Quiz 69, May 29th, 2020

Welcome to the 69th FOAMed Quiz. 


Eefje, Nicole, Joep and Rick

Source image: www.thebottomline.org.uk

Question 1

The ACTT-1 trial was covered by almost every FOAMed blog and podcast this week. This preliminary report concerning an RCT comparing Remdesivir to placebo for in COVID-19 patients was published earlier this week. 

Which of the following statements is true about this trial?

A: A clear mortality benefit was found in favour of the Remdesivir group

B: Time to recovery was shorter in favour of the Remdesivir group

C: The sickest patients seem to benefit most from Remdesivir therapy

The correct answer is B

This trial was covered by:

Justin Morgenstern on First10EM 

Fraser Magee on the Bottom Line 

Salim Rezaie on RebelEM 

Josh Farkas on EMcrit 

Rory Spiegel on EMcrit 

They all come to the same conclusion. Yes, the trial shows faster recovery in the not very ill COVID-19 patients (11 vs. 15 days). However there are some methodological concerns. The trial was stopped early (full outcomes available of 69% of the patients). The primary outcome was changed after data collection commenced (but before data analysis). A lot of data is not reported (including laboratory results).


Question 2

Quite some research has been published recently on the Canadian Syncope Risk Score (CSRS). It seems to have excellent diagnostic diagnostic accuracy for serious adverse events (SAE) (sensitivity of 99% if cutoff is -2 and sensitivity of 98% if cutoff is -1 on serious adverse events at 30 days) in syncope patients. NT-proBNP is found to have an independent association with mortality and SAE in patients with syncope. 

Does adding NT-pro-BNP to the CSRS improve its diagnostic accuracy? 

A: Yes, it does

B: No, it does not

C: it might

The correct answer is B

Clay Smith covered this paper last week on JournalFeed.

Of 1452 patients enrolled, 152 had 30-day SAEs. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them, but adding this value did not significantly improve prognostication.

Source image: www.pixabay.com

Question 3

Malaria continues to cause 230 million clinical infections and almost half a million deaths each year. Therefore it continues to caused a lot more deaths than COVID-19 (so far at least).

Which of the following statements about malaria is true?

A: A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria

B: A thick blood film is used to determine the Plasmodium species

C: Severe malaria only occurs secondary to Plasmodium falciparum infection

D: Artemether can cause severe hemolysis in patients with G6PD deficiency

The correct answer is A

Malaria was covered on Don´t forget the bubbles this week.

A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria . Some guidelines recommend 3 negative tests to exclude malaria in patients with a high pre-test probability.

A thick blood film is used to detect the presence of the parasites and the percentage of parasitised erythrocytes.

Severe malaria was previously considered only to occur secondary to P. falciparum, although there are increasing case reports of patients with P. vivax or P. knowlesi malaria presenting severely ill.

When prescribing primaquine you should definitely be aware of G6PD deficiency, as it can cause severe hemolysis.


Source image: www.pixabay.com

Question 4

A 36 year old man with a history of severe alcohol abuses comes in with diaphoresis, tachycardia, hypertension and a tremor. He is clearly anxious and agitated. You expect he might be suffering from alcohol withdrawal and you consider different treatment options.

Which of the following statements about phenobarbital versus lorazepam for alcohol withdrawal is true?

A: Phenobarbital and benzodiazepines both target NMDA receptors in order to decrease withdrawal symptoms

B: Phenobarbital has a shorter length of action (i.e. half life) compared to lorazepam

C: Phenobarbital has low bioavailability when administered PO so it has to be given IV, whereas lorazepam can be administered IV, IM and PO

D: Phenobarbital dosing is more standardised compared to lorazepam dosing and is therefore more predictable and easier to titrate

The correct answer is D

Nuem covered treatment of alcohol withdrawal this week.

Alcohol withdrawal can be treated in multiple ways. Benzodiazepines are the current treatment of choice whereas phenobarbital was used as a first line treatment in the past although it seems to be making a comeback.

Both lorazepam and phenobarbital target GABA receptors to decrease excitatory tone. Phenobarbital does this more effectively since it does not rely on the presence of endogenous GABA hormone alone.

Both lorazepam and phenobarbital can be given IV, IM or PO. One benefit of phenobarbital is its longer half life of 80-120 hours compared to 14-20 hours for lorazepam.

The efficiency of lorazepam varies between different patients and drug levels. Therefore its effect is very hard to predict. The linear relationship between cumulative weight based dose and resulting plasma concentration of phenobarbital make it easier to achieve the right target dose and also easier to avoid levels in which toxicity may occur.

This subject was previously also discussed on Emcrit. 

Source image: www.tamingthesru.com

Question 5

You see a 64 year old female with a history of hypertension and diabetes. Her chief complaints are shortness of breath and a productive cough. She has a fever and an SpO2 of 82% on ambient air. She looks ill and she has diminished breath sounds on the right. You place her on a non-rebreather mask at 15 liters per minute. As part of your further work-up, you perform point-of-care ultrasound (POCUS). You suspect she has pneumonia.

Which of the following ultrasonographic signs are not typically found in case of pneumonia?

A: Shred sign

B: Localized B-lines

C: Subpleural fluid / pleural effusion

D: Lung point

E: Air bronchograms

F: Hepatization of the lung

The correct answer is D

POCUS for the diagnosis of pneumonia was covered by Taming the SRU this week.

The shred sign refers to a shredded deep border of the tissular image, as in connection with the aerated lung.

Localised B-lines and air bronchograms are typically seen in pneumonia. 

Hepatization of the lung refers to tissue-like appearance of the lung in which lung tissue loses its traditional artificial appearance and takes on an echo texture which is similar to liver tissue. 

A lung point is seen in pneumothorax. 

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This quiz was written by Eefje Verschuuren, NIcole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen