Pentoxifylline and kidney

Q: Pentoxifylline if used in patients with diabetic nephropathy tends to? (select one) 

A) help the kidney 

B) hurt the kidney 

Answer: A

 Pentoxifylline is commonly used in vascular patients with claudication. It has also been used in alcoholic hepatitis. Pentoxifylline is a putative anti-inflammatory agent. It is a nonspecific phosphodiesterase inhibitor. Pentoxifylline is found to help estimated glomerular filtration rate (eGFR) in patients with diabetic nephropathy. 

This is the added benefit with the use of standard management with either angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs). Pentoxifylline reduces the rate of eGFR decline in diabetic nephropathy. The dose is 600 mg twice daily.  As the evidence is not fully established, it has not yet become a standard of care.

#nephrology

References:

1. Navarro-González JF, Mora-Fernández C, Muros de Fuentes M, et al. Effect of pentoxifylline on renal function and urinary albumin excretion in patients with diabetic kidney disease: the PREDIAN trial. J Am Soc Nephrol 2015; 26:220. 

2. Perkins RM, Aboudara MC, Uy AL, et al. Effect of pentoxifylline on GFR decline in CKD: a pilot, double-blind, randomized, placebo-controlled trial. Am J Kidney Dis 2009; 53:606. 

3. Goicoechea M, García de Vinuesa S, Quiroga B, et al. Effects of pentoxifylline on inflammatory parameters in chronic kidney disease patients: a randomized trial. J Nephrol 2012; 25:969.

Eosinophillia in drug fever

 Q: Eosinophilia is one of the essential features of "drug fever." (select one) 

A) True 

B) False 

 Answer: B

It has been estimated that about one-third of patients in the hospital develop drug fever. No absolute reason is known but it is assumed that this is due to subclinical allergic or allergic-type (idiosyncratic) reaction. Also, it can be due to an effect on thermoregulation system. 

 Although eosinophilia is common in drug fever it occurs only in one-fourth of the patients.

#pharmacology

Reference:

Mackowiak PA, LeMaistre CF. Drug fever: a critical appraisal of conventional concepts. An analysis of 51 episodes in two Dallas hospitals and 97 episodes reported in the English literature. Ann Intern Med 1987; 106:728.

anti seizure meds in PCNSL

 Q: 48 years old male is admitted to ICU with mental status change. Subsequent workup led to the diagnosis of Central Nervous System Lymphoma (PCNSL). Oncology service has been consulted. Anticonvulsants should be used in this patient as prophylaxis? (select one) 

A) Yes 

B) No 

Answer: B

Although patients with PCNSL are at increased risk for seizures, prophylactic anti-seizure meds are not indicated. This is due to the finding that their prescription has no effect on the frequency of subsequent seizures. Also, anticonvulsants can harm the patient due to their high tendency of drug-drug interaction with chemotherapy and dexamethasone, the most used steroids. 

In general, except for metastatic melanoma anti-seizure drugs are not used in primary or metastatic brain tumors without any evidence of seizure. Anticonvulsants should be added only when there are documented or witnessed seizures.

#oncology

#neurology

References:

1. Sirven JI, Wingerchuk DM, Drazkowski JF, et al. Seizure prophylaxis in patients with brain tumors: a meta-analysis. Mayo Clin Proc 2004; 79:1489. 

2. Tremont-Lukats IW, Ratilal BO, Armstrong T, Gilbert MR. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev 2008; :CD004424. 

3. Mikkelsen T, Paleologos NA, Robinson PD, et al. The role of prophylactic anticonvulsants in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2010; 96:97. 

4. Goldlust SA, Hsu M, Lassman AB, et al. Seizure prophylaxis and melanoma brain metastases. J Neurooncol 2012; 108:109.

A.fib and VT in WPW

 Q: Which arrhythmia is more common in Wolff-Parkinson-White (WPW) syndrome? (select one) 

A) Atrial fibrillation (AF)

B) Ventricular tachycardia (VT)

Answer: A

About one-third of patients with WPWmay have AF. Although AF can originate independently from atria or pulmonary veins, the hallmark pathology is via an accessory pathway due to retrograde conduction. If AF occurs via an accessory pathway, EKG shows the characteristic change of QRS morphology from beat to beat. AF in WPW at the rapid ventricular rate (RVR) of 180-200 beats/minute appears as "pseudo-regularized" and above 300 beats/minute degenerate into V.fib. 

Primary VT is very uncommon in WPW.

#cardiology

References:

1. Josephson ME. Preexcitation syndromes. In: Clinical Cardiac Electrophysiology, 4th, Lippincot Williams & Wilkins, Philadelphia 2008. p.339.

