Quiz 2 Flashcards
(77 cards)
1
Q
Specific aim of the GRADE trial
A
comparison of relative effects of 4 commonly used diabetes medications w/ different mechanisms of actions on:
- Maintenance of metabolic control
- defined as TIME TO PRIMARY FAILURE w/ A1c >/= 7.0% while on maximally tolerated doses of both metformin (up to 2000mg/d) and the assigned medication
2
Q
Which 4 drugs are being assessed in the GRADE trial?
A
Glimepiride -> sulfa
sitagliptin -> DPP-4 inhibitor
liraglutide -> GLP-1 analog
glargine -> long acting insulin
3
Q
UKPDS
DCCT/EDIC
ACCORD
- patient population
- effects of intensive diabetes tx (HbA1c of 7 vs. 9)
A
3
- UKPDS -> early DM2, adults
- DCCT/EDIC -> early mid DM1, kids/young adults
- ACCORD -> older DM2, high CVD
Both #1 and #2
- long term f/u showed dec microvascular disease
- UKPDS -> dec mortality
- DCCT/EDIC -> no change in mortality
- dec in microvascular disease but INCREASE in mortality
- deaths amongst those that tried but failed to achieve tight control
4
Q
operation features of biological weapons
A
need 2/3:
- payload
- delivery system
- dispersion system
5
Q
Define the 3 categories of biochemical agents
A
Category A -> high priority agents
-high mortality, easily spread
Category B -> 2nd high priority agents
-moderate mortality, easily spread
Category C -> emerging infectious diseases
-potential high mortality
6
Q
BE PAST
A
for category A agents
Botulism Ebola (and other viral hemorrhagic fevers) Plague Anthrax Smallpox Tularemia
7
Q
Smallpox
- agent
- transmission
- pathology events
- clinical events
- brief ddx
- category
A
Agent
-variola major -> DS DNA virus
Transmission
- airborne droplets (usually)
- contact-spread (sometimes)
- human to human only
Pathology events
- pneumonia, immune complexes
- can lead to death
Clinical events
- macular to papular rash at palms, soles
- microscopic -> Guarnieri bodies
Brief ddx
-chicken pox from VZV (rash dense on torso)
Category A
8
Q
Hantavirus pulmonary syndrome
- transmission
- pathology events
- clinical events
- brief ddx
- category
A
Transmission
- inhaled aerosolized droppings of deer mice
- NOT person to person
Pathology events
- capillary permeability -> lung alveolar edema
- interstitial inflammation
Clinical events
- muscle aches
- nausea
- diarrhea
- cough
- respiratory failure
Brief ddx
-influenza
Category -> C
Extra info
RNA virus
SS neg circular w/ 3 segments
9
Q
Mono presents with? Possible complication? Which virus?
A
- Fever
- Hepatosplenomegaly
- Pharyngitis
- Lymphadenopathy -> especially posterior cervical nodes
Splenic rupture!
EBV (HHV-4) but also CMV (HHV-5) can cause mono but much less common w/ CMV
10
Q
Cancer risks associated w/ EBV
A
burkitt’s lymphoma -> africa
- 8:14 translocation
- c-myc proto-oncogene moved next to Ig heavy chain gene -> c-myc overexpression -> inc cell proliferation (high grade)
Nasopharyngeal carcinoma -> Asia
Hodgkin’s lymphoma -> 50% of cases associated with EBV (first aid)
11
Q
Mononucleosis
- agent
- transmission mode
- pathology events
- clinical events
- brief ddx
A
Agent
-EBV»>CMV
Transmission mode
- person to person
- “kissing disease”
Pathology events
-EBV infects lymphocytes and nasopharyngeal epithelial cells
Clinical events
- fatigue
- fever
- pharyngitis
- lymphadenopathy
- overseas cancer risk
Brief ddx
- lymphoma
- acute HIV infection
- splenomegaly of toxoplasmosis
12
Q
Cowdry type A inclusions resemble? Where are they found?
A
Owl eyes
intranuclear inclusions
13
Q
Congenital CMV infection
- transmission mode
- pathology events
- clinical events
- brief ddx
A
Transmission mode
-vertical -> from mom: transplacental or birth canal/milk
Pathology events
-hepatitis, neurological damage, cerebral calcifications
Clinical events
-impaired intelligence seizures, deafness, rash
Brief ddx
- Rubella
- other ToRCHeS infections
14
Q
Hep B and C
- transmission mode
- pathology events
- clinical events
- brief ddx
A
Transmission mode
-blood, semen, vaginal fluids
Pathology events
- damage hepatocytes
- elevated AST, ALT
- anti-viral Abs
Clinical events
- jaundice
- stigmata of chronic liver disease
- hepatocellular carcinoma
Brief ddx
- alcoholic liver disease
- genetics (hemochromatosis etc.)
- other viruses
15
Q
Ebola virus
- virus class
- transmission mode
- pathology events
- clinical events
- brief ddx
- bioterrorism category
A
Filovirus -> ssRNA linear
Transmission mode
- unknown reservoir
- person to person spread (blood, fluids)
Pathology events
-DIC
Clinical events
- fever
- pharyngitis
- dyspnea
- maculopapular rash
- subconjunctival bleed
Brief ddx
-other viral hemorrhagic fevers -> bunyavirus, arenavirus, filovirus, flavivirus
Category A
16
Q
Hand-foot-mouth disease
- virus
- transmission mode
- pathology events
- clinical events
- brief ddx
A
Coxsackievirus
- picornavirus (ssRNA linear)
- B4 and B5 -> MCC of viral myocarditis in very young children and adults (necrosis w/ dense lymphocytic infiltrate)
Transmission mode
- fecal-oral
- amongst infants and kids
Pathology events
-aseptic meningitis, serious myocarditis (both rare)
Clinical events
- maculopapular rash of FOOT, HANDS and MOUTH
- good prognosis
Brief ddx
- chicken pox
- herpes simplex
- kawasaki disease
17
Q
Dxic criteria for renal artery stenosis by arterial cath
A
pressure gradient >21mmHg
18
Q
What 2 things stimulate aldosterone secretion in an independent and synergistic manner?
A
AGII and hyperkalemia
19
Q
4 clinical clues to presence of hyperaldosteronism
A
- Spontaneous hypokalemia
- diuretic induced hypokalemia
- refractory HTN
- FH hx of HTN
20
Q
Minimum cutoff for serum aldo to make dx of primary hyperaldo
A
> 15 ng/dl
21
Q
11-beta dehydrogenase deficiency
- cause
- effects
A
Cause
-chew tobacco and licorice inactivates the enzyme
Effects
- Cortisol can’t be converted to cortisone in collecting tubule cells
- Cortisol free to act strongly on the MR receptor once it gets into the cell -> hypertension
22
Q
Glucocorticoid remediable aldosteronism
tx?
A
- unequal crossing over b/w genes for aldosterone synthase and regulatory region of 11-beta hydroxylase
- hybrid aldosterone synthase sensitive to ACTH -> hyperaldosteronism
Give steroids -> blocks ACTH and reduces aldosterone synthesis
23
Q
2 forms of pseudohypoaldosteronism type 1
A
Renal form
- mutation in mineralocorticoid receptor -> aldosterone resistance
- volume depletion, hyponatremia, mild hyperkalemia, metabolic acidosis
Systemic form
- mutation in ENaC
- salt wasting, hypovolemia, hyperkalemia, metabolic acidosis
-renin and serum aldo are high
24
Q
Gordon’s syndrome (PHA type 2)
tx?
A
overexpression of WNK kinase 1 or inactivating mutation in WNK kinase 4
overactive distal NaCl transported
HTN and hyperkalemia
mild hyperchloremic metabolic acidosis
Responds well to THIAZIDES
25
Definition of pre-HTN
139-129/89-80
26
Daily salt intake should be
4g NaCl - latest AHA recommendation
10g NaCl = 170 mEq Na = 4g Na -> this is what the average US adult actually takes
27
Curable causes of HTN all interfere w/
Na excretion (e.g. prim hyperaldo)
Renal sensing of inc BP (e.g. renal artery stenosis)
28
Relationship b/w obesity and EH
obesity -> SNS stimulation -> renal vasoconstriction -> inc BP
clonidine -> alpha-2 agonist
-reduces sympathetic response
29
HPA axis in kids vs adults w/ PTSD
Kids - elevated CRH and cortisol
Adults - high levels of CRH and LOW cortisol
-enhanced negative inhibition of HPA axis
30
1st line tx for PTSD
SSRIs
- paroxetine
- fluoxetine
31
List 2 alpha 2 agonists used with PTSD and effects
Clonidine
- Decreased hyperarousal, hypervigilance, sleep disruption, exaggerated startle responses, and nightmares in open-label trials of adults with war-related PTSD
- adult borderline personality disorder w/ co-morbid PTSD
Guanfacine
- less potent
- reduce nightmares in children with PTSD
32
2 MC side effects leading to d/c of prazosin?
for quetiapine?
dizziness and sedation
quetiapine -> sedation
33
Dxic criteria for Kawasaki
Fever lasting 4+ days plus 4/5 of the following:
1. bilateral NON-purulent conjunctival injection
2. changes of lips and oral cavity
- strawberry tongue
- intense reddening, swelling, vertical cracking of the lips
3. Polymorphous rash
- any except blistering
4. non-purulent swelling of a cervical lymph node > 1.5 cm
5. changes of peripheral extremities
- reddening of palms and sole
- indurative edema of hands and feet
- membranous desquamation of the fingertips (hands affected later in the disease)
34
Tx for kawasaki? what is the goal of tx? When should tx be given?
High dose aspirin and IVIG -> prevention of CORONARY ANEURYSMS
-25% of untxed KD -> coronary artery aneurysms
IVIG and ASA should be given w/in 1st 10 days of illness
side note: desquamation of fingers/toes occurs in subacute phase REGARDLESS of treament
35
Serum sickness
- which HSR?
- cause?
- type to develop sxs
- presentation
Type III HSR
exposure to therapeutic heterologous serum or medications (e.g. amoxil)
-rarely after blood transfusion
manifests 7-21 days AFTER exposure to exogenous protein or chemicals
fever, urticaria, rash at interface of dorsal and palmar or plantar aspects of hands and feet
36
platelet count in HSP?
NORMAL
37
HSP epidemiology
- age
- male vs female
- rare in which age group?
age 3-15
boys:girls = 1.5:1
rare in children < 2
38
age group for kawasaki's disease
age < 4
39
HSP classification criteria
2/4 -> good Sn and Sp
1. palpable purpura -> NOT related to thrombocytopenia
2. age
40
Path of skin bx in HSP
-bx rarely need to make dx
leukocytoclastic (neutrophil) vasculitis in dermal capillaries and postcapillary venules
Deposition of IgA!!!
41
HSP tx and course
usually supported
steroids rarely needed
Course
- runs 4 weeks for 2/3 of patients
- 1/3 to 1/2 have at least one recurrence
42
HSP GI manifestations
Seen in 2/3 children w/ HSP
-w/in 1 weeks of onset of skin manifestations
vasculitis of bowel can lead to
- intussusception -> telescoping
- gangrene
- over perforation
Intestinal angina
- colicky pain
- intermittent
- periumbilical
43
HSP - renal disease
GN in 1/3 but serious in 10%
-develops w/in 1 month of rash onset
Can lead to renal failure
44
Fever of unknown origin
- classical
- health care associated
- immune-deficient
- HIV related
1. Classical
> 38 C, > 2 visits or 3 days in hospital
2. Health-care assoc
> 38 C, > 3 days, not present on admission
3. Immune deficient
> 38 C, > 3 days, neg blood cultures after 48 hours
4. HIV
> 38, > 3 weeks for outpatients and > 3 days for inpatients
45
Which lymph nodes always indicate abnormality when palpated?
Epitrochlear
46
3 solid tumors that can cause fevers
HCC
RCC
Pheo
myeloproliferative malignancies (leukemia, lymphoma) more likely to cause fever than solid tumors
47
2 drugs mentioned in lecture associated w/ drug fever
how does drug fever present?
sulfas and phenytoin (dilantin = brand)
patients appear well despite fever and it goes away once drug is removed
-NOT an allergy
48
2 mc fungal infections in neutropenic patients
Candida
- dimorphic yeast
- pseudohyphae
Aspergillus
-acute angles
49
HIV associated FUO
Infections are MC
- mycobacterium avium
- pneumocystis
- CMV
- fungal -> histo or coccidioidomycosis
Malignancy
-lymphoma
50
SED rate > 100 think?
