Splenic injury grading

Q: The American Association for the Surgery of Trauma (AAST) has a spleen injury grading scale based upon all of the following except? 

A) Imaging (CT) criteria 
B) Operative criteria
C) Pathologic criteria 
D) Clinical criteria


Answer: D

The objective of above question is to emphasize that splenic injury graded on the basis of CT is not always concordant with the grade of injury identified in the operating room.

The AAST imaging criteria for splenic injury are graded up to 5 levels and are different on the basis of

• CT findings criteria
• Operative criteria
• Pathologic criteria

#surgicalcriticalcare

#trauma

References:

1. Cohn SM, Arango JI, Myers JG, et al. Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries. Am Surg 2009; 75:133. 

2.  Sutyak JP, Chiu WC, D'Amelio LF, et al. Computed tomography is inaccurate in estimating the severity of adult splenic injury. J Trauma 1995; 39:514. 

3.  Becker CD, Spring P, Glättli A, Schweizer W. Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery? AJR Am J Roentgenol 1994; 162:343.

4.  Kohn JS, Clark DE, Isler RJ, Pope CF. Is computed tomographic grading of splenic injury useful in the nonsurgical management of blunt trauma? J Trauma 1994; 36:385. 

5.  Marmery H, Shanmuganathan K, Alexander MT, Mirvis SE. Optimization of selection for nonoperative management of blunt splenic injury: comparison of MDCT grading systems. AJR Am J Roentgenol 2007; 189:1421.

I-FABP

Q: What is I-FABP in intestinal ischemia?

Answer: I-FABP is an intestinal fatty acid-binding protein and is a good marker of intestinal ischemia. I-FABP is a water-soluble protein abundantly present in the mucosa of the small bowel from the duodenum to the ileum. It rapidly starts releasing into the bloodstream whenever there is a small intestinal mucosal damage due to ischemia.

#surgicalcriticalcare
#gastroenterology


References:

1. Kanda T, Fujii H, Tani T, et al. Intestinal fatty acid-binding protein is a useful diagnostic marker for mesenteric infarction in humans. Gastroenterology 1996; 110:339. 

2. Matsumoto S, Sekine K, Funaoka H, et al. Diagnostic performance of plasma biomarkers in patients with acute intestinal ischaemia. Br J Surg 2014; 101:232.

PPCM

Q: Which endocrine drug is reported to have benefit in peripartum cardiomyopathy (PPCM)?



Answer:  Bromocriptine

Although data is small but preliminary results are strong and have shown that early start of bromocriptine in PPCM as an adjuvant treatment help markedly in recovery of left ventricular function 2, 3, 4, 5 . This  assumption came from the animal data that  inhibition of prolactin secretion, prevents the development of PPCM in mice 1.

#cardiology
#endocrinology


References:

1. Hilfiker-Kleiner D, Kaminski K, Podewski E, et al. A cathepsin D-cleaved 16 kDa form of prolactin mediates postpartum cardiomyopathy. Cell 2007; 128:589. 

2. Sliwa K, Blauwet L, Tibazarwa K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation 2010; 121:1465.

3. Habedank D, Kühnle Y, Elgeti T, et al. Recovery from peripartum cardiomyopathy after treatment with bromocriptine. Eur J Heart Fail 2008; 10:1149. 

4. Haghikia A, Podewski E, Libhaber E, et al. Phenotyping and outcome on contemporary management in a German cohort of patients with peripartum cardiomyopathy. Basic Res Cardiol 2013; 108:366. 

5. Carlin AJ, Alfirevic Z, Gyte GM. Interventions for treating peripartum cardiomyopathy to improve outcomes for women and babies. Cochrane Database Syst Rev 2010; :CD008589.

cyanide poisoning

Q: All of the following blood tests are vital on a patient during first few hours of presentation in suspected cyanide poisoning except?

