persistent anosmia

Q: 72 years old male in ICU reports post-stroke persistent anosmia due to subarachnoid hemorrhage (SAH) last year. Persistent anosmia is more common with (select one) 

A) aneurysmal SAH 

B) nonaneurysmal SAH

Answer: A

The objective of this question is to highlight the importance of history taking in ICU - unfortunately, a lost art! Persistent anosmia is common after subarachnoid hemorrhage (SAH), but it provides a clue that SAH was probably aneurysmal. Persistent anosmia is 3-5 times more common after aneurysmal than nonaneurysmal SAH. 

There could be many CNS or non-CNS related causes for persistent anosmia.  CNS reasons include neurodegenerative diseases such as Alzheimer's, Parkinson's, dementia with Lewy bodies, ischemia to any component of the central olfactory pathway, Kallmann syndrome, idiopathic intracranial hypertension, multiple sclerosis (MS), and tumors.

COVID-19 has so far shown transient anosmia though news channels have reported anecdotal cases of persistent anosmia.

#neurology

#neurosurgery

References:

1. Greebe P, Rinkel GJ, Algra A. Anosmia after perimesencephalic nonaneurysmal hemorrhage. Stroke 2009; 40:2885. 

2. Wermer MJ, Donswijk M, Greebe P, et al. Anosmia after aneurysmal subarachnoid hemorrhage. Neurosurgery 2007; 61:918.

HB-Antigens

 Q: 32 years old male is admitted to ICU with severe jaundice and liver insufficiency. Further workup led to the diagnosis of acute hepatitis B. Which of the following is expected to be seen in acute hepatitis B infection? (select one)

A) Anti-HBe

B) Anti-HBs

C) IgG Anti-HBC

D) IgM Anti-HBC

Answer: D

#hepatology

Reference:

Anna SF Lok, Rafael Esteban, Jennifer Mitty, MD, MPH - Hepatitis B virus: Screening and diagnosis - UpToDate, 2021 Link: https://www.uptodate.com/contents/hepatitis-b-virus-screening-and-diagnosis

NOTE: THE ABOVE DIAGRAM IS USED ONLY FOR THE EDUCATIONAL PURPOSE. ALL RIGHTS ARE RESERVED WITH UpToDate.

Dig and calcium

Q: Calcium infusion is contraindicated in digoxin-induced cardiotoxicity? 

A) True 

B) False

Answer: B

Despite the caveat that hypercalcemia may potentiate the cardiotoxicity of digitalis, calcium infusion is recommended to stabilize the cardiac membrane. In such a situation, calcium should be given slowly. Calcium gluconate is preferred over calcium chloride, as chloride formulation contains three times higher elemental calcium than gluconate version. 

Calcium should be given as 10 mL of 10% Ca-gluconate in 100 mL of D-5 water over a period of half an hour. This prevents acute hypercalcemia and minimizes the cardiotoxic effect of "dig." 

Said that digoxin-specific antibody fragments is the ideal treatment for symptomatic toxicity.

#toxicology

#pharmacology

#cardiology

References:

1. Levine M, Nikkanen H, Pallin DJ. The effects of intravenous calcium in patients with digoxin toxicity. J Emerg Med. 2011 Jan;40(1):41-6. doi: 10.1016/j.jemermed.2008.09.027. Epub 2009 Feb 6. PMID: 19201134. 

2. Hack JB, Woody JH, Lewis DE, Brewer K, Meggs WJ. The effect of calcium chloride in treating hyperkalemia due to acute digoxin toxicity in a porcine model. J Toxicol Clin Toxicol. 2004;42(4):337-42. doi: 10.1081/clt-120039538. PMID: 15461240.

Reappearance of Kayser-Fleischer

 Q: 54 years old male with a history of liver transplantation seven years ago due to Wilson disease is admitted to ICU with sepsis. Kayser-Fleischer rings are noticed on physical exam. A review of chart shows that rings were noted to be disappeared on the last clinic visit about 2 years ago. The reappearance of Kayser-Fleischer rings signifies what? 

Answer: Probable noncompliance 

Kayser-Fleischer rings are brownish or gray-greenish rings in Descemet's membrane in the cornea, and they are close to the endothelial surface. They can be best seen on examination at the inferior and superior poles of the cornea. They are fine pigmented granular deposits of copper. Though they are not specific but highly suggestive of Wilson disease. Their presence also signifies neurological involvement. 

Kayser-Fleischer rings gradually disappear with medical treatment or after a liver transplant. The reappearance of Kayser-Fleischer rings raises high suspicion of non-compliance. In our patient, another red flag is absence from the follow-up clinic for 2 years.

#tranplantation

#hepatology

References: 

1. Song HS, Ku WC, Chen CL. Disappearance of Kayser-Fleischer rings following liver transplantation. Transplant Proc. 1992 Aug;24(4):1483-5. PMID: 1496628.

2. Suvarna JC. Kayser-Fleischer ring. J Postgrad Med. 2008 Jul-Sep;54(3):238-40. doi: 10.4103/0022-3859.41816. PMID: 18626182.

Sleep issues of ICU workforce

 Q: ICU workforce at night can eliminate sleepiness by daytime sleep? 

