Term
| What organism generally causes the development of NSTI following trivial soft tissue trauma? |
|
Definition
| gram positive skin flora such as group A beta hemolytic streptococcus |
|
|
Term
| What should the initial antibiotic therapy be when you suspect NSTI? |
|
Definition
| braod spectrum (gram pos gram neg and anaerobes) |
|
|
Term
| Where should a pt with NSTI be admitted? |
|
Definition
| ICU because distant end organ dysfunction may occur (acut respiratory, renal or liver insufficiency) and pts need to be monitored closely for those complications |
|
|
Term
| What causes the systemic consequences of NSTI? |
|
Definition
| overwhelming sepsis and circulating toxins (associated with staph and group A strep toxic shock syndrome) |
|
|
Term
| What signs on inspection of subq tissue should suggest that you should treat the pt with debridement? |
|
Definition
| easy separation of the subcutaneous tissue from teh underlying fascia indicates microvascular thrombosis and necrosis and should be treated by tissue debridement |
|
|
Term
| Why do skin changes occur late in the disease process of NSTI? |
|
Definition
| skin has a rich blood supply |
|
|
Term
| What is one of the leading factors contributing to delays in recognition of NSTI? |
|
Definition
| lack of skin abnormalities |
|
|
Term
| What type of NSTI is known for involving tissue below the fascia? |
|
Definition
|
|
Term
| What's the difference between cellulitis and NSTI? |
|
Definition
| cellulitis is milder and without microvascular thrombosis and necrosis; pts also do not have evidence of systemic toxicity and can be adequately treated with antibiotic therapy; NSTI affects primarily the dermis and subcutaneoustissue |
|
|
Term
| What are the early manifestations of NSTI? |
|
Definition
| extension of edema beyond the spread of erythema and severe pain |
|
|
Term
| What are the late manifestations of NSTI? |
|
Definition
| crepitation, formation of skin vesicles,cutaneous anesthesia, and focal necrosis |
|
|
Term
| How do you differentiate between cellulitis and NSTI? |
|
Definition
| MRI and CT can help but diagnosis of NSTI can be made clinically most of the time; definitive diagnosis is based on needle aspiration, gram stain, or exploration and visualization of subQ tissue under anesthesia |
|
|
Term
| Why are antibiotics alone an insufficient treatment for NSTI? |
|
Definition
| thrombosis of the blood vessels leads to poor antibiotic penetration into the affected tissue |
|
|
Term
| What organism is referred to in teh lay press as the "flesh-eating infection"? |
|
Definition
| group A beta hemolytic strep |
|
|
Term
| T/F "Flesh-eating infection" talked about in the lay press is more common in pts with compromised immune systems. |
|
Definition
|
|
Term
| What percent of GAS NSTI are community acquired? |
|
Definition
|
|
Term
| What percent of people with GAS NSTI develop bacteremia or TSS? |
|
Definition
|
|
Term
| How do you treat GAS NSTI? |
|
Definition
| clindamycin and penicillin (some evidence to suggest that IV Ig may neutralize bacteria produced superantigens and improve pt outcome) |
|
|
Term
| What are the symptoms of TSS? |
|
Definition
| mental obtundation, hyperdynamic shock, and multiple organs dysfunction syndrome |
|
|
Term
| What is Fournier gangrene? |
|
Definition
| a specific form of scrotal gangrene; anaerobic streptococci are the predominant causitive organism with secondary infection caused by gram negative orgnaisms; strictly speaking only refers to anaerobic strep scrotal infection but is frequently used to discribegram negativesynergistic soft tissue infections of the perineum and groin |
|
|
Term
| NSTI acquired after contact with fish or seawater= |
|
Definition
|
|
Term
| How do you treat vibrio NSTI? |
|
Definition
| ceftazidime plusquinolone or tetracycline |
|
|
Term
| What are the clinical manifestations of NSTI caused by vibrio? |
|
Definition
| rapid progression of soft tissue infection, fever, rigors, and hypotension |
|
|
Term
| What organisms should you suspect in NSTI's involving perirectal complications or GI surgery complications? |
|
Definition
| mixed gram negative aerobes and anaerobes |
|
|
Term
| How do you treat clostridial NSTI? |
|
Definition
| penicillin (questionable benefit with hyperbaric therapy) |
|
|
Term
| What is the typical presentation of clostridial NSTI? |
|
Definition
| swollen, tense skin, crepitation, and skin vesicles, frequently present with systemic toxic therapy |
|
|
Term
| What organisms usually cause NSTI related to IVDA? |
|
Definition
| clostridial species and other gram positive anaerobes |
|
|
Term
| What are the symptoms of NSTI associated with IVDA? |
|
Definition
| swelling and systemic toxicity due to the release of exotoxins, as the injections are through the fascia and into the muscles, the area of infection is in teh muscles and below thefascia; these infections ahve very high mortality due to sepsis and organ failure |
|
|
Term
| What antibiotics should be used for NSTI assoc with IVDA? |
|
Definition
| penicillin, clindamycin, and vancomycin |
|
|
Term
| T/F Patients with NSTI have systemic signs such as high fever. |
|
Definition
| true; but pts can be hypothermic sometimes |
|
|
Term
| When NSTI is strongly suspected, how can you establish the diagnosis in a rapidfashion? |
|
Definition
| small skin incision with would exploration |
|
|
Term
| What study determines how you treat Wilm's tumor? |
|
Definition
| imaging studies to determine whether preop chemo is needed |
|
|
Term
| When do you need preop chemo for Wilms tumor? |
|
Definition
| is the tumor is massive orbilateral and an intacaval extension of the tumor extends proximally to the hepatic veins |
|
|
Term
| How do you treat Wilm's tumor? |
|
Definition
| preop chemo if certain criteria are met, nephrectomy, almost all pts recieve chemo after surgery and pts with tumor spillage (preop capsular rupture or intraoperative spill) get radiation therapy |
|
|
Term
| What kinds of tumors are Wilm's tumor? |
|
Definition
| renal embryonal neoplasms |
|
|
Term
| In what age group does Wilm's tumor peak? |
|
Definition
| children between 1 and 5 yoa |
|
|
Term
| What are the major causes of renal masses in neonates? |
|
Definition
| hydronephrosis, multicystic dysplastic kidney, polycystic kidney disease, mesoblastic nephroma and Wilms tumor |
|
|
Term
| What are causes of a genital mass in a neonate? |
|
Definition
| hydrometrocolpos, ovarian mass, simple cyst, teratoma, torsion |
|
|
Term
| What are the causes of gastrointestinal mass in neonates? |
|
Definition
| duplication cyst, complicated meconium ileus, mesenteric or omental cyst |
|
|
Term
| What are the causes of retroperitoneal mass in a neonate? |
|
Definition
| adrenal hemorrhage, neuroblastoma, teratoma, rhabdomyosarcoma, lymphangioma, hemangioma |
|
|
Term
| What are causes of hepatobiliary masses in neonates? |
|
Definition
| hemangioendothelioma, hepatic mesenchymal hamartoma, choleochal cyst, hepatoblastoma |
|
|
Term
| What are common causes of renal masses in 1 yo to 18 yo? |
|
Definition
| wilms tuomr, hydronephrosis, rhabdoid tumor, clear cell sarcoma, polycystic kidney isease |
|
|
Term
| What are the causes of retroperitoneal masses in chlidren age 1-18? |
|
Definition
| neuroblastoma, rabdomyosarcoma, lymphoma, teratoma, lymphangioma, hemangioma |
|
|
Term
| What are the causes of GI mases in children age 1-18? |
|
Definition
| appendiceal abscess, intussusception, duplication cysts, functional constipation, hirschsprung disease, mesenteric or omental cyst, lymphoma |
|
|
Term
| What are hte causes of hepatobiliary masses in children from 1-18 yrs? |
|
Definition
| hepatoblastoma, hepatocellular carcinoma, benign liver tumors, choledochal cyst |
|
|
Term
| What are the causes of genital mass in children age 1 to 18? |
|
Definition
| ovarian mass (simple cyst, teratoma, tosion), hyrometrocolpos, undescended testicle, neoplasm, or torsion |
|
|
Term
| What might be the first sign of a neonatal bowel obstruction? |
|
Definition
|
|
Term
| How do you work up children with abdominal masses? |
|
Definition
| AXR to rule out Gi obstruction, assess bowel gas patterns and determine presence or abscence of calcifications; if AXR is nonspecific, U/S is next test of choice and can usually determine organ of origin, whether it is cystic or solid an vascular flow characteristics; CT scan if ultrasoun is nondiagnostic or shows a solid tumor |
|
|
Term
| What kind of calcifications should you look for on AXR of a child with an abdominal mass? |
|
Definition
