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).

#pharmacology


References:

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

AUB and SIS

 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.

#Ob-Gyn


References:

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)

#ID


References:

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.

Tuesday, April 13, 2021

CHL and B symptoms

 Q: Which of the following is NOT considered a part of B symptoms in Classic Hodgkins Lymphoma (CHL)? - select one

A) Fever 

 B) Sweats 

 C) Weight loss 

 D) Pruritus 


 Answer:

It should be understood that B symptoms have a formal definition in Lugano classification. It has three components with its own defined delineations. 

1. Fever should be persistent and above  38°C (>100.4°F). There is a variation of fever known as Pel-Ebstein fever that may be present. This variation of fever cyclically increases and decreases over a period of one to two weeks. In most cases, the patient complains of subjective fever more in the evening time.

2. Sweats should be described by the patient as drenching night sweats 

3. Weight loss should not be explained by any other means and should be more than 10 percent of actual body weight over the past six months.

Pruritus (choice D) though is not considered as a B symptom but has a high diagnostic value. In some patients, it precedes by many months before an actual diagnosis is made. It is usually generalized and can be severe enough to cause intense scratching and excoriations. 

#oncology


References:

1. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 2014; 32:3059.

2. Good GR, DiNubile MJ. Images in clinical medicine. Cyclic fever in Hodgkin's disease (Pel-Ebstein fever). N Engl J Med 1995; 332:436. 

3. Gobbi PG, Cavalli C, Gendarini A, et al. Reevaluation of prognostic significance of symptoms in Hodgkin's disease. Cancer 1985; 56:2874

Monday, April 12, 2021

COVID and GI

 Q: In patients with inflammatory bowel disease (IBD), use of which of the following is found to have increased risk of COVID-19? (select one) 

 A) glucocorticoids 

B) anti-TNF therapy 


 Answer:

Overall patients with IBD have found to have no higher risk than the general population to acquire COVID-19, although patients on active treatment may have higher risk. Surprisingly, patients on glucocorticoids are found to have higher risk than patients on anti-TNF therapy (TNF = Tumor necrosis Factor). 

The gastrointestinal (GI) symptoms in COVID are due to the presence of widely expressed angiotensin-converting enzyme 2 (ACE2) receptors in the intestine. They are most prevalent in the cytoplasm of gastric cells, intestinal epithelial cells, and the cilia of glandular epithelial cells.

Caution: Literature on COVID-19 is still evolving.


#COVID

#GI


References:

1. Norsa L, Indriolo A, Sansotta N, et al. Uneventful Course in Patients With Inflammatory Bowel Disease During the Severe Acute Respiratory Syndrome Coronavirus 2 Outbreak in Northern Italy. Gastroenterology 2020; 159:371. 

2. Rubin DT, Feuerstein JD, Wang AY, Cohen RD. AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the COVID-19 Pandemic: Expert Commentary. Gastroenterology 2020; 159:350. 

3.  Brenner EJ, Ungaro RC, Gearry RB, et al. Corticosteroids, But Not TNF Antagonists, Are Associated With Adverse COVID-19 Outcomes in Patients With Inflammatory Bowel Diseases: Results From an International Registry. Gastroenterology 2020; 159:481.

Sunday, April 11, 2021

Radiology in NSTIs

 Q: Due to gas formation in tissues which is the best diagnostic modality in necrotizing soft tissue infections (NSTIs)? (select one)

A) CT scan

B) MRI

C) Ultrasound


Answer: A

Though MRI and ultrasound can be performed in NSTIs, they are not as reliable to delineate surgical demarcation as a CT scan. MRI is oversensitive and cannot distinguish well between necrotizing cellulitis and deeper infection. Ultrasound can be used due to the presence of gas but so far evidence for its use is not very supportive. 

CT scan can reliably show gas presence in soft tissues, collection of fluid, heterogeneity of tissue enhancement, and inflammatory changes.

#surgical-critical-care

#radiology


References:

1. Zacharias N, Velmahos GC, Salama A, et al. Diagnosis of necrotizing soft tissue infections by computed tomography. Arch Surg 2010; 145:452. 

2. Schmid MR, Kossmann T, Duewell S. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol 1998; 170:615.

Saturday, April 10, 2021

Acute flare of gout in ICU

 Q: 55 years old male with brittle diabetes and recent GI bleed is recovering from Diabetes Keo Acidosis (DKA) in ICU. Patient developed an acute flare of his gout. Patient uses colchicine as prophylaxis at home. Can colchicine be used to control the flare of gout?

A) Yes

B) No


Answer: A

Although glucocorticoids or NSAIDs are preferred to control acute gout in ICU, many patients may not be a candidate for either like our patient in the above question. In such cases, colchicine can be used. Colchicine is most effective if taken early in the course. 

Said that care should be taken as overdosing on colchicine is common and interaction/toxicity is common due to various commonly used drugs in ICU. 

The maximum dose is 1.8 mg in a divided dose on day one of the flare.

#rheumatology 


Reference:

1. Engel B, Just J, Bleckwenn M, Weckbecker K. Treatment Options for Gout. Dtsch Arztebl Int. 2017;114(13):215-222. doi:10.3238/arztebl.2017.0215

Friday, April 9, 2021

acute prostatis

 Q: 34 years old male with history of diabetes mellitus is transferred to ICU from the medical ward due to septic shock. Patient was admitted to hospital two days prior to transfer with acute prostatitis with an abscess formation. Which of the following part of the management may have led to septic shock in this patient? (select one)

A) failure to add a second antibiotic

B) failure of immediate surgical drainage

C) insertion of foley catheter

D) failure to do gram-stain of urine


Answer: C

The most common entry of infection in a susceptible male with acute severe prostatitis is through the urethra. Insertion of foley catheter in such an inflamed and infected urethra may lead to septic shock and possible rupture of the abscess. A suprapubic catheter is preferred.

Monotherapy with quinolone is usually sufficient in acute severe prostatis (choice A) although aminoglycoside may be added.

Emergent surgical drainage is not required but should be considered if antibiotics failed to resolve the abscess (choice B).

Gram-stains and cultures should be carried out as part of treatment but with the initiation of broad-spectrum antibiotics failure to do so should not cause septic shock by itself (choice D).

#ID

#urology


References:

1. Davis NG, Silberman M. Bacterial Acute Prostatitis. 2021 Jan 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29083799.

