vision loss in GCA

 Q: 74 years old male is admitted to ICU with a presumed diagnosis of Giant Cell Arteritis (GCA) with vision loss. Pulse steroid is started. Vision loss will probably be? (select one)

A) reversible

B) irreversible

Answer: B

Vision loss in GCA is rarely reversible. Interestingly, patients report improvement in vision. Also, visual acuity tests confirm the improvement. Unfortunately, this is not a true recovery of retinal or optic nerve function. This subjective feeling is due to eccentric compensation for permanent visual deficits.

In any case, to salvage vision, patients should receive  3 days of 500 to 1000 mg of IV methylprednisolone followed by oral prednisone 1 mg/kg/day up to clinician discretion.

#vascular

#rhematology

References:

1. Hayreh SS, Zimmerman B, Kardon RH. Visual improvement with corticosteroid therapy in giant cell arteritis. Report of a large study and review of literature. Acta Ophthalmol Scand 2002; 80:355. 

2. Danesh-Meyer H, Savino PJ, Gamble GG. Poor prognosis of visual outcome after visual loss from giant cell arteritis. Ophthalmology 2005; 112:1098. 

3. Singh AG, Kermani TA, Crowson CS, et al. Visual manifestations in giant cell arteritis: trend over 5 decades in a population-based cohort. J Rheumatol 2015; 42:309. 

4. Hayreh SS, Zimmerman B. Visual deterioration in giant cell arteritis patients while on high doses of corticosteroid therapy. Ophthalmology 2003; 110:1204.

typhoid encephalopathy

 Q: Which one intervention may make a difference of life and death in "typhoid encephalopathy"? 

 Answer: Administering IV dexamethasone 

Although headache is the most common symptom in typhoid, it may progress to "typhoid encephalopathy." In this advanced neuro stage patient may develop altered mental status such as delirium, confusion, obtundation, or stupor. Once a patient develops "typhoid encephalopathy," the mortality is very high. Administration of intravenous dexamethasone if there is a sign of encephelopathy decreases mortality by more than 50 percent.

#ID

References:

1. Chisti MJ, Bardhan PK, Huq S, et al. High-dose intravenous dexamethasone in the management of diarrheal patients with enteric fever and encephalopathy. Southeast Asian J Trop Med Public Health 2009; 40:1065.

2. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med 1984; 310:82. 

3. Butler T, Islam A, Kabir I, Jones PK. Patterns of morbidity and mortality in typhoid fever dependent on age and gender: review of 552 hospitalized patients with diarrhea. Rev Infect Dis 1991; 13:85.

independent risk factor for infection with resistant Acinetobacter

Q: Bedridden status is itself an independent risk factor for infection with resistant Acinetobacter? 

A) True 

B) False 

 Answer: A 

 The objective of this question is to highlight the various factors which are modifiable to decrease the risk of healthcare-acquired infections. Acinetobacter infection is one hard-to-treat infection in ICUs as resistance to primary antibiotics is high and second-line antibiotics have either high side-effects or require prolonged treatment. The requirement for isolation can also become challenging and costly. Few of the risk-factors are influenced by the practice of healthcare like overuse of carbapenems or fluoroquinolone, not practicing early mobilization, prolong or overuse of central lines (including PICC), prolonged mechanical ventilation, and overuse of glucocorticoids. 

Another less known fact is that prior colonization with methicillin-resistant S. aureus (MRSA) is an independent risk factor for infection with resistant strains of Acinetobacter - a result of overuse of antibiotics, poor isolation, and hand-hygiene. 

Some of the risk factors are hard to modify such as recent surgery, hemodialysis, or malignancy.

#ID
#pharmacology

References:

1. Tacconelli E, Cataldo MA, De Pascale G, et al. Prediction models to identify hospitalized patients at risk of being colonized or infected with multidrug-resistant Acinetobacter baumannii calcoaceticus complex. J Antimicrob Chemother 2008; 62:1130. 

2.  Vitkauskiene A, Dambrauskiene A, Cerniauskiene K, et al. Risk factors and outcomes in patients with carbapenem-resistant Acinetobacter infection. Scand J Infect Dis 2013; 45:213.

3. Karruli A, Boccia F, Gagliardi M, et al. Multidrug-Resistant Infections and Outcome of Critically Ill Patients with Coronavirus Disease 2019: A Single Center Experience. Microb Drug Resist 2021.

lobar nephronia

 Q: 66 years old female is admitted to ICU with urosepsis. CT scan report reads "lobar nephronia". What is lobar nephronia? 

 Answer: "Lobar nephronia", a term described almost four decades ago, is a CT scan finding evident only with intravenous (IV) contrast. This is unlike renal abscess which can be seen without IV contrast. Diabetes is the highest risk factor. 

It is present as a single round or wedge-shaped hypodense image in single lobe on a CT scan. It is usually not very well defined. It is a concerning sign of renal ischemia and mostly presents due to bacterial infection. It may progress to necrosis, a walled-off cavity, and eventually to cortical scarring.

