Saturday, May 15, 2021

polyarticular gout

 Q: 42 years old male is admitted to ICU with possible polyarticular septic arthritis. Subsequent workup turned it out to be gout instead of sepsis. Initial gout presentation can be polyarticular in which conditions?

Answer: In primary gout, the initial presentation is mostly uniarticular but polyarticular gout can happen in few conditions where hyperuricemia occurs. The two most prominent clinical situations are:

1. Myeloproliferative disorder or lymphoproliferative disorder. This was first described more than five decades ago.

2. Patients on immunosuppressant drugs such as cyclosporine or tacrolimus. Cyclosporine is more common than tacrolimus to cause polyarticular gout, and in few cases switching cyclosporine to tacrolimus may help. 

Another feature of polyarticular gout flare is its sequential or migratory nature. It may also occur in a cluster form i.e., involving adjacent joints, tendons, and bursas.



1. Yü TF. Secondary gout associated with myeloproliferative diseases. Arthritis Rheum 1965; 8:765.

2. Stamp L, Searle M, O'Donnell J, Chapman P. Gout in solid organ transplantation: a challenging clinical problem. Drugs. 2005;65(18):2593-611. doi: 10.2165/00003495-200565180-00004. PMID: 16392875.

Friday, May 14, 2021

vitamin k

 Q: Vitamin K absorption requires which organ to be properly functional? (select one)

A) Pancreas

B) Kidney


Answer: A

Once oral Vitamin K is taken its absorption requires three properly working functions:

  • pancreatic 
  • biliary 
  • fat absorption
Vitamin K is protein-bound as it reaches the intestine. Pancreatic enzymes in the small intestine through proteolytic action cleave vitamin K from protein. Once liberated, vitamin K solubilizes into mixed micelles by bile salts. These mixed micelles get absorbed into enterocytes, where they are incorporated into chylomicrons, facilitating absorption into the intestinal lymphatics and portal circulation.



1. Food and Nutrition Board of the Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc (2000). National Academies Press, Washington DC, 2000. p. 162-196 (Accessed on April 29, 2021)

Thursday, May 13, 2021

AA and cardiac temponade

 Q: Why the perforation of proximal ascending aorta can cause cardiac tamponade? 

Answer: This is due to the anatomic location of the aortic root and first 10 cm of the ascending aorta, which lies within the pericardium. 

This is a surgical emergency. Without an appropriate workup, proceeding to pericadiocentesis just on the basis of echocardiography is not a prudent thing to do. Sole pericardiocentesis should be avoided as it may instantly lead to death due to increase tear of the aorta. Clinical presentation and other radiological findings should be carried out if time permits otherwise emergent call to OR is needed.




1. Guo R, Feng YM, Wan D. Hemorrhagic cardiac tamponade complicated by acute type A aortic dissection: A case report with critical care ultrasound findings. Medicine (Baltimore). 2017;96(49):e8773. doi:10.1097/MD.0000000000008773 

2. Ryu, D.W., Lee, M.K. Cardiac tamponade associated with delayed ascending aortic perforation after blunt chest trauma: a case report. BMC Surg 17, 70 (2017).

Wednesday, May 12, 2021

PPI and magnesium

 Q: Use of proton pump inhibitor (PPI) in ICU may cause? (select one) 

A) hypomagnesemia 

B) hypermagnesemia

Answer: A

There are many reasons for hypomagnesemia in ICU. These include diarrhea, history of alcohol use, PPI use, and diuretics. Hypomagnesemia may lead to unexplained hypocalcemia or refractory hypokalemia. This may also cause cardiac arrhythmias and neuromuscular disturbances.




1. Florentin M, Elisaf MS. Proton pump inhibitor-induced hypomagnesemia: A new challenge. World J Nephrol. 2012;1(6):151-154. doi:10.5527/wjn.v1.i6.151

2. Semb S, Helgstrand F, Hjørne F, Bytzer P. Persistent severe hypomagnesemia caused by proton pump inhibitor resolved after laparoscopic fundoplication. World J Gastroenterol. 2017;23(37):6907-6910. doi:10.3748/wjg.v23.i37.6907

Tuesday, May 11, 2021

Glucagon adjuvant treatment

 Q: 52 years old female admitted to ICU with an intentional overdose of metoprolol. IV glucagon has been planned as an antidote. Which one adjuvant treatment may be helpful to counter the side effect of glucagon?

Answer: antiemetic 

Despite weak evidence,  glucagon is frequently getting used in beta-blockers overdose. Glucagon should be given as a slow bolus followed by a continuous infusion. Glucagon activates adenylate cyclase causing an increase in adenosine 3'-5'-cyclic monophosphate (cAMP). Elevations in cAMP increase the intracellular calcium which augments contractility. 

Glucagon is known to induce vomiting. It may be helpful to add an antiemetic like ondansetron.