2. Coker TJ, Dierfeldt DM. Acute Bacterial Prostatitis: Diagnosis and Management. Am Fam Physician. 2016 Jan 15;93(2):114-20. PMID: 26926407.

Thursday, April 8, 2021

SSZ MOA

 Q:  How Sulfasalazine (SSZ) works to be used in the management of two different diseases? 

Answer: SSZ is a unique drug that is used in two very different diseases via its route of elimination. It goes through a very interesting roller coaster ride after its oral ingestion. SSZ is a combination (inactive prodrug) of two compounds - 5-aminosalicylic acid (5-ASA) and sulfapyridine. 5-ASA helps in inflammatory bowel disease and sulfapyridine is used as a disease-modifying antirheumatic drug (DMARD). 

About one-third of SSZ absorbed by the small bowel and returned back intact via enterohepatic circulation into the bile. And from here most of the SSZ reaches the large intestine. SSZ needs coliform bacteria in the colon to be effective. Azoreductase is the enzyme that comes from the bacteria and breaks SSZ into its two compounds 5-ASA and sulfapyridine. 

5-ASA gets excreted in the feces making it very useful in the treatment of inflammatory bowel disease. Sulfapyridine is a DMARD. Sulfapyridine gets metabolized in the liver.

#pharmacology


References:

1. Box SA, Pullar T. Sulphasalazine in the treatment of rheumatoid arthritis. Br J Rheumatol 1997; 36:382.

2. Smedegård G, Björk J. Sulphasalazine: mechanism of action in rheumatoid arthritis. Br J Rheumatol 1995; 34 Suppl 2:7.

3. Das KM. Sulfasalazine therapy in inflammatory bowel disease. Gastroenterol Clin North Am. 1989 Mar;18(1):1-20. PMID: 2563989.

Wednesday, April 7, 2021

Severe hyperthyroidism in pregnancy

 Q: 27 years old 20 weeks pregnant female never been under clinical care is admitted to ICU with severe hyperthyroidism. All of the following can be parts of management EXCEPT?

A) Thionamides 

B) Beta-blockers 

C) Thyroidectomy

D) Plasmapheresis 

E) Radioiodine


Answer: E

Pregnancy presents special challenges in hyperthyroidism, particularly in an acute situation. One of the objectives of this question is to introduce the readers the use of plasmapheresis (choice D) in an acutely decompensating pregnant female with hyperthyroidism.

Thionamides (choice A) continues to be the mainstay of severe hyperthyroidism in pregnancy. When it comes to B-blockers (choice B), it should be remembered that atenolol is not recommended in pregnant patients, though metoprolol or propranolol can be used. Thyroidectomy (choice C) is reserved for rare cases like females who are not candidates for thionamides treatment.

Radioiodine (choice E) is absolutely contraindicated in pregnancy.

#ob-gyn
#endocrine


References:

1. De Groot L, Abalovich M, Alexander EK, et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:2543. 

2. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343. 

3. Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315. 

4. Adali E, Yildizhan R, Kolusari A, et al. The use of plasmapheresis for rapid hormonal control in severe hyperthyroidism caused by a partial molar pregnancy. Arch Gynecol Obstet 2009; 279:569. 

5. Stoffer SS, Hamburger JI. Inadvertent 131I therapy for hyperthyroidism in the first trimester of pregnancy. J Nucl Med 1976; 17:146.

Tuesday, April 6, 2021

VBG in ICU

 Q: Which venous blood gas (VBG) is preferable? (select one)

A) Central venous 

 B) Peripheral venous


Answer: A

In ICUs arterial blood gas (ABG) is preferred. During hemodynamic instability the discrepancy between ABG and VBG becomes significantly high and VBG cannot be relied upon. In shock state, the difference between mixed venous (SvO2) and arterial PCO2 increased by three times. 

Said that, in otherwise hemodynamically stable patients, VBG can be utilized. If a central venous catheter (CVC) (central line) is present VBG should be obtained from it. This is due to the fact that during normal hemodynamics HCO3 tends to be the same in ABG and CVC-VBG. In peripheral VBG, HCO3 is about 2-3 meq/L higher. Moreover, inappropriate use of a tourniquet during peripheral blood draw can make VBG unreliable due to transient local ischemia.

#acid-base


References:

1. Malinoski DJ, Todd SR, Slone S, et al. Correlation of central venous and arterial blood gas measurements in mechanically ventilated trauma patients. Arch Surg 2005; 140:1122. 

2. Walkey AJ, Farber HW, O'Donnell C, et al. The accuracy of the central venous blood gas for acid-base monitoring. J Intensive Care Med 2010; 25:104.

Monday, April 5, 2021

acute dysphagia

Q: 74 years old male while recovering from community-acquired pneumonia in ICU complained of food stuck in his esophagus at mid-chest (acute dysphagia). There is no shortness of breath and saturation stayed 100%. Which drug can be tried to relieve acute dysphagia before emergent endoscopy is called?


Answer: Glucagon

Intravenous glucagon relaxes the lower esophageal sphincter. This may prompt the food to pass in the stomach. The dose is 0.5 to 1-mg once. Patient may experience transient nausea. 

#GI


Reference:

Colon V, Grade A, Pulliam G, et al. Effect of doses of glucagon used to treat food impaction on esophageal motor function of normal subjects. Dysphagia 1999; 14:27.

Sunday, April 4, 2021

KS and steroid

 Q: Extent of Kaposi Sarcoma (KS) can be controlled with the maintenance of low dose steroid? 

 A) True 

B) False 


 Answer: B

The objective of the above question is to highlight the inverse relationship between steroids and KS. Steroids tend to worsen KS and weaning/withdrawal of steroid is associated with regression of KS lesions. 

In immunocompromised patients, there is a frequent need to use steroids such as during PJP treatment in AIDS patients. The risk of KS or proliferation of existing KS lesions should be kept in mind if steroids are instituted in immunocompromised patients such as AIDS, post-transplant, autoimmune and lymphoproliferative diseases.

#oncology


References:

1. Trattner A, Hodak E, David M, Sandbank M. The appearance of Kaposi sarcoma during corticosteroid therapy. Cancer 1993; 72:1779. 

