Route of administration for calcitonin in hypercalcemia

Q: To treat severe symptomatic hypercalcemia, calcitonin should be given intranasally to have immediate effect.

A) True

B) False

Answer: B

Calcitonin is least effective when given intranasally. In moderate to severe symptomatic hypercalcemia, calcitonin should be given intramuscularly (IM). The Subcutaneous (SQ) route is also effective. 

This should be noted that patients can be either calcitonin sensitive or not. This requires close monitoring of serum or ionized levels of calcium. The initial recommended dose is 4 units/kg every 4-6 hours. If it is effective, the dose can be continued as 8 units/kg every 6 to 12 hours for a total duration of 48 hours. Unfortunately, calcitonin is not very effective after 48 hours due to tachyphylaxis.

#electroloytes

#endocrinology

References:

1. Bilezikian JP. Clinical review 51: Management of hypercalcemia. J Clin Endocrinol Metab 1993; 77:1445.

2. Basso SM, Lumachi F, Nascimben F, Luisetto G, Camozzi V. Treatment of acute hypercalcemia. Med Chem. 2012 Jul;8(4):564-8. doi: 10.2174/157340612801216382. PMID: 22571195.

Arsenic toxicity

Q: What is the chelating agent to treat arsenic poisoning?


Answer: Dimercaprol

Dimercaprol sequesters the arsenic away from blood proteins and is used in treating acute arsenic poisoning. The most important side effect is hypertension.

It also treats mercury, gold, lead, and other toxic metal poisonings. In addition, previously, it has been used to treat Wilson's disease.

#toxicology

Reference: 

Ratnaike RN. Acute and chronic arsenic toxicity. Postgrad Med J. 2003 Jul;79(933):391-6. doi: 10.1136/pmj.79.933.391. PMID: 12897217; PMCID: PMC1742758.

Acute vs chronic GVHD

Q: Acute graft-versus-host disease (GVHD) uses a cutoff point if occurs within? (select one)

A) 48 hours

B) one week

C) 30 days

D) 100 days

Answer: D

GVHD is a multisystem complication status post allogeneic hematopoietic cell transplant (HCT). GVHD is usually marked by maculopapular rash, persistent nausea with or without vomiting, abdominal cramps, diarrhea, and hyperbilirubinemia. GVHD occurs when immune cells from donor (graft) recognize the recipient (host) as foreign. 

Classically, GVHD is divided into acute and chronic types. It is based on a cutoff of 100 days. Said that there are controversies around this conventional classification. Many experts use the nature of clinical signs and symptoms to differentiate between two variants.

#hematology

#oncology

#transplantation

References:

1. Toubai T, Sun Y, Reddy P. GVHD pathophysiology: is acute different from chronic? Best Pract Res Clin Haematol. 2008 Jun;21(2):101-17. doi: 10.1016/j.beha.2008.02.005. PMID: 18503979.

2. Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant 2005; 11:945.

bicarbonate in ASA poisoning

Q: Arterial pH of 7.55 is contraindicated for sodium bicarbonate in salicylate poisoning?

A) True

B) False

Answer: B

Urine alkalization is the mainstay of treatment in salicylate poisoning. Most of these patients present with respiratory alkalosis with higher PH. This should not deter a clinician from using bicarb. Said that close monitoring of PH is prudent to avoid severe alkalemia. The cut off point is around PH >7.60. The goal is to get urinary pH of 7.5 to 8. Urine alkalinization enhances salicylate excretion by many folds. 

Achieving euvolemia simultaneously enhances this excretion further. Said that diuretics don't increase salicylate excretion.

#toxicology

References:

1. Proudfoot AT, Krenzelok EP, Vale JA. Position Paper on urine alkalinization. J Toxicol Clin Toxicol 2004; 42:1.

2. Prescott LF, Balali-Mood M, Critchley JA, et al. Diuresis or urinary alkalinisation for salicylate poisoning? Br Med J (Clin Res Ed) 1982; 285:1383.

3. Vree TB, Van Ewijk-Beneken Kolmer EW, Verwey-Van Wissen CP, Hekster YA. Effect of urinary pH on the pharmacokinetics of salicylic acid, with its glycine and glucuronide conjugates in human. Int J Clin Pharmacol Ther 1994; 32:550.

Zoonotic disease with night sweats with a strong, peculiar, moldy odor

Q: Which Zoonotic disease may cause night sweats with a strong, peculiar, moldy odor?

Answer: Brucellosis

Brucellosis is the most common zoonotic disease worldwide, and as the world is getting more globalized, the western world's physicians are now encountering it frequently. It is mostly transmitted by domesticated to human animals like cattle, sheep, goats, camels, or pigs. The most common transmission is via unpasteurized milk or by contact. The other names for this disease are 'undulant fever,' 'Mediterranean fever,' or 'Malta fever.' It is often hard to diagnose as the incubation period lasts weeks to months. 

Signs and symptoms include fever, malaise, night sweats which may have a strong, peculiar, moldy odor, arthralgias, weight loss, low back pain, headache, dizziness, anorexia, dyspepsia, abdominal pain, cough, depression, hepatomegaly, splenomegaly, and/or lymphadenopathy. Many times fever pattern may be spiking and relapsing and associated with rigors. This may confuse clinicians with malaria.

#ID

References:

1. Pappas G, Akritidis N, Bosilkovski M, Tsianos E. Brucellosis. N Engl J Med 2005; 352:2325.

2. Bosilkovski M, Krteva L, Dimzova M, et al. Human brucellosis in Macedonia - 10 years of clinical experience in endemic region. Croat Med J 2010; 51:327.

3. Young EJ. Brucellosis: current epidemiology, diagnosis, and management. Curr Clin Top Infect Dis 1995; 15:115.

Sister Mary Joseph nodule

Q: An umbilical nodule associated with ascites is a warning sign for which underlying pathology?

Answer: carcinoma

The underlying pathology in patients with ascites is quite wide, but it can be narrowed down significantly with physical examination. An umbilical nodule popularly known as Sister Mary Joseph nodule associated with ascites is usually due to underlying carcinoma of stomach, colon, hepatocellular, pelvis, or lymphoma, proving otherwise. One caution for clinicians to be aware of is sometimes the deceiving appearance of the umbilicus. Often underlying bowel or omentum may give an appearance of a nodule and should be properly ruled out.

Historical trivia: Sister Mary Joseph nodule is the term given in honor of Sister Mary Joseph in the early twentieth century, who was the first to notice this association. She was a superintendent nurse at St. Mary's Hospital in Rochester, Minnesota, USA. This honor was bestowed upon her by probably the most well-known English surgeon of all time Sir Hamilton Bailey in 1949.

#GI

#physical-exam

References:

1. Abu-Hilal M, Newman JS. Sister Mary Joseph and her nodule: historical and clinical perspective. Am J Med Sci. 2009 Apr;337(4):271-3. doi: 10.1097/MAJ.0b013e3181954187. PMID: 19365173.

2. Powell FC, Cooper AJ, Massa MC, Goellner JR, Su WP. Sister Mary Joseph's nodule: a clinical and histologic study. J Am Acad Dermatol. 1984 Apr;10(4):610-5. doi: 10.1016/s0190-9622(84)80265-0. PMID: 6715609.

TPP

Q: What is the recommended end-expiratory transpulmonary pressure (TPP)? (select one)

A) -5 and zero

B) Zero and 5

C) Zero and 10

D) > 10

E) < 15

       

Answer: C

       

Transpulmonary Pressure (TPP) can be estimated by the formula

Transpulmonary pressure = airway pressure - pleural pressure

       

At the bedside airway pressure is measured from applied PEEP as its surrogate, and esophageal pressure is an estimate of pleural pressure. 

Recommended end-expiratory transpulmonary pressure is between zero and 10 cm H2O and an end-inspiratory transpulmonary pressure ≤25. Optimum end-expiratory transpulmonary pressure reduces cyclic alveolar collapse, and optimum end-inspiratory transpulmonary pressure reduces alveolar overdistension.

       

#ventilators

       

       

Reference:

Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 2008; 359:2095.

