Remdesivir and Kidney

Q: A 67-year-old male with renal insufficiency with a baseline Glomerular Filtration Rate (GFR) of 34 is admitted to the ICU with COVID-19 during the 2025 flu season. Remdesivir is contraindicated in this patient due to acute-on-chronic renal failure.

A) True

B) False

Answer: B

Remdesivir can be safely used in patients with acute kidney injury (AKI) and chronic kidney disease (CKD) without fear of worsening kidney function, including those on dialysis. There is no need to adjust the dose. Previously, it was suggested that the cyclodextrin vehicle of this drug can accumulate in renal failure, but concern seems to be unfounded, at least clinically. 

Also, Remdesivir can be relatively safely used in decompensated liver disease. Care should be taken to check baseline Liver Function Tests (LFTs) and to monitor them while remdesivir is in use. It can be safely used till alanine aminotransferase (ALT) elevation is below >10 times the upper limit of normal.

#ID

#pharmacology

#nephrology

#hepatology

References:

1. Thakare S, Gandhi C, Modi T, et al. Safety of Remdesivir in Patients With Acute Kidney Injury or CKD. Kidney Int Rep 2021; 6:206.

2. Seethapathy R, Wang Q, Zhao S, et al. Effect of remdesivir on adverse kidney outcomes in hospitalized patients with COVID-19 and impaired kidney function. PLoS One 2023; 18:e0279765.

3. Sise ME, Santos JR, Goldman JD, et al. Efficacy and Safety of Remdesivir in People With Impaired Kidney Function Hospitalized for COVID-19 Pneumonia: A Randomized Clinical Trial. Clin Infect Dis 2024; 79:1172.

4. Sabers AJ, Williams AL, Farley TM. Use of remdesivir in the presence of elevated LFTs for the treatment of severe COVID-19 infection. BMJ Case Rep. 2020 Oct 31;13(10):e239210. doi: 10.1136/bcr-2020-239210. PMID: 33130588; PMCID: PMC10577715.

5. Shah S, Ackley TW, Topal JE. Renal and Hepatic Toxicity Analysis of Remdesivir Formulations: Does What Is on the Inside Really Count? Antimicrob Agents Chemother. 2021 Sep 17;65(10):e0104521. doi: 10.1128/AAC.01045-21. Epub 2021 Jul 26. PMID: 34310212; PMCID: PMC8448111.

Eye symptoms in MS

Q: In a typical attack of multiple sclerosis (MS), visual loss is usually associated with? select one

A) pain

B) no pain

Answer: A

The typical presentation of multiple sclerosis (MS), also called clinically isolated syndrome (CIS), is usually the first clinical episode suggestive of MS. Visual loss due to optic neuritis typically has three characteristic symptoms:

• monocular visual loss consisting of visual blurring or scotoma
• reduced color vision
• pain with eye movements

On exam, there is a relative afferent pupillary defect on examination.

#neurology

# ophthalmology

References:

1. Thompson AJ, Banwell BL, Barkhof F, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol 2018; 17:162.

2. Brownlee WJ, Hardy TA, Fazekas F, Miller DH. Diagnosis of multiple sclerosis: progress and challenges. Lancet 2017; 389:1336.

3. Kale N. Optic neuritis as an early sign of multiple sclerosis. Eye Brain. 2016 Oct 26;8:195-202. doi: 10.2147/EB.S54131. PMID: 28539814; PMCID: PMC5398757.

VAP

Q: Ventilator-associated pneumonia (VAP) also includes patients who develop nosocomial pneumonia (HAP) within 48 hours of extubation.

A) True 

B) False

Answer: A

The term ventilator-associated pneumonia (VAP) can be a little misleading, as it suggests that it counts only pneumonia that occurs while on a ventilator. Patients who are already extubated but still within 48 hours and develop pneumonia are counted as VAP.

Several different terminologies have been designated to categorize these patients. The basic idea for such a classification is that there may be various kinds of 'bugs', often multidrug-resistant (MDR), that are frequently encountered in these different patient categories and can help start appropriate antibiotics before culture results are available.

Hospital-acquired pneumonia (HAP), also known as nosocomial pneumonia, is defined as pneumonia that occurs 48 hours or more after hospital admission and did not appear to be incubating at the time of admission. 

VAP and non-ventilator-associated HAP (nvHAP) are types of HAP.

#ID

#pulmonary

#ventilators

References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Mumtaz H, Saqib M, Khan W, Ismail SM, Sohail H, Muneeb M, Sheikh SS. Ventilator associated pneumonia in intensive care unit patients: a systematic review. Ann Med Surg (Lond). 2023 May 12;85(6):2932-2939. doi: 10.1097/MS9.0000000000000836. PMID: 37363470; PMCID: PMC10289715.

Hallucinations in Dementia with Lewy bodies

Q: 78 years old male is admitted to the ICU with acute psychosis kind of symptoms. The patient has been previously diagnosed with dementia with Lewy bodies (DLB). Which is more common in DLB? - select one

A) Auditory hallucinations

B) Visual hallucinations

Answer: B

The three major core clinical features of DLB are:

• cognitive fluctuations
• visual hallucinations, and 
• parkinsonism

Rapid eye movement (REM) sleep behavior disorder is also described as an early sign of DLB. Genetic predisposition is highly associated.

