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Flashcards in THE THIRD MIDTERM Deck (302):
1

What are three common symptoms of breast diseases?

1. Pain

2. Palpable Masses

3. Nipple Discharge

2

Why don't we screen women for breast cancer until age 40?

• Start screening at ~40 yrs because younger women have denser breast tissue making it difficult to identify a mass

3

What does mammography help with?

1. It detects density

2. Can show architectural distortions

3. Identifies calcification

4. Changes over time and these changes can indication pathologies such as cancers

5. Can use imaging to help guide biopsy needle in order to sample a growth.

4

What percent of breast cancers can't be detected through mammography?

~10% of breast cancers that are not detected by mammography, can be detected by palpitation

5

What are the characteristics of acute mastitis?

• Can cause breast abscesses and necrosis

• Typically associated with women who are breast feeding.

• Can be caused by plugged ducts

• Can be infectious or non-infectious

6

What is fat necrosis of the breast usually associated with?

• Usually associated with trauma (from a seat belt during an accident)

7

What are the characteristics of breast cysts?

• Fibrolytic changes

• Higher risk of breast cancer

• Occurs 20-40 years old

• Doesn’t typically occur after menopause

• Can calcify

• Can look like cancer on mammogram

8

What are the characteristics of benign neoplasms of the breast?

• Fibroadenomas are the most common

• Mostly connective tissue

• Well circumscribed

• Don’t typically remove unless uncomfortable.

9

What are the breast carcinoma statistics?

  • Rarely occurs
  • ~30% incidence by 70 yrs of age
  • No racial influence, but there is environmental influences
  • Inherited=5-10% (BRCA 1 and 2 the most common inherited genes)

~250,000 new breast cancers in U.S./yr.

10

What are the symptoms of breast carcinoma?

• Pain

• Masses (assessed by palpitation, mammography, ultrasound, MRI, or tissue biopsied)

11

What is the prognosis of breast carcinoma?

• Based on size, axillary node status, and distant metastasis

• 5 year Survival rate of stage 0 (early stage)=92%, stage IV (late)= 13%

• If tumor expresses estrogen/progesterone receptors, it often responds to hormonal treatment

12

What are the types of breast carcinoma?

• Invasive carcinoma: 75-85%

• Most are ductal and the incidence increases with age and have invasive and non-invasive types

• Can do lumpectomies to remove smaller masses.

13

What are benign epithelial lesions?

Benign epithelial lesions

-typically fibrocytic changes (e.g.,60% of women have microscopic cysts associated with epithelial tissue.

14

What is the main type of cervical cancer and what are the risk factors?

• HPV (human papillomavirus)- associated squamous cell neoplasm represents most cervical cancers -use pap smear to detect early

• Risk factors -multiple sex partners -Immunosuppression -early age of first sexual contact -oral contraception for >5 years -nicotine use

15

What are the three main causes of polyps in the endometrium?

1. Hypertension

2. Obesity

3. Late menopause

16

What are the risks and treatment associated with endometrial cancer (adenocarcinoma)?

1. Risks • Obesity • Diabetes • Hypertension

2. Treatment • Hysterectomy-treatment of choice • Radiation/chemotherapy adjunctive

17

What is the main cause of endometritis?

IUDs

18

What is endometrial hyperplasia and what are the treatments?

• Exaggerated responses due to excessive estrogen (e.g., excessive ovarian activity), that can progress to cancer.

• Treatment: Progesterone, Hysterectomy

19

What are the two main types of ovarian masses?

• Non-neoplastic cysts (e.g., follicular)

• Neoplastic: e.g., endometroioid

• Most are sporadic

• Contraceptives can decrease risk

• Treatment: -total hysterectomy + removal of surrounding tissue + chemotherapy

20

What are the symptoms of ovarian masses? When is the screening recommended for ovarian cancer?

• Pelvic pain

• Pelvic mass

• Abdominal bleeding

Unlike cervical cancer, there is no effective screening for ovarian cancer

21

How do estrogens and progestins work as hormone replacement therapy options?

Estrogens and Progestins

1. Natural estrogens are steroid hormones—synthesized estrogens may be non-steroidal

2. They cross cell membranes and activate estrogen receptors inside cell—modulate expression of genes

22

What are the names of the three stages of the menstrual cycle?

The menstrual cycle:

• Menstrual stage—menses

• Follicular stage—proliferative

• Luteal stage—secretory

23

As populations age, they spend less time in menopause (females) or andropause (males). True or False?

False, they spend more time.

24

What are the names of the three natural estrogens? And at what stage of life are these predominant?

• Estrone (predominant during menopause)- E1

• Estradiol (predominant during productive years)—E2

• Estratriol (predominant during pregnancy)—E3

25

What are the two main synthetic estrogens?

• Steroidal: ethinyl estradiol

• Non-steroidal: diethylstilbesterol

26

What are the six physiologic functions of estrogens?

1. Sexual maturity

2. Increased CNS excitability (seizure inducing?)

3. Increased endometrial and uterine growth

4. Maintain skin elasticity

5. Reduce bone adsorption

6. Increase blood coagulability

27

What are the two main clinical uses for estrogens?

• Primary hypogonadism

• Postmenopausal

(1) Guidelines for use

• Always use the smallest dose for the shortest period of time possible

• Sometimes local creams are preferred to minimize exposure

28

What are the main adverse effects of estrogens?

• Postmenopausal bleeding

• Nausea, breast tenderness

• Migraines

• Hypertension

• Hyperpigmentation (especially around eyes)

• Increases some cancers (e.g.. breast and endometrial)

29

What are the three scenarios in which estrogens are contraindicated?

• Liver disease (slows metabolism)

• Breast/endometrial cancers

• Thrombolytic disorders

30

What are progestins made from, other characteristics, hal-life, etc?

• Made from cholesterol

• Present in males, but less than females

a. Progesterone (natural)—most important progestin in human • Precursor to estrogen, androgen and adrenalcortical steroids (e.g., cortisol)

• Also precursor to testosterone and estradiol c. Half life= 5 min. (very short acting)

31

What are the four main physiologic effects of progestins?

1. Increase fat deposition

2. Decrease CNS excitability (e.g., antiseizure—opposite of estrogen)

3. Increase aldosterone---increase Na+ retention—increase BP—increase water retention and blood volume

4. Increase body temperature

32

What are the four main clinical uses of progestins?

• Replacement therapy

• Oral contraception

• Long-term ovarian suppression (e.g., dysmenorrhea or endometriosis)—in contrast to estrogens, no problem with bleeding or clotting

• Contraindications:

• Breast cancer is a risk

• Severe hypertension or heart disease is risk

33

What does the progesterone and estrogen contraceptive combination do?

• Decreases ovulation (approaching 100%)

• Decreases conception and implantation

34

What does the progestin only contraceptive do?

Progestin only (less effective, ~80-90%)

• Decreases ovulation 50-80%

• Thickens mucus and reduces sperm penetration

• Impairs implantation

35

What are the different types of delivery forms for contraceptives?

• Combinations:

  • • Monophasics- constant doses of both estrogen and progesterone
  • • Biphasic- dosage of one or both change one time during cycle
  • • Triphasic-dosages change 2 times

• Progestin only—referred to as the “minipill” (no estrogen); fewer side effects, but less effective

• Implantable

• Injections (i.m., sustained effects)

• Intravaginal rings

• IUDs with and without estrogen/progestin

• Transdermal combinations

36

What are the side effects of combination contraceptives?

• Reduced ovarian functions and size

• Increased breast size and tenderness

• Increased thromboembolytic events (clotting)

• Increased heart rate and BP

• Hyperpigmentation, especially around the eye

• Mild nausea, breakthrough bleeding, headaches

• May interact with antibiotics that disrupt G.I. normal flora (e.g., wide spectrum antibiotics such as amoxicillin)—normal absorption of contraceptives from GI system is dependent on these flora

37

What are the three main uses of contraceptives?

• Oral contraception

• Menstrual disorders, irregularity, heavy discharge

• Acne

38

Tamoxifen

Estrogen receptor antagonist. Blocks actions of estrogen in breast-used to treat breast cancers.

39

Mifepristone

Mifepristone is a synthetic, steroidal anti-progestogen and anti-glucocorticoid pharmaceutical drug. Morning after contraceptive: blocks progesterone and glucocorticoid receptors. Ends a pregnancy that is less than 7 weeks along (49 days or less since the start of your last menstrual period). Also used to control high blood sugar in patients with Cushing syndrome who also have type 2 diabetes and have failed surgery or are not candidates for surgery.

40

Danazol

Danazol is a derivative of the synthetic steroid ethisterone that suppresses the production of gonadotrophins and has some weak androgenic effects. Suppresses ovarian function (has a masculinizing effect). Treats endometriosis, fibrocystic breast disease, and hereditary angioedema.

41

Clomiphene

Clomifene or clomiphene is a selective estrogen receptor modulator that has become the most widely prescribed drug for ovulation induction to reverse anovulation or oligoovulation. Ovulation-inducing; for promoting fertilization and pregnancy (increased risk of multiple births—e.g., twins). Clomed.

42

What is testosterone?

It is an androgen, causes male puberty.

• Converts to estradiol

• Replacement therapy for males

• Gynecological disorders—reduces breast size (gynecomastia)

• Has protein anabolic effects—helps replace muscle loss

• Growth stimulation—can prematurely close growth plates in growing adolescents

• Counter some age-related loss of muscle mass

• Adverse effects in women especially—masculinization

• Testosterone analogs abused for muscle and strength building—can cause acne, aggressiveness and “roid rage”, although this is controversial.

43

What are the characteristics to bone?

• 99% Calcium stored in bones

• In adult, the bones are the primary site of hematopoeises

• Constantly remodeling

• Medullary bone resists compression forces, Cortical bone is thick and resists bending forces

• Periosteum is tough fibrous membrane—covers bone surfaces except at joints—well innervated

44

What is osteogenesis imperfecta?

1. Osteogenesis imperfecta

a. Deficient or defective type 1 collagen—too little bone

b. Generalized osteopenia

• Multiple fractures and bone deformities

• Malformed teeth (dentin deficiency)

45

What are the nutritional, endocrine, and systemic deficiency bone diseases?

