Inhalers in pulmonary medicine

Q: A 21-year-old male with a history of Asthma is admitted again to ICU with exacerbation of his symptoms. Patient insists that he takes his prescribed medicines and inhalers religiously. Almost half of the patients used their inhalers incorrectly.

A) True

B) False

 

Answer: A

One area where clinicians failed miserably is instructing patients on using inhalers correctly. This results in higher hospitalizations and emergency room visits. Less appreciated is that it also increases the domino effects of blood glucose issues and obesity due to frequent oral steroid courses. 

Multiple studies have established that less than one-half of the patients used their inhalers correctly. Interestingly, in the last four decades, despite increased presumed education, there is little to no improvement in rates of correct inhaler technique!

#pulmonary

 

References:

1. Price DB, Román-Rodríguez M, McQueen RB, et al. Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes. J Allergy Clin Immunol Pract 2017; 5:1071.

2. Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team (ADMIT). Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest 2016; 150:394.

3. Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Immunol 2013; 9:8.

Medication to avoid in ASPD

Q: All of the following medications can be tried in a patient with Anti-Social Personality Disorder (ASPD), particularly with aggressive tendencies EXCEPT?

A) Risperidone

B) Quetiapine

D) Sertraline

D) Propranolol

E) Alprazolam

Answer: E

Patients with ASPD having aggressive tendencies may require medications. The first line of drugs is second-generation antipsychotic medications such as risperidone. Quetiapine has also been used with success. In case of failure with first-line agents, Selective serotonin reuptake inhibitors (SSRIs) can be tried, such as sertraline or fluoxetine.

Lithium has also been described for use in ASPD. Antiseizure medications like carbamazepine and phenytoin can be of value also. Clinicians have utilized other drugs, such as propranolol, buspirone, and trazadone, with success.

Benzodiazepines and opioids should not be used due to their high dependence issue as well as the high chance of paradoxical exacerbation of aggressive outbursts.

#psychiatry

#pharmacology

References:

1. Khalifa NR, Gibbon S, Völlm BA, et al. Pharmacological interventions for antisocial personality disorder. Cochrane Database Syst Rev 2020; 9:CD007667.

2. Hirose S. Effective treatment of aggression and impulsivity in antisocial personality disorder with risperidone. Psychiatry Clin Neurosci. 2001 Apr;55(2):161-2. doi: 10.1046/j.1440-1819.2001.00805.x. PMID: 11285097.

3. Cowdry RW, Gardner DL. Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry 1988; 45:111.

PREGNANCY-ASSOCIATED RISK MARKERS for ASCVD

Q: All of the following are the PREGNANCY-ASSOCIATED RISK MARKERS for atherosclerotic cardiovascular disease (ASCVD) in the future EXCEPT? (select one)

A) Hypertensive disorders of pregnancy 

B) Gestational diabetes

C) Preterm delivery 

D) Placental abruption

E) Lactation

Answer: E

Although emerging data shows that males and females carry almost the same burden of risks for ASCVD, females have some particular risk markers for ASCD, including.

• preeclampsia 
• gestational hypertension
• gestational diabetes 
• preterm delivery 
• delivery of infants with fetal growth restriction
• placental abruption
• spontaneous pregnancy loss
• stillbirth

These associations may be due to either the risk of developing a chronic state after pregnancy is over, such as HTN and DM or to procoagulant and proinflammatory states associated with some of these conditions.

Lactation is found to have a protective effect.

#cardiology

#obgyn

References:

1. Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e902.

2. Crump C, Sundquist J, McLaughlin MA, et al. Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study. BMJ 2023; 380:e072112.

3. Nguyen B, Jin K, Ding D. Breastfeeding and maternal cardiovascular risk factors and outcomes: A systematic review. PLoS One 2017; 12:e0187923.

Lidocaine inhalation for cough

Q:  Nebulized lidocaine is frequently used for refractory cough. Name at least one caveat that should be considered while using it in the ICU?

Answer: Aspiration pneumonia or pneumonitis

Nebulized lidocaine is an effective tool in ICU for refractory cough. Its two major side effects are an unpleasant taste and symptomatic aspiration. 

Lidocaine is usually prescribed as 3 mL of 4 percent lidocaine in nebulizer form, which is equivalent to 120 mg. It can be increased up to a 5 mL dose with an equivalency of 200 mg. Every 12 to 8 hours should be sufficient. It numbs the throat, so the patient should be instructed to report or closely watch for choking on water or food.

#pulmonary

References:

1. Lim KG, Rank MA, Hahn PY, et al. Long-term safety of nebulized lidocaine for adults with difficult-to-control chronic cough: a case series. Chest 2013; 143:1060.

2. Abdulqawi R, Satia I, Kanemitsu Y, Khalid S, Holt K, Dockry R, Woodcock AA, Smith JA. A Randomized Controlled Trial to Assess the Effect of Lidocaine Administered via Throat Spray and Nebulization in Patients with Refractory Chronic Cough. J Allergy Clin Immunol Pract. 2021 Apr;9(4):1640-1647. doi: 10.1016/j.jaip.2020.11.037. Epub 2020 Nov 28. PMID: 33259976.

3. Udezue E. Lidocaine inhalation for cough suppression. Am J Emerg Med. 2001 May;19(3):206-7. doi: 10.1053/ajem.2001.21724. PMID: 11326346.

Drugs in cardiac cachexia

Q: Which of the following drugs can help independently in cardiac cachexia?

A) ACE-I

B) Hydralazine

C) Clonidine

D) Ca-Channel-blockers

E) spironolactone

Answer: A

Angiotensin-converting enzyme inhibitors (ACE inhibitors) can independently be beneficial in reducing cardiac cachexia in patients with chronic heart failure. 

Actually, ACE inhibitors can also be used to reverse frailty and muscle wasting in elderly patients without heart failure! (weak evidence).

Beta-blockers have been described with the same effect. However, all other choices given in the above question have not shown such an independent association.

#pharmacology

#cardiology

#geriatrics

References:

1. Rolfe M, Kamel A, Ahmed MM, Kramer J. Pharmacological management of cardiac cachexia: a review of potential therapy options. Heart Fail Rev. 2019 Sep;24(5):617-623. doi: 10.1007/s10741-019-09784-3. PMID: 30923991.

2. Israili ZH, Hall WD. ACE inhibitors. Differential use in elderly patients with hypertension. Drugs Aging. 1995 Nov;7(5):355-71. doi: 10.2165/00002512-199507050-00004. PMID: 8573991.

FMT in other diseases beside C.Diff.

Q: Name at least one disease besides severe C. diff. Colitis in which Fecal Microbiota Transplantation (FMT) may be helpful?

Answer: Irritable Bowel Syndrome (IBS)

Although IBS is described as a brain-gut disease, numerous pharmacological and non-pharmacological modalities have been tried. Unfortunately, some patients may fail to respond to all the endeavors. There is weak evidence that fecal microbiota (stool) transplantation may help. FMT is usually performed via colonoscopy. FMT is said to be more helpful in the IBS-diarrhea form.

#GI

#procedures

References:

1. Johnsen PH, Hilpüsch F, Cavanagh JP, et al. Faecal microbiota transplantation versus placebo for moderate-to-severe irritable bowel syndrome: a double-blind, randomised, placebo-controlled, parallel-group, single-centre trial. Lancet Gastroenterol Hepatol 2018; 3:17.

2. El-Salhy M, Hausken T, Hatlebakk JG. Increasing the Dose and/or Repeating Faecal Microbiota Transplantation (FMT) Increases the Response in Patients with Irritable Bowel Syndrome (IBS). Nutrients 2019; 11.

3. El-Salhy M, Winkel R, Casen C, Hausken T, Gilja OH, Hatlebakk JG. Efficacy of Fecal Microbiota Transplantation for Patients With Irritable Bowel Syndrome at 3 Years After Transplantation. Gastroenterology. 2022 Oct;163(4):982-994.e14. doi: 10.1053/j.gastro.2022.06.020. Epub 2022 Jun 14. PMID: 35709830.

EILO

Q: The typical patient for Exercise-Induced-Laryngeal-Obstruction (EILO) is "a male adolescent competitive athlete who describes the repetitive onset of inspiratory stridor and breathlessness during high-intensity exercise, which may become fatal if not treated promptly."

A) True

B) False

Answer: B

EILO is typically present in young female athletes, although cases have been reported in males and with other high-intensity work.  

This condition is different from Asthma regarding glottic or supraglottic obstruction. Association with high-intensity work is essential for the diagnosis. However, the diagnosis may become challenging if the patient has a simultaneous history of asthma.

As expected, symptoms include dyspnea on exertion, stridor, globus pharyngeus, nonproductive cough, difficulty swallowing saliva, and hoarseness. It is rarely fatal. The obstructive episode is quickly followed by resolution within minutes after cessation of exercise. Patients with repeated episodes need referral and treatment.

#pulmonary

References:

1. Røksund OD, Heimdal JH, Clemm H, et al. Exercise inducible laryngeal obstruction: diagnostics and management. Paediatr Respir Rev 2017; 21:86.

2. Walsted ES, Famokunwa B, Andersen L, et al. Characteristics and impact of exercise-induced laryngeal obstruction: an international perspective. ERJ Open Res 2021; 7.

3. Marcinow AM, Thompson J, Chiang T, et al. Paradoxical vocal fold motion disorder in the elite athlete: experience at a large division I university. Laryngoscope 2014; 124:1425.

4. Halvorsen T, Walsted ES, Bucca C, et al. Inducible laryngeal obstruction: an official joint European Respiratory Society and European Laryngological Society statement. Eur Respir J 2017; 50.

Images in EGD

Q: As per the European Society of Gastrointestinal Endoscopy (ESGE), the endoscopist should take at least how many photos during an upper GI endoscopy?

