CPS Drugs

Question 1

Which of the following is false?

a) the incidence of neural tube defects in Canada is 1-4/1000
b) the rates of neural tube defects is higher in Atlantic Canada than west (seems to decrease east to west)
c) the recurrence rate of neural tube defects is 10%
d) drug therapy with valproic acid or carbamazepine increases the risk of neural tube defects

Answer 1

c) recurrence rate is 2%people who have already had a child with neural tube defects,

4 percent in high risk populations, high risk groups include Welsh, Irish and Sikh

neural tube defects - spina bifida and anencephaly

2nd most common malformation to cause mortality in the perinatal period after cardiac malformations

Question 2

Which of the following statements is false about prenatal screening?

a) combo of alpha feto protein and ultrasound can detect 85-95% of neural tube defects
b) there are options for in utero treatment of neural tube defects
c) for women who have had previous child with neural tube defect, test with amnio for alpha veto protein, which will detect defect in >95% cases
d) the risk of fetal loss from amniocentesis is 0.5-1%

Answer 2

b) false- no treatment, therefore primary prevention is of utmost importance
a) true between 15-20 weeks gestation

Question 3

The recommendations for folic acid is which of the following?

a) all women women of child bearing age consume 0.4-0.8 mg folic acid in the pre conceptual period, including women who have had a previous pregnancy with neural tube defect
b) women of child bearing age consume 0.4 mg folic acid in the pre conceptual period, 0.4-0.8 mg for women who have had a previous pregnancy with neural tube defect
c) women of child bearing age consume 0.4-0.8 mg folic acid in the pre conceptual period, 0.8-4 mg for women who have had a previous pregnancy with neural tube defect

Answer 3

c) is the answer

4 studies - 1 case control didn’t show any protective effects, the other 3 case control studies, the cohort study and the interventional study showed reduction in risk

adherence leads to decrease in risk of 60-70%, complex cause (multifactorial inheritance, in some cases single gene i.e. valproic acid and carbamazepine)

still trying to find optimal dose

goal of food fortification is to make intake 0.5-1 mg /day based on how much most women of child bearing age eat

flour is fortified
safety question is with pernicious anemia (B12 deficiency) since folate supplementation will mask the anemia but keep having the neuro symptoms, no evidence that that will happen

old statement -goes into the studies needed to supplement etc.

Question 4

Which of the following is not associated with fatalities from over the counter cold medications for children?
a) age

Answer 4

a) age

Question 5

Which of the following is true of evidence regarding cough and cold medications in children?

a) evidence overall is against cough and cold medication
b) Health Canada advises that cough and cold medications not be used in children

Answer 5

d) is the answer

the rest false

a) Cochrane meta-analysis - including 8 paediatric studies, no evidence for or against CCM in children
b) false - Health Canada advises not to use 6 years, FDA recommends not to use

Question 6

Which of the following did not show any benefits for symptom severity in treating the common cold in research studies?

a) echinacea
b) steam inhalation
c) honey
d) zinc

Answer 6

a) echinacea -

fluid - helps by softening secretions
humidified air - 3/6 studies showed benefits for Symptom relief, but Cochrane review couldn’t recommend using it for treatment
NSAIDs - Cochrane review of 9 RCTs, >1000 patients, NSAIds, did not significantly reduce total symptom score or duration of cold, but did help with discomfort/pain caused by viral illness
anti-histamines - Cochrane review - no clinically significant effect in children in general recovery when used as mono therapy, small effect on rhinorrhea and sneezing, but overshadowed by side effects,
antihistamine + decongestant showed no positive effect
older children/adults, some small effects on general recovery and nasal symptom recovery, but unclear if these symptoms were clinically significant
echinacea - Cochrane review - no evidence to suggest effectiveness to prevent the common cold in children (with use for 8-12 weeks)
zinc - has been suggested that it can inhibit viral growth - some studies showed benefits (especially if used within 24 hours) whereas others didn’t show benefit, therefore not recommended
honey - evidence that was better (see next question)

Question 7

Which of the following has been shown to be best for symptom relief of cold in children in two recent studies?

a) dextromorphan
b) diphenhydramine
c) honey
d) placebo

Answer 7

c) honey

can be used safely in age >1 year old
paired comparaisons - honey better than placebo, no treatment or diphenhydramine
in Cochrane review, not enough benefit
recent RCT of 139 children (age 24-60 months of age)improved cough frequency and severity, as well as sleep, in 59% of children, better then dextromorphan, diphenhydramine and placebo
anti-oxidant properties, can release cytokines, can sooth the throat
use more around bedtime

Question 8

Which of the following has not been shown regarding vitamin C?

a) beneficial for improvement of symptoms of common cold
b) beneficial for prophylaxis of the common cold
c) reduction in length of symptoms for common cold

Answer 8

a)

Cochrane review of 30 comparisons

• no significant improvement in symptoms with vitamin C, reduction in cold duration by 13%
• prophylactic vitamin C in skiiers, runners and soldiers, 50% RR in developing a cold in 6 studies

no clear recommendations for vitamin C, no dose or anticipated interactions

overall honey may show benefit, the others show little or no benefit, not recommended

Question 9

Which of the following is an appropriate indication for azithromycin in paediatrics?

a) strep pharyngitis - 1st line
b) mycoplasma pneumonia
c) otitis media - 1st line
d) community acquired pneumonia

Answer 9

b) use only for atypical pneumonia in children or as adjust to 3rd generation cephalosporin in severe pneumonia

should not be used for the other 3 unless life threatening beta-lactam allergy

Question 10

Which of the following is false of azithromycin?

a) bioavailability >30%
b) long half life up to 96h
c) stable in basic pH
d) significant intracellular distribution
e) should be avoided in patients at high risk of bacteria

Answer 10

c) false - stable in acidic pH

significant distribution to intracellular components and polymorphonuclear neutrophils
intracellular concentrations up to 100 times higher than plasma concentrations
high concentration in phagocytes so good to treat intracellular agents
breakthrough bacteremia has been described in patients on azithromycin (because drug transported by cells rather than by blood)

Question 11

Which of the following statements is false?

a) macrolides, including azithromycin, bind to the 50S subunit of the ribosomes and block protein translocation
b) azithromycin has lower action on gram positive bacteria including strep pneumonia compared to erythromycin
c) azithromycin has better action on gram negative ( i.e. haemophilus influenza and moraxella catarrhalis) compared to erythromycin
d) lower respiratory infections are the most common indication for azithromycin use in children and youth in Western countries

Answer 11

d) false, upper and lower respiratory infections are the main indication

lead to pneumococcal resistance, much more pneumococal resistance, more common than penicillin resistance, strains which are resistance to macrolide usually also resistance to penicillin

since heptavalent pneumococcal vaccine, the prevalence of pneumococcal strains not susceptible to erythromycin has decreased from 8.8 to 5% in alberta, but increased to 23% in Quebec, suggests prescribing patterns also play a role

azithromycin incorrect use affects the increased carriage nasopharyngeally of resistant pneumococci

Question 12

Which of the following statements is true?

a) should use as first line for treatment of otitis media
b) azithromycin worked better than amox/clav at treating otitis media in one study
c) good clinical efficacy against H influenza
d) good treatment option for pneumonia

Answer 12

b) is the answer

problems with using azithromycin for otitis media is increase strains of resistant pneumococci and poor clinical efficacy against H influenza, AAP does not recommend for treatment of acute otitis media unless anaphylactic to amoxicillin

should only use for atypical pneumonia or for serious pneumonia in conjunction with cefotaxime/ceftriaxone, has serious risk of treatment failure

Question 13

Which of the following is not a characteristic of atypical pneumonia?

