journal review n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Journal Review PowerPoint Presentation
Download Presentation
Journal Review

Loading in 2 Seconds...

play fullscreen
1 / 106

Journal Review - PowerPoint PPT Presentation


  • 240 Views
  • Uploaded on

Journal Review. American Academy of Family Physicians October 1 st , 2009 Am Fam Physician .2009; 80 (7). Journal Review. Diagnosis and Management of Dehydration in Children Henoch-Schönlein Purpura Gadolinium-Associated Nephrogenic Systemic Fibrosis

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Journal Review' - cade


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
journal review

Journal Review

American Academy of Family Physicians

October 1st, 2009

Am Fam Physician.2009; 80 (7)

journal review1
Journal Review
  • Diagnosis and Management of Dehydration in Children
  • Henoch-Schönlein Purpura
  • Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Diagnosis and Treatment of Bladder Cancer
diagnosis and management of dehydration in children
Diagnosis and Management of Dehydration in Children
  • Fluid and electrolyte disturbances from acute gastroenteritis result in 1.5 million outpatient visits, 200,000 hospitalizations, and 300 deaths per year, among children in the United States.
  • Clinical dehydration scales based on a combination of physical examination findings are the most specific and sensitive tools for accurately diagnosing dehydration in children.
diagnosis and management of dehydration in children1
Diagnosis and Management of Dehydration in Children
  • Parental report of vomiting, diarrhea, or decreased oral intake is sensitive, but not specific, for identifying dehydration in children.
  • Comparing change in body weight from before and after rehydration is the standard method for diagnosing dehydration.
diagnosis and management of dehydration in children2
Diagnosis and Management of Dehydration in Children
  • To identify dehydration in infants and children before treatment the most useful individual signs for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern.
  • Combination of physical examination findings are much better predictors.
diagnosis and management of dehydration in children3
Diagnosis and Management of Dehydration in Children
  • Gorelick et al. found that the presence of two or more of these four factors indicates a fluid deficit of at least 5%:
    • capillary refill time of more than two seconds
    • absence of tears
    • dry mucous membranes
    • ill general appearance
  • Goldman et al. found that the presence of this factors were associated with length of hospital stay and need for IV fluids:
    • ill general appearance
    • degree of sunken eyes
    • dry mucous membranes
    • tear production
diagnosis and management of dehydration in children4
Diagnosis and Management of Dehydration in Children
  • Assessment of capillary refill time, done in warm temperature. Measured on the sternum of infants and on a finger or arm at heart level, in older children. Not affected by fever . NL is < 2 seconds.
  • Skin turgor is the time required for the skin to recoil, NL is instantaneous. Assessment is done by pinching skin on the lateral abdominal wall at the level of the umbilicus. Increases with degree of dehydration.
diagnosis and management of dehydration in children5
Diagnosis and Management of Dehydration in Children

Labs:

  • Serum creatinine level changes with age. Therefore, BUN/creatinine ratio is not useful in children.
  • A serum bicarbonate level of <17 mEq/L may improve sensitivity of identifying children with moderate to severe hypovolemia.
  • A serum bicarbonate level of <13 mEq/L is associated with increased risk of failure of outpatient rehydration efforts.
diagnosis and management of dehydration in children6
Diagnosis and Management of Dehydration in Children
  • The AAP recommends oral rehydration therapy (ORT) as the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to moderate dehydration.
  • It is as effective as IV fluid and, can be initiated more quickly, and can be administered at home.
  • Parents are more satisfied with the visit when ORT had been used.
  • With ORT, the same fluid can be used for rehydration, maintenance, and replacement of stool losses.
diagnosis and management of dehydration in children7
Diagnosis and Management of Dehydration in Children
  • Contraindications for ORT: AMS with risk of aspiration, abdominal ileus, and underlying intestinal malabsorption.
  • Nasogastric rehydration therapy with ORT solution is an alternative to intravenous fluid therapy in patients with poor oral intake.
