Lecture 11 (labs)-Exam 5 Flashcards
1
Q
What does pleural fluid serve as?
A
serves as a physiologic function in respiration, a lubricant allowing the two layers of the pleura to glide smoothly past each other- also useful in diagnosis of disease, trauma, and other abnormalities
2
Q
- Pleural fluid is produced by what? What is the normal amount?
- Significant fluid accumulation in the pleural cavity usually indicates What?
A
Is continuously produced by the parietal circulation and reabsorbed by the lymphatic system
* In healthy human, the pleural space contains a small amount of fluid (10-20mL) with a low protein count
Significant fluid accumulation in the pleural cavity usually indicates excess production of pleural fluid, lymphatic blockage, or some other source of fluid such as bleeding
3
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Pleural effusion
* What is the light criteria?
A
used to determine if an effusion is exudative or transudative
4
Q
Pleural effusions develop when?
A
Pleural effusions develop when changes in fluid and solute homeostasis occur, and the mechanism causing these changes determines whether it will be an exudative (high protein content) or transudative (low protein content) effusion.
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6
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What is exudative and transudative?
A
- Exudative is fluid that leaks around the cells of the capillaries and is caused by inflammation
- Transudative is fluid pushed through the capillary due to an imbalance between the hydrostatic and oncotic pressure within the capillary
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11
Q
What is a bronchoalveolar lavage?
* What is the recommended site? Why?
A
is a minimally invasive procedure that involves instillation of sterile normal saline into a subsegment of the lung, followed by suction and collection of the instillation for analysis
* The middle lobe or the lingula is recommended as the standard site for BAL if diffuse lung disease presents
* From these lobes about 20% more fluid and cells are recovered than from the lower lobes
12
Q
Bronchoalveolar lavage (BAL)
* Serves as what?
* Sample sent for what?
A
Serves as a diagnostic tool for the evaluation of lower respiratory tract pathology
* Has a specific value for the diagnosis of certain interstitial lung diseases
Sample sent for cell count (total and differential), culture and cytology
13
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What is the BAL process?
A
14
Q
Sputum culture
* Invasive or non-invasive?
* What is prefered? (How do you do it?)
* Can also be obtain with what?
* Aim to detect the causes of what?
* Sent for what? Can also send out for what?
A
15
Q
AFB
* What is this?
* Bacteria detected by what?
* AFB stain test positive result?
* AFB stain test negative result?
A
- AFB stain
- Bacteria detected by the test will be positive or negative
- AFB stain test positive result: the acid-fast bacilli, such as mycobacterium tuberculosis, retain the red or pink color
- AFB stain test negative result: no red or pink bacteria are found in the stained slide
16
Q
What are the examples of Fungus?
A
- Aspergillosis
- Candidiasis
- Candida auris
- Cryptoccocus neoformans
- Pneumocystis pneumonia
17
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Cytology
* What is it?
* Can see what? (2)
* What are examples (3)
A
18
Q
Gastrointestinal (GI):
peptic ulcer disease
* What is the bacteria?
* What are the different tests?
What are two two diseases?
A
19
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Disease
Peptic Ulcer Disease (PUD)
* Characterized by what?
* PUD has various causes, but…
* What is a H.pylorus? (responsible for what, colonizes where, impairs what?
A
20
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H. Pylori testing:Invasive testing
* What are the three types and explain them?
A
- Endoscopy
- Histology/biopsy- gold standard for diagnosis – HE staining or FISH is highly sensitive (97% sensitivity) and specific (100% specificity)
- PCR: Can use gastric biopsy specimen, or saliva, stook, or gastric juice. Greater than 95% sensitivity and specificity
21
Q
Non-invasive testing
* Urea breath test: How does it work and what does it do?
A
Urea breath test
* Used for almost 30 years- most popular and accurate test
* High sensitivity and specificity (>95%)
* Patient ingests a labeled urea, the H. Pylori organism hydrolyzes it to labeled CO2 in the stomach. Then it gets into the blood and then the lungs and is exhaled and measured.
* Can be used to confirm eradication after 4-6 weeks of stopping treatment
22
Q
H. Pylori testing: Non-invasive testing
* Stool antigen test: What is S&S? What does it detect?
A
- Sensitivity (94%) Specificity (97%)
- Detects H. Pylori antigen in stool samples
23
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H. Pylori testing: non-invasive test
* Antibodies to H. Pylori can be measured: Based by what? Can be used for what? Cannot be used for what?
A
- Serologic tests based on the detection of anti-H. Pylori IgG antibody
- Can be used for screening
- Cannot be used to assess eradication of disease as antibody levels can persist in the blood for long periods of time after
24
Q
Celiac disease
* What is this?
* happens from what?
A
- Enteropathy of the small intestines triggered by exposure to gluten in the diet
- Happens from the immune system reacting adversely to gluten and one of the proteins involved is an antibody to tissue transglutaminase
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Celiac disease-testing:
* Start with what? (what does it test)
* MUST heck what? Why?
* What is the gold standard?
* What has been strongly associated with celiac disease?
* Also look for what?
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Celiac disease
* People with celiac disease carry what?
* Carrying those genes is not what?
* However, if you carry the genes, what is the risk?
* People with celiac disease carry one or both of the HLA DQ2 and DQ8 genes, but so does up to 25-30% of the general population
* Carrying those genes is not a diagnosis of celiac disease nor does it mean you will ever develop celiac disease
* However, if you carry the genes your risk of developing celiac disease is 3% instead of the general population risk of 1%
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What are these?
Celiac disease
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Pancreatitis: Acute
* Developed when?
* What can cause it?
* Develops suddenly, as a result of gallstones or alcohol ingestion
* Medications, trauma, or infectious causes can also be a cause
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Pancreatitis: chronic:
* What happens?
* What is it from?
* Pancreas continues to sustain damage and lose function over time
* Happens from ongoing alcohol abuse or in cases such as cystic fibrosis
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Pancreatitis: Lab testing
* Serum lipase and amylase: what are they?
Lipase – higher sensitivity (79%) in comparison with other serum tests
* Needs to be at least three times greater than the upper limit of normal
* Earlier and longer lasting elevation (up to 2 weeks)
Amylase – lower clinical value, only elevated for up to five days
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Pancreatitis: Lab testing
* Urinary trypsinogen-2: how do you this? What do people say?
Urinary dipstick – debatable if this is better than lipase – some studies said it had higher sensitivity, others showed the same, some showed lower
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Thyroid
* What is this?
* What is it responible for?
The thyroid gland is a vitally important endocrine gland
* Responsible for metabolism, growth, and development of the body
* Production of thyroid hormones is regulated by the pituitary gland
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Thyroid
* Pituitary makes a hormone called what? What does that stimulate?
* What type of feedback?
* Pituitary makes a hormone called TSH (thyroid stimulating hormone)
* TSH stimulates the production of the thyroid hormones and influences the size of the gland
* Produces the thyroid hormone triiodothyronine (T3) and thyroxine (T4)
* Negative feedback loop
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Thyroid testing:
* What can be an early sign?
A change in the TSH level can be an early sign of a thyroid problem. For this reason, it is common to only measure the TSH level at first.
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* If the TSH level in the blood is higher or lower than normal, what other levels need to be measured?
* Most thyroid hormones are bound to what?
* What about unbound? What are we evaluting?
* If the TSH level in the blood is higher or lower than normal, the levels of the thyroid hormones T4 and T3 are also measured.
* Most thyroid hormones are bound to certain proteins in the blood. Only unbound “free” thyroid hormones are active and have an effect, though. So only the free thyroid hormones are measured (FT3 and FT4 – where “F” stands for “free”).
* So we are evaluating the :
* Thyroid stimulating hormone- TSH
* Free Triiodothyronine – Free T3
* Free Thyroxine – Free T4
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* What does it mean when Thyroid-stimulating hormone is high and low?
