TrueLearn #1 Flashcards

Question

Why is lymph node metastatis of gallbladder cancer uncommon (Less than 10%) in T1 disease? [True Learn]

Answer 1

T1 tumors have not yet invaded the subserosal layer, which contains lymphatics

Answer 2

1. Amyl nitrite 2. Sodium nitrite 3. Sodium thiosulfate [Cyanide toxicity manifests as weakness and confusion, followed by pulmonary edema. Thiocyanate levels can be checked to ensure the patient does not have a toxic level of cyanide.]

Answer 3

Manometry [It will show a hypertensive lower esophageal sphincter with failure of relaxation during swallowing. The esophageal body will show pressure above baseline, mirrored contractions with no progressive peristalsis, and low amplitude waveforms.]

Answer 4

Nodal involvement [Lymph node status is considered the most important indicator, however, nodal involvement in 5-year survivors has been documented.]

Answer 5

Cytotoxic-mediated hypersensitivity reaction associated with immunoglobulins attached to a surface antigen with subsequent complement fixation or autoantibodies attached to cell surface receptors [I.E Hashimoto's thyroiditis or Grave's disease.]

Answer 6

Rigid proctoscopy [The quality of the rectal tissue (fibrosis, friability, etc.) and its associated compliance will help determine what type of operation should be performed, and it may help to localize the fistula. CT scan, transvaginal U/S, transrectal U/S, and barium enema cannot reliably assess the condition of the rectal tissue like endoscopy can.]

Answer 7

Disseminated intravascular coagulation (DIC)

Answer 8

Interstitial cells of Cajal [Rarely, they are inherited on an autosomal dominant basis.]

Answer 9

The upper lobe of the left lung

Answer 10

McVay (or Cooper's) repair [This is because the McVay repair closes the femoral canal defect without incorporating mesh. The technique consists of approximating the transversus abdominis aponeurosis to Cooper's ligament.]

Answer 11

* Hematoma: Subcapsular, greater than 50% surface area or expanding; ruptured subcapsular or parechymal hematoma; intraparenchymal hematoma greater than or equal to 5 cm or expanding * Laceration: Greater than 3 cm parenchymal depth or involving trabecular vessels

Answer 12

Glossopharyngeal nerve (CN IX) [The upper epiglottis nerve supply is via CN IX, which provides the sensory pathway of the gag reflex.]

Answer 13

1. Abdominal pain has resolved 2. Hematocrit is stable

Answer 14

1. Impending or actual rupture 2. Symptoms (congestive heart failure, angina, aortic regurgitation, stroke, pain.) 3. Malperfusion 4. Aortic expansion greater than 1 cm/year 5. Type A Aneurysm size: Greater than 5.5 cm 6. Type B Aneurysm size: Greater than 6.5 cm

Answer 15

1. Phosphorus 2. Magnesium 3. Potassium

Answer 16

Bleomycin [Bleomycin commonly causes interstitial pneumonitis which can progress to pulmonary fibrosis. This effect is dose related and occurs in approximately 10% of patients treated with cumulative doses of greater than 350 to 400 U.]

Answer 17

80% of its final tensile strength [Final tensile strength of a wound is never as strong as the skin's pre-wound strength.]

Answer 18

Lateral or below the lower border of the pectoralis minor muscle [This includes the axillary vein, external mammary, and scapular groups Level II = superficial or deep to the pectoralis minor Level III = Medial to or above upper border of pectoralis minor]

Answer 19

Corticosteroids for 2-4 weeks or until symptoms resolve [AIP responds rapidly to steroids and therefore surgery is not necessary. AIP is rarely refractory to corticosteroids and rarely recurs, therefore lifelong corticosteroid treatment is not necessary. A minority of patients will require maintenance therapy.]

Answer 20

Ureteral stents help identify ureteral injuries once they have occured [Ureteral stents have not been definitively shown to prevent injuries, but this could change as more studies are done with new lighted stents]

Answer 21

Children 10-12 years of age or younger [The cricothyroid membrane is very delicate in this age group]

Answer 22

Yes [3 large randomized trials of postop chemoradiation have shown a survival benefit.]

Answer 23

Greater than 1.0

Answer 24

It is the formula used to calculate the total required volume of resuscitation Total volume of resuscitation = weight in Kg x % total body surface area burned x 4 [The total volume calculated is given over 24 hours with half of this volume given over the first 8 hours and the remaining half over the next 16 hours. Even when using the Parkland formula, urine output must be closely followed to determine whether fluid rates must be altered.]

Answer 25

Yes [Full thickness large bowel injuries in the setting of minimal fecal contamination should undergo simple repair. The suture line failure rate for primary repair is approximately 1%, which is less than the rate generally reported for elective colon and rectal surgery. Mortality associated with suture line failure in this setting is uncommon.]

Answer 26

The probability of obtaining a result as/or more extreme than the one observed if the null hypothesis is true [It provides a measure of inductive evidence against the null hypothesis.]

Answer 27

CT scan (63% sensitivity and 100% specificity) [Those injuries that occur without herniation may be missed but these are more common in penetrating trauma than in blunt trauma.]

Answer 28

Meckel's diverticulum [It occurs when the omphalomesenteric duct fails to close during gestation and is located along the antimesenteric border of the ileum.]

Answer 29

Cell mediated immunity [I.E. contact dermatitis such as poison Ivy contact dermatitis.]

Answer 30

* Conservative treatment * Stop narcotics * Correct electrolyte abnormalities * Bowel rest * NG tube decompression [If these measures fail, 2.5mg of neostigmine should be administered intravenously over 3 minutes. Resolution of the condition is indicated within less than 10 minutes of administration of the drug by the passage of stool and flatus.]

Answer 31

Meckel's diverticulum [2% may become symptomatic, usually within the first 2 years of life. The most common symptom in kids is bleeding. Diagnosis in the pediatric patient is with Meckel's scintigraphy (85% sensitive in pediatric patients) due to concentrated heterotopic gastric mucosa within the diverticulum. This becomes much less sensitive in the adult population due to atrophic gastric mucosa.]

Answer 32

Median sternotomy [The innominate vein can be safely ligated for better visualization. Blunt traumatic injuries can present with an avulsion at the origin with the aortic arch. These are most often repaired with a direct bypass from the arch to an area distal to the innominate injury. The injured site can then be oversewn. Rarely, patients will need to go on cardiopulmonary bypass for the procedure.] - If exposure is necessary, the incision can be extended up into the (left or right?) cervical region.]

Answer 33

1. Women undergoing a prophylactic mastectomy 2. Women with small, peripheral tumors or in situ disease [The oncological safety of NSM is unkown secondary to lack of long-term follow up data. Nipple or areolar necrosis is one of the most serious complications of this procedure. Additional complications include lack of sensation to the nipple, change in nipple pigmentation, and improper nipple positioning following reconstruction.]

Answer 34

1. Vincristine 2. Cisplatin [Vincristine can lead to constipation and hepatotoxicity.]

Answer 35

Terminal ileum [Gallstone ileus occurs secondary to inflammation that causes a fistula tract between the gallbladder and the small bowel. This tract allows the passage of gallstones into the small bowel, which can lead to an obstruction. Obstructions most commonly occur at the terminal ileum.]

