Quiz 75, July 10th, 2020

Welcome to the 75th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Case courtesy of Dr Bahman Rasuli, Radiopaedia.org, rID: 74573

Question 1

This recently published cohort study examined associations between NSAID, COX-2-inhibitor (e.g. celecoxib) and opioid prescriptions and the rate of nonunion of long-bone fractures.

What did the authors find?

A: Exposure to selective COX-2-inhibitors was associated with an increased risk of nonunion of long-bone fractures

B: Exposure to NSAIDs was associated with an increased risk of nonunion of long-bone fractures

C: Exposure to none of the three medication groups increased the risk of nonunion of long-bone fractures

The correct answer is A

Clay Smith covered this paper on Journal Feed this week.

Exposure to selective COX-2 inhibitors was associated with a significant 84% (OR 1.84; 95% CI 1.38 to 2.46) increase in the odds of nonunion respectively compared to NSAIDs (OR 1.07; 95% CI 0.93 to 1.23). Use of opioids was also associated with a significant increase (69% (OR 1.69; 95% CI 1.53 to 1.86)).

Selective COX-2 inhibitors, as the name suggests, only inhibit COX-2 while NSAIDs have some COX-1 and COX2 inhibition. The important role of COX-2 in fracture healing, due to its role in the inflammatory response, could be the explanation for the difference that was found for nonunion in long-bone fractures between selective COX-2 inhibitors and NSAIDs.

It is unknown if the increased odds ratio for nonunion of long-bone fractures in patients with an opioid prescription could be explained by the fact that these patients probably had more severe injuries.

 

Question 2

Source: https://first10em.com/atrial-fibrillation/

The RAFF2 paper is about electrical versus pharmacological cardioversion of stable atrial fibrillation. 

Subjects in one group received procainamide first, followed by electrical cardioversion (ECV) if normal sinus rhythm was not achieved. Subjects in the other group received placebo first, followed by ECV if sinus rhythm was not achieved.

What did the authors find?

A: Conversion to normal sinus rhythm (NSR) was more often achieved in the procainamide + ECV group compared to the placebo + ECV group

B: Conversion to normal sinus rhythm (NSR) was more often achieved in the placebo + ECV group compared to the procainamide + ECV group

C: Conversion to normal sinus rhythm (NSR) was similar in the placebo + ECV group compared and the procainamide + ECV group

The correct answer is C

RebelEM covered this paper last week. It was published in the Lancet in Februari 2020.

396 Subjects were enrolled.

Both the drug-shock and shock-only strategy led to similar conversion rates (96 and 92 percent) and rates of discharge home (97 and 95 percent). 52% of patients in the drug-shock group converted after drug infusion only vs 9% in the shock only group.

RAFF2: Electrical vs Pharmacological Cardioversion for ED Patients with Acute Atrial Fibrillation

Question 3

Your 45-year old male patient comes in with severe chest pain and dyspnea. He has a history of sickle cell disease and you think he might be suffering from acute chest syndrome.

Which of the following statements about the treatment of acute chest syndrome is true?

A: The recommended oxygen saturation target is >88%

B: A state of hypervolemia should be obtained

C: Exchange transfusion is likely more effective than simple blood transfusion

D: NSAIDs can safely be used

The correct answer is C

Josh Farkas covered sickle cell acute chest syndrome this week on the IBCC podcast.

Acute chest syndrome can be described as a vaso-occlusive crisis which involves the lungs and is defined as a combination of a new opacity on chest X-ray with either fever and/or respiratory symptoms (e.g. cough, dyspnea or chest pain) in patients with sickle cell disease.

Adequate oxygenation is essential to decrease progressive sickling of erythrocytes. An oxygen saturation target of >92% or >95% is therefore commonly recommended.

Normovolemia should be obtained since hypovolemia could increase blood viscosity and thereby increase sickling. Hypervolemia potentially causes fluid overload since these patients could have acute lung injury, cardiac dysfunction and/or renal failure.

Exchange transfusion is likely more effective than simple transfusion because it allows for a rapid and dramatic reduction of sickle hemoglobin without increasing blood viscosity.

Analgesia with NSAIDs should be avoided in most patients since patients with severe acute chest syndrome are prone to develop renal failure.

IBCC chapter & cast – Sickle Cell Acute Chest Syndrome

Question 4

Cyclic vomiting syndrome in children is associated with an increased risk in adulthood on

A: Inflammatory bowel disease

B: Migraine

C: Hyperemesis gravidarum

D: Psoriasis

The correct answer is B

Cyclic vomiting syndrome is characterised by recurrent episodes of vomiting in a stereotypical pattern. It is a clinical diagnosis based on the history, and can only be made after several other causes are excluded. The pathogenesis is not understood, but there is an association with migraine in adulthood. Many children respond to anti migraine medication like sumatriptan.

Cyclic Vomiting Syndrome

Source image: www.ultrasoundgel.org

Question 5

Deep learning is a branch of artificial intelligence that holds a lot of promise for point-of-care ultrasound.

Investigators from this recent paper used a deep learning algorithm to label upper extremity structures such as veins, nerves, bones and tendons. They compared DL to expert POCUS users in order to define who can interpret the images most accurately.

What did the investigators find?

A. The DL algorithm proved to be more accurate in identifying 4 common structures compared to the POCUS experts

B. The DL algorithm had an equal accuracy in identifying 4 common structures compared to the POCUS experts

C. The DL algorithm proved to be less accurate in identifying 4 common structures compared to the POCUS experts

The correct answer is A

This week Michael Prats covered this study on the Ultrasound G.E.L. Podcast.

In the comparison of the deep learning algorithm to the POCUS experts, only one out of two POCUS experts beat the algorithm on identifying blood vessels. In the identification of 4 key anatomic structures (such as veins, nerves, bones and tendons) in transverse ultrasound images of the upper extremity the deep learning outperformed both POCUS experts.

It seems DL might help us identify structures in the future. How the benefits hold up in day to day emergency medicine remains to be seen.

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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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