SANS 22-23 (4/4): Other General

(Bank #4) Which of the following activities must be submitted to the Institutional Review Board for supervision? -A quality improvement project designed at limiting waste in the OR -A dictated note from an attending physician -A resident quality improvement project -A medical student presentation on rounds -A survey research project about medical student sleep habits

A survey research project about medical student sleep habits The Common Rule applies to human subject research conducted, and describes what types of research must be regulated, requirements for Institutional Review Board membership, authority, and review procedures, and lists the general requirements for informed consent. Any research must be submitted to the IRB. Research with little or no chance of harm and minimal intervention may qualify for exemption or expedited review. Quality improvement and education or clinical activities not intended for research do not require IRB review. References: Reference (1)Emanuel EJ, Menikoff J. Reforming the regulations governing research with human subjects. N Engl J Med. 2011 Sep 22; 365(12): 1145-1150. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/21787202/ Reference (2) https://www.hhs.gov/ohrp/regulations-and-policy/regulations/finalized-revisions-common-rule/index.html Reference (3) https://www.research.va.gov/programs/pride/resources/Common_Rule_Flyer.pdf

(Bank #4) In a randomized study, the chance of a Type I error, a false-positive error in which a study finds that treatment A is better than treatment B when in fact it is not, is equal to which of the following? -1-beta -Delta -Beta -1-alpha -Alpha

Alpha Type 1 error is equivalent to the alpha value, the probability that the researcher rejects the null hypothesis stating that there is a significant difference between the interventions when in reality there is no statistically significant difference. 1-alpha is the confidence interval, the probability that you correctly accept the null hypothesis that there is no statistically significant difference between the interventions. The statistical power is 1- beta which is the probability that you correctly reject the null hypothesis as there is a statistically significant difference between the interventions. Type II errors are false negatives where the researcher accepts the null hypothesis; however in reality there is a statistically significant difference between the interventions; this is represented by beta. References: Reference (1)Banerjee A, Chitnis UB, Jadhav SL, Bhawalkar JS, Chaudhury S. Hypothesis testing, type I and type II errors. Ind Psychiatry J. 2009 Jul;18(2):127-31. doi: 10.4103/0972-6748.62274. PMID: 21180491; PMCID: PMC2996198. Pubmed Web link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996198/

(Bank #4) A neurosurgeon has been waiting to enroll a patient into her clinical research protocol that was recently approved by her institutional review board. A 69-year-old male patient is admitted, and upon initial screening meets nearly all inclusion criteria; however, he has late-stage dementia. This scenario demonstrates the need for which of the following aspects of proper informed consent? -A clear distinction between research and treatment -An ability to understand the risks and benefits of participation -The availability of possible compensation for injury sustained -Removal of possible sources of coercion -A written consent detailing the research study, its risk and benefits

An ability to understand the risks and benefits of participation. The question focuses on the core features of proper informed consent. This includes informing the subject of the purpose, benefits, and risks of the procedure, informing them of alternatives to participation, and providing them with contact information in the case questions or concerns arise. Implicit in this is the understanding that the patient can comprehend the costs and benefits of, and alternatives to participation in the study. In this stem the patient is portrayed as have late-stage dementia. It is therefore unlikely that he retains sufficient capacity to understand these aspects of the informed consent process. The availability of compensation for injuries sustained during the study and the removal of sources of coercion are not clearly jeopardized in the present scenario, which focuses specifically on the ability of the patient to provide informed consent. A detailed written consent is insufficient as a substitute in the case of a patient who lacks the competency to make an informed decision. References: Reference (1)Henderson GE. "Is informed consent broken?" American Journal of Medical Science. 2011. 342(4):267-272. Doi: 10.1097/MAJ.0b013e31822a6c47 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/21817873/ Reference (2) Lidz CW. " Informed consent: a critical part of modern medical research." American Journal of Medicine Science. 2011. 342(4):273-275. Doi: 10.1097/MA.0b013e318227e0cc Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/21804363/

(Bank #4) Which of the following ethical principles underlies the ability of an individual to refuse to participate in a clinical research study? -Truth Telling -Non-maleficence -Autonomy -Beneficence -Confidentiality

Autonomy There are four important ethical principles that apply to the care of patients every day: respect for patient autonomy, beneficence, nonmaleficence, and justice. The principles can help to resolve ethical conflicts which occur when they come into conflict with each or with a patient's or provider's values. Respect for patient autonomy involves allowing patients to make informed choices regarding their healthcare. Beneficence is doing what is best for the patient and nonmaleficence doing no harm. Justice involves fair allocation of resources. References: Reference (1)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923912/#:~:text=The%20Fundamental%20Principles%20of%20Ethics%201%20Beneficence%20The,Consent%20...%205%20Truth-Telling%20...%206%20Confidentiality%20 Reference (2) Taylor RM. Ethical principles and concepts in medicine. Handb Clin Neurol. 2013;118:1-9. doi:10.1016/B978-0-444-53501-6.00001-9 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/24182363/

(Bank #4) According to the Institute of Medicine , which of the following is classified as an adverse event? -Anaphylactic reaction after first exposure to a drug to which patient had no prior allergic history -The latest blood glucose on a patient results >300. Being an isolated elevate BG result, resident calls the laboratory requesting to recheck the sample. Updated result is 100. Patient is not given insulin. -Intracranial mass is missed during initial CT Head read but eventually recognized by team, patient receives the correct diagnosis and treatment plan -Ten-fold overdose order of morphine by physician that gets intercepted and corrected by the pharmacist -Retained surgical object in patient that is identified during count and removed before case concluded

Anaphylactic reaction after first exposure to a drug to which patient had no prior allergic history The Institute of Medicine (IOM) defined an adverse event as "an injury caused by medical management rather than the underlying condition of the patient" and a medical error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" [1]. A preventable adverse event is an adverse event that results from an error. However, it is important to note that most adverse events do not result from a medical error, and most medical errors do not result in adverse events. [1][2] In the examples mentioned above, the anaphylactic reaction is an adverse event not caused by a medical error. The rest of the answer choices are medical errors that did not result in adverse events. References: Reference (1)Murff H, Patel V, Hripcsak G, et al. Detecting adverse events for patient safety research: a review of current methodologies. J Biomed Inform. 2003 Feb-Apr;36(1-2):131-43. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/14552854/ Reference (2)Grober E, Bohnen J. Defining medical error. Can J Surg. 2005 Feb;48(1):39-44. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/15757035/

(Bank #4) A 35-year-old man comes to the office with a four-day history of moderate, nonradicular lumbar pain after strenuous garden work. Ibuprofen has provided some relief. Physical examination shows perilumbar tenderness only. He insists on an MR imaging scan and wont leave until one is ordered. Which of the following is the most appropriate initial step in management? -Tell him to ask for the MRI from his PCP -Ask him to leave politely and see a different neurosurgeon in the future -Follow-up in 6 weeks and ignore the patient's MRI request -Ask him why he feels he needs an MRI, acknowledge his feelings, and explain to him why an MRI is not necessary -Tell him insurance will not cover it

Ask him why he feels he needs an MRI, acknowledge his feelings, and explain to him why an MRI is not necessary This patient likely has a muscle strain or possibly lumbar disc herniation. This diagnosis is supported by his pattern of pain and lack of neurologic red flag or radicular symptoms. The first line of management for patients with back pain is conservative including NSAIDs, rest, and then possibly physical therapy and/or injections. It can be difficult to communicate with patients who are requesting medically unnecessary imaging. Physicians have different strategies to deal with this problem but the best strategy is honest patient-physician communication. References: Reference (1)Alessandro Chiarotto, P.T., Ph.D., and Bart W. Koes, Ph.D. Nonspecific Low Back Pain. N Engl J Med 2022; 386:1732-1740DOI: 10.1056/NEJMcp2032396 Reference (2) Gallagher TH, Lo B, Chesney M, Christensen K. How do physicians respond to patient's requests for costly, unindicated services? J Gen Intern Med. 1997 Nov;12(11):663-8. doi: 10.1046/j.1525-1497.1997.07137.x. PMID: 9383133; PMCID: PMC1497183. Pubmed Web link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497183/

(Bank #4) A neurosurgeon reports outcomes for a new surgical procedure he has performed on ten patients with degenerative spondylolisthesis. He provides data on the clinical and radiographic patient outcomes, including health related quality of life data both before and after surgery. This type of study design is best described as which of the following? -Prospective cohort study -Cross-sectional study -Case series -Non-inferiority trial -Case-control study

Case series Here the question asks about basic clinical study design. The study in the present question summarizes the results of a small set of non-randomly assigned patients in which there is no comparison group. As a result, it cannot be a non-inferiority trial, cohort study, or case-control study. Description of the study suggests that the sample is not representative of some larger population and may be of patients treated over some period of time in the surgeon's practice. Consequently, cross-sectional study is also incorrect. This study is best described as a case series, a detailed description of [an often small series] of cases without a control group. References: Reference (1)Noordzij et al. "Study designs in clinical research." Nephron Clinical Practice. 2009: 113(3): c218-21. Doi: 10.1159/000235610 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/19690439/ Reference (2) Manja V, Lakshminrusimha S. Epidemiology and Clinical Research Design, Part 1: Study Types. Neoreviews. 2014;15(12):e558-e569. doi:10.1542/neo.15-12-e558 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/25848346/

(Bank #4) Which of the following strategies most effectively minimizes the risk of a medication error? -Identifying route of dosage -Checking labs prior to prescribing -Not using drug abbreviations -Understanding drug-drug interactions -Computer order entry for prescribing

Computer order entry for prescribing The correct answer is a computerized physician order entry system which can help eliminate serious medication errors by more than half. This allows for standardized prescribing methords as well as computerized adverse event surveillance, coupled with alerts to pharmacists about drug allergies, standardization of antibiotic administration rates, and physician notification about polypharmacy and drug-drug interactions. The other answer choices are elements that should be done as a part of good practice, but have not been shown to reduce serious medication errors. References: Reference (1)Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998 Oct 21; 280(15): 1311-1316. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/9794308/ Reference (2) Tariq RA, Vashisht R, Sinha A, Scherbak Y. Medication Dispensing Errors And Prevention. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 3, 2022. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/30085607/

(Bank #4) Which of the following is the primary barrier to achieving safe health care? -disrespectful behavior by health professionals -Healthcare associated infections -Health care expenses -Lack of insurance coverage -Physician shortage

Disrespectful behavior by health professionals. The correct answer is disrespectful behavior by health professionals. It is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients. The other answer choices can be limiting factors in getting healthcare, but not a barrier to safe healthcare. References: Reference (1)Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012 Jul;87(7):845-52. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/22622217/ Reference (2) Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med. 2012 Jul;87(7):853-8. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/22622219/ Reference (3) Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005;142(9):756-764. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/15867408/

(Bank #4) The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorizes funding to incentivize which of the following practices? -Health savings accounts -Health insurance marketplaces -Electronic health records -Enhanced recovery after surgery pathways -Bundled payment models

Electronic health records The Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) provides for grants and financial incentives designed to encourage the "meaningful use" of electronic health records, the four core functionalities of which are: 1) documentation of clinical findings, 2) computerized order entry, 3) records of results (tests and imaging), and 4) clinical-decision support. The act is not designed to incentivize enhanced recovery after surgery (ERAS) pathway, alter reimbursement models, or alter the means by which patients pay for care,. References: Reference (1)Mangalmurti SS et al. "Medical malpractice liability in the age of electronic health records." New England Journal of Medicine. 2010. 363(21): 2060-2067. doi: 10.1056/NEJMhle1005210 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/21083393/ Reference (2) Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382-385. doi:10.1056/NEJMp0912825

(Bank #1) The medication most commonly used for management of Meniere disease is an antagonist of which of the following receptor types? -acetylcholine receptors -histamine receptors -serotonin receptors -NMDA receptors -GABA receptors

Histamine receptors One of the most common drugs used to treat Menieres disease is betahistine which is an antagonist of histamine H3 receptors. Its exact mechanism of action is unclear but a 2016 Cochrane review found that for patients with Meniere's disease, the effect of betahistine was stronger than placebo, with Menieres disease patients reporting a 56% reduction in vertigo when taking betahistine as compared with placebo. The other main class of drugs used to treat Menieres disease are diuretics. The most common diuretics used to treat Menieres disease are thiazides with or without potassium-sparing diuretics such as hydrochlorothiazide/triamterene or spironolactone as well as the carbonic anhydrase inhibitor acetazolamide as a second-line therapy. References: Basura GJ, Adams ME, Monfared A, Schwartz SR, Antonelli PJ, Burkard R, Bush ML, Bykowski J, Colandrea M, Derebery J, Kelly EA, Kerber KA, Koopman CF, Kuch AA, Marcolini E, McKinnon BJ, Ruckenstein MJ, Valenzuela CV, Vosooney A, Walsh SA, Nnacheta LC, Dhepyasuwan N, Buchanan EM. Clinical Practice Guideline: Ménière's Disease. Otolaryngol Head Neck Surg. 2020 Apr;162(2_suppl):S1-S55. doi: 10.1177/0194599820909438. PMID: 32267799. Scholtz AW, Hahn A, Stefflova B, Medzhidieva D, Ryazantsev SV, Paschinin A, Kunelskaya N, Schumacher K, Weisshaar G. Efficacy and Safety of a Fixed Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg vs Betahistine Dihydrochloride 16 mg in Patients with Peripheral Vestibular Vertigo: A Prospective, Multinational, Multicenter, Double-Blind, Randomized, Non-inferiority Clinical Trial. Clin Drug Investig. 2019 Nov;39(11):1045-1056. doi: 10.1007/s40261-019-00858-6. PMID: 31571128; PMCID: PMC6800407.

(Bank #4) A patient with palinopsia will have which of the following complaints? -Inability to recognize familiar faces -Inappropriate recurrence or persistence of an image -Difficulty fixating on an object -Denial of blindness -Inability to perceive more than one object at a time

Inappropriate recurrence or persistence of an image Palinopsia describes the persistence or recurrence of visual images after the stimulus has been removed and is typically associated with posterior cortical lesions. Inability to recognize familiar faces is known as prosopagnosia and is associated with lesions of the fusiform gyrus. The inability to perceive more than one object at a time is known as simultagnosia and is associated with parieto-occipital lesions. Denial of blindness or "cortical blindness" is known as Anton syndrome and is associated with bilateral occipital lobe lesions. References: Reference (1)Gersztenkorn D, Lee AG. Palinopsia revamped: a systematic review of the literature. Surv Ophthalmol. 2015 Jan-Feb;60(1):1-35. Reference (2) Belcastro V, Cupini LM, Corbelli I, Pieroni A, D'Amore C, Caproni S, Gorgone G, Ferlazzo E, Di Palma F, Sarchielli P, Calabresi P. Palinopsia in patients with migraine: a case-control study. Cephalalgia. 2011 Jul;31(9):999-1004. doi: 10.1177/0333102411410083. Epub 2011 May 31. PMID: 21628437

(Bank #4) Which of the following addresses the problem of error from unknown confounders? -Avoiding matching amongst two groups -Decreasing sample size -Decreasing randomization -Unrestricted patient recruitment/groups -Increasing randomization

Increasing randomization. A confounder is a variable that relates both to the exposure and outcome being studied but not identified on the causal pathway between the two. It therefore affects the variables being studied such that the results do not represent the actual relationship being studied. Ways to mitigate confounders include randomization so that they are split evenly across groups, restriction to a particular sample, and matching based on possibly confounding variables. References: Reference (1)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017459/

(Bank #4) A 27-year-old pregnant woman is evaluated for painless, progressive visual loss in the right eye. Examination shows no light perception or direct pupillary response in the eye, and a pale optic nerve, plus a superior temporal visual field defect in the left eye. The etiology of her signs and symptoms is most likely which of the following? -Pseudotumor cerebri -Optic neuritis -Sheehan Syndrome -Glaucoma -Intracranial tumor

Intracranial tumor The patient in this vignette is experiencing unilateral, progressive vision loss. The key pieces of the history here that may influence a differential diagnosis are demographics (young, pregnant woman) and unilateral, chronic symptoms. The patient demographics may elevate pseudotumor cerebri or Sheehan's syndrome on the differential, but the unilateral symptoms make these answer choices less likely. The chronicity of the symptoms makes central retinal artery occlusion unlikely as this would be expected to be sudden in onset. Although optic neuritis is most commonly seen in young women and can be associated with vision changes, it is also associated with dyschromatopsia, a relative afferent pupillary defect, and a swollen optic nerve, none of which are described. Unilateral and progressive visual symptoms are concerning for a mass lesion. Specifically, meningiomas can cause progressive vision loss with associated visual field defects and a pale optic nerve on ophthalmoscopy due to progressive invasion of the bony optic canal and compression of the optic nerve. Additionally, approximately 30% of meningiomas express estrogen receptors and 55-70% express progesterone receptors which can result in increased tumor mass effect due to increased serum progesterone levels, particularly in the second half of pregnancy. References: Reference (1)Ebner FH, Bornemann A, Wilhelm H, et al. Tuberculum sellae meningioma symptomatic during pregnancy: pathyphysiological consideration. Acta Neurochir (Wien). 2008 Feb;150(2):189-193. Epub 2008 Jan 23. Reference (2) Murad-Kejbou S, Eggenberger E. Pituitary apoplexy: evaluation, management, and prognosis. Curr Opin Ophthalmol. 2009 Nov;20(6):456-461

(Bank #4) A lesion at which of the following sites is most likely to cause an internuclear ophthalmoplegia? -Medial longitudinal fasciculus (MLF) -Cranial nerve III nucleus -Frontal eye fields -Cranial nerve VI nucleus -Paramedian pontine reticular formation

Medial longitudinal fasciculus (MLF) Internuclear ophthalmoplegia (INO) is characterized by loss of adduction of the ipsilateral eye in attempted horizontal gaze. The horizontal gaze center is made up of the paramedian pontine reticular formation (PPRF) and CN VI nuclei. Fibers from the CN VI nucleus cross to the contralateral CN III via the medial longitudinal fasciculus (MLF) to innervate the medial rectus for conjugate lateral gaze. Thus, a lesion in the MLF will result in impaired adduction and INO. References: Reference (1)Frohman TC, Galetta S, Fox R, Solomon D, Straumann D, Filippi M, Zee D, Frohman EM. Pearls & Oy-sters: The medial longitudinal fasciculus in ocular motor physiology. Neurology. 2008 Apr 22;70(17):e57-67. doi: 10.1212/01.wnl.0000310640.37810.b3. PMID: 18427066. Reference (2) Stalcup ST, Tuan AS, Hesselink JR. Intracranial causes of ophthalmoplegia: the visual reflex pathways. Radiographics. 2013 Sep-Oct;33(5):E153-69. doi: 10.1148/rg.335125142. PMID: 24025940.

(Bank #1) A 23-year-old man with a history of depression and drug abuse is evaluated for agitation and a confused state. Examination shows tachycardia, mydriasis, anhidrosis, and urinary retention. This suggests intoxication with a drug with which of the following actions? -Calcium-channel blockade -Opioid receptor antagonism -GABA receptor agonist -Muscarinic receptor antagonist -Beta-adrenergic receptor blockade

Muscarinic receptor antagonist The anticholinergic toxidrome is characterized by dilated pupils (mydriasis), tachycardia, mental-status changes, anhidrosis, urinary retention, dry mouth, flushed skin, absent bowel sounds and temperature elevations. The patient presents with concern for anticholinergic toxicity, indicating overdose of a drug with muscarinic acetylcholine receptor antagonism. Pure anticholinergic toxicity is often seen in antidepressant overdose, particularly with tricyclic antidepressants and phenothiazines. References: Holstege CP, Borek HA. Toxidromes. Crit Care Clin. 2012 Oct;28(4):479-98. doi: 10.1016/j.ccc.2012.07.008. Epub 2012 Aug 27. PMID: 22998986. Benarroch EE. Basic Neurosciences with Clinical Applications. Philadelphia: Butterworth Heinemann/Elsevier; 200

(Bank #4) A 68-year-old man comes to the emergency department because of painful swelling of his forehead and fever. A photograph of the forehead (Figure 1) and a CT image of the head are shown (Figure 2). He recalls falling and striking his forehead on a door five weeks earlier, but he did not seek medical attention. Which of the following is the most likely diagnosis? -Pseudomeningocele -Langerhans Cell Histiocytosis -Subgaleal hematoma -Pott's Puffy Tumor -Facial lymphatic malformation

Pott's Puffy Tumor. The combination of a recent history of trauma, development of painful swelling, imaging characteristics of an underlying fluid-filled mass in the scalp soft tissue with communication with the frontal sinus, and a suggestion of infection with the fever, all point toward Pott's Puffy Tumor (correct answer). Pott's Puffy Tumor (PPT) is a misnomer in that it is a non-neoplastic entity originating as sequela to untreated sinusitis secondary to trauma, substance abuse, and odontogenic disease. It is characterized by osteomyelitis with subperiosteal abscess formation. It can be associated with intracranial extension leading to an epidural abscess, subdural empyema, or a cerebral abscess formation. Treatment, therefore, is surgical followed by antibiotics. A subgaleal hematoma would be expected to have resolved by 5 weeks and would not typically be associated with a fever. CSF leak through violation of the anterior cranial fossa dura should lead to rhinorrhea instead of a pseudomeningocele. Langerhans Cell Histiocytosis is the abnormal proliferation of Langerhans cells or dendritic cells. It has a predilection for children less than 15 years of age and is not typically associated with trauma. Similarly, facial lymphatic malformations, which are dilated lymphatic channels with no connections to the normal lymphatic drainage pathway, are most commonly found in children. These congenital lesions often come to light with trauma or infection, causing them to swell and enlarge. They can compromise vision and breathing. References: Reference (1)Rohde R, North L, Murray M, et al. Pott's puffy tumor: A comprehensive review of the literature. Am J Otolaryngol. 2022 Jun 9;43(5):103529 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/35700606/ Reference (2) Colletti G, Biglioli F, Poli T, et al. Vascular malformations of the orbit (lymphatic, venous, arteriovenous): Diagnosis, management and results. J Craniomaxillofac Surg. 2019 May;47(5):726-740. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/30770258/