Answer 36

It is treated based on the presence or absence of dysplasia * No dysplasia = Nissen fundoplication * High grade dysplasia or adenocarcinoma = Esophagectomy

Answer 37

In the space between the latissimus dorsi, the **serratus posterior inferior**, and the posterior border of the internal oblique muscle [I think serratus posterior inferior is wrong.] [SCORE: Lumbar hernias can be congenital or acquired after an operation on the flank and occur in the lumbar region of the posterior abdominal wall. Hernias through the superior lumbar triangle (Grynfeltt triangle) are more common. The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle. Less common are hernias through the inferior lumbar triangle (Petit triangle), which is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Weakness of the lumbodorsal fascia through either of these areas results in progressive protrusion of extraperitoneal fat and a hernia sac. Lumbar hernias are not prone to incarceration. Small lumbar hernias are frequently asymptomatic. Larger hernias may be associated with back pain. CT is useful for diagnosis.] [UpToDate: The superior lumbar triangle (Grynfeltt) is an inverted triangle, its base is the twelfth rib, its posterior border is the erector spinae, and its anterior border is the posterior margin of the external oblique; its apex is at the iliac crest inferiorly.] [Wikipedia: The lumbar triangle can refer to either the inferior lumbar (Petit) triangle, which lies superficially, or the superior lumbar (Grynfeltt) triangle, which is deep and superior to the inferior triangle. Of the two, the superior triangle is the more consistently found in cadavers, and is more commonly the site of herniation; however, the inferior lumbar triangle is often simply called the lumbar triangle, perhaps owing to its more superficial location and ease in demonstration. The margins of the inferior lumbar (Petit's) triangle are composed of the iliac crest inferiorly and the margins of two muscles – latissimus dorsi (posteriorly) and external abdominal oblique (anteriorly). The floor of the inferior lumbar triangle is the internal abdominal oblique muscle. The fact that herniations occasionally occur here is of clinical importance. The superior lumbar (Grynfeltt-Lesshaft) triangle is formed medially by the quadratus lumborum muscle, laterally by the internal abdominal oblique muscle, and superiorly by the 12th rib. The floor of the superior lumbar triangle is the transversalis fascia and its roof is the external abdominal oblique muscle.]

Answer 38

Cardiovascular defects [Genitourinary, gastrointestinal, skeletal, neurologic, and craniofacial defects are found with increased frequency in patients with esophageal atresia as well.]

Answer 39

The inferior thyroid artery [The inferior thyroid artery is a branch of the thyrocervical trunk which is a branch of the subclavian artery. Cervical esophageal lymphatics drain into recurrent laryngeal, paratracheal, jugular, and superior mediastinal nodes.]

Answer 40

Enterochromaffin-like cells (also known as Kulchitsky cells)

Answer 41

Administration of calcium gluconate [Cardiac complications such as ventricular fibrillation and cardiac arrest may occur with untreated hyperkalemia. Calcium stabilizes the membrane potentials an prevents further cardiac sequelae. The effect of calcium is only transient and further steps are required to correct the patient's hyperkalemia.]

Answer 42

Delayed immune hemolytic reactions [This occurs after a second transfusion (antibodies are formed after the first transfusion). Symptoms of hemolysis appear within 3 to 10 days and include fever, malaise, unconjugated hyperbilirubinemia, or a declining hemoglobin/hematocrit.]

Answer 43

1. Failure of 8 weeks of medical management 2. Large cavity over 4-6cm 3. Hemoptysis 4. Rule out malignancy

Answer 44

Symptomatic patients should be worked up and patients with persistent symptoms or an enlarging mass need to be considered for resection. [Even symptomatic patients should be managed conservatively at first as the symptoms are likely to resolve. Because FNH is a benign diagnosis, resection must be performed with minimal morbidity and mortality]

Answer 45

Wide local excision with postoperative radiation [Sentinel lymph node biopsy is indicated, especially if a total mastectomy is performed.]

Answer 46

Annular pancreas [Duodenal atresia also presents with a double bubble sign.]

Answer 47

Subtotal colectomy with ileorectal anastomosis

Answer 48

Pancreatic pseudocyst [pseudocysts have markedly elevated Amylase.]

Answer 49

Laparotomy, proximal enterotomy, stone removal, and cholecystectomy [The recommended treatment approach is surgical removal of the gallstone, and obliteration of the biliary-enteric fistula tract. A proximal enterotomy is preferred to avoid disruption of the ileocecal junction. With the proximal approach, the gallstone must be milked toward the enterotomy and then removed. Then a cholecystectomy can be performed with closure of the fistula tract in the small bowel.]

Answer 50

Early debridement and grafting

Answer 51

1. Doxorubicin 2. Daunorubicin [The anthracyclines, notably Doxorubicin and daunorubicin, are well-known causes of late-onset cardiomyopathy, characterized by increased afterload followed by development of a dilated, thin-walled left ventricle that eventually becomes poorly compliant.]

Answer 52

Continuous [Continuous doppler signal in the outflow vein indicates good flow and pulsatile signal indicates outflow obstruction.]

Answer 53

Rate control with a beta-blocker [Patients with new onset atrial fibrillation who are hemodynamically stable and have no or minimal symptoms should be treated with rate control first. The rate control agent of choice is beta-blocking agents as long as there is no evidence of underlying lung disease. Diltiazem should only be used as a first line rate control agent in the presence of severe underlying COPD or bronchospasm. Chemical cardioversion should only be used after unsuccessful attempt of rate control first. Electrical cardioversion is only indicated in hemodynamically unstable patients and those with recurrent or persistent A-fib despite unsuccessful chemical cardioversion.]

Answer 54

* Transudative: Results from a poorly balanced hydrostatic and/or osmotic pressure across the pleural membrane * Exudative: Results from inflammation or neoplastic processes that cause increased capillary leakage at the pleural membrane

Answer 55

Intraductal papillary neoplasm (IPMN)

Answer 56

Ewing Sarcoma [It often presents with a soft tissue mass, pain, fever, and weight loss. Ewing sarcomas have a classic "onion skin" periosteal reaction, and underlying bone often appears mottled.]

Answer 57

* Hematoma: Sucapsular, less than 10% of suface area * Laceration: Capsular tear, Less than 1 cm parenchymal depth

Answer 58

ERCP [The prevalence of pancreas divisum is 10-20%. Rarely it is the primary cause of pancreatitis.

Answer 59

It is also known as the brachiocephalic artery. It is the first branch off the aortic arch. [There is typically no branch arteries from the innominate artery, but the thyroid ima artery, which supplies the medial aspects of both lobes of the thyroid gland, may originate from here]

Answer 60

Core needle biopsy including the skin [This is required to rule out inflammatory breast cancer. Other possible diagnoses include mastitis or an abscess.]

Answer 61

* Lidocaine: 5mg/kg * Lidocaine + Epinephrine: 7mg/kg [Doses of lidocaine and mepivacaine can be increased to 7 mg/kg if epinephrine is added. Lower doses may be toxic if infiltrated subcutaneously. With intercostal nerve blocks, larger doses of lidocaine and mepivacaine may be tolerated if given by epidural injection.]

