Quiz 71, June 12th, 2020

Welcome to the 71th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

This week’s COVID-19 Randomised Controlled Trial (RCT) is about Ruxolitinib. Ruxolitinib blocks a shared signal transduction pathway which is used by several cytokine receptors (many immunomodulatory therapies only block one specific interleukin). 43 Severely ill but not yet intubated patients were enrolled and randomised to either Ruxolitinib or placebo (in this case Vitamin C).

What did the authors find?

A: Ruxolitinib did improve cytokine levels and C-reactive protein

B: Immunomodulation was found to delay viral clearance

C: A statistically significant reduction in mortality was found at day 28 in the treatment group

D: A statistically significant reduction in duration of invasive ventilation was found in the treatment group

The correct answer is A

Josh Farkas discusses this RCT this week on PulmCrit.

Yet another study that was terminated early. This time due to the simple fact that there were no more patients with COVID-19 in the Chinese center to enroll. A not statistically significant reduction in mortality (7.3 vs 14.3 percent) was found in favor of the treatment group. No difference was found in time to clinical improvement. However, cytokine levels and CRP were reduced in the treatment group indicating its ability to function rapidly as an immunomodulator. Ruxolitinib was not found to delay viral clearance.

PulmCrit Wee – Multicenter RCT evaluating ruxolitinib (a JAK inhibitor) for COVID-19

 

 

Question 2

Your 75 year old patient comes in with sudden onset vertigo and vomiting. Her vertigo is provoked by specific types of head movements and the episodes last for about 20 seconds. She has no other neurologic complaints. The Dix-Hallpike test shows a rotational nystagmus which disappears after 10 seconds.

You suspect Benign Paroxysmal Positional Vertigo (BPPV). The patient does not believe the Epley maneuver will be helpful as it just sounds silly and wants to know what the literature says. What do you tell your patient?

A: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (83% vs 5%) for a NNT of 1.2

B: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%) for a NNT of 3

C: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (61% vs 55%) for a NNT of 17

D: Compared to sham groups, Epley maneuver does not increase likelihood of symptom resolution

The correct answer is B

Clay Smith covered this review on the Epley Manoeuvre last week.

The paper reviews a cochrane review and another recent randomized trial set in 6 EDs.

Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%).

Well, you can’t get around an NNT of 3.

Source image: www.aliem.com

Question 3

Your 75 year old patient tells you that he used some fresh herbs out of his garden to prepare dinner. Shortly after his meal he started to be dyspnoeic, the parsley out of his garden turned out to be Poison Hemlock.

Which of the following statements is true about Poison Hemlock?

A: It causes a cholinergic toxidrome

B: It causes a anticholinergic toxidrome

C: It causes a sympathomimetic toxidrome

D: It causes a sedative-hypnotic syndrome

The correct answer is C

This week Aliem posted about poison hemlock.

Poison hemlock is a plant that can be mistaken for parsley, wild carrots or sweet fennel.

Poison Hemlock contains multiple toxic agents of which the most important is coniine. Coniine causes primarily nicotinic effects (muscle fasciculations, weakness, paralysis, coma, seizures, tachycardia and hypertension) and secondary muscarinic symptoms (salivation, lacrimation, vomiting, diarrhea, wheezing, bradycardia, diaphoresis, and small pupils).

Treatment is usually supportive and intubation might be required. Muscarinic symptoms (bradycardia, bronchorrhea, or bronchospasm) can be treated with atropine.

ACMT Toxicology Visual Pearls: A Foraging Experience to Die For

Source image: www.pixabay.com

Question 4

Which of the following statements is true about pediatric ECGs?

A: The amplitude of the p-wave increases with age

B: The duration of the p-wave shortens with age

C: A right QRS axis is normal in children < 6 months

D: Inversion of T-waves a week after birth is concerning

 The correct answer is C

The very basics of pediatric ECG’s were covered at Don’t Forget the Bubbles last week.

The amplitude of the p-wave does not increase with age (should be < 3 mm). The duration of the p-wave lengthens a little with age. A right axis in young children is normal in the very young due to right ventricular dominance. After the first week of life T waves become inverted in V1-3.

Approaching the paediatric ECG

 

Source image: www.emottowablog.com

Question 5

Which of the following statements about the use of ultrasound in COVID-19 is true?

A: It is possible to differentiate a COVID-19 pneumonia from other viral pneumonia on ultrasound

B: B-lines are not typically seen in COVID-19 patients

C: Irregularity of the pleural line is typically seen in COVID-19 patients

D: Large pleural effusions are common in COVID-19

The correct answer is C

EMOttawa covered ultrasound in COVID-19 patients this week.

It is not possible to distinguish COVID-19 from other viral pneumonia on ultrasound (or any other imaging as far as I’m aware). B-lines, irregularity of the pleural line and subpleural consolidation are common findings. Lung sliding is typically present but can be absent in case of ARDS. Large pleural effusions are typically absent in COVID-19.

Protocol for lung ultrasound in COVID-19 patients

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

Reviewed and edited by Rick Thissen

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