Sunday, February 19, 2017

Q; Which of the following part of the gastrointestinal tract is more prone to stress ulceration in first few days of ICU admission?

A) Fundus and body of the stomach
B) Antrum
C) Duodenum
D) Distal esophagus
E) Colon


Answer:  

Stress ulceration in first few days of ICU admissions tends to occur in the proximal regions of the stomach. But, stress ulcerations that develop later during the intensive care hospitalization tend to be more distal and deeper.



References: 

1.  Shuman RB, Schuster DP, Zuckerman GR. Prophylactic therapy for stress ulcer bleeding: a reappraisal. Ann Intern Med 1987; 106:562. 

2. Cook DJ, Griffith LE, Walter SD, et al. The attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Crit Care 2001; 5:368. 

3. DePriest JL. Stress ulcer prophylaxis. Do critically ill patients need it? Postgrad Med 1995; 98:159. 

4. Terdiman JP, Ostroff JW. Gastrointestinal bleeding in the hospitalized patient: a case-control study to assess risk factors, causes, and outcome. Am J Med 1998; 104:349.

Saturday, February 18, 2017

Q; Intra Aortic Balloon Pump (IABP) decreases afterload via

A) a vacuum effect
B) Increasing blood supply to mesenteric vessels
C) Inflating Aortic diameter
D) Increasing blood supply to carotid arteries
E) Increasing blood supply to Right subclavian artery


Answer: 

Basic principles of IABP are unchanged since its clinical introduction. Two major effects of IABP are

1.  During inflation of IABP in diastole of heart cycle, blood is displaced to the proximal aorta 
2.   During deflation of IABP in systole of heart cycle, aortic volume, i.e afterload reduction occurs via a vacuum effect (created by rapid balloon deflation).



 Reference: 

 Weber KT, Janicki JS. Intraaortic balloon counterpulsation. A review of physiological principles, clinical results, and device safety. Ann Thorac Surg 1974; 17:602.

Friday, February 17, 2017

Q: When all measures fail in acute exacerbation of idiopathic Pulmonary Fibrosis (AE-IPF), lung transplant should be pursue aggressively as a last resort of salvage therapy..

A) True
B) False


Answer: B

Lung transplantation in IPF has sown good outcome only if its done as an elective process. It should not pursue as a salvage therapy in AE-IPF. It carries a very high mortality rate. Lately, some centers are using extracorporeal membrane oxygenation (ECMO) as a bridge to transplant (BTT) in AE-IPF, but data is still very thin. Ideally, all patients with IPF should undergo transplant evaluation while they are clinically at their baseline.


Reference: 

 Yusen RD, Edwards LB, Kucheryavaya AY, et al. The Registry of the International Society for Heart and Lung Transplantation: Thirty-second Official Adult Lung and Heart-Lung Transplantation Report--2015; Focus Theme: Early Graft Failure. J Heart Lung Transplant 2015; 34:1264.

Thursday, February 16, 2017

Q: What is Phlebosclerotic colitis?


Answer: Phlebosclerotic colitis is a  form of ischemic colitis that results from venous obstruction, usually involving right side of the colon. It is hallmarked by fibrotic sclerosis and calcification of the walls of the mesenteric veins. It can be diagnosed or at least suspected on plain films (KUB), if linear calcifications are seen in the region of the right colon. Diagnosis can be confirmed by CT scan, with colonic wall thickening and mesenteric venous calcifications. This is usually self-limiting and resolve spontaneously, only requiring supportive treatment.


Reference:

Jan YT, Yang FS. Phlebosclerotic colitis. J Am Coll Surg 2008; 207:785.

Wednesday, February 15, 2017

Q: How lupus and antiphospholipid syndrome (APS) can be differentiated from Heparin Induced Thrombocytopenia (HIT)?


Answer: 

1. Lupus usually causes only mild thrombocytopenia and  almost never drops platelet count below  50,000/microL. Moreover, lupus-associated antiplatelet antibodies do not activate platelets and do not cause thrombosis.

2. APS,  like HIT can cause arterial and venous thrombosis but can be differentiated  from HIT
  • by interaction of APS antibodies with phospholipids i.e cardiolipin and ß2-GP-I
  • prolongation of the aPTT
  • Platelet count almost never dropping below 50,000/microL

Tuesday, February 14, 2017

Q: Calculation of Pulmonary vascular resistance requires all of the followings except?

