Myopathies series - Part 4

Hello! :)

In previous post, I left you with a question

How do we identify the site and cause of lesion?

Important points in history and neurological examination that is suggestive of myopathy are:-

1. MUSCLE WEAKNESS

According to Taber's medical dictionary, Lacking physical strength or vigor; infirm especially as compared with what would be the normal or usual for that individual.

Most muscle diseases produces symmetrical weakness of the large muscles of the girdles and trunk.

A) HIP GIRDLE (MOST COMMONLY AFFECTED)

- Difficulty in getting up from squatting position or from low chair,

-Inability to climb stairs,

-Waddling gait.

B) UPPER GIRDLE WEAKNESS

- Difficulty in hanging clothes on a cloth line

-Difficulty in taking down item from high shelves.

C) TRUNK WEAKNESS

-Difficulty in turning in bed and getting up from recumbent position.

D) NECK MUSCLE WEAKNESS 

-Inability to control neck while in a vehicle as it rapidly accelerates and decelerates.

-neck pain and stiffness.

E) CRANIAL MUSCULATURE WEAKNESS

1. FACIAL WEAKNESS:-

-Inability to close eyes fully.

-Difficulty in drinking with a straw.

2. OCCULAR WEAKNESS:- (I will explain this below in bit detail )

-ptosis

-extraoccular movement weakness are seen.

F) DISTAL MUSCULATURE WEAKNESS

-Difficulty in opening lids of jar

-turning keys in keyholes

-tend to trip on uneven ground with repeated falls.

2. GAIT

3. FATIGUE

According to Taber's medical dictionary, the condition of an organ or tissue in which its response to stimulation is reduced or lost as a result of over activity.

Abnormal fatigability after exercise can result from certain metabolic and mitochondrial myopathies.

And as I have already discussed the importance of duration and intensity of exercise that provokes fatigue. It helps to distinguish metabolic myopathies.

4. MYALGIA

-Episodic= metabolic myopathies

-Constant=inflammatory muscle disorders

5. OCULOBULBAR WEAKNESS

6. SENSORY SYSTEM = NORMAL 

7. MYOGLOBINURIA 

- Why? As caused by the excessive release of myoglobin from muscles during periods of rapid muscles destruction (rhabdomyolysis)

-Results in renal failure in severe cases.

-Patient complains of exercise induced myalgia then ask about "Cola colored" or "red colored” urine during this episodes. 

That's all for today.

I hope it helped.

In next post I will continue with the relation of age and progression to diagnose myopathy. 

-Upasana Y. :)

Emphysematous Cholecystitis

Hello guys! Here's a brief description about Emphysematous Cholecystitis.

What are the risk factors for Emphysematous Cholecystitis?

1. Diabetes Mellitus (Most Important)
2. Immunosuppresion
3. Vascular compromise (Obstruction & stenosis of Cystic artery).

Emphysematous Cholecystitis is a life-threatening form of Acute cholecystitis & caused due to infection of the gall bladder wall with Gas forming bacteria like: Clostridium welchi.
Gas forms in gall bladder wall with occasional detection of crepitation (that's why called Emphysematous).

Development of gangrene & perforation is common.

It is managed by Emergency cholecystectomy with broad spectrum antibiotics.

Thank you

MD Mobarak Hussain (Maahii)

How to study for USMLE Step 2 CK

If you are short of time, don't read this. Seriously, if you have 2-3 months to prepare - Just do UW, assessments and give the exam. You will do great!

If you have a good 6-12 months, you are just starting your prep and need honest advice, here is mine.

I haven't got my score yet, but the post has been requested before I even gave my exam. So here it is =) I wonder if my credibility changes after my result. Oh well, guess I'll never know.

Medicowesome secret project: Poem on recycling

What is the Earth day secret project about?

Medicowesome secret project: Stalking the Future

What is the secret project? How can I participate?

Medicowesome secret project: The Ordeal

What is the secret project? How can I participate?

Pills of knowledge in Ophthalmology-Pupil and the third nerve palsy

The parasympathetic fibres passing along with the 3rd cranial nerve which supply the pupil lie towards the periphery of the nerve. Hence, surgical compressive lesions like tumors or aneurysms which compress the 3rd nerve end up involving the pupil as well.

In contrast, medical lesions like diabetis mellitus or hypertension affect the vasa nervosum which supply the nerve starting from its core.These rarely affect the pupil as the outer, peripheral fibres may remain relatively spared.

This however, is not a strict rule.This criterion can just be used for the primary evaluation of the possible lesion.

That's all!

Triad of Retinitis pigmentosa mnemonic

The mnemonic for remembering the Triad of retinitis pigmentosa (RP) is BAD

1. B- jet Black spots which are perivascular.
2. A- Attenuation of arterioles.
3. D- Disc palor.

Thanks for reading.

