chronic hemolysis and vitamin deficiency

Q: Chronic hemolysis leads to the deficiency of which vitamin?

Answer: B9 (Folate)

Folate deficiency in chronic hemolysis is due to increased demand for compensatory red blood cell (RBC) production. The four major causes of folate deficiency are

• Pregnancy and lactation
• Chronic hemolytic anemias
• Exfoliative skin diseases
• Hemodialysis

Folate is essentially needed for DNA synthesis. 

#hematology

References:

1. Green R, Datta Mitra A. Megaloblastic Anemias: Nutritional and Other Causes. Med Clin North Am 2017; 101:297.

2. Allen LH. Causes of vitamin B12 and folate deficiency. Food Nutr Bull. 2008 Jun;29(2 Suppl):S20-34; discussion S35-7. doi: 10.1177/15648265080292S105. PMID: 18709879.

Regression of LVH and AF

Q: Regression of Left Ventricular Hypertrophy (LVH)? (select one)

A) decreases the frequency of paroxysmal atrial fibrillation

B) increases the frequency of paroxysmal atrial fibrillation

Answer: A

The objective of this question is to introduce students to the effect of angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) on reduction of atrial fibrillation with re-modelling of heart, or to be precise with regression of LVH. 

This effect is pure mechanical due to reduction in left atrial pressure as well as diameter. The biggest advantage is in the reduce frequency of new onset AF. ACEIs and ARBs have similar effect in this regard. This advantage is found to be more pronounced in patients with heart failure.

#cardiology

References:

1. Hennersdorf MG, Schueller PO, Steiner S, Strauer BE. Prevalence of paroxysmal atrial fibrillation depending on the regression of left ventricular hypertrophy in arterial hypertension. Hypertens Res 2007; 30:535.

2. Okin PM, Wachtell K, Devereux RB, et al. Regression of electrocardiographic left ventricular hypertrophy and decreased incidence of new-onset atrial fibrillation in patients with hypertension. JAMA 2006; 296:1242.

3. Healey JS, Baranchuk A, Crystal E, et al. Prevention of atrial fibrillation with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: a meta-analysis. J Am Coll Cardiol 2005; 45:1832.

SSRIs and cardiotoxicity

Q: Which of the Selective Serotonin Reuptake Inhibitors (SSRIs) is the most cardiotoxic? (select one)

A) citalopram

B) escitalopram 

C) fluoxetine

D) paroxetine

E) sertraline 

Answer: A

The major cardiotoxicity from citalopram (and other SSRIs) is due to prolong QTc interval, ultimately leading to torsades de pointe. Citalopram is metabolized in the liver and produces desmethylcitalopram (DCT) and didesmethylcitalopram (DDCT). The latter is cardiotoxic.

Citalopram is five times more likely to prolong the QTc interval when compared to other SSRIs. It can also cause left and right bundle branch blocks, Premature ventricular beats (PVCs), sinus bradycardia or tachycardia, supraventricular tachycardia, ST segment changes, and in extreme cases ventricular fibrillation. It is also known to cause seizures.

Bicarbonate infusion can be a lifesaver.

#toxicology

#pharmacology

#psyvhiatry

References:

1. Personne M, Sjöberg G, Persson H. Citalopram overdose--review of cases treated in Swedish hospitals. J Toxicol Clin Toxicol 1997; 35:237.

2. Personne M, Persson H, Sjöberg E. Citalopram toxicity. Lancet 1997; 350:518.

3. Kelly CA, Dhaun N, Laing WJ, et al. Comparative toxicity of citalopram and the newer antidepressants after overdose. J Toxicol Clin Toxicol 2004; 42:67.

Combintation Rx with ACE-I

Q: 42 years old afro-american male with no known previous history is admitted to ICU with accelerated hypertension (HTN). He responded to intravenous infusion of anti-hypertensive. PO Angiotensin-converting enzyme inhibitor (ACE inhibitor) started as a monotherapy with partial response. Which of the following may work well with ACE inhibitors? (select one)

A) Angiotensin II receptor blockers (ARBs)

B) Beta-blockers (BB)

C) Calcium Channel blockers (CCB)

D) Diuretics

E) C and D

Answer: E

Afro-American patients do not respond well to monotherapy with ACE inhibitors. But, a similar response can be obtained with the addition of a low dose of thiazide (diuretic) - choices D & E. The combination of ACE inhibitors and diuretics provides a synergistic effect. It may also help to attenuate some metabolic responses that occur only due to diuretics, such as hypokalemia, diuretic-induced hyperglycemia, the elevation of cholesterol, and hyperurecemia.

Also, CCB also provides a good combination therapy with ACE inhibitors - choices C & E.

Although, BB can be used with an ACE inhibitor but the response may not be desirable - choice B.

ARBs should not be added with ACE inhibitors - choice A.

#cardiology

#hemodynamics

References:

1. Pickering TG. The use of angiotensin converting enzyme inhibitors in combination with other antihypertensive agents. Am J Hypertens 1991; 4:73S.

2. Materson BJ, Reda DJ, Cushman WC, et al. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. N Engl J Med 1993; 328:914.

3. Townsend RR, Holland OB. Combination of converting enzyme inhibitor with diuretic for the treatment of hypertension. Arch Intern Med 1990; 150:1175.

Rinsing the mouth prior to expectoration

Q: Rinsing the mouth prior to expectoration improves the quality of the sputum?

A) True

B) False

Answer: A

The yield of the sputum Gram stain correlates directly with the quality of sputum submitted to the lab, particularly in community-acquired pneumonia (CAP). In contrast, sputum Gram stain does not help much in atypical pneumonia. This is due to the fact that patients with atypical pneumonia have a lot of mucoid sputum, and large Polymorphonuclear neutrophils (PMNs) but a few organisms. 

The diagnosis yield of sputum can be increased by a few measures such as:

• Obtaining the sputum prior to antibiotic administration
• Rinsing mouth prior to obtaining sample
• NPO an hour or two prior to expectoration
• Prompt inoculation of the culture media 
•  Rapid transport to the lab

#lab-medicine

#ID

#pulmonary

References:

1. Moncayo-Nieto OL, Reid P, Laurenson IF, Simpson AJ. Improving the use of sputum cultures in lower respiratory tract infection. J R Coll Physicians Edinb. 2013;43(2):108-13. doi: 10.4997/JRCPE.2013.204. PMID: 23734350.

2. Cartuliares MB, Skjøt-Arkil H, Rosenvinge FS, Mogensen CB, Skovsted TA, Pedersen AK. Effectiveness of expiratory technique and induced sputum in obtaining good quality sputum from patients acutely hospitalized with suspected lower respiratory tract infection: a statistical analysis plan for a randomized controlled trial. Trials. 2021 Oct 2;22(1):675. doi: 10.1186/s13063-021-05639-1. PMID: 34600559; PMCID: PMC8487344.

Antimicrobial strategy for severe community-acquired legionnaires' disease

Q: Doxycycline is a good choice of treatment in patients with Legionnaires' disease?

A) True

B) False

Answer: B

Tetracyclines like doxycycline are not a good choice to treat Legionnaires' disease as resistance is high. The two most effective antibiotics are levofloxacin and azithromycin. Both of these antibiotics are

• bactericidal
• achieve high intracellular concentrations
• penetrate lung tissue, and 
• active against all Legionella species

Alternatively, drugs from the same classes can be used.

Said that combining levofloxacin and azithromycin does not provide any added benefit. Similarly, adding rifampin also does not provide any benefit.

Tigecycline can be tried as a salvage therapy in refractory L. pneumophila infections.

#ID

#antibiotics

References:

1. Cecchini J, Tuffet S, Sonneville R, et al. Antimicrobial strategy for severe community-acquired legionnaires' disease: a multicentre retrospective observational study. J Antimicrob Chemother 2017; 72:1502.

2. Garcia-Vidal C, Sanchez-Rodriguez I, Simonetti AF, et al. Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis. Clin Microbiol Infect 2017; 23:653.

3. Grau S, Antonio JM, Ribes E, et al. Impact of rifampicin addition to clarithromycin in Legionella pneumophila pneumonia. Int J Antimicrob Agents 2006; 28:249.

4. Bopp LH, Baltch AL, Ritz WJ, et al. Activities of tigecycline and comparators against Legionella pneumophila and Legionella micdadei extracellularly and in human monocyte-derived macrophages. Diagn Microbiol Infect Dis 2011; 69:86.

recurrence of acute acalculous cholecystitis

Q: 58 years old male admitted to ICU with sepsis developed acalculous cholecystitis. Gallbladder drainage is performed via percutaneous cholecystostomy. Symptoms subsided after 4 days. Although resolved, acalculous cholecystitis has a high recurrence rate, and the drainage tube should be left for at least 8 weeks?

A) True

B) False

Answer: B

Although acalculous cholecystitis can be fatal in ICU patients if not promptly treated, the silver lining is that the recurrence rate is very low. Once symptoms subside and ultrasound confirms the resolution of inflammation with drainage and antibiotics, tube can be removed to avoid superimposed infection.

The rule of thumb is to remove the tube once the drainage is less than 10 cc per day.

#hepatology

#surgical-critical-care

References:

1. Chung YH, Choi ER, Kim KM, et al. Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis? J Clin Gastroenterol 2012; 46:216.

2. McLoughlin RF, Patterson EJ, Mathieson JR, et al. Radiologically guided percutaneous cholecystostomy for acute cholecystitis: long-term outcome in 50 patients. Can Assoc Radiol J 1994; 45:455.

bleed in CKD patients

Q: In patients with severe chronic kidney disease (CKD), which is a more common gastrointestinal (GI) bleed due to underlying uremia? (select one)

A) Upper GI 

B) Lower GI

Answer: B

A massive Canadian data collected over 10 years from 1998 to 2008 of over 11,000 patients, published in 2014, showed the following frequency of bleed in older renal patients (>65 years) who initiated chronic dialysis.

• Lower GI tract – 9 percent
• Upper GI tract – 6 percent
• Intracerebral – 1 percent
• Subarachnoid – 0.1 percent

Recent data published of about 6000 renal patients of all categories showed that they have almost double the likelihood of having intracerebral bleeding over non-renal patients.

#nephrology

#hematology

References:

1. Sood MM, Bota SE, McArthur E, et al. The three-year incidence of major hemorrhage among older adults initiating chronic dialysis. Can J Kidney Health Dis 2014; 1:21.

2. Vanent KN, Leasure AC, Acosta JN, et al. Association of Chronic Kidney Disease With Risk of Intracerebral Hemorrhage. JAMA Neurol 2022; 79:911.

CT chest in smoke inhalations

Q: How CT chest can help to establish prognosis in patients subjected to smoke inhalation?

Answer: The standard of care in smoke inhalation patients is to obtain only the chest X-ray (CXR). The presence and frequency of lung parenchymal opacities guide a clinician to the level of prognosis. 

Performing CT of the chest is not (yet) a standard of care in patients subjected to smoke inhalation. If obtained, the airway wall thickness to total bronchial diameter (T/D) ratio is a good parameter to establish a prognosis, especially regarding days on the ventilator.

#pulmonary

References:

1. Yamamura H, Kaga S, Kaneda K, Mizobata Y. Chest computed tomography performed on admission helps predict the severity of smoke-inhalation injury. Crit Care 2013; 17:R95.

2. Yamamura H, Morioka T, Hagawa N, et al. Computed tomographic assessment of airflow obstruction in smoke inhalation injury: Relationship with the development of pneumonia and injury severity. Burns 2015; 41:1428.

phosphene

Case: 32 years old male is admitted to ICU with acute psychosis. Psychiatry service note reads: "patient having phosphenes."

Answer:

Visual hallucination are common in ICU patients, particularly with underlying mental disease. They can be either formed or unformed. Visual hallucinations may involve lights, colors and shapes.

Simple hallucinations of light are classified as 

• phosphenes, meaning hallucinations of lights without structure, and 
• photopsias, meaning hallucinations of lights with geometric structure such as triangles, diamonds, squares, etc.

#psychiatry

References:

1. Cervetto L, Demontis GC, Gargini C. Cellular mechanisms underlying the pharmacological induction of phosphenes. Br J Pharmacol. 2007 Feb;150(4):383-90. doi: 10.1038/sj.bjp.0706998. Epub 2007 Jan 8. PMID: 17211458; PMCID: PMC2189731.

2. Bókkon I. Phosphene phenomenon: a new concept. Biosystems. 2008 May;92(2):168-74. doi: 10.1016/j.biosystems.2008.02.002. Epub 2008 Feb 16. PMID: 18358594.