| complicated cystic meconium ileus can be associated with a neonate with a calcified mass; calcifications in an older child can lead to iagnosis of neuroblastoma |
|
|
Term
| What kind of lab test should you get if you suspect neuroblastoma? |
|
Definition
|
|
Term
| What kind of test should you get if you suspect the child has hepatoblastoma? |
|
Definition
|
|
Term
| How do you treat intussusception in an infant? |
|
Definition
| IV hydration and barium or air contast enema to both diagnose and reduce the intussusception |
|
|
Term
| What symptoms are associated with neuroblastoma in children? |
|
Definition
|
|
Term
| What is the treatment for neuroblastoma? |
|
Definition
| tumor biopsy, neoadjuvant chemo, tumor resection |
|
|
Term
| How do you calculate BMI using pounds? |
|
Definition
| multiply weight in pounds by 704 and dividing by the height in inches squared |
|
|
Term
|
Definition
|
|
Term
| What is an overweight BMI? |
|
Definition
|
|
Term
| What are the different classifications of obesity? |
|
Definition
| mild= 30.0 to 34.9; moderate= 35.0 to 39.9; severe= >40 |
|
|
Term
| What does it mean to be superobese? |
|
Definition
|
|
Term
| Name some obesity related comorbidities? |
|
Definition
| hypertension, hyperlipidemia, DM, atherosclerosis, cardiomyopathy/hypertrophic heart disease, sleep apnea, gallstones, osteoarthritis/lumbosacral disk disease, urinary incontinence, infertility/polycycstic ovarian syndrome, and cancer |
|
|
Term
| What is laparoscopic adjustable gastric banding? |
|
Definition
| placement of a silastic band around the proximal stomach at approximately 1 cm below the GE junction; band is attached to a subQ port that may be injected with saline to adjust the gastric luminal opening |
|
|
Term
| Which is better, woux en y or vertical banded gastroplasty? |
|
Definition
| RYGB is better because VBG does not result in adequate sustained weight loss and is associated with complications |
|
|
Term
| Does surgery work to cure obesity? |
|
Definition
| most pts achieve a reduction in weight that is frequently sustainable but pts rarely achieve the ideal body weight prescribed in standard hieght weight tables |
|
|
Term
| T/F Gastric bypass can increase longevity |
|
Definition
| this has not been demonstraded but bypass can reduce obesity related complications |
|
|
Term
| What is another name for Roux-en-Y gastic bypass? |
|
Definition
| small pouch gastric bypass |
|
|
Term
| What is roux en Y small pouch gastricbypass? |
|
Definition
| proximal pouch to roux limb of jejunum |
|
|
Term
| What are the different types of gastric bypass? |
|
Definition
| roux-en-Y small pouch gastric bypass, verticle banded gastroplasty, adjustable lap band, duodenal switch |
|
|
Term
|
Definition
| stomach reduction with division of duodenum at teh pylorus; the distal small bowel is attached to the gastric tube and the proximal small bowel is attached to the lower ileum |
|
|
Term
| What are the results of vertical banded gastroplasty? |
|
Definition
| sustained weight loss is diffficult especially with sweets eaters; high reoperation rate for stoma erosion; frequent GERD |
|
|
Term
| What are hte results of roux-en-Y bypass? |
|
Definition
| sustained results are good loss of 50-60% of excess weight; B12 deficiency, iron deficiency in 20%, marginal ulcer in 2-10%; osteoporosis |
|
|
Term
| What are the results of gastric banding? |
|
Definition
| loss of 33% to 64% of excess weight at 3 to 5 yrs; up to 23% rate of band slippage, resulting in reoperation |
|
|
Term
| What is the effect of gastric bypass on diabetes meliitus? |
|
Definition
| 82% of pts cured of DM type II at 15 yr followup |
|
|
Term
| Does gastric bypass cure sleep apnea? |
|
Definition
| up to 93% of pts have improvement |
|
|
Term
| What is the effect of gastric bypass on hypertension? |
|
Definition
| success correlated with teh amount of weight loss |
|
|
Term
| What is the effect of gastric bypass on serum lipid abnormalities? |
|
Definition
| sucessful gastric bypass is associated with a sustained reduction in triglycerides and low density lipoproteins and an increase in high-density lipoprotiens |
|
|
Term
| How do you select pts to undergo gastric bypass? |
|
Definition
