McConnell’s Sign

Q: What is McConnell’s Sign?


Answer: McConnell’s sign is a distinct echocardiographic finding in patients with acute pulmonary embolism (PE). It is consistent with akinesia of the mid free wall of the right ventricle but normal motion at the apex. Although echo has a low sensitivity to diagnose PE, but visibilty of McConnell’s sign is very suggestive of PE.

#cardiology
#pulmonary


References:

1. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996; 78: 469–473

2. Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002; 136: 691–700.

Unmasking Brugada syndrome

Q:  27 year old male is admitted to ICU after he suddenly collapsed at basketball practice. He was revived quickly. He regained consciousness and is admitted to ICU. Patient's first cousin died of sudden cardiac death previously. Cardiology service is highly suspicious of Brugada syndrome but EKG does not follow the classic pattern of the syndrome. Which of the following drugs can be used as a  provocative test to unmask type 1 Brugada pattern in  patients who have clinical presentation suggestive but not diagnostic of Brugada syndrome?

A) Amiodarone 
B) Lopressor
C) Procainamide
D) Flecainide
E) Digoxin


Answer: D

Sodium channel blockers (flecainide, ajmaline, or procainamide) can transiently induce the  Brugada EKG pattern. As oral flecainide is easily available, it can be safely used to unmask Type 1 Brugada pattern in controlled enviroment such as ICU. Most institutions have protocol to carry out the "flecainide challenge test".

#cardiology
#pharmacology


References:

1. Gasparini M., Priori S.G., Mantica M., Napolitano C., Galimberti P., Ceriotti C. Flecainide test in Brugada syndrome: a reproducible but risky tool. Pacing Clin Electrophysiol. 2003 Jan;26(1 Pt 2):338–341 

2.. Dubner S., Azocar D., Gallino S., Cerantonio A.R., Muryan S., Medrano J. Single oral flecainide dose to unmask type 1 Brugada syndrome electrocardiographic pattern. Ann Noninvasive Electrocardiol. 2013 May;18(3):256–261

Massive hemoptysis

Q: What is the correct sequence in the management of the massive hemoptysis?

A) Establish a patent airway, insure adequate gas exchange and hemodynamics, position the patient, and control the bleeding 
B) Position the patient, establish a patent airway, insure adequate gas exchange and hemodynamics, and control the bleeding 
C) Control the bleeding, position the patient, establish a patent airway, and insure adequate gas exchange and hemodynamics
D) Insure adequate gas exchange and hemodynamics, position the patient, establish a patent airway, and control the bleeding 
E) Establish a patent airway, position the patient, insure adequate gas exchange and hemodynamics, and control the bleeding 



Answer: B 

Massive hemoptysis is a life-threatening emergency in ICU. 

As a first step patient should be positioned first with side of the bleeding lung on the dependent position to avoid spillage of blood in non-affected lung, while preparation to intubate and protect the airway, insuring ventilation and stable hemodynamics. Ultimately control of bleeding via bronchoscopy and other methods is the definite treatment.


#pulmonary
#hemodynamic



Reference:

Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.

Inverted U wave

Q: 53 year old male is admitted to ICU after he developed chest pain and shortness of breath at cardiology's office during exercise stress test. EKG during exercise testing showed "reverse/inverted U wave". Which vessel(s) be the most probable culprit?


Answer: left main or left anterior descending (LAD)

Reverse or inverted U wave during stress may be indicative either of volume overload or "tight stenosis" of the left main or left anterior descending (LAD) coronary artery. 

#cardiology



References:

1. Gerson MC, Phillips JF, Morris SN, McHenry PL (1979). "Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery". Circulation. 60: 1014–1020.

2. Conrath C, Opthof T (2005). "The patient U wave". Cardiovasc Res. 67 (2): 184–6.

Troponin in non cardiac diseases

Q: Elevated troponin can be seen beside acute myocardial infarction in all of the following conditions?