A) True 

B) False 

Answer: B

Intensivists, mid-levels, nurses, respiratory therapists, pharmacists, and all other healthcare workers who work at night or on schedule with rotating day/night shifts struggle with sleep cycles. 

Unfortunately, daytime sleep does not fully eliminate sleepiness during the nocturnal hours. 

One effective trick is to take a short (power) nap either just before or during the shift. Nap is recommended to be restricted below an hour to avoid entering the deep-sleep phase and disorientation from sleep inertia. 

Coffee: Coffee helps! but should be limited to the early half of the night shift to avoid insomnia later in the day. One study showed that one single cup/dose of coffee/caffeine at the beginning of the night shift is better than the intermittent or divided doses throughout the shift 6. This prevents tolerance to caffeine. 

Wake-promoting agent i.e., modafinil or armodafinil has been suggested during the shift but should be monitored and prescribed by an experienced clinician.

#sleep

#ICU-work

References:

1. Schweitzer PK, Randazzo AC, Stone K, et al. Laboratory and field studies of naps and caffeine as practical countermeasures for sleep-wake problems associated with night work. Sleep 2006; 29:39. 

2. Sallinen M, Härmä M, Akerstedt T, et al. Promoting alertness with a short nap during a night shift. J Sleep Res 1998; 7:240. 

3. Purnell MT, Feyer AM, Herbison GP. The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers. J Sleep Res 2002; 11:219. 

4. Bonnefond A, Muzet A, Winter-Dill AS, et al. Innovative working schedule: introducing one short nap during the night shift. Ergonomics 2001; 44:937. 

5. Ker K, Edwards PJ, Felix LM, et al. Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database Syst Rev 2010; :CD008508. 

6. Walsh JK, Muehlbach MJ, Schweitzer PK. Hypnotics and caffeine as countermeasures for shiftwork-related sleepiness and sleep disturbance. J Sleep Res 1995; 4:80.

hematology in hyperthyroidism

 Q: Which is more common in hyperthyroidism? (select one) 

A) anemia

B) polycythemia 

Answer: A

Contrary to the expectation, despite an increase in red blood cell mass, patients with hyperthyroidism have normochromic, normocytic anemia. This is due to an increase in plasma volume. Another factor that plays a part is pernicious anemia. 

These patients may also have immune thrombocytopenia (ITP) and antineutrophil antibodies. These patients may also have high serum ferritin. 

Paradoxically, these patients have high prothrombotic factors, which include factors VIII, IX, fibrinogen, von Willebrand factor, and plasminogen activator inhibitor-1. This makes these patients prothrombotic.

#endocrinology

References:

1. Nightingale S, Vitek PJ, Himsworth RL. The haematology of hyperthyroidism. Q J Med 1978; 47:35. 

2. Franchini M, Lippi G, Targher G. Hyperthyroidism and venous thrombosis: a casual or causal association? A systematic literature review. Clin Appl Thromb Hemost 2011; 17:387. 

3. Stuijver DJ, van Zaane B, Romualdi E, et al. The effect of hyperthyroidism on procoagulant, anticoagulant and fibrinolytic factors: a systematic review and meta-analysis. Thromb Haemost 2012; 108:1077.

BP control in DKD

 Q: In patients with severe albuminuria in Diabetic Kidney Disease (DKD), angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARBs) is preferred to be combined with? (select one) 

A) calcium channel blocker 

B) beta-blocker 

Answer: A

The objective of this question is to highlight the importance of intensive blood pressure (BP) control in DKD and severe albuminuria. Intensive blood sugar and BP control go hand in hand to prevent or prolong time to End-Stage Renal Disease (ESRD) and cardiovascular (CV) events. 

Either an ACE-I or ARBs (NOT BOTH) is the first line of treatment. It should be ideally combined with a dihydropyridine calcium channel blocker. In extremely high albuminuria, a nephrologist may decide to add a diuretic and/or use a nondihydropyridine calcium channel blocker.

Beta-blocker can be added in patients who already have CV pathology or if a clinician will appropriate per a patient situation.

#nephrology

#cardiology

References:

1. Patney V, Whaley-Connell A, Bakris G. Hypertension Management in Diabetic Kidney Disease. Diabetes Spectr. 2015;28(3):175-180. doi:10.2337/diaspect.28.3.175

2. Sugahara M, Pak WLW, Tanaka T, Tang SCW, Nangaku M. Update on diagnosis, pathophysiology, and management of diabetic kidney disease. Nephrology (Carlton). 2021 Jun;26(6):491-500. doi: 10.1111/nep.13860. Epub 2021 Feb 17. PMID: 33550672.

Acute akinesia in PD

 Case: 72 years old male with long history of Parkinson's Disease (PD) is admitted to ICU with acute akinesia.

Discussion: Acute akinesia can be fatal in patients with PD, and should be managed by experienced hands. This is different from the "freezing of Gait" (FOG) phenomenon. It is a sudden exacerbation of PD. Patient stays in an akinetic state for days and unfortunately is not very responsive to antiparkinsonian meds. 

