Milrinone in congestive heart failure

Today, my resident was teaching us about different drugs used in heart failure when he started talking about ionotropes like milrinone and dobutamine.

For those of you who don't know, Milrinone is a phosphodiesterase inhibitor and it enhances cardiac contractility by increasing intracellular levels of cyclic AMP.

Milrinone has a lot of beneficial hemodynamic actions short term. It can provide acute hemodynamic and symptomatic benefit in patients with advanced heart failure with reduced ejection fraction, improving functional status and reduce hospitalization [1].

BUT long-term therapy with oral milrinone increases the morbidity and mortality of patients with severe chronic heart failure [2]. The mechanism by which the drug exerts its deleterious effects is unknown.

Milrinone causes more harm than benefit in patients with ischemic cardiomyopathy [3].

That's why, like my resident called it, milrinone is also known as Killrinone! I just like how he made the kill pun, so I wrote about it and wanted to let you guys know :D

To summarize: Even though milrinone is used in patients with refractory heart failure for symptomatic relief, it has no long term mortality benefit.

That's all!

If you've noticed, I am trying to level up my blogs by referencing articles, I won't get too technical and you will still see the smiley faces. But I think it's time for Medicowesome to grow up and be more evidence based :)

-IkaN

References:
[1] Safety and clinical utility of long-term intravenous milrinone in advanced heart failure.
AUMehra MR, Ventura HO, et-al. Am J Cardiol. 1997;80(1):61. PMID 9205021
[2] Effect of Oral Milrinone on Mortality in Severe Chronic Heart Failure
Milton Packer, Joseph R. Carver, et-al. N Engl J Med 1991; 325:1468-1475 November 21, 1991 DOI: 10.1056/NEJM199111213252103
[3] Heart failure etiology and response to milrinone in decompensated heart failure: results from the OPTIME-CHF study.
Felker GM1, Benza RL, et-al. J Am Coll Cardiol. 2003 Mar 19;41(6):997-1003. PMID: 12651048

Ibutilide

Hey guys.

So here is a random fact. Ibutilide is the only drug that converts atrial fibrillation to sinus rhythm.. All the other drugs..propranolol, verapamil, digoxin etc reduce the ventricular rate only.

A short post on how to apply for electives

This is a very short post.

What is electives?
Electives is hands on clinical experience in the US.

Why do I need it?
To show the residency program you are applying to that you have experienced the US clinical setting and that you are comfortable in it.
To get a letter of recommendation required for the residency application.
It also helps you know a lot of people in your field, that can help you get a research or an interview.

When can I go for electives?
In the final year of your medical school. BEFORE you graduate. Once you graduate, you can't do electives.

Mechanism of pulsus paradoxus in pericardial diseases like constrictive pericarditis and pericardial tamponade

Okay, so let's begin!

Normally, during inspiration, a decrease in intrathoracic pressure is transmitted to the right heart, augmenting venous return.

What happens to the left heart?

During inspiration, expansion of the lungs and pulmonary tissues causes pulmonary blood volume to increase, which transiently decreases the flow of blood from the lungs to the left atrium and therefore, left ventricle.

Understood this? Okay, cool.

Right ventricular volume increases, pushing the interventricular septum towards the left ventricle.

Submissions: Klumpke's paralysis notes

These were submitted by Jinju! It's her day#2 of sending me her notes!

Step 2 CS: Upper limb neurological examination

So I am practicing for my CS exam. I am memorizing what I will tell my patient and writing them down for my reference. Uploading it on the blog for whoever finds it helpful.

I recommend watching videos and making your own "Set of dialogues" and practicing over and over again. Here are mine for upper limb neurological examination:

Submissions: Kawasaki disease mnemonic

Kawasaki disease mnemonic: FEBRILE

F- Fever (for more than 16 days)
E- Enanthem
B- Bulbar conjunctivitis
R- Rash, redness of lip, tongue, finger tips
I- Inflammation of blood vessels (vasculitis)
L- Lymphadenopathy (mostly cervical
E- Extremity affection

One more with same mnemonic

Submissions: Lymphatic drainage of the breast diagrams

These diagrams where drawn by Jinju. She is drawing one anatomy diagram everyday and sending them to me =)

Diseases and their twins.

There a few diseases which quite resemble an other disease in presentation and sometimes pathology.Here's a list I made-

1. Wolf-Parkinson-White and
    Lown-Ganong-Levine syndrome-

    -What's similar?
     The tachycardia, short PR   
      interval, pre- excitation

   -What's different?
     While in WPW syndrome,the
     culprit is a naughty extra pathway,
     the bundle of Kent, in LGL the AV
     node itself is naughty.(The
     hypothesized bundle of James 
     hasn't been discovered yet)
     Conduction through the AV node
     occurs rapidly.
    
     ECG findings- WPW syndrome has
     a short PR interval and a Delta
     wave on the QRS complex. No
     Delta waves occur in the LGL
     syndrome.
    
     Also, the risk of sudden death
     remains lower in LGL syndrome.

Study group discussion: ESR, HbA1c and diabetes

Did you know the ESR in diabetic patient may be elevated in the absence of overt infection?

Don't let the score get you down

"Sometimes, I wonder if I should judge myself by the marks I get at the university exams.

I work hard, sickening hard, but my scores don't give justice. I've never been able to enter in the league of 70+s and Ds.

Does it make me less of a doctor? Or have I chosen a wrong profession? Confused.

I seek some inspiring comments. Thank you in advance."

-Asked on my college group

Studying anatomy again

Hey, I really like your blog a lot. I'm still doing my first year. I failed again. This is my 5th trial over all. I feel pretty lost at the moment, I don't know where I'm going wrong. I really love this field but day by day I'm losing my groove and don't even feel like reading the same stuff again. Please do help me out. I want to come out of this mess, so hard for me to motivate myself. I really feel lost. Thanks for your inspiring messages before. God bless you! :)

-Asked by Anonymous

Hey. I can understand that what you are going through must be really tough. Studying for the same subject again and again is really boring and can be frustrating at times. I am so sorry you have to go through this :(

 Alright! So what can we do?

Tip 1: Fake it till you make it.
Pretend you are a super awesome anatomy professor and teach it to yourself after reading.
Write cool things and fun facts about anatomy. Make colorful notes.
Celebrate after every page you read. Be happy while studying.
You have to fake interest in the subject. Because otherwise you won't be able to study for it.

Tip 2: Figure out what went wrong in the previous attempts.
I think you can tell what went wrong. Was there an easy question in your viva that you did not answer? Was there a question with high weight age that you didn't about? Did you mark more than half MCQ's wrong? Did you fail to draw diagrams? Did you forget the answer or did you not know about it? Are you just studying important questions and not reading everything that is supposed to be read? What are your weak points: Neuroanatomy? Abdominal anatomy? Embryology?

Work on it.

Tip 3: Get another book or resource
Maybe your textbook isn't good enough for you any more. Stick to you but get new books just to have a read in other words.
Google for diagrams.
Make mnemonics.
YouTube songs on anatomy. Play them and sing them!
There is a lot of help available, just look for it.

Tip 4: Visualize it
Palpate your brachial artery and tendons while studying. Imagine the muscles in your feet. Visualize how your skull looks like on the inside. Look at diagrams, cadavers and notice the origin and insertion of various muscles. If you can't see it, you won't be able to answer questions related to it.

Tip 5: Live in anatomy
So here's a fun thing you can do. Talk to yourself in anatomy.

Today, when I didn't know the answer to the question, I used my trapezius with my 11th cranial nerve to shrug my shoulders.
To tease my friend, I used Genioglossus to protrude my tongue :P
I used my facial nerve and orbicularis oculi to wink at my girl friend ;)
I am glad I have strong pelvic muscles iliococcygeus and my internal organs aren't prolapsing.

Maybe you could write a "Life in anatomy" diary! xD

Make stupid anatomy jokes. (Soleus has a soul and heart?) Play anatomy games and quizzes.

Have fun with studying, please. But please, study everyday. Make a study plan and study a lil bit of everything. An hour everyday of: Head and neck, limbs, neuroanatomy, embryology, etc. Revise. Revise. Revise. Anatomy is all about memorization and you are likely to forget if you don't revise. Have someone keep a track of your progress. If you can't, email me. I would love to help you out and see you kick anatomy's gluteus maximus this year :D

-IkaN

On 23rd Aug 2016 the person who asked this question messaged me:

Ikaannn... I passsedd! Thank you so much for everything. Really, you helped me so much, IkaN, you have no ideaa. I was so down. You lifted me up and helped me through it. I owe you <3

Sending you big teddy bear hugs :*

Thank you for keeping me in your prayers!

 

Related posts:
Giving the exam you failed in
When you get tired of studying

Did you know soleus is known as the second heart?

Hello!

The heart is not the only pump in the body.  While the heart pumps blood out towards the extremities, deep muscles assist in pumping blood back towards the heart.  One of the most important muscles for assisting blood flow back to the heart is the soleus muscle!

Cocaine and beta blockers

Hello! Let's talk about cocaine and beta blockers! :)

But just to cover the basics:

Cocaine blocks the reuptake of norepinephrine and dopamine at the presynaptic adrenergic terminals, causing an accumulation of catecholamines at the postsynaptic receptor (Mnemonic). That makes it a powerful sympathomimetic agent. Cocaine causes increased heart rate and blood pressure.

Study tips on preparing for PG CET

Hey everyone!

So many of you have been asking me how to prepare for the Indian PG exams. As you all know, I am preparing for studies abroad and I don't find myself competent to answer the question. But, we convinced Dr. Prateek Charuchandra Joshi to share his study tips with us.. And he agreed! How cool is this guy! Thanks, Prateek! ^__^

I asked him a few questions focusing on the strategy of studying and irrelevant questions like - how many months/attempts did you take, what were your MBBS scores, how was internship, etc. were not asked simply because these are variable for all of you and you can't do anything about it. What you can do is get a general idea from this post, and make your personalized study schedule :)

Cocaine blocks the reuptake of norepinephrine mnemonic

Hello! Short post for the day!

Cocaine blocks the reuptake of norepinephrine, dopamine and serotonin.

How do you remember this?

Lipoprotein A and Thrombosis

It is a well known fact that Lipoprotein A is a cardiovascular risk factor.

Increased levels of Lipoprotein A causes Thrombotic events.

But why does this happen?

Random mnemonic on multiple sclerosis

I sometimes get blank as to what happens in multiple sclerosis.

Drugs causing SIADH mnemonic

Hello!

Because ADH makes you retain water, the mnemonic goes: "SIADH Causes Poor Voiding"

S: SSRIs (Sertaline)
I: Indomethacin (Analgesics)
A: Antidepressants (Tricyclics)
D: Diuretics (Thiazides)
Desmopressin
H: Hello :D

Study group discussion: GI hemorrhage and urea

Why does GI haemorrhage increase serum urea?

Any patient with GI bleeding will have an increased serum urea.

Urea is an end product of protein metabolism. Digested blood contains loads of proteins so it's as good as having a meal rich in proteins. Blood proteins include hemoglobin, Immunoglobulins, etc.

Glucose in pleural fluid analysis

Hi :)

A low pleural fluid glucose concentration (less than 60 mg/dL, or a pleural fluid/serum glucose ratio less than 0.5) narrows the differential diagnosis of the exudate.

Causes of low glucose in pleural fluid include: