CKD
In the report, “Social Determinants of Racial Disparities in CKD,” Norton et al. investigates CKD and describes the disparities between black and white Americans. Which of the following about CKD disparities is true between black and white Americans?
A. CKD disparities are a result of solely genetic factors.
B. White Americans face greater disparities to CKD related care than black Americans.
C. CKD disparities is the result of genetic and environmental factors, reflecting the balance of nature and nurture.
D. Racial classification systems will continue to be useful in the future for helping to diagnose CKD and black Americans.
The correct answer is C.
Answer A is incorrect because CKD disparities are also a result of environmental factors. Answer B is incorrect because black Americans face greater disparities to CKD related care than white Americans.
Answer D is incorrect because racial classification systems will not be useful in the future. The United States is becoming increasingly diverse and the number of people who are “mixed race” is increasing.
SPIKES is a six-step protocol for delivery of bad news which emphasizes the importance of giving knowledge and information to the patient (part K.) One key aspect to part-K is using accessible language, rather than medical jargon, to ensure that the patient can best understand their diagnoses. Which of the following is the best example of accessible communication of information to the patient?
A. Essentially, we did a biopsy and found that your tumor has metastasized into the surrounding tissue.
B. Essentially, we did a biopsy and found that your tumor has spread into the surrounding tissue.
C. Essentially, we analyzed a sample of tissue and found that your tumor has metastasized into the surrounding tissue.
D. Essentially, we analyzed a sample of tissue and found that your tumor has spread into the surrounding tissue.
Answer Key: The correct answer is D. In ‘Spikes- a six step protocol for delivering bad news: application to the patient with cancer’ by Baile et al, part K of SPIKE outlines the importance of informing the patient of their situation in a way that yields the greatest understanding. Methods to ensure the best understanding include using accessible language, avoiding blunt language, and breaking up information into chunks to check for understanding along the way. An example is provided in the article (under STEP 4) to demonstrate favorable alternatives to common medical jargon. Here, they suggest using “spread” rather than “metastasized” and “sample of tissue” instead of “biopsy.”
Which groups of people are more likely to carry a BRCA gene mutation, thereby increasing their risk of developing breast and ovarian cancer?
A. Women over the age of 70
B. Ashkenazi Jewish folx w/ an ovary and/or breasts
C. African American women
D. Ashkenazi Jewish women
Correct Answer: B. There are two aspects to the correct answer in this question. Answer A is incorrect because age is simply a risk factor but has no impact on the presence of a mutation. The mutation would be something present from the day of birth. Answer C is incorrect; just because African American women are less likely to be diagnosed and treated for these cancers is not any indication of the presence of a mutation. While choices B and D might seem similar, choice D is incorrect because it is not inclusive of those who may not identify as a women but still have the organs that could be genetically predisposed to cancers. (Hereditary Breast Cancer and BRCA Genes, author CDC, Page 5)
Which of the following is the first step in discussing end of life care?
A. Work with the patient and family to determine who will make medical decisions
B. Recommend palliative care or hospice to the patient and their family
C. Have conversations about health goals and preferences before illness worsens
D. List out various pain medications and other treatments available to the patient
C is correct. It is best to begin talking about what the patient would prefer to happen if and when their illness worsens, in terms of symptom control (versus treatment), life-saving care, etc. This can help the patient and family feel more prepared and less shocked when such decisions become relevant. Choice A would come after this, and B and D would occur as needed in the later stages of end of life care.
Source: Blinderman & Billings, Comfort Care for Patients Dying in the Hospital, 2549-2550.
A 30-year-old patient presents with a respiratory rate of 10 breaths per minute; the patient has overdosed on fentanyl. Which of the following antidotes should be immediately administered at gradually increasing doses until symptoms improve?
A. Propanolol
B. Methadone
C. Acetaminophen
D. Naloxene
The answer is D. Naloxene works as a competitive mu opioid receptor antagonist that reverses signs of opioid intoxication. The other answers are distractors.