The two major causes are underlying infection/sepsis and manipulation/error of antiparkinsonian drugs. A potential cause particularly in hospitalized patients is the administration of a dopamine receptor blocker or an antipsychotic drug with dopamine blocking properties. 

It should be watched closely in PD patients after surgeries. Diarrhea can also cause acute akinesia.

#neurology

Reference:

Onofrj M, Thomas A. Acute akinesia in Parkinson disease. Neurology 2005; 64:1162.

Oxygen in SCD

 Q: Application of supplemental oxygen helps in relieving acute vaso-occlusive pain crisis in Sickle Cell Disease (SCD) and should be routinely applied: 

A) True

B) False

Answer: B

Supplemental and routine use of oxygen is not encouraged in patients who present with acute vaso-occlusive pain crisis in SCD unless there is significant evidence of hypoxia or oxygen desaturation. This is due to the fact that supplemental oxygen may mask the decline in respiratory status, and may delay recognition of any comorbidity occurring simultaneously.

Supplemental oxygen's value in acute pain crisis is not established.

#hematology

#pulmonary

Reference:

Michael R DeBaun - Acute vaso-occlusive pain management in sickle cell disease -  

UptoDate: https://www.uptodate.com/contents/acute-vaso-occlusive-pain-management-in-sickle-cell-disease (Last accessed December 21, 2021)

Vitamin K test

 Q: What is 'Vitamin K test' in the evaluation of jaundice?

Answer: First described 80 years ago, vitamin K can be used to differentiate between obstructive jaundice and jaundice due to hepatocellular injury. 

If an elevated INR can be corrected with exogenous vitamin K, it signifies impaired intestinal absorption of fat-soluble vitamins. It is compatible with obstructive jaundice. In contrast, if INR continue to stay elevated despite vitamin K administration, it predicts hepatocellular pathology. Impaired hepatic function keeps INR elevated despite vitamin K on board. Heparocellular damage is mostly accompanied by hypoalbuminemia.

#hepatology

References:

1. Stewart JD. PROTHROMBIN DEFICIENCY AND THE EFFECTS OF VITAMIN K IN OBSTRUCTIVE JAUNDICE AND BILIARY FISTULA. Ann Surg. 1939 Apr;109(4):588-95. doi: 10.1097/00000658-193904000-00008. PMID: 17857347; PMCID: PMC1391301.

2. Johnson MA. Influence of vitamin K on anticoagulant therapy depends on vitamin K status and the source and chemical forms of vitamin K. Nutr Rev. 2005 Mar;63(3):91-7. doi: 10.1111/j.1753-4887.2005.tb00126.x. PMID: 15825811.

High dose steroid & adjuvant Rx

 Q: 28 years old female is admitted to ICU with exacerbation of Multiple Sclerosis (MS) and started on high dose steroid. What two adjuvant treatments may help to blunt the adverse effects?

Answer: MS patients usually require a short course of a gram of prednisolone per day. The two notable side effects can be gastritis and psychiatric symptoms. Psychiatric disturbances can be depressive, manic, or hypomanic. It may help to add 

• proton pump inhibitor (PPI), and 
• clonazepam

Other adverse effects to watch are hyperglycemia, particularly in diabetic or pre-diabetic patients, and increased susceptibility to infections. It would be prudent to treat infection, if present prior to pulse steroid treatment.

On a side note, clonazepam has also shown promise in patients who develop psychiatric symptoms from tacrolimus, hemodialysis, or SLE.

#neurology

#pharmacology

References:

1. Morrow SA, Barr J, Rosehart H, Ulch S. Depression and hypomania symptoms are associated with high dose corticosteroids treatment for MS relapses. J Affect Disord 2015; 187:142. 

2. Viswanathan R, Glickman L. Clonazepam in the treatment of steroid-induced mania in a patient after renal transplantation. N Engl J Med. 1989 Feb 2;320(5):319-20. doi: 10.1056/NEJM198902023200517. PMID: 2643052.

3. Ithman M, Malhotra K, Bordoloi M, Singh G. Treatment-Refractory Mania with Psychosis in a Post-Transplant Patient on Tacrolimus: A Case Report. Clin Med Res. 2018 Jun;16(1-2):47-49. doi: 10.3121/cmr.2018.1409. Epub 2018 May 18. PMID: 29776917; PMCID: PMC6108512. 

4. Jones BD, Chouinard G. Clonazepam in the treatment of recurrent symptoms of depression and anxiety in a patient with systemic lupus erythematosus. Am J Psychiatry. 1985 Mar;142(3):354-5. doi: 10.1176/ajp.142.3.354. PMID: 3970277. 

5. Jarecke CR, De Moya VF, Ware MR. A case of mania secondary to hemodialysis: successful treatment with clonazepam. J Clin Psychopharmacol. 1990 Aug;10(4):298-9. doi: 10.1097/00004714-199008000-00018. PMID: 2286703.

TTBI

 Q: The risk of transfusion-transmitted bacterial infection (TTBI) is increased by the longer shelf life of blood products. 

A) True 

B) False 

 Answer: A

Although increased storage time of blood products may increase the risk of TTBI, it should not prompt the clinicians to ask for fresh blood products from a blood bank, which can create a massive disruption of blood supplies. 