  • A regular age-appropriate diet should be initiated as soon as children with acute gastroenteritis are rehydrated.
diagnosis and management of dehydration in children8
Diagnosis and Management of Dehydration in Children
  • Commercial ORT solutions (Pedialyte)are recommended over homemade solutions because of the risk of preparation errors.
  • They typically contain:
    • 50 mEq per L of sodium: consistent with the sodium content of diarrhea caused by rotavirus
    • 25 g /L of dextrose: helps prevent hypoglycemia without causing osmotic diuresis
    • 21 and 30 mEq per L of bicarbonate: leads to less vomiting and more efficient correction of acidosis.
  • Clear sodas and juices should not be used for ORT because hyponatremia may occur.
diagnosis and management of dehydration in children10
Diagnosis and Management of Dehydration in Children
  • For mild dehydration, 50 mL/kg of ORT solution should be administered over 4hours using a spoon, syringe, or medicine cup = 1 mL/kg q5 minutes.
  • If the child vomits, resume treatment after 30 minutes.
  • After the 4hour treatment period, maintenance fluids should be given and ongoing losses assessed and replaced q2 hours.
  • Maintenance therapy includes providing anticipated water and electrolyte needs for the next 24 hours in the child who is now euvolemic .
diagnosis and management of dehydration in children11
Diagnosis and Management of Dehydration in Children
  • Holliday-Segar method formula for estimating water needs.
  • Based on average weights of infants and children.
  • Maintenance ORT at home: 1oz/hr for infants, 2oz/hr for toddlers, and 3oz/hr for older children.
  • Ongoing losses, 10mL/kg for every loose stool and 2mL/kg for every episode of emesis.
diagnosis and management of dehydration in children13
Diagnosis and Management of Dehydration in Children
  • For moderate dehydration, 100 mL/kg of ORT should be given over 4hours in the physician’s office or ER.
  • If successful the child may be sent home, where caregivers should provide maintenance therapy and replace ongoing losses q2 hours as for mild dehydration.
  • Unsuccessful = severe, persistent vomit of at least 25 % of the hourly oral requirement or if ORT cannot keep up with the volume of stool losses.
diagnosis and management of dehydration in children14
Diagnosis and Management of Dehydration in Children
  • Severe dehydration should be treated with 20mL/ kg IV of isotonic crystalloid over 10 to 15 minutes .Repeat as necessary.
  • Monitor pulse strength, capillary refill time, mental status, urine output and electrolyte s
  • After resuscitation administer 100mL/kg of ORT solution over 4hours, then maintenance fluid and replacement of ongoing losses.
  • If ORT fails administer 100mL/kg IV of isotonic crystalloid over 4hours, followed by a maintenance solution.
diagnosis and management of dehydration in children15
Diagnosis and Management of Dehydration in Children
  • IV maintenance fluid should be D5 and ¼ NS, plus 20 mEq/L of K.
  • I&O, and VS q4 hours
  • If stool output >30 mL/kg per day, replace equal volume q4 hours with an IV comparable in electrolytes with the stool (1/2 NS plus 20 to 30 mEq per L of potassium), in addition to the volume of maintenance fluid, until ORT can be tolerated.
diagnosis and management of dehydration in children16
Diagnosis and Management of Dehydration in Children
  • Fever may require 1 mL/kg/Cqhour.
  • Postoperatively and in children with CNS infection or injury 20% to 50% less fluid and fluid with higher sodium content may be needed because of abnormal antidiuretic hormone.
diagnosis and management of dehydration in children17
Diagnosis and Management of Dehydration in Children
  • Medication to decrease diarrhea is not recommended.
  • Lactobacillus effectiveness in patients with diarrhea has not been demonstrated.
  • A single dose of ondansetron (Zofran) has been shown to facilitate ORT. Recurrent dosing has not been studied.
diagnosis and management of dehydration in children18
Diagnosis and Management of Dehydration in Children
  • Complications of dehydration include hypernatremia, hyponatremia, and hypoglycemia.
diagnosis and management of dehydration in children19
Diagnosis and Management of Dehydration in Children
  • Hypernatremia indicates water loss in excess of sodium.
  • Signs of dehydration are less pronounced in this setting.
  • Circulatory disturbance is not likely to be noted until dehydration reaches 10%.
  • Findings include a “doughy” feeling rather than tenting when testing for skin turgor, increased muscle tone, irritability, and a highpitched cry.
diagnosis and management of dehydration in children20
Diagnosis and Management of Dehydration in Children
  • Hyponatremia is often caused by inappropriate use of oral fluids that are low in sodium.
  • If severe dehydration is present, hydrate with isotonic crystalloid until stabilized.
  • If after initial volume repletion, hyponatremia remains moderate to severe (serum Na <130 mEq/L) replacement of the remaining fluid deficit should be altered, with a principal goal of slow correction.
diagnosis and management of dehydration in children21
Diagnosis and Management of Dehydration in Children
  • Wathen et al. found blood glucose levels of <60mg/dL in 9% of children < 9years admitted to the hospital with diarrhea.
  • Blood glucose screening may be indicated for toddlers with diarrhea.
diagnosis and management of dehydration in children22
Diagnosis and Management of Dehydration in Children
  • 1. Which one of the following statements about oral rehydration therapy (ORT) for moderate dehydration in children is correct, compared with intravenous fluid therapy?
  • A. ORT leads to a higher hospitalization rate.
  • B. ORT has a higher failure rate.
  • C. ORT requires more emergency department staff time.
  • D. Parents are more satisfied with ORT.
diagnosis and management of dehydration in children23
Diagnosis and Management of Dehydration in Children
  • 1. Which one of the following statements about oral rehydration therapy (ORT) for moderate dehydration in children is correct, compared with intravenous fluid therapy?
  • A. ORT leads to a higher hospitalization rate.
  • B. ORT has a higher failure rate.
  • C. ORT requires more emergency department staff time.
  • D. Parents are more satisfied with ORT.
diagnosis and management of dehydration in children24
Diagnosis and Management of Dehydration in Children
  • 2. Which of the following is/are contraindications for ORT in children with diarrhea?  (check all that apply)
  • A. Ondansetron (Zofran) use.
  • B. Abdominal ileus.
  • C. Altered mental status with risk of aspiration.
  • D. Intestinal malabsorption.
diagnosis and management of dehydration in children25
Diagnosis and Management of Dehydration in Children
  • 2. Which of the following is/are contraindications for ORT in children with diarrhea?  (check all that apply)
  • A. Ondansetron (Zofran) use.
  • B. Abdominal ileus.
  • C. Altered mental status with risk of aspiration.
  • D. Intestinal malabsorption.
diagnosis and management of dehydration in children26
Diagnosis and Management of Dehydration in Children
  • 3. Which of the following recommendations for children with gastroenteritis is/are correct?  (check all that apply)
  • A. A normal diet should be initiated after they are rehydrated.
  • B. Diphenoxylate/atropine (Lomotil) may be used to reduce diarrhea.
  • C. A single dose of ondansetron may be used to increase ORT tolerance.
  • D. Hypernatremia should be suspected if the child’s skin feels “doughy.”
diagnosis and management of dehydration in children27
Diagnosis and Management of Dehydration in Children
  • 3. Which of the following recommendations for children with gastroenteritis is/are correct?  (check all that apply)
  • A. A normal diet should be initiated after they are rehydrated.
  • B. Diphenoxylate/atropine (Lomotil) may be used to reduce diarrhea.
  • C. A single dose of ondansetron may be used to increase ORT tolerance.
  • D. Hypernatremia should be suspected if the child’s skin feels “doughy.”
henoch sch nlein purpura
Henoch-Schönlein Purpura
  • Henoch-Schönlein purpura is an acute, systemic, immune complex–mediated, leukocytoclastic vasculitis.
  • Clinical triad: palpable purpura (without thrombocytopenia), abdominal pain, and arthritis.
  • Complications: glomerulonephritis and gastrointestinal bleeding.
henoch sch nlein purpura1
Henoch-Schönlein Purpura
  • 10 to 22 persons in 100,000 each year.
  • Most common from late autumn to early spring
  • > 90% of patients are children <10 years, with a peak incidence at six years of age.
  • Milder in infants and children younger than 2 years.
  • More severe in adults.
  • Slight male predominance.
henoch sch nlein purpura2
Henoch-Schönlein Purpura
  • Pathophysiology:
    • Immunoglobulin A (IgA) immune complexes are deposited in small vessels, which causes petechiae and palpable purpura.
    • Small vessels of the intestinal wall involvement may lead to GI hemorrhage.
    • In the kidney, it may produce glomerulonephritis.
  • Exposure to an antigen from an infection, medication, or other environmental factor may trigger antibody and immune complex formation.
henoch sch nlein purpura3
Henoch-Schönlein Purpura
  • Group A streptococcus found in more than 30% of cases with nephritis.
  • Parvovirus B19, Bartonella henselae, Helicobacter pylori, Haemophilus parainfluenza, Coxsackie virus, adenovirus, hepatitis A and B viruses, mycoplasma, Epstein-Barr virus, varicella, campylobacter and MRSA.
henoch sch nlein purpura4
Henoch-Schönlein Purpura
  • Purpura, abdominal pain, arthritis, fatigue and low-grade fever.
  • Nonpruritic rash that starts as erythematous papules or urticarial wheals, and then matures into crops of petechiae and purpura.
  • Timing of symptoms may be within days or weeks.
  • Usually follows an upper respiratory infection.
henoch sch nlein purpura5
Henoch-Schönlein Purpura
  • Purpura is defined as nonblanching cutaneous hemorrhages that > 10 mm in diameter.
  • May enlarge into palpable ecchymoses.
  • The lesions change from red to purple to rust-colored before fading over a period of approximately 10 days.
  • Rash most common in dependent areas that are subject to pressure (lower extremities, belt line, and buttocks.
  • Purpura most common on extensor surfaces of the extremities.
henoch sch nlein purpura7
Henoch-Schönlein Purpura
  • A nonmigratory arthritis occurs in 75% of patients.
  • Affects knees and ankles.
  • Transient swelling, warmth, and tenderness. Leave no deformity.
  • May precede the purpuric rash in 15% to 25% of patients.
henoch sch nlein purpura8
Henoch-Schönlein Purpura
  • Abdominal Pain in 60% to 65% of patients.
  • May mimic an acute abdomen.
  • Colicky, occurs about one week after the onset of the rash.
  • Vomiting and GI bleeding will develop in 30% of patients.
  • Complications: severe GI hemorrhage and intussusception.
henoch sch nlein purpura9
Henoch-Schönlein Purpura
  • Renal disease 40% to 50% of patients.
  • Leading cause of death .
  • Risk greatest in pt > 10 years with persistent purpura, severe abdominal pain, or relapsing episodes.
  • Usually starts within the first month and rarely six months after the illness begins.
  • Microscopic hematuria, red cell casts, and proteinuria.
  • Will spontaneously remit in most patients.
  • May progress to glomerulonephritis
henoch sch nlein purpura10
Henoch-Schönlein Purpura
  • Diagnosis:
    • Clinical triad: purura, abdominal pain and arthritis
    • Palpable purpura in the absence of thrombocytopenia.
    • Punch biopsy of the skin: leukocytoclastic vasculitis
    • Renal biopsy: membranoproliferative glomerulonephritis
henoch sch nlein purpura11
Henoch-Schönlein Purpura
  • Treatment:
  • Spontaneous resolution in 94% of children and 89% of adults.
  • Supportive treatment is the primary intervention.
  • Acetaminophen for arthralgia
  • NSAIDS may aggravate GI symptoms and should be avoided in patients with renal involvement.
  • Relative rest and elevation of affected extremities during the active phase.
  • Pt may have recurrent purpura as they increase their activity level.
henoch sch nlein purpura12
Henoch-Schönlein Purpura
  • Hospitalization may be required for dehydration, hemorrhage, or pain control.
