ACEI and ARBs in congestive heart failure

Hey everyone!

Today, I will be talking about ACEI and ARBs in congestive heart failure (based on ACC and ECS guidelines).

Here are a few points on what the guidelines say:

EPISODE 04 - INTERNSHIP DIARIES (What will I do with your blood? -Vials and sampling)

- By Upasana and Jay

It has been a tired day at the hospital. You are almost at the end of your day of duty when your senior resident asks you,

“Dr Kesh, can you please prepare the Laboratory forms, sign them for me and then, submit these blood samples to the Main laboratory?

“Yes sir!” You pressure a smile and look at the blood samples and the empty Laboratory request forms needing your signature and your gleaming new stamp with your licence number.

You sit down to prepare the blood samples.

EPISODE 03 - INTERNSHIP DIARIES (Let me gain access into your veins)

(Lesson 1.2)

Inserting an IV line or an Intravenous line is a very much of an expected skill from a Medical professional. Although often performed by Nurses, the skill can come handy at any time because in a case of a hard insertion the nurse or the ancillary staff may refer the patient to you to perform.

Before inserting an IV line you need to know what is an IV Cannula or an IV Catheter.

A cannula or a catheter is a small tube made out of medical grade materials that would allow a medical professional introduce or extract a substrate to or from the body. In a case of an INTRA-VENOUS cannula the access is taken in to the VEINS.

Usually an IV cannula can be used to introduce IV fluids, IV medications as well as sometimes to draw blood(often at the insertion moment).

1. The catheter itself is composed of (a) a tip for insertion into the vein, (b) wings for manual handling and securing the catheter with adhesives, (c) a valve to allow injection of drugs with a syringe also called a LUER lock-valve, (d) an end which allows connection to an intravenous infusion line, and capping in between uses.
2. The needle (partially retracted) which serves only as a guidewire for inserting the cannula.
3. The protection cap which is removed before use.

(By courtesy of Wikipedia (https://en.wikipedia.org/wiki/Peripheral_venous_catheter) retrieved 7/5/2019)

These cannulas come in different shapes and sizes, and the sizes are measured in BIRMINGHAM GAUGE SYSTEM often abbreviated as G. In this system the lower number is having a higher diameter and a higher number is having a lower diameter of the catheter tube. (This is different from French Gauge System where it is opposite from this numbering system and is often used in NGT tube sizes)

So, an 18G IV cannula is larger than a 20G IV cannula.

The recognizing of these cannulas are done by the colour of its Luer lock-valve or the tip of the needle in some varieties.

The colours are pretty constant throughout the world but sometimes it differs. So always refer to your senior before checking out a cannula for the first time or better yet, READ WELL of its packaging.

(Note that in some countries 26G could be of Purple colour)
- Table by courtesy of Wikipedia (Retrieved 7/5/2019) -

Check for your needed equipment and material.

• Alcohol or Hand Sanitizer/Soap and water
• An alcohol wipe. - To sanitize the skin
• A tourniquet. - To block the venous flow and engorge the vein as well as fix it.
• An IV cannula - As mentioned above.
• A suitable plaster or a Tegaderm® - To fixate the IV cannula/catheter on to the skin
• A syringe with normal saline - To flush the Catheter
• A clinical waste bin with a sharp disposal section - To dispose the waste including the needle.

STEPS

1. Identify a visible and/or tangible vein. Try to feel it. A rule of thumb is, the better you feel the vein the more successful your insertion will be.
2. Once you identify the vein, apply the tourniquet and recheck on the vein if its engorged and tangible.
3. Apply alcohol on your hands and clean it. Wear your gloves properly as explained before; in case you were already wearing gloves, check if you can request for a change of your gloves. Touching a patient without gloves is discouraged.
4. Clean the patient's skin with Alcohol wipe, a cotton ball soaked in Isopropyl Alcohol 70% or Ethyl Alcohol 70% is alright.
5. Before inserting the catheter and check if the catheter tip is clear without any manufacturer's defects such as a defect end. Check the needle for its bevel up. 
6. Stretch the skin distally, and look for your insertion point. If your vein-in-concern is not much engorged you can try slightly tap on it.
7. Tell your patient to expect a sharp pinch on their point of insertion.
8. Insert your needle beveled up, usually around 30-45 degrees to the skin and advance your needle to see if there is a flashback of blood at the hub of the syringe.
9. If you see the flashback, then advance the whole needle about 2-3mm and then retrieve the needle slowly and check if a streak of blood is following the returning needle. If it does...Congratulations! IF NOT, try withdrawing the needle a bit and change the position until you see the flashback.
10. If you cannot do it while the needle is inside, then retrieve the whole catheter and re insert at a different point of a different vein.
11. If you still cannot, then ask for help from a senior.
12. In the fortunate incident of you are already inside the vein, remove the tourniquet and while removing the needle, give pressure to the top of the cannula tip already inside the body so the blood will not reek out making your field a mess!
13. Insert your prepared flush into the catheter and try to inject. If it proceeds with no resistance, then you are good to go!
14. Get your Primed IV line or HEPLOCK (which is used to administer IV medications in a later  time via the catheter and it will stop the blood from reeking out) or close the end with the white cap of the needle(Often used with those catheter types with Luer lock-valve where a heplock is not needed)
15. Take your previously prepared Plasters or already opened Tegaderm® and secure the IV catheter on to the skin. There are several methods of securing the IV catheter on to skin using plasters. We will discuss 
16. Dispose your needle to the sharps disposal.
17. Clean and wash your hands.

Congratulations, you are done with your IV catheter/cannula insertion.

*******

You look at the face of the patient after finishing your work, and you are proud that you got access in one hit and did not spill the blood.

"Thank you doctor!" Your patient thanks you.

"You are welcome!" You smile and leave the patient with your tray.


*************

Thanks guys for the support! Thanks for the messages you have been sending to my Whatsapp requesting for more articles. We will try to provide more topics soon. 

With love,

Jay

Fregoli and Capgras.

So this post is regarding Delusional misidentifiaction syndromes.
There are two of them i. e. Capgras and Fregoli syndrome.

Now both of them are super confusing and are often asked in entrances. I made a mnemonic to remember them. If you can remember any one of them, you can figure out other.

So I hope all of you are aware of GOT-Game of thrones! Remember Arya stark had face swaping ability? She killed entire Frey family by it. So did how she kill them? She disguised herself as head of the family - Walder Frey and killed them.

So take A from Capgras. Here A stands for Arya stark. Arya killed family of Frey by disguising as Walder Frey (Family member). So in Capgras, patient thinks that murderer is going to disguise as a  family member and kill him. Eg Nurse disguised as a wife to kill him.
Capgras is also know as The Delusion of doubles! 

OR (To non GOT fans)

FreGoli:
F= Family
G=Gun (In hindi you can simply remember Goli)
"Family members trying to kill patient with Gun but disguised as someone else"
Eg: Wife disguised as Nurse to kill patient (Husband)

"Valar Morghulis"

That's it

-Demotional bloke.

EPISODE 02 - INTERNSHIP DIARIES (Protecting you and myself)

NOTICE!

Awesomites, I'm super sorry for being super late, I was so busy with my MD graduation hence I couldn't update the promised topics on Internship Diaries. I will update as soon as possible all the topics we need to discuss.

With love,

Jay

(LESSON 1.1)

WEARING SURGICAL GLOVES

       There are three forms of wearing gloves. 

1. OPEN, 
2. CLOSED 
3. ASSISTED. 

Closed is the most sterile method and used mainly in operating rooms where you wear gowns and glove yourself and asepsis is highly expected. 

You utilize the Open method in situations in wards, and other Non-OR situations. 

Assisted method is when someone else such as, a nurse or a fellow colleague will serve you the gloves and you simply slip your hands in.

OPEN method,

1. Remove whatever you are wearing in your hands, including rings, bracelets and watches. Try to keep it free elbow-down.
2. Wash your hands with soap, and use Sterilium(R) or Isopropyl or Ethyl alcohol 70%. (Using them will eliminate the remaining bubbles of the soap.) 
3. Then wipe your hands with a sterile towel.
4. You will take your surgical gloves, open the outer cover and bring the inner cover outside without touching inside the gloves. 

   

   Surgical Gloves Inner cover

5. Leave it on a flat clean surface and open the flaps, and you will see two gloves one for the right hand and the other for left hand.
6. You will also notice the sleeves of the gloves are rolled upwards. The inside out part is considered unsterile and the inside the roll part is considered sterile. 

   

   S = Sterile part   |    US = Unsterile part

7. So you use your non sterile dominant hand, hold the glove from the non sterile outside part and slip over your non dominant hand. Do NOT flap back the sleeve because will get contaminated because you are not yet wearing gloves on that hand.
8. Now use your non dominant hand with the glove on, and slip the four long fingers of your hand into the rolled sleeve of the other glove. Because it is sterile. Bring it up and slip the glove over your non gloved hand. And flip back your sleeve.
9. Then use your newly gloved hand to roll down the sleeve of your other glove from the inside the roll.

You are successfully gloved!!!

In closed method someone will open the outer cover for you and you take the inner cover out, and wear it in such a way where you do not touch the glove at all skin-to-skin directly, but it will be discussed later. Too much info in one post will cause brain freeze. 

In Assisted method after gowning yourself, someone else will open gloves and serve you. Check if the thumb side is correct accordingly and slip in. If not you will be stuck and will need a new pair of gloves. Waste of time, waste of gloves and waste of effort!!

*******
You put on your gloves and see the nurse has prepared alcoholized cotton balls, 5 plaster strips of around 4 inches long and partially opened the IV catheter pack.

You take one alcoholized cotton ball and start looking for a vein.

[ To be continued... ]

*******

The answers to our previous questions regarding gloving are,

1. There are 3 methods
       1. Open
       2. Closed
       3. Assisted

2. There are 2 types of gloves
       1. Examination gloves - Often clean but not essentially sterile although some sterile varieties exist.
       2. Surgical gloves - Often sterile and comes in a tightly sealed pack. Do not use if the pack is already open.

Of Surgery and Wounds

Hey guys, here’s a classification of surgical procedures, wounds and their infection risk.

[Please click on the image to enhance it]

Thank you for your time.
- Ashish Singh.

What Is Going On In Fibromyalgia?

Hi there! Let’s talk about pathophysiology of fibromyalgia; a chronic disorder where fatigue and widespread pain feature prominently.

Current hypothesis says, it’s caused by aberrant peripheral and central pain processing.
Two key features are allodynia, that is, pain in response to a non-painful stimulus and hyperaesthesia, which is, exaggerated perception of pain in response to mildly painful stimulus.

Modern research says, certain antidepressants- with both serotonergic and noradrenergic activity- such as TCAs and venlafaxine, can relieve pain and other symptoms; suggesting the pathway involvement.

Some evidence says, alternative therapies such as acupuncture and spa therapies alleviate pain, which have been postulated to act via similar spinal pain-modulatory pathways.

CSF studies show increased levels of substance P, with decreased levels of noradrenaline and serotonin metabolites. All three are neurotransmitters involved in descending pain-modulatory pathways in the spinal cord.

PET images show an abnormal central dopamine response to pain.

The critical question here is: what is cause and what is effect?

Small sample size and short periods of study, remain the most cumbersome challenge to our complete understanding of fibromyalgia.  



Thank you for reading.
- Ashish Singh.

Mnemonic: Duke’s Criteria for Infective Endocarditis

Infective endocarditis is diagnosed using the modified Duke’s criteria.
Let’s look at them in an easy-to-remember way.

MAJOR CRITERIA
It’s, quite literally, proving the name Infective Endocarditis to be true.

Infective, that is, positive blood culture:
• Typical bugs in 2 separate cultures
• Persistently positive blood cultures, say > 12h apart
• Single positive blood culture for Coxiella burnetii

Endocarditis, that is, endocardium involvement:
• On imaging with 2D Echo or CT, look for vegetation, abscess, pseudoaneurysm or dehiscence of prosthetic valve
• On clinical exam, find new regurgitation murmur

MINOR CRITERIA
Remember, patients feel very ill when they have infective endocarditis.
Predisposing factors: congenital heart disease, prosthetic heart valves, iv drug abuse
Fever > 38 °C
Vascular phenomena: emboli, Janeway’s lesions
Immunologic phenomena: glomerulonephritis, Osler’s nodes

What if the blood culture is positive but does not meet the major criteria?
It’s considered as a minor criterion (casually speaking, problematic but not majorly problematic).

How do we use this for diagnosing?
2 major OR
1 major + 3 minor OR
All 5 minor criteria, make up the diagnosis.

Clinical Pearl: Fever with any new-onset murmur is taken as infective endocarditis, unless proven otherwise.



Hope this helps. Happy studying!
- Ashish Singh.

CABG For Undergraduates

CABG is Coronary Artery Bypass Graft; a surgical procedure where dying heart muscle is resupplied with blood.

Indications
[decided after a SYNTAX scoring system]
• Left main stem disease
• Triple-vessel disease involving proximal left anterior descending
• Patients unsuitable for angioplasty 
• Failed angioplasty
• Refractory angina

Procedure
• The heart is usually stopped and blood pumped artificially by a machine outside the body, a cardiac bypass. An alternative, that does not require this, is minimally invasive thoracotomy.
• As the graft, patient’s own great saphenous vein, internal mammary artery or radial artery is used. Multiple grafts may be placed. Arterial grafts last longer but may cause donor site numbness.

After CABG
• Continue aspirin 75 mg/day indefinitely. Consider clopidogrel, if aspirin contraindicated.
• Ensure optimal management of hypertension, diabetes and dyslipidemia.
• Counsel for smoking and alcohol cessation.
• Chart out graded physical activity through rehabilitation.
• Uncommonly, angina may persist or recur [from poor graft run-off, distal disease, new atheroma or graft occlusion]. If so, restart anti-anginal drugs and consider angioplasty.

Clinical Pearl: Recent randomised control trials indicate that early procedural mortality rates and 5-year survival rates are similar after PCI and CABG.



Thank you for reading.
- Ashish Singh.

Understanding Refeeding Syndrome

Refeeding syndrome is a life-threatening metabolic complication of - stay with me - refeeding. It can happen via any route after prolonged starvation.

Who are at risk?

They’re patients with prolonged artifical feeding [parenteral or enteral], malignancy, anorexia and alcoholism.

Why does it happen?

During starvation, the body uses fat and protein for energy. There’s no carbs so there’s little to no insulin.

After refeeding, carbohydrate load causes a spike in insulin level.

Now first prof biochemistry tells you, more insulin means more cellular uptake of phosphate.

That’s it. That low serum phosphate level is the main problem.

How does it present?

Non-specifically and catastrophically. Features are rhabdomyolysis, red and white blood cell dysfunction, respiratory insufficiency, cardiac arrhythmias and seizures.

Left unchecked, it can lead to sudden death.

How do I prevent it?

Identify at-risk patients and give high-dose, high-potency Vitamin C and B complex injection, during re-feeding window.

Monitor vitals and labs closely. Close involvement of nutritionist is ideal.

What if it’s already happened? How do I treat it?

The biggest challenge is management of complications.

As regards phosphate, get the levels back up. Administer oral as well as parenteral phosphate, upto 18 mmol per day.

Thank you, that’d be all.

- Ashish Singh.

What are APS?

APS or Autoimmune Polyendocrine Syndromes are exactly what the name suggests.
They’re autoimmune in origin and they attack more than one endocrine system.

[Please click on the image to enhance it]

Let’s not forget autoimmunity begets autoimmunity.

APS are commonly seen with hypogonadism, vitiligo, alopecia, pernicious anaemia and coeliac disease, among others.

That’d be all. Happy studying!

- Ashish Singh.

PR depression in pericarditis

Do you know what P-R segment deviations in acute pericarditis mean?

It is due to subepicardial atrial injury!

Residency in India: Harassment, abuse and suicide

A few days ago, a resident committed suicide. One of us committed suicide.

In my opinion, it seems like the reason for the suicide was harassment, abuse, and excessive work load. If you ask any resident in any government hospital in Mumbai - they are all treated the same. The verbal abuse is probably different - They used casteist slurs for her. If you are privileged, they will call you different names.

How can we make sure this never happens again? Stop carrying forward the culture of abuse. It is high time. We have to fight the system. The past. The belief that it is okay just because it's residency. Don't look at how our seniors treated us but look at how we treat our juniors.

We need to treat each other better. Treat others how you would like to be treated yourself.

We need to help each other.

It is our fault that the life of an innocent was lost. It's because we didn't fight and we stayed silent when we saw abuse around us. We need to create awareness among medical students that will be joining residency. Let's talk about the abuse and how we can stop it. Residents should know who to report to without fear of negative consequences.

It will take time and it will probably not change in a day. But we are the future and we need to fight.

Fundoscopic images of Diabetic Retinopathy

Fundoscopic images of Diabetic Retinopathy

Images and audio by Sushrut.

Indications of skin grafting mnemonic + notes

Hello,

Indications of skin grafting :

☆ Mnemonic - BITS

Sites of Bronchiectasis

Bronchiectasis site in lung depends upon the etiological factors

Upper lobe bronchiectasis:

Mnemonic: Upper - PCT
Upper- Upper lobe
P- Post radiation
C- Cystic fibrosis
T- Tuberculosis

Middle lobe bronchiectasis:

Mnemonic: MMC (Like BMC!)
M- Middle lobe
M- Mycobacterium avium
C- Ciliary dyskinesia

Lower lobe bronchiectasis:

Mnemonic: Left-ICA (Internal carotid artery)
Left- Lower lobe
I- Interstitial lung disease
CA- Chronic aspiration

That's all.
Thank you :)

-Demotional bloke

History, physiology and medical aspects of fasting

Hello everyone,

My senior resident at JFK Medical Center did a presentation on fasting. I thought of sharing it with you (especially since it is Ramazan/Ramadan).

Hook effect of prolactin in large pituitary adenomas

Hello everyone,

Here's something I learnt today when a case of large pituitary adenoma causing visual field loss was presented today.

But let's talk about my favorite subject first - Immunology!

The intensity of an antigen-antibody interaction depends primarily on the relative proportion of the antigen and the antibody. A relative excess of either will impair adequate immune complex formation. This is called the “high-dose hook effect” or the “prozone phenomenon.”

This is important consideration whe measuring prolactin. Extremely high levels of prolactin can interfere with the assay and produce falsely low readings.

This high-dose hook effect occurs because there is not enough antibody to bind to both ends of all antigenic peptides, in this case, prolactin.

Most prolactin is complexed to a single antibody. Only few remaining prolactin peptides are “sandwiched” and therefore detectable.

This results in a falsely low prolactin value.

Hence, as the antigen concentrations increase, there is a proportional increase in assay titers up to a certain level. Antigen concentrations above this threshold level would “hook” down the assay values resulting in very low measurements.

In order to avoid the high-dose hook effect, the serum prolactin should be estimated in appropriate dilution in all patients with large pituitary tumors.

-IkaN (tired Internal Medicine Resident)

Source:
The 'hook effect' on serum prolactin estimation in a patient with macroprolactinoma. https://www.ncbi.nlm.nih.gov/m/pubmed/11303248/

Protein gap

The gamma gap aka paraprotein gap or protein gap is the difference between total serum proteins and albumin measured from a comprehensive metabolic panel.

Albumin accounts for the majority of total serum protein.

Viral infections, plasma cell malignancies, or autoimmune conditions there is an excess of immunoglobulins, raising the total amount of serum protein independent of albumin.

The gamma gap is typically considered to be elevated if it is above 4 g/dL.

In the right clinical context, gamma gap should be worked up with SPEP, UPEP, and a serum free light chain assay.

Random exercise: Calculate the protein gap.
Total protein 8.9 g/dL (normal 6.4-8.3 g/dL)
Albumin is 3.6 g/dL (normal 3.4-4.8 g/dL)

That's all!

-IkaN

Work up of thyroid nodule

Hello,

Here is the shorter version of this post: Investigating thyroid nodule for Step 2 CK (link: https://www.medicowesome.com/2016/06/step-2-ck-investigating-thyroid-nodule.html)

So - if you find a thyroid nodule on physical examination - what do you do next?

Caudal anaesthesia

Hello Awesomites!

Caudal anesthesia is a type of epidural anesthesia. 

INDICATIONS
The indications for single shot CA are abdominal,urologic or orthopedic surgical procedures located in the sub-umbilical abdominal, pelvic and genital areas, or the lower limbs, where postoperative pain does not require prolonged strong analgesia. Examples include inguinal or umbilical herniorrhaphy, orchidopexy, hypospadias and club foot surgery.

Anatomical landmarks (Figure)
The sacrum is roughly the shape of an equilateral triangle,with its base identified by feeling the two
posterosuperior iliac processes and a caudal summit corresponding to the sacral hiatus.The sacral hiatus is located at the caudal end of the median crest and is created by failure of the S5 laminae
to fuse (Figure). The hiatus is surrounded by the sacral cornu.

Preparation
Obtain consent for the procedure either from the patient or, if appropriate, from the parents. After induction of general anaesthesia and airway control, the patient is positioned laterally (or ventrally),
with their hips flexed to 90°. Skin disinfection should be performed carefully, because of the proximity to the anus.
After defining the bony landmarks of the sacral triangle, the two sacral cornuae are identified by moving your fingertips from side to side.The gluteal cleft is not a reliable mark of the midline. The puncture is performed between the two sacral cornuae. The needle is oriented 60° in relation to back plane, 90° to skin surface. The needle bevel is oriented ventrally, or parallel to the fibers of the sacro-coccygeal ligament.
After verifying absence of spontaneous reflux of blood or cerebrospinal fluid (more sensitive than an aspiration test), injection of LA should be possible be without resistance. Inject slowly (over about one minute).

-Upasana Y. :)