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MRCS part B- JMB > Surgical Pathology > Flashcards

Surgical Pathology Flashcards

1
Q

Function of plasma proteins?

A 
Albumin- binds and transports calcium, on oncotic pressure
Immune system
Completement cascade
Clotting
Enzymes
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2
Q

Causes of raised urate?

A

Idiopathic
Inborn errors of metabolism

Alcohol
Diuretics
Protein rich foods

Causes
Gout
Renal failure
Renal calculus

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3
Q

Role liver?

A 
Bike production and conjugation
Clotting factor production
Drug metabolism
Glycogen storage
Plasma proteins 
Reticulendothelium system
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4
Q

Life cycle of bilirubin

A

RBCs broken down to haem and then biliverdin
Converted to bilirubin
Conjugated by binding to albumin by hepatocytes
Excreted in bile
Excreted in kidneys as urobilin- yellow
Farces- sterobiliogen- brown

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5
Q

Commonest renal stones?

A 
Calcium oxalate- 77%
Struivate- 15%
Uris acid -5% (radiolucent)
Cystine- 2%
Xanthine- 1%
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6
Q

Gall stone commonest?

A

Mixed-85%- fat femal fair forty
Cholesterol-10%
Pigment-5% haemolysis

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7
Q

Bile volume per day and composition?

A

1500ml/day

Bike pigments
Bike salts
Cholesterol
Electrolytes
Water and bicarbonate
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8
Q

Amyloid definition?

A

A group of degradation resistant proteins with a beta pleated structure

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9
Q

How to diagnose amyloidosis?

A

Biopsy
Stain with Congo red
Apple green birefringence under polarised light

Isotope scan for hotspots

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10
Q

Types of amyloid?

A

AL- myeloma leading to global production of Ig amyloid
AA- chronic inflammation- macrophages releasing interleukins. Ra/ibd/tb
PrP- prion diseaze

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11
Q

Consequences of amyloid?

A

Organ failure
Localised deposits- larynx and thyroid
Medullary thyroid cancer
Organomegally

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12
Q

Cause of death in amykoidosis?

A

Myocardial amyloid

Leads to arrhythmia sand heart failure

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13
Q

Aetiology of microcytic anaemia?

A

Iron deficiency- bleeding, poor intake, low absorption, increase demand
Thalassaemia
Sideroblastic anaemia

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14
Q

Aetiology of macrocyclic anaemia?

A 
B12/folate deficiency- megloblasts on blood film
Alcohol
Hypothyroidism
Myelodysplasia 
All normoblasts on blood film
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15
Q

Normocytic anaemia aetiology

A

Chronic disease
Renal failure- epo
Sickle cell anaemia- hydrolysis
Spherocytosis

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16
Q

Microscopy of b12 anaemia?

A

Macrocytosis
Howell jolly bodies
Hypersegmented neuclei in neutrophils

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17
Q

Aetiology of b12

A

Poor intake
Pernicious anaemi
Ileal/ gastric resection
Crohns

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18
Q

Aetiology of folate deficiency

A

Decrease intake
High demand- pregnancy/cancer
Drugs- methotrexate
Malabsorption-coeliac

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19
Q

Sickle cell pathogenesis?

A

Autosomal recessive
10-20 day turnover of rbcs
Defective beta chains in HbA leads to less soluble hbS. Which leads to sickle cells

Veno-occlusive disease
Ischaemia
Pain crises

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20
Q

Blood film findings of sickle cell

A 
Normochrmia
Normocytic
Reticulocytes
Sickle cells
Target cells
Howell jolly bodies
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21
Q

Causes of sickle cell crises?

A

Infective
Low o2
Hypothermia
Dehydration

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22
Q

Thalassaemia features?

A 
Autosomal recessive haemolytic disease
3 types
Alpha
Beta
Delta
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23
Q

Beta thalassaemia blood film?

A 
Hypochromic
Microcytic
Reticulocytes
Target cells
Howell jolly bodies
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24
Q

Process of haemostasis?