a) acute onset
b) non lobal infiltrate
c) minimal leukocytosis
d) prominent cough

Answer 13

a) false subacute onset

the rest are features, usually in a school age child

Question 14

Which of the following is true?

a) 75% of drugs carry safety and dosing recommendations for children
b) most children receive an average of 10 prescriptions a year
c) currently lots of active paediatric drug research in Canada
d) 26% of children account for 72% of drugs prescribed

Answer 14

d) is true

the rest false

a) the opposite, 75% don’t carry safety and dosing recommendations for children
b) average of 4 prescriptions a year
c) not a lot, need to have more, lots of recommendations for different organizations to do more research

chance of child dying

Question 15

Which of the following is not categorized as a natural health product by Health Canada?

a) homeopathic preparation
b) substance used in traditional medicine such as ayurvedic medicine
c) chiropractic treatment
d) a mineral or trace element

Answer 15

c) is the answer

while some chiropractors do recommend natural health products, the practice of chiropracty itself does not involve the use of natural health products

the other 3 are categorized as natural health products by health canada
homeopathy - most common use in canada ear, throat and respiratory problems
more children now are using NHPs, including kids with chronic/refractory conditions and critically ill, as well as eating disorders

Question 16

Which of the following has had the most RCTs done in children?

a) Magnesium
b) vitamin A
c) Zinc
d) vitamin C

Answer 16

b) is the most
see table which goes through the RCTs done so far
there are studies in children of NHPs
some of these studies have significant methodical issues

Question 17

Which of the following statements is false?

a) dietary supplements are closely regulated in the US
b) there is a wide range of active ingredient in natural health products
c) product standards are affected by product identification, extraction technique, adulteration
d) contamination is a major problem with natural health products

Answer 17

a) false

the rest are true
in U.S. - Dietary Supplement Health and Education Act of 1994- if manufacturer call a product a dietary supplement, they avoid the premarket testing needed for pharmaceuticals

in Canada, Natural Health Products Directorate, regulations regarding good manufacturing practices and develop standards for labelling claims

issues with NHPs - determining optimal dosage (similar to issues for conventional meds),

Question 18

Which of the following is false regarding drug - herb interactions for NHPs?

a) there is not significant evidence of drug/herb interactions based on research studies
b) st. John’s wort may interact with numerous medications, including oral contraceptives, chemotherapy, anaesthetics, etc.
c) physicians should ask about patients complementary and alternative medication use and report to authorities
d) CAMs are not surveilled for serious adverse reactions

Answer 18

d) false

since Jan 2004 - Canadian Pediatric surveillance Program monitors for serious drug side effects , including herbal and CAMs

lots of obstacles to research, concerns about safety, patients less likely to report reactions about CAMs to providers

need to address educational gaps
educate the public that they are not always safe
Marketing Health Products Directorate, in conjunction with Health Products directorate, monitors the safety of all natural health products

Question 19

All but which of the following is a reasonable approach for a doctor whose patient has disclosed use of CAMs?

a) ensure no opportunity cost such as delaying therapy of an important disease
b) if no harm, consider its use and follow the patient
c) if it causes harm, tell the patient that if they keep taking it you can’t keep following them
d) try to follow evidence based guidelines as much as possible

Answer 19

c) is the answer - if causes harm, tell the patient and still follow them closely
try to find as much evidence as possible to guide decisions
don’t be defensive, do no harm

Question 20

Which of the following is true?

a) the AAP recommends that body checking not be allowed for children

Answer 20

a) true

b and C are reversed -
body checking is taught by hockey Canada

in Canada no girls/women’s hockey allows body checking, AAP classifies hockey as a collision sport

d) false
2003, 4/13 provinces allowed body checking in boys as young as 9 years old 2009, in peewee leagues (age 11-12), Quebec, age 13 year old since 2002 (used to be age 14 for bantam)
initiation - 5-6 year old, novice- 7-8 year old, atom 9-10 year old, peewee - 11-12, bantam 13-14 year old, midget 15-17 year old,