#psychiatry

#neurology

#geriatrics

References:

1. Devenyi RA, Hamedani AG. Visual dysfunction in dementia with Lewy bodies. Curr Neurol Neurosci Rep. 2024 Aug;24(8):273-284. doi: 10.1007/s11910-024-01349-8. Epub 2024 Jun 22. PMID: 38907811; PMCID: PMC11258179.

2. Ballard C, McKeith I, Harrison R, O'Brien J, Thompson P, Lowery K, Perry R, Ince P. A detailed phenomenological comparison of complex visual hallucinations in dementia with Lewy bodies and Alzheimer's disease. Int Psychogeriatr. 1997 Dec;9(4):381-8. doi: 10.1017/s1041610297004523. PMID: 9549588.

3. Rampello L, Cerasa S, Alvano A, Buttà V, Raffaele R, Vecchio I, Cavallaro T, Cimino E, Incognito T, Nicoletti F. Dementia with Lewy bodies: a review. Arch Gerontol Geriatr. 2004 Jul-Aug;39(1):1-14. doi: 10.1016/j.archger.2003.11.003. PMID: 15158576.

Azithromycin's longer effect

Q: Why is a short course of azithromycin considered relatively sufficient in comparison to other macrolides?

Answer: For most infections, a once-daily 5-day regimen of azithromycin is considered as effective as 10-day courses of the other macrolides.

This is because azithromycin has a long intracellular half-life (40 to 68 hours) and a slow rate of release from tissue sites. For example, a 2-gram extended-release oral suspension of azithromycin is given as a single dose due to its long half-life. The only caution is to take the extended-release suspension 1 hour before or 2 hours after meals, and to consume it within 12 hours of reconstitution.

#pharmacology

#ID

References:

1. Azithromycin extended-release (Zmax) for sinusitis and pneumonia. Med Lett Drugs Ther 2005; 47:78.

2. Crokaert F, Hubloux A, Cauchie P. A Phase I Determination of Azithromycin in Plasma during a 6-Week Period in Normal Volunteers after a Standard Dose of 500mg Once Daily for 3 Days. Clin Drug Investig. 1998;16(2):161-6. doi: 10.2165/00044011-199816020-00009. PMID: 18370534.

A note on pulse methylprednisolone and arrhythmias

A note on pulse methylprednisolone and arrhythmias

Glucocorticoids, particularly high doses, tend to cause arrhythmias like atrial flutter and fibrillation, irrespective of underlying pulmonary or cardiovascular disease. Sinus bradycardia has been reported, particularly with high "pulse" dose.  Although sudden death has also been attributed during pulse infusions of glucocorticoids, it's difficult to determine, as most of these patients have underlying severe comorbidities.

Cardiac monitoring is recommended, particularly when there is an underlying cardiac disease, diuretics on board, or associated electrolyte derangements are present.

#pharmacology

#cardiology

#pulmonary

References:

1. White KP, Driscoll MS, Rothe MJ, Grant-Kels JM. Severe adverse cardiovascular effects of pulse steroid therapy: is continuous cardiac monitoring necessary? J Am Acad Dermatol 1994; 30:768.

2. Christiansen CF, Christensen S, Mehnert F, et al. Glucocorticoid use and risk of atrial fibrillation or flutter: a population-based, case-control study. Arch Intern Med 2009; 169:1677.

3. Akikusa JD, Feldman BM, Gross GJ, et al. Sinus bradycardia after intravenous pulse methylprednisolone. Pediatrics 2007; 119:e778.

Four classes of acutely incarcerated/strangulated groin hernia

Q: What are the four classes of acutely incarcerated/strangulated groin hernia?

Answer: Acutely incarcerated or strangulated groin hernia are divided into four classes to determine whether to use mesh and which kind of mesh should be used while repairing an acutely incarcerated or strangulated groin hernia. This classification is per the Centers for Disease Control and Prevention (CDC).

Class 1 (clean) – Bowel incarceration but not strangulation, and there is no need for bowel resection. Synthetic mesh should be used to repair the hernia. 

Class 2 (clean-contaminated) – For patients with bowel strangulation and/or a concomitant bowel resection, the wound should be classified as clean-contaminated, and a synthetic, monofilament, large-pore mesh should be used to repair the hernia.

Class 3 (contaminated) and class 4 (dirty-infected) – For patients with bowel perforation and/or abscess formation, the wound should be classified as contaminated or dirty-infected, in which case no mesh should be used to repair the hernia. Once source control has been achieved, the hernia can be repaired with or without mesh, depending on the patient's clinical condition. 

#surgical-Critical-Care

References:

1. HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018; 22:1.

2. Elsebae MM, Nasr M, Said M. Tension-free repair versus Bassini technique for strangulated inguinal hernia: A controlled randomized study. Int J Surg 2008; 6:302.

3. Hentati H, Dougaz W, Dziri C. Mesh repair versus non-mesh repair for strangulated inguinal hernia: systematic review with meta-analysis. World J Surg 2014; 38:2784.

pleural pathology and lung cancer

Q: Which of the pleural findings on imaging is usually more of a sign of concern for cancer?

A) Nodularity

B) Plaque

Answer: A

Any of the following findings in the imaging should raise suspicion of lung cancer.

• Lesions >3 cm that are new
• Measurable growth in any nodule or mass from the previous
• Pleural nodularity 
• Asymmetric or significantly enlarged hilar or paratracheal nodes
• An endobronchial lesion
• An area of consolidation thought to be pneumonia that fails to resolve with medical management

Pleural plaques usually indicate significant asbestos exposure.

