October - November 2020 Flashcards
What is the concern in regards to the use of ACEi to COVID 19?
COVID 19 enters the cells via the ACE 2 receptors, which is located in many cells, not only the pneumatocytes
Pathophysiology:
- COVID 19’s viral spike protein will bind to the ACE 2 receptor of a cell
- Certain cells will also have a concomitant protease called TMPRSS2 - Type 2 Transmembrane Serine Protease - that cleaves ACE2 and activates the viral spike protein
- Activated viral spike protein is endocytosed
Postoperative atrial fibrillation following CABG is common. Does it lead to longterm risk of CVA?
OCT 2020
Yes
Retrospective study
Population: 3023 patients, of whom 734 (24.3%) developed pAF with the remaining 2289 maintaining sinus rhythm
Results: At 10 years, the cumulative incidence of CVA was 6.3% (4.6%-8.1%) versus 3.7% (2.9%-4.5%) in patients with pAF and sinus rhythm, respectively.
pAF was an independent predictor of CVA at 10 years (hazard ratio, 1.53 [95% CI, 1.06-2.23]; P=0.025) even when CVAs that occurred during the index admission were excluded from the analysis (hazard ratio, 1.47 [95% 1.02-2.11]; P=0.04).
Benedetto U, Gaudino MF, Dimagli A, et al. Postoperative Atrial Fibrillation and Long-Term Risk of Stroke After Isolated Coronary Artery Bypass Graft Surgery. Circulation. 2020 Oct 6;142(14):1320-1329. doi: 10.1161/CIRCULATIONAHA.120.046940. Epub 2020 Oct 5.
Does empiric antibiotic treatment of acute cholecystitis include anaerobic coverage?
No
IDSA 2010
What scenario would empiric antibiotic treatment of acute cholecystitis include anaerobic coverage?
Biliary-enteric anastomosis
What is the EKG criteria for LVH?
Criteria must be met in BOTH precordial AND limb leads
Precordial leads: “25, 35, 45” rule
- R wave in V4, V5 or V6 > 26 mm
- R wave in V5 or V6 plus S wave in V1 > 35 mm
- Largest R wave plus largest S wave in precordial leads > 45 mm
Limb leads: “10, 15, 20, 25” rule
- TIP: LRF - cross my heart like catholic
- R wave in aVL > 11 mm
- S wave in aVR > 14 mm
- R wave in aVF > 20 mm
- R wave in lead I + S wave in lead III > 25 mm
Metabolic causes of bradycardia?
TIP: all of the causes are LOW electrolytes EXCEPT Hyperkalemia
Hyperkalemia (> 8 mmol/L) can cause sinus bradycardia, sinus arrest, and intraventricular (IV) conduction blocks, especially in patients with renal failure
Hypoxemia
Hypothyroidism (uncommon, usually causes sinus bradycardia with first-degree atrioventricular [AV] block)
Hypothermia due to environmental exposure can cause sinus bradycardia
Hypogonadotropic hypogonadism
Hypoglycemia
Hypokalemia
Hypocalcemia
What ACS can lead to bradycardia?
Acute ischemic and infarction, especially inferior ischemia due to right coronary artery occlusion
How to decide what empiric antibiotics to initiate for a patient who presents with acute cholecystitis?
Mild and moderate:
- Cefazolin
- Cefuroxime
- Ceftriaxone
If patients with “severe physiologic disturbance, advanced age, immunocompromised OR bilioenteric anastomosis” or APACHE II >15, treat with
Monotherapy (mostly the penems)
- Mero
- Imipenem-Cilastatin
- Doripenem
- Pip-Tazo
OR dual therapy
Metronidazole
PLUS
Ceftazidime
Cefepime
Ciprofloxacin
Levoflox
IDSA 2010
Diagnosis of Posterior MI in the EKG?
V1-V3
TIP: posterior part of heart is at the opposite side of anterior part of heart. Since EKG only reads the anterior part, the V1-V3 findings should be reciprocal
Horizontal ST depression
Tall, broad R waves (>30ms)
Upright T waves
Dominant R wave (R/S ratio > 1) in V2
What is the role of surgery in SCLC?
In general, surgical resection is not routinely recommended for patients because even patients with LD-SCLC still have occult micrometastases.
TIP: “Small cell” really means small cell - its everywhere
TIP: if patient had pneumonectomy or lobectomy, then cancer must be one of the NSCLC
What is the staging of SCLC? What is the basis of the staging criteria?
Based on tolerable radiation window
Limited disease vs extensive disease; limited means it can be encompassed by radiation window
Patient with SCLC diagnosed by pleural effusion. Limited or extensive disease?
Extensive since it CAN’T be encompassed by a radiation window
Patient with known history of hives recently had a cardiac arrest when skinny dipping. The cause?
Cold urticaria
Though cold urticaria is a localized disease, vascular collapse may occur if an individual is submerged in cold water.
Treatment for cold urticaria
H1 blocker
Framework Question:
What is the cause of Sarcoidosis?
An infectious or non-infectious environmental agent that triggers an inflammatory response in genetically susceptible patients
Infectious: mycobacterium proteins found in histology; Propionibacterium acnes has been found in LN tissue
Non-infectious: linked to exposure to molds, insecticides; health care workers with higher risk
What are the different domains of speech to evaluate when evaluating for aphasia?
When evaluating someone who reports difficulty with language, it is important to assess speech in several different domains:
spontaneous speech comprehension repetition naming reading writing
What domain is most commonly affected in aphasic patients?
Anomia refers to the inability to name common objects and is the most common finding in aphasic patients
How does the FSH/LH levels vary from birth to puberty to menopause
After birth and the loss of placenta-derived steroids, gonadotropin levels rise. FSH levels are much higher in girls than in boys. This rise in FSH results in ovarian activation
By 12–20 months of age, the reproductive axis is again suppressed, and a period of relative quiescence persists until puberty. At the onset of puberty, pulsatile GnRH secretion induces pituitary gonadotropin production.
Gonadotropin levels are cyclic during the reproductive years and increase dramatically with the loss of negative feedback that accompanies menopause
Diagnosis of peritonitis in patient with PD catheter?
This can be diagnosed by the presence of >100/μL leukocytes with >50% polymorphonuclear cells on microscop
Most common organism implicated in PD catheter related peritonitis?
Staph epi
Peritonitis from PD cath: IV vs PD antibiotics?
A Cochrane review (Wiggins KJ et al: Cochrane Database Syst Rev 1:CD005284, 2008) concluded that intraperitoneal administration of antibiotics was more effective than intravenous administration
What is the cause of the massive diuresis from post obstructive diuresis?
This is likely due to postobstructive diuresis, which results from release of obstruction, increase in GFR over the course of days, decreased tubule pressure, and increased solute load per nephron, resulting in increased urine output. Decreased medullary osmolarity is a feature of chronic obstruction and persistent obstruction
Characteristic odor of sulfur mustard?
Burnt garlic or horseradish
What is the presentation of sulfur mustard exposure?
Predominantly mucocutaneous
Eye: Red eyes = most sensitive part, almost always present
Skin: Sunburn, vesicular rash in moist areas - axilla, groin, neck
Airway: Laryngospasm, necrosis
Ascites in cirrhosis: Na restriction vs fluid restriction?
Na restriction 2 gm/day
Tip: Common misconception is fluid restriction
First line treatment for cryptogenic organizing pneumonia?
Steroids
Biospy for a patient with subacute symptoms of shortness of breath. Concern for cryptogenic organizing pneumonia - expected histology?
Pathology shows the presence of granulation tissue plugging airways, alveolar ducts, and alveoli.
EWWW
What is the gram stain findings consistent with Actinomyces?
Sulfur granules are an in vivo concretion of Actinomyces bacteria, calcium phosphate, and host material. Gram stain of Actinomyces infection shows intensely positive staining at the center with branching rods at the periphery
Most common physical exam finding in HCC?
Hepatomegaly is the most common physical sign in patients with HCC, occurring in 50%–90% of the patients.
Difference between the following:
- Gilbert Syndrome
- Dubin Johnson
- Criggler Najjar Type I/Type 2
Gilbert: UDP glucuronosyltransferase deficiency - inability to conjugate unconjugated bili to conjugated
- TIP: hence autoimmune hemolytic anemia is on the diff diagnosis
- Criggler Najjar Type I/Type 2: same enzyme defect but more severe
- Type I: U. Bili > 20 - present since birth and stays as compared to Gilbert
- Type II: U. Bili < 20
Dubin Johnson: elevated CONjugated bili
- TIP: hence obstructive jaundice is on the diff diag
Common initial presentation of pemphigus vulgaris?
Clinically, most patients with pemphigus vulgaris present after age 40, and the initial lesions are on mucosal surfaces, predominantly the oral mucosa. These lesions erode quickly to ulcers and are typically quite painful.
They may be the only manifestation or precede the development of blistering skin lesions by several months
Biopsy findings consistent with pemphigus vulgaris
Acantholytic blister formation in the suprabasal layer of the epidermis with intradermal vesicle formation. Means junctions between the keratinocytes are lost.
Basal keratinocytes remain attached to the epidermal basement membrane - hence a blister made from keratinocytes, hence easily broken blisters
First line for pemphigus vulgaris?
Prednisone at a dose of 1 mg/kg daily
Framework question:
Cause of pemphigus vulgaris?
Autoimmune mediated blistering skin disorder in which IgG antibodies target desmoglein, the junction proteins between keratinocytes, causing blistering lesions that easily burst.
Diagnosis of pulmonary alveolar proteinosis?
BAL - shows macrophages with PAF stain demonstrating a lot of protein and amorphous proteinacious material
CT findings consistent with pulmonary alveolar proteinosis?
Classically, the CT appearance is described as “crazy pavement” with ground-glass alveolar infiltrates in a perihilar distribution and intervening areas of normal lung
Do IVC filters yield a clinical benefit for prevention of PE and death?
OCT 2020
Cochrane Systematic Review and Meta-analysis
Studies: randomised controlled trials (RCTs) and controlled clinical trials (CCTs)
- 6 studies, but only 2 could be evaluated
Conclusion:
Two of the six identified studies were relevant for current clinical settings. One showed no evidence of a benefit of retrievable filters in acute PE for the outcomes of PE, death, DVT and bleeding during the initial three months in people who can receive anticoagulation (moderate-certainty evidence). The other study did not show any benefit for prophylactic filter insertion in people who sustained multiple traumatic injuries, with respect to symptomatic PE, mortality, or lower extremity venous thrombosis (moderate-certainty evidence). We can draw no firm conclusions regarding filter efficacy in the prevention of PE from the remaining four RCTs identified in this review. Further trials are needed to assess vena caval filter effectiveness and safety, and clinical differences between various filter types
Young T, Sriram KB Vena caval filters for the prevention of pulmonary embolism. Cochrane Database Syst Rev. 2020 Oct 8;10:CD006212. doi: 10.1002/14651858.CD006212.pub5.
What is the difference between the following trials:
- RCT
- Controlled Non-randomized Study of Investigation (NRSI)
- Non-controlled non-randomized study of investigation
“Controlled” refers to control group, hence in controlled studies, researchers are able to determine which subjects receive the intervention and which do not. Uncontrolled may mean there is NO control group.
“Randomized” refers to randomization of the intervention
Convalescent plasma in COVID 19?
Studies: 19 studies (2 RCTs, 8 controlled NRSIs, 9 non-controlled NRSIs) with 38,160 participants, of whom 36,081 received convalescent plasma
LOE: The overall certainty of evidence was low to very low, due to study limitations and results including both potential benefits and harms
Conclusion:
- We are uncertain whether convalescent plasma is beneficial for people admitted to hospital with COVID-19
- here was limited information regarding grade 3 and 4 AEs to determine the effect of convalescent plasma therapy on clinically relevant SAEs.
What are the neurologic symptoms of COVID? How common are they?
Neurologic manifestation at any time during disease course in 82.3%
- 42.2% at symptom onset
- 62.7% at hospital admission
Neurologic manifestations included
myalgia in 44.8% headache in 37.7% encephalopathy in 31.8% dizziness in 29.7% dysgeusia in 15.9% anosmia in 11.4% syncope in 4.3% rhabdomyolysis in 3.5% orthostatic hypotension in 3.1% ischemic stroke in 1.4%
Efficacy of mRNA COVID 19 Vaccine?
NEJM Sept 2020
messenger RNA vaccine encoding stabilized prefusion SARS-CoV-2 spike protein (mRNA-1273) reported to illicit neutralizing antibody response in all adults, but with high rate of mild-to-moderate adverse events
Non controlled randomized trial
45 adults aged 18-55 years received mRNA-1273, 2 intramuscular injections given 28 days apart
Conclusion:
- High adverse rate:
- > 30 % after first vaccination, dose dependent, that is, high the vaccine dose, more likely to get symptom
- > 50% after second - chills, HA, myalgias
- ALL had seroconversion at 15 days with virus-neutralizing activity capable of reducing infectivity by ≥ 80% by day 43
What may ST elevation in aVR be indicative of?
- Occlusion in the LMCA
- Proximal left anterior descending artery (LAD) occlusion
- Severe triple-vessel disease (3VD)
TIP: Almost all the indications for CABG
MOA of Tranexamic acid? Relation to aminocaproic acid?
Tranexamic acid, a synthetic amino acid, is a competitive inhibitor of plasminogen activation, and at much higher concentrations, a noncompetitive inhibitor of plasmin (ie, actions similar to aminocaproic acid). Tranexamic acid is about 10 times more potent in vitro than aminocaproic acid
TIP: Think of plasma (or lava) melting away clots
Patient presents with a severe GIB. Utility of Tranexamic acid?
LANCET JUNE 2020
NO
Study design: international, multicentre, randomised, placebo-controlled trial
Participants: >16 yo, significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding
- 5956 patients in the tranexamic acid group and 5981 patients
Intervention: loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%
Results: Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82-1·18)
Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020 Jun 20;395(10241):1927-1936. doi: 10.1016/S0140-6736(20)30848-5.
What cells do cyclosporine/tacrolimus target?
Primarily on T helper cells, although some inhibition of T suppressor
Cyclosporine and tacrolimus are primarily used in the treatment of what type of transplant?
Solid organ transplant
What is the MOA of tacrolimus and cyclosporine?
End goal: T lymphocyte proliferation is reduced
Both drugs bind with high affinity to a family of cytoplasmic proteins present in most cells: cyclophilins for cyclosporine and FK-binding proteins for tacrolimus. The drug-receptor complex specifically and competitively binds to and inhibits calcineurin, a calcium- and calmodulin-dependent phosphatase [1-4]. This process inhibits the translocation of a family of transcription factors (NF-AT), leading to reduced transcriptional activation of cytokine genes for interleukin (IL)-2, tumor necrosis factor (TNF)-alpha
TIP: “Cyclo”philin bound by “cyclo”sporine; “FK Tacro”
What part of the conduction system is affected in 2nd degree AV block, Mobitz Type I vs II?
Mobitz Type I: at the AV node (hence progressive prolongation of the PR interval)
Mobitz Type II: His purkinje system
What is the relationship between the presence of 2nd degree AV block, Mobitz Type I vs II with structural heart disease?
Mobitz Type II is more likely to be related to underlying structural heart abnormalities (e.g. infarction, fibrosis or necrosis)
What other EKG abnormality accompany 2nd degree AV block, Mobitz Type II?
Patients typically have an underlying LBBB OR bifascicular block, hence the 2nd degree AV block is produced by the intermittent failure of the remaining fascicle
TIP: “Bilateral bundle branch block”
What EKG finding can further localize where the block is in the conduction system in patients with 2nd degree AV block, Mobitz Type I vs II?
In around 75% of cases, the conduction block is located distal to the Bundle of His, producing broad QRS complexes.
In the remaining 25% of cases, the conduction block is located within the His Bundle itself, producing narrow QRS complexes.
What are key characteristics to distinguish a Mobitz Type I compared to both Type II and complete heart block?
Intermittent non-conducted P waves WITHOUT progressive prolongation of the PR interval (compare this to Mobitz I).
The PR interval in the conducted beats remains CONSTANT.
The P waves ‘march through’ at a CONSTANT rate.
The RR interval surrounding the dropped beat(s) is an exact multiple of the preceding RR interval (e.g. double the preceding RR interval for a single dropped beat, treble for two dropped beats, etc).
Role of Tocilizumab in COVID?
NEJM OCT 2020
No
- Type: Randomized, Double Blind, Controlled Trial
- Patients: COVID patients on supplemental O2; 243 patients; 141 (58%) were men, and 102 (42%) were women. Median age 59.8 years (range, 21.7 to 85.4), and 45% of the patients were Hispanic or Latino
- Design: 2:1, single dose, 8mg/kg of Tocilizumab (IL 6 blocker)
- Outcome: death + preventing intubation
- Results: The hazard ratio for intubation or death in the tocilizumab group as compared with the placebo group was 0.83 (95% confidence interval [CI], 0.38 to 1.81; P = 0.64)
- Conclusion: Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19.
Stone JH, Frigault MJ, Serling-Boyd NJ, et al. Efficacy of Tocilizumab in Patients Hospitalized with Covid-19. N Engl J Med. 2020 Oct 21. doi: 10.1056/NEJMoa2028836.
Vericiguat - What is it? What disease has it been tested for? Efficacy?
Oral soluble guanylate cyclase stimulator
HFpEF
Not effective in regards to improvement of physical limitation scores
Armstrong PW, Lam CSP, Anstrom KJ, et al. Effect of Vericiguat vs Placebo on Quality of Life in Patients With Heart Failure and Preserved Ejection Fraction: The VITALITY-HFpEF Randomized Clinical Trial. JAMA. 2020 Oct 20;324(15):1512-1521. doi: 10.1001/jama.2020.15922.