A) Anion gap 
B)  Lactate 
C) Arterial blood gas (ABG)
D) Venous blood gas (VBG)
E) Blood cyanide level


Answer:  E

Two major teaching objectives for the above question are:

First, the turn around time for blood cyanide level is long and even if available the results are not reliable due to possible improper storage conditions.

Second, besides history, physical exam and other lab tests, simultaneous ABG and VBG can be very helpful. A narrowing of the venous-arterial PO2 gradient due to venous hyperoxia is one of the features of cyanide-poisoning. Cyanide inhibits cellular oxidative phosphorylation. This causes a marked decrease in peripheral tissue oxygen extraction from the blood, resulting in venous hyperoxia.

#toxicology


Reference:

Johnson RP, Mellors JW. Arteriolization of venous blood gases: a clue to the diagnosis of cyanide poisoning. J Emerg Med 1988; 6:401.

SS

Q; All of the following could be the parts of Serotonin syndrome (SS) management except?

A) Benzodiazepines
B) Inravenous cyproheptadine
C) Therapeutic Paralytics  
D) Intubation
E) Preferably avoiding antipyretics


Answer: B

There are two objectives to this question.

First, to highlight the vital importance of cyproheptadine in the management of SS. Although there are no robust studies available (Grade 1 recommendations) for the use of cyproheptadine, it is relatively a benign drug and should be used if benzodiazepines fail to control the symptoms of SS. It can quickly culminate into a fatal scenario. Cyproheptadine is a histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties. Technically it acts as an antidote. It is available only as oral formulation, so if a patient is not coherent enough to take it orally, the first dose of 12 mg should be delivered via oro/nasogastric tube emergently, followed by regular interval till symptoms subside.

Second, antipyretics has no role in SS because hyperthermia is not due to an alteration in the hypothalamic temperature set point. It is due to high muscular activity, that's why paralysis may be required (choice C).

#neurology
#pharmacology


References: 

1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112. 

2.  Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med 1998; 16:615. 

3.  Baigel GD. Cyproheptadine and the treatment of an unconscious patient with the serotonin syndrome. Eur J Anaesthesiol 2003; 20:586. 

4.  McDaniel WW. Serotonin syndrome: early management with cyproheptadine. Ann Pharmacother 2001; 35:870.

"new-onset diabetes after transplantation" (NODAT)

Q: All of the following are true regarding "posttransplant diabetes" (PTDM) in kidney patients except? 

 A) new kidney metabolizes and excretes insulin less efficiently 
B) new kidney is gluconeogenic 
C) Immunosuppression medications are diabetogenic 
D) Age is a risk factor 
E) hepatitis C virus infection is a predisposing factor 


Answer: A

The new designated term for "posttransplant diabetes" (PTDM) is "new-onset diabetes after transplantation" (NODAT).

All of the above choices are true except A. 

The objective of the above question is to highlight the less known fact that newly transplanted kidney metabolizes and excretes insulin more efficiently, exposing patient to hyperglycemia.

#transplantation
#neprology


References: 

1. Davidson J, Wilkinson A, Dantal J, et al. New-onset diabetes after transplantation: 2003 International consensus guidelines. Proceedings of an international expert panel meeting. Barcelona, Spain, 19 February 2003. Transplantation 2003; 75:SS3. 

2. Sharif A, Hecking M, de Vries AP, et al. Proceedings from an international consensus meeting on posttransplantation diabetes mellitus: recommendations and future directions. Am J Transplant 2014; 14:1992.

pitfall of PET for evaluation of a mediastinal mass

Q: What is the pitfall of using Positron emission tomography (PET) for evaluation of a mediastinal mass? 


Answer: PET scan is frequently used along with CT and MR scan to evaluate a mediastinal mass to identify a preferred biopsy site as well as to monitor the response to treatment. But it should be kept in mind that sometimes it can mislead physicians as nonmalignant mass like teratoma or thymic cysts can have 18F-fluorodeoxyglucose (FDG) accumulation. This is particularly important to keep in mind when patient is getting evaluated for malignancy somewhere else in the body.

