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Review Corner Archive
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
Prepared by Dr. Jennifer W. Mbuthia, Walter Reed Army Medical Center
1. Which of the following statements about pediatric allergic rhinitis is TRUE?
A. In childhood, girls outnumber boys with allergic rhinitis.
B. Symptoms of allergic rhinitis develop before the age of 20 years in 80% of cases.
C. Approximately 80% develop symptoms during adolescence.
D. Symptoms of allergic rhinitis develop in approximately 80% by age 6 years.
2. Which of the following is NOT a preformed mast cell mediator?
A. Tryptase
B. Heparin
C. Prostaglandin D2
D. Kininogenase
3. In the classification of allergic rhinitis, which of the following is TRUE?
A. Approximately 20% are strictly seasonal, 40% are perennial, and 40% are mixed (perennial with seasonal exacerbation).
B. Approximately 40% are strictly seasonal, 10% are perennial, and 50% are mixed.
C. Approximately 5% are strictly seasonal, 15% are perennial, and 80% are mixed.
D. Approximately one-third are strictly seasonal, one-third are perennial, and one-third are mixed.
4. Nasal polyps are commonly seen in which childhood illness/disease?
A. Choanal atresia
B. Non-allergic rhinitis with eosinophilia syndrome (NARES)
C. Allergic rhinitis
D. Cystic fibrosis
5. What is the most common form of nonallergic rhinitis in children?
A. Foreign body rhinitis
B. Nasal polyps
C. Primary ciliary dyskinesia
D. Infectious rhinitis
6. Often children with seasonal respiratory allergy will not have a positive skin test until:
A. After 2 seasons of exposure
B. 8 to 10 months of age
C. Age 6 years
D. Infants can have a positive skin test within the first 6 months of life due to transplacental sensitization to seasonal allergens.
7. Which is the most sensitive for the diagnosis of environmental allergens?
A. Nasal swab for eosinophils
B. Skin prick test
C. Total serum IgE
D. Allergen specific serum immunoassay
8. Which of the following antihistamines has the longest time to onset of action (3 hours)?
A. Loratidine
B. Cetirizine
C. Azelastin nasal spray
D. Fexofenadine
9. Which of the following statements about antihistamine use is TRUE?
A. Antihistamines are more effective when taken on an as-needed basis compared to daily maintenance use.
B. Second-generation antihistamines are non-sedating metabolites of first-generation antihistamines.
C. In general, antihistamines reduce sneezing and pruritis, but have little or no effect on nasal congestion.
D. All generations of antihistamines act by blocking the H1 receptor and having moderate anti-inflammatory effects.
10. Which intranasal corticosteroid is NOT well absorbed through the GI tract?
A. Mometasone furoate
B. Budesonide
C. Flunisolide
D. Beclomethasone
Answers
1. B, page 288
Approximately 40% develop allergic rhinitis by age 6 years, and 30% develop during adolescence. In childhood, boys outnumber girls with allergic rhinitis, but the numbers are equal in adulthood.
2. C, page 288
Histamine, tryptase, chymase, kininogenase, and heparin are all preformed mediators. LTC4, LTD4, LTE4, and prostaglandin D2 are not preformed but are released during the early phase of allergen exposure.
3. A, page 289
4. D, page 289
5. D, page 289
6. A, page 292
Children younger than 1 year may not display a positive skin test, and often it takes two seasons of exposure for a child to have a positive skin test.
7. B, page 292
Skin testing has greater sensitivity than serum immunoassay, and neither total serum IgE or nasal swab for eosinophils will identify specific allergen sensitivities.
8. C, page 294
All of the other antihistamines listed have an onset of action between 1 and 2 hours (Table 28-6).
9. C, page 294
Third-generation antihistamines are non-sedating metabolites of second-generation agents, and several of the newer agents have been shown to have mild anti-inflammatory properties. Antihistamines are most effective when taken prophylactically before exposure or on a daily basis.
