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0
Q

Relate quotidian fevers, systemic inflammatory disorder, evanescent rash, arthritis, elevated ferritin and multisystem involvement to?

A

Adult onset stills dz

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1
Q

How often and when to colo in pts with UC?

A

Every 1-2 yrs and 8-10 yrs after dx

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2
Q

Name complications after subarachnoid hemorrhage? Both earky and late

A

First 48- aneurysm rerupture and hydrocephalus

Day 5 and after can have cerebral artery vasospasm(presents as decline in neuro function

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3
Q

Note:Results of a D dimer assay performed after a period of anticoagulation therapy have been shown to be predictive of thrombotic recurrence.

A

.

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4
Q

Gottron Papules and heliotrope rash. Proximal weakness, +Ana,

A

Dermatomyocytis

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5
Q

In patients with HCM. What to avoid and why?

A

Patients can present with hemodynamic collapse secondary to acute severe left ventricular outflow tract obstruction. This may be spontaneous or precipitated by inotropic agents like dopamine or dobutamine, withdrawal of negative inotropic agents like beta blockers or calcium channel blockers, volume depletion, vasodilators, sustained atrial arrhythmias or sinus tachycardia

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6
Q

Drugs used in apkd to treat infection

A

Cipro has good cyst penetration. Ampicillin , cephalosporins, and nitrofurantoin do not

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7
Q

20 yof 4 week hx of fatigue, poly arthritis, le edema, creatinine bump, cytopenias, oral ulcers, htn.

A

Proliferative lupus nephritis

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8
Q

Treatnent of significant metabolic alkalosis and hypervolemia in a patient given blood products( citrate metabolized leads to production of extra bicarb.
Especially in a pt with impaired renal function

A

Acetazolamide

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9
Q

Bilirubin in urine think…

A

Sever liver dz, or obstructive jaundice

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10
Q

Urobilinogen is produced in the gut from the metabolism of Bilirubin…

A

A positive urine dipstick for urobilinogen results from hemolytic anemia or hepatic necrosis and not from obstructive causes

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11
Q

What are the causes of sterile pyuria?

A

Mycobacterium tuberculosis infection
Acute interstitial nephritis cause by antibiotics and nsaids or proton pump inhibitors
Kidney stones and kidney transplant rejection

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12
Q

Name some causes of hypernatremia and their associated urine osmolality

A 
Hypotonic fluid loss
G.I. losses > 600
Diuretics 150
Pure water loss
Insensible water losses > 600
Diabetes insipid us <200
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13
Q

Drugs used in apkd to treat infection

A

Cipro has good cyst penetration. Ampicillin , cephalosporins, and nitrofurantoin do not

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14
Q

Causes of central diabetes insipid us

A

Malignancy, neurosurgery, trauma, sarcoidosis, histiocytosis X, Wegener’s, hypoxic encephalopathy, Sheehan syndrome

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15
Q

Causes of nephrogenic diabetes insipidus

A

Lithium, other medications and filters amphotericin B, foscarnet
Sickle cell nephropathy, urinary tract infection, amyloidosis

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16
Q

Causes of anion gap met acidosis

A

Advanced kidney dz, etoh/dm ketoacid, lactic acidosis (sepsis, metformin, salicilates), liver failure. Propofol

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17
Q

Name some signs and symptoms of cryoglobulinemia

A

Purpura, gangrene, arthralgias, renal, neurologic, liver

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18
Q

When treating patients with CKD, it is acceptable to allow a 25% increasing creatinine for blood pressure control

A

Note

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19
Q

What is fibromuscular dysplasia?

A

A non-inflammatory vascular disease involving almost any artery but most often the renal and carotid.

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20
Q

Causes of nephrotic syndrome

A

FS GS, membranous glomerulopathy, amyloidosis, systemic diseases like diabetic nephropathy, HIV nephropathy, multiple myeloma, hepatitis B

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21
Q

Causes of membranoproliferative glomerukonephritis

A

HIV, chronic liver dz, ibd, celiac

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22
Q

Hcv glomerulonephritis can associated with…

Hbv glomerulonephritis can be associated with…

A

MPgs and Systemic cryoglobunemic vasculitis

Mpgs and poly arteritis nodosa

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23
Q

How long after acute progenic infection do I get post infectious GLom nephritis

A

> 1w

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24
Q

Anti gbm if lung and kidney think.. Then treat?…

A

Goodpastures

Treat with plasmapheresis!! And cyclophosphamide and steroids.

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25
Q

Types of pauci immune glomerulonephritis?

A

Polyangitis(wegener), microscopic polyangitis, churg strauss.
Remember these r absence of immune complex and anti gbm.
+anca

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26
Q

Clinical presentation of fever, hemolytic anemia, consumptive thrombocytopenia, neuro findings, kidney failure. Think…

A

Ttp and hus.

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27
Q

Cryoglobulinemia is associated usually with..

A

Hepatitis C!

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28
Q

Classic presentation of AIN

Causes of AIN

A

Fever, rash, eosinophilia with elevated Cr.
Meds: b-lactams, flouriquinolones, sulfonamides, indanavir, abacavir, NSAIDs, cox2 inh, ppi, 5asa, allopurinol, phenytoin, sle, sarcoidosis, mm, lymphoma, leukemia, HIV

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29
Q

Diagnostic criteria for hepato renal syndrome

A

Liver dz: cirrhosis with ascites
Kidney dz: cr>1.5
Kidney function not improved after fluid challenge, diuretics held, and albumin given
All other Etiologies ruled out(shock, nephrotixic agents
No evidence if parenchymal dz

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30
Q

Findings in TLS

A

hyperkalemia, hyperphosphatemia, hyperuricemia and hyperuricosuria, hypocalcemia, and consequent acute uric acid nephropathy and acute renal fail

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31
Q

Which statin is better if pt is on fluconazole?

A

Pravastatin

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32
Q

Define first-degree AV block

Define second degree AV block

A

PR interval of greater than 200 ms
Mobitz type 1 wenkenbach- Progressive lengthening of the PR interval until a QRS complex is dropped
Type 2- characterized by a drop QRS complex with no change in preceding PR interval. This is more worrisome. Suggests his-perkinje dz
Note: in patients with 2 to 1 AV block it is impossible to differentiate between Mobitz type 1 and 2 AV block

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33
Q

Indications for permanent pacemaker

A

Symptomatic bradycardia with heart rates less than 40 or sinus pauses
Symptomatic complete heart block or second degree heart block
Atrial fibrillation with pauses greater than five seconds
Alternating bundle branch block

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34
Q 
Antiarrhythmic medications
Class 1A, class 1b, class 1C, class 2, class III, class iv
A

Class 1-sodium channel blockade
Class 2- beta blockade
Class III- potassium channel blockade
Class iv- calcium channel blockade

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35
Q

Class two and class iv (beta and ca) agents should be avoided in patients with…

A

Decompensated systolic heart failure or or Wolff-Parkinson-White syndrome

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36
Q

Class one and class 3 agents have greater antiarrhythmic effects but

A

Have toxicities that limit their use

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37
Q

Class 1c medications are often prescribed for atrial flutter and atrial fib but are contraindicated in

A

Coronary artery disease especially after myocardial infarction because they increase the risk of polymorphic VT
Note: often these agents are used with an AV nodal blocker to avoid rapid one-to-one AV nodal conduction

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38
Q

Class 1a eg
Class 1b
Class 1c

A

Quinidine, Procainamide, disopyramide
Lidocaine, mexiletine, phenytoin
Flecainide, propafenone

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39
Q

Eg class ii meds

A

Metoprolol, propranolol, atenolol

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40
Q

Class iii

A

Sotalol amiodarone dofetilide Dronedarone

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41
Q

Class iv

A

Verapamil, dilt

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42
Q

Do you shock atrial fibrillation with synchronized or unsynchronized

A

Synchronized cardioversion on r wave to prevent r on t shock and induction v fib

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43
Q

Name the types of supra ventricular tachycardias

A

Atrial fibrillation and atrial flutter

A V N RT(avnodal reentrant tachy), AVRT(av reciprocating tachy), and atrial tachycardia

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44
Q

What is the Koebner phenomenon

A

Development of typical lesions following injury to the skin

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45
Q

Name some common presentations for lichen planus

A

Pruritic pink to purple flat top papules or plaques and wickham striae which is a reticulated network a fine white lines

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46
Q

Pan cytopenia, thrombophilia, hemolytic anemia??

