Question of the Week #483


Beta-blockers reduce mortality in patients who have chronic heart failure, systolic dysfunction, and are on background treatment with diuretics and angiotensin-converting enzyme inhibitors. We aimed to compare the effects of carvedilol and metoprolol on clinical outcome.


In a multicenter, double blind, and randomized parallel group trial, we assigned 1511 patients with chronic heart failure to treatment with carvedilol (target dose 25 mg twice daily) and 1518 to metoprolol (metoprolol tartrate, target dose 50 mg twice daily). Patients were required to have chronic heart failure (NYHA II-IV), previous admission for a cardiovascular reason, an ejection fraction of less than 0.35, and to have been treated optimally with diuretics and angiotensin-converting enzyme inhibitors unless not tolerated. The primary endpoints were all-cause mortality and the composite endpoint of all-cause mortality or all-cause admission. Analysis was done by intention to treat.


The mean study duration was 58 months (SD 6). The mean ejection fraction was 0.26 (0.07) and the mean age 62 years (11). The all-cause mortality was 34% (512 of 1511) for carvedilol and 40% (600 of 1518) for metoprolol (hazard ratio 0.83 [95% CI 0.74-0.93], p=0.0017). The reduction of all-cause mortality was consistent across predefined subgroups. Incidence of side effects and drug withdrawals did not differ by much between the two study groups.


  1. To which of the following patients are the results of this clinical trial applicable?
    1. A 62-year-old male with primarily diastolic congestive heart failure.
    2. A 75-year-old female with systolic dysfunction and an EF of 45%.
    3. A 56-year-old male with NYHA class I systolic heart failure.
    4. A newly diagnosed 66-year-old male who has yet to begin treatment for his NYHA class II systolic heart failure.
    5. A 68-year-old male with NYHA class II systolic heart failure and EF 30%.


Question of the Week #482



Aldosterone blockade reduces mortality and morbidity among patients with severe heart failure. We conducted a double blind, placebo-controlled study evaluating the effect of eplerenone, a selective aldosterone blocker, on morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure.


Patients were randomly assigned to eplerenone (25 mg per day initially, titrated to a maximum of 50 mg per day; 3319 patients) or placebo (3313 patients) in addition to optimal medical therapy. The study continued until 1012 deaths occurred. The primary end points were death from any cause and death from cardiovascular causes or hospitalization for heart failure, acute myocardial infarction, stroke, or ventricular arrhythmia.


During a mean follow-up of 16 months, there were 478 deaths in the eplerenone group and 554 deaths in the placebo group (relative risk, 0.85; 95 percent confidence interval, 0.75 to 0.96; P=0.008). Of these deaths, 407 in the eplerenone group and 483 in the placebo group were attributed to cardiovascular causes (relative risk, 0.83; 95 percent confidence interval, 0.72 to 0.94; P=0.005). The rate of the other primary end point, death from cardiovascular causes or hospitalization for cardiovascular events, was reduced by eplerenone (relative risk, 0.87; 95 percent confidence interval, 0.79 to 0.95; P=0.002), as was the secondary end point of death from any cause or any hospitalization (relative risk, 0.92; 95 percent confidence interval, 0.86 to 0.98; P=0.02). There was also a reduction in the rate of sudden death from cardiac causes (relative risk, 0.79; 95 percent confidence interval, 0.64 to 0.97; P=0.03). The rate of serious hyperkalemia was 5.5 percent in the eplerenone group and 3.9 percent in the placebo group (P=0.002), whereas the rate of hypokalemia was 8.4 percent in the eplerenone group and 13.1 percent in the placebo group (P<0.001).

  1. Which of the following statements represents the most accurate interpretation of the results from the aforementioned clinical trial?
    1. There was no significant difference in the incidence of hyperkalemia between trial arms.
    2. There was no significant difference in the rate of sudden cardiac death between trial arms.
    3. Epleranone, when added to optimal medical therapy, decreases all cause mortality in patients with left ventricular dysfunction following myocardial infarction.
    4. The rate of hypokalemia was not significantly different between trial arms.
    5. The most common causes of death seen in enrolled patients over the course of this trial were non-cardiac in nature.

Question of the Week #481

A 90 year old man with history of advanced dementia is brought to hospital with aspiration pneumonia. This is his 5th episode of Aspiration pneumonia in the past 1 year. He is accompanied by his daughter who also happens to be his healthcare proxy. She wants to focus on her father’s comfort as the goal of care and requests no further diagnostic interventions and she would like to avoid further hospitalizations. She wants to know what would make him eligible to receive hospice care. Based on which of the following factors, can he be qualified for hospice?