* What does high and low Free triiodothyronine (FT3) and free thyroxine (FT4) mean?
* Thyroid-stimulating hormone (TSH): High TSH levels are a sign of an underactive thyroid (hypothyroidism). The pituitary gland produces more TSH in order to stimulate the thyroid gland to produce thyroid hormones. Very low TSH levels in the blood may be a sign of an overactive thyroid (hyperthyroidism). The pituitary gland then produces less TSH, in order to stop “telling” the thyroid gland to make more hormones.
* Free triiodothyronine (FT3) and free thyroxine (FT4): High levels of free thyroid hormones in the blood may be a sign of an overactive thyroid, and low levels could be a sign of an underactive thyroid
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Thyroid antibody tests: What does it look at?
* What about hashimoto's and graves disease?
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What is Thyroglobulin?
protein produced by the thyroid gland that plays a role in thyroid hormone synthesis- can be used to monitor for recurrence of thyroid cancer after treatment
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Gout
* What is the most common of? First described when?
* Characterized by what?
One of the most common causes of chronic inflammatory arthritis
* First described by Hippocrates in ancient Greece!
Characterized by monosodium urate monohydrate crystals deposition in the tissue
* Patients have extracellular fluid urate saturation which is reflected in hyperuricemia in the blood
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Gout-Testing:
* What levels are done (blood)
* During are the levels During an acute gout flare-up?
* What is helpful in the clinical diagnosis of gout in symptomatic patients?
* What is not uncommon in the general population?
* What is the gold standard for gout?
* Serum urate levels – different for men and women
* During an acute gout flare-up, serum urate level may be high, normal, or low.
* Hyperuricemia is helpful in the clinical diagnosis of gout in symptomatic patients, but hyperuricemia alone does not definitively confirm the diagnosis.
* Asymptomatic hyperuricemia is not uncommon in the general population.
* Monosodium urate crystal identification remains the gold standard for gout diagnosis. Gout flare is marked by the presence of MSU crystals in synovial fluid obtained from affected joints of bursas visualized by direct examination of a fluid sample using compensated polarized light microscopy.
41
Pseudogout
* What is it caused by?
* It is unknown why CPP crystals form, but may be due to what?
* What is the testing?
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What is the difference between gout and pseudogout under mircoscope?
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Creatine phosphokinase (CPK): AKA Creatine kinase
* What is it?
* Phosphocreatine is used to supply what?
* When does levels increase?
* Can use this lab test to assess what?
* Enzyme that catalyzes the reaction of creatinine to phosphocreatinine
* Phosphocreatine is used to supply tissues and cells that require substantial amounts of ATP (ex: the brain, skeletal muscles and the heart)
* Leaks out of muscle during damage- elevated levels happens in: rhabdomyolysis, muscle damage, heart disease, kidney disease
* Can use this lab test to assess if damage present, monitor amount of damage
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What are the further subsets of CPK?
* CKMB
* CKBB
* CKMM
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Compartment Syndrome
* When does it occur?
* Muscle necrosis occurs and must be immediately addressed with what?
* Occurs when the interstitial pressure within the compartment exceeds the perfusion pressure at the level of the capillary beds
* Muscle necrosis occurs and must be immediately addressed with fasciotomy
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What is SIRS CRITERIA? What is sepsis, severe sepsis, septic shock and mods?
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Sepsis
* What is it?
* Sepsis encompasses a spectrum of what?
* Sepsis ranks in what?
* The pathophysiology of sepsis arises largely from what?
* The signs and symptoms of sepsis are influenced by ?
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Starts with systemic inflammatory response syndrome (SIRS)
* What do you need to the presence of?
4 clinical signs – need the presence of two of 4)
* Fever (greater than 100.4 F)
* Tachycardia
* Tachypnea
* Leukocytosis >12k with or without bandemia
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Sepsis shock:
* What happens?
