BPT Trial Exam Questions 5 Flashcards
A 70 year old man presents to the emergency department for abdominal pain for the past several days. This is associated with bowels not opening for the same amount of time, and more recently nausea and vomiting. His past medical history is unremarkable except for colorectal cancer which was surgically removed with a high anterior resection 2 years ago. This was stage II at the time, with no evidence of locoregional nodes or metastases. A CT of his abdomen is performed which demonstrates a small bowel obstruction with no transition point identified. A left adrenal mass is also detected, measuring approximately 2 cm in diameter, with Hounsfield units of 8. Which of the following is the LEAST appropriate investigation of his adrenal lesion?
- FDG PET scan
- Plasma metanephrines
- Low dose dexamethasone test
- Plasma renin and aldosterone ratio
Answer: A - FDG PET scan
Feedback
Patient has imaging features consistent with a benign lesion. PET scan can be done to help differentiate benign versus malignant however, the CT features have demonstrated that it is benign. Plasma metanephrines and low dose dex test recommended in incidentalomas. Plasma renin aldosterone can also be done in those who have unexplained hypokalemic or hypertensive
Which of the following is a not a side effect of IL-6 inhibition?
- Thrombocytosis and leucocytosis
- Elevated lipid levels
- Bowel perforation
- Deranged liver function
Answer: A - Thrombocytosis & Leukocytosis
Feedback
Side effect profile of tocilizumab can cause all the following except option a. It causes thrombocytopenia and leukopenia
A 60 year old gentleman is newly diagnosed with colorectal cancer. He presented to his GP with altered bowel habits and underwent a colonoscopy demonstrating a right sided fungating mass, with biopsy subsequently identifying adenocarcinoma. CT staging is performed which demonstrates transmural involvement of the bowel wall, with no nodal or metastatic disease. He undergoes surgical resection which demonstrates involvement of the visceral peritoneum. His pathology demonstrates lymphovascular invasion. His completed colorectal cancer staging is 2. Which of the following is the MOST appropriate subsequent management?
A. Adjuvant chemotherapy
B. No further therapy given his staging
C. Adjuvant radiotherapy
D. Adjuvant chemotherapy with anti-EGFR antibody cetuximab
Answer: A - Adjuvant chemotherapy
Feedback
Patient has stage IIB cancer. Despite being stage 2, this patient has high risk features which would warrant the use of adjuvant chemotherapy. Some of the indications for adjuvant chemotherapy in patients who present with bowel perforation, lymphvascular invasion, incomplete lymph node staging, T4 disease, involvement of visceral peritoneum. This patient has both lymphovascular involvement, involvement of visceral peritoneum. https://www.cancer.net/cancer-types/colorectal-cancer/stages
A 20 year old female has relapsed 6 months after a stem cell transplant for B-ALL, and is enrolled into a clinical trial involving CD19 chimeric antigen receptor therapy. She receives fludarabine and cyclophosphamide lymphodepletion on days -4 to -2, followed by CD19 CAR T cells infusion on day 0. On day 3 she became febrile to 39, hypotensive with a blood pressure of 80/60, and a new oxygen requirement. A septic screen has been performed which is negative. Which of the following therapies should be used first line for her most likely condition?
A. Glucocorticoids
B. Tociluzumab
C. Infliximab
D. Canakinumab
Answer: B - Tocilizumab
Feedback
Patient has severe cytokine release syndrome after adoptive T cell therapy. Emerging evidence is that IL-6 is the key mediator. Tocilizumab can quickly reverse deteriorating patients. Corticosteroid used if this doesn’t work
http://www.bloodjournal.org/content/124/2/188?sso-checked=true
Cholinesterase inhibitors use in Alzheimer’s dementia may exacerbate all the following except:
A. Asthma
B. Sleep disturbances
C. Sinus tachycardia
D. Peptic ulcer disease
Answer: C - Sinus tachycardia
Feedback
Answer: C
Cholinesterase inhibitors may have vagotonic effects causing bradycardia even in patients without a history of cardiac disease. Donepezil may be associated with QT prolongation. Use wih caution in patients with sick sinus syndrome, bradycardia or conduction abnormalities.