#pulmonary

#oncology

#radiology

References:

1. Del Giudice ME, Young SM, Vella ET, Ash M, Bansal P, Robinson A, Skrastins R, Ung Y, Zeldin R, Levitt C. Guideline for referral of patients with suspected lung cancer by family physicians and other primary care providers. Can Fam Physician. 2014 Aug;60(8):711-6, e376-82. PMID: 25122814; PMCID: PMC4131959.

2. Hyldgaard C, Trolle C, Harders SMW, Engberg H, Rasmussen TR, Møller H. Increased use of diagnostic CT imaging increases the detection of stage IA lung cancer: pathways and patient characteristics. BMC Cancer. 2022 Apr 27;22(1):464. doi: 10.1186/s12885-022-09585-2. PMID: 35477356; PMCID: PMC9047294.

3. Erasmus LT, Strange TA, Agrawal R, Strange CD, Ahuja J, Shroff GS, Truong MT. Lung Cancer Staging: Imaging and Potential Pitfalls. Diagnostics (Basel). 2023 Nov 1;13(21):3359. doi: 10.3390/diagnostics13213359. PMID: 37958255; PMCID: PMC10649001.

platelets storage

Q: Platelets are routinely stored at? - select one

A) cold temperature

B) room temperature 

Answer: B

Platelets are best stored at room temperature because cold temperatures induce clustering of von Willebrand factor (vWF) receptors on the platelet surface. It also causes morphological changes in platelets, leading to enhanced hepatic macrophage clearance and decreased platelet survival in the recipient. All platelets remain metabolically active at room temperature. Platelet bags are designed to allow oxygen and carbon dioxide gas exchange. Citrate is added to prevent clotting and to maintain proper pH. Dextrose is also added as an energy source.

One caveat a clinician should be aware of is that the risk of bacterial infection increases with storage duration. The shelf-life of platelets stored at room temperature is generally only 5 days, counting from midnight on the day of collection. This can be increased to seven days if they use a container approved by the FDA for seven-day storage - AND if the platelet unit(s) are subsequently tested for infection using a bacterial detection device approved and labeled by the FDA as a "safety measure."

#transfusion-medicine

#hematology

References:

1. McCullough J. Overview of platelet transfusion. Semin Hematol 2010; 47:235.

2. Murphy S, Gardner FH. Effect of storage temperature on maintenance of platelet viability--deleterious effect of refrigerated storage. N Engl J Med 1969; 280:1094.

3. Hoffmeister KM, Felbinger TW, Falet H, et al. The clearance mechanism of chilled blood platelets. Cell 2003; 112:87.

4. Rumjantseva V, Grewal PK, Wandall HH, et al. Dual roles for hepatic lectin receptors in the clearance of chilled platelets. Nat Med 2009; 15:1273.

Thiazide therapy in diabetes insipidus

Q: One of the reasons for the effectiveness of thiazide diuretics is via weight loss in arginine vasopressin resistance (AVP-R), also known as nephrogenic diabetes insipidus.

A) True

B) False

Answer: A

Thiazide diuretics are effective pharmacological therapies for AVP-R.

The treatment modality is volume depletion induced by a low-sodium diet and a thiazide diuretic such as hydrochlorothiazide, 25 mg once or twice daily (or its equivalent). This causes weight loss. As little as 1 to 1.5 kg of weight loss reduces urine output by more than 50 percent, from 10 L/day to below 3.5 L/day. This simple synergistic modality was discovered more than six decades ago, and still works well.

The mechanism of action (MoA) of thiazide diuretics is also mediated by a hypovolemia-induced increase in proximal sodium and water reabsorption, thereby diminishing water delivery to ADH-sensitive collecting tubular segments and reducing urine output. 

Another advantage of thiazides is to decrease the likelihood of hypoglycemia in patients who are also treated with chlorpropamide. It can be used in combination.

#nephrology

#endocrinology

References:

1. Earley LE, Orloff J. THE MECHANISM OF ANTIDIURESIS ASSOCIATED WITH THE ADMINISTRATION OF HYDROCHLOROTHIAZIDE TO PATIENTS WITH VASOPRESSIN-RESISTANT DIABETES INSIPIDUS. J Clin Invest 1962; 41:1988.

2. Webster B, Bain J. Antidiuretic effect and complications of chlorpropamide therapy in diabetes insipidus. J Clin Endocrinol Metab 1970; 30:215.

IVT and stroke severity

Q: The high severity of neurologic deficit in stroke should be considered for intravenous thrombolysis (IVT) due to the high risk of intracerebral hemorrhage.

A) True

B) False

Answer: B

The severity of neurologic deficit is measured by the National Institutes of Health Stroke Scale (NIHSS) score. Although the high severity of neurologic deficit is indeed associated with high risk of intracerebral bleed, stroke severity alone should not be used to determine a patient's inclusion or exclusion for IVT therapy. The benefit of IVT is similar regardless of stroke severity.

#neurology

References:

1. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014; 384:1929.

2. Whiteley WN, Emberson J, Lees KR, et al. Risk of intracerebral haemorrhage with alteplase after acute ischaemic stroke: a secondary analysis of an individual patient data meta-analysis. Lancet Neurol 2016; 15:925.

3. Whiteley WN, Slot KB, Fernandes P, et al. Risk factors for intracranial hemorrhage in acute ischemic stroke patients treated with recombinant tissue plasminogen activator: a systematic review and meta-analysis of 55 studies. Stroke 2012; 43:2904.

