Depression: A Summary

Hey guys! Here’s a review of Major Depressive Disorder using a whiteboard as help.

Depression is a type of mood disorder with primary disturbance in internal emotional state causing subjective distress and socio-occupational dysfunction.

Learned helplessness is when the individual learns that he/she is helpless in situations where there is a presence of aversive stimuli, has accepted that there’s no control over it, and thus gives up trying.

CLINICAL FEATURES:

The classic mnemonic goes as-

• Depressed mood: Can show diurnal variation. Patient reported. Essential for diagnosis.
• Sleep disturbance: Patients have decreased slow wave sleep duration and R.E.M. latency while having increased total R.E.M. duration with early R.E.M. onset in sleep cycle.
• Interest loss or anhedonia: Inability to attain pleasure from almost any activity. Patient reported. Essential for diagnosis.
• Guilty: Patients have feelings of worthlessness or sin for events they have little or no role in/ control of.
• Energy loss or fatigue
• Concentration difficulties: Usually accompanied with indecisiveness.
• Appetite and weight changes: Can increases or decrease. Usually, there’s a loss of body weight by 5% or more, associated with GI complaints of constipation, dyspepsia etc.
• Psychomotor changes: Retardation or agitation.
• Suicidal ideations: Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide.

MANAGEMENT:

1st line-

Psychotherapy: Cognitive Behavioural Therapy, Problem Solving Therapy, Emotions Focused Therapy and Behavioural Activation etc.

Selective Serotonin Reuptake Inhibitors: Fluoxetine, Paroxetine, Fluvoxamine, Escitalopram and Sertraline.

2nd line-

Serotonin/ Norepinephrine Reuptake Inhibitors: Duloxetine, Venlafaxine, Desvenlafaxine.

Tricyclic Antidepressants: Amitriptyline, Nortriptyline, Clomipramine, Desipramine and Imipramine.

Monoamine Oxidase Inhibitors: Tranylcypromine, Phenelzine, Isocarboxazid, Selegiline.

Atypical antidepressants: Bupropion, Trazodone, Mirtazapine.

Last line-

Electroconvulsive therapy is reserved for:

-Need for a rapid antidepressant reponse

-Failure of drug therapies

-History of good response to ECT

-High risk of suicide

-High risk of medical morbidity and mortality

Further reading:

Normal vs. abnormal grief reaction

Cyclothymia vs Dysthymia

Types of psychotherapy

Hope this helps. Happy studying!

--Ashish Singh

USMLE Mentorship

Hey there. How's it going? So I had this idea of compartmentalizing mentorship for different phases of USMLE.

Normally, what happens is a person asks questions which aren't very specific to a particular phase, and ends up annoying the opposite person.

So what if we divide usmle into 3 steps as they already are, also about paper work, electives, observerships, lodging boarding in different parts of USA, and make a list of people  specific to each step who want to help and provide mentorship. This way many people who are looking to give back to this process, have a chance of passing on the kindness.

So if you are done with any of the steps or want to provide mentorship for any of the things listed above, or have a thing that should be added to the list, send us your name and which part of the process you would like to help with. This way there can be more focused distribution of knowledge and mentorship.

People willing to help, send us your details. If we have enough people willing to volunteer, we can grow this thing into something really helpful. Depending on the number of  responses of volunteers, we will take this thing forward.

Leave your ideas and suggestions, if you have any. Thanks for reading.

If you are willing to help - email me at medicowesome@gmail.com with "USMLE Mentor" in the subject.

If you have IkaNs number on Whatsapp, contact her.

Varicose Veins : Overview

Varicose Vein

Hello Awesomites!
Through this post I'm trying to share the high yielding points on Varicose Veins.

VARICOSE VEINS
Primary:
Congenital absence or incompetence of valves
Inheritance with FOXC2 gene
Klippel-Trenuanay syndrome
Congenital AV fistula
Cutaneous hemangiomas
Hypertrophy of involved limb
Absence of deep venous system

Secondary:
Recurrent thrombophlebitis
Occupational – prolonged standing
Obstruction to venous return –abdominal tumors, retroperitoneal mass, Pregnancy.
Iliac vein thrombosis

Clinical features

Lipodermatosclerosis (brawny induration), pigmentation, thickening, chronic inflammation and induration of skin in calf muscle and around ankle.

Brodie-Trendelenburg test
To assess the competence of SFJ
Patient lies flat, elevate the leg and gently empty the veins, palpate the SFJ and ask the patient to stand whilst maintaining pressure. If the veins do not refill- SFJ is incompetent. If the veins do refill SFJ may or may not be incompetent, presence of distal incompetent perforators.

Cough impulse (Morrisey's test)
Locate the saphenofemoral junction(2-4 cm inferolateral to pubic tubercle) and ask the patient to cough. Impulse or fluid thrill felt indicates saphenofemoral incompetence.

Modified Perthes Test:Ask the patient to stand and tourniquet is applied at SF junction and ask to walk. Superficial veins become prominent – indicate deep vein thrombosis.

Three tourniquet test - To find the site of incompetent perforator
Tourniquets at SFJ, above knee level, below knee level.

Fegan's test:Detect the perforators

Investigations:
Duplex Ultrasound imaging – gold standard
Doppler examination – only when duplex is not available
Phlebography – not needed in primary venous insufficiency. Only performed as preoperative adjuncts when deep venous reconstruction is being planned
Ascending phlebography – differentiates primary from secondary insufficiency
Descending phlebography - identifies specific valvular incompetence suspected on B mode scanning.

Medical treatment:
Calcium dobesilate
Diosmin
Hesperidin
Toxerutin

Surgical management:
Trendelenburg's operation (juxta femoral flush ligation + stripping the varicose vein) for SFJ incompetency

Subfacial ligation of Cockett and Dodd :perforator incompetence with SF competency

VNUS closure(ablation catheter introduced into the SF junction and slowly withdrawn)

TRIVEX – veins identified by subcutaneous illumination; injection of fluid & superficial veins are sucked

Endo venous laser ablation (EVLA)

Sclerotherapy

That's all. Thank you.

-MD Mobarak Hussain (Maahii)

Hutchinson in Medicine

Here's a summary of the important Hutchinson's in medicine!

1. Hutchinson Teeth 
Seen in -  Congenital Syphilis
Feature -  Peg shaped Incisors , Widely spaced and smaller teeth.
Associations - Mulberry Molars : Multi-cusped Molars.

2. Hutchinson Sign of the Nail
Seen in -  Subungual Melanoma
Feature -  Melano-nychia ( Black colored nail) , feature of a melanoma below the nail plate.

3. Pseudo Hutchinson Sign of the Nail
Seen in -  Melanocytic be of nail bed
Feature -  Melano-nychia like appearance.

4. Hutchinson sign
Seen in -  Varicella Zoster infection
Feature -  Vesicle at the tip of the nose - indicative of Zoster infection. May precede Herpes Zoster Ophthalmicus.