#surgicalcriticalcare
#radiology
#oncology


Reference: 

Kitami A, Sano F, Ohashi S, et al. The Usefulness of Positron-Emission Tomography Findings in the Management of Anterior Mediastinal Tumors. Ann Thorac Cardiovasc Surg 2017; 23:26.

RSBI

Q: If rapid shallow breathing index (RSBI) is measured on T-piece instead of keeping a patient attached to ventilator, it will be? (select one)

A) higher
B) lower


Answer: A

RSBI tends to record a lower measurement if it is performed while patient stays attached to ventilator. This may be due to the fact that ventilator may underestimate the patient's inspiratory efforts that are not sensed by the ventilator known as 'untriggered breaths'. These unmeasured inspiratory efforts falsely lower the RSBI. The best way to mitigate this effect is to use a pressure support (PS)  of 0 cm H2O and a positive end-expiratory pressure (PEEP) of 0 cm H2O, without flow trigger. Other frequently ignored factors in ICU while measuring RSBI are narrow endotracheal tube, supine position, and very recent suctioning.


#ventilators
#pulmonary


References:  

1. El-Khatib MF, Zeineldine SM, Jamaleddine GW. Effect of pressure support ventilation and positive end expiratory pressure on the rapid shallow breathing index in intensive care unit patients. Intensive Care Med 2008; 34:505. 

2. Patel KN, Ganatra KD, Bates JH, Young MP. Variation in the rapid shallow breathing index associated with common measurement techniques and conditions. Respir Care 2009; 54:1462. 

3. Kheir F, Myers L, Desai NR, Simeone F. The effect of flow trigger on rapid shallow breathing index measured through the ventilator. J Intensive Care Med 2015; 30:103.

Acute lower abdominal pain in a female

Q: Which of the following diseases is associated with the feature of sudden onset severe unilateral (mostly right side) lower abdominal pain following sexual intercourse. On exam, there is no cervical or vaginal discharge?

A) Ectopic pregnancy
B) Pelvic inflammatory disease
C) Ovarian torsion
D) Ruptured ovarian cyst
E) Acute endometritis


Answer: D

The differential diagnosis of ruptured ovarian cyst is important, as it is mostly clinical but may subject patients to either undue procedures or wrong management. One of the biggest clues to the diagnosis is an association with physical activity. Another diagnostic clue is the side of the pain. Although ovary of either side can be affected, in most cases the right side is affected, because the rectosigmoid colon protects the left ovary.

In case of hemodynamic instability and deteriorating clinical signs, patient should be taken for emergent surgery, otherwise expectant treatment is the desired course. 

Choice A - Ectopic pregnancy is mostly associated with vaginal bleeding typically after 6-8 weeks of the last menstrual period (LMP).

Choice B - In pelvic inflammatory disease (PID), lateralization is uncommon and often associated with cervical discharge.

Choice C - Ovarian torsion is hard to distinguish but usually associated with an adnexal mass. 

Choice E - Acute endometritis is often occurred in a patient with an established diagnosis of endometriosis and associated with dysmenorrhea, pelvic pain, dyspareunia, and/or infertility, as well as with bowel or bladder symptoms. 


#ob-gyn
#surgicalcriticalcare



References: 

Kim JH, Lee SM, Lee JH, et al. Successful conservative management of ruptured ovarian cysts with hemoperitoneum in healthy women. PLoS One 2014; 9:e91171. 

Abduljabbar HS, Bukhari YA, Al Hachim EG, et al. Review of 244 cases of ovarian cysts. Saudi Med J 2015; 36:834.

Reducing the risk of post LP headahe

Q: Which one small trick can prevent the risk of post Lumbar Puncture (LP) headache?


Answer: Replacing the stylet before the spinal needle is removed can reduce the risk of post-LP headache.

Over the decades, many risk factors have been identified for Post-LP headache including female gender, pregnancy, prior headaches, young and middle age, Low opening pressure, low BMI, position during procedure, the experience of the clinician, reinsertion of stylet, and quality, brand, orientation and size of the needle tip.

