must have at least 5 symptoms of depression

a least 1 must be either

depressed mood or

anhedonia

the other 4 can be any of the following

sleep disorder, guilt, energy deficit, concentration deficit, appetite disorder, psychomotor retardation or agitation, and suicidality

selective seratonin reuptake inhibitors,

serotonin/norepinephrine reuptake inhibitors,

serotonin modulators,

dopamine reuptake inhibitors,

tricyclic antidepressants,

monoamine oxidase inhibitors

first line agents for depression

vary in side effects and kinetics

long half life

base on age, side effects, past response, cost

better tolerability than TCAs and MAOIs

side effects: insomnia, GI, headache, sexual dysfunction

inhibit nore as well as sero,

possibly higher response rates

Side effects: increased bp, nausea/vomiting, GI, insomnia, sweating

no activity on serotonin,

lower incidence of sexual side effects,

side effects: GI, insomnia, lowers seizure threshold, contraindicated in patients with eating disorders (electrolyte imbalances increased likliness of seizures)

block reuptake of 5ht and NE,

used less because of side effects and overdose problems

side effects: weight gain, sexual dysfunction,

anticholinergic effects - dry mouth, constipation, urinary retention, blurred vision, memory impairment,

Adrenergic effects - orthostatic hypertension, tachycardia,

caustion with cardiovascular disease as severe arrythmias can occur w/ overdose,

cannot abruptly discontinue

rarely used

increase 5ht, ne  and da

multiple drug and food interactions

hypertensive crisis with tyramine (in cheese, beer and processed meats)

St. johns wort, studies show mixed results.

not regulated by FDA,

many drug interactions

low cost, otc

Discuss important patient counseling points for depression

depression is a medical condition not a character defect or punishment

side effects can start immediately but therapeutic effects take 2-4 weeks,

must be taken everyday

dont abuptly discontinue

serotonin syndrome - when other meds increase serotonin also and there is too much in brain

consult physician/pharmacist before taking OTC if on MAOI

1 episode - 6-12 mos

2 episodes - 3 years

3+ or with complicating factors - indefinitely

first line= non-stimulating ssris or snri

second line = benzodiazapine, buspirone, tca

facts about benzodiazapines

anxiolytic, sedative properties

tolerance and dependence common

potential for abuse

side effects: drowsiness, dizziness, ataxia, memory impairment

treatment for GAD not panic disorder,

more effective in benzo naive

takes 2-4 weeks to work

breathing and relaxation techniques and psychotherapy

then SSRIs first at lower doses than depression.

benzodiazapines for acute attacks.

Men: prostate, lung/bronchus, colorectal

Women: Breast, Lung/bronchus, colorectal

men: lung, prostate, colorectal

women: lung, breast, colorectal

Compare and contrast normal cell growth and cancer cell growth

the cell cycle of cancer cells takes longer than normal cells (so they grow slower technically) but the process is uncontrolled (making them grow faster over all) 

the uncontrolled cancer cell growth is due to activated oncogenes and deactivated tumor suppressor genes, neither of which happen in normal calls. 

cancer cells also dont undergo apoptosis, or cellular senescence (when a cell doubles a certain number of times then dies naturally, has to do with telomeres)

Differentiate between benign and malignant tumors

benign - noncancerous growths, frequently encapsulated, localized and seldom metastasize, rarely recur after removal

malignant - invade and destroy surrounding tissue, genetically unstable (mutations) loss of structure and function (anaplasia) metastasize and recur

List early warning signs for cancer for adults

change in bowel or bladder habits

a sore throat that doesnt heal

unusual bleeding or  discharge

thickening or lump in breast or elsewhere

indigestion or difficulty swallowing

obvious change in a mole or wart

nagging cough or hoarseness

Compare & contrast clinical & TNM staging systems

tnm staging classifies the tumor by size, degree of nodal involvement, and presence/absence of metastasis

clinical staging uses the tnm method but classifies them i-iv by whether it is

i localized

ii local or regional spread

iii more local or regional spread

iv distant metastasis

Compare & contrast treatment modalities

Surgery - extremely invasive, best chance with solid tumors in early stage, less useful for widespread tumors

radiation - ionizing radiation to kill cancer cells, only useful for local cancer, damaging to surrounding normal tissue

chemotherapy - used for widespread tumors, less effective for bulky tumors, have serious side effects and sanctuary sites where chemo cant reach (cns and testes)

biologics (hormones) - limited usefulness, use in cancers that are hormone dependant (breast and prostate)

biologics (hormones) - tries to use endogenous immune system

combinations

Discuss principles of chemotherapy with respect to timing, frequency, and combinations

chemotherapy should be started when tumor burden is low and growth fraction is high.  chemo kills a constant percentage of cells, not a constant number - importance of continued therapy

combinations will usually kill a larger percentage of tumor cells than single agent chemo

it should also be administered no sooner than every 3-4 weeks depending on patient recovery.

intermittent therapy is preferred.  cell cycle secific drugs are given in continued, prolonged schedules.  cell cycle nonspecific are given in large intermittent doses

Compare and contrast adjuvant and neo-adjuvant combination chemotherapy

adjuvant therapy - given when no detectable tumor (after surgical resection) measured in terms of survival not tumor response, goal is to destroy metastatic disease

Neoadjuvant chemotherapy - given prior to surgery to reduce tumor size, reduces the extent of disfigurement from surgery

List and discuss responses to chemotherapy and corresponding response criteria

responses to therapy

cure - means disease free; life expectancy the same as no cancer

complete response - complete elimination of all evidence of disease (complete remission) required for cure but does not mean cure

partial response  - >or = 50% reduction in tumor size, lastine 1 month with no new lesions

measurable response - <50% reduction

stable disease - no change

progressive disease - INCREASE in tumor burden during therapy

overall response =CR + PR

Describe major adverse effects associated with use of chemotherapy and, where applicable, management and/or prevention of same.

bone marrow  - neutrophils are rapidly dividing cells which make them a target for chemo (wbcs should be above 3000 and neutrophils must be above 1500/mm^3)

febrile neutropenia -  absent of usual signs and symptoms of infection (take seriously!) empiric antibiotics to treat, csfs to prevent

red blood cells, an platelet levels can drop too

alopecia - very common but will grow back

nausea and vomiting - again very common, but different levels of drugs have different emetogenic potential use 5-HT antagonists to counteract

mucositis, stomatitis watch oral hygiene and use analgesics or topical anesthetics for pain

tumor lysis syndrome too much intracellular junk made extracellular.  prevent with allopurinol and urinary alkylation

extravasation - leakage of chemo into surrounding tissues vesicants more damaging than irritants (anthracyclin = worst)

hypercalcemia - cancer cells release pth like substance steals ca++ from bones

Identify risk factors for developing VTE

Virchows triad

hypercoagulable state

-pregnancy

-estrogen therapy

-protein c&s deficienct

endothelial injury

-hip/knee replacement

-trauma

-atherosclerosis

-indwelling venous catheters

-previos dvt/pe ***major risk factor

-valvular disease or replacement

circulatory stasis

-medical illness

-surgery

-paralysis

-obesity

-varicose veins

-increasing age

Describe the clinical presentation of deep vein thrombosis

Describe appropriate monitoring of anticoagulant therapy

aPTT for like everything, anti factor xa activity, platelet count, hemoglobin, and watch for any signs of bleeding (to be discussed later) scr to test for renal function and elimination of heparins

warfarin therapy uses pt and INR

dti uses aptt and act

List the classes of medications used to treat VTE

unfractionated heparin

low molecular weight heparin

factor xa inhibitors

vitamin k agonists

direct thrombin inhibitors

List the common adverse effects associated with anticoagulation and, when applicable, how they may be treated

bleeding is always a possible adverse effect

heparin counteracted by protamine sulfate

warfarin counteracted by vitamin k

HIT - treat with direct thrombin inhibitors

skin necrosis (warfarin)