Midodrine in chylothorax

Q: Midodrine can be used as an adjuvant treatment in chylothorax?

A) True

B) False

Answer: A

Although limited to case reports, there is weak evidence to utilize midodrine in chylothorax, particularly when the cause is idiopathic or in postoperative, high-output chylothorax. Midodrine, due to its alpha 1-adrenergic agonist property, causes vasoconstriction of the lymph system and reduces chylothorax. Midodrine can be used as a last resort if other standards of chylothorax treatments fail like dietary modifications or surgical intervention.

#pulmonary

References:

1. Liou DZ, Warren H, Maher DP, et al. Midodrine: a novel therapeutic for refractory chylothorax. Chest 2013; 144:1055.

2. Sivakumar P, Ahmed L. Use of an Alpha-1 Adrenoreceptor Agonist in the Management of Recurrent Refractory Idiopathic Chylothorax. Chest 2018; 154:e1.

desalination

Q: What is "desalination"?

Answer: Desalination is a phenomenon when a volume expansion occurs due to a large infusion of isotonic fluid. Simultaneously, if the antidiuretic hormone (ADH) level is high, it increases sodium excretion in the urine, leading to acute serum hyponatremia. This is common post-operatively due to surgery-induced syndrome of inappropriate antidiuretic hormone (SIADH). 

To make things worse, a clinician unaware of this underlying pathology may administer further isotonic saline to counter hypotension and set up a vicious cycle of worsening acute hyponatremia.

#electrolytes

Reference:

Steele A, Gowrishankar M, Abrahamson S, et al. Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 1997; 126:20.

Desmopressin oral to IV

Q: What's the ratio of Desmopressin for oral to intravenous (IV) form?

Answer: 400:1

Desmopressin has a wide variety of dose bioavailability depending on the route. Four major routes available are melt (sublingual), tablet, spray, and IV. Doses have different dose comparability.

Melt:Tablet:Spry:IV 

= 240:400:10:1*

- All doses in mcg

* It's even less than 1 mcg

Moreover, bioavailability varies between manufacturers, regions, and countries. To make things more confusing, not all formulations are approved for any given disease process.

#endocrinology

#pharmacology

Reference;

Oiso Y, Robertson GL, Nørgaard JP, Juul KV. Clinical review: Treatment of neurohypophyseal diabetes insipidus. J Clin Endocrinol Metab 2013; 98:3958-67. https://www.endocrine.org/journals/jcem. Copyright © 2013 The Endocrine Society.

risk factors for higher mortality in emphysematous pyelonephritis

Q;  All of the following are risk factors for higher mortality in emphysematous pyelonephritis EXCEPT?

A) thrombocytopenia

B) acute kidney injury

C) confusion

D) hypernatremia

E) septic shock 

Answer: D

Emphysematous pyelonephritis can be devastating. Few risk factors in this regard are

• thrombocytopenia
• diabetes
• obstructive renal failure
• severe sepsis
• older age
• multidrug-resistant organism
• hyponatremia below 130 (choice D)

#ID

References:

1. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000; 160:797.

2. Desai R, Batura D. A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis. Int Urol Nephrol 2022; 54:717.

Modernized Classification of Cardiac Antiarrhythmic Drugs 2018

Q: Under Vaughan Williams classification of antiarrhythmic drugs (Revised 2018), statins have been classified under which class?

A) Class I

B) Class II

C) Class III

D) Class IV

E) Class VII

Answer: E

Under Revised (2018) Vaughan Williams classification of antiarrhythmic drugs, there are eight classes

• Class 0 (HCN channel blockers)
• Class I (voltage-gated Na+ channel blockers)
• Class II (autonomic inhibitors and activators)
• Class III (K+ channel blockers and openers)
• Class IV (Ca++ handling modulators)
• Class VII (upstream target modulators)

Class V (mechanosensitive channel blockers) and Class VI (gap junction channel blockers) have no authorized drugs. Both are still investigational classes.

Class VII i.e., upstream target modulators include Angiotensin-converting enzyme inhibitors, Angiotensin receptor blockers, Omega-3 fatty acids, and Statins

#cardiology

#pharmacology

Reference:

Lei M, Wu L, Terrar DA, Huang CL. Modernized Classification of Cardiac Antiarrhythmic Drugs. Circulation. 2018 Oct 23;138(17):1879-1896. doi: 10.1161/CIRCULATIONAHA.118.035455. Erratum in: Circulation. 2019 Mar 26;139(13):e635. PMID: 30354657.

AF, DAPT and oral anticoagulation

Q: For patients with Atrial fibrillation (AF) dual antiplatelet treatment (DAPT) should be stopped once oral anticoagulation is started?

A) True

B) False

Answer: A

All patients with atrial fibrillation qualifies for oral anticoagulation unless there is a contraindication (or patient refusal). Patients with severe Transient Ischemic Attack (TIA) who get diagnosed with AF should be started on warfarin or a direct oral anticoagulant (DOAC). And, once it is on board DAPT should be stopped to avoid bleeding issues, unless other strong indications are present for DAPT. 

DOACs achieve effect within hours and do not require heparin bridge.

#cardiology

Reference:

1. Barra S, Providência R. Anticoagulation in atrial fibrillation. Heart. 2021 Mar;107(5):419-427. doi: 10.1136/heartjnl-2020-316728. Epub 2020 Oct 28. PMID: 33115763.

2. 2019 AHA/ACC/HRS Focused Update of the 2014 Guideline for Management of Patients with Atrial Fibrillation: link: https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Guidelines/2019/2019-Afib-Guidelines-Made-Simple-Tool.pdf (last accessed September 5, 2022)

Facial trauma and hair

Q: In severe facial trauma eyebrows should be shaved?

A) True

B) False

Answer: B

Ideally, eyebrows should not be shaved or clipped in facial trauma. The reason behind this is that they provide an anatomic landmark for repair. Moreover, they may not fully grow back. 

Similarly, facial hairs such as beards should not be shaved though they can be clipped if dense. Skin shaving creates debris. This debris can contaminate the wound and is hard to remove if it moves deeper.

#trauma

Further reading:

1. Braun TL, Maricevich RS. Soft Tissue Management in Facial Trauma. Semin Plast Surg. 2017 May;31(2):73-79. doi: 10.1055/s-0037-1601381. PMID: 28496386; PMCID: PMC5423789.

2. Kretlow JD, McKnight AJ, Izaddoost SA. Facial soft tissue trauma. Semin Plast Surg. 2010 Nov;24(4):348-56. doi: 10.1055/s-0030-1269764. PMID: 22550459; PMCID: PMC3324223.

3. Ridgway EB, Pribaz JJ. The reconstruction of male hair-bearing facial regions. Plast Reconstr Surg. 2011 Jan;127(1):131-141. doi: 10.1097/PRS.0b013e3181fad328. PMID: 21200207.

NSAIDs and warfarin

Q: Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) _______________ the effect of warfarin? (select one)

A) attenuates

B) enhances

Answer: B

Except for aspirin (ASA), all NSAIDs are highly protein bound. This phenomenon leads to the displacement of other protein-bound drugs like phenytoin or warfarin. 

Once warfarin is displaced, its serum level is increased, and so does the effect. 

#pharmacology

Reference:

Choi KH, Kim AJ, Son IJ, Kim KH, Kim KB, Ahn H, Lee EB. Risk factors of drug interaction between warfarin and nonsteroidal anti-inflammatory drugs in practical setting. J Korean Med Sci. 2010 Mar;25(3):337-41. doi: 10.3346/jkms.2010.25.3.337. Epub 2010 Feb 17. PMID: 20191029; PMCID: PMC2826747.

neurologic symptoms in SS

Q: Neurologic symptoms precede the diagnosis of Sjögren's syndrome (SS)?

A) True

B) False

Answer: A

It is imperative that neurologic symptoms precede the diagnosis of Sjögren's syndrome (SS). Patients may have classic symptoms of SS such as dry eyes, dry mouth, dental caries, or parotid gland enlargement but usually, get missed.

Another hurdle in the diagnosis is the wide array of neurologic manifestations in SS. It may present as brain fog, meningoencephalitis, autoimmune encephalitis, headache, psychiatric disorders, asymptomatic MRI lesions, optic neuritis, transverse myelitis, neuromyelitis optica spectrum disorder (NMOSD), and progressive spastic paraparesis.

#rheumatology

#neurology

References:

1. McCoy SS, Baer AN. Neurological Complications of Sjögren's Syndrome: Diagnosis and Management. Curr Treatm Opt Rheumatol 2017; 3:275.

2. Margaretten M. Neurologic Manifestations of Primary Sjögren Syndrome. Rheum Dis Clin North Am 2017; 43:519.

3. Bhattacharyya S, Helfgott SM. Neurologic complications of systemic lupus erythematosus, sjögren syndrome, and rheumatoid arthritis. Semin Neurol 2014; 34:425.

4. Alunno A, Carubbi F, Bartoloni E, et al. The kaleidoscope of neurological manifestations in primary Sjögren's syndrome. Clin Exp Rheumatol 2019; 37 Suppl 118:192.

Drugs causing DKA

Q: Name at least five drugs that can cause Diabetic Keto-Acidosis (DKA)?

Answer: DKA can be induced for various reasons, particularly in Type 1 diabetic patients. Medications are one of them. From an ICU perspective following drugs are important:

• glucocorticoids
• higher-dose thiazide diuretics
• dobutamine (sympathomimetic) 
• terbutaline (sympathomimetic)
• "atypical" antipsychotics
• sodium-glucose co-transporter 2 (SGLT2) inhibitors (known to cause DKA with euglycemia among inpatients)
• cocaine (can cause recurrent DKA)

#endocrinology

References:

1. Kitabchi AE, Murphy MB. Consequences of insulin deficiency. In: Atlas of Diabetes, 4th, Skyler J (Ed), Springer US, New York 2012. p.39.

2. Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs 2005; 19 Suppl 1:1.

3. Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab 2015; 100:2849

4. Nyenwe EA, Loganathan RS, Blum S, et al. Active use of cocaine: an independent risk factor for recurrent diabetic ketoacidosis in a city hospital. Endocr Pract 2007; 13:22.

pre-procedural anxiety

Q: Alprazolam is not a good choice for pre-procedural anxiety because of its slower onset of action.

A) True

B) False

Answer: A

It is frequent for ICU patients to take trips to radiology or other procedural units as well as undergo procedures inside the ICU. 1-3 mg of Intravenous (IV) midazolam continues to be the drug of choice.

Oral alprazolam has shown mixed results but overall efficacy stayed inferior due to its slower onset of action as well as relatively short duration of effect. Sublingual (SL) alprazolam has been tried with success but data is very limited.

#procedures

References:

1. De Witte JL, Alegret C, Sessler DI, Cammu G. Preoperative alprazolam reduces anxiety in ambulatory surgery patients: a comparison with oral midazolam. Anesth Analg 2002; 95:1601.

2. Beydon L, Rouxel A, Camut N, et al. Sedative premedication before surgery--A multicentre randomized study versus placebo. Anaesth Crit Care Pain Med 2015; 34:165.

3. Shavakhi A, Soleiman S, Gholamrezaei A, et al. Premedication with sublingual or oral alprazolam in adults undergoing diagnostic upper gastrointestinal endoscopy. Endoscopy 2014; 46:633.

ANCA in CV-EGPA

Q: patients with cardiovascular (CV) involvement in eosinophilic granulomatosis with polyangiitis (EGPA)(Churg-Strauss) are prone to have? (select one)

A) negative ANCA

B) positive ANCA

Answer: A

Although lungs and skin tend to be more involved in EGPA, half of the mortality comes from CV involvement. One unique characteristic of CV involvement in EGPA is a tendency to have less likely positive antineutrophil cytoplasmic antibody (ANCA) but relatively a higher peripheral blood eosinophil count. CV involvement may manifest as heart failure, pericarditis, or rhythm issues. 