#ID

#nephrology

#radiology

References:

1. Demertzis J, Menias CO. State of the art: imaging of renal infections. Emerg Radiol 2007; 14:13. 

2. Rosenfield AT, Glickman MG, Taylor KJ, et al. Acute focal bacterial nephritis (acute lobar nephronia). Radiology 1979; 132:553. 

3. Talner LB, Davidson AJ, Lebowitz RL, et al. Acute pyelonephritis: can we agree on terminology? Radiology 1994; 192:297.

Doripenem in VAP

 Q: Doripenem is highly effective among all carbapenems in ventilator-associated pneumonia (VAP)? 

A) Yes 

B) No

Answer: B

Doripenem became popular for VAP as they were found to be more potent in vitro against P. aeruginosa. But subsequent follow-up study showed increased 28-days mortality in VAP patients. In fact, the study was stopped early. This leads FDA to add a warning on Doripenem for use in VAP patients.

#ID

References:

1. Kollef MH, Chastre J, Clavel M, et al. A randomized trial of 7-day doripenem versus 10-day imipenem-cilastatin for ventilator-associated pneumonia. Crit Care 2012; 16:R218. 

 2. US Food and Drug Administration. FDA approves label changes for antibacterial Doribax (doripenem) describing increased risk of death for ventilator patients with pneumonia. http://www.fda.gov/Drugs/DrugSafety/ucm387971.htm (Last accessed on March 11, 2021).

3. Paterson DL, Depestel DD. Doripenem. Clin Infect Dis 2009; 49:291.

Primary upper extremity DVT

 Q: Primary upper extremity deep vein thrombosis (DVT) is more common in? (select one) 

A) Younger people 

B) Older people 

 

Answer: A 

Primary upper extremity DVT is more common in younger people, including children and adolescents. Also, it is high in athletic muscular males. This is due to the high prevalence of strenuous exercise, sports, and overt or covert trauma due to repetitive extremities hyperabduction. 

Other contributing factors are congenital or acquired anatomical abnormalities of the thoracic outlet and hematologic disorder such as thrombophilia.

#vascular

#hematology

References:

1. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation 2012; 126:768. 

2. Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremities. N Engl J Med 2011; 364:861. 

3. Hendler MF, Meschengieser SS, Blanco AN, et al. Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects. Am J Hematol 2004; 76:330. 

4. Martinelli I, Battaglioli T, Bucciarelli P, et al. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004; 110:566.

Methadone effects

 Q: What are the few beneficial clinical effects of Methadone in hospitalized patients?

Answer: 

Methadone's use has seen an increased rise in the USA in hospitalized patients particularly after the COVID-19 pandemic due to the shortage of intravenous opioids and the high requirement of analgesics by COVID patients. Methadone is a long-acting opioid agonist. It works by binding to mu-opioid receptors. Its main beneficial effects are: 

• prevents withdrawal symptoms for 24 hours or longer
• reduces the craving for opioids
• maintains high levels of opioid tolerance
• reduces the euphoric effects of subsequent illicit opioid use

In patients with prolong hospitalization, the daily dose of 30 mg can be utilized and can be continued during the course of hospital stay with clinicians and pharmacists' mutual coordination.

#pain

#pharmacology

References:

1. Shir Y, Rosen G, Zeldin A, Davidson EM. Methadone is safe for treating hospitalized patients with severe pain. Can J Anaesth. 2001 Dec;48(11):1109-13. doi: 10.1007/BF03020377. PMID: 11744587. 

2. Noska A, Mohan A, Wakeman S, Rich J, Boutwell A. Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings. J Addict Behav Ther Rehabil. 2015;4(2):1000138. doi:10.4172/2324-9005.1000138

Which features distinguish strongyloidiasis from ulcerative colitis

 Q: 44 years old male, a recently migrant from southeast Asia is admitted to ICU with gastrointestinal (GI) symptoms including pain and lower GI bleed. Subsequent workup led to the presumed diagnosis of strongyloidiasis. Colonoscopy is performed to rule out ulcerative colitis. Which features distinguish strongyloidiasis from ulcerative colitis?

Answer: 

Strongyloides colitis can mimic ulcerative colitis. Although endoscopies are not routinely performed in strongyloidiasis but may require ruling out other potentially life-threatening conditions. Strongyloides colitis can be differentiated from ulcerative colitis by noticing skip pattern of inflammation, distal attenuation of the disease, eosinophil-rich infiltrates, relatively intact crypt architecture, and frequent involvement of submucosa with erythematous nodules. 

 

If upper endoscopy is performed, the stomach may show thickened folds and mucosal erosions. And, the duodenum may show edema, brown mucosal discoloration, erythematous spots, subepithelial hemorrhages, and megaduodenum. A biopsy can be taken to document parasites in the gastric crypts or duodenal glands and eosinophilic infiltration of the lamina propria.

#GI
#ID

References:

1. Rivasi F, Pampiglione S, Boldorini R, Cardinale L. Histopathology of gastric and duodenal Strongyloides stercoralis locations in fifteen immunocompromised subjects. Arch Pathol Lab Med 2006; 130:1792. 