Thiamine and Lactate

Q: Lactic Acidosis (LA) due to thiamine deficiency may not respond to intravenous sodium bicarbonate.

A) True

B) False

Answer: A

One of the hallmarks of LA secondary to thiamine deficiency is that it may not respond to IV sodium bicarbonate, but only and rapidly to IV thiamine administration.

Thiamine plays an integral role in the metabolism of lactic acidosis. It is a necessary cofactor for two key enzymes in the tricarboxylic acid cycle: pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase. LA secondary to thiamine deficiency is ubiquitous in patients in the ICU receiving total parenteral nutrition (TPN), which usually has a high glucose load.

Overall, there is some weak evidence that IV thiamine enhances the lactate clearance in ICU patients.

#metabolism

#acid-base

References:

1. Centers for Disease Control and Prevention (CDC). Lactic acidosis traced to thiamine deficiency related to nationwide shortage of multivitamins for total parenteral nutrition -- United States, 1997. MMWR Morb Mortal Wkly Rep 1997; 46:523.

2. Salvatori G, Mondì V, Piersigilli F, et al. Thiamine Deficiency in a Developed Country: Acute Lactic Acidosis in Two Neonates Due to Unsupplemented Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2016; 40:886.

3. Woolum JA, Abner EL, Kelly A, et al. Effect of Thiamine Administration on Lactate Clearance and Mortality in Patients With Septic Shock. Crit Care Med 2018; 46:1747.

Temperature in Myxedema coma

Q: The severity of the hypothermia is related to mortality in Myxedema coma.

A) True

B) False

Answer: A

The seven cardinal signs, though not all may be present in myxedema coma, are:

1. Decreased mental status
2. Hypothermia
3. Bradycardia
4. Hyponatremia
5. Hypoglycemia
6. Hypotension
7. Evidence of Precipitating illness/factor

The severity of the hypothermia is very much related to mortality in severe hypothyroidism, so the level of hypothermia should be established with a reliable temperature-measuring device.

#endocrinology

References:

1. Yamamoto H, Hongo T, Nojima T, Obara T, Kosaki Y, Ageta K, Tsukahara K, Yumoto T, Nakao A, Naito H. Successfully treated case of severe hypothermia secondary to myxedema coma. Acute Med Surg. 2023 Mar 14;10(1):e828. doi: 10.1002/ams2.828. PMID: 36936740; PMCID: PMC10014422.

2. Zhang Y, Chu L, Han H. Myxedema coma: challenges and future directions, a systematic survey and review. Thyroid Res. 2025 Oct 7;18(1):48. doi: 10.1186/s13044-025-00268-1. PMID: 41053871; PMCID: PMC12502585.

glucocorticoid and psychosis

Q: Which of the glucocorticoids is least likely to induce psychosis? - select one

A) Methylprednisolone

B) Dexamethasone

C) Betamethasone

D) Hydrocortisone

Answer: B

Corticosteroids are well known to cause insomnia, irritability, impaired concentration, mood changes, and, in severe cases, florid steroid psychosis. Stopping the drug is the best option, but if glucocorticoids are absolutely needed, there is some weak evidence that dexamethasone is least likely to induce psychosis. However, it is not a foolproof statement! 

Adjuvant use of antipsychotic agents may help. Lithium is particularly effective in steroid psychosis. 

#psychiatry

#pharmacology

References:

1. Huynh G, Reinert JP. Pharmacological Management of Steroid-Induced Psychosis: A Review of Patient Cases. J Pharm Technol. 2021 Apr;37(2):120-126. doi: 10.1177/8755122520978534. Epub 2020 Dec 2. PMID: 34752563; PMCID: PMC7953074.

2.  Janes M, Kuster S, Goldson TM, Forjuoh SN. Steroid-induced psychosis. Proc (Bayl Univ Med Cent). 2019 Jul 22;32(4):614-615. doi: 10.1080/08998280.2019.1629223. PMID: 31656440; PMCID: PMC6793974.

3. Julio A Chalela, Michael J Aminoff, Janet L Wilterdink - Acute toxic-metabolic encephalopathy in adults - last updated: May 22, 2024. Link: https://www.uptodate.com/contents/acute-toxic-metabolic-encephalopathy-in-adults (last accessed : November 3, 2025) 

4. Falk WE, Mahnke MW, Poskanzer DC. Lithium prophylaxis of corticotropin-induced psychosis. JAMA. 1979 Mar 9;241(10):1011-2. PMID: 216818.

Pitfalls in diagnosing SS

Q: All of the following conditions EXCEPT ONE may bar patients from diagnosis of Sjögren's syndrome (SS) and participation in SS studies or therapeutic trials because of overlapping clinical features or interference with criteria tests? - select one

A) Positive Anti-Ro/SSA

B) History of head and neck radiation 

C) Active hepatitis C infection 

D) Sarcoidosis

E) Amyloidosis

Answer: A

Positive Anti-Ro/SSA actually is a part of diagnosis of SS. The five major components to diagnose SS are:

• Labial salivary gland with focal lymphocytic sialadenitis and focus score of ≥1 foci/4 mm2
• Anti-Ro/SSA positive
• Ocular staining score ≥5 (or van Bijsterveld score ≥4) in at least one eye
• Schirmer test ≤5 mm/5 minutes in at least one eye
• Unstimulated whole saliva flow rate ≤0.1 mL/minute

Prior diagnosis of any of the following conditions would exclude diagnosis of SS and participation in SS studies or therapeutic trials because of overlapping clinical features or interference with criteria tests:

• History of head and neck radiation treatment
• Active hepatitis C infection (with positive PCR)
• Acquired immunodeficiency syndrome
• Sarcoidosis
• Amyloidosis
• Graft-versus-host disease
• IgG4-related disease

#rheumatology

References:

1. Daniels TE, Cox D, Shiboski CH, et al. Associations between salivary gland histopathologic diagnoses and phenotypic features of Sjögren's syndrome among 1,726 registry participants. Arthritis Rheum 2011; 63:2021.

