Tuesday March 16, 2010
Q: Name at least 3 general conditions beside genetic increased plasma cholinesterase activity which may prolong succinylcholine action?
Answer:
1. Metoclopramide (Reglan) - which may prolong succinylcholine action due to effects on pseudocholinesterase.
2. Obesity - may cause resistance to succinylcholine due to more plasma cholinesterase activity.
3. In myasthenia gravis - due to reduced number of nicotinic, neuromuscular junctional receptors which is the target for the drug succinylcholine.
Tuesday, March 16, 2010
Monday, March 15, 2010
Monday March 15, 2010
Unusual course (sling) of left pulmonary artery
Pulmonary artery sling is a rare condition in which the left pulmonary artery anomalously originates from a normally positioned right pulmonary artery. The left pulmonary artery then progresses posteriorly over the right main bronchus near its origin from the trachea, traverses between the trachea and the esophagus and enters the left hilum. Symptoms include cyanosis, dyspnoea and apnoeic spells. It is almost always fatal and usually requires surgical intervention. Mostly it is diagnosed in childhood and rarely it is asymptomatic and is detected incidentally in asymptomatic adults in whom it can mimic a mediastinal adenopathy.
Unusual course (sling) of left pulmonary artery
Pulmonary artery sling is a rare condition in which the left pulmonary artery anomalously originates from a normally positioned right pulmonary artery. The left pulmonary artery then progresses posteriorly over the right main bronchus near its origin from the trachea, traverses between the trachea and the esophagus and enters the left hilum. Symptoms include cyanosis, dyspnoea and apnoeic spells. It is almost always fatal and usually requires surgical intervention. Mostly it is diagnosed in childhood and rarely it is asymptomatic and is detected incidentally in asymptomatic adults in whom it can mimic a mediastinal adenopathy.
Sunday, March 14, 2010
Sunday March 14, 2010
Q: What is “oxygen saturation gap”?
Answer: The “oxygen saturation gap” is the difference between the calculated oxygen saturation from a standard blood gas machine and the reading from a pulse oximeter. If it is greater than 5%, the patient’s hemoglobin may be abnormal, representing carbon monoxide poisoning, methemoglobinemia, or sulfhemoglobinemia.
Q: What is “oxygen saturation gap”?
Answer: The “oxygen saturation gap” is the difference between the calculated oxygen saturation from a standard blood gas machine and the reading from a pulse oximeter. If it is greater than 5%, the patient’s hemoglobin may be abnormal, representing carbon monoxide poisoning, methemoglobinemia, or sulfhemoglobinemia.
Saturday, March 13, 2010
Saturday March 13, 2010
Picture Diagnosis
Picture Diagnosis
Answer: Pseudomembranous colitis
Above is the endoscopic visualization of pseudomembranous colitis, a characteristic manifestation of full-blown Clostridium difficile colitis. Classic pseudomembranes are visible as raised yellow plaques ranging from 2-10 mm in diameter and scattered over the colorectal mucosa.
Friday, March 12, 2010
Friday March 12, 2010
American Board of Internal Medicine Maintenance of Certification Program
(Poll at NEJM)
"A 55-year-old physician, who graduated from medical school in 1979, completed his internship and junior residency in internal medicine in 1981. He did 3 years of fellowship training in endocrinology, followed by a third year of residency in internal medicine. He then completed and passed the American Board of Internal Medicine (ABIM) qualifying examinations in internal medicine and endocrinology; the ABIM issued to him certificates of unlimited duration, specifying that he held board certification in internal medicine and endocrinology. For the past 24 years, he has been in the practice of general internal medicine with an emphasis on endocrinology. He estimates that about half of his patients see him for endocrine problems exclusively and the remainder see him for issues regarding general internal medicine. He is on the faculty of the medical school from which he graduated, but he spends most of his time caring for patients in an outpatient setting. For 6 months of each year, he has third-year residents, training in internal medicine, shadowing him at his outpatient practice. For one 3-week block each year, he serves as an attending physician on the general medical service of the hospital where he has inpatient privileges, a minor teaching hospital of his medical school at which he trained. During this 3-week period, he has two medical students, two interns, and a senior medical resident under his direct supervision.
He attends the grand rounds lecture series regularly. Once a year, he leaves his practice to attend a weeklong postgraduate course, alternating between internal medicine and general endocrinology. He has never considered enrolling in the maintenance of certification (MOC) program in either internal medicine or endocrinology. His reasoning is that he is up to date in his practice, that he makes frequent use of point-of-care reference services to check on the latest diagnostic or therapeutics practices when he encounters a condition that he does not see frequently, and that the money and time needed to undertake MOC would not be well spent. He has received a communication from the ABIM urging him to undergo the MOC process. He consults you, as a friend and colleague, for advice about what to do.."
Your Vote /Recommendation Click here
(last 1169 people voted with 66% voting against MOC!)
American Board of Internal Medicine Maintenance of Certification Program
(Poll at NEJM)
"A 55-year-old physician, who graduated from medical school in 1979, completed his internship and junior residency in internal medicine in 1981. He did 3 years of fellowship training in endocrinology, followed by a third year of residency in internal medicine. He then completed and passed the American Board of Internal Medicine (ABIM) qualifying examinations in internal medicine and endocrinology; the ABIM issued to him certificates of unlimited duration, specifying that he held board certification in internal medicine and endocrinology. For the past 24 years, he has been in the practice of general internal medicine with an emphasis on endocrinology. He estimates that about half of his patients see him for endocrine problems exclusively and the remainder see him for issues regarding general internal medicine. He is on the faculty of the medical school from which he graduated, but he spends most of his time caring for patients in an outpatient setting. For 6 months of each year, he has third-year residents, training in internal medicine, shadowing him at his outpatient practice. For one 3-week block each year, he serves as an attending physician on the general medical service of the hospital where he has inpatient privileges, a minor teaching hospital of his medical school at which he trained. During this 3-week period, he has two medical students, two interns, and a senior medical resident under his direct supervision.
He attends the grand rounds lecture series regularly. Once a year, he leaves his practice to attend a weeklong postgraduate course, alternating between internal medicine and general endocrinology. He has never considered enrolling in the maintenance of certification (MOC) program in either internal medicine or endocrinology. His reasoning is that he is up to date in his practice, that he makes frequent use of point-of-care reference services to check on the latest diagnostic or therapeutics practices when he encounters a condition that he does not see frequently, and that the money and time needed to undertake MOC would not be well spent. He has received a communication from the ABIM urging him to undergo the MOC process. He consults you, as a friend and colleague, for advice about what to do.."
Your Vote /Recommendation Click here
(last 1169 people voted with 66% voting against MOC!)
Thursday, March 11, 2010
Wednesday, March 10, 2010
Wednesday March 10, 2010
Oxygen Index
Oxygen index (OI) is one of the objective number to measure the severity of ARDS/lung disease. Recently it has been postulated as cutoff point for initiation of ECMO (extracorporeal membrane oxygenation). There has been a significant resistant in the use of ECMO due to various other non-conventional methods available like high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), prone positioning, APRV ventiliation etc. One study 1 showed that OI of 33.2 is a suitable cutoff value for ECMO. Otherwise also it has been said as a better indicator of lung function than P/F ratio
Oxygen Index
Oxygen index (OI) is one of the objective number to measure the severity of ARDS/lung disease. Recently it has been postulated as cutoff point for initiation of ECMO (extracorporeal membrane oxygenation). There has been a significant resistant in the use of ECMO due to various other non-conventional methods available like high-frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), prone positioning, APRV ventiliation etc. One study 1 showed that OI of 33.2 is a suitable cutoff value for ECMO. Otherwise also it has been said as a better indicator of lung function than P/F ratio
Oxygen Index (OI) = FiO2 x MAP x 100
---------------------
PaO2
PaO2
* MAP = Mean Airway pressure
FiO2 is in %
1. Oxygenation index for extracorporeal membrane oxygenation: is there predictive significance? - Journal of Artificial Organs, Volume 10, Number 1, March 2007 , pp. 6-9(4)
Tuesday, March 9, 2010
Tuesday March 9, 2010
Dopamine v. Norepinephrine in Shock
Following pearl is contributed by:
TheAnh Nguyen, PharmD
UT-Austin
ahacorner@yahoo.com
Norepinephrine was as effective and safer than dopamine in a trial of 1,679 patients with shock. Used as first-line vasopressor therapy, the two agents produced these outcomes over the 28 days after randomization.