1. Vitamin deficiencies : scurvy (vit. C), rickets (vit. D)

2. Endocrine factors—hyperparathyroidism

3. Osteoporosis—common in elderly women, after menopause

4. Osteomalacia—vitamin D deficiency

46

What are the genetic and behavioral causes of osteoporosis?

Genetic: age, low estrogen, fair hair and skin, tall and thin

Behavior: inactivity, smoking/alcohol, malnutrition, medication (chronic corticosteroids)

47

What are the statistics of osteoporosis?

• 10 million have osteoporosis in US, mostly women

• 1/3 women >50 years old have at least one osteoporitic fracture

48

What is kyphosis?

Abnormal forward curvature of spine

49

What is scoliosis?

Abnormal lateral curvature of spine

50

What are the four types of bone fracture?

• Complete

• Closed (overlying tissue intact)

• Commuted—bone splintered

• Displaced

51

What is osteomyelitis and what are the five things that can cause it?

Osteomyelitis (inflammation of bone/marrow)

a. blood-born or direct

b. trauma from compound fractures

c. pyogenic infections (e.g., staph aureus or salmonella)

d. granulomatous (TB or fungal)- called “Pott disease” when associated with TB

e. Diabetes—due to poor circulation in the extremities-if chronic can form a drainage site and can even become osteosarcoma

52

What is osteoarthritis?

a. Loss of articular cartilage with secondary changes in bone

b. Presents in some degree in most persons >65 years of age. Symptoms worsen with excessive use.

c. Due to wear and tear

d. No inflammatory changes

53

What is rheumatoid arthritis?

a. Autoimmune- 1% prevalence

b. Most common in Caucasians/ uncommon in Asians

c. Onset age: 25-50 yrs.-75% female/ can have juvenile RA

d. Joint swelling, pain and tenderness—often cause extreme distortions of joints and surrounding bone—deforming and debilitating

e. Other areas also affected: • Ulcers • Pulmonary nodules and fibrosis • Carditis and pericarditis • Vasculitis

54

What are the "other" inflammatory arthritides?

a. Psoriatic (psorias) arthritis

b. Other autoimmune diseases (e.g., lupus [erythematosus], scleroderma)

c. Postinfections (e.g., rheumatic fever)

d. Infectious—staph/strep, TB

e. Gout (crystallized uric acid)

f. Lyme disease, if not treated—arthritis and neurological consequences

55

What are the characteristics of gout?

a. Primary cause by reduced renal excretion of purine

b. A primary treatment is with allopurinol—decreases the synthesis of purines

c. Symptoms:

• Hot, swollen, pain in joints---progressive joint destruction—gouty tophi (crystalized aggregates of uric acid)

d. Pseudo-gout—crystal deposits of calcium pyrophosphate

56

What are ganglion cysts?

Ganglion cysts—a cyst resulting from connective tissue around joints—often painful

57

What are the main cell types of skin?

• Cell types include: squamous cells, basal cells, melanocytes

58

What are the main appendages of skin?

• Appendages include: apocrine (sweat milky with odors-located near hair follicles), eccrine (found widely distributed, and sweat is watery for thermo control), sebaceous (also located near hair follicles—secrets oily sebum for lubrication and to prevent water loss).

59

What are the various skin definitions? (macule, papule, etc)

• Macule- flat, circumscribed (5 mm)

• Plaque-elevated flat-topped lesion (> 5mm)

• Lichenfication-thickened skin due to repeated rubbing

• Pustule-discrete, pus-filled raised lesion

• Scale-dry, plate-like excrescence, imperfect cornification

• Vesicle-fluid filled raised area, 5 mm

• Dyskeratosis—abnormal keratization, deeper in epidermis

• Hyperkeratosis—hyperplasia of stratum cornum

• Spongiosis-intercellular edema of epidermis

60

What are the four main acute inflammatory diseases?

1. Urticaria (hives)

2. Eczematous dermatitis

3. Allergic contact dermatitis

4. Erythema multiforma

61

What are the characteristics behind the four main acute inflammatory skin diseases?

• urticaria (hives), hypersensitivity mediated by antigens (e.g., pollen, food, drugs; mediated by IgE)

• eczematous dermatitis (e.g, contact dermatitis most common, delayed hypersensitivity reaction, can be pruritic, edematous or oozing plaques/vesicles),

• Allergic contact dermatitis—cellular memory of the reaction so that future contacts cause an increased dermatitis reaction

• Erythema multiforma (hypersensitivity to infections and drugs-dermal edema-can have blisters and necrosis)-wide range of expressions and severity -can be severe life-threatening reaction known as Stevens-Johnson Syndrome—generalized all over the body—reaction to medicines (e.g., sulfonamides, salicylates)—can also be a reaction to infections such as herpes virus or fungal infections

62

What are the two main chronic inflammatory skin diseases?

1. Psoriasis

2. Lichen Planus

63

What are the characteristics behind the two main chronic inflammatory skin diseases?

• psoriasis, inciting antigen—auto-rejection or environmentally induced -1-2% in US -can be accompanied by increased heart attacks and arthritis -treatment includes NSAIDS and immunosuppressant drugs -well-marked by pink to salmon colored plaques -regular acanthosis in epidermis

• lichen planus; -middle age -extremities and oral cavity -lace-like white markings. -resolve after 1-2 years although often persists in oral cavity Hyperkerotosis, and epidermal hyperplasia -Unknown inciting mechanisms

64

What are the characteristics behind bacterial, viral, and fungal infections dermatosis?

- bacterial (e.g., impetigo: staph and strep infections superficial) on face and extremities, contagious through contact, --primarily kids; honey color crust-pustules

-fungal (tinea [ring worm] or candida); often infections in immunocompromised patients

-viral (wart pathology-human papillomavirus-HPV; verrucae); contagious by direct contact; can auto-innoculate and spread/epidermal hyperplasia, papillo mitosis

• Bulbous blistering prominent feature: pemphigus (painful flaccid blister like-deep erosions and crust after rupture-hypersensitivity reaction), dermatitis herpetiformis-use immunosuppressive treatment -tend to be auto-immune responses

65

What are the characteristics of herpes simplex, varicella zoster?

• Oral expression: HSV 1 (cold sores) Genital: HSV 2

• Expressions: -group vesicles—epidermal acantholysis—vesicles—sloughing

• Zoster: -dermatomal distribution (can get trigeminal nerve involvement and can be very dangerous spreading to surrounding tissue such as eye or brain) - Varicella Zoster Virus (VZV) can cause shingles usually later in life in those who experienced chicken pox (i.e., exposed to the VZV when young)

• Unilateral, dermatomal distribution

• Expresses as a band of rash that often itches, burns or throbs. It may persist for weeks to months. Usually is relieved by anti-inflammatories or opioid analgesics

• In extreme cases it becomes like an intense neuralgia and does not respond to traditional analgesics

• Not contagious, typically does not repeat, but can in some cases.

66

What are the three expressions of acne?

• Opened comodones (blackheads)

• Closed comodones (white heads)

• Cysts, pustules and abscesses

67

What are the characteristics of acne vulgaris?

• Hormone changes (i.e., sex hormones)-increases testosterone influence

• Blocks hair follicle and sebaceous gland

• Hair follicle have proliferation of lining cells and cellular sloughing—forms a cellular plug and traps bacteria, cellular debris and sebum

• Gland ruptures and contents spreads to form cysts, abscesses and scarring—area is inflamed and swollen

• Treatments: -antibiotics -keratolytics -drying agents -vitamin A (topical and systemic-Accutane)

68

What are the characteristics of perioral dermatitis?

• Young women

• Long-term steroid use or cosmetic use

• Follicular papules, vesicles and pustules

69

What is the main neoplastic benign skin disease?

• Seborrhea keratosis (elderly, middle age-coin-like plaques;stuck-on appearance, tan to dark brown-granular surface)

70

What are the characteristics of the three main malignant skin diseases?

Malignant (most are UV-induced especially in fair skinned persons)-most common cancers

• Basal cell-most common, least aggressive/ most common malignancy worldwide. Slow growing. -remove with local incision—does not metastasize

• Squamous cell- next most common, intermediate aggression, no metastasis -red scaling plaques—locally aggressive

• Melanoma- least likely, typically aggressive and metastasizes -warnings: rapid enlargement of nevus; new pigmented lesion-not from pre-existing nevi; irregular borders; irregular surface and colors -caused by UV exposure and genetics -prognosis: poor if metastasized (common sites are lungs, liver and brain)

• High mitotic rate, lack of immune response to slow spread especially once it hits lymph nodes

71

What types of diseases or conditions can chronic inflammation lead to?

• Cancers

• Pulmonary diseases

• Cardiovascular diseases

• Diabetes

• Alzheimer’s disease

• Oral diseases (periodontal tissues)

• Neurological disease

• Arthritis

72

What are the characteristics of NSAIDS?

• Decrease pain and inflammation

• Cox I (GI, bleeding and kidney side effects) and Cox II (MI and stroke and hypertension side effects) inhibitors

• Aspirin, ibuprofen, naproxen are non-selective COX I and II inhibitors

• Celecoxib is COX II inhibiton

Side Effects

  • (a) CNS-tinnitis
  • (b) CVS-hypertension
  • (c) GI-nausea, ulcers or bleeding
  • (d) Hepatic-altered liver functions
  • (e) Pulmonary-asthma
  • (f) Skin-rashes
  • (g) Renal- insufficiency, in extreme can have failure

73

What are the characteristics of glucocorticoids?

• Rapidly acting

• Dramatic effect on inflammation and slowing bone erosions in rheumatoid arthritis

• Side effect: loss of muscle mass, osteoporosis, diabetogenesis, peptic ulcers, round face, buffalo hump

• Drugs: -dexamethasone: long-acting -cortisone, prednisone: short- to medium-acting

74

What are the characteristics of DMARDS?