2. Overstreet K, Chen J, Rodriguez JW, Wiener G. Endoscopic and histopathologic findings of Strongyloides stercoralis infection in a patient with AIDS. Gastrointest Endosc 2003; 58:928.

3. Qu Z, Kundu UR, Abadeer RA, Wanger A. Strongyloides colitis is a lethal mimic of ulcerative colitis: the key morphologic differential diagnosis. Hum Pathol 2009; 40:572. 

4. Thompson BF, Fry LC, Wells CD, et al. The spectrum of GI strongyloidiasis: an endoscopic-pathologic study. Gastrointest Endosc 2004; 59:906.

Oculomasticatory Myorhythmia

Q: What is Oculomasticatory Myorhythmia and signifies which disease?

 Answer: It is a continuous rhythmic movement of eye convergence with concurrent contractions of the masticatory or other muscles. This signifies the central nervous system (CNS) involvement in Whipple's disease. 

It is usually associated with cognitive abnormalities. If there is an involvement of skeletal muscles, it is called oculofacial-skeletal myorhythmia. The cause is not fully understood for this symptom. If present, eyes oscillate synchronously horizontally towards and away from each other. Other muscles involved can be any/some/all of masticatory, lids, tongue, palate, arms, and legs. Bilateral ptosis may be present. Interestingly, this is found to be associated with hypersomnolence. To make things complicated in isolated CNS involvement, PAS-positive cells may be negative on intestinal biopsy. 

Treatment for CNS Whipple's disease is not established though tetracycline, ceftriaxone, trimethoprim-sulfamethoxazole, pefloxacin, and valproate has been described.

#neurology

References:

1. Adler CH, Galetta SL. Oculo-facial-skeletal myorhythmia in Whipple disease: treatment with ceftriaxone. Ann Intern Med 1990; 112:467. 

2. Simpson DA, Wishnow R, Gargulinski RB, Pawlak AM. Oculofacial-skeletal myorhythmia in central nervous system Whipple's disease: additional case and review of the literature. Mov Disord 1995; 10:195. 

3. Hausser-Hauw C, Roullet E, Robert R, Marteau R. Oculo-facio-skeletal myorhythmia as a cerebral complication of systemic Whipple's disease. Mov Disord 1988; 3:179. 

4. Rajput AH, McHattie JD. Ophthalmoplegia and leg myorhythmia in Whipple's disease: report of a case. Mov Disord 1997; 12:111. 

5. Amarenco P, Roullet E, Hannoun L, Marteau R. Progressive supranuclear palsy as the sole manifestation of systemic Whipple's disease treated with pefloxacine. J Neurol Neurosurg Psychiatry 1991; 54:1121. 

6. Panegyres PK, Goh J. Sleep disorders of Whipple's disease of the brain. QJM 2015; 108:99. 

7. Calandra-Buonaura G, Provini F, Guaraldi P, et al. Oculomasticatory myorhythmia and agrypnia excitata guide the diagnosis of Whipple disease. Sleep Med 2013; 14:1428.

8.Adler CH, Galetta SL. Oculo-facial-skeletal myorhythmia in Whipple disease: treatment with ceftriaxone. Ann Intern Med 1990; 112:467. 

CNS and extracerebral toxoplasmosis

 Q: Central nervous system (CNS) toxoplasmosis is more common than extracerebral toxoplasmosis?

A) True 

B) False 

 Answer: A

Immuno-compromise state is the biggest risk factor for clinical toxoplasmosis. Interestingly, CNS is the most affected system. Solo extracerebral toxoplasmosis is rare. Toxoplasmosis in lungs, eyes, or as disseminated infection usually occur along with CNS infection.

Another important pearl for clinicians to remember is that fever may not be present in toxoplasmic encephalitis due to immunosuppression. Headache is the most prominent symptom with mental status change or seizure. 

Multiple ring-enhancing lesions on brain imaging is considered a hallmark for the diagnosis.

#ID

#neurology

References:

1. Belanger F, Derouin F, Grangeot-Keros L, Meyer L. Incidence and risk factors of toxoplasmosis in a cohort of human immunodeficiency virus-infected patients: 1988-1995. HEMOCO and SEROCO Study Groups. Clin Infect Dis 1999; 28:575.

2. Rabaud C, May T, Amiel C, et al. Extracerebral toxoplasmosis in patients infected with HIV. A French National Survey. Medicine (Baltimore) 1994; 73:306.

3. Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327:1643.

Labs in NMS

Q: A low serum iron in Neuroleptic Malignant Syndrome (NMS) is (select one) 

A) sensitive marker 

B) specific marker 

 

Answer: A 

NMS is a life-threatening neurologic emergency. It requires a very high level of suspicion. Failure to recognize NMS carries high mortality. It is a clinical diagnosis although some lab abnormalities are associated with it, including: 

• high CPK
• high WBC
• high LDH
• high LFT
• low calcium
• low magnesium 
• high or low sodium
• high potassium 
• metabolic acidosis 
• rhabdomyolysis, myoglobinuria, and acute renal failure

Low serum iron is common in NMS. It is an extremely sensitive marker but is not very specific.

#neurology

References:

1. Lee JW. Serum iron in catatonia and neuroleptic malignant syndrome. Biol Psychiatry 1998; 44:499. 

2.Modi S, Dharaiya D, Schultz L, Varelas P. Neuroleptic Malignant Syndrome: Complications, Outcomes, and Mortality. Neurocrit Care 2016; 24:97.

Post-transplant diabetes

 Q: The newly transplanted kidney excretes insulin more efficiently than previously failed native kidneys? 

A) True 

B) False 

 Answer: A

There is more than one reason for new-onset diabetes mellitus after transplantation (NODAT) particularly after kidney transplant. Blood glucose monitoring continued to be essential monitoring in newly transplanted patients. The new kidney metabolizes and excretes insulin more efficiently. Also, the new kidney is gluconeogenic. These extra myriads are in conjunction with the inherent risks of immunosuppressants required in most post-transplant patients. Post-transplant issues such as age, obesity, and gestations further compound the issue of NODAT.

#tranplantation

#endocrinology

Reference:

1. Shivaswamy V, Boerner B, Larsen J. Post-Transplant Diabetes Mellitus: Causes, Treatment, and Impact on Outcomes. Endocr Rev. 2016;37(1):37-61. doi:10.1210/er.2015-1084 

Procal in COVID-19

Q: Elevated procalcitonin can be used reliably to add antibiotics in hospitalized COVID-19 patients? 

A) True 

B) False 

 

Answer: B 

In advance COVID-19 patients, despite lack of any other evidence for infections, procalcitonin levels are found to be elevated. It is up to clinician discretion in such cases to add or hold back on antibiotics. The prudent thing would be to draw blood cultures, sputum culture and perform urinanalysis (UA) and decide in conjugation with other clinical evidence. Infectious Disease (ID) consult may be helpful too. 

A low procalcitonin level may be more helpful in deciding against the addition of antibiotics.

#ID

#COVID-19

References:

1. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020; 382:1708. 

2. Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020; 180:934. 

3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054.

Peptic ulcer Mx

Q: 38 years old male is admitted to ICU with an upper GI bleed. Upper endoscopy showed active peptic ulcer disease. Proton pump inhibitor (PPI) was initiated. PPIs have higher healing rates in peptic ulcer disease in comparison to H2 receptor antagonists (H2RA)? 

A) True 

B) False 

 

Answer: A

PPIs are found to be superior to H2RA in peptic ulcer disease management. Not only they control symptoms faster but also have a higher healing rate. This is due to their ability to have more potent acid suppression. PPIs continue to keep that advantage in Non-steroidal-anti-inflammatory-drugs (NSAIDs) induced peptic ulcer disease. 

Previously, it was suggested that the combination of PPIs with H2RA will further enhance the management due to their different mechanism of action. This was not found to be true. Solo treatment with PPIs is enough in the treatment of non-H. Pylori peptic ulcer disease.

#GI

Reference:

Yeomans ND, Tulassay Z, Juhász L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med 1998; 338:719.

MALA first line of Mx

 Q: 64 years old male is admitted to ICU after accidental ingestion of metformin. Patient is found to be in severe metabolic acidosis with a PH of 7.08. Patient should receive activated charcoal? 

A) Yes

B) No

Answer: A

Metformin-associated Lactic Acidosis (MALA) is a potentially a fatal condition. As a first line of treatment, all patients with acute ingestion should receive activated charcoal, if they can tolerate it or there is no contraindication otherwise. The recommended dose is 1 gm/kg but as a rule of thumb, all patients can just be given 50 grams once. 

The patients who are in severe lactic acidosis, hemodialysis is a life-saving treatment, but it takes time and effort to arrange hemodialysis. 

In between patient can be treated with a soda-bicarb bolus followed by infusion to avoid hemodynamic collapse from severe acidosis. The usual cut-off point is at the PH of 7.10 or at the clinician's discretion. In an adult patient, the dose is 1-2 meq/kg bolus followed by 133-150 meq in one liter of D5W at a rate of 250 mL/hour.

#toxicology

Reference:

Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol. 2016 Dec;29(6):783-789. doi: 10.1007/s40620-016-0267-8. Epub 2016 Jan 22. PMID: 26800971.

immunosuppressants drug action

 Q: All of the following drugs may increase the serum concentrations of immunosuppressants EXCEPT? 

A) Amiodarone 

B) Fluconazole

C) Phenytoin 

D) Azithromycin 

E) Diltiazem

Answer: C

The objective of this question is to enhance the fragile serum levels of immunosuppressants in relatively sick patients in ICU. Most of the commonly used drugs in ICU have some kind of interaction with immunosuppressants i.e., cyclosporine, tacrolimus, sirolimus, or everolimus. Drug interactions may either increase the serum level of these immunosuppressants or decrease the level. Some drugs may just have the additive effect, and some may just cause hyperkalemia. This is beyond the scope here to list all such drugs. It can be very tricky as macrolide antibiotics increase the serum level of immunosuppressant but nafcillin decreases the level! Most of the interactions occur via CYP3A metabolism and/or P-glycoprotein drug efflux pump. 

All the drugs in the above question except choice C increase the serum levels of immunosuppressant. In fact, phenytoin decreases the tacrolimus level and has been tried as an antidot in tacrolimus toxicity.

#transplant

#pharmacology

References:

1. Katalin Monostory (July 25th 2018). Metabolic Drug Interactions with Immunosuppressants, Organ Donation and Transplantation - Current Status and Future Challenges, Georgios Tsoulfas, IntechOpen, DOI: 10.5772/intechopen.74524. Available from: https://www.intechopen.com/books/organ-donation-and-transplantation-current-status-and-future-challenges/metabolic-drug-interactions-with-immunosuppressants (last accessed March 15, 2021)

2. Jantz AS, Patel SJ, Suki WN, Knight RJ, Bhimaraj A, Gaber AO. Treatment of acute tacrolimus toxicity with phenytoin in solid organ transplant recipients. Case Rep Transplant. 2013;2013:375263. doi:10.1155/2013/375263

post bypass vasoplegia

 Q: All of the following are risk factors for post-cardiac bypass surgery vasoplegia Except?

A) pre-operative use of angiotensin-converting enzyme (ACE) inhibitors 

B) warmer core temperature on bypass

C) use of vasopressin perioperatively 

D) longer time on aortic cross-clamping and bypass

E) pre-bypass hemodynamic instability

Answer: C

All of the conditions described in choices A, B, D, and E are risk factors for refractory vasoplegia after bypass surgery.

Vasopressin (choice C) is one of the pressors which has the strongest evidence among all pressors to have clinical efficacy in post-cardiac surgery vasoplegia. Vasopressin has five effects simultaneously by binding to V1a, V1b, and V2 receptors. It causes 

• vasoconstriction 
• water reabsorption at the renal collecting ducts 
• increased secretion of cortisol 
• increased secretion of insulin 
• bradycardia by augmenting baroreflex inhibition of efferent sympathetic nerve activity

Said that vasopressin should not be used beyond recommended dose due to its high affinity to cause vasoconstriction at the capillary level causing renal and gastrointestinal (GI) ischemia.

#hemodynamic

References:

1. Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med 2009; 24(5): 293–316.

2. Schmittinger CA, Torgersen C, Luckner G, et al. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38(6): 950–958. 

3. Demiselle J, Fage N, Radermacher P, et al. Vasopressin and its analogues in shock states: a review. Ann Intensive Care 2020; 10(1): 9. 

4. Treschan TA, Peters J. The vasopressin system: physiology and clinical Strategies. Anesthesiology 2006; 105(3): 599–612

treatment in myoclonus

Q: All of the following are found to be helpful in myoclonus EXCEPT? 

A) Levetiracetam 

B) Phenytoin 

C) Clonazepam 

D) Valproic acid 

E) Zonisamide

Answer: B

Physicians tend to reflexly use anti-seizure meds to treat myoclonus. Only a few drugs found to be effective in myoclonus. The most rigorously tested and found to be an effective drug is Levitractam. Other drugs found to be helpful include Piracetam, Brivaracetam, Clonazepam, and Zonisamide. Many other drugs have been described with limited effectiveness like Baclofen, Benztropine, Carbamazepine, Diazepam, Lamotrigine, Phenobarbital, Primidone, Sumatriptan, Tetrabenazine, Topiramate and Trihexyphenidyl. Besides pharmacology treatment stimulation and surgical interventions have also been used, where the most widely used is Deep Brain Stimulator (DBS).

 The response to treatment in myoclonus can be assessed by the Unified Myoclonus Rating Scale (UMRS). 

 Phenytoin (choice B) so far has not shown any role in the treatment of myoclonus. In fact, in many cases, it is found to worsen myoclonus.

#neurology

References:

1. Eldridge R, Iivanainen M, Stern R, et al. "Baltic" myoclonus epilepsy: hereditary disorder of childhood made worse by phenytoin. Lancet 1983; 2:838.

2. Genton P, Gélisse P. Antimyoclonic effect of levetiracetam. Epileptic Disord 2000; 2:209.

3. Roze E, Vidailhet M, Hubsch C, et al. Pallidal stimulation for myoclonus-dystonia: Ten years' outcome in two patients. Mov Disord 2015; 30:871.

Effects of pentoxifylline

Q: Pentoxifylline has a beneficial effect on all of the following diseases except? 

A) claudication 

B) alcoholic hepatitis 

C) septic shock 

D) venous leg ulcer

Answer: C

Pentoxifylline is a nonspecific phosphodiesterase inhibitor, which is well known for its use in patients with vascular claudication (choice A) and venous leg ulcer (choice D). It is also found to be effective in alcoholic hepatitis (choice B). Its major action is to work as a blood viscosity reducer agent and an anti-inflammatory agent. 

Pentoxifylline has no role in septic shock so far (choice C).

#pharmacology

References:

1.  Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012;12:CD001733.