Re-insertion of stylet is particularly helpful if a pencil point needle is used.


#procedures
#neurology


References:

Strupp M, Brandt T, Müller A. Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients. J Neurol 1998; 245:589.

Sleep agents in ICU

Q: Trazadone is now used with increasing frequency in ICU as a sleep aid. Trazadone is a 

 A) Melatonin receptor agonist 
B) Serotonin modulator 
C) Nonbenzodiazepine benzodiazepine receptor agonist 
D) Second-generation antihistamine 
E) Barbiturate


Answer: B

Sleep disturbance in ICU is a major problem. Non-pharmacological interventions play a major role, but very frequently requires pharmacological interventions.

Trazadon is a serotonin modulator and has shown to be very effective. 

 Another very effective and increasingly used medicine is melatonin receptor agonists like ramelteon, which is found to be of particular help in older patients as a sleep aid and an anti-delirium agent.

Zolpidem, eszopiclone/zopiclone, and zaleplon are nonbenzodiazepine benzodiazepine receptor agonists. They were introduced in ICU with a lot of fanfare but fastly lost the attraction with increasing reports of high association with delirium and other cognitive issues. 

 Antihistamines are around for a long time, and expect to stay despite their anticholinergic effects!

 Barbiturates are not ideal to be used as a sleep aid in ICU.


#pharmacology


References:  

1.  Kanji S, Mera A, Hutton B, et al. Pharmacological interventions to improve sleep in hospitalised adults: a systematic review. BMJ Open 2016; 6:e012108. 

2. Hatta K, Kishi Y, Wada K, et al. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry 2014; 71:397. 

3. Doroudgar S, Chou TI, Yu J, et al. Evaluation of trazodone and quetiapine for insomnia: an observational study in psychiatric inpatients. Prim Care Companion CNS Disord 2013; 15. 

4.  Richards K, Rowlands A. The impact of zolpidem on the mental status of hospitalized patients older than age 50. Medsurg Nurs 2013; 22:188. 

5.  Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med 2013; 8:1. 

6. Vande Griend JP, Anderson SL. Histamine-1 receptor antagonism for treatment of insomnia. J Am Pharm Assoc (2003) 2012; 52:e210.

resorption atelectasis

Q: What is resorption atelectasis? 

Answer: When a patient breathes high concentration of oxygen, it replaces nitrogen (room air) in the alveoli of the lungs. Nitrogen is very poorly soluble in blood, it stays in the alveoli and keeps alveoli open. Replacing nitrogen with oxygen causes alveoli to collapse, causing atelectasis. 

Clinical significance: Prolong high preoxygenation (denitrogenation) prior to intubation may decrease the time to desaturation if intubation is delayed.


#procedures


Reference: 

Woodring JH, Reed JC. Types and mechanisms of pulmonary atelectasis. Woodring JH1, Reed JC. J Thorac Imaging. 1996 Spring;11(2):92-108.

Water balance, respiration and ventilator

Q: Water via oxidation in the human body is? (select one)

A) fluid gain
B) fluid loss


Answer: A

Water generated via oxidation of carbohydrates and fatty acid in the body is a gain of about 300 mL. But this loss is balanced via the respiratory tract where water and CO2 are eliminated in parallel because the partial pressures of water vapor and CO2 are almost equal in alveolar air. 

This concept is important for understanding as this physiologic process get disrupted in a patient who are tachypenic (more loss) or on a ventilator, inspiring humidified air which decreases alveolar water losses.


#fluidbalance
#pulmonary


Reference:

Shafiee MA, Bohn D, Hoorn EJ, Halperin ML. How to select optimal maintenance intravenous fluid therapy. QJM 2003; 96:601.

elemental formula

Q: Predigested enteral nutrition (elemental) tube feed formula typically has all of the following characteristics except? 

A) short-chain peptides 
B) decreased total fat 
C) decreased medium-chain triglycerides 
D) beneficial in chylothorax 
E) no difference in mortality


Answer: C

There are two objectives of the above question.

One, to re-emphasize that elemental formula is beneficial in chylothorax (choice D) as it has increased medium-chain triglycerides (choice C). Medium-chain triglycerides tend not to enter the lymphatic capillaries in the small intestine. 

Second, Despite some advantages in mal-absorptive situation, predigested formulas failed to show any decrease in mortality, infectious complications, or the incidence of diarrhea. (choice E is correct).

#nutrition



References:

1. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159. 

2. Seres DS, Ippolito PR. Pilot study evaluating the efficacy, tolerance and safety of a peptide-based enteral formula versus a high protein enteral formula in multiple ICU settings (medical, surgical, cardiothoracic). Clin Nutr 2017; 36:706.

Halo Sign

Q: What is the "Halo sign" in pulmonary?



Answer: The halo sign is usually on the high resolution CT scan of chest. It is a ground glass opacity surrounding a pulmonary nodule or mass. It represents hemorrhage.

It is highly suspicious of  angioinvasive aspergillosis.

See picture and details by clicking the link at 

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4184607/

#pulmonary
#radiology
#infectious-diseases 


Reference:

Shroff S, Shroff GS, Yust-Katz S, Olar A, Tummala S, Tremont-Lukats IW. The CT halo sign in invasive aspergillosis. Clin Case Rep. 2014;2(3):113-4.

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4184607/

Measuring Bladder pressure

Q: Intra-abdominal pressure can be measured via all of the routes except? 

 A) intragastric 
B) intracolonic 
C) urinary bladder 
D) inferior vena cava (IVC) 
E) superior Vena Cava (SVC) 


Answer: E

The objective of the above question is to teach the pearl that: "any hollow viscus or a vascular structure inside the abdomen with a free moving membrane which can transduce pressure can measure intra-abdominal pressure".

There are other less known but available methods to measure intra-abdominal pressure beside intravesical (urinary bladder) pressure. But "bladder pressure" is the most non-invasive, easily available, reliable and easy to teach method.

SVC catheter can't measure intra-abdominal pressure as they are outside the abdomen.

#procedures


Reference:

1. Malbrain ML. Different techniques to measure intra-abdominal pressure (IAP): time for a critical re-appraisal. Intensive Care Med 2004; 30:357. 

2. Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39:1190.

Gas gangrene and NSTI

Q: Gram stain with gram-positive rods is the hallmark of? (select one) 

 A) Clostridial myonecrosis (gas gangrene) 
B) Necrotizing soft tissue infections (NSTI) 


 Answer: A 

The early clinical distinction between NSTI and gas gangrene is very important as it may salvage the life or the limb. Clinically, they are hard to distinguish as they both are associated with gas in the tissues. Early gram stain can be very helpful. Gram stain in gas gangrene by default usually demonstrates gram-positive rods, while NSTI is polymicrobial. Gas gangrene requires early attention towards amputation to save the life, whereas early right antibiotics can salvage both limbs as well as life in NSTI.

#surgicalcriticalcare
#infectiousdisease


References:

1. Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med 2017; 377:2253.

2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis 2014; 59:147. 

3. Jerrold B. Leikin; Frank P. Paloucek, eds. (2008), "Clostridium perfringens Poisoning", Poisoning and Toxicology Handbook (4th ed.), Informa, pp. 892–893

HSV-1 encephalitis

Q: All of the following are the features of Herpes simplex virus (HSV) type 1 encephalitis except?

A) Klüver-Bucy syndrome (KBS)
B) lymphocytic pleocytosis in CSF
C) increased erythrocytes in CSF
D) elevated protein in CSF
 E) low glucose in CSF


Answer: E

HSV-1 encephalitis is the most common cause of sporadic fatal encephalitis in USA and around the world. It is characterized by its unique clinical symptoms and cerebro-spinal fluid (CSF) finding. 

