December 2020 Flashcards

Question

What is the most common presentation of symptomatic CMV infection?

Answer 1

Heterophile-negative infectious mononucleosis

Answer 2

Prolonged fever, mild pharyngitis, hepatitis

Answer 3

Concurrent alveolar hemorrhage and glomerulonephritis Dyna med has one section under diffuse alveolar hemorrhage

Answer 4

Group of diseases characterized clinicopathologically by inflammation of AND damage to blood vessels. Inflammation leads to compromise which causes ischemia to the organs/tissues supplied by the involved vessels

Answer 5

- Immune complex formation - ANCA Antibodies - Pathogenic T lymphocyte response

Answer 6

Excess antigen leads to an excess of antigen-antibody complexes Vasoactive amines such as histamine causes permeability of vessels Immune complexes then are able to deposit in the vessel walls Activate the complement system, especially C5a, which is chemotactic Neutrophils invade the cell walls, phagocytose the immune complexes, release intracytoplasmic enzymes that damage the vessel walls Compromise vessel

Answer 7

Tip: there is evidence for and against the idea that they play a role in the pathophysiology Evidence for: ANCA primed neutrophils will adhere to and kill endothelial cells in vitro Evidence against: - GPA does exist even in the absence of PR3 Ab - GPA activity does NOT correlate with PR3 levels PR3 levels can remain high for YEARS even in remission

Answer 8

Review: Helper T Cells (CD4) interact with antigen presenting cells via HLA 2 (2x4 = 8) Vascular endothelial cells can present HLA II molecules when activated by cytokines. They, like antigen presenting macrophages, can interact with CD4 T cells and cause an immune response at the level of the vessels

Answer 9

TIP: the diseases with acronyms, mostly SMALL vessel vasculitis GPA EGPA MPA Tip: though ANCA stands for anti neutrophilic cytoplasmic ANTIBODIES, the renal disease associated with ANCA vasculitides are “pauci” immune, that is, there are NO antibody depositions

Answer 10

C- ANCA -> PR3 -TIP: CPR3 P-ANCA -> MPO -TIP: PMPO

Answer 11

NSAID and Colchicine if no contraindications 800mg TID and Colchicin 0.5 to 0.6 mg BID

Answer 12

``` Glomerulonephritis Palpable purpura Pulmonary infiltrates – so common! Chronic inflammatory sinusitis Unexplained ischemic events Microscopic hematuria Mononeuritis multiplex ```

Answer 13

#1: persistent microscopic hematuria Other presentation: Progressive kidney disease Glomerulonephritis Rapidly progressive glomerulonephritis Nephrotic syndrome

Answer 14

There is a lot of overlap The treatment for vasculitis is immunosuppression which could be devastating in the setting of infection or life-saving in a patient rapidly deteriorating

Answer 15

Small vessels!

Answer 16

Upper tract 95% Lower tract 90% Kidneys 75% TIP: G picmonic affecting the upper resp tract, lower tract and kidneys

Answer 17

GPA: Necrotizing vasculitis with granuloma formation EGPA: Necrotizing vasculitis with granuloma formation with infiltrating eosinophils - TIP: It’s in the name! Granuloma MPA: Necrotizing vasculitis W/O granulomas. - TIP: absence of granulomas is what distinguishes MPA from the other 2 TIP: grandmas are almost dead, hence granulomas are also necrotizing

Answer 18

Multiple, bilateral, nodular cavitary infiltrates

Answer 19

Pauci immune! Don’t get confused. Though ANCA is an antibody we use to diagnoses ANCA vasculitis, there are actually NO immune complexes deposited in the kidneys

Answer 20

FSGS, but can progress to RPGN

Answer 21

Upper respiratory tract (95%) Lower respiratory tract (90%) Renal ( 75%) Joints (70%) Eyes (50%) Fever (50%) Skin (46%)

Answer 22

Upper airway tract (95%) ``` Sinusitis Sinus drainage/purulence Hearing loss Subglottic stenosis Ear pain Oral lesions Otitis media ```

Answer 23

Think GPA due to retroorbital mass

Answer 24

90% of patients with GPA have PR3-ANCA Very high specificity

Answer 25

Higher risk of VTE

Answer 26

Biopsy Pulmonary tissue offers the highest diagnostic yield Tip: Definitive diagnosis of all vasculitides is biopsies

Answer 27

Insulin drip or apheresis

Answer 28

Insulin lowers triglyceride levels, but the goal of insulin therapy in severe acute pancreatitis associated with severe hypertriglyceridemia is to reverse the stress-associated release of fatty acids from adipocytes, to promote intracellular triglyceride generation within adipocytes, and to promote fatty acid metabolism in insulin sensitive cells, often in the setting of diabetes and peripheral insulin resistance TIP: insulin promotes TG formation IN tissue and OUT of the blood

Answer 29

Induction of remission Maintenance of remissioin

Answer 30

Induction of remission Maintenance of remissioin

Answer 31

Cyclophosphamide + steroids OR Rituximab + steroids Both are just as good

Answer 32

Cyclophosphamide + steroids OR Rituximab + steroids Both are just as good

Answer 33

2 mg/kg/day – need to adjust for renal insufficiency

Answer 34

Cyclophosphamide/Steroids

Answer 35

Steroids + either the following: Methotrexate Azathioprine Rituximab MMF

Answer 36

No Therapy is usually given 2 years after remission, then consideration of tapering is considered

Answer 37

No! In non-major organs, the benefit of treatment must be weighed against that of treatment

Answer 38

dyspnea cough hemoptysis

Answer 39

Systematic Review and Meta-analysis Oct 2020 Jama Open Network Pediatrics Conclusion: Ibuprofen -19 studies, 11 randomized/8 non-randomized -240,000 participants - Conclusion: In this study, use of ibuprofen vs acetaminophen for the treatment of fever or pain in children younger than 2 years was associated with reduced temperature and less pain within the first 24 hours of treatment, with equivalent safety. Tan E, Braithwaite I, McKinlay CJD, et al. Comparison of Acetaminophen (Paracetamol) With Ibuprofen for Treatment of Fever or Pain in Children Younger Than 2 Years: A Systematic Review and Meta-analysis. JAMA Netw Open. 2020 Oct 1;3(10):e2022398. doi: 10.1001/jamanetworkopen.2020.22398.

Answer 40

Circulation Nov 2020 RCT: The PEARL study - Primary endpoint: composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge (Cerebral Performance Category score =2), echocardiographic measures of left ventricular ejection fraction >50%, and a normal regional wall motion score of 16 within 24 hours of admission - 2nd endpoint: presence of culprit lesion - Patient: >18, out of hospital arrest, no STEMI - Results: - premature termination of trial. 49/99 patients with early angiography. - No difference in composite or simply survival - 47% of patients with culprit lesion - Conclusion: Understudied study showed no difference in outcomes for early coronary angiography Kern KB, Radsel P, Jentzer JC, et al. Randomized Pilot Clinical Trial of Early Coronary Angiography Versus No Early Coronary Angiography After Cardiac Arrest Without ST-Segment Elevation: The PEARL Study. Circulation. 2020 Nov 24;142(21):2002-2012. doi: 10.1161/CIRCULATIONAHA.120.049569. Epub 2020 Sep 28.

Answer 41

Proximal small intestine But small amounts can also be absorbed in the mouth, esophagus, stomach, and large intestines as well

Answer 42

- rapid gastric emptying, which can be induced by concurrent consumption of carbonated beverages - the ingestion of alcohol in the absence of other calorie sources such as proteins, fat, or carbohydrates. - A final factor that can increase absorption is to drink alcohol that is diluted to a modest concentration (~20% or less). AKA lower concentration has higher absorption rate compared to higher

Answer 43

Nausea, indigestion and upper back pain

Answer 44

Women present 10-15 years later Women have more co-morbidities than men Women present with atypical features

Answer 45

Women are still referred less often by physicians for diagnostic and therapeutic cardiovascular procedures, and there are more false-positive and false-negative diagnostic tests in women. Women are also less likely than men to receive angioplasty, thrombolysis, coronary artery bypass grafting, aspirin, and β-blockers. Despite this, the 5- and 10-year survival rates following coronary artery bypass grafting are the same between the sexes.

Answer 46

Anaerobic bacteria It is widely thought that colonization of the gingival crevices by anaerobic bacteria or microaerophilic streptococci (especially in patients with gingivitis and periodontal disease), combined with a risk of aspiration, is important in the development of lung abscesses.

Answer 47

Aspiration

Answer 48

Because most cases of lung abscess occur in the context of RECLINING aspiration, the dependent lobes of the lung are most vulnerable. The dependent lobes include the superior segment of the lower lobes and the posterior segment of the upper lobes, with the right lung more commonly involved than the left lung. The middle lobe and the lingula are the most ventral lobes and are therefore nondependent in the supine position.

Answer 49

The most common cause of primary lung abscess is aspiration

Answer 50

Cervical cancer

Answer 51

HPV-16 and -18 are the types most frequently associated with high-grade dysplasia and targeted by both U.S. FDA–approved vaccines Interesting: More than 60 types of HPV are known, with approximately 20 types having the ability to generate high-grade dysplasia and malignancy

Answer 52

Cofactor (epidemiology) is a condition that exacerbates the effects of another condition;