2. Campbell RW, Smith RA, Gallagher JJ, et al. Atrial fibrillation in the preexcitation syndrome. Am J Cardiol 1977; 40:514. 

3. Sharma AD, Klein GJ, Guiraudon GM, Milstein S. Atrial fibrillation in patients with Wolff-Parkinson-White syndrome: incidence after surgical ablation of the accessory pathway. Circulation 1985; 72:161.

side effect of ACE-I/ARBs

 Q: Which side effect of Angiotensin-Converting Enzyme (ACE) inhibitors can be used as a treatment in post-transplant patients?

Answer: Anemia

ACE inhibitors as well as Angiotensin II receptor blockers (ARBs) suppress erythropoietin. This suppression is enhanced in patients with renal insufficiency. This occurs due to accumulation of the compound N-acetyl-seryl-aspartyl-lysyl-proline. This compound causes inhibition of stem cell multiplication. This side effect of ACE-I and ARBs is used in two forms of anemia

•  posttransplant erythrocytosis, and 
• high altitude increase in red cells 

#pharmacology

#nephrology

#transplantation

References:

1. Yildiz A, Cine N, Akkaya V, et al. Comparison of the effects of enalapril and losartan on posttransplantation erythrocytosis in renal transplant recipients: prospective randomized study. Transplantation 2001; 72:542. 

2. Plata R, Cornejo A, Arratia C, et al. Angiotensin-converting-enzyme inhibition therapy in altitude polycythaemia: a prospective randomised trial. Lancet 2002; 359:663.

PGD in Transplantation

 Q: All of the following are considered as causes of primary graft dysfunction (PGD) EXCEPT? (select one) 

A) preexisting donor heart disease 

B) reperfusion injury 

C) massive blood transfusion 

D)ischemia during the process of organ recovery

Answer: C

The consensus conference on primary graft dysfunction after cardiac transplantation (Reference # 1) defines PGD as: "Left Ventricular (LV), Right Ventricular (RV) or biventricular dysfunction that occurs within 24 hours after surgery and is not associated with a discernible cause such as hyperacute rejection, pulmonary hypertension, or uncontrolled intraoperative bleeding resulting in massive blood product transfusions and prolonged graft ischemic time". 

Hyperacute rejection, volume overload, and pulmonary hypertension in the recipient's heart are all considered as secondary graft dysfunction. 

#transplantation

#cardiology

Reference:

1. Kobashigawa J, Zuckermann A, Macdonald P, et al. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant 2014; 33:327.

RLS

 Q: Trazodone is a good choice for patients in ICU with complaints of Restless leg syndrome (RLS)?

A) True

B) False

Answer: B

Serotonergic agents i.e., trazodone or mirtazapine makes RLS symptoms worse and should not be used exclusively for this purpose. Similarly, benzodiazepine receptor agonists (BZRAs) like zolpidem can also increase the risk for complex sleep-related behaviors. 

Drugs recommended for RLS are dopamine agonists such as cabergoline, lisuride, pergolide, pramipexole, ropinirole, and rotigotine. Cabergoline and pramipexole are found to be superior to other dopamine agonists. Also, alpha-2-delta ligands i.e. gabapentin and pregabalin are also found to be useful. 

 #Neurology 

References:

1. Aurora RN, Kristo DA, Bista SR, et al. The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline. Sleep 2012; 35:1039. 

2. Scholz H, Trenkwalder C, Kohnen R, et al. Dopamine agonists for restless legs syndrome. Cochrane Database Syst Rev 2011; :CD006009. 

3. Allen RP, Chen C, Garcia-Borreguero D, et al. Comparison of pregabalin with pramipexole for restless legs syndrome. N Engl J Med 2014; 370:621. 

4. Trenkwalder C, Benes H, Grote L, et al. Cabergoline compared to levodopa in the treatment of patients with severe restless legs syndrome: results from a multi-center, randomized, active controlled trial. Mov Disord 2007; 22:696. 

5. Bassetti CL, Bornatico F, Fuhr P, et al. Pramipexole versus dual release levodopa in restless legs syndrome: a double blind, randomised, cross-over trial. Swiss Med Wkly 2011; 141:w13274.

Components of SVR

 Q: Systemic Vascular Resistance (SVR) is determined by all of the following EXCEPT? (select one)

A) Afterload 

 B) Vessel length 

C) Vessel tone 

D) Vessel diameter 

E) Blood viscosity

Answer: A

Hemodynamic stability vs instability is basically determined at bedside by the vital of systemic blood pressure (BP)

BP = CO X SVR 

 Where BP is Blood-Pressure, CO is Cardiac-Output and SVR is Systemic Vascular Resistance. 

