MLA: Medicine and Stroke

Question 1

which investigation has now replaced TRUS biopsy as the first line in suspected prostate cancer?

Answer 1

multiparametric MRI

Question 2

what is a key reason for considering Neo-adjuvant chemo in breast cancer?

Answer 2

to downsize the tumour before surgery and allow breast conserving surgery rather than mastectomy

Question 3

what is the surgical outcome in an emergency setting, if a colonic tumour is associated with perforation?

Answer 3

the risk of anastomosis is much great in these patients so the result is an end colostomy = Hartmann’s procedure

Question 4

what does a Hartmann’s procedure entail?

Answer 4

resection of the sigmoid colon, closure of the rectal stump, and formation of an end colostomy

Question 5

what features are present in an emergency presentation of colonic adenocarcinoma?

Answer 5

perforation and peritonitis

Question 6

why is an end colostomy used in an emergency presentation of colonic adenocarcinoma?

Answer 6

it is imperative to divert faecal flow away from the site of perforation to promote healing while minimising postoperative complications - an end colostomy accomplishes this by exteriorising the proximal segment of the colon through an abdominal wall incision, facilitating stool diversion from the compromised area

Question 7

all patients with newly diagnosed colorectal cancer should have what investigations for staging?

Answer 7

1. CEA
2. CT of the chest, abdomen and pelvis
3. the entire colon must be evaluated with colonoscopy or CT colonography
4. patients whose tumour lie below the peritoneal reflection should have their mesorectum evaluated with MRI

Question 8

which intervention is the only option for cure in patients with colon cancer?

Answer 8

resectional surgery

Question 9

what type of resection occurs for adenocarcinomas in the sigmoid colon?

Answer 9

high anterior resection

Question 10

how do bisphosphonates work?

Answer 10

they are analogues of pyrophosphate, a molecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis

Question 11

what are the clinical uses of bisphosphonates?

Answer 11

1. prevention and treatment of osteoporosis
2. hypercalcaemia
3. Paget’s disease
4. pain from bone mets

Question 12

what are the adverse effects of bisphosphonates?

Answer 12

1. oesophageal reactions: oesophagitis, ulcers
2. osteonecrosis of the jaw
3. increased risk of atypical stress fractures of the proximal femoral shaft
4. acute phase response: fever, myalgia and arthralgia
5. hypocalcaemia: due to reduced calcium efflux from bone

Question 13

what are the signs of right-sided heart failure?

Answer 13

raised JVP, ankle oedema and hepatomegaly

Question 14

which medication is used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention?

Answer 14

Duloxetine

Question 15

which antiplatelet is preferred for secondary prevention following a stroke

Answer 15

Clopidogrel 75mg - if contraindicated, low-dose aspirin (75mg) and modified-release dipyridamole can be used second-line

Question 16

which investigation is used to investigate (and assess the degree of stenosis) carotid artery stenosis?

Answer 16

Duplex USS

Question 17

carotid artery stenosis is implicated in what percentage of stroke?

Answer 17

10-15%

Question 18

what is the new ‘tissue-based’ definition of TIA?

Answer 18

a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infection

Question 19

what are the clinical features of a TIA

Answer 19

sudden onset, focal neurological deficit but, rather than persisting, the features resolve, typically within one hour

Question 20

what is the immediate management of a patient presenting with a TIA?

Answer 20

be given aspirin 300mg immediately unless contraindicated and to be assessed within 24 hours by a stroke specialist

Question 21

which medications should be considered in TIA patients within 24 hours of onset/minor ischaemic stroke with low risk of bleeding?

Answer 21

Clopidogrel (300mg followed by 75mg OD) + aspirin (initial 300mg then 75mg OD for 21 days), followed by mono therapy with Clopidogrel 75mg OD
(Ticagrelor + Clopidogrel is an alternative)

Question 22

which medication would be used for a patient with resolved TIA Sx, awaiting specialist review within 24 hours?

Answer 22

Aspirin

Question 23

which medications should be given to a patient reviewed by a specialist, within the first 21 days when the patient is at high risk of further events?

Answer 23

aspirin and clopidogrel

Question 24

which medication should be given as a long-term secondary prevention after 21 days of resolved TIA Sx?

Answer 24

Clopidogrel