Journal Review

1
Journal Review

• American Academy of Family Physicians
• October 1st, 2009
• Am Fam Physician.2009 80 (7)

2
Journal Review

• Diagnosis and Management of Dehydration in
  Children
• Henoch-Schönlein Purpura
• Gadolinium-Associated Nephrogenic Systemic
  Fibrosis
• Diagnosis and Treatment of Bladder Cancer

3

• Diagnosis and Management of Dehydration in
  Children

4
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.

5
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.

6
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.

7
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

8
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 lt 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.

9
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 lt17 mEq/L may
  improve sensitivity of identifying children with
  moderate to severe hypovolemia.
• A serum bicarbonate level of lt13 mEq/L is
  associated with increased risk of failure of
  outpatient rehydration efforts.

10
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.

11
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.

12
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.

13
Diagnosis and Management of Dehydration in
Children
14
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 .

15
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.

16
Diagnosis and Management of Dehydration in
Children
17
Diagnosis and Management of Dehydration in
Children

• For moderate dehydration, 100 mL/kg of ORT should
  be given over 4hours in the physicians 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.

18
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.

19
Diagnosis and Management of Dehydration in
Children

• IV maintenance fluid should be D5 and ¼ NS, plus
  20 mEq/L of K.
• IO, and VS q4 hours
• If stool output gt30 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.

20
Diagnosis and Management of Dehydration in
Children

• Fever may require 1 mL/kg/C qhour.
• 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.

21
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.

22
Diagnosis and Management of Dehydration in
Children

• Complications of dehydration include
  hypernatremia, hyponatremia, and hypoglycemia.

23
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.

24
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 lt130 mEq/L)
  replacement of the remaining fluid deficit should
  be altered, with a principal goal of slow
  correction.

25
Diagnosis and Management of Dehydration in
Children

• Wathen et al. found blood glucose levels of
  lt60mg/dL in 9 of children lt 9 years admitted to
  the hospital with diarrhea.
• Blood glucose screening may be indicated for
  toddlers with diarrhea.

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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.

28
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.

29
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.

30
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.

31
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
  childs skin feels doughy.

32
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
  childs skin feels doughy.

33

• Henoch-Schönlein Purpura

34
Henoch-Schönlein Purpura

• Henoch-Schönlein purpura is an acute, systemic,
  immune complexmediated, leukocytoclastic
  vasculitis.
• Clinical triad palpable purpura (without
  thrombocytopenia), abdominal pain, and arthritis.
  
• Complications glomerulonephritis and
  gastrointestinal bleeding.

35
Henoch-Schönlein Purpura

• 10 to 22 persons in 100,000 each year.
• Most common from late autumn to early spring
• gt 90 of patients are children lt10 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.

36
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.

37
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.

38
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.

39
Henoch-Schönlein Purpura

• Purpura is defined as nonblanching cutaneous
  hemorrhages that gt 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.

40
Henoch-Schönlein Purpura
41
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.

42
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.

43
Henoch-Schönlein Purpura

• Renal disease 40 to 50 of patients.
• Leading cause of death .
• Risk greatest in pt gt 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

44
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

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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.

51
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.

52
Henoch-Schönlein Purpura

• For severe renal involvement treatment options
  include
• High-dose steroids with immunosuppressants
• High-dose intravenous immunoglobulin
• Plasmapheresis
• Cyclophosphamide
• Renal transplant.

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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.

55
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

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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.

58
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.

59
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.

60
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.

61
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.

62
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.

63

• Gadolinium-Associated Nephrogenic Systemic
  Fibrosis

64
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.

65
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) lt30 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.

66
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.

67
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.

68
Gadolinium-Associated Nephrogenic Systemic
Fibrosis

• The plaques may coalesce to form a peau dorange
  appearance.
• Skin manifestations are symmetric, typically
  involve the extremities and trunk, and rarely
  affect the face.

69
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.

70
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.

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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 .

73
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.

74
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.

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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 patients risk of
  developing nephrogenic systemic fibrosis after
  gadolinium exposure?
• A. Female sex.
• B. Native American ethnicity.
• C. Age younger than 35 years.
• D. Malignancy.

77
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 patients risk of
  developing nephrogenic systemic fibrosis after
  gadolinium exposure?
• A. Female sex.
• B. Native American ethnicity.
• C. Age younger than 35 years.
• D. Malignancy.

78
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

79
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

80
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.

81
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.

82

• Diagnosis and Treatment of Bladder Cancer

83
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 deaths year caused by this disease.
• 80 of new cases occur in persons gt60 years.
• 3 times more prevalent in men
• It is more prevalent in white persons however,
  mortality rates are higher in black persons.

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Diagnosis and Treatment of Bladder Cancer
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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.

88
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.

89
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.

90
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.

91
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.

92
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.

93
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.

94
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.

95
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.

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Diagnosis and Treatment of Bladder Cancer
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102
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.

103
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.

104
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.

105
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.

106
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-Associat
  ed Nephrogenic Systemic Fibrosis. AFP. October 1,
  2009.
• Sharma S, Ksheersagar P, Sharma P. Diagnosis and
  Treatment of Bladder Cancer. AFP. October 1,
  2009.