Said that in the case of documented TTBI, all factors should be identified including the shelf life of the product.

It is impossible to distinguish TTBI and acute hemolytic transfusion reactions. A protocol in any such event should be promptly initiated to support patient's hemodynamic and to determine the cause of either TTBI or hemolytic reaction. Being a clinician at the bedside, it should be ensured that blood workup ordered such as culture, Coombs test, plasma-free hemoglobin, and type/crossmatch should be drawn from the arm other than the arm with IV infusion. In case of central line infusion, an attempt should be made to draw blood from the peripheral site away from the central line site.

#hematology

#ID

References:

1. Dellinger EP, Anaya DA. Infectious and immunologic consequences of blood transfusion. Crit Care 2004; 8 Suppl 2:S18. 

2. Wagner SJ. Transfusion-transmitted bacterial infection: risks, sources and interventions. Vox Sang. 2004 Apr;86(3):157-63. doi: 10.1111/j.0042-9007.2004.00410.x. PMID: 15078249.

3. Suddock JT, Crookston KP. Transfusion Reactions. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29489247.

acute cholangitis

 Q: What are the criteria to make clinical diagnosis of acute cholangitis? 

Answer: The objective of this question is to highlight the fact that the diagnosis of acute cholangitis requires - all four - systemic, hepatic, laboratory as well as radiological evidence.

Diagnosis of acute cholangitis requires demonstration of systemic inflammation with one of the following: 

• Fever and/or shaking chills or any laboratory evidence such as leukocytosis or elevated CRP

And both of the following: 

• Evidence of cholestasis with bilirubin ≥2 mg/dL, elevated alkaline phosphatase, GGTP, or transaminases 1.5 times the normal. 
• Radiological evidence such as ultrasound

#hepatology

References:

1. An Z, Braseth AL, Sahar N. Acute Cholangitis: Causes, Diagnosis, and Management. Gastroenterol Clin North Am. 2021 Jun;50(2):403-414. doi: 10.1016/j.gtc.2021.02.005. Epub 2021 Apr 23. PMID: 34024448.

2. Mosler P. Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep. 2011 Apr;13(2):166-72. doi: 10.1007/s11894-010-0171-7. PMID: 21207254.

3. Sokal A, Sauvanet A, Fantin B, de Lastours V. Acute cholangitis: Diagnosis and management. J Visc Surg. 2019 Dec;156(6):515-525. doi: 10.1016/j.jviscsurg.2019.05.007. Epub 2019 Jun 24. PMID: 31248783.

PGS

 Q: The risk of purple glove syndrome (PGS) due to phenytoin is _____________ by administering it via central line? (select one)

A) decreased

B) increased

Answer: A

The pathogenesis of purple glove syndrome is very poorly understood. It occurs only with intravenous infusions (though one case has been reported with oral ingestion 5), which gives the presumption that it may be related to leakage into soft tissue. This is further confirmed by the fact that arterial dopplers usually stays normal, and symptoms occur only on the arm receiving phenytoin. 

Associated symptoms are edema, blistering, pain, and purple discoloration. Histopathology shows superficial venous thrombosis. Due to its association only with intravenous form, it is proposed that actual culprits are added preservatives i.e., propylene glycol and sodium hydroxide.

#toxicology

#pharmacology

References:

1. O'Brien TJ, Cascino GD, So EL, Hanna DR. Incidence and clinical consequence of the purple glove syndrome in patients receiving intravenous phenytoin. Neurology 1998; 51:1034. 

2. Santoshi JA, Justin AS, Jacob JI, et al. Purple glove syndrome: a case report. Hand surgeons and physicians be aware. J Plast Reconstr Aesthet Surg 2010; 63:e340. 

3. Chokshi R, Openshaw J, Mehta NN, Mohler E 3rd. Purple glove syndrome following intravenous phenytoin administration. Vasc Med 2007; 12:29. 

4. Bhattacharjee P, Glusac EJ. Early histopathologic changes in purple glove syndrome. J Cutan Pathol 2004; 31:513. 

5. Yoshikawa H, Abe T, Oda Y. Purple glove syndrome caused by oral administration of phenytoin. J Child Neurol 2000; 15:762.

Anbx in pancreatitis

 Q: Antibiotics are indicated along with antifungals in severe acute pancreatitis.

A) True

B) False

Answer: B

Infections occur only in one-fifth of patients with acute pancreatitis. In general, prophylactic antibiotics are not recommended, and this is irrespective of severity. Also, the development/demonstration of interstitial or necrotizing pancreatitis should not prompt automatic initiation of antibiotics. 

Said that, a clinician should start broad-spectrum antibiotics if an infection is suspected.  Simultaneously, appropriate de-escalation is advised. 

Prophylactic antifungal is not recommended to be added along with antibiotics unless there is a high suspicion of fungal infection.

#GI

References:

1. Soulountsi V, Schizodimos T. Use of antibiotics in acute pancreatitis: ten major concerns. Scand J Gastroenterol. 2020 Oct;55(10):1211-1218. doi: 10.1080/00365521.2020.1804995. Epub 2020 Aug 17. PMID: 32805137. 