2. Singal AK, Bataller R, Ahn J, et al. ACG Clinical Guideline: alcoholic liver disease. Am J Gastroenterol. 2018;113(2):175-194. doi: 10.1038/ajg.2017.469

Rocking tenderness over liver

 Q: Which of the following may have a rocking tenderness on the physical exam? (select one) 

 A) Pyogenic liver abscess 

 B) Acute cholecystitis

Answer: A

Rocking tenderness is demonstrated by gently rocking the patient's abdomen, particularly the right upper quadrant. It is one of the associated signs of pyogenic liver abscess. Other clinical signs and symptoms are pain, guarding, tenderness or rebound tenderness, hepatomegaly, and jaundice.  Although their absence does not rule out the disease.

These findings should be combined with laboratory and imaging findings. In this regard, often ignored are the associated findings on chest x-ray which may show an elevated right hemidiaphragm, right basilar infiltrate, or/and right-sided pleural effusion.

#hepatology

References:

1. Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: ten years experience in a UK centre. QJM 2002; 95:797.

2. Longworth S, Han J. Pyogenic liver abscess. Clin Liver Dis (Hoboken). 2015;6(2):51-54. Published 2015 Aug 24. doi:10.1002/cld.487 

3. Serraino C, Elia C, Bracco C, et al. Characteristics and management of pyogenic liver abscess: A European experience. Medicine (Baltimore). 2018;97(19):e0628. doi:10.1097/MD.0000000000010628

precipitants for hepatic encephalopathy

 Q: Which of the following is more of a risk for increased ammonia production, its absorption, or its entry into the brain to exacerbate hepatic encephalopathy? (select one) 

 A) Metabolic acidosis

 B) Metabolic alkalosis

Answer: B

The list of precipitants for hepatic encephalopathy is long including drugs, dehydration, portosystemic shunting, vascular occlusions, and primary hepatocellular carcinoma. 

Factors that increase ammonia production, or its absorption, or its entry into the brain includes excess dietary intake of protein, gastrointestinal bleeding, infection, electrolyte disturbances (most importantly hypokalemia), constipation, and metabolic alkalosis.

#hepatology

References:

1. Khungar V, Poordad F. Hepatic encephalopathy. Clin Liver Dis 2012; 16:301. 

2. Mumtaz K, Ahmed US, Abid S, et al. Precipitating factors and the outcome of hepatic encephalopathy in liver cirrhosis. J Coll Physicians Surg Pak 2010; 20:514. 

3. Onyekwere CA, Ogbera AO, Hameed L. Chronic liver disease and hepatic encephalopathy: clinical profile and outcomes. Niger J Clin Pract 2011; 14:181.

ACE in sarcoidosis

Q: Serum angiotensin converting enzyme (ACE) has a very high sensitivity and specificity to diagnose sarcoidosis?

A) True

B) False

Answer: B

None of the serologic markers including ACE, adenosine deaminase, serum amyloid A, soluble interleukin-2 receptor, or D-dimer have shown any definite evidence to exclusively diagnose sarcoidosis. Although 3/4th of the patients with sarcoidosis have high ACE levels, it has very poor sensitivity and unreliable specificity. 

Other diseases which can also have high ACE levels include Asbestosis, Beryllium disease, Coccidioidomycosis, Diabetes mellitus (DM), Hodgkin disease, Hypersensitivity pneumonitis, Hyperthyroidism, Leprosy, Lung cancer, Primary biliary cirrhosis (PBC), Silicosis and Tuberculosis (TB).

#sarcoidosis

References:

1. Studdy PR, Bird R. Serum angiotensin converting enzyme in sarcoidosis-its value in present clinical practice. Ann Clin Biochem 1989; 26 ( Pt 1):13. 

2. Baughman RP. Pulmonary sarcoidosis. Clin Chest Med 2004; 25:521. 

3. Ungprasert P, Carmona EM, Crowson CS, Matteson EL. Diagnostic Utility of Angiotensin-Converting Enzyme in Sarcoidosis: A Population-Based Study. Lung 2016; 194:91.

Mayo score for ulcerative colitis

 Q: All of the following are the components of Mayo scoring to determine the severity of disease in ulcerative colitis - EXCEPT?

A) Stool pattern 

B) Most severe rectal bleeding of the day 

C) Severity of leukocytosis 

D) Endoscopic findings 

E) Global assessment by a clinician

Answer: C

Mayo scoring to determine the severity of disease in ulcerative colitis is divided into four components. Each of the following components is further divided into 4 parts and get points (0-3) depending on the severity. Depending on a score from 0 to 12, the severity of ulcerative colitis is determined. 

•  Stool pattern 
•  Most severe rectal bleeding of the day 
•  Endoscopic findings 
•  Global assessment by a clinician

#gastroenterology

Reference:

Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. A randomized study. N Engl J Med 1987; 317:1625.

Lavage in upper GI bleed

Q: Nasogastric Lavage in upper gastrointestinal (GI) bleed is associated with? (select one) 

A) shorter time to endoscopy

B) reduced mortality

C) decrease length of hospital stay

D) decrease rate of surgery

E) decrease rate of transfusion 

Answer: A

Previously it was a common practice to insert a nasogastric tube (NGT) in patients with suspected upper GI bleed. This practice failed to show any benefit in mortality (choice B), length of hospital stay (choice C), surgery (choice D), or transfusion requirement (Choice E). The only advantage is a shorter time to endoscopy. Also, it can be used to clean the stomach (like blood clots or food particles) prior to endoscopy. Bilious output from NGT gives an indication that bleed is probably distal to pylorus.

#GI

#procedures

References:

1. Rockey DC, Ahn C, de Melo SW Jr. Randomized pragmatic trial of nasogastric tube placement in patients with upper gastrointestinal tract bleeding. J Investig Med 2017; 65:759.

 

2. Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011; 74:981. 

3. Karakonstantis S, Tzagkarakis E, Kalemaki D, et al. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Rev Gastroenterol Hepatol 2018; 12:63. 

4. Huang ES, Karsan S, Kanwal F, et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011; 74:971. 

Post DBS complications

Q: 74 years old male is admitted to ICU after insertion of subthalamic nucleus Deep Brain Stimulator (STN-DBS) for Parkinson's Disease (PD). A review of chart shows a strong psychiatric history. What would be your major concern in this patient? 

 Answer: Increased risk of suicide 

 Parkinson's Disease is usually associated with many psychiatric issues like anxiety, depression, hallucinations, and delusions. Patients with such associated symptoms may have an increased risk for suicide post-DBS implantation. Also, there is a high tendency for such patients to have a higher rate of transient confusion post-operatively. 

Other postoperative complications include infections, intracerebral hemorrhage (ICH), seizures, pulmonary embolism (PE), cerebrospinal fluid (CSF) leak, and venous infarction.

#neurology

#surgical-critical-care

#psychiatry

References:

1. Soulas T, Gurruchaga JM, Palfi S, et al. Attempted and completed suicides after subthalamic nucleus stimulation for Parkinson's disease. J Neurol Neurosurg Psychiatry 2008; 79:952. 

2. Voon V, Krack P, Lang AE, et al. A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson's disease. Brain 2008; 131:2720. 

3. Giannini G, Francois M, Lhommée E, et al. Suicide and suicide attempts after subthalamic nucleus stimulation in Parkinson disease. Neurology 2019; 93:e97. 

4. Kleiner-Fisman G, Herzog J, Fisman DN, et al. Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 2006; 21 Suppl 14:S290. 

5. Pahwa R, Factor SA, Lyons KE, et al. Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66:983.

FES - non-trauma

 Q: Name few non-orthopedic trauma causes of Fat Embolism Syndrome (FES)? 

 Answer: Although FES is usually associated with either accidental or surgical trauma to bones, there are few significant non-orthopedic trauma causes of FES. These include 

•  soft tissue injury 
•  burns 
• liposuction and lipo-injection 
•  fat grafting 
• cardiopulmonary resuscitation (mostly due to intraosseous access) 
•  cesarean section 
•  donor-related FES after lung transplantation
• osteomyelitis

Besides the above, there are also many completely non-traumatic clinical causes of FES.

• pancreatitis
• amniotic fluid embolism
• diabetes mellitus 
• prolonged steroid therapy 
• sickle cell hemoglobinopathies 
• fatty liver disease 
• Lipid infusion 
• cyclosporine solvent 
• intravenous lipid emulsion therapy
• intraoperative cell salvage 
• metastases from fatty tumors 

#trauma 

#surgical-critical-care

References:

1. Levine M, Skolnik AB, Ruha AM, et al. Complications following antidotal use of intravenous lipid emulsion therapy. J Med Toxicol 2014; 10:10.

2. Mendoza-Morales RC, Camberos-Nava EV, Luna-Rosas A, et al. A fatal case of systemic fat embolism resulting from gluteal injections of vitamin e for cosmetic enhancement. Forensic Sci Int 2016; 259:e1. 

3. Jacob S, Courtwright A, El-Chemaly S, et al. Donor-acquired fat embolism syndrome after lung transplantation. Eur J Cardiothorac Surg 2016; 49:1344. 

4. Schrufer-Poland T, Singh P, Jodicke C, et al. Nontraumatic Fat Embolism Found Following Maternal Death after Cesarean Delivery. AJP Rep 2015; 5:e1.

Pseudo CS

 Q: All of the following may have some clinical features of Cushing's Syndrome (CS) EXCEPT?

A) Prolong ICU stay  

B) Severe major depressive disorder

C) Poorly controlled diabetes 

D) Glucocorticoid resistance

E) Obstructive sleep apnea

Answer: D

Physiologic hypercortisolism is also called pseudo-CS. They may have some clinical features of CS or may not. 

Conditions with some clinical features of CS include: pregnancy, severe visceral obesity, polycystic ovary syndrome (PCOS), severe major depressive disorder, poorly controlled diabetes mellitus, prolonged illness/hospitalization, and obstructive sleep apnea. 

Physiologic hypercortisolism that are unlikely to have clinical features of CS are anorexia nervosa, intense chronic exercise, hypothalamic amenorrhea, high corticosteroid-binding globulin (CBG) and glucocorticoid resistance.

