A few USPSTF guidelines

Hello,

USPSTF guidelines are important to remember for step 2 CK, step 3 and residency!

Here are a few high yield ones!

Ingenious Immune System

Hello friends, today let's take a moment to appreciate how amazing is our immune system.

In our immune system, just like any regular car, there are brakes in place to regulate its working. Removing brakes can certainly enhance its function which underlies the concept of immune checkpoint blockade.

Two such molecules on the surface of T-cells are CTLA-4(Cytotoxic T-lymphocyte associated protein 4) and PD-1(Programmed cell death protein 1).

When CTLA-4 binds to its ligands B7-1 and B7-2 which are often expressed in increased numbers on tumor cells it results in inhibition of T-cells and hence allowing tumor cells to evade apoptosis and survive.

Similarly when PD-1 binds to PD-L1on tumor cells inhibitory signals are relayed to T-cells.

In macrophages signal, regulatory protein alpha mediates inhibitory signals on interacting with CD47 on tumor cells.

In NK-cells KIR2DL1(killer cell immunoglobulin-like receptor 2DL1) mediates inhibitory signals.

So blocking these inhibitory signals by monoclonal antibodies can remove "brakes" on the immune system ultimately enhancing their ability to kill tumor cells.

Approved antibodies include:

Anti CTLA-4-Ipilimumab

Anti PD-1-Nivolumab, Pembrolizumab

Anti PD-L1-Avelumab,Durvalumab

Kirtan Patolia

Authors' diary: 53 facts about me

Another vlog before my long weekend ends =)

Pemphigus vulgaris vs Paraneoplastic Pemphigus vulgaris (PNP)

Hello friends, today let's talk about subtle differences between pemphigus Vulgaris and Paraneoplastic Pemphigus Vulgaris

1. SITE OF INVOLVEMENT

Pemphigus Vulgaris usually involves buccal and labial mucosa.

PNP causes severe stomatitis as well as targetoid lesions on palms and soles much like erythema multiforme.

2. ANTIBODIES INVOLVED

In Pemphigus Vulgaris antibodies are directed against intercellular adhesion molecules desmoglein-1 and desmoglein-3.

However, in PNP apart from desmoglein-1 and desmoglein-3 antibodies are also directed against envoplakin, plectin, desmoplakin, periplakin, and BPAG-1. 

3. IMMUNOFLUORESCENT PATTERN

In Pemphigus Vulgaris typical chicken-wire pattern is seen due to the intercellular deposition of IgG and C3

In PNP, that is not the case as although there is IgG deposition in all layers but not intercellularly and furthermore C3 is deposited along basement membrane as in Bullous pemphigoid.

4. VISCERAL INVOLVEMENT

In Pemphigus Vulgaris it is rare while in PNP often mucosa of the esophagus, stomach, duodenum, intestines, and the pulmonary epithelium is seen.

Prognosis is quite poor in PNP with bronchiolitis obliterans and sepsis being chief complications.

Mostly seen in Non- Hodgkin's lymphoma and CLL.

- Kirtan Patolia

Talazoparib: Zenith of novelty

Recently, talazoparib was approved by FDA for BRCA mutated breast cancer. Several other drugs related to it such as niraparib, olaparib are already approved for ovarian and breast cancer.

So how they work:

In eukaryotic cells, there is highly intricated network of sensors, transducers and mediators for DNA damage recognition and subsequent successful repair.

One of the such molecule is PARP (polyADP ribose polymerase) which serves to identify single strand breaks (SSBs) and seal them.

If PARP is inhibited (say, by talazoparib) then SSBs would progress to double strand breaks (DSBs). DSBs can also be effectively repaired by BRCA 1 and BRCA 2 complex by homologous recombination method.

However, in cancer cells with mutated BRCA, DSBs would not be repaired, ultimately causing apoptosis via molecules such as PUMA (p53 upregulated modulator of apoptosis), NOXA and p21.

Furthermore, talazoparib is known to induce formation of cytotoxic PARP-DNA complex, further contributing to it's mechanism.

That is definitely zenith of novel mechanism.

