Q: Patient is admitted to ICU with fever, malaise and cough. High resolution CT scan (HRCT) is performed and bronchoalveolar lavage (BAL) is performed. Result of BAL is c/w mixed cellularity with more lymphocytes, some neutrophils and some eosinophils. "Mixed pattern" of increased cellularity is characteristic of which disease process?


Answer: Cryptogenic organizing pneumonia (COP)

BAL in COP is performed more to rule out other pulmonary disease processes. If bronchoscopy remains without specific findings and BAL shows 'mixed cellularity", it points more towards COP. Patients with COP usually have higher lymphocyte counts than those with idiopathic pulmonary fibrosis (IPF), but similar in proportion to hypersensitivity pneumonitis. BAL may also shows foamy macrophages, mast cells and plasma cells.



References:

1. Katzenstein AL, Myers JL, Prophet WD, et al. Bronchiolitis obliterans and usual interstitial pneumonia. A comparative clinicopathologic study. Am J Surg Pathol 1986; 10:373. 

2. Colby, TV, Myers, JL. The clinical and histologic spectrum of bronchiolitis obliterans including bronchiolitis obliterans organizing pneumonia (BOOP). Semin Respir Med 1992; 13:119.

Q: Though administration of foscarnet can cause various electrolyte dysfunctions, which electrolyte abnormality is established and need attention?



Answer: Foscarnet is used for the treatment of ganciclovir-resistant cytomegalovirus (CMV). It is establish to cause hypocalcemia via forming complex formation with free calcium. Attention should also be paid if simultaneous hypomagnesemia is present. Without treating magnesium depletion, hypocalcemia will not get better.


Reference:

Guillaume MP, Karmali R, Bergmann P, Cogan E. Unusual prolonged hypocalcemia due to foscarnet in a patient with AIDS. Clin Infect Dis 1997; 25:932.

Q: Lactic acidosis due to Linezolid requires at least two weeks of administration?

A) True
B) False


Answer:  B

Linezolid acts at bacterial ribosomes but can also affect human mitochondrial ribosomes and may lead to lactic acidosis. Usually linezolid-induced lactic acidosis happens after few days of therapy but now case reports have been out of lactic acidosis at induction of therapy.



References:

Velez JC, Janech MG. A case of lactic acidosis induced by linezolid. Nat Rev Nephrol 2010; 6:236.

Q; What is Gerstmann syndrome? 


Answer: Gerstmann syndrome is a combination of patient's symptoms of acalculia, agraphia, finger agnosia, and right-left disorientation. This is due to infarcts involving Left posterior cerebral artery (PCA) territory.

In contrast, infarcts involving right PCA territory presents as difficulty in recognizing familiar faces, spatial disorientation, and visual neglect.

Clinical pearl to remember in either right or left posterior cerebral artery (PCA) territory infarcts is that they are due to embolism from the heart, aorta, or vertebral arteries. Dissection of the PCAs is very uncommon. The most frequent finding in patients with PCA territory infarction is a hemianopia. All of the above findings described are in addition and to differentiate between right and left PCA.


References:

1.  Caplan L. Posterior circulation ischemia: then, now, and tomorrow. The Thomas Willis Lecture-2000. Stroke 2000; 31:2011.
2. Yamamoto Y, Georgiadis AL, Chang HM, Caplan LR. Posterior cerebral artery territory infarcts in the New England Medical Center Posterior Circulation Registry. Arch Neurol 1999; 56:824. 
3. Benson DF, Marsden CD, Meadows JC. The amnesic syndrome of posterior cerebral artery occlusion. Acta Neurol Scand 1974; 50:133. 

Q; Prednisone respond earlier to Immune thrombocytopenia (ITP) in adults than Dexamethasone?

A) True
B) False

Answer:  False

Different treatment modalities have different response time in ITP including even types of steroid.  Dexamethasone works faster than Prednisone. 