DMARDS (Disease modifying anti-rheumatic drugs) and other Immunosuppressants

• E.g., methotrexate, sulfasalazine

• Decrease inflammation and slow bone damage in rheumatoid arthritis

• Potentially more toxic than other options -severe hepatotoxicity -stomatitis -immunosuppression

75

Salicylic Acid

Is a keratolytic used for acne vulgaris. Topical keratolytics-removes keratin layer and opens sebaceous glands (also used as wart removers). has been extensively used in dermatologic therapy . Salicylic acid works as a keratolytic, comedolytic, and bacteriostatic agent, causing the cells of the epidermis to shed more readily, opening clogged pores and neutralizing bacteria within, preventing pores from clogging up again by constricting pore diameter, and allowing room for new cell growth.

76

Benzoyl Peroxide

Is a keratolytic used for acne vulgaris. Topical keratolytics-removes keratin layer and opens sebaceous glands (also used as wart removers). containing preparations also work as peeling agents to increases skin turnover, clearing pores (comedolytic) and reducing the bacterial count (P. acnes) as well as acting directly as an antimicrobial.

77

Erythromycin

Antibiotic used for acne. macrolide antibiotic used to treat P. acnes.; antibiotic resistant strains are an ongoing complication of macrolides, especially when exposed to staphylococci.

– Broad spectrum, generally well-tolerated

– Local adverse effects include burning sensation, drying, & irritation.

78

Clindamycin

Antibiotic used for acne. antiribosomal antibiotic useful against gram positive and anaerobic bacteria; only ~10% absorbed topically.

– Common side effects include GI upset and diarrhea. Rarely bloody diarrhea and colitis have been reported, even with topical application.

79

Metronidazole

Antibiotic used for acne. nitroimidazole antibiotic for anaerobic bacterial & parasitic infections and the inhibition of Demadex brevis (parasitic mites)

– Demodex mites are ~3x more prevalent in acne vulgaris paDents than in healthy controls.

– Anti-inflammatory effect (inhibits neutrophils)

– Common adverse effects include local dryness, burning and stinging.

– Contraindicated during pregnancy, in nursing mothers, or in children due to risk of carcinogenesis.

80

Dapsone

Antibiotic used for acne. 5% gel, sulfone antibiotic for Acne vulgaris, antibacterial mechanism unclear, anti-inflammatory effects.

– Should not be used orally in patients with glucose-6-phosohatedehydrogenase(G6PD) deficiency due to risk of hemolysis, but risk is minimal with topical preparaDons.

– Adverse effects include Dryness, redness, skin peeling.

– Dapsone + benzoyl peroxide may temporarily discolor skin and hair yellow.

81

Tretinoin

Retinoid (vitamin A) used for acne. Tretinoin (Retin-A) topical retinoid cream available at 0.025%, 0.05% and 0.1% concentrations.

• promotes epithelial cell turnover, causing the extrusion of the plugged material from the follicle and preventing the formation of new comedones

• may cause dryness and increased sensitivity to sunlight, redness, scaling, itching, and burning.

82

Isotretinoin

Retinoid (Vitamin A) used for acne. Isotretinoin (Accutane) – oral retinoid used for severe cystic acne and acne that has not responded to other treatments.

• Considered the only true “cure” for acne. It also reduces the amount of oil secreted by glands in the skin.

• Isotretinoin has been associated with bowel diseases (Crohn’s disease), liver damage, depression, teratogenicity and miscarriage.

• contraindicated during pregnancy as they have been shown to cause CNS, craniofacial, cardiovascular and other birth defects.

– At least two negative pregnancy tests are required and either signed statement of abstinence (iPledge contract) or confirmation of 2 forms of contraception is required to obtain a prescription.

83

Tetracyclines

Antibiotics for Acne Vulgaris. Minocycline is more lipophilic (may accumulate in sebaceous gland).

• Chelated by dairy products, calcium, and magnesium so passes though gut without absorbtion with wrong foods/drinks.

• has higher incidence of inner ear disturbances with associated dizziness, ataxia, vertigo and Tinnitus (especially in women), and is more expensive than doxycycline.

• Doxycycline may be associated with more GI upset than minocycline.

– Harder to chelate thus beNer absorbed with food.

– All tetracycline antibiotics are associated with increased risk of irritable bowel syndrome.

– If tetracyclines aren’t tolerated or effective, then 3rd line opDon is trimethaprim or trimethaprim-sulfamethoxazole (TMP-SMZ). - Category D pregnancy Risk

84

What are the non-drug treatments of Acne?

Diet therapy: avoidance of fatty “junk foods”.

• UV Phototherapy- P. acnes bacteria produce a natural byproduct of metabolism called porphyrins. Porphyrins are light sensitive and thus vulnerable to UV and narrow band visible blue light.

85

What do muscle relaxants do and when are they primarily used?

They enhance levels of inhibition, usually via CNS (GABA-mediated). Uses include Surgical relaxation – esp., intra-abdominal & intrathoracic surgery

• Endotracheal intubation – relaxes pharyngeal and laryngeal muscles

• Control of Ventilation – reduce chest wall resistance during intubation

• Anticonvulsant – relax the motor manifestations of status epilepticus or motor seizures due to local anesthetic toxicity.

86

What are the three types of therapeutic groups for muscle relaxants?

1. Spasmolytics (reduce spasticity by modifying the stretch reflex arc and/ or interfering directly with excitation-contraction coupling of the skeletal muscles. (Diazepam, Baclofen, Tizanidine, Dantrolene)

2. Non-depolarizing blocking (produce muscle paralysis by either nondepolarizing blockade (d-tubocurarine))

3. Depolarizing blocking (paradoxical depolarizing blockade (desensitization) (succinylcholine) of the ganglionic nicotinic ACh receptor)

87

Dantrolene

-An anti-spasmotic that is used as a muscle relaxant. is a postsynaptic muscle relaxant that lessen excitation-contraction coupling in muscle cells by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores by antagonizing ryanodine receptors.

-It is the primary drug used for the treatment and prevention of malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia.

-Its direct effect is peripheral only.

88

Diazepam

An anti-spasmotic used as a muscle relaxant. Diazepam -Facilitates (Increases frequency of opening) GABAA receptor; central acting -Increased interneuron inhibition; central sedation -Spasms related to CP, stroke, spinal cord injury, acute muscle injury =Hepatic metabolism; 12-24h duraDon; sedaDon, depression, suppression of REM sleep

89

Balcofen

An anti-spasmotic used as a muscle relaxant. GABA B agonist. -GABAB agonist; central acting -Pre- and post- synaptic inhibition of motor output -Severe spasticity due to CP, MS, stroke -p.o., i.t.; sedation, weakness

90

Tizanidine

An anti-spasmotic used as a muscle relaxant.

-Alpha2 adrenoreceptor agonist (spinal cord) ; central acting

-Pre- and post- synaptic inhibition of reflex motor output

-Spasms related to ALS, stroke, MS

-Renal and hepatic elimination; 3-6h duration; weakness, sedation, hypotension

91

Carisoprodol

Muscle relaxant/sedative; may have some dependence problems, works by blocking pain sensations.

92

D-tubocurarine

Is a non-depolarizing neuromuscular blocker. Blocks ganglionic nicotinic receptor.

93

How are non-depolarizing blockers reversed?

Non-depolarizing blockers are reversed by acetylcholinesterase (AChE) inhibitors, since they are competitive antagonists at the ACh receptor.

94

Succinylcholine

Depolarizing neuromuscular blocker. Blocks ganglionic nicotinic receptors by desensitizing (overstimulating?)

- fast acting, get initial twitching before paralysis

-rapid onset (30sec) but very short duration of action (5–10 min); agonist at nicotinic ACh receptors, depolarizes the muscle fiber (similar to ACh), but in a biphasic manner:

– Phase I (depolarizing phase) muscle twitches occur while depolarizing the muscle fibers.

– Phase II (desensitizing phase) aqer sufficient depolarization has occurred the muscle is no longer responsive to ACh released by the motor neurons. At this point, full neuromuscular block (paralysis) has been achieved.

• Effects are sustained under the influence of AChE inhibitor.(not reverse by administering the AChE inhibitor)

• Adverse effects: Postoperative myalgia and fatigue, arrhythmia, hyperkalemia (burn patients), increased ocular pressure, increased risk of regurgitation/aspiration (obese patients, diabetic patients).

– Rare, inheritable risk for interaction with volatile anesthetics causing malignant hyperthermia (abnormal release of Ca2+ from skeletal muscle stores.)

– Treated with dantrolene.

95

Acyclovir

-(Zovirax, Denavir ointments): most effective for herpes simples virsus (HSV-1 and HSV-2)

-cold sores on mouth and nose; less potent on Varicella-zoster virus (VZV-chickenpox--shingles).

-Requires activation by the HSV thymidine kinase enzyme.

96

Famciclovir

-Effective against VZV virus and shingles and herpes viruses. Longer acting than acyclovir

-Requires activation by the HSV thymidine kinase enzyme.

97

Foscarnet

Used for shingles and herpes. selectively inhibits viral DNA polymerase enzymes (not kinases).

-Unlike acyclovir and ganciclovir, foscarnet is not activated by viral protein kinases, making it useful in acyclovir- or ganciclovir-resistant HSV and CMV infections.

-Do not require activation by viral thymidine kinase and thus have preserved activity against acyclovir-resistant strains of HSV and VZV.

98

What is usually stronger, an ointment or a cream?

Potency is effected by the topical formulation selected, since ointments are absorbed more effectively than creams. Thus, at the same dosage, most topical preparations will be considered “stronger” (more potent) when packaged as an ointment than as a cream although patients prefer creams as they spread more easily due to higher water/oil ratio.

99

Which trimester is best for dental work during pregnancy?

2nd

100

What category drug is lidocaine?

Lidocaine (FDA Category B): most commonly used drug for dental work.  Since it crosses the placenta after administration, the amount of anesthesia administered should be minimal dose sufficient to make patient comfortable.

101

What is a sty?

It is a skin infection like a pimple on eyelid-mostly external

102

What are the main cancers of the eye and ear?

• basal and squamous cell carcinomas of eyelid—usually slow growing

• melanoma-varying colors and potentially aggressive—usually occurs in older people

103

What is glaucoma?

It is high intraocular pressure in anterior chamber: Increased pressure within eye due to increased production or decreased outflow of aqueous humor (replaced every 2 hours; supplies nutrients and removes waste). Can damage optic nerve and cause blindness.

