The New England Journal of Medicine

Question 1

What is spindle-cell sarcoma?

Answer 1

“Spindle-cell sarcoma is a rare connective-tissue tumor that can grow rapidly.”

[NEJM, Feb 28, 2019]

It can occur in bone, muscle, fat, fibrous tissue, or other connective or supportive tissue.

Question 2

“Aspiration measured by this technique occurs commonly in healthy young men during sleep, is unrelated to sleep quality, and is variable within subjects studied on more than one occasion. The quantity aspirated is of an order of magnitude likely to contain bacterial organisms in _______________ ___________ quantities.”

Answer 2

physiologically significant

[Quantitative aspiration during sleep in normal subjects
By: Gleeson, K (Gleeson, K); Eggli, DF (Eggli, DF); Maxwell, SL (Maxwell, SL)
CHEST, May 1997
Volume: 111 Issue: 5 Pages: 1266-1272
DOI: 10.1378/chest.111.5.1266]

Question 3

Aspiration of small amounts of oropharyngeal secretions is normal in healthy persons during sleep, yet _______________ is also the major pathogenetic mechanism of most pneumonias.

Answer 3

microaspiration

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 4

Large-volume aspiration (_______________) of colonized oropharyngeal or upper gastrointestinal contents is the sine qua non of aspiration pneumonia.

Answer 4

macroaspiration

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 5

Virulence is defined as:

Answer 5

“the relative capacity of a microorganism to cause damage to a host.”

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 6

The _______ adaptive ______ model suggests that acute bacterial pneumonia results from enhancement of a growth-promoting signal by a positive feedback loop. This may result in a rapid shift from a diverse microbial mixture to dominance by a single species (e.g., Streptococcus pneumoniae or Pseudomonas aeruginosa). Various signaling molecules in humans, including neurotransmitters, cytokines, and hormones such as glucocorticoids, have been shown in vitro to promote the growth of S. pneumoniae and certain gram-negative rods.

Answer 6

complex adaptive system model

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 7

One hypothesis linking the airway microbiome with aspiration pneumonia is that illness may result in a change in the lung microbiota (_________), which may, in turn, interfere with or impair pulmonary ________. A macroaspiration event, particularly in a patient with risk factors for impaired bacterial elimination, such as reduced consciousness or an impaired cough reflex, could then overwhelm the elimination side of the immigration–elimination balance, further disrupting bacterial homeostasis and triggering an increase in a positive feedback loop leading to acute infection.

Answer 7

dysbiosis

defenses

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 8

An important clinical context for aspiration pneumonia is cardiac arrest. In a study involving 641 patients with cardiac arrest, pneumonia developed within 3 days after the event in __% of the patients.
The presumed mechanism is aspiration of gastric contents during resuscitation (promoted by stomach ventilation and the resuscitation procedure) and inhalation of oral secretions during bag–valve–mask ventilation and intubation.

Answer 8

65%

[Perbet S, Mongardon N, Dumas F, et al. Early-onset pneumonia after cardiac arrest: characteristics, risk factors and influence on prognosis.
Am J Respir Crit Care Med 2011; 184:1048-1054.]

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 9

Chemical pneumonitis is characterized by a sudden onset of dyspnea, hypoxemia, tachycardia, and diffuse wheezes or crackles on examination. A chest radiograph is usually abnormal, and a pattern that is characteristic of acute respiratory distress syndrome develops in up to 16.5% of patients with witnessed aspiration, although the frequency rises if other risk factors (shock, trauma, or pancreatitis) are also present51 (Figure 2B). Low-pH aspirates are usually sterile, and bacterial infection is unusual initially, although ______________ may develop subsequently.

Answer 9

superinfection

[“Aspiration Pneumonia”, NEJM, February 14, 2019]

Question 10

The Apixaban for Reduction in Stroke and Other
Thromboembolic Events in Atrial Fibrillation
trial (ARISTOTLE; ClinicalTrials.gov number,
NCT00412984) showed that in patients with atrial fibrillation, ________ was superior to ________ in preventing stroke or system embolism, caused less bleeding, and resulted in _____ _________.

Answer 10

apixaban was superior to warfarin
lower mortality

[“Apixaban versus Warfarin in Patients
with Atrial Fibrillation”, 2011]

The investigators found that apixaban was not only
noninferior to warfarin, but actually superior, reducing the risk of stroke or systemic embolism by 21% and the risk of major bleeding by 31%. In predefined hierarchical testing, apixaban, as compared with warfarin, also reduced the risk of death from any cause by 11%.