Week 3

Question 1

1 cancer for mets to brain?

In specifically women?

List 3 other cancers w/ brain mets

Answer 1

overall -> lungs

women -> breast

malignant melanoma > colon > kidney

Question 2

Match lymph node w/ primary cancer location

1. axillary
2. cervical
3. pelvic

Answer 2

Axillary -> breast

Cervical -> lung > thyroid > head/neck

Pelvic -> GYN > prostate> colorectal

Question 3

Grading vs staging tumors

• which is most important for prognosis (exception)
• which is most important for treatment decisions

Answer 3

Grading -> “grade” how many abnormal changes are present in tumor cells
-pathology tool

Staging -> extent of tumor spread

• pathology and radiology tool
• most important for prognosis!!! (exception = brain tumor)

BOTH important for making tx decisions

Question 4

TNM staging

Answer 4

T - primary tumor (T1-T4)

N - lymph node involvement

• N0 = none
• N1 - N3 = increasing nodal involvement

M - mets

• M0 - no distant mets
• M1 - M2 - mets present

Question 5

IHC markers for the following tumors

• lymphoma
• carcinoma
• melanoma
• sarcoma

Answer 5

• lymphoma -> CD45
• carcinoma -> Cytokeratin
• melanoma -> S-100
• sarcoma -> VIM

Question 6

Bead (particle) based assays good for assessing

Answer 6

paraneoplastic syndromes

Question 7

Neoadjuvant vs adjuvant

Answer 7

1. Adjuvant therapy - any treatment given after primary therapy to increase the chance of long-term survival
2. Neoadjuvant therapy - given before primary therapy

Question 8

Tx for GBM

Answer 8

surgery followed by chemo (alkylating agent) + radiation

Question 9

Doxorubicin = adriamycin
(anthracyclines = aminoglycosides derived from bacteria)
-MoA
-side effects/risks

Answer 9

• intercalates DNA damaging it and inhibiting replication
• generates free radicals

Risks

• neutropenia
• cardiac damage

Question 10

Vincristine

-MoA

Answer 10

binds to dimers of spindle protein tubulin -> inhibits polymerization into microtubules
-M phase arrest (no mitotic spindle formation)

Question 11

Cyclophosphamide

-MoA

Answer 11

• alkylating agent
• binds DNA -> modifies G residues to mispair as G-T -> crosslinks DNA -> blocks replication

First aid

• covalently cross links (interstrand) DNA at guanine N-7
• requires bioactivation by liver

Question 12

Cytarabine

• analog of?
• MoA
• side effects/risks

Answer 12

• cytosine analog
• incorporates into DNA and interferes w/ DNA replication (S phase)

Mutagenic
risk of neutropenia

Question 13

Bevacizumab (avastin)

-MoA

Answer 13

anti-VEGF mAb

prevents formation of new blood supply to tumor

Question 14

Rituximab

-MoA

Answer 14

MAb against CD20

• used for B cell lymphoma
• immune mediated destruction of tumor cells

Question 15

Imatinib (Gleevec)

-MoA

Answer 15

tyrosine kinase inhibitor -> apoptosis, reduced proliferation
-made using “rational drug design)

Question 16

Tx for syphilis by stages

Answer 16

Primary, 2ndary, early latent and late latent -> benzathine penicillin (IMx3 for late latent and IM x 1 for rest)

Neurosyphilis

• penicillin G IV -> every 4 hours for 10-14 days
• or procaine penicillin IM + probenecid

Doxycycline (binds 30S ribosome) -> if penicillin allergy

Question 17

3 complications of tertiary syphilis

Answer 17

1-10 years later

1. gumma (see pic)
2. aortitis -> widened arch; can rupture
3. neurosyphilis
   - optic atrophy,
   - speech disturbances
   - argyll robertson pupil
   - tabes dorsalis -> ataxia, impotence, + Romberg, peripheral neuropathy
4. hearing loss

Question 18

Ohio laws for HIV reporting

Answer 18

Can disclose to individual’s:

• legal guardian
• spouse
• ANY sexual partner

Question 19

Class A reporting

Answer 19

report IMMEDIATELY via telephone to local health dept or ohio dept of health
-severe and potential for epidemic spread

Question 20

Class B reporting

Answer 20

Send case report

Class B1 disease – by the end of the next business day

Class B2 disease – by the end of the business week

Question 21

Class C

Answer 21

case report by end of next business DAY

-unless there is an outbreak or potential epidemic of public health concern to local health dept or ohio dept of health

Question 22

What type of infections are expected with the following deficiencies:

B cell
T cell
Innate

Answer 22

B cell - bacterial and viral

T cell - viral, fungal (e.g. pneumocystis), mycobacterial

Innate - bacterial or viral

Question 23

Autoimmune antibodies to cytokines: match disease associated w/ the Abs against the following cytokines:

• IFN-gamma
• GM-CSF

Answer 23

1. IFN-gamma -> Tb

2. GM-CSF -> pulmonary alveolar proteinosis and cryptococcosis

Question 24

Dementia classifications requires absence of?

list 3 other key features of dementia

Answer 24

Absence of DELIRIUM

Other key elements

1. Primary impairment in COGNITION
2. Global deficits -> multiple domains of cognition
3. Decline must affect person’s ADL, vocational abilities or social ix

Question 25

Differentiate mild vs major neurocognitive disorder using DSM V criteria

Answer 25

Mild -> cognitive deficits DO NOT interfere w/ capacity for independence in everyday activities -the can do IADL but may require greater effort or compensatory strategies

Question 26

2 pathological presentations of Alzheimer's in the brain. separate by intracellular and extracellular

Answer 26

Neuritic plaques - extracellular - insoluble beta amyloid protein fragments Neurofibrillary tangles - intracellular - hyperphosphorylated tau protein -> insoluble cytoskeletal elements - correlated w/ degree of dementia

Question 27

Alzheimer's though be due to reduction in which NT? Evidence?

Answer 27

Acetylcholine -> loss of neurons in cholinergic rich areas (e.g. nucleus basalis of meynert)

Question 28

degeneration in AD begins where?

Answer 28

Entorhinal cortex

Question 29

Genetic condition associated w/ early onset alzheimers?

Answer 29

Down's (trisomy 21) Also chromosome's 1 and 14 - autosomal dominant - amyloid processing genes

Question 30

Gene/protein associated w/ later onset alzheimer's

Answer 30

Chr 19 -> ApoE4 | -autosomal recessive

Question 31

Main focus of tx for AD is?

Answer 31

behavioral sxs - agitations - delusions - hallucinations - physical aggression (these were in bold)

Question 32

List 2 major classes of AD drugs and the names

Answer 32

Acetylcholine esterase inhibitors - donepezil - galantamine - rivastigmine Antagonist at the glutamate-gated NMDA receptor - memantine -> for moderate to severe disease - prevents glutamate excitotoxicity

Question 33

DNR comfort care vs DNR comfort care arrest

Answer 33

DNRCC allows ONLY the administration of comfort care before, during or after person's heart/breathing stops DNRCC-arrest -> use comfort care after heart/breathing stops but can use life saving measures before

Question 34

Extraction ratio | -define and give equation

Answer 34

ER = VO2/DO2 amount of oxygen utilized relative to that supplied

Question 35

3 components to focus on with oxygen delivery

Answer 35

CO Hgb SaO2

Question 36

low BP w/ warm skin suggests what w/ regards to SVR and etiology of shock?

Answer 36

SVR inadequately elevated - distributive problem (e.g. neurogenic or septic)

Question 37

Difference b/w SP and DP proportional to?

Answer 37

SV

Question 38

Mixed venous sat (MVO2) should be around?

Answer 38

70%

Question 39

What 2 fungal infections to worry about in patients with severe neutropenia (ANC<100)

Answer 39

candidiasis or aspergillus | -use fluconazole after 7 days of persistent fever despite antibiotic tx

Question 40

Which drug to use in patients w/ streptococcal infections that are allergic to penicillin

Answer 40

Macrolides (e.g. azithromycin)

Question 41

Good drug for methicillin (or oxacillin) sensitive staph aureus infection?

Answer 41

Nafcillin (naf for staff) -if resistance -> VANC

Question 42

C. dif - which 2 antibiotics inc risk? - how to make a dx - tx? for severe disease? for recurring cases?

Answer 42

-clindamycin and ampicillin -> INCREASED RISK dx -> must detect C. dif toxins in the stool Tx - metronidazole - oral vanc if severe - recurring cases -> fecal transplant

Question 43

Approach to assessing neuropathy in diabetic patients

Answer 43

monofilament test first - good Sp but crappy Sn - detects severe neuropathy Vibratory testing next -better at picking up mild disease

Question 44

Respiratory rate in pregnancy? other respiratory markers?

Answer 44

STAYS THE SAME Tidal volume increases -> progesterone Minute vent increases -> resp alk

Question 45

IOM guidelines for weight gain during pregnancy

Answer 45

* Underweight -> 35 lbs * Normal weight -> 20-30 lbs * obese -> no more than 15

Question 46

BP in pregnancy

Answer 46

Drops due to dec SVR but starts going back up halfway through due to increased volume

Question 47

3 causes of death with peripartum CM

Answer 47

- pump failure - sudden death - thromboembolic events

Question 48

Drug of choice for txing heart failure due to CM in pregnancy patients

Answer 48

Hydralazine and nitrates - for afterload reduction Digoxin - for improved contractility

Question 49

Patient recovers from peripartum CM and wants to have another baby. What should you tell her?

Answer 49

HEEEELL NAW!!

Question 50

Anesthesia choice for C-section?

Answer 50

spinal/epidural anesthesia preferred

Question 51

Mendelsons' syndrome

Answer 51

Aspiration of gastric contents during general anesthesia | -pregnant women at inc risk

Question 52

Definition of menorrhagia

Answer 52

> 80 mL blood loss OR > 7 days of menses

Question 53

Patient w/ hx of HF should have what test done before going into surgery?

Answer 53

Resting echo

Question 54

Dxic criteria for delirium

Answer 54

CAM ``` Requires #1 and #2 and either #3 or #4 #1 Acute and Fluctuating course #2 Inattention #3 Disorganized thinking #4 Altered L.O.C. ```

Question 55

Defects in Th1 lead to issues w/ which cytokine response? consequences?

Answer 55

IFN gamma -> important for defense against intracellular infections can't activate macrophages to phagocytize pathogen -tb and fungal infections

Question 56

STAT3, IL-17 or IL-17R mutations associated w/ which specific infection?

Answer 56

CANDIDA

Question 57

X-linked lymphoproliferative syndromes assoc w/?

Answer 57

Uncontrolled EBV-induced B cell lymphoma

Question 58

Mutation in TLR3 associated with which increased risk for which infection?

Answer 58

HSV-1 encephalitis tx w/ acyclovir

Question 59

Cold abscess - think?

Answer 59

Leukocyte adhesion deficiency

Question 60

Early latent vs late latent syphilis w/ regards to relapse of 2ndary syphilis

Answer 60

Early later -> relapses can occur -patient is infectious!!! Late latent -> relapse do not recur

Question 61

Scoring for MMSE

Answer 61

Max 30 ``` Normal -> 27-30 Borderline -> 24-26 Mild -> 19-23 Moderately -> 10-18 Severe - < 9 ```