MedicoTips.Com

Cryoglobulinemia, Cryoglobulinemia Causes, Symptoms & Treatment

2020-08-25T14:52:00.007+05:00

Cryoglobulinemia causes

Hep C
Myeloma,
Waldenstrom’s macroglobulinemia,
SLE,
Rheumatoid arthritis,
Sjogren’s syndrome,

Symptoms,

Immunoglobulins precipitate when cooled under skin, ulcers, rashes, gangrene, Raynaud’s phenomenon.

Treatment.

Plasma exchange,

Chemotherapy,

Treat the cause.

MTI program Royal College of Physicians UK for International Doctors

2020-08-11T05:27:00.004+05:00

MTI (Mutual Training Initiative) is a program which is sponsored by the Royal College of Physicians UK (all three colleges), you can work in the UK for a period of up to two years.

It has the following requirements;

1. You should have MRCP part 1 passed (minimum requirement)

2. You must have got the required score in the IELTS or OET

a. For IELTS the required score is minimum 7.0 in all subcategories (reading, listening, writing and speaking) and an overall score of 7.5.

b. For OET the required score is grade B in all subcategories.

3. You must appear in an interview conducted by the Royal College of Physicians in your country and selected for the post OR you find a Job in the UK directly and inform Royal College of Physicians (London) that you have got the job by yourself and now you need RCP sponsorship for GMC registration.

You do not need to pass PLAB or MRCP (all parts) to get the GMC registration. Royal College of Physicians will send the sponsorship letter to GMC and you will get the permanent registration without passing PLAB or MRCP.

If you have any questions please write them in the comments section below.

IELTS or OET - Reviews - Personal Experience - Which to Choose - IETLS vs OET

2019-05-03T15:12:00.001+05:00

OET and IELTS both are used to assess the knowledge of English Language.

The basic difference between the above two is this, IETLS is a more generalized English language assessment test, on the other hand, OET is profession specific. For example, if you are a doctor, the content of the test will be related to your occupation. Because of this, the OET is being chosen by many healthcare professional instead of IELTS.

Both tests have the same sub-categories, that is listening, speaking, writing and reading.
Lets us discuss the differences one by one.

TEST	OET	IELTS	OET Compared to IELTS is ………. (Author’s opinion)
Speaking	You will need to do two role plays. You will be given a situation and asked to counsel the patient about a disease and treatment or break the bad news.	It has 3 parts, first is an introduction and general question, In the second part you will be provided with a topic to speak for 2 minutes. In the 3rd part, you will be asked various question about a different topic.	Compared to IELTS, OET Speaking is easier. Healthcare professionals are familiar with such a situation as dealing with their patients, they handle the task usually well. I got 390/500 (grade B) in speaking. I had got 7 band in IELTS speaking.
Reading	Consist of 3 parts. Part A: you will need to answer 20 questions in 15 minutes. Part B and C: you will be given 45 minutes to answer 22 questions. Although part A seems difficult, it is the easiest task of reading, you just need to pay attention and practice. You need 30 correct answers to get a grade B.	Consist of 3 paragraphs and you need to answer 40 questions in 60 minutes. Unlike, OET there is no time limit on the individual part. You need 30 correct answers to get a band 7.	Compared to IELTS, OET reading is much more difficult. Every question is paraphrased. You need to pay attention and learn the tricks. When I gave OET, I was very worried about the reading but surprisingly I got 500/500 (Grade A) in reading. It means reading is difficult but doable. I got 8.5 in IETLS reading as well, so probably my reading is strong. But many I know, failed in reading.
Listening	You need to answer 42 questions. Part A: Consists of 2 subparts. You will hear the doctor and patient conversation and answer the question. Part B: you will hear a short extract and answer a single question, there are six such questions. Part C: You will hear two lectures and answer 12 questions.	In IELTS listening you will need to answer 40 questions. 1st part is usually a conversation. The 2nd part is related to a figure or a MAP and the 3rd part is usually based on a lecture.	IELTS listening and OET listening, I will give them same difficulty level. I scored 450/500 (Grade A) in OET listening and I had got 7.5 in IELTS listening.
Writing	In OET writing you need to write a referral letter to another doctor or a therapist (physiotherapist, speech therapist etc). You need to write 180 – 200 words in 45 minutes.	IELTS writing consists of two parts. In part A you need to write a short essay of 150 words about a figure or a graph and in Part B, you need to write a 250-word essay on a general topic.	I would grade IELTS writing “very difficult” compared to OET writing. In OET health care professionals have this benefit that they are already familiar with the vocabulary and do the related tasks on a daily basis. On the other hand, IELTS writing is very difficult, you can get a topic from anywhere. OET writing is more practical and makes more sense because you have the information and you need to arrange it. On the other hand, in IELTS, you should have prior knowledge about the topic as well. Therefore, IELTS writing is not just writing test, It also assesses your knowledge about the topic as well. They say that they only assess writing, but it seems it is not true. OET writing seems like a test of your writing skills as the information you need to write is already provided to you. I got 350/500 (grade B) in OET writing. And I had got band 6 in IELTS writing.

I hope this information will help you to choose between the two exams.

If you have any queries, please feel free to comment below.

Regards.

Dr. Adil Ramzan

RCP-UK-MTI Program for Pakistani Doctors - How to approach

2019-04-29T21:27:00.000+05:00

This article is under review: Author's MTI application is under process via RCPE and RCPL, and this article will be updated in future for further guidance.

29-April-2019: Royal College of Physicians and Surgeons started Mutual Training Initiative. In this program, post-graduate medical residents are asked to apply and shortlisted candidates are interviewed. Among those interviewed, almost all are selected if they have passed the IELTS.

MTI program - Who is eligible.

