Friday, December 31, 2021
Thursday, December 30, 2021
Q: 32 years old male is admitted to ICU with severe jaundice and liver insufficiency. Further workup led to the diagnosis of acute hepatitis B. Which of the following is expected to be seen in acute hepatitis B infection? (select one)
C) IgG Anti-HBC
D) IgM Anti-HBC
Reference:Anna SF Lok, Rafael Esteban, Jennifer Mitty, MD, MPH - Hepatitis B virus: Screening and diagnosis - UpToDate, 2021 Link: https://www.uptodate.com/contents/hepatitis-b-virus-screening-and-diagnosis
Wednesday, December 29, 2021
Dig and calcium
Despite the caveat that hypercalcemia may potentiate the cardiotoxicity of digitalis, calcium infusion is recommended to stabilize the cardiac membrane. In such a situation, calcium should be given slowly. Calcium gluconate is preferred over calcium chloride, as chloride formulation contains three times higher elemental calcium than gluconate version.
Calcium should be given as 10 mL of 10% Ca-gluconate in 100 mL of D-5 water over a period of half an hour. This prevents acute hypercalcemia and minimizes the cardiotoxic effect of "dig."
Said that digoxin-specific antibody fragments is the ideal treatment for symptomatic toxicity.
References:1. Levine M, Nikkanen H, Pallin DJ. The effects of intravenous calcium in patients with digoxin toxicity. J Emerg Med. 2011 Jan;40(1):41-6. doi: 10.1016/j.jemermed.2008.09.027. Epub 2009 Feb 6. PMID: 19201134.
Tuesday, December 28, 2021
Reappearance of Kayser-Fleischer
Q: 54 years old male with a history of liver transplantation seven years ago due to Wilson disease is admitted to ICU with sepsis. Kayser-Fleischer rings are noticed on physical exam. A review of chart shows that rings were noted to be disappeared on the last clinic visit about 2 years ago. The reappearance of Kayser-Fleischer rings signifies what?
Answer: Probable noncompliance
Kayser-Fleischer rings are brownish or gray-greenish rings in Descemet's membrane in the cornea, and they are close to the endothelial surface. They can be best seen on examination at the inferior and superior poles of the cornea. They are fine pigmented granular deposits of copper. Though they are not specific but highly suggestive of Wilson disease. Their presence also signifies neurological involvement.
Kayser-Fleischer rings gradually disappear with medical treatment or after a liver transplant. The reappearance of Kayser-Fleischer rings raises high suspicion of non-compliance. In our patient, another red flag is absence from the follow-up clinic for 2 years.
1. Song HS, Ku WC, Chen CL. Disappearance of Kayser-Fleischer rings following liver transplantation. Transplant Proc. 1992 Aug;24(4):1483-5. PMID: 1496628.2. Suvarna JC. Kayser-Fleischer ring. J Postgrad Med. 2008 Jul-Sep;54(3):238-40. doi: 10.4103/0022-3859.41816. PMID: 18626182.
Monday, December 27, 2021
Sleep issues of ICU workforce
Q: ICU workforce at night can eliminate sleepiness by daytime sleep?
Intensivists, mid-levels, nurses, respiratory therapists, pharmacists, and all other healthcare workers who work at night or on schedule with rotating day/night shifts struggle with sleep cycles.
Unfortunately, daytime sleep does not fully eliminate sleepiness during the nocturnal hours.
One effective trick is to take a short (power) nap either just before or during the shift. Nap is recommended to be restricted below an hour to avoid entering the deep-sleep phase and disorientation from sleep inertia.
Coffee: Coffee helps! but should be limited to the early half of the night shift to avoid insomnia later in the day. One study showed that one single cup/dose of coffee/caffeine at the beginning of the night shift is better than the intermittent or divided doses throughout the shift 6. This prevents tolerance to caffeine.
Wake-promoting agent i.e., modafinil or armodafinil has been suggested during the shift but should be monitored and prescribed by an experienced clinician.
1. Schweitzer PK, Randazzo AC, Stone K, et al. Laboratory and field studies of naps and caffeine as practical countermeasures for sleep-wake problems associated with night work. Sleep 2006; 29:39.
2. Sallinen M, Härmä M, Akerstedt T, et al. Promoting alertness with a short nap during a night shift. J Sleep Res 1998; 7:240.
3. Purnell MT, Feyer AM, Herbison GP. The impact of a nap opportunity during the night shift on the performance and alertness of 12-h shift workers. J Sleep Res 2002; 11:219.
4. Bonnefond A, Muzet A, Winter-Dill AS, et al. Innovative working schedule: introducing one short nap during the night shift. Ergonomics 2001; 44:937.
5. Ker K, Edwards PJ, Felix LM, et al. Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database Syst Rev 2010; :CD008508.6. Walsh JK, Muehlbach MJ, Schweitzer PK. Hypnotics and caffeine as countermeasures for shiftwork-related sleepiness and sleep disturbance. J Sleep Res 1995; 4:80.
Sunday, December 26, 2021
hematology in hyperthyroidism
Q: Which is more common in hyperthyroidism? (select one)
Contrary to the expectation, despite an increase in red blood cell mass, patients with hyperthyroidism have normochromic, normocytic anemia. This is due to an increase in plasma volume. Another factor that plays a part is pernicious anemia.
