SASP Studying Tidbits Flashcards
Solifenacin
AKA Vesicare
Treats OAB
MOA: Cholinergic receptor antagonist (anti-cholinergic)
Contraindications: urinary retention, gastroparesis, uncontrolled or severe glaucoma, severe liver disease, HD
Effects of spinal shock on:
- Smooth sphincter
- Striated sphincter
- Guarding reflex
In spinal shock, both autonomic and somatic activity is suppressed, and the bladder is acontractile and areflexic
Smooth sphincter - synergic
Striated sphincter - synergic
Guarding reflex - absent
The striated sphincter response during filling (i.e., normal guarding reflex) is absent and there is loss of voluntary sphincter control - BUT patient usually has intact sphincter tone
Paratesticular rhabdomyosarcoma (RMS)
Comprise up to 10% of genitourinary RMS, arise from the testicular tunicae, epididymis, or spermatic cord
Embryonal subtype is the most common, representing > 90% of cases
Current recommendations (patients > 10 yo) with paratesticular RMS = ipsilateral staging RPLND, even with negative imaging studies, as these patients have been found to be more likely to harbor retroperitoneal disease
International Metastatic RCC Database Consortium (IMDC) poor-risk RCC (4 risk factors)
IMDC score is generated with 1 point for each of the following: < 1 year from diagnosis to systemic therapy, Karnofsky performance status (KPS) < 80%, hemoglobin < 12 g/dL, elevated corrected calcium, elevated neutrophils, and elevated platelets
Results from the Checkmate 214 trial demonstrated the superiority of nivolumab and ipilimumab when compared to sunitinib in those patients with previously untreated intermediate- and poor-risk clear cell RCC
Other preferred first-line options based on NCCN guidelines for newly diagnosed intermediate or poor-risk metastatic clear cell RCC are axitinib/pembrolizumab or cabozantinib
The concept of hypofractionation for prostate cancer treatment is to deliver higher fraction sizes per treatment, which in turns shortens treatment duration, and thereby confers favorable implications for patient convenience, cost, and resource utilization. Specifically, conventional XRT fractionation involves a fraction size of 180 to 200 cGy, while moderate hypofractionation is defined as a fraction size between 240 cGy and 340 cGy. Multiple prospective randomized trials have compared moderate hypofractionation to conventional fractionation and have reported no statistically significant difference in cancer outcomes. The toxicity of moderate hypofractionation versus conventional fractionation has likewise been assessed from clinical trial results, with similar rates of acute and late genitourinary toxicity consistently reported from these series. Meanwhile, mildly increased risks of acute gastrointestinal (GI) toxicity have been reported with moderate hypofractionation, with similar late rates of GI toxicity. These trials have included patients across the spectrum of disease risk, with high-risk patients comprising nearly 20% of the studied populations to date, and no evidence of a significant interaction between treatment effect and risk group. As such, per current ASTRO/ASCO/AUA guidance, moderate hypofractionation should be offered to men with high-risk prostate cancer receiving external beam XRT (EBRT) to the prostate as long as the intended treatment does not include the pelvic lymph nodes, as the clinical target volume in the majority of studies evaluating moderate hypofractionation did not include the pelvic lymph nodes.
Kleinfelter Syndrome
Klinefelter syndrome affects 1:650 newborn boys and is characterized by hypergonadropic hypogonadism. In addition to hypogonadism, males with Klinefelter syndrome are at increased risk for gynecomastia, visceral obesity, osteoporosis, male infertility, learning problems, breast cancer, and extragonadal germ cell tumors.
ANOVA
Analysis of Variance (ANOVA) is a statistical formula used to compare variances across the means (or average) of different groups. A range of scenarios use it to determine if there is any difference between the means of different groups.
Logistic regression
Logistic regression is used to estimate the relationship between a dependent variable and one or more independent variables, but it is used to make a prediction about a categorical variable versus a continuous one.
Changes that occur after placement of a ureteral stent?
A number of changes occur after placement of a ureteral stent, including hyperplasia and inflammation of the urothelium, smooth muscle hypertrophy, increased intrapelvic pressure (transmission of bladder pressures to upper tracts), decrease in ureteral contractility, and VUR. Decreased ureteral contractility contributes to VUR, which may have implications in infected systems in the setting of bladder outlet obstruction.
Preservation of the sacral nerve arcs, as indicated by an intact bulbocavernosus reflex, suggests the potential for detrusor-sphincter dyssynergia. While other parameters such as lower extremity movement, spontaneous voiding, and normal anal sphincter tone may also suggest the presence of intact sacral arcs, the bulbocavernosus reflex is the most clinically specific. Unlike spinal cord injury, in patients with lumbosacral spina bifida, neural function and urodynamic findings cannot be predicted by the level of the lesion.
FENa values and level of issue
FENa values < 1% indicate a pre-renal etiology such as sepsis, hypovolemia, congestive heart failure or renal artery stenosis.
A FENa of >/= 2% is consistent with acute renal injury such as acute interstitial nephritis, acute tubular necrosis, or glomerulonephritis.
Finally, a FENa of more than 4% indicates a post-renal etiology of acute renal failure, such as bilateral ureteral obstruction, bladder stones, bladder outlet obstruction or urethral stricture.
The patient’s findings are classic for chancroid which is due to H. ducreyi. It affects men three times more than women. It is associated with inguinal adenopathy that is typically unilateral and tender with a tendency to become suppurative and fistulize. Single-dose treatment with azithromycin 1 gram orally or ceftriaxone 250 mg intramuscularly is first line therapy. While ciprofloxacin can be a secondary regimen, resistance to ciprofloxacin has been reported in some regions. Acyclovir, penicillin, or doxycycline are not indicated. Patients should be reexamined in five to seven days. Sexual partners should be treated if sexual relations were held within two weeks before or during the eruption of the ulcer.
Urinary concentrating defects following obstructive lesions may produce nephrogenic diabetes insipidus. This is often seen with PUV. It may be extremely difficult to reduce urinary volumes due to a fixed concentrating defect that is unresponsive to DDAVP. With large urine volumes, this boy is likely experiencing overflow incontinence and possibly poor bladder contractility. Therefore, antimuscarinics, onabotulinumtoxinA or imipramine would be unlikely to improve his urinary incontinence. With a fixed concentrating defect, fluid restriction may be dangerous, risking severe dehydration. Timed, double voiding would be the best initial treatment to aid in bladder emptying and would potentially reduce his incontinence.
The phase III METEOR trial compared everolimus versus cabozantinib for patients with disease progression after previous tyrosine kinase inhibitor therapy (as is the case here) and demonstrated a significantly improved overall survival with cabozantinib (21.4 months) versus everolimus (16.5 months). Cabozantinib was also associated with a significantly improved objective response rate and progression-free survival. Based on these trial findings, cabozantinib is listed by the National Comprehensive Cancer Network (NCCN) as a category 1 preferred option for patients with progression after tyrosine kinase inhibitor therapy, and specifically should be used preferentially over everolimus in eligible patients. Further, cabozantinib can be used in patients with chronic kidney disease.
Nivolumab is an immune checkpoint inhibitor antibody that blocks the interaction between PD-1 and its ligands. Nivolumab also has category 1 designation in this setting by the NCCN due to the results from a phase III randomized trial which noted superior overall survival for nivolumab (25 months) versus everolimus (19.6 months) among previously treated patients. However, the immune-mediated mechanism of nivolumab renders this agent not a good choice for a patient with an active autoimmune disease (lupus) requiring treatment and patients requiring glucocorticoid treatment were excluded from the aforementioned clinical trial.
For a similar reason, pembrolizumab (as part of a combination regimen with axitinib) would not be recommended.
Sunitinib, while an option for this patient, is listed by the NCCN as a category 2A option for second-line therapy, as limited prospective data exist to demonstrate its efficacy following progression on tyrosine kinase inhibitor therapy.
Meanwhile, high-dose interleukin-2 represents an option for highly selected patients, specifically those with excellent performance status and normal organ function but is listed by the NCCN as a category 2B treatment choice.
Opioid abuse can impair fertility via:
Secondary hypogonadism
One potential adverse effect experienced by abusers is the suppression of pituitary LH secretion, via pathways mediated by the hypothalamus. Decreased LH secretion results in decreased Leydig cell production of testosterone, a condition called “hypogonadotropic hypogonadism” or “secondary hypogonadism.” Reduced intratesticular testosterone levels, in turn, commonly result in reduced spermatogenesis and male factor infertility. Upon opioid cessation, LH and testosterone secretion and spermatogenesis typically improve within weeks to months.
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.
