Essentials of enteral nutrition

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

A) hypotonic to serum

B) isotonic to serum

Answer: B

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

●Caloric density of About  1 kcal/mL

●Lactose-free

●Isotonic to serum

●Protein content of about 40 g/1000 mL (intact- nonhydrolyzed)

●Mixture of simple and complex carbohydrates

●Essential vitamins, minerals, and micronutrients included

#nutrition

Reference:

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

*authors of this site created this mnemonic

Epi of paradoxical embolism

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

A) True

B) False

Answer: A

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

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

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

#cardiovascular

#hematology

References:

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

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

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

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

physical exam in viral meningitis

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

A) enterovirus

B) primary HIV

C) mumps 

D) HSV-2 

E) west Nile virus 

Answer: B

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

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

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

Mumps can be confused with symptoms of primary HIV but it is mostly present with

parotitis and history of unvaccinated (choice C). 

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

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

#ID

#physical exam

References:

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

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

Samter's triad

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

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

•  asthma
• aspirin sensitivity
• nasal polyps 

#pulmonary

#allergy

References:

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

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

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

cricoid pressure

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

A) True 

B) False

Answer: B

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

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

#procedures

Reference:

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

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

ARF and Carditis

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

A) pericarditis

B) epicarditis

C) myocarditis 

D) endocarditis

E) pancarditis 

Answer: E

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

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

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

#rheumatology

#cardiology

References:

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

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

3. Sika-Paotonu D, Beaton A, Raghu A, et al. Acute Rheumatic Fever and Rheumatic Heart Disease. 2017 Mar 10 [Updated 2017 Apr 3]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes : Basic Biology to Clinical Manifestations [Internet]. Oklahoma City (OK): University of Oklahoma Health Sciences Center; 2016-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK425394/

primidone

Q: 22 years old male is brought to ER with acute symptoms of ataxia, nausea, vomiting, severe sedation, and dizziness. Primidone is recently added to patient's anti-seizure medicines. Primidone is a prodrug of? (select one)

 A) phenobarbital

B) phenytoin

C) clonazepam

D) gabapentin

E) valproate

Answer: A

In the body, Primidone gets converted into two active metabolites, named phenobarbital and phenylethylmalonamide (PEMA). Phenobarbital binds to the GABA(A) receptor. PEMA enhances the activity of phenobarbital. 

Although primidone is a prodrug of phenobarbital and as expected many side-effects are the same as of phenobarbital, primidone can produce acute adverse reactions independent of it consisting of dizziness, ataxia, nausea, and vomiting.

#toxicology

#pharmacology

#neurology

References:

1. Abou-Khalil BW. Antiepileptic Drugs. Continuum (Minneap Minn) 2016; 22:132.

2. Lenkapothula N, Cascella M. Primidone. 2021 Jul 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32965968.

Pyridoxine and status epilepticus

Q: In patients with status epilepticus, pyridoxine level is expected to be? (select one)

 A) high

B) low

Answer: B

There is an inverse correlation between pyridoxine level and the risk of status epilepticus. Repleting low or low-normal pyridoxine may help to shorten the period of status epilepticus.

#neurology

Reference:

Dave HN, Eugene Ramsay R, Khan F, et al. Pyridoxine deficiency in adult patients with status epilepticus. Epilepsy Behav 2015; 52:154.

AF acute RVR control

Q: Propranolol is a good choice to control ventricular rate in acute situations with atrial fibrillation (AF).

A) Yes

B) No

Answer: A

 

Intravenous (IV) metoprolol and esmolol are very popular amongst clinicians to control Rapid Ventricular Rate (RVR) in acute situations with AF. The objective of this question is to highlight the efficacy of propranolol in similar acute situations with AF. 

1 mg of IV propranolol over a minute is usually sufficient but, can be repeated up to three doses total. It has an advantage over metoprolol where clinicians may need to wait 5 minutes (sometimes quite a long time for a bedside clinician) between 2 doses. Propranolol can be repeated at 2 minutes intervals.