A

Vasoconstriction
Platelet aggregation and activation
Clotting cascade- secures platelet plug

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25
Function of platelets?
Primary haemostasis vWF and TXA2 for platelet activation Phagocytosis Cytokines signalling
26
Draw clotting cascade
https://www.osmosis.org/answers/coagulation-cascade
27
Which clotting factor is calcium?
Factor 4
28
What are the moa of heparin, clopidogrel and txa?
Heparin- inhibited factor 10a- potentiates antithrombin III Clopidogrel- ADP receptor inhibitor- prevents platelet aggregation TXA- inhibits plasmin, prevents clots from breaking down
29
How is blood processed to be ready for transfusion?
Viral screening Centrifugation Leucofiltration- decreases cmv reaction Irradiation- optional- prevent gvhd
30
What is FFP and cryoprecipitate
FFP- top layer of centrifuged blood- plasma, contains clotting factors, compliment, fibrinogen, vWF and albumin Cryo- precipitate of ffp, factors 8, 13 and vWF.
31
Definition of oedema?
Generalised or localised collection extracellular fluid
32
Aetiology of lymphoedema? Surgical treatment?
1- milroys 2- iatrogenic, malignancy, infection Treatment surgical- homans/Charles/lympho anastomoses
33
What is starlings law of the capillaries?
Governs the net filtration across capillaries = capillary pressure- interstitial hydrostatic pressure - capillary pressure - oncotic pressure Taking into account lymphatic drainage Hydrostatic pressure- pressure blood exerts on the wall
34
Oedema aetiology?
Increase hydrostatic pressure- heart failure, fluid overload Decrease oncotic pressure- liver/kidney failure Capillary leakage- inflamm/anaphylaxis Lymphatic failure Drugs- nifedipine Gravitational
35
Types of hypersensitivity reactions?
Acids ``` Type 1- allergic Type 2- cytotoxic- good pastures Type 3- immune complexes- sle Type 4- delayed- transplant related Type 5- stimulatory- graves ```
36
Name some cell mediators of the immune response?
Bradykinin- vasodilation and permeability Histamine- same as above + puritus + gastric acid secretion Leukotrines c4- bronchoconstriction + vascular permeability Prostaglandins d2- neutrophil recruitment, vasodilation, bronchoconstriction TXA2- vasoconstriction, bronchoconstriction, platelet aggregation
37
Name some cytokines?
Il4- cd4 t helper cell proliferator B cell ige synthesis Il5 histamine and leukotrine release B cell proliferation, eosinophil recruitment Il13 cd4 t helper cell proliferation Tnfalpha neutrophil activation
38
What is the complement cascade?
Part of the innate immune system Involved in the clearance of pathogens via production of MAC 4 pathways Classic Lectin- independent of ab-ag complexes Alternative- same as above Final common- leads to MAC production, opsonisation, chemotaxsis
39
What is the composition of Ig?
Fab region- heavy and light chains- fragment bindings region- variable region Fc region- interacts with cell surface fc receptors- contstant
40
Types of immune response?
Cell mediated- T cell mediated- production of cd4 T cells, macrophages and NKCs Humoral- B cell mediated- ab release, complement, opsonisation, phagocytosis
41
Roles of the Ig?
``` IgM- first released IgG- majority of humoral response Crosses placenta IgD on b lymphocytes and bind to Ag IgA primary Ab in bodily secretions IgE binds to basophils and mast cells to promote degranulations of cytokines and mediators ```
42
What is leukocyte margination and emigration?
Normally flow in centre of blood stream Margination- move to plasmatic peripheral zone Emigration- pavementing then active migration across endothelium
43
What is a granuloma?
Collection of modified macrophages +- time of surrounding lymphocytes Seen in TB/sarcoid
44
What is the cellular process during chronic inflamm?
``` Lymphokine production- IFN gamma Activate macrophages release growth factors Fibroblast proliferation Neovascularisation Tissue destruction ```
45
What is a cyst and pseudo cyst?
Cyst abnormal membrane lined sac containing fluid- epithelial cells Abnormal collection of fluid surrounded by granuloma/fibrous tissu
