AKT 4 Flashcards
What is the initial empirical therapy for meningitis in patients aged < 3 months?
IV cefotaxime + amoxicillin (or ampicillin)
This treatment covers common pathogens in young infants.
What is the recommended initial empirical therapy for meningitis in patients aged 3 months to 59 years?
IV ceftriaxone
Ceftriaxone is effective against many pathogens causing meningitis in this age group.
What is the initial empirical therapy for meningitis in patients aged ≥ 60 years?
IV ceftriaxone + amoxicillin (or ampicillin)
This combination targets a broader range of pathogens due to increased risk in older adults.
What is the treatment for meningococcal meningitis?
IV benzylpenicillin or IV ceftriaxone
Both antibiotics are effective against Neisseria meningitidis.
What is the recommended treatment for pneumococcal meningitis?
IV ceftriaxone
Ceftriaxone is a preferred agent for Streptococcus pneumoniae infections.
What is the treatment for meningitis caused by Haemophilus influenzae?
IV ceftriaxone
This antibiotic effectively targets Haemophilus influenzae.
What is the treatment for meningitis caused by Listeria?
IV amoxicillin (or ampicillin) + gentamicin
This combination is used to effectively treat Listeria monocytogenes infections.
When do most neurologists start antiepileptics?
Following a second epileptic seizure
What does NICE guidelines suggest regarding starting antiepileptics after the first seizure?
Start if any of the following are present:
* Neurological deficit
* Structural abnormality on brain imaging
* Unequivocal epileptic activity on EEG
* Patient or family considers risk of further seizure unacceptable
What is the first-line drug treatment for males with generalised tonic-clonic seizures?
Sodium valproate
What is the first-line drug treatment for females with generalised tonic-clonic seizures?
Lamotrigine or levetiracetam
What is the first-line treatment for girls under 10 years with generalised tonic-clonic seizures?
Sodium valproate may be offered first-line
What is the first-line treatment for focal seizures?
Lamotrigine or levetiracetam
What are the second-line treatments for focal seizures?
Carbamazepine, oxcarbazepine or zonisamide
What is the first-line treatment for absence seizures (Petit mal)?
Ethosuximide
What is the second-line treatment for male patients with absence seizures?
Sodium valproate
What is the second-line treatment for female patients with absence seizures?
Lamotrigine or levetiracetam
What drug may exacerbate absence seizures?
Carbamazepine
What is the first-line treatment for males with myoclonic seizures?
Sodium valproate
What is the first-line treatment for females with myoclonic seizures?
Levetiracetam
What is the first-line treatment for males with tonic or atonic seizures?
Sodium valproate
What is the first-line treatment for females with tonic or atonic seizures?
Lamotrigine
What substances may worsen seizure control in patients with epilepsy?
Alcohol, cocaine, amphetamines, ciprofloxacin, levofloxacin, aminophylline, theophylline, bupropion, methylphenidate, mefenamic acid
These substances can negatively impact seizure management.
Which medications may provoke seizures during withdrawal?
Benzodiazepines, baclofen, hydroxyzine
Withdrawal from these medications can lead to increased seizure activity.
True or False: Alcohol can improve seizure control in patients with epilepsy.
False
Alcohol is known to worsen seizure control.
Fill in the blank: _______ is a medication that may worsen seizure control in patients with epilepsy.
Bupropion
Bupropion is listed among drugs that can worsen seizures.
Name one fluoroquinolone that may worsen seizure control.
Ciprofloxacin or levofloxacin
Both ciprofloxacin and levofloxacin are known to negatively affect seizure control.
What class of drugs does methylphenidate belong to?
Stimulants
Methylphenidate is commonly used in the treatment of ADHD.
What is Infantile spasms also known as?
West’s syndrome
Characterized by brief spasms beginning in the first few months of life.
What are the key features of Infantile spasms?
- Flexion of head, trunk, limbs
- Extension of arms (Salaam attack)
- Last 1-2 seconds
- Repeat up to 50 times
- Progressive mental handicap
- EEG: hypsarrhythmia
These features indicate the severity and nature of the spasms.
What are potential causes of Infantile spasms?
- Serious neurological abnormality (e.g. tuberous sclerosis)
- Encephalitis
- Birth asphyxia
- Idiopathic
These conditions may lead to the development of Infantile spasms.
What are possible treatments for Infantile spasms?
- Vigabatrin
- Steroids
These treatments are used to manage the condition, but the prognosis remains poor.
What is the prognosis for Infantile spasms?
Poor prognosis
Indicates that many affected children may face severe long-term challenges.
Typical absence seizures are also known as what?
Petit mal seizures
These seizures typically occur in children.
What is the typical age of onset for typical absence seizures?
4-8 years
This is the age range when these seizures commonly begin.
What is the duration of typical absence seizures?
Few-30 seconds
These seizures have a very short duration.
What is the EEG finding for typical absence seizures?
3Hz generalized, symmetrical
This characteristic EEG pattern helps in diagnosis.
What is the prognosis for children with typical absence seizures?
90-95% become seizure free in adolescence
Indicates a favorable outcome for most children.
What is Lennox-Gastaut syndrome often an extension of?
Infantile spasms
This syndrome may evolve from earlier seizure types.
What is the typical age of onset for Lennox-Gastaut syndrome?
1-5 years
Early childhood is when this syndrome typically manifests.
What are the key features of Lennox-Gastaut syndrome?
- Atypical absences
- Falls
- Jerks
- 90% moderate-severe mental handicap
- EEG: slow spike
These features highlight the complexity of the syndrome.
What treatment may help in Lennox-Gastaut syndrome?
Ketogenic diet
This dietary approach can be beneficial for some patients.
What is the most common childhood epilepsy?
Benign rolandic epilepsy
This type of epilepsy is particularly prevalent in children.
What are the features of benign rolandic epilepsy?
- Paraesthesia (e.g. unilateral face)
- Usually on waking up
These symptoms are characteristic of this type of epilepsy.
What is juvenile myoclonic epilepsy also known as?
Janz syndrome
Named after the physician who first described it.
What is the typical age of onset for juvenile myoclonic epilepsy?
Teenage years
This condition typically begins during adolescence.
What are the features of juvenile myoclonic epilepsy?
- Infrequent generalized seizures
- Daytime absences
- Sudden, shock-like myoclonic seizure
These features are crucial for diagnosis and management.
What is the treatment response for juvenile myoclonic epilepsy?
Usually good response to sodium valproate
This medication is effective for many patients with this condition.
What are focal seizures previously termed?
Partial seizures
Focal seizures start in a specific area on one side of the brain.
What are the classifications of awareness in focal seizures?
- Focal aware (previously ‘simple partial’)
- Focal impaired awareness (previously ‘complex partial’)
- Awareness unknown
The level of awareness can vary in focal seizures.
What types of features can focal seizures have?
- Motor (e.g. Jacksonian march)
- Non-motor (e.g. déjà vu, jamais vu)
- Aura
Focal seizures can be classified based on their features.
What characterizes generalized seizures?
Engage networks on both sides of the brain at the onset
Consciousness is lost immediately during generalized seizures.
What is not needed in the classification of generalized seizures?
Level of awareness
All patients lose consciousness during generalized seizures.
What are the subdivisions of generalized seizures?
- Motor (e.g. tonic-clonic)
- Non-motor (e.g. absence)
Generalized seizures can be further classified into these categories.
What are the specific types of generalized seizures?
- Tonic-clonic (grand mal)
- Tonic
- Clonic
- Typical absence (petit mal)
- Atonic
These are specific examples of generalized seizures.
What does ‘unknown onset’ refer to in seizure classification?
When the origin of the seizure is unknown
This classification is reserved for seizures without a defined starting point.
What are focal to bilateral seizures previously termed?
Secondary generalized seizures
These seizures start on one side of the brain in a specific area before spreading to both lobes.
What is the referral guideline for lung cancer according to the 2015 NICE guidelines?
Refer people using a suspected cancer pathway referral for lung cancer if they have chest x-ray findings suggesting lung cancer or are aged 40 and over with unexplained haemoptysis.
What is the age threshold for urgent chest x-ray referral to assess lung cancer symptoms?
40 years and over.
What symptoms warrant an urgent chest x-ray in people aged 40 and over?
If they have 2 or more of the following unexplained symptoms or if they have ever smoked and have 1 or more of the following symptoms:
* cough
* fatigue
* shortness of breath
* chest pain
* weight loss
* appetite loss.
List the symptoms that indicate a need for urgent chest x-ray in smokers aged 40 and over.
At least 1 of the following unexplained symptoms:
* cough
* fatigue
* shortness of breath
* chest pain
* weight loss
* appetite loss.
What additional factors should be considered for urgent chest x-ray in people aged 40 and over?
Consider an urgent chest x-ray for:
* persistent or recurrent chest infection
* finger clubbing
* supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
* chest signs consistent with lung cancer
* thrombocytosis.
True or False: A person aged 40 and over with unexplained haemoptysis should be referred for lung cancer assessment.
True.
Fill in the blank: An urgent chest x-ray should be performed within _______ to assess for lung cancer.
2 weeks.
What does the acronym NICE stand for in the context of cancer referral guidelines?
National Institute for Health and Care Excellence.
What are the referral guidelines for suspected breast cancer published by NICE in 2015?
Refer people using a suspected cancer pathway referral for breast cancer if they are:
* aged 30 and over with an unexplained breast lump with or without pain
* aged 50 and over with nipple discharge, retraction, or other changes of concern
The guidelines emphasize the urgency based on age and symptoms.
What age and symptom criteria warrant an urgent referral for breast cancer?
People aged 30 and over with an unexplained breast lump or aged 50 and over with nipple changes.
Symptoms include discharge, retraction, or other concerning changes.
What additional criteria should be considered for a suspected cancer pathway referral?
Consider referral for:
* Skin changes that suggest breast cancer
* People aged 30 and over with an unexplained lump in the axilla
This allows for early detection of potential breast cancer.
What is the recommendation for non-urgent referral in individuals under 30?
Non-urgent referral for people under 30 with an unexplained breast lump with or without pain.
This reflects a lower risk profile in younger individuals.
True or False: All individuals with unexplained breast lumps should be referred urgently.
False
The urgency of referral depends on age and the presence of specific symptoms.
What is dyspepsia?
A condition characterized by discomfort or pain in the upper abdomen.
Dyspepsia can include symptoms like bloating, nausea, and indigestion.
According to the 2015 NICE guidelines, who needs urgent referral for an endoscopy?
Patients with:
* dysphagia
* upper abdominal mass consistent with stomach cancer
* aged >= 55 years with weight loss and any of:
* upper abdominal pain
* reflux
* dyspepsia
These guidelines aim to identify potential cases of cancer quickly.
What symptoms indicate non-urgent referral for endoscopy?
Patients with:
* haematemesis
* aged >= 55 years with:
* treatment-resistant dyspepsia
* upper abdominal pain with low haemoglobin levels
* raised platelet count with any of:
* nausea
* vomiting
* weight loss
* reflux
* dyspepsia
* upper abdominal pain
* nausea or vomiting with any of:
* weight loss
* reflux
* dyspepsia
* upper abdominal pain
Non-urgent cases still require evaluation but are not as time-sensitive.
What is the significance of weight loss in patients aged >= 55 years?
It is a critical factor in determining the need for urgent referral for endoscopy when combined with upper abdominal pain, reflux, or dyspepsia.
Weight loss can indicate serious underlying conditions, including cancer.
True or False: All patients with dyspepsia require urgent referral for endoscopy.
False
Only specific cases of dyspepsia, particularly in older patients with additional concerning symptoms, require urgent referral.
Fill in the blank: Patients with _______ and weight loss are considered for urgent endoscopy referral.
upper abdominal pain
This combination raises concerns for serious underlying conditions.
What is the recommended age to consider PSA testing in men?
Men older than 50 years of age who request a PSA test
PSA testing should also be considered in men with suspected prostate cancer.
What should be done if a patient’s PSA level is above the threshold for their age?
Refer on the suspected cancer pathway referral for an appointment within 2 weeks
This applies to patients with possible symptoms of prostate cancer.
What is the PSA threshold for men aged 50-59?
> 3.5 ng/ml
This threshold indicates a higher likelihood of prostate cancer for this age group.
What are the PSA level thresholds for men aged 60-69?
> 4.5 ng/ml
Patients above this threshold should be referred if symptomatic.
What factors can raise PSA levels?
- Benign prostatic hyperplasia (BPH)
- Prostatitis and urinary tract infection (postpone test for 6 weeks after treatment)
- Ejaculation (ideally not in the previous 48 hours)
- Vigorous exercise (ideally not in the previous 48 hours)
- Urinary retention
- Instrumentation of the urinary tract
These factors can affect the accuracy of PSA testing.
True or False: Around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer.
True
This statistic highlights the poor specificity of PSA testing.
What percentage of men with a PSA of 10-20 ng/ml will likely have prostate cancer?
60%
This indicates an increased risk with higher PSA levels.
What percentage of men with prostate cancer have a normal PSA?
Around 15%
This underscores the limitations of PSA testing in diagnosing prostate cancer.
What should be used for men under 40 when considering PSA testing?
Clinical judgement
There is no specific threshold for this age group.
What is bladder cancer?
The second most common urological cancer.
What age group is most commonly affected by bladder cancer?
Males aged between 50 and 80 years.
What is the increased risk factor for bladder cancer in smokers?
2-5 fold increased risk.
What substance exposure increases the risk of bladder cancer?
Hydrocarbons such as 2-Naphthylamine.
What is a rare cause of chronic bladder inflammation that can lead to squamous cell carcinomas?
Schistosomiasis infection.
What are two examples of benign tumours of the bladder?
- Inverted urothelial papilloma
- Nephrogenic adenoma
What type of carcinoma accounts for over 90% of bladder malignancies?
Urothelial (transitional cell) carcinoma.
What percentage of bladder malignancies are squamous cell carcinomas?
1-7%.
What percentage of bladder malignancies are adenocarcinomas?
2%.
What is ‘field change’ in relation to urothelial carcinomas?
The effect that allows tumours to arise as multifocal lesions.
What is the growth pattern of up to 70% of transitional cell carcinomas?
Papillary growth pattern.
What is the prognosis for superficial urothelial tumours?
Better prognosis.
What is the risk of regional or distant lymph node metastasis for those with T3 disease or worse?
30% (or higher) risk.
What does T0 indicate in TNM staging?
No evidence of tumour.
What does Ta indicate in TNM staging?
Non invasive papillary carcinoma.
What does T1 indicate in TNM staging?
Tumour invades sub epithelial connective tissue.
What does T2a indicate in TNM staging?
Tumour invades superficial muscularis propria (inner half).
What does T2b indicate in TNM staging?
Tumour invades deep muscularis propria (outer half).
What does T3 indicate in TNM staging?
Tumour extends to perivesical fat.
What does T4 indicate in TNM staging?
Tumour invades prostatic stroma, seminal vesicles, uterus, vagina.
What does T4a indicate in TNM staging?
Invasion of uterus, prostate or bowel.
What does T4b indicate in TNM staging?
Invasion of pelvic sidewall or abdominal wall.
What does N0 indicate in TNM staging?
No nodal disease.
What does N1 indicate in TNM staging?
Single regional lymph node metastasis in the true pelvis.
What does N2 indicate in TNM staging?
Multiple regional lymph node metastasis in the true pelvis.
What does N3 indicate in TNM staging?
Lymph node metastasis to the common iliac lymph nodes.
What does M0 indicate in TNM staging?
No distant metastasis.
What does M1 indicate in TNM staging?
Distant disease.
When should men be referred for a suspected prostate cancer pathway?
