Wednesday, April 24, 2019

Think before you order a test: High resolution CT scan (HRCT)

Hello, 

Let's talk about HRCT today!

HRCT is the use of thin-section CT images (0.625-mm to 1.5-mm slice thickness) with a high spatial frequency reconstruction algorithm, to detect and characterize diseases that affect the pulmonary parenchyma and small airways.

HRCT cuts THIN slices.

Awesome, isn't it? Why not use an HD camera for every photograph?

Because it comes with a price!

Treating Alcohol withdrawal - scheduled vs PRN benzodiazepines

Hello,

Sometimes it's frustrating to see different physicians use different approaches to management of the same condition or disease. How do you practice in that case?

You look at the evidence, the guidelines and make your own decision based on it.

Then even though if your attending practices something opposite of what the guidelines say, you know what is right and what you will practice in the future :)

Anyway, now that I am done venting - what do guidelines say about scheduled vs as needed benzodiazepines for alcohol withdrawal?

Thursday, April 18, 2019

Chimeric antigen receptor T cells (CAR T cells) therapy simplified

Hey everyone! Upasana - our funny medical student made a simplified video on CAR T cell therapy. Check it out!



I copy-pasted a quick short post in text for reference :)

Monday, April 15, 2019

Orthopaedics: Facebook Septic arthritis Vs Transient synovitis

#Medicowesome
#Orthopaedics

Q) A 4 year old kid comes to OPD with complaints of high grade fever, decreased appetite and pain in right hip. On examination he has dehydration/ tenderness in Scarpa's traingle/ swelling in right hip region, flexion, abduction and external rotation at hip/ absent movements in right hip region. On Xray there is mild increase in medial joint space. Diagnosis is

1) Septic arthritis
2) Transient synovitis
3) Tubercular arthritis
4) Dislocation of hip

Answer is 1) Septic arthritis

Let us dissect this Multiple choice question. Read the question one more time and let's follow up. Put your Sherlock holmes hat and let's see what we can deduce!

1) A 4 year old kid.
2) Toxic due to dehydration.
3) In his right hip we have - Flexion, abduction, and external rotation. This collectively is called as FABER! Big clue here.
4) Absent movements

Looking at the option given, we can definitely eliminate dislocation of hip. It has FADIR - Flexion, Adduction and internal rotation.
Coming to TB. Now if try to recollect the 5 stages of TB you will find that 1st stage is FABER and next two stages are FADIR! 5th stage is Fibrous ankylosia known as TB arthritis. 4th stage has Wandering Acetabulum (It is a misnomer because both acetabulum and femur head is destroyed so actually remaining part of femur wanders! - also known as - Pestle and Mortar type)

Now two options left - Transient synovitis and Septic arthritis. Well you know Septic arthritis is an emergency condition. Even if you don't know any thing about other option, you can still get it correct. Child is toxic and absent movements points out toward emergency condition.

Both Transient synovitis and septic arthritis causes FABER which leads to more space in the joint leading to more inflammation and swelling. Any swelling disease in Orthopedics is approached as
"XMAS"
X- Xray
M-MRI
A-Arthroscopy which is USG guided.
S-(for)Swelling diseases

Wait! What would be treatment modalitis for both of them?
Ofcourse surgery followed by 6 weeks of Antibiotics for Septic arthritis
Whereas Transient synovitis as name suggest is less severe so we do conservative treatment.

Remember:
Septic arthritis - Absent movements
Transient synovitis - Decrease movements

Saturday, April 13, 2019

What Is Going On In Migraine?

Despite the high prevalence of migraines, the underlying pathophysiology is poorly understood.

What was thought?
Cerebral and meningeal arteries dilatation. Now largely disproven.

What do we think?
- MRI says episodic cerebral edema with dilatation of intracereberal vessels and less water diffusion that doesn’t respect vascular territories.

- PET says it’s a subcortical disorder affecting modulation of sensory processing.

- Magneto-EncepaloGraphic (MEG) scan suggests failure of inhibitory circuitry in the visual cortex.

- Hormones play a role. Migraines occur just as commonly in males as in pre-pubertal and post-menopausal females but the ratio tilts towards women of reproductive age group by 3:1. About half of the women complain of migraine synchrony with menses.

- 5-HT overload as suggested by its metabolites in the urine. While the exact significance is controversial, the efficacy of Triptans (5-HT 1b/1d agonists) supports its role.

- Trigeminal nerve dysfunction suggested by blockade of trigeminal nerve impulses by Triptans. They also inhibit release of substance P and pro-inflammatory neuropeptides.

This is what we know so far. To thread this string is your responsibility, future Dr. Neurologist. Good luck!



- Ashish Singh

Thursday, April 11, 2019

Hierarchy Of Evidence

Evidence-based medicine is the conscientious and judicious use of current, best research evidence to optimise management plans.
Here’s the order of importance.


[Please click on the image to enhance it]



That’d be all.


- Ashish Singh











Wednesday, April 10, 2019

Unique iris behavior in bleeding

Iridodialysis bleeds profusely as the circulus major arteriosus lies near it's root.
Conversely, sphincterotomies or YAG iridotomies hardly bleed. Why? Because the vessels in the iris away from it's root are intertwined within it's musculature. The muscles contract immediately, halting any hemorrhage.


Monday, April 8, 2019

Burnout Advice.... Jay's 2 cents s/p reading Ikan's post

Burnout is a very common thing among us medicos. That spans from being a medical student upto a resident or even a consultant sometimes!

We feel stupid most of the times and some of our seniors have that bad habit of making the juniors feel bad.