A

Paroxysmal nocturnal hemoglobinuria

Check flow cytometry

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47
Q

What is propofol related infusion syndrome

A

Characterized by lactic, acidosis rhabdomyolysis, hyper triglyceridemia and myocardial abnormalities

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48
Q

How do you manage acute chest syndrome in patients with sickle cell disease

A

Empiric broad-spectrum antibiotics, supplemental oxygen, pain medication, avoidance of overhydration, bronchodilators as needed, and erythrocyte transfusion for persistent hypoxia despite supplemental oxygen

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49
Q

Patients that present with acute lower extremity arthritis and erythema nodosum, fever, anterior uveitis.. Think…

A

Löfgren syndrome. Or acute sarcoidosis.

The classic triad is hilar lymphadenopathy, acute oligo arthritis, and erythema nodosum

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50
Q

Painless jaundice, elevated Billy Rubin, elevated IgG4… Think

A

Autoimmune pancreatitis

Treated with corticosteroids first (not ercp) even if Narrowed pancreatic

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51
Q

How to reverse warfarin induced subdurAl hematom

A

Intra-Venus vitamin K and PCC (prothrombin complex concentrate)

52
Q

Diarrhea, bloating, weight loss, macrocytic anemia secondary to vitamin B 12 deficiency and an association with an elevated serum folate is classic for what

A

Small intestinal bacterial overgrowth

53
Q

Community acquired meningitis antimicrobial therapy
1. Age less than one month
2. Age 1 to 23 months
3. Aged 2 to 50 years
4. Age greater than 50 years
What are the common bacterial pathogens for each and selected antimicrobial therapy?

A
  1. GBS, E.col I, Listeria, klebsiella- ampicillin plus cefotaxime
  2. S. Pneumonie, gbs, h flu, E. coli, neisseria- vanc and cefotaxime or ceftriaxone
  3. S pneumonie, neisseria,- vanc and cefotaxime or ceftriaxone
  4. S pneumo, neiserria, listeria, aerobic gram neg- vanc and cefotaxime or ceftriaxone and ampicillin
54
Q

Treatment of CA MRSA?

A

Bactrim, doxy, clinda, linezolid

55
Q

Dx criteria of staph toxic shock

A

Fever greater than 102,
Systolic blood pressure less than 90
Diffuse macular rash with subsequent desquation Especially on palms and soles
Involvement of three of the following organ systems
1.gi
2. muscular
3. Mucous membrane
4. kidney
5. liver
6. blood platelet counts less than 100,000
7.central nervous system
For Rocky Mountains spotted fever leptospirosis and measles.

56
Q

Thiazolidinediones
Name some..
Contraindicated in..

A

Pioglitazone

Can’t use in chf 3 or 4

57
Q

What are first-line agents for the Esbl organisms

A

carbepenems, including mero

58
Q

An acute febrile illness with thrombocytopenia, leukopenia and increased liver enzymes in travelers returning from Asia is highly suggestive of

A

Dengue fever

Can also maculopapular are petechial rash

59
Q

What is the treatment of cryptococcal meningitis in HIV-infected patients

A

Induction therapy is amphotericin b plus flucytosine for at least two weeks it is then followed by oral fluconazole for eight weeks

60
Q

Can improve mortality in severe ards

A

Prone

Neuromuscular blockage

61
Q

Goal for ards volume

A

6 ml/ kg (ideal body weight)

Vs 12

62
Q

Spirometry

Gold classification

A

Post bronchodilator <30

63
Q

Mgmt of copd

A

Reduce exposure-smoking cessation
Physical activity/pulm rehab
Flu and pneumovax shot

Short acting b agonist Or anticholinerrhic (ipra)

Long acting of the above 2 (tio)

+corticosteroids AFTER frequent exac despite being in laba or lama!!!!

Phosphodiesterase 4 inh

Cpap for osa pts with copd

Lung reduction surgery?!?

Lung transplant (survival data is limited)

64
Q

Def of copd exac…
Precipitated by…
Mgmt

A

Precip by infections usually (strep, h flu, morax)
Other cause mi, pe, chf, aspiration, environmental air pollution
Acute onset change in sxs
Leads to change in meds

Systemic steroids-30-40mg/day, 60mg if critically ill (maybe only need to give for 5 days not 14!!)
Abx if hcap or cap treat but if no change in X-ray or change in sputum maybe don’t have to

O2 titrate to low 90s
Consider noninvasive vent if dyspneic

65
Q

Which Statin is contraindicated in patients taking HIV protease inhibitor’s and why

A

Simvastain because of cytochrome P4 50 drug metabolism which would raise Simvastatin concentrations to dangerous levels (use atorv!)

66
Q

When do you perform a CT or ultrasound in patients with UTI

A

It is indicated for those with pyelonephritis persistent pain or fever after 72 hours of antimicrobial therapy to exclude a perry nephric or intrarenal abscess

67
Q

When do you treat asymptomatic bacturea?

A

In pregnant women and men and women undergoing invasive urologic procedures

68
Q

Interpretation of ppd by induration

A

> 5- hiv,
recent contact with person with active tb,
Person with fibrotic change on cxr,
Transplant pts(receiving immunosupp agents)
10- recent arrival from tb area,
Ivdu,
Resident of prison, nursing, hospital, homeless shelter,
15- all others

69
Q

Basic uses for fluconazole

A

Cocci, crypto, candida (not glabrata or cruzzi)

70
Q

Basic uses for voriconazole

A

Aspergillosis, ?fuziform

71
Q

Basic uses for itraconazole

A

Endemic mycosis like histo, blasto,

72
Q

How to treat candida glabrata or cruzzi

A

Think micafungin

73
Q

Treatment for tb and ltbi?

A

Active tb- 2 month of rifampin, isoniazid, pyrazinamide, ethambutol. Then 4-7 months of just rifampin and isoniazid

Ltbi- 9 months of isoniazid and b6

74
Q

How do you treat sporotrichosis

A

Intraconazole

75
Q

What is the treatment for MSSA prosthetic valve endocarditis

A

Nafcillin and rifampin for six weeks plus a two week course of gentamicin

76
Q

This noninvasive measurement reflects active airway inflammation and generally correlates with airway eosinophilia.

A

Exhaled nitric oxide levels

- decreased in response to corticosteroid therapy and can be used to determine adherence to therapy.

77
Q

Asthma
Mild
Mod
Severe

A

Mild >2x week (sxs or Saba use), 3-4x month
Mod- daily or weekly at night
Severe -

78
Q

When there is concern for primary immunodeficiency syndrome, frequent infections by which pathogens are suspect?

A

Streptcoccus pna, Neisseria species, H influenza

79
Q

What is the most common primary immunodeficiency and what is unique about it

A

I G A deficiency

Some patients have severe anaphylactic reactions to administration of IV IG or blood products

80
Q

Who frequently developed chronic lung disease, autoimmune disorders, Malibu, recurrent infections, and lymphoma and their response to vaccination is poor

A

Patients with common variable immunodeficiency cvid

81
Q

This is a Graham positive boxcar shaved aerobic non-Motile Bacillus

A

Bacillus anthracis

82
Q

Clinical manifestations of this consist of a classic triad of the descending flaccid paralysis with prominent bulbar signs,normal body temperature and normal mental status

A

Botulism

83
Q

What are bulbar signs

A

Dysphasia diplopodia dysarthria dysphonia

84
Q

Symptoms of this include fatigue fever (usually last 4-8 weeks if untreated )headache cough anorexia and a time of presentation patients are usually constipated (though diarrhea may be present early)

A

Typhoid fever

Treat with flouroquinolones or 3rd gen cef

85
Q

Diarrheal illness caused by ingestion of pork intestines

A

Yersinia

86
Q

Diarrheal illness caused by fresh versus salt water contaminated fish

A

Salt think vibrio

Fresh think aeromonas or plesiomonas

87
Q

Diarrheal illness and can cause a bloody diarrhea and a late complication Guillan barre or reactive arthritis

A

Campy

88
Q

Diarrheal on this bloody diarrhea high fever and is known for causing diarrhea with very low infectious inoculum

A

Shigella

89
Q

Although a rare complication this diarrheal illness should be considered in patients with known arthrosclerosis disease and persistent bacteremia despite antibiotic therapy

A

Salmonellosis (remember association with osteo and sickle cell too)

90
Q

Liver abscesses and well described complication of this parasite

A

Entamoeba histolytica

91
Q

Most transplant centers use a three drug regimen consisting, calcineurin inhibitor and an anti-metabolite given example of each

A 
Cytotoxic agents (anti metabolites)-Mycophenolate mofetil, azathioprine, mtx, cyclophosphamide 
Calcineurin inhibitors- cyclosporine and tacrolimus.
92
Q

What are the most common viral infections and transplant recipients

A

CMP, EBV, polyoma BK virus, hepatitis B and hepatitis C

93
Q

Removal of the central line is important during Central and infections but it is specially important when these three pathogens are present

A

S aureus, pseudomonas, candida

94
Q

How do you treat Carbepenem resistant Enterobacteriace

A

Fosfomycin and tigecycline

95
Q

Which Carbepenem cannot be used in Pseudomonas

A

Ertapebem

96
Q

Infective endocarditis prophylaxis is recommended for patients with?

A
  1. a prosthetic cardiac valve
  2. a previous episode of infective endocarditis
  3. congenital heart disease characterized by unrepaired cyanotic congenital heart disease or recently repaired in the last six months
  4. for cardiac transplantation recipients
97
Q

Which antiretrovirals should never be given to pregnant women with HIV

A

Efavirans

Preferred antiretroviral regimen and pregnancy is zidovudine, lamivudine and lopinavir/ritonavir

98
Q

Why should you not use topical steroids in patients with HIV in the Symplex virus is known or suspected?

A

it is known to cause ocular infections if used

99
Q

When is herpes zoster vaccination indicated

A

And persons aged 60 or older

100
Q

What are some newer agents that are useful for treating MRSA

A

Daptomycin is indicated complicated skin and soft tissue infections involving staph strep and enterococcus faecalis
Telavancin- $$$, longer half life so daily dosing
Linezolid- oral therapy-!- causes Milo suppression notably thrombocytopenia and requires weekly complete blood counts
Ceftaroline-

101
Q

What drug can be used for MRsa, Vre and multi drug resistant gram-negative organisms

A

Fosfomycin

102
Q

Name the drug that is important in the treatment of Gram negative bacilli that are resistant to other anti microbial’s including Carbepenem resistant enterobacteriacaea, pseudomonas, acinetobacter

A

Polymyxins

103
Q

What are some absolute contraindications to hyperbaric oxygen therapy

A

Pneumothorax and the recent chemotherapy with doxorubicin or cisplatin

104
Q

What are the alarm symptoms that would prompt endoscopy as a first step for the evaluation of GERD or dyspepsia

A

Dysphasia, anemia, vomiting, or weight loss, age of onset after 50, odynophagia, family history of upper G.I. malignancy, personal history of PUD, gastric surgery, abdominal mass or lymphadenopathy on examination

105
Q

What condition starts with a single pink 2 to 4 cm in shape to plaque the scale at the periphery followed by development of many smaller lesions days to week later

A

Piryriasis rosea

No treatment necessary

106
Q

Lung ca staging basic

A

1a 3m
2 Hilar nodes
3 mediastinal node
4 Mets include pleural effusion

107
Q

Molecular markers lung ca

A

Egfr
Alk tyrosine kinase
Ras
These have implication for treatment

108
Q

How to determine proper cuff size for taking bp

A

The bladder should encircle 80% of arm without overlap.

Too small of a cuff will cause falsely elevated readings.

109
Q

Stages of htn

A 
Nml is less than 120/80
Pre htn 120-139/80-89
Htn
Stage 1 140-159/90-99
Stage 2 >160/100
110
Q

Name some manifestations of an organ damage and hypertensive emergency both acute and chronic

A

Acute:::Hypertensive encephalopathy he putting headache altered mental status seizure nausea vomiting, intracranial hemorrhage, unstable angina, acute myocardial infarction, left ventricular failure with pulmonary edema, acute aortic dissection, eclampsia

Chronic:::lvh, cad, stroke, retinovascular dz, atherosclerosis, claudication, diminished pulses, esrd

111
Q

What are the major causes of secondary hypertension

A

Renal artery stenosis, pheochromocytoma, hyperaldosteronism, hypercortisolism

112
Q

What is the pathophysiology of clinical presentation diagnosis of renal artery stenosis

A

Pathophysiology-under perfused kidney produces excess Renin
clinical presentation- sudden onset hypertension and abdominal bruit
Diagnosis- mra, cta, renal Doppler

113
Q

What is the pathophysiology, clinical presentation, diagnosis and treatment of pheo

