Q: Which cutaneous malignancy is common after solid organ transplant? - Select one

A) Basal Cell Carcinoma
B) Squamous Cell Carcinoma



Answer: B

Due to long-term immunosuppression squamous cell carcinoma is common after solid organ transplant. Clinically, it is important to identify them, as in transplant recipients they tend to have a very aggressive course.

Q: What is the targeting lower INR before doing emergent endoscopy in patients with life-threatening upper gastro-intestinal bleed (UGIB)?


Answer: 3

In life-threatening UGIB, emergent endoscopy should be done as soon as possible to diagnose and stop the bleed. Studies have shown that upper GI endoscopy can be performed safely with INR less than 3. Also, in patients with cirrhosis INR is not a reliable indicator of coagulopathy because it only reflects changes in procoagulant factors.



Further reading/References:

1. Maltz GS, Siegel JE, Carson JL. Hematologic management of gastrointestinal bleeding. Gastroenterol Clin North Am 2000; 29:169.

2. ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70:1060.

3.Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol 2007; 102:290.

Q: how much Iron get transfused with one unit pRBC bag (300 cc)? 


Answer:  200 mg

 Life-threatening anemia requires pRBC. Each bag of red blood transfusion (approximately 250-300 cc) infuse about 200 mg of iron in the form of hemoglobin. Unfortunately, just Iron infusion will not serve the purpose in acute situation as directly infused iron  requires time for incorporation into RBCs.

Q: Which one trick may increase the sensitivity of spontaneous bacterial empyema (SBEM) in patients with hydrothorax?


Answer:  The sensitivity for detecting spontaneous bacterial empyema (SBEM) increase from 33% to 77% by inoculating fluid directly into a blood culture bottle at the bedside, instead of sending collected fluid tubes/bottle to microbiology laboratory.


References: 

1. Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology 1996; 23:719. 

2. Gurung P, Goldblatt M, Huggins JT, et al. Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest 2011; 140:448.

Q: By definition, what is the difference between Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)?


Answer: 

Stevens-Johnson syndrome (SJS): There is  less than 10 percent of the skin detachment of the body surface. And, involvement of mucous membranes are more than 90 percent of patients, usually at two or more major sites such as ocular, oral, and genital.

Toxic epidermal necrolysis (TEN): There is more than 30 percent of body surface is involved, and though mucous membranes are involved but not as distinctly as in SJS. 

In between or overlap cases are called SJS/TEN.

Q: What is the most likely cause of primary graft dysfunction (PGD) in new lung transplant patients? 

Answer:  Ischemia-reperfusion injury

About 10-15 percent of patients develop PGD after lung transplantation. It has been classified into four grades which determines increased 90 days mortality.

• Grade 0 – P/F ratio more than 300 with normal chest x-ray 
• Grade 1 – P/F ratio more than 300  but with diffuse allograft infiltrates on chest x-ray 
• Grade 2 – P/F ratio 200 to 300 
• Grade 3 – P/F ratio less than 200

Reference: 

Christie JD, Carby M, Bag R, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part II: definition. A consensus statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2005; 24:1454. 

Q: Given if Decadron (Dexamethasone) is not available, what is the dose of Solumedrol (methylprednisolone) is appropriate to use in post-extubation stridor/risk of laryngeal edema?


Answer:    Methylprednisolone 20 mg every four hours for a total of four doses. 

Dexamethasone 4 mg for total of four doses is usually used in ICUs to avoid re-intubation secondary to laryngeal edema. Methylprednisolone can be used also instead of Dexamethasone. 20 mg of Methylprednisolone is usually enough. At the most 40 mg should be suffice. Objective of this question is to emphasize to avoid massive dose of steroid.


 Reference: 

 Cheng KC, Chen CM, Tan CK, et al. Methylprednisolone reduces the rates of postextubation stridor and reintubation associated with attenuated cytokine responses in critically ill patients. Minerva Anestesiol 2011; 77:503.

Q: What is Monod sign?    

