Pursuing ophthalmology in India

Since my mom first introduced me to the slit lamp view of the eye and dad to the indirect ophthalmoscopy, I developed a liking for ophthalmology. The magnified view of the eye through the slit lamp just looks 'oh so beautiful' and it's such a fun challenge to master indirect ophthalmoscopy- I didn't think much in the counselling room while 'locking' the MS Oph option. Also, the fact that you have to work with all the cool gadgets and gizmos, lasers and stuff made me incline towards it.

Ophthalmology is a mutifaceted branch. Those who are into diagnostics and literature get their own share as well as those who want to take matters into their own hands and like to cut,paste, and remove things. The puzzle of diagnosis and the thrill of surgery, both can be had here.

Though not as demanding as general medicine or surgery, ophthalmic surgeries like cataract have a steep learning curve,a personal opinion of mine. But when you make sure that all the things fall into places rightly, it is highly satisfying an experience. The patient's smile the next day when they see clearly feels so good to the heart.

Experience in residency varies per college. I for one am happy with mine. I have done a few basic surgeries like pterygium and dacryocystectomy independently but under supervision during my  first year itself. Currently, I'm working on tunnel making in cataract surgery.
I have seen a lot of interesting cases of lids, cornea, and the fundus.
At times though, performing sac syringing of every pre op patient and filling up of discharge cards of the post op patients makes me go meh. But this is just nitpicking, I have a fair idea about the extreme workload of redundant stuff in other colleges.

After passing out, there are many fellowship programs offered by institutions. Getting a fellowship done is sort of a norm nowdays.

As mentioned before, this is an investment intensive branch, one needs to continually upgrade their machines and bring in new ones
if interested in establishing a privately owned set up. A job in an institution can be an option but things may get pushy or so I've heard.

Summing it up, this is like a cute little baby who is rather tough to please, but when you get it right, the smile is priceless.

How to leave a good impression during your clinical rotations?

Many of us are looking for observerships/electives in the US to gain some clinical experience, have recommendation letters and become more familiar with the medical system in USA.

In this post, I will shine the light on some points that will help in getting the maximum benefit from your rotations.

So, Let’s go:

1- Always come early and show commitment
If the working day starts at 7:30 am, be there at 7:20 am.

2- Dress properly
>Many hospitals have a dress-code, this is usually mentioned in the paperwork that you have to read/fill.
Eg: Business casual; shirts, ties and no jeans for men.
>Take care of your personal hygiene, use deodorants....etc

3- Write down notes
Have a small notebook and a pen. Write new cases that you see or any interesting syndrome. When you go back home, read more about these cases and check if there are any new scientific papers about them.

4- Be proactive
Don’t just sit and do nothing. Ask questions and check if you can present a case / give a talk or a presentation. Especially if you are doing an observership, the outcome at the end can really vary depending on how you use your time and how you reflect yourself as a doctor.

5- Know when to ask questions
It is nice to know more and to show interest but avoid the times when residents/fellows are busy, these include but are not limited to: pre-rounding, immediately after rounds when orders will be entered.

6- Don’t be “Mr. Know-it-all”
Although answering questions is important and can give a very good idea about you. Acting snobby and answering everything including questions that are directed to the residents may have an opposite effect.
Be patient and don’t interrupt. Answer when the question is directed to you or when it is open to everyone to answer.

7- Identify important "players"
Get to know who is the program director, the associate program director, attendings who are known to write good recommendation letters and those who are not. You will find a resident/senior/fellow who will provide this piece of info.
After all, you need to be remembered and to have a good recommendation letter when you apply for the match so do your best go get one! A strong recommendation letter from a chairman has much more weight than an average one from a newly appointed attending!

8- Be social
Respect everyone, smile, shake hands and introduce yourself to people who you meet for the 1st time. It is also cool to have nice conversations outside the field of medicine. For example, movies, books and sports. This will give an idea that you are well-rounded and more approachable rather than just an outsider who is there to do a job.

9- Discover the place
Try to be familiar with the hospital, its departments, the floors and the outpatient clinics. This will lessen the moments - especially during the first week of the rotation - when you will suddenly stop, conclude that you are lost and start blankly looking around :D

10- Remember that the first impression is vital and very hard to change, so be sure that the first impression that is made about you is positive.

In short, just be yourself and give it your best shot :)

Good luck everyone!