 On further refinement 

 CO = HR X SV 

 Where HR is Heart Rate and SV is Stroke Volume 

 The stroke volume is determined by three entities 

•  Preload 
•  Myocardial contractility 
•  Afterload 

 and SVR is determined by: 

•  Vessel length 
•  Blood viscosity 
•  Vessel diameter, and 
•  Vessel tone

Afterload (choice A) is more of a determinant of SV than SVR.

#hemodynamics

References:

1. Bighamian R, Hahn JO. Relationship between stroke volume and pulse pressure during blood volume perturbation: a mathematical analysis. Biomed Res Int. 2014;2014:459269. doi:10.1155/2014/459269 

2. Reynolds HR, Hochman JS. Cardiogenic shock current concepts and improving outcomes. Circulation. 2008;117(5):686–697

Vitals in acute opioid toxicity

 Q: Which of the following is the best predictor of severity of acute opioid toxicity?

A) constricted pupils 

B) decreased respiration 

C) altered mental status 

D) decreased bowel sounds 

E) altered temperature 

 Answer: B

Decreased respiratory rate is consistently found to be the best predictor of acute opioid toxicity as well as response to antidote i.e., naloxone. 

The pupillary exam can be very unreliable (choice A) as patient may have co-abuse sympathomimetics or anticholinergics. Mental status not necessarily to be depressed in acute opioid toxicity. A patient can be very euphoric. (choice C). Similarly, this is true for bowel sounds (choice D) and temperature (choice E).

#toxicology

Reference:

Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med 1991; 20:246.

"sonographic Murphy's sign"

 Q: A "sonographic Murphy's sign" is more reliable than a manual Murphy's sign? 

A) True 

B) False

Answer: A

Positive murphy's sign is considered a hallmark in the diagnosis of acute cholecystitis. It is considered positive if during deep palpation of the right upper quadrant (RUQ) patient is asked to take a deep breath and if he/she abruptly holds the breath due to the severity of pain.

A similar response can be elicited from the transducer (probe) during RUQ ultrasound. It is found to be more accurate and reliable than conventional Murphy's sign, as stone and bile duct can be visualized at the same time, and correlation can be established. 

Historical trivia: Murphy's sign is named after an American surgeon John Benjamin Murphy (1857–1916) who was simultaneously a general, orthopedics, neuro, and cardiothoracic surgeon.

#hepatology

References:

1. Kiewiet JJ, Leeuwenburgh MM, Bipat S et-al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264 (3): 708-20. doi:10.1148/radiol.12111561 

2.  Jackson PG, Evans SRT. 2017. Sabiston Textbook of Surgery. 20th ed. New York (NY). Chapter 54, The biliary system, p.1482-1519. 

3. Musana K, Yale SH. John Benjamin Murphy (1857 - 1916). (2005) Clinical medicine & research. 3 (2): 110-2

Terson syndrome

Q: What is Terson syndrome? 

Answer: Terson syndrome is the presence of intraocular hemorrhages in association with hypertension. If this occurs in Sub-Arachnoid Hemorrhage (SAH), it implies poor prognosis and potentially high mortality. These patients usually lies at the higher grade on Hunt and Hess scale. This is due to abrupt increase in intracranial pressure (ICP). 

Clinicians should look it differently from relatively more benign retinal hemorrhages present in SAH. Although it is mostly pre-retinal but it can be sub-retinal, retinal, sub-hyaloidal, or intra-vitreal.

#neurology

#opthalmology

References:

1. Medele RJ, Stummer W, Mueller AJ, Steiger HJ, Reulen HJ. "Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure". J. 1998. Neurosurg. 88 (5): 851–4. doi:10.3171/jns.1998.88.5.0851. PMID 9576253. 

2. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2004; 75:491. 

3. Suarez JI. Diagnosis and Management of Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2015; 21:1263. 

4. Terson A. "De l'hémorrhagie dans le corps vitre au cours de l'hémorrhagie cerebrale". Clin Ophthalmol. 6: 309–12. 1900

serum amylase in hypertriglyceridemia-induced pancreatitis

Q: Why serum amylase may stay normal in hypertriglyceridemia-induced pancreatitis? 

 Answer: Serum amylase level comes out normal in hypertriglyceridemia-induced pancreatitis due to a circulatory inhibitor which interferes with the assay. This is usually a case when plasma triglyceride levels are higher than 500 mg/dL. 

Experienced laboratory personnel can recognize lactescent plasma and can provide true serum amylase value by serial dilution techniques. 

#GI

#laboratory-science

References:

1. Howard JM, Reed J. Pseudohyponatremia in acute hyperlipemic pancreatitis. A potential pitfall in therapy. Arch Surg 1985; 120:1053. 

2. Fallat RW, Vester JW, Glueck CJ. Suppression of amylase activity by hypertriglyceridemia. JAMA 1973; 225:1331.

3. Wong EC, Butch AW, Rosenblum]L. The clinical chemistry laboratory and acute pancreatitis. Clin Chem 1993;39:234-43.

physiologic reasons for high alkaline phosphatase

 Q; Patients may have elevated alkaline phosphatase (AP) depending on their blood type? 

A) True 

B) False 

Answer: A 

In the human body, there are two major sources of AP: liver and bones. Also, there are many physiologic reasons for elevated AP, for which no further intervention or investigation is required. Some of such conditions are:

1. Third trimester of pregnancy. This is due to the influx of the placental AP in maternal blood. 

2. Infants, toddlers, and adolescents due to increased osteoblastic activity. 

3. Women in the age group 40 and above. This correlates with higher age. 

4. Diabetes mellitus. 

5. Familial increased intestinal alkaline phosphatase. 

6. Interestingly people with blood types O and B may have elevated AP after eating a fatty meal.

#hepatology

References:

1. Siddique A, Kowdley KV. Approach to a patient with elevated serum alkaline phosphatase. Clin Liver Dis. 2012;16(2):199-229. doi:10.1016/j.cld.2012.03.01

2. Lowe D, Sanvictores T, John S. Alkaline Phosphatase. 2020 Aug 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083622.

3. Nannipieri M, Gonzales C, Baldi S, et al. Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study. Diabetes Care 2005; 28:1757.

4. Lieverse AG, van Essen GG, Beukeveld GJ, et al. Familial increased serum intestinal alkaline phosphatase: a new variant associated with Gilbert's syndrome. J Clin Pathol. 1990;43(2):125-128. doi:10.1136/jcp.43.2.125

diagnostic criteria of Kawasaki disease (KD)

 Q: The diagnostic criteria of Kawasaki disease (KD) requires fever for at least? (select one)

A) 3 days

B) 5 days

C) 7 days

D) 10 days

E) 2 weeks

Answer: B

Kawasaki disease is mostly presents in children but sometimes may occur in adults too (reference # 2). The most profound hallmark feature of KD is fever above 101.3ºF which remains unresponsive to antipyretics. For KD, fever should last more than 5 days. Besides, four out of the five criteria should be present. 

Criteria were presented more than five decades ago by Dr. Kawasaki T. as "Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children".  

1. Changes in extremities: Acute erythema and edema of hands and feet and in the convalescent period, membranous desquamation of fingertips.
2. Polymorphous exanthema.
3. Bilateral, painless bulbar conjunctival injection without exudate.
4. Changes in lips and oral cavity: Erythema and cracking of lips, strawberry tongue, diffuse injection of oral and pharyngeal mucosae.
5. Cervical lymphadenopathy (≥1.5 cm in diameter) is usually unilateral.

Cardiac involvement is not required to diagnose KD though it strongly supports the diagnosis.

#rheumatology

References:

1. Kawasaki T. [Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children]. Arerugi 1967; 16:178. 

2. Anne E. et. al. Acute Kawasaki Disease: Not Just for Kids J Gen Intern Med. 2007 May; 22(5): 681–684. doi: 10.1007/s11606-006-0100-5 PMCID: PMC1852903 PMID: 17443379 

3.  Burns JC, Glodé MP. Kawasaki syndrome. Lancet 2004; 364:533.

folate, folic acid, folinic acid, and 5-methyltetrahydrofolate

 Q: What is the difference between folate, folic acid, folinic acid, and 5-methyltetrahydrofolate (5-MTHF)? 

 Answer: Although folate and folic acid are used interchangeably, technically they are different terms. 

• Folate in actuality is vitamin B-9 and comes naturally from plant-based foods and fortified grains.  
• Folic acid is the synthetic oxidized, water-soluble form.
• Folinic acid and 5-MTHF are also naturally occurring, and are reduced forms of folate. 

 Clinical implications: 

1. Folic acid, folinic acid, and 5-MTHF are all effective in treating folate deficiency. 

2. Folinic acid has a special clinical advantage in preventing toxicities of methotrexate but potentiating the cytotoxicity of fluorouracil (chemotherapy agent).

#pharmacology

References:

1. Scaglione F, Panzavolta G. Folate, folic acid and 5-methyltetrahydrofolate are not the same thing. Xenobiotica 2014; 44:480. 

2. Kelly GS. Folates: supplemental forms and therapeutic applications. Altern Med Rev 1998; 3:208.

AUB and SIS

 Q: 48 years old female is admitted to ICU with severe abnormal uterine bleeding (AUB). Ob-Gyn service is called while ICU service worked on hemodynamic stabilization. At the bedside service requests for sterile saline. What is the purpose of sterile saline in Ob-Gyn examination and in AUB?

Answer: Instilling sterile saline directly into the uterine cavity via the cervix during ultrasound of the uterus enhances endometrial visualization. It helps in delineate different endometrial pathologies like polyps, hyperplasia, cancer, leiomyomas, or adhesions. A recent version of Saline Infusion Sonography (SIS) is to replace saline with hydroxyethylcellulose gel, which provides a relatively more stable filling of the uterine cavity and does not require continuous installation. In severe AUB a balloon tamponade can be used with saline infusion to control heavy bleeding. 

Although SIS is a very safe procedure in experienced hands there is always a concern about disseminating infection and carcinoma. SIS may give rise to false diagnoses due to blood clots, debris, mucus plugs, and other artifacts.

#Ob-Gyn

References:

1. American College of Obstetricians and Gynecologists. ACOG Technology Assessment in Obstetrics and Gynecology No. 5: sonohysterography. Obstet Gynecol 2008; 112:1467. 

2. Guideline developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of Sonohysterography. J Ultrasound Med 2015; 34:1.

3. Chawla I, Tripathi S, Vohra P, Singh P. To Evaluate the Accuracy of Saline Infusion Sonohysterography (SIS) for Evaluation of Uterine Cavity Abnormalities in Patients with Abnormal Uterine Bleeding. J Obstet Gynaecol India. 2014;64(3):197-201. doi:10.1007/s13224-013-0501-4 

4. Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand 2000; 79:321.

How Linezolid works in anthrax?

 Q: How Linezolid works in anthrax?

Answer: Linezolid has a fascinating mechanism of action in infections with Bacillus anthracis. Although so far it has been mostly demonstrated in vitro it has been proposed as a better treatment option in Anthrax. It abolishes the toxin production 100 percent and reduces the sporulation in Bacillus anthracis. 

Linezolid was found superior to ciprofloxacin, which is so far considered the standard of treatment in Bacillus anthracis (reference # 3)

#ID

References:

1. Head BM, Alfa M, Sitar DS, et al. In vitro evaluation of the effect of linezolid and levofloxacin on Bacillus anthracis toxin production, spore formation and cell growth. J Antimicrob Chemother 2017; 72:417. 

2. Hendricks KA, Wright ME, Shadomy SV, et al. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20. 

3. Louie A, Vanscoy BD, Heine HS 3rd, Liu W, Abshire T, Holman K, Kulawy R, Brown DL, Drusano GL. Differential effects of linezolid and ciprofloxacin on toxin production by Bacillus anthracis in an in vitro pharmacodynamic system. Antimicrob Agents Chemother. 2012 Jan;56(1):513-7. doi: 10.1128/AAC.05724-11. Epub 2011 Nov 7. PMID: 22064542; PMCID: PMC3256020.

CHL and B symptoms

 Q: Which of the following is NOT considered a part of B symptoms in Classic Hodgkins Lymphoma (CHL)? - select one

A) Fever 

 B) Sweats 

 C) Weight loss 

 D) Pruritus 

 Answer: D 

It should be understood that B symptoms have a formal definition in Lugano classification. It has three components with its own defined delineations. 

1. Fever should be persistent and above  38°C (>100.4°F). There is a variation of fever known as Pel-Ebstein fever that may be present. This variation of fever cyclically increases and decreases over a period of one to two weeks. In most cases, the patient complains of subjective fever more in the evening time.

2. Sweats should be described by the patient as drenching night sweats 

3. Weight loss should not be explained by any other means and should be more than 10 percent of actual body weight over the past six months.

Pruritus (choice D) though is not considered as a B symptom but has a high diagnostic value. In some patients, it precedes by many months before an actual diagnosis is made. It is usually generalized and can be severe enough to cause intense scratching and excoriations. 

#oncology

References:

1. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 2014; 32:3059.

2. Good GR, DiNubile MJ. Images in clinical medicine. Cyclic fever in Hodgkin's disease (Pel-Ebstein fever). N Engl J Med 1995; 332:436. 