Haldane effect

Q: What is Haldane effect?

Answer: The Haldane effect (named after John Scott Haldane) describe that deoxygenation of the blood increases its ability to carry carbon dioxide. Conversely, oxygenated blood has a reduced capacity for carbon dioxide.

The Haldane effect promotes dissociation of carbon dioxide from hemoglobin in the presence of oxygen. In the oxygen-rich capillaries of the lung, this property causes the displacement of carbon dioxide to plasma as venous blood enters the alveolus and is vital for alveolar gas exchange.

This partially explains the observation that some patients with emphysema might have an increase in PaCO2 following administration of supplemental oxygen even if content of CO2 stays equal.

Oxygenation of Hb promotes dissociation of H+ from Hb, which shifts the bicarbonate buffer equilibrium towards CO2 formation; therefore, CO2 is released from RBCs.

#oxygenation

Reference:

Malte H, Lykkeboe G. The Bohr/Haldane effect: a model-based uncovering of the full extent of its impact on O2 delivery to and CO2 removal from tissues. J Appl Physiol (1985). 2018 Sep 1;125(3):916-922. doi: 10.1152/japplphysiol.00140.2018. Epub 2018 May 10. PMID: 29745803.

Total Artificial Heart - Animation

NSAIDs in cardiac patients

Q: 56 years old male with history of chronic back pain is admitted to ICU from the cardiac cath lab after stents for coronary artery disease (CAD). Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with recent cardiac events?

A) True

B) False

Answer: A

NSAIDs are well known for their relative contra-indication in renal insufficiency or acute kidney injury (AKI) in ICU. Unfortunately, their relative contra-indication in cardiac patients is not always as emphasized. 

NSAIDs should be avoided in patients with established CAD due to two reasons. These patients are usually on other anti-thrombotic drugs, such as aspirin or clopidogrel, which highly increases gastrointestinal (GI) bleeding risk. Secondly, NSAIDs can directly increase the risk of recurrent MI, ischemic stroke or transient ischemic attack (TIA), or systemic arterial embolism with an extremely high hazard ratio (HR) of almost 1:7

#cardiology

#pharmacology

References:

1. Kang DO, An H, Park GU, et al. Cardiovascular and Bleeding Risks Associated With Nonsteroidal Anti-Inflammatory Drugs After Myocardial Infarction. J Am Coll Cardiol 2020; 76:518.

2. Ray WA, Varas-Lorenzo C, Chung CP, et al. Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease. Circ Cardiovasc Qual Outcomes 2009; 2:155.

3. Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med 2016; 375:2519.

CSF lactate

Q: What is the importance of measuring lactate level in Cerberospinal fluid (CSF)?

Answer:  Although not usually measured but measuring CSF lactate is a great way of differentiating bacterial and viral meningitis. The diagnostic accuracy of CSF lactate is found to be superior to CSF white blood cell count, glucose, and protein concentration in such differentiation. To note ideally lactate should be measured in CSF prior to the administration of antibiotics. 

Said that Lactate in CSF is not exclusively for bacterial meningitis. It can be elevated in other CNS diseases.

#neurology

References:

Huy NT, Thao NT, Diep DT, et al. Cerebrospinal fluid lactate concentration to distinguish bacterial from aseptic meningitis: a systemic review and meta-analysis. Crit Care 2010; 14:R240.

Sakushima K, Hayashino Y, Kawaguchi T, et al. Diagnostic accuracy of cerebrospinal fluid lactate for differentiating bacterial meningitis from aseptic meningitis: a meta-analysis. J Infect 2011; 62:255.

errors in SC CVC

Q: All of the following are the common errors while putting subclavian (SC) central venous catheter (CVC) EXCEPT? (select one)

A) improper identification of anatomic landmarks

B) improper needle insertion site

C) too deep a needle trajectory

D) insertion of needle through periosteum of clavicle bone

Answer: C

The objective of this question is to highlight the undue fears and myths associated with insertion of SC-CVC. SC vein continued to be the favored site over the internal jugular (IJ) and femoral to insert CVC (not counting PICCs). 

The biggest fear house-staff encountered while inserting SC-CVC is causing pneumothorax by going too deep in the chest. Due to this fear, one of the most common errors while inserting SC-CVC is keeping too shallow a needle trajectory. The other common errors are as described in choices A, B, and D, i.e., inadequate identification of anatomic landmarks, improper needle insertion site, and piercing the needle through the periosteum of the clavicle.

#procedures

Reference:

Kilbourne MJ, Bochicchio GV, Scalea T, Xiao Y. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg 2009; 208:104.

Clonidine toxicity

Q: The preferred method of counteracting clonidine overdose/toxicity is? (select one)

A) Naloxone 

B) Yohimbine

C) Hemodialysis

Answer: A

There is no specific antidote for clonidine. Supportive care and other basic management like gastrointestinal decontamination still stay as the mainstay of therapy.

Naloxone has been reported to reverse some of the effects of clonidine or related imidazoline, particularly central nervous system (CNS), and to some extent respiratory depression without causing rebound hypertension. There have been some reports of using alpha-adrenergic antagonists such as tolazoline and yohimbine, but due to the risk of associated hypotension, its use is not recommended.

Clonidine does not get removed by hemodialysis.

#toxicology

References:

1. Seger DL, Loden JK. Naloxone reversal of clonidine toxicity: dose, dose, dose. Clin Toxicol (Phila) 2018; 56:873.

2. Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila) 2017; 55:187.

3. Roberge RJ, McGuire SP, Krenzelok EP. Yohimbine as an antidote for clonidine overdose. Am J Emerg Med 1996; 14:678.

Metformin induced vitamin def.

Q: Metformin tends to decrease the level of which vitamin?

Answer: Vitamin B12

Patients on Metformin on a long-term basis may develop vitamin B12 deficiency. Metformin is known to lower serum vitamin B12 concentrations, particularly in patients who are also vegan or have absorption issues. Although the actual mechanism for this effect is not well understood but appears to be absorption related, as metformin is known to decrease the appetite and cause weight loss.

#pharmacology

#endocrinology

Reference:

Yang W, Cai X, Wu H, Ji L. Associations between metformin use and vitamin B12 levels, anemia, and neuropathy in patients with diabetes: a meta-analysis. J Diabetes. 2019 Sep;11(9):729-743. doi: 10.1111/1753-0407.12900. Epub 2019 Mar 29. PMID: 30615306.

Bedrails and falls

Q: 84 years old male is getting discharged to long-term acute care (LTAC) facility post-stroke. Orders must be written for the use of bed rails. Bed rails in medical and institutional settings are found to be associated with a decrease in injuries and deaths in elderly patients? 

A) True

B) False

Answer: B

Contrary to popular belief, falls in medical and institutional settings such as hospitals and nursing homes occur more frequently and are associated with greater morbidity than falls in the community. 

Also, bedrails were found not to prevent falls but may be associated with increased injuries and deaths. On the same token, avoiding bedrails may not decrease the total number of falls but may decrease the frequency of serious falls.

#geriatric-care

#preventive-care

References:

1. Leland NE, Gozalo P, Teno J, Mor V. Falls in newly admitted nursing home residents: a national study. J Am Geriatr Soc 2012; 60:939.

2. Capezuti E, Maislin G, Strumpf N, Evans LK. Side rail use and bed-related fall outcomes among nursing home residents. J Am Geriatr Soc 2002; 50:90.

3.Hanger HC, Ball MC, Wood LA. An analysis of falls in the hospital: can we do without bedrails? J Am Geriatr Soc 1999; 47:529.

AERD and ETOH

Q: 32 years old male with a known history of asthma is admitted to ICU with acute asthma exacerbation after a dorm party where he consumed alcohol. He denied the use of aspirin or NSAIDs. Which disease needs to be ruled out? 

Answer: Aspirin-exacerbated respiratory disease (AERD)

AERD, popularly known as the Samter triad, consists of

• asthma
• aspirin sensitivity, and 
• nasal polyps

For reason not fully understood, most patients have high reactions when they consume alcoholic beverages. However, they have no exposure to aspirin (ASA) or Non-Steroidal Anti -Inflammatory Drugs (NSAIDs). Symptoms include nasal congestion, rhinorrhea, wheezing, and shortness of breath. Symptoms usually appear within an hour of ingestion.

#pulmonary

References:

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

2. Ta V, White AA. Survey-Defined Patient Experiences With Aspirin-Exacerbated Respiratory Disease. J Allergy Clin Immunol Pract 2015; 3:711.

3. Cardet JC, White AA, Barrett NA, et al. Alcohol-induced respiratory symptoms are common in patients with aspirin exacerbated respiratory disease. J Allergy Clin Immunol Pract 2014; 2:208.

On Ivermectin

Q: Ivermectin is derived from soil mold?

A) True

B) False

Answer: A

Ivermectin gained a lot of (in)famous popularity during COVID-19 due to some reports of its efficacy against the corona virus, though unable to produce any substantial evidence. It is a semisynthetic derivative of avermectin derived from the soil mold named Streptomyces avermitilis. For a clinician at the bedside, two important lessons are:

1. Due to its lipophilic nature, it should be prescribed by actual body weight.

2. Ivermectin is contraindicated in pregnant or lactating women.

Its mechanism of action (MOA) is opening glutamate-sensitive chloride channel currents in helminths.

In obese patients, it may stay in the system longer and result in a longer half-life.

Ivermectin is the first line of treatment in onchocerciasis, and strongyloidiasis. However, it has been utilized against wuchereria bancrofti, Brugia malayi, Loa loa, ascariasis, trichuriasis, enterobiasis, cutaneous larva migrans and Mansonella ozzardi. There is also some evidence of its effectiveness in scabies and lice infestations.

#pharmacology

References:

1. Fox LM. Ivermectin: uses and impact 20 years on. Curr Opin Infect Dis 2006; 19:588.

2. Naquira C, Jimenez G, Guerra JG, et al. Ivermectin for human strongyloidiasis and other intestinal helminths. Am J Trop Med Hyg 1989; 40:304.

omega-3 fatty acids and atrial fibrillation

Q: 62 years old male who consumes many over the counter (OTC) nutritional products including vitamins and omega-3 fatty acid is admitted to ICU with atrial fibrillation (AF). Omega-3 fatty acid may have contributed to his AF?

A) True

B) False

Answer: A

There is a weak evidence from few cardiovascular studies that omega-3 fatty acids may be associated with an increased risk of AF. A meta-analysis composed of more than 80,000 patients and seven randomized controlled trials (RCTs) showed Hazard Ratio (HR) of 1.25 of AF association with omega-3 fatty acids.

#cardiology

Reference:

Gencer B, Djousse L, Al-Ramady OT, et al. Effect of Long-Term Marine ɷ-3 Fatty Acids Supplementation on the Risk of Atrial Fibrillation in Randomized Controlled Trials of Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Circulation 2021; 144:1981.

spironolactone and furosemide in treating ascites

Q: 54 years old male patient with cirrhosis is now ready to get transferred out of ICU. What is the preferred ratio of spironolactone and furosemide in treating ascites to maintain eukalemia?

Answer: 100:40

First-line diuretic therapy for cirrhotic ascites is the combined use of spironolactone and furosemide. Both drugs can be titrated as needed. 100: 40 mg ratio of spironolactone to furosemide is generally recommended to maintain normal electrolyte balance. Maximum accepted dosages are 400 and 160 mg/day of spironolactone and furosemide, respectively.

#hepatology

#electrolytes

Reference:

Management of Cirrhotic Ascites: Treatment of Cirrhotic Ascites - Medscape General Medicine. 2002;4(4)

Cerebral protection device during TAVR

statin and liver

Q: 54 years old male with a history of coronary artery disease (CAD) and on statins is admitted to ICU for chest pain. Review of the chart shows that patient's last liver function was checked two years ago. Patients on statin therapy should have their liver enzymes checked periodically?

A) True

B) False

Answer: B

The recent Food and Drug Administration (FDA) guidelines advise doing a liver function test (LFT) only before starting statin therapy and later ONLY if clinically indicated. It is recommended that statin should be either changed or the dose should be lowered if the ALT level goes beyond three times the upper limit of normal on two occasions. 

The risk of liver injury and need for follow-up is highest in the first 12 weeks, though the risk of complete liver failure is very low.

#hepatology

#pharmacology

References:

US Food and Drug Administration. FDA Drug Safety Communication: Important safety label changes to cholesterol-lowering statin drugs. February 28, 2012. Available at: http://www.fda.gov/Drugs/DrugSafety/ucm293101.htm (Accessed on February 2, 2023).

post TIPS

Q; After successful completion of Transjugular Intrahepatic Porto-systemic Shunt (TIPS) for variceal bleeding - hepatic encephalopathy __________? (select one)

A) tends to get better

B) tends to get worse

C) It has nothing to do with TIPS

Answer: B

Hepatic encephalopathy tends to get worse after the successful completion of TIPS. Due to shunting, blood flow to the liver is reduced, which might result in increased toxic substances reaching the brain without being metabolized first by the liver. It can be treated medically through diet, lactulose, or narrowing the shunt by inserting a reducing stent.

#hepatology

References: 

1. Treatment for hepatic encephalopathy: tips from TIPS? - Journal of Hepatology 42 (2005) 626–628

2. Hepatic encephalopathy after TIPS-- retrospective study - Vnitr Lek. 2002 May;48(5):390-5

3. Madoff DC, Wallace MJ. Reduced stents and stent-grafts for the management of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation. Semin Intervent Radiol. 2005 Dec;22(4):316-28. doi: 10.1055/s-2005-925558. PMID: 21326710; PMCID: PMC3036296.

NSAIDs, statins, PPIs for risk of adenocarcinoma in Barrett's esophagus

Q: Aspirin and NSAIDs may have a protective effect on Barrett's esophagus for the development of esophageal carcinoma?

A) True

B) False

Answer: A

Although it may be counterintuitive to think that aspirin (ASA) or nonsteroidal anti-inflammatory drugs (NSAIDs) have a protective effect for esophageal carcinoma in patients with Barrett's esophagus, studies have shown some weak evidence for it. In other words, they can be labeled chemopreventive in Barrett's esophagus. Of both, aspirin appears to contribute more in delaying the progression of Barrett's esophagus. This effect seems enhanced and synergistic when combined with Proton-Pump-Inhibitors (PPIs) and statin.

This effect appears to be transmitted via the inhibition of cyclooxygenase-2 suppresses growth and induces apoptosis.

#GI

#oncology

References:

1. Nguyen DM, El-Serag HB, Henderson L, et al. Medication usage and the risk of neoplasia in patients with Barrett's esophagus. Clin Gastroenterol Hepatol 2009; 7:1299.

2. Corley DA, Kerlikowske K, Verma R, Buffler P. Protective association of aspirin/NSAIDs and esophageal cancer: a systematic review and meta-analysis. Gastroenterology 2003; 124:47.

3. Souza RF, Shewmake K, Beer DG, et al. Selective inhibition of cyclooxygenase-2 suppresses growth and induces apoptosis in human esophageal adenocarcinoma cells. Cancer Res 2000; 60:5767.

4. Nguyen DM, Richardson P, El-Serag HB. Medications (NSAIDs, statins, proton pump inhibitors) and the risk of esophageal adenocarcinoma in patients with Barrett's esophagus. Gastroenterology 2010; 138:2260.

MOA of docusate

Q: How stool softener docusate works?

Answer: Stool softeners are frequently used in ICU for constipation. Very few people know that actually, its mechanism of action is due to its property of surfactant. It lowers the surface tension of stool. This allows water to easily enter the stool. This is for the same reason they are effective as ear wax removers!!

#pharmacology

References:

1. Bharucha AE, Pemberton JH, Locke GR 3rd. American Gastroenterological Association technical review on constipation. Gastroenterology 2013; 144:218.

2. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000 Sep;36(3):228-32. doi: 10.1067/mem.2000.109166. PMID: 10969225.

chylous ascites

Q: Milky ascites confirm malignancy?

A) True

B) False

Answer: B

Milky ascites is due to high triglyceride levels, usually above 200 mg/dL, and is also known as chylous ascites. Although malignancy should be suspected in chylous ascites, it is more common in cirrhosis.

#hepatology

References:

1. Rector WG Jr. Spontaneous chylous ascites of cirrhosis. J Clin Gastroenterol 1984; 6:369.

2. Cardozo PL. A critical evaluation of 3000 cytologic analyses of pleural fluid, ascitic fluid, and pericardial fluid. Acta Cyto 1966; 10:455.