Ortoski Objectives Flashcards Preview

Hematology-Oncology Exam 2 > Ortoski Objectives > Flashcards

Flashcards in Ortoski Objectives Deck (204):
1

What are the 3 conditions for transmission of HIV?

HIV must be present in...
1. Body fluid
2. In sufficient quantity
3. Portal of entry into bloodstream

2

What 3 things is transmission of HIV leading to disease progression dependent on?

1. Size of viral inoculin
2. Virulence of infecting virus (how fit is the virus and what is it's replication capacity)
3. Patients cytotoxic lymphocyte response (CD8)

3

What are the 3 basic modes of HIV transmission?

1. Sexual
2. Blood
3. Vertical

4

What is sexual transmission associated with?

Traumatic sex (anal), multiple partners, and lack of protection

5

What are some influencing factors with sexual transmission?

Oral/vaginal/anal receptive, no condom, genital ulcer (syphilis, active herpes)

6

What is associated with blood HIV transmission?

Transfusion/transplant before 1985, drug use, occupational exposure

7

What can reduce the risk of vertical transmission during pregnancy?

AZT

8

There are 14 AIDS defining conditions listed... name as many as you can.

1. Candidiasis of respiratory system, esophagus
2. Cervical cancer – invasive
3. Coccidioidomycosis
4. Cryptosporidiosis
5. CMV (retinitis)
6. Herpes simplex chronic ulcers (> 1 mo duration)
7. HIV related encephalopathy
8. Isorporiasis (chronic intestinal)
9. Kaposi’s sarcoma (HHV8)
10. Lymphoma
11. MAC complex, mycobacterium TB, PCP, toxoplasmosis
12. Recurrent pneumonia (>2 infections in 12 mo)
13. Progressive multifocal leukoencephalopathy (PML)
14. Salmonellosis

9

What are main general categories of HIV testing?

Antibody testing and viral assays

10

When can antibody testing be done for HIV?

6 month waiting period exists after infection (the time needed for the immune system to make Antibodies

11

What are 6 tests for HIV that are antibody tests?

1. ELISA
2. Western blot
3. OraSure OraQuick Advance
4. Unti-Gold Recombigen and Reveal G2
5. Multispot
6. P24 Antigen Capture Assay

12

What antibody test is a screening test that is non-specific?

ELISA

13

What antibody test is a confirmatory test with decreasing false results?

Western Blot

14

What antibody test detects Ab to HIV1 and HIV2 in whole blood, oral fluids, and plasma with results in 20 minutes?

OraSure, OraQuick Advance

15

What antibody test detects antibodies to HIV1 in serum and plasma?

Uni-Gold Recombigen and Reveal G2

16

What antibody test detects antibodies to HIV1 and HIV2 in serum and plasma?

Multispot

17

What antibody test measures the chief component of nucleocapsid?

P24 antigen capture assay

18

What is a vrial RNA Assay?

Measures the viral load of HIV...HIV RNA by PCR and HIV branched DNA

19

When is a DNA PCR assay used?

In newborns and needle exposure patiens

20

When can you say HIV+?

Multiple antibody results or a single viral load assay

Ex. 2 ELISAs and 1 Western Blot

21

What will be positive with an acute retroviral infection symptoms in a primary HIV infection?

1 Viral Load Assay

22

ACTG

AIDS clinical trials group

23

ADAP

AIDS drug assistance program

24

AMfar

American foundations of AIDS research

25

CD4 cells

T-Helper Cells

26

CD8 cells

Cytotoxic Cells

27

Discordant couples

Those sexually active partners where one is HIV+ and the other is HIV-

28

Expanded Acess

Initial monitored access to medications prior to public access

29

HAART/ART

High active antiretroviral therapy (the cocktail)

30

HIV1

Virus that causes AIDS/ HIV2 most prevalent in Africa

31

IDU

Intravenous drug user

32

Immune Reconstitution

Ability of immune system cells to replenish themselves with memory

33

Index (source) patient

The individual known to have been the source of the infection

34

MAC/DM Avium

Mycobacterium Avium Complex/ Disseminated Mycobacterium Avium

35

MSM

Men who have sex with men

36

Entry Inhibitor

Inhibits HIV entry into the host cells

37

Integrase

Inhibits integrase within the host nucleus

38

Inhibitor

Inhibits maturation of virion at exit from host cell

39

Maturation

Nucleoside reverse transcriptase inhibitors

40

Inhibitor

Necleotide reverse transcriptase inhibitor

41

NRTI

Non-nucleoside reverse transcriptase inhibitors

42

NtRTI

Protease Inhibitors

43

NNRTI

D4t, ddl, ddC, AZT

44

Mutations

Amino acid changes that occur within the genome of the virus

45

Nadir CD4

Lowest number reached

46

Naive

No prior exposure to a certain drug

47

OIs

Opportunistic infections, AIDS defining illness

48

PHI/Acute Retroviral Syndrome

Primary HIV infection: Flu-mono-like symptoms associated with acute infection

49

Reverse Transcriptase/Protease/Integrase

Viral enzymes, proteins, needed for viral replication

50

Sequestered virus/mutations

Those viruses or viral mutations that are in the minority and not detectable

51

Sexual Exposure

Passive versus active/Receptive versus insertive

52

VL

Viral load- Estimated amount of virus in the blood stream

53

VL set point

Highest viral load without HAART

54

Viral Fitness

Ability of virus to replicate in a defined environment

55

Replication capacity

Reasonable proxy for viral fitness

56

Viral Reservoir

Areas where virus is maintained and not read into serum viral load assay

57

Wild Type Virus

Original virus without mutations

58

Quasi Species

Multiple mutations in the virus of one host

59

What should be done on examination for HIV infected individual?

1. Weight
2. LN Enlargement
3. CMV retinitis
4. Oral Lesion
5. Hepatosplenomegaly
6. Abdominal masses
7. Genital sores/warts/STD lesions
8. DRE or anal cancer (caution/not done in severely immunocompromised patients)
9. Neuro
10. Joint and muscle pain

60

What serial tests should be done every 3 months and when needed for HIV patients?

1. CBC and Plts – leucopenia, anemia, thrombocytopenia (can be due to HIV or meds)
2. Chemical profile - Liver enzymes, elevated globulin fraction of total protein, serum albumin, amylase and lipase, renal function (creatinine clearance can dec due to meds, urinalysis shows positive proteins in renal damage)

61

What are 2 HIV related lab tests done on patients with HIV?

1. CD4 absolute count and percent
2. Viral load assays: PCR (bDNA, NASBA)

62

What are 2 examinations that are done on a different schedule in HIV patients?

1. Cervical/Rectal Pap (more frequently done)
2. PSA/Prostate (earlier)

63

What testing should be done yearly as indicated?

1. PPD Mantoux
2. STD Testing (GC/CT, RPR)
3. Urine Protein (especially for those on tenofovir)

64

What testing should be done initially and at intermittent screening? (5 things)

1. HLAB 5701: For hypersensitivity reaction with abacavir
2. Hepatitis A/B/C
3. Toxoplasmosis and CMV: Requires baseline IgG
4. Free testosterone levels: For wasting/depression in men
5. Lactic acid levels: W/ use of D drugs and for unexplained pain

65

What are 6 vaccines given to HIV patients?

1. Hepatitis A/B
2. Influenza (yearly)
3. MMR
4. Tdap
5. Pneumococcal
6, HPV (females 9-26)

66

What vaccines are contraindicated in HIV patients?

LIVE ONES
-Varicella Zoster
-MMR (Only if patients CD4 count is under 200)

67

What can assess relative risk of disease progression and time of death along with providing an assessment of efficacy of antiretroviral therapies for HIV patients?

Viral Load Assays

68

What are 3 things that a viral load assay can do?

1. Measure HIV
2. Study pathogenesis
3. Determine HIV Kinetics (replication)

69

With respect to a viral load assay, equilibrium is established between what?

Viral replication and immune response

70

True or False: Viral load assays can show viremia when culture reveals none

TRUE

71

How fast should HIV RNA decrease upon starting treatment?

With in days

72

If you have an adherent patient, how long until Nadir (or lowest possible viral load count) is reached in a HIV patient after starting treatment?

16-24 weeks

73

What can increases of RNA viral load reveal?

Outgrowth of drug-resistant HIV-variants or non-adherence to drugs

74

What RNA level change is associated with a biologically and clinically relevant change?

Over 0.5log10

75

What are viral blips?

Insignificant low level rises

76

True or False: Undetectable means eradication

FALSE: Undetectable doesn't mean eradication...this is not possible with today's drugs

77

What are some viral reservoirs?

Lymphoreticular system, GALT (GI Lymph Tissue), CNS, Gential tract

78

What are 3 uses of CD4 counts?

1. Assess extent of immune system damage
2. Assess relative risk of disease progression and time of death
3. Provide assessment of risk of developing opportunistic infections

79

What is done with regards to CD4 number?

Prophylactic medication is given

80

True or False: With immune reconstitution, discontinuation of meds is possible

TRUE

81

With a CD4 count under 200, what do you give for prophylaxis?

TMP-SMX for pnuemocystis jiroveci (PCP)

82

With a CD4 count under 100, what do give for prophylaxis?

TMP-SMX for toxoplasma gondii

83

With a CD4 count under 50, what do you give for prophylaxis?

Biaxin and azithromycin for Mycobacterium avium complex

84

What is the significance of CD4 Nadir?

When ART is stopped...they body will easily return to the CD4 nadir level

85

Who should CD4 levels be performed on?

All new diagnosed patients
-Levels can vary up to 30%- Monitoring levels over time is important

86

True or False: Levels must be monitored (even in untreated patients) to check disease progression and degree of immunodeficiency

True

87

What % of newly infected patients and resistant to at least 1 drug?

15%- Transmitted drug resistance (some persists in absence of treatment)

88

What is clinical resistance?

Lack of clinical benefit from antiretroviral agents

89

Where is the mutation/resistance located at in viral resistnace?

The codon of the enzyme genome

90

What reveals changes in viral genome that appear as consequence of drug exposure and natural replication?

Genotype testing for genotype resistance

91

What is the interpretation for genotype testing for gentypic resistance?

For each list of mutations, which drugs will still work in the patient

92

What reveals the ability of virus to grow in culture despite persistance of antiretroviral agent?

Phenotype testing for phenotypic resistnace

93

What is the interpretation of phentotype testing for phenotypic resistance?

For each drug, how large a fold change makes the drug no longer work

94

What does a virtual phenotype reveal?

The % of drugs responses as seen in database of known mutations

95

What is a trofile?

Tropism test- a specific phenotypic assay

96

What are the 2 HIV trophisms?

1. M-tropic
2. T-Tropic

97

What virus is M-tropic associated with and what is it attracted to and what is the timeline?

R5 Virus
CCR5 co-receptors (macrophages)
EARLY

98

What virus is T-Tropic associated with and what is it attracted to and what is the timeline?

X4 Virus
CXCR4 co-receptors (T-cell)
LATE

99

What does T-tropic X4 virus correlate to?

Rapid progression to AIDS

100

What does resistance analysis require?

A sample of greater than 1000 viral load copies

101

What does resistance analysis measure?

Majority variants (20% or more of the viral population)

102

What can false positives with resistance analysis result from?

Amplification

103

What is the availability of resistance analysis for genotypes and phenotypes?

Genotypes: Many labs (2-4 weeks for results)
Phenotypes: 2 labs in the world (SF and Ireland) (4-6 weeks for esults)

104

Nomenclature on reported mutations....what do the 3 components stand for?

M184V
M: AA found in wild type
184: AA position
V: AA substitution

105

What 3 circumstances do you order resistance testing?

1. Acute HIV infection
2. All chronically infected patients prior to therapy initiation
3. Virologic failure

106

What is virologic failure?

Failure to achieve or sustain a viral load under 50c/ml after 16-24 weeks of HAART and within 4 weeks after therapy discontinuation

107

What does it mean for a drug to have a low genetic barrier to resistance?

It is easy for these drugs to obtain resistance after certain mutations

108

What are 2 drugs that have a low barrier to resistance and don't kill the virus after a 184V mutation?

Lamivudine and emtricitabine

109

What is a drug that has a low carrier to resistance and is ineffective with 103 mutation?

Efavirenz and other NNRTIs (Whole class really?)

110

How many approved agents are there and with how many fixed dose combination medications?

27 approved agents with 7 fixed dose combination medications

111

What are 5 examples of classes of drugs for HIV?

1. Reverse transcriptase inhibitors: Nucleoside, nucleotide, non-nucleoside
2. Protease inhibitors: Attachment, CCR5, CXCR4, Fusion, T-20
3. Integrase inhibitors
4. Entry inhibitors
5. Maturation inhibitors

112

What is important for AIDS patients with regards to opportunistic disease?

Prophylaxis

113

What is the treatment for wasting syndrome?

-Anabolic steroids, testosterone replacement, appetite stimulants, growth hormone injections, Egrifta, GH-releasing factor analog

114

What 3 things constitute HIV related illness?

Anemia, dementia, opportunistic diseases

115

What is one big SE of antiretrovirals?

Lipodystrophy syndrome (fat redistribution and metabolic complications)

116

What is HAART used for?

Long term management of chronic infection

117

What are some general guidelines for beginning antiretroviral therapy? (9)

1. Acute HIV infection?
2. Symptomatic HIV disease
3. AIDS defining illness
4. Severe symptoms of HIV infection
5. CD4 100,000 (treatment may be considered)
7. Pregnant women
8. Pts w/ HIV-associated neuropathy
9. Hepatitis B virus co-infection

118

What is the goal of therapy?

To get HIV RNA to undetectable levels
-THIS DOES NOT MEAN ERADICATION...virus reservoirs like CNS, lymph, ect.

119

True or False: Mutated virus can be given to an infected patient by the index/source patient

TRUE

120

Why shouldn't monotherapy be used for patient treatment?

Drug resistance and cross-resistance

121

What is the 1 exception where monotherapy can be used for HIV?

ACTG 076 where AZT alone is given to mother and newborn--> TREATMENT IS AIMED TOWARDS FETUS

122

When initiation combination treatment, are all drugs started at once?

YES

123

After initiation, what does the patient have to take their meds at?

THE RECOMMENDED DRUG DOSE

124

Antiretroviral rug resistance is less likely under what circumstance?

If all therapy is temporarily stopped versus dose-reduction or one component being withheld

125

Patient education on what is mandatory?

COMPLIANCE

126

What are the HIV drug interactions due to?

Liver metabolism

127

NNRTIs decrease the level of what?

PIs

128

What drugs require dosage adjustment in renal dysfunction?

NRTIs

129

What drugs can cause liver damage or dysfunction?

AZT, NNRTIs, PIs

130

What do ED agents like VIagra do to HIV meds?

Increase concentration when given with a bunch of drugs, but NO EFFECT on PIs

131

Can you use a PPI with a PIs?

NEVER USE PPI with ATAZANAVIR

132

What are some other drugs that have interactions with antiretrovirals?

-Anticonvulsants, antifungals, anti-mycobacterials (TB drugs), benzodiazapines, cardiac drugs (CCBs), statins, macrolides, methadone (IV drug use), oral contraceptives, grapefruit juice, theophylline, disipramine, st. john’s wort, vitamin E

133

What does nevirapine cause?

Hepatic necrosis

134

WHat does abacavir cause?

HS reaction

135

What causes lactic acidosis (mitochondrial toxicities)?

NRTI or "d drugs"

136

What does Stevens-Johnson Syndrome?

NNRTI

137

What does tipranavir cause?

Bleeding and intracranial hemorrhage

138

What does zidovudine cause?

BM suppression

139

What drug causes hepatotoxicity?

ALL OF THEM

140

What 2 drugs cause nephrolithiasis?

Indinivir and atazanavir

141

What 2 drugs cause nephrotoxicity?

Indinivir and tenofovir

142

What 2 drugs cause pancreatitis?

Didanosine and stavudine

143

What are 4 long-term complications of PIs?

CV effects, hyperlipidemia, insulin resistnace, osteonecrosis

144

What drug can cause CNS effects?

Efavirenz

145

What class of drugs causes fat maldistribution and GI intolerance?

PIs

146

What drug causes injection site reactions?

Enfuvirtide

147

What does dianosine, stavidine, and "d drugs" cause?

Peripheral neuropathy

148

What is the result of HIV associated lipodystrophy syndrome?

Fat redistribution

149

This is when there is subQ adipose wasting in face, chest, buttocks, legs and is treated by changing the drug regimen

Lipoatrophy

150

This is when there is visceral adipose tissue accumulation and resultant increased abdominal girth (crix belly, protease paunch), bloating, and dyspepsia?

Lipohypertrophy

151

What are 2 other sites of fat accumulation in HIV associated lipodystrophy syndrome?

Breasts and dosrocervical region (buffalo hump)

152

What are 3 metabolic complications from HIV drugs?

1. Dyslipidemia
2. Insulin resistance
3. Mitochondrial dysfunction toxicities

153

What is seem in terms of dyslipiemia?

Increase TGs (especially with RTV combinations), increased total cholesterol and LDL, normal HLD

154

Can you treat a person on HIV drugs with Simvastatin or Lovastatin?

NOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

155

What drug induces insulin resistance and decreases insulin secretion?

Indinivir
-This results in glucose intolerance and diabetes

156

What are some mitochondrial dysfunction toxicities seen?

Lactic acidosis (stop NRTI’s if this condition exsists), peripheral neuropathy, pancreatitis, lipodystrophy, myopathy, cardiomyopathy

157

True or False: CAD is more prevalent in HIV patients

TRUE

158

What regimen is linked to more MIs than NNRTI regimens?

PI regimens

159

Why do you need to order DEXA scans in HIV patients?

They have decreased bone mineral density resulting in osteopenia, osteoporosis, and osteomalacia

160

How do you treat decreased bone density in HIV patients?

Calcium and Vitamin D

161

What are 4 things that can cause osteonecrosis (avascular necrosis) in an HIV patient?

1. Corticosteroid use
2. Alcohol abuse
3. Smoking
4. Hypercholesterolemia

162

How do you diagnose avascular necrosis?

CT or MRI

163

What is given to treat avascular necrosis?

ERT, bisphosphates (fosamax or actonel), evista (estrogen replacement), calcitonin

164

What are 5 malignancies associated with HIV?

1. Kaposi Sarcoma
2. Non-Hodgkin's Lymphoma
3. Cervical CA
4. Primary CNS lymphoma
5. Anal CA

165

What are the risk factors with Non-Hogkin lymphoma?

1. Duration of HIV
2. Low CD4
3. Older age
4. Chronic B cell stimulation

166

What % of HIV patients with Non-Hodkin's lymphoma have uncontrolled HIV?

75%

167

What 3 things are seen in HIV patients with Non-Hodgkin's Lymphoma?

1. Frequent CNS disease
2. Poor prognosis
3. Survival 6-20 months

168

What is recommended in both genders for HIV patients to look for dysplasia caused by HPV?

Annual DRE and Rectal Paps

169

Who is anal cancer more common in in patients with HIV?

Patients over 50, women, blacks, and men who have sex with men

170

What is seen in the nervous system with HIV patients?

Hepatitis C co-infection and penetration of the BBB

171

What are the secondary HIV complications relating to the nervous system due to?