Dopamine v. Norepinephrine in Shock
Following pearl is contributed by:
TheAnh Nguyen, PharmD
UT-Austin
ahacorner@yahoo.com
Norepinephrine was as effective and safer than dopamine in a trial of 1,679 patients with shock. Used as first-line vasopressor therapy, the two agents produced these outcomes over the 28 days after randomization.
- There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group, P = 0.10)
- There were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P less than 0.001)
- A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1,044 patients with septic shock or the 263 with hypovolemic shock (P = 0.03 for cardiogenic shock, P = 0.19 for septic shock, and P = 0.84 for hypovolemic shock, in Kaplan-Meier analyses)
Mar. 4 issue of the New England Journal of Medicine (2010; 362) - link here
Monday, March 8, 2010
Sunday, March 7, 2010
Sunday March 7, 2010
Q: 26 year old female with recent history of abortion presented with hypotension, fever and severe abdominal pain. OB/Gyn service ordered intravenous urogram. Following abdominal film is obtained?
Answer: Uterine gas gangrene
Anaerobic infections with Clostridium perfringens (CP) occur rarely but are associated with considerable maternal mortality. Targeted antibiotics should be started ASAP. Surgery backup should be called to perform a hysterectomy and necrosis removal. Clostridium perfringens is ubiquitous and is found vaginally in 1 - 10 % of healthy women and usually does not cause a serious infection. Under the right conditions it can cause an endometritis leading to sepsis. Early recognition and interdisciplinary treatment are of extreme importance.
Q: 26 year old female with recent history of abortion presented with hypotension, fever and severe abdominal pain. OB/Gyn service ordered intravenous urogram. Following abdominal film is obtained?
Answer: Uterine gas gangrene
Anaerobic infections with Clostridium perfringens (CP) occur rarely but are associated with considerable maternal mortality. Targeted antibiotics should be started ASAP. Surgery backup should be called to perform a hysterectomy and necrosis removal. Clostridium perfringens is ubiquitous and is found vaginally in 1 - 10 % of healthy women and usually does not cause a serious infection. Under the right conditions it can cause an endometritis leading to sepsis. Early recognition and interdisciplinary treatment are of extreme importance.
Saturday, March 6, 2010
Friday, March 5, 2010
Friday March 5, 2010
TRALI - not very uncommon!
Objectives: To determine the incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of critically ill patients.
Design: In a retrospective cohort study, patients with transfusion-related acute lung injury were identified using the consensus criteria of acute lung injury within 6 hrs after transfusion. Inclusion criterion was a length of intensive care unit admission more than 48 hrs. Patients developing transfusion-related acute lung injury were matched (on age, sex, and admission diagnosis) to transfused control subjects and patients developing acute lung injury from another origin.
Measurements and Main Results:
- Of 5208 admitted patients, 2024 patients had a length of stay more than 48 hrs, of whom 109 were suspected transfusion-related acute lung injury cases.
- Compared with transfused control subjects, risk factors for transfusion-related acute lung injury were emergency cardiac surgery, hematologic malignancy, massive transfusion, sepsis , mechanical ventilation and high Acute Physiology and Chronic Health Evaluation II score
- The volume of platelets and plasma transfused was associated with transfusion-related acute lung injury in the univariate analysis. However, this association disappeared in the multivariate analysis.
- Compared with acute lung injury control subjects, risk factors for transfusion-related acute lung injury were sepsis and high Acute Physiology and Chronic Health Evaluation II score whereas pneumonia was a negative predictive factor.
- Patients with transfusion-related acute lung injury had a longer duration of mechanical ventilation compared with transfused control subjects and acute lung injury control subjects
- Also, 90-day survival of patients with transfusion-related acute lung injury was lower compared with transfused control subjects and acute lung injury control subjects
Conclusions: Transfusion-related acute lung injury is common in critically ill patients. Transfusion-related acute lung injury may contribute to an adverse outcome associated with transfusion. This study identifies transfusion-related acute lung injury risk factors, which may aid in assessing the risks and benefits of transfusion in critically ill patients.
Risk factors and outcome of transfusion-related acute lung injury in the critically ill: A nested case-control study - Critical Care Medicine: March 2010 - Volume 38 - Issue 3 - pp 771-778
Thursday, March 4, 2010
Thursday March 4, 2010
Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty
Study Question: What is the relative safety and feasibility of the transradial versus transfemoral approach for coronary angiography and intervention?
Methods: The authors randomized a total of 1,024 patients undergoing coronary catheterization to the transradial or transfemoral approach. Patients with an abnormal Allen's test, history of CABG, simultaneous right heart catheterization, chronic renal insufficiency, or known difficulties with the radial or femoral access were excluded.
Results:
Conclusions: The use of radial access is associated with an increased procedural duration and radiation exposure, and a marked reduction in vascular complications.
Editors' opinion: The reduction in groin complications and bleeding with the use of a radial approach has been highlighted in multiple studies. However, the increased radiation exposure to the patient and the operator is increasingly being recognized, and may translate into an increased late risk of malignancies. Better shielding strategies are needed to reduce this exposure so that the benefits of the radial approach can be obtained at minimal hazard to the patients or the operators.
JACC Cardiovasc Interv 2009;2:1047-1054
Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty
Study Question: What is the relative safety and feasibility of the transradial versus transfemoral approach for coronary angiography and intervention?
Methods: The authors randomized a total of 1,024 patients undergoing coronary catheterization to the transradial or transfemoral approach. Patients with an abnormal Allen's test, history of CABG, simultaneous right heart catheterization, chronic renal insufficiency, or known difficulties with the radial or femoral access were excluded.
Results:
- Successful catheterization was more common in the femoral (99.8% vs. 96.5%) compared with the radial group.
- Procedure time (median procedural duration 37.0 minutes vs. 40.2 minutes, p = 0.046) and radiation exposure (median dose area product 38.2 Gycm2 vs. 41.9 Gycm2, p = 0.034) were significantly lower in the transfemoral group compared with the transradial access group.
- There was no difference in the amount of contrast media use between the two groups.
- Vascular access site complications were higher in the transfemoral group (3.71% vs. 0.58%, p = 0.0008).
Conclusions: The use of radial access is associated with an increased procedural duration and radiation exposure, and a marked reduction in vascular complications.
Editors' opinion: The reduction in groin complications and bleeding with the use of a radial approach has been highlighted in multiple studies. However, the increased radiation exposure to the patient and the operator is increasingly being recognized, and may translate into an increased late risk of malignancies. Better shielding strategies are needed to reduce this exposure so that the benefits of the radial approach can be obtained at minimal hazard to the patients or the operators.
JACC Cardiovasc Interv 2009;2:1047-1054
Wednesday, March 3, 2010
Tuesday, March 2, 2010
Tuesday March 2, 2010
Q: What is Redistributive hyponatremia?
Answer: Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. The TBW (Total Body Water) and total body sodium are unchanged. This condition occurs with hyperglycemia or administration of mannitol.
Q: What is Redistributive hyponatremia?
Answer: Water shifts from the intracellular to the extracellular compartment, with a resultant dilution of sodium. The TBW (Total Body Water) and total body sodium are unchanged. This condition occurs with hyperglycemia or administration of mannitol.
Monday, March 1, 2010
Monday March 1, 2010
Q: Which steroid is preferable during treatment of Thyroid storm?
Answer: Dexamethasone (Decadron)
Dexamethasone (2 mg every 6 hours during first 24 hours) not only inhibit hormone production but also decreases peripheral conversion from T4 to T3. After acute episode subsides and there is an indication or suspicion of adrenal insufficiency Hydrocortisone (Solu-Cortef) 100 mg IV every 8 hours should be given.
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