Answer: Ten

Photodocumentation is now considered a standard in reporting upper gastrointestinal (GI) endoscopy. The European Society of Gastrointestinal Endoscopy (ESGE) recommended that the endoscopist take at least 10 photos:

1. proximal esophagus
2. distal esophagus
3. Z-line and diaphragm indentation
4. cardia and fundus in inversion
5. corpus in forward view including lesser curvature
6. corpus in retroflex view, including greater curvature
7. angulus in partial inversion
8. antrum
9. duodenal bulb, and 
10. second part of the duodenum. 

Additional images should be added for any abnormalities.

#GI

#procedures

References:

1. Bisschops R, Areia M, Coron E, et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2016; 48:843.

2. Park WG, Shaheen NJ, Cohen J, et al. Quality indicators for EGD. Am J Gastroenterol 2015; 110:60.

3. ASGE Endoscopy Unit Quality Indicator Taskforce, Day LW, Cohen J, et al. Quality indicators for gastrointestinal endoscopy units. VideoGIE 2017; 2:119.

Stages of Sarcoidosis on chest X-ray

Q: What are the four stages of Sarcoidosis on chest X-ray?

Answer: Most of the times,, sarcoidosis gets diagnosed during the course of a chest radiography, performed for other reasons. 

Stage 0 - normal chest x-ray.

Stage 1 - chest x-ray with enlarged lymph nodes but otherwise clear lungs.

Stage 2 - chest x-ray with enlarged lymph nodes plus infiltrates in the lungs.

Stage 3 - chest x-ray that shows the infiltrates are present, but the lymph nodes are no longer seen.

Stage 4 - shows scar tissue in the lung tissue.

X-ray stages do not tell the severity of the disease. However, in general, the higher the stage of the X-ray, the worse the person’s symptoms and lung function (PFTs). There is a lot of individual variation, and persons at Stages 0 through 3 may or may not have symptoms. Further workup via CT scan and lab workup should be followed.

#pulmonary

#radiology

#rheumatology

Reference:

 Maller V, Elfeky M, Knipe H, et al. Thoracic sarcoidosis (staging). Reference article, Radiopaedia.org (Accessed on 16 May 2024) https://doi.org/10.53347/rID-4997

Refractory delirium tremens

Q: How is "refractory delirium tremens" usually defined?

Answer: Refractory delirium tremens is also called "benzodiazepine-resistant alcohol withdrawal." Although no absolute definition exists for clinically unresponsive patients, IV administration of more than 50 mg of diazepam or 10 mg of lorazepam during the first hour of treatment or 200 mg of diazepam or 40 mg of lorazepam during the initial three to four hours of treatment is considered resistant.

The reason could be the low endogenous GABA concentrations or acquired conformational changes in the GABA receptor.

Such patients need more aggressive or next-level treatment with phenobarbital, propofol, and dexmedetomidine. Most of these patients usually require mechanical ventilation.

#toxicology

References:

1.  Langlois H, Cormier M, Villeneuve E, et al. Benzodiazepine resistant alcohol withdrawal: What is the clinician's preferred definition? CJEM 2020; 22:165.

2. Lindsay DL, Freedman K, Jarvis M, et al. Executive Summary of the American Society of Addiction Medicine (ASAM) Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med 2020; 14:376.

3. Schmidt KJ, Doshi MR, Holzhausen JM, et al. Treatment of Severe Alcohol Withdrawal. Ann Pharmacother 2016; 50:389.

4. Cagetti E, Liang J, Spigelman I, Olsen RW. Withdrawal from chronic intermittent ethanol treatment changes subunit composition, reduces synaptic function, and decreases behavioral responses to positive allosteric modulators of GABAA receptors. Mol Pharmacol 2003; 63:53.

CPR in VAE

Q: While the nurse was pulling the central venous line, the patient took a deep breath and soon after went into a PEA arrest. There is a high suspicion of venous Air Embolism (VAE). The patient was put in bed, and CPR started. CPR serves two purposes in VAE.

Discussion: If CPR is required in venous air embolism, the patient should be placed in a head-down and left lateral position.  CPR in venous air embolism serves a dual purpose. Besides maintaining cardiac output,  CPR may also help to break large air bubbles into smaller ones. 

Literature shows that cardiac massage is as effective as putting the patient in the left lateral position and as effective as intracardiac air aspiration via a central venous catheter.

#hemodynamic

#resuscitation

References:

1. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology. Jan 2007;106(1):164-77.

2. Sviri S, Woods WP, van Heerden PV. Air embolism--a case series and review. Crit Care Resusc. Dec 2004;6(4):271-6.

3. Muth CM, Shank ES. Gas embolism. N Engl J Med. Feb 17 2000;342(7):476-82. 

4. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. Jun 15 2004;140(12):1025-33. 

K and Dig-tox

Q: The degree of hyperkalemia in acute digoxin toxicity correlates with the risk of death.

A) True

B) False

Answer: A

Acute digoxin toxicity results in hyperkalemia due to inhibition of the sodium-potassium-ATPase pump. The higher the degree of inhibition, the higher the hyperkalemia and the chances of death. Digoxin-specific Fab fragments bring the sodium-potassium ATPase pump function to normal, and potassium moves intracellularly. On the flip side, very aggressive treatment of hyperkalemia during that period may result in life-threatening hypokalemia following digitalis antidote therapy.

Although the literature is old in this regard, it is still very valid.

#electrolytes

#pharmacology

#cardiology

#toxicology

References:

1. Bismuth C, Gaultier M, Conso F, Efthymiou ML. Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications. Clin Toxicol 1973; 6:153.

2. Manini AF, Nelson LS, Hoffman RS. Prognostic utility of serum potassium in chronic digoxin toxicity: a case-control study. Am J Cardiovasc Drugs. 2011 Jun 1;11(3):173-8. doi: 10.2165/11590340-000000000-00000. PMID: 21619380; PMCID: PMC4961037.

3. Papadakis MA, Wexman MP, Fraser C, Sedlacek SM. Hyperkalemia complicating digoxin toxicity in a patient with renal failure. Am J Kidney Dis. 1985 Jan;5(1):64-6. doi: 10.1016/s0272-6386(85)80139-6. PMID: 3966471.

C. Diff - Adjuvant Treatment

Q: Name at least 3 antibiotics/medicines that may be used as adjuvants in treating C. diff. colitis along with Fidaxomicin, Metronidazole, or oral Vancomycin.

Answer:

Many antibiotics have shown partial or full activity against C. Diff. To name a few for use, particularly in suspected relapsing outbreaks, are:

• Rifampin
• Linezolid 
• Teicoplanin
• Cholestyramine (anion-exchange resin agent)
• Nitazoxanide
• Rifaximin
• Tinidazole
• Probiotics

#ID

#pharmacology

References:

1. Oksi J, Anttila VJ, Mattila E. Treatment of Clostridioides (Clostridium) difficile infection. Ann Med. 2020 Feb-Mar;52(1-2):12-20. doi: 10.1080/07853890.2019.1701703. Epub 2019 Dec 13. PMID: 31801387; PMCID: PMC7877971.

2. Kelly CR, Fischer M, Allegretti JR, LaPlante K, Stewart DB, Limketkai BN, Stollman NH. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021 Jun 1;116(6):1124-1147. doi: 10.14309/ajg.0000000000001278. Erratum in: Am J Gastroenterol. 2022 Feb 1;117(2):358. PMID: 34003176.

3. Normington C, Chilton CH, Buckley AM. Clostridioides difficile infections; new treatments and future perspectives. Curr Opin Gastroenterol. 2024 Jan 1;40(1):7-13. doi: 10.1097/MOG.0000000000000989. Epub 2023 Nov 9. PMID: 37942659; PMCID: PMC10715702.

Catamenial Pneumothorax

Q; What is Catamenial pneumothorax?

 

Answer: Catamenial pneumothorax is a rare condition defined as recurrent spontaneous pneumothorax occurring within 72 hours before or after the onset of menstruation. 

The etiology of this syndrome is unknown, although many theories have been proposed to explain it. Historically, it has been attributed to intrathoracic endometriosis. Diaphragmatic fenestrations that freely communicate with the peritoneal cavity are often present in patients with catamenial pneumothorax. During uterus lining shedding during menstruation, air passes into the pleural space through these holes. If blood from endometriosis enters the pleural cavity, it may be accompanied by hemothorax. 

 This condition occurs predominantly on the right side., and generally occurs in women in their thirties and forties.  The mean age at presentation varies between 32 and 37 years. The most common symptoms are chest pain and dyspnoea. The disease is believed to be rare, with a prevalence of 1% to 5% among menstruating women with spontaneous pneumothorax.

 

Acute treatment includes pneuma (air) drainage, chest tube, pleurodesis in recurrent cases, and surgical closure of diaphragmatic fenestrations if required.

 

A referral should be made to a GYN service for hormonal and related management of endometriosis.

#pulmonary

#ob-gyn

References: 

1. Gil Y, Tulandi T. Diagnosis and Treatment of Catamenial Pneumothorax: A Systematic Review. J Minim Invasive Gynecol. 2020 Jan;27(1):48-53. doi: 10.1016/j.jmig.2019.08.005. Epub 2019 Aug 8. PMID: 31401265.

2. Marjański T, Sowa K, Czapla A, Rzyman W. Catamenial pneumothorax - a review of the literature. Kardiochir Torakochirurgia Pol. 2016 Jun;13(2):117-21. doi: 10.5114/kitp.2016.61044. Epub 2016 Jun 30. PMID: 27516783; PMCID: PMC4971265.

3. Visouli AN, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Zaric B, Branislav P, Porpodis K, Zarogoulidis P. Catamenial pneumothorax. J Thorac Dis. 2014 Oct;6(Suppl 4):S448-60. doi: 10.3978/j.issn.2072-1439.2014.08.49. PMID: 25337402; PMCID: PMC4203986.