What is the mutation associated with Hereditary Hemochromatosis?
Type 1 HFE-related is a mutation in the HFE gene where patients are homozygous for the C282Y mutation
What ethic population is at the highest risk for Hereditary hemochromatoiss?
Caucasians have 6x higher risk compared to blacks
What organ can hereditary hemochromatosis affect?
Virtually any organ
Clinical tip: on differential diagnosis of “infiltrative” diseases affecting multiple organs
What iron tests are indicative and can be diagnostic of hereditary hemochromatosis?
Transferrin saturation > 45% is diagnostic
Ferritin > 300, but extremely high like > 4000 is highly suggestive
Patients with Hereditary Hemachromatosis are at particular risk for which bacterial organisms?
Yersinia Enterolitica
Vibrio vulnificus
Conventional treatment of Hereditary Hemachromatosis? Goal Ferritin/iron saturation?
Tip: simply iron overload, RBC’s are the source, hence remove the RBCs
Phlebotomy weekly initially
Goal: Iron sat < 50%, Ferritin 50-100
What is the relationship between liver and spleen with mesenteric ischemia?
Splenic infarcts or hepatic infarcts can be indicative of mesenteric ischemia.
TIP: Makes sense since the celiac artery and possibly the SMA feeds spleen/liver
What is Weil’s Disease?
A severe form of Leptospirosis that is characterized by
- Pulmonary hemorrhage
- Renal failure
- Jaundice
Hence, liver, renal and respiratory failure
Leptospirosis PICMONIC about transmission
- Gram negative aeriobic spirochete
- Arab mouse with drills for hands - Penetrates non-intact skin
- drills for hands penetrate skin
-
What is conjunctival suffusion?
Conjunctival erythema WITHOUT presence of an inflammatory exudate
Treatment of Leptospirosis?
Doxycycline
TIP: Just like syphilis’s second line treatment
What is the definition of “Typical Atrial Flutter”?
Typical atrial flutter (90% of the cases), also called counterclockwise atrial flutter, is characterized by
1) POSITIVE waves in lead V1
2) NEGATIVE flutter waves in leads II, III, and aVF
Tip: counter intuitive, because one would think “typical” is “clockwise”, but its the reverse
Clinical tip: the “teeth” or the “pointed” ends of the flutter waves indicate if they are positive or negative waves
What is the definition of “Atypical Atrial Flutter”? (AKA reverse typical atrial flutter)
Atypical atrial flutter, also called clockwise atrial flutter, is characterized by
1) NEGATIVE waves in inferior leads V1
2) POSITIVE flutter waves in leads II, III, and aVF
Tip: counter intuitive, because one would think “typical” is “clockwise”, but its the reverse
Clinical tip: the “teeth” or the “pointed” ends of the flutter waves indicate if they are positive or negative waves
What is the pathway or the reentrant tract that atrial flutter takes?
In typical atrial flutter, the reentrant wavefront travels up the interatrial septum and down the right atrial free wall anterior to the crista terminalis and traverses the cavotricuspid isthmus to complete the circuit in a counterclockwise direction in the right atrium
Apart from typical atrial flutter and atypical, what are other uncommon ones that exist?
Simply different in the pathway of the circuit
Left atrial flutter, double wave reentry atrial flutter (two reentrant wave fronts simultaneously circulating in the same reentrant circuit), lower loop and upper loop reentry right atrial flutter, and atrial flutter caused by reentry around a surgical incision160 have also been described
What is the relationship between Atrial fibrillation and Atrial Flutter?
Atrial flutter often is initiated by AF. Atrial flutter occurs commonly in association with AF
And hence, ANY disease state that is commonly associated with Afib, can easily cause Atrial Flutter such as chronic obstructive pulmonary disease, mitral or tricuspid valve disease, thyrotoxicosis, and postsurgical repair of certain congenital cardiac lesions (eg, atrial septal defect, the Mustard procedure, the Senning procedure, or the Fontan procedure), as well as enlargement of the atria for any reason, especially the right atrium.
What is clinical tip to diagnose Atrial flutter if they EKG shows a rhythm that is too fast to accurately identify saw tooth waves?
Adenosine or vagal maneuvers to slow the AV node so that there will be longer time between every QRS and hence P or saw tooths can be seen more easily
What is the difference between Atrial fibrillation and A flutter in regards to the choice between rate control and rhythm?
Although the choice between rate and rhythm control is similar to that in AFib, there is bias toward rhythm control in atrial flutter as a result of the relative ease and HIGH success rate of catheter ablation, but also to the difficulty in many patients to achieve good rate control.
What is considered “valvular atrial fibrillation”?
Valvular AF is defined as moderate-to-severe mitral stenosis or mechanical heart valves
What is the CHADS VASC score that most guidelines will recommend anticoagulation?
There is agreement among guideline recommendations that women with a CHA2DS2-VASc score of ≥ 3 and men with a score of ≥ 2 are at an increased risk of stroke and should be given anticoagulant therapy based on the benefits greatly outweighing the bleeding risk.
Patient has new onset afib, but CHADSVASC score of 1. Anticoag?
Most will say consider AC
American College of Chest Physicians (ACCP) - offer stroke prevention to patients with atrial fibrillation and ≥ 1 non-sex CHA2DS2-VASc stroke risk factor, such as males with CHA2DS2-VASc score ≥ 1
Strong recc, moderate evidence
TIP: Almost ALL patients with Afib should be treated with AC
ASA for Afib?
No
Definitive treatment of atrial flutter?
Catheter ablation is highly successful, typically 90% or greater, to eliminate the typical atrial flutter
How accurate is Chest CT for the diagnosis of COVID 19?
Cochrane Review Sept 2020
TLDR: Sensitive, but no specific
Our findings indicate that chest CT is sensitive but not specific for the diagnosis of COVID-19 in suspected patients, meaning that CT may not be capable of differentiating SARS-CoV-2 infection from other causes of respiratory illness. This low specificity could also be the result of the poor sensitivity of the reference standard (RT-PCR), as CT could potentially be more sensitive than RT-PCR in some cases.
Salameh JP, Leeflang MM, Hooft L, et al. Thoracic imaging tests for the diagnosis of COVID-19. Cochrane Database Syst Rev. 2020 Sep 30;9:CD013639. doi: 10.1002/14651858.CD013639.pub2.
In patients with candiduria, who gets treatment?
Treatment is not recommended for asymptomatic patients except for high-risk patients such as neonates and those with neutropenia or having urologic procedures
What is the treatment from candida UTI
Fluconazole 200 mg orally daily for 14 days
What population of patients are at risk of candiduria and fungal UTI?
Most commonly arises in catheterized, instrumented, or obstructed patients
In inpatient settings:
diabetes indwelling catheter urinary tract obstruction recent surgery ICU patients
Patients receiving immunosuppressive therapy
What is relationship between the presence of candiduria and disseminated candidal infection?
Rarely, the presence of yeast in the urine is a sign of disseminated infection.
What is the expected axis of the R wave in aVR?
Expected R wave is NEGATIVE
Why: aVR is positive, located in the right arm, and since the overall vector goes in a down and left direction, AWAY from aVR, then aVR shows a NEGATIVE R wave.
Differential diagnosis of a dominant R wave in AVR?
Poisoning with sodium-channel blocking drugs (e.g. TCAs)
Dextrocardia
Incorrect lead placement (left/right arm leads reversed)
Commonly elevated in ventricular tachycardia (VT)
What is the first line imaging modality for concern for ovarian malignancy?
US
Yes, EVEN if CT already obtained. It is because US characteristics are taken into account to determine risk of malignancy
What patient requires a Ca 125 upon diagnosis of ovarian cyst?
ALL postmenopausal women with ovarian cyst regardless of the characteristics
Does CA 125 rule out ovarian cancer in patients with ovarian cysts?
NO
It can be low in limited disease, and tends to be high in extensive disease. So it could rule out extensive disease, but not the presence of disease
What anticoagulant has shown some evidence of reduced incidences of post thrombotic syndrome?
Sept 2020
Meta-analysis and Systematic Review
RIVAROXABAN
- Seven comparative studies, comprising 2364 participants
- VKA vs Rivaroxaban
- Results:
- [pooled unadjusted odds ratio (OR): 0.53, 95%CI: 0.43-0.65, P < 0.00001]
- reduced risk of mild PTS (OR: 0.64, 95%CI: 0.50-0.82, P = 0.0005)
- moderate PTS (OR: 0.64, 95%CI: 0.45-0.91, P = 0.01),
- severe PTS (OR: 0.52, 95%CI: 0.33-0.82, P = 0.005).
CONCLUSION: In comparison to VKAs, the use of rivaroxaban for DVT treatment has the potential to reduce PTS events. However, well-designed studies with larger sample sizes are needed to corroborate these findings.
Li R, Yuan M, Cheng J, et al. Risk of post-thrombotic syndrome after deep vein thrombosis treated with rivaroxaban versus vitamin-K antagonists: A systematic review and meta-analysis. Thromb Res. 2020 Sep 17;196:340-348. doi: 10.1016/j.thromres.2020.09.014.
What is the efficacy of Tocilizumab for moderate to severe COVID 19?
OCT 2020
JAMA
- NO
- Cohort-embedded, investigator-initiated, multicenter, open-label, bayesian randomized clinical trial
- Intervention Tocilizumab at 1 and 3 days
- 64 pts vs 63 pts, admitted on at leas 3 L NC, BUT not intubated OR in the ICU
- Outcomes: progression score, death at 14 days, and need for MV
Conclusion: TCZ did NOT reduce WHO-CPS scores lower than 5 at day 4 but MIGHT have reduced the risk of NIV, MV, or death by day 14. NO difference on day 28 mortality was found
Hermine O, Mariette X, Tharaux PL, et al. Effect of Tocilizumab vs Usual Care in Adults Hospitalized With COVID-19 and Moderate or Severe Pneumonia: A Randomized Clinical Trial. JAMA Intern Med. 2020 Oct 20. pii: 2772187. doi: 10.1001/jamainternmed.2020.6820.
How much of Ca is bound to Albumin?
About 50% of total calcium is ionized, and the rest is bound principally to albumin.
What is the correction of Ca for a low albumin level?
Every 1.0 g/dL of albumin below 4, add 0.8mg/dL to the Calcium
What is the difference in the characteristics of the ST elevation in acute pericarditis vs acute myocardial infarction?
In acute myocardial infarction, ST elevations are CONVEX (big hill), and reciprocal depression is usually more prominent
TIP: counter intuitive to what I would think. Con CAVE, makes me think of cave, that is, hill shaped. ConVEX, makes be think of the big V between the T wave and the QRS.
What EKG characteristics of pericarditis that are helpful in distinguishing from acute myocardial infarction?
- Q waves
- Concave (pericarditis) vs convex ST elevation (tombstone)
- PR depression (compared to TP segment) - interesting: caused by atrial involvement
- T wave inversion AFTER ST changes return to baseline is characteristic of pericarditis (TWI can occur in acute setting of AMI)
Most common cardiac abnormality in newborns of mothers with SLE?
AV block
Patient with brain tumor diagnosed. What are the chances that it is primary vs metastatic?
3 times more likely that a new diagnosis of brain tumor is metastatic
Differential diagnosis of brain tumor?
3x more likely metastatic
If primary:
- 30% glioma
- 35% meningiomas
- 10% vestibular schwannoma
What type of glioma is more likely to present with acute seizures?
Low grade glioma
NOTE: Interesting!
Best imaging choice for suspected brain tumor?
Malignant brain tumors—whether primary or metastatic—typically enhance with gadolinium and may have central areas of necrosis; they are characteristically surrounded by edema of the neighboring white matter.
FDA treatment for IPF - idiopathic pulmonary fibrosis?
Nintedanib is an intracellular tyrosine kinase inhibitor that inhibits several growth factors including vascular endothelial growth factor, fibroblast growth factor, and platelet-derived growth factor. A recent trial demonstrated that use of this medication slowed the rate of decline in FVC and could potentially decrease mortality.
Pirfenidone is an oral antifibrotic medication that has been demonstrated to decrease fibroblast proliferation and collagen synthesis.
NOTE: both have antifibrotic qualities
Expected PFT for IPF?
TLC
VC
RV
DLCO
Pulmonary function tests demonstrate restrictive ventilatory defect (low TLC, low RV, low VC) with a low DLCO.
CT findings that are clue that diagnosis of subacute shortness of breath is likely NOT IPF?
Atypical findings that should cause one to consider an alternative diagnosis include the presence of ground-glass infiltrates, nodular opacities, an upper lobe predominance of disease, and prominent hilar or mediastinal lymphadenopathy
Clinical: acute exacerbations of IPF will have GOO on imaging
What is the difference between phototoxic and photoallergic reaction when exposed to glyburide?
The sulfonylureas are sulfa drugs!
Phototoxicity: nonimmunologic reaction that can occur without a latency period after taking a drug. The response resembles a sunburn and occurs in sun-exposed areas. Like a sunburn, a phototoxic reaction can blister and desquamate
Photoallergy: UV rays transform the drug into an unstable hapten capable of stimulating an immune response. This delayed hypersensitivity response is intensely pruritic. Sun-exposed skin appears lichenified and leathery. In rare cases (5%–10%), persistent hypersensitivity to light will persist even after the offending drug is discontinued, a condition known as persistent light reaction
At what lung volume does the outward recoil of the chest wall equal the inward elastic recoil of the lung?
The functional residual capacity of the lung refers to the volume of air that remains in the lung following a normal tidal respiration
What is head and neck cancer staging?
Stage I and II (NO nodal involvement at all)
- Stage I: Tumor < 2 cm WITHOUT extraparenchymal involvement
- Stage II: Tumor > 2 cm WITHOUT extraparenchymal involvement
Stage III - automatically once 1 LN has metastatic disease
What is stage I or II head and neck cancer? Treatment of choice?
Stage I and II (NO nodal involvement at all)
- Stage I: Tumor < 2 cm WITHOUT extraparenchymal involvement
- Stage II: Tumor > 2 cm WITHOUT extraparenchymal involvement
Radiation therapy to preserve voice - NOT surgery
What BMI is lethal for men vs women?
Normal BMI ranges between 20 and 25 kg/m2, and a patient is considered underweight with likely moderate malnutrition at a BMI of 18.5 kg/m2.
Severe malnutrition is expected with a BMI of <16 kg/m2.
In men, a BMI of <13 kg/m2 is lethal
In women, the lethal BMI is <11 kg/m2
How many homeless are there in Ca?
134,000 on any given night (2017)
Most common composition of renal stones?
Calcium (75 to 85%) > Uric acid > Cysteine > Struvite
What are non-acs causes of elevated troponins?
ESRD
Heart specific: PE, myo/pericarditis, hypotension, hypertension
Lesson: It is important to remember that although cardiac troponin biomarkers (troponin I or T) are quite sensitive for myocardial infarction due to coronary occlusion, they lack somewhat in specificity.
What are the components that contribute to oxygen delivery to tissue? Least important part?
QO2 = CO × [1.39 × hemoglobin × SaO2 + (0.003 × PaO2)]
Delivery of O2 is dependent on the CO and the Oxygen content.
Note that the PaO2 is negligible in regards to the content of O2
Most common extra-articular complication of ankylosing spondylitis?
Anterior uveitis is the most common, occurring in 40% of patients with ankylosing spondylitis.
What criteria is the gold standard for diagnosis VAP?
There is NO gold standard, not even endotraheal cultures (as this can be due to colonization)
Usually, its the presence of a constellation of symptoms that point toward VAP:
- New O2 requirement
- Fever
- Increased secretions
- Leukopenia or leukocytosis
What are the suggested regimens for H. Pylori treatment?
“Bismuth Quadruple therapy” - notice the QID for 14 days
- Bismuth QID
- PPI BID
- Metronidazole QID
- Tetracycline QID
“Concomitant therapy” - not sure the meaning, but the tip is that each med is BID for 14 days
- PPI BID
- Clarithro BID
- Amox 1gm BID
- Metro 500 mg BID
Tip: PPI and Metronidazole is the same for both regimens
How do opioids provide relief of dyspnea for patients in hospice care?
Opioids reduce the sensitivity of the central respiratory drive center and often reduce the sensation of dyspnea.
Clinical tip: Opioids are first line for dyspnea in end of life care
Monitor AST/ALT during initiation of statin therapy?
Because clinically meaningful aminotransferase elevations are so rare after statin use and do not differ in meta-analyses from the frequency of such laboratory abnormalities in placebo recipients, the National Lipid Association’s Safety Task Force concluded that liver test monitoring was not necessary in patients treated with statins and that statin therapy need not be discontinued in patients found to have asymptomatic isolated aminotransferase elevations during therapy
Most common organs involved in cryoglobulinemic vasculitis?
The most common manifestations of cryoglobulinemic vasculitis are cutaneous vasculitis, arthritis, peripheral neuropathy, and glomerulonephritis
Which RTA is associated with Srogrens?
RTA Type I
Expected Urine pH in RTA Type I?
pH > 5.5
Basic because tubules unable to excrete H+ ions. In contrast with RTA Type II in which bicarb can’t be reabsorbed, BUT DCT can still excrete H, hence pH < 5.5
Efficacy of pentoxyfylline for Intermittent Claudication in PAD?
COCHRANE REVIEW OCT 2020
Conclusion: There is a lack of high-certainty evidence for the effects of pentoxifylline compared to placebo, or other treatments, for IC. There is low-certainty evidence that pentoxifylline may improve PFWD and TWD compared to placebo, but no evidence of a benefit to ABI or QoL (moderate-certainty evidence).
Broderick C, Forster R, Abdel-Hadi M, et al. Pentoxifylline for intermittent claudication. Cochrane Database Syst Rev. 2020 Oct 16;10:CD005262. doi: 10.1002/14651858.CD005262.pub4.
Convalescent plasma for COVID RCT?
BMJ Oct 2020
PLACID Trial
RCT Phase II Trial
Patients: Indian; confirmed moderate covid-19 (partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) ratio between 200 mm Hg and 300 mm Hg or a respiratory rate of more than 24/min with oxygen saturation 93% or less on room air
Intervention: two doses of 200 mL convalescent plasma, transfused 24 hours apart
NOTE: neutralizing ab NOT measured prior
MAIN OUTCOME MEASURE: Composite of progression to severe disease (PaO2/FiO2 <100 mm Hg) or all cause mortality at 28 days post-enrolment.
CONCLUSION: Convalescent plasma was not associated with a reduction in progression to severe covid-19 or all cause mortality
Agarwal A, Mukherjee A, Kumar G, et al. Convalescent plasma in the management of moderate covid-19 in adults in India: open label phase II multicentre randomised controlled trial (PLACID Trial). BMJ. 2020 Oct 22;371:m3939. doi: 10.1136/bmj.m3939.
Tocilizumab RCT for COVID - effective?
JAMA OCT 2020
Prospective, open label RCT - 1st for Tocilizumab
Who: COVID-19 pneumonia documented by imaging, partial pressure of arterial oxygen to fraction of inspired oxygen (Pao2/Fio2) ratio between 200 and 300 mm Hg, and an inflammatory phenotype defined by fever and elevated C-reactive protein.
Patients: 60 vs 66 patients
Intervention: Tocilizumab 8mg/kg (max 800) x 2 doses (12 hours apart)
Outcome: composite outcome was defined as entry into the intensive care unit with invasive mechanical ventilation, death from all causes, or clinical aggravation documented by the finding of a Pao2/Fio2 ratio less than 150 mm Hg, whichever came first
Results: Seventeen patients of 60 (28.3%) in the tocilizumab arm and 17 of 63 (27.0%) in the standard care group showed clinical worsening within 14 days since randomization (rate ratio, 1.05; 95% CI, 0.59-1.86)
Conclusion: The trial was prematurely interrupted after an interim analysis for futility. Tocilizumab provided no benefit on disease progression was observed compared with standard care.
Salvarani C, Dolci G, Massari M, et al. Effect of Tocilizumab vs Standard Care on Clinical Worsening in Patients Hospitalized With COVID-19 Pneumonia: A Randomized Clinical Trial. JAMA Intern Med. 2020 Oct 20. pii: 2772186. doi: 10.1001/jamainternmed.2020.6615.
What are the vessels that a transcranial Doppler can evaluate?
MCA, PCA, ACA, Vertebrobasilar flow and ICA!
ALL the arteries you’d be interested in and that a CTA or MR Angiography could evaluate
TCD can detect acute MCA occlusions with high (> 90%) sensitivity, specificity, and positive and negative predictive values.40–43TCD can also detect occlusion in the ICA siphon, vertebral, and basilar arteries with reasonable (70 to 90%) sensitivity and positive predictive value and excellent specificity and negative predictive value (> 90%
What is the difference between what part of the brain is affected by P1 stroke vs P2 stroke from a PCA stroke?
P1 – Midbrain stroke
P2 – occipital and temporal lobe involvement
How does the hemianopia between PCA stroke vs MCA stroke differ?
MCA stroke – spares the macula
PCA stroke does NOT spare the macula since P2 segment perfuses the calcarine cortex
What is the characteristic presentation of an ischemic stroke due to embolism to the top of the basilar artery?
Acute onset of bilateral signs:
- Bilateral ptosis
- Pupillary asymmetry
- Somnolence (few strokes cause somnolence)
- Posturing
- Myoclonic jerks that look like seizures
What part of the brain is supplied by the PICA?
Review: PICA comes from the vertebral artery
Lateral medulla AND inferior part of the cerebellum
How do the different parts of the vertebral artery differ in how strokes are produced?
Review: 4 parts of the vertebral artery
- V1 and V4 and the most common part disposed to strokes
- V1 and V4 atherothrombotic which can lead to thrombotic occlusion and extension OR embolism
V2 and V3 dissection
What are the possible arteries involved in if patient presents with medial medullary syndrome? Lateral medullary syndrome?
Medial medullary: Vertebral artery (or branch of vertebral artery or lower basilar artery)
Lateral medullary syndrome: any of the following 5 vessels
- Vertebral
- PICA
- Superior, middle or inferior lateral medullary arteries
What is the presentation of lateral medullary syndrome?
AKA Wallenberg’s Syndrome
TIP: NO hemiparesis; Deficits are mainly from the neck above; brainstem heavy presentation
Horner syndrome Double vision Hoarseness Dysphagia Dysarthria Vertigo Numbness of ipsilateral face and CONTRA lateral limbs
Picmonic:
- Horse with a horn like a unicorn; wearing glasses and crossed eyes, on a skate board, wearing a muzzle (dysarthria), half of face black and half of body black like a jester
What is the relationship between a cerebellar infarction and respiratory depression and cardiac arrest?
Cerebellar edema leads to ICP and closure of the aqueduct of Sylvius and 4th ventricle leading to hydrocephalus
NUS emergency! But easy fix if caught
Framework concept/question:
What is the presentation of brainstem strokes?
PICMONIC
Clinical tip: brainstem strokes can come from any variety of vessels that supply the brainstem, AKA any of the posterior cerebral circulation, hence vertebral, PICA, medullary arteries, basilar arteries and their branches, etc, but brainstem strokes tend to have the following presentation in common:
- Vertigo
- Dysarthria
- Diplopia
- Hyperacusis/Tinnitus
- Ataxia
- Coma
- Word salad
- Cranial nerve involvement
Hence, lateral medullary syndrome, since it involves the vertebral artery, or PICA or medullary arteries, can have above findings on presentation
What part of the brainstem is most affected by a basilar artery stroke?
PONS
Why: basilar artery first starts at the medullarpontine junction, spans the pons and ends at the midbrain pontine junction
What is the presentation of complete basilar occlusion?
EASY:
- Bilateral long tract signs (motor/sensory),
- cranial nerve involvement
- cerebellar involvement
Basilar artery supplies mostly the PONS, hence presentation of a basilar artery stroke should represent pontine ischemia
Since basilar artery supplies the anterior part of the pons and that is where corticospinal tracts run through, the sx are bilateral and motor/sensory
Ataxia due to cerebellar involvement
TIP: Asymmetry but bilaterality of neurologic signs is the rule AKA one side is predominantly affected, but both sides are always affected to some extent
What is the purpose of non-contrast CT Head in ALL patients with CVA (stroke or TIA)?
Since stroke is a clinical diagnosis, CT head is NOT needed for diagnosis. However, it aids in clarifying the diagnosis - looking for masqueraders and determining if the stroke is hemorrhagic.
CT is helpful as part of treatment, as a hemorrhage would make TPA contraindicated
Masqueraders: tumors, abscess, extraparenchymal hemorrhage
What does MRI brain provide that CT Head does not in regards to stroke?
MRI scan shows extent and location of infarction in ALL areas of brain
CT: does not show posterior fossa well; does not show infarct in the first 24-48 hours
What is the gold standard image to evaluate the intracranial and extracranial vessels in the setting of stroke?
CT Angiography is the GOLD standard
WATCHOUT: gold might be X ray angiography
How does CT Angiography compare to MR Angiography in regards to evaluating intra/extracranial vessel disease in setting of stroke? When is one used as opposed to the other?
CT Angiography
MR Angiography: Highly sensitive for extra and intracranial stenosis of LARGE vessels; Can also evaluate for dissections like CTA; However, overestimates the degree of stenosis in instances of higher grade stenosis compared to CTA.
In acute stroke protocols, CTA is used. MRI, being time consuming, is used most often OUTSIDE the acute period.
When is MRI Head used in regards to stroke evaluation?
AFTER the acute period given its limitations of availability and timing
- Clearly defining the extent of tissue injury and discriminating old from new regions of infarction
TIA patients as it allows identification of new infarction
Framework concept: acute stroke imaging
In acute stroke, CT remains the main imaging modality given ease, availability, speed and efficacy
- Non-contrast CT Head
- Then, CT Angiography of head/neck to evaluate for stenosis
All others are used in the post stroke period – MRI and Ultrasound
Clinical tip: AHA/ASA
- Suggest CT head OR MRI head first to eval for intracranial hemorrhage
- Following the above, suggest either CTA OR MRA with DWI (with or without perfusion) to eval if patient candidate for thrombectomy
TLDR: both CT and MRI are both kosher
What is “perfusion” in regards to CT or MRI?
CT Angiography OR MR Angiography does NOT imply perfusion.
Perfusion is a technique that can be added to CT (SPECT) or MRI (perfusion) that reports relative cerebral blood flow and ultimately increases sensitivity of detecting ischemia
Does addition of PSCK9 to current active LDL lowering therapy lead to improved CVD outcomes?
Cochrane OCT 2020
No to patients with active LDL lowering therapy - low certainty evidence
Yes to patients NOT on active therapy
Outcomes: CVD events, stroke, MI, all cause mortality
24 studies with 60,997 participants.
18 trials alirocumab and 6 to evolocumab.
Alirocumab compared with placebo
Alirocumab reduces CVD events, mortality, MI and stroke when compared to placebo all with high certainty evidence, but when compared to active treatments showed no difference in all outcomes with low certainty evidence
Evolocumab reduces CVD events, not mortality, yes MI and stroke when compared to placebo all with high certainty evidence, but but when compared to active treatments showed no difference in all outcomes (stroke unable to measure) with low to very low certainty evidence
TLDR: PSCK9 inhibitors are clearly beneficial for patients not actively being treated with LDL lowering therapy, but there is no evidence to demonstrate that would be helpful as additional therapy for people already on LDL lowering therapy
Schmidt AF, Carter JL, Pearce LS, et al. PCSK9 monoclonal antibodies for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2020 Oct 20;10:CD011748. doi: 10.1002/14651858.CD011748.pub3.
Should patients with anti-phospholipid syndrome be treated with secondary prevention with either anticoagulation or antiplatelet therapy or both?
October 2020 Cochrane review
8 RCTs total with 811 patients total
Conclusion: Interestingly, a lot of the treatments were associated with an increased risk of thromboembolic events
- VKA vs NOAC
- VKA with antiplatelet vs VKA alone
- no placebo trials
Bala MM, Celinska-Lowenhoff M, Szot W, et al. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev. 2020 Oct 12;10:CD012169. doi: 10.1002/14651858.CD012169.pub3
What is the penumbra?
The dysfunctional tissue that surrounds the core of infarction in a stroke that is defined as “ischemic but reversible”
Clinical tip: the acute treatment of stroke is focused on saving the penumbra
How does hyperglycemia affect patients with acute stroke?
Worsens the brain injury, hence it is essential to control the hyperglycemia if present
Patient presents with acute stroke – what to do about VTE chemical prophylaxis?
Essential to prevent VTE as acute ISCHEMIC stroke patients have high morbidity from VTE. Hence, if no contraindication, start chemical ppx for VTE
Where does the pain in osteoarthritis come from?
Because cartilage is aneural, cartilage loss in a joint is not accompanied by pain.
Thus, pain in OA likely arises from structures OUTSIDE the cartilage. Innervated structures in the joint include the synovium, ligaments, joint capsule, muscles, and subchondral bone.
Patient with possible OA, but also presentation that may be indicative of inflammatory arthritis – how will synovial fluid analysis help?
If > 1000 WBC, likely inflammatory
What patients in the US (or developed countries) are at risk of Vitamin C deficiency?
Elderly
Alcoholics
Autistic children
What is treatment for IPF?
Nintedanibis an intracellular tyrosine kinase inhibitor that inhibits several growth factors including vascular endothelial growth factor, fibroblast growth factor, and platelet-derived growth factor.