High Yields 2018 Qs

Question 1

How does the PD-1/PD-L1 interaction relate to tumor growth?
TEST QUESTION

Answer 1

Programmed cell death protein 1 (PD-1) is a transmembrane protein expressed on T cells, B cells, and natural killer (NK) cells. It has an inhibitory effect and binds to the programmed cell death ligand 1 and 2.

PDL-1 is expressed on the surface of multiple tissue types, including many tumor cells, as well as hematopoietic cells.

PD-1 is the negative regulator of cell activation.
The tumor microenvironment up-regulates PD-1 on tumor reactive T cells, and contributes to impaired antitumor immune responses (the PD-1/PDL-1 intercation inhibits apoptosis of the tumor cell)

• PD-1 inhibitors:
  Nivolumab
  Pembrolizumab
  Cemiplimab
  Dostarlimab
  Retifanlimab
  Toripalimab
  Tislelizumab

PDL-1 inhibitors:
Atezolizumab
Avelumab
Durvalumab

CTLA-4 inhibitors:
Ipilimumab
Tremelimumab

Question 2

what are Interferons?

Answer 2

non specific immune modulators named for interfering with viral machinery

*INF Gamma upregulates PD-1 and PDL-1. It is also an important activator of macrophages and inducer of major histocompatibility complex class II molecule expression.

Question 3

what part of the Her2 receptor is the target of intervention? (ie: Intracellular, tyrosine kinase, extracellular, transmembrane)

Answer 3

extracellular portion

Question 4

What is the other name for protein Ca125?

Answer 4

The gene for CA 125 is called MUC16 or mucin16

Question 5

What distinguishes PSTT from choriocarcinoma?

Answer 5

1.INTERMEDIATE trophoblasts
2.Human Placenta Lactogen
3. Lower betaHCG

*all of these

Question 6

What distinguishes endometrial stromal nodule (ESN) from low grade endometrial stromal sarcoma (LG-ESS)?

A ESS has more mitoses
B ESS has more atypia
C presence of spiral arterioles
D absence of LVSI in ESN

Answer 6

Absence of LVSI is the correct answer choice

The histologic features of ESN are identical to LG-ESS but ESN has a circumscribed, noninfiltrating border without evidence of myometrial or vascular invasion. ESN is a benign neoplasm that is cured with simple hysterectomy.

B&H: Because diagnosis is based on complete circumscription and absence of lymphovascular invasion, the distinction between stromal nodule and stromal sarcoma can usually be made only at the time of hysterectomy.

Question 7

Ratio of tumor markers for ovca and colon cancer?

Answer 7

CA125/CEA (this one, 25:1), HE4/CEA

Question 8

Picture of pap serous uterine cancer histology

Answer 8

pap serous
other test options that are wrong: LMS, endometrioid

Architecture:
Papillary with or without appreciable fibrovascular cores; micropapillary pattern can be seen
Slit-like spaces
Gland-like spaces may be observed
Psammoma bodies may be present in up to 33% of cases
Cytoplasm usually scant but can be abundant with eosinophilia or clearing
Tumor cells can colonize existing endometrial glands
Tumor cells can appear discohesive
Nuclei are typically high grade with pleomorphism, hyperchromasia, prominent nucleoli and frequent mitotic figures (including atypical mitotic figures)

Question 9

Napsin A (IHC stain)

Answer 9

clear cell carcinoma

• Immunophenotype: most often lacks estrogen receptors and WT-1. Do have: p53 expression, napsin-A, hypoxia-inducible factor 1 alpha (HIF-1 alpha), glypican-3, and hepatocyte nuclear factor 1-beta (HNF-1 beta).

Question 10

POLE mutated (group 1)

Answer 10

excellent prognosis regardless of grade POLE (why? high tumor mutation burden, tumor neoantigen production, and tumor infiltrating T cells)

Question 11

MSI hypermutated (group 2)

Answer 11

Most common methylation of MLH1; also can have mutated MLH1, MSH2, MSH6, PMS2; MLH1 + PMS2, MSH2 + MSH6 form dimers so if one degraded the other is; immunotherapy candidates if recurrent; radiation beneficial

High TMB ≥10 mutations/megabase > pembrolizumab.

dMMR/MSI-H: pembrolizumab or dorstalimab.

Tumors without dMMR or high TMB: Pembrolizumab plus lenvatinib

Question 12

MSS/copy number low (group 3 - PTEN, ARID1A, PIK3CA mut, ER/PR pos)

Answer 12

Good prognosis; respond to hormonal therapy; PI3K/mTOR inhibitors for metastatic disease

Question 13

Copy number high (group 4) of endometrial cancer molecular subgroup is most likely what histology?

Answer 13

serous; p53 mutated; poor prognosis; trastuz if HER2 +/ERBB2 amp

Question 14

what are the most common MMR defects in Hnpcc?

Answer 14

MLH1/MSH2 (this one); PMS2, MSH6

MLH1 and MSH2 genes are by far the most commonly mutated in Lynch syndrome patients accounting for ~70% of the mutations identified (32% in MLH1 and 38% in MSH2)

Question 15

KRAS associations?

Answer 15

Type 1 ovary tumors, mucinous histology ; also recurrent low grade serous carcinoma (unlike BRAF)

Question 16

Integrin role in cancer?

Answer 16

metastases role (cell invasion and migration)
adhesion of leukocytes to endothelial cells

Question 17

Mechanism of ERBB2 oncogenicity?

Answer 17

AMPLIFICATION of oncogene producing HER2 protein

Question 18

How do kinases work?

Answer 18

Phosphorylation

*Tyrosine kinases are enzymes that selectively phosphorylates tyrosine residue in different substrates. Receptor tyrosine kinases are activated by ligand binding to their extracellular domain. Ligands are extracellular signal molecules (e.g. EGF, PDGF etc) that induce receptor dimerization (except Insulin receptor) and a cascade of events.

Question 19

Which of the following is a tumor site not included in risk for HNPCC ?

A breast
B gastric
C pancreatic
D urethral
E brain

Answer 19

“breast // does include endometrial, colon, gastric, ovarian, pancreatic, urethral, brain (glioblastoma), small intestinal,
sebaceous gland adenomatous polyps, keratoacanthomas

Question 20

Histopath of leiomyosarcoma?
List 3

Answer 20

-prominent cellular atypia
-abundant mitoses (≥10 per 10 high power fields)
-areas of coagulative necrosis

*Two of these are necessary for a diagnosis

Question 21

Grade 1 endometrioid, young, normal weight - tumor most likely to express:

A MSH2
B CK7
C ER
D PR

Answer 21

MSH2

Question 22

Germ cell tumor least likely to have elevated AFP

Answer 22

Dysgerminoma and choriocarcinoma both not elevated

Question 23

Genetic mut associated with type I endometrial cancer

Answer 23

PTEN (PTEN tumor suppressor is the most important negative regulator of PI3K signaling)

Question 24

How does Loss of heterozygosity occur (two mechanisms)

Answer 24

Deletion (most common) or methylation

*Loss of heterozygosity: refers to a type of mutation that results in the loss of one copy of a segment of DNA

*LOH occurs when a cancer cell that is originally heterozygous at a locus loses one of its two alleles at that locus, either by simple deletion of one allele (copy-loss LOH), or by deletion of one allele accompanied by duplication of the remaining allele (copy-neutral LOH). When a cancer cell undergoes LOH of an essential gene, further loss or inhibition specifically of the allele retained in the tumor should not be tolerated, whereas normal cells will be able to survive relying solely on the remaining allele

Question 25

High LET has what effect on cancer cells?

Answer 25

Tumor necrosis, higher LET is more direct damage *Linear energy transfer (LET) average amount of energy lost per unit track length in tissue by a type of radiation *High LET radiation: particles with substantial mass and charge such as alpha particles or neutrons *Low LET radiation: X-rays, gamma rays

Question 26

Elevated CA19-9 and CEA

Answer 26

mucinous tumor

Question 27

Downstream effect of VEGF receptor binding

Answer 27

Capillary permeability (THIS ONE), increased intratumor pressure, other options

Question 28

Cowden What is the germline mutation? Clinical picture (non-cancer)? Screening?

Answer 28

PTEN Clinical picture: GI polyps, thyroid disease, benign breast disease, mucocutaneous lesions Cancer risk: breast, thyroid, endometrial Screening for breast cancer: breast self awareness from 18yo, clinical breast exam q6-12mo from age 25 (or 5-10 years before earliest family dx), annual MMG+MRI from 35yo (or 10 years before earliest family dx) per NCCN 6/2023 Screening for colon: start c/scope age 35-40 or 5-10yr before earliest family dx) Screening for endometrial cancer: start 35yo. prompt eval of AUB. consider q1-2yr EMB per NCCN 6/2023 | invasive/image screenings all start at 35

Question 29

Cowden most common GYN cancer

Answer 29

Endometrial cancer (lifetime risk 19-28%)

Question 30

Cowden most common cancer

Answer 30

Breast * The lifetime risk of breast cancer for affected female patients is frequently reported at between 25 and 50 percent, although more recent reports project a cumulative risk as high as 81 to 91 percen

Question 31

What causes invasion through the basement membrane?

Answer 31

MMP Matrix metalloproteinases

Question 32

Function of integrins?

Answer 32

migration and invasion

Question 33

What tumor is associated with FOXL2 mutation?

Answer 33

Granulosa cell tumor *FOXL2 encodes a transcription factor that is expressed as a nuclear protein and is critically important in the development of granulosa cells. Somatic mutations in FOXL2 have been identified in 97 percent of adult subtype granulosa cell tumors and only 1 of 10 juvenile subtype granulosa cell tumors

Question 34

Which common medication inhibits the mTOR pathway?

Answer 34

Metformin

Question 35

Which of the following is an oncogene: listed choices were PTEN, P53, BRCA and c-myc?

Answer 35

c-myc

Question 36

CA 125 is also known as?

Answer 36

MUC 16 *Direct questions

Question 37

BRAF mutation in which ovarian tumor?

Answer 37

low grade serous

Question 38

What type of endometrial cancer is associated with p53 and her2neu?

Answer 38

Type II endometrial cancer | Copy number High

Question 39

Kras mutation in which ovarian histology- mucinous, serous, clear cell, endometrioid?

Answer 39

MUCINOUS *Direct question: also low grade serous, this was 2 different questions on the exam

Question 40

First step in carcinogenesis of ovarian cancer: p53 mutation, fallopian tube stic, a few other options - which one?

Answer 40

p53 mutation

Question 41

MC **germline** mutation in ovarian cancer?

Answer 41

BRCA 1

Question 42

Mutation most common in p53?

Answer 42

Missense mutation | Exons 5-8

Question 43

How do you protect vulva skin during radiation? anti fungal estrogen cream positioning (frogleg) cold packs Using a diluted water/H2O2 rinse

Answer 43

positioning (frogleg) Based on MCG RadOnc text consult Diluted hydrogen peroxide water on the vulvar during EBRT to decrease - Wake RadOnc Lecture

Question 44

How does HDR differ from LDR?

Answer 44

decreased treatment time

Question 45

How does cisplatin augment radiation?

Answer 45

inability to repair DNA

Question 46

What radiation source the longest half-life?

Answer 46

Radium -cesium 137 - 30 years -irdium 192 - 74 days (SHORTEST) -radium 226: very long like 1600 years -colbalt 60 - 5 years

Question 47

What is the half life of cesium?