These patients may also have immune thrombocytopenia (ITP) and antineutrophil antibodies. These patients may also have high serum ferritin.
Paradoxically, these patients have high prothrombotic factors, which include factors VIII, IX, fibrinogen, von Willebrand factor, and plasminogen activator inhibitor-1. This makes these patients prothrombotic.
1. Nightingale S, Vitek PJ, Himsworth RL. The haematology of hyperthyroidism. Q J Med 1978; 47:35.
2. Franchini M, Lippi G, Targher G. Hyperthyroidism and venous thrombosis: a casual or causal association? A systematic literature review. Clin Appl Thromb Hemost 2011; 17:387.
3. Stuijver DJ, van Zaane B, Romualdi E, et al. The effect of hyperthyroidism on procoagulant, anticoagulant and fibrinolytic factors: a systematic review and meta-analysis. Thromb Haemost 2012; 108:1077.
Friday, December 24, 2021
BP control in DKD
Q: In patients with severe albuminuria in Diabetic Kidney Disease (DKD), angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARBs) is preferred to be combined with? (select one)
A) calcium channel blocker
The objective of this question is to highlight the importance of intensive blood pressure (BP) control in DKD and severe albuminuria. Intensive blood sugar and BP control go hand in hand to prevent or prolong time to End-Stage Renal Disease (ESRD) and cardiovascular (CV) events.
Either an ACE-I or ARBs (NOT BOTH) is the first line of treatment. It should be ideally combined with a dihydropyridine calcium channel blocker. In extremely high albuminuria, a nephrologist may decide to add a diuretic and/or use a nondihydropyridine calcium channel blocker.
Beta-blocker can be added in patients who already have CV pathology or if a clinician will appropriate per a patient situation.
1. Patney V, Whaley-Connell A, Bakris G. Hypertension Management in Diabetic Kidney Disease. Diabetes Spectr. 2015;28(3):175-180. doi:10.2337/diaspect.28.3.175
2. Sugahara M, Pak WLW, Tanaka T, Tang SCW, Nangaku M. Update on diagnosis, pathophysiology, and management of diabetic kidney disease. Nephrology (Carlton). 2021 Jun;26(6):491-500. doi: 10.1111/nep.13860. Epub 2021 Feb 17. PMID: 33550672.
Thursday, December 23, 2021
Acute akinesia in PD
Case: 72 years old male with long history of Parkinson's Disease (PD) is admitted to ICU with acute akinesia.
Discussion: Acute akinesia can be fatal in patients with PD, and should be managed by experienced hands. This is different from the "freezing of Gait" (FOG) phenomenon. It is a sudden exacerbation of PD. Patient stays in an akinetic state for days and unfortunately is not very responsive to antiparkinsonian meds.
The two major causes are underlying infection/sepsis and manipulation/error of antiparkinsonian drugs. A potential cause particularly in hospitalized patients is the administration of a dopamine receptor blocker or an antipsychotic drug with dopamine blocking properties.
It should be watched closely in PD patients after surgeries. Diarrhea can also cause acute akinesia.
Onofrj M, Thomas A. Acute akinesia in Parkinson disease. Neurology 2005; 64:1162.
Wednesday, December 22, 2021
Oxygen in SCD
Q: Application of supplemental oxygen helps in relieving acute vaso-occlusive pain crisis in Sickle Cell Disease (SCD) and should be routinely applied:
Supplemental and routine use of oxygen is not encouraged in patients who present with acute vaso-occlusive pain crisis in SCD unless there is significant evidence of hypoxia or oxygen desaturation. This is due to the fact that supplemental oxygen may mask the decline in respiratory status, and may delay recognition of any comorbidity occurring simultaneously.
Supplemental oxygen's value in acute pain crisis is not established.
Reference:Michael R DeBaun - Acute vaso-occlusive pain management in sickle cell disease -
Tuesday, December 21, 2021
Vitamin K test
Q: What is 'Vitamin K test' in the evaluation of jaundice?
Answer: First described 80 years ago, vitamin K can be used to differentiate between obstructive jaundice and jaundice due to hepatocellular injury.If an elevated INR can be corrected with exogenous vitamin K, it signifies impaired intestinal absorption of fat-soluble vitamins. It is compatible with obstructive jaundice. In contrast, if INR continue to stay elevated despite vitamin K administration, it predicts hepatocellular pathology. Impaired hepatic function keeps INR elevated despite vitamin K on board. Heparocellular damage is mostly accompanied by hypoalbuminemia.
Monday, December 20, 2021
High dose steroid & adjuvant Rx
Q: 28 years old female is admitted to ICU with exacerbation of Multiple Sclerosis (MS) and started on high dose steroid. What two adjuvant treatments may help to blunt the adverse effects?
Answer: MS patients usually require a short course of a gram of prednisolone per day. The two notable side effects can be gastritis and psychiatric symptoms. Psychiatric disturbances can be depressive, manic, or hypomanic. It may help to add
- proton pump inhibitor (PPI), and
Sunday, December 19, 2021
Q: The risk of transfusion-transmitted bacterial infection (TTBI) is increased by the longer shelf life of blood products.
