Cardiology
Question: What is the FDA black box warning for use of everolimus in heart transplant patients? Answer:The US Food and Drug Administration issued a black box warning for everolimus due to the increased risk of mortality observed within the first three months posttransplanstation among patients started on the higher dose (3.0 mg/day) as de novo immunosuppression.
Question: What are manifestations of fulminant giant cell myocarditis? Answer: Giant cell myocarditis is a rare but potentially fatal form of myocarditis, characterized by severe heart failure, arrhythmias, and conduction disturbances. Clinical manifestations include new onset severe heart failure requiring parenteral inotropic or mechanical circulatory support, new ventricular arrhythmias, Mobitz type II second-degree atrioventricular (AV) block, third-degree AV block, or refractory heart failure.
Question: What is the oral torsemide dose equivalent for oral furosemide 80 mg? Answer: The oral torsemide dose equivalent to oral furosemide 80 mg is 40 mg.
Question: What is the mechanism of action for milrinone? Answer: Milrinone is a phosphodiesterase-3 inhibitor that increases cyclic AMP concentration, leading to enhanced calcium influx into the cell, a rise in cell calcium concentration, and increased contractility. It also has vasodilatory effects, decreasing cardiac filling pressures and increasing cardiac index.
Question: What is the standard INR goal for patients with a left ventricular assist device? Answer: The target INR for left ventricular assist device (LVAD) patients is 2.0–3.0, according to the 2019 EACTS Expert Consensus on long-term mechanical circulatory support.
Cardiothoracic Surgery
Question: Does on pump or off pump CABG yield better results? Answer: Both on and off pump CABG can be performed safely with roughly equivalent long term mortality rates. On pump CABGs tend to yield more bypass grafts which tend to stay patent longer. Off pump CABG has theoretical benefits of decreasing CVA’s or renal failure but this was not supported in the larger RCTs.
Question: Which is better, open or endovascular harvesting of saphenous vein for CABG? Answer: Endoscopic vein-graft harvesting is preferred to an open technique for CABG due to a comparable rate of major adverse cardiovascular events (MACE) such as mortality or vein-graft failure but a lower incidence of wound (leg) complications, better cosmetic appearance, and less pain.
Question: How many mitral valve repairs does a surgeon need to perform to attain mastery? Answer: This is currently unknown and would depend on several individual factors.
Question: What is a myocardial bridge? Answer: A myocardial bridge is a segment of an epicardial coronary artery that is intramyocardial, with the muscle overlying the intramyocardial segment. It is most commonly seen in the left anterior descending artery and is found in up to 25 percent of the population. It can cause myocardial ischemia, coronary thrombosis, myocardial infarction, and stress cardiomyopathy.
Question: What is the best second choice conduit for CABG? Answer: The second best choice conduit for CABG depends on patient characteristics including age, weight, coronary anatomy, pulmonary status, and renal failure as well as quality of the conduit. Generally speaking, the radial artery is likely the best choice as a second conduit in left sided lesions with high grade stenoses.
Infectious Disease
Question: Should secondary prophylaxis for CMV viremia be used for solid organ transplant recipients? Answer: Secondary prophylaxis against CMV is not routinely recommended for solid organ transplant (SOT) patients based on recent data showing that it prolonged the recurrence of CMV but didn’t alter outcomes otherwise. It could be considered in certain patients who have risk factors for severe disease or who may not tolerate early relapse well.
Question: What is the preferred treatment for Stenotrophamonas maltophilia infections? Answer: Bactrim is first line therapy for treatment of stenotrophomonas. Bactrim dosing would typically be 15 mg/kg of trimethoprim component divided q8 over 24 hours. Levofloxacin, ceftazidime, and minocycline are other options if the isolate is susceptible.
Question: When can CNS shunt be replaced after removal in CNS shunt infection? Answer: The optimal timing of new shunt placement has not been defined, but it should be tailored to an individual patient’s response to therapy. For patients with coagulase-negative staphylococci or C. acnes infection without associated CSF abnormalities and with negative CSF cultures for 48 hours following externalization of the shunt, a new shunt can be placed as soon as the third day following removal of the infected shunt. For patients with coagulase-negative staphylococci or C. acnes infection with associated CSF abnormalities but with negative repeat CSF cultures, a new shunt can be placed after 7 days of antibiotics. For patients with infection caused by S. aureus or gram-negative bacilli, a new shunt can be placed 10 days after CSF cultures are negative.
Question: What is the treatment for Mycobacterium abscessus infection? Answer: Treatment of Mycobacterium abscessus depends on the severity of infection and site involved. It generally requires use of at least 3 active agents, and usually includes an induction phase with at least 1 IV agent. For macrolide susceptible disease, this could be azithromycin plus amikacin plus either cefoxitin or imipenem. For macrolide resistant disease this may be IV amikacin plus cefoxitin or imipenem plus tigecycline. Agents like omadacycline, clofazimine, linezolid, tedizolid also have activity and can be used. Duration depends on site of involvement.
Question: What is the appropriate empiric treatment for ventilator associated pneumonia? Answer: Empiric therapy depends on the local resistance patterns of the hospital. In general, therapy should cover broadly for nosocomial pathogens including MRSA and Pseudomonas and other gram negative rods. As such vancomycin or linezolid in combination with piperacillin/tazobactam, cefepime, or meropenem would be reasonable. If local resistance of pseudomonas is high than using 2 pseudomonal agents up front pending susceptibility data is recommended.
Neurology
Question: What is the antiseizure medication of choice for benzodiazepine refractory status epilepticus? Answer: The antiseizure medication of choice for benzodiazepine refractory status epilepticus is a nonbenzodiazepine antiseizure medication, such as levetiracetam, fosphenytoin, or valproate, with lacosamide or phenobarbital as alternatives.
Question: What auto-antibodies are commonly associated with neuromyelitis optica spectrum disorders? Answer: Neuromyelitis optica spectrum disorders (NMOSD) are primarily mediated by the humoral immune system and are associated with a disease-specific autoantibody known as the AQP4 autoantibody. These auto-antibodies are highly specific for NMOSD and are present in approximately 70–80% of patients with the condition. In rare cases, patients with NMOSD may have auto-antibodies against myelin oligodendrocyte glycoprotein (MOG-IgG), another protein found in the central nervous system.
Question: What are the criteria for surgery for acute subdural hemorrhage? Answer: Urgent surgical hematoma evacuation is recommended for patients with acute subdural hematoma (SDH) and clinical signs attributable to brain herniation or elevated intracranial pressure (ICP), with urgent surgical hematoma evacuation for patients with SDH thickness >10 mm or midline shift >5 mm on initial brain scan. Larger SDH volumes are associated with worse outcomes.
Question: When do you give steroids for meningitis? Answer: Dexamethasone is recommended for adults with suspected bacterial meningitis in developed regions, and is given 15 to 20 minutes before or at the time of antibiotic administration to reduce the rate of hearing loss, other neurologic complications, and mortality in patients with meningitis caused by S. pneumoniae, which is the most common cause of bacterial meningitis in adults in the developed world. In areas of the developing world with high prevalence of HIV infection, poor nutrition, and significant delays in clinical presentation, dexamethasone is not recommended
Question: What is the MRI imaging pattern of toxic leukoencephalopathy and what are the causes of toxic leukoencephalopathy? Answer: MRI imaging of toxic leukoencephalopathy shows diffuse, symmetrical white matter hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences with a posterior to anterior gradient of involvement; the frontal lobes may be relatively spared. The most common causes of toxic leukoencephalopathy include exposure to certain drugs or chemicals, such as chemotherapeutic agents, immunosuppressants, and recreational drugs. Other causes may include infectious or metabolic disorders, such as hypoglycemia or hyperammonemia.
Pediatrics
Question: Are bronchodilators indicated in the treatment of bronchiolitis? Answer: Bronchodilators are not recommended for the treatment of bronchiolitis. Oral bronchodilators have been associated with adverse effects, such as increased heart rate, and have not been shown to shorten clinical illness or improve clinical parameters.
Question: What imaging studies are indicated following a febrile UTI in a 2 month old infant? Answer: Following a febrile UTI in a 2 month old infant, routine renal and bladder ultrasonography (RBUS) is indicated. Additionally, voiding cystourethrogram (VCUG) may be obtained to diagnose vesicoureteral reflux (VUR).
Question: What are the common causes of microcytic anemia in a child? Answer: The most common causes of microcytic anemia in children are iron deficiency and thalassemia.
Question: What are the clinical criteria needed to diagnose Kawasaki disease? Answer: Kawasaki disease is diagnosed based upon evidence of systemic inflammation (eg, fever) in association with signs of mucocutaneous inflammation. The characteristic clinical signs are bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, rash, extremity changes, and cervical lymphadenopathy. Diagnosis requires the presence of fever for more than 5 days, combined with at least four of the other five signs of mucocutaneous inflammation, without any other explanation.
Question: How do you mitigate liver dysfunction when a patient requires TPN? Answer: Several measures can be taken to mitigate liver dysfunction. These include protecting the TPN solution from light, minimizing the amount of aluminum contamination, avoiding intravenous tubing containing DEHP, and changing the lipid source to a fish oil-based lipid emulsion.