PPCM and heart transplant

Q: : Patients with Peripartum Cardiomyopathy (PPCM) who undergoes heart transplant have better outcome than compared group.

A) True

B) False

Answer: B

Unfortunately, patients who have been transplanted for PPCM have worse outcomes compared with other cardiac transplant recipients, with higher one year, 5 years and 10 years mortality, higher rejection, poorer graft survival, and higher re-transplantation rates. The underlying factors are higher allo-sensitization, and higher pre-transplant acuity. 

#transplantation

#cardiology

#Ob-gyn

Reference:

1. Kwon JH, Tedford RJ, Ramu B, et al. Heart Transplantation for Peripartum Cardiomyopathy: Outcomes Over 3 Decades. Ann Thorac Surg 2022; 114:650.

C-peptide level in factitious hypoglycemia

Q: 22 years old college student residing at dorm presented to ED third time in a month with hypoglycemia without the history of diabetes. There is a suspicion of factitious hypoglycemia. as roommate showed showed suspicion that he may be using his insulin. C-peptide level is send. In an event of factitious hypoglycemia, C-peptide level is supposed to be? select one

A) Less than 0.2 nmol/L

B) ≥0.2 nmol/L 

Answer B

Two tests which rules out factitious hypoglycemia or accidental or surreptitious insulin administration are

• C-peptide level less than 0.2 nmol/L, and
• plasma proinsulin level less than 5 pmol/L        

C-peptide level ≥0.2 nmol/L and plasma proinsulin ≥5 pmol/L need to be ruled out for an endogenous origin of hyperinsulinism, or other etiologies such as oral hypoglycemic agent-induced hypoglycemia, insulin autoimmune hypoglycemia, and nesidioblastosis/islet cell hypertrophy.

#endocrinology

References:

1. Bonnet-Serrano F, Devin-Genteuil C, Thomeret L, Laguillier-Morizot C, Leguy MC, Vaczlavik A, Bouys L, Zientek C, Bricaire L, Bessiène L, Guignat L, Libé R, Mosnier-Pudar H, Assié G, Groussin L, Guibourdenche J, Bertherat J. C-peptide level concomitant with hypoglycemia gives better performances than insulin for the diagnosis of endogenous hyperinsulinism: a single-center study of 159 fasting trials. Eur J Endocrinol. 2023 Feb 14;188(2):lvad012. doi: 10.1093/ejendo/lvad012. PMID: 36756737.

2. Awad DH, Gokarakonda SB, Ilahi M. Factitious Hypoglycemia. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542310/

"Round belly sign"

Q: What is the "Round belly sign" on a CT scan in patients with suspicion of intra-abdominal compartment syndrome (IACS)?

Answer: The round-belly sign will be termed positive for IACS if abdominal distention has an increased ratio of anteroposterior-to-transverse abdominal diameter of more than 0.80, with 100% sensitivity and 94% specificity. Setting the value to 0.82 increased specificity to 99%.

#surgical-critical-care

References:

1. Pickhardt PJ, Shimony JS, Heiken JP, Buchman TG, Fisher AJ. The abdominal compartment syndrome: CT findings. AJR 1999;173:575 -579

2. Bouveresse S, Piton G, Delabrousse E. The round belly sign. Abdom Radiol (NY). 2017 Feb;42(2):663-664. doi: 10.1007/s00261-016-0895-4. PMID: 27638514.

3. Lombardi AF, Thompson CP, Zulfiqar M, Jain A, Krishnan I, Sandrasegaran K. Radiologic evaluation of abdominal compartment syndrome: an updated educational review. Abdom Radiol (NY). 2025 Aug 18. doi: 10.1007/s00261-025-05148-8. Epub ahead of print. PMID: 40824534.

liver abscess

Q: Liver abscesses are more commonly involved in which lobe of the liver? - select one

A) Right

B) Left

C) Caudate lobe

D) Quadrate lobe

Answer: A

The right lobe of the liver is larger and has a greater blood supply, making it the most commonly involved lobe in abscesses. The major distinction is required between a cyst and an abscess. Cysts appear as fluid collections without surrounding stranding or hyperemia. 

Another differential diagnosis is a tumor (solid), which becomes challenging when there is necrosis and bleeding within the tumor.

#hepatology

#ID

References:

1. Kozielewicz DM, Sikorska K, Stalke P. Liver abscesses – from diagnosis to treatment. Clin Exp Hepatol. 2021 Dec;7(4):329–36. doi: 10.5114/ceh.2021.110998. Epub 2021 Nov 26. PMCID: PMC8977881.

2. Lin AC, Yeh DY, Hsu YH, Wu CC, Chang H, Jang TN, Huang CH. Diagnosis of pyogenic liver abscess by abdominal ultrasonography in the emergency department. Emerg Med J. 2009 Apr;26(4):273-5. doi: 10.1136/emj.2007.049254. PMID: 19307388.

Pulmonary in SJS/TEN

Q: What could be the pulmonary findings in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)?

Answer: sloughing of the bronchial epithelium

SJS/TEN can involve any organ, including the eye, kidney, GI tract, or liver. About one in four patients gets pulmonary involvement. On bronchoscopy, sloughing of the bronchial epithelium can indicate direct pulmonary involvement. Additionally, common complications may include pneumonia, pulmonary edema, atelectasis, and ARDS. These patients have a high chance of respiratory failure requiring a ventilator.

#dermatology

#Allergy-immunology

#pulmonary

References:

1. Wankhade BS, Alrais ZF, Beniamein MMK, Issa LH, Eldelpshany MSA. Acute pulmonary complication of Stevens-Johnson syndrome-toxic epidermal necrolysis overlap. Anaesthesiol Intensive Ther. 2025 Apr 15;57(1):70-72. doi: 10.5114/ait/200234. PMID: 40237533; PMCID: PMC12210361.

2. Lee KCH, Ko JP, Oh CC, Sewa DW. Managing respiratory complications in Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Int J Dermatol. 2022 Jun;61(6):660-666. doi: 10.1111/ijd.15888. Epub 2021 Sep 8. PMID: 34494255.

3. Woo T, Saito H, Yamakawa Y, Komatsu S, Onuma S, Okudela K, Nozawa A, Aihara M, Ikezawa Z, Ishigatsubo Y. Severe obliterative bronchitis associated with Stevens-Johnson syndrome. Intern Med. 2011;50(22):2823-7. doi: 10.2169/internalmedicine.50.5582. Epub 2011 Nov 15. PMID: 22082897.

Proper measurement of BP

Q: While obtaining the blood pressure (BP) via the classical auscultatory method, the cuff should be deflated? - select one

A) 1 mmHg per second

B) 2 mmHg per second

C) 3 mmHg per second

Answer: B

It should always be appreciated that measuring BP via the classical auscultatory method is an art and requires precise external conditions and specific steps to perform. Careless, or in mild words, not following all steps correctly, may give wrong numbers and may harm the patient with an inappropriate prescription (or no prescription) of treatment. Readers are requested to refer pto the proper guidelines/checklists in this regard, but some vital components are:

• Avoid caffeine, exercise, and smoking for at least 30 minutes before measurement
• Empty bladder
• Sitting in a chair (feet on floor, back supported) for >5 minutes
• Remove all clothing covering the location of the cuff placement
• Reliable and calibrated device
• Arm resting on a desk
• The middle of the cuff on the patient's upper arm at the level of the right atrium (the midpoint of the sternum)
• Use the correct cuff size, such that the bladder encircles 80% of the arm
• Inflate the cuff 20 to 30 mmHg above the pulse obliteration pressure.
• Deflate the cuff pressure 2 mmHg per second, and listen for Korotkoff sounds.
• Use an average of ≥2 readings obtained on ≥2 occasions to estimate the individual's BP level

#cardiology

References:

1.  Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. 

2. Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Hypertension 2025; 82:e212.

rumination syndrome

Q: The rumination syndrome is described as recurrent vomiting in mentally disadvantaged children.

A) True

B) False

Answer: B

The rumination syndrome is frequently misdiagnosed as vomiting, gastroparesis, or gastroesophageal reflux disease (GERD). Instead, it is primarily a behavioral disorder. Unlike previously believed, it is not only limited to mentally-disadvantaged children, but it can also occur in normal adolescents and adults.

It requires only two conditions for 3 months for diagnosis (with symptom onset at least 6 months before diagnosis), and is known as the Rome IV criteria.

• Persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing
• Regurgitation is not preceded by retching

Supportive symptoms are:

• Effortless regurgitation events are usually not preceded by nausea
• Regurgitant contains recognizable food that might have a pleasant taste
• The process tends to cease when the regurgitated material becomes acidic

The primary treatment is behavioral modification via diaphragmatic breathing techniques.

#GI

#psychiatry

References:

1. Stanghellini V, Chan FK, Hasler WL, et al. Gastroduodenal Disorders. Gastroenterology 2016; 150:1380.

2. Pomenti S, Katzka DA. Current state of rumination syndrome. Dis Esophagus. 2024 Aug 29;37(9):doae041. doi: 10.1093/dote/doae041. PMID: 38741462.

Bulimia Nervosa - and - cardiac & skeletal muscles toxicity

Case: 22 year old female is admitted to the ICU with supraventricular tachycardia (SVT), premature atrial complexes (PACs), and hypotension. EKG also showed inverted T waves and prolonged QT and PR intervals. FoCUS at the bedside showed pericardial effusion. On exam, the patient appears to have weak skeletal muscle tone, strength, and weak reflexes. Lab showed elevated Liver enzymes. The patient has been previously admitted to the hospital with electrolyte imbalances and has been diagnosed with bulimia nervosa. Patient acknowledged that recently she started using Ipecac.

Answer: About one in five patients with bulimia nervosa may ingest ipecac to induce vomiting. Ipecac contains emetine, which, along with electrolyte imbalances, causes severe cardiac and skeletal muscle myopathy. Emetine is eliminated from patients very slowly. It can be found in urine even after two months of use. Small, chronic doses may have cumulative and fatal toxicity. Moreover, the absorption of emetine is enhanced in patients who become refractory to the emetic effects of the drug with chronic misuse. The worst part is that emetine accumulates in cardiac muscle cells, is toxic and emetine induced cardiomyopathy may be irreversible. Although cases have been reported of reversibility but cardiac dysfunction from associated electrolyte abnormalities is hard to distinguish. The only treatment is supportive care. There is no antidote.

Fortunately, skeletal muscle weaknesses can be reversed, though slowly, with physical therapy as emetine gets eliminated from the body.

#toxicology

References:

1. Effects of ipecac on the heart. N Engl J Med. 1986 May 8;314(19):1253-5. doi: 10.1056/NEJM198605083141914. PMID: 2871487.

2. Steffen KJ, Mitchell JE, Roerig JL, Lancaster KL. The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives. Int J Eat Disord 2007; 40:360.

3. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016; 129:30.

4. Dresser LP, Massey EW, Johnson EE, Bossen E. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatry. 1993 May;56(5):560-2. doi: 10.1136/jnnp.56.5.560. PMID: 8099367; PMCID: PMC1015020.

ETOH treatment

Q: 58 years old male is admitted to the ICU with severe alcohol ketoacidosis (AKA). Patient is now recovering in the ICU. The patient has previously failed many interventions to quit alcohol, and now desires only to reduce his dependence on ETOH, and feels he can't stop it completely. The pharmacologic treatment of ETOH disorder can be carved with the treatment goal to?