Due to its affinity for the temporal lobe and limbic structures, neurological symptoms include elevated mood, excessive animation, decreased need for sleep, inflated self-esteem, and hypersexuality. 

KBS is consistent with "psychic blindness" (when a patient’s eyes are working, but the mind is not seeing), amnesia and loss of normal anger and fear responses. 

In CSF, all of the findings described i.e., lymphocytic pleocytosis, increased erythrocytes with atraumatic tap and elevated protein occurs, but low glucose should caution clinician to look for alternate diagnosis as it is almost not a case in HSV-1 encephelitis.


#neurology
#infectiousdiseases


References:

1.  Hart RP, Kwentus JA, Frazier RB, Hormel TL. Natural history of Klüver-Bucy syndrome after treated herpes encephalitis. South Med J 1986; 79:1376. 

2. Fisher CM. Hypomanic symptoms caused by herpes simplex encephalitis. Neurology 1996; 47:1374. 

3. Nahmias AJ, Whitley RJ, Visintine AN, et al. Herpes simplex virus encephalitis: laboratory evaluations and their diagnostic significance. J Infect Dis 1982; 145:829.

Quinolones route of metabolism

Q: Which of the Quinolones does not require adjustment in renal failure?

A) moxifloxacin 
B) levofloxacin 
C) ciprofloxacin 
 D) norfloxacin 
E) delafloxacin


Answer: A

Moxifloxacin, levofloxacin and ciprofloxacin are the most commonly used quinolones in ICU. 

Despite the institution of hemodialysis or continuous renal replacement therapy (CRRT) - ciprofloxacin and levofloxacin need dose adjustment. 

 Moxifloxacin does not require any adjustment in renal failure as major route of metabolism for this quinolone is hepatic.


#pharmacology


Reference:

Stass H, Kubitza D. Pharmacokinetics and elimination of moxifloxacin after oral and intravenous administration in man. J Antimicrob Chemother 1999; 43 Suppl B:83.

GBS

Q: All of the following have a role in the management of Guillain-Barré syndrome (GBS) except? 

 A) plasma exchange (PE) (plasmapheresis) 
 B) intravenous immune globulin (IVIG) 
C) glucocorticoids 
D) erythromycin 
 E) gabapentin


Answer: C

Steroids have been tried in GBS in the hope that due to their anti-inflammatory role they will be helpful, but they failed to show any promising effect. Instead, they can be harmful if continued for prolong duration with myopathy and other related side effects, including infections etc. None of the studies or meta-analyses spread over 25 years were able to show any benefit, and the issue seems settled for the role of glucocorticoids in GBS. 

PE and IVIG remained as a mainstay of treatment as disease-modifying modalities. Erythromycin helps in bowel dysfunction and gabapentin is very effective in relieving neural pain.

#neurology


References:

1.  Hughes RA. Ineffectiveness of high-dose intravenous methylprednisolone in Guillain-Barré syndrome. Lancet 1991; 338:1142.

2. Double-blind trial of intravenous methylprednisolone in Guillain-Barré syndrome. Guillain-Barré Syndrome Steroid Trial Group. Lancet 1993; 341:586. 

3. Hughes RA, Brassington R, Gunn AA, van Doorn PA. Corticosteroids for Guillain-Barré syndrome. Cochrane Database Syst Rev 2016; 10:CD001446.

Hepatic enzymes in yellow fever

Q: In life-threatening liver dysfunction due to yellow fever, which liver enzyme tends to have a higher value?

A) alanine aminotransferase (ALT) 
B) aspartate aminotransferase (AST) 


Answer: B 

In contrast to other viral hepatitides, serum aspartate aminotransferase (AST) levels may exceed those of alanine aminotransferase (ALT) by 2 to 3 times. And the severity of enzymes elevation is proportional to the disease severity.

#infectiousdiseases



References:

Tuboi SH, Costa ZG, da Costa Vasconcelos PF, Hatch D. Clinical and epidemiological characteristics of yellow fever in Brazil: analysis of reported cases 1998-2002. 

