Thursday, June 18, 2020

Pediatric Residency Series: Preparing for Fellowships

Welcome to this post of Pediatric Residency Series. In this post, we will talk about fellowships including some factors that can help you in getting the fellowship you want:

Mentors / Research / Conferences:
Please click here for a detailed description of these points.

Know your timeline:
For most Pediatric specialties, ERAS opens early June, you can upload the needed documents till mid July. Interviews in August, September and possibly early October. Finalizing Rank Order List in November. Match results around mid December. You apply at the end of your 2nd year/start of your 3rd year and gets the results at the middle of your 3rd year.
Check ERAS for fellowships timeline and any other updates.
 
Letters of recommendation (LORs):
LoRs are very essential and have a tremendous impact on your fellowship application. Choose your letter writers carefully. Letters from big names and titles are amazing but are not as good as a personalized letter from another doctor who knows you personally and who has worked with you for a long period of time. LoRs are like a testimony of your worth to the new program. Remember to ask your colleagues about good LoR writers, also remember to approach the potential letter writers politely. Give your writer an ample amount of time to write your letter. It would be great to approach your potential letter writer two months before the application deadline. Whenever ERAS opens, send your personalized ERAS LoR request to the writer so he/she can upload your waived LoR to your account. You will need 3-4 letters for your fellowship applications; one of them will be from your Program Director (PD). Letter writers are not limited to people who supervised you clinically but they can include your research mentors too.

Personal Statement (PS):
Your Personal Statement is your way to express yourself informally after letting your CV show your formal side. Be sure to have a catchy start. Take your time in preparing your PS. Proofread it and make sure it has no grammatical errors. PS can make a PD curious to meet you!

Rotations: 
Rotations whether electives or less preferably observerships are your opportunity to prove yourself. They become even more important if you are doing your residency in a small program with a modest patient load. When you are doing an away rotation, you are being compared to the residents in the other program so do your best to impress. You can get amazing LoRs in your away rotations that can be so helpful in your fellowship application. You may also match in a program that you rotated at.

Study/Read:
Make it a habit to read one small thing about your desired specialty as frequent as you can. You can not imagine how much info you can have just by reading small things over a long period of time. However, be careful, do not let that interfere with your normal residency studying schedule. Ask your seniors/attendings about the available study material (books, articles, videos..etc).

Choosing programs:
It is advisable to have a checklist for the things you want in your desired fellowship program. Do you want a heavy research program? Does the program have the advanced fellowships that you want? Would you like to live in a city? 
Develop your own approach, do your own extensive research and of course ask seniors and mentors about their input. The interview day itself can either make you want that program more or can ring a bell and let your drop that program to a lower position in your ranking list.
FRIEDA ranks programs per reputation/research output/visa sponsorship..etc. However, make sure to check the website for each program to get the most updated data always since Frieda may not be uptodate all the time.

Comment below if you feel like anything can be added to this post :)

- Murad

Wednesday, June 17, 2020

Topics to read before PG entrance exams!

Hello Awesomites!

The aim is to help the students who want to give upcoming NEET PG Exam and are clueless about how to plan and prepare ?
I know my friend struggling day in and out for life in Covid wards. Exams doesn't matter now.
When they will have time in hand I want to help them out with plan beforehand. They are already brilliant enough to have been through all the challenges. :)

I know you can't predict what is important for this or next exams. Atleast with time in hand you can glance through some topics that contribute 70% of any exam. I am sharing the list 1st year subject I made during my preparation.

1.ANATOMY
  • Embryology 
  1. Pharyngeal arches
  2. Neural crest derivatives
  3. Oogenesis and spermatogenesis
  4. Notochord and remnants 
  5. Extraembryonic mesoderm
  6. Diaphragm 
  7. Cardiovascular system ( Abnormal subclavian artery)
  8. Urogenital system 
  • Histology 
  1. Cerebellum
  2. Osteoblasts
  3. Urinary bladder epithelium
  4. Cell junctions
  5. Collagen types
  6. cartilage
  7. Tonsil,Lymph nodes, spleen,thymus
  8. Stomach glands
  9. Skin with sebaceous glands
  10. Connective tissue types
  11. Retina 
  12. Salivary gland
  • NEUROLOGY
  1. Fornix 
  2. Corpus callosum
  3. Cranial nerves and its lesion
  4. Brainstem syndromes (lateral medullary )
  5. Foramen of skull
  6. Facial nerve and trigeminal nerve
  7. blood brain barrier
  8. Functional area and functional columns
  9. Parasympathetic ganglion 
  10. Phrenic nerve and vagus
  • GROSS
  1.  Compartments of lower limb with nerve and blood supply
  2. Blood supply of thyroid,oesophagus,ureter,Anal canal 
  3. Waldeyer ring
  4. External carotid artery
  5. Circle of willis
  6. Muscle of eye
  7. Brachial plexus (Sensory and motor supply of upper limb)
  8. Perineum
  9. Cruciate ligaments
  10. Vocal cords
  11. Mediastinum
  12. IVC tributaries
  13. Cavernous sinus and superior orbital fissure 
  14. Splanchanic plexus
2. BIOCHEMISTRY
  • Inborn error of metabolism (Types,Enzyme deficient,hallmark feature,Investigation of choice and treatment)
  • Rate limiting step 
  • Carbohydrate metabolism (Glycolysis,Glycogen storage disease,Glucogenesis,glycogenolysis,PFK-1)
  • Lipid metabolism ( Hyperlipoproteinemia and hypolipoproteinemia)
  • Vitamin (Coenzyme)
  • Electron transport chain inhibitor
  • Heme metabolism and Porphyria
  • Ketone body formation 
  • Urea cycle disorder
  • Competitive, non competitive and allosteric inhibitors
  • Mitochondrial disorders 
  • Amino acid disorder
  • Lead poisoning
  • Translation process 
3.PHYSIOLOGY
  • Receptors
  • Neurotransmitter and functions
  • Second messenger
  • Reflexes
  • Baroreceptors and chemorecptors
  • JVP 
  • ECG And EEG
  • Spirometry
  • RAAS 
  • Counter current exchanger and multiplier
  • Factors affecting compliance of lung 
  • Action potential
  • Smooth muscle and cardiac muscle
  • Channels and types 
  • GIT hormones 
  • Tracts and lesions(brown sequerd syndrome)
  • LH,FSH,GH and insulin glucagon
 Following are the list of 2nd year topics.

1.FORENSIC MEDICINE
  • Ballistics (Bullet ranges)
  • Identification (female male, blood sample)
  • Recent amendments in acts (POCSO act, MTP Act)
  • Application of IPC,CrPC sections
  • Postmortem changes
  • Dentition And Xray of wrist elbow and pelvis to determine age
  • Injuries -fracture of skull, RTA, Bruise
  • Toxicology- Plant based image, Preservation of viscera, Snakes,Arsenic, OP poisoning,Mercury,cadmium,Cardiac poison
  • Consent
  • Grievous hurt and murder vs culpable homicide
  • Seminal stains
  • Dowry death and Rape
  • Battered baby syndrome
  • Plant Toxicology (castor,abrus,strychnine,Dhatura,Aconite,Oleander,Calotropis,Opium,Cannabis)
2. PATHOLOGY-
  • Breast cancer, Lung cancer and Ovarian and testicular cancer
  • CD markers
  • Hemolytic anemia
  • Vasculitis
  • Endocarditis And MI
  • Types of hypersensitivity reaction
  • Platelet and coagulation disorder(ITP,TTP,hemophilias,vWD)
  • Stains And vacutainers
  • Transfusion reaction 
  • Graft rejction
  • Crohns vs Ulcerative colitis
  • Necrosis, apoptosis and its variant
  • Mode of inheritance
  • Leukemia and lymphoma prognostic markers
  • Renal histology and gross
  • Liver histology and gross
  • CNS tumors 
3.PHARMACOLOGY
  • Antimicrobial Drug of choice and mechanism of action 
  • Classification - aminoglycoside , MRSA And drugs for cystic fibrosis
  • Hypolipidemic Agents 
  • Asthma ( New drugs and guidelines)
  • Arthritis (RA and gout)
  • General pharmacology ( Pharmacokinetics,clinical trial,Pharmacodynamics)
  • Concentration dependent kinetics and time dependent kinetics and post antibiotic effect
  • Anti TB drugs
  • Anti viral and anti HIV (anti hep B and C)
  • Anti fungal
  • CVS- MI ,HF, angina managment
  • Endocrine- DM,Osteoporosis,SERM,SERD,Gnrh agonist
  • GIT-Constipation (opioid induced,IBS related) ,Diarrhea,peptic ulcer
  • CNS-Anti epileptic, Sedative,lithium toxicity,neurodegenerative disorder, side effect 
  • ANS- Emergency medicines,anaphylaxis, receptors ,poisoning 
  • Chemotherapy-Anticancer,monoclonal antibody,small molecules,kinase inhibitors
  • Prostaglandins 
  • Insulin 
4.MICROBIOLOGY-
  • Sterilisation and disinfection (Indicator)
  • Immunology (Antibody,complement deficiency,Primary immunodeficiency)
  • Latest outbreaks (Zika,Congohemorrhagic fever,Ebola,Corona)
  • Sexually transmitted infections
  • Vectors
  • Parasitology -Eggs
  • Congenital infections-Toxoplasmosis,congenital syphillis,rubella,herpes,varicella
  • HPV infection,HHV-8
  • Bioterrorism
  • Larva migrans,larva currens (cutaneous and visceral)
  • CD4 counts and Opportunistic infection
  •  HIV and TB
  • Food poisoning
  • Atypical bacteria treatment and infection 
  • Dimorphic fungi
  • Actinomycosis,Botryomycosis and eumycetoma
  • Meningitis
  • Exanthematous disease
  • Neisseria,diphtheria,Listeria,bacillus anthrax,legionella,campylobacter jejuni
  • Bacterial virulence factors,growth factors
  • Rickettsial disease, spirochetes(weils ds) 
  • Drug resistance mechanism

Following is the list of 3rd year topics.

1.COMMUNITY MEDICINE-
  • Surveillance programs
  • Sensitivity, specificity,PPV and NPV (Screening of disease)
  • Types of studies 
  • Odds ratio and relative risk ratio
  • Bias
  • Sampling 
  • Biostatistics- central tendency  (Box and whisker plot )
  •  Level of prevention 
  • Vaccine and types (Toxoid and live attenuated)
  • Demography and family planning
  • Biomedical waste
  • Health programmes ( RNTCP, HIV)
  • Communication
  • Nutrition and related programmes
  • Disaster
  • Null hypothesis,P value and alpha value
  • Confidence limit 
2.OPHTHALMOLOGY-
  •  Refractive errors (Astigmatism)
  • Surgery and post op complication(Glaucoma,cataract,squint)
  • Conjuctivitis
  • Corneal ulcer (Bacterial,fungal and herpetic) (Stains)
  • ROP and systemic retinopathy (Hypertensive and diabetic retinopathy)
  • Retinitis pigmentosa and syndromes
  • Retinal detachment and cause
  • Retinoblastoma
  •  Strabismus
  • Optic neuritis
  • Visual field defect 
  • Blow out fracture and trauma to eye
  • Glaucoma and drugs(Contraindication and indication)
  • Managment of ptosis
  • Light reflex and accomodation reflex and pupil
  • 3,4,6 Cranial nerve
  •  OCT ,Fluorescein angiograhy,tonometers,charts,
  • Sudden loss of vision and gradual loss of vision differentials
3. ENT-
  • Appearance of tympanic membrane in various disease
  • Surgery (Tonsillectomy,Adenoidectomy,Mastoidectomy)
  • Paranasal sinus
  • CSF rhinorrhea
  • Laryngeal disease (Papilloma,vocal cord paralysis, laryngeal muscles action, laryngeal cancers)
  • Tracheostomy
  • Abscess 
  • Nasopharyngeal carcinoma
  • Juvenile angiofibroma
  • Test of hearing and vertigo
  • Otosclerosis
  • Cochlear implants
  • Oral cavity cancers 
  • cervical Lymph node  and neck dissections
 Following is the list of Final year topics.