Although increased storage time of blood products may increase the risk of TTBI, it should not prompt the clinicians to ask for fresh blood products from a blood bank, which can create a massive disruption of blood supplies.
Said that in the case of documented TTBI, all factors should be identified including the shelf life of the product.
It is impossible to distinguish TTBI and acute hemolytic transfusion reactions. A protocol in any such event should be promptly initiated to support patient's hemodynamic and to determine the cause of either TTBI or hemolytic reaction. Being a clinician at the bedside, it should be ensured that blood workup ordered such as culture, Coombs test, plasma-free hemoglobin, and type/crossmatch should be drawn from the arm other than the arm with IV infusion. In case of central line infusion, an attempt should be made to draw blood from the peripheral site away from the central line site.
1. Dellinger EP, Anaya DA. Infectious and immunologic consequences of blood transfusion. Crit Care 2004; 8 Suppl 2:S18.
2. Wagner SJ. Transfusion-transmitted bacterial infection: risks, sources and interventions. Vox Sang. 2004 Apr;86(3):157-63. doi: 10.1111/j.0042-9007.2004.00410.x. PMID: 15078249.
3. Suddock JT, Crookston KP. Transfusion Reactions. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29489247.
Saturday, December 18, 2021
Q: What are the criteria to make clinical diagnosis of acute cholangitis?
Answer: The objective of this question is to highlight the fact that the diagnosis of acute cholangitis requires - all four - systemic, hepatic, laboratory as well as radiological evidence.
Diagnosis of acute cholangitis requires demonstration of systemic inflammation with one of the following:
- Fever and/or shaking chills or any laboratory evidence such as leukocytosis or elevated CRP
And both of the following:
- Evidence of cholestasis with bilirubin ≥2 mg/dL, elevated alkaline phosphatase, GGTP, or transaminases 1.5 times the normal.
- Radiological evidence such as ultrasound
Friday, December 17, 2021
Q: The risk of purple glove syndrome (PGS) due to phenytoin is _____________ by administering it via central line? (select one)
The pathogenesis of purple glove syndrome is very poorly understood. It occurs only with intravenous infusions (though one case has been reported with oral ingestion 5), which gives the presumption that it may be related to leakage into soft tissue. This is further confirmed by the fact that arterial dopplers usually stays normal, and symptoms occur only on the arm receiving phenytoin.
Associated symptoms are edema, blistering, pain, and purple discoloration. Histopathology shows superficial venous thrombosis. Due to its association only with intravenous form, it is proposed that actual culprits are added preservatives i.e., propylene glycol and sodium hydroxide.
1. O'Brien TJ, Cascino GD, So EL, Hanna DR. Incidence and clinical consequence of the purple glove syndrome in patients receiving intravenous phenytoin. Neurology 1998; 51:1034.
2. Santoshi JA, Justin AS, Jacob JI, et al. Purple glove syndrome: a case report. Hand surgeons and physicians be aware. J Plast Reconstr Aesthet Surg 2010; 63:e340.
3. Chokshi R, Openshaw J, Mehta NN, Mohler E 3rd. Purple glove syndrome following intravenous phenytoin administration. Vasc Med 2007; 12:29.
4. Bhattacharjee P, Glusac EJ. Early histopathologic changes in purple glove syndrome. J Cutan Pathol 2004; 31:513.
5. Yoshikawa H, Abe T, Oda Y. Purple glove syndrome caused by oral administration of phenytoin. J Child Neurol 2000; 15:762.
Thursday, December 16, 2021
Anbx in pancreatitis
Q: Antibiotics are indicated along with antifungals in severe acute pancreatitis.
Infections occur only in one-fifth of patients with acute pancreatitis. In general, prophylactic antibiotics are not recommended, and this is irrespective of severity. Also, the development/demonstration of interstitial or necrotizing pancreatitis should not prompt automatic initiation of antibiotics.
Said that, a clinician should start broad-spectrum antibiotics if an infection is suspected. Simultaneously, appropriate de-escalation is advised.
Prophylactic antifungal is not recommended to be added along with antibiotics unless there is a high suspicion of fungal infection.
1. Soulountsi V, Schizodimos T. Use of antibiotics in acute pancreatitis: ten major concerns. Scand J Gastroenterol. 2020 Oct;55(10):1211-1218. doi: 10.1080/00365521.2020.1804995. Epub 2020 Aug 17. PMID: 32805137.
2. Beger HG, Gansauge F, Poch B, Schwarz M. The use of antibiotics for acute pancreatitis: is there a role? Curr Infect Dis Rep. 2009 Mar;11(2):101-7. doi: 10.1007/s11908-009-0015-5. PMID: 19239799.
3. Golub R, Siddiqi F, Pohl D. Role of antibiotics in acute pancreatitis: A meta-analysis. J Gastrointest Surg. 1998 Nov-Dec;2(6):496-503. doi: 10.1016/s1091-255x(98)80048-6. PMID: 10457308.
4. Trikudanathan G, Navaneethan U, Vege SS. Intra-abdominal fungal infections complicating acute pancreatitis: a review. Am J Gastroenterol 2011; 106:1188.
