Understanding randomization in clinical trials

Hi, 

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

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

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

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

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

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

Two most important  features of successful randomization:

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

Randomization techniques:

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

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

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

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

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


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

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

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


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

Thanks,
Dr. Gee


References:

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

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

Management of Stroke

Hello, seeker of knowledge! Let’s see how we manage one the most common emergencies in medicine, stroke or cerebrovascular accident.


PRE-HOSPITAL CARE:

Cincinnati Pre-Hospital Stroke Scale (CPSS) helps make a prompt diagnosis and includes FAST -

Face drooping

Arm weakness

Speech difficulty

Time to call Emergency Medical Services

HOSPITAL CARE:

TIA = Transient Ischemic Attack
ABC = Airway, Breathing and Circulation
BGL = Blood Glucose Level; Both HYPO- and HYPER- glycemia are to be corrected
Hhg = Hemorrhage
Lytes=Electrolytes; ABG =Arterial Blood Gas; RFT=Renal Function Test; LFT=Liver Function Test
rTPA = recombinant tissue plasminogen activator
ASA = Acetyl Salicylic Acid = Aspirin
UFH = Unfractionated Heparin;  LMWH = Low Molecular Weight Heparin

ADDITIONAL INVESTIGATIONS MAY BE DONE - PROVIDED THROMBOLYSIS, IF INDICATED PER CT - IS NOT DELAYED


TREATMENT PRINCIPLES:

To minimize:
Ischemic penumbra (area around umbra/ ischemia)
Secondary brain injury
Risk of recurrence


THROMBOLYSIS:

INDICATIONS -

Mnemonic: ADD 1/3rd to CT after consent

Age 18 years or more
Diagnosis of Acute Ischemic Stroke(AIS)
Duration of symptoms 4.5 hours or less
AIS involves more than 1/3rd MCA territory
CT reveals no hemorrhage or edema
Consent of the patient or surrogate decision maker

CONTRAINDICATIONS -

Mnemonic: SHIP BLAST

Stroke in the last 3 months
Head injury in last 3 months
Intracranial hemorrhage
Prothrombin Time > 15 sec
BP > 185/110
Lumbar puncture in last 7 days
Anticoagulants use / Arterial puncture in last 7 days
Surgery within last 14 days
Thrombocytopenia < 100,000

PRECAUTIONS:
No anti-thrombotics for 24 hours
No Foley’s catheter for 2 hours

ADVERSE DRUG REACTIONS:
Intra-cranial hemorrhage
Allergy


ANTI-COAGULANTS:

INDICATIONS:

Mnemonic: My L.A.P.D. job

Recent MI
Left ventricle aneurysm or dyskinesia
Atrial fibrillation
Prosthetic heart valve
Deep vein thrombosis prophylaxis


MEDICINE PEARL: MI and stroke have essentially the same pathophysiology. Clots blocking arteries! However, we give DUAL anti-platelet therapy [DAPT], i.e. Aspirin and Clopidogrel for MI while there’s only Aspirin administered to a patient with stroke.


NURSING CARE:
Bowel and bladder care
Prevention and treatment of bed sores

REHABILITATION:
Use of walkers and crutches
Full range of active and passive joint movements


FURTHER READING:
Other rehabilitative therapies offered
Risk factors and preventive strategies
Alternative drugs and procedures


Hope this helps. Happy studying!
-- Ashish Singh.

Pathophysiology and symptoms of STEMI

Hello awesomites! In this post we are going to discuss about STEMI.

So, let's get started with pathophysiology of STEMI.

A) Pathophysiology:

1) Atherosclerotic plaque in the coronary artery causes formation of the thrombos. However, in rare cases, plaque may be formed by emboli, congenital abnormality or coronary spasm.

2) In case of formation of the collateral circulation there is no STEMI development. When thrombos develops at the site of vasculature injury (Which may be aggregated by hypertension or increase in lipid content in the artery), two process initiates. Both process at the end causes formation of the clot.

3) Let us consider 1st process.
This process involves platelets. Due to injury, there is change in the flow of the blood, which includes stasis of the blood. Slowly, this leads to the formation of the first layer of the lipid core which is potentiated by collagen, ADP, NA and serotonin.

This also leads to platelets activation. Platelet activation means there is confirmational change in glycoprotien receptor 2b/3a on platelet.
Receptors become adhesive due to which there is fibrinogen adhesion. Fibrinogen is multivalent protein so, it holds two platelet simultaneously!
Also, there is increase formation of the thromboxane A2, which is the vasoconstricter causing further platelet aggregation.

4) Injury also causes exposure of cells to subendothelium which leads to activation of tissue factor. Due to this the external pathway of coagulation is initiated. This ends up forming clot with other process.

Pathophysiology of atherosclerosis

B) Clinical presentation:

1) Pain is the most common presenting complaint. Pain is usually - Heavy, Squeezing and crushing! (Sometimes it can be Stabbing or burning). Pain is similar to angina pectoris, but it is more severe and lasts longer and occurs usually at rest.

2) ‎Typically it occurs at the central portion of the chest with or without epigastrium involvement and sometimes radiates to arm.
Less common site of pain includes -Back, lower jaw and neck. Also, beneath the xiphoid process and episgastrium.

Pain usually occurs at rest and does not subside with cessation of activity which is in contrast to angina pectoris.
Pain is not uniformly present in patients with STEMI.

Painless STEMI is seen in DM patients and also in old people.

Note: In STEMI, there is no radiation of the pain to Trapezius. If in case, there is it is suggestive of pericarditis.

3) Also weakness, sweating, nausea and vomiting is also seen. Other less common symptoms include - Loss of consciousness, confusional state, arrhythmia and drop in pulse pressure.

C) Physical findings:

1) Patient keeps moving in an attempt relieve pain.
2) ‎Pain + sweating + coolness of extremities commonly seen.
3) ‎Substernal chest and sweating for more than 30 minutes suggests STEMI.
4) Patients have normal blood pressure and pulse rate in 1st hour of onset.

In 1/4th of the patients having "Anterior Infarction" there is tachycardia seen due to manifestation of sympathetic nervous system. Abnormal systolic pulsation caused by dyskinetic bulging of infracted myocardium. Leading to periapical area pulsation within 1st day and resolves on 1st day itself.

On the other hand, in half of the patient having inferior infraction we see  bradycardia and hypotension due to Parasympathetic hyperactivity.

5) Other physical signs: Ventricular dysfunction, 4th and 3rd heart sounds heard decrease in intensity of 1st heart sound and paradoxical splitting of the second heart sound.
6) ‎ Cardiac pulse decreases in volume, reflecting decrease stroke volume.
7) ‎ Temperature elevation upto 38°C in first week of STEMI.

NEET preparation in early years of MBBS

Hey everyone! 

Pratibha Jha agreed to write a post on how to study for NEET during MBBS for all those still in medical school! :D

Here is what she has to say -

1. Concentrate on individual year subject: Strengthen your subjects in that year itself.

2. Be friends with reference books: Don't get scared by the size. You don't have to read it completely but just the regular topics, markings, that you read from theory books. Read them from reference books. (Guyton, Robbins, Harrison, Love and Bailey - Always try to read these books!)

3. Raise questions in mind and search answers in books! 
Spend time on understanding what you read. Take help of online videos (Rajeev Ranjan anatomy lectures, Dr Najeeb lectures, Khan academy physiology class, Dr Smily ma'am, Dr. Karthikeyan biochemistry videos, embryology videos, Armando Hasudungan videos - are some specific ones but it is endless on YouTube)

Bottom line is take every effort to make your reading conceptual - it makes learning interesting, don't just mug it up.

Be consistent!
Take college classes, practicals, all exams little more seriously (too much sincere-ness is not possible but little will go long way :P)
Just be regular with reading and library. It is better to read everyday some pages then overloading at the end.

4. Should I join classes?
Yes, I feel it is required to make concepts so if possible join it!
Make sure to come and revise the notes after class or else you will forget them and can't even understand your own words written later.

5. When do I join classes? 
Two strategies:
I. I have joined in second year - it gives u very early orientation of PG exams which is important. It helps in UG years and university exams. You can build base gradually, there is no hurry. You can take your time according to your pace to understand stuff.