5. Hutchinson Triad
Seen in -  Congenital Syphilis
Feature -  Hutchinson teeth + Interstitial keratitis + Sensorineural Hearing loss.

6. Hutchinson Patch
Seen in -  Syphilitic Keratitis
Feature -  Salmon patch on the cornea

7. Hutchinson Mask
Seen in -  Tabes Dorsalis, Neurosyphilis
Feature -  Mask like sensation over the face due to involvement of trigeminal.

8. Hutchinson  Pupil
Seen in -  Raised Intracranial tension especially due to a mass.
Feature -  Pupil dilated and unreactive to light due to 3rd cranial nerve compression.

Those are all the Hutchinson I can think of !
Let me know if you got any more.
Happy Studying!
Stay Awesome !

Growth Rates in Dermatology

Hi everyone. My skin Lecturer just taught me this so I thought let's post this =)

So growth rates !
We need to know 3 of them - Hair , Finger nails and Toe Nails.

Hair is the fastest growing.
So remember just one number for it - 0.37 mm/day.

Now , next fastest is finger nails.
For this divide by 3.
0.12 so 0.1 mm / day is finger nails.

Now divide this by 3 to get the value for Toe nails.
So 0.03 mm/ day is for Toe nails !

That's all for this post !
Stay awesome !
Happy Studying !
~ A.P.Burkholderia

MIL : Tinea (Dermatophytosis)

Hi everyone ! 
This is my 2nd MIL! Hope it's illustrative and informative ! 

(Click on the image to see it in Full View). 

Description : 

This is an Image of Tinea Corporis (Ringworm) infection of the skin. 

Notice - the lesion is annular in shape , has a ring like appearance. 

The lesion seems to be erythematous and  elevated (papular) towards its outside, and shows central area of clearing. 

This is classic of Tinea! 

Tinea is actually a fungal infection caused by Dermatophytes. 

____________________________

Clinical Features -

- Include such a lesion over different body parts which are severely itchy. 

- Occur particularly in summers.

Tinea Corporis = Tinea infection occuring over the body. 

Some common forms are - 

Tinea Cruris = Tinea Infection in the groin area (Jock itch).

Tinea Glutealis = Tinea along the natal cleft and towards the Gluteal regions. 

Tinea Pedis = Athelete's foot, occuring in the feet. 

Tinea Capitis = Scalp and hair. 

- Predisposed to get this in areas of constant sweat and moisture. 

Hence dryness is very important to maintain. 

____________________________ 

Ix : 

Usually a clinical diagnosis. 

Differentiate from Psoriasis : Lesions are not clear centrally ; there are plaques with Scales in Psoriasis and there maybe history of pin point bleeders.

Can confirm using Biopsy / Analysis of skin scraping and obtaining a species specific diagnosis. 

____________________________

Rx : 

A. Topical Anti fungals 

- Resistance is rampant. 

- Most promising ones are Luliconazole and Terbinafine creams.

- Can try Clotrimazole and Ketoconazole Shampoo for the site of lesion.

B. Oral Anti fungals 

- Itraconazole is a wonderful drug , dose being 5mg/kg / day. Roughly 100 mg twice a day is good enough. 

- Griseofulvin was an option but resistance seen now.

C. Anti histaminic for allergy. 

D. Duration of Rx is almost 2-3 months. It's a hard fungus to kill..

E. Steroids not to be used strictly. ( I've seen some horrendous results where the whole body was covered with Tinea when the patient stopped applying the steroids. Best to avoid them as per clinical as well as literature review). 

Hope this was helpful! 

Happy studying ! 

Stay Awesome ! 

~ A.P.Burkholderia 

Being street-smart during interviews: Buses!

Match season is a a really unique life-time experience. You will travel for interviews, meet new friends, visit states you have never visited before and of course, spend some money.

Although flights in general are the fastest most-convenient way to travel, you may try “bus inter-state travelling” which is much cheaper than taking a flight.

I will briefly write about some bus companies that are there and their pros and cons:

Greyhound:

Pros:
> It covers most of the states in the US.
> they have stations where you can sit and wait in (which is very important especially during Winter when it is freezing and snow is everywhere!).
> Starting from late 2017, you can use an E-ticket (emailed to you) instead of a printed ticket.
> They have nice discounts up to 50% sometimes, be sure to sign in and check their website for promo codes especially on Thanksgiving, Black Friday, New Year’s Eve.
(If you are planning to travel in January, don’t rush and buy the ticket early)

Cons:
> in general, their prices are more expensive than other bus companies.
> slow wifi (sometimes non-existent :D).
> Be careful around the stations especially at night, stay indoors!
> If you buy the ticket using a visa card with a different card-holder name than your’s, they will charge you an extra 18 dollars :( .
> Some passengers may be really weird.

If you miss your trip, you will be charged 20$ to issue a new ticket and catch the next one.

Megabus:

Pros:
> Cheaper and can be as cheap as 1 dollar! Check their website regularly.
> E-tickets are available too.
> Buses are newer and more comfortable.
> Passengers are “less weird”.

Cons:
> less state coverage than Greyhound.
> No stations, you have to wait in the street which can be very bard especially if it is raining heavily or snowing.

You can change your trip (if more than 3 hours left till departure) after paying a fee of 20 dollars. This is good to avoid losing your money if you had to cancel your scheduled trip for any reason.


Bustogo:
Less state coverage but they have a nice feature which is using the ticket within a year of purchasing it.

This is based on a personal experience, so you are welcome to try anything you want and put in mind that delays may occur here or there especially with bad weather.


Before you travel to any state, check this website: http://www.smartmedtravel.com/
It will show you names of buses and trains that are available in that state in addition to airports and car rental options.

Wishing y’all a successful Match/interview season and safe travels :D

-Murad

Mixed Connective Tissue Disease : An Overview

Hi everyone ! Just a short post reviewing MCTD! References are Harrison's and Medscape!

Mixed Connective Tissue Disease (MCTD)

1. What is it ?
- It's a somewhat ambiguously used term for disease characterised by a collection of few symptoms from different autoimmune connective tissue disorders.

- Namely , features of Systemic Sclerosis (SSc) , Lupus , Myositis and sometimes RA are present in some proportion in the same patient.
________________________________________
2. What are its chief presenting features ?

A. Features of SSc :
- Raynaud's is often the presenting feature. May also get edematous fingers.
- Dactylitis and digital gangrenes may be + due to Raynaud's
- Sclerodactyly
- Other Limited Cutaneous SSc features like CREST.

B. Features of Lupus :
- Arthritis
- Photosensitivity and Malar rash
- Evidence of Anti phospholipid Antibody Syndrome - associated with SLE. 

C. Features of Myositis :
- Proximal myopathy features
- Muscle tenderness
- May get Cutaneous features of Dermatomyositis.

Also may have Pulmonary Hypertension, Pulmonary Fibrosis.
________________________________________
3. What are the criteria for diagnosis ?

• Immunologically = Anti U1 RNP +

• Clinically = ( any 3 )

Mnemonic = A REM Sleep

Acrosclerosis
Raynaud's
Edematous Hands
Myositis (proven)
Synovitis-Arthritis

________________________________________
4. When to suspect MCTD?
- When a Patient comes with features of Limited Scleroderma (Raynaud's) , but not enough to fulfill its criteria ;

- SSc specific antibodies are not generally positive. (Anti Histone or Topoisomerase) ;

- Suspected SSc patients with  unusually prominent features of Arthritis, Muscle Pain or Rash

________________________________________
5.What tests would one order if suspecting MCTD ?

A. CBC with ESR -
May see Leucopenia with fairly elevated ESR

B. Serology -

• Confirm absence of SSc - Anti Centromere and Anti Topoisomerase.

• For MCTD -
U1 RNP Ab's are fairly specific

• For Myositis -
Anti Jo Ab's (Especially polymyositis)
Anti Mi Ab's (Especially Dermatomyositis)

• For Lupus -
ANA
Complement levels.

• For RA -
Anti CCP Ab's

C. Blood profile -
• Creatine Kinase - Elevated in Myositis
• Urine Routine + Microscopy for Lupus Nephritis type changes
• Electrolytes

D. For Complications -
• Chest X Ray for any ILD or fibrosis
• HRCT if needed.
• Pulmonary Function Tests
• MRI Brain for multi infarct lesions if APLA is + and if neurological changes are +
• ECG - For myocarditis
________________________________________
6. How is the treatment like ?

- NSAIDs - Symptomatic Relief.
- Steroids confer some Relief unlike in SSc. So it's important to differentiate the two!
- Hydroxy chloroquine and Methotrexate may be used to keep disease activity in check.
- Treatment of complications.

Hope this was helpful!
Happy Studying!
Stay Awesome!

~ A.P.Burkholderia

What if I don't Match?

The 12th of March has arrived and what you didn't see coming has unfortunately happened. You checked your email to find an email from NRMP saying: "You did not match". Life suddenly became unbearable and an infinite tornado of thoughts and questions has started! The main one though is: "What to do now?"

Below are some suggestions that may help in answering this question:

 1- Give yourself some time

 > Give yourself the time needed to sink the truth in, yes, not matching is harsh, depressing and soul-crushing. Vent to your friends and cry your lungs out if you feel this will make you feel better.

 > Not matching is hard, but be completely sure, this is not the end of the world, look back at what you achieved till now, you finished medschool, sat for USMLEs, traveled for interviews. You achieved what may be impossible for many others!

 > Check NRMP stats that are released after the Match day, you are not alone, consider this a temporary stop in your life and a chance to build your CV and know more people. Consider it also a test and a challenge that will push your forward to overcome it! The ranking process itself is complicated and is affected by a myriad number of factors so don’t blame yourself and when you feel you are ready, start developing your plan!

2- Polish your CV

 > Sit with a senior/friend/attending and ask him/her how to make your CV better.
Are there any awards or honors that you haven’t mentioned? Any volunteering work that you didn’t add? Can you describe what you did in your previous work experiences in a better way? Are you a member of any international medical organization and you forgot to mention that?

 > You can also review the chapter about writing CVs in “The Successful Match” book which gives many hints about improving your CV. For example, it is advised to use “the action verbs” like “managed” instead of “helped”. The book is available on Amazon, Ebay and many other websites.

 3- Revise/Review your whole application

 In addition to polishing/revising your CV, be sure to check every single component of your application:

 > Did you apply late? Apply earlier this year
> Was one of your letter of recommendations (LoRs) generic or weak? Try to get a new stronger one by asking more people or doing more rotations.
> Did you apply to enough programs? Think of applying to more programs
> Do u qualify for the programs you applied to? Above their cut-offs..etc? Double-check that

 Don’t hesitate to ask seniors or any experienced person who may help.

 4- Taking USMLE Step 3 (if not taken yet)

 > There are many merits of taking USMLE step 3 including the possibility of being ranked higher, an opportunity to have an H1B visa (if you are a non-US International Medical Graduate) and more focus on your residency.

 > A good score in Step 3 also helps if you have any red flag in your application like an exam attempt. It may also decrease the impact of low scores in the USMLE exams and of course it is something nice to add to your CV and show that your are progressing.

 5- Research

 > Research can strengthen your CV and open the doors for more interviews especially from University programs. It can also let you meet new people who may be your contacts in the next match. Some people matched in famous hospitals after doing research there for “a period of time (as short as few months up to few years).

 > Look for research positions either by asking friends/seniors or by emailing institutions like MGH, Mayoclinic...etc. Another way is via websites like indeed.com, some research opportunities are publicized via Linkedin, so it is advisable to have a neat account there and follow the accounts of major institutions. Linkedin may suggest jobs based on your geographic location too.

> When you apply for research,  check the mentor’s/PI’s name on Pubmed. It is better to join people who are more active and publish faster. A good time to start looking for a research position is about a month or a bit more before the match results. Many researchers who are doing their post-doc fellowships leave their positions after they match so if you know anyone who is doing his/her post-doc fellowship, be sure to contact him/her.

 6- More United States Clinical Experience? (USCE)

>Consider doing more rotations whether observerships or externships. This may allow you to apply to more programs that require a certain number of US clinical training months to be eligible.

 >Through rotations, you may get stronger recommendation letters, make new contacts or may even impress and match in the same program in which you are rotating!

 7- Contacts

 > A contact is any human being who can help you! A contact can be a friend, an intern, a chief resident, an attending, a research fellow and even the PD himself/herself...simply anyone!

 > This is one of the most important things that you have to work on before your next match cycle. Whether you are in a rotation or in a research lab, approach politely and ask for help, people out there are good and are willing to help.

 8- Motivation

 > Develop a habit of being motivated, surround yourself with positive people who always encourage you.Watch motivational videos - Eric Thomas has nice ones, check them - on youtube.

 > Talk to residents who didn’t match the first time they applied and see how successful they became now. This happened because of one thing: they worked hard and never gave up!


 Finally, I wish you all the best of luck and I remind you with what Steve Jobs once said: "You can't connect the dots looking forward; you can only connect them looking backwards, so you have to trust that the dots will somehow connect in your future"

 -Murad

My USMLE Step 2 CK Experience (241)

I would like to thank everyone who I met during this journey from all over the world, Thank you everyone!