| unsuccessful attempts at supervised weight loss programs, BMI >35 with comorbidity or BMI > 40 without comorbidity; willing to comply with post op lifestyle changes; traditionally pts 18-60 yoa |
|
|
Term
| What is a very common and very serious complication of gastric bypass? |
|
Definition
| leakage from the attachment of the stomach to the intestine characterized by fever, leukocytosis, and left shoulder pain on pod 3 to 5 |
|
|
Term
|
Definition
| production of antiplatelet immunoglobulin bythe spleen; spleen may also function as a primary site of sequestration and destruction of sensitized platelets |
|
|
Term
| What are the symptoms associated with ITP? |
|
Definition
| ecchymoses, gum bleeding, purura, excessive vaginal bleeding and GI tact bleeding |
|
|
Term
| ITP is a diagnosis of exclusion and you need what study to definitively make the diagnosis? |
|
Definition
| bone marrow biopsy with demonstration of normal to hypercellular megakaryocyte count |
|
|
Term
| How long do platelets live? |
|
Definition
| 10-14 days until they are removed by the spleen |
|
|
Term
| What are the functions of the spleen? |
|
Definition
| remove senescent RBCs and platelets, remove abnomral erythrocyte particles and erythrocytes with abnormal membranes; spleen is also a site of opsonins (tuftsin and properdin) and antibodies (particularly IgM) production |
|
|
Term
|
Definition
| depends on teh severity of the thrombocytopenia asymptomatic pts above 30,000, to 50,000 may simply require monitoring initial treatment is corticosteroids which leads to an increased platlet count by 50-75%, other medical therapies include IV Ig, plasmapheresis and chemotherapy; splenectomy is last resort |
|
|
Term
| When is splenectomy recommended for pts with ITP? |
|
Definition
| pts who do not respond to steroids, those who require an excessively high steroid dose and those who require chronic steroid therapy (>1 yr) |
|
|
Term
| How many people have sustained remissions of ITP after splenectomy? |
|
Definition
|
|
Term
| What is the best indication that splenectomy will be of lasting benefit for ITP? |
|
Definition
| increase in platelet count with steroid therapy |
|
|
Term
| When is splenectomy indicated for children with ITP? |
|
Definition
| rarely as spontaneous remission occurs in most children (85%); when splenectomy is needed it should be delayed until after 4 yoa at which time the risk of post splenectomy sepsis is dramatically reduced |
|
|
Term
| Is there an advantage to open vs laparoscopic splenectomy? |
|
Definition
| lap splenectomy allows pts to toelrate feeding sooner, require less pain medication and be discharged from the hospital sooner |
|
|
Term
| Are platelet transfusions given in pts with ITP during their splenectomies? |
|
Definition
| only given if bleeding is uncontrollable and should be held intraoperatively until just after the spleen is removed; if given before this time, they are consumed and confer minimal benefit |
|
|
Term
| What is the most common indication for splenectomy? |
|
Definition
|
|
Term
| What are nontraumatic indications for splenectomy other than ITP? |
|
Definition
| congenital hemolytic anemias such as hereditary spherocytosis and thalassemia major; myeloproliferative disoders may lead to massive splenomegaly which can cause symptoms that are bestrelieved by splenectomy |
|
|
Term
| What factors affect risk for overwhelming postsplenectomy sepsis? |
|
Definition
| age (0.3% of adults, 0.6% of children) and reason for splenectomy (more common with splenectomy for hematologic disease) |
|
|
Term
| When is overwhelming postsplenectomy sepsis (OPSS) most common? |
|
Definition
| within 2 yrs of splenectomy |
|
|
Term
| What are the symptoms of OPSS? |
|
Definition
| malaise, headache, nausea, and confusion |
|
|
Term
| What is the mortality of OPSS? |
|
Definition
| more than 50% in children and about 20% in adults |
|
|
Term
| What are the most common organisms for OPSS? |
|
Definition
| encapsulated bacteria: strep pneumo, HIB, neisseria meningitidis |
|
|
Term
| What vaccines should pts undergoing elective splenectomy? |
|
Definition
| all pts should recieve a polyvalent pneumococcal vaccination 2 weeks before surgery; children and all immunosuppressed patients should be vaccinated against pneumococcus, HIB and meningococcus |
|
|
Term
| T/F Splenomegally is often associated with ITP |
|
Definition