Answer 62

1. Appendix (45%) 2. Small bowel (28%) 3. Rectum (16%) [Carcinoid tumors occur most commonly in the appendix, but carcinoid syndrome occurs most commonly from a small bowel primary] [UpToDate: The distribution of carcinoids has shifted over time in the United States. In a report from the SEER database of 11,427 carcinoid cases treated between 1973 and 1997, the majority were located in the gastrointestinal (GI) tract (55%) and bronchopulmonary system (30%). Within the GI tract, most carcinoids arose in the small intestine (45%, most commonly in the ileum), followed by the rectum (20%), appendix (16%), colon (11%), and stomach (7%). However, since the implementation of screening colonoscopy (approximately in the year 2000), the proportion of patients diagnosed with rectal carcinoids has been greater than the proportion of those diagnosed with small intestinal carcinoids in 12 of 13 SEER registry reporting agencies. Distribution may differ in other geographic areas. As an example, colorectal carcinoids may be more frequent in the Asia/Pacific region as compared with Europe, where carcinoids are more commonly found in the stomach and ileum. An important point is that the SEER database may be inconsistent in recording tumors that are not considered "malignant" (ie, trivial gastric carcinoids that are encountered at endoscopy in patients with chronic atrophic gastritis).]

Answer 63

Primary repair of the lesion, proton pump inhibitors and H. pylori treatment [Larger perforations require a Graham patch. This is performed by placing a tension free piece of omentum over the perforation and sewing it in place with absorbable sutures to the surrounding healthy tissue. Definitive treatment with an acid reducing and drainage procedure (such as truncal vagotomy and Billroth reconstruction) should be considered in patients unlikely to comply with medical treatment postoperatively or those who developed ulceration while on acid reduction therapy]

Answer 64

Thrombotic thrombocytopenic purpura (TTP) [TTP (Moschcowitz syndrome) is characterized by widespread thrombosis of the arterioles and capillaries by hyaline membranes composed of platelets and fibrinogen. The classic pentad of symptoms includes thrombocytopenic purpura, neurologic manifestations due to microvascular disease in the brain, kidney injury or hematuria due to microvascular disease in the kidney, hemolytic anemia due to destruction of red cells, and fever. The precise etiology is unkown.]

Answer 65

Careful anatomic dissection [This procedure is associated with a considerable morbidity. Anastomotic leak rates in low anterior resections have been quoted from 10-30% which often prompts creation of diverting ostomies at the time of the operation. Urinary and sexual dysfunction may also occur. The only modality shown to reduce the risk of this complication is careful anatomic dissection at the time of surgery.]

Answer 66

MRSA infection

Answer 67

Inferior: Superior pubic ramus Lateral: Femoral vein Anterior and medial: Iliopubic tract [The femoral canal is the site of femoral hernias when a peritoneal sac protrudes through its ring. The femoral canal contains preperitoneal fat and lymph nodes. The canal is a 1-2cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis.]

Answer 68

Disseminated intravascular coagulation

Answer 69

Treatment of underlying disease [Septic patients require empiric antibiotics and resuscitation. Blood products can transiently improve the abnormal laboratory values, but the definitive treatment of DIC is to correct its cause. Even with optimal therapeutic intervention, the outcomes in patients with DIC are poor.]

Answer 70

The accessory nerve [It is cranial nerve XI and it is solely a motor nerve.]

Answer 71

Parafollicular cells of the thyroid [It acts to oppose parathyroid hormone (PTH). It is stimulated by high levels of calcium and acts to inhibit osteoclastic activity.]

Answer 72

No [Surgical treatment can be delayed until after several episodes of diverticulitis without an increase in morbidity or mortality. Surgical resection for diverticulitis mandates that the entire sigmoid is removed down to the proximal rectum (even if not diseased) to prevent possible recurrent diverticulitis in the remaining segment.]

Answer 73

A gastrointestinal stromal tumor (GIST) [GISTs are a relatively uncommon type of small bowel mass that is best demonstrated as a well-circumscribed mass on an upper GI series.]

Answer 74

Perianal abscess [Together with ischiorectal abscesses, they account for more than 90% of perianal infections. Other types of anorectal abscesses include supralevator and intersphincteric abscesses. They begin in the anal glands that surround the anal canal and empty into the anal crypts at the dentate line.]

Answer 75

It is a dopamine antagonist that acts by stimulating the release of acetylcholine

Answer 76

Mucinous cystic neoplasm (MCN) [MCNs have markedly elevated CEA. A positive mucin stain or a high viscosity reliably identify mucinous neoplasms from serous neoplasms. An intracystic CEA concentration greater than 250 ng/ml reliably differentiates mucinous from a serous neoplasm, whereas a value of less than 5ng/ml is quite sensitive for excluding a mucinous neoplasm. Other tumor markers like CA 19-9, CA 72-4, CA 125, and CA 15.3 may be present in MCN, however, their diagnostic and discriminatory values appear limited.]

Answer 77

Detorsion of the involved testicle and bilateral orchiopexy [Surgery should be performed within 4-6 hours of the onset of pain. The testicular salvage rate if detorsion is performed within 6 hours of symptoms is 97%. An orchiopexy should be performed by fixing the testicle to the scrotal wall at three points. The anatomic predisposition to torsion affects both testicles; therefore the contralateral testicle should be similarly repaired.]

Answer 78

Worse [Post op discomfort is worse with TRAM flap reconstruction because of the extent of abdominal wall dissection]

Answer 79

It acts by binding and activating motilin receptors located on smooth muscle cells in the GI tract

Answer 80

Median sternotomy [This can be modified with supraclavicular, cervical, or trapdoor incisions to gain exposure to the brachiocephalic vessels or descending thoracic aorta. When dissecting the distal arch, it is important to identify and protect both the left vagus nerve with its recurrent branch and the left phrenic nerve.]

Answer 81

1. Pyloroplasty 2. Gastric pacer implantation

Answer 82

The recurrent laryngeal nerve [The recurrent laryngeal nerve also innervates all the muscles of the larynx except the cricothyroid. Injury to an unilateral recurrent laryngeal nerve can lead to hoarseness.]

Answer 83

Withing the first 24-72 hours following the onset of thrombosis [External hemorrhoids are asymptomatic except when secondary thrombosis occurs. After 72 hours, the pain generally diminishes, and expectant treatment is all that is necessary. If operative treatment is chosen, the entire thrombosed hemorrhoid is excised under local anesthesia. Incision and drainage of the clot is avoided as this often results in re-thrombosis and worsening symptoms.]

Answer 84

Immediate hypersensitivity reaction associated with binding of antigens to IgE and subsequent mast cell and basophil degranulation

Answer 85

Streptococcus pyogenes [The diagnosis is made clinically.]

Answer 86

B12 or folic acid deficiency [Other more rare but possible causes of macrocytic anemia include: drug-induced macrocytosis, liver disease, hypothyroidism, and inherited disorders of DNA synthesis.]

Answer 87

Bladder cancer

Answer 88

Serous cystic neoplasm (SCN) [It may present with abdominal pain, nausea, vomiting, or dyspepsia, although 30% are asymptomatic. Fluid analysis obtained by endoscopic ultrasound reveals low viscosity, low CEA, and low amylase. Grossly they have thick fibrous walls and histologically they are characterized by bland, cuboidal epithelium. They are rarely malignant.]

Answer 89

Hypokalemic, hypochloremic metabolic alkalosis [This occurs secondary to the loss of hydrochloric acid and dehydration from repeated episodes of emesis.]

Answer 90

Asymptomatic patients with typical radiologic features (mass with central stellate scar) do not require treatment. Without diagnostic certainty, resection may be necessary for histologic confirmation (FNA has been recommended but is often unrevealing). [In general FNH is a benign indolent tumor. Asymptomatic patients usually remain asymptomatic for a long time. Rupture, bleeding, and infarction are extremely rare. Malignant degeneration has never been reported.]

