Week 3--lecture slides Flashcards
why are late effects of cancer more severe in childhood survivors than adult survivors
radiation and chemo inhibit normal tissue growth–kids still growing
–> organ growth, brain growth, development, psychosocial development, MSK growth can all be affected
treatment more intensive for children
survivors of childhood cancers have more years to survive for the late effects to show themselves than adults
what is the risk of cancer recurrence or second cancer in childhood cancer survivors
5-10x increased risk
what is a stage 3 wilms tumour
rupture with tumour spillage
how are wilms tumours treated
standard chemo–> vincristine, doxorubicin, actinomycin
+ whole abdo radiation
what are the concerning side effects of anthrocyclines like doxorubicin
can affect the heart and so they require yearly follow up
can caused decreased ejection fraction etc and may require cardiac meds to manage cardiac disease–> cause cardiomyopathy
this is dose and age dependent–> worsens with length of follow up, exacerbated by radiation to heart, pregnancy, obesity, sudden growth
what is the most common cause of death in childhood cancer survivors
recurrence of cancer
what is the second most common cause of death in childhood cancer survivors
cardiac disease
anthrocyclines (i.e doxorubicin) cause cardiomyopathy, and radiation to the chest can also cause heart problems
how does chemo affect the female reproductive organs in childhood cancer survivors
alkylating agents (i.e cyclophosphamide) can cause ovarian failure–> dose and age dependent, may develop primary ovarian failure or premature menopause (process of losing eggs that happens normally throughout life is sped up due to chemo/radiation)
how does radiation affect the female reproductive organs in childhood cancer survivors
abdo/pelvic radiation has direct effect on ovaries and uterus
cranial radiation can disrupt the pituitary-ovarian axis
how should you monitor childhood cancer survivors who have female reproductive organs
monitor LH, FSH, estrogen
best predictor is antral follicle count, anti-mullerian hormone–> kind of like a “bank balance” of oocytes left–> not covered by MSP but costs about $100
consider oocyte storage, provide counselling at time of pregnancy
how is pregnancy affected in childhood cancer survivors
no increases in abnormalities or cancer in offspring after mother treated with chemo
after radiation to abdo/pelvis, can have an increase in prematurity and pregnancy loss due to effects on uterine growth etc
how does chemo affect the male reproductive system in childhood cancer survivors
alkylating agents have dose dependent and immediate effects on germinal cells in the testes
leydig cells which produce testosterone arent as affected
how does radiation affect the male reproductive system in childhood cancer survivors
to testes–> germinal cells can be impaired, leydig cells more resistant
to brain–> at risk for hypogonadotropic hypogonadism, risk is lifelong
can advise sperm banking in the post pubertal patient but difficult to manage in pre pubertal boys
what is the most important cause of secondary cancer in childhood cancer survivors
radiation
thyroid, brain, breast, skin and salivary glands are the most susceptible organs
important to know dose and site of radiation as you follow these patients in adulthood
does chemo usually cause a second cancer
no not usually
secondary leukemia can be associated with alkylating agents and hereditary issues
what cancers in children are often hereditary
bilateral retinoblastoma
what patients are particularly at risk for secondary cancers
- those treated for hodgkins disease–> if female and received chest radiation during adolescence, have 25-35% chance of breast cancer by age 25, need mammograms or MR scans
- -> 5% risk of thyroid cancer is had chest, neck radiation and thus need thyroid function and regular ultrasound - those who received cranial radiation for ALL–> 12% risk of benign meningiomas by age 25, 2-3% risk of malignant brain tumour, need regular MR scans
what are the effects of cancer treatment on intellectual development in childhood cancer survivors
XRT effects are age and dose related–> decreased intellectual function (poor attention, working memory, executive function); risk of leukencephalopathy which is rare but involved demyelination, loss of oligodendroglia
chemo or high dose IV methotrexate can also have effects
can have damage from brain tumour or surgery
can have hydrocephalus
what side effect can cancer treatment cis platinum have on childhood cancer survivors
can get hearing loss
can sometimes predict who will get this loss but often dont have a choice whether to use or not because it is so effective
get high frequency hearing loss, happens very quickly
this hearing loss can affect speech and learning in school
what endocrine problems can childhood cancer survivors have after treament
- thyroid irradiation can cause hypothyroidism or thyroid malignancy–> requires screening with annual T4, TSH, exam, U/S
- cranial irradiation–> all pituitary hormones can be affected but GROWTH hormones most sensitive and often patients will require replacement
what condition is fairly common in childhood cancer survivors that received radiation or had cancer in the spine
scoliosis
what MSK effects can be the result of treatment of childhood cancer
scoliosis
osteoporosis (after steroid tx for leukemias, replace vit D)
amputation (for bone tumours)
avascular necrosis of joins (from high dose steroids, worse in teens and females, will require joint replacement)
what psychosocial effects can be seen in childhood cancer survivors
depression/anxiety/PTSD
career and financial effects
difficulty making friends, forming relationships
childhood cancer survivors tend to have lower paying jobs
generally miss alot of school
huge impact on the family as a larger unit
what resources are there for you as a physician caring for childhood cancer survivors
cardio-oncology clinic at VGH
BMT f/u at VGH
LEAF clinic (late effect adult follow up)
what is fibromyalgia
diffuse MSK pain arising in the soft tissues
no inflammation
lab tests are normal
how do you diagnose fibromyalgia
11/18 painful FM tender points–distributed in all 4 quadrants
9 pairs of points–> 6 pairs in upper body, 3 pairs in lower
what are the comorbidities associated with fibromyalgia
migraine headahe
vertigo and tinnitus
TMJ symptoms
atypical chest pain (must work it up tho)
IBS
interstitial cystitis/vulvodynia
leg cramps
chronic fatigue
how do you treat fibromyalgia
education, reassurance
night time meds–> TCAs or flexeril
analgesics
exercise
CBT
other drugs –> treat depression (SSRI), nerve modulating drugs (gabapentin)
what is myofascial pain syndrome
regional pain syndrome
localized area of soft tissue pain
painful “trigger” point
what is polymyalgia rheumatica
in patients above 55 years old, can get aching and stiffness of the shoulder and hip girdle regions
ESR often very high
responds within 72 hours to low dose prednisone
about 1/3 are associated with TEMPORAL ARTERITIS
what serious condition is associated with polymyalgia rheumatica
temporal arteritis
what is temporal arteritis
large cell vasculitis
occurs in patients above 55
consider in new onset of headache in someone over 55
may or may not have associated swelling or tenderness of the temporal artery
jaw claudication may be present
how do you diagnose temporal arteritis
temporal artery biopsy
ESR is elevated at least two fold
how do you manage temporal arteritis
RHEUM EMERGENCY
treat with high dose steroids at 1 mg/kg/day
what history should you get RE osteoarthritis
duration of sx
diurnal variation? (worse in AM? AM stiffness?)
other joints affected
fever, chills, sources of infection, trauma, rashes (psoriasis/psoriatic arthritis?), family hx gout, rheumatology ROS
ddx osteoarthritis
infection
trauma
non inflammatory (OA)
inflammatory–> seropositive: RA, other CVD/seronegative: psoriatic arthritis, reactive arthritis
crystal–>gout or pseudogout
idiopathic
sarcoid?
what should you look for on exam for OA
varus deformity (due to medial compartment narrowing)
what investigations should you do for OA?
synovial fluid analysis–?gram stain, C and S, cell count and diff, crystals, protein, glucose
Xray
what should you see on x ray for OA
radiographic evidence of calcification in hyaline and/or fibrocartilage
accumulation of calcium pyrophosphate dihydrate crystals in connective tissues
treatment of OA
education anf physio
tylenol (1st line)–> 3-4g per day if liver and kidneys normal
NSAID + PPI, or celebrex 2nd line
consider viscosupplementation, corticosteroid injection of knee
acute treatment of gout
indomethacin (NSAID), colchicine or corticosteroids (PO, IV or IA)
do NOT start allopurinol during acute attack
chronic management of gout
start allopurinol after three or more attacks once the acute attack is over
keep on NSAID/colchicine/ prednisone for interval
risk factors for gout
overweight
heavy alcohol use (beer)
dehydration
renal failure
metabolic syndrome
drugs (HCTZ, low dose ASA)
what foods to avoid if have gout
beef
seafood
beer
high fat dairy
soda pop
how to treat mild rheumatoid arthritis
plaquenil (hydroxychloroquine) or sulfalazine
how to treat moderate to severe RA
disease modifying anti-rheumatic drugs (DMARDs)
1st line–> methotrexate
can also try gold therapy, leflunamide, cyclosporine
which biologics can be used for RA (and also ankylosing spondylitis, psoriatic arthritis)
TNF inhibitors
rituximab (anti B cell Ab)
what is lupus
an autoimmune disorder related to increased antibodies by B lymphocytes
often mild with mucocutaneous and joint manifestations/fatigue/ +ANA
can progress to involve other organs like kidneys, bone marrow
what are the diagnostic criteria for lupus
must have 4/11
“MD SOAP BRAIN”
Malar rash
Discoid rash
Serositis (pleuritis/pericarditis)
Oral or nasopharyngeal ulcers
Arthritis
Photosensitivity
Blood –hemolytic anemia, leukopenia, lymphopenia or tcp
Renal disorder
Antinuclear antibodies (99% sensitive, 49% specific)
Immunologic disorder (+ anti smith, anti-ds DNA, anti phospholipid)
Neuro disorder –seizures or psychosis
how do you monitor lupus
BUN
Cr
Uric acid
how do you treat lupus
plaquenil (hydroxychloroquine)
how might an inflammatory muscle disease like polymyositis or dermatomyositis present
NOT pain or stiffness but of chronic muscle weakness, weakness of the proximal large muscles
characteristic inflammatory features on EMG and muscle biopsy
often linked with malignancy
ask about statin drugs
high level CK
what drugs should you ask about in the setting of new onset polymyositis or dermatomyositis
statins
what are the signs of dermatomyositis
heliotrope
gottren’s papules
V sign
shawl sign
how do you treat polymyositis or dermatomyositis
high dose prednisone
IVIG
sometimes imuran or methotrexate
how is worksafe funded
employer funded
what are some of the special services provided by worksafe BC
expedited specialist consults
expedited diagnostic imaging
expedited surgical care
nurse advisors
return to work support
psychology network
vocational rehab
multiple contracted rehab programs
how does RTW likelihood change with length of leave
decreases with longer leaves–50% return if have 12-24 wrrks of absence
define impairment
loss or abnormality of psychological, physiological or anatomical function that is observable
define disability
caused by impairments, always relative to a task
list methods of assessing GFR
serum urea
serum creatinine
serum cystatin C
timed urine collections with creatinine and inulin clearance calculated
nuclear medicine methods