Thursday, December 24, 2020

The three O's of GI bleeding : Overt, obscure, and occult

GI bleeding can be classified into three O's: Overt, obscure, and occult! Can you define these terms?

If not, I'll help you out

Sunday, December 20, 2020

Pediatrics | Pulmonary & Critical Care | CK Uworld

The BNT162b2 Covid-19 Vaccine: Pfizer-BioNTech Vaccine


The BNT162b2 mRNA Covid-19 vaccine, popularly known as the Pfizer vaccine is the first Covid-19 vaccine to receive authorization for use in the general public. The first jab was given to a 90-year old lady in the UK on December 8, 2020; a monumental event that brought hope to billions of people all across the globe. In this article, I will discuss this vaccine’s clinical trial and potential future implications.


How does it act?

The BNT162B2 is a lipid nanoparticle-formulated, nucleoside-modified mRNA that encodes the SARS-CoV-2 full-length spike protein, modified by two proline mutations to lock it in the prefusion conformation. This means that this is an mRNA that has been modified to resist disintegration by nucleases and that translates into the SARS-CoV-2 spike protein. However, this spike protein has also been modified to lock it into its pre-fusion conformation; so that it doesn’t fuse with the target cell’s plasma membrane and remain exposed to immunogenic stimulation.


Who is it for?

This primarily depends on the characteristics of the population included in the vaccine’s clinical trial. This trial randomised 43,458 persons from six countries: USA, Argentina, Brazil, South Africa, Germany, and Turkey. More than three-fourth of the study population (76.7%) belonged to the USA. Moving on to the representation of race or ethnicity in the study population - 82.9% were white, 27.9% were Hispanic, while African Americans, Asians, and Native Americans comprised 9.2%, 4.2%, and 0.5% of the study group. Males and females were almost equally included. The age range is from 16 years to 89 years in the intervention group. This trial did not evaluate the efficacy of the vaccine in children, adolescents, and pregnant women.  


Is it effective?

Define effective; it depends on the trial’s efficacy end points. The primary endpoint was the efficacy of the vaccine to prevent Covid-19 infection 7 days after the second dose in participants who had no serologic (antigen and antibodies) or virologic (RT-PCR) evidence of SARS-CoV-2 infection up to 7 days after the second dose; the second primary endpoint was to prevent infection in those with and without evidence of prior infection. Confirmed Covid-19 was defined as – the presence of at least one symptom (fever, new or worsened cough, new or worsened dyspnoea, chills, new or worsened muscle pain, new loss of taste or smell, sore throat, diarrhoea or vomiting combined with a positive RT-PCR test within 4 days).    



Efficacy End Point


BNT162b2 Group


Placebo Group

Vaccine efficacy, % (95% credible interval)

Covid-19 Cases


Covid-19 Cases


1st Primary






2nd Primary






 This trial showed that a two-dose regimen of BNT162b2 (30 micrograms per dose, given 21 days apart) was 95% effective in preventing symptomatic Covid-19 infection 7 days after its course. The efficacy was 52% after the first dose, and 91% in the first 7 days after the second dose.

However, the trial results did not show the efficacy in preventing asymptomatic infection. We don’t know if this vaccine can safeguard against transmissible asymptomatic infection; therefore, people who have taken the vaccine should not stop wearing masks for the sake of the people around them.


Is it safe?

The vaccine group reported more local reactions, such as pain, redness, and swelling at the injection site than the placebo group. In general, these were mild-to-moderate in severity and resolved within 1-2 days. The systemic adverse effects were also reported more in the intervention group, especially in the younger population (16 to 55 years of age), and more after the second dose. These included – fever (11%), fatigue (51%), headache (39%), chills (23%), muscle pain (29%), joint pain (19%), and 38% of the vaccine group needed to use antipyretic medication. These were generally mild and resolved within 1-2 days. Two deaths happened in the vaccine group, one from arteriosclerosis, and one from cardiac arrest. These deaths weren’t related to the vaccine or Covid-19. The investigators plan to continue the surveillance for adverse events for further 2 years.  


This study has importance beyond the efficacy of the BNT162b2 vaccine candidate. It demonstrates the utility of RNA-based vaccines, its speed of development, and its promising efficacy in preventing infectious diseases. The success of this clinical trial immensely improves our preparedness for a future pandemic.


Polack, FP, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. New England Journal of Medicine. Dec 10, 2020. 10.1056/NEJMoa2034577. C4591001 Clinical Trial group


Thursday, December 17, 2020

All mnemonics for how to determine axis deviation of EKG

Hello Everybody! 

Before reading this post I would like to suggest please see both the videos of How to determine axis deviation in real scenarios... Then come back here for summary & some extra mnemonics. 

Hope it’ll definitely helps you!

How to remember numbers...? 

“Isoelectric Method” 

You are in front of me ... as arrows in the image..... 
I is perpendicular to avF ..
II  to avL 
III to  avR .....

So finally I & you are the leads 😂. 
Thank you..!! 
-Dr. Drashtant!

Wednesday, December 16, 2020

Tips on creating a Rank Order List (point system) for residency and fellowship

Types of Left Ventricular Hypertrophy (LVH)

 Types of Left Ventricular Hypertrophy (LVH)

LVH = increase in the mass of the left ventricle (LV)

Caused due to:
1. enlargement of the muscle cells
2. extracellular fibrosis

Concentric LVH 
- occurs in response to pressure overload
- examples: aortic stenosis or hypertension
- associated with: reduced cavity size

Eccentric hypertrophy
- occurs in response to volume overload
 -examples: aortic or mitral regurgitation
- associated with: dilation

LVH is also classified based on the cause
Due to primary condition (hypertrophic cardiomyopathy)
Secondary to pathology (hypertension, myocardial infarction, and valvular heart disease)

That's all!

Pediatrics | Male Reproductive System | CK Uworld

Tuesday, December 15, 2020

J-1 visa: Statement of Need and surety bond for Indian International Medical Graduates (IMGs)

Histoplasmosis mnemonic

Histoplasmosis mnemonic

Bubonic plague mnemonic

Bubonic plague mnemonic 

COVID-19 Vaccine Development

The worldwide magnitude of the COVID-19 pandemic is ineffable; it is unsurprisingly compared to the Spanish flu pandemic, which ravaged the world during the First World War (adding fuel to the fire!). One of the pandemic's various positive impacts has been the unprecedented research collaboration and data sharing across the world. Such singular efforts made it possible to cut down the usual time to achieve an approved vaccine from 10+ years to less than a year.

To put things into perspective, it took 60 years from the time of the first polio outbreak to developing its vaccine; in the case of Ebola, it took 15 years. Vaccine candidates for SARS-CoV-1 and MERS did not receive the necessary impetus to advance into fruition. However, with SARS-CoV-2, the situation is very different. Global initiatives such as ACTIV (Accelerating COVID-19 Therapeutic Interventions and Vaccines), a public-private partnership comprising of bigwigs like CDC, FDA, EMA (European Medicines Agency), and numerous leading biopharmaceutical enterprises. Another project on a similar scale is Operation Warp Speed, which has invited comparison to the infamous Manhattan Project.

What is an "ideal" COVID-19 vaccine? There are three criteria from the immunological perspective: 1) It induces a robust humoral immune response that produces long-lasting neutralizing antibodies against SARS-CoV-2 antigens, 2) It generates a strong cell-mediated immunity that includes the production of memory T cells, 3) It should be free of any serious local or systemic adverse effects. Considering the logistics of vaccinating the entire world, there are three more criteria: 1) It should be easy to administer, preferably in one or two doses, 2) It should be easy to produce on a large-scale, 3) Its storage should be uncomplicated, ideally possible at room temperature.

 Source: Front. Pharmacol., 19 June 2020 |

Let us discuss the vaccines that are currently in development. We all have heard about a few of them in the news and social media, namely, Pfizer, Moderna, Covaxin, Astra Zeneca, and so on. There are, impressively, 125+ SARS-CoV-2 vaccines in development globally. Broadly, there are six platforms currently being utilized for vaccine development –

1.   DNA

2.   mRNA (examples – Moderna, Pfizer)

3.   Protein (Subunit vaccines)

4.   Viral vector – replicating/non-replicating (examples - Oxford/Astra Zeneca, Johnson & Johnson)

5.   Live attenuated virus

6.   Inactivated virus

Almost all of the above models have targeted the spike glycoprotein, which is present on the surface of SARS-CoV-2, to interfere with the viral entry into a cell.

This article is an oversimplified summary of the vaccine development process. I haven't covered the vaccine platforms, molecular targets, and vaccine candidates in detail. With the advent of vaccine administration, whether it's Pfizer's or any other, there will be a massive surge in vaccine-related information. There will be challenges at every step, from distribution to underdeveloped areas of the world to alleviate the concerns of the skeptical anti-vaxxers. Let us hope that these vaccines start the end of the pandemic.


J-1 visa: Statement of need (SON) attestation from Indian Consulate

Saturday, December 12, 2020

About the Pfizer BioNTech COVID-19 Vaccine trial

Important things we know about the Pfizer BioNTech COVID-19 Vaccine

• From roughly 44000 participants, vaccine and placebo were administered 1:1 ratio, the vaccine participants demonstrated 95% efficacy in preventing COVID-19 in those without prior infection 7 days or more after the second dose.

• Partial protection from the vaccine candidate appeared as early as 12 days after the first dose.

• The vaccine has shown consistent results in people of different ages, races, BMI, and with various co-morbid conditions.

Emoticon game: Acute Liver Failure answers

If you haven't tried the emoticon game, check it out here:

The answers are posted below.

Emoticon game: Causes of Acute Liver Failure

Pediatrics Allergy & Immunology UWorld Step 2 CK


COVID-19 and the increased risk of Parkinson's disease


Currently posted in psychiatry, I was reading articles on Parkinson's disease and came through this important finding in context with the coronavirus disease.

Friday, December 11, 2020

Cosmetic surgery and Nontuberculous Mycobacterial infections

There has been an increase in plastic surgery tourism because some countries offer cheap cosmetic surgery. Common surgical procedures sought are breast augmentation surgery, liposuction, eyelid surgery, facelift, labiaplasties, and gluteal lift procedures. [1]

Conus medullaris syndrome vs. Cauda equina syndrome

Both of these are orthopedic/neurosurgical emergencies! But in general, CM syndrome is more severe than CE syndrome.

Here's a comparison between the two...

Guidelines for management of gout by ACR 2020


Long time..

Urate-lowering therapy indications and important guidelines for management of gout, as updated by ACR in 2020:

Monday, December 7, 2020

Saturday, December 5, 2020

Mechanical ventilation

Terms you need to know

1.       PaO2: Oxygen saturation in arterial blood  (N = 80-100)

2.       PaCO2: Carbon Dioxide saturation in arterial blood (N = 35 – 45)

3.       FiO2: Fraction of inhaled O2 (N = 21% i.e. the fraction of O2 in atmosphere air which we inhale)

4.       PEEP: Positive End Expiratory Pressure – The pressure needed at the end of expiration to keep the alveoli open.

5.       RR: Respiratory rate (N = 12-16)

6.       TV: Tidal Volume (N = 6-8 ml/kg = approx. 500 ml)

Saturday, November 7, 2020

It's a Carny Problem


Carney's Syndrome - multiple benign tumors, mainly of heart and skin

Carney Stratakis Syndrome - Pediatric GIST (Gastrointestinal Stromal Tumor)

Friday, November 6, 2020

Shock by Dr. Ganti (Pulm/Crit)


Blood Donation




  • Men can donate safely once every three months while women can donate every four months
  • Age between 18 and 60 years
  • The donor should be in a healthy state of mind and body
  • Past one year - not been treated for Rabies or received Hepatitis B immune globulin
  • Past six months - not had a tattoo, ear or skin piercing or acupuncture, not received blood or blood products, no serious illness or major surgery, no contact with a person with hepatitis or yellow jaundice.
  • Past three months - not donated blood or been treated for Malaria
  • Past one month - had any immunizations
  • Past 72 hours - had dental work or taken Aspirin
  • Past 48 hours - taken any antibiotics or any other medications (Allopathic or Ayurveda or Siddha or Homeopathy)
  • Past 24 hours - taken alcoholic beverages
  • Presently - not suffering from cough, influenza or sore throat, the common cold
  • Women should not be pregnant or breastfeeding her child or menstruating.
  • No diabetes, chest pain, heart disease or high BP, cancer, blood clotting problem or blood disease, unexplained fever weight loss, fatigue, night sweats, enlarged lymph nodes in armpits, neck or groin, white patches in the mouth, etc.
  • No history of TB, bronchial asthma or allergic disorder, liver disease, kidney disease, fits or fainting, blue or purple spots on the skin or mucous membranes, received human pituitary - growth hormones, etc.


  • Temperature - Normal (oral temperature not exceeding 37.50 C)
  • Pulse - between 50 and 100/minute with no irregularities
  • Blood Pressure -Systolic 100-180 mm Hg and Diastolic 50 - 100 mm Hg
  • Bodyweight - not less than 45 Kg
  • Hemoglobin - not less than 12.5 g/dL-

Procedure to measure Hb using CuSO4:

i) Massage the finger to be pricked (preferably ring finger)

ii) Disinfect it

iii) Prick using disposable needle/ lancet

iv) Put the drop of blood in CuSO4 containing beaker

v) If the blood drop sinks, Hb is more than 12.5, hence the person can donate blood (provided no other contraindication).


  • Identify donor and label blood collection bag and test tubes
  • Ask the donor to state their full name
  • Ensure that:

    1. the blood collection bag is of the correct type;
    2. the labels on the blood collection bag and all its satellite bags, sample tubes and donor records have the correct patient name and number;
    3. the information on the labels matches with the donor's information

  • Select a large, firm vein, preferably in the antecubital fossa, from an area free from skin lesions or scars
  • Clean the site of venepuncture by alcohol and let it dry
  • Perform phlebotomy using a 16-gauge needle, which is usually attached to the blood collection bag. Use of a retractable needle or safety needle with a needle cover is preferred if available, but all should be cut off at the end of the procedure.
  • Ask the donor to open and close the fist slowly every 10–12 seconds during collection
  • Remove the tourniquet when the blood flow is established or after 2 minutes, whichever comes first
  • Ask the patient to squeeze a ball intermittently during the procedure
  • Monitor the donor and the donated unit
  • Remove the needle and collect samples
  • Cut off the needle using a sterile pair of scissors
  • Collect blood samples for laboratory testing



  • ask the donor to remain in the chair and relax for a few minutes
  • inspect the venepuncture site; if it is not bleeding, apply a bandage to the site; if it is bleeding, apply further pressure
  • ask the donor to sit up slowly and ask how the person is feeling
  • before the donor leaves the donation room, ensure that the person can stand up without dizziness and without a drop in blood pressure
  • offer the donor some refreshments


  • Transfer the blood unit to a proper storage container according to the blood center requirements and the product
  • Ensure that collected blood samples are stored and delivered to the laboratory with completed documentation, at the recommended temperature, and in a leakproof, closed container


Written by our guest authors HARSH JOGI and AYUSHI GUPTA

Tuesday, November 3, 2020

Ascitic Tap

Written informed consent, Betadine, Spirit, Sterile gloves, Sterile drapes, a 1.5-3.5 cm 20-22 G needle, a 5-20mL syringe is used, 18-20 G needle attached to a non-collapsible tubing to a sterile collection bag.

1. Follow universal precautions. 

2. Skin around the site of puncture to be disinfected with betadine or Chlorhexidine and spirit and draped with sterile drapes.

3. Position: The patient should be in supine position.

4. Site: In the flank mid-way between the anterior superior iliac crest and 
umbilicus (lateral to rectus muscle). Areas of scars of previous surgery should be 

5. Local Anaesthesia:
a) Skin, subcutaneous tissue, abdominal wall layers up to parietal peritoneum to be anesthetized with 2% lidocaine filled syringe using a 22-25 G needle.The needle is advanced into the subcutaneous tissue aspirating every 2-3 mm prior to injecting. 
b) Once a loss of resistance is felt and peritoneal fluid is drawn into the syringe, it indicates that we have entered the peritoneal cavity. Additional lidocaine is then injected to anesthetize the pain-sensitive parietal 
(A total of approx. 4-5 ml lidocaine is adequate.) 
c) The needle is then withdrawn. 

