CVP via Jugular veins

Q: Which of the following veins can be used to estimate jugular venous pressure (JVP) - select one

A) internal jugular (IJ) 

B) external jugular (EJ)

C) both

Answer: C

Traditionally, the IJ vein is used at the bedside to assess the volume status or Right Atrial Pressure clinically. It is larger in diameter, less tortuous, and has no valves.

However, despite its limitations, EJ should also be evaluated simultaneously as the pulsation of the external jugular vein is more easily seen, and inspection of this venous pulse alone has been shown to correlate with direct measurements made by a central venous catheter positioned in the right atrium.

#hemodynamic

Reference:

Vinayak AG, Levitt J, Gehlbach B, et al. Usefulness of the external jugular vein examination in detecting abnormal central venous pressure in critically ill patients. Arch Intern Med 2006; 166:2132.

Stigmata of liver cirrhosis

Q: What are Muehrcke's nails?

Answer: Muehrcke's nails, also called Muehrcke's lines or Muehrcke's striae, are white bands across the second, third, and fourth fingernails. In other words, they are the manifestations of leukonychia due to an abnormality in the vasculature of the nail bed. This is one of the stigmata of liver cirrhosis but can occur in other diseases such as nephrotic syndrome, glomerulonephritis, malnutrition, and in mountain climbers.

The objective of this question is to highlight the importance of (vanishing art of) physical exams in clinical medicine. 

The authors of this website use liver cirrhosis as an example here. Liver cirrhosis is a classic disease where history and physical exam can establish the diagnosis without any labs or imaging, though it should be done to re-confirm the diagnosis. Some of the classic stigmata of cirrhosis are: 

• jaundice
• spider angiomas (or nevi or telangiectasias)
• palmar erythema
• pruritus
• xerosis
• xanthelasma
• paper money skin
• muehrcke's nails
• hepatomegaly 
• ascites
• caput medusa
• splenomegaly
• dupuytren's contracture
• gynecomastia
• scant chest hair and axillary hair 
• asterixis
• fetor hepaticus

#physical-exam

#hepatology

#nephrology

References:

1. MUEHRCKE RC. The finger-nails in chronic hypoalbuminaemia; a new physical sign. Br Med J. 1956 Jun 9;1(4979):1327-8. doi: 10.1136/bmj.1.4979.1327. PMID: 13316143; PMCID: PMC1980060.

2. Schwartz RA, Vickerman CE. Muehrcke's lines of the fingernails. Arch Intern Med. 1979 Feb;139(2):242. PMID: 434982.

3. Smith A, Baumgartner K, Bositis C. Cirrhosis: Diagnosis and Management. Am Fam Physician. 2019 Dec 15;100(12):759-770. PMID: 31845776.

GBS in HIV

Q: Guillain-Barré syndrome(GBS) tends to occur in ΗІV infection during which phase? - select one

A) early

B) late

Answer: A

Although GBS can occur in any stage of НΙV infection, but it tends to occur in very early phase. It is thought to be due to acute HІV seroconversion and following immune reconstitution syndrome from the highly active antiretroviral therapy.

#neurology

#ID

Reference:

Piliero PJ, Fish DG, Preston S, et al. Guillain-Barré syndrome associated with immune reconstitution. Clin Infect Dis 2003; 36:e111.

Rasmussen's aneurysm

Q: What is Rasmussen's aneurysm?

Answer: Rasmussen's aneurysm is a pulmonary artery aneurysm adjacent to or within a tuberculous cavity. It may rupture and lead to fatal hemoptysis. Rasmussen's aneurysm is caused by weakening of the pulmonary artery wall from adjacent cavitary tuberculosis.

#pulmonary

#ID

References:

1. Chatterjee K, Colaco B, Colaco C, Hellman M, Meena N. Rasmussen's aneurysm: A forgotten scourge. Respir Med Case Rep. 2015 Aug 12;16:74-6. doi: 10.1016/j.rmcr.2015.08.003. PMID: 26744661; PMCID: PMC4681976.

2. Marak JR, Kumar T, Gara H, Dwivedi S. Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis. Respir Med Case Rep. 2023 Jul 20;45:101897. doi: 10.1016/j.rmcr.2023.101897. PMID: 37577119; PMCID: PMC10413191.

3. Fadul KY, Alsayed A, Abdalla E, Mohamed RS, Salman AM, Meer A, Fadul A. Rasmussen's Aneurysm in Active Pulmonary Tuberculosis: A Case Report. Cureus. 2024 Aug 29;16(8):e68148. doi: 10.7759/cureus.68148. PMID: 39347312; PMCID: PMC11438579.

Cryo-poor plasma

Q: 43 year old female is transferred to ICU with diagnosis of thrombocytopenic purpura (TTP). Looking at previous records, you found a similar episode 4 years ago. It is mentioned that patient didn't respond to regular plasma exchange and required cryo-poor plasma exchange. What is cryo-poor plasma? 

 Answer: Cryo-poor plasma or cryosupernatant refers to plasma from which cryoprecipitate has been removed. The resulting plasma has reduced Factor VIII, von Willebrand factor, Factor XIII, fibronectin, and fibrinogen levels. Cryo-poor plasma may treat relapsing TTP, for which regular plasma exchange is ineffective. 

The rationale for using cryo-poor plasma in these refractory patients is that no additional von Willebrand factor will be administered to these patients who already have too much von Willebrand factor activity due to the presence of extra-large multimers of vWf. Caution: It is not a component regularly stocked in the blood bank. Usually, it will require special preparation and advance notice.

 

#hematology 

 Reference: 

Marcela P. Mafra, Maria Meritxell Roca Mora, Amanda Godoi, Andres Valenzuela - Cryoprecipitate-Poor Plasma Instead of Fresh Frozen Plasma As Replacement Therapy in Thrombotic Thrombocytopenic Purpura: A Systematic Review and Meta-Analysis - Blood (2023) 142 (Supplement 1): 2629.- https://doi.org/10.1182/blood-2023-188500

Anaphylaxis after rectal exam

Case: 54 years old male is admitted to ICU with pneumonia. Patient is found to be moderately anemic. To be complete in evaluation and to rule out possible GI bleed, you asked resident to do rectal exam for guaiac stool. Resident performed rectal exam with latex-free gloves and surgilube (surgical lubricant). 10 minutes later patient coded with severe anaphylactic reaction. What could be a reason assuming no new medication administered?

Answer: Possible allergic reaction to Chlorhexidine

Surgilubes (surgical lubricants, aka KY Jelly) are usually considered innocuous compounds, but they contain chlorhexidine. Patients with severe allergies to chlorhexidine may react badly, particularly if it enters blood circulation after a rectal exam.

#allergy-immunology

#physical exam

References:

1. A Case of Anaphylaxis to Chlorhexidine during Digital Rectal Examination - J Korean Med Sci. 2008 June; 23(3): 526–528.

2. Anaphylaxis to the chlorhexidine component of Instillagel®: a case series - Advance Access published online on November 5, 2008, - British Journal of Anaesthesia

3. Chlorhexidine anaphylaxis in Auckland - Br. J. Anaesth., May 1, 2009; 102(5): 722 - 723.

4. Chlorhexidine anaphylaxis: case report and review of the literature - Contact Dermatitis. 2004 Mar;50(3):113-6

Hypotensive symptoms (ACE-I vs ARB)

Q: 58 years old noncompliant male is admitted to ICU with hypertensive crisis. He has improved after intravenous infusion of anti-hypertensive. Now ICU team is considering to switch over his IV anti-hypertensive to oral. Because of his previous history of congestive heart failure (CHF) and diabetes, ACE-Inhibitor (ACE-I) or angiotensin II receptor blockers (ARBs) are under consideration. Another factor to consider is autonomic dysfunction because of his diabetes. Which group of drugs are more prone to cause hypotensive symptoms? - select one

A) ACE-Is

B) ARBs

Answer: B

ARBs have an advantage over ACE-Is when it comes to cough and angioedema. But, hypotensive symptoms are more common with ARBs.

In patients who may have underlying autonomic dysfunction (like our patient in this question), it can be severe. It may require permanent discontinuation. This effect persists for a while after discontinuation (see reference #2). A desirable 'washout period' should be taken into consideration before exposing a patient to any such other risk (see reference #3)

#hemodynamic

#pharmacology

References:

1. ONTARGET Investigators, Yusuf S, Teo KK, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008; 358:1547.

2. Lee JH, Kim YY, Heo HJ, Kim G, Oh C. Severe refractory hypotension during induction of general anesthesia in patient after 48 hours of azilsartan discontinuation: A case report. Medicine (Baltimore). 2023 Nov 24;102(47):e36126. doi: 10.1097/MD.0000000000036126. PMID: 38013296; PMCID: PMC10681524.

3. Hojo T, Shibuya M, Kimura Y, Otsuka Y, Fujisawa T. Refractory Hypotension During General Anesthesia Despite Withholding Telmisartan. Anesth Prog. 2020 Jun 1;67(2):86-89. doi: 10.2344/anpr-67-02-02. PMID: 32633774; PMCID: PMC7342806.

H2blockers and heart

Q; 42 years old male is admitted to ICU with Small Bowel Obstruction. Patient is made NPO. Also, famotidine is prescribed as an intravenous bid dose. During the administration of IV famotidine, the patient became hypotensive, and cardiac arrhythmia was noted on the monitor, which degenerated into cardiac arrest. H2-blockers (H2B) tend to cause? - select one

A) Sinus bradycardia

B) Sinus tachycardia

Answer: A

The use of anti-ulcer medications is common in the ICU. Although not common, rapid infusion of H2B may cause sinus bradycardia, hypotension, atrioventricular (AV) blocks, prolongation of the QT interval, and cardiac arrest. If possible, it is preferred to use the oral route as its bioavailability is not much affected by food, though first-pass metabolism may cause some decreased effects. Unfortunately, our patient in question can not have it. In such cases, slow administration is preferred. 

Risk factors for cardiac arrest are rapid intravenous infusion, high dose, renal or hepatic dysfunction(delays clearance), and underlying heart condition.

#pharmacology

#cardiology

References:

1. Hinrichsen H, Halabi A, Kirch W. Clinical aspects of cardiovascular effects of H2-receptor antagonists. Eur J Clin Invest 1995; 25 Suppl 1:47.

2. Lee KW, Kayser SR, Hongo RH, et al. Famotidine and long QT syndrome. Am J Cardiol 2004; 93:1325.

Vitamins, Pregnancy and Asthma

Q: 24 years old female is admitted to ICU with severe exacerbation of Asthma. While recovering, her spouse, who also has history of severe asthma, inquires about a news report that some vitamin intake by mother during pregnancy may reduce the risk of developing Asthma in the offspring. Which vitamin has been shown to reduce such risk in the early childhood of offspring? - select one

A) Vitain A

B) Vitamin B

C) Vitamin C

D) Vitamin D

E) Multi-Vitamin

Answer: D

There is a weak evidence of high-dose vitamin D intake (2000 to 4000 IU/day) by women during pregnancy - that reduces the risk of developing early life wheezing and allergic rhinitis, at least up to the age of 3-5 years in their children. This effect has been said to be more pronounced in northern climates (away from the equator). The effect is at least a 20% reduction. This effect is independent of other related factors such as maternal smoking status, maternal intake of vitamin E, zinc, and calcium, and vitamin D intake by the children. 

The proposed mechanism involves immunomodulation of multiple cell types, notably dendritic and T regulatory cells, and effects on in-utero lung development.

The high dose intake is in addition to the recommended dietary allowance (RDA) of 600 IU/day of vitamin D (the standard dose of prenatal vitamins). 

#ob-gyn

#vitamins

References:

1. Litonjua AA, Carey VJ, Laranjo N, et al. Effect of Prenatal Supplementation With Vitamin D on Asthma or Recurrent Wheezing in Offspring by Age 3 Years: The VDAART Randomized Clinical Trial. JAMA 2016; 315:362.

2. Erkkola M, Kaila M, Nwaru BI, et al. Maternal vitamin D intake during pregnancy is inversely associated with asthma and allergic rhinitis in 5-year-old children. Clin Exp Allergy 2009; 39:875.

3. Rothers J, Wright AL, Stern DA, et al. Cord blood 25-hydroxyvitamin D levels are associated with aeroallergen sensitization in children from Tucson, Arizona. J Allergy Clin Immunol 2011; 128:1093.

4. Litonjua AA. The role of vitamin D in the development, exacerbation, and severity of asthma and allergic diseases. In: Vitamin D and the lung: Mechanisms and disease associations, Litonjua AA (Ed), Humana Press, New York 2012.

5. Ramirez LG, Lee-Sarwar K, Kelly RS, et al. Association of Prenatal Maternal and Infant Vitamin D Supplementation with Offspring Asthma. Ann Am Thorac Soc 2024; 21:279.

BCIS

Q 28 years old motorbike rider, is taken to the Operating Room (OR) after motor vehicle trauma. The patient sustained multiple long bone fractures. Perioperatively, patient developed acute hypotension, severe hypoxia, cardiac arrhythmia and eventually went into cardiac arrest. Diagnosis of bone cement implantation syndrome (BCIS) is made. What is Bone cement implantation syndrome?

Answer:

BCIS is potentially a fatal complication during orthopedic surgeries, mostly associated with polymethylmethacrylate cement. The use of a long-stem femoral component is a significant risk factor. It is characterized by acute hypotension, hypoxia, neurologic symptoms, and cardiac arrhythmias. 

It is probably due to multiple mechanisms, including fat and marrow debris embolization, cement monomer toxicity, anaphylatoxin release, and prostaglandin release. 

Patients require aggressive volume resuscitation, oxygen, and usual care as in any shock situation.

#trauma

#orthopedics

#surgical critical care

References:

1. Saleh KJ, Kassim R, Yoon P, Vorlicky LN. Complications of total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2002; 31:485.

2. Patterson BM, Healey JH, Cornell CN, Sharrock NE. Cardiac arrest during hip arthroplasty with a cemented long-stem component. A report of seven cases. J Bone Joint Surg Am 1991; 73:271.

3. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth 2009; 102:12.

4. Mudgalkar N, Ramesh KV. Bone cement implantation syndrome: A rare catastrophe. Anesth Essays Res. 2011 Jul-Dec;5(2):240-2. doi: 10.4103/0259-1162.94796. PMID: 25885400; PMCID: PMC4173385.

AIP

Q: Which organ transplantation can be considered in extreme cases pf Acute Intermittent porphyria (AIP)? - select one

A) Pancreas

B) Liver

Answer: B

Interestingly, hepatic transplant is considered very effective in most cases of AIP where other therapies failed and were exhausted. It should be considered if patient does not have advanced motor neuropathy like quadriplegic patients.

Indications for liver transplant are frequent hospitalizations, unresponsiveness to hemin or givosiran, and poor quality of life. It should be highly considered in patients of AIP who develop primary liver cancer or have other acute hepatic porphyrias. 

It should be noted that traditionally used model for end-stage liver disease [MELD] score for liver transplantation does not apply to patients with AIP because they usually do not have advanced parenchymal liver damage even when neuropathic manifestations are severe. Patients with AIP and severe neuropathic symptoms who are being considered for liver transplant receive exception points for expedited waitlist priority. In the case of a living-related donor, the donor should be ruled out for AIP or latent AIP. Sibling donors may have asymptomatic AIP.

#hepatology

#transplantation

References:

1. Soonawalla ZF, Orug T, Badminton MN, et al. Liver transplantation as a cure for acute intermittent porphyria. Lancet 2004; 363:705.

2. Seth AK, Badminton MN, Mirza D, et al. Liver transplantation for porphyria: who, when, and how? Liver Transpl 2007; 13:1219.

3. Lissing M, Nowak G, Adam R, et al. Liver Transplantation for Acute Intermittent Porphyria. Liver Transpl 2021; 27:491.

EtCO2 and Epi

Q: During cardiac resuscitation, administration of epinephrine may cause erroneous ___________ in End-Tidal CO2 (EtCO2)? - select one

A) rise 

B) fall

Answer: B

The use of EtCO2 is on the rise in the ICU for various reasons. It is important to know the confounding factors.

EtCO2 may decrease rapidly moments after administration of epinephrine, although hemodynamics may show improvement. This effect is short-lived, though.

#resuscitation

#hemodynamics

Reference:

Sandroni C, De Santis P, D'Arrigo S. Capnography during cardiac arrest. Resuscitation 2018; 132:73.

TXA in UGIB

Q: Intravenous (IV) Tranexamic acid can be used as an effective adjuvant therapy in severe upper GI bleeding if it does not resolve appropriately with continuous Proton Pump Inhibitor (PPI) infusion.

A) true

B) False

Answer: B

Although Tranexamic acid is an effective antifibrinolytic agent, it failed to show any efficacy in patients with upper GI bleeds. It should not be used and has no major benefit.