Answer 47

30 years

Question 48

What type of radiation is produced by cobalt ?

Answer 48

Gamma ## Footnote Cobalt (Gamma ray, from nucleus, avg Cobalt energy is ~1.25MeV)

Question 49

What is most sensitive to side effects from pelvic radiation?

Answer 49

ileum *2 questions on this topic

Question 50

What do you call the area around the gross tumor volume that might have microscopic tumor?

Answer 50

clinical target volume

Question 51

Inverse square law, if you go from 2 cm to 1 cm how much does dose increase?

Answer 51

400% *this is on every year The radiation inverse square law specifies that: the intensity of the radiation goes down by the square of the distance from the source. For instance if you move twice as far from the source the intensity of the radiation will decrease by a factor of 4. Intensity = 1 / (distance ^2)

Question 52

Adjuvant treatment for positive right inguinal lymph node?

Answer 52

bilateral radiation to nodes and pelvic field

Question 53

XRT vs brachy - which symptom is shared?

Answer 53

FATIGUE (answer) -wrong answers: vaginal stenosis, 2 other

Question 54

Which chemo causes delayed bone marrow suppression? **TEST QUESTION**

Answer 54

mitomycin C Marrow suppression at 28 to 42 days with recovery 40 to 60 days after treatment And Melphalan and chlorambucil

Question 55

Which drug do you need to dose reduce for renal insufficiency? A bev B vinca C taxol D etoposide **TEST QUESTION **

Answer 55

Etoposide A BICC THE MMP require renal dosing modifications ActD, Bleo, ifos, cytoxan, capecitabine, Topo, hydroxyurea, etopo, mtx/pemetrexed, melphalan, platinum (carbo/cis, oxali)

Question 56

Dose limiting toxicity of carbo? **TEST QUESTION **

Answer 56

thrombocytopenia

Question 57

What drug is most likely to cause constipation? a.     Paclitaxel b.     Vincristine c.     Cisplatin d.     Gemcitabine **TEST QUESTION **

Answer 57

Vincristine FYI per the SGO chemo book, vinblastine >>vincristine | SGO handbook says "vinblastine, rarely vincristine"

Question 58

What is the mechanism of action of Capecitabine? a. Inhibits topoisomerase I b. Creates DNA crosslinks c. Prodrug, converted to 5-FU in the tumor tissue d. Prodrug, converted to 5-FU in the liver **TEST QUESTION **

Answer 58

c. Prodrug, converted to 5-FU in the tumor tissue ## Footnote "Capecitabine is an oral fluorouracil prodrug that is converted in tumor tissue to the active cytotoxic agent, 5-FU." SGO HB

Question 59

What is the mechanism of action of gemcitabine? a.     Prodrug, converted to 5-FU b.     Creates ss DNA breaks c.     Stabilizes microtubules d.     Prodrug, converted to a fraudulent base pair **TEST QUESTION **

Answer 59

d. Prodrug, converted to a fraudulent base pair Also important that it requires active transport

Question 60

How does liposomal doxorubicin differ in mechanism of action from doxorubicin a.     Liposomal coating creates a more basic tumor microenvironment b.     Liposomal coat causes increased receptor affinity with the tumor cells c.     Liposomal coat causes slower drug release which decreases toxicity d.     Liposomal coat causes increased hepatic metabolization **TEST QUESTION **

Answer 60

c.     Liposomal coat causes slower drug release which decreases toxicity

Question 61

How to reduce thrombocytopenia in patient getting taxol/carbo? **TEST QUESTION **

Answer 61

Dose reduce carbo Carbo causes thrombocytopenia

Question 62

Imatinib: MOA, target, drug class ** TEST QUESTION **

Answer 62

BCR-ABL Tyrosine Kinase Inhibitor Bcr-Abl tyrosine kinase is the constitutive abnormal gene product of the PHL chromosome in CML. Inhibition of this enzyme blocks proliferation and induces apoptosis in Bcr-Abl positive cell lines. Also inhibits tyrosine kinase for platelet-derived growth factor (PDGF), stem cell factor (SCF), c-kit, and cellular events mediated by PDGF and SCF. | Also used in GIST tumors

Question 63

What do tyrosine kinase receptors do? a.     Increase the membrane action potential by increasing flow through ion channels b.     Activate cell replication machinery c.     Activate DNA repair mechanisms d.     Activate/phosphorylate proteins through signal transduction cascades **TEST QUESTION **

Answer 63

Activate/phosphorylate proteins through signal transduction cascades

Question 64

What to do if you have patient with family h/o colon cancer, has endometrial ca at young age? **TEST QUESTION **

Answer 64

Screen for Lynch with IHC testing first

Question 65

What is homologous recombination repair? ** TEST QUESTION **

Answer 65

High fidelity, template dependent DNA repair mechanism for double stranded DNA breaks Steps: 1. dsDNA breaks are recognized by the MRN complex and checkpoint proteins 2. 5’-3 exonuclease generates 3’ overhangs, which are coded with replication protein a 3. BRCA1/RAD51 forms a complex. 4. RAD51 assembles onto single stranded ends. 5. Homology search, strand invasion, and DNA synthesis. 6. Links between DNA strands (double holliday junctions) resolved to produce exchange between chromosomes or no exchange.

Question 66

Which immune cell releases granules? A NK cells B B cells C macrophages

Answer 66

NK cells release granzymes & perforins NK cells secrete preformed secretory lysosomes called lytic granules (LGs) directly toward bound target cells, a process known as cell-mediated cytotoxicity True granules released by: mast cells, basophils, neutrophils, eosinophils (granulocytes)

Question 67

Effect of statins on endometrial cancer growth

Answer 67

statins inhibit phosphorylation of AKT and also inhibit mTORC1 preventing progression of PI3K pathway leading to multiple downstream effects (see image). Exert anti-inflammatory effects via a myriad of molecular mechanisms, reflected by decreased levels of C-reactive protein (CRP) and interleukin-6 (IL-6). Inhibit Th1 immune response PI3K —> PIP3 —> PDK —> AKT—> mTOR ## Footnote statins = HMG-CoA reductase inhibitors

Question 68

What happens when you alternate Tamoxifen and Megace?

