Thema 5: Neoplasma/nieuwvorming II. Een complete samenvatting van alle tentamenstof!
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Thema 5 Nieuwvorming
Établissement
Rijksuniversiteit Groningen (RuG)
Op aanraden van mijn medestudenten verkoop ik nu mijn samenvattingen! In deze samenvatting maak ik veel gebruik van afbeeldingen, tabellen en opsommingen. Hierdoor hoef je geen lange lappen saaie en ingewikkelde tekst te lezen. In deze samenvatting staat alle stof van de boeken, colleges en leerdoe...
,Content
Week 16: On death.................................................................................................................................. 5
On life and death ................................................................................................................................. 5
Medical vs cultural and historical perspectives .............................................................................. 5
Philippe Aries: nature vs culture ..................................................................................................... 5
Death mentality in history ............................................................................................................... 5
Ethical issues with end of life decisions on the ICU ............................................................................ 7
Intensive care .................................................................................................................................. 7
Case ................................................................................................................................................. 7
Definitions ....................................................................................................................................... 8
Ethical issues: .................................................................................................................................. 8
Futility .............................................................................................................................................. 9
APACHE and SAPS score ................................................................................................................ 10
Forensic science................................................................................................................................. 11
Post-mortem ................................................................................................................................. 11
The process of dying ...................................................................................................................... 12
Suspicious signs ............................................................................................................................. 14
Finally............................................................................................................................................. 15
Medicalisation of death..................................................................................................................... 16
Historical and sociological perspective ......................................................................................... 16
Medicalisation of death: crisis in the early 1970s ......................................................................... 16
The Dutch response....................................................................................................................... 17
Euthanasia: dilemma’s and debate ............................................................................................... 17
Death (de-)medicalised ................................................................................................................. 18
Coping with stress in clinical practice................................................................................................ 19
Case ............................................................................................................................................... 19
Stages of a burnout: ...................................................................................................................... 19
What can you do for someone with symptoms: ........................................................................... 20
Week 17: Skin cancer ............................................................................................................................ 22
Histology: epithelial tissue ................................................................................................................ 22
Classification .................................................................................................................................. 22
Cell polarisation ............................................................................................................................. 24
Keratinised squamous epithelium ................................................................................................. 25
Melanocytes .................................................................................................................................. 26
Formation of glands ...................................................................................................................... 26
Histology: connective tissue .............................................................................................................. 29
2
, Classification .................................................................................................................................. 29
Cells of the connective tissue ........................................................................................................ 29
Extracellular matrix ....................................................................................................................... 29
Connective tissue proper .............................................................................................................. 30
Adipose tissue................................................................................................................................ 30
The skin.............................................................................................................................................. 31
Benign skin tumours .......................................................................................................................... 34
Seborrhic keratosis ........................................................................................................................ 34
Solar lentigo................................................................................................................................... 34
Sebaceous hyperplasia .................................................................................................................. 35
Dermatofibroma ............................................................................................................................ 36
Neurofibroma ................................................................................................................................ 36
Pyogenic granuloma ...................................................................................................................... 37
Haemangioma ............................................................................................................................... 38
Skin cancer......................................................................................................................................... 39
Basal cell carcinoma (least aggressive).......................................................................................... 41
Squamous cell carcinoma .............................................................................................................. 43
Melanocytic tumours .................................................................................................................... 46
Immunotherapy................................................................................................................................. 52
New developments ....................................................................................................................... 53
Week 18: Cancer of the male genital system ........................................................................................ 55
Anatomy of the pelvis ....................................................................................................................... 55
Muscles .......................................................................................................................................... 56
True and false pelvis ...................................................................................................................... 57
Pelvic peritoneum ......................................................................................................................... 59
Male pelvis..................................................................................................................................... 60
The prostate .................................................................................................................................. 62
Vascularisation of the true pelvis .................................................................................................. 64
Lymphatic drainage ....................................................................................................................... 66
Physiology.......................................................................................................................................... 67
Spermatogenesis ........................................................................................................................... 67
The male sexual act ....................................................................................................................... 68
Male sex hormones ....................................................................................................................... 68
Prostate cancer.................................................................................................................................. 70
Epidemiology ................................................................................................................................. 70
Screening ....................................................................................................................................... 70
3
, Evaluation ...................................................................................................................................... 70
Causes ............................................................................................................................................ 71
Staging and grading ....................................................................................................................... 71
Treatment ...................................................................................................................................... 73
Testicular cancer ............................................................................................................................... 76
Penile carcinoma ............................................................................................................................... 78
Week 19: Painful swelling in the leg – Osteosarcoma and bone metastasis ........................................ 79
Diagnostics..................................................................................................................................... 79
Staging for benign tumours ........................................................................................................... 82
Staging for malignant disease ....................................................................................................... 82
RECIST criteria ............................................................................................................................... 82
Bone metastasis ................................................................................................................................ 83
Benign tumours ................................................................................................................................. 86
Benign bone tumours .................................................................................................................... 86
Malignant tumours ............................................................................................................................ 90
Malignant bone tumours............................................................................................................... 90
Malignant soft tissue tumours ...................................................................................................... 91
Rehabilitation .................................................................................................................................... 92
International Classification of Functioning, Disability and Health (ICF) ........................................ 92
4
,Week 16: On death
On life and death
Medical vs cultural and historical perspectives
Medical Historical
Protocols and guidelines for: Research into human and cultural attitudes
- Palliative sedation and euthanasia towards death in the course of history
- Research into the organic process of
dying
- Determination of death
- Time and causes of death
- Regulation of organ donation
Instrumental rationality (utility) Substantive rationality (meaning)
Medical-juridical motive Existential motive
Philippe Aries: nature vs culture
➔ Working hypothesis: death is (as part of nature) wild and threatening, but it can be
tamed (by culture).