Immunosuppression

172

What are primary HIV complications of the nervous system?

Dementia, encephalopathy, myelopathy, peripheral neuropathy

173

True or False: Patients with psychiatric disorders are more likely to get HIV, get less treatment, and die.

TRUE

174

What are 2 renal concerns for patients with HIV?

1. Nephrolithiasis
2. Fanconi syndrome (proximal tubular dysfunction leading to acidosis)

175

Name 8 metabolic issues seen in HIV patients

1. Insulin resistance
2. DM
3. Dyslipidemia
4. Lypodystrophy
5. Bone Density Loss
6. Mitochondrial Toxicity
7. Chronic Inflammation
8. HTN

176

Name 8 Organ-Related issues seen in HIV patients

1. Liver disease
2. Kidney disease
3. Peripheral vascular disease
4. Cardiovascular disease/MI
5. Cerebrovascular disease
6. Osteopenia/osteoporosis
7. Non-AIDS CA
8. CA caused by chronic infection (anal, liver, Hodgkins)

177

Name 7 neuropsychiatric conditions seen in HIV patients

1. HIV-associated dementia
2. HIV encephalopathy
3. Depression
4. Mild neurocognitive impairment
5. Delirium
6. Depression
7. Anxiety

178

What CD4 count is TMP-SMZ given to prevent pneumocystis jiroveci?

Under 200

179

What is the mm reaction for mycobacterium tuberculosis to give isoniazid prophylaxis?

Over 5mm

180

What is required to start TMP-SMZ prophylaxis for toxoplasma gondii?

CD4 under 100 and IgG+

181

When is biaxin and zithromax given prophylactically for mycobacterium avium complex?

CD4 under 50

182

When is Varicella zoster immune globulin given prophylactically?

With significant exposure

183

What CD4 count do you give the pneumococcal vaccine for Strep Pneumo?

Under 200

184

Do all HIV patients get 3 doses of Hep B Vaccine?

Yes... all that are susceptible

185

Do all HIV patients get influenza vaccine?

Yes- Inactivated vaccine
Oseltamivir, Rimantadine, Amantadine

186

Who gets 2 doses of Hep A Vaccine?

All susceptible with chronic Hep C

187

When is G-CSF given for an HIV patient?

When there is neutropenia

188

What CD4 count if fluconazole given at for cryptococcus neoformans?

Uner 50

189

When is itraconazole given for histoplasma capsulatum?

CD4 under 100

190

When is oral gancyclovir given for CMV?

CD4 under 50 or CMV Ab+

191

What is given to reduce vertical transmission of HIV from mom to baby?

AZT

192

What drug is used alone during labor to reduce vertical transmission?

Nevirapine

193

What is Mom on throughout pregnancy to prevent HIV transmission?

HAART

194

When is AZT given to the baby?

At birth...given first 6 weeks of life and discontinued at 6 weeks in the DNA PCR is negative

195

How many DNA PCR positive results are sufficient for newborn HIV diagnosis?

2

196

WHat is required for exclusion of HIV in newborn?

2 DNA PCR negative results when done at >1 month and >4 months

197

When are 2 positive antibody tests with confirmatories sufficient for diagnosis of HIV in child?

After 18 months

198

When may 2 negative antibody tests exclude HIV1 infection?

When both are done at >6 months

199

Children who havne't seroconverted should continue to be monitored until they have what?

Negative HIV antibody tests

200

What if given for PCP prophylaxis in newborn to HIV mom?

Start bactrim at 6 weeks... if HIV + or is positivity is still unknown or negative

201

What must be given to all HIV-exposed infants?

Vaccinations

202

True or False: Breastfeeding is contraindicated in an HIV positive Mom

TRUE

203

There is a better outcome if an HIV-infected individual was treated by a clinician that had at least how many patients they were following?

5

204

True or False: Clinicians that manage a small number of HIV-infected patients shouldn't treat without assistance from more expert colleagues

TRUE