2. Beger HG, Gansauge F, Poch B, Schwarz M. The use of antibiotics for acute pancreatitis: is there a role? Curr Infect Dis Rep. 2009 Mar;11(2):101-7. doi: 10.1007/s11908-009-0015-5. PMID: 19239799. 

3. Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: A meta-analysis. J Gastrointest Surg. 1998 Nov-Dec;2(6):496-503. doi: 10.1016/s1091-255x(98)80048-6. PMID: 10457308. 

4. Trikudanathan G, Navaneethan U, Vege SS. Intra-abdominal fungal infections complicating acute pancreatitis: a review. Am J Gastroenterol 2011; 106:1188.

PHS

 Q: 73 years old male with a known history of Parkinson's Disease is admitted to ICU with high fever and symptoms like "Neuroleptic Malignant Syndrome" (NMS). Patient's levodopa should be? (select one)

A) completely stopped

B) started at previous dose

C) cut into half

D) escalate the dose

Answer: B

Patient has probably developed parkinsonism-hyperpyrexia syndrome (PHS) which is very much like NMS. This mostly occurs during the dose adjustment phase of levodopa. These patients simultaneously require management on two aspects, readjusting the levodopa dose and controlling the severe symptoms. Levodopa (or if any other Dopamine Agonist is used), the dose should be brought back prior to adjustment. These patients usually can't swallow. Naso-Gastric tube (NGT) should be inserted as the first line of treatment and levodopa should be given - again with the dose prior to the adjustment - as soon as possible. 

If NGT can not be inserted, apomorphine should be given intravenously. Apomorphine can be given as scheduled doses or in continuous infusion. If neither NGT can be inserted or IV can be obtained, rotigotine can be given transdermally. 

PHS symptoms are treated as NMS with dantrolene, bromocriptine, and/or amantadine.

#neurology

References:

1. Newman EJ, Grosset DG, Kennedy PG. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care 2009; 10:136. 

2. Factor SA. Fatal Parkinsonism-hyperpyrexia syndrome in a Parkinson's disease patient while actively treated with deep brain stimulation. Mov Disord 2007; 22:148.

Mixed cryoglobulinemia and platelet counts

 Q: Mixed cryoglobulinemia may give false? (select one) 

A) thrombocytosis 

B) thrombocytopenia

Answer: A

The objective of this question is to highlight the importance of blood smears. In many conditions, automated counter machines may give erroneous values. One example is mixed cryoglobulinemia. When a blood sample is tested at a temperature ≤30°C, precipitated cryoglobulin particles get falsely counted as platelets. To obtain true platelet count in a patient with mixed cryoglobulinemia the blood sample needs to be maintained at body temperature until the testing. 

Other conditions which may cause pseudothrombocytosis by the automated counter machine are leukemia or lymphoma cells, hemolysis, or burns where circulating cytoplasmic fragments or fragmented red cells may be falsely read as platelets.

#hematology

#lab-medicine

References:

1. Hutchinson CV, Stelfox P, Rees-Unwin KS. Needle-like cryoglobulin crystals presenting as spurious thrombocytosis. Br J Haematol 2006; 135:280. 

2. Ballard HS, Sidhu G. Cytoplasmic fragments causing spurious platelet counts in hairy cell leukemia: ultrastructural characterization. Arch Intern Med 1981; 141:942. 

3. Berkessy S. [Cytoplasm fragmentation of malignant lymphoma cells]. Folia Haematol Int Mag Klin Morphol Blutforsch 1983; 110:651. 

4. Lawrence C, Atac B. Hematologic changes in massive burn injury. Crit Care Med 1992; 20:1284.

heart rate and pulse pressure

 Q: Bradycardia ______________ the pulse pressure? (pick one)

A) decreases 

B) increases 

Answer: B

The definition of pulse pressure is systolic blood pressure minus the diastolic pressure. Many factors affect the value of pulse pressure including age, gender, height, genetic predisposition, pathologies affecting systolic and diastolic blood pressure. 

In ICU bradycardia or tachycardia is a common occurrence. Slow heart rate tends to result in greater pulse pressure.

#cardiology

#hemodynamics

References:

1. Pastor-Barriuso R, Banegas JR, Damián J, et al. Systolic blood pressure, diastolic blood pressure, and pulse pressure: an evaluation of their joint effect on mortality. Ann Intern Med 2003; 139:731.

2. Dart AM, Kingwell BA. Pulse pressure--a review of mechanisms and clinical relevance. J Am Coll Cardiol. 2001 Mar 15;37(4):975-84. doi: 10.1016/s0735-1097(01)01108-1. PMID: 11263624.

PERC

 Q: What is PERC rule for Pulmonary embolism? 

 Answer: The PERC rule stands for Pulmonary Embolism Rule-out Criteria. There are eight components of it and if patient meets all of them, the PE can be ruled out with good confidence. It is clinically described as a low clinical probability of PE - and further testing can be avoided. 