2. Gill PS, Loureiro C, Bernstein-Singer M, et al. Clinical effect of glucocorticoids on Kaposi sarcoma related to the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1989; 110:937.

Saturday, April 3, 2021

B-blockers selectivity

 Q: Which of the following is a selective beta-1 adrenergic blocker? (select one)

A) atenolol 

B) propranolol


Answer: 

Atenolol being a selective beta-1 adrenergic blocker can be alternatively used where beta-blockers can not be used due to the effect on B--2 receptors such as asthma or bronchospasm. One of the drawbacks of atenolol is that its efficacy goes down at a higher dose i.e., above 100 mg per day. 

It is a drug with decades of experience and uses worldwide in a wide range of clinical conditions including angina, hypertension, rate control in atrial fibrillation/flutter, Marfan syndrome with an aortic aneurysm, migraine prophylaxis, thyrotoxicosis, anxiety, and essential tremor. 

Interestingly, in clinical practice atenolol is prescribed more for off-label uses than approved indications. 

#pharmacology


References:

1. Lin HW, Phan K, Lin SJ. Trends in off-label beta-blocker use: a secondary data analysis. Clin Ther. 2006 Oct;28(10):1736-46; discussion 1710-1. doi: 10.1016/j.clinthera.2006.10.015. PMID: 17157130.

2. Rehman B, Sanchez DP, Shah S. Atenolol. [Updated 2020 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539844/

Friday, April 2, 2021

Lyme carditis

 Q: Which finding on EKG is the best predictor of impending AtrioVentricular (AV) block in patients with Lyme carditis? 

Answer: PR interval greater than 300 milliseconds (ms) 

It takes about one to two months after infection for disseminated Lyme disease to show cardiac effects. Other systemic effects may occur at the same time including neurological symptoms. Once the heart gets involved patient may complain of palpitations and shows signs of conduction abnormalities, myocarditis, pericarditis, and CHF. Impending AV conduction abnormality sets off quickly and can be life-threatening. First-degree AV block quickly progresses to second or complete AV block. 

A PR interval greater than 300 milliseconds is a good predictor of impending AV block. Fortunately, it is reversible with treatment in few weeks. The drug of choice is IV ceftriaxone, which should be continued till the PR interval drops below 300 ms. Oral antibiotic maintained with doxycycline is required for few weeks.

#cardiology
#rheumatology


References:

1. Steere AC, Batsford WP, Weinberg M, et al. Lyme carditis: cardiac abnormalities of Lyme disease. Ann Intern Med 1980; 93:8.

2. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The Clinical Assessment, Treatment, and Prevention of Lyme disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089.

Thursday, April 1, 2021

cupola sign

 Q; What is  cupola sign?

Answer: Cupola sign is visible on the chest or abdominal x-ray and signifies the presence of pneumoperitoneum. "Cupola" is a Latin word and means "little cup". 

In a supine patient with pneumoperitoneum when non-dependent air rises up it can be seen as a lucency under the central area of the diaphragm. This lucency makes the lower thoracic vertebral bodies more prominent. This lucency appears as a cup with a well-defined upper border, Lower border of the cup remains unremarkable.



#radiology
#surgical-critical-care

Reference:

1. Fleming J, Honour H, Pevsner N. The Penguin Dictionary of Architecture: Fourth Edition. Penguin Books. ISBN:0140512411

2. Mindelzun RE, McCort JJ. The cupola sign of pneumoperitoneum in the supine patient. Gastrointest Radiol. 1986;11(3):283-5. doi: 10.1007/BF02035091. PMID: 3743953.

Wednesday, March 31, 2021

vision loss in GCA

 Q: 74 years old male is admitted to ICU with a presumed diagnosis of Giant Cell Arteritis (GCA) with vision loss. Pulse steroid is started. Vision loss will probably be? (select one)

A) reversible

B) irreversible


Answer: B

Vision loss in GCA is rarely reversible. Interestingly, patients report improvement in vision. Also, visual acuity tests confirm the improvement. Unfortunately, this is not a true recovery of retinal or optic nerve function. This subjective feeling is due to eccentric compensation for permanent visual deficits.

In any case, to salvage vision, patients should receive  3 days of 500 to 1000 mg of IV methylprednisolone followed by oral prednisone 1 mg/kg/day up to clinician discretion.

#vascular

#rhematology


References:

1. Hayreh SS, Zimmerman B, Kardon RH. Visual improvement with corticosteroid therapy in giant cell arteritis. Report of a large study and review of literature. Acta Ophthalmol Scand 2002; 80:355. 

2. Danesh-Meyer H, Savino PJ, Gamble GG. Poor prognosis of visual outcome after visual loss from giant cell arteritis. Ophthalmology 2005; 112:1098. 

3. Singh AG, Kermani TA, Crowson CS, et al. Visual manifestations in giant cell arteritis: trend over 5 decades in a population-based cohort. J Rheumatol 2015; 42:309. 

4. Hayreh SS, Zimmerman B. Visual deterioration in giant cell arteritis patients while on high doses of corticosteroid therapy. Ophthalmology 2003; 110:1204.

Tuesday, March 30, 2021

typhoid encephalopathy

 Q: Which one intervention may make a difference of life and death in "typhoid encephalopathy"? 

 Answer: Administering IV dexamethasone 

Although headache is the most common symptom in typhoid, it may progress to "typhoid encephalopathy." In this advanced neuro stage patient may develop altered mental status such as delirium, confusion, obtundation, or stupor. Once a patient develops "typhoid encephalopathy," the mortality is very high. Administration of intravenous dexamethasone if there is a sign of encephelopathy decreases mortality by more than 50 percent.

#ID


References:

1. Chisti MJ, Bardhan PK, Huq S, et al. High-dose intravenous dexamethasone in the management of diarrheal patients with enteric fever and encephalopathy. Southeast Asian J Trop Med Public Health 2009; 40:1065.

2. Hoffman SL, Punjabi NH, Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med 1984; 310:82. 

3. Butler T, Islam A, Kabir I, Jones PK. Patterns of morbidity and mortality in typhoid fever dependent on age and gender: review of 552 hospitalized patients with diarrhea. Rev Infect Dis 1991; 13:85.

Monday, March 29, 2021

independent risk factor for infection with resistant Acinetobacter

Q: Bedridden status is itself an independent risk factor for infection with resistant Acinetobacter? 