A) Central Venous Pressure (CVP)
B) Mean Pulmonary Artery Pressure (mean Pap)
C) Pulmonary capillary wedge pressure (PCWP)
D) Cardiac Output (CO)
E) Constant 80


Answer: A

Formulae for Systemic vascular resistance (SVR) and Pulmonary vascular resistance (PVR) is almost same except as SVR represent systemic circulation, it takes into account of CVP and MAP (Mean arterial Pressure). And, as PVR represents only pulmonary circulation, it takes into account of PCWP and mean-Pap instead of CVP and MAP respectively.

SVR = 80x [MAP – CVP]/CO)

PVR = 80 x [mean Pap – PCWP]/CO)

Monday, February 13, 2017

Q: Cirrhotic cardiomyopathy is usually due to

A) Secondary to underlying ETOH abuse
B) Itself is a primary disease
C) Due to hypoalbunemia of cirrhosis 
D) Due to frequent sepsis in cirrhosis
E) Due to Budd-Chiari Syndrome


Answer: 

 Cirrhotic cardiomyopathy is an independent disease found in cirrhosis. It is different from alcoholic cardiomyopathy. It is least understood of all cardiomyopathies. It is kind of a diagnosis of exclusion manifested as impaired contractile responsiveness to stress and/or diastolic dysfunction. Electrical abnormalities include QT interval prolongation, electrical and mechanical dyssynchrony, and chronotropic incompetence. One of the hallmark is the dilated left atrium but normal LV cavity size in most cases.



References: 

1.  Milani A, Zaccaria R, Bombardieri G, et al. Cirrhotic cardiomyopathy. Dig Liver Dis 2007; 39:507. 

2. Møller S, Henriksen JH. Cirrhotic cardiomyopathy. J Hepatol 2010; 53:179. 

3. Zardi EM, Abbate A, Zardi DM, et al. Cirrhotic cardiomyopathy. J Am Coll Cardiol 2010; 56:539.

4. Timoh T, Protano MA, Wagman G, et al. A perspective on cirrhotic cardiomyopathy. Transplant Proc 2011; 43:1649.

Sunday, February 12, 2017

TTM in TH

Q; Recently for Therapeutic Hypothermia, 36°C for 24 hours has been recommended for otherwise non-complicated patient in coma after cardiac arrest. In which situations still lower temperature at 33°C for 24 hours is recommended?

Answer:  Studies have shown similar outcomes in non-complicated patients with either 36°C or 33°C for 24 hours. 

36°C is sufficient for patients 
  • in coma but still, exhibit some motor response, 
  • no malignant EEG patterns,  
  • no cerebral edema 
Otherwise 32°C to 34°C should be applied for patients 
  • in deep coma
  • EEG c/w seizure
  • cerebral edema

References:

1. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33°C versus 36°C after cardiac arrest. N Engl J Med 2013; 369:2197.

2. Arrich J, Holzer M, Havel C, et al. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database Syst Rev 2016; 2:CD004128.

Saturday, February 11, 2017

Mayo Clinic criteria for Takotsubo cardiomyopathy

Q: Diagnosis of Takotsubo cardiomyopathy (broken-heart syndrome) includes all of the following except?

A) Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture
B) Regional wall motion abnormalities typically in a single coronary distribution
C) Presence of EKG abnormalities
D) Troponin elevation
E) Absence of pheochromocytoma or myocarditis.


Answer:  B

Mayo Clinic diagnostic criteria 1 requires all of the following four criteria for the diagnosis
  1. Transient left ventricular systolic (LV) dysfunction, which is typically regional and extend beyond a single epicardial coronary distribution*
  2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture^
  3.  New EKG abnormalities (e.g ST elevation or T wave inversion) or some elevation in cardiac troponin. 
  4. Absence of pheochromocytoma or myocarditis.

*rare exceptions within one coronary distribution and the global type have been reported.
^ If coronary disease is found, the diagnosis of stress cardiomyopathy can still be made if the wall motion abnormalities are not in the distribution of the coronary disease 2



References:


1. 
Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008; 155:408. 

2. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929.

Friday, February 10, 2017

Q: What is the half-life of transfused cryoprecipitate?

Answer:  Half-life of transfused cryoprecipitate is about two to four days.

