Other

Question 1

Medications for high-output ostomy

Answer 1

Cholestyramine, somatostatin

Question 2

What is the benefit of looking at PFS over OS?

Answer 2

Not confounded by additional lines of treatment (due to frequent crossover)

Question 3

Where and what % potassium is excreted throughout the GI tract? Why is this significant?

Answer 3

10% stomach
20% small bowel
30% colon
Diarrhea - can result in significant hypokalemia

Question 4

How do you repair a ureteral injury based on location (above/below pelvic brim)?

Answer 4

Upper 2/3: ureteroureterostomy (may need Psoas Hitch or Boari flap if not enough length)
Lower 1/3: ureteroneocystotomy (reimplantation)
Cysto to ensure efflux from both orifices
*Always leave a DRAIN in! It will leak!

Question 5

How do you repair bladder injury based on size/location?

Answer 5

<2mm: leave a foley in, expectant mgmt
=1cm: 1-layer closure, foley for 5-7d
>1cm: 2-layer closure, test integrity intraop, maintain foley, cystogram at removal
Re-epithelialization occurs in 4-5d
Full strength at 21d
Trigone injury*** - call Urology, ensure ureters ok, often will need ureteral stents

Question 6

Signs of unidentified urinary tract injury

Answer 6

leakage of urine from vagina/incision
flank pain
hematuria, oliguria, anuria 
abdominal pain, distension
Ascites --> peritonitis --> ILEUS
N/V, fever, sepsis

Question 7

Diagnosing urinary tract injury

Answer 7

Exam, labs, imaging
Lytes, Cr, BUN
If ascites –> tap for Cr
Imaging: US good first line if not SICK (hydronephrosis, ascites), CT, retrograde pyelogram (XR w/con), cystogram (XR w/retrograde con)

Question 8

Postop antibiotics for urinary tract injury?

Answer 8

NO if identified intraop

If foley maintained postop: NO abx

Question 9

Delayed detection of urinary tract injury

Answer 9

May be very sick, febrile, septic.
Elevated WBC, BUN, Cr. Low Na.
STABILIZE FIRST - resuscitate, abx, correct obstruction with PCNT/stents. Delay final surgical correction ~12weeks.

Question 10

ECOG scale

Answer 10

0 fully active, no restrictions
1 restricted in strenuous activity
2 ambulation, self care, up >50% time, doesn’t work
3 limited self care, confined to bed/chair >50%
4 completely disabled, unable to perform self care, 100% confined
5 dead

Question 11

Emetogenic Risk scale (frequency of emesis without propylaxis)

Answer 11

High >90%
Mod 30-90%
Low 10-30%
Min <10%

Question 12

Neutropenia grade

Answer 12

Grade 1 - LLN to ANC 1500
Grade 2 - 1000-1500
Grade 3 - 500-1000
Grade 4 - <500

Question 13

Neutropenic fever

Answer 13

ANC<1500 AND
single temp > 101F, or 1hr sustained temp >100.4
MASCC score to determine high vs low risk FN

Question 14

Organisms causing neutropenic fever

Answer 14

60% GP
40% GN
Staph epi most common
Also fungi (candida, aspergillus) and virus (Zoster)

Question 15

How frequently will you ID source of neutropenic fever?

Answer 15

20-30% will identify organism

Question 16

Management of neutropenic fever

Answer 16

Start abx within 1hr of diagnosis to decrease mortality
Cefepime, zosyn, meropenem (need pseudomonas coverage)
MRSA coverage with Vanc if risk (port, line, soft tissue infection, PNA)
Anaerobe coverage if GI infection

Question 17

Mortality of neutropenic fever if hospitalized

Answer 17

5-11%

Question 18

GCSF administration and utility

Answer 18

Help increase ANC
Make thrombocytopenia WORSE
Figrastim - 3d course after chemo
PEGfilgrastim - 1x dose
Avoid administering 48hrs before and 24hrs after chemo

Question 19

GCSFs adverse effects

Answer 19

Bone pain (treat with antihistamine and aleve), splenic rupture (rare)

Question 20

When to use GCSF?

Answer 20

Primary ppx - to prevent neutropenia (decrease FN risk, infection related mortality, and all cause mortality)
Secondary ppx - for patient with history of neutropenia
Therapeutic - ONLY for FN, if very sick, suspect fungal infection, PNA

Question 21

Should you give antibiotic prophylaxis for patients with neutropenia?

Answer 21

NO it is not cost effective

Question 22

Early effects of radiation

Answer 22

fatigue (takes up to 6 months to improve), diarrhea, dysuria (from EBRT)

Question 23

Late effects of radiation

Answer 23

cystitis, proctitis, diarrhea (may be chronic), bone marrow depression, chronic anemia, narrowing of the terminal ileum (due to its position fixed in the pelvis by cecum) (from EBRT)

vaginal atrophy (only from VBT)

Question 24

How can you protect the small bowel from radiation?

Answer 24

RT done with full bladder - to push small bowel out of the pelvis

Question 25

How far does VBT penetrate for treatment dose?

Answer 25

0.5cm depth

Question 26

What is the role of BRAF, and what does mutation cause? What other protein in this pathway is a target of drugs targeting this pathway?

Answer 26

Cell signaling pathway promoting normal growth. Mutation can result in stimulation of growth/cell replication. MEK is downstream of BRAF, and is a target of immunotherapies.

Question 27

What cumulative dose of RT results in ovarian failure?

Answer 27

800cGy