Stones in Crohn's disease

Hello everyone, 

In this post, I'll be talking about the different types of stones seen in Crohn's disease. Let's learn why they form! 

CHOLESTEROL GALLSTONES: Either due to ileal involvement or ileostomy, in Crohn's, enterohepatic circulation of bile acids is perturbed resulting in supersaturation of bile with the cholesterol, altering the delicate composition of bile acids, phospholipids, and cholesterol of 10:3:1 in bile fluid.

CALCIUM BILIRUBINATE GALLSTONES: Due to alteration in colonic flora conjugated bilirubin is converted to unconjugated bilirubin, which along with seepage of excessive unabsorbed bile acids from the ileum, results in enhanced absorption of bilirubin from the colon causing increased concentration in bile.

CALCIUM OXALATE RENAL STONES:

Usually, calcium in the GI tract forms a complex with oxalate ions resulting in its excretion in stool but in Crohn's due to steatorrhea excessive unabsorbed negatively charged fatty acids bind with calcium, leaving unbound oxalate to be absorbed and subsequently excreted by urine causing nephrolithiasis.

URIC ACID RENAL STONES: Diarrhea in Crohn's causes metabolic acidosis due to decreased bicarbonate absorption or increased excretion from the colon which increases the acidity of tubular fluid. The increased acidity, simultaneous dehydration, hypocitraturia, and hypomagnesemia in such patients precipitate uric acid stones.

-Kirtan Patolia

Authors' diary: Residency and life so far (after moving to the US)

Hey!

I am video blogging now :)

True or False #9

1.Atopic dermatitis presents on flexor surfaces in infants. T or F

ANSWER

F

Extensor surfaces

Flexor in older children and adults

How to remember this?

Infants slEEEEEEEp a lot right.

Hence EEEEEEEExtensor surface involved in infants in atopic dermatitis

That will help you remember the opposite ( flexor surfaces) involved in older children and adults

That's all.

Calcium monitoring in ethylene glycol poisoning

Seizures often occurs in ethylene glycol poisoning.  It has multifaceted pathophysiology but one of the major cause is hypocalcemia.

Hypocalcemia occurs in ethylene glycol poisoning because ethylene glycol is metabolized to oxalate, which forms calcium oxalate depleting calcium from ECF.

Also, correcting associated metabolic acidosis by bicarbonate supplementation can further cause hypocalcemia due to increased binding of calcium to albumin.

This is why, calcium levels should always be monitored meticulously in such patients.

- Kirtan Patolia ( BJ medical college)

Cryptic conundrum in ET: Thrombosis or bleeding?

In essential thrombocytosis, contrary to what might be surmised, bleeding is more of threat than thrombosis.

This is because high platelet count especially above 1 million/mm3 cause acquired von willebrand disease, much like type 2b von willebrand disease, where excessive affinity of vWF for platelet Gpib result in excessive removal of platelet-vWF complex by spleen results in  thrombocytopenia and loss of high molecular weight vWF multimers.

However, incidence of erythromelalgia , transient ischemic attack and other microvascular events are also high in patients with essential thrombocytosis.

Pretty complex and contradictory, right?

- Kirtan Patolia ( BJ medical college).

Diabetic amyotrophy

Hello everyone!

Today, I will be talking about diabetic amyotrophy.

Diabetic amyotrophy has a lot of names!

It is also known as Bruns-Garland syndrome, diabetic myelopathy, proximal diabetic neuropathy, diabetic polyradiculopathy, diabetic motor neuropathy, diabetic radiculoplexopathy, diabetic lumbosacral plexopathy, and diabetic LRPN.

Diabetic amyotrophy typically occurs in patients with type 2 diabetes mellitus. The traditional features include the acute, asymmetric, focal onset of pain followed by weakness involving the proximal leg, with associated autonomic failure and weight loss. Progression occurs over months and is followed by partial recovery in most patients.

The diagnosis of diabetic amyotrophy is mainly based upon the presence of suggestive clinical features in a patient with known or newly diagnosed diabetes mellitus. Appropriate laboratory investigations, particularly electrodiagnostic studies, and neuroimaging in select patients, are useful to exclude other peripheral and central nervous system etiologies as a cause of the neurologic symptoms and signs.

No treatments are proven to be effective for diabetic amyotrophy or for idiopathic LRPN.

PS: Distal symmetric sensorimotor polyneuropathy is the most common type of diabetic neuropathy - it is characterized by a progressive loss of distal sensation correlating with loss of sensory axons, followed, in severe cases, by motor weakness and motor axonal loss. Classic "stocking-glove" sensory loss is typical in this disorder.

Source: UpToDate

That's all!

-IkaN

Zebra series: Lemierre's syndrome

Hello everyone!

Let's talk about Lemierre's syndrome today.

Lemierre's syndrome is characterized by disseminated abscesses and thrombophlebitis of the internal jugular vein after infection of the oropharynx. The predominant pathogen is a gram-negative anaerobic bacillus, Fusobacterium necrophorum.

That's the Zebra for the day!

IkaN

True or False #8 Lower GI Bleed

1. Angiodysplasia is a high volume arterial bleed. T or F

2. Diverticulosis is a low volume arterial bleed. T or F

ANSWERS

1. FALSE

Angiodysplasia  more often than not involves low volume venous bleeding.

Angiodysplasias are composed of ectatic, dilated, thin-walled vessels that are lined by endothelium alone or endothelium along with small amounts of smooth muscle. Studies in which casts of angiodysplasias were made by injecting a silicone material demonstrated that the most prominent feature in angiodysplasias is the presence of dilated, tortuous submucosal veins.
Small arteriovenous communications are also present and are due to incompetence of the precapillary sphincter. Enlarged arteries may be seen in larger angiodysplasias and may be associated with arteriovenous fistulas, which explains why bleeding can be brisk in some patients.
Histologic confirmation is often difficult. When obtained, it shows dilated vessels in the mucosa and submucosa, sometimes covered by only a single layer of surface epithelium.

2. FALSE

Diverticular bleeding involves high volume arterial bleed

Diverticular bleeding — As a diverticulum herniates, the penetrating vessel responsible for the wall weakness at that point becomes draped over the dome of the diverticulum, separated from the bowel lumen only by mucosa. Over time, the vasa recta is exposed to injury along its luminal aspect, leading to eccentric intimal thickening and thinning of the media. These changes may result in segmental weakness of the artery, predisposing to rupture into the lumen. Diverticular bleeding typically occurs in the absence of diverticulitis

Authors' diary: Internist's disease

Hello,

We had an interesting morning report today and I learnt this from Dr. L (L for Legend!)

Zebra series: Stauffer syndrome

Hello,

I'll be talking about Stauffer syndrome today!

Authors' diary: Zebra series

Hello!

I am starting a Zebra Series on Medicowesome.

True or False #7

1.Depression increases the risk of morbidity and mortality in Cardiovascular disease. T or F

2. Patients with Cardiovascular disease are more likely to develop Depression. T or F

True or False #6

1. Nightmare is a REM sleep behavior disorder. T or F

2. Night Terror is a REM sleep behavior disorder. T or F

ANSWERS

1. True

Things you should REMember for Nightmare disorder are :

REM

Second half of the night

Responsive to comfort

REMembers the dream

2. False

Night terrors:  Abrupt arousals from sleep (panicked scream, terror, autonomic arousal, unresponsive to comfort)

- Little or no dream recall

- Amnesia for episodes

Sleep is a gift, always be grateful for it.

True or False #5

1. Narcolepsy exhibits a reduced REM latency. T or F

ANSWER

1. True

Narcolepsy: depletion of hypocretin secreting neurons in lateral hypothalamus that are involved in maintaining wakefulness

Diagnostic: recurrent lapses into sleep or napping several times in the same day, >3 times a week for >3mo. and at least 1 of the following
-Cataplexy: Conscious of bilateral loss of muscle tone precipitated by emotions or abnormal facial movement (without emotional triggers)

-Hypocretin - 1 (orexin A) deficiency in CSF

- REM sleep latency <15 minutes

Tetrad:
-Sleep attacks

-Cataplexy

-Hypnagogic or hypnopompic hallucinations

-Sleep paralysis

Dx: Shortened REM sleep latency on polysomnografy
Low levels of hypocretin 1 in CSF

You may feel weak, you may fall down, say no to Cataplexy, say yes to CATA GETUP!!

True or False #4

1. Imaging is contraindicated in pregnancy for diagnosing latent TB. T or F

2. Check for latent TB before prescribing Infliximab. T or F

ANSWERS

1. False

Diagnostic evaluation after positive test — Patients with a positive TST or IGRA must undergo clinical evaluation to rule out active tuberculosis. This includes evaluation for symptoms (eg, fever, cough, weight loss) and radiographic examination of the chest (with appropriate shielding), regardless of gestational age.

Patients with a positive TST or IGRA with no evidence of active TB may be presumed to have latent TB.

2. True

Toxicity of Infliximab includes :

Respiratory infection (possible reactivation of latent TB)

Fever

Hypotension

Last man standing wins. Keep grinding.

True or False #3

1. A high potassium diet, decreases risk of kidney stone. T or F

2. Increase Sodium intake  for reducing kidney stones. T or F

ANSWERS

1. True

A high potassium diet decreases urinary calcium excretion.

Foods rich in potassium enhance urinary Citrate excretion, likely from urinary alkalization, forming soluble calcium Citrate and thereby preventing stone formation

2. False

Decrease the sodium intake

So that when sodium is reabsorbed by the nephron, calcium is also passively reabsorbed and hence decreased calcium in urine.

You are your own Kingdom, pick up the Crown.

Bhopalwala. H

True or False #2

1. Herpangina involves the anterior oropharynx with grey vesicles and ulcers. T or F

2. Pleurodynia is also known as Bornholm disease. T or F

ANSWERS

1. False

Herpangina is caused by Coxsackievirus and involves the posterior oropharynx

Herpetic gingivostomatitis caused by HSV involves the anterior oropharynx and grey vesicles and ulcers

2. True

Pleurodynia — Pleurodynia is an acute enteroviral illness characterized by fever and paroxysmal spasms of the chest and abdominal muscles . Most cases occur during localized summer outbreaks among adolescents and adults. Regional and nationwide outbreaks involving a large number of older children and young adults have been reported at infrequent intervals, often separated by decades. The role of the group B coxsackieviruses, the most important cause of epidemic pleurodynia, was established in 1949 . Other agents rarely implicated in pleurodynia include echovirus serotypes 1, 6, 9, 16, and 19 and group A coxsackievirus serotypes 4, 6, 9, and 10 .

Pleurodynia can mimic more serious diseases, including bacterial pneumonia, pulmonary embolus, myocardial infarction, acute surgical abdomen, and herpes zoster infection. Most patients are ill for four to six days. Children have milder disease than adults, who are often confined to bed.

True or False #1

1. Vareniciline increases the risk of suicide and depression. T or F

2. Vareniciline increases the risk of CVS events. T or F

Facebook: ANM registration

#Medicowesome
#PSM

In a subcenter population, Crude birth rate is 20. What is minimum expected number of pregnencies registered with ANM?

1) 110
2) 120
3)  55
4) 100

Answer within 24 hours.

Answer is Option 3)

Let's get to this tricky question.

Total subcentre population is 5000.
Total CBR =20 per 1000 mid year  population.
Hence, 20/1000* 5000
=100 births.

Now here comes the tricky part.

Abortion and still birth accounts for 10% wasted pregnencies.
So 100+10 (10% of total births)
=110.
As per rule, ANM should have 50% registration, therefore 110/2=55
Approximately C) 60

That's all.

-Demotional bloke.

Authors' diary: CHADSVasc High

*talking about atrial fibrillation*

Management of Diabetic Ketoacidosis

Hi guys! Let’s look at how we manage one of the the most dreaded medical emergencies; a complication of Diabetes Mellitus type 2.

[Please click on the image to enhance it]

- Patients with DKA have a triad of hyperglycaemia, ketosis and metabolic acidosis and they are severely dehydrated due to osmotic diuresis.