6. Puncture: 
For diagnostic tap – a 1.5-3.5 cm 20-22 G needle attached to a 5-20mL syringe 
is used. 
Technique – The aim is to prevent leak by ensuring the skin puncture site is 
not directly over the puncture site into the peritoneal cavity. 
 Z track technique – Pull skin about 2 cm downward before puncturing 
skin→ then leave the skin after entering few mm so as to form a Z
 Angular insertion technique - Insert the needle by keeping at an acute angle to the skin surface. Then advance the needle slowly through the underlying subcutaneous 
tissue in 5 mm increments while intermittently aspirating. Generally for the diagnostic purposes, the sample is sent for the following 
tests, all of them collecting in separate containers:
● Routine & microscopy
● Culture and sensitivity 
● MGIT+ Gene Xpert
● LDH 
● Amylase
● Cytology (optional)
For therapeutic tap - A large bore 1.5-2 cm 16-18 G needle is used instead.The syringe is detached and the needle is attached to a non-collapsible rubber tubing.The ascites fluid is drained slowly through the rubber tubing 
connected to the needle into a sterile collection bag. 

7. Seal : After the puncture, the punctured skin is sealed with a tincture benzoin 

8. Post procedures: T.P.R, B.P to be recorded half hourly and the 
patient should not be given feeds for the next 4 hours. If there is pain, analgesics may be given.

- Mitali shroff

Monday, November 2, 2020

USMLE STEP 1: Resources and preparation


These two resources are inevitable for Step 1 preparation.
First Aid for Step 1
Uworld question bank

Kaplan videos (subject wise)
Boards and Beyond videos
Sketchy videos for microbiology and pharmacology
Pathoma videos and notes for pathology
UW biostats review for biostatistics
BRS books for behavioral science.
Conrad Fischer’s 100 cases for ethics



Read FA 3-4 times, from cover to cover.
FA provides every single concept in brief. You may need supplemental resources and videos in order to understand these concepts, but once you do, the final high yield topic is mentioned in FA.
Consider it the most concise version of take away points of all subjects.
Read a section/ topic/ subject/ system from first aid, and always solve MCQs simultaneously for reinforcement. 
If you find it difficult to understand a particular subject, supplement it with videos at that time.

EG: I started reading biochemistry from first aid and couldn’t grasp the concept. What do I do?
Watch Kaplan videos (or BNB or any other resource) for biochemistry. 
Annotate important points from the videos into my FA.
Read the same sub-topic from FA simultaneously.
Finally, when I have a good grasp of the concept, I will solve only biochemistry MCQs from UW (or any other q-bank)
This way, I have consolidated learning biochemistry by using FA, UW and videos to understand the concept
If you work well with flashcards, I will make my own flashcards using ANKI or used pre-formed flashcards from ANKI for intermittent learning.

This is a question bank which has various options for subscription. Understand that you will need this q-bank until the date of your exam, so either take a 6 month or 1-year subscription.
This needs to be done TWICE. Period.

1. Timed: You get 60 minutes to solve 40 questions (You cannot read the explanation until you have finished the whole block)
2. Tutor: No limit on solving questions. (You can exceed 60 minutes for 40 questions)
3. Timed-tutor: You will be timed, but there will be an option of “show answer”, which will give you the explanation right away after you have marked an answer and clicked on it.

FIRST PASS: Use timed-tutor mode.
Always use timed mode as it will help you overcome the time issues in the final exam, especially if you are within 6 months of your exam date. 
If you have just begun and are using uworld to solve questions along with your first reading of FA, you may prefer using the tutor mode.
Make sure to annotate extra information from UW into your FA. FA does not have enough space, so get it spiral binded and add pages within or make an extra notebook.
If you are not comfortable writing so much extra information into FA and prefer flashcards, make flashcards in UW of all the info which is not mentioned in FA.

Remember, in the end UW and FA will be your final resources during your dedicated phase, so you need all information consolidated at one place.
How to make flashcards: Keep all the tables and flowcharts under one deck. Make separate decks according to subjects. Make a deck of super volatile concepts and concepts not mentioned in FA.

SECOND PASS: Use timed mode
Timed mode will help you prepare for your test.
Reset UW again and start from scratch in the 2nd pass. Alternatively, if you don’t have enough time, solve your incorrect and marked questions only.
Keep revising a few pages of FA daily.

If you are a visual learner, this is an amazing tool. It will help you to remember these bugs till your Step 3 exam as well. 
Keep revising the pictures at regular intervals as it is easy to forget them.
If it gets too much, just focus on sketchy for viruses and fungi. 
Do sketchy for VIRUSES and keep your FA open. Read from both places and learn simultaneously. Sketchy really helps with virology.

Go through the videos and annotate in FA.
Solve MCQs after finishing each sub-topic

These are needed during the early part of your prep to understand the concepts.
Keep FA open and annotate important points from the videos or make your own notes in a separate notebook.
Don’t underestimate their importance in building your base in these concepts as they will help you with Step 2 and Step 3 as well.


Use this in the end. After you have gone through UW twice and still want additional practice, use Amboss.
They have tougher questions, so don’t get discouraged.
No need to annotate information unless it seems high yield.
Use it to practice as many questions.


These are assessments which give you a score at the end. They may or may not be able to predict your final score, so use them to see how much improvement is needed, but do not rely on them blindly.
Take an online NBME or UWSA1 after the first pass of UW (which would coincide with at least the 2nd or 3rd reading of FA)
Find out your weaknesses. See videos, re-learn FA, solve UW incorrects to improve upon those weak areas.
When you are within 3 months of your step 1 date, start taking assessments every 10-15 days.
Leave NBME 18 and UWSA 2 for the last one month as they are ‘considered’ to be predictive.

In the descending order:

Dedicated Study Period: Last 2-3 months (8-10 hours per day)
Final revision of FA
UW incorrects
Amboss questions for practice
Assessments every 15 days

Pre-dedicated period: 2-3 months (4-8 hours per day)
2nd and 3rd revision of FA
Start UW with annotation in FA/ make separate notes/ make flashcards of high yield points not mentioned in FA
Take an assessment (NBME or UWSA1) and see your weakness. Go through supplementary material for those weak areas (videos, other books)

Initial Phase: 4-6 months (4-8 hours per day)
1st reading of FA
Videos and text for establishing basic concepts
Solving any q-bank for practice and reinforcement
Annotating important points

Written by Amrin Kharawala

Thursday, October 22, 2020

USMLE Step 3 experience (247 score)

Ø  Score: 247
Ø  Preparation time: 1.5 months
Ø  Main Resources: Step 3 UW + UW CCS Cases +
Ø  Supplemental Resources: Step 1 First Aid + Crush CCS pdf + USMLE Primum software + Random overview of few Step 2 CK notes

PCOS explained

PCOS with Sherlock Holmes

Hello guys, this is my first video/podcast on Medicowesome.

Sunday, October 11, 2020

Saturday, October 10, 2020

Gerstmann's syndrome physical examination

 Gerstmann's syndrome is caused by lesions in the dominant parietal lobe (usually left).

Hoffman sign in neurology

Hello! Let's learn about the Hoffman sign.

The Hoffman sign: Involuntary flexion of the thumb and/or index finger when the fingernail of the middle finger is flicked down. 

Friday, October 9, 2020

Shingles vaccine

What do we know about the Shingrix Vaccine?

This vaccine is recommended for patients over the age of 50 years. It is a live attenuated vaccine. It is a
recombinant vaccine containing the glycoprotein E named RZV or Shingrix. Two doses are
required 2-6 months apart and can be safely given with influenza (flu) vaccine. History of chickenpox or varicella zoster doesn’t determine whether to give the vaccine or not because antibodies gained through the infection wanes with time.

Internship diaries: Perception of nipple discharge

A 60-year-old female complained of clear discharge from her right breast for one week. 

On examination, the right breast nipple was painful and there was clear fluid around the nipple. Expressing the breast produced no discharge. Incidentally, she mentioned a rash that was hurting on her right shoulder. The rash was a distinctive cluster of fluid-filled blisters with inflamed underlying skin, suggestive of shingles. 

Mechanism of action of lipid-lowering drugs

Hey everyone! 

I wanted to talk about the new lipid-lowering drug, bempedoic acid. But first, let’s just quickly go through the mechanism of action of the existing lipid-lowering drugs:

Statin reduces cholesterol synthesis by HMG-CoA Reductase inhibition.

Ezetimibe inhibits cholesterol absorption from the intestine.

Sunday, October 4, 2020

Sub-specialty WhatsApp groups

 Hi everyone!

I have decided to create sub-specialty groups on WhatsApp in addition to our regular study groups. If more than 5 people are interested in it, we will create a group.

Friday, September 25, 2020

Sodium-glucose co-transporter 2 (SGLT2) inhibitors notes and mnemonics

 A short post on SGLT2i!

Canagliflozin (brand name Invokana)
Empagliflozin (brand name Jardiance)
Dapagliflozin (Farxiga)
Ertugliflozin (Steglatro)

Mechanism: Blocks renal glucose absorption, resulting in glycosuria.
Mnemonic: GliFlozIN makes Glucose Flow In Nephrons

In addition:
Has beneficial effects on ASCVD events, heart failure, and CKD.
Causes weight loss  (Mnemonic: SGLT2 Surely Generates Less Tummy).
No risk of hypoglycemia.

Side effects:
Genital fungal infections.
Fournier’s gangrene.
Dehydration may result.
Euglycemic diabetic ketoacidosis (should be held 24H prior to scheduled surgeries).
Canagliflozin may increase the risk of leg amputation (should be avoided in those with peripheral vascular disease).

Caution: Renal dose adjustment is required in CKD.

That's all!

Metformin notes and mnemonics

 A short post on Metformin!

Decreases hepatic glucose output by reducing hepatic gluconeogenesis and glycogenolysis.
Enhances peripheral glucose uptake and enhances insulin sensitivity.
Decreases glucose absorption in the GI tract.
Reduces hemoglobin A1C levels by 1.5%.

In addition:
Decreases triglyceride levels.
Decreases LDL-cholesterol.
May increase HDL-cholesterol.

Side effects:
Vitamin B12 deficiency may develop
Risk of lactic acidosis in renal or liver disease or CHF

Contraindicated in: GFR <30ml/min.

That's all!

Related posts:
Oral hypoglycemic drugs used for diabetes mellitus mnemonic: Metformin meets glucose and advises it to stay out of the blood. It asks the liver to keep glucose in the house (Inhibits hepatic glucose production) and asks the glucose in the bloodstream to go into adipose and skeletal muscle (Stimulates peripheral uptake of glucose). Metformin never met a glucose molecule and did not tell him to not stay in the blood (Illustration in the original post).

Thursday, September 24, 2020

Virtual interview tips

Interview questions for practice

 Hi everyone! 

Here are some of the questions I was asked during my cardiology fellowship interviews. They can be useful to practice during medical school or residency interviews as well, which is why I am writing this post.

How do you answer these questions? Always attach a story (situation) to it. It only comes with practice - so please, practice a lot.

Wednesday, September 23, 2020

Fragmented QRS

Fun fact: Fragmented QRS can be caused by conduction around the scarred myocardium, resulting in multiple spikes within the QRS complex.


Thursday, September 17, 2020

No-reflow or low reflow phenomenon in total coronary artery occlusion

What is the no-reflow or low reflow phenomenon?

If blood flow to the ischemic tissue continues to be impeded after relief of the occlusion.

Why does this happen?

After prolonged cessation of coronary perfusion and restoration of blood flow to the epicardial coronary arteries, structural damage occurs to the microvasculature that prevents the restoration of normal blood flow to the cardiac myocytes. Various mechanisms are implicated in the genesis of the no-reflow phenomenon.

Friday, September 11, 2020

SLC gene Mutations and related Disease

Hello Awesomites!

Enjoy this crisp post on SLC gene mutations.

SLC= Solute carrier


Acrodermatitis enteropathica 




Hartnup disease 


Renal glucosuria

FYI-Diseases associated with SLC6A4 include Anxiety and Obsessive-Compulsive Disorder

For further information read this article SLC transporters as therapeutic targets.

 -Upasana Y.

Fact- Reversible ADP-r inhibitors cause breathlessness


 Reversible inhibitors of ADP-r (P2Y12) such as ticagrelor, cangrelor, and elinogrel used as anti-platelet drugs have a unique side effect of dyspnea, unlike the irreversible ones. This is hypothesized to occur because of reversible inhibition of ADP-r on sensory neurons. Since half-life of the reversible inhibitors is shorter than that of irreversibles, repeated doses lead to permanent inhibition of the P2Y12 receptors on sensory neurons.

 Moreover, oral administration is found to cause more severe effects on the breathing difficulties than the parenteral route.

 Source- Research gate 


That's  all

- Jaskunwar Singh

Thursday, September 10, 2020

Naegele's formula

 Naegele's formula
The Naegele's formula is a simple arithmetic method for calculating the EDD (estimated date of delivery) based on the LMP (last menstrual period). 
To the date of the first day of the LMP (e.g. 22nd June 2019):
  • add seven days (i.e 29th)
  • subtract 3 months (i.e March)
  • add one year (i.e 2020)
Note: If the interval of cycles is longer, the extra days are to be added and if the interval is shorter, the lesser days are to be subtracted to get the EDD.

Friday, September 4, 2020

Lover's heel

Lover's heel is a term used for Gonococcal tenosynovitis of the Achilles tendon given the sexually transmitted nature of gonorrhea.

I just wanted to share this interesting fact with you.


Friday, August 14, 2020

Answer: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Question: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Sickle cell retinopathy

 What is the hallmark of sickle cell retinopathy?

Sea fan neovascularization.

All patients with SCD should have dilated funduscopic examinations every 1 to 2 years beginning at age 10, preferably by a retina specialist.

Treatment is usually Laser photocoagulation.

Anti-VEGF medications such as bevacizumab or ranibizumab may lead to partial regression of sea-fan neovascularization.

Sickle cell anemic retinopathy is seen mostly in heterozygous S-C trait and S-Thal trait. 

Fun fact: Sea fans are beautiful soft corals.


Sunday, August 9, 2020

Anion Gap

What is Anion Gap?

We need an equal amount of anions and cations to keep the body electrically neutral. So anion gap is not a real thing, it is just a diagnostic concept. Remember, in cations, we mainly measure Na, the other ‘unmeasured’ but important cations are K, Mg, Ca. Unmeasured means not routinely measured. In anions, we routinely measure Cl- and HCO3-, others important but ‘unmeasured’ anions are PO4, Sulfate and  Albumin.
The formula: Anion gap=Na-Cl-HCO3
(normally 8-16meq) is calculated mostly in metabolic acidosis as either normal anion gap or increased anion gap.

Now the most important thing to always remember is that, if due to anyreason, HCO3 or Chloride (measured anions) decreases, the relative concentration of unmeasured anions will increase, as if the unmeasured anions are trying to compensate the loss of their fellow measured anions by increasing their own concentration 
             In Metabolic Acidosis, HCO3 is low, assume that Na is unchanged for now,  so due to low HCO3, other anions like Cl-( measured) and other unmeasured anion will try to compensate by increasing themselves. If Cl- can increase to replace to loss of HCO3’s negative charge, the anion gap will remain within normal limits, if Cl- is too low and can't compensate, then, by the formula AG=Na(normal)- Cl(low)-HCO3(low), The Anion Gap will increase.

- Vaibhav Jain

Thursday, August 6, 2020

Breastfeeding in COVID-19

Hello Friends!
     On the International Breastfeeding week, I would like to share information about “Breastfeeding in COVID-19”, whether it is safe or not to breastfeed the neonates & infants in this pandemic situation.
The COVID-19 Virus has not been detected in the breast milk of any mother either with confirm or suspected COVID-19. So, COVID-19 testing does not have any immediate implications for decisions on infant and young child feeding .The numerous benefits of breastfeeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.Meanwhile researchers continue to test breast milk from infected mother.

Some information that you all need to know are-
1)WHO recommends that all mothers confirm or suspected COVID-19 continue to have skin to skin contact and to breastfeed. In all socio – economic conditions breastfeeding improves-
- Survival and provide lifelong health
- Development advantage to newborns &infants
- Reduce the risk of breast cancer & ovarian cancer in mother
- Skin to skin contact including kangaroo mother care reduce neonatal mortality especially in low birth weight newborns and it also improves thermal regulation of newborns and several other physiological outcomes. There are numerous benefits of skin to skin contact and breast feeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.

2) While infants & neonates can contract COVID-19 they are at low risk of infection .A few confirm  cases of COVID-19 in young children have experience only mild or asymptomatic illness.

3)In all socio- economic settings Breastfeeding improves survival and provides lifelong health and development advantage to new born & infants.

4) If a mother is confirmed / suspected COVID- 19( for the time when she is likely to be infective ,i.e. while symptomatic or through the 14 days after the start of symptoms ,whichever is longer) then, 
(a) She should wash hands frequently with soap and water or use alcohol based sanitizer before touching the baby.
(b) She should wear a medical mask while feeding .It is important to-
* Replace mask as soon as they become damp 
* Dispose of mask immediately 
* Not reuse a mask 
* Not touch the front of mask but unite it from behind.
- Sneeze or cough into a tissue, immediately dispose of it and use alcohol based hand rub or wash hands again with soap and water.
- Regularly clean & disinfect surfaces.
(c) If medical mask not available to her, breastfeeding should be continued.
Other infection prevention measures such as washing hands , cleaning surface, sneezing or coughing into a tissue are also important .Non- Medical mask( homemade or cloth mask)have not been evaluated .At this time it is not possible to make a recommendation for or against their use. 
(d) If she had just coughed over her exposed chest or breast then she should gently wash the breast with soap and warm water for at least 20 seconds prior to feeding. It is not necessary to wash the breast before every breastfeed or prior to expressing milk.
(e) If she is not able to breastfeed then best alternatives are-
• Expressed breast milk
- Expression of breast milk is primarily done or taught through hand expression, with the use of a mechanical pump only when necessary. Hand expression and using a pump can be equally effective.
- The choice of how to express will depend on maternal preference, availability of equipment, hygiene condition and cost.
- The mother and anyone helping the mother, should was their hands before  expressing breast milk or touching any pump or bottle part and ensure pump, feeding utensils, milk storage container should be cleaned  after each use with liquid soap e.g. dishwashing liquid and warm water .Rinse after with hot water for 10- 15 seconds.
- Express breast milk should we feed to child preferably using a clean cup or spoon by a person who has no sign a symptom of illness and whom  the baby feel comfortable. The mother should was their hand before feeding the newborn / infant.
•Donor human milk
- Mother is unable to express milk and milk is available from human milk Bank, Donor human milk can be feed to the baby while the mother is recovering.
• If expressing breast milk or donor human milk and not feasible or available then consider-   
*Wet – nursing (another woman breastfeed the child).In settings where HIV is prevalent, prospective wet-nurses should undergo HIV counselling and rapid testing according to National guidelines where available. In the absence of testing if visible undertake HIV risk assessment. If HIV risk assessment/counselling is not possible, facilitate and support wet-nursing. Provide counselling on avoiding HIV infection during breastfeeding. Prioritise wet – nurses for the youngest infants.
* Infant formula Milk with measures to ensure that it is feasible, correctly prepared, safe and sustainable. There are always risk associated with giving infant formula Milk to newborns and infants in all setting. It is commonly of variable quality, of the wrong type, not accompanied by an essential package of care, distributed indiscriminately, not targeted to those who need it. That risk associated are increased whenever human  community conditions are compromised example reduce access to health service if baby become unwell / reduce access to clean water / access to supplies of infant formula milk difficult or not guaranteed not affordable and not sustainable.
 Donations of infant formula milk from confirm/ suspected mothers should not be accepted. If needed, supplies should be purchased based on assessed need. 
 Mother can start breastfeed when she feel well enough to do so. There is no fixed time interval to wait after confirmed or suspected COVID-19.There is no evidence that breastfeeding changes the clinical course of COVID-19 in a mother. Health workers or breastfeeding counsellors should support mothers to relactate.
(f) There is no need to provide a' top- up' with an infant formula milk. Giving a ‘top -up' will reduce the amount of milk produced by a mother. Mother who breastfeed should be counselled unsupported to optimise positioning and attachment to insure adequate milk production. Mother should be counselled about responsive feeding and perceived milk insufficiency and how to respond to their infant's hunger and feeding cues to increase the frequency of breastfeeding

5) Recommendations for adult and older children to maintain social distancing aim to reduce contact with asymptomatic person who have covid-19 and transmission of virus that may result. This strategy will reduce the overall prevalence of covid-19 and the number of adults who experience more serious disease.
The aim of recommendations on the care and young children whose mother have confirm or suspected covid-19 infection is to improve the immediate and lifelong survival, children health and development of newborns and infants. These recommendations consider likelihood and potential risks of COVID-19 in infants and also the risks of serious illness and death when infants are not breastfeed or when infant formula milk are used inappropriately as well as the protective side effects of breastfeeding and skin to skin contact.
Thus, It is safe to breastfeed the infants and neonates because no active COVID-19 Virus has not, to date been detected in breast milk of any confirm/suspected mother and it also provides remarkable benefits to the baby.