104

What is closed-angle glaucoma?

Closed-angle glaucoma: iris fused to cornea

  • Rapid closure of drainage canals
  • Symptoms typically noticeable
  • Surgery usually necessary

105

What is open-angle glaucoma?

Open-angle glaucoma: wide space between iris and cornea

• most common-90%

• slow clogging of drainage canals

• symptoms subtle and often undetected

• 3 million cases in US

• African Americans especially vulnerable

• Increased risk with diabetes and HP

106

What does a gonioscopy do?

It measures the anterior chamber angle in the eye

107

What does tonometry measure?

It measures intraocular pressure

108

Pilocarpine

Treats glaucoma. Cholinomimetic-contract ciliary muscle and increases outflow of aqueous humor. ACh1 agonist.

109

Timolol

Treats glaucoma. Beta blocker-decreases aqueous humor secretion (popular for open angle glaucoma).

110

Epinephrine

Alpha-agonist non-selective that can help treat glaucoma.

111

Lantanoprost

Treats glaucoma. Prostaglandin-increase outflow of aqueous humor (popular for Open angle glaucoma).

112

Which types of drugs or stimulants worsen glaucoma?

Anticholinergics and stimulants (amphetamines)

113

Acetazolamide

Helps treat glaucoma. Carbonic anhydrase inhibitor. Reduces aqueous humor secretion.

114

What is a cataract?

Opacification of the lens

115

What are the main causes and treatment of cataracts?

• Causes include: -diabetes -UV exposure -aging

• Treatment is typically surgical removal

116

What are the characteristics of diabetic retinopathy?

-associated with hemorrhaging and ischemic spots (expressed as cottonwool spots)

-hypertension causes similar retinopathies as diabetes

117

What are the characteristics of age-related macular degeneration?

• >10% of patients > 80 years old

• Most common cause of severe loss of sight in 60+ pts.

• Almost never occurs in individuals > 50 years of age

  • Smoking is a risk factor
  • Associated with gene polymorphisms, smoking, cardiovascular disease
  • Loss of central vision
  • Progress of disease faster in wet (hemorrhage and fluid present) than dry (large majority) macular degeneration
  • Pharmacological options minimal; some evidence that antioxidants (e.g., vit. C or zinc oxide may help reduce development, but benefit is minimal) for wet AMD. No treatment for dry AMD.
  • Treatment: monoclonal Ab (anti-angiogenic Ab)- e.g., bevacizumab (Avestatin)

-inject into vitreous humor; 1-2x/ month, for wet AMD

118

What is retinal detachment?

• Usually a retinal tear resulting from trauma

119

What is a retinoblastoma?

It is the most common tumor in children

120

Why is the ear often involved in referred pain associated with the mouth and dental structures?

Because both are innervated by the trigeminal complex

121

What are the characteristics of Meniere disease?

a. Symptoms: vertigo, hearing loss, nausea, sometimes migraine headaches, hearing loss, swimming feeling, tinnitus, balance problems

b. Pathology: endolymphatic hydrops—swelling/excess fluid in labyrinth • Risks- • Improper inner ear fluid drainage • Allergies • Viral infections • Head trauma • Migraines

c. Diagnostic tests: • Hearing and balance assessments

d. Some surgical interventions, but extreme

122

Meclizine

Treats Meniere disease. H1 blocker, anticholinergic, CNS depressant-antimotion sickness medication, causes xerostomia.

123

Diazepam

Treats Meniere disease. It is an anxiolytic.

124

Promethazine

Treats Meniere disease. H1 blocker, anticholinergic, antinausea and motion sickness, xerostomia.

125

Hydrochlorothiazide

Treats Meniere disease. Diuretic-regulate fluid volume and pressure in inner ear.

126

Dexamethasone

Treats Meniere disease. Long-acting steroid/inject into the ear—it reduces fluid.

127

What are the characteristics of Otitis Media?

• Typically associated with blockage of the Eustachian tube

• Often associated with infections by strep. Pneum. Or Haemophilus influe.

a. Symptoms: pain, ear discharge, headache, hearing loss, tinnitus, vertigo, immobile eardrum (swollen and inflamed), fever

128

Amoxicillin or Amoxicillin + Clavulanate or Cefaclor

Antibiotics used to treat acute otitis media. Second level drugs include Trimethoprim or macrolides.

129

What is the 2nd leading cause of death in the US?

Cancers

130

What causes cancers?

• Caused by accumulation of DNA mutations in cells acquired spontaneously or induced-usually multiple mutations

131

What are the five main properties of cancer?

• Non-responsive to normal physiologic cues

• Lack of response to growth inhibitory signals

• Avoid normal cell cycle mediated death

• Develops own angiogenesis

• Evades immune detection

132

What are the characteristics of neoplasms and what are the main ones?

1. Uncontrolled growth of cells, progeny of a single cell

2. Names usually end in –oma

3. Benign epithelial tumor is adenoma (if glandular), a papilloma (if papillary)

4. Malignant tumor (metastasizes)

• Epithelial= carcinoma

• Mesenchymal= sarcoma

• Lymphoid= lymphoma

• Melanocytic tumor=melanoma

• Hematopoietic= leukemia

 

• Squamous cell carcinomas

• Adenosarcomas-grandular epithelium

• Lipoma-benign

• Liposarcoma-malignant

• Osteosarcoma-malignant bone cancer

• Rhabdomyosarcoma-malignant skeletal muscles, usually kids

• Rhabdomyoma-benign

• Leiomyosarcoma-malignant tumor of smooth muscle

• Leiomyoma- benign tumor

133

What are the three main non-neoplastic tumors?

• Granulomas are an inflammatory mass-not a neoplasm

• Hemartoma: mal-developed tissue native to site (e.g., nodular tongue)

• Choristoma: mal-developed tissue in other organs

134

What is the leading cause of cancer death in the US?

Lung cancer, followed by prostate in men and breast in females.

135

What is the most common cause of sporadic cancers?

Environment. Just a subset are hereditary.

136

What are solid tumor mutation panels used for?

They are next generation sequencing used for solid tumor tissue and assessed for multiple potential targets for therapeutic responses, can sometimes predict prognosis.

137

What are the chromosomal changes associated with cancers?

• Deletions

• Translocations

• Duplications

• Amplifications

• Abnormal number of chromosomes

138

What strategies are used to detect chromosomal abnormalities?

PCR, microarrays, really just cytogenetics is used to look for these abnormalities. For example, there is a 9:22 translocation on chromosome 22, called the Philadelphia chromosome, that leads to chronic myelocytic leukemia.

139

What must a malignant tumor do to grow?

• Develop a signal to proliferate

• Avoid apoptosis

• Invade stroma (if carcinoma)

• Metastasize

• Induce angiogenesis

• Alter DNA in order to allow continued mitosis (normally cells stop dividing after 15X doubling)

• Develop telomerase to prevent cellular senescence

140

What are the main genetic targets for tumors?

• Oncogenes (promote proliferation)-e.g. growth factors or corresponding receptors

• Tumor suppressor genes (inhibit tumor growth-e.g., BRCA-1 and BRCA-2 (breast and ovary)

• P53 gene is most common suppressor gene mutation (lost in 50% of malignancies)

• WT-1 gene- regulates apoptosis such as in Wilms tumor

• APC-adenomatous polyposis coli-tumors in bowel and pancreas

• Apoptosis regulating genes (P53 gene also affects apoptosis)

• DNA repair genes

• Mismatched repair genes- e.g., HNPCC gene (hereditary nonpolyposis colon cancer)

• Angioneogenesis (tumors release vascular endothelial growth factor)

• Develop properties for invasiveness

141

Which type of cells do most chemotherapies target?

Proliferating cells. Consequently, good for killing fast growing tumors, not so good for slow or non-growing tumor cells. Injure rapidly proliferating normal cells such as bone marrow, intestinal mucosa, hair.

142

Metastatic patterns are almost identical between tumors. True or False?

False. They vary due to varying growth factors.

143

What are the main causes of cancer?

• Mutation (e.g., chemical carcinogens-alkylating agents or nitrosamines in food, UV light-skin cancers, radiation)-

• Ames test measures if a chemical alters genetic changes in bacteria and would be a carcinogen

• Tumor viruses • HPV-human papilloma virus-carcinoma of cervix and oropharyngeal

• Epstein-Barr: mononucleosis

• Hep B & C viruses: hepatocellular carcinoma

• HHV 8 herpes virus- Kaposi sarcoma (often linked with AIDS)

• Bacteria and inflammation (H. pylori [gastric adenocarcinoma], and asbestosis)

• Chemical carcinogens

• Reactive chemical (e.g., free radicals) alter DNA

• Alkylating agents—some of which are used to tx cancer

• Polycarbon aromatics: e.g., benzopyrene in smoke and cooked meat

• Aflatoxin- fungus on peanuts and other foods- not so much in US

• Nitrosamine/nitates in foods

• Metal ions: nickel, arsenic

• Hormonal activation (sex hormones)

• Lack of immune responses (i.e., immunocompromised) - altered host response to tumor can interfere with natural defense mechanisms -immunosuppressed children have 200X increased risk for cancer

• Genetic predisposition

• Variation in hepatic susceptibility of CYP1A1 and glutathione activity

• Radiation: -skin cancer caused by UV rays

• X-rays/gamma radiation -leukemias -papillary thyroid and breast cancers

144

What is the ames test?

• Ames test measures if a chemical alters genetic changes in bacteria and would be a carcinogen

145

What are the four main ways that cancers actually kill?

a. Growth and metastasis

b. Involve vital organs

c. Get a flood of cytokines that shut down organ functions

d. Cachexia

146

What are the characteristics of carcinoid syndrome?

• Metastasis of intestinal carcinoid

• Flushing and diarrhea

• Right heart fibrosis

147

What are the characteristics of carcinoma, and what are its subsets?

Carcinoma—epithelium/endothelium • Most common type of malignancy

a. Most often metastasizes to regional lymph nodes, but can spread through blood-dependent on type

b. Squamous cell Carcinoma • similar appearance regardless of primary site • usually slow growing in the skin • associated with lips or lung more dangerous • can form keratin whirls

c. Adenocarcinoma (eg, colon or breast adenocarcinoma) • forms glands • tumors of cuboidal or columnar cells • types include: ➢ colon ➢ prostate-fairly innocuous looking ➢ breast-many positive for estrogen receptors ➢ lung-small cell carcinomas are aggressive with poor prognosis -large cell carcinomas are slower with better prognosis

d. neuroendocrine tumors-carcinoids of GI tract and lung

148

What are the characteristics of mesenchymal (sarcomas) tumors?

➢ sarcomas-Kaposi’s sarcoma [linked with AIDS],

➢ angiosarcoma, malignant tumor of endothelial tissue (vessels); can result from radiation therapy

➢ chondrosarcoma-malignant tumor of cartilage (chondrocytes).

➢ osteosarcoma,

➢ leiomyosarcoma (vs. benign leiomyoma) - malignant tumor of smooth muscle

➢ liposarcoma

• Pushing, rather than an invasive cancer

149

What are the characteristics of lymphomas?

➢ Hodgkins lymphoma -younger patients -usually good prognosis -sometimes characterized by Reed Sternberg cells (large, multinucleated B lymphocytes)

➢ Non-Hodgkin’s lymphoma -various levels of aggressiveness/sometimes poor prognosis - Burkitt’s Lymphoma- a type of non-Hodgkin’s lymphoma; very aggressive from B lymphocytes. Prognosis can be poor.

150

What is the definition of incidence when referring to cancer terms?

• Incidence: newly diagnosed cases/time

151

What is the definition of mortality when referring to cancer terms?

• Mortality: death/time period

152

What is the definition of prevalence when referring to cancer terms?

• Prevalence: # new and pre-existing cases at one moment

153

How does grading of tumors work and what are the four main serological tests and when are they used?

• TNM grading -T, size and extent of primary tumor -N, presence and number of lymph node metastases -M, presence of distant mestatses

• Serological tests- most useful for assessing cancer recurrence after treatment -PSA: prostate specific antigen -CBA: carcinoembryonic antigen-colon carcinoma -CA-125: serous ovarian carcinoma -HCG: choriocarcinoma

154

Which country has a 7X increase of gastric cancer compared to US?

Japanese

155

What is the most common type of carcinoma in Africa?

Liver cell carcinoma most common in Africa due to link with viral hepatitis.

156

Where in the world is breast cancer most common?

Breast cancer more common in US and Europe than in other countries

157

What gene is linked to familial adenomatous polyposis/colon cancer?

APC gene

158

What genes are linked to some breast and ovarian cancers?

BRCA 1 & 2 genes

159

What are the three main types of treatment for cancer?

a. Surgical removal

b. Radiation therapy-maximize exposure of tumor and minimize exposure of normal tissue

c. Chemotherapy

  • • most damage to rapidly proliferating cells
  • • treats whole body
  • • tumor can develop resistance
  • • often multiple drugs required
  • • can cause cancer later

160

What percentage of patients are usually cured with local treatment like surgery or radiotherapy? When are chemotherapy and anticancer drugs used?

1. 1/3 patients cured with local treatment (surgery, radiotherapy)

2. Chemotherapy used for advanced disease or as an adjuvant (administered after primary treatment (e.g., surgery or radiation) to prevent secondary tumor development or spread)

3. Anticancer drugs usually exert action on cells in cell cycle

4. Typically requires combination of drugs: Combine chemo/radiation tx in locally advanced disease

5. Need maximal cell kill within the range of toxicity tolerated by host

6. Adjust scheduling and overlapping toxicities to protect the patient.

161

What is the mutation that occurs in up to 50% of all human tumors?

• P53 is a mutation that occurs in up to 50% of all human tumors-leads to resistance to radiation therapy and anticancer agents

162

Imatinib

Cancer treatment strategy. Tyrosine hydroxylase inhibitor used for multiple types of cancers such as myelogenous leukemia.

163

Erlotinib

Cancer treatment strategy. Blocks ECGR (epidermal growth factor receptor): treatment, non-small cell lung and pancreatic cancer.

164

For which types of cancers are hormones commonly used to treat?

Hormones for breast and prostate cancers

165

What does retinoic acid sometimes help out with?

• Retinoic acid-induced differentiation of some leukemias (e.g., promyelocytic leukemia)

166

Usually single drugs at clinically tolerable doses are able to cure cancer alone. True or False?

False. Need a combination.

167

What are the principles of optimal scheduling with anti-cancer drugs?

• Design optimal scheduling-e.g., maintain constant intervals with treatment free interval as short as possible, while allowing most sensitive tissue adequate time to recover (e.g., bone marrow).

168

Which type of cancer often exhibits resistance on initial exposure?

• Melanoma: exhibits primary resistance on initial exposure (lack of tumor response)-need multiple exposures to treatment to get response of tumor

• Sometimes tumor acquires resistance during treatment

169

Cyclophosphamide

Treats cancer, is an alkylating agent.

1. E.g, Cyclophosphamide • Hodgkin’s lymphoma • Multiple myeloma • Leukemia • Breast cancer

2. Mechanism: Transfer their alkyl groups to various cell constituents such as DNA, alkylation of DNA in nucleus—cause miscoding—can break DNA strands

3. Resistance: increased capacity to repair damaged DNA

4. Adverse effects: • Nausea, vomiting • Damage to rapidly growing tissues (bone marrow, G.I. tract, reproductive tissue) • Carcinogenic in nature (increases risk of secondary cancer)

170

Procarbazine

Treats cancer, is a nitrosourea. Used for combination regimens for Hodgkin's Lymphoma. Passes blood brain barrier and used to treat brain tumors.

171

Cisplatin

Treats cancer, is a platinum analog. Used for broad range of solid tumors. Is nephrotoxic.

172

Methyltrexate

Treats cancer, is an antimetabolite, anti-inflammatory.

1. Acts on intermediary metabolism of proliferating cells

2. E.g., methyltrexate-folic acid analog

• Inhibits tetrahydrofolate--Interferes with formation of DNA, key proteins

• Treats head and neck cancers, breast cancer

• Toxicity: mucositis, diarrhea

173

Fluorouracil

Treats cancer.

1.Inhibits thymidine synthase, decreases NDA synthase and decreases DNA synthesis and function

2. treats: colorectal, anal, breast, head  neck, and hepatocellular cancers

174

Vinblastine or Vincristine

Is a natural product cancer, chemotherapy drug.

2. Inhibits tubulin polymerization-cytoskeleton component—arrests in cell division and causes cell death

3. Toxicity: mucositis, myelosuppression

4. Treat: breast cancer and Kaposi’s lymphoma

175

Doxorubicin

Is an antitumor antibiotic, in the class of anthracyclines, that treat breast cancer.

• Mechanism: formation of free radicals that bind to DNA, causing breaks

• Treat: lymphomas, breast cancer and thyroid cancer

• Toxicity: nausea and red (not blood) urine

176

Bleomycin

Is an antitumor antibiotic, in the class of anthracyclines, that treat breast cancer.

• Mechanism: formation of free radicals that bind to DNA, causing breaks

• Treat: lymphomas, breast cancer and thyroid cancer

• Toxicity: nausea and red (not blood) urine

177

What is the most common cancer in children?

Acute Lymphoblast Leukemia (ALL)

178

What is the most common acute form of leukemia in adults?

Acute Myelogenous Leukemia (AML). Cytarabine is the most single active agent.

179

What are the characteristics of Hodgkin's Lymphoma?

• Hodgkin’s lymphoma much better controlled today

• B-cell neoplasm (Reed-Sternberg cell)

• EBV virus found in ~80%

• Tx: anthracycline, doxorubicin, bleomycin, vinblastine

180

What are the characteristics of Multiple Myeloma?

1. Plasma cell malignancy, primarily in bone marrow

2. Symptoms: • Bone pain • Fractures • Anemia

• Tx: alkylating agent; prednisone

181

What are the stages of breast cancer?

• Stage I: small, primary tumor --surgery alone is an 80% cure

• Stage II: positive node; post-operative use of chemo (e.g., 6 cycles of cyclophosphamide, methotrexate and fluorouracil).

• Stage III-IV: a major challenge

• Breast cancer-much more effective resolution due to early treatments

182

What are the characteristics of prostate cancer?

• 1 in 8 men, Elevates PSA and acid phosphatase

• Treat by eliminating testosterone production through surgical castration

• LH-releasing hormone agonists

183

What are the characteristics of gastrointestinal cancer?

• Colorectal cancer most common GI malignancy

• Tx: 5-fluorouracil (40-50% response rates)

184

What are the characteristics of secondary malignancies?

• Late complication of alkylating agents

• Most frequent is acute myelogenous leukemia—observed as early as 2-4 years after; also see Non-Hodgkin’s lymphoma and bladder cancer

185

What is chemical esophagitis, and what are some examples?

Irritants to squamous mucosa.

• corrosives, smoking, alcohol, chemotherapy. Acute inflammation and possible ulceration.

186

What is infectious esophagitis?

Usually immunosuppressed (often Herpes, Candida, and cytomegalovirus [CMV])

• Often ulcers

• CMV:

  • • Affects entire GI tract
  • • Neonates acquire thru birth canal or infected breast milk
  • • Adults acquire through sexual transmission or needles
  • • Multiple discrete, well-circumscribed superficial ulcers.

187

How does CMV affect the GI tract?

Cytomegalovirus (CMV) affects entire GI tract-elderly or immunocompromised-multiple discrete, well-circumscribed superficial ulcers.

188

What are the characteristics of reflux esophagitis?

a. Relaxation of gastroesophageal sphincter

b. Symptoms: Burning, Excessive salivation, Choking

c. Aggravating factors: obesity, pregnancy, (decrease esophageal pressure: alcohol/tobacco, narcotics, nicotine patch) use

d. Medical treatment: antacids, H2 blockers, PPI -lose weight, stop smoking/drinking

e. lifestyle treatment: lose weight, stop smoking and drinking

f. Complications: ulceration, stricture, Barrett esophagus (long tongues of extended columns of epithelium cells into esophagus

189

What are the seven main diseases associated with the stomach?

