Uhl's anomaly

Q: What is Uhl's anomaly in the heart?

Answer: Uhl's anomaly is also called parchment right ventricle. It was first described seven decades ago by Dr. Uhl. This condition is characterized by extremely thin and devoid of muscle fiber right ventricle (RV), or part of RV. This makes RV in complete apposition of endocardium and epicardium.

Caution: In some places, it has been described as arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic right ventricular dysplasia (ARVD).  Uhl's anomaly is different from ARVC/ARVD with its own pathologic features, clinical findings, and presentations. Uhl anomaly is more common in childhood and marked by heart failure in contrast to ARVC, which is marked by arrhythmia, syncope, and/or sudden death.

#cardiology

References:

1. UHL HS. A previously undescribed congenital malformation of the heart: almost total absence of the myocardium of the right ventricle. Bull Johns Hopkins Hosp 1952; 91:197.

2. Gerlis LM, Schmidt-Ott SC, Ho SY, Anderson RH. Dysplastic conditions of the right ventricular myocardium: Uhl's anomaly vs arrhythmogenic right ventricular dysplasia. Br Heart J 1993; 69:142.

GCA - risks and protections

Q: Q: Fever and elevations of the acute phase reactants are indicators for higher risk of vision loss in Giant Cell Arteritis (GCA)?

A) True

B) False

Answer: B

In paradox to expectations that high inflammatory status as fever, elevations of the acute phase reactants such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin (IL) 6, as well as anemia will increase the risk of vision loss in GCA - they are found to be protective. This is due to two reasons. IL-6 has angiogenic properties and counteracts arteritis-induced ischemia. Second, severe inflammatory responses lead patients to seek medical care early in the process.

#rheumatology

References:

1. González-Gay MA, García-Porrúa C, Llorca J, et al. Visual manifestations of giant cell arteritis. Trends and clinical spectrum in 161 patients. Medicine (Baltimore) 2000; 79:283.

2. Liozon E, Dalmay F, Lalloue F, et al. Risk Factors for Permanent Visual Loss in Biopsy-proven Giant Cell Arteritis: A Study of 339 Patients. J Rheumatol 2016; 43:1393.

3. Cid MC, Font C, Oristrell J, et al. Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic complications in giant cell (temporal) arteritis. Arthritis Rheum 1998; 41:26.

4. Nesher G, Nesher R, Mates M, et al. Giant cell arteritis: intensity of the initial systemic inflammatory response and the course of the disease. Clin Exp Rheumatol 2008; 26:S30.

Hyponatremia in SAH

Q: The first step of management in hyponatremia related to subarachnoid hemorrhage (SAH) is fluid restriction?

A) True

B) False

Answer: B

 Although it is true that syndrome of inappropriate antidiuretic hormone secretion (SIADH) is more coomon in SAH than cerebral salt wasting (CSW), fluid restriction in SAH increases the risk of cerebral vasospasm. On the contrary, these patients benefit from volume expansion. 

Hypertonic (usually 3 percent) saline is preffered.

#neurology

#electrolytes

Reference:

1. Woo CH, Rao VA, Sheridan W, Flint AC. Performance characteristics of a sliding-scale hypertonic saline infusion protocol for the treatment of acute neurologic hyponatremia. Neurocrit Care 2009; 11:228.

Palliative care definition

Q: What is the Center to Advance Palliative Care's definition of palliative care?

Answer: For readers' benefit three important definitions of palliative care are given below:

The Center to Advance Palliative Care definition: “Specialized medical care for people with serious illnesses…focused on providing patients with relief from the symptoms, pain and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.”

WHO definition: “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.”

The Centers for Medicare and Medicaid Services (CMS) definition: “Palliative care means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitating patient autonomy, access to information, and choice.”

#palliative-care

#end-of-life-care

References:

1. Center to Advance Palliative Care. About palliative care: What is palliative care? Available at: https://www.capc.org/about/palliative-care/ (Accessed on June 11, 2022).