• Dexamethasone response time is 2 to 14 days, and
• Prednisone response time is 4 to 14 days

In cases where more rapid response is needed like in active bleeding, patients urgent invasive procedure etc, intravenous immune globulin (IVIG) should be used, which can increase platelet count within 24 to 48 hours.


References:

1.  Salib M, Clayden R, Clare R, et al. Difficulties in establishing the diagnosis of immune thrombocytopenia: An agreement study. Am J Hematol 2016; 91:E327. 

2. Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood 2009; 113:2386.

Q; 52 year old male is transferred to floor with hemoptysis after intubation. To determine which side of the lung is have bleeding, the next step should be

A) Auscultation
B) CXR
C) CT chest
D) Change single lumen to double lumen endotracheal tube
E) Bronchoscope


Answer: A 

 CXR, CT chest, bronchoscope, changing ETT and bronchoscope are all valid in management of massive hemoptysis but they sometimes take time. Simple auscultation may provide good clue to bleeding coming from which lung. Usually it is a gurgling sound. This is an extremely important step as if auscultated well patient should be immediately placed with presumed bleeding lung in the dependent position, to prevent non-bleeding lung from spillage of blood from the bleeding lung.

Q: Pleural fluid eosinophilia (PFE) is defined as? 

 A) pleural fluid consist of more than 10 percent eosinophils and mostly exudative
 B) pleural fluid consist of more than 10 percent eosinophils and mostly transudative
 C) pleural fluid consist of more than 20 percent eosinophils and mostly exudative
 D) pleural fluid consist of more than 20 percent eosinophils and mostly transudative
 E) pleural fluid consist of more than 25 percent eosinophils and can be either transudative or exudative


Answer: B

 Pleural fluid eosinophilia (PFE) is precisely defined as pleural fluid with a nucleated cell count containing more than 10 percent eosinophils. Only about 10 percent of exudative pleural effusions are eosinophilic.


References:

1. Kalomenidis I, Light RW. Eosinophilic pleural effusions. Curr Opin Pulm Med 2003; 9:254.

2. Martínez-García MA, Cases-Viedma E, Cordero-Rodríguez PJ, et al. Diagnostic utility of eosinophils in the pleural fluid. Eur Respir J 2000; 15:166.

Q: 57 year old male is admitted via ED to ICU with sepsis. Blood cultures drawn in ED grew 2 of 2 bottles positive culture for Abiotrophia. Next day patient developed right sided hemiplegia. What would be your concern?


Answer: Possible Endocarditis

Abiotrophia in humans is a resident of oral, urogenital and intestinal tracts,  and can be a cause of infective endocarditis. Also it may raise suspicion of underlying intestinal malignancy if there is no previous history of valve or prosthetic surgeries or of dental work.



Reference:

1. Seohyun Park, Hea Won Ann, Jin Young Ahn, Nam Su Ku, Sang Hoon Han, Geu Ru Hong, Jun Young Choi, Young Goo Song, and June Myung Kim - A Case of Infective Endocarditis caused by Abiotrophia defectiva in Korea - Infect Chemother. 2016 Sep; 48(3): 229–233. 

2. Akkoyunlu Y, Iraz M, Kocaman G, Ceylan B, Aydin C, Aslan T. - Abiotrophia defectiva endocarditis presenting with hemiplegia. - Jundishapur J Microbiol. 2013;6:e8907.

On oral liposomal iron

 Effect of oral liposomal iron versus intravenous iron for treatment of iron deficiency anaemia in CKD patients: a randomized trial. 

 Pisani A, Riccio E, Sabbatini M, Andreucci M, Del Rio A, Visciano B.

Nephrol Dial Transplant. 2015 Apr;30(4):645-52. 

INTRODUCTION: Iron deficiency is a common cause of anaemia in non-dialysis chronic kidney disease (ND-CKD). Controversies exist about the optimal route of administration for iron therapy. Liposomal iron, a new generation oral iron with high gastrointestinal absorption and bioavailability and a low incidence of side effects, seems to be a promising new strategy of iron replacement. Therefore, we conducted a study to determine whether liposomal iron, compared with intravenous (IV) iron, improves anaemia in ND-CKD patients.

