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Clin Path > Week 11 > Flashcards

Week 11 Flashcards

1
Q

Dietary Reference Intakes (DRIs)

A

1) RDA (Recommended Dietary Allowance): Meets the nutrient needs of 97-98% of a particular population

2) EAR (Estimated Average Requirement): Meets the nutrient needs of 50% of a population

3) AI (Adequate Intake): Target intake level based on people’s dietary intake

4) UL (Upper intake Level): Higher nutrient intake than this would be harmful

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2
Q

Macronutrients

A

1) Carbohydrates (4 kcal/g): provide energy for the body, specifically for the brain and muscles.

2) Proteins (4 kcal/g): help build and repair tissues and provide essential amino acids.

3) Fats (9 kcal/g): necessary structural component of every cell. They help protect internal organs against injury, and provide many essential nutrients.

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3
Q

Recommended Carb intake (Sedentary 70kg person)

A

300g or 40-50% of total daily calories

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4
Q

Recommended Carb intake (physically active person)

A

400-600g or 60% of total daily calories

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5
Q

Recommended carb intake (athlete)

A

70% of total daily calories (8-10g per kg body mass)

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6
Q

Daily recommended lipid intake

A

20-30% of total daily kcal (carries with lipid type)

Ex: . Substitute foods high in saturated fatty acids with fruits, vegetables, whole grains, fish, poultry, and lean meat

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7
Q

Recommendations for protein intake

A

1) Adults: 0.8 g/kg of body weight per day
2) Sedentary: 0.364 g/lb of body weight per day
3) Athlete: have higher requirements to synthesize muscle tissue and contribute to the energy pathways
Ex: Endurance athlete (1.2-1.4 g/kg of body weight), Resistance trained athlete (1.4-1.8 g/kg of body weight)

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8
Q

Malnutrition

A

1) Overnutrition: ex: obesity
2) Undernutrition: ex: lacks calories, proteins or other nutrients needed for maintenance and repair

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9
Q

Malnutrition (Diagnosis)

A

Requires 2 of the following:

*Insufficient energy intake
*Weight loss
*Loss of muscle mass
*Loss of subcutaneous fat
*Localized or generalized fluid accumulation (may mask weight loss)
*Diminished functional status measured by hand-grip strength

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10
Q

Starvation related malnutrition

A

Inflammation NOT present
Pure chronic starvation
Anorexia Nervosa

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11
Q

Chronic disease related malnutrition

A

Inflammation IS present (mild)
Organ failure
Pancreatic cancer
Sarcopenic obesity
Rheumatoid arthritis

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12
Q

Acute disease or injury related malnutrition

A

Inflammation IS present (marked, inflammatory response)
Major infection
Burns
Trauma
Closed head injury

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13
Q

Obesity

A

excessive accumulation of body fat that contributes to numerous chronic diseases as well as early mortality and morbidity.

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14
Q

Common measures to define obesity in adults

A

1) BMI: Overweight (BMI > 25 kg/m2), Obese (BMI > 30 kg/m2), Morbid obesity (BMI > 40 kg/m2)

2) Waist circumference

3) Waist to hip ratio: associated with increased risk of MI (85% for women, 90% for men)

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15
Q

Obesity risk factors

A

1) sedentary lifestyle
2) high glycemic diet
3) underlying illness
4) genetic disorder
5) familial and biological factors
6) medications
7) environmental or psychological behavioral factors

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16
Q

Obesity pathogenesis

A

1) Neuroendocrine dysfunction – spontaneous genetic mutations that impair CNS signaling cause disrupted food intake and weight management.

2) Hormonal dysfunction – impaired cortisol secretion, insulin resistance, elevated BP, and visceral accumulation of body fat

3) Energy dysregulation – Obese people may have fewer ATPase pumps expending less energy

4) Adipose cell theory – obease people inherently have excessive number and larger fat cells, with elevated lipoprotein lipase (helps fat be deposited into adipocytes).

5) Microbial theory – gut microflora has improved ability to extract and store energy from ingested food

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17
Q

Obesity complications

A
  • Metabolic syndrome
  • Type 2 diabetes mellitus
  • Liver diseases
  • Osteoarthritis
  • Sleep apnea
  • Atherosclerosis; hypertension; cardiovascular diseases
  • Stroke
  • Asthma
  • Cancer
  • Menstrual disorders and infertility
  • Lymphedema
  • Impaired mobility
  • Gallbladder disease
  • Psychologic disturbances such as irritability, loneliness, depression, binge eating, and tension
  • Premature death
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18
Q

Clinical manifestation of obesity

A

1) Diabetes

2) Asthma

3) Functional impairments/deficits
Ex: Shortness of breath, ADL limitations, Increased risk of falls, Increased incidence of hip, knee, back pain

4) Lower extremity lymphedema (BMI > 59 may impair lymphatic flow)

5) Complications with pregnancy

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19
Q

Obesity treatment

A

1) Weight loss
Ex: moderate calorie intake, behavioral modifications, exercise, social support

2) Medication

3) Briatic surgery

4) Behavioral and lifestyle changes

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20
Q

What happens in cancer?

A

genetic mutations (all cells have mutations) that can be
1) hereditary: inherited
2) sporadic: environmental, cancer cells

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21
Q

How do mutations occur?

A

normal: cell birth leads to cell death by apoptosis
Cancer: changes to the genome permit cells to override this process

Understanding mutations = targeted therapy, personalized cancer medicine

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22
Q

List the hallmarks of cancer

A

1) sustaining proliferative signaling
2) evading growth suppressors
3) activating invasion and metastasis
4) enabling replication immortality
5) inducing angiogenesis (formation of new blood vessels)
6) resisting cell death

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23
Q

What are the grades of cancer?

A

grade 1: Cancer cells resemble normal cells and aren’t growing rapidly

Grade 2: Cancer cells don’t look like normal cells and are growing faster than normal cells

Grade 3: Cancer cells look abnormal and may grow or spread more aggressively

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24
Q

What are the cancer stages?

A
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25
Q

Explain the TNM staging system

A
  • “T” refers to the size and extent of the main tumor aka the primary tumor
  • “N” refers to the number of nearby lymph nodes that have cancer
  • “M” refers to whether the cancer has metastasized
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26
Q

List the components of the “T” category

A
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27
Q

List the components of the “N” category

A
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28
Q

List the components of the “M” category

A
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29
Q

Describe solid tumors

A

they don’t contain cysts or liquid areas. Solid tumors may be benign (not cancerous) or malignant
(cancerous). Different types of solid tumors are named for the type of cells that form them.
* Carcinoma * Sarcoma * Lymphoma

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30
Q

Can blood cancer occur from solid tumors?

A

No.
It can occur from:
* Leukemia * Multiple myeloma

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31
Q

What makes up 85% of all cancer cell types?

A

Epithelial: skin, lining of spaces, organs, cavities
* Squamous cell, basal cell & transitional cell carcinoma
* Malignant melanoma
* Adenocarcinoma

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32
Q

What is the most common cancer in women and what causes it?

A

breast cancer. The causes include environmental factors/unknown; only 5-10% are inherited

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33
Q

Assess this case

A
  • Patient presents with significantly decreased R shoulder range of motion into abduction and flexion, secondary to post- surgical lymphovenous bypass precautions, weakness in scapular muscles and hypomobility at GHJ/ACJ
  • Patient demonstrates no signs of lymphedema at this time with normal circumferential/volumetric measurements.
  • Patient presents with poor scapular control with decreased upward rotation due to postural weakness.
  • Patient would benefit from physical therapy given the current restrictions and risk of developing lymphedema as well as worsening mobility with radiation
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34
Q

What does radiation therapy do? How often is it used?