Fresh-Frozen -Plasma is thawed at 4°C for about 24 hours, which makes precipitates of cold-insoluble proteins, which are very rich in blood coagulation factors. This product can be kept frozen at -18°C for about one year to use for clinical transfusions. After transfusion, it is effective for about 2-4 days.

Thursday, February 9, 2017

BNP and MR

Q: What is the clinical significance of  Brain Natriuretic Peptide (BNP) in Mitral Regurgitation (MR)?


Answer:   Unlike exacerbation of congestive heart failure (CHF), BNP in MR is more of prognostic value and reflection of the clinical outcomes rather than the severity of MR. Interestingly, it is an independent predictive value of mortality with adjustment to all other risk factors including low ejection fraction.

To be of surprise, serum BNP level just more than 31 pg/mL predicts lower five-year survival. Moreover, it also predicts poor outcomes after mitral valve surgery.


Reference:

1. Magne J, Mahjoub H, Pierard LA, et al. Prognostic importance of brain natriuretic peptide and left ventricular longitudinal function in asymptomatic degenerative mitral regurgitation. Heart 2012; 98:584. 

2. Hwang IC, Kim YJ, Kim KH, et al. Prognostic value of B-type natriuretic peptide in patients with chronic mitral regurgitation undergoing surgery: mid-term follow-up results. Eur J Cardiothorac Surg 2013; 43:e1. 

3. Perreas K, Samanidis G, Dimitriou S, et al. NT-proBNP in the mitral valve surgery. Crit Pathw Cardiol 2014; 13:55.

Wednesday, February 8, 2017

Q: What is the most common site of wall usually involved in the dissection of ascending aorta?



Answer: The most common site of wall usually involved in the dissection of ascending aorta is the right lateral wall.


Reference:

Larson EW, Edwards WD. Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol 1984; 53:849.

Tuesday, February 7, 2017

Q: Foley catheter balloon should be inflated with (select one)

A) Sterile water 
B) Normal Saline 


Answer: Sterile water

Foley catheter balloon should be inflated with sterile water (after urine flow is confirmed). Normal Saline should never be used to inflate the Foley catheter balloon because it may cause crystal formation, obstruct the balloon channel and later prevent the deflation of balloon.



Reference:


Daneshmand S, Youssefzadeh D, Skinner EC. Review of techniques to remove a Foley catheter when the balloon does not deflate. Urology 2002; 59:127.

Monday, February 6, 2017

Hypoxia in drowning

Q: What is the recommended oxygen saturation in a post drowning patient? 

 A) 88% 
B) 90% 
C) 92% 
D) 94% 
E) 100%

Answer: D (94%)

In post drowning patients higher than normal pulse-ox saturation or PO2 (60 mmHg) is recommended as tissue hypoxia is the major cause of the fatality. While managing hypoxia in post drowning patient, at least three points should be kept in mind

  • There should be a low threshold for intubation and beside hypoxia, even mild to moderate hypercarbia requires intubation at PCO2 50 mmHg (some even suggests more than 45 mm Hg)
  • In comparison to other patients, the orogastric tube is almost mandatory in post drowning patients as gastric distension may hamper ventilation.
  • Positive pressure ventilation (PPV) with higher PEEP is recommended but it comes with its own price in post drowning patients, as the line of demarcation between hypotension due to PPV and therapeutic oxygenation is very thin, and requires particular monitoring post intubation.


Reference:

Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology 2009; 110:1390.

Sunday, February 5, 2017

Q; In patients with a history of alcohol abuse which three vitamins required to be replaced on relatively urgent basis after admission?

Answer:
  • Thiamine 100 mg daily, 
  • Vitamin B6 2 mg daily, and 
  • Folic acid 1 mg daily
Another difference between other patients and patients with ETOH abuse is, they require frequent feedings, with the goal of an energy intake of 35 to 40 kcal/kg of body weight/day and protein intake of 1.2 to 1.5 g/kg of body weight/day.


Reference: 

The European Society for Clinical Nutrition and Metabolism (ESPEN). ESPEN Guidelines. http://www.espen.org/espenguidelines.html 

Saturday, February 4, 2017

Q: In patients with Aplastic Anemia transfusions should only be given from close family members?

A) True 
B) False

Answer: B (False)

Ideally, patients with Aplastic Anemia should not receive blood product transfusions from a sibling or a family member, to minimize the risk of an immune reaction to donor antigens, as in the case of Hematopoietic Cell Transplantation (HCT), which may lead to graft failure.