Sources used for studying:

> MTB step 2 for IM
> MTB step 3 for other subjects
> Uworld
> Uworld biostat review
> Kaplan step 2 patient safety chapter
> Conrad fischer 100 ethics cases
> Uptodate (only looking for details if needed)
> +/- kaplan epidemiology part for step 2 (for biostats)
> CMS
> NBME 4 6 7 and UWSA1

Method of studying:

>Did a fast read of MTBs then started UW offline systemically with taking notes using Anki flashcards program.
>Did UW online systemically in tutor mode  with marking difficult/incorrect questions and writing any new notes that are not in the offline version.
(if you feel you have a problem with time management, do more timed mode blocks)
>Did marked questions in random timed mode
>Revised whole notes in 2-3 weeks
>Solved CMS blocks ( good for introducing some new ideas and practicing more questions)
>Did NBME 4, 6 then 7 ..and did UWSA1 ( scores ranged between high 230s and high 240s...the real score was 241
>When I did the exam, NBME 8 and UWSA2 were not released, so it is better to do those too, and NBME4 can be done offline if needed.

Subjects:
Always check UW diagrams/tables before studying the chapter from MTB

>Peds: 
UW is really solid in Peds and covers most if not all the needed concepts in the exam.

>Surg:
UW ...surgery doesn’t constitute a big chunk of the exam, so I felt UW was more than enough for it

>IM:
Also MTB + UW

>Obgyn:
Please check uw tables and diagrams for Obgyn before studying MTB and compare between the two..sometimes there are differences and UW is always the correct one. You don’t want to memorize the info wrong first then correct it again.
So UW tables hand in hand with MTB then UW.
Kaplan vids for Obgyn may be used if needed.
==
-No comprehensive book for CK like First Aid for Step1 but It is an exam that tests your concepts and the more questions you do the more confident you ll feel.
(In my opinion, Kaplan qbank in step 2 is not needed and may confuse you!)

- It is advised to leave long abstract and drug ad questions till the end because they need time to be solved

- I did CK before step1, some people argue against this. Regardless of what you do first, any step that you will do first will help in the next step ( 2 before 1 or 1 before 2)

Good luck :)

-Murad

Koebner Phenomenon

Hi everyone!
Koebner Phenomonon is a much talked about skin phenomenon.
In this post I'll just discuss Koebner's and its variants briefly.

1. What is it ?
- Many skin conditions tend to occur at the sites of previous trauma.
- This propensity of some new disease to be localised to trauma marks from before is called Koebner's. 
- Also called ' Isomorphic Phenomonon'.

2. Why does it occur ?
- So that's kind of unclear ! But it is said that trauma causes some amount of Subacute inflammation.
- This Subacute inflammation is mainly IL1 and 17 mediated.
- Such an inflammatory condition predisposes the site to further Autoimmune damage.

3. Conditions where Koebner Occurs ?

Mnemonic :
Truly , she Pees Very Little.

True Koebner seen in
Psoriasis
Vitiligo
Lichen Planus

4.  What is Pseudo Koebner's  ?
- Now the basis of true Koebner is that on a site for existing trauma, a new autoimmune lesion appears.
- When the trauma site gets secondarily seeded by some organism causing lesions along its line it's called 'Pseudo Koebner's phenomena'.
Examples =
Molluscum contagiosum
Verruca Vulgaris ( Warts).

5. What is Reverse Koebner ?
- When a lesion along a trauma line gets resolved spontaneously it's called Reverse Koebner.
- Seen in Psoriasis and Granuloma Annulare.

6. What is Reverse Remote Koebner ?
- (isn't that about enough with this topic now?! Are they kidding us with this?)
- So it's seen in Vitiligo. When one patch undergoes resolution with surgery etc , patches elsewhere get resolved too. (God knows what this means , but yeah. *yawns* )

7. What is Pathergy test ?
- So this is a somewhat similar reaction.
- In people with Behcet Disease, if they're poked on their forearm with a needle , they tend to develop pustules and ulcers over it.! It's almost diagnostic of Behcet's.

So, that's all in this post !
Hope this was helpful.
Happy Studying!
Stay awesome!

~ A.P.Burkholderia.

Renal Causes of Hypertension : A Summary

Hypertension in a young individual needs specific evaluation to rule out Non Essential Hypertension (Secondary Hypertension). The Most Common cause of this is Renal Hypertension.

Renal causes of Hypertension can be summarized as follows  -

A. Reno-vascular ( Atherosclerotic/ Fibromuscular Dysplasia - FMD)
(Uncommon = Vasculitis , AV Malformation)

B. Parenchymal Renal Diseases like Glomerulonephritis.

Typical Presentations :

• FMD =
- A young 20-30 year old female , with Hypertension and possibly asymmetrical pressures in both limbs, and associated with a Renal Artery bruit.

- Typically have history of some form of Cranial vessel involvement in the form of Strokes in a Young Female , TIA's , other transient neurological phenomena.

- Carotidynia may be + (Due to carotid dissection).

- Ix =  Rule out Atherosclerosis;
Angiography -  String of beads appearance.

- Rx = Anti Platelets , Anti HT .
May need Endovascular clot treatment.
________________________________________

• GN = 
- A 10-25 year old male or female with cola colored urine , fever and periorbital puffiness. Older adults may have more atypical features like Hypertensive Encephalopathy and may develop Uremia.

- H/O antecedent Streptococcal infection - 3-4 weeks prior.

- Ix - Urine report shows Hematuria, RBC Casts and Nephritic range proteinuria.
Renal profile and Urine output to be done and monitored regularly.
Get ASO titers for previous strep infection.

- Rx - Symptomatic. IV fluids.
May need Renal Replacement if Uremia sets in.
________________________________________

In Addition to routine , the extra Investigations to rule out Renal cause in a young patient with Hypertension -

1. Urine Routine and Microscopy
( Look for Hematuria,  RBC Casts, dysmorphic RBCs )

2. Renal Function Testing -
( Look for rise in S. Creatinine, BUN and electrolyte imbalances)
(Also gives a clue to the Adrenal cause of Hypertension with Sodium and Potassium changes).

3. Imaging -
• Pelvic Ultrasound for any structural abnormality of urological tract - due to Congneital or Acquired causes.
• Angiography (Digital Subtraction Angiography) - to look for renal artery stenosis. (Always with a pre procedure creatinine)
• MRI if needed. 

4. Serology -
• ASO Titres
• Anti DNAse B Ab's ( not done commonly)
• Complement levels - may be reduced.
• Antibody panel for various Vasculitis - ANCA , ANA and AMA.

5. Lipid profile for Atherosclerotic vascular disease. 

That's all for this post !
Hope this helps - both on the wards and the boards.
Happy Studying!
Stay Awesome !
~ A.P. Burkholderia

Mortality benefit of drugs for Heart Failure

Hello guys!