METHODS: In this randomized, open-label trial, 99 patients with CKD (stage 3-5, not on dialysis) and iron deficiency anaemia [haemoglobin (Hb) ≤12 g/dL, ferritin ≤100 ng/mL, transferrin saturation ≤25%] were assigned (2:1) to receive oral liposomal iron (30 mg/day, Group OS) or a total dose of 1000 mg of IV iron gluconate (125 mg infused weekly) (Group IV) for 3 months. The patients were followed-up for the treatment period and 1 month after drug withdrawal. The primary end point was to evaluate the effects of the two treatments on Hb levels; the iron status, compliance and adverse effects were also evaluated.

RESULTS: The short-term therapy with IV iron produced a more rapid Hb increase compared with liposomal iron, although the final increase in Hb was similar with either treatment; the difference between the groups was statistically significant at the first month and such difference disappeared at the end of treatment. After iron withdrawal, Hb concentrations remained stable in Group IV, while recovered to baseline in the OS group. The replenishment of iron stores was greater in the IV group. The incidence of adverse event was significantly lower in the oral group (P < 0.001), and the adherence was similar in the two groups.

CONCLUSIONS: Our study shows that oral liposomal iron is a safe and efficacious alternative to IV iron gluconate to correct anaemia in ND-CKD patients, although its effects on repletion of iron stores and on stability of Hb after drug discontinuation are lower. 

Q: What is FeMg?

Answer:  Fractional excretion of magnesium

In refractory hypomagnesemia, it may require to find the route of continous loss of magnesium from the body. Two major routes of elimination of magnesium from the body are either gastrointestinal (GI) and renal. To distinguish magnesium loss between these two routes can be made by FeMg by formula

                           UMg  x  PCr
 FEMg    =    —————————   x    100 percent
                    (0.7  x  PMg)  x  UCr


U = Urine
P = Plasma
Cr = Creatinine


FEMg more than 2% indicates inappropriate renal wasting.


References:

1. Topf, J.M. & Murray, P.T. (2003) Hypomagnesemia and hypermagnesemia. Reviews in Endocrine & Metabolic Disorders, 4, 195– 206.

2. Elisaf M, Panteli K, Theodorou J, Siamopoulos KC. Fractional excretion of magnesium in normal subjects and in patients with hypomagnesemia. Magnes Res 1997; 10:315.

Q: All of the following electrolyte abnormalities occurs during Cardio-Pulmonary-Bypass (CPB) except? 

A) hypocalcemia
B) hyperkalemia, 
C) hypermagnesemia
D) hyperglycemia


Answer: C

Hypomagnesemia is frequently occurred during CPB due to two reasons

1. Diuresis 
2. Hemodilution with magnesium-free fluids during CPB

Therefore, it is a common practice to administer 2 grams of magnesium sulfate 2 g at the conclusion of CPB.


References:

1.  England MR, Gordon G, Salem M, Chernow B. Magnesium administration and dysrhythmias after cardiac surgery. A placebo-controlled, double-blind, randomized trial. JAMA 1992; 268:2395. 

2. Booth JV, Phillips-Bute B, McCants CB, et al. Low serum magnesium level predicts major adverse cardiac events after coronary artery bypass graft surgery. Am Heart J 2003; 145:1108.

Q: All of the following drugs can be used as a rescue therapy in refractory delirium tremens (DT) except?

A) phenobarbital 
B) Propofol 
C) dexmedetomidine 
D) haloperidol 
E)) higher dose of lorazepam


Answer:  D

Once patient requires more than 10 mg of lorazepam, suspicion for refractory DT should be raised. Lorazepam dose can be further escalated  up to 40 mg in first four hours of treatment (as far as hemodynamics remain stable). All other choices in this question i.e A, B and C are appropriate choices.

Phenobarbital has the advantage of working in synergy with benzodiazepines 1.