Wednesday, December 15, 2021
Q: 73 years old male with a known history of Parkinson's Disease is admitted to ICU with high fever and symptoms like "Neuroleptic Malignant Syndrome" (NMS). Patient's levodopa should be? (select one)
A) completely stopped
B) started at previous dose
C) cut into half
D) escalate the dose
Patient has probably developed parkinsonism-hyperpyrexia syndrome (PHS) which is very much like NMS. This mostly occurs during the dose adjustment phase of levodopa. These patients simultaneously require management on two aspects, readjusting the levodopa dose and controlling the severe symptoms. Levodopa (or if any other Dopamine Agonist is used), the dose should be brought back prior to adjustment. These patients usually can't swallow. Naso-Gastric tube (NGT) should be inserted as the first line of treatment and levodopa should be given - again with the dose prior to the adjustment - as soon as possible.
If NGT can not be inserted, apomorphine should be given intravenously. Apomorphine can be given as scheduled doses or in continuous infusion. If neither NGT can be inserted or IV can be obtained, rotigotine can be given transdermally.
PHS symptoms are treated as NMS with dantrolene, bromocriptine, and/or amantadine.
References:1. Newman EJ, Grosset DG, Kennedy PG. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care 2009; 10:136.
Tuesday, December 14, 2021
Mixed cryoglobulinemia and platelet counts
Q: Mixed cryoglobulinemia may give false? (select one)
The objective of this question is to highlight the importance of blood smears. In many conditions, automated counter machines may give erroneous values. One example is mixed cryoglobulinemia. When a blood sample is tested at a temperature ≤30°C, precipitated cryoglobulin particles get falsely counted as platelets. To obtain true platelet count in a patient with mixed cryoglobulinemia the blood sample needs to be maintained at body temperature until the testing.
Other conditions which may cause pseudothrombocytosis by the automated counter machine are leukemia or lymphoma cells, hemolysis, or burns where circulating cytoplasmic fragments or fragmented red cells may be falsely read as platelets.
1. Hutchinson CV, Stelfox P, Rees-Unwin KS. Needle-like cryoglobulin crystals presenting as spurious thrombocytosis. Br J Haematol 2006; 135:280.
2. Ballard HS, Sidhu G. Cytoplasmic fragments causing spurious platelet counts in hairy cell leukemia: ultrastructural characterization. Arch Intern Med 1981; 141:942.
3. Berkessy S. [Cytoplasm fragmentation of malignant lymphoma cells]. Folia Haematol Int Mag Klin Morphol Blutforsch 1983; 110:651.
4. Lawrence C, Atac B. Hematologic changes in massive burn injury. Crit Care Med 1992; 20:1284.
Monday, December 13, 2021
heart rate and pulse pressure
Q: Bradycardia ______________ the pulse pressure? (pick one)A) decreases
Sunday, December 12, 2021
Q: What is PERC rule for Pulmonary embolism?
Answer: The PERC rule stands for Pulmonary Embolism Rule-out Criteria. There are eight components of it and if patient meets all of them, the PE can be ruled out with good confidence. It is clinically described as a low clinical probability of PE - and further testing can be avoided.
- Age less than 50
- Heart rate less than 100
- Saturation more than/equal to 95%
- No hemoptysis
- No estrogen use
- No prior DVT/PE
- No unilateral leg swelling
- No hospitalization in prior 4 weeks due to surgery/trauma
Saturday, December 11, 2021
sildenafil and left ventricular (LV) contractility
Q: Sildenafil (select one)
A) increases the left ventricular (LV) contractility
B) reduces the left ventricular (LV) contractility
Answer: BSildenafil is a selective type 5 phosphodiesterase (PDE-5) inhibitor. Although its clinical efficacy has been established in Erectile Dysfunction and pulmonary hypertension, so far it has not shown any major benefit in congestive heart failure (CHF). It has three main effects in hemodynamic.
- It decreases the pulmonary vascular resistance
- It lowers the systemic arterial load
- It reduces the left ventricular (LV) contractility
Friday, December 10, 2021
Q; 44 years old female is admitted to ICU with seizures and Bupropion overdose. Hemodialysis is indicated?
The objective of this question is to highlight the fact that hemodialysis has no role in serotonin-norepinephrine reuptake inhibitors (SNRIs) and nonselective serotonin reuptake inhibitors (non-SSRIs).
It includes venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta), milnacipran (Savella), mirtazapine (Remeron), and bupropion (Wellbutrin, Zyban).This is due to their large volume of distribution.
Thursday, December 9, 2021
Right sided and posterior EKGs
Q: If posterior wall ischemia is suspected on EKG, it may help to obtain another EKG by putting? (select one)
A) V4, V5, and V6 leads on right side of the lower anterior chest area
B) V7, V8, and V9 leads below the left scapula area
If posterior wall ischemia is suspected due to prominent R waves and ST depressions in leads V1 and V2 on initial EKG, it may help to do another EKG by putting leads V7, V8, and V9 below scapula (posteriorly on the chest). This will demonstrate ST elevation on lead V4, V5 and V6.
Similarly, if inferior wall ischemia is expected in leads II, III, and aVF, putting leads V4R, V5R, and V6R at right sight of the chest will show significant ST elevations in these Leads. This is popularly known as right-sided EKG.