2. Whitcher JP, Shiboski CH, Shiboski SC, et al. A simplified quantitative method for assessing keratoconjunctivitis sicca from the Sjögren's Syndrome International Registry. Am J Ophthalmol 2010; 149:405.

3. Van Bijsterveld OP. Diagnostic tests in the Sicca syndrome. Arch Ophthalmol 1969; 82:10.

4. Navazesh M, Kumar SK, University of Southern California School of Dentistry. Measuring salivary flow: Challenges and opportunities. J Am Dent Assoc 2008; 139 Suppl:35S.

5. Shiboski CH, Shiboski SC, Seror R, et al. 2016 American College of Rheumatology/European League Against Rheumatism classification criteria for primary Sjögren's syndrome: A consensus and data-driven methodology involving three international patient cohorts. Ann Rheum Dis 2017; 76(1):9-16. 

Size of PTX

Q: While evaluating pneumothorax (PTX) on Chest-X-Ray (CXR), a distance of ≥3 cm between the pleural line and the chest wall at the level of the apex roughly correlates with a 50 percent pneumothorax.

A) True

B) False

Answer: A

Although not an exact science, at least in the United States, PTX ≥3 cm between the pleural line and the chest wall at the level of the apex is usually considered sufficient to distinguish a small from a large PTX. In Europe, physicians use a cutoff of ≥2 cm at the hilum. 

Clinical symptoms play a significant role in draining PTX and largely depend on the clinician's discretion.

#procedures

References:

1. Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax 2023; 78:1143.

2. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590.

3. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 Suppl 2:ii18.

4. Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015; 3:578.

5. Yoon J, Sivakumar P, O'Kane K, Ahmed L. A need to reconsider guidelines on management of primary spontaneous pneumothorax? Int J Emerg Med 2017; 10:9.

RCVS

Case: 44 years old female is admitted to the ICU with severe, sudden headache in the occipital region, associated with nausea and photosensitivity, triggered after sexual activity and orgasm. MRI of the brain showed vasogenic edema and sulcal hyperintensities on fluid-attenuated inversion recovery (FLAIR) (dot sign). Patient gets diagnosed with reversible cerebral vasoconstriction syndrome (RCVS). As primary angiitis of the central nervous system (PACNS) is also under consideration, administering glucocorticoids should be considered.

A) True

B) False

Answer: B

Although PACNS shares various features with RCVS, administering glucocorticoids is not recommended. It is vital to perform a thorough differential diagnosis between the two conditions by using angiography and the RCVS-2 score. A classic clinical difference is that PACNS usually have an insidious progressive clinical course with chronic headaches and rarely have a thunderclap headache, which is typical of RCVS. A neurologist should be consulted for such a critical differential. 

Glucocorticoids are associated with worse outcomes in RCVS. Fortunately, a period of observation after a dramatic presentation provides time to differentiate between the two situations and does not significantly affect the outcome by delaying glucocorticoid administration. Empiric glucocorticoid therapy should be carried out only if there is a rapidly worsening clinical course while the diagnosis remains uncertain. 

Aneurysmal subarachnoid hemorrhage is another differential to be considered closely. Angiography is an essential tool..

#neurology

References:

1. Singhal AB. Reversible cerebral vasoconstriction syndrome: A review of pathogenesis, clinical presentation, and treatment. Int J Stroke 2023; 18:1151.

2. Singhal AB, Hajj-Ali RA, Topcuoglu MA, et al. Reversible cerebral vasoconstriction syndromes: analysis of 139 cases. Arch Neurol 2011; 68:1005.

3. Singhal AB, Topcuoglu MA. Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome. Neurology 2017; 88:228.

4. Ribas MZ, Paticcié GF, de Medeiros SDP, de Oliveira Veras A, Noleto FM, Dos Santos JCC. Reversible cerebral vasoconstriction syndrome: literature review. Egypt J Neurol Psychiatr Neurosurg. 2023;59(1):5. doi: 10.1186/s41983-023-00607-9. Epub 2023 Jan 11. PMID: 36647436; PMCID: PMC9833030.

infectious and non-infectious causes of aPL

Q: Which of the following parasites is so far known to cause positive antiphospholipid antibodies (aPL)?

A) Toxoplasma 

B) Malaria

C) Amoeba 

D) Giardia 

E) Cryptosporidium 

Answer: B

Many infectious and non-infectious conditions may cause aPL, which is usually IgM (aCL).

Infectious causes have some tendency to cause thrombosis, in contrast to medication-induced causes, which are usually transient and rarely associated with thrombosis. 