1. Bailey B. Glucagon in beta-blocker and calcium channel blocker overdoses: a systematic review. J Toxicol Clin Toxicol 2003; 41:595. 

2. Boyd R, Ghosh A. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta blocker overdose. Emerg Med J 2003; 20:266.

3. Ranganath L, Schaper F, Gama R, Morgan L. Mechanism of glucagon-induced nausea. Clin Endocrinol (Oxf). 1999 Aug;51(2):260-1. doi: 10.1046/j.1365-2265.1999.00845.x. PMID: 10469001.

Monday, May 10, 2021

ASA and ACE-I angioedema

 Q: Aspirin is a good adjuvant treatment for Angiotensin-Converting Enzyme Inhibitor (ACE-I) induced angioedema?

A) True

B) False

Answer: B

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAID) are risk factors to increase the likelihood of angioedema in patients taking ACE-I. Other risk factors include: 

  • Age over 65 years 
  • Female gender 
  • Tobacco history
  • History of seasonal allergies 
  • Previous episodes of angioedema


1. Kostis JB, Kim HJ, Rusnak J, et al. Incidence and characteristics of angioedema associated with enalapril. Arch Intern Med 2005; 165:1637.

2. Banerji A, Clark S, Blanda M, et al. Multicenter study of patients with angiotensin-converting enzyme inhibitor-induced angioedema who present to the emergency department. Ann Allergy Asthma Immunol 2008; 100:327. 

3.Hoover T, Lippmann M, Grouzmann E, et al. Angiotensin converting enzyme inhibitor induced angio-oedema: a review of the pathophysiology and risk factors. Clin Exp Allergy 2010; 40:50.

Sunday, May 9, 2021

Ascites and SBP

 Q:  The removal of ascitic fluid helps in decreasing the odds of spontaneous bacterial peritonitis (SBP)? 

A) True

B) False

Answer: A

Removal of ascitic fluid turns ascitic fluid opsonins more concentrated. This decreases the odds of SBP. 

A less tense abdomen also protects against the development of cellulitis and abdominal wall hernia. There is also less risk of developing hydrothorax by decreasing the chances of diaphragmatic rupture. Another less known effect is reduced expenditure of energy to heat the ascitic fluid. 

 Above said, despite all these benefits, there is no solid evidence that it improves underlying mortality.




1. Runyon BA, Van Epps DE. Diuresis of cirrhotic ascites increases its opsonic activity and may help prevent spontaneous bacterial peritonitis. Hepatology 1986; 6:396. 

2. Runyon BA, Antillon MR, McHutchison JG. Diuresis increases ascitic fluid opsonic activity in patients who survive spontaneous bacterial peritonitis. J Hepatol 1992; 14:249. 

3. Dolz C, Raurich JM, Ibáñez J, et al. Ascites increases the resting energy expenditure in liver cirrhosis. Gastroenterology 1991; 100:738.

Saturday, May 8, 2021

palmar erythema

 Q: The palmar erythema in cirrhosis is more prominent on? (select one) 

A) thenar eminence 

B) hypothenar eminence

Answer: B

The objective of this question is to enhance the importance of astute physical exams at the bedside. The presence of palmar erythema helps to confirm the diagnosis. Cirrhosis is one of the diseases which presents a wide range of physical findings. Few dermatological signs in cirrhosis are popularly known as 'stigmata of cirrhosis', and include spider angioma, palmar erythema, and abdominal wall collaterals. The palmar erythema is usually blotchy and patchy. It is more prominent on the hypothenar eminence. This palmar erythema spares the center of the palm. These findings are relatively easily identifiable on fair skin patients. 

Palmar erythema can be present in other diseases besides cirrhosis including Wilson's disease, neoplasms, and diabetes. Pregnant patients may also develop it transiently. 




 1. Serrao R, Zirwas M, English JC. Palmar erythema. Am J Clin Dermatol. 2007;8(6):347-56. doi: 10.2165/00128071-200708060-00004. PMID: 18039017.

2. Kakehashi R, Watanabe S, Ikoma J, Suzuki S. [Clinical symptoms of patients with liver cirrhosis]. Nihon Rinsho. 1994 Jan;52(1):40-4. Japanese. PMID: 8114308.

Friday, May 7, 2021


 Q: Patients developing severe thrombosis after the COVID-19 vaccine should be treated with heparin?

A) True

B) False

Answer: B

Vaccine-induced thrombotic thrombocytopenia (VITT) has been reported after the COVID-19 vaccine, particularly after adenovirus-based COVID-19 vaccines. This condition should be treated as Heparin-Induced Thrombocytopenia (HIT). Although there is no exposure to heparin clinical behavior is the same. Moreover, there are reports that patients deteriorate after receiving heparin in VITT. In these patients, it would be prudent to do anticoagulation only with non-heparin agents. In severe cases, intravenous immune globulin (IVIG) should be considered early in the case. 

Another important aspect is to follow the fibrinogen level. if it is below 100, consideration should be given to transfuse via blood product or synthetic version of fibrinogen. Alike all HIT patients, platelet transfusions should be avoided unless the bleeding is life-threatening. A hematologist should be on board to guide these unfortunate complex patients.




1. Greinacher A, Thiele T, Warkentin TE, et al. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med 2021. 

2. (Accessed on May 6, 2021). 

3. (Accessed on May 6, 2021).

Thursday, May 6, 2021

Insulin resistance in COVID

 Q: Insulin resistance in COVID-19 is found to correlate with inflammatory markers? 

A) True 

B) False 


One of the relatively less described subjects in hospitalized COVID-19 patients is cytokine-induced severe insulin resistance. This becomes even more important with the addition of dexamethasone in the treatment of the COVID-19. Moreover, the risk of hypoglycemia also becomes high as COVID-19 improves or nutritional status changes during hospitalization. This requires very close monitoring. Fortunately, insulin resistance is found to correlate with inflammatory markers of COVID-19, particularly IL-6. 

Or vice versa, insulin resistance itself can be a sign of poor outcome in COVID-19.




1. Wu L, Girgis CM, Cheung NW. COVID-19 and diabetes: Insulin requirements parallel illness severity in critically unwell patients. Clin Endocrinol (Oxf) 2020; 93:390.

2. Ren H, Yang Y, Wang F, et al. Association of the insulin resistance marker TyG index with the severity and mortality of COVID-19. Cardiovasc Diabetol 2020; 19:58.

Wednesday, May 5, 2021


 Q: Tramadol is frequently used in ICUs. It can cause respiratory depression?

A) Yes

B) No

Answer: A

Tramadol is a part of various post-operative protocols as an analgesic. Providers should be aware that it comes with some inherent risks like respiratory depression. It is available as intravenous injection, immediate-release, and extended-release tablets. In ICUs, its administration may concurrently occur with benzodiazepines or other CNS depressants. This can be potentially fatal in a non-intubated patient. Tramadol also increases the risk of seizures.

Staff should be instructed that tramadol tablet or capsule particularly extended-release should not be split, break, chew, crush, or dissolve. 




 1. Dhesi M, Maldonado KA, Maani CV. Tramadol. [Updated 2020 Aug 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:

2. Stamer UM, Stüber F, Muders T, Musshoff F. Respiratory depression with tramadol in a patient with renal impairment and CYP2D6 gene duplication. Anesth Analg. 2008 Sep;107(3):926-9. doi: 10.1213/ane.0b013e31817b796e. PMID: 18713907.

3. Minkowitz H, Leiman D, Lu L, et al. IV Tramadol - A New Treatment Option for Management of Post-Operative Pain in the US: An Open-Label, Single-Arm, Safety Trial Including Various Types of Surgery. J Pain Res. 2020;13:1155-1162. Published 2020 May 22. doi:10.2147/JPR.S251175

Tuesday, May 4, 2021

sch in pregnancy

 Q: Succinylcholine should be given to a pregnant patient depending on total body weight? 

A) True 

B) False 


Dose of succinylcholine is given based on total body weight. Interestingly, this is true for pregnant patients too. This is due to the fact that overestimation of the dose of succinylcholine causes the same level of paralysis. One of the caveat is that duration of action of succinylcholine is longer in pregnant women. Serum cholinesterase activity is 30% less in pregnant females and immediate postpartum females. 

Recommended dose in these patients is 1.0 mg/kg.





1. Guay J, Grenier Y, Varin F. Clinical pharmacokinetics of neuromuscular relaxants in pregnancy. Clin Pharmacokinet 1998; 34:483. 

2. Patanwala AE, Sakles JC. Effect of patient weight on first pass success and neuromuscular blocking agent dosing for rapid sequence intubation in the emergency department. Emerg Med J 2017; 34:739. 

3. Gyasi HK, Mohy O, Abu-Gyamphi, Naquib M. Plasma cholinesterase level in Pregnancy-effect of enzyme activity on the duration of action of succinylcholine. Middle East J Anesthesiol 1986;8:379-85. 

4. Leighton BL, Cheek TG, Gross JB, Apfelbaum JL, Shantz BB, Gutsche BB, et al. Succinylcholine pharmacodynamics in peripartum females Anesthesiology 1986;64:202-5 

5. Rasheed MA, Palaria U, Bhadani UK, Quadir A. Determination of optimal dose of succinylcholine to facilitate endotracheal intubation in pregnant females undergoing elective cesarean section. J Obstet Anaesth Crit Care 2012;2:86-91

Monday, May 3, 2021

Yersinia enterocolitica and blood disorder

 Q; 19 years old adolescent male with some kind of blood disorder (not known to his roommate) is brought to ICU from a college dorm with sepsis-like symptoms. Subsequent workup led to the diagnosis of yersiniosis. Patients with which blood disorder are more prone to have yersiniosis?  

Answer: Thalassemia

Yersinia is ferrophilic (iron-loving). Thalassemia patients frequently develop iron overload due to frequent blood transfusions. Said that patients with thalassemia can develop severe yersiniosis without very high iron load. The reason for this phenomenon is not understood. 

Other risk factors are undercooked/raw pork products, un-sanitized water, cirrhosis, hemochromatosis, aplastic anemia, thalassemia, malignancy, diabetes, malnutrition, and gastrointestinal illnesses.



Adamkiewicz TV, Berkovitch M, Krishnan C, et al. Infection due to Yersinia enterocolitica in a series of patients with beta-thalassemia: incidence and predisposing factors. Clin Infect Dis 1998; 27:1362.

Sunday, May 2, 2021


 Q: Doxycycline being a tetracycline needs to be adjusted in renal dysfunction? 

A) True 

B) False

Answer: B

This is true for most of the tetracyclines that they get eliminated via renal route and need adjustment in renal insufficiency. Doxycycline is one of the tetracyclines which gets 80 percent excreted in the feces via bile. Tigecycline is another tetracycline that does not require adjustment in the renal insufficiency. 

Tetracyclines are usually contraindicated in children due to their tendency to cause tooth discoloration and bony growth retardation. Doxycycline is one unique tetracycline that can be used in children less than eight years of age. Also it can be used in pregnant and breastfeeding females if required.



Vojtová V, Urbánek K. Farmakokinetika tetracyklinů a glycylcyklinů [Pharmacokinetics of tetracyclines and glycylcyclines]. Klin Mikrobiol Infekc Lek. 2009 Feb;15(1):17-21. Czech. PMID: 19399726.

Saturday, May 1, 2021

Sinus brady

Q; Which EKG findings confirm the sinus node origin of bradycardia (sinus bradycardia)?

Answer:  A quick glance at the following 2 findings on EKG confirm the sinus bradycardia
  • an upright P wave in leads I, II, and aVL, and 
  • a negative P wave in lead aVR
Although this is a very basic teaching pearl but an essential one to rule out other causes of bradyarrhythmia - a common scenario in ICU.



Kadish AH, Buxton AE, Kennedy HL, et al. ACC/AHA clinical competence statement on electrocardiography and ambulatory electrocardiography. A report of the ACC/AHA/ACP-ASIM Task Force on Clinical Competence (ACC/AHA Committee to Develop a Clinical Competence Statement on Electrocardiography and Ambulatory Electrocardiography). J Am Coll Cardiol 2001; 38:2091.

Friday, April 30, 2021

Pentoxifylline and kidney

Q: Pentoxifylline if used in patients with diabetic nephropathy tends to? (select one) 

A) help the kidney 
B) hurt the kidney 

Answer: A

 Pentoxifylline is commonly used in vascular patients with claudication. It has also been used in alcoholic hepatitis. Pentoxifylline is a putative anti-inflammatory agent. It is a nonspecific phosphodiesterase inhibitor. Pentoxifylline is found to help estimated glomerular filtration rate (eGFR) in patients with diabetic nephropathy. 

This is the added benefit with the use of standard management with either angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs). Pentoxifylline reduces the rate of eGFR decline in diabetic nephropathy. The dose is 600 mg twice daily.  As the evidence is not fully established, it has not yet become a standard of care.



1. Navarro-González JF, Mora-Fernández C, Muros de Fuentes M, et al. Effect of pentoxifylline on renal function and urinary albumin excretion in patients with diabetic kidney disease: the PREDIAN trial. J Am Soc Nephrol 2015; 26:220. 

2. Perkins RM, Aboudara MC, Uy AL, et al. Effect of pentoxifylline on GFR decline in CKD: a pilot, double-blind, randomized, placebo-controlled trial. Am J Kidney Dis 2009; 53:606. 

3. Goicoechea M, García de Vinuesa S, Quiroga B, et al. Effects of pentoxifylline on inflammatory parameters in chronic kidney disease patients: a randomized trial. J Nephrol 2012; 25:969.

Thursday, April 29, 2021

Eosinophillia in drug fever

 Q: Eosinophilia is one of the essential features of "drug fever." (select one) 

A) True 

B) False 

 Answer: B

It has been estimated that about one-third of patients in the hospital develop drug fever. No absolute reason is known but it is assumed that this is due to subclinical allergic or allergic-type (idiosyncratic) reaction. Also, it can be due to an effect on thermoregulation system. 

 Although eosinophilia is common in drug fever it occurs only in one-fourth of the patients.



Mackowiak PA, LeMaistre CF. Drug fever: a critical appraisal of conventional concepts. An analysis of 51 episodes in two Dallas hospitals and 97 episodes reported in the English literature. Ann Intern Med 1987; 106:728.

Wednesday, April 28, 2021

anti seizure meds in PCNSL

 Q: 48 years old male is admitted to ICU with mental status change. Subsequent workup led to the diagnosis of Central Nervous System Lymphoma (PCNSL). Oncology service has been consulted. Anticonvulsants should be used in this patient as prophylaxis? (select one) 

A) Yes 

B) No 

Answer: B

Although patients with PCNSL are at increased risk for seizures, prophylactic anti-seizure meds are not indicated. This is due to the finding that their prescription has no effect on the frequency of subsequent seizures. Also, anticonvulsants can harm the patient due to their high tendency of drug-drug interaction with chemotherapy and dexamethasone, the most used steroids. 

In general, except for metastatic melanoma anti-seizure drugs are not used in primary or metastatic brain tumors without any evidence of seizure. Anticonvulsants should be added only when there are documented or witnessed seizures.




1. Sirven JI, Wingerchuk DM, Drazkowski JF, et al. Seizure prophylaxis in patients with brain tumors: a meta-analysis. Mayo Clin Proc 2004; 79:1489. 

2. Tremont-Lukats IW, Ratilal BO, Armstrong T, Gilbert MR. Antiepileptic drugs for preventing seizures in people with brain tumors. Cochrane Database Syst Rev 2008; :CD004424. 

3. Mikkelsen T, Paleologos NA, Robinson PD, et al. The role of prophylactic anticonvulsants in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 2010; 96:97. 

4. Goldlust SA, Hsu M, Lassman AB, et al. Seizure prophylaxis and melanoma brain metastases. J Neurooncol 2012; 108:109.

Tuesday, April 27, 2021

A.fib and VT in WPW

 Q: Which arrhythmia is more common in Wolff-Parkinson-White (WPW) syndrome? (select one) 

A) Atrial fibrillation (AF)
B) Ventricular tachycardia (VT)

Answer: A

About one-third of patients with WPWmay have AF. Although AF can originate independently from atria or pulmonary veins, the hallmark pathology is via an accessory pathway due to retrograde conduction. If AF occurs via an accessory pathway, EKG shows the characteristic change of QRS morphology from beat to beat. AF in WPW at the rapid ventricular rate (RVR) of 180-200 beats/minute appears as "pseudo-regularized" and above 300 beats/minute degenerate into V.fib. 

Primary VT is very uncommon in WPW.



1. Josephson ME. Preexcitation syndromes. In: Clinical Cardiac Electrophysiology, 4th, Lippincot Williams & Wilkins, Philadelphia 2008. p.339.

2. Campbell RW, Smith RA, Gallagher JJ, et al. Atrial fibrillation in the preexcitation syndrome. Am J Cardiol 1977; 40:514. 

3. Sharma AD, Klein GJ, Guiraudon GM, Milstein S. Atrial fibrillation in patients with Wolff-Parkinson-White syndrome: incidence after surgical ablation of the accessory pathway. Circulation 1985; 72:161.

Monday, April 26, 2021

side effect of ACE-I/ARBs

 Q: Which side effect of Angiotensin-Converting Enzyme (ACE) inhibitors can be used as a treatment in post-transplant patients?

Answer: Anemia

ACE inhibitors as well as Angiotensin II receptor blockers (ARBs) suppress erythropoietin. This suppression is enhanced in patients with renal insufficiency. This occurs due to accumulation of the compound N-acetyl-seryl-aspartyl-lysyl-proline. This compound causes inhibition of stem cell multiplication. This side effect of ACE-I and ARBs is used in two forms of anemia

  •  posttransplant erythrocytosis, and 
  • high altitude increase in red cells 



1. Yildiz A, Cine N, Akkaya V, et al. Comparison of the effects of enalapril and losartan on posttransplantation erythrocytosis in renal transplant recipients: prospective randomized study. Transplantation 2001; 72:542. 

2. Plata R, Cornejo A, Arratia C, et al. Angiotensin-converting-enzyme inhibition therapy in altitude polycythaemia: a prospective randomised trial. Lancet 2002; 359:663.

Sunday, April 25, 2021

PGD in Transplantation

 Q: All of the following are considered as causes of primary graft dysfunction (PGD) EXCEPT? (select one) 

A) preexisting donor heart disease 

B) reperfusion injury 

C) massive blood transfusion 

D)ischemia during the process of organ recovery

Answer: C

The consensus conference on primary graft dysfunction after cardiac transplantation (Reference # 1) defines PGD as: "Left Ventricular (LV), Right Ventricular (RV) or biventricular dysfunction that occurs within 24 hours after surgery and is not associated with a discernible cause such as hyperacute rejection, pulmonary hypertension, or uncontrolled intraoperative bleeding resulting in massive blood product transfusions and prolonged graft ischemic time". 

Hyperacute rejection, volume overload, and pulmonary hypertension in the recipient's heart are all considered as secondary graft dysfunction. 



1. Kobashigawa J, Zuckermann A, Macdonald P, et al. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant 2014; 33:327.

Saturday, April 24, 2021


 Q: Trazodone is a good choice for patients in ICU with complaints of Restless leg syndrome (RLS)?

A) True

B) False

Answer: B

Serotonergic agents i.e., trazodone or mirtazapine makes RLS symptoms worse and should not be used exclusively for this purpose. Similarly, benzodiazepine receptor agonists (BZRAs) like zolpidem can also increase the risk for complex sleep-related behaviors. 

Drugs recommended for RLS are dopamine agonists such as cabergoline, lisuride, pergolide, pramipexole, ropinirole, and rotigotine. Cabergoline and pramipexole are found to be superior to other dopamine agonists. Also, alpha-2-delta ligands i.e. gabapentin and pregabalin are also found to be useful. 



1. Aurora RN, Kristo DA, Bista SR, et al. The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline. Sleep 2012; 35:1039. 

2. Scholz H, Trenkwalder C, Kohnen R, et al. Dopamine agonists for restless legs syndrome. Cochrane Database Syst Rev 2011; :CD006009. 

3. Allen RP, Chen C, Garcia-Borreguero D, et al. Comparison of pregabalin with pramipexole for restless legs syndrome. N Engl J Med 2014; 370:621. 

4. Trenkwalder C, Benes H, Grote L, et al. Cabergoline compared to levodopa in the treatment of patients with severe restless legs syndrome: results from a multi-center, randomized, active controlled trial. Mov Disord 2007; 22:696. 

5. Bassetti CL, Bornatico F, Fuhr P, et al. Pramipexole versus dual release levodopa in restless legs syndrome: a double blind, randomised, cross-over trial. Swiss Med Wkly 2011; 141:w13274.

Friday, April 23, 2021

Components of SVR

 Q: Systemic Vascular Resistance (SVR) is determined by all of the following EXCEPT? (select one)

A) Afterload 

 B) Vessel length 

C) Vessel tone 

D) Vessel diameter 

E) Blood viscosity

Answer: A

Hemodynamic stability vs instability is basically determined at bedside by the vital of systemic blood pressure (BP)


 Where BP is Blood-Pressure, CO is Cardiac-Output and SVR is Systemic Vascular Resistance. 

 On further refinement 

 CO = HR X SV 

 Where HR is Heart Rate and SV is Stroke Volume 

 The stroke volume is determined by three entities 

  •  Preload 
  •  Myocardial contractility 
  •  Afterload 

 and SVR is determined by: 

  •  Vessel length 
  •  Blood viscosity 
  •  Vessel diameter, and 
  •  Vessel tone
Afterload (choice A) is more of a determinant of SV than SVR.



1. Bighamian R, Hahn JO. Relationship between stroke volume and pulse pressure during blood volume perturbation: a mathematical analysis. Biomed Res Int. 2014;2014:459269. doi:10.1155/2014/459269 

2. Reynolds HR, Hochman JS. Cardiogenic shock current concepts and improving outcomes. Circulation. 2008;117(5):686–697

Thursday, April 22, 2021

Vitals in acute opioid toxicity

 Q: Which of the following is the best predictor of severity of acute opioid toxicity?

A) constricted pupils 

B) decreased respiration 

C) altered mental status 

D) decreased bowel sounds 

E) altered temperature 

 Answer: B

Decreased respiratory rate is consistently found to be the best predictor of acute opioid toxicity as well as response to antidote i.e., naloxone. 

The pupillary exam can be very unreliable (choice A) as patient may have co-abuse sympathomimetics or anticholinergics. Mental status not necessarily to be depressed in acute opioid toxicity. A patient can be very euphoric. (choice C). Similarly, this is true for bowel sounds (choice D) and temperature (choice E).



Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med 1991; 20:246.

Wednesday, April 21, 2021

"sonographic Murphy's sign"

 Q: A "sonographic Murphy's sign" is more reliable than a manual Murphy's sign? 

A) True 

B) False

Answer: A

Positive murphy's sign is considered a hallmark in the diagnosis of acute cholecystitis. It is considered positive if during deep palpation of the right upper quadrant (RUQ) patient is asked to take a deep breath and if he/she abruptly holds the breath due to the severity of pain.

A similar response can be elicited from the transducer (probe) during RUQ ultrasound. It is found to be more accurate and reliable than conventional Murphy's sign, as stone and bile duct can be visualized at the same time, and correlation can be established. 

Historical trivia: Murphy's sign is named after an American surgeon John Benjamin Murphy (1857–1916) who was simultaneously a general, orthopedics, neuro, and cardiothoracic surgeon.



1. Kiewiet JJ, Leeuwenburgh MM, Bipat S et-al. A systematic review and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology. 2012;264 (3): 708-20. doi:10.1148/radiol.12111561 

2.  Jackson PG, Evans SRT. 2017. Sabiston Textbook of Surgery. 20th ed. New York (NY). Chapter 54, The biliary system, p.1482-1519. 

