Heme synthesis mnemonic

Hey everyone! Long time no see!

Today we'll be learning about heme synthesis.

The biosynthesis of heme mnemonic 

Study group discussion: Temporal arteritis

A 60 year old male presents with headache, scalp tenderness, painful temples, pain on chewing & visual disturbances.. Diagnosis?

Answer: Temporal arteritis

What tests you would do to confirm the diagnosis?

Answer: Raised ESR, temporal artery biopsy

Treatment?

Answer: High dose steroids like prednisolone!

Temporal artery branch of?

Answer: ECA, the external carotid artery!

Study group discussion: Causes of edema

Today, we'll be talking about causes of edema.

Causes of Edema can be inflammatory and noninflammatory!

Noninflammatory causes:
1) Increased hydrostatic pressure
2) Hypoproteinaema
3) Lymphatic obstruction
4) Sodium retention

Inflammatory causes:
1) Acute inflammation
2) Chronic inflammation
3) Angiogenesis

Here is a mnemonic shared by an awesomite: HILARI IS SAVE (Hilary)
Heart failure
Iatrogenic
Liver causes
Aldosterone increased/ ADH increased
Renal cause
Inadequate protein in blood (hypoalbuminaemia)

Causes for the inadequate protein in blood are:
Intake Inadequate (Kwashiorkor)
Secretion fro pancreas decreased (pancreatitis)
Synthesis decreased (liver failure)
Absorption decreased (Crohn's disease)
Vomit (pyloric stenosis)
Excretion increased (nephrotic)

I remember this in Conrad Fischer's tone, "Cirrhotic, Nephrotic and CHF. Cirrhotic, Nephrotic and CHF!" though.

That's all!

-IkaN

Study group discussion: Drugs contraindicated in myasthenia gravis

Hey everyone!

Today's topic is about drugs that are contraindicated in myasthenia.

Can you guess them all?

Drug a. Myasthenic woman with eclampsia develops ptosis

Drug b. Patient with hepatitis C develops respiratory depression

Drug c. Filmstar drug

Drug d. Wilson's disease

Answers:
a. MgSO4
b. Interferon
c. Botox
d. Penicillamine

Random fact:
The actor, Amitabh Bachchan has interferon induced myasthenia gravis which was used to cure his hepatitis C infection. And because of that he can't use botox.. Hence, his skin looks so wrinkled compared to other film stars of his age. Hence, two important drugs causing myasthenia and who worsen it are interferon and botox.

More information on study group

Here is some more information, since people have been asking!

How do I join?

Click here!

Can I view the group discussions without being on the group?

Yes! View the Study group index. All topics discussed may or may not be posted on the blog, do to time limitation, of course.

Study group discussion: Evening rise of temperature in tuberculosis and malaria

Why is there an evening rise of body temperature in tuberculosis?

Answer: Because endogenous corticosteroid have their levels low in the evening. Cortisol bursts are least frequent in the evening. And steroids are anti-inflammatory!

Why not in all infections? What's special about tuberculosis?
We don't know the answer to this question. If you do, please tell us!

This answer was submitted to us by an awesomite: Increased Cortisol Cortisone Ratio in Acute Pulmonary Tuberculosis: Recent research works regarding TB has revealed that there is increased cortisol level in TB.
Cortisol & IL-1 interaction: At high level cortisol has negative feedback effect on IL-1.
Conclusion: In TB, cytokines, specifically, IL-1 level is markedly increase that leads to fever, but as cortisol level is also high than normal it counteract the action of IL-1 & as a result fever remains low grade.
Due to exaggerated diurnal variation,cortisol effect is very high in late night while very less in evening onwards that leads to evening rise of temperature & night sweating. Normal diurnal variation of body temperature also play a role to make this change more prominent.
Source: http://www.doctorshangout.com/m/blogpost?id=2002836%3ABlogPost%3A423964

Even malarial paroxysms occur in the evening, don't they?

Answer: Yep. Malarial paroxysms have a different reasons. Steroids ain't responsible.

What's the reason for malarial paroxysms then?

Answer: It depends when the entire cycle of trophozoites burst from RBC's.

Here's from one of the members personal experience:
I have had malaria.. I had paroxysms at late night.

Study group discussion: Smoking and hernia

I have a doubt .. Today in surgery ward, my professor asked me how does smoking directly cause hernia! :/

I know the indirect cause! Coughing!

By weakening collagen?

Does smoking affect collagen synthesis or metabolism? At which step does smoking affect collagen?

It causes less production!
The synthesis of subcutaneous collagen in smokers is specifically impeded, indicating an impaired wound-healing process. Because mature collagen is the main determinator of strength of an operative wound, the results support the view that patients should be advised to stop smoking before an operation.
Source: http://www.ncbi.nlm.nih.gov/pubmed/9551072

In conclusion, smoking is an important risk factor for recurrence of groin hernia, presumably due to an abnormal connective tissue metabolism in smokers.
Source: http://www.ncbi.nlm.nih.gov/pubmed/11910469

Oh....ok. Thanks!

Autonomic system drugs mnemonic

Please give some tips on remembering cholinergic and adrenergic drugs.

- ine are beta agonists
(Terbutaline, ritrodine)

Drugs ending in

-sin are alpha antagonists 

(Prazosin, terazosin)

- olol are beta blockers

(Propanolol, metoprolol)

- alol are alpha + beta blockers (Labetalol)

- stigmine are cholinergic drugs
(Neostigmine, physiostigmine)

Alice in Wonderland syndrome

Came across this interesting syndrome a few days back. Described by Dr. John Todd 1955, it is also known as Todd's syndrome or lilliputian syndrome. The causative factors involved are usually migraines, tumors or hallucinogens. Epstein Barr virus is also thought to be associated with it.

Study group discussion: Structures that pass through the diaphragm mnemonic

When we go to thorax or abdomen... It's hard to remember their relation... Are there any tips?

What sort of relation? The relation of structures that pass through the diaphragm?

Yep.

Ok I know one mnemonic for that.

I ate (8) ten eggs at twelve.

I: Inferior vena cava
aTe: T8!
Eggs: Esophagus (Vagus rhymes with it!)
Ten: T10
AT: Azygous vein, Thoracic duct! Twelve: T12

So to summarize:
IVC - T8
Esophagus, vagus - T10
Azygous, thoracic duct - T12

Hope this helps!

Study group discussion: Purtscher's retinopathy

Does anyone know the name of retinopathy occurring in pancreatitis?

Purtscher's retinopathy!

What are it's characteristics?

Signs visible on fundoscopic examination include
pathognomonic Purtscher flecken and cotton-wool spots around the optic nerve n intraretinal h'age

Yes. The macula is affected too. Granulocyte deposition occurs in the posterior retinal artery.

Study group discussion: Chloroquine and Behcets disease

Antimalarial that causes irreversible retinal toxicity??

Chloroquine?

Yes. It's hydroxychloroquine..!!

Also used in...??

DLE, rheumatoid arthritis!

Lepra reactions too!

Also in extra intestinal amoebiasis!

Skin lesions in dermatomyositis!

Okay, so what pathology in the eye does hydroxychloroquine cause..??

It accumulates there because of high volume of distribution?

It causes Bull's eye maculopathy..!!

And the pathogenesis?

It is said that the drug binds to melanin in the RPE, which could explain the persistent toxicity even if after discontinuation of the medication!!!

I remember the use of hydroxychloroquine (Plaquenil) in Behcet's Disease. Follow up with eye exam every 2-3 months.

What's Behcets disease?

Behcets syndrome is inflammatory, multi system disease of small vessels resulting in frequent aneurysms and rupture..!! Eyes, genitals and mucous membranes are involved.

It takes many months to treat genital ulcers!

What is that test to confirm behcets..??

Pathergy test

Pricking the skin with a needle = pathergy test. After one or two days, people with Behçet's can develop a lump or nodule where the needle broke the skin.

Correct!

I had a patient with several mouth ulcer's looking like Aphthous ulcer. No other symptoms, just episodic mouth ulcers!

Okay.. Could be due to stress and vitamin deficiency..

And it turned out to be Behçet's disease.

They have a lot Behçet's disease clinic's in Turkey! Must be genetic which is why it is so common.

The exact cause of the disease remains unclear. But Behçet's disease is thought to involve an autoimmune response. This means the body's defense mechanism begins to attack its own tissues. Something in the environment may trigger this abnormal immune response in susceptible individuals. Genetic factors may also play a role.

It is common in young men in Mediterranean area..

Our patient was a woman.

Oh nice to know, thanks!

Study group experience #14

Cutaneous signs of insulin resistance and lipoproteinemia

Diabetes 

Electrolyte abnormalities that cause constipation 

Biceps femoris reflex

Scissoring posture 

Aspirin 
Cycloserine 
Morphine and atropine 
Drug for neurological manifestations of Wilson's disease 

ACE in lung diseases 
Central trachea in pleural effusion 
Walking pneumonia 

Aortic regurgitation 
Pressure and volume reservoir in the human body 
HOCM 
Cardiac embryology and fetal heart sounds 
Atrial septal defects - Why do they present late? 

Gallstone ileus
Hepatic encephalopathy 
Kartageners syndrome 
Haemosiderosis and haemochromatosis

Thyroid surgery practicals viva questions 
Venous ulcer 

Pre-eclampsia and HELLP syndrome 
Differentials of discharge in a pregnant woman 

Glycogen storage diseases mnemonic
Cytochrome c 
Agranular cytoplasmic reticulum
Colorful amino acids and pH

Difference between antibody and anti-toxin 

Lymph nodes in various diseases 

Chionablepsia and Anisakiasis

It's been a crazy busy week, especially with group 3 and all, I stay on my toes!

-IkaN

Study group discussion: Haemosiderosis and haemochromatosis

Differences between haemosiderosis and haemochromatosis?

Haemochromatosis is iron overload primary and secondary, iron overload is within cells and interstitium, causes tissue damage. Hemochromatosis is primarily genetic!

Where as haemosiderosis  is a form of secondary hemochromatosis due to repeated blood transfusions, deposition of haemosiderin in the cells, with reversible accumulation of iron in RES. I hope its clear!

So heamochromatosis is irreversible?
The tissue damage, I agree, will have consequences. But you can chelate the excess iron?

Yes! But reversible if in the form of secondary- haemosiderosis

Blood letting! Pts encouraged to donate blood it seems, and iron chelating agents would help.

Those untreated develop HCC
Even cardiomegaly
And endocrine issues.. Especially, pituitary and the adrenals

Yeah I think they continuously need to get their iron chelated

So it can be counted as reversible then?

Not reversible..But manageable.

Yes that's a good term actually

Controllable I would say!

Heart failure cells are macrophages laden with haemosiderin in LVF OR pulmonary odema.

Was an episode in house MD. The girl was suspected to have it cause her skin tone had changed several tones darker.

There was this one more episode where they diagnosed Wilson's disease based on the colour change of nailbed on rubbing it with nail remover! I so want to try that.

Really ?

The blood copper level wasn't raised.. No kf rings in cornea.
The lady was a mean woman.. She couldn't feel emotions.. Was manipulative. And the change in personality happened when she was a teenager.

Interesting!

They applied nail remover and behold.. The  nail turned blue.
I had a suspected case of Wilson's disease in my college.. She took discharge before I could experiment this.

There is even one more episode on Wilson's in season 1. They diagnose it by observing KF ring over the cornea.
Also, an another episode on Hemochromatosis with a mean chess playing lad.

Yup.. I remember both the episodes! The alcoholic mom with schizophrenia had Wilson's. And the jerk xD

Yeah! Actually, she did not have schizophrenia. They were the manifestations of Wilson's itself.

It was pretty cool how House figures that self sacrifice isn't a symptom of Schizophrenia

Yeah! I love the way House has epiphanies leading to diagnoses.

Study group discussion: Haemosiderosis and haemochromatosis

Differences between haemosiderosis and haemochromatosis?

Haemochromatosis is iron overload primary and secondary, iron overload is within cells and interstitium, causes tissue damage. Hemochromatosis is primarily genetic!

Where as haemosiderosis  is a form of secondary hemochromatosis due to repeated blood transfusions, deposition of haemosiderin in the cells, with reversible accumulation of iron in RES. I hope its clear!

So heamochromatosis is irreversible?
The tissue damage, I agree, will have consequences. But you can chelate the excess iron?

Yes! But reversible if in the form of secondary- haemosiderosis

Blood letting! Pts encouraged to donate blood it seems, and iron chelating agents would help.

Those untreated develop HCC
Even cardiomegaly
And endocrine issues.. Especially, pituitary and the adrenals

Yeah I think they continuously need to get their iron chelated

So it can be counted as reversible then?

Not reversible..But manageable.

Yes that's a good term actually

Controllable I would say!

Heart failure cells are macrophages laden with haemosiderin in LVF OR pulmonary odema.

Was an episode in house MD. The girl was suspected to have it cause her skin tone had changed several tones darker.

There was this one more episode where they diagnosed Wilson's disease based on the colour change of nailbed on rubbing it with nail remover! I so want to try that.

Really ?

The blood copper level wasn't raised.. No kf rings in cornea.
The lady was a mean woman.. She couldn't feel emotions.. Was manipulative. And the change in personality happened when she was a teenager.

Interesting!

They applied nail remover and behold.. The  nail turned blue.
I had a suspected case of Wilson's disease in my college.. She took discharge before I could experiment this.

There is even one more episode on Wilson's in season 1. They diagnose it by observing KF ring over the cornea.
Also, an another episode on Hemochromatosis with a mean chess playing lad.

Yup.. I remember both the episodes! The alcoholic mom with schizophrenia had Wilson's. And the jerk xD

Yeah! Actually, she did not have schizophrenia. They were the manifestations of Wilson's itself.

It was pretty cool how House figures that self sacrifice isn't a symptom of Schizophrenia

Yeah! I love the way House has epiphanies leading to diagnoses.

Study group discussion: Haemosiderosis and haemochromatosis

Differences between haemosiderosis and haemochromatosis?

Haemochromatosis is iron overload primary and secondary, iron overload is within cells and interstitium, causes tissue damage. Hemochromatosis is primarily genetic!

Where as haemosiderosis  is a form of secondary hemochromatosis due to repeated blood transfusions, deposition of haemosiderin in the cells, with reversible accumulation of iron in RES. I hope its clear!

So heamochromatosis is irreversible?
The tissue damage, I agree, will have consequences. But you can chelate the excess iron?

Yes! But reversible if in the form of secondary- haemosiderosis

Blood letting! Pts encouraged to donate blood it seems, and iron chelating agents would help.

Those untreated develop HCC
Even cardiomegaly
And endocrine issues.. Especially, pituitary and the adrenals

Yeah I think they continuously need to get their iron chelated

So it can be counted as reversible then?

Not reversible..But manageable.

Yes that's a good term actually

Controllable I would say!

Heart failure cells are macrophages laden with haemosiderin in LVF OR pulmonary odema.

Was an episode in house MD. The girl was suspected to have it cause her skin tone had changed several tones darker.

There was this one more episode where they diagnosed Wilson's disease based on the colour change of nailbed on rubbing it with nail remover! I so want to try that.

Really ?

The blood copper level wasn't raised.. No kf rings in cornea.
The lady was a mean woman.. She couldn't feel emotions.. Was manipulative. And the change in personality happened when she was a teenager.

Interesting!

They applied nail remover and behold.. The  nail turned blue.
I had a suspected case of Wilson's disease in my college.. She took discharge before I could experiment this.

There is even one more episode on Wilson's in season 1. They diagnose it by observing KF ring over the cornea.
Also, an another episode on Hemochromatosis with a mean chess playing lad.