Answer:  Monod or Monad sign refers to air that surrounds an aspergilloma in a pre existing pulmonary cavity.This is in contrast to "Air-Crescent" sign which is new crescent shaped air inside aspergilloma cavity and represents recovery. This can also be best described as mobile aspergilloma or gravity-dependent aspergilloma within a pulmonary cystic cavity, and not a good prognostic sign.

Q: What is "Air-Cresent" sign?

Answer:  An air crescent sign is a crescent of air usually seen in invasive aspergillosis or any disease process that cause pulmonary necrosis. It is due to increased granulocyte activity. This is regarded as a good sign as it may herald recovery. As patient recovers necrotic tissues starts getting absorbed from periphery and retraction of the infarcted center creates air filled crescent area. Though it is considered as a hallmark sign of aspergillosis, it may also be seen in pulmonary tuberculous cavity, pulmonary abscess, bronchogenic carcinoma, pulmonary haematoma and Pneumocystis jirovecii pneumonia (PJP).

Q: Which organ failure is found to be associated with linezolid-induced thrombocytopenia?


Answer:  Renal

Not fully explained but linezolid associated thrombocytopenia is found to be more common in patients with End Stage Renal Disease (ESRD).



Reference: 

Wu VC, Wang YT, Wang CY, et al. High frequency of linezolid-associated thrombocytopenia and anemia among patients with end-stage renal disease. Clin Infect Dis 2006; 42:66.

Q: What is physiologic pulmonary Right-to-Left  shunt?


Answer:   When perfusion occurs to non-ventilated alveoli like in atelectasis, pneumonia or ARDS is called physiologic Right-to-Left shunt. It results in hard to correct  hypoxemia.

Q: Which group of antibiotic has been reported to be associated with retinal detachment?


Answer: Fluoroquinolone

Reports are out there in literature showing an association between current use of fluoroquinolones and retinal detachment.


References: 

 Etminan M, Forooghian F, Brophy JM, et al. Oral fluoroquinolones and the risk of retinal detachment. JAMA 2012; 307:1414. 

Pasternak B, Svanström H, Melbye M, Hviid A. Association between oral fluoroquinolone use and retinal detachment. JAMA 2013; 310:2184.

Q: Closure of atrial septal defect (ASD) is indicated in all of the following except?

A) Shunt causing right ventricular volume overload 
B) evidence of paradoxical emboli
C) Arrhythmias
D) Severe irreversible pulmonary hypertension 
E) Orthodeoxia-platypnea


Answer: ASD closure is indicated or at least suggested in most of the cases except severe irreversible pulmonary hypertension or Eisenmenger syndrome. Patients with severe irreversible pulmonary hypertension (defined as Pulmonary Vascular Resistance more than two-third of systemic vascular resistance) should not undergo ASD closure. This is for two reasons. First, these patients usually have lower life expectancy and risk of procedure may supercede benefit of closure. Second, maintenance of interatrial communication provides a mechanism to maintain cardiac output though at the expense of desaturation but in acceptable or rather advantageous way.


 Reference: 

 Baumgartner H, Bonhoeffer P, De Groot NM, et al. ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010; 31:2915.

Q: Does "edge-to-edge leaflet repair device" (trade name=MitraClip) implantation for Transcatheter mitral valve repair (TMVR) requires infective endocarditis prophylaxis?


Answer:  There is a lack of consensus among experts regarding antibiotic prophylaxis for infective endocarditis for patients undergoing minimally invasive "edge-to-edge leaflet repair device"  implantation for Transcatheter mitral valve repair (TMVR). European Society of Cardiology infective endocarditis guidelines (2015) suggest antibiotic prophylaxis, but American Heart Association/American College of Cardiology valve guidelines (2014) does not require infective endocarditis prophylaxis. Patients should be instructed to practice dental hygiene and watch for any sign of infection.


References: 

1. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.

2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.

Q: For patients with symptomatic Nonsustained Ventricular Tachycardia (NSVT), the first line of treatment is? 