• Age less than 50 
• Heart rate less than 100 
• Saturation more than/equal to 95% 
• No hemoptysis 
• No estrogen use 
• No prior DVT/PE 
• No unilateral leg swelling 
• No hospitalization in prior 4 weeks due to surgery/trauma

Said that PERC is valid for acute presentations like in ED, and should not be used for patients who have prolong hospitalization.

#pulmonary

References:

1. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6:772. 

2. Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701. 

3. Hugli O, Righini M, Le Gal G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost 2011; 9:300. 

4. Singh B, Mommer SK, Erwin PJ, et al. Pulmonary embolism rule-out criteria (PERC) in pulmonary embolism--revisited: a systematic review and meta-analysis. Emerg Med J 2013; 30:701. 

5. Freund Y, Cachanado M, Aubry A, et al. Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients: The PROPER Randomized Clinical Trial. JAMA 2018; 319:559. 

sildenafil and left ventricular (LV) contractility

 Q: Sildenafil (select one) 

A) increases the left ventricular (LV) contractility 

B) reduces the left ventricular (LV) contractility

Answer: B

Sildenafil is a selective type 5 phosphodiesterase (PDE-5) inhibitor. Although its clinical efficacy has been established in Erectile Dysfunction and pulmonary hypertension, so far it has not shown any major benefit in congestive heart failure (CHF). It has three main effects in hemodynamic. 

• It decreases the pulmonary vascular resistance 
• It lowers the systemic arterial load 
• It reduces the left ventricular (LV) contractility

It may improve the peak VO2 in CHF patients with reduced LVEF but no benefit in patients with preserved ejection fraction.

#hemodynamic

#cardiology

#pulmonary

#pharmacology

References:

1. Borlaug BA, Lewis GD, McNulty SE, et al. Effects of sildenafil on ventricular and vascular function in heart failure with preserved ejection fraction. Circ Heart Fail 2015; 8:533. 

2. Zhuang XD, Long M, Li F, et al. PDE5 inhibitor sildenafil in the treatment of heart failure: a meta-analysis of randomized controlled trials. Int J Cardiol 2014; 172:581.

non-SSRI toxicity

 Q; 44 years old female is admitted to ICU with seizures and Bupropion overdose. Hemodialysis is indicated? 

A) Yes 

B) No

Answer: B

The objective of this question is to highlight the fact that hemodialysis has no role in serotonin-norepinephrine reuptake inhibitors (SNRIs) and nonselective serotonin reuptake inhibitors (non-SSRIs). 

It includes venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Savella), mirtazapine (Remeron), and bupropion (Wellbutrin, Zyban).

This is due to their large volume of distribution.

#toxicology

References:

1. Mandrioli R, Protti M, Mercolini L. New-Generation, Non-SSRI Antidepressants: Therapeutic Drug Monitoring and Pharmacological Interactions. Part 1: SNRIs, SMSs, SARIs. Curr Med Chem. 2018;25(7):772-792. doi: 10.2174/0929867324666170712165042. PMID: 28707591.

2. Protti M, Mandrioli R, Marasca C, Cavalli A, Serretti A, Mercolini L. New-generation, non-SSRI antidepressants: Drug-drug interactions and therapeutic drug monitoring. Part 2: NaSSAs, NRIs, SNDRIs, MASSAs, NDRIs, and others. Med Res Rev. 2020 Sep;40(5):1794-1832. doi: 10.1002/med.21671. Epub 2020 Apr 13. PMID: 32285503.

Right sided and posterior EKGs

 Q: If posterior wall ischemia is suspected on EKG, it may help to obtain another EKG by putting? (select one) 

A) V4, V5, and V6 leads on right side of the lower anterior chest area

B) V7, V8, and V9 leads below the left scapula area

Answer: B

If posterior wall ischemia is suspected due to prominent R waves and ST depressions in leads V1 and V2 on initial EKG, it may help to do another EKG by putting leads V7, V8, and V9 below scapula (posteriorly on the chest). This will demonstrate ST elevation on lead V4, V5 and V6.

 Similarly, if inferior wall ischemia is expected in leads II, III, and aVF, putting leads V4R, V5R, and V6R at right sight of the chest will show significant ST elevations in these Leads. This is popularly known as right-sided EKG.

#cardiology

References:

1. Katoh T, Ueno A, Tanaka K, Suto J, Wei D. Clinical significance of synthesized posterior/right-sided chest lead electrocardiograms in patients with acute chest pain. J Nippon Med Sch. 2011;78(1):22-9. doi: 10.1272/jnms.78.22. PMID: 21389644. 

2. Teigeler TL, Ellenbogen KA, Padala SK. The Right-Sided ECG for the Right Diagnosis. Circulation. 2018 Jul 3;138(1):107-109. doi: 10.1161/CIRCULATIONAHA.118.035254. PMID: 29967235.

Antocoagulation after reperfusion therapy

 Q: Which of the following is most unlikely to be used as anticoagulation after fibrinolytic therapy in acute ST-elevation myocardial infarction (STEMI)? (select one)

A) enoxaparin 

B) unfractionated heparin 

C) fondaparinux 

D) bivalirudin

Answer: D

Most cardiologists follow STEMI patients who receive fibrinolytic therapy with an anticoagulant. Unfractionated heparin (choice A) is usually the treatment of choice as it can be easily measured with PTT, has a relatively short half-life, and easy to maneuver if coronary stent is carried out. 

Many clinicians prefer enoxaparin (choice B) as literature leans towards its efficacy after fibrinolytic therapy, and less danger of Heparin-Induced Thrombocytopenia (HIT). 

Fondaparinux (choice C) is not the first line of choice in this situation but can be used if required. 

Bivalirudin (angiomax) (choice D) is usually avoided as evidence shows increased risk of moderate bleeding. Also, there is no data available to compare it with Placebo. This may change in the future if more data is available.

#cardiology

Reference:

White H, Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial Investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet 2001; 358:1855.

HIV and statin

 Q: 47 years old male with history of HIV who is on chronic antiretroviral treatment (ART) is admitted to ICU status post coronary stents after acute myocardial infarction. Out of the following which statin should be avoided? (select one)

A) Pitavastatin 

B) Atorvastatin 

C) Rosuvastatin 

D) Pravastatin 

E) Simvastatin

Answer: E

The objective of this question is to highlight the importance of understanding the risk of statin therapy in HIV patients on ART. As HIV patients are now mostly living a normal life span and statins are among one of the most commonly prescribed drugs, it is of paramount importance to involve a clinical pharmacist to choose statin in this patient population.

HIV protease inhibitors and boosting agents are strong inhibitors of CYP3A4. Simvastatin and lovastatin are highly dependent upon CYP3A4 for clearance and should be avoided.

#pharmacology

References:

1. Chastain DB, Stover KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol. 2017 Feb 22;8:6-14. doi: 10.1016/j.jcte.2017.01.004. PMID: 29067253; PMCID: PMC5651339.

2. Singh S, Willig JH, Mugavero MJ, Crane PK, Harrington RD, Knopp RH, Kosel BW, Saag MS, Kitahata MM, Crane HM. Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients. Clin Infect Dis. 2011 Feb 1;52(3):387-95. doi: 10.1093/cid/ciq111. Epub 2010 Dec 28. PMID: 21189273; PMCID: PMC3106249.

Inflammatory AAA

 Q: All of the following are associated with inflammatory abdominal aortic aneurysm (AAA) EXCEPT? 

A) chronic abdominal pain 

B) weight loss 

C) elevated ESR 

D) Increased incidence of rupture

Answer: D

If following triad is present with AAA, it highly suggests inflammatory AAA

• chronic abdominal pain
• weight loss
• elevated ESR

There is an interesting paradox in inflammatory AAA. Although there are more chances to be symptomatic when compared to the same size non-inflammatory AAA, the chance of actual rupture is low.

Said that, all symptomatic AAA require repair irrespective of size.

#surgical-critical-care

References:

1. Tang T, Boyle JR, Dixon AK, Varty K. Inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2005 Apr;29(4):353-62. doi: 10.1016/j.ejvs.2004.12.009. PMID: 15749035.

2. Lindblad B, Almgren B, Bergqvist D, et al. Abdominal aortic aneurysm with perianeurysmal fibrosis: experience from 11 Swedish vascular centers. J Vasc Surg 1991; 13:231. 

3. Hellmann DB, Grand DJ, Freischlag JA. Inflammatory abdominal aortic aneurysm. JAMA. 2007 Jan 24;297(4):395-400. doi: 10.1001/jama.297.4.395. PMID: 17244836.

PTE

 Case: 59 years old male with a history of kidney transplant due to polycystic kidney disease is admitted to ICU with massive pulmonary embolism.  Initial workup showed hematocrit of 54 percent. What could be the probable diagnosis?

Answer: post-transplant erythrocytosis (PTE) 

There are many risk factors that lead to post-transplant erythrocytosis (PTE). These include 

• male gender 
• a rejection-free course 
• preserved GFR 
• hypertension
• diuretic use 
• longer duration of dialysis 
• smoking 
• diabetes history 
• polycystic kidney disease (PKD) 
•  glomerulonephritis as a cause of kidney failure  
• retained native kidneys 

First suspected four decades ago, retained native kidneys usually become the source of increased erythropoietin. The associated phenomenon is called "tertiary hypererythropoietinemia," where biological feedbacks that suppress erythropoietin become dysfunctional. 

Treatment includes ACE inhibitors/ARBs and phlebotomy.

#transplantation

#nephrology

References:

1. Vlahakos DV, Marathias KP, Agroyannis B, Madias NE. Posttransplant erythrocytosis. Kidney Int 2003; 63:1187.

2. Dagher FJ, Ramos E, Erslev AJ, et al. Are the native kidneys responsible for erythrocytosis in renal allorecipients? Transplantation 1979; 28:496.

3. Einollahi B, Lessan-Pezeshki M, Nafar M, et al. Erythrocytosis after renal transplantation: review of 101 cases. Transplant Proc 2005; 37:3101.

4. Aeberhard JM, Schneider PA, Vallotton MB, et al. Multiple site estimates of erythropoietin and renin in polycythemic kidney transplant patients. Transplantation 1990; 50:613.

fecal calprotectin

 Q: 28 years old male is admitted to ICU with hypovolemic shock due to severe diarrhea. All workup for infectious causes is negative. GI service ordered fecal calprotectin. What is the efficacy of this test in severe diarrhea? 

