Morning Report Question & Answer

Source is in blue, just click on it to get to the original article.

Cocaine induced Stroke: Answers to some queries dug up by Dr Damodaran...
1-Pathophysiology of cocaine induced stoke?
2-Can multiple strokes occur in patients using cocaine?
3-Whether you can give tPA in cocaine induced stroke?
4-What percentage of the strokes caused by cocaine are ischemic vs hemorragic?
5-what is the Etiology of cocaine induced stroke?


1-Pathophysiology of cocaine induced stoke?
Answer: The principal mechanism of cocaine-induced cerebral ischemia is vasospasm of large cranial arteries or within the cortical microvasculature. Increased levels of extracellular monoamines, particularly dopamine, mediate vasospasm. Neuroanatomical and labeling studies also have shown that dopamine-innervated neurons may regulate cerebral blood flow. Indeed, dopamine-rich brain regions appear to be relatively specific targets for cocaine-induced cerebral ischemia. Neuroimaging studies show thatcerebral ischemia. Neuroimaging studies show that cocaine-induced hypoperfusion can persist even after 6 months of abstinence. Hypoperfusion can result in deficits on complex and simple psychomotor tasks but perhaps not on memory or attention. Severe cerebral ischemia can directly precipitate neuronal death and degradation, a condition exacerbated by liberation of the excitatory amino acid glutamate. Other causes of cerebral ischemia include thrombogenesis and vasculitis.

2-Can multiple strokes occur in patients using cocaine?
Answer : Yes, Since the causes are multifactorial , multiple strokes can occur in a patient. It has been seen in a study although less commonly.

3-Whether you can give Tpa in cocaine induced stroke?
Answer: Although antithrombotic agents have potential in alleviating cocaine's neurotoxic effects, their use may be limited by the risk of spontaneous hemorrhage.

4-What percentage of the strokes caused by cocaine are ischemic vs hemorragic?
Answer: Stroke followed cocaine use by inhalation, intranasal, intravenous, and intramuscular routes. Intracranial aneurysms or arteriovenous malformations were present in 17 of 32 patients studied angiographically or at autopsy; cerebral vasculitis was present in two patients. Cerebral infarction occurred in 10 patients (22%), intracerebral hemorrhage in 22 (49%), and subarachnoid hemorrhage in 13 (29%). Thus in cocaine-associated stroke, the frequency of intracranial hemorrhage exceeds that of cerebral infarction.

5-what is the Etiology of cocaine induced stroke?

The etiology of cocaine-induced brain ischemia is multifactorial:

Cocaine stimulates vasospasm, presumably by increasing levels of extracellular monoamines, particularly dopamine. Cocaine may cause thrombus formation in the cerebral vasculature, in the same way that it causes coronary artery thrombosis (see above). Long-term cocaine use may cause pathologic changes in the cerebral vasculature (vasculitis) that impair cellular oxygenation by exacerbating nonlaminar blood flow and sludging in the vessels, with consequent increase in platelet aggregation and thrombus formation.

Regardless of the precise mechanism, cocaine-induced cerebral ischemia can cause marked hypoperfusion abnormalities associated with severe neurologic deficits. More subtle cognitive deficits also can occur. Over time, repeated ischemic episodes and subsequent reperfusion can weaken vessel walls, thereby increasing the likelihood of cerebral hemorrhage

Sources uptodate, ovid, medline and Harrisons

What is the incidence and prevalence of UTI in nursing home patients with and without foleycatheters?
UTI is the most common bacterial infection in the nursing homes. In prevalencestudies performed in Europe, Canada, and the US, 17-55% of women and 15 to 30% of menWITHOUT indwelling catheters in nursing homes were bacteriuric. The incidence of newepisodes of bacteriuria was 45 per 100 patient yrs for men and 1.2 per resident year forwomen.5-10% of nursing home patients are managed WITH indwelling catheters and thay have a100%prevalence of bacteriuria.Clinical and microbiologic limitations in the diagnosis of symptomatic infection limit theefforts to accurately measure the morbidity from UTI. Symptomatic UTI may be defined as apositive urine culture in a patient with fever and no other apparent source, permissively.Restrictively it is a positive urine culture in a patient with fever and acute symptomsreferable to the urinary tract.Reports using the permissive definition certainlyoverestimate the incidence of urinary infection and those using the restrictive definitionunderestimate the incidence. However the incidence of symptomatic urinary infection variesfrom 0.1-2.4 per 1000 resident days (to remember is the influence of different surveillancedefinitions)
Source: Clinical Microbiological review 1996;9(1):1-17
There is an interesting and useful review article in Geriatrics May 2002, pg45-56 which gives an overview of how to manage nursing home patients with UTI with andwithout chronic catheterization.

