Non malignant disease Flashcards
1
Q
State EF for:
HFrEF
HFmrEF
HFpEF
A
<40%
40-50%
>50%
2
Q
Median survival for CHF exacerbation and age >65
A
2 years
3
Q
3 prognostic tools in CHF
A
Seattle HF score
HF survival score
MAGGIC
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
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
6
Q
Which SSRI/SNRI’s have proven safety in CHF?
A
Sertraline
Venlafaxine
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)
8
Q
What is the major adverse effect of combining Furosemide and Risperidone?
A
Incr. mortality in the elderly
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
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
11
Q
Indications for pacemakerinCHF
A
EF <35%
LBBB
Wide QRS
Improvements in QOL and survival
12
Q
What is the consequence of overtreating hypoxia in CHF
A
vasocontriction -> SVR -> reduction in CO
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
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
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
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
17
Q
Aside from diuresis, how else does furosemide work
A
Immediate venodilatory effect
18
Q
What are indications for deactivation of ICD?
A
inconsistent with goals
withdrawal of anti-arrhythmic
nearing EOL
19
Q
No therapy has been proven to alter the course of which type of heart failure
A
HFpEF
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
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)
22
Q
What specific aspect must be covered in ACP for ALS patients?
A
intubation preference
23
Q
What are the benefits of NIV in ALS?
A
improved QOL and symptoms
slows rate of respiratory decline
survival
24
Q
how does resp failure usually present in ALS?
A
nocturnal hypoventilation
25
Optimal timing for feeding tube insertion in ALS
When FVC still >50
26
2 treatments for spasticity in ALS
baclofen
tizanidine
other: gaba, bzp, dantrolene, botox
european society - keppra
27
management of secretions in ALS
- list the 2 types and respective approaches
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)
28
What type of cognitive impairment is common in ALS
How does it present?
FTD
apathy, disinhibition, decr. executive function, loss of insight and empathy
29
Management for pseudobulbar affect (pharmacological)
quinidine + dextromethorphan
some evidence for the use of SSRI, TCA
(inappropriate expression INCONGRUENT with true mood)
30
2 variants of ALS
Bulbar (20%) - starts with cranial nerve dysfunction
Spinal (80%) - starts with asymmetric tetraparesis
31
What respiratory intervention should be avoided in ALS
supplemental O2
32
medication approved for spasticity in MS that may be used "off label" in ALS
cannabis
33
How do ALS patients die
Mostly whilst sleeping
- resp failure
- autonomic failure
34
What are the 4 parkinson plus syndromes
- DLB
- CBD
- MSA
- PSP
35
Key distinguishing features of dementia with lewy bodies
- cognitive impairment (fluctuating)
- hallucinations (early in course of disease)
- neuroleptic sensitivity
- also more likely to have paradox. agitation with benzo.
36
Key distinguishing features of progressive supranuclear palsy
- supranuclear gaze palsy (esp. downward)
- early dysarthria
- early dysphagia
37
Key distinguishing features of multiple systems atrophy
Prominent and severe autonomic dysfunction (orthostatic hypotension, sexual dysfunction, neurogenic bladder)
38
Key distinguishing features of corticobasal degeneration
myoclonus
dystonias
apraxia (difficulty with skilled movements)
alien limb phenomena
39
How does the disease course and prognostic outlook of PD plus syndromes compare with PD
PD plus syndromes experience quicker progression, worse prognosis
Less responsive to dopamine
40
Key side-effects of dopamine / dopamine agonists
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
41
Failure to wean off levodopa will result in what?
parkinsonian crisis / parkinsonism-hyperpyrexia syndrome - a neuroleptic-like malignant syndrome (life threatening)
42
What factors predict 6-12mo mortality in PD?
- dysphagia
- weight loss
- reduction in medication required due to a neuropsychiatric effect
43
What are 3 common nighttime symptoms in PD and related disorders?
Sundowning / night-time hallucinations
Restless legs syndrome
REM sleep behaviour disorder
44
Medication approach to sundowning / hallucinations in parkinsons:
Withdraw culprits in following order:
- anticholinergics, dopamine agonists, COMT inhibitors, levodopa
may trial low dose seroquel
45
Treatments for REM sleep d/o:
Which PD like d/o is this common in?
1) Melatonin
2) Clonazepam
Cholinergics (cholinesterase inhibitors)
Dopamine agonists
More common in lewy body dementia
46
Treatments for RLS:
- rule out Fe deficiency (treat if ferritin low)
- dopamine
- benzodiazepines
- gabapentin
47
Management of dysautonomia (orthostatic hypotension) in PD
Hydrate and increase Na intake
Compression stockings
Reduce levodopa
Midodrine
Fludrocortisone
48
What is the role of NG feeding in patients with acute stroke?
What are the outcomes?
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
49
What are the benefits of feeding tubes in ALS
- nutrition
- medication administration
- prolong survival
50
Non motor symptoms of parkinsons
- delayed gastric emptying
- constipation
- urge incontinence
- erectile dysfunction
- depression
- anxiety
- cognitive impairment
- REM sleep behaviour d/o
51
Symptoms/signs of parkinsonism hyperpyrexia syndrome
Lab findings
Treatment
- 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)
52
Symptoms/signs of serotonin syndrome
Treatment
- 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
How does MS present?
Highly variable
- gait abnormalities
- dysphagia and dysarthria
- ataxia
- psychological distress
54
What are the most common causes of pain in MS?
1) Central neuropathic
2) MSK = spasticity / spasm
55
Top agents for spasticity in MS:
baclofen
tizanidine
botox
cannabinoid
56
List prognostic scores for ischemic and hemorrhagic stroke
What are their pros and cons?
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
What is the greatest prognostic challenge in stroke?
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
List some important / distinctive points to consider when engaging in ACP for stroke patients
- 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
what are common under-recognized symptoms in stroke
- pain (central and MSK) - 50%
- CPSP (central post stroke pain - esp. sensory cortex and thalamic lesions)
- Spasticity
- depression - 30%
- cognitive impairment - 80%
- fatigue
60
How do you distinguish PD from LBD
Motor symptoms are present for >12mo in PD before onset of dementia
61
2 scales that measure dementia severity
CDR - clinical dementia rating
FAST - functional assessment staging scale
62
List 1 dementia prognostic tool
ADEPT
63
Dementia prognosis for those diagnosed after age 65
4-8yrs
64
6 mo. mortality in advanced dementia patients with hip#
50%
65
Mortality of pneumonia in someone with advanced dementia
40-50%
66
What is the general approach to behavioural disturbance in patient with dementia
search for an unmet need
67
how does depression present in dementia?
atypical
refusal to eat
aggression
vocalization
68
evidence for use of SSRI's in dementia
questionable
69
Cholinesterase inhibitors show benefit in which types of dementia
AZ
DLB
70
CCS criteria for CRT pacing in heart failure patients (in sinus)
NYHA Class II-IV
and
EF <35%
and
LBBB with QRS>130
71
What variables does the Seattle Heart Failure score evaluate?
clinical
pharmacological
laboratory
device
72
Which variable is consistently associated with poor prognosis in HF and how can this be further refined?
HF hospitalizations, refined further by age
73
When should discussions about ICD deactivation be held?
- prior to implantation
- annual HF reviews
- after major milestones
- nearing EOL
74
Review the sequential escalation of bronchodilator therapy in COPD
1) SABD PRN + LAMA or LABA
2) " + LAMA/LABA
3) " + LAMA/LABA/ICS
75
ICS risks
pneumonia
thrush
76
ICS indications
severe COPD
bronchial hyper-reactivity/asthma
recurrent exacerbations
77
What is the evidence for PDE-4 inhibitors in COPD
- reduce exacerbation rates
- bronchodilation
- anti-inflammatory
78
Role of prophylactic abx. in COPD
Macrolides (azithro)
Prevent exacerbations in non-smokers
79
What are the 4 aspects of pulmonary rehab?
Key outcomes?
exercise (supervised - intensive outpatient exercise program)
education
nutrition
psychosocial
outcomes: better symptom control, QOL, function, psychosocial health
80
Criteria for O2 in COPD
PO2 <55 or SaO2 <88%
OR
PO2 55-60 + PHTN, polycythemia, CHF
81
Pathophysiology of ILD is characterized by:
- cellular proliferation
- interstitial inflammation
- fibrosis
82
How are ILD's classified?
- known associations (CTD, dusts, drugs etc.)
- granulomatous (sarcoid, hypersensitivity etc.)
- idiopathic (interstitial pneumonias)
83
Describe the various trajectories of ILD
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
What are the key treatments for IPF?
Indications?
What are the outcomes?
nindetanib and pirfenidone
mild-mod IPF - significant reducing dz. progression, impr. survival
severe IPF - less helpful
no improvement in function, symptoms, QOL
85
Management of IPF exacerbations
supportive care
steroid (weak evidence)
abx. coverage
86
IPF - what kind of hypoxia is common?
exertional (more so than COPD)
87
IPF
survival w/o transplant?
survival post-transplant?
2-4 year survival
post-transplant 4.5yrs
88
10 non-pharmacological management strategies for COPD and ILD
- 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
review mmrc scale for dyspnea
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
COPD diagnosis PFT
FEV/FVC <0.7
91
COPD severity by FEV criteria
Mild - FEV1 >80
Mod - FEV1 50-80
Severe - FEV1 30-50
Very Severe - FEV<30
92
PFT findings for ILD
reduced FVC
reduced DLCO
93
3 qualities of breathlessness / dyspnea
air hunger
chest tightness
work / effort
94
prognostic factors in HIV
age
race
baseline cd4
gender - women, black men
transmission risk group - msm
95
CD4 count
PJP risk in HIV
TB and pneumococcal risk in HIV
<200
<400
96
What are the AIDS defining malignancies
kaposi sarcoma
non-hodgkins lymphoma
cervical ca
97
Why are HIV patients at higher risk of other chronic disease?
"premature aging" - immune dysfunction
potentially lifestyle related
98
Which diseases are more common in HIV patients?
all cancers
renal failure (HIV nephropathy)
liver failure (coinfection HCV, NAFLD)
hypogonadism
dementia
frailty
psychiatric
99
most common s/e of HAART
GI upset
100
What correlates best with prognosis in late stage HIV
age and function (not cd4 or viral count)
101
Does fentanyl dose need adjusting in renal failure
Yes - parent chemical can build up
Consider using 50-75% of the usual dose
102
Does methadone dose need adjusting in renal failure?
theoretically no (fecal excretion thought to compensate)
BUT, suggested caution and 50-75% usual as starting point
103
What are the top causes of fatigue in renal failure
anemia
uremia
dialysis (either too burdensome, or inadequate)
hyperparathyroidism
104
outline management of pruritis in renal failure
renal mgmt - hyperphos, hyperparathyroid can provoke
skin issues
pharmacotherapy -
gabapentin (most evidence),
anti-histamine,
opioid antagonist, SSRI (sertraline)
other - UVB light, tacrolimus
105
Which benzodiazepines are preferred in renal failure?
short acting (lorazepam, midazolam)
reduce doses
(midazolam recommendation of 25% if GFR<10)
106
No survival advantage of dialysis seen beyond what age?
80
107
survival advantage of dialysis is offset by what in the the elderly?
days in hospital
108
what has been postulated to slow rate of renal decline in late stages?
stopping ACEi/ARB
low protein diet (controversial)
109
What is the typical survival post discontinuation of dialysis?
days to short weeks (usually <2 weeks)
(depends on residual function)
110
which analgesic is contraindicated in dialysis?
baclofen
111
what is the median survival for compensated vs. decompensated cirrhosis?
12yrs
2yrs
112
2 prognostic tools for cirrhosis
child-pugh c
meld (meld-na. meld 3.0)
113
child pugh c criteria
bili
inr
albumin
encephalopathy
ascites
114
meld na criteria
bilirubin
inr
cr
na
need for dialysis
115
SAAG criteria for portal hypertension
>11g.l
116
treatment for ascites in liver failure
na restriction <2g/d
diuretics - spironolactone:lasix 100:40 ratio
(resistance if not managed by 400/160 dose)
117
treatments for diuretic resistant ascites
paracentesis
indwelling catheter
TIPS
118
pharmacological treatments for pruritis in liver failure
cholestyramine
rifampin
opioid antagonist
SSRI (sertraline)
antihistamines - weak evidence
ursodiol - only recommended in PBC
119
what is the distinguishing factor between overt (Stage II-IV) hepatic encephalopathy and covert hepatic encephalopathy?
disorientation and asterixis
120
list 6 consequences of stigma in healthcare
decreased QOL
isolation
depression
distrust
reduced adherence to treatments
reduced access to care
121
max dose of acetaminophen in liver failure
2g
122
which opioid half life is greatly prolonged and should be used with caution in liver failure?
oxycodone
123
describe uremic caliphylaxis
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
clinical presentation of calciphylaxis
early - pain, purple discoloration (livedo reticularis)
later - SC nodules, plaques, ulcerations
greatest affected areas - fatty tissue
125
diagnosis of calciphylaxis
clinical
imaging shows calcification
biopsy deferred usually (poor healing)
126
Treatments for calciphylaxis
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
What is the typical prognosis of CJD?
Age of onset?
Incubation period?
<1 year from symptom onset
most die within 6mo.
onset age 60
incubation 10 years prior to symptom onset
128
What should trigger clinical consideration for CJD?
non-reversible dementia over days to months
often present with ataxia, emotional lability, concentration challenges, disordered sleep and hallucinations
