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GI Joe Medical Boards

GI Joe Medical Boards

著者： Joseph Kumka
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 I'm Dr. Joseph Kumka, Gastroenterology Fellow, educator, and host of evidence-based, board-oriented medical podcasts. Whether you're a resident gearing up for the boards, a fellow diving deep into subspecialty topics, or a practicing clinician hungry for high-yield updates—you’re in the right place.2025 衛生・健康的な生活 身体的病い・疾患
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  • Cardiology - Cardiovascular Disease and Cancer

    Cardiology - Cardiovascular Disease and Cancer
    2025/08/05
    Cardiovascular Disease in CancerI. Cardiotoxicity of Radiation Therapy to the ThoraxPrevalence and Significance: Radiation therapy, while improving survival in patients with thoracic malignancies (e.g., Hodgkin lymphoma, early-stage breast cancer), has led to cardiovascular disease becoming "the most common nonmalignant cause of death in patients treated with chest radiation therapy, accounting for 25% of deaths in survivors of Hodgkin lymphoma."Mechanism and Onset: Thoracic irradiation damages all cardiac cells and structures, including the "pericardium, myocardium, valves, coronary and peripheral vasculature, and conduction system." Clinical disease typically presents "two to three decades after treatment," though some manifestations can occur earlier.Increased Risk Factors: The risk of radiation-induced cardiac injury is heightened in patients receiving "concomitant anthracyclines or trastuzumab." Contemporary radiation techniques aim to "limit total dosage and field size" to decrease complications.Spectrum of Cardiovascular Diseases (Table 42):Pericardial Disease:Acute pericarditis: "Most common early manifestation," affecting 2.5% of patients.Chronic or constrictive pericarditis: Develops in "10% to 20% of patients 5 to 10 years after radiation therapy." Pericardial calcification is not always present, and late constriction can occur without prior acute pericarditis.Cardiomyopathy: Radiation damages microvasculature, leading to "endothelial dysfunction and ischemia that result in myocardial fibrosis, diastolic dysfunction, and restrictive physiology." Differentiating it from pericardial constriction is crucial for treatment.Valvular Disease: Affects all valves, predominantly left-sided. "Valvular regurgitation due to tissue retraction is the most common valvular lesion in the first two decades after therapy," evolving to "mixed regurgitation and stenosis" with later fibrosis and calcification.Conduction Defects: Common in long-term survivors, including "atrioventricular block, bundle branch block." Increased need for permanent pacing after valve replacement surgery in irradiated patients.Coronary Artery Disease (CAD): Occurs "earlier and with increased incidence." Lesions are typically "ostial, long, smooth, and concentric and have higher fibrotic content than typical atherosclerotic lesions." Traditional risk factors (smoking, dyslipidemia, hypertension) exacerbate incidence, requiring aggressive management.Surgical Outcomes: Surgical outcomes for radiation-associated cardiovascular disease are "significantly worse than in matched cohorts." Percutaneous approaches, such as percutaneous aortic valve replacement, "may be preferable" for aortic stenosis in this group.Surveillance and Prevention:No consensus on cardiac testing in asymptomatic patients, but "baseline evaluation including echocardiography is reasonable."Some organizations recommend "stress echocardiography at 5 to 10 years after completion of therapy or at age 30 years, whichever comes first."Serum biomarkers, nuclear medicine testing, and coronary CT are "not recommended" for routine screening.Statins, ACE inhibitors, and aldosterone antagonists have "not been proved to prevent radiation-induced cardiovascular disease," despite their role in risk factor reduction.II. Cardiotoxicity of ChemotherapyGeneral Principles: Chemotherapy can cause "reversible or dose-dependent, irreversible cardiac injury" (Table 43). Strategies to minimize risk include optimizing traditional risk factors and identifying high-risk patients (Table 44) before treatment.Key Cardiotoxic Agents and Effects (Table 43 & associated text):Left Ventricular Dysfunction (LVD):Anthracyclines (Doxorubicin, Epirubicin, Idarubicin):Acute toxicity: Rare (<1%), reversible, presenting as heart block, arrhythmias, heart failure, myocarditis, or pericarditis.Chronic progressive toxicity: Typically irreversible, presenting as dilated cardiomyopathy. "Most closely linked with doxorubicin."Onset: Early (within 1 year) in 1.6% to 2.1%; late (after 1 year) in up to 5%.Dose-dependent: "Late-onset chronic progressive toxicity is related to total cumulative dose." Incidence of heart failure up to 26% at 550 mg/m2 doxorubicin, with clinical evidence appearing "10 to 20 years after treatment."Mitigation strategies: Dexrazoxane (iron chelator) for high-risk patients; continuous infusion vs. bolus; liposomal formulations of doxorubicin. ACE inhibitors, ARBs, and beta-blockers have not been proven to prevent toxicity.Trastuzumab: Causes "LV systolic dysfunction, with symptoms of heart failure in 3% to 7% of patients." More common in patients older than 50 and with concomitant anthracycline use. Toxicity often reversible.Other Agents: Alkylating agents (cyclophosphamide, ifosfamide), antimicrotubular agents (paclitaxel, docetaxel), proteasome inhibitors (bortezomib, carfilzomib), tyrosine kinase inhibitors (sunitinib).Ischemia: Antimetabolites (5-fluorouracil, capecitabine), antimicrotubular ...
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    32 分
  • Cardiology - Cardiomyopathies in Pregnancy