#endocrinology

References:

1. Lacroix A, Feelders RA, Stratakis CA, Nieman LK. Cushing's syndrome. Lancet 2015; 386:913. 

2.  Arnaldi G, Angeli A, Atkinson AB, et al. Diagnosis and complications of Cushing's syndrome: a consensus statement. J Clin Endocrinol Metab 2003; 88:5593. 

3. Newell-Price J, Trainer P, Besser M, Grossman A. The diagnosis and differential diagnosis of Cushing's syndrome and pseudo-Cushing's states. Endocr Rev 1998; 19:647. 

4. Loosen PT, Chambliss B, DeBold CR, et al. Psychiatric phenomenology in Cushing's disease. Pharmacopsychiatry 1992; 25:192.

Percutaneous vs operative tracheostomy

 Q: Which of the following has a higher risk of posterior tracheal wall perforation? (select one) 

A) Percutaneous tracheostomy 

 B) Operative tracheostomy 

Answer: A

Over the last few years, percutaneous tracheostomy has become a norm for ICU patients due to its various advantages such as its cost-effectiveness, can be performed promptly at patients' bedside, and doesn't require scheduled time in the operating room (OR). Also, it can be performed by intensivists with appropriate training. 

Said that percutaneous tracheostomy has a higher rate of anterior as well as posterior tracheal wall perforations.

#procedures

References:

1. Trottier SJ, Hazard PB, Sakabu SA, et al. Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention. Chest 1999; 115:1383. 

2.  Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006; 10:R55. 

3. Silvester W, Goldsmith D, Uchino S, et al. Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up. Crit Care Med 2006; 34:2145.

GS in septic arthritis

 Q: The sensitivity of gram stain in septic arthritis is? (select one)

A) reliable

B) not very reliable

Answer: B

The gram stain in septic arthritis is positive in only some cases and the sensitivity is only 30 to 50 percent. There is a good chance of false-positive gram stain as precipitated crystal violet (gentian violet) and mucin in synovial fluid may mimic gram-positive cocci. 

False-negative results are due to the presence of crystals and/or clotting in the synovial fluid.

#ID

References:

1. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA 2007; 297:1478.

2. Stirling P, Faroug R, Amanat S, et al. False-negative rate of gram-stain microscopy for diagnosis of septic arthritis: suggestions for improvement. Int J Microbiol 2014; 2014:830857.

3. Stirling P, Tahir M, Atkinson HD. The Limitations of Gram-stain Microscopy of Synovial Fluid in Concomitant Septic and Crystal Arthritis. Curr Rheumatol Rev 2018; 14:255. 

JVP In Kussmaul's sign

 Q: In Kussmaul's sign - the Jugular Venous Pressure (JVP) _____________ during inspiration? (select one) 

 A) decreases 

 B) increases 

Answer: B 

 In a healthy adult patient, the height of JVP should declines with inspiration i.e., towards the clavicle. If it fails to occur or on the contrary rises up in the neck, it is called Kussmaul's sign. Kussmaul’s sign is a classical presentation of constrictive or effusive pericarditis or restrictive cardiomyopathy. 

Other conditions that may be associated with it are Right Ventricular (RV) infarction, RV dysfunction, massive pulmonary embolism (PE), partial obstruction of the venae cavae, right atrial and RV tumors, severe tricuspid regurgitation, tricuspid stenosis, and rarely cardiac tamponade.

#cardiology

#physical-exam

References:

1. Meyer TE, Sareli P, Marcus RH, et al. Mechanism underlying Kussmaul's sign in chronic constrictive pericarditis. Am J Cardiol 1989; 64:1069. 

2. Nadir AM, Beadle R, Lim HS. Kussmaul physiology in patients with heart failure. Circ Heart Fail 2014; 7:440. 

3.  Dell'Italia LJ, Starling MR, O'Rourke RA. Physical examination for exclusion of hemodynamically important right ventricular infarction. Ann Intern Med 1983; 99:608.

emphysematous UTI

 Q: 82 years old diabetic female is admitted to ICU with urosepsis. The plain abdominal film showed emphysematous Urinary Tract Infection (UTI). What is the most common cause of emphysematous UTI? (select one) 

A) Escherichia coli 

B) Candida 

 Answer: A

Emphysematous UTI can either be in the upper or lower urinary tract and is hallmarked with gas formation. The most common risk factor is diabetes mellitus. This gas formation is not fully understood as the most common pathogens are the same who are the usual culprits in simple UTI i.e., Escherichia coli and Klebsiella pneumonia. 

Other pathogens that may be involved are Proteus, Enterococcus, Pseudomonas, Clostridium, Streptococcus, Cryptococcus, and sometimes polymicrobial. Candida is rarely implicated. It is suggested that hyperglycemia provides a suitable environment for gas-formation.

#ID

References:

1. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore) 2007; 86:47. 

2. Chang SW, Yen DH, Fung CP, et al. Klebsiella pneumoniae renal abscess. Zhonghua Yi Xue Za Zhi (Taipei) 2000; 63:721. 

3. Hildebrand TS, Nibbe L, Frei U, Schindler R. Bilateral emphysematous pyelonephritis caused by Candida infection. Am J Kidney Dis 1999; 33:E10.