But trust me, you WILL become as good as them, and even better! Medical field needs experience and alot of reading. Med school teaches us maybe 1/10th of what we should know as a doctor. And the remaining we learn on the job.

There is always more to learn more to read and more to understand but medicine is not a lonely game. Always refer, and ask! In Medicine, 2 brains are always better than 1 brain. Don't feel shy or bad to ask for help.

Use your head! If they belittle you, tell yourself you will learn it. Smile and move on.

For me each time I lose motivation, I watch an episode of a Medical TV series. It could be HouseMD, The Resident, New Amsterdam, Good Doctor, Chicago Meds, or any random episode I find in Youtube.
Watching them gives me the feeling of impact I can have in others' lives.

I also go through Youtube videos from famous Medical youtubers, few of my favorites are Jane and Jady, TheStriveToFit, Ali Abdal, DoctAura etc. They have amazing study tips and other medical related things that can give you the motivation to read and learn.

Sometimes I go through #Studygram handle in Instagram. There are many colourful notebooks and workspaces, it really inspires me and gives me a free mind to study.

I also like to read the study tips written by my fellow authors. They have eye opening and motivational tips that really makes me go sit and get that one chapter done.

If all these don't work, just listen to your favorite songs and move your body a little bit when your room mates are not watching! 😂 It definitely gives some positivity to shrug off that sad burnout feels.

Yes! I find most of my inspiration and motivation by online activities rather than going out and resting under the trees. One reason being Im not a very outgoing person and another being I have very little time as a Junior Intern.

And also it helps to clean your room. And cooking a meal for you and/or your family/partner. It would leave you with a clutter free environment and a tasty meal to eat. And if things go well, a lot of praising for your yummy food by others with make your self esteem get better too.

Then get a yummy dessert or make one. Sometimes I just eat a slice of custard cake on my way home, or cook a simple bread pudding and share with my roomies. Although they jump into finish it
and finally leaving me a little piece. ( Those two a-holes!!! 😂😂)

You don't need a trip to beach or hike to mountain, but sometimes sleep on a cozy bed with newly washed sheets, after a warm bath, applying your favorite night lotion, a drop of nice smelling essential oil behind your ears and wearing relaxing clothes will refresh you too.

These are few of my techniques to feel good after a toxic day with disastrous rounds.

Confession : I have had my fair share of bad days. I was punished for silly mistakes. I was sanctioned with extension of duty and forced to work extra hours to compensate for it. But we gotta accept our short comings, learn from our mistakes and move on. We at Medicowesome are not saints or gods to dictate how you should live and everyone of us had made errors, said wrong things in rounds, got shouted at, failed exams, and some of us even went through psychiatric help to get over any of the depressive periods we had

But what is most important is, NONE of us gave up! I take this time to thank my Medicowesome family for helping each other and even helping me rise up in such times when I was so low. Behind the groups and the blog, we are an amazing group of friends although many of us have never met each other. Medicowesome is my support group, and we all need one including you. Find your supportive group, and for the records don't forget we at Medicowesome as also on your back, ready to hold you up.

Stay strong and comment or message us about your methods of tackling a toxic day or a burn out session. So we all can learn from it.

Keep it up! Take care and always....be awesome!

With love,
-Jay

Sunday, April 7, 2019

Residency and burn out advice

Here's a conversation I had with a friend of mine. She's a resident in a busy government hospital in Mumbai.

I still feel like Jon Snow (I know nothing). I feel like I'm stuck at the basics. And seniors expect a lot. It is somehow unfathomable to me that someday I will be even one tenth as smart as them. Morning rounds as a massacre. It's like beheading my already non existent self confidence. I feel so stupid everyday. I have no energy to study.

I'm trying so hard to not let it get to me but everyday I get to hear criticisms either from professors or immediate seniors. I wasn't born stupid Nakeya but everyday I feel like I've bitten off more than I can chew and chosen a career that's too difficult for me. I feel thoroughly demotivated these days. Like I'm just working because I have to. I feel like I've lost interest only to improve and be better everyday.

Me:
It's OKAY to feel stupid. I think it's everyone of us. It's a part of learning. Indian culture has not developed a way to give constructive feedback... So you got to modify the words they say and take it in a way that motivates and inspires you. It's... I'm pretty sure it's just the culture that makes you feel more stupid than you should feel. The career is not difficult. The training is. You're not stupid. The way they teach is!

We do this thing every week - We share our humanistic experiences with everyone. It could be as simple as holding grocery bags for an old lady.  It really helps. We tend to think about the things we did wrong and belittle ourselves. But we need to think about the good things we did. The things we did right. Made a baby smile when they were sick. Made a correct medical decision. Got the IV in the first go. We need to celebrate the little things.

Take time off from medicine and rest whenever you get a chance.

-IkaN

Wednesday, April 3, 2019

Asking Questions

History taking in medicine is science just as much as art. Here are some tips.

DOs

Open questions: ‘How are you?’ ‘How does it feel?’
The direction a patient chooses offers valuable information.
‘Tell me about the vomit’
‘It was dark’
‘How dark?’
‘Dark bits in it’
‘Like...?’
‘Like bits of soil in it’
This information is gold although it does not cast in the form of coffee grounds.

Patient-centred questions: Patients may have their own ideas about their symptoms, how they impact and what should be done. This is ever truer as patients frequently consult Dr. Google before their physicians. Unless their ideas, concerns and expectations are dealt with, your patient may never be fully satisfied with you or be fully involved in their own care.

Considering the whole: Humans are not self sufficient units; we are complex relational beings, constantly reacting to events, environment and each other. To understand your patient’s concerns, you must understand their context: family, friends, work, dreams and fears. A headache caused by anxiety is best treated not with analgesics; but by helping the patient access support.

