SASP Flashcards
Stabilization of the myocardium during life-threatening hyperkalemia associated with loss of P waves and widening of the QRS complex on the EKG is best accomplished using: A. I.V. calcium gluconate. B. I.V. sodium bicarbonate. C. 10% glucose with regular insulin. D. potassium exchange resin with sorbitol. E. hemodialysis.
A. Severe hyperkalemic cardiotoxicity must be treated immediately, not by lowering serum potassium concentration alone, but by preventing cardiac excitability and antagonizing the cardiotoxic effects of hyperkalemia. Thus, I.V. calcium gluconate is the initial treatment of choice. This must be followed by measures to immediately lower serum potassium since the duration of calcium effects are brief. Bicarbonate and glucose should be given next, but they are short-acting and exchange resins or dialysis should be planned for more long-term treatment.
If the inferior mesenteric artery is ligated, the artery that maintains blood supply to the rectum is: A. superior mesenteric B. Ileocolic C. Middle sacral D. External Iliac E. Hypogastric
E. Blood supply to the rectum arises proximally from the superior rectal artery, which branches from the inferior mesenteric artery, and distally from the middle and inferior rectal arteries. When the inferior mesenteric artery is ligated, blood supply to the rectum is maintained by the middle rectal artery, which is a branch of the anterior division of the internal iliac (hypogastric) artery, and the inferior rectal artery, a branch of the internal pudendal artery also arising from the anterior division of the hypogastric artery. The superior mesenteric, ileocolic, middle sacral, and external iliac arteries do not provide blood supply to the rectum.
Three years after placement of an artificial urinary sphincter with initial good results for post-prostatectomy incontinence, a 55-year-old man has recurrent incontinence. Examination of the device and cystoscopy suggests normal cycling and no cuff erosion. The next step is:
Three years after placement of an artificial urinary sphincter with initial good results for post-prostatectomy incontinence, a 55-year-old man has recurrent incontinence. Examination of the device and cystoscopy suggests normal cycling and no cuff erosion. The next step is:
D. Urethral atrophy results from chronic compression of the corpus spongiosum by the cuff and is the leading cause of urinary incontinence in this setting. However, urodynamic evaluation may reveal detrusor overactivity or decreased bladder compliance. Deactivation will not permit improved sphincter function. Surgical exploration is not indicated if the cause of the incontinence is unrelated to the device (i.e., detrusor overactivity or impaired compliance). Alpha-blockers would not be expected to have any effect on urinary incontinence in this case regardless of the underlying cause. Antimuscarinics would not treat causes of incontinence related to device malfunction. Treatment options for this patient, if he indeed has recurrent stress incontinence, would include downsizing the cuff or moving the cuff to a more proximal or distal location.
A 59-year-old man on active surveillance for Gleason 3+3=6 prostate cancer with a stable PSA of 5.1 ng/mL has intraductal carcinoma on repeat biopsy. He prioritizes maintenance of sexual function. The next step is: A. PSA in six months. B. MRI scan in one year. C. repeat biopsy in one year. D. whole gland cryosurgery. E. nerve-sparing radical prostatectomy.
E. Intraductal carcinoma of the prostate is an aggressive lesion for which immediate treatment, rather than active surveillance, is recommended. Thus, obtaining PSA in six months or waiting one year for an MRI scan or repeat biopsy would not be advised as these approaches risk delay in definitive therapy. Further, while limited data exist regarding the optimal treatment modality for intraductal carcinoma, whole gland cryosurgery likely represents undertreatment, particularly given the young age of the patient. Moreover, whole gland cryosurgery may significantly impact erectile function, such that AUA Guidelines state, “clinicians should inform localized prostate cancer patients considering whole gland cryosurgery that erectile dysfunction is an expected outcome”. Among the management options listed, although nerve-sparing radical prostatectomy poses risk to erectile function, it represents the optimal approach. XRT would also be an acceptable treatment option. If XRT is given with androgen deprivation, the risk of early/intermediate sexual dysfunction increases.
Question 5. The renal toxicity of I.V. iodinated contrast material is due to:
A.
glomerular injury.
B.
afferent arteriolar constriction.
C.
efferent arteriolar constriction.
D.
intrarenal vasoconstriction and tubular necrosis.
E.
efferent arteriolar dilation and tubular necrosis.
D. Three key risk factors that may provoke iodinated contrast-induced renal injury include pre-existing renal dysfunction (serum creatinine > 1.6 mg/dL or estimated GFR < 60 mL/min/1.73m2), pre-existing diabetes, and reduced intravascular blood volume. Contrast agents evoke renal injury by two mechanisms: first, by acting as an intrarenal vasoconstricting agent resulting in decreased intrarenal blood flow and hypoxemia; second, by a direct toxic effect of the contrast agent on tubular epithelial cells. The combination of renal medullary ischemia and direct cellular toxicity leads to increased renal epithelial cell apoptosis and acute tubular necrosis. The osmolality of the contrast agent once believed to be of paramount importance in the induction of contrast-induced nephropathy has been shown to play a minimal role in contrast-induced nephropathy. Indeed, recent studies have found that viscosity of the contrast agent is more important than osmolality. These findings resulted in the recommendation that periprocedural hydration along with limiting the amount of contrast agent are the key to preventing contrast-induced renal damage. A recent meta-analysis to evaluate the various interventions employed for prevention of this complication (assessing sodium bicarbonate solutions, adenosine antagonists [theophylline], N-acetylcysteine, and ascorbic acid) noted mixed results with no definitive proof that these agents could prevent the complication. Randomized control studies have, however, shown that in patients with a creatinine of > 3.5 mg/dL, prophylactic hemodialysis prior to and following the study can reduce the risk of this complication.
A 19-year-old with a pelvic fracture-related urethral injury undergoes endoscopic realignment. Three months after catheter removal, he has a weak stream. Retrograde urethrogram and VCUG are shown. The next step is:
A. urethral dilation. B. internal urethrotomy. C. anastomotic urethroplasty. D. buccal mucosa graft urethroplasty. E. penile skin flap urethroplasty. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
C. The images demonstrate a posterior urethral stricture. Anastomotic urethroplasty offers high success rates for urethral stenosis that occurs after urethral disruption injury due to pelvic fracture. Dilation and urethrotomy are potential options for first time treatment of short anterior urethral strictures, but not for posterior disruption injuries. Substitution urethroplasties, whether with buccal mucosa or penile skin flaps, are not appropriate when there is no lumen to augment, as in pelvic fracture urethral disruption. AUA Guidelines recommend anastomotic urethroplasty given the high success rates and the very low success rates of endoscopic management.
Ten days after an abdominal hysterectomy for cervical cancer, a 64-year-old woman has leakage of urine and purulent material from the vagina. A cystogram is normal, but a retrograde pyelogram demonstrates a left ureterovaginal fistula and marked hydronephrosis. The right upper tract is normal. The next step is I.V. antibiotics and: A. percutaneous nephrostomy tube. B. ureteral stent placement. C. vaginal cuff drain placement. D. ureteroneocystostomy. E. transureteroureterostomy
B. In the present case, the ureteral obstruction is not complete, as retrograde injection of contrast outlines the proximal ureter. Placement of a ureteral stent may result in resolution of the fistula. If retrograde placement is not successful, an antegrade approach can be undertaken. A percutaneous nephrostomy tube can be considered if stent placement is unsuccessful from either approach. If the fistula does not resolve after stent drainage, surgical repair would be indicated. There is no consensus as to the timing of surgical repair, though many would consider waiting at least four to six weeks after the initial surgery in order to optimize local tissue quality for healing. If surgical repair is necessary and she has a distal ureteral injury, then ureteroneocystostomy would likely be sufficient. A transureteroureterostomy would not be the initial repair for ureterovaginal fistula. Placement of a vaginal drain would not address the primary issue of the fistula.
A 22-year-old woman is evaluated for microscopic hematuria. Abdominal films demonstrate bilateral nephrocalcinosis with fine flecks of calcium appearing in most papillae. Renal function is normal. The most likely diagnosis is: A. distal RTA. B. idiopathic hypercalciuria. C. Fanconi syndrome. D. proximal RTA. E. hyperparathyroidism.
A. Nephrocalcinosis occurs primarily in children and young adults with distal RTA. This is characterized by impaired hydrogen ion excretion in the distal collecting duct. It rarely occurs in proximal RTA which results from an impairment in proximal tubular bicarbonate reabsorption or in Fanconi syndrome where excessive amounts of amino acids are excreted along with organic anions, such as citrate, which tend to prevent calcium precipitation. Idiopathic hypercalciuria and primary hyperparathyroidism rarely cause nephrocalcinosis, but when present, the acidification defect found in distal RTA usually coexists.
A 48-year-old woman develops a vesicovaginal fistula one week after vaginal hysterectomy. Cystoscopy shows a 5 mm area of erythema just cephalad to the trigone. Bilateral retrograde pyelograms are normal. Although vaginal leakage of urine persists, the majority of urine is voided normally. The next step is: A. fulgurate fistula. B. bilateral nephrostomy tubes. C. immediate fistula repair. D. urethral catheter drainage. E. suprapubic cystostomy.
D. In this patient, a trial of conservative management using urethral catheter drainage is indicated because of the small size of the fistula and the brief interval after the surgery. Given that the patient has no prior history of XRT or pelvic surgery, tissues should be adequately vascularized and capable of healing. Bilateral nephrostomy tubes to divert the urine drainage is more invasive and would not provide additional benefit over bladder drainage alone for a vesicovaginal fistula (VVF). Similarly, a suprapubic cystostomy does not offer benefit over a urethral catheter. There is little data to support fulguration of a VVF. Should catheter drainage fail, early repair may be done using a vaginal approach.
In a man with low-risk prostate cancer, the genomic test which provides an estimate of adverse pathologic features is: A. Oncotype Dx®. B. Decipher®. C. Prolaris®. D. Confirm MDx®. E. Mitomic®. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
A. A variety of commercially available biopsy-based genomic tests are available in prostate cancer. Oncotype Dx® (mRNA expression in 17 genes) was developed to predict the likelihood of Gleason 4+3=7 or extracapsular extension at prostatectomy. Decipher® (mRNA expression of 22 genes) and Prolaris® (mRNA expression of cell cycle progression genes) predict the likelihood of metastasis or cancer-specific mortality. Confirm MDx® (epigenetic evaluation of hypermethylation in three genes) and Mitomic® (mitochondrial DNA) evaluate prostate tissue from a negative biopsy to predict the likelihood of cancer on a subsequent biopsy.
A two-month-old girl with a lumbar myelomeningocele had a febrile UTI. After therapy, videourodynamics show bilateral grade 5 VUR, a trabeculated bladder, leakage around the 7 Fr urodynamics catheter at a volume of 40 mL, and a detrusor pressure of 50 cm H2O. The next step is: A. vesicostomy. B. incontinent ileovesicostomy. C. antibiotics and oxybutynin. D. augmentation and bilateral ureteral reimplants. E. bilateral ureteral reimplants and CIC.
A.
vesicostomy.
This patient has high-grade VUR and a small trabeculated bladder with reduced capacity and poor compliance. This is combined with high urethral resistance. Antibiotics alone, with or without ureteral reimplantations, would be inadequate therapy. With grade 5 VUR, a bladder volume of only 40 mL (which would predominantly be made up of the volume of the upper tracts) and poor compliance with adequate urethral outlet, ureteral reimplantation without correction of the poor bladder compliance would be inadequate with a high risk of VUR recurrence. CIC may be helpful for the short-term; however, very poor compliance would make catheterization alone inadequate. Augmentation with ureteral reimplants and CIC or ileovesicostomy may ultimately be the therapy of choice but is not the best therapy for a two-month-old. Vesicostomy would provide temporary effective therapy.
A 15-year-old sexually active boy has urethritis, confluent red papules with a yellowish scale on the glans penis, arthritis of the knees, and uveitis. The best initial treatment of the skin lesions is: A. intramuscular penicillin G. B. systemic retinoids. C. topical steroids. D. topical podophyllin. E. oral doxycycline.
C. topical steroids
This boy has reactive arthritis (formerly Reiter’s Syndrome) which includes urethritis, genital skin lesions similar to those of psoriasis, arthritis, and inflammatory disease of the eye (uveitis). The skin lesions alone are difficult to distinguish from psoriasis, but the complex of symptoms is specific for reactive arthritis. The etiology is unknown but may be triggered by infection and is likely genetic as almost all affected patients have the HLA-B27 haplotype. Initial treatment is usually with topical steroids. If symptoms persist, systemic retinoids or even methotrexate may be needed. Oral or I.V. antibiotics are not indicated for this patient. Podophyllin is useful in treating genital warts but would not be beneficial in this patient.