3. Gobbi PG, Cavalli C, Gendarini A, et al. Reevaluation of prognostic significance of symptoms in Hodgkin's disease. Cancer 1985; 56:2874

COVID and GI

 Q: In patients with inflammatory bowel disease (IBD), use of which of the following is found to have increased risk of COVID-19? (select one) 

 A) glucocorticoids 

B) anti-TNF therapy 

 Answer: A 

Overall patients with IBD have found to have no higher risk than the general population to acquire COVID-19, although patients on active treatment may have higher risk. Surprisingly, patients on glucocorticoids are found to have higher risk than patients on anti-TNF therapy (TNF = Tumor necrosis Factor). 

The gastrointestinal (GI) symptoms in COVID are due to the presence of widely expressed angiotensin-converting enzyme 2 (ACE2) receptors in the intestine. They are most prevalent in the cytoplasm of gastric cells, intestinal epithelial cells, and the cilia of glandular epithelial cells.

Caution: Literature on COVID-19 is still evolving.

#COVID

#GI

References:

1. Norsa L, Indriolo A, Sansotta N, et al. Uneventful Course in Patients With Inflammatory Bowel Disease During the Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak in Northern Italy. Gastroenterology 2020; 159:371. 

2. Rubin DT, Feuerstein JD, Wang AY, Cohen RD. AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary. Gastroenterology 2020; 159:350. 

3.  Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids, But Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results From an International Registry. Gastroenterology 2020; 159:481.

Radiology in NSTIs

 Q: Due to gas formation in tissues which is the best diagnostic modality in necrotizing soft tissue infections (NSTIs)? (select one)

A) CT scan

B) MRI

C) Ultrasound

Answer: A

Though MRI and ultrasound can be performed in NSTIs, they are not as reliable to delineate surgical demarcation as a CT scan. MRI is oversensitive and cannot distinguish well between necrotizing cellulitis and deeper infection. Ultrasound can be used due to the presence of gas but so far evidence for its use is not very supportive. 

CT scan can reliably show gas presence in soft tissues, collection of fluid, heterogeneity of tissue enhancement, and inflammatory changes.

#surgical-critical-care

#radiology

References:

1. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg 2010; 145:452. 

2. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 1998; 170:615.

Acute flare of gout in ICU

 Q: 55 years old male with brittle diabetes and recent GI bleed is recovering from Diabetes Keo Acidosis (DKA) in ICU. Patient developed an acute flare of his gout. Patient uses colchicine as prophylaxis at home. Can colchicine be used to control the flare of gout?

A) Yes

B) No

Answer: A

Although glucocorticoids or NSAIDs are preferred to control acute gout in ICU, many patients may not be a candidate for either like our patient in the above question. In such cases, colchicine can be used. Colchicine is most effective if taken early in the course. 

Said that care should be taken as overdosing on colchicine is common and interaction/toxicity is common due to various commonly used drugs in ICU. 

The maximum dose is 1.8 mg in a divided dose on day one of the flare.

#rheumatology 

Reference:

1. Engel B, Just J, Bleckwenn M, Weckbecker K. Treatment Options for Gout. Dtsch Arztebl Int. 2017;114(13):215-222. doi:10.3238/arztebl.2017.0215

acute prostatis

 Q: 34 years old male with history of diabetes mellitus is transferred to ICU from the medical ward due to septic shock. Patient was admitted to hospital two days prior to transfer with acute prostatitis with an abscess formation. Which of the following part of the management may have led to septic shock in this patient? (select one)

A) failure to add a second antibiotic

B) failure of immediate surgical drainage

C) insertion of foley catheter

D) failure to do gram-stain of urine

Answer: C

The most common entry of infection in a susceptible male with acute severe prostatitis is through the urethra. Insertion of foley catheter in such an inflamed and infected urethra may lead to septic shock and possible rupture of the abscess. A suprapubic catheter is preferred.

Monotherapy with quinolone is usually sufficient in acute severe prostatis (choice A) although aminoglycoside may be added.

Emergent surgical drainage is not required but should be considered if antibiotics failed to resolve the abscess (choice B).

Gram-stains and cultures should be carried out as part of treatment but with the initiation of broad-spectrum antibiotics failure to do so should not cause septic shock by itself (choice D).

#ID

#urology

References:

1. Davis NG, Silberman M. Bacterial Acute Prostatitis. 2021 Jan 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083799.

2. Coker TJ, Dierfeldt DM. Acute Bacterial Prostatitis: Diagnosis and Management. Am Fam Physician. 2016 Jan 15;93(2):114-20. PMID: 26926407.