Dexmedetomidine is now frequently used as it may help in avoiding mechanical intubation, though evidence-based used is still weak 2.

Propofol is another excellent choice though it surely buys mechanical ventilation 3.

Haloperidol should never be used used or to least with maximum caution as  it lower the seizure, interfere with heat dissipation and cause QT prolongation.


References:

1. Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med 2013; 44:592. 

2. Tolonen J, Rossinen J, Alho H, Harjola VP. Dexmedetomidine in addition to benzodiazepine-based sedation in patients with alcohol withdrawal delirium. Eur J Emerg Med 2013; 20:425. 

3. McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000; 28:1781. 

Q: After lung volume reduction surgery in COPD patients, they should be left intubated till air leak on chest tubes resolved. 

A) Yes 
B) No


Answer:  No

Ideally, after lung volume reduction surgery in COPD patients, patients should be extubated in OR to avoid positive pressure ventilation, given other clinical scenarios are stable. If needed, reintubation can be salvaged with transient use of Non-invasive positive pressure ventilation (NIPPV).



Reference: 

 Boasquevisque CH, Yildirim E, Waddel TK, Keshavjee S. Surgical techniques: lung transplant and lung volume reduction. Proc Am Thorac Soc 2009; 6:66.

Q: How it could be determined to administer drug before or after plasmapheresis? 

 Answer: Plasmaphresis is frequently performed in ICU for various immunologic, infectious, drug overdose and metabolic diseases. If it is a lipophillic drug, it should be administer after plasmaphresis, as they are highly protein-bound, and have a small volume of distribution.


Reference: 

Kale-Pradham PB, Woo MH. A review of the effects of plasmapheresis on drug clearance. Pharmacotherapy. 1997;17:684-695

Q: If hyperbaric oxygen is used as an adjuvant to treat deep tissue infection, what is the target tissue oxygen tension?


Answer: Above 300 mmHg

Hyperbaric Oxygen, popularly known as HBO is now increasingly used in tertiary care centers as an adjuvant treatment in deep tissue infections such as gas gangrene, necrotizing fasciitis, and Fournier's gangrene. It requires 2-3 sessions daily of HBO with target to keep tissue oxygen tension above 300 mmHg to inhibit clostridial spore and exotoxin production.


Reference:

Roth RN, Weiss LD. Hyperbaric oxygen and wound healing. Clin Dermatol 1994; 12:141.

Q: 54 year old female is in ICU with end stage metastatic ovarian cancer. Patient is made DNR/DNI by the family. Patient has painful ascites and palliative large volume paracentesis is planned. Should albumin be given for large volume malignant related paracentesis?

A) Yes
B) No


Answer: No

Large volume paracentesis for malignancy-related ascites usually does not cause hemodynamic issues, so forth albumin infusion is not needed alike other causes of ascites. 


Reference:

Halpin TF, McCann TO. Dynamics of body fluids following the rapid removal of large volumes of ascites. Am J Obstet Gynecol 1971; 110:103.

Q: Which of the following electrolyte abnormality may increase the risk of post-operative ileus

A) Hypokalemia
B) Hyperkalemia


Answer: A

Post-operatively hypokalemia worsens ileus. 

Though newer evidences have questioned this conventional teaching, but so far it is important  to continue to consider hypokalemia as one of the causes of post-operative ileus. 


References:

1. . Lowman RM. The potassium depletion states and postoperative ileus. The role of the potassium ion. Radiology 1971;98:691-4.

Q: Ultrasound-based elastography can be used to evaluate

A) liver fibrosis
B) Acute Kidney Injury
C) Non-Ischemic Cardiomyopathy
D) Splenic infarction
E) Response to thrombolytic therapy


Answer: A

 Principle behind ultrasound-based elastography is simple. As expected, fibrotic tissue differs from normal healthy tissue in a way that they respond to excitation. Ultrasound-based elastography can be used as an alternative to liver biopsy for the assessment of hepatic fibrosis. Not only liver biopsy carries bleeding risk due to its invasive nature but also provides only a small portion of the liver parenchyma.

