Advances in Internal Medicine What a Let it Bugs & Pain - - PowerPoint PPT Presentation

6/21/2019 1

Advances in Internal Medicine

• Team captain selects question for their

team to answer by ARS voting

• Everyone on team votes – captain can

accept consensus answer or veto

• A correct answer lets a team select one

additional question (maximum 2)

• After an incorrect answer or 2 correct

answers, control of the board switches to the other team

Jeopardy Rules

$100 $200 $300 $500 $400

What a Drag…

$100 $200 $300 $500 $400

Potpourri

$100 $200 $300 $500 $400

Let it Bleed

$100 $200 $300 $500 $400

Bugs & Drugs

$100 $200 $300 $500 $400

Pain & Suffering

Final Jeopardy

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• A. He’s too old per USPSTF

guideline

• B. He hasn’t had enough

exposure (insufficient pack- years)

• C. He quit too long ago
• D. The false positive rate is
• ver 90%

A. B. C. D.

13% 83% 4% 0%

A 70-year-old man with 30 pack-years of smoking who quit 10 years ago asks whether he’s too old to benefit from lung cancer screening. Which statement is true? Main Board A 70-year-old man with 30 pack-years of smoking who quit 10 years ago asks whether he’s too old to benefit from lung cancer screening. Which statement is true?

• A. He’s too old per USPSTF

guideline

• B. He hasn’t had enough

exposure (insufficient pack- years)

• C. He quit too long ago
• D. The false positive rate is
• ver 90%

You are taking care of an elderly rock star with critical aortic stenosis. Which statement about transcatheter aortic valve replacement (TAVR) is correct?

• A. In low risk patients, TAVR
• utcomes are better than

surgical valve replacement

• B. In intermediate & high risk

patients, TAVR outcomes are equivalent to surgical valve replacement

• C. Long term valve function

remains uncertain

• D. All of the above are true

A. B. C. D.

4% 84% 4% 8%

Main Board You are taking care of an elderly rock star with critical aortic stenosis. Which statement about transcatheter aortic valve replacement (TAVR) is correct?

• A. In low risk patients, TAVR
• utcomes are better than

surgical valve replacement

• B. In intermediate & high risk

patients, TAVR outcomes are equivalent to surgical valve replacement

• C. Long term valve function

remains uncertain

• D. All of the above are true

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• A. Major bleeding
• B. CV disease
• C. Cancer-related mortality
• D. None of the above

The ASPREE study randomized an elderly cohort without known CV disease to aspirin or placebo. Which of the following outcomes was better (less frequent) in the aspirin arm?

A. B. C. D.

11% 72% 11% 6%

Main Board The ASPREE study randomized an elderly cohort without known CV disease to aspirin or placebo. Which of the following outcomes was better (less frequent) in the aspirin arm?

• A. Major bleeding
• B. CV disease
• C. Cancer-related mortality
• D. None of the above

Which of the following is a limitation of the FRAX model with regards to predicting fracture risk in elderly patients?

• A. It only applies to women
• B. It only provides relative risk (not

absolute risk)

• C. Results not validated for patients
• n osteoporosis treatment
• D. It doesn’t account for smoking or

alcohol use

A. B. C. D.

8% 16% 44% 32%

Main Board Which of the following is a limitation of the FRAX model with regards to predicting fracture risk in elderly patients?

• A. It only applies to women
• B. It only provides relative risk (not

absolute risk)

• C. Results not validated for patients
• n osteoporosis treatment
• D. It doesn’t account for smoking or

alcohol use

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Which statement about Sacubitril/Valsartan (Entresto) is true?

A. It is most effective when added to ACE-inhibitor therapy B. Patients should be stabilized on an ACE-inhibitor or angiotensin receptor blocker before starting Sacubitril/Valsartan C. It prevented HF-related hospitalization better than an ACE- inhibitor D. It is effective for heart failure with both reduced and preserved ejection fraction

A. B. C. D.

0% 11% 78% 11%

Main Board Which statement about Sacubitril/Valsartan (Entresto) is true?