10. A, page 295
Neither fluticasone nor mometasone is well-absorbed through the GI tract. Beclomethasone, budesonide, flunisolide, and triamcinolone are readily absorbed from the GI tract into systemic circulation and subsequently undergo significant first-pass hepatic metabolism.
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.
1. In regards to allergen immunotherapy:
A. Efficacy is not dose dependent.
B. There is significant placebo effect.
C. Most patients will have a clinical response within the first six months of therapy.
D. Systemic reactions are a rare occurrence.
2. In the first few months of starting aeroallergen immunotherapy:
A. Allergen specific IgG decreases and allergen specific IgE increases
B. Allergen specific IgG increases and allergen specific IgE decreases
C. Allergen specific IgG increases and allergen specific IgE increases
D. Allergen specific IgG decreases and allergen specific IgE decreases
3. Injection immunotherapy would be most appropriate in which of the following situations?
A. Atopic dermatitis
B. Egg allergy
C. Adult patient with swelling of entire extremity after wasp sting
D. Child with diffuse urticaria and wheezing after fire ant sting
4. Which of the following would most likely lead to significant degradation due to protease activity?
A. Cat and oak
B. Dog and birch
C. Cockroach and maple
D. Ragweed and bermuda
5. Loss of potency in diluted immunotherapy solutions can best be prevented by addition of:
A. Phenol
B. Glycosylated extracts
C. 10% glycerin
D. 50% glycerin
6. Systemic reactions with injection immunotherapy occur in what frequency?
A. <1%
B. ~5%
C. ~15%
D. 20% or more
7. Which of the following is the greatest risk factor for a systemic reaction?
A. Receiving maintenance therapy
B. Severe asthma
C. A child of any age
D. Concurrent use of ACE inhibitors
8. Which of the following allergen extracts is standardized in the United States?
A. Cat
B. Cockroach
C. Timothy grass
D. All of the above
9. The following resuscitation equipment should be available in a medical facility administering immunotherapy:
A. Oxygen mask
B. Intravenous corticosteroids
C. Injectable vasopressor
D. All of the above
10. Recombinant allergens have the following major advantage for use in immunotherapy:
A. Reduce the risk of IgE mediated reactions
B. More cost effective
C. Shorter duration
D. All of the following
Answers
1. B, Box 27-1
2. C, page 279, Figure 27-2
3. D, page 272, Table 26-2
4. C, page 281-2
5. D, page 281-2
6. B, page 282; 70-90% of reactions begin within the first 30 minutes
7. B, page 282
8. A, page 281, Table 27-1
9. D, page 283, Table 27-3
10. A, page 283
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.
1. Which item is a clinically proven dust mite allergen control measure?
A. Air filtration systems
B. Steam cleaning carpets
C. Washing bedding in cold water
D. Encasements for pillows and mattresses
2. Which state’s climate is most unfavorable for dust mite growth?
A. New Mexico
B. Florida
C. Louisiana
D. Georgia
3. Which cat allergen reduction strategy is most effective?
A. Air filtration
B. Removing carpet from the bedroom
C. Evicting the cat
D. Feline co-bedding with the allergic child
4. Which of the following allergens would be difficult to sample from the air?
A. Cat
B. Dust mite
C. Dog
D. Mold
5. According to the Tucson asthma study, sensitivity to which allergen was predictive of asthma at ages 6 and 11?
A. Alternaria
B. Dust mite
C. Cockroach
D. Cat
6. The two major dust mite species known to be associated with allergic disease are Dermatophagoides pteronyssinus and:
A. Euroglyphus maynei
B. Dermatophagoides farinae
C. Glyphagus domesticus
D. Acarus siro
7. Dust mites grow poorest when the relative humidity is less than:
A. 90 percent
B. 80 percent
C. 60 percent
D. 40 percent
8. Which of the following is true of pet allergens?
A. Once a cat is removed from the home, clinical benefit can be seen very quickly because allergen levels fall within hours.
B. Particles carrying animal allergens appear to be very sticky and can be found in high levels on walls and other home surfaces.
C. The vast majority of homes do not contain cat allergen unless a pet has lived there.
D. Sensitivity to cat and dog allergens has been shown in only 15 percent of asthmatic children.
9. What two species of cockroach are the most common in both household infestation and allergic sensitization?
A. Brown-banded Cockroaches (Supella longipalpa) and American Cockroaches (Periplaneta americana)
B. Oriental Cockroaches (Blatta orientalis) and American Cockroaches (Periplaneta americana)
C. German Cockroach (Blattella germanica) and American Cockroaches (Periplaneta americana)
D. German Cockroach (Blattella germanica) and Brown-banded Cockroaches (Supella longipalpa)
10. Which of the following measures for cockroach infestation control can reduce cockroach numbers by 90 percent or more?
A. Bait stations with hydranethylon
B. Boric acid
C. Acaricides
D. Daily cleaning of kitchen floor with standard home cleanser
Answers
1. D, page 270. Table 26-1
2. A, page 269
3. C, page 272. Table 26-2
4. B, pages 270, 272-274
Dust mite and cockroach are larger particles and typically are not airborne.
5. A, page 274
6. B, page 269
7. D, page 269
8. B, page 272
9. C, page 273
10. A, page 273
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.
1. Which two-mite species account for over 90 percent of the mite fauna in U.S. house dust samples?
A. Euroglyphus maynei and Blomia tropicalis
B. Dermatophagoides pteronyssinus and D. farina
C. Lepidoglyphus destructor and Thyrophagus putrescentiae
D. Acarus siro and Euroglyphus maynei
2. Which of the following is most associated with asthma symptoms among children in the inner-city setting?
A. Cockroach
B. Dust mite
C. Cladosporium
D. Cat
3. Which of the following indoor allergens appears to have the lowest threshold for sensitization among atopic individuals?
A. Cockroach
B. Dust mite
C. Cladosporium
D. Cat
4. Which of the following statements is true?
A. Allergens are either bioactive enzymes or enzyme inhibitors
B. Allergens are named using the first four letters of the source genus
C. Allergens are soluble proteins or glycoproteins of 10 to 50 kDa
D. Allergen allergenicity is determined by its biologic function
5. Which of the following dust mite species would likely be found in areas such as southern Florida or southern California?
A. Lepidoglyphus destructor
B. Tyrophagus putrescentiae
C. Acarus siro
D. Blomia tropicalis
6. The threshold for sensitization to dust mites is thought to be:
A. 0.2 mcg/g of household dust
B. 2 mcg/g of household dust
C. 20 mcg/g of household dust
D. 200 mcg/g of household dust
7. Sensitization to which allergen is the strongest independent risk factor for asthma for many parts of the world?
A. Cat
B. Dog
C. Cockroach
D. Dust mite
8. Most dust mite allergens are:
A. Digestive enzymes excreted in their urine
B. Digestive enzymes excreted in their feces
C. Lipocalins
D. Pheromone-binding proteins
9. One of the major allergens for cockroach is designated as:
A. Asp f 1
B. Bla g 1
C. Blo t 5
D. Bos d 2
10. Which of the following regarding allergen sampling and detection are true?
A. Fel d 1 and Can f 1 are generally undetectable in homes where there are no cats or dogs as pets.
B. To date, no recombinant allergens have been produced in any significant quantity.
C. Indoor allergen measurement by ELISA is the gold standard for exposure assessment.
D. Allergens are typically measured on dust samples collected by vacuuming an area of 15m2 for 5 minutes.
Answers
1. B, page 261
2. A, pages 261, 266
3. A, pages 261, 266
4. C, page 262
5. D, page 261
Euroglyphus maynei and Blomia tropicalis are dust mite species found in subtropical areas such as Florida, southern California, Texas & Puerto Rico.
6. B, page 265
7. D, page 265
8. B, page 262
9. B, page 263, Table 25-1
10. C, pages 263-4
Allergens are typically measured on dust samples collected by vacuuming an area of 1m2 for two minutes and extracting 100 mg of fine dust.
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?