A 53-year-old man with a history of cyclophosphamide chemotherapy has clot urinary retention. He continues to require daily blood transfusions despite cystoscopic fulguration and catheter clot evacuation. Alum irrigations and percutaneous nephrostomy drainage have been unsuccessful. A cystogram shows no VUR. The next step is: A. 2-Mercaptoethane sulfonate (mesna). B. 10% formalin bladder irrigations. C. 10% formaldehyde bladder irrigations. D. cystectomy. E. 1% formalin bladder irrigations
E. Formaldehyde is a gas that can be dissolved in water. The maximum dissolution is 37% formaldehyde in an aqueous solution. In other words, 100% formalin equals 37% formaldehyde solution. This solution is then diluted to give an appropriate concentration of formalin. Since formaldehyde is a gas, it is not instilled into the bladder until it is dissolved in water yielding formalin. Typically, one starts with a low concentration (1%) of formalin bladder irrigations. If this fails, subsequent irrigations can be increased to higher concentrations. However, prior a cystogram should be performed to exclude VUR, and if reflux is found, ureteral occlusion balloons should be placed. Patients should be aware of potential postoperative pain, decreased bladder volume, and marked urinary urgency and frequency. Cystectomy should be reserved for situations that do not respond to less aggressive measures. Mesna has been utilized for prophylaxis of cyclophosphamide-induced hemorrhagic cystitis but is not therapeutic once cystitis has developed.
A 35-year-old man with C5 quadriplegia is managed with a condom catheter. He has recurrent febrile UTIs and episodes of autonomic dysreflexia. CMG reveals a detrusor LPP of 60 cm H2O at 150 mL, detrusor-external sphincter dyssynergia, and a residual of 75 mL after reflex bladder contraction. The next step is: A. observation. B. CIC. C. antimuscarinic medication. D. external sphincterotomy. E. male sling.
D. Suprasacral spinal cord injury is often a management dilemma, as it may present with both storage and emptying failure. If bladder pressures are suitably low, or can be safely lowered by various means, the issue can be treated as an emptying failure and CIC may be used. This man, on the other hand, has several issues that require intervention including a high detrusor LPP which puts his upper urinary tracts at risk, recurrent UTIs and autonomic dysreflexia (AD). Observation may result in upper tract compromise and do not address his recurrent UTIs or AD; thus, is not a viable option at this time. Since he is a high quadriplegic, CIC is typically not feasible for these patients unless there is a caregiver or family member who are able to perform regular CIC. Additionally, his functional bladder capacity is only 150 mL, therefore, CIC alone would be inadequate. Antimuscarinic medication alone would also not be helpful since it would not address the dyssynergia or issues with incomplete emptying. A male sling would increase his outlet resistance and do nothing to reduce the impact of his bladder on the upper urinary tract. An external sphincterotomy can be used in these men to decrease the outlet resistance and lower the detrusor LPP. This would also likely address his issues with AD and recurrent UTI and he can continue to manage his bladder with the condom catheter; thus, avoiding the need for CIC in a patient who does not have the manual dexterity to perform that task.
A 76-year-old asymptomatic woman has a urine culture showing > 105 Klebsiella CFU/mL. Treatment with amoxicillin may: A. reduce mortality. B. reduce morbidity. C. increase mortality. D. increase morbidity. E. increase risk of stone formation.
D.
increase morbidity.
Prospective randomized trials comparing antimicrobial versus no therapy in elderly male and female nursing home residents with asymptomatic bacteriuria consistently document no benefit of antimicrobial therapy. There was no decrease in symptomatic episodes and no change in survival. In fact, treatment with antimicrobial therapy was associated with increased morbidity including increased occurrence of adverse drug effects, reinfection with resistant organisms, and increased cost of treatment. Therefore, asymptomatic bacteriuria in elderly patients should not be treated with antimicrobial agents. There is no increased risk of stone formation when treating with amoxicillin.