Answer 91

4th week [Development of the human respiratory tract begins as primitive epithelial cells branch off of the ventral foregut of the embryo into the surrounding mesenchyme at the beginning of the fourth week of gestation. There are ongoing processes that involve both elongation and separation of the foregut (esophagus) and the airway (trachea). At the end of the fourth week of gestation, the esophagus and trachea have completely separated to the level of the larynx.]

Answer 92

Superficial or deep to the pectoralis minor muscle [This includes the central and interpectoral groups] Level I = Lateral or below lower border of pectoralis minor Level III = Medial to or above upper border of pectoralis minor]

Answer 93

Collis gastroplasty [A vertical incision is made in the stomach parallel to the left border of the esophagus. This effectively lengthens the esophagus. This has been shown in several series to decrease recurrence rates after anti-reflux operations with a shortened esophagus.]

Answer 94

Laparoscopic repair of the hernia with mesh [Re-approximating the fascial defect with sutures alone, carries a recurrence rate of _\>_50%, making it a poor choice to be considered of historical interest only. Only mesh-based techniques have proved to be effective with some series achieving recurrence rates of 10% or less. This can be done laparoscopically as an intraperitoneal onlay to minimize infection risk and bowel manipulation.]

Answer 95

Reimplanting the ureter back into the bladder (ureteroneocystostomy) [If extra length is needed, a psoas hitch can be performed]

Answer 96

Insulinoma [They are evenly distributed throughout the pancreas.]

Answer 97

An accidental wound that involves violation of sterile fields or gross spillage of infectious content into a previously sterile field

Answer 98

Serous cystic neoplasm (SCN) [SCNs are characterized by the absence of mucin. In contrast to other cyst-forming tumors of the pancreas (such as IPMN and MCN, SCN are almost always benign. They are usually found in the tail of the pancreas, and may be associated with von Hippel-Lindau syndrome.

Answer 99

The gastrohepatic ligament [During a nissen fundoplication, the dissection begins at the caudate lobe of the liver and moves toward the right crus of the diaphragm. After identifying the right and left crura, the lesser omentum is opened to gain access to the right crus. The gastrohepatic ligament is identified as it courses toward the diaphragm to the right crus.]

Answer 100

* Artery: Greater than 2mm without hemodynamically significant inflow stenosis * Vein: Greater than 3mm without hemodynamically significant outflow stenosis [Autogenous access is always preferred over prosthetic access due to low infection rates.]

Answer 101

1. The prolonged operating time 2. The longer inpatient hospitalization 3. The potential need for blood transfusion 4. The morbidity related to the donor site

Answer 102

Colonic pseudoobstruction (Ogilvie syndrome) [Conservative treatment followed by administration of neostigmine]

Answer 103

Pneumocystis carinii [Pneumocystis carinii infection is not only confined to the lungs, but may also be disseminated via lymphatics and hematogenous routes. Disseminated infection most commonly involves thyroid, liver, bone marrow, lymph nodes, and spleen.]

Answer 104

THE Pros: * Less thoracotomy-related morbidity * Cervical anastomosis leak has fewer complications THE Cons: * Higher anastomotic leak rate * Theoretically associated with incomplete lymph node dissection TTE Pros: * Better visualization for lymph node dissection and locoregional control * Lower rate of anastomic leak TTE Cons: * Higher risk of postop pulmonary complications and postop thoracotomy-related morbidity * Thoracic anastomosis leak is associated with more morbidity [Neither has shown a survival benefit

Answer 105

Urea breath test [After treatment, the best test for eradication of the bacteria is with a urea breath test. Testing should be delayed for four weeks to ensure reliable results. If the patient needs to be evaluated with endoscopy for concern of brisk bleeding or perforation upon initial evaluation, then the rapid urease assay is recommended for diagnosis.]

Answer 106

Type III collagen is initially present, but it gets replaced with type I collagen [A wounds final tensile strength is dependent on the type I collagen. This is reached at 8 weeks.]

Answer 107

Acetylating cyclooxygenase [This causes permanent dysfunction of the platelets over the span of their 7 day existence. These qualitative defects can be measured by abnormal bleeding times.]

Answer 108

An accessory left hepatic artery originating from the left gastric artery [Care must be taken during this dissection to avoid inadvertent division of a replaced left hepatic artery. When this anomaly occurs, the primary arterial blood flow to the left lobe of the liver traverses this tissue.]

Answer 109

Greater than 75% [The rest is derived primarily from the medial aspect of the breast, flows through the lymph vessels that accompany the perforating branches of the internal mammary artery, and enters the parasternal (internal mammary) group of lymph nodes.]

Answer 110

The first rib and scalene muscles

Answer 111

1. Heart failure 2. New onset heart block 3. Persistent sepsis 4. Dehiscence of the valve 5. Systemic embolism 6. Fungal infection

Answer 112

Less than 0.7

Answer 113

Prior surgery [Multiple reoperations have a risk of mortality odds ratio of 4.19. First reoperation odds ratio is 2.76.]

Answer 114

Excision of the overlying nail and oral antibiotics

Answer 115

Balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube

Answer 116

Simple mastectomy, sentinel lymph node biopsy, and postoperative radiation [Wide local excision is still an option. Comedo subtype of DCIS is associated with a more aggressive cancer the is more likely to recur and have multicentric disease]

Answer 117

Dobutamine [It decreases the afterload in addition to its inotropic effect.]

Answer 118

Positive cultures from blood, bone marrow, spleen, or liver [Sending two separate blood samples will achieve a diagnosis in 99% of cases. In early disease, bone marrow biopsy with culture may be the most sensitive test]

Answer 119

Circulating antigen-antibody reactions with subsequent complement fixation [I.E. serum sickness]

Answer 120

E. Coli [Other causative organisms include proteus, klebsiella, enterococcus, and staphylococcus saprophyticus.]

Answer 121

No [It provides no protection against microbial colonization of burn eschar.]

Answer 122

Fibromuscular dysplasia [Typically renal artery stenosis causing hypertension in a young female is caused by fibromuscular dysplasia.]

Answer 123

* Type A: All dissections that involve the ascending aorta * Type B: Dissections that originate in the descending thoracic and thoracoabdominal aorta.

Answer 124

Abdominal xray [This study can show evidence of an obstruction, as well as pneumobilia, and possibly the obstructing stone itself.]

Answer 125

Metabolic acidosis [It can cause pain on application, and as a carbonic anhydrase inhibitor, it can cause metabolic acidosis. Sulfamylon is used to treat intermediate- and deep-thickness burns, traditionally when cartilage is exposed or with threatening exposure (I.E. ear burns). It provides broad spectrum antimicrobial coverage and it penetrates eschars.]

Answer 126

The physician [If the patient needs an urgent operation, it is recommended that the surgeon first seek the opinion of another surgeon and that this consultation is documented. If there is not enough time even to seek a second opinion then implied consent should be accepted and the patient should proceed to the operative room without delay. Ultimately the decision must be made in the best interest of the patient and this burden will likely fall onto the shoulders of the surgeon.]

Answer 127

Yes. Up to 10% of patients will have invasive cancer in the mastectomy. [Once the breast is gone, a SLNB cannot be performed for staging. If SLNB is not performed at the time of the mastectomy, a full axillary lymph node dissection would have to be performed if the specimen showed invasive cancer]

Answer 128

Mucinous cystic neoplasm (MCN) [Fluid analysis reveals high viscosity, elevated CEA, and low amylase. Grossly, they do not communicate with pancreatic ducts, are multiloculated and microscopically characterized by tall, columnar epithelium surrounded by ovarian like stroma. MCNs are malignant in 10-50% of cases.]