(Bank #4) The Physician Payments Sunshine Act requires drug and device manufacturers to report any payments made to physicians to which of the following entities? -Internal Revenue Service (IRS) -Hospital administrators -State medical board -Open Payments Database -Directly to patients

Open Payments Database. With the passage of the Affordable Care Act in 2010 and its section 6002 (the Physician Payments Sunshine Act) there was the creation of the Open Payments Database, a publicly available list where industry entities are required to report any payments made to physicians. This database is administered by the Centers for Medicare and Medicaid Services (CMS). Though these other entities may be interested in conflicts of interest regarding the involved physician, there is not a federal statutory requirement that industry report payments to any of these others. It is ethically appropriate to discuss any conflicts with patients, though it is not required that a physician directly report this information to their patients, though the information is publicly available on the internet. References: Reference (1)https://pubmed.ncbi.nlm.nih.gov/29850841/ Pubmed Web link PMID: 29850841 Reference (2) https://www.healthaffairs.org/do/10.1377/hpb20141002.272302/#:~:text=The%20Physician%20Payments%20Sunshine%20Act%20%28PPSA%29--also%20known%20as,of%20value%20made%20to%20physicians%20or%20teaching%20hospitals.

(Bank #4) An obtunded 15-year-old boy is evaluated for a one-week history of fever, headache, nasal drainage, and forehead swelling. Contrast-enhanced CT scan shows frontal sinusitis and a large frontal subdural empyema. Which of the following is the most appropriate next step in management? -Endoscopic sinus surgery -Open surgical evacuation -Obtain a contrast-enhanced MRI -Expanded endoscopic endonasal approach -Initiation of broad-spectrum antibiotics

Open surgical evacuation. When the diagnosis of a subdural empyema is made, especially in a patient with neurologic compromise, prompt surgical evacuation (the correct answer) is warranted to minimize morbidity and mortality. Predictors of poor outcome include GCS ≤ 8, cerebral venous sinus thrombosis, and presence of infarction. Subdural empyema, if not treated in a timely fashion, will lead to cerebral infarction through involvement/irritation of the arterial vasculature, venous sinus thrombosis with resultant venous infarction, and seizures. Antibiotics/antimicrobials should be tailored to the organisms and, as far as possible, should be initiated after cultures are obtained to minimize the risks of a sterile culture. Endoscopic sinus surgery addresses the source of the infection and may occasionally be a reasonable first step in a patient without neurologic compromise. In the pediatric population, 44% of the patients undergoing endoscopic sinus surgery alone eventually require neurosurgical intervention. Surgical evacuation of subdural empyema is traditionally performed via a burr hole or a craniotomy. Expanded endoscopic endonasal approaches may be a reasonable alternative in situations where the empyema is small and confined to the midline at the skull base. Occasionally, the diagnosis may not be as straightforward. A contrast-enhanced MRI is the gold standard in diagnosing subdural empyema. However, when the clinical suspicion is high, and a diagnosis can be rendered off a CT scan, the definitive treatment should not be delayed in an attempt to obtain an MRI. References: Reference (1)Greenlee JE. Subdural Epyema. Curr Treat Options Neurol. 2003 Jan;5(1):13-22. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/12521560/ Reference (2) Konar S, Gohil D, Shukla D, et al. Predictors of outcome of subdural empyema in children. Neurosurg Focus. 2019 Aug 1;47(2):E17 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/31370020/ Reference (3) Gillard DM, Cai Y, Rothey PK, et al. Efficacy of endoscopic sinus surgery alone versus in combination with neurosurgical intervention for the treatment of pediatric subdural empyema. Int J Pediatr Otorhinolaryngol. 2021 Sep;148:110836. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/34271525/

(Bank #4) A 26-year-old woman is evaluated in the emergency department because of a three-day history of progressive loss of vision in the right eye, decreased visual acuity, and pain with eye movement. Examination shows dyschromatopsia, a relative afferent pupillary defect, and a swollen optic nerve. Which of the following is the most likely diagnosis? -Cluster Headache -Optic Neuritis -Tolosa Hunt Syndrome -Horner Syndrome -Cavernous Sinus Thrombosis

Optic Neuritis. The patient presents with subacute, progressive vision loss accompanied by painful ophthalmoplegia. At this point, the differential is broad and could indicate orbit vs. cavernous sinus pathology. The key here is the "swollen optic nerve" on ophthalmoscopy. Optic neuritis is the most common cause of optic-nerve dysfunction in young adults and is characterized by loss of central vision, painful eye movement, dyschromatopsia, and a relative afferent pupillary defect, all of which are described in this clinical vignette. Cavernous sinus thrombosis is characterized by various cranial neuropathies but would not be expected to affect visual acuity. Cluster headache is characterized by cyclical patterns and dysautonomic features which may be similar to Horner syndrome. Tolosa hunt syndrome is characterized by painful ophthalmoplegia and retro-orbital pain, with or without pupillary involvement, due to non-specific inflammation of the cavernous sinus and superior orbital fissure. None of the other answer choices would be expected to have reduced visual acuity, dyschromatopsia, or a swollen optic nerve on an exam. References: Reference (1) Cestari DM, Metson RB, Cunnane ME, et al. Case 40-2008: a 26-year-old man with blurred vision. NEJM. 2008; 359:2825-33. Reference (2) Pula JH, Macdonald CJ. Current options for the treatment of optic neuritis. Clin Ophthalmol. 2012;6: 1211-23. doi:10.2147/OPTH.S28112

