29.6.08
Opportunities
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C C I H News and Opportunies
Here are news and opportunities with Christian Connection for International health affiliates some of them apply more to those with public health background.
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Birthday Message
Watch Out: It's your DESTINY
Watch your THOUGHTS for they become your Words
Watch your WORDS for they become your Actions
Watch your ACTIONS for they become your Habits
Watch your HABITS for they become your CHARACTER
Watch your Character for it becomes your
DESTINY
World news
BANGING the BIG BANG Theory
On September 10, 2008 a test run of a massive particle collider is being called "one of the great engineering milestones of mankind."
Just outside of Geneva, scientists shot a particle beam fully around a 17-mile loop in the world's most powerful particle accelerator -- the Large Hadron Collider (LHC). Twenty years after development of the collider began, a particle beam made the full journey around the accelerator for the first time. It's a forebear to the time when scientists will accelerate two particle beams toward each other at 99.9% of the speed of light.
Smashing the beams together will create showers of new particles that should recreate conditions in the universe just moments after its conception, giving scientists the chance to answer one of humanity's oldest questions: How was the universe created?
"This is truly one of the great engineering milestones of mankind," said Harvey Newman, a physics professor at the California Institute of Technology. "It was characterized as having gone as 'smooth as silk,' considering everything that had to work."
Newman told Computerworld that scientists sent one beam around the tube and then sent a beam in the opposite direction -- each going one at a time. Each beam made one circle around the accelerator. And they hit 99.999998% of the speed of light.
"It's actually very exciting," said Bolek Wyslouch, a professor of physics at MIT who has been working on the collider project for the past seven years. "We were anxiously waiting, with the whole world watching, to see how this worked."
Wyslouch said he's not sure when scientists will run the first particle-collision experiment, but he estimated that it will be closer to days or weeks away rather than months.
"That's really exciting because just a few minutes of [that experiment] will give us a hint of where this is going … and confidence that we are on the right track," he added.
Scientists predicted that they will be running particle-collision experiments for the next 10 to 15 years.
The $9 billion LHC project, which sits astride the Franco-Swiss border, operates a tunnel buried 50 meters to 150 meters below the ground. The tunnel, or tube, is designed to facilitate and control a head-on collision between two beams of the same kind of particles -- either protons or ions. Traveling through a vacuum comparable to outer space, the beams are guided around the tube by more than 1,000 superconducting magnets.
According to documents from CERN, as the European Organization for Nuclear Research is known, each of the two beams will contain about 3,000 bunches of particles. Each bunch will hold as many as 100 billion particles. Despite these huge numbers, the particles are so tiny that a collision between any two is quite small. However, since the beams will be traveling at near light speed around the 17-mile tube, they'll cross each other about 30 million times per second, resulting in an estimated 600 million collisions.
If a beam circulates around the tunnel for 10 hours, for instance, it will travel more than 10 billion kilometers, which is the distance it would take to travel to Neptune and back.
With the Big Bang theory, scientists largely believe that more than 13 billion years ago, an amazingly dense object the size of maybe a coin expanded into the universe that we know now -- with planets, stars, black holes and life.
A main goal of the experiments is to find the elusive Higgs particle, which is believed to be responsible for giving other particles their mass. Though its existence hasn't been proven yet, it's believed that Higgs particles are what give electrons their weight, for instance.
Scientists are also hoping that the particle collider will give them information about so-called dark energy and dark matter.
"This is part of the quest to explore our surroundings. It's part of the quest to understand our world and ourselves," Wyslouch said in a previous interview.
Well, if you were asked to pay 9 billion dollar for having believed something so crazy as a big bang theory, would you still believe it and pay this amount or would you rather believe in the Loving God who cares for us all?
At least it tells us that you have to pay price for what you believe. Now is the time to examine your faith and your heart. If we do not make up our mind to believe the TRUTH, we'll be asked to pay far more than 9 billion dollar.
People like Warren Buffet and Bill Gates have proved to us that earning billions of dollar is possible. We already have something which is worth far more than trillions of dollars, that is our SOUL. Let's not lose it.
For what profit is there to a man who gains the whole world and loses his own Soul.....
On September 10, 2008 a test run of a massive particle collider is being called "one of the great engineering milestones of mankind."
Just outside of Geneva, scientists shot a particle beam fully around a 17-mile loop in the world's most powerful particle accelerator -- the Large Hadron Collider (LHC). Twenty years after development of the collider began, a particle beam made the full journey around the accelerator for the first time. It's a forebear to the time when scientists will accelerate two particle beams toward each other at 99.9% of the speed of light.
Smashing the beams together will create showers of new particles that should recreate conditions in the universe just moments after its conception, giving scientists the chance to answer one of humanity's oldest questions: How was the universe created?
"This is truly one of the great engineering milestones of mankind," said Harvey Newman, a physics professor at the California Institute of Technology. "It was characterized as having gone as 'smooth as silk,' considering everything that had to work."
Newman told Computerworld that scientists sent one beam around the tube and then sent a beam in the opposite direction -- each going one at a time. Each beam made one circle around the accelerator. And they hit 99.999998% of the speed of light.
"It's actually very exciting," said Bolek Wyslouch, a professor of physics at MIT who has been working on the collider project for the past seven years. "We were anxiously waiting, with the whole world watching, to see how this worked."
Wyslouch said he's not sure when scientists will run the first particle-collision experiment, but he estimated that it will be closer to days or weeks away rather than months.
"That's really exciting because just a few minutes of [that experiment] will give us a hint of where this is going … and confidence that we are on the right track," he added.
Scientists predicted that they will be running particle-collision experiments for the next 10 to 15 years.
The $9 billion LHC project, which sits astride the Franco-Swiss border, operates a tunnel buried 50 meters to 150 meters below the ground. The tunnel, or tube, is designed to facilitate and control a head-on collision between two beams of the same kind of particles -- either protons or ions. Traveling through a vacuum comparable to outer space, the beams are guided around the tube by more than 1,000 superconducting magnets.
According to documents from CERN, as the European Organization for Nuclear Research is known, each of the two beams will contain about 3,000 bunches of particles. Each bunch will hold as many as 100 billion particles. Despite these huge numbers, the particles are so tiny that a collision between any two is quite small. However, since the beams will be traveling at near light speed around the 17-mile tube, they'll cross each other about 30 million times per second, resulting in an estimated 600 million collisions.
If a beam circulates around the tunnel for 10 hours, for instance, it will travel more than 10 billion kilometers, which is the distance it would take to travel to Neptune and back.
With the Big Bang theory, scientists largely believe that more than 13 billion years ago, an amazingly dense object the size of maybe a coin expanded into the universe that we know now -- with planets, stars, black holes and life.
A main goal of the experiments is to find the elusive Higgs particle, which is believed to be responsible for giving other particles their mass. Though its existence hasn't been proven yet, it's believed that Higgs particles are what give electrons their weight, for instance.
Scientists are also hoping that the particle collider will give them information about so-called dark energy and dark matter.
"This is part of the quest to explore our surroundings. It's part of the quest to understand our world and ourselves," Wyslouch said in a previous interview.
Well, if you were asked to pay 9 billion dollar for having believed something so crazy as a big bang theory, would you still believe it and pay this amount or would you rather believe in the Loving God who cares for us all?
At least it tells us that you have to pay price for what you believe. Now is the time to examine your faith and your heart. If we do not make up our mind to believe the TRUTH, we'll be asked to pay far more than 9 billion dollar.
People like Warren Buffet and Bill Gates have proved to us that earning billions of dollar is possible. We already have something which is worth far more than trillions of dollars, that is our SOUL. Let's not lose it.
For what profit is there to a man who gains the whole world and loses his own Soul.....
"I'm so lost. Will I ever find myself?"
"It hurts, as if someone took a part of me, tore it out, mercilessly stomped all over and threw it out."
"My dream is to fly. Oh, my rainbow it is too high."
.. .. .. I don't care what you say ... I know why my other relationships didn't work out, 'cause I'm unpredictable. "
"Love is the sun, desire – only flash," she wrote."Desire dazzles, and the sun gives life."
"Love does not take away from one in order to give to another."
A tragic mystery, a shocking death of a beautiful 20 year old supermodel 2 days before her birthday has made us clueless about why she jumped from her New Nork apartment Saturday. Ms Korshunova was born in Kazakhstan in the town of Almaty.
The above quotes hints that she had feelings of being lost, confused and unloved and suffered from mood swings, a normal phenomena for a 20-year-old girl. Hardly anybody will jump from ninth floor of 12 story apartment building for that. We do not know if something else happened in the name of suicide.
To many she looked like something out of a fairytale, a really incredible woman, with feline features and timeless beauty.”
She was also famous for “The Long Hair Goddess” for her locks, which she did not cut until she was 15. She had “a face to be excited about”,a very sweet girl, always smiling, never depressed-looking.”
..HACKER.. ..HACKED..
FBI agents are using proxy server logs to track down the hacker who broke into Sarah Palin’s Yahoo email account. The hacker gained access to the Republican Vice Presidential candidate’s account by resetting the password. He then posted details of his adventures up on a popular online forum, but that information is now leading reporters and federal investigators to the suspect – a Tennessee university college student and son of state democratic representative Mike Kernell.
A few days ago, someone going by the name of “Rubico” gloated on 4chan.org that he managed to hack into Sarah Palin’s Yahoo account. He forced a password reset by answering questions about Palin’s birthdate, zip code and where she met her spouse, Wasilla High School. Of course, by being the Republican candidate for Vice President, this information is all very easily found on the Internet. After answering the questions, Rubico reset the password to “popcorn” and read through Palin’s emails.
And it seems he was pretty thorough, saying he read, “ALL OF THEM” on the boards. He even posted up screenshots of the Yahoo email page, complete with the full URL (we’ll talk about that later). Rubico says he didn’t find anything incriminating and the emails were actually fairly mundane family pictures and correspondence. But his jubilation turned into horror as he realized that he didn’t take proper precautions in covering his tracks.
Rubico used a proxy server that shields the source IP address from website logging scripts. While this sounds great, Rubico posted, “Yes I was behind a proxy, only one, if this sh** ever got to the FBI I was FU****”
In his gloating, Rubico posted up screenshots of the Yahoo account complete with the full URL which included the proxy server url (ctunnel.com) appended with a unique identifier. For example, we used ctunnel.com to surf to YouTube and the URL reads - http://ctunnel.com/index.php/1010110A/58a5cd1e8ab47088982c83282fd768456ebe14f44221026. So it doesn’t take a genius to go through the logs and match up the ID to the appropriate IP address and BAM, you got the hacker.
But aren’t proxy servers supposed to anonymize your information? Yes and no. Dan Goodin over at The Register talked to Gabriel Ramuglia, the owner of the ctunnel.com proxy server that Rubico allegedly used. Ramuglia is upset about the ordeal because his service was never meant to be used for illegal activies and says Rubico definitely broke his site’s terms of service. Ramuglia added that every incoming IP address is logged with the time and destination website.
Ramuglia told Goodin that he hasn’t a chance yet to examine his logs, but added that there is a good chance that it will lead to the hacker. Since the interview, he’s received a call from the Anchorage Alaska FBI field office and agents there are highly suggesting that he not lose the logs.
But it gets even better. White hat hackers didn’t even need proxy information to find the culprit because they discovered that the Rubico forum handle was linked to rubico10@yahoo.com. A few searches on Google and YouTube further links this email address to 20-year-old David Kernell, a student at the University of Tennessee-Knoxville. His father is Democratic Tennessee state representative Mike Kernell.
As you can expect, the Yahoo account has been frozen and all the incriminating forum posts on 4chan.org have been deleted. But this didn’t stop Wired.com from printing some of the posts. Don’t you just love it when hackers brag about the “leet” skills?
"It hurts, as if someone took a part of me, tore it out, mercilessly stomped all over and threw it out."
"My dream is to fly. Oh, my rainbow it is too high."
.. .. .. I don't care what you say ... I know why my other relationships didn't work out, 'cause I'm unpredictable. "
"Love is the sun, desire – only flash," she wrote."Desire dazzles, and the sun gives life."
"Love does not take away from one in order to give to another."
A tragic mystery, a shocking death of a beautiful 20 year old supermodel 2 days before her birthday has made us clueless about why she jumped from her New Nork apartment Saturday. Ms Korshunova was born in Kazakhstan in the town of Almaty.
The above quotes hints that she had feelings of being lost, confused and unloved and suffered from mood swings, a normal phenomena for a 20-year-old girl. Hardly anybody will jump from ninth floor of 12 story apartment building for that. We do not know if something else happened in the name of suicide.
To many she looked like something out of a fairytale, a really incredible woman, with feline features and timeless beauty.”
She was also famous for “The Long Hair Goddess” for her locks, which she did not cut until she was 15. She had “a face to be excited about”,a very sweet girl, always smiling, never depressed-looking.”
..HACKER.. ..HACKED..
FBI agents are using proxy server logs to track down the hacker who broke into Sarah Palin’s Yahoo email account. The hacker gained access to the Republican Vice Presidential candidate’s account by resetting the password. He then posted details of his adventures up on a popular online forum, but that information is now leading reporters and federal investigators to the suspect – a Tennessee university college student and son of state democratic representative Mike Kernell.
A few days ago, someone going by the name of “Rubico” gloated on 4chan.org that he managed to hack into Sarah Palin’s Yahoo account. He forced a password reset by answering questions about Palin’s birthdate, zip code and where she met her spouse, Wasilla High School. Of course, by being the Republican candidate for Vice President, this information is all very easily found on the Internet. After answering the questions, Rubico reset the password to “popcorn” and read through Palin’s emails.
And it seems he was pretty thorough, saying he read, “ALL OF THEM” on the boards. He even posted up screenshots of the Yahoo email page, complete with the full URL (we’ll talk about that later). Rubico says he didn’t find anything incriminating and the emails were actually fairly mundane family pictures and correspondence. But his jubilation turned into horror as he realized that he didn’t take proper precautions in covering his tracks.
Rubico used a proxy server that shields the source IP address from website logging scripts. While this sounds great, Rubico posted, “Yes I was behind a proxy, only one, if this sh** ever got to the FBI I was FU****”
In his gloating, Rubico posted up screenshots of the Yahoo account complete with the full URL which included the proxy server url (ctunnel.com) appended with a unique identifier. For example, we used ctunnel.com to surf to YouTube and the URL reads - http://ctunnel.com/index.php/1010110A/58a5cd1e8ab47088982c83282fd768456ebe14f44221026. So it doesn’t take a genius to go through the logs and match up the ID to the appropriate IP address and BAM, you got the hacker.
But aren’t proxy servers supposed to anonymize your information? Yes and no. Dan Goodin over at The Register talked to Gabriel Ramuglia, the owner of the ctunnel.com proxy server that Rubico allegedly used. Ramuglia is upset about the ordeal because his service was never meant to be used for illegal activies and says Rubico definitely broke his site’s terms of service. Ramuglia added that every incoming IP address is logged with the time and destination website.
Ramuglia told Goodin that he hasn’t a chance yet to examine his logs, but added that there is a good chance that it will lead to the hacker. Since the interview, he’s received a call from the Anchorage Alaska FBI field office and agents there are highly suggesting that he not lose the logs.
But it gets even better. White hat hackers didn’t even need proxy information to find the culprit because they discovered that the Rubico forum handle was linked to rubico10@yahoo.com. A few searches on Google and YouTube further links this email address to 20-year-old David Kernell, a student at the University of Tennessee-Knoxville. His father is Democratic Tennessee state representative Mike Kernell.
As you can expect, the Yahoo account has been frozen and all the incriminating forum posts on 4chan.org have been deleted. But this didn’t stop Wired.com from printing some of the posts. Don’t you just love it when hackers brag about the “leet” skills?
28.6.08
Announcements
Wedding Invitation From Anton
Hi People,
Sorry I couldnt call you in person and sending an Email.
My wedding is on the 20th of this month.
I would really love to see you all there.
Please let me know of your plan so that I can make arrangements.
Regards
Anton
Hi people (to be politically correct as I am also addressing the women),
The Christmas was memorable in a way that I went home met someone got engaged and came back.
Well you heard it right the first time. She is in PIMS pondy.
Will let you know of further details soon.
Anton.
Some News from Arpit and Amy
Hi everyone,
Hope you are all well and fulfilled in your different areas of work and life. Getting in touch with all of you individually would be my ideal way of doing this, but I will have to compromise due to the obvious time constraints and for that I apologise.
By God's grace, I have found a lady who has agreed to marry me (!!). Her name is Amy and the wedding will probably be on the 19th of January 2009 in Vellore.
I would love for all of you to make it if possible and will send you official invitations asap. Please keep both of us in your prayers.
With love,
Arpit
P.S. - Sorry this letter sounds so formal!! ;-)Alumni Reunion 2008
Those of us who are away, this August is the time to come back to vellore as alumni. It is almost 14 years since we joined CMC as batch in July 13 in 1995.
All alumni will join at the Alumni Dinner in the evening of Saturday, 9th August.
For those traveling by train, computerized ticket booking facilities are now available at most places.
There is no special programme on Friday (8th) night. That evening will be kept free for `special batch activities’.
Join the rest of alumni for the evening session on Thursday 7th and Friday 8th, at 4.30 pm. A special request to all alumni to attend the Saturday morning meetings and the Thanksgiving Service in Chapel.
Let's look forward to seeing each other and one another.
PROVISIONAL PROGRAM
Alumni Reunion 2008
Thursday, August 7th 2008 -
“Meet the Faculty/Intramural alumni” Venue - Norman Auditorium
Scientific Session : Tea at 4.30 pm. 5.00 – 6.30 pm.
Friday, August 8th 2008 – “Meet the Students” Venue – Norman Auditorium,
Special Programme : Tea at 4.30 pm. 5.00 – 6.30 pm.
Saturday, August 9th 2008 - General Reunion Venue – Scudder Auditorium
8.15 am. - Dedication of the Alumni Guest House
8.30 am. (onwards) - Registration
9.00 am - Open meeting
Annual General Body Meeting
10.45 to 11.00 am - Refreshments
11.15 am. - Introduction & Photographs
1.00 pm. - Lunch at the Men’s / Women’s Hostels.
6.00 pm. - Thanksgiving and Dedication Service, College Hill Chapel.
7.30 pm. - Alumni Dinner at Scudder Hall
followed by informal ENTERTAINMENT by special batches.
20.6.08
Homepage
Dear friends...
It is wonderful being a part of MBBS Batch of 1995 of CMC Vellore, simply because we are all there in it.....
Even though most of us are miles apart,working in different parts of the world with busy schedules, to keep up the class unity and spirit of togetherness this website is created...please do keep in touch.
Please send your suggestions, comments and articles to the email
cmcVellore95@gmail.com
We look forward to your contributions.
Medical News
AP Photo/Harvard University, Livett- Weissman-Sanes-Lichtman
Brain cells of a laboratory mouse glowing with multicolor fluorescent proteins.
The fluorescent proteins are now routinely used for observing the growth and fate of specific cells like nerve cells damaged during Alzheimer’s disease.
The winners are Osamu Shimomura, 80, an emeritus professor at the Marine Biological Laboratory in Woods Hole, Mass., and Boston University Medical School; Martin Chalfie, 61, a professor of biological sciences at Columbia University; and Roger Y. Tsien, 56, a professor of pharmacology at the University of California, San Diego.
Each will receive a third of the 10 million krona prize (about $1.4 million) awarded by the Royal Swedish Academy of Sciences.
Dr. Shimomura said he received a 5 a.m. phone call informing him he was a Nobelist. “The reaction was just surprise,” he said.
Dr. Tsien was not caught completely unaware. Last week, the Thomson Reuters news service listed him among its predictions for this year’s Nobel Prize winners. “I didn’t want to put any credence in it,” Dr. Tsien said, noting that the predictions for the physics and medicine prizes this week were wrong.
Dr. Tsien (pronounced chen) added that his work was “only one little piece” amid the work of many. “It wasn’t necessarily the case they had to give it to me,” he said. “Obviously, it’s pretty nice to hear.”
Dr. Chalfie never received the phone call from Sweden. “I slept through it,” he acknowledged at a news conference at Columbia. He said he had inadvertently turned down the ringer on his telephone a couple of days ago. He woke up at 6:10 in the morning and thought the soft ring was coming from a neighboring apartment.
“I was a little bit annoyed that they weren’t answering their phone,” he said. “I then realized because it was after 6, that they must have announced the Nobel Prize in Chemistry. I decided to find out who the schnook was that won it this year. So I opened up my laptop and found out I was the schnook.”
Biologists have long observed that some sea creatures glow in the dark. In 1962, Dr. Shimomura, then a researcher at Princeton, and Frank Johnson, a Princeton biology professor, isolated a specific glowing protein in the Aequorea victoria, a jellyfish that drifts in the ocean currents off the west coast of North America.
The protein looked greenish under sunlight, yellowish under a light bulb and fluorescent green under ultraviolet light. Dr. Shimomura and Dr. Johnson called it the green protein, but now it is known as green fluorescent protein, or G.F.P. for short.
The green fluorescent protein consists of a chain of 238 amino acids bent into a beer can-like cylindrical shape, and for two and a half decades it remained a little-known biological curiosity.
Dr. Chalfie first heard about the protein at a seminar in 1988, and thought he might be able to use it in his studies of Caenorhabditis elegans, a transparent roundworm.
“It didn’t take much to realize that if I put that fluorescent protein inside this transparent animal, I would be able to see the cells that were making it,” he said. “And that’s what we set out to do.”
He thought that the fluorescent protein could be made to serve as a biological marker by splicing the gene that makes the protein into an organism’s DNA next to a gene switch or another gene.
“That serves as a lantern,” Dr. Chalfie said, and biologists would be able to see when specific genes turn on or off and where different proteins are produced.
He was not able to pursue the idea until Douglas C. Prasher, a scientist then at the Woods Hole Oceanographic Institution in Massachusetts, found the G.F.P. gene and shared it with Dr. Chalfie in 1992. Dr. Chalfie said that within a month his group was able to insert the gene into E. coli bacteria.
In 1994, Dr. Chalfie and his collaborators reported that they had inserted the protein into six cells of the C. elegans worm. When placed under ultraviolet light, those cells shined green, revealing their location.
For many biologists, it was a surprise that inserting the G.F.P. gene was all that needed; many had thought that other jellyfish proteins would be needed to help G.F.P. fold into its light-emitting shape.
Dr. Tsien was thinking along similar lines as Dr. Chalfie, also contacting Dr. Prasher. But for the biology experiment he wanted to conduct, he needed two colors of fluorescent proteins. Dr. Tsien started mutating the G.F.P gene and looking at the resulting proteins. Some, he found, glowed blue instead of green.
“That was the first evidence you could change the color,” Dr. Tsien said.
Other scientists have since expanded the palette, enlisting similar proteins from corals to produce fluorescent reds. The multiple colors allow biologists to track different processes simultaneously. In one experiment, the brain of a mouse was transformed into a kaleidoscope of color by tagging different nerve cells with different fluorescent proteins.
The protein has even entered the world of art. In 2000, Eduardo Kac, an artist, displayed a green glowing rabbit named Alba, which he had commissioned a French laboratory to modify genetically with the G.F.P gene.
Topiramate Linked to Birth Defects
Study on 203 pregnant women finds a connection...................
Topiramate has been found to raise the risk of birth defects as much as 14-fold when taken by pregnant women, especially in combination with another drug called valproateBut the results are not surprising, as Topamax has been shown to cause similar defects in animals.
Despite the enormous risks, doctors say that epileptic women cannot stop taking the drugs during pregnancy because seizures can also damage the unborn infant, perhaps even more severely.
But women who are taking the drug to prevent migraines should halt its use if they become pregnant or are planning to do so.
Topamax accounts for about 1 in 5 prescriptions for treatment for epilepsy in 2.7 million Americans.
Valproate, another very common drug used in treating the disorder, has previously been associated with birth defects or fetal death in about 20% of women who take it.
Of the 203 pregnancies, 18 ended in spontaneous abortions, two in stillbirths and five in induced abortions. Of the 178 babies born, 16 had major birth defects. In three of those cases, the mothers had taken only topiramate, and in the other 13, the mothers had taken it in combination with other drugs.
Four of the babies had cleft palates or lips, a rate 11 times the normal rate of 1 in 500 expected among women not taking epilepsy drugs. Four male babies had genital birth defects, which is 14 times the normal rate of 1 in 300.s.
'Breakthrough' in malaria fight
| |
 A sticky substance allows infected blood cells to stick to the blood vessels |
A potential treatment to combat malaria has been identified.
This discovery could be a major breakthrough in the fight against malaria.
The malaria parasite produces a glue-like substance which makes the cells it infects sticky, so they cannot be flushed through the body.
Removal of a protein responsible for the glue can destroy its stickiness, and undermine the parasite's defence.
The malaria parasite - Plasmodium falciparum - effectively hijacks the red blood cells it invades, changing their shape and physical properties dramatically.
Among the changes it triggers is the production of the glue-like substance, which enables the infected cells to stick to the walls of the blood vessels.
This stops them being pased through the spleen, where the parasites would usually be destroyed by the immune system.
A mutant strains of P. falciparum, each lacking one of 83 genes known or predicted to play a role in the red cell remodeling process was developed. And it was seen that eight proteins were involved in the production of the key glue-like substance.
Removing just one of these proteins stopped the infected cells from attaching themselves to the walls of blood . So targeting the protein with drugs - or possibly a vaccine - could be key to fighting malaria.
"If we block the stickiness we essentially block the virulence or the capacity of the parasite to cause disease".
Malaria is preventable and curable disease but it kills more than a million people each year.MDR-TB Detection in 2 days!