Management of Opioid Analgesic Overdose article by Edward W. Boyer
Kidney failure is the final stage of chronic kidney disease (CKD), better known as end-stage renal disease (ESRD). What is generally considered the preferred treatment for patients with ESRD?
a. Hemodialysis
b. Kidney transplantation (KT)
c. Either hemodialysis or KT, depending on the state of the patient’s kidneys
d. Lifestyle changes to salvage any remaining healthy part of the kidney
Correct Answer: B. While hemodialysis is a prescribed treatment for many ESRD patients, KT is the preferred treatment as it is associated with improved patient survival and quality of life compared to patients on hemodialysis. Options C and D contradict the fact that patients with ESRD have final stage, almost failing, kidneys. There are no alternative states for kidneys to be in and there are no remaining healthy portions to salvage. (Social Determinants of Racial Disparities in CKD, author Norton)
Alex is a 21-year old male who is the only surviving relative to his boyfriend, Thomas, who died in an unexpected car accident when speeding home on US-495 from his job at Brown University to Alex's house. Dr. Merritt is manning the ICU, and has to break the news to Alex. Dr. Merritt leads Alex to a family room in the ED and sits down next to him. Per the SPIKES protocol, what is the appropriate next thing to say?
A) "What have you been told about Thomas's condition so far?"
B) "How would you like me to give the information about Tiffany's condition so far"
C) "I'm sorry to tell you that Thomas expired."
D) "I know that this isn’t what you wanted to hear. I wish the news were better."
Answer: A. The clinical vignette shows that Dr. Merritt set up the interview. the next step is P for perception. Option choices B, C, D correlate to other parts of the SPIKES protocol and would not be appropriate as of yet.
What is an example of a tumor suppressor gene?
1) n-Myc
2) BRCA2
3) c-Myc
4) EGFR
Key: Correct answer is 2, other examples are oncogenes.
Hospice care is a type of health care that primarily focuses on the palliative aspect of health care for terminally ill patients. The intent is to relieve a patient's pain/symptoms and attending to their emotional needs towards the end of their life, thus prioritizing comfort and quality of life through a reduction of pain and suffering. Which of the following statements accurately describes the hospice utilization rates among different racial populations in the United States as mentioned in the article, “Social Justice and Palliative Care Policy” by Suzanne Marmo, PhD.
A.) Hospice utilization rates for Blacks and Hispanics/Latinx persons are still vastly disproportionate when compared to the general population, in that blacks and Hispanics/Latinx persons face lower utilization rates for hospice care.
B.) Hospice utilization rates for Caucasian persons are disproportionate when compared to the general population, in that Caucasian persons face lower utilization rates for hospice care.
C.) Hospice utilization rates are proportionate among all racial groups when compared to their total population of each racial group.
D.) Hospice utilization rates are highest for Blacks, with Caucasians having a slightly lower utilization rate than blacks but higher than Hispanics/Latinx persons.
Answer: A.) The answer is A because hospice utilization rates are lower for Blacks and Hispanics/Latinx persons than for Caucasian people. All other answer choices are not consistent with this fact and suggest these groups have higher hospice utilization rates than they actually do.
Citation: “Social Justice and Palliative Care Policy” by Suzanne Marmo, PhD.
https://www.swhpn.org/index.php?option=com_dailyplanetblog&tag=-palliative-care
What do all opioid overdoses commonly share?
1) Death
2) First Exposure
3) Alcohol
4) Emergency Services
Key: Correct answer is 2, first exposure is a common characteristic of opioid overdose.
African Americans are ____ as likely than Whites to develop End Stage Renal Disease (ESRD), and ____ as likely to receive kidney transplants.
A) 10 times; a quarter
B) 4 times; half
C) a third; 3 times
D) a quarter; 6 times
Answer: B
Source: Ng et al, Does Racial Disparity in Kidney Transplant Waitlisting Persist After Accounting for Social Determinants of Health? Page 1, first few sentences of Introduction
Understanding protocols for communicating bad news is essential to being a compassionate and trustworthy physician. In the SPIKES Protocol for delivering bad news, what is the meaning of the letter I?
a) Invitation- Determine how much information the patient would like disclosed to them
b) Initiation- engage the patient in conversation and set up a comfortable space
c) Infer- Deduce the patient’s emotional state based on previous encounters and the present moment.
d) Indication- Pick up on emotional cues from the patient to know how much information to divulge
The answer is a. It is important to understand that different patients want different amount of information disclosed to them. According to the Baile reading, “shunning information is a valid psychological coping mechanism and may be more likely to be manifested as the illness becomes more severe.” In the event a patient does not want to know many details, offer to answer questions they may have in the future or speak with friends/relatives.
Citation: “SPIKES—A Six‐Step Protocol for Delivering Bad News: Application to the Patient with Cancer” Baile et al. Section titled “STEP 3: I—Obtaining the Patient's INVITATION”
1. What is the name of the multi-component, community-based intervention created by Black et al. that sought to reduce Black-White cancer disparities?
a. ACCURE
b. CBPR
c. EQUITY
d. CCARES
Answer: A
Explanation: ACCURE is the correct answer as Black et al. came up with a systems-change intervention called Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) to improve transparency and accountability within the healthcare system, improve care for all patients, and use an antiracist lens to combat racial inequities in health. ("Using
an antiracism framework to analyze patients’ encounters in the cancer system" paper, authors Black et al., pp. 2-3)
MCQ 2: According to Blinderman et al in “Comfort Care for Patients Dying in the Hospital”, patients with pain scale rating 1-3 out of 10 should be initially treated with
a. no pain medication
b. acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID)
c. oral opioids
d. intravenous opioids
The paper states, “Patients with mild pain (scores of 1 to 3 on a 10-point verbal reporting scale) should initially be treated with acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If treatment with these agents fails to control pain, a low dose of an opioid can be added”. Thus B is the correct answer.
According to the NEJM article by Babu et al., the prescribing of opioids is not well supported by evidence, and can pose significant health risks. Which of the following is a result of long-term opioid therapy?
A) Enhanced functional improvement
B) Improved pain through opioid-induced hyperalgesia
C) Increase in sleep-disordered breathing
D) Increased risk of diarrhea
Source: NEJM Prevention of Opioid Overdose Article, p. 2248
Correct Answer: C
Long-term use of opioids has been associated with an increase in sleep-disordered breathing (since opioids are known to cause respiratory depression), therefore C is the correct answer. A is incorrect, as opioids have actually been associated with decreased functional improvement when used long-term. B is incorrect; while this seems counterintuitive, as chronic opioid usage can lead to worsened pain through opioid-induced hyperalgesia. D is incorrect, as long-term opioid use is associated with severe constipation, not diarrhea.
An 18 year old man had recently received a kidney transplant with a donor kidney from his mother. Prior to surgery, he was not producing urine at all. After surgery, he was producing urine at a normal level for about two weeks, and then stopped producing urine suddenly and expired a week later. Assuming no sepsis or any other life threatening condition in any other major organ system, what was the likely cause of death post-surgery?
A. Immunosuppressives
B. Organ rejection
C. Overproduction of T cells
D. Kidney cell necrosis
B. Immunosuppressives would have stopped rejection of the organ (temporarily), and the other two answers are grab bags with causes outside of simple transplantation. B is the only answer here. Organ rejection is also not immediate and may set in after a few weeks where the patient appears to function well. (source: Dr. Morrissey lecture week 7)
During your Friday day shift in the ER, a multiple casualty incident occurs at 10am. You are tasked with treating a 16-year-old gunshot victim, George. Unfortunately, despite your best efforts in the OR, the student is left paralyzed from the waist down. While George is in post-op recovery, the family arrives. You introduce yourself and invite the family to sit down in your office to speak. Which of the following would be an appropriate action to take and relates to the ‘P’ in the SPIKES protocol?
A. Tell that family that George will live, but, unfortunately, will likely be unable to walk.
B. Ask the family what they understand about George’s current medical situation.
C. Offer the family tissues and tell them that you are here if they need support.
D. Lay out George’s treatment plan, providing necessary referrals to specialists and support organizations.
Answer: (B) All of these in are generally good actions you may take in breaking bad news to a patient, but it is important to assess a patient/family’s current knowledge first. The family may have a level of information that you are not aware of, and this will impact your subsequent actions. This is also the only response that fits in with the Perception aspect of SPIKES.
Source: SPIKES- A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer, Baile et al, STEP 2: P-Assessing the Patient’s Perception
It is important to be familiar with health system statistics to put clinical practice into the appropriate scope and context. In particular, statistics illustrating disparities in cancer treatment are rather surprising. According to the Commonwealth Fund reading by Hostetter and Klein, how much more likely is a black woman to die of cervical cancer in comparison to a white woman?
a) 10%
b) 45%
c) 71%
d) 86%
The answer is c. This descriptive statistic was presented in the Commonwealth Fund reading. While this figure does not adjust for covariates, it provides a sense of scale for disparities in cancer treatment across intersectional racial groups.
Citation: Commonwealth Fund, Hostetter and Klein “In Focus: Reducing Racial Disparities in Health Care by Confronting Racism” (2018), Section Titled “Targeting Maternal Morbidity and Mortality”
Cardiopulmonary resuscitation (CPR) is an emergency procedure frequently included in discussions of end-of-life care. Which statement about CPR is correct?
a. Some hospitals have recently prevented patients with COVID-19 from receiving CPR, due to concerns that danger to healthcare providers outweighs the potential benefit to the patient.
b. Patients are often wary of CPR due to well-publicized dangers of violent resuscitation. Caregivers must often recommend CPR be allowed in their end-of-life care discussions before patients agree.
c. In an informed consent model-oriented care conversation, a physician explains the advantages and disadvantages of CPR and other extreme end-of-life measures to a patient with advancing illness, and lets the patient decide their treatment wishes.
d. With CPR, up to 40% of out-of-hospital sudden cardiac arrest victims can survive to hospital discharge.
Anwer: (a). This answer is stated in the reading. Because CPR is a “desperate measure” with low probability of success for critically ill patients, some hospitals have assessed that the risk of spreading COVID-19 in such a procedure is far higher than a miniscule potential patient benefit. (b) Incorrectly identifies patient perceptions of CPR: medical TV shows portray CPR as more successful than it really is. When patients are informed of the true statistics, they are often surprised that physicians even offer care of dubious benefit to terminally ill patients. (c) conflates an “informed consent” framework with the “shared decision-making” framework described here. In an informed consent framework, a patient near death is strongly recommended against choosing CPR or intubation to prolong life. (d) understates this mortality: the actual survival rate to hospital discharge is only 10%.
Source: Jacobsen J. et al. Case 19-2020: A 74-Year-Old Man with Acute Respiratory Failure and Unclear Goals of Care. JAMA (2020).
The issue of structural racism in drug policy being enacted through the inequitable arrest and incarceration of people of color for drug-related crimes is a problem described by Michelle Alexander in her book
a. Notes of a Native Son
b. The New Jim Crow
c. The War on Drugs
d. Race in America
Answer: B
Explanation: The specific issue of drug policies being applied equitably to people of color and incarcerating them is detailed in The New Jim Crow (Structural Racism and the Opioid Overdose Epidemic Article, author Kunins, page 2, paragraph 2)
In his lecture on kidney transplantation, Dr, Morrissey described a few different racial disparities in health outcomes in the field of nephrology. Which of the following accurately describes these existing disparities?
A. Native Americans experience the greatest increase in life expectancy in comparison to other races after a successful transplant
B. Black Americans have better survival rates on hemodialysis but worse results than other races with kidney transplants
C. White Americans have better survival rates with hemodialysis and kidney transplants
D. Asian Americans have better survival rates on peritoneal dialysis but not hemodialysis
Answer B.
Only B references a disparity discussed by Dr. Morrissey, all of the other choices are meant to be distractors.
Source Dr. Morrissey Lecture “Organ Transplantation” slide 37
In the article “SPIKES - A Six-Step Protocol for Delivering Bad News”, the authors cited several stressors as potential barriers to delivering bad news, based on a survey administered at an American Society of Clinical Oncology (ASCO) Meeting. Which of the following was what the symposium attendees perceived to be the most difficult part of discussing bad news?
A) Being honest but not taking away hope
B) Dealing with the patient’s emotion (e.g., crying, anger)
C) Spending the right amount of time
D) Involving friends and family of the patient
Source: SPIKES article, Paragraph 2 under “Barriers to Breaking Bad News” and Table 1
Correct Answer: A
The correct answer is A, being honest but not taking away hope, which was the answer given by 58% of respondents. Dealing with a patient's emotion, while also a significant concern, comprised only 25.1% of responses. Spending the right amount of time comprised 10.3% of responses, while involving friends and family of the patient comprised 6.5% of the responses.
The biopsy result shows that the patient has a Her2neu positive breast cancer. What treatment do you recommend?
a) Tamoxifen
b) Trastuzumab
c) Tamoxifen + chemotherapy
d) Trastuzumab + chemotherapy
The answer is (d) Trastuzumab + chemotherapy. Trastuzumab is used to treat Her2neu+ cancers, while Tamoxifen is used to treat ER+ cancers. Trastuzumab is also more effective when given in conjunction with chemotherapy.
Donald is a 74-year-old with Stage IV Stomach Cancer with metastases to the lungs. Given his situation, Dr. Byedn sent him to you, a palliative care physician. Donald reports his pain as 5 on a scale of 10. What drugs do you prescribe?
A. Dexamethasone
B. NSAIDs
C. Opioids
D. Haloperidol
Answer: C. See Comfort Care for Patients Dying in the Hospital. Pain higher than 3 should be treated with opioids.
The ________ opioid receptor is responsible for the preponderance of clinical effects caused by opioids. Studies in knockout mice confirm that agonism of these receptors mediates both analgesia and opioid dependence.
a. Kappa
b. Delta
c. Chi
d. Mu
(d) The mu opioid receptor is indicated in dependency and analgesic effects of exogenous opioids.