Every post-graduate medical trainee who has completed two years of residency training in a subject (department) is eligible to apply.
Many say MRCP 1 or IMM is a mandatory requirement and these requirements are mentioned on their official website as well. But in reality, this is not strictly followed. If your CV and academic background are good, you can be selected.
Furthermore, Many say IELTS is a mandatory requirement, but again this is not strictly followed. I know a few students who are called for the interview, are selected and given time to pass their IELTS.
Passing IMM, once again is not mandatory. but you can apply. There is a chance you can be selected if they have a shortage of doctors.

But keep in mind, Those students who have passed IMM, IELTS and MRCP 1 are preferred and in most of the cases are selected.

Those who have completed two years of residency in any subject may apply and if they are lucky can be selected.

I will update this thread with success stories and reviews with the passage of time.
If you have any questions, please feel free to comment below.

Cardiac Axis in Right and Left Bundle Branch Block

2019-04-28T22:22:00.001+05:00

Reading ECG (electrocardiogram) can be a tricky thing. It needs a clear understanding of the underlying physiology.

ECG is a graphical representation of the heart's electrical activity. With the help of the ECG, we can determine the heart rate, rhythm, axis or any other abnormality of the electrical conduction system. When ECG is not normal it means there is some problem in the conduction system. The cause of this problem is usually damage to the myocardium. The damaged myocardium or an abnormal myocardium can't conduct the electrical charges in a normal way and these abnormal conductions are reflected on an electrocardiogram (ECG).

Axis can also be determined with the help of an ECG. Cardiac axis can deviate to right or left. But please keep in mind in pure right bundle branch block or in pure left bundle branch block cardiac axis remains normal.

Thus, if you find a right axis deviation or a left axis deviation think of a pathology. Please note that the right axis deviation can occur in a normal healthy person, on the other hand, a left axis deviation is always pathological.

Non-Pharmacological or Home treatment of Yeast Infection

2018-11-25T21:58:00.000+05:00

How do you treat yeast infection in men?

Yeast infection can be eradicated. There are two aims of yeast therapy.

1. Inhibition of growth of already present yeasts by limiting the available space and nutrients for their growth.

2. Killing them by using fungicidal substances.

Non-Pharmacological or Home treatment of Yeast Infection:

i) Reduce the intake of sugar:

Sugar (carbohydrates) is a favourite food of yeast and it accelerates its growth. Sugar based foods for example; Gluten-based foods, yeast foods, milk products, soy-foods, swordfish, tuna fish, shark, etc must be avoided.

ii) Unsweetened Yogurt:

Unsweetened Yogurt increases the number of good bacteria called lactobacillus. These bacteria inhibit the growth of yeast infection by occupying space and consuming the nutrients. Yeast is left with little space and nutrients and can’t be able to grow.

iii) Drink plenty of water.

Yeast makes the intestinal environment acidic which accelerate its growth. Drink plenty of water which will wash the acids out of the intestine. Moreover, increased water intake will lead to increase urine formation which washes the urethra and clear the toxins. (in case of genital candidiasis)

iv) Take a clove of garlic daily.

Garlic has this useful fungicidal and bactericidal property. It has been used in ancient medicine to treat infections. Take a slice of garlic daily and add garlic to your regular meals.

v) Take warm baths.

Warm the water and add one or two cups of vinegar into it. It will reduce the itchiness and will maintain the pH of the skin which will inhibit the growth of yeast.

vi) Keep yourself dry:

Yeasts flourish in a warm and moist environment. That’s why sweaty feet (because they are mostly covered by shoes) and genitals are very prone to yeast infection. Dry yourself after a shower and change the swimsuit immediately after swimming. In summer, keep your feet and genital dry.

vii) Wear light clothing.

Cotton clothes have pores and promote air exchange and evaporation of water. Hence they keep the area dry and cool and inhibit the growth of yeasts. Avoid nylon and silk briefs which tend to keep the area warmer and cooler.

viii) Rinse Your Mouth with warm water.

If you have an oral yeast infection then Rinse your mouth with warm salt water three-five times a day. Decrease the intake of sweet food.

Pharmacological Treatment of Yeast Infection:

Taking Antifungal medicines along with adopting the above measures accelerate the therapeutic benefits and decrease the chances of recurrence significantly. Anti-fungal medicines are available in the following forms.

1. Antifungal creams and ointments.

Antifungal creams and ointments are applied to the affected area. Over-the-counter antifungal creams are available without a prescription and are commonly available.

2. Oral Antifungal pills.

In case of severe infection oral antifungal pills are used. You should take these pills only after consulting your doctor.

Oral Good Bacteria supplements:

In the case of intestinal infection, syrups containing good bacteria can be taken (Optiflora). These bacteria are not harmful and inhibit the growth of yeast.

Child Abuse,Types of Child Abuse,High Risk Child,Management of Abused Child and Hospital Care

2018-11-25T13:33:00.000+05:00

What is Child Abuse:

Any action of commission or omission by individuals, institutions or society as a whole and any condition resulting from such actions or inactions, which deprive children of their equal rights and liberties and/or interfere with their optimal development, constitute by definition abusive or neglectful acts or conditions.
Child Abuse Prevention and Treatment Act (public law 93 – 247):
Defines it (Child abuse) as the physical or mental injury, sexual abuse, negligent treatment or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that child’s health and welfare is harmed or threatened thereby.

Child abuse is not a disease but a family dysfunction most of the times due to disturbed relationships, failure on the part of parents, family or society.

TYPES OF CHILD ABUSE:

Physical abuse
Sexual abuse
Psychological emotional and verbal abuse
Munchausen syndrome by proxy
Neglect

Epidemiology:

Victimization rate is 11.8 per 1000 children (1%).
In the home survey, 5 – 14%.
The National Child Abuse and Neglect Data system (NCANDS) indicated:
1) Child neglect 58.4%
2) Physical abuse 21.4%
3) Sexual abuse 11.3%
4) Emotional abuse 5 %?

Physical Abuse (non-accidental injury):
10% of injured children below 5 years of age are in emergency rooms due to child abuse.
1/3 are below 1 year of age and 1/3 are between 1-6 years of age.
50% of children below 1 year of age are with fractures and 15% are with burns.
More than 90% of the parents are neither psychotic nor criminals.
30-40% of parents of abused children have been abused in their childhood.
Fathers were involved in 21% cases, mothers in 21% as well, boyfriends of the mother in 9%, babysitters in 8%, stepfathers in 5% of cases of physical abuse.
2000 children deaths per year occur due to physical abuse in the USA.

Causes of Physical abuse:

Poverty (Unemployment, overcrowding)
Stress on parents due to loss of jobs, marital strive, the death of a sibling or spouse, physical exhaustion, acute or chronic illness, teenage pregnancy, single parenthood, substance abuse
No social or economic support during the crisis
Effect of increased violence in the community
Social stigmas
Military base
Schools, madrasas (sticks, chains, dark rooms etc)
Workplace (“chotas” working in tea shops, auto workshops, carpet industry, begaar camps)

High-risk children:

Premature infants
Infants with chronic medical conditions
Mentally and physically handicapped children
Colicky babies
Children with learning and behaviour problems
Orphans
Adopted children etc
Children in institutions

High-risk parents:
Young teenager parents with no experience in child development and care
Single parents
Unmarried parents and their families (infanticide of a newborn)
Discrimination against female babies
Stressed parents due to any cause

Suspect physical abuse:
If there is a delay in seeking medical help
Unexplained, unexplainable or implausible injury
Injury incompatible with the history given or with child development
History of a repeated hospital or ER admissions
Signs of previous injuries

Evaluation:

Detailed history from parents, relatives, siblings, friends etc
Date and time of injury and time of seeking medical help

Examination of child:

Growth parameters to assess nutrition
General condition (calm, withdrawn or afraid)

Bruises are the most common injury
Site: Buttocks, genitals, back, back of the hands, bilateral or symmetrical
Shape: Geometric marks, marks of whips, sticks, pedals, belts and hands etc
Age of bruise: Blue or reddish purple, yellow, green, brown

Burns (10%)
Age of burn, a shape of burns (cigarette, hot iron etc)
Type of burn (emersion in hot water causes glove and stocking burn pattern with sparing of flexion creases. Children below two years of age are unable to enter a tub and turn a knob)
Examine bruises, burns, fractures at odd places
Fractures (bone trauma in 10-20% cases)
Fractures of metaphyses, ribs, scapulae, the outer end of the clavicle, vertebrae are present
Usually, spiral due to twisting of limbs, bucket or handle type due to pulling, may be multiple or symmetrical with various healing stages

Head Injuries:
Hair (alopecia, broken ends at various lengths)
Intentional head trauma (ITH- 29%)
95% of intracranial injuries during the 1st year of life are due to ITH so in any injured infant with coma and convulsions CT scan of the brain is advised and fundoscopy for retinal haemorrhages present in 85% of cases
ICH without fracture of the skull may be due to a blow with hand or slamming against an object or shake injury (sub glial hand prints on autopsy)

Intraabdominal injuries are the 2nd most common cause of death while ITH is the 1st most common cause.
Ruptured liver, spleen, injury to intestines are very common and life-threatening.

Lab investigations:
Full blood count, coagulation profile
A skeletal survey in children below 2 years of age. Repeat it after 7-10 days to see the healing of fractures
CT scan of brain and fundoscopy in case of head trauma, ultrasound and CT scan of the abdomen
Urine and stool examination for blood
Photographs of lesions

Diagnosis:
By detailed history, physical examination and evidence of trauma
A fall from 3 ft height doesn’t normally cause linear fracture of clavicle or skull, fall from 6 ft rarely causes concussions, subdural haemorrhages or lacerations, a fall from more than 10 ft can cause severe brain injury or death
A separate interview with an abused child of more than 3 years of age

Indications for hospital admissions:
Serious injuries
Unclear diagnosis
No alternate safe place for custody
Fear of abduction of a child

Management of abused child:
In case of suspicions don’t discharge child without consulting CPS
CPS personal, social worker, law enforcement team and doctors should decide that the child should go with the parents or stay in the hospitals
If parents insist to take the child, take legal action

Prevention of child abuse:
Identification of potential (at risk) family and the introduction of the family into the management system
Introduction of helplines such as hotlines, crisis nurseries, child-rearing counselling, marital counselling, social workers’ help, individual or group psychotherapy, advisory clinics with family practitioners, enforcement of law and order, monitoring and follow up
Role of parents
Parents have the Primary Responsibility to protect and provide careRole of the Family
Families can provide support to parents and share in taking care of the child
Role of Society
Community should
Feel responsible for the welfare and care of children and identify elements that can harm children
Make arrangements for the emergency care of the abused child and the family

Role of Media
To provide knowledge and motivation to act
Inter-professional cooperation is vital if the investigation of reported cases and intervention are to be effective
To publicize effective schemes
To probe and ask questions of the state and institutions over which it has influence

Newborn Vaccination Latest - Pakistan EPI Vaccination Schedule Latest

2018-11-25T13:26:00.000+05:00

2019 - 2020 EPI Pakistan Vaccine Schedule.

1. At Birth:

BCG Vaccine
Oral Polio Vaccine
Hep B Vaccine

2. At 6 weeks

Oral polio vaccine (1)
Rota virus (1)
Pneumococcal vaccine (1)
Pentavalent (1)

3. At 10 Weeks of Age

Oral polio vaccine (2)
Rota virus (2)
Pneumococcal Vaccine (2)
Pentavalent (2)

4. At 14 Weeks of Age

Oral polio vaccine (3)
Inactivated polio vaccine (IPV)
Pneumococcal vaccine (3)
Pentavalent vaccine (3)

5. At 9 months of Age

Measles vaccine (1)

6. At 14 months of Age

Measles Vaccine (2).

Dr. Fibhaa Syed - ECG Class - ECG interpretation Steps.