A. His advanced age

B. Diagnosis of advanced dementia

C. Prognosis

D. His wishes to die at home

News from USMLE :

USMLE Step 3 Change in number of items and score delay

Beginning the week of January 18, 2016, the number of items on the Step 3 examination will decrease. There will be a delay in reporting scores for exams administered between January 18 and April 30, 2016. The target date for reporting Step 3 scores for most examinees testing during this time period is May 25, 2016.

Although this change will occur quickly at many test centers, there may be some locations where the transition takes longer to complete. The overall transition period should last approximately six weeks. Please note that:

  • The length of the testing days will not change.
  • Day 1 (Foundations of Independent Practice [FIP]) will continue to be an approximately 7-hour testing session, including time for breaks and tutorials.
  • Day 2 (Advanced Clinical Medicine [ACM]) will continue to be a 9-hour testing session, including time for breaks and tutorials.
  • Day 1 (FIP) will continue to be divided into six 60-minute blocks.
  • Each FIP block will have 38 to 40 multiple-choice questions (MCQs).
  • The total number of MCQs on the FIP portion of the examination will be 233.
  • Day 2 (ACM) will continue to be divided into six 45-minute blocks of MCQs, and 13 computer-based case simulations (CCS).
  • Each ACM MCQ block will have 30 items.
  • The total number of MCQ items on the ACM portion of the examination will be 180.
  • Scores on examination forms taken before and after the change – as well as scores on forms with different numbers of items – will be comparable; the possible variation in the number of items per form will be accounted for in scoring the examination.

Score reports for Step 3 are usually available within four weeks of testing. However, because of the change described above, as well as routine modifications to the test item pool, score reporting for most Step 3 examinations administered from January 18, 2016 through April 30, 2016 will take longer. As noted above, the target date for reporting Step 3 scores for most examinees testing during this time period is May 25, 2016.

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Question of the week # 480

A 32-year-old man comes in regularly because his back hurts. You suspect malingering because he continually requests narcotic pain relievers and imaging studies of his spine. He has come 5 times in the last 6 months with the same problem, typically stating that the pain improves with exercise and leaning forward but is worse at night; pain also occurs at times in his buttocks and does not improve with rest. On physical examination you find no abnormalities of the spine besides inflexibility of the lower spine when he leans forward. Neurological examination is normal, including the absence of pain on a straight-leg raise test. X-ray of the spine and sacroiliac joint is normal. All blood tests including rheumatoid factor, ESR, and C-reactive protein are normal. Today, he again claims to have only minimal improvement with ibuprofen. He is requesting narcotics and a “doctor’s note to get out of work.” What is the next best step in management?

A. MRI of the sacroiliac joint
B. Anti-cyclic citrullinated peptide (anti-CCP)
C. HLA-B27 testing
D. Methotrexate
E. Report to employer for malingering

Question of the Week # 479

479. A 57 year old female presents for second opinion of a left breast lesion that had been diagnosed as ‘eczema’ by her regular nurse practitioner, which briefly improved after a short course of topical steroids. On physical exam there is an erythematous, scaly lesion involving the left breast. Image is shown below. Her last mammogram was a year ago and it was “fine”. She does not report any family history of breast cancer. What is the next step in the patient’s management?

image br rash

A – Bilateral breast ultrasound

B – Bilateral mammography and punch biopsy of nipple

C – Maintain regular annual mammography appointment

D – Oral corticosteroids

E – Left breast MRI

Question of the Week # 478

478) You are evaluating a 24-year-old female patient who presented with severe abdominal pain two hours prior to admission. She states the pain began in the periumbilical region and has moved to the low abdomen, and she had one episode of emesis with nausea, but no diarrhea. Her last menstrual period was normal and began 27 days ago. On examination, she has a temperature of 98.9, heart rate of 118 beats per minute, and respirations 20/min. Her blood pressure is 100/80. Examination of the abdomen reveals diffuse tenderness to palpation, and she is guarding moderately and has diminished bowel sounds. Complete blood count reveals a hemoglobin of 12 g/dL and a hematocrit of 38%. White blood cell count is 12,500/mm3 with a left shift. Urinalysis reveals 2-5 WBC/hpf. Which of the following is the next best step in management of this patient?

A. Flat and upright abdominal film

B. Pelvic ultrasound

C. Urine b HCG

D. CT abdomen and pelvis

E. Serum beta HCG

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