A) True 
B) False 

 Answer:

 The objective of this question is to highlight the various factors which are modifiable to decrease the risk of healthcare-acquired infections. Acinetobacter infection is one hard-to-treat infection in ICUs as resistance to primary antibiotics is high and second-line antibiotics have either high side-effects or require prolonged treatment. The requirement for isolation can also become challenging and costly. Few of the risk-factors are influenced by the practice of healthcare like overuse of carbapenems or fluoroquinolone, not practicing early mobilization, prolong or overuse of central lines (including PICC), prolonged mechanical ventilation, and overuse of glucocorticoids. 

Another less known fact is that prior colonization with methicillin-resistant S. aureus (MRSA) is an independent risk factor for infection with resistant strains of Acinetobacter - a result of overuse of antibiotics, poor isolation, and hand-hygiene. 

Some of the risk factors are hard to modify such as recent surgery, hemodialysis, or malignancy.

#ID
#pharmacology



References:

1. Tacconelli E, Cataldo MA, De Pascale G, et al. Prediction models to identify hospitalized patients at risk of being colonized or infected with multidrug-resistant Acinetobacter baumannii calcoaceticus complex. J Antimicrob Chemother 2008; 62:1130. 

2.  Vitkauskiene A, Dambrauskiene A, Cerniauskiene K, et al. Risk factors and outcomes in patients with carbapenem-resistant Acinetobacter infection. Scand J Infect Dis 2013; 45:213.

3. Karruli A, Boccia F, Gagliardi M, et al. Multidrug-Resistant Infections and Outcome of Critically Ill Patients with Coronavirus Disease 2019: A Single Center Experience. Microb Drug Resist 2021.

Sunday, March 28, 2021

lobar nephronia

 Q: 66 years old female is admitted to ICU with urosepsis. CT scan report reads "lobar nephronia". What is lobar nephronia? 

 Answer: "Lobar nephronia", a term described almost four decades ago, is a CT scan finding evident only with intravenous (IV) contrast. This is unlike renal abscess which can be seen without IV contrast. Diabetes is the highest risk factor. 

It is present as a single round or wedge-shaped hypodense image in single lobe on a CT scan. It is usually not very well defined. It is a concerning sign of renal ischemia and mostly presents due to bacterial infection. It may progress to necrosis, a walled-off cavity, and eventually to cortical scarring.

#ID

#nephrology

#radiology


References:

1. Demertzis J, Menias CO. State of the art: imaging of renal infections. Emerg Radiol 2007; 14:13. 

2. Rosenfield AT, Glickman MG, Taylor KJ, et al. Acute focal bacterial nephritis (acute lobar nephronia). Radiology 1979; 132:553. 

3. Talner LB, Davidson AJ, Lebowitz RL, et al. Acute pyelonephritis: can we agree on terminology? Radiology 1994; 192:297.

Saturday, March 27, 2021

Doripenem in VAP

 Q: Doripenem is highly effective among all carbapenems in ventilator-associated pneumonia (VAP)? 

A) Yes 

B) No


Answer: B

Doripenem became popular for VAP as they were found to be more potent in vitro against P. aeruginosa. But subsequent follow-up study showed increased 28-days mortality in VAP patients. In fact, the study was stopped early. This leads FDA to add a warning on Doripenem for use in VAP patients.

#ID


References:

1. Kollef MH, Chastre J, Clavel M, et al. A randomized trial of 7-day doripenem versus 10-day imipenem-cilastatin for ventilator-associated pneumonia. Crit Care 2012; 16:R218. 

 2. US Food and Drug Administration. FDA approves label changes for antibacterial Doribax (doripenem) describing increased risk of death for ventilator patients with pneumonia. http://www.fda.gov/Drugs/DrugSafety/ucm387971.htm (Last accessed on March 11, 2021).

3. Paterson DL, Depestel DD. Doripenem. Clin Infect Dis 2009; 49:291.

Friday, March 26, 2021

Primary upper extremity DVT

 Q: Primary upper extremity deep vein thrombosis (DVT) is more common in? (select one) 

A) Younger people 

B) Older people 

 

Answer:

Primary upper extremity DVT is more common in younger people, including children and adolescents. Also, it is high in athletic muscular males. This is due to the high prevalence of strenuous exercise, sports, and overt or covert trauma due to repetitive extremities hyperabduction. 

Other contributing factors are congenital or acquired anatomical abnormalities of the thoracic outlet and hematologic disorder such as thrombophilia.

#vascular

#hematology


References:

1. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation 2012; 126:768. 

2. Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremities. N Engl J Med 2011; 364:861. 

3. Hendler MF, Meschengieser SS, Blanco AN, et al. Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects. Am J Hematol 2004; 76:330. 

4. Martinelli I, Battaglioli T, Bucciarelli P, et al. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004; 110:566.

Thursday, March 25, 2021

Methadone effects

 Q: What are the few beneficial clinical effects of Methadone in hospitalized patients?

Answer: 

Methadone's use has seen an increased rise in the USA in hospitalized patients particularly after the COVID-19 pandemic due to the shortage of intravenous opioids and the high requirement of analgesics by COVID patients. Methadone is a long-acting opioid agonist. It works by binding to mu-opioid receptors. Its main beneficial effects are: 
  • prevents withdrawal symptoms for 24 hours or longer
  • reduces the craving for opioids
  • maintains high levels of opioid tolerance
  • reduces the euphoric effects of subsequent illicit opioid use
In patients with prolong hospitalization, the daily dose of 30 mg can be utilized and can be continued during the course of hospital stay with clinicians and pharmacists' mutual coordination.

#pain
#pharmacology


References:

1. Shir Y, Rosen G, Zeldin A, Davidson EM. Methadone is safe for treating hospitalized patients with severe pain. Can J Anaesth. 2001 Dec;48(11):1109-13. doi: 10.1007/BF03020377. PMID: 11744587. 

2. Noska A, Mohan A, Wakeman S, Rich J, Boutwell A. Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings. J Addict Behav Ther Rehabil. 2015;4(2):1000138. doi:10.4172/2324-9005.1000138

Wednesday, March 24, 2021

Which features distinguish strongyloidiasis from ulcerative colitis

 Q: 44 years old male, a recently migrant from southeast Asia is admitted to ICU with gastrointestinal (GI) symptoms including pain and lower GI bleed. Subsequent workup led to the presumed diagnosis of strongyloidiasis. Colonoscopy is performed to rule out ulcerative colitis. Which features distinguish strongyloidiasis from ulcerative colitis?