In experienced hands, ultrasound-based elastography can also be used to predict complications of cirrhosis such as development of varices and hepatocellular carcinoma. Also, it can differentiate between benign and malignant lesions and can diagnose focal nodular hyperplasia.

To further refine, this technique is divided accordingly into transient elastography, point-shear wave elastography (SWE), two-dimensional (2D)-SWE, and strain elastography. 


 References: 

1.  Parkes J, Guha IN, Roderick P, et al. Enhanced Liver Fibrosis (ELF) test accurately identifies liver fibrosis in patients with chronic hepatitis C. J Viral Hepat 2011; 18:23.

2. Guibal A, Boularan C, Bruce M, et al. Evaluation of shearwave elastography for the characterisation of focal liver lesions on ultrasound. Eur Radiol 2013; 23:1138.

3. Brunel T, Guibal A, Boularan C, et al. Focal nodular hyperplasia and hepatocellular adenoma: The value of shear wave elastography for differential diagnosis. Eur J Radiol 2015; 84:2059.

4. Lu Q, Ling W, Lu C, et al. Hepatocellular carcinoma: stiffness value and ratio to discriminate malignant from benign focal liver lesions. Radiology 2015; 275:880.

5. Nahon P, Kettaneh A, Tengher-Barna I, et al. Assessment of liver fibrosis using transient elastography in patients with alcoholic liver disease. J Hepatol 2008; 49:1062.

A note on Ultrasound Enhanced Thrombolysis in CVA 

Though literature is still young but it shows that ultrasound energy may have a biologic effect that may facilitates the activity of intravenous tPA in ischemic stroke. It is provided via high-frequency transcranial Doppler (TCD). This combination can be further enhanced by the administration of microbubbles (air or gas) which is used as ultrasound contrast agents. While applying this technique, it should be kept in mind that there is some evidence that combination of ultrasound and tPA in ischemic stroke may increase the risk cerebral hemorrhage.


References:

 1. Alexandrov AV, Molina CA, Grotta JC, et al. Ultrasound-enhanced systemic thrombolysis for acute ischemic stroke. N Engl J Med 2004; 351:2170.

2. Ricci S, Dinia L, Del Sette M, et al. Sonothrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev 2012; :CD008348. 

3. Nacu A, Kvistad CE, Naess H, et al. NOR-SASS (Norwegian Sonothrombolysis in Acute Stroke Study): Randomized Controlled Contrast-Enhanced Sonothrombolysis in an Unselected Acute Ischemic Stroke Population. Stroke 2017; 48:335. 

4. Dinia L, Rubiera M, Ribo M, et al. Reperfusion after stroke sonothrombolysis with microbubbles may predict intracranial bleeding. Neurology 2009; 73:775. Tsivgoulis G, Alexandrov A. Ultrasound-enhanced thrombolysis: from bedside to bench. Stroke 2008; 39:1404.

Q: Reexpansion pulmonary edema (RPE) may arises after rapid re-expansion of a lung that has been collapsed, for at least how many days?


Answer: Three

Re-expansion pulmonary edema (RPE) is a well known but potentially life-threatening complication of chest tube insertion that usually arises after rapid pulmonary re-expansion that has been down or collapsed, for usually about three days - either due to air (pneumo) or fluid (pleural / hemo / hydro thorax).

Q: Which of the following may be use as an antidote in Tacrolimus toxicity?

A)  Eslicarbazepine acetate (Aptiom)
B)  Gabapentin (Neurontin)
C)  Phenytoin (Dilantin)
D)  Levetiracetam (Keppra)
E) Divalproex (Depakote) 


Answer: C

 Tacrolimus is metabolized by the CYP3A enzymes, which are found in the liver and intestinal wall. Unfortunately, hemodialysis or plasma exchange are ineffective in Tacrolimus toxicity. It has been suggested that CYP3A4 inducers phenytoin and phenobarbital can used to increase the clearance and of the tacrolimus. They also have the additional benefit of seizure prevention, another well documented effect of tacrolimus overdose. 