Answer 129

1. Cirrhosis 2. Pregnancy 3. Poor cardiopulmonary status [Splenomegaly, although more challenging, can be safely performed laparoscopically by the experienced surgeon.]

Answer 130

1. Saliva: 1500 ml 2. Stomach: 1000-2000 ml 3. Bile: 500 ml 4. Pancreas: 1500 ml 5. Small bowel: 1500 ml

Answer 131

Doxycycline

Answer 132

Fibrothorax [This can result in chronically diminished pulmonary function, pain, and dyspnea]

Answer 133

Hyponatremia and hypochloremia [Since concentrated silver nitrate causes a chemical burn, the bacteriostatic solution used for burn wounds is very hypotonic (it is reconstituted in water rather than saline to avoid silver chloride precipitation) and causes osmotic dilution in the tissues, leading to hyponatremia and hypochloremia.]

Answer 134

Urgent incision and drainage [To avoid necrosis of the septal cartilage]

Answer 135

Epstein-Barr Virus (EBV) positive B-cells [While the symptoms can be vague and non-descript, they most commonly include fever, lymphadenopathy, and bowel obstruction. Syndromes can range from mononucleosis like illness to widespread lymphoma. A high clinical index of suspicion must be maintatined in the transplant population. PTLD results from the immortalization of EBV positive B-cells. Quantitative polymerase chain reaction measurement demonstrates a rising viral load of EBV. In the lung transplant population, PTLD typically occurs within the first year.]

Answer 136

1. Deoxycholic acid 2. Lithocolic acid [Primary bile acids are synthesized in the liver from cholesterol precursors. Primary bile acids include cholic acid and chenodeoxycholic acid.]

Answer 137

Bleeding time

Answer 138

The ipsilateral side [The hypoglossal nerve innervates the muscles of the tongue and is solely a motor nerve. It functions to control tongue protrusion.]

Answer 139

Mucinous cystic neoplasm [Overall, most (85%) pancreatic cysts are not neoplastic. Neoplastic pancreatic cysts include serous cystic neoplasms, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary tumors. All neoplastic cysts of the pancreas have malignant potential to varying degrees.]

Answer 140

1. Painless bleeding 2. Protrusion [Pain is rarely associated with internal hemorrhoids because they originate above the dentate line in insensate rectal mucosa. Contrary to popular belief, hemorrhoids are not related to the superior hemorrhoidal artery and vein, to the portal vein, or to portal hypertension.]

Answer 141

Hypernatremia [Typically, this is a consequence of inadequate replacement of insensible water loss.]

Answer 142

Duct of Wirsung is drained via the major papilla Duct of Santorini is drained via the lesser papilla [In pancreatic divisum, the duct of Wirsung drains the uncinate process and part of the head of the pancreas. The duct of Santorini drains the head, body and tail of the pancreas.]

Answer 143

Tumor thickness is 1mm or more

Answer 144

Close to 100% [Survival of resection is dependent on nodal status and depth of penetration. Survival for a simple cholecystectomy for T1 disease is nearly 100%. 5-year survival rates for patients with T2 and T3 tumors without nodal disease are greater than 50%.]

Answer 145

1. Iron deficiency 2. Thalassemia 3. Sideroblasts 4. Lead poisoning

Answer 146

Retyping and screening the patient's blood

Answer 147

Internal laryngeal nerve [This is a branch of the superior laryngeal nerve (which is a branch of the vagus nerve). Below the vocal folds, the sensory innervation of the larynx is provided by branches of the recurrent laryngeal nerve. The vocal fold itself receives innervation from both nerves.]

Answer 148

Yes [Adenomatous polyps include tubular, tubulovillous, and villous polyps. They all have an increased risk for malignancy. Hyperplastic polyps, however, are benign.]

Answer 149

1. Low grade dysplasia = 16% 2. High grade dysplasia = 4% 3. Adenocarcinoma = 2%

Answer 150

Hereditary pancreatitis [Though several gene mutations are associated with hereditary pancreatitis, a mutation in the cationic trypsinogen gene, PRSS1, is diagnostic for hereditary pancreatitis. This is true even in the absence of clinical and radiographic findings of acute or chronic pancreatitis.]

Answer 151

Yes [Lifetime surveillance is essential. Recurrences are reported as late as 9 years postoperatively; this is not surprising, because surgical intervention does not cure a viral infection.]

Answer 152

Superficial- and intermediate-thickness burns covering a large % of total body surface area [It provides broad spectrum antimicrobial coverage, but it does not penetrate eschars.]

Answer 153

Neostigmine

Answer 154

Li-Fraumeni syndrome [The classical LFS malignancies include sarcoma, cancers of the breast, brain and adrenal glands. These comprise about 80% of all cancers that occur in this syndrome.]

Answer 155

1. Methylene blue tampon test 2. Vagina "bubble" test 3. CT with IV and rectal contrast 4. Barium enema

Answer 156

MRA [Ultrasound can demonstrate characteristics such as hypoechoic, heterogenous lesions, but MRA is the best imaging modality to analyze plaque irregularities and intra-plaque hemorrhages. The downside is the increased time and cost. The overall clinical implications of analyzing plaque morphology is still being evaluated, and therefore MRA is still mainly used on an investigation basis. If plaque characteristics begin to alter surgical treatment strategies institutionally, MRA may play a larger role in the work up of carotid disease in the future.]

Answer 157

Achalasia [Patients can sometimes have retrosternal chest pain from retained food in the esophagus. Aspiration can result in the late phase of the disease with pulmonary complications. Esophagram will show a dilated esophagus with distal narrowing showing a bird's beak appearance.]

Answer 158

Renal cell carcinoma [It is always clear cell type]

Answer 159

Autosomal dominant [It is a disease characterized by a deficiency of spectrin in the erythrocytes, making them more fragile as they pass through the spleen. Ultimately, the cells get trapped and are destroyed, leading to anemia, reticulocytosis, and possibly jaundice.]

Answer 160

Esophageal Leiomyoma [Leiomyomas account for roughly 2/3 of all benign tumors of the esophagus. Approximately 80% are located intramurally and originate in the muscularis propria. 90% are found in the middle and lower esophagus, reflecting the relative paucity of smooth muscle in the upper esophagus.]

Answer 161

Longitudinal duodenotomy and minor papilla sphincteroplasty [Only 5-10% of people with pancreas divisum will have pancreatitis. Common etiologies of pancreatitis are more likely to cause pancreatitis than pancreas divisum even among patients who have pancreas divisum. Specific treatment for pancreas divisum starts with endoscopic minor papillotomy and pancreatic duct stenting and may progress to surgical longitudinal duodenotomy and minor sphincteroplasty if endoscopic therapies fail.]

Answer 162

Wide local excision with thorough assessment of the excision margin is mandatory to prevent local recurrence [Adjuvant radiation for soft tissue sarcoma is indicated for tumors that are high-grade or more than 5 cm in size. Dermatofibrosarcoma is a tumor that arises from the fibroblasts in the dermis. It is associated with microscopic lateral extension; therefore, thorough margin assessment during excision is needed to prevent tumor recurrence. Multiple excisions may be required and reconstruction with tissue flap or skin graft is often needed.]