In the rheumatoid synovium, which of the following cytokines would be expected to be present in the lowest concentration?
A. Interleukin-13
B. Interleukin-17
C. Interferon-γ
D. Tumour necrosis factor-α
Answer: A - IL-13
Feedback
Answer: A
The rheumatoid synovium is dominated by CD4+ T cells and macrophages. The T cells are predominantly of the Th17 phenotype (high IL-17, TNF-α), with some Th1 cells (IL-2 and IFN-γ) and essentially no Th2 cells (no IL-4 or IL-13). Macrophages release multiple cytokines including IL-1 and IL-6.
Which condition is not a synucleinopathy?
A. REM-sleep disorder
B. Lewy-body dementia
C. Multisystem atrophy
D. Progressive supranuclear palsy
Answer: D - PSP
A 42-year-old woman has noticed temperature-related discolouration of her fingers over the last six months. She presents with a four week history of progressive dyspnoea, myalgia and weakness in her arms and legs. You note skin changes over her chest which she admits have been developing over the last three months.
A. Anti-Jo1
B. Anti-Ro52 (TRIM21)
C. Anti-U1RNP
D. Anti-p155 (TIF1gamma)
Answer: B - Anti-Ro52
Feedback
Anti Ro-52 is associated with ILD and systemic sclerosis
Which of the following is the least negative prognostic factor following non-ST elevation myocardial infarction (NSTEMI)?
A. Chronic Kidney Disease
B. Increasing Age
C. Significant Troponin Elevation
D. Prior Stroke
Answer: C - Significant troponin elevation
Feedback
CKD: In an analysis of three major trials of over 19,000 patients with a non-ST elevation acute coronary syndrome (NSTEACS), the patients with impaired renal function (estimated baseline creatinine clearance below 70 mL/min) had increased mortality at both 30 days and six months (approximately 10.5 versus 3.4 percent at six months). They were also older and had more baseline risk factors. After accounting for these differences, the adjusted hazard ratio for death or MI at six months was significantly increased in patients with reduced renal function (1.23 and 1.08, respectively, for each 10 mL/min decrement in creatinine clearance). The increase in risk was most pronounced in patients with the lowest creatinine clearances (median 45 mL/min).
Age: Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA 2011; 306:2120.
Goldberg RJ, McCormick D, Gurwitz JH, et al. Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995). Am J Cardiol 1998; 82:1311.
Troponin: The largest experience on the magnitude of the predictive value of troponin T comes from the GUSTO IV ACS trial of over 7000 patients who did not undergo early revascularization. The patients were stratified by quartiles of troponin T (≤0.01, 0.01 to 0.12, 0.12 to 0.47, and 0.47). The 30-day mortality rate increased from 1.1 to 7.4 percent from the first to fourth quartiles of cTnT. There was also a significant increase in the 30-day rate of MI from the first to second quartiles of cTnT (2.5 versus 6.7 percent), but no further increase between the upper three quartiles
Stroke: In an analysis of older patients treated in routine practice in the large CRUSADE registry of patients with NSTEMI, a history of stroke was a significant predictor of long-term mortality (hazard ratio approximately 1.35)
Which of the following is NOT associated with significant elevation in Brain Natriuretic peptide (BNP)?
A. Constrictive Pericarditis
B. Pulmonary Hypertension
C. Sepsis
D. Valvular Heart Disease
Answer: A - Constrictive pericarditis
Feedback
Plasma brain natriuretic peptide (BNP) and N-terminal pro-BNP levels (NT-proBNP) are elevated in patients with heart failure (HF) as well as in some patients without overt HF with a variety of conditions including renal failure, coronary heart disease, valvular heart disease, restrictive cardiomyopathy, pulmonary hypertension, and sepsis. Whilst constrictive pericarditis can cause mild elevations in BNP, it is thought that the constrictive effect prevents atrial stretching and resultant release in BNP.
28 year old woman admitted to high dependency unit 4 hours after an overdose of amitriptyline for cardiac monitoring. She is drowsy and nauseated. Her ECG shows a QRS length of 140msec. Which one of the following would help minimise risk of amitriptyline related cardiac toxicity?
A. Activated Charcoal
B. Haemodialysis
C. Magnesium
D. Sodium Bicarbonate
Answer: D - Sodium bicarbonate
In regards to alcohol withdrawal seizures, which of the following statements is TRUE?
A. Insomnia during abstinence is characterised by decreased sleep latency and decreased rapid-eye movement sleep
B. Chronic alcohol consumption inhibits AMPA receptor expression and function in the cortex
C. First presentation seizure in alcohol withdrawal is associated with more severe and medically complicated withdrawal seizures compared to subsequent presentations of alcohol withdrawal seizure
D. An individual presenting with alcohol withdrawal seizure has a poorer prognosis and higher mortality rate than an individual presenting with seizure of unknown aetiology.
Answer: D - An individual presenting with alcohol withdrawal seizure has a poorer prognosis and higher mortality rate than an individual presenting with seizure of unknown aetiology.
Feedback
Alcohol withdrawal has been asked previously (see 2015 recall exam), so it is important to know the neurobiological effects. An excellent summary can be found in [Becker &
Mulholland 2014, Neurochemical mechanisms of alcohol withdrawal, Alcohol and the Nervous System, vol 125;pp133-156
Also highlighted in this question is that answer options often have really niche scientific scary sounding words (ie: AMPA receptor expression). It’s important not to be thrown by these, as it can be easy to get panicked at reading options that you have no idea about. Stay calm, read the questions, in (D) there is logical sense…alcohol dependent patients with alcohol withdrawal seizures often have associated comorbidities that contribute to mortality.
In explaining the other answers (a lot of this detail is probably excessive):
A: Insomnia during abstinence is characterized by fragmentation of sleep architecture that manifests as increased sleep latency, reduced total sleep, compromised sleep efficiency, and a transient increase (rebound) in rapid-eye movement sleep.
B: While alcohol initially facilitates the inhibitory actions of GABA and inhibits excitatory effects mediated by glutamate transmission, chronic alcohol exposure results in compensatory changes in these amino acid transmitter systems that are opposite in nature and revealed upon withdrawal.
Chronic alcohol exposure also results in phosphorylation of the GluN2B subunits by the Src family tyrosine kinase Fyn (via dissociation from the scaffolding protein RACK1), resulting in increased NMDA receptor channel activity. Similarly, chronic alcohol-induced enhancement of AMPA receptor expression and function has been reported in cortex. Chronic exposure to alcohol is well documented to induce neuroadaptive changes in pre- and postsynaptic GABAergic transmission and expression of receptor subunit transcript/peptide levels that are temporally, subunit, and brain region-dependent
C: A history of multiple previous detoxifications was reported to be associated with more severe and medically complicated withdrawal syndromes, as well as an increased likelihood of hospital readmission for alcohol-related problems
D: An increased risk of seizures in alcoholics with a history of multiple detoxifications is of clinical significance since poorer prognosis and a higher mortality rate have been reported for patients presenting with alcohol withdrawal-related seizures in contrast to individuals with seizures of unknown aetiology
A mutation in the gene that encodes aquaporin 2 is most likely to result in
A. Diabetes Insipidus
B. Minimal change disease
C. Alport syndrome
D. Medullary sponge kidney
Answer: A - Diabetes insipidus
You review a 42-year-old woman six weeks following a renal transplant for focal segmental glomerulosclerosis. Following the procedure she was discharged on a combination of tacrolimus, mycophenolate, and prednisolone. She has now presented with a five day history of feeling generally unwell with anorexia, fatigue and arthralgia. On examination her sclera are jaundiced and she has widespread lymphadenopathy with hepatomegaly. What is the most likely diagnosis?
A. Cytomegalovirus
B. Epstein Barr Virus
C. Hepatitis A
D. HIV
Answer: A - CMV
Feedback
Cytomegalovirus is the most common and important viral infection in solid organ transplant recipients. Ganciclovir is the treatment of choice in such patients.