II. Some join in majors or internship but I feel by then you are hurried and already occupied by other things. You don't have time to read reference books. In short pressure starts building up. But the advantage is that your notes are fresh, you understand them and it's more fresh memory considering nearness of exams.

6. When to start reading medicine and surgery:
Minor, I feel, is good time. Always sit with pathology and pharmacology books alongside. When reading Harrison, don't be reluctant to go to previous year books when you are stuck with something.

7. MCQ books in UG? 
I think yes. I did it. It sounds too much but it is no extra efforts, really. It is just solving question based on what you have read and like revision, you have don't have to learn anything new. It is just compact version of what you have already read.

8. Read theory given in MCQ book or only solve question? Why not directly solve MCQ book?
Theory is very crisp, read it. Its not new information as you have already read it. First read from book, then read theory in MCQ book and then go for questions and not retrograde.

9. How to do all this together?
Example: If you are in second year, reading inflammation from pathology - Read Robbins, understand, then go through Devesh Mishra - read theory and then test yourself on a question. It is okay to be wrong! Keep solving.

10. Keep a balance. 
Don't neglect fun for studies and end up feeling frustrated and averted to books. Vice versa don't neglect studies for fun so much that at the end, it piles up to a giant monster and seems impossible. A balance between both is very much possible.

11. Don't give up if you don't understand something: It doesn't make sense in first 2-3 reads, really! So that's normal, keep reading and struggling with it till it starts making sense!

Hard work is the key to success. If you start early, it is easier later. So it is the best way. If you start late, it is difficult relatively but if you decide to give the hard work it takes, you can do it. It is never too late.

Written by Pratibha Jha

PS: Pratibha scored an All India Rank of 21 this year (Isn't she completely awesome?)

How to study for NEET by Pratibha Jha

Hey everyone! 

My awesome junior, Pratibha Jha, agreed to write a post on how to study for NEET :)

Her experience and study tips are so genuine - I feel like they can be applied to any exam - be it USMLE, PLAB or just a final year theory exam.

Here is what she has to say -

1.  Be focused on your aim and not on your distractions, weaknesses and problems. You have them, everyone has them. We are fighting so many issues in our mind but with so many thoughts and anxieties running through your mind - you have to take that one thought, "I have to do it" and focus on it repeatedly. The rest of the anxieties will blur out

2. Every subject is important. Make sure you read all the subjects. It shouldn't be like you know too much of one subject and nothing of the other.

3. What to read? Multiple choice question (MCQ) books? Class notes? 
If you have attended classes and have  notes, read them. Then solve questions and update it in your notes - the areas that are left out, whatever more important points you come across.

If not, MCQ books are good as well, they cover more topics. So less chance of missing out a question. I like to read MCQ book and add left out important points in my notes. You will know once you start reading, what suits you.

3. Time the subjects. Set a time for a particular subject. It can vary individually but try to finish a subject in that time limit. This keeps you tied up with a schedule. Otherwise, it takes forever considering every subject is huge in itself. But also make sure that you understand what you read and you're not hurrying up too much as well. It's okay if you're a little late of the schedule.

4. Always solve MCQs! 
It's a must. Make it everyday habit, not just weekly test!
Because ultimately, you have to learn to apply concepts on MCQs and it will only come with practice. I recommend the marrow app and pre pg app.
Whatever topic you read, back them up with MCQs of that chapter. It helps memorize better. Make it a mental rule - you have completed a topic only if you have solved its MCQs. Develop technique of eliminating rather than jumping directly on answers. Think about why the rest of the three options are not the answer.

5. Revise and revise!
Make sure you remember what you read, for that revise.
Before starting with a new subject, give 2 hours of the day to revise the subject that you have already done.

What to revise? Notes, tables, important MCQ and lines that you have marked. This is very important during first read - we all know what we will forget!

6. If you can't revise: Try to keep time distance between first read and subsequent revision to 1-2 week so that it doesn't appear from your memo. First read after you take up the subject like 1 month later, but just make sure to revise.

