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PM Review > Non malignant disease > Flashcards

Non malignant disease Flashcards

1
Q

State EF for:
HFrEF
HFmrEF
HFpEF

A

<40%
40-50%
>50%

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2
Q

Median survival for CHF exacerbation and age >65

A

2 years

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3
Q

3 prognostic tools in CHF

A

Seattle HF score
HF survival score
MAGGIC

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4
Q

Challenge with HF prognosis tools

A

None are good at predicting prognosis within months
Seattle heart failure score overestimates prognosis in advanced disease

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5
Q

Which medications should be avoided / used with caution in CHF?

A

NSAID (CHF, AKI, and mortality risk)
Amphetamines
Steroids (Dex is safest)
Gabapentinoids (increase edema Pregab > Gaba)
TCA’s
Antipsychotics

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6
Q

Which SSRI/SNRI’s have proven safety in CHF?

A

Sertraline
Venlafaxine

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7
Q

Evidence based treatments for HFrEF

A
  • ACEi/ARB
  • B-blockers
  • Spironolactone
  • If channel inhibitor (Ivabradine)
  • Hydralazine / Nitrates (esp. if unable to tolerate ACE/ARB)
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8
Q

What is the major adverse effect of combining Furosemide and Risperidone?

A

Incr. mortality in the elderly

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9
Q

How does digitalis work?

A

Reduced sympathetic tone (augments parasympathetic tone), improves myocardial contraction
HFrEF - improved symptoms (fatigue, dyspnea), no mortality benefit
HFpEF - no benefit

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10
Q

Inotropes
- 2 key medications and what they do
- Outcomes and indications

A

Milrinone (inotrope, vasodilator) and Dobutamine (synthetic catecholamine)

Improve symptoms but increase mortality
Short term indication to increase CO and diuresis
Palliative HF

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11
Q

Indications for pacemakerinCHF

A

EF <35%
LBBB
Wide QRS

Improvements in QOL and survival

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12
Q

What is the consequence of overtreating hypoxia in CHF

A

vasocontriction -> SVR -> reduction in CO

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13
Q

LVAD
- time to, and duration of benefit
- indications
- morbidities

A

3 months to benefit, up to 2yrs

bridge to transplant (now also destination)

stroke and arrhythmia

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14
Q

NYHA classes of heart failure

A

1 - No symptoms with ordinary physical activity
2 - No symptoms at rest, symptoms with ordinary levels of activity
3 - No symptoms at rest, symptoms with less than ordinary levels of activity
4 - Symptoms at rest

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15
Q

List some treatments for PAH
What are the key goals of therapy

A
  • CCB’s
  • PDE5 inhibitors
  • Prostacyclin pathway agonist
  • Endothelin antagonist
  • Reduce pulm. vasocontriction and reduce proliferation of arteriolar smooth muscle cells
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16
Q

What specific considerations must be taken into account when managing palliative PAH care

A
  • RV failure v. sensitive to hypotension, incr. RV afterload and reduction in RV contractility
  • Use opioid, TCA, anti-psychotic with caution
  • Gut edema is common (med absorption)
  • Avoid drugs with sympathomimetic and pro-arrhythmic property
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17
Q

Aside from diuresis, how else does furosemide work

A

Immediate venodilatory effect

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18
Q

What are indications for deactivation of ICD?

A

inconsistent with goals
withdrawal of anti-arrhythmic
nearing EOL

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19
Q

No therapy has been proven to alter the course of which type of heart failure

A

HFpEF

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20
Q

How to HFrEF and HFpEF patients compare in terms of demographics and symptom burden?

A

HFpEF patients are older, higher BMI, have greater comorbidities, worse QOL, and worse prognosis

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21
Q

What is the prognosis of ALS?
Median age of diagnosis?
Negative prognostic factors?

A

prognosis 20-48 mo (<2yrs in most) - 10/10 rule (only 10% live >10yrs)

median age of dx. 55

negative prognostic factors:
- age
- bulbar onset
- frontotemporal dementia
- gen mutations (SOD1)

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22
Q

What specific aspect must be covered in ACP for ALS patients?

A

intubation preference

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23
Q

What are the benefits of NIV in ALS?

A

improved QOL and symptoms
slows rate of respiratory decline
survival

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24
Q

how does resp failure usually present in ALS?