Answer 68

Tamoxifen increases PR expression which sensitizes to Megace

Question 69

Effect of EGF binding to its receptor

Answer 69

After ligand binding, EGFR (ErbB-1) dimerizes with itself or with its homologs ErbB-2 (her2/neu), ErbB-3, or ErbB-4 and consequently increases its intracellular tyrosine kinase activity. This activates signaling cascades that have many effects: cell proliferation, reduced apoptosis, and angiogenesis. RAS —> RAF —> MEK —> MAPK [—> to nucleus] —> promote transcription of genes involved in tumor growth (e.g., MYC, JUN, FOS). -or- PI3K —> PIP3 —> PDK —> AKT —> mTOR

Question 70

effect of IGF1 on endometrial cancer **TEST QUESTION **

Answer 70

IGF‐1 is known to promote cancer development by inhibiting apoptosis and stimulating cell proliferation. (Insulin like growth factor) Binding to IGRF1 stimulates PI3K —> PIP3 —> PDK —> AKT —> mTOR ## Footnote Metformin increases your IGF1 binding globulin and inhibits IGF-1 binding, the opposite of insulin!

Question 71

What tumor is associated with ARID1A mutation? ** TEST QUESTION **

Answer 71

Clear cell ovarian cancer > Endometrioid ovarian cancer Endometriosis related cancers Tumor suppressor gene: participates in DNA repair through interaction with checkpoint kinase ATR ## Footnote ARID1A = AT-rich interactive domain-containing protein 1A

Question 72

Kras mutation in which ovarian histology A mucinous B serous C clear cell D endometrioid **TEST QUESTION **

Answer 72

Mucinous 50-70% of mucinous cases, missense MT | 25-50% borderline 20-50% low grade serous

Question 73

Recommended screening for BRCA variant of unknown significance? **TEST QUESTION **

Answer 73

Routine screening ## Footnote Per NCCN: Retrospective analyses have estimated that 82.1% to 91.2% of the time, if a VUS is reclassified, it is downgraded to benign or likely benign, while 8.7% to 17.9% are upgraded from VUS to pathogenic. Therefore, VUS should not be used to alter medical management. (AW)

Question 74

Most common cancer in Cowdens? ** TEST QUESTION **

Answer 74

Breast lifetime risk 25-50% ## Footnote lifetime risk for endometrial cancer approx 19% to 28% (AW) lifetime risk of thryoid cancer approx 3-38% (AW)

Question 75

Reduction in breast ca risk in brca patient with BSO ** TEST QUESTION **

Answer 75

50%; however, this has recently been called into question on lit review

Question 76

60 year old getting chemo, what vaccine would you most recommend? a.     live intranasal flu b.     shingles (zostavax) c.     MMR d.     pneumococcal **TEST QUESTION **

Answer 76

Pneumonia normally after 65, but anytime if weakened immune sys. All 50+yo need shingles. *new shingles vaccine is dead = shingrix *old shingles vax is live = zostavax | live vaccines should not be given during chemo. ## Footnote Per NCCN: pneumococcal conjugate vaccine (PCV20) should be administered to adults newly diagnosed with cancer who are pneumococcal vaccine-naïve. meningococcal vaccination recommended for patients at increased risk for meningococcal disease = persistent complement component deficiencies, taking a complement C5 inhibitor (eg, eculizumab, ravulizumab),or anatomic or functional asplenia (AW)

Question 77

Cause of chronic metabolic alkalosis: **TEST QUESTION ** Duplicate

Answer 77

long-term NGT suctioning Notes says: NG tube. two most common causes of metabolic alkalosis in general are loss of gastric acid (vomiting, NG drainage) and diuretics (specifically furosemide and thiazides)

Question 78

Which opioid causes prolonged QT? **test question **

Answer 78

Methadone

Question 79

What is the best initial management of hyperkalemia with EKG changes? **TEST QUESTION **

Answer 79

●Intravenous calcium to antagonize the membrane actions of hyperkalemia (if electrocardiogram (ECG) changes consistent with hyperkalemia are present)

Question 80

EKG changes for hypokalemia **TEST QUESTION ** Duplicate

Answer 80

Flattened or inverted T waves, depression of ST segment, prominent U waves, prolongation of QT interval —> can lead to torsades

Question 81

EKG changes for hypomagnesemia **TEST QUESTION ** Duplicate

Answer 81

QT prolongation —> torsades de pointes Long PR, QRS Peaked T waves initially —> flatten at higher concentrations artial/ventricular arrhythmias

Question 82

EKG changes for hypercalcemia **TEST QUESTION **

Answer 82

Shortening of QT interval

Question 83

EKG changes for hypocalcemia **TEST QUESTION **

Answer 83

Prolonged QT interval —> torsades de pointes

Question 84

EKG changes for hyperkalemia **TEST QUESTION **

Answer 84

Peaked T waves (1st), flattened P waves, PR prolong (2nd), prolonged QRS complexes —> sine wave —> ventricular fibrillation / cardiac arrest ST depression

Question 85

What electrolyte derangement is most likely for patient with refractory hypokalemia:

Answer 85

hypomag

Question 86

Which of the following is a cause of non-anion gap Metabolic acidosis? A pancreatic fistula B rhabdomyolysis C renal failure D salicylates **TEST QUESTION** (Duplicate)

Answer 86

Pancreatic fistula Loss of bicarbonate-rich pancreatic fluid via a pancreatic fistula can result in a hyperchloraemic or normal anion gap metabolic acidosis. "USED PART": Urinary diversion, Small bowel fistula, Extra Chloride, Diarrhea, Pancreatic fistula, Addisons/Acetazolamide, Renal tubular acidosis, Tenofivir/Topiramate ## Footnote High AG metabolic acidosis MUD PILES: Methanol, Uremia, Diabetes, Paraldehyde, Iron (and Isoniazid), Lactate, Ethylene glycol, and Salicylate. Rhabdo —> lactic acidosis

Question 87

electrolyte changes in patients with urinary conduits **TEST QUESTION ** DUPLICATE

Answer 87

Hyperchloremic metabolic acidosis can result from resorption of excreted metabolites through the intestinal mucosa of the diversion: ammonia, hydrogen and chloride are reabsorbed=chronic acid load

Question 88

Best abx for MRSA:

Answer 88

vanco

Question 89

Best management for neutropenic fever anc 850:

Answer 89

cefepime Other choices: cefepime + growth factors, other abx choices

Question 90

Longest ½ life of narcotic **TEST QUESTION **

Answer 90

methadone

Question 91

Best opioid in renal failure:

Answer 91

Fentanyl Per B& H: Fentanyl or methadone best = no active metabolites - Buprenorphine, ketamine, lidocaine remifentanil also ok=no prolonged clearance Morphine and codeine are not recommended, because the accumulation of their metabolites may cause neurotoxic symptoms

Question 92

How to correct DIC in CHF w fibrinogen <100? **TEST QUESTION **

Answer 92

Cryoprecipitate, also called "cryo" (1 unit = 10 to 20 mL) Indicated for DIC Notes were unsure of cryo vs concentrated fibrinogen but pretty sure its cryo (AW) Fibrinogen concentrates: prepared from pooled human plasma and are available as lyophilized powders… reconstituted in a small volume. More for prevention and congenital fibrinogen def., off label for DIC. https://www.ncbi.nlm.nih.gov/books/NBK537184/ FFP higher volume (1 unit = 200 to 300 mL) indicated for DIC, not good for CHF

Question 93

Most sensitive test for heparin induced thrombocytopenia?

Answer 93

anti-platelet factor 4 antibodies *gold standard=Serotonin release assay (SRA). measures plt activation via detecing release of serotonin from test plts in presence of pt serum and heparin. Sens/spec >95% More commonly used=ELISA: detects the presence of Ab to -platelet factor 4 (PF4)/heparin complex in patient serum. Sensitivity 91->97%, but low specificity

Question 94

Reason to check an anti-Xa level in patient on Lovenox:

Answer 94

obesity anti-Xa monitoring when optimal dosing less predictable: renal insufficiency, under/overweight (≤ 40 kg or ≥150 kg), pregnancy newborns/children prolonged therapy (≥7–10 days) advanced age

Question 95

80 yo patient s/p surgery, CrCl 40, what dose of prophylactic Lovenox do you give? (no weight given): **TEST QUESTION ** Duplicate

Answer 95

Standard dosing (40mg/daily) CrCl 30 to 50 mL/minute: No dose adjustment necessary for most indications. BMI ≥40 kg/m2: - 40 mg twice daily or 0.5 mg/kg twice daily (based on actual body weight) BMI >50 kg/m2, - 60 mg twice daily or 0.5 mg/kg twice daily (based on actual body weight)

Question 96

Which of anticoagulant needs renal dose reduction? ** TEST QUESTION **

Answer 96

Skinny answer: LMWH + Rivaroxaban lovenox, nadroparin (not US): requires renal dose reduction CrCl <30 Xarelto/Rivaroxaban, Edoxaban: requires renal dose reduction CrCl<50 Dalteparin: no adjustment, avoid CrCl <30 Tinzaparin (not US drug): no adjustment, avoid CrCl <30 Fondaparanux: consider decrease in ppx dose if CrCl <50. avoid CrCl <30 Eliquis/Apixiban: no dose adjustment for VTE/PE Warfarin: no specific adjustements, check INR more freq, start lower dose Heparin: NO DOSE REDUCTION Argatroban: NO DOSE REDUCTION ## Footnote Aw edited the long version to match UTD

Question 97

When do you stop heparin and start fonadaparinux

Answer 97

Transitioning from UFH continuous infusion to fondaparinux: Start fondaparinux within one hour after UFH continuous infusion has been stopped Option for anticoagulation treatment in the setting of HIT

Question 98

What are the treatment options for HIT? ** TEST QUESTION ** Duplicate

Answer 98

argatroban (Parenteral direct thrombin inhibitor) is probably best option Others: Bivalirudin (Parenteral DTI) Danaparoid (Parenteral inhibitor of thrombin and factor Xa (indirect, heparinoid) Fondaparinux (parental Xa inhibitor) Apixaban, Edoxaban, Rivaroxaban (PO Xa inhibitor) Dabigatran (ODTI) Warfarin (CANNOT BE USED INITIALLY)

Question 99

What is Heparin-induced thrombocytopenia (HIT)? Duplicate

Answer 99

Life-threatening complication of exposure to heparin (UFH, LMWH). Occurs in up to 5% of pts exposed, regardless of dose, schedule, or route of administration. plt drop >50% baseline, new onset plts <150, occurs 5-10d after exposure (could be earlier if recently exposed to heparin). resolution after stopping heparin is usually 7d HIT results from an autoantibody directed against platelet factor 4 (PF4) in complex with heparin (referred to as a HIT antibody). HIT antibodies activate platelets and can cause catastrophic arterial and venous thrombosis (50%, venous > arterial). THROMBOSIS (can lead to skin necrosis, limb gangrene, organ infarction) Mortality rate as high as 20-30%, w/ improved recognition and early intervention, mortality rates < 2% reported.

Question 100

Best test to diagnose c.diff?