The long list of infectious and non-infectious causes of aPL is below:

• Bacterial sepsis
• leptospirosis
• syphilis
• Lyme disease (borreliosis)
• tuberculosis
• leprosy
• infective endocarditis
• post-streptococcal rheumatic fever
• Klebsiella 
• Hepatitis A and B
• mumps
• human immunodeficiency virus (HIV)
• human T-lymphotropic virus type 1 (HTLV-I)
• cytomegalovirus
• varicella-zoster
• Epstein-Barr virus (EBV)
• adenovirus; parvovirus; rubella
• severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
• COVID-19
•  Malaria
• Pneumocystis jirovecii
• visceral leishmaniasis (also known as kala-azar)
• phenothiazines (chlorpromazine)
• phenytoin
• hydralazine
• procainamide
• quinidine
• quinine
• ethosuximide
• alpha interferon
• amoxicillin
• chlorothiazide
• oral contraceptives
• propranolol 
• Solid tumors 
• Hodgkin disease and non-Hodgkin lymphoma
• MPNs (primary myelofibrosis, polycythemia vera)
• myeloid and lymphocytic leukemias 

#Rheumatology

References:

1. Smiyan S, Kuzmina G, Garmish O, Komorovsky R. Infection-Triggered Antiphospholipid Syndrome: A Critical Overview. Open Access Rheumatol. 2025 Aug 24;17:173-183. doi: 10.2147/OARRR.S541224. PMID: 40894518; PMCID: PMC12393084.

2. Sherer Y, Blank M, Shoenfeld Y. Antiphospholipid syndrome (APS): where does it come from? Best Pract Res Clin Rheumatol. 2007 Dec;21(6):1071-8. doi: 10.1016/j.berh.2007.09.005. PMID: 18068862.

3. Willis R, Pierangeli SS. Pathophysiology of the antiphospholipid antibody syndrome. Auto Immun Highlights. 2011 Mar 24;2(2):35-52. doi: 10.1007/s13317-011-0017-9. PMID: 26000118; PMCID: PMC4389016.

4. Jakobsen PH, Morris-Jones SD, Hviid L, Theander TG, Høier-Madsen M, Bayoumi RA, Greenwood BM. Anti-phospholipid antibodies in patients with Plasmodium falciparum malaria. Immunology. 1993 Aug;79(4):653-7. PMID: 8406592; PMCID: PMC1421917.

Synovial fluid analysis

Q: A normal synovial fluid viscosity when expelled from the syringe to drop into a suitable receptacle will produce ______________ as it falls? - select one

A) a long string-like extension 

B) a circular formation 

Answer: A

The first step in the synovial fluid analysis is the gross inspection, which consists of three major components: 

• Clarity 
• Color
• Viscosity

The best way to test viscosity is to slowly expel the fluid from the syringe and allow it to drop into a suitable receptacle. A normal fluid usually starts forming a long, string-like extension as it falls. 

The inflamed joint releases proteolytic enzymes into the synovial fluid, leading to a loss of viscosity. This is an excellent way of quickly distinguishing a normal joint from an inflammatory joint. In contrast, in septic arthritis, the effusion may be relatively more viscous.

A clinician should be aware of some caveats. If the fluid sits for a long time, the test may become unreliable.

#rheumatology

References:

1. Pascual E, Jovaní V. Synovial fluid analysis. Best Pract Res Clin Rheumatol. 2005 Jun;19(3):371-86. doi: 10.1016/j.berh.2005.01.004. PMID: 15939364.

2. Martínez-Castillo A, Núñez C, Cabiedes J. Análisis de líquido sinovial [Synovial fluid analysis]. Reumatol Clin. 2010 Nov-Dec;6(6):316-21. Spanish. doi: 10.1016/j.reuma.2009.12.010. Epub 2010 Jun 26. PMID: 21794741.

Code blue efficacy without Arterial line

Case: While performing a 'code blue' on a patient, an arterial line can not be obtained. What would be the best way to determine the efficacy of resuscitation?

Answer: Venous Blood Gas (VBG)

Arterial blood gas (ABG) analysis helps evaluate the clinical condition of critically ill patients; however, arterial puncture or the insertion of an arterial catheter may not be feasible or available in many situations. The VBG is easier, quicker, and safer to obtain, and is associated with significantly less patient pain. It would be convenient for the physician and patient to replace the ABG with the VBG for analysis of base excess (acidosis). In code situations, VBG is a better indicator of overall acidosis. If VBG results are normal, ABG analysis should not be necessary. Conversely, abnormal venous levels predicted abnormal arterial values. A venous pH of 7 or lower, for example, predicted an arterial pH of 7.2 or lower.

In cardiac arrest victims, the disparity between arterial and venous values is even greater. During cardiac arrest, tissue hypoxia is all but certain and is reflected by lower pH and higher PCO2 on the venous side.

#hemodynamics

#acid-base

References:

1. Kelly AM. Can VBG analysis replace ABG analysis in emergency care? Emerg Med J. 2016 Feb;33(2):152-4. doi: 10.1136/emermed-2014-204326. Epub 2014 Dec 31. PMID: 25552544.

2. Bloom BM, Grundlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2014 Apr;21(2):81-8. doi: 10.1097/MEJ.0b013e32836437cf. PMID: 23903783.

3. Giani D, Santoro MC, Gabrielli M, Di Luca R, Malaspina M, Lumare M, Scatà LA, Pala M, Manno A, Candelli M, Covino M, Gasbarrini A, Franceschi F. The Role of Venous Blood Gas Analysis in Critical Care: A Narrative Review. Medicina (Kaunas). 2025 Jul 24;61(8):1337. doi: 10.3390/medicina61081337. PMID: 40870384; PMCID: PMC12387505.

