Thursday, March 31, 2022

Sicca syndrome and sicca complex

Q: What is the difference between sicca syndrome and sicca complex? 


Sicca syndrome is a synonym for Sjögren's syndrome (SS). On the other hand, sicca complex refers to dryness of the eyes and mouth without specification to different etiologies, like about 40% of patients with active chronic hepatitis and 70% with primary biliary cirrhosis (PBC) have it.

Term sicca complex came from keratoconjunctivitis sicca which denotes the ocular findings of SS, and was coined by Swedish ophthalmologist Henrik Sjögren. Other terms used are dry eye syndrome and dysfunctional tear syndrome.



1. Sjögren H. Zur Kenntnis der Keratoconjunctivitis sicca. Acta Ophthalomol 1933; 11(suppl II):1. 

2. Golding PL, Bown R, Mason AM, Taylor E. "Sicca complex" in liver disease. Br Med J. 1970 Nov 7;4(5731):340-2. doi: 10.1136/bmj.4.5731.340. PMID: 5472806; PMCID: PMC1819706. 

3. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007; 5:75.

Thursday, March 24, 2022

Appendicitis in pregnancy

Q: 28 years old female who is 32 weeks pregnant is admitted to ICU with acute appendicitis. Cesarean delivery should be carried out with appendectomy?

A) True
B) False

Answer: B

Pregnant patients with acute appendicitis are treated more or less as in normal population. Pharmacy should be consulted if antibiotics are prescribed to avoid fetal toxicity. Appendectomy is curative in pregnancy. Relying solely on on antibiotic treatment is not appropriate.

Delaying surgery carries a high risk of perforation. Cesarean delivery (C-section) is rarely required. Risk of dehiscence or uterine perforation later in vaginal delivery is low if fascia is closed properly.



1. Mazze RI, Källén B. Appendectomy during pregnancy: a Swedish registry study of 778 cases. Obstet Gynecol 1991; 77:835. 

2. Joo JI, Park HC, Kim MJ, Lee BH. Outcomes of Antibiotic Therapy for Uncomplicated Appendicitis in Pregnancy. Am J Med 2017; 130:1467. 

3. Silvestri MT, Pettker CM, Brousseau EC, et al. Morbidity of appendectomy and cholecystectomy in pregnant and nonpregnant women. Obstet Gynecol 2011; 118:1261. 

4.  McGory ML, Zingmond DS, Tillou A, et al. Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss. J Am Coll Surg 2007; 205:534. Ito K, Ito H, Whang EE, 

5. Tavakkolizadeh A. Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy. Am J Surg 2012; 203:145.

Wednesday, March 16, 2022

lopressor-coreg conversion

 Q: What's the conversion ratio of Metoprolol to Carvedilol?

Answer: About 4:1




Cohen-Solal A, Jacobson AF, Piña IL. Beta blocker dose and markers of sympathetic activation in heart failure patients: interrelationships and prognostic significance. ESC Heart Fail. 2017 Nov;4(4):499-506. doi: 10.1002/ehf2.12153. Epub 2017 Apr 19. PMID: 29154422; PMCID: PMC5695165.

Tuesday, March 15, 2022

oral Metronidazole failure in c-diff.

Q: What usually leads to failure of oral metronidazole in clostridioides difficile infection? 

Answer:Although not completely clear but it appears that oral metronidazole has a capacity to get well absorbed, which turns out to be a cause of failure! As colonic inflammation improves and metronidazole stool level decreases (due to increase gut absorption), treatment failure may ensues. 

In contrast, oral vancomycin or fidaxomicin is very poorly absorbed from the gut. Their stool drug level remains high leading to a better prospect of treatment in clostridioides difficile infection.



1. Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005; 40:1586.

2. Hu MY, Maroo S, Kyne L, et al. A prospective study of risk factors and historical trends in metronidazole failure for Clostridium difficile infection. Clin Gastroenterol Hepatol 2008; 6:1354.

3. Bolton RP, Culshaw MA. Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut 1986; 27:1169.

4. Appaneal HJ, Caffrey AR, LaPlante KL. What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease. Clin Infect Dis 2019; 69:1288.

Monday, March 14, 2022

Olanzapine in NV

Q: Olanzapine can be used in acute nausea and vomiting?

A) Yes
B) No

Answer: A

Olanzapine is a second-generation antipsychotic. It not only blocks serotonin 5-hydroxytryptamine (5-HT2) receptors but also dopamine D2 receptors. This property makes Olanzapine an attractive choice in both acute and delayed nausea and vomiting. Actually, a recent meta-analysis (2019) shows that olanzapine-containing regimens are most effective in preventing chemotherapy-induced nausea vomiting (CINV). 

A 5 mg dose is recommended to avoid the dangers of prolonged QTc and is found to be as effective as 10 mg.



1. Sutherland A, Naessens K, Plugge E, et al. Olanzapine for the prevention and treatment of cancer-related nausea and vomiting in adults. Cochrane Database Syst Rev 2018; 9:CD012555.

2. Yokoe T, Hayashida T, Nagayama A, et al. Effectiveness of Antiemetic Regimens for Highly Emetogenic Chemotherapy-Induced Nausea and Vomiting: A Systematic Review and Network Meta-Analysis. Oncologist 2019; 24:e347.

3. Navari RM, Qin R, Ruddy KJ, et al. Olanzapine for the Prevention of Chemotherapy-Induced Nausea and Vomiting. N Engl J Med 2016; 375:134.

4. Yanai T, Iwasa S, Hashimoto H, et al. A double-blind randomized phase II dose-finding study of olanzapine 10 mg or 5 mg for the prophylaxis of emesis induced by highly emetogenic cisplatin-based chemotherapy. Int J Clin Oncol 2018; 23:382.

5. Hashimoto H, Abe M, Tokuyama O, et al. Olanzapine 5 mg plus standard antiemetic therapy for the prevention of chemotherapy-induced nausea and vomiting (J-FORCE): a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol 2020; 21:242.

Sunday, March 13, 2022

5 Ds

Q: What are the 5 Ds in Medicine?

Answer: At all levels of medical care and preventions (primary, secondary, and tertiary), in general physicians strive to prevent 5 Ds:

  • death
  • disease
  • disability
  • discomfort
  • dissatisfaction

Primary prevention: to keep the disease from occurring at all.

Secondary prevention: to detect disease early at the asymptomatic stage and prevent it from progressing.

Tertiary prevention: to prevent further deterioration and complications.



1. Prevention. In: Clinical Epidemiology: The Essentials, 6th ed, Fletcher G (Ed), Lippincott Williams and Wilkins 2020.

2. Grant S Fletcher, Evidence-based approach to prevention: UpTodate: Last updated: Feb 17, 2022. Link:

Saturday, March 12, 2022

steroids in transplant surgery

Q: Methylprednisolone is usually given intraoperatively during lung transplantation. It should be given? (select one)

A) before the perfusion of graft
B) after the perfusion of graft

Answer: A

Immunosuppression is the most vital component in the success of transplantation. Some immunosuppressants are given preoperatively and some are perioperatively and are continued later on for a longer period of time for years. 

500 to 1000 mg of methylprednisolone is given in OR and preferably should be given before the perfusion of the graft. 



1. Chandrashekaran S, Crow Pharm SA, Shah SZ, Arendt Pharm CJ, Kennedy CC. Immunosuppression for Lung Transplantation: Current and Future. Curr Transplant Rep. 2018 Sep;5(3):212-219. doi: 10.1007/s40472-018-0199-4. Epub 2018 Jul 13. PMID: 30740294; PMCID: PMC6366648.

2. Nelson J, Kincaide E, Schulte J, Hall R, Levine DJ. Immunosuppression in Lung Transplantation. Handb Exp Pharmacol. 2021 Nov 19. doi: 10.1007/164_2021_548. Epub ahead of print. PMID: 34796380.

Friday, March 11, 2022

fentanyl patch and heat

 Q: 78 years old male with metastatic esophageal cancer is admitted to ICU with urosepsis. The patient is on a chronic transdermal fentanyl patch from home and requested to continue it. 