Answer 100

If choose just one, NAAT ?best is gold standard cell culture cytotox assay (aw) two-step approach: enzyme immunoassay (EIA) test first for glutamate dehydrogenase (GDH), followed by a toxin test and/or a nucleic acid test. Alternatively, in institutions where established clinical algorithms guide testing, a nucleic acid test alone is acceptable. Best is combination of EIA GDH then EIA for toxins A&B or NAAT Cdiff tests: ●NAAT: specific for toxigenic strains but do not test for active toxin protein production and are capable of detecting asymptomatic carriers of C. difficile ●Enzyme immunoassay for C. difficile GDH: GDH antigen enzyme is produced by all C. difficile isolates; cannot distinguish btw toxigenic and nontoxigenic strains… useful initial screening step in multistep approach ●Enzyme immunoassay for C. difficile toxins A and B: sensitivity of EIA for toxins A and B is on average about 75 percent, specificity ~99%).high false-negative rate since 100-1000 pg of toxin must be present for the test to be positive. used together with toxin EIA ●Cell culture cytotoxicity assay: sensitive and specific but resource intensive and time consuming. Not routine but *has been used as a gold standard test for diagnosis of C. difficile* ●Selective anaerobic culture: useful for epidemiologic studies but generally too slow and labor intensive for routine use

Question 101

Treatment to quickly reverse Coumadin after vitamin K and FFP? Duplicate

Answer 101

4-factor prothrombin complex concentrate aka Kcentra (PCC, contains Factors II, VII, IX, and X). [these are vit K dependent factors 2+7=9, 10] A plasma product such as thawed plasma or FFP (approximately 10 mL/kg, depending on INR) can be used as an alternative if PCC is not available. Vitamin K (intravenous) Hold warfarin Recheck the prothrombin time (PT)/INR at approximately 30 minutes following PCC administration, and periodically thereafter, with the frequency determined by the severity of bleeding.

Question 102

Intrabdominal compartment syndrome, how to diagnose? **TEST QUESTION **

Answer 102

Intravesicular pressure (JS: bladder pressure may not be accurate w/adhesions, pelvic hematomas, pelvic fractures, abdominal packs, or neurogenic bladder. Best when patient intubated and paralyzed) | ACS = IAP of >/=20 mmHg + organ failure

Question 103

Which of the following is associated with steatosis in TPN:

Answer 103

excess calories due to sugar

Question 104

Treatment of afib postop: A beta blocker B fluid C anticoagulation ** TEST QUESTION **

Answer 104

Beta-blocker

Question 105

Most common presenting symptom of PE? Duplicate

Answer 105

The most common presenting symptom is dyspnea followed by chest pain (classically pleuritic but often dull) and cough (UTD)

Question 106

How to confirm ET placement: **TEST QUESTION ** Duplicate

Answer 106

ETCO2 (~40mmHg) Waveform capnography is the most reliable tool to confirm placement of an advanced airway, both for endotracheal (ET) tubes and supraglottic-airway devices. When a device is placed correctly, a waveform and end-tidal CO2 (ETCO2) reading appear within seconds after the first ventilation is delivered to the patient

Question 107

Cardiovascular collapse after insertion of Veress needle, what is best treatment? ** TEST QUESTION **

Answer 107

Likely getting at air embolus: - tx is Trendelenburg and left lateral decubitus position 1. desufflation of the abdomen 2. The Durant or Trendelenburg position is used to direct the gas bubble into the right ventricle apex and away from the pulmonary artery. 3. Ventilation with 100% oxygen could be used to wash out CO2, reduce ventilation-perfusion mismatch, and improve hypoxemia. 4. Hyperventilation is also used to help eliminate CO2 Second thought is massive bleeding, but seems less likely

Question 108

Question about what cancer is caused by a translocation? transitional ovarian granulosa cell tumor Sertoli Leydig cell tumor Peutz-Jeghers syndrome tumors (Duplicate Q)

Answer 108

STK11 mutations only account for about half of PJS cases, and a second disease locus has been proposed at chromosome segment 19q13.4 on the basis of genetic linkage analysis in one family. We identified a t(11;19)(q13;q13.4) in a PJS polyp arising from the small bowel in a female infant age 6 days. PJS associated with Ovarian sex cord tumor with annular tubules granulosa: FOXL2 is a point mutation). Though translocation in a case report: https://www.sciencedirect.com/science/article/abs/pii/016546089290231V JS (need to confirm)- clear cell ovary (ARID1A translocation) endometrioid ovary (PTEN, bcatenin translocation) small cell ovary hypercalcemic type (SMARCA4 translocations)

Question 109

What vasopressor is most inotropic? **TEST QUESTION **

Answer 109

Dobutamine: is not a vasopressor but rather is an inotrope that causes vasodilation Vasopressors elevate blood pressure Inotropes enhance cardiac output Inotropes: - dopamine: dose dependent. Inotropic and vasopressor - dobutamine - Isoproterenol: primarily an inotropic and chronotropic agent rather than a vasopressor. Vasopressors: - epinephrine: dose dependent. Inotropic and vasopressor - norepinephrine: both Inotropic and vasopressor - phenylephrine: vasopressor only - vasopressin: antidiuretic hormone, vasopressor - Ephedrine: mostly vasopressor. For epidural hypotension

Question 110

Effects of dopamine: low / medium / high doses ** TEST QUESTION **

Answer 110

low dose 1 to 2 mcg/kg per minute - dopamine-1 receptors in the renal, mesenteric, cerebral, and coronary beds, resulting in selective vasodilation. medium dose 5 to 10 mcg/kg per minute - also stimulates beta-1 adrenergic receptors and increases cardiac output, predominantly by increasing stroke volume with variable effects on heart rate high dose >10 mcg/kg per minute - stimulate alpha-adrenergic receptors and produce vasoconstriction with an increased SVR

Question 111

Postop patient who is old, has hx of afib, CVA and is undergoing surgery for endometrial staging… what would you anticoag with? A Lovenox B ASA C Coumadin D Plavix

Answer 111

Lovenox

Question 112

What shock has low SVR, high CO?