PS: this post is subjective to updates whenever I remember any new point that will help :)

-Murad

MIL : Pemphigus Vulgaris

Hi everyone ! This is my first MIL post ! 

My USMLE Step 1 Experience ( Road to 255 )

Hello everyone :) I would like to share with you what I did/studied for USMLE Step 1

It is gonna be long because I tried to include every single question that I was asked about my prep

First of all, I would like to thank everyone who I met during this journey from all over the world, Thank you everyone!

 Sources used for studying:

>First Aid

>First aid proposed and official errata (please check the proposed errata before studying any page in First Aid, it may have nice mnemonics, corrections. concepts..etc):

*https://www2.usmle-rx.com/proposed-errata-and-suggestions-fa-step-1

*https://firstaidteam.com/updates-and-corrections/

>Uworld

>Uworld biostat review

> +/- kaplan epidemiology part for step 2 ( those 2 youtube videos may be used in addition to  kaplan):

https://www.youtube.com/watch?v=75pQPB1RF50

https://www.youtube.com/watch?v=VMI9UuNqoGI

>Pathoma

>a person rearranged Pathoma into this amazing Onenote website:

https://onedrive.live.com/view.aspx?cid=375c2c99998a5c62&page=view&resid=375C2C99998A5C62!2705&parId=375C2C99998A5C62!2703&authkey=!AHH10BbZMBrqM0k&app=OneNote

>Sketchy micro and pharm videos ( I didn’t watch all videos but a lot them are really helpful)

>Kaplan videos for biochem / Sam Turco

>Kaplan step 2 patient safety chapter

>Conrad fischer 100 ethics cases

>+/- Flashcards notes ( Brosencephalon Anki deck for revision for some First Aid chapters)

>+/- BRS physio (curves and their questions in cardiology/respiratory)

 Method of studying:

>Did First aid general principles part except biochem 

Did some systems then went back to biochem

Then completed the systems

 >Uworld mainly done after first solid read of First Aid ( I started doing Uworld after finishing some of First Aid then I stopped and continued studying First Aid)

 >I didn’t do any online NBME but I solved NBME 15 16 17 18  and biostat and genetics questions in older NBMEs

Also did UWSA 1, 2 and FRED

(I felt my level was ok, I don’t advice you to do this..do 2 online NBMEs at least. I also didn’t try to convert my offline score and compare it..again, don’t do what I did :D)

==============================================

==============================================

 First Aid and Uworld are used for all the subjects in addition to what is mentioned below:

•  Biochem:

>Kaplan Biochem Videos by Dr. Sam Turco 

>Kaplan biochem book for pages that correspond to the videos only..fast skimming, don’t spend much time doing it!

•  Immuno:

>https://www.youtube.com/watch?v=T_4TrNRa3v8

>https://mynotes4usmle.tumblr.com/post/74125122501/anticancer-drugs-no-bms-mnemonic#.WnqBQZx97IU

>https://mynotes4usmle.tumblr.com/post/95332165430/immunosupressants-drug-mnemonic-bc-everythings#.WnqB-Zx97IU

•  Micro:

>Sketchymicro videos +/- pdf file of videos helps to cement info

>Use a lot of mnemonics whether from the proposed errata or any other source you find, also take care of the pics of organisms because they can be a question too.

> viruses DNA vs RNA and taxonomy mnemonic:

https://www.youtube.com/watch?v=Df_qAFF58Ec&t=1s

The video is drawn in a nicer way here too:

https://www.youtube.com/watch?v=rgz_3Yjw0vY

• General Patho:

Pathoma

• General Pharm:

Dr Raymond in Kaplan pharm about energy and inhibitors

•  Public Health Sciences:

>Biostat: the more questions you solve the better, as mentioned above: uw biostat review

>+/-Kaplan step 2 epidemiology may help in giving a broader idea for a person who is studying biostat for the 1st time 

>Conrad 100 ethics cases + behavioral:Kaplan step 2 patient safety chapter

•  Cardiology:

-Embryology:

https://www.youtube.com/watch?v=YxPp67XluQA&t=6s

 -Physiology:

BRS Physio - Cardio chapter ( if needed)

 -Pathology:

Pathoma

-Pharmacology:

Some mnemonics that may help in hyperdyslipidemia:

> https://www.youtube.com/watch?v=fTA5HOa87pM

> https://www.youtube.com/watch?v=HOXSaGpiSuo&t=3s

>http://www.medicowesome.com/2013/08/how-to-remember-lipoprotein-disorders.html

 Antiarrythmics:

> http://www.medicowesome.com/2014/10/antiarrhythmic-drug-classes-mnemonic.html

>http://usmle1mikmonics.tumblr.com/post/81324508295/bacman-class-1-antiarrhythmic-na-blockers

•  Endocrine:

-Physiology:

+/-BRS Physio 

-Pathology

Pathoma

-Pharmacology

Sketchypharm..some really nice videos for anti-Diabetic drugs

•  GI:

Pathology:

Pathoma

•  Hemonc:

>Pathology and a lot of physio:

Pathoma

>Pharmacology:

In addition to many mnemonics that are found online, you may check the anti-Neoplastic part of Sketchy pharm, I haven’t seen it but I heard it is cool.

• Musculoskeletal:

Pathology:

Pathoma

• Neuro:

Anatomy:

>Some books in First Aid are not clear enough ..eg: the foramina of the skull,,I suggest looking for some pics that are not clear in First Aid.

 > A much simpler way to understand Basal Ganglia:

https://www.youtube.com/watch?v=-5PXAUdWDgU

(the whole channel: “Draw it to know it” is amazing)

>An amazing video to memorize the Brachial plexus:

https://www.youtube.com/watch?v=gTas7ijp0YE&t=328s

>Sleeping associated neurotransmitters

https://mynotes4usmle.tumblr.com/post/74247543467/neurotransmitters-associated-with-sleep-mnemonic

Pathology:

Pathoma presents tumors in a simpler way

• Psych:

I suggest studying drug toxicities, DSM rules and drugs mech of action from Uworld because it is more arranged and accurate than First Aid.

• Renal:

Patho and some physio:

Pathoma is great in pathology here and some parts of physiology are covered too

• Reproductive:

>Physio:

Mnemonic for tanner staging:

https://mynotes4usmle.tumblr.com/post/152650094930/tanner-stages-of-development-mnemonics

>Patho:

The tumors part can be rearranged better in First Aid, I suggest focusing on Pathoma and checking the reproductive part here too, tables can really make things easier:

https://onedrive.live.com/view.aspx?cid=375c2c99998a5c62&page=view&resid=375C2C99998A5C62!2705&parId=375C2C99998A5C62!2703&authkey=!AHH10BbZMBrqM0k&app=OneNote

• Respiratory:

>Embryology:

http://epomedicine.com/medical-students/lung-development-embryology-made-easy/

>Physio:

+/- curves from BRS physio

>Pathology:

Pathoma

 ==============================================

==============================================

 General advices/Before Exam:

-Mnemonics:

Mnemonics (memory aids) are a very vital part of step 1 ( at least for me :D ) that make remembering stuff much easier. A lot of the data is very dry but it stuck to your mind with mnemonics especially with pictures. I suggest checking the mnemonics in First Aid itself, First Aid proposed errata and these two very awesome websites:

http://www.medicowesome.com 

(for sure :D you ll find mnemonics for everything here)

https://mynotes4usmle.tumblr.com

 -Concepts:

Although memorizing is very important for step1, be sure to understand the concept before memorizing it. This is especially true in physiology because one fact may be asked in many ways.

 -How much time needed?

I have seen ppl doing it in a period as short as 5 months ( esp if step2 is done before) up to more than 1 year with others. In my case, It was on and off but if you want to put a timeline I would say 6-7 months.

 -How many times do I have to do First Aid? 

No fixed answer to this question. It depends on your type of studying. Are you the type who likes to read fast then revise again and again? Or you like one solid 1st time then a fast revision?

I personally prefer a very solid 1st studying time with mnemonics and concepts and a fast revision after that. In my case, I studied First Aid once and skimmed it once

 -Active studying

After you study First Aid and solve Uworld, try asking First Aid facts in a question form, do that on Facebook groups,Whatsapp..or with your study partner. Asking facts in question form will let you see many lines in First Aid that your eyes can oversee!

 -Every single line can be a question

Please don’t omit any line, diagram..curve in First Aid, anything can be asked! 

 -Arrangement

It is not necessary to study the subjects in a system exactly like First Aid

The 2 that are very connected are physiology and pathology. I sometimes used to finish Anatomy, Embryology and Pharmacology then go back to physiology and pathology.

 -Taking notes

This really differs for every person, some ppl like to write notes on extra notebooks, others write on First Aid or add sticky notes to it.

I starting adding notes from Uworld to First Aid then I stopped and continued taking notes using the flashcard program/app: Anki

It lets you search, add pics, audio and video 

Always remember the best notes are those you make yourself.

(Taking notes may take a lot of time sometimes so it’s ok too if you use other ppl notes)

 -Revision

You can come up with any personalized revision schedule you like, for me, revision was done after I finish the whole chapter in addition to its Uworld questions in the form of questions and answers with my friends on Facebook/Whatsapp.

Some already made Anki decks are there for step1, the most famous one is the Bronsenchephalon deck.

 -What if I need more?

I suggest making Google images and Youtube videos your new friend, they can simplify a lot of concepts. I didn’t use DIT videos so I can’t comment on them. Idea is when you need extra clarification go to youtube or google and don't feel obliged to watch video series like DIT or Kaplan..etc

I believe that watching Dr. Najeeb’s videos or studying Goljan or textbooks..etc is NOT needed and is beyond the scope of Step1 and will just take extra time from you with no much difference in score!

 -Uworld..how many times?

Regardless of how many times you ll do it, the 1st time should be always so solid, understanding concepts, writing notes..etc

Because when you solve Uworld again, recall bias would kick in and you ll be able to answer some questions not because you understand them but because you remember the question.

 -Uworld timed or not?

Many factors affect this, but if it is your first time with the USMLEs, you can do some blocks untimed in tutor mode then try timed mode, if you feel there is no problem with time, you can continue doing tutor mode.

Another method done by some ppl is to do Uworld tutor mode first read then timed mode in their 2nd read.

This is also affected by how fast you read English, how you train your eyes to omit distractors and by resisting the urge to re-reading the question sometimes. 

With time, this becomes easier!

 -Uworld system-wise, Subject-wise or mixed?

It depends on each person and each has his own approach.

 I think the 1st time should be done system wise excluding anatomy, microbiology, biostat. Biochem and genetics 

Eg: Cardio => physio, patholo, pathophsyio, pharm...same for other systems

Anatomy should be done all together, same for biochem, genetics, biostat, micro

This will help integrating the relevant data together.

Mixed mode can be done for marked questions or the 2nd read of Uworld ( depending on how many times you ll do Uworld)

-How to approach questions?

Always read the last line first...sometimes you may be asked a pharmacology question that is 10 lines long, then the question may be: the drug works by the following mechanism! This will greatly help in saving time for more questions in the exam.

After reading the last line, you can start reading the question from the start, a good thing is to highlight the abnormalities or the main points so your eyes can pinpoint what the question is asking.

 -Kaplan Videos and qbank

This questions depends on your level. I did my step 1 after graduation and I did CK before that, so in my case, I felt I didn’t need videos to explain the basics for me.

>I felt kaplan videos were needed for biochem, because in First Aid biochem is not that clear.

My advice is to watch the videos by Dr. Sam Turco, then look at Kaplan Biochem book to read what he explained but don’t see other pages that he doesn’t talk about because they are low yield.

>Kaplan pharmacology vid by Dr. Raymond may be used to explain the general pharmacology part of inhibitors.

>Kaplan qbank: in my opinion, it is not needed but it may be used for more practice for genetics and biostats questions.

 -Ethics!

Even after studying First Aid, Uworld, Conrad Fischer 100 ethics cases, you may find some questions in the exam in which you are left with 2 answers to choose from. Follow your guts and move on :D

 -NBMEs

>My advice is doing NBMEs starting from NBME 15 ...till 19

At least do 2 NBMEs online to get used to the exam preferably NBME 18 and 19

In my opinion. Older NBMEs don't represent exam trend and may have some very strange questions..but if you have time, do the biostat, genetic bands questions to be more used to deal with those. If you really have more time and you want to do all of NBMEs, you can do them too but know the concepts.

>Take NBMEs as an average, mostly your score will be somewhere between your lowest and highest score, It is something good to see you score increasing in each NBME, but put in mind that mostly NBME17 is underpredictive and that online ones are graded differently than offline ones. 

>If you get scores in NBMEs that are near the passing score postpone your exam till you get a satisfactory result! Step 1 score will haunt you all the way :D so give it your best shot :D

 - Step 2 and Step 1

I did CK before Step 1 so it helped in Pathology, micro, ethics, biostat, behavioral and a lot of pharm. In short, any step that you do before will help in the next one which leads to shorter studying time.

Exam day:

 -Sleep well..arrive early,,skip the tutorial  

 -Breaks during exam?

>If you skip the 15-min tutorial at the start of the exam, you ll have an hour of break time

>I took a break after each block with a larger break after my 3rd block, relaxing more, eating a bit more.

>Eat a bit in breaks, go to the restroom and try to relax your mind,

>Wear something that has less pockets to save time because you will be checked each time you enter the exam room after any break.

>Do a simulation test for yourself before the exam, spend 8 hours with breaks in between and know when you feel more tired or more hungry and decide how to divide breaks in the actual exam accordingly.

 -WTF questions

No matter how much you study, be prepared to find some strange questions in the exam, don’t panic, just follow your common sense, choose an answer and go on.

After the exam:

 >You ll feel some relief, you did a great job...8 hours are gone and It’s time to breaaathe and maybe eat a large meal :D 

>Now your mind will start remembering every single stupid mistake you did and you ll feel like: Who did I do that????

>Now 2 things: either leave it and suppress your ideas and hide anything related to Step 1 or go and do a brainstorming session and remember everything to reach a level of internal peace with what you did.

>You ll have some waves of anxiety for score anticipation in the 3 weeks after your exam :D this is NORMAL :)

Good luck everyone!

Written by: Murad 

Adverse reactions of Digitalis mnemonic

Hey guys
I am back :D

My first blog post of the year - Adverse effects of Digitalis ( Digitalis toxicity ) mnemonics

Though the ADRs are divided into extra-cardiac and cardiac symptoms, I will present a more systematic mnemonification ;p

Pulp Stones

This post is about age changes in the pulp. If the first thing that comes to your mind is pulp stone! That's correct! So, Let's dive into pulp and learn more about it :))

In Pulp cavity, age changes causes 

• Cellular changes
• Fibrosis of tissue
• Pulp stones or denticles
• Diffuse calcification

Cellular changes

There is a decrease in 

• Number of cells
• Size of cell 
• Number of Organelles

Fibrosis of tissue

• Accumulation of bundles of fibers
• In radicular pulp: longitudinal fiber bundle
• In coronal pulp: diffuse fibers

Therefore collagen fiber content increases in pulp organ. 

Pulp stone or denticle

• They are nodular or calcified masses
• They have calcium:phosphate ratio comparable to dentin
• They can be Single or multiple
• Present in functional and unerupted teeth
• It is present in both coronal and pulpal portion

Classification: According to structure 

True pulp stone

• Rare 
• Found in the apex region 
• The remnant of epithelial root sheath within pulp induce pulp cells to differentiate into odontoblast to form dentin masses

False pulp stone:  they appear as concentrically years of mineralized tissue

Classification: According to location

1. Free pulp stone is entirely surrounded by Dentin 
2. Attached pulpstone is partially fused with Dentin 
3. Embedded pulpstone is entirely surrounded by pulp 

This Post is written by Anisha Valli,

Types of Dentin

Hey friends,

Dentin is a very important question.

It comes as a question worth 4 points in my theory exam paper! I have tried my best to make it simpler for you all in this blog :))

I hope this will help you!

Primary Dentin

It is divided into Mantle and Circumpulpal Dentin 

A. Mantle Dentin 

• First formed dentin in the Crown
• Type III collagen
• It is less mineralized
• Matrix vesicles are present which help in Globular calcification

B. Circumpulpal Dentin

• It forms the bulk of the tooth
• Type one collagen
• It is more mineralized
• Matrix vesicles are present which help in Linear and globular calcification

Secondary Dentin

• It is formed after the root completion
• It contains dentinal tubules which are S-shaped
• The mineral ratio is similar to primary Dentin 
• Secondary Dentin is a narrow band of Dentin bordering the pulp
• As age increases, inorganic content increases
• Therefore the Dentin becomes sclerosed
• It means It protects the pulp from exposure in older teeth

Tertiary Dentin 

It is formed in response to stimuli

Attrition
Abrasion
Erosion
Cavity preparation

• It is deposited on the pulpal surface of Dentin only in the affected area
• The appearance of Dentin varies as it is formed by an odontoblast 
• Quality and quantity of tertiary Dentin depends on intensity and duration of stimuli

Reactionary Dentin 

Dentin is deposited by pre-existing odontoblasts

Reparative Dentin 

Dentin is deposited by newly differentiated odontoblast-like cells

Written by Anisha Valli :))))

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.