A) Complete abstinence 

B) Reduction of use

C) Either

Answer: C

It may be interesting that many patients with Alcohol/ETOH abuse may desire to reduce their dependence only!

Disulfiram is a known pharmacologic treatment when complete abstinence is desired.

In cases where the patient's treatment goal is only the reduction of use, naltrexone, acamprosate, and topiramate can be utilized.

Said all of the above, a trained clinician should take the initiative in treating such a disorder, as these patients frequently have many co-occurring morbidities, a preference for different modalities such as monthly injection versus daily medication, a rate of noncompliance, and a previous history of relapses.

#toxicology

References:

1. Mann K, Aubin HJ, Witkiewitz K. Reduced Drinking in Alcohol Dependence Treatment, What Is the Evidence? Eur Addict Res. 2017;23(5):219-230. doi: 10.1159/000481348. Epub 2017 Sep 22. PMID: 28934736.

2. Henssler J, Müller M, Carreira H, Bschor T, Heinz A, Baethge C. Controlled drinking-non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta-analysis and meta-regression. Addiction. 2021 Aug;116(8):1973-1987. doi: 10.1111/add.15329. Epub 2020 Dec 14. PMID: 33188563.

3. Fukuda T, Nakai M, Murakami M. [Reduction in alcohol consumption as a treatment goal of alcohol dependence: actual conditions in Okinawa]. Nihon Arukoru Yakubutsu Igakkai Zasshi. 2013 Feb;48(1):58-63. Japanese. PMID: 23659006.

HCAP

Q: Health care-associated pneumonia (HCAP) is a critical concept for any clinician to be aware of, as it helps start antibiotics before cultures are available, saves lives, and decreases overall use of inappropriate antibiotics.

A) True

B) False

Answer: B

The category/idea/concept of health care-associated pneumonia (HCAP) has been removed from the 2016 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, as well as the combined 2017 European and Latin American Hospital-acquired pneumonia (HAP) (nosocomial) guidelines.

Previously, HCAP was defined as pneumonia acquired in health care facilities such as Long-Term Acute Care (LTAC), nursing homes, rehab centers, hemodialysis centers, or outpatient clinics, or within 90 days of a hospitalization. The whole purpose was to treat with antibiotics at the early stage of infection, particularly multidrug-resistant (MDR) infections. 

Later studies and evidence have shown that this was not a very prudent approach, as it led to increased, more inappropriate use of broad-spectrum antibiotics. The use of 'big guns' antibiotics was very high in comparison to the risk for MDR pathogens. This negates the concept of 'antibiotics stewardship'.

A new approach returns to the previous practice of treating HCAP as community-acquired pneumonia (CAP), and decides whether to consider MDR pathogens on a case-by-case basis based on prior exposures, risk factors, severity of illness, prior antimicrobial use, comorbidities, and functional status.

#ID

References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

3. Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50.

4. Kollef MH. Health care-associated pneumonia: perception versus reality. Clin Infect Dis 2009; 49:1875.

5. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330.

substernal goiter

Q; 52 years old female from Denmark* presented to ED with sudden enlargement of her known substernal goiter associated with pain. A bedside ultrasound followed by a CT scan confirmed hemorrhage into a goiter. Substernal goiter enlargement tends to do more of what? - select one

A) dysphagia 

B) stridor

Answer: B

Dysphagia is less common in substernal goiter because the esophagus is posteriorly located. An obstructive cervical or substernal goiter can enlarge and press on the trachea; when the tracheal lumen is less than 5 mm, stridor or wheezing at rest is expected. It would be prudent to secure the airway before relieving compression in acute cases. An experienced anesthesiologist should be called, as the margin of error is small.

Other symptoms which may occur are compression of a recurrent laryngeal nerve causing transient or permanent vocal cord palsy, manifesting as hoarseness, phrenic nerve paralysis, Horner's syndrome due to compression of the cervical sympathetic chain, and, in a few cases, jugular vein compression or thrombosis, cerebrovascular steal syndromes, or the superior vena cava syndrome.

#ENT

#endocrinology

#procedures

#surgical-critical-care

References:

1. O’Connor, Eoin, Looney, Michael, Lennon, Emma - Massive retrosternal goitre causing stridor and respiratory distress—a case report - Journal of Emergency and Critical Care Medicine - Vol 9 (March 30, 2025) /, https://jeccm.amegroups.org/article/view/8867

2. Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis 1975; 111:631.

3. Aragón Valera C, Antón Bravo T, Sanchón Rodríguez R, Martínez Bermejo E, Paniagua Ruiz A, Alvarez Santirso R. Dyspnea and stridor due to multinodular goiter in an obese woman. Endocrinol Nutr. 2008 May;55(5):234-6. English, Spanish. doi: 10.1016/S1575-0922(08)70674-0. Epub 2008 Oct 15. PMID: 22967919.

*Denmark epidemiology is consistent with mild-to-moderate iodine-deficient goiter.

IG and HG

Q: What's the difference between immune globulin (IG) and hyperimmune globulin (HG)?

Answer:

Immune globulin is derived from the plasma of random donors. It can be used for an array of disorders, including primary and secondary immune deficiency states, as well as many autoimmune and inflammatory disorders. It is mainly given intravenously (IVIG), but can also be given subcutaneously (SCIG) or intramuscularly (IMIG). Additives and stabilizers are usually added to the product.

Hyperimmune globulin refers to immune globulin obtained from the plasma of individuals with high titers of specific antibodies to certain pathogens, or from individuals immunized or naturally exposed to particular antigens. In some diseases, it can also be obtained from animals.

#immunology

References:

1. Schroeder HW Jr, Cavacini L. Structure and function of immunoglobulins. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S41-52. doi: 10.1016/j.jaci.2009.09.046. PMID: 20176268; PMCID: PMC3670108.