Madhuri Reddy

Injury to spinal accessory nerve

Hello friends,

This post is about damage to spinal accessory nerve.

We know that this nerve in the neck first supplies sternocleidomastoid,then lies on levator scapulae to supply trapezius.

On excision biopsy for matted cervical lymph nodes,we may damage that part of nerve which is lying on levator scapulae.So, this may lead to paralysis of trapezius.

To find this:

Ask the patient to shruggle his shoulder,

To do overhead abduction of arm, and

See for winging of scapula at rest.

On paralysis, there will be difficulty in shruggling his shoulders , difficulty in overhead abduction of arm and winging of scapula at rest.

Winging of scapula is also seen in paralysis of serratus anterior but prominent on movement like pushing the wall, whereas in paralysis of trapezius, it's seen at rest.

Thanks for reading!

Madhuri Reddy (Madhu)

Myopathies series -Part 3

Hello! :)

In previous post, I discussed about metabolic myopathies.

Today we see the general classification of myopathies.

Myopathies are classified as

-CONGENITAL

-ACQUIRED

I. CONGENITAL:-

1. Denervation atrophy;-

-spinal muscular atrophy (infantile motor neuron disease)

2. Muscular dystrophies

a) Autosomal recessive Muscular dystrophy 

-Limb-girdle form

b) Autosomal dominant muscular dystrophy

-Facioscapulohumeral

-Occular

c) Sex linked muscular dystrophy

-Duchene 

-Becker

-Emery Dreifuss

3. Myotonic dystrophy

4. Ion channel myopathies

5. Congenital myopathies

6. Myopathies associated with inborn errors of metabolism (This we have already studied in previous posts.)

II.ACQUIRED MYOPATHIES

1. Inflammatory myopathies

-Infectious

-non-Infectious

-systemic inflammatory disease (involves other organs also)

2. Toxic myopathies

-Thyrotoxic myopathy (There is an awesome post By Ojas )
http://www.medicowesome.com/2017/03/pathophysiology-of-myopathy-caused.html

-Ethanol myopathy

-Drug induced myopathy

So this means, we have long way to go: D

 "MOTOR ACTIVITY” is a broad term. It includes 

1) Voluntary movements 

2) Reflex movements

3) Rhythmic motor patterns

The pathway of any motor activity includes:

1. Cortical level

2. Brainstem and associated structures 

-Brainstem centers 

-Basal ganglia

-cerebellum

3. Spinal cord

4. Lower motor neurons

5. Neuromuscular junction 

6. Muscle 

 Myopathy means we are discussing problem in MUSCLES.

So how do we know the correct site of lesion?

To diagnose any myopathy, we need to know its site and cause of lesion. The following helps in the diagnosis.

1. History

2. Examination

3. Investigations 

Take care.
x

-Upasana Y. :)

x

Brain Abscess - Important facts

Hello guys! Here are some important facts about Brain Abscess.

Most Common site: Frontal lobe

Sequence of involvement: Frontal lobe > Temporal lobe > Parietal Lobe > Occipital lobe.

Most Common site of Brain Abscess in Tetralogy of Fallot: Parietal Lobe.

Most Common site of Brain Abscess in CSOM: Temporal lobe (Mastoiditis).

Most Common organisms involved are Anaerobic bacteria > Staphylococcus aureus > Streptococcus pyogenes.

Empirical therapy: Vancomycin + Ceftriaxone + Metronidazole for 4 to 8 weeks.

I hope that it's helpful to you.
Thank you!

MD Mobarak Hussain (Maahii)

Granulomas and hematolymphoid malignancies

Granulomas are rare findings in a bone marrow of hematolymphoid malignancies. They are commoner with Hodgkin lymphoma and rarer with acute leukemias. They are most commonly non caesating epitheloid granulomas and may stain negative for tuberculosis and fungi! So, what are they really? They are believed to be a immune response to tumour antigens or to immune complexes when the patient is on treatment...
All granulomas need not be tubercular!

Branches of subclavian artery mnemonic

Hello friends,

Today let's memorise the branches of subclavian artery.

The mnemonic is  VITamin 'C ' and 'D'

Here VIT corresponds to branches arising from first part. 

'C' from second part. 

'D' from third part  of subclavian artery.

So from first part:

V - Vertebral

 I - Internal thoracic artery

T - Thyrocervical trunk or Thyroscapulocervical trunk( this makes our task easy to memorize branches of this trunk)

Thyroscapulocervical - Gives  rise to 3 arteries:

Thyro -- Inferior thyroid artery

Scapulo -- suprascapular artery

Cervical - superficial cervical artery.

From second part:

C - Costocervical trunk which gives rise to superior intercostal artery and deep cervical artery.

From third part:

D - Dorsal scapular artery.

Sometimes, instead of superficial cervical and dorsal scapular arteries arising as 2 separate arteries, there is a single branch which arises from 1 st part of subclavian artery that is Transverse cervical artery.