Trans R Soc Trop Med Hyg 2007; 101:169. Oudart JL, Rey M. Proteinuria, proteinaemia, and serum transaminase activity in 23 confirmed cases of yellow fever]. Bull World Health Organ 1970; 42:95.

neuropsychiatric symptoms of dementia

Q: 72 years old male with a known history of dementia is admitted to ICU with sepsis. It was noted that patient developed severe and refractory neuropsychiatric symptoms. All of the following can be used for the management of neuropsychiatric symptoms of dementia except?

A) Benzodiazepines
B) Olanzapine
C) Risperidone
D) Quetiapine
E) Carbamazepine


Answer:   A

Dementia may exacerbate with an underlying medical condition. The mainstay of the treatment is to treat the underlying disease and use nonpharmacologic interventions. Most of the atypical antipsychotics (choices B, C, and D) are helpful but should be used only in severe or refractory situations. 

Unfortunately, two drugs are commonly used by clinicians in such situations, may not be of any help but may be harmful - Benzodiazepines (choice A) and diphenhydramine. Benzodiazepine may worsen the gait and may cause paradoxical agitation. Similarly, many clinicians used antihistamines under the false pretext that they are benign but they may also tend to exacerbate the neuropsychiatric symptoms of dementia.

Interestingly, carbamazepine (choice E), Gabapentin and Lamotrigine may be of help as adjuvant treatments. 

#psychiatry
#neurology
#pharmacology


References:

1. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 2005; 293:596.

2. Meehan KM, Wang H, David SR, et al. Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: a double-blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology 2002; 26:494. 

3. Tariot PN, Erb R, Podgorski CA, et al. Efficacy and tolerability of carbamazepine for agitation and aggression in dementia. Am J Psychiatry 1998; 155:54.

Potassium in IVF

Q: The addition of potassium to isotonic saline makes it? ((select one) 

 A) hypertonic 
 B) hypotonic


Answer:  A

The addition of potassium to 0.9 normal saline (NS) should be taken seriously as it can have a significant effect on serum osmolality and consequently on the water balance across the cell. Potassium in 0.9 NS converts it from an isotonic solution to a hypertonic solution. For example, the addition of 40 mEq of potassium to 1 Litre of 0.45 NS converts it to a solution which is osmotically equal to three-quarters of 0.9 NS. Despite increasing the tonicity of the solution, potassium does not help in expanding the same extracellular fluid (ECF) as most of the potassium quickly shifts inside the cell.

This concept is extremely important during the management of Diabetic Ketoacidosis (DKA) where serum is already hyperosmolar and early addition of potassium can worsen the hyperosmolarity. Potassium management is probably the trickiest part in the management of DKA and should be initiated and followed through with extreme care with a guided protocol. This concept again becomes of paramount effect during IVF management in End Stage Renal Disease (ESRD) patients.

#electrolytes
#waterbalance
#endocrinology
#nephrology


References/further readings:

1. Adrogué HJ, Lederer ED, Suki WN, Eknoyan G. Determinants of plasma potassium levels in diabetic ketoacidosis. Medicine (Baltimore) 1986; 65:163. 

2. Beigelman PM. Potassium in severe diabetic ketoacidosis. Am J Med 1973; 54:419. 

3. Murthy K, Harrington JT, Siegel RD. Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge. Endocr Pract 2005; 11:331.

'monotherapy' in low-risk community-acquired intra-abdominal infections

Q: 28 year old man is admitted to ICU with severe abdominal pain. CT scan is consistent with appendiceal abscess. Which of the following antibiotics can be used as a 'monotherapy' in low-risk community-acquired intra-abdominal infections?

