AERD

Q: Patients with Aspirin-Exacerbated Respiratory Distress (AERD) are usually sicker than patients with aspirin-tolerant asthma?

A) True

B) False

Answer: A

Popularly known as the Samter triad, it consists of the following:

• asthma
• aspirin sensitivity, and
• nasal polyps  

Patients with a full triad are usually adults, as the three components develop sequentially over the years. Unfortunately, these patients are more likely to have severe and many times resistant asthma, requiring ventilator and systemic steroids. One of the diagnostic points is that lung inflammation is nearly always eosinophilic and more driven by cysteinyl leukotrienes.

#pulmonary

References:

1. Rajan JP, Wineinger NE, Stevenson DD, White AA. Prevalence of aspirin-exacerbated respiratory disease among asthmatic patients: A meta-analysis of the literature. J Allergy Clin Immunol 2015; 135:676.

2. Mascia K, Haselkorn T, Deniz YM, et al. Aspirin sensitivity and severity of asthma: evidence for irreversible airway obstruction in patients with severe or difficult-to-treat asthma. J Allergy Clin Immunol 2005; 116:970.

3. Comhair SAA, Bochenek G, Baicker-McKee S, et al. The utility of biomarkers in diagnosis of aspirin exacerbated respiratory disease. Respir Res 2018; 19:210.

Characteristics of anemia in hypothyroid patients

Q: Hypothyroidism tends to cause? (select one)

A) Macrocytic anemia

B) Microcytic anemia

Answer: A

In hypothyroidism, macrocytic anemia occurs due to various etiologies. Interestingly, these patients may have normal vitamin B12, folate, and iron levels. Not all patients, but some patients may resolve this macrocytosis after thyroxine replacement. MCV in these patients is usually in the range of 90 to 100 fL

A particular subtype of this disease process is autoimmune hypothyroidism, where autoantibodies to gastric parietal cells may have concomitant vitamin B12 deficiency. This situation may co-exist with pernicious anemia.

#hematology

#endocrinology

References:

1. Szczepanek-Parulska E, Hernik A, Ruchała M. Anemia in thyroid diseases. Pol Arch Intern Med. 2017 May 31;127(5):352-360. doi: 10.20452/pamw.3985. Epub 2017 Mar 28. PMID: 28400547.

2. Antonijević N, Nesović M, Trbojević B, Milosević R. Anemije u hipotireozi [Anemia in hypothyroidism]. Med Pregl. 1999 Mar-May;52(3-5):136-40. Croatian. PMID: 10518398.

3. Erdogan M, Kösenli A, Ganidagli S, Kulaksizoglu M. Characteristics of anemia in subclinical and overt hypothyroid patients. Endocr J. 2012;59(3):213-20. doi: 10.1507/endocrj.ej11-0096. Epub 2011 Dec 27. Erratum in: Endocr J. 2013;60(4):541. Mehmet, Erdogan [corrected to Erdogan, Mehmet]; Aybike, Kosenli [corrected to Kösenli, Aybike]; Mustafa, Kulaksizoglu [corrected to Kulaksizoglu, Mustafa]. PMID: 22200582.

Nitrogen Narcosis

Q; What is Nitrogen narcosis?

Answer: Nitrogen Narcosis affects scuba divers and is also called 'rapture of the deep.' As we all know, air comprises 79% of Nitrogen. At the surface pressures, it has no sedating effect. At greater depths, however, nitrogen affects the brain in precisely the same way as nitrous oxide (laughing gas). The effect (the onset and disappearance) are instantaneous. A diver may be quite clear-headed at 20 meters, and yet "silly" at 30 meters. Ascending to 20 meters will almost instantly clear the head. Divers suffering nitrogen narcosis may put themselves at risk by doing life threatening things such as taking off their masks and dance!

#neurology

References:

1. Grover CA, Grover DH. Albert Behnke: nitrogen narcosis. J Emerg Med. 2014 Feb;46(2):225-7. doi: 10.1016/j.jemermed.2013.08.080. Epub 2013 Nov 19. PMID: 24262058.

2. Kirkland PJ, Mathew D, Modi P, Cooper JS. Nitrogen Narcosis In Diving. 2023 Jul 31. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29261931.

Vasopressin in cocaine toxicity

Q: Why vasopressin is preferred over epinephrine in cardio-pulmonary arrest due to cocaine overdose?

Answer: Epinephrine, like cocaine, has alpha-adrenergic effects. Because of this similarity in the cardiovascular effects, administration of epinephrine to a patient who was arrested in a hyperadrenergic state is like "pouring gasoline over the fire." 

 Moreover, cocaine prevents reuptake of exogenously administered epinephrine. Therefore, if epinephrine is used, AHA Guidelines recommend that high-dose epinephrine be avoided and the interval for its administration be increased (q 5-10min). 

 Vasopressin offers considerable advantages over epinephrine in cardiac arrest secondary to cocaine toxicity. The hyperadrenergic state caused by cocaine increases myocardial oxygen demand, and vasopressin increases coronary blood flow, thereby reducing myocardial oxygen availability. Also, cocaine toxicity causes acidosis, and epinephrine loses much of its effectiveness in an acidotic environment, whereas vasopressin demonstrates good efficacy even with severe acidosis.

#hemodynamic

#toxicity

Further reads:

1. Richards JR, Garber D, Laurin EG, Albertson TE, Derlet RW, Amsterdam EA, Olson KR, Ramoska EA, Lange RA. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016 Jun;54(5):345-64. doi: 10.3109/15563650.2016.1142090. Epub 2016 Feb 26. PMID: 26919414.

2. Richards JR, Le JK. Cocaine Toxicity. 2023 Jun 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28613695.

pulmonary nocardial infection via hematogenous dissemination

Q: The most common site from pulmonary nocardial infection via hematogenous dissemination is? (select one)

A) brain

B) heart

C) liver

D) kidney

E) intestine

Answer: A

Although nocardia begins as a localized disease at the port of entry, it can disseminate directly or hematogeneously. The two most common entry sites are lungs and skin, with lungs in almost two-thirds of the cases. The most common site of hematogenous dissemination is the brain.

Symptoms begin as fever and cough and progress to night sweats, fatigue, anorexia, weight loss, hemoptysis, dyspnea, and pleuritic chest pain. Almost 50 percent of lung infections disseminate hematogenously, mostly to the brain, irrespective of immunocompetent status. 

Spread to adjacent structures may cause empyema, mediastinitis, pericarditis, and superior vena cava syndrome.

#ID

#pulmonary

#neurology

References:

1. Martínez-Barricarte R. Isolated Nocardiosis, an Unrecognized Primary Immunodeficiency? Front Immunol 2020; 11:590239.

2. Coussement J, Lebeaux D, van Delden C, et al. Nocardia Infection in Solid Organ Transplant Recipients: A Multicenter European Case-control Study. Clin Infect Dis 2016; 63:338.

3. Corsini Campioli C, Castillo Almeida NE, O'Horo JC, Challener D, Go JR, DeSimone DC, Sohail MR. Clinical Presentation, Management, and Outcomes of Patients With Brain Abscess due to Nocardia Species. Open Forum Infect Dis. 2021 Apr 7;8(4):ofab067. doi: 10.1093/ofid/ofab067. PMID: 33855101; PMCID: PMC8026153.

VCP

Q: In vocal cord paralysis (VCP), the wheezing is usually? (select one)

A) expiratory

B) inspiratory

Answer: B

Intubation is one of the most common procedures in the ICU. Vocal cord paralysis is a common side effect of intubation. During intubation, either due to trauma or a bigger size tube, the vocal cords may stay adducted to a median position. This airflow obstruction is pronounced in inspiration. During expiration, the paralyzed cords open due to the force of alveolar air.

Other causes of VCP are neck surgery (mostly anterior approach) and various neurologic disorders.

#pulmonary

#procedures

#ENT

References:

1. Seyed Toutounchi SJ, Eydi M, Golzari SE, Ghaffari MR, Parvizian N. Vocal cord paralysis and its etiologies: a prospective study. J Cardiovasc Thorac Res. 2014;6(1):47-50. doi: 10.5681/jcvtr.2014.009. Epub 2014 Mar 4. PMID: 24753832; PMCID: PMC3992732.

2. Salik I, Winters R. Bilateral Vocal Cord Paralysis. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 32809687.

Zone 4 for retroperitoneal region

Q: The retroperitoneum is usually divided into three zones from a surgical perspective. What does zone 4 mean when it is mentioned?

Answer: The retroperitoneum is usually divided into 3 zones from the trauma or surgical perspective. When the surgeon speaks of Zone 4, it means more than one zone is involved. It may carry a higher mortality. It may affect the injury severity score. It may be interesting to learn that mortality is usually higher for blunt trauma than for stab wounds. The usual domino effect and cause of death are multiorgan failure (MSOF), hypovolemic shock, and sepsis. Other factors that may lead to death are a delay of surgery beyond 6 hours and the extent of the injury.

Besides zone 4, zone 1-only injury is also considered high risk.

#trauma

References:

1. Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for trauma. Injury 2014; 45:1378.

2. Manzini N, Madiba TE. The management of retroperitoneal haematoma discovered at laparotomy for trauma. Injury. 2014 Sep;45(9):1378-83. doi: 10.1016/j.injury.2014.01.026. Epub 2014 Feb 3. PMID: 24606980.

Exchange transfusion and life-threatening malaria.

Q: Exchange transfusion is an effective treatment for life-threatening malaria.

A) Yes

B) No

Answer: B

Although theoretically, it makes sense that removing infected red blood cells and lowering the parasite load by replacing the unparasitized cells should help in severe malaria, the evidence fails to support this hypothesis. There are no differences in outcome. Although previously Centers for Disease Control and Prevention (CDC) supported this hypothesis but does not recommend exchange transfusion for treatment of severe malaria anymore.

Similarly, WHO guidelines does not make any such recommendations.

#ID

#hematology

References:

1. World Health Organization. Guidelines for malaria, 25 November 2022. https://www.who.int/publications/i/item/guidelines-for-malaria (Accessed on March 3, 2024).

2. Riddle MS, Jackson JL, Sanders JW, Blazes DL. Exchange transfusion as an adjunct therapy in severe Plasmodium falciparum malaria: a meta-analysis. Clin Infect Dis 2002; 34:1192.

3. Tan KR, Wiegand RE, Arguin PM. Exchange transfusion for severe malaria: evidence base and literature review. Clin Infect Dis 2013; 57:923.

Static and Dynamic hemodynamic monitoring

Q: Central Venous Pressure (CVP) is considered as a _________ hemodynamic  monitoring? (Fill in the blank - select one)

A) Static 

B) Dynamic 

Answer: A

In acute care settings, there are two types of hemodynamic monitoring

- Static 

- Dynamic

In comparison, dynamic monitoring is more reliable. Static monitoring is assessible more readily on electronic medical record and trend provides a good sense of hemodynamics.

Static monitoring includes – blood pressure & Mean Arterial Pressure (MAP). Also, the following static measurements via central line can be used to determine adequate management:

• CVP
• ScvO2 (Central venous oxygen saturation)

Dynamic monitoring includes

• Respiratory variation in the vena caval diameter (via ultrasound)
• radial artery pulse pressure variation
• aortic blood flow peak velocity
• left ventricular outflow tract velocity-time integral
• carotid or brachial artery blood flow velocity 
• passive leg-raising maneuver

Said that, dynamic monitoring is highly dependent on cardiac rhythm and respiratory pattern. Tachypnea and arrhythmia can artifact reading and clinical judgement.

#hemodynamic

#cardiology

References:

1. Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063.

2. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368.

3. ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370:1683.

4. ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496.

Properties of Librium

Q: Chlordiazepoxide (Librium) is a commonly used drug in ICU. Describe its four essential properties?

Answer: Chlordiazepoxide is unique in a sense and a good choice in alcohol withdrawal not only because its active metabolite has a very long half-life but also because it is

• amnestic,
• anxiolytic,
• hypnotic and
• skeletal muscle relaxant

#pharmacology

#toxicity

References:

1. Ahwazi HH, Patel P, Abdijadid S. Chlordiazepoxide. 2024 Jan 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 31613439.

2. Kumar CN, Andrade C, Murthy P. A randomized, double-blind comparison of lorazepam and chlordiazepoxide in patients with uncomplicated alcohol withdrawal. J Stud Alcohol Drugs. 2009 May;70(3):467-74. doi: 10.15288/jsad.2009.70.467. PMID: 19371497.

Oxygenation Index

Q: What is the Oxygenation Index?

Answer: 

The Oxygenation Index (OI) is defined as the reciprocal of PF times MAP (Mean Airway Pressure)

OI = (FiO2 × mean airway pressure)/PaO2

It is proposed that OI is a better representative of oxygenation dysfunction as it takes in account mean airway pressure from the ventilator. A lower oxygenation index is better. As the oxygenation of a person improves, they will be able to achieve a higher PaO2 at a lower FiO2

#ventilators

#pulmonary

References:

1. Vadi S. Correlation of Oxygen Index, Oxygen Saturation Index, and PaO2/FiO2 Ratio in Invasive Mechanically Ventilated Adults. Indian J Crit Care Med. 2021 Jan;25(1):54-55. doi: 10.5005/jp-journals-10071-23506. PMID: 33603302; PMCID: PMC7874290.

2. Dechert RE, Park PK, Bartlett RH. Evaluation of the oxygenation index in adult respiratory failure. J Trauma Acute Care Surg. 2014 Feb;76(2):469-73. doi: 10.1097/TA.0b013e3182ab0d27. PMID: 24458052.

3. Myers LC, Mark D, Ley B, Guarnieri M, Hofmeister M, Paulson S, Marelich G, Liu VX. Validation of Respiratory Rate-Oxygenation Index in Patients With COVID-19-Related Respiratory Failure. Crit Care Med. 2022 Jul 1;50(7):e638-e642. doi: 10.1097/CCM.0000000000005474. Epub 2022 Feb 7. PMID: 35120044; PMCID: PMC9196918.

A cardiology case in a young patient

Case: 24 years old male with no past medical history presented to ER with SVT (Supraventricular Tachycardia). His heart rate is 210. Patient was given Adenosine and went into ventricular fibrillation. CPR started and converted to NSR (normal sinus rhythm) with cardioversion. What is your first thought?

Answer: Wolff-Parkinson-White syndrome (WPW)

People with WPW syndrome have an extra electrical pathway between the atria and the ventricles. This "accessory pathway," is also known as the bundle of Kent. This accessory pathway may conduct electrical activity at a significantly higher rate than the AV node, particularly when it is blocked and may degenerate into ventricular fibrillation.

Adenosine and other AV node blockers should be avoided, including calcium channel and beta blockers. Patients with atrial fibrillation and rapid ventricular response are better treated with procainamide or cardioversion in hemodynamic instability.

#cardiology

References:

1. Gupta AK, Shah CP, Maheshwari A, Thakur RK, Hayes OW, Lokhandwala YY. Adenosine induced ventricular fibrillation in Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol. 2002 Apr;25(4 Pt 1):477-80. doi: 10.1046/j.1460-9592.2002.00477.x. PMID: 11991373.

2. Walker KW, McAnulty JH, Kron J, Silka MJ, Halperin BD. Unmasking accessory pathway conduction with adenosine-induced atrioventricular nodal block after radiofrequency catheter ablation. Chest. 1993 Nov;104(5):1614-6. doi: 10.1378/chest.104.5.1614. PMID: 8222839.

3. Bartlett TG, Friedman PL. Current management of the Wolff-Parkinson-White syndrome. J Card Surg. 1993 Jul;8(4):503-15. doi: 10.1111/j.1540-8191.1993.tb00401.x. PMID: 8353339.

4. Redfearn DP, Krahn AD, Skanes AC, Yee R, Klein GJ. Use of medications in Wolff-Parkinson-White syndrome. Expert Opin Pharmacother. 2005 Jun;6(6):955-63. doi: 10.1517/14656566.6.6.955. PMID: 15952923.

Haldol in burn

Q: Why should Haloperidol be used with caution in burn patients?

Answer: Neuropsychiatric complications are commonly seen in major burn patients. Haloperidol is frequently used to treat severe psychopathic behavior. In burn patients, there could be an increased tendency for severe muscle rigidity, an extrapyramidal side effect of the agent. Haloperidol causes a relative imbalance of dopaminergic and cholinergic neuronal activity in the basal ganglia, with a relative increase in cholinergic activity responsible for EPS. The burn patient may be more prone to extrapyramidal symptoms because of the increased sensitivity of skeletal muscle neuromuscular junctions to acetylcholine after thermal injury.

#pharmacology

#burn

References:

1. Datta PK, Roy Chowdhury S, Aravindan A, Saha S, Rapaka S. Medical and Surgical Care of Critical Burn Patients: A Comprehensive Review of Current Evidence and Practice. Cureus. 2022 Nov 15;14(11):e31550. doi: 10.7759/cureus.31550. PMID: 36540501; PMCID: PMC9754771.

2. Huang V, Figge H, Demling R. Haloperidol complications in burn patients. J Burn Care Rehabil. 1987 Jul-Aug;8(4):269-73. doi: 10.1097/00004630-198707000-00006. PMID: 3654715.

3. Chang CM, Wu KY, Chiu YW, Wu HT, Tsai YT, Chau YL, Tsai HJ. Psychotropic drugs and risk of burn injury in individuals with mental illness: a 10-year population-based case-control study. Pharmacoepidemiol Drug Saf. 2016 Aug;25(8):918-27. doi: 10.1002/pds.3995. Epub 2016 Mar 28. PMID: 27476980.

SMI and CVD

Q: Individuals having schizophrenia are twice as likely to die from Cardio Vascular Disease (CVD).

A) True

B) False

Answer: A

Patients with severe mental illness (SMI) usually have a lower lifespan of 15 to 25 years. And the most common cause is CVD. In this regard, schizophrenia has the worst prognosis. People with schizophrenia are twice as likely to die from CVD. The various reasons are drug-induced obesity leading to diabetes, a sedentary lifestyle, high blood pressure, increased tendency towards smoking, poor nutrition, drug-induced dyslipidemia, and relatively less recognized QTc prolongation.

#psychiatry

#cardivascular

References:

1. Laursen TM, Nordentoft M, Mortensen PB. Excess early mortality in schizophrenia. Annu Rev Clin Psychol 2014; 10:425.

2. Henderson DC, Nguyen DD, Copeland PM, et al. Clozapine, diabetes mellitus, hyperlipidemia, and cardiovascular risks and mortality: results of a 10-year naturalistic study. J Clin Psychiatry 2005; 66:1116.

3. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000; 177:212.

Rhupus

Q: Which patients usually get labeled as Rhupus?

Answer: Patients often have combined or overlapping features of Systemic Lupus Erythematosus (SLE) and Rheumatic Arthritis (RA). There are no objective criteria, either clinically and/or immunologically, to describe it as a distinct disease.

One of the clinical features that characterized these patients is erosive arthropathy, which is unlikely to present in SLE.

#rheumatology

References:

1. Antonini L, Le Mauff B, Marcelli C, Aouba A, de Boysson H. Rhupus: a systematic literature review. Autoimmun Rev. 2020 Sep;19(9):102612. doi: 10.1016/j.autrev.2020.102612. Epub 2020 Jul 12. PMID: 32668290.

2. Upadhyaya S, Agarwal M, Upadhyaya A, Pathan.ia M, Dhar M. Rhupus Syndrome: A Diagnostic Dilemma. Cureus. 2022 Sep 11;14(9):e29018. doi: 10.7759/cureus.29018. PMID: 36249648; PMCID: PMC9550206.

3. Ahsan H. Rhupus: dual rheumatic disease. J Immunoassay Immunochem. 2022 Mar 4;43(2):119-128. doi: 10.1080/15321819.2021.1941096. Epub 2021 Jul 6. PMID: 34228594

ECG in acute pericarditis

Q: ST elevation on EKG in acute pericarditis is usually? (select one)

A) concave-up

B) convex-up

Answer: A

Although not a confirmed science but a great tool to remember that in acute pericarditis the ST elevation is usually present in all the leads in a concave-up manner. In contrast, ST elevation in myocardial infarction (MI) is usually limited to the affected area in a convex-up manner.

EKG in acute pericarditis mostly evolves through four stages.

Stage 1 (hours to days) - widespread ST elevation (typically concave up) with reciprocal ST depression in leads aVR and V1. There is also frequently an atrial current of injury, reflected by elevation of the PR segment in lead aVR and depression of the PR segment in other limb leads and in the left chest leads, primarily V5 and V6. Thus, the PR and ST segments typically change in opposite directions. PR segment deviation is highly specific, though less sensitive.

Stage 2 (first week) - normalization of the ST and PR segments.

Stage 3 (afterward) - development of diffuse T-wave inversions.

Stage 4 - normalization of the EKG.

#cardiology

References:

1. Sarda AK, Thute P. Importance of ECG in the Diagnosis of Acute Pericarditis and Myocardial Infarction: A Review Article. Cureus. 2022 Oct 24;14(10):e30633. doi: 10.7759/cureus.30633. PMID: 36426313; PMCID: PMC9683083.

2. Liu YL, Lin CS, Cheng CC, Lin C. A Deep Learning Algorithm for Detecting Acute Pericarditis by Electrocardiogram. J Pers Med. 2022 Jul 15;12(7):1150. doi: 10.3390/jpm12071150. PMID: 35887647; PMCID: PMC9324403.

3. Masek KP, Levis JT. ECG diagnosis: acute pericarditis. Perm J. 2013 Fall;17(4):e146. doi: 10.7812/TPP/13-044. PMID: 24361030; PMCID: PMC3854820.

Sialorrhea

Q: 66 years old male with metastatic lung cancer has been made comfort care in ICU. Patient is struggling with severe Sialorrhea (excess salivation). There is no response to glycopyrrolate. Botulinum toxin A (Botox) injection in salivary gland should be considered?

A) Yes

B) No

Answer: A

Sialorrhea is a common problem with various centrally acting and neurological diseases such as amyotrophic lateral sclerosis (ALS), cerebral palsy, stroke, and Parkinson's disease. Patients with Alzheimer's disease or myasthenia gravis are usually prescribed drugs with reversible cholinesterase inhibitor activity, and develop excess salivation as a side effect.

This can be distressing to patients as well as to the family. Also, it may lead to aspiration pneumonia. A few drugs which can be helpful are glycopyrrolate and scopolamine. In case of resistant sialorrhea intrasalivary gland injection of botulinum toxin A may be helpful. In extremely severe cases radiation to the parotid and submandibular glands could be considered. 

