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NEJM Jan2014-Sep2015 > Sep 2014 > Flashcards

Sep 2014 Flashcards

1
Q

How are internal and external haemorrhoids differentiated?

How many grades?

A 
Internal = proximal to dentate line
External = distal to dentate line

Grades 1-4

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2
Q

What are risk factors for haemorrhoids?

A
  1. Increased venous pressure and drainage - cirrhosis with ascites, pregnancy, straining, squatting
  2. Abnormal bowel function - constipation/diarrhoea
  3. Collagen vascular disease
  4. Pelvic floor abnormalities
  5. Low fibre intake
  6. Obese / Sedentary
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3
Q

What is the treatment of low-grade haemorrhoids?

A
  1. Hygiene
  2. Bowel regulation - water and fibre
  3. Avoid straining
  4. Topical medications

If above fails - rubber-band ligation

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4
Q

What is the treatment of high-grade complicated haemorrhoids?

A
  1. Sclerotherapy / haemorrhoidectomy
  2. Thrombectomy of external haemorrhoid thrombosis
  3. Stapled haemorrhoidopexy
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5
Q

What is the 2 most common symptoms of haemorrhoids?

A

Haematochezia (60%)

Itching (55%)

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6
Q

Patient returns from West Africa and presents initially with fever and polyarthralgia with intense pain. 3 days later a maculopapular rash arises that lasting 5 days.

what is the important DDx?

A

Chikungunya - anthropod borne virus endemic to West Africa (RNA virus)

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7
Q

What are the options for diagnosing Chikungunya?

A
  1. IgM/IgG anti-chikungunya viral antibodies

2. RT-PCR for virus

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8
Q

What is the vector for Chikungunya transmission?

A

Mosquitos

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9
Q

What is the treatment of Chikungunya?

A
  • Treat pain - analgesia (e.g. NSAIDS)

- No antiviral available

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10
Q

Which of the following 2 options improves prolonged progression-free survival in multiple myeloma:

  1. high dose melphalan consolidation + ASCT
  2. melphalan + prednisone + lenalidomide
A

high dose melphalan consolidation + ASCT

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11
Q

True/False: In the treatment of myeloma, addition of Lenalidomide maintenance significantly improves prolonged progression-free survival compared to no maintenance.

A

True

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12
Q

What is a better alternative to melphalan-prednisone-thalidomide regimen in Transplant-ineligible patients with myeloma?

A

lenallidomide-dexamethasone improves progression-free survival

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13
Q

What % of pancreatic cancers are adenocarcinomas?

A

85% (most)

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14
Q

What are the 3 most common mutations in pancreatic ductal adenocarcinomas?

A

KRAS (90%)
p53 (70%)
CDKN2A (50%)

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15
Q

Anatomically, where do most pancreatic cancers occur?

A

Head (70%) - most

Body/Tail (25%)

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16
Q

What are common clinical features of pancreatic cancers?

What other medical condition is likely to be associated?

A
  • Abdominal pain / weight loss / asthenia / anorexia
  • Jaundice (if pancreatic head implicated)
  • DM in 50%
17
Q

Where does pancreatic cancer metastasise to?

A

Obvious: liver and abdomen

Less obvious: lungs

18
Q

What is the treatment of Stage 1/2 pancreatic cancer?

A
  • Surgery (pancreaticoduodenectomy (Whipple procedure) if in head/neck
  • Adjuvant chemotherapy: 6m of gemcitabine or fluorouracil
  • +/- Radiation therapy - controversial
  • Neoadjuvant (pre-op chemotherapy) - trials only
19
Q

What is the treatment of Stage 3/4 pancreatic cancer?

A
  • FOLFIRINOX + gemcitabine-nab-paclitaxel

- Erlotinib improves survival by 2 weeks in stage 4 disease

20
Q

Which 2 genetic syndromes increase the risk of pancreatic cancer?

A
  • Hereditary pancreatitis (PRSS1, SPINK1) - 50%

- Peutz-Jeghers syndrome (STK11[LKB1]) - 40%

21
Q

What new therapy in HF-REF may reduce risk of death and hospitalisation compared to ACEi?

A

LCZ696 = AT2R inhibitor + neprilysin (valsartan + sacubitril)

Superior to ACEi (enalapril) in the treatment of HF-REF

Neprilysin = enzyme that degrades natriuretic peptides

22
Q

What is the significance of PCR detection of AR-V7 (androgen receptor isoform encoded by splice variant 7) in castration-resistant prostate cancer?

A

Detection of AR-V7 in circulating tumour cells suggest resistance to enzalutamide and abiterone therapy.

AR-V7 lacks the ligand bind domain for these medications.

23
Q

What is Ticagrelor?

A

Direct acting platelet P2Y12 receptor agonist

24
Q

True/False: pre-hospital administration of ticagrelor in acute STEMI is safe and improves pre-PCI reperfusion.

A

False.

Safe but does NOT improve pre-PCI reperfusion.

25
Q

Describe the action of insulin in muscle and liver.

A

Insulin acts on insulin receptor tyrosine kinase and activates PI3K which promotes expression of GLUT 4 to cell surface.

26
Q

What type of virus in Ebola?

A

RNA virus in the filovirus family

27
Q

Are the symptoms of Ebola specific?

A

No - fever, nausea, vomiting, diarrhoea and weakness.

28
Q

True/False: Ivabradine is of NO use in patients with stable CAD and without HF and a HR > 70bpm.

A

True - no benefit.

29
Q

True/False: thrombus aspiration prior to primary PCI improves primary (30d mortality) and secondary (1 year mortality) end points.

A

False - no benefit.

30
Q

True/False: prednisone therapy or immunotherapy with mycobacterium indicus pranii in tuberculous pericarditis improves outcomes.

A

False - no benefit.

31
Q

Is it appropriate for an ED physician to perform a bedside US to diagnose suspected nephrolithiasis rather than order departmental US or abdominal CT scan?

A

Yes - similar outcome and with lower cumulative radiation exposure.

32
Q

True/False: A diagnosis of depression in the elderly (>60yrs) is NOT associated with increased risk of dementia and neurological abnormalities.

A

False.

Depression in the elderly is associated with increased risk of both neurological deficits and dementia.

33
Q

What are the first-line therapies of depression in the elderly from the following options:

  1. Psychotherapy
  2. ECT
  3. SSRIs
  4. SNRIs
  5. Mirtazepine
  6. Bupropion
A

1st line:

  • Psychotherapy
  • SSRIs (sertraline/escitalopram)

2nd line:

  • SNRIs / Mirtazepine / Bupropion
  • ECT
34
Q

What are the treatment options for varicose veins?

A
  1. US-guided foam sclerotherapy (fewer complications)
  2. Endovenous laser ablation
  3. Surgery (better QoL)
35
Q

What type of immune response is employed in asthma?

A

Th2 with IL4 / IL5 / IL13

36
Q

What may be considered in the treatment of severe eosinophilic asthma with sputum eosinophilia with greater than 3%.

A

Anti-IL5 mAb (IV/SC) - reduces exacerbations and is steroid-sparing

3 options:

  • Mepolizumab
  • Reslizumab
  • Benralizumab
37
Q

What is Fractional Flow Reserve guided PCI for stable CAD?

A

Angiographically visible stenosis with FFR 0.80 or less benefit from FFR guided PCI - improved outcomes.

NEJM Jan2014-Sep2015 (4 decks)

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