Passmedicine Flashcards
What are the contraindications to percutaneous liver biopsy?
Deranged clotting (e.g. INR >1.4)
Low platelets (e.g. <60)
Anaemia
Extrahepatic biliary obstruction
Hydatid cysts
Haemangioma
Uncooperative patient
Ascites
What common drugs act on the NMDA receptor?
Methadone
Ketamine
Memantine
What analgesics are safe to use in renal impairment?
Oxycodone (down to eGFR 10)
Methadone
Fentanyl
Alfentanyl
Buprenorphine
Hydromorphone
HIV associated nephropathy (HIVAN) causes what on renal biopsy?
Collapsing FSGS (presents as nephrotic syndrome)
What are the poor prognostic factors in CLL?
Male sex
Age >70 years
Lymphocyte count > 50
Prolymphocytes comprising more than 10% of blood lymphocytes
Lymphocyte doubling time <12 months
Raised LDH
CD38 expression positive
TP53 mutation
Del 17p
What study demonstrated reduced risk of AIDS and mortality if ART is started no matter the CD4 count?
SMART study
Reduced chance of AIDS, a serious non-AIDS event or death by 57% with similar results in high, middle and low-income countries.
What is the antibiotic therapy for peritoneal dialysis peritonitis?
Intraperitoneal vancomycin and ceftazidime
What are the complications of gastrectomy?
Dumping syndrome:
-Early: food of high osmotic potential moves into small intestine causing fluid shift
-Late (rebound hypoglycaemia): surge of insulin following food of high glucose value in small intestine -2-3 hours later the insulin overshoots causing hypoglycaemia
Weight loss, early satiety
Iron-deficiency anaemia
-Hydrochloric acid important for reducing Fe3+ (largely insoluble) to ferrous (Fe2+) iron. Iron supplementation may be required lifelong
Osteoporosis/ osteomalacia
Vitamin B12 deficiency
Other:
-Increased risk of gallstones
-Increased risk of gastric cancer
When do you use venesection in erythrocytosis secondary to obstructive sleep apnoea?
Should be treated with venesection in the presence of hyperviscosity symptoms or a PCV (HCT) > 0.56.
A target PCV of 0.50 - 0.52 has been shown to increase exercise tolerance.
What antibody is present in miller-fisher syndrome?
Anti-GQ1b present in 85-90% of patients with Miller-Fisher syndrome.
What is the mechanism of action of ranolazine?
When is it contraindicated?
Late inward Na channel antagonist
Second line anti-anginal
What is the mechanism of action of ivabradine?
If channel antagonist to reduce heart rate.
Should not be used in patients with moderate to severe angina as it has been shown to increase the incidence of cardiovascular events in these patients.
What is the role of revascularisation techniques such as PCI in stable angina?
Has not been shown to reduce mortality or rate of MI in stable coronary artery disease. Therefore, medical therapy options should be exhausted before consideration of invasive treatment.
Summarise the treatment of angina
1st line: PRN GTN
2nd line: BB or CCB
-BB preferred as mortality benefit
3rd line (if no hypotension): ISMN or nicorandil
3rd line (if hypotension):
-Ranolazine (HR <70) - contraindicated in renal dx
-Ivabradine (HR >70)
What is the incidence of WPW?
0.1-0.3%
What is the abnormal pathway in WPW called?
Bundle of Kent
What drugs should be avoided in WPW?
Digoxin
Adenosine
Diltiazem
Verapamil
Other CCBs or B-blockers
————————
These all enhance conduction down accessory pathway by increasing refractory period in AV node.
What are the hypertension stage cut offs?
Stage 1: clinic (140/90), HBPM (135/85)
Stage 2: clinic (160/100), HBPM (150/95)
Severe Hypertension: systolic >180 or diastolic >110
What is the mechanism of action of disulfram?
This is an acetaldehyde dehydrogenase inhibitor. By inhibiting this enzyme, consumption of alcohol leads to a build-up of acetaldehyde, which can cause unpleasant symptoms such as flushing of the skin, nausea, vomiting, and arrhythmias. However, a problem with the use of disulfiram is poor compliance, as it does not reduce cravings for alcohol.
What is the mechanism of action of acamprostate?
Rather than causing unpleasant symptoms, it reduces the craving for alcohol. It is a weak antagonist of NMDA receptors.
Why should flumazenil only be used in reversal of anasthesia?
Flumazenil is the reversal agent for benzodiazepines and is a GABA receptor antagonist. It is known as a ‘dirty drug’ due to its many known complications and side effects, including arrhythmias, agitation and seizures. It is advised that flumazenil should not be given in unknown drug overdoses, even if the causative drug is presumed, due to the side effect profile and risks. It is now advised that flumazenil should only be used to reverse benzodiazepines in anaesthesia.
What do you monitor when starting aminocalicylates (mesalazine)?
Renal function should be monitored before starting an oral aminosalicylate, at 3 months and then annually thereafter. This should be done more often in the presence of renal impairment. Blood disorders can also occur with mesalazine, and patients should be asked to look out for bruising, bleeding, purpura, fever and sore throat.
When can corticosteroids be used in shingles?
Corticosteroids can be used in refractory pain in shingles if simple analgesia and neuropathic analgesia do not help, but only for acute shingles
What are the ECG findings in Wellen’s syndrome?
Wellen’s syndrome is the critical ischaemia of the left anterior descending artery. Patients typically have a history of chest pain and ECG findings include biphasic T waves in the anterior leads or deep symmetrical T wave inversion in leads I and aVL associated with 1mm ST elevation in the chest leads. These can be seen in this patient’s ECG.
What are the ECG findings in Brugada syndrome?
Brugada syndrome is an autosomal dominant inherited cardiovascular disease. It can be asymptomatic and lead to sudden cardiac death. ECG changes consistent with Brugada syndrome include convex ST-segment elevation > 2mm in at least 1 of V1-V3 that is followed by T wave inversion. A partial right bundle branch block may also be seen. Sometimes, a patient may have an appearance of a normal electrocardiogram (ECG). However, following the administration of flecainide, these ST-segment changes may appear.
When do you anticoagulate patients with new AF post stroke?
