DIAGNOSTIC PRIMARY CA LUNG — Diagnostic evaluation is
focused upon confirmation of the presence and
histopathologic type of tumor, staging of the lesion,
and in many cases, functional evaluation of the
patient as a potential surgical candidate.
Staging of non-small cell lung cancer involves a
traditional approach based upon the characteristics of
the primary tumor (T), the presence or absence of
hilar or mediastinal lymph node involvement (N), and
the presence or absence of distant metastatic disease
(M)
In contrast, staging of small cell carcinoma of the
lung involves distinguishing between disease
restricted to the ipsilateral (ie, same side)
hemithorax (limited disease) and disease extending
beyond the ipsilateral hemithorax (extensive disease).
Functional evaluation is performed when patients are
considered potential surgical candidates for lung
resection, and is particularly important given the
common coexistence of COPD and lung cancer based upon
their shared risk factor of smoking.
---------------------------------------------------
Zinc deficiency secondary to TPN
Clinical manifestations — Numerous signs and symptoms
have been associated with zinc depletion. Mild zinc
deficiency is associated with depressed immunity,
impaired taste and smell, onset of night blindness,
and decreased spermatogenesis. Severe zinc deficiency
is characterized by severely depressed immune
function, frequent infections, bullous pustular
dermatitis, diarrhea, and alopecia .
In some situations, zinc depletion is documented by
measurement of zinc concentration in plasma,
lymphocytes, or neutrophils. Because zinc is a
cofactor for alkaline phosphatase activity, alkaline
phosphatase serves as a serologic marker for zinc
depletion . In other situations, the diagnosis of zinc
depletion is inferred by the response to zinc
supplementation in placebo-controlled intervention.
-----------------------------------------------------
Rx Fournier's gangrene
Fournier's gangrene — In the perineal area,
penetration of the gastrointestinal or urethral mucosa
by enteric organisms can cause Fournier's gangrene, an
aggressive infection. These infections begin abruptly
with severe pain and may spread rapidly onto the
anterior abdominal wall, into the gluteal muscles and,
in males, onto the scrotum and penis. These infections
are induced by a mixture of aerobic and anaerobic
organisms and are therefore classified as type I
infections
Rx
Fournier's gangrene — Fournier's gangrene is a
surgical emergency, and early aggressive drainage or
debridement is essential. Affected patients may
require cystostomy, colostomy, or orchiectomy
ABX
Type I — With suspected type I necrotizing fasciitis,
antibiotic treatment should be based upon Gram's
stain, culture, and sensitivity. Early empiric
treatment could include ampicillin or
ampicillin-sulbactam combined with either clindamycin
or metronidazole. Broader gram-negative coverage might
be necessary if the patient has had prior
hospitalization or if antibiotics have been used
recently. This can be accomplished by substituting
ticarcillin-clavulanate or piperacillin-tazobactam for
ampicillin-sulbactam or by adding a fluoroquinolone,
an aminoglycoside, an extended spectrum cephalosporin,
or a carbapenem.
Anaerobic coverage is essential for type I disease.
Clindamycin or metronidazole should be added to the
antibiotic regimen unless a beta-lactam-beta-lactamase
inhibitor (eg, piperacillin-tazobactam) or carbapenem
was selected since these latter agents are active
against anaerobes.
------------------------------------------------------
Staging Hepatocellular Carcinoma
STAGING AND PROGNOSTIC SCORING SYSTEMS — A number of
systems have been proposed to predict the prognosis
for hepatocellular carcinoma (HCC), none of which has
been universally adopted. These schema variably
incorporate four features that have been recognized as
being important determinants of survival: the severity
of underlying liver disease, the size of the tumor,
extension of the tumor into adjacent structures, and
the presence of metastases. The three most commonly
used systems are the TNM and Okuda systems and, more
recently, the CLIP score.
Tumor, node, metastasis (TNM) staging — The American
Joint Committee on Cancer (AJCC) TNM staging system.
This system recognizes the most important predictors
of prognosis: presence of vascular invasion within the
tumo, and firosis in the underlying liver. Compared to
the 1997 staging system, it recognizes that although
tumor size and number may predict the presence of
vascular invasion, solitary tumors as large as 5 cm
without vascular invasion have the same prognosis as
small (<2 cm) solitary tumors.
The presence and degree of severe cirrhosis or
fibrosis can be used to stratify outcome for every
tumor (T) classification.However, at present, neither
fibrosis nor grade is used to assign the final tumor
stage in the 2002 AJCC classification.
Five-year survival rates, based upon the newer staging
system are as follows:
Stage I – 55 percent
Stage II – 37 percent
Stage III – 16 percent
For patients with severe underlying liver disease, the
Okuda and CLIP systems are useful to stratify
prognosis.
Okuda system — In contrast to the TNM classification,
includes tumor size, and three measures of the
severity of cirrhosis (the amount of ascites and the
serum albumin and bilirubin levels). In one study,
survival was 8.3, 2.0, and 0.7 months for untreated
patients with Okuda stages, I, II, and III,
respectively. The Okuda system does not stratify
patients by vascular invasion or the presence or
absence of nodal metastases. Because most patients
staged according to this system are not candidates for
resection, it is a purely clinical scoring system.
CLIP score — The Cancer of the Liver Italian Program
score (CLIP) is the most recently developed prognostic
scoring system for HCC. It combines tumor-related
features (macroscopic tumor morphology, serum
alpha-fetoprotein levels, and the presence or absence
of portal vein thrombosis) with an index of the
severity of cirrhosis to determine a prognostic score
ranging from 0 to 6 . Several studies from varied
geographic regions have suggested that CLIP performed
better at predicting survival compared to the TNM,
Okuda, or Child-Pugh systems . In a validation study,
the median survival rates for patients with CLIP
stages 0, 1, 2, 3, 4, and 5 to 6 were 31, 27, 13, 8,
2, and 2 months, respectively .A modified version of
the score (incorporating the MELD score) has also been
proposed .
------------------------------------------------------
Side effect Pancuronium
ADVERSE REACTIONS SIGNIFICANT — Frequency not defined.
Cardiovascular: Elevation in pulse rate, elevated
blood pressure and cardiac output, tachycardia, edema,
skin flushing, circulatory collapse
Dermatologic: Rash, itching, erythema, burning
sensation along the vein
Gastrointestinal: Excessive salivation
Neuromuscular & skeletal: Profound muscle weakness
Respiratory: Wheezing, bronchospasm
Miscellaneous: Hypersensitivity reaction
Postmarketing and/or case reports: Acute quadriplegic
myopathy syndrome (prolonged use), myositis ossificans
(prolonged use)
TOXICOLOGY / OVERDOSE COMPREHENSIVE — Symptoms include
apnea, respiratory depression, and cardiovascular
collapse. Pyridostigmine, neostigmine, or edrophonium
in conjunction with atropine will usually antagonize
the action of pancuronium.
------------------------------------------------------
Rx of Barrett's esophagus/ High grade dysplasia
TREATMENT OF DYSPLASIA — For patients with verified
high-grade dysplasia in Barrett's esophagus, there are
generally four proposed management options:
Esophagectomy
Endoscopic therapies that ablate the neoplastic tissue
Endoscopic mucosal resection
Intensive endoscopic surveillance in which invasive
therapies are withheld until biopsy specimens reveal
adenocarcinoma.
All four choices are associated with substantial risks
and unclear benefits. The follow-up duration in most
studies on treatments for dysplasia in Barrett's
esophagus is considerably less than five years. As a
result, the efficacy of these therapies in reducing
cancer deaths is not established, although at least
two cost-effectiveness analyses concluded that
endoscopic ablation provided the longest quality
adjusted life expectancy
------------------------------------------------------
Fuel source CNS in prolong starvation
Ketone can be used by CNS for energy in prolonged
starvation
-------------------------------------------------------
Rx of ITP
Supportive care — Regardless of whether pharmacologic
therapy is used, restriction of activity (especially
contact sports) should be recommended in all children
with ITP. In addition, medications with antiplatelet
activity (including aspirin-containing preparations,
ibuprofen and other non-steroidal anti-inflammatory
drugs) or those with anticoagulant activity should be
avoided.
Pharmacologic intervention — As previously noted,
there are limited data on the use of pharmacologic
intervention in children with ITP.
In our practice, the presence of one or more of the
following factors is used as an indication for
pharmacologic intervention:
Presence of severe or life-threatening bleeding
Risk of significant bleeding, such as a child
undergoing a procedure that is likely to induce blood
loss
Any concomitant or preexisting condition that
increases the risk of thrombocytopenia or bleeding
(eg, hemophilia)
When it is decided to use pharmacologic therapy,
treatment options include corticosteroids, intravenous
immunoglobulin (IVIG or IGIV), or intravenous
anti-Rho(D) immune globulin
If ICH or any other life-threatening hemorrhage
occurs, immediate intervention should be given to the
affected patient. In our institution this includes the
following;
Platelet transfusions
IVIG — 1000 mg/kg per day for two days
Methylprednisolone — 30 mg/kg per day administered
intravenously for three days
Splenectomy — A small percentage of patients with
chronic ITP will have persistent significant
hemorrhagic symptoms and require repeated, sometimes
almost continuous, pharmacologic interventions. For
such patients, the risks and benefits of splenectomy
must be considered.
Treatment of refractory chronic ITP — Approximately 25
to 30 percent of children with chronic ITP have
ongoing hemorrhagic problems after splenectomy. In
these cases, evaluation should identify any possible
accessory spleen, which should be removed, if present.
------------------------------------------------------
Rx for Carbon monoxide poisoning
Treatment
Secure airway, breathing, and circulation
Intubate as clinically indicated
Apply high-flow oxygen to all CO poisoned patients
regardless of pulse oximetry or arterial pO2
Direct fire department to assess for environmental
exposure and remove victims
We suggest hyperbaric oxygen (HBO) for:
CO level >25 percent (>20 percent if pregnant)
Loss of consciousness
Severe metabolic acidosis (pH <7.1)
Concern for end-organ ischemia (chest pain, ECG
changes, altered mental status)
-------------------------------------------------------
Role TNF in Cancer
TNF BIOLOGY — TNF, originally known as cachexin, was
recognized in 1975 for its ability to lyse tumors in a
variety of in vitro and mouse models (hence, the name
"tumor necrosis factor"). The biology of TNF is
discussed in detail separately.
The activity of TNF against tumors in laboratory
models and potentially in humans raises the
possibility that TNF inhibition might potentiate the
clinical risk of malignancy. A significant body of
literature supports the concept that TNF is active
against some forms of cancer. Experimental evidence of
an anti-tumor effect for TNF led to the systemic
administration of this cytokine for the treatment of
some malignancies.
------------------------------------------------------
Serum marker testicular cancer
Serum tumor markers — In a man suspected of having a
testicular cancer, blood should be obtained for a
chemistry profile, complete blood count, and serum
tumor markers. Three serum tumor markers have
established roles in testicular cancer: alpha
fetoprotein (AFP), the beta subunit of human chorionic
gonadotropin (beta-hCG, since the alpha subunit is
common to several pituitary hormones), and lactate
dehydrogenase (LDH). Serum levels of AFP and/or
beta-hCG are elevated in 80 to 85 percent of men with
NSGCTs, even when nonmetastatic. In contrast, serum
beta-hCG is elevated in fewer than 20 percent of
testicular seminomas, and AFP is not elevated in pure
seminomas.
Serum beta-hCG concentrations above 10,000 mIU/mL
occur only in GCTs, the rare patient with
trophoblastic differentiation of a lung or gastric
primary cancer, or, in women, pregnancy or gestational
trophoblastic disease
Serum AFP concentrations above 10,000 ng/mL occur
almost exclusively in GCTs and hepatocellular
carcinoma.
Although serum tumor markers are helpful at the time
of initial diagnosis of a testicular cancer and for
prognostication, their main utility is for subsequent
follow-up of disease status after primary treatment.
-------------------------------------------------------
Condition associate Medullary Thyroid CA
In most patients with MTC, the disease has already
metastasized at the time of diagnosis. Approximately
50 percent of patients have clinically detectable
cervical lymph node involvement, up to 15 percent have
symptoms of upper aerodigestive tract compression or
invasion such as dysphagia or hoarseness, and about 5
percent have distant disease
Systemic symptoms may occur due to hormonal secretion
by the tumor. Tumor secretion of calcitonin,
calcitonin-gene related peptide, or other substances
can cause diarrhea or facial flushing in patients with
advanced disease. In addition, occasional tumors
secrete corticotropin (ACTH), causing Cushing's
syndrome.
MEN2A is associated with MTC, pheochromocytoma, and
primary parathyroid hyperplasia. While the penetrance
of MTC is nearly 100 percent, there is inter- and
intra-family variability in the specific pattern of
the other disease manifestations.
MEN2B shares the inherited predisposition to MTC and
pheochromocytoma present in MEN2A, but does not
include hyperparathyroidism. MTC occurs in almost all
patients. The tumor develops at an earlier age and may
be more aggressive than in MEN2A.
FMTC is a variant of MEN2A, in which there is a strong
predisposition to MTC but not the other clinical
manifestations of MEN2A (or 2B).
------------------------------------------------------
Etiology lymphangitis
Lymphangitis is an infection of the lymphatic vessels,
an important component of the immune system's
filtration process, that is caused by a bacterial
infection. If left untreated, lymphangitis can spread
quickly throughout the bloodstream and is potentially
fatal.
The bacteria that cause lymphangitis can enter the
body in a variety of ways. Common entry methods
include scratches, cuts, surgical wounds, insect
bites, and any other type of skin wound. When the
bacteria successfully enter the lymphatic system, they
multiply and move throughout the system.
The most common bacteria to cause lymphangitis is
Streptococcus pyogenes, which is also the bacteria
that causes strep throat. It also causes infections of
the spinal cord, heart, and lungs. Because of its
ability to lead to lymphangitis, this bacteria is also
sometimes referred to as “flesh–eating bacterium.”
Staphylococci bacteria may also cause lymphangitis.
As the bacteria move through the lymphatic system,
they cause the vessels to become inflamed. This
inflammation causes the red streaks that are
characteristic of lymphangitis. Since the bacteria
grow so quickly, the immune system is unable to
respond quickly enough to prevent the infection from
forming.
------------------------------------------------------
Structure injury in inguinal hernia repair
Complications that can occur during surgery include
injury to the spermatic cord structure; injuries to
veins or arteries, causing hemorrhage; severing or
entrapping nerves, which can cause paralysis; injuries
to the bladder or bowel