A

nocturnal hypoventilation

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25
Q

Optimal timing for feeding tube insertion in ALS

A

When FVC still >50

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26
Q

2 treatments for spasticity in ALS

A

baclofen
tizanidine

other: gaba, bzp, dantrolene, botox

european society - keppra

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27
Q

management of secretions in ALS
- list the 2 types and respective approaches

A

anterior secretions - dry it up (glyco/anticholinergics, suction, sage tea, botox, RT)

posterior secretions - thin them out (fluid, guaifenesin, cough assist device)

other - respiratory exercise (chest wall physiotherapy, chest wall oscillator)

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28
Q

What type of cognitive impairment is common in ALS
How does it present?

A

FTD
apathy, disinhibition, decr. executive function, loss of insight and empathy

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29
Q

Management for pseudobulbar affect (pharmacological)

A

quinidine + dextromethorphan
some evidence for the use of SSRI, TCA

(inappropriate expression INCONGRUENT with true mood)

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30
Q

2 variants of ALS

A

Bulbar (20%) - starts with cranial nerve dysfunction

Spinal (80%) - starts with asymmetric tetraparesis

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31
Q

What respiratory intervention should be avoided in ALS

A

supplemental O2

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32
Q

medication approved for spasticity in MS that may be used “off label” in ALS

A

cannabis

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33
Q

How do ALS patients die

A

Mostly whilst sleeping
- resp failure
- autonomic failure

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34
Q

What are the 4 parkinson plus syndromes

A
  • DLB
  • CBD
  • MSA
  • PSP
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35
Q

Key distinguishing features of dementia with lewy bodies

A
  • cognitive impairment (fluctuating)
  • hallucinations (early in course of disease)
  • neuroleptic sensitivity
  • also more likely to have paradox. agitation with benzo.
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36
Q

Key distinguishing features of progressive supranuclear palsy

A
  • supranuclear gaze palsy (esp. downward)
  • early dysarthria
  • early dysphagia
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37
Q

Key distinguishing features of multiple systems atrophy

A

Prominent and severe autonomic dysfunction (orthostatic hypotension, sexual dysfunction, neurogenic bladder)

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38
Q

Key distinguishing features of corticobasal degeneration

A

myoclonus
dystonias
apraxia (difficulty with skilled movements)
alien limb phenomena

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39
Q

How does the disease course and prognostic outlook of PD plus syndromes compare with PD

A

PD plus syndromes experience quicker progression, worse prognosis
Less responsive to dopamine

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40
Q

Key side-effects of dopamine / dopamine agonists

A

neuromotor - dyskinesias
neuromotor - motor fluctuations (wearing off, dose failures, sudden off time)
psychiatric - impulse control disorder, psychosis, delirium
autonomic - orthostatic hypotension
GI - nausea and vomiting

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41
Q

Failure to wean off levodopa will result in what?

A

parkinsonian crisis / parkinsonism-hyperpyrexia syndrome - a neuroleptic-like malignant syndrome (life threatening)

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42
Q

What factors predict 6-12mo mortality in PD?

A
  • dysphagia
  • weight loss
  • reduction in medication required due to a neuropsychiatric effect
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43
Q

What are 3 common nighttime symptoms in PD and related disorders?

A

Sundowning / night-time hallucinations

Restless legs syndrome

REM sleep behaviour disorder

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44
Q

Medication approach to sundowning / hallucinations in parkinsons:

A

Withdraw culprits in following order:
- anticholinergics, dopamine agonists, COMT inhibitors, levodopa

may trial low dose seroquel

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45
Q

Treatments for REM sleep d/o:

Which PD like d/o is this common in?

A

1) Melatonin
2) Clonazepam

Cholinergics (cholinesterase inhibitors)
Dopamine agonists

More common in lewy body dementia

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46
Q

Treatments for RLS:

A
  • rule out Fe deficiency (treat if ferritin low)
  • dopamine
  • benzodiazepines
  • gabapentin
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47
Q

Management of dysautonomia (orthostatic hypotension) in PD

A

Hydrate and increase Na intake
Compression stockings
Reduce levodopa
Midodrine
Fludrocortisone

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48
Q

What is the role of NG feeding in patients with acute stroke?
What are the outcomes?

A

Short term measure to support nutritional intake (end points: regained ability to swallow or long term PEG)
Outcomes - improved recovery, does not reduce risk of aspiration

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49
Q

What are the benefits of feeding tubes in ALS

A
  • nutrition
  • medication administration
  • prolong survival
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50
Q

Non motor symptoms of parkinsons

A
  • delayed gastric emptying
  • constipation
  • urge incontinence
  • erectile dysfunction
  • depression
  • anxiety
  • cognitive impairment
  • REM sleep behaviour d/o
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51
Q

Symptoms/signs of parkinsonism hyperpyrexia syndrome
Lab findings
Treatment

A
  • rigidity (can lead to rhabdo)
  • mental status change
  • fever
  • autonomic instability (labile BP, tachycardia)

labs: elevated CK, AKI, transaminitis, myoglobinuria, leukocytosis

treatment: supportive care, resume dopaminergics, benzodiazepines PRN
(classic NMS therapy bromocriptine, dantrolene, amantadine has poor evidence in this situation)

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52
Q

Symptoms/signs of serotonin syndrome

Treatment

A
  • mental status change
  • fever
  • hyper-reflexia, clonus (including ocular), myoclonus, tremor
  • n/v/diarrhea
  • rigidity
  • flushed skin and diaphoresis

Treatment: benzo, supportive care, cyproheptadine

53
Q

How does MS present?

A

Highly variable
- gait abnormalities
- dysphagia and dysarthria
- ataxia
- psychological distress

54
Q

What are the most common causes of pain in MS?

A

1) Central neuropathic
2) MSK = spasticity / spasm

55
Q

Top agents for spasticity in MS:

A

baclofen
tizanidine
botox
cannabinoid

56
Q

List prognostic scores for ischemic and hemorrhagic stroke
What are their pros and cons?

A

Ischemic - NIHSS scale (score >16 strong predictor of poor outcome at 3mo.)
Hemorrhagic - ICH score (validated for 30 day mortality)

Scores mortality and morbidity, but not QOL / recovery to patient centric goals

57
Q

What is the greatest prognostic challenge in stroke?

A

Peak recovery doesn’t occur for months (majority at 3mo, but noted up to 12mo)
Early recovery at 1 week is a good sign

58
Q

List some important / distinctive points to consider when engaging in ACP for stroke patients

A
  • burden on family could be high (patient not able to communicate, sudden event etc.)
  • seek to understand the minimum acceptable outcome from QOL perspective
  • determine QOL facets and cherished critical abilities
  • consider level of functional recovery, but also adaptation to new health status
  • beware of the “disability paradox” - we underestimate disabled people’s QOL
59
Q

what are common under-recognized symptoms in stroke

A
  • pain (central and MSK) - 50%
  • CPSP (central post stroke pain - esp. sensory cortex and thalamic lesions)
  • Spasticity
  • depression - 30%
  • cognitive impairment - 80%
  • fatigue
60
Q

How do you distinguish PD from LBD

A

Motor symptoms are present for >12mo in PD before onset of dementia

61
Q

2 scales that measure dementia severity

A

CDR - clinical dementia rating
FAST - functional assessment staging scale

62
Q

List 1 dementia prognostic tool

A

ADEPT

63
Q

Dementia prognosis for those diagnosed after age 65

A

4-8yrs

64
Q

6 mo. mortality in advanced dementia patients with hip#

A

50%

65
Q

Mortality of pneumonia in someone with advanced dementia

A

40-50%

66
Q

What is the general approach to behavioural disturbance in patient with dementia

A

search for an unmet need

67
Q

how does depression present in dementia?

A

atypical
refusal to eat
aggression
vocalization

68
Q

evidence for use of SSRI’s in dementia

A

questionable

69
Q

Cholinesterase inhibitors show benefit in which types of dementia

A

AZ
DLB

70
Q

CCS criteria for CRT pacing in heart failure patients (in sinus)

A

NYHA Class II-IV
and
EF <35%
and
LBBB with QRS>130

71
Q

What variables does the Seattle Heart Failure score evaluate?

A

clinical
pharmacological
laboratory
device

72
Q

Which variable is consistently associated with poor prognosis in HF and how can this be further refined?

A

HF hospitalizations, refined further by age

73
Q

When should discussions about ICD deactivation be held?

A
  • prior to implantation
  • annual HF reviews
  • after major milestones
  • nearing EOL
74
Q

Review the sequential escalation of bronchodilator therapy in COPD

A

1) SABD PRN + LAMA or LABA
2) “ + LAMA/LABA
3) “ + LAMA/LABA/ICS

75
Q

ICS risks

A

pneumonia
thrush

76
Q

ICS indications

A

severe COPD
bronchial hyper-reactivity/asthma
recurrent exacerbations

77
Q

What is the evidence for PDE-4 inhibitors in COPD

A
  • reduce exacerbation rates
  • bronchodilation
  • anti-inflammatory
78
Q

Role of prophylactic abx. in COPD

A

Macrolides (azithro)
Prevent exacerbations in non-smokers

79
Q

What are the 4 aspects of pulmonary rehab?
Key outcomes?

A

exercise (supervised - intensive outpatient exercise program)
education
nutrition
psychosocial

outcomes: better symptom control, QOL, function, psychosocial health

80
Q

Criteria for O2 in COPD

A

PO2 <55 or SaO2 <88%
OR
PO2 55-60 + PHTN, polycythemia, CHF

81
Q

Pathophysiology of ILD is characterized by:

A
  • cellular proliferation
  • interstitial inflammation
  • fibrosis
82
Q

How are ILD’s classified?

A
  • known associations (CTD, dusts, drugs etc.)
  • granulomatous (sarcoid, hypersensitivity etc.)
  • idiopathic (interstitial pneumonias)
83
Q

Describe the various trajectories of ILD

A

reversible
- self-limited (RB-ILD) or with risk of progression NSIP, DIP, COP)

stable residual disease (NSIP)

progressive with potential for stabilization (NSIP)

progressive and irreversible (IPF)

84
Q

What are the key treatments for IPF?
Indications?
What are the outcomes?

A

nindetanib and pirfenidone

mild-mod IPF - significant reducing dz. progression, impr. survival
severe IPF - less helpful

no improvement in function, symptoms, QOL

85
Q

Management of IPF exacerbations

A

supportive care
steroid (weak evidence)
abx. coverage

86
Q

IPF - what kind of hypoxia is common?

A

exertional (more so than COPD)

87
Q

IPF
survival w/o transplant?
survival post-transplant?

A

2-4 year survival

post-transplant 4.5yrs

88
Q

10 non-pharmacological management strategies for COPD and ILD

A
  • smoking cessation
  • exercise training
  • pulmonary rehab
  • breathing exercise (purse lip, diaphragmatic etc)
  • gait aids
  • chest wall vibration
  • neuromuscular electrical muscle stimulation
  • fan
  • energy conservation / management
  • positioning - recovery (upright, forward)
  • oxygen
  • non-invasive ventilation
89
Q

review mmrc scale for dyspnea

A

1 - trouble with strenuous activity only
2 - SOB hurrying on level ground, walking up hill
3 - walks slower than average on level ground
4 - stops walking after few mins or 100 yards on level ground
5 - unable to leave house, breathless when dressing/undressing

90
Q

COPD diagnosis PFT

A

FEV/FVC <0.7

91
Q

COPD severity by FEV criteria

A

Mild - FEV1 >80
Mod - FEV1 50-80
Severe - FEV1 30-50
Very Severe - FEV<30

92
Q

PFT findings for ILD

A

reduced FVC
reduced DLCO

93
Q

3 qualities of breathlessness / dyspnea

A

air hunger
chest tightness
work / effort

94
Q

prognostic factors in HIV

A

age
race
baseline cd4
gender - women, black men
transmission risk group - msm

95
Q

CD4 count
PJP risk in HIV
TB and pneumococcal risk in HIV

A

<200
<400

96
Q

What are the AIDS defining malignancies

A

kaposi sarcoma
non-hodgkins lymphoma
cervical ca

97
Q

Why are HIV patients at higher risk of other chronic disease?

A

“premature aging” - immune dysfunction
potentially lifestyle related

98
Q

Which diseases are more common in HIV patients?