(Bank #4) Which of the following is the most important prerequisite to identifying and resolving medical errors? -Accountability -Transparent documentation -Psychological safety -Fear of punishment -Clear policies

Psychological safety The best answer is psychological safety for physicians and other team members, as errors are more likely to be disclosed if there is not a culture of blame and punishment, but rather a culture of continued improvement. Though clear policies, accountability mechanisms, and transparent documentation are important when operating a health care organization, they are insufficient to produce the types of candid assessments of errors that promote optimal quality improvement. Accountability is a critical aspect of the process of rectifying errors, but it will not necessarily aid in identifying them when they happen. References: Reference (1)https://www.ncbi.nlm.nih.gov/books/NBK499956/ Pubmed Web link PMID: 29763131 Reference (2) https://pubmed.ncbi.nlm.nih.gov/28904910/ Pubmed Web link PMID: 28904910

(Bank #4) Under the Emergency Medical Treatment and Labor Act (EMTALA), which of the following is an illegal act? -Triage causing patients with non-emergency conditions to wait many hours for care -Sending an outpatient to a nearby emergency department to expedite treatment -Discharging a patient against their will from the emergency department -Transferring a pt to a hospital with equivalent or fewer specialty services -Refusing to accept a pt transfer from a hospital without necessary specialty services

Refusing to accept a pt transfer from a hospital without necessary specialty services. The Emergency Medical Treatment and Active Labor Act (EMTALA) is a component of federal healthcare law which creates specific obligations by physicians and hospitals regardless of patients' ability to pay. Specifically, these include medical screening and stabilization of emergency department patients, accepting appropriate transfers from other hospitals, and providing adequate on-call physician specialty services. Under EMTALA, it is illegal to refuse to accept a transfer patient to a hospital which provides a necessary specialty service when the referring hospital lacks this capacity. This does not create a one-way flow of patients. A patient at a tertiary hospital may be transferred to another institution if the patient is stable and the condition can be appropriately managed at the receiving hospital. EMTALA obligates emergency departments to provide appropriate screening and stabilization. Triage of patients by acuity and discharging patients who do not require emergency care are part of this process. Sending an outpatient to the emergency department to speed their care is permissible, but the care in the emergency department will be subject to the same regulations. References: Reference (1)Bitterman RA. EMTALA and the ethical delivery of hospital emergency services. Emerg Med Clin North Am. 2006 Aug;24(3):557-77. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/16877130/ Reference (2) Ladd & Gupta. Cobra Laws and EMTALA. StatPearls 2022 Jan. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/32310395/

(Bank #1) In 2009, the United States Food and Drug Administration mandated updated labeling for all anticonvulsant medications to indicate an increased risk of which of the following? -Aplastic Anemia -Stevens-Johnson Syndrome -Weight Gain -Dystonia -Suicidal Ideation

Suicidal Ideation In 2008, the FDA conducted a meta-analysis of 199 placebo-controlled trials of 11 antiepileptic agents, including gabapentin, divalproex, felbamate, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, tiagabine, topiramate, zonisamide, and carbamazepine. Of the 43,892 patients captured, the risk of suicidality was twice as likely in patients receiving these medications relative to placebo controls (0.43% versus 0.22%). Risks were found to increase soon after initiation of the agent and persisted through at least six months of use. The FDA subsequently issued a safety mandate warning of suicidal ideation and risk associated with antiepileptic medications. Depression is not uncommon among patients with chronic epilepsy, however, suicidality has not be shown to correlate with the severity of illness. Recognition of this risk should be considered and patients starting anticonvsulvie medication for any indication should be counseled appropriately. References: Arana A, Wentworth CE, Ayuso-Mateos JL, et al. Suicide-related events in patients treated with antiepileptic drugs. N Engl J Med. 2010 Aug 5;363(6):542-551.Mula M, Kanner AM, Schmitz B, Schachter S. Antiepileptic drugs and suicidality: an expert consensus statement from the Task Force on Therapeutic Strategies of the ILAE Commission on Neuropsychobiology. Epilepsia 2013;54:199-203.Hesdorffer DC, Kanner AM. The FDA alert on suicidality and antiepileptic drugs: fire or false alarm? Epilepsia 2009;50:978-986.

(Bank #4) Cost effective health care and resource utilization refer most accurately to which of the following core competencies? -Patient Care -Professionalism -Systems Based Practice -Practiced Based Learning and Improvement -Interpersonal and Communication Skills

Systems Based Practice. According to the ACGME Milestones Guidebook for Residents and Fellows, the six core competencies are patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. While the other answers may be important skills for resident physicians to develop, they are not part of the core competencies required by the ACGME. References: Reference (1)https://www.acgme.org/ Reference (2) https://med.stanford.edu/gme/housestaff/current/core_competencies.html

(Bank #4) Which of the following is one of the general competencies required for residency education by the Accreditation Council for Graduate Medical Education (ACGME)? -Socioeconomics of healthcare knowledge -Interprofessional collaboration -Leadership -Diagnostic skill -Systems-based Practice

Systems-based Practice. According to the ACGME Milestones Guidebook for Residents and Fellows, the six core competencies are patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. While the other answers may be important skills for resident physicians to develop, they are not part of the core competencies required by the ACGME. References: Reference (1)ACGME Milestones Guidebook for Residents and Fellows Pubmed Web link https://www.acgme.org/globalassets/pdfs/milestones/milestonesguidebookforresidentsfellows.pdf

