Skin and hernia Flashcards

Question

Gorlin syndrome

Answer 1

Rare Autosomal dominant PTCH1 gene syndrome of: * multiple BCCs * odontogenic keratocysts of the jaw * developmental delay

Answer 2

Common, lifetime risk ~30% in fair skinned people Risk increases with age closer to the equator increases risk men 1.3:1 women

Answer 3

UV exposure * probably more UVA than UVB Tanning beds Arsenic exposure Radiation exposure Fair skin, red hair Family history of skin cancer Pigment disorders * xeroderma pigmentosum, albinism Immunosuppression * HIV, transplant, CRF

Answer 4

Basal layer of epidermis

Answer 5

More indolent * Nodular (most common, ~80%) * Superficial * Pigmented BCC (6%) * Fibroepithelial (most indolent) More aggressive * Infiltrative/mopheaform * Micronodular * Basosqumaous (part BCC part SCC)

Answer 6

Pearly rolled edge, depressed centre Ulceration common Teleangiectasia centrally is common Locally invasive, extremely rarely metastatic 80% are found on the face and neck

Answer 7

4-5mm Although those with 2mm margins only recur 4%

Answer 8

5% cream Immune response modifier * Promotes innate immune response * Activation of Toll-like receptor 7 incites cells to produce cytokines * IFN-a, IL-6, TNF-a Dosing regimens vary per indication * Warts 3x weekly until clearance max 8/52 * BCC 5x weekly for 6/52

Answer 9

5% cream Antimetabolite * Thymidylate synthase * inhibits DNA synthesis Apply 1-2x per day for 2-4 weeks, avoid contact with, or decontaminate, non diseased skin (esp the applying fingertip)

Answer 10

* Rapid course of lesion development * Initial lesion consistent with papule, pustule, or vesicle * Pain out of proportion to lesion * History of preceding trauma (pathergy) * History of disorders associated with PG * Ulcerated lesion with violaceous margin and undermining

Answer 11

Neutrophilic dermatosis Neutrophil infiltration, dysfunction and inapproprate action Often associated with systemic inflamation * IBD, Arthritis Progressive dermatitis and erosion of skin and soft tissue, neutrophil mediated * TNFa implicated * Responds to antiTNFa treatment (infliximab)

Answer 12

Key is diagnosis with biopsy If associated with IBD surgery for that disease may lead to resolution Treatment is immunosuppression * Systemic glucocorticoids * Topical tacrolimus * Single small RCT using infliximab shows good resolution Analgesia Wound cares Avoidance of trauma Surgery is reserved for infection/necrosum

Answer 13

Follicular epithelial hyperplasia * hyperkeratosis * follicular plugging and distension * Mechnical stress forces esp. in intertrigonous areas * duct rupture, leakage of keratin fragments, sebum and bacteria into tissue * foreign body granulomatous response NB: Likely not from sweat glands as the name suggests

Answer 14

Education and wound care * Avoid Trauma * Avoid tape * Smoking cessation (and nicotine) * Weight loss Hurley I * Topical clindamycin * Punch debridement Hurley II-III * Doxycycline 100mg OD-BD * OCP, spironolactone may help * Surgery * Simple excisions * Excision and grafting

Answer 15

Hurley Classification * Stage I – Simple abscess * Abscess formation (single or multiple) without sinus tracts and cicatrization/scarring * Stage II – Sinus/fibrosis without confluence * Recurrent abscesses with sinus tracts and scarring, single or multiple widely separated lesions * Stage III – Confluence * Diffuse or almost diffuse involvement, or multiple interconnected sinus tracts and abscesses across the entire area

Answer 16

The clinical appearance of invasive cSCC often correlates with the level of tumor differentiation. * Well-differentiated lesions usually appear as indurated or firm, hyperkeratotic papules, plaques, or nodules. * Lesions are usually 0.5 to 1.5 cm in diameter but may be much larger. * Ulceration may or may not be present. * In contrast, poorly differentiated lesions are usually fleshy, granulomatous papules or nodules that lack the hyperkeratosis that is often seen in well-differentiated lesions. * Poorly differentiated tumors may have ulceration, hemorrhage, or areas of necrosis.

Answer 17

Clinical nodal assessment * FNA CT CAP if high risk features * Bone, muscle, fascia involvement * Large size (\>2cm) * Breslow \>2mm * Nodal involvement * Near or invading major nerves * In transit mets PET- no evidence No evidence for (or against) SLNB

Answer 18

Two theories * Traditional (and still valid) view is origin in Merkel cells * Neural mechanoreceptor cell of the basal layer of the dermis * Alternative view is origin in dermal totipotential cell * Acquires neuroendocrine features during malignant transformation

Answer 19

Merkel Cell Polyomavirus | (present on PCR in 80% of tumours)

Answer 20

* Asymptomatic * 88 percent * Expanding rapidly * (significant growth in ≤3 months) * Immune suppression * HIV infection, solid organ transplant recipient, chronic lymphocytic leukemia * Older than 50 years age * Most common \>80 * Ultraviolet (UV)-exposed area in a fair-skinned individual

Answer 21

Inferior (Petit) * between * external oblique * iliac crest * latissimus dorsi Superior (Grynfeltd) * between * quadratus lumborum * internal oblique * 12th rib

Answer 22

Excision biopsy to 2mm margin is the recommended by the australian cancer council. Of the incomplete biopsy methods incisional biopsy has the lowest false negative rate (1.4%)

Answer 23

STOMAMESH trial shows no reduction in the incidence of parastomal hernia at 1 year

Answer 24

Type I * polymicrobial * both anaerobic and aerobic Type II * Lancefield group A streptococci * pyogenes * or other beta haemolytic strep Type III * gas gangrene, or clostridial myonecrosis

Answer 25

Polymicrobial with anaerobic and aerobic bacteria * Typically at least one each of: * Anaerobe * Bacteroides * Clostridium * Peptostreptococcus * Enterobacteriaceae (gram neg family) * E.coli * Enterobacter * Klebsiella * Proteus * Facultative anaerobic Streptococci (other than GAS) * Enterococci * Strep. agalactiae * Fungi occasionally implicated

Answer 26

Monomicrobial * Beta haemolytic streptococcal infection * Group A Strep, almost always pyogenes * M protein is the important virulence factor * bacterial strains can produce pyrogenic exotoxins * important mediator of toxic shock syndrome * Staph aureaus * Uncommon * Vibrio vulnificus * Salt water injuries * Aeromonas hydrophila * Fresh water injuries

Answer 27

* Major penetrating trauma * Minor laceration or blunt trauma * Skin breach (esp IVDU) * Recent surgery * Mucosal breach * hemorrhoids, rectal fissures, episiotomy * Immunosuppression * (diabetes, cirrhosis, neutropenia, HIV infection) * Malignancy * Obesity * Alcoholism * In women: pregnancy, childbirth, pregnancy loss, gynecologic procedures

Answer 28

* Erythema * (without sharp margins; 72 percent) * Oedema that extends beyond the visible erythema * (75 percent) * Severe pain * (out of proportion to exam findings in some cases; 72 percent) * Fever * (60 percent) * Crepitus * (50 percent) * Skin bullae, necrosis, or ecchymosis * (38 percent)

Answer 29

Type I (polymicrobial) necrotizing soft tissue infection of the perineum * More common in men * often involves penis and scrotum * Diabets and obesity are major risk factors

Answer 30

Gram negative aquatic organism often implicated in salt water soft tissue infections treatment with fluoroquinolones or tetracyclines * In severe infection a 3rd generation cephalosporin may be helpful (ceftriaxone, cefotaxime)

Answer 31

My choice * Meropenem, and * Vancomycin, and * Clindamycin General principles are: * Broad spectrum coverage against gram negatives, gram positives and anaerobes * Tazosin is a reasonable alternative to a carbapenem * Cover MRSA * Vancomycin * Clindamycin * Suppresses bacterial toxin production * Decreases penicillin binding protein production (synergistic beta lactam effect)

Answer 32

By coagulative necrosis

Answer 33

Flame Scald Hot (or cold) surface contact Chemical Electricity

Answer 34

Direct cellular membrane injury and thermal injury. * induces both colliquation and coagulative necrosis

Answer 35

Zone of coagulative necrosis * Irreversible cellular injury at time of insult Zone of stasis * Vascular damage and leaky endothelium * poor tissue perfusion * Thromboxane A2 is an important mediator of burn induced vasoconstriction in the zone of stasis * May be reversible or progress to coagulative necrosis Zone of hyperaemia * Vasodilation and inflammation * Usually not at risk for further necrosis

Answer 36

Superficial Partial * Superficial partial * Deep partial Full thickness 4th degree

Answer 37

* Involve only the epidermal layer of skin. * Do not blister but are painful, dry, red, and blanch with pressure. * Over two to three days the pain and erythema subside, and by approximately day 4, the injured epithelium peels away from the newly healed epidermis. * Such injuries are generally healed in six days without scarring. * This process is commonly seen with sunburns.

Answer 38

* Characteristically form blisters within 24 hours between the epidermis and dermis. * Painful, red, and weeping and blanch with pressure. * Burns that initially appear to be only epidermal in depth may be determined to be partial thickness 12 to 24 hours later. * Generally heal in 7 to 21 days * A layer of fibrinous exudates and necrotic debris may accumulate on the surface, which may predispose the burn wound to heavy bacterial colonization and delayed healing. * These burns typically heal without functional impairment or hypertrophic scarring * pigment changes may occur.