How much does aricept slow or reverse dementia?
Actually there are many studies done on aricept and its benefits in dementia patients.One study measured the progression of hippocampal atrophy in pts with alzheimers dis andcompared MRIbased volumetric studies of hippocampal atrophy ofpts on aricept therapy vs pts not on aricept.Otherbackground charecteristics like ,sex, age etc were comparable.Conclusion was that donezepilslows progression of hippocampal atrophy suggesting a neuroprotective effect in alzheimerspts.Donezepil also slows deterioration of cognition and global function in pts with moderate tosevere alzheimers disease.So the therapeutic effect of aricept in dementia is well established but itscost effectiveness is still in questions and I could not find any study thatestablished its cost effectiveness.
Reference: Pubmed abstract

Recurrent Furunculosis: Staph aureus carrier state. Treament and eradication recommendations
Recurrent furunculosis secendary to persistent S. aureus in the nares, perineum and body folds.
Topical therapy: Shower with povidone iodine soap or benzoyl peroxide (bar or wash). Advising patient to use dettol bar is also useful and effective by using three times a week.
Apply Mupirocin ointment daily to the inside of the nares and other areas of Staph carriage.
Rifampin 600 mg for 7-10 days for eradication of carrier state.
REFERENCE: FITZPATRICK'S, COLOR ATLAS AND SYNOPSIS OF CLINICAL DERMATOLOGY COPYRIGHT 2005SECTION 22: BACTERIAL INFECTIONS INVOLVING THE SKIN.PAGE: 596.

Patient with ESRD on HD is having atypical CP. The troponin is 2. Did he have an MI?
We cannot be sure. You need a second tropinin level in 6-8 hours.
Elevations in troponins are commonly observed in patients with CRI (or ESRD on HD) in the absence of acute myocardial ischemia.
Troponin T (TnT) is elevated in 68% of stable ESRD patients on routine HD. TnI and CK-MB levels are elevated in 3.5% and 9%, respectively, that is why TnT is much more specific for myocardial damage than TnI. Dialysis does not affect troponin levels.
If you want to rule out MI, the best approach is serial measurements of TnI. A sequential rise in TnI rules in MI in patients with CRI in the appropriate clinical settings. If TnI is elevated but does not change over time of the hospitalization, this is less consistent with a new MI.
Source: J Am Coll Cardiol, eMedicine, Clin Nephrol, UpToDate

77 yo AAF is admitted with suspected small bowel obstruction (SBO). Abdominal X-rays are inconclusive. She is NPO. Should we do a noncontrast CT scan of the abdomen?
Yes. The sensitivity of plain X-rays for SBO is only 45-70%. Avoid barium studies in patients with suspected perforations or complete SBO.
CT of the abdomen has a sensitivity and specificity of 90-100% in SBO. Intraluminal administration of contrast may not be necessary because the fluid and gas in the bowel provide sufficient contrast. National Guideline Clearinghouse rates the usefulness of imaging studies in acute abdomen on 1-9 scale (1 = least appropriate, 9= most appropriate). CT with oral and IV contrast rates 8 vs. CT without oral or IV contrast - 6.
Source: Guideline.gov, VH.org - Univ Iowa, Radiographics J, eMedicine, Postgrad Med,

Patient is having acute DVT. Heparin is started. Can I order protein C, S, and other tests to rule out hypercoagulability now?
No. It is never a good time to do hypercoagulability tetsts when the patient is in the hospital with acute DVT. Both protein S and protein C may be low in acute thrombosis and illness. AT-III can be low in acute thrombosis and rarely with heparin therapy. Heparin does not alter plasma protein C and S levels.

Normal protein C, S and AT-III levels drawn acute DVT rule this out deficiency as a cause of a hypercoagulable state. Protein C and protein S are vitamin K dependent proteins their levels will be reduced by warfarin therapy. The optimal time for performing these tests is 6 months after the DVT, when a decision should be made about continuing anticoagulant therapy.
Source: NEJM

Patiens has been on Coumadin for one year after 2 episodes of DVT. Can I check for protein S, C and other deficiencies now?
Yes, stop Coumadin for 2 weeks (cover the patient with Lovenox during this time), and then order the tests. Protein S is a vitamin K-dependent clotting factor and the diagnosis of its deficiency is difficult in anticoagulated patients. Protein C level is decreased 35 to 50% by Coumadin. Two methods are used to make the diagnosis of protein S deficiency in patients on Coumadin:
-compare levels with those of another vitamin K-dependent factor such as factor X
-use normal ranges for patients taking warfarin

The normal range for free protein S in stably anticoagulated patients is 0.27 to 0.79 (0.64-1.30 in patients not on Coumadin).
The approach is similar when assessing protein C. Some labs use protein C activity assays in conjunction with measurements of factor VII, a vitamin K-dependent factor with a similar plasma half-life to protein C.
Source: eMedicine, NEJM, Blood J 3/00

76 yo lady presents with a 5.5 cm asymptomatic AAA. Should I recommend surgery?
The answer is to consult a surgeon; she may need to have the AAA repaired.
AAA rupture has 80% mortality. Elective repair has an operative mortality of 4 to 6 percent.
Abdominal U/S has a sensitivity and a specificity of nearly 100 percent for AAA.
Elective surgical repair is indicated when an asymptomatic AAA is greater than 5.5 cm in diameter. The size for elective repair of thoracic aorta aneurysm is bigger, more than 6 cm.
The USPTF recommends U/S screening for male smokers older than 65 (less clear for women).
Source: Click here to see how the AAA looks on U/S, CT and aortogram (AFP 2002)
AFP 1, 2, NEJM, BMJ 1, 2, Oxford Bandolier