3. Musana K, Yale SH. John Benjamin Murphy (1857 - 1916). (2005) Clinical medicine & research. 3 (2): 110-2

Tuesday, April 20, 2021

Terson syndrome

Q: What is Terson syndrome? 

Answer: Terson syndrome is the presence of intraocular hemorrhages in association with hypertension. If this occurs in Sub-Arachnoid Hemorrhage (SAH), it implies poor prognosis and potentially high mortality. These patients usually lies at the higher grade on Hunt and Hess scale. This is due to abrupt increase in intracranial pressure (ICP). 

Clinicians should look it differently from relatively more benign retinal hemorrhages present in SAH. Although it is mostly pre-retinal but it can be sub-retinal, retinal, sub-hyaloidal, or intra-vitreal.



1. Medele RJ, Stummer W, Mueller AJ, Steiger HJ, Reulen HJ. "Terson's syndrome in subarachnoid hemorrhage and severe brain injury accompanied by acutely raised intracranial pressure". J. 1998. Neurosurg. 88 (5): 851–4. doi:10.3171/jns.1998.88.5.0851. PMID 9576253. 

2. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2004; 75:491. 

3. Suarez JI. Diagnosis and Management of Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2015; 21:1263. 

4. Terson A. "De l'hémorrhagie dans le corps vitre au cours de l'hémorrhagie cerebrale". Clin Ophthalmol. 6: 309–12. 1900

Monday, April 19, 2021

serum amylase in hypertriglyceridemia-induced pancreatitis

Q: Why serum amylase may stay normal in hypertriglyceridemia-induced pancreatitis? 

 Answer: Serum amylase level comes out normal in hypertriglyceridemia-induced pancreatitis due to a circulatory inhibitor which interferes with the assay. This is usually a case when plasma triglyceride levels are higher than 500 mg/dL. 

Experienced laboratory personnel can recognize lactescent plasma and can provide true serum amylase value by serial dilution techniques. 



1. Howard JM, Reed J. Pseudohyponatremia in acute hyperlipemic pancreatitis. A potential pitfall in therapy. Arch Surg 1985; 120:1053. 

2. Fallat RW, Vester JW, Glueck CJ. Suppression of amylase activity by hypertriglyceridemia. JAMA 1973; 225:1331.

3. Wong EC, Butch AW, Rosenblum]L. The clinical chemistry laboratory and acute pancreatitis. Clin Chem 1993;39:234-43.

Sunday, April 18, 2021

physiologic reasons for high alkaline phosphatase

 Q; Patients may have elevated alkaline phosphatase (AP) depending on their blood type? 

A) True 

B) False 


In the human body, there are two major sources of AP: liver and bones. Also, there are many physiologic reasons for elevated AP, for which no further intervention or investigation is required. Some of such conditions are:

1. Third trimester of pregnancy. This is due to the influx of the placental AP in maternal blood. 

2. Infants, toddlers, and adolescents due to increased osteoblastic activity. 

3. Women in the age group 40 and above. This correlates with higher age. 

4. Diabetes mellitus. 

5. Familial increased intestinal alkaline phosphatase. 

6. Interestingly people with blood types O and B may have elevated AP after eating a fatty meal.



1. Siddique A, Kowdley KV. Approach to a patient with elevated serum alkaline phosphatase. Clin Liver Dis. 2012;16(2):199-229. doi:10.1016/j.cld.2012.03.01

2. Lowe D, Sanvictores T, John S. Alkaline Phosphatase. 2020 Aug 30. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083622.

3. Nannipieri M, Gonzales C, Baldi S, et al. Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study. Diabetes Care 2005; 28:1757.

4. Lieverse AG, van Essen GG, Beukeveld GJ, et al. Familial increased serum intestinal alkaline phosphatase: a new variant associated with Gilbert's syndrome. J Clin Pathol. 1990;43(2):125-128. doi:10.1136/jcp.43.2.125

Saturday, April 17, 2021

diagnostic criteria of Kawasaki disease (KD)

 Q: The diagnostic criteria of Kawasaki disease (KD) requires fever for at least? (select one)

A) 3 days

B) 5 days

C) 7 days

D) 10 days

E) 2 weeks

Answer: B

Kawasaki disease is mostly presents in children but sometimes may occur in adults too (reference # 2). The most profound hallmark feature of KD is fever above 101.3ºF which remains unresponsive to antipyretics. For KD, fever should last more than 5 days. Besides, four out of the five criteria should be present. 

Criteria were presented more than five decades ago by Dr. Kawasaki T. as "Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children".  

  1. Changes in extremities: Acute erythema and edema of hands and feet and in the convalescent period, membranous desquamation of fingertips.
  2. Polymorphous exanthema.
  3. Bilateral, painless bulbar conjunctival injection without exudate.
  4. Changes in lips and oral cavity: Erythema and cracking of lips, strawberry tongue, diffuse injection of oral and pharyngeal mucosae.
  5. Cervical lymphadenopathy (≥1.5 cm in diameter) is usually unilateral.