After 14 days
Recent meta-analysis collated the results of seven trials studying early anticoagulation in acute ischaemic strokes. Although the risk of further ischaemic strokes between days 7 and 14 is significantly reduced from 4.9 to 3%, the risk of symptomatic intracerebral haemorrhage was also significantly increased from 0.7% to 2.5%. As a result, early anticoagulation before 14 days is not indicated by NICE or the American Heart and Stroke Associations.
What auto-antibodies are found in myasthenia gravis?
Most (but not all) patients with MG are seropositive for the acetylcholine receptor (AChR) antibody.
Antibodies to muscle-specific receptor tyrosine kinase (MuSK), a surface membrane component essential in the development of the neuromuscular junction, have recently been identified and are found in up to 50% of MG patients who are seronegative for AChR antibodies. Emerging data suggests that the patterns of weakness and response to certain treatments may be different from those with AChR positive MG.
Anti-striated muscle antibody usually positive in MG patients that have a thymoma.
Meningitis as a complication of ear infection is almost always caused by which organism?
Streptococcus pneumoniae
What is the treatment for NRG-1 overdose?
NRG-1, a synthetic cathinone, can cause agitation, hyponatraemia and serotonin syndrome.
Treatment is with benzodiazepines, cooling and hypertonic saline if hyponatraemic. Patients may require intubation and paralysis to control hyperpyrexia
How does sodium thiosulphate work in cyanide poisoning?
In normal human physiology, detoxification of cyanide occurs via rhodanese, an enzyme found in many tissues but particularly in the liver and muscle. Rhodanese converts cyanide to thiocyanate, a water-soluble molecule excreted in the urine.
In poisoning, rhodanese is saturated and unable to remove the surplus cyanide molecules. Sodium thiosulfate serves as a sulfur donor in the reaction catalyzed by rhodanese. Hence administration of sodium thiosulfate increases cyanide to thiocyanate conversion. Hydroxocobalamin (vitamin B12) has also been approved for the treatment of cyanide poisoning.
What imaging should be performed in multiple myeloma?
NICE advises that all patients suspected to have a diagnosis of myeloma should be offered whole body MRI as first-line imaging, and only consider whole body CT if the patient declines MRI or is unable to have it. Skeletal survey should only be considered if CT and MRI are both not possible. Fluorodeoxyglucose positron emission tomography CT (FDG PET CT) can be considered once a diagnosis is confirmed.
What is the treatment for histioplasmosis?
Amphotericin or itraconazole are the pharmacological agents of choice for histoplasmosis
Histoplasmosis is due to the fungus Histoplasma capsulatum. It is most commonly encountered in the Mississippi and Ohio River valleys.
What is the management for xanthelasma?
Xanthelasma - high lipid levels leading to soft yellow/orange plaques, periorbitally.
They are not of clinical concern - except for the underlying lipid profile which should be investigated and treated accordingly.
They can be left alone, but if patients are keen for treatment, a commonly used option is topical trichloroacetic acid.
Peripheral neuropathy occurs in what percentage of those taking susceptible chemotherapies?
This is a condition that can occur in up to 40% of patients being given chemotherapy with agents such as platinum based drugs (cisplatin and oxaliplatin), vinca alakloids (vincristine and vinblastine), thalidomide and taxanes (paclitaxel and docetaxel).
In most cases it is irreversible. The best medication for treatment is gabapentin or pregabalin which should be titrated up to therapeutic levels and used in conjunction with another analgesic agents.
What are the surveillance timings for adenoma found on colonoscopy?
Low risk:
one or two adenomas smaller than 10 mm.
Intermediate risk:
three or four adenomas smaller than 10 mm or
one or two adenomas if one is 10 mm or larger.
High risk:
five or more adenomas smaller than 10 mm or
three or more adenomas if one is 10 mm or larger.
How do you differentiate Superior Orbital Fissure, Cavernous sinus syndrome and orbital apex syndrome?
Superior Orbital Fissure- Affects CN III, CN IV, CN V(1), CN VI
Carvenous sinus syndrome- Affects CN III, CN IV, CN V(1 &2), CNVI
Orbital apex syndrome- Affects CN II, CN III, CN IV, CN V(1), CN VI
i.e. Orbital apex syndrome is SOF plus visual loss
An aortic dissection causes ST elevation in which leads?
Inferior leads: II, III and aVF
The origin for the right coronary artery is the right coronary sinus which is at the bases of the aorta.
What is the treatment for chemotherapy induced vomiting refractory to maximum dose ondansetron?
Dexamethasone with ondansetron is effective in refractory chemotherapy-induced vomiting
What is the treatment for H. Pylori?
Amoxcillin, a PPI, and either metronidazole or clarithromycin (decision re: metronidazole or clarithro is taken on the basis of recent exposure to these antibiotics)
If patients are Penicillin allergic they get a PPI + Metronidazole and Clarithromycin as this question states.
IF they are penicillin allergic and have had previous exposure to clarithromycin then they get PPI + Bismuth + Metronidazole + Tetracycline.
How is frequency of colonoscopy determined in ulcerative colitis?
Lower risk
5 year follow up colonoscopy
Extensive colitis with no active endoscopic/histological inflammation
OR left sided colitis
OR Crohn’s colitis of <50% colon
3 year colonoscopy
Extensive colitis with mild active endoscopy/histological inflammation
OR post-inflammatory polyps
OR family history of colorectal cancer in a first degree relative aged 50 or over
1 year follow up colonoscopy
Extensive colitis with moderate/severe active endoscopic/histological inflammation
OR stricture in past 5 years
OR dysplasia in past 5 years declining surgery
OR primary sclerosing cholangitis / transplant for primary sclerosing cholangitis
OR family history of colorectal cancer in first degree relatives aged <50 years
What is the treatment escalation in Crohn’s disease?
The initial monotherapy of prednisolone is effective at high dose but symptoms return on tapering its dose. An add-on treatment is therefore needed. The next agent to think about is azathioprine or mercaptopurine, in accordance with NICE guidance. Before either is commenced, a TPMT level must be done. If it is deficient, very low or absent, neither azathioprine or mercaptopurine should be offered.
Methotrexate is the next most suitable agent to add if the patient cannot tolerate mercaptopurine or azathioprine.
Infliximab is used only when patients have failed conventional therapy, including immunosuppressives and corticosteroids.
Primary Biliary Cirrhosis is associated with which conditions?
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
Why do you give human albumin solution in patients with SBP?
Intravenous albumin treatment has been shown to reduce in-hospital mortality of patients with uncomplicated SBP. Patients with associated renal dysfunction appear to derive the most benefit. Albumin decreases renal insufficiency, probably by increasing the circulatory volume and by binding pro-inflammatory molecules.
How do you differentiate a sigmoid and caecal volvulus?
Note that a sigmoid volvulus will not retain haustra and typically originate in the left lower quadrant and extend to the right upper quadrant as is the case here.
A caecal volvulus will typically originate in the right lower quadrant and extend to the left upper quadrant. Additionally, caecal volvuli retain haustra. As both of these features are not present here, a sigmoid volvulus is a more likely diagnosis.
Why should you be cautious about a positive Hep C antibody test?
However, it must be noted that Hep C Antibody testing can throw up false positives (up to 10%).
Where Hep C antibodies are positive and RNA viral load is undetected it may be appropriate to repeat the antibody test using a different antibody assay.
The false positive rate is thought to be secondary to other similar antibodies in the circulation.
If the patient has Hep C antibodies and is Hep C RNA positive for more than 2 months they should be considered for treatment.
What is the histological diagnosis of Whipple’s disease?
Diagnosis is made with small intestinal biopsy showing macrophages containing Periodic acid-Schiff (PAS) granules infiltrating into the lamina propria.
How must you correct coagulation profile prior to paracentesis?
Paracentesis is not contraindicated in patients with an abnormal coagulation profile. The majority of patients with ascites due to cirrhosis have prolongation of the prothrombin time and some degree of thrombocytopenia. There are no data to support the use of fresh frozen plasma before paracentesis although if thrombocytopenia is severe (<40 * 109/l) most clinicians would give pooled platelets to reduce the risk of bleeding.
What medications inhibit oral iron replacement?
Antacid solutions, such as peptac, act by coating the stomach with an alkaline solution containing magnesium and calcium, thus improving heartburn symptoms. Unfortunately, this can lead to failed absorption of oral iron replacement. Alternate routes should be considered.
Post op transaminitis may be secondary to what?
Although the incidence of anaesthetic related hepatitis has decreased over recent years with the introduction of modern agents such as desflurane and sevoflurane, cases are still reported. The rapid rise in transaminases, gamma GT and alkaline phosphatase so soon after surgery fits well with the diagnosis. Supportive therapy is the only option, no therapeutic interventions, (including corticosteroids), have proved effective.
What examinations findings particularly relate to alcoholic hepatitis?
Alcoholic hepatitis almost always presents with clinical jaundice and the presence of a hepatic bruit is particularly suggestive.
What is the mortality benefit of using prednisolone in alcoholic hepatitis?
Prednisolone has been shown in meta-analyses to confer a significant reduction in 28-day mortality in patients with an MDS >32 or hepatic encephalopathy, however, there was no demonstrable benefit at 90 days or at one year.
Combination therapy with prednisolone and pentoxifylline confers no additional benefit over treatment with prednisolone alone, whilst the use of N-acetylcysteine as monotherapy in alcoholic hepatitis is not recommended. In one randomised controlled trial, combination therapy with prednisolone and N-acetylcysteine was shown to be superior to prednisolone monotherapy in reducing mortality at 28 days; largely due to a reduction in the incidence of HRS and superimposed infection.
What is the first, second and third line treatment for first episode C. Diff infection according to 2021 NICE guidelines?
First episode of Clostridium difficile infection
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
What is the treatment for recurrent C diff infection?
Recurrent episode
recurrent infection occurs in around 20% of patients, increasing to 50% after their second episode
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
What is the treatment for life threatening C diff infection?
Life-threatening Clostridium difficile infection
oral vancomycin AND IV metronidazole
specialist advice - surgery may be considered
What is the mechanism of action of bezlotoxumab?
bezlotoxumab is a monoclonal antibody which targets Clostridium difficile toxin B
NICE do not currently support its use to prevent recurrences as it is not cost-effective
When may faecal transplant be considered in C diff?
faecal microbiota transplant
may be considered for patients who’ve had 2 or more previous episodes
What lifestyle factor significantly increases risk of relapses in crohn’s disease?
A prospective study suggests that continued smoking raises the risk of Crohn’s exacerbation by approximately 50%.The study examined 573 Crohn’s disease patients for a follow up period of 4 years. In comparison with nonsmokers, continuing smokers relapsed more frequently with an incidence rate ratio of 1.53 (95% confidence interval : 1.102.17). Former smokers and quitters had similar relapse incidences compared with nonsmokers.
http://www.nature.com/ajg/journal/v111/n3/full/ajg2015401a.html
What is the evidence for mesalazine in Crohn’s disease?
Mesalazine in Crohn’s disease has debatable efficacy. A meta-analysis conducted in 2004 revealed a statistically significant but probably clinically insignificant effect on disease progression.
Plummer-vinson syndrome is also called by what other name?
Paterson–Brown–Kelly syndrome
What is the diagnostic criteria for toxic megacolon?
Radiographic evidence of colonic distension
plus at least three of the following:
1) Fever >38.6°C
2) Heart rate >120 beats per minute (The most reliable sign is the pulse rate)
3) Neutrophilic leucocytosis >10.5 × 109/L, or
4) Anaemia.
Plus, at least one of the following:
1- Dehydration
2- Altered mental status
3- Electrolyte disturbances, or
4- Hypotension.
Why is chromogranin A no longer used for carcinoid syndrome diagnosis?
Although well-differentiated carcinoid tumours secrete elevated levels of plasma chromogranin A, it is increasingly recognised that falsely positive elevated levels can be produced by other neuroendocrine tumours, hyperthyroidism, hyperparathyroidism, pituitary tumours, colon carcinoma, IBD, hypertension, COPD, ACS amongst many others. The low specificity of the test means that it is recommended that it is not used on its own as a screening test.
What are the clinical features of Fabry’s disease?
Acroparaesthesia: tingling, burning pain in the hands and feet triggered by stress such as emotion, extreme temperatures, or exercise
Angiokeratoma corporis diffusum: lightly verrucous, deep-red to blue-black papules on the trunk (in the bathing trunk distribution)
Cardiac: mitral valve prolapse or regurgitation usually, but any valvular heart defect can occur
Strokes: including young strokes/TIAs
Chronic Kidney Disease: proteinuria usually, can present late in fulminant renal failure
Classically death occurred in the 4th decade but this has improved since the availability of dialysis. It would be important to organise urgent renal investigations in this young man amongst your workup.
What is the pathophysiology of Fabry’s disease?
This is an X-linked recessive lipid storage disorder in which there a deficiency in the fat enzyme alpha-galactosidase. This results in the accumulation of alpha-galactosyl-lactosyl-ceramide in various tissues, including kidney, liver, blood vessels and nerve ganglion cells.
How does the enhanced liver fibrosis test influence management?
recent guidelines suggest that individuals with an incidental finding of NAFLD should be offered an enhanced liver fibrosis (ELF) blood test. If the ELF result indicates advanced liver fibrosis ( 10.51) then the individual should receive specialist monitoring and intervention. If the ELF result is negative (< 10.51) then the individual is likely to have a benign prognosis from their NAFLD and can be monitored in primary care. For these individuals, a repeat ELF blood test is recommended every 3 years.
What is involved in the enhanced liver fibrosis test?
The Enhanced Liver Fibrosis (ELF) test is a commercially
available algorithm that combines 3 direct serum markers of extracellular matrix remodeling and fibrogenesis: hyal-
uronic acid, the N-terminal pro-peptide of collagen type III,
and tissue inhibitor of metalloproteinase-1.
Which drugs cause an intrahepatic liver derangement?
LFTs1
Drug induced
Peter - paracetamol
Had - halothane
Epilepsy - sodium valproate/phenytoin
And - amiodarone
Alcoholic - etoh
Tb - anti tb meds
He met - methyldopa
Norman in - nitro
Shadwell - statins
How is autoimmune hepatitis divided?
It is sub-divided into type I and type II depending upon the antibodies present:
-Type I Anti-smooth muscle antibodies or anti-nuclear antibodies; this constitutes 75% of patients
-Type II Anti-LKM-1 or anti-liver cytosolic-1 antibodies
Primary biliary cholangitis puts you at what level of increased risk of HCC?
20x
How common is vitamin A deficiency following bariatric surgery?
The incidence of vitamin A deficiency has been reported between 5 and 10% after bariatric surgery.
Vitamin A deficiency is associated with night blindness, xerophthalmia, and occasionally complete blindness. Night blindness usually manifests as an inability in adjustment to dimmed light and is an early feature of vitamin A deficiency.
What is the mechanism of action of metoclopramide?
whilst metoclopramide is primarily a D2 receptor antagonist, the mechanism of action is quite complicated:
it is also a mixed 5-HT3 receptor antagonist/5-HT4 receptor agonist
the antiemetic action is due to its antagonist activity at D2 receptors in the chemoreceptor trigger zone. At higher doses the 5-HT3 receptor antagonist also has an effect
the gastroprokinetic activity is mediated by D2 receptor antagonist activity and 5-HT4 receptor agonist activity
In UGIB what pre-endoscopy target haemoglobin level gives the best outcomes?
70-80
Recent evidence has shown that conservative blood transfusion in the setting of acute upper gastrointestinal bleeding produces better outcomes compared to liberal blood transfusion.
An important observation was that there was an improvement in survival rates with the restrictive transfusion strategy. There was a reduction in the risk of further bleeding, the need for rescue therapy, and the rate of complications.
In Villanueva et al patients who were transfused when the haemoglobin was below 70g/dL had better outcomes compared to those who received blood transfusion below 100g/dL.
What is involved with a SeHCAT scan?
SeHCAT is bile acid analogue which can be detected by a nuclear medicine scan. The SeHCAT test involves a baseline scan, and then a 7 day scan. A 7-day SeHCAT retention value of less than 15% is generally considered indicative of bile salt malabsorption
What is first second and third line management for an acute dystonic reaction?
First line treatment in the UK is procyclidine, a rapid acting anticholinergic, with benzodiazepines and anticholinergic antihistamines 2nd and 3rd line respectively
What is the target HbA1c following pancreatic resection?
It’s important to remember in diabetes related to pancreatic resection, both alpha cells producing glucagon, and beta cells producing insulin, are removed in the pancreatectomy. This reduces the intensity of any counter regulatory response to hypoglycaemia and thus impacts on prospects of recovery and increases the severity of individual events. For this reason a more lax HbA1c target is instigated for patients who have a history of pancreatectomy, of 53.
How do you manage hyponatraemia in liver cirrhosis? When do you alter diuretics?
Sodium 126-135 mmol/L with normal creatinine - Continue normal diuretic regimen and observe, do not fluid restrict the patient.
Sodium 121-125 mmol/L with normal creatinine - International opinion is to continue diuretics, however, the British Society of Gastroenterology recommend a more cautious approach, and suggest either stopping diuretics or reducing the dose.
Sodium 121-125 mmol/L with raised creatinine (>150 mmol/L or >120 mmol/L and rising) - Stop diuretics and volume expand with human albumin solution 4.5%, gelofusine, or haemaccel
Sodium <121 mmol/L - Incredibly controversial, but the British society of gastroenterology suggest stopping diuretics and volume expanding with human albumin solution 4.5%, gelofusine, or haemaccel (which all contain sodium concentrations similar to that of normal saline).
How do some drugs cause oxidative haemolytic anaemia?
Drugs such as sulphasalazine, dapsone, ribavirin and poisoning with paraquat ingestion leads to the oxidation of Fe2+ (ferrous) components of haem to Fe3+ (ferric), forming methaemoglobin. When the intrinsic antioxidation mechanism of NADPH and glutathione is overwhelmed, red cell components undergo oxidative damage and cell death, leading to haemolysis, explaining the significantly raised LDH. Methaemoglobin is converted to hemichromes and eventually precipitated to Heinz bodies.
When are platelets indicated in resus for an UGIB?
<50
When is FFP and cryoprecipitate indicated in resus for an UGIB?
FFP is indicated due to raised INR/APTT > 1.5 x normal.
Cryoprecipitate is only required if fibrinogen remains below 1.5 after FFP.
Hydatid cysts are caused by which organism?
They are caused by the tapeworm parasite Echinococcus granulosus
What are the causes of “very” high ALT = >1000
The 4 main causes for hepatitis with very high ALTs (>1000) = mnemonic ‘DIVA’
1. Drug-induced hepatitis
2. Ischaemic hepatitis
3. Viral hepatitis
4. Autoimmune hepatitis
What are the pathological findings in carcinoid heart disease?
The characteristic pathological findings of carcinoid heart disease are endocardial plaques of fibrous tissue that may involve the tricuspid valve, pulmonary valve, cardiac chambers, venae cavae, pulmonary artery, and coronary sinus.
How do you differentiate hydatid cyst and amoebic liver abcess on CT?
Hydatid cyst is usually loculated.
What is the stepwise approach to investigating occult GI bleeding?
The SIGN guidelines for occult bleeding recommend OGD and colonoscopy. If they are both normal they recommend either repeat OGD or capsule endoscopy. If the capsule is negative then either a second capsule or enteroscopy is indicated. CT angiography would be used for acute occult bleeding where the patient is compromised and embolisation of the bleeding vessel is needed
What are the absolute and relative contraindications to TIPPS procedure?
ABSOLUTE
Severe and progressive liver failure (Child-Pugh score >12 is associated with a high risk of early death)
Uncontrolled hepatic encephalopathy
Right-sided heart failure
Uncontrolled sepsis
Unrelieved biliary obstruction
RELATIVE
Severe uncorrectable coagulopathy (INR >5)
Thrombocytopenia <20 * 109/l
Portal and hepatic vein thrombosis
Pulmonary hypertension
Central hepatoma
What is the first line investigation for small bowel overgrowth syndrome?
Hydrogen breath testing is an appropriate first line test for diagnosis of small bowel overgrowth syndrome
What is the “M rule” for primary biliary cholangitis?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
What are the features of Wellen’s Syndrome and what does it signify?
Deeply inverted T waves in V2-V3 are very suggestive of Wellens’ syndrome which is highly specific for critical stenosis of the left anterior descending artery (LAD). It should be treated as a STEMI with urgent angiography and revascularisation.
When are B blockers and CCBs used in angina?
First line therapy in the treatment of angina is beta-blockade. Beta-blockers reduce myocardial oxygen consumption by acting as a negative inotrope and also by reducing heart rate. Some patients are unable to take beta-blockers such as asthmatics, or find that side effects such as tiredness, eczema or sexual dysfunction mean they are not tolerable. In these instances, use of calcium channel blockers such as diltiazem are recommended as first-line treatment. Since both of these classes of drug cause a reduction in heart rate and blood pressure their use must be monitored carefully, especially in the elderly. Concomitant use of beta-blockers and calcium channel blockers should be avoided where possible due to the risk of high degree conduction block and cardiac arrest.
When are nitrates and nicorandil used in angina?
Long-acting nitrates, such as isosorbide mononitrate or dinitrate are considered second-line therapy in stable angina. They can be used as monotherapy or as an adjunct to beta-blocker or calcium channel blocker therapy. They work by causing vasodilatation; both drugs possess a nitric oxide moiety which causes endothelial relaxation in blood vessels. This causes coronary vasodilation and improved blood flow to the myocardium with improved symptoms. A consequence of vasodilatation is hypotension and this should be considered when prescribing this drug to patients.
Another second-line option drug for stable angina in those patients who cannot tolerate nitrates or they are ineffective is nicorandil. This drug has a similar ultimate effect in that it causes dilatation of peripheral and coronary vessels to reduce symptoms of angina. It works by activating potassium channels on endovascular smooth muscle cells reducing intracellular calcium and hence relaxing the blood vessel. It too can cause profound hypotension and severe headaches.
When can ivabradine be used?
Ivabradine is a drug which can be used for both angina and heart failure. It works by reducing heart rate to reduce myocardial oxygen demand and improve diastolic function. In this case, the heart rate is adequately controlled so reduction is not necessary. Ivabradine also works by inhibiting the hearts natural pacemaker potential in the sinoatrial node, hence it only works when the patient is in sinus rhythm.
How does ranolazine work?
Ranolazine is a viable option in the management of angina where other avenues have been exhausted. It works by inhibiting the delayed sodium influx channel in the myocardium, reducing the intracellular calcium concentrations in the heart muscle. This, in turn, leads to a negative inotropic effect and reduction in symptoms of angina. Ranolazine does not cause a profound hypotensive effect and is the best choice in this scenario.
What is the stepwise approach to angina management?
1st line: PRN GTN
2nd line: BB or CCB (dont mix BB with Diltiazem or Verapamil -> risk of CHB).
3rd line: Add on CCB/BB (whatever was missed in 2nd line)
4th line (if no hypotension after 3rd line) ISMN/nicorandil
5th line (if no hypotension after 4th line) Add on ISMN or nicorandil (wtv was missed)
6th line (if hypotension after 5th line):
HR<70: RANOLAZINE (contraindicated in severe renal/liver disease)
HR>70: IVABRADINE (contraindicated in Sick sinus syndrome)
What can cause a raised ALP?
liver: cholestasis, hepatitis, fatty liver, neoplasia
Paget’s
osteomalacia
bone metastases
hyperparathyroidism
renal failure
physiological: pregnancy, growing children, healing fractures
What should you do if you need to transfuse patients awaiting transplant?
Transfusions in patients awaiting renal transplants are usually avoided where possible, due to the potential risk of circulating antibodies and thus organ rejection.
The transplant team would need to be informed and the patient advised that a transplant will be postponed for at least 3 months, following repeat antibody screening.
Which diabetes medication is associated with pancreatitis?
GLP-1 antagonists - “glutides”
What is first, second and third line for bone metastasis pain?
NSAIDS/ Bisphosphonates
Radiotherapy
Denosumab (unlicenced)
What are the main adverse events of overtreatment with levothyroxine?
Osteoporosis and atrial fibrillation
How can some testicular tumours lead to hyperthyroidism?
hCG is homologous to TSH in structure and therefore can lead to hyperthyroidism
What is the treatment for sodium valproate toxicity?
Valproate-induced hyperammonaemic encephalopathy (VHE) is an unusual complication characterised by a decreasing level of consciousness, focal neurological deficits, cognitive slowing, vomiting, drowsiness, and lethargy. Asymptomatic hyperammonaemia occurs in 15–50% of patients on valproate.
Treatment with L-carnitine may be beneficial in reducing ammonia levels.
Widespread T-wave inversion in chest leads can be a normal variant in who?
Widespread T wave inversion in the chest leads can be a normal variant in patients with Afro-Caribbean ethnicity
What do you do if alendronate is not tolerated due to GI side effects?
NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to risedronate or etidronate
What heart failure patients qualify for Ivabradine therapy?
Ejection fraction <35%
Heart rate >75/min
Sinus rhythm
NYHA class 2-4
Maximally titrated beta blocker therapy.
What class of antibiotics are most effective against ESBL producing organisms?
Extended spectrum B-lactamase (ESBL) producing organisms are typically resistant to penicillins and cephalosporins and as such the carbapenem class of antibiotics are typically first-line although nitrofurantoin or fosfomycin are also frequently effective. ESBL producers are most commonly Escherichia coli (E. coli) and Klebsiella species.
How important is HLA-B27 in ankylosing spondylitis?
HLA-B27, although associated with the disease in textbooks, is not particularly useful in making the diagnosis. It is not particularly specific, nor sensitive. 10% of patients with ankylosing spondylitis are HLA-B27 negative, and 10% of the healthy population are HLA-B27 positive.
How do you manage superficial vein thrombosis?
Superficial vein thrombosis (also referred to as thrombophlebitis) is a common condition and in the majority of cases is self-limiting. Patients presenting with a superficial vein thrombosis are at increased risk of a venous thromboembolic event and up to 20% of patients will already have a deep vein thrombosis (DVT) on presentation. Patients are more likely to have thrombus extension into the deep venous system if they have more than 5cm of thrombus within 10cm of the saphenofemoral junction (i.e. within the proximal long saphenous vein).
The evidence for how superficial vein thrombosis should be managed comes from a Cochrane review and is used to support the Scottish intercollegiate guidelines network (SIGN) guidelines on the prevention and management of venous thromboembolism (guide 122). The guidelines recommend that all patients with clinical signs of a superficial vein thrombosis should have an ultrasound scan to exclude a DVT.
Patients with a confirmed diagnosis of a superficial vein thrombosis should be considered for treatment with anti-embolism stockings and prophylactic doses of low molecular weight heparin (LMWH) for 30 days or fondaparinux for 45 days. In cases where LMWH is contraindicated, 8-12 days of oral non-steroidal anti-inflammatory drugs should be offered as this has been shown to reduce the risk of thrombus extension.
How do you differentiate CMV colitis and cryptosporidiosis?
Cytomegalovirus (CMV) colitis is usually seen in patients who are immunocompromised. It is a member of the herpes virus, for which around 50-80% of the general population are seropositive. The virus lays dormant until the patient is sufficiently immunocompromised.
Approximately 30% of all patients with AIDS will develop a gastrointestinal CMV infection. This usually occurs when the CD4+ counts drop to below 100 mm3.
CMV can affect the gastrointestinal tract from the oesophagus to the rectum, and symptoms depend on the site of infection. CMV oesophagitis causes odynophagia and retrosternal chest pain. CMV enterocolitis commonly presents with diarrhoea, fever, weight loss and per rectal bleeding. Tenesmus can occur if there is rectal involvement.
Cryptosporidiosis is a protozoal infection caused by cryptosporidium parvum. Immunocompromised individuals are particularly susceptible. The incubation period is between 2-10 days (average 7) and symptoms usually last about 1 to 2 weeks, although can occur for longer. The most common symptom is watery diarrhoea. Other symptoms include stomach cramps, dehydration, nausea and vomiting and fever.
How do you manage hiccups in palliative care?
chlorpromazine is licensed for the treatment of intractable hiccups
haloperidol, gabapentin are also used
dexamethasone is also used, particularly if there are hepatic lesions
What is the treatment for scleroderma renal crisis?
The optimal drug of choice is an ACE inhibitor, preferably captopril, which has been trialed with the greatest experience, but other ACEi are also likely to be beneficial. In a 15 year prospective cohort, one year survival increased from 15% to 76% with the use of ACEi against other anti-hypertensives1. Steroids should be strictly avoided in SRC, they increase the risk of SRC prior to the event and may exacerbate SRC in the acute setting. Renal dialysis may be required in patients who progress to end-stage renal failure despite ACEi treatments.
What are the good prognostic features in MS?
female sex
age: young age of onset (i.e. 20s or 30s)
relapsing-remitting disease
sensory symptoms only
long interval between first two relapses
complete recovery between relapses
Why do you give oxygen in pneumothorax?
Patients who are diagnosed with a pneumothorax should be given high-flow oxygen as it allows the exchange of nitrogen from the air trapped forming the pneumothorax with the additionally inspired oxygen from given to the patient. This exchange increases the oxygen content of the pneumothorax whilst decreasing the nitrogen concentration. Oxygen is more readily absorbed, and therefore the pneumothorax resolves more quickly.
When do you investigate anaemia in CKD?
As per NICE guidelines, for patients with chronic kidney disease, investigations for anaemia should be considered if their haemoglobin falls below 110g/L OR they develop symptoms suggestive of anaemia. This should begin with testing for iron deficiency using percentage of hypochromic red cells or reticulocyte haemoglobin content. In patients with anaemia of CKD, do not request transferrin saturation or serum ferritin measurement alone to assess iron deficiency status.
What antiretroviral therapy causes mitochondrial toxicity?
NRTIs - in particular stavudine, didanosine and zidovudine - classically cause mitochondrial toxicity as an unwanted side effect. This can result in nausea, pancreatitis, lactic acidosis and lipoatrophy as demonstrated above.
When do you start biologic therapy in rheumatoid arthritis?
Current NICE guidelines recommend the starting of biologic therapy when the patient has been on at least two DMARDs, including methotrexate, reporting two DAS 28 scores of greater than 5.1 at least one month apart
How do you use renin and aldosterone values in hypertension?
Helps divide primary and secondary hyperaldosteronism.
Primary
Renin is low due to something directly making or stimulating aldosterone meaning kidneys well filled so no renin needed
Cushing’s
Conns
CAH all examples
Secondary think kidney being underfilled despite euvolemia/hypervolemia , leading to high renin >high aldosteronism
RAS
Heart failure (bp less likely todav htn)
Excess diuretics
What is the most common electrolyte abnormality in alcohol withdrawal?
Hypophosphataemia is the most common electrolyte abnormality during alcohol withdrawal and is a recognised cause of seizures. It is often present at baseline in alcoholic patients and can further decrease in withdrawal. It is thought that this is due to effects on the proximal renal tubule. It can cause muscle pain and disorientation at very low levels (< 0.3 mmol/l).
When do you use tolvaptan in ADPKD?
Tolvaptan is a selective vasopressin receptor 2 antagonist and has been shown to reduce the annual rate of kidney growth and reduce the rate of decline of renal function over a three year period. In England and Wales, tolvaptan is recommended for patients with rapidly progressive disease at CKD stages 2-3. There is no current definition of rapidly progressive disease although an increase in total kidney volume of > 5 % per year is a predictor of rapid disease progression.
When is pravistatin used in ADPKD?
Pravastatin was shown to slow disease progression in children with ADPKD, but there is no evidence of benefit in adult patients.
What is the treatment for methotrexate toxicity?
Folinic Acid
methotrexate inhibits the enzyme which converts folic acid to folinic acid. So if you have methotrexate toxicity you’re unlikely to respond to folic acid as the enzyme is already inhibited, thus you have to give folinic acid.
Why should you avoid digoxin in cardiac amyloidosis?
Digoxin administration is not recommended in cardiac amyloidosis owing to a higher risk of digoxin toxicitiy, as the drug binds avidly to amyloid fibrils.
How do you manage amiodarone induced hypothyroidism?
Continue amiodarone and start levothyroxine.
How do you treat amiodarone induced thyrotoxicosis type 1
Continue amiodarone and start carbimazole.
This is excess iodine- induced thyroid hormone synthesis. A goitre will be present
How do you treat amiodarone induced thyrotoxicosis type 2?
Stop amiodarone and start prednisolone
This is amiodarone related destructive thyroiditis with an absent goitre.
What test do you carry out in normal T4 and suppressed TSH?
T3
How does combination nicotine replacement compare with non-combination
Combination = long acting patch and short acting formulation (either oral or nasal spray) to help manage acute cravings
Combination absolute abstinence rate 32% compared to 25% for non-combination nicotine replacement.
When is the arginine-GHRH stimulation test employed to assess GH secretion?
In patients with ischaemic heart disease or seizure where insulin tolerence test will be inappropriate. (risks of hypoglycaemia)
What percentage of growth hormone deficiency patients will have normal IGF-1 level?
30-40%
low IGF-1 may point to diagnosis of GHD but needs to be confirmed with dynamic tests for GH secretion. IGF-1 levels are influenced by age, time of onset of GHD, and degree of hypopituitarism. Insulin tolerance test is considered the gold standard.
What medications increase lithium toxicity risk without increasing serum lithium levels?
Carbamazepine increases risk of toxicity without affecting levels
Amiodarone increases risk of VT without increasing lithium levels.
JAK2 V617F mutation is present in >95% PRV. However when do you need to test for the rarer JAK2 exon 12 mutation?
Low serum erythropoietin is suggestive of primary bone marrow disease even in the absence of JAK2 mutation and should prompt testing for the rarer exon 12 mutation of JAK2. This test should be performed before the more invasive bone marrow biopsy.
How do you differentiate thiazide use from familial hypocalciuric hypercalcaemia?
Both present with hypercalcaemia and low urinary calcium (other causes of hypercalcaemia cause high urinary calcium)
FHH has an inappropriately NORMAL PTH due to loss of function mutations in the CASR calcium sensing receptor. This decreases sensitivity to calcium, meaning PTH remains unsuppressed at higher than normal serum calcium levels.
Hypocalciuria results from a loss of CASR-mediated negative feedback of tubular reabsorption/excretion of calcium.
When do you consider haemodialysis in lithium toxicity?
Dialysis should be considered in symptomatic lithium toxicity and:
-A lithium concentration greater than 5.0 mmol/L in patients with acute lithium overdose and who are not prescribed lithium
-A lithium concentration greater than 2.5 mmol/L in patients with chronic poisoning
Haemodialysis should be continued until:
-All new neurological features have resolved, and
-Lithium concentration remains stable at less than 1mmol/L
Acute on chronic overdose of lithium can lead to serious toxicity even after a modest overdose, as the extracellular tissues are already saturated with lithium.
What liver enzyme metabolises theophylline?
CYP1A2
Why do patients with end stage renal failure require IV rather than oral iron replacement?
Elevated serum levels of hepcidin preventing intestinal absorption of iron.
What is the treatment for iron overdose?
< 40mg/kg elemental iron and are asymptomatic can be observed at home.
> 40mg/kg elemental iron or who are symptomatic need medical assessment with serum iron levels measured 2-4 hours post-ingestion and abdominal x-ray.
> 60mg/kg elemental iron or have undissolved tablets on abdominal x-ray within 4 hours who have ingested = Whole bowel irrigation
If tablet still present after irrigation give Desferrioxamine.
> 90mg/kg elemental iron or in SHOCK= Desferrioxamine.
No role for activated charcoal
Captecitabine is broken down by which enzyme? What side effect may people suffer if they are deficient?
Capecitabine is the oral analog of 5-flourouraxil, a chemotherapeutic agent which is broken down predominantly, by dihydropyramidine dehydrogenase (DPD). Deficiency is autosomal recessive and can lead to a toxin buildup which in homozygous patients is usually fatal
What blood sugar levels should people with type 1 diabetes aim for: on waking, before meals and after eating?
5-7 mmol/litre on waking
4-7 mmol/litre before meals
5-9 mmol/litre 90 mins after eating.
How do you manage HIV in pregnancy?
It is recommended that women conceiving on an effective antiretroviral (ART) regimen should continue this even if it contains efavirenz or does not contain zidovudine.
Exceptions are: (1) Protease inhibitor (PI) monotherapy should be intensified to include (depending on tolerability, resistance and prior antiretroviral history) one or more agents that cross the placenta. (2) The combination of stavudine and didanosine should not be prescribed in pregnancy
Although there is most evidence and experience in pregnancy with zidovudine plus lamivudine, tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones. In the absence of specific contraindications, it is recommended that the third agent in ART should be efavirenz or nevirapine (if the CD4 cell count is less than 250 cells/L) or a boosted PI.
No routine dose alterations are recommended for ARVs during pregnancy if used at adult licensed doses.
With a viral load <50 at 36 weeks a vaginal delivery is recommended in the absence of any obstetric complications.
What is the treatment for lymphatic filariasis?
Diethylcarbamazine
How do you achieve formal diagnosis of idiopathic intracranial hypertension?
Formal diagnosis (by Modified Dandy criteria), requires CSF opening pressure greater than 25 cmH2O and normal brain imaging. Imaging is required to exclude venous sinus thrombosis, which could result in the same signs and symptoms and is also more common in women on the oral contraceptive pill. The gold standard imaging for this would be MRI with contrast of the head and orbits and MR venogram.
At what level of PTH do you begin supplementation with calcium and vitamin D in secondary hyperparathyroidism?
Supplementing calcium and vitamin D in secondary hyperparathyroidism runs the risk of adynamic bone disease if this is begun at less than twice the upper limit of the normal range for PTH. For this reason levels are usually tracked until they cross this threshold, where upon supplementation is commenced.
In the event that patients with PTH levels greater than twice the upper limit of normal are left untreated, there is significant risk of progression to tertiary disease, and increased propensity to complications associated with hyperparathyroidism including bone resorption, fracture and ectopic calcification.
What is the difference between autoimmune polyendocrinopathy syndrome type 1 and 2?
APS type 2 has a polygenic inheritance and is linked to HLA DR3/DR4. Patients have Addison’s disease plus either:
type 1 diabetes mellitus
autoimmune thyroid disease
APS type 1 is occasionally referred to as Multiple Endocrine Deficiency Autoimmune Candidiasis (MEDAC). It is a very rare autosomal recessive disorder caused by mutation of AIRE1 gene on chromosome 21
Features of APS type 1 (2 out of 3 needed)
chronic mucocutaneous candidiasis (typically first feature as young child)
Addison’s disease
primary hypoparathyroidism
Vitiligo can occur in both types
How can you differentiate Conn’s adenoma and adrenal hyperplasia in hypokalaemia alkalosis and low renin?
Aldosterone on standing
Aldosterone is increased on prolonged standing in adrenal hyperplasia.
In Conn’s adenoma, the aldosterone would stay the same or drop on standing.
What is a normal short synACTHen test?
30 minute serum cortisol concetration greater than 420 nmol/L
What is the long synACTHen test?
Once adrenal insufficiency is confirmed with the short synACTHen test the location of the lesion can be achieved by measurement of ACTH or by performing the long Synacthen test.
Interpretation of this test is governed by the following:
1. In primary adrenal failure: we would not expect there to be a significant rise in cortisol during the long Synacthen rest since the adrenal glands are intrinsically dysfunctional
2. In secondary adrenal failure: chronically low levels of ACTH due to pituitary failure result in atrophy of the adrenal glands. Prolonged stimulation of the adrenal glands by ACTH in the long Synacthen test results in a degree of recovery by the adrenal glands resulting in a significant rise in cortisol. A response that rises gradually to a peak at 24 hours occurs in secondary adrenal failure. This pattern of results also occurs due to prolonged corticosteroid therapy use.
An important point is to remember that in some cases of long-standing adrenal atrophy due to secondary adrenal insufficiency, the adrenal glands will not respond even after 24 hours and will require several daily doses of depot Synacthen before an adrenal response is seen. The majority of these cases should be identifiable by measurement of plasma ACTH, which would be expected to be very low (in contrast to primary adrenal insufficiency where ACTH levels are very high).
What are the contraindications to commencing testosterone replacement in individuals who have panhypoputiutarism?
Elevated PSA >4ng/ml
Male breast Ca
Severe sleep apnoea
Severe LUTS due to BPH
What are the steroid sparing agents in GCA?
1st line MTX
2nd line MMF, Azathioprine, cyclophosphamide
What are the causes of a normal anion gap metabolic acidosis?
Azetozolamide
Topiramate
RTA Type 1 and Type 2
Diarrhoea
Ureterosigmoidostomy
Post hypocapnic state
What further diagnostic testing should you carry out in Type 1 RTA?
Type 1 RTA can be the first presentation of Sjogren’s so these patients should have autoimmune screening (anti-Ro, anti-La, RF and ANA)
What urine test can you do to differentiate RTA type 1 and 2?
Urine pH
High in RTA type 1 due to a failure to acidify the urine.
What are the features of listeria meningitis?
Low glucose
Raised protein
lymphocytic predominant WCC
What are the features of tuberculous meningitis?
Normal or slightly reduced glucose
Low protein
Monocyte predominant WCC (count usually <500)
How often do you retinal screen diabetic patients during pregnancy?
All patients with type 1 or type 2 diabetes should have retinal screening during pregnancy as there is an increased risk of developing retinopathy. Patients should be advised to have retinal screening before 13 weeks unless their yearly screening has been done very recently. If any signs of retinopathy are picked up, repeat testing between 16-20 weeks is recommended, otherwise further testing at 28 weeks would suffice.
What is the management of lupus nephritis?
Initially managed with high dose steroids alongside either mycophenolate or cyclophosphamide.
Maintanence 1st line: Mycophenolate
Other maintanence options: azathioprine, tacrolimus
What is the first and second line treatment in alzheimer’s disease?
Donepezil first line
Memantine second line
(donepezil is generally avoided in patients with bradycardia and is used with caution in other cardiac abnormalities)
Why do you delay radio-iodine therapy post contrast CT for 8 weeks?
Iodine in IV contrast stays in body for 2 months and limits therapeutic uptake of radio-iodine by the thyroid gland.
What is the Leser-Trelat sign?
The abrupt appearance of multiple seborrhoeic keratoses.
Suggests underlying cancer and most associated with gastrointestinal adenocarcinomas and hepatic cancers.
Why do you stop aspirin in acute thyrotoxicosis?
It can worsen the storm by displacing T4 from thyroid binding globulin.
When can degludec (Tresiba) be used in T1DM over detemir (Levemir)?
Degludex has a much higher half life than levemore and therefore maintains a basal insulin level when the patient omits or forgets doses. This can prevent DKA.
What are the cut offs and management of vitamin D deficiency?
> 50 nmol/L = dietary recommendations
30-50 nmol/L = maintenance dose vitamin D
<30 nmol/L = loading dose vitamin D
What is the treatment of Cryptosporidiosis?
First line: Nitazoxanide
Second line: Rifaximin
What drugs alter the effect of adenosine?
DEAR
Dipyridamole enhances (large ventricular standstill)
Amiphyline reduces (short vent standstill)
What drug is used to prevent pathological bone fractures in metastatic cancer if eGFR <30
Denosumab
