Tuesday, October 17, 2017

Q: All of the following tetracyclines can be used in renal insufficiency except?

A) Doxycycline
B) Minocycline
C) Demeclocycline
D) Tigecycline


Answer: C

Out of all tetracyclines - Doxycycline, Minocycline and Tigecycline do not require any adjustment in renal dysfunction. Demeclocycline should be avoided in renal dysfunction.Demeclocycline inhibits the renal action of antidiuretic hormone, which may be used as an advantage in the syndrome of inappropriate antidiuretic hormone secretion (SIADH), but should be avoided for any other reasons, if renal insufficiency is present.

Monday, October 16, 2017

Q; Calorie dense formula contains

A) higher than usual free water as calories are dense
B) lower than required free water for patients' need
C) it doesn't contain any free water
D) Pharmacy adjust free water in each bag per patients' need


Answer: B

Calorically dense formulas contain as little as 60% free water, and may require supplementation of free water to avoid dehydration and electrolyte imbalance, particularly hypernatremia.

C is wrong answer as all formulas contain free water.

D is a wrong answer as enteral nutrition bags are prepackaged from commercial companies. And at least in US, hospital pharmacies don't prepare enteral formula for each patient, but they do prepare only Total Parenteral Nutrition (TPN), adjusting each patient need.


Sunday, October 15, 2017

Q: After terminal discontinuation of ventilator support in patients destined for comfort care (withdrawal of care), all of the following effect the time to death except?

A) Number of organs not working
B) Vasopressor on board
C) Volume status
D) Surgical versus medical patient
E) Length of time on ventilator prior to extubation


Answer: E

As per study published in chest (2010), looking over 1500 patients, the median time to death after withdrawal of ventilator support was 0.9 hours. The major factors effecting the time to death included all of the above (Choices A, B, C and D) except the length of the time spent on ventilator prior to extubation.



Reference: 

Cooke CR, Hotchkin DL, Engelberg RA, et al. Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU. Chest 2010; 138:289.

Saturday, October 14, 2017

ARTE Trial

ARTE (Aspirin Versus Aspirin + Clopidogrel Following TAVR) - DAPT vs SAPT

So far all patients who go through transcatheter aortic valve replacement (TAVR), receive dual-antiplatelet therapy (DAPT) per present guidelines, but here is the new development. ARTE trial were presented at the annual congress of the European Association of Percutaneous Cardiovascular Interventions by Dr. Josep Rodes-Cabau of Laval University in Quebec City.

ARTE was a multicenter, prospective, international open-label study of 222 TAVR patients who were randomized to 3 months of single-antiplatelet therapy (SAPT) with aspirin at 80-100 mg/day or to DAPT with aspirin at 80-100 mg/day plus clopidogrel at 75 mg/day after a single 300-mg loading dose.  Patients  had a mean Society of Thoracic Surgery Predicted Risk of Mortality score of 6.3%.

Results:

The primary outcome was the 3-month composite of
  • death, 
  • MI, 
  • major or life-threatening bleeding, 
  • stroke or transient ischemic attack. 
Results concluded 15.3% in the DAPT group and 7.2% in the SAPT group. Though study didn't achieve a statistical significance value (P = .065), probably  because of small sample size. But, importantly and most relevantly it showed strong and consistent benefit favoring SAPT,  in major or life-threatening bleeding achieved statistical significance.  Four bleeding events in the SAPT group were vascular in nature, while five of the 12 in the DAPT group were gastrointestinal. All the bleeding events in the SAPT group occurred within 72 hours after TAVR, whereas 5 of 12 in the DAPT recipients occurred later.

Only one patient on SAPT experienced life-threatening bleeding, compared with seven DAPT patients.

Important note: Trial was halted prematurely. The original study was planned to recruit 300 patients with over a year of follow-up. Trial was stopped due to slow enrollment and withdrawal of financial support by the study sponsors.


Reference:

Rodés-Cabau J and et al: - Aspirin Versus Aspirin Plus Clopidogrel as Antithrombotic Treatment Following Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve: The ARTE (Aspirin Versus Aspirin + Clopidogrel Following Transcatheter Aortic Valve Implantation) Randomized Clinical Trial.  .JACC Cardiovasc Interv. 2017 Jul 10;10(13):1357-1365. Epub 2017 May 17. 

Friday, October 13, 2017

Q: Which of the following has the highest chance of chemical cardioversion of atrial fibrillation

A) Ibutilide
B) Esmolol
C) Esmolol plus ibutilide
D) Digoxin


Answer: C

Esmolol plus ibutilide has shown higher chances of chemical conversion of recent-onset atrial fibrillation in comparison to ibutilide monotherapy alone. This is probably due to the fact that esmolol decreases the ventricular response. The slower the ventricular rate at the time of ibutilide administration, the greater is the probability of conversion to sinus rhythm. Moreover, combo therapy of esmolol and ibutilide  not only decreases the incidence of immediate atrial fibrillation recurrence but also the risk of torsade de pointes.

Digoxin has no direct role in chemical conversion of atrial fibrillation.


Reference:

Fragakis N, Bikias A, Delithanasis I, et al. Acute beta-adrenoceptor blockade improves efficacy of ibutilide in conversion of atrial fibrillation with a rapid ventricular rate. Europace 2009; 11:70.

Thursday, October 12, 2017

Q; During Cardiopulmonary bypass (CPB) heparinization is considered to be adequate if target heparin concentration is

 A) More than or equal to 4 units/mL 
 B) More than or equal to 40 units/mL 
C) Less than 4 units/mL 
D) Heparin levels can't be measured by any means
E) Measuring heparin level is not standard, so activated clotting time (ACT) should be used


Answer: A

Though activated whole blood clotting time (ACT) between 400 to 480 seconds is considered to be adequate for heparinization during CPB, but another reliable method is to keep heparin concentration  more than or equal to 4 units/mL.


D is not true (we just made it up :)


Reference:

Finley A, Greenberg C. Review article: heparin sensitivity and resistance: management during cardiopulmonary bypass. Anesth Analg 2013; 116:1210.

Wednesday, October 11, 2017

Q: Glucocorticoids are used in thyroid storm for all of the following actions except? 

A) Reduce T4-to-T3 conversion
B) Promote vasomotor stability
C) Treat an associated relative adrenal insufficiency (if present)
D) Block new hormone synthesis


Answer: D

Thyroid storm requires multi-dimensional approach to manage different steps of thyroid synthesis, secretion, action and recirculation, like beta blocker controls the symptoms induced by increased adrenergic tone, a thionamide blocks the new hormone synthesis, an iodine solution blocks the release of thyroid hormone and an iodinated radiocontrast agent inhibits the peripheral conversion of T4 to T3. Some clinicians add bile acid sequestrants to decrease enterohepatic recycling of thyroid hormones.

Glucocorticoids reduces T4-to-T3 conversion, promote vasomotor stability, and treat an associated relative adrenal insufficiency, if present. It has no role in blocking new hormone synthesis.


Reference:

Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343.

Tuesday, October 10, 2017

Q: Magnesium sulfate should be infused with caution in which of the following patients

A) Myasthenia gravis
B) Asthma
C) Hypocalcemia
D) Hypokalemia
E) Torsade de pointes 


Answer:  A

Magnesium sulfate infusion should be used with caution in patients with myasthenia gravis since it can precipitate a severe myasthenia crisis. Magnesium is indicated in all other cases given in the question.



Reference:


Paramveer Singh, MD, Olakunle Idowu, MD, Imrana Malik, MD, and Joseph L. Nates, MD, MBA - Acute Respiratory Failure Induced by Magnesium Replacement in a 62-Year-Old Woman with Myasthenia Gravis - Tex Heart Inst J. 2015 Oct; 42(5): 495–497.

Monday, October 9, 2017

Q: Which method provides optimum way of suctioning in postoperative suction drainage bulbs , like Jackson-Pratt (JP) drain?  - Choose one

A)  by pressing the sides of the reservoir together 

B) by pushing the bottom of the reservoir toward the top



Answer: A

In suction based postoperative drains, compressing the sides of the reservoir is a far better technique for establishing negative pressure than pressing the bottom of the drain up toward the top.



Reference:

Carruthers KH, Eisemann BS, Lamp S, Kocak E. - Optimizing the closed suction surgical drainage system - Plast Surg Nurs. 2013 Jan-Mar;33(1):38-42;

Sunday, October 8, 2017

Q: What's the easiest way ("rule of thumb") to calculate calories provided by standard tube feeding formulas in ICU? 


Answer: Most standard formulas in ICU provide 1 calorie per 1 milliliter (mL) and a nutrient composition quite similar to what is recommended for healthy individuals. 

Adjustment should be done looking at the label of the formula at bedside if caloric density formulas are on board. They are usually labelled as (formula name) 1.5. 



Saturday, October 7, 2017

Q:  In vitro studies refers to experimentation in a controlled environment outside of a living organism. In vivo studies refers to experimentation inside or using a living organism. What does it means by in silico studies?


Answer: In silico refers to experimentations performed on computer or via computer simulation. Term is invented by a mathematician, Pedro Miramontes to characterize biological experiments carried out entirely in a computer. This aspect is can be used for identifying bacteria via in silico methods to sequence bacterial DNA and RNA. It is also used in polymerase chain reaction (PCR), generating millions or more copies of a particular DNA sequence.



References: 


1. Dantas, Gautam; Kuhlman, Brian; Callender, David; Wong, Michelle; Baker, David (2003), "A Large Scale Test of Computational Protein Design: Folding and Stability of Nine Completely Redesigned Globular Proteins", Journal of Molecular Biology, 332 (2): 449

2.  Dobson, N; Dantas, G; Baker, D; Varani, G (2006), "High-Resolution Structural Validation of the Computational Redesign of Human U1A Protein", Structure, 14 (5): 847

3. Dantas, G; Corrent, C; Reichow, S; Havranek, J; Eletr, Z; Isern, N; Kuhlman, B; Varani, G; et al. (2007), "High-resolution Structural and Thermodynamic Analysis of Extreme Stabilization of Human Procarboxypeptidase by Computational Protein Design", Journal of Molecular Biology, 366 (4): 1209–21
Q: After Staphylococcus spp, which of the following organism is the most common cause of infected (mycotic) arterial aneurysm?

A) Salmonella 
B) Treponema pallidum
C) Mycobacterium spp
D) Coxiella burnetii 
E) Candida



Answer: A

Staphylococcus spp and Salmonella spp, are so far the most common cause of mycotic aneurysm. Though list of organisms are long, but for reasons not fully understood Salmonella is easily prone to bacteremic seeding of atherosclerotic plaque.




References:

1. Brossier J, Lesprit P, Marzelle J, et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: a single-centre experience. Eur J Vasc Endovasc Surg 2010; 40:582.

2. Hsu RB, Tsay YG, Wang SS, Chu SH. Surgical treatment for primary infected aneurysm of the descending thoracic aorta, abdominal aorta, and iliac arteries. J Vasc Surg 2002; 36:746.

3. Gomes MN, Choyke PL, Wallace RB. Infected aortic aneurysms: a changing entity. Ann Surg. 1992;215:435-442.

Thursday, October 5, 2017

Q: Name few treatments for Post-lumbar puncture headache (PHPHA) if bed-rest and conventional analgesics don't work?


Answer: 
  • Epidural blood patch 1
  • Caffeine (oral or IV) 2,3
  • IM adrenocorticotropic hormone (ACTH) 4
  • IV hydrocortisone 5
  • PO  theophylline 6
  • SQ sumatriptan 7
  • sphenopalatine block 8
  • PO gabapentin 9
  • Epidural saline 10


References:


1. Boonmak P, Boonmak S. Epidural blood patching for preventing and treating post-dural puncture headache. Cochrane Database Syst Rev 2010; :CD001791. 


2.  Camann WR, Murray RS, Mushlin PS, Lambert DH. Effects of oral caffeine on postdural puncture headache. A double-blind, placebo-controlled trial. Anesth Analg 1990; 70:181. 


3. Jarvis AP, Greenawalt JW, Fagraeus L. Intravenous caffeine for postdural puncture headache. Anesth Analg 1986; 65:316. 


4. Foster P. ACTH treatment for post-lumbar puncture headache. Br J Anaesth 1994; 73:429


5. Noyan Ashraf MA, Sadeghi A, Azarbakht Z, et al. Evaluation of intravenous hydrocortisone in reducing headache after spinal anesthesia: a double blind controlled clinical study [corrected]. Middle East J Anaesthesiol 2007; 19:415.


6. Feuerstein TJ, Zeides A. Theophylline relieves headache following lumbar puncture. Placebo-controlled, double-blind pilot study. Klin Wochenschr 1986; 64:216


7. Connelly NR, Parker RK, Rahimi A, Gibson CS. Sumatriptan in patients with postdural puncture headache. Headache 2000; 40:316. 


8. Kent S, Mehaffey G. Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED. Am J Emerg Med 2015; 33:1714.e1.


9. The effect of oral gabapentin on postdural puncture headache. Acute Pain 2006; 8:169.


10. RICE GG, DABBS CH. The use of peridural and subarachnoid injections of saline solution in the treatment of severe postspinal headache. Anesthesiology 1950; 11:17. 



Wednesday, October 4, 2017

Q: 64 year old male with End Stage Renal disease (on hemodialysis) presented to Emergency Room (ER) with chest pain and found to have unstable angina. Patient is known to cardiology service from previous 'cath' three months ago and was advised to go through bypass surgery but he opted for medical management. Now patient is agreeable for surgery. Review of his record showed that 3 months  ago while in hospital, he was tested positive for Heparin Induced Thrombocytopenia (HIT). His platelet counts are now normal, but to prepare him for surgery, his HIT panel was send again and found to be stayed positive. All of the following can be used in operation theater (OR) except?

A) preemptive  transfusion of platelets

B) Bivalirudin
C) Heparin reexposure but with intravenous Epoprostenol
D) Plasma exchange upon initiation of cardiopulmonary bypass (CPB)
E) Argatroban


Answer: A

Objective of above question is to highlight a less known option, epoprostenol. Epoprostenol is a prostaglandin PGI2 which can be used if heparin is used in a patient with positive HIT panel. Though bivalirudin or Argatroban can be used in this scenario but a surgeon may choose against them due to their inability to reverse the anticoagulant effect at the conclusion of cardiopulmonary bypass (CPB). Another viable option is plasma exchange upon initiation of CPB to reduce the titer of HIT antibodies prior to heparin exposure.

Epoprostenol potently desensitizes platelets during exposure to heparin by inhibiting platelet activation and by increasing intracellular concentrations of platelet cyclic adenosine monophosphate. It is given as an intravenous infusion while CPB runs and till protamine is administered to reverse heparin effect. Pharmacy service should be consulted for protocolized infusion of  epoprostenol. The most common side effect is vasoplegia.

Choices A is not a recommended option.



References:

1. Welsby IJ, Um J, Milano CA, et al. Plasmapheresis and heparin reexposure as a management strategy for cardiac surgical patients with heparin-induced thrombocytopenia. Anesth Analg 2010; 110:30.

2.  Koster A, Dyke CM, Aldea G, et al. Bivalirudin during cardiopulmonary bypass in patients with previous or acute heparin-induced thrombocytopenia and heparin antibodies: results of the CHOOSE-ON trial. Ann Thorac Surg 2007; 83:572.

3. Aouifi A, Blanc P, Piriou V, et al. Cardiac surgery with cardiopulmonary bypass in patients with type II heparin-induced thrombocytopenia. Ann Thorac Surg 2001; 71:678.

4. Mertzlufft F, Kuppe H, Koster A. Management of urgent high-risk cardiopulmonary bypass in patients with heparin-induced thrombocytopenia type II and coexisting disorders of renal function: use of heparin and epoprostenol combined with on-line monitoring of platelet function. J Cardiothorac Vasc Anesth 2000; 14:304. 

5. Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. Ann Thorac Surg 2003; 76:2121. 

6. Argatroban pharmacokinetics and pharmacodynamics in critically ill cardiac surgical patients with suspected heparin-induced thrombocytopenia. Thromb Haemost 2016; 115:1081.

Tuesday, October 3, 2017

4 Ds of increased obstetric mortality

Q; What are the 4 Delays (also called 4 Ds) of increased obstetric mortality?

Answer:
  • Delay in decision
  • Delay in transferring
  • Delay in arranging (medical help)
  • Delay in initiation (emergency treatment including IV Oxytocin, uterine massage and others)*

* Click here to see Obstetric Hemorrhage Checklist from The American College of Obstetricians and Gynecologists.

Monday, October 2, 2017

Q: What are the four Ts of Obstetric Hemorrhage?

Answer:
  • Tone (i.e., atony) 
  • Trauma (i.e., laceration) 
  • Tissue (i.e., retained products) 
  • Thrombin (i.e., coagulation dysfunction)

Sunday, October 1, 2017

Q; What percentage of patients have neurological complications who require Extra Corporeal Membrane Oxygenation (ECMO) for pulmonary reason and cardiopulmonary reason respectively?


Answer:  As per  Extracorporeal Life Support Organization (ELSO) registry, the incidence of neurologic injury in adult respiratory failure (ARDS or ALI) patients is 10 percent but the incidence rise to 50 percent, if ECMO support is instituted  during cardiopulmonary resuscitation.

In pure pulmonary pathology, Veno-Venous (V-V ECMO) is required but in hemodynamic collapse Veno-Arterial (V-A ECMO) is required.


References: 

1. Brogan TV, Thiagarajan RR, Rycus PT, et al. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 2009; 35:2105.

2. Mateen FJ, Muralidharan R, Shinohara RT, et al. Neurological injury in adults treated with extracorporeal membrane oxygenation. Arch Neurol 2011; 68:1543.

Saturday, September 30, 2017

Q; Why 4 coagulation factors combination is called FEIBA?


Answer: FEIBA stands for 'factor eight inhibitor bypassing agent'. It is a combination of Factors II, VII, IX and X. 

FEIBA is used in patients who have antibodies or deficiency of Factor VIII e.g. in haemophilic patients. FEIBA contains the proenzymes of the prothrombin complex factors, prothrombin, FVII, FIX and FX, but only very small amounts of their activation products, with the exception of FVIIa, which is contained in FEIBA in greater amounts. FEIBA controls bleeding by induction and facilitation of thrombin generation, (a process for which FV is crucial). 


Reference:

Turecek PL, Váradi K, Gritsch H, Schwarz HP - FEIBA: mode of action - Haemophilia. 2004 Sep;10 Suppl 2:3-9. 

Friday, September 29, 2017

Q: All of the following are orally active direct factor Xa inhibitors except

A) rivaroxaban (Xarelto),
B) apixaban (Eliquis),
C) edoxaban (Lixiana, Savaysa), 
D) betrixaban (Bevyxxa)
E) dabigatran (Pradaxa)


Answer: E

Dabigatran (Pradaxa) is the orally active Direct Thrombin Inhibitor (DTI), all others are orally active direct factor Xa inhibitors.

Reversal for Dabigatran is available. Also, it is dialysable.



Thursday, September 28, 2017

Q: It is important to avoid hyperthermia after Cardio-Pulmonary Bypass (CPB). Out of following which organ failure has shown to be associated with hypethermia after CPB?

A) Liver
B) Kidney
C) Right heart
D) Pancreas
E) Adrenal


Answer: B

Hyperthermia (body temperature more than 37°C) after CPB has shown to be  associated with Acute Kidney Injury (AKI), worsened neurologic and neurocognitive outcomes and mediastinitis.


References:

1. Engelman R, Baker RA, Likosky DS, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management during Cardiopulmonary Bypass. J Extra Corpor Technol 2015; 47:145.

2. Grocott HP, Mackensen GB, Grigore AM, et al. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke 2002; 33:537.

3. Newland RF, Tully PJ, Baker RA. Hyperthermic perfusion during cardiopulmonary bypass and postoperative temperature are independent predictors of acute kidney injury following cardiac surgery. Perfusion 2013; 28:223.

4. Groom RC, Rassias AJ, Cormack JE, et al. Highest core temperature during cardiopulmonary bypass and rate of mediastinitis. Perfusion 2004; 19:119. Fallis WM. Monitoring bladder temperatures in the OR. AORN J 2002; 76:467.

Wednesday, September 27, 2017

Q: What is "Ketofol"?

Answer: "Ketofol" is a nickname of combination used for Ketamine and Propofol. There is a very weak evidence out there that this combination may work better for procedures. Ketamine is a dissociative anesthetic and provides sedation, analgesia, and amnesia, and exerts a sympathomimetic effect. Propofol is an ultra short-acting hypnotic agent, with an added advantage of antiemetic property.

Recommend mix is 1:1 ratio.



References:

1.  Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57(5):425-33.e2. 

3. Andolfatto G, Abu-Laban R, Zed P, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012;59(6):504-12.e1-2.

Tuesday, September 26, 2017

Q: In Thromboelastography (TEG) :: "G" stands for? 

 A) Reaction time 

 B) Clot formation time 
C) Maximal amplitude 
 D) Lysis at 30 min 
 E) Clot viscoelasticity


Answer: E


Objective of above question is to highlight an important entity in Thromboelastography (TEG). It is a value calculated from platelet and fibrin performance, and represents the CLOT STRENGTH or CLOT STABILITY. It is a log derivative of Maximal Amplitude (MA) and has the units of Kdynes/cm2.

"R" is the reaction time (the time it takes the coagulation cascade to generate thrombin and fibrin).
"K" is the clot firmness ( clot firmness).
"α" (alpha) is the angle (describes the kinetics of clot formation).
"MA" is the maximum amplitude (describes the maximum clot strength).
"Ly30" is the percent clot lysis 30 minutes (after the MA is reached).







Monday, September 25, 2017

Q: What is HEART score?

Answer: Heart score is an attempt to objectively quantify the risk of Myocardial Infarction on presentation depending on five factors.

H = History
E = EKG
A = Age
R = Risk factors
T = Troponin

Low risk = 0-3
Intermediate risk = 4-6
High risk = 7-10


Sunday, September 24, 2017

Q: Smoking decreases the risk of recurrence in Crohn's Disease (CD)?

A) True

B) False


Answer: False 

There are four types of recurrences in Crohn's Disease
  • Histological
  • Clinical, 
  • Endoscopic, and 
  • Surgical 
Smoking increases the recurrence rate of all types of CD. Post-operative advice against smoking is essential in CD.


References:

1. 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.

2. Reese GE, Nanidis T, Borysiewicz C, et al. The effect of smoking after surgery for Crohn's disease: a meta-analysis of observational studies. Int J Colorectal Dis 2008; 23:1213.

Saturday, September 23, 2017

Q: How you can differentiate acute Sub-Dural-Hematoma (SDH) from subacute or chronic SDHs on CT scan of head?


Answer: 

On CT scan of head, acute SDH appears as a high-density crescentic collection across the hemispheric convexity. 

In contrast, subacute and chronic SDH appears as isodense or hypodense crescent-shaped lesions  that deform the surface of the brain.





Friday, September 22, 2017

Q: Which of the following can be used in the treatment of severe diarrhea in immunocompromised host secondary to Cryptosporidium except

A) Nitazoxanide
B) Paromomycin
C) Azithromycin 
D) Clarithromycin 


Answer: D

Debilitating diarrhea secondary to Cryptosporidium   is a significant problem in immunocompromised hosts. Though supportive treatment, reduction of immunosuppression or restoration of the immune system are the mainstay of treatment. But, in life-threatening diarrhea usually nitazoxanide or paromomycin in combination with  azithromycin can be used. Interestingly, azithromycin though effective as a treatment but is not effective as a prophylaxis. On the other hand, clarithromycin or rifabutin may be protective, but not useful as a treatment.



References:

1.  Legrand F, Grenouillet F, Larosa F, et al. Diagnosis and treatment of digestive cryptosporidiosis in allogeneic haematopoietic stem cell transplant recipients: a prospective single centre study. Bone Marrow Transplant 2011; 46:858. 

2.  Palmieri F, Cicalini S, Froio N, et al. Pulmonary cryptosporidiosis in an AIDS patient: successful treatment with paromomycin plus azithromycin. Int J STD AIDS 2005; 16:515. 

3. Rossignol JF. Nitazoxanide in the treatment of acquired immune deficiency syndrome-related cryptosporidiosis: results of the United States compassionate use program in 365 patients. Aliment Pharmacol Ther 2006; 24:887. 

4. Holmberg SD, Moorman AC, Von Bargen JC, et al. Possible effectiveness of clarithromycin and rifabutin for cryptosporidiosis chemoprophylaxis in HIV disease. HIV Outpatient Study (HOPS) Investigators. JAMA 1998; 279:384.

Thursday, September 21, 2017

Q: 28 year old male with previous history of ulcerative colitis is admitted to ICU with exacerbation of his disease upto fulminant level. Radiological workup showed colonic dilatation of 5.5 cm. Beside regular management with IVF, NPO, naso-gastric tube decompression, antibiotics, steroids and surgical evaluation - which one simple non-pharmacological maneuver at bedside may help?


 Answer: Intermittent rolling maneuvers every couple of hours or the knee-elbow position may help to redistribute gas in the colon and may help in promoting decompression.



References:


1. Present DH, Wolfson D, Gelernt IM, et al. Medical decompression of toxic megacolon by "rolling". A new technique of decompression with favorable long-term follow-up. J Clin Gastroenterol 1988; 10:485. 

2. Panos MZ, Wood MJ, Asquith P. Toxic megacolon: the knee-elbow position relieves bowel distension. Gut 1993; 34:1726.

Wednesday, September 20, 2017

Q; Which laboratory triad is highly suspicious and virtually diagnostic of Hantavirus?


Answer: 
  • Thrombocytopenia
  • a left-shifted granulocytic series
  • an immunoblast abundance that exceeds 10 percent of the total lymphoid series
In cases, where suspicion of Hantavirus is high due to history of exposure, above triad is virtually diagnostic. Moreover, it carries an extremely significant herald of probable life-threatening Hantavirus Cardiopulmonary Syndrome. It warrants transfer to a tertiary care center where Extracorporeal Membrane Oxygenation (ECMO) is available.


References:

1. Koster F, Foucar K, Hjelle B, et al. Rapid presumptive diagnosis of hantavirus cardiopulmonary syndrome by peripheral blood smear review. Am J Clin Pathol 2001; 116:665. 

2. Moolenaar RL, Dalton C, Lipman HB, et al. Clinical features that differentiate hantavirus pulmonary syndrome from three other acute respiratory illnesses. Clin Infect Dis 1995; 21:643.

Tuesday, September 19, 2017

Q: All of the following are the Predictive scoring systems in the intensive care unit except? 

A) Acute Physiologic and Chronic Health Evaluation (APACHE) 
B) Simplified Acute Physiologic Score (SAPS) 
C) Mortality Prediction Model (MPM0)
D) Sepsis-related (or Sequential) Organ Failure Assessment (SOFA)
E) CURB 65


Answer:  E

One imp
ortant and often misunderstood point to know regarding predictive scoring systems in ICU is that they are measures of disease severity that are used to predict outcomes (or mortality) of patient populations. They are not a great tool to predict outcomes in a single patient.

First four (choices A,B,C and D) are well validated  ICU predictive scoring systems.

CURB 65 is a  validated scoring to predict mortality in community-acquired pneumonia.


Recommended reading:

Scoring systems in the intensive care unit: A compendium-Rapsang AG, Shyam DC. Scoring systems in the intensive care unit: A compendium. Indian Journal of Critical Care Medicine :. 2014;18(4):220-228.

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033855/

Monday, September 18, 2017

Q: Which of the following is usually not a dominant feature in amebiasis?

A) bloody stool
B) fecal leukocytes
C) Abdominal pain
D) Fever
E) Liver abscess


Answer: B

Amebiasis destroy leukocytes. In suspected cases, depending on clinical history,  the presence of bloody diarrhea in the absence of fecal leukocytes is suggestive of amebiasis. Though, this is not always true but guide towards the probable cause. Fecal leukocytes (and presence of their density) signifies an invasive pathogen, and usually very true for Salmonella or Shigella. 

Few or no leukocytes but many erythrocytes suggests amebiasis. 



Reference:

Pickering LK, DuPont HL, Olarte J, et al: Fecal leukocytes in enteric infections. Am J Clin Pathol 1977;68:562-565

Sunday, September 17, 2017

Q: 44 year old male, recently migrated from a developing country is admitted to ICU with 'sepsis kind of picture', hypotension, fever, cough and low grade fever. CXR showed cavitary lesion at right upper lobe. Interferon-gamma release assays (IGRAs) is ordered by an on-call resident, which is reported negative now. Negative IGRAs rule out the active tuberculosis (TB). 

A) True
B) False


Answer: False

IGRAs is still a controversial test and has raised many eyebrows of experts as it has 'issues' with reproducibility in  labs, and require many perfect technical parameters. IGRAs can be a good diagnostic tools for latent tuberculosis infection (LTBI). But, it cannot distinguish between latent infection and active tuberculosis (TB).


A positive IGRA result may not necessarily indicate active TB, and a negative IGRA result may not rule out active TB.


References:

1. Menzies D, Pai M, Comstock G. Meta-analysis: new tests for the diagnosis of latent tuberculosis infection: areas of uncertainty and recommendations for research. Ann Intern Med 2007; 146:340.

2. Metcalfe JZ, Everett CK, Steingart KR, et al. Interferon-γ release assays for active pulmonary tuberculosis diagnosis in adults in low- and middle-income countries: systematic review and meta-analysis. J Infect Dis 2011; 204 Suppl 4:S1120.

3. Mazurek GH, Jereb J, Vernon A, et al. Updated guidelines for using Interferon Gamma Release Assays to detect Mycobacterium tuberculosis infection - United States, 2010. 

4. MMWR Recomm Rep 2010; 59:1. 2. Sester M, Sotgiu G, Lange C, et al. Interferon-γ release assays for the diagnosis of active tuberculosis: a systematic review and meta-analysis. Eur Respir J 2011; 37:100.


Saturday, September 16, 2017

Q: All of the following are symptoms of lung abscess(es) except

A) fever
B) shaking chills
C) sour-tasting sputum
D) night sweats
E) weight loss


Answer: B

As lung abscess(es) develop over the period of time, rigors (shaking chills) is usually absent as a clinical symptom.


Reference:

Clinical conferences at the Johns Hopkins Hospital: lung abscess. Johns Hopkins Med J 1982; 150:141.