Septic shock is what happens when the blood pressure drops due to the burden of infection
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Findings in sepsis, severe sepsis, and septic shock are as follows: (other labs)
* Hyperglycemia (glucose more than 120 mg/dL)
* Leukocytosis (WBC more than 12,000/mm3) or leukopenia (WBC less than 4000/mm3)
* Bandemia (more than 10%)
* C-reactive protein or procalcitonin more than 2 SD above normal
* Mixed venous saturation of less than 70%
* PaO2: FiO2 less than 300
* Pre-renal azotemia
* Coagulopathy, INR more than 1.5 or PTT more than 60 sec
* Thrombocytopenia (platelets less than 100,000/mL)
* Hyperbilirubinemia (total bilirubin more than 4 mg/dL)
* Lactic acidosis (more than 2 mmol/L)
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Procalcitonin (PCT)
* What is regarded as?
* PCT measurement aids in the diagnosis of what?
* PCT is regarded as a biomarker specific for bacterial infections, used in a variety of clinical settings
* PCT measurement aids in the diagnosis of sepsis and to guide and monitor antibiotic therapy
| normal level: less likely an infected source
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Malignancy markers by organ system
* Lunga CA mutations:
* Colorectal CA:
* Pancreatic CA/Cholangiocarcinoma:
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Malignancy markers by organ system
* Prostate CA
* Ovarian CA
* Testicular CA
* Breast CA
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What the different types of non small cell lung cancer (3)
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What is the difference between small cell and non small cell?
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Lung cancer markers:
* EGFR (Epidermal growth factor receptor?
* KRAS?
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Lung cancer markers
* ALK?
* NSE?
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Colorectal CA: Fecal immunochemical test
* What is it?
* Can be done when?
* What is Cologuard?
* Stool test that detects occult (hidden) blood in the stool- can also look for DNA changes
* Can be done at home with a kit, no dietary restrictions
* Cologuard: Tests for both DNA changes and blood in stool
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Colorectal CA: Fecal occult
* What is this/ what is an issue?
Older test, have drug and dietary restrictions prior to test (NSAIDS, Vit C, red meat), also more reactive to bleeding in the upper part of the digestive tract, such as the stomach
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Colorectal CA: Carcinoembryonic Antigen (CEA)
* What is it?
* Can be used to aid what?
* CEA is a valuable tumor marker in what?
* Typically reserved for those with what?
* Protein that is often elevated in the blood of individuals with colorectal cancer
* Can be used to aid in the diagnosis, staging, and monitoring treatment
* CEA is a valuable tumor marker in colorectal CA management, but it is not used as a screening tool for the general population due to its limited sensitivity and specificity
* Typically reserved for those with a confirmed diagnosis and to monitor for reoccurrence
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Prostate CA Prostate specific antigen (PSA)
* What is it?
* Levels can be high when?
PSA is a protein made by the prostate gland
Levels can be elevated in CA, but also can be elevated with other conditions (BPH, prostatitis, certain medications)
* The higher the PSA level, the more likely a prostate problem is present
* This is why the screening for prostate CA is a PSA and digital rectal examination
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Ovarian CA
* What is the marker?
* where is it high?
* Elevated when?
* Screening with this biomarker is not recommended, why?
Cancer Antigen 125 (CA 125) has played the most significant role in screening, detecting, and managing ovarian CA for the last 4 decades
* Is a high molecular weight mucinous glycoprotein found on the surface of ovarian cancer cells
* Elevated in 50% of early stage tumors and 92% of advanced stage tumors
* Screening with this biomarker is not recommended as the incidence of ovarian CA is low and screening would result in a considerable number of false positives
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Testicular CA
* Nearly all testis tumors are germ cell tumors (GCTs), which are categorized as either what?
* NSCGTs are divided into four subtypes?
* Nearly all testis tumors are germ cell tumors (GCTs), which are categorized as either seminoma or nonseminoma GCTs (NSGCTs) based on histology.