|
|
Term
| Do obstructions associated with Crohns and UC generally need medical or surgical treatment? |
|
Definition
| depends on whether they are due to chornic fibrotic strictures (surgery) or acute inflammation (medical) |
|
|
Term
| What are the disease patterns of Crohn disease? |
|
Definition
| intra-abdominal, perianal or both; intraabdominal crohn disease usually results in one of three predominant disease patterns: stricture perforation or inflammation; perianal disease results in anal stricture fistulas-in-ano, and abscesses |
|
|
Term
|
Definition
| when strictured segment is divided longitudinally and then reapproximated transversely thus increasing the diameter of that segment without resection to preserve small bowel length |
|
|
Term
| What is the % breakdown of where crohn's occurs in the GI tract? |
|
Definition
35-50% terminal ileum and right colon
30-35% ileum
25-35% colon
0.5-4% stomach/duodenum |
|
|
Term
| T/F Anorectal involvement is frequently found in patients with small bowel Crohn disease and may be the initial manifestation in 10% of patients |
|
Definition
|
|
Term
| What causes Crohn disease? |
|
Definition
| etiology remains unknown but it is in part caused by stimulation of an intestinal immune cascade in genetically susceptible individuals |
|
|
Term
| What are the different types of medical therapies used to treat crohn disease? |
|
Definition
| nutritional, antimicrobial, antiinflammatory, immunomodulatory, and anti-TNF |
|
|
Term
| What is nutritional therapy for Crohn disease? |
|
Definition
| bowel rest with total parenteral nutrition, elemental feeding or omega 3 fatty acid supplementation; produce improvement and cause remission in patients with active disease however because of the impact of nutritional therapy on a patient's lifestyle, nutritional therapy has been limited tothe short term treatment of active disease |
|
|
Term
| What is the clinical presentation of mild to moderate crohns? |
|
Definition
| ambulatory, eating and drinking without dehydration, toxicity, abdominal tenderness, painful mass, obstruction or 10% weight loss |
|
|
Term
| What is the clinical presentation of moderate to severe crohn disease? |
|
Definition
| failure of response to mild medical therapies or fevers, significant weight loss, abdominal pain or tenderness, intermittent nausea and vomiting without obstructive findings or significant anemia |
|
|
Term
| What is teh clinical presentation of severe to fulminant crohn disease? |
|
Definition
| persistent symptoms despite use of corticosteroids as outpatient or high fevers, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, evidence of abscess |
|
|
Term
| What are the drugs used for mild to moderate crohn disease and maintenance therapy? |
|
Definition
|
|
Term
| What are the adverse effects of 5-ASA? |
|
Definition
| sperm abnormalities, folate malabsorption, nausea, dyspepsia, headache |
|
|
Term
| What are the adverse effects of metronidazole? |
|
Definition
| nausea, metallic taste, peripheral neuropathy, disulfruam like reaction |
|
|
Term
| What drugs are indicated for moderate to severe crohn disease? |
|
Definition
| corticosteroids, azathioprine and 6 mercaptopurine, methotexate, anti-TNF alpha |
|
|
Term
| What ae the side effects of azathioprine and 6-mercaptopuine? |
|
Definition
| nausea, rash, fever, hepatitis, bone marrow suppression, B-cell lymphoma |
|
|
Term
| What are the side effects of methotrexate? |
|
Definition
| nausea, hepatotoxicity, bone marrow suppresion, stomatitis |
|
|
Term
| What drugs are indicated for severe crohn? |
|
Definition
|
|
Term
| What are the side effects of cyclosporin A/ |
|
Definition
| hypertension, opportunistic infections, gingival hyperplasia, tremor, parathesias, nephotoxicity, hepatotoxicity |
|
|
Term
| What are the adverse effects of anti-TNF? |
|
Definition
| abdominal pain, myalgias, lymphoma, teratogenic effects, delayed hypesensitivity eactions, nausea, fatigue |
|
|
Term
| What kind of antimicobial theapy is used for crohn's? |
|
Definition
| metronidazole or cipofloxacin |
|
|
Term
| What is the mechanism by how antimicrobials treats crohns? |
|
Definition
| largely unknown and may be in pat based on its immunosuppessive effects |
|
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