Answer 112

Septic shock. Low SVR, splanchnic vasoconstriction, increased cardiac output, characterize the hyperdynamic phase of shock. Low SVR - hypotension High CO - tachycardia

Question 113

Mechanism of hypotension in early septic shock?

Answer 113

Inc venous capacitance Low SVR, splanchnic vasoconstriction, increased cardiac output, characterize the hyperdynamic phase of shock. Venous capacitance is increased and results in diminished effectiveness of the circulating the blood volume.

Question 114

Which of the following is most diagnostic of ARDS? ** TEST QUESTION ** Duplicate

Answer 114

Berlin Definition of ARDS all of the following ●Respiratory symptoms begun within one week of a known clinical insult. ●Bilateral opacities on chest imaging. ●respiratory failure must not be fully explained by cardiac failure or fluid overload. ●A moderate to severe impairment of oxygenation must be present, as defined by the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2). The severity of the hypoxemia defines the severity of the ARDS: •Mild ARDS – The PaO2/FiO2 is >200 mmHg, but ≤300 mmHg. •Moderate ARDS – PaO2/FiO2 >100 mmHg, but ≤200 mmHg. •Severe ARDS – The PaO2/FiO2 is ≤100 mmHg Notes say: b/l infiltrates vs PaO2/FIO2 ratio <200 (we all put different answers) - b/l infiltrates is non specific By definition, arterial blood gas (ABG) analysis shows hypoxemia, which is often initially accompanied by acute respiratory alkalosis, and an elevated alveolar-arterial oxygen gradient

Question 115

Best way to not worsen ARDS with vent settings? ** TEST QUESTION**

Answer 115

#1 most important- low tidal volume with permissive hypercapnia (limitation of tidal volume (6 ml/kg predicted body weight) ** higher tidal volumes result in barotrauma. #2 importance - adequate high PEEP (>12 cmH2O),

Question 116

How to calculate SVR? ** TEST QUESTION ** Duplicate

Answer 116

Systemic vascular resistance (SVR) = 80 x ([MAP – CVP or RAP]/CO) CO =SV x HR Normal SVR is 700 to 1,500 dynes/seconds/cm-5 right atrial pressure (RAP) central venous pressure (CVP) mean arterial pressure (MAP) cardiac output (CO) These indices can be obtained from an accurately placed pulmonary artery catheter (PAC): ●Central venous pressure (CVP) ●Right-sided intracardiac pressures (right atrium, right ventricle) ●Pulmonary arterial pressure (PAP) ●Pulmonary artery occlusion pressure (PAOP; pulmonary capillary wedge pressure [PCWP]; pulmonary artery wedge pressure [PAWP]) ●Cardiac output (CO) ●Mixed venous oxyhemoglobin saturation (SvO2)

Question 117

What is the purpose of PEEP? A Decrease respiratory work B decreases FIO2 requirement by increasing PaO2 C increases FIO2 requirement by decreasing PaO2

Answer 117

Decreases FIO2 requirement Mechanism for improving oxygenation Physiologic PEEP is 4 cm H2O Increasing PEEP is preferred for improving oxygenation opposed to increasing the FIO2 for postop pts Addition of PEEP recruits collapsed alveoli, improves oxygenation and lung compliance

Question 118

Most common type of type of neoplastic colon lesion: A Tubular adenoma B hyperplastic C tubulovillous adenoma D inflammatory

Answer 118

Adenomatous (tubular adenoma) About 70 percent of all polyps are adenomatous, making it the most common type of colon polyp Adenomas are the most frequently observed neoplasms. By definition adenomas are benign lesions but there is a relationship to the development of invasive cancer (Vogelstein 1990). There are three forms of colonic adenomas: tubular, villous, and mixed.

Question 119

POD#1 s/p debulk with peritonectomy patient complains of sob. What’s the most likely etiology? A pleural effusion B pna C pe

Answer 119

Pleural effusion: possible complication of debulking diaphragmatic disease Pneumonia: 48 to 72 hours after hospital admission PE: 3-20d postop

Question 120

Raised border wound infx with lymphangitis, spreading erythema A Nec fasc B gas gangrene C strep D staph Duplicate

Answer 120

Strep pyogenes - aka erysipelas (this one), strep > staph Lymphangitis most often results from an acute streptococcal infection of the skin. Less often, it is caused by a staphylococcal infection. The infection causes the lymph vessels to become inflamed. Lymphangitis may be a sign that a skin infection is getting worse

Question 121

Effect of intraop fluid restriction?

Answer 121

Decreased postoperative complications

Question 122

What leads to decreased hospital stay?

Answer 122

POD#0 feeding > POD Ambulation (JS: cannot confirm nor deny...)

Question 123

Patient who is a smoker, BMI 40, low albumin, has endometrial cancer, what is the best way to decrease her risk of SSI? A continue abx postop B quit smoking C diet modifications to increase albumin D do surgery MIS

Answer 123

MIS

Question 124

What is the most likely reason to have leak after LAR? a. Anastomosis >5cm from anal verge b. Anastomosis <5cm from anal verge c. Stapled anastomosis d. Pelvic drain

Answer 124

Anastomosis <5cm from anal verge (JS) RF for leak: albumin <3.5, >/=1 bowel resections, <6cm from anal verge, older age, handsewn

Question 125

What is the best the way to protect a LAR? a. mechanical bowel prep b. antibiotic prep c. loop colostomy d. loop ileostomy

Answer 125

loop ileostomy

Question 126

What is the most common complication of loop colostomy? a. Prolapse b. Diarrhea c. Constipation d. High output

Answer 126

Prolapse

Question 127

What is the best way to handle a 1cm injury to large bowel with no prep? a. primary closure b. primary closure with protective ileostomy c. ostomy d. resection/re-anastomosis

Answer 127

primary closure Primary closure is best suited to small lesions (1 cm or less) that are a result of cold or sharp injury. However, thermal injury sustained via electrosurgical devices induces delayed tissue damage beyond the visible edges of the immediate defect, and surgeons should consider a resection of bowel to at least 1 cm beyond the immediately apparent injury site. If appropriate antibiotic prophylaxis for colonic surgery has not been given prior to skin incision, it should be administered once the colotomy is identified.