SSZ MOA

 Q:  How Sulfasalazine (SSZ) works to be used in the management of two different diseases? 

Answer: SSZ is a unique drug that is used in two very different diseases via its route of elimination. It goes through a very interesting roller coaster ride after its oral ingestion. SSZ is a combination (inactive prodrug) of two compounds - 5-aminosalicylic acid (5-ASA) and sulfapyridine. 5-ASA helps in inflammatory bowel disease and sulfapyridine is used as a disease-modifying antirheumatic drug (DMARD). 

About one-third of SSZ absorbed by the small bowel and returned back intact via enterohepatic circulation into the bile. And from here most of the SSZ reaches the large intestine. SSZ needs coliform bacteria in the colon to be effective. Azoreductase is the enzyme that comes from the bacteria and breaks SSZ into its two compounds 5-ASA and sulfapyridine. 

5-ASA gets excreted in the feces making it very useful in the treatment of inflammatory bowel disease. Sulfapyridine is a DMARD. Sulfapyridine gets metabolized in the liver.

#pharmacology

References:

1. Box SA, Pullar T. Sulphasalazine in the treatment of rheumatoid arthritis. Br J Rheumatol 1997; 36:382.

2. Smedegård G, Björk J. Sulphasalazine: mechanism of action in rheumatoid arthritis. Br J Rheumatol 1995; 34 Suppl 2:7.

3. Das KM. Sulfasalazine therapy in inflammatory bowel disease. Gastroenterol Clin North Am. 1989 Mar;18(1):1-20. PMID: 2563989.

Severe hyperthyroidism in pregnancy

 Q: 27 years old 20 weeks pregnant female never been under clinical care is admitted to ICU with severe hyperthyroidism. All of the following can be parts of management EXCEPT?

A) Thionamides 

B) Beta-blockers 

C) Thyroidectomy

D) Plasmapheresis 

E) Radioiodine

Answer: E

Pregnancy presents special challenges in hyperthyroidism, particularly in an acute situation. One of the objectives of this question is to introduce the readers the use of plasmapheresis (choice D) in an acutely decompensating pregnant female with hyperthyroidism.

Thionamides (choice A) continues to be the mainstay of severe hyperthyroidism in pregnancy. When it comes to B-blockers (choice B), it should be remembered that atenolol is not recommended in pregnant patients, though metoprolol or propranolol can be used. Thyroidectomy (choice C) is reserved for rare cases like females who are not candidates for thionamides treatment.

Radioiodine (choice E) is absolutely contraindicated in pregnancy.

#ob-gyn

#endocrine

References:

1. De Groot L, Abalovich M, Alexander EK, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:2543. 

2. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343. 

3. Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315. 

4. Adali E, Yildizhan R, Kolusari A, et al. The use of plasmapheresis for rapid hormonal control in severe hyperthyroidism caused by a partial molar pregnancy. Arch Gynecol Obstet 2009; 279:569. 

5. Stoffer SS, Hamburger JI. Inadvertent 131I therapy for hyperthyroidism in the first trimester of pregnancy. J Nucl Med 1976; 17:146.

VBG in ICU

 Q: Which venous blood gas (VBG) is preferable? (select one)

A) Central venous 

 B) Peripheral venous

Answer: A

In ICUs arterial blood gas (ABG) is preferred. During hemodynamic instability the discrepancy between ABG and VBG becomes significantly high and VBG cannot be relied upon. In shock state, the difference between mixed venous (SvO2) and arterial PCO2 increased by three times. 

Said that, in otherwise hemodynamically stable patients, VBG can be utilized. If a central venous catheter (CVC) (central line) is present VBG should be obtained from it. This is due to the fact that during normal hemodynamics HCO3 tends to be the same in ABG and CVC-VBG. In peripheral VBG, HCO3 is about 2-3 meq/L higher. Moreover, inappropriate use of a tourniquet during peripheral blood draw can make VBG unreliable due to transient local ischemia.

#acid-base

References:

1. Malinoski DJ, Todd SR, Slone S, et al. Correlation of central venous and arterial blood gas measurements in mechanically ventilated trauma patients. Arch Surg 2005; 140:1122. 

2. Walkey AJ, Farber HW, O'Donnell C, et al. The accuracy of the central venous blood gas for acid-base monitoring. J Intensive Care Med 2010; 25:104.

acute dysphagia

Q: 74 years old male while recovering from community-acquired pneumonia in ICU complained of food stuck in his esophagus at mid-chest (acute dysphagia). There is no shortness of breath and saturation stayed 100%. Which drug can be tried to relieve acute dysphagia before emergent endoscopy is called?