A) Beta Blocker (BB)
B) Calcium Channel Blocker (CCB)
C) Amiodarone
D) Catheter ablation


Answer: A

 Beta blockers(BB) are usually good to control NSVT. In case if patient doesn't respond to BB, CCB (either verapamil or diltiazem) is the second line of treatment. Antiarrhythmic medications e.g. amiodarone should be used as a third line of treatment. Catheter ablation remains a last resort. To add, patients who have NSVT with congestive heart failure (CHF) may become a candidate for the automatic implantable cardioverter-defibrillator(AICD)


Reference: 

Pedersen CT, Kay GN, Kalman J, et al. EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace 2014; 16:1257.

Q: Which size of chest tube should be inserted in trauma patients when hemothorax is suspected?


Answer: 36 F

It takes about 300 cc of blood in chest for hemothorax to be seen on an upright CXR.  36 F chest tube would be best to drain if needed.

Q: 54 year old female is transferred to ICU from oncology floor with coma which requires intubation. Labs send 2 hours ago showed calcium of 18.4 mg/dL. What should be the next step (Best answer)

A) Intravenous fluid (IVF)
B) intravenous fluid with Furosemide
C) Hemodialysis
D) Intravenous Bisphosphonate
E) Zoledronic acid


Answer: C

Hemodialysis(HD) rarely gets mentioned as treatment for life threatening hypercalcemia but once calcium level cross 18 mg/dL with obvious clinical signs, HD becomes an absolute indication. IVF, IV Bisphosphonates or Zoledronic acid are all valid treatments of hypercalcemia but in extreme situation, HD is indicated.

Q: During insertion of Central Venous Catheter (CVC), resistance is felt during guidewire  advancement. You decided to withdraw wire to check patency of needle in the vessel again. While withdrawing wire you feel some resistance at withdrawal also. What should be your line of action?




Answer:  Simultaneously remove the needle and guidewire.

If resistance is felt during guidewire advancement as well as on withdrawal, needle and guidewire should be removed simultaneously. Trying to remove guidewire only may shear off the wire by the needle and may cause embolization of broken wire piece. 

Q: In trauma patients, which side of diaphragm is more prone to injury? Left or Right?



Answer: Left

Left-sided diaphragmatic rupture occurs as twice as posterolateral aspect of the left hemidiaphragm is relatively weak. Also, the bowel and stomach provide relatively less protection to left diaphragm than the hepatic support for right diaphragm.

Q: 52-year-old female is admitted to ICU with abdominal pain. CT scan reports described adrenal mass. All of the followings are in favour of benign adrenal mass (incidentaloma) except?

A) Size less than 4 cm in diameter
B) Smooth border
C) Rapid contrast medium washout
D) Tumor calcification
E) Low attenuation value


Answer:  D

A Characteristics of incidentaloma are: size less than 4 cm in diameter, a smooth border, an attenuation value less than 10 Hounsfield unit (HU) on unenhanced CT, and rapid contrast medium washout (more than 50 percent at 10 minutes). On the contrary, mass more than 4 cm in diameter, irregular shape, tumor calcification, a high attenuation value on unenhanced CT and delayed contrast medium washout (less than 50 percent at 10 minutes) are highly suggestive of either adrenal carcinoma or metastases.

Q: What are the good indicators in Diabetic Ketoacidosis (DKA) to transit from IV insulin infusion to subcutaneous insulin injections? 


Answer: According to American Diabetes Association (ADA) guidelines for DKA,  IV insulin can be tapered and subcutaneous insulin doses can be scheduled to start when the blood glucose is less than 200 mg/dL and 2 of the following 3 goals are met

• Serum anion gap less than 12
• Serum bicarbonate more than or equal to 15
• Venous PH more than 7.30

References:

Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335.

Q: In Central Nervous System injury, the distinction between Cerebral Salt Wasting(CSW) and SIADH is critically important since both disorders may occur but are managed differently, and choosing wrong algorithm of treatment may be fatal. Which one clinical sign differentiate between CSW and SIADH? 



Answer:  Hypovolemia

Both disease processes in CNS injury shared many similar characteristics like

• The high urine osmolality 
• The urine sodium is usually more than 40 meq/L 
• Serum uric acid concentration is reduced due to urinary loss

Hypovolemia despite significant urinary sodium highly suggests CSW

Treatment of hypovolemia with isotonic saline in CSW helps in resolving the issue but same isotonic saline may worsens the hyponatremia in SIADH.



References:

1. Palmer BF. Hyponatremia in patients with central nervous system disease: SIADH versus CSW. Trends Endocrinol Metab 2003; 14:182. 

2. Maesaka JK, Imbriano LJ, Ali NM, Ilamathi E. Is it cerebral or renal salt wasting? Kidney Int 2009; 76:934.

Q: 45 year old male is admitted to ICU with exacerbation of Crohn's disease. Patient c/o aphthous ulcerations in mouth. What is the treatment?


Answer:   Aphthous ulcers in crohn's disease flare are important as clinically they can be so painful that may overshadow patient's abdominal complaints. Triamcinolone acetonide provides relief but actual treatment is taking care of intestinal flare which simultaneously resolves aphthous ulcers.

Q: What is the added advantage of endoscopic application of hemoclips in upper gastro-intestinal bleed?


Answer: They may serve as a radiopaque marker for subsequent interventional angiographic or surgical intervention.

Q: 49 year old male with previous history of crohn's disease with colectomy is admitted to ICU from floor due to hypotension and severe diarrhea. What should be the first concern?


Answer: C. Diff.

C. difficile infection in patients with Inflammatory Bowel Disease with previous surgery is very common and can get fatal without treatment. Oral vancomycin is said to be better than metronidazole.




References:

1. Issa M, Vijayapal A, Graham MB, et al. Impact of Clostridium difficile on inflammatory bowel disease. Clin Gastroenterol Hepatol 2007; 5:345. 

2. Horton HA, Dezfoli S, Berel D, et al. Antibiotics for Treatment of Clostridium difficile Infection in Hospitalized Patients with Inflammatory Bowel Disease. Antimicrob Agents Chemother 2014; 58:5054.

Q: 54 year old female with no past medical history is admitted to ICU due to shortness of breath requiring intubation. Over the course of the days patient is diagnosed with Non Small Cell Lung Cancer (NSCLC). Radiation-oncologist calls you saying: "Patient has high standardized uptake value (SUV)". What does it means?


Answer: 

During staging of Lung cancer Positron emission tomography (PET) measures tumor's metabolic activity and get reported as standardized uptake value (SUV) to assess the tumor uptake of fluorodeoxyglucose (FDG). A  high SUV is associated with a poor prognosis and a lower FDG uptake is associated with a better prognosis.

Pearl on percutaneous Cholecystostomy 

ICU patients are very prone to develop acalculous cholecystitis - and unfortunately most of them are not surgical candidate. These patients usually receive drainage tube via cholecystostomy. Patients should start showing sign of recovery within 24-36 hours - and in case of failure to show improvement further consideration should be given to either complications like gangrenous cholecystitis, resulting in  bile leakage, or catheter malposition.

Q: Out of the following, which electrolyte imbalance is the hallmark of MDMA (ecstasy) intoxication?

A) Hyponatremia
B) Hyperkalemia (due to hyperthermia)
C) Hypocalcemia
D) Hypernatremia
E) Hypokalemia


Answer:  A

MDMA  may induce mild to moderate and in some instances severe hyponatremia, causing life-threatening effects like seizures, cerebral edema leading to brain herniation. Hyponatremia should be treated with caution as in any other circumstances to avoid complications from rapid correction.

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Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome A Randomized Clinical Trial

Importance  Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients.

Objective  To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS.

Design, Setting, and Participants  Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015.

Interventions  Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group.

Main Outcomes and Measures  The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator–free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality.

Results  Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, −43.3%; 95% CI, −62.4% to −24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, −22.3%; 95% CI, −43.3 to −1.4; P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers).

Conclusions and Relevance  Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings.

Reference:


Bhakti K. Patel, MD; Krysta S. Wolfe, MD; Anne S. Pohlman, MSN; Jesse B. Hall, MD; John P. Kress, MD - Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome A Randomized Clinical Trial -  JAMA. 2016;315(22):2435-2441