 Answer:  Calprotectin is a zinc and calcium-binding protein. It is derived from neutrophils and monocytes, and a marker of neutrophil activity, particularly in mucosal inflammation. It has a very good negative value in diarrhea of undetermined etiology. If negative, inflammatory Bowel Disease (IBD) is unlikely as a cause of diarrhea. This test is also valuable as it correlates with the endoscopic disease activity of IBD and can further differentiate between active and inactive IBD. 

This test is not a gold standard and should be used with other laboratory and fecal tests such as fecal lactoferrin, and colonoscopy. 

#GI

References:

1.  Schoepfer AM, Beglinger C, Straumann A, et al. Fecal calprotectin correlates more closely with the Simple Endoscopic Score for Crohn's disease (SES-CD) than CRP, blood leukocytes, and the CDAI. Am J Gastroenterol 2010; 105:162. 

2. Lobatón T, López-García A, Rodríguez-Moranta F, et al. A new rapid test for fecal calprotectin predicts endoscopic remission and postoperative recurrence in Crohn's disease. J Crohns Colitis 2013; 7:e641. 

3. D'Haens G, Ferrante M, Vermeire S, et al. Fecal calprotectin is a surrogate marker for endoscopic lesions in inflammatory bowel disease. Inflamm Bowel Dis 2012; 18:2218. 

4. Mosli MH, Zou G, Garg SK, et al. C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2015; 110:802. 

BL in HIV

 Q: 34 years old male with a known history of HIV is admitted with life-threatening pneumonia. Patient is also diagnosed with Burkitt lymphoma (BL). Noncompliance to antiretroviral therapy (ART) should be suspected? 

A) True 

B) False 

Answer: B 

It is surprising that despite adherence to antiretroviral therapy (ART), the rate of BL doesn't go down in HIV patients. It is most prevalent in young HIV patients. Another paradox is its diagnosis in patients who have their CD4 count above 200 cells/microL. 

This is in contrast to primary CNS lymphoma and/or non-CNS diffuse large B cell lymphoma which shows a correlation with lower CD4 counts. 

#ID

#HIV

References:

1. Guech-Ongey M, Simard EP, Anderson WF, et al. AIDS-related Burkitt lymphoma in the United States: what do age and CD4 lymphocyte patterns tell us about etiology and/or biology? Blood 2010; 116:5600.

2. Ferry JA. Burkitt's lymphoma: clinicopathologic features and differential diagnosis. Oncologist 2006; 11:375. 

3. Gabarre J, Raphael M, Lepage E, et al. Human immunodeficiency virus-related lymphoma: relation between clinical features and histologic subtypes. Am J Med 2001; 111:704.

Sodium in meningitis

 Q: Which is more common in acute bacterial meningitis? (select one) 

A) hypernatremia 

B) hyponatremia 

Answer: B

Concomitant abnormal laboratory findings are common in acute bacterial meningitis. It includes leucocytosis or leukopenia, thrombocytopenia, DIC, anion gap metabolic acidosis, and hyponatremia. 

Presence of leukopenia and/or thrombocytopenia is correlated with poor outcomes. On the other hand, the presence of hyponatremia has no bearing and doesn't require treatment.

#ID

#electrolytes

References:

1. Brouwer MC, van de Beek D, Heckenberg SG, et al. Hyponatraemia in adults with community-acquired bacterial meningitis. QJM 2007; 100:37. 

2. Kaplan SL. Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis. Infect Dis Clin North Am 1999; 13:579. 

3. Kornelisse RF, Westerbeek CM, Spoor AB, et al. Pneumococcal meningitis in children: prognostic indicators and outcome. Clin Infect Dis 1995; 21:1390.

cholesterol pleural effusion

 Q: Cholesterol pleural effusion should always be read in conjunction with serum cholesterol level? 

A) True

B) False

Answer: B

Serum cholesterol is usually not elevated in cholesterol pleural effusions. There is no correlation. 

High cholesterol level in pleural effusion is called cholesterol pleural effusion. The other names used are chyliform effusion or pseudochylothorax. 

Note: Cholesterol effusion is not chylothorax. 

Cholestol pleural effusion occurs due to chronic inflammation. The two most common causes are Mycobacterium tuberculosis and rheumatoid arthritis. 

Cholestrol pleural effusion occurs during a chronic inflammatory situation where lysis of RBCs and neutrophils releases cholesterol and lipid constituents from degenerating cell membranes. Also, contributing phenomenon is the accumulation of serum lipids bound to low-density lipoproteins (LDLs) in pleural space during inflammation.

#pulmonary

References:

1. Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31:743. 

2. Lama A, Ferreiro L, Toubes ME, et al. Characteristics of patients with pseudochylothorax-a systematic review. J Thorac Dis 2016; 8:2093. 

3. Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration 1991; 58:294. 

4. Prakash, UBS. Chylothorax and pseudochylothorax. Eur Respir Mon 2002; 7:249.