Thursday, February 28, 2019

Cogan's Syndrome

●Cogan's syndrome (CS) is a chronic inflammatory disorder that most commonly affects young adults. Clinical hallmarks are interstitial keratitis (IK) and vestibuloauditory dysfunction, and associations between CS and systemic vasculitis, as well as aortitis, also exist. There are a range of pathologic findings, most of which reflect immune-mediated injury of the affected tissues; however, despite an association with systemic vasculitis, eye and inner ear specimens of those with CS do not reveal any evidence of vasculitis. The underlying mechanisms responsible for the eye and inner ear disease in CS are unknown.

●The predominant ocular feature of CS is IK, which typically causes eye redness, pain, photophobia, and blurred vision. Slit-lamp examination commonly demonstrates a patchy, deep, granular corneal infiltrate. IK is not essential for the diagnosis; ocular inflammation may involve other parts of the eye and may lead to iridocyclitis, conjunctivitis, episcleritis, anterior or posterior scleritis, or retinal vasculitis.

●The inner ear manifestations of CS are Ménière-like attacks consisting of vertigo, ataxia, nausea, vomiting, tinnitus, and hearing loss. Vestibular dysfunction may also cause oscillopsia, and caloric testing often reveals absent vestibular function. Recurrent episodes of inner ear disease frequently result in profound sensorineural hearing loss. Noninflammatory down-fluctuations in hearing may be difficult to distinguish from those of inflammatory origin. If hearing loss is associated with eye inflammation or other features of active CS or does not resolve within three to five days, an inflammatory origin is more likely.

●When present, the systemic vasculitis associated with CS is a large- or medium- to small-sized vessel vasculitis or an aortitis. The pattern of vessel involvement may be overlapping. Other systemic manifestations of CS include fever, fatigue, weight loss, lymphadenopathy, hepatomegaly, hepatitis, splenomegaly, pulmonary nodules, pericarditis, abdominal pain, arthralgia, arthritis, myalgia, and urticaria. An association with inflammatory bowel disease has also been observed.

●Evaluation of the patient with possible CS requires ophthalmologic examination to establish the presence of IK, scleritis, or episcleritis and to exclude other diseases and ocular pathology; neurologic and otologic examination to establish the presence of vestibuloauditory abnormalities; and rheumatologic examination to seek evidence of systemic vasculitis. We diagnose CS based upon the presence of characteristic inflammatory eye disease and vestibuloauditory dysfunction. The eye and inner ear are nearly equally likely to be the cause of presenting symptoms, while less than 5 percent of patients initially present with systemic manifestations

Bhopalwala. H

Wednesday, February 27, 2019

GPA vs MPA Flares

The distinction between GPA ( Granulomatosis with Polyangiitis) and MPA (Microscopic Polyangiitis) is important chiefly because of differential tendencies to flare. Although both diseases may flare after the achievement of remission, GPA is substantially more likely to relapse.

That's all.

Bhopalwala. H

ANCA titers and Disease flare.

Does a rise in ANCA titers predict a disease flare? — This has been a controversial area in the literature almost since ANCA were first identified in the 1980s. However, several rigorous studies have demonstrated that elevations in the titers of ANCA do not predict disease flares in a timely manner . The largest of these studies was performed on a clinical trial cohort of 180 patients (Wegener's Granulomatosis Etanercept Trial [WGET] Research Group, 2005), with serum samples drawn at three-month intervals and ANCA assays performed at the Mayo Clinic . The following findings were observed:
●Among patients who were PR3-ANCA positive compared with negative at baseline, there were no differences in the median time to relapse, disease activity score , or organ involved at relapse. Decreases in PR3-ANCA levels were not associated with a shorter time to remission, and increases were not associated with relapse.
●Relapses occurred among 46 of 101 patients (46 percent) who were mature-PR3-ANCA positive at baseline and achieved remissions of at least six months' duration. However, the proportion of patients who experienced a disease flare within one year of an elevation in ANCA titer was only 40 percent.
Other studies have come to slightly different conclusions, indicating that persistently high or rising titers of ANCA are associated with an increased risk of disease relapse . However, even in those studies, the temporal relationship between a rise in ANCA titer and the occurrence of a disease flare was poor. As an example, in a prospective study of 100 ANCA-positive patients observed over a two-year period, relapse did not occur in 43 and 29 percent of those with a rise in ANCA titers by immunofluorescence and in PR3-ANCA titers by ELISA, respectively .
In addition, a meta-analysis of 18 studies found that neither a rise in ANCA titer nor a persistently elevated ANCA titer were strong predictors of a subsequent disease flare . Therapies for relapsed ANCA-associated vasculitis (often, high doses of glucocorticoids and cytotoxic agents) carry substantial risk, including severe infections, cystitis, bladder cancer, lung fibrosis (rarely), and death. Treating all patients with increases in ANCA titers would result in unnecessary risks of toxicity in a substantial percentage of patients, nearly 30 percent in the study mentioned above. Because of these concerns, using a rise in ANCA titer as the sole parameter to justify altering immunosuppressive therapy cannot be endorsed.
A reasonable recommendation is to closely follow patients with rising ANCA titers but not to alter their therapy unless there are clear clinical signs of active disease.

Bhopalwala. H

POTS Syndrome

●The postural tachycardia syndrome (POTS) is defined as a form of orthostatic intolerance characterized by an excessive increase in heart rate that occurs on standing without arterial hypotension.

●The etiology of POTS is not clear, but the disorder may be heterogeneous. Abnormalities in autonomic regulation that may either be genetic or acquired are described. Proposed mechanisms include partial sympathetic denervation leading to discordant cardiac and vascular sympathetic control, hypovolemia and impairment of the renin-angiotensin-aldosterone system, venous abnormalities and baroreflex dysfunction.

●The clinical symptoms of POTS are varied and nonspecific, and include dizziness, lightheadedness, weakness, blurred vision, and fatigue upon standing. The orthostatic nature of the symptoms is the primary clue to the diagnosis.

●The diagnosis of POTS is established from the history and head-up tilt testing which demonstrates a heart rate increase of >30 bpm over baseline or to >120 bpm. Dehydration, prolonged bedrest, medications, and other dysautonomias should be excluded as etiologies.

●The optimal therapy of POTS is not established. Patients should avoid precipitating factors, and physical activity should be encouraged. We suggest volume repletion and fludrocortisone (0.05 to 0.2 mg per day) as the first line of therapy . Some patients may benefit from midodrine or beta blocking agents. Other therapies remain under investigation, and further confirmation of benefit is needed before they can be recommended.

Bhopalwala. H

Tuesday, February 26, 2019

Classification of Cryoglobulinemia

●The Brouet classification criteria is the most commonly used system that classifies cryoglobulinemia into three different subgroups based on their Ig composition. These classification criteria are also useful in that the subgroups partly correlate with pathogenicity and clinical manifestations.

•In type I cryoglobulinemia, the cryoglobulins are monoclonal Ig, typically IgG or IgM, and less commonly IgA or free Ig light chains. Type I cryoglobulinemia develops in the setting of protein-secreting monoclonal gammopathies such as a monoclonal gammopathy of undetermined significance (MGUS) or a B-cell lineage malignancy (eg, multiple myeloma, Waldenström macroglobulinemia, or chronic lymphocytic leukemia).

•In type II cryoglobulinemia, the cryoglobulins are composed of a mixture of a monoclonal IgM (or IgG or IgA) with rheumatoid factor (RF) activity and polyclonal Ig. Type II cryoglobulins are often associated with persistent viral infections, particularly hepatitis C virus (HCV) infection, and are associated with the mixed cryoglobulinemia syndrome. Other clinical associations with type II cryoglobulinemia include other infections such as hepatitis B virus (HBV), HIV, autoimmune diseases (mainly systemic lupus erythematosus [SLE] and Sjögren's syndrome), and lymphoproliferative disorders.

•In type III cryoglobulinemia, the cryoglobulins are composed of a mixture of polyclonal IgG (all isotypes) and polyclonal IgM. These cases are often secondary to autoimmune disorders, but can also be associated with infections (mainly HCV).

Bhopalwala. H

Eye Findings in GCA

●Anterior ischemic optic neuropathy – At least 80 percent of cases of vision loss in patients with GCA are caused by AION . The ischemic insult in arteritic AION is typically the consequence of occlusion of the posterior ciliary artery, a branch of the ophthalmic artery from the internal carotid artery, and the main arterial supply to the optic nerve.

Only about five percent of the total occurrences of AION are due to GCA, the majority being nonarteritic and secondary to atherosclerotic disease . About 40 percent of patients who suffer nonarteritic AION regain some amount of visual acuity, in contrast to visual loss due to GCA, which is more often massive and irreversible .

●Central retinal artery occlusion – CRAO is responsible for approximately 10 percent of the cases of visual loss in GCA . On the other hand, approximately two percent of older patients with CRAO have underlying GCA . Bilateral CRAOs in an older adult should prompt evaluation for GCA.

●Posterior ischemic optic neuropathy – PION occurs in less than five percent of patients with GCA . It results from the interruption of blood flow to the retrobulbar portion of the optic nerve. Histopathologic examination typically reveals inflammatory occlusion of the short nutrient posterior ciliary arteries .

●Branch retinal artery occlusion – BRAO is distinctly uncommon in GCA, though it has been described.

●Cerebral ischemia — Homonymous hemianopia is a visual field defect involving either the two right or the two left halves of the visual fields of both eyes. The most common cause in GCA is an occipital lobe infarction resulting from a lesion in the vertebrobasilar circulation. In rare cases, bilateral occipital lobe involvement leads to bilateral homonymous field defects and to the development of cortical blindness.

Bhopalwala. H

Imaging Findings in PMR

Imaging —

As discussed above, there are characteristic features of periarticular structures (eg, bursitis and tenosynovitis) that can be seen on ultrasonography, magnetic resonance imaging (MRI), and positron emission tomography (PET) . Routine radiographs do not show abnormalities in patients with PMR.

Ultrasound (US) and MRI can demonstrate synovitis of the glenohumeral and hip joints and frequent involvement of extraarticular structures, especially the subacromial/subdeltoid bursa, long head of the biceps, and trochanteric bursa. While subdeltoid/subacromial bursitis is a characteristic imaging feature of PMR, it is not specific and is seen in patients with rheumatoid arthritis (RA) and other shoulder pathology .

Bhopalwala. H

How to Diagnose Polymyalgia Rheumatica?

General approach — There is no pathognomonic test or established diagnostic criteria for polymyalgia rheumatica (PMR). We use the presence of all of the following empirically formulated criteria for the clinical diagnosis of PMR in whom another disease to explain the findings is not present :

●Age 50 years or older at disease onset.

●Proximally and bilaterally distributed aching and morning stiffness (lasting at least 30 minutes or more) persisting for at least two weeks. The stiffness should involve at least two of the following three areas: neck or torso, shoulders or proximal regions of the arms, and hips or proximal aspects of the thighs.

●Erythrocyte sedimentation rate (ESR) ≥40 mm/hour.

●Rapid resolution of symptoms with low-dose glucocorticoids. Symptoms are generally 50 to 70 percent better within three days in patients with PMR started on prednisone at a dose of 10 to 20 mg/day, and almost all patients respond completely within three weeks of beginning treatment. The lack of response to initial therapy strongly suggests an alternative diagnosis. Symptomatic improvement with low-dose glucocorticoid treatment can also be seen in patients with rheumatoid disease, psoriatic arthritis, and other inflammatory arthritides.

Bhopalwala. H

Adalimumab (Humira)


Ankylosing spondylitis: Treatment (to reduce signs/symptoms) of active ankylosing spondylitis in adults

Crohn disease: Treatment (to reduce signs/symptoms and to induce and maintain clinical remission) of active Crohn disease (moderate to severe) in adults and pediatric patients ≥6 years of age (Humira only) with an inadequate response to conventional therapy or who have lost response to or are intolerant to infliximab.

Hidradenitis suppurativa (Humira only): Treatment of moderate to severe hidradenitis suppurativa in adults and children ≥12 years of age

Juvenile idiopathic arthritis: Treatment (to reduce signs/symptoms) of active polyarticular juvenile idiopathic arthritis (moderate to severe) in pediatric patients ≥2 years of age (Humira) or ≥4 years of age (Amjevita; Cyltezo); may be used alone or in combination with methotrexate

Plaque psoriasis: Treatment of chronic plaque psoriasis (moderate to severe) in adults who are candidates for systemic therapy or phototherapy, and when other systemic therapies are less appropriate (with close monitoring and regular follow-up)

Psoriatic arthritis: Treatment (to reduce signs/symptoms, inhibit progression of structural damage, and improve physical function) of active psoriatic arthritis in adults; may be used alone or in combination with nonbiologic disease-modifying antirheumatic drugs (DMARDs)

Rheumatoid arthritis: Treatment (to reduce signs/symptoms, induce major clinical response, inhibit progression of structural damage, and improve physical function) of active rheumatoid arthritis (moderate to severe) in adults; may be used alone or in combination with methotrexate or other nonbiologic DMARDs

Ulcerative colitis: Treatment (to induce and sustain clinical remission) of active ulcerative colitis (moderate to severe) in adults who have had an inadequate response to immunosuppressants such as corticosteroids, azathioprine, or 6-mercaptopurine. (Note: Efficacy in patients that are intolerant to or no longer responsive to other TNF blockers has not been established.)

Uveitis (Humira only): Treatment of non-infectious intermediate, posterior, and panuveitis in adults and children ≥2 years of age

Mechanism of Action

Adalimumab is a recombinant monoclonal antibody that binds to human tumor necrosis factor alpha (TNF-alpha), thereby interfering with binding to TNFα receptor sites and subsequent cytokine-driven inflammatory processes. Elevated TNF levels in the synovial fluid are involved in the pathologic pain and joint destruction in immune-mediated arthritis. Adalimumab decreases signs and symptoms of psoriatic arthritis, rheumatoid arthritis, and ankylosing spondylitis. It inhibits progression of structural damage of rheumatoid and psoriatic arthritis. Reduces signs and symptoms and maintains clinical remission in Crohn disease and ulcerative colitis; reduces epidermal thickness and inflammatory cell infiltration in plaque psoriasis.

Bhopalwala. H

Monday, February 25, 2019

Detection of Cryoglobulins

Detection of cryoglobulins — To detect cryoglobulin, 10 to 20 mL of blood are drawn into syringes and/or collection tubes that have been prewarmed to 37ºC without anticoagulants. These precautions are required because failure to prewarm may lead to false-negative results, due to loss of the cryoglobulin in the clotted blood (eg, if there is cooling below 37°C during collection, clotting, or centrifugation) and because the presence of anticoagulants may produce false-positive results due to the formation of cryofibrinogen or heparin-precipitable complexes.

After clotting at 37°C for one-half to one hour, the serum is separated by centrifugation at 37°C, placed in a graduated (Wintrobe) tube, and refrigerated (4°C) to allow the precipitation of cryoglobulin. In type I cryoglobulinemia, precipitates are often seen within 24 hours (sometimes in less than 90 minutes). However, three to five days are usually allowed for complete precipitation, especially for the mixed cryoglobulins, and some type II and type III cryoglobulins require up to seven days for precipitation . Most laboratories will determine a cryocrit, which is a measure of the packed (centrifuged) volume of the precipitate as a percentage of the original serum volume at 4°C.

Further confidence that the precipitate is a true cryoglobulin is obtained by washing the precipitate three to six times in cold saline solution to reduce the possibility of precipitated salts or other proteins. In addition, the precipitate can then be redissolved in saline at 37°C to confirm the warm solubility of the cryoglobulins. At this time, cryoglobulin protein concentration can be determined by spectrophotometry. Further characterization can be accomplished by immunofixation, enzyme-linked immunosorbent assay (ELISA), or another specific immunologic assay.

Some laboratories perform further testing consisting of a measurement of absolute cryoglobulin concentration, along with a description of the components of the immune complexes, including mono- or polyclonality of IgM, IgG, IgA, IgE, kappa, and/or lambda light chains. In type II cryoglobulinemia, the monoclonal component is typically IgM kappa with rheumatoid factor (RF) activity.

The cryocrit in individuals without cryoglobulinemia is close to zero; generally, a cryocrit over 0.5 to 1 percent or cryoglobulin concentration over 50 mcg/mL is considered clinically significant . The cryocrit in affected patients may approach 50 percent or may encompass the entire serum volume in type I cryoglobulinemia under conditions in which the monoclonal protein forms a gel.

The cryocrit is generally between 2 and 7 percent in type II and between 1 and 3 percent in type III disease, but there is a poor correlation between the cryocrit and clinical symptoms and features.

When cryoglobulinemia is suspected clinically, a negative result from routine laboratory testing for cryoglobulins does not exclude cryoglobulin-mediated disease . The clinician may need to draw a new specimen after consulting with the laboratory staff or clinical pathologist to assure that procedures are in place for the appropriate handling of the patient's blood when the sample is obtained and transported and to be certain that the laboratory has the necessary equipment (particularly a temperature-controlled centrifuge) to prevent premature cooling of the sample.

Bhopalwala. H

Vision Loss in Giant Cell Arteritis

Causes of vision loss —

Permanent loss of vision in GCA results from arteritic anterior ischemic optic neuropathy (AION), central or branch retinal arterial occlusion (CRAO/BRAO), posterior ischemic optic neuropathy (PION), or, rarely, cerebral ischemia

●Anterior ischemic optic neuropathy – At least 80 percent of cases of vision loss in patients with GCA are caused by AION . The ischemic insult in arteritic AION is typically the consequence of occlusion of the posterior ciliary artery, a branch of the ophthalmic artery from the internal carotid artery, and the main arterial supply to the optic nerve.

Only about five percent of the total occurrences of AION are due to GCA, the majority being nonarteritic and secondary to atherosclerotic disease . About 40 percent of patients who suffer nonarteritic AION regain some amount of visual acuity, in contrast to visual loss due to GCA, which is more often massive and irreversible .

●Central retinal artery occlusion – CRAO is responsible for approximately 10 percent of the cases of visual loss in GCA . On the other hand, approximately two percent of older patients with CRAO have underlying GCA . Bilateral CRAOs in an older adult should prompt evaluation for GCA.

●Posterior ischemic optic neuropathy – PION occurs in less than five percent of patients with GCA . It results from the interruption of blood flow to the retrobulbar portion of the optic nerve. Histopathologic examination typically reveals inflammatory occlusion of the short nutrient posterior ciliary arteries .

●Branch retinal artery occlusion – BRAO is distinctly uncommon in GCA, though it has been described.

●Cerebral ischemia — Homonymous hemianopia is a visual field defect involving either the two right or the two left halves of the visual fields of both eyes. The most common cause in GCA is an occipital lobe infarction resulting from a lesion in the vertebrobasilar circulation. In rare cases, bilateral occipital lobe involvement leads to bilateral homonymous field defects and to the development of cortical blindness.

Bhopalwala. H

Low Alkaline Phosphatase

Subnormal values — Extremely low serum alkaline phosphatase concentrations can be seen in patients with fulminant Wilson disease complicated by hemolysis .
Low values can also occur in patients with hypothyroidism, pernicious anemia, zinc deficiency, congenital hypophosphatemia, and certain types of progressive familial intrahepatic cholestasis in children.

Bhopalwala. H

Sunday, February 24, 2019

Old Classification Criteria for Fibromyalgia

The final 1990 ACR FM classification criteria included:

●Symptoms of widespread pain, occurring both above and below the waist and affecting both the right and left sides of the body

●Physical findings of at least 11 of 18 defined tender points

These simple criteria had greater than 85 percent sensitivity and specificity for differentiating patients with FM from those with other rheumatic diseases.

In office practice, the diagnosis of FM can be made even if fewer than 11 of 18 tender points are present, provided that the history is consistent with FM and that the major differential diagnoses have been excluded . The tender points represent heightened pain perception rather than sites of inflammation or tissue pathology. Thus, they are proxies for detecting widespread pain, and the exact number necessary to diagnose FM clinically is somewhat arbitrary. It is important to recognize that the classification criteria were validated for large patient populations and should be used primarily in clinical research and epidemiologic studies of FM

Bhopalwala. H

Beighton Score for Joint Hypermobility

Beighton score for joint hypermobility —

JHM should be evaluated in all patients suspected of JHS. JHM is ascertained by determination of their Beighton score, which depends on the presence of JHM in the hands, elbows, lumbar spine, and knees using specific examination techniques . One point is awarded for the ability to perform each of nine maneuvers (including four maneuvers tested bilaterally and evaluation of the spine). A score of 4 or more points represents generalized hypermobility. The specific maneuvers include:

●Passive apposition of the thumb to the volar aspect of the ipsilateral forearm

●Passive hyperextension of fingers, demonstrated by passive dorsiflexion of the fifth metacarpophalangeal joint to at least 90 degrees

●Hyperextension of the elbow to at least 10 degrees

●Hyperextension of the knee to at least 10 degrees

●Flexion of the spine with placement of the palms flat on the floor without bending the knees

The presence of JHM can be documented by an examination limited to those areas required for calculating the Beighton score, but an examination for JHM and joint stability that is adequate for fuller assessment of the patient and the formulation of treatment plans should also encompass the other joints, including the temporomandibular joints, shoulders, hips, cervical and thoracic spine, ankles, and feet.

In addition to determination of the Beighton score based upon the examination, the presence of generalized JHM, including its presence historically, may also be suspected in patients who answer ‘yes’ to two or more questions in a simple five-part questionnaire :

●Can you now (or could you ever) place your hands flat on the floor without bending your knees?

●Can you now (or could you ever) bend your thumb to touch your forearm?

●As a child did you amuse your friends by contorting your body into strange shapes OR could you do splits?

●As a child or teenager did your shoulder or kneecap dislocate on more than one occasion?

●Do you consider yourself double-jointed?

Bhopalwala. H

Saturday, February 23, 2019

Standing up & speaking out - 2

Hello people

I am glad for your support. In reality when I first chose to speak up about it , I knew none would support me, I mean why would they.
They all had nothing to gain, but a lot to loose.

I have been with my guide for a long time , there were instances which would seem impossible, I mean how can one do this?
How can someone stoop this low ?

We students were in-charge of her ot slippers. Sketchers worth 2k. As soon as the operation theatre ended we had to keep track of getting it washed and keeping it in her locker.
The ambulance was her personal vehicle, ANC and paediatric patients were made to wait for hours, while the ambulance was used to get her tiffin, drop her students at school.

Whenever she had interviews, we were asked to wear new coats and wait outside her office, and come in one by one , while the camera was rolling and ask her questions and doubts.

The operatives where we would put our hand and leg on the weighing scale to increase the weight of the tumour.

None of this can be proved but it all happened.
Her students passed out years before all have gone through this.
We were like her jewellery to make her look pretty in public , and we were thrown away and stepped on in private.

But I can't take it anymore, and I feel anger and despair that how did I even allow her to treat me like this.
This is a shout out to all those times

Friday, February 22, 2019

Simpson's Grading for Brain Tumors.

Hello Everyone!
So my Neurosurgery residency diaries continue and I continue sharing as I learn.
Learnt about the Grades of Tumor resection while operating on a Glioma.

These are Simpsons Grades of Tumor resection and are correlated as the degree of surgical resection completeness with with symptomatic recurrence. 

Grade I-complete removal including resection of underlying bone and associated dura.
9% symptomatic recurrence at 10 years

Grade II-complete removal and coagulation of dural attachment.
19% symptomatic recurrence at 10 years

Grade III-complete removal without resection of dura or coagulation.
29% symptomatic recurrence at 10 years

Grade IV-subtotal resection of the tumor.
44% symptomatic recurrence at 10 years

Grade V-simple decompression with or without biopsy
100% symptomatic recurrence at 10 years.

That was it!

Let's Learn Together!
-Medha Vyas 

Difference Between Solitary and Singular Brain Metastasis.

Hello Guys!
So we were operating on a metastatic brain lesion the other day when My Consultant happened to ask me the question-  " What is the difference between Solitary and Singular Brain Metastasis?" Well I happened to have a vague idea and managed to blabber something, the actual definition goes as-
• A solitary brain metastasis is defined as the only known metastasis of a tumour in the whole body which happens to be
localised in the central nervous system.
• A singular brain metastasis is defined as a single cerebral metastasis with additional metastases in other organ systems.
Well it's a small nugget, may save you some embarrassing moments.
Let's Learn Together!
-Medha Vyas.

Thursday, February 21, 2019

Residency in India: Harassment and speaking up against it

Let me be honest with you, when I first heard about the abuse of a resident by Dr. Rajashree Katke madam, I chose to ignore it.

"She's not that bad," I thought. Doesn't the resident know how the system works?

I'm embarrassed that the system has made me feel like it is okay for mentors to treat you like this. Mentors are supposed to guide you, inspire you. Not humiliate you at every chance they get.

I'm ashamed of myself because I'm used to how the government hospitals in India can get and used to not raising my voice against it.

I forgot how deeply I condemned such practices - people like her are one of the reasons why I didn't want to do my residency in India.

I worked as a CMO under Dr. Rajashree Katke and I've seen students, residents, medical officers, nurses, paramedical staff and even peons be verbally abused by her at some point. I'm confident none of them will come forward. (I'm also confident that I'll never get my experience letter after writing this, the one I asked for multiple times but never got signed because I didn't show up with an expensive gift.)

People who are asking for proof: There'll be no proof. I wish I recorded her disrespecting people. There'll be no proof of her refusing to teach if her demands aren't met. I can recall residents waiting for her outside her office. Isn't someone's word proof? Is it not evidence?

I'm glad the resident spoke up. Residency is tough. Isn't there too much work already for doctors? Is it too much to expect humane behavior from our mentor?

To the resident:
Maybe you weren't an unlucky girl.

Maybe it was fate who wanted you to be in that position, so that you can raise your voice against such people. You are the reason that hopefully, this abuse will end.

And no other resident will have to deal with this ever again.

Thanks for raising your voice.


This post is supporting a resident and our dear author, Sakkan. She has been doing her residency with a verbally abusive mentor. 

She decided to speak up against it and without our support, no action will be taken. Read more here:

Standing up & speaking out

Hello everyone.
I used to be an author here.
But haven't been active since I got into post-graduation.

I want to tell the story of my journey.

During MBBS the most wonderful thing I ever witnessed was a childbirth with all the gore , the scream, the horridness.
But the moment the child was born my heart would sing " Innocence" by Avril Lavigne

Alas after hours and hours of studying day and night, missing out on life, missing out on religion & social life, missing out on your payed of and I scored a seat.
And I took in OBGY

I chose my hospital, cause I wanted to be near to my home. It was very tempting to pick up other options, but I choose to be in Mumbai , cause I had spent too many years away from home.

The next big question after choosing the hospital is who you get as a guide. My department had a chit system, through which I got allotted my recent guide.
Now being from Mumbai I was aware of the type of person she is, my cousin had worked under her , so I was very well aware of it all.
But my naseeb was a bit too short and I picked her name in the chit. I was devastated.
But I had no option, so I decided to buckle up and just stick with it for the next three years. After all my home was here, I felt falsely assured.

In first year of residency, I was a bystander , silently observing what my seniors went through day and night.
I quietly empathized , sometimes even asking my seniors to just be calm, to not let her affect them this much. That it would pass, that it was okay.

Things weren't that different when I became a year senior.
Every day was a terror, waking up , sleeping at night every minute my guide thoughts would torment me.
She would call late at night, sometimes even 11pm, to know where I was. If I failed to attend she would send my juniors to my room to know where was I.

She judged and demanded that my clothes, my hair , my makeup every thing should be to her standards, sometimes going to the extent of even calling me a kaamwalibai / maid in public.
She would make me sit outside her chambers from 9am to 7pm, just so that I was always available for her vip visitors.
After 7pm she would take me to her home for her entertainment and gossip buddy.
Relieving me late night at 9 /9:30 pm.
I had to rush to see my ward work, only for her to not listen to my informing till late night.

It was an accepted norm to give her gifts, either an esbeda bag or a silk sari , a min budget of 5k and not less. The first thing she saw on the gifts was the price tag.

If I fell short I would be chucked out of the operation theatre.
I had to suck up to her. I had to. I mean she is my guide yes.
I did it all. All that was necessary

But not anymore.

I have worked under teachers who made me a better person, who taught me self respect, who gave me the confidence to stand tall.

But she affected me to an extent , that I felt more like a slave, a slave hungry for cutting and operatives.
I doubted myself, I hated myself, I cried silently.
I stopped buying new clothes and being myself.
It was a common norm within my seniors to not take bath and change clothes, so she wouldnt take us out to her conferences to hold her purse, I followed too for a time being.

I have a raised a voice now. I just want to be heard.
To all the medicos , there will be times when you think that it is okay to compromise , that it is a profession where you need to dance around your seniors.
No one deserves to be treated this way.

Have pride in what you are.

Bohan and Peter Criteria for diagnosing DM-PM

Bohan and Peter in 1975 defined DM and PM based upon the following features :

●Symmetric proximal muscle weakness

●Typical cutaneous eruption of DM (the only feature distinguishing DM from PM)

●Elevated serum muscle enzymes

●Myopathic changes on EMG

●Characteristic muscle biopsy abnormalities and the absence of histopathologic signs of other myopathies

Patients with the cutaneous eruption and at least three of the other four criteria met the requirements for definite DM according to these criteria, while requirements for definite PM were met by those with all four criteria other than the cutaneous features . Patients with findings indicating the presence of other disorders that may present similarly were excluded. Patients who did not meet these criteria but who lacked any of the exclusions could potentially have been diagnosed with possible or probable DM or PM, depending upon the number of criteria met.

Skin Findings in Dermatomyositis

Skin findings — Several distinct cutaneous eruptions, which are generally evident at the time of clinical presentation, occur in DM but not in PM . Other skin changes may occur in patients with PM and in patients with DM and are not specific to either disorder. Dermatologic manifestations may be prominent but can be quite subtle in some patients.

Characteristic dermatomyositis findings — Gottron's papules and the heliotrope eruption are the hallmark and likely pathognomonic features of DM. Gottron's sign, photodistributed erythema, poikiloderma, nailfold changes, scalp involvement, and calcinosis cutis are also characteristic and useful in distinguishing DM from PM.

●Gottron's papules – Gottron's papules are erythematous to violaceous papules that occur symmetrically over the extensor (dorsal) aspects of the metacarpophalangeal (MCP) and interphalangeal (IP) joints (picture 1A-C). In addition, these lesions may involve the skin between the MCP and IP joints, particularly when the eruption is prominent. Gottron's papules often have associated scale and may ulcerate. When scaling is present, the lesions may mimic psoriasis or lichen planus.

●Gottron's sign – Definitions used for Gottron's sign have varied in the literature. We define Gottron's sign as the presence of erythematous to violaceous macules, patches, or papules on the extensor surfaces of joints in sites other than the hands, particularly the elbows, knees, or ankles. By contrast, some authors have used the term Gottron's papules to refer to papules in these areas, reserving Gottron's sign for macular or patch-like lesions (picture 2) .

●Heliotrope eruption – The heliotrope eruption is an erythematous to violaceous eruption on the upper eyelids, sometimes accompanied by eyelid edema, which, at times, may be quite marked .

●Facial erythema – Patients may have midfacial erythema that can mimic the malar erythema seen in SLE . In contrast to those with SLE, patients with DM will often have involvement of the nasolabial fold, which can be helpful in distinguishing these two photosensitive midfacial eruptions.