    Cardiology - Cardiomyopathies in Pregnancy
    2025/08/05
    Cardiovascular DiseaseExecutive SummaryThis briefing document summarizes key information regarding cardiovascular health during pregnancy, drawing insights from "Pregnancy and Cardiovascular Disease - Cardiovascular Medicine Text - MKSAP 19.pdf". It highlights the increasing maternal mortality in the US due to cardiovascular disorders, the physiological changes during normal pregnancy, and the critical importance of prepregnancy evaluation, multidisciplinary management, and careful consideration of medication and anticoagulation therapies for women with pre-existing or pregnancy-related cardiovascular conditions. Special attention is given to high-risk conditions like peripartum cardiomyopathy and Marfan syndrome.I. Maternal Mortality Trends and Primary CausesMaternal mortality in the United States has increased over the past two decades, a trend contrasting with decreasing rates in other Western countries. The leading cause of maternal mortality is acquired cardiovascular disorders, specifically "cardiomyopathy, coronary artery disease, and aortic disorders."II. Cardiovascular Changes During Normal PregnancyUnderstanding normal physiological changes is crucial for distinguishing between healthy and pathologic signs. Key cardiovascular adaptations during a normal pregnancy include:Relative Anemia: Due to a greater increase in plasma volume compared to erythrocyte mass.Decreased Mean Arterial Pressure: Resulting from "reduced systemic vascular resistance and increased heart rate and cardiac output."Increased Heart Rate and Cardiac Output: Maternal cardiac output "peaks at approximately 40% to 50% above the prepregnancy level by the 32nd week," and can further increase to "as much as 80% above the prepregnancy level" during delivery.Common Normal Symptoms/Signs: Mild dyspnea, dyspnea with exertion, atrial and ventricular premature beats, heart rate increased by 20-30%, modest blood pressure decrease (~10 mm Hg), and a "basal systolic murmur grade 1/6 or 2/6 present in 80% of pregnant patients, S3."Table 45 (Normal Versus Pathologic Signs and Symptoms in Pregnancy) provides a detailed comparison, distinguishing normal physiological changes from symptoms like orthopnea, chest pain, atrial fibrillation, heart rate >100/min, high blood pressure (≥140/90 mm Hg), systolic murmur grade ≥3/6, or any diastolic murmur/S4, which are considered pathologic.III. Prepregnancy Evaluation and Risk StratificationMandatory Prepregnancy Counseling: "All women with cardiovascular disease should receive pregnancy counseling," including genetic counseling and testing if appropriate. Multidisciplinary Approach: A comprehensive evaluation involving a "cardiologist, a maternal-fetal medicine specialist, and an obstetric anesthesiologist" is essential to assess risks and formulate a management plan for labor and postpartum. Risk Assessment Tool: The modified World Health Organization pregnancy risk classification is currently the "most accurate system of risk assessment."A. Low-Risk ConditionsWomen with certain conditions generally experience no increased morbidity or mortality:Uncomplicated small patent ductus arteriosusMild pulmonary stenosisMitral valve prolapseSuccessfully repaired simple lesions (atrial or ventricular septal defect, patent ductus arteriosus, anomalous pulmonary venous drainage)Isolated atrial or ventricular ectopic beatsTetralogy of Fallot, most supraventricular arrhythmias, and Turner syndrome without aortic dilatation. These patients can typically be managed and deliver in a local hospital.B. Extremely High-Risk Conditions (Require Expert Center Care)Conditions conferring "extremely high risk for maternal mortality or severe morbidity" necessitate care and delivery at "an expert center for pregnancy and cardiac disease":Pulmonary hypertensionPrevious peripartum cardiomyopathy with residual left ventricular dysfunctionSevere left ventricular dysfunction (ejection fraction <30% or NYHA functional class III-IV symptoms)Severe mitral stenosisSymptomatic severe aortic stenosisMarked ascending aorta dilatationIV. Management of Cardiovascular Disease During PregnancyA. Valvular LesionsObstructive: Symptoms may arise due to increased blood volume/cardiac output; intervention before pregnancy should be considered.Regurgitant: Generally well-tolerated during pregnancy.B. Hypertrophic CardiomyopathySymptomatic obstructive hypertrophic cardiomyopathy: Treated with "nonvasodilating β-blockers, with monitoring of fetal growth."C. ArrhythmiasMost arrhythmias are benign.Shared decision-making is crucial for antiarrhythmic drugs, considering maternal and fetal risks/benefits.Most β-blockers (except atenolol) are safe for pregnancy and breastfeeding.Adenosine is the drug of choice for acute symptomatic supraventricular tachycardia.Amiodarone is rarely used due to toxicity.D. Delivery MethodVaginal delivery is generally preferred due to "less blood loss, quicker recovery, and lower risk for thrombosis."Cesarean delivery...
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    37 分
  • Cardiology - Congenital Disease

    Cardiology - Congenital Disease
    2025/08/05
    Adult Congenital Heart Disease (ACHD)Date: October 26, 2023Purpose: This briefing document summarizes key themes, important ideas, and facts regarding Adult Congenital Heart Disease (ACHD) based on the provided source material.Executive SummaryMedical and surgical advancements have led to a growing population of adults with congenital heart disease (CHD). This demographic requires specialized, multidisciplinary care due to common cardiovascular "residua" from previous interventions. The document highlights various specific CHD conditions, including Patent Foramen Ovale (PFO), Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), Patent Ductus Arteriosus (PDA), Pulmonary Stenosis (PS), Aortic Coarctation, and Tetralogy of Fallot (TOF), detailing their pathophysiology, clinical presentation, diagnostic evaluation, treatment, and post-closure follow-up. A significant theme across all conditions is the importance of specialized cardiology follow-up, careful consideration of activity restrictions, and comprehensive reproductive health counseling, especially regarding pregnancy risks and contraception. Additionally, the document addresses the unique challenges and management strategies for patients with cyanotic CHD, including Eisenmenger syndrome, emphasizing the need for highly specialized care for these complex cases.Main Themes and Key Insights1. Growing ACHD Population and the Need for Specialized Care: * Key Fact: "Medical and surgical advances have resulted in more adults than children with congenital heart disease (CHD) in North America." * Importance: This highlights a fundamental shift in patient demographics, necessitating a focus on adult-specific management strategies and long-term care. * Implication: The specialized nature of ACHD management underscores the "importance of periodic follow-up by a team ideally consisting of the internist and a cardiologist trained in adult CHD." * Specifics: "Specialized care is critical for patients born with complex and cyanotic congenital cardiac disease, symptomatic patients, and patients who desire pregnancy."2. Comprehensive Patient Counseling and Holistic Care: * Reproductive Health: "Patients with CHD should be offered reproductive health counseling." This includes discussions on contraception, balancing its use against pregnancy risks, and pre-pregnancy counseling for those on anticoagulation due to associated "maternal and fetal risks." * Psychological Well-being: "Anxiety and depression are prevalent but underrecognized in patients with CHD, and screening for these mood disorders should be a routine aspect of care." This emphasizes a holistic approach to patient management beyond purely cardiac issues. * Infectious Disease Prevention: Hepatitis C screening is recommended, and Hepatitis B vaccination is advised for non-immune individuals.3. Common Cardiovascular Residua and Long-Term Follow-up: * General Principle: "Cardiovascular residua are common in patients with previous intervention for congenital cardiac lesions." This necessitates lifelong monitoring. * Condition-Specific Examples: * ASD: Atrial fibrillation risk persists after closure, and "Rare complications after device closure include device migration, erosion into the pericardium or aorta, and sudden death." * VSD: "Residual or recurrent VSD, arrhythmias, PH, endocarditis, and valve regurgitation are recognized complications following VSD closure." * PS: "Patients with previous PS intervention (balloon or surgical) often have severe pulmonary regurgitation; thus, long-term clinical and TTE follow-up is recommended." * Aortic Coarctation: "Following coarctation repair, hypertension occurs in up to 75% of patients and should be treated." * TOF: "Severe long-standing pulmonary regurgitation causes right heart enlargement, tricuspid regurgitation, exercise limitation, and both atrial and ventricular arrhythmias and is the most common reason for reoperation after TOF repair." The incidence of sudden cardiac death after TOF repair is "approximately 2% per decade."4. Condition-Specific Management Strategies:* **Patent Foramen Ovale (PFO):** * **Diagnosis:** Typically by transesophageal echocardiography (TEE) with color flow Doppler or agitated saline injection. * **Treatment:** Antiplatelet therapy for embolic stroke of undetermined source. PFO closure is recommended for patients under 60 with embolic-appearing infarcts and no other stroke mechanism, offering a "3.4% at 5 years" recurrent stroke risk reduction, but with a "3.9%" periprocedural complication rate and increased atrial fibrillation risk (0.33% per year). No treatment is needed for asymptomatic, incidentally detected PFO. * **Associated Conditions:** Platypnea-orthodeoxia syndrome and Atrial Septal Aneurysm (ASA), which "reportedly increases the risk for stroke compared with PFO alone."* **Atrial Septal Defect (ASD):** * **Types:** Ostium secundum (most common), ostium primum, sinus venosus, and coronary ...
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    1 時間 12 分
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