patho II sec 2

what stage of sleep do we spend the most time in

stage 2

what stage is the most restorative stage of sleep

stage 3 or "delta" or "slow" wave

what is seen on EMG for stage I sleep

vertex waves

what is seen on EMG for stage II sleep

K complexes and sleep spindles

what is seem on EMG for REM sleep

sawtooth waves

what is REM sleep required for

memory consolidation

what is stage 1 sleep and what occurs during

change over from wakefulness to sleep

heartbeat, breathing, eye movements slow

what is stage 2 sleep and what occurs during

period of light sleep before you enter deeper sleep

heartbeat and breathing slow, muscles relax, body temp drops, eye movements stop

how long is the sleep cycle

90 minutes

what occurs during REM sleep

breathing becomes faster and irregular, eyes move rapidly, HR and BP increase, dreaming, arms and legs become paralyzed

what occurs during each progressive sleep cycle during the night

less time spent in delta sleep, more time spent in other stages

what occurs to sleep as you age

less total sleep, less delta sleep

what secretes melatonin

pineal gland

what does melatonin bind to

MT1 and MT2 receptors in the SCN

what is the function of melatonin

convey information concerning the daily cycle of light and darkness

what are the alerting neurotransmitters

ACh, histamine, NE, orexin, serotonin, dopamine

what is the sleep promoting NT

GABA

what is the most important wake promoting NT

orexin

which gender is insomnia more common in

females

what are the DSM criteria for insomnia

at least one of the following 3 nights a week for at least 3 months:

difficulty initiating sleep

difficulty maintaining sleep

early morning awakening with inability to return to sleep

what are the suggest criteria for defining insomnia

sleep latency >30min

wake after sleep onset >30 mins

total sleep time <6.5hrs

what are the risk factors for primary insomnia

female

age >60

what are risk factors for secondary insomnia

stress, night shift, jet lag, poor sleep routine/environment, smoking, alcohol, caffeine, excessive food/fluid/stimulation late in the day, psych illness, pain, obesity, illicit/Rx drugs

what prescription medications often cause insomnia

amphetamine, bupropion, corticosteroids, diuretics, propranolol, SSRIs, thyroid supplement

what are the 3 Ps of insomnia

predisposing factors (genetics, female, age)

precipitating factors (stress, bad environment)

perpetuating factors (maladaptive coping strategies)

how do you counsel on sleep hygiene

keep a regular sleep schedule, don't exercise before bed, avoid alcohol/stimulants in late afternoon, maintain a comfortable sleeping environment, avoid lots of food/liquid before bed

how do you counsel on stimulus control

only go to bed when sleepy, avoid naps, if you can't go to sleep, leave the room and return when sleepy, use bed for sleep and intimacy

how do you counsel on relaxation training

reduce somatic arousal, reduce mental arousal, use biofeedback

what is the main non-pharm intervention for insomnia

CBT-I

what should every patient with insomnia do

keep a sleep journal

where do DVTs mostly happen

in the lower leg, thigh, or pelvis

what is primary hemostasis

formation of a platelet plug

what is secondary hemostasis

fibrin strands stabilize platelet plug

what do medications treating VTE normally target

secondary hemostasis

what are clotting factors also called

zymogens

what clotting factors are involved in VTE

II, VII, IX, X, IIa, I, Ia

what is clotting factor II

prothrombin

what is clotting factor IIa

thrombin

what is clotting factor I

fibrinogen

what is clotting factor Ia

fibrin

how do clotting factors for fibrin

by activating the next clotting factor in the cascade and forming complexes

what is required for thrombosis

vitamin K

what is the role of the liver in hemostasis

bile salts made in the liver absorb vitamin K from the GI tract

synthesizes clotting factors

what produces vitamin K

gut bacteria

if a patient has diarrhea, what occurs

they may not be absorbing vitamin K

what 3 things help break down a clot

antithrombin III, protein C, protein S

how is vitamin K required for the formation/breakdown of clots

formation: needed for synthesis of II, VII, IX, X

breakdown: protein C and S require vitamin K

what is the process of fibrinolysis

plasminogen is converted to plasmin which breaks down fibrin

what does protein C/protein S inhibit

Va and VIIIa

what does antithrombin inhibit

IIa, IXa, Xa

what is required for protein C and S to do their job

vitamin K

what is the difference between venous and arterial clots

arterial clots are made of platelets

venous clots are made of fibrin

which proteins have longer half lives

II and X

which proteins have shorter half lives

VII and IX

why does it take warfarin a longer time to take effect

it doesn't have any effect on clotting factors that are already made, the clotting factors in the body must be broken down before effect of warfarin are seen. factors II and X have a long half-life so it will take a long time to see effect on these