Answer 53

Risk factors for HPV infection and, in particular, dysplasia include a high number of sexual partners, early age of first intercourse, and history of venereal disease TIP: all about sexual exposure, hence more partners, earlier age and STD’s because STD’s imply sexual encounters

Answer 54

Stage 0: In situ Stage 1: Only cervix Stage 2: Outside cervix but NOT in lower third vagina and NOT in pelvis Stage 3: Outside cervix but only lower third vagina or in pelvic wall Stage 4: Pelvic organs or metastasis

Answer 55

CK: 4-8 hours rise, 48-72 hours duration Trop: 4-8 hours rise, 7-10 days duration

Answer 56

Blood collected in tubes with EDTA, the anticoagulant in the test tubes, (purple top) will clump. EDTA is ethylenediaminetetraacetic acid. It will decrease the Ca content of blood, leading to agglutination of the platelets to IgG. Obtaining a blood smear will show platelet clumps. Secondly, you can obtain blood sample in a green or blue top which will reveal normal blood count

Answer 57

4 attacks, or 1x/week

Answer 58

The efficacy in decreasing migraine attacks is 50%–75%. However, the treatment effect is delayed 2–12 weeks.

Answer 59

Arm and shoulder pain Brachial plexus neuropathy Horner syndrome Explanation: Apically located, the tumor extends to involve the 8th cervical and first and second thoracic nerve, and as it grows involves the sympathetic ganglia

Answer 60

Non-small cell lung cancer

Answer 61

IGF 1 since GH is highly pulsatile so random levels are not reliable

Answer 62

At normal dosing, the hepatocytes are NOT injured, but at high doses, the metabolite NAPQI (N-acetyl-p-benzoquinone imine), will overwhelm the gluthathione stores that are needed to convert NAPQI to a nontoxic metabolite Clinical tip: direct toxic effect to hepatocytes comes from the drug itself or a toxic metabolite of the drug

Answer 63

Idiosyncratic reactions are infrequent and unpredictable There is no dose dependency, and the timing of hepatic injury has little association with the duration of drug treatment.

Answer 64

The most common causes of thiamine deficiency in developed countries are alcoholism and chronic illnesses such as cancer.

Answer 65

Alcohol interferes with the absorption of thiamine as well as the synthesis of thiamin pyrophosphate. In addition, alcohol increases the excretion of thiamine in the urine. Moreover, most chronic alcoholics have low dietary intake of thiamine.

Answer 66

When there is additional loss of memory with confabulatory psychosis, the syndrome is called Wernicke-Korsakoff syndrome

Answer 67

Thiamine should be repleted intravenously at a dose of 200 mg IV three times daily until there is no further improvement in acute symptoms, and then long-term oral thiamine at a dose of 10 mg daily should be continued until recovery is complete.

Answer 68

Both are different presentations of thiamine deficiency. Beriberi is divided into either “wet” or “dry” depending on the presence of high output heart failure and cardiomegaly Alcoholic patients also demonstrate central nervous system effects. Acutely, this can consist of horizontal nystagmus, ophthalmoplegia, cerebellar ataxia, and mental impairment. This constellation of findings is called Wernicke encephalopathy.

Answer 69

Lymphoplasmacytic lymphoma

Answer 70

Primary effusion lymphoma and multicentric castleman disease

Answer 71

Incubation period 7-14 days Fever is first symptom – high 104 Koplik spots follow – grains of sand on red base Rash – maculopapular starting at hairline and spreads down body

Answer 72

4 days prior to sx to 4 days after rash hence, after 4 days of rash, not infectious

Answer 73

“Fever/rash” presentations should always prompt diagnosis Koplik spots are pathognomonic Clinical Tip: highly misdiagnosed

Answer 74

Koplik spots are pathognomonic These are 1- to 3-mm whitish, grayish, or bluish elevations with an erythematous base, typically seen on the buccal mucosa opposite the molar teeth, though they can spread to cover the buccal and labial mucosa as well as the hard and soft palate.

Answer 75

Neurologic and pulmonary complications CNS: - PME: primary measles encephalitis - SSPE: subacute sclerosing panencephalitis which is fatal - MIBE: measles inclusion body encephalitis - ADEM: acute disseminated encephalomyelitis Pulm: - bronchopneumonia, - laryngotracheobronchitis (croup)

Answer 76

12-15 mos then 4-6 years

Answer 77

Vitamin A Tip: Malnutrition is also a risk factor, they go hand in hand

Answer 78

A meta-analysis has concluded that there is clear evidence that two megadoses of vitamin A can lower the risk of death in children HOSPITALIZED with measles, particularly those under the age of TWO.

Answer 79

Henoch-Schönlein purpura Cryoglobulinemic vasculitis associated with hepatitis C, Serum sickness Cutaneous vasculitic syndromes Polyarteritis nodosa–like vasculitis associated with hepatitis B

Answer 80

Nitrogen, Oxygen are from aerophagia Hydrogen, CO2 and methane are produced by small intestine bacteria

Answer 81

Downbeat nystagmus is a pure vertical nystagmus associated with cerebellar disease. Gaze-evoked nystagmus - cerebellar disease. Rebound nystagmus is a type of primary position nystagmus provoked by eccentric gaze - cerebellar or brainstem disease. Pure torsional nystagmus - central sign. Conjugate horizontal jerk nystagmus may be seen in either peripheral or central causes of vertigo Unidirectional horizontal nystagmus usually indicates peripheral lesion

Answer 82

The direction of nystagmus described the direction of the FAST phase

Answer 83

Nystagmus in an eccentric gaze with the fast phase beating in gaze direction (such as right beating in a right-looking gaze, left beating in the left-looking gaze, hence the “direction” changes (remember direction is determined by the fast phase) Gaze evoked and end-gaze nystagmus are synonymous Unidirectional horizontal means there is only one direction, so won’t change direction when gazing the opposite direction

Answer 84

Increasing evidence suggests that the ultimate cause of ganglion cell degeneration in achalasia is an autoimmune process attributable to a latent infection with human HSV-1 combined with genetic susceptibility.

Answer 85

Hydrocortisone should be considered at a dose of 50 mg every 6 hours in patients with septic shock on vasopressors. If clinical improvement occurs with use of hydrocortisone over 24–48 hours, then a course of therapy for 5–7 days is indicated

Answer 86

SIRS: 2/4 SIRS Sepsis: 2/4SIRS + suspected or documented infection Severe sepsis: sepsis w/ end organ damage - BP - Lactic acid - Urine output - Lung injury: PaO2/FiO2 < 250 without PNA or PaO2/FiO2 <200 with PNA - Renal injury - Liver injury – bili or INR - Hematologic- thrombocytopenia Septic shock: persistent hypotension after fluid resus

Answer 87

Nystagmus is jerk, when it corrects during its fast corrective phase

Answer 88

The definition of sepsis is based on the prediction rule SOFA Sepsis - life-threatening organ dysfunction caused by dysregulated host response to infection “Organ dysfunction” is defined by SOFA, and needs 2 points Septic shock is sepsis with persistent hypotension (MAP < 65 mmHg) requiring vasopressors

Answer 89