Although there is weak evidence that it may decrease the risk of re-bleeding and the need for surgery, it has no significant effect on the number of blood transfusions or on mortality.

#GI

References:

1. Bennett C, Klingenberg SL, Langholz E, Gluud LL. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev 2014; :CD006640.

2. HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927.

3. Burke E, Harkins P, Ahmed I. Is There a Role for Tranexamic Acid in Upper GI Bleeding? A Systematic Review and Meta-Analysis. Surg Res Pract. 2021 Jan 29;2021:8876991. doi: 10.1155/2021/8876991. PMID: 33564713; PMCID: PMC7864761.

FUO types

<500 48="" and="" cd4="" cells="" count="" fall="" for="" hiv="" hours.="" impending="" level="" microl="" neutrophils="" occasions="" on="" or="" patients="" recorded="" several="" temperature="" that="" to="" with="" within="">

Q: Which of the following is not a type of Fever of Unknown Origin (FUO)?

A) Classic FUO

B) Healthcare-associated FUO

C) Immunocompromised patients' FUO

D) Fictitious FUO

E) Travel-associated FUO

Answer: D

Multiple definitions of FUO have been proposed, but at its core, FUO is the fever in the absence of an identifiable cause despite reasonable evaluation for at least 3 weeks, above temperature >38.3°C. This definition describes classic FUO (choice A).

Healthcare-associated FUO

• ICU patient - Temperature >38.3°C (100.9°F) recorded several times in an ICU patient despite ≥3 days of investigations. The fever must not have been present or incubated upon admission.
• Non-ICU patient - Same definition as for ICU patients, except the patient is hospitalized but not critically ill.
• Post-operative patient—The same definition as for ICU patients applies, except fever is usually defined as ≥38.0°C (100.4°F).

FUO in immunocompromised patients

• Neutropenic patients - Temperature ≥38.3°C (100.9°F) or ≥38.0°C (100.4°F) sustained over one hour, recorded on several occasions over at least 3 days, despite appropriate antimicrobial therapy. Neutropenia is <500 neutrophils/microL or impending fall to that level within 48 hours.
• Patients with HIV and CD4 count <200 cells/microL - Despite appropriate evaluation, temperatures≥38.3°C (100.9°F) were recorded on several occasions for >3 weeks for outpatients or >3 days for inpatients.

Travel-associated FUO

A temperature>38.3°C (100.9°F) was recorded on several occasions for >3 weeks, despite 3 outpatient clinic evaluations, 1 week of intensive outpatient investigation, or 3 days of hospital-based evaluation, in a patient who traveled to another country, typically within the prior 12 months.

Although patients can have a fictitious fever, it is not a part of officially described types (at least yet) - Choice D

#ID

References:

1. Wright WF, Mulders-Manders CM, Auwaerter PG, et al. Fever of unknown origin (FUO) – A call for new research standards and updated clinical management. Am J Med 2022; 135:173.

Adapted from:

2. Wright W, Mackowiak P. Fever of unknown origin. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 8th ed, Bennett J, Dolin R, Blaser M (Eds), Elsevier Saunders 2015. p. 721.

3. Haidar G, Singh N. Fever of Unknown Origin. N Engl J Med. 2022; 386:463.

4. Wright WF, Auwaerter PG. Fever and fever of unknown origin: Review, recent advances, and lingering dogma. Open Forum Infect Dis 2020; 7:ofaa132.

5. Durack DT, Street AC. Fever of unknown origin – reexamined and redefined. Curr Clin Top Infect Dis 1991; 11:35.

bupropion and brain

Q: 22 years old female is admitted to ICU with severe electrolyte imbalance due to underlying bulimia nervosa. After repletion, patient's electrolyte profile improved. Patient's bulimia nervosa seems related to her desire to lose weight. She read on internet that Bupropion helps in depression as well as it leads to weight loss. It may be a good idea to prescribe Bupropion.

A) True

B) False

Answer: B

Patients with bulimia nervosa or anorexia nervosa seem to have an extremely high risk of developing seizures from bupropion. In fact this drug is contraindicated in such patients.

Bupropion increases risk of seizures, especially with immediate-release formulations. This risk is dose-dependent and increases with higher dosage.

Although Bupropion does indeed help in weight reduction, it would not be prudent to use this drug solely for the purpose of weight reduction.

#pharmacology

#neurology

References:

1. Fava M, Rush AJ, Thase ME, et al. 15 years of clinical experience with bupropion HCl: from bupropion to bupropion SR to bupropion XL. Prim Care Companion J Clin Psychiatry 2005; 7:106.

2. Johnston JA, Lineberry CG, Ascher JA, Davidson J, Khayrallah MA, Feighner JP, Stark P. A 102-center prospective study of seizure in association with bupropion. J Clin Psychiatry. 1991 Nov;52(11):450-6. PMID: 1744061.

3. Serretti A, Mandelli L. Antidepressants and body weight: a comprehensive review and meta-analysis. J Clin Psychiatry 2010; 71:1259.

open vs lap choly

Q: Laparoscopic cholecystectomy is preferred over open cholecystectomy due to lower rate of overall serious complication rates?

A) True

B) False

Answer: B

Laparoscopic cholecystectomy, popularly known as "lap chole," is considered the "gold standard" for gallstones requiring surgical intervention due to various advantages, such as less postoperative pain, aesthetically appealing, shorter length of stay, and less disability off days from work. However, the overall serious complication rate in laparoscopic cholecystectomy is higher than in open cholecystectomy. 

It should be accepted that this inference on higher complications is biased for two reasons. First, open cholecystectomy is now reserved only for complicated and challenging cases, and less open cholecystectomies are performed nowadays. Second, if lap-choly requires conversion to open-choly in OR, it results in severe complications, with worst injuries to bile duct, hepatic artery, or portal vein - and all this goes under the banner of lap-chole!!

#surgical-critical-care

#hepatology

#procedures

References:

1. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007; 65:247.

2. Hogan NM, Dorcaratto D, Hogan AM, et al. Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study. Int J Surg 2016; 33 Pt A:151.

3. Visser BC, Parks RW, Garden OJ. Open cholecystectomy in the laparoendoscopic era. Am J Surg 2008; 195:108.

psychological basis of hydrophobia and aerophobia in rabies

Q: What is the psychological basis of hydrophobia and aerophobia in rabies?

Answer: Fear of pharyngeal muscle spasms

Hydrophobia is more common than aerophobia. Other clinical symptoms of rabies include fever, pharyngeal spasms, and hyperactivity, progressing to paralysis, coma, and death.

Hydrophobia, first described in 1900 (see reference # 1), is the most characteristic clinical sign of rabies. It begins as feeling of discomfort in the throat or dysphagia. Patient develops an overwhelming terror of water based on involuntary pharyngeal muscle spasms during attempts to drink, which proceeds even to the sight or mention of water.

Aerophobia occurs less frequently and is also pathognomonic of rabies. A draft of air causes pharyngeal spasms lasting a few seconds. This may also be associated with painful inspiratory spasms of the diaphragm and accessory inspiratory muscles. Symptoms include coughing, choking, vomiting, and hiccups, followed by asphyxiation and respiratory arrest.

#ID

#psychiatry

References:

1. D.E. Salmon: Rabies and Hydrophobia - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9346709/pdf/jcmvetarch131802-0015.pdf

2. Hemachudha T, Laothamatas J, Rupprecht CE. Human rabies: a disease of complex neuropathogenetic mechanisms and diagnostic challenges. Lancet Neurol 2002; 1:101.

3. Tongavelona JR, Rakotoarivelo RA, Andriamandimby FS. Hydrophobia of human rabies. Clin Case Rep. 2018 Oct 18;6(12):2519-2520. doi: 10.1002/ccr3.1846. PMID: 30564365; PMCID: PMC6293146.

4. Bleck TP, Rupprecht CE. Rhabdoviruses. In: Principles and Practice of Infectious Diseases, Sixth Ed, Mandell GL, Bennett JE, Dolin R (Eds), Churchill Livingstone, Philadelphia 2005. p.2047.

lacunar syndrome

Q: Pure motor hemiparesis can occur as a lacunar syndrome.

A) True

B) False

Answer: A

Lacunar infarcts are small i.e., about 2 to 15 mm in diameter noncortical infarcts. These occur by occlusion of a single penetrating branch of a large cerebral artery. Infarct occurs as these branches arise at acute angles from the large arteries of the circle of Willis, the stem of the middle cerebral artery (MCA), or the basilar artery. 

An expert clinician can make a preliminary diagnosis just by physical examination prior to any radiological tests. This led to the concept of lacunar syndromes. The five classic lacunar syndromes, which may present as transient ischemic attacks (TIAs) in addition to stroke, are named according to their clinical manifestations:

• Pure motor hemiparesis
• Pure sensory stroke
• Ataxic hemiparesis
• Sensorimotor stroke
• Dysarthria-clumsy hand syndrome

Said above, all patients with acute ischemic stroke should be evaluated to determine eligibility for reperfusion therapy and/or mechanical thrombectomy.

#neurology

#clinicalexam

References:

1. Giacomozzi S, Caso V, Agnelli G, Acciarresi M, Alberti A, Venti M, Mosconi MG, Paciaroni M. Lacunar stroke syndromes as predictors of lacunar and non-lacunar infarcts on neuroimaging: a hospital-based study. Intern Emerg Med. 2020 Apr;15(3):429-436. doi: 10.1007/s11739-019-02193-2. Epub 2019 Sep 18. PMID: 31535289.

2. Arboix A, Massons J, García-Eroles L, Targa C, Comes E, Parra O. Clinical predictors of lacunar syndrome not due to lacunar infarction. BMC Neurol. 2010 May 18;10:31. doi: 10.1186/1471-2377-10-31. PMID: 20482763; PMCID: PMC2877662.

BAL in DAH

Q: Subsegmental bronchoscopy guided by chest X-ray in Diffuse Alveolar Hemorrhage (DAH) will yield? - select one

A) progressively less hemorrhagic output

B) progressively more hemorrhagic output

Answer: B

Many times hemoptysis may not be evident in DAH. Flexible bronchoscopy with sequential Broncho-Aleveloar Lavage (BAL) should be carried out. Depending on radiographic opacities, a fiberoptic bronchoscope is wedged into a subsegmental bronchus. Sequential BAL should be performed by instilling and retrieving three aliquots of 50 to 60 mL sterile saline from the suspected subsegmental bronchus. Alveolar hemorrhage is confirmed when lavage aliquots are progressively more hemorrhagic, a finding characteristic of DAH, irrespective of the cause.

Although hemosiderin-laden macrophages from Prussian blue staining is considered characteristic of DAH, it can also be found in diffuse alveolar damage (DAD) and idiopathic pulmonary fibrosis (IPF).

#procedures

#pulmonology

References:

1. De Lassence A, Fleury-Feith J, Escudier E, et al. Alveolar hemorrhage. Diagnostic criteria and results in 194 immunocompromised hosts. Am J Respir Crit Care Med 1995; 151:157.

2. Prasad P, Gupta A, Nath A, Hashim Z, Gupta M, Krishnani N, Khan A. Clinical characteristics of patients with diffuse alveolar hemorrhage diagnosed by cytological examination of 1000 bronchoalveolar lavage samples. Sarcoidosis Vasc Diffuse Lung Dis. 2023 Mar 28;40(1):e2023004. doi: 10.36141/svdld.v40i1.13413. PMID: 36975056; PMCID: PMC10099654.