7. Remembering memory based info: Compile them, go through them frequently (eg I made a pdf via cam scanner of everything that's volatile for me (eg  paeds milestones, scoring of pancreatitis, trauma scores - TRISS/MESS/Glasgow..or list of osteochondritis, enzymes in biochemistry, or chromosomal locations, table of CD mutation/translocations in lymphomas) before sleeping and anytime you're having a break. Go through them frequently, it forms visual memory.

9. Images! Don't forget them. Keep looking for the images as and when you come across them. May be click it and make an album in your phone, keep seeing them when you have tea / fb break.

10. Surround yourself with the right people who will motivate you, will give you positive boost. Discuss difficult topics with them and please don't compare, underestimate or overestimate. Just be focused on how you are doing and continuously analyse yourself and work on your flaws. Stay away from anything that disturbs you mentally. Keep bringing yourself back to the track which leads you to your goals.

11. Time gone is gone. You can only compensate for it by focusing on the time you have right now in hand. It's never too late - never! You just have to start and be strong-headed!

12. Take regular tests and keep assessing your performance: Especially, in the last 3 months. Check where you lose more marks and focus on those subjects. Revise them more. Many of us fear that we will score less and lose our confidence but remember, it's all in the head. Do not lose confidence but let it make you stronger. If you don't score well, find out why you are not scoring well, find out where is the lag and work on it! All the best!

To summarize: Read - solve MCQ - revise - repeat!

Written by Pratibha Jha

PS: Pratibha scored an All India Rank of 21 this year (SHE IS SO COOL!)

Nonstress test and biophysical profile mnemonic video

The video is up!

Video notes, Nonstress test and biophysical profile mnemonic: http://www.medicowesome.com/2018/03/nonstress-test-and-biophysical-profile.html

Biophysical profile mnemonic and step 2 CK notes: http://www.medicowesome.com/2016/09/biophysical-profile-mnemonic-and-step-2.html

-IkaN

Nonstress test and biophysical profile mnemonic video notes

Video notes

Nonstress test: Measure the heart rate of the fetus in response to its own movements

Very easy to perform using a doppler.

The definition currently recommended by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (2007) is:

- Two or more accelerations of FHR
- Occurring within 20 minutes of beginning the test
- Acceleration should peak at 15 bpm or more above baseline
- Should last 15 seconds or more,

Assesses fetal well being.

Accelerations with or without fetal movements be accepted, and that a 40-minute or longer tracing—
to account for fetal sleep cycles—should be performed before concluding that there was insufficient fetal reactivity.

VAS (Vibroacoustic stimualtion): Vibratory sound stimulus to induce FHR accelerations.

Biophysical profile:
Sonography machine and Doppler ultrasound to record fetal heart rate.
Typically, these tests require 30 to 60 minutes of examiner time.

Five biophysical components assessed.

Normal variables are assigned a score of 2 each and abnormal variables, a score of 0.
Thus, the highest score possible for a normal fetus is 10.

Fetal breathing: > 1 episode of rhythmic breathing lasting > 30 sec within 30 min
Amnionic fluid volume: A pocket of amnionic fluid that measures at least 2 cm in two planes perpendicular to each other (2 x 2 cm pocket)

Fetal tone: 1 episode of extremity extension and subsequent return to flexion

Fetal movements: 3 discrete body or limb movements within 30 min
Fetal heart rate acceleration: > 2 accelerations of  > 15 beats/min for > 15 sec within 20–40 min

That's all!

-IkaN

PCR tests for HIV

The polymerase chain reaction (PCR) is a method of amplifying a sample of DNA exponentially.

Can be used for:
1. Detection of viral DNA in the patient (for diagnosis.)
2. Detection of HIV RNA (as a measure of viral load - track response to therapy.)
3. Detect mutations in the HIV viral DNA (for determining source of therapy failure.)

Introduction to neuroanatomy

This video was made by our Medicowesome Student Guest Author, Salman!!!!

UTI Series: Pathogenesis, risk factors and diagnosis

Hello Awesomites! :)

This post on Urinary Tract Infection (UTI) is brought to you by our passionate MSGA Calvin Ong K.Y. and me, Upasana Y. 

The following parts can be infected in an UTI:

- Kidney

- Urinary bladder

- Ureter

Infections of urethra is known as Urethritis, which is dealt under different clinical syndromes. Infection of the urethra is mainly caused by N. gonorrhoeae, C. trachomatis, M. genitalium. T. vaginalis, HSV, and adenovirus can also cause urethritis.

Pathogens

Escherichia coli - It is the most common urinary pathogen.

Proteus, Klebsiella, Pseudomonas species and Staphylococcus aureus are associated with hospital acquired infections because their resistance to antibiotics favor their selection. Catheterization and gynecological surgery increase risk for these infections.

Proteus infections are associated with renal stones. Proteus produces a potent urease which acts on ammonia, rendering the urine alkaline.

S. saprophyticus infections are found in sexually active young women.

Candida infection is usually seen in diabetic patients and in the immunosuppressed.

M. tuberculosis is carried in blood to kidney from another site of infection. (eg. respiratory TB)

Polymicrobial bacteruria is due to fistulas, urinary retention, infected stones or catheters.

Pathogenesis of UTI

1. COLONIZATION - Pathogens colonizes the periurethral area and ascends through urethra upward towards the bladder.

2. UROEPITHELIUM PENETRATION - Fimbria allow bladder epithelial cell attachment and penetration. Bacteria continue to replicate and may form biofilm.

3. ASCENSION  -Bacterial toxins may also play a role by inhibiting peristalsis (reducing the flow of urine)

4. PYELONEPHRITIS

5. ACUTE KIDNEY INJURY

Risk factors of UTI

IATROGENIC/DRUGS-

• Indwelling catheter
• Antibiotic use
• Spermicides

BEHAVIOURAL-

• Voiding dysfunction
• Frequent or recurrent sexual intercourse

ANATOMIC/PHYSIOLOGIC-

• Vesicoureteral reflux
• Female sex (short urethra ~4cm)
• Pregnancy (progesterone mediated smooth muscle relaxation to the bladder and ureters and compression of ureters by the uterus)

GENETIC-

• Familial tendency
• Susceptible uroepithelial cells 
• Vaginal mucus properties

Route of spread

• Ascending route
• Hematogenous
• Lymphatic

Signs & Symptoms of Urinary Tract Infection

Urinary tract affected:

1. Urethra – cause urethritis

-Burning and pain with urination 
(Urethritis is classified as an STI and not UTI by many textbooks)

2. Bladder – cause cystitis

-Painful urination

-Frequent and persistent urge to urinate

-Lower abdomen discomfort

-Cloudy/Strong-smelling urine

3. Kidneys – cause pyelonephritis

-Flank pain (Upper back and side)

-Fever 

-Chills

-Nausea and vomiting

Diagnostic Testing for Urinary Tract Infections:

Types of urine Samples

-Mid stream Urine sample

-Catheter specimen of urine during cystoscopy

-Suprapubic aspirate

-Early morning urine (TB of urinary tract)

-Initial flow (Urethritis, prostatitis)

                                                 

Test

1. Urine microscopy

-Pyuria (pus presented in urine + elevated white blood cells in urine)

-Hematuria (red blood cells in urine)

RBCs may be found in the urine during menstruation in a woman’s urine sample, thus leading to a false positive result.

-Motile bacteria – E.Coli, Proteus, Pseudomonas

-Non-motile bacteria – Klebsiella

-Presence of cocci – Staphylo-, Strepto-, Enterococci 

**Presence of WBC casts indicates pyelonephristis rather than cystitis

**If urine sample contains abundant squamous epithelial cells - sample is contaminated and results are not reliable

2. Urine dipsticks 

-Use different chemicals reagants on a strip that is dipped in urine to diagnose urinary tract diseases

-E.g. of dipstick result (positive leukocyte esterase, positive nitrite, positive haemoglobin)

3. Urine culture

-Culture of mid-stream urine – Blood agar, Mac Conkey agar

-Midstream void - ≥1 × 105 CFU/μL is consistent with infection

-Samples collected via catheterization -≥1 × 102 CFU/μL is consistent with infection

**Contamination of samples may occur when urine passes through outer third of urethra

**Therefore, numeric threshold of colony-forming units (CFU) per millilitre is used to confirm infection.

4. Imaging test:- 

It is not routinely done in case of UTI.