Answer: 

Strongyloides colitis can mimic ulcerative colitis. Although endoscopies are not routinely performed in strongyloidiasis but may require ruling out other potentially life-threatening conditions. Strongyloides colitis can be differentiated from ulcerative colitis by noticing skip pattern of inflammation, distal attenuation of the disease, eosinophil-rich infiltrates, relatively intact crypt architecture, and frequent involvement of submucosa with erythematous nodules. 
 
If upper endoscopy is performed, the stomach may show thickened folds and mucosal erosions. And, the duodenum may show edema, brown mucosal discoloration, erythematous spots, subepithelial hemorrhages, and megaduodenum. A biopsy can be taken to document parasites in the gastric crypts or duodenal glands and eosinophilic infiltration of the lamina propria.

#GI
#ID


References:

1. Rivasi F, Pampiglione S, Boldorini R, Cardinale L. Histopathology of gastric and duodenal Strongyloides stercoralis locations in fifteen immunocompromised subjects. Arch Pathol Lab Med 2006; 130:1792. 

2. Overstreet K, Chen J, Rodriguez JW, Wiener G. Endoscopic and histopathologic findings of Strongyloides stercoralis infection in a patient with AIDS. Gastrointest Endosc 2003; 58:928.

3. Qu Z, Kundu UR, Abadeer RA, Wanger A. Strongyloides colitis is a lethal mimic of ulcerative colitis: the key morphologic differential diagnosis. Hum Pathol 2009; 40:572. 

4. Thompson BF, Fry LC, Wells CD, et al. The spectrum of GI strongyloidiasis: an endoscopic-pathologic study. Gastrointest Endosc 2004; 59:906.

Tuesday, March 23, 2021

Oculomasticatory Myorhythmia

Q: What is Oculomasticatory Myorhythmia and signifies which disease?

 Answer: It is a continuous rhythmic movement of eye convergence with concurrent contractions of the masticatory or other muscles. This signifies the central nervous system (CNS) involvement in Whipple's disease. 

It is usually associated with cognitive abnormalities. If there is an involvement of skeletal muscles, it is called oculofacial-skeletal myorhythmia. The cause is not fully understood for this symptom. If present, eyes oscillate synchronously horizontally towards and away from each other. Other muscles involved can be any/some/all of masticatory, lids, tongue, palate, arms, and legs. Bilateral ptosis may be present. Interestingly, this is found to be associated with hypersomnolence. To make things complicated in isolated CNS involvement, PAS-positive cells may be negative on intestinal biopsy. 

Treatment for CNS Whipple's disease is not established though tetracycline, ceftriaxone, trimethoprim-sulfamethoxazole, pefloxacin, and valproate has been described.

#neurology


References:

1. Adler CH, Galetta SL. Oculo-facial-skeletal myorhythmia in Whipple disease: treatment with ceftriaxone. Ann Intern Med 1990; 112:467. 

2. Simpson DA, Wishnow R, Gargulinski RB, Pawlak AM. Oculofacial-skeletal myorhythmia in central nervous system Whipple's disease: additional case and review of the literature. Mov Disord 1995; 10:195. 

3. Hausser-Hauw C, Roullet E, Robert R, Marteau R. Oculo-facio-skeletal myorhythmia as a cerebral complication of systemic Whipple's disease. Mov Disord 1988; 3:179. 

4. Rajput AH, McHattie JD. Ophthalmoplegia and leg myorhythmia in Whipple's disease: report of a case. Mov Disord 1997; 12:111. 

5. Amarenco P, Roullet E, Hannoun L, Marteau R. Progressive supranuclear palsy as the sole manifestation of systemic Whipple's disease treated with pefloxacine. J Neurol Neurosurg Psychiatry 1991; 54:1121. 

6. Panegyres PK, Goh J. Sleep disorders of Whipple's disease of the brain. QJM 2015; 108:99. 

7. Calandra-Buonaura G, Provini F, Guaraldi P, et al. Oculomasticatory myorhythmia and agrypnia excitata guide the diagnosis of Whipple disease. Sleep Med 2013; 14:1428.

8.Adler CH, Galetta SL. Oculo-facial-skeletal myorhythmia in Whipple disease: treatment with ceftriaxone. Ann Intern Med 1990; 112:467. 

Monday, March 22, 2021

CNS and extracerebral toxoplasmosis

 Q: Central nervous system (CNS) toxoplasmosis is more common than extracerebral toxoplasmosis?

A) True 

B) False 


 Answer: A

Immuno-compromise state is the biggest risk factor for clinical toxoplasmosis. Interestingly, CNS is the most affected system. Solo extracerebral toxoplasmosis is rare. Toxoplasmosis in lungs, eyes, or as disseminated infection usually occur along with CNS infection.

Another important pearl for clinicians to remember is that fever may not be present in toxoplasmic encephalitis due to immunosuppression. Headache is the most prominent symptom with mental status change or seizure. 

Multiple ring-enhancing lesions on brain imaging is considered a hallmark for the diagnosis.

#ID

#neurology


References:

1. Belanger F, Derouin F, Grangeot-Keros L, Meyer L. Incidence and risk factors of toxoplasmosis in a cohort of human immunodeficiency virus-infected patients: 1988-1995. HEMOCO and SEROCO Study Groups. Clin Infect Dis 1999; 28:575.

2. Rabaud C, May T, Amiel C, et al. Extracerebral toxoplasmosis in patients infected with HIV. A French National Survey. Medicine (Baltimore) 1994; 73:306.

3. Porter SB, Sande MA. Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome. N Engl J Med 1992; 327:1643.

Sunday, March 21, 2021

Labs in NMS

Q: A low serum iron in Neuroleptic Malignant Syndrome (NMS) is (select one) 

A) sensitive marker 
B) specific marker 

 
Answer:

NMS is a life-threatening neurologic emergency. It requires a very high level of suspicion. Failure to recognize NMS carries high mortality. It is a clinical diagnosis although some lab abnormalities are associated with it, including: 
  • high CPK
  • high WBC
  • high LDH
  • high LFT
  • low calcium
  • low magnesium 
  • high or low sodium
  • high potassium 
  • metabolic acidosis 
  • rhabdomyolysis, myoglobinuria, and acute renal failure
Low serum iron is common in NMS. It is an extremely sensitive marker but is not very specific.