2. World Health Organization (WHO) definition of palliative care, available online at http://www.who.int

3. Federal Register 2008 - 73 FR 32204, June 5, 2008.

LFT in acute HCV

Q: Normalization of the serum aminotransferases signifies resolution of acute Hepatitis C infection?

A) True

B) False

Answer: B

Aminotransferase i.e., alanine transaminase (ALT) and aspartate transaminase (AST) can be very deceiving in acute Hepatitis C virus (HCV) infection. It can vary widely during acute infection with short periods of time. It can vary from  20 times the upper limit of normal to within normal range. Elevation of LFTs starts prior to symptoms.

#hepatology

#ID

References:

1. Loomba R, Rivera MM, McBurney R, et al. The natural history of acute hepatitis C: clinical presentation, laboratory findings and treatment outcomes. Aliment Pharmacol Ther 2011; 33:559.

2. Maheshwari A, Thuluvath PJ. Management of acute hepatitis C. Clin Liver Dis 2010; 14:169.

3. McGovern BH, Birch CE, Bowen MJ, et al. Improving the diagnosis of acute hepatitis C virus infection with expanded viral load criteria. Clin Infect Dis 2009; 49:1051.

4. Santantonio T, Sinisi E, Guastadisegni A, et al. Natural course of acute hepatitis C: a long-term prospective study. Dig Liver Dis 2003; 35:104.

Chloramphenicol in meningitis

Q: Why Chloramphenicol is not first-line therapy in treatment of meningitis?

Answer: As it is not a bactericidal antibiotic and only has bacteriostatic characteristics

Chloramphenicol despite achieving high concentration in cerebrospinal fluid (CSF) usually has a high failure rate. This is due to its bacteriostatic characteristic. The organism may not only persists but chloramphenicol-resistant organisms also may emerge during the treatment. It should be used when no other viable choices are available.

#neurology

#pharmacology

References:

1. Landesman SH, Cherubin CE, Corrado ML. Gram-negative bacillary meningitis. New therapy and changing concepts. Arch Intern Med 1982; 142:939.

2. Levitz RE, Quintiliani R. Trimethoprim-sulfamethoxazole for bacterial meningitis. Ann Intern Med 1984; 100:881.

Clostridium requires higher concentrations of the metronidazole for inhibition

Q: Which of the Clostridium requires higher concentrations of  metronidazole for its inhibition?

Answer: Clostridium ramosum

Metronidazole is well known for its excellent bactericidal activity against  anaerobic gram-positive bacilli of clostridium spp. Said that, clostridium ramosum may require higher concentrations of the drug for inhibition.

  

Clostridium ramosum is a common enteric anaerobe but rare to cause infections. Case reports have been published stating it as the cause of bacteremia. 

#ID

References:

1. Alexander CJ, Citron DM, Brazier JS, Goldstein EJ. Identification and antimicrobial resistance patterns of clinical isolates of Clostridium clostridioforme, Clostridium innocuum, and Clostridium ramosum compared with those of clinical isolates of Clostridium perfringens. J Clin Microbiol 1995; 33:3209.

2. Forrester JD, Spain DA. Clostridium ramosum bacteremia: case report and literature review. Surg Infect (Larchmt). 2014 Jun;15(3):343-6. doi: 10.1089/sur.2012.240. Epub 2013 Nov 27. PMID: 24283763.

3. Gerber JS, Berney-Meyer L, Segerer S. Clostridium Ramosum-A Rare Cause of Peritoneal Dialysis-Related Peritonitis. Perit Dial Int. 2018 May-Jun;38(3):231-232. doi: 10.3747/pdi.2017.00153. PMID: 29848602.

4. García-Jiménez A, Prim N, Crusi X, Benito N. Septic arthritis due to Clostridium ramosum. Semin Arthritis Rheum. 2016 Apr;45(5):617-20. doi: 10.1016/j.semarthrit.2015.09.009. Epub 2015 Oct 1. PMID: 26546506.