Ultrasonography is indicated

-Obstruction in urinary flow

-Stones

-Measurement of bladder residual volume in BPH 

-Recurrent UTI 

-Pyelonephritis or hematuria.

KUB is most useful in suspected case of urolithiasis.

Computed tomography urography is used to view the kidneys and adjacent structures, and may be considered to further evaluate patients with possible abscess, obstruction, or suspected anomalies when ultrasonography is not diagnostic.

If urinalysis is unrevealing, cystoscopy can be performed to evaluate for bladder cancer, hematuria, and chronic bladder symptoms.

Urodynamic studies can be performed for persistent voiding symptoms.

Intravenous urography - for hematuria evaluation if CT urography is not available.

Men with UTI

US with abdominal X-RAY and flow rate

• No abnormality detected  - no further imaging 
• Abnormal upper tract 
• Abnormal lower urinary tract - further investigation (e.g.cystoscopy,urodynamics or transrectal US)

We are grateful to our teachers. :)

- Upasana Y. and Calvin Ong K.Y.

Stroke Series: Cortical lobar functions

This is a basic post on our stroke series -
CORTICAL LOBAR FUNCTIONS.

1. Frontal lobe:
Okay guys, for frontal lobe, I think of an average guy (not the musician, not the good looking) trying to get a relationship - well, that's were you need your frontal lobe for.

• Personality - definitely, it's one of the prime qualities an average guy should have.

• Flirting skills - Social behaviour and language.

• Emotional control - you have to have good emotional control even if you fail at it multiple times.

• Other functions are Motor and Micturition.

2. Parietal lobe:
It has dominant as well as a non dominant side. For the dominant side, think of a calculator and for the non dominant side think of playing Tetris video game.

• Dominant side - Calculation and language.

• Non dominant side - Spatial orientation and constructional skills  (Tetris game).

3. Temporal lobe:
For the temporal lobe, it has both dominant as well as non dominant side. For this, you have to think of the position of temporal lobe near your temples, near which you have your ears, mouth and nose and for the non dominant side it's the musicians area.

• Dominant side - Auditory perception and balance, Smell, Verbal memory, Language.

• Non dominant side - Melody, Pitch, Non verbal memory (musicians remember music, not words, it's a weird way to remember!)

4. Occipital lobe:
O looks like an Eye to me O_o for vision.

    • Visual processing

That's all!

This is a basic post. I'll come up with a detailed one soon. Enjoy studying!

The Stroke Series is written by our Medicowesome Student Guest Author, Nikhil. More to come soon!

How I scored a 258 on USMLE Step 1

I scored a 258 on the USMLE Step 1 a year back!

How I prepared:

I studied for a total duration of dedicated 6 months. I used following resources:
-Google/Youtube/wikipedia (my prime educators)
-FA 2016
- uWorld offline 2016 (was tight on my budget so didn't buy online)
- BRS pyhsio (only did renal, body fluids and Acid base)
- BRS behavioural (only for devlopemental milestones, physician patient relationship, medicoloegal/ethical issues, healthcare delivery and epidemiology/biostats)
- High yield biostats (only for study designs, bias, probablities and aplha/beta concepts)
- BRS genetics (only for population and hardweinberg genetics)
- Shelf notes (anatomy)
- Beckers anatomy (only for selected topics in neuroscience [didn't do entire neuroscience], upper and lower limb)
- Beckers immuno/micro (for immuno and bactrial/viral  genetics [didn't do entire micro]
- DIT 2015 (short and precise, found it effective atleast for me)
- Kaplan 2014 video (only for pharma)
- NBMEs ( all of them)
- Kaplan Qbank offline (only for genetics, pathophysio and pathology)
-Goljan audio lectures

I started my prep with offline uWorld, did all the questions according to systems and used it solely as a learning tool.

Meanwhile, I was also using DIT, FA, Goljan audio lectures and NBMEs

- How did I use offline uWorld?