#neurology



References:

1. Lee JW. Serum iron in catatonia and neuroleptic malignant syndrome. Biol Psychiatry 1998; 44:499. 

2.Modi S, Dharaiya D, Schultz L, Varelas P. Neuroleptic Malignant Syndrome: Complications, Outcomes, and Mortality. Neurocrit Care 2016; 24:97.

Saturday, March 20, 2021

Post-transplant diabetes

 Q: The newly transplanted kidney excretes insulin more efficiently than previously failed native kidneys? 

A) True 

B) False 


 Answer: A

There is more than one reason for new-onset diabetes mellitus after transplantation (NODAT) particularly after kidney transplant. Blood glucose monitoring continued to be essential monitoring in newly transplanted patients. The new kidney metabolizes and excretes insulin more efficiently. Also, the new kidney is gluconeogenic. These extra myriads are in conjunction with the inherent risks of immunosuppressants required in most post-transplant patients. Post-transplant issues such as age, obesity, and gestations further compound the issue of NODAT.

#tranplantation

#endocrinology


Reference:

1. Shivaswamy V, Boerner B, Larsen J. Post-Transplant Diabetes Mellitus: Causes, Treatment, and Impact on Outcomes. Endocr Rev. 2016;37(1):37-61. doi:10.1210/er.2015-1084 

Friday, March 19, 2021

Procal in COVID-19

Q: Elevated procalcitonin can be used reliably to add antibiotics in hospitalized COVID-19 patients? 


A) True 
B) False 

 
Answer:

In advance COVID-19 patients, despite lack of any other evidence for infections, procalcitonin levels are found to be elevated. It is up to clinician discretion in such cases to add or hold back on antibiotics. The prudent thing would be to draw blood cultures, sputum culture and perform urinanalysis (UA) and decide in conjugation with other clinical evidence. Infectious Disease (ID) consult may be helpful too. 

A low procalcitonin level may be more helpful in deciding against the addition of antibiotics.

#ID
#COVID-19


References:

1. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020; 382:1708. 

2. Wu C, Chen X, Cai Y, et al. Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020; 180:934. 

3. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054.

Thursday, March 18, 2021

Peptic ulcer Mx

Q: 38 years old male is admitted to ICU with an upper GI bleed. Upper endoscopy showed active peptic ulcer disease. Proton pump inhibitor (PPI) was initiated. PPIs have higher healing rates in peptic ulcer disease in comparison to H2 receptor antagonists (H2RA)? 

A) True 
B) False 

 
Answer: A

PPIs are found to be superior to H2RA in peptic ulcer disease management. Not only they control symptoms faster but also have a higher healing rate. This is due to their ability to have more potent acid suppression. PPIs continue to keep that advantage in Non-steroidal-anti-inflammatory-drugs (NSAIDs) induced peptic ulcer disease. 

Previously, it was suggested that the combination of PPIs with H2RA will further enhance the management due to their different mechanism of action. This was not found to be true. Solo treatment with PPIs is enough in the treatment of non-H. Pylori peptic ulcer disease.

#GI


Reference:

Yeomans ND, Tulassay Z, Juhász L, et al. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med 1998; 338:719.

Wednesday, March 17, 2021

MALA first line of Mx

 Q: 64 years old male is admitted to ICU after accidental ingestion of metformin. Patient is found to be in severe metabolic acidosis with a PH of 7.08. Patient should receive activated charcoal? 

A) Yes

B) No


Answer: A

Metformin-associated Lactic Acidosis (MALA) is a potentially a fatal condition. As a first line of treatment, all patients with acute ingestion should receive activated charcoal, if they can tolerate it or there is no contraindication otherwise. The recommended dose is 1 gm/kg but as a rule of thumb, all patients can just be given 50 grams once. 

The patients who are in severe lactic acidosis, hemodialysis is a life-saving treatment, but it takes time and effort to arrange hemodialysis. 

In between patient can be treated with a soda-bicarb bolus followed by infusion to avoid hemodynamic collapse from severe acidosis. The usual cut-off point is at the PH of 7.10 or at the clinician's discretion. In an adult patient, the dose is 1-2 meq/kg bolus followed by 133-150 meq in one liter of D5W at a rate of 250 mL/hour.

#toxicology


Reference:

Moioli A, Maresca B, Manzione A, Napoletano AM, Coclite D, Pirozzi N, Punzo G, Menè P. Metformin associated lactic acidosis (MALA): clinical profiling and management. J Nephrol. 2016 Dec;29(6):783-789. doi: 10.1007/s40620-016-0267-8. Epub 2016 Jan 22. PMID: 26800971.

Tuesday, March 16, 2021

immunosuppressants drug action

 Q: All of the following drugs may increase the serum concentrations of immunosuppressants EXCEPT? 

A) Amiodarone 

B) Fluconazole

C) Phenytoin 

D) Azithromycin 

E) Diltiazem


Answer: C

The objective of this question is to enhance the fragile serum levels of immunosuppressants in relatively sick patients in ICU. Most of the commonly used drugs in ICU have some kind of interaction with immunosuppressants i.e., cyclosporine, tacrolimus, sirolimus, or everolimus. Drug interactions may either increase the serum level of these immunosuppressants or decrease the level. Some drugs may just have the additive effect, and some may just cause hyperkalemia. This is beyond the scope here to list all such drugs. It can be very tricky as macrolide antibiotics increase the serum level of immunosuppressant but nafcillin decreases the level! Most of the interactions occur via CYP3A metabolism and/or P-glycoprotein drug efflux pump. 

All the drugs in the above question except choice C increase the serum levels of immunosuppressant. In fact, phenytoin decreases the tacrolimus level and has been tried as an antidot in tacrolimus toxicity.

