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WCS > PFD 3 Endometriosis, Interstitial Cystitis > Flashcards

PFD 3 Endometriosis, Interstitial Cystitis Flashcards

1
Q

What is the difference between bladder pain syndrome (BPS) and interstitial cystitis (IC)?

A

BPS focuses on the symptom complex while IC implies an inflammatory process within the bladder urothelium

IC involves gaps or spaces in bladder tissue, whereas BPS does not require a specific pathologic diagnosis.

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2
Q

What are the criteria for diagnosing bladder pain syndrome (BPS)?

A

Chronic pelvic pain (>6 months), pressure or discomfort related to the urinary bladder, and at least one other urinary symptom

Other urinary symptoms may include persistent urge to void or frequency.

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3
Q

What findings are used in the diagnosis of BPS?

A

Cystoscopy with hydrodistention, morphological findings in bladder biopsies, and ESSIC criteria

ESSIC stands for European Society for the Study of Interstitial Cystitis.

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4
Q

What dietary modifications are recommended for interstitial cystitis (IC)?

A

Avoidance of coffee, citrus, alcoholic beverages, carbonated drinks, caffeine, spicy foods, tomatoes, and vinegar

Arylalkylamine containing foods such as bananas, beer, cheese, and nuts should also be avoided.

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5
Q

How does is process of elimination diet helpful for IC patients?

A

To decrease dietary acid load and urinary alkalinization . Can be done with baking soda or potassium citrate

This approach has been effective for many IC patients.

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6
Q

What is the recommended urinary pH range for IC patients using potassium citrate?

A

6.0-6.5

Maintaining this pH level may help alleviate symptoms.

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7
Q

Water intake frequncy

A

Steady intake to dilute urine and decrease constipation

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8
Q

What is CystoProtek and its function?

A

CystoProtek contains components similar to bladder surface glycosaminoglycans (GAGs) to reduce bladder wall dysfunction and inflammation

It also contains soflavinoids to decrease bladder inflammation.

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9
Q

What is the main active ingredient in Prelief?

A

Calcium glycerophosphate (CGP)

Prelief provides urinary alkalinization.

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10
Q

What is bladder retraining/biofeedback?

A

A method where patients focus on inhibiting the urge to urinate to extend the voiding interval

This approach has shown a decrease in frequency, nocturia, and urgency.

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11
Q

What psychological therapy helps patients develop coping strategies for chronic pain?

A

Cognitive behavioral therapy (CBT)

CBT focuses on reducing helplessness and increasing perceived control over pain.

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12
Q

What is contextual cognitive behavioral therapy (CCBT) designed to address?

A

It is effective for patients with longstanding and complex chronic pain conditions

CCBT incorporates exposure, acceptance, cognitive de-fusion, mindfulness, and value-based methods.

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13
Q

How does physical therapy assist IC patients?

A

Myofascial therapy and addressing pelvic floor muscle dysfunction

High-tone pelvic floor muscle dysfunction (HTPFD) is common in IC patients.

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14
Q

What is the benefit of percutaneous nerve stimulation (PTNS) for IC/BPS?

A

PTNS therapy shows approximately 60% to 80% improvement in symptoms

Improvements include decreased leakage episodes, nocturia, daytime frequency, and volume voided.

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15
Q

True or False: Acupuncture has shown significant benefits in the treatment of IC.

A

False

Acupuncture had minimal changes to study subjects in clinical evaluations.

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16
Q

What does dysmenorrhea in isolation not constitute?

A

Chronic pelvic pain (CPP)

Dysmenorrhea refers to painful menstruation, which does not alone indicate the presence of chronic pelvic pain.

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17
Q

Can chronic pelvic pain have a structural cause?

A

Can or can not

CPP may arise from identifiable structural causes or be idiopathic.

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18
Q

What are some identifiable structural pelvic pathologies associated with chronic pelvic pain?

A
  • Endometriosis
  • Adenomyosis
  • Chronic pelvic inflammatory disease (with adhesions or hydrosalpinx)

These conditions can be linked to persistent pelvic pain.

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19
Q

What is a common cause of chronic pelvic pain in women?

A

Endometriosis

Endometriosis is a chronic inflammatory condition affecting 6-10% of women of reproductive age.

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20
Q

What is defined as endometriosis?

A

A chronic inflammatory condition affecting endometrial-like tissue outside the uterus

This condition commonly affects the lining of the pelvis and ovaries.

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21
Q

What symptoms are frequently caused by endometriosis?

A
  • Subfertility
  • Pain during periods
  • Pain during sexual intercourse
  • Pain during defecation (dyschezia)

These symptoms significantly affect the quality of life of affected individuals.

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22
Q

What is the relationship between symptoms and severity of endometriosis?

A

More severe disease correlates with higher pain scores during periods

Some women may not have a direct correlation between tissue presence and pain levels.

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23
Q

What is the ‘gold standard’ for diagnosing causes of chronic pelvic pain?

A

Laparoscopy

This procedure is considered costly and invasive but is the most reliable method.

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24
Q

What is the effectiveness of MRI scans for diagnosing chronic pelvic pain?

A

Not sufficiently accurate

MRI should not replace laparoscopy for diagnosing causes of CPP.

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25
Q

What are some predictors for diagnosing endometriosis?

A
  • Pain and menstrual symptoms occurring within the same year
  • Lower gastrointestinal symptoms occurring within 90 days of gynecological pain

These predictors can aid in the early identification of endometriosis.

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26
Q

What is the effect of hormonal therapy with a GnRH agonist after surgery for endometriosis?

A

Limited or no benefit for endometriosis

Hormonal therapy has shown inconclusive results in preventing pain recurrence.

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27
Q

What dietary factor increases the risk of endometriosis?

A

Consuming more than two servings per day of red meat

This dietary habit is linked to a 56% higher risk of developing endometriosis.

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28
Q

What type of exercise is recommended for managing chronic pelvic pain?

A

Exercise should be considered due to the inflammatory nature of the disease

Exercise can help alleviate some symptoms associated with chronic pelvic pain.

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29
Q

What psychological intervention showed improvement in symptoms for life?

A

Psychotherapy with somatosensory stimulation

This approach included a combination of several therapeutic techniques delivered over three months.

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30
Q

What is the effect of progressive muscle relaxation on anxiety and depression?

A

Improvement in state anxiety, trait anxiety, and depression

This intervention demonstrated beneficial effects in managing psychological symptoms.

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31
Q

What is the relationship between severe endometriosis and surgery outcomes?

A

Women with more severe endometriosis experience better pain improvement after surgery

Complete excision of endometriosis is necessary for optimal outcomes.

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32
Q

What is one of the challenges in diagnosing endometriosis?

A

Delay in diagnosis

There are currently no usable diagnostic algorithms to predict the disease successfully.

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33
Q

Fill in the blank: Chronic pelvic pain can often be —– resistant.

A

Surgery

Many patients find only partial relief from surgical interventions.

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34
Q

What is a common misconception about pain in endometriosis?

A

Pain should correlate with the increased presence of tissue

This may be true for some women, but not universally applicable.

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35
Q

DONT DELETE What additional symptom should be considered in smokers when diagnosing IC/BPS?

A

Hematuria due to increased risk of bladder cancer

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36
Q

What tools can be used to establish baseline voiding symptoms and pain levels in IC/BPS patients?

A

Bladder diary, genitourinary pain index (GUPI), interstitial cystitis symptom index (ICSI), visual analog scale (VAS)

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37
Q

When should cystoscopy and/or urodynamics be considered in the diagnosis of IC/BPS?

A

When the diagnosis is in doubt

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38
Q

Is cystoscopy necessary for uncomplicated presentations of IC/BPS?

A

No, it is not necessary for making the diagnosis

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39
Q

What is the only consistent cystoscopic finding that leads to a diagnosis of IC/BPS?

A

The appearance of Hunner lesions
This is the only reliable way to diagnose hunner lesions

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40
Q

What is recommended for patients suspected of having Hunner lesions?

A

Cystoscopy should be performed

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41
Q

What should be done if pain management for IC/BPS is inadequate?

A

Consider a multidisciplinary approach and refer the patient appropriately

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42
Q

What should patients be educated about regarding IC/BPS?

A

Normal bladder function, treatment options, known and unknown aspects of IC/BPS, benefits versus risks/burdens of treatments

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43
Q

What self-care practices should be discussed with IC/BPS patients?

A

Modifying behaviors, hydration status, avoidance of bladder irritants, stress management practices

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44
Q

What type of physical therapy should be offered to patients with pelvic floor tenderness?

A

Appropriate manual physical therapy techniques

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45
Q

What pharmacologic agents may be prescribed for IC/BPS pain management?

A

Urinary analgesics, acetaminophen, NSAIDs, opioid/non-opioid medications

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46
Q

What is the purpose of cystoscopy under anesthesia with low-pressure hydrodistension?

A

To rule out other causes of pain and potentially provide relief of bladder pain

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47
Q

What should be performed if Hunner lesions are present?

A

Fulguration (with electrocautery) and/or injection of triamcinolone

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48
Q

What treatment may be administered if other treatments have not improved symptoms of IC/BPS?

A

Intradetrusor onabotulinumtoxin A

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49
Q

What may be necessary if neuro-modulation is successful in treating IC/BPS?

A

Permanent neurostimulation device may be implanted

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50
Q

What treatments should NOT be offered for IC/BPS?

A

Long-term oral antibiotics, intravesical instillation of bacillus Calmette-Guerin, high-pressure long-duration hydrodistension, systemic long-term glucocorticoid administration

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51
Q

What is interstitial cystitis (IC)?

A

Pelvic pain that can be exacerbated by bladder filling, often associated with urinary frequency and urgency

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52
Q

What is the first line of treatment for interstitial cystitis?

A

Conservative therapy

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53
Q

What is the next line of treatment for patients that fail conservative therapy?

A

Oral medications

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54
Q

What type of medication is Amitriptyline?

A

A tricyclic antidepressant used for neuropathic pain

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55
Q

What is the role of Hydroxyzine/cimetidine in treating IC?

A

Preventing mast cell degranulation and histamine release

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56
Q

What is the function of Pentosan polysulfate (PPS) in IC management?

A

Repairing the glycosaminoglycan (GAG) layer of the bladder urothelium and reducing its permeability

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57
Q

What is Cyclosporine A used for in IC treatment?

A

Reserved for refractory patients to inhibit calcineurin, necessary for T cell activation

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58
Q

What does intravesicular therapy involve?

A

Direct introduction of a treatment agent into the bladder via a catheter

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59
Q

What is the effect of Dimethyl sulfoxide (DMSO) in IC treatment?

A

Reduces inflammation, causes detrusor relaxation, dissolves collagen, acts as an analgesic

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60
Q

What is heparin known for in the context of IC treatment?

A

A highly sulfonated GAG used as an anticoagulant and anti-inflammatory

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61
Q

What is the purpose of lidocaine in IC management?

A

Topical anesthetic

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62
Q

What is cystoscopy with hydrodistention used for?

A

Trialed if 1st/2nd line treatments fail, to inspect the bladder for lesions. Hydrodistention allows for the breakdown and reconstruction of damaged nerve pathways

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63
Q

What anatomical measurement is emphasized during cystoscopy?

A

Staging by measuring anatomical capacity

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64
Q

What are Hunner’s lesions?

A

Reddish mucosal areas with small vessels, increased likelihood of bleeding

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65
Q

What is the prevalence of Hunner’s lesions in IC patients?

A

5-10%. rare

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66
Q

What is the result of fulguration or sclerosing of Hunner’s lesions?

A

Complete or almost complete resolution of pain symptoms for over a year

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67
Q

What is a corticosteroids lfor IC treatment?

A

triamcinolone Useful in reducing symptoms, but safety data on maximum dose is lacking

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68
Q

What is intradetrusor botulinum toxin A (BTX-A)?

A

A neurotoxic protein used in IC treatment, best given with hydrodistention

69
Q

What is sacral nerve stimulation (SNS)?

A

A procedure involving insertion of a test lead to stimulate pelvic and pudendal nerves

70
Q

What must patients be advised about neuromodulation treatments?

A

Used for treating voiding symptoms, pain relief may not occur

71
Q

Fill in the blank: The mechanism of action for Cyclosporine A involves inhibiting _______.

A

Calcineurin

72
Q

True or False: Hydrodistention is theorized to allow for the breakdown and reconstruction of damaged nerve pathways.

A

True

73
Q

What defines endometriosis?

A

The presence of viable, estrogen-sensitive endometrial-like glands and stroma outside the uterus.

74
Q

What is the average age of diagnosis for endometriosis?

A

28 years.

75
Q

What are some epidemiological risk factors for endometriosis?

