Transplant medicine

Transplant medicine US Medical PG Question 1: A research team develops a new monoclonal antibody checkpoint inhibitor for advanced melanoma that has shown promise in animal studies as well as high efficacy and low toxicity in early phase human clinical trials. The research team would now like to compare this drug to existing standard of care immunotherapy for advanced melanoma. The research team decides to conduct a non-randomized study where the novel drug will be offered to patients who are deemed to be at risk for toxicity with the current standard of care immunotherapy, while patients without such risk factors will receive the standard treatment. Which of the following best describes the level of evidence that this study can offer?

• A. Level 1
• B. Level 3 (Correct Answer)
• C. Level 5
• D. Level 4
• E. Level 2

Transplant medicine Explanation: ***Level 3*** - A **non-randomized controlled trial** like the one described, where patient assignment to treatment groups is based on specific characteristics (risk of toxicity), falls into Level 3 evidence. - This level typically includes **non-randomized controlled trials** and **well-designed cohort studies** with comparison groups, which are prone to selection bias and confounding. - The study compares two treatments but lacks randomization, making it Level 3 evidence. *Level 1* - Level 1 evidence is the **highest level of evidence**, derived from **systematic reviews and meta-analyses** of multiple well-designed randomized controlled trials or large, high-quality randomized controlled trials. - The described study is explicitly stated as non-randomized, ruling out Level 1. *Level 2* - Level 2 evidence involves at least one **well-designed randomized controlled trial** (RCT) or **systematic reviews** of randomized trials. - The current study is *non-randomized*, which means it cannot be classified as Level 2 evidence, as randomization is a key criterion for this level. *Level 4* - Level 4 evidence includes **case series**, **case-control studies**, and **poorly designed cohort or case-control studies**. - While the study is non-randomized, it is a controlled comparative trial rather than a case series or retrospective case-control study, placing it at Level 3. *Level 5* - Level 5 evidence is the **lowest level of evidence**, typically consisting of **expert opinion** without explicit critical appraisal, or based on physiology, bench research, or animal studies. - While the drug was initially tested in animal studies, the current human comparative study offers a higher level of evidence than expert opinion or preclinical data.

Transplant medicine US Medical PG Question 2: A 22-year-old man is brought to the emergency department by ambulance 1 hour after a motor vehicle accident. He did not require any circulatory resuscitation at the scene, but he was intubated because he was unresponsive. He has no history of serious illnesses. He is on mechanical ventilation with no sedation. His blood pressure is 121/62 mm Hg, the pulse is 68/min, and the temperature is 36.5°C (97.7°F). His Glasgow coma scale (GCS) is 3. Early laboratory studies show no abnormalities. A search of the state donor registry shows that he has registered as an organ donor. Which of the following is the most appropriate next step in evaluation?

• A. Evaluation of brainstem reflexes (Correct Answer)
• B. Brain MRI
• C. Electroencephalography
• D. Cerebral angiography
• E. Apnea test

Transplant medicine Explanation: ***Evaluation of brainstem reflexes*** - In a patient with a **Glasgow Coma Scale (GCS) of 3** and no response to noxious stimuli/sedation, assessment of **brainstem reflexes** is a critical step in determining brain death. - This evaluation includes checking for pupillary light reflex, corneal reflex, vestibulo-ocular reflex (doll's eyes), oculocephalic reflex, and gag/cough reflexes to ascertain the complete absence of brainstem function. *Brain MRI* - While a brain MRI can provide detailed anatomical information regarding brain injury, it is **not the primary diagnostic test** for determining brain death. - Brain death is a **clinical diagnosis** based on the irreversible loss of brain and brainstem function, which can be confirmed rapidly by clinical examination. *Electroencephalography* - **EEG** measures electrical activity in the brain and can show electrocerebral silence, which is consistent with brain death. - However, EEG is **not always required** for the diagnosis of brain death and is often used as a confirmatory test in specific situations, such as when clinical examination is inconclusive or legal requirements necessitate it. *Cerebral angiography* - **Cerebral angiography** can demonstrate the absence of cerebral blood flow, which is a criterion for brain death. - This is an **invasive procedure** and is generally reserved for situations where clinical examination tests are difficult to perform or interpret (e.g., severe facial trauma, drug intoxication), and is not the initial step. *Apnea test* - The **apnea test** is a critical component of the brain death evaluation, confirming the absence of spontaneous breathing response to hypercapnia. - It is performed **after the absence of brainstem reflexes** has been established and all confounding factors (e.g., hypothermia, hypotension, sedatives) have been ruled out.