 1.OBSTETRIC AND GYNECOLOGY-

  • Pre-eclampsia (Definitions)
  • HELLP
  • PPH (prophylaxis and treatment)
  • Perineal tear (Types and managment)
  • Diabetes and anomalies scan 
  • Shoulder dystocia maneuvers
  • Molar pregnancy (High risk and low risk for GTN)
  • Ectopic (Diagnosis, Investigation and managment)
  • Abortions 
  • Recurrent pregnancy loss (Investigations and causes)
  • Cervical incompetence
  • MTP
  • Diagnosis and physiological changes of pregnancy 
  •  Abruptio vs placenta previa vs Vasa previa
  • Heart disease
  • MgSO4 and drug
  • Fetal monitoring -NST,BPP,doppler
  • Twins and complications
  • Labor-stages,partogram
  • Placenta types and associated pathology
  • Rh incompatibility
  • Amenorrhea (primary and secondary)
  • Mullerian anomalies (Class)
  • Asherman, AIS,Gonadectomy indication
  • Puberty and precocious puberty
  • Menopause (Hormone replacement therapy guidelines) 
  • Postmenopausal bleeding and premature ovarian failure (Levels of FSH)
  • Semen analysis (Evaluation and IUI and TESE)
  • PCOS -Diagnosis,drugs
  • Endometriosis
  • Cervical,vulval,ovarian,endometrial cancer,Fibroid
  • Krukenberg
  • PID
  • Prolapse 
  • Emergency contaceptives
  • IUD
  • Absolute contraindications in whole subject
  • Female sterilisation  
2.PEDIATRICS-
  • Developmental milestones
  • Neonatal reflexes
  • Neonatal resuscitation
  • Jaudice,sepsis,Hyaline membrane disease
  • Congenital infections-TORCH
  • Vaccines(IAP and NIS)
  • Diarrhea,pneumonia,dehydration managment
  • Pediatric epilepsy
  • Febrile seizure (Risk factors,recurrent risk,prohylaxis)
  • Severe acute malnutrition
  • Rickets
  • meningitis
  • Neuro-Cerebral palsy and neurocutaneous syndrome
  • Pediatric vasculitis-HSP and Kawasaki Disease
  •  Nephrotic syndrome
  • Congenital heart disease( VSD,TOF,TGA and ductus dependent CHD)
  • Trisomies
  • Hypoxic Ischemic encephalopathy VS Periventricular leukomalacia
  • Fluid managment including shock managment in children
  • Childhood pneumonia, Epiglottitis, Acute laryngotracheobronchitis
  • Microcephaly and macrocephaly 
  • Hydrocephalus and Neural tube defect  
  • Fetal alcohol syndrome,warfarin syndrome
3. ANESTHESIA-
  • IV anesthetic agents (Propofol)
  • Day care surgery (Drug of choice)
  • Venous air embolism
  • Local anesthetic (Remember concentration also)
  • Vaporisers color 
  • Inhalational agents 
  • Monitoring (Capnography)
  • Color coding of cylinder
  • Circuits
  • Mallampati and ASA grading
  • Premedication duration of stoppage and continuation
  • Muscle relaxant
  • Airway devices
  • Endotracheal tube (formula)
  • Epidural vs spinal anesthesia (Level of blocks)
  • Modes of ventilation
 4.DERMATOLOGY-
  •  Pigmentation Diseases 
  1. Hyperpigmentation
  2. Nevus (Nevus of ota/mongolian spot/CMN/AMN)
  3. Melasma
  4. Acanthosis nigricans
  5. Becker nevus
  6. Hypopigmentation -PKDL/Pityriasis versicolor/alba/Hansens
  7. Depigmentation-Vitiligo/Contact leukoderma
  • Signs (Auspitz,nikolsky,bulla spread sign)
  • Histopathology of psoriasis and lichen planus
  • Mast cell disorder-Urticaria pigmentosa image
  • Papulosquamous disease - Psoriasis ,lichen planus
  • Treatment of Psoriasis
  • STD (Syphillis,chancroid,donovanosis,Herpes genitalis,syndromic approach)
  • Microbiology of STD organism( Dark ground,school of fish,Tzanck smear,Donovan body,Gonococcus)
  • Drug Reaction -Fixed drug eruption, erythema multiforme,SJS/TEN
  •  Blistering disease 
  1. Pemphigus(clinical treatment)
  2. Bullos pemphigoid
  3. dermatitis herpetiformis
  4. Histopathology of blister level and Direct immunofluorescence image
  • Infections
  1. Fungal (Tinea /pityriasis versicolor)
  2. Hansens 
  3. TB
  4. Viral (HPV/HHV/Molluscum contagiosum)
  • Hair disease-Alopecia images,DLE,trichotillomania
  • Acne,Rosacea
  • cutaneous markers of internal malignancy
5.RADIOLOGY-
  • Emergency radiology-RTA,splenic injury,FAST,Perforation
  • Radiological anatomy especially applied aspect
  • CNS tumor
  • Bone tumor
  • BIRADS
  • TIRADS
  • Radiation physics and acute radiation syndrome
  • Radiotherapy basics
  • Contrast in various studies
  • USG and doppler
  • Doppler waveforms
6.ORTHOPEDICS-
  • Knee joint (Everything)
  • Shoulder dislocation
  • Bone (Oncology+radiological picture)
  • Pediatric Hip(Rdaiology +managment)
  • Infections(TB,Osteomyelitis)
  • CTEV
  • AVN
  • Tennis elbow and dequeverian
  • Eponyms and test
  • Blood supply of femur
  • Pseudoarthrosis
  • Genu varum/valgus,cubitus varus/valgus
  • malunion 
  • Instruments
7.SURGERY-
  • Glasgow coma scale (Changes)
  • Burn
  • Cannula color coding 
  • Triage
  • Trauma
  • Incisions,suture,foleys,NG tube,Knots,Scores
  • Latest updates in breast cancer,thyroid and hepatobiliary cancers,Pancreatic cancer,stomach,colorectal cancer
  • Bed sores staging 
  •  Renal stones managment
  • Gall stone managment and surgical complication
  • Bariatric surgery
  • Acute pancreatitis managment 
  • Upper GI and lower GI bleed management and causes
  • Aortic aneurysm
  • Meckel diverticulum
  • Wound classification
  • Cancer-(Breast,rectum,stomach,oesophagus,HCC,prostate,thyroid)
  • Cancer follow up duration 
  • Carcinoid and GIST and gastrinoma
 8.MEDICINE-
  •  ECG visuals
  • Cardiac emergencies-Arrest,Unstable angina,MI,Arrhythmia,Dissection
  • Respiratory emergency-Pulmonary embolism,pneumothorax,Asthma 
  • Stroke
  • Meningitis (Bacterial,viral,aseptic)
  • Approach to patient in Coma
  • Seizure
  • Electrolyte imbalance
  • ABG
  • Hypertension and its emergency and management
  • Murmurs and valvular lesions
  • Pericardial d/o
  • hepatitis(Viral,autoimmune)
  • Non alcoholic and alcoholic liver disease
  • Glomerular disease
  • UTI
  • CKD
  • DM (management of different complications)
  • Neurodegenerative d/o ,neuropathy,myopathy
  • Septic shock guidelines
  • GBS
  • Poisoning 
  • New asthma guidelines
  • RTA and Inherited channelopathies
  • MEN syndrome
  • SIADH, DI,Pheochromocytoma
  • AIDS defining illness
  • Connective tissue disorder
  • Infective endocarditis and rheumatic heart disease
  • Prakinson and alzheimers
  • IBS,UC ,Crohns
  • Cardiomyopathy
  • Jones and dukes criteria
  • dyslipidemia management 
10.PSYCHIATRY-
  • General psychiatry (terms and its meaning )
  • MMSE
  • Psychotic disorders
  1. Schizophrenia
  2. Delusional d/o- Named syndromes (Capgras,Fregoli,Othello,Ekbom)
  • Mood disorder (Treatment is very important)
  1. Mania
  2. Depression
  3. Bipolar
  • Neurotic disorder 
  1. Anxiety disorder
  2. OCD related disorder
  3. Dissociative disorder
  4. Trauma and stress related disorder
  5. Somatoform disorder
  • Substance abuse and deaddiction
  • Organic mental disorder(dementia)
  • Sleep disorder
  • Eating disorder
  • Sexual disorder
  • Personality types and disorder
  • Drugs (SSRI and its sideeffect)
  • Psychotherapy types and choice
  • Defence mechanism  
You can edit this according to you. 
Hope it will help.
-Upasana Y.

Monday, June 15, 2020

MY IELTS Experience


MY IELTS EXPERIENCE
  • Appeared on 19.03.20
  • Score = 8.0; Max = 8.5 on Speaking
  • Resources = IELTS Charlie + e2Cademy + IELTSAdvantage (all free)
  • Time = 07 days (inconsistent)
  • Writing - Practiced 3 -5 a day. Completed short essay in under 10 minutes and long essay in under 25 minutes. Spent the rest of the time trying to read the question repeatedly to ensure that I never went off topic
  • Listening - Practiced 3 a day
  • Speaking - 2 a day because I feel I am fluent. Use IELTS Charlie to learn some grammar. It helps. Familiarize yourself with topics that you feel you have NEVER read or don't have an idea of the global scenario about. STICK TO THE TOPIC.
  • Reading - practiced 4 in all. I didn't find that I have any difficulty in writing while I listen except for the occasional errors


If you're Just Starting Out 
  1. Make sure you have your resources compiled. I wasted a fair amount of time trying to assess what is best in the middle of my prep.
  2. Ensure that you know what you need to work on by listening to others who have appeared for the exam 
  3. Buzz me for queries and links to material.
  4. Read this - http://www.howtocrackplab.com/search/label/IELTS
  5. Realise that this is not a test of how proficient you are with the language, these are their standards to assess you because well.. somebody had to set some standards.
  6. Make sure you have a clear goal as to when you wish to appear for PLAB 1 (if you do wanna appear for it).
  7. You may appear for a pen and paper version or a computerised version. Play to your strengths. This is most important to know.
  8. Read the prospectus more than once. Their information tables are more than sufficient to help you avoid silly mistakes that reduce your band score.
Watch Out For
  1. The types of sentences you use in the written test.
  2. WORD LIMIT - Going over is good. Going under is just going under the bus,
  3. CONCENTRATION - Listening test audio will be played only once. Ensure that you focus. If you lose touch you may land into a 6.5 band score and goof up your chances of appearing for PLAB 1.
  4. OPINIONS - On both the speaking and writing tests, unless asked for state a fact rather than your opinion.


Plan your preparation

Hi Awesomites!

Let us begin with journey for upcoming NEET PG and AIIMS PG.
Today I will share with you the tips on "How to plan your preparation for NEET PG?"

"An hour of planning can save you from hours of doing nothing."

Essentials:-
1.Google calendar or Print out of calendar   -->Get printable calender here
2.Pen
3.Blank paper

I) Google calendar:-

I started my preparation in March. I had schedule of the rotations beforehand.
Lesson 1:- "Do you have 9 months for Jan NEET PG ?"
"No"
It seems so we have months for prep but we have only days .
So make realistic plan by counting out the days you will be busy with TND and grand tests.
To see how your whole year going to look like make a virtual plan.
I color coded each event I had for the entire year.

Purple-The posting in the given month
Green-The days I am free
Blue-The test and discussion day
Orange-The test and discussion I missed
Red-Grand test
II) Take out print or write on paper specifying 19 subjects :-



After every Grand test I list out the topics I am weak at.
Lesson 2:- You are not weak at subject, you are weak at topics in that subject.

III) Stick to one resource.

IV) Make separate and single notebook for test and discussion . Do not add everything in notes in one go.

V) Take breaks.

VI) Do passive studying when you are exhausted .
- I recorded the nerve injuries and certain ADR of drugs in my phone and used to listen it whenever I was unable to carry notes.

- I used to call my friends and discuss the topic after we are done with targets for the day.

VII) Don't be hard on yourself.Give some time to things you love.


Hope this will help.

-Upasana Y.


Sunday, June 14, 2020

Pediatric Residency Series: Research

In addition to its valuable role in helping humanity, research is one of the most important aspects of the fellowship application.


In this post, I will mention some points that will help in getting more research and in having a more systematic approach towards this field.


1-Start early

Time in residency flies very fast. If you know which specialty you are targeting, start doing research as early as you can. This will expose you to more ideas, allow you to have more possible publications and may also strengthen your clinical grasp on that specialty. 


2-Mentors

A mentor can be a current senior or an attending in your program or in any other program. Mentors have more experience and will shine a light on things that you may not consider. They will also give you research ideas and inform you about the conferences specific to your field of interest. The fellowship world is smaller than the residency one and mentors can write you letters of recommendation, put a good word for you and direct you to fellowship programs that best suit you.


Do not forget to check the: AAP Mentorship Program. As an AAP member, you have free access to this mentorship program which links you to mentors through its algorithm based on your preferences. This AAP feature is a hidden jewel that everyone should use.


3-Finding Research:

“How can I find research opportunities?” This is the-million-dollar-question and one of the most frequent ones I get.

I like to divide the answer into two main parts:


*Research at your program

This varies a lot based on your residency program but options include and are not limited to:

A- Case reports and case series

Do you have an interesting case on the Pediatric ward, PICU or NICU? Ask your attending if it is reportable, decide which journal or conference to target and start writing!

AAP has an amazing summary about this here.


B- Retrospective studies

Is your NICU big and with a high patient turnover? Come up with a research hypothesis or let your seniors and attendings aid you in this. These days and especially with the ICD code system, you can think about any research idea and find the research objects within seconds!


C- QI projects

Have you noticed anything in your program that can be improved? Is it an order set that can be added to your EMR? Do you feel a teaching module for residents or students would help? Create your own QI project, compare pre and post intervention results and present the findings at a regional conference or wherever you deem appropriate.


D- Surveys

Surveys are usually easy to do. Come up with the survey questions (search and ask while doing so) and run it by your mentor. You may do a pilot survey on a smaller amount of people before sending your official survey to your target group. The downside is possible low response rates which can make the survey hard to be published.


Do not forget to obtain the needed IRB approval in your program before doing anything :D 


*Research outside your program


A- Meta-analysis / Systematic reviews / Review articles

The above mentioned types of research can be done anywhere and anytime. They are usually carried out in teams including a statistician (or anyone who knows statistics) needed for meta-analysis. They may be time consuming so keep that in mind.


B- Global projects

Collaborative research is a type of research that is recently getting more publicity. There are infinite projects out there that you can join. You just have to know about them. An example is the Covidsurg collaborative project


C- Databases

Databases are incredible - and sometimes costly- sources for retrospective research. The hardest part is formulating the research question. After you have your idea, search online to see if it has been done before. An example is the famous Healthcare Cost and Utilization Project (HCUP) database. This database has many sub-databases with gigantic amounts of info that can be used for research purposes. Every disease you can think of is there with its corresponding ICD code. KID (Kids Inpatient Database) and NIS (National Inpatient Sample) are two subsets that include Pediatric patients. 


D- Twitter

Yes, as you have read! Some research projects can be posted on Twitter and you can directly contact whoever posted them and start.


4-Conferences

Conferences are very vital when it comes to research. Not only that attending conferences gives you the chance to meet people who share your interest, socialize and make new connections, find mentors, look for possible away electives and present your work. It also excites you, gives you new ideas and allows you to discover new places which will help in breaking the “stressful” residency routine.


Always know when the conferences are held, the early vs late registration fee, abstract submission opening date and deadlines so you can plan your traveling, accommodation and schedule changes.


Stay tuned for a list for conferences that you can attend/present at whether for general Pediatrics or Pediatric sub-specialties.


This post mainly applies to those in Pediatrics but same principles apply to most other specialties.



-Murad :)


Saturday, June 13, 2020

Clinical correlates: Epinephrine vs Norepinephrine reversal

Hey Awesome peeps :)

This post is about variation in the effects of epi- and norepinephrine depending on its dose.

Monday, June 8, 2020

Topical Drug Absorption.

Hello everyone!

This is the brief mention about the extent of topical absorption of drugs. 

In decreasing order-

Posterior auricular
Scrotal
Scalp
Dorsum of hand
Plantar area.

Absorption mainly depends on the thickness of the skin and is inversely proportional to it.



Hope this was helpful! 

Let's learn Together! 

Dr. Medha Vyas 


Tympanogram.

Hello Everybody!

Let us quickly review the different curves of a tympanogram. 


The following are the yypes of curves in you'll see on a tympanogram:

Type A – Normal pressure and normal compliance in normal ear.

Type As – Reduced compliance (‘s’ means stiffness leading to reduced compliance) and normal pressure.

  • Seen in
    • Otosclerosis or other ossicular fixation
    • Tympanosclerosis
Type Ad – Increased compliance (‘d’ means discontinuity leading to increased mobility) and normal pressure.
  • Seen in
    • Ossicular discontinuity
    • Thin and lax TM

 

Type B – Flat or dome shaped graph i.e. reduced compliance.

Seen in case of:Serous otitis media.

Thick tympanic membrane.


Type C – Normal compliance but negative pressure due to eustachian tube obstruction.

  • Seen in case of:
    • Retracted tympanic membrane,
    • Early stages before collection of fluid in middle ear.


Hope this was helpful. 

Let's Learn Together! 
Dr. Medha Vyas 

Sunday, May 24, 2020

Tuesday, May 19, 2020

High-yield : Risk of stroke with cardioversion

Hello

Electrical/chemical cardioversion performed in a case of atrial fibrillation may carry a high-risk of stroke, especially if >48 hours of time has passed (thrombus formation takes about 48 hours).

Monday, May 18, 2020

Causes of holosystolic murmur mnemonic

Hello

Causes of holosystolic murmur: MTV reality shows
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defect

- Jaskunwar Singh

Sunday, May 17, 2020

High-yield : Absence of tachycardia in cardiac tamponade (mnemonic)

Hello

Tachycardia is a characteristic feature of decreased systolic blood pressure in the patients of cardiac tamponade. However, there are exceptions to be taken care of during diagnosis and workup on the patients with following conditions (absence of tachycardia):

A Factor A Day Keeps Colon Cancer Away

Protective Factors For Colon Carcinoma

A - Aspirin,vitamin A 

B - Bisphosphonates
C - Calcium, Coffee, vitamin C
D - Dietary Fiber
E - vitamin E
F - Fruits
G - Green Vegetables

Chest pain in acute pericarditis vs myocardial infarction

Hello

Acute myocardial infarction is one of the miscellaneous causes of acute pericarditis. Differentiating features of chest pain in these two cases are many, but the high-yield points to be noted are:-

Friday, May 15, 2020

Mnemonico diagnostico - murmur in mitral stenosis

Hello

Mitral stenosis murmur features:
(mnemonic: MITRAL STENOSIS)

Pericardial knock v/s Pericardial rub

Hello

Pericardial knock:
- most common cause is constrictive pericarditis
- occurs during the healing phase of the disease (fibrocalcifications)
- during the early diastolic phase of cardiac cycle (after opening snap)
- On auscultation: high frequency sound

Pericardial rub:
- commonly seen in acute fibrinous or sero-fibrinous pericarditis
- sero-fibrinous exudate in between two layers of pericardium (disease process going on)
- may occur during ventricular systole, or ventricular early diastole (due to expansion) or late diastole (due to atrial contraction).
- on auscultation: rough scraping sound described as "leather rubbing against leather"


That's all
- Jaskunwar Singh

Thursday, May 14, 2020

Apraxia vs autotopagnosia

Hello Awesomites !

Here we will discuss two from many parietal lobe lesion.

1.APRAXIA
Inability to carry out well organized voluntary movement correctly.
Despite motor, sensory & coordinated functions are not significantly impaired.

Ideomotor : It is a type of apraxia.
Patient performs the task but makes errors; there is a common tendency to substitute a body part for an object.
2.AGNOSIA
Abnormalities of perception of sensation despite normal sensory pathways.
Visual & body perception are impaired in parietal lobe lesions 

Agnosia of body scheme or autotopagnosia
Inability to locate, identify & orient one’s body parts.

Suppose while on rounds in neurology ward:- You see a patient brushing his knee early morning.(according to above discussion)

Apraxia -Patient has forgotten how to use toothbrush.Brushing knee as a toothbrush rather than pretending to hold one.
Autotopagnosia- the patient has forgotten the body part itself.

In either case localisation of lesion is PARIETAL LOBE.

Isn't the interpretation of one neurological sign seems interesting?
"Eyes see what mind knows"

Below is the link which is very descriptive and I came across it while reading more on this topic.
Happy studying !
-Upasana Y.

Beta 2 agonist and effect on muscles

Hello Awesomites !

I used to have a doubt why does Salbutamol cause uterine relaxation but causes contraction of skeletal muscle and cardiac muscle(tremors and tachycardia)?

Despite they have same receptors (Beta 2) how can be the action on muscle is so different.
Grossly it seems like one receptor Beta 2. This beta2 adrenergic receptor is a type of GPCR.
GPCR  are Gs, Gq ,Gi type.

Beta 2 receptor anywhere (Uterus -smooth muscle, heart- cardiac muscle, hands- skeletal muscle) is also same type of GPCR i.e Gs.

Still no difference.

Gs activates adenyl cyclase to form cAMP from ATP.
cAMP increases in all type of muscle on stimulation of Beta 2 receptor.
But it cause relaxation in smooth muscle (inhibit myosin light chain kinase)
And causes contraction of heart and skeletal muscle (activate cAMP dependent protein kinase A lead to activation of L-type calcium channel).

At one level we all may appear to be doing same thing yet at other level we are different and have our role.:)

 Happy studying !
-Upasana Y.

Tuesday, May 12, 2020

COVID-19 and Vasculopathy

Over the past few months, overwhelming evidence has accumulated suggesting the dysregulation of the coagulation pathways in COVID patients stemming from the altered immune and inflammatory response towards SARS-CoV2.

Observed coagulation abnormalities have multi-faceted pathogenesis. The most likely suspect is microvascular dysfunction secondary to cytokine storm-like state, tipping the balance towards thrombosis. Direct vascular injury is also likely with evidence of endothelial viral inclusions in some cases.

-Pulmonary Intravascular Thrombosis

Evidence suggests that starking discrepancy exists between hypoxemia onset and respiratory failure in COVID patients, with the former occurring fairly early in the disease course, pointing to the fact that it's not classic ARDS-like pathology that is responsible for the marked deterioration in the pulmonary gas exchange process. It is appropriately explained by the diffuse thrombosis affecting the pulmonary vasculature. In fact, it's so prominent that a whole new entity called "Pulmonary Intravascular Thrombosis" has been proposed as the framework for explaining this phenomenon.

