXACIN AND THEOPHYLLINE. These reactions have included cardiac arrest, seizure, status epilepticus, and respiratory failure. Although similar serious adverse effects have been reported in patients receiving theophylline alone, the possibility that these reactions may be potentiated by ciprofloxacin cannot be eliminated. If concomitant use cannot be avoided, serum levels of theophylline should be monitored and dosage adjustments made as appropriate.
- Mosby's Drug ConsultCopyright © 2002

Cipro may attenuate elimination of theophylline, increasing the risk of theophylline toxicity. (also prolongs the half-life of caffeine)
- Physician’s Drug Handbook 7th ed: pg 214

230

A patient is found to have a tooth abscess that is growing Bacteroides. The best antibiotic is?
a) Pen G
b) Tetracycline
c) Clindamycin
d) Erythromycin
e) Gentamycin

Answer: Clindamycin

For anaerobic infections:
Nearly always active:
Metronidazole
Carbapenems
Beta-lactam plus beta-lactamase inhibitors

Usually active:
Clindamycin
Cefoxitin

Variable activity
Penicillin
Cephalosporins
Tetracycline
Vancomycin
Macrolides
Fluoroquinolones
Tigecycline

Poor activity:
Aminoglycosides
Trimethoprim-sulfamethoxazole
Monobactams (aztreonam)

231

The quinolones, including ciprofloxacin, ofloxacin and norfloxacin are effective against most gram negative bacilli. Their mechanism of action is via:
a) inhibition of cell wall synthesis
b) inhibition of DNA gyrase
c) inhibition of ribosomal protein synthesis
d) inhibition of mitochondrial electron transfer
e) inhibition of folic acid metabolism

Answer: inhibition of DNA gyrase

The quinolones are chemical modifications of the basic nalidixic acid
structure. They have antibacterial potencies 1000 times greater than that of nalidixic acid and are active against gram-negative and gram-positive organisms. The intracellular target of the quinolones is DNA gyrase, an enzyme involved in DNA breakage and repair. It appears that quinolones actually bind to DNA breaks caused by DNA gyrase, with at least four drug molecules binding per site; the binding is stabilized by the enzyme itself.
- Schwartz

232

Hepatitis B causes what cancer?

Answer: Hepatocellular carcinoma

233

What is the MOST common infecting organism associated with needle-stick injuries:
A. HAV
B. HBV
C. HCV
D. EBV

Answer: HBV>Hep C>HIV

Worldwide, 35 million healthcare workers are potentially at risk of needlestick injuries. According to calculations by Prüss-Üstün et al., some 2.1 million healthcare workers per year are exposed to HBV through percutaneous injuries. For HCV, exposure affects 926000 personnel and for HIV, 327 000 personnel. The seroconversion rate after needlestick injury is estimated at 30 to 100% for HBV, at 3% for HCV, and at less than 0.3% for HIV.
Although HBV, HCV, and HIVare the main focus of attention, other viruses can occur temporarily viremically during infection. These include hepatitis Avirus, hepatitis D virus, cytomegaly virus, Epstein-Barr virus, parvovirus B19, HTLV1/2, enteroviruses, and dengue viruses. In all these viruses, the risk of infectious transmission by needlestick injury is rather low (11).
- Sabine Wicker, René Gottschalk, Holger F. Rabenau. Risk of Needlestick Injuries From an Occupational Medicine and Virological Viewpoint. Dtsch Arztebl 2007; 104(45):A 3102–7

234

What is the % of transmitting hepatitis B by needlestick to health worker:
a. 80%
b. 50%
c. 20%
d. 3%
e. 0%

Answer: 20% (around 30%)

easy way to remember:
HBV 30% (if not immunized)
HCV 3%
HIV 0.3%

The seroconversion rate after needlestick injury is estimated at 30 to 100% for HBV, at 3% for HCV, and at less than 0.3% for HIV.
- Sabine Wicker, René Gottschalk, Holger F. Rabenau. Risk of Needlestick Injuries From an Occupational Medicine and Virological Viewpoint. Dtsch Arztebl 2007; 104(45):A 3102–7

235

Hepatitis C causes all of the following except?
a) Lymphoma
b) Cryoglobulinemia
c) hepatocellular carcinoma
d) cirrhosis

Lymphoma (yes (NHL))
Cryoglobulinemia (yes)
hepatocellular carcinoma (yes)
cirrhosis (yes)

236

#1 cause of Hep C infection in Canada is due to what?
a-IVDU
b-Transfusions
c-Sex
d-oral-fecal route

Answer: IVDU

237

The most common cause of mortality in health workers in Canada is:
a. HIV.
b. HBV.
c. HCV.
d. EBV

Answer: HCV

Fun facts: EBV can cause nasopharyngeal cancer & Burkitt’s lymphoma

238

Which of the following is the prophylactic antibiotic of choice (if only one could be chosen), for a patient set to undergo abdominal surgery and who has a penicillin allergy and has an artificial valve:
a) vancomycin
b) clindamycin
c) metronidazole
d) cipro

uptodate 2016:
Genitourinary and gastrointestinal tracts — Routine prophylaxis is not warranted for any gastrointestinal (GI) or genitourinary (GU) procedure, even for patients with high-risk cardiac conditions [1,4]. The risk of bacteremia for invasive GU procedures such as dilation of strictures, insertions of catheters, and prostatectomy is relatively low. The risk of bacteremia for invasive GI procedures such as lower bowel endoscopy with biopsy or endoscopic retrograde cholangiopancreatography is also low.

Patients with high-risk cardiac conditions AND ongoing GI or GU tract infection warrant antimicrobial therapy with activity against enterococci (amoxicillin or ampicillin); vancomycin is an acceptable alternative for patients unable to tolerate beta-lactams.

239

For which of the following is bacterial endocarditis prophylaxis required?
a) Myringotomy tubes
b) Cardiac catheterization
c) Sclerosis of esophageal varices
d) Flexible bronchoscopy
e) Intubation

none?

Comparison of Recommendations by the American Heart
Association for Prevention of Bacterial Endocarditis

Bronchoscopy
1997: Recommended
2007: NOT Recommended

Sclerosis of esophageal varices
1997: Recommended
2007: NOT recommended (not mentioned, but no to GI/GU)

Routine cardiac catheterization
Not Recommended

Myringotomy
Not Recommended

Intubation
Not recommended

240

Antibiotic prophylaxis is indicated in all of the following EXCEPT:
A. Surgery > 2 hrs in length
B. Femoral embolectomy
C. Emergency C section
D. Aortic valve replacement
E. Insertion of prostheses

Answer: Surgery > 2 hrs in length

I guess you could have a 2h+ long BCC removal with Moh's surgery and you wouldn't give antibiotics. The other choices you FOR SURE need to give abx.

Cesarean section: cefazolin 1-2 g IV after cord clamping
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Antibiotic prophylaxis to prevent endocarditis is strongly recommended in patients with prosthetic valves.
- Rakel: Textbook of Family Medicine, 7th ed.

Length of preoperative stay, remote site infection at the time of surgery, and duration of the procedure have also been associated with an increased bacterial load and SSI rate.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Indications for antibiotic prophylaxis:
- when bacterial contamination of the wound is likely OR for patients having clean operations in which a prosthetic device is placed (cardiac valve, vascular graft, prosthetic joint)
- where bacterial contamination is likely - traumatic wounds, entry of intestinal tract, in gastroduodenal surgery, high risk biliary tract surgery, gynecological operations
- studies indicate that prophylactic antibiotics can lower the risk of all infectious complications in clean surgery (hernia, breast), BUT the incidence of wound infection is not reduced
- duration of OR is an important variable. If OR time 6 hours, infection rate of 18%
- Abx prophylaxis is recommended in Schwartz for C-section, and I talked to an OB/gyne resident who verifies the use of prophylactic Abx
Reference: Schwartz

241

When you should give the second dose of prophylactic antibiotic:
a. if the procedure last longer than the half life of Abx
b. surgery last > 3 hrs
c. Blood lose >750 cc

Answer: if the procedure last longer than the half life of Abx

For operations that are prolonged, the prophylactic agent chosen is given in repeated doses at intervals of one to two half-lives for the drug being used. Prophylactic antibiotic coverage for more than 12 hours for a planned operation is never indicated.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

242

Prophylactic antibiotics are not indicated for:
a. tracheotomy
b. leg amputation
c. cardiac valve surgery
d. colorectal surgery
e. open fracture

Answer: trachetomy (old)

243

Which of the following patients do not need antibiotics prophylaxis pre OP:
a. 28 year female on contraceptive for cholecystectomy
b. 38 year male for hernia repair
c. 55 year for lower anterior resection of rectum
d. 25 year male for appendectomy
e. 65 year old for right hemicolectomy

Answer key: 28 year female on contraceptive for cholecystectomy

a. 28 year female on contraceptive for cholecystectomy (if elective, or laparoscopy and no risk then no AB required; if pt is high risk = age >60, evidence of cholecystitis, jaundice, previous cholecystitis, etc then AB required)
b. 38 year male for hernia repair (if mesh used, then yes for AB otherwise none required)
c. 55 year for lower anterior resection (yes)
d. 25 year male for appendectomy (yes)
e. 65 year old for right hemicolectomy (yes)


The appropriate antibiotic is chosen before surgery and administered before the skin incision is made ( Table 12-11 ).[24] Repeat dosing occurs at an appropriate interval, usually 3 hours for abdominal cases or twice the half-life of the antibiotic, although the patient's renal function may alter the timing ( Table 12-12 ).[25] Perioperative antibiotic prophylaxis generally is not continued beyond the day of surgery. With the advent of minimal-access surgery, the use of antibiotics seems less justified because the risk for wound infection is extremely low. For example, routine antibiotic prophylaxis in patients undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis is of questionable value. It may have a role, however, in cases that result in prosthetic graft (i.e., mesh) placement, such as laparoscopic hernia repair.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

244

Prophylactic antibiotics for surgery are best given as:
a. 3 doses over the 24 hours prior to surgery
b. 1 dose 4 hours prior to surgery
c. 1 dose 30 minutes prior to surgery
d. 1 dose as the case finishes
e. none of the above

c.

Systemic antibiotics should be given immediately before the incision is
made and serum levels maintained throughout the procedure above the minimally inhibitory concentration. Redosing is necessary in long
procedures.
- Schwartz chapter 11

245

What prophylactic antibiotic is best for superficial parotid excision
a – ancef
b – erythromycin
c – penicillin G
d – None

none
good blood supply to the face

246

1) Source of organism causing wound infection in a Clean Case?
a. patient’s skin and mucosa
b. OR personnel’s nares
c. Breaks in sterile techniques
d. Inadvertent entry into GI/GU/respiratory tract

a. patient’s skin and mucosa

247

2) What is the classification of the case of you operating on a patient with appendicitis with NO perforation:
a. Clean
b. Clean-contaminated
c. Contaminated
d. Dirty

b. Clean-contaminated

248

3) Which of these is a contaminated wound?
a) traumatic and open
b) bacteria and pus
c) perforated viscus
d) GI case that is open, but without fecal spillage

a) traumatic and open

249

4) A 23 year old, foreign sailor sustains an open fracture to his right tibia along with numerous abrasions to both hands. This was done after falling from the upper deck of a ship while unloading cargo approximately 7 hours ago. The ER physician that saw him ha splinted his leg and started IV antibiotics. The patient is taken to the OR for an open reduction and internal fixation of the right tibial fracture. The circulating nurse in the OR asks you for classification of this case. You tell her it is:
a) clean
b) clean- contaminated
c) contaminated
d) dirty
e) none of the above

C or D.

Classification Criteria

Clean (Infection rate: 1.5 – 2.9%)
o Elective, not emergency, non-traumatic, primarily closed
o no acute inflammation
o no break in technique
o respiratory, gastrointestinal, biliary and genitourinary tracts not entered

Clean-contaminated (Infection rate: 2.8 – 7.7%)
o Urgent or emergency case that is otherwise clean
o elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g. appendectomy) not encountering infected urine or bile
o minor technique break.

Contaminated (Infection rate: 6.4 – 15.2%)
o Non-purulent inflammation
o gross spillage from gastrointestinal tract
o entry into biliary or genitourinary tract in the presence of infected bile or urine
o major break in technique
o penetrating trauma 4 hours old.

250

The most common post-operative complication is:
a) Wound infection
b) UTI
c) Pneumonia

Answer: Wound infection

251

What is the most common infectious agent responsible for a wound infection POD#2
a) Staph aureus
b) E-coli
c) Enterococcus
d) Pseudomonas

???

Fever during the first 24 to 48 hours is usually secondary to atelectasis (actually I think this is not believed to be true anymore). However, two rare types of wound infections are so virulent that they produce toxicity within the first 48 hours. Classically, these early infections are those produced by Clostridium species and acute β-hemolytic streptococcal infection. Clinically, wound infections secondary to β-hemolytic streptococci appear swollen and red and have an odorless discharge. In contrast, infections secondary to Clostridium are boggy and edematous, and the discharge has a sweet odor.
- Katz: Comprehensive Gynecology, 5th ed.

252

All the following have been shown to decrease the incidence of wound infection EXCEPT one. What is the EXCEPTION?
a. supplemental O2
b. design and engineering of operating room theatres
c. preoperative patient skin prepping
d. prophylactic antibiotics

a. supplemental O2

253

The preparation that has the most immediate activity and greatest decrease in bacterial count is …
a) iodophores
b) chlorhexidine
c) isopropyl alcohol
d) soap
e) hexachlorophene

Isopropyl alcohol

Iodophors: effective against a broad range of microorganism. Less irritating to skin/mucus membranes. Effectiveness is moderately reduced by blood or other organic material. Effective 1-2 minutes after application.
Chlorhexidine (Hibitane, Savlon): broad range of microorganisms, not effective against fungi/tuberculosis. Good persistent effect, lasts ~6 hours. No decrease in effectiveness if contacts blood.
Alcohol (60-90%): Effective against a broad range of microorganisms. Kills organisms most rapidly. Most effective in reducing microorganism. Effectiveness is only moderately reduced by blood. Cannot be used when skin dirty or wet.
- www.igc.apc.org/avsc/ip/aseptic/at4b.html

254

Wound develops a distinct margin of erythema, most likely organism
a – staph
b – beta-hemolytic strep
c –clostridium

b. b-hemolytic strep

This is erysipelas - well demarcated (more than cellulitis)

255

Which of the following sterilizes surgical equipment the best?
a) Soap
b) Chlorhexidine
c) Gluteraldehyde
d) Betadine
e) Steam sterilization

Of all the methods available for sterilization, moist heat in the form of saturated steam under pressure is the most widely used and the most dependable. Steam sterilization is nontoxic, inexpensive,[173] rapidly microbicidal, and sporicidal, and steam rapidly heats and penetrates fabrics (see Table 301-3).
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

256

Which of the following decrease the risk of infection:
a. Double gloves
b. Face mask
c. Scrub solutions
d. Head cover
e. None of the above

E.?

Antimicrobial operative site prep is only choice that helps to diminish wound infection. Others are mentioned in the text but there has been no evidence to show effect.
- Schwartz, Chapter 5, Surgical Infections

No evidence to support preop surgeon scrubbing,
- Schwartz Chapter 5, Surgical Infections

257

None of the following contribute to diminshing wound infection EXCEPT:
a. antimicrobial operative site prep
b. pre-op shower with chlorhexidine
c. pre-op shaving
d. surgeons wearing masks
e. plastic adhesive dressing

a.

I guess I better stop showering before all my cases

Antimicrobial operative site prep is only choice that helps to diminish wound infection. Others are mentioned in the text but there has been no evidence to show effect.
- Schwartz, Chapter 5, Surgical Infections

258

Which of the following INCREASES the risk of developing a postoperative surgical site infection?
A. Surgeon scrub for less than 5 minutes
B. Perioperative blood transfusion
C. Forced warm air in the OR
D. Preoperative shower

B. Perioperative blood transfusion

Other factors that may decrease perioperative infection include strict control of glucose in patients with diabetes and the avoidance of unnecessary blood transfusion in view of the immunosuppressive effect of the latter.
- Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed.

Perioperative blood transfusion has been associated with an increased rate of postoperative infections, including wound infection, with donated white blood cell (WBC)-induced immunosuppression implicated as the culprit.
- Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Sabiston mentions blood transfusions but not length of surgical scrub as a risk factor.

In the end, the only mention I found that scrub time was important was a text, not a study.

259

Which of the following have shown to be beneficial in decreasing post-operative wound infections? (multiple answers
a. plastic gowns and laminar flow in redo total knees
b. masks
c. double glove
d. Shorter OR time
e Younger patients (

d,e,f,h

Shaving increases risk of infection, especially if done the day before. you should CLIP the hair right before the OR

260

All are true of soft tissue necrotizing infection except:
1) anaerobic environment
2) bacterial synergy
3) thrombosis of nutrient vessel that supplies the skin and fascia
4) streptococcal exotoxins

???

I guess 2) cause sometimes it can be monomicrobial???

Polymicrobial necrotizing SSTIs are, by far, most common. These infections are caused by the synergistic interaction between mixed facultative anaerobic and obligate anaerobic gram-positive and gram-negative bacteria, such as Escherichia coli, Klebsiella spp, Proteus spp, the staphylococci, the streptococci, and Bacteroides spp.
By far the most common isolate responsible for this condition is group A streptococcus (Streptococcus pyogenes), which might or might not cause concomitant streptococcal toxic shock syndrome and which can have devastating consequence.
- Bope: Conn's Current Therapy 2010, 1st ed.

Most bacteria, especially facultative gram-negative rods such as E. coli, make insoluble gases whenever they are forced to use anaerobic metabolism. Thus, the presence of gas in a soft tissue infection implies anaerobic metabolism.
Clindamycin has been shown to block exotoxin production from bacteria, one of the key bacterial factors that perpetuates and leads to spreading of the infection through tissues.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Necrotizing Fasciitis: Skin changes may occur over 24 to 48 hours as thrombosis of nutrient vessels and resultant cutaneous ischemia develops.
- Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.

261

All are true regarding gas gangrene Except:
a. Caused by C. perferinges
b. Can follow minor trauma
c. Gas in X-ray is pathognomonic

Answer: Gas in X-ray is pathognomonic

Gas in the soft tissues is neither sensitive nor specific for gas gangrene. Many different bacteria, trauma, and visceral perforation can cause soft tissue gas. Plain radiographs or ultrasonography can be used to look for the presence of gas.
- http://emedicine.medscape.com/article/782709-diagnosis

262

What is the most sensitive way to detect gas in gangrenous tissue:
a. Radiological imaging
b. Palpation
c. Needle aspiration.
d. Smelling.

Answer: Palpation

Unless you get a CT/MRI, or are a truffle-hog

263

A patient is post-op day 1 for left hemicolectomy and now has decreased oxygen saturation, elevated temp, wound crepitus and unimpressive findings on wound inspection. What is going on?

Answer: Necrotizing soft tissue infection

264

65 year old diabetic arrives to ER, febrile, confused. Left leg is Red, and blotches of dusky skin throughout. The ER physician said the he made a small incision and was easily able to insert a hemostat along the fascia of the lower leg. You are the senior resident responsible for this patient. Your next step would involve:
a) I.V. antibiotics after blood culture done
b) Immediately to the OR for debridement and possible amputation of the limb

b) Immediately to the OR for debridement and possible amputation of the limb

For POS buzzwords: "dishwater, dusky, grayish" = NEC FASC

265

What is the source of the enzymes that degrade tissue in an abscess:
a) neurophils
b) macrophages
c) eosinophils
d) mast cells

Answer: macrophages (given) ??? I think neutrophils is a better answer.

This type of inflammation is characterized by the production of large amounts of pus or purulent exudate consisting of neutrophils, liquefactive necrosis, and edema fluid. There is usually a zone of preserved neutrophils around this necrotic focus, and outside this region vascular dilation and parenchymal and fibroblastic proliferation occur, indicating chronic inflammation and repair.
- Kumar: Robbins and Cotran Pathologic Basis of Disease,
Professional Edition , 8th ed

266

All of the following are true regarding Fournier's Gangrene EXCEPT:
a. requires debridement of all necrotic tissue
b. usually requires orchiectomy
c. skin needs to be unroofed to viable tissue
d. localization and drainage of the source is part of the initial procedure

b. usually requires orchiectomy

Fournier's gangrene is a necrotizing fasciitis of the male genitalia and perineum that primarily involves subcutaneous tissues. The disease can rapidly progress and, although mortality is dependent on severity of disease, it has exceeded 50% in some series.[12] The most common cause of Fournier's gangrene is infection of the colon, rectum, or lower genitourinary tract or cutaneous infection of the genitals, perineum, or anus. The most common risk factors are diabetes mellitus, alcohol use, and immunocompromised states. Infections can spread along the dartos, Collie's, and Scarpa's fascia because these fascial planes are continuous. The spread of infection rarely involves the deep fascial planes and musculature.
Both aerobic and anaerobic organisms can cause the infection. The most common isolated organism is Escherichia coli; other commonly cultured organisms include enterococci, staphylococci, streptococci, Bacteroides fragilis, and Pseudomonas aeruginosa.
The presenting sign is usually a painful swelling and induration of the penis, scrotum, or perineum. Cellulitis, eschar, necrosis, crepitus, foul odor, and fever may be accompanying signs.
Aggressive surgical débridement of all necrotic, ischemic, and infected tissue, along with copious irrigation, are critical. Infected tissue is cultured and initial broad-spectrum IV antibiotic coverage (e.g., ampicillin, gentamicin, and clindamycin) instituted. Suprapubic catheter placement can help divert the urine and decrease the risk for further bacterial seeding of the wound.
If a colonic source is the suspected cause, proctoscopy under general anesthesia can be performed, and if necessary, diverting colostomy may be indicated. Additional débridement in 24 hours after the initial débridement may be necessary. Careful attention to wound care, frequent dressing changes, strict control of diabetes and metabolites, and adequate nutritional support are critical to proper wound healing.
- Townsend: Sabiston Textbook of Surgery, 18th ed.

Orchiectomy is almost never required since the testes have their own blood supply independent of the compromised fascial and cutaneous circulation to the scrotum.

267

A farmer presents with back spasms and diffculty eating, also a laceration.

(tetanus?)

268

A description of the wound including colour of pus and question what organism is responsible? (staph or strep)

Something that creates pus is called suppurative, pyogenic, or purulent. If it creates mucus as well as pus, it is called mucopurulent. The most common agents that induce pus formation are bacteria, such as Staphylococcus aureus.
Despite normally being of a whitish-yellow hue, changes in the color of pus can be observed under certain circumstances. Pus is sometimes green because of the presence of myeloperoxidase, an intensely green antibacterial protein produced by some types of white blood cells. Blue-green pus is found in certain infections of Pseudomonas aeruginosa as a result of the pyocyanin bacterial pigment it produces; amoebic abscesses of the liver produce brownish pus. Pus might have a reddish tint to it after mixing with blood. Pus can also have a foul odor.
- http://en.wikipedia.org/wiki/Pus

? Staph produces pus but strep doesn’t ?

Staph: thick yellow pus.