HRS-AKI - Controversies in terlipressin and transplantation

Q: If there is a high chance that a patient with hepatorenal syndrome-acute kidney injury (HRS-AKI) will get a liver transplant, vasoconstrictors like terlipressin should not be used.

A) True

B) False

Answer: B

Previously, it has been suggested that a positive response to vasoconstrictors is associated with a reduction in serum creatinine in patients with HRS-AKI, thereby lowering the Model for End-stage Liver Disease (MELD) score and potentially leading to patients being excluded from consideration for definitive treatment of HRS-AKI, i.e., liver transplantation. New studies have shown that a positive response to vasoconstrictors in HRS-AKI is associated with improved transplant-free survival days, even if there is a longer wait time for liver transplantation. Also, it lowers the risk of post-transplant chronic kidney disease.

Some programs have adopted a strategy of locking the MELD score before vasoconstrictor therapy in the acute phase.

$transplantation

#hepatology

#nephrology

References:

1. Piano S, Gambino C, Vettore E, et al. Response to Terlipressin and Albumin Is Associated With Improved Liver Transplant Outcomes in Patients With Hepatorenal Syndrome. Hepatology 2021; 73:1909.

2. Reddy KR, Weinberg EM, Gonzalez SA, et al. Safety and efficacy of continuous terlipressin infusion in HRS-AKI in a transplant population. Liver Transpl 2024; 30:1026.

3. Przybyszewski EM, Wilechansky RM, McLean Diaz P, et al. Controversies in terlipressin and transplantation in the United States: How do we MELD the two? Liver Transpl 2024; 30:753.

Iron absorption and Vitamins

Q: Which of the vitamins may enhance the absorption of iron? - select one

A) Vitamin A

B) Vitamin B

C) Vitamin C 

D) Vitamin D

E) Vitamin E

Answer: Vitamin C 

Vitamin C (ascorbic acid) may enhance absorption of iron from both dietary and supplementary sources. Absorption of fruits and vegetables and/or a Vitamin C supplement can be used as a strategy in patients who do not respond appropriately to iron intake. This inappropriate iron absorption is common in patients who consume large amounts of tea and/or calcium/phosphate supplements. In such cases, Vitamin C is a good way to reverse these inhibitions.

#nutrition

#vitamins

#minerals

References:

1. Skolmowska D, Głąbska D. Effectiveness of Dietary Intervention with Iron and Vitamin C Administered Separately in Improving Iron Status in Young Women. Int J Environ Res Public Health. 2022 Sep 20;19(19):11877. doi: 10.3390/ijerph191911877. PMID: 36231177; PMCID: PMC9564482.

2. Lynch SR, Cook JD. Interaction of vitamin C and iron. Ann N Y Acad Sci. 1980;355:32-44. doi: 10.1111/j.1749-6632.1980.tb21325.x. PMID: 6940487.

3. Rhode BM, Shustik C, Christou NV, MacLean LD. Iron absorption and therapy after gastric bypass. Obes Surg 1999; 9:17.

Nicardipine. - CVS effect

Q: Nicardipine is a Calcium Channel Blocker (CCB), but how is it distinct from other CCBs?

Answer: Nicardipine (Cardene) is a Calcium Channel Blocker with the distinction that it has highly vascular, selective calcium channel blockade. It has a strong cerebral and coronary vasodilatory effect. It has no to minimal impact on left ventricular function and conduction. It is now the preferred drug of choice as an IV infusion in a hypertensive crisis.

For rapid blood pressure control, therapy is initiated with a loading dose of 5 mg/hr and titrated by 2.5 mg/hr every 5 minutes to a maximum of 15 mg/hr until the desired results are achieved. For gradual blood pressure reduction, the infusion rate is increased every 15 minutes until the desired blood pressure is achieved.

#pharmacology

#hemodynamics

References:

1. Curran MP, Robinson DM, Keating GM. Intravenous nicardipine: its use in the short-term treatment of hypertension and various other indications. Drugs. 2006;66(13):1755-82. doi: 10.2165/00003495-200666130-00010. PMID: 16978041.

2. Sorkin EM, Clissold SP. Nicardipine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy, in the treatment of angina pectoris, hypertension and related cardiovascular disorders. Drugs. 1987 Apr;33(4):296-345. doi: 10.2165/00003495-198733040-00002. PMID: 3297616.

Hydralazine effects in ESRD

Q: 53 years old male with ESRD (End Stage Renal Disease) is in the ICU. The nurse requested a PRN medicine for BP control. Intravenous (IV) Hydralazine is written. One hour after administration of Hydralazine, the patient developed a mental status change.

Answer: In patients, particularly with renal failure/uremia, hydralazine may produce a marked decrease in blood pressure, resulting in central reactions such as anxiety, delirium, disorientation, depression, and coma.

Also, Hydralazine is a cerebral vasodilator and is known to increase intracranial pressure, which, together with its effect upon systemic blood pressure, reduces the cerebral perfusion pressure.

#pharmacology

#hemodynamics

#nephrology

#CVS

#neurology

References:

1. Schroeder T, Sillesen H. Dihydralazine induces marked cerebral vasodilation in man. Eur J Clin Invest. 1987 Jun;17(3):214-7. doi: 10.1111/j.1365-2362.1987.tb01238.x. PMID: 3113965.