A

Pathophysiology – tumor in the adrenal medulla that releases catecholamines
Presentation: headache, sweating, palpitations, anxiety, weight loss
Dx- screen with plasma free metanephrines confirm with 24 hour urine for catecholamines, the VMA, metanephrines
Txt- remove

114
Q

What is the pathophysiology, clinical presentation, diagnosis, treatment of hyperaldosteronism

A

Pathophysiology is an adenoma the produces aldosterone
Pres.- spontaneous hypokalemia and a hypertensive patient
Dx- screen with plasma aldosterone and serum renin a ratio in greater than 20 suggest disease. Confirmed by measuring 24 hour urine aldo

115
Q

What is the pathophysiology,, diagnosis and treatment of hypercortisolism

A

Pathophysiology, ACTH secreting tumor, adrenal adenoma, excellent topic ACTH secretion
Pres.-Truncal obesity, moon faces, proximal weakness, hirsutism, hyperglycemia
Dx-screen with 24 hour urinary frequency, salivary cortisol, or 1 mg overnight dex suppression test.
If positive form high-dose dexamethasone suppression test
Txt- resect

116
Q

Name some drugs that can be used in the treatment of hypertensive emergency

A

Nitroprusside, nitroglycerin, nicardipine, labetalol, fenoldopam, enalaprilat, esmolol

117
Q

Differential diagnosis for hypertriglyceridemia

A

Alcohol consumption, obesity, pregnancy, diabetes, hypothyroidism, chronic renal failure, medications like nonselective beta blocker’s, high dose diuretics, estrogen replacement therapy

118
Q

Clinical identification of metabolic syndrome

A

Abdominal obesity and then greater than 40 inches wide 35 inches, I glycerides greater than 150, HDL and then less than 40 and 50, blood pressure greater than 130/85, fasting glucose greater than 100

119
Q

When Statin therapy does not lower LDL should screen for this

A

Lipoprotein a

120
Q

What are some features of a high risk stress test that may warrant a cardiac catheterization

A

Angina or ischemic ECG changes at low workload, ST segment depression greater than 2 mm, ST segment elevation, ST segment depression persisting greater than six minutes into the recovery period, exercise-induced hypotension

121
Q

What is the definition of an STEmi

A

Presence of more than 1 mm ST segment elevation two or more continuous Limley’s or more than 2 mm ST segment elevation and two or more continuous precordial leads or a new left bundle branch block

122
Q 
Timi score
(Low 0 to 1-2 intermediate to 3-4 high-risk is five and six)
A

Age. >65
At least three coronary artery disease risk factors (cigarette smoking, hypertension or on hypertensive medicine, Family history of coronary artery disease, remember if HDL greater than 60 subtract one point)
Coronary stenosis greater than 50%
ST changes on EKG
Use of aspirin in the last seven days
At least two anginal episodes in past 24 hours
Elevated troponin

123
Q

Treat chronic systolic heart failure and

A 
Ace inhibitor beta blockers, diuretics (add spiro in class 4), low salt
Add hydral and isosorbide dintrate for aa pts who cont to be symptomatic , icd when ef <35
124
Q

What drugs to Avoid and chronic systolic heart failure and

A

On the steroid anti-inflammatory agents, calcium channel blocker’s, antiarrhythmics( only amio and dofetilide do not negatively effect survival), alcohol, cocaine, tobacco

125
Q

In patients with ventilator associated pna which antibiotic can be used to replace vanco if allergic

A

Linezolid

Note: Daptomycin is bound by surfactant and effective in the treatment of the pna

126
Q

When does a pleural effusion require not only antibiotics but pleuraldrainage

A

Large Ephesians greater than one half of the hemithorax, septations and areas of a loculation, plural fluid pH less than 7.2, glucose level less than 60 and positive Gram stain or culture

127
Q

What is the definition of the transfer data versus exudative pleural effusion and the importance of Ph, glucose

A

And exudative the fusion is coming to find as their own fluid total protein to see you’re in total protein ratio greater than .5 and or pleural fluid LDH level greater than two thirds the upper limit of normal.
**calc prot or alb gradient in the setting of ongoing diuresis
Plural fluid glucose levels less than 60 is commonly due to TB, parapneumonic effusion, malignant the fusion or rheumatoid disease
Plural fluid pH less than 7.2 is seen in complicated here in a Monica fusion, esophageal rupture, rheumatoid and TB, malignant disease…

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