46
What is an abscess? Why?
Localised collection of pus surrounded by granulation tissue Neutrophils/macrophages release enzymes that split large molecules to small ones increasing the oncotic pressure
47
What is a fistula / sinus
Fistula is an abnormal communication between two epithelial surfaces Sinus- blinding ending tract in communication with an epithelial surfsce
48
What is pus?
Pus is made out of fluid and solid components Fluid- exudate of plasma proteins, water Solid- live and dead- macrophages/neutrophils/bacteria Dead human cellS Fibrin
49
Describe the process of wound healing?
Cutting is pleasing repetitive Coagulation- seconds Inflammatory days Proliferation weeks- granulation and epithelisation Remodelling- years- reorganisation, regression, scar tissue
50
Epidemiology of SSIs?
5% of cases Superficial skin Muscle/fascia Organ/cavity
51
What are endotoxins?
Proteins released by gram - bacteria. Lead to pyrexia/shock/dic Activate clotting/complement Cause fibrin degradation Lead to cytokines formation
52
What are exotoxins?
Formed by gram + can lead to tetanus and gangrene
53
What are nosocomial infections?
Hospital acquired infections
54
Phases of the cell cycle
G0 resting phase G1 regulation of the duration of cell cycle R restriction point in G1. Rb tumour suppression gene S synthesis phases G2 rapid growth and 2nd check point p53 M mitosis
55
What stimulates and inhibits the cell cycle?
Stimulation Cyclins d&e Cyclin dependent kinase Inhibition P53 Rb gene
56
Difference between dysplasia, metaplasia and neoplasia?
Dysplasia is abnormal cell development. Premalignant Metaplasia is replacement of one fully differentiated cell type with another Neoplasia is an abnormal mass of tissue due to uncontrolled and progressive cell division
57
Tumour markers for testicular teratoma? And breast/pancreas/ovary?
Testicle- bhcg, afp Breast ca153 Pancreas ca199 Ovary ca125
58
``` Carcinogens? Bladder Burkitts Cervix Cholangiocarcinoma HCC Kaposi Leukaemia Lymphoma Lung Nose Skin ```
``` Dyes and nitrosamines Ebv Hpv Liver flukes Afalatoxin, HBV HCV HHV8 HTLV Cyclophosphamide Asbestos and tobacco Sawdust UV light ```
59
Cellular features of malignancy
``` Macroscopic Growth Necrosis Infiltration Metastasis Haemorrhage ``` ``` Microscopic High mitotic rate Pleomorphism Hyperchromatism High nucleus to cytoplasmic ratio ```
60
Commonest cancers and highest mortality?
Skin, lung, prostate, breast colorectal Lung, colorectal, breast, prostate, oesophageal
61
Endocrine paraneoplastic syndromes?
Cushings- small cells lung and pancreas SIADH- small cell lung cancer Hypercalcaemia- squamous lung cancer, breast, ovarian, rcc Carcinoid- lymphoma, gastric, pancreatic
62
Haematological paraneoplastic syndromes
``` Aplastic anaemia (pan cytopeni) - thymus Polycythaemia- RCC/HCC ```
63
MSK paraneoplastic syndromes
Acanthodians nigracans- gastric/lung cancer- EGF | Dermatomyositis (skin rash, muscle weakness) -breast/ lung
64
Neurological paraneoplastic syndromes?
Cerebellum degeneration- lung overian breast | Lamber Eaton syndrome- lung prostate cervix
65
Definition of of clot thrombus and embolus
A clot describes a collection of solid material (made of the constituents of blood) found in stagnant blood Thrombosis is the progression of a clot with Virchow triad in the same place as it formed in flowing blood Embolus is a clot distant to where it was formed
66
What is Virchow triad?
Endothelial damage Hypercoagulable stage Stasis or turbulent blood flow Leads to thrombosis
67
Trauma triad?
Hypothermia Acidosis Coagulopathy (Hypocalcaemia?- citrate theory)
68
Definition and RFs of an atheroma
Lipid collection within the tunica intima of arteries. May have foam cells Congenital- fhx, make, familial hyperlipidaemia Acquired- diabetes, smoking, hypertension, hyperlipidaemia
69
Theories of the formation of an atheroma?
Imbition- circulating lipoproteins Proliferation- smooth muscle hyperplasia Encrustations- lipid portion of atheroma derived from pre existing thrombus
70
Definitions of infarction and ischaemia?
Ischaemia- abnormal reduction in blood supply/drainage | Infarction- tissue/organ necrosis due to poor blood supply
71
Definition of an aneurysm?
Abnormal vessel dilation by more than 50%
72
Classification of aneurysms?
Aetiology- congenital/acquired- infection/trauma/hypertension Morphology- saccular vs fusiform Pathology- true/false/dissecting
73
Aetiology of aneurysms?
``` Congenital Atherosclerosis Htn Infective Ischaemia Traumatic Iatrogenic ```
74
Difference between true, dissecting and false aneurysms?
True involve all three layers of arterial wall False does not Dissecting- blood running through media/adventitia. Can lead to vessel occlusion
75
Composition of bones?
Cellular- osteoprogenitor cells Osteoclasts, osteoblasts Matrix- inorganic- calcium hydroxapitate Organic- type 1 collagen
76
Types of bone
Anatomically- Flat vs Long bone Macroscopically- Cortical vs Cancellous Microscopically- Lamellar vs woven Flat bone- irregular structure- skull/scaphoid Long- regular structure- diaphysos, metaphysis, epiphysis- femur/tibia Woven- haphazardly organised collagen fibres, pathological/immature Lamellar- regular parallel alignment of collagen fibres Cortical- hard outer layer of bones. Composed of tightly tightly packed osteons with Haversian canals Cancellous- porous central layer of bone, high turnover
77
What is the process of fracture healing?
Coagulation- haematoma formation Inflammatory- granulation and fibroblasts proliferation Proliferation- callous- woven bone- chondroblasts and osteoblasts. Lamellar bone formation. Remodelling- cortical bone replaces woven bone
78
Principles of fixation principles
Reduce Restrict Rehab
79
Why does smoking lead to poor bone healing?
Decreased calcium absorption Decreased vit d Increased non union and malunion
80
Osteomyelitis aetiology < 4 months 4months- teenager Adults DM Immunocomprimised HIV Sickle cell
Vaginal flora- staph a/strep/ E. coli Staph a/gas/hi Staph a/enterococcus/gbs Anaerobes Aspergillosis/candida TB salmonella
81
Pathogenesis of osteomyelitis?
Acute inflam leads to compression of capillaries Osteonecrosis Dead bone fracture separate off necrosis New bone formation around this
82
Aetiology of septic arthritis?
Direct trauma Haematogenous spread Dissemination- osteomyelitis/cellulitis Iatrogenic
83
What is the reconstructive ladder?
Secondary intention Primary closure Skin graft Flap (free vs pedicled) Adjuncts- negative pressure dressings
84
What are the different types of graft?
Split skin graft- takes epidermis and portion of dermis- poor colour/contracts Full skin graft- takes epidermis and Dermis- requires a well vascularised bed
85
Differences between keloid and hypertrophic scars?
Keloid- thick and raised. Extends beyond boarders. Appears over years. Afro Caribbean. Increased collagen synthesis Hypertrophic- thick and raised. Within boarders, appears in weeks, regresses
86
Types of muscles
Skeletal- located at joints- striated and voluntary Type 1- slow twitch, type 2 fast twitch Cardiac- striated and voluntary Smooth- vessels and viscera. Greater stretch ability and prolonged contraction. Calmodulling is binding agent
87
Draw a sarcomere and describe the sliding protein theory and muscle contraction
88
Types of cartilage
Fibrocartillage- type 1 collagen. Pubic symphysis. High tensile strength Hyaline- type 2 collagen. Hard. Smooth articular surfaces Elastic- lots of elastin. Pinna. Epiglottis. Fibroelastic- meniscus Physeal
89
Features of Men 1
Pancreatic tumour Pituitary adenoma Primary hyperparathyroidism
90
Features of men 2a/b
2a- phaeochrmocytoma, medullary thyroid ca, 1o hyperparathyroidism 2b- phaeochromyocytoma, medullary thyroid cancer, multiple neuromas, marfanoid habitus
91
Aetiology of gynaecomastia
Raised oestrogen to androgen ratio Physiological- puberty/old age Pathological- cirrhosis, hyperthyroidism, hypogonadism, kleitfelters, testicular tumours. Pharmacological- steroids, spironolactone (anti androgen)
92
Draw out the pth and calcium homeostasis
https://www.researchgate.net/figure/Calcium-Homeostasis-and-Selected-Causes-of-Hypercalcemia-in-Pediatric-Patients-The-serum_fig1_49822084
93
Embryological Origins of superior and inferior parathyroid glands
Superior- 4th pharyngeal pouch | Inferior - 3rd pharyngeal pouch
94
Aetiology of hyperparathyroidism?
1o- single parathyroid adenoma (85%) Parathyroid hyperplasia (10%) Carcinoma (1%) 2o - physiological response to chronic hypocalcaemia secondary to renal failure 3o - hyperplasia of parathyroids from 2o leading to raised pth
95
Cushing’s syndrome clinical features?
``` Ulcers Cataracts Diabetes Fluid retention Atrophy Pancreatitis ```
96
Aetiology of Cushing’s syndrome?
ACTH dependent- cushings disease- pituitary adenoma. Paraneoplastic cancer Independent- steroids, adrenal cortex neoplasm
97
Carcinoid syndrome definition?
Neuroendocrine tumour arising from APUD cells Intestinal- appendix/ small bowel Extra intestinal- lung ovary testis
98
Classical carcinoid syndrome and diagnosis?
``` Abdo cramps Bronchoconstriction Cardiac failure Diarrhoea Flushing ``` 24 hr urinary 5-HIAA octreo scan- hot spots Ct/mri Laparotomy
99
Draw the thyroid hormone homeostasis
100
Aetiology of hyper and hypo thyroid
Hyper- iodine excess, graves (anti tsh receptor abs), toxic nodule, subacute thyroiditis Hypo- iodine deficiency, hashimoto’s (anti tpo abs anti thyroglobulin abs)
101
Role of thyroid hormone
Cellular metabolism and glycogenolysis Growth and development Increased sensitivity to adrenaline Increased gut motility
102
Types of amyloid disease?
AL amyloid- Clonal expansion of plasma cells producing amyloid Ig AA amyloid- chronic inflam lead to macrophages stimulating hepatocytes to produce precursor to amyloid Prions disease
103
Complications of EVAR?
Intraop- rupture, failure of op- endo leak | Post op- mesenteric/renal ischaemia, infection, MI
104
Causes of appendicitis?
Faecoliths Tumours- carcinoid Lymphoid tissue Foreign object
105
Ascites aetiology? More detail
Exudate- increased vascular permeability 4Ps- peritonitis, post irradiation, peritoneal mets, pancreatitis Transudate Increased interstitial pressure- cirrhosis, budd chiari, RHF Decreased oncotic pressure- liver/renal failure
106
Underlying process of atherosclerosis?
Endothelial damage leading to inflam response (caused by trauma/htn) Foam cells and lipid core (aided by hypercholesterolaemia) Stenosis/thrombosis
107
What is the carcinogenic version of fibroadenoma?
Phyllodes tumour | Worry if rapid growth and in >35yo
108
Management of breast abscesses?
Lactational vs non lactational (smoking association) USS + Drain for MCS IV Abx
109
Causes of gynaecomastia?
Physiological Lower testosterone- testicular tumour/atrophy Raised oestrogen- leydig cell tumour, liver disease, obesity, adrenal tumours Medication- spironolactone, antipsychotics, chemo Idiopathic
110
Causes of nipple discharge?
``` Physiological Prolactinoma Duct ectasia Intra-ductal papilloma Hyperplasia ```
111
Causes of a cholangiocarcinoma?
Developed world- PSC Non developed- Liver flukes HIV/Chronic liver disease
112
Difference between PSC and PBC?
PBC- interlobar ducts affected Chronic granulomatous disease leading to cirrhosis/cholestasis AMA +ve PSC- intra and extrahepatic ducts Fibrosis and stenosis pANCA
113
Types of bone tumours?
Benign- osteochondroma (10-20yrs old), giant cell tumours 1o- multiple myeloma Osteosarcoma Ewings- onion skin, 5-20 yo ``` 2o- mets Breast Lung Thyroid Kidney Prostate ``` BLT and a packet of KP crisps
114
Layers of the GI tract?
Mucosa (epithelium, lamina propria, musclaris mucosa) Submucosa Musclaris propria Adventitia
115
What is the adnoma carcinoma sequence?
A series of mutations leading to hyperproliferation metaplasia and dyslplasia APC, KRAS, p53
116
What is a neoplasm?
A tumour Abnormal mass of tissue Demonstrating uncoordinated growth And continued growth despite removal of the stimulus
117
What is metaplasia and dysplasia?
Reversible change in cell type Dysplasia- uncoordinated cellular development, no basement membrane invasion, mitosis and pleomorphism
118
What type of cells involve a carcinoma and a sarcoma?
Carcinoma- epithelial cells | Sarcoma- connective tissue
119
Causes of hypoparathyroidism and hypothyroidism?
Iatrogenic- surgery/ DTx Autoimmune- Parathyroid- addison's, thyroid- hashimotos PTH- hypomagmanesia Thyroid- iodine deficiency
120
What is the LN drainage of the tongue?
Tip- submental Ant 2/3- submandibular Post 1/3- deep cervical LNs
121
How does H pylori evade destruction?
Burrows into mucus lining Produces urease which neutralises HCL Forms Ammonia- which cause inflammation of gastric lining
122
How to Dx h pylori?
Urea breath test Stool Ag Biposy + CLO testing
123
Are chief cells and oxyphyill cells present in normal parathyroid tissue?
Yes
124
Components of the corpus callosum?
Rostrum Genu Body Sternium
125
What are the stages of acute inflammation?
Rubor, Dolor, Calor, Tumour ``` Vascoconstriction then dilation Permeability Neutrophil migration Phagocytosis Resolution/chronicity/abscess/death ```
126
Which cells are present in chronic inflammation?
Macrophages Lymphocytes Plasma cells
127
What is a granuloma and giant cell?
Granuloma- collection of epitheloid macrophages (lots of giant cells) Giant cell- fusion of epitheloid cells (derived from macrophages)
128
Difference between branchial cyst, dermoid cyst and cystic hygromas
Branchial cyst- anterior triangle, failure of obliteration of branchial arch Dermoid cyst- teratomas, neck midline Cystic hygroma- lymphatic system blockage, lymphangioma Post triangle- kids
129
What is the procedure called to remove a thryoglossal cyst?
Sistrunk's- removal of middle part of hyoid bone
130
Types of necrosis?
``` Coagulative- MI in heart Liquefactive- Stroke in brain Caseous- TB Fat- Breast trauma Fibrinoid- Type III hypersensitivity ```
131
Examples of hypertrophy and hyperplasia?
Hypertrophy- exercise and muscles, uterus in preg HOCM Hyperplasia- grave's, bph Breasts in puberty/thyroid in pregnancy
132
What does the glasgow score for pancreatitis tell you?
>/3 in 48 hours- ITU discussion- severe pancreatitis
133
Difference classically between a DU and GU?
DU- pain relieved by eating, returns after 3 hours | GU- pain related to meals
134
Dumping's syndrome?
Rapid gastric emptying of undigested foods Leading to fluid shifts (secondary to increased intestinal osmolality) Hypotension, bloating, flushing, abdo pain
135
Types of intestinal polyps?
Benign- harmatomas, inflammatory Neoplastic- commonest- tublar, villous, tublovillous Malignant potential- tublovillous, villous, tubular
136
What is PSA?
Prostate specific antigen Tumour marker for Prostate cancer Enzyme that liquifies semen
137
Types of dialysis?
Haemodialysis- cheaper, simpler, diffusion across PPM Haemofiltration- convection of fluid, iTU Peritoneal dialysis
138
Complications of renal transplants?
``` Rejection- dx via biopsy Delayed function Thrombosis/stenosis of artery/vein Ureteric stricture Infection Lymphocele Failure of anastamosis ```
139
What tumour markers do testicular tumours produce?
Teratomas- bHCG and AFP | Seminomas- bHCG
140
What is the role of the white and red pulp of the spleen?
Red pulp- filtration of rbc/wbc/platelets | White pulp- Ab production
141
Causes of splenomegaly?
``` Infective- EBV, TB, malaria Portal HTN Lymphoma/leukaemia Sickle cell/thalassaemia Systemic- sacroid/amyloid/RA ```
142
Difference between staging and grading of cancers?
Staging- size and spread | Grading- differnetiation of a tumor from original cells
143
Causes of SqCC of the bladder?
Chronic inflam Schisto Catheter- long term Bladder stones
144
How does hypercalcaemia lead to groans?
Leads to increased HCL release- ulcers
145
How to Dx TB?
Active disease- biopsy + PCR, CT/CXR | Latent- quanterferon gold/mantoux test
146
Causes of granulomas?
INfective- TB/schisto/fungal | Non infective- sarcoid/RA/Crohn's
147
Types of bones?
Long vs flat Macroscopically- cortical vs cancellous Microscopically- lamellar (organised), woven (pathological/growing)

MRCS part B- JMB (10 decks)

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