``` Kidney Lung Cardiovascular Brain Liver Heme ```

Answer 90

Hypotension SBP < 100mmHG AMS Tachypnea > 22 Clinical Tip: HAT

Answer 91

Clinically isolated syndrome

Answer 92

The hallmark of internuclear ophthalmoplegia is impaired adduction in the eye ipsilateral to the affected medial longitudinal fasciculus and nystagmus in the opposite eye when abducting

Answer 93

Lesion of the median longitudinal fascículos It is a paired white matter tract passing close to the midline, through the brainstem lying ventral to the cerebral aqueduct in the midbrain and the fourth ventricle in the pons and medulla

Answer 94

NEJM Dec 2020 RCT Fidelio CKD trial In patients with CKD and type 2 diabetes, treatment with finerenone resulted in lower risks of CKD progression and cardiovascular events than placebo. (Funded by Bayer; FIDELIO-DKD ClinicalTrials.gov number, NCT02540993.). Bakris GL, Agarwal R, Anker SD, et al. Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes. N Engl J Med. 2020 Dec 3;383(23):2219-2229. doi: 10.1056/NEJMoa2025845. Epub 2020 Oct 23.

Answer 95

Systematic Review and Meta Analysis Eur Heart Journal Nov 2020 Forty-nine studies were included, with a total sample size of 670 594. Among these, 12 studies were randomized controlled trials (RCTs; seven crossover and five parallel RCTs) and 37 studies were observational (including four post hoc analyses of data from RCTs). The hazard ratios (HRs) of COPD exacerbation between COPD patients who were not treated with BBs and - those who were treated with BBs 0.77j [95% confidence interval (CI) 0.67, 0.89] - cardioselective BBs 0.72 [95% CI 0.56, 0.94] - noncardioselective BBs 0.98 [95% CI 0.71, 1.34, respectively] (HRs <1 indicate favouring BB therapy). The HRs of all-cause mortality between patients with COPD who were not treated with BBs and - those who were treated with BBs 0.70 [95% CI 0.59, 0.83] - cardioselective BBs 0.60 [95% CI 0.48, 0.76] - noncardioselective BBs 0.74 [95% CI 0.60, 0.90] (HRs <1 indicate favouring BB therapy) CONCLUSION: The use of BBs in patients with chronic obstructive pulmonary disease is not only safe but also reduces their all-cause and in-hospital mortality. Cardioselective BBs may even reduce chronic obstructive pulmonary disease exacerbations. In addition, cardioselective BBs do not affect the action of bronchodilators. Importantly, BBs reduce the heart rate acceleration caused by bronchodilators. BBs should be prescribed freely when indicated in patients with chronic obstructive pulmonary disease and heart disease. Yang YL, Xiang ZJ, Yang JH, et al. Association of beta-blocker use with survival and pulmonary function in patients with chronic obstructive pulmonary and cardiovascular disease: a systematic review and meta-analysis. Eur Heart J. 2020 Nov 19. pii: 5992317. doi: 10.1093/eurheartj/ehaa793.

Answer 96

NEJM Nov 2020 RCT Solidarity Trial by the WHO Mortality trials of four repurposed antiviral drugs - remdesivir, hydroxychloroquine, lopinavir, and interferon beta-1a At 405 hospitals in 30 countries, 11,330 adults - 2750 were assigned to receive remdesivir, - 954 to hydroxychloroquine - 1411 to lopinavir (without interferon) - 2063 to interferon (including 651 to interferon plus lopinavir) - 4088 to no trial drug Adherence was 94 to 96% CONCLUSIONS: These remdesivir, hydroxychloroquine, lopinavir, and interferon regimens had little or no effect on hospitalized patients with Covid-19, as indicated by overall mortality, initiation of ventilation, and duration of hospital stay. Pan H, Peto R, Henao-Restrepo AM, et al. Repurposed Antiviral Drugs for Covid-19 - Interim WHO Solidarity Trial Results. N Engl J Med. 2020 Dec 2. doi: 10.1056/NEJMoa2023184.