If their prostate feels malignant on digital rectal examination
Referral should be for an appointment within 2 weeks.
What tests should be considered to assess for prostate cancer?
Prostate-specific antigen (PSA) test and digital rectal examination
These tests are recommended for men with specific symptoms.
What symptoms warrant consideration of a PSA test and digital rectal examination?
- Any lower urinary tract symptoms (nocturia, urinary frequency, hesitancy, urgency, retention)
- Erectile dysfunction
- Visible haematuria
These symptoms may indicate the need for further investigation.
What PSA levels indicate a need for referral for prostate cancer?
If PSA levels are above the age-specific reference range
This is a critical factor for referral.
What is a suspected cancer pathway referral for penile cancer?
An appointment within 2 weeks for suspected penile cancer.
What conditions warrant a referral for suspected penile cancer?
Either a penile mass or ulcerated lesion with excluded sexually transmitted infection, or a persistent penile lesion post-STI treatment.
What should be excluded as a cause for a penile mass before referral?
A sexually transmitted infection.
What symptoms may indicate a need for referral for penile cancer?
Unexplained or persistent symptoms affecting the foreskin or glans.
What is the time frame for a suspected cancer pathway referral for penile cancer?
Within 2 weeks.
Fill in the blank: A persistent penile lesion after treatment for a sexually transmitted infection may require a _______.
[suspected cancer pathway referral]
What is the age threshold for referral using a suspected cancer pathway for bladder cancer?
45 years and over
This age threshold is crucial for identifying individuals at risk for bladder cancer.
What is a key symptom for referral for bladder cancer in individuals aged 45 years and over?
Unexplained visible haematuria without urinary tract infection
Visible haematuria is a significant indicator of potential bladder cancer.
What condition must be present for individuals aged 60 years and over to be referred for bladder cancer?
Unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
These symptoms warrant urgent investigation for bladder cancer.
What is the recommendation for non-urgent referral for bladder cancer in people aged 60 years and over?
Recurrent or persistent unexplained urinary tract infection
This indicates a need for further evaluation for bladder cancer.
What is the age threshold for referral using a suspected cancer pathway for renal cancer?
45 years and over
Similar to bladder cancer, this age threshold is critical for renal cancer referrals.
What is a key symptom for referral for renal cancer in individuals aged 45 years and over?
Unexplained visible haematuria without urinary tract infection
This symptom is a significant red flag for renal cancer.
What additional condition must be met for referral for renal cancer if visible haematuria is present?
Visible haematuria that persists or recurs after successful treatment of urinary tract infection
This persistence indicates the need for further investigation.
Fill in the blank: Referral for bladder cancer should be made if a patient has unexplained visible haematuria without _______.
urinary tract infection
This condition is a key indicator for bladder cancer.
True or False: Individuals aged 60 years and over with unexplained non-visible haematuria should be referred for renal cancer.
False
The referral criteria for renal cancer focus on visible haematuria.
What is the primary development pathway for most colorectal cancers?
Most cancers develop from adenomatous polyps.
By what percentage has screening for colorectal cancer been shown to reduce mortality?
16%
What type of screening does the NHS offer to older adults for colorectal cancer?
Home-based, Faecal Immunochemical Test (FIT) screening.
What age group is targeted by the NHS national screening programme FIT in England?
Men and women aged 60 to 74 years.
What is the age range for colorectal cancer screening in Scotland?
50 to 74 years.
What can patients aged over 74 years do regarding colorectal cancer screening?
They may request screening.
How are eligible patients notified about the Faecal Immunochemical Test (FIT)?
They are sent FIT tests through the post.
What does the Faecal Immunochemical Test (FIT) specifically detect?
Human haemoglobin (Hb).
What is the main advantage of FIT over conventional faecal occult blood (FOB) tests?
It only detects human haemoglobin, not animal haemoglobin from diet.
How many faecal samples are needed for the FIT compared to conventional FOB tests?
Only one sample is needed for FIT, compared to 2-3 for conventional FOB tests.
What information is provided to the patient regarding the numerical value generated by FIT?
It is not reported to the patient or GP.
What happens to patients with abnormal FIT results?
They are offered a colonoscopy.
At colonoscopy, what percentage of patients typically have a normal exam?
5 out of 10 patients.
What percentage of patients at colonoscopy may be found to have polyps?
4 out of 10 patients.
What is the potential risk associated with the polyps found during colonoscopy?
They may have premalignant potential.
What percentage of patients at colonoscopy will be found to have cancer?
1 out of 10 patients.
When should I refer a person with suspected colorectal cancer?
Refer if they have:
* An abdominal mass
* A change in bowel habit
* Iron-deficiency anaemia
* Aged 60 years and over with anaemia (even without iron deficiency)
* Aged 40 years and over with unexplained weight loss and abdominal pain
* Aged under 50 years with rectal bleeding and unexplained abdominal pain or weight loss
* Aged 50 years and over with unexplained rectal bleeding, abdominal pain, or weight loss
These criteria help guide timely referrals for suspected cases.
What quantitative testing should be offered to guide referral for suspected colorectal cancer?
Offer quantitative faecal immunochemical testing (FIT) using HM-JACKarc or OC-Sensor
FIT is used to detect hidden blood in the stool, which can indicate colorectal cancer.
What should be considered if people need help returning their faecal sample?