67 yo CF with end-stage pancreatic cancer feels depressed (depression at the end of life). What antidepressant should we choose?
Ritalin (methylphenidate). Stimulnats are used when a rapid response (within 24 to 48 hours) is desired. They are most effective in patients with psychomotor retardation. Stimulants should be avoided in agitated patients and in those who are confused or delirious. SSRIs and TCAs have a much slower onset of action (within 3-4 weeks).
Source: AFP, J Clin Onc, Ann Int Med

Can we use Lasix in rhabdomyolysis-induced acute renal failure? What about mannitol?
Diuretics (loop or others) should not be used because they do not improve, and may actually worsen, the final renal outcome. The use of mannitol remains controversial. It is mostly supported by animal studies.
Source: AFP 2002

Can hypocalcemia cause rhabdomyolysis?
Hypocalcemia is listed among the causes of rhabdomyolysis but in most cases, it is a consequence rather than the cause of rhabdomyolysis. Hypocalcemia occurs in rhabdomyolysis and is most likely related to calcium deposition in injured tissues. Elevation in 1,25(OH)2 D plays an important role in the hypercalcemia during the diuretic phase of patients with rhabdomyolysis-induced acute renal failure. The usual sequence is hypoCa++ --> hyperCa++.
Source: NEJM 1981, Journal of Clinical Endocrinology & Metabolism 1986

Can ischemia cause a long QT-interval?
Certainly, although more common causes are medications and electrolyte disturbances.
Source: ECG Library, Univ of Florida, FP Notebook, Ann Int Med 1995

How often do patients with seizures have urinary incontinence?
No specific number is reported but the literature reviews show that incontinence occurs commonly in seizures and is uncommon in syncope.
Source: eMedicine

Is there a "30-seconds rule" in syncope and what does it mean?
Yes, there is. Syncope is loss of consciousness from temporary disruption of cerebral oxygenation. This is typically due to the interruption of blood flow to the brain, and the loss of consciousness usually lasts for less than 30 seconds.
Source: eMedicine 1, 2, NEJM

Do people with ICD feel the shock? Can they have a silent shock that is revealed only during the ICD interrogation?
When the ICD delivers pacing therapy, patients may not feel anything. Some people feel a fluttering in their chest. Cardioversion is stronger than a pacing pulse. It feels like being thumped in the chest. The defibrillator shock is the strongest treatment. Many people say it feels like being kicked in the chest. It usually comes suddenly and lasts only a second.
Source: Familydoctor - AAFP 2/00, Texas Heart Institute

Can we use prolactin level to diagnose a seizure?
Yes. Prolactin level, if done within 10-20 minutes of a seizure, is elevated 5-30 times above the baseline. It is a useful diagnostic tool to exclude pseudoseizures. A positive test result is highly predictive of a seizure, however a negative test result does not exclude a seizure. Prolactin should be measured in patients presenting to the ER within an hour of a syncope. Prolactin may also be elevated after pseudo-epileptic seizures.
Source: eMedicine, Emerg Med J 2004; 21:e3

What is the driving restriction for an epileptic patient in Ohio?
The physician decides if the patient can drive or not. He or she needs a reevaluation every year until seizure-free or off medication and seizure-free for 1 year, and the physician may be liable for the driving recommendation. Doctors are not required by law to report epilepsy.
Source: Neurology 2001;57:1780-1785, epilepsy.com

Can you give antibiotics to treat a UTI in a DNR-CC patient?
Yes, if the UTI is causing symptoms. The difference between DNR-CCA and DNR-CC is the goal. In DNR-CC the goal is to treat the disease symptoms, in DNR-CCA the goal is to cure the disease.
Comfort care definition:
(1) "Nutrition when administered to diminish the pain or discomfort of a principal, but not to postpone death; (2) Hydration when administered to diminish the pain or discomfort of a principal, but not to postpone death; or (3) Any other medical or nursing procedure, treatment, intervention, or other measure that is taken to diminish the pain or discomfort of a principal, but not to postpone death." Ohio Revised Code § 1337.11(C)
Source:
A publication of the Ohio Legal Rights Service (OLRS) - Ohio.gov
CCF Implementation of the New Ohio "DNR Comfort Care" Rules and Regulations - CCF

How sensitive is the physical exam for DVT? Is it like a toss-up, 50% only?
Sensitivity of the clinical examination for DVT ranges from 60% to 96%. Tenderness occurs in 75% of patients, edema in 97%.
Source: JAMA, eMedicine, Pubmed 1, 2, J Fam Practice

What is the CK level in PMR? What about fibromyalgia?
PMR: ESR greater than 50 mm/h, normal CK level
Fibromyalgia: mean ESR is 15 mm/h, normal CK level
Source: AFP, Merck, eMedicine - PMR, eMedicine - Fibromyalgia

Is jaundice one of the causes of sinus bradycardia?
No. Although jaundice is listed among the causes of sinus bradycardia in some sources this is not confirmed by studies. Jaundice is not among the causes of bradycardia in UpToDate or eMedicine.
Source: Pubmed