1. Reactive (erosive gastritis) gastropathy a. Induced by: alcohol, NSAIDS, iron, Stress, bile reflux

2. Acute injury a. Acute gastritis—asymptomatic with possible significant blood loss

3. Acute peptic ulceration a. Nausea, vomiting, NSAIDs, stress

4. Chronic gastritis a. H. pylori gastritis-duodenal and pyloric ulcers; may lead to cancer b. Autoimmune gastritis

5. Peptic Ulcer Disease a. H. pylori and NSAIDs causative b. Increased acid c. Punched our ulcers-potential for perforation and hemorrhage d. Likely also involved in adenocarcinoma development

6. Polyps a. Hyperplastic, sporadic • Response to gastric injury, around ulcers

7. Gastric carcinoma • Looks like intestinal tissue, and diffuse • Some have hereditary connection

8. Autoimmune atrophic gastritis • Genetic factors • No ulcers • Decreased gastric acid • Intestinal metaplasia • Long-term effects relate to malabsorption of B12 (pernicious anemia)

190

What are the two main causes of intestinal obstruction of the small bowel, colon?

a. Usually mechanical (80%)

b. Neoplasm and infarction (20%)

191

What is irritable bowel syndrome?

• Relapsing pain, bloating, constipation/diarrhea

• Diet, abnormal motility and stress are factors

• No gross microscopic abnormalities

192

What causes self-limiting colitis?

• Caused by microorganisms such as salmonella, E. coli, shigella, clostridium

193

What is pseudomembranous colitis?

• Cells Slough Off

  • Usually caused by clostridium difficile

• Spread via person to person

• Often follows antibiotic therapy

• Most common nosocomial infection in older adults

194

What are the characteristics of the two main inflammatory bowel diseases?

a. Crohn disease: • Similar to ulcerative colitis • It skips lesion and has intermediate constrictures • Granulomas • Fistulas and perianal disease • Also affects upper GI tract • Transmural inflammation • Fistulas, perianal

• Oral manifestation: ➢ 0.5% have oral lesions ➢ Usually males ➢ Linear and deep ulcerations

b. Ulcerative colitis • More continuous especially in the colon • No transmural inflammation • No fistulas and not perianal

• Oral manifestation: ➢ Less common than in CD ➢ Usually males ➢ Edematous oral submucosa

195

What is Hirschsprung disease, and what part of the GI does it involve?

Hirschsprung disease

• Congenital defect in colonic innervation

• Failure to pass meconium The small bowel, colon.

196

What are the five main selected diarrheal diseases?

a. Celiac sprue • Immune mediated—triggered by ingestion of gluten • Malnutrition: • Fe, B12 malabsorption • Atrophic glossitis • Dental effects: enamel defects, delayed tooth eruption, recurrent aphthous ulcers, cheilosis,

b. Lymphocytic colitis • Increased intraepithelial lymphocytes

c. Irritable bowel syndrome • Relapsing pain, bloating, relapsing and alternating constipation/diarrhea • Diet, abnormal motility and stress are factors • No gross microscopic abnormalities

d. Infectious self-limiting colitis • Caused by microorganisms such as salmonella, E. coli, shigella, clostridium

e. Pseudomembranous colitis, cells slough off • Usually caused by clostridium difficile • Spread via person to person • Often follows broad spectrum antibiotic therapy • Most common nosocomial infection in older adults

197

What are the characteristics of colonic polyps?

Colonic polyps

• Hyperplastic polyps- no malignant potential

• Adenoma- precursor to adenocarcinoma

198

What are the characteristics of invasive colonic adenocarcinoma?

Invasive colonic adenocarcinoma

• Responsible for 15% of all cancer related deaths in USA

• Dietary features: increased risk with low fiber, high intake carbohydrates/fats Affects small bowel/colon

199

How amazing are you?

So amazing

200

What is Burkitt's Lymphoma?

Burkitt’s Lymphoma- a type of non-Hodgkin’s lymphoma linked to Epstein-Barr infection and can affect maxilla and mandible; very aggressive from B lymphocytes. Prognosis can be poor.

201

What does acute leukemia primarily affect?

Acute leukemia principally affects bone marrow

202

What is cholecystitis?

Cholecystitis (bile is common mechanism for excretion of toxins and drugs)

• Acute often caused by gallstones and obstruction. Can become chronic

• Cholestasis causes jaundice

203

What are the main five liver diseases?

Liver diseases-summary-these diseases can go on to cirrhosis 1. Fatty liver • Caused by ETHOH, obesity and diabetes Mel.

2. Hepatitis • Caused by virus, drug or autoimmune

3. Biliary disease

4. Metabolic disease

5. Vascular

204

What are the characteristics of the liver?

• Liver made up of hepatocytes, duct cells and blood vessels

• Organization: Portal tracts contain the triad (portal triad) of (i) bile ducts, (ii) portal veins (bring blood from gut with nutrients and recently consumed drugs), and (iii) hepatic artery from the heart. Blood goes to the sinusoids and enriches hepatocytes, then goes to central vein and drains back to the heart to be recycled. Blood from different sources mix in the sinusoids drains into the “central veins” and exits to the hepatic vein that goes to the heart

• Hepatocytes do all of the metabolic work of the liver and absorb nutrients and drugs.

• Most hepatotoxic events occur around the ‘central vein’ • Drugs are the #1 cause of liver toxicity!

• Biopsy of liver can be potentially dangerous due to major hemorrhaging

205

What are some other details about the liver?

1. Fatty (fat globules in hepatocytes) liver-steatosis • Worst destruction is fibrosis. It leads to collagen scar and permanent injury. End stage is cirrhosis • Causes—alcohol, obesity and diabetes (known as the metabolic syndrome)

2. If hepatocytes die in large sheets, the areas fill up with blood. Blood can build up due to heart failure and cause backflow around the central vein

3. If cannuliculi in liver fill with bile due to cholestasis, the person becomes jaundiced (often caused by drugs)

4. Acute more lobular, chronic is more portal with fibrosis and collagen bridges

5. Hepatitis is inflammation of liver. If caused by viruses can be contagious and dentists must be very careful with these patients • Can also be caused by toxins and drugs • Acute can often resolve itself. Chronic less likely to recover (fibrosis often a part of this) • Acute caused by Hepatitis A and E viruses (1-3 months) • Hep B and C viruses start with acute hepatitis and progress to chronic with fibrosis progressing to cirrhosis and hepatocellular carcinoma: tend to be the more severe

206

What are the characteristics of Hepatitis A?

Source: Feces

Route of Transmission: Fecal/oral

Chronic Infection: No

Prevention: pre/post exposure, immunization

207

What are the characteristics of Hepatitis B?

Source: blood body fluids

Route of Transmission: Percutaneous, permucosal

Chronic Infection: Yes

Prevention: pre/post exposure, immunization

  • Heb B virus, 2 billion chronically exposed in world, 350 infected. 15-25% of infected will go into chronic phase and most will die from complications. Can lead to cancer of liver (hepatocarcinoma) -important to get vaccinated.
  • • Caused by DNA virus
  • • Cirrhosis (chronic phase)= portal hypertension; causes ascites 85% of time in chronic phase with cirrhosis

208

What are the characteristics of Hepatitis C?

Source: blood body fluids

Route of Transmission: Percutaneous, permucosal

Chronic Infection: Yes

Prevention: blood screening, risk behavior modification 6. Hep C virus found in >170 million carriers worldwide • Acute phase usually asymptomatic and not diagnosed • Chronic phase, Ab present at 5-20 weeks • 60% related to parenteral exposure • Caused by RNA virus • Can lead to hepatocarcinoma • No vaccines

209

What are the characteristics of Hepatitis D?

Source: blood body fluids

Route of Transmission: Percutaneous, permucosal

Chronic Infection: Yes

Prevention: pre/post exposure immunization, blood screening, risk behavior modification

210

What are the characteristics of Hepatitis E?

Source: feces

Route of Transmission: fecal/oral

Chronic Infection: oral

Prevention: ensure safe drinking water

211

What are the characteristics of autoimmune hepatitis?

Autoimmune hepatitis unusual- found in obese females predominantly

• Rapid response to steroids

• 80% have extensive fibrosis

212

Fatty liver disease is an inflammatory disease. True or False?

False. It is not.

• Caused by ETOH, obesity, diabetes mellitus etc.

213

What are the metabolic diseases of the liver often associated with?

Metabolic disease:

• Often associated with iron overloads

• Wilson’s disease: copper metabolic defect goes to hepatitis then cirrhosis

214

How is evaluation of hepatitis severity usually performed?

Evaluation of hepatitis severity:

• Grade= degree of inflammation

• Stage= degree of fibrosis-this is the most important for prognosis-extreme if it progresses to cirrhosis that includes collagen surrounding hepatic nodules (hepatocytes)

215

What are the characteristics of hepatocellular carcinoma?

Hepatocellular carcinoma

• Most deadly cancer

• It has been increasing due to increases in the incidence of Hep B and C

216

What are the characteristics of GERD?

Gastroesophageal reflux disease (GERD) is chronic; ‘acid reflux” is acute (isolated incidents)

1. Episodes referred to as heartburn and occurs daily in 7% of population

2. Aggravating factors: empty stomach, inclined, increased age, obesity, fatty foods, caffeine/alcohol/smoking, large meals, some drugs

3. Relief: small meals, reduced fat, reduced weight, elevate head of bed, avoid aspirin/NSAIDs

4. Dental tips: • Protect teeth from erosion by gastric acids (i.e., mouth guard, neutralize acid with basic solution, don’t brush teeth after gastric juices are in mout-i.e., acidic

217

Antacids

Used for GERD. Antacids-neutralize gastric HCl

• Types: magnesium salts (can cause diarrhea); bicarbonate (causes gas); calcium carbonate (chalky and constipation); aluminum salts (not very effective)

218

Cimetidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut.

• Side effects: headaches, diarrhea, drowsiness.

219

Ranitidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut.

• Side effects: headaches, diarrhea, drowsiness.

220

Famotidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut.

• Side effects: headaches, diarrhea, drowsiness.

221

Omeprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx

• Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut.

• Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers

• Often combined with H2 blockers - Can also add sodium bicarbonate for fast release.

222

Lansoprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx

• Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut.

• Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers

• Often combined with H2 blockers

223

Esomeprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx

• Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut.

• Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers

• Often combined with H2 blockers

224

What are the causes and symptoms of peptic ulcer disease?

1. Includes gastric and duodenal ulcers

a. Causes: (1) Inflammation of epithelium (2) Errosion (3) Infection by H. pylori (70-80% incidence)

b. Symptoms: • Epigastric burning, alleviated by eating or antacids • Pain worse on empty stomach and at nigh • Pain often mistaken for a heart attack and vice versa - One treatment includes suppressing acidity to heal sores (but not cure) • Antacids, PPIs, H2 blockers

225

Prevpac

Used to treat peptic ulcer disease.

Cure if H pylori-related –H pyloria is contagious especially within family members

• Prevpac; combination of lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin

226

Milk of Magnesia

Used to treat peptic ulcer disease.

Cure if H pylori-related –H pyloria is contagious especially within family members

• Prevpac; combination of lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin

• Milk of Magnesia (magnesium based) may also help kill bacteria

227

Which nutrients are absorbed in the stomach?

Water, alcohol

228

Which nutrients are absorbed in the duodenum?

Fe, Ca, Mg, Na, Fats, water, proteins, vitamins,

229

Which nutrients are absorbed in the jejunum?

carbohydrates, proteins

230

Which nutrients are absorbed in the ileum?

Bile salts, B12, Cl

231

Which nutrients are absorbed in the colon?

Water, electrolytes

232

Bisacodyl

Laxative used for constipation.

• Stimulant of smooth muscles

• Fast acting

• OTC

• Suppository/oral

• Cramps

233

Docusate

Laxative used for constipation.

• Water retention in stools, softens stools

• OTC (e.g., Dulcelax)

234

Loperamine

Treats diarrhea. Imodium; mild opioid agonist: if severe, can use strong opioid agonists

235

Bismuth subsalicylate

Treats diarrhea. Is Pepto-Bismol.

Anti-cholinergics such as atropine can also be used to treat diarrhea.

236

What are the symptoms of irritable bowel syndrome?

• No structural defect –not sure of the exact cause

• Typically episodic pain and bloating

• Could be 5HT-dependent neuromuscular disorder

• 20% of population have suffered (most common GI disorder)

• Most common in young adults and ~50 Years old—possible association with stress and poor diet

237

Linaclotide

Used for irritable bowel syndrome.

b. Treatment:

(1) Typically symptomatic (i.e., deal with diarrhea or constipation with diet and anti-stress changes)

(2) Drugs: only linaclotide (Linzess) is FDA-approved for IBS with constipation • It is a guanylate cyclase-C agonist-it increases bowel movement, fluid secretion and reduces pain

• Side effects: diarrhea, gas

238

In what percent of the population is inflammatory bowel disease found in?

Less than 1%

239

What are the symptoms of Crohn's Disease?

Crohn's is an IBS.

(1) Crohn’s disease

(a) Symptoms: • Chronic diarrheal problems • Can affect entire GI, but more intense in ileum and colon and intermittent areas with strictures between -ulcerations -swelling and scarring • Hypogastric pain • Perianal fissures/fistules • Higher incidence of arthritis • Fatty liver • Possible genetic link • Perhaps abnormal inflammatory response to normal flora • Has remission • Increase incidence of colon cancer

240

Mesalamine

Used for Crohn's disease. Is an anti-inflammatory. Corticosteroids-act systemically and Metronidazole has an antibiotic mechanism and they can also be used for Crohn's. b. Ulcerative colitis • Similar to Crohn’s disease but limited to colon and more generalized (no strictures) • Medications are similar to Crohn's disease

241

Which hepatitis virus is the most significant dental occupation hazard?

a. HBV infection most significant occupational dental hazard (vectors: blood, saliva, nasopharyngeal secretions)

b. In mouth, highest concentration is gingival sulcus

c. Manifestations (infections and bleeding based): • Lichen planus • Periodontal disease • Candidiasis • Increased oral bleeding • Increased incidence of type II diabetes • Sjogrens syndrome

242

How can you manage an HBV exposure in a dental office?

• Accidental exposure:

• Carefully wash wound-don’t rub (embeds viruses)

• Use antiviral disinfectant (e.g., iodine or chlorine formulations)

• Initiate HBV vaccine series

• Don’t be judgmental

243

Tamoxifen

Estrogen receptor antagonist. Blocks actions of estrogen in breast-used to treat breast cancers.

244

Mifepristone

Mifepristone is a synthetic, steroidal anti-progestogen and anti-glucocorticoid pharmaceutical drug. Morning after contraceptive: blocks progesterone and glucocorticoid receptors. Ends a pregnancy that is less than 7 weeks along (49 days or less since the start of your last menstrual period). Also used to control high blood sugar in patients with Cushing syndrome who also have type 2 diabetes and have failed surgery or are not candidates for surgery.

245

Danazol

Danazol is a derivative of the synthetic steroid ethisterone that suppresses the production of gonadotrophins and has some weak androgenic effects. Suppresses ovarian function (has a masculinizing effect). Treats endometriosis, fibrocystic breast disease, and hereditary angioedema.

246

Clomiphene

Clomifene or clomiphene is a selective estrogen receptor modulator that has become the most widely prescribed drug for ovulation induction to reverse anovulation or oligoovulation. Ovulation-inducing; for promoting fertilization and pregnancy (increased risk of multiple births—e.g., twins).

247

Salicylic Acid

Is a keratolytic used for acne vulgaris. Topical keratolytics-removes keratin layer and opens sebaceous glands (also used as wart removers). has been extensively used in dermatologic therapy . Salicylic acid works as a keratolytic, comedolytic, and bacteriostatic agent, causing the cells of the epidermis to shed more readily, opening clogged pores and neutralizing bacteria within, preventing pores from clogging up again by constricting pore diameter, and allowing room for new cell growth.

248

Benzoyl Peroxide

Is a keratolytic used for acne vulgaris. Topical keratolytics-removes keratin layer and opens sebaceous glands (also used as wart removers). containing preparations also work as peeling agents to increases skin turnover, clearing pores (comedolytic) and reducing the bacterial count (P. acnes) as well as acting directly as an antimicrobial.

249

Erythromycin

Antibiotic used for acne. macrolide antibiotic used to treat P. acnes.; antibiotic resistant strains are an ongoing complication of macrolides, especially when exposed to staphylococci. – Broad spectrum, generally well-tolerated – Local adverse effects include burning sensation, drying, & irritation.

250

Clindamycin

Antibiotic used for acne. antiribosomal antibiotic useful against gram positive and anaerobic bacteria; only ~10% absorbed topically. – Common side effects include GI upset and diarrhea. Rarely bloody diarrhea and coliDs have been reported, even with topical application.

251

Metronidazole

Antibiotic used for acne. nitroimidazole antibiotic for anaerobic bacterial & parasitic infections and the inhibition of Demadex brevis (parasitic mites) – Demodex mites are ~3x more prevalent in acne vulgaris paDents than in healthy controls. – AnD-inflammatory effect (inhibits neutrophils) – Commonadverseeffectsincludelocaldryness,burningandsDnging. – Contraindicatedduringpregnancy,innursingmothers,orinchildrenduetoriskof carcinogenesis.

252

Dapsone

Antibiotic used for acne. 5% gel, sulfone antibiotic for Acne vulgaris, antibacterial mechanism unclear, anti-inflammatory effects. – ShouldnotbeusedorallyinpaDentswithglucose-6-phosohatedehydrogenase(G6PD) deficiency due to risk of hemolysis, but risk is minimal with topical preparaDons. – AdverseeffectsincludeDryness,redness,skinpeeling. – Dapsone+benzoylperoxidemaytemporarilydiscolorskinandhairyellow.

253

Tretinoin

Retinoid (vitamin A) used for acne. Tretinoin (Retin-A) topical retinoid cream available at 0.025%, 0.05% and 0.1%concentrations. • promotes epithelial cell turnover, causing the extrusion of the plugged material from the follicle and preventing the formaDon of new comedones • may cause dryness & increased sensitivity to sunlight, redness, scaling, itching, and burning.

254

Isotretinoin

Retinoid (Vitamin A) used for acne. Isotretinoin (Accutane) – oral retinoid used for severe cystic acne and acne that has not responded to other treatments. • Considered the only true “cure” for acne. It also reduces the amount of oil secreted by glands in the skin. • Isotretinoin has been associated with bowel diseases (Crohn’s disease), liver damage, depression, teratogenicity and miscarriage. • contraindicated during pregnancy as they have been shown to cause CNS, craniofacial, cardiovascular and other birth defects. – At least two negative pregnancy tests are required and either signed statement of abstinence (iPledge contract) or confirmation of 2 forms of contraception is required to obtain a prescription.

255

Tetracyclines

Antibiotics for Acne Vulgaris. Minocycline is more lipophilic (may accumulate in sebaceous gland). • Chelated by dairy products, calcium, and magnesium so passes though gut without absorbtion with wrong foods/drinks. • hashigherincidenceofinnereardisturbanceswithassociated dizziness, ataxia, vertigo and Tinnitus (especially in women), and is more expensive than doxycycline. • Doxycycline may beassociated with more GI upset than minocycline. – Harder to chelate thus beNer absorbed with food. – All tetracycline antibiotics are associated with increased risk of irritable bowel syndrome. – If tetracyclines aren’t tolerated or effective, then 3rd line opDon is trimethaprim or trimethaprim-sulfamethoxazole (TMP-SMZ). - Category D pregnancy Risk

256

Dantrolene

-An anti-spasmotic that is used as a muscle relaxant. is a postsynaptic muscle relaxant that lessen excitation-contraction coupling in muscle cells by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores by antagonizing ryanodine receptors. -It is the primary drug used for the treatment and prevention of malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia. -Its direct effect is peripheral only.