References:1. Katoh T, Ueno A, Tanaka K, Suto J, Wei D. Clinical significance of synthesized posterior/right-sided chest lead electrocardiograms in patients with acute chest pain. J Nippon Med Sch. 2011;78(1):22-9. doi: 10.1272/jnms.78.22. PMID: 21389644.
Wednesday, December 8, 2021
Antocoagulation after reperfusion therapy
Q: Which of the following is most unlikely to be used as anticoagulation after fibrinolytic therapy in acute ST-elevation myocardial infarction (STEMI)? (select one)
B) unfractionated heparin
Most cardiologists follow STEMI patients who receive fibrinolytic therapy with an anticoagulant. Unfractionated heparin (choice A) is usually the treatment of choice as it can be easily measured with PTT, has a relatively short half-life, and easy to maneuver if coronary stent is carried out.
Many clinicians prefer enoxaparin (choice B) as literature leans towards its efficacy after fibrinolytic therapy, and less danger of Heparin-Induced Thrombocytopenia (HIT).
Fondaparinux (choice C) is not the first line of choice in this situation but can be used if required.
Bivalirudin (angiomax) (choice D) is usually avoided as evidence shows increased risk of moderate bleeding. Also, there is no data available to compare it with Placebo. This may change in the future if more data is available.
Reference:White H, Hirulog and Early Reperfusion or Occlusion (HERO)-2 Trial Investigators. Thrombin-specific anticoagulation with bivalirudin versus heparin in patients receiving fibrinolytic therapy for acute myocardial infarction: the HERO-2 randomised trial. Lancet 2001; 358:1855.
Tuesday, December 7, 2021
HIV and statin
Q: 47 years old male with history of HIV who is on chronic antiretroviral treatment (ART) is admitted to ICU status post coronary stents after acute myocardial infarction. Out of the following which statin should be avoided? (select one)
The objective of this question is to highlight the importance of understanding the risk of statin therapy in HIV patients on ART. As HIV patients are now mostly living a normal life span and statins are among one of the most commonly prescribed drugs, it is of paramount importance to involve a clinical pharmacist to choose statin in this patient population.
HIV protease inhibitors and boosting agents are strong inhibitors of CYP3A4. Simvastatin and lovastatin are highly dependent upon CYP3A4 for clearance and should be avoided.
1. Chastain DB, Stover KR, Riche DM. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol. 2017 Feb 22;8:6-14. doi: 10.1016/j.jcte.2017.01.004. PMID: 29067253; PMCID: PMC5651339.
2. Singh S, Willig JH, Mugavero MJ, Crane PK, Harrington RD, Knopp RH, Kosel BW, Saag MS, Kitahata MM, Crane HM. Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients. Clin Infect Dis. 2011 Feb 1;52(3):387-95. doi: 10.1093/cid/ciq111. Epub 2010 Dec 28. PMID: 21189273; PMCID: PMC3106249.
Monday, December 6, 2021
Q: All of the following are associated with inflammatory abdominal aortic aneurysm (AAA) EXCEPT?
A) chronic abdominal pain
B) weight loss
C) elevated ESR
D) Increased incidence of rupture
If following triad is present with AAA, it highly suggests inflammatory AAA
- chronic abdominal pain
- weight loss
- elevated ESR
There is an interesting paradox in inflammatory AAA. Although there are more chances to be symptomatic when compared to the same size non-inflammatory AAA, the chance of actual rupture is low.
Said that, all symptomatic AAA require repair irrespective of size.
References:1. Tang T, Boyle JR, Dixon AK, Varty K. Inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2005 Apr;29(4):353-62. doi: 10.1016/j.ejvs.2004.12.009. PMID: 15749035.
Sunday, December 5, 2021
Case: 59 years old male with a history of kidney transplant due to polycystic kidney disease is admitted to ICU with massive pulmonary embolism. Initial workup showed hematocrit of 54 percent. What could be the probable diagnosis?
Answer: post-transplant erythrocytosis (PTE)
There are many risk factors that lead to post-transplant erythrocytosis (PTE). These include
- male gender
- a rejection-free course
- preserved GFR
- diuretic use
- longer duration of dialysis
- diabetes history
- polycystic kidney disease (PKD)
- glomerulonephritis as a cause of kidney failure
- retained native kidneys
First suspected four decades ago, retained native kidneys usually become the source of increased erythropoietin. The associated phenomenon is called "tertiary hypererythropoietinemia," where biological feedbacks that suppress erythropoietin become dysfunctional.
Treatment includes ACE inhibitors/ARBs and phlebotomy.
1. Vlahakos DV, Marathias KP, Agroyannis B, Madias NE. Posttransplant erythrocytosis. Kidney Int 2003; 63:1187.
2. Dagher FJ, Ramos E, Erslev AJ, et al. Are the native kidneys responsible for erythrocytosis in renal allorecipients? Transplantation 1979; 28:496.
3. Einollahi B, Lessan-Pezeshki M, Nafar M, et al. Erythrocytosis after renal transplantation: review of 101 cases. Transplant Proc 2005; 37:3101.4. Aeberhard JM, Schneider PA, Vallotton MB, et al. Multiple site estimates of erythropoietin and renin in polycythemic kidney transplant patients. Transplantation 1990; 50:613.