List common signs and symptoms of bleeding

hematuria

bright red in stool

black or tarry stool

bright red blood in vomit or coffee ground appearance

sob

abdominal pain

drugs must be active for the specific type of cancer

choose drugs with different mechanisms

drugs that compliment eachother can help reduce the developement of resistance

non cross-resistant

avoid overlapping toxicities - different types and timings

response criteria

reduction in tumor size

reduction in tumor cell counts

reduction in tumor cell markers

reduction in ascites/effusions

improvement in organ function

Describe signs and symptoms of infection

fever

swelling, tenderness, erythema

dysuria, frequency

cough, sputum

wbc count, esr, c-reactive protein, radiographic evidence, fluid analysis

Discuss principles and methods of pathogen identification;

direct examinations

gram stain

cultures

biochemical/serological testing

susceptability testing

Differentiate between colonization and infection;

colonization is for organisms that are not pathogenic - they provide benefits such as defense by occupying space, competing for nutrients, suppressing growth of pathogenic bacteria

infection is more of a colonization of pathogenic bacteria

Differentiate between minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC);

MIC is the lowest concentration of the drug to inhibit visible growth of an organism

MBC is the lowest concentration to kill 99.9% of growth

Compare and contrast methodology, advantages, and disadvantages of macrodilution and microdilution for determination of MIC and MBC

macrodilution - uses serial 2 fold dilutions of antibiotics, and adds a standard 10^5 bact. in each one wait 18-24 hrs at 35 deg. c and test turbidity

MIC- lowest conc. with clear tube

MBC- lowest conc. with no growth on a plate

disadvantages - time and labor intensive

microdilution - uses microtiterplates with similar quantity of broth, and serial dilutions of multiple antibiotics

advantages- less labor, automated, faster

disadvantages-cant be used for some organisms, less flexability in antibiotics tested, decreased sensitivity to some strains

Describe appropriate use of breakpoints for determination of susceptible, intermediate, or resistant

breakpoints - conc of indiv. drug against 1 indiv. microorganism (1 drug v. 1 bug)

conc. of drug published for bact. sensitivity to show effectiveness. 

susceptible - likely to achieve optimal therapeutic outcome with usual doses of antibiotic

intermediate - may achieve optimal therapeutic doses with maximal doses or infections where drug concentrates at site. 

resistant - not likely to achieve optimal therapeutic response

Compare and contrast principles and methods of empiric and streamlined therapy

empiric therapy - directed at organisms most likely to cause infection (based on site of infection) broad spectrum, begin therapy without full information

streamlined therapy - meds based on the specific infection the patient has; most narrow agent possible based on the results of culture and sensitivity data

Describe monitoring strategies and methods of monitoring anti-microbial therapy

resolutions of signs and symptoms - temp, wbc, local symptoms/signs, radiologic improvement, serum drug conc. monitoring. 

if no improvement after 3 days consider alternate causes - fungal, viral, noninfectious

Describe therapeutic failure and discuss reasons for such failure

failure= no improvement after 3 days

consider non bacterial, like viral, fungal or noninfectious etiology or possibly anttimicrobial resistance

Describe appropriate counseling of patients receiving an antibiotic

take all doses

take missed doses as soon as you remember or add them to the end

with/without food and "stuff"

expected effects, like delay in onset, inf no improvement in 3 days call doctor, adverse effects (GI most common)

DO NOT TREAT DIARRHEA

viruses

bacteria

fungus

protazoa

others

types of infection by site

CNS

URTI

LRTI

abdomen

G/U

M.S.

Skin

CNS - meningitis

URTI - otitis media, pharyngitis, sinusitis

LRTI - acute bronchitis, AECB, COPD exacerbation, pneumonia (CAP, HAP, TB, PJP)

abdomen - peritonitis

G/U - UTIs

M.S. - osteomyelitis, septic arthritis

Skin - cellulitis, ersiplelas, others

leukocytes present by infection type

virus

fungal

bacterial

parasite

tuberculosis

virus - lymphocytes

fungal - lymphocytes

bacterial - neutrophils

parasite - eosinophils

tuberculosis - monocytes