Fever will __________ the systemic absorption? (select one)

A) increases

B) decreases

Answer: A

Transdermal fentanyl has some weak evidence to show reduced risk of constipation over other narcotics i.e., morphine patch. Also, it does not produce active metabolites. 

Said that any exposure of patch to heat such as fever, a heating pad, or warming blanket may increase the systemic fentanyl absorption, bearing the risk of respiratory depression.



Newshan G. Heat-related toxicity with the fentanyl transdermal patch. J Pain Symptom Manage. 1998 Nov;16(5):277-8. doi: 10.1016/s0885-3924(98)00100-6. PMID: 9846020.

Thursday, March 10, 2022

CSF in carcinomatous meningitis

Q: The cerebrospinal fluid (CSF) pressure in leptomeningeal metastases is usually? (select one)

A) high
B) low

Answer: A

Brain is covered (from outside to inside) with three layers
  • dura mater
  • arachnoid mater
  • pia mater
The arachnoid and the pia mater are collectively called leptomeninges. Whenever any tumor involves the leptomeninges, it is leptomeningeal metastases. It is also called meningeal carcinomatosis, carcinomatous meningitis, and neoplastic meningitis. 

In a patient with a history of tumor and clinical signs, a high opening pressure is almost always synonymous with leptomeningeal metastases. Other expected CSF findings are low glucose, high protein, lymphocytic pleocytosis, and positive cytology. Unfortunately, positive cytology is not always present.



1. Bönig L, Möhn N, Ahlbrecht J, Wurster U, Raab P, Puppe W, Sühs KW, Stangel M, Skripuletz T, Schwenkenbecher P. Leptomeningeal Metastasis: The Role of Cerebrospinal Fluid Diagnostics. Front Neurol. 2019 Aug 20;10:839. doi: 10.3389/fneur.2019.00839. PMID: 31481919; PMCID: PMC6710356.

2. Chamberlain MC. Leptomeningeal metastasis. Semin Neurol. 2010 Jul;30(3):236-44. doi: 10.1055/s-0030-1255220. Epub 2010 Jun 24. PMID: 20577930.

Tuesday, March 8, 2022

Nodules in RA

 Q: 32 years old female with a known history of Rheumatoid Arthritis (RA) is admitted to ICU with septic arthritis. Patient is found to have rheumatoid nodules at pressure points on the skin examination. Presence of nodules is a bad prognostic sign in RA.

A) True

Answer: A

Patients who exhibit rheumatoid nodules usually have a severe RA phenotype. They tend to have rapid progression of joint destruction. Unfortunately, these patients may develop nodules in internal organs too, and have higher risk of hospitalizations, vasculitis, Felty syndrome as well as pulmonary, cardiovascular and all-cause mortality.



1. García-Patos V. Rheumatoid nodule. Semin Cutan Med Surg 2007; 26:100. 

2. Nyhäll-Wåhlin BM, Turesson C, Jacobsson LT, et al. The presence of rheumatoid nodules at early rheumatoid arthritis diagnosis is a sign of extra-articular disease and predicts radiographic progression of joint destruction over 5 years. Scand J Rheumatol 2011; 40:81. 

3. Kaushik P, Solomon DH, Greenberg JD, et al. Subcutaneous nodules are associated with cardiovascular events in patients with rheumatoid arthritis: results from a large US registry. Clin Rheumatol 2015; 34:1697.

Monday, March 7, 2022

steroid dosepaks

Q: 37 years old male is admitted to ICU with Gastrointestinal (GI) bleed after he was prescribed 'medrol dosepak" for his COVID-like symptoms. Prepackaged steroid courses are relatively safe?

A) True
B) False

Answer: In the United States, it is a very popular practice to prescribe 'medrol dosepack' when steroid is indicated. Nearly half of the steroids prescribed in the USA are prepackaged. Unfortunately, these prepackaged 'dosepaks' are not only relatively expensive but also deliver a higher glucocorticoid dose in less than a week. 

