Quiz 85, September 18th, 2020

Welcome to the 85th FOAMed Quiz. 


Eefje, Nicole, Joep and Rick

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Question 1

Pediatric Inflammatory Multisystem Syndrome (PIMS) is a recently described clinical syndrome associated with COVID-19 infection. Children present with persistent fever and other nonspecific symptoms. It can present with mucocutaneous, gastrointestinal, dermatologic, neurologic or cardiac manifestations.

Which of the following statements about PIMS is true?

A: Most patients with PIMS only have mild symptoms

B: It affects mostly children with pre existing comorbidity

C: About 2 percent of the patients require inotropic support

D: Myocarditis prevalence increases with age

The correct answer is D

First10EM covered PIMS this week. This syndrome is also known as multisystem inflammatory syndrome in children.

It is a febrile inflammatory syndrome associated with covid-19 infections and can present with a wide variation of symptoms. It affects mostly previously healthy children.

It presents 3 to 6 weeks following exposure to covid-19 virus and can progress rapidly to multiorgan dysfunction.

80 percent of the children have cardiac involvement, and prevalence of myocarditis increases with age.

80 percent of the children are admitted to the intensive care unit, and 50 percent need inotropic support.

Pediatric Inflammatory Multisystem Syndrome (PIMS)

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Question 2

Your 61 year old male patient with a history of diabetes and myocardial infarction presents with diffuse abdominal pain which began after eating dinner. This is the first time he experiences these symptoms. Physical exam reveals a mild diffuse tenderness of the abdomen. CTA reveals bowel ischemia.

Which of the following etiologies is most likely to be the cause of the bowel ischemia in this patient?

A: An arterial embolic occlusion

B: An arterial thrombotic occlusion

C: Arterial non-occlusive ischemia

D: A venous occlusion

The correct answer is A

Mesenteric ischemia was covered on emDOCs this week.

Mesenteric ischemia is known to have several distinct etiologies.

The majority of cases (60%) of mesenteric ischemia are caused by an arterial embolism. Most commonly the superior mesenteric artery (SMA) and less frequently in the celiac artery or inferior mesenteric artery (IMA) are occluded. These patients commonly have atrial fibrillation and often present with a severe sudden abdominal pain which is out of proportion to abdominal tenderness during physical examination.

Thrombotic occlusion of the mesenteric arteries may present with similar acuity or a more progressive onset depending on the preexisting vessel disease and collateral flow.

Mesenteric vein thrombosis presents more insidiously with vague abdominal pain and risk factors include hypercoagulability which can be seen in sepsis, malignancy, liver disease, portal hypertension and thrombophilias.

Nonocclusive arterial mesenteric ischemia results from inadequate supply of blood due to an underlying critical illness or treatment with eg. vasopressors.

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Question 3

Patients with Sickle Cell disease develop symptoms when polymerisation of hemoglobin occurs leading to ‘sickling’ of red blood cells. This process is often triggered by hypoxia or other underlying illness of stress.

Different types of Sickle Cell disease exist, depending on the genetic combination coding for hemoglobin.

Which of the following genetic combinations results in the most severe form of Sickle Cell disease?

A: HbAS: HbA (normal Hb) and HbS (Sickle cell Hb)

B: HbSS: Homozygous for HbS

C: HbSβ: HbS and Hbβ (Beta Thalassemia)

D: HbSC: HbS and HbC (abnormal hemoglobin forming crystals)

The correct answer is B

Don’t forget the Bubbles covered Sickle Cell disease last week.

In sickle cell anaemia, individuals are homozygous for HbS (HbSS). This is the most frequent and severe form of the disease.

Patients with Sickle Cell trait (HbAS) usually do not develop symptoms and are not considered to have Sickle Cell disease.

In patients with Sickle Cell beta Thalassemia the frequency and severity of symptoms vary based on the mount normal Hb (HbA) still formed (not all beta Thalassemia result in the absence of formation of normal Hb).

In HbSC disease, HbC does not participate in polymerization leading to less frequent and severe symptoms compared to HbS disease.

Question 4

Which of the following is not part of the classic triad in Wernicke Encephalopathy (WE)?

A: Cachexia

B: Ataxia

C: Altered mental status

D: Ophthalmoplegia

The correct answer is A

Anand Swaminathan recorded a podcast on RebelEM about Wernicke Encephalopathy.

The classic triad consists of ataxia, altered mental status and ophthalmoplegia. However, the full triad is present in only 10 percent of patients with WE. Therefore, suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms.

REBEL Core Cast 40.0 – Wernicke Encephalopathy

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Question 5

In patients pulmonary embolism (PE), the majority of patients has a low 30-day mortality risk. These patients can be identified by clinical decision tools such as PESI, sPESI and Hestia Criteria and can be managed as an outpatient.These patients are most often treated with either a DOAC or a vitamin K antagonist (VKA). Outpatient treatment of low risk PE with VKA seems to be safe, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients.

This systematic review is about the outcome of patients discharged from the ED with low risk PE and the association with anticoagulation class (DOAC vs vitamin K antagonist).

The authors investigated major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 90 days from discharge from the ED.

What did the authors find?

A: Major adverse outcomes were very low in both patients treated with VKA and patients treated with DOAC

B: Major adverse outcomes were more common in patients treated with VKA compared to patients treated with DOAC

C: Major adverse outcomes were more common in patients treated with DOAC compared to patients treated with VKA

D: Major adverse outcomes were unacceptably high in both patients treated with VKA and patients treated with DOAC

The correct answer is A.

Bo Stubblefield covered this systematic review on journalfeed this week.

There were very low rates of major adverse outcomes in both patients treated with VKA and patients treated with DOA. The 90 day all cause mortality was 0.7%. No episodes of recurrent VTE of major bleeding were reported in the majority of included studies. 

No significant association has been found between class of anticoagulant and rates of major adverse events.

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

Reviewed and edited by Rick Thissen