#transplant

#pharmacology


References:

1. Katalin Monostory (July 25th 2018). Metabolic Drug Interactions with Immunosuppressants, Organ Donation and Transplantation - Current Status and Future Challenges, Georgios Tsoulfas, IntechOpen, DOI: 10.5772/intechopen.74524. Available from: https://www.intechopen.com/books/organ-donation-and-transplantation-current-status-and-future-challenges/metabolic-drug-interactions-with-immunosuppressants (last accessed March 15, 2021)

2. Jantz AS, Patel SJ, Suki WN, Knight RJ, Bhimaraj A, Gaber AO. Treatment of acute tacrolimus toxicity with phenytoin in solid organ transplant recipients. Case Rep Transplant. 2013;2013:375263. doi:10.1155/2013/375263

Monday, March 15, 2021

post bypass vasoplegia

 Q: All of the following are risk factors for post-cardiac bypass surgery vasoplegia Except?

A) pre-operative use of angiotensin-converting enzyme (ACE) inhibitors 

B) warmer core temperature on bypass

C) use of vasopressin perioperatively 

D) longer time on aortic cross-clamping and bypass

E) pre-bypass hemodynamic instability


Answer: C

All of the conditions described in choices A, B, D, and E are risk factors for refractory vasoplegia after bypass surgery.

Vasopressin (choice C) is one of the pressors which has the strongest evidence among all pressors to have clinical efficacy in post-cardiac surgery vasoplegia. Vasopressin has five effects simultaneously by binding to V1a, V1b, and V2 receptors. It causes 
  • vasoconstriction 
  • water reabsorption at the renal collecting ducts 
  • increased secretion of cortisol 
  • increased secretion of insulin 
  • bradycardia by augmenting baroreflex inhibition of efferent sympathetic nerve activity
Said that vasopressin should not be used beyond recommended dose due to its high affinity to cause vasoconstriction at the capillary level causing renal and gastrointestinal (GI) ischemia.

#hemodynamic


References:

1. Dünser MW, Hasibeder WR. Sympathetic overstimulation during critical illness: adverse effects of adrenergic stress. J Intensive Care Med 2009; 24(5): 293–316.

2. Schmittinger CA, Torgersen C, Luckner G, et al. Adverse cardiac events during catecholamine vasopressor therapy: a prospective observational study. Intensive Care Med 2012; 38(6): 950–958. 

3. Demiselle J, Fage N, Radermacher P, et al. Vasopressin and its analogues in shock states: a review. Ann Intensive Care 2020; 10(1): 9. 

4. Treschan TA, Peters J. The vasopressin system: physiology and clinical Strategies. Anesthesiology 2006; 105(3): 599–612

Sunday, March 14, 2021

treatment in myoclonus

Q: All of the following are found to be helpful in myoclonus EXCEPT

A) Levetiracetam 
B) Phenytoin 
C) Clonazepam 
D) Valproic acid 
E) Zonisamide


Answer: B

Physicians tend to reflexly use anti-seizure meds to treat myoclonus. Only a few drugs found to be effective in myoclonus. The most rigorously tested and found to be an effective drug is Levitractam. Other drugs found to be helpful include Piracetam, Brivaracetam, Clonazepam, and Zonisamide. Many other drugs have been described with limited effectiveness like Baclofen, Benztropine, Carbamazepine, Diazepam, Lamotrigine, Phenobarbital, Primidone, Sumatriptan, Tetrabenazine, Topiramate and Trihexyphenidyl. Besides pharmacology treatment stimulation and surgical interventions have also been used, where the most widely used is Deep Brain Stimulator (DBS).

 The response to treatment in myoclonus can be assessed by the Unified Myoclonus Rating Scale (UMRS). 

 Phenytoin (choice B) so far has not shown any role in the treatment of myoclonus. In fact, in many cases, it is found to worsen myoclonus.

#neurology


References:

1. Eldridge R, Iivanainen M, Stern R, et al. "Baltic" myoclonus epilepsy: hereditary disorder of childhood made worse by phenytoin. Lancet 1983; 2:838.

2. Genton P, Gélisse P. Antimyoclonic effect of levetiracetam. Epileptic Disord 2000; 2:209.

3. Roze E, Vidailhet M, Hubsch C, et al. Pallidal stimulation for myoclonus-dystonia: Ten years' outcome in two patients. Mov Disord 2015; 30:871.

Saturday, March 13, 2021

Effects of pentoxifylline

Q: Pentoxifylline has a beneficial effect on all of the following diseases except

A) claudication 
B) alcoholic hepatitis 
C) septic shock 
D) venous leg ulcer


Answer: C

Pentoxifylline is a nonspecific phosphodiesterase inhibitor, which is well known for its use in patients with vascular claudication (choice A) and venous leg ulcer (choice D). It is also found to be effective in alcoholic hepatitis (choice B). Its major action is to work as a blood viscosity reducer agent and an anti-inflammatory agent. 

Pentoxifylline has no role in septic shock so far (choice C).


#pharmacology



References:

1.  Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012;12:CD001733.

2. Singal AK, Bataller R, Ahn J, et al. ACG Clinical Guideline: alcoholic liver disease. Am J Gastroenterol. 2018;113(2):175-194. doi: 10.1038/ajg.2017.469

Friday, March 12, 2021

Rocking tenderness over liver

 Q: Which of the following may have a rocking tenderness on the physical exam? (select one) 

 A) Pyogenic liver abscess 

 B) Acute cholecystitis


Answer: A

Rocking tenderness is demonstrated by gently rocking the patient's abdomen, particularly the right upper quadrant. It is one of the associated signs of pyogenic liver abscess. Other clinical signs and symptoms are pain, guarding, tenderness or rebound tenderness, hepatomegaly, and jaundice.  Although their absence does not rule out the disease.

These findings should be combined with laboratory and imaging findings. In this regard, often ignored are the associated findings on chest x-ray which may show an elevated right hemidiaphragm, right basilar infiltrate, or/and right-sided pleural effusion.

#hepatology


References:

1. Mohsen AH, Green ST, Read RC, McKendrick MW. Liver abscess in adults: ten years experience in a UK centre. QJM 2002; 95:797.

2. Longworth S, Han J. Pyogenic liver abscess. Clin Liver Dis (Hoboken). 2015;6(2):51-54. Published 2015 Aug 24. doi:10.1002/cld.487 

3. Serraino C, Elia C, Bracco C, et al. Characteristics and management of pyogenic liver abscess: A European experience. Medicine (Baltimore). 2018;97(19):e0628. doi:10.1097/MD.0000000000010628

Thursday, March 11, 2021

precipitants for hepatic encephalopathy

 Q: Which of the following is more of a risk for increased ammonia production, its absorption, or its entry into the brain to exacerbate hepatic encephalopathy? (select one) 

 A) Metabolic acidosis

 B) Metabolic alkalosis


Answer: B

The list of precipitants for hepatic encephalopathy is long including drugs, dehydration, portosystemic shunting, vascular occlusions, and primary hepatocellular carcinoma. 