Risk-factors for AF in postop cardiac surgery patients

Q: Which ethnicity has a higher risk of postoperative atrial fibrillation after cardiac surgery? (select one)

A) Caucasian

B) Afro-American

C) Southeast Asian

D) Native Indian

Answer: A

Atrial fibrillation and atrial flutter are common in postoperative cardiac surgery patients. There are many risk factors described:

• age 
• Previous history
• mitral stenosis
• increased left atrial size 
• cardiomegaly
• any previous cardiac surgery
• COPD
• high preoperative hemoglobin A1c 
• caucasian race
• obesity 
• withdrawal of preoperative beta-blocker
• right coronary artery stenosis 
• electrolyte imbalance
• alcohol abuse

#surgical-critical-care

#cardiology

References:

1. Mathew JP, Fontes ML, Tudor IC, et al. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA 2004; 291:1720.

2. Asher CR, Miller DP, Grimm RA, et al. Analysis of risk factors for development of atrial fibrillation early after cardiac valvular surgery. Am J Cardiol 1998; 82:892.

3. Zaman AG, Archbold RA, Helft G, et al. Atrial fibrillation after coronary artery bypass surgery: a model for preoperative risk stratification. Circulation 2000; 101:1403.

4. Deliargyris EN, Raymond RJ, Guzzo JA, et al. Preoperative factors predisposing to early postoperative atrial fibrillation after isolated coronary artery bypass grafting. Am J Cardiol 2000; 85:763.

Obesity and BNP

Q: Obesity __________ natriuretic peptide levels? (select one)

A) decreases

B) increases

Answer: A

The objective of this question is to highlight the confounders while interpreting natriuretic peptide levels i.e., BNP or NT-proBNP. Two major factors are:

• Renal insufficiency - causes elevated BNP and even greater elevated NT-proBNP levels.
• Obesity - depresses BNP and NT-proBNP levels.

Also, normal natriuretic peptide levels do not exclude the diagnosis of Heart Failure with preserved Ejection Fraction (HFpEF).

#cardiology

References:

Horwich TB, Hamilton MA, Fonarow GC. B-type natriuretic peptide levels in obese patients with advanced heart failure. J Am Coll Cardiol. 2006 Jan 3;47(1):85-90. doi: 10.1016/j.jacc.2005.08.050. Epub 2005 Dec 15. PMID: 16386669.

Takase H, Dohi Y. Kidney function crucially affects B-type natriuretic peptide (BNP), N-terminal proBNP and their relationship. Eur J Clin Invest. 2014;44(3):303-8. doi: 10.1111/eci.12234. Epub 2014 Jan 20. PMID: 24372567.

insulin and D-50 treatment for high K

Q: In hyperkalemic emergency, a bolus of 10 units of regular insulin with 1 amp of D-50 glucose is expected to drop potassium by how much?

Answer: approximately 1 mEq/L

Untreated hyperkalemia can be fatal. Even if there are no EKG changes, various measures should be applied, including administering calcium, bicarbonate, and insulin/dextrose combo.

10 units of regular insulin, followed immediately by 50 mL of 50 percent dextrose, is expected to reduce serum potassium by 1 mEq/L. It is common for clinicians to forget at the bedside that despite regular insulin, the insulin levels remain high long enough to cause hypoglycemia an hour or more after. Insulin gets effective within 10-20 minutes, peaks at 30-60 minutes, and may last for 4-6 hours. Glucose levels should be monitored for a few hours in such instances. This gets significantly important in patients with renal insufficiency, where insulin's half-life can be prolonged.

#electrolytes

#endocrine

References:

1. Harel Z, Kamel KS. Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS One 2016; 11:e0154963.

2. Tee SA, Devine K, Potts A, et al. Iatrogenic hypoglycaemia following glucose-insulin infusions for the treatment of hyperkalaemia. Clin Endocrinol (Oxf) 2021; 94:176.

3. Lens XM, Montoliu J, Cases A, et al. Treatment of hyperkalaemia in renal failure: salbutamol v. insulin. Nephrol Dial Transplant 1989; 4:228.

4. Emmett M. Non-dialytic treatment of acute hyperkalemia in the dialysis patient. Semin Dial 2000; 13:279.

MM and phosphate

Q: Multiple myeloma may lead to? (select one)

A) hyperphosphatemia 

B) hypophosphatemia 

Answer: B

In adult patients, multiple myeloma (MM) leads to Fanconi syndrome, which is characterized by impairment in proximal tubular function leading to urinary wasting of compounds normally reabsorbed in the proximal tubule. Overall result is hypophosphatemia, glucosuria, hypouricemia, aminoaciduria, and proximal renal tubular acidosis RTA-2) due to bicarbonate loss in the urine. 

Beside MM, tenofovir is another major cause of Fanconi syndrome in adults.

#electrolytes

References:

Caras JA. Spurious hypophosphatemia associated with multiple myeloma. Endocr Pract. 1997 May-Jun;3(3):135-6. doi: 10.4158/EP.3.3.135. PMID: 15251473.

Jeffs P, Mangual-García M, González-Bóssolo A, Rivera-Santana N. Transient Hypophosphatemia: A Dangerous Event in Multiple Myeloma. Case Rep Endocrinol. 2021 Jan 16;2021:3609346. doi: 10.1155/2021/3609346. PMID: 33510918; PMCID: PMC7826227.

AIT

Q: There are how many types of Amiodarone-Induced Thyrotoxicosis (AIT)?

Answer: Two

There are two types of AIT. The distinction plays an important role and helps clinicians determine whether to continue amiodarone or not?

Type I is marked by increased synthesis of thyroid hormones, i.e., T4 and T3. These patients usually have the preexisting disease. The excess iodine results in providing increased substrate leading to thyroid hormone production.

Type II is destructive in nature and causes excess release of T4 and T3. There is no increased hormone synthesis. There is a direct toxic effect on thyroid follicular epithelial cells.

#endocrinology

References:

1. Martino E, Bartalena L, Bogazzi F, Braverman LE. The effects of amiodarone on the thyroid. Endocr Rev 2001; 22:240.

2.Lambert M, Unger J, De Nayer P, et al. Amiodarone-induced thyrotoxicosis suggestive of thyroid damage. J Endocrinol Invest 1990; 13:527.

3. Brennan MD, Erickson DZ, Carney JA, Bahn RS. Nongoitrous (type I) amiodarone-associated thyrotoxicosis: evidence of follicular disruption in vitro and in vivo. Thyroid 1995; 5:177.

most nephrotoxic aminoglycoside

Q; Which of the following is considered the most nephrotoxic aminoglycoside? (select one)

A) Gentamicin 

B) Tobramycin

C) Amikacin

D) Netilmicin

E) Streptomycin 

Answer: A

Aminoglycosides are well known for their nephrotoxicity and ototoxicity. It is imperative to pick the least toxic aminoglycoside in conjunction with organism and reported sensitivity. In descending order, aminoglycosides in terms of nephrotoxicity are gentamicin, tobramycin, amikacin, netilmicin, and streptomycin.

Other effective strategy to counter toxicity is correcting hypovolemia, hypokalemia and hypomagnesemia before infusing aminoglycoside.

#pharmacology

References:

1. Humes HD. Aminoglycoside nephrotoxicity. Kidney Int 1988; 33:900.

2. Wargo KA, Edwards JD. Aminoglycoside-induced nephrotoxicity. J Pharm Pract. 2014 Dec;27(6):573-7. doi: 10.1177/0897190014546836. Epub 2014 Sep 7. PMID: 25199523.

3. Lopez-Novoa JM, Quiros Y, Vicente L, Morales AI, Lopez-Hernandez FJ. New insights into the mechanism of aminoglycoside nephrotoxicity: an integrative point of view. Kidney Int. 2011 Jan;79(1):33-45. doi: 10.1038/ki.2010.337. Epub 2010 Sep 22. PMID: 20861826.

Mg in VT

Q: In Polymorphic ventricular tachycardia, intravenous (IV) magnesium sulfate (MgSo4) is of benefit even in patients with normal serum magnesium level.

A) True 

B) False

Answer: A

Polymorphic ventricular tachycardia (VT) is an unstable rhythm with a continuously varying QRS complex morphology in any recorded electrocardiographic (ECG) lead. When polymorphic VT occurs in the setting of QT prolongation in sinus rhythm, it is called torsades de pointes. It usually creates hemodynamic instability and requires cardioversion. In patients who are conscious and have recurrent episodes, IV magnesium sulfate is still the first-line of treatment. It treats polymorphic-VT and helps prevent a recurrence, even in patients with normal serum Mg levels.

The dose is 1-2 grams over 15 minutes in IVPB and can be followed by an intravenous drip. 

#cardiology

References:

1. Siraj TZ, Ganim I, Barker W, Abraham J, Landa E. Torsades de Pointes With a Normal Magnesium Level in the Setting of Short Bowel Syndrome. Cureus. 2021 Jul 29;13(7):e16743. doi: 10.7759/cureus.16743. PMID: 34513369; PMCID: PMC8405364.

2. Matsuura C, Kato T, Koyama K. Successful Management of Refractory Torsades De Pointes Due to Drug-Induced Long QT Syndrome Guided by Point-of-Care Monitoring of Ionized Magnesium. Cureus. 2021 Mar 17;13(3):e13939. doi: 10.7759/cureus.13939. PMID: 33880279; PMCID: PMC8051539.

DP

Q: How Driving Pressure (DP) can easily be calculated on the ventilator?

Answer: DP is increasingly used as guiding target in patients with ARDS who requires Low Tidal Volume Ventilation (LTVV). There are two easy ways to calculate DP

plateau-pressure minus applied PEEP 

and/or

Tidal-Volume/compliance

A value less than 20 cm H2O, and preferably below 15 cm H2O is of benefit.

#ventilators

References:

1. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015; 372:747. 

2. Bellani G, Grassi A, Sosio S, et al. Driving Pressure Is Associated with Outcome during Assisted Ventilation in Acute Respiratory Distress Syndrome. Anesthesiology 2019; 131:594. 

3. Villar J, Martín-Rodríguez C, Domínguez-Berrot AM, et al. A Quantile Analysis of Plateau and Driving Pressures: Effects on Mortality in Patients With Acute Respiratory Distress Syndrome Receiving Lung-Protective Ventilation. Crit Care Med 2017; 45:843. 

4. Pereira Romano ML, Maia IS, Laranjeira LN, Damiani LP, Paisani DM, Borges MC, Dantas BG, Caser EB, Victorino JA, Filho WO, Amato MBP, Cavalcanti AB. Driving Pressure-limited Strategy for Patients with Acute Respiratory Distress Syndrome. A Pilot Randomized Clinical Trial. Ann Am Thorac Soc. 2020 May;17(5):596-604. doi: 10.1513/AnnalsATS.201907-506OC. PMID: 32069068.

Kikuchi-Fujimoto Disease

Case: 24 years old female is admitted to ICU with fever, cervical lymphadenopathy and sepsis. Subsequent workup led to the diagnosis of Kikuchi disease.

Answer: Kikuchi disease is also known as Kikuchi-Fujimoto disease. It's proper nomenclature is  Kikuchi histiocytic necrotizing lymphadenitis due to its histopathological finding. 

Usually patients get admitted with unknown cause of fever and cervical lymphadenopathy. In most cases, biopsy of the involved node leads to the diagnosis. It is usually a benign disease. Contrary to popular belief it is found worldwide. Major symptoms are lymphadenopathy, leukopenia, fever, rash, arthritis, fatigue, and rarely hepatosplenomegaly. It may also present as aseptic meningitis.

Although various treatments have been tried such as high-dose glucocorticoids, hydroxychloroquine, and interleukin 1 inhibitor, there is no established effective treatment.

Its clinical significance lies in the fact that these patients are more prone to develop systemic lupus erythematosus (SLE), and recurrences of Kikuchi disease.

#lymphadenopathies

References:

1. Perry AM, Choi SM. Kikuchi-Fujimoto Disease: A Review. Arch Pathol Lab Med. 2018 Nov;142(11):1341-1346. doi: 10.5858/arpa.2018-0219-RA. PMID: 30407860.

2. Alam H, Saeed MO, Saeed AB, Zaidi A. Kikuchi disease. J Pak Med Assoc. 2015 Dec;65(12):1349-50. PMID: 26627522.

Veins of UE

Q: Interosseous veins in the forearm are? (select one)

A) superficial

B) deep 

Answer: B

Knowing a vein is superficial or deep determines the line of management in case of thrombosis. In upper extremities:

• cephalic, basilic, median antebrachial, median antecubital, and accessory cephalic veins are superficial veins
• paired ulnar, radial, and interosseous veins in the forearm; paired brachial veins of the upper arm; and axillary veins are deep veins

#vascular

Reference:

Bosch FTM, Nisio MD, Büller HR, van Es N. Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis. J Clin Med. 2020 Jul 1;9(7):2069. doi: 10.3390/jcm9072069. PMID: 32630244; PMCID: PMC7408847.

Theo-toxicity

Q: Theophylline toxicity causes? (select one)

A) hypercalcemia

B) hypocalcemia 

Answer: A

Theophylline toxicity may cause hypercalcemia. Treatment is beta-adrenergic antagonist. 

Theophylline causes adrenergic stimulation, which leads to hypercalcemia, hypokalemia, metabolic acidosis, and hypophosphatemia.

#toxicity

#electrolytes

References:

1. Jacobs TP, Bilezikian JP. Clinical review: Rare causes of hypercalcemia. J Clin Endocrinol Metab 2005; 90:6316.

2. McPherson ML, Prince SR, Atamer ER, et al. Theophylline-induced hypercalcemia. Ann Intern Med 1986; 105:52.

3. Paloucek FP, Rodvold KA. Evaluation of theophylline overdoses and toxicities. Ann Emerg Med 1988; 17:135.

4. Bernard S. Severe lactic acidosis following theophylline overdose. Ann Emerg Med 1991; 20:1135.

urine albumin-to-creatinine ratio

Q: At what urine albumin-to-creatinine ratio albuminuria may become significant?

Answer: 30

It is recommended that at least 2 out of 3 specimens fall within the moderately increased or severely increased albuminuria range over 3-6 month period. But even random, single-voided urine (preferably first morning) sample is found to have sensitivity of 100 percent for moderately increased albuminuria. 

Pitfalls: vigorous exercise within 24 hours before sample may give an erroneous result. Also, different labs may have different methods to measure the ratio. As expected value varies with muscle mass, gender, and race/ethnicity of the patient

#nephrology

References:

1. Nathan DM, Rosenbaum C, Protasowicki VD. Single-void urine samples can be used to estimate quantitative microalbuminuria. Diabetes Care 1987; 10:414.

2. Jefferson IG, Greene SA, Smith MA, et al. Urine albumin to creatinine ratio-response to exercise in diabetes. Arch Dis Child 1985; 60:305.

3. Younes N, Cleary PA, Steffes MW, et al. Comparison of urinary albumin-creatinine ratio and albumin excretion rate in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Clin J Am Soc Nephrol 2010; 5:1235.

4. Mattix HJ, Hsu CY, Shaykevich S, Curhan G. Use of the albumin/creatinine ratio to detect microalbuminuria: implications of sex and race. J Am Soc Nephrol 2002; 13:1034.

cefepime side effects

Q: Cefepime increases the risk of candida superinfection?

A) True

B) False

Answer: A

Cefepime is one of the most frequently used antibiotics in hospitalized patients in United States. In prolonged use, it may increase risk of superinfection with enterococci and/or Candida.

Another less appreciated side effect of cefepime is nonconvulsive status epilepticus, particularly in patients with decreased renal function.

#pharmacology

References:

Lynch JP 3rd. Combination antibiotic therapy is appropriate for nosocomial pneumonia in the intensive care unit. Semin Respir Infect 1993; 8:268.

Odor of urine

Q: Describe any three examples where urine odor can help in diagnosis.

Answer: Urine odor can be a strong predictor of underlying disease:

• Abnormally pungent odor - bacteriuria (due to production of ammonia by bacteria)
• Sweet or fruity odor - ketonuria
• Maple syrup odor - maple syrup urine disease
• Musty or mousy odor - phenylketonuria
• sweaty feet odor - isovaleric acidemia
• rancid butter or fishy odor - hypermethioninemia

#nephrology

Reference:

Visser EH, Berkhout DJC, Singh J, et al. Smell - Adding a New Dimension to Urinalysis. Biosensors (Basel). 2020;10(5):48. Published 2020 May 5. doi:10.3390/bios10050048

AAST 5 grades for SBO

Q: AAST grading criteria for small bowel obstruction divide patients via following of the two criteria? (select one)

A) Clinical & operative 

B) Radiographic & operative 

C) Clinical & radiographic

Answer; B

American Association for the Surgery of Trauma (AAST) has established five grades for small bowel obstruction (SBO).

Grade I - Partial SBO

Grade II - Complete SBO; bowel viable and not compromised

Grade III - Complete SBO with compromised but viable bowel

Grade IV - Complete SBO with nonviable bowel or perforation with localized spillage

Grade V - SB perforation with diffuse peritoneal contamination

These grades can be established either via radiographic criteria or operative criteria

#trauma

Reference:

Hernandez MC, Haddad NN, Cullinane DC, et al. The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. J Trauma Acute Care Surg 2018; 84:372. DOI: 10.1097/TA.0000000000001736. Copyright © 2018 American Association for the Surgery of Trauma. Reproduced with permission from Wolters Kluwer Health.

Doxy and TAA

Q: Doxycycline may have a ________________ effect on Thoracic Aortic Aneurysm (TAA)? (select one)

A) destructive

B) protective

Answer: B

Although not a part of regular clinical practice, doxycycline may have a protective effect on TAA. In animal models with fibrillin-1-deficient, doxycycline reduces matrix metalloproteinase (MMP) activity resulting in decreased elastin destruction and may prevent aortic root aneurysm. Similar benefit has been reported in Abdominal Aortic Aneurysm (AAA), though data is conflicting.

In contrast, fluoroquinolones should be avoided as they have confirmatory destructive effect on vessels.

#vascular-surgery

#pharmacology

References:

1. Chung AW, Yang HH, Radomski MW, van Breemen C. Long-term doxycycline is more effective than atenolol to prevent thoracic aortic aneurysm in marfan syndrome through the inhibition of matrix metalloproteinase-2 and -9. Circ Res 2008; 102:e73.

2. Pasternak B, Inghammar M, Svanström H. Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ 2018; 360:k678.

"down-then-up-maneuver"

Q: What is "down-then-up-maneuver" in airway intubation?

Answer: "Down-then-up-maneuver" is usually attempted when a foreign body get stuck in supraglottic region or in trachea, and asphyxiation is imminent. An endo-tracheal-tube (ETT) with deflated cuff and a stylet is passed to displace suspected foreign subject into the bronchus which is usually the right bronchus. ETT is gently pushed as far as it could be. Once the obstruction is removed, ETT is pulled back 3 to 5 cm above the carina and the cuff is inflated.

Other option is emergent cricothyrotomy.

#procedures

Reference:

Walls, Ron M, Murphy, F. Foreign body in the adult airway. In: Manual of Emergency Airway Management, Fourth Ed., Wolters kluwer/Lippicott Williams and Wilkins, Philadelphia p.419-423.

VIR and opioids

Q: Vancomycin Infusion Reaction (VIR), popularly known as Red Man Syndrome, can be inhibited by simultaneous administration of opioids? 

A) Yes

B) No

Answer: B

Any drug which potentiate mast cell degranulation can make VIR worse. These include opioids, radiocontrast dye and muscle relaxants.

Such agents should be given with good proximation of vancomycin infusion.