* NSCGTs are divided into four subtypes: choriocarcinoma, yolk sac, embryonal, and teratoma
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Testicular CA: biomarkers
* What is Alpha-fetoprotein (AFP)?
* What is it secreted by?
* Can be elevated in who?
Alpha-fetoprotein (AFP) – protein secreted by the fetal yolk sac, liver, GI tract and appears in high levels in the blood of a fetus
* Is secreted by non-seminomatous germ cell tumors that contain embryonal carcinoma, yolk sac tumor or teratoma
* Any patient with elevated AFP must have non-seminomatous component of testis cancer
* Can be elevated in patients with other malignancies including liver carcinoma, stomach cancer, pancreas, biliary tract
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Testicular CA: Human chorionic gonadotropin (hCG)
* In germ cell tumors of the testis, including what?
* Higher levels indicate what?
* In germ cell tumors of the testis, including seminomas and NSGCT, cancerous cells can transform into syncytiotrophoblasts (component of the placenta) and secrete hCG
* Higher levels indicates a worse prognosis
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Testicular CA: Testicular Lactate dehydrogenase
* What is LDH?
* Less specific for what?
* LDH is a cellular enzyme found in every tissue in the body (highest concentrations in muscle)
* Less specific for testis cancer than hCG or AFP, but elevated LDH levels are correlated to high tumor burden in seminoma and reoccurrence in NSGCT
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Breast CA
* How many subtypes?
* Some breast cancers are fueled by hormones, explain the two hormones
*
Six distinct molecular subtypes
Some breast cancers are fueled by hormones
* Estrogen receptor – cells of this type of cancer have receptors that allow them to use estrogen to grow – endocrine therapy blocking estrogen can block the growth of cancer cells
* Progesterone receptor – this type is sensitive to progesterone, cells have receptors that allow them to use this hormone to grow- blocking progesterone can block growth of cancer cells
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Breast CA: Her2
* What is it?
* Cancer cells that have too many copies of the HER2 gene produce what?
* How can it be found?
* HER2 breast CA are likely to benefit from what?
* HER2 is a growth promoting protein, allows cancer to grow fast and aggressively
* Cancer cells that have too many copies of the HER2 gene produce too much HER2
* Can be found with FISH evaluation
* HER2 breast CA are likely to benefit from chemotherapy targeted to HER2
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BRCA1/BRCA2
* The genes most commonly affected in who?
* How many women have mutated BRCA1/2
The genes most commonly affected in hereditary breast CA and ovarian CA
About 1 in every 500 women in the US have a mutation in either BRCA1 or BRCA2
* About 50 out of 100 women with a BRCA1 or BRCA2 gene mutation will get breast cancer by the time they turn 70 years old, compared to only 7 out of 100 women in the general United States population.
* About 30 out of 100 women with a BRCA1 or BRCA2 gene mutation will get ovarian cancer by the time they turn 70 years old, compared to fewer than 1 out of 100 women in the general U.S. population.
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Normally BRCA1/BRCA2 genes are what? What can happen?
Normally BRCA1/BRCA2 genes are tumor suppressor genes, but mutations to the gene prevent them from working properly
* Mutations to both copies creates an environment for malignancy
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Where are the BRCA genes located on chromones
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Pancreatic CA
* What is the marker?
* Its utility in screening special population groups and determining management for what?
* The marker is useful beyond pancreatic pathologies, with current studies pointing towards its potential use in
* Carbohydrate antigen 19-9 (CA 19-9) is the “go-to” tumor marker when one discusses the diagnosis, prognosis, and recurrence of pancreatic ductal adenocarcinoma.
* Its utility in screening special population groups and determining management for pancreatic ductal adenocarcinoma is more obscure, with many interpretations of its utility in the literature.
* CA 19-9 is useful beyond pancreatic pathologies, with current studies pointing towards its potential use in gastrointestinal, urological, pulmonary, uterine, ovarian, thyroid, and salivary gland diseases