Pulmonary Intravascular Thrombosis could be considered as lying along the spectrum of classic DIC with few important dissimilarities. It is usually localized to the pulmonary vascular bed at least initially and doesn't feature hypofibrinogenemia, consistent with the acute phase response driving continued fibrinogen production. D-dimers levels, however, are significantly elevated suggesting thrombus formation and ongoing hyperfibrinolysis.

-Pathogenesis

ACE2 is expressed in huge numbers on the alveolar epithelial cells, especially type 2 cells and also pulmonary endothelial cells. Hence, in contrast to patchy involvement classically seen in bronchopneumonia, in COVID, extensive involvement of the alveolo-capillary network is seen. This, in turn, results in florid interstitial inflammation resulting in efflux and activation of macrophages in the alveoli. It is so rampant that it has been likened to Macrophage Activation Syndrome (MAS) or sHLH like state. Activated epithelial cells and macrophages then orchestrate the cytokine storm leading to microvascular dysfunction and widespread thrombosis in the juxtaposed capillary network. Enhanced tissue factor and thrombin expression, coupled simultaneously with the reduced levels of PAI-1 drives thrombosis. Hypoxemia due to V/Q mismatch further exacerbates this process.

Levels of ACE2 in alveoli initially decrease as the virus particles are internalized. ACE2, by virtue of its ability to convert AngII to anti-inflammatory Ang1-7 peptide, keeps excessive inflammation in check. Hence, reduced ACE2 expression compounds the thrombotic propensity in the vascular bed. Direct involvement of endothelial cells by virus leading to endothelitis/vasculitis has also been suggested, although endothelial activation due to inflammatory cytokines seems more likely.

Reduced type 1 interferon signaling pathways are another intriguing possibility contributing to hyperinflammation. The role of positive pressure ventilation in forcing the viral particles and cytokines in vasculature also merits consideration.

- Skin manifestations

A variety of skin manifestations ranging from pseudo-chilblains to livedoid lesions have been described in COVID patients. While some of the lesions, like acral vesicles and pustules, confer to the pattern of viral exanthem, livedoid lesions suggest the possibility of vascular injury. These vasculopathy eruptions are known as "toevids", appearing as violaceous plaque-like eruptions over toes. Upon molecular testing, such patients often are negative, suggesting that they have probably cleared the infection and vascular injury is perhaps immune-mediated.
Interestingly, papular gloves and socks syndrome, occasionally seen in association with viral infections, especially Parvovirus, bears substantial similarity to certain COVID lesions, both clinically and histologically, with some reports even documenting evidence of leukocytoclastic vasculitis in the former.



-Clinical Relevance

Significant elevations in pulmonary pressures due to diffuse thrombosis strains the right ventricle causing hemodynamic dysfunction. Elevated D-dimer, pro- BNP, and troponin levels have been proven to be poor prognostic markers consistently across various studies. The development of an overt DIC-like state certainly portends a dismal prognosis.

Troponinemia in COVID can be attributed to severe right ventricular strain in the setting of pulmonary embolism and/or Pulmonary Intravascular Thrombosis. Some evidence also exists regarding the possibility of myocarditis, however, without classic lymphocytic infiltration characteristic of viral myocarditis.



To summarize, the intricate interplay of diffuse pulmonary intravascular thrombosis and MAS-like state drives the severe and often fatal pulmonary microvascular dysfunction in COVID.

SARS-CoV2 infection--> diffuse alveolar damage--> interstitial inflammation--> MAS like state--> massive activation of macrophages--> local inflammatory cytokine milieu--> Microvascular dysfunction--> Pulmonary  Intravascular Thrombosis

-Kirtan Patolia


Reference:

1.) https://doi.org/10.1016/S2665-9913(20)30121-1
https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(20)30121-1/fulltext

2.) https://doi.org/10.1111/bjd.19163
https://onlinelibrary.wiley.com/doi/abs/10.1111/bjd.19163

Monday, May 4, 2020

Bugs causing bloody diarrhoea - mnemonic

Hello

Bugs that cause bloody diarrhoea : HE Is ClASSY

enteroHEmorragic E coli
enteroInvasive E coli

Campylobacter
EntAmoeba histolytica
Salmonella (non-typh)
Shigella
Y enterocolitica


Hope that helps
- Jaskunwar Singh

Thursday, April 30, 2020

Friedreich's Ataxia Mnemonic

Check out this mnemonic if you have difficulty memorizing it :)



Metronidazole : spectrum of organisms covered mnemonic

Hello

Metronidazole has bactericidal activity against

Protozoa:
- Giardia
- Entamoeba
- Trichomonas

Bacteria: (anaerobic gram-negatives)
- Bacteroides
- Clostridium sp (doc in pseudomembranous colitis)
- GARDNerella
- H. pylori

mnemonic: GET BaC in the GARDEN, Hippo

- Jaskunwar Singh

Wednesday, April 29, 2020

Red man syndrome - ADR of vancomycin

Hello

Red man syndrome, RMS is an adverse reaction to rapid infusion of vancomycin that leads to flushing/redness of face, neck and upper torso. The mechanism of this reaction is histamine release (anaphylactoid reaction).

Prevention - slow IV infusion of vancomycin over 1 hr

PS - I remember this as lots of wine causes flushing, so does v(w)ancomycin ;D

That's all
- Jaskunwar Singh

Clinical vignette: Meningitis due to Listeria monocytogenes

Hello

Listeria monocytogenes is the 3rd most common organism that causes bacterial meningitis.
Cephalosporins do not cover this gram - positive bacteria under its spectrum. More aptly saying, the cephs do not kill this bacteria. So, especially in high-risk patients such as neonates, elderly, and the immunocompromised, cephalosporins are given in combination with ampicillin, and never alone.

Ceftriaxone is avoided for use in neonates due to its decreased biliary metabolism and sludging.
The choice of ceph in neonates and other high-risk groups in the case of meningitis is cefotaxime.

That's all
- Jaskunwar Singh

Authors' diary: No visitors policy during the COVID-19 pandemic

Tuesday, April 28, 2020

Clinical correlate: Sildenafil contraindicated for pilots

Hello

Not just type-5, but Sildenafil is also a phosphodiesterase type-6 inhibitor.
PDE-6 is present in the eyes.

What is AI and Why You Should Be Excited About It

In 1950, Alan Turing asked, “Can machines think?”. Fast-forward to 2010 and artificial intelligence can diagnose diseases, fly drones, translate between languages, recognise emotions, trade stocks and even beat humans at Chess and Go.

Artificial Intelligence (AI), in essence, is machines mimicking human intelligence. Now, that can be of two types:
1. One that's already here, narrow AI, where a computer performs some very specific task. Take for example, Apple's Siri or Netflix's recommender system.
2. The other, general AI, that remains science fiction for now. If you're thinking of Jarvis in “Iron Man" or R2-D2 in “Star Wars”, you're quite right.

An application of AI is Machine Learning, where the computer automatically improves at performing a task, with more experience. Deep Learning is a subset of machine learning that is more intensive; uses more data and more complex algorithms.