3. Maldonado F, Parambil JG, Yi ES, Decker PA, Ryu JH. Haemosiderin-laden macrophages in the bronchoalveolar lavage fluid of patients with diffuse alveolar damage. Eur Respir J. 2009 Jun;33(6):1361-6. doi: 10.1183/09031936.00119108. Epub 2009 Jan 7. PMID: 19129275.

EMB

Q; Which side of the Endomyocardial biopsy (EMB) has a higher risk of complications? - select one

A) Right ventricle (RV)

B) Left Ventricle (LV) 

C) Similar risk

Answer: C

Although Biventricular EMB biopsy provides a much higher incremental diagnostic yield, RV EMB is mainly performed via the internal jugular of the femoral vein due to presumed safety reasons and ease. In some cases, such as suspected cardiac sarcoidosis or myocarditis with primary LV involvement, LV-EMB is performed. 

Interestingly, biopsy in the region of late gadolinium enhancement on CV-MRI does not increase the diagnosis yield. Complication rates are usually similar for LV and RV biopsy.

#procedures

#cardiolgy

References:

1. Cooper LT Jr. Right from the heart: when should myocardial biopsy be performed for suspected arrhythmogenic right ventricular cardiomyopathy/dysplasia? Eur Heart J 2008; 29:2705.

2. Cooper LT Jr. Role of left ventricular biopsy in the management of heart disease. Circulation 2013; 128:1492.

3. Yilmaz A, Kindermann I, Kindermann M, et al. Comparative evaluation of left and right ventricular endomyocardial biopsy: differences in complication rate and diagnostic performance. Circulation 2010; 122:900.

4. Seferović PM, Tsutsui H, McNamara DM, et al. Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy. Eur J Heart Fail 2021; 23:854.

Nonselective BB in SBP

Q: 54 years old male with known alcoholic cirrhosis was admitted to ICU with sepsis due to spontaneous bacterial peritonitis (SBP). Patient is now off pressor. Patient's non-selective Beta-Blocker (BB) should be restarted as soon as possible as his maintenance treatment for cirrhosis.

A) True

B) False

Answer: B

BB in SBP carries poor outcomes. It should be discontinued and kept off permanently once patient develops SBP!

BB increases the mortality rate by 58% in SBP. Also, rates of hepatorenal syndrome and length of hospital stay go higher.

#hepatology

#ID

Reference:

1. Mandorfer M, Bota S, Schwabl P, et al. Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 2014; 146:1680.

Movement Disorders and Musculoskeletal System

Q: What's the difference between Chorea and Ballismus?

Answer: Neurological movements can be of different patterns. A few essential patterns to know are:

Myoclonus: rapid, shock-like muscle jerks

Chorea: rapid, jerky twitches, similar to myoclonus but more random in location and more likely to blend into one another

Athetosis: slow, writhing movements of the limbs

Ballismus: large amplitude flinging limb movements

Dystonia: maintenance of an abnormal posture or repetitive twisting movements

#neurology

#physicalexam

References:

1. Walker HK. Involuntary Movements. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 70. Available from: https://www.ncbi.nlm.nih.gov/books/NBK394/

2. Pandey S, Chouksey A, Pitakpatapee Y, Srivanitchapoom P. Movement Disorders and Musculoskeletal System: A Reciprocal Relationship. Mov Disord Clin Pract. 2021 Dec 16;9(2):156-169. doi: 10.1002/mdc3.13390. PMID: 35146055; PMCID: PMC8810446.

'downhill' esophageal varices

Q: "Downhill" esophageal varices are mostly due to? - select one

A) End Stage Liver Disease (ESLD)

B) End Stage Renal Disease (ESRD)

Answer: B

Some patients with ESRD who are on hemodialysis may develop upper esophagus varices. These are called "downhill" esophageal varices because the direction of the blood flow is downwards. These varices are secondary to superior vena cava (SVC) obstruction resulting from the creation of upper-extremity hemodialysis access.

These patients are usually asymptomatic, but in case of recurrent or severe upper GI bleeding, treatment of the underlying SVC obstruction may be required. Symptomatic treatment remains the same with endoscopic variceal band ligation or sclerotherapy at the proximal end of the varix.

#vascular

#GI

#nephrology

References:

1. Blam ME, Kobrin S, Siegelman ES, Scotiniotis IA. "Downhill" esophageal varices as an iatrogenic complication of upper extremity hemodialysis access. Am J Gastroenterol 2002; 97:216.

2. Chandra A, Tso R, Cynamon J, Miller G. Massive upper GI bleeding in a long-term hemodialysis patient. Chest 2005; 128:1868.

3. Loudin M, Anderson S, Schlansky B. Bleeding 'downhill' esophageal varices associated with benign superior vena cava obstruction: case report and literature review. BMC Gastroenterol 2016; 16:134.

PICS, PICS-p and PICS-F

Q: PICS, PICS-p and PICS-F terminologies stand for?

Answer:

PICS stands for Post-Intensive Care Syndrome, where a patient, after ICU discharge, exhibits new or worsening function in at least one of the following domains

• Cognitive function
• Psychiatric function
• Physical function

PICS-p is similar symptoms in pediatric patients (PICS-p), but it includes a fourth domain:

• social health

PICS-F is the term applied when a caregiver, family or a family member exhibits similar symptoms.

#PICS

References:

1. Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012; 40:502.

2. Manning JC, Pinto NP, Rennick JE, et al. Conceptualizing Post Intensive Care Syndrome in Children-The PICS-p Framework. Pediatr Crit Care Med 2018; 19:298.

