Quiz 113, May 7th, 2021

Welcome to the 113th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Vaccine induced immune thrombotic thrombocytopenia (VITT) (or vaccine-induced prothrombotic immune thrombocytopenia (VIPIT), or Thrombosis with Thrombocytopenia Syndrome (TTS)), is a very very rare, but possibly fatal adverse effect of Astra-Zeneca and Johnson & Johnson COVID-19 vaccines.

Which of the following statements about VITT is true?

A: Platelet count is typically normal in VITT

B: Platelet Factor 4 ELISA is generally positive in VITT (like in Heparin Induced Thrombocytopenia)

C: Normal d-dimer levels are often seen in VITT

D: Heparin is the mainstay of treatment of VITT

The correct answer is B

EM Quick Hits covered VITT last week.

VITT is an evolving disorder and changes in practice come quickly when new data become available.

In VITT, there is typically thrombocytopenia, elevated d-dimer and a positive PF4 ELISA.

Treatment consists of intravenous immune immunoglobulin (IVIG) and nonheparin anticoagulation.

Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org, rID: 14979

Question 2

Shortening the duration of antibiotic therapy should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs.

This recently published double blind, randomised, placebo-controlled trial  is about a 3 day course of B-lactam antibiotics versus a 8 day course of B-lactam antibiotics for Community Acquired Pneumonia (CAP) in admitted non-ICU patients.

The primary outcome was resolution of symptoms at 15 days post randomisation.

What did the authors find?

A: 3 days of B-lactam treatment in patients with moderate CAP was non-inferior to 8 days of treatment

B: 3 days of B-lactam treatment in patients with moderate CAP was inferior to 8 days of treatment

C: 3 days of B-lactam treatment in patients with moderate CAP was superior to 8 days of treatment

The correct answer is A

RebelEM covered The Pneumonia Short Treatment Trial

The authors found that discontinuing B-lactam treatment after 3 days in patients with moderate CAP who were clinically stable, was non-inferior to patients who continued treatment for an additional 5 days.

113 of 145 (78%) of patients in the 3 day β-lactam group and 100 of 146 (68%) of patients in the 8 day β-lactam group were cured.

Because the authors used a relatively small sample size and the study was conducted in one country (France) a large multinational trial should be performed in order to make major practical changes.

The Pneumonia Short Treatment Trial: Antibiotic Treatment for 3 days vs 8 days

Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 8720

Question 3

A 17 year old competitive athlete visits the emergency department with pain in her right ankle since a few days without a specific trauma. Besides this problem she tells you that she missed periods and states she cannot be pregnant.

On the X-ray of the ankle you see a stress fracture at the distal tibial metaphysis. You suspect the female athlete triad.

Which of the following symptoms are part of the female athlete triad?

A: Menstrual dysfunction, insufficient energy intake and alopecia

B: Menstrual dysfunction, low bone mineral density and insufficient energy intake

C: Cachexia, osteoporosis and alopecia

The correct answer is B

AliEM covered the Female Athlete Triad this week

Stress fractures can be multifactorial due to increased activity and poor nutrition which can lead to disordered eating with or without an eating disorder.

You should be aware of this triad in patients with risk factors such as participation in sports that emphasize leanness or a specific weight or appearance. These sports typically include gymnastics, ice skating, wrestling, boxing, dance, and track and field.

SplintER Series: What is Wrong With My Daughter?

Source image: www.rcemlearning.co.uk

Question 4

A 35 year old otherwise healthy man, visits your ED because of inflammation on his left leg. The leg is red and warm, but there is no outflow of pus, you doubt whether you feel fluctuation of an abscess.

Which of the following pathogens is most likely to cause cellulitis after penetrating trauma or in the presence of an abscess?

A: Streptococci

B: Pseudomonas

C: Staphylococcus aureus

D: Vibrio vulnificus

The correct answer is C.

This week, emDOCs discussed cellulitis.

Cellulitis without abscess is usually caused by streptococci. However, if an abscess is found, S. aureus is the most common cause.

EMdocs discussed indications for intravenous antibiotic therapy in cellulitis and hospitalization versus treatment at home.

Source image: www.coreultrasound.com

Question 5

The least common place to find free intraperitoneal fluid in the focused assessment with sonography in trauma (FAST) exam is the left upper quadrant.

However, in case you find free fluid in the left upper quadrant, what is the most likely place?

A: Paracolic gutter

B: Suprasplenic

C: Kohler’s pouch

The correct answer is B

Jacob Avila covered the RUSH exam last week on Core Ultrasound.

In contrast to the right upper quadrant (where the most caudal tip of the liver / inferior pole of the kidney is the most likely place to find free fluid), the suprasplenic space is the most common place to find free fluid in the left upper quadrant.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen