Fragmented QRS

Fun fact: Fragmented QRS can be caused by conduction around the scarred myocardium, resulting in multiple spikes within the QRS complex.

-IkaN

No-reflow or low reflow phenomenon in total coronary artery occlusion

What is the no-reflow or low reflow phenomenon?

If blood flow to the ischemic tissue continues to be impeded after relief of the occlusion.

Why does this happen?

After prolonged cessation of coronary perfusion and restoration of blood flow to the epicardial coronary arteries, structural damage occurs to the microvasculature that prevents the restoration of normal blood flow to the cardiac myocytes. Various mechanisms are implicated in the genesis of the no-reflow phenomenon.

SLC gene Mutations and related Disease

Hello Awesomites!

Enjoy this crisp post on SLC gene mutations.

SLC= Solute carrier

SLC39A4	Acrodermatitis enteropathica
SLC26A4	Pendred
SLC6A9	Hartnup disease
SLC5A2	Renal glucosuria

FYI-Diseases associated with SLC6A4 include Anxiety and Obsessive-Compulsive Disorder

For further information read this article SLC transporters as therapeutic targets.

 -Upasana Y.

Fact- Reversible ADP-r inhibitors cause breathlessness

Hi

 Reversible inhibitors of ADP-r (P2Y12) such as ticagrelor, cangrelor, and elinogrel used as anti-platelet drugs have a unique side effect of dyspnea, unlike the irreversible ones. This is hypothesized to occur because of reversible inhibition of ADP-r on sensory neurons. Since half-life of the reversible inhibitors is shorter than that of irreversibles, repeated doses lead to permanent inhibition of the P2Y12 receptors on sensory neurons.

 Moreover, oral administration is found to cause more severe effects on the breathing difficulties than the parenteral route.

 Source- Research gate 

 

That's  all

- Jaskunwar Singh

Naegele's formula

 Naegele's formula

The Naegele's formula is a simple arithmetic method for calculating the EDD (estimated date of delivery) based on the LMP (last menstrual period). 

To the date of the first day of the LMP (e.g. 22nd June 2019):

• add seven days (i.e 29th)

• subtract 3 months (i.e March)

• add one year (i.e 2020)

Note: If the interval of cycles is longer, the extra days are to be added and if the interval is shorter, the lesser days are to be subtracted to get the EDD.

Lover's heel

Lover's heel is a term used for Gonococcal tenosynovitis of the Achilles tendon given the sexually transmitted nature of gonorrhea.

I just wanted to share this interesting fact with you.

-IkaN

Answer: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Question: 17-year-old male presents with confusion and drowsiness

A 17-year-old male presents with confusion and drowsiness for 1 day. 

He has been healthy and playing in the high school basketball team for the last 2 years. His practice sessions always included 10 minutes of intense work followed by a period of rest or decreased activity. He also had complaints of dark urine which the previous doctor diagnosed as dehydration and was asked to drink more water. 

He recently started a football club and has been playing football in addition to basketball. He has had oliguria for 4 days. Vitals are BP 124/86 mm of Hg, HR 85 b/min. Pupils are non dilated and reactive to light equally bilaterally. The remainder of the physical examination is within normal limits. Lab work shows:

Sickle cell retinopathy

 What is the hallmark of sickle cell retinopathy?

Sea fan neovascularization.

All patients with SCD should have dilated funduscopic examinations every 1 to 2 years beginning at age 10, preferably by a retina specialist.

Treatment is usually Laser photocoagulation.

Anti-VEGF medications such as bevacizumab or ranibizumab may lead to partial regression of sea-fan neovascularization.

Sickle cell anemic retinopathy is seen mostly in heterozygous S-C trait and S-Thal trait. 

Fun fact: Sea fans are beautiful soft corals.

-IkaN

Anion Gap

What is Anion Gap?

We need an equal amount of anions and cations to keep the body electrically neutral. So anion gap is not a real thing, it is just a diagnostic concept. Remember, in cations, we mainly measure Na, the other ‘unmeasured’ but important cations are K, Mg, Ca. Unmeasured means not routinely measured. In anions, we routinely measure Cl- and HCO3-, others important but ‘unmeasured’ anions are PO4, Sulfate and  Albumin.

The formula: Anion gap=Na-Cl-HCO3

(normally 8-16meq) is calculated mostly in metabolic acidosis as either normal anion gap or increased anion gap.

Now the most important thing to always remember is that, if due to anyreason, HCO3 or Chloride (measured anions) decreases, the relative concentration of unmeasured anions will increase, as if the unmeasured anions are trying to compensate the loss of their fellow measured anions by increasing their own concentration 

             In Metabolic Acidosis, HCO3 is low, assume that Na is unchanged for now,  so due to low HCO3, other anions like Cl-( measured) and other unmeasured anion will try to compensate by increasing themselves. If Cl- can increase to replace to loss of HCO3’s negative charge, the anion gap will remain within normal limits, if Cl- is too low and can't compensate, then, by the formula AG=Na(normal)- Cl(low)-HCO3(low), The Anion Gap will increase.

- Vaibhav Jain

Breastfeeding in COVID-19

BREASTFEEDING IN COVID-19

Hello Friends!

     On the International Breastfeeding week, I would like to share information about “Breastfeeding in COVID-19”, whether it is safe or not to breastfeed the neonates & infants in this pandemic situation.

The COVID-19 Virus has not been detected in the breast milk of any mother either with confirm or suspected COVID-19. So, COVID-19 testing does not have any immediate implications for decisions on infant and young child feeding .The numerous benefits of breastfeeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.Meanwhile researchers continue to test breast milk from infected mother.

Some information that you all need to know are-

1)WHO recommends that all mothers confirm or suspected COVID-19 continue to have skin to skin contact and to breastfeed. In all socio – economic conditions breastfeeding improves-

- Survival and provide lifelong health

- Development advantage to newborns &infants

- Reduce the risk of breast cancer & ovarian cancer in mother

- Skin to skin contact including kangaroo mother care reduce neonatal mortality especially in low birth weight newborns and it also improves thermal regulation of newborns and several other physiological outcomes. There are numerous benefits of skin to skin contact and breast feeding substantially outweigh the potential risks of transmission and illness associated with COVID-19.

2) While infants & neonates can contract COVID-19 they are at low risk of infection .A few confirm  cases of COVID-19 in young children have experience only mild or asymptomatic illness.

3)In all socio- economic settings Breastfeeding improves survival and provides lifelong health and development advantage to new born & infants.

4) If a mother is confirmed / suspected COVID- 19( for the time when she is likely to be infective ,i.e. while symptomatic or through the 14 days after the start of symptoms ,whichever is longer) then, 

(a) She should wash hands frequently with soap and water or use alcohol based sanitizer before touching the baby.

(b) She should wear a medical mask while feeding .It is important to-

* Replace mask as soon as they become damp 

* Dispose of mask immediately 

* Not reuse a mask 

* Not touch the front of mask but unite it from behind.

- Sneeze or cough into a tissue, immediately dispose of it and use alcohol based hand rub or wash hands again with soap and water.

- Regularly clean & disinfect surfaces.

(c) If medical mask not available to her, breastfeeding should be continued.

Other infection prevention measures such as washing hands , cleaning surface, sneezing or coughing into a tissue are also important .Non- Medical mask( homemade or cloth mask)have not been evaluated .At this time it is not possible to make a recommendation for or against their use. 

(d) If she had just coughed over her exposed chest or breast then she should gently wash the breast with soap and warm water for at least 20 seconds prior to feeding. It is not necessary to wash the breast before every breastfeed or prior to expressing milk.

(e) If she is not able to breastfeed then best alternatives are-

• Expressed breast milk

- Expression of breast milk is primarily done or taught through hand expression, with the use of a mechanical pump only when necessary. Hand expression and using a pump can be equally effective.

- The choice of how to express will depend on maternal preference, availability of equipment, hygiene condition and cost.

- The mother and anyone helping the mother, should was their hands before  expressing breast milk or touching any pump or bottle part and ensure pump, feeding utensils, milk storage container should be cleaned  after each use with liquid soap e.g. dishwashing liquid and warm water .Rinse after with hot water for 10- 15 seconds.

- Express breast milk should we feed to child preferably using a clean cup or spoon by a person who has no sign a symptom of illness and whom  the baby feel comfortable. The mother should was their hand before feeding the newborn / infant.

•Donor human milk

- Mother is unable to express milk and milk is available from human milk Bank, Donor human milk can be feed to the baby while the mother is recovering.

• If expressing breast milk or donor human milk and not feasible or available then consider-   

*Wet – nursing (another woman breastfeed the child).In settings where HIV is prevalent, prospective wet-nurses should undergo HIV counselling and rapid testing according to National guidelines where available. In the absence of testing if visible undertake HIV risk assessment. If HIV risk assessment/counselling is not possible, facilitate and support wet-nursing. Provide counselling on avoiding HIV infection during breastfeeding. Prioritise wet – nurses for the youngest infants.

* Infant formula Milk with measures to ensure that it is feasible, correctly prepared, safe and sustainable. There are always risk associated with giving infant formula Milk to newborns and infants in all setting. It is commonly of variable quality, of the wrong type, not accompanied by an essential package of care, distributed indiscriminately, not targeted to those who need it. That risk associated are increased whenever human  community conditions are compromised example reduce access to health service if baby become unwell / reduce access to clean water / access to supplies of infant formula milk difficult or not guaranteed not affordable and not sustainable.

 Donations of infant formula milk from confirm/ suspected mothers should not be accepted. If needed, supplies should be purchased based on assessed need. 

 Mother can start breastfeed when she feel well enough to do so. There is no fixed time interval to wait after confirmed or suspected COVID-19.There is no evidence that breastfeeding changes the clinical course of COVID-19 in a mother. Health workers or breastfeeding counsellors should support mothers to relactate.

(f) There is no need to provide a' top- up' with an infant formula milk. Giving a ‘top -up' will reduce the amount of milk produced by a mother. Mother who breastfeed should be counselled unsupported to optimise positioning and attachment to insure adequate milk production. Mother should be counselled about responsive feeding and perceived milk insufficiency and how to respond to their infant's hunger and feeding cues to increase the frequency of breastfeeding

5) Recommendations for adult and older children to maintain social distancing aim to reduce contact with asymptomatic person who have covid-19 and transmission of virus that may result. This strategy will reduce the overall prevalence of covid-19 and the number of adults who experience more serious disease.

The aim of recommendations on the care and young children whose mother have confirm or suspected covid-19 infection is to improve the immediate and lifelong survival, children health and development of newborns and infants. These recommendations consider likelihood and potential risks of COVID-19 in infants and also the risks of serious illness and death when infants are not breastfeed or when infant formula milk are used inappropriately as well as the protective side effects of breastfeeding and skin to skin contact.

Thus, It is safe to breastfeed the infants and neonates because no active COVID-19 Virus has not, to date been detected in breast milk of any confirm/suspected mother and it also provides remarkable benefits to the baby.

By- Neha Kumari

2nd year MBBS student

GMC BETTIAH

Pathology related to Breastfeeding

Breastfeeding has been playing an important role for the development of infant since ages. According to WHO and AAP, Breastfeeding is the normal way of providing young infants with nutrients they need for healthy growth or development. Scaling up breastfeeding could save lives of more than 8,20,000 -children under the age of 5. It could lower the rates of allergies, Ear -Lung Infection , Obesity , Sudden Infant Death ,Necrotizing Enterocolitis And associated sepsis .Not only it could be beneficial for the infant but also for the mother because it could reduce the chances of uterine bleeding , burn calories , reduce the risk of breast / ovarian / uterine cancer , osteoporosis , Arthritis , Type II Diabetes mellitus and Heart Disease. Initially the breast releases colostrum which has high content of immune cells and antibodies, a much lower fat content and also acts as a laxative to pass out the first stool meconium. But there could be several problems associated with breastfeeding. I would like to list down a few of them-

1. DIFFICULTIES FROM LATCHING INTO THE BREAST – A good latch promotes high milk flow and minimizes nipple discomfort for the mother whereas a poor latch results in poor milk transfer to the baby and can quickly lead to sore and cracked nipples.

2. CRACKED NIPPLES- A shallow latch or Thrush (Candiasis) or Dry skin around The Areola could be the general causes. Cracked nipples could be a little frightening and uncomfortable at the beginning and could be associated with some bloody discharge. Treatments for this could be application of Soothing Gel pads, nursing ointments or painkillers like Acetaminophen (Tylenol).

3. ENGORGEMENTS OF BREAST- A sense of breast fullness or heaviness within 36 hrs. of delivery. The increased blood supply, accumulated milk and swelling all contribute to painful engorgement. Engorgement may affect the areola, the periphery of the breast or the entire breast and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola / nipple. This makes latching a daunting task for the baby.  The possible treatments could express or pumping. Gentle massage or pressure could soften the areola. Application of cold compresses to reduce the swelling pain and vascularity even more. One published study suggested that the use of Chilled Cabbage leaves could produce mixed results. Acetaminophen could relieve the pain too.

4. MILK STASIS- When alveolar and lactiferous ducts are blocked and cannot drained properly. This can be treated by varying the baby’s feeding position and applying heat before feeding.

5. MASTITIS- Inflammation of Breast in Association with dolor, rubor, tumor and calor. This could be due to Primary causes as in milk stasis or secondarily with infectitious organisms such as Staphylococcus sp., Streptococcus sp., and E-Coli. Continued Breast feeding, plenty of rest and fluid intake could possibly cure such conditions.

6. Dysphoric Milk Ejection Reflex (D – MER)- A newly recognized condition affecting lactating women that is characterized by abrupt dysphoria or negative emotions that occurs before milk release. The possible cause may be due to inappropriate dopamine activity at the time of milk ejection reflex.

7. INVERTED NIPPLES- A condition where the nipple instead of pointing outwards, is retracted back into the breast. The etiology to these conditions might be due to 

• Fat necrosis

• BREAST CANCER- 

o Breast Carcinoma 

o Inflammatory Breast Cancer 

o Paget’s Disease

• BREAST INFECTIONS- 

o Mammary Duct Ectasia 

o Breast Abscess

o Mastitis

• GENETIC VARIANT OF NIPPLE SHAPE

o Weaver Syndrome

o Kennerknecht – Sorgo – Oberhoffer Syndrome

8. RAYNAUDS OF THE NIPPLE/ NIPPLE BLANCHING- Can be caused by vasospasm of the nipple. Blood does not flow properly to the nipple which causes the nipple to blanch. This could be due to early breastfeeding or candidal infection of the nipple. There could be associated throbbing pain in between the breastfeeding sessions when the nipple is blanched.  In some instances, heart medication nifedipine is used to help flow of blood to the nipples.

9. TONGUE TIE/ANKYLOGLOSSIA- This condition is present at birth that restricts the range of motion of the tongue. With tongue tie an unusually short, thick and tight band of tissue (lingual frenulum) tethers the bottom of the tongue’s tip to the floor of the mouth so it may interfere with breast feeding. It could also affect the way a child eats, speaks and swallows.

10. POSTNATAL DEPRESSISON- Many women feel a bit down, tearful or anxious in the first week after giving birth. Symptoms might include insomnia, a persistent feeling of sadness and low mood, loss of appetite, intense irritability and difficulty of bonding with the baby.

AISHANI KUNDU 

MBBS

SMU, CHINA

Breastfeeding: The Mother & Baby Bond

In today's fast pacing era what can be most necessary and unaltered for a new guest in this world. What can be a moving experience from a women's point of view. Definitely it's breast feeding. An Emotional saga for every women's life. An experience to be relished lifelong. It's not only a rational experience rather a lifetime experience for her. 

From the beginning of human settlements many things have changed but not this loving and caring bond between a mother and her child. The happiness felt by a mother during the nourishment of her newborn is unmeasurable.  She forgets all her pain and discomfort in front of this joy. This is the reason why mothers are portrayed as goddess in every religion and culture.

Apart from these aesthetical values there are many Scientific theories which proves why breastfeeding is important and is considered as an emotional experience. Mother’s milk is highly nutritious and contains varieties of Carbohydrates, protein, vitamines and immune boosting complexes which are sufficient for the growth of baby in 1st six months of life. 

During the process of breast-feeding maternal pituitary releases prolactin and oxytocin. These hormones along with increasing the milk production help in reducing mental anxiety of mother. 

Thus the first connection of baby to her mother is undoubtedly important and can't be substituted. If this process is ever altered I think our existence will be questioned. 

By- Sudipt Anand (S.K.M.C.H)