Graft Failure:
Hyperacute acute rejection (minutes to hours)
due to pre-existent antibodies against donor HLA type 1 antigens (a type II hypersensitivity reaction)
rarely seen due to HLA matching
Acute graft failure (< 6 months)
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
other causes include cytomegalovirus infection
may be reversible with steroids and immunosuppressants
Causes of chronic graft failure (> 6 months)
both antibody and cell mediated mechanisms cause fibrosis to the transplanted kidney (chronic allograft nephropathy)
recurrence of original renal disease (MCGN > IgA > FSGS
A patient is receiving Erlotinib therapy for non-small cell lung cancer. Which of the following is most likely to reduce the efficacy of Erlotinib?
A. Omeprazole
B. Aprepitant
C. Grapefruit Juice
D. Ciprofloxacin
Answer: A - Omeprazole
Feedback
Erlotinib maximum serum concentration (Cmax) and AUC were decreased by an average of 61% and 46%, respectively, when coadministered with the proton pump inhibitor (PPI) omeprazole. In another study, in 14 patients who received erlotinib and esomeprazole (40 mg x 3 days) the erlotinib AUC and Cmax were 48% and 49% lower, respectively, than the AUC and Cmax of 14 patients who received erlotinib without esomeprazole The suspected mechanism of this interaction is a decrease in erlotinib solubility in the upper gastrointestinal tract due to the PPI-mediated increase in gastric pH. Erlotinib solubility is known to be inversely related to gastric pH (i.e., solubility decreases with increasing pH)
Erlotinib is a major CYP3A4 substrate and minor CYP1A2 substrate. Aprepitant is a weak-moderate inhibitor of CYP3A4 which may increase concentrations of Erlotinib. Grapefruit Juice is a moderate inhibitor of CYP3A4 which may increase concentrations of Erlotinib. Ciprofloxacin is a weak inhibitor of CYP3A4 and a strong inhibitor of CYP 1A2 which may increase concentrations of Erlotinib
Which cystic fibrosis transmembrane conductance regulator (CFTR) acts as a potentiator for patients with gating mutations?
A. Lumacaftor
B. Tezacaftor
C. Ivacaftor
D. Elexacaftor
Answer: C - Ivacaftor
Feedback
Ivacaftor increases gating and conductance of the CFTR channels present at the cell surface.
The others are all correctors which increase the number and function of CFTR channels at the cell surface.
A new highly sensitive D-dimer assay has a sensitivity of 99.5% but a specificity of only 50%. What is the likelihood ratio for a positive result nearest to?
A. 2
B. 5
C. 10
D. 20
Answer: A - 2
Feedback
Likelihood ratio for + result = sensitivity/1-specificity
= 99.5/50
= 1.99 ~(2)
An autosomal recessive disease has a frequency of 1 in 14400. What is the carrier rate in the community?
A. 1:40
B. 1:60
C. 1:80
D. 1:160
Answer: B - 1:60
Feedback
Square root of frequency divided by 4. You can check the answer in the following way. The chance that both members of a couple will be carriers is 1/60 x 1/60 = 1/3600. If they are both carriers, their chance of having an affected child is ¼, given autosomal recessive inheritance . Frequency of disorder in community is therefore 1/3600 x ¼ = 1/14400
Resistance to which of the following agents conveys the GREATEST likelihood of treatment failure for tuberculosis?
A. Ethambutol and pyrazinamide
B. Rifampicin and isoniazid
C. Amikacin and ethionamide
D. Capreomycin and moxifloxacin
Answer: B - Rifampicin & Isoniazid
Feedback
Resistance to both isoniazid and rifampicin and possibly additional agents is referred to as multi drug resistant tuberculosis (MDR-TB). Extensively drug-resistant TB (XDR-TB) refers to MTB resistant to at least isoniazid, rifampicin, and fluoroquinolones as well as either aminoglycosides (amikacin, kanamycin) or capreomycin or both. MDR-TB and XDR-TB has a treatment failure rate of 52-77% and 48-62% respectively.
A 50 year old man presented with chronic, watery diarrhoea up to 5 times per day associated with 10kg weight loss over the last 8 months. He has a known diagnosis of Crohn’s disease involving his terminal ileum. He had ileal resection with ileo-colic anastomosis 5 years ago. His CRP was 0.8mg/L (< 5). A colonoscopy was performed which was unremarkable. Which of the following is the MOST LIKELY cause of his symptoms?