Question 21

Which for the following is false?

a) body checking is the most common mechanism of injury in hockey
b) fatality rates for ice hockey are half those for American football
c) Canadian association of sports medicine recommends that boys only have body checking introduced and no earlier than bantam (age 13-14) or midget
d) a recent systemic review showed that body checking was a risk factor for all hockey injuries , especially concussion

Answer 21

b) false - fatality 2x that of american football, and 4x catastrophic spinal cord injuries, traumatic brain injury appears to be rising

despite lack of evidence, proponents of body checking say that it is a fundamental skill which if learned early may prevent future injuries

d) for all hockey injuries with a IRR of 2.45% and a risk factor for concussion (OR 1.71), a review of 24 studies and a meta analysis; other newer studies,
- compared injury rates between Alberta (body checking introduced at age 11) vs Quebec (age 13) - 3x increase in all injuries and of injury resulting in >7 day loss from sport, 4x increase of game related concussion, 5 year cohort study, injuries increased 3.75 x in leagues that allow body checking vs those that don’t
- second study - whether introduction of body checking at 11 years or 13 year (again Alberta vs Quebec) affected injury rates in later years (age 13-14)
no reduction of game related risk of all injuries, including concussion in 13-14 year olds (bantam hockey players), in those where it was introduced earlier, concussion rate in Alberta peewee higher than bantam in either province,
- injury to bantam players that resulted in missing sport>7 days were reduced by 33% in the Alberta players, who had 2 more years of body checking experience, but should interpret in light of the 3-4 x greater injury and concussion risk in Alberta, also “survivor effect” (i.e. those who keep playing remain healthier)

Question 22

Which of the following is false of how recent policy changes have affected the rates of body checking injuries?

a) after rule change to allow body checking in younger kids, the injury rates of body checking injuries increased in all centres studied
b) most studies found that relative risk for hockey related injury injury increased with age
c) injury risk higher in games than in practice, lower for goalies than other players, generally, injury increases with increasing skill level
d) conflicting evidence about the effect of body size
e) previous history of concussion increased risk factor of further concussion and rein jury

Answer 22

a) false, CHIRPP data - looked at boys presenting to ER in Kingston, looked at 2002 rule change to allow body checking in younger players, no chane in rates from 1997-2002 (when reduced to age 11) and 2002-2007 (when introduced at 9 years), overall rate of injury actually declined, may have been biased by stronger rule enforcement, better coaching certification and declines in ER use for this type of injury;
another looked at 5 hospitals, looked at 1994-2004 (rule change in 2008 allowed checking in 9-10 year olds), 2.2 x increased risk in 9-10 year olds, another study 10-13 year oldOntario vs Quebec, more in Ontario (where body checking allowed younger)

the rest true - risk generally increased with age, a few studies said no. looked at relative age - no evidence that older or younger at greater risk (including peewee) one study did find for bantam players that increased risk in 1st year players
risk increases with increased skill in general, large cohort studies greater risk of injury among more highly skilled peewee players, but not same trend in bantam players

position - 3 studies, different positions found to be highest risk, in general goalies protected

d) some say smaller at more risk, others say heavier

fair play programs, reduced risk by 60% but not statistically significant (encourages sportsman like play)

Question 23

Which for the following is not a CPS recommendation for body checking in hockey?

a) body checking should be eliminated from all non competitive male ice hockey
b) girls and women should continue to participate in non body checking leagues
c) elite male hockey players should play in hockey leagues that introduce body checking later (bantam age 13-14)
d) should delay introduction of body checking to

Answer 23

d) false - this is AAP, CPS says until age 13-14 (bantam)

the rest are true

other recommendations include better policies, surveillance, educating coaches, boys should play in recreational/non competitive leagues that do not allow body checking as much as possible, parents should learn risk reduction strategies including concussion prevention