Rheumatic chorea - variable clinical presentation timelines

 Hello

Variations in clinical presentation of rheumatic/ sydenham's chorea -

Relative wall thickness on echocardiography

Relative wall thickness (RWT) is calculated as two times posterior wall thickness (PWT) divided by the left ventricular internal diastolic diameter (LVIDd). 

RWT allows further classification of LV mass increase as either concentric hypertrophy (RWT >0.42) or eccentric hypertrophy (RWT ≤0.42).

-IkaN (Nakeya Dewaswala Bhopalwala) 

Infective endocarditis vegetations - which side do they develop?

Infective endocarditis vegetations tend to develop on the upstream side of the valve (flow side) which is typically tend to be the lower pressure side. These are the ventricular side of the aortic valve and the atrial side of the mitral or tricuspid valve. 

Image shows parasternal long axis view on echocardiography showing vegetations on the mitral and aortic valve (green vegetations because vegetables are green lol!)

-IkaN 

COVID - OMICRON

Hello friends!

This post is about omicron variant of COVID.

Why do we have to know about any new variants?

✓ more infectious than previous one?

✓ if it's more virulent?

✓ any diagnostic difficulties?

✓ treatment failure?

✓ does previous vaccine work for it?

Basically this OMICRON has more than 30 different mutations on surface of S1 or S2 spike protein with lineage number B.1.1.529 variant of concern (voc).

Preliminary data shows that it is highly infectious but the data is limited. We need to wait for further studies.

Most of the vaccines are targeting 'S' spike protein so antibodies are produced against 'S' spike. Risk of vaccine failure due to 'S' spike mutation is still a point of concern but data is limited now.

Diagnostics- most of the other targets (including N and RdRp genes) remain unaffected. These RTPCR tests detect atleast 2 different SARS-CoV-2 targets, which serves as a backup in case mutation arises. Current PCR tests can detect this variant. 'S' gene target failure can occur if not detected.

Severity of disease - more in immunocompromised and extremes of age groups.

Effectiveness of vaccines - Antibodies decrease severity and death .

Reinfection is higher with omicron.

Treatment - steroids and IL-6 receptor blockers are still effective.

So, be cautious but don't panic! 

That's all!

Dr.Madhuri 

EVALUATION OF THYROID FUNCTION

1-Plasma TSH is the first investigation of choice  in a patient with suspected thyroid diease.

This may be mildly elevated in mild or subclinical hypothyroidism

TSH levels may be suppressed  in hyperthyroidism.

The anterior pituitary is very sensitive to minor changes in thyroid hormone levels which is why TSH is usually considered to be the most reliable investigation of thyroid function. 

2- Plasma free T4- confirms the diagnosis and assesses the severity of hyperthyroidism.  It is also used to diagnose secondary hypothyroidism. 

Both TSH and free T3 and T4 levels should be considered as it may be misleading in patients suffering from any pituitary disease. 

Eg: TSH may be normal or low in secondary hypothyroidism 

Raised T4 and T3 levels may be seen in initial stage of levothyroxine therapy. 

Other investigations may include measurement of antibodies against TSH receptors or other Thyroid antigens 

For instance: Antibodies to TPO, Thyroglobulin, TSH Receptor.

Some drugs may affect TFTs. For example: amiodarone may cause a decrease in free T4 and elevation of TSH. Amiodarone may also cause a decrease in TSH  causing hyperthyroidism in certain patients.

-Rudrani

Mitral valve anatomy and types of mitral regurgitation mnemonic

Mnemonic:

Prolapse tip points towards LV

Flail tip flips away from LV

Secondary stay away from each other (dilation) 

Job's syndrome

Job's syndrome is also known as hyper- IgE syndrome.

It has autosomal dominant inheritance ( STAT3 gene).

Here is the mnemonic to remember its key features :

A - Abscesses of face and lungs by staphylococcus aureus ( pneumatocele)

B - Bone fragility

C - Coarse facies

D - Dermatological features like eczema.

E - Eosinophilia, increased Ig E.

Trick to remember important points: 

"Steve Jobs is a dominant person, interested in business STATs"

That's all!

Dr. Madhuri.

Metoprolol tartrate vs succinate dosing mnemonic

Metoprolol tartrate is short acting. 

Metoprolol succinate is long acting. 

Mnemonic succinate single dose, tartrate two doses.

-IkaN (Nakeya Dewaswala Bhopalwala) 

EKG quiz #1

What does this EKG show? 

Answer will be posted soon.

-IkaN

Treatment of myocardial infarction associated pericarditis

Hi everyone! There are two types of myocardial infarction associated with pericarditis. Let

s learn more about the management!

Early infarct-associated pericarditis: Occurs 1 to 3 days after transmural myocardial infarction (because of the interaction of the healing necrotic epicardium with the overlying pericardium). 

Late post-myocardial infarction pericarditis (Dressler’s syndrome): Occurs weeks to months after myocardial infarction. 

Initial therapy includes high-dose aspirin (650 to 1,000 mg every 6 to 8 hours).

Proton pump inhibitor (PPI)  - improves the gastric tolerability of the aspirin. 

Acetominophen can be added for pain management.

Dosing of aspirin:

Initial: 650 mg to 1 g every 8 hours until resolution of symptoms for at least 24 hours and normalization of inflammatory biomarkers (eg, C-reactive protein). A treatment period of one to two weeks before tapering is usually sufficient. 

Taper: Decrease each dose by 250 to 500 mg every 1 to 2 weeks. Ensure patient remains asymptomatic and inflammatory biomarkers are normal. 

There is no published experience on the use of colchicine in peri-infarction pericarditis. Colchicine may reduce the need for pericardiocentesis or other pericardial interventions and is usually given at a dose of 0.6 mg twice daily for a month, or longer if the patient has a recurrence of symptoms.

Why are NSAIDs such as ibuprofen avoided in the peri-infarct period?

Interferes with the antiplatelet aggregation effects of aspirin. 

Interferes with myocardial healing.

PS: Acetominophen does not affect the coagulation system and can be used.

References:

Post-cardiac injury syndrome: aetiology, diagnosis, and treatment https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Post-cardiac-injury-syndrome-aetiology-diagnosis-and-treatment

Pericardial Disease https://www.ahajournals.org/doi/10.1161/circulationaha.105.561514

-IkaN (Nakeya Dewaswala)

Read EKGs with me #1

Answer below:

Normal P wave ECG notes and mnemonic

Here is the video:

 

Mnemonic:

Notes:
Sinus P waves
Axis: 0 and +75 degrees
Upright: Leads I, II, V5, V6
Inverted: aVR
Duration: <120ms or 3 small squares
Amplitude:
Limb leads: < 2.5 mm (0.25mV)
Precordial leads: < 1.5 mm (0.15mV)

-IkaN

Determining pacemaker type from EKG (RV pacing vs biventricular pacing)

 Hello, cardiowesomites!

Today we are going to learn how to determine pacemaker type from EKG (RV pacing vs biventricular pacing)

Notes:

Normal cardiac pressures mnemonic (Normal Swan-Ganz pressures)

LV aneurysm: Difference between true LV aneurysm and LV pseudoaneurysm

LV aneurysms are most commonly caused by myocardial infarction. What's the difference between true aneurysm and pseudoaneurysm?

Types of pulmonary hypertension mnemonic

Here are my notes and a video on types of pulmonary hypertension - WHO classification! It comes with a mnemonic :)

RV pressure and volume overload notes

Cardiac valves anatomy and mnemonics

Check out the YouTube video here!

-IkaN 

ECG axis mnemonic (short version)

Video here:

 

Notes below:

Brainstem & Cortical Strokes | Mnemonic & Tricks

 https://www.youtube.com/watch?v=5SOe6PzbKgQ

HVPG = Hepatic Venous Pressure Gradient

 HVPG = WHVP - Free Hepatic venous pressures 

• WHVP = Wedged hepatic venous pressure
• gradient between pressures in the portal vein and the intra-abdominal portion of IVC 
• When blood flow in a hepatic vein is stopped by a wedged catheter, the proximal static column of blood transmits the pressure from the preceding communicated vascular territory (hepatic sinusoids) to the catheter. Thus, WHVP reflects hepatic sinusoidal pressure.
• In the normal liver, due to pressure equilibration through interconnected sinusoids, wedged pressure is slightly lower than portal pressure, though this difference is clinically insignificant.

➡️ While in Cirrhosis , Sinusoidal interconnection are lost. Therefore, WHVP gives an accurate estimation of portal pressure in cirrhosis !!!

Normal HVPG = 1-5 mm hg 

HVPG >5 = Portal HTN 

HVPG > 10 = Clinically Significant portal HTN 

HVPG > 12 = Threshold for Variceal Rupture = So use Beta Blocker to ⬇️ it.

Measurement of the Hepatic Venous Pressure Gradient (HVPG)

https://www.youtube.com/watch?v=9cEOpr-MRL4

Thank you ! 🩺

Cardiovascular drugs that can cause digoxin toxicity

A number of cardiovascular drugs predispose patients to digoxin toxicity, including verapamil, quinidine, and amiodarone. The dosage of digoxin must be reduced if given concomitantly with these drugs. The presumed mechanism underlying this interaction involves the ability of these drugs to inhibit the P-glycoprotein transporter.

Mnemonic: These drugs cause you to go whack! VAQ - Verapamil, Amiodarone, Quinidine

Other drugs to keep in mind are Diltiazem, Spironolactone, Flecainide.

Mnemonic by Huzefa Bhopalwala

References:

Waldorff S, Hansen PB, Egeblad H, Berning J, Buch J, Kjaergård H, Steiness E. Interactions between digoxin and potassium-sparing diuretics. Clin Pharmacol Ther. 1983 Apr;33(4):418-23. doi: 10.1038/clpt.1983.56. PMID: 6831820.

Andrejak M, Hary L, Andrejak MT, Lesbre JP. Diltiazem increases steady state digoxin serum levels in patients with cardiac disease. J Clin Pharmacol. 1987 Dec;27(12):967-70. doi: 10.1002/j.1552-4604.1987.tb05598.x. PMID: 3437068.

Lewis GP, Holtzman JL. Interaction of flecainide with digoxin and propranolol. Am J Cardiol. 1984 Feb 27;53(5):52B-57B. doi: 10.1016/0002-9149(84)90502-2. PMID: 6695818.

Koren, G., MacLeod, S. CHARACTERISTICS OF DIGOXIN INTERACTION WITH QUINIDINE, VERAPAMIL AND AMIODARONE: IN VIVO AND IN VITRO STUDIES. Pediatr Res 18, 154 (1984). https://doi.org/10.1203/00006450-198404001-00367

SYNTAX score mnemonic

In the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial, patients with 3-vessel and left main coronary artery disease (LMCAD) treated with coronary artery bypass graft surgery (CABG) compared with percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) had lower 5-year rates of death, myocardial infarction (MI), stroke, or unplanned revascularization.

Abdominal aortic aneurysm notes

Here are my notes for the ABIM. Old post https://www.medicowesome.com/2016/11/step-2-ck-abdominal-aortic-aneurysm.html

-IkaN 

Glimpse into my plan for "Last 18 Days to NEET PG"

 Hello believers at other end,

If You have a plan and it is working well for you then no need to read it further.
All the best and Happy studying.


18 days= 14 days(2 weeks) + 4 days( I would never count in last days )
 

 I) 1st week = divide each day in three major slot and 2 minor slots

By the end of 1st week I want to complete major and minor notes 6 minor + 4 major subject + PYQ +MCQ  of important topics + review images and volatile stuff.

Seems daunting and impossible !?
Say it to yourself "not daunting for me" Just 7 days and see the progress in the end.

morning hours = 

1 hour [ half hour pharma ( General,ANS,CVS,GIT ,RS+HORMONES,NEURO,Antimicrobial) 7 days)

+ 

other half an hour ( Carb,lipid ,proteins,molecular,vitamins) *5days + last 2days when bio is completed I added PSM formulas for half an hour)

9am-12pm  =

PYQ in form of GT on desktop like an exam ( And do it within 1 and half hour superficially) Review wrong ones .( Aim is to go through papers in stipulated time and when you do the same for consecutive 7 days you can analyze a pattern of your mistakes and type of questions being repeated)

12 pm lunch 

Afternoon 12:30- 4pm ( further divide into 2 slots ) 

2 hour fast reading. I complete minor subjects (Ortho,FMT,anesthesia,dermatology,ophthalmology,Ent,psychiatry)

Next 2 hours I divide for major subject (Surgery+med+obsgynae) 2days and 2 hours each. +pedia 1 day only

4-5 I take nap of 15 min and then do volatile stuff
5-6 I go for walk with earphones and revised imp scores criterias  oR TEACH A FRIEND ON PHONE

6-8 I practice MCQ as much as possible.(I do mcq of selective topics sometime mixed bags )

8-9 [half an hour micro ( gram positive,gram negative,viro rna,viro dna,mycobacterium+immuno,parasito,lifecycles) +half an hour Patho ( systemwise with images) ]

9-10 long break with dinner + telegram or updating yourself with any new thing or some series (depend on mood)

10-11 Images +graphs+formulas

11- 12 Previous day video at 2X until I fall asleep



By the end of 1 week = (SURG+MED+PEDIA+OBS) +(Ortho,FMT,anesthesia,dermatology,ophthalmology,Ent,psychiatry) +IMAGES +PYQ +WEAK TOPIC MCQ+PHARMA +MICRO+PATHO+BIOCHEM= 15 SUBJECTS with images.

II) 2nd week =Remaining 4 subjects

Morning hours and after 6pm slot is same .

9-12 pm I give mock after 2 days and aim is time management only . Assess wrong only if not much time is left . (I would advise you to give mock rather than GT )

afternoon = 2 hours ( physio,PSM) + 2 hours (Anat) (Radio I followed what Zainab mam has told us to do )

+COVID notes
+Revision revision and revision

III) 4 days(NO GT) = Revise volatile stuff + pyq incorrect ones+images+ mcq (I plan it accordingly whatever I feel right and confident with )

In free time or breaks I take printout of admit card and keep the necessary documents ready 2 day before.

Plan 2 days before what topics you feel can come and you are not confident with and want to go through it once. write it down .It is your gut feeling :D

NOTE- You need not to follow it like what I have said .I respect your journey as much as I respect mine. So do what makes you confident.

In the end, it is just an exam. You will get another chance. Just stay calm.

All the best.

Colonoscopy screening intervals and management of polyps for ABIM boards

Here is the video

-IkaN

Colonoscopy screening intervals and management of polyps notes

Causes of Membranous nephropathy - Mnemonic

 

Babeosis mnemonic

This is how I remember babeosis is associated with Maltese cross appearance.

You know you love me, xoxo, gossip girl!

-IkaN 

Lesch Nyhan syndrome - Mechanisms (Revised post)

 Hello friends! Let's refresh our biochemistry knowledge today.

Lesch-Nyhan syndrome is characterized by choreoathetosis, dystonia, hyperuricemia, gout, self mutilatory behavior especially self-biting of fingers, and intellectual disability due to HGPRTase mutations.

So how do HGPRTase mutations actually cause dystonia and other extrapyramidal signs and symptoms?

1.)  For the synthesis of dopamine, tetrahydrobiopterin as a cofactor for tyrosine hydroxylase is required.
Tetrahydrobiopterin itself is derived by a series of reactions in which GTP cyclohydrolase is a rate-limiting enzyme.
Now HGPRTase deficiency causes depletion of GTP thereby ultimately depleting tetrahydrobiopterin.

In fact, GTP cyclohydrolase mutations are known to cause dopa-responsive dystonia and phenotype similar to Lesch-Nyhan syndrome.

2.)  Secondly, dopamine receptors are linked to G-protein coupled receptors which alternate between GTP-GDP bound states, yet another link between GTP depletion and perturbation of dopamine signaling.

3.) Adenosine deficiency due to the reduction in salvage may adversely affect the role of adenosine as a neuroprotective agent.

Lastly, in Lesch Nyhan syndrome no characteristic imaging abnormalities are seen but reduced dendritic arborizations in the caudate nucleus, putamen, and nucleus accumbens are thought to underlie clinical manifestations.

So to summarise, Lesch Nyhan syndrome can be considered as one of the basal ganglia disorders with Wilson's disease and Huntington's disease being the other notable ones.

Have a great day!

-Kirtan Patolia