Now, as a community of medicos, why should we bother about tech at all? Well, the future of healthcare looks increasingly facilitated by technology. The aim is to shift from "treating illness" to "sustaining wellness"; to have have a more proactive, rather than a reactive, model of care delivery. AI will help redesign our services and better utilise our resources. The goal isn't to replace what humans do, but instead augment it.

Here are a few ways AI can potentially help medicine:
1. Image recognition and diagnostic radiography, eg: Qure.ai, and Stanford's CheXpert system 
2. Preliminary diagnoses, eg: Babylon Health, and DeepMind's Streams application 
3. Virtual nursing assistants, eg: Care Angel's virtual nurse assistant
4. Clinical trials participant identifier, eg: deep6.ai
5. Computer-assisted robotic surgery, eg: Heartlander miniature robot
6. 3D mapping and printing, eg: 3D printed heart stents
7. Administrative workflow assistance, eg: IBM Watson 
8. Fraud detection and Cybersecurity, eg: H2O.ai 

[The list is by no means exhaustive. I implore you to know more about the examples mentioned by simply copy-pasting them into Google search.]

To conclude, the future of healthcare looks exciting and will be far more collaborative than it is today, working in alliance with AI, data science, statistics, engineering, and genomics. The ultimate objective is always to improve quality of treatment and patient outcomes.

Author's note: If, as a med student or a doctor, you're interested in kickstarting your own career towards AI and healthcare, please let me know in the comments. I will appropriately refer you to the relevant resources. To give you a brief background, I’ve worked with data scientists on seven medicine related portfolio projects, utilising machine and deep learning algorithms. I worked as a clinician and a programmer (have professional working proficiency in Python). Here’s my top 3:
1. Breast Cancer Detection Using Python & Machine Learning, with a model accuracy of 95% using artificial neural networks and support vector machine, on Wisconsin diagnostic data set
2. Identifying Skin Lesions Using Python & Deep Learning, with a model accuracy of 79% using convolution neural networks, on Cornell HAMNIST-10000 data set
3. Determining the Efficacy of Corrective Spinal Surgery in Childhood Kyphosis Using Python & Machine Learning, with a model accuracy of 88% using decision trees and random forest classifier on a Kaggle datset 

Thank you for reading.

- Ashish Singh

Saturday, April 25, 2020

COVID-19: Whose Virus Is It Anyway? Possible origins of SARS-CoV-2

It's only reasonable you may want to know about the origins of the COVID-19 pandemic. After all, our lives have been affected, one way or the other. But was it the bat? Was it the pangolin? Or was it a lab experiment gone wrong? Let's look at the two most definitive evidence we have at hand: virus genomics and structure.

Evidence #1

The receptor binding domain (RBD) in the spike protein is the most variable part of the coronavirus family genome. SARS-CoV-2 seems to have an RBD that binds with high affinity to ACE2 from humans, and other species with high receptor homology. This RBD has six key amino acid residues.

Evidence #2

The second notable feature of SARS-CoV-2 is a polybasic cleavage site at the junction of S1 and S2, the two subunits of the spike. This allows effective cleavage by furin and other proteases and has a role in determining viral infectivity and host range. Insertion of proline to this site and subsequent addition of O-linked glycans are unique to SARS-CoV-2.

Keeping these in mind, we have:

Theory #1
Natural selection in animal before zoonotic transfer

As many early cases of COVID-19 were linked to the Huanan market in Wuhan, it is possible that an animal source was present at this location.

Given the similarity of SARS-CoV-2 to bat SARS-CoV-like coronaviruses, it is likely that bats serve as reservoir hosts for its progenitor. This "bat virus" or more formally, RaTG13 is nearly 96% identical to SARS-CoV-2. Its spike diverges in the RBD, which suggests that it may not bind efficiently to human ACE2. 

Malayan pangolins illegally imported into Guangdong province contain coronaviruses similar to SARS-CoV-2. Some "pangolin coronavirus" exhibit strong similarity to SARS-CoV-2 in the RBD, including all six key RBD residues. This clearly shows that the SARS-CoV-2 spike protein optimised for binding to human-like ACE2 is the result of natural selection.

Neither the bat nor the pangolin coronavirus, however, has polybasic cleavage sites. This means, no animal coronavirus has been identified that is sufficiently similar to be the direct progenitor of SARS-CoV-2. That said, the diversity of coronaviruses in bats and other species is massively undersampled. Mutations, insertions and deletions can occur near the S1–S2 junction of coronaviruses, which shows that the polybasic cleavage site can arise by a natural evolutionary process. This perfectly sets us up for our next theory.

Theory #2
Natural selection in human after zoonotic transfer

It is possible that a progenitor of SARS-CoV-2 jumped into humans to acquire the genomic features described above through adaptation, during undetected human-to-human transmission. Once acquired, these adaptations would enable the pandemic to take off.

All SARS-CoV-2 genomes sequenced so far have the genomic features described above and are thus derived from a common ancestor that had them too. The "pangolin coronavirus" has an RBD very similar to that of SARS-CoV-2, by the process of natural selection. From this, we can infer the same happened with the virus that jumped to humans. So we can say, with some degree of confidence, the insertion of polybasic cleavage site occured during human-to-human transmission.

From what we know the first case of COVID-19 has been traced back to November 2019. This presumes a period of unrecognised human-to-human transmission, between the initial zoonotic event and the acquisition of the polybasic cleavage site.

Theory #3
Lab experiment gone wrong

Basic research involving passage of bat SARS-CoV-like coronaviruses in cell culture and animal models has been ongoing for many years in biosafety level 2 laboratories across the world, and there are documented instances of laboratory escapes of SARS-CoV. In theory, it is possible that SARS-CoV-2 acquired RBD mutations during adaptation to passage in cell culture.

Having said that, the "pangolin coronavirus" with nearly identical RBDs, provides a much stronger explanation of how SARS-CoV-2 acquired these via recombination or mutation. The high-affinity binding of the SARS-CoV-2 spike protein to human ACE2 is most likely the result of natural selection on a human or human-like ACE2.

The acquisition of both the polybasic cleavage site and predicted O-linked glycans also argues against culture-based scenarios. New polygenic cleavage sites have only been observed after prolonged in-vivo passage whereas generating O-linked glycans likely involves an immune system.

Furthermore, if genetic manipulation had been performed, one of the several reverse-genetic systems available for coronaviruses would probably have been used. However, the genetic data irrefutably show that SARS-CoV-2 is not derived from any previously used virus backbone.

These are strong arguments that SARS-CoV-2 is not the product of purposeful manipulation.

Conclusion
Theory #2 seems most likely, given the information currently available, but more scientific data could swing the balance of evidence to favour one hypothesis over another. What's important is to further study the possible origins, not just for understanding the current zoonotic pandemic but also to prevent the potential future ones.