●Photodistributed poikiloderma (including the shawl and V signs) – Poikiloderma refers to skin that demonstrates both hyperpigmentation and hypopigmentation, as well as telangiectasias and epidermal atrophy. In DM, patients may demonstrate poikiloderma in any photo-exposed site; however, classic areas of involvement are the upper back (shawl sign) and the V of the neck and upper chest. The poikiloderma in DM often presents with a violaceous hue. Early in the course of cutaneous disease, these areas may demonstrate only erythema rather than well-developed poikiloderma . The erythema may be macular (nonpalpable) or papular. In rare patients, these lesions become thickened and resemble papular mucinosis. The cutaneous eruption of DM is often associated with significant pruritus, which may assist in distinguishing its photo-exacerbated eruption from that of lupus erythematosus (LE).

●Holster sign – Patients with DM may also have poikiloderma on the lateral aspects of the thighs, referred to as the "Holster sign" . It is unclear why this cutaneous manifestation occurs on this classically photo-protected site.

●Generalized erythroderma – In rare patients, erythroderma may occur, which involves extensive cutaneous surface area, including areas that are less exposed to ultraviolet light.

●Periungual abnormalities – The capillary nail beds in DM may be erythematous and may show vascular changes similar to those observed in other systemic rheumatic diseases (eg, scleroderma and SLE). Abnormal capillary nail bed loops may be evident, with alternating areas of dilatation and dropout and with periungual erythema . In addition, cuticular overgrowth, sometimes termed "ragged cuticles," is characteristic and may be associated with hemorrhagic infarcts within the hypertrophic area . The degree of cuticular involvement is thought to reflect ongoing cutaneous disease activity, representing active vasculopathy .

●Psoriasiform changes in scalp – Changes in the scalp resembling seborrheic dermatitis or psoriasis occur in a high percentage of patients with DM . The scalp involvement in DM is diffuse, often associated with poikilodermatous changes and with prominent scaling. Scalp involvement may result in severe burning, pruritus, and/or sleep disturbance. In addition, severe pruritus may occur in patients without visible disease.

●Calcinosis cutis – The deposition of calcium within the skin, a finding known as calcinosis cutis, occurs commonly in juvenile DM. It is infrequent in adult DM. In children, calcinosis has been associated with a delay in treatment with glucocorticoids and/or immunosuppressive therapy. Calcinosis cutis, which is known to be very challenging to treat, may be seen in a variety of conditions, including SSc, particularly limited cutaneous SSc; SLE (rarely); and overlap connective tissue disorders. It may be more common in patients with DM with the anti-p140/anti-MJ autoantibody

Bhopalwala. H

Antisynthetase Syndrome

Antisynthetase syndrome — Up to 30 percent of patients with DM or PM have a constellation of clinical findings termed the "antisynthetase syndrome" . These findings include relatively acute disease onset, constitutional symptoms (eg, fever and weight loss), myositis, the Raynaud phenomenon, mechanic's hands, arthritis that is generally nonerosive, and ILD . Affected patients have antibodies to aminoacyl-transfer ribonucleic acid (tRNA) synthetase enzymes; the presence of one of these antibodies is highly specific for DM, PM, or ILD .

This syndrome can be further characterized as follows:

●Not all patients with antisynthetase antibodies or even those classified as having the antisynthetase syndrome have all manifestations of this syndrome. The syndrome is generally considered present in patients with an antisynthetase antibody plus two of the following features, which are elements of the syndrome: ILD, inflammatory myopathy, and inflammatory polyarthritis.

●This group of clinical findings or this general clinical picture is not specific for antisynthetase antibodies. Patients with other types of autoantibodies (eg, anti-PM-Scl or anti-U1 ribonucleoprotein [RNP] antibodies) can also present with these types of features. However, patients with antisynthetase antibodies generally have more prominent or severe myositis and ILD, and they usually lack some of the other clinical features seen in patients with these other autoantibodies.

●Some patients with antisynthetase antibodies have relatively little or no myositis, while ILD or other features are more prominent. The absence of myositis is seen more often with some antisynthetase antibodies than with others.

Bhopalwala. H

DM - PM (Abs associated with Malignancy)

Serum autoantibodies — Some serum antibodies in DM and PM confer a positive risk of malignancy, whereas others are associated with a negative risk.

●Positive risk – "Cancer-associated myositis" (CAM) in adults has been associated in several studies with antibodies to transcription intermediary factor (TIF)-1gamma (anti-p155, anti-p155/140) and with antibodies to nuclear matrix protein (NXP)-2 (anti-MJ or anti-p140) .

●Negative risk – Conversely, the presence of myositis-specific (anti-synthetase antibodies, anti-Mi-2, anti-SRP) and myositis-associated antibodies (anti-RNP, anti-PM-Scl, anti-Ku) appears to be associated with a decreased risk of malignancy but an increased risk of interstitial lung disease in DM . More study is required to determine the utility of these autoantibodies for cancer screening in patients with myositis.

Around 30% of patients with Dermatomyositis develop Malignancy.

Around 5% of patients with Polymyositis develop malignancy.

Bhopalwala. H

Wednesday, February 20, 2019

Irregularly irregular rhythms

Quiz: Name the three types of irregularly irregular rhythms.


Atrial fibrillation

Multifocal atrial tachycardia

Atrial flutter with variable conduction

That's all!


Baricitinib (Olumiant)

Mechanism of Action

Baricitinib inhibits Janus kinase (Jak) enzymes, which are intracellular enzymes involved in stimulating hematopoiesis and immune cell function through a signaling pathway. In response to extracellular cytokine or growth factor signaling, Jaks activate signal transducers and activators of transcription (STATs), which regulate gene expression and intracellular activity. Inhibition of Jaks prevents the activation of STATs and reduces serum IgG, IgM, IgA, and C-reactive protein


Rheumatoid arthritis: Treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies.

Limitation of use: Use of baricitinib in combination with other JAK inhibitors, biologic DMARDs, or with potent immunosuppressants such as azathioprine and cyclosporine is not recommended.

Bhopalwala. H

Certolizumab (Cimzia)

Mechanism of Action

Certolizumab is a pegylated humanized antibody Fab’ fragment of tumor necrosis factor alpha (TNF-alpha) monoclonal antibody. Certolizumab binds to and selectively neutralizes human TNF-alpha activity. (Elevated levels of TNF-alpha have a role in the inflammatory process associated with Crohn disease and in joint destruction associated with rheumatoid arthritis.) Since it is not a complete antibody (lacks Fc region), it does not induce complement activation, antibody-dependent cell-mediated cytotoxicity, or apoptosis. Pegylation of certolizumab allows for delayed elimination and therefore an extended half-life

Use :

Ankylosing spondylitis: Treatment of adults with active ankylosing spondylitis (AS)

Crohn disease: Treatment of moderately to severely active Crohn disease in patients who have inadequate response to conventional therapy

Plaque psoriasis: Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy

Psoriatic arthritis: Treatment of adult patients with active psoriatic arthritis

Rheumatoid arthritis: Treatment of adults with moderately to severely active rheumatoid arthritis (RA) (as monotherapy or in combination with nonbiological disease-modifying antirheumatic drugs [DMARDS])

Bhopalwala. H

Monday, February 18, 2019

Classification Criteria for Rheumatoid Arthritis

2010 ACR/EULAR criteria —

Using the 2010 ACR/EULAR classification criteria for RA, classification as definite RA is based upon the presence of synovitis in at least one joint, the absence of an alternative diagnosis that better explains the synovitis, and the achievement of a total score of at least 6 (of a possible 10) from the individual scores in four domains . The highest score achieved in a given domain is used for this calculation. These domains and their values are:

●Number and site of involved joints

•2 to 10 large joints (from among shoulders, elbows, hips, knees, and ankles) = 1 point

•1 to 3 small joints (from among the metacarpophalangeal joints, proximal interphalangeal joints, second through fifth metatarsophalangeal joints, thumb interphalangeal joints, and wrists) = 2 points

•4 to 10 small joints = 3 points

•Greater than 10 joints (including at least 1 small joint) = 5 points

●Serological abnormality (rheumatoid factor or anti-citrullinated peptide/protein antibody)

•Low positive (above the upper limit of normal [ULN]) = 2 points

•High positive (greater than three times the ULN) = 3 points

●Elevated acute phase response (erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]) above the ULN = 1 point

●Symptom duration at least six weeks = 1 point

In addition to those with the criteria above, which are best suited to patients with newly presenting disease, the following patients are classified as having RA:

●Patients with erosive disease typical of RA with a history compatible with prior fulfillment of the criteria above

●Patients with longstanding disease, including those whose disease is inactive (with or without treatment) who have previously fulfilled the criteria above based upon retrospectively available data

Fun fact : Hand ultrasound is done to evaluate for inflammation in RA, if it's not clinically evident.

Bhopalwala. H


The arthritis in SLE may look very similar to RA.

The main difference is that it is non erosive, unlike RA.

Pearls of wisdom :

When treating chronic conditions like Rheumatoid Arthritis, Osteoarthritis, SLE, Fibromyalgia, Psoriasis, and Psoriatic Arthritis, you've got to involve the patient in the care. You've got to explain to them that these are  chronic conditions with no cure. Goals should be damage control and remission.

A good strong patient doctor relationship when dealing with these conditions, works better than any pill on planet Earth.

Credits : Dr.G

Bhopalwala. H

Discoid Lupus Erythematosus

Discoid lupus erythematosus — It is estimated that 15 to 30 percent of patients with SLE develop DLE . Patients with localized or generalized DLE are estimated to have cross-sectional prevalences of concurrent SLE between 5 and 28 percent.

The presence of DLE lesions among patients with SLE may modify the risk of specific SLE features. Compared with SLE patients without DLE, those with DLE have increased risk for photosensitivity and leukopenia but decreased risk for serositis and arthritis. There is no obvious change in risk of nephritis despite variable reports of a "renal-protective effect" of the presence of discoid lesions among SLE patients.

Data on the risk for progression of DLE to SLE are limited to retrospective cohort studies, studies lacking power to detect statistical significance of potential markers of progression, and studies that do not address DLE specifically as a CLE subset. In these studies, progression to SLE has occurred in 0 to 28 percent of patients initially presenting with DLE . Progression to SLE often is delayed; in a Swedish-based population cohort study, 10 percent of patients with DLE who subsequently developed SLE did so within the first year and 17 percent developed SLE within the first three years . Two retrospective studies have suggested SLE develops within five years in 50 percent of the DLE patients who indeed go on to develop SLE . Risk factors for progression include an increasing number of clinical and serologic features of SLE: more widespread DLE lesions, arthralgias and arthritis, high antinuclear antibody (ANA) titers, leukopenia, and high erythrocyte sedimentation rates .

It is worth noting that patients with DLE and other mucocutaneous manifestations of LE may meet ACR classification criteria for SLE without having other end-organ disease . Revised classification criteria (the SLICC criteria) have been proposed to address some limitations of the ACR criteria.

●Clinical manifestations – The classic findings of DLE are discrete, erythematous, somewhat indurated plaques covered by a well-formed adherent scale that extends into dilated hair follicles (follicular plugging). The plaques tend to expand slowly with active inflammation at the periphery and then heal, leaving depressed central scars, atrophy, telangiectasias, and hyperpigmentation and/or hypopigmentation . DLE most often involves the face, neck, and scalp but may also occur on the ears (particularly conchal bowls) and, less frequently, on the upper torso . Localized DLE is limited to sites above the neck. Generalized DLE refers to DLE occurring both above and below the neck.

Hypertrophic DLE is an uncommon clinical variant of DLE characterized by the development of hyperkeratotic, verrucous plaques

Fun Fact : SEAL, the famous singer suffers from DLE.

Bhopalwala. H

Clinical Indications for Thalidomide

Use :

Erythema nodosum leprosum: Acute treatment of cutaneous manifestations of moderate to severe erythema nodosum leprosum; maintenance treatment for prevention and suppression of cutaneous manifestations of erythema nodosum leprosum recurrence

Limitation of use: Thalidomide is not indicated as monotherapy for erythema nodosum leprosum treatment in the presence of moderate to severe neuritis.

Multiple myeloma: Treatment of newly diagnosed multiple myeloma (in combination with dexamethasone)

Mechanism of Action :

Thalidomide exhibits immunomodulatory and antiangiogenic characteristics; immunologic effects may vary based on conditions. Thalidomide may suppress excessive tumor necrosis factor-alpha production in patients with erythema nodosum leprosum, yet may increase plasma tumor necrosis factor-alpha levels in HIV-positive patients. In multiple myeloma, thalidomide is associated with an increase in natural killer cells and increased levels of interleukin-2 and interferon gamma. Other proposed mechanisms of action include suppression of angiogenesis, prevention of free-radical-mediated DNA damage, increased cell mediated cytotoxic effects, and altered expression of cellular adhesion molecules.

Fun fact : Thalidomide causes congenital defects called phocomelia.

Bhopalwala. H

Labs in SLE

Laboratory testing — We obtain the following routine laboratory tests, which may provide diagnostically useful information:

●Complete blood count and differential may reveal leukopenia, mild anemia, and/or thrombocytopenia

●Elevated serum creatinine may be suggestive of renal dysfunction

●Urinalysis with urine sediment may reveal hematuria, pyuria, proteinuria, and/or cellular casts

In addition to the routine laboratories described above, we perform the following laboratory tests which support the diagnosis of SLE if abnormal:


●Antiphospholipid antibodies (lupus anticoagulant [LA], IgG and IgM anticardiolipin [aCL] antibodies; and IgG and IgM anti-beta2-glycoprotein [GP] I)

●C3 and C4 or CH50 complement levels

●Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) levels

●Urine protein-to-creatinine ratio

The ANA test is positive in virtually all patients with SLE at some time in the course of their disease . If the ANA is positive, one should test for other specific antibodies such as dsDNA, anti-Sm, Ro/SSA, La/SSB, and U1 ribonucleoprotein (RNP). In some labs, a positive ANA test by indirect immunofluorescence will automatically result in testing for such additional antinuclear antibodies that are often present in patients SLE.

●Anti-dsDNA and anti-Sm antibodies are highly specific for SLE, but anti-Sm antibodies lack sensitivity . Anti-dsDNA and anti-Sm antibodies are seen in approximately 70 and 30 percent of patients with SLE, respectively.

●Anti-Ro/SSA and anti-La/SSB antibodies are present in approximately 30 and 20 percent of patients with SLE, respectively; however, both antibodies are more commonly associated with Sjögren's syndrome.

●Anti-U1 RNP antibodies are observed in approximately 25 percent of patients with SLE, but they also occur in patients with other conditions and high levels are almost always present in patients with mixed connective tissue disease (MCTD).

●Antiribosomal P protein antibodies have a high specificity for SLE, but have low sensitivity for SLE. They also lack specificity for involvement of a particular organ system or disease manifestation.

If the initial ANA test is negative, but the clinical suspicion of SLE is high, then additional antibody testing may still be appropriate. This is partly related to the differences in the sensitivity and specificity among the methods used to detect ANA. A more detailed discussion on the techniques used to detect ANA is presented separately.

Fun fact : Anti-Sm antibody was actually named after a patient with Lupus, Mr. Smith.

Bhopalwala. H

Secukinumab (Cosentyx)

Use :

Ankylosing spondylitis: Treatment of active ankylosing spondylitis in adults.

Plaque psoriasis: Treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy.

Psoriatic arthritis: Treatment of active psoriatic arthritis in adults.

Mechanism of Action :

Secukinumab is a human IgG1 monoclonal antibody that selectively binds to the interleukin-17A (IL-17A) cytokine and inhibits its interaction with the IL-17 receptor. IL-17A is a naturally occurring cytokine involved in normal inflammatory and immune responses. Secukinumab inhibits the release of proinflammatory cytokines and chemokines.

Never treat a test, test the patient always #Dr. G

Bhopalwala. H

Ixekizumab (Taltz)


Plaque psoriasis: Treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy.

Psoriatic arthritis: Treatment of active psoriatic arthritis in adult patients.

Mechanism of Action :

Ixekizumab is a humanized IgG4 monoclonal antibody that selectively binds with the interleukin 17A (IL-17A) cytokine and inhibits its interaction with the IL-17 receptor. IL-17A is a naturally occurring cytokine that is involved in normal inflammatory and immune responses. Ixekizumab inhibits the release of proinflammatory cytokines and chemokines.

Bhopalwala. H

Saturday, February 16, 2019

Belimumab ( Benlysta)

Mechanism of Action :

Belimumab is an IgG1-lambda monoclonal antibody that prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocyte stimulator protein (BLyS) to receptors on B lymphocytes. This reduces the activity of B-cell mediated immunity and the autoimmune response.

Use :

Systemic lupus erythematosus: Treatment of adult patients with active, autoantibody-positive systemic lupus erythematosus (SLE) who are receiving standard therapy.

Limitations of use: Use is not recommended in patients with severe active lupus nephritis, severe active CNS lupus, or in combination with other biologics, including B-cell targeted therapies or intravenous (IV) cyclophosphamide.

Bhopalwala. H

Guttate Psoriasis

The papules and plaques of guttate psoriasis are usually less than 1 cm in diameter (giving rise to the name guttate, which means drop-like). The trunk and proximal extremities are the primary sites of involvement.

Guttate psoriasis typically occurs as an acute eruption in a child or young adult with no previous history of psoriasis. Less commonly, a guttate psoriatic flare occurs in a patient with preexisting psoriasis. There is a strong association between recent infection (usually streptococcal pharyngitis) and guttate psoriasis

Bhopalwala. H

Pustular Psoriasis

Pustular psoriasis — Pustular psoriasis is a form of psoriasis that can have life-threatening complications. The most severe variant (the von Zumbusch type of generalized pustular psoriasis) presents with the acute onset of widespread erythema, scaling, and sheets of superficial pustules . This form of psoriasis can be associated with malaise, fever, diarrhea, leukocytosis, and hypocalcemia. Renal, hepatic, or respiratory abnormalities and sepsis are potential complications.

Reported causes of pustular psoriasis include pregnancy (impetigo herpetiformis), infection, and the withdrawal of oral glucocorticoids. The term impetigo herpetiformis has been used to refer to pustular psoriasis of pregnancy.

Bhopalwala. H

Inverse Psoriasis

Inverse psoriasis — "Inverse psoriasis" refers to a presentation involving the intertriginous areas, including the inguinal, perineal, genital, intergluteal, axillary, or inframammary regions . This presentation is called "inverse" since it is the reverse of the typical presentation on extensor surfaces. This variant can easily be misdiagnosed as a fungal or bacterial infection since there is frequently no visible scaling.

Bhopalwala. H

Grading of Sacroiliitis on Imaging

Plain radiographs of the sacroiliac (SI) joints can be semiquantitatively graded based upon the presence of the characteristic radiographic findings :

●Grade 0: Normal .

●Grade 1: Suspicious changes .

●Grade 2: Minimal abnormality – Small localized areas with erosions or sclerosis, without alteration in the joint width . Erosions usually first appear on the iliac side.

●Grade 3: Unequivocal abnormality – Moderate or advanced sacroiliitis with erosions, evidence of sclerosis, widening, narrowing, or partial ankylosis .

●Grade 4: Severe abnormality – Total ankylosis

Bhopalwala. H

Classification Criteria for Axial Spondyloarthritis

Axial SpA — Classification criteria for axial SpA, including criteria for those without plain radiographic changes (nonradiographic axial SpA [nr-axSpA]) and with radiographic (radiographic axial SpA) changes of sacroiliitis, were based upon a large multicenter study [39]. In patients with a history of back pain of unknown origin, which was of at least three months' duration and which began before age 45, the classification criteria for axial SpA exhibited sensitivity of 83 percent and specificity of 84 percent [39]. This algorithm is as follows:

●The entry step is that the patient must have had back pain of any type for at least three months, and the age of onset must be less than 45 years.

●The second step consists of two arms that are evaluated separately based upon the presence either of sacroiliitis on imaging or of human leukocyte antigen (HLA)-B27:

•HLA-B27-positive patients – In patients who test positive for HLA-B27, at least two additional features of SpA from the list below are required for classifying a patient as having axial SpA (see 'SpA features' below)

•Sacroiliitis on imaging – In patients diagnosed with sacroiliitis based upon plain radiographs (structural changes) or magnetic resonance imaging (MRI) (subchondral bone marrow edema [BME]), at least one other feature of SpA from the list below should be present (see 'SpA features' below)

SpA features — The following are SpA features that contribute to the classification criteria for axial SpA (see 'Axial SpA' above):

●Inflammatory back pain – Several definitions for inflammatory back pain have been proposed. For classification purposes, inflammatory back pain can be defined as having at least four of the five following parameters [67]:

•Age of onset <40 years

•Insidious onset

•Improvement with exercise

•No improvement with rest

•Pain at night (with improvement upon arising)

●Other SpA features (each of equal weight) – Other SpA features include the presence of one or more of the non-spinal features noted below. The occurrence can be either before or at the time of evaluation for the following items listed: arthritis, heel enthesitis, uveitis, dactylitis, psoriasis, and inflammatory bowel disease. The features are:

•Arthritis – As diagnosed by a clinician

•Heel enthesitis – Spontaneous pain or tenderness at site of insertion of Achilles tendon or plantar fascia at the calcaneus diagnosed by a clinician

•Uveitis – Confirmed by an ophthalmologist

•Dactylitis – Diagnosed by a clinician

•Psoriasis – Diagnosed by a clinician

•Inflammatory bowel disease – Crohn disease or ulcerative colitis diagnosed by a clinician

•Good response to nonsteroidal antiinflammatory drugs (NSAIDs) – Within 24 to 48 hours

•Family history of SpA – Presence in first- or second-degree relatives of AS or acute anterior uveitis [37]

•Elevated C-reactive protein (CRP) – After exclusion of other causes for elevated CRP

Bhopalwala. H

Classification Criteria for Peripheral Spondyloarthritis

For classification as having peripheral SpA, the patient should NOT have concurrent inflammatory back pain. In that case, the axial SpA criteria should be used. However, inflammatory back pain in the past is considered as a contributing SpA feature. There are two steps in the algorithm for classifying peripheral SpA:

The entry step is that the patient should have, at the time of being seen, at least one of the following three findings:


●Enthesitis (spontaneous pain or tenderness at any enthesis)


If the patient satisfies the entry criteria, the patient should show (or have had in the past) at least one of the features of SpA in Group A (below) or at least two of the features of SpA in group B (below):

●Group A SpA features:

•Uveitis – Confirmed by an ophthalmologist

•Psoriasis – Diagnosed by a clinician

•Crohn disease or ulcerative colitis – Diagnosed by a clinician

•Preceding infection – Urethritis/cervicitis or diarrhea within one month prior to onset of arthritis/enthesitis/dactylitis


•Sacroiliitis on imaging

●Group B SpA features:

•Arthritis – Diagnosed by a clinician

•Enthesitis – Diagnosed by a clinician

•Dactylitis – Diagnosed by a clinician

•Inflammatory back pain in the past

•Family history of SpA – Presence in first- or second-degree relatives of AS and acute uveitis

Bhopalwala. H

How to Define Inflammatory Back Pain

●Inflammatory back pain – Several criteria have been proposed for defining IBP ; we use the "ASAS [Assessment of SpondyloArthritis International Society] expert criteria" to identify patients with IBP . The criteria for IBP are met if at least four of the following five features are present and IBP is described as "suggested" in the presence of three of five features:

•Onset of back discomfort before the age of 40 years

•Insidious onset

•Improvement with exercise

•No improvement with rest

•Pain at night (with improvement upon arising)

The presence of four of the five features listed above has a sensitivity and specificity of 80 and 74 percent, respectively, for an inflammatory cause of the back pain among patients with chronic back pain of unclear origin and onset of the back pain at <45 years of age who were evaluated by local rheumatologists . However, when IBP is present, and considered independently of other factors, the probability of AS among patients with chronic back pain increases only from 5 percent to 14 to 16 percent .

Bhopalwala. H


Rhupus – The term rhupus has been used to describe patients with overlapping features of both SLE and RA. Whether rhupus is clinically and immunologically a distinct entity, a true overlap of SLE and RA, or a subset of patients with SLE remains a matter of debate. In addition to having serologies consistent with both SLE and RA, some patients classified as rhupus may have an erosive arthropathy that is atypical for SLE

Bhopalwala. H

Kikuchi's disease

●Kikuchi's disease – Kikuchi's disease is a benign and usually self-limited form of histiocytic-necrotizing lymphadenitis. Clinical features at presentation include lymphadenopathy as well as fever, myalgias, arthralgias, and, less commonly, hepatosplenomegaly. Associations with SLE have been reported, but the clinical course is usually favorable with spontaneous remission often occurring within four months. The diagnosis of Kikuchi's disease is based on a lymph node biopsy, which reveals a histiocytic cellular infiltrate.

Bhopalwala. H

Friday, February 15, 2019

Psoriatic Arthritis

Diagnostic criteria for Psoriatic Arthritis :

●CASPAR criteria – The CASPAR study concluded that a patient with an inflammatory musculoskeletal disease (peripheral arthritis, spondylitis, or enthesitis) can be classified as having PsA if a total of at least three points is accumulated from the presence of the following list of features (each of which is assigned a certain number of points):

•Skin psoriasis that is:

-Present – two points, OR

-Previously present by history – one point, OR

-A family history of psoriasis, if the patient is not affected – one point

•Nail lesions (onycholysis, pitting) – one point

•Dactylitis (present or past, documented by a rheumatologist) – one point

•Negative rheumatoid factor (RF) – one point

•Juxtaarticular bone formation on radiographs (distinct from osteophytes) – one point

These classification criteria should facilitate studies in PsA and may function well in diagnosing PsA, given sensitivity and specificity in four studies, including two of early arthritis patients, ranging from 91 to 100 percent and 97 to 99 percent, respectively [90-94]. However, these criteria can only be applied to individuals who demonstrate evidence for inflammatory musculoskeletal disease (peripheral arthritis, axial disease, or enthesitis).

Rheumatology has a lot of Rheum (Room) for Internal Medicine.

Bhopalwala. H

Wednesday, February 13, 2019

Orotic aciduria

Hello Awesomites!
The question has helped me to learn the pyrimidine biosynthesis and urea cycle better. Felt like sharing it.
Let's get started.

OROTIC ACIDURIA= Excessive excretion of orotic acid in urine.
Orotic aciduria is caused by defect in either UMP synthase enzyme or Ornithine trancarbomylase (OTC) enzyme.

When UMP synthase is defective, orotic acid builds up and the synthesis of nucleic acid is impaired, leading to deficient hematopoiesis and growth. Orotic aciduria is associated with megaloblastic anemia due to decreased pyrimidine synthesis. This megaloblastic anemia is refractory to Vitamin B12, folic acid supplementation. This megaloblastic anemia present in infants.

Incessant crying due to orotic acid crystals in ureter produces colicky pain
Growth retardation

Tachycardia and faint murmur due to hyperdynamic circulation in anemia.

Urine analysis show orotic acid crystals.
Peripheral blood smear show hypochromic megaloblastic anemia and hypersegmented neutrophils.
We can distinguish this increase in orotic acid secondary to OTC deficiency from hereditary orotic aciduria by looking at blood ammonia levels and the BUN (blood urea nitrogen).

HYPERAMMONAEMIA is present in OTC deficiency.

Administration of uridine, which is converted to UMP, will bypass the metabolic block and provide the body with a source of pyrimidine. Uridine triacetate is a drug approved by FDA to be used in the treatment of hereditary orotic aciduria.

Have a great day.
-Upasana Y. :)

Sunday, February 10, 2019

RACE protocol in Atrial fibrillation.

Hello! This is a short post regarding RACE protocol. Before starting it, here are some high yielding points regarding Atrial fibrillation.
Most common cause of embolic stroke: Non rheumatic Atrial fibrillation.
Examination shows
1) Pulse: Fast
2) Rhythm: Irregular
3) Pulse deficit more than 10/ min is diagnostic of Atrial fibrillation.
Ecg finding:
1) No P wave
2) R-R interval keep varying
R. A. C. E. protocol is followed in treatment of the Atrial fibrillation.
1) Rate control :
Short acting beta blockers are given to decrease heart rate. Decreasing heart rate leads to increase filling time of the heart. This in turn leads to increase diastolic time. It Increases end diastolic volume, stroke volume, cardiac output and increase BP.
Atrial fibrillation causes increase clot formation in heart. Clots can be detected by Transesophageal Echo.
3) Rhythm control:
Antiarrythmic drugs are given to control rhythm.
Chemicals cardioversion is drugs used to terminate ectopic foci.
4) Electrical cardioversion:
If chemical cardioversion fails, go for electrical cardioversion. In this technique patient is sedated and DC shock of 200J biphasic is given.
That's it!
-Demotional bloke

Amiodarone and thyroid dysfunction

Amiodarone, a class III antiarrhythmic drug is associated with a number of side effects, including thyroid dysfunction (both hypo- and hyperthyroidism)

There are two types of amiodarone-induced thyrotoxicosis (AIT):
Type I: This type is typically seen in patients with preexisting multinodular goiter or latent Graves disease, the excess iodine from amIODarone results in enhanced thyroid hormone production.

Type II: In type II AIT there is destructive thyroiditis caused by the drug itself that results in excess release of T4 and T3(There is no hormone production). It typically occurs in patients without underlying thyroid disease.

1)Normally after exposure to an iodine load (eg, radiocontrast), iodine transport and thyroid hormone synthesis are transiently inhibited to prevent normal individuals from becoming hyperthyroid(the Wolff-Chaikoff effect). Normally patients escape this Wolff-Chaikoff effect and come back to normal within a few weeks, but patients with pre-existing subclinical thyroid disease fail to escape and develop hypothyroidism.

2)Amiodarone also inhibits 5'-deiodinase which is responsible for the peripheral conversion of T4 to T3. So there is a decrease in T3 production.

-Srikar Sama

Saturday, February 9, 2019

Wolff-Parkinson's White syndrome

Hello! This post is regarding WPW syndrome. It is an Autosomal recessive disorder.
In Normal heart, conduction is from SA node to cardiac myocytes via AV node and Purkinje fibers. In WPW syndrome, SA node transfers electric activity directly to cardiac myocytes. This transfer is done by 'Bundle of Kent'.  Since AV node is responsible for delay of the conduction in normal heart, skipping of the AV node causes excitation prior to the expected time. Hence low Cardiac output is sign in WPW syndrome.

Investigation: ECG done

Findings in ECG.

1) Since AV node is skipped in conduction, short P-R interval is seen.

2) q wave is responsible for conduction in septal region, here also it is skipped in ECG (Remember conduction directly from SA node to cardiac myocyte!). At the same time we see Delta waves.

What are Delta waves?
-Change in the upswinging of the 'R' wave.

3) PJ interval is normal

What is PJ interval?
-J point is the point where S wave ends.
Starting point of P wave to J point is called as PJ interval.

(Remember: Segments does not include waves, interval loves waves! Example: ST segment is from end of S to start of T wave)

Now, as we can figure it out PJ interval is PR + qRS
PR becomes shorter and qRS becomes  broader in WPW syndrome. qRS is broader because conduction of cardiac myocytes is slower than Purkinje fibers. (Hope you remember clue sentence here - conduction from SA node directly to cardiac myocytes!) Hence PJ interval is normal.


Flecainide given orally is DOC.
Treatment of choice is Radio-frequency ablation.