2018-09-15T23:41:00.002+05:00

By

Dr. Fibhaa Syed
MBBS, FCPS, MRCP, SC Endocrinology
Assistant Professor of Medicine
Shaheed Zulfiqar Ali Bhutto Medical University,
Pakistan Institute of Medical Sciences

Following steps should be follow while interpreting ECG. Details may be found elsewhere, in this article brief outlines regarding ECG interpretation are shared, which were explained by Assistant Professor of Medicine, Dr. Fibhaa Syed during a Post-Graduate teaching session at Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad Pakistan.

Please note Normal Criteria is shared here unless specified otherwise.

ECG Interpretation Steps

Identification

Name,
Date and Time

Calibration

Normally

Width = 5 squares (1 big square), (one small square = 0.04 seconds)
Height = 10 small squares (1 small square = 0.1mV, 10 small squares = 1mV

Rate

300 divided by Number of of large squares between two QRS complex = Rate / min

Rhythm

Check in lead II.

QRS should be preceded by the P Wave.
Check if Regular or Irregular
Check if P wave present or not.

P wave morphology

Criteria of normality

Check in lead 2.

should not be broader than 3 small squares
should not be taller than 2.5 small squares.

Check in V1 as well

Negative component should not exceed the positive component.

PR interval

Normal: 3 - 5 small squares

Cardiac axis

Calculate the axis, (Cardiac Axis Details Click here)

Q waves

Abnormal when

Width is more than 1 small square,
Depth is more than is 1/4th of the R wave.

QRS complex

Duration:

Should not be more than 2.5 small squares.

Voltage : check height in aVL and aVF

aVL: not more than 13 small squares
aVF: not more than 20 small squares
Tall R waves V1
If height is more than 3-4 small squares it will termed as tall R wave in V1.

Progression of R wave

Normal Progression if

Usually V5 is the tallest
V5 is tallest and V6 is smaller
V4 is taller than V5 which is taller than V6.
If V4 is taller than V5 and V5 is also smaller than V6 this is abnormal.

Transition zone,

When 1st positive becomes the first negative, Normally in V3 or V4.

QRS waves in chest leads.

Voltage criteria,

R wave should not be taller than 27 small squares
S wave should not be deeper than 30 small squares
and Sum of R and S should not be more than 40 small squares

Ventricular activation time

Beginning of Q wave to the tip of R wave
Check in V5 and V6 and it should not be more than 1 small square.

T waves;

In Limb leads:

should follow QRS complex, if is not following then calculate T wave axis and Compare T wave axis with cardiac axis, If difference is more than 45 then it is pathological.

Check T waves in chest leads.

Height should not be more than 2/3rd of the height of the R wave
Generally upright but;

In 30% inverted in V1
In 10% inverted in V1 and V2
and in 1% inverted in V1, V2 and V3 (west Indian heart)

should have previous ECG present to compare in above 3 cases.

Generally T wave inversion in V4, V5 and V6 is abnormal.

ST changes:

Elevation and depressions (details will be added later)

QT interval

Normal 14 small squares.

RBBB criteria:

Broad QRS > 2.5 small squares
Secondary R wave in V1

Additional Criteria

ST depression
T wave inversions in V1 to V4
Deep S wave in V1 and aVL

LBBB Criteria

Broad QRS > 3 small squares
Absence of secondary R wave in V1
Normal Axis
ST-T changes in V5 V6, lead 1 and aVL.

Left ventricular hypertrophy

Tallest R wave > 20 small squares
Deepest S wave > 30 small squares
Sum of both more than 40 small squares
Ventricular activation time > 1 small square

Right ventricular hypertrophy

Frontal axis is more than 90
Dominant R wave in V1
Tall R Wave in V1, that is greater than 3 - 4 small squares.

Left axis deviation causes

left anterior hemiblock
LBBB
Hyerkalemia

Right axis deviation causes

RVH
left posterior hemiblock
inferior wall MI.

Disclaimer:

Article is under review and is not final. Errors may be present.

Special thanks to Prof. Dr. Rauf Niazi.
and Dr. Salman for providing the missing data.

Dr. Adil Ramzan

MBBS, MD Internal Medicine Resident,

Shaheed Zulfiqar Ali Bhutto Medical University

Pakistan Institute of Medical Sciences.

Heart Failure with reduced ejection fraction Management 2017 Update, ACC/AHA Guidelines, Summary

2018-04-01T11:23:00.003+05:00

In heart failure, the heart fails to pump enough blood to maintain sufficient blood flow throughout the body.

The goal of the heart is to maintain the cardiac output, which is the amount of blood which is pumped by the heart in one minute. Our body tries to compensate by

Increasing the heart rate.
Activating the Renin-Angiotensin-Aldosterone-System (RAAS), which cause an increase in blood volume and vasodilatation.
Sympathetic activation, which causes tachycardia and cardiac remoulding.
The release of BNP, in response to stretch of cardiac muscle which causes natriuresis and inhibition of aldosterone.

These compensatory mechanisms increase the load on the failing heart. Our goal is to inhibit these compensatory mechanisms to decrease the further load on the failing heart which these compensatory mechanisms (especially activation of RAAS and sympathetic system) put. The BNP release is not enough in the presence of activated RAAS.

Thus,

we will inhibit the RAAS by an ACEi or ARB (e.g Enalapril, Ramipril, Valsartan or Candesartan).
Give a maximum tolerated a dose of a beta blocker, gradually titrated if there are no signs of fluid overload (that is after the management of acute exacerbation with diuretics, but will start as soon as possible) (Carvedilol, Metoprolol or Bisoprolol are preferred)
Give diuretics to manage the fluid overload and acute exacerbation. Thiazide diuretics to manage mild fluid overload and loop diuretics to manage severe heart failure and acute exacerbations. (Hydrochlorothiazide, Furosemide, Torsemide)
An aldosterone antagonist such as spironolactone or eplerenone should be a part of the standard therapy for heart failure i.e, (ACEi/ARB + Beta-blocker + Spironolactone/eplerenone), because it has shown to decrease mortality by 29%.
If symptoms are not controlled by the above medications then will consider any one of the following, per patient's need.
Give a Neprilysin inhibitor such as sacubitril, which inhibit degradation of BNP, which further decrease the blood volume by counteracting the RAAS, and decrease the mortality by 20% as compared to ACEi (enalapril) alone. Try to switch the ACEi or ARB alone to Valsartan-Sacubitril if a patient can tolerate it.
Decrease the heart rate by (if EF still < 35%) Ivabradine if the maximum tolerated a dose of beta-blockers alone not able to control the symptoms and if the patient's heart rate is more than 70.
Consider adding digoxin if rate control is needed, and the patient has atrial fibrillation.
Hydralazine, Nitrates or their combination is preferred in African-Americans (because ACEi/ARBs are less effective in African-Americans) or if symptoms are not controlled with ARBs/ACEis and the EF is still < 35%. There is a high risk of hypotension with these and are difficult to tolerate, Monitor closely.
Consider adding Cardiac resynchronization therapy if the patient has conduction defects such as LBBB, QRS width > 120msec and EF < 35%.
Consider ICD placement if the patient has a history of MI or arrhythmias with EF < 35
%.
Anticoagulation has no added benefit, except in patients with acute MI, where it should be given for 3 months if not contraindicated.
Reassess the symptoms if controlled, consider decreasing the dose of diuretics.
If nothing from above work consider, palliative care, cardiac transplantation, left ventricular assist device or drugs or devices under investigation.

Date Updated: 31st March 2018 by Dr Adil Ramzan

Tiotropium, If started early decreases annual FEV1 decline in COPD - Review - Dr. Adil Ramzan

2018-01-06T00:59:00.001+05:00

Tiotropium is a long-acting muscarinic antagonist. Its effect last for 24 hours. It causes relaxation of smooth muscles of the respiratory tract and also helps to decrease the mucus secretion by goblet cells.

The chronic obstructive pulmonary disease is characterized by chronic productive cough and shortness of breath. The chronic obstructive pulmonary disease has two components; chronic bronchitis and emphysema. Chronic bronchitis is defined as a productive cough for 3 months for 2 consecutive years. On the other hand, emphysema occurs as a result of the destruction of alveolar walls and air entrapment in the alveoli.

The risk factors include cigarette smoking (the most common one), biomass fuel exposure, wood burning smoke, industrial smoke and occupational and chemical exposures, genetics and ageing also have a role in the development and progression of chronic obstructive pulmonary disease (COPD).

The noxious stimuli (eg. Cigarette smoke) damages the cilia (hair-like projections) present on the surface of the respiratory tract. The damaged cilia are unable to push the mucus out of the respiratory tract. Mucus starts to collect, can’t be cleared properly and thus cough occurs as an attempt to remove this mucus. The collection of mucus also results in bacterial overgrowth and chronic inflammation. Therefore, with the passage of time the bronchial wall thickening occurs due to the proliferation of lymphocytes and endothelial cells. The lumen narrows. Air pass through the narrowed lumen with difficulty as compared to the normal lumen. The patient uses accessory muscles in order to push the air in and out of the lungs. The alveoli lose their natural recoil and are unable to push the air out properly. The alveolar walls become weak and destroyed.

The COPD is classified into 4 types according to severity. Class 1, 2, 3, and 4. Class 1 is mild, 2 is moderate, 3 is severe and 4 and very severe COPD (GOLD staging).

Usually, COPD is not treated in stage 1 due to mild symptoms. Yumin Zhou et al. studied the use of tiotropium in early COPD and they found that the use of tiotropium slows the progression of COPD. The tiotropium use caused a lesser decline in FEV1 per year as compared to placebo, and also they found that FEV1 was generally higher in the treatment group as compared to placebo after 2 years of treatment and follow-up.

Thus one may consider adding tiotropium in early COPD instead of waiting for the COPD to progress in later stages, and then considering initiating tiotropium.

Patiromer - a new potassium binder - Replaces Kayexalate.

2017-12-23T22:59:00.003+05:00

Patiromer is a relatively new potassium binder and studies showed it is superior to Kayexalate which has been conventionally used to lower potassium in hyperkalemia due to various causes, especially renal failure.

Patiromer works by binding to free potassium available the intestine and prevent its absorption into the bloodstream. It releases positive calcium ions which are absorbed instead of potassium if needed. As free potassium readily combines to the Patiromer, thus less potassium is available for absorption, this results in a decrease in potassium blood potassium level.

Patiromer is not absorbed by the gut, thus it has no systemic side effects. The side effects are mainly related to the gut. Another advantage of Patiromer over Kayexalate is that it can be given in heart failure, hypertension, and CKD etc. Kayexalate has high sodium content and this can be potentially harmful in case of heart failure, hypertension and even in advanced chronic kidney disease.

Another advantage of Patiromer is that its dosage frequency is very less as compared to Kayexalate. Kayexalate is given 4 times a day per orally and two times a day per rectally. On the other hand, Patiromer is given in once or maybe twice weekly doses, which is very convenient and cost-effective and also compliance is easy. Moreover, Kayexalate has much interaction with other drugs, Patiromer, on the other hand, and has significantly lesser interaction (Interaction with Ciprofloxacin is being reported.) (12/23/17).

Patiromer is not yet available in Pakistan market. But hopefully, soon it will replace the conventional Kayexalate.

Testosterone injections cause infertility - Decreased Sperm Production.

2017-11-03T23:12:00.000+05:00

Testosterone is a hormone responsible for secondary sexual characteristics in a male. It promotes muscle size, increases bone mass, increases red cell production, improves mood, behaviour, libido and sexual function.

Testosterone is widely used among the bodybuilders for the purpose of muscle growth. Yes, it does help, but you will have to pay a price.

Exogenous testosterone in a normal person, who doesn't have testosterone deficiency causes a decrease in the production of FSH and LH by the pituitary gland. FSH in males is required for spermatogenesis and it stimulates natural testosterone production by the testes. Now if you are providing your body with already made testosterone, the receptors present in the pituitary will not produce FSH, as your blood has a high level of testosterone because of exogenous injections. Now due to lack of FSH and LH, the two hormones required for sperm production, the sperm production decreases, testicular size may also decrease, as they become dormant, not producing testosterone and sperms.

Decrease sperm production may result in sub or infertility.

When you stop exogenous testosterone injection, your body may take 6 - 18 months to regain fertility.

Thus it is not safe to use exogenous testosterone in a normal young adult. It decreases sperm count, testicular size and causes infertility.

Azithromycin with Statins causes severe rhabdomyolysis leading to acute renal failure

2017-10-30T22:09:00.000+05:00

Azithromycin a widely used broad-spectrum antibiotic used to treat community-acquired pneumonia or respiratory tract infections. It is observed that azithromycin if given with statins, may cause severe rhabdomyolysis which may lead to an acute renal shutdown.

A case reported by Dr Gaurav Alreja shows a possible interaction of azithromycin with simvastatin,
A 73 years old male who was given azithromycin for bronchitis, he was taking simvastatin. He presented in emergency with the acute weakness of all extremities, he was found to have abnormal renal function tests with elevated creatinine. Simvastatin was stopped, and he was started on supportive management, bicarbonate was replaced, his renal function improved, and two months later he was again started on simvastatin without recurrence of symptoms. This gives us an indication that probably the azithromycin was responsible for the acute severe rhabdomyolysis and resultant acute renal failure when was given along with the statin.

So far, rhabdomyolysis occurred in 23% of cases who were given azithromycin along with statins.

Professor Dr. Rauf Niazi, Dean of Medicine and Allied, Shaheed Zulfiqar Ali Bhutto Medical University, advised, "Take careful drug history before prescribing azithromycin, as we know that azithromycin may cause QT prolongation and we should avoid giving it to the patient who are already taking a drug known to cause QT prolongation, now we also know that if azithromycin is given with statins, may cause severe rhabdomyolysis, so now what we can do is;
1. Stop statins while the patient is supposed to be on Azithromycin.
2. Don't give azithromycin, choose another antibiotic such as levofloxacin or moxifloxacin instead"

Special Thanks:
Dr Sadia Mansoor, Postgraduate resident, Internal Medicine, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan.

References:

1. Rhabdomyolysis caused by an unusual interaction between azithromycin and simvastatin: Gaurav Alreja et al. 2012 Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516014/

2. Rhabdomyolysis a result of azithromycin and statins: an unrecognized interaction, Johanna Starandell et al. 2009. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766483/

Author:
Dr. Adil Ramzan, MBBS, MD Internal Medicine Resident, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan.

Testosterone replacement in Elderly, Benefits

2017-10-19T22:31:00.001+05:00

Testosterone is an androgen, responsible for the masculinity in males. It is responsible for the development of secondary sexual characteristics in males, it increases libido, promote the growth of muscles and bones and improves mood and behaviour.
The testosterone level in the blood reaches its peak at the age of 20 and with the passage of time it gradually decreases and by the age of 80, its level reaches 10 - 20 % of testosterone level at age 20.

Studies showed that testosterone replacement in elderly, not only improves sexual function, but also prevents osteoporosis, improves cognitive function and overall health of the elderly individual.

In a study published in New England Journal of Medicine on Feb 24th, 2016, 790 men with serum testosterone level less than 275ng/dl were given testosterone and their testosterone level was maintained at a mid-normal range for age 20-40. By the end of 12 months, it was observed that libido and erectile function was improved, as well as patient’s mood, but there wasn’t any effect on the vitality and 6 minutes walking distance.

Other studies, showed testosterone improves cognitive function, bone mineralization and over-all health of an elderly individual.

Difference Between Direct and Indirect Coomb's test - Dr. Adil Ramzan

2017-10-13T00:32:00.001+05:00

Coomb's test is very helpful in making a diagnosis of hemolytic anemia.
Once a patient is found to have anemia, with raised bilirubin and raised retic count, hemolysis becomes the most likely possibility. Coomb's test is of two types.
1. Direct Coomb's test
2. Indirect Coomb's test.

Direct Coomb's test:

In case of direct Coomb's test, patient's RBC's are washed clear of plasma and are mixed with Coomb's serum (antihuman globulins), if agglutination occurs, it means the Direct Coomb's test is positive.
If the direct Coomb's test is positive it means the patient has autoimmune hemolytic anemia.

Indirect Coomb's test.

In indirect Coomb's test, the patient's serum is taken instead of RBCs and this serum is then mixed and incubated with RBCs with a known antigen if the patient's serum contains antibodies against the RBCs antigens then antibody-antigens complexes are formed, then coombs serum is added to the sample, if agglutination occurs it means the indirect Coomb's test is positive.
indirect Coomb's test is used in blood cross-matching and also used in the screening of a pregnant woman for the presence of antibodies that can cause hemolytic disease of the newborn.

Example 1:
Pregnant Woman screening

1. Serum from the blood sample of the pregnant woman is taken.
2. This serum is then mixed with the RBCs of the fetus.
3. Coomb's serum is added to the sample
4. If agglutination occurs, then the indirect Coomb's test is positive and the baby is at risk of developing the hemolytic disease of the newborn.

Example 2.
Crossmatching

1. Serum from the blood sample of the recipient is taken
2. This serum is then incubated with the RBCs of the donor.
3. Coomb's serum is added to the sample
4. If agglutination occurs then it means indirect Coomb's test is positive and the donor's blood is unsuitable for the patient.

Treatment of Epilepsy in Pregnancy - Dr. Adil Ramzan

2017-09-08T00:00:00.000+05:00

Q: A 28 y/o F comes to OPD, she is known the case of epilepsy since childhood, taking Valproate and levetiracetam, she has been seizure free since last 11 months, she tells you that she is 8 weeks pregnant, what will you do?

Answer:

In pregnancy, the incidence of seizure may increase or decrease. But seizure in pregnancy can be potentially dangerous and life-threatening, therefore, the anti-epileptic drugs which patient is taking with optimal control of seizures should be continued and the patient should be counselled about the risk of teratogenicity and benefits. More-over, anti-epileptic drugs increase the risk to 6% as compared to placebo (3%), and among anti-epileptic drug valproate possess the highest risk (up to 20%), newer antiepileptic drugs have a far lower risk of teratogenicity as compared to valproate and topiramate (which have the highest). Alternatively if patient is not pregnant and wants to be pregnant you may choose to wean her off anti-epileptics if more than 2 years are passed without a seizure or you may choose a newer agent and gradually taper off valproate or topiramate, but this patient is already pregnant and seizure are controlled on valproate and levetiracetam and less than 1 year has passed since she had her last seizure, we will not take the risk of stopping or changing the valproate, as seizure in pregnancy can be deadly to mother and baby.

Should I take protein supplement on rest day? Weight Training.

2017-08-30T23:31:00.000+05:00

When you work out, the production of muscle protein is enhanced for the next 24 to 48 hours. It is important to provide essential building blocks for protein synthesis. These building blocks called amino acids must be already available for the protein synthesis, if you train hard but do not provide your body with the appropriate amount of proteins to repair the damage caused by the hard training of muscles, then it doesn’t provide any benefit to your body, instead, you may end up with muscle pains, fatiguability, and weakness that may last for a long time.

Therefore, intake of readily available proteins is advised to those people who actively workout with an aim to build their muscle mass. Eggs are a great natural source of readily available and easily digestible proteins. Egg contains all the essential amino acids, that is why the intake of eggs is advised to all bodybuilders.

But a single egg contains 3 – 6 g of proteins, you may need to take more than a dozen eggs to meet the daily requirement, which is not easy for all. Therefore, protein supplements are considered. A single serving of a protein supplement usually contains 25 – 30 grams of readily available and easily digestible and absorbable proteins. You may choose to take a serving after the workout and one early in the morning. Your goal must be to take at least 1.8 grams per kg body weight of proteins daily. You may go up to 2g/kg for better results.

Now let’s come back to the question, should you take protein supplement also on your rest day? The answer is yes because after the hard training muscle proteins continue to be synthesized at a faster pace for next 24 to 48 hours, so if you provide the building blocks on your rest day also then it will help you get you good results sooner.

Safe Anti-Epileptics - Not Enzyme Inducers or Inhibitors - Dr. Adil Ramzan

2017-08-27T17:51:00.000+05:00

Sometimes it becomes difficult to choose a drug in those patients who have multiple co-morbidities. That is are suffering from more than one disease and physician needs to choose a few out of many drugs to avoid drug-drug interactions.

Anti-epileptic drugs, or the drugs which are used to treat seizures, do interact with other drugs.

Carbamazepine, phenytoin, phenobarbital, oxcarbazepine, topiramate and primidone are enzyme inducers. Enzyme inducers decrease the efficacy of a drug which is metabolized by the induced enzymes because more concentration of the enzyme will be available and the drug will be quickly metabolized and removed from the system.

Valproic acid, felbamate, rufinamide, and stiripentol, on the other hand, are enzyme inhibitors.

Therefore, we can't give these drugs to a patient who is taking a drug for any medical problem which is metabolized by the liver enzymes (eg cytochrome p450 enzyme system).

The anti-epileptic drugs which are not an enzyme inducer or inhibitor.

The following three anti-epileptic drugs are neither enzyme inducers, nor inhibitors and can be used safely in those patients who are taking drugs which are metabolized by liver enzyme system.

1. Levetiracetam.

2. Vigabatrin

3. Gabapentin

4. Lamotrigine

Levetiracetam and gabapentin are widely used drugs for this purpose. Vigabatrin is not available in most of the countries as of now (8/27/2017). Lacosamide another anti-epileptic is also found to be safe.

Special Thanks:

Professor Dr. Rauf Niazi, Dean, Dept. of Medicine SZABMU, PIMS, Islamabad.(for providing this information to us, his students).

Dr. Fibah Syed, Asst. Professor, SZABMU, PIMS

Dr. Shaukat Bukhari. Registrar Medicine, SZABMU PIMS.

Author:

Dr. Adil Ramzan.

MBBS, MD Internal Medicine Resident.

SZABMU, Pakistan Institute of Medical Sciences. Islamabad. Pakistan.

4 signs of pericardial effusion - Dr. Adil Ramzan

2017-08-12T23:37:00.000+05:00

Pericardial effusion is the collection of fluid around the heart. In this brief article, we will be discussing the signs of pericardial effusion on physical examination.

Following are the 4 signs of pericardial effusion.

1. Pulsus Paradoxus.

Pulsus Paradoxus means a decrease in systolic blood pressure of more than 10mm of Hg during inspiration. The fall occurs due to increase in intrathoracic negative pressure during inspiration. In cardiac tamponade, Pulsus Paradoxus is exaggerated and a fall of more than 10 mm of Hg occurs during inspiration. An arterial line for blood pressure measurement is a good tool to measure inspiratory and expiratory blood pressures.

2. Ewart's sign

In case of a large pericardial effusion, dullness is present below the left scapular angle along with bronchial breathing. this sign is called Ewart's sign.

3. Increased Cardiac dullness.

The area of cardiac dullness increases upon the percussion of the anterior chest due to a large pericardial effusion.

4. Kussmaul sign.

Normally JVP rises during expiration and falls during inspiration due to a decrease in chest pressure because the thoracic cavity expands during inspiration. But in Kussmaul sign, JVP doesn't fall during inspiration.

Doctor for Home Visit in Islamabad and Rawalpindi.

2017-07-09T23:15:00.001+05:00

Notice: These Services are no Longer Available Currently.