Transplant medicine US Medical PG Question 3: A 50-year-old man presents to a clinic with oliguria. Four weeks ago, he had a kidney transplant. Postoperative follow-up was normal. He is currently on cyclosporine and admits that sometimes he forgets to take his medication. On physical examination, the vital signs include: temperature 37.1°C (98.8°F), blood pressure 165/110 mm Hg, heart rate 80/min, and respiratory rate 16/min. There is mild tenderness on renal palpation. His serum creatinine level is 4 mg/dL, well above his baseline level after the transplant. Which of the following best describes the histological finding if a biopsy is taken from the transplanted kidney?

• A. Lymphocytic infiltration of graft vessels and endothelial damage (Correct Answer)
• B. Thrombosis and occlusion of vessels
• C. Atherosclerosis on angiography
• D. Necrosis with granulation tissue
• E. Thickening of blood vessels, fibrosis of graft vessels, and parenchymal atrophy

Transplant medicine Explanation: ***Lymphocytic infiltration of graft vessels and endothelial damage*** - The patient's presentation with **oliguria**, elevated **creatinine**, and **hypertension** following a recent kidney transplant, especially with a history of non-adherence to **cyclosporine** (an immunosuppressant), strongly indicates **acute rejection**. - Histologically, acute rejection is characterized by **lymphocytic infiltration** of the graft vessels (often referred to as **vasculitis** or **endotheliitis**) and associated **endothelial damage**. *Thrombosis and occlusion of vessels* - This finding is more characteristic of **hyperacute rejection**, which typically occurs within minutes to hours of transplantation, not weeks later. - Hyperacute rejection is mediated by **pre-formed antibodies** and leads to severe, rapid graft failure due to widespread intravascular thrombosis. *Atherosclerosis on angiography* - While post-transplant patients can develop accelerated atherosclerosis (a form of **chronic rejection**), it is typically a long-term complication developing months to years after transplantation. - The acute presentation with rapid creatinine elevation is not typical for primary atherosclerosis. *Necrosis with granulation tissue* - **Necrosis** with **granulation tissue** is a general healing response to significant tissue injury or inflammation. - While some cellular necrosis can occur in severe rejection, it's not the defining feature, and granulation tissue indicates a more prolonged, subacute process rather than the primary histological hallmark of acute rejection. *Thickening of blood vessels, fibrosis of graft vessels, and parenchymal atrophy* - These are classic features of **chronic rejection**, which manifests months to years after transplantation as a gradual decline in graft function. - **Chronic rejection** involves progressive damage leading to vasculopathy, interstitial fibrosis, and tubular atrophy, rather than the acute inflammatory cellular infiltrate seen here.

Transplant medicine US Medical PG Question 4: A 14-year-old boy has undergone kidney transplantation due to stage V chronic kidney disease. A pre-transplantation serologic assessment showed that he is negative for past or present HIV infection, viral hepatitis, EBV, and CMV infection. He has a known allergy for macrolides. The patient has no complaints 1 day after transplantation. His vital signs include: blood pressure 120/70 mm Hg, heart rate 89/min, respiratory rate 17/min, and temperature 37.0°C (98.6°F). On physical examination, the patient appears to be pale, his lungs are clear on auscultation, heart sounds are normal, and his abdomen is non-tender on palpation. His creatinine is 0.65 mg/dL (57.5 µmol/L), GFR is 71.3 mL/min/1.73 m2, and urine output is 0.9 mL/kg/h. Which of the following drugs should be used in the immunosuppressive regimen in this patient?

• A. Belatacept
• B. Sirolimus
• C. Omalizumab
• D. Daclizumab
• E. Basiliximab (Correct Answer)

Transplant medicine Explanation: **Basiliximab** - **Basiliximab** is a **monoclonal antibody** that targets the **IL-2 receptor (CD25)** on activated T cells, preventing their proliferation and inducing immunosuppression. - It is commonly used as **induction therapy** in kidney transplant recipients due to its good safety profile, especially in pediatric patients, without the nephrotoxicity associated with calcineurin inhibitors, minimizing acute rejection risks immediately post-transplant. *Belatacept* - **Belatacept** works by co-stimulation blockade, binding to **CD80 and CD86** on antigen-presenting cells to prevent T-cell activation. - It is typically reserved for patients who cannot tolerate calcineurin inhibitors due to **nephrotoxicity** or require a steroid-sparing regimen, which is not indicated as an immediate need in this patient. *Sirolimus* - **Sirolimus** is an **mTOR inhibitor** that works by blocking T-cell proliferation and B-cell differentiation. - It is associated with several side effects, including **delayed wound healing**, **thrombocytopenia**, and **hyperlipidemia**, which are undesirable in the immediate post-transplant period, especially in a growing adolescent. *Omalizumab* - **Omalizumab** is an **anti-IgE monoclonal antibody** primarily used for allergic asthma and chronic spontaneous urticaria. - It has no role in **immunosuppression for organ transplantation** as its mechanism of action is unrelated to preventing graft rejection. *Daclizumab* - **Daclizumab** is another **monoclonal antibody** that also targets the **IL-2 receptor (CD25)**, similar to basiliximab. - However, daclizumab has been **withdrawn from the market** due to serious adverse effects including severe liver injury and autoimmune encephalitis, making it unavailable for clinical use in transplantation.

Transplant medicine US Medical PG Question 5: A 58-year-old man is brought to the emergency department because of confusion, weight loss, and anuria. He has chronic kidney disease, hypertension, and type 2 diabetes mellitus. He was diagnosed with acute lymphoblastic leukemia at the age of 8 years and was treated with an allogeneic stem cell transplantation. He is HIV-positive and has active hepatitis C virus infection. He drinks around 8 cans of beer every week. His current medications include tenofovir, emtricitabine, atazanavir, daclatasvir, sofosbuvir, insulin, amlodipine, and enalapril. He appears lethargic. His temperature is 36°C (96.8°F), pulse is 130/min, respirations are 26/min, and blood pressure is 145/90 mm Hg. Examination shows severe edema in his legs and generalized muscular weakness. Auscultation of the lung shows crepitant rales. Laboratory studies show positive HCV antibody and positive HCV RNA. His HIV viral load is undetectable and his CD4+ T-lymphocyte count is 589/μL. Six months ago, his CD4+ T-lymphocyte count was 618/μL. An ECG of the heart shows arrhythmia with frequent premature ventricular contractions. Arterial blood gas analysis on room air shows: pH 7.23 PCO2 31 mm Hg HCO3- 13 mEq/L Base excess -12 mEq/L The patient states he would like to donate organs or tissues in the case of his death. Which of the following is an absolute contraindication for organ donation in this patient?

• A. HIV infection
• B. Childhood leukemia (Correct Answer)
• C. Alcoholism
• D. No absolute contraindications
• E. Acute kidney injury

Transplant medicine Explanation: ***Correct: Childhood leukemia*** - **History of hematologic malignancy** (including acute lymphoblastic leukemia) is an **absolute contraindication** for solid organ donation according to UNOS and OPTN guidelines. - Even though this patient was treated 50 years ago with allogeneic stem cell transplantation, the concern for **residual malignant cells** or **transmission to immunosuppressed recipients** makes this an absolute exclusion. - Unlike solid tumors (which may be acceptable after long disease-free intervals), **leukemias and lymphomas carry lifelong exclusion** from organ donation due to their systemic nature and potential for dormant cells. *Incorrect: Acute kidney injury* - **Acute kidney injury (AKI)** is NOT an absolute contraindication for organ donation. - While the kidneys themselves may not be suitable for transplantation, other organs (heart, liver, lungs, corneas) could still be viable. - Each organ is assessed individually for suitability. *Incorrect: HIV infection* - **Well-controlled HIV infection** (undetectable viral load, stable CD4 count >200) is no longer an absolute contraindication. - Under the **HOPE Act (HIV Organ Policy Equity Act)**, organs from HIV-positive donors can be transplanted into HIV-positive recipients. - This patient has excellent viral control (undetectable VL, CD4 589), making HIV not an absolute barrier. *Incorrect: Alcoholism* - **Alcohol use disorder** alone is not an absolute contraindication for organ donation. - The suitability depends on individual organ assessment (e.g., liver function, cardiac health). - This patient drinks 8 beers/week, which is moderate consumption and doesn't preclude donation of undamaged organs. *Incorrect: No absolute contraindications* - This patient **does have an absolute contraindication**: his history of hematologic malignancy (acute lymphoblastic leukemia). - Despite the long time since treatment, hematologic cancers remain absolute exclusions for organ donation.

Transplant medicine US Medical PG Question 6: A 68-year-old woman comes to the physician for a follow-up examination. Three months ago, she underwent heart transplantation for restrictive cardiomyopathy and was started on transplant rejection prophylaxis. Her pulse is 76/min and blood pressure is 148/82 mm Hg. Physical examination shows enlargement of the gum tissue. There is a well-healed scar on her chest. Serum studies show hyperlipidemia. The physician recommends removing a drug that decreases T cell activation by inhibiting the transcription of interleukin-2 from the patient's treatment regimen and replacing it with a different medication. Which of the following drugs is the most likely cause of the adverse effects seen in this patient?

• A. Mycophenolate mofetil
• B. Azathioprine
• C. Tacrolimus
• D. Cyclosporine (Correct Answer)
• E. Prednisolone

Transplant medicine Explanation: ***Cyclosporine*** - The patient's symptoms of **gingival hyperplasia**, **hypertension**, and **hyperlipidemia** are classic side effects associated with cyclosporine. - Cyclosporine is a calcineurin inhibitor that **decreases T-cell activation** by inhibiting IL-2 transcription, matching the drug description. *Mycophenolate mofetil* - Mycophenolate mofetil is an **antiproliferative agent** that inhibits purine synthesis, primarily affecting lymphocytes. - Its common side effects are mainly **hematologic** (leukopenia, anemia) and **gastrointestinal** (diarrhea, nausea), not gingival hyperplasia or hypertension. *Azathioprine* - Azathioprine is a **purine analog** that impairs DNA synthesis and inhibits lymphocyte proliferation. - Key side effects include **myelosuppression** (leukopenia, thrombocytopenia) and **hepatotoxicity**, which are not present here. *Tacrolimus* - Tacrolimus is also a **calcineurin inhibitor** that inhibits IL-2 transcription, similar to cyclosporine. - While it can cause **hypertension** and **hyperlipidemia**, it is less commonly associated with **gingival hyperplasia** than cyclosporine. *Prednisolone* - Prednisolone is a **corticosteroid** used for immunosuppression, acting broadly on the immune system. - Common side effects include **hyperglycemia**, **osteoporosis**, and **cataracts**, not specific gingival overgrowth.

