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December 30, 2008 Allergy and Immunology Review Corner: Chapter 43 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 43: New Directions in Asthma Management Prepared by Nathanael Brady, D.O., University Hospitals, Cleveland, and Jennifer W. Mbuthia, M.D., Walter Reed Army Medical Center. 1. Current asthma guidelines emphasize which of the following as core elements in the management of childhood asthma? A. Family history B. Identification of possible food allergies C. Environmental control D. Side effects of medication 2. Based on the Asthma Predictive Index, which of the following is a major risk factor that could predict the persistence of asthma? A. Parental history of asthma or eczema B. Eosinophilia > 4 percent C. Wheezing with colds D. Presence of allergic rhinitis 3. Which statement is true in patients with difficult-to-control asthma? A. All patients consistently maintain an FEV1 below 70 percent. B. Caucasians are two times more likely to suffer complications compared to African-Americans. C. There is solid evidence that tools to measure airway inflammation (i.e.: exhaled NO, BAL) can reliably be applied clinically. D. Some patients may have substantial airway changes or persistent inflammation. 4. According to the 2007 NHLBI/NAEPP Asthma Guidelines, which of the following is true? A. Inhaled corticosteroids are part of preferred treatment only for children age 5 years and older. B. Because of the variability of asthma, the severity should be considered not only when initiating therapy, but when monitoring control, as well. C. For asthma assessments, current impairment and future risk should be considered. D. When assessing asthma control, there are two age groups: 0 to 5 years, and 6 years and older. 5. Which mediators are predominantly associated with airway inflammation? A. IL4, IL5, IL13, interferon gamma B. IL4, IL5, IL10, tumor necrosis factor C. IL4, IL5, IL10, IL13 D. IL4, IL10, IL13, interferon gamma 6. The best way to monitor response to asthma treatment is by assessing which of the following? A. Subjective symptoms primarily B. Both clinical control and pulmonary function C. Compliance with prescribed medication D. Frequency of hospitalization and emergency room visits 7. Which of the following statements about Omalizumab monoclonal anti-IgE therapy is true? A. IgE levels need to be followed every three to six months while on therapy. B. Omalizumab acts as a competitive inhibitor of IgE by binding to the high affinity Fc receptor on basophils and mast cells. C. Omalizumab is administered intramuscularly every two to four weeks. D. After discontinuing therapy, total IgE levels may take up to one year to return to pre-treatment levels. 8. In treatment of asthma in children less than 5 years old, which statement is true? A. Omalizumab therapy is approved for use in children as young as 4 years old. B. Assessment in this age group is primarily based on symptoms because pulmonary function cannot be reliably measured. C. Inhaled dry powder or metered dose fluticasone propionate is approved for use in children 2 years and older. D. Montelukast is the preferred treatment for intermittent asthma in children under 4 years old. 9. In the Childhood Asthma Management Program (CAMP) Research Group studies, which conclusion was drawn from their data? A. Inhaled nedocromil was shown to be as effective as inhaled corticosteroids in improving pre- and post-bronchodilator FEV1. B. Patients treated with inhaled nedocromil were shown to have a higher number of episode-free days, but there was no effect on number of urgent care visits or oral steroid courses. C. Medications used in the CAMP study completely eliminated the morbidity associated with asthma. D. The only detectable long-term effect of inhaled steroid therapy on growth was a transient reduction of growth velocity limited to 1cm in the first year of treatment. 10. According to the 2007 NHLBI/NAEPP Asthma Guidelines, which of the following is true? A. Patient’s asthma should be well-controlled for two to six weeks before stepping down therapy. B. When assessing asthma control, an exacerbation requiring one course of oral steroids per year defines asthma as Not Well or Poorly Controlled. C. Increasing use of short-acting beta agonist or use > two times per week for relief (not including EIB) indicates the need to step up treatment. D. When comparing impairment versus risk, number of emergency room visits within one year is a measurement of risk. Answers 1. C, page 465 Current Management of Childhood Asthma 2. A, page 468 Early Recognition 3. D, page 470 Difficult-to-Control Asthma 4. C, 2007 NHLBI Asthma Guidelines 5. A, page 470 New Medications 6. B, page 471 Box 43-3 Therapeutic Principle 7. D, Omalizumab package insert 8. B, page 466 and fluticasone propionate package insert 9. D, page 468 10. C, 2007 NHLBI Asthma Guidelines December 17, 2008 Allergy and Immunology Review Corner: Chapter 42 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 42: Promoting Adherence and Effective Self-Management in Patients with Asthma Prepared by Jennifer W. Mbuthia, M.D., and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. Which is not a risk of self-imposed drug holidays seen because of patient noncompliance? A. Waning drug action B. Hazardous rebound effects C. Overdose effects on resumption D. Tachyphylaxis 2. Which of the following is NOT true regarding asthma training and management? A. A brief verbal presentation is all that was needed to see improved appropriate prescribing patterns among ED residents. B. Many physicians have insufficient familiarity with guidelines, and others disagree or are unwilling to follow them. C. Studies of patients with asthma failed to reveal significantly improved outcomes when teaching and communication skills were taught to physicians. D. Physician training in recognizing and addressing patient distress was successful in reducing psychological stress among patients and lowered, short-term, their health utilization costs. 3. Which of the following is not a process in Acquisition and Performance of Asthma Self-Management? A. Goal selection B. Decision-making C. Self-reaction D. Outcome anticipation E. Information processing and evaluation 4. Which is not an acceptable strategy to use when decision-making your asthma management of a patient? A. Relying on memory B. Treating the attack in a stepwise manner C. Generating various treatment options and then selecting which is best for a particular attack D. Considering potential outcomes in terms of probability 5. What is a patient requisite for improved adherence? A. Basic understanding of asthma B. Trust in the physician C. Belief in one’s own ability to manage the disease D. All of the above 6. Processes involved in the self–management of chronic conditions, including asthma, do not include: A. Goal selection B. Self-reflection C. Information collection D. Information processing and evaluation E. Decision making 7. Which of the following does not appear to improve adherence and health outcomes for adults with asthma? A. Self monitoring by peak flow B. Self monitoring symptoms C. Regular medical review D. Repeated chest x-rays at regular intervals E. A written action plan 8. Physician requisites to enhance adherence do not include: A. A thorough understanding of asthma and its treatment B. Willingness to communicate with the patient C. Willingness to negotiate a shared treatment goal with the patient D. Acceptance of the fact that most patients take all of their medication E. Willingness to change prescribed treatment to improve adherence Answers 1. D, page 457 2. C, page 459 3. D, page 459 4. A, page 461 5. D, page 463 6. B, page 459 7. D, page 461 8. D, Box 42-2, page 462 December 3, 2008 Allergy and Immunology Review Corner: Chapter 41 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 41: Refractory Childhood Asthma: New Insight into the Pathogenesis, Diagnosis, and Management Prepared by Jennifer W. Mbuthia, M.D., and Christopher R. Martin, M.D., Walter Reed Army Medical Center. 1. What percent of patients have severe asthma that is often recalcitrant to available treatment modalities? A. 0-5 percent B. 5-10 percent C. 10-25 percent D. 25-40 percent 2. Which of the following is true regarding medical conditions that may contribute to, or mimic, refractory asthma? A. Concurrent vocal cord dysfunction (VCD) is identified in 30-40 percent of patients with severe asthma. B. Inflammation of the nose and sinuses is associated with lower airway hyperresponsiveness. C. GERD shows a prevalence of 10-25 percent in children with asthma. D. Most children with refractory asthma are not atopic, therefore allergen exposure does not contribute to airway inflammation. 3. Which of the following is NOT a measure of asthma short-term control? A. Exercise tolerance (with or without beta agonist pre-treatment) B. Frequency of burst oral corticosteroid use C. Frequency of daytime and nighttime symptoms D. Frequency of inhaled beta agonist use 4. When comparing asthma severity vs. asthma control, which statement is true? A. Asthma control appears to be reflective of the natural history of the disease. B. Asthma severity is more likely than asthma control to vary over time. C. Patients on high-dose inhaled corticosteroids often demonstrate poor asthma control. D. Studies show a significant correlation between asthma control and hospital contact for asthma exacerbation. 5. According to the NHLBI, which is one of the clinical criteria that may be used for diagnosis refractory asthma? A. Patient must be on daily oral corticosteroids B. History of frequent visits to emergency room for asthma exacerbations within previous 12 months C. A history of a previous respiratory failure/intubation, or near-fatal episode D. History of frequent pneumonia 6. Characteristics of children with severe asthma include which of the following? A. Many children with refractory asthma have FEV1 values greater than 70 percent of those predicted B. Children with refractory asthma are usually not atopic by skin testing C. Morbid obesity is seen in only 10 percent of children with refractory asthma D. Rhinosinusitis is seen in less than 50 percent of these patients 7. A risk factor for glucocorticoid-insensitive asthma in childhood is: A. FEV1 less than 70 percent predicted when asthma is diagnosed B. Caucasian ethnicity C. Need for oral GCs at an earlier age D. Wide swings in lung function (“chaotic” pattern) 8. Studies have shown GERD can affect airway function in all of the following ways EXCEPT: A. Vagally mediated reflexive alterations of respiratory function B. Impaired chemotaxis of early phase leukocytes due to pH changes C. Esophageal acidification can lead to the release of substance P and other tachykinins into the airway. D. Esophageal acidification has been associated with heightened nonspecific hyperresponsiveness of the airways. 9. Which cellular immunologic abnormality can be seen in glucocorticoid-resistant asthma? A. Decreased number of circulating T cells bearing surface activation markers (CD25) B. Increased eosinopenic response following administration of GCs C. Increased ability of GCs to inhibit mitogen-stimulated IL-2 and interferon-beta D. Failure of GCs to inhibit mRNA IL-4 expression from bronchoalveolar lavage lymphocytes 10. Which medications can delay theophylline clearance? A. Macrolides B. Penicillins C. Corticosteroids D. Cephalosporins Answers 1. B, page 444 2. B, pages 447-448 3. B, page 444 4. D, pages 444-445 5. C, page 445 6. A, page 445 7. C, page 445 8. B, page 447 9. D, page 448, Table 41-3 10. A, page 452 November 19, 2008 Allergy and Immunology Review Corner: Chapter 40 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 40: Asthma and the Athlete Prepared by Dr. Jennifer W. Mbuthia, Walter Reed Army Medical Center. 1. Which of the following is not a variable in Exercise-Induced Asthma (EIA)? A. Type and duration of exercise B. Core body temperature C. Ambient humidity D. Ambient temperature 2. According to Godfrey et al, which exercise listed has the largest effect on reduction in PEFR? A. Walking B. Running C. Bicycle riding D. Swimming 3. When comparing Exercise Induced Asthma (EIA) and Vocal Cord Dysfunction (VCD), which of the following statements is true? A. In VCD, symptoms appear abruptly but take longer to resolve than EIA. B. VCD is more likely to demonstrate expiratory wheeze and symptoms only during the daytime. C. EIA and VCD do not often occur together in children. D. Patients with VCD may appear to be refractory to standard EIA treatment. 4. Which of the following is a true statement about the “Osmotic Theory” to explain the pathophysiology of EIA? A. It suggests that the osmotic gradient caused by water loss induces cells to release mediators such as leukotrienes. B. The transfer of heat from the airway mucosa to the airways and back to the mucosa during hyperpnea is the primary trigger of bronchoconstriction. C. Accumulation of moisture in the lower airways during hyperpnea leads to an osmotic gradient. D. Breathing warm, humid air produces airway narrowing in the asthmatic patient. 5. Which of the following statements about treatment of EIA is true? A. Long-acting bronchodilators used 15 minutes before exercise have been used as effective single drug therapy. B. The use of devices that warm and humidify the air have become widely accepted by elite athletes with EIA. C. Montelukast is approved for use in EIA given 2 hours prior to exercise. D. The use of inhaled corticosteroids may provide 8 to 10 hours of relief in patients with mild intermittent asthma and EIA symptoms. Answers 1. B, page 436 2. B, pages 435-436 3. D, page 438 4. A, page 438 5. C, pages 440-442 November 5, 2008 Allergy and Immunology Review Corner: Chapter 39 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 39: Asthma Education Programs for Children Prepared by Dr. Jennifer W. Mbuthia, Walter Reed Army Medical Center. 1. Which of the following is not a barrier to compliance with asthma medication use? A. Parental reluctance to giving a child regular medication B. Absence of unpleasant taste and side effects contributes to medication overuse C. The complexity of some dosing schedules D. Parental difficulty with tobacco cessation 2. Effectiveness and efficiency of patient education in changing patient/parent behavior appear to depend on all of the following EXCEPT: A. The health care provider must have extended clinic visits in order to effectively communicate B. Whether health care providers have a thought-out plan for education C. Appropriate patient education tools that are readily available D. Whether health care providers focus their message on patients 3. In the “stages of self-regulation” model of asthma management, the stage when a family adheres to preventive medication but perceives fluctuations in asthma status as treatment failure is called: A. Asthma avoidance B. Asthma acceptance C. Asthma adherence D. Asthma control 4. Which of the following statements about literacy levels is true? A. Self-reported parental education attainment is an accurate predictor of reading ability B. Studies have shown the mean literacy skills among adults to be at a fourth-grade level or below C. When reading material is too simple, parents often become insulted and do not adhere to physician instructions D. Many people in the United States have low literacy levels and even lower comprehension of quantitative information 5. Peak expiratory flow can be erroneously high due to what circumstance? A. Building up pressure in the mouth before releasing it as a blast into the meter B. Submaximal effort C. Submaximal inspiration D. Incomplete seal between the patient’s lips and the mouthpiece of the meter Answers 1. B, page 427 2. A, page 428 3. C, page 429 4. D, page 429 5. A, page 432 October 22, 2008 Allergy and Immunology Review Corner: Chapter 38 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 38: Asthma in Older Children Prepared by Drs. Bret R. Haymore and Jennifer W. Mbuthia, Walter Reed Army Medical Center. 1. Which statement about asthma is true? A. By puberty, asthma becomes more prevalent among males. B. There is no set genetic pattern that predicts presence of asthma or defines its severity. C. There is a strong association between socioeconomic status and both asthma development and disease severity. D. Early exposure to endotoxin growing up on a farm with close exposure to farm animals is associated with an increased prevalence of asthma. 2. When reading pulmonary function tests in children: A. FEV1 is more sensitive in identifying airflow obstruction than FEV1/FVC which has more intrapatient variability. B. Patients may demonstrate increased TLC with normal or decreased RV. C. Patients with VCD without asthma often demonstrate intrathoracic airway obstruction with blunting of the inspiratory loop. D. Most children with asthma have FEV1 within the normal range, even in the presence of severe disease. 3. Which statement about rhinitis and asthma in children is true? A. Perennial rhinitis in nonatopic children can be a risk factor for more severe asthma. B. Most rhinitis that worsens asthma is perennial. C. Topical nasal steroids therapy has been shown to exacerbate the BHR during the grass pollen season. D. Pharmacologic treatment of rhinitis has been shown to delay the diagnosis and management of asthma. 4. When comparing VCD and asthma: A. Cough is an uncommon finding in VCD. B. Exercise is a frequent precipitant in both. C. Throat tightness, but not chest tightness, is a common complaint in patients with VCD. D. Nocturnal symptoms are common in VCD. 5. Allergic sensitization to which mold has been associated with a marked increased risk of sudden, severe asthma episodes in children? A. Aspergillus B. Alternaria C. Cladosporium D. Penicillium 6. Which of the following is true regarding asthma and obesity: A. The relationship between asthma and obesity is greater for adolescent females than males. B. The relationship between asthma and obesity is greater for adolescent males than females. C. The relationship between asthma and obesity is the same for adolescent males and females. D. There is no relationship between asthma and obesity in adolescents. 7. With regard to low-moderate doses of inhaled corticosteroid use during childhood and growth: A. Even low doses, such as the equivalent of 100 mcg of fluticasone propionate per day, have significant effects on growth. B. The effects are dependent on which inhaled corticosteroid is used. C. The effects appear to be transient reduction in growth velocity early in the treatment course rather than reductions in attained adult height. D. Inhaled corticosteroids do not affect growth, regardless of dose. 8. The selective leukotriene receptor antagonists montelukast and zafirlukast inhibit which receptor? A. BLT1 B. BLT2 C. CysLT1 D. CysLT2 9. The onset of action of formoterol is: A. 3 minutes B. 13 minutes C. 30 minutes D. 60 minutes 10. Which of the following is most likely to increase the serum levels of theophylline: A. Ceftazidime B. Clarithromycin C. Penicillin D. Phenytoin Answers 1. B, pages 405-406 2. D, page 411 3. A, page 412 4. B, pages 412-413 5. B, page 411 6. A, page 407 7. C, pages 416-417 8. C, page 417 9. A, page 417 10. B, page 418 October 8, 2008 Allergy and Immunology Review Corner: Chapter 37 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 37: Inner City Asthma Prepared by Dr. Jennifer W. Mbuthia at Walter Reed Army Medical Center. 1. Which is true about asthma mortality in the U.S.? A. Deaths from asthma occur predominantly in rural settings. B. The aging population accounts for the steady increase in asthma mortality. C. Asthma mortality rates are more than three-times greater for African Americans than for Caucasians. D. In urban settings, lower income populations are at no higher risk for death from asthma than higher income populations. 2. Which factor most likely contributes to the increase in asthma in the inner city? A. Genetic changes B. Higher levels of cockroach allergens in inner city homes C. Increased amount of cat allergen exposure D. Increased exposure to indoor aeroallergens 3. The Institute of Medicine concluded what two exposures showed sufficient evidence to establish an etiologic role in asthma? A. Tobacco smoke exposure and dust mite B. Tobacco smoke exposure and cockroach C. Dust mite and cockroach D. Cockroach and air pollution 4. Which statement about indoor allergens is true? A. Risk of sensitization is related to the concentration of cockroach allergen in the kitchen. B. Cockroach allergy has been found to be a significant factor in the morbidity of inner city asthma. C. Exposure to dust mite was shown to significantly affect asthma hospitalizations. D. There has been a 25-percent increase in cockroach and dust mite allergens in inner city homes during the past 25 years. 5. What is the single most significant risk factor for the development of asthma? A. Lower socioeconomic status B. Ethnicity C. Atopy D. Tobacco smoke exposure 6. Which statement about asthma and ethnic minorities is true? A. Little is known about the prevalence and morbidity of asthma in inner city Asian populations. B. In the U.S., asthma prevalence, hospitalization, and mortality rates are highest for Hispanics of Mexican ancestry. C. In the U.S., asthma prevalence and rates of hospitalization among Hispanics of Puerto Rican ancestry are considerably lower than other Hispanic populations. D. After adjusting for socioeconomic factors and other confounding variables, there is no difference in asthma morbidity or prevalence associated with race/ethnicity. 7. In the U.S., which is true of populations most affected by asthma? A. The prevalence of asthma increased by over 150 percent in children 5 to 14 years old. B. The greatest proportionate rise in asthma prevalence has occurred in children. C. Low socioeconomic status is directly correlated with asthma prevalence. D. The greatest increases in asthma prevalence among ethnic minorities have been among African-Americans and Mexican-Americans. 8. Accurate measurements of asthma prevalence in inner city populations in the U.S. are problematic due to which reasons? A. Access to health care make answering standardized questionnaires an obstacle B. The nonspecific nature of bronchial provocation tests and the lack of uniform definition of asthma make measurements difficult C. Lack of funding to support studies to accurately survey asthma prevalence in inner cities D. The variable nature of health care access at different ages makes it difficult to assess disease prevalence in these age groups 9. What is identified by the Institute of Medicine as the single most important barrier to health care services for children in the United States? A. Poor access to asthma specialists B. Inadequate education on asthma care and medication use C. Difficulty accessing their primary care physician for acute medical visits D. Lack of adequate health insurance 10. Which is a characteristic of inner-city asthma? A. Deficiencies in the quality of preventive medical care for inner-city inhabitants plays a major role in increased asthma mortality, but is not a factor in asthma morbidity. B. There is consistent association between air pollutant levels and asthma activity. C. Sensitization and subsequent re-exposure to high levels of certain allergens may contribute to asthma morbidity. D. Exposure to pollutants like diesel particles and tobacco smoke are not significant in the etiology of asthma. Answers 1. C, page 393 2. B, page 394 3. A, pages 394-395 4. B, page 394 5. C, page 395 6. A, page 396 7. B, page 392 8. B, page 393 9. D, page 397 10. C, page 398 September 24, 2008 Allergy and Immunology Review Corner: Chapter 36 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 36: Special Considerations for Infants and Young Children Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center. 1. In an infant or child with recurrent wheeze, consideration for controller therapy should be considered if: 2. Which of the following is true in regard to exhaled nitric oxide (eNO): 3. The single most important factor for infants/children in development of persistent wheeze and subsequent asthma appears to be: 4. Regarding nebulized budesonide in children with asthma: 5. Which of the following inhibits both the early- and late-phase allergic response: 6. For a 4-year-old patient with mild persistent asthma in whom the parents are insistent that corticosteroids not be used, the most desirable alternative therapy would be: 7. In regard to leukotriene modifying agents: 8. In regard to long-acting inhaled beta-agonists in children: 9. Which of the following is the most likely to inhibit clearance of theophylline: 10. All of the following are recommended nonpharmacologic interventions for asthma EXCEPT: Answers September 10, 2008 Allergy and Immunology Review Corner: Chapter 35 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 35: Infections and Asthma Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center. 1. The most common cause of asthma exacerbations in children is: A. Adenovirus B. Influenza C. Rhinovirus D. Respiratory syncytial virus 2. In relation to respiratory syncytial virus (RSV): A. In early childhood, very few children are infected by RSV but those who are tend to develop severe symptoms. B. Those who develop RSV bronchiolitis are destined to develop asthma. C. Those who develop severe RSV bronchiolitis as an infant are very likely to have wheezing symptoms that persist into adulthood. D. RSV bronchiolitis, particularly in the first year of life, is a significant risk factor for subsequent wheezing in the first decade of life. 3. In relation to asthma, pathogenic Mycoplasma species have been most associated with: A. Being a direct cause of asthma B. Chronicity of disease C. Resolution of disease by adolescence D. They have no relation to asthma 4. The host cell that appears most critical in the pathogenesis of viral respiratory infections and initiation of the innate immune response is: A. Epithelial cell B. Airway smooth muscle cell C. Macrophage D. Neutrophil 5. Select the most correct statement in relation to rhinovirus infection: A. Rhinovirus can replicate in the upper airway only. B. Rhinovirus can replicate in the lower airway only. C. Rhinovirus cannot be detected in lower airway cells. D. Rhinovirus can replicate in the upper and lower airway. 6. Which statement about virally-induced wheezing is true? A. Inhaled corticosteroid (ICS) treatment after RSV bronchiolitis clearly decreases the development of chronic lower airway symptoms. B. Chronic treatment with ICS clearly reduces the frequency and severity of intermittent virus-induced wheezing episodes. C. Treatment of virus-induced asthma exacerbations with oral corticosteroids clearly has no demonstrated benefit. D. ICS appear to improve asthma symptoms when administered for acute exacerbations of asthma. 7. In regards to developing therapies for prevention of RSV and rhinovirus infections: A. Developing a vaccine to cover most serotypes of rhinovirus appears feasible. B. RSV vaccination should be given to children at high risk for asthma before age 1. C. One promising approach is to hinder binding to the cellular receptors for these viruses (e.g. soluble ICAM or capsid-binding agents). D. Treatment with Palivizumab in patients at risk for RSV reduces the incidence of asthma. Answers 1. C, page 367 2. D, page 366 3. B, page 368-369 4. A, page 369-70, Box 35-1 5. D, page 372 6. D, page 374-5, Box 35-3 7. C, page 375 August 27, 2008 Allergy and Immunology Review Corner: Chapter 34 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 34: Functional Assessment of Asthma Prepared by Dr. Jennifer W. Mbuthia, Walter Reed Army Medical Center. 1. A time-based recording of expired volume is called: A. Maximal inspiratory flow-volume curve B. Maximal expiratory flow rate C. Peak flow D. Spirogram 2. Which statement about asthma is true? A. FEV1 is diminished and FEF 25-75 remains stable B. Loss of clinical signs of airway obstruction does not mean there has been physiologic recovery C. Use of peak flow at home as a method of monitoring flow rate is highly inaccurate and too costly D. Normal diurnal variation is usually less that 20 percent 3. Which measure is usually increased the most during an asthma exacerbation? A. Residual volume (RV) B. Functional residual capacity (FRC) C. Total lung capacity (TLC) D. Vital capacity (VC) 4. The characteristic blood gas pattern during an acute asthma exacerbation is: A. Hypoxia with metabolic acidosis B. Hypoxia with respiratory alkalosis C. Hypercapnea with respiratory acidosis D. Hypercapnea and hypoxia, without change in pH 5. Which statement about acute asthma exacerbation is true? A. A normal PaCO2 is reassuring since hypercapnea is not likely to occur B. Hypercapnea is likely to occur even with modest degrees of obstruction C. A low PaCO2 and respiratory acidosis are commonly seen D. A normal or elevated PaCO2 is cause for concern 6. Although they can present with clinical symptoms similar to asthma, children with bronchiolitis obliterans usually: A. Do not demonstrate obstructive pattern on spirometry B. Show no evidence of hyperinflation C. Lack significant reversal of airway obstruction with therapy such as corticosteroids D. Have a normal chest X-ray 7. Children with interstitial lung disease usually present with which findings? A. Hyperinflated lungs B. Normal FEV1 and normal FEV1/FVC ratio C. Normal FEV1 and decreased FEV1/FVC ratio D. Decreased FEV1 and normal FEV1/FVC ratio 8. Which of the following is true about vocal cord dysfunction (VCD)? A. Truncation of the inspiratory portion of the flow-volume loop may be found B. Paradoxical abduction of the vocal cords during expiration confirms the diagnosis on laryngoscopy C. Maximal expiratory and inspiratory flow-volume loop resembles a variable intrathoracic obstruction D. Treatment is accomplished primarily with inhaled corticosteroids 9. In regard to home management of acute asthma exacerbation, which of the following is true? A. Serial measurements of peak flow before and after therapy are useful ways to assess severity of exacerbation and response to treatment. B. Home bronchodilator therapy can be safely repeated every 8 hours if peak flows are less than 80 percent of the patient’s personal best. C. A good response is commonly defined as a PEFR of at least 50 percent of personal best, with response sustained for 4 hours. D. Beta agonist therapy can be given with either a metered dose inhaler or by nebulization with 5ml of a 5mg/ml solution in 3ml of normal saline. 10. Which of the following findings on physical exam is considered an “ominous finding” during an acute asthma attack? A. Pulsus paradoxus of greater than 10 mm Hg during expiration B. Tachypnea C. A “quiet chest” in an anxious patient struggling to breathe D. Use of accessory muscles of respiration Answers 1. D, page 358 2. B, pages 358-359 3. A, page 359 4. B, page 359 5. D, page 360 6. C, page 361 7. D, page 362 8. A, page 362 9. A, page 363 10. C, page 362 August 13, 2008 Allergy and Immunology Review Corner: Chapter 33 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 33: Guidelines for Treatment of Asthma Supplemented by the National Asthma Education and Prevention Program (NAEPP), Expert Panel Report 3 (EPR-3) Guidelines Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center 1. A six-year-old patient is in your office for an initial evaluation. She has experienced numerous recurrent cough and wheezing episodes during the last year, two of which have required oral corticosteroids. Although, on average, the patient has symptoms less than two days a week and spirometry is normal, this patient’s asthma severity would be classified as: A. Intermittent B. Mild persistent C. Moderate persistent D. Severe persistent 2. A 26-year-old patient is seen for the first time. He has a prolonged history of recurrent cough and wheezing episodes — more than two days a week, but not daily. On spirometric testing, the FEV1 is 70 percent. This patient’s asthma severity would be classified as: A. Intermittent B. Mild persistent C. Moderate persistent D. Severe persistent 3. With regard to the stepwise treatment of asthma: A. Long-acting beta agonists can be used as monotherapy in mild persistent asthma. B. There is no role for treatment with omalizumab. C. There is no role for treatment with allergen immunotherapy. D. Inhaled corticosteroids can be used in any step of therapy for persistent asthma. 4. From the current (EPR-3) guidelines, in regard to pulmonary function testing in the diagnosis of asthma: A. It is recommended that FEV1, FEV6, FVC, FEV1/FVC be measured before and after a short-acting bronchodilator. B. Significant reversibility is defined as an increase in FEV1 of >200 mL or 12 percent from baseline after a short-acting bronchodilator. C. Some studies indicate that an increase 15 percent of the predicted FEV1 after short-acting bronchodilator may help separate asthma from COPD. D. Measurement of peak flow is comparable to spirometry and thus can be used in the diagnosis of asthma. 5. If the patient is sensitive to an animal, the treatment of choice is removal of exposure from the home. If this is not possible or acceptable, then it is recommended: A. Keep the pet out of the patient’s bedroom. B. Keep the patient’s bedroom door closed as much as possible. C. Remove upholstered furniture and carpets from the home, or isolate the pet from these items to the extent possible. D. All of the above. 6. Recommended measures to control dust mite exposure include all of the following EXCEPT: A. Encase the mattress in an allergen-impermeable cover. B. Encase the pillow in an allergen-impermeable cover or wash it weekly. C. Obtain a high-efficiency air filter for the home. D. Wash the sheets and blankets on the patient’s bed weekly in hot water. 7. In regard to environmental control of asthma, all of the following are recommended actions to modify indoor air EXCEPT: A. Cleaning air ducts of heating/air conditioning systems is clearly beneficial. B. Use of a dehumidifier to reduce dust mite levels in areas where the humidity of the outside air remains high for most of the year. C. Avoid exertion or exercise outside when levels of air pollution are high. D. Avoid exposure to gas stoves that are not vented to the outside and fumes from wood-burning fireplaces. 8. A 35-year-old Caucasian male with history of asthma has experienced more symptoms during the past several months. Most predominantly is nocturnal cough and a brackish taste in the oropharynx. The patient’s physical exam is normal and hi BMI is 22. Your best advice to the patient would be: A. Immediate skin testing for Aspergillus B. Avoiding food/drink three hours prior to sleep and elevating head of bed 8 inches C. Weight loss D. Laryngoscopy 9. A six-year-old patient with asthma is seen in follow-up. He is experiencing symptoms less than two days a week, having nighttime awakenings three times a month and on spirometric testing has a FEV1 >80 percent. This patient’s asthma control would be classified as: A. Well controlled B. Not well controlled C. Very poorly controlled D. Cannot determine from information given 10. A 26-year-old patient is seen in follow-up for asthma. His activity has been limited, and he is utilizing his short-acting bronchodilator daily. His Asthma Control Test (ACT) score is 13. This patient’s asthma control would be classified as: A. Well controlled B. Not well controlled C. Very poorly controlled D. Cannot determine from information given Answers From the the National Asthma Education and Prevention Program (NAEPP), Expert Panel Report 3 (EPR-3) Guidelines. 1. B, NAEPP, EPR-3, Fig 4-1b & Fig 4-5 2. C, NAEPP, EPR-3, Fig 4-1b & Fig 4-5 3. D, NAEPP, EPR-3, Fig 4-1b & Fig 4-5 4. A, NAEPP, EPR-3, pages 43-44 5. D, NAEPP, EPR-3 page 170 6. C, NAEPP, EPR-3 page 171 7. A, NAEPP, EPR-3, pages 175-6 8. B, NAEPP, EPR-3, pages 201-202 9. B, NAEPP, EPR-3, page 310 10. C, NAEPP, EPR-3, page 344 July 30, 2008 Allergy and Immunology Review Corner: Chapter 32 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al Chapter 32: Immunology of the Asthmatic Response Prepared by Drs. Jennifer W. Mbuthia, Walter Reed Army Medical Center, and Gregory Metz, Duke University. 1. The cytokine that plays a central role in the differentiation of Th2 lymphocytes is: A. IL-1 B. IL-2 C. IL-4 D. IL-21 2. The common gamma chain is shared by cell surface receptors for various interleukins including: A. IL-1 B. IL-2 C. IL-3 D. IL-5 3. Overexpression of the TH2-associated transcription factor GATA-3 induces ________ and inhibits ________ production. A. IL-1, INF-gamma B. IL-4, INF-gamma C. INF-gamma, IL-1 D. INF-gamma, IL-4 4. The immediate-phase response of asthma is IgE dependent and mediated by which cells? A. Eosinophils B. Mast cells C. Basophils D. Activated Th2 cells 5. Bronchial hyperresponsiveness can be induced independent of eosinophilic inflammation through which Th2 cytokine? A. IL-3 B. IL-5 C. IL-13 D. IL-25 6. In regards to antigen-presenting cells in the lung, the most potent stimulator of naïve T cells is: A. Alveolar macrophages B. Non-alveolar macrophages C. B cells D. Dendritic cells 7. Plasmacytoid preDC2 (dendritic cells) express Toll-like receptor 9, which responds to: A. Bacterial flagellin B. LPS C. Unmethylated CpG motifs D. Viral hemagglutinin 8. Which chemokine receptor is found on BOTH basophils and eosinophils? A. CCR2 B. CCR3 C. CCR4 D. CXCR4 9. CCR4 is found on Th2 cells. Expression of the CCR4 ligands MDC and ________ is up-regulated in epithelial cells after allergen challenge. A. RANTES B. Eotaxin C. TARC D. I-309 10. Which of the following is true about ICOS (inducible T cell co-stimulator)? A. ICOS is preferentially expressed on Th1, but not Th2, cells. B. In the absence of ICOS signaling, production of IL-4 and IgE is greatly reduced. C. ICOS binds B7-1 and B7-2 expressed on B cells. D. ICOS is preferentially expressed on naïve T cells. Answers 1. C, page 337 2. B, page 339 The common gamma chain is shared by cell surface receptors for IL-2, IL-4, IL-7, IL-9, IL-15 and IL-21. 3. B, page 339 4. B, page 339 5. C, page 341, box 32-1 6. D, page 341 Dendritic cells line the mucous membrane airways and are the most potent APC stimulators of naïve T cells. 7. C, page 341 8. B, page 343 Basophils express CCR2, 3, and 4, while eosinophils express CCR3, CXCR4, and VLA-4. 9. C, page 343 Th2 cells express both CCR4 and CCR8, however, after allergen challenge, only the CCR4 ligands MDC and TARC are up regulated, NOT the CCR8 ligand I-309. 10. B, page 341-342 ICOS is expressed on activated T cells and germinal center T cells, binding to the ICOS ligand (ICOSL or B7RP-1), which is a B7-related protein. ICOS is preferentially expressed on Th2, but not Th1, cells. July 16, 2008 Allergy and Immunology Review Corner: Chapter 31 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al Chapter 31: Chronic Cough Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center. 1. With regard to chronic cough: A. Chronic cough is defined as lasting longer than two weeks. B. The cause of chronic cough cannot be determined in most patients. C. Post-nasal drip is the most common cause of chronic cough. D. Bacterial infections are the most common cause of acute cough. 2. The most essential consideration for the etiology of cough in the neonatal period is: A. Asthma B. Cardiac or pulmonary congenital abnormality C. Gastro-esophageal reflux D. Immunodeficiency 3. With regard to cough-variant asthma: A. Asthma most often presents as cough alone. B. The symptom of cough alone almost always responds to asthma medications. C. A prolonged history of cough with evidence of airway hyperresponsiveness without concurrent wheezing may be considered to be cough-variant asthma. D. From the literature, there is no debate as to whether cough-variant asthma is a real clinical entity. 4. Bronchiolitis is a common cause of cough in children. The most common cause of epidemic bronchiolitis is: A. Adenovirus B. Influenza C. Parainfluenza type 3 D. Respiratory syncytial virus 5. Which of the following is approved for the prevention of respiratory syncytial virus in children younger than 24 months? A. Adalimumab B. Daclizumab C. Efalizumab D. Palivizumab 6. The major source of disease transmission for Bordetella pertussis to young children is: A. Infants B. Other young children C. Adolescents and adults D. Administration of acellular pertussis vaccine 7. A child with cough, poor weight gain, and abnormal stools most likely has: A. Aspiration syndrome B. Cystic fibrosis C. Gastroesophageal reflux D. Vascular ring 8. An adolescent female athlete presents with cough and shortness of breath, most often associated with exertion. Chest radiograph, spirometry, and methacholine challenge are normal. The next best test is: A. Spirometry pre- and post- bronchodilator B. Skin prick testing C. Laryngoscopy D. Nasal smear 9. The most frequent cause of pneumonia in children from 5 to 15 years of age is: A. Mycoplasma pneumoniae B. Bordetella pertussis C. Corynebacterium diphtheriae D. Respiratory syncytial virus 10. In a child with cough, chronic sinusitis, and abnormal stools, the most useful test in evaluation would be: A. Chest radiograph B. Electrocardiogram C. Skin prick testing D. Sweat chloride Answers 1. C, page 321 & Box 31-1 2. B, pages 321-322 3. C, page 325 4. D, page 326 5. D, page 326 6. C, page 327 7. B, page 331 8. C, page 331 9. A, page 327 10. D, page 331, Fig 31-1 July 2, 2008 Allergy and Immunology Review Corner: Chapter 30 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al Chapter 30: Sinusitis Prepared by Drs. Jennifer W. Mbuthia, Walter Reed Army Medical Center, and Tracy Pitt, Winnipeg Children’s Hospital. 1. With respect to sinus development in childhood: A. Maxillary and ethmoid sinuses become radiographically visible from 7 to 15 years of life. B. Frontal and sphenoid sinuses become radiographically visible from 1 to 2 years of life. C. Maxillary and sphenoid sinuses become radiographically visible from 7 to 15 years of life. D. Maxillary and ethmoid sinuses become radiographically visible from 1 to 2 years of life. 2. The most common recovered pathogen responsible for acute sinusitis is: A. Haemophilus influenzae B. Streptococcus pneumoniae C. Moraxella catarrhalis D. Staphlococcus aureus 3. The cell type(s) playing a central role in the pathogenesis of chronic sinusitis: A. Th2 cells B. Th1 cells C. Th2 cells and eosinophils D. Eosinophils 4. Which is true of chronic sinusitis? A. It is defined as symptoms lasting more than 6 weeks. B. Invasive disease is common in children. C. S. aureus and anaerobes tend to be disproportionately associated with protracted, severe, or complicated disease. D. Usually less than 15 percent of children with chronic sinusitis have positive cultures of sinus aspirates. 5. Which of the following statements about the risk factors for chronic sinusitis is true? A. Allergic rhinitis and inhalant allergen sensitization are not associated with sinusitis in children. B. Chronic sinusitis and nasal polyps are hallmark features of cystic fibrosis. C. IVIG therapy should be considered to treat chronic sinusitis in addition to IV antibiotics. D. Studies show siblings of patients with CF have a significantly higher number of episodes of chronic sinusitis. 6. Which of the following statements concerning the American College of Radiology recommendations on radiographic imaging for sinusitis is true? A. Coronal sinus CT is recommended when imaging patients with chronic sinusitis. B. Sagittal sinus CT is recommended when imaging patients with chronic sinusitis. C. The diagnosis of acute and chronic sinusitis should be made on the basis of imaging studies and not made clinically due to increased antibiotic resistance. D. Plain radiographs of the sinuses are discouraged, especially in children under 4 years of age. 7. Intracranial complications from sinusitis are primarily the result of disease in which sinus? A. Ethmoid B. Maxillary C. Sphenoid D. Frontal 8. Which of the following is/are the most likely complication(s) of maxillary sinusitis? A. Mucocele B. Orbital cellulitis C. Orbital cellulitis and preseptal cellulitis D. Cavernous sinus thrombosis 9. Which of the following is LEAST effective in treating acute sinusitis secondary to Moraxella catarrhalis ? A. Amoxicillin-clavulanate B. Cefuroxime C. Clarithromycin D. Clindamycin 10. Consider sinus aspiration for microbiological identification and targeted antimicrobial therapy if disease is: A. Associated with sinus pain and pressure B. In immunocompromised patient C. In patient with concurrent acute otitis media D. Poor response to first-line antibiotics and before initiation of broad spectrum antibiotics Answers 1. D, page 309 2. B, page 310 3. C, page 311 4. C, page 311 5. B, page 312 6. A, page 314 7. D, page 314 8. A, page 314, Table 30-3 9. D, page 316 10. B, page 315 June 18, 2008 Allergy and Immunology Review Corner: Chapter 29 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al Chapter 29: Otitis Media Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center 1. Which of the following statements about pediatric otitis media (OM) is TRUE? A. In childhood, girls are affected more than boys B. White children are affected more than any other ethnic group C. The best-defined risk factor for OM is preceding viral infection D. Compared with bottle-feeding, breast-feeding is associated with a decreased risk of acute OM 2. Which of the following regarding eustachian tube (ET) structure and function is TRUE? A. The ET provides an anatomic communication between the middle ear and ethmoid sinus, through which it drains B. The lining of the ET is stratified squamous epithelium C. The physiologic function of the ET is unknown D. Active opening of the ET is accomplished through contraction of the tensor veli palatine 3. The most common infectious agent in all age groups for otitis media is: A. Streptococcus pneumonia B. Haemophilus influenza C. Moraxella catarrhalis D. Streptococci (group A) 4. In regards to the relation between allergy and otitis media, which of the following is TRUE? A. No study has demonstrated a link between allergic disease and otitis media with effusion B. There is some evidence for allergic rhinitis contributing to chronic otitis media with effusion in the setting of nasal obstruction in some patients C. There is a definitive association between allergic rhinitis and acute otitis media D. The middle ear mucosa is a common site as an allergic ‘shock organ’ via IgE antibody 5. First line therapy for acute otitis media is: A. Amoxicillin B. Amoxicillin-clavulanate C. Azithromycin D. Cefuroxime 6. If a middle-ear effusion has persisted more than three months, the most important intervention to consider is: A. A course of antibiotics B. Allergy skin testing C. Audiometry D. No intervention is necessary 7. In a child who has received all the appropriate vaccinations and has had four documented cases of acute otitis media in the last 12 months, what would be the most appropriate next step? A. Give booster of pneumoccal and influenza vaccines B. Allergy skin prick testing C. Adenoidectomy and/or tonsillectomy D. Serum immunoglobulins Answers 1. C, page 298-99 2. D, page 299-300 3. A, page 302, Table 29-4 4. B, page 302; Box 29-1 5. A, page 304 6. C, page 304; Box 29-1 7. D, page 304 June 4, 2008 Allergy and Immunology Review Corner: Chapter 28 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al Chapter 28: Allergic Rhinitis
May 21, 2008 Allergy and Immunology Review Corner: Chapter 27 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 27: Immunotherapy for Allergic Disease Prepared by Drs. Bret R. Haymore, Walter Reed Army Medical Center, and Kusum Sharma, Penn State University at Milton Hershey Medical Center. May 7, 2008 Allergy and Immunology Review Corner: Chapter 26 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 26: Indoor Allergen Environmental Control Prepared by Drs. Jennifer W. Mbuthia, Walter Reed Army Medical Center, and Thomas G. Sternberg, Le Bonheur Children’s Medical Center. April 23, 2008 Allergy and Immunology Review Corner: Chapter 25 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 25: Indoor Allergens Prepared by Drs. Bret Haymore and Jiun Yoon, Walter Reed Army Medical Center. April 9, 2008 Allergy and Immunology Review Corner: Chapter 24 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 24: Outdoor Allergens Prepared by Dr. John Kemp, Penn State University at Milton Hershey Medical Center; and Drs. Jennifer Mbuthia and Bret Haymore, Walter Reed Army Medical Hospital. 1. Which grass pollen is designated as Phl p? 2. Which of the following is a continuous volumetric sampler that is useful for identifying aeroallergens, in particular small fungal spores? 3. Which of the following is true regarding pollens? 4. A patient living in Texas complaining of rhinoconjuctivitis symptoms in December and January is most likely allergic to: 5. Allergenic grass pollens in the United States: 6. Which of the following pairs of tree pollen would be expected to show the greatest in vitro cross-reactivity? 7. In which area of the United States would you have the least likelihood to become sensitized to ragweed? 8. Which of the following has been associated with sudden severe asthma episodes in children and young adults? 9. Forest workers in the Pacific Northwest have demonstrated specific sensitization to: 10. Which of the following is a by-product of atmospheric reactions requiring nitrogen oxides, sunlight & volatile organic compounds; the levels of which when >0.11ppm are associated with increased emergency room visits for asthma in school children? Answers March 26, 2008 Allergy and Immunology Review Corner: Chapter 23 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 23: In Vivo Testing for Immunoglobulin E – Mediated Sensitivity Prepared by Dr. Bret R. Haymore, Walter Reed Army Medical Center 1. In comparison to intradermal skin testing, skin prick testing is: 2. In comparison to skin prick testing, intradermal skin testing: 3. In considering the reactivity of the skin in different areas of the body: 4. The typical volume used for intradermal skin testing is: 5. Regarding the safety of skin testing: Answers March 12, 2008 2. The only validated means in the United States for detection of latex-specific IgE in patients with suggestive clinical history of latex allergy is: 3. Elevated quantitative IgE antibody levels to selected foods (milk, egg, fish, and peanut): 4. Beta-tryptase is considered a measure of ________, and non-diseased individuals typically have Beta-tryptase levels less than _______. 5. Systemic mastocytosis should be suspected if the baseline total serum tryptase level exceeds: 6. When evaluating for extrinsic allergic alveolitis or hypersensitivity pneumonitis, the classic precipitin assay detects: 7. Which of the following is not routinely tested in evaluating indoor aeroallergen surface dust? 8. The four molds that constitute the majority of indoor molds are: 9. Low levels of venom-specific IgG are associated with which of the following: 10. Competitive inhibition of IgE RAST specific for Polistes wasp venom (PWV) is used for: Answers February 27, 2008
February 13, 2008
January 30, 2008
January 16, 2008 January 2, 2008 Chapter 17 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al. Chapter 17: Intravenous Immune Serum Globulin Therapy Prepared by Drs. Bret R. Haymore and Jennifer W. Mbuthia, Walter Reed Army Medical Center. 1. Which of the following steps in intravenous immunoglobulin preparation is used primarily for viral inactivation: A. Cold ethanol fractionation B. Addition of amino acids C. Treatment with detergent D. Chon-Oncley modification 2. Older intramuscular formulations of parenteral immunoglobulin were not able to be administered intravenously because of serious reactions that were thought to occur due to aggregates of IgG. In modern processing, what is added to intravenous immunoglobulin preparations to stabilize the IgG molecules from reaggregation? A. Addition of solvents B. Anti-idiotype antibodies C. Antibodies to the Fc portion of IgG to prevent complement activation D. Sugars and amino acids 3. Which of the following is NOT an indication for IVIG treatment: A. Kawasaki disease B. Transient hypogammaglobulinemia of infancy C. Autosomal recessive hyper-IgM syndrome D. Severe combined immunodeficiency syndrome 4. Generally, it should take about what length of time to reach steady state of serum IgG when administering intravenous immunoglobulin: A. 1 month B. 3 months C. 6 months D. 9 months 5. A greater risk of renal complications related to intravenous immunoglobulin has been noted with what component of the product? A. Sodium Chloride B. Amino acids C. Sucrose D. Albumin 6. Which of the following is true: A. IgE antibodies to IgA have not been identified in any patients after treatment with IVIG B. Patients with antibodies against IgA should never be given any IVIG product C. All IVIG products contain the same IgA content D. IgE antibodies to IgA have been reported to cause severe transfusion reactions in IgA-deficient patients 7. The most appropriate dose of IVIG for patients with autoimmune disorders would be: A. 200mg/kg for 4-5 days B. 400-600mg/kg every four weeks C. 1-2g/kg over 1-2 days D. Large enough dose to maintain serum trough levels of IgG >500mg/dL 8. For which of the following conditions has IVIG demonstrated efficacy in controlled studies: A. Atopic dermatitis B. Systemic lupus erythematosus (SLE) C. Multiple sclerosis D. Childhood idiopathic thrombocytopenic purpura 9. For which of the following conditions has IVIG NOT clearly demonstrated efficacy in controlled studies: A. Autoimmune hemolytic anemia B Kawasaki disease C. Guillain-Barre syndrome D. Adult dermatomyositis 10. Which of the following regarding side effects of intravenous immunoglobulin administration are true: A. Most adverse reactions related to IVIG are not rate related B. Patients with active infections tend to have less severe reactions C. Aseptic meningitis occurs more often in patients with autoimmune disease than with immunodeficiency D. Pretreatment with NSAIDs, acetaminophen does not help prevent common adverse reactions such as headache, backache, and myalgias Answers 1. C, page 183 Treatment with solvent, detergent or pasteurization is used as a step for viral inactivation, especially enveloped viruses 2. D, page 183, tables 17-1 & 17-3 Several methods have been used to eliminate IgG aggregates, including treatment with trace amounts of proteolytic enzymes (e.g. pepsin), ultracentrifugation, or other additions such as sugars, amino acids, and albumin, which stabilize the IgG molecule from reaggregation and protect it during lyophilization. 3. B, page 183, tables 17-1 & 17-2 4. B, page 184 Total IgG has a half-life of about 17-30 days. The half-life of IgG3 is 7-9 days; IgG1 &IgG2 have half-lives of about 27-30 days 5. C, page 187 6. D, page 187, table 17-3 7. C, page 190, box 17-2 8. D, page 188, table 17-5 9. A, page 188, table 17-5 10. C, page 186-187 |
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