Yup.. I remember both the episodes! The alcoholic mom with schizophrenia had Wilson's. And the jerk xD

Yeah! Actually, she did not have schizophrenia. They were the manifestations of Wilson's itself.

It was pretty cool how House figures that self sacrifice isn't a symptom of Schizophrenia

Yeah! I love the way House has epiphanies leading to diagnoses.

Study group discussion: Hepatic encephalopathy

In liver failure, what is the cause of hepatic encephalopathy?

They are not sure yet but they think it's ammonia.

Yes, NH3 and other substances.

They act as pseudotransmitters.

But how do ammonia levels rise?

Liver detoxifies ammonia by forming urea.. Failure to convert ammonia into urea.

Since liver is damaged.. Ammonia rises.

Does it occur on inhaling ammonia?

You mean, inhaling ammonia when liver is damaged or in normal people? Ammonia is an irritant to the 5th nerve, if I am not wrong. Why would anyone inhale it for a long time?

If by an accident?

Umm. I haven't heard of a situation like that

We inhale ammonia everytime we pass an unclean public toilet! :P

Argh.

Hahaha!

Study group discussion: Walking pneumonia

What is walking pneumonia?

Walking pneumonia is generally atypical pneumonia. It's called walking because even though you feel sick, you are not sick enough and you're walking around unlike the usual can't-get-out-of-bed pneumonia patients.

These patients have an interstitial inflammation that does not cause a consolidation like that of typical pneumonia.

Common causes include Mycoplasma pneumoniae and Chlamydia pneumoniae. 

Study group discussion: Venous ulcer

*a picture of an ulcer was posted on which this discussion took place in the group*

Which side is the lesion on? Medial or lateral?

If it is medial, it can be venous ulceration too! Mass obstructing the venous outflow.

Yup could be as it is superficial.. And also it could be venous ulcer because it looks like the ulcer is in gaiters area..above the medial malleolus..

What is gaiters area?

Gaiters area is where venous ulcers are usually seen. Above medial malleolus!

Where there is highest preasure in vein due to gravitational pull! And incompetent valve also in varicose vein

What's the name of the perforator in that area?

They are cockett boyd dodd and hunter from below upwards.

I have a mnemonic for the perforators

Do share!

http://medicowesome.blogspot.ae/2014/09/types-of-perforators-of-lower-limb.html

Study group discussion: Kartageners syndrome

What is Kartagener syndrome?

Immotile cilia syndrome

May result in Situs inversus
Bronchiectasis
Sinusitis

Glue ear too!

Infertiliy? Sperm motility is also affected i guess

Sperm motility is affected.
The protein involved is 'dynein'.

I've seen a case of Kartageners in my hospital. The auscultation and looking at radiographs was fascinating!

Study group discussion: Gallstone ileus

*a picture of gall stone ileus was posted in the group as guess the diagnosis after which this discussion took place*

Commonest position of obstruction by gallstone in ileum

Ileocaecal junction?

Not ileocaecal valve. The position in books have been mentioned terminal ileum. A little proximal to the ileocaecal valve.

Most commonly, obstruction occurs at the distal ileum.

I didn't know gallstone ileus could be this big. I imagined them to be tiny!

Me too!

I've heard there has to be a fistula for the stone to be that big to obstruct the ileum. Something that connects the gall bladder to the intestine.. Because a stone this big wouldn't pass the common bile duct

I agree with IkaN

Yup I'm sure the patient suffered from a fistula too..

It enters the intestine through cholecystoduodenal fistula commonly..

I've heard my resident mention fistula once

Yep.. And the predisposed patients are those with Crohn's disease! Thanks, just wanted to confirm it :D

Large stones, >2.5 cm in diameter, are thought to predispose to fistula formation by gradual erosion through the gallbladder fundus...

Ohh that makes sense! The huge stone itself causes fistula formation which is why they are common!

"A fistula develops between a gangrenous gallbladder and the duodenum or other parts of the gastrointestinal tract, allowing passage of the stone. Occasionally the stone may enter the intestine through a fistulous communication between the bile duct and the gastrointestinal tract."