Here's a short and simple way to remember drugs that provide mortality benefit in patients with heart failure:

AA BMC

A = Aldosterone antagonists
A = ACE Inhibitors
B = Bisoprolol
M = Metoprolol
C = Carvedilol

You could also remember BMC as the Beta Blockers that have mortality benefit in Heart Failure patients!

(Off note: The acronym "BMC" works for me as I am studying in one of the BMC hospitals in Mumbai, India. BMC is a local body of the State government here!)

Let me know if you guys have any acronyms for cardiac drugs.
Happy studying!
Stay awesome!

Female genital tumors mnemonics

Hey everyone :) I would like to share some mnemonics that will help in remembering some facts about female genital tumors:

> Mnemonic for most deadly cancers : OUCh

Ovarian cancer> Uterine > Cervical

===
> Mnemonic for the most common female genital tumors in US:
Eradicate Ur Ovary Completely
Endometrial/Uterine > Ovarian > Cervical

===
> Effect of OCPs:

OCPs decrease the risk of cancers that start with vowels 
so ===> they decrease Endometrial cancer and Ovarian cancer
but they increase the risk of cervical cancer :O

===
> Effect of breastfeeding:
Breastfeeding decreases the risk of BOob cancer :P
so ==> it decreases the risk of Breast cancer and Ovarian cancer

And that's it :)


Written by: Murad

Cincinnati pre-hospital stroke scale

Hey Awesomites

Cincinnati Pre - Hospital Stroke scale is one of the most common scale to detect stroke early on. Remember the mnemonic - FAST

Writing a personal statement for residency

Your personal statement (PS) should be your experiences, what make you who you are.

Think of it this way - if you were to sum up your life in one page, how would you do it?

How do you let a person "meet" you without actually meeting you?

How do you put things that are not in your CV on your application?

That's your personal statement my friend.

Now there are many tips on the internet on how to write a personal statement - these are mine and what I found helpful.

Femoral triangle and femoral sheath contents mnemonic

Hello!

The femoral triangle is a subfascial space bounded superiorly by the inguinal ligament, medially by the adductor longus muscle, and laterally by the sartorius muscle.

Contents of the femoral triangle mnemonic:

Authors diary: Octopus and tyrosinase

Hey everyone!

Here's another way I study - when I am looking up cool things in other creatures, I compare it to the human body. It's fun!

Pursuing ophthalmology in India

Since my mom first introduced me to the slit lamp view of the eye and dad to the indirect ophthalmoscopy, I developed a liking for ophthalmology. The magnified view of the eye through the slit lamp just looks 'oh so beautiful' and it's such a fun challenge to master indirect ophthalmoscopy- I didn't think much in the counselling room while 'locking' the MS Oph option. Also, the fact that you have to work with all the cool gadgets and gizmos, lasers and stuff made me incline towards it.

Ophthalmology is a mutifaceted branch. Those who are into diagnostics and literature get their own share as well as those who want to take matters into their own hands and like to cut,paste, and remove things. The puzzle of diagnosis and the thrill of surgery, both can be had here.

Though not as demanding as general medicine or surgery, ophthalmic surgeries like cataract have a steep learning curve,a personal opinion of mine. But when you make sure that all the things fall into places rightly, it is highly satisfying an experience. The patient's smile the next day when they see clearly feels so good to the heart.

Experience in residency varies per college. I for one am happy with mine. I have done a few basic surgeries like pterygium and dacryocystectomy independently but under supervision during my  first year itself. Currently, I'm working on tunnel making in cataract surgery.
I have seen a lot of interesting cases of lids, cornea, and the fundus.
At times though, performing sac syringing of every pre op patient and filling up of discharge cards of the post op patients makes me go meh. But this is just nitpicking, I have a fair idea about the extreme workload of redundant stuff in other colleges.

After passing out, there are many fellowship programs offered by institutions. Getting a fellowship done is sort of a norm nowdays.

As mentioned before, this is an investment intensive branch, one needs to continually upgrade their machines and bring in new ones
if interested in establishing a privately owned set up. A job in an institution can be an option but things may get pushy or so I've heard.

Summing it up, this is like a cute little baby who is rather tough to please, but when you get it right, the smile is priceless.

How to leave a good impression during your clinical rotations?

Many of us are looking for observerships/electives in the US to gain some clinical experience, have recommendation letters and become more familiar with the medical system in USA.

In this post, I will shine the light on some points that will help in getting the maximum benefit from your rotations.

So, Let’s go:

1- Always come early and show commitment
If the working day starts at 7:30 am, be there at 7:20 am.

2- Dress properly
>Many hospitals have a dress-code, this is usually mentioned in the paperwork that you have to read/fill.
Eg: Business casual; shirts, ties and no jeans for men.
>Take care of your personal hygiene, use deodorants....etc

3- Write down notes
Have a small notebook and a pen. Write new cases that you see or any interesting syndrome. When you go back home, read more about these cases and check if there are any new scientific papers about them.

4- Be proactive
Don’t just sit and do nothing. Ask questions and check if you can present a case / give a talk or a presentation. Especially if you are doing an observership, the outcome at the end can really vary depending on how you use your time and how you reflect yourself as a doctor.

5- Know when to ask questions
It is nice to know more and to show interest but avoid the times when residents/fellows are busy, these include but are not limited to: pre-rounding, immediately after rounds when orders will be entered.

6- Don’t be “Mr. Know-it-all”
Although answering questions is important and can give a very good idea about you. Acting snobby and answering everything including questions that are directed to the residents may have an opposite effect.
Be patient and don’t interrupt. Answer when the question is directed to you or when it is open to everyone to answer.

7- Identify important "players"
Get to know who is the program director, the associate program director, attendings who are known to write good recommendation letters and those who are not. You will find a resident/senior/fellow who will provide this piece of info.
After all, you need to be remembered and to have a good recommendation letter when you apply for the match so do your best go get one! A strong recommendation letter from a chairman has much more weight than an average one from a newly appointed attending!

8- Be social
Respect everyone, smile, shake hands and introduce yourself to people who you meet for the 1st time. It is also cool to have nice conversations outside the field of medicine. For example, movies, books and sports. This will give an idea that you are well-rounded and more approachable rather than just an outsider who is there to do a job.

9- Discover the place
Try to be familiar with the hospital, its departments, the floors and the outpatient clinics. This will lessen the moments - especially during the first week of the rotation - when you will suddenly stop, conclude that you are lost and start blankly looking around :D

10- Remember that the first impression is vital and very hard to change, so be sure that the first impression that is made about you is positive.

In short, just be yourself and give it your best shot :)

Good luck everyone!

PS: this post is subjective to updates whenever I remember any new point that will help :)

-Murad

MIL : Pemphigus Vulgaris

Hi everyone ! This is my first MIL post ! 

My USMLE Step 1 Experience ( Road to 255 )

Hello everyone :) I would like to share with you what I did/studied for USMLE Step 1

It is gonna be long because I tried to include every single question that I was asked about my prep

First of all, I would like to thank everyone who I met during this journey from all over the world, Thank you everyone!

 Sources used for studying:

>First Aid

>First aid proposed and official errata (please check the proposed errata before studying any page in First Aid, it may have nice mnemonics, corrections. concepts..etc):

*https://www2.usmle-rx.com/proposed-errata-and-suggestions-fa-step-1

*https://firstaidteam.com/updates-and-corrections/

>Uworld

>Uworld biostat review

> +/- kaplan epidemiology part for step 2 ( those 2 youtube videos may be used in addition to  kaplan):

https://www.youtube.com/watch?v=75pQPB1RF50

https://www.youtube.com/watch?v=VMI9UuNqoGI

>Pathoma

>a person rearranged Pathoma into this amazing Onenote website:

https://onedrive.live.com/view.aspx?cid=375c2c99998a5c62&page=view&resid=375C2C99998A5C62!2705&parId=375C2C99998A5C62!2703&authkey=!AHH10BbZMBrqM0k&app=OneNote

>Sketchy micro and pharm videos ( I didn’t watch all videos but a lot them are really helpful)

>Kaplan videos for biochem / Sam Turco

>Kaplan step 2 patient safety chapter

>Conrad fischer 100 ethics cases

>+/- Flashcards notes ( Brosencephalon Anki deck for revision for some First Aid chapters)

>+/- BRS physio (curves and their questions in cardiology/respiratory)

 Method of studying:

>Did First aid general principles part except biochem 

Did some systems then went back to biochem

Then completed the systems

 >Uworld mainly done after first solid read of First Aid ( I started doing Uworld after finishing some of First Aid then I stopped and continued studying First Aid)

 >I didn’t do any online NBME but I solved NBME 15 16 17 18  and biostat and genetics questions in older NBMEs

Also did UWSA 1, 2 and FRED

(I felt my level was ok, I don’t advice you to do this..do 2 online NBMEs at least. I also didn’t try to convert my offline score and compare it..again, don’t do what I did :D)

==============================================

==============================================

 First Aid and Uworld are used for all the subjects in addition to what is mentioned below:

•  Biochem:

>Kaplan Biochem Videos by Dr. Sam Turco 

>Kaplan biochem book for pages that correspond to the videos only..fast skimming, don’t spend much time doing it!

•  Immuno:

>https://www.youtube.com/watch?v=T_4TrNRa3v8

>https://mynotes4usmle.tumblr.com/post/74125122501/anticancer-drugs-no-bms-mnemonic#.WnqBQZx97IU

>https://mynotes4usmle.tumblr.com/post/95332165430/immunosupressants-drug-mnemonic-bc-everythings#.WnqB-Zx97IU

•  Micro:

>Sketchymicro videos +/- pdf file of videos helps to cement info

>Use a lot of mnemonics whether from the proposed errata or any other source you find, also take care of the pics of organisms because they can be a question too.

> viruses DNA vs RNA and taxonomy mnemonic:

https://www.youtube.com/watch?v=Df_qAFF58Ec&t=1s

The video is drawn in a nicer way here too:

https://www.youtube.com/watch?v=rgz_3Yjw0vY

• General Patho:

Pathoma

• General Pharm:

Dr Raymond in Kaplan pharm about energy and inhibitors

•  Public Health Sciences:

>Biostat: the more questions you solve the better, as mentioned above: uw biostat review

>+/-Kaplan step 2 epidemiology may help in giving a broader idea for a person who is studying biostat for the 1st time 

>Conrad 100 ethics cases + behavioral:Kaplan step 2 patient safety chapter

•  Cardiology:

-Embryology:

https://www.youtube.com/watch?v=YxPp67XluQA&t=6s

 -Physiology:

BRS Physio - Cardio chapter ( if needed)

 -Pathology:

Pathoma

-Pharmacology:

Some mnemonics that may help in hyperdyslipidemia:

> https://www.youtube.com/watch?v=fTA5HOa87pM

> https://www.youtube.com/watch?v=HOXSaGpiSuo&t=3s

>http://www.medicowesome.com/2013/08/how-to-remember-lipoprotein-disorders.html

 Antiarrythmics:

> http://www.medicowesome.com/2014/10/antiarrhythmic-drug-classes-mnemonic.html

>http://usmle1mikmonics.tumblr.com/post/81324508295/bacman-class-1-antiarrhythmic-na-blockers

•  Endocrine:

-Physiology:

+/-BRS Physio 

-Pathology

Pathoma

-Pharmacology

Sketchypharm..some really nice videos for anti-Diabetic drugs

•  GI:

Pathology:

Pathoma

•  Hemonc:

>Pathology and a lot of physio:

Pathoma

>Pharmacology:

In addition to many mnemonics that are found online, you may check the anti-Neoplastic part of Sketchy pharm, I haven’t seen it but I heard it is cool.

• Musculoskeletal:

Pathology:

Pathoma

• Neuro:

Anatomy:

>Some books in First Aid are not clear enough ..eg: the foramina of the skull,,I suggest looking for some pics that are not clear in First Aid.

 > A much simpler way to understand Basal Ganglia:

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

(the whole channel: “Draw it to know it” is amazing)

>An amazing video to memorize the Brachial plexus:

https://www.youtube.com/watch?v=gTas7ijp0YE&t=328s

>Sleeping associated neurotransmitters

https://mynotes4usmle.tumblr.com/post/74247543467/neurotransmitters-associated-with-sleep-mnemonic

Pathology:

Pathoma presents tumors in a simpler way

• Psych:

I suggest studying drug toxicities, DSM rules and drugs mech of action from Uworld because it is more arranged and accurate than First Aid.

• Renal:

Patho and some physio:

Pathoma is great in pathology here and some parts of physiology are covered too

• Reproductive:

>Physio:

Mnemonic for tanner staging:

https://mynotes4usmle.tumblr.com/post/152650094930/tanner-stages-of-development-mnemonics

>Patho:

The tumors part can be rearranged better in First Aid, I suggest focusing on Pathoma and checking the reproductive part here too, tables can really make things easier:

https://onedrive.live.com/view.aspx?cid=375c2c99998a5c62&page=view&resid=375C2C99998A5C62!2705&parId=375C2C99998A5C62!2703&authkey=!AHH10BbZMBrqM0k&app=OneNote

• Respiratory:

>Embryology:

http://epomedicine.com/medical-students/lung-development-embryology-made-easy/

>Physio:

+/- curves from BRS physio

>Pathology:

Pathoma

 ==============================================

==============================================

 General advices/Before Exam:

-Mnemonics:

Mnemonics (memory aids) are a very vital part of step 1 ( at least for me :D ) that make remembering stuff much easier. A lot of the data is very dry but it stuck to your mind with mnemonics especially with pictures. I suggest checking the mnemonics in First Aid itself, First Aid proposed errata and these two very awesome websites:

http://www.medicowesome.com 

(for sure :D you ll find mnemonics for everything here)

https://mynotes4usmle.tumblr.com

 -Concepts:

Although memorizing is very important for step1, be sure to understand the concept before memorizing it. This is especially true in physiology because one fact may be asked in many ways.

 -How much time needed?

I have seen ppl doing it in a period as short as 5 months ( esp if step2 is done before) up to more than 1 year with others. In my case, It was on and off but if you want to put a timeline I would say 6-7 months.

 -How many times do I have to do First Aid? 

No fixed answer to this question. It depends on your type of studying. Are you the type who likes to read fast then revise again and again? Or you like one solid 1st time then a fast revision?

I personally prefer a very solid 1st studying time with mnemonics and concepts and a fast revision after that. In my case, I studied First Aid once and skimmed it once

 -Active studying

After you study First Aid and solve Uworld, try asking First Aid facts in a question form, do that on Facebook groups,Whatsapp..or with your study partner. Asking facts in question form will let you see many lines in First Aid that your eyes can oversee!

 -Every single line can be a question

Please don’t omit any line, diagram..curve in First Aid, anything can be asked! 

 -Arrangement

It is not necessary to study the subjects in a system exactly like First Aid

The 2 that are very connected are physiology and pathology. I sometimes used to finish Anatomy, Embryology and Pharmacology then go back to physiology and pathology.

 -Taking notes

This really differs for every person, some ppl like to write notes on extra notebooks, others write on First Aid or add sticky notes to it.

I starting adding notes from Uworld to First Aid then I stopped and continued taking notes using the flashcard program/app: Anki

It lets you search, add pics, audio and video 

Always remember the best notes are those you make yourself.

(Taking notes may take a lot of time sometimes so it’s ok too if you use other ppl notes)

 -Revision

You can come up with any personalized revision schedule you like, for me, revision was done after I finish the whole chapter in addition to its Uworld questions in the form of questions and answers with my friends on Facebook/Whatsapp.

Some already made Anki decks are there for step1, the most famous one is the Bronsenchephalon deck.

 -What if I need more?

I suggest making Google images and Youtube videos your new friend, they can simplify a lot of concepts. I didn’t use DIT videos so I can’t comment on them. Idea is when you need extra clarification go to youtube or google and don't feel obliged to watch video series like DIT or Kaplan..etc

I believe that watching Dr. Najeeb’s videos or studying Goljan or textbooks..etc is NOT needed and is beyond the scope of Step1 and will just take extra time from you with no much difference in score!

 -Uworld..how many times?

Regardless of how many times you ll do it, the 1st time should be always so solid, understanding concepts, writing notes..etc

Because when you solve Uworld again, recall bias would kick in and you ll be able to answer some questions not because you understand them but because you remember the question.

 -Uworld timed or not?

Many factors affect this, but if it is your first time with the USMLEs, you can do some blocks untimed in tutor mode then try timed mode, if you feel there is no problem with time, you can continue doing tutor mode.

Another method done by some ppl is to do Uworld tutor mode first read then timed mode in their 2nd read.

This is also affected by how fast you read English, how you train your eyes to omit distractors and by resisting the urge to re-reading the question sometimes. 

With time, this becomes easier!

 -Uworld system-wise, Subject-wise or mixed?

It depends on each person and each has his own approach.

 I think the 1st time should be done system wise excluding anatomy, microbiology, biostat. Biochem and genetics 

Eg: Cardio => physio, patholo, pathophsyio, pharm...same for other systems

Anatomy should be done all together, same for biochem, genetics, biostat, micro

This will help integrating the relevant data together.

Mixed mode can be done for marked questions or the 2nd read of Uworld ( depending on how many times you ll do Uworld)

-How to approach questions?

Always read the last line first...sometimes you may be asked a pharmacology question that is 10 lines long, then the question may be: the drug works by the following mechanism! This will greatly help in saving time for more questions in the exam.

After reading the last line, you can start reading the question from the start, a good thing is to highlight the abnormalities or the main points so your eyes can pinpoint what the question is asking.

 -Kaplan Videos and qbank

This questions depends on your level. I did my step 1 after graduation and I did CK before that, so in my case, I felt I didn’t need videos to explain the basics for me.

>I felt kaplan videos were needed for biochem, because in First Aid biochem is not that clear.

My advice is to watch the videos by Dr. Sam Turco, then look at Kaplan Biochem book to read what he explained but don’t see other pages that he doesn’t talk about because they are low yield.

>Kaplan pharmacology vid by Dr. Raymond may be used to explain the general pharmacology part of inhibitors.

>Kaplan qbank: in my opinion, it is not needed but it may be used for more practice for genetics and biostats questions.

 -Ethics!

Even after studying First Aid, Uworld, Conrad Fischer 100 ethics cases, you may find some questions in the exam in which you are left with 2 answers to choose from. Follow your guts and move on :D

 -NBMEs

>My advice is doing NBMEs starting from NBME 15 ...till 19

At least do 2 NBMEs online to get used to the exam preferably NBME 18 and 19

In my opinion. Older NBMEs don't represent exam trend and may have some very strange questions..but if you have time, do the biostat, genetic bands questions to be more used to deal with those. If you really have more time and you want to do all of NBMEs, you can do them too but know the concepts.

>Take NBMEs as an average, mostly your score will be somewhere between your lowest and highest score, It is something good to see you score increasing in each NBME, but put in mind that mostly NBME17 is underpredictive and that online ones are graded differently than offline ones. 

>If you get scores in NBMEs that are near the passing score postpone your exam till you get a satisfactory result! Step 1 score will haunt you all the way :D so give it your best shot :D

 - Step 2 and Step 1

I did CK before Step 1 so it helped in Pathology, micro, ethics, biostat, behavioral and a lot of pharm. In short, any step that you do before will help in the next one which leads to shorter studying time.

Exam day:

 -Sleep well..arrive early,,skip the tutorial  

 -Breaks during exam?

>If you skip the 15-min tutorial at the start of the exam, you ll have an hour of break time

>I took a break after each block with a larger break after my 3rd block, relaxing more, eating a bit more.

>Eat a bit in breaks, go to the restroom and try to relax your mind,

>Wear something that has less pockets to save time because you will be checked each time you enter the exam room after any break.

>Do a simulation test for yourself before the exam, spend 8 hours with breaks in between and know when you feel more tired or more hungry and decide how to divide breaks in the actual exam accordingly.

 -WTF questions

No matter how much you study, be prepared to find some strange questions in the exam, don’t panic, just follow your common sense, choose an answer and go on.

After the exam:

 >You ll feel some relief, you did a great job...8 hours are gone and It’s time to breaaathe and maybe eat a large meal :D 

>Now your mind will start remembering every single stupid mistake you did and you ll feel like: Who did I do that????

>Now 2 things: either leave it and suppress your ideas and hide anything related to Step 1 or go and do a brainstorming session and remember everything to reach a level of internal peace with what you did.

>You ll have some waves of anxiety for score anticipation in the 3 weeks after your exam :D this is NORMAL :)

Good luck everyone!

Written by: Murad 

Adverse reactions of Digitalis mnemonic

Hey guys
I am back :D

My first blog post of the year - Adverse effects of Digitalis ( Digitalis toxicity ) mnemonics

Though the ADRs are divided into extra-cardiac and cardiac symptoms, I will present a more systematic mnemonification ;p

Pulp Stones

This post is about age changes in the pulp. If the first thing that comes to your mind is pulp stone! That's correct! So, Let's dive into pulp and learn more about it :))

In Pulp cavity, age changes causes 

• Cellular changes
• Fibrosis of tissue
• Pulp stones or denticles
• Diffuse calcification

Cellular changes

There is a decrease in 

• Number of cells
• Size of cell 
• Number of Organelles

Fibrosis of tissue

• Accumulation of bundles of fibers
• In radicular pulp: longitudinal fiber bundle
• In coronal pulp: diffuse fibers

Therefore collagen fiber content increases in pulp organ. 

Pulp stone or denticle

• They are nodular or calcified masses
• They have calcium:phosphate ratio comparable to dentin
• They can be Single or multiple
• Present in functional and unerupted teeth
• It is present in both coronal and pulpal portion

Classification: According to structure 

True pulp stone

• Rare 
• Found in the apex region 
• The remnant of epithelial root sheath within pulp induce pulp cells to differentiate into odontoblast to form dentin masses

False pulp stone:  they appear as concentrically years of mineralized tissue

Classification: According to location

1. Free pulp stone is entirely surrounded by Dentin 
2. Attached pulpstone is partially fused with Dentin 
3. Embedded pulpstone is entirely surrounded by pulp 

This Post is written by Anisha Valli,

Types of Dentin

Hey friends,

Dentin is a very important question.

It comes as a question worth 4 points in my theory exam paper! I have tried my best to make it simpler for you all in this blog :))

I hope this will help you!

Primary Dentin

It is divided into Mantle and Circumpulpal Dentin 

A. Mantle Dentin 

• First formed dentin in the Crown
• Type III collagen
• It is less mineralized
• Matrix vesicles are present which help in Globular calcification

B. Circumpulpal Dentin

• It forms the bulk of the tooth
• Type one collagen
• It is more mineralized
• Matrix vesicles are present which help in Linear and globular calcification

Secondary Dentin

• It is formed after the root completion
• It contains dentinal tubules which are S-shaped
• The mineral ratio is similar to primary Dentin 
• Secondary Dentin is a narrow band of Dentin bordering the pulp
• As age increases, inorganic content increases
• Therefore the Dentin becomes sclerosed
• It means It protects the pulp from exposure in older teeth

Tertiary Dentin 

It is formed in response to stimuli

Attrition
Abrasion
Erosion
Cavity preparation

• It is deposited on the pulpal surface of Dentin only in the affected area
• The appearance of Dentin varies as it is formed by an odontoblast 
• Quality and quantity of tertiary Dentin depends on intensity and duration of stimuli

Reactionary Dentin 

Dentin is deposited by pre-existing odontoblasts

Reparative Dentin 

Dentin is deposited by newly differentiated odontoblast-like cells

Written by Anisha Valli :))))

Understanding randomization in clinical trials

Hi, 

I am writing this to clear basics about randomization. It is a very important concept for understanding the clinical trial design and can come handy while critically analyzing any trial or designing your own study. 

This is not very important for any med school exam. I believe this is really important because of more extensive use of evidence-based medicine (EBM) in clinical practice and many clinicians lack the ability to skillfully evaluate a scientific manuscript.

I am planning to write more blogs related to evidence-based medicine, which might help our readers across the world to become expert in EBM.

• RANDOMIZATION - randomly allocating participants into different treatment arms, purely on the basis of chance.  

• Randomization is the cornerstone of clinical trial design. It's a very tricky concept and gets trickier when you start evaluating scientific literature critically or start designing a robust clinical trial.

• It is pivotal in distributing confounders (eg. sex, age, history) equally in every treatment arm. Except for chance variation among the randomized group at baseline

Two most important  features of successful randomization:

1. Procedure truly allocates treatments randomly (based on chance)
2. Assignments are tamper proof

Randomization techniques:

1. Simple randomization:
By coin flipping (one side for treatment 1 and another side for treatment 2), shuffled deck of cards (even numbers for treatment 1 and odd numbers for treatment 2), throwing dice (numbers <3 for treatment 1 and numbers >3 for treatment 2). More better methods are random table method in stats books and computer software like excel.

Uses: in large sample size (>100 it should be preferred over block randomization)
Drawback: problematic in small sample size because it can create  unequal numbers in groups.

2. Block randomization: Ensure that participants are equally distributed among each group. Randomization is done in blocks, eg block size of six.
For example, a scientist enrolls only 6 patients per visit for a trial of total 60 patients. On each visit, he divides 3 patients each to treatment group A and B. At the end he will have 30 patient in both groups. See the figure 1 below.

 
 Figure 1. Block randomization of 60 patients in 6 patient blocks.

Drawbacks: Not suitable for randomization in non blinded trials, because randomization in small blocks makes a prediction of sequence easy.


3. Stratified Block randomization: It ensure that important predictor of outcome is more evenly distributed among study groups.
For example, if the age is a major determining factor in effectiveness or toxicity of the treatment then its imperative to have a similar distribution of ages in both treatment groups. Hence patients will be the first stratified into age groups and then they will be equally randomized in each arm. Like we did for Block randomization.

Drawback: only small number of baseline variables (2-3) can be managed by this technique.

4. Adaptive randomization: used for balancing more than 2-3 baseline variables.
5. Minimization: more complex adaptive randomization


I will continue more in next blog on randomization or other important concepts. Kindly post comments or question, which might help me, you, or other readers.

Thanks,
Dr. Gee


References:

Hulley SB, Cummings SR, Browner WS, Grady DG, Newman TB. Designing clinical research. Lippincott Williams & Wilkins; 2013 May 8.

Suresh, K. (2011). An overview of randomization techniques: An unbiased assessment of outcome in clinical research. Journal of Human Reproductive Sciences, 4(1), 8–11. http://doi.org/10.4103/0974-1208.82352