Answer 39

* Extend into the deeper dermis * Deep burns damage hair follicles and glandular tissue. * Painful to pressure only * Almost always blister (easily unroofed), are wet or waxy dry, and have variable mottled colorization from patchy cheesy white to red * Do not blanch with pressure. * If infection is prevented and wounds are allowed to heal spontaneously without grafting, they will heal in two to nine weeks. * These burns invariably cause hypertrophic scarring. If they involve a joint, joint dysfunction is expected even with aggressive physical therapy. * A deep partial-thickness burn that fails to heal in two weeks is functionally and cosmetically equivalent to a full-thickness burn. * Differentiation from full-thickness burns is often difficult.

Answer 40

* Extend through and destroy all layers of the dermis and often injure the underlying subcutaneous tissue. * Burn eschar, the dead and denatured dermis, is usually intact. * can compromise the viability of a limb or torso if circumferential. * Usually anesthetic or hypo-aesthetic. * Skin appearance can vary from waxy white to leathery gray to charred and black. * Skin is dry and inelastic and does not blanch with pressure * Hairs can easily be pulled from hair follicles. * Vesicles and blisters do not develop. * Pale full-thickness burns may simulate normal skin except that the skin does not blanch with pressure. * Eschar eventually separates from the underlying tissue and reveals an unhealed bed of granulation tissue. * Without surgery, these wounds heal by wound contracture with epithelialization around the wound edges. * Scarring is severe with contractures; complete spontaneous healing is not possible.

Answer 41

Fourth-degree burns are deep and potentially life-threatening injuries that extend through the skin into underlying soft tissue and can involve muscle and/or bone.

Answer 42

Lund browder chart (most accurate, especially in children) Rule of 9's Palm method

Answer 43

All except superficial burns are included

Answer 44

Modified Lund Browder chart The most accurate method of burn area prediction

Answer 45

For adult assessment, the most expeditious method to estimate TBSA in adults is the "Rule of Nines" * Head represents 9 percent TBSA * Each arm represents 9 percent TBSA * Each leg represents 18 percent TBSA * The anterior and posterior trunk each represent 18 percent TBSA

Answer 46

Small or patchy burns can be approximated by using the surface area of the patient's palm. * The palm of the patient's hand, excluding the fingers, is approximately 0.5 percent of total body surface area * The entire palmar surface including fingers is 1 percent in children and adults

Answer 47

* Persistent cough, stridor, or wheezing * Hoarseness * Deep facial or circumferential neck burns * Nares with inflammation or singed hair * Carbonaceous sputum or burnt matter in the mouth or nose * Blistering or edema of the oropharynx * Depressed mental status, including evidence of drug or alcohol use * Respiratory distress * Hypoxia or hypercapnia * Elevated carbon monoxide and/or cyanide levels

Answer 48

\>15% TBSA * Calculated as any burn greater than superficial

Answer 49

Hartmanns or Lactated Ringers

Answer 50

The Parklands formula * The traditional formula is * 4ml x (patient body weight in kg) x (TBSA in %) * Half is given over the first 8 hours * Half over the subsequent 16 hours * This is likely to overestimate fluid requirements * In our local unit a modified Parklands of 3ml/kg/TBSA% is used for initial resus An early switch to goal directed therapy and urine output monitored resuscitation is recommended with a goal of 0.5ml/kg/hour * there is evidence that this improves outcomes

Answer 51

Diagnostic criteria debated but: * Large number of naevi at an early age * Multiple atypical naevi (at least 2) * Classical description is \>100 naevi * At least one \>8mm * One or more atypical Screening should begin at 10 years of age, melanoma may develop in teens * Monthly self exam and specialist dermatologist review recommended

Answer 52

The inferior epigastric vessels (both superficial and proper) form anastomotic arcades with the superior epigastrics and form the thoracoepigastric veins * These are a site of large volume shunting from IVC to SVC in IVC obstruction

Answer 53

Medial * lacunar ligament Posterior * pectineal ligament Anterior * inguinal ligament Lateral * femoral vein

Answer 54

2cm or greater

Answer 55

BRAF inhibitors * vemurafenib PD1 inhibitors * pembrulizumab Systemic chemotherapy * doxirubicin * not very effective and quite toxic

Answer 56

Elasticity and tensile strength * mesh must be able to conform to the abdominal wall in motion or it would cause distorsion, tissue disruption and pain * tensile strength of 16 N/cm²is the maximum tensile strength required Porosity * large pores permit integration with tissues and most importantly integration of immune competent tissue * microporous meshes \<100µm are associated with chronic infection and fibrosis Density (weight) * lower density meshes have lower burden of foreign body per unit area, they therefore are associated with a decreased inflammatory response and better tissue integration. Constitution * mesh can be either monofilament or polyfolament weave * the microporous areas within polyfilament weave are associated with increased bacterial infection * monofilament is generally more stiff Absorption * mesh can be either absorbable or non absorbable * absorbable mesh relies on scar formation which is never as strong as the initial tissue and may increase the risk of recurrence * non absorbable mesh may stiffen and contract over time and if there is infection it will persist

Answer 57

Atrium prolite mesh * good tensile strength (too high at 138 N/m²) * lightweight (80g/m²) * polypropylene monofilament construction * nonabsorbable * large pore size (0.8mm)