Answer 97

IV beta blocker such as esmolol Add vasodilator if goal is still not achieved such as nitroprusside or nicardipine

Answer 98

BP 110 to 120 HR < 60

Answer 99

1) acute onset of thoracic or abdominal pain described as tearing or ripping 2) mediastinal widening on chest radiograph 3) either pulse differential (absence of proximal extremity or carotid pulse) OR BP differential (>20 sbp in left vs right arm) Clinical tip: all of these can easily be assessed prior to CT!

Answer 100

Bradykinesia Tremor Cogwheel rigidity Postural instability

Answer 101

Parkinson Disease is one cause of parkinsonism Parkinsonism is the constellation of signs/symptoms, but Parkinson disease is a specific cause

Answer 102

Bradykinesia Movement Disorder Society (MDS) Clinical Diagnostic Criteria for Parkinson Disease based on consensus criteria derived from MDS task force for definition of Parkinson disease diagnostic criteria - bradykinesia with at least 1 of muscular rigidity (such as cogwheeling) resting tremor of 4-6 hertz

Answer 103

Approximately two-thirds of filtered Na+-Cl– is reabsorbed by the renal proximal tubule, via both paracellular and transcellular mechanisms The thick ascending limb of Henle subsequently reabsorbs another 25%–30% of filtered Na+-Cl– via the apical, furosemide-sensitive Na+-K+-2Cl– co-transporter. Cool tip: 1.5 kg of salt is filtered daily via the kidneys! Hence, reabsorption is a must

Answer 104

Tip: all have to do with invasive procedures. This is unlike the risk factors for Pseudomonas. Chronic dialysis – access Home antibiotics – frequent access Wound care - debridement

Answer 105

The presence of cardiac involvement is influenced by race. Although over a quarter of Japanese sarcoidosis patients develop cardiac disease, only 5% of sarcoidosis patients in the United States and Europe develop symptomatic cardiac disease

Answer 106

Cefepime Zosyn Antipseudomonal Carbapenem e.g. Meropenem, Imipenem Cilastin TIP: All cover gram positive and gram negative organisms including Pseudomonas

Answer 107

The cancer risks in Crohn disease and UC are probably equivalent for similar extent and duration of disease. Thus, the same endoscopic surveillance strategy used for UC is recommended for patients with chronic Crohn colitis

Answer 108

Patients with Crohn disease may have an increased risk of non-Hodgkin lymphoma, leukemia, and myelodysplastic syndromes

Answer 109

Within 8 years Then the frequency is 1-3 years depending on factors Dynamed

Answer 110

COLECTOMY!!!

Answer 111

HPV types 6 and 11 cause 90% of anogenital warts, whereas types 16 and 18 are responsible for 70% of cervical cancers.

Answer 112

After vaccination, Pap testing is recommended to detect disease caused by other oncogenic HPV types. Because 30% of cervical cancers are caused by HPV types not contained in the vaccines, no changes in cervical cancer screening programs are currently recommended

Answer 113

Suspect Lynch in any pateitn with cancer < 50 yo from an organ specifically characteristic of Lynch syndrome Top 3 - Colorectal - Endometrial - Gastric TIP: - GI heavy: Colorectal, small intestine, gastric, biliary and pancreatic - GU: Ureteral and renal pelvis - Female GU: Endometrial and ovarian

Answer 114

3 family members with colon cancer 2 generations 1 of the cases < 50 yo Tip: "3, 2, 1" rule

Answer 115

The most common presenting symptom in ALS is asymmetric weakness of insidious onset, which is most prominent in the lower extremities. TIP: Probably abnormal gait is the presentation

Answer 116

The pathologic hallmark of ALS is loss or death of both upper and lower motor neurons. The upper motor neuron loss can be demonstrated by degeneration of the corticospinal tracts typically originating in layer five of the motor cortex and descending downward via the pyramidal tract to synapse with the lower motor neurons both directly and indirectly via interneurons. The lower motor neuron disease is manifested by death of anterior horn cells in the spinal cord and brainstem, which can lead to bulbar symptoms.

Answer 117

♣ 0: absent reflex ♣ 1+: trace, or seen only with reinforcement ♣ KEY: 2+ is normal ♣ 3+: brisk ♣ 4+: nonsustained clonus (i.e., repetitive vibratory movements) ♣ 5+: sustained clonus

Answer 118

The largest source of calories and nutrients in the diet is carbohydrates. At least 45%–55% of a person’s total calories are derived from carbohydrates. Carbs > Fats > Proteins

Answer 119

Patients with procidentia, that is, rectal prolapse, often are socially withdrawn and depressed given the symptoms of fecal incontinence and poor hygiene/smell Tip: Women are more affected. Related to pelvic floor disorder

Answer 120

Surgical therapy is the mainstay

Answer 121

TP segment, that is, the line created by the end of the T to the beginning of the P wave

Answer 122

It is identified as the segment between | the end of the QRS complex and the beginning of the T wave.