References:

1. Z. Karasu, A. Gurakar, J. Carlson et al., “Acute tacrolimus overdose and treatment with phenytoin in liver transplant recipients,” Journal of Oklahoma State Medical Association, vol. 94, no. 4, pp. 121–123, 2001.

2. Wada, M. Takada, T. Ueda et al., “Drug interactions between tacrolimus and phenytoin in Japanese heart transplant recipients: 2 case reports,” International Journal of Clinical Pharmacology and Therapeutics, vol. 45, no. 9, pp. 524–528, 2007

Q: What percentage of patients after Left Ventricular Assist Device (LVAD) may developed Aortic Regurgitation?

Answer:  In about 25 percent

Those patients who develop clinically significant aortic regurgitation may require surgery. One non-surgical fix is to keep the pump speed set to maintain intermittent AV opening under. This should be performed by experienced cardiologist under echocardiographic monitoring. This is probably due to the fusion of aortic valve leaflets. 


References:

1. Pak SW, Uriel N, Takayama H, et al. Prevalence of de novo aortic insufficiency during long-term support with left ventricular assist devices. J Heart Lung Transplant 2010; 29:1172. 

2. Cowger J, Pagani FD, Haft JW, et al. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail 2010; 3:668. 

3. Hatano M, Kinugawa K, Shiga T, et al. Less frequent opening of the aortic valve and a continuous flow pump are risk factors for postoperative onset of aortic insufficiency in patients with a left ventricular assist device. Circ J 2011; 75:1147. 

Q; 74 year old male is admitted to ICU with  widely metastasize cancer of unknown origin. Patient stays "full code" as per his wishes. Oncology service has planned full body radiation therapy (RT). Patient previously had an immense issue with nausea and vomiting (NV) with chemotherapy. Patient should be given

A) Prophylactic treatment for NV with Steroids and Ondansetron
B) Prophylactic treatment for NV with Steroids only
C) Prophylactic treatment for NV with  Ondansetron only
D) Prophylactic treatment is not needed for Radiation therapy


Answer: A

Like chemotherapy, RT also induces NV (RINV) depending on patient's characteristic and amount of radiation. RT is classified into four categories

High – Total body irradiation
Moderate – upper abdominal irradiation as well as craniospinal radition
Low – region specific like cranium, head and neck, thorax or pelvic region
Minimal – Breast and extremities

Except for minimal risk, all patients may benefit from some sort of prophylactic treatment oin RINV. Patients with high and +/- moderated risks should be treated with dual coverage


References: 

1. Basch E, Prestrud AA, Hesketh PJ, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011; 29:4189.

2. Ruhlmann CH, Jahn F, Jordan K, et al. 2016 updated MASCC/ESMO consensus recommendations: prevention of radiotherapy-induced nausea and vomiting. Support Care Cancer 2017; 25:309.

3. Roila F, Molassiotis A, Herrstedt J, et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol 2016; 27:v119.

Picture Diagnosis

Q: 22 year old male is admitted to ICU with severe abdominal pain and anemia. While in ICU, patient was diagnosed with intestinal obstruction due to intussusception. Patient's family history is undetermined. Looking at his lips, what is the most probable diagnosis?

Answer: Peutz-Jeghers syndrome (PJS)

 PJS has a specific characteristic muco-cutaneous ppigmenation. Black to brown spots with less than 1 mm size presented mostly on lower lips and perioral area. Diagnosis can be confirmed with genetic testing.


Reference:

Akimaru K, Katoh S, Ishiguro S, Miyake K, Shimanuki K, Tajiri T. Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case. Surg Today 2006;36(11):997-1002

Q: How the proximal left anterior descending (LAD) coronary artery disease get define?

A)  proximal to and including the first major septal branch off left anterior descending coronary artery
B) proximal to and before the first major septal branch off left anterior descending coronary artery
C) First 3 cm 
D) It is an approximation on visual of artery


Answer: A

Definition of proximal left anterior descending (LAD) coronary artery disease includes the first major septal branch off left anterior descending coronary artery.

Q: Which of the following can have a predictive value in acute myocardial infarction (AMI)?

A) Glucose 
B) Sodium
C) Potassium
D) Calcium
E) Creatinine


Answer: A

In patients who don't have diabetes, and  have glucose concentrations between 110 and 143 mg/dL at presentation with AMI have a 3.9-fold higher risk of death in comparison to patients with lower glucose concentrations. Moreover, glucose values between 144 and 180 mg/dL  have a three-fold higher risk of  some degree of cardiogenic shock.

Diabetic patients with glucose concentrations more or equal to 180 to 196 mg/dL  have a higher risk of death compared with diabetic patients having normal or lower glucose level.



References:

1. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355:773. 

2. Malmberg K, Norhammar A, Wedel H, Rydén L. Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study. Circulation 1999; 99:2626. 

3. Goyal A, Mehta SR, Díaz R, et al. Differential clinical outcomes associated with hypoglycemia and hyperglycemia in acute myocardial infarction. Circulation 2009; 120:2429.

Q; 34 year old man with recent Lyme disease is getting transferred to ICU for trans-venous pacemaker. EKG shows only 1st degree heart block. What could be the reason?


Answer:  Patients with lyme disease and first degree AV block with a PR interval more than or equal to 300 msec, should be watched in controlled environment and should be considered for a temporary pacemaker. Treatment with antibiotics should be pursued. Actually, improvement in PR interval could be a guide to a response to antibiotics in lyme disease carditis.



Reference: 

Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.

Q; Which of the following anti-seizure medicine has been reported to cause sinus node dysfunction and heart blocks?

A) Carbamazepine 
B) Tegretol 
C) Diazepam 
D) Lacosamide 
E) Levetiracetam


Answer: D

Lacosamide, due to its action enhances the slow inactivation of voltage-dependent sodium channels. This results in cardiac conduction disturbances, mostly atrial fibrillation and atrioventricular block.


References: 

1. Degiorgio CM. (2010) Atrial flutter/atrial fibrillation associated with lacosamide for partial seizures. Epilepsy Behav 18:322–324. 

2. Krause LU, Brodowski KO, Kellinghaus C. (2011) Atrioventricular block following lacosamide intoxication. Epilepsy Behav 20:725–727. 

3. Nizam A, Mylavarapu K, Thomas D, Briskin K, Wu B, Saluja D, Wong S. (2011) Lacosamide-induced second-degree atrioventricular block in a patient with partial epilepsy. Epilepsia 52:e153–e155. 

Q: What is the pathophsyiology behind Superior mesenteric artery syndrome? 


Answer: Superior mesenteric artery syndrome (first reported around little less than 100 years ago) can cause proximal small bowel obstruction. Loss of the intervening mesenteric fat pad causes narrowing of the space between the superior mesenteric artery and aorta. It leads to compression of the third portion of the duodenum. It's popular nick name is Cast syndrome, and also known as chronic duodenal ileus.


References:

1. Wilkie DP. Chronic duodenal ileus. Br J Surg 1921; 9:204. Cohen LB, Field SP, Sachar DB. 

2. The superior mesenteric artery syndrome. The disease that isn't, or is it? J Clin Gastroenterol 1985; 7:113. 

3. Ylinen P, Kinnunen J, Höckerstedt K. Superior mesenteric artery syndrome. A follow-up study of 16 operated patients. J Clin Gastroenterol 1989; 11:386.

Q; In which conditions an apical lordotic view of chest x-ray can be useful? 


 Answer: In regular chest x-ray, apices of lungs are covered by the clavicles. Idea behind obtaining an apical lordotic view of chest x-ray is to visualize the lung apices better, like in pancoast tumor or apical tuberculosis. In this era of CT scans, it may be only of academic interest but is expected of physicians to be aware of its utility.