A. Bermuda
B. Bahia
C. Johnson
D. Timothy
2. Which of the following is a continuous volumetric sampler that is useful for identifying aeroallergens, in particular small fungal spores?
A. Rotorod sampler
B. Kramer-Collins trap
C. Burkard trap
D. Durham sampler
3. Which of the following is true regarding pollens?
A. Mature pollen grains contain a hard outer wall called an intine.
B. It requires >100 pollen grains/m3 to provoke symptoms in sensitized individuals.
C. Wind-pollinated plants are more allergenic than plant pollinated by other means.
D. Tree pollen production tends to be longer and less intense that that of grasses or weeds.
4. A patient living in Texas complaining of rhinoconjuctivitis symptoms in December and January is most likely allergic to:
A. Juniperus scopulorum
B. Juniperus ashei
C. Poa pratensis
D. Quercus alba
5. Allergenic grass pollens in the United States:
A. Have grains that are generally morphologically distinct
B. Are the most important cause of allergic rhinoconjunctivitis
C. Are the second most important cause of allergic rhinoconjunctivitis
D. Commonly come from grass family members such as cereal grains (corn, rye, oat, wheat), sedges, and rushes
6. Which of the following pairs of tree pollen would be expected to show the greatest in vitro cross-reactivity?
A. Alder and maple
B. Elm and cottonwood
C. Mulberry and walnut
D. Oak and beech
7. In which area of the United States would you have the least likelihood to become sensitized to ragweed?
A. Mid-Atlantic
B. Midwest
C. Southeast
D. Pacific Northwest
8. Which of the following has been associated with sudden severe asthma episodes in children and young adults?
A. Epicoccum
B. Cephalosporium
C. Fusarium
D. Alternaria
9. Forest workers in the Pacific Northwest have demonstrated specific sensitization to:
A. Hairs shed from the wings and bodies of Mayflies, provoking conjunctivitis, rhinitis, or asthma
B. Midge hemoglobin from adult caddis flies, provoking conjunctivitis, rhinitis, or asthma
C. Scales from the tussock moth (Hemerocampa pseudotsugata) that infests Douglas fir trees
D. Scales from the moth (Pseudaletia unipuncta) that infests Douglas fir trees
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?
A. Sulfur dioxide
B. Ozone
C. Particulate matter < 2.5 micrometers in diameter (PM2.5)
D. Particulate matter < 10 micrometers in diameter (PM10)
Answers
1. D, page 252
The genus and species of Timothy grass is Phleum pretense. Allergens are typically designated by the first three letters of the genus, followed by a space, the first letter of the species, another space, and then an Arabic number.
2. C, page 253 Table 24-1
3. C, page 253.
The outer wall of pollen grains are called the exine and softer inner wall intine. 20-100 pollen grains/ m3 is sufficient to induce symptoms in sensitized individuals. Tree pollen production is generally shorter and more intense than grasses or weeds.
4. B, page 253 and 256
Juniperus ashei is mountain cedar, which peaks between December and February in Texas and Oklahoma
5. C, page 256-7
Ragweed pollen is the biggest cause of rhinoconjunctivitis in the U.S., grasses are second. The cereal grain members of the grass family are less allergenic and grass pollens are generally morphologically indistinct, all being monoporate.
6. D, page 256, Table 24-2
There is often significant cross-reactivity in members of the same family of trees but little cross-reactivity between families. The Aceraceae family includes box elder and maple, Betulaceae family includes alder and birch, Fagaceae family includes beech and oak, Juglandaceae includes hickory and walnut.
7. D, page 257
8. D, page 258
9. C, page 258-9
10. B, page 259
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:
A. Less safe to perform
B. More technically demanding
C. Less painful
D. Takes longer to perform
2. In comparison to skin prick testing, intradermal skin testing:
A. Has better reproducibility
B. Has less sensitivity
C. Requires more concentrated extracts
D. Uses more stable extracts
3. In considering the reactivity of the skin in different areas of the body:
A. There is no difference in skin reactivity between different areas of the body
B. The forearms are more reactive than the back
C. The lower third of the back is more reactive than the upper third
D. The lower third of the back is less reactive than the upper third
4. The typical volume used for intradermal skin testing is:
A. 0.02ml
B. 0.05ml
C. 1.0ml
D. 2.0ml
5. Regarding the safety of skin testing:
A. Intradermal testing has less risk of systemic reaction than prick testing
B. Systemic reactions with skin prick testing have not been reported to occur
C. Delayed reactions with skin prick testing have not been reported to occur
D. The risk of a systemic reaction with skin prick testing is ~1-2 per 10,000 tests
Answers
1. C, Table 23-1 & Box 23-1
2. A, Table 23-1
3. C, page 244
4. A, page 245
5. D, page 248.
March 12, 2008
Allergy and Immunology Review Corner: Chapter 22 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al.
Chapter 22: Laboratory (In Vitro) Analyses
Prepared by Drs. Jennifer Mbuthia, Walter Reed Army Medical Center, and Gregory Metz, Duke University.
1. The most important analyte measurement in the clinical laboratory for the diagnostic work-up in allergic disease is:
A. Allergen-specific IgE
B. Allergen-specific IgG
C. Tryptase
D. Total IgE
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:
A. Use of FDA-licensed natural rubber latex reagent for skin prick testing
B. In office, prick-prick test (prick latex glove, then prick patient)
C. Laboratory-based serologic assays
D. Patch testing
3. Elevated quantitative IgE antibody levels to selected foods (milk, egg, fish, and peanut):
A. Can be used as a screening tool for food allergies on infant newborn screen
B. May eliminate need for double-blind, placebo-controlled food challenges
C. Do not correlate with double-blind, placebo-controlled food challenges as well as food antigen specific IgG4 antibody
D. Can be used clinically to diagnose systemic anaphylaxis to food allergens if drawn within 30 to 60 minutes after suspected reaction.
4. Beta-tryptase is considered a measure of ________, and non-diseased individuals typically have Beta-tryptase levels less than _______.
A. Mast cell number, 5ng/ml
B. Mast cell activation, 5ng, ml
C. Mast cell number, 1ng/ml
D. Mast cell activation, 1ng/ml
5. Systemic mastocytosis should be suspected if the baseline total serum tryptase level exceeds:
A. 5ng/ml
B. 10ng/ml
C. 15ng/ml
D. 20ng/ml
6. When evaluating for extrinsic allergic alveolitis or hypersensitivity pneumonitis, the classic precipitin assay detects:
A. Precipitating IgM antibodies
B. Precipitating IgG antibodies
C. Precipitating IgE antibodies
D. Precipitating IgA antibodies
7. Which of the following is not routinely tested in evaluating indoor aeroallergen surface dust?
A. Der p1 (dust mite)
B. Can f 1 (dog)
C. Alt a 1 (Alternaria)
D. MUP (mouse)
8. The four molds that constitute the majority of indoor molds are:
A. Alternaria, Fusarium, Helminthosporium, Curvularia
B. Cladosporium, Pullularia, Phycomycetes, Aspergillus
C. Alternaria, Aspergillus, Cladosporium, Penicillium
D. Alternaria, Fusarium, Penicillium, Saccharomyces
9. Low levels of venom-specific IgG are associated with which of the following:
A. Indicator of treatment success after 3 to 5 years of VIT with yellow jacket
B. Indicator of treatment success after 3 to 5 years of VIT with honeybee
C. Strong predictor of treatment failure in patients on VIT with yellow jacket or mixed venom for more than 4 years
D. Elevated risk of treatment failure during the first 4 years of VIT with yellow jacket or mixed venom
10. Competitive inhibition of IgE RAST specific for Polistes wasp venom (PWV) is used for:
A. Detecting cross reactivity with yellow jacket venom (YJV) in order to minimize number of venoms needed for VIT
B. Alternative to skin testing in potentially wasp-sensitive patients
C. Detecting cross reactivity with honeybee venom (HBV) in order to minimize number of venoms needed for VIT
D. Determining whether 50 microgram maintenance VIT dose should be used instead of 100 microgram dose
Answers
1. A, page 235
2. C, page 237
3. B, page 237 and page 241, Box 22-1
4. D, page 238
5. D, page 238
6. B, page 238
7. C, page 240
8. C, page 240
9. D, page 239
10. A, page 239
February 27, 2008
Allergy and Immunology Review Corner: Chapter 21 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al.
Chapter 21: Stem Cell Therapeutics: An Overview
Prepared by Dr.Bret R. Haymore, Walter Reed Army Medical Center.
1. Which of the following is true regarding stem cells:
A. The usefulness of embryonic stem cell therapies has been well-proven in a variety of clinical trials.
B. Adult stem cells have essentially equal ability to embryonic stem cells in their ability to proliferate and differentiate.
C. Stem cells have not been found in the neural tissue of humans.
D. Stem cells can be found in embryonic as well as adult tissues.
2. Stem cells are defined by what two essential characteristics:
A. Ability to self-renew and to secrete cytokines that stimulate the differentiation of other cells
B. Found only in embryos and they secrete cytokines that stimulate the differentiation of other cells
C. Ability to self renew and to differentiate into multiple different tissue types
D. Easily grown in culture and seldom lead to ethical controversy
3. The only kind of adult stem cell successfully used in human trials is:
A. Pancreatic stem cells for diabetes mellitus
B. Neural stem cells for Parkinson’s disease
C. Hematopoietic stem cells for malignant hematologic diseases
D. Hematopoietic stem cells for congestive heart failure
4. Which of the following markers is used to identify and enrich stem cells from suspensions of bone marrow or peripheral blood cells for transplantation to reconstitute the hematopoietic system:
A. CD32
B. CD34
C. CD35
D. CD36
5. Which of the following are true in regards to ethical issues related to stem cells:
A. Donor sources should be carefully screened for pedigree evaluation/genetic testing and infectious diseases.
B. Because most stem cells are maintained in culture before transplant, standardized practices must be followed to maintain the integrity of the preparations.
C. Before transplant, stem cell preparations must be shown to possess relevant biologic activity (e.g. pancreatic islet-like cells must secrete insulin).
D. Proof of concept must be clearly established in an animal model to demonstrate the validity, efficacy and safety of the therapy.
E. All of the above
Answers
1. D, box 21-1
2. C, page 224 & box 21-1
3. C, page 228-229
Hematopoietic stem cells have been successfully used for a wide variety of hematologic diseases. This includes ‘benign’ conditions such as aplastic anemia, beta-thalassemia, etc. and malignant disease, such as leukemia and lymphoma. There has been limited success with fetal stem cells in the treatment of Parkinson’s disease and some attempts at treatment of congestive heart failure with both embryonic and adult stem cells.
4. B, page 228
Hematopoietic stem cells are often identified by their expression of two proteins: CD34 & stem cell antigen-1 (Sca-1). CD32 is an Fc receptor & CD35 is the complement receptor 1 (CR1).
5. E, page 229-230
February 13, 2008
Chapter 20 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al.
Chapter 20: Gene Therapy and Allergy
Prepared by Drs. Jennifer W. Mbuthia, Walter Reed Army Medical Center, and Tracy Pitt, Winnipeg Children’s Hospital
1. All of the following are true of Adenoviral vectors EXCEPT:
A. They are non-integrating
B. They express their genes in non-dividing cells
C. They are unsuited for any application requiring long-term expression in a rapidly turning over cell population
D. All of the above are true
2. Gene Therapy cannot:
A. Provide insights into cell biology
B. Produce a protein
C. Produce a functional change in every cell
D. Remove a protein
3. Gene Therapy can:
A. Correct a deficit in every cell
B. Restore cell function/correct cell deficits
C. Produce tightly regulated trasgenes
D. Produce very high levels of products
4. All of the following are characteristics of Lentivius Vectors EXCEPT:
A. Integrate into dividing cells
B. Are expressed in non-dividing cells
C. Have no stable packaging system
D. Have a smaller insertion size than murine retroviruses
5. The first disease treated by gene therapy using autologous T cells transduced with a retrovirus was:
A. Chediak-Higashi Syndrome
B. Adenosine Deaminase Deficiency
C. Chronic Granulomatous Disease
D. Common gamma chain deficiency
6. Which vector has the disadvantage/limitation of being highly immunogenic?
A. Moloney murine leukemia virus
B. Lentivirus
C. Adenovirus
D. Plasmid DNA
7. Which cytokine favors the development of regulatory T cells?
A. IL-4
B. IL-5
C. IL-10
D. IL-12
8. The Notch Pathway is important in:
A. Promoting IgE class switching
B. Determining lymphoid cell differentiation
C. Up-regulation of Fas ligand expression and Fas-mediated apoptosis
D. Plasmid vector tranfection and transduction of the target cell
9. Public health concerns that vector systems will recombine to form mutant infectious particles came from work with which disease?
A. Asthma
B. Malaria
C. HSV
D. HIV
10. One of the main limitations of Moloney-based murine vectors is:
A. The pre-integration complex cannot penetrate the small pores of the nuclear membrane
B. They exhibit unstable integration into dividing cells
C. They exhibit minimal immunogenicity
D. They possess an unstable packaging system
Answers:
1. D, page 214
2. C, page 220
3. B, page 219
4. D, page 212
5. B, page 219
6. C, page 212 and Box 20-1, p.214
7. C, page 217. TGF-beta also favors T reg development.
8. B, page 217 and 218 fig 20-4
9. A, page 214
10. A, page 212
January 30, 2008
Chapter 19 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al.
Chapter 19: Immunizations
Prepared by Drs. Bret R. Haymore, Walter Reed Army Medical Center.
1. Which of the following regarding passive immunization is true:
A. Immune memory responses are evoked.
B. There is no risk of blood-borne pathogen transmission.
C. Repeated equine anti-serum therapy has virtually no risk of adverse events.
D. It can be used effectively in a wide variety of infectious diseases both as pre- and post- exposure therapy.
2. The type of vaccine, such as for Haemophilus spp, designed to augment the immature (infant) immune system response to polysaccharide antigens is most accurately called a:
A. Subunit vaccine
B. Conjugate vaccine
C. Killed vaccine
D. DNA vaccine
3. The type of vaccine that would be most likely to produce a mucosal (IgA) response to vaccination would be:
A. Killed vaccine
B. Subunit vaccine
C. Conjugated vaccine
D. Live-attenuated vaccine
4. Which of the following regarding immunizations is true:
A. HIV-infected patients should never receive live viral vaccines.
B. No vaccine contraindications exist for primary complement deficiencies.
C. Patients with phagocytic defects can routinely receive live bacterial vaccines.
D. Influenza vaccine should be withheld during the first trimester of pregnancy.
5. Which of the following immunizations does NOT contain egg protein:
A. Influenza
B. MMR
C. Varicella
D. Yellow fever
6. According to current guidelines (pre-event setting), which of the following groups should NOT receive the smallpox vaccine:
A. Military personnel
B. Healthcare workers
C. Public health outbreak investigation teams
D. Members of the general public who wish to be vaccinated
Answers:
1. D, page 205.
The disadvantages of passive immunization are that its effects are short-lived and there is no immune memory response. There is a potential risk of blood-borne pathogens as it is derived from human plasma, though with modern techniques the risk is quite low. Serum sickness is frequently seen with multiple administrations of equine antiserum, which has been used to treat conditions such as tetanus, botulism. Passive immunization is effective for a number of infectious diseases.
2. B, page 205.
Polysaccharide antigens, such as that of Haemophilus spp. and Streptococcus pneumoniae, mount a T cell-independent immune response resulting in low-affinity, high-avidity IgM production. This is most inefficient in infants. Thus conjugated vaccines have been developed for use in children in which polysaccharide antigens are conjugated to carrier proteins (often tetanus and diphtheria) to augment the immune response.
