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Allergy/Immunology Board Review FIT Corner Questions from Middleton's > Specific Diagnostic Modalities 2018-2020 > Flashcards

Specific Diagnostic Modalities 2018-2020 Flashcards

1
Q
  1. Why is measuring exhaled nitric oxide more useful as a marker of asthma than allergic rhinitis?
    A. Local production of nitric oxide by the nasal mucosa is diluted as a consequence of the high nitric oxide production from paranasal sinuses
    B. Nitric oxide is not elevated in patients with allergic rhinitis
    C. Nitric oxide is not increased further during the late response to inhaled allergen
    D. There is not increased expression of inducible nitric oxide synthase in airway epithelial cells
A
  1. A, Local production of nitric oxide by the nasal mucosa is diluted as a consequence of the high nitric oxide production from paranasal sinuses, p. 333.
    Nitric oxide is elevated in patients with allergic rhinitis. Nitric oxide is increased further during the late response to inhaled allergen. There is increased expression of inducible nitric oxide synthase in airway epithelial cells.

Chapter 21: Pathophysiology of Allergic Inflammation
Middleton’s Allergy Principles and Practice, 8th Edition

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2
Q
  1. How much more radiation on average is delivered with a CT chest compared to a posterior-anterior chest radiograph?
    A. 10-60 times more radiation is delivered with a CT chest
    B. 60-120 times more radiation is delivered with a CT chest
    C. 120-180 times more radiation is delivered with a CT chest
    D. 180-240 times more radiation is delivered with a CT chest
A
  1. B, 60-120 times more radiation is delivered with a CT chest, p. 1062.
    On average a CT chest delivers 60-120 times more radiation than a posterior-anterior chest radiograph.

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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3
Q
  1. Which of the following was found NOT to be significantly correlated with air trapping in asthma?
    A. Severe refectory asthma as defined by ATS criteria
    B. Asthma-related hospitalizations
    C. Intensive care unit hospitalizations
    D. Need for mechanical ventilation
A
  1. A, Severe refectory asthma as defined by ATS criteria, p. 1058.
    Air trapping in asthma as visualized on imaging was not significantly correlated with severe refractory asthma.

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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4
Q
  1. What is a serious safety concern with use of MRI with hyperpolarized helium-3 (HP He)?
    A. MRI with HP He is generally considered safe
    B. Patients experience prolonged hemoglobin desaturation secondary to He-N2 gas mixture
    C. Patients experience respiratory exacerbations
    D. Patients receive high doses of ionizing radiation
A
  1. A, MRI with HP He is generally considered safe, p. 1058.
    There is no ionizing radiation dose. Mild adverse events have been reports in fewer than 10% of patients. The primary safety concern is the anoxic He-N2 gas mixture as it displaces air in the
    lungs. But even with breath holds of 10 to 20 seconds, the hemoglobin saturation rarely falls below 90% and it recovers to normal within seconds

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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5
Q 
4. What is the most commonly used molecule in PET imaging?
A. Carbon-11
B. 18F-fluorodeoxyglucose
C. Fluoride-18
D. Oxygen-15
A
  1. B,
    18F-fluorodeoxyglucose, p. 1061.
    The most used molecule is 18F-fluorodeoxyglucose (FDG).

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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6
Q 
5. In an FDG-PET performed to evaluate lung inflammation in asthma, which cell type is the primary reason for an increased FDG signal?
A. Basophils
B. Eosinophils
C. Lymphocytes
D. Neutrophils
A
  1. D, Neutrophils,p. 1062.
    Primed and activated neutrophils are the main source of an increased FDG signal

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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7
Q
  1. In asthmatic patient, which of the following statements about airway wall thickening seen on CT chest is true?
    A. Airway wall thickening is associated with increased intraepithelial neutrophils
    B. Airway wall thickening is associated with increased intraepithelial eosinophils
    C. Airway wall thickening is associated with increased exhaled nitric oxide
    D. CT airway measures do not appear to provide an adequate measure of airway inflammation
A
  1. D, CT airway measures do not appear to provide an adequate measure of airway inflammation, p. 1057.
    CT airway measurements do not appear to provide an adequate measure of airway inflammation. There is currently weak to little evidence linking airway wall thickening to airway
    inflammation biomarkers.

Chapter 65: Lung Imaging
Middleton’s Allergy Principles and Practice, 8th Edition

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8
Q
  1. What is considered the gold-standard test for the diagnosis of IgE-mediated food allergy?
    A. Double-blinded, placebo-controlled oral food challenge
    B. In-vitro IgE testing
    C. Open oral food challenge
    D. Single-blinded, placebo-controlled oral food challenge
A
  1. A, Double-blinded, placebo-controlled oral food challenge, p. 1357.
    In vivo and in vitro IgE mediated testing for food allergy has improved over time. However, methods are still significantly limited that oral food challenge testing, specifically double
    blinded placebo controlled oral food challenges remain the gold standard for diagnosis.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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9
Q 
2. Open food challenges are limited by the potential for bias on part of the patient and the observer most often resulting in false positive results. Some suggest the false positive rate is
as high as:
A. 15%
B. 20%
C. 25%
D. 30%
A
  1. D, 30%, p. 1358.
    The limitations of OFC include the chance of bias on the part of the patient and the observer.
    This bias most often results in false-positive challenge results, with some authorities suggesting a false-positive rate of up to 30%. This common problem occurs most often when the patient has significant anxiety about the challenge or when the patient’s prior symptoms have been more subjective in nature.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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10
Q
  1. Open food challenges are characterized by:
    A. higher false negative rate in infants and toddlers compared to older patients.
    B. higher false positive rate in infants and toddlers compared to older patients.
    C. lower false negative rate in infants and toddlers compared to older patients.
    D. lower false positive rate in infants and toddlers compared to older patients.
A
  1. D, lower false positive rate in infants and toddlers compared to older patients, p. 1358-9.
    Despite limitations of bias open OFC’s have significant clinical utility due to high negative predictive value. Negative open challenges often serve as the first line test when the risk of
    true IgE mediated food allergy based on SPT of sIgE testing is low. A negative challenge may obviate the risk for DBPCFC. in infants and toddlers, for whom the impact of anxiety and other
    psychological factors is likely to be minimal thus minimizing the risk of bias, open challenges may be appropriate as a first-line challenge procedure. Open challenges are significantly
    easier to perform because food preparation is far simpler than for a blinded challenge, and the entire challenge can be performed with a single visit.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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11
Q
  1. Which of the following is true about double-blinded, placebo-controlled food challenges (DBPCFC)?
    A. DBPCFC are more likely to provoke severe allergic reactions in patients as compared to open challenges.
    B. DBPCFC are not recommend for patients with chronic symptoms, delayed reactions or subjective symptoms.
    C. DBPCFC protocols can be completed in one visit.
    D. Open challenges should be completed after a negative DBPCFC for full evaluation of food allergy.
A
  1. D, Open challenges should be completed after a negative DBPCFC for full evaluation of food allergy, p. 1359-60.
    Because of the limited observer and patient bias, DBPCFC remain the gold standard is diagnosis of food allergy. It is the recommend test in patients with chronic symptoms,
    delayed reactions or subjective symptoms. DBPCFC require 2 visits to complete the protocols.
    Open challenges should be completed after a successful negative DBPCFC.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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12
Q 
5. What is the estimated false positive rate in double blinded placebo-controlled food challenges(DBPCFC)?
A. 1%
B. 5%
C. 10%
D. 15%
A
  1. A, 1%, p. 1360.
    Although it is the best available test to diagnose food allergy, even the DBPCFC is not perfect, and estimated false-positive and false-negative rates are between 1% and 3%.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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13
Q
  1. What would preclude proceeding with OFC?
    A. Asthma exacerbation two weeks prior to the challenge
    B. Atopic dermatitis flare on challenge day
    C. One to two isolated hives during the challenge
    D. Subjective symptoms such as abdominal pain, during the challenge
A
  1. B, Atopic dermatitis flare on challenge day, p. 1360.
    OFC may be given if the patient is at their clinical baseline prior to starting the challenge. It should be postponed if the patient has been treated for an asthma exacerbation within 1 week
    of the challenge. If there are 1-2 isolated hives during the challenge, particularly in area where food may have touched, the provider may continue the challenge. The same is true for
    subjective complaints such as abdominal pain.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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14
Q 
7. What is the recommended time interval between doses during an OFC?
A. 0-10 minutes
B. 10-20 minutes
C. 20-30 minutes
D. 30-40 minutes
A
  1. B, 10-20 minutes, p. 1360-62.
    The challenge food should be provided gradually at 10- to 20-minute intervals and should begin with a dose unlikely to trigger a reaction. The challenge should progress stepwise with
    escalating doses, with an option to repeat doses or delay doses longer should symptoms develop.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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15
Q
  1. What are the most common reactions elicited during a positive OFC?
    A. Skin and cardiovascular reactions
    B. Skin and gastrointestinal reactions
    C. Respiratory and gastrointestinal reactions
    D. Respiratory and skin reactions
A
  1. B, Skin and gastrointestinal reactions, p. 1360-61.
    Positive OFC elicit some combination of cutaneous, gastrointestinal, respiratory, and cardiovascular reactions. Skin and gastrointestinal reactions are most common, and severe or
    life-threatening reactions are rare.

Chapter 83: Oral Food Challenge Testing
Middleton’s Allergy Principles and Practice, 8th Edition

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16
Q 
1. What is the test of choice to monitor a patient’s asthma status?
A. Exhaled nitric oxide
B. Peak flow
C. Spirometry
D. Symptom frequency
A 
1. C, Spirometry, p. 702.
Spirometry correlates well with airway cross-sectional area and is more sensitive than a patient’s report of symptoms and physical examination results. Spirometry can predict mortality for patients with chronic airway disease. Spirometry is the test of choice in all settings.  
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
17
Q 
2. Which of the following lung volume measurements would be expected to first become abnormal in asthma?
A. Expiratory reserve volume
B. Residual volume
C. Total lung capacity
D. Vital capacity
A
  1. B, Residual volume, p. 705 and 711.
    Elevations in residual volume (>150%) are usually the first alteration in lung volume. The residual volume is a sensitive measure of the function of the small airways.
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
18
Q 
3. For spirometry results to be considered reproducible, what is the maximum volume error?
A. 50 mL
B. 100 mL
C. 150 mL
D. 200 mL
A
  1. C, 150 mL, p. 710.
    It is critical that spirometry be reproducible. Successive spirometry results taken at one time with the same patient should not have greater than 150 mL in variation.
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
19
Q 
4. What volume amount and percent change in pre-bronchodilator FEV1 or FVC to postbronchodilator FEV1 or FVC, respectively, are considered to be a positive bronchodilator response?
A. 150 mL and 10%
B. 150 mL and 12%
C. 200 mL and 12%
D. 200 mL and 15%
A
  1. C, 200 mL and 12%, p. 711.
    American Thoracic Society (ATS) criteria states that FEV1 or FVC should increase by at least 200 mL and 12%.
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
20
Q 
5. In a patient with lung disease, an elevated diffusing capacity for carbon monoxide (DLCO) indicates which of following disease states?
A. Anemia
B. COPD
C. Interstitial lung disease
D. Uncontrolled asthma
A
  1. D, Uncontrolled asthma, p. 711.
    In patients with asthma the diffusing capacity for carbon monoxide (DLCO) is either normal or elevated. If the DLCO is elevated, that indicates that the asthma may be uncontrolled. The DLCO would be decreased in COPD and interstitial lung disease.
    Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
    Middleton’s Allergy Principles and Practice, 8th Edition
21
Q
  1. What is the difference between male and female gender in terms of airway/lung volume ratios prior to puberty?
    A. Females have a greater airway/lung volume ratio than males
    B. Males have a greater airway/lung volume ratio than females
    C. No difference
    D. Not well studied
A
  1. A, Females have a greater airway/lung that males, p. 700 and 701.
    Males prior to puberty have smaller airways than females and thus a smaller airway/lung volume ratio. This difference in airway size has been proposed as a theory to explain the increased prevalence of asthma among prepubertal males compare to females
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
22
Q
  1. What is the most typical change seen on the inspiratory flow loop in vocal cord dysfunction?
    A. Consistent truncation of the inspiratory flow loop
    B. Enlargement of the inspiratory flow loop
    C. No change seen
    D. Partial truncation of the inspiratory flow loop
A
  1. D, Partial truncation of the inspiratory flow loop, p. 704.
    Typically, partial truncation of the inspiratory flow loops is seen in vocal cord dysfunction though vocal cord dysfunction can present with different patterns. A consistent truncation is
    generally indicative of a large airway obstruction or an extra thoracic lesion
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
23
Q 
8. Which of the following measurement is best to detect subtle airflow limitation?
A. Peak expiratory flow
B. FEV1
C. FEF25-75
D. FEV1/FVC
A
  1. D, FEV1/FVC, p. 704.
    FEV1 is the most reproducible pulmonary function test but can be normal in those with significant disease. FEF25-75 is determined over the middle 50% of the patient’s expired volume. It varies more and is less reproducible. Its use in adults is discouraged.
Chapter 44(1): Development, Structure, and Physiology in Normal Lung and Asthma
Middleton’s Allergy Principles and Practice, 8th Edition
24
Q
  1. Bronchial challenges are useful tests for the evaluation of asthma. Tests can be performed with direct acting constrictors or indirect-acting constrictors. Which of the following is an
    example of an indirect-acting constrictor?
    A. Albuterol
    B. Histamine
    C. Mannitol
    D. Methacholine
A
  1. C, Mannitol, p. 757.
    Both methacholine and histamine are considered direct-acting constrictors in bronchial challenges.
    Indirect acting constrictors include mannitol, adenosine, exercise, and cold air.
    There is little difference between the use of histamine and methacholine; however, methacholine is used more widely due to fewer side effects. One disadvantage of the direct
    acting constrictors is that they produce positive tests for patients with asthma and COPD. This has led to the use of alternative agents that act indirectly by releasing mediators from mast cells in the airway. However, the indirect acting constrictors have not been studied as extensively as methacholine and histamine.
Chapter 48(2): Epidemiology of Asthma and Allergic Airway Diseases
Middleton’s Allergy Principles and Practice, 8th Edition
25
Q
  1. What is considered the gold-standard for the diagnosis of food allergy?
    A. Double-blinded placebo-controlled food challenge
    B. Blinded food challenge
    C. Open food challenge
    D. Specific IgE testing
A
  1. A, Double-blinded placebo-controlled food challenge, p. 758.
    The gold standard for diagnosing food allergy is the double-blinded placebo-controlled food challenge. Currently there are no validated questionnaires for the diagnosis for food allergy,
    unlike other allergic conditions. This has complicated the epidemiologic study of food allergy. Many reported food allergy symptoms are unable to be confirmed when a full diagnostic evaluation is completed. As such, estimates from invalidated questionnaires are likely to be inflated.
Chapter 48(2): Epidemiology of Asthma and Allergic Airway Diseases
Middleton’s Allergy Principles and Practice, 8th Edition
26
Q 
3. In skin prick testing, what is the wheal diameter size above the negative control that
is considered a “positive” result?
A. 3 mm
B. 4 mm
C. 5 mm
D. 6 mm
A 
Chapter 48(2): Epidemiology of Asthma and Allergic Airway Diseases
Middleton’s Allergy Principles and Practice, 8th Edition

Allergy/Immunology Board Review FIT Corner Questions from Middleton's (15 decks)

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