According to systems (first did all the questions of particular system followed by explanations with read of relevant topics in FA [This is how I integrated all the scattered topics in FA relevant to that system], I never read FA cover to cover but with this strategy I was going through the same topic many times.

Advice: Make seperate notes of UW acc to systems rather than annotating it on FA, clean FA really helped me in the end.

- How did I use audio/video stuff?

Parallel with UW and FA (It didn't take long, since DIT videos were short and oriented to FA. Goliyan audio lectures were also short. Kaplan pharmacology lectures I watched in  x1.5 speed [I really can't sit for straight 4 hours :D ])

- How much time all this took?
UW with FA and audio/video stuff took 4 months.

- When did I start NBMEs?

I started them right after after 1 month of starting UW & FA (first I needed to figure out what topics were  being tested and to what extent [though USMLE site gives info on it but you only get to know it when you start doing NBMEs], then I  focused on HOW CONCEPTS were tested rather than what concepts were being tested. By this type of analytics you get general idea of predicting different ways a concept can be tested.

Advice: Please start doing NBME early in your prep, all the NBMEs asess your baseline knowledge in different ways. So if used properly NBMES can be a learning tool aswell as an assessment tool.

Opinion: In my view NBME 12, 16 & 18 were closest to my exam (real exam was a beast but that doesn't mean its not doable). For me NBME 12 was an eye opener, it really fine tuned my Q approach and provided guidance on what areas to work on. It is after this NBME that i was able to push my scores beyond 180/200.
Note: I used NBME 1-11 for learning, practice and analysis.
NBME 12-18 I used for asessment.

- What about last 2 months?
In last 2 months I did assessment NBMEs (was doing it at every one week interval, in btw interval I was doing FA + my notes, read relevant topics from resources I mentioned in part#1, did kaplan Qbank questions and also BRS Qs (questions given in the back of each chapter and at the end of book) so one week before exam I was done with all the NBMEs.
- NOT TO MENTION THAT I was GOOGLING/YOUTUBING all the time during my prep...lol :D

- My NBME scores:
  Nbme 12 -178/200
   Nbme 13 - 190/200
   Nbme 15 - 188/200
   Nbme 16 - 183/200
   Nbme 17-  186/200
   Nbme 18 - 259 (online)
   Real deal - 258!

Advice: Before your exam do 2 NBMEs or UWSA 1 and 2 in a row in one day to practice endurance, because in my experience fatigue almost killed my concentration  in 6th/7th block.

Feel free to ask questions.
Study hard and smart.
Good luck everyone :)

Written by Ammar Mushtaq

Save lives, Donate blood.

Blood Donation

Facts about blood donation

1.     There’s 10 pints of blood in the average adult body (1 pint = ~473ml)

2.     1 pint of blood can save 3 lives

3.     Type O- can be transfused to patients of all blood types

4.     Red blood cells can be stored for 42 days

5.     Platelets can be stored for 5 days

Eligibility requirements

1.     18-60 years old

2.     Free from medication and alcohol (avoid alcohol a day before donating)

3.     Healthy (physical & mental, free from chronic disease)

4.     Sufficient sleep ( >5 hours ) before donating

5.     Does not involve in high risk activity (drug intake, multiple sex partners)

6.     Not pregnant, not during menstrual cycle

After donating

1.     Avoid strenuous activities

2.     Drink plenty of fluids

3.     If you feel dizzy, lie down with both your feet raised above head level

Frequently asked question

1.     How long will it take to replenish the pint of blood I donate?
-Red cell – 4-8 weeks
-Plasma – 24 hours

2.     How long should I wait till my next donation?
-Men – Once in 3 months

-Women – Once in 4 months

3.   Reasons to donate my blood?
      -Save life (accident victims, burn victim, patient who need surgery, dengue patient)
      -Reduce risk of heart disease
      -Replenishes blood cells
      -Weight loss
      -Free health check-up (please donate with the heart of saving lifes, not for the sake of free health         check-up)

You can save 3 lives just under 60 minutes, so why not? :)
-Calvin Ong K. Y.