Consider if people need additional help, information, or support
Ensuring that individuals can return their samples is crucial for accurate testing.
Should FIT be offered even if a person has had a negative result from the NHS bowel screening programme?
Yes, offer FIT even if the person has previously had a negative FIT result
This ensures that potential cases are not overlooked.
What FIT result indicates a referral for colorectal cancer using a suspected cancer pathway?
A FIT result of at least 10 micrograms of haemoglobin per gram of faeces
This threshold helps identify individuals at higher risk of colorectal cancer.
What should be done if a person has not returned a faecal sample or has a FIT result below 10 micrograms?
Ensure safety netting processes are in place
This is important to monitor symptoms and ensure timely intervention.
What action should be taken if there is a strong clinical concern of cancer due to ongoing unexplained symptoms?
Do not delay referral to an appropriate secondary care pathway
Timeliness is crucial in managing potential cancer cases.
What is a sign that might indicate an CONSIDERATION of urgent referral is necessary?
Evidence of rectal mass
A rectal mass is a significant clinical finding that requires prompt action.
What is the most common cause of cancer in the UK?
Breast
Other common causes include lung, colorectal, prostate, bladder, non-Hodgkin’s lymphoma, melanoma, stomach, oesophagus, and pancreas.
What is the leading cause of death from cancer in the UK?
Lung
Other leading causes include colorectal, breast, prostate, pancreas, oesophagus, stomach, bladder, non-Hodgkin’s lymphoma, and ovarian.
Fill in the blank: The most common cause of cancer in women in the UK is _______.
BREAST
Which cancer has the highest incidence in men in the UK?
PROSTATE
Other common cancers in men include lung and bowel.
List the common causes of cancer in the UK.
- Breast
- Lung
- Colorectal
- Prostate
- Bladder
- Non-Hodgkin’s lymphoma
- Melanoma
- Stomach
- Oesophagus
- Pancreas
List the most common causes of death from cancer in the UK.
- Lung
- Colorectal
- Breast
- Prostate
- Pancreas
- Oesophagus
- Stomach
- Bladder
- Non-Hodgkin’s lymphoma
- Ovarian
Fill in the blank: The second most common cause of cancer in the UK is _______.
Lung
What is the third most common cause of cancer in the UK?
Colorectal
What is the fourth most common cause of cancer in the UK?
Prostate
Fill in the blank: The fifth most common cause of cancer in the UK is _______.
Bladder
What type of cancer is the most common in women after breast cancer?
Lung
Bowel cancer also has significant incidence among women.
What is a common site of cancer incidence in women aside from breast and lung?
Uterus
ORDER of cancer incidence in women
Incidence of cancer in women:
1.BREAST
2.lung
3.Bowel
4.OTTHER SITES
5. UTERUS
Order of cancer incidence in men
Incidence of cancer in men:
1. PROSTATE
2.lung
3.Bowel
What are the two main categories of treatment for ulcerative colitis?
Inducing and maintaining remission
What is the classification of ulcerative colitis severity?
Mild, moderate, severe
Define mild ulcerative colitis.
< 4 stools/day, only a small amount of blood
Define moderate ulcerative colitis.
4-6 stools/day, varying amounts of blood, no systemic upset
Define severe ulcerative colitis.
> 6 bloody stools/day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
What is the first-line treatment for mild-to-moderate proctitis?
Topical (rectal) aminosalicylate
If remission is not achieved within 4 weeks for proctitis, what should be added?
Oral aminosalicylate
What should be done if remission is still not achieved after adding oral aminosalicylate for proctitis?
Add topical or oral corticosteroid
What is the first-line treatment for proctosigmoiditis and left-sided ulcerative colitis?
Topical (rectal) aminosalicylate
After 4 weeks of treatment for proctosigmoiditis and left-sided ulcerative colitis, if remission is not achieved, what options are available?
- High-dose oral aminosalicylate
- Switch to high-dose oral aminosalicylate and topical corticosteroid
What is the treatment approach for extensive disease in ulcerative colitis?
Topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
What is the treatment protocol for severe colitis?
Should be treated in hospital with IV steroids first-line
What should be considered if there is no improvement after 72 hours of treating severe colitis?
- Add IV ciclosporin to IV corticosteroids
- Consider surgery
What is the maintenance treatment following a mild-to-moderate ulcerative colitis flare for proctitis and proctosigmoiditis?
- Topical (rectal) aminosalicylate alone
- Oral aminosalicylate plus topical (rectal) aminosalicylate
- Oral aminosalicylate by itself
What maintenance treatment is recommended for left-sided and extensive ulcerative colitis?
Low maintenance dose of an oral aminosalicylate
What is the recommended treatment following a severe relapse or >=2 exacerbations in the past year?
Oral azathioprine or oral mercaptopurine
Is methotrexate recommended for the management of ulcerative colitis?
No, it is not recommended
What evidence exists regarding probiotics in ulcerative colitis management?
Probiotics may prevent relapse in patients with mild to moderate disease
What is the surgical option when ulcerative colitis is unresponsive to optimal medical therapy?
Consider surgery
What does subtotal colectomy involve?
Removal of part of the colon, usually with a temporary loop ileostomy
What is the preferred surgical approach for ulcerative colitis?
Restorative proctocolectomy (IPAA)
What does complete panproctocolectomy entail?