3. Putowski Z, Rachfalska N, Majewska K, Megger K, Krzych Ł. Identification of risk factors for post-intensive care syndrome in family members (PICS-F) among adult patients: a systematic review. Anaesthesiol Intensive Ther. 2023;55(3):168-178. doi: 10.5114/ait.2023.130831. PMID: 37728444; PMCID: PMC10496103.

Smoking and CHD

Q: Approximately how long does it take for cigarette smoking effects to be reversed for coronary heart disease? - select one

A) one year

B) two years

C) five years

D) ten years

Answer: B

Tobacco smoking is a reversible risk factor for CHD. The incidence of  Myocardial Infarction (MI) is increased sixfold in women but only threefold in men who smoke a pack per day. It is higher in inhalers compared to non-inhalers.

The recurrent infarction risk fell normalized to nonsmokers within two years.

#cardiology

References:

1. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56.

2. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:937.

3. Prescott E, Hippe M, Schnohr P, et al. Smoking and risk of myocardial infarction in women and men: longitudinal population study. BMJ 1998; 316:1043.

Serologic hallmark in PBC

Q: Which of the following is the serologic hallmark of Primary Biliary Cirrhosis (PBC)? - select one

A) Antinuclear antibodies (ANA)

B) Antimitochondrial antibodies (AMA)

Answer: B

Expected lab findings in PBC are elevated alkaline phosphatase, mild elevations in the aminotransferases, and bilirubin levels. Hyperlipidemia and iron deficiency anemia are also common.

AMA is considered the serologic hallmark of PBC, which is rarely missing. In such cases, it is called AMA-negative PBC. Interestingly, many patients with positive AMA will eventually go on to develop features of PBC! AMA also predicts rapid progression and a poorer prognosis.

Although ANA is also common but not considered a hallmark as it is generally positive in many other etiologies. Other antibodies that may be present are anticentromere, anti-SSA/Ro, and anti-dsDNA antibodies.

#hepatology

#rheumatology

#markers

References:

1. Sun C, Xiao X, Yan L, Sheng L, Wang Q, Jiang P, Lian M, Li Y, Wei Y, Zhang J, Chen Y, Li B, Li Y, Huang B, Li Y, Peng Y, Chen X, Fang J, Qiu D, Hua J, Tang R, Leung P, Gershwin ME, Miao Q, Ma X. Histologically proven AMA positive primary biliary cholangitis but normal serum alkaline phosphatase: Is alkaline phosphatase truly a surrogate marker? J Autoimmun. 2019 May;99:33-38. doi: 10.1016/j.jaut.2019.01.005. Epub 2019 Jan 30. PMID: 30709684.

2. Chascsa DM, Lindor KD. Antimitochondrial Antibody-Negative Primary Biliary Cholangitis: Is It Really the Same Disease? Clin Liver Dis. 2018 Aug;22(3):589-601. doi: 10.1016/j.cld.2018.03.009. PMID: 30259855.

3. Hu CJ, Zhang FC, Li YZ, Zhang X. Primary biliary cirrhosis: what do autoantibodies tell us? World J Gastroenterol. 2010 Aug 7;16(29):3616-29. doi: 10.3748/wjg.v16.i29.3616. PMID: 20677333; PMCID: PMC2915421.

4. Colapietro F, Lleo A, Generali E. Antimitochondrial Antibodies: from Bench to Bedside. Clin Rev Allergy Immunol. 2022 Oct;63(2):166-177. doi: 10.1007/s12016-021-08904-y. Epub 2021 Sep 29. PMID: 34586589; PMCID: PMC8480115.

Cutaneous Sarcoidosis

Q: Which ink color is more prone to develop Tattoo sarcoidosis? - select one

A) black

B) blue

C) red

D) green

E) purple

Answer: C

It may be interesting to know that sarcoid granulomas if developed in tattoos, can present signs of sarcoidosis. All such patients should be evaluated for systemic disease. It may take decades for such manifestation to appear, but it usually happens within one year of the tattoo placement.

For unknown reasons, its the red ink (cinnabar) tattoos which are more prone to develop

sarcoidosis, though other pigments can also be responsible for that. Eyebrows and lips tend to get affected more.

On physical exam, it appears like papules within a tattoo that are usually raised, firm, and edematous. The patient reports pain and/or pruritus. Histopathology shows the presence of sarcoid granulomas with aggregates of epithelioid cells surrounded by peripheral rings of lymphocytes. Differential diagnosis includes foreign body reactions.

#dermatology

#vasculitis

References:

1. Antonovich DD, Callen JP. Development of sarcoidosis in cosmetic tattoos. Arch Dermatol 2005; 141:869.

2. Caplan A, Rosenbach M, Imadojemu S. Cutaneous Sarcoidosis. Semin Respir Crit Care Med. 2020 Oct;41(5):689-699. doi: 10.1055/s-0040-1713130. Epub 2020 Jun 27. PMID: 32593176.

3. Abdelghaffar M, Hwang E, Damsky W. Cutaneous Sarcoidosis. Clin Chest Med. 2024 Mar;45(1):71-89. doi: 10.1016/j.ccm.2023.08.004. Epub 2023 Oct 28. PMID: 38245372.

PLASMIC Score

Q: All of the following are components of  PLASMIC Score for suspected thrombotic thrombocytopenic purpura (TTP) EXCEPT? - select one

A) Platelet count

B) Evidence for Hemolysis

C) History of active cancer

D) INR  less than 1.5

E) Liver enzymes twice normal

Answer: E

PLASMIC score helps to identify patients who are at high risk of TTP. It is a validated score to estimate the probability of ADAMTS13 activity ≤10 percent in patients with Microangiopathic hemolytic anemia (MAHA) and thrombocytopenia. 