A) Sepsis 
B) Subarachnoid hemorrhage 
C) Pulmonary embolism
D) Aortic dissection
E) All of the above

Answer: E

The objective of above question is to highlight the statement that: "Troponin is highly specific for myocardial cell release, it is not specific for acute coronary syndrome as the cause".

There is a long list of conditions where troponin can be elevated without acute coronary disease.

#cardiology


References:

1. Lim W, Qushmaq I, Devereaux PJ, et al. Elevated cardiac troponin measurements in critically ill patients. Arch Intern Med 2006; 166:2446.

2. Ammann P, Fehr T, Minder EI, et al. Elevation of troponin I in sepsis and septic shock. Intensive Care Med 2001; 27:965. 

3. Arlati S, Brenna S, Prencipe L, et al. Myocardial necrosis in ICU patients with acute non-cardiac disease: a prospective study. Intensive Care Med 2000; 26:31. 

4. Bakshi TK, Choo MK, Edwards CC, et al. Causes of elevated troponin I with a normal coronary angiogram. Intern Med J 2002; 32:520.

Medical treatment of CHF due to amyloidosis

Q: Which of the following drugs should be use with caution in cardiac Amyloidosis?

A) Digoxin
B) ACE inhibitors 
C) Angiotensin II inhibitors 
D) Calcium channel blockers (CCB)
E) All of the above


Answer: E

Medical management of heart failure due to cardiac amyloidosis is very difficult as most drugs have high risk profile.

Digoxin can be the biggest culprit as it binds to amyloid fibrils and may quickly culminate patient into "Dig. toxicity"(Choice A). Both ACE inhibitors and angiotensin II inhibitors can induce profound and life-threatening hypotension even with lowest dose (Choices B and C). CCB can cause a significant negative inotropic effect (Choice D).

Mainstay of treatment in cardiac amyloidosis is diuretic.


#cardiology


Reference:

Falk R. Diagnosis and management of the cardiac amyloidoses. Circulation 112, 2047–2060 (2005).

Anbx in Neutropenic Fever

Q: Out of the following which one is the least preferred in neutropenic patients (in USA)

A) Cefepime
B) Meropenem
C) Imipenem-cilastatin
D) Piperacillin-tazobactam 
E) Ceftazidime


Answer: E

In USA, there is an increasing tendency of resistance for ceftazidime 1. Fever in high-risk neutropenic patients is a medical emergency, up to the point that now it is argued to administer empiric broad-spectrum antibiotics within 30 minutes instead of typical 60 minutes for other causes of sepsis 2. There is a very little room to afford resistance.

#infectiousdiseases



References:

1.  Initial management of fever and neutropenia (link here) © 2018 UpToDate, Inc.

2. Rosa RG, Goldani LZ. Cohort study of the impact of time to antibiotic administration on mortality in patients with febrile neutropenia. Antimicrob Agents Chemother 2014; 58:3799.

Lithium and Thyroid

Scenario; 55 year old male with a recent history of thyroid cancer is admitted to ICU from ED with lithium toxicity. Patient has no psychiatric history but according to wife lithium has been prescribed as an adjuvant treatment for his thyroid cancer.


Answer:  Objective of above question is two folds.

First to emphasize the risk of thyroid dysfunction with lithium treatment. Second is to describe the use of lithium in thyroid cancer. Lithium is known to cause goiter, hypothyroidism, and hyperthyroidism.  Lithium has a triple effect on the thyroid.

1. It increases the intrathyroid iodine content,
2. It inhibits the coupling of iodotyrosine residues to form T4 and T3, and
3. It inhibits the release of T4 and T3

Taking advantage of these effects, lithium is used in thyroid cancer after treatment with iodine-131. It may increase the retention of the isotope by cancer tissue.


#toxicology
#oncology
#endocrine



References:

1. Burrow GN, Burke WR, Himmelhoch JM, et al. Effect of lithium on thyroid function. J Clin Endocrinol Metab 1971; 32:647. 