Removal of the entire colon and rectum, resulting in a permanent ileostomy
What is Crohn’s disease?
A form of inflammatory bowel disease that commonly affects the terminal ileum and colon but may occur anywhere from the mouth to anus.
When did NICE publish guidelines on the management of Crohn’s disease?
In 2012.
What lifestyle change should patients with Crohn’s disease be strongly advised to make?
Stop smoking.
What medications are generally used to induce remission in Crohn’s disease?
Glucocorticoids (oral, topical, or intravenous).
What is an alternative medication to glucocorticoids for inducing remission in some patients?
Budesonide.
What dietary approach may be used to induce remission in Crohn’s disease?
Enteral feeding with an elemental diet.
What second-line drugs are used after glucocorticoids to induce remission?
5-ASA drugs (e.g., mesalazine).
Which medications may be used as an add-on to induce remission but not as monotherapy?
Azathioprine or mercaptopurine.
What is the role of infliximab in Crohn’s disease?
Useful in refractory disease and fistulating Crohn’s.
What is the first-line medication to maintain remission in Crohn’s disease?
Azathioprine or mercaptopurine.
What should be assessed before starting azathioprine or mercaptopurine?
TPMT activity.
What is the second-line medication used to maintain remission?
Methotrexate.
What percentage of patients with Crohn’s disease will eventually require surgery?
Around 80%.
What surgical procedure is indicated for stricturing terminal ileal disease?
Ileocaecal resection.
What is a perianal fistula?
An inflammatory tract or connection between the anal canal and the perianal skin.
What is the investigation of choice for suspected perianal fistulae?
MRI.
What is the typical treatment for symptomatic perianal fistulae?
Oral metronidazole.
What may be effective in closing and maintaining closure of perianal fistulas?
Anti-TNF agents such as infliximab.
What is a draining seton used for?
Complex fistulae.
What is required for a perianal abscess?
Incision and drainage combined with antibiotic therapy.
What are the standard incidence ratios for small bowel cancer and colorectal cancer in Crohn’s disease?
Small bowel cancer = 40; colorectal cancer = 2.
What additional health risk is associated with Crohn’s disease?
Osteoporosis.
What is Von Willebrand’s disease?
The most common inherited bleeding disorder
How is Von Willebrand’s disease primarily inherited?
In an autosomal dominant fashion
What are common symptoms of Von Willebrand’s disease?
- Epistaxis
- Menorrhagia
What symptoms are rare in Von Willebrand’s disease?
- Haemoarthroses
- Muscle haematomas
What is the role of von Willebrand factor?
- Promotes platelet adhesion to damaged endothelium
- Carrier molecule for factor VIII
What is the size of von Willebrand factor multimers?
Up to 1,000,000 Da
What are the types of Von Willebrand’s disease?
- Type 1: partial reduction in vWF
- Type 2: abnormal form of vWF
- Type 3: total lack of vWF
Which type of Von Willebrand’s disease is the most common?
Type 1
What is a characteristic finding in the investigation of Von Willebrand’s disease?
Prolonged bleeding time
What might be a prolonged test in Von Willebrand’s disease?
APTT may be prolonged
What happens to factor VIII levels in Von Willebrand’s disease?
They may be moderately reduced
What is a specific test finding in Von Willebrand’s disease?
Defective platelet aggregation with ristocetin
What is a treatment option for mild bleeding in Von Willebrand’s disease?
Tranexamic acid
What is desmopressin (DDAVP) used for in Von Willebrand’s disease?
Raises levels of vWF by inducing release from Weibel-Palade bodies
What is another treatment option for Von Willebrand’s disease?
Factor VIII concentrate
What is thrombophilia?
A condition that increases the risk of thrombosis.
What is the most common inherited cause of thrombophilia?
Factor V Leiden (activated protein C resistance).
What is the second most common inherited cause of thrombophilia?
Prothrombin gene mutation.
What are the deficiencies of naturally occurring anticoagulants associated with thrombophilia?
- Antithrombin III deficiency
- Protein C deficiency
- Protein S deficiency
Which deficiency has the highest relative risk of venous thromboembolism (VTE)?
Antithrombin III deficiency.
What is an acquired cause of thrombophilia?
Antiphospholipid syndrome.
What drug is associated with an increased risk of thrombophilia?
The combined oral contraceptive pill.
Fill in the blank: The most common cause of thrombophilia is _______.
factor V Leiden (activated protein C resistance).
True or False: Protein S deficiency is one of the deficiencies of naturally occurring anticoagulants.
True.
List three inherited causes of thrombophilia.
- Factor V Leiden (activated protein C resistance)
- Prothrombin gene mutation
- Deficiencies of naturally occurring anticoagulants
What is thrombocytosis?
An abnormally high platelet count, usually > 400 * 10^9/l.
What are the causes of reactive thrombocytosis?
- Severe infection
- Surgery
- Iron deficiency anaemia
Name two malignancies associated with thrombocytosis.
- Chronic myeloid leukaemia
- Polycythaemia rubra vera
What is essential thrombocytosis?
A myeloproliferative disorder characterized by megakaryocyte proliferation and overproduction of platelets.
What is the platelet count indicative of essential thrombocytosis?
> 600 * 10^9/l
What are two complications associated with essential thrombocytosis?
- Thrombosis (venous or arterial)
- Haemorrhage
What is a characteristic symptom of essential thrombocytosis?