It provides confidence for diagnosing TTP, as the results of ADAMTS13 activity testing may take prolonged time when decision for management plans need to be made. It has seven components:

1. Platelet count - if less than <30 x 109/L
2. Evidence of hemolysis like reticulocyte count >2.5%, haptoglobin undetectable, or indirect bilirubin >2.0 mg/dL
3. Evidence of active cancer treatment within the past year
4. History of solid-organ or stem-cell transplant
5. INR <1.5
6. Creatinine <2.0 mg/dL
7. MCV <9.0 x 10-14 L 

  

Each component gets one point if the answer is yes, except for cancer and solid-organ or stem cell transplant, which gets zero points if the answer is yes (please refer to any online calculator).      

         

Risk of severe ADAMTS13 deficiency

• 0 to 4 = Low risk
• 5 = Intermediate risk
• 6 to 7 = High risk

  

A score less than 5 generally does not require further workup, and a score ≥5 requires ADAMTS13 to be sent.

  

Oncology service should be consulted.

         

 

#hematology

#scores

         

         

         

Reference:

         

1. Bendapudi PK, Hurwitz S, Fry A, et al. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol 2017; 4:e157.

Statin and liver

Q: Severe Hepatic injury due to statin intake, if it occurs, usually happens in the first two weeks of initiation of drug therapy.

A) True

B) False

Answer: B

There is little chance of severe liver injury from statin therapy. It is considered almost as near as to the general population. The most common effect is aminotransferase elevation.

If a hepatic failure occurs, it usually occurs three to four months after initiation. Although the range is extremely wide—between one month and 10 years—the occurrence within two weeks of initiation should prompt a clinician to look for other causes.

The FDA recommends liver function testing only before initiating statin therapy and repeating such testing only with clinical indications afterwards.

Standard clinical practice is to change medications or lower statin dose if ALT level is more than three times the upper limit of normal, which is confirmed on repeat lab tests.

#pharmacology

#hepatology

References:

Russo MW, Hoofnagle JH, Gu J, et al. Spectrum of statin hepatotoxicity: experience of the drug-induced liver injury network. Hepatology 2014; 60:679.

Cohen DE, Anania FA, Chalasani N, National Lipid Association Statin Safety Task Force Liver Expert Panel. An assessment of statin safety by hepatologists. Am J Cardiol 2006; 97:77C.

Charles EC, Olson KL, Sandhoff BG, et al. Evaluation of cases of severe statin-related transaminitis within a large health maintenance organization. Am J Med 2005; 118:618.

US Food and Drug Administration. FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. February 28, 2012. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm293101.htm (Accessed on September 8, 2024).

Frank cyanosis and oxygen saturation level

Q: 67 years old male collapsed at the hospital parking lot. "Code blue" is called. On arrival, patient appears to be in frank cyanosis. CPR is started, and the team proceeds to perform intubation. Cyanosis appears to be resolving with CPR and bagging via endotracheal tube (ETT). Frank cyanosis corresponds to an arterial oxygen saturation (SaO2) of around what percentage? - select one

A) 85%

B) 75%

C) 65%

Answer: C

Frank cyanosis usually does not develop until the arterial oxygen saturation (SaO2) level drops to around 65-67 percent. This corresponds to the level of deoxyhemoglobin of about 5 g/dL.

Although pulse oximetry is a great tool for assessing oxygenation, cyanosis often occurs in code situations or in ARDS, and pulse oximetry may not be able to pick up accurate parameters. Clinical exam may play a vital role.

Clinicians should understand that cyanosis is affected by many variables, such as peripheral perfusion, skin pigmentation, and hemoglobin concentration.

#oxygenation

#physical-exam

Reference:

Grace RF. Pulse oximetry. Gold standard or false sense of security? Med J Aust 1994; 160:638.

LBO

Q; 75 years old male is admitted to ICU with severe abdominal pain and is found to have large bowel obstruction due to a tumor formation. Which of the following sites is more prone to have large bowel obstruction? - select one

A) hepatic flexure (Right)

B) splenic flexure (Left)

Answer: B

One-fourth of the bowel obstructions are caused by large bowel obstruction (LBO), and three-fourths by small bowel obstruction (SBO). LBO is more common in elderly people at or above age 70.

One of the most common cause of large bowel obstruction is colon cancer, and in about one-third of the cases, it can be a leading presentation.

Most LBOs occur at or distal to the transverse colon, as the colonic lumen is narrowing there. The most common site of obstructing colorectal cancer is the sigmoid colon. Tumors at the splenic flexure are more likely to obstruct than tumors at the hepatic flexure.

#surgical-critical-care

#oncology

#GI

References:

1. Aslar AK, Ozdemir S, Mahmoudi H, Kuzu MA. Analysis of 230 cases of emergent surgery for obstructing colon cancer--lessons learned. J Gastrointest Surg 2011; 15:110.

2. Biondo S, Parés D, Frago R, et al. Large bowel obstruction: predictive factors for postoperative mortality. Dis Colon Rectum 2004; 47:1889.

3. Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2014; 207:127.

Analgesic use and the risk of hearing loss

Q: Hearing loss with aspirin is? - select one

A) reversible

B) irreversible

Answer: A

Although high-dose aspirin, about 6 to 8 g/day, can cause hearing loss, it is reversible with discontinuation.

It's not very common, but regular use of standard-dose aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs can also be associated with an increased risk of hearing loss. Interestingly, this is more common in younger (not older) patients less than 50 years of age. Moreover, similar findings were observed in women with acetaminophen and ibuprofen but not with aspirin.

#pharmacology

#ENT

References:

1. Curhan SG, Eavey R, Shargorodsky J, Curhan GC. Analgesic use and the risk of hearing loss in men. Am J Med 2010; 123:231.

2. Curhan SG, Shargorodsky J, Eavey R, Curhan GC. Analgesic use and the risk of hearing loss in women. Am J Epidemiol 2012; 176:544.