Detecting MDR TB has never been easier... two days instead of the standard 2-3 months is a great news.
Multiple-drug-resistant TB, or MDR-TB, is dangerous. 5% of new TB cases are resistant to first-line drugs. per WHO 9 million new TB cases are detected each year.
“This revolutionary new test called "LINE PROBE ASSAY" described on Monday, detects mutations in bacterial DNA linked to drug resistance and costs little less than $8.
Had there been higher demand and funding, it could have been developed 5 years earlier. It took widespread publicity about an outbreak in South Africa of XDR-TB, a shorthand for extensively-drug-resistant TB, to demonstrate the urgency and duty to bring sophisticated technology.It is estimated that only 2 percent of drug-resistant cases worldwide are detected and treated appropriately. The potential for outbreaks of MDR-TB to evolve into those of the even deadlier XDR-TB would be disastrous.
The TB test is performed by extracting DNA from a sputum specimen and then large numbers of copies of the DNA is produced by using amplifying techniques.
The presence of certain genetic mutations that are linked to resistance with drugs like isoniazid and rifampin can be determined.
This test is being urged to be used everywhere, particularly in poor countries where H.I.V. is also epidemic.
Two Medical Helicopters Collided Killing 6 People
On Sunday, June 29, 2008 in Arizona, USA when this happened, it killed both patients, critically injured a nurse and two emergency workers suffered minor burns.One of the helicopters that crashed Sunday was carrying a patient with a medical emergency . The other helicopter was coming from the nearby community of Winslow.
There have been nine serious accidents with emergency medical aircraft this year, six of them involving helicopters,
Both aircraft were Bell 407 models, it is rare for two medical helicopters to attempt to land at a hospital at the same time. The falling debris set off a brush fire, which spread to 10 acres before it was contained.
HOPE for SEVERE DEPRESSION
The psychiatry researchers in USA are working on Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. This is the largest study ever on the treatment of major depressive disorder and is considered a benchmark in the field of depression research. The six-year, $33 million study initially included more than 4,000 patients from clinics across the country. STAR*D provided evidence for step-by-step guidelines to address treatment-resistant depression and found that half of depressed patients became symptom-free or had major improvement after the first two treatments with medication.
Based on thEse findings, a computerized treatment system has been developed and is being tested it in a Nashville, TN. The computer software provides a step-by-step guide to assist doctors as they're treating patients.
"This computerized system gives doctors assistance at the time that they are seeing the patient. "It's like walking with someone learning to ride a bike versus just sitting there and telling them how to ride."
"Previous research has pulled out a few drops of water from a pond, whereas now we are looking at the whole pond and all its possible murkiness," Dr. Trivedi said.
MOLECULAR RESEARCH
Two Scientists from UCSF and Yale grabbed America's largest prize for work in medicine, amounting to half a million dollars for their groundbreaking work in molecular research. Elizabeth Blackburn from UCSF has a worldwide reputation for her pioneering work on telomeres, the DNA sequences at the end of chromosomes. She discovered the ribonucleoprotein enzyme telomerase, which strengthens telomeres.Before this research, the "clock" of cellular life was a mystery to scientists. Telomeres becomes progressively shorter over the life of a cell and when they become too short, the cell dies.
Elizabeth Blackburn showed that telomerase can add DNA back to the ends of telomeres and effectively turn back the clock. Blackburn's another work has shown a link between low levels of telomerase and chronic stress that can lead to early onset of a range of age-related conditions such as neurodegenerative and cardiovascular diseases. She is also looking into ways to stop cancer by manipulating telomerase.
Joan Steitz from Yale achieved global recognition when she discovered how small ribonucleoproteins (snRNPs) behave in pre-messenger RNA, the earliest product of DNA transcription. She found out that snRNPs get rid of introns, the useless chunks of DNA and pre-messenger RNA, by "splicing" them out and then joining the severed ends together to make messenger RNA. Messenger RNA then instruct the production of proteins, the essential building blocks of the body's biology.
Steitz's work mainly focus on the formation of proteins, and especially on the intricate transformations that occur as the immune system and brain develop. Understanding more about the "splicing" function of snRNPs may lead to discoveries about how to prevent many human diseases.
Should MEN of 95 eat Broccoli instead?
Just a few more portions of broccoli each week has shown to protect men from prostate cancer.
A chemical in the food could have sparked hundreds of genetic changes, activating