#pharmacology

References:

1. Levy JH, Marty AT. Vancomycin and adverse drug reactions. Crit Care Med 1993; 21:1107.

2. Wong JT, Ripple RE, MacLean JA, et al. Vancomycin hypersensitivity: synergism with narcotics and "desensitization" by a rapid continuous intravenous protocol. J Allergy Clin Immunol 1994; 94:189.

Orthostatic hypotension and transient loss of vision in only one eye

Q: Orthostatic hypotension may cause transient loss of vision (TLV) in only one eye?

A) True

B) False

Answer: A

Hypotension from any reason i.e., cardiac vs low volume may cause TLV popularly known as amaurosis fugax. This loss in vision can be limited to one eye (monocular) if some underlying pathology exists simultaneously like carotid occlusive disease, retinopathy, optic neuropathy, or glaucoma.

#hemodynamic

References:

1. Lord RS. Transient monocular blindness. Aust N Z J Ophthalmol 1990; 18:299.

2. Current management of amaurosis fugax. The Amaurosis Fugax Study Group. Stroke 1990; 21:201.

3. Mimura T, Funatsu H, Kitano S, et al. Diabetic retinopathy with repeated amaurosis fugax caused by orthostatic hypotension. Am J Ophthalmol 2003; 136:930.

Battle sign

Q: What is Battle Sign in trauma?

Answer: It is called Battle sign not because it occurs in trauma but because it was first described by Dr. William Henry Battle. It is bruising over the mastoid process ( mastoid ecchymosis) of temporal bone, and signifies possible fractures to the posterior aspect of skull base. It usually become visible after a day or two of trauma but may be visible early. It's presence should alert the physician of the possibility of severe internal injury to brain and not just the posterior cranial structure or mastoid. 

#trauma

#neurosurgery

References:

1. Naumann, Hans Heinz; Jan Helms (1998). Head and neck surgery. Thieme. p. 154. ISBN 0-86577-660-1.

2. Becker A, Metheny H, Trotter B. Battle Sign. 2021 Aug 1. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30725789.

blast crisis in CML

Q: Blast crisis of Chronic Myeloid Leukemia (CML) is? (select one)

A) ≥20 percent blasts in peripheral blood or bone marrow

B) ≥30 percent blasts in peripheral blood or bone marrow

Answer: A

The objective of this question is to underline the new threshold of blast crisis in CML. Previously, blast crisis has been defined as ≥30 percent blasts in the bone marrow. In 2017, the World Health Organization (WHO) established the definition of blast crisis with presence of one of the following:

● ≥20 percent blasts in peripheral blood or bone marrow

● Extramedullary proliferation of blasts (ie, myeloid sarcoma)

Scientific significance: While reviewing the systemic review and/or meta-analyses, a change of definition may create a confounder or bias in establishing the conclusion.

#oncology

#clinical research

References:

1. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues, revised 4th edition, Swerdlow SH, Campo E, Harris NL, et al. (Eds), International Agency for Research on Cancer (IARC), Lyon 2017.

2. Cortes JE, Talpaz M, O'Brien S, et al. Staging of chronic myeloid leukemia in the imatinib era: an evaluation of the World Health Organization proposal. Cancer 2006; 106:1306.

3. Hehlmann R. How I treat CML blast crisis. Blood 2012; 120:737.

Coffee and Liver

Q; High Coffee consumption increases the risk of cirrhosis?

A) True

B) False

Answer: B

Coffee consumption actually decreases the risk as well as disease progression of cirrhosis and liver fibrosis. A meta-analysis of 16 observational studies consisting of 3034 coffee drinkers and 132076 non-coffee drinker showed that Odd Ratio (OR) decreases to 0.61 with Confidence Interval 0.45-0.84. This benefit extends to the sub-group of patients with alcoholic liver disease and chronic hepatitis C virus (HCV).

#hepatology

Reference:

Liu F, Wang X, Wu G, et al. Coffee Consumption Decreases Risks for Hepatic Fibrosis and Cirrhosis: A Meta-Analysis. PLoS One 2015; 10:e0142457.