A. It is most effective when added to ACE-inhibitor therapy B. Patients should be stabilized on an ACE-inhibitor or angiotensin receptor blocker before starting Sacubitril/Valsartan C. It prevented HF-related hospitalization better than an ACE- inhibitor D. It is effective for heart failure with both reduced and preserved ejection fraction

For small (< 3 mm) incidental, unruptured intra-cranial aneurysms, a comparative effectiveness analysis concluded that the best management is:

• A. Do nothing
• B. Yearly MRI
• C. Biannual MRI
• D. Endovascular coiling

A. B. C. D.

83% 0% 7% 10%

Main Board For small (< 3 mm) incidental, unruptured intra-cranial aneurysms, a comparative effectiveness analysis concluded that the best management is:

• A. Do nothing
• B. Yearly MRI
• C. Biannual MRI
• D. Endovascular coiling

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A. They should not be used in patients with severe mitral stenosis B. They should not be used with mechanical heart valves C. Reversal agents should be given for uncontrolled bleeding D. They remain effective after bariatric surgery

Which statement about use of direct-acting oral anticoagulants (DOAC) in atrial fibrillation is INCORRECT?

A. B. C. D.

19% 63% 13% 6%

Main Board

A. They should not be used in patients with severe mitral stenosis B. They should not be used with mechanical heart valves C. Reversal agents should be given for uncontrolled bleeding

• D. They remain effective after

bariatric surgery

Which statement about use of direct-acting oral anticoagulants (DOAC) in atrial fibrillation is INCORRECT?

A. B. C. D.

11% 0% 54% 36%

A. Aspirin + Clopidogrel + Anticoagulant B. Aspirin + Anticoagulant C. Clopidogrel + Anticoagulant D. Aspirin + Clopidogrel

A patient on aspirin & clopidogrel for a drug-eluting coronary stent who develops atrial fibrillation is most likely to benefit from taking: Main Board

A. Aspirin + Clopidogrel + Anticoagulant B. Aspirin + Anticoagulant C. Clopidogrel + Anticoagulant D. Aspirin + Clopidogrel

A patient on aspirin & clopidogrel for a drug-eluting coronary stent who develops atrial fibrillation is most likely to benefit from taking:

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Which statement about continuing aspirin through the perioperative period in a patient with coronary artery disease is true?

• A. Bleeding risk does not increase
• B. Overall mortality risk decreases
• C. Patients with coronary stents are

more likely to benefit

• D. The AHA & ACC give it a grade 1

recommendation

A. B. C. D.

0% 0% 100% 0%

Main Board Which statement about continuing aspirin through the perioperative period in a patient with coronary artery disease is true?

• A. Bleeding risk does not increase
• B. Overall mortality risk decreases
• C. Patients with coronary stents are

more likely to benefit

• D. The AHA & ACC give it a grade 1

recommendation

A. Anticoagulation is strongly recommended B. Anticoagulation is optional, but favored if the affected segment is > 5 cm long C. Anticoagulation is optional, but favored if the patient has cancer or prior VTE

• D. If anticoagulation is desired,

fondaparinux is somewhat preferred over LMWH

Your patient complains of acute right leg pain and

• swelling. Ultrasound shows thrombus in the

superficial femoral vein. According to ACCP guidelines, how should this patient be managed?

A. B. C. D.

54% 14% 11% 21%

Main Board Your patient complains of acute right leg pain and

• swelling. Ultrasound shows thrombus in the

superficial femoral vein. According to ACCP guidelines, how should this patient be managed?

• A. Anticoagulation is clearly

recommended B. Anticoagulation is optional, but favored if the affected segment is > 5 cm long C. Anticoagulation is optional, but favored if the patient has cancer

• D. If anticoagulation is desired,

fondaparinux is somewhat preferred over LMWH

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• A. Metronidazole orally
• B. Vancomycin orally
• C. Vancomycin slow taper
• D. Fidaxomicin

After treatment for Clostridium difficile associated diarrhea with metronidazole, a patient has a mild

• recurrence. What should be prescribed now?

A. B. C. D.

3% 0% 24% 72%

Main Board After treatment for Clostridium difficile associated diarrhea with metronidazole, a patient has a mild

• recurrence. What should be prescribed now?
• A. Metronidazole orally
• B. Vancomycin orally
• C. Vancomycin slow taper
• D. Fidaxomicin

Which of these statements about treatment of chronic HCV infection with an anti-viral agent is true?

A. B. C. D.

5% 32% 5% 59%

A. The success rate is around 75% B. After successful treatment, regular HCV viral load testing is not needed C. Patients will be immune to HCV after treatment D. Patients with decompensated cirrhosis should still be treated

Main Board Which of these statements about treatment of chronic HCV infection with an anti-viral agent is true?

A. The success rate is around 75% B. After successful treatment, regular HCV viral load testing is not needed C. Patients will be immune to HCV after treatment D. Patients with decompensated cirrhosis should still be treated

6/21/2019 8

When using the CURB-65 decision tool, which of the following is NOT a criteria that encourages admission for pneumonia?

• A. BUN > 20
• B. Altered mental status
• C. Respiratory rate > 30
• D. PaO2 < 65 or SpO2 < 90%

A. B. C. D.

50% 23% 12% 15%

Main Board When using the CURB-65 decision tool, which of the following is NOT a criteria that encourage admission for pneumonia?

• A. BUN > 20
• B. Altered mental status
• C. Respiratory rate > 30
• D. PaO2 < 65 or SpO2 < 90%

Which of the following statements about necrotizing fasciitis is true?

A. The LRINEC prediction tool is effective for ruling it out B. Pain is surprisingly mild given the exam findings C. SGLT-2 inhibitor use increases the risk D. Antibiotic therapy alone is usually effective

A. B. C. D.

22% 0% 65% 13%

Main Board Which of the following statements about necrotizing fasciitis is true?

A. The LRINEC prediction tool is effective for ruling it out B. Pain is surprisingly mild given the exam findings C. SGLT-2 inhibitor use increases the risk D. Antibiotic therapy alone is usually effective

6/21/2019 9

An asymptomatic 21-y.o. female college student presents to obtain oral contraceptives. She is monogamous and presently using condoms with her male partner. You should recommend:

A. No screening for sexually transmitted infections B. Urine for nucleic acid amplification test (NAAT) for GC & chlamydia C. Patient-collected vaginal swab for NAAT for GC & chlamydia D. Cervical swab for chlamydia & GC culture + HSV-2 PCR

A. B. C. D.

6% 3% 61% 29%

Main Board An asymptomatic 21-y.o. female college student presents to obtain oral contraceptives. She is monogamous and presently using condoms with her male partner. You should recommend:

A. No screening for sexually transmitted infections B. Urine for nucleic acid amplification test (NAAT) for GC & chlamydia C. Patient-collected vaginal swab for NAAT for GC & chlamydia D. Cervical swab for chlamydia & GC culture + HSV-2 PCR

A woman with history of migraines complains of headache occurring on most days. She needs to take OTC analgesics on most days and APAP/Codeine every 2-3 days. What is the most likely diagnosis?

A. Chronic migraine B. Cluster headache C. Medication overuse HA D. Tension HA

A. B. C. D.

3% 3% 93% 0%

A woman with history of migraines complains of headache occurring on most days. She needs to take OTC analgesics on most days and APAP/Codeine every 2-3 days. What is the most likely diagnosis?

A. Chronic migraine B. Cluster headache C. Medication overuse HA D. Tension HA

6/21/2019 10

A 12-month randomized trial compared opioids to non-opioid medications for moderate-severe back, hip, or knee pain due to osteoarthritis. Compared to opioids, the non-opioid regimen

• A. Improved pain-related

function more effectively

• B. Reduced pain intensity

more effectively

• C. Had similar incidence of

side effects

• D. Included up front use of

duloxetine or pregabalin

A. B. C. D.

61% 11% 0% 28%

Main Board A 12-month randomized trial compared opioids to non-opioid medications for moderate-severe back, hip, or knee pain due to osteoarthritis. Compared to opioids, the non-opioid regimen:

• A. Improved pain-related

function more effectively

• B. Reduced pain intensity

more effectively

• C. Had similar incidence of

side effects

• D. Included up front use of

duloxetine or pregabalin

Which of the following statements about using acupuncture to treat pain is NOT correct?

• A. It is more effective for back pain

than for hip & knee pain

• B. Bruising is a side effect
• C. It is mildly effective for aromatase

related joint pain

• D. While effective, it was poorly

tolerated due to puncture site pain

A. B. C. D.

29% 39% 25% 7%

Main Board

• A. It is more effective for back pain

than for hip & knee pain

• B. Bruising is a side effect
• C. It is mildly effective for

aromatase related joint pain

• D. While effective, it was poorly

tolerated due to puncture site pain

Which of the following statements about using acupuncture to treat pain is NOT correct?

6/21/2019 11

A. It’s possible, the Achilles tendon is most often affected B. It’s doubtful, older patients are at lower risk C. It’s doubtful, prednisone is protective D. It’s doubtful, the symptoms

• ccurred too soon

A 70-year-old patient starts levofloxacin and prednisone for COPD exacerbation. He complains

• f ankle pain one day later. What should you say

about the possibility of fluoroquinolone-associated tendinopathy?