Answer 123

Slight (< 1 mm) ST segment | depression or elevation

Answer 124

Earliest sign: T wave change which is large upright T wave. T wave inversion occurs DURING ST elevation present ST elevation: occurs within minutes to hours of infarction Q waves: last to develop, taking hours to days and typically lasts indefinitely TIP: T changes, then ST changes, then Q changes

Answer 125

Most leads EXCEPT aVR and V1-V3

Answer 126

Q waves in any leads EXCEPT aVR and V1-V3 that last < 0.03 seconds and < 2mm depth Tip: 0.04s is 1 small box

Answer 127

ANY Q wave in V1-V3 Q waves lasting > 0.03 seconds, deeper than 2 mm or 25% of the QRS height in V4-V6, aVL/Lead I and Lead II/aVF Tip: lateral leads and inferior leads

Answer 128

Present in 2 continguous leads and depth > 1 mm

Answer 129

Sensitivity = 22%, specificity = 95% • S in V3 + R in aVL > 24 mm (men) • S in V3 + R in aVL > 20 mm (women) Clinical Tip: Best criteria to rule IN

Answer 130

V1 Hence, the presence of Q wave in V1 means that septum is involved

Answer 131

``` Right axis deviation: between 100 and 180 II, III, avF: qR complexes I, aVL: rS complexes QRS prolonged between 80 and 110 aVF: Prolonged R peak time ``` TIP: vector is going down and to the right Clinical tip: eval ALL patients with RAD for LPFB

Answer 132

I, aVF and II – ALL POSITIVE II, III, aVF: R wave > S wave V1 to V6: Transition between V2-V4, R wave V5>V6 aVR: negative deflection I, aVL, V5, V6: Positive R wave

Answer 133

ST depression and T Wave inversions

Answer 134

NOT! It is normal! Hence, if there is any deviation, eval for fascicular blocks or LVH, etc

Answer 135

3 major categories, of which malignancy is the most common cause Malignancy Infection Organ failure (not including the heart, as HF leads to SAAG > 1.1) TIP: Malignancy usually causes fibrosis of LN and lymphatics Infection -TB, Chlamydia, Coccidioidomycosis Organ failure: - Pancreatitis; diabetic nephropathy - Neprhotic syndrome, HD - Biliary ascites - Liver: Budd chiari, SOS

Answer 136

RBC > 10,000 Repeat paracentesis if safe to eval if RBC is due to traumatic tap vs true hemorrhagic ascites Then, find the source of bleeding

Answer 137

<1000 RBC is normal

Answer 138

The total protein concentration may also help differentiate uncomplicated ascites from cirrhosis from cardiac ascites, both of which have a SAAG ≥1.1 g/dL (≥11 g/L). In the case of ascites from cirrhosis, the total protein is <2.5 g/dL (<25 g/L), whereas in cardiac ascites it is ≥2.5 g/dL (≥25 g/L)

Answer 139

Tip: Top organs involved are liver and heart ``` Cirrhosis Alcoholic hepatitis Massive hepatic metastases Budd-Chiari syndrome Portal vein thrombosis Idiopathic portal fibrosis ``` Heart failure Constrictive pericarditis

Answer 140

Parkinsonism is the syndrome characterized by Bradykinesia Rigidity Postural instability Tremor Parkinson disease is one of the causes of parkinsonism syndrome. Parkinson disease is a specific type of parkinsonism that responds to Levodopa

Answer 141

Postural instability postural instability (most common and EARLYpresentation), characterized by lurching gait and/or unexplained backward falls without loss of consciousness TIP: gait is the first sign of PSP

Answer 142

Postural instability (most common presentation), characterized by lurching gait and/or unexplained backward falls without loss of consciousness Supranuclear vertical gaze palsy - presents 4 years into disease so don't count on it Personality change/cognitive impairment within 2 years, much earlier than idiopathic Parkinson TIP: "PSP" ``` P = Postural instability S = Supranuclear vertical gaze palsy P = Personality change/cognitive impairment ```

Answer 143

PSP's presentation is prominent for early gait involvement, early postural instability and eye involvement while Parkinsons has falls LATE in its disease course and no eye involvement Parkinsons has tremors and PSP has NO tremor

Answer 144

Clinical tip: the presence of ocular manifestations is a great way to distinguish PSP from other Parkinsonisms Supranuclear vertical gaze palsy obviously Eyelid retraction and staring gaze with characteristic surprised, worried facial appearance, due to overactivity of frontalis, procerus, and corrugator muscles ocular symptoms are common, including dry, red, sore eyes photophobia blurred vision difficulty focusing involuntary eyelid closure or apraxia of eyelid opening, often prominent when talking or eating and can cause functional blindness spontaneous blink rate severely impaired and may lead to ocular irritation, epiphora, and blurring of vision

Answer 145

The hummingbird sign located in the midbrain

Answer 146