By- Neha Kumari
2nd year MBBS student

Tuesday, August 4, 2020

Pathology related to Breastfeeding

Breastfeeding has been playing an important role for the development of infant since ages. According to WHO and AAP, Breastfeeding is the normal way of providing young infants with nutrients they need for healthy growth or development. Scaling up breastfeeding could save lives of more than 8,20,000 -children under the age of 5. It could lower the rates of allergies, Ear -Lung Infection , Obesity , Sudden Infant Death ,Necrotizing Enterocolitis And associated sepsis .Not only it could be beneficial for the infant but also for the mother because it could reduce the chances of uterine bleeding , burn calories , reduce the risk of breast / ovarian / uterine cancer , osteoporosis , Arthritis , Type II Diabetes mellitus and Heart Disease. Initially the breast releases colostrum which has high content of immune cells and antibodies, a much lower fat content and also acts as a laxative to pass out the first stool meconium. But there could be several problems associated with breastfeeding. I would like to list down a few of them-

1. DIFFICULTIES FROM LATCHING INTO THE BREAST – A good latch promotes high milk flow and minimizes nipple discomfort for the mother whereas a poor latch results in poor milk transfer to the baby and can quickly lead to sore and cracked nipples.

2. CRACKED NIPPLES- A shallow latch or Thrush (Candiasis) or Dry skin around The Areola could be the general causes. Cracked nipples could be a little frightening and uncomfortable at the beginning and could be associated with some bloody discharge. Treatments for this could be application of Soothing Gel pads, nursing ointments or painkillers like Acetaminophen (Tylenol).

3. ENGORGEMENTS OF BREAST- A sense of breast fullness or heaviness within 36 hrs. of delivery. The increased blood supply, accumulated milk and swelling all contribute to painful engorgement. Engorgement may affect the areola, the periphery of the breast or the entire breast and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola / nipple. This makes latching a daunting task for the baby.  The possible treatments could express or pumping. Gentle massage or pressure could soften the areola. Application of cold compresses to reduce the swelling pain and vascularity even more. One published study suggested that the use of Chilled Cabbage leaves could produce mixed results. Acetaminophen could relieve the pain too.

4. MILK STASIS- When alveolar and lactiferous ducts are blocked and cannot drained properly. This can be treated by varying the baby’s feeding position and applying heat before feeding.

5. MASTITIS- Inflammation of Breast in Association with dolor, rubor, tumor and calor. This could be due to Primary causes as in milk stasis or secondarily with infectitious organisms such as Staphylococcus sp., Streptococcus sp., and E-Coli. Continued Breast feeding, plenty of rest and fluid intake could possibly cure such conditions.

6. Dysphoric Milk Ejection Reflex (D – MER)- A newly recognized condition affecting lactating women that is characterized by abrupt dysphoria or negative emotions that occurs before milk release. The possible cause may be due to inappropriate dopamine activity at the time of milk ejection reflex.

7. INVERTED NIPPLES- A condition where the nipple instead of pointing outwards, is retracted back into the breast. The etiology to these conditions might be due to 
• Fat necrosis
o Breast Carcinoma 
o Inflammatory Breast Cancer 
o Paget’s Disease
o Mammary Duct Ectasia 
o Breast Abscess
o Mastitis
o Weaver Syndrome
o Kennerknecht – Sorgo – Oberhoffer Syndrome

8. RAYNAUDS OF THE NIPPLE/ NIPPLE BLANCHING- Can be caused by vasospasm of the nipple. Blood does not flow properly to the nipple which causes the nipple to blanch. This could be due to early breastfeeding or candidal infection of the nipple. There could be associated throbbing pain in between the breastfeeding sessions when the nipple is blanched.  In some instances, heart medication nifedipine is used to help flow of blood to the nipples.

9. TONGUE TIE/ANKYLOGLOSSIA- This condition is present at birth that restricts the range of motion of the tongue. With tongue tie an unusually short, thick and tight band of tissue (lingual frenulum) tethers the bottom of the tongue’s tip to the floor of the mouth so it may interfere with breast feeding. It could also affect the way a child eats, speaks and swallows.

10. POSTNATAL DEPRESSISON- Many women feel a bit down, tearful or anxious in the first week after giving birth. Symptoms might include insomnia, a persistent feeling of sadness and low mood, loss of appetite, intense irritability and difficulty of bonding with the baby.


Breastfeeding: The Mother & Baby Bond

In today's fast pacing era what can be most necessary and unaltered for a new guest in this world. What can be a moving experience from a women's point of view. Definitely it's breast feeding. An Emotional saga for every women's life. An experience to be relished lifelong. It's not only a rational experience rather a lifetime experience for her. 
From the beginning of human settlements many things have changed but not this loving and caring bond between a mother and her child. The happiness felt by a mother during the nourishment of her newborn is unmeasurable.  She forgets all her pain and discomfort in front of this joy. This is the reason why mothers are portrayed as goddess in every religion and culture.
Apart from these aesthetical values there are many Scientific theories which proves why breastfeeding is important and is considered as an emotional experience. Mother’s milk is highly nutritious and contains varieties of Carbohydrates, protein, vitamines and immune boosting complexes which are sufficient for the growth of baby in 1st six months of life. 
During the process of breast-feeding maternal pituitary releases prolactin and oxytocin. These hormones along with increasing the milk production help in reducing mental anxiety of mother. 
Thus the first connection of baby to her mother is undoubtedly important and can't be substituted. If this process is ever altered I think our existence will be questioned. 

By- Sudipt Anand (S.K.M.C.H)