References
1. 'The proximal origin of SARS-CoV-2' by Andersen et al: www.nature.com/articles/s41591-020-0820-9
2. 'A pneumonia outbreak associated with a new coronavirus of probable bat origin' by Zhou et al: www.nature.com/articles/s41586-020-2012-7
3. 'A new coronavirus associated with human respiratory disease in China' by Wu et al: www.nature.com/articles/s41586-020-2008-3

Ashish Singh

Friday, April 24, 2020

Coronary artery anatomy mnemonic and video for visualization

Let's learn about the coronary artery anatomy today (and never forget it!)

Watch the video. Text and images below.


Coronary artery dominance and EKG changes

Hello, hello!

Coronary arterial dominance is defined by the vessel which gives rise to the posterior descending artery (PDA).

Funnel Plot

-also called as Begg’s plot
-type of scatter plot
-used to examine biases in meta-analyses

An ideal funnel plot is symmetric.
If no biases, 95% of studies lie within the triangle.


Thursday, April 16, 2020

Thioamides in pregnancy

Hello

Propylthiouracil is a pro. It always comes first (used in first trimester of pregnancy).
Methimazole causes Malformations in the embryo (teratogenic).

There are two M's in MethiMazole. This drug is used in second (and third trimester of pregnancy).
Propylthiouracil piles up, causing liver toxicity, thus limiting its use.

Hope it helps
- Jaskunwar Singh

Wednesday, April 15, 2020

Importance of Ischial spine

Following are the important points of the ishial spine :-
Mnemonic SID BPL
1) Station of fetal head is calculated with respect to Ischial spine.
2) Internal rotation of fetal head occurs at this level.
3) Deep transverse arrest occurs at this level.
4) It is site for giving pudendal block.
5) Place at which ring pessory inserted.
6) Levator ani muscle is attached here.

PS : Question which was asked in central institute examination (I felt it should be mentioed here)
Which ligament is felt while giving pudendal block?
Sacrospinal ligament.

Clinical pearl : TNF-alpha therapy

Hello

In case of granulomatous diseases, macrophages activated by Th1 cells lead to increased levels of TNF-alpha. Now, TNF-alpha induces and maintains granuloma formation. Basic, right?

So we give anti-TNF drugs (adalimumab, infliximab, etc.). However, they cause the granuloma to break down, thus leading to disseminated disease.

Bottom line - Always remember to check for the presence of latent TB before starting anti-TNF therapy.

That's all
- Jaskunwar Singh

Tuesday, April 14, 2020

COVID-19: effects on reproduction

Hello

In this post, I will be talking about effects of SARS-CoV-2 on the male reproductive system, as evidenced from a recent study.

Friday, April 10, 2020

COVID-19: Whatsapp group

I created a COVID-19 Whatsapp group to strictly discuss the medical aspect of the disease, the latest research/community practices. Email me if interested: medicowesome@gmail.com

-IkaN

Thursday, April 9, 2020

COVID-19: Neurological manifestations


Since the Chinese health authorities confirmed the first case of novel coronavirus infection, almost all of the clinical focus has been on the viral's prodromal symptoms and severe life-threatening adverse effects such as ARDS. However, neurologists all over the world have been reporting the neurological manifestations of COVID-19 such as, ataxia, encephalopathy, myelitis among others. One neurological symptom in particular received inordinate attention, anosmia, even though it barely has any diagnostic relevance. It is safe to say that the neurological deficits are ongoing in this pandemic without getting noticed appropriately. However, since we are in the early phases of understanding the clinical conundrum of the COVID-19, such relative blindness is expected.

How does SARS-CoV-2 enter the CNS?

Two pathways have been postulated:
1. Through the cribriform plate
2. Systemic circulatory dissemination after infecting the lungs.

Reported neurological manifestations:

1. Anosmia - Can be explained by the proximity of the olfactory bulb to the cribriform plate
2. Hypoguesia, dysguesia
3. Headache, malaise
4. Unstable walking or ataxia, dizziness
These four can occur in the early phase of the disease.

5. Cerebral hemorrhage - This has been hypothesized to be due to decrease in expression and function of ACE2 proteins, especially in hypertensive patients in whom the expression of ACE2 is already low. Given that ACE2 signaling lowers BP, lack of ACE2 function would lead to higher BP which might precipitate cerebral hemorrhage.
6. Cerebral infarction (acute cerebrovascular disease causing stroke)
7. Ondine's curse - The central respiratory centres lose their function, which consequently impairs involuntary respiration severely.
8. Acute encephalopathy - headache, altered mental status, convulsions.
9. Myopathy

Interestingly, the CSF in the patients were normal, which implies that COVID-19 does not cross the blood brain barrier and hence cannot cause meningitis or encephalitis. We should keep in mind that the neurological manifestations could be secondary to hypoxia, respiratory or metabolic acidosis and other complications of the COVID-19 infection.

Thank you!

-Vinayak

References:

1. Necrotizing Encephalopathy: CT and MRI Features
https://pubs.rsna.org/doi/10.1148/radiol.2020201187

2. Neurological Complications of Coronavirus Disease (COVID-19): Encephalopathy
https://www.cureus.com/articles/29414-neurological-complications-of-coronavirus-disease-covid-19-encephalopathy

3. Neurological Manifestations of Hospitalized Patients with COVID-19 in Wuhan, China: a retrospective case series study
https://www.medrxiv.org/content/10.1101/2020.02.22.20026500v1





COVID-19: Lymphopenia and pneumonia

Hello everyone!

In the context of COVID-19, we will talk about two specific terms: Lymphopenia and Pneumonia.

COVID-19 Pneumonia
We mention "pneumonia" when there is an acute inflammation of the lungs following an infection. Pneumonia is one of the common features in infected patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This pneumonia has various clinical and radiological characteristics depending on the stage of the disease. It evolves rapidly, even in asymptomatic patients from local unilateral to diffuse bilateral ground-grass opacities which progress within 1-3 weeks to consolidation or co-exists with. A retrospective study at Wuhan describes radiological findings from 81 patients with COVID-19 pneumonia. The predominant pattern of abnormality observed was bilateral (79%), peripheral (54%), ill-defined (81%) and ground-glass opacification (65%), mainly involving the right lower lobes. [1]

Instructions for new authors: Images, plagiarism, and grammar

Hello awesome authors,

I thought of writing a small guide on things to be mindful when posting images or writing new blogs.

COVID-19: Use of masks

Hi everyone!

We used the WHO guidelines to write the pdf and uploaded it over here

COVID 19: How to limit the spread?

COVID19 spreads primarily through droplets of saliva or discharge from the nose when an infected patient coughs or sneezes (we should so cough or sneeze into a tissue or flexed elbow). The SARS-CoV-2 can also be carried, that's why the handwashing is so important.

We use other means of prevention to limit the spreading, for example, masks and negative pressure rooms. Let us see how it is done.

Wednesday, April 8, 2020

COVID-19: Containment strategy by South Korea

Hello everyone!

In this post, we will discuss the manner with which South Korea managed to contain the virus rather successfully.

So let me help you catch up:-

Club foot: Age-wise Management Flowchart

Club foot is one that resembles a golf club. It is also called Congenital Talipes Equino Varus or CTEV.
Figure 1. Dennis-Brown Splint