3. D, page 205-6.
Live-attenuated vaccines elicit a complete immune response because they induce limited viral replication. This immune response includes both mucosal and cellular immunity, along with humoral. A risk of live vaccines of course is for dissemination of the virus, particularly in the immunocompromised.
4. B, page 207-208.
In HIV-patients without evidence of immunocompromise certain live viral vaccines such as measles or varicella are recommended by the CDC because of the severity of the natural disease. Women infected with influenza virus during pregnancy are at increased risk for serious complications and hospitalization. Recent recommendations from the Advisory Committee on Immunization Practices (ACIP) state vaccination is recommended in any trimester for healthy pregnant women and pregnant women with co-morbid medical conditions.
5. C, page 208
6. D, page 208
January 16, 2008
Chapter 18 of Pediatric Allergy: Principles & Practices, edited by Donald Y.M. Leung, et al.
Chapter 18: Bone Marrow Transplantation
Prepared by Dr.Jennifer W. Mbuthia, Walter Reed Army Medical Center.
1. Administration of G-CSF after transplantation has shortened the time to development of this cell type:
A. NK cells
B. Neutrophils
C. Monocytes
D. Eosinophils
2. In acute GVHD (Graft versus Host Disease), the three organs/organ systems primarily involved are:
A. CNS, liver, and GI tract
B. Lungs, liver, and skin
C. CNS, lungs, and GI tract
D. Skin, liver, and GI tract
3. The staging of GVHD into 4 main categories is based on:
A. Number of days post-transplant
B. Severity and number of organ systems involved
C. Which organ was transplanted
D. What the underlying immunodeficiency is that the patient has
4. Acute GVHD is termed chronic GVHD if it persists for how many days?
A. Seven days
B. 60 days
C. 100 days
D. Six months
5. In which immunodeficiency is bone marrow transplantation done without pre-transplantation chemotherapy?
A. Severe Combined Immunodeficiency (SCID)
B. Combined Variable Immunodeficiency (CVID)
C. Chediak-Higashi Syndrome
D. Chronic Granulomatous Disease
6. All of the following are risk factors for more severe GVHD EXCEPT:
A. Use of HLA-matched unrelated donors (MUDs)
B. Pretreatment with cyclosporine for less than nine months
C. Gender mismatch
D. Prior Herpesvirus infection
7. When T cell-depleted bone marrow is given, the stem cells must go to the host thymus for maturation. How many days does it take before these T cells enter circulation?
A. 7-21 days
B. 21-28 days
C. 30-60 days
D. 90-120 days
8. In infants with SCID who have received bone marrow transplants, the TRECs seen in the peripheral blood are most likely from:
A. Thymically derived T cells from donor marrow
B. Host T cells that were present prior to transplantation
C. Transplacentally transferred maternal T cells
D. Positive and negative selection of donor T cells in bone marrow
9. Factors influencing the likelihood of engraftment of donor marrow cells include all of the following EXCEPT:
A. Number of marrow cells administered
B. The degree of immunocompetence of the recipient
C. Type of pre-conditioning chemotherapy given to donor
D. Degree of MHC disparity
10. In acute GVHD, the clinical appearance and histology of the skin lesions most resemble:
A. Drug reactions
B. Scleroderma
C. Atopic dermatitis
D. Vitiligo
Answers:
1. B, page 197
2. D, page 194
3. B, page 194
4. C, page 194
5. A, pages 196 & 199
6. B, page 195
7. D, page 197
8. A, page 199
Despite a vestigial thymus in SCID infants, T cells post-transplantation show evidence of thymic maturation due to emergence of TRECs and CD45RA+ cells.
9. C, page 196
Pre-conditioning chemotherapy is given to the recipient and not the donor.
10. A, page 195
The skin lesions of acute GVHD resemble drug eruption/reaction, typically with a morbilliform maculopapular erythematous rash. Chronic GVHD can look more like scleroderma with skin atrophy, hyperkeratosis, and reticular hyperpigmentation.
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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