The other objective of this question is also to clear the misconception that short courses of steroids are safe. These short courses can also cause serious side effects, though association seems linear with dose and period of the course.



1. Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017; 357:j1415. 

2. Yao TC, Huang YW, Chang SM, et al. Association Between Oral Corticosteroid Bursts and Severe Adverse Events : A Nationwide Population-Based Cohort Study. Ann Intern Med 2020; 173:325.

Sunday, March 6, 2022

Essentials of enteral nutrition

Q: Typical Enteral Nutrition should be? ( select one)

A) hypotonic to serum
B) isotonic to serum

Answer: B

There are a few characteristics that should be the same in any standard enteral nutrition. This can be remembered from mnemonic CLIP ME*

●Caloric density of About  1 kcal/mL
●Isotonic to serum
●Protein content of about 40 g/1000 mL (intact- nonhydrolyzed)

●Mixture of simple and complex carbohydrates
●Essential vitamins, minerals, and micronutrients included



McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2016; 40:159.

*authors of this site created this mnemonic

Saturday, March 5, 2022

Epi of paradoxical embolism

Q: Patients with paradoxical embolism are usually younger? (select one)

A) True
B) False

Answer: A

Paradoxical embolism implies a thrombus in the venous circulation entering the arterial side. This mainly occurs via heart defects, mostly patent foramen ovale (PFO). Younger patients (average age 39 years) are more prone to paradoxical embolism than other patients who develop other forms of arterial thromboembolization (average age 68 years). 

There is a misconception that patients with paradoxical embolism only present with stroke, popularly known as cryptogenic stroke. There is a substantial number of patients who may develop acute extremity ischemia. 

Younger age should prompt a clinician to look for cardiac defects.



1. Miller S, Causey MW, Schachter D, et al. A case of limb ischemia secondary to paradoxical embolism. Vasc Endovascular Surg 2010; 44:604.

2. Dao CN, Tobis JM. PFO and paradoxical embolism producing events other than stroke. Catheter Cardiovasc Interv 2011; 77:903.

3.Hugl B, Klein-Weigel P, Posch L, et al. Peripheral ischemia caused by paradoxical embolization: an underestimated problem? Mt Sinai J Med 2005; 72:200

4. Herity NA, Dalzell GW. Venous thrombosis causing arterial embolization to the same limb through a patent foramen ovale. Clin Cardiol 1997; 20:893.

Friday, March 4, 2022

physical exam in viral meningitis

Q: 29 years old male is admitted to ICU with mental status change. There is a high suspicion of viral meningitis. Physical exam showed oropharyngeal thrush accompanied with cervical lymphadenopathy. Which of the following is most likely cause? (select one)

A) enterovirus
B) primary HIV
C) mumps 
D) HSV-2 
E) west Nile virus 

Answer: B

The objective of this question is to highlight the importance of a physical exam in diagnosis. Besides classic signs of meningitis, there are various other clues that may help to determine the exact cause of the diagnosis. 

Oropharyngeal thrush with cervical lymphadenopathy is usually seen with primary HIV (choice B). 

Enteroviral meningitis is frequently accompanied by a diffuse maculopapular exanthem (choice A). 

Mumps can be confused with symptoms of primary HIV but it is mostly present with
parotitis and history of unvaccinated (choice C). 

As expected HSV-2 usually has vesicular and ulcerative genital lesions (choice D). 

West Nile virus meningitis has a classic symptom of flaccid paralysis, mostly asymmetric (choice E).

#physical exam


1. Kohil A, Jemmieh S, Smatti MK, Yassine HM. Viral meningitis: an overview. Arch Virol. 2021;166(2):335-345. doi:10.1007/s00705-020-04891-1. 

2. Ihekwaba UK, Kudesia G, McKendrick MW. Clinical features of viral meningitis in adults: significant differences in cerebrospinal fluid findings among herpes simplex virus, varicella zoster virus, and enterovirus infections. Clin Infect Dis. 2008 Sep 15;47(6):783-9. doi: 10.1086/591129. PMID: 18680414. 