what is virchow's triad

blood stasis, hypercoagulability, vascular injury

what are risk factors for blood stasis

surgery, paralysis, immobility, obesity, polycythemia vera

how do paralysis and immobility cause clots

no muscle assistance for venous return

how does obesity cause clots

increased abdominal fat puts pressure on abdomen and decreases venous return

how does polycythemia vera cause clots

increased red blood cells increases blood viscosity and decreases blood flow

what are risk factors for vascular injury

major orthopedic surgery, trauma, venous catheters

what are risk factors for hypercoagulability that increase secondary hemostasis

cancer, IBD, pregnancy

what are risk factors for hypercoagulability that increases filtration of anti-coagulants

nephrotic syndrome

what is antiphospholipid syndrome

immune system creates antibodies that effect hemostasis and breakdown of clots

what are inheritable clotting disorders

elevated factor VII, factor V leiden, hyperhomocysteinemia, antithrombin/protein C/protein S deficiency

what is factor V leiden disorder

factor V is resistant to inactivation by protein C

what medications are known to cause hypercoagulability

estrogen, chemotherapy

what are the symptoms of DVT

one-sided leg pain, redness, swelling, warmth

what are symptoms of PE

chest pain, SOA, cough, chest tightness, palpitation, hemoptysis

what are signs of DVT

dilation of superficial veins, homan's sign

what does the d-dimer measure

fibrin degradation

what are tests that can help diagnose VTE

D-dimer, compression ultrasound, CT angiography, ventilation/perfusion scan

which test is specific for PE

ventilation perfusion scan

what test is specific for DVT

compression US

what does a d-dimer <500 indicate

likely NO VTE

what is angiography

contrast dye is injected through IV into blood vessels

what V/Q ratio is indicative of PE

high ratio

when do symptoms resolve in VTE

within a few days

how long does it take a PE to fully dissolve

months-years

how long does it take for a DVT to fully resolve

3-6 months

what are complications of DVT

subsequent PE and post-thrombotic syndrome

what type of DVT is more fatal

proximal

what are complications of PE

death, chronic thromboembolic pulmonary HTN

what type of cell forms the barrier of the alveoli

type I alveolar cell

what is the function of type II alveolar cell

produces surfactant

when are accessory muscles used to breathe

when a patient struggles to breathing using the muscles of inspiration

what is dyspnea

subjective feeling of difficulty breathing

what leads to increased respiratory drive/work of breathing

primary motor cortex sends signals to the muscles of respiration

what leads to the sensation of air hunger

peripheral chemoreceptors sense hypoxia

central chemoreceptors sense hypercapnia

what stimulates slow adapting mechanoreceptors

tension in airways

what stimulates rapid adapting mechanoreceptors

volume expansion due to fluid in the lungs

what stimulates C-fibers

irritating stimuli

what is FVC

maximum amount of air that can be rapidly and forcefully exhaled from the lungs after a full inspiration

what is FEV1

volume of air expired in the first second of FVC

what is the FEV1/FVC ratio

volume of air expired in the first second expressed as a percentage of the FVC

what is COPD

heterogeneous lung condition characterized by the chronic respiratory symptoms due to abnormalities of the airways that cause persistent, often progressive, airflow obstruction

what is chronic bronchitis

chronic productive cough for 3 months in each of 2 successive years in a patient who doesn't have another reason for a chronic cough

what is emphysema

abnormal permanent enlargement of the airspaces distal to the terminal bronchioles accompanied by destruction of their walls without obvious fibrosis

what mostly causes COPD

smoking

what is the difference between the etiology of asthma and COPD

asthma: onset early in live, most reversibly, eosinophils involved

COPD: onset later in life, not fully reversible, neutrophils involved