This artery divides into superficial ascending branch and deep descending branch as shown in the flow chart below.

Thanks for reading and do correct me if there is anything wrong.

Madhuri Reddy (Madhu)

Rash involving hands and feet mnemonic

This is the association I use to remember the organisms causing rash that includes hands and feet - You drive CARS with your hands and feet. 

CA- Coxsackie A virus

R- Rickettsia rickettsii 

S- Syphilis (secondary)

S - Staphylococcus (TSS) 

We often forget Toxic Shock Syndrome in our differential. Keep it in mind! 

That's all! 

-IkaN 

Hypervitaminosis A mnemonic

Hello!

Here's a mnemonic to remember the features of Hypervitaminosis A.

The mnemonic is, "H.A.R.D. Puzzle."
H - Hepatosplenomegaly, Hair sparse, Hyperostosis
A - Anemia, Anorexia
R - Really painful bones
D - Dry skin
Puzzle - Pseudotumor cerebri

Thank you.

MD Mobarak Hussain (Maahii)

Necrotizing Enterocolitis - Important points

Here are some high yield points about Necrotizing Enterocolitis.

1. It is the most common life threatening emergency of gastrointestinal tract in neonates.

2. Triad of - Intestinal ischemia, enteral nutrition and bacterial translocation.

3. Distal part of Ileum and proximal segment of colon are most frequently involved.

4. Coagulation necrosis is the characteristic histological finding in the intestinal specimens in Necrotizing Enterocolitis.

5. Pneumatosis intestinalis (air in the bowel) is diagnostic on X-ray.

6. Portal venous gas shadow is a sign of severe Necrotizing Enterocolitis on X-ray.

7. Most important risk factor is Prematurity.

8. Pneumoperitoneum is a sign of advanced NEC with perforation.

These points should help you in quick revision.

Thank you!

MD Mobarak Hussain (Maahii)

Lung Cancer Subtypes

Subtypes of lung cancer:-
1. Squamous cell cancer-
Most common variant in India.
Smoking is a risk factor.
Central in location.
Local growth is surgically resectable.
Cavity formation is seen.

2. Adenocarcinoma-
Most common variant of lung cancer overall.
Most common lung cancer among non smokers.
Peripheral in location.
Transbronchial spread i.e. it arises at one lobe and spreads to the another lobe.

3. Small cell carcinoma/Oat cell carcinoma-
Most aggressive variant.
Smoking is a risk factor.
Central  in location.
It exhibits micrometastasis.
It has worst prognosis.

4. Large cell carcinoma-
Observed in Non smokers.
Peripheral in location.
This is associated with Estrogen production which manifests as Gynecomastia.

I hope this will help you to distinguish between the various subtypes.

Thank you
-Md Mobarak Hussain (Maahii)

Oxalate stones in Crohn's Disease

A tricky Concept based question often asked in Medicine/Pathology MBBS Professional Exam-

Why Crohn's Disease patient often develop Kidney/Renal STONES, particularly OXALATE stones?

Tachyarrhythmias

Here are some high yielding MCQ points on arrhythmia

Most common arrhythmia mechanism is re-entry.
Most common sustained arrhythmia is atrial fibrillation.
Most common benign rhythm identified is atrial premature contraction.
Most common arrhythmia in COPD patient is multifocal atrial tachycardia.
Post operative atrial fibrillation is managed with landiolol hydrochloride.
Atrial fibrillation getting converted to ventricular fibrillation is seen with accessory pathway conducting antegradely like Bundle of Kent in WPW syndrome.
VT storm or electrical storm is  3 or more separate episodes of VT within 24 hours.
Most commonly identified arrhythmia in cardiac arrest patient is ventricular fibrillation.
Most common cause of Sudden death in HCM is polymorphic VT/Ventricular fibrillation VF.

Thank you

-Md Mobarak Hussain (Maahii)

ERAS token, AAMC account, Letter of Recommendation

My juniors and colleagues requested that I guide them through this, so ta-da, another "How to" post.

I am attaching screenshots of the process - step by step. Sorry for all the scribbling. I was too bored to Photoshop.

Viral Exanthems - Mnemonic

Mnemonic to remember the Viral Exanthems of childhood

ME gave ROSE to my BELLA after eating CHICKEN at 5 PM.

ME =MEasles
ROSE= ROSEola
BELLA = ruBELLA
CHICKEN = CHICKEN Pox
5 P= 5th disease (Parvovirus)

Thank you!
-Md Mobarak Hussain (Maahii)

Megaloblastic Anemia

1. Why do we get " Megaloblasts" in Megaloblastic anaemia?
2. Why we get anaemia in Megaloblastic anaemia?
Megaloblastic anaemia is called so due to presence of " Megaloblasts" in bone marrow.
What are " Megaloblasts" They're gigantic, abnormally BIG RBC-precursors seen in bone marrow. WHY do we see them ?
It needs some conceptual understanding.                           
Normally, RBC-precursors are big cells which divide rapidly as they mature & become progressively smaller as they divide while maturing towards mature-form of RBCs.  Now, the problem begins in Megaloblastic anaemia that this cell-division is impaired due to lack of nutrients ( Folate & Vitamin B12).  Vit B12 & Folate are critical for normal DNA synthesis & cell maturation.                                                             It's also described by a complex -term called " Nuclear-Cytoplasmic Asynchrony".
As DNA-synthesis is impaired, nuclear maturation of RBC-precursors get slowed up & could not match with the pace of cytoplasmic maturity/development. This DEFECTIVE NUCLEAR MATURATION halts cell-division & those big "MEGA" RBC-precursors remain as Big, MEGA, gigantic " Megaloblasts" in bone marrow giving the name as " Megaloblastic anaemia". Moreover, these " Megaloblasts" do NOT mature enough to get released into the peripheral blood & most RBC-precursors undergo " apoptosis " or apoptotic-death in bone marrow ..this  causes anaemia in Megaloblastic anaemia.

Hope this helps some of you to understand the basic concepts.

-Md Mobarak Hussain (Maahii)

Step 2 CK: Which Pneumococcal Vaccine to administer & when?

Brain to gut: Lets talk

Hey Awesomites

The brain and gut chat and share neurohumoral and immunologic messages with each other most of the times. That is why our emotions affect our stomach and intestines and vice versa. This healthy communication is disturbed when we are stressed out, anxious, or depressed.



Stress (more of psychological type) influences the type of bacteria inhabiting the gut, making a loss of our bowel flora diversification and increasing the concentration of harmful pathogens in the gut, thus leading to certain inflammatory and infectious processes.

Chronic flare - ups of inflammatory bowel disease result in deviation of the mood towards negative side by upto 60 percent by a process of rewiring the neuronal circuitary, called neuroplasticity. This inturn worsens the condition of gut on long-term basis.
Recent studies suggest that talk therapy - particularly cognitive behavioral therapy, and anti- depressants may be supportive in such cases to reduce the flaring up of inflammatory bowel syndrome.

In case of irritable bowel syndrome, that is a functional disorder ( without any actual organic cause ), the CBT and use of anti- depressants improve the symptoms in upto 60 percent patients. But which patients are likely to benefit still needs further research. Till then, we know that a referral for talk therapy in the patients of IBS is a must.


Thats all
- Jaskunwar Singh

Favorites of brain cells: The game of genetics

Hey Awesomites

Many cells in the brain express two copies of a gene - maternal and paternal. But some express only one. If the single copy that is expressed carries a genetic mutation, it may result in cellular dysfunction and thus there are consequences.

Research on newborn mouse suggests that in about 85 percent of genes in the dorsal raphe nucleus, known for secreting serotonin, differentially activate their maternal and paternal gene copies. Ten days later in the juvenile brain, both copies are activated equally for all but 10 percent of genes.

The disparity also occurs in humans and in other systems like liver and muscles.

Like for example, in humans, a gene called DEAF1 that is implicated in autism and intellectual disability, shows a preferential expression of one copy of genes in multiple areas of brain. This is true for genes in other mental and neurologic disorders like Huntington's disease, schizophrenia, ADHD, and bipolar disorder.
( Source )


Thats all
- Jaskunwar Singh

Novel Monoclonal Antibodies: Emicizumab and Caplacizumab

Emicizumab:

Patients with Haemophilia A need regular infusions of Factor VIII, and a majority of patients develop antibodies against this exogenous factor VIII rendering the therapy less effective.

Emicizumab is here to solve this problem. It mimics the physiological function of factor VIII, that is to enhance the interaction between activated factor IX and factor X to facilitate the activation of factor X. Emicizumab binds both factor IXa and factor X and increases the interaction between them.

Caplacizumab:

Patients with Thrombotic Thrombocytopenic Purpura(TTP) has antibodies against ADAMTS13. Reduction of ADAMTS13 levels leads to formation of vWF multimers that enhance platelet aggregation and consequent thrombus formation in all major systemic blood vessels. The current therapy protocol consists of Plasma exchange and Immunosuppressants.

Caplacizumab binds to vWF and prevents its interaction with GP1b receptor on platelets, thereby inhibiting platelet aggregation.




-VM

Fact of the day: Liquid biopsy for cancer detection

Hey Awesomites

We have known since long that surgical biopsies done routinely in cancer patients to diagnose and detect progression of the disease may increase the risk of carcinogenic changes in the cells in future, due to the changes that had prompted the biopsies.

A non - invasive and painless diagnostic tool that replaces the cutting is "liquid biopsy" that finds the hidden cancer cells anywhere in the body. The liquid biopsy is taken from a simple blood test to look for microscopic pieces of DNA circulating in the blood that contains genetic mutations causing tumors to spread, among billions of other DNA that were in the blood.
A year ago, a circulating tumor DNA test was approved by FDA that spots these mutations.


Thats all
- Jaskunwar Singh

Poikilocytosis

Red blood cells

Also known as erythrocytes, is the most common type of blood cell and the principal means of oxygen transport in the body.

The normal biconcave shape is the essential feature of its biological function.
Through various stages of development and maturation, RBC loses its nucleus and most organelles in order to accommodate maximum space for haemoglobin.
This feature of RBC is critically affected by genetic and acquired pathological conditions.

Poikilocytosis is the term used to denote the variation in the shape of red blood cells.
Let's look at the major abnormalities in the shape of RBCs and the conditions in which they are seen:

1. Spherocyte - hereditary spherocytosis, autoimmune haemolytic anaemia, ABO haemolytic disease of the new born

2. Schistocyte - thalassemia, hereditary elliptocytosis, megaloblastic anaemia, iron deficiency anaemia and severe burns

3. Irregular contracted red cells - drug and chemical induced haemolytic anaemia, unstable haemoglobinopathies

4. Target cell (a type of leptocytosis)- iron deficiency anaemia, thalassemia, chronic liver disease and after splenectomy

5. Sickle cell (drepanocyte)- sickle cell anaemia

6. Tear drop cell - myelofibrosis, underlying marrow infiltrate

7. Crenated red cell - in blood films due to alkaline pH, presence of traces of fatty sustances on the slides or film allowed to stand over night

8. Acanthocyte - post splenectomy, chronic liver disease, Abetalipoproteinemia, McLeod blood group phenotype

9. Burr cell - uremia, liver disease, artifact

10. Stomatocyte - hereditary stomatocytosis, chronic alcoholism

11. Ovalocyte - hereditary ovalocytosis, hereditary elliptocytosis, severe iron deficiency anaemia

The diagram given represents the corresponding cells





Credits to: Shivani Mangalgi.

Myopathies series- Part 2

METABOLIC MYOPATHIES

In previous post, I gave an introduction of metabolic myopathies.

Today we cover:-

I.Diagnostic role of creatine kinase in metabolic myopathies.

II.Metabolic myopathies and its types.

Diagnostic role of enzyme in myopathies.

The following diagram shows the enzymes related to myopathies and their associated metabolic reactions.( Note:- The metabolic pathway is not only for skeletal muscle .It is in general . My main aim is to show enzymes of liver and muscle along with the pathways.Remember urea cycle occurs in liver )

http://chemistry.elmhurst.edu/vchembook/images/641serumenzymes.gif

Creatine kinase: - This enzyme will help us to evaluate different METABOLIC myopathies.

1. ELEVATED CK: - In Glycogen storage disease associated myopathies.
    (In some GSD there will be mild elevated CK)
2. MILD ELEVATED CK:- In Fatty acid oxidation disorder.
3. NORMAL CK: - In Mitochondrial myopathies.Also in some fatty acid oxidation disorder.
   
   Metabolic myopathies types:-

I.                    DISORDER OF GLYCOGEN METABOLISM (MUSCLE GYCOGENOSES)

II.                  DISORDER OF FATTY ACID OXIDATION

III.                MITOCHONDRIAL MYOPATHIES

CLINICAL FINDINGS :-

1. Second wind phenomenon: - suggestive of GSD V / McArdle’s

2. Out-of-wind phenomenon: - suggestive of GSD VII/ Tarui

3. Myoglobinuria (Burgundy colored urine):- GSD V, GSD IX
                                                                         LDH, PGM or PGK enzyme deficiency
                                                                         CPTII Deficiency
4. Proximal weakness: - GSD II / Pompe.

5. Exercise intolerance,ataxia,multisystem involvement:- Mitochondrial disorder, Coenzyme Q10 Deficiency.

LAB TESTS:-

1. Serum CK levels.

2. Lactate 

3.Serum electrolytes.

4. ammonia

5.AST,ALT,GGT 

6. Urinalysis

7.Forearm exercise test.

8.EMG

9.Routine muscle biopsy

SPECIFIC TESTS:- 

1. Urine organic acids

2. Plasma acylcarnitine profile

CONFIRMATORY BUT COSTLY :-

1. Enzyme analysis

2. DNA Analysis on leukocytes, fibroblasts and liver.

Click on the below given link to read on how to differentiate between McArdle, CPT II deficieny and mitochondrial myopathy. (this link helped me with the notes) 

*If you are running short of time, then Read only Case 1 and Case 2

 http://www.the-rheumatologist.org/article/diagnosis-myopathy/

I hope it helped. 

-Upasana Y. :)

Fact of the day: Gonorrhea and vulvovaginitis

Gonorrheal infection is generally limited to superficial mucosal surfaces lined with columnar epithelium. The areas most frequently involved are the cervix, urethra, rectum, pharynx, and conjunctiva. 

Evaluation of Pseudophakia

Clinical evaluation of a case of Pseudophakia.

Pseudophakia is a term used to describe the condition wherein an artificial intraocular lens is implanted after surgery for cataract.

On history - History of cataract surgery present.

On examination -

1) Deep Anterior Chamber (the posterior support for the iris is lost as the IOLs are thinner that the natural lens)
2) Conjunctival flap and subconjunctival hemorrhage ( seen only in recent cases)
3) Scleral/ Corneal incision and scar.
4) Iridodonesis (tremulous iris)
5) Jet black pupil
6) Shimmering light reflex from the IOL.

Oculocardiac Reflex

Oculocardiac Reflex/Aschner phenomenon.

This is one of the trigeminovagal reflexes produced on digital massage of eye. Digital massaging of the eyeball is done to lower intraocular pressure after producing a retrobulbar or a peribulbar block. But rarely....this event is followed by cardiac depression, asystole and even death. The afferent is by the ophthalmic division of trigeminal nerve which relays in the visceral motor nucleus of the vagus nerve. The efferent is carried by the parasympathetic vagus nerve to the heart. It is most commonly seen in pediatric cases during squint surgery.
It is not seen very commonly in adults and in other surgeries as the procedure would involve just one eye and massaging of this eye is not sufficient to produce bradycardia normally.

Treatment: atropine or glycopyrrolate . Cardiopulmonary resuscitation might be needed in severe cases.

Bulbar and Psuedobulbar palsy : Overview

Here's a short overview of Bulbar and Pseudobulbar palsy !

If there is a lesion is at the level of Medulla - affecting the motor neurons : The nuclei of the cranial nerves -  you get LMN Palsy features - Flaccid paralysis of 9 10 11 12 Cranial nerves. This is called a 'Bulbar palsy' as the bulb (Medulla) is involved in isolation.

Now , essentially when the fibres supplying the motor neurons of the bulb (your Medulla)  are affected themselves - that is any neurons above the nucleus of the nerve - it's a UMN lesion. So you get 9 10 11 12 UMN palsy - Spastic paralysis.
This would be Pseudo-bulbar as same CN involved but lesion is above the Medulla

So Pseudobulbar you'd have a hyper active gag reflex while it'll be absent in Bulbar.(Mediated by 9th cranial nerve).

You'd have a Hot potato like speech in Pseudobulbar as your vocal muscles of larynx and tongue are spastic. - (10th and Cranial 11th. )

While you'd see a nasal twang in Bulbar (also called Donald duck speech)
As your soft palate doesn't abut against the nasal cavity (due to LMN flaccid paralysis). Also causing nasal Regurgitation of food in Bulbar.

So they both essentially present with 9 10 features and some of the 11 12. Hence one is Pseudo and the other is true Bulbar.

Psuedobulbar would also have emotional problems. Called Pseudobulbar affect (as the higher fibres are involved - lesions are generally multiple infarcts in the cortex).

A few important causes : 

Psuedobulbar palsy :

- Vascular = B/L Frontal lobe lesion , B/L Pontine stroke , Vascular dementia = Multi infarct dementia.

- Central Pontine Myelinolysis

- Degenerative = Multiple sclerosis  , Motor neuron disease

- Cerebral Palsy

_________________________________
Bulbar palsy :

- Guillian Barre Syndrome

- Polio

- Motor neuron Disease

- B/L Medullary infarction

Hoping this helped !
Happy studying guys !
And stay awesome !!

~ A.P.Burkholderia.

Myopathies series - Part 1

Hello :)

Before starting with the series, I will post on the basics you need to know for myopathies.

Q. What do you mean by muscular dystrophy and myopathy?

A. I found that following definition from Harrison is simple.

Skeletal muscle disease myopathies, are disorder with structural changes or functional impairment of muscle.

Muscular dystrophy refers to a group of hereditary progressive diseases with unique phenotypic and genetic features.

Do you know glycogen storage diseases?

Yes! But why do you need to mention it here? Because, skeletal muscles are the store house of glycogen. It gets converted into glucose-6-phosphate (Note:- Never in glucose unlike liver. Why? Otherwise glucose will move out from the myocyte to blood. And myocytes will fail to utilize their own stored glycogen. That is why muscle lack an enzyme called glucose-6-phosphatase.)

There are some glycogen storage disease which will lead to myopathies.

For now remember that myopathies have different way of presentation. 

Muscle weakness is one of the clinical feature.

The muscle weakness can either be 1. Intermittent or 2. Persistent.

If there is energy deficiency in muscle, it will become weak.

Today, we are focusing mainly on skeletal muscle energy metabolism.

Glycogen storage disease are described in the Roman numerals. Not all glycogen storage disease lead to myopathies. Some glycogen storage disease lead to myopathies is mentioned in the diagram.

 More is coming up.:) 

-Upasana Y.  

Pathophysiology of laboratory findings in tumor lysis syndrome

Which of the following electrolysi abnormalities will you see in tumor lysis syndrome?
Answer either high, normal or low for each of these - calcium, phosphate, potassium, uric acid.

Answers:
Labs in tumor lysis syndrome -
Hypocalcemia 
Hyperuricemia
Hyperphosphatemia
Hyperkalemia

Why?

When cancer cells lyse, they release potassium, phosphorus, and nucleic acids, which are metabolized into hypoxanthine, then xanthine, and finally uric acid. 

This leads to:

Hyperkalemia can cause serious — and occasionally fatal — dysrhythmias.

Hyperphosphatemia can cause secondary hypocalcemia, leading to neuromuscular irritability (tetany), dysrhythmia, and seizure, and can also precipitate as calcium phosphate crystals in various organs (e.g., the kidneys, where these crystals can cause acute kidney injury).

Uric acid can induce acute kidney injury not only by intrarenal crystallization but also by crystal-independent mechanisms, such as renal vaso-constriction, impaired autoregulation, decreased renal blood flow, oxidation, and inflammation.

Crystal-induced tissue injury occurs in the tumor lysis syndrome when calcium phosphate, uric acid, and xanthine precipitate in renal tubules and cause inflammation and obstruction.

That's all!

-IkaN

Causes of microcytic erythrocytosis

A high RBC count combined with a low mean volume is seen in:

1. Thalassemia minor, either alpha or beta
2. Polycythemia vera with iron deficiency
3. Secondary polycythemia (hypoxia) with incidental iron deficiency.

Differentiating thalassemia minor from polycythemia vera:

The RBC size distribution curves reliably distinguish between thalassemia minor and polycythemia with iron deficiency.

RDW is elevated in iron deficiency. It is normal in thalassemia minor.

That's all!

-IkaN

Type 2 RTA pathophysiology, notes and mnemonic

Hello! This post is on type 2 renal tubular acidosis.

What causes Type 2 RTA?
Defect in proximal bicarbonate reabsorption - resulting in a hypokalemic hyperchloremic metabolic acidosis.

The defect in proximal reabsorption of filtered HCO3-  in effect leads to decreased proximal NaCl reabsorption and a tendency for salt wasting. This causes hyperaldosteronism -  leading to increased K secretion by the distal nephrons.

Staphylococcal Scalded Skin Syndrome vs Bullous Impetigo

How do you differentiate Staphylococcal Scalded Skin Syndrome (SSSS) from Bullous Impetigo (BI)?

The exfoliative toxins are restricted to the area of infection in BI. In SSSS, infection is diffuse.

In BI, bacteria can be cultured from the blister contents. Cultures from blisters are negative in SSSS.

Blood cultures are usually negative in SSSS (positive in BI).

In SSSS, Nikolsky sign is positive. It is negative in BI.

In BI, patients are usually not ill appearing.

That's all!
-IkaN

Pills of knowledge in Ophthalm- squint and frontal eye field

Mentally challenged people may have a squint as the frontal eye field in the brain cortex is involved in ocular movements as well. It also may explain why somebody's eyes go crazy when they're starting into nothingness.

That's all!

-Sushrut Dongargaonkar

Settings for mechanical ventilation

These are my quick and dirty notes to help ventilator settings related questions on the USMLE.

Treponemal and nontreponemal tests for syphilis (notes + mnemonic)

Nontreponemal tests include:

Rapid plasma reagin (RPR)
Venereal Disease Research Laboratory (VDRL)
Toluidine Red Unheated Serum Test (TRUST) 

Mnemonic:
Do not trust VDRL rapidly.

Features of non treponemal tests:

They are based upon the reactivity of serum from infected patients to a cardiolipin-cholesterol-lecithin antigen. 

Used for initial syphilis screening due to their relatively low cost, ease of performance, and ability to be quantified for the purpose of following response to therapy.

Specific treponemal tests include:

Fluorescent treponemal antibody absorption (FTA-ABS)
Microhemagglutination test for antibodies to T. pallidum (MHA-TP)
T. pallidum particle agglutination assay (TPPA)
T. pallidum enzyme immunoassay (TP-EIA)
Chemiluminescence immunoassay (CIA)

Features of treponemal tests:

Treponemal tests have been more complex and expensive to perform than nontreponemal tests. Thus, they have traditionally been used as confirmatory tests for syphilis when the nontreponemal tests are reactive.

Treponemal tests are qualitative only and are reported as "reactive" or "nonreactive" 

Once a patient has a positive treponemal test, this test usually remains positive for life. Thus, these tests are generally not useful for confirming a diagnosis of syphilis in a patient with prior treated disease.

That's all!
-IkaN

Postural variations in pulmonary edema and embolism

Hey Awesomites

Patients with pulmonary edema prefer to be in an upright position, while those with pulmonary embolism prefer flat position.


This is because in cases of edema, there is excess fluid accumulation in lungs, which limits respiratory movements. In upright position, the fluid will settle down and thus it lowers the pressure in pulmonary vessels which makes it easier to breathe.

On the other hand, in case of pulmonary embolism, the patient  is placed in left lateral decubitus (durant maneouver) and Trendelenburg position immediately. The air embolus moves through the right side of heart to enter into the lungs. But in Durant's maneouvre and Trendelenburg position, the embolus gets trapped in the apex of the heart and so does not get transported through pulm arteries to enter the lungs.
Check this link for more detail on venous emboli management


Thats all
- Jaskunwar Singh

New drug launched for Sickle Cell Disease

Heyy guys, I have taken this post from Medscape. Nonetheless, awareness about this new drug should be spread.

The US Food and Drug Administration (FDA) has approved L-glutamine oral powder (Endari, Emmaus Medical Inc) to reduce severe complications of sickle cell disease in patients aged 5 years and older with the disorder. This is the first approval for the rare disorder in almost 20 years.

"Endari is the first treatment approved for patients with sickle cell disease in almost 20 years," Richard Pazdur, MD, acting director of the Office of Hematology and Oncology Products in the FDA's Center for Drug Evaluation and Research and director of the FDA's Oncology Center of Excellence, said in an FDA news release. "Until now, only one other drug was approved for patients living with this serious, debilitating condition."

The decision follows consideration of data from a randomized trial of patients aged 5 to 58 years who had suffered two or more sickle cell pain crises within the 12 months before enrollment in the trial. The researchers randomly assigned patients to receive L-glutamine or placebo. Treatment was evaluated during a 48-week period.

Those who received L-glutamine experienced fewer hospital visits for pain crises that resulted in treatment with parenteral narcotics or ketorolac, on average, compared with those who received placebo (median three vs median four), fewer sickle cell pain hospitalizations (median two vs median three), and fewer hospitalized days (median 6.5 days vs median 11 days).

Those who were given L-glutamine also experienced fewer episodes of acute chest syndrome — a life-threatening sickle cell disease complication — compared with those who were given placebo (8.6% vs 23.1%).

Frequent adverse events include constipation, nausea, headache, abdominal pain, cough, extremity pain, back pain, and chest pain.

L-glutamine received orphan drug designation for sickle cell disease. The FDA's Office of Orphan Products Development (OOPD) is intended to incentivize the development of drugs for rare diseases. Development of this drug was supported in part by the OOPD Grants Program, which provides grants to conduct clinical studies on safety and effectiveness of treatments for rare diseases or conditions.

Approximately 100,000 people in the United States have sickle cell disease, according to the National Institutes of Health. The disease primarily affects African Americans, Latinos, and other minority groups. The average life expectancy for those with sickle cell disease in the United States is 40 to 60 years.

-VM

Parkinson's disease associated with melanoma: Research update

Hey Awesomites

Patients with movement disorder such as the Parkinson's are at four-fold higher risk for malignant melanoma, and vice versa. This is likely due to mutual genetic, environmental and pathogenic ( immune system ) abnormalities and factors that they both share, as suggested by a research study at Mayo clinic.
( Source )

- Jaskunwar Singh

Causes of dilated cardiomyopathy mnemonic

Hi awesomites!

Here's a short note on causes Dilated cardiomyopathy.

It's mostly idiopathic.

Other causes are:

1. G enetic Mutation
2. Myocarditis

3.  Alcohol  abuse
4.  Drugs
5.  Pregnancy
6.  Hemochromatosis

Mnemonic.  GMM ADPH

That's all :)
 
H@Mid

Why do newborns have a higher heart rate?

Hey guys!

Have y'll ever wondered why do babies have heart rates as high as 160s?

Answer:
Babies have a high proportion of Body Surface Area to heart than that in adults. Therefore, in order to maintain adequate blood flow, baby's "li'l heart" has to pump more often to cover the "large Body Surface Area"!

I hope y'll find this interesting!

Till then, stay awesome!

-Rippie

Nasal Encephalocele vs Nasal Glioma

Both nasal encephalocele and nasal gliomas are congenital conditions in which there is herniation of glial tissues and meninges into the nasal cavity through the foramen cecum.

Both the masses are seen in the nasal cavity as bluish masses with nasal obstruction.

Nasal gliomas have no communication to the brain as the communication gets detached after the fusion of cranial bones in late IUL. Gliomas are firm and non compressible mass.

Encephalocele also presents as nasal mass with obstruction. The swelling increases in size in response to coughing. Most common site is occipital and then frontal.

Bilateral compression of the internal jugular vein also leads to the increase in the size of mass called as Frustenberg Test.
Frustenberg test is positive in encephalocele and negative in gliomas.

Investigation of choice for both is MRI.

Hope this helps!
Ashita Kohli