Saturday, December 4, 2021
Q: 28 years old male is admitted to ICU with hypovolemic shock due to severe diarrhea. All workup for infectious causes is negative. GI service ordered fecal calprotectin. What is the efficacy of this test in severe diarrhea?
Answer: Calprotectin is a zinc and calcium-binding protein. It is derived from neutrophils and monocytes, and a marker of neutrophil activity, particularly in mucosal inflammation. It has a very good negative value in diarrhea of undetermined etiology. If negative, inflammatory Bowel Disease (IBD) is unlikely as a cause of diarrhea. This test is also valuable as it correlates with the endoscopic disease activity of IBD and can further differentiate between active and inactive IBD.
This test is not a gold standard and should be used with other laboratory and fecal tests such as fecal lactoferrin, and colonoscopy.
1. Schoepfer AM, Beglinger C, Straumann A, et al. Fecal calprotectin correlates more closely with the Simple Endoscopic Score for Crohn's disease (SES-CD) than CRP, blood leukocytes, and the CDAI. Am J Gastroenterol 2010; 105:162.
2. Lobatón T, López-García A, Rodríguez-Moranta F, et al. A new rapid test for fecal calprotectin predicts endoscopic remission and postoperative recurrence in Crohn's disease. J Crohns Colitis 2013; 7:e641.
3. D'Haens G, Ferrante M, Vermeire S, et al. Fecal calprotectin is a surrogate marker for endoscopic lesions in inflammatory bowel disease. Inflamm Bowel Dis 2012; 18:2218.
4. Mosli MH, Zou G, Garg SK, et al. C-Reactive Protein, Fecal Calprotectin, and Stool Lactoferrin for Detection of Endoscopic Activity in Symptomatic Inflammatory Bowel Disease Patients: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2015; 110:802.
Friday, December 3, 2021
BL in HIV
Q: 34 years old male with a known history of HIV is admitted with life-threatening pneumonia. Patient is also diagnosed with Burkitt lymphoma (BL). Noncompliance to antiretroviral therapy (ART) should be suspected?
It is surprising that despite adherence to antiretroviral therapy (ART), the rate of BL doesn't go down in HIV patients. It is most prevalent in young HIV patients. Another paradox is its diagnosis in patients who have their CD4 count above 200 cells/microL.
This is in contrast to primary CNS lymphoma and/or non-CNS diffuse large B cell lymphoma which shows a correlation with lower CD4 counts.
1. Guech-Ongey M, Simard EP, Anderson WF, et al. AIDS-related Burkitt lymphoma in the United States: what do age and CD4 lymphocyte patterns tell us about etiology and/or biology? Blood 2010; 116:5600.
2. Ferry JA. Burkitt's lymphoma: clinicopathologic features and differential diagnosis. Oncologist 2006; 11:375.
3. Gabarre J, Raphael M, Lepage E, et al. Human immunodeficiency virus-related lymphoma: relation between clinical features and histologic subtypes. Am J Med 2001; 111:704.
Thursday, December 2, 2021
Sodium in meningitis
Q: Which is more common in acute bacterial meningitis? (select one)
Concomitant abnormal laboratory findings are common in acute bacterial meningitis. It includes leucocytosis or leukopenia, thrombocytopenia, DIC, anion gap metabolic acidosis, and hyponatremia.
Presence of leukopenia and/or thrombocytopenia is correlated with poor outcomes. On the other hand, the presence of hyponatremia has no bearing and doesn't require treatment.
1. Brouwer MC, van de Beek D, Heckenberg SG, et al. Hyponatraemia in adults with community-acquired bacterial meningitis. QJM 2007; 100:37.
2. Kaplan SL. Clinical presentations, diagnosis, and prognostic factors of bacterial meningitis. Infect Dis Clin North Am 1999; 13:579.
3. Kornelisse RF, Westerbeek CM, Spoor AB, et al. Pneumococcal meningitis in children: prognostic indicators and outcome. Clin Infect Dis 1995; 21:1390.
Wednesday, December 1, 2021
cholesterol pleural effusion
Q: Cholesterol pleural effusion should always be read in conjunction with serum cholesterol level?
Serum cholesterol is usually not elevated in cholesterol pleural effusions. There is no correlation.
High cholesterol level in pleural effusion is called cholesterol pleural effusion. The other names used are chyliform effusion or pseudochylothorax.
Note: Cholesterol effusion is not chylothorax.
Cholestol pleural effusion occurs due to chronic inflammation. The two most common causes are Mycobacterium tuberculosis and rheumatoid arthritis.
Cholestrol pleural effusion occurs during a chronic inflammatory situation where lysis of RBCs and neutrophils releases cholesterol and lipid constituents from degenerating cell membranes. Also, contributing phenomenon is the accumulation of serum lipids bound to low-density lipoproteins (LDLs) in pleural space during inflammation.
1. Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31:743.
2. Lama A, Ferreiro L, Toubes ME, et al. Characteristics of patients with pseudochylothorax-a systematic review. J Thorac Dis 2016; 8:2093.
3. Hamm H, Pfalzer B, Fabel H. Lipoprotein analysis in a chyliform pleural effusion: implications for pathogenesis and diagnosis. Respiration 1991; 58:294.