Cardiac involvement is not required to diagnose KD though it strongly supports the diagnosis.



1. Kawasaki T. [Acute febrile mucocutaneous syndrome with lymphoid involvement with specific desquamation of the fingers and toes in children]. Arerugi 1967; 16:178. 

2. Anne E. et. al. Acute Kawasaki Disease: Not Just for Kids J Gen Intern Med. 2007 May; 22(5): 681–684. doi: 10.1007/s11606-006-0100-5 PMCID: PMC1852903 PMID: 17443379 

3.  Burns JC, Glodé MP. Kawasaki syndrome. Lancet 2004; 364:533.

Friday, April 16, 2021

folate, folic acid, folinic acid, and 5-methyltetrahydrofolate

 Q: What is the difference between folate, folic acid, folinic acid, and 5-methyltetrahydrofolate (5-MTHF)? 

 Answer: Although folate and folic acid are used interchangeably, technically they are different terms. 

  • Folate in actuality is vitamin B-9 and comes naturally from plant-based foods and fortified grains.  
  • Folic acid is the synthetic oxidized, water-soluble form.
  • Folinic acid and 5-MTHF are also naturally occurring, and are reduced forms of folate. 

 Clinical implications: 

1. Folic acid, folinic acid, and 5-MTHF are all effective in treating folate deficiency. 

2. Folinic acid has a special clinical advantage in preventing toxicities of methotrexate but potentiating the cytotoxicity of fluorouracil (chemotherapy agent).



1. Scaglione F, Panzavolta G. Folate, folic acid and 5-methyltetrahydrofolate are not the same thing. Xenobiotica 2014; 44:480. 

2. Kelly GS. Folates: supplemental forms and therapeutic applications. Altern Med Rev 1998; 3:208.

Thursday, April 15, 2021


 Q: 48 years old female is admitted to ICU with severe abnormal uterine bleeding (AUB). Ob-Gyn service is called while ICU service worked on hemodynamic stabilization. At the bedside service requests for sterile saline. What is the purpose of sterile saline in Ob-Gyn examination and in AUB?

Answer: Instilling sterile saline directly into the uterine cavity via the cervix during ultrasound of the uterus enhances endometrial visualization. It helps in delineate different endometrial pathologies like polyps, hyperplasia, cancer, leiomyomas, or adhesions. A recent version of Saline Infusion Sonography (SIS) is to replace saline with hydroxyethylcellulose gel, which provides a relatively more stable filling of the uterine cavity and does not require continuous installation. In severe AUB a balloon tamponade can be used with saline infusion to control heavy bleeding. 

Although SIS is a very safe procedure in experienced hands there is always a concern about disseminating infection and carcinoma. SIS may give rise to false diagnoses due to blood clots, debris, mucus plugs, and other artifacts.



1. American College of Obstetricians and Gynecologists. ACOG Technology Assessment in Obstetrics and Gynecology No. 5: sonohysterography. Obstet Gynecol 2008; 112:1467. 

2. Guideline developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of Sonohysterography. J Ultrasound Med 2015; 34:1.

3. Chawla I, Tripathi S, Vohra P, Singh P. To Evaluate the Accuracy of Saline Infusion Sonohysterography (SIS) for Evaluation of Uterine Cavity Abnormalities in Patients with Abnormal Uterine Bleeding. J Obstet Gynaecol India. 2014;64(3):197-201. doi:10.1007/s13224-013-0501-4 

4. Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand 2000; 79:321.

Wednesday, April 14, 2021

How Linezolid works in anthrax?

 Q: How Linezolid works in anthrax?

Answer: Linezolid has a fascinating mechanism of action in infections with Bacillus anthracis. Although so far it has been mostly demonstrated in vitro it has been proposed as a better treatment option in Anthrax. It abolishes the toxin production 100 percent and reduces the sporulation in Bacillus anthracis. 

Linezolid was found superior to ciprofloxacin, which is so far considered the standard of treatment in Bacillus anthracis (reference # 3)



1. Head BM, Alfa M, Sitar DS, et al. In vitro evaluation of the effect of linezolid and levofloxacin on Bacillus anthracis toxin production, spore formation and cell growth. J Antimicrob Chemother 2017; 72:417. 

2. Hendricks KA, Wright ME, Shadomy SV, et al. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20. 

3. Louie A, Vanscoy BD, Heine HS 3rd, Liu W, Abshire T, Holman K, Kulawy R, Brown DL, Drusano GL. Differential effects of linezolid and ciprofloxacin on toxin production by Bacillus anthracis in an in vitro pharmacodynamic system. Antimicrob Agents Chemother. 2012 Jan;56(1):513-7. doi: 10.1128/AAC.05724-11. Epub 2011 Nov 7. PMID: 22064542; PMCID: PMC3256020.