Transplant medicine US Medical PG Question 7: A 66-year-old man presents to the emergency department for a 1-hour history of right arm weakness. He was having breakfast this morning when his right arm suddenly became weak, causing him to drop his coffee mug. He also noticed that he was slurring his speech and had some additional weakness in his right leg. He had no symptoms prior to the onset of the weakness and noted no other unusual phenomena. These symptoms lasted for about 30 minutes, but they resolved completely by the time he arrived at the emergency department. His medical history is notable for hypertension and hyperlipidemia, but he does not receive close follow-up from a primary care physician for these conditions. The patient currently is not taking any medications. His pulse is 75/min, the blood pressure is 160/95 mm Hg, and the respiratory rate is 14/min. Physical exam is remarkable for a high-pitched sound heard on auscultation of the neck, the remainder of the exam, including a complete neurological exam, is entirely unremarkable. CT angiography of the head and neck shows no active hemorrhage and 80% stenosis of the left internal carotid artery. Which of the following is the next best step in the long-term management of this patient?

• A. Administration of tissue plasminogen activator (tPA)
• B. Brain MRI
• C. Initiation of lisinopril
• D. Initiation of aspirin and atorvastatin (Correct Answer)
• E. Carotid endarterectomy

Transplant medicine Explanation: ***Initiation of aspirin and atorvastatin*** - This patient experienced a **transient ischemic attack (TIA)** as evidenced by transient neurological symptoms (right-sided weakness, slurred speech) that resolved completely within 24 hours. The presence of **80% left internal carotid artery stenosis** and a **carotid bruit** identifies the source of the embolic event. - **Antiplatelet therapy (aspirin)** and **high-intensity statin therapy (atorvastatin)** are critical for **secondary stroke prevention** in patients with TIA due to atherosclerotic disease. Aspirin reduces platelet aggregation, and atorvastatin stabilizes plaques and lowers cholesterol. *Administration of tissue plasminogen activator (tPA)* - **tPA** is indicated for **acute ischemic stroke** within a specific time window (typically 3-4.5 hours from symptom onset) and requires confirmation of **active stroke (not TIA)** and absence of contraindications. This patient's symptoms **resolved completely**, indicating a TIA, not an acute ischemic stroke that would benefit from tPA. - Furthermore, tPA carries a significant risk of **hemorrhagic transformation**, which is not warranted in a patient whose symptoms have already resolved. *Brain MRI* - While a **brain MRI** (diffusion-weighted imaging) is highly sensitive for detecting acute ischemic changes and can help confirm a TIA diagnosis by ruling out small infarcts, it is not the **next best step in long-term management** after already identifying significant carotid stenosis as the likely source. - The immediate priority for long-term management is to prevent future, potentially disabling, ischemic events through medical therapy. *Initiation of lisinopril* - **Lisinopril**, an ACE inhibitor, is an appropriate medication for managing **hypertension**, which is a significant risk factor for TIA and stroke. The patient's blood pressure of 160/95 mmHg indicates uncontrolled hypertension. - However, while important for overall cardiovascular health, **blood pressure control alone** is not the most immediate and comprehensive step for **secondary prevention of ischemic events** given the specific finding of significant carotid stenosis; **antiplatelet and statin therapy** are more directly targeted at preventing recurrent embolic events from the plaque. *Carotid endarterectomy* - **Carotid endarterectomy (CEA)** is a surgical procedure to remove atherosclerotic plaque from the carotid artery and is considered for patients with symptomatic **carotid artery stenosis of 70-99%**. Given the 80% stenosis, this procedure is a strong consideration. - However, for patients with symptomatic carotid stenosis, medical management (aspirin and statin) is typically **initiated first** and often continued even after CEA. CEA, while highly effective, is an invasive procedure with its own risks and requires careful patient selection and timing in conjunction with optimal medical therapy.

Transplant medicine US Medical PG Question 8: A 35-year-old man arrives at the emergency department within minutes after a head-on motor vehicle accident. He suffered from blunt abdominal trauma, several lacerations to his face as well as lacerations to his upper and lower extremities. The patient is afebrile, blood pressure is 45/25 mmHg and pulse is 160/minute. A CBC is obtained and is most likely to demonstrate which of the following?

• A. Hb 17 g/dL, Hct 20%
• B. Hb 15 g/dL, Hct 45% (Correct Answer)
• C. Hb 5 g/dL, Hct 30%
• D. Hb 20 g/dL, Hct 60%
• E. Hb 5 g/dL, Hct 20%

Transplant medicine Explanation: ***Hb 15 g/dL, Hct 45%*** - This option represents **normal hemoglobin and hematocrit values**, which are expected in the **initial minutes following acute hemorrhage**. - In acute blood loss, **whole blood is lost** (both RBCs and plasma together), so the **concentration of RBCs remains unchanged** initially. - **Hemodilution has not yet occurred**, as there hasn't been enough time for fluid shifts from the extravascular to the intravascular space to dilute the blood. - This is a **critical teaching point**: early CBC values can be **falsely reassuring** and don't reflect the severity of hemorrhagic shock. *Hb 17 g/dL, Hct 20%* - This option shows a **medically implausible combination** - the normal Hb:Hct ratio is approximately **1:3**, so an Hb of 17 g/dL should correspond to an Hct of approximately 51%, not 20%. - This combination cannot occur physiologically and does not represent any stage of acute blood loss. *Hb 5 g/dL, Hct 30%* - This shows an **incorrect Hb:Hct ratio** (6:1 instead of the expected 3:1) - if Hb is 5 g/dL, the Hct should be approximately 15%, not 30%. - While severe anemia can occur with massive blood loss, this would only be apparent **hours after injury** once hemodilution from fluid shifts occurs, not within minutes. - The implausible ratio makes this medically incorrect. *Hb 20 g/dL, Hct 60%* - These values represent **polycythemia** (abnormally high red blood cell counts), which is the opposite of what would be expected after acute traumatic blood loss. - The Hb:Hct ratio is appropriate (1:3), but the elevated values suggest chronic hypoxemia, dehydration, or myeloproliferative disorders - not acute hemorrhage. *Hb 5 g/dL, Hct 20%* - This shows an **incorrect Hb:Hct ratio** (4:1 instead of the expected 3:1) - if Hb is 5 g/dL, the Hct should be approximately 15%, not 20%. - Even if we accept these as severe anemia values, they would only be seen **several hours after injury** when sufficient time has passed for fluid shifts and hemodilution to occur, not within minutes of the trauma.

Transplant medicine US Medical PG Question 9: A 63-year-old man presents to the ambulatory medical clinic with symptoms of dysphagia and ‘heartburn’, which he states have become more troublesome over the past year. Past medical history is significant for primary hypertension. On physical exam, he is somewhat tender to palpation over his upper abdomen. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Barium swallow fluoroscopy demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax. Given the following options, what is the most appropriate next step in the management of this patient’s underlying condition?

• A. Lifestyle modification
• B. Antacid therapy
• C. Cimetidine
• D. Surgical gastropexy (Correct Answer)
• E. Omeprazole

Transplant medicine Explanation: ***Surgical gastropexy*** - This patient has a **paraesophageal hiatal hernia** (Type II or III), evidenced by the barium swallow showing a **subdiaphragmatic gastroesophageal junction** with **herniation of the gastric fundus into the left hemithorax**. - In paraesophageal hernias, the GE junction remains in relatively normal position while the gastric fundus herniates through the diaphragmatic hiatus alongside the esophagus. - **Symptomatic paraesophageal hernias** warrant **surgical repair** (fundoplication with hernia reduction and hiatal repair) due to significant risk of complications including **gastric volvulus, strangulation, incarceration**, and **ischemia**. - The patient's progressive dysphagia and year-long symptoms indicate this is not an incidental finding but a symptomatic hernia requiring definitive surgical management. *Omeprazole* - **Proton pump inhibitors** are first-line medical therapy for **sliding hiatal hernias (Type I)** where the GE junction migrates above the diaphragm, causing GERD symptoms. - In **paraesophageal hernias**, the primary pathophysiology is **mechanical** (herniation and potential obstruction/strangulation), not acid-related, so PPIs address symptoms but not the underlying structural problem. - While PPIs may provide some symptomatic relief, they do **not prevent the serious mechanical complications** of paraesophageal hernias and are insufficient as definitive management. *Lifestyle modification* - **Lifestyle modifications** are appropriate adjunctive measures for GERD and sliding hiatal hernias but do not address the mechanical nature and complication risk of paraesophageal hernias. - They cannot prevent gastric volvulus or strangulation, which are life-threatening complications unique to paraesophageal hernias. *Antacid therapy* - **Antacids** provide temporary symptom relief but have no role in managing the structural abnormality or preventing complications of paraesophageal hernia. - They are even less effective than PPIs for acid suppression and similarly fail to address the mechanical problem. *Cimetidine* - **H2-receptor antagonists** like cimetidine reduce gastric acid production but are less potent than PPIs. - Like PPIs, they may provide some symptomatic relief but do not address the **mechanical herniation** or prevent the serious complications that make surgical repair necessary for paraesophageal hernias.

