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111 Cards in this Set

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Solid Organ Transplant: Matching Organs: Blood Typing
HLA (Human Leukocyte Antigen), PRA (Panel Reactive Antibody), & Crossmatch (XM)
• Matching 6 = 0 mismatch / matching 0 = 6 mismatch
• HLA Class I: A, B, & C
o CD8 T-cells (cytotoxic)
• HLA Class II: DR, DP, & DQ
o CD4 T-cells (helper)
Solid Organ Transplant: Matching Organs: Blood Typing - HLA
encodes MHC; match A, B & DR
Screens for anti-HLA cytotoxic antibodies
• ≥ 80% PRA = Poor Match
• 20%-80% PRA= Moderate Match
• ≤ 20% PRA = Good Match
Solid Organ Transplant: Matching Organs: Blood Typing - PRA
mix the donor & recipient serum and see what % react
Screens for anti-HLA cytotoxic antibodies specific to that donor
• Positive = Bad (usually)
• Negative = Good (usually)
Solid Organ Transplant: Matching Organs: Blood Typing - Crossmatch
donor lymphocytes mixed with patient serum
Solid Organ Transplant: Allorecognition
Direct: A donor cell floats around out of the donated organ and initiates an issue (lymphatic system → CD8→ destruction)
Indirect: An recipient APC goes into new organ, grabs some of the donor tissue, and reports the issue
Solid Organ Transplant: Support Medications: Opportunistic Infections
UTI (women), Pneumocystis pneumonia, Oral candidiasis, Cytomegalovirus
Solid Organ Transplant: Support Medications: Opportunistic Infections: UTI (women)
Bactrim or Nitrofurantoin for 2 months
Solid Organ Transplant: Support Medications: Opportunistic Infections: Pneumocystis pneumonia
maybe Bactrim for those at risk or heart/lung transplants
Solid Organ Transplant: Support Medications: Opportunistic Infections: Oral candidiasis
fluconazole 50mg qd for 2 months (or clotrimazole troches or nystatin)
Solid Organ Transplant: Support Medications: Opportunistic Infections: Cytomegalovirus
Valganciclovir
Adjust for Renal Function:
• Recip +/Donor + and Donor -: 450 mg daily for 3 months
• Recip -/Donor +: 900 mg daily for 6 months
• Recip -/Donor -: None
Solid Organ Transplant: Support Medications: Other Infections
Anemia, Leukopenia/Neutropenia, Dyspepsia, Osteoporosis, Hypophosphatemia, Hypomagnesemia, HTN, Hyperlipidemia
Solid Organ Transplant: Support Medications: Other Infections: Anemia
Fe or EPO if deficient; maybe ↓ MMF
Solid Organ Transplant: Support Medications: Other InfectionsLeukopenia/Neutropenia
dose reduction of immunosuppressants
Solid Organ Transplant: Support Medications: Other Infections: Dyspepsia
Famotidine or PPI
Solid Organ Transplant: Support Medications: Other Infections: Osteoporosis
(from Prednisone) Ca (1000-1500mg/d) & Vit D (400-800mg/d)
Solid Organ Transplant: Support Medications: Other Infections: Hypophosphatemia
(from steroid)
Solid Organ Transplant: Support Medications: Other Infections: Hypomagnesemia
(from CNI)
Solid Organ Transplant: Support Medications: Other Infections: HTN
BP Goal <130/80; add ACEI/ARB for renal protection
Solid Organ Transplant: Support Medications: Other Infections: Hyperlipidemia
LDL <100 for most; add statins
Solid Organ Transplant: Rejection
Acute: ≤3 months; H>K>L
Solid Organ Transplant: Rejection: Cellular
• T-cells (90%)
o Methylprednisolone: 1st line
o rATG: severe or MP-resistant
Solid Organ Transplant: Rejection: Humoral/Antibody mediated
• B-cells (10%)
o IV Immune Globulin from pooled patients (competition for binding)
o Plasmapheresis: machine strains proteins (Ab) from blood
o Rituximab: mab against B-cells (CD20)
 375mg/m2 = most 600-700 mg/day
Hypersensitivity: Type I
Anaphylactic
• 30 min; Allergen binds to IgE
• Allergens: large molecular weight that bind to IgE on mast cells; smaller allergens (drugs) bind to proteins (haptenation)
o Sensitization occurs on first exposure; reaction on subsequent exposures
Hypersensitivity: Type II
Cytotoxic
• 5-12 hours;
Hypersensitivity: Type III
Immune Complex Mediated
• 3-8 hours;
Hypersensitivity: Type IV
Cell Mediated (delayed)
• 24-72 hours;
Allergic Rhinitis: Pathophysiology:
 Minutes: sneezing & pruritus …. histamine, leukotrienes, & cytokines
 Hours: earlier + postnasal drip…. cytokines & chemokines
Allergic Rhinitis: Pathophysiology: 1st Exposure:
allergen in nose -> processes by lymphocytes -> IgE Ab made
Allergic Rhinitis: Pathophysiology: 2nd Exposure
IgE bound to mast cells/basophils bind to allergen -> inflammatory mediators
Allergic Rhinitis: Seasonal
symptoms present <4 days OR <4 weeks
• Trees, grasses, weeds, mold
Allergic Rhinitis: Perennial
>4 days AND >4 weeks
• House mites, animals, roaches, indoor mold/fungi
Allergic Rhinitis: Mild
• Rhinorrhea
• Sneezing
• Nasal congestion
• Postnasal drip
• Itchy eyes, ears, nose, throat
Allergic Rhinitis: Moderate-Severe (Mild+)
• Sleep disturbance
• School/work impair
• Impair daily life
• Troublesome sx
Allergic Rhinitis: Antihistamines (systemic)
Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: +/-
Ocular/Conjunctivitis: ++
Allergic Rhinitis: Decongestants
Sneezing/Itching: -
Rhinorrhea: -
Congestion: ++
Ocular/Conjunctivitis: -
Allergic Rhinitis: Intranasal Steriods
Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: ++
Ocular/Conjunctivitis: +
Allergic Rhinitis: Cromolyn Nasal
Sneezing/Itching: +
Rhinorrhea: +
Congestion: +
Ocular/Conjunctivitis: +/-
Allergic Rhinitis: Ipratropium Nasal
Sneezing/Itching: -
Rhinorrhea: ++
Congestion: -
Ocular/Conjunctivitis: -
Allergic Rhinitis: Ocular Antihistamines
Sneezing/Itching: -
Rhinorrhea: -
Congestion: -
Ocular/Conjunctivitis: ++
Allergic Rhinitis: Leukotriene Antagonist
Sneezing/Itching: ++
Rhinorrhea: ++
Congestion: +/-
Ocular/Conjunctivitis: ++
Burns: Types
Superficial, Superficial partial thickness, Deep partial thickness, Full thickness
Burns: Superficial
epidermis, no blisters, 3-6 days
Burns: Superficial partial thickness
blisters, moist, weeping, 2-3 weeks
Burns: Deep partial thickness
blanched, drier, scarring, 6 weeks – go to ER
Burns: Full thickness
skin death, dry, leathery, no pain, scarring, grafting, PT needed
Burns: Minor
• 15% BSA Superficial partial thickness
• 2% BSA Deep partial thickness / Full thickness
Burns: Moderate
• 15-25% BSA Superficial partial thickness
• 2-10% BSA Deep partial thickness / Full thickness
Burns: Major
• 25% BSA Superficial partial thickness
Burns: Treatments
• Skin protectants
• Systemic analgesics
• Topical Analgesics
• Antimicrobials
Burns: Treatments: Systemic analgesics
Ibuprofen, naproxen, aspirin
Burns: Treatments: Topical Analgesics
Benzocaine, Dibucaine, Lidocaine, Tetracaine (Rx) (NOT hydrocortisone)
o Deep burn = ↓ concentration (absorbtion)
Burns: Treatments: Antimicrobials
o Silver sulfadiazine (SSD) (Rx)
o Triple Antibiotic
Burns: Refer Burns When...
• ≥2% BSA
• Eyes, ears, face, hands, feet, perineum
• Chemical/Electrical/Inhalation
• Elderly
• DM or multiple issues
• Immunocompromised
• ≥7 days with no improvement
Wounds: Stages
Stage I: unbroken skin
Stage II: all epidermis & some dermis
Stage III: all dermis & some SQ
Stage IV: SQ & tissue/muscle/tendon/bone
Wounds: Treatments: Antiseptics
• Hydrogen Peroxide = Soap & Water effectiveness
• Ethyl Alcohol: apply around wound, not in; (dries skin)
• Isopropyl Alcohol: stronger than EtOH; (even drier)
• Iodine: works great! (stains skin)
• Camphorated phenol: caution; use on dry skin only
Wounds: Treatments: Antibiotics
• Bacitracin: Gram +
• Neomycin: Gram -; allergic contact dermatitis
• Polymixin B: Gram -
Wounds: Refer Wounds When...
• Junk in wound
• Chronic
• Animal/human bite
• Infection
• Face, mucus membranes, nuts
• Deep, acute wound
Contact Dermatitis
acute/chronic inflammatory condition after contact with offending agent
Contact Dermatitis: Allergic
Induced by antigen
• Delayed hypersensitivity (Type IV); genetic link potential
• Takes days to weeks
• Causes: “new offender” usually (may be not)
o Fragrance, rubber, metal, glues, plastics, formaldehyde, wool, neomycin, paraben, preservatives, Urushiol
• Sx: super itchy rash
• Treatment:
o Wet dressing; emollients, oatmeal
o Topical Corticosteroids (med-high potency)
Contact Dermatitis: Irritant
Induced by substance
• Epidermal barrier disrupted -> inflammation (secondary)
• Within hours
• Causes: physical, mechanical, or chemical
o over-washing hands, bleach, acids, alkalis
• Sx: erythema, chapped skin, dryness, fissures, itching
• Treatment:
o Avoidance
o Severe Cases: topical corticosteroid under occlusion
• Diaper: acute inflammatory dermatitis of baby butts
o Treatment: Talcum powder / Zinc oxide, titanium dioxide, petrolatum
Atopic Dermatitis
AKA eczema - Usually associated with hay fever, asthma, & allergic rhinitis
• Genetic Link (1 parent = 60% chance, both = 80% chance); ↑Eosinophils & IgE
• Sx: itching, flares -> abnormal protective layer
Atopic Dermatitis: Types
• Acute: rash with lesions that are itchy, erythematous
• Subacute: thicker and scaly
• Chronic: thickened plaques and accentuated skin markings
Atopic Dermatitis: Treatments
• Topical Corticosteroids
• Anti-Histamines
• Calcineurin Inhibitors
• Coal Tar Preps
Atopic Dermatitis: Treatments:Topical Corticosteroids
o High Potency: <3 weeks for acute or thickened
o Medium: chronic AD of trunk & extremities
o Low: children; sometimes face
o SE: skin atrophy, striae, hypopigment, acne
Atopic Dermatitis: Treatments: Anti-Histamines
meh
Atopic Dermatitis: Treatments: Calcineurin Inhibitors
Long term option; can be put anywhere:
o Tacrolimus: Moderate-to-severe AD… SE: burning/itching
o Pimecrolimus: Mild-to-moderate AD
Atopic Dermatitis: Treatments: Coal Tar Preps
stain, smelly, not on oozing, maybe photosensitivity
Psoriasis:
T-cell mediated autoimmune disease
Psoriasis: Assessment
PASI: Psoriasis Assessment & Severity Index
- tells you (1)redness, (2)thickness, (3)scaliness, & (4)area involved
• Mild: < 12
• Moderate: 12-18
• Severe: > 18
PGA: scaled 7-1 (1 worst)
NPF-PS: mild, moderate, or severe
- Incorporates QOL
Psoriasis: Types
Plaque, Guttate, Pustular (localized), Pustular (generalized), Erthrodermic
Psoriasis: Types: Plaque
Red, thick & silvery
- Scalp, hands, feet elbows
Psoriasis: Types: Guttate
Small drop-like plaques
- Trunk, torso / children & young adults
Psoriasis: Types: Pustular (localized)
Splitting of skin
- Hands & feet
Psoriasis: Types: Pustular (generalized)
11 – spread out more
Psoriasis: Types: Erthrodermic
Less common, more flattened;
- generalized redness all over
Psoriasis: Non-Rx Treatment:
• Emollients: 18
• Balneotherapy: salt water bath or mud/clay products; may ↓T-cell activity in skin
• Phototherapy: antiproliferation & anti-inflammatory/immunomodulatory
o PUVA: Psoralen + UVA
• Lasers
Acne: Types
Comedones:
• Blackhead: open comedo
• Whitehead: closed comedo
Pustule: elevated skin lesion with pus
Papule: small bump with no head
Nodule: cysts
Acne: Types: Mild Comedonal
• 1st: Topical Retinoid
• Alt: other TD, Salicyclic acid, ot azelacic acid
52!!!
Acne: Types: Moderate Papular Pustule
• 1st: Oral Antibiotic AND Topical Retinoid +/- BPO
• Alt: same with different TR
• Alt: Oral Antiandrogen
Rosacea
Chronic inflammatory disorder of facial pilobaceous units -> ↑capillary reactivity -> flushing & telangiectasia
- Starts at 30-50 yo peaking around 40-50; Females>male
Rosacea: Type 1
Erythematotelangiectatic - facial redness
• Topical metronidazole or azelaic acid or sulfacetamide/sulfur
• Oral tetracyclines (mino or doxy)
• Lasers
Rosacea: Type 2
Papilopustular - papules/pustules present
• Combo topical metronidazole or azelaic acid or sulfacetamide/sulfur AND Oral tetracyclines
• Lasers
Rosacea: Type 3
Phymatous - Cyrano nose
• Oral tetracyclines (mino or doxy)
• Referral for isotretinoin
• Dye Lasers / electrosurgery
Rosacea: Type 4
Ocular: eye irritation
• Topical or oral tetracyclines (mino or doxy)
• Eyelid Hygiene & maybe referral to ophthalmologist
Cosmeceuticals:
• Bimatoprost (Latisse®)
• Eflornithine (Vaniqa®)
• Minoxidil (Rogaine)
• Hydroquinone
• Dihydroxyacetone
• OnabotulinumtoxinA (Botox®)
• Arbutin (Uva Ursi)
Cosmeceuticals: Bimatoprost (Latisse®)
Eyelash growth
• Use caution with any other eye products; May cause permanent discoloration of eyes
Cosmeceuticals: Eflornithine (Vaniqa®)
Reduction of unwanted facial hair
• not a depilatory agent, but rather a hair growth retarding drug; condition may return to 8 weeks after stopping
Cosmeceuticals: Minoxidil (Rogaine)
Male pattern alopecia
• originally an anti-hypertensive agent; can be used in women
Cosmeceuticals: Hydroquinone
Removal pigmentation, Freckles, or Melasma
• effective for sun damage to the neck and upper chest; wear sunblock
Cosmeceuticals: Dihydroxyacetone
Darken light or unpigmented areas of skin affected by vitiligo, scars, and other
• May stain hair or clothing when wet; wear sunscreen
Cosmeceuticals: OnabotulinumtoxinA (Botox®)
“Wrinkled face”
• BBB for infection & hypersensitivity; Only FDA approved cosmetic use is glabellar lines
Cosmeceuticals: Arbutin (Uva Ursi)
Skin-lightening
• Use should not exceed 7-10 days; May turn your urine green; derived from Bearberries
Psoriasis TX: Topical 1st Line Drugs
• Corticosteroids
• Vit D Analogues
• Tazarotene
Psoriasis TX: Topical 1st Line: Corticosteroids
Prevents scales & itching:
o Use for finite period of time
o Class I for thick, chronic plaque (ointments best)
o Medium & low potency for face
o ADR: striae, skin atrophy, rare HPA suppression, rare hyperglycemia
Psoriasis TX: Topical 1st Line: Vit D Analogues
Plaque-type; inhibits keratinocyte differentiation/proliferation:
o Calcipotriene: 25
o Calcitriol: mild-moderate plaque
o ADR: hypercalcemia
Psoriasis TX: Topical 1st Line: Tazarotene
Modulates keratinocyte differentiation/proliferation:
o Never apply to >20% BSA!!
o ADR: burning, itching, redness, peeling
Psoriasis TX: Topical 2nd Line Drugs
• Coal tar
• Anthralin
• Calcineurin inhibitors
Psoriasis TX: Topical 2nd Line: Coal tar
Hyperplasia then epidermal thinning
o ADR: messy, smelly, stains, photosensitivity
Psoriasis TX: Topical 2nd Line: Anthralin
Inhibits DNA synthesis; skin or scalp (Dritho-Scalp)
o ADR: similar to coal tar
Psoriasis TX: Topical 2nd Line: Calcineurin inhibitors
NOT FDA approved; ↓T-cell activation:
o Do NOT induce skin atrophy like steroids
Psoriasis TX: Systemic 1st Line Drug Types
• TNF-α inhibitors
• T-cell activation inhibitors
• Oral
Psoriasis TX: Systemic 1st Line: TNF-α inhibitors
• BBB
• Infliximab
• Etanercept
• Adalimumab
Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: BBB
HSTCL (hepatosplenic T-cell lymphoma), TB, other infections
Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Infliximab
Chronic severe plaque & arthritis:
- ADR: HA, fever, chills, fatigue, D, URTI, UTI, hypersensitivity, BBB
Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Etanercept
Chronic severe plaque & arthritis:
- 35
Psoriasis TX: Systemic 1st Line: TNF-α inhibitors: Adalimumab
Chronic severe plaque & arthritis:
- 36
Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors
o Alefacept
o Ustekinumab
Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors: Alefacept
Chronic severe plaque only:
- 39,40
Psoriasis TX: Systemic 1st Line: T-cell activation inhibitors: Ustekinumab
Chronic severe plaque only:
- 41,42,43
Psoriasis TX: Systemic 1st Line: Oral
o Acitretin: oral retinoid for psoriasis only
- 51,52
o Cyclosporine: immunosuppressant that ↓T-cell activation
- 53,55
- ADR: 53
o Methotrexate (MTX): 56,57
Psoriasis TX: Systemic 2nd Line
Only for failed others
o Bad ADRs – bone marrow suppression, GI effects
• Myclophenolate mofetil
• Sulfasalazine
• 6-thioguanine
• Hydroxyurea