#cardiology

References:

1. Kojuri J, Mahmoodi Y, Jannati M, Shafa M, Ghazinoor M, Sharifkazemi MB. Ability of amiodarone and propranolol alone or in combination to prevent post-coronary bypass atrial fibrillation. Cardiovasc Ther. 2009 Winter;27(4):253-8. doi: 10.1111/j.1755-5922.2009.00100.x. PMID: 19903189.

2. Reiffel JA. Drug choices in the treatment of atrial fibrillation. Am J Cardiol. 2000 May 25;85(10A):12D-19D. doi: 10.1016/s0002-9149(00)00902-4. PMID: 10822036.

slow code

 Q: In case of patient's imminent death a 'slow code' is an appropriate choice?

A) Yes

B) No

Answer: No

It is common in ICU when physicians are not in agreement with a family regarding the aggressiveness of care. In such situations, physicians sometimes run a half-hearted 'code' just to satisfy the family's emotional needs. There are various terms used such as slow code, show code, Hollywood code, symbolic code, or short code. 

THIS IS ETHICALLY WRONG AND DECEPTIVE. This should be discouraged. 

#ethics

References:

1. Lantos JD, Meadow WL. Should the "slow code" be resuscitated? Am J Bioeth 2011; 11:8. 

2. Frader J, Kodish E, Lantos JD. Ethics rounds. Symbolic resuscitation, medical futility, and parental rights. Pediatrics 2010; 126:769. 

3. Snyder L, American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med 2012; 156:73.

NS

Q: 28 years old male never been under medical care is admitted with shortness of breath. Cardiologist wrote in ECHO report: "strong suspicion of Noonan Syndrome" (NS). Which of the following is more common in NS? (select one)

A) pulmonic stenosis

B) mitral stenosis

C) early ascending aortic dissection

D) thinning of myocardial wall 

Answer: A 

Pulmonary valve stenosis is the most common feature of NS. It is due to dysplasis of the valve. These patients usually require percutaneous balloon pulmonary valvuloplasty/ies. 

Instead of mitral stenosis (choice B) and thinning of the myocardial wall (choice D), they tend to have hypertrophic cardiomyopathy (HCM). 

Although few of these patients may have aortic root dilatation but ascending aortic dissection (choice C) is not reported.

These patients may have various other cardiac manifestations like atrial septal defect, right and left axis deviation on EKG. coronary artery atresia, ectasia, and aneurysm.

#cardiology

References:

1. Binder G, Grathwol S, von Loeper K, Blumenstock G, Kaulitz R, Freiberg C, Webel M, Lissewski C, Zenker M, Paul T. Health and quality of life in adults with Noonan syndrome. J Pediatr. 2012 Sep;161(3):501-505.e1. doi: 10.1016/j.jpeds.2012.02.043. Epub 2012 Apr 10. PMID: 22494877. 

2.  Prendiville TW, Gauvreau K, Tworog-Dube E, et al. Cardiovascular disease in Noonan syndrome. Arch Dis Child 2014; 99:629. 

3. Cornwall JW, Green RS, Nielsen JC, Gelb BD. Frequency of aortic dilation in Noonan syndrome. Am J Cardiol 2014; 113:368. 

4.  Gelb BD, Roberts AE, Tartaglia M. Cardiomyopathies in Noonan syndrome and the other RASopathies. Prog Pediatr Cardiol 2015; 39:13.

HIT, OD and SRA

Q: In the diagnosis of Heparin Induced Thrombocytopenia (HIT), Optical-Density (OD) corelates with the probability of Serotonin release assay (SRA) positivity?

 A) True

B) False

Answer: A

SRA is considered as a gold standard for the diagnosis of HIT but is not widely available. At least one large study has shown a good correlation between anti-platelet factor 4 (PF4)/heparin antibodies and SRA. OD signifies the level of titer of antibody in patient's serum.