Friday, February 3, 2017

Q: In otherwise routine cases, which part of the kidney is usually targeted for biopsy?



Answer: Lower pole

Kidney Biopsy is usually performed with patient in prone position with pillow underneath, and under ultrasound. The lower pole is targeted  as it minimize the chances of hitting any major vessel.




References:


1. Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002; 22:254.


2. Whittier WL, Korbet SM. Renal biopsy: update. Curr Opin Nephrol Hypertens 2004; 13:661.

3.  Korbet SM, Volpini KC, Whittier WL. Percutaneous renal biopsy of native kidneys: a single-center experience of 1,055 biopsies. Am J Nephrol 2014; 39:153.

5. Shidham GB, Siddiqi N, Beres JA, et al. Clinical risk factors associated with bleeding after native kidney biopsy. Nephrology (Carlton) 2005; 10:305.

6. Wiseman DA, Hawkins R, Numerow LM, Taub KJ. Percutaneous renal biopsy utilizing real time, ultrasonic guidance and a semiautomated biopsy device. Kidney Int 1990; 38:347.

Thursday, February 2, 2017

Q: How far cuff of endotracheal tube should be placed to prevent vocal cord palsy?


Answer:  At least 15 mm below the vocal cords

Vocal cord palsy is an undesired, though rare  but a serious complication of endotracheal intubation. The anterior branch of recurrent laryngeal nerve traverses between the lamina of thyroid cartilage and laryngeal mucosa. Overinflated cuff of ET-Tube may compress to cause vocal cord paralysis. First 10 mm of the area below vocal cord is most sensitive for damage. Ideally, ET-tube cuff should be at least at 15 mm below the vocal cords.



Reference: 

Benumof JL, Saidman J, editors. 2nd ed. London: Mosby; 1999. Anesthesia and Perioperative Complications; p. 9.

Wednesday, February 1, 2017

Q: What one advantage urinary trypsinogen activation peptide (TAP) has over amylase and lipase in acute pancreatitis? 

Answer: Trypsinogen activation peptide (TAP) is a five amino-acid peptide elevated in acute pancreatitis. It is cleaved from trypsinogen to become active trypsin. Though it may only be of academic interest but it is one of the earliest marker of acute pancreatitis, as well as it co-relates with severity of acute pancreatitis.


References: 

1. Tenner S, Fernandez-del Castillo C, Warshaw A, et al. Urinary trypsinogen activation peptide (TAP) predicts severity in patients with acute pancreatitis. Int J Pancreatol 1997; 21:105. 

2. Khan Z, Vlodov J, Horovitz J, et al. Urinary trypsinogen activation peptide is more accurate than hematocrit in determining severity in patients with acute pancreatitis: a prospective study. Am J Gastroenterol 2002; 97:1973.

Tuesday, January 31, 2017

Q: All of the following are causes of Antithrombin (AT) deficiency except?

A)  Liver cirrhosis
B) Nephrotic syndromes 
C) Extracorporeal membrane oxygenation (ECMO) 
D) Hemodialysis 
E) Normal pregnancy


Answer: E

Objective of above question is to highlight the fact that patients on ECMO and HD may have lower AT deficiency. This may be related to cannula itself. As these patients, while in ICU frequently requires heparin, deficiency of AT may cause ineffective anticoagulation. In such scenarios administration of AT may be required. Normal pregnancy does not cause any AT deficiency but may be present in preeclampsia or eclampsia.


Cirrhosis and Nephrotic syndrome are understandably the causes of AT deficiency.  


References:

1. Alegre A, Vicente V, Gonzalez R, Alberca I. Effect of hemodialysis on protein C levels. Nephron 1987; 46:386. 

2. Weenink GH, Treffers PE, Vijn P, et al. Antithrombin III levels in preeclampsia correlate with maternal and fetal morbidity. Am J Obstet Gynecol 1984; 148:1092.

Monday, January 30, 2017

Q: What is one simple (and probably only) advantage of impedance plethysmography over compression ultrasonography in the diagnosis and follow-up of Deep Venous Thrombosis (DVT)?


Answer:  Impedance plethysmography normalizes relatively more quickly after a previous episode of DVT, and can be more helpful in patients with recurrent DVT or in the follow-up of present DVT.