A burning sensation in the hands
What mutation is found in around 50% of patients with essential thrombocytosis?
JAK2 mutation
What medication is widely used to manage essential thrombocytosis?
Hydroxyurea (hydroxycarbamide)
Which treatment may be used for younger patients with essential thrombocytosis?
Interferon-α
True or False: Low-dose aspirin may be used in essential thrombocytosis to reduce thrombotic risk.
True
Fill in the blank: Thrombocytosis can occur as a result of _______.
hyposplenism
What age range should be considered for suspected haematological malignancy management?
0-24 years
What is the urgency for a full blood count if features of leukaemia are present?
Very urgent, within 48 hours
Name a symptom that should prompt a full blood count in young people suspected of leukaemia.
Pallor
What symptom indicates a need for immediate investigation in young people for leukaemia related to energy levels?
Persistent fatigue
What unexplained symptom could suggest leukaemia in a young person?
Unexplained fever
What type of persistent infections should raise suspicion for leukaemia in young individuals?
Unexplained persistent infections
What physical finding, characterized by swelling of lymph nodes, should prompt a full blood count?
Generalised lymphadenopathy
What symptom related to bone health may indicate leukaemia in young people?
Persistent or unexplained bone pain
What unexplained symptom involving skin discoloration may suggest leukaemia?
Unexplained bruising
What type of abnormality involving bleeding could indicate leukaemia in young individuals?
Unexplained bleeding
What is immune thrombocytopenia (ITP)?
An immune-mediated reduction in the platelet count
Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex.
How does ITP commonly present in children?
Usually has an acute thrombocytopenia that may follow infection or vaccination.
How does ITP commonly present in adults?
Tends to have a more chronic condition.
What demographic is more commonly affected by ITP?
Older females.
How may ITP be detected in adults?
Incidentally following routine blood tests.
What are common symptoms of ITP in adults?
- Petechiae
- Purpura
- Bleeding (e.g. epistaxis)
Is catastrophic bleeding (e.g. intracranial) a common presentation of ITP?
No, it is not a common presentation.
What is the typical finding in a full blood count for ITP?
Isolated thrombocytopenia.
What investigations are used for ITP?
- Full blood count
- Blood film
Is a bone marrow examination routinely used in the investigation of ITP?
No, it is no longer used routinely.
What is the sensitivity of antiplatelet antibody testing in ITP?
Poor sensitivity.
What is the first-line treatment for ITP?
Oral prednisolone.
What is the role of pooled normal human immunoglobulin (IVIG) in ITP management?
Raises the platelet count quicker than steroids; may be used if active bleeding or an urgent invasive procedure is required.
Is splenectomy commonly used in the management of ITP?
No, it is now less commonly used.
What is Evan’s syndrome?
ITP in association with autoimmune haemolytic anaemia (AIHA).
What is Haemophilia?
An X-linked recessive disorder of coagulation
What percentage of patients with Haemophilia have no family history of the condition?
Up to 30%
What causes Haemophilia A?
A deficiency of factor VIII
What is Haemophilia B also known as?
Christmas disease
What causes Haemophilia B?
A lack of factor IX
List three features of Haemophilia.
- haemoarthroses
- haematomas
- prolonged bleeding after surgery or trauma
What blood test result is prolonged in Haemophilia?
APTT
What are the normal blood test results in Haemophilia?
- bleeding time
- thrombin time
- prothrombin time
What percentage of patients with Haemophilia A develop antibodies to factor VIII treatment?
Up to 10-15%
What are the inducers of the P450 system?
Inducers include:
* phenytoin
* carbamazepine
* phenobarbitone
* rifampicin
* St John’s Wort
* chronic alcohol intake
* griseofulvin
* smoking
Smoking affects CYP1A2, which is why smokers require more aminophylline.
What mnemonic can help remember the inducers of the P450 system?
PCBRASS + griseofulvin
Name two antiepileptic drugs that are inducers of the P450 system.
phenytoin and carbamazepine
Which barbiturate is an inducer of the P450 system?
phenobarbitone
What is the effect of chronic alcohol intake on the P450 system?
It induces the P450 system.
What are the inhibitors of the P450 system?
Inhibitors include:
* ciprofloxacin
* erythromycin
* isoniazid
* cimetidine
* omeprazole
* amiodarone
* allopurinol
* ketoconazole
* fluconazole
* fluoxetine
* sertraline
* ritonavir
* sodium valproate
* acute alcohol intake
* quinupristin
These inhibitors reduce the effect of the desired drug.
True or False: Rifampicin is an inhibitor of the P450 system.
False
Which two antibiotics are known inhibitors of the P450 system?
ciprofloxacin and erythromycin
Fill in the blank: _______ is an imidazole that inhibits the P450 system.
ketoconazole
What is the effect of acute alcohol intake on the P450 system?
It inhibits the P450 system.
Name one SSRI that inhibits the P450 system.
fluoxetine or sertraline
What is the chemical name for Vitamin A?
Retinoids
What is the deficiency state associated with Vitamin A?
Night-blindness (nyctalopia)
What is the chemical name for Vitamin B1?
Thiamine
What are the deficiency states associated with Vitamin B1?
- Beriberi
- Polyneuropathy
- Wernicke-Korsakoff syndrome
- Heart failure
What is the chemical name for Vitamin B3?