Dr. Adil Ramzan is the founder of Medicotips.com, He is a Resident Internal Medicine at Pakistan Institute of Medical Sciences and Shaheed Zulfiqar Ali Bhutto Medical University.

Dr. Adil believes in traditional allopathic medicine and appreciates developing a close relationship with his patients. He does not practice in an office, therefore he is easy to reach and accessible to schedule home visits.

Dr. Adil Ramzan is available to manage and follow patients in their home as well as the hospital, which is very important in the continuation and management of patient care. We have helped many of patients make informative and appropriate choices that affect their short term and long term health goals.

Email: support@medicotips.com

Malignant and Para-Malignant Pleural Effusions, Difference - Dr. Adil Ramzan

2017-06-02T03:58:00.000+05:00

Paramalignant pleural effusions and malignant pleural effusions are often used interchangeably which is wrong, these are two different types of pleural effusions, Said Dr Kausar Rehanna, assistant professor of the department of pulmonology, Shaheed Zulfiqar Ali Bhutto Medical University, Pakistan Institute of Medical Sciences, Islamabad, Pakistan.

Paramalignant and malignant pleural effusions both occur in the presence of a solid tumour, but In case of a malignant effusion, there is direct pleural involvement and pleural fluid cytology shows malignant cells, therefore, an effusion which occurs as a result of metastatic pleural involvement and contains malignant cells is called a malignant effusion.

On the other hand, a paramalignant effusion does not contain malignant cells, it occurs as a result of complication of malignancy, such as hypoalbuminemia due to malnutrition or lymphatic obstruction etc. there is no pleural involvement in case of a para-malignant pleural effusion and the pleural fluid cytology doesn’t show any malignant cell, a malignant effusion is usually exudative, but a para-malignant effusion can be a transudate or an exudate.

Signs of COPD on Chest X-Ray. Dr. Adil Ramzan

2017-04-23T23:13:00.000+05:00

Chest X-Ray in COPD is often normal. Even in advanced disease chest X-ray can be normal.
But if the following signs are found in a chest X-Ray then they will be highly suggesting of COPD.

Hyperinflation of lungs. Hyperinflation of lungs can be identified with the help of physical examination or chest X-Ray. On physical examination, you may find the upper border of liver displaced down and a barrel-shaped chest. While on chest X-Ray you may find hyper lucent lungs, flattening of hemi-diaphragms, and seven or more anterior ribs are seen over the lung shadow.
Pruning of Vessels: Central vessels are more prominent while less blood is seen in peripheral lung fields.
Large Bullae

It is not necessary for a patient with COPD to have all of the above signs, as it has been mentioned earlier, the chest x-ray can be normal even when the disease is advanced, therefore, if you notice any of the above sign in a chest x-ray, then you may consider COPD as a differential in the absence of documented history or examination findings.

Drugs Known to Cause Pulmonary Arterial Hypertension (PAH): Dr. Adil Ramzan

2017-04-19T00:05:00.000+05:00

Pulmonary artery hypertension can be caused by a number of drugs. Some drugs are known to cause pulmonary arterial hypertension, while others are thought to be involved.
Below is the list of drugs that may cause pulmonary arterial hypertension (PAH)

Definitive causes of Pulmonary Artery Hypertension

Aminorex: A drug which was previously prescribed for weight loss, later withdrawn from the market when it was noticed that it causes pulmonary artery hypertension.
Fenfluramine: Another drug which was used in past for the purpose of weight loss, it is an anorectic drug, and decreases appetite. It was also withdrawn because it causes pulmonary artery hypertension.
Dexfenfluramine: An isomer of fenfluramine, was being used to induce weight loss.
Topical rapeseed oil: used as an anti-ageing agent.
Benfluorex: similar structure as that of fenfluramine.

Likely causes of Pulmonary Artery Hypertension.

Amphetamines: CNS stimulant
Tryptophan: an amino acid.
Methamphetamines: CNS stimulant.

Possible causes of Pulmonary Artery Hypertension

Cocaine has the potential for abuse.
Phenylpropanolamine: St John Wort
SSRIs: eg paroxetine, citalopram, escitalopram, sertraline, fluoxetine.
Pergolide: used for management of Parkinson.

Acetaminophen (Paracetamol) Poisoning, fatal dose and Management.

2017-03-01T02:44:00.001+05:00

Acetaminophen is an over the counter drug, easily available without a prescription, but if taken especially if more than 12g is taken which is potentially fatal. The cause of death or the complication is usually the liver failure, which likely occurs if more than 250mg/kg of paracetamol is taken.

If a patient arrives at the emergency department with paracetamol poisoning and has taken more than 200mg/kg or more than 10g of paracetamol then immediately resuscitate and start acetylcysteine which is the antidote for paracetamol poisoning.

The dose of Acetylcysteine and Method of Administration

Consider Oral acetylcysteine, if the patient is not confused and can easily tolerate the medicine orally, the injectable acetylcysteine may also be given by oral route.
The oral dose is as follows.

Oral Administration of Acetylcysteine

The loading dose is 140mg/kg, after giving the loading dose, wait for four hours and after four hours give the maintenance dose, which is 70mg/kg. Repeat the maintenance dose after every 4 hours and give total seventeen doses, one dose after every four hours (total seventeen doses)
If the patient vomits within one hour of oral administration, repeat the dose.

Intravenous Administration of Acetylcysteine

If a patient is unable to tolerate the oral dose due to repeated vomiting or confusion then give acetylcysteine intravenously according to the following directions;
1. Give loading dose, which is 150mg/kg, mix it with 200ml of dextrose water 5%, and infuse is over the period of one hour.
2. After the loading dose, give 50mg/kg, mixed with 500ml of dextrose 5% and transfuse it over the period of 4 hours,
3. after this add 100mg/kg of acetylcysteine to 1000ml of dextrose 5% and infuse it over the period of sixteen hours.

Monitor vital signs, liver and renal function test, mental status, and urine output.