Reference:

1. Huisman MV, Büller HR, ten Cate JW. Utility of impedance plethysmography in the diagnosis of recurrent deep-vein thrombosis. Arch Intern Med 1988; 148:681.


Sunday, January 29, 2017

Q; Which one precaution should be taken while administrating lidocaine as local anesthetic during talc procedure for pleurodesis?


Answer:  Talc slurry may get adsorp to lidocaine, so it should be administer a few minutes before the talc slurry administration. Lidocaine is usually given as a spray of 25 mL (250 mg) of 1 percent lidocaine intrapleurally. Beside lidocaine, patient should also receive intravenous analgesic and midazolam for comfort.


Reference:  


 Lee P, Colt HG. A spray catheter technique for pleural anesthesia: a novel method for pain control before talc poudrage. Anesth Analg 2007; 104:198.

Saturday, January 28, 2017

Q: Which of the following found to be having some role in treatment of hepatic encephelopathy

A) Methadone
B) Flumazenil
C) Naloxone
D) Fomepizole
E) ETOH


Answer:  B

There is some evidence of an increase in benzodiazepine receptor ligands in patients with hepatic encephalopathy, so multiple attempts have been made to use benzodiazepine receptor antagonists to treat hepatic encephalopathy with various levels of success. But still evidence is far from enough to label it as a strong agent for use as a standard of treatment. It may be used in acute situations to buy some time and/or as temporizing measure for two to four hours. On positive note, those patients who respond to flumazenil usually have a favorable prognosis. 


References:


1.  Basile AS, Harrison PM, Hughes RD, et al. Relationship between plasma benzodiazepine receptor ligand concentrations and severity of hepatic encephalopathy. Hepatology 1994; 19:112. 

2. Gyr K, Meier R, Häussler J, et al. Evaluation of the efficacy and safety of flumazenil in the treatment of portal systemic encephalopathy: a double blind, randomised, placebo controlled multicentre study. Gut 1996; 39:319. 

3. Cadranel JF, el Younsi M, Pidoux B, et al. Flumazenil therapy for hepatic encephalopathy in cirrhotic patients: a double-blind pragmatic randomized, placebo study. Eur J Gastroenterol Hepatol 1995; 7:325. 

4. Pomier-Layrargues G, Giguère JF, Lavoie J, et al. Flumazenil in cirrhotic patients in hepatic coma: a randomized double-blind placebo-controlled crossover trial. Hepatology 1994; 19:32. 

5. Als-Nielsen B, Kjaergard LL, Gluud C. Benzodiazepine receptor antagonists for acute and chronic hepatic encephalopathy. Cochrane Database Syst Rev 2001; :CD002798. 

6. Goulenok C, Bernard B, Cadranel JF, et al. Flumazenil vs. placebo in hepatic encephalopathy in patients with cirrhosis: a meta-analysis. Aliment Pharmacol Ther 2002; 16:361.

Friday, January 27, 2017

Q; In recent years prophylaxis for infective endocarditis has been curtailed down significantly  prior to various dental, urologic, gastrointestinal and invasive procedures. What is the reason behind it?

Answer:  In experimental animals as well as long term studies have shown that it is almost impossible to induce/have endocarditis unless the valvular endocardium is first damaged. Endocardial injury is the 101 requisite to develop infective endocarditis. Without any previous history of endocarditis or evidence of congenital or acquired endocardial lesions, prophylaxis is usually not recommended.

Please refer elsewhere to see guidelines from various societies in this regard.

Thursday, January 26, 2017

Q: Why auscultation of heart is an important component in the evaluation of hemoptysis?


Answer: To rule out mitral stenosis or mitral regurgitation as a cause of hemoptysis

Though not high on the list, but the presence of murmur of mitral valve should raise the possibility of the cardiac source of hemoptysis. This can be supplemented with echocardiography and evaluation of upper lobes of lungs via radiological workup.


References and further readings:

1. Ramsey HW, de la Torre A, Bartley T, et al: Intractable hemoptysis in mitral stenosis. Ann Intern Med 1967; 67:588-593

2. P. A. Schnyder, A. M. Sarraj, B. E. Duvoisin, L. Kapenberger, and M. J.-M. Landry, “Pulmonary edema associated with mitral regurgitation: prevalence of predominant involvement of the right upper lobe,” The American Journal of Roentgenology, vol. 161, no. 1, pp. 33–36, 1993.

3. H. W. Ramsey, A. de la Torre, T. D. Bartley, and J. W. Linhart, “Intractable hemoptysis in mitral stenosis treated by emergency mitral commissurotomy,” Annals of Internal Medicine, vol. 67, no. 3, pp. 588–593, 1967.

4. T. H. Spence and J. C. Connors, “Diffuse alveolar hemorrhage syndrome due to “silent” mitral valve regurgitation,” Southern Medical Journal, vol. 93, no. 1, pp. 65–67, 2000.

5. K. Woolley and P. Stark, “Pulmonary parenchymal manifestations of mitral valve disease,” Radiographics, vol. 19, no. 4, pp. 965–972, 1999.

 6. A. W.-T. Yeung, H. P. Shum, G. S.-M. Lam, K. K.-C. Chan, S. K. Li, and W. W. Yan, “Diffuse alveolar hemorrhage and intravascular hemolysis due to acute mitral valve regurgitation,” Critical Care and Shock, vol. 16, no. 1, pp. 3–7, 2013.

7. U. Kim HG, D. H. Kim, S. H. Lee et al., “Diffuse alveolar hemorrhage due to acute mitral regurgitation,” Journal of Cardiovascular Ultrasound, vol. 15, no. 1, pp. 16–18, 2007.

8. J. M. Roach, K. C. Stajduhar, and K. G. Torrington, “Right upper lobe pulmonary edema caused by acute mitral regurgitation: diagnosis by transesophageal echocardiography,” Chest, vol. 103, no. 4, pp. 1286–1288, 1993.

Wednesday, January 25, 2017

Q: Hemodynamic management at bedside may be combined by doing Passive-Leg-Raising (PLR) test and observing change in End-tidal-CO2 - (EtCO2)

PLR test will

A) Increase the EtCO2
B) decrease  the EtCO2
C) Either increase or decrease in ETCO2 predicts hypovolemia
D) It need to be read by obtaining full Arterial Blood Gas (ABG) at same time
E) It is not possible to combine upper two entities


Answer: A

Though there is not a huge data available but at least one study has shown that if PLR testing increase the EtCO2 by five percent, it predicts a fluid-induced increase in Cardiac Index (CI)  with lesser sensitivity (71%) but 100% specificity.


Reference:

Monnet X, Bataille A, Magalhaes E, Barrois J, Le Corre M, Gosset C, Guerin L, Richard C, Teboul JL. End-tidal carbon dioxide is better than arterial pressure for predicting volume responsiveness by the passive leg raising test. Intensive Care Med. 2013 Jan;39(1):93-100

Tuesday, January 24, 2017

A note on Diuretics and Thiamine deficiency

A very under-appreciated cause of thiamine deficiency is use of diuretics as well as any polyuria in ICU, and/or accompanied by poor nutrition. Loss of thiamine via diarrhea, dialysis and vomiting is well known but in ICU setting loss via diuretics become a significant factor. Polyuria for any reason may cause thiamine deficiency, and should be supplemented. CHF patients who are on chronic diuretic therapy are particularly prone to thiamine deficiency.


References:

1. Wooley, JA. Characteristics of thiamin and its relevance to the management of heart failure. Nutr Clin Pract. Oct-Nov 2008. 23:487-93. 

2. Sica DA. Loop diuretic therapy, thiamine balance, and heart failure. Congest Heart Fail. 2007 Jul-Aug. 13(4):244-7.

3. Hanninen SA, Darling PB, Sole MJ, et al. The prevalence of thiamin deficiency in hospitalized patients with congestive heart failure. J Am Coll Cardiol. 2006 Jan 17. 47(2):354-61.

Monday, January 23, 2017

Q: Patients with chron disease are prone to which of the following complications in hospital (select one)

A) Pulmonary Embolism
B) Acute MI
C) Intracranial bleed
D) Upper GI bleed
E) Acute liver failure


Answer: A

Patients with inflammatory bowel disease (IBD) are more prone to venous thromboembolism as well as pulmonary embolism. It is of critical importance that patients with acute exacerbation of IBD in hospitals should not miss DVT prophylaxis.



References:

1. Miehsler W, Reinisch W, Valic E, et al. Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut 2004; 53:542. 

2. Nguyen GC, Sam J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. Am J Gastroenterol 2008; 103:2272. 


Sunday, January 22, 2017

Q: All of the following are recommended to pursue during acute exacerbation of Idiopathic Pulmonary Fibrosis (AE-IPF) except?

A)  High-flow oxygen

B) Anti-acid/reflux treatment
C) Invasive mechanical ventilation
D) Broad spectrum antibiotic 
E) High dose steroids


Answer: C

 Invasive mechanial ventilation has an extremely high mortality in acute execerbation of IPF, and should be pursue only if patient or family insist despite full discussion and disclosure of potential harm, and high probaility of its failure as a salvage therapy.

Choice B may look surprising but reflux has been described as a possible cause of AE-IPF.


References:

1. Gaudry S, Vincent F, Rabbat A, et al. Invasive mechanical ventilation in patients with fibrosing interstitial pneumonia. J Thorac Cardiovasc Surg 2014; 147:47. 

2. Mallick S. Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care unit. Respir Med 2008; 102:1355. 

3. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med 2011; 183:788.

4. Lee JS, Collard HR, Anstrom KJ, et al. Anti-acid treatment and disease progression in idiopathic pulmonary fibrosis: an analysis of data from three randomised controlled trials. Lancet Respir Med 2013; 1:369.

Saturday, January 21, 2017

Q: One unit of cryoprecipitate (cryo) raises the fibrinogen level by how much?


Answer: Plasma fibrinogen level rise by approximately 7 to 10 mg/dL, with each unit of cryo transfusion. The usual formula to calculate the requirement of cryo is 1 unit of cryo per 10 kg of body weight. In massive surgical bleed, it should be calculated as 1 unit per 5 kg of body weight. One unit of cryo is about 10 to 15 mL in volume and is obtained from one unit of whole blood, and is about 200 to 400 mg in each unit of cryo.

Friday, January 20, 2017

Q: All of the following are risk factors for re-intubation except?

A) weak cough strength
B) requiring frequent suctioning
C) a rapid shallow breathing index (RSBI) more than 58 breaths/min per L, 
D) a negative fluid balance during the 24 hours preceding extubation, 
E) Intubation secondary to pneumonia 


Answer: D

Below 15 percent of failed planned extubations is a acceptable number for any ICU. There are many factors which may lead to failure of planned extubation including choice A, B and C.

Choice C is interesting as conventional teaching is RSBI less than 100 breaths/min per L is acceptable. It is true in most situations but risk of extubation failure start to rise once it goes above 58 breaths/min per L 2. It is actually a positive fluid balance particularly in preceding 24 hours which may be a problem. Also, patient's baseline cardiopulmonary health plays an important role in success of extubation.



References: 

1.  Frutos-Vivar F, Ferguson ND, Esteban A, et al. Risk factors for extubation failure in patients following a successful spontaneous breathing trial. Chest 2006; 130:1664. 

2. Thille AW, Harrois A, Schortgen F, et al. Outcomes of extubation failure in medical intensive care unit patients. Crit Care Med 2011; 39:2612.

3. Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study. JAMA 2002; 287:345.

Wednesday, January 18, 2017

Q: Harvey-Bradshaw Index (HBI) is a grading system for the severity of which disease? 

A) Crohn Disease

B) Ulcerative Colitis
C) Acute appendicitis
D) Acute Peritonitis
E) Diverticulitis

Answer: A


Crohn's Disease Activity Index (CDAI) is a commonly used grading system to measure the severity of Crohn disease. Harvey-Bradshaw Index (HBI) is created as a simplified version of CDAI.



0-149 points: Asymptomatic remission
150-220 points: Mildly to moderately active Crohn's disease
221-450 points: Moderately to severely active Crohn's disease
451-1100 points: Severely active to fulminant disease


A Harvey-Bradshaw Index of less than 5 correlates with clinical remission.


References:

1. Harvey RF, Bradshaw JM. A simple index of Crohn's disease activity. Lancet. 1980 Mar 8;1(8167):514.

2. Best WR. Predicting the Crohn's disease activity index from the Harvey-Bradshaw Index. Inflamm Bowel Dis. 2006 Apr;12(4):304-10. 

3. Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn's disease activity index. National Cooperative Crohn's Disease Study. Gastroenterology. 1976 Mar;70(3):439-44.