TXA and CS

Q: If topical or intravenous tranexamic acid is used in the surgery, the cell salvage technique (CS = cell-saver) should never be applied.

A) True

B) False

Answer: B

Meticulous care should be taken while obtaining cell-saver and transfusing back to patients. Salvaged blood should never be used when solutions may be in contact with potentially harmful contents such as antibiotic irrigation, hydrogen peroxide, alcohol, or povidone-iodine solutions. Also, CS should never be transfused with hypotonic fluids like sterile water, which may lead to hemolysis. The same rule is applied to admixture with hemostatic products or bone cement, which includes topical thrombin, fibrin glue, and microfibrillar bovine collagen-based products. 

Topical or intravenous tranexamic acid is considered safe and can be used along with CS.

#hematology

#surgical-critical-care

References:

1. Waters JH. Intraoperative blood recovery. ASAIO J 2013; 59:11.

2. Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus 2011; 9:139.

3. Murphy GJ, Mango E, Lucchetti V, Battaglia F, Catapano D, Rogers CA, Angelini GD. A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006 Sep;132(3):475-80, 480.e1-8. doi: 10.1016/j.jtcvs.2006.01.064. PMID: 16935098.

Disulfiram-ETOH interaction - Part 2

 Case: 44 years old male who is on Disulfiram maintenance treatment with alcohol (ETOH) abstinence is admitted to ICU with chest pain, sweating, headache, dyspnea, flushing, palpitations, nausea, and vomiting. Cardiac etiology has been ruled out. Patients report some viral flu-like symptoms lately and use over-the-counter cough medicine. Patient failed supportive treatment with anti-emetics, IV resuscitations, and diphenhydramine. Which antidote can be considered?

Answer: Fomepizole

Disulfiram has been used as a medical treatment for ETOH abuse. After 2 days of abstinence, disulfiram can be started with a dose of 250 to 500 mg/day for one to two weeks, followed by a maintenance dose if needed.

Disulfiram discourages ETOH drinking by causing an accumulation of acetaldehyde, alcohol’s primary metabolite - resulting in symptoms as described above in our case.

If the patient accidentally consumes ETOH, which is frequently present in many over-the-counter symptom-relieving drugs or mouthwashes, the patient may experience the said symptoms. The treatment is supportive. Hypotension is common and may require IV resuscitations, pressor, and Trendelenburg positioning. Diphenhydramine may be of good help. 

These patients may have some EKG changes despite clean coronaries but need to be ruled for any cardiac injury. 

If the patient does not respond to supportive treatment, Fomepizole should be considered. Fomepizole, a 4-methylpyrazole, helps patients with severe presentations. It is suggested because it blocks alcohol dehydrogenase and is expected to reverse disulfiram reactions.

Caution should be exercised in pregnant patients, as limb-reduction anomalies in infants born to disulfiram-treated alcoholic mothers have been reported.

#toxicology

References:

1. Schicchi A, Besson H, Rasamison R, et al. Fomepizole to treat disulfiram-ethanol reaction: a case series. Clin Toxicol (Phila) 2020; 58:922.

2. Sande M, Thompson D, Monte AA. Fomepizole for severe disulfiram-ethanol reactions. Am J Emerg Med 2012; 30:262.e3.

3. Reitnauer PJ, Callanan NP, Farber RA, Aylsworth AS. Prenatal exposure to disulfiram implicated in the cause of malformations in discordant monozygotic twins. Teratology 1997; 56:358.

4. Nora AH, Nora JJ, Blu J. Limb-reduction anomalies in infants born to disulfiram-treated alcoholic mothers. Lancet 1977; 2:664.

5. Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies Into Medical Practice, Substance Abuse and Mental Health Services Administration (US), Rockville, MD 2009.

Disulfiram-ETOH interaction - Part 1

Case: 44 years old male who is on Disulfiram maintenance treatment with alcohol (ETOH) abstinence is admitted to ICU with chest pain, sweating, headache, dyspnea, flushing, palpitations, nausea, and vomiting. Cardiac etiology has been ruled out. Patient reports some viral flu-like symptoms lately and uses an over-the-counter cough medicine. Disulfiram-ETOH interaction may cause? (select one)

A) hypertension

B) hypotension

Answer: B

Disulfiram has been used as a medical treatment for ETOH abuse. After 2 days of abstinence, disulfiram can be started with a dose of 250 to 500 mg/day for one to two weeks, followed by a maintenance dose if needed.

Disulfiram discourages ETOH drinking by causing an accumulation of acetaldehyde, alcohol’s primary metabolite - resulting in symptoms as described above in our case.

If patient accidentally consumes ETOH, which is frequently present in many over-the-counter symptom-relieving drugs and mouthwashes, the patient may experience the said symptoms. Treatment is supportive. Hypotension is common and may require IV resuscitations, pressor, and Trendelenburg positioning. Diphenhydramine may be of good help.

Caution should be exercised in pregnant patients as limb-reduction anomalies in infants born to disulfiram-treated alcoholic mothers have been reported.

#toxicology

References:

1. Ait-Daoud N, Johnson BA. Medications for the treatment of alcoholism. In: Handbook of Clinical Alcoholism Treatment, Johnson BA, Ruiz P, Galanter M (Eds), Lippincott Williams & Wilkins, Baltimore 2003. p.119.

2. Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One 2014; 9:e87366.

3. Saitz R. Medications for alcohol use disorders. JAMA 2014; 312:1349.

4. Soyka M, Müller CA. Pharmacotherapy of alcoholism - an update on approved and off-label medications. Expert Opin Pharmacother 2017; 18:1187.

5. Nora AH, Nora JJ, Blu J. Limb-reduction anomalies in infants born to disulfiram-treated alcoholic mothers. Lancet 1977; 2:664.

FTT

Q: Which of the following is NOT part of the definition of  syndrome of Failure to Thrive (FTT)? (select one)

A) weight loss

B) decreased appetite 

C) poor nutrition

D) inactivity

E) loss of height

Answer: E

The United States National Institute of Aging described FTT as "syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol". FTT in older adults may represent a final common pathway or a syndrome of global decline, which eventually culminates in death unless interventions are applied to reverse the course.

A wide range of causes can induce FTT, including, but not limited to, malignancy, medical comorbidities, medications, and psychological factors.

#nutrition

#geriatrics

References:

1. Sarkisian CA, Lachs MS. "Failure to thrive" in older adults. Ann Intern Med 1996; 124:1072.

2. Homan GJ. Failure to Thrive: A Practical Guide. Am Fam Physician. 2016 Aug 15;94(4):295-9. PMID: 27548594.

Tripe palm

Q: The presence of tripe palm is the possible manifestation of which cancers?

Answer; Gastric or lung cancer

The nomenclature for 'Tripe palm' is acanthosis palmaris or acquired pachydermatoglyphia. It is called tripe palm because it resembles the stomach mucosa of ruminants (tripe). It appears as a velvety thickening of the palms with a ridged or rugose appearance.

It is mostly associated with stomach or lung cancer, though it may be present in other cancers or can be independently idiopathic.

Its clinical significance lies in its possible earliest manifestation of the underlying cancer. It usually resolves with the start of treatment or resolution of malignancy.

#dermatology

#oncology

#pulmonary

References:

1. Güngör S, Topal I. Images in clinical medicine. Tripe palms. N Engl J Med 2014; 370:558.

2. Cohen PR, Grossman ME, Almeida L, Kurzrock R. Tripe palms and malignancy. J Clin Oncol 1989; 7:669.

3. Ameen M, Chopra S, Darvay A, et al. Erythema gyratum repens and acquired ichthyosis associated with transitional cell carcinoma of the kidney. Clin Exp Dermatol 2001; 26:510.

Acute Appendicitis: Diagnosis

Q: Describe at least 5 clinical signs at bedside for diagnosis of acute appendicitis?

Answer:  Various clinical maneuvers have been described to diagnose acute appendicitis. Some of the tests to perform are mentioned below.

1. Rovsing's sign: Continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon) may cause pain in the right iliac fossa

2. Psoas sign or Obraztsova's sign: is right lower-quadrant pain that is produced by either the passive extension of the patient's right hip (patient lying on left side, with knee in flexion) or the patient's active flexion of the right hip while supine. The pain elicited is due to inflammation of the peritoneum.

3. Dunphy's sign: Increased pain in the right lower quadrant with coughing.

4. Sitkovskiy or Rosenstein's sign: Increased pain in the right iliac region as patient lies on his/her left side.

5. Rebound tenderness: Deep palpation of the viscera over the suspected inflamed appendix followed by sudden release of the pressure causes severe pain on the site (Blumberg's sign).  

#surgical-critical-care

#GI

References:

1. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA. 2021 Dec 14;326(22):2299-2311. doi: 10.1001/jama.2021.20502. PMID: 34905026.

2. Snyder MJ, Guthrie M, Cagle S. Acute Appendicitis: Efficient Diagnosis and Management. Am Fam Physician. 2018 Jul 1;98(1):25-33. PMID: 30215950.

Azithromycin and lungs

Q: Azithromycin is an effective antibiotic for pulmonary infections because levels in the lung can be 10 to 100 times more than in plasma.

A) True

B) False

Answer: A

Azithromycin penetrates very well into most tissues and fluids, giving it great credibility as an anti-infective, particularly for the lung. This also includes its high concentration in epithelial lining fluid, neutrophils, and alveolar macrophages. In this regard, azithromycin performs better than clarithromycin. 

Sputum and lung concentrations are 10 to 100 times higher in the plasma.

Moreover, this high level of azithromycin persists in tissues for extended periods, though it can be seen as a risk for resistance development.

#ID

#pharmacology

#pulmonary

References:

1. Nesbitt WJ, Aronoff DM. Macrolides and clindamycin. In: Principles and Practice of Infectious Diseases, 9th ed, Bennett JE, Dolin R, and Blaser MJ (Eds), Elsevier, 2020.

2. Ballow CH, Amsden GW. Azithromycin: the first azalide antibiotic. Ann Pharmacother 1992; 26:1253.

neck postures of cervical dystonia

Q: Name at least three abnormal neck postures of cervical dystonia.

Answer: Abnormal neck posture is the defining feature of cervical dystonia, which is present only while a patient is awake. Chronic musculoskeletal deformities may occur over the years. This can be socially very unpleasant and disturbing to a patient and people.

• Torticollis – Rotation to either direction in the transverse plane
• Laterocollis – Lateroflexion to either direction in the coronal plane
• Retrocollis – Retroextension in the sagittal plane
• Anterocollis – Anteroflexion in the sagittal plane
• Sagittal shift – Base of the neck is shifted in the sagittal plane
• Horizontal (lateral) shift – Base of the neck is shifted towards either shoulder

Antero- and retrocollis occur exclusively alone. All others may exist in combination.

Further sub-classifications have been described, but details can be extensive (out of the scope of our small pearls). 

Botulism may help.

#neurology

#musculoskekeletal

References:

1. Jankovic J, Leder S, Warner D, Schwartz K. Cervical dystonia: Clinical findings and associated movement disorders. Neurology 1991; 41:1088.

2. Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia 2011; 1:5.

3. Jost WH, Tatu L, Pandey S, et al. Frequency of different subtypes of cervical dystonia: a prospective multicenter study according to Col-Cap concept. J Neural Transm (Vienna) 2020; 127:45.

Mild TBI

Q: A 23-year-old football player is admitted to ICU after a traumatic event at a college game where he developed confusion, retrograde amnesia, and a brief period of loss of consciousness (LOC). CT head is consistent with a mild Traumatic Brain Injury (TBI). Which of the following is NOT considered a symptom of mild TBI? (select one)

A) inability to walk a straight line

B) vacant stare 

C) delayed verbal expression

D) disorientation 

E) pupillary abnormality

Answer: E

TBI is popularly known as concussion. The majority of patients develop confusion, antegrade or retrograde amnesia, sometimes loss of consciousness, incoordination, vacant stare, delayed verbal expression, inability to focus attention, disorientation, slurred speech, and emotional variability. Transient neurologic deficits, cortical blindness, extraocular muscle weakness, vertigo, and nystagmus are also described. Symptoms may occur several minutes or hours later.

Focal neurologic findings such as extremity weakness or hemiparesis, visual field deficit, pupillary abnormality, or Horner syndrome are not consistent with mild TBI. They signify traumatic vascular injury and should go more with stroke-like symptoms.

#neurology

References:

1. Capizzi A, Woo J, Verduzco-Gutierrez M. Traumatic Brain Injury: An Overview of Epidemiology, Pathophysiology, and Medical Management. Med Clin North Am. 2020 Mar;104(2):213-238. doi: 10.1016/j.mcna.2019.11.001. PMID: 32035565.

2. Katz DI, Cohen SI, Alexander MP. Mild traumatic brain injury. Handb Clin Neurol. 2015;127:131-56. doi: 10.1016/B978-0-444-52892-6.00009-X. PMID: 25702214.

3. Vella MA, Crandall ML, Patel MB. Acute Management of Traumatic Brain Injury. Surg Clin North Am. 2017 Oct;97(5):1015-1030. doi: 10.1016/j.suc.2017.06.003. PMID: 28958355; PMCID: PMC5747306.

MAP in HRS-AKI-1

Q: What is the Mean Arterial Pressure (MAP) goal in active treatment of Acute Kidney Injury (AKI) from hepatorenal syndrome? (select one)

A) > 65 mm Hg

B) > 70 mm Hg

C) > 80 mm Hg

Answer: C

Many of us may find such a high MAP goal unusual, but the concept behind goal MAP > 80 mm Hg (to be precise, 82 mmHg) is to minimize renal injury by keeping renal perfusion pressure high. All anti-hypertensives should be discontinued. An immediate goal is to raise MAP by 10 to 15 mmHg from the baseline. The preferred vasopressor is Norepinephrine, along with an infusion of albumin. Vasopressin infusion is also an appropriate choice.

To achieve this goal, other modalities, such as terlipressin, midodrine, and octreotide, should also be applied.

As a rule of thumb, 9 mmHg increase in MAP predicts 1 mg/dL decrease in serum creatinine. It is predicted that an increase in MAP of 9 to 13 mmHg is needed to achieve resolution in most patients with hepatorenal syndrome-acute kidney injury (HRS-AKI)/type 1 hepatorenal syndrome.

#hepatology

#nephrology

#hemodynamics

References:

1. Velez JC, Nietert PJ. Therapeutic response to vasoconstrictors in hepatorenal syndrome parallels increase in mean arterial pressure: a pooled analysis of clinical trials. Am J Kidney Dis 2011; 58:928.