Factors that increase ammonia production, or its absorption, or its entry into the brain includes excess dietary intake of protein, gastrointestinal bleeding, infection, electrolyte disturbances (most importantly hypokalemia), constipation, and metabolic alkalosis.

#hepatology


References:

1. Khungar V, Poordad F. Hepatic encephalopathy. Clin Liver Dis 2012; 16:301. 

2. Mumtaz K, Ahmed US, Abid S, et al. Precipitating factors and the outcome of hepatic encephalopathy in liver cirrhosis. J Coll Physicians Surg Pak 2010; 20:514. 

3. Onyekwere CA, Ogbera AO, Hameed L. Chronic liver disease and hepatic encephalopathy: clinical profile and outcomes. Niger J Clin Pract 2011; 14:181.

Wednesday, March 10, 2021

ACE in sarcoidosis

Q: Serum angiotensin converting enzyme (ACE) has a very high sensitivity and specificity to diagnose sarcoidosis?

A) True
B) False


Answer: B

None of the serologic markers including ACE, adenosine deaminase, serum amyloid A, soluble interleukin-2 receptor, or D-dimer have shown any definite evidence to exclusively diagnose sarcoidosis. Although 3/4th of the patients with sarcoidosis have high ACE levels, it has very poor sensitivity and unreliable specificity. 

Other diseases which can also have high ACE levels include Asbestosis, Beryllium disease, Coccidioidomycosis, Diabetes mellitus (DM), Hodgkin disease, Hypersensitivity pneumonitis, Hyperthyroidism, Leprosy, Lung cancer, Primary biliary cirrhosis (PBC), Silicosis and Tuberculosis (TB).

#sarcoidosis


References:

1. Studdy PR, Bird R. Serum angiotensin converting enzyme in sarcoidosis-its value in present clinical practice. Ann Clin Biochem 1989; 26 ( Pt 1):13. 

2. Baughman RP. Pulmonary sarcoidosis. Clin Chest Med 2004; 25:521. 

3. Ungprasert P, Carmona EM, Crowson CS, Matteson EL. Diagnostic Utility of Angiotensin-Converting Enzyme in Sarcoidosis: A Population-Based Study. Lung 2016; 194:91.

Tuesday, March 9, 2021

Mayo score for ulcerative colitis

 Q: All of the following are the components of Mayo scoring to determine the severity of disease in ulcerative colitis - EXCEPT?

A) Stool pattern 

B) Most severe rectal bleeding of the day 

C) Severity of leukocytosis 

D) Endoscopic findings 

E) Global assessment by a clinician


Answer: C

Mayo scoring to determine the severity of disease in ulcerative colitis is divided into four components. Each of the following components is further divided into 4 parts and get points (0-3) depending on the severity. Depending on a score from 0 to 12, the severity of ulcerative colitis is determined. 

  •  Stool pattern 
  •  Most severe rectal bleeding of the day 
  •  Endoscopic findings 
  •  Global assessment by a clinician

#gastroenterology


Reference:

Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis. A randomized study. N Engl J Med 1987; 317:1625.

Monday, March 8, 2021

Lavage in upper GI bleed

Q: Nasogastric Lavage in upper gastrointestinal (GI) bleed is associated with? (select one) 

A) shorter time to endoscopy
B) reduced mortality
C) decrease length of hospital stay
D) decrease rate of surgery
E) decrease rate of transfusion 


Answer: A

Previously it was a common practice to insert a nasogastric tube (NGT) in patients with suspected upper GI bleed. This practice failed to show any benefit in mortality (choice B), length of hospital stay (choice C), surgery (choice D), or transfusion requirement (Choice E). The only advantage is a shorter time to endoscopy. Also, it can be used to clean the stomach (like blood clots or food particles) prior to endoscopy. Bilious output from NGT gives an indication that bleed is probably distal to pylorus.

#GI
#procedures


References:

1. Rockey DC, Ahn C, de Melo SW Jr. Randomized pragmatic trial of nasogastric tube placement in patients with upper gastrointestinal tract bleeding. J Investig Med 2017; 65:759.
 
2. Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated? Gastrointest Endosc 2011; 74:981. 

3. Karakonstantis S, Tzagkarakis E, Kalemaki D, et al. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Rev Gastroenterol Hepatol 2018; 12:63. 

4. Huang ES, Karsan S, Kanwal F, et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc 2011; 74:971. 


Sunday, March 7, 2021

Post DBS complications

Q: 74 years old male is admitted to ICU after insertion of subthalamic nucleus Deep Brain Stimulator (STN-DBS) for Parkinson's Disease (PD). A review of chart shows a strong psychiatric history. What would be your major concern in this patient? 

 Answer: Increased risk of suicide 

 Parkinson's Disease is usually associated with many psychiatric issues like anxiety, depression, hallucinations, and delusions. Patients with such associated symptoms may have an increased risk for suicide post-DBS implantation. Also, there is a high tendency for such patients to have a higher rate of transient confusion post-operatively. 

Other postoperative complications include infections, intracerebral hemorrhage (ICH), seizures, pulmonary embolism (PE), cerebrospinal fluid (CSF) leak, and venous infarction.

#neurology
#surgical-critical-care
#psychiatry


References:

1. Soulas T, Gurruchaga JM, Palfi S, et al. Attempted and completed suicides after subthalamic nucleus stimulation for Parkinson's disease. J Neurol Neurosurg Psychiatry 2008; 79:952. 

2. Voon V, Krack P, Lang AE, et al. A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson's disease. Brain 2008; 131:2720. 

3. Giannini G, Francois M, Lhommée E, et al. Suicide and suicide attempts after subthalamic nucleus stimulation in Parkinson disease. Neurology 2019; 93:e97. 

4. Kleiner-Fisman G, Herzog J, Fisman DN, et al. Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 2006; 21 Suppl 14:S290. 

5. Pahwa R, Factor SA, Lyons KE, et al. Practice Parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66:983.