Interestingly, CV patients in EGPA have a shorter duration of EGPA-associated symptoms, probably due to vital hemodynamic organ involvement.

#rheumatology

#cardiology

References: 

1. Neumann T, Manger B, Schmid M, et al. Cardiac involvement in Churg-Strauss syndrome: impact of endomyocarditis. Medicine (Baltimore) 2009; 88:236.

2. Dennert RM, van Paassen P, Schalla S, et al. Cardiac involvement in Churg-Strauss syndrome. Arthritis Rheum 2010; 62:627.

3. Szczeklik W, Miszalski-Jamka T, Mastalerz L, et al. Multimodality assessment of cardiac involvement in Churg-Strauss syndrome patients in clinical remission. Circ J 2011; 75:649.

HE

Q: Hypereosinophilia is defined as? (select one)

A) an absolute eosinophil count (AEC) >1.5 x 109/L separated by at least one week

B) an absolute eosinophil count (AEC) >1.5 x 109/L separated by at least one month

Answer: B

As per experts' consensus Hypereosinophilia (HE) is defined as an absolute eosinophil count (AEC) >1.5 x 109/L (or >1500 cells/microL) in the peripheral blood on two examinations separated in time by at least one month and/or pathologic confirmation of tissue HE. For tissue infiltration it is subjective per the discretion except in case of bone marrow where percentage of eosinophils above 20 percent qualifies as HE.

#hematology

Reference:

1. Valent P, Klion AD, Horny HP, et al. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol 2012; 130:607.

CDAI

Q:  Crohn's Disease Activity Index (CDAI) in adults takes into account all of the following EXCEPT? (select one)

A) Gender

B) General wellbeing each day over 30 days

C) Iritis or uveitis

D) Anal fissure, fistula, or abscess

E) An abdominal mass

 

Answer; B

Crohn's Disease Activity Index (CDAI) in adults has been now widely used to determine the further line of management. Calculator (easily accessible on any search engine) is easy to put on data and gives points for various clinical signs and symptoms. 

0 - 149 points: Asymptomatic remission

150 - 220 points: Mildly to moderately active Crohn's disease

221 - 450 points: Moderately to severely active Crohn's disease

451 - 1100 points: Severely active to fulminant disease

The answer is B as CDAI counts for general well-being in only the last 7 days.

It takes into account of

• Gender
• Weight   
• Height   
• Hematocrit   
• Average number of liquid or soft stools per day over 7 days (14 points per stool)   
• Using diphenoxylate or loperamide for diarrhea
• Average abdominal pain rating over 7 days
• General wellbeing each day over 7 days
• Arthritis or arthralgia
• Iritis or uveitis
• Erythema nodosum, pyoderma gangrenosum, or aphthous stomatitis
• Anal fissure, fistula, or abscess
• Other fistulae
• Temperature over 100°F (37.8°C) in the last week
• Finding an abdominal mass

 

#gastroenterology

References:

1. Best WR. Predicting the Crohn's disease activity index from the Harvey-Bradshaw Index. Inflamm Bowel Dis 2006; 12:304.

2. Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn's disease activity index. National Cooperative Crohn's Disease Study. Gastroenterology 1976; 70:439.

3. Lichtenstein GR, Loftus EV, Isaacs KL, et al. ACG Clinical Guideline: Management of Crohn's Disease in Adults. Am J Gastroenterol 2018; 113:481.

4. Vermeire S, Schreiber S, Sandborn WJ, et al. Correlation between the Crohn's disease activity and Harvey-Bradshaw indices in assessing Crohn's disease severity. Clin Gastroenterol Hepatol 2010; 8:357.

Post CVA hiccups

Q: 72 years old male with recent stroke developed intractable hiccups lasting more than 48 hours. What is the drug of choice for post-CVA hiccups?

Answer: Gabapentin

Although there are many non-pharmacological, pharmacological, and surgical interventions for intractable and prolonged cough but in patients who develop hiccups after stroke, gabapentin is considered to be the first line of drugs. It can also be combine with other known agents such as proton pump inhibitor (PPI), baclofen, or metoclopramide.

In refractory cases, more aggressive interventions may be needed such as vagus nerve stimulator, implantable breathing pacemaker, a trial of positive pressure ventilation, phrenic nerve blocking, cervical epidural blocks at C3 to C5 (levels supplying the phrenic nerve).

References:

Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther 2015; 42:1037.

Thompson DF, Brooks KG. Gabapentin therapy of hiccups. Ann Pharmacother 2013; 47:897.

Grewal SS, Adams AC, Van Gompel JJ. Vagal nerve stimulation for intractable hiccups is not a panacea: a case report and review of the literature. Int J Neurosci 2018; 128:1114.

Byun SH, Jeon YH. Treatment of idiopathic persistent hiccups with positive pressure ventilation -a case report-. Korean J Pain 2012; 25:105.

Kim JE, Lee MK, Lee DK, et al. Continuous cervical epidural block: Treatment for intractable hiccups. Medicine (Baltimore) 2018; 97:e9444.

ARISCAT

Q; What is ARISCAT Risk Index?

Answer: ARISCAT Risk Index predicts incidence of postoperative pulmonary complications.It is a validated and easy to use and can be calculated at the bedside via easily available calculator on any search engine. It takes into account of seven factors

• age
• oxygen saturation
• respiratory infection in last 30 days
• preoperative anemia
• upper abdominal or thoracic surgery
• surgery lasting more than two hours
• emergent surgery

#pulmonary

References:

1. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113:1338.

2. Mazo V, Sabaté S, Canet J, et al. Prospective external validation of a predictive score for postoperative pulmonary complications. Anesthesiology 2014; 121:219.

Lidocaine toxicity

Q: How can lidocaine-induced cardiovascular (CVS) toxicity be minimized?

Answer: By reducing the rate of administration

This question aims to highlight the difference between lidocaine-induced neurologic and CVS toxicity. The neurologic toxicity is usually dose-dependent, while CVS toxicity occurs with overdosing and/or due to rapid administration of lidocaine. 

The first warning sign of neurologic toxicity is usually tremors, which can lead to dysarthria, slurred speech, ataxia, agitation, change in sensorium, nystagmus, hallucinations, and seizures. The CVS toxicity is marked by bradycardia which may proceed to asystole.

#pharmacology

#neurology

#cardiology

References:

Rademaker AW, Kellen J, Tam YK, Wyse DG. Character of adverse effects of prophylactic lidocaine in the coronary care unit. Clin Pharmacol Ther 1986; 40:71.

DeToledo JC. Lidocaine and seizures. Ther Drug Monit 2000; 22:320.

A-line analysis

Q: All of the following may give under-damping of an arterial line EXCEPT?

A) excessive tubing length

B) tachycardia

C) high cardiac output

D) hypothermia

E) arterial spasm

Answer: E

An arterial line placement (A-line or Art-line) is one of the most common procedures in ICU. Said that it can mislead a physician if not interpreted properly. There are various factors that can either be an "over-damped" or an "under-damped" arterial line. A few common causes are below:

Over-damping (not very well formed waveform)

• air bubbles in the tubing 
• clots in the tubing
• loose connections
• kinks in the tubing
• arterial spasm

Under-damping (systolic pressure overshoot)

• excessive tubing length
• tachycardia
• high cardiac output
• hypothermia

#procedures

#cardiovascular

Reference:

Esper SA, Pinsky MR. Arterial waveform analysis. Best Pract Res Clin Anaesthesiol. 2014 Dec;28(4):363-80. doi: 10.1016/j.bpa.2014.08.002. Epub 2014 Sep 6. PMID: 25480767.

postpartum preeclampsia

Q:  Postpartum preeclampsia usually occurs within? (select one)

A) 24 hours

B) 48 hours 

C) 72 hours

D) one week

Answer: B

About one in 20 cases of preeclampsia cases get diagnosed up to 48 hours of delivery. Between 48 hours and up to six weeks of delivery, it is called delayed-onset or late postpartum preeclampsia. 

Other unusual presentations of preeclampsia are onset before 20 weeks (associated with complete or partial molar pregnancy or antiphospholipid syndrome), preeclampsia without hypertension, isolated hypertension, and isolated proteinuria.

