AFP Review

1. Susana A. Alfonso, M.D. January 15, 2009 AFP Review

2. Uses of Radiation Therapy • Primary: improved or equivalent outcomes with less morbidity (ie-anal, head and neck, cervical, prostate ect • Pts unfit for surgery • Anatomically unresectable (bladder, pancreas, skin) • Preoperative (esophageal, rectal) • Palliative: Limits bony pain, limits bleeding, relieves luminal or airway obstruction (BLTKP) GU, lung, colon

3. Principles of Radiation Therapy • Ionizing radiation causes DNA strands to break and cross link • Normal cells are better able to repair • Administering small doses over several weeks • Teletherapy: (90% of treatments) EM radiation for particulate radiation from an external source • Brachytherapy: radiation supply placed within the patient

4. Old vs. New Radiation Techniques • Difficulty with localization, patient, and tumor movement led to side effects (radiation proctitis) • CT and MRI have led to image guided and intensity modulated radiation (beamlets) • Stereotactic Radiosurgery: relies on patient mobilization and specialized equipment to allow delivery of high potency radiation to a very specific area

5. Brachytherapy • Iodine-125 permanent seed implants for prostate cancer • Temporary • Intracavitary catheters for GYN cancers • Liquid radioisotopes via balloon catheters for breast cancer

6. Systemic Radiation Therapy • Iodine-131 for thyroid cancer and hyperthyroidism • Strontium-89 and Samarium-153 for bony mets • Radioimmunotherapy: radioisotopes attached to monoclonal antibodies )non-Hodgkin lymphoma)

7. Choosing Different Modalities • Patient Preference for surgery vs. radiation (ie localized prostate cancer) • Type of radiation dependent on • Tumor • Proximity to critical structures • Cost

8. Receiving Radiation Therapy • Fractions delivered daily (rarely bid) • Two –Seven Weeks • Intensity Modulated and stereotactic each dose may take 30-45 minutes • Temporary brachytherapy may require hospitalization • Permanent brachytherapy requires restricted contact for one month • Radioimmunotherapy patients may receive tx as outpatients, but careful body fluid disposal for one week • Birth control essential

9. Follow up for Family Physicians • Early Toxicities • Localized skin changes: Tx with non-scented lanolin-free hydrophilic cream • Fatigue • Dependent on site treated Resolve within two months Late Toxicities • Lymphedema, cognitive changes, infertility, xerostomia

10. CME Questions • A 60 YOA patient is scheduled to receive permanent brachytherapy to treat prostate cancer. Which one of the following is correct: • A. Implants will be inserted through a catheter • B. He will be radioactive for the rest of his life. • C. He will not have to limit social contacts during the initial period after treatment. • D. This patient will swallow “seeds” filled with the treatment.

11. CME Questions • An 85 yo woman who has breast cancer with bone mets has intractable pain. Which statement about radiation therapy is correct? • A. Bone pain from metastatic cancer can be improved with radiation therapy. • B. It has no role in her treatment because the cancer has spread. • C. If she receives radiation therapy she would have to limit her social contacts after the treatment • D. It is likely to cause secondary treatment and should be avoided.

12. Delirium in Hospitalized Older Pts • Most common complication in hospitalized older patients • Affects 20% of >65yoa • 10-30% of older pts. Admitted from the ED delirium is the presenting symptom for a life threatening condition • LOS is increased by EIGHT days • Mortality rate is DOUBLED

13. Epidemiology • 11-42% of hospitalized patients • 50% of those at high risk • Unrecognized in 70% of patients • Mortality rate in hospitalized pts. 22-76% • One year mortality rate 35-40% • Etiology unknown: ???changes in cerebral perfusion

14. Risk Factors • Underlying cognitive impairment • Poor functional status • Heavy Alcohol use • Presence of a urinary catheter • Polypharmacy • Metabolic abnormalities • Medications: • Anticholinergics • Narcotics • Sedative-hypnotics

15. Diagnosis • Clinical • Confusion Assessment Method • Acute onset, fluctuating course, inattention and either • Disorganized thinking or Altered LOC

16. Types of Delirium • Hyperactive: agitated, anxious, delusional, disoriented • Hypoactive (more common): Lethargic, stuporous, subdued, or comatose • Mixed

17. Diagnostic Testing • CBC, Chemistry, TSH, Cardiac enzymes, EKG, pulse ox, UA, CXRAY, or LP • IF there are no focal neurologic signs, or hx of head trauma, or encephalopathy and fever…neuroimaging is not needed

18. Treatment and Prevention • ABC’s • General supportive measure while seeking underlying cause • Avoid restraints • Medications: Use only when other methods fail and an underlying cause has been found • Haldol • Atypical antipsychotics

19. Best Treatment is Prevention • Stratify patients with Predictive mode • Vision impairment 1point • Cognitive impairment 1 point • APACHE score >16 or nurse determination of severe illness 1 point • Elevated BUN/creatinine ratio >18 1 point Low risk = 0 (10% risk of delirium) Intermediate = 1-2 (25% risk of delirium) High = 3-4 (80% risk of delirium)

20. Prevention Strategies • Daily cognitive stimulating activities • Correction of volume depletion • Early mobilization • Minimization of noise and stimuli • Promotion of good sleep hygiene • Removal of urinary catheters and restraints • Repeated reorientation • Use of eyeglasses or a magnifying lens • DECREASES DELIRIUM BY 33%

21. CME • Which one of the following statements about pharmacologic treatment of delirium is correct? • A. Lorazepam should not be used in patients with Parkinson’s disease • B. Risperidone is associated with increased mortality in older patients with dementia • C. Olanzapine has more extrapyramidal effects than haloperidol. • D. Haloperidol should be used in patients with hepatic insufficiency.

22. CME • Which one of the following is characteristic of delirium? • A. Persistent, nonfluctuating course • B. Disorganized thinking • C. Relatively preserved ability to focus attention • D. Slowly progressive course

23. CME • Which one of the following interventions is/are effective in reducing the risk of delirium in hospitalized patients? • A. Promoting good sleep hygiene • B. Regularly reorienting the patient to person and place • C. Using physical restraints • D. Correcting dehydration

24. Management of Hypertension in Diabetic Patients • Why? • CAD and CV disease account for 65% of deaths in diabetics • Decreases MI, CVA (ie macrovascular complications) • Decreases retinopathy and nephropathy (microvascular complications)

25. Guidelines • JNC-VII, ADA, NKF all recommend <130/80 • Measure at each patient encounter • If 130-139/80-89…you can do three month trial of lifestyle modifications: • Alcohol • Diet (DASH, 5 and 5, Calcium 1250mg, Mg 500mg, K+ 4700mg, cholesterol < 150mg, 6% saturated fat) • Physical Activity • Smoking Cessation • Sodium Restriction • Weight loss

26. ACE inhibitors • FIRST LINE • Prevent or delay microvascular and macrovascular complications • Decreases all cause mortality • Decreases risk of death from MI, CVA, and other Cardiovascular events • Use in at least half of maximum dose

27. Hypertension in Diabetics with Kidney Failure • NKF recommends use in stages 1, 2, 3, or 4 • May increase serum creatinine transiently • Transient increase up to 30% is associated with subsequent preservation of renal function • Acute increase >30% or development of hyperkalemia should prompt decreased dose or d/c

28. ARB’s • Reduce nephropathy and progression to renal failure • Inconsistent reduction in all cause mortality and cardiovascular mortality • Reserve for patients intolerant of ACE inhibitors • Renoprotective effects are independent of pressure lowering therefore can be used together

29. Diuretics • SHEP: Chlorthalidone reduced Cardio and cerobrovascular events in type 2 DM and pts. With isolated systolic HTN • ALLHAT: lower incidence of heart failure vs. lisinopril and amlodipine • Decreased effectiveness if GFR< 50 • At 12.5-25mg metabolic derangements minimal

30. Beta-Blockers • Comparable with ACE to reduce microvascular complication, MI, DM related death and all cause mortality • Decrease post MI mortality and mortality associated with heart failure • Metabolic derangements minimal • Carvedilol is less likely to worsen insulin sensitivity

31. Calcium Channel Blockers • Dihydropyridine: amlodipine • Inconsistent effect on CV events and mortality Non-dihydropyridine: verapamil, diltiazem • Reduction in CV events may be similar to BB and diuretic based regiments • Less effective than ACE and ARB in reduction of nephropathy

32. Summary of Anti-hypertensive medications in Diabetic patients • ACE inhibitors are FIRST LINE at least at one half of maximum dose if tolerated • ARB’s if pt. cannot tolerate ACE • Thiazide diuretics next (loop if GFR < 50) • BB and Calcium channel blockers next (be careful of non-dihydropyridine + BB because of nodal blockade) • Alpha blockers, hydralazine are options (consider referral)

33. CME • Which of the following statement about blood pressure control in diabetics is correct: • A. A pt. with a bp of 135/85 should begin tx immediately with an ACE inhibitor. • B. A pt. with a bp of 135/85 should begin a three month trial of lifestyle modifications. • C. CCB are a good initial therapy because of renoprotective effects. • D. The target bp in patients with diabetes is 140/90.

34. CME • Which one of the following drugs is recommended as a first-line tx for pts with dm and htn? • A. Lisinopril • B. Atenolol • C. Verapamil • D. Amlodipine

35. CME • After a pt. with DM and HTN begins lisinopril Tx, his serum Cr increases from 1.2 to 1.5. Which one of the following actions is recommended? • A. Immediately D/C drug and begin CCB. • B. Immediately D/C drug and begin ARB. • C. Continue the drug and add thiazide diuretic • D. Continue the drug and monitor serum Cr.

36. Varicose Veins • Not just in the lower extremities • Increased intravenous pressure • Prolonged standing • Intra-abdominal pressure from tumors • Chronic constipation • Obesity • Pregnancy • Secondary vascularization from DVT • AV shunting

37. Diagnosis • Clinical: pain, burning or itching • Complications: • Skin pigment changes • Eczema • Thrombophlebitis • Venous ulcerations • Loss of Sub Q tissue • Lipodermatosclerosis (loss of circumference) Imaging not generally needed

38. Treatment • Conservative: leg elevation, avoid prolonged standing, external compression (20-30mmHg), modification of CV risk factors, weight loss • Meds: Horse Chestnut (some evidence supports) Buthcher’s Broom (no evidence) • External Laser: works best on <0.5mm • Sclerotherapy: works best on up to 5mm • Endovenous Obliteration of the saphenous vein:

39. Surgery • Reduces 12month ulcer recurrence • 88% chance of ulcer healing • Risk of neovascularization is 15-30% • Beyond year 3-5 surgery may have better outcomes

40. CME • Which one of the following statements about external laser therapy for varicose veins is correct: • A. It is most effective for larger veins • B. It is most effective for smaller veins • C. It works by scarring the wall of the veins. • D. It is not effective for telangiectasias

41. CME • Which one of the following statements about vv tx is correct: A. Sclerotherapy appears to provide better LT outcomes than surgery B. Surgery appears to provide better LT outcomes than sclerotherapy C. Use of a tourniquet does not reduce blood loss during surgery D. Sclerotherapy is not an effective tx for VV.

42. CME • Which of the following statements about nonsurgical tx. of VV is/are correct? • A. Horse Chestnut seed extract has been shown to be effective in clinical trials. • B. Butcher’s broom has been shown to be effective in clinical trials. • C. Diuretics have been shown to be effective in clinical trials. • D. Support stockings can provide relief from discomfort.

43. References • Gerber, DE and Chan, TA. Recent Advances in Radiation Therapy. American Family Physician. December, 78.11, 1254-1261. • Miller, MO. Evaluation and Management of Delirium in Hospitalized Older Patients. American Family Physician. December, 78.11, 1265-1270. • Whalen, KL and Stewart, RD. Pharmacologic Management of Hypertension in Patients with Diabetes. American Family Physician. December, 78.11, 1277-1282. • Jones, RH and Carek, PJ. Management of Varicose Veins. American Family Physician. December, 78.11, 1289-1294.