Answer 163

The recurrent laryngeal nerve [The recurrent laryngeal nerve is primarily a motor nerve. Injury to an unilateral recurrent laryngeal nerve can lead to hoarseness.]

Answer 164

CT scan [This is the most sensitive test to confirm a SBO (more sensitive and specific than an abdominal xray). CT scans are also helpful in bein able to look for signs of strangulated or infarcted bowel, which include wall thickening, pneumatosis, or swirling of the mesentery. The findings on the CT scan will help to guide initial treatment down the surgical or non-operative pathways.]

Answer 165

Anaphylaxis

Answer 166

The power is the probability of rejecting the null hypothesis when it is, in fact, false [Alternatively, it is the ability of a study to detect a true difference when one exists. It is directly related to the sample size of the population and is dependent on the magnitude of difference that one would like to detect. Power = 1 - chance of type II error]

Answer 167

Posterolateral thoracotomy [The patient is positioned in the right lateral decubitus. The pelvis is slanted posteriorly to allow access to both femoral vessels. A posterolateral thoracotomy in the fourth intercostal space provides sufficient access to the aorta. A thoracoabdominal incision may be required to access the abdominal aorta in the case of visceral malperfusion. This may be performed through either a transperitoneal or a retroperitoneal approach.]

Answer 168

The jejunum [Biopsies of a GIST should be avoided to prevent bleeding or spread of the neoplasm to distant areas and are usually not required because management is generally resection.]

Answer 169

Mid proximal phalanx [2 cm margins are needed which is not compatible with preserving the middle phalanx.]

Answer 170

1. Insulinoma: 10% 2. VIPoma: 50% 3. Gastrinoma: 70% 4. Somatostatinoma: Greater than 90% 5. Glucagonoma: Greater than 90%

Answer 171

Roughly 50% [True Paget's disease of the perianal skin must be distinguished from downward intraepidermal spread of a signet-ring cell adenocarcinoma of the rectum, which it resembles histologically. A complete colonoscopy with a thorough examination of the rectum and anal canal should be performed.]

Answer 172

Standard error of the mean (SEM) [This is an estimate of the precision and uncertainty of how the sample represents the underlying population being studied.]

Answer 173

The proto-oncogene c-KIT [This is a tyrosine kinase receptor.]

Answer 174

1. Intravenous volume replacement with isotonic fluids 2. Intravenous steroid replacement therapy with dexamethasone [Acute adrenal insufficiency (Addisonian Crisis) usually manifests as shock in a patient with undiagnosed chronic adrenal insufficiency who has been subjected to physiologic stress. Hydrocortisone acetate is detected in laboratory measurement for cortisol so dexamethasone should be used for replacement of glucocorticoid function until ACTH testing is complete. Thereafter, 100mg of hydrocortisone is administered intravenously every 6-8 hours and is tapered to standard replacement doses as the patient's condition stabilizes.]

Answer 175

Less than 2 cm in size (without involvement of the base or mesoappendix) [30-60% of lesions greater than 2 cm in diameter are associated with nodal or distant metastases. Thus, right colectomy is recommended for tumors that are larger than 2 cm, have mesoappendiceal invasion, or have lymphovascular invasion. Carcinoid tumors have an excellent prognosis and low likelihood of metastatic disease.]

Answer 176

Leukopenia [This is typically self-limited and necessitates no change in therapy. It may also cause irritation in those with sulfa allergy.]

Answer 177

Cyclophosphamide [It can also cause alopecia, bladder fibrosis, and should be used cautiously in younger patients because of its potential to cause infertility and leukemia.]

Answer 178

1. Failure of medical management (persistent or recurrent pain or medically uncontrolled hypertension) 2. Expanding aortic diameter 3. Progressive dissection 4. Impending or actual rupture 5. Malperfusion [Most patients with acute type B aortic dissections survive the acute and subacute phases with medical management alone. However, approximately 20-30% of patients present with complicated type B dissection, which require urgent operative (surgical or endovascular) intervention. Complicated dissection can be defined as imminent or actual aortic rupture, aortic expansion, hemodynamic instability, persistent pain despite medical management, drug-resistant hypertension, and malperfusion syndrome. The most frequent causes of death in acute type B dissection are aortic rupture and visceral malperfusion.]

Answer 179

Diverticulae become inflamed secondary to obstruction of the tic which leads to venous congestion [The tic can then perforate which is often contained within the pericolic mesentery. More severe cases cause a focal or distant abscess, and may also lead to frank perforation of the colon with fecal peritonitis. More aggressive courses of diverticulitis are seen with younger males. Western diets low in fiber have an increased prevalence of diverticulitis. Colonoscopy should be performed in 6 weeks after the inflammation resolves to rule out malignancy. Diverticulitis is most common at the sigmoid colon.]

Answer 180

Splenic hilum [The other most common locations from most to least common include: Splenic pedicle, greater omentum, tail of the pancreas, and splenocolic ligament.]

Answer 181

Primary repair or vein patch [Larger injuries should have patch repairs to avoid post-repair stenosis. Ligation of the common iliac artery is avoided even in an unstable patient because of the high risk of limb loss. If a large segment is missing and the patient requires a more complicated procedure, shunts can be placed until the patient is stabilized. Then a definitive repair can be performed under more stable conditions.]

Answer 182

Splenectomy and cholecystectomy [Children are advised to delay splenectomy until after the age of 5 to allow their immune system to fully develop. All patients should have an ultrasound performed preoperatively to rule out gallstones so that a cholecystectomy can be performed at the same time as the splenectomy when indicated.]

Answer 183

Yes [A recent study suggests that adjuvant chemotherapy may offer benefit for patients with resected gallbladder cancer; however, a large scale study is required before definitive conclusions can be drawn regarding outcomes. There is no data in the literature to support the use of neoadjuvant chemotherapy or radiation in the treatment of patients with gallbladder cancer.]

Answer 184

Hypertension [Other causes are ischemic heart disease, diabetes, hypertrophic and restrictive cardiomyopathy. Diastolic heart failure is associated with normal ejection fraction and diastolic dysfunction.]

Answer 185

Papillary tumors [These tumors typically grow on the gallbladder lumen. Gallbladder cancer that has grade and vascular invasion is indicative of a poor prognosis.]

Answer 186

8 weeks [At 8 weeks, the wound is 100% of its final tensile strength, which correlates to about 80% of its pre-wound tensile strength.]

Answer 187

Intraoperative cholangiogram should be performed by injection of contrast into the infundibulum of the gallbladder.

Answer 188

Supportive care and pain control [1st-degree burns are very superficial and they do not involve the dermal appendages. They heal without scar formation and do not require debridement and grafting.]

Answer 189

Superficial- and intermediate-thickness burns (second and small third degree burns) [It provides broad spectrum antimicrobial coverage, but it does not penetrate eschars.]

Answer 190

Salivary duct carcinoma [Salivary duct carcinoma is physiologically similar to high grade carcinoma of the breast. They express androgen receptors and in 15% of cases, HER2. Adjuvant hormone therapy can be used following surgery or primarily for disseminated disease. High grade mucoepidermoid, adenoid cystic, and advanced acinic cell carcinomas are treated with adjuvant RADIATION therapy.]

Answer 191

* Grade I = Bleeding without prolapse * Grade II = Prolapse that spontaneously reduces * Grade III = Prolapse requiring manual reduction * Grade IV = Irreducible prolapse

Answer 192

* The major (or oblique) fissure separates the lower lobe from the middle lobe * The minor fissure separates the middle lobe form the upper lobe

Answer 193

1. Calcium gluconate 2. Calcium chloride [A 10ml ampule of 10% calcium gluconate contains 93mg elemental calcium. The same of calcium chloride contains 232mg elemental calcium. Either can be administered in 50-100ml D5W over 10-15 minutes to treat severe hypocalcemia. Calcium carbonate is administered orally.]

Answer 194

Femoral hernia [Femoral hernias have the highest risk of strangulation. The risk has been estimated between 15-20%. Because of this, all femoral hernias should be repaired, even if asymptomatic.]

Answer 195

Intraductal papillary mucinous neoplasm (IPMN) [IPMN communicate with the pancreatic ducts and are subdivided into main duct, branch duct, or mixed duct IPMN. Microscopically they are characterized by tall, columnar mucin producing epithelium on papillary projections and no ovarian like stroma. They range from benign to malignant and are considered a disease of the entire pancreas.]

Answer 196

The acceptance of the null hypothesis when in fact, the null hypothesis is false.

Answer 197

Thrombin and plasmin [Laboratory values will show an elevated INR, aPTT, thrombocytopenia, and an increased bleeding time]

Answer 198

Reduction in immunosuppression

Answer 199

Acute subdural hematoma [It results from tearing of bridging veins. It does not cross the midline.]

Answer 200

Interstitial cells of Cajal

Answer 201

Ultrasound [This has high sensitivity and specificity in the diagnosis of inguinal hernias. CT scan can also be useful especially in the diagnosis of unusual hernias or in the case of atypical presentation.]

Answer 202

Medial to or above the upper border of the pectoralis minor muscle [This includes the subclavicular group Level I = Lateral or below lower border of pectoralis minor Level II = superficial or deep to the pectoralis minor]

Answer 203

3 to 10 days after a second transfusion [It presents with signs/symptoms of hemolysis.]

Answer 204

Adenocarcinoma [The 3 subtypes are papillary, nodular, and tubular. Squamous cell carcinomas are rare and occur in less than 5% of cases. Anaplastic lesions occur in around 10% of cases.]

Answer 205

The rejection of the null hypothesis when in fact, the null hypothesis is true.

Answer 206

A sterile wound with no source of infection present other than potential skin contaminants

Answer 207

intermediate- and Deep-thickness burns, traditionally when cartilage is exposed or with threatening exposure (I.E. ear burns) [It provides broad spectrum antimicrobial coverage and it penetrates eschars.]

Answer 208

Preformed antibodies by the recipient against the donor [The antibodies bind to the graft's vascular endothelium and activate the compliment cascade. This leads to a dark, swollen graft which undergoes ischemic necrosis. It is minimized by preoperative crossmatching, which uses microcytotoxicity or flow cytometry to assess the recipient's serum for the presence of preformed antibodies against donor cells.]

Answer 209

1. Proper irrigation with iodine solution 2. Debridement if necessary 3. Antimicrobial coverage 4. Tetanus booster [Amoxicillin/Clavulanic acid is most appropriate for non-complicated wounds. Vaccination for corynebacteria is included in the tetanus vaccination. For severe cases, the patient should be admitted for IV antibiotics. IV antibiotic therapy includes, cefoxitin, cefotetan, or piperacillin-tazobactam.]

Answer 210

Human herpesvirus 8 (HHV-8) [It typically presents as asymptomatic, elliptical, linear, cutaneous lesions of the legs, face, oral cavity, and genitalia. The color of the lesions typically changes from light brown to violet.]

Answer 211

Carcinoid tumor [Most commonly found in the ileum. The tumor can release serotonin and other neuroendocrine metabolites into the bloodstream that are cleared by the liver. Patients do not typically exhibit symptoms of carcinoid syndrome (flushing, diarrhea, bronchospasm, and right sided heart failure) unless they have metastasis to the liver.]

Answer 212

25-30% [Over transfusion may worsen portal hypertension]

Answer 213

Repeat endoscopy in 1-2 years [10-20% of patients with newly diagnosed cirrhosis are found to have large varices on screening endoscopy. Nonselective beta blockers or endoscopic variceal ligation should be considered in patients with large varices. If no varices are detected at the initial endoscopy, then a repeat endoscopy should be carried out in 2-3 years.]

Answer 214

A traumatic wound that has a significant delay in attaining treatment, oftentimes including areas of necrosis or frank purulence

Answer 215

Right colectomy [Ileocecectomy is not an oncologically sound surgical option and is reserved for cases that involve clearly benign pathology. Systemic chemotherapy has failed to demonstrate a role for carcinoid tumors even when associated with metastatic disease.]

Answer 216

Solid pseudopapillary tumor (SPT) [Microscopically, SPT demonstrate polygonal epithelial cells.]

Answer 217

1. 5-FU 2. Leucovorin 3. Oxaliplatin [This is known as the FOLFOX therapy, and has shown to increase survival in patients with stage III colon cancer.]

Answer 218

Tracheal-esophageal groove in the posterior superior mediastinum (27%) [The anatomy of the parathyroid glands is fairly consistent, however, anatomical variations can occur.]

Answer 219

Medullary thyroid cancer [Calcitonin is released from parafollicular cells of the thyroid.]

Answer 220

Neostigmine [The main side effect of neostigmine is bradycardia - Atropine should be readily available.]

Answer 221

Autosomal recessive Familial (MYH-associated) adenomatous polyposis [This is an inherited condition in which numerous adenomatous polyps form mainly in the epithelium of the large intestine.]

Answer 222

A sterile wound that requires opening of nonsterile hollow viscus organ without significant spillage of infectious contents

Answer 223

An epidural hematoma [It results from injury to the middle meningeal artery. It does not cross any suture lines]

Answer 224

Nutcracker esophagus [Also known as hypertensive peristalsis. Normal progressive contractions, LES pressure and relaxation, but hyperperistalsis in duration (longer than 6 seconds) or pressure (greater than 180 mmHg).]

Answer 225

No [Silver sulfadiazine does not penetrate eschar and is thus ineffective against established burn wound infections.]

Answer 226

Presence of ascending aortic involvement is an indication for operative management [The goals of surgery in acute type A dissection are to prevent or treat an aortic catastrophe while restoring blood flow to the true lumen of the aorta. Aortic catastrophe includes aortic rupture into the pericardium or pleural space, dissection and occlusion of the coronary ostia, and progression to aortic valvular incompetence. The presence of ascending aortic involvement is therefore an indication for operative management in all but the highest-risk patients.]

Answer 227

Transverse Rectus Abdominus Muscle (TRAM) flap [The TRAM flap is based on the superior epigastric artery and vein as the flap's blood supply. The main disadvantages of this procedure are the prolonged operating time, the longer inpatient hospitalization, the potential need for blood transfusion, and the morbidity related to the donor site.]

Answer 228

Chronic subdural hematoma [Chronic subdural hematomas fade to a density similar to CSF on CT scan]

Answer 229

ERCP, sphincteroplasty, and stent placement [Open sphincteroplasty is considered for refractory cases. Pancreatic divisum usually remains asymptomatic, but can present with pancreatitis from obstruction at the lesser papilla. It results from failure of fusion of the ventral and dorsal pancreatic ducts.]

Answer 230

Leakage of splanchnic lymph due to portal venous congestion [Cirrhosis of the liver causes fibrosis of the hepatocytes leading to portal hypertension and congestion. As a result, the hepatic and splanchnic lymphatic beds become overloaded and begin to leak lymph into the peritoneum, thereby causing ascites. Albumin is often given to replace drained ascites because of the protein content of the lymphatic fluid.]

Answer 231

Numerical grade of splenic injury + 2 weeks [The common recommendation for high grade injuries is 6 weeks.]

Answer 232

Kayexylate

Answer 233

Serology testing for IgG [The most accurate method for detecting H. pylori infection is with a histological examination from two sites after endoscopic biopsy, combined with either a rapid urease test or microbial culture, however, biopsy is invasive. All patients presenting with signs of peptic ulcer disease need to be worked up for H. Pylori. In patients who are stable and do not warrant an endoscopic evaluation, confirmation of H. Pylori can best be achieved with serologic studies. This method has high sensitivity and specificity, is cost effective, and is the least invasive.] [UpToDate: The diagnosis of H. pylori can usually be established during endoscopy by one of three methods: biopsy urease test, histology, and, less commonly, bacterial culture. Choosing among these tests depends upon the clinical circumstance, the accuracy of the tests, and the relative costs. Endoscopy is not indicated solely for the purpose of establishing H. pylori status. A variety of noninvasive tests for the diagnosis of H. pylori are available. These include urea breath testing (UBT), stool antigen testing, and serology. In the past, post-treatment testing was recommended only for patients with complicated ulcer disease or with persistent or recurrent symptoms. However, because the costs of noninvasive stool and breath tests have fallen and because antibiotic resistance is increasing, it is now reasonable to confirm eradication of infection in all patients four to six weeks following treatment, although guidelines vary as to when such confirmation is recommended. Laboratory-based serologic testing using ELISA technology to detect immunoglobulin G (IgG) antibodies is inexpensive, noninvasive, and well suited to primary care practice. However, concerns over its accuracy have limited its use. Large studies have found uniformly high sensitivity (90% to 100%), but variable specificity (76% to 96%); the accuracy has ranged from 83% to 98%. Serologic tests require validation at the local level, which is impractical in routine practice. Local prevalence of H. pylori affects the positive predictive value (PPV) of antibody testing. In areas where the prevalence of H. pylori is less than 20%, as in much of the United States, a positive result on serologic testing represents active infection approximately 50% of the time. As the low accuracy of serology would result in inappropriate treatment in significant numbers of patients, guidelines recommend that serologic testing should not be used in low prevalence populations; testing for active infection with stool antigen assay or UBT is recommended in these populations. RECOMMENDATION - In patients who do not require endoscopic evaluation for evaluation of new onset dyspepsia (those under age 55 who do not have alarm symptoms), initial diagnosis of H. pylori should be made with a test for active infection (stool antigen or urea breath test). Serology, as it cannot differentiate between past or current infection and has a low positive predictive value in much of the United States, is not recommended in patients with a low pre-test probability. Endoscopic biopsy should be reserved for patients who are undergoing a diagnostic endoscopy and are found to have an ulcer and for those who require endoscopy to follow up a gastric ulcer or for the diagnosis or follow-up of suspected MALT lymphoma. Biopsy urease testing can be performed in patients not taking antibiotics or a proton pump inhibitor when histopathology is not required. We suggest confirmation of eradication because of the availability of accurate, relatively inexpensive, noninvasive tests (stool and breath tests) and because of increased resistance to antibiotic therapy, at least 4 weeks after treatment.]

Answer 234

Orchiectomy and retroperitoneal radiation [Patients with a seminoma have normal AFP levels, but may have an elevation in the beta-HCG. Even with no evidence of lymph node metastasis on imaging, micrometastasis cannot be ruled out and radiation therapy is still indicated.]

Answer 235

* High risk: Active bleeding or a visible vessel * Intermediate risk: Adherent clot * Low risk: Ulceration with a black spot or with a clean base

Answer 236

1. Preoxygenation 2. Fentanyl 3. Etomidate 4. Succinylcholine 5. Head extension

Answer 237

In the space bounded by the latissimus dorsi posteriorly, the iliac crest inferiorly, and the posterior border of the external oblique muscle anteriorly [SCORE: Lumbar hernias can be congenital or acquired after an operation on the flank and occur in the lumbar region of the posterior abdominal wall. Hernias through the superior lumbar triangle (Grynfeltt triangle) are more common. The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle. Less common are hernias through the inferior lumbar triangle (Petit triangle), which is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Weakness of the lumbodorsal fascia through either of these areas results in progressive protrusion of extraperitoneal fat and a hernia sac. Lumbar hernias are not prone to incarceration. Small lumbar hernias are frequently asymptomatic. Larger hernias may be associated with back pain. CT is useful for diagnosis.] [UpToDate: The superior lumbar triangle (Grynfeltt) is an inverted triangle, its base is the twelfth rib, its posterior border is the erector spinae, and its anterior border is the posterior margin of the external oblique; its apex is at the iliac crest inferiorly.] [Wikipedia: The lumbar triangle can refer to either the inferior lumbar (Petit) triangle, which lies superficially, or the superior lumbar (Grynfeltt) triangle, which is deep and superior to the inferior triangle. Of the two, the superior triangle is the more consistently found in cadavers, and is more commonly the site of herniation; however, the inferior lumbar triangle is often simply called the lumbar triangle, perhaps owing to its more superficial location and ease in demonstration. The margins of the inferior lumbar (Petit's) triangle are composed of the iliac crest inferiorly and the margins of two muscles – latissimus dorsi (posteriorly) and external abdominal oblique (anteriorly). The floor of the inferior lumbar triangle is the internal abdominal oblique muscle. The fact that herniations occasionally occur here is of clinical importance. The superior lumbar (Grynfeltt-Lesshaft) triangle is formed medially by the quadratus lumborum muscle, laterally by the internal abdominal oblique muscle, and superiorly by the 12th rib. The floor of the superior lumbar triangle is the transversalis fascia and its roof is the external abdominal oblique muscle.]

Answer 238

* Hematoma: Subcapsular, 10-50% of surface area, intraparenchymal, less than 5 cm in diameter * Laceration: Capsular tear, 1-3 cm parenchymal depth that does not involve a trabecular vessel

Answer 239

Segmental ileal resection to include the diverticulum as well as the ulcer [The ulcer is usually opposite the diverticulum in the ileal mucosa. segmental ileal resection is performed as a V-shaped diverticulectomy and transverse closure of the ileum.]

Answer 240

1. Correct coagulopathy and infuse vasopressin and nitroglycerin (to prevent ischemia) * Octreotide and a PPI can also be administered 2. EGD with sclerotherapy and banding 3. Balloon tamponade with Sengstaken-Blakemore tube or Minnesota tube 4. Surgical shunt or TIPs

Answer 241

1. Cholic acid 2. Chenodeoxycholic acid [Secondary bile acids are formed by deconjugation of primary bile acids by intestinal bacteria. Secondary bile acids include deoxycholic acid and lithocolic acid.]

Answer 242

No [Omphaloceles large in size are best observed initially with the overlying membrane used as a temporary silo. Actual repair is delayed until a feasible intra-abdominal domain is developed. Defects may be either closed primarily or repaired with any of several staged approaches, depending on their size.]

Answer 243

Proton pump inhibitor [Type I hernias, which are also known as sliding hernias, are treated with medical management. Surgical correction is necessary for types II, III, and IV hernias due to the risk of a volvulus.]