• OD <0.40 – SRA positive in 0.0-0.1 percent
• OD 0.40 to <1.00 – SRA positive in 1-5 percent
• OD 1.00 to <1.40 – SRA positive in 18-30 percent
• OD 1.40 to <2.00 – SRA positive in 50-58 percent
• OD >2.00 – SRA positive in 89-100 percent

#hematology

References:

1. Warkentin TE, Sheppard JI, Moore JC, et al. Quantitative interpretation of optical density measurements using PF4-dependent enzyme-immunoassays. J Thromb Haemost 2008; 6:1304. 

2. Whitlatch NL, Kong DF, Metjian AD, et al. Validation of the high-dose heparin confirmatory step for the diagnosis of heparin-induced thrombocytopenia. Blood 2010; 116:1761.

3. Baroletti S, Hurwitz S, Conti NA, et al. Thrombosis in suspected heparin-induced thrombocytopenia occurs more often with high antibody levels. Am J Med 2012; 125:44.

tacro and false levels

 Q: Which one precaution at the bedside may help to avoid falsely elevated level of Tacrolimus? 

Answer: Tacrolimus has a potential to leach into the plastic catheters. If blood is drawn to measure the tacrolimus level from the same port which is used to administer tacrolimus, the levels are likely to be falsely high. 

Another clinical point to remember is that following oral administration, tacrolimus absorption can be erratic and incomplete. It is advisable to start oral tacrolimus when a patient is back to normal oral intake.

#transplantation

#pharmacology

References:

1. Jusko WJ, Piekoszewski W, Klintmalm GB, et al. Pharmacokinetics of tacrolimus in liver transplant patients. Clin Pharmacol Ther 1995; 57:281. 

2. Mekki Q, Lee C, Aweeka F, et al. Pharmacokinetics of tacrolimus (FK506) in kidney transplant patients. Clin Pharmacol Ther 1993; 53:238. 

3. Friciu M, Zaraa S, Leclair G. Stability of Extemporaneously Compounded Tacrolimus in Glass Bottles and Plastic Syringes. Can J Hosp Pharm. 2017;70(1):51-53. doi:10.4212/cjhp.v70i1.1629

smoking in UC

 Q: 37 years old male is admitted to ICU with lower gastrointestinal (GI) bleed. Workup led to diagnosis of ulcerative colitis (UC). Patient recently quit his smoking habit. UC is relatively hard to treat in this patient.

A) True

B) False

Answer: A

Cigarette smoking has a protective tendency in UC. Interestingly, patients who develop UC after quitting tobacco are relatively hard to treat. On the same token, disease severity may improve at the resumption of cigarette smoking. 

In contrast, smoking increases the risk of Crohn's disease (CD) and may make CD symptoms worse.

#GI

References:

1. To N, Ford AC, Gracie DJ. Systematic review with meta-analysis: the effect of tobacco smoking on the natural history of ulcerative colitis. Aliment Pharmacol Ther 2016; 44:117.

2. Beaugerie L, Massot N, Carbonnel F, et al. Impact of cessation of smoking on the course of ulcerative colitis. Am J Gastroenterol 2001; 96:2113.

3.  Ryan WR, Allan RN, Yamamoto T, Keighley MR. Crohn's disease patients who quit smoking have a reduced risk of reoperation for recurrence. Am J Surg 2004; 187:219.

4. Boyko EJ, Perera DR, Koepsell TD, et al. Effects of cigarette smoking on the clinical course of ulcerative colitis. Scand J Gastroenterol 1988; 23:1147.

5. Beaugerie L, Massot N, Carbonnel F, et al. Impact of cessation of smoking on the course of ulcerative colitis. Am J Gastroenterol 2001; 96:2113.

ending paracentesis

 Q: Which one simple maneuver at the end of paracentesis may help to finish the procedure smoothly with no/less pain to the patient?

Answer: Ask patient to cough

Removal of needle at the end of paracentesis can be a painful experience for the patient. Actually, it can be the most unpleasant part of the procedure. This is mostly due to the fact that local anesthesia given at the beginning of the procedure may be dissipated by then.

Asking a patient to cough before removing the needle makes things easy for the patient. It not only distracts the patient but also due to competitive inhibition of reflexes decreases the pain transmission through nerves.

#procedure

Reference:

Bruce A Runyon, Sanjiv Chopra, Kristen M Robson. Diagnostic and therapeutic abdominal paracentesis. © UpToDate. Topic last updated: Oct 29, 2021. 

Link: https://www.uptodate.com/contents/diagnostic-and-therapeutic-abdominal-paracentesis

Knee effusion

 Q: It requires at least 50 mL of fluid to be present to appreciate knee effusion on an exam?

A) True

B) False

Answer: B

The objective of this question is to highlight the fact that in comparison to other body cavities knee requires very little fluid to have symptoms. Only 5 mL of fluid can be appreciated with proper examination. The level of quantity requires is pretty low:

• small effusions: 5-10 mL
• moderate effusion: 10-15 mL
• large effusion: 20-30 mL

Bulge, bubble, or wave sign: Performing "milking the fluid", also known as brush or stroke test, can make a clinician appreciate a small effusion. Watch here the maneuver: 

https://youtu.be/LHOmmWB_PFo

#physical-exam

#rheumatology

References:

1. Mathison DJ, Teach SJ. Approach to knee effusions. Pediatr Emerg Care. 2009 Nov;25(11):773-86; quiz 787-8. doi: 10.1097/PEC.0b013e3181bec987. PMID: 19915432.

2. Johnson MW. Acute knee effusions: a systematic approach to diagnosis. Am Fam Physician. 2000 Apr 15;61(8):2391-400. PMID: 10794580.

FOUR score

Q: FOUR score is useful in assessing? (select one)

A) Mental unresponsiveness 

B) Ventilator extubation parameter

Answer: A

FOUR stands for 'Full Outline of UnResponsiveness'. It is usually performed in Traumatic Brain Injury (TBI). It should be performed with Glasgow coma scale (GCS) to grade injury in intubated patients as well as to assess brain stem function. It is found to be as valuable as GCS in TBI to predict long-term outcomes.

It consists of four parameters.

1. Eye response

2. Motor response

3. Brainstem reflexes

4. Respiration

It can be found here: here (URL: https://www.mdcalc.com/four-full-outline-unresponsiveness-score)

#neurology

#trauma

References:

1. Fischer M, Ruegg S, Czaplinski A, et al. Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care 2010; 14:R64. Copyright © 2010 BioMed Central Ltd.

2. Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58:585. 

3. McNett MM, Amato S, Philippbar SA. A Comparative Study of Glasgow Coma Scale and Full Outline of Unresponsiveness Scores for Predicting Long-Term Outcome After Brain Injury. J Neurosci Nurs 2016; 48:207. 

4. Kasprowicz M, Burzynska M, Melcer T, Kübler A. A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score (GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg 2016; 30:211.

Epi and LA

Q: How intravenous (IV) epinephrine generates lactic acidosis?

Answer: IV epinephrine essentially leads to lactic acidosis by three mechanisms 

1. increase glycolysis in skeletal muscle 

2. hypoperfusion of the gastrointestinal (GI) tract

3. reduce hepatic lactate uptake. 

Side note: This is the same mechanism by which lactic acidosis is produced in pheochromocytoma.

#pharmacology

#acid-base

References:

1. Day NP, Phu NH, Bethell DP, et al. The effects of dopamine and adrenaline infusions on acid-base balance and systemic haemodynamics in severe infection. Lancet 1996; 348:219. 

2. Madias NE, Goorno WE, Herson S. Severe lactic acidosis as a presenting feature of pheochromocytoma. Am J Kidney Dis 1987; 10:250.

K-sparing diuretics and Mg

Q: Potassium-sparing diuretics ________ magnesium excretion? (select one)

A) enhances

B) reduces

Answer: B

It is true that loop and thiazide diuretics tend to cause urinary magnesium loss. In contrast, potassium-sparing diuretics tend to reduce magnesium excretion. 

Potassium-sparing diuretics which include amiloride, triamterene, and spironolactone decrease sodium entry in the connecting tubule and cortical collecting tubule. This is mediated by epithelial sodium channels in these areas. This effect enhances magnesium reabsorption and so decreases magnesium excretion. 