2. Novaretti MC, Dinardo CL. Immunoglobulin: production, mechanisms of action and formulations. Rev Bras Hematol Hemoter. 2011;33(5):377-82. doi: 10.5581/1516-8484.20110102. PMID: 23049343; PMCID: PMC3415776.

3. Pati I, Cruciani M, Candura F, Massari MS, Piccinini V, Masiello F, Profili S, De Fulvio L, Pupella S, De Angelis V. Hyperimmune Globulins for the Management of Infectious Diseases. Viruses. 2023 Jul 13;15(7):1543. doi: 10.3390/v15071543. PMID: 37515229; PMCID: PMC10385259.

allopurinol and heart

Q: Allopurinol can be used as an anti-anginal drug.

A) True

B) False

Answer: A

There is weak evidence that Allopurinol, a xanthine oxidase inhibitor, may be beneficial in stable angina.

It significantly increased the median time to ST depression and the median total exercise time when compared to placebo.

The mechanism of action is proposed to be improved endothelium-dependent vasodilation and the abolition of oxidative stress. The suggested dose is 600 mg per day.

#cardiology

#pharmacology

References:

1. Noman A, Ang DS, Ogston S, et al. Effect of high-dose allopurinol on exercise in patients with chronic stable angina: a randomised, placebo controlled crossover trial. Lancet 2010; 375:2161.

2. Rajendra NS, Ireland S, George J, et al. Mechanistic insights into the therapeutic use of high-dose allopurinol in angina pectoris. J Am Coll Cardiol 2011; 58:820.

Urine Dipstick in the Rapid Diagnosis of Septic Arthritis

Q: What is the urine "dipstick" test, which can help in the diagnosis of septic arthritis?

Answer:

The two confirmatory (aka gold standard) tests for diagnosing a septic joint are synovial fluid culture or synovial biopsy. Said that many times: both are hard to obtain or require a wait for results.

Many adjuvant tests help to establish a probable diagnosis, along with clinical signs and other tests such as blood counts and blood cultures. Recently, nucleic acid amplification tests like polymerase chain reaction (PCR) and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectometry have been used at advanced centers, particularly when routine cultures are negative but clinical suspicion is high. But these tests are time-consuming and not very cost-effective.

Interestingly, a simple, quick, and highly cost-effective urine "dipstick" test to measure synovial fluid leukocyte esterase can be used as an adjunct to diagnose septic arthritis (reference 1 for details).

#ID

#laboratory-medicine

#rheumatology

References:

1. Aslani H, Pasha Zanoosi MR, Navali AM. Urine Dipstick Leukocyte Esterase in the Rapid Diagnosis of Septic Arthritis. Arch Bone Jt Surg. 2022 Jan;10(1):38-44. doi: 10.22038/ABJS.2021.47573.2334. PMID: 35291247; PMCID: PMC8889425.

2. Dey M, Al-Attar M, Peruffo L, et al. Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1740.

2. Sanpera I, Salom M, Alves C, Eastwood D. Diagnosis and management of septic arthritis: A current concepts review. J Child Orthop. 2025 Jan 2;19(1):14-19. doi: 10.1177/18632521241311302. PMID: 39758603; PMCID: PMC11694264.

Remdesivir and Kidney

Q: A 67-year-old male with renal insufficiency with a baseline Glomerular Filtration Rate (GFR) of 34 is admitted to the ICU with COVID-19 during the 2025 flu season. Remdesivir is contraindicated in this patient due to acute-on-chronic renal failure.

A) True

B) False

Answer: B

Remdesivir can be safely used in patients with acute kidney injury (AKI) and chronic kidney disease (CKD) without fear of worsening kidney function, including those on dialysis. There is no need to adjust the dose. Previously, it was suggested that the cyclodextrin vehicle of this drug can accumulate in renal failure, but concern seems to be unfounded, at least clinically. 

Also, Remdesivir can be relatively safely used in decompensated liver disease. Care should be taken to check baseline Liver Function Tests (LFTs) and to monitor them while remdesivir is in use. It can be safely used till alanine aminotransferase (ALT) elevation is below >10 times the upper limit of normal.

#ID

#pharmacology

#nephrology

#hepatology

References:

1. Thakare S, Gandhi C, Modi T, et al. Safety of Remdesivir in Patients With Acute Kidney Injury or CKD. Kidney Int Rep 2021; 6:206.

2. Seethapathy R, Wang Q, Zhao S, et al. Effect of remdesivir on adverse kidney outcomes in hospitalized patients with COVID-19 and impaired kidney function. PLoS One 2023; 18:e0279765.

3. Sise ME, Santos JR, Goldman JD, et al. Efficacy and Safety of Remdesivir in People With Impaired Kidney Function Hospitalized for COVID-19 Pneumonia: A Randomized Clinical Trial. Clin Infect Dis 2024; 79:1172.

4. Sabers AJ, Williams AL, Farley TM. Use of remdesivir in the presence of elevated LFTs for the treatment of severe COVID-19 infection. BMJ Case Rep. 2020 Oct 31;13(10):e239210. doi: 10.1136/bcr-2020-239210. PMID: 33130588; PMCID: PMC10577715.

5. Shah S, Ackley TW, Topal JE. Renal and Hepatic Toxicity Analysis of Remdesivir Formulations: Does What Is on the Inside Really Count? Antimicrob Agents Chemother. 2021 Sep 17;65(10):e0104521. doi: 10.1128/AAC.01045-21. Epub 2021 Jul 26. PMID: 34310212; PMCID: PMC8448111.

Eye symptoms in MS

Q: In a typical attack of multiple sclerosis (MS), visual loss is usually associated with? select one

A) pain

B) no pain

Answer: A

The typical presentation of multiple sclerosis (MS), also called clinically isolated syndrome (CIS), is usually the first clinical episode suggestive of MS. Visual loss due to optic neuritis typically has three characteristic symptoms:

• monocular visual loss consisting of visual blurring or scotoma
• reduced color vision
• pain with eye movements

On exam, there is a relative afferent pupillary defect on examination.

#neurology

# ophthalmology

References:

1. Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17:162.

2. Brownlee WJ, Hardy TA, Fazekas F, Miller DH. Diagnosis of multiple sclerosis: progress and challenges. Lancet 2017; 389:1336.

3. Kale N. Optic neuritis as an early sign of multiple sclerosis. Eye Brain. 2016 Oct 26;8:195-202. doi: 10.2147/EB.S54131. PMID: 28539814; PMCID: PMC5398757.

VAP

Q: Ventilator-associated pneumonia (VAP) also includes patients who develop nosocomial pneumonia (HAP) within 48 hours of extubation.

A) True 

B) False

Answer: A

The term ventilator-associated pneumonia (VAP) can be a little misleading, as it suggests that it counts only pneumonia that occurs while on a ventilator. Patients who are already extubated but still within 48 hours and develop pneumonia are counted as VAP.

Several different terminologies have been designated to categorize these patients. The basic idea for such a classification is that there may be various kinds of 'bugs', often multidrug-resistant (MDR), that are frequently encountered in these different patient categories and can help start appropriate antibiotics before culture results are available.

Hospital-acquired pneumonia (HAP), also known as nosocomial pneumonia, is defined as pneumonia that occurs 48 hours or more after hospital admission and did not appear to be incubating at the time of admission. 

VAP and non-ventilator-associated HAP (nvHAP) are types of HAP.

#ID

#pulmonary

#ventilators

References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Mumtaz H, Saqib M, Khan W, Ismail SM, Sohail H, Muneeb M, Sheikh SS. Ventilator associated pneumonia in intensive care unit patients: a systematic review. Ann Med Surg (Lond). 2023 May 12;85(6):2932-2939. doi: 10.1097/MS9.0000000000000836. PMID: 37363470; PMCID: PMC10289715.

Hallucinations in Dementia with Lewy bodies

Q: 78 years old male is admitted to the ICU with acute psychosis kind of symptoms. The patient has been previously diagnosed with dementia with Lewy bodies (DLB). Which is more common in DLB? - select one

A) Auditory hallucinations

B) Visual hallucinations

Answer: B

The three major core clinical features of DLB are:

• cognitive fluctuations
• visual hallucinations, and 
• parkinsonism

Rapid eye movement (REM) sleep behavior disorder is also described as an early sign of DLB. Genetic predisposition is highly associated.

#psychiatry

#neurology

#geriatrics

References:

1. Devenyi RA, Hamedani AG. Visual dysfunction in dementia with Lewy bodies. Curr Neurol Neurosci Rep. 2024 Aug;24(8):273-284. doi: 10.1007/s11910-024-01349-8. Epub 2024 Jun 22. PMID: 38907811; PMCID: PMC11258179.

2. Ballard C, McKeith I, Harrison R, O'Brien J, Thompson P, Lowery K, Perry R, Ince P. A detailed phenomenological comparison of complex visual hallucinations in dementia with Lewy bodies and Alzheimer's disease. Int Psychogeriatr. 1997 Dec;9(4):381-8. doi: 10.1017/s1041610297004523. PMID: 9549588.

3. Rampello L, Cerasa S, Alvano A, Buttà V, Raffaele R, Vecchio I, Cavallaro T, Cimino E, Incognito T, Nicoletti F. Dementia with Lewy bodies: a review. Arch Gerontol Geriatr. 2004 Jul-Aug;39(1):1-14. doi: 10.1016/j.archger.2003.11.003. PMID: 15158576.

Azithromycin's longer effect

Q: Why is a short course of azithromycin considered relatively sufficient in comparison to other macrolides?

Answer: For most infections, a once-daily 5-day regimen of azithromycin is considered as effective as 10-day courses of the other macrolides.

This is because azithromycin has a long intracellular half-life (40 to 68 hours) and a slow rate of release from tissue sites. For example, a 2-gram extended-release oral suspension of azithromycin is given as a single dose due to its long half-life. The only caution is to take the extended-release suspension 1 hour before or 2 hours after meals, and to consume it within 12 hours of reconstitution.

#pharmacology

#ID

References:

1. Azithromycin extended-release (Zmax) for sinusitis and pneumonia. Med Lett Drugs Ther 2005; 47:78.

2. Crokaert F, Hubloux A, Cauchie P. A Phase I Determination of Azithromycin in Plasma during a 6-Week Period in Normal Volunteers after a Standard Dose of 500mg Once Daily for 3 Days. Clin Drug Investig. 1998;16(2):161-6. doi: 10.2165/00044011-199816020-00009. PMID: 18370534.

A note on pulse methylprednisolone and arrhythmias

A note on pulse methylprednisolone and arrhythmias

Glucocorticoids, particularly high doses, tend to cause arrhythmias like atrial flutter and fibrillation, irrespective of underlying pulmonary or cardiovascular disease. Sinus bradycardia has been reported, particularly with high "pulse" dose.  Although sudden death has also been attributed during pulse infusions of glucocorticoids, it's difficult to determine, as most of these patients have underlying severe comorbidities.

Cardiac monitoring is recommended, particularly when there is an underlying cardiac disease, diuretics on board, or associated electrolyte derangements are present.

#pharmacology

#cardiology

#pulmonary

References:

1. White KP, Driscoll MS, Rothe MJ, Grant-Kels JM. Severe adverse cardiovascular effects of pulse steroid therapy: is continuous cardiac monitoring necessary? J Am Acad Dermatol 1994; 30:768.

