Saturday, January 31, 2015

Study group discussion: Extrapyramidal effects of antipsychotics and treatment

Guys do you know the side effect/time line of antipsychotics?

I mix up akathisa  akinesia etc. Then there's tardive dyskinesia and dystonia!
So confusing.

4 hours dystonia
4 days akinesia
4 weeks akathesia
4 months tardive dyskinesia

Thank you!

I was discussing timeline of extra pyramidal side effects of antipsychotics earlier and got a doubt - Some books say akinesia comes before akathesia while others say akathesia comes before akinesia.
Like my book says opposite of the image of a book posted by someone on the group and I couldn't find a good resource online.
Anyone has an insight on what we actually see clinically?

Well after asking around it seems the general consensus is that akathisia precedes akinesia. At since it has logic to it that's what I'm sticking with.

Thanks! Why is it logical though? Because Parkinsonian symptoms take longer to appear?

Well akathisia is restlessness and agitation, and akinesia is when you start losing voluntary movements, and it seems logical that it would precede dyskinesia.

Makes sense to me now, thanks!

Hey concerning the extrapiramidal effects of antipsychotics, I consulted my Goodman and Gilman and found this:
Akathesia: 5-60 days.
Parkinsonian symptoms: 5-30 days.
There we go. Basically the argument could be made for either order since their appearance overlaps.

Oh. So you can't have a clear cut line. Thanks for this!

You use anticholinergics for akinesia, right?

Yes, right. And for akathisia beta blockers like propanolol is drug of choice.

Ohh and what's the treatment for dystonia?

Probably Anticholinergics or muscle relaxant like baclofen. Not confirmed.

Dopaminergic drugs
Anticholinergic drugs
GABA Agonists
Carbamazepine
They all can be used in dystonia!

Woah. I didn't know this.

Dopaminergic drugs like?

Levodopa

Here's a post I wrote after this discussion - Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic  http://medicowesome.blogspot.com/2015/01/antipsychotics-timing-of-evolution-of.html

Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic

Greetings people!

The timing of evolution of extra pyramidal symptoms of antipsychotics is something you should be thorough with:

4 hours dystonia
4 days akathesia
4 weeks akinesia
4 months tardive dyskinesia

I made a mnemonic for it because I have been struggling with it since forever!

The mnemonic is, "Distant people are Restless. Parking cars is Stereotyped and Retarded."

"Distant" is for Dystonia which comes first!

"Restless" is for akathesia (Compelling desire to move restlessly!)

"Parking" is for the Parkinsonian like symptoms seen in akinesia.

Sterotypical ("Sterotyped") movements are seen in tardive ("Retarded") dyskinesia.

Lastly, a mnemonic to remember the treatment of Neuroleptic Malignant Syndrome!

The mnemonic is, "BAD NMS"
Bromocriptine
Amantidine
Dantrolene

That's all!

-IkaN
Related post:
Extrapyramidal effects of antipsychotics and treatment (Link: http://medicowesome.blogspot.com/2015/01/study-group-discussion-extrapyramidal.html)

Study group discussion: Oculogyric crisis

What's oculogyric crisis?

I have read it a couple of times as a side effect of a couple of drugs, I don't remember the drugs though.

Neuroleptic drugs.

It's antipsychotic induced.

But what happens in it.. How does the patient present?

Sounds like deviation of the eye.

These are the ones I came accross:
Mutism, palilalia, eye blinking, lacrimation, pupil dialation, drooling, increased BP and HR, flushed face, headache, vertigo, anxiety, fixed stare or maximal deviation in all direction (usually at one a time), malaise.

Seems like it messes up your autonomic nervous system along with the eyes.

Yeah :-/

General question, what does gyric mean? Like is it a Spanish or Latin word?

Latin. It's like twisting.

Study group discussion: Hybridoma technology

Something about immunology?

What about immunology?

I love immunology. Have a separate immunology comics blog, as you probably know :D

Can you provide the link for the immunology comics blog?

immense-immunology-insight.blogspot.com

I thought you guys knew.

Thanks!

Hybridoma technology. I wanna know about that!

I'll have to read those up. Anyone in the group has an idea on those?

Hybridoma technology. Never knew of this. I'm reading into now. Cool stuff.

Let us know a short summary once you're done!

Yeah sure. I'll try.

If anyone can better explain please feel free.

This is regards to the question of Hybridomas.

Hybridomas are cells that have been specialized to produce a specific antibody in large amounts. Made by exposing the test subject (animal) to an antigen to which your insterested in isolating a antibody against.

Once the animals splenocytes are isolated, the B cells and immortalized myeloma cells are fused.

The new product is incubated in HAT (Hypoxanthine, Aminopetrin, Thymidine) medium. The medium is specialized to allow only the hybrids to survive.

The dilution process and the disired antibody production is then checked.

What ever cells are not producing the antibody they're removed and over a course of weeks the status of the subject is checked.

Oh I remember! We were taught this is first year!

Theres alot more. As far as I got :-/

Ohh thank you.

Glad I could help. Interesting read.

Yo it's really nice of you!

My pleasure.

Study group discussion: Myopia and power mnemonic

Myopia (short sightedness) mnemonic, "Cave May Be Long"

CAVE - We use conCAVE lens
MaY - in MYopia
BE - BEfore image is formed before retina
LONG - eyeball eLONGate

When eye become Myopic it is acting as converging lens (+) convex lens (bend the rays coming from object the rays towards centre) more power more convergence more bending so we use diverging lens which is a concave lens to correct or to neutralise the bending or converging.

Concave lens negative (-ve) power.

Another study link! http://medicowesome.blogspot.ae/2013/10/myopia-and-hypermetropia-mnemonic.html

Study group discussion: Remembering Anatomy

Is there any easy way to remember the relations of the viscera?

Diagrams will help you remember the relations! There are a few mnemonics for arteries and stuff but in general, painting a picture in your head is the best way to remember!

Use Atlas for visualisation, see  videos of anatomy (Acland, Dalhousie) for awesome live experience... Highly recommended.

Seeing the viscera during cadaver dissection also helps in anatomy.

For anatomy, I find it helpful to draw the pictures out and label them. This allows you to appreciate the boundaries. 

I always drew diagrams in anatomy..Netter's helped a lot. 

Dissections are equally important...I  always read anatomy and revised it in my dissection class

Paroxysmal nocturnal hemoglobinuria mnemonic

Here's a mini post on PNH!

P: PIG A gene affected (On X chromosome that makes a glycosyl phosphatidyl inositol anchor)
N: Night. Hemolysis occurs at night.
H: Ham test confirms the diagnosis.

Patient presents with a history of dark coloured urine in the morning.

That's all!

-IkaN

Study group discussion: Succinylcholine

Can someone explain succinylcholine?

Succinylcholine is different than other neuromuscular blockers because it has two phases.

It is broken down in our body by pseudocholinesterase. And this enzyme differs in different people based on genetics. Hence, while using as a muscle relaxant it can prove quite deleterious to some people who have a weaker type of the enzyme.

Deficiency of pseudocholinesterase in some people causes succinyl choline apnoea.

Also, pseudocholinesterase is different than the more common acetyl cholinesterase enzyme.

Hepatitis B serum markers mnemonic

HBsAg: Surface protein of hepatitis B which means the person has infection presently. It's a marker for current infection.
Mnemonic: S antigen Stays in Sick patients (Active or chronic infection, negative in resolved infection).

Study group discussion: Difference between acute myelogenous leukemia and chronic myeloid leukemia

Good morning everyone! Just about to start studying some haematology. I can't seem to differentiate between acute and chronic myeloid leukemias.

The number of blast cells help you differentiate on blood smear! Blasts cells are present in acute myelogenous leukemia and are absent in chronic myelogenous leukemia.

Philadelphia chromosome too.

Ph +ve or -ve

The philadelphia chromosome in chronic, right?

Yep.

But there are some CML's without the chromosome.

The major difference in AML and CML is the mortality.
Death in AML occurs in 2 months is not treated, whereas in CML, it prolongs to 4-5 years.

CML has three phases..Chronic, accelerated and blast transformation.
In blast transformation, the patient's profile converts to AML and the prognosis is grave.

Basophilia in CML, classically.

Auer rods are characteristic of AML.

Most prominent cells in CML are myelocytes and metamyelocytes.

Thanks for the help everyone :)

AML is of seven types.

Study links!

http://medicowesome.blogspot.ae/2014/02/french-american-british-classification.html

http://medicowesome.blogspot.ae/2014/12/cml-treatment-mnemonic.html

Thanks!

Study group discussion: When dealing with a lesbian, gay, bisexual and transgender patient

Although talking about it, makes me wonder how all of you would handle an LGBT person if you saw one in the course of practicing medicine (And you probably will... whether you notice or not).

LGBT?

Why would it be different if you are handling an LGBT patient?

Lesbian, gay, bi- and trans*

Their sexuality may be a thing to consider but I doubt it should alter your duty to care.

Mostly if you're handling a trans* patient, actually.  Things like referring to them by correct pronouns (which sometimes won't match the gender listed on their medical records), or using a name they're more comfortable with, even if it's not their legal name.

I know a gynaecologist who refused to treat a gay, referred him to another doctor.

Right.  And intersex people.  That's kind of controversial as far as medical things go.  What would you advise the parents of an intersex baby?
Intersex as in a baby that isn't biologically male or female.
A lot of the time doctors will perform surgery on them to make their genitals more male or female.  But a lot of intersex people think that's a bad thing to do.

We had a girl come to our clinic for primary amenorrhoea.
She was later diagnosed as genetically male.
Intersex girl with amenorrhoea. She was 15.

Oh, that's kind of interesting.
Did she want male genitals?

I don't think she was given much of a choice. And as far as I know..People out here prefer a male child better.

That's a great share.

Hmm.  I'm sorry to hear she wasn't given much of a choice.  I hope she identified as male.

My bff is an LGBT.
We've been best friends for 10 years now, so I know how to treat an LGBT person: just like another human being.
They're actually very sensitive on how you call them.
I used to have a male patient that was in transition and she told me to call her: female transgender. She used to show me pics of herself modeling at the patients room and they were actually awesome.
I don't think people should treat other people differently because of their sex preferences.

I had seen a neurofibromatosis patient in the bus once. They were no place to even stand there..But even then nobody sat besides him..It was heartbreaking.

I think on one hand, treating an LGBT person is the same way you should treat any other person, but there are also some things that are different, like having to be careful about pronouns and gendered terms (for trans* people), or being careful about how you refer to their potential partners (i.e. not referring to future boyfriends when talking to a lesbian).

Also nonbinary people have a hard time, because they can't always access transition (because a lot of resources for gender dysphoria are for people who identify as male or female), and because their gender can't go on their medical records since very few countries recognise nonbinary genders (i.e. people who don't identify as male or female, but kind of somewhere in the middle, or they don't identify with gender at all etc.)

I don't think patients should be treated differently regardless of anything.  I think everyone should be offered the same standard of care, regardless of race, sexuality, gender or even things like mental health status (I strongly disagree with people not being given the same quality of health care for self-inflicted injuries).

Human beings are different from each other, yet so similar.... That is what makes humans so beautiful in their own kind of ways.

Intersex babies are often taken into surgery here (They mostly make them "more male", bc it's a patriarchal society and having a son is important). There was a major case in Cyprus a few years back, a surgeon operated on an intersex baby without fully informing the parents about the condition and/or their options. The whole deal was very ugly.

I've been actively working to improve the conditions of LGBTI patients here for years. I work with local and national Queer associations, and Turkish Medical Students' International Committee to teach medical students about the LGBT community, so that we can be more sensitive and we can help them out more. The society here is quite homophobic, so trans people can't access healthcare at all in some places. Only 2 weeks ago a trans acquaintance of mine passed away due to an infection after her gender-reassignment surgery because some of the hospital staff didn't take care of her. Very sad situation.

I'm a queer person myself (most people can't decide if I'm a man or a woman when they first see me) and that also brings about some funny conversations. Patients tend to not care though, as long as I have the white coat on, I could be a 6 foot lizard and they wouldn't mind.

Haha the 6 foot lizard bit!
I like how people are able to get through any situation with a good sense of humor :)

That's amazing..Hopefully one day the world will stop labelling people.. And consider everyone a human.

That's a feeling I get everytime someone is chastised for their choices..I just say out loud..Have you looked inside a human body? I have! And I know for sure we all are the same on the inside.

Well put!

Study group discussion: Diuretics

Which diuretic would you use in a person who has a previous history of skin rashes by the use of sulphonamides?

The only loop diuretic you can use in a patient with sulfa drug allergy is ethacrynic acid.
Also, you have to monitor the levels... Because ethacrynic acid is the most ototoxic.

There is an antibiotic that causes ototoxicity too. Which one?

Aminoglycosides!

Study group discussion: A question on ascites

Here's a exam oriented question I made up:

28 year old male presents with abdominal distension. Temp 37, pulse 92, BP 110/70, RR 18. On examination you find that he has hepatomegaly, ascites and his jvp is 8 cm above the sternal angle. Urinalysis is normal. He has history of alcohol abuse, had a viral infection few weeks back.

What is the cause of his ascites?
Urinary protein loss
Malnutrition
Liver disease
Portal vein compression
Thrombosis of hepatic vein
Pericarditis
Nephrotic syndrome

Discussion:

Liver disease?

Umm it's not liver disease. He would have symptoms of jaundice if he had liver disease.

Ohh, I thought hepatitis virus.

Pericarditis! The jvp and viral infection is the catch here.

Yes!

Nice question.. Hungry for more!

I almost thought it was viral hepatitis then I remembered that viral hepatitis shrinks the liver...Good question ..moore.

But what's the connection between pericarditis and the ascites!? Someone explain please!

Blood can't fill in the heart adequately during diastole, which causes an elevated venous pressure. It results in JVP, ascites etc

What's the answer to the case IkaN?

It's pericarditis.

Anyone wants to guess the etiology? Like what caused the pericarditis?

Alcohol abuse? Immunosuppression?

The alcohol abuse was intended to be a huge distractor. The guy simply had viral pericarditis due to Coxsackie B virus.

You have to assume Coxsackie because it's the most common cause of viral pericarditis.

I read somewhere that people who binge drink a lot are at risk of getting bacterial pericarditis..Streptococcus or Staphylococcus type..I didnt know about viral...It makes a lot sense though..Epidemiology rarely lies.

Oh I didn't know this. I know that alcoholics are predisposed to spontaneous bacterial peritonitis.

Yah its due to low immunity..another risk is in patients who have undergone pericardiocentesis.

Yes.

What is the mechanism of pericarditis?

Pericarditis is when there is inflammation of the pericardial sac. One of the many uses of pericardial sac is to reduce the friction over the heart with every heartbeat. There also can be collection of fluid in the pericardial sac.

It can be acute or chronic, and is usually classified by what the pericardiac fluid contains.