- Those with altered sensorium or pH < 7.0 require intensive care. A comprehensive flow sheet of changes in vital signs, fluid intake/output and lab values must be maintained.

- Despite a bicarbonate deficit, most DKA patients often do not require bicarbonate replacement but may be given if arterial pH < 7.0

- Serum phosphate, magnesium and calcium may rarely need supplementation.

- Patient education is of utmost importance to prevent future recurrences.

Happy studying!

- Ashish Singh.

Assessment and plan: New onset atrial fibrillation with rapid ventricular response

Hello!

Here is case one for the A&P series!

Assessment and plan: 99 yo M with PMH of ... admitted for ... is being evaluated for new onset atrial fibrillation with rapid ventricular response.

Authors' diary: Assessment and plan

Hey everyone!

As a medical student rotating in the US, I would have a tough time "typing" the assessment and plan. I would have it straight in my head but putting it all into words was difficult. I guess because I came from a different medical system where we don't write assessment and plan in our notes.

Ventricular arrhythmia notes

Hello! 

Anti-Ro/SSA antibodies and neonatal lupus

Hello everyone!

Did you know? Anti-Ro/SSA antibodies are associated with neonatal lupus (congenital heart block (CHB), neonatal transient skin rash, hematological and hepatic abnormalities).

How do I remember this? 

Algorithmic Management of Organophosphate Poisoning

Hey guys, this whiteboard provides a general overview of how to manage patients with OrganoPhosphorous Compounds (OPC) poisoning.

      [Please click on the image to enhance it]

*Use of benzodiazepines has been associated with decreased mortality and morbidity, even in the absence of convulsions.

Signs of atropinization refer to the target end-points for atropine therapy and includes:
- Clear chest on auscultation, no wheeze
- Heart rate >80 beats/min
- Systolic Blood Pressure >90 mmHg
- Dry axillae
- Pupils no longer pin-point (miotic)

Early treatment with oximes is necessary before phosphorylated cholinesterase enzymes undergo “aging” and become resistant to reactivation (due to loss of their alkyl group).

That would be all.
Happy studying!

- Ashish Singh.

Role of BNP in acute exacerbation of COPD

Hello Awesomites!

Heart failure and COPD are common and they commonly co-exist in the same patient. Diagnosis may be difficult during acute exacerbation.

BNP/nT-pro-BNP is good Negative predictive value to rule out the presence of heart failure.

Spirometry is useful when the patient’s volume status is optimized. During acute HF exacerbation, diagnostic accuracy may be limited.

ECHO may be helpful to rule out systolic or diastolic dysfunction.

Why is it important to know?

Some therapies in COPD may be associated with worsening cardiac events in HF patients.

1) Oral steroids: - increased sodium and fluid retention.

2) Beta2 agonist: - increased HR and increased oxygen demand.

3) Aminophylline: - increased risk of arrhythmia.

You can further read about this in Link between COPD and HF
HAPPY STUDYING !
-Upasana Y. :)

IRIS (Immune reconstitution inflammatory syndrome)

Hello Awesomites!

In terms of understanding immunity, HIV and leprosy never fails to fascinate me.There is whole spectrum of change in response of immune system.

So let us begin with the immune system which begins to recover. (Fall down 7 times get up 8!)

Immune reconstitution inflammatory response abbreviated as IRIS is a condition seen in some cases of AIDS or immunosuppression, in which the immune system begins to recover, but then responds to a previously acquired opportunistic infection with an overwhelming inflammatory response that paradoxically makes the symptoms of infection worse.

There are 2 presentations:-

1. Paradoxical IRIS: worsening of symptoms of a known disease during ART

2. Unmasking IRIS: present of an occult opportunistic infection, in which disease that was not clinically apparent prior to ART, manifests during ART

Proper history:

-Time course of symptoms

 -History of Opportunistic infection,

-Recently diagnosed Opportunistic infections

-Treatment of Opportunistic infection: date of initiation, adherence, duration and clinical response

 -ART initiation date,

- Specific antiretroviral regimen,

-medication adherence,

-Previous history of ART

 -CD4 cell count and HIV viral load before ART initiation

 -Current CD4 cell count and HIV viral load,

The risks of corticosteroid therapy should be weighed against the severity of the IRIS manifestations and the potential benefits.Risks of corticosteroid therapy include the following:

-Hyperglycemia.
-Hypertension.
-Mental status changes.
-Avascular necrosis.
-Worsening of an existing infection.
-Predisposition to a new infection.