2. Mutimer CA, Yassi N, Wu TY. Blood Pressure Management in Intracerebral Haemorrhage: when, how much, and for how long? Curr Neurol Neurosci Rep. 2024 Jul;24(7):181-189. doi: 10.1007/s11910-024-01341-2. Epub 2024 May 23. PMID: 38780706; PMCID: PMC11199276.

3. Talseth T. Studies on hydralazine. II. Elimination rate and steady-state concentration in patients with impaired renal function. Eur J Clin Pharmacol. 1976 Sep 30;10(5):311-7. doi: 10.1007/BF00565619. PMID: 976304.

CS in cancer patients

Q: Patients with active malignancy should not receive Cell Saver (CS) blood during surgery, as it may increase the chances of metastasis.

A) True

B) False

Answer: B

Intraoperative blood salvage technique is popular in all surgical cases where high blood loss is anticipated. Previously, patients with active malignancy were considered high risk for CS, as theoretically, the chances of spread of malignancy may be high. But evidence failed to prove such a notion. CS technique can be successfully used in surgery for patients with active malignancy.

Consider adding leukocyte-reduction filters, as studies have shown they remove tumor cells from salvaged blood.

#hematology

#procedures

References: 

1. Waters JH, Yazer M, Chen YF, Kloke J. Blood salvage and cancer surgery: a meta-analysis of available studies. Transfusion 2012; 52:2167.

2. Kumar N, Tan JYH, Chen Z, et al. Intraoperative cell-salvaged autologous blood transfusion is safe in metastatic spine tumour surgery: early outcomes of prospective clinical study. Eur Spine J 2023; 32:2493.

3. Frietsch T, Steinbicker AU, Horn A, et al. Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature. Transfus Med Hemother 2022; 49:143.

4. Kumar N, Lam R, Zaw AS, et al. Flow cytometric evaluation of the safety of intraoperative salvaged blood filtered with leucocyte depletion filter in spine tumour surgery. Ann Surg Oncol 2014; 21:4330.

Myxedema coma with normothermia

Q: 34 years old female with a known history of hypothyroidism is admitted to the ICU with hypotension, hyponatremia, hypoglycemia, bradycardia, and mental status change. Myxedema coma is suspected. Patient's temperature taken on arrival is reported as normal. The first clinical maneuver should be? - select one

A) Reconsider the diagnosis of myxedema coma

B) Recheck temperature with a reliable thermometer

C) Consult endocrinologist

D) Redraw labs to confirm hyponatremia

E) Request pharmacy to send IV vasopressin STAT

Answer: B

A frankly hypothermic body temperature may not be measured by a regularly used thermometer, and may even falsely be reported as normal. The establishment of the severity of hypothermia (choice B) is essential, as the severity of hypothermia is directly proportional to mortality in severe hypothermia.

Reconsidering the diagnosis of myxedema coma (choice A), like all diagnoses, is a prudent thing. Still, it should not bar a physician from starting the crucial time-sensitive treatment and clinical path.

Consulting an endocrinologist (choice C) is the right thing to do, too, but it will take a lot of time and may not be the first step.

Redrawing labs to confirm hyponatremia (choice D) is not required, as labs are usually reliable if they correlate with clinical signs. They can be redrawn after a period of treatment to confirm the improvement of the clinical condition.

Starting Intravenous (IV) vasopressin as a first step (choice E) is not a good choice, as it may even harm the patient, particularly if hyponatremia is present. Hyponatremia in myxedema coma is due to an impairment in free water excretion due to inappropriate excess vasopressin secretion. Concomitant adrenal insufficiency or acute kidney injury may be playing roles too. 

#endocrinology

Referencxes:

1. Mathew V, Misgar RA, Ghosh S, Mukhopadhyay P, Roychowdhury P, Pandit K, Mukhopadhyay S, Chowdhury S. Myxedema coma: a new look into an old crisis. J Thyroid Res. 2011;2011:493462. doi: 10.4061/2011/493462. Epub 2011 Sep 15. PMID: 21941682; PMCID: PMC3175396.

2. Iwasaki Y, Oiso Y, Yamauchi K, et al. Osmoregulation of plasma vasopressin in myxedema. J Clin Endocrinol Metab 1990; 70:534.

3. Liamis G, Filippatos TD, Liontos A, Elisaf MS. MANAGEMENT OF ENDOCRINE DISEASE: Hypothyroidism-associated hyponatremia: mechanisms, implications and treatment. Eur J Endocrinol 2017; 176:R15.

IV vs SQ epoetin

Q: The advantage of giving epoetin intravenously (IV) is to have lower dosing.

A) True

B) False

Answer: B

The Subcutaneous (SQ) route is best for treating anemia patients who require epoetin for three reasons.

• SQ dose of epoetin needed to achieve a target Hb is approximately 30 percent lower than that required with IV.
• Patient can self-administer at home. 
• It preserves the integrity of the dialysis access vessels.

#nephrology

#pharmacology

References:

1. Kaufman JS, Reda DJ, Fye CL, et al. Subcutaneous compared with intravenous epoetin in patients receiving hemodialysis. Department of Veterans Affairs Cooperative Study Group on Erythropoietin in Hemodialysis Patients. N Engl J Med 1998; 339:578.

2. Wright DG, Wright EC, Narva AS, et al. Association of Erythropoietin Dose and Route of Administration with Clinical Outcomes for Patients on Hemodialysis in the United States. Clin J Am Soc Nephrol 2015; 10:1822.