2. Jung CY, Chang JW. Hepatorenal syndrome: Current concepts and future perspectives. Clin Mol Hepatol. 2023 Oct;29(4):891-908. doi: 10.3350/cmh.2023.0024. Epub 2023 Apr 13. PMID: 37050843; PMCID: PMC10577351.

3. Maiwall R, Rao Pasupuleti SS, Hidam AK, Kumar A, Tevethia HV, Vijayaraghavan R, Majumdar A, Prasher A, Thomas S, Mathur RP, Kumar G, Sarin SK. A randomised-controlled trial (TARGET-C) of high vs. low target mean arterial pressure in patients with cirrhosis and septic shock. J Hepatol. 2023 Aug;79(2):349-361. doi: 10.1016/j.jhep.2023.04.006. Epub 2023 Apr 23. PMID: 37088310.

CPM after surgery

Q: Central Pontine Myelinolysis (CPM) may be a complication of which of the following post transplant surgery?

A) Heart

B) Liver 

C) Kidney

D) Pancreas

Answer: B

The other known causes of Central Pontine Myelinolysis (CPM) are

• Malnourishment
• rapid correction of hyponatremia 
• occasionally, after rapid correction of hypernatremia
• Wilson's disease
• Burn patients (with a prolonged period of serum hyperosmolality)
• withdrawal of chronic alcoholism
• post hematopoietic stem cell transplantation
• severe liver disease
• post liver transplantation
• severe burns
• malnutrition 
• hyperemesis gravidarum

#transplant

#surgical-critical-care

#neurology

References:

Singh N, Yu VL, Gayowski T. Central nervous system lesions in adult liver transplant recipients: clinical review with implications for management. Medicine (Baltimore). Mar 1994;73(2):110-8.

Adams RD, Victor M, Mancall EL. Central pontine myelinolysis: a hitherto undescribed disease occurring in alcoholic and malnourished patients. AMA Arch Neurol Psychiatry. Feb 1959;81(2):154-72. 

Kumar S, Fowler M, Gonzalez-Toledo E, Jaffe SL. Central pontine myelinolysis, an update. Neurol Res. Apr 2006;28(3):360-6. 

Valsalva Maneuver

Q: Patient is in Supraventricular tachycardia (SVT). For the sake of discussion - name few vagal maneuvers (activation of the parasympathetic nervous system)?

Answer:

• The Valsalva maneuver *1.
• Just holding one's breath for a few seconds,
• Coughing,
• Putting towel of ice cold water on face(diving reflex)*2
• Drinking a glass of ice cold water,
• Standing on one's head!
• Carotid sinus massage *3
• Act of defecation or rectal massage
• Act of urination

*1 The Valsalva maneuver works by increasing intra-thoracic pressure and affecting baro-receptors (pressure sensors) within the arch of the aorta.

*2 Diving reflex is triggered specifically by cold water contacting the face - less than 21 °C (70 °F). Submersion of body parts other than the face does not cause diving reflex. It cause bradycardia and peripheral vasoconstriction.

*3 Carotid sinus massage is often not recommended due to risks of stroke in those with plaque in the carotid arteries.

#hemodynamics

#cardiology

References:

1. Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. The Valsalva manoeuvre: physiology and clinical examples. Acta Physiol (Oxf). 2016 Jun;217(2):103-19. doi: 10.1111/apha.12639. Epub 2016 Jan 5. PMID: 26662857.

2. Looga R. The Valsalva manoeuvre--cardiovascular effects and performance technique: a critical review. Respir Physiol Neurobiol. 2005 May 12;147(1):39-49. doi: 10.1016/j.resp.2005.01.003. PMID: 15848122.

3. Srivastav S, Jamil RT, Zeltser R. Valsalva Maneuver. [Updated 2023 Aug 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537248/

Synkinesia

Q: What is Synkinesia?

Answer: Synkinesia means an involuntary contraction or twitching of part of the musculature upon voluntary movement of the related muscles. It can occur after stroke to any group of muscles but now the term is almost always applied to facial muscles, particularly after Bell's Palsy. This represents a complication of disorganized and misdirected nerve regeneration. Not all patients develop this complication.

Some examples are: 

• twitching of the angle of the mouth when the patient blinks forcefully
• contracture of the orbicular oculi and narrowing of the palpebral fissure with smiling
• a salivary stimulus resulting in excess lacrimation - called syndrome of gustatory tearing or "crocodile tears."
• salivation causes facial sweating

In severe cases, botulinum toxin injections can be applied.

#neurology

References:

1. Guntinas-Lichius O, Prengel J, Cohen O, Mäkitie AA, Vander Poorten V, Ronen O, Shaha A, Ferlito A. Pathogenesis, diagnosis and therapy of facial synkinesis: A systematic review and clinical practice recommendations by the international head and neck scientific group. Front Neurol. 2022 Nov 9;13:1019554. doi: 10.3389/fneur.2022.1019554. PMID: 36438936; PMCID: PMC9682287.

2. Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg. 2008 May;24(2):242-9. doi: 10.1055/s-2008-1075840. PMID: 18470836.