It teaches me something about "Balance".
-Upasana Y. :)

Facebook:ENT X-rays part - 1

#Medicowesome
#Ent

Which is the last sinus to appear radiologically on X-ray?
1) Maxillary sinus
2) Ethmoid sinus
3) Sphenoid sinus
4) Frontal sinus

Answer with detail explanation through blog in 12 hours.

So, this post is regarding our Facebook page question on ENT X-rays.
Correct answer is Option 4- Frontal sinus.

Let's get into some details and all of them are potential one liner questions.

Order of development of Paranasal sinus is
Maxillary > Ethmoid > Sphenoid > Frontal

I remember this order with mnemonic - "MESs Food"

Maxillary sinus and (Anterior) Ethmoid sinus are present at birth.
Maxillary sinus appears at 4-5 months of age radiologically.
(Anterior) Ethmoid appears at 1 year of age radiologically.

Sphenoid sinus: Development start at 2nd or 3rd year after birth and continues till adulthood. Making it last sinus to complete development.
It appears radiologically after 4 year of birth.

Frontal sinus: Development starts after 4 year of birth and completed at 13-14 years of age.
It appears radiologically after 6 years of birth.

Happy learning :)

-That's all

-Demotional bloke.

CHA2DS2-VASc Risk Score

Hello Awesomites !

You all must be familiar with the complications of atrial fibrillation (AF). The management of atrial fibrillation is centered on these complications.
Thromboembolism is caused by AF. CHA2DS2VASc score is to estimate stroke risk in AF patients and to start OACs (oral anticoagulants).
Previously, we have CHADS2 Score.

HEART FAILURE OR LVEF LESS THAN OR EQUAL TO 40%	1
HYPERTENSION	1
AGE MORE THAN OR EQUAL TO 75	2
DIABETES MELLITUS	1
STROKE,TIA or THROMBOEMBOLISM	2
VASCULAR DISEASE (PREVIOUS MI,PERIPHERAL ARTERY DISEASE, OR AORTIC PLAQUE)	1
AGE 65-74 YEARS	1
FEMALE SEX (BUT NOT A RISK FACTOR IF FEMALE SEX IS THE ONLY FACTOR)	1
MAXIMUM SCORE	9

SCORE 0	RECOMMEND NO THROMBOTIC THERAPY
SCORE 1	CONSIDER RISK/BENEFIT AND HAS-BLED SCORE TO AID DECISION OF ANTI-THROMBOTIC OR ANTI PLATELET THERAPY
SCORE 2	RECOMMEND OACs

HAS-BLED is a scoring system developed to assess 1-year risk of major bleeding in patients taking anticoagulants with atrial fibrillation.

-Upasana Y. :)

Studying for Step One

Studying for the USMLE can be a daunting task, especially when you're an International Medical Student/Graduate. Coming from a different background - culturally and educationally - the questions asked in these examinations reflect the health system and health needs of the US's population. Apart from the questions, the financial aspects of attaining residency in the United States may also be a setback for some. Overall, this journey is a test of patience and dedication to the profession and one's career goals.

Euvolemic hyponatremia algorithm

Just happened to create this image so I thought of sharing with you guys :)

-IkaN

Lab values Fishbone skeleton / Ishikawa Diagram in text

Hey, 

I was looking for this skeleton to manually put in the outside labs for my patient.

Why is the level of Vitamin B12 increased in CML?

Why is the level of Vitamin B12 increased in Chronic Myeloid Leukemia (CML)?

Pathophysiology: The transport of vitamin B12 in the blood as well as hepatic uptake require the presence of transcobalamins (TCBs).

TCB types I (TCB I) and III (TCB III) ensure the binding of ∼80% of circulating vitamin B12.