Transplant medicine US Medical PG Question 10: A 55-year-old woman who works as a chef is brought to the hospital for evaluation of burns sustained in a kitchen accident. Physical examination reveals 3rd-degree burns over the anterior surface of the right thigh and the lower limbs, which involve approx. 11% of the total body surface area (TBSA). The skin in the burned areas is thick and painless to touch, and the dorsalis pedis pulses are palpable but weak. Initial fluid resuscitation has been started and the patient is hemodynamically stable. Which of the following is the most appropriate next step in management?

• A. Delayed excision and skin grafting
• B. Fluid resuscitation with Ringer’s lactate solution per the Parkland formula
• C. Early excision and split-thickness skin grafting (Correct Answer)
• D. Topical antibiotic application of mafenide acetate
• E. Early excision and full-thickness skin grafting

Transplant medicine Explanation: **Early excision and split-thickness skin grafting** - **Early excision and split-thickness skin grafting** is the most appropriate next step for **deep 3rd-degree burns** of this size to prevent infection, reduce inflammation, and promote wound healing. - The burns cover 11% TBSA, which is a significant area where **skin grafting** would be beneficial to minimize scarring and improve functional outcomes. *Delayed excision and skin grafting* - **Delayed excision and grafting** increases the risk of **infection, sepsis, and prolonged hospitalization**. - Early intervention is crucial for **optimal outcomes** in large, deep burns. *Fluid resuscitation with Ringer’s lactate solution per the Parkland formula* - While **fluid resuscitation** is critical in burn management, it is typically initiated **immediately upon presentation** and often pre-hospital or in the emergency department. - The question asks for the "most appropriate next step in management" after initial evaluation and stabilization, implying that urgent surgical intervention is being considered for the **definitive wound closure**. *Topical antibiotic application of mafenide acetate* - **Topical antibiotics** like mafenide acetate are used to prevent **wound infection** but are primarily adjuncts to surgical treatment for deep burns. - They do not address the need for **wound closure and definitive healing** in deep burns covering a significant TBSA. *Early excision and full-thickness skin grafting* - **Full-thickness skin grafts** are typically reserved for smaller, deeper defects in areas where cosmesis and durability are paramount, such as the face or hands. - For **large-area 3rd-degree burns** like those on the thigh and lower limbs, **split-thickness skin grafts** are preferred due to their greater availability and ability to cover larger areas.

Transplant medicine Flashcard 1 of 3

Question: What type of graft is from self? _____

Answer: Autograft

Transplant medicine Flashcard 2 of 3

Question: Patients who have undergone _____ surgery can sometimes manifest with symptoms of hypoparathyroidism and hypocalcemia.

Answer: Thyroid

Transplant medicine Flashcard 3 of 3

Question: In a renal transplant a patient presenting with fever and leakage of urine into the pelvic cavity 5 - 10 days following the transplant most likely has _____

Answer: distal ureteral ischemia