Jipmer Previous Exam Questions

Transfusion-transmitted viral infections are increasingly rare due to improved screening and testing. The prevalence for cytomegalovirus antibodies in the general population is between 50% to 80%; therefore, a transfusable unit is not tested routinely for cytomegalovirus unless the recipient is seronegative and either pregnant, a potential or present transplant candidate, immunocompromised, or a premature infant. The organism's transmission is prevented by transfusing leukocyte-depleted blood products, which is consistent with the fact that CMV is a leukocyte-associated pathogen.

Blood Disorders > Infectious Diseases Transmitted Through Transfusion
o Current Medical Diagnosis & Treatment 2015

Chapter 233. Transfusion Therapy > Infectious Complications of Blood Transfusion
o Tintinalli's Emergency Medicine

Chapter 113. Transfusion Biology and Therapy > Adverse Reactions to Blood Transfusion
o Harrison's Online

Crohn disease
Antibiotics

Both ciprofloxacin (500 mg twice daily) and metronidazole (1–1.5 g/day) are widely used in the treatment of mild to moderate Crohn disease. Uncontrolled trials have suggested a clinical benefit for these two antibiotics in colonic and perianal Crohn disease, but convincing randomized placebo-controlled evidence is lacking.
Corticosteroids

Oral and intravenous corticosteroids are effective in inducing clinical remission in Crohn disease. Oral prednisone (40–60 mg/day) is a common option for patients with moderate disease. For patients with severe disease or in whom enteric absorption is a concern, intravenous methylprednisolone (40–60 mg/day) or hydrocortisone (200–300 mg/day) is an option. Although useful in achieving remission, steroids are not effective in maintaining it. Therefore, once a satisfactory clinical response has been achieved (usually within 2 weeks), steroids should be tapered gradually.
5-Aminosalicylates

There is a modest benefit of sulfasalazine for achieving remission in patients with colonic Crohn disease. Other 5-ASA drugs that lack the sulfa moiety of sulfasalazine have yielded more equivocal results, with some studies suggesting a modest clinical benefit. Neither sulfasalazine nor other 5-ASA agents have been shown to be effective in maintaining clinical remission in Crohn disease. Certain mesalamine preparations allow release of the drug in the small bowel, theoretically allowing therapy to be directed there rather than the colon. Unfortunately, evidence that such treatment alters disease course is lacking. Despite the limited evidence supporting their use, the favorable safety profile of 5-ASA medications has made them a popular choice for the treatment of patients with mild to moderate disease.

Cholestyramine

Patients with terminal ileal disease or previous terminal ileal resection may not absorb bile acids normally, and this abnormality can lead to secretory diarrhea in the colon. These patients may benefit from bile acid sequestrants (eg, cholestyramine or colestipol). Those who have extensive ileal disease or have undergone resection of more than 100 cm of the ileum have defective bile salt absorption and develop steatorrhea; they benefit from a low-fat diet and medium-chain triglyceride preparations. Bile sequestrants exacerbate this type of diarrhea.

Chapter 3. Inflammatory Bowel Disease: Medical Considerations
o CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 2e

http://emedicine.medscape.com/article/172940-treatment#showall

Chapter 295. Inflammatory Bowel Disease
o Harrison's Online

Management of COPD

Smoking cessation continues to be the most important therapeutic intervention for COPD. Currently, no treatments aside from lung transplantation have been shown to significantly improve lung function or decrease mortality.

Approaches to management by stage include the following:
 Stage I (mild obstruction): Short-acting bronchodilator as needed
 Stage II (moderate obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation
 Stage III (severe obstruction): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbations
 Stage IV (very severe obstruction or moderate obstruction with evidence of chronic respiratory failure): Short-acting bronchodilator as needed; long-acting bronchodilator(s); cardiopulmonary rehabilitation; inhaled glucocorticoids if repeated exacerbation; long-term oxygen therapy (if criteria met); consider surgical options such as lung volume reduction surgery (LVRS) and lung transplantation.

Bronchodilators (beta2 agonists and/or anticholinergics) are the backbone of any COPD treatment regimen. These drugs provide symptomatic relief but do not alter disease progression or decrease mortality.

Theophylline is a nonspecific phosphodiesterase inhibitor and is now limited to use as an adjunctive agent.
Oxygen administration reduces mortality rates in patients with advanced COPD because of the favorable effects on pulmonary hemodynamics. Long-term oxygen therapy improves survival 2-fold or more in hypoxemic patients with COPD.

Chapter 260. Chronic Obstructive Pulmonary Disease
o Harrison's Online

Chapter 7. Chronic Obstructive Pulmonary Disease
o CURRENT Diagnosis & Treatment in Pulmonary Medicine

Obstructive sleep apnea (OSA)

OSA is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.

OSA is defined as the coexistence of unexplained excessive daytime sleepiness with at least five obstructed breathing events (apnea or hypopnea) per hour of sleep. Apneas are defined in adults as breathing pauses lasting ≥10 s and hypopneas as events ≥10 s in which there is continued breathing but ventilation is reduced by at least 50% from the previous baseline during sleep.
Polysomnography

A PSG is necessary to accurately diagnose OSA and to assess treatment benefit. Obstructive apnea is the cessation of airflow for at least 10 seconds with persistent respiratory effort. Central apnea is the cessation of airflow for at least 10 seconds with no respiratory effort.

The apnea-hypopnea index (AHI) is derived from the total number of apneas and hypopneas divided by the total sleep time. Recommendations for cutoff levels on AHI include 5-15 episodes per hour for mild, 15-30 episodes per hour for moderate, and more than 30 episodes per hour for severe.

Weight loss, avoidance of alcohol for 4-6 hours prior to bedtime, and sleeping on one’s side rather than on the stomach or back may help.

People with moderate-to-severe apnea should be treated with nasal continuous positive airway pressure (CPAP). Nasal CPAP therapy is the most effective treatment for OSA. All patients with an apnea-hypopnea index (AHI) greater than 15 are considered eligible for CPAP. For patients with an AHI of 5-14.9, CPAP is indicated only if the patient has one of the following: excessive daytime sleepiness, hypertension, or cardiovascular disease.

Surgery is indicated only if noninvasive types of therapy have not worked or are rejected by the patient. Surgical management of snoring and OSA is indicated when a surgically correctable abnormality is believed to be the source of the problem and the patient has tried continuous positive airway pressure (CPAP) without success. Uvulopalatopharyngoplasty (UPPP) is indicated for retropalatal obstruction. Tracheostomy is the only operation shown to be nearly 100% effective as a sole procedure for OSA.
Mandibular Repositioning Splint (MRS)

Also called oral devices, MRSs work by holding the lower jaw and the tongue forward, thereby widening the pharyngeal airway. This is not as effective as CPAP.


Chapter 265. Sleep Apnea > Obstructive Sleep Apnea
o Harrison's Online

Chapter 19. Sleep and Its Abnormalities > Obstructive Sleep Apnea
o Adams & Victor's Principles of Neurology, 10e

Chapter 26. Chronic Ventilatory Failure > Hypoventilation Disorders or Obstructive Sleep Apnea
o CURRENT Diagnosis & Treatment in Pulmonary Medicine


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