2. Christiansen CF, Christensen S, Mehnert F, et al. Glucocorticoid use and risk of atrial fibrillation or flutter: a population-based, case-control study. Arch Intern Med 2009; 169:1677.

3. Akikusa JD, Feldman BM, Gross GJ, et al. Sinus bradycardia after intravenous pulse methylprednisolone. Pediatrics 2007; 119:e778.

Four classes of acutely incarcerated/strangulated groin hernia

Q: What are the four classes of acutely incarcerated/strangulated groin hernia?

Answer: Acutely incarcerated or strangulated groin hernia are divided into four classes to determine whether to use mesh and which kind of mesh should be used while repairing an acutely incarcerated or strangulated groin hernia. This classification is per the Centers for Disease Control and Prevention (CDC).

Class 1 (clean) – Bowel incarceration but not strangulation, and there is no need for bowel resection. Synthetic mesh should be used to repair the hernia. 

Class 2 (clean-contaminated) – For patients with bowel strangulation and/or a concomitant bowel resection, the wound should be classified as clean-contaminated, and a synthetic, monofilament, large-pore mesh should be used to repair the hernia.

Class 3 (contaminated) and class 4 (dirty-infected) – For patients with bowel perforation and/or abscess formation, the wound should be classified as contaminated or dirty-infected, in which case no mesh should be used to repair the hernia. Once source control has been achieved, the hernia can be repaired with or without mesh, depending on the patient's clinical condition. 

#surgical-Critical-Care

References:

1. HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018; 22:1.

2. Elsebae MM, Nasr M, Said M. Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study. Int J Surg 2008; 6:302.

3. Hentati H, Dougaz W, Dziri C. Mesh repair versus non-mesh repair for strangulated inguinal hernia: systematic review with meta-analysis. World J Surg 2014; 38:2784.

pleural pathology and lung cancer

Q: Which of the pleural findings on imaging is usually more of a sign of concern for cancer?

A) Nodularity

B) Plaque

Answer: A

Any of the following findings in the imaging should raise suspicion of lung cancer.

• Lesions >3 cm that are new
• Measurable growth in any nodule or mass from the previous
• Pleural nodularity 
• Asymmetric or significantly enlarged hilar or paratracheal nodes
• An endobronchial lesion
• An area of consolidation thought to be pneumonia that fails to resolve with medical management

Pleural plaques usually indicate significant asbestos exposure.

#pulmonary

#oncology

#radiology

References:

1. Del Giudice ME, Young SM, Vella ET, Ash M, Bansal P, Robinson A, Skrastins R, Ung Y, Zeldin R, Levitt C. Guideline for referral of patients with suspected lung cancer by family physicians and other primary care providers. Can Fam Physician. 2014 Aug;60(8):711-6, e376-82. PMID: 25122814; PMCID: PMC4131959.

2. Hyldgaard C, Trolle C, Harders SMW, Engberg H, Rasmussen TR, Møller H. Increased use of diagnostic CT imaging increases the detection of stage IA lung cancer: pathways and patient characteristics. BMC Cancer. 2022 Apr 27;22(1):464. doi: 10.1186/s12885-022-09585-2. PMID: 35477356; PMCID: PMC9047294.

3. Erasmus LT, Strange TA, Agrawal R, Strange CD, Ahuja J, Shroff GS, Truong MT. Lung Cancer Staging: Imaging and Potential Pitfalls. Diagnostics (Basel). 2023 Nov 1;13(21):3359. doi: 10.3390/diagnostics13213359. PMID: 37958255; PMCID: PMC10649001.

platelets storage

Q: Platelets are routinely stored at? - select one

A) cold temperature

B) room temperature 

Answer: B

Platelets are best stored at room temperature because cold temperatures induce clustering of von Willebrand factor (vWF) receptors on the platelet surface. It also causes morphological changes in platelets, leading to enhanced hepatic macrophage clearance and decreased platelet survival in the recipient. All platelets remain metabolically active at room temperature. Platelet bags are designed to allow oxygen and carbon dioxide gas exchange. Citrate is added to prevent clotting and to maintain proper pH. Dextrose is also added as an energy source.

One caveat a clinician should be aware of is that the risk of bacterial infection increases with storage duration. The shelf-life of platelets stored at room temperature is generally only 5 days, counting from midnight on the day of collection. This can be increased to seven days if they use a container approved by the FDA for seven-day storage - AND if the platelet unit(s) are subsequently tested for infection using a bacterial detection device approved and labeled by the FDA as a "safety measure."

#transfusion-medicine

#hematology

References:

1. McCullough J. Overview of platelet transfusion. Semin Hematol 2010; 47:235.

2. Murphy S, Gardner FH. Effect of storage temperature on maintenance of platelet viability--deleterious effect of refrigerated storage. N Engl J Med 1969; 280:1094.

3. Hoffmeister KM, Felbinger TW, Falet H, et al. The clearance mechanism of chilled blood platelets. Cell 2003; 112:87.

4. Rumjantseva V, Grewal PK, Wandall HH, et al. Dual roles for hepatic lectin receptors in the clearance of chilled platelets. Nat Med 2009; 15:1273.

Thiazide therapy in diabetes insipidus

Q: One of the reasons for the effectiveness of thiazide diuretics is via weight loss in arginine vasopressin resistance (AVP-R), also known as nephrogenic diabetes insipidus.

A) True

B) False

Answer: A

Thiazide diuretics are effective pharmacological therapies for AVP-R.

The treatment modality is volume depletion induced by a low-sodium diet and a thiazide diuretic such as hydrochlorothiazide, 25 mg once or twice daily (or its equivalent). This causes weight loss. As little as 1 to 1.5 kg of weight loss reduces urine output by more than 50 percent, from 10 L/day to below 3.5 L/day. This simple synergistic modality was discovered more than six decades ago, and still works well.