Answer: Glucagon

Intravenous glucagon relaxes the lower esophageal sphincter. This may prompt the food to pass in the stomach. The dose is 0.5 to 1-mg once. Patient may experience transient nausea. 

#GI

Reference:

Colon V, Grade A, Pulliam G, et al. Effect of doses of glucagon used to treat food impaction on esophageal motor function of normal subjects. Dysphagia 1999; 14:27.

KS and steroid

 Q: Extent of Kaposi Sarcoma (KS) can be controlled with the maintenance of low dose steroid? 

 A) True 

B) False 

 Answer: B

The objective of the above question is to highlight the inverse relationship between steroids and KS. Steroids tend to worsen KS and weaning/withdrawal of steroid is associated with regression of KS lesions. 

In immunocompromised patients, there is a frequent need to use steroids such as during PJP treatment in AIDS patients. The risk of KS or proliferation of existing KS lesions should be kept in mind if steroids are instituted in immunocompromised patients such as AIDS, post-transplant, autoimmune and lymphoproliferative diseases.

#oncology

References:

1. Trattner A, Hodak E, David M, Sandbank M. The appearance of Kaposi sarcoma during corticosteroid therapy. Cancer 1993; 72:1779. 

2. Gill PS, Loureiro C, Bernstein-Singer M, et al. Clinical effect of glucocorticoids on Kaposi sarcoma related to the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1989; 110:937.

B-blockers selectivity

 Q: Which of the following is a selective beta-1 adrenergic blocker? (select one)

A) atenolol 

B) propranolol

Answer:  A 

Atenolol being a selective beta-1 adrenergic blocker can be alternatively used where beta-blockers can not be used due to the effect on B--2 receptors such as asthma or bronchospasm. One of the drawbacks of atenolol is that its efficacy goes down at a higher dose i.e., above 100 mg per day. 

It is a drug with decades of experience and uses worldwide in a wide range of clinical conditions including angina, hypertension, rate control in atrial fibrillation/flutter, Marfan syndrome with an aortic aneurysm, migraine prophylaxis, thyrotoxicosis, anxiety, and essential tremor. 

Interestingly, in clinical practice atenolol is prescribed more for off-label uses than approved indications. 

#pharmacology

References:

1. Lin HW, Phan K, Lin SJ. Trends in off-label beta-blocker use: a secondary data analysis. Clin Ther. 2006 Oct;28(10):1736-46; discussion 1710-1. doi: 10.1016/j.clinthera.2006.10.015. PMID: 17157130.

2. Rehman B, Sanchez DP, Shah S. Atenolol. [Updated 2020 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539844/

Lyme carditis

 Q: Which finding on EKG is the best predictor of impending AtrioVentricular (AV) block in patients with Lyme carditis? 

Answer: PR interval greater than 300 milliseconds (ms) 

It takes about one to two months after infection for disseminated Lyme disease to show cardiac effects. Other systemic effects may occur at the same time including neurological symptoms. Once the heart gets involved patient may complain of palpitations and shows signs of conduction abnormalities, myocarditis, pericarditis, and CHF. Impending AV conduction abnormality sets off quickly and can be life-threatening. First-degree AV block quickly progresses to second or complete AV block. 

A PR interval greater than 300 milliseconds is a good predictor of impending AV block. Fortunately, it is reversible with treatment in few weeks. The drug of choice is IV ceftriaxone, which should be continued till the PR interval drops below 300 ms. Oral antibiotic maintained with doxycycline is required for few weeks.

#cardiology

#rheumatology

References:

1. Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93:8.

2. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment, and Prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.

cupola sign

 Q; What is  cupola sign?

Answer: Cupola sign is visible on the chest or abdominal x-ray and signifies the presence of pneumoperitoneum. "Cupola" is a Latin word and means "little cup". 

In a supine patient with pneumoperitoneum when non-dependent air rises up it can be seen as a lucency under the central area of the diaphragm. This lucency makes the lower thoracic vertebral bodies more prominent. This lucency appears as a cup with a well-defined upper border, Lower border of the cup remains unremarkable.

#radiology

#surgical-critical-care

Reference:

1. Fleming J, Honour H, Pevsner N. The Penguin Dictionary of Architecture: Fourth Edition. Penguin Books. ISBN:0140512411

2. Mindelzun RE, McCort JJ. The cupola sign of pneumoperitoneum in the supine patient. Gastrointest Radiol. 1986;11(3):283-5. doi: 10.1007/BF02035091. PMID: 3743953.