Silence and echoes: Often the most valuable details are the most difficult to verbalise.
Trade secret: the best diagnosticians in medicine are not internists, but patients. If only the doctor would sit down, shut up and listen, the patient will eventually tell him the diagnosis.
While powerful, silence should not be oppressive- try echoing the last words said to help your patient vocalise a particular thought better.

DON’Ts

Closed questions: Permit no assumptions. Take no subtle information for granted. Let the patient paint you a picture.

Questions suggesting an answer: The doctor’s expectation and hurry to get the evidence into a pre-decided format have tarnished the patient’s story enough to render it useless.

- Ashish Singh

Pathophysiology: Diabetic Ketoacidosis

Hello guys, here’s a whiteboard summary of how DKA happens.


[Please click on the image to enhance it]

- DKA is a medical emergency. It’s a complication of type 2 diabetes.
- DKA has a triad of hyperglycemia, ketosis [metabolic acidosis] and dehydration.
- Main ketone bodies are beta-hydroxybutyrate and acetoacetate. Acetone is only a minor ketoacid.
- Lactic acidosis also contributes to metabolic acidosis.
- More glucose in blood leads to more glucose filtered into urine causing osmotic diuresis.


- Ashish Singh 

Friday, March 29, 2019

Burkitt’s Lymphoma types

There are three types of Burkitt’s Lymphoma: Endemic (African), Sporadic  (non-endemic) and immunodeficiency-associated.

Molecular mayhem - AML relapse after HSCT

Hello,

For many hematological disorders including AML, CLL, ALL HSCT is the only viable therapeutic option when cytogenetics are not conducive for chemotherapeutic agents. However subsequent relapses are not uncommon which are due to subtle molecular alterations because of underlying and acquired mutations.

Thursday, March 28, 2019

WhiteBoard Summary: Lichen Planus

Hi guys, let’s talk dermatology.

Lichen Planus is a papulosquamous disease that affects skin, nails and mucous membrane, caused by cell-mediated immunity of unknown aetiology. Here’s a (not-so-white) whiteboard summary.

[Please click on the image to enhance it]


- Morphological variants can be hypertrophic, atrophic, erosive, follicular, annular, vesicular, bullous, actinic or pemphigoid.
- Lichenoid reaction can be caused by drugs (thiazides, antimalarials, penicillamine, gold) and even in Graft vs. Host disease.
- Those with steroid resistance/ intolerance are treated by hydroxyquine, methotrexate or sulfasalazine.
- Psoralens can also be used along with UV-A radiation.
- Patient education regarding self-limiting and recurrent nature of the disease is important.


- Ashish Singh

Wednesday, March 27, 2019

Pathophysiology: Multiple Sclerosis

Hey guys, let’s look at the fundamentals of multiple sclerosis.

Multiple sclerosis is an autoimmune disease of the CNS characterised by
- chronic inflammation
- demyelination
- reactive gliosis/ scarring
- neuronal loss
with a course that is relapsing-remitting or progressive
and lesions that are disseminated in time and space.

Here’s how it happens:

[Please click on the image to enhance it]


- Ashish Singh

Antibiotics: Action and Resistance

A series of fortunate events - including a cancelled holiday and an unpredictable British summer - in 1928 began the antibiotic revolution, when Alexander Flemming’s observation that a contaminating Penicillium colony caused lysis of Staphylococci.

Here’s a pictorial summary of various sites of action of modern-day antibiotics.

[Please click on the image to enhance it]


However, the capacity for prokaryotic bugs to develop resistance far outweighs the human capacity to develop new antiobiotic drugs.
Antibiotic resistance can be:
- Intrinsic: Inherent structural or functional characteristics, eg: vancomycin cannot cross the outer membrane of Gram negative bacteria.
- Extrinsic: Acquired through years of mutation and/or transfer of resistance properties. This evolutionary phenomenon is accelerated by selection pressure from antibiotic use, eg: beta lactamase producing Gram positive bacteria.



- Ashish Singh

WHO Pain Ladder

Humans are the most exquisite devices ever made for experiencing pain; the richer our inner lives, the greater the varieties of pain there are for us to feel.
As physicians, never forget how painful pain is, nor how fear magnifies pain. Try not to let these sensations, so often interposed between your patient and recovery, be invisible to you as he/ she bravely puts up with them.

[Please click on the image to enhance it]

ALWAYS GO UP THE PAIN LADDER, IF PAIN PERSISTS/ INCREASES.
- Simple analgesics are non-narcotic.
- Review and chart each pain carefully and individually.
- Identify and treat underlying pathology, wherever possible.
Adjuvants:
1. Neuropathic pain: Gabapentin, Pregabalin, Amitriptyline, Duloxetine, Steroids
2. Bone cancer pain (primary or mets): Radiotherapy, Bisphosphonates
3. Intestinal/ Renal colic: Hyoscine butylbromide
4. Muscle spasm: Baclofen
5. Brief pain relief: Nitrous oxide (usually with oxygen)


- Ashish Singh

Friday, March 22, 2019

Mnemonic: Incubation Period of Hepatitis

Hey guys, here’s a simple little mnemonic to remember the incubation period of various hepatitis infections.

Rule of 4 to 8:

Hep A - 4 weeks
Hep E - 5 to 6 weeks
Hep C - 7 weeks
Hep B/D - 8 to 12 weeks

Pay attention to the order of Hep infections from 4 to 8.

Why A&E first? That’s because they enter through the mouth (feco-oral mode of transmission) and your mouth is the first part of your GI.
Remember Hep D co-infects or super-infects Hep B.

- Ashish Singh

Thursday, March 21, 2019

A-a Gradient

A-a gradient =[PAO2 - PaO2]
where:

A-a gradient = difference between alveolar PO2 and arterial PO2

PAO2 = alveolar PO2 (calculated from the alveolar gas equation)

PaO2 = arterial PO2 (measured in arterial blood)

PAO2 =150 - PaCo2/0.8


Normal range for A-a gradient is

10-15 mm Hg


ALL causes of hypoxemia lead to ↑ A-a gradient, EXCEPT:

Hypoventilation, high altitude, upper airway obstruction (e.g. epiglottitis from Haemophilus influenzae, or croup from parainfluenza virus)

Everything else will cause ↑ A-a gradient (e.g. shunt, V/Q mismatch, etc.).  

It's much better to remember the exceptions, then everything else becomes the rule!


Also to adjust for age, the thumb rule to calculate A-a gradient is :

Age /4   plus 4


A-a gradient >30 is considered elevated regardless of age.


Bhopalwala. H

Catheter Removal Timing

Removal — Following diagnosis of catheter-related infection, catheter removal is warranted in the following circumstances :

●Severe sepsis

●Hemodynamic instability

●Endocarditis or evidence of metastatic infection

●Erythema or exudate due to suppurative thrombophlebitis

●Persistent bacteremia after 72 hours of antimicrobial therapy to which the organism is susceptible

Source :Uptodate

Bhopalwala. H

Lung Biopsy in VAP

Lung biopsy in Ventilator-associated Pneumonia may be reserved for patients in whom infiltrates are progressive despite antibiotic therapy or patients in whom a non-infectious etiology is suspected.

The purpose of acquiring tissue under these circumstances is to identify a pathogen that may have been missed with previous sampling or a pathogen that is difficult to culture (eg, fungus, herpes viruses) or to identify a noninfectious process masquerading as infection (eg, cancer, cryptogenic organizing pneumonitis, lymphangitis, interstitial pneumonitis, vasculitis).

Source: Uptodate

Bhopalwala. H

Just when you lose hope....

(This is a bit of an off-academic post. So if you are on exam season, avoid reading this.)

Being a doctor!..... we all have dreamt of it. Since we were kids we wanted to wear that stethoscope, walk in long hall ways, go to those people with pain and help them...

You wil watch a TV series and when a surgeon would say "Scalpel please!" you feel goosebumps thinking one day you wanna do it...

But there are somedays you just get home or to hostel from medschool or hospital, and you just don't want to do it anymore. You feel like your passion is lost. You feel like you are no more yourself!

YES! We all have gone through this at least once or even more times in our lives. And when you say this, many other medical students will relate to you too.

Whenever you feel so demotivated, just think WHY YOU STARTED THIS AT THE FIRST PLACE? Did you do it by your will? What made you decide this?

For an example, I always wanted to be a doctor, but my will to become a doctor became so strong when my grandpa passed away in a govt hospital because the doctor in charge didn't diagnose that he was having a heart attack. That day I decided I want to be that doctor who will correctly diagnose and treat people to the best capability I can. I wanted to stop anyone else's family member to pass away because of gross incapacity of a doctor.

You may also have a reason like this if you dig inside your mind. And you will find this reason to fire you up again. To make you push through that one more chapter. Go to that one more ward with a wide smile despite you are sleepless and tired.

Find your reason to stay, not to leave! Because once you are on this voyage, you have decided to work for the betterment of the world and the people, and if you quit midway, it's such a waste, my friend!

Many people dream to be in our shoes. If we give it up, we just are ruining a chance of someone else to be a doctor. So make that medschool seat you owned, be worth it.

Another thing! Going through medschool is not a single man's job. It needs hell load of a support. Find this support system in your family, in your significant other, in your friends, and anyone who would give you strength to carry on, and someone who would motivate you, someone who would be there to say "You can do this! I'm with you!".

Medical books are boring, but books are not the only way you can learn anymore in this digital world. You have millions of videos and interactive websites you can find. You have blogs like our www.medicowesome.com where we breakdown big medical info into small pieces and clarify.

Get your stuff together, clean up your workspace. Cleaner table will motivate you to study too. Use some motivating words in front of your workspace, On your phone's wall paper, On your notebooks! Simply everywhere you would see. If someone would judge you for that, make them your motivation too. Stick up a motivating note on their forehead too! 😂 Just kidding! Ya just keep that smile on always!

Life is great! Medical life is even greater! With all its failures, late night cries, exam phobhias, senior bullies, colleague dramas, its all worth it.

Finish your degree...! This pain lasts only few years! Once you are a fully fledged doctor, you can go ahead and be that wonderful human being you always wanted to be! Don't kill that wonderful person even before you get there!!

We are all voyagers of this same hard journey wherever we are in this world! So let's do this! And in any case you need someone to guide you through your academic related depression or demotivation, always count on us here in Medicowesome!

Have a great day and go own that damn degree!!! 😍

Good luck! See ya later!

Yours,

Jay.

About me by Srikar Sama

Hello there awesomites!

I am a new author here. I am really excited to be here!!! Let me introduce myself


I am Dr. Srikar Sama currently doing internship from Gandhi Medical College, Hyderabad, India. I'm currently preparing for step1 and hope to match into IM/Radiology soon :)

Talking about my hobbies,I love Sci-Fi and fantasy movies (Huge fan of MCU too :P).
I'm obsessed with Game of Thrones, Breaking bad and House MD💙. 
I love dogs, especially Samoyed😍.
I like to travel, meet new people and want to taste local cuisine in all the cities I visit :P
I also love anime(Death Note is my all time fav!!!!), Playing video games and cricket :)

Thanks IkaN for giving me this opportunity! I love making new mnemonics and writing articles for this blog!! I hope you'll enjoy reading my articles.
That'll be all for now. Good luck awesomites.Love Y'all. Live long and prosper✌

-Srikar Sama.

Diagnosing the cause of polycythemia

Polycythemia refers to an increased hemoglobin concentration and/or hematocrit in peripheral blood.
For Diagnosing the specific cause of polycythemia follow these 3 steps:

STEP1: First check for RBC mass
1)Elevation of Hgb and/or Hct due to a decrease in plasma volume alone (ie, without an increase of the RBC mass) is referred to as relative polycythemia.
2)An increase of RBC mass refers to Absolute polycythemia. It can be categorized as either primary or secondary polycythemia.

STEP2: To diagnose the causes of absolute polycythemia. Check for EPO levels
1)Primary polycythemia is caused by a mutation in RBC progenitor cells that results in increased RBC mass. So there is a decrease in EPO levels. Ex: polycythemia vera (PV)
2)Secondary polycythemia refers to an increase of RBC mass caused by elevated serum EPO. Most often, this is due to an appropriate physiologic response to tissue hypoxia, or by autonomous EPO production(eg, an EPO-secreting tumor) 

STEP3: To diagnose the causes of secondary polycythemia. Check PaO2 and SaO2 levels
1)If PaO2<65% and SaO2<92% then it is because of chronic hypoxia due to high altitude, COPD, Smoking, etc.
2)If PaO2 and SaO2 levels are normal then consider EPO-secreting tumor(renal cell carcinoma, pheochromocytoma).

-Srikar Sama

Places to Target for Research

Places to target first for a Research Position (Big Guns) :
Mayo Clinic, Rochester
Mayo Clinic, Florida
Cleveland clinic, Ohio
Cleveland clinic, Florida

Email Format for Research

Email Format  for a Research Position

Hello Dr. XYZ,

I am ABC, a medical student, currently doing clinical elective rotations.

I'm highly interested in cardiology. Your /Case Western Reserve University's research work ( refer to either the person's or the University's work) , particularly in general cardiology and electrophysiology is exemplary.

I believe you accept volunteer Research Scholars. It would be an honor to work in this institute as a Research Scholar.

I would be willing to work for a year, and would also consider an unpaid position.

I am attaching my CV with this email.

Hoping to hear back from you.

Wish you a happy new year.

Thanks.

Hope this helps :)

Bhopalwala. H

How to Land a Research Spot in USA

Hey guys, how's it going?
So this post is going to be about how to land a research position in USA.
First of all I would like to briefly speak about  why it is important to have some research experience in USA. Common idea is it helps people to build a strong CV to cover up low scores or any red flags in the CV. What I have realized is that it is not the only benefit, to get into a competitive specialty for residency and also for future fellowships it's very important to have some research background in the field of your interest.

Now let's talk about the steps to go through before you land a research spot.

Wednesday, March 20, 2019

Catheter Related Candidemia Treatment Indications

Empiric therapy for suspected catheter-related candidemia should be administered for septic patients with the following risk factors:
●Total parenteral nutrition
●Prolonged use of broad-spectrum antibiotics
●Hematologic malignancy
●Hematopoietic cell or solid organ transplant
●Femoral catheterization
●Colonization due to Candida species at multiple sites

Source: Uptodate

Bhopalwala. H

Antibiotic Lock Therapy

Antibiotic lock therapy —
The premise of ALT is to achieve sufficient therapeutic concentrations to kill microbes growing in a biofilm . ALT may be a useful adjunctive therapy together with systemic antibiotic therapy for intraluminal infections due to coagulase-negative staphylococci or gram-negative organisms in the setting of CRBSI (Catheter Related Blood Stream Infection) when the catheter cannot be removed .
ALT should not be used for extraluminal infections nor for management of infections due to S. aureus, P. aeruginosa, drug-resistant gram-negative bacilli, or Candida.

Source: Uptodate

Bhopalwala. H

Timing of Catheter Replacement in CRBSI

In general, the patient should receive antibiotic therapy for at least two to three days following device removal prior to device replacement. At the time of device replacement, the patient should be hemodynamically stable with negative blood cultures and no sequelae of bloodstream infection .In addition, for patients with CRBSI ( Catheter Related Blood Stream Infection) due to S. aureus, a new catheter may be placed if additional blood cultures demonstrate no growth at 72 hours

Source: Uptodate

Bhopalwala. H

Immunization certificate sample for electives and observerships

Hello,

Since many of you emailed me regarding the  immunization form, I thought of sharing it on Google Docs.

Tuesday, March 19, 2019

Step 2 CS: Neurology Case mnemonic

The following mnemonic (HDFC ST) helps me cover all bases in a Neurology case.

Right to left shunt causing Hypoxemia

A right-to-left shunt exists when blood passes from the right to the left side of the heart without being oxygenated. There are two types of right-to-left shunts:

●Anatomic shunts exist when the alveoli are bypassed. Examples include intracardiac shunts, pulmonary arteriovenous malformations (AVMs), and hepatopulmonary syndrome.

●Physiologic shunts exist when non-ventilated alveoli are perfused. Examples include atelectasis and diseases with alveolar filling (eg, pneumonia, acute respiratory distress syndrome).

Right-to-left shunts cause extreme V/Q mismatch, with a V/Q ratio of zero in some lung regions. The net effect is hypoxemia, which is difficult to correct with supplemental oxygen.

The degree of shunt can be quantified from the shunt equation:

Qs/Qt  =  (CcO2  -  CaO2)  ÷  (CcO2  -  CvO2)

where Qs/Qt is the shunt fraction, CcO2 is the end-capillary oxygen content, CaO2 is the arterial oxygen content, and CvO2 is the mixed venous oxygen content. CaO2 and CvO2 are calculated from arterial and mixed venous blood gas measurements, respectively. CcO2 is estimated from the PAO2.

Source: UpToDate

Bhopalwala. H

Causes of Hypoventilation

Hypoventilation — 

The lung alveolus is a space in which gas makes up 100 percent of the contents. This means that once the partial pressure of one gas rises, the other must decrease. Both arterial (PaCO2) and alveolar (PACO2) carbon dioxide tension increase during hypoventilation, which causes the alveolar oxygen tension (PAO2) to decrease. As a result, diffusion of oxygen from the alveolus to the pulmonary capillary declines with a net effect of hypoxemia and hypercapnia. Because the respiratory quotient (Defined as CO2 eliminated/O2 consumed) is assumed to be 0.8, hypoventilation affects PaCO2more than O2.

Hypoxemia due to pure hypoventilation (ie, in the absence of an elevated A-a gradient) can be identified by two characteristics. First, it readily corrects with a small increase in the fraction of inspired oxygen (FiO2). Second, the paCO2 is elevated. An exception exists when the hypoventilation is prolonged because atelectasis can occur, which will increase the A-a gradient . Abnormalities that cause pure hypoventilation include:

●CNS depression, such as drug overdose, structural CNS lesions, or ischemic CNS lesions that impact the respiratory center

●Obesity hypoventilation (Pickwickian) syndrome

●Impaired neural conduction, such as amyotrophic lateral sclerosis, Guillain-Barré syndrome, high cervical spine injury, phrenic nerve paralysis, or aminoglycoside blockade

●Muscular weakness, such as myasthenia gravis, idiopathic diaphragmatic paralysis, polymyositis, muscular dystrophy, or severe hypothyroidism

●Poor chest wall elasticity, such as a flail chest or kyphoscoliosis

Bhopalwala. H

Thursday, March 14, 2019

Types of Sphenoid Sinues.

Hello Guy's!

Here's a sneak peek into the world of Neurosurgery!

In cases of Pituitary Adenomas, the general surgical approach is a TransNasal TransSphenoidal Approach for the excision of the lesion.

To know the type of sphenoid sinus is an important step in the pre-operative planning for the surgery. It also helps in estimating the site where we are most likely to encounter the tumor and the pituitary gland.

Hamburger classified 3 types of pneumatization based on its relationship to the sella turcica.

1)Conchal (rudimentary or absent sphenoid sinus)

2)Presellar (a posterior sphenoid sinus wall that is separated from sella by thick bone).

3)Sellar (a posterior sphenoid sinus wall that is adjacent to sella).

That's all for now... Time to Scrub.

Let's learn Together!

~Medha Vyas.



Tuesday, March 12, 2019

Restrictive vs Liberal approach to transfusion in Sepsis

Hello everyone, 

Here are some studies on approach to blood transfusion during sepsis:

One multicenter randomized study of 998 patients with septic shock reported no difference in 28-day mortality between patients who were transfused when the hemoglobin was ≤7 g/dL (restrictive strategy) and patients who were transfused when the hemoglobin was ≤9 g/dL (liberal strategy) . The restrictive strategy resulted in 50 percent fewer red blood cell transfusions (1545 versus 3088 transfusions) and did not have any adverse effect on the rate of ischemic events (7 versus 8 percent).

One randomized trial initially reported a mortality benefit from a protocol that included transfusing patients to a goal hematocrit >30 (hemoglobin level 10 g/dL) . However, similarly designed studies published since then reported no benefit to this strategy. 

Bhopalwala. H

Source: UpToDate 

Norepinephrine in ICU

Norepinephrine (noradrenaline) Levophed

8 to 12 mcg/minute (0.1 to 0.15 mcg/kg/minute)

A lower initial dose of 5 mcg/minute may be used, eg, in older adults 2 to 4 mcg/minute (0.025 to 0.05 mcg/kg/minute) 35 to 100 mcg/minute (0.5 to 0.75 mcg/kg/minute; up to 3.3 mcg/kg/minute has been needed rarely)

Initial vasopressor of choice in septic, cardiogenic, and hypovolemic shock.
Wide range of doses utilized clinically.

Must be diluted; eg, a usual concentration is 4 mg in 250 mL of D5W or NS (16 micrograms/mL).

Bhopalwala. H

Milrinone in ICU

Inotrope (nonadrenergic, PDE3 inhibitor)

Milrinone Primacor

Optional loading dose: 50 mcg/kg over 10 minutes (usually not given) 0.125 to 0.75 mcg/kg/minute

Alternative for short-term cardiac output augmentation to maintain organ perfusion in cardiogenic shock refractory to other agents.

Increases cardiac contractility and modestly increases heart rate at high doses; may cause peripheral vasodilation, hypotension, and/or ventricular arrhythmia.

Renally cleared; dose adjustment in renal impairment needed.

Must be diluted; eg, a usual concentration is 40 mg in 200 mL D5W (200 micrograms/mL); use of a commercially available pre-diluted solution is preferred.

Bhopalwala. H

Dobutamine in ICU

Dobutamine Dobutrex

0.5 to 1 mcg/kg/minute

(alternatively, 2.5 mcg/kg/minute in more severe cardiac decompensation) 2 to 20 mcg/kg/minute
20 to 40 mcg/kg/minute;

Doses >20 mcg/kg/minute are not recommended in heart failure and should be reserved for salvage therapy

Initial agent of choice in cardiogenic shock with low cardiac output and maintained blood pressure.
Add-on to norepinephrine for cardiac output augmentation in septic shock with myocardial dysfunction (eg, in elevated left ventricular filling pressures and adequate MAP) or ongoing hypoperfusion despite adequate intravascular volume and use of vasopressor agents.

Increases cardiac contractility and rate; may cause hypotension and tachyarrhythmias.
Must be diluted; a usual concentration is 250 mg in 500 mL D5W or NS (0.5 mg/mL); use of a commercially available pre-diluted solution is preferred.

Bhopalwala. H

Vasopressin in ICU

Vasopressin (arginine-vasopressin) Pitressin, Vasostrict

0.03 units per minute (alternatively 0.01 to 0.03 units/minute initially) 0.03 to 0.04 units per minute (not titrated)
0.04 to 0.07 units/minute;

Doses >0.04 units/minute can cause cardiac ischemia and should be reserved for salvage therapy

Add-on to norepinephrine to raise blood pressure to target MAP or decrease norepinephrine requirement. Not recommended as a replacement for a first-line vasopressor.
Pure vasoconstrictor; may decrease stroke volume and cardiac output in myocardial dysfunction or precipitate ischemia in coronary artery disease.

Must be diluted; eg, a usual concentration is 25 units in 250 mL D5W or NS (0.1 units/mL)

Bhopalwala. H

Sunday, March 10, 2019

LMR(Last minute revision) Stuff

Hello Awesomites!

In LMR sessions, I will share final year MBBS Viva things on drugs and specimen.You can add your list in the comments below. 
Today I will share the Obstetric and gynaecology viva on drugs. 
Lets get started.

1.Tranexamic acid and mefanemic acid combination

Tranexamic acid:
  • anti-fibrinolytic
  • Amino caproic acid derivative 
  • CONVERTS plasmin to plasminogen
  • given during menstruation
  • Adverse effect:- Intracranial thrombosis

Mefanemic Acid:
  • COX inhibitor.
  • Given during menstruation
  • Adverse effect:- dyspepsia,gastric ulcer
USE:-
  • Ovulatory cycles of DUB
  • Post IUCD bleeding
  • Post sterilization mennorhagia
  • Fibroid
2.Doxylamine and Vitamin B6 combination

Doxylamine is anti histaminics that has effects on acetylcholine and serotonin release. And you know their receptor is present on CTZ centers.
Vitamin B6 is pyridoxine.
In pregnancy and poor diet the amount decreases.

USE:- Emesis during pregnancy at bedtime (not more than 2 tablet in a day).

3.Dinoprostone gel
  • Prostaglandin E2
  • 500 micro gram into the cervical canal below the level of internal os
  • Or 1-2 mg in the posterior fornix 
  • maximum 3 doses 6 hourly
  • Applied in posterior fornix when membrane is ruptured
  • applied in internal os when membrane is intact
  • USE- Cervical ripening in IOL.
  • Before and after CTG monitoring is must.
  • C/I- Previous CS, Impending scar rupture,fetal distress,asthma,severe heart disease
S/E- hyperstimulation of uterus,fetal distress

4.L-Arginine+Folic acid+isothiocyanidin
  • L-Arginine is precursor for Nitric oxide generation that will lead to vasodialtion
  • USE: In IUGR, Severe oligohydroamnios, preventing pre-eclampsia
5.Misoprostol

  • PGE1
  • ROUTE= sublingual,vaginal,rectal (never parentral)
  • S/E:Fever,chills,shivering
  • Teratogenic: Mobius syndrome (Category X drug)
  • USES:-
  1. OBSTETRIC USES:
  • Termination of pregnancy
  • PPH prevention and treatment.
     2.GYNECOLOGICAL USE:
  • Pe hysterectomy
  • IUI
  • Cervical pregnancy
    3.GIT USE:
  • Treatment of peptic ulcer caused by NSAIDs.
6.Frusemide:
  • Loop diuretic.
  • prior to blood transfusion in severe anemia
  • congestive cardiac failure
  • used in complications not as anti hypertensives
  • PIH with massive edema
7.Clindamycin+Clotrimazole 
  • USE: Mixed bacterial and fungal vaginosis 
8.Omeprazole+Ondansetron:
  • USE: GERD, peptic ulcer
9.Heparin:
  • Injectable Anti-coagulant
  • In 1st trimester
  • Antidote: Protamine sulfate
  • USE: DVT, APLA, PE, recurrent abortion (Prophylaxis:ASPIRIN+HEPARIN)
10.Iron folic acid:
  • Prophylactic: 100mg elemental iron+500 micro gram folic acid daily from 2nd trimester throughout pregnancy +6 month postpartum
  • Treatment: Oral  iron 200 mg elemental iron daily
  • Folic acid deficiency lead to abortions, abruptio, IUGR, NTD
  • In folic acid deficiency dose is 4000mg
11.Anti-D Immunoglobulin:
  • IgG, intramuscular
  • 300 micro gram=15 ml of D positive red cell/ 30 ml of fetal whole blood 
  • If ICT -VE at 28 weeks
12.Hydrocortisone:
  • 2 doses 12 mg betamethasone i/m 24 hours apart
  • 4 doses 6 mg dexamethasone 12 hours apart
13.Sodium Bicarbonate:
  • IV for Heart resuscitation, poor kidney function, Cocaine toxicity
  • Poisoning cases
  • Reviving newborn
  • Preventing chemotherapy side effects
  • Hyperkalemia
  • metabolic acidosis
14.Diazepam:
  • Central Muscle relaxant and anti convulsant, Tranquilizer
  • S/E:- Maternal (Hypotension) and Fetal (Respiratory depression, hypotonia)
15.Nifedipine:
  • Direct arteriolar vasodilator
  • Calcium channel blocker
  • USE:Tocolytics
  • A/E: Flushing, Hypotension, headache, Inhibition of labor
16.Labetalol:
  • Anti-hypertensive
  • combined alpha and beta blocker
  • orally 100mg tid to 2.4 g daily
  • USE: Hypertension and hypertensive crisis
  • S/E:tremor, headache, CCF.
  • C/I: Hepatic disorder, asthma, CCF
17.Magnesium Sulphate:
  • Anti-spasmodic (PDE-4 Inhibitor)
  • Enhance cervical dilatation during childbirth
  • USE: Acute renal colicky, augment labor.
19.Oxytocin:

20.Methergine:

21.Prostaglandins:


More is coming up !
-Upasana Y. :)

Saturday, March 9, 2019

Classification Criteria for Adult Still Disease

●Yamaguchi criteria – The Yamaguchi criteria require the presence of five features, with at least two being major diagnostic criteria . In addition, the presence of any infection, malignancy, or other rheumatic disorder known to mimic ASD in its clinical features precludes the diagnosis of ASD, at least for the purpose of research.

The four major Yamaguchi criteria are:

•Fever of at least 39ºC (102.2ºF) lasting at least one week

•Arthralgias or arthritis lasting two weeks or longer

•A nonpruritic macular or maculopapular skin rash that is salmon-colored in appearance and usually found over the trunk or extremities during febrile episodes

•Leukocytosis (10,000/microL or greater), with at least 80 percent granulocytes

The minor Yamaguchi criteria include:

•Sore throat

•Lymphadenopathy

•Hepatomegaly or splenomegaly

•Abnormal liver function studies, particularly elevations in aspartate and alanine aminotransferase and lactate dehydrogenase concentrations

•Negative tests for antinuclear antibody (ANA) and rheumatoid factor (RF)

Bhopalwala. H

Friday, March 8, 2019

Useful Pediatrics mobile apps


Technology is a crucial part of our life nowadays. Below are some apps that can make a pediatric student/resident/specialist life easier :D


1- Uptodate

The famous app for the well-known website “ Uptodate” where you can get peer-reviewed data for nearly any subject you may think of. It also has a section for adult and pediatric medication dosing which can be helpful. Another nice section is the patient education section that is really helpful to explain complex medical things to parents in layman terms.
  
Keep in mind that you ll need an account which may be provided to your through your residency program, a friend or you yourself paying for Uptodate.

2- Medscape

The app for the amazing peer-reviewed website Medscape. Just create an account and search for any disease you like (epidemiology, incidence, clinical presentation, treatment, prognosis..etc).

3- Medstudy and Medstudy audio apps

The apps for the Medstudy book series. Listen to a medstudy chapter on your way somewhere or revise some pages through your app. These apps require an active Medstudy subscription

4- PCO / Pediatric Care Online 

A nice app by the American Academy of Pediatrics (AAP). Through this app, you get access to “Red Book”, one of the most famous books/sources for Infectious diseases and their treatments, “Bright futures” which is helpful to hone your skills in your continuity clinic among many other things.
  
To get access completely, you need an AAP account which will be provided by your residency program. 

5- Heartpedia

A great app from Cincinnati Children’s Hospital. Through this app, you can have a 3D visual construction of the most common congenital heart anomalies (ASD, VSD, PDA, COA..etc). Choose the angle you like, zoom in or out. The app also has links to youtube videos explaining the defect. This app is particularly very helpful if you are trying to explain a congenital heart defect for a parent and for further clarification to a student.   

6- CDC Vaccine Schedules (Vaccinations, catchup, contraindication)

Vaccines are a vital part of any Well Child Check visit. This app from the CDC has all the tables for Pediatrics and Adult vaccines including the catch-up schedule as well as the contraindications for these vaccines.

An amazing website to help with this is : https://www.vacscheduler.org/
Just enter the age of the patient, the vaccines that he/she got and the website will tell you what the patient needs

7- Bilicalc

For nursery folks, you should have Bilicalc on your smart-phones, it is the best app to know the lightable levels (LL) for babies. Just enter the baby’s hours of life as well as the bili result and wait for the app to tell you the LL for low, medium and high risk curves.

It does the same job that www.bilitool.org does.

 8- eBooks by inkling

This app acts like a “template” through which you can read different books. A must-to-have book is Harriet-Lane (every Pediatrician should have this book :D). To access it, use the code that is located on the first page of the book’s hardcopy. It is given by most residency programs to the residents. If not, you should consider buying it for sure.
  
9- MDcalc

Scoring systems in medicine are endless. This is the best app that can be your savior. Are you looking for: Westley’s croup scoring? Pediatric Asthma scoring? Calculating maintenance fluids for a child? Well, you just hit the jackpot.
 
10- GoodRx

Help your patients find coupons so they can buy the medications they need at a lower price.
  
11- Google keep

Although not medical but this app is wonderful to take notes and to create lists. Write all your lists in one place and use different colors. Synchronize all your notes/lists with any other device: tablet, laptop..etc. Organize your life, a much 
  
12- Anki

Another non medical app, Anki is a wonderful flashcards app. It acts like a template that you can create flashcards with or use already pre-made shared cards. Add your notes to any deck you like, synchronize between your devices and have your info with you everywhere. 


 Comment below if you have any apps or websites that may be helpful for pediatricians or anyone who is interested in Pediatrics :)


-Murad