- vasculitis
- chronic infections (e.g. osteomylitis)
- lymphoma
51
Pathophys of tumor lysis syndrome
Cellular breakdown leads to inc in:
1. Uric acid
- due to purine catabolism
- poorly soluble -> precipitates in kidney
2. Phosphate
- nucleotide breakdown
- CaPO4 -> precipitation
3. Hyperkalemia
Can lead to acute renal failure
52
2 drugs used to tx TLS
Allopurinol -> blocks xanthine oxidase
rasburicase (recombinant urate oxidase) -> converts uric acid to allantoin
-increased solubility
Also be sure to HYDRATE patient
53
management of hyperkalemia
Calcium gluconate by IV
regular insulin + dextrose IV
NaHCO3
Dialysis
Na polystyrene sulphonate
54
Remission induction for ALL
Prednisone
vincristine
asparaginase
daunorubicin
55
mutation assoc w/ poor outcome in ALL
t(9;22) -> BCR-ABL fusion
HSC transplant better than chemo
56
List 5 ways to prevent anthracycline (e.g. daunorubicin) induced cardiomyopathy
- reduce exposure
- iron chelation
- liposomal preps
- ACE inhibition tx
- afterload reduction when appropriate
57
AIF syndromes w/ mutation in NACHT domain of NALP3 have which pattern of inheritance?
Autosomal dominant
58
Rash of FCAS vs MWS
FCAS -> urticaria (pruritus)
MWS -> urticaria-like -> aching NOT itchy
59
FCAS characteristics (3)
- cold-induced urticaria
- fever
- arthralgia
60
MWS characteristics (3)
- urticaria
- amyloidosis (25%)
- deafness
61
NOMID characteristics (3)
- neonatal-onset urticaria
- CNS disease -> non-infections meningitis (PMNs in CSF)
- arthropathy -> starts in growth plates
62
3 IL-1 blocking agents and MoA
Anakinra -> binds to IL-1 receptor 1
Canakinumab -> mAb w/ IL-1beta specificity
Rilonacept -> IL-1 trap
-contains EC domains of IL-1R1
63
Hyper-IgD w/ periodic fevers syndrome
- inheritance pattern
- age
- common trigger
- presentation
- which enzyme?
Autosomal recessive
early age (< 1 usually)
trigger -> vaccine
Presentation
- serosal inflammation
- arthralgia
- mucocutaneous lesions -> non-migratory rash and aphthous ulcer (mouth and vagina)
- lymphadenopathy and hepatosplenomegaly
10-15% activity of mevalonate kinase
-inc levels of mevalonate in urine DURING attacks
64
TRAPS
- inheritance
- duration
- trigger
- presentation (compare to HIDS)
- path
autosomal dominant
Duration
-long episodes -> 1-4 weeks
Trigger -> physical trauma
Presentation
- MIGRATORY erythematous rash (note HIDS doesn't migrate)
- peritoneal adhesions
- myalgias
- PERIORBITAL SWELLING (only AIS seen w/ TRAP)
- conjunctivitis
Impaired shedding of TNF receptor
- can't shut down TNF response
- inc activation of IL1-beta
65
MC AIS in kids
- dxic criteria
- prognosis
PFAPA -> regularly recurring fevers (>38.3C) usually w/ early age of onset (<5 y/o)
syndrome of fever w/
- aphthous stomatitis (canker sores)
- pharyngitis
- cervical lymphadenopathy
Prognosis
-usually benign and resolves by puberty
66
PFAPA vs cyclic neutropenia
Look at CBC!!
neutrophil account will be NORMAL or slightly elevated w/ PFAPA
LOW w/ cyclic neutropenia
67
Predictor of poor outcome w/ PFAPA
severe abdominal pain
68
Trauma 3 way imaging
- lateral c-spine
- CXR
- pelvis x-rayq
69
How much blood needs be lost until there is drop in BP
30-40% (Class III hypovolemic shock)
70
1st step of acute burn injury
evaluate and secure airway
71
Rule of 9 for burns
head and arm -> 9% each
chest (front and back) - 18% each
legs -> 18% each
genitals -> 1%
72
2 drugs to prevent burn sepsis
Bacitracin - face and ears
Silver sulfadiazine - body
73
Parkland formula
24 hour volume to be infused
%TBSA burned x weight in kg x 4 ml lactated ringer's/kg
use ONLY 2nd and 3rd degree burns
give half in 1st 8 hours and the other half in the next 16
74
Escharotomy indications
Phys exam UNRELIABLE
Doppler
direct measure of tissue pressure
Neurovascular damage when interstitial pressure > 40 mmHg
75
Fasciotomy pressure indications
> 30 torr
| -intramuscular compartment pressure
76
Drugs for VAP
Gm pos -> vanc
Gm neg -> tobra and/or cefepime
77
List 4 endogenous pyrogens. What do they activate to cause fever?
IL-1beta
TNF-alpha
IFN
IL-6
Activate PGE2 -> fever