Niacin
What are the deficiency states associated with Vitamin B3?
- Pellagra
- Dermatitis
- Diarrhoea
- Dementia
What is the chemical name for Vitamin B6?
Pyridoxine
What are the deficiency states associated with Vitamin B6?
- Anaemia
- Irritability
- Seizures
What is the chemical name for Vitamin B7?
Biotin
What are the deficiency states associated with Vitamin B7?
- Dermatitis
- Seborrhoea
What is the chemical name for Vitamin B9?
Folic acid
What are the deficiency states associated with Vitamin B9?
- Megaloblastic anaemia
- Neural tube defects during pregnancy
What is the chemical name for Vitamin B12?
Cyanocobalamin
What are the deficiency states associated with Vitamin B12?
- Megaloblastic anaemia
- Peripheral neuropathy
What is the chemical name for Vitamin C?
Ascorbic acid
What are the deficiency states associated with Vitamin C?
- Scurvy
- Gingivitis
- Bleeding
What is the chemical name for Vitamin D?
Ergocalciferol, cholecalciferol
What are the deficiency states associated with Vitamin D?
- Rickets
- Osteomalacia
What is the chemical name for Vitamin E?
Tocopherol
What are the deficiency states associated with Vitamin E?
- Mild haemolytic anaemia in newborn infants
- Ataxia
- Peripheral neuropathy
What is the chemical name for Vitamin K?
Naphthoquinone
What are the deficiency states associated with Vitamin K?
- Haemorrhagic disease of the newborn
- Bleeding diathesis
What protozoa is primarily responsible for the majority of malaria cases?
Plasmodium falciparum
Around 75% of malaria cases are caused by this protozoa.
What percentage of patients who develop malaria did not take prophylaxis?
The majority
This indicates a significant gap in preventative measures.
What happens to UK citizens from malaria endemic areas regarding immunity?
They quickly lose their innate immunity.
What should be consulted prior to prescribing malaria prophylaxis?
Up-to-date charts with recommended regimes for malarial zones.
What is the time to begin Atovaquone + proguanil (Malarone) before travel?
1 - 2 days.
What are the side effects of Atovaquone + proguanil (Malarone)?
GI upset.
How long after travel should Atovaquone + proguanil (Malarone) be continued?
7 days.
How often is Chloroquine taken for malaria prophylaxis?
Weekly.
What side effects are associated with Chloroquine?
Headache, contraindicated in epilepsy.
What is the time to begin Chloroquine before travel?
1 week.
How long after travel should Chloroquine be continued?
4 weeks.
What are the side effects of Doxycycline?
Photosensitivity, Oesophagitis.
What is the time to begin Doxycycline before travel?
1 - 2 days.
How long after travel should Doxycycline be continued?
4 weeks.
What is the time to begin Mefloquine (Lariam) before travel?
2 - 3 weeks.
What are the side effects of Mefloquine (Lariam)?
Dizziness, Neuropsychiatric disturbance, contraindicated in epilepsy.
How often is Mefloquine taken for malaria prophylaxis?
Weekly.
What is the time to begin Proguanil (Paludrine) before travel?
1 week.
How long after travel should Proguanil (Paludrine) be continued?
4 weeks.
What should pregnant women be advised regarding travel to malaria endemic regions?
To avoid travelling.
What is a challenge in diagnosing malaria in pregnant women?
Parasites may not be detectable in the blood film due to placental sequestration.
What is advised for folate supplementation in pregnant women taking Proguanil?
5mg od.
What is the recommendation for children travelling to malaria endemic regions?
They should take malarial prophylaxis.
What percentage of DEET has been shown to repel mosquitoes effectively?
20-50%.
What is the licensing age for Doxycycline in the UK for children?
Over 12 years.
True or False: Doxycycline is contraindicated for pregnant women.
True.
What are the major congenital infections encountered in examinations?
Rubella, toxoplasmosis, cytomegalovirus
Which congenital infection is the most common in the UK?
Cytomegalovirus
Is maternal infection of cytomegalovirus usually symptomatic or asymptomatic?
Asymptomatic
What are the characteristic features of rubella?
- Sensorineural deafness
- Congenital cataracts
- Congenital heart disease (e.g. patent ductus arteriosus)
- Glaucoma
What are additional features of rubella?
- Growth retardation
- Hepatosplenomegaly
- Purpuric skin lesions
- ‘Salt and pepper’ chorioretinitis
- Microphthalmia
- Cerebral palsy
What are the characteristic features of toxoplasmosis?
- Cerebral calcification
- Chorioretinitis
- Hydrocephalus
- Low birth weight
What are other features of toxoplasmosis?
- Anaemia
- Hepatosplenomegaly
- Cerebral palsy
What are the characteristic features of cytomegalovirus?
- Purpuric skin lesions
- Sensorineural deafness
- Microcephaly
What are other features of cytomegalovirus?
- Visual impairment
- Learning disability
- Encephalitis/seizures
- Pneumonitis
- Hepatosplenomegaly
- Anaemia
- Jaundice
- Cerebral palsy
Fill in the blank: The characteristic feature of rubella that involves heart defect is _______.
Congenital heart disease (e.g. patent ductus arteriosus)
True or False: Hydrocephalus is a characteristic feature of toxoplasmosis.
True
Fill in the blank: One of the other features of cytomegalovirus is _______.
Visual impairment