The mechanism of action (MoA) of thiazide diuretics is also mediated by a hypovolemia-induced increase in proximal sodium and water reabsorption, thereby diminishing water delivery to ADH-sensitive collecting tubular segments and reducing urine output. 

Another advantage of thiazides is to decrease the likelihood of hypoglycemia in patients who are also treated with chlorpropamide. It can be used in combination.

#nephrology

#endocrinology

References:

1. Earley LE, Orloff J. THE MECHANISM OF ANTIDIURESIS ASSOCIATED WITH THE ADMINISTRATION OF HYDROCHLOROTHIAZIDE TO PATIENTS WITH VASOPRESSIN-RESISTANT DIABETES INSIPIDUS. J Clin Invest 1962; 41:1988.

2. Webster B, Bain J. Antidiuretic effect and complications of chlorpropamide therapy in diabetes insipidus. J Clin Endocrinol Metab 1970; 30:215.

IVT and stroke severity

Q: The high severity of neurologic deficit in stroke should be considered for intravenous thrombolysis (IVT) due to the high risk of intracerebral hemorrhage.

A) True

B) False

Answer: B

The severity of neurologic deficit is measured by the National Institutes of Health Stroke Scale (NIHSS) score. Although the high severity of neurologic deficit is indeed associated with high risk of intracerebral bleed, stroke severity alone should not be used to determine a patient's inclusion or exclusion for IVT therapy. The benefit of IVT is similar regardless of stroke severity.

#neurology

References:

1. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384:1929.

2. Whiteley WN, Emberson J, Lees KR, et al. Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 2016; 15:925.

3. Whiteley WN, Slot KB, Fernandes P, et al. Risk factors for intracranial hemorrhage in acute ischemic stroke patients treated with recombinant tissue plasminogen activator: a systematic review and meta-analysis of 55 studies. Stroke 2012; 43:2904.

Thiamine and Lactate

Q: Lactic Acidosis (LA) due to thiamine deficiency may not respond to intravenous sodium bicarbonate.

A) True

B) False

Answer: A

One of the hallmarks of LA secondary to thiamine deficiency is that it may not respond to IV sodium bicarbonate, but only and rapidly to IV thiamine administration.

Thiamine plays an integral role in the metabolism of lactic acidosis. It is a necessary cofactor for two key enzymes in the tricarboxylic acid cycle: pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase. LA secondary to thiamine deficiency is ubiquitous in patients in the ICU receiving total parenteral nutrition (TPN), which usually has a high glucose load.

Overall, there is some weak evidence that IV thiamine enhances the lactate clearance in ICU patients.

#metabolism

#acid-base

References:

1. Centers for Disease Control and Prevention (CDC). Lactic acidosis traced to thiamine deficiency related to nationwide shortage of multivitamins for total parenteral nutrition -- United States, 1997. MMWR Morb Mortal Wkly Rep 1997; 46:523.

2. Salvatori G, Mondì V, Piersigilli F, et al. Thiamine Deficiency in a Developed Country: Acute Lactic Acidosis in Two Neonates Due to Unsupplemented Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2016; 40:886.

3. Woolum JA, Abner EL, Kelly A, et al. Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock. Crit Care Med 2018; 46:1747.

Temperature in Myxedema coma

Q: The severity of the hypothermia is related to mortality in Myxedema coma.

A) True

B) False

Answer: A

The seven cardinal signs, though not all may be present in myxedema coma, are:

1. Decreased mental status
2. Hypothermia
3. Bradycardia
4. Hyponatremia
5. Hypoglycemia
6. Hypotension
7. Evidence of Precipitating illness/factor

The severity of the hypothermia is very much related to mortality in severe hypothyroidism, so the level of hypothermia should be established with a reliable temperature-measuring device.

#endocrinology

References:

1. Yamamoto H, Hongo T, Nojima T, Obara T, Kosaki Y, Ageta K, Tsukahara K, Yumoto T, Nakao A, Naito H. Successfully treated case of severe hypothermia secondary to myxedema coma. Acute Med Surg. 2023 Mar 14;10(1):e828. doi: 10.1002/ams2.828. PMID: 36936740; PMCID: PMC10014422.

2. Zhang Y, Chu L, Han H. Myxedema coma: challenges and future directions, a systematic survey and review. Thyroid Res. 2025 Oct 7;18(1):48. doi: 10.1186/s13044-025-00268-1. PMID: 41053871; PMCID: PMC12502585.

glucocorticoid and psychosis

Q: Which of the glucocorticoids is least likely to induce psychosis? - select one

A) Methylprednisolone

B) Dexamethasone

C) Betamethasone

D) Hydrocortisone

Answer: B

Corticosteroids are well known to cause insomnia, irritability, impaired concentration, mood changes, and, in severe cases, florid steroid psychosis. Stopping the drug is the best option, but if glucocorticoids are absolutely needed, there is some weak evidence that dexamethasone is least likely to induce psychosis. However, it is not a foolproof statement! 

Adjuvant use of antipsychotic agents may help. Lithium is particularly effective in steroid psychosis. 

#psychiatry

#pharmacology

References:

1. Huynh G, Reinert JP. Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases. J Pharm Technol. 2021 Apr;37(2):120-126. doi: 10.1177/8755122520978534. Epub 2020 Dec 2. PMID: 34752563; PMCID: PMC7953074.

2.  Janes M, Kuster S, Goldson TM, Forjuoh SN. Steroid-induced psychosis. Proc (Bayl Univ Med Cent). 2019 Jul 22;32(4):614-615. doi: 10.1080/08998280.2019.1629223. PMID: 31656440; PMCID: PMC6793974.

3. Julio A Chalela, Michael J Aminoff, Janet L Wilterdink - Acute toxic-metabolic encephalopathy in adults - last updated: May 22, 2024. Link: https://www.uptodate.com/contents/acute-toxic-metabolic-encephalopathy-in-adults (last accessed : November 3, 2025) 

4. Falk WE, Mahnke MW, Poskanzer DC. Lithium prophylaxis of corticotropin-induced psychosis. JAMA. 1979 Mar 9;241(10):1011-2. PMID: 216818.

Pitfalls in diagnosing SS

Q: All of the following conditions EXCEPT ONE may bar patients from diagnosis of Sjögren's syndrome (SS) and participation in SS studies or therapeutic trials because of overlapping clinical features or interference with criteria tests? - select one

A) Positive Anti-Ro/SSA

B) History of head and neck radiation 

C) Active hepatitis C infection 

D) Sarcoidosis

E) Amyloidosis

Answer: A

Positive Anti-Ro/SSA actually is a part of diagnosis of SS. The five major components to diagnose SS are:

• Labial salivary gland with focal lymphocytic sialadenitis and focus score of ≥1 foci/4 mm2
• Anti-Ro/SSA positive
• Ocular staining score ≥5 (or van Bijsterveld score ≥4) in at least one eye
• Schirmer test ≤5 mm/5 minutes in at least one eye
• Unstimulated whole saliva flow rate ≤0.1 mL/minute

Prior diagnosis of any of the following conditions would exclude diagnosis of SS and participation in SS studies or therapeutic trials because of overlapping clinical features or interference with criteria tests:

• History of head and neck radiation treatment
• Active hepatitis C infection (with positive PCR)
• Acquired immunodeficiency syndrome
• Sarcoidosis
• Amyloidosis
• Graft-versus-host disease
• IgG4-related disease

#rheumatology

References:

1. Daniels TE, Cox D, Shiboski CH, et al. Associations between salivary gland histopathologic diagnoses and phenotypic features of Sjögren's syndrome among 1,726 registry participants. Arthritis Rheum 2011; 63:2021.

2. Whitcher JP, Shiboski CH, Shiboski SC, et al. A simplified quantitative method for assessing keratoconjunctivitis sicca from the Sjögren's Syndrome International Registry. Am J Ophthalmol 2010; 149:405.

3. Van Bijsterveld OP. Diagnostic tests in the Sicca syndrome. Arch Ophthalmol 1969; 82:10.

4. Navazesh M, Kumar SK, University of Southern California School of Dentistry. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 2008; 139 Suppl:35S.

5. Shiboski CH, Shiboski SC, Seror R, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren's syndrome: A consensus and data-driven methodology involving three international patient cohorts. Ann Rheum Dis 2017; 76(1):9-16. 

Size of PTX

Q: While evaluating pneumothorax (PTX) on Chest-X-Ray (CXR), a distance of ≥3 cm between the pleural line and the chest wall at the level of the apex roughly correlates with a 50 percent pneumothorax.

A) True

B) False

Answer: A

Although not an exact science, at least in the United States, PTX ≥3 cm between the pleural line and the chest wall at the level of the apex is usually considered sufficient to distinguish a small from a large PTX. In Europe, physicians use a cutoff of ≥2 cm at the hilum. 

Clinical symptoms play a significant role in draining PTX and largely depend on the clinician's discretion.

#procedures

References:

1. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax 2023; 78:1143.

2. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590.

3. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii18.

4. Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015; 3:578.

5. Yoon J, Sivakumar P, O'Kane K, Ahmed L. A need to reconsider guidelines on management of primary spontaneous pneumothorax? Int J Emerg Med 2017; 10:9.

RCVS

Case: 44 years old female is admitted to the ICU with severe, sudden headache in the occipital region, associated with nausea and photosensitivity, triggered after sexual activity and orgasm. MRI of the brain showed vasogenic edema and sulcal hyperintensities on fluid-attenuated inversion recovery (FLAIR) (dot sign). Patient gets diagnosed with reversible cerebral vasoconstriction syndrome (RCVS). As primary angiitis of the central nervous system (PACNS) is also under consideration, administering glucocorticoids should be considered.

A) True

B) False

Answer: B

Although PACNS shares various features with RCVS, administering glucocorticoids is not recommended. It is vital to perform a thorough differential diagnosis between the two conditions by using angiography and the RCVS-2 score. A classic clinical difference is that PACNS usually have an insidious progressive clinical course with chronic headaches and rarely have a thunderclap headache, which is typical of RCVS. A neurologist should be consulted for such a critical differential. 

Glucocorticoids are associated with worse outcomes in RCVS. Fortunately, a period of observation after a dramatic presentation provides time to differentiate between the two situations and does not significantly affect the outcome by delaying glucocorticoid administration. Empiric glucocorticoid therapy should be carried out only if there is a rapidly worsening clinical course while the diagnosis remains uncertain. 

Aneurysmal subarachnoid hemorrhage is another differential to be considered closely. Angiography is an essential tool..

#neurology

References:

1. Singhal AB. Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment. Int J Stroke 2023; 18:1151.

2. Singhal AB, Hajj-Ali RA, Topcuoglu MA, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol 2011; 68:1005.

3. Singhal AB, Topcuoglu MA. Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome. Neurology 2017; 88:228.

4. Ribas MZ, Paticcié GF, de Medeiros SDP, de Oliveira Veras A, Noleto FM, Dos Santos JCC. Reversible cerebral vasoconstriction syndrome: literature review. Egypt J Neurol Psychiatr Neurosurg. 2023;59(1):5. doi: 10.1186/s41983-023-00607-9. Epub 2023 Jan 11. PMID: 36647436; PMCID: PMC9833030.