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PBL SEM 4 > CASE 8 > Flashcards

CASE 8 Flashcards

1
Q

what categories can tumour markers be divided into?

A
  • monoclonal antibodies against carbohydrate or glycoproteins tumour antigens
  • tumour antigens
  • enzymes (ALP, neurone specific enolase)
  • hormones (eg. calcitonin, ADH)
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2
Q

tumour markers usually have a ______

A

low specificity

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3
Q

what monoclonal antibodies can be used to identify ovarian, pancreatic and breast cancers?

A

ovarian = CA 125
pancreatic = CA 19-9
breast = CA 15-3

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4
Q

what tumour antigen is used to identify prostatic carcinoma?

A

prostate specific antigen (PSA)

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5
Q

what tumour antigen can be used to identify hepatocellular carcinoma, teratoma?

A

alpha-feto protein (AFP)

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6
Q

what tumour antigen can be used to identify colorectal cancer?

A

carcinoembryonic antigen (CEA)

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7
Q

what tumour antigen can be used to identify melanoma, schwannomas?

A

S-100

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8
Q

what tumour antigen can be used to identify neuroblastoma?

A

bombesin

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9
Q

what is PSA?

A

= prostate specific antigen

= a serine protease enzyme produced by normal and malignant prostate epithelial cells

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10
Q

what are the age-adjusted upper limits for PSA recommended by the Prostate Cancer Risk Management programme (PCRMP)?

A

50-59 years = 3.0

60-69 years = 4.0

> 70 years = 5.0

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11
Q

what does NICE recommend as the cut off PSA?

A

men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

note this is a lower threshold than the PCRMP 60-69 years limits recommended above

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12
Q

what can PSA be raised by?

A
  • benign prostatic hyperplasia (BPH)
  • prostatitis and UTI (NICE recommend to postpone the PSA test for at least 1 month 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

whether DRE actually causes a rise in PSA levels is a matter of debate

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13
Q

around ___% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. with a PSA of 10-20 ng/ml this rises to ___% of men.

around __% with prostate cancer have a normal PSA

various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time)

A
  • 33%
  • 60%
  • 20%
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14
Q

what is inclusion health?

A

a growing discipline that aims to prevent and redress health and social inequities among people in extremes of poor health due to poverty, marginalisation, and multiple morbidity

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15
Q

asylum seekers vs refugees

A
  • asylum seekers in process of being assessed to gain legal status
  • refugees have ‘status’ or leave to remain— often temporary
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16
Q

what is utilitarianism?

A

Utilitarianism is an ethical theory that determines right from wrong by focusing on outcomes. It is a form of consequentialism. Utilitarianism holds that the most ethical choice is the one that will produce the greatest good for the greatest number.

outcome is more important than action
aim to maximise the ‘good’
utility = human welfare/well-being
utilitarianism aims to maximise human welfare

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17
Q

describe Maslow’s hierarchy of needs

A
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18
Q

describe virtue ethics

A
  • collection of normative ethical philosophies that focus on how we ought to act
  • being, rather than doing
  • morality stems from character of individual
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19
Q

what are the 3 approaches to ethics?

A
  1. virtue ethics = an action is only right if it is an action that a virtuous person would carry out in the same circumstances
  2. consequentialism = a theory that says whether something is good or bad depends on its outcomes
  3. deontology = a theory that says actions are good or bad according to a clear set of rules
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20
Q

equality vs equity vs justice

A

equality = dividing resources equally but does not factor differences in need and ability. Everybody is given the exact same quantity of resources

equity = not only dividing resources fairly and equally, but also factoring in differences amongst people.

justice = long-term equity. It looks to create equity in systems as well as individuals

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21
Q

obesity and PSA?

A

lower

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22
Q

low vs high creatinine

A

high in renal failure

low if low muscle mass

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23
Q

what electrolyte problem can you get from a transurethral resection of the prostate (TURP)?

A

hyponatraemia

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24
Q

where do the 2 ureters enter the bladder?

A

at the uppermost angles of the trigone

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25
Q

what does the bladder neck open into at the lowermost apex of the trigone?

A

posterior urethra

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26
Q

internal vs external sphincter muscle and innervation

A

internal = smooth muscle = involuntary control (PS)

external = skeletal muscle = voluntary control (somatic)

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27
Q

what is normal urine flow?

A

20-50 ml/s

28
Q

somatic innervation to the bladder?

A

pudendal nerve — voluntary contraction of external sphincter

29
Q

parasympathetic vs sympathetic bladder innervation

A

PS = pelvic splanchnic nerve

S = hypogastric nerve

30
Q

what is micturition?

A

the process by which the urinary bladder empties when it becomes filled

31
Q

micturition involves what 2 main steps?

A
  1. the bladder fills until the tension in its walls rises above a threshold level
  2. this elicits a nervous reflex called the micturition reflex that empties the bladder or, if this fails, at least causes a conscious desire to urinate
32
Q

what area of the brain is responsible for coordinating the actions of the urinary sphincters and the bladder, and invpv;ed in the storage phase?

A

To stimulate storage, impulses from the cerebral cortex travel to the pons. The pons is responsible for co-ordinating the actions of the urinary sphincters and the bladder, and the area involved in the storage phase is the pontine continence centre (on the left-hand side of the pons).

33
Q

roots of hypogastric nerve

A

T10-L2

34
Q

what does the hypogastric nerve stimulate at the bladder?

A

Relaxation of the detrusor muscle in the bladder wall – via stimulation of β3-adrenoreceptors in the fundus and the body of the bladder.
Contraction of the IUS – via stimulation of α1-adrenoreceptors at the neck of the bladder

35
Q

how is somatic innervation involved in the storage phase of micturition?

A

the EUS is under voluntary somatic control. In the storage phase, impulses travel to the EUS via the pudendal nerve (nerve roots S2-S4) to nicotinic (cholinergic) receptors on the striated muscle, resulting in contraction of the EUS. This prevents any urine from leaking out.

36
Q

stress vs urge vs overflow vs neurological incontinence

A

Stress incontinence – urine leakage when pressure is exerted on the bladder. This is common in pregnancy and can sometimes happen when laughing or sneezing, due to increased intra-abdominal pressure

Urge incontinence – urine leakage as soon as the urge to urinate arise. This is seen in urinary tract infections (UTIs) and can also be caused by medications, alcohol or caffeine.

Overflow incontinence – urine leakage due to the bladder being overfilled. Causes of this include bladder stones and chronic urinary retention.

Neurological incontinence – urine leakage caused by nerve lesions or neurological conditions, such as multiple sclerosis or spinal cord compression

37
Q

what are the effects of a spinal cord lesion above T12 on the bladder?

A

In an upper motor neuron lesion, sympathetic input to the bladder is lost, leading to an inability for the detrusor muscle to relax, or the IUS to contract.

Afferent signals via the sensory pelvic nerve are also unable to reach the brain, so the EUS remains constantly relaxed. The result is decreased bladder capacity and detrusor overactivity. The parasympathetic system initiates detrusor wall contraction in response to bladder wall stretch, resulting in the bladder automatically emptying as it fills. This is known as a reflex bladder.

The causes of such spinal cord injuries include trauma and multiple sclerosis.

38
Q

what can be used to treat incontinence?

A

Anticholinergics (e.g. Oxybutynin, Tolterodine) – these reduce parasympathetic input to the bladder. However, anticholinergics can cause side effects such as a dry mouth or constipation, therefore are not used frequently. Oxybutynin in particular should be avoided in frail patients, due to an increased risk of falls.

β3-adrenoceptor agonists (e.g. Mirabegron) – these drugs bind to β3-receptors on the detrusor muscle to cause relaxation. By doing so, these drugs increase the bladder’s capacity to store urine. β3-receptors are particularly useful for treating urge urinary incontinence.

Other possible therapies include the injection of botulinum toxin A, sacral nerve stimulation, and surgical procedures such as Augmentation enterocystoplasty or urinary diversion.

39
Q

passing of urine is under what control?

A

parasympathetic

40
Q

Upon the voluntary decision to urinate, neurons of the pontine micturition centre fire to excite what?

A

the sacral preganglionic neurons

41
Q

describe parasympathetic stimulation in the voiding phase of micturition

A

parasympathetic stimulation to the pelvic nerve (nerve roots S2-4) causes a release of acetylcholine (ACh), which works on muscarinic ACh receptors (M3 receptors) on the detrusor muscle, causing it to contract and increase intra-vesicular pressure. The pontine micturition centre also inhibits Onuf’s nucleus, with a resultant reduction in sympathetic stimulation to the internal urethral sphincter causing relaxation.

42
Q

what is vesical tenesmus?

A

the feeling of incomplete emptying of the bladder following urination)

43
Q

what are complications of urinary retention?

A
  • Urinary incontinence
  • Nocturia (the need to urinate at night)
  • Hydronephrosis – high pressure in bladder can push urine back up ureters into kidneys. This causes the renal pelvises to expand
  • Kidney failure
  • Sepsis
  • Bladder rupture – retention can lead to anuria (inability to pass urine). This can cause the bladder to stretch and possibly tear
44
Q

describe the ureterorenal reflex

A
  • the ureters are well supplied with pain nerve fibres
  • when a ureter becomes blocked (eg by a ureteral stone), intense reflex constriction occurs, associated with severe pain
  • also, the pain impulses cause a sympathetic reflex back to the kidney to constrict the renal arterioles, thereby decreasing urine output from the kidney
  • this effect is called the ureterorenal reflex and is important for preventing excessive flow of fluid into the pelvis of a kidney with a blocked ureter
45
Q

how is micturition affected if there is damage to the brain stem?

A
  • inhibitory signals mostly interrupted
  • the uninhibited neurogenic bladder results in frequent and relatively uncontrolled micturition
  • facilitative impulses passing continually down the cord keep the sacral centres so excitable that even a small quantity of urine elicit is an uncontrollable micturition reflex, thereby promoting frequent urination
46
Q

what zone of the prostate is response for BPH?

A

transitional

47
Q

what is the function of the sugars secreted by the prostate?

A

act as nutrition for sperm

48
Q

testosterone is produced in the testicles, after which it travels to the prostate for what to happen?

A

converted to dihydrotestosterone (DHT) in the stromal cells by the action of the enzyme type 2 5a-reductase

49
Q

what is the ultimate mediator of prostatic growth and why?

A

DHT as it causes cell growth and inhibits apoptosis

50
Q

although the ultimate cause of BPH is unknown, it is believed that DHT-induced growth factors act by what?

A

increasing the proliferation of stromal cells and decreasing the death of epithelial cells

51
Q

during ejaculation, the connection between the bladder and the urethra is what?

A

closed

52
Q

what do the first changes in BPH involve?

A

proliferation of glandular tissue in the transitional zone

53
Q

what can androgens do to cause BPH?

A

increase cellular proliferation and inhibit cell death

54
Q

prostate cancer usually occurs in what zone of the prostate?

A

peripheral

55
Q

histologically, what is prostate cancer?

A

adenocarcinoma

56
Q

what is hydronephrosis?

A

dilation of the renal pelvis and calyces associated with progressive atrophy of the kidney due to obstruction to the outflow of urine

  • even with complete obstruction, glomerular filtration persists
  • because of this continued filtration, the affected calyces and pelvis become dilated
57
Q

what may mask the deterioration in renal function associated with ageing in that the serum creatinine may be less than 120mmol/L in a patient with low GFR?

A

a reduction in muscle mass

58
Q

what is acute renal failure definition?

A

an abrupt decline in the renal function wiht increased creatinine and increased blood urea nitrogen levels (uraemia)

failure of renal excretory function due to depression of the GFR

59
Q

what are Na+ and osmolarity like in renal failure?

A

decreased

Na+ not reabsorbed. the backflow of urine increases the tubular fluid in the kidneys - dilutes the Na+ present in the tubular fluid hence decreasing osmolarity

60
Q

why is K+ raised in renal failure?

A

renal dysfunction —> person cannot secrete K+ into the tubular fluid (urine) so K+ builds up in cells

61
Q

why is there metabolic acidosis in renal dysfunction?

A
  • kidney unable to secrete H+ ions into the urine
  • kidney unable to reabsorbed HCO3- from urine
62
Q

why does pCO2 decrease in acute renal failure?

A

metabolic acidosis so the patient hyperventilates as resp compensation

63
Q

urea and creatinine levels in renal dysfunction?

A

elevated

64
Q

Hb in renal dysfunction?

A

drops - because kidneys secrete less erythropoietin

65
Q

what points along the urinary tract are more susceptible to obstruction?

A
  1. pelvic-ureteric junction
  2. where the ureters cross the pelvic brim (at the level of the iliac vessels)
  3. vesico-ureteric junction
66
Q

describe prostate secretions

A

thin, mild coloured and alkaline

67
Q

how does insulin treat hyperkalaemia?

A

insulin stimulates NaH exchanger in GIT — more substrate for NaK ATPase

PBL SEM 4 (50 decks)

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