A
  • Early menarche
  • Short menstrual cycle length
  • Heavy menstrual periods
  • Nulliparity
  • Low body mass index
  • Alcohol use
  • Certain phenotypes (freckles, nevi)
76
Q

What role does exercise play in the risk of endometriosis?

A

Exercise can be protective.

77
Q

How does a family history of endometriosis affect risk?

A

A first-degree relative with endometriosis increases risk 7- to 10-fold.

78
Q

What is the typical symptom timeline for diagnosis for endometriosis?

A

7–8 years.

79
Q

What is the histological appearance of endometriotic lesions?

A

They have the same histologic appearance as the endometrium with distinct endometrial glands and stroma.

80
Q

What is the theory of müllerianosis regarding endometriosis?

A

Misplaced endometrial tissue develops into endometriosis during fetal organogenesis.

81
Q

What is progesterone resistance in the context of endometriosis?

A

Altered hormone response and enhanced cellular survival and inflammation at ectopic sites. resulting in metabolically active estradial

82
Q

What are endometriomas?

A

Cysts within the ovary containing ‘chocolate’ fluid.

83
Q

How are endometriomas different from other cysts?

A

Endometriomas are firmly adherent to the cortex and underlying stroma.
Progressively form cystic lesions via adhesions from ovary to sidewall

84
Q

What can cause pain in endometriosis?

A

Increased systemic and local proinflammatory cytokines and growth factors.

85
Q

What is the relationship between endometriosis and fertility?

A

Severe endometriosis can impact fertility, but the effect of minimal lesions is debated.
Peritoneal environment damages sperm DNA, lower for son fecundity rates, accelerated folicle depletion, lower baseline antimularian hormone

86
Q

What is the natural course of endometriosis?

A

Endometriosis should not be assumed to be progressive; most women will experience disease progression.

87
Q

What are common clinical presentations of endometriosis?

A
  • Dysmenorrhea
  • Deep dyspareunia
  • Dyschezia
  • Chronic abdominopelvic pain
  • Subfertility
88
Q

What imaging modality is preferred for assessing endometriosis?

A

Pelvic ultrasonography.

89
Q

What is the significance of staging in endometriosis?

A

Staging (I-IV) is not a great predictor of quality of life.

90
Q

What is the main goal of medical treatments for endometriosis pain?

A

To induce a local hypoestrogenic state by suppressing ovulation.

91
Q

What is the preferred surgical management for endometriomas?

A

Excision of the cyst is preferred to reduce recurrence.

Excision for dx confirmation recommended

92
Q

What are potential symptoms of urinary tract involvement in endometriosis?

A
  • Voiding dysfunction
  • Dysuria
  • Urgency
  • Pain with a full bladder
  • Hematuria
93
Q

What treatment is effective for severe pain associated with endometriosis?

A

Hysterectomy.

94
Q

What is the recommendation for patients with endometriosis who are interested in fertility?

A

IVF rather than surgery should be the first approach.

95
Q

What are the chronic pelvic pain approaches in endometriosis management?

A

Recognizing central sensitization and myofascial pain.

96
Q

True or False: Endometriosis is a benign disease.

A

True.

97
Q

What is the relationship between endometriosis and malignancy?

A

Women with endometriosis have an increased risk of epithelial ovarian malignancy.

98
Q

What is the recommended management for postmenopausal women with endometriosis?

A

Combined estrogen and progesterone treatment.

99
Q

Fill in the blank: The presence of deeply infiltrating endometriosis has a _______ effect on IVF.

A

negative

100
Q

What role do GnRH agonists play in endometriosis treatment?

A

They inhibit gonadotropin secretion and downregulate ovarian steroidogenesis.

Unclear if GnRH Agnes are affective for fertility treatment

101
Q

What is the ideal duration of postoperative hormonal suppressive therapy for endometriosis?

A

A minimum of 6–24 months.

102
Q

What are fertility treatments available for people with endometriosis

A

Intrauterine insemination, GnRH agonists/excision of endometriomas, IVF

103
Q

What factors exist that place the greatest risk for fertility compromise in patients with endometriosis, what are their options for conception?

A

Several surgeries, bilateral endometriosis. Options for these people include cryopreservation which may not make sense financially

104
Q

Who is an ideal candidate for surgery for endometriosis versus not

A

A good candidate for surgery is someone with advanced disease, young, significant pain, large endometriomas, Yeutter or bowel contrisction.

bad candidate- Advanced maternal age, low ovarian reserve male factor for conceiving, should consider in vitro fertilization

105
Q

Should you use myofascial release in IC?

A

Yes, better than global massage

106
Q

What is endometriosis?

A

A condition where tissue similar to the lining of the uterus grows outside the uterus, causing pain and other symptoms.

107
Q

What is the main symptom of endometriosis in the beginning?

A

Nociceptive pain, specifically dysmenorrhea and cyclic lower abdominal pain.

108
Q

What can develop over time in patients with endometriosis?

A

Nociplastic processes leading to lowered pain threshold, spinal hyperalgesia, and pelvic floor dysfunction.

Nociceptive pain >nociplastic pain > neurogenic inflammation

109
Q

What are some symptoms that may result from endometriosis?

A

Dysuria, dyschezia, dyspareunia, and chronic pelvic pain.

110
Q

What leads to hormone-independent, acyclic lower abdominal pain in endometriosis?

A

Neurogenic inflammation due to changes in inflammatory processes and innervation within lesions.

111
Q

Is primary surgical diagnosis needed when there is no organ destruction in endometriosis?

A

No, primary surgical diagnosis is not needed if symptoms are well-managed and the patient does not desire to have a child.

112
Q

What is usually recommended as mono therapy for managing endometriosis?

A

Progestogen therapy.

113
Q

What should be ruled out before treating pain in endometriosis patients?

A

Surgical problems and organ destruction.

114
Q

What are the first steps in treating endometriosis-related chronic pain?

A

Treatment of hormones, surgery, and analgesics.

115
Q

What is a common belief about hormonal therapy for endometriosis?

A

Some patients believe that synthetic hormones are bad, which is not always the case.

Endometriosis is hormonal and needs horror moans to address it consider patient beliefs

116
Q

What should be considered if a patient experiences bleeding while on hormonal therapy for endometriosis?

A

Medications or alterations can be provided; consider if bleeding is from a cyst.

117
Q

What should be attempted if a patient on hormonal therapy has no bleeding but persistent pain?

A

Switching from combined oral contraceptives (COCs) to progestin-only pills (POPs).

118
Q

Which therapy achieves comparable levels of pain reduction during first-line treatment for endometriosis?

A

Dienogest (Dng) and Gonadotropin analogues (GnRha).

119
Q

What is an important indication for considering a second surgery in endometriosis patients?

A

Persisting pain under adequate therapy.

120
Q

What should be compared to evaluate if all endometriosis lesions were removed during surgery?

A

Histological findings with the surgical report.

121
Q

What does the WHO recommend as a first step for pain management in endometriosis?

A

Using OTC anti-inflammatories.

122
Q

What alternative therapies can be beneficial for pain management in endometriosis?

A

TENS, yoga, pelvic floor exercises, and education about pain with sex.

123
Q

What dietary changes can help manage endometriosis symptoms?

A

More fruits and vegetables, less sugar, gluten, and meat.

endo belly pro-inflammatory environment gives rise to free radicals and leads to oxidative stress

124
Q

What is the psychological impact of severe pain in endometriosis patients?

A

Higher likelihood of depressive symptoms and anxiety disorders.

125
Q

What types of therapies can be included in pain education courses for endometriosis patients?

A

Progressive muscle relaxation, autogenic training, relaxation exercises, yoga, chi gong, creative therapies, and hypnosis.

126
Q

What may be an option for endometriosis patients if outpatient services are not sufficient?

A

Inpatient care.

127
Q

What characterizes chronic pain states?

A

Central and peripheral sensitization, allodynia, and regional hyperalgesia

128
Q

Define myofascial pain.

A

A non-articular musculoskeletal disorder characterized by myofascial trigger points, which are hard, palpable, discrete, localized nodules within taut bands of skeletal muscle that are painful upon compression

129
Q

Where are abdominal wall myofascial trigger points reported?

A

In those with endometriosis

130
Q

What clinical signs were documented in women with endometriosis-associated chronic pelvic pain?

A

Signs of sensitization and myofascial dysfunction in the abdomino-pelvic regions

131
Q

How were women classified as having regional allodynia or regional hyperalgesia?

A

By having six or more affected segments on a side

132
Q

Which spinal segments were assessed in the study?

A

From T9 through S2

133
Q

What is allodynia?

A

Pain due to a non-noxious stimulus

134
Q

How was allodynia assessed?

A

Using a pinch and roll technique

135
Q

Define hyperalgesia.

A

An increased pain response to a noxious stimulus

136
Q

How was hyperalgesia assessed?

A

By rolling a Wartenberg pinwheel vertically along the skin adjacent to the spinous processes

137
Q

What defines a lowered pressure-pain-threshold?

A

Less than 9 lbs/cm2 in six or more segments per side

138
Q

What do findings suggest about the central nervous system in women with a history of endometriosis?

A

Long-term remodeling may persist after lesions are treated

139
Q

What is myofascial dysfunction associated with?

A

Pain and clinical evidence of sensitization (regional allodynia and/or regional hyperalgesia)

140
Q

Who is more likely to have sensitization?

A

Women with any history of endometriosis compared to those without and healthy volunteers

141
Q

What correlates with endometriosis in patients with chronic pelvic pain?

A

Abdominal wall myofascial trigger points

142
Q

How can painful myofascial trigger points affect visceral structures?

A

They can sensitize segmentally-related visceral structures

143
Q

What do painful endometriotic lesions do?

A

Send noxious signals to a wide range of spinal cord neurons

144
Q

What is the unclear relationship mentioned in the study?

A

The relationship between lesions and pain with ectopic growths

145
Q

What may occur before surgery in relation to sensitization?

A

Sensitization may occur before symptoms

146
Q

How might endometriosis initiate sensitization and myofascial pain?

A

Via neurogenic inflammation

147
Q

What factors increase the likelihood of sensitization?

A

Depression and anxiety

148
Q

What type of exam is recommended for better describing a pain experience?

A

Comprehensive neuro-musculoskeletal exam

Inclusion of objective findings of allodynia hyperalgesia pain pressure threshold and myofascial trigger points

149
Q

What objective findings are associated with chronic pelvic pain?

A

Allodynia, hyperalgesia, pressure-pain-threshold, and myofascial trigger points

A part of comprehensive neuromuscular exam

150
Q

Why are traditional methods of classifying pain considered inadequate?

A

They are based on disease, duration, and anatomy

151
Q

What is the peak occurrence age range for endometriosis?

A

25 years to 35 years

152
Q

What is the estimated monthly medical cost for women with endometriosis in the US?

A

US$706/ month

153
Q

What phenomenon is involved in the pathogenesis of endometriosis?

A

Retrograde menstruation phenomenon

154
Q

What are the typical locations for endometriosis occurrence?

A

Pouch of Douglas, left ovary, uterus

155
Q

Fill in the blank: Estrogens fuel ___ growth in endometriosis.

A

ectopic endometrium

156
Q

What does progesterone normally trigger in the uterine endometrium?

A

Inhibition of estrogen-dependent proliferation of epithelial cells

157
Q

What inflammatory mediators are associated with endometriosis?

A

Prostaglandins, cytokines, chemokines

158
Q

What is a common symptom associated with deep endometriosis?

A

Deep dyspareunia

159
Q

True or False: Histological diagnosis of endometriosis always requires surgery.

A

False

160
Q

What is the benefit of conservative ovarian surgery for endometriosis?

A

Relatively safe procedure for treating ovarian endometriotic cysts

161
Q

What is the main indication for surgery in women with endometriosis?

A

Temporary pain relief

162
Q

What is the risk associated with resection of rectovaginal lesions?

A

Relatively high overall risk of complications

163
Q

What are the objectives of medical therapy for endometriosis?

A

Inhibition of ovulation, abolition of menstruation, achievement of a stable steroid hormone milieu

164
Q

Fill in the blank: Hormonal medical treatment has no effect on __ in women with endometriosis.

A

infertility

165
Q

What is the recurrence rate of symptoms and lesions at 5-year follow-up without postoperative adjuvant treatment?

A

40% to 50%

166
Q

What is a risk factor for epithelial ovarian cancer associated with endometriosis?

A

Oxidative stress and mutation of genes for cancer suppression

167
Q

What is recommended for women with endometriosis up to their early forties?

A

Contraceptive use

168
Q

What surgical procedure may be the best risk-reducing approach for women over forty with endometriosis?

A

Unilateral oophorectomy plus bilateral salpingectomy.

WCS (6 decks)

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