#nephrology

#electrolytes

References:

Dyckner T, Wester PO, Widman L. Amiloride prevents thiazide-induced intracellular potassium and magnesium losses. Acta Med Scand 1988; 224:25.

Risk factor in steroid induced psychosis

Q: 44 years old female with a known history of Systemic Lupus Erythematosus (SLE) is admitted with psychosis. Subsequent workup led to the diagnosis of glucocorticoid-induced psychosis. Which of the following may exacerbate the glucocorticoid-induced psychosis in this patient? (select one)

A) Hypoalbuminemia

B) Hypercholesterolemia

Answer: A

There are a lot of misconceptions on glucocorticoid-induced psychosis. It has been commonly believed that glucocorticoid-induced psychosis can occur at any dose and even with a short course. In fact, it 'almost exclusively' occurs with prednisone above 20 mg/day for a prolonged period. Second, it has been incorrectly mentioned that it is usually irreversible. In reality, the response to antipsychotic drugs is usually robust.

Patients with SLE who are on chronic steroids and have hypoalbuminemia are particularly prone to it.

#psychiatry

#pharmacology

#rheumatology

References:

1. Da Silva JA, Jacobs JW, Kirwan JR, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data. Ann Rheum Dis 2006; 65:285. 

2. Acute adverse reactions to prednisone in relation to dosage. Clin Pharmacol Ther 1972; 13:694. 

3. Dubovsky AN, Arvikar S, Stern TA, Axelrod L. The neuropsychiatric complications of glucocorticoid use: steroid psychosis revisited. Psychosomatics 2012; 53:103. 

4. Chau SY, Mok CC. Factors predictive of corticosteroid psychosis in patients with systemic lupus erythematosus. Neurology 2003; 61:104.

sarcopenia

Q: 72 years old male is admitted to ICU with community-acquired pneumonia. Chart reveals the development of sarcopenia over the last few months. What is sarcopenia? 

Answer: Unintentional weight loss, cachexia, and sarcopenia are progressive levels of weight loss. 

Unintentional weight loss is defined as loss of more than 5 percent of actual body weight over 6-12 months. Sarcopenia is defined by the loss of muscle mass, strength, as well as performance. This is an advanced category of cachexia which is defined as weight loss from loss of muscle mass. Cachexia doesn't account for the fat loss. 

#geriatrics

References:

1. Wong CJ. Involuntary weight loss. Med Clin North Am 2014; 98:625. 

2. Landi F, Calvani R, Cesari M, Tosato M, Martone AM, Ortolani E, Savera G, Salini S, Sisto A, Picca A, Marzetti E. Sarcopenia: An Overview on Current Definitions, Diagnosis and Treatment. Curr Protein Pept Sci. 2018 May 14;19(7):633-638. doi: 10.2174/1389203718666170607113459. PMID: 28595526. 

3. Larsson L, Degens H, Li M, Salviati L, Lee YI, Thompson W, Kirkland JL, Sandri M. Sarcopenia: Aging-Related Loss of Muscle Mass and Function. Physiol Rev. 2019 Jan 1;99(1):427-511. doi: 10.1152/physrev.00061.2017. PMID: 30427277; PMCID: PMC6442923. 

4. Dhillon RJ, Hasni S. Pathogenesis and Management of Sarcopenia. Clin Geriatr Med. 2017 Feb;33(1):17-26. doi: 10.1016/j.cger.2016.08.002. PMID: 27886695; PMCID: PMC5127276.

Non-selective BB in portal hypertension

 Q: What is the mechanism of action for non-selective beta-blockers to reduce portal hypertension?

Answer: Beta-blockers do not work directly to reduce portal hypertension. It's the 'down the stream' effect which decreases portal hypertension by decreasing portal venous inflow. The two recommended nonselective beta-blockers are propranolol and nadolol. Nonselective beta-blockers block the adrenergic dilatory tone in mesenteric arterioles. This causes an unopposed alpha-adrenergic mediated vasoconstriction. This vasoconstriction causes decrease portal venous inflow. 

This is one of the major reasons that cardioselective beta-blockers such as atenolol doesn't have a good effect on portal hypertension, as it tends to works directly via decreasing cardiac output.

#hepatology

References:

1. Sanyal AJ, Shiffman ML. The pharmacologic treatment of portal hypertension. Annu Rev Gastrointest Pharmacol 1996; :242.

2. Hillon P, Lebrec D, Muńoz C, Jungers M, Goldfarb G, Benhamou JP. Comparison of the effects of a cardioselective and a nonselective beta-blocker on portal hypertension in patients with cirrhosis. Hepatology. 1982 Sep-Oct;2(5):528-31. doi: 10.1002/hep.1840020503. PMID: 7118065.

Acetaminophen overdose in pregnancy

 Q: The acetaminophen overdose in pregnancy should be approached with a higher dose of N-acetylcysteine? 

A) True

B) False

Answer: B

Acetaminophen crosses the placenta and potentially may cause fetal death from hepatic necrosis. The approach to the treatment in pregnancy with acetaminophen overdose is not different from any other patient, as the effect on the liver is similar.  Dosing and the duration of treatment stay the same. Either oral or IV route has the same effect but the IV route is preferred as a pregnant patient may have increased nausea and vomiting. 

Lengthening the N-acetylcysteine treatment in pregnancy may increase the risk of miscarriage and fetal death.

Moreover, if a baby is born with toxic acetaminophen concentrations, he/she should be treated with N-acetylcysteine with standard dosing.

#Ob-Gyn

#hepatology

#toxicology

References:

1. Haibach H, Akhter JE, Muscato MS, et al. Acetaminophen overdose with fetal demise. Am J Clin Pathol 1984; 82:240. 

2. McElhatton PR, Sullivan FM, Volans GN. Paracetamol overdose in pregnancy analysis of the outcomes of 300 cases referred to the Teratology Information Service. Reprod Toxicol 1997; 11:85. 

3. Lederman S, Fysh WJ, Tredger M, Gamsu HR. Neonatal paracetamol poisoning: treatment by exchange transfusion. Arch Dis Child 1983; 58:631. 

4. Horowitz RS, Dart RC, Jarvie DR, et al. Placental transfer of N-acetylcysteine following human maternal acetaminophen toxicity. J Toxicol Clin Toxicol 1997; 35:447. 

patients with refractory schizophrenia and schizoaffective disorder who stayed persistent suicidal

Q: 24 years old male with an established diagnosis of schizophrenia and previous suicidal ideations is admitted again with similar symptoms. Trial of which medicine is indicated? (select one) 

A) Clozapine 

B) Olanzapine

Answer: A

Clozapine stands out to work amongst all antipsychotics for patients with refractory schizophrenia and schizoaffective disorder who stayed persistent with suicidal tendencies. This is based on a strong study of about 90,000 patients from Europe. 

Clozapine is approved for this indication by US Food and Drug Administration (FDA). 

Due to its potential side effects, it is reserved as a second-line of treatment.

#psychiatry

References:

1. Meltzer HY, Alphs L, Green AI, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 2003; 60:82. 

2. Taipale H, Lähteenvuo M, Tanskanen A, et al. Comparative Effectiveness of Antipsychotics for Risk of Attempted or Completed Suicide Among Persons With Schizophrenia. Schizophr Bull 2021; 47:23.

TPN and hyperbilirubinemia

Q: Total parenteral nutrition (TPN) tends to cause? (select one)

A) Conjugated hyperbilirubinemia

B) Unconjugated hyperbilirubinemia 

  

Answer: A

The mere recognition of conjugated (direct) and unconjugated (indirect) hyperbilirubinemia may help to determine the actual underlying pathophysiology. A major underlying cause of unconjugated hyperbilirubinemia (and often unrecognized) in ICU is TPN. Most of the time, in ICU complex patients, there are two or even more causes of direct and/or indirect hyperbilirubinemia. 