A) Piperacillin-tazobactam
B) Metronidazole
C) Cefuroxime
D) Cefotaxime
E) Levofloxacin


Answer: A

This question is written to reinforce the idea of antibiotics stewardship, simplify the regimen to avoid medication errors, and to shun the practice of dual antibiotics coverage on each admission. Low-risk community-acquired intra-abdominal infections are generally defined as those that are of mild-to-moderate severity in the absence of risk factors for antibiotic resistance or treatment failure. Other antibiotics which can be used in such situations are ertapenem, ticarcillin-clavulanate, cefoxitin, moxifloxacin, and tigecycline.

#infectiousdiseases
#surgicalcriticalcare


References:

1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.

2. Ohlin B, Cederberg A, Forssell H, et al. Piperacillin/tazobactam compared with cefuroxime/ metronidazole in the treatment of intra-abdominal infections. Eur J Surg 1999; 165:875. 

3. Cohn SM, Lipsett PA, Buchman TG, et al. Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections. Ann Surg 2000; 232:254. 

4.  Sartelli M, Catena F, Abu-Zidan FM, et al. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017; 12:22.

Painless Aortic Dissection

Q: Which category of the patients tends to have relatively painless aortic dissection? (select one)

A) older with ascending aortic dissection 
 B) older with descending aortic dissection 


 Answer: A

Although painless aortic dissection is uncommon it may occur. Interesting it is more common with ascending aortic dissection in older patients with a mean age of 67. Other risk factors to have painless aortic dissection include diabetes, previous history of an aortic aneurysm, or cardiovascular surgery. These patients usually present with symptoms related to aortic dissection other than chest pain like heart failure, syncope, or CVA.

#cardiology
#surgicalcriticalcare


References:

1. Mehta RH, O'Gara PT, Bossone E, et al. Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002; 40:685.

2. Park SW, Hutchison S, Mehta RH, et al. Association of painless acute aortic dissection with increased mortality. Mayo Clin Proc 2004; 79:1252.

obesity and intubation

Q: Obesity directly increases the risk of laryngeal complications after intubation? (select one)

A) True
B) False


Answer: B

Although it is true that obesity contributes to difficult intubation but as such, this is a myth that obese patients are directly at higher risk of laryngeal complications after intubation.

#procedures


Reference: 

Dargin JM, Emlet LL, Guyette FX. The effect of body mass index on intubation success rates and complications during emergency airway management. Intern Emerg Med 2013; 8:75.

PROSEVA trial in ARDS

Q: PROSEVA is considered a landmark trial for?

A) Small tidal volumes in ARDS
B) High vs low PEEP in ARDS
C) High vs low driving pressures in ARDS
D) Prone positioning in ARDS
E) Early vs late extubation in ARDS


Answer: D

The objective of the above question is to emphasie the need of knowing the major landmark trials in Medicine. When it comes to Acute Respiratory Distress Syndome (ARDS), few trials are extremely important to know which have impacted the basic clinical practices.

Prone positioning in ARDS has a long tortuous history. One of the trials which were able to settle the said issue was PROSEVA (Prone Positioning in Severe ARDS) trial published in June 2013. It was a fairly large trial of 466 patients evenly distributed between two arms. 

The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group, with a hazard ratio of 0.39.

The unadjusted 90-day mortality was 23.6% in the prone group versus 41.0% in the supine group with a hazard ratio of 0.44.

You can read the full trial here:: https://www.nejm.org/doi/pdf/10.1056/nejmoa1214103

#Pulmonary
#ARDS


Reference:

Guérin C, and et al. for PROSEVA Study Group.  Prone positioning in severe acute respiratory distress syndrome. .N Engl J Med. 2013 Jun 6;368(23):2159-68. doi: 10.1056/NEJMoa1214103.

Rigler triad

Q; What is Rigler triad?

Answer: Rigler triad is a classic radiological finding in ileus related to gallstones. 

It consists of

• bowel obstruction,
• pneumobilia, and 
• an ectopic gallstone

For pictures and further reading click on 

Rigler triad in gallstone ileus

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787193/)

#gastroenterology
#radiology
#surgicalcriticalcare


Reference:

Roothans D, Anguille S. Rigler triad in gallstone ileus. CMAJ. 2013;185(14):E690.