(Bank #4) Regulations regarding the protection of human subjects and related basic ethical principles were revised and expanded by the Department of Health and Human Services in 1981 and later entered into the Code of Federal Regulations. These regulations created which of the following regulations that is still in effect today? -The Affordable Care Act -HIPAA -Medicaid -The Patient Safety and Quality Improvement Act -The Common Rule

The Common Rule The Common Rule applies to human subject research conducted, and describes what types of research must be regulated, requirements for Institutional Review Board membership, authority, and review procedures, and lists the general requirements for informed consent. HIPAA relates to patient privacy in any encounter. The affordable care act is legislation passed in 2010 designed to improve access to quality, affordable health care for all in the US. The patient safety and quality act, passed in 2005 to improve accessibility and sharing of data related to quality and safety. Medicaid is public insurance for children, pregnant woman, parents, and seniors with income qualifications and individuals with disabilities. Reference (1)Emanuel EJ, Menikoff J. Reforming the regulations governing research with human subjects. N Engl J Med. 2011 Sep 22; 365(12): 1145-1150. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/21787202/ Reference (2) https://www.hhs.gov/ohrp/regulations-and-policy/regulations/finalized-revisions-common-rule/index.html Reference (3) https://www.research.va.gov/programs/pride/resources/Common_Rule_Flyer.pdf

(Bank #4) A patient has told his family that he would not want to live as a "vegetable." Five days after a large left hemispheric stroke, the patient is noncommunicative, and has a right hemiplegia. His wishes are voiced by his family. The stated request should be understood by the treating physician to mean which of the following? -The patient wants all medical and surgical measures taken to sustain his life. -The patient does not want intubation or cardiac resuscitation (DNR/DNI). -The patient would want his care redirected to comfort measures only. -The patient does not want artificial feeding. -The patient does not want his life sustained if he were in a minimally conscious state.

The patient does not want his life sustained if he were in a minimally conscious state. Interpretation of a patient's wishes when he is not able to communicate them himself is left up to surrogate decision-makers, which can include a spouse/partner, immediate family, or close friends, when not otherwise designated by an advanced directive. In this case, the patient made a specific statement regarding life-sustaining treatment if he were a "vegetable"—in a minimally conscious state—indicating that this quality of life would be unacceptable to him. The correct answer choice keeps to this narrow interpretation of the patient's wishes. The patient is not currently in a vegetative state; thus, his surrogate decision-maker(s) may not have strict guidance when making other choices on his behalf. It may be appropriate in some circumstances to designate the patient Do No Resuscitate / Do Not Intubate (DNR/DNI) or to withhold artificial feeding, but these are not specifically addressed by the patient's statement. Redirection of the patient's care to comfort measures only may be appropriate if his surrogate decision-maker(s) agree but is not implied by the patient's statement. Continued aggressive medical and/or surgical care may be appropriate if the patient's surrogate decision-maker(s) feel that his quality of life continues to be acceptable. References: Reference (1)University of Washington School of Medicine. Bioethics Topics. Available at: https://depts.washington.edu/bioethx/topics/index.html. Published 2009. Pubmed Web link https://depts.washington.edu/bioethx/topics/index.html Reference (2) Ethical Considerations in Surgical Decompression for Stroke. Stroke. 2022; 53: 2673-2682. Pubmed Web link https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.038493

(Bank #4) A ventricular catheter is to be placed perpendicularly through a burr hole 2.5 cm above and 2.5 cm behind the top of the pinna in a 45-year-old woman with a normally shaped skull. The catheter will first enter which of the following CSF-containing structures? - Trigone of the lateral ventricle - Temporal horn of the lateral ventricle - Body of the lateral ventricle - Foramen of Monro - Anterior horn of the lateral ventricle

Trigone of the lateral ventricle The ventricles are routinely accessed for a variety of elective and emergent neurosurgical procedures. There is a multitude of ventricular access points that have been described over the past century depending on the indication. The point that was described in the current case is Keen's point. In Keen's point, the burr hole is 2.5 cm above and 2.5 cm behind the top of the pinna followed by placement of the catheter perpendicular to the cortex aiming in a slight cephalic direction with advancing it by 4-5 cm or until reaching the ipsilateral trigone of the lateral ventricle. In the Kocher's point, the burr hole is 11 cm posterior and superior to the nasion (or 1 cm in front of the coronal suture) and 3 cm lateral to the midline followed by placement of the catheter perpendicular to the intersection of lines drawn from the ipsilateral medial canthus and the ipsilateral external auditory meatus with advancing it by 6 cm or until reaching the frontal horn of the ipsilateral lateral ventricle or just before the foramen of Monro. Regarding Sanchez's point, the burr hole is placed 2.7 cm lateral to the midline and 5.6 cm above the inion followed by placement of the catheter with an angle of 30° inferior toward the orbitomeatal plane and 5° lateral to the parasagittal plane with advancing it by 9-10 cm until reaching the ipsilateral temporal horn of the lateral ventricle. Finally, Frazier's point, the burr hole is 3 to 4 cm lateral to the midline and 6 cm superior to the inion followed by directing the catheter to a point that lies 4 cm above the contralateral medial canthus and passed 5 cm or until CSF is encountered. This is followed by removing the catheter stylet and the soft passing the catheter for an additional 5 cm placing it within the body of the lateral ventricle. References: Reference (1)Morone, Peter J MD, MSCI,; Dewan, Michael C MD, MSCI; Zuckerman, Scott L MD, MPH; Tubbs, R Shane PhD, PA-C; Singer, Robert J MD, MS. Craniometrics and Ventricular Access: A Review of Kocher's, Kaufman's, Paine's, Menovksy's, Tubbs', Keen's, Frazier's, Dandy's, and Sanchez's Points. Operative Neurosurgery: May 2020 - Volume 18 - Issue 5 - p 461-469 doi: 10.1093/ons/opz194 Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/31420653/ Reference (2) Lind CR, Tsai AM, Law AJ, Lau H, Muthiah K. Ventricular catheter trajectories from traditional shunt approaches: a morphometric study in adults with hydrocephalus. J Neurosurg. 2008 May;108(5):930-3. doi: 10.3171/JNS/2008/108/5/0930. PMID: 18447709. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/18447709/