Meta-analysis JAMA internal medicine Nov 2020 Conclusions and Relevance: These findings suggest that treating 100 adults (aged 50-75 years) without known cardiovascular disease with a statin for 2.5 years prevented 1 MACE in 1 adult. Statins may help to prevent a first MACE in adults aged 50 to 75 years old if they have a life expectancy of at least 2.5 years. There is no evidence of a mortality benefit. Study Selection: Randomized clinical trials of statins for primary prevention focusing on older adults (mean age >55 years). Main Outcomes and Measures: The primary outcome was time to ARR thresholds (0.002, 0.005, and 0.010) for a first MACE, as defined by each trial. There were broad similarities in the definition of MACE across trials, with all trials including myocardial infarction and cardiovascular mortality. Results: Eight trials randomizing 65?383 adults (66.3% men) were identified. The mean age ranged from 55 to 69 years old and the mean length of follow-up ranged from 2 to 6 years. Only 1 of 8 studies showed that statins decreased all-cause mortality. The meta-analysis results suggested that 2.5 (95% CI, 1.7-3.4) years were needed to avoid 1 MACE for 100 patients treated with a statin. To prevent 1 MACE for 200 patients treated (ARR = 0.005), the TTB was 1.3 (95% CI, 1.0-1.7) years, whereas the TTB to avoid 1 MACE for 500 patients treated (ARR = 0.002) was 0.8 (95% CI, 0.5-1.0) years. Yourman LC, Cenzer IS, Boscardin WJ, et al. Evaluation of Time to Benefit of Statins for the Primary Prevention of Cardiovascular Events in Adults Aged 50 to 75 Years: A Meta-analysis. JAMA Intern Med. 2020 Nov 16. pii: 2773065. doi: 10.1001/jamainternmed.2020.6084.

Answer 147

European Respiratory Journal July 2020 RCT, double blinded Vitamin C Conclusion: In offspring of pregnant smokers randomised to vitamin C versus placebo, vitamin C during pregnancy was associated with a small but significantly increased airway function at 3 and 12 months of age, suggesting a potential shift to a higher airway function trajectory curve. Continued follow-up is underway. McEvoy CT, Shorey-Kendrick LE, Milner K, et al. Vitamin C to Pregnant Smokers Persistently Improves Infant Airway Function to 12 Months of Age: A Randomised Trial. Eur Respir J. 2020 Jul 2. pii: 13993003.02208-2019. doi: 10.1183/13993003.02208-2019.

Answer 148

ST changes develop in seconds to minutes after MI and resolves minutes to hours as long as reperfusion is provided. Without reperfusion, resolves in hours to days. ST elevation that persists >48 hours is a poor prognostic factor TIP: "seconds to minutes", "minutes to hours", and "hours to days"

Answer 149

Yes, most commonly CAD

Answer 150

Obesity COPD Infiltrative cardiomyopathy Myxedema

Answer 151

* The amplitudes of all the QRS complexes in the limb leads are < 5 mm; or * The amplitudes of all the QRS complexes in the precordial leads are < 10 mm

Answer 152

Symptomatic COVID (high quality evidence) Does NOT prevent colonization, dose NOT prevent severe infection, does NOT prevent death. Though these is assumption that prevention of symptomatic disease will prevent severe disease and death.

Answer 153

COVID patients that are hospitalized on high flow nasal cannula

Answer 154

The only significant benefit is shorter time to recovery (7 days vs 8 days) and improved clinical status at 15 day Patients in the combination group were also more likely to have improved clinical status at day 15 (odds ratio, 1.3; 95% CI, 1.0 to 1.6)

Answer 155

NIH panel said that there are insufficient data to recommend for or against baricitinib in combination with remdesivir for the treatment of COVID-19 in hospitalized patients in cases where corticosteroids can be used instead. The panel said it recommends baricitinib in combination with remdesivir in hospitalized, nonintubated patients with COVID-19 who require oxygen supplementation only in the rare circumstances where corticosteroids cannot be used

Answer 156

JAMA Dec 2020 Double blinded RCT No The primary outcome was the time to the composite of all-cause death or cardiopulmonary hospitalization during each enrolling season. Conclusions and Relevance: In patients with high-risk cardiovascular disease, high-dose trivalent inactivated influenza vaccine, compared with standard-dose quadrivalent inactivated influenza vaccine, did not significantly reduce all-cause mortality or cardiopulmonary hospitalizations. Influenza vaccination remains strongly recommended in this population. Vardeny O, Kim K, Udell JA, et al. Effect of High-Dose Trivalent vs Standard-Dose Quadrivalent Influenza Vaccine on Mortality or Cardiopulmonary Hospitalization in Patients With High-risk Cardiovascular Disease: A Randomized Clinical Trial. JAMA. 2020 Dec 4. pii: 2773989. doi: 10.1001/jama.2020.23649.

Answer 157