Question 128

Patient had previous maylard what flap should you use for exent:

Answer 128

gracilis (not tram/vram) Maylard incision: deep inferior epigastric vessels are isolated, clamped, transected, and ligated. TRAM (transverse rectus abdominus muscle) and vertical rectus abdominis myocutaneous (VRAM) flap both use deep inferior epigastric vessels as pedicles

Question 129

Best plastic closure/flap for vaginal reconstruction? A TRAM B gracilis C split thickness D V-Y **TEST QUESTION **

Answer 129

VRAM or TRAM best based on the below, if not option, gracillis For full thickness defects, a variety of reconstructive options Fasciocutaneous and myocutaneous flaps are probably the most commonly used options for reconstruction of partial and circumferential vaginal defects. These have the advantage of providing a large quantity of pliable tissue, which can be used as soft tissue filler in the pelvis, in addition to tissue for vaginal reconstruction. The neovagina also tends to retain its caliber over time, and does not stenose. However, the lack of natural lubrication often necessitates the use of supplemental lubricants during sexual intercourse. Other disadvantages include incidence of partial or complete flap necrosis. However, the incidence of this is relatively low. Flap specific complication rates are lowest for vertical rectus abdominis myocutaneous (VRAM) flaps compared with gracilis and Singapore flaps.

Question 130

Easy/serious to injury when mobilizing anterior/superior liver surface? ** TEST QUESTION **

Answer 130

Right Hepatic vein

Question 131

What IHC stains are consistent with metastatic colon cancer to the ovary? a. CK7+ CK20+ b. CK7- CK20+ c. CK7- CK20- d. CK7+ CK20- **TEST QUESTION **

Answer 131

CK7- CK 20+ metastatic colon cancer Ovarian mucinous CK7+ CK20+ Endometrial CK7+ CK20-

Question 132

What is the most specific serum tumor marker for colon cancer? a. CA125 b. CA19-9 c. CK d. CEA

Answer 132

CEA

Question 133

Splenectomy, how long to wait after to give vaccinations? ** TEST QUESTION ** Duplicate

Answer 133

2 wks (2 questions one was 14 days and the other gave options of 0-10days v. 2-4weeks) UTD: In order to optimize the immune response to vaccination, we vaccinate patients at least 2 weeks, and ideally 10 to 12 weeks, prior to splenectomy when possible. When vaccines cannot be given at least two weeks prior to splenectomy, we vaccinate two weeks following the procedure.

Question 134

Splenectomy common complications?

Answer 134

bleeding, thrombosis, and infections. Notes say: thrombocytosis. This seems to be incorrect based on below AS (Chi): acute complications hemorrhage, LLL atelectasis, splenic vein thrombosis. Most common infection: s. pneumo (3.2% prevalence)

Question 135

Which has higher rate of injury laparoscopically than open? A Bowel B urinary tract C vascular

Answer 135

Urinary tract Notes said: we all put different things but right answer is probably bowel

Question 136

Elderly lady, unexpected splenectomy what is worst bug? A H. flu B s. pneu C n. meningitidis D e. coli ** TEST QUESTION **

Answer 136

The single most important pathogen is S. pneumoniae. This organism accounts for approximately 40 to 60 percent of cases of severe infection and overwhelming sepsis in splenectomized patients [10,13,14]. Although the overall incidence of S. pneumoniae infections is declining because of widespread pneumococcal vaccination [29,30], patients with impaired splenic function are still at higher risk for S. pneumoniae infection and poorer outcomes when compared with patients who have normal splenic function

Question 137

Why to do TPN as opposed to enteral feeds for critically ill pt in ICU?

Answer 137

Direct comparisons of enteral nutrition with parenteral nutrition in critically ill patients from randomized trials indicate that outcomes in patient receiving enteral or parenteral nutrition are comparable Probably not a fair question. Notes say: Mortality vs caloric requirements UTD: Earlier evidence suggests early parenteral nutrition may increase the risk of infection. Data since then refutes these findings, and better safety practices may account for comparable outcomes between enteral nutrition and parenteral nutrition.

Question 138

Most common cause for wrong site surgery: A high volume surgeon B teaching hospital C OR start time D lack of universal protocol / time out (Duplicate)

Answer 138

The answer is D. "In response to the occurrence of these preventable errors, the Joint Commission issued two National Patient Safety Goals on January 1, 2003 to target wrong-site surgery: Goal 1—to improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures."

Question 139

What is this pathology? A uterine endometrioid carcinoma B uterine LMS C uterine serous carcinoma D endometrial stromal sarcoma

Answer 139

uterine serous carcinoma Architecture: Papillary with or without appreciable fibrovascular cores; micropapillary pattern can be seen Slit-like spaces Gland-like spaces may be observed Psammoma bodies may be present in up to 33% of cases Cytoplasm usually scant but can be abundant with eosinophilia or clearing Tumor cells can colonize existing endometrial glands Tumor cells can appear discohesive Nuclei are typically high grade with pleomorphism, hyperchromasia, prominent nucleoli and frequent mitotic figures (including atypical mitotic figures)