4. Prakash, UBS. Chylothorax and pseudochylothorax. Eur Respir Mon 2002; 7:249.
Tuesday, November 30, 2021
anticoagulation after WATCHMAN device
Q; 64 years old male with a longstanding history of atrial fibrillation is admitted to ICU after WATCHMAN DEVICE implantation. Patient anticoagulation should be stopped onwards?
WATCHMAN device is a percutaneous closure of Left Atrial Appendage (LAA). It is advisable to continue anticoagulation for 6 weeks after the procedure with either warfarin (keeping INR 2-3) or direct oral anticoagulant (DOAC) plus daily aspirin (81 or 325 mg).
If patient can't tolerate anticoagulation dual antiplatelet therapy (DAPT) should be kept on for one-six months (as per the clinician's discretion). Afterward, a patient can be managed only on daily aspirin.
It would be prudent to let the cardiology service manage the anticoagulation.
1. Pacha HM, Hritani R, Alraies MC. Antithrombotic Therapy After Percutaneous Left Atrial Appendage Occlusion Using the WATCHMAN Device. Ochsner J. 2018;18(3):193-194. doi:10.31486/toj.18.0012
2. Bergmann MW, Betts TR, Sievert H, Schmidt B, Pokushalov E, Kische S, Schmitz T, Meincke F, Stein KM, Boersma LVA, Ince H. Safety and efficacy of early anticoagulation drug regimens after WATCHMAN left atrial appendage closure: three-month data from the EWOLUTION prospective, multicentre, monitored international WATCHMAN LAA closure registry. EuroIntervention. 2017 Sep 20;13(7):877-884. doi: 10.4244/EIJ-D-17-00042. PMID: 28606886.
3. Enomoto Y and et. al. Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device. Heart Rhythm. 2017 Jan;14(1):19-24. doi: 10.1016/j.hrthm.2016.10.020. Epub 2016 Oct 19. PMID: 27771552.
Monday, November 29, 2021
Edinburgh Depression Scale
Q: 34 years old female with no significant past medical history is admitted to ICU with severe depression and suicidal ideation. Psychiatry service is called and details are given. Consultant asked you to obtain Edinburgh Depression Scale till they see the patient. In which particular situation Edinburgh Depression Scale is applied? (select one)
A) death of a loved one
C) recent diagnosis of cancer
D) unexpected divorce
E) unexpected death of a living child
Edinburgh Depression Postnatal Scale (EDPS) is an easy 10 items questionnaire. It is particularly designed to determine the severity of disease in postnatal period. In doubtful cases, it may be repeated in 2 weeks. The maximum possible score is 30. The score of 20 shifts the severity to a severe zone. Obstetric complications such as fetal loss, postpartum hemorrhage, or low fetal birth weight may play a part.
Caution: This scale is not meant for mothers with anxiety neuroses, phobias, or personality disorders.
Scale is freely available on search engines:
Authors request that: "Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies."
References:1. Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .
Sunday, November 28, 2021
FoCUS in PE
Q: What are the two evaluations in the diagnosis of pulmonary embolism (PE) with bedside focus cardiac ultrasound (FoCUS)?
Answer: Point Of Care Ultrasound (POCUS) and Focus Cardiac Ultrasound (FoCUS) has now become a standard of care in ICU management.
If the following two are demonstrated simultaneously on a patient, it almost confirms the diagnosis of PE:
- ratio of the size of Right Ventricle (RV) and Left Ventricle (LV) more than 1:1
- a floating thrombus in the RA, RV, or a clot in transit
Saturday, November 27, 2021
Vesicular lesion at the tip of the nose
Q; 52 years old male with history of renal insufficiency is recovering in ICU from community-acquired pneumonia. The patient develops zoster-like vesicular lesion at the tip and side of the nose. What's the underlying danger?
Answer: Herpes zoster ophthalmicus (HZO)
Friday, November 26, 2021
SUP in ICU
Q: At what level of International Normalized Ratio (INR), it would be prudent to add stress ulcer prophylaxis (SUP) in ICU patients? (select one)
A) > 1.5
B) > 2.0
Answer: AThere is a long list of risk factors which cause stress induced gastrointestinal (GI) bleed in ICU patients. Coagulopathy is high on the list. SUP is advisable if platelet count is less than 50,000/m3, INR above 1.5, or a partial thromboplastin time (PTT) > 2 times the control.
- Mechanical ventilation for more than 48 hours
- Septic shock
- Renal failure (including CRRT)
- Liver failure
- History of peptic ulcer with H.Pylori -or history upper GI bleed
- Burns (mostly over 35% of TBSA)
- Organ transplant
- Anti-platelet drugs or drugs prone to cause GI bleed like NSAIDs
Thursday, November 25, 2021
Wednesday, November 24, 2021
sense of smell
On olfaction (sense of smell)
One of the perks of COVID pandemic is the renewed interest in physical exam! It is widely reported that due to COVID, a patient may lose sense of taste and smell.
Olfaction is a test of first cranial nerve (CN I). It can be quickly tested by occluding one nostril with closed eyes and identify any common scent from the other nostril. Said that the proper evaluation of olfaction is itself a complicated science.
Said that, the proper evaluation of olfaction is itself a complicated science. There are three articles for further readings, below in the reference section.
1. Kronenbuerger M, Pilgramm M. Olfactory Testing. [Updated 2020 Dec 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565861/
2. Cain WS, Gent J, Catalanotto FA, Goodspeed RB. Clinical evaluation of olfaction. Am J Otolaryngol. 1983 Jul-Aug;4(4):252-6. doi: 10.1016/s0196-0709(83)80068-4. PMID: 6625103.
3. Reden J, Draf C, Frank RA, Hummel T. Comparison of clinical tests of olfactory function. Eur Arch Otorhinolaryngol. 2016 Apr;273(4):927-31. doi: 10.1007/s00405-015-3682-x. Epub 2015 Jun 7. PMID: 26050222.
Tuesday, November 23, 2021
Q: What is the physiological basis of using atropine in establishing brain death?
Answer: The dorsal motor vagal nucleus is in the medulla. Atropine works via this center and provides an assessment of caudal medullary function. This is one of the last functions which gets lost in brain death. Atropine provides a restricted assessment of brainstem function.
The test is performed by giving 2-3 mg atropine intravenously. The test is considered positive (means brain is dead) if heart rate fails to increase by 3% compared with basal heart rate.This excludes people with denervation like a previous heart transplant.
Monday, November 22, 2021
ETOH in ethylene Glycol toxicity
Q: ETOH can be given orally in Ethylene Glycol toxicity?
Although Fomepizole is now the standard treatment for ethylene glycol toxicity, ETOH is still a viable treatment.
ETOH/distilled spirits (40 to 50% volume/volume) should be diluted to a 20 percent solution and can be given via oral or via nasogastric tube at 5 mL/kg of a 20 percent solution to raise serum concentrations by 100 mg/dL. It should be continued as 0.5 mL/kg/hour for the maintenance dose.
1. Sasanami M, Yamada T, Obara T, Nakao A, Naito H. Oral Ethanol Treatment for Ethylene Glycol Intoxication. Cureus. 2020;12(12):e12268. Published 2020 Dec 25. doi:10.7759/cureus.12268
2. Achappa B, Madi D, Kanchan T, Kishanlal NK. Treatment of Ethylene Glycol Poisoning with Oral Ethyl Alcohol. Case Rep Med. 2019 Jan 30;2019:7985917. doi: 10.1155/2019/7985917. PMID: 30838047; PMCID: PMC6374870.
Sunday, November 21, 2021
AKI with drug interactions
Case: 54 years old male with past medical history only significant for hypertension (HTN) stable over years with lisinopril, brought to ED with mental status change. The patient is found to be in Acute Kidney Failure. History is negative for any recreational drug abuse, though wife acknowledges he was in a motor vehicle accident (MVA) 8 weeks ago and was lately using over-the-counter pain killers. Which drug interaction is suspected to cause his AKF?
Answer: nonsteroidal anti-inflammatory drug (NSAID) and angiotensin-converting enzyme (ACE) inhibitors
The objective of this question is to identify the risk factors which can quickly culminate in renal injury. One of the biggest risk factors is the drug-interaction. Over-use of NSAID itself is one of the leading causes of Acute Kidney Injury (AKI) and the risk multiplies when combined with other drugs or clinical conditions. AKI due to NSAID gets exacerbated when used with diuretics, CHF, nephrotic syndrome, cirrhosis, hypercalcemia, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcineurin inhibitors (CNIs).
The AKI due to NSAID is dose-dependent, and usually reversible when NSAID is discontinued.
References:1. Huerta C, Castellsague J, Varas-Lorenzo C, García Rodríguez LA. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population. Am J Kidney Dis 2005; 45:531.
Saturday, November 20, 2021
abscesses in complicated acute diverticulitis
Q: In complicated acute diverticulitis, abscesses are classified as small and large depending on size. The cutoff is? (select one)
A) more than 2 cm
B) more than 4 cm
Abscess formation is common in complicated acute diverticulitis. Depending on the size, the invasive vs non-invasive approach can be decided. Abscess size above 5 cm has a higher rate of complication. Given that a more aggressive approach is needed for sizes above 4 cm.
In smaller abscesses antibiotics is usually sufficient. Percutaneous drainage of diverticular abscesses should be strongly considered if the size is at or above 4 cm, though the American Society of Colon and Rectal Surgeons (ASCRS) recommends percutaneous drainage at or above 3 cm. Drainage catheter can be left till output is minimal. Catheter sinograms can be performed periodically as well as serial CT scans to evaluate the resolution.
In severe cases, open surgery may be needed.
1. Hall J, Hardiman K, Lee S, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Left-Sided Colonic Diverticulitis. Dis Colon Rectum 2020; 63:728.
2. Gregersen R, Mortensen LQ, Burcharth J, et al. Treatment of patients with acute colonic diverticulitis complicated by abscess formation: A systematic review. Int J Surg 2016; 35:201.
3. Francis NK, Sylla P, Abou-Khalil M, et al. EAES and SAGES 2018 consensus conference on acute diverticulitis management: evidence-based recommendations for clinical practice. Surg Endosc 2019; 33:2726.
4. Siewert B, Tye G, Kruskal J, et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 2006; 186:680.
5. Gaertner WB, Willis DJ, Madoff RD, et al. Percutaneous drainage of colonic diverticular abscess: is colon resection necessary? Dis Colon Rectum 2013; 56:622.