Nature: wild and threatening? → disease, decay, death (human condition) = nature
Culture: order in chaos, some control? → medicine/dealing with death = culture
➔ Cultural history: collective death mentality continuously changes
Death mentality in history
Phase 1: tamed death (500-1200)
- Death was not an individual fate, but a public collective event
- Collective/public experience mediated and tamed by rituals
- Waiting for Return of Christ + eternal bliss
Phase 2: one’s own death/death of the self (1200-1500)
- Shift from death as a collective, anonymous event to the death of an individual
identity
- Shift from return of Christ to Final Judgement
- New preoccupation with individual death the final judgment based on the deathbed
(e.g. transi tombe, dance macabre, ars moriendi)
2 pillars:
- Momento mori
o Spiritual purification of an individual
o Death as preacher, judge and confessor
o Growing importance of moment of dying
- Social didactics: inequality in earthly society → but in the end everyone is equal
Shift: remote and imminent death (1500-1780)
- End of phase 2
5
, - Impact of Renaissance (humanism
o Remote death: alienation with death
o Imminent death: remained momento mori
➔ First signs of modern fear of death
- Impact of reformation and counter-reformation
o Not just deathbed, but entire life is decisive for last judgment
o Restraint and modesty as life motto: Protestantism
Phase 3: thy death/death of the other (1780-1950)
- Romantic sensitivity: the beloved other
o Origin of privacy
o Evolution of family from financial unit to emotional entity
o Relatives do not grief for death as such, but for the physical spereation from
the disease
o Belief in heaven, hell faded to the background
o Increased focussed on earthly relations
- More elaborate mourning culture
- Beginning of privatization (no longer public event) and denial of death
Phase 4: forbidden/invisible death (1950-present)
- Death disappeared from intimacy and community or family, became private event in
hospital, supervised by hospital
o Rationalization and medicalisation of death: medical technology dismisses
one from his responsibility for intimacy
o Juridification of death: regulation of unnameable
- Deritualisation
- Threat
Criticism: death has become to scientific and technological
➔ We are not as good anymore in dealing with death, we lost the sense of meaning
Sherwin Nuland: “We have become good at the art of saving life, but this cost our ability of
dealing with death”.
Nuland’s plea: change of culture
- Acceptance of death
- Not stretching life
- More intimate setting of dying
Phase 5: spectacular death (Jacobsen) (1980-present)
- New mediated/mediatised visibility of death
- Commercialisation and re-ritualisation of death
- Palliative care revolution
Paradoxical death: accepting death vs prolonging life
6
,Ethical issues with end of life decisions on the ICU
Intensive care
Critically ill patient = someone who presents with severe physiological instability requiring
technical and/or artificial life support
➔ Also medications that are not allowed to be given on a regular ward
Elective admission:
- Arranged on forehand
- Minimize morbidity/mortality
- Lower long turn medical costs
Intensive care unit:
- Lifesaving
- High mortality rates
- Often prolonged length of stay
Pros Cons
Diagnostics and therapy: No added value:
- Everything is possible - Unnecessary suffering
- Valuable for the family - Loss of dignity
- Good feeling
- Time for the doctors
Family:
- Endure considerable emotional
pressure
- False expectations
Waste of money: resources are limited
Case
- 24 years old
- 26+1 weeks pregnant
- Healthy
- Just married
- Comatose: trapped brain → suspected cerebral bleeding
- Cause: cerebral lesion
Then: admitted to the ICU
- Emergency craniotomy
- Mechanically ventilated
- Hemodynamic support
- Wide pupils → not reacting to light
Hours after the operation:
- Serious brain injury
- Risk: vegetive state
7
, Definitions
Coma: unconsciousness/unresponsiveness due to severe brain injury or drug induced (XTC,
anaesthetics)
Minimally conscious state: patient is able to produce subtle and intermittent signs of
consciousness
Vegetative status: patient shows no sign of consciousness or adequate response to stimuli.
The patient has brain and brain stem activity
Brain death: cessation of brain and brain stem activity, the patient is unresponsive
Ethical issues:
- Neurologically severely damaged patient
- 26+1 weeks pregnant
- Who decides over mother and child
- Where do we draw the line in treating mother/child when mother deteriorates
Options:
- Extubate after 3 days
- We need more time to clarify
- This patients should go to a coma rehabilitation centre with mechanical ventilation
facilities
Why do intensivists sometimes admit patient without any chance of survival?
- Uncertainty or disagreement
- Pressure:
o Patient/family
o Colleagues
o Nursing shortage on general ward
Who decides for a comatose patient? Shared decision making:
- The patient:
o Living will
o Written advanced directive: CPR, coma, feeding, etc.
- Medical team:
o Expertise
o Paternalistic
- Others: surrogate decision maker
o Family
Problems with family as surrogate decision makers:
- Close to the patient
o No experience
o Emotional
- Feel responsible
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