#ob-gyn

References:

1. Yancey LM, Withers E, Bakes K, Abbott J. Postpartum preeclampsia: emergency department presentation and management. J Emerg Med 2011; 40:380.

2. Matthys LA, Coppage KH, Lambers DS, et al. Delayed postpartum preeclampsia: an experience of 151 cases. Am J Obstet Gynecol 2004; 190:1464.

3. Al-Safi Z, Imudia AN, Filetti LC, et al. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol 2011; 118:1102.

OMG

Q: Which of the following is the most prominent symptom of Ocular Myasthenia Gravis (OMG)?

A) diplopia

B) lagophthalmus

C) "curtaining" of the contralateral eyelid 

D) anisocoria 

E) failure of pupillary light reflex

Answer: A

Due to fatigue of rectus muscles, diplopia and ptosis are the most common presenting symptom of OMG. Diplopia is usually binocular means present only with both eyes open. The easiest and most reliable (80% efficacy) test at the bedside is to perform an 'ice test.' Ptosis usually improves after putting ice on the upper lid. Ice should be applied for 60 seconds. The improvement lasts only a few seconds but strongly favors the diagnosis of OMG. Ice test may also improve diplopia.

All other choices (B, C, D, and E) are rare in OMG.

#neurology

#opthalmology

References: 

1. Chatzistefanou KI, Kouris T, Iliakis E, et al. The ice pack test in the differential diagnosis of myasthenic diplopia. Ophthalmology 2009; 116:2236.

2. Averbuch-Heller L, Poonyathalang A, von Maydell RD, Remler BF. Hering's law for eyelids: still valid. Neurology 1995; 45:1781.

3. BAPTISTA AG, SILVA E SOUZA H. Pupillary abnormalities in myasthenia gravis. Report of a case. Neurology 1961; 11:210.

4. Cooper J, Pollak GJ, Ciuffreda KJ, et al. Accommodative and vergence findings in ocular myasthenia: a case analysis. J Neuroophthalmol 2000; 20:5.

Acute Apathy Syndrome

Q: What is "acute apathy syndrome"?

Answer: Despite increased awareness and development of various tools/scores, delirium continues to deceive clinicians, particularly in ICU. Conventionally, delirium is broadly categorized as hyperactive, hypoactive, and mixed delirium. Hypoactive delirium is the most unrecognized delirium, particularly in elderly patients. 

Lately, it has been suggested that it might be time to recognize hypoactive delirium as a different entity and should be named "Acute Apathy Syndrome".

#neurology

#psychiatry

Reference:

Schieveld JNM, Strik JJMH. Hypoactive Delirium Is More Appropriately Named as "Acute Apathy Syndrome". Crit Care Med 2018; 46:1561.

Anemia in an HCV and ESRD patient

Case: 54 years old male with a past medical history of end-stage renal disease (ESRD) and on regular hemodialysis is admitted to ICU with severe anemia. Patient is recently started on anti-Hepatitis C drugs. Which drug is the most probable culprit?

Answer: Ribavarin

Once a patient is started on Ribavirin, patient should be watched for hemolysis. The following patients' population are at high risk:

1. pre-existing anemia - even with previous mild anemia i.e., below 12 g/dL (males) or <11 g/dL (females)

2. renal insufficiency - even mild insufficiency, i.e., GFR below 60 mL/min per 1.73 m2

3. coronary artery disease

4. history of hemoglobinopathies

Also, it should be avoided in pregnant females (highly teratogenic).

                                                                             

#ID

#pharmacology

References:

1. Soota K, Maliakkal B. Ribavirin induced hemolysis: a novel mechanism of action against chronic hepatitis C virus infection. World J Gastroenterol. 2014 Nov 21;20(43):16184-90. doi: 10.3748/wjg.v20.i43.16184. PMID: 25473172; PMCID: PMC4239506.

                                                                             

2. Reichard O, Schvarcz R, Weiland O. Therapy of hepatitis C: alpha interferon and ribavirin. Hepatology 1997; 26:108S.