Thursday, March 3, 2022

Samter's triad

Q: 22 years old female is admitted to ICU with exacerbation of asthma. Pulmonologist wrote the diagnosis of Samter's triad. What is  Samter's triad?

 Answer: Although aspirin sensitivity for asthma patients is known for more than a century, five decades ago Samter and Beers added another component to it which came to known as Samter's triad. There is a renewed interest in this triad. Please see references # 2 and 3.

  •  asthma
  • aspirin sensitivity
  • nasal polyps 


1. Samter M, Beers RF Jr. Intolerance to aspirin. Clinical studies and consideration of its pathogenesis. Ann Intern Med 1968; 68:975.

2. Kim SD, Cho KS. Samter's Triad: State of the Art. Clin Exp Otorhinolaryngol. 2018 Jun;11(2):71-80. doi: 10.21053/ceo.2017.01606. Epub 2018 Apr 13. PMID: 29642688; PMCID: PMC5951071.

3. Krouse HJ, Krouse JH. Samter's Triad to Aspirin-Exacerbated Respiratory Disease: Historical Perspective and Current Clinical Practice. ORL Head Neck Nurs. 2015 Autumn;33(4):14-8. PMID: 26753248.

Wednesday, March 2, 2022

cricoid pressure

Q: In case of vomiting during intubation cricoid pressure (Sellick's maneuver) should be applied to prevent aspiration? 

A) True 
B) False

Answer: B

In case of vomiting during intubation cricoid pressure should be avoided or removed. There is a huge 'danger' of esophageal rupture if the esophagus cannot release the pressure with vomiting at either end.

In other words, aspiration should be accepted as a lower risk instead of esophageal rupture.  



1. Zdravkovic M, Rice MJ, Brull SJ. The Clinical Use of Cricoid Pressure: First, Do No Harm. Anesth Analg. 2021 Jan;132(1):261-267. doi: 10.1213/ANE.0000000000004360. PMID: 31397697.

2. Salem MR, Khorasani A, Zeidan A, Crystal GJ. Cricoid Pressure Controversies: Narrative Review. Anesthesiology. 2017 Apr;126(4):738-752. doi: 10.1097/ALN.0000000000001489. PMID: 28045709.

Tuesday, March 1, 2022

ARF and Carditis

Q: 24 years old female is admitted to ICU with chest pain and shortness of breath. ECHO showed acute mitral regurgitation. Patient was subsequently found to have carditis associated with acute Rheumatic fever (ARF). Carditis in ARF is usually? (select one)

A) pericarditis
B) epicarditis
C) myocarditis 
D) endocarditis
E) pancarditis 

Answer: E

The usual acute cardiac presentation of ARF is mitral regurgitation (MR). It may also present as aortic regurgitation (AR). Clinical history with the presence of murmurs can be diagnostic. In MR, Carey Coombs murmur is classic. This murmur can be heard as a short mid-diastolic murmur loudest at the apex.

The carditis in ARF is usually pancarditis involving pericardium, epicardium, myocardium, and endocardium along with valvulitis. Said that any form of carditis i.e., choices A, B, C, and D may occur independently.

An echocardiogram is indicated as subclinical carditis can occur with high frequency and can be highly damaging.



1. Gewitz MH, Baltimore RS, Tani LY, et al. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: A scientific statement from the American Heart Association. Circulation 2015; 131:1806.

2. Fabi M, Calicchia M, Miniaci A, Balducci A, Tronconi E, Bonetti S, Frabboni I, Biagi C, Bronzetti G, Pession A, Donti A, Lanari M. Carditis in Acute Rheumatic Fever in a High-Income and Moderate-Risk Country. J Pediatr. 2019 Dec;215:187-191. doi: 10.1016/j.jpeds.2019.07.072. Epub 2019 Oct 3. PMID: 31587860.

3. Sika-Paotonu D, Beaton A, Raghu A, et al. Acute Rheumatic Fever and Rheumatic Heart Disease. 2017 Mar 10 [Updated 2017 Apr 3]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from: