Quiz 83, September 4th, 2020

Welcome to the 83th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

The recently published THALES trial is about Ticagrelor and Aspirin versus Aspirin alone in patients with acute ischemic stroke (NIHSS score of 5 or less who were not undergoing intravenous or endovascular thrombolysis) or TIA. Ticagrelor is not dependent on metabolic activation (as opposed to clopidogrel) and its efficacy might be more reliable compared to clopidogrel.

What did the authors find?

A: Patients in the ticagrelor + aspirin group had a higher incidence of subsequent ischemic stroke compared to patients on aspirin alone

B: Patients in the ticagrelor + aspirin group had a equal rate of severe hemorrhage and cerebral hemorrhage compared to patients on aspirin alone

C: Patients in the ticagrelor + aspirin group had a equal incidence of overall disability compared to patients on aspirin alone

The correct answer is C.

Benjamin Gerritsen covered the THALES trial on REBELem this week.

The authors randomized 11016 patients.

Patients in the ticagrelor + aspirin group had a lower incidence of subsequent ischemic stroke at 30 days compared to patients on aspirin alone. However, no benefit of ticagrelor + aspirin over aspirin alone was found on overall disability and mortality. A higher incidence of severe bleeding was noted in the ticagrelor + aspirin group compared to the aspirin alone group.

The THALES Trial: Ticagrelor and Aspirin vs Aspirin Alone in Acute Ischemic Stroke or TIA

Source image: www.pixabay.com

Question 2

You find yourself working in a ski-resort at 2700 meters. A 45 year old man comes in with profound respiratory distress. He normally lives at sea level and came for holidays to the mountains. You give supplemental oxygen and plan for descent.

Which of the following drugs can be considered in treatment of acute high altitude pulmonary edema (HAPE)?

A: Acetazolamide

B: Nifedipine

C: Dexamethasone

D: Sildenafil

The correct answer is B

NuEM covered Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE).

The mainstay of treatment of severe HAPE is supplemental oxygen and descent.

Acetazolamide is used as prophylaxis for AMS and HACE and might be beneficial as prophylactic medication for HAPE as well. It has no role in acute HAPE.

Dexamethasone is used for treatment of HACE or severe AMS. It might be beneficial in HAPE prophylaxis, but this is controversial.

Sildenafil has been shown to be effective as prophylaxis for HAPE, but has not been studied as treatment for acute HAPE.

Nifedipine is the preferred agent for prophylaxis and treatment of HAPE, although not a large body of evidence is available so for. The dosage is 60 mg extended-release orally divided daily (30 mg orally every 12 hours; or 20 mg orally every 8 hours).

 

Question 3

Source image: www.pixabay.com

Appendicitis can be a challenging diagnosis in the ED.

How accurate is physician gestalt in appendicitis according to this recently published paper?

A: Physician gestalt for acute appendicitis diagnosis performed poorly

B: Physician gestalt for acute appendicitis diagnosis performed well, especially in high-risk patients

C: Physician gestalt for acute appendicitis diagnosis performed well, especially when employed by experienced physician

The correct answer is C

BrownEM covered this paper last week.  

This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain. 

Physician gestalt for acute appendicitis diagnosis performed well, especially in low‐risk patients and when employed by experienced physicians.

Question 4

High sensitive troponin rule-out and rule-in strategies are not really uniform around the world. There are huge differences in used protocols between continents, countries and even between hospitals in the same region.

We slowly seem to move towards shorter time interval troponin testing (0 and 1 hour / 0 and 3 hour).

This recently published paper evaluated a 0 and 1 hour rule-out and rule-in strategies (among others), using a new high-sensitivity cardiac troponin I (hscTnI) assays from Siemens Healthineers. The primary outcome was meeting STEMI test criteria according to the 3rd Universal Definition of Acute Myocardial Infarction.

Which of the following statements is true?

A: The 0 and 1 hour rule out strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

B: The 0 and 1 hour rule out strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

C: The 0 and 1 hour rule in strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

D: The 0 and 1 hour rule in strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

The correct answer is B 

CoreEM covered this paper last week. 

It turns out a 0 and 1 hours rule-out strategy actually has a very high sensitivity in this US population using this TnI assay.

Source image: coreem.net

Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study

Question 5

A 64-year old female patient is brought in by EMS after she was found unconscious and cyanotic. She has a known history of dermatitis herpetiformis for which she is treated with dapsone. The first thing you notice when you look at her is the blue color of her skin. Your differential diagnosis includes methemoglobinemia.

Which of the following clinical findings are typically found in profound methemoglobinemia?

A: The presence of a peripheral oxygen saturation in the 80’s, improving with oxygen administration

B: Cherry red colour of blood

C: An arterial blood gas with a high PaO2 combined in combination with a low peripheral oxygen saturation

The correct answer is C.

Methemoglobinemia was covered by Justin Morgenstern on First10EM this week.

Methemoglobinemia can be congenital or acquired (exposure to certain medicines, chemicals or foods). Typical symptoms include headache, shortness of breath, nausea, tachycardia, confusion and loss of consciousness.

Patients with profound methemoglobinemia appear cyanotic with saturations below 80%. Saturation levels do not improve with oxygen administration.

The diagnosis is confirmed by an arterial blood gas (typical chocolate brown blood) with elevated methemoglobin levels. The treatment consists of methylene blue 1-2 mg/kg infused over 5 minutes. Methylene blue is contra-indicated in patients with a known G6PD deficiency.

Methemoglobinemia

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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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