A

all cancers
renal failure (HIV nephropathy)
liver failure (coinfection HCV, NAFLD)
hypogonadism
dementia
frailty
psychiatric

99
Q

most common s/e of HAART

A

GI upset

100
Q

What correlates best with prognosis in late stage HIV

A

age and function (not cd4 or viral count)

101
Q

Does fentanyl dose need adjusting in renal failure

A

Yes - parent chemical can build up
Consider using 50-75% of the usual dose

102
Q

Does methadone dose need adjusting in renal failure?

A

theoretically no (fecal excretion thought to compensate)
BUT, suggested caution and 50-75% usual as starting point

103
Q

What are the top causes of fatigue in renal failure

A

anemia
uremia
dialysis (either too burdensome, or inadequate)
hyperparathyroidism

104
Q

outline management of pruritis in renal failure

A

renal mgmt - hyperphos, hyperparathyroid can provoke

skin issues

pharmacotherapy -
gabapentin (most evidence),
anti-histamine,
opioid antagonist, SSRI (sertraline)

other - UVB light, tacrolimus

105
Q

Which benzodiazepines are preferred in renal failure?

A

short acting (lorazepam, midazolam)
reduce doses
(midazolam recommendation of 25% if GFR<10)

106
Q

No survival advantage of dialysis seen beyond what age?

A

80

107
Q

survival advantage of dialysis is offset by what in the the elderly?

A

days in hospital

108
Q

what has been postulated to slow rate of renal decline in late stages?

A

stopping ACEi/ARB

low protein diet (controversial)

109
Q

What is the typical survival post discontinuation of dialysis?

A

days to short weeks (usually <2 weeks)

(depends on residual function)

110
Q

which analgesic is contraindicated in dialysis?

A

baclofen

111
Q

what is the median survival for compensated vs. decompensated cirrhosis?

A

12yrs
2yrs

112
Q

2 prognostic tools for cirrhosis

A

child-pugh c
meld (meld-na. meld 3.0)

113
Q

child pugh c criteria

A

bili
inr
albumin
encephalopathy
ascites

114
Q

meld na criteria

A

bilirubin
inr
cr
na
need for dialysis

115
Q

SAAG criteria for portal hypertension

A

> 11g.l

116
Q

treatment for ascites in liver failure

A

na restriction <2g/d
diuretics - spironolactone:lasix 100:40 ratio
(resistance if not managed by 400/160 dose)

117
Q

treatments for diuretic resistant ascites

A

paracentesis
indwelling catheter
TIPS

118
Q

pharmacological treatments for pruritis in liver failure

A

cholestyramine
rifampin
opioid antagonist
SSRI (sertraline)

antihistamines - weak evidence
ursodiol - only recommended in PBC

119
Q

what is the distinguishing factor between overt (Stage II-IV) hepatic encephalopathy and covert hepatic encephalopathy?

A

disorientation and asterixis

120
Q

list 6 consequences of stigma in healthcare

A

decreased QOL
isolation
depression
distrust
reduced adherence to treatments
reduced access to care

121
Q

max dose of acetaminophen in liver failure

A

2g

122
Q

which opioid half life is greatly prolonged and should be used with caution in liver failure?

A

oxycodone

123
Q

describe uremic caliphylaxis

A

calcification of small blood vessels -> ischemia
presents as painful skin / visceral lesions
most common in ESRD (dialysis > non-dialysis patients)
poorly understood d/o

RF: female, hypercoagulable states, DM, hyperPTH, hypoalbumin

124
Q

clinical presentation of calciphylaxis

A

early - pain, purple discoloration (livedo reticularis)
later - SC nodules, plaques, ulcerations

greatest affected areas - fatty tissue

125
Q

diagnosis of calciphylaxis

A

clinical
imaging shows calcification
biopsy deferred usually (poor healing)

126
Q

Treatments for calciphylaxis

A

underlying conditions - DM and hyper PTH
supplements - stop Ca and vit D
diet - low phosphate
medical - calcimimetic, incr. dialysis frequency
symptoms - pain control and wound care
other - O2 therapy and hyperbaric O2

127
Q

What is the typical prognosis of CJD?
Age of onset?
Incubation period?

A

<1 year from symptom onset
most die within 6mo.

onset age 60

incubation 10 years prior to symptom onset

128
Q

What should trigger clinical consideration for CJD?

A

non-reversible dementia over days to months

often present with ataxia, emotional lability, concentration challenges, disordered sleep and hallucinations

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