257

Diazepam

An anti-spasmotic used as a muscle relaxant. Diazepam -Facilitates (Increases frequency of opening) GABAA receptor; central acting -Increased interneuron inhibition; central sedation -Spasms related to CP, stroke, spinal cord injury, acute muscle injury =Hepatic metabolism; 12-24h duraDon; sedaDon, depression, suppression of REM sleep

258

Balcofen

An anti-spasmotic used as a muscle relaxant. GABA B agonist. -GABAB agonist; central acting -Pre- & post- synaptic inhibition of motor output -Severe spasticity due to CP, MS, stroke -p.o., i.t.; sedation, weakness

259

Tizanidine

An anti-spasmotic used as a muscle relaxant. -Alpha2 adrenoreceptor agonist (spinal cord) ; central acting -Pre- & post- synaptic inhibition of reflex motor output -Spasms related to ALS, stroke, MS -Renal & hepatic elimination; 3-6h duration; weakness, sedation, hypotension

260

Carisoprodol

Muscle relaxant/sedative; may have some dependence problems, works by blocking pain sensations.

261

D-tubocurarine

Is a non-depolarizing neuromuscular blocker. Blocks ganglionic nicotinic receptor.

262

Succinylcholine

Depolarizing neuromuscular blocker. Blocks ganglionic nicotinic receptors by desensitizing (overstimulating?) - fast acting, get initial twitching before paralysis -rapid onset (30sec) but very short duration of action (5–10 min); agonist at nicotinic ACh receptors, depolarizes the muscle fiber (similar to ACh), but in a biphasic manner: – Phase I (depolarizing phase) muscle twitches occur while depolarizing the muscle fibers. – Phase II (desensitizing phase) aqer sufficient depolarization has occurred the muscle is no longer responsive to ACh released by the motor neurons. At this point, full neuromuscular block (paralysis) has been achieved. • Effects are sustained under the influence of AChE inhibitor.(not reverse by administering the AChE inhibitor) • Adverse effects: Postoperative myalgia and fatigue, arrhythmia, hyperkalemia (burn patients), increased ocular pressure, increased risk of regurgitation/aspiration (obese patients, diabetic patients). – Rare, inheritable risk for interaction with volatile anesthetics causing malignant hyperthermia (abnormal release of Ca2+ from skeletal muscle stores.) – Treated with dantrolene.

263

Acyclovir

-(Zovirax, Denavir ointments): most effective for herpes simples virsus (HSV-1 and HSV-2)-cold sores on mouth and nose; less potent on Varicella-zoster virus (VZV-chickenpox--shingles). -Requires activation by the HSV thymidine kinase enzyme.

264

Famciclovir

-Effective against VZV virus and shingles and herpes viruses. Longer acting than acyclovir -Requires activation by the HSV thymidine kinase enzyme.

265

Foscarnet

Used for shingles and herpes. selecDvely inhibits viral DNA polymerase enzymes (not kinases). -Unlike acyclovir and ganciclovir, foscarnet is not activated by viral protein kinases, making it useful in acyclovir- or ganciclovir-resistant HSV and CMV infections. -Do not require activation by viral thymidine kinase and thus have preserved activity against acyclovir-resistant strains of HSV and VZV.

266

Pilocarpine

Treats glaucoma. Cholinomimetic-contract ciliary muscle and increases outflow of aqueous humor. ACh1 agonist.

267

Timolol

Treats glaucoma. Beta blocker-decreases aqueous humor secretion (popular for open angle glaucoma).

268

Epinephrine

Alpha-agonist non-selective that can help treat glaucoma.

269

Lantanoprost

Treats glaucoma. Prostaglandin-increase outflow of aqueous humor (popular for Open angle glaucoma).

270

Acetazolamide

Helps treat glaucoma. Carbonic anhydrase inhibitor. Reduces aqueous humor secretion.

271

Meclizine

Treats Meniere disease. H1 blocker, anticholinergic, CNS depressant-antimotion sickness medication, causes xerostomia.

272

Diazepam

Treats Meniere disease. It is an anxiolytic.

273

Promethazine

Treats Meniere disease. H1 blocker, anticholinergic, antinausea and motion sickness, xerostomia.

274

Hydrochlorothiazide

Treats Meniere disease. Diuretic-regulate fluid volume and pressure in inner ear.

275

Dexamethasone

Treats Meniere disease. Long-acting steroid/inject into the ear—it reduces fluid.

276

Amoxicillin or Amoxicillin + Clavulanate or Cefaclor

Antibiotics used to treat acute otitis media. Second level drugs include Trimethoprim or macrolides.

277

Imatinib

Cancer treatment strategy. Tyrosine hydroxylase inhibitor used for multiple types of cancers such as myelogenous leukemia.

278

Erlotinib

Cancer treatment strategy. Blocks ECGR (epidermal growth factor receptor): treatment, non-small cell lung and pancreatic cancer.

279

Cyclophosphamide

Treats cancer, is an alkylating agent. 1. E.g, Cyclophosphamide • Hodgkin’s lymphoma • Multiple myeloma • Leukemia • Breast cancer 2. Mechanism: Transfer their alkyl groups to various cell constituents such as DNA, alkylation of DNA in nucleus—cause miscoding—can break DNA strands 3. Resistance: increased capacity to repair damaged DNA 4. Adverse effects: • Nausea, vomiting • Damage to rapidly growing tissues (bone marrow, G.I. tract, reproductive tissue) • Carcinogenic in nature (increases risk of secondary cancer)

280

Procarbazine

Treats cancer, is a nitrosourea. Used for combination regimens for Hodgkin's Lymphoma. Passes blood brain barrier and used to treat brain tumors.

281

Cisplatin

Treats cancer, is a platinum analog. Used for broad range of solid tumors. Is nephrotoxic.

282

Methyltrexate

Treats cancer, is an antimetabolite, anti-inflammatory. 1. Acts on intermediary metabolism of proliferating cells 2. E.g., methyltrexate-folic acid analog • Inhibits tetrahydrofolate--Interferes with formation of DNA, key proteins • Treats head and neck cancers, breast cancer • Toxicity: mucositis, diarrhea

283

Fluorouracil

Treats cancer. 1.Inhibits thymidine synthase, decreases DNA synthase and decreases DNA synthesis and function 2. treats: colorectal, anal, breast, head & neck, and hepatocellular cancers

284

Vinblastine or Vincristine

Is a natural product cancer, chemotherapy drug. 2. Inhibits tubulin polymerization-cytoskeleton component—arrests in cell division and causes cell death 3. Toxicity: mucositis, myelosuppression 4. Treat: breast cancer and Kaposi’s lymphoma

285

Doxorubicin

Is an antitumor antibiotic, in the class of anthracyclines, that treat breast cancer. • Mechanism: formation of free radicals that bind to DNA, causing breaks • Treat: lymphomas, breast cancer and thyroid cancer • Toxicity: nausea and red (not blood) urine

286

Bleomycin

Is an antitumor antibiotic, in the class of anthracyclines, that treat breast cancer. • Mechanism: formation of free radicals that bind to DNA, causing breaks • Treat: lymphomas, breast cancer and thyroid cancer • Toxicity: nausea and red (not blood) urine

287

Antacids

Used for GERD. Antacids-neutralize gastric HCl • Types: magnesium salts (can cause diarrhea); bicarbonate (causes gas); calcium carbonate (chalky and constipation); aluminum salts (not very effective)

288

Cimetidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut. • Side effects: headaches, diarrhea, drowsiness.

289

Ranitidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut. • Side effects: headaches, diarrhea, drowsiness.

290

Famotidine

Used for GERD. H2 receptor blockers-not effective at the H1 receptors (i.e., not good antihistamines)-reduce gastric secretions by blocking H2 receptors in gut. • Side effects: headaches, diarrhea, drowsiness.

291

Omeprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx • Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut. • Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers • Often combined with H2 blockers - Can also add sodium bicarbonate for fast release.

292

Lansoprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx • Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut. • Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers • Often combined with H2 blockers

293

Esomeprazole

Used for GERD. Proton pump inhibitors (PPIs) –available OTC and by Rx • Mechanism: disrupts hydrogen exchange for K in parietal cells, which blocks production and release of HCl into gut. • Side effects: diarrhea, interferes with digestion, increases food allerges, oral sores/ulcers • Often combined with H2 blockers

-Protein Pump Inhibitors take a while to kick in, at least a few days, not immediate!!!

294

Prevpac

Used to treat peptic ulcer disease. (2) Cure if H pylori-related –H pyloria is contagious especially within family members • Prevpac; combination of lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin

295

Milk of Magnesia

Used to treat peptic ulcer disease. (2) Cure if H pylori-related –H pyloria is contagious especially within family members • Prevpac; combination of lansoprazole (a PPI) and the antibiotics amoxicillin and clarithromycin • Milk of Magnesia (magnesium based) may also help kill bacteria

296

Bisacodyl

Laxative used for constipation. • Stimulant of smooth muscles • Fast acting • OTC • Suppository/oral • Cramps

297

Docusate

Laxative used for constipation. • Water retention in stools, softens stools • OTC (e.g., Dulcelax)

298

Loperamine

Treats diarrhea. Imodium; mild opioid agonist: if severe, can use strong opioid agonists

299

Bismuth subsalicylate

Treats diarrhea. Is Pepto-Bismol. (3) Anti-cholinergics such as atropine can also be used to treat diarrhea.

300

Linaclotide

Used for irritable bowel syndrome. b. Treatment: (1) Typically symptomatic (i.e., deal with diarrhea or constipation with diet and anti-stress changes) (2) Drugs: only linaclotide (Linzess) is FDA-approved for IBS with constipation • It is a guanylate cyclase-C agonist-it increases bowel movement, fluid secretion and reduces pain • Side effects: diarrhea, gas

301

Mesalamine

Used for Crohn's disease. Is an anti-inflammatory. Corticosteroids-act systemically and Metronidazole has an antibiotic mechanism and they can also be used for Crohn's. b. Ulcerative colitis • Similar to Crohn’s disease but limited to colon and more generalized (no strictures) • Medications are similar to Crohn's disease

302

Infliximab

Treatment of orofacial granulomatosis (an oral lesion from IBD).  TNF-alpha blocker.  

Treatmentofgranulomatosis: not well established, but some success with infliximab— TNF-α blocker

-blocks inflammatory reactions to mycobacterial infections (exclude TB as cause)