The major causes of conjugated hyperbilirubinemia in ICU are "inside liver-based" - and can be remembered as direct - 

• Hepatitis and steatohepatitis 
• Primary biliary cholangitis 
• Drugs
• Toxins 
• Ischemia 
• Infiltration 
• Inherited disorders 
• Total parenteral nutrition 
• Postoperative jaundice 
• Intrahepatic cholestasis of pregnancy 
• End-stage liver disease 
• Post-organ transplant

In contrast, the causes of unconjugated hyperbilirubinemia occur outside the liver (indirect) like

• Hemolysis 
• Dyserythropoiesis 
• Stress situation (most common is sepsis) (increased production of bilirubin)
• Impaired bilirubin uptake or conjugation

#hepatology

References:

1. Tripathi N, Jialal I. Conjugated Hyperbilirubinemia. 2021 Sep 28. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 32965843. 

2. Singh A, Koritala T, Jialal I. Unconjugated Hyperbilirubinemia. 2021 Dec 6. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31747203.

Fever in neutropenic patients

 Q: In a neutropenic patient a single spike of temperature more than/equal to 38.3°C (101°F) qualifies as fever.

A) True 

B) False

Answer: A

Fever in a neutropenic patient is usually accepted or defined as 

• a single spike of temperature more than/equal to 38.3°C (101°F), and/or 
• a temperature more than/equal to 38°C (100.4°F) sustained over a one-hour period 

Said that fever may not occur in all neutropenic patients like in older patients or who are on corticosteroids. Sometimes, hypothermia may be a sign of infection in a neutropenic patient.

#ID

(A pearl on this similar concept has previously been posted here )

Reference:

Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56.

NMS and Iron

 Q: 52 years old male admitted to ICU with acute malignant catatonia 2 days ago. Now he developed Neuroleptic Malignant Syndrome (NMS). Iron level is expected to be? (select one) 

A) high 

B) low 

Answer: B

Although not a specific marker but low iron level is a very sensitive marker for NMS. The mean level is 5.71 micromol/L, particularly in acutely sick psychiatric patients with NMS.

In the above question, patient with catatonia is chosen because the symptoms are sometimes hard to distinguish between the two conditions. Moreover, they both can exist together.

#psychiatry

#electrolytes

References:

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

2. Koch M, Chandragiri S, Rizvi S, et al. Catatonic signs in neuroleptic malignant syndrome. Compr Psychiatry 2000; 41:73. 

3. Velamoor VR. Neuroleptic malignant syndrome. Recognition, prevention and management. Drug Saf 1998; 19:73. 

4. Fleischhacker WW, Unterweger B, Kane JM, Hinterhuber H. The neuroleptic malignant syndrome and its differentiation from lethal catatonia. Acta Psychiatr Scand 1990; 81:3.

SNOOP10

 Q:  What is SNOOP10?

Answer:  SNOOP10 is a mnemonic which reminds a clinician of 'danger signs' that headache can be secondary to a serious underlying pathology other than simple migraine. There may be a stroke, infection, metabolic encephalopathy or a systemic disease. 

• Systemic symptoms like fever
• Neoplasm 
• Neurologic deficit (or mental status change)
• Onset (sudden) 
• Old age 
• Pattern change (a new type of headache)
• Position (headache change by position)
• Precipitating factors like sneeze, cough, or exercise
• Papilledema
• Progressive headache 
• Pregnancy (puerperium)
• Painful eye 
• Post-traumatic onset 
• Pathology of the immune system (e.g., HIV)
• Painkiller overuse (i.e., medication overuse headache or drug-induced headache)

#neurology

Reference:

Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 2019; 92:134.

Hyponatremia-Hypoxemia connection

Hyponatremia-Hypoxemia connection

A relatively less appreciated fact is the role of hypoxemia in acute hyponatremia. Acute hyponatremia may lead to impending cerebral herniation and causes hypoventilation and/or noncardiogenic pulmonary edema, resulting in hypoxemia. This hypoxemia exacerbates the hyponatremia-induced cerebral edema, setting a fatal vicious cycle. Mild symptoms of nausea, vomiting, headache and confusion can quickly culminate into cerebral herniation when sodium acutely fells below 130 mEq/L.  Fortunately careful correction of sodium by only 4-6 mEq/L can prevent this complication.

High risk patients include psychogenic polydipsia, marathon runners/high exercise, use of ecstasy, acute postoperative hyponatremia particularly in pediatric patients, traumatic brain injury (TBI), recent brain surgery, or brain tumor.

#electrolytes

#neurology

References:

1. Ayus JC, Varon J, Arieff AI. Hyponatremia, cerebral edema, and noncardiogenic pulmonary edema in marathon runners. Ann Intern Med 2000; 132:711. 

2. Sterns RH, Nigwekar SU, Hix JK. The treatment of hyponatremia. Semin Nephrol 2009; 29:282. 

3. Chawla A, Sterns RH, Nigwekar SU, Cappuccio JD. Mortality and serum sodium: do patients die from or with hyponatremia? Clin J Am Soc Nephrol 2011; 6:960.

seizure in meningitis

 Q: 32 years old male is admitted to ICU with seizure due to bacterial meningitis. Seizure in meningitis is a poor prognostic sign.

A) True

B) False

Answer: A

The occurrence of seizure during acute meningitis is usually a poor prognostic sign, particularly in adults. It is associated with a higher risk of neurologic deficits at hospital discharge and death. It is more common with pneumococcal meningitis. 

Also, these patients carry a higher risk of seizure subsequently later in life.

#neurology

#ID

References:

1. Zoons E, Weisfelt M, de Gans J, et al. Seizures in adults with bacterial meningitis. Neurology 2008; 70:2109. 

2. Annegers JF, Hauser WA, Beghi E, et al. The risk of unprovoked seizures after encephalitis and meningitis. Neurology 1988; 38:1407.

3. van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351:1849.

FS and splenomegaly

 Q: 38 years old female with a known history of Felty syndrome (FS) is admitted to ICU with bacteremia. Physical examination followed by an ultrasound of abdomen showed massive splenomegaly. The size of splenomegaly correlates well with the severity of FS. 

A) True 

B) False

Answer: B

FS is consist of a triad 

• Rheumatoid arthritis (RA)
• Splenomegaly
• Neutropenia

Splenomegaly is usually massive in FS with a mean weight four times the normal. Despite that spleen size has no correlation with the other two components of triad i.e., degree of neutropenia and/or severity of RA. Patient with minimal or no splenomegaly can have severe FS.

#rheumatology

References:

1. Ruderman M, Miller LM, Pinals RS. Clinical and serologic observations on 27 patients with Felty's syndrome. Arthritis Rheum 1968; 11:377. 

2. Sienknecht CW, Urowitz MB, Pruzanski W, Stein HB. Felty's syndrome. Clinical and serological analysis of 34 cases. Ann Rheum Dis 1977; 36:500.

3. Campion G, Maddison PJ, Goulding N, et al. The Felty syndrome: a case-matched study of clinical manifestations and outcome, serologic features, and immunogenetic associations. Medicine (Baltimore) 1990; 69:69. 

4. Laszlo J, Jones R, Silberman HR, Banks PM. Splenectomy for Felty's syndrome. Clinicopathological study of 27 patients. Arch Intern Med 1978; 138:597.

Dig in A.fib

 Q:  Although less in use but digoxin is more effective than beta-blockers (BBs) and calcium channel blockers (CCBs) in terminating atrial fibrillation (AF).

A) True

B) False

Answer: B

The answer is false (choice B). Neither it is more effective than BBs and CCBs nor does it has any ability to terminate AF. In ICUs digoxin should not be used as a first-line drug for rate control during Rapid Ventricular Rate (RVR), though it can be used in case of no response to BBs and/or CCBs - or as an adjuvant treatment. Moreover, it has no immediate effect. It has to bind with protein to act, which takes about 2-3 hours.

#cardiology

#pharmacology

References:

1. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071. 

2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199.

3. Shettigar UR, Toole JG, Appunn DO. Combined use of esmolol and digoxin in the acute treatment of atrial fibrillation or flutter. Am Heart J 1993; 126:368.