October 2008 Journals

1. October 2008 Journals By Zoe Salgado

2. Titles • Multiple Myeloma: Diagnosis and Treatment • Essentials of Skin Laceration Repair • Systemic Sclerosis/ Scleroderma: A Treatable Multisystem Disease • Musculoskeletal Injections

3. Multiple Myeloma • MC primary bone malignancy • Median age at diagnosis is 70 • Rate is twice as high in black persons than in the white population • Risk factors: genetics, farming pesticides, petrochemical exposure, ionizing radiation • 5 year survival rate 33% • Median survival rate is 33 months

4. Pathophysiology • Immunoglobulin overproduction by monoclonal plasma cells leading to hyperviscosity and end organ damage • Cytokines stimulate osteoclasts, suppress osteoblasts, lead to invasive bone lesions causing bone pain, OP, and hypercalcemia • Bone marrow invasion leads to anemia

7. Clinical presentation • Unexplained bone pain or backache • Pathologic fx in 26-34% of patients • Vertebral compression fx can lead to weakness and paresthesias in LE • Carpal tunnel is MC peripheral neuropathy • Anorexia, somnolence, nausea, polydypsia are sx of hypercalcemia • Weakness and malaise come from anemia

8. Clinical presentation • Impaired Ab and leukopenia cause recurrent infection (PNA) • Weight loss occurs in less than ¼ of pts • Fever is rare • 34% are asxic • CRAB • (calcium> 11, renal (Cr >2), anemia (Hg< 10), bone) mnemonic

11. Diagnostic Criteria for MM • Serum or urine electrophoresis :+ M protein • Bone marrow clonal plasma cell • Myeloma related organ or tissue damage • “Smoldering” (asymptomatic) MM is serum M protein of 3 g/dL, 10% bone marrow plasma cells and no organ or tissue damage

13. MGUS • Premalignant disorder • A clone of plasma cells produce a monoclonal paraprotein with no organ damage • Present in 2% of persons > 50 yo • Risk of progressing to MM is 1% per year • Up to 20% of MM arise from MGUS

14. Bence Jones Myeloma • 20% have normal or slightly high M protein, instead have high light chain excretion –Bence Jones myeloma • light chains measured with urine protein immunofixation

15. Imaging • No clear imaging guidelines • Skeletal survey recommended • MRI for suspected compression fx • CT more sensitive for small long bone lesions but is not recommended for initial survey • NOT recommended: nuclear bone scans or DEXA scans

17. Treatment • Refer to oncology • If smoldering MM-no treatment • Autologous stem cell transplantation for younger than 65 yo • Clinical trials • Bortezomib (Velcade) • Thalidomide analogue> lenalidomide (Revlimid)

18. Treatment • Chemotherapy • Melphalan, prednisolone, dexamethasone, vincristine, doxorubicin, bortezomib, thalidomide(Side effects: neuropathy, somnolence, DVT) • Bone pain • Opiates, bisphosphonates, radiotherapy, vertebroplasty, kyphoplasty • Avoid NSAIDs • Hypercalcemia • Saline, steroids, lasix, bisphosphonates

20. Questions on MM • 1. A 72 yo M presents with chronic low back pain, fatigue, and mild anemia. Which of the following tests should be performed to check for MM? • A. dual energy x-ray absorptiometry • B. serum and urine electrophoresis and immunofixation • C. urine dipstick test for Bence Jones protein • D. nuclear bone scan

21. Questions • A 62 yo M is diagnosed with MM. In addition to influenza and pneumococcal vaccines, which of the following immunizations should he receive? • A. HiB • B. meningococcal meningitis • C. hep B • D. measles

23. Essentials of Skin Laceration Repair • Management for Primary care • wound eval, preparation, and repair techniques • when to refer to surgery • How to provide follow up care

26. Optimal time from injury to lac repair is not clear ( up to 12 hours post injury if not contaminated) • Wound irrigation with NS or tap water • Local anesthesia • Lidocaine 1%, bupivicaine 0.25%, EMLA cream • Sting of local injection may be decreased by smaller needle(25-30g), injecting slowly, warming or buffering the solution

27. Use suture if extensive debridement or multiple layers of closure, • Sutures or staples in areas of high skin tension (over joints or on back (thick dermis) • Tissue adhesives okay in areas of low skin tension ( face, shin, dorsal hand)

28. Sutures • Absorbable sutures to close deep, multilayer lacs • Vycril, Monocryl, Dexon ( in 4-8 wks absorbed) • Nylon, nonabsorbable monofilament Prolene Needs removal • Silk no longer used to close skin • Trunk 3-0 or 4-0, extremities and scalp 4-0 or 5-0, face 5-0 or 6-0, mucosal absorbable 3-0 or 4-0

33. Tissue adhesives • Dermabond • Are comparable with sutures in cosmetic results, dehiscence, and infection rates • Slough off spontaneously in 5 – 10 days • Low tensile strength • Contraindicated if high risk of slow healing (immunocompromised or diabetics) • Avoid in mucosal or moist areas

35. Staples • Use in extremities, trunk, scalp • Not for use in scalp if CT or MRI of head is suspected

39. Questions on Lac repair • After falling out of a tree, a 6 yo M has 2 cm laceration on his left elbow. If the wound was closed using nonabsorbable, single interrupted sutures, in how many days should the patient return for suture removal? • A. 3 • B. 5 to 7 • C. 7 to 10 • D. 18 to 21

40. Systemic Sclerosis • A chronic connective tissue disease of unknown etiology that causes widespread microvascular damage and excessive collagen deposition in the skin and internal organs • Associated with vasculopathy, autoimmunity, and fibrosis • Raynaud and scleroderma(hardening of the skin) are hallmarks of the disease

41. Leading cause of death: • Pulmonary fibrosis and pulmonary HTN • Classification system based on skin, organ involvement and autoantibodies • Limited cutaneous (60%)-skin thickening is distal to elbows and knees • Diffuse cutaneous (35%)

49. Clinical presentation • Young or middle aged woman with Raynaud’s and skin changes along with MSK and GI discomfort • Facial thickening-may c/o difficulty opening mouth • MSK: puffy hands with arthralgia, myalgia • GI: GERD, dysphagia

50. CV: • Raynauds, digital pitting, HF, abnl conduction, • Lungs • Pulmonary HTN, ILD • Renal • Renal crisis