Diuretics and Na

Q: Which group of diuretics tend to induce hyponatremia? (select one)

A) Loop

B) Thiazide

Answer: B

Thiazides are notorious for causing hyponatremia and typically occur within the first two weeks. It can be a challenging situation for a clinician since patients with thiazide-induced hyponatremia are usually clinically euvolemic and exhibit many of the features of inappropriate ADH secretion. 

Hyponatremia rarely occurs with loop diuretics. This is because the inhibition of sodium chloride transport in the loop of Henle impairs the generation of the countercurrent gradient and, therefore, limits the ability of ADH to promote water retention. However, this should not be taken as a universal rule, as patients with CHF or cirrhosis may develop hyponatremia, as these disease processes are prone to cause hyponatremia or may be subject to over-diuresis.

#nephrology

#electrolytes

#pharmacology

References:

1. Filippone EJ, Ruzieh M, Foy A. Thiazide-Associated Hyponatremia: Clinical Manifestations and Pathophysiology. Am J Kidney Dis. 2020 Feb;75(2):256-264. doi: 10.1053/j.ajkd.2019.07.011. Epub 2019 Oct 9. PMID: 31606239.

2. Burst V, Grundmann F, Kubacki T, Greenberg A, Becker I, Rudolf D, Verbalis J. Thiazide-Associated Hyponatremia, Report of the Hyponatremia Registry: An Observational Multicenter International Study. Am J Nephrol. 2017;45(5):420-430. doi: 10.1159/000471493. Epub 2017 Apr 19. PMID: 28419981; PMCID: PMC5452281.

RCRI

Q: Which of the following is NOT part of the Revised Cardiac Risk Index (RCRI) for pre-operative cardiac complications after noncardiac surgery? (select one)

A) Elevated-risk surgery

B) History of ischemic heart disease

C) History of liver insufficiency

D) History of cerebrovascular disease

E) Diabetes requiring insulin Rx

Answer: C

The revised Cardiac Risk Index for Pre-Operative Risk (RCRI) is created to estimate the risk of cardiac complications after noncardiac surgery. It consists of six parameters.

1. High-risk surgery such as intraperitoneal, intrathoracic, or supra-inguinal vascular surgeries

2. History of ischemic heart disease proven by previous history of myocardial infarction (MI); history of positive exercise test; history of angina requiring use of nitrate therapy or ECG with pathological Q waves

3. History of congestive heart failure (CHF) known by the history of pulmonary edema, bilateral rales, or S3 gallop; paroxysmal nocturnal dyspnea; chest x-ray (CXR) showing pulmonary vascular redistribution

4. History of cerebrovascular disease (CVA), either transient ischemic attack (TIA) or stroke

5. Diabetes Mellitus with pre-operative treatment with insulin

6. Pre-operative creatinine >2 mg/dL

Liver insufficiency is not a part of this calculator.

#surgical-critical-care

#cardiology

References:

1. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999 Sep 7;100(10):1043-9. doi: 10.1161/01.cir.100.10.1043. PMID: 10477528.

2. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ. 2005 Sep 13;173(6):627-34. doi: 10.1503/cmaj.050011. PMID: 16157727; PMCID: PMC1197163.

PLR and Et-CO2

Q: Passive Leg raising (PLR) _______________ the End Tidal CO2 (ET-CO2)? - select one

A) decreases

B) increases

Answer: B

PLR-induced increase in EtCO2 by about 5 %. PLR increases fluid-induced increase CI by about 15 %.

There is weak evidence that ET-Co2 may be better than arterial pressure for predicting volume responsiveness by the passive leg raising test!

#hemodynamics

Reference:

End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test - Intensive Care Med (2013) 39:93–100

CUS for DVT

Q: Compression ultrasonography (CUS) is more sensitive and specific in Deep Venous Thrombosis (DVT) for? (select one)

A) proximal veins

B) distal veins

Answer: A

Compression ultrasonography (CUS) with Doppler is the diagnostic test of choice in patients with suspected DVT. The non-compressibility of the imaged vein determines the test's positivity.

The proximal veins, i.e., the common femoral, deep femoral, and popliteal veins, are easy to access and more visible for compressibility. Their sensitivity and specificity are almost >95 percent for the test. The distal veins, i.e., the peroneal, posterior and anterior tibial, and muscular veins, do not have such great sensitivity and specificity. 

Calf and iliac vein thrombosis are difficult to determine as calf veins are less readily compressed, and iliac veins often cannot be assessed.

#vascular

#procedures

References: 

1. Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for Lower Extremity Deep Venous Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference. Circulation 2018; 137:1505.

2. Lensing AW, Doris CI, McGrath FP, et al. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep vein thrombosis. Arch Intern Med 1997; 157:765.

3. Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Deep vein thrombosis: update on diagnosis and management. Med J Aust. 2019 Jun;210(11):516-524. doi: 10.5694/mja2.50201. Epub 2019 Jun 2. PMID: 31155730.

Dose dumping

Q: What is dose dumping?

Answer: Dose dumping is a phenomenon of drug metabolism in which environmental factors causes the premature and mostly exaggerated release of a drug, causing particular drug toxicity. Most common reason of drug dumping is taking fatty meals with a particular drug that increases drug delivery. It is mostly described with extended-release forms of drug. 

Various explanations have been given including breakdown of drug's capsule or stimulation of the body's absorptive surfaces to increase the drug uptake.

Alcohol is another major factor that may cause drug dumping syndrome.

#pharmacology

References:

1. Shader RI. Dose dumping and the dumping of doses. J Clin Psychopharmacol. 2007 Aug;27(4):327-8. doi: 10.1097/JCP.0b013e318133fc23. PMID: 17632214.

2. Bílik T, Pavelková M, Kubová K, Vysloužil J. Dose dumping of modified-release solid oral dosage forms. Ceska Slov Farm. 2022 Fall;71(6):251-258. English. PMID: 36513519.

BPD

Q: Borderline personality disorder (BPD) features all of the following dimensions EXCEPT? (select one)

A) Impaired relatedness 

B) Affective dysregulation 

C) Behavior dysregulation 

D) Psychosomatic manifestations

Answer: D

Borderline personality disorder (BPD) has been modeled under three dimensions.

• Impaired relatedness
• Affective dysregulation
• Behavior dysregulation 

Out of the above three, 'affective dysregulation' is considered to be the most sensitive and specific single manifestation of BPD. It is also considered to be a potentially helpful screen. It is featured by affective lability, excessive anger, and efforts to avoid abandonment.

Impaired relatedness is manifested as unstable relationships with others, identity disturbance, and chronic emptiness.

Behavior dysregulation is marked by impulsivity, suicidality, and self-injurious behavior.

Patients with chronic emptiness are prone to have higher morbidity, including suicidality, history of suicide attempts and hospitalizations, social and work dysfunction, axis I (symptom) disorder comorbidity, and global functioning.

Although psychosomatic symptoms (choice D) may occur, they are not the hallmark of BPD.

#psychiatry

References:

1. Sanislow CA, Grilo CM, McGlashan TH. Factor analysis of the DSM-III-R borderline personality disorder criteria in psychiatric inpatients. Am J Psychiatry 2000; 157:1629.

2. Zimmerman M, Multach MD, Dalrymple K, Chelminski I. Clinically useful screen for borderline personality disorder in psychiatric out-patients. Br J Psychiatry 2017; 210:165.

3. Ellison WD, Rosenstein L, Chelminski I, et al. The clinical significance of single features of borderline personality disorder: Anger, affective instability, impulsivity, and chronic emptiness in psychiatric outpatients. J Pers Disord 2016; 30:261.

Auscultation in VSD

Q: A loud holosystolic murmur in the Ventricular Septal Defect (VSD) is a relatively favorable sign?

A) True

B) False

Answer: A

VSDs cause a holosystolic murmur if the pressure in the right ventricle is lower than the left ventricle throughout systole—a continuous left-to-right shunt. This signifies that the VSD is probably small, and pulmonary artery pressure and pulmonary vascular resistance are still in the normal range. Hence, a loud holosystolic murmur in a patient with a VSD signifies a favorable sign in the sense that there are relatively normal right-sided pressures.

VSD murmur is usually accompanied by a thrill. 

The character and timing of the systolic murmur change with large VSDs due to increased right ventricular and pulmonary artery pressure and elevated pulmonary vascular resistance. Instead of being holosystolic, it becomes early systolic, and the peak of the murmur occurs earlier.

#physical-exam

#cardiology

References: 

1. CRAIGE E. Phonocardiography in interventricular septal defects. Am Heart J 1960; 60:51.

2. HOLLMAN A, MORGAN JJ, GOODWIN JF, FIELDS H. Auscultatory and phonocardiographic findings in ventricular septal defect. A study of 93 surgically treated patients. Circulation 1963; 28:94.

Andexanet Alfa and Unfractionated Heparin

Q: A 52-year-old male with recent history of pulmonary embolism started on Low Molecular Weight (LMW) heparin two days ago. Patient developed severe gastrointestinal (GI) bleeding. GI service is on way to scope the patient. Patient reports history of vasectomy and refuse to take protamine. Andexanet alfa can be used to reverse anti Factor Xa action of Low Molecular Weight heparin (LMWH)?

A) True

B) False

Answer: A

Andexanet alfa can be used beside protamine to reverse the anti-factor Xa activity of LMW heparin. Andexanet alfa also reverses the anti-factor IIa activity. 

The recommended dose is 800 mg bolus at a rate of 30 mg/min, followed within two minutes by an infusion of 8 mg/minute for up to 120 minutes, with a maximum infusion dose of 960 mg. 

The caveat of using andexanet alfa is the concern for thrombotic events.

#hematology

#toxicity

References:

1. Connolly SJ, Crowther M, Eikelboom JW, et al. Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors. N Engl J Med 2019; 380:1326.

2. Lewis J, Iqbal O, Jeske W, Hoppensteadt D, Siddiqui F, Fareed J. Differential Neutralization of Unfractionated Heparin and Enoxaparin by Andexanet Alfa. Clin Appl Thromb Hemost. 2022 Jan-Dec;28:10760296221099934. doi: 10.1177/10760296221099934. PMID: 35535398; PMCID: PMC9096191.

3. Maneno JN, Ness GL. Andexanet Alfa, the Possible Alternative to Protamine for Reversal of Unfractionated Heparin. Ann Pharmacother. 2021 Feb;55(2):261-264. doi: 10.1177/1060028020943160. Epub 2020 Jul 15. PMID: 32667214.

Fever in Serotonin Syndrome

Q: 44 years old female is admitted to ICU with symptoms consistent with Serotonin toxicity, i.e., agitation, restlessness, confusion, tachycardia, autonomic dysfunction, ocular clonus, and hyperthermia up to 41 C. Patient required intubation. Cooling measures started. Acetaminophen can be used as an adjuvant treatment to control hyperthermia?

A) True 

B) False

Answer: B

Antipyretics have no role in treating hyperthermia due to serotonin syndrome because the rise in body temperature is due to an increase in muscular activity, not an alteration in the hypothalamic temperature set point. In extreme cases, like our patient in the above question, supportive treatment with intubation, sedation, and neuro-muscular blockade (NMB) should be initiated.

Cyproheptadine is recommended as an antidote. Cyproheptadine is a histamine-1 receptor antagonist with nonspecific 5-HT1A and 5-HT2A antagonistic properties and weak anticholinergic activity.

#toxicology

References:

1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112.

2. Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine. J Emerg Med 1998; 16:615.

3. Scotton WJ, Hill LJ, Williams AC, Barnes NM. Serotonin Syndrome: Pathophysiology, Clinical Features, Management, and Potential Future Directions. Int J Tryptophan Res. 2019 Sep 9;12:1178646919873925. doi: 10.1177/1178646919873925. PMID: 31523132; PMCID: PMC6734608.

Nightmares and beta-blockers

Q: Which of the following beta-blockers is most prone to cause nightmares? (select one)

A) propranolol

B) sotalol

C) carvedilol

D) labetalol 

E) atenolol

Answer: A

Although many classes of drugs are known to cause nightmares, such as dopamine agonists, antidepressants, antimicrobials, antipsychotics, antiseizures, and ketamine, it is less appreciated with anti-hypertensives, particularly beta-blockers (BB).

Almost one-third of the patients having nightmares report using beta blockers! 

BBs that are lipophilic, have higher serotonin 5HT1A receptor affinity, shorter half-lives, and lacking alpha-blockade are more likely to cause nightmares. These include propranolol, metoprolol, and pindolol. Nightmares are least common with sotalol, carvedilol, and labetalol. Although atenolol is hydrophilic, case reports of nightmares have been reported with its use.

#psychiatry

#pharmacology

References:

1. Thompson DF, Pierce DR. Drug-induced nightmares. Ann Pharmacother 1999; 33:93.

2. Garcia P, Montastruc JL, Rousseau V, et al. β-adrenoceptor antagonists and nightmares: A pharmacoepidemiological-pharmacodynamic study. J Psychopharmacol 2021; 35:1441.

3. Westerlund A. Central nervous system side-effects with hydrophilic and lipophilic beta-blockers. Eur J Clin Pharmacol 1985; 28 Suppl:73.

Bosniak radiological approach to renal cysts

Q: Bosniak classification of kidney cysts is done via? (select one)

A) intravenous (IV) contrast-enhanced computed tomography (CT)

B) ultrasonography (US)

C) magnetic resonance imaging (MRI)

D) level of pain

Answer: A

The biggest challenge in evaluating kidney cysts is differentiating between simple and complex cysts, mainly when the cyst size is > 1 cm. Bosniak kidney cyst classification helps diagnose and manage complex cysts. It requires a CT scan of the kidneys with IV contrast. It is named after Dr. Bosniak.

US or MRI should be used when the cyst size is less than 1 cm. Cysts are classified into five categories in ascending order of complexity: Category I, II, IIF*, III, and IV.

                                                  

The more complex the cyst, the higher the chances of malignancy.

                                                  

In the 2019 version, the Bosniak classification was updated.

#nephrology

#radiology

* F is for staging on follow-up

References:

1. Bosniak MA. The current radiological approach to renal cysts. Radiology 1986; 158:1.

2. Israel GM, Bosniak MA. An update of the Bosniak renal cyst classification system. Urology 2005; 66:484.

3. Curry NS, Cochran ST, Bissada NK. Cystic renal masses: accurate Bosniak classification requires adequate renal CT. AJR Am J Roentgenol 2000; 175:339.

4. Harisinghani MG, Maher MM, Gervais DA, et al. Incidence of malignancy in complex cystic renal masses (Bosniak category III): should imaging-guided biopsy precede surgery? AJR Am J Roentgenol 2003; 180:755.

5. Silverman SG, Pedrosa I, Ellis JH, et al. Bosniak Classification of Cystic Renal Masses, Version 2019: An Update Proposal and Needs Assessment. Radiology 2019; 292:475.

Hyperbilirubinemia and Sepsis

Q: Hyperbilirubinemia ________________ intestinal wall permeability? (select one)

A) decreases

B) increases

Answer: B

It is important to understand that hyperbilirubinemia can have many indirect consequences. It alters mucosal immunity, increases permeability, and may promote bacterial sepsis, particularly gram-negative bacteremia from the gut flora. 

Sepsis and hyperbilirubinemia can have synergistic negative effects on each other. Sepsis usually causes a low perfusion state, which leads to cholestasis. Other factors during sepsis, such as hypotension, drugs, and bacterial endotoxins, contribute to this pathology. All these factors give rise to hyperbilirubinemia, which sets a negative cycle, as described in the first paragraph above.

Similar pathology occurs with hyperbilirubinemia, as in heart failure and hypoxemia (ARDS).

#hepatology

References:

1. Fuchs M, Sanyal AJ. Sepsis and cholestasis. Clin Liver Dis 2008; 12:151.

2. Patel JJ, Taneja A, Niccum D, Kumar G, Jacobs E, Nanchal R. The association of serum bilirubin levels on the outcomes of severe sepsis. J Intensive Care Med. 2015 Jan;30(1):23-9. doi: 10.1177/0885066613488739. Epub 2013 May 22. PMID: 23753252.

3. Ghenu MI, Dragoş D, Manea MM, Ionescu D, Negreanu L. Pathophysiology of sepsis-induced cholestasis: A review. JGH Open. 2022 May 25;6(6):378-387. doi: 10.1002/jgh3.12771. PMID: 35774351; PMCID: PMC9218521.

CVS

Q: A 22-year-old female is admitted to ICU with severe dehydration and hypotension, requiring IVF fluid resuscitation and low-dose pressors. The patient reports severe episodes of nausea and vomiting. All workup stayed negative. Patient reports similar episodes in the past. Mother reports that the patient prefers hot-water showers during such episodes or rapid drinking of fluids after such episodes. Patient was previously diagnosed with cyclic vomiting syndrome (CVS). CVS is considered a psychiatric disease.

A) True

B) False

Answer: B

CVS is common in children and adults. This is not a psychiatric disease, though many behavioral symptoms, as described in our patient above, may falsely lead people around to believe that it is a psychiatric disorder. Also, its association with migraine, menses and the use of cannabinoids make it a hard-to-diagnose disease. CVS is believed to have underlying mitochondrial and/or autonomic dysfunctions. Also, hyperactivity of the hypothalamic-pituitary-adrenal axis is suspected.

#GI

#psychiatry

References:

1. Li BU, Balint JP. Cyclic vomiting syndrome: evolution in our understanding of a brain-gut disorder. Adv Pediatr 2000; 47:117.

2. Fleisher DR, Gornowicz B, Adams K, et al. Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med 2005; 3:20.

3. Kovacic K, Li BUK. Cyclic vomiting syndrome: A narrative review and guide to management. Headache. 2021 Feb;61(2):231-243. doi: 10.1111/head.14073. Epub 2021 Feb 23. PMID: 33619730.

4. Bhandari S, Jha P, Thakur A, Kar A, Gerdes H, Venkatesan T. Cyclic vomiting syndrome: epidemiology, diagnosis, and treatment. Clin Auton Res. 2018 Apr;28(2):203-209. doi: 10.1007/s10286-018-0506-2. Epub 2018 Feb 13. PMID: 29442203.

MERS-CoV and steroids

Q: Glucocorticoids have a beneficial effect on Middle East respiratory syndrome coronavirus (MERS-CoV) infection.

A) True

B) False

Answer: B

Although steroids have shown some efficacy and were largely used during the COVID-19 pandemic, glucocorticoid treatment failed to show any benefit in MERS-CoV infections. Instead, it was found to be associated with a delay in virus clearance. 

The only treatment that has some benefit, though statistically not significant, is the combination of lopinavir/ritonavir plus subcutaneous interferon (IFN)-beta-1b.

#ID

References:

1. Falzarano D, de Wit E, Rasmussen AL, et al. Treatment with interferon-α2b and ribavirin improves outcome in MERS-CoV-infected rhesus macaques. Nat Med 2013; 19:1313.

2. Arabi YM, Mandourah Y, Al-Hameed F, et al. Corticosteroid Therapy for Critically Ill Patients with Middle East Respiratory Syndrome. Am J Respir Crit Care Med 2018; 197:757.

orthostatic hypotension, lying supine and kidney

Q: 68-year-old male with a history of severe diabetes, autonomic dysfunction, moderate renal insufficiency, and known orthostatic hypotension is recovering in ICU from a bout of Diabetes Ketoacidosis (DKA).  Patient's blood pressure while lying supine tends to be? (select one)

A) high

B) low

Answer: A

Supine hypertension is a known side effect of patients with orthostatic hypotension. Supine hypertension is a systolic blood pressure (SBP) of at least 140 mmHg or a diastolic blood pressure of at least 90 mmHg after at least five minutes in the supine resting position. 

A large number of patients with a history of orthostatic hypotension tend to have supine hypertension along with renal dysfunction. These patients should be advised to sleep while raising the head of the bed 30 to 45 degrees. This simple maneuver decreases nocturnal diuresis, reducing supine hypertension and end-organ damage.

#hemodynamics

#nephrology

#cardiology

#endocrinology

#neurology

References:

1. Fanciulli A, Jordan J, Biaggioni I, et al. Consensus statement on the definition of neurogenic supine hypertension in cardiovascular autonomic failure by the American Autonomic Society (AAS) and the European Federation of Autonomic Societies (EFAS) : Endorsed by the European Academy of Neurology (EAN) and the European Society of Hypertension (ESH). Clin Auton Res 2018; 28:355.

2. Fan CW, Walsh C, Cunningham CJ. The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial. Age Ageing 2011; 40:187.

HFNC and PEEP effect

Q: The continuous positive airway pressure (CPAP) effect, also known as the "PEEP effect" of high-flow nasal cannula oxygenation, is better achieved with? (select one) 

A) mouth close

B) mouth open

Answer: A

Oxygen delivered via high-flow nasal cannulae (HFNC) is gaining popularity in ICUs as it carries many advantages and often prevents invasive intubation. Some of the benefits are:

1. Patient comfort due to small pliable nasal prongs

2. Warming and humidification of secretions

3. Washout of nasopharyngeal dead space 

4. More accurate delivery of oxygen

5. Decreases inspiratory effort 

6. "PEEP effect"

HFNC increases nasopharyngeal airway pressure that peaks at expiration's end, creating the "PEEP effect". This unload auto-PEEP if present, decrease work of breathing (WOB), and enhance oxygenation in patients with alveolar filling pathologies such as congestive heart failure CHF) or the acute respiratory distress syndrome (ARDS). This effect is dose dependent. The best PEEP effect comes when mouth is closed. Every increase of 10 L/minute of flow yields approximately 0.7 cm H2O of airway pressure when the mouth is closed and 0.35 cm H2O when the mouth is open.

#pulmonary

#ventilation

References:

1. Groves N, Tobin A. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care 2007; 20:126.

2. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low level positive airway pressure. Br J Anaesth 2009; 103:886.

3. Corley A, Caruana LR, Barnett AG, et al. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth 2011; 107:998.

Characteristics Hemoptysis

 Q: Hemoptysis blood is supposed to be? - select one

A) acidic

B) alkalotic

Answer: B

#GI

#pulmonary

References:

1. O'Gurek D, Choi HYJ. Hemoptysis: Evaluation and Management. Am Fam Physician. 2022 Feb 1;105(2):144-151. PMID: 35166503.

2. Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int. 2017 Jun 5;114(21):371-381. doi: 10.3238/arztebl.2017.0371. PMID: 28625277; PMCID: PMC5478790.

Ketamine and Urology

Case: 77-year-old patient has been in ICU intubated due to severe community-acquired pneumonia for the last 2 weeks. The patient was unable to tolerate propofol, dexmedetomidine, or benzodiazepine infusions either due to exaggerated response or reports of allergy. Finally, ketamine infusion appears to work well with the patient. On the 12th day of infusion, it is noted that the patient's BUN and creatinine are rising, and the urine bag shows signs of hematuria. What is your concern?

Answer: Urologic injury 

Ketamine causes irritation of the urologic system. In an unintubated patient, it includes symptoms of urge incontinence, decreased bladder compliance, decreased bladder volume, detrusor overactivity, and hematuria. In an intubated patient, as the patient is sedated and may not be able to complain, it progressively leads to hydronephrosis or papillary necrosis, eventually leading to renal failure. 

Patients who develop concomitant liver injury may have worse outcomes. It is a serious complication as ketamine-induced uropathy can be a permanent injury. 

Ketamine abuse (with a mushroom of ketamine inhalation bars in various parts of the world), a large number of erectile dysfunction is reported among chronic male users.

#pharmacology

#nephrology

#toxicology

References:

1. Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology 2007; 69:810. 

 2. Middela S, Pearce I. Ketamine-induced vesicopathy: a literature review. Int J Clin Pract 2011; 65:27. 

 3. Suppiah B, Vicknasingam B, Singh D, Narayanan S. Erectile Dysfunction among People Who Use Ketamine and Poly-Drugs. J Psychoactive Drugs 2016; 48:86. 

 4. Yang SS, Jang MY, Lee KH, et al. Sexual and bladder dysfunction in male ketamine abusers: A large-scale questionnaire study. PLoS One 2018; 13:e0207927. 

5. Ou SH, Wu LY, Chen HY, et al. Risk of Renal Function Decline in Patients with Ketamine-Associated Uropathy. Int J Environ Res Public Health 2020; 17.

PPCM

Q: The most commonly used definition of Peripartum Cardiomyopathy (PPCM) requires the development of heart failure (HF) towards the end of pregnancy or within _________ month(s) following delivery. (select one)

A) One

B) Two 

C) Three

D) Four

E) Five 

Answer: E

The definition developed by the 2010 European Society of Cardiology (ESC) Working Group on Peripartum Cardiology is widely used. It has been included in the 2018 ESC guidelines on managing cardiovascular diseases during pregnancy and in the position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy (PPCM). It requires all three conditions:

- Development of HF in the last month of pregnancy (or toward the end of pregnancy) or within five months following delivery.

- Absence of another identifiable cause for the HF.

- Left ventricular (LV) systolic dysfunction with LV ejection fraction (LVEF) of less than 45 percent, with or without LV dilation.

#cardiology

#ob-gyn

References:

1. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010; 12:767.

2. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Kardiol Pol 2019; 77:245.

3. Bauersachs J, König T, van der Meer P, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail 2019; 21:827.

allodynia, hyperalgesia, or dysesthesia

Q: What is the difference between allodynia, hyperalgesia, or dysesthesia?

Answer: Most patients who experience stroke central poststroke pain can be manifested in them as allodynia, hyperalgesia, or dysesthesia due to damage to the somatosensory tract. However, other causes of allodynia, hyperalgesia, or dysesthesia could exist.

Allodynia is pain due to a stimulus that does not normally provoke pain.

Hyperalgesia, as the name appears, is defined as an excessive response to any pain stimuli.

Dyesthesia is an abnormal and mostly uncomfortable or unpleasant physical touch sensation without an outside cause.

#neurology

References:

1. Liampas A, Velidakis N, Georgiou T, et al. Prevalence and Management Challenges in Central Post-Stroke Neuropathic Pain: A Systematic Review and Meta-analysis. Adv Ther 2020; 37:3278.

2. Shumway NK, Cole E, Fernandez KH. Neurocutaneous disease: Neurocutaneous dysesthesias. J Am Acad Dermatol. 2016 Feb;74(2):215-28; quiz 229-30. doi: 10.1016/j.jaad.2015.04.059. PMID: 26775772.

3. Jensen TS, Finnerup NB. Allodynia and hyperalgesia in neuropathic pain: clinical manifestations and mechanisms. Lancet Neurol. 2014 Sep;13(9):924-35. doi: 10.1016/S1474-4422(14)70102-4. PMID: 25142459.

Acetaminophen and ARDS

Q: There is weak evidence available that the use of acetaminophen may reduce the occurrence of acute respiratory distress syndrome (ARDS) in patients with sepsis and respiratory or circulatory organ failure.

A) True

B) False

Answer: A

An interesting randomized trial of 447 patients was published last month in JAMA, which was conducted from October 2021 to April 2023 with a 90-day follow-up (see reference #1). Patients with sepsis and respiratory or circulatory organ failure, when treated with acetaminophen in a dose of one gram every 6 hours for 5 days, reduce the rate of ARDS. However, there may not be any benefit in days alive and free of organ support - measured for 20 days each.

#pulmonary

#pharmacology

#ARDS

#sepsis

Reference:

1. Ware LB, Files DC, Fowler A, Aboodi MS, Aggarwal NR, Brower RG, Chang SY, Douglas IS, Fields S, Foulkes AS, Ginde AA, Harris ES, Hendey GW, Hite RD, Huang W, Lai P, Liu KD, Thompson BT, Matthay MA; National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network. Acetaminophen for Prevention and Treatment of Organ Dysfunction in Critically Ill Patients With Sepsis: The ASTER Randomized Clinical Trial. JAMA. 2024 May 19. doi: 10.1001/jama.2024.8772. Epub ahead of print. PMID: 38762798.

2. Janz DR, Bastarache JA, Peterson JF, et al. Association between cell-free hemoglobin, acetaminophen, and mortality in patients with sepsis: an observational study. Crit Care Med 2013; 41:784.

3. Suzuki S, Eastwood GM, Bailey M, et al. Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study. Crit Care 2015; 19:162.

Pines and non-pines of CCBs

Q: Which class of calcium channel blockers (CCBs) may help reduce proteinuria? - select one

A) dihydropyridines

B) Non-dihydropyridines

Answer: B

Knowing the difference between the two major classes of CCBs is essential.

1. Dihydropyridines
2. Non-dihydropyridines 

The dihydropyridines are known to have negligible or no adverse effect on cardiac contractility or conduction. They are used to treat hypertension or chronic stable angina via a vasodilatory mechanism. This class includes

• nifedipine
• isradipine
• felodipine
• nicardipine
• nisoldipine
• lacidipine
• amlodipine

The non-dihydropyridines reduce proteinuria and are typically used for hypertension, chronic stable angina, and cardiac arrhythmias. They are not as potent vasodilators as the above group and have a depressive effect on cardiac conduction and contractility. This class includes:

• verapamil 
• diltiazem

#pharmacology

#cardiology

#nephrology

References:

1. McKeever RG, Patel P, Hamilton RJ. Calcium Channel Blockers. 2024 Feb 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29494080.

2. Zhu J, Chen N, Zhou M, Guo J, Zhu C, Zhou J, Ma M, He L. Calcium channel blockers versus other classes of drugs for hypertension. Cochrane Database Syst Rev. 2022 Jan 9;1(1):CD003654. doi: 10.1002/14651858.CD003654.pub6. PMID: 35000192; PMCID: PMC8742884.

3. McKeever RG, Patel P, Hamilton RJ. Calcium Channel Blockers. [Updated 2024 Feb 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482473/

Mg in COPD

Q: In acute exacerbation of COPD, how much intravenous Magnesium (IV-Mg) is recommended?

A) 2 grams

B) 4 grams

C) 6 grams

Answer: A

Magnesium sulfate has shown a beneficial bronchodilator effect in acute exacerbation of COPD. It has an adjuvant value when short-acting inhaled bronchodilators are not or partially relieving the symptoms. The mechanism of action is the inhibition of calcium influx into airway smooth muscle cells. Usually, 2 grams of IV magnesium sulfate are given for over 20 minutes. 

Like digoxin in congestive heart failure (CHF), it is found to decrease hospitalizations in COPD exacerbations.

#pulmonary

References:

1. Gourgoulianis KI, Chatziparasidis G, Chatziefthimiou A, Molyvdas PA. Magnesium as a relaxing factor of airway smooth muscles. J Aerosol Med 2001; 14:301.

2. Ni H, Aye SZ, Naing C. Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2022; 5:CD013506.

3. Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev 2014; :CD010909.

Accessory spleen, Hypersplenism, and Splenosis

Q: What is the difference between Accessory spleen, Hypersplenism, and Splenosis?

Answer: A few related terms are commonly used and easy to understand, such as Asplenia (anatomical or physiological absence of the spleen), Hyposplenia (decreased splenic function), and Splenomegaly (large spleen size).

Accessory spleen is the presence of a separate region of splenic tissue in the abdomen. It is not well known that 15 percent of humans carry them.

Hypersplenism refers to splenic sequestration and/or destruction of blood cells (all three lineages) up to causing one or more cytopenias.

Splenosis is mostly iatrogenic by the seeding of the abdominal cavity with splenic cells that can occur during surgery or trauma.

#surgical-critical-care

#anatomy

#pathology

References:

1. Suttie AW. Histopathology of the spleen. Toxicol Pathol. 2006;34(5):466-503. doi: 10.1080/01926230600867750. PMID: 17067940.

2. Vikse J, Sanna B, Henry BM, Taterra D, Sanna S, Pękala PA, Walocha JA, Tomaszewski KA. The prevalence and morphometry of an accessory spleen: A meta-analysis and systematic review of 22,487 patients. Int J Surg. 2017 Sep;45:18-28. doi: 10.1016/j.ijsu.2017.07.045. Epub 2017 Jul 15. PMID: 28716661.

3. Tandon YK, Coppa CP, Purysko AS. Splenosis: a great mimicker of neoplastic disease. Abdom Radiol (NY). 2018 Nov;43(11):3054-3059. doi: 10.1007/s00261-018-1601-5. PMID: 29651643.

Atlanta classification

Q: Which of the following pathologies goes under the Atlanta classification? (select one) 

 A) acute pancreatitis 

 B) Acute Kidney failure 

C) Acute GI bleed 

D) Acute stroke 

E) Acute intestinal ischemia

Answer: A 

 Atlanta classification divides acute pancreatitis into two broad categories: 

1.  Interstitial edematous acute pancreatitis - characterized by acute inflammation of the pancreatic parenchyma and peripancreatic tissues, but without recognizable tissue necrosis. 
2.  Necrotizing acute pancreatitis - characterized by inflammation associated with pancreatic parenchymal necrosis and/or peripancreatic necrosis. 

Though it sounds simple, the management line becomes different for each category. 

#GI 

 Reference: 

 Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.

Type-3c Diabetes Mellitus

Q: What is type 3C diabetes?

Answer: Pancreatogenic diabetes

Pancreatogenic diabetes is usually a complication of Chronic pancreatitis and sometimes pancreatic cancer.

Long-standing chronic pancreatitis causes a wide range of exocrine insufficiency, leading to metabolic consequences. These include osteopenia, osteoporosis, bone fractures, pancreatogenic diabetes, and opioid dependency due to frequently prescribed narcotics. It may also cause pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites, pancreatic pleural effusion, splenic vein thrombosis, arterial pseudoaneurysms, small intestinal bacterial overgrowth, gastroparesis, pancreatic ductal adenocarcinoma.

#GI

#endocrinology

References:

1. Hart PA, Bellin MD, Andersen DK, et al. Type 3c (pancreatogenic) diabetes mellitus secondary to chronic pancreatitis and pancreatic cancer. Lancet Gastroenterol Hepatol 2016; 1:226.

2. Vonderau JS, Desai CS. Type 3c: Understanding pancreatogenic diabetes. JAAPA. 2022 Nov 1;35(11):20-24. doi: 10.1097/01.JAA.0000885140.47709.6f. PMID: 36219100.

3. Bhattamisra SK, Siang TC, Rong CY, Annan NC, Sean EHY, Xi LW, Lyn OS, Shan LH, Choudhury H, Pandey M, Gorain B. Type-3c Diabetes Mellitus, Diabetes of Exocrine Pancreas - An Update. Curr Diabetes Rev. 2019;15(5):382-394. doi: 10.2174/1573399815666190115145702. PMID: 30648511.

Lyme carditis

 Q: 44 years old male who was diagnosed with Lyme's disease 4 weeks ago is now admitted to ICU with syncope and Atrio-ventricular block (AV-block) on EKG. It would be prudent to insert a permanent pacemaker to avoid sudden cardiac death?

A) True

B) False

Answer: B

AV block due to Lyme carditis is usually short-lived and resolved in six weeks. A temporary pacemaker may be required, but a permanent pacemaker is rarely needed. While evaluating the EKG of a patient suspected of having Lyme carditis, it is important to pay attention to the PR interval. If the PR interval is more than 300 milliseconds, there is a high chance of the patient progressing to complete AV block, which may require a temporary pacemaker. 

Patients who fail to complete the antibiotic course appropriately for any early signs of Lyme disease, erythema migrans, are more prone to progress to Lyme carditis.

#cardiology

References:

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

2. Yeung C, Baranchuk A. Diagnosis and Treatment of Lyme Carditis: JACC Review Topic of the Week. J Am Coll Cardiol. 2019 Feb 19;73(6):717-726. doi: 10.1016/j.jacc.2018.11.035. Erratum in: J Am Coll Cardiol. 2019 Nov 26;74(21):2709-2711. PMID: 30765038. 

3. Sangha O, Phillips CB, Fleischmann KE, et al. Lack of cardiac manifestations among patients with previously treated Lyme disease. Ann Intern Med 1998; 128:346. 

4. van der Linde MR, Crijns HJ, Lie KI. Transient complete AV block in Lyme disease. Electrophysiologic observations. Chest 1989; 96:219.

LAA thrombi in AF

Q: What percentage of left atrial thrombi in atrial fibrillation (AF) originates from Left Atrial Appendage? (select one)

A) 50%

B) 70%

C) 90%

Answer: C

The objective of asking this question is to cover two concepts.

First, as 90% of thrombi in AF originate in the LAA, it is a good practice in cardiac surgery to ligate, amputate, or occlude the LAA if the patient already has an open sternum for other indications, particularly in those patients who cannot take oral anticoagulation. Other patients who are not undergoing cardiac surgery may get such ablation/occlusion via procedures such as the WATCHMAN device.

Second, clinicians should be mindful that 10% of thrombi are NOT coming from the LAA and should evaluate the caveats. It may be left atrial structural or functional abnormalities or a hypercoagulable state. Also, if the LAA is not properly amputated, residual communication between the LAA and Left Atrium (LA)—known as residual jet—can lead to stroke. A residual jet >5 mm may predispose to thrombus formation. 

#cardiology

#cardiac-surgery

References:

1. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61:755.

2. Saraf K, Morris GM. Left Atrial Appendage Closure: What the Evidence Does and Does Not Reveal-A View from the Outside. Interv Cardiol Clin. 2022 Apr;11(2):171-183. doi: 10.1016/j.iccl.2021.11.009. Epub 2022 Mar 11. PMID: 35361462.

3. Dudziñska-Szczerba K, Kułakowski P, Michałowska I, Baran J. Association Between Left Atrial Appendage Morphology and Function and the Risk of Ischaemic Stroke in Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev. 2022 Apr;11:e09. doi: 10.15420/aer.2022.08. PMID: 35846423; PMCID: PMC9272406.

ICP in cryptococcal meningitis

Q: 42 years old male with known history of AIDS and previous cryptococcal meningoencephalitis is brought to ED by his roommate with clouding of sensorium and ataxia. On exam patient is found to have visual and hearing loss, and papilledema. Lumbar puncture (LP) was planned. What is considered to be the increased Intra Cranial Pressure (ICP) in cm of H2O? - select one

A) >10 

B) >20 

C) >30

D) >40 

Answer: B

One of the essential procedures required in patients with AIDS and suspected cryptococcal meningoencephalitis is LP to measure ICP.

High ICP is one of the hallmark of cryptococcal meningoencephalitis. It is probably due to increased vascular permeability secondary to cytokine-induced inflammation. Also, clogging of arachnoid villi with fungal antigen and/or yeasts, plays role by impairment of CSF resorptive function.

Pressure above >20 cm of H2O is considered as high ICP.

#procedures

#ID

References:

1. Chang CC, Harrison TS, Bicanic TA, et al. Global guideline for the diagnosis and management of cryptococcosis: an initiative of the ECMM and ISHAM in cooperation with the ASM. Lancet Infect Dis 2024.

2. The World Health Organization. Guidelines for the diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents, and children. http://apps.who.int/iris/bitstream/handle/10665/260399/9789241550277-eng.pdf;jsessionid=7A37044AC579D4A69EBBBF0B47BC60AF?sequence=1 (Accessed on May 19, 2024).

3. Claus JJ, Portegies P. Reversible blindness in AIDS-related cryptococcal meningitis. Clin Neurol Neurosurg 1998; 100:51.

4. Pappas PG. Managing cryptococcal meningitis is about handling the pressure. Clin Infect Dis 2005; 40:480.

Fibrinogen in DIC

Q: Normal fibrinogen level in DIC is a good prognostic feature. 

A) True 

B) False 

Answer: B 

Disseminated intravascular coagulation (DIC) is a symptom of the underlying disease, and severity usually correlates with the underlying disease's severity. It is marked by abnormalities such as 

• prolonged PT and aPTT 
• low fibrinogen
• increased D-dimer 
• low platelet count 
• microangiopathic hemolytic anemia (MAHA) on blood smear. 

Fibrinogen is an acute-phase reactant. In sepsis, malignancy, and other inflammatory conditions may have markedly increased fibrinogen production; thus, a plasma fibrinogen level within the normal range may represent a severe underlying process.

 #hematology 

References:

1. Papageorgiou C, Jourdi G, Adjambri E, Walborn A, Patel P, Fareed J, Elalamy I, Hoppensteadt D, Gerotziafas GT. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost. 2018 Dec;24(9_suppl):8S-28S. doi: 10.1177/1076029618806424. Epub 2018 Oct 8. PMID: 30296833; PMCID: PMC6710154. 

 2. Kim HK, Lee DS, Kang SH, Kim JQ, Park S, Cho HI. Utility of the fibrinogen/C-reactive protein ratio for the diagnosis of disseminated intravascular coagulation. Acta Haematol. 2007;117(1):34-9. doi: 10.1159/000096786. Epub 2006 Nov 8. PMID: 17095857.

BT in asthma

Q: A 24-year-old male is admitted to ICU with a fourth exacerbation of Asthma within the last 6 months. The patient continued to fail all therapies despite full compliance. The patient has now registered for a Bronchial Thermoplasty (BT) trial. Which of the lobes is usually NOT treated during this procedure? - select one

A) Right upper lobe

B) Righe middle lobe

C) Right lower lobe

D) Left upper lobe

E) Left lower lobe

Answer: B

BT is a measure of extreme for patients who continued to fail all conventional medical therapy for Asthma. The procedure involves applying heat via localized controlled radiofrequency waves with a bronchoscope. It aims to reduce the increased mass of airway smooth muscle associated with asthma. 

The procedure is usually completed with three consecutive bronchoscopies three weeks apart. The target tissue temperature is kept at 65˚C for the airway walls. All accessible airways distal to the mainstem bronchus that are 3 to 10 mm in diameter are treated once, except those in the right middle lobe, which are left untreated due to difficulty with access.

#procedures

#pulmonary

References:

1. Wahidi MM, Kraft M. Bronchial thermoplasty for severe asthma. Am J Respir Crit Care Med 2012; 185:709.

2. Langton D, Wang W, Sha J, et al. Predicting the Response to Bronchial Thermoplasty. J Allergy Clin Immunol Pract 2020; 8:1253.

3. Torrego A, Solà I, Munoz AM, et al. Bronchial thermoplasty for moderate or severe persistent asthma in adults. Cochrane Database Syst Rev 2014; :CD009910.

4. Chupp G, Kline JN, Khatri SB, et al. Bronchial Thermoplasty in Patients With Severe Asthma at 5 Years: The Post-FDA Approval Clinical Trial Evaluating Bronchial Thermoplasty in Severe Persistent Asthma Study. Chest 2022; 161:614.

Type B - LA - types

Q: What is Type B1, Type B2 and Type B3 Lactic acidosis?

Answer; Basically, there are 2 major types of Lactic acidosis: A and B (let's forget about type D for a while!!)

Type A lactic acidosis occurs in the setting of poor tissue perfusion or oxygenation. It is due to either overproduction or underutilization.

Overproduction: Circulatory, pulmonary, or hemoglobin transfer disorders are commonly responsible.

Underutilization: Liver disease, gluconeogenesis inhibition, thiamine deficiency, and uncoupled oxidative phosphorylation

Type B lactic acidosis is when there is no evidence of poor tissue perfusion. Type B is divided into 3 subtypes.

• Type B1 is associated with systemic diseases such as renal and hepatic failure, diabetes, and malignancy.
• Type B2 is caused by drugs and toxins, including biguanides, alcohols, iron, isoniazid, and salicylates. HIV drugs have been described, too.
• Type B3 is due to inborn errors of metabolism.

#metabolism

References:

1. Seheult J, Fitzpatrick G, Boran G. Lactic acidosis: an update. Clin Chem Lab Med. 2017 Mar 1;55(3):322-333. doi: 10.1515/cclm-2016-0438. PMID: 27522622.

2. Claudino WM, Dias A, Tse W, Sharma VR. Type B lactic acidosis: a rare but life threatening hematologic emergency. A case illustration and brief review. Am J Blood Res. 2015 Jun 15;5(1):25-9. PMID: 26171281; PMCID: PMC4497494.