2. Liu YY, van der Pluijm G, Karperien M, et al. Lithium as adjuvant to radioiodine therapy in differentiated thyroid carcinoma: clinical and in vitro studies. Clin Endocrinol (Oxf) 2006; 64:617. 

Definition of a true aneurysm

Q: The Society of Vascular Surgery defines any true aneurysm as a focal, isolated dilation that includes all three layers of the arterial wall and measures at least _________  times the diameter of the disease-free proximal adjacent arterial segment?

A) 1 cm
B) 1.5 cm
C) 2 cm
D) 3 cm
E) 5 cm


Answer:  1.5 cm 

The Society of Vascular Surgery defines any true aneurysm as a focal, isolated dilation that includes all three layers of the arterial wall and measures at least 1.5 times the diameter of the disease-free proximal adjacent arterial segment.

#vascular



References:

Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. J Am Coll Cardiol 2006; 47:1239.

BAI

Q: 24 year old male is brought to ED after motor vehicle accident (MVA). Initial CXR showed following features:

• Left "apical cap" 
• Deviation of nasogastric (NG) tube rightward 
• Deviation of trachea rightward 
• Deviation of right mainstem bronchus downward 
• Wide left paravertebral stripe

Your major concern?

Answer:  Blunt aortic injury (BAI)

BAI is a trauma emergency. Initial bedside CXR is a great way to look for signs of BAI. Following features on CXR warrants emergent intervention or CT chest if clinical stability permits.

• Wide mediastinum (8 cm if supine or 6 cm if upright)
• Obscured aortic knob
• Abnormal aortic contour 
• Pleural blood above the apex of left lung (known as apical cap) 
• Signs of left hemothorax 
• Deviation of NG tube rightward 
• Deviation of trachea rightward 
• Deviation of right mainstem bronchus downward 
• Wide left paravertebral stripe

#trauma

References: 

1. Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol 2009; 192:599. 

2. Marnocha KE, Maglinte DD, Woods J, et al. Blunt chest trauma and suspected aortic rupture: reliability of chest radiograph findings. Ann Emerg Med 1985; 14:644. 

3. Ekeh AP, Peterson W, Woods RJ, et al. Is chest x-ray an adequate screening tool for the diagnosis of blunt thoracic aortic injury? J Trauma 2008; 65:1088. 

TIA vs Stroke

Q: Transient ischemic attack (TIA) is defined as a neurologic dysfunction caused by all of the following except?

A) Focal brain ischemia
B) Spinal cord ischemia
C) Retinal ischemia
D) With or without acute infarction
E) Less than 24 hours



Answer: D

The objective of above question is to highlight the main differential point between stroke and TIA. Infarction of any neurological tissue is regarded as a stroke. Technically TIA is defined as a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. There is no time limit set for such episode (Choice E).

#neurology


Reference:

Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009; 40:2276.

ASPECTS

Q: What does ASPECTS stands for in stroke? 


Answer:  ASPECTS  stands for "The Alberta Stroke Program Early CT score"

This score is developed depending on CT scan changes to assess ischemic changes after acute  stroke to identify patients who are unlikely to make an independent recovery despite thrombolytic treatment. This leads to evaluate these patients for mechanical thrombectomy for acute ischemic stroke.

#neurology


References: 

1. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355:1670. 

2. Pexman JH, Barber PA, Hill MD, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001; 22:1534.

Unsuccessful cardioversion in AF

Q: Cardioversion from atrial fibrillation (AF) to normal sinus rhythm (NSR) has low likelihood in the presence of all of the following except?

A) AF continuously present for more than 3 months
B) Markedly enlarged atriums
C) Pneumonia
D) Thyrotoxicosis
E) Mitral valve disease


Answer:  A

If underlying diseases are not treated (choices C, D and E), chances of successful cardioversion from AF to NSR remains low. Markedly enlarged atriums with left atrium having dimension >6.0 cm or right atrium having dimension >37 mm may also be a hindrance in this process (choice B). 3

Time period described to make successful cardioversion from AF to NSR is to be present continuously for about one year.

#cardiology


References: 

1. Elhendy A, Gentile F, Khandheria BK, et al. Predictors of unsuccessful electrical cardioversion in atrial fibrillation. Am J Cardiol 2002; 89:83. 

2. Dittrich HC, Erickson JS, Schneiderman T, et al. Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1989; 63:193. 

3. Henry WL, Morganroth J, Pearlman AS, et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation 1976; 53:273. 

Diabetic Osteomyelitis

Q: 66 year old male with past medical history of diabetes mMellitus, sensory and autonomic neuropathy, diabetic nephropathy and peripheral arterial disease is admitted to ICU with septic shock. All of the following features support the diagnosis of osteomyelitis except? 

A) Ability to probe to bone
B) Ulcer size larger than 5 cm2
C) 'Sausage toe'
D) Erythrocyte sedimentation rate (ESR) >70 mm/h
E) High initial radiographic suspicion


Answer: B

All of the above choices highly support the diagnosis of osteomyelitis due to uncontrolled diabetes except the choice B. Ulcer size larger than 2 cm2 is sufficient to support the diagnosis of diabetic osteomyelitis in the presence of other features. 

The objective of above question is to make the emphasis on cost-effective and clinical diagnosis of diabetic osteomyelitis. Though magnetic resonance imaging (MRI) has high sensitivity and specificity for the diagnosis of osteomyelitis, but if the history and clinical findings 3, 4 are present with highly supportive simple radiographic evidence (choice E), MRI may not be needed.

#infectiousdisease
#physicalexam



References:

1. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132.

2. Butalia S, Palda VA, Sargeant RJ, et al. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008; 299:806.

3. Dinh MT, Abad CL, Safdar N. Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis 2008; 47:519.

4.  Rajbhandari SM, Sutton M, Davies C, et al. 'Sausage toe': a reliable sign of underlying osteomyelitis. Diabet Med 2000; 17:74.

Copper deficiency

Q: Copper is absorbed in?

A) Stomach and proximal duodenum
B) Small intestine
C) Transverse colon
D) Sigmoid colon 
E) Rectum


Answer:  A

Copper is absorbed in the stomach and proximal duodenum. Clinical significance of this question is to address the need of elemental supplements post bariatric surgeries like Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS) surgeries. Deficiency of copper leads to microcytic anemia, neutropenia, and ataxia.

#surgicalcriticalcare



References: 

 1. Griffith DP, Liff DA, Ziegler TR, et al. Acquired copper deficiency: a potentially serious and preventable complication following gastric bypass surgery. Obesity (Silver Spring) 2009; 17:827. 

2. Gletsu-Miller N, Broderius M, Frediani JK, et al. Incidence and prevalence of copper deficiency following roux-en-y gastric bypass surgery. Int J Obes (Lond) 2012; 36:328.

Allen test for lower extremity

Q: The Allen's test should be performed before inserting arterial line catheter in

A) Radial artery 
B) Dorsalis pedis artery 
C) Brachial artery 
D) Femoral artery
E) A and B


Answer: E

It is well known that Allen or modified Allen test should be performed prior to insertion of arterial line in radial artery to assess the collateral circulation via ulnar artery. Similarly, Allen test should be performed if arterial line needs to be inserted in dorsalis pedis artery to assess collateral circulation via posterior tibial artery. It is performed by elevating the lower extremity until the plantar skin blanches followed by compression of dorsalis pedis artery and lowering of extremity to dependency. The foot rapidly resumes color if the posterior tibial artery flow is adequate. Allen test for lower extremity has also been described with  Doppler signals.

#procedures



Reference: 

Haddock N.T., Garfein E.S., Saadeh P.B., Levine J.P. (2009) The lower-extremity allen test. Journal of Reconstructive Microsurgery, 25 (7) , pp. 399-403.

Acute headache

Q: Which of the following is of the highest priority in an approach to the urgent evaluation of an acute headache?

A) Carbon Monooxide (CO) poisoning
B) Subarachnoid hemorrhage
C) Meningitis
D) Giant cell (temporal) arteritis
E) Optic neuritis


Answer: A

Indeed all of the above conditions require immediate attention but carbon mono-oxide exposure is top on the list due to the fact that if not treated promptly or misdiagnosed, may result in a very rapid death of the patient. And, it is easy to treat with 100% oxygen therapy. CO diffuses rapidly across the pulmonary capillary membrane and binds to the iron moiety of heme with 240 times the affinity of oxygen. 

#toxicity
#neurology



 References:

1. Hampson NB. U.S. Mortality Due to Carbon Monoxide Poisoning, 1999-2014. Accidental and Intentional Deaths. Ann Am Thorac Soc 2016; 13:1768.

2. Approach to the urgent evaluation of headache in an adult - © 2018 UpToDate, Inc. link here

Synchronized Cardioversion

Q: Synchronized electrical cardioversion is targeted to which part of the electrocardiogram (EKG) cycle? 

A) P wave
B) PR interval
C) QT interval
D) QRS complex
E) T wave


Answer: D


Cardiac cycle has a vulnerable and a refractory period. The refractory period is during the QRS complex, and the vulnerable period is during the T wave. Application of electrical cardioversion during vulnerable period may induce ventricular fibrillation.

#procedure
#cardiology



Reference:

Link, M. Arkins D. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010, Volume 122, Issue 18 suppl 3 :: http://circ.ahajournals.org/content/122/18_suppl_3/S706.full#sec-24

Cryptogenic stroke

Q; Cryptogenic stroke (CS) requires the documentation of atrial fibrillation?

A)True
B) False


Answer: False

Cryptogenic stroke is a diagnosis of exclusion. In fact, definition of cryptogenic stroke is an ischemic stroke without any well-defined etiology, including any cardiac source.

Various possible causes for CS has been proposed including undocumented occult paroxysmal atrial fibrillation (AF), paradoxical embolism via patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect (VSD, or via pulmonary arteriovenous malformation (AVM). Other causes include undefined hypercoagulable state due to antiphospholipid antibodies, occult cancer causing hypercoagulabe state and vasculopathies.

#cardiology
#neurology


References:

1. Saver JL. CLINICAL PRACTICE. Cryptogenic Stroke. N Engl J Med 2016; 374:2065. 

2.  Hart RG, Diener HC, Coutts SB, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13:429.

Ferritin

Q: Which of the following is an acute phase reactant (select one)

A) Serum ferritin
B) Transferrin 


Answer: A

Ferritin is mostly described with the metabolism of iron and in discussion with iron deficiency and iron overload. Ferritin is an indirect marker of the total stored iron in the body. But it is also an acute phase reactant and its level may be increased in inflammation, infection or cancer. The objective of above question is to highlight the point that measuring ferritin to rule out iron deficiency anemia in ICU patients may not be a reliable test.

#hematology
#SIRS


References:

1. Zandman-Goddard G, Shoenfeld Y. Ferritin in autoimmune diseases. Autoimmun Rev. 2007;6:457–463.

2. Weinberg ED, Miklossy J. Iron withholding: a defense against disease. J Alzheimers Dis. 2008;13:451–463.

3. Wang W, Knovich MA, Coffman LG, Torti FM, Torti SV. Serum Ferritin: Past, Present and Future. Biochimica et biophysica acta. 2010;1800(8):760-769. 

HSV-1 encephalitis

Q: Why Herpes Simplex Virus (HSV)-1 encephalitis is not much common in immunocompromised patients despite high occurrence of mucocutaneous HSV-1 infections in these patients? 


 Answer:  Herpes Simplex Virus (HSV)-1 encephalitis is not much common in immunocompromised patients because most of the brain damage from CNS HSV-1 infection is immune mediated. In immunocompromised patient it has only a mild histopathologic changes.

#infectiousdiseases 
#neurology


Reference:

Pepose JS, Hilborne LH, Cancilla PA, Foos RY. Concurrent herpes simplex and cytomegalovirus retinitis and encephalitis in the acquired immune deficiency syndrome (AIDS). Ophthalmology 1984; 91:1669.

Caprini risk score

Q: What is Caprini risk score?

Answer: The Caprini risk score is a risk assessment tool for the occurrence of venous thromboembolism (VTE) among surgical patients. It comprehensively takes into account of many variables including

•  Stroke (in last four weeks)
•  Fracture of the hip, pelvis, or leg
•  Elective arthroplasty or Arthroscopic surgery
•  Acute spinal cord injury (in last four weeks)
•  Age
•  Prior episodes of VTE
• Positive family history for VTE
• Prothrombin 20210 A
• Factor V Leiden
•  Lupus anticoagulants
• Anticardiolipin antibodies
•  High homocysteine in the blood
• Heparin-induced thrombocytopenia
• Other congenital or acquired thrombophilia
• Laparoscopy lasting more than 45 minutes
• General surgery lasting more than 45 minutes
• Cancer
• Plaster cast
• Bedbound for more than 72 hours
• Central venous access
• BMI > 25 Kg/m2
• Edema in the lower extremities
• Varicose veins
• Pregnancy
• Post-partum
• Oral contraceptive or Hormonal therapy
• Unexplained or recurrent abortion
• Sepsis (in last four weeks)
• Serious lung disease (abnormal PFT) or pneumonia (in last four weeks) 
• Acute myocardial infarction
• Congestive heart failure
• Bed rest
• Inflammatory bowel disease

Score 0-1: Low risk of VTE
Score 2: Moderate of VTE
Score 3-4: High risk of VTE
Score ≥ 5: Highest risk for VTE


Online calculators are easily available at various search engines.



References:

1. Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F (1991). "Clinical assessment of venous thromboembolic risk in surgical patients.". Semin Thromb Hemost. 17 Suppl 3: 304–12. 

2. Caprini JA (2005). "Thrombosis risk assessment as a guide to quality patient care.". Dis Mon. 51 (2-3): 70–8.

steroid induced myopathy and liver transplant

Q: Which organ transplant patients are relatively more prone to steroid induced myopathy?

A) Kidney
B) Heart
C) liver
D) Lung
E) Pancreas 


Answer: C

About seven percent of patients may develop acute critical illness myopathy after liver transplant (OLT). As expected risk factors include severity of illness, dialysis requirement, and higher doses of glucocorticoids. Carnitine deficiency in liver failure patients is advocated as a contributory factor in these patients.

#transplantation
#hepatology


Reference:

Campellone JV, Lacomis D, Kramer DJ, et al. Acute myopathy after liver transplantation. Neurology 1998; 50:46.

Anticoagulation in unprovoked proximal DVT

Q; 44 years old male is admitted to ICU with shortness of breath and diagnosed having a pulmonary embolism. Patient has a healthy lifestyle and no risk factors are identified. The patient responded well to intravenous heparin without any tendency to bleeding. Workup till discharge from ICU remained negative except proximal lower extremity deep venous thrombosis (DVT). Hematology service declared it as an "unprovoked DVT". The patient will require anticoagulation for?

A) 3 months
B) 6 months
C) 12 months
D) indefinite
E) Till discharge from hospital


Answer:   D

The estimated risk of recurrence following stopping of anticoagulation in patients with a first unprovoked episode of proximal DVT or PE is 10 percent at twelve months and 30 percent at five years. Full anticoagulation reduces the risk of recurrence by 90 percent. In a healthy patient who has no risk for an increased bleed, benefit of anticoagulation outweighs the risk of bleeding.

#pulmonary
#hematology


References:

1. Baglin T, Bauer K, Douketis J, et al. Duration of anticoagulant therapy after a first episode of an unprovoked pulmonary embolus or deep vein thrombosis: guidance from the SSC of the ISTH. J Thromb Haemost 2012; 10:698. 

2. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315.

3. Patients with a first symptomatic unprovoked deep vein thrombosis are at higher risk of recurrent venous thromboembolism than patients with a first unprovoked pulmonary embolism. J Thromb Haemost 2010; 8:1926. 

4. Couturaud F, Sanchez O, Pernod G, et al. Six Months vs Extended Oral Anticoagulation After a First Episode of Pulmonary Embolism: The PADIS-PE Randomized Clinical Trial. JAMA 2015; 314:31. 

5. Kyrle PA, Kammer M, Eischer L, et al. The long-term recurrence risk of patients with unprovoked venous thromboembolism: an observational cohort study. J Thromb Haemost 2016; 14:2402. 

QT Interval

Q: Which leads have the longest QT interval?


Answer: Leads V2 and V3

QT intervals vary significantly among different EKG leads. Leads V2 and V3 usually has the longest QT measurements. This simultaneously make these leads most favorable as well as unfavorable, as they are more precise giving the longest measurement but at the same time can deceive due to presence of U waves in these leads  (particularly in adolescents).

#cardiology


Reference:

Cowan JC, Yusoff K, Moore M, et al. Importance of lead selection in QT interval measurement. Am J Cardiol 1988; 61:83.

Risk factors for recurrence of ICH

Q: Out of the following risk factors which one is the most important risk factor for recurrence of intracranial hemorrhage (ICH)?

A) Uncontrolled hypertension 
B) Lobar location of initial ICH 
C) Male gender 
D) Ongoing anticoagulation 
E) Greater number of microbleeds on MRI 


Answer: A

Objective of the above question is two-folds. First is to emphasize that the simple strategy to control blood pressure is the most promising way to avoid recurrence of ICH. Second is to emphasize that the patients can be re-started on anticoagulation if needed though very close monitoring and discussion about risks vs benefits is required. Most patients once out of the acute period can tolerate anticoagulation if necessary. In long run, uncontrolled blood pressure is the biggest risk factor for the recurrence of ICH.

#neurology
#cardiology



References:

1. Chen ST, Chiang CY, Hsu CY, et al. Recurrent hypertensive intracerebral hemorrhage. Acta Neurol Scand 1995; 91:128

2. Huhtakangas J, Löppönen P, Tetri S, et al. Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study. Stroke 2013; 44:585. 

3. Kase CS, Kurth T. Prevention of intracerebral hemorrhage recurrence. Continuum (Minneap Minn) 2011; 17:1304. 

VTE prophylaxis in SCI

Q: Prophylaxis to prevent deep venous thrombosis and pulmonary embolism - VTE - should be continued for at least how long after spinal cord injuries (SCI)?

A) Two weeks
B) Four weeks
C) Three months
D) Six months
E) Indefinite


Answer: C

In patients with acute SCI, after considering all risks and benefits, usual recommended duration for VTE prophylaxis is about three months. Ideally, pharmacologic intervention with low molecular weight heparin (LMWH) is recommended but warfarin with Internationalized Normalized Ratio (INR) of 2 to 3 is also acceptable.

#trauma



References:

1. Paralyzed Veterans of America. Consortium for Spinal Cord Medicine. Prevention of Thromboembolism in individuals with Spinal Cord Injury. Clinical practice guideline for healthcare providers. 3rd Edition. 2016. 

2. Ploumis A, Ponnappan RK, Maltenfort MG, et al. Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis. J Bone Joint Surg Am 2009; 91:2568.

Ischemic cholangiopathy after liver transplant

Q: What could be the risk to the transplanted liver with the use of a non-heart beating donor graft?



Answer: Ischemic cholangiopathy

Blood supply to the major bile ducts comes exclusively from the hepatic artery via the peribiliary plexus. Ischemic cholangiopathy mostly happened after liver transplantation, particularly with the use of a non-heart beating donor graft.

#transplantation
#hepatology


References:

1. de Vries Y, von Meijenfeldt FA, Porte RJ. Post-transplant cholangiopathy: Classification, pathogenesis, and preventive strategies. Biochim Biophys Acta 2018; 1864:1507. 

2. Mourad MM, Algarni A, Liossis C, Bramhall SR. Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation. World J Gastroenterol 2014; 20:6159. 

3. Cameron AM, Busuttil RW. Ischemic cholangiopathy after liver transplantation. Hepatobiliary Pancreat Dis Int 2005; 4:495.

Mycotic Aneurysm

Q: Out of the following which organism is most likely to cause a mycotic aneurysm and diseased aorta is most vulnerable to it? 

A) Salmonella 
B) Listeria 
C) Yersinia 
D) Haemophilus influenzae 
E) Clostridium septicum


Answer:  A

Staphylococcus spp and Salmonella spp are the most common organisms to most likely cause a mycotic aneurysm. For not an absolutely clear reason, the diseased aorta is relatively found to be more vulnerable to Salmonella and is isolated in the bacteremic seeding of atherosclerotic plaque.

All others are less common causes of a mycotic aneurysm.

#infectious diseases
#cardiology



References:

1.  Brossier J, Lesprit P, Marzelle J, et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience. Eur J Vasc Endovasc Surg 2010; 40:582. 

2. Marques da Silva R, Caugant DA, Eribe ER, et al. Bacterial diversity in aortic aneurysms determined by 16S ribosomal RNA gene analysis. J Vasc Surg 2006; 44:1055. 

uremic bleeding

Q: 58 year old male with End Stage Renal Disease (ESRD) is back from OR after coronary artery bypass (CABG). Patient had issue with severe uremic coagulopathy in OR for which Desmopressin (DDAVP) was given twice. Also patient required pRBC transfusions along with platelets, Fresh Frozen Plasma (FFP), Four-Factor Prothrombin Complex Concentrate (4F-PCC) and Cryoprecipitate. Patient had his session of hemodialysis a night before surgery. Postoperative his coagulation profiles are in normal range. Patient is hemodynamically unstable requiring multiple vasopressors and not stable to start continuous renal replacement therapy (CRRT). Which of the following agent can be used for his uremic platelet dysfunction?

A) Factor 7 (2 mg)
B) Repeat dose of 4F-PCC
C) intravenous Estrogen
D) Repeat dose of Desmopressin
E) intrinsic Nitric oxide (iNO)



Answer: C

Though estrogen is commonly used as a long term therapy for uremic platelet disorder but there are reports of its use in acute setting. Intravenous form of estrogen can be effective within six hours, and can be used in extreme situations where all other options have been exhausted. 

Out of all of the above choices, estrogen is the only answer by exclusion.

- Factor 7 has no role in uremic bleeding. Also, it may occlude the coronary grafts (choice A). 
- Repeating 4F-PCC would not be very useful if all coagulation profiles are normal (choice B). 
- DDAVP develop tachyphylaxis quickly and is usually not effective after two doses, which patient has already received in OR (choice D). 
- iNO has no role in uremic bleeding (choice E).


#hematology
#surgicalcriticalcare
#nephrology

References:

1. Livio M, Mannucci PM, Viganò G, et al. Conjugated estrogens for the management of bleeding associated with renal failure. N Engl J Med 1986; 315:731.

2. Heunisch C et al. (1998) Conjugated estrogens for the management of gastrointestinal bleeding secondary to uremia of acute renal failure. Pharmacotherapy 18: 210-217