A. Small bowel Crohn’s disease
B. Short gut syndrome
C. Irritable bowel syndrome
D. Bile salt diarrhoea
Answer: D - Bile salt diarrhoea
Feedback
Bile salts/acids are important for lipid absorption. After release into the duodenum post-prandially, it is reabsorbed in the terminal ileum. With his previous ideal resection, increased bile acids in the colon leads to cholerheic diarrhoea.
Which of the following is the STRONGEST predictor of liver-related mortality in non-alcoholic fatty liver disease?
A. Obesity
B. Type 2 diabetes mellitus
C. Stage 4 fibrosis
D. Smoking
Answer: C - Stage 4 fibrosis
Which of the following molecular characteristics of the tumour in metastatic colorectal cancer is suggestive of a response to treatment with cetuximab?
A. Wild type c-kit gene
B. Mutant type c-kit gene
C. Wild type K-ras gene
D. Mutant type K-ras gene
Answer: C - Wild-type K-rase gene cancers respond best to anti-EGFR treatment with Cetuximab
What is the approximate lifespan of a circulating platelet?
A. 24-48hours
B. 72 hours
C. 7-10 days
D. 15-20 days
Answer: C - 7-10 days
Feedback
I always remember from how long pre-operatively you’d hold antiplatelets
Treatment for which of the following malignancy is associated with the highest risk of tumour lysis syndrome?
A. Burkitt’s lymphoma
B. Multiple myeloma
C. Chronic myeloid leukemia
D. Small cell lung cancer
Answer: A - Burkitt lymphoma
Feedback
Tumours that have a high tumour cell proliferation rate and chemosensitivity harbour a greater risk of tumour lysis syndrome, such as Burkitt’s lymphoma, other NHL and AML/ALL. Solid malignancies have less risk of tumour lysis syndrome compared to most haematological malignancies.
Sensation at the umbilicus is associated with which dermatome?
A. T4
B. T7
C. T10
D. T12
Answer: C - T10
Which of the following statements is most correct relating to a systemic rheumatologic disorder and its neurological manifestations?
A. The most common neurologic manifestation of Sjogren’s syndrome is a length dependent distal symmetrical sensory or sensorimotor axonal polyneuropathy.
B. Cervical spine involvement is seen in less than 25% of patients with rheumatoid arthritis, but can be associated with atlantoaxial instability and progressive myelopathy.
C. The most common CNS manifestations of systemic lupus erythematosus are mood disorder and cognitive impairment.
D. A true inflammatory myopathy may be associated with systemic sclerosis, particularly in the presence of anti-PM/Scl positivity. The first line treatment is high dose glucocorticoids.
Answer: A - The most common neurologic manifestation of Sjogren’s syndrome is a length dependent distal symmetrical sensory or sensorimotor axonal polyneuropathy.
Feedback
Neurologic manifestations of systemic and chronic diseases are considered a key condition in the current RACP Knowledge Guide and probably worth having at least a superficial understanding of (although I may be biased).
The most common neurologic manifestation of Sjogren’s syndrome is a length dependent distal symmetrical sensory or sensorimotor axonal polyneuropathy. A much rarer but important to recognise syndrome is a sensory neuronopathy (ganglionopathy), manifesting with non length-dependent sensory loss, pseudoathetosis, and ataxia due to lymphocytic inflammation of the dorsal root ganglion.
Cervical spine involvement is relatively common in rheumatoid arthitis, affecting >40% of patients. It can take the form of bony erosions, atlantoaxial subluxation, subaxial subluxation and vertical subluxation, and can be associated with a chronic compressive myelopathy.
The five most common CNS manifestations of SLE (pooled prevalence from prospective studies) are headache (23.3%; 37% when excluding studies underreporting or not including headache), mood disorders (14.9%), cognitive dysfunction (13.9%), seizures (8.0%), and cerebrovascular disease (7.2%).
A true inflammatory myopathy may indeed be associated with systemic sclerosis, particularly in the presence of anti-PM/Scl positivity, but high dose glucocorticoids are usually avoided given the risk of precipitating scleroderma renal crisis. First line treatment considerations could be low dose glucocorticoids alone or in combination with methotrexate or azathioprine.