A

(around 60% of cancer patients will receive radiation therapy)

Radiation therapy Modifies or kills cancerous cells by changing the DNA
(the energy from high frequency subatomic particles is able to remove electrons from atoms or molecules causing ionization.)
* Free radicals
* External beam radiation (linear accelerator & proton therapy) vs.
Internal (brachytherapy & radiopharmaceuticals)
* Effective radiation dose : Ionizing radiation > CT Scan > x-ray

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35
Q

What are some examples of radiation therapy?

A

1) Proton beam therapy: capable of
superior targeting and enhanced tumor control
Benefit: 2-3x less energy deposited in
uninvolved tissue
Advantageous for: ocular, skull-based, specific pediatrics, prostate

2) Linear accelerator: utilizes high-frequency electromagnetic waves to accelerate charged particles

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36
Q

What are the side effects of radiation therapy?

A
  • Acute radiation syndrome: destruction of normal cells (hair
    loss, skin redness, salivary gland production, low sperm
    count)
  • Late side effects : fibrosis, infertility, sperm and egg mutations, free radical, GI dysfunction, cancer development
  • Radiation fibrosis:
  • Progressive fibrotic tissue sclerosis
  • Can affect any tissue type- skin, muscle, ligament, tendon, nerve, heart, lung, GI, GU, bone
  • Can continue to worsen for 1-5 years after radiation
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37
Q

How does metastasis commonly occur?

A

(Certain tumor types tend to consistently spread to certain sites)

  • Metastasis can occur via:
  • Blood pathways
  • Lymph pathways
  • Along fascial planes
38
Q

What are the common metastases sites

A
  • Lungs
  • Liver
  • Lymph nodes
  • Bones
    – Vertebrae (approx. 60-70% patients with systemic cancer will have spinal metastases, unfortunately, only 10% of these patients are symptomatic
    – Femur
    – Ribs
39
Q

What are common types of pain to be aware of if a patient has had cancer before?

A

Be aware of weakness/issues in (bending, twisting, lifting) “BLT”

You can refer the patient but also check for other signs of cancer so its not just “back pain”

40
Q

What are some late effects of radiation?

A

radiation fibrosis, infertility, cancer development

41
Q

What muscles does cranial nerve 11 innervate? Where would you expect to see atrophy? What movements would be limited?

A

accessory nerve XI

1) SCM, traps
2) lateral neck
3) shrugs, neck rotation

42
Q

Create assessments for this case

A

Manual therapy:
* Manual lymph drainage
* Myofacial release/soft tissue mobilization to lateral neck/pectoralis
* Joint mobilization; glenohumeral joint, ACJ
* Scapular neuromuscular re-education:
Scapular setting isometrics–>active assist–>active–>resisted
Progressing from supine –> sidelying –> seated/standing
Dynamic stability exercises
* Global UE strengthening/endurance

43
Q

List cancer types if the affected cells are connective tissue and muscle

A
  • Fibrosarcoma
  • Liposarcoma
  • Chondrosarcoma
  • Osteosarcoma
  • Hemangiosarcoma
  • Leiomyosarcoma
  • Rhabdhomyosarcoma
  • Ewing’s Sarcoma (round-cell tumor in bone or soft tissue)
44
Q

What is chemotherapy? What does it do?

A

Chemotherapy:
Drugs that modify or kill cells at different phases of the cellular cycle.

Oral, intravenous, injection, intrathecal, intraarterial,
intraperitoneal, topical

Three main goals:
– Cure
– Control
– palliation

45
Q

What are some common side effects of chemotherapy?

A

Immunosuppression
Nausea/vomiting
Anemia
Alopacia
Chemo brain Dehydration
Loss of appetite
Constipation
Mouth and mucous membrane sores Fatigue
Skin and hair changes
Fertility problems
Neuropathy

46
Q

What muscles are affected by femoral nerve transection?

A

quads, illiacus, Pectineus,

(Sensation is altered in the ant., medial thigh)

47
Q

List tumors that affect nerve tissue

A

Brain tumors

– Glioma (most common type- found in all 4 lobes of brain, brain stem, cerebellum & spinal cord):
o Ependymomas (benign), Oligodendrogliomas, Astrocytomas (Glioblastoma – Grade IV), mixed, brainstem, optic nerve

– Neuroblastoma
– Meningeal sarcoma (Meningioma)
– Neurilemmoma
– Retinoblastoma
– Neurofibromatosis

48
Q

What are the treatment options for brain tumors?

A

-Whole brain radiation
-Surgery (tumor resection/craniotomy)
-Chemotherapy

49
Q

What are the grades of brain tumors?

A

Low Grade: slowly growing
Surgery may be able to completely remove tumor

High Grade: rapidly growing
Usually treated with combination of surgery, radiation, and chemotherapy

50
Q

How do brain tumors present?

A
  • Headache
  • Nausea/Vomiting
  • Seizures
  • Focal neurological symptoms: hemiparesis, gait abnormalities,
    aphasia, vision changes, impaired sensation, bowel/bladder
    changes
  • Altered Mental Status
  • Personality or cognitive changes
51
Q

Describe metastatic brain tumors

A
  • Cancer cells from other areas of the body spread to brain via bloodstream
  • Main treatment is radiation and surgery, chemo usually not as helpful
52
Q

Describe leptomeningeal disease

A
  • Cancer cells that spread from another area to the meninges that cover the brain & spinal cord
  • Can spread to CSF
  • Prognosis is poor (median survival ~2-3 months)
  • Treatment options:
  • Palliative
  • Radiation
  • Chemotherapy
  • Central Nervous System (CNS) lymphoma (primary or secondary): a
    non-Hodgkins lymphoma subset: pathology confined to CNS
    parenchyma, dura and leptomeninges, cranial nerves, spinal cord, or
    intraocular compartment.
53
Q

Describe lymphomas

A

Lymphoid tissue
– Lymph nodes, spleen, intestinal lining
* Although it originates in the lymphoid system and primarily in lymph nodes- it can spread to other sites such as spleen, liver and bone marrow

Hodgkin lymphoma (HL) vs non-hodgkins lymphoma
(NHL)
– NHL: the most common hematologic malignancy and one of
the most common cancers overall

54
Q

List hematopoietic tissue cancer and their incidence rates

A

Leukemias, myelodysplasia, myeloproliferative, syndromes
Multiple myeloma

55
Q

Describe pathogenesis of leukemia

A

The pathogenesis of leukemia involves the abnormal proliferation of blood cells, typically white blood cells, originating in the bone marrow. In leukemia, genetic mutations lead to uncontrolled growth and division of immature blood cells, which fail to mature into functional cells. This accumulation of abnormal cells crowds out healthy cells in the bone marrow, reducing the body’s ability to produce normal red blood cells, white blood cells, and platelets. As a result, individuals with leukemia may experience symptoms like anemia, increased risk of infections, and bleeding problems. The mutations driving leukemia can be due to a variety of factors, including genetic predisposition and environmental exposures.

56
Q

Describe immunotherapy

A

Uses substances made from living organisms (biotherapy) to help the bodies immune system find and target cancer cells. A couple of examples:
* Monoclonal antibodies
* Flu like symptoms
* CAR T Cell therapy
* Neurological fluctuations

57
Q

What is the role of stem cell therapy?

A

(part of immunotherapy)

  • Replace defective marrow
  • Replete store of blood-forming cells, restoring hematopoesis in patients with hematologic and non-
    hematologic malignancies after intensive chemotherapy regimens
  • Induce a graft-vs tumor effect against the underlying malignancy
  • more commonly used with leukemias & multiple myeloma
58
Q

Describe myelosupression

A

Bone marrow activity is decreased resulting in fewer RBCs, WBCs and platelets.
– Cancer cells (passes incorrect DNA for a new blood cell)
– Blood cancers
– Chemotherapy
– Radiation

Anemia, thrombocytopenia, neutropenia, pancytopenia

59
Q

What is anemia? What are the side effects?

A

Reduction of RBCs (hemoglobin)

Side effects: decreased oxygenation, increased cardiac output and respiratory rate, fatigue

60
Q

What are the grades of anemia?

A
61
Q

Describe thrombocytopenia

A

Low blood platelets (blood clotting
ability)

  • Bleeding precautions:
    <25K: no resistance exercise; most likely to get infusion
    <10K: refrain from straining & mod A or greater transfer
62
Q

Describe neutropenia and pancytopenia

A

Neutropenia: Low neutrophil count in the blood: <1,500 per mm3

Precautions: hand washing, protective isolation, hygiene, no fresh flowers/animals

63
Q

List some common nutritional deficiencies

A
  • Anorexia: lack of appetite, unable to eat. Supplements help
  • Cachexia: extensive weight loss and muscle mass loss; >5% in 6 mos. Sarcopenia. Shortened survival.
  • Can be tumor effects and chemotherapy
  • ID physiologic barriers: dysphagia, digestive pains, depression, N/V, vitamin deficiencies
64
Q

Describe osteoporosis and pathological fractures

A
  • Osteoporosis: chemotherapy and radiation effects on decreased
    osteoblast activity. Vitamin D deficiencies.
  • Pathologic fractures: strongly correlated with increased risk for death in all cancers (except lung)
65
Q

List pain types

A
  • Visceral: pain in the organs
    or tissue lining organs of the
    heart, lungs, abdominal and
    pelvic organs (cramps, increased pressure, squeezing)
  • Somatic: bony, muscular, skin (localized, achy)
  • Neuropathic: neural symptoms (numbness/tingling)
66
Q

What are steroid induced side effects?

A
  • Corticosteroids: suffix ends in “-one”
    Hydrocortisone, prednisone, dexamethasone
  • Indications: improves appetite, improved immune response, decreased inflammatory response, transplant rejection
  • Side effects: numerous, common:
    Sleep disturbance- too much energy at night Steroid induced myopathy
    – Strength training important
67
Q

What are some side effects on cognition from cancer treatment?

A
  • Chemo brain: delayed processing, multi-tasking, short term memory
  • Delirium and/or dementia:
  • Patient considerations:
    Patient needs time to finish sentences, guide when needed & encourage patient to think for themselves vs rely on caregiver
    Blocked practice: repeat tasks and education Teach back method
68
Q

What are some causes for fatigue in patients with cancer?

A

sleep disorder
Activity level
Malnutrition
Chemo/radiation
Myelosuppression
Cancer
Emotional distress/pain
Non cancer comorbidities

69
Q

Describe Chemotherapy Induced Peripheral Neuropathy

A
  • Prominent dose-limiting toxicity
  • Common chemo is vincristine
  • Peripheral nerve involvement (hands/feet more affected)
    Sometimes causes foot drop
  • Management - pharmacology, cognitive / behavioral, pain management, acupuncture, exercise, desensitization
70
Q

What are some common pulmonary toxicities? What are the patient considerations?

A
71
Q

Describe cardiac dysfunction

A
  • Valve disease, pericardial disease, rhythm disturbances, myocardial dysfunction, heart failure
  • Due to chemotherapy, cancer and radiation. Patients often admitted during chemotherapy if drugs are expected to affect heart function (cardiotoxic)
  • Patient considerations: Monitor RPE, HR, O2 sats
72
Q

Describe renal dysfunction

A
  • Renal function: filters waste from blood, role in BP regulation
  • Acute renal failure/injury/insufficiency: elevated
    creatinine or blood urine nitrogen
    Side effects: weakness, shortness of breath, lethargy, edema, confusion
  • Chronic renal failure: fatal without dialysis to filter waste
    Therapy as tolerated even on days of dialysis
73
Q

What are the components of the lymphatic system?

A

Initial lymphatics

Precollectors

Collectors
* Lymphangions

Lymphatic ducts

Lymph nodes

74
Q

How many lymph nodes is an individual born with?

A

400-700 lymph nodes

75
Q

What are the components of lymphatic fluid?

A
  • Interstitial fluid
  • Protein
  • Fats
  • Substances not reabsorbed into blood vessels
76
Q

Describe lymphatic load (aka: lymph obligatory load) vs. transport capacity

A

Lymphatic Load
* Total amount/volume of fluid (water, proteins, cells, lipids)

Transport Capacity
* Maximum amount of fluid the lymphatic system can carry
* Healthy system: 10x the lymphatic load

77
Q

What is lymphedema?

A
  • When the lymphatic system cannot carry the required lymphatic fluid back to the circulatory system
  • Protein-rich fluid accumulation in the interstitial space due to reduced transport capacity (result of damage to or malformation of the lymph vessels/nodes)
  • Most commonly caused by the removal of or damage to lymph nodes as a part of cancer treatment
78
Q

What are symptoms of lymphedema?

A
  • Feeling of heaviness/tightness
  • Limited range of motion
  • Aching/discomfort
  • Infection
79
Q

What are the types of lymphedema?

A
  • Primary – congenital
    1) Hereditary
    2) Females > males, legs > arms
    3) Usually begins distally and moves proximally
    4) Unilateral presentation (sometimes bilateral)
  • Secondary – traumatic
    1) Caused by damage to the lymph system
    2) Surgical removal
    3) Radiation
    4) Filariasis
    5) Usually begins proximally and moves distally
    6) Unilateral presentation
80
Q

What are the forms of primary lymphedema?

A

Three forms
* Congenital lymphedema (infancy - 1 yo)
* Lymphedema praecox (1 - 35 yo)
* Lymphedema tarda (after 35 yo)

Turner Syndrome
* Underdevelopment of the lymphatic system
* Lymphedema present in more than 60% of patients

81
Q

What are the stages of lymphedema?

A

(four stages)

Stage 0 – subclinical/latency
* Known damage to lymph system without onset of swelling, normal
limb measurements

Stage 1 – mild/spontaneously reversible
* Pitting edema, resolves while sleeping, elevation helps

Stage 2 – moderate/not spontaneously reversible (DOES NOT go away overnight)
* Doesn’t pit as much secondary to fibrosis

Stage 3 – severe/lymphostatic elephantiasis
* Fluid may weep out from the skin, severe skin changes

82
Q

What stage of lymphedema is this?

A

Stage 2, secondary lymphedema

83
Q

What stage of lymphedema is this?

A

Stage 3, secondary lymphedema

because of mastectomy scar which means it started proximally

84
Q

What systems/practice patterns are affected by lymphedema?

A

Musculoskeletal
Neuromuscular
Cardiovascular
Integumentary

Quality of Life

85
Q

What is the lymphedema treatment plan?

A
  • Stage 0 – range of motion, exercise, preventative garments
  • Stage 1 – compression bandaging, garments
  • Stage 2 – manual lymph drainage (MLD), bandaging, and/or garments
  • Stage 3 – MLD, bandaging, garments, pump, possible surgical intervention
86
Q

What is manual lymph drainage?

A

Manual Lymph Drainage
* Skin stretch technique to move fluid under the surface of the skin
* Avoid heavy pressure
* Follow with compression

87
Q

What type of bandages are used for lymphedema?

A

ONLY Short-stretch bandages
* Acute episodes or initial treatment
* 2-6 weeks
* 23 hours per day
* Transition to garments

88
Q

What are the compression garments for lymphedema?

A

Compression class I
* Stage 0-1 lymphedema, Edema, 20-30 mmHg

Compression class II
* Stage 2-3 lymphedema, 30-40 mmHg

Off the shelf vs. Custom

89
Q

Explain edema

A

Swelling caused by excess fluid trapped in the tissues

Normal response of the body to inflammation or injury

Related to medical conditions or imbalance of substances in the blood
* Low albumin
* Kidney disease
* Medications
* Chemotherapy

Bilateral presentation

90
Q

What is the treatment plan for edema?

A
  • Compression bandaging and/or garments
  • Ambulation, exercise for muscle and joint pumps
  • Medical management
91
Q

Can lymphedema occur in non cancerous situations/cases?

A

yes

Clin Path (12 decks)

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