A. B. C. D.

75% 25% 0% 0%

Main Board A 70-year-old patient starts levofloxacin and prednisone for COPD exacerbation. He complains

• f ankle pain one day later. What should you say

about the possibility of fluoroquinolone-associated tendinopathy?

• A. It’s possible, the Achilles

tendon is most often affected B. It’s doubtful, older patients are at lower risk C. It’s doubtful, prednisone is protective

• D. It’s doubtful, the symptoms
• ccurred too soon

Which of the following statements about using allopurinol to treat gout is correct?

• A. Starting dose should not

exceed 100 mg daily

• B. Maximum dose should

not exceed 300 mg daily

• C. Dose should be reduced

if a rash occurs

• D. It should not be started

during an acute flare

A. B. C. D.

75% 10% 15% 0%

Main Board Which of the following statements about using allopurinol to treat gout is correct?

• A. Starting dose should not

exceed 100 mg daily

• B. Maximum dose should

not exceed 300 mg daily

• C. Dose should be reduced

if a rash occurs

• D. It should not be started

during an acute flare

6/21/2019 12

What is the most common side effect of immunotherapy (i.e., checkpoint inhibitors) for cancer treatment.

• A. Liver toxicity
• B. Endocrinopathy
• C. Rash
• D. Opportunistic infection

A. B. C. D.

26% 5% 63% 5%

Main Board What is the most common side effect of immunotherapy (i.e., checkpoint inhibitors) for cancer treatment.

• A. Liver toxicity
• B. Endocrinopathy
• C. Rash
• D. Opportunistic infection
• A. Anchoring
• B. Deference to authority
• C. Framing
• D. Availability

An ER physician picks up a chart that says: “35-y.o. female c/o abdominal pain; h/o heroin use.” He makes a diagnosis of opiate withdrawal but misses an ectopic

• pregnancy. What type of heuristic led to this error.

A. B. C. D.

14% 5% 81% 0%

Main Board An ER physician picks up a chart that says: “35-y.o. female c/o abdominal pain; h/o heroin use.” He makes a diagnosis of opiate withdrawal but misses an ectopic

• pregnancy. What type of heuristic led to this error.
• A. Anchoring
• B. Deference to authority
• C. Framing
• D. Availability

6/21/2019 13

Which pairing of diabetes drug and side effect is NOT correct?

• A. GLP1 agonist – GI intolerance

and risk of pancreatitis

• B. SGLT inhibitor – UTI,

dehydration

• C. DPP4 inhibitor – acute renal

failure

• D. Sulfonylurea – weight gain

A. B. C. D.

5% 14% 77% 5%

Main Board

• A. GLP1 agonist – GI intolerance

and risk of pancreatitis

• B. SGLT inhibitor – UTI,

dehydration

• C. DPP4 inhibitor – acute renal

failure

• D. Sulfonylurea – weight gain

Which pairing of diabetes drug and side effect is NOT correct?

• A. Beta-carotene
• B. Vitamin A
• C. Vitamin E
• D. All of the above

Which of these antioxidant vitamins increased mortality in a randomized trial?

A. B. C. D.

16% 65% 10% 10%

Main Board

• A. Beta-carotene
• B. Vitamin A
• C. Vitamin E
• D. All of the above

Which of these antioxidant vitamins increased mortality in a randomized trial?

6/21/2019 14

Your patient is using a long acting beta agonist (LABA) for COPD. What should you expect to happen if you add an inhaled corticosteroid?

A. B. C. D.

3% 86% 3% 7%

• A. Large improvement in FEV1
• B. Large reduction in number of

exacerbations

• C. Ability to wean off the LABA
• D. Increased risk of pneumonia

Main Board Your patient is using a long acting beta agonist (LABA) for COPD. What should you expect to happen if you add an inhaled corticosteroid?

• A. Large improvement in FEV1
• B. Large reduction in number of

exacerbations

• C. Ability to wean off the LABA
• D. Increased risk of pneumonia
• A. Less than a day
• B. 1-2 days
• C. 3-5 days
• D. 5-7 days
• E. Over a week…

…maybe forever

How long does it take for Lego to pass through the gastrointestinal tract?

A. B. C. D. E.

2% 67% 4% 2% 26%

How long does it take for Lego to pass through the gastrointestinal tract?

• B. 1-2 days

6/21/2019 15

Thank You for Playing

See you next year!