In the ICU, a portable suction device can be used.

#palliative care

References:

1. Hugel H, Ellershaw J, Gambles M. Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide. J Palliat Med 2006; 9:279.

2. Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369.

3. Hockstein NG, Samadi DS, Gendron K, Handler SD. Sialorrhea: a management challenge. Am Fam Physician 2004; 69:2628.

Anti-hypertensive Scleroderma Renal Crisis (SRC)

Q: Which of the following anti-hypertensive is relatively contraindicated in Scleroderma Renal Crisis (SRC)? (select one)

A) Labetalol 

B) Angiotensin-converting enzyme (ACE) inhibitors

C) calcium channel blockers

Answer: A

Scleroderma Renal Crisis (SRC) is one of the few rheumatological emergencies where early diagnosis and treatment can significantly affect the outcome. Wrong diagnosis may lead to wrong management pathway and eventually to a very high mortality. SRC is heralded with hypertensive crisis and is associated with acute renal failure. The pearl is to avoid IV Labetalol or nitroprusside and gradually decrease blood pressure with PO angiotensin-converting enzyme (ACE) inhibitors. calcium channel blockers may help. Renal dialysis is a last resort. Another important differential diagnosis is from SLE (renal). It has been suggested that the use of steroids is associated with the onset of scleroderma renal crisis.

Labetalol is known to cause vasospasm at the microcirculatory level.

References: 

1. Hudson M, Ghossein C, Steen V. Scleroderma renal crisis. Presse Med. 2021 Apr;50(1):104063. doi: 10.1016/j.lpm.2021.104063. Epub 2021 Feb 3. PMID: 33548376.

2. Bose N, Chiesa-Vottero A, Chatterjee S. Scleroderma renal crisis. Semin Arthritis Rheum. 2015 Jun;44(6):687-94. doi: 10.1016/j.semarthrit.2014.12.001. Epub 2014 Dec 11. PMID: 25613774.

3. Foocharoen C, Tonsawan P, Pongkulkiat P, Anutrakulchai S, Mahakkanukrauh A, Suwannaroj S. Management review of scleroderma renal crisis: An update with practical pointers. Mod Rheumatol. 2023 Jan 3;33(1):12-20. doi: 10.1093/mr/roac028. PMID: 35349704.

4. Nagaraja V. Management of scleroderma renal crisis. Curr Opin Rheumatol. 2019 May;31(3):223-230. doi: 10.1097/BOR.0000000000000604. PMID: 30870219.

Fournier's Gangrene

Q: Which gender is more to get Fournier gangrene? (select one) 

A) Males 

B) Females 

 Answer: A 

Necrotizing fasciitis of the perineum is called Fournier gangrene. It is vital to know that Fournier gangrene occurs when there is a breach in the integrity of the gastrointestinal (GI) or genital-urethral (GU) mucosa. This basic understanding is essential to comprehend the urgency and polymicrobial nature of the disease. 

This breach in the mucosa of GI or GU symptomatically begins abruptly with severe pain, usually rapidly reaching the anterior abdominal wall and gluteal muscles. This classic presentation makes life easier for clinicians to keep a low threshold to involve surgical service way early in the process. Men are more commonly affected with scrotal and penile involvement. 

#ID 

#surgical-critical-care

 References: 

 1. Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier's gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086. 

 2. Stephens BJ, Lathrop JC, Rice WT, Gruenberg JC. Fournier's gangrene: historic (1764-1978) versus contemporary (1979-1988) differences in etiology and clinical importance. Am Surg 1993; 59:149. 

 3. Huayllani MT, Cheema AS, McGuire MJ, Janis JE. Practical Review of the Current Management of Fournier's Gangrene. Plast Reconstr Surg Glob Open. 2022 Mar 14;10(3):e4191. doi: 10.1097/GOX.0000000000004191. PMID: 35295879; PMCID: PMC8920302.

Characteristic finding of CSF In GBS

Q: What is the characteristic finding in CSF in Guillain–Barré syndrome (GBS)?

Answer: Albumino-cytological dissociation

In Guillain–Barré syndrome, cerebrospinal fluid (CSF) shows characteristic findings of albumin-cytological dissociation. It is considered as a diagnostic hallmark. In contrast to infectious causes, there is an elevated protein level (100–1000 mg/dl), without pleocytosis. An increased white blood cell count may indicate an alternative diagnosis, probably an infection.