NEJM Dec 2020 THALES Trial Randomized, placebo-controlled, double-blind trial Yes, but severe bleeding; uncertain if worth it The primary outcome was a composite of stroke or death within 30 days The primary safety outcome was severe bleeding. CONCLUSIONS: Among patients with a mild-to-moderate acute noncardioembolic ischemic stroke (NIHSS score =5) or TIA who were not undergoing intravenous or endovascular thrombolysis, the risk of the composite of stroke or death within 30 days was lower with ticagrelor-aspirin than with aspirin alone, but the incidence of disability did not differ significantly between the two groups. Severe bleeding was more frequent with ticagrelor. (Funded by AstraZeneca; THALES ClinicalTrial.gov number, NCT03354429.). Johnston SC, Amarenco P, Denison H, et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med. 2020 Jul 16;383(3):207-217. doi: 10.1056/NEJMoa1916870.

Answer 158

Tip: 3 different choices, all low quality evidence and weak reccomendation per IDSA 2017 guidelines 1) Oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence) OR 2) 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence) OR 3) 10-day course of vancomycin rather than a second course of metronidazole if metronidazole was used for the primary episode (weak recommendation, low quality of evidence)

Answer 159

Severe: EITHER WBC >15k OR Cr > 1.5 Fulminant: Hypotension, shock, ileus or megacolon

Answer 160

Tip: Toxic + Megacolon Megacolon (>6 cm of colonic distension) AND ``` ≥ 3 of the following features temperature > 38.6 degrees C (101.5 degrees F) pulse rate > 120/min white blood cell count > 10.5 × 109/L anemia ``` ≥ 1 of the following features dehydration hypotension altered level of consciousness electrolyte abnormalities

Answer 161

Fulminant C Difficile infection

Answer 162

BOTH are the same! IDSA 2017 Guidelines Vancomycin 125 mg orally 4 times daily for 10 days (IDSA/SHEA Strong recommendation, High-quality evidence; ESCMID Grade A-I) OR Fidaxomicin 200 mg orally twice daily for 10 days (IDSA/SHEA Strong recommendation, High-quality evidence) Both are equally good!

Answer 163

C4 and/or C2 levels If normal, C1 inhibitor def is unlikely

Answer 164

All who are hospitalized and on O2 supplementation, regardless of the mode e.g. high flow, noninvasive ventilation, mechanical ventilation

Answer 165

Hospitalized patients NOT on O2 Discharged patients, that is, non-hospitalized patients NIH Guidelines

Answer 166

0.5 mg for adults Tip: Epi 1 mg is dead man dose, 0.5mg is almost dead man dose Kids: 0.3mg for < 50kg, once >50kg, treat like adult

Answer 167

Lymphoproliferative malignancy

Answer 168

Childhood to young adult onset likely hereditary Middle aged and on likely acquired

Answer 169

Kallikrein-kinin pathway Complement pathway

Answer 170

C1 inhibitor plays a role in inhibiting 2 major pathways - Kallikrein-kinin pathway/Complement pathway. Interesting how the immune system and the vasodilatory/coagulation system are connected by this one inhibitor. PreKallikrein -> Kallikrein via Factor XIIa High Molecular Weight Kininogen -> Bradykinin via Kallikrein Bradykinin binds to Bradykinin 2 receptors -> release of substance P -> Substance P causes vasodilation Bradykinin also causes Plasminogen ***

Answer 171

Men who are overweight or obese frequently have low serum testosterone concentrations, which are associated with increased risk of type 2 diabetes.

Answer 172

LANCET DIABETES JAN 2021 RCT YES! Between Feb 5, 2013, and Feb 27, 2017, of 19 022 men who were pre-screened, 1007 (5%) were randomly assigned to the placebo (n=503) and testosterone (n=504) groups. At 2 years, 2-h glucose of 11·1 mmol/L or higher on OGTT was reported in 87 (21%) of 413 participants with available data in the placebo group and 55 (12%) of 443 participants in the testosterone group (relative risk 0·59, 95% CI 0·43 to 0·80; p=0·0007). The mean change from baseline 2-h glucose was -0·95 mmol/L (SD 2·78) in the placebo group and -1·70 mmol/L (SD 2·47) in the testosterone group (mean difference -0·75 mmol/L, -1·10 to -0·40; p<0·0001). The treatment effect was independent of baseline serum testosterone. CON: Testosterone treatment for 2 years reduced the proportion of participants with type 2 diabetes beyond the effects of a lifestyle programme. Increases in haematocrit might be treatment limiting. Longer-term durability, safety, and cardiovascular effects of the intervention remain to be further investigated. Wittert G, Bracken K, Robledo KP, et al. Testosterone treatment to prevent or revert type 2 diabetes in men enrolled in a lifestyle programme (T4DM): a randomised, double-blind, placebo-controlled, 2-year, phase 3b trial. Lancet Diabetes Endocrinol. 2021 Jan;9(1):32-45. doi: 10.1016/S2213-8587(20)30367-3.

December 2020 Flashcards

(205 cards)