Thursday, February 26, 2015

Study group discussion: Chain messages

There was a chain message being circulated on Whatsapp which started our discussion. The discussion gave me a new perspective on things.

I never read chain messages because I find them stupid. But one awesomite pointed out on how we must be aware of chain messages, since as a doctor, we'd undoubtedly run into patients who've read things like that and we should be able to talk to them about those things.

Also, tell us about stuff you've read on the internet that had no proved scientific basis, incidents of people who have believed such messages and outcomes associated with them. I'm interested and open to these things now as I feel there is value in knowing them.

I'm posting the discussion we had here for ya'll to read -

This was the "Prevent Swine Flu" message forwarded on our study group:
1. Frequent hand-washing (well highlighted in all official communications).
2. "Hands-off-the-face" approach. Resist all temptations to touch any part of face (unless you want to eat, bathe or slap).
3. * Gargle twice a day with warm salt water (use Listerine if you don't trust salt).
* H1N1 takes 2-3 days after initial infection in the throat/ nasal cavity to proliferate and show characteristic symptoms. Simple gargling prevents proliferation. In a way, gargling with salt water has the same effect on a healthy individual that Tamiflu has on an infected one. Don't underestimate this simple, inexpensive and powerful preventative method.
4. Similar to 3 above, * clean your nostrils at least once every day with warm salt water.
* Not everybody may be good at Jala Neti or Sutra Neti (very good Yoga asanas to clean nasal cavities), but * blowing the nose hard once a day and swabbing both nostrils with cotton buds dipped in warm salt water is very effective in bringing down viral population.
5. * Boost your natural immunity with foods that are rich in Vitamin C (Amla and other citrus fruits).
* If you have to supplement with Vitamin C tablets, make sure that it also has Zinc to boost absorption.
6. * Drink as much of warm liquids (tea, coffee, etc) as you can.
* Drinking warm liquids has the same effect as gargling, but in the reverse direction. They wash off proliferating viruses from the throat into the stomach where they cannot survive, proliferate or do any harm.

Is this actually good medical advice (Except for the sensationalist language...)?
1 and 2 definitely sound like good advice, but 6 sounds a little bit questionable to me.

Forwards always sound questionable to me! I've never heard about "Drinking warm liquids to prevent viral proliferation" though.. I'll look it up!

I tried Googling all sorts of stuff for the warm tea bit and found nothing on the 6th point.
Then finally, I Googled, "Reverse Gargling" and the forward created by the same guy comes up! There is no such thing!

It seems like a publicity move by the doctor who wrote it. (Why would any one list the names of hospitals they visit in an educational advice?!)

I'm interested in understanding the yoga for nasal cleansing!?

You can Google for videos. And do not try unless you are confident enough that you can do it. Sometimes the water goes in the wrong pipe!

I didn't mean interested as in wanting to try it :P
I'm from Britain so these sort of techniques are rare to say the least.

Yoga for nasal cleaning is simply putting water in one nostril and getting it out through other nostril. Simply irrigation and drainage.

Nasal yoga reminds me of Neti pots. Anyone wants to weigh the scientific evidence of that?

I wouldn't really trust this advice. I speak this from personal experience. Some guy who used to believe in these things told my grandpa to do some of these practices. He told my granddad to basically eat upwards of 6 lemons a day and also convinced him that the lemons would reverse effects of hypertension and diabetes. It didn't work, my grandpa passed away. I know this isn't relevant to the group, but I'm always wary of advice such as this.

That sounds so much like bad advice...  Everything in moderation. Six lemons a day is not moderation. Also, lemons have so much sugar in them, wouldn't that exacerbate the diabetes?

It's so sad that people believe such things and over do it causing more harm than good.

I didn't read after I looked at the last line - "Forward this to everyone and 20 might live cause of this." :/
It's when you guys got it to my attention that I actually read the whole thing!

I'm pretty wary of any kind of chain email advice. I think there's value in discussing them and critically analyzing them from a more scientific point of view, though. Especially since as a doctor you'd undoubtedly run into patients who've read things like that, and you'd need to be able to talk to them about those things.

I agree with that!

I once read of a case where a young girl was told to rub almonds on her face to clear acne, but her "acne" just kept getting worse. Turned out she was allergic to almonds.

Our residents had a discussion on how each and every relative was asking about Ebola because of the forwards they were receiving!

My aunt is very into chain emails.   I usually try to find time to point out all the scientific inaccuracies in them.

I don't trust anything.. Except soup for cold and honey for soothing the throat!

Soup works wonders!

See some things do no harm, like old wives tales of rubbing a potato on warts then burying the potato... But others are strange and potentially harmful.

There is some good science in some of these chain emails. But there is so much bad science.
Like the one that recommended aspirin to prevent heart attacks.   I mean, yes, it can certainly help, but it can also kill you if you have certain health conditions or if you try to overdo it.   Eating as much aspirin as you possibly can is also very much a bad idea.

The one I enjoyed most was the one that said cancer cells can't grow in alkaline environments so people should eat alkaline foods! I worked in a cancer research lab.  We grew cancer cells in alkaline medium!

Hahaha! This one is hilarious.

I was about to ask for hilarious incidents and here we have one!

Hahahaha my mum believed the alkaline treatment for cancer and my expression was basically: T_T
But there seems to be substantial information on alkaline treatments for cancer. Apparently, it's all over Google.

My aunt and mother believed it too.   But then I told them about the fact that we cultured cancer in alkaline medium with great success and they decided to believe me instead.

So umm what's alkaline food anyway?

Fruits are the main source of alkali in our diet. - Ganong

I tried looking up alkaline foods...  Orange was listed as one of them...

All I can think of is.. Food that alkalinizes urine. Cause citrus fruits do that!

Ah, that makes sense!

Hmm. I wonder if perhaps the foods that alkalinize urine can prevent cancer.  I doubt that causing the body to be more alkaline (Can that even be done?) would help with cancer, but perhaps the thing that makes foods alkalinize urine, or something else those foods have in common, also helps with cancer.

The only benefit alkalinizing foods can offer is prevention of kidney stones and maybe overdose of a few drugs, scientifically.

But then surely we would circulate "Food that contains this compound..." Rather than food that alkalised. If there was a common anticancer property that wasn't anything to do with alkaline food.

Hmm...  I'm disinclined to believe that The importance of knowing chain messages in modern Medicine it has any genuine anticancer properties, but I'm equally disinclined to reject the possibility.  I would like to see scientific evidence before forming an opinion either way. Medical research is constantly happening.  Just because we haven't discovered something doesn't mean it doesn't have merit.

I think the creator of the chain message (Considering he considered anything!) wanted to highlight that we should consume fruits to prevent colon cancer - so they used words like alkaline and stuff to make it all science-y and legit to the lay man?

That makes some sense, although I don't know why on earth they couldn't just use legitimate science.   It's possible to use fancy science words to make even basic science seem legitimate to people.   Especially with medicine where all the parts of the body can be expressed in fancy Latin.

But it spooks the lay-man into overdoing it. It's potentially harmful.

I agree so much. That's a very genuine concern. Even too much water can kill you, and I think that's a thing people fail to appreciate.

Yes, but in a perfectly healthy individual - Fruits would do no harm.

I must say, it's those who are affected by chronic diseases are more inclined to believe "Anything that could be of potential help" to them in curing their sickness.

*We discussed water intoxication syndrome. Since it's irrelevant to this post, I wrote a separate blog post on it here --> *

Woah. There are always some messages circulating on whatsapp regarding some wonder drug with a 100% guarantee.

My father gets influenced too. Due to some video.. I spent 15 mins explaining that white bread is bad for health and brown bread is good.

But but...Aren't the benefits of fiber well known?

White bread is simple nonsense.. It's bad for your intestines.. Plus no real nutrient benefit. It is refined wheat.. So there is hardly and fibre property to it.

How is it bad for the intestines?

I had come across a patient who had an intestinal onstruction. She was denied eating white bread. It reduces bowel movements.

“The Whiter The Bread, The Sooner
You’re Dead.” I've heard the phrase somewhere!

Exactly.

Wow. Seriously.

Whole wheat is all good. Except in patients suffering from celiac disease..I haven't come across any other condition where they shouldn't be eaten.

Gluten freeee.

Yup.

My mother was convinced that she should go on a gluten free, casein free diet even though she isn't diagnosed with celiac disease or anything like that. Someone told her that going GF, CF was good for everyone regardless of medical history.

It's not a bad idea per se, but I reckon patients who are not trained or well informed about nutritional science are at higher risks of deficiencies especially if they restrict their food choices. I think as physicians we should inform them of the possible risks and still provide them the autonomy and explain how to alter their diet to prevent deficiencies. Like vegetarians basically.

I guess I minded more that she wanted me to go on a GF CF diet and I enjoy too many gluten and casein containing foods for that to make sense for me.

Lol. Well I feel the same way. But we shud be realistic about the risks and not overexaggerate the dangers of gluten free diet because then the Coeliac's society might be affected as well.

But vaccines on the other hand, I'm sorry but we need to jab everyone possible because it's a public health issue.

Yes. Vaccines causing autism is utter bull. People are forgetting how bad the vaccine preventable diseases are (Since they don't see them anymore, thanks to the vaccines) and are being ignorant!

Study group discussion: CHARGE syndrome and related case

A newborn turns cyanotic upon breast feeding and crying turns him pink again? What's happening here? Also the mechanism?

Tracheo esophageal fistula?
That explains the cyanosis part only but in that crying won't turn him pink again.

Laryngomalacia?
In laryngomalacia, the cartilage collapses inward upon inhalation.
But that's not the answer.

Nasal polyps?
It is unlikely to have been formed in a new born infant.

Nasal or Choanal atresia.
He is breathing through mouth. Breast feeding obstructs his only breathing route. So he turns cyanotic. Crying allows him to turn breathe through the mouth, turning him pink again.

Correct! Full marks!

Thank you :P

What's CHARGE syndrome?

C coloboma
H heart defects
A atresia choanal
R retardation (mental and growth) G genital defect
E ear defect

Excellent!

Study group discussion: Mechanism of tet spells

Can anyone explain why crying causes cyanosis in Tetralogy of Fallot? I don't get the concept crystal clear.

In TOF, patient has the suck rest suck cycle. Starts sweating and cyanotic in breast feeding because he can't do the work of suckling. I think it's grade 2 dyspnea according to NYHA.

But how cyanosis and crying are related?

Increased catecholamines during crying causes increased right to left shunt.

Crying causes decrease in the pulmonary blood flow, increased right to left shunt and systemic desaturation that lead to cyanosis.

It also leads to peripheral vasodilation and further increase in R-L shunt when crying. There is release of catecholamines too which contributes as well.

But shouldn't catecholamines cause vasoconstriction?

Same doubt!

Yup, catecholamines causes vasoconstriction. Increased catecholamines causes decreased pulmonary blood flow and increased right to left shunt. That leads to activation of mechanoreceptors in right ventricle that inturn leads to peripheral vasodilation. Sorry if I'm confusing you all!

Ohh.. I get it. Basically, the pulmonary resistance increases.. Which causes shunting of blood, right? And the mechanism for vasodilation is different?

Yes. The mechanism is different.

They're called tet spells, right?

Yes, known as tet spells.

So it all begins with the catecholamines? Are they the main player here?

Yup it all begins with catecholamines.

So this phenomenon happens in a normal child too and it is aggravated in TOF due to pulmonary stenosis?

Obviously, due to pulmonary stenosis and ventricular septal defect.

Here's a link on tet spells! http://kidshearticu.com/cyanoticspells.asp

Of Iron, bacteria, hemochromatosis and plague

Iron is one unsung hero in our body. Apart from oxygen transport, it plays a vital role in constituting important enzymes as well as some detoxification reactions and also in converting sugars into energy.

But, during infections,the same iron stored in our body can prove lethal. It has been studied that bacteria use our very own iron stores to launch a full scale attack. That is why, intracellular bacteria like Mycobacteriae which use iron repositories in macrophages can cause so much damage.
It has been observed that a certain Somalian population, despite being anaemic was resistant to diseases like malaria, tuberculosis and so on. When doctors prescribed iron supplements, infections gained an upper hand. Actually, the population wasn't facing the infection despite the anaemia, but because of it!

Going by this, wouldn't patients with hemochromatosis be a playground for bacteria?

No!

Let me explain. Patients of hemochromatosis also have an another mutation, C282Y on HFE gene. This results into decreased levels of the C282Y protein, resulting into increased sensitivity of the WBCs to the chelator, transferrin resulting further into bacteria being unable to use iron as it remains 'locked' away at sites rather inaccessible to them.

Where does plague come into this?
It is being thought that when plague was rampaging through Europe, population with hemochromatosis was rather resistant and hence the gene for the disease was selected. This is why people of northern and western European descent have a higher prevalence of hemochromatosis.


Study group discussion: Shift to left

Would someone tell me what exactly is 'shift to left' in WBCs?

The production of immature cells... And release of them in circulation.

If you draw the stages of white blood cells from left to right, becoming more mature.. Shift to left would mean immature WBC's have been released into circulation.

Woah. Didn't know it.

Oh, thanks! Had this query since second year! :D

In which conditions do we get a left shift?

Infection, inflammation, leukemia.

Which leukemia? Acute or chronic? Myeloid or lymphoid?

I think it's fair to say it occurs in all leukemias.. I couldn't find a reliable resource online on the same.

Study group experience #12

So someone came up with this great idea about having study days. For example - Tuberculosis day, ECG day, anatomy day, etc.
The idea is - we could all study a particular topic and then discuss the same topic through out the day - as and when we come online, considering time zone differences.
It's all experiment-y, let's see how it goes though. Really excited!

Monday, February 23, 2015

Abnormal breath sounds: Crackles, Wheeze, Rhonchi and Stridor

Crackles (Also Known as Rales)
What do crackles sound like?
Roll your hair between your fingers next to your ear.. That's what fine crackles sound like! (Or the sound of salt heated on a frying pan, if you've ever tried cooking :P)
Coarse crackles sound like ripping open Velcro.

When are crackles heard?
Crackles are much more common during the inspiratory than the expiratory phase of breathing, but they may be heard during the expiratory phase.

Mechanism of crackles:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways or if atelectasis is present.

Causes of crackles:
Crackles is often a sign of adult respiratory distress syndrome, early congestive heart failure, asthma, and pulmonary edema.

Rhonchi
What do Rhonchi sound like?
Try making a snoring sound or try to make a sound as if you're gargling your mouth. That's what Rhonchi sounds like!

When are Rhonchi heard?
Rhonchi are more prominent on exhalation.

Mechanism of Rhonchi:
Secretions in large airways, as occurs with bronchitis, may produce these sounds; they may clear somewhat with coughing.

Causes of Rhonchi:
Pneumonia, chronic bronchitis, and cystic fibrosis are patient populations that commonly present with rhonchi.

Wheezes
What do wheezes sound like?
Try whistling slowly while exhaling.. That's what wheezes sounds like! Wheezes are continuous musical tones. 

When do wheezes occur?
Wheezes are most commonly heard at end inspiration or early expiration.

Mechanism of wheeze:
As the airway lumen becomes smaller, the air flow velocity increases resulting in harmonic vibration of the airway wall and thus the musical tonal quality. They result as a collapsed airway lumen gradually opens during inspiration or gradually closes during expiration. 

Causes of wheezes:
Heard when listening to an asthmatic patient. Sibilant wheezes are caused by asthma, congestive heart failure, chronic bronchitis, and COPD too.

PS: Wheeze is also known as sibilant rhonchi.
Rhonchi is also known as sonorous wheeze.

Stridor
What does stridor sound like?
Stridor are intense, high-pitched, continuous monophonic wheezes (musical sound) heard loudest over extrathoracic airways.  Similar to a creaking or a grating sound.

When is stridor heard?
They tend to be accentuated during inspiration when extrathoracic airways collapse due to lower internal lumen pressure.

Mechanism of stridor:
It usually caused by a foreign body obstruction of the larger airways, such as the trachea or a main bronchus.

Causes of stridor:
It is also the most common type of breath sound heard in children with croup (Laryngotracheobronchitis caused by parainfluenza) and a foreign body airway obstruction.
Also heard in Bacterial tracheitis, Diphtheria, Epiglottitis (H. Influenza) and Broncholitis (RSV).

Stertor
What is Stertor?
It is like stridor but it's more harsh, less musical and low pitched.

Mechanism of stertor: Respiratory sound that originates from pharynx, basically, anywhere  above larynx.

Causes of stertor: Seen in partial obstruction  of airway above larynx characterised by heavy snoring and gasping like in obstructive sleep apnea.

Thanks Nab, for explaining stertor to me!

Sunday, February 22, 2015

Study group discussion: Radiological findings in meningioma

A 36-years-old female has been complaining of recurrent headaches since four months. On examination, she has papilledema. MRI of brain showed an extra-axial, dural based and enhancing lesion in frontoparietal region with positive ‘dural tail’ sign. Diagnosis?

The dural tail sign occurs as a result of thickening of the dura. It's meningioma..

Other sign associated with meningioma is the mother in law sign..

The mother in law sign is perhaps uncharitably (depends on the mother in law I suppose) used to describe lesions that enhance early during the arterial phase and remain opacified well after the venous phase. The joke is that a mother in law comes early and stays late.

It is most frequently equated with the angiographic appearance of a meningioma.

Study group discussion: To anticoagulate or to not anticoagulate

One quick review question:
So patient has new onset atrial fibrillation. Would you start the anticoagulation right away?

Its only after 48 hrs of onset, that too you have to rule out intra-atrial thrombus by trans esophageal endoscopy. If the thrombus is present, you give heparin.

Yeah when there is thrombus that's a must! But let's say no thrombus now what? 35 yrs old male.  Can we start  anticoagulants?

There is specific criteria. For assessment of thromboembolic risk. It's called CHADS2.

Oh yes, if the score is >=1 then you start it. One point each for CHF, HTN, age >75, diabetes and 2 points for prior stroke or TIA.

If patients have not been adequately anticoagulated and the AF is more than 24–48 h in duration, a transesophageal echocardiogram (TEE) can be performed to exclude the presence of a left atrial thrombus that might dislodge with the attempted restoration of sinus rhythm with either nonpharmacologic or pharmacologic therapy.

It can be a different scenario!
* In the case I was discussing above the AF resolved soon after metoprolol.

And in that case anticoagulation are started as prophylaxis. So would be oral warfarin or the LMWHs.

Study group discussion: Charcot's in Medicine

I read about charcot and who knows the conditions, name of diseases starting with charcot?

Charcot Leyden crystals - Eosinophils in sputum of patients with allergic diseases.

Then charcot joint too.. In diabetes, syphilis. Neuropathic joints, basically.

Charcot triad is of which condition?

One is of infection of gallbladder - Jaundice, fever, right hypochondriac region pain.

Charcot's triad in multiple sclerosis is sin - Speech disturbance, intention tremors, nystagmus!

I thought intention tremors were characteristic of cerebellar disease.
Exactly but seen in MS though not pathognomonic.

More charcots?

Charcots disease is ALS.. Amyotrophic lateral sclerosis !

The ice bucket challenge one. It's other name is based on some famous baseball player, right? Lou Gehrigs disease!

Charcot's artery?
Lenticulostriate artery!

The ones responsible for lenticular infarcts? There are five types, right?

Pure motor, pure sensory, clumsy hand, ataxia and sensorimotor!

Charcot bouchard aneurysms!

Charcot marie tooth disease !

Charcot wilbrand syndrome- visual agnosia!

Nice one! Keep learning and sharing :D

Study group discussion: Pathogenesis of symptoms in glucagonoma

Why does glucagonoma cause dermatitis and DVT?

The exact cause isnt known, but one of the reasons may be, because the excess glucagon produced reduces the amount of albumin (which carries Zinc) hence producing a relative deficiency of Zinc. The similar type of which is also found in Zn deficiency. And hence, the dermal manifestation!

The dermal manifestation is called NME - Necrolytic Migratory Erythema

That was one of my MCQ! Also glucagonoma is the commonest type pancreatic tumours to occur in MEN 1 syndrome.

And deep vein thrombosis?

The mechanism for the coagulopathy is poorly understood and seems to be related to an increased factor X production by the pancreatic alpha-cells.

Anyone would like to name the 4 D's of glucagonoma?

Diabetes
Dermatitis (rash),
Deep vein thrombosis (e.g., blood clot in the legs)
Depression

Study group discussion: Can a child less than 6 months be given anything other than breast milk?

Hello. I had this little doubt, I'm in the second year and haven't been exposed to paeds yet. So...
Do you give a child below six months anything other than breast milk? If no, then what do you do if a mother isn't producing enough milk and the baby is still hungry?

What I learned in peds (only did one of three semesters so far) it's that there's very very rare for the mother to not produce enough milk. most of the times is a matter of wrong breast feeding technique.
But formulas can be used, if in the right proportion of formula to water.  Or even cow milk, but it also has a specific recipe to dilute it.

I'm not sure. It's probably not recommended as the milk will be different from the mother's.

You can use fórmulas, you can't give them cow Milk until they are one year old.

I learned that if the family can't afford formulas is ok to give cow milk since the birth. It has to be diluted with water and added some sugar and a drop of soy oil to make it more similar to breast milk.

It is possible that sometimes a woman other than the mother can breastfeed too.

In my peads wards, I have seen mothers giving top feeds with the not enough milk production excuse.

If the child doesn't have a mother, I think they're provided with diluted cows milk or infant formulas.
The only reason it isn't recommended in infants who have mothers who can feed their child is because they have nipple confusion / detachment and they won't consume the mothers milk anymore (Which is super important for the baby, since they have antibodies!)

Study group discussion: Krukenberg in Medicine

What is..
Krukenberg tumor? 
Krukenberg procedure?
Krukenberg spindle?

Study group discussion: Mifepristone

Major use of mifepristone in obstetrics gynaecology is?
A) ectopic pregnancy
B) molar pregnancy
C) fibroid uterus
D) threatened abortion

A??

Yes, it's A. Please explain.

Mifepristone is abortifacient. It causes abortion by blocking progesterone.

But what if the ectopic site is not in connection with the uterine lumen. How will it be aborted?

I guess progesterone level in required to maintain the implantation.. A decrease in progesterone will cause it ectopic pregnancy to abort from that place.

That's right.

Mifepristone is also sometimes used to end pregnancies when more than 49 days have passed since the woman's last menstrual period; as an emergency contraceptive after unprotected sexual intercourse ('morning-after pill'); to treat tumors of the brain, endometriosis (growth of uterus tissue outside the uterus), or fibroids (noncancerous tumors in the uterus); or to induce labor (to help start the birth process in a pregnant woman).

Rh incompatibility USMLE Step 2 CK doubt

If the patient is sensitized and is making Rh antibody, there is no point giving, Rhogam right?

Nope. It is only for prevention to Rh sensitisation. It's not the treatment.

I see!

So once she is sensitized, nothing can be done?

Nope.

So, say there is a mother who had a kid with hemolytic disease last pregnancy. Will I be giving her Rhogam next pregnancy?

No.

You monitor the Rh antibody levels (by titres using indirect antiglobulin test).

If >1:4 woman is considered sensitized.

If >1:16 do the spectrometric test by using fetal cells taken by amniocentesis (To monitor bilirubin levels!)

Bilirubin low: Repeat amniocentesis in 2-3 weeks.

Bilirubin high: Measure hematocrit of baby using percutaneous umbilical blood sampling.

If the baby is affected (Fetal hematocrit low), only treatment is to give blood transfusion to the baby in utero (Intrauterine transfusion) And delivery at 37 weeks. Or even earlier.

Ooh. I get it all now <3

Study group discussion: Drugs and conditions that enhance Digoxin toxicity and the mechanism behind it

I read some cool things today on the group!

Why is there an increased risk of toxicity with digoxin in hypokalemia, hypercalcemia and hypomagnesemia?

Answers:
Potassium and digoxin compete for the binding site so if there will be less of potassium more of digoxin gets the chance to bind leading to toxicity. The NaKATPase is the binding site.

Digoxin toxicity is aggravated by increased calcium cause more calcium accumulates intracellulary. This leads to increased contraction.
Calcium intracellularly also increases the generation of ectopic foci within contractile cells.

Magnesium is used as treatment in the treatment of toxicity.
Magnesium is the cofactor for the Na-k pump. Less magnesium..less functioning of the pump. Hence aggaravated toxicity!

Here's an additional fun concept:
Drug of choice for supraventricular tachycardia?

Answer: Verapamil.

So if you have SVT in digoxin toxicity.. Would you give verapamil?

Answer: No.

Why not?

Don't know? Let me approach the explanation in a way which helps you think better - What is the mechanism of excretion for digoxin?

Answer: Renal excretion.
Digitoxin is via hepatic.
Here's a mnemonic on renal / liver excretion of Digoxin / Digitoxin: http://medicowesome.blogspot.ae/2014/03/how-to-remember-digoxin-is-renally.html

So when digoxin enters the tubular cell, it is excreted into the lumen via p-gp receptors. Those are the same receptors responsible for multidrug resistant. In cases of anti-cancer agents and anti-malarials. You see, verapamil is one of the rare drugs that block p-gp. Hence, decreasing digoxin excretion, thus, precipitating it's toxicity.
*pgp refers to P Glycoprotein receptors

Verapamil for the same reason is used to reverse resistance to anticancer and anti-malarials. Pretty cool info, ain't it?

I just fell in love with the whole drama digoxin plays in your body :D
So what drug is used in SVT induced by digoxin then?

Answer: Beta blocker.

That's all for today!

I'm trying to edit the stugy group discussions in a more reader friendly format. Hope you like them!

-IkaN

Study group discussion: Food analogies in Medicine

Who likes oreo cookies? I came to know about the Oreo Cookie sign today!
It's seen on a chest x ray (lateral view) when there is a pericardial effusion!
The anterior most layer (the chocolate part!) is the epicardial fat.
The mid layer (the cream part...yumm!) Is the fluid.
And the posterior layer (again, the  chocolate part) is the pericardial fat!

Coffee bean sign seen in?
Sigmoid volvulus! Also called omega sign!

Name some terms that starts with strawberry referring some conditions in our body:
Strawberry cervix - Trichomonas vaginalis infection
Strawberry tongue - Kawasaki disease, scarlet fever.
Strawberry scrotum - multiple sebaceous cysts (They're actually calcified epidermal cysts aka calcinosis cutis)
Strawberry haemangioma!

Speaking of food analogies.. Let's catch em all!

Oat cell carcinoma - Small cell carcinoma of the lung.

Cafe au lait spots - Neurofibromatosis.

We had a chart in pathology department - 'Pathology restaurant'

Apple birefringence - Amyloidosis!

Apple peel sign - Intestinal atresia.

Bread and butter appearance -  Fibrinous pericarditis.

Bread crumbs appearance in complicated cataract!

Honeycomb appearance of lungs.
Interstitial fibrosis.
Also pneumocystis, not sure.

Honey comb appearance of liver too.
Which condition is honey comb liver seen?
Seen in actinomycosis infection of liver. Burkholderia is a gram - bacteria. The honeycomb liver is seen in burkholderia infection....Which causes abcess...It's a radiologic sign!
Woah.

There's nutmeg liver - right heart failure!

Onion skin appearance - Ewings sarcoma!

Another Onion skin appearence seen in?
It's seen in Hyperplastic arteriolosclerosis!

Swiss cheese appearance - Metropathica hemorrhagica.

Also swiss cheese pattern in multiple serpingenous ventricular septal defects in VSD.

What appareance is in caseous necrosis, tuberculosis granuloma?

Cheese like?

Yeah. Here in spain is called: Queso fresco!

Cheesy necrosis in tuberculosis!

Dry cheese appearance in candida growth.

Cottage cheese appearance is found in which pathology?
Histological finding of caseous necrosis e.g in tuberculosis.

Anchovy sauce - Amoebic liver abscess!

Salt pepper appearance in?
EBV.

Salt and pepper skull - Hyperparathyroidism.

Rice water stools - cholera!! :)

Currant jelly sputum in?
Klebsiella pneumonia

Currant jelly stools in?
Intussuception!

So this is obvious - Maple syrup urine in?
Maple syrup urine disease!

Blue berry muffin rash - Congenital rubella.

Mulberry molars - Late congenital syphilis.

Olive shaped mass - Hypertrophic pyloric stenosis.

I know about Peau de orange!
Breast carcinoma.
And why is that?
Blockage of cutaneous lymphatics due to infiltration.
Blockage of lymphatic causes accumulation in the third space so it swells and the point where ligament is attached to the skin becomes pitted. Just like the skin of orange which has many small pits.

What about orange eyes?
Orange eyes are seen in Leptospirosis.

Apple core sign is found in which disease?
Colon cancer
Oesophageal carcinoma
Also a sign of IBD, I think.

What disease have Chicken drumsticks like fingers?
Psoriatic arthritis.

Napkin ring appearance also in colon cancer.

Which disease had grapefruit appearance?
Hyadatidiform mole.

There's chocolate cyst of ovary - endometriosis.

And chocolate agar!

Updated on 28th February, 2015:
A sandwich sign (sometimes known as a hamburger sign) refers to a mesenteric +/- para-aortic nodal mass giving an appearance of a hamburger. Confluent lymphadenopathy on both sides of the mesenteric vessels gives rise to an appearance described as the sandwich sign. The sign is specific for mesenteric lymphoma (typically non-Hodgkin’s)

Sandwich vertebra - Osteoporosis!

Updated on 1st March, 2015:
IkaN, did you get salt and pepper retinopathy on your foodie blog?

Yes, EBV!

Okay, I read that as a part of rubella. Could you explain what exactly happens tho?

Salt-and-pepper fundus with diffuse pigmentary lesions can be the signature of a previous systemic infection that had ocular involvement. Examples include inactive chorioretinal scars secondary to Lyme disease, tuberculosis, syphilis, congenital rubella, toxoplasmosis and bartonellosis.

There's a salt and pepper appearance in skin too! Systemic sclerosis and scleroderma have salt and pepper skin.

I found another salt and pepper term! In osteitis fibrosa cystica, punched out lesions produce a salt and pepper appearance on radiography. Multiple myeloma as well!

Updated on 3rd March, 2015:
Potato tumor: Carotid body tumor
Coconut appearance: Hyatid cyst

Saturday, February 21, 2015

Study group discussion: Fatal familial insomnia, harmful effects of working at night and sleeping during the day

By the way, I saw a video on a very bad disease the other day - Fatal familial insomnia. Caused by prions just like Creutzfeldt Jacob disease.

I know about the disease.. I can't imagine not being able to sleep!

Has a late onset and the patient or rather I say victim does within a few weeks.
It's genetic.. Thalamus, sleep centre is damaged!
Therefore no sleep!
It's progressive, one falls into coma and finally death!
They basically sleep to die!

You can live without sleep for 5 days to a week, I suppose.

I had heard in physiology too.. That mice die if they are awakened before REM sleep chronically.

Even humans have reduced life span if they sleep for less than 4 hrs chronically.

Yes, I had heard someone who survived 2 weeks. He slept for only 4 hours per day

Why would anyone do that to themselves?

Workaholics.
Medical students!
Perfectionists.
Preparing for exams xD
We awesomites!

I sleep more than I should #vacations :P

That is also harmful.

How? =(
I get rebound insomnia though.

Read it in some article.

Ah.

6 to 7 hrs optimum.

Work hard. Sleep tighter.

Btw are there any harmful effects of working at night and sleeping during the day chronically?
I don't know and someone wanted to know!

Something related to messing up the circadian cycle? Because we have a diurnal surge of hormones?

Since all hormones are secreted at night and not sleeping at night disturbs the proper hormonal process... That's the reason people who don't sleep at night are also fat...

So they'd grow fat, that's it?

Anti aging 2, remember?
Serotonin mostly secreted from 11 p.m to 2 a.m and sleep during these is essential!

I found what I was looking for: Symptoms much like jet lag are common in people who work nights or who perform shift work. Because these people's work schedules are at odds with powerful sleep-regulating cues like sunlight, they often become uncontrollably drowsy during work, and they may suffer insomnia or other problems when they try to sleep. Shift workers have an increased risk of heart problems, digestive disturbances, and emotional and mental problems, all of which may be related to their sleeping problems. The number and severity of workplace accidents also tend to increase during the night shift. Major industrial accidents attributed partly to errors made by fatigued night-shift workers include the Exxon Valdez oil spill and the Three Mile Island and Chernobyl nuclear power plant accidents. One study also found that medical interns working on the night shift are twice as likely as others to misinterpret hospital test records, which could endanger their patients. It may be possible to reduce shift-related fatigue by using bright lights in the workplace, minimizing shift changes, and taking scheduled naps.

IkaN, goodjob!

Makes sense.

Is there any treatment for insomnia, if it's familial?

I don't think there is a treatment.. Since your thalamus is damaged, no pharmacotherapy can help you.
It's like in the thalamic pain syndrome, no amount of pain killers can help you!

So true! :(

Somogyi effect and dawn phenomenon in diabetes

So I read a lot of interesting things today and I'm formulating questions based on it.

A person took too much insulin at night and went to sleep. He checks his morning blood sugar levels and it's elevated. Why?

It's because stress hormones were released while he was asleep which caused the hyperglycemia. (This is called Somogyi effect!)

Now, a person took his appropriate dose of insulin at night and went to sleep. He checks his morning blood sugar levels and it's elevated. What happened this time?

There is a normal hormone surge at 7 am (Growth hormone, cortisol, glucagon and epinephrine) which caused the hyperglycaemia. This is called dawn phenomenon.

How will you differentiate Somogyi effect from dawn phenomenon? Why is this clinically relevant?

I guess the person with Somogyi effect will have certain signs and symptoms related to hypoglycemia. For instance, night terrors. Right?

People with hypoglycemia don't wake up but have nightmares.

The 3 am glucose levels to be precise. It is low in Somogyi effect and maybe normal or high in dawn phenomenon. You'll decrease NPH insulin at night in the former and increase the NPH insulin dose in the latter. 

NPH is an intermediate acting insulin. NPH insulin is usually taken at night. Duration of action 7- 14 hours!

In Somogyi, the excess insulin caused hyperglycemia. So you'll decrease the dose.
And similarly, in dawn phenomenon, the inadequate dosing caused the hyperglycaemia, so you'll increase NPH insulin.

If you're under the impression that is inadequate insulin and if you increase the dose of insulin, you can put the patient into a hypoglycemic coma! This is why, recognising Somogyi effect is very important.

I didn't get the management.. How is the adequacy of insulin assessed? If a patient comes with morning hyperglycemia, will you order 3 am glucose levels?

Nope. That would be hectic too. You wanna decrease the dose and see if the patient improves. If the patient doesn't, it means it wasn't the dreaded Somogyi effect and it was just the regular dawn phenomenon, so you can go ahead and increase the dose.

You keep tailoring the dose to suit the patient. 

Study group discussion: Some virology review questions

Hey everyone! I have a major virology exam coming up, would you like to go over some review questions with me? :)

Yes!!!

Great! I'll start:

Yaay!

Heterophile antibodies are positive in which viral infection?

These are multiple choice questions, shall I write the choices?

No, write them only when we can't guess it.

Ok :)

EBV?

Yes!

Which test is positive and is used to diagnose when there is an EBV infection?

Infectious mononucleosis.. Presence of human anti sheep antibodies, I think.

Yes! The test has a specific name though, anyone know it?

Umm.. Monospot test?

Coombs test ??

Neither of those

Would you like the choices?

Okay

Paul-Bunnel Test
Coombs Test
Indirect IFA
Western Blot
ELISA

Paul Bunnell! I forgot that.. Thanks!
Ok, ready for a new question?

Yes!

Which test is used to determine the specific genotype of HPV?
Another question would be, what is the first test you used to check for the existence of an HPV infection?

First test is Pap smear. Correct!

We'll need choices for the genotype - I'm guessing PCR though.

Ok here are the choices:
Consensus PCR
Line Probe Assay
Western Blot
Pap Smear
Latex aglutination

Consensus PCR?

No, I initially thought that too.

I'd say the line probe.

It is LiPA!

Why is that?

It uses the reverse hybridization to id specific  hpv genotypes by detection of specific sequences in the l1 region of the HPV genome.

It is more specific than the PCR

I see.

While we're on the topic of HPV, what are the high risk genotypes? And the most common low risk genotypes?

High risk: 16, 18
Low risk: 4, 6, 11

16 and 18 is usually used in the vaccine as well!

This changes a lot from place to place though, my medical faculty is working on developing a vaccine specially for this area/country

Oh that's great.. I didn't know that thanks.

:) no problem!

You guys want some more questions?

Yes

What is the main cause of non-bacterial gastroenteritis epidemics?

Rotavirus

That is one the choices here, but it's actually not that

Ooh. It's the main cause in India!

Choices?

Rotavirus
Norovirus
Adenovirus
Enterovirus
Astrovirus

Rotavirus usually infects infants and younger children, if I'm not mistaken.

Yup. So it's something else in adults?

Adults aren't really effected, the one we're looking for can infect people from different ages.

It's actually Norovirus!

It is the leading cause of viral gastroenteritis in the world!

Never heard of it :O
Is it the same as Norwalk virus?

Yes! Norwalk virus is a species of this genus. It's responsible for almost 90% of viral gastroenteritis epidemics globally!

Woah. That's a lot.

Norovirus happens in outbreaks, and stays infectious for a long time on surfaces yes?

Yes, exactly.

It's a calcivirus! http://medicowesome.blogspot.in/2014/04/how-i-remember-that-norwalk-virus-is.html

Family : Calcivirus, Genus: Norovirus :)

I'm going to have to leave soon, would you like 1 or 2 more questions?

Yes!

Which one of the viruses listed below, has a non-segmented genome?

Orthomyxovirus
Reovirus
Coronavirus
Arenavirus
Bunyavirus

Coronavirus?

Correct!

Review question: Does anyone know the clinical significance of the segmented genome?

A segmented genome has evolutionary advantages! Like, reassortment!

Allows reassortment and thus new viral strains in mixing vessels. Eg avian influenza.

What is the cause of Roseola?

Human herpes virus 6 or 7

Correct!

Brilliante!

One last question before I leave for now? :)

Yep yep yep

What is the most common cause of bronchiolitis in newborns?

Oh oh I know this.

RSV

Respiratory synctitial virus.

Correct :)

That was good, thanks!

I love random review question sessions!

Do it more often!

I have to go now, my friends are coming over to study! This was great, talk to you soon!

I have hundreds of review questions for my exam! Great! Looking forward to it.

This review question session was held by Fidan :) Thanks!

Friday, February 20, 2015

Study tips: Anxiety for test day

This is my first time talking to anyone I follow on anywhere... Be it twitter or tumblr. I am not very involved in social media, but I guess I am a bystander.

I am messaging you because I am in a bit of a dilemma. I am writing my USMLE step 1 exam in 5 days. I have been studying for it, believe it or not, for 2 years.

In this time, I have been home, my parents looking after me after I had gone to a med school on the island. I suffer from text anxiety... So like in the middle of the exam my brain just gives up, I feel at loss of hope. I just get this overwhelming feeling of failure.

I have bought the exam twice now and my date is scheduled for the last day possible. My parents are just fed up and they want me to get moving with my life. I have inconveninced them.

I have written all the NBMEs and I have never got a score above 300. I study so hard, but I hate to memorize if that makes sense. I have watched all the Kaplan videos, all the DIT videos and I have completed both Q banks. I know everything, but when it comes to route memorization... I can't do it for some reason, because I have this fear of it even is going to stick. I don't know what to do and I hoped some wise words from you might help me. You have some awesome things to say and they helped me lurch back up on a low day. I am literally trying to fly the coop right now.

Hope I am not intruding with my story.

- Email from an awesomite

Hey!

I'm glad you chose to speak to me.

The USMLE step 1 exam is scary. And it gets scarier as it gets closer. I had scheduled it on the last day too! My mum needed to go abroad and I had inconvenienced her. I never scored above 300 either in my NBME. But I got a good score on my step.

I'm telling you this to assure you that this is normal. That many have gone through the feelings you're going through and have made it before you. That you're not alone. That there is always hope.

You made it through various exams as you got here. Let's do this and get done with it. You have studied and you can trust yourself in midst of self doubt. You can do this.

You shouldn't be afraid of consequences. You've given your best shot. You have worked hard. Be confident that it'll work out for you in the best possible way.

Now this is a personal belief - I believe that not all five fingers are the same. Everyone is unique. That you have your own limitations and strengths. So some will score better than you, some won't. Accept it.

Once you have done your preparations well and that there is not one more thing you could've done, you must not worry about the results. Everything happens for the best. There's a good reason behind why things don't work out the way we want to - we don't see it right now but it doesn't mean it's not there. So I'm content with the results even before they come out.

I also believe that scores don't matter. That you can do wonderful things with your life without the scores. Yes, a good score will help you feel good about yourself and open doors - but a fear of a bad score shouldn't fill you with despair. The little anxiety you get should help you work hard, not come in your way.

I understand your memorization dilemma. Remembering things comes to us with repetition whether we like it or not.

There's not much you can do 5 days before the exam. But if there are certain high yield facts that you know you have not memorized - You can store facts in your short term memory and then forget them forever. We are capable of it. So you can't memorize everything, but please do what you can!

On the exam day: Focus on the question. Don't let your mind wander - go into past disappointments or future failures. Stay there. Read the question. What's the best answer to this question? Hmm.. This is an interesting one. What could the answer to this be? What are they trying to tell me in this question? Oh I don't know about this - will read about it later. The hints they're giving me are awesome. Ooh. This is a tricky one! I likey! I love medicine and it's enough. I'm living my passion. I'm lucky to be here. And that positivity, I tell you, will pull you through and give you hope.

I'm glad the things I said helped you. I hope this does too.

You're not intruding, be free to message me whenever you like (:

I understand that you might not get the time to reply after reading this - so I'll hear from you after the step. All the very best to you. I'll pray that you do well.

Love,
IkaN