What is a more comon cause of hemoptysis - TB or PE?
TB. DDx of Hemoptysis : CA (28%), chronic bronchitis (19.8%), bronchiectasis (14.5%), pneumonia or lung abscess (11.5%), idiopathic (8%), and TB and its sequelae (5.7%), cardiac diseases (1.5%) and PE (2.3%).
Source: Pubmed, Merck manual

How specific are night sweats for TB?
Difficult to evaluate. Night sweats are seen in 33% of adults and 13% of elderly with TB.
Source: PMJ

What is the mechanism of contraction alkalosis when diuretics are used?
Dehydration concentrates the body electrolytes. Contraction alkalosis occurs when there is loss of relatively large volumes of bicarbonate-free fluid. The plasma bicarbonate concentration rises in this setting because there is contraction of the extracellular volume around a relatively constant quantity of extracellular bicarbonate. Administration of a loop diuretic to induce rapid fluid removal in a markedly edematous patient is the most common cause of a contraction alkalosis.
Source: eMedicine, UpToDate, First described in 1965 in Ann of IM, click to see a diagram

Can PE present with asthma-like diffuse wheezing? Is it true that PE causes only localized wheezing?
"All that wheezes is not asthma" (Chevallier Jackson) and also PE is known as "the great masquerader". PE may appear as asthma when diffuse wheezing results from the release of vasoactive and bronchoactive mediators. Just 10-20% of PE patients present with wheezing.
Source: eMedicine, Pubmed 1, 2, 3, 4, 5

How to recognize MI if the patient is having an old LBBB?
The answer is in the Feb 1996 edition of NEJM. The 3 EKG criteria for diagnosing AMI in patients with LBBB are ST-segment elevation of >= 1 mm concordant with (in the same direction as) the QRS complex; ST-segment depression >= 1 mm in lead V1, V2, or V3; and ST-segment elevation >= 5 mm discordant with (in the opposite direction from) the QRS complex. A scoring system (0 to 5) was developed, which allowed a highly specific diagnosis of AMI to be made.
Source: NEJM, see the flowchart, editorial

Patient is having a new-onset AFib. Can we start Coumadin at the same time as Heparin?
Yes. Warfarin-induced skin necrosis is an uncommon complication - it occurs in only 0.01-0.1% of patients (85% of reported patients are females). Full heparinization should be achieved before starting warfarin.
Source: eMedicine, Medscape, AFP, CCF

Should we start Coumadin at a dose of 5 or 10 mg?
Either can be used. Some authors recommend starting at 5 mg because of a slightly increased risk of skin necrosis if the first Coumadin dose is >= 10 mg.
Source: CCF, Annals, NEJM

65 yo male with DVT is started on Lovenox. Two days later he is having several bloody BM. VS and H/H are stable. Colonoscopy done 2 weeks ago showed diverticulosis. What to do?
Give protamine. No agent, including FFP and vit. K, is effective for complete reversal of supratherapeutic anticoagulation with LMWH. Reversal of LMWH with protamine sulfate may be incomplete, with neutralization of 60 to 75% at most.
Source: NGC

67 yo male with new onset AFib needs anticoagulation. Can we use Lovenox?
Probably yes. Lovenox is not FDA approved yet for anticoagulation in AFib. Lovenox may be approved in the future though because a recent study (2004) showed that Lovenox was noninferior to UFH + phenprocoumon for prevention of ischemic and embolic events in TEE-guided cardioversion of atrial fibrillation.
Source: Circulation

How effective is chemical cardioversion in AFib?
30-70%
Source: AFP

What is the risk of stroke in AFib? How much does Coumadin cut the risk?
5-8% without anticoagulation. Coumadin decreases the stroke risk to 1.7%.
(Rate of stroke per year in %)
Source: AFP

How often is Hep. C acute?
Infection due to HCV accounts for 20% of all cases of acute hepatitis. Acute infection is usually asymptomatic, 20% of patients develop jaundice, 75% of those infected develop chronic disease with chronically elevated ALT, and 20% of patients eventually develop cirrhosis.
Source: eMedicine, FPH

How to diagnose acute Hep. C infection?
RNA-HCV will be positive after 1-2 weeks of the initial contact with HCV. Antibodies against HCV are detected later (after 7-8 weeks on average), and are not useful in distinguishing acute infection from chronic infection.
Source: Pubmed

Can HIV cause hepatitis?
Yes. Elevated LFT have been reported in 21 % of patients with symptomatic primary HIV, and an acute-hepatitis–like picture has been described.
Source: NEJM

What is the sensitivity and specificity of lipase in acute pancreatitis (AP)?
When the cutt-off levels of amylase were set at the upper normal level or up to 5-fold as high, the sensitivity decreased from 92% to 74%, the specificity increased from 85% to 99%. Lipase sensitivity is similar but the specificity is lower. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy.
Approach to elevated amylase -UpToDate
Source: Pubmed 1, 2, AFP

62 yo lady with metastatic pancreatic adenoCA is having recurrent DVT despite being on Coumadin and INR 2.9. What to do?
LMWH (not Coumadin) is the treatment of choice. In Trousseau's syndrome, a condition in which recurrent, migratory thromboembolism is found in patients with adenoCAt was found that 19% of patients benefited from warfarin while 65% benefited from heparin. CA patients treated with warfarin for their first venous thromboembolism had a recurrence rate of 22% within 3 months in contrast to those treated with heparin (standard or LMWH) who had a recurrence rate of 7%.
Source: The Oncologist, Cancer 1997

62 yo lady smoker with COPD is c/o increased cough and SOB. On physical exam there is decreased air entry (B) but no wheezing. Is it COPD exacerbation?
Yes. You don't need to have wheezing to define COPD exacerbation.
Definition of COPD exacerbation:
One or more of the following: increase in sputum purulence, increase in sputum volume, and worsening of dyspnea.
Type I (severe) has all 3 symptoms, type II (moderate) has 2, and type III (mild) has 1 symptom plus at least 1 of the following: URTI, fever, increased wheezing, increased cough, or increase in RR or HR by 20% above baseline.
Source: Chest 1, 2; NEJM; PMJ

What is the sensitivity of elevated LDH in PCP?
Sensitivity and specificity are 0.94 and 0.78 at a cutoff point of LDH greater than 220 IU/L.
Source: Pubmed, eMedicine

Can hypernatremia cause central pontine myelinolysis?
Yes. Although central pontine myelinolysis is observed more commonly with rapid correction of hyponatremia (low Na) it can also occur with the correction of the hypernatremia (high Na).
Source: Pubmed, eMedicine

We know that ASA and beta-blockers are good for AMI but how good are they? What is the absolute risk reduction (ARR)?
ASA: ARR 2.4%, NNT 42 for vascular death; ARR 1.2%, NNT 84 for non-fatal reinfarction.
Beta-blockers: ARR 0.4%
Source: Clinical Evidence-BMJ

Should we use ASA for primary prevention?
ASA role in primary prevention is uncertain.
Source: Clinical Evidence-BMJ (create your password starting from our front page link)

Should we use Plavix for stroke prevention (secondary prevention)?
No. ASA is good enough. There is no good evidence that Plavix is superior to ASA for secondary prevention of stroke. There is no significant difference between Plavix and aspirin - ARR 1.1% for both.
Source: Clinical Evidence-BMJ

What are the guidelines for using ASA and Plavix for primary and secondary prevention of CAD and stroke?
According to the Clinical Evidence:
Primary prevention: no data, trials are underway.
Secondary prevention of CAD: either ASA or Plavix (CAPRIE trial, which showed that Plavix was slightly better, barely reached significance with P 0.043). The situation is different when patients need PCI, then Plavix + ASA combination is indicated (PCI-CURE trial).
Secondary prevention of stroke: ASA or Plavix.

According to one of our neurologists, Dr. Hachwi, the choice is as follows:
Primary prevention - no data, trials are underway.
Secondary prevention of CAD: ASA + Plavix (CURE trial).
Secondary prevention of stroke: Plavix alone, if patient cannot afford it for financial reasons, then ASA alone. The combo ASA + Plavix increases the bleeding risk and this offsets any benefits.

Source: AFP 3/03, the Clinical evidence 1, 2, 3, CAPRIE trial in Lancet 1996, GP Notebook
Clinical Evidence-BMJ (create your password starting from our front page link)

Should we use dobutamine for decompensated end-stage CHF?
No. Positive inotropes (other than digoxin) are likely to be ineffective or harmful. One non-systematic review (6 RCTs, 8006 people) of RCTs found that non-digitalis inotropes increased mortality compared with placebo.
Source: Clinical Evidence-BMJ

Patient had a left carotid endarterectomy (CEA) 5 years ago. Do I need to monitor for restenosis by carotid Duplex?
No. The incidence of recurrent stenosis 70% or greater is 0.5% during a 6-year follow-up after a CEA. On the other hand there is often a progression in the stenosis of the contralateral artery which did not have a CEA. Bottom line: there is no established policy for post-CEA monitoring.
Remember that the carotid angioplasty and stenting (CAS) and CEA may be equally effective and safe.
Source: Pubmed

39 yo lady smoker is having bilateral toe pain and weak pulses. Can it be Buerger's disease?
Yes. Though Buerger disease is more common in males (male-to-female ratio, 3:1), incidence is believed to be increasing among women, and this trend is postulated to be due to the increased prevalence of smoking among women. Most patients with Buerger disease are aged 20-45 years.
Source: eMedicine

Does Raynaud's disease affect lower extremities?
Yes. In one study of of 474 females with primary Raynaud's Syndrome, 54·6% exhibited attacks in the fingers only, 42·7% in the fingers and toes, and less than 1% in the toes only.
Source: eMedicine, Podiatry college

How sensitive is elevated ESR in connective tissue diseases?
An elevated ESR value has a sensitivity of approximately 80 percent for polymyalgia rheumatica and greater than 95 percent for temporal arteritis. But normal ESR values do not rule out these conditions.
The sensitivity of an elevated ESR value is approximately 50 percent in patients with signs of rheumatoid arthritis. However, the specificity of an elevated ESR is quite low, limiting its use as a diagnostic test.
An extremely elevated ESR (>100 mm/hr) will usually have an apparent cause--most commonly infection, malignancy or temporal arteritis.
Source: AFP 1999, AFP 2002, FP Handbook

Patient is having a sickle cell trait (not the disease). Is it possible that she may have veno-occlusive crises?
Yes, although this is very rare. Patients with sickle trait have RBCs that contain only 30-40% HbS and have a benign clinical course. Sickling does not occur under physiologic conditions. Rarely, patients may experience hypoxia or shock when flying at high altitudes in an unpressurized aircraft, causing vaso-occlusive phenomena. Spontaneous hematuria, usually from the left kidney, also can occur. Dehydration may precipitate a crisis in people with sickle cell trait.
Source: eMedicine 1, 2

What is the iron profile of a person with sickle cell disease?
Iron profile typically shows iron overload. It is recommended to check ferritin or serum iron and TIBC at least once per year.
Source: AFP

65 yo male with DM2 wants a prescription for Viagra. Does he need a stress test?
Yes. Pre-Viagra treadmill tests to assess for stress-induced ischemia in patients with overt and covert CAD can guide the physician relative to the risk of cardiac ischemia during sexual intercourse. If the patient can achieve 5 to 6 METS on an ETT without demonstrating ischemia, the risk of ischemia during coitus is probably low and Viagra can be prescribed. In one study none of the men with a negative stress test had an MI during intercourse.
Source: ACC/AHA Expert Consensus Document - 1999
Erectile Dysfunction - NEJM 2000, Sexual Activity in Patients With Angina - JAMA 2003

What is the incidence of primary sclerosing cholangititis (PSC)?
Incidence in men is 1.25 per 100,000 person-years compared with 0.54 per 100,000 person-years in women. Prevalence of PSC is 20.9 per 100,000 men and only 6.3 per 100,000 women (95% CI, 0.1 to 12.5). Seventy-three percent of cases have IBD, the majority with UC.
Source: Gastroenterology

How often do we see pyoderma gangrenosum (PG) in IBD?
0.6% incidence. PG appeared 6.5 years on average after diagnosis of IBD in all patients. PG is a rare extra-intestinal manifestation of IBD that coincides with the exacerbation of the IBD but does not always respond to treatment of the bowel disease.
Erythema nodosum is seen in up to 3% of patients.
Source: Pubmed
Additional info: PowerPoint file on PG

Can the primary chancre in syphilis be painful?
Yes. In fact oral primary syphilis lesions are often painful. Genital primary chancre is classically not painful unless there is a superimposed bacterial infection but a reported literature review of 23 textbooks challenged this statement.

Bottom line: Don't rule out syphilis if a genital ulcer is painful.
Source: Pubmed, AFP, eMedicine, BDJ

Can the lesions of primary and secondary syphilis occur at the same time?
Yes, although typically the rash of secondary syphilis develops 4-8 weeks after the chancre heals. 30% of patients with secondary syphilis have evidence of a healed chancre.
Source: FP Handbook, Cecil Textbook of Medicine

Can TB cause a scrotal ulcer?
Yes, although this is rare and it is a consequence of chronic epididymitis or epididymoorchitis.
Source: eMedicine

What is the Incidence of Seizures after Head Trauma?
It depends on the severity of the injury.
The risk of posttraumatic seizures after severe injury is 7.1% within 1 year and 11.5% in 5 years, after moderate injury the risk is 0.7 and 1.6%, and after mild injury the risk is 0.1 and 0.6%. The incidence of seizures after mild head injuries is not significantly greater than in the general population.
Source: Neurology, Vol 30, Issue 7 683-689

Does eating peanuts increase cholesterol?
No. Actually peanuts are good for you. Eating peanuts decreases LDL by 14%. In general nuts consumption leads to 30-40% reduction in CAD risk. Don't go nuts for nuts though - there is a catch. Nuts are high in fat. In order to avoid gaining weight you should decrease the intake of other fats if you planning to increase your nuts consumption. In this case peanuts decrease even DM risk.
Source: Curr Atheroscler, Am J Clin Nutr, JAMA

Shrimp is high in cholesterol. Does eating shrimp increase serum LDL levels?
Yes, LDL is increased by 7% but at the same HDL is increased by 12% and TG are decreased. Study conclusion was that shrimp may be included in the "heart healthy" diet.
Source: Medline 1, 2

What is Job's Syndrome?
Job is character in the Old Testament who suffered from skin disease and other misfortunes. It is also called hyperIgE syndrome - an immune d%eficiency disorder secondary to deficient T cell production of gamma interferon. Children with the syndrome have very high IgE serum levels. Clinically they get severe recurrent infection, mainly due to Candida and staphylococci, presenting as skin, sinus and pulmonary infection.
Source: OMIM

What is the half life of Albumin?
20 days

What are the causes of Hypoalbuminemia?
Liver disease, Nephrotic Syndrome, Poor nutrition, Rapid IV hydration, Protein losing enteropathy, IBD, Severe burns, Neoplasia, Chronic inflammatory disease, Pregnancy, Oral Contraceptives, Prolonged immobility
Source: Family Practice Notebook

Does Troponin Increase in PE? How high can it go?
Yes. In a small case series, troponin concentrations were raised in patients with massive PE because of the dilatation of RV. The range in this case series was about 0.01-0.18 but in another study they mentioned levels as high as 2.5.
Source: BMJ

What is the definition of heavy alcohol use? What is a "drink"?
NIAAA definition for "heavy" alcohol use is
Men: Over 5-6 drinks per day
Women: Over 3-4 drinks per day

A drink is 12 grams of alcohol, e.g.
Can of 4.5% Beer (12 oz)
Glass of 12.9% Wine (5 oz)
Glass of 40% or 80-proof Liquor (1.5 oz)
Source: Family practice notebook

What is the risk of alcoholics to develop liver damage?
10-15 % of heavy alcoholics will develop liver damage
Source: Harrison's

How does Gout present?
90 percent of first attacks are monoarticular. In more than 50% the first MTP joint is the initial joint involved, a condition known as podagra. Joint involvement (in decreasing frequency) includes the MTP, the instep/forefoot, the ankle, the knee, the wrist and the fingers. In chronic gout polyarticular involvement becomes more common over time and can often mimic other forms of arthritis.
Source: AFP

What is the most common age for migrane headache onset?
The first attack often is in childhood, and incidence increases in adolescence. More than 80% of patients who develop migraines will have a first attack by age 30. They may begin or occur at any age but are less likely to begin after age 50.
Source: eMedicine

What are the causes of aseptic meningitis?
1-Viruses - most common - Enteroviruses – 50-80% , Arboviruses , HIV, HSV, Lymphocytic choriomeningitis virus, Mumps
2-Mycobacteria, 3-Listeria, 4-Syphilis, 5-Leptospira, 6-Toxoplasma, 7-Fungi - Cryptococcus, 8-Meningeal carcinomatosis, 9-Meningeal reaction to nearby inflammation, destructive process or medications
Source: Univ of North Carolina

Is liver failure one of the causes of high AG metabolic acidosis?
No. Liver failure can cause nonanion gap metabolic acidosis because of the failure to execrate ammonium. Just remember the mnemonic MUD PILES for causes of high AG metabolic acidosis.
Source: Harrison's, Family Practice Notebook

What is the earliest time to see an ischemic stroke on CT brain?
12-18 h. The sensitivity of the brain CT scan in the first 24h for brain infarction is 58% only.
Source: MGH

Patient with cirrhosis is having fever. Can I use Tylenol ?
Yes. In patients with chronic liver disease who have pain, acetaminophen can be used safely in a dosage of no more than 2 g per day. NSAIDs can cause idiosyncratic liver toxicity. Fatalities associated with NSAID use have been reported. Because of the unpredictable hepatotoxicity of NSAIDs, patients who have chronic liver disease should not use these medications.
Source: AFP

Are the neurofibrillary tangles and plaques specific for Alzheimer's dementia?
No. it can can happen in various other clinical diseases.
Source: NEJM

Is the multi infarct dementia region specific?
No. Any region infarction can be a high risk for dementia. However one study mentioned increased risk in lacunar infarcts and with hippocampal involvement (the memory area).
Source: Harrison's Textbook

What are the Causes of Junctional Rhythm?
1-Sick sinus syndrome (SSS)
2-Digoxin toxicity
3-Ischemia of the AV node especially with acute inferior MI
4-Acutely after cardiac surgery
5-Acute inflamatory process (eg. acute rheumatic fever)
6-Diphtheria
7-Drugs (eg. Beta blockers, CCB and most antiarrhythmic agents)
Source: eMedicine

Is Digoxin indicated in Cor Pulmonale?
No, except in cases of coexisting left sided CHF

What are the EKG changes in Cor Pulmonale?
Right axis deviation, Increased P wave amplitude in lead II, Incomplete or complete RBBB

What is the evidence behind the use of surgery in COPD?
Not very good.
There was a RCT Comparing Lung-Volume–Reduction Surgery with Medical Therapy for Severe Emphysema published in NEJM in 5/2003.
Lung-volume–reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with non–upper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volume–reduction surgery, because of increased mortality and negligible functional gain.
Source: NEJM

What is the incidence of asthma in the elderly?
6-7%.
Source: Pubmed.

What are the causes of hypoglycemia in nondiabetic patients?
The causes of hypoglycemia in nondiabetic patients can be divided into 2 categories:
1. Reactive hypoglycemia which happens after meals and is most commonly seen:
-after gastric surgery
-rare enzyme deficiency disorders like fructose intolerance

2. Fasting hypoglycemia which can be caused by:
-Medications: oral hypoglycemics, aspirin, Quinine, sulfa and pentamidine
-Alcohol
-Critical illnesses like sepsis with multiple organ failure, cirrhosis or kidney failure
-Hormonal deficiency: low glucagone, low cortisole, low GH, Low epinephrine or hypopituitarism
-Tumors like insulinoma
-Early diabetes
Source: NIH

How do we grade pitting edema? What is 2+ or 3+ ?
• 1+ - mild pitting, slight indentation
• 2+ - moderate pitting edema, indentation subsides rapidly
• 3+ - deep pitting - indentation remains for a short time, leg looks swollen
• 4+ - deep pitting, leg is very swollen

Source: college website but I think I've seen it in Bates' physical exam book.

Medscape is a better source:
Pitting" is the term used to describe the indentation caused when pressure is applied to the skin, forcing fluids into the underlying tissue. It occurs when there is an increased amount of low protein fluid in the interstitial space and is associated with disorders caused by high capillary filtration (DVT, chronic venous insufficiency, or venous obstruction) or hypoalbuminemia. Pitting is a subjective assessment using the grading scale of 1+ for mild and up to 4+ for deep pitting. Given the subjective nature of this assessment, continuity of provider is ideal when making successive assessments.

Yale SH, Mazza JJ. Approach to diagnosing lower extremity edema. Compr Ther, 2001, 27;242-252

Patient is having CRI, should I start ACEi ? What if Cr is 3? What if Cr increases from 2 to 4 with ACEi?
In patients with renal insufficiency, no creatinine level is an absolute contraindication to ACE inhibitor therapy. ACE inhibitors are not nephrotoxic. Baseline serum creatinine levels of up to 3.0 mg per dL (27 µmol per L) are generally considered safe. The manufacturers make recommendations for initiating treatment and suggest titrating the dosage slowly. An increase of 20 percent in the serum creatinine level is not uncommon and is not a cause for discontinuing the medication. For any higher increase, the family physician should consider a nephrologist. During the first four weeks of treatment, serum potassium and creatinine levels should be monitored closely.
AFP, CCF 1, 2

Is the CRI anemia a part of the anemia of chronic disease?
(CRI - Chronic Renal Insufficiency)
Anemia of chronic disease is associated with a wide variety of chronic disorders, including inflammatory conditions, infections, neoplasms and various systemic diseases. The diagnosis of anemia of chronic disease is NOT USUALLY applied to the anemias associated with renal, hepatic or endocrine disorders.
AFP

What is the MCV in CRI anemia? Normal or Low?
The anemia is usually normocytic but may be microcytic.
AFP

How accurate is the cocaine urine test?
Over 95% accurate

How long does cocaine and other drugs stay in the urine?
Cannabinoids (THC,Marijuana) 20-90 days
Cocaine (Crack) 3-5 days
Phencyclidine (PCP, Angel Dust) 1-30 days, Single (Use : 1-7 days, Regular Use : up to 30 days)
Opiates (heroin, Vicode, morphine, codeine) 2-7 days

When to D/C a patient with rhabdomyolysis? Is there a specific CK level which is safe for D/C?
Rhabdomyolysis is defined by a serum CK level of more than 1,000 U/L (more than fivefold that of normal).

High rates of IV fluid administration should be used at least until the CK level decreases to or below 1,000.

In a 1988 review, Ward suggested that predictors for the development of renal failure include peak CK more than 6000 IU/L, dehydration (hematocrit >50, serum sodium >150 mEq/L, orthostasis, pulmonary wedge pressure <5 href="http://www.emedicine.com/emerg/topic508.htm">eMedicine

There is much lower incidence of acute renal failure in exercise-induced rhabdomyolysis without nephrotoxic cofactors than in other forms of rhabdomyolysis.

When to use bicarbonate in rhabdomyolysis?
Urinary alkalinization is recommended for patients with rhabdomyolysis and CK levels in excess of 1000 IU/L. The objectives are to alkalinize urine to a pH of greater than 6.5 (thereby decreasing the toxicity of myoglobin to the tubules) and to enhance the flushing of myoglobin casts from renal tubules by means of osmotic diuresis. However, these measures should not be employed if oliguria is established despite initial generous hydration with normal saline. Conclusion - NS first, then bicarb. No bicarb. if oliguric.

Once the blood pressure is stable and urine output is adequate, the hydration fluid can be switched to a solution such as one-half isotonic saline to which sodium bicarbonate has been added. The goal of bicarbonate therapy is to alkalinize the urine, while minimizing any alkalinization of the plasma, which can promote calcium phosphate deposition and worsen or induce the manifestations of hypocalcemia. Thus, monitoring the urine pH, which should rise above 6.5 for renal protection, is essential. This goal may not be achievable in patients who already have developed renal injury. Thus, bicarbonate administration should be stopped if the plasma bicarbonate concentration becomes elevated in the absence of an alkaline diuresis. UpToDate

Abnormal CK levels are common among critically injured patients, and a CK level greater than 5,000 U/L is associated with RF. BIC/MAN does not prevent RF, dialysis, or mortality in patients with creatine kinase levels greater than 5,000 U/L.

How often do we see rhabdomyolysis in cocaine users?
24% of the cocaine users have rhabdomyolysis The patients' mean creatine kinase level was 12,187 U per liter (range, 1756 to 85,000). Thirteen of the 39 patients (33 percent) had acute renal failure; 6 of them died.

Is AVN (avascular necrosis) more common in young adults or in the elderly?
AVN is more common in adults 30-60 yo rather than in the elderly. Source: eMedicine, Dr.Erfan

I hear a carotid bruit - how significant is that?
Sensitivity and sensitivity of a carotid bruit for significant carotid stenosis (>70%) are in the 60s percentage wise.
Source: Best Practice of Medicine - Merck