  • Nephrology referral if significant renal involvement.
  • Early steroid treatment is for children with renal involvement or severe extra renal symptoms.
  • Oral prednisone at 1 to 2 mg/kg/day x 2 weeks.
henoch sch nlein purpura13
Henoch-Schönlein Purpura
  • For severe renal involvement treatment options include:
    • High-dose steroids with immunosuppressants
    • High-dose intravenous immunoglobulin
    • Plasmapheresis
    • Cyclophosphamide
    • Renal transplant.
henoch sch nlein purpura14
Henoch-Schönlein Purpura
  • Follow up:
  • Most patients recover fully within four weeks.
  • Recurrences occur in up to 1/3 of patients within the first six months after onset.
  • Long-term prognosis depends on the severity of renal involvement; end-stage renal disease occurs in 1% to 5% of patients.
henoch sch nlein purpura15
Henoch-Schönlein Purpura
  • BP measurement and UA should be performed at the time of diagnosis and at each f/u visit.
  • Serum BUN and creatinine should be obtained if hematuria or proteinuria are identified.
  • If the initial UA is normal a monthly urinalysis should be performed for the first 6 months after the diagnosis
henoch sch nlein purpura16
Henoch-Schönlein Purpura
  • 1. Which one of the following statements about the clinical presentation of Henoch-Schönlein purpura is correct?
  • A. Purpura, abdominal pain, and arthritis are universally present.
  • B. Purpura usually occurs on the flexor surfaces of the extremities.
  • C. The rash is first identified as crops of petechiae and purpura.
  • D. The rash usually fades over a period of approximately 10 days.
henoch sch nlein purpura17
Henoch-Schönlein Purpura
  • 1. Which one of the following statements about the clinical presentation of Henoch-Schönlein purpura is correct?
  • A. Purpura, abdominal pain, and arthritis are universally present.
  • B. Purpura usually occurs on the flexor surfaces of the extremities.
  • C. The rash is first identified as crops of petechiae and purpura.
  • D. The rash usually fades over a period of approximately 10 days.
henoch sch nlein purpura18
Henoch-Schönlein Purpura
  • 2. A seven-year-old child is diagnosed with Henoch-Schönlein purpura and has moderate symptom severity. Which one of the following treatments is most appropriate?
  • A. Supportive care only.
  • B. A nonsteroidal anti-inflammatory drug or acetaminophen.
  • C. Corticosteroids only.
  • D. Corticosteroids plus adjunctive immunosuppressant drugs.
henoch sch nlein purpura19
Henoch-Schönlein Purpura
  • 2. A seven-year-old child is diagnosed with Henoch-Schönlein purpura and has moderate symptom severity. Which one of the following treatments is most appropriate?
  • A. Supportive care only.
  • B. A nonsteroidal anti-inflammatory drug or acetaminophen.
  • C. Corticosteroids only.
  • D. Corticosteroids plus adjunctive immunosuppressant drugs.
henoch sch nlein purpura20
Henoch-Schönlein Purpura
  • 3. Which of the following statements about the diagnosis of Henoch-Schönlein purpura is/are correct?  (check all that apply)
  • A. Renal biopsy is the definitive initial diagnostic test.
  • B. Palpable purpura in the absence of thrombocytopenia is universally present.
  • C. Punch biopsy of the skin will reveal a leukocytoclastic vasculitis.
  • D. Abdominal computed tomography should be performed if renal biopsy is positive.
henoch sch nlein purpura21
Henoch-Schönlein Purpura
  • 3. Which of the following statements about the diagnosis of Henoch-Schönlein purpura is/are correct?  (check all that apply)
  • A. Renal biopsy is the definitive initial diagnostic test.
  • B. Palpable purpura in the absence of thrombocytopenia is universally present.
  • C. Punch biopsy of the skin will reveal a leukocytoclastic vasculitis.
  • D. Abdominal computed tomography should be performed if renal biopsy is positive.
gadolinium associated nephrogenic systemic fibrosis
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Nephrogenic systemic fibrosis was first noted in 1997.
  • Thought to be a scleromyxedema-like cutaneous disease in patients with renal failure.
  • Renamed nephrogenic systemic fibrosis after postmortem evaluations revealed the fibroses extending into other organ.
  • The relationship between nephrogenic systemic fibrosis and gadolinium based contrast agents used in MRI was reported in 2006.
gadolinium associated nephrogenic systemic fibrosis1
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • The FDA recommends against using gadolinium-based contrast agents in patients with acute or chronic renal insufficiency, with a glomerular filtration rate (GFR) <30 mL/min/ 1.73 m2, or with any acute renal failure caused by the hepatorenal syndrome or perioperative liver transplantation, unless the diagnostic information is essential and not available with noncontrast-enhanced MRI.
gadolinium associated nephrogenic systemic fibrosis2
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • The incidence of nephrogenic systemic fibrosis in patients with severe renal insufficiency following exposure to gadoliniumbased contrast agents appears to be approximately 4%, without any regard to sex, race, or age.
gadolinium associated nephrogenic systemic fibrosis3
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Symptoms of nephrogenic systemic fibrosis may develop from the first day of exposure to gadolinium to several months after.
  • Median time to symptoms is ~ 11.5 days after exposure.
  • Patients present with pruritic, erythematous plaques with associated induration and edema.
gadolinium associated nephrogenic systemic fibrosis4
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • The plaques may coalesce to form a peau d’orange appearance.
  • Skin manifestations are symmetric, typically involve the extremities and trunk, and rarely affect the face.
gadolinium associated nephrogenic systemic fibrosis5
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Joint contractures are common and often lead to significant disability.
  • The fibrosis is not limited to the skin and can affect multiple organs, leading to multisystem organ failure.
  • Can cause respiratory failure from diaphragmatic involvement that may lead to death.
  • Mortality has been reported to be 31%.
gadolinium associated nephrogenic systemic fibrosis6
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Diagnosis of nephrogenic systemic fibrosis is made by high clinical suspicion in at-risk patients and confirmed by the characteristic findings on skin biopsy.
  • Nephrogenic systemic fibrosis is a rare condition, and cases should be reported to the International Center for Nephrogenic Fibrosing Dermopathy Research at Yale.
gadolinium associated nephrogenic systemic fibrosis7
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • The pathophysiology is unclear.
  • Gadolinium is toxic and, therefore, is chelated when administered as a contrast.
  • One theory (transmetallation) refers to another element displacing gadolinium from the chelate and forming a free gadolinium ion.
  • The free gadolinium ion may deposit in tissues.
  • Proinflammatory states likely make the gadolinium more likely to undergo transmetallation .
gadolinium associated nephrogenic systemic fibrosis8
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • Renal failure increases the duration of the gadolinium exposure through decreased clearance, with a higher incidence of deposition into tissue.
  • This deposition leads to the recruitment of fibrocytes, which, along with the proinflammatory state, causes tissue injury and further fibrocyte recruitment, ultimately leading to nephrogenic systemic fibrosis.
gadolinium associated nephrogenic systemic fibrosis9
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • There is no effective treatment.
  • Trials with corticosteroids, photopheresis, plasmapheresis, thalidomide, thiosulfate, and methotrexate have not had consistent success.
  • Hemodialysis can be effective at removing gadolinium contrast media from the body, but there is no evidence that immediate hemodialysis protects against the development of nephrogenic systemic fibrosis.
gadolinium associated nephrogenic systemic fibrosis10
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 1. A patient with severe renal insufficiency is scheduled for contrast-enhanced magnetic resonance imaging. Which one of the following factors increases this patient’s risk of developing nephrogenic systemic fibrosis after gadolinium exposure?
  • A. Female sex.
  • B. Native American ethnicity.
  • C. Age younger than 35 years.
  • D. Malignancy.
gadolinium associated nephrogenic systemic fibrosis11
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 1. A patient with severe renal insufficiency is scheduled for contrast-enhanced magnetic resonance imaging. Which one of the following factors increases this patient’s risk of developing nephrogenic systemic fibrosis after gadolinium exposure?
  • A. Female sex.
  • B. Native American ethnicity.
  • C. Age younger than 35 years.
  • D. Malignancy.
gadolinium associated nephrogenic systemic fibrosis12
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 2. Which one of the following statements most accurately represents the U.S. Food and Drug Administration (FDA) recommendation on gadolinium use?
  • A. Gadolinium is safe to use if preventive hemodialysis is performed.
  • B. Gadolinium should be avoided whenever possible in patients at risk of developing nephrogenic systemic fibrosis.
  • C. The FDA recommends a ban on gadolinium.
  • D. Gadolinium does not pose enough risk in humans to alter prescribing practices
gadolinium associated nephrogenic systemic fibrosis13
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 2. Which one of the following statements most accurately represents the U.S. Food and Drug Administration (FDA) recommendation on gadolinium use?
  • A. Gadolinium is safe to use if preventive hemodialysis is performed.
  • B. Gadolinium should be avoided whenever possible in patients at risk of developing nephrogenic systemic fibrosis.
  • C. The FDA recommends a ban on gadolinium.
  • D. Gadolinium does not pose enough risk in humans to alter prescribing practices
gadolinium associated nephrogenic systemic fibrosis14
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 3. Which of the following measures should be considered in preventing nephrogenic systemic fibrosis?  (check all that apply)
  • A. Switching to a safer type of gadolinium.
  • B. Screening all patients for renal dysfunction.
  • C. Using gadolinium with caution in pregnant patients.
  • D. Using peritoneal dialysis instead of hemodialysis in patients with chronic kidney failure.
gadolinium associated nephrogenic systemic fibrosis15
Gadolinium-Associated Nephrogenic Systemic Fibrosis
  • 3. Which of the following measures should be considered in preventing nephrogenic systemic fibrosis?  (check all that apply)
  • A. Switching to a safer type of gadolinium.
  • B. Screening all patients for renal dysfunction.
  • C. Using gadolinium with caution in pregnant patients.
  • D. Using peritoneal dialysis instead of hemodialysis in patients with chronic kidney failure.
diagnosis and treatment of bladder cancer
Diagnosis and Treatment of Bladder Cancer
  • Sixth most prevalent malignancy in the United States.
  • Fourth most common cancer in men and the eighth most common in women.
  • 14,000 deathsyear caused by this disease.
  • 80% of new cases occur in persons >60 years.
  • 3 times more prevalent in men
  • It is more prevalent in white persons; however, mortality rates are higher in black persons.
diagnosis and treatment of bladder cancer2
Diagnosis and Treatment of Bladder Cancer
  • The incidence of bladder cancer in a patient with gross hematuria is 20% and with microscopic hematuria is 2%.
  • Symptoms of bladder irritation (urinary frequency and urgency) are more common in patients with bladder carcinoma in situ.
diagnosis and treatment of bladder cancer3
Diagnosis and Treatment of Bladder Cancer
  • Diagnosis:
    • Careful history, including any history of cigarette smoking or occupational exposures.
    • Patients with urinary symptoms should have a urinalysis with urine microscopy and a urine culture to rule out infection.
diagnosis and treatment of bladder cancer4
Diagnosis and Treatment of Bladder Cancer
  • Urine cytology is a noninvasive test for the diagnosis of bladder cancer.
  • Used to identify high-grade tumors and monitor patients for persistent or recurrent disease following treatment.
  • Urine cytology has a high specificity (95 to 100 percent), but a low sensitivity (66 to 79 percent) for the detection of bladder cancer.
diagnosis and treatment of bladder cancer5
Diagnosis and Treatment of Bladder Cancer
  • Cystoscopy, an office procedure usually performed under local anesthesia, remains the mainstay of diagnosis and surveillance.
  • Provides information about the tumor location, appearance, and size.
  • Detection of flat neoplastic lesions, such as carcinoma in situ, can be enhanced by using fluorescence cystoscopy.
diagnosis and treatment of bladder cancer6
Diagnosis and Treatment of Bladder Cancer
  • Bladder wash cytology detects carcinoma in situ in almost all cases, even when the urothelium appears grossly normal, and obviates the need for random bladder biopsies.
diagnosis and treatment of bladder cancer7
Diagnosis and Treatment of Bladder Cancer
  • Evaluation of Upper Urinary Tract
  • Additional workup for all patients with bladder cancer includes evaluation of the upper urinary tract with intravenous urography (IVU), renal ultrasonography, computed tomography (CT) urography, or magnetic resonance (MR)urography.
  • Renal ultrasonography alone is insufficient to complete the evaluation of hematuria in a patient with bladder cancer because it cannot delineate details of the urinary collecting system.
diagnosis and treatment of bladder cancer8
Diagnosis and Treatment of Bladder Cancer
  • Evaluation for metastatic disease:
  • CBC, CMP(alkaline phosphatase , LFT), chest radiography, and CT or magnetic resonance imaging of the abdomen and pelvis should be included in the metastatic workup for invasive bladder cancer.
  • Bone scan if alkaline phosphatase level is elevated or if symptoms suggesting bone metastasis are present.
diagnosis and treatment of bladder cancer9
Diagnosis and Treatment of Bladder Cancer
  • Tumor markers:
  • Bladder tumor antigen (BTA); fluorescence in situ hybridization (FISH)analysis; ImmunoCyt test; nuclear matrix protein 22(NMP22) test and telomeric repeat amplification protocol.
  • FDA approved NMP tests and FISH analysis for chromosomal changes in cells in urine, have demonstrated a superior sensitivity to urine cytology for low-grade tumors and an equivalent sensitivity for high-grade tumors and carcinoma in situ.
diagnosis and treatment of bladder cancer10
Diagnosis and Treatment of Bladder Cancer
  • No tumor markers have the specificity of traditional urine cytology for detection of bladder cancer; therefore, tumor markers should not be used for diagnosis.
diagnosis and treatment of bladder cancer12
Diagnosis and Treatment of Bladder Cancer
  • 1. Which of the following statements about risk factors for bladder cancer is/are correct?  (check all that apply)
  • A. Schistosoma haematobium infection is a risk factor.
  • B. Having a job as a truck driver is a risk factor.
  • C. The best known behavioral risk factor is cigarette smoking.
  • D. Previous exposure of the bladder to radiation increases the risk of bladder cancer one to two years after treatment.
diagnosis and treatment of bladder cancer13
Diagnosis and Treatment of Bladder Cancer
  • 1. Which of the following statements about risk factors for bladder cancer is/are correct?  (check all that apply)
  • A. Schistosoma haematobium infection is a risk factor.
  • B. Having a job as a truck driver is a risk factor.
  • C. The best known behavioral risk factor is cigarette smoking.
  • D. Previous exposure of the bladder to radiation increases the risk of bladder cancer one to two years after treatment.
diagnosis and treatment of bladder cancer14
Diagnosis and Treatment of Bladder Cancer
  • 2. Which of the following should be included in the initial workup of suspected bladder cancer?  (check all that apply)
  • A. Urinalysis.
  • B. Cystoscopy.
  • C. Patient history.
  • D. Tumor marker tests.
diagnosis and treatment of bladder cancer15
Diagnosis and Treatment of Bladder Cancer
  • 2. Which of the following should be included in the initial workup of suspected bladder cancer?  (check all that apply)
  • A. Urinalysis.
  • B. Cystoscopy.
  • C. Patient history.
  • D. Tumor marker tests.
references
References
  • Canavan A, Arant B. Diagnosis and Management of Dehydration in Children. American Family Physician. October 1, 2009.
  • Reamy B, Williams P, Lindsey T. Henoch-Schönlein Purpura. AFP. October 1, 2009.
  • Schlaudecker J, Bernhesiel C. Gadolinium-Associated Nephrogenic Systemic Fibrosis. AFP. October 1, 2009.
  • Sharma S, Ksheersagar P, Sharma P. Diagnosis and Treatment of Bladder Cancer. AFP. October 1, 2009.