#neurology

#procedures

References:

1. Rath J, Zulehner G, Schober B, Grisold A, Krenn M, Cetin H, Zimprich F. Cerebrospinal fluid analysis in Guillain-Barré syndrome: value of albumin quotients. J Neurol. 2021 Sep;268(9):3294-3300. doi: 10.1007/s00415-021-10479-9. Epub 2021 Mar 2. PMID: 33651153; PMCID: PMC8357680.

2. Vargas-Cañas ES, Galnares-Olalde JA, León-Velasco F, García-Grimshaw M, Gutiérrez A, López-Hernández JC. Prognostic Implications of Early Albuminocytological Dissociation in Guillain-Barré Syndrome. Can J Neurol Sci. 2023 Sep;50(5):745-750. doi: 10.1017/cjn.2022.288. Epub 2022 Aug 18. PMID: 35979659.

3. Illes Z, Blaabjerg M. Cerebrospinal fluid findings in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathies. Handb Clin Neurol. 2017;146:125-138. doi: 10.1016/B978-0-12-804279-3.00009-5. PMID: 29110767.

Erythrocytosis and smoking.

Q: Erythrocytosis resolves with the cessation of smoking.

A) Yes

B) No

Answer: A

It is a well-known fact erythrocytosis and consequently, polycythemia is common in smokers. One of the pearls that often get missed in teaching smokers to quit is that one of the benefits of smoking cessation is the resolution of polycythemia and lesser risks from all its associated effects such as stroke other vascular thrombosis like DVT.

#hematology

References:

1. Smith JR, Landaw SA. Smokers' polycythemia. N Engl J Med 1978; 298:6.

2. Aitchison R, Russell N. Smoking--a major cause of polycythaemia. J R Soc Med 1988; 81:89.

Adjunct Rx of behavioral effects due to levetiracetam

Q: Which adjuvant treatment may take care of some of the central effects of Levetiracetam?

Answer: Vitamin B6 (Pyridoxin)

Levetiracetam (Keppra) may have central effects like depression, hallucinations, irritability, anger, suicidal thoughts, seizures, double vision, etc. Pyridoxine (vitamin B6) may curtail some of the central symptoms. These side effects can be particularly pronounced in the elderly population.

#neurology

#pharmacology

References:

1. Dreischmeier E, Zuloaga A, Kotloski RJ, Karasov AO, Gidal BE. Levetiracetam-associated irritability and potential role of vitamin B6 use in veterans with epilepsy. Epilepsy Behav Rep. 2021 May 3;16:100452. doi: 10.1016/j.ebr.2021.100452. PMID: 34142077; PMCID: PMC8188361.

2. Besag FMC, Vasey MJ, Sen A. Current evidence for adjunct pyridoxine (vitamin B6) for the treatment of behavioral adverse effects associated with levetiracetam: A systematic review. Epilepsy Behav. 2023 Mar;140:109065. doi: 10.1016/j.yebeh.2022.109065. Epub 2023 Feb 13. PMID: 36791631.

Benzodiazepines as antiemetics

Q: Benzodiazepines are relatively strong antiemetic agents and are less utilized for this purpose.

A) True

B) False

Answer: B

The benzodiazepines are weak antiemetic agents. Although it has been used for this purpose, particularly in Chemotherapy-Induced Nausea and Vomiting (CINV), most of its benefits are from reducing anticipatory emesis.

They can be best utilized in combination with other effective anti-emetic dexamethasone and metoclopramide in CINV to reduce anxiety-associated nausea and vomiting.

#GI

#pharmacology

References:

1. Bowcock SJ, Stockdale AD, Bolton JA, et al. Antiemetic prophylaxis with high dose metoclopramide or lorazepam in vomiting induced by chemotherapy. Br Med J (Clin Res Ed) 1984; 288:1879.

2. Kris MG, Gralla RJ, Clark RA, et al. Antiemetic control and prevention of side effects of anti-cancer therapy with lorazepam or diphenhydramine when used in combination with metoclopramide plus dexamethasone. A double-blind, randomized trial. Cancer 1987; 60:2816.

Cachexia and sarcopenia

Q: What is the difference between sarcopenia and cachexia?

Answer:

Cachexia is generally defined as weight loss due to loss of muscle mass. Although it is universally associated with fat loss, it is not required.

Sarcopenia is characterized by loss of muscle mass, strength, and performance. It does not necessarily result in overall weight loss like muscle loss in obesity, known as sarcopenic obesity. By core definition, it is defined as loss of skeletal muscle mass, two standard deviations below sex-specific normal values for young adults. Sarcopenia may occur due to various underlying reasons such as disuse, changing endocrine function, underlying chronic diseases, inflammation, insulin resistance, nutritional deficiencies, and cancer treatment.

#musculoskeletal

References:

1. Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 1998; 147:755.

2.  Kotler DP. Cachexia. Ann Intern Med. 2000 Oct 17;133(8):622-34. doi: 10.7326/0003-4819-133-8-200010170-00015. PMID: 11033592.

3. Ardeljan AD, Hurezeanu R. Sarcopenia. 2023 Jul 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 32809648.

Factors predictive of corticosteroid psychosis in patients with SLE

Q: 34 years old female with a history of lupus and on home steroids is admitted to ICU with severe psychosis. Which of the following is a risk factor for glucocorticoid-induced psychosis in Systemic lupus erythematosus (SLE)? (select one)

A) Hyperalbuminemia

B) Hypoalbuminemia 

Answer: B

Psychosis in lupus is well-known. The most difficult part is to identify whether this psychosis is a direct manifestation of the disease itself or is due to the high glucocorticoid dose, prevalent for treatment in SLE. One of the underlying factors that may help to identify the cause of psychosis in this patient population is hypoalbuminemia, which may be a risk factor for glucocorticoid-induced psychosis in patients with SLE.

#rheumatology

#psychiatry

#pharmacology

#neurology

Reference:

Chau SY, Mok CC. Factors predictive of corticosteroid psychosis in patients with systemic lupus erythematosus. Neurology 2003; 61:104.

Boas' sign

Q: What is Boas' sign?

Answer: Boas's sign is hyperaesthesia below the right scapula in acute cholecystitis. It has also been described as 'point tenderness' in the region to the right of the 10th to 12th thoracic vertebrae. Boas' sign can also be present in the stomach and duodenal disease.

The objective of asking this question is that clinical signs in acute cholecystitis can be tricky and no single clinical finding (like the famous Murphy's sign) carries sufficient weight to establish or exclude acute cholecystitis without further testing.

#hepatology

#physical-exam

References:

1. Iyer HV. Boas' sign revisited. Ir J Med Sci. 2011 Mar;180(1):301. doi: 10.1007/s11845-010-0640-x. Epub 2010 Nov 18. PMID: 21086060.

2.  Gunn A, Keddie N. Some clinical observations on patients with gallstones. Lancet 1972;2:230-241

3. Trowbridge, RL; Rutkowski, NK; Shojania, KG (1 January 2003). "Does this patient have acute cholecystitis?". JAMA. 289 (1): 80–6.

CRD

Q: As per consensus-based guidelines from an academic panel (2004), 'death' is considered a grade in the management of chemotherapy-related diarrhea (CRD).

A) True

B) False

Answer: A

As per consensus-based guidelines from an academic panel convened to address the management of CRD in 2004, there were five grades of diarrhea.

Grade 1 - Increase of <4 stools per day over baseline; mild increase in ostomy output compared with baseline

Grade 2 - Increase of four to six stools per day over baseline; moderate increase in ostomy output compared with baseline; limiting instrumental activities of daily living (ADL).

Grade 3 - Increase of seven or more stools per day over baseline; hospitalization indicated; severe increase in ostomy output compared with baseline; limiting self-care ADL.

                         

Grade 4 - Life-threatening consequences; urgent intervention indicated

                         

Grade 5 - Death

                         

 It was advised to divide CRD into two categories          

•  "uncomplicated" (Grade 1 or 2)
•  "complicated." - all above grades                       

                         

  #GI

  #oncology

                         

  

                         

References:

                         

 1. Benson AB 3rd, Ajani JA, Catalano RB, et al. Recommended guidelines for the treatment of cancer treatment-induced diarrhea. J Clin Oncol 2004; 22:2918.

                         

2. National Institutes of Health, National Cancer Institute. Available at: https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Reference_8.5x11.pdf (Accessed February 27, 2024).

          

Asplenia and neutrophils

Q: Asplenia tends to cause? (select one)

A) neutrophilia

B) neutropenia

Answer: A

Asplenia may occur due to various reasons including splenectomy and auto-infarction. Asplenia leads to an exaggerated response to either infection or inflammation which includes both neutrophilia and thrombocytosis. Differential diagnosis can be made by the presence of Howell-Jolly bodies or nucleated red blood cells.

#hematology

#surgical-critical-care

References:

1. McBride JA, Dacie JV, Shapley R. The effect of splenectomy on the leucocyte count. Br J Haematol 1968; 14:225.

2. Tahir N, Zahra F. Neutrophilia. [Updated 2023 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570571/

3. Spencer RP, McPhedran P, Finch SC, Morgan WS. Persistent neutrophilic leukocytosis associated with idiopathic functional asplenia. J Nucl Med 1972; 13:224.