(Bank #4) Which of the following is the most appropriate way to communicate postsurgical instructions to a non-English speaking family when a trained hospital interpreter is unavailable? -Utilizing the help of a bilingual friend -Non-bilingual physician but with adequate language skills -Utilizing Telephone Interpreter Services -Utilizing the help of a bilingual hospital staff -Utilizing the help of family member

Utilizing Telephone Interpreter Services According to the latest U.S Bureau Census, more than 25 million individuals in the U.S speak English less than very well. This patient population has generally less access to health care resources, and is at a higher risk for poorer outcomes following hospitalization, including higher rates of treatment related adverse events, increased length of stay and readmission. Language barrier between these patients and the medical team is one of the main reasons for such outcomes, highlighting the need and importance of professional interpretation. In most studies, language concordance, when a physician is fluent in a patient's preferred language, has been shown to improve these health-related outcomes. However, in the absence of a trained professional interpreter and a language concordant physician, utilizing telephone interpreter services provides the best mean of language interpretation in the health care setting. Using ad-hoc interpreters, such as untrained staff or family members can be acceptable only in emergency situations. References: Reference (1)Juckett G, Unger K. Appropriate use of medical interpreters. Am Fam Physician. 2014 Oct 1;90(7):476-80. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/25369625/ Reference (2) Diamond L, Izquierdo K, Canfield D, et al. A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019 Aug;34(8):1591-1606. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/31147980/

(Bank #4) Which of the following best describes the purpose of randomization in randomized-controlled clinical trials? -To eliminate bias in study subject enrollment -To ensure that confounders are similarly distributed among treatment groups -To ensure that subjects are equally distributed into treatment and placebo groups -To prevent subjects from knowing their treatment allocation -To prevent researchers from knowing subjects treatment allocation

To ensure that confounders are similarly distributed among treatment groups Randomization in clinical trials serves the purpose of distributing patient factors symmetrically across treatment arms. This ensures that underlying confounders are also evenly distributed and therefore less likely to bias trial results. This is related to, but distinct from, selection bias. Randomization helps to prevent selection bias among enrolled subjects but does not address selection bias related to the population from which subjects are recruited. Randomized clinical trials do not always require equal sample sizes among treatment arms, and randomization protocols can be modified to distribute subjects into asymmetric groups without introducing additional bias. Blinding procedures prevent study subjects from knowing whether they are in a treatment or placebo arm. Double-blinding also prevents researchers from learning this information. References: Reference (1)Rosenberger et al. Randomization: The forgotten component of the randomized clinical trial. Stat Med 2019 Jan 15; 38(1): 1-12. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/30047159/ Reference (2) Berger et al. A roadmap to using randomization in clinical trials. BMC Med Res Methodol 2021 Aug 16; 21(1): 168. Pubmed Web link https://pubmed.ncbi.nlm.nih.gov/34399696/

(Bank #4) A 40-year-old man is evaluated because of a two-week history of severe left-sided retro-orbital head pain and diplopia. He has no history of serious illness and takes no medications. Examination shows a miotic pupil on the left with decreased elevation and adduction of the left globe. Which of the following is the most likely diagnosis? -Ramsey-Hunt syndrome -Horner syndrome -Gradenigo syndrome -Tolosa-Hunt syndrome -Carotid cavernous fistula

Tolosa-Hunt syndrome The patient in this vignette presents with subacute diplopia and retro-orbital headache, the physical exam finding of miosis here with decreased adduction and elevation of the globe is consistent with oculomotor nerve dysfunction. The next step in developing a differential is to consider locations where a lesion may simultaneously cause CNIII and sympathetic dysfunction. The carotid-sympathetic plexus gives off sympathetic fibers to the orbit that travel through the superior orbital fissure, directly adjacent to cranial nerves III, IV, and VI as well as branches of the trigeminal nerve (lacrimal and frontal nerves branching from V1). Tolosa hunt syndrome is characterized by painful ophthalmoplegia, retro-orbital pain, with or without pupillary involvement due to non-specific inflammation of the cavernous sinus and superior orbital fissure. Thus, this syndrome is the correct answer as it can most easily explain the patient's physical exam findings. Gradenigo syndrome describes petrous apex osteomyelitis that is associated with retro-orbital pain and cranial nerve VI palsy and often occurs as a result of extension from severe otitis. Ramsey hunt syndrome is a herpes infection of the geniculate ganglion and is characterized by ear pain and vesicles in the external auditory meatus. Horner syndrome is characterized by ptosis, miosis, and anhidrosis and results from sympathetic chain dysfunction. Carotid-cavernous fistulas are direct vascular shunts between the carotid artery or adjacent branch and cavernous sinus. These present with retro-orbital pain, chemosis, pulsatile proptosis, ocular bruit, and vision loss. References: Reference (1)Iaconetta G, Stella L, Esposito M, Cappabianca P. Tolosa-Hunt syndrome extending in the cerebello-pontine angle. Cephalalgia. 2005 Sep;25(9):746-50. doi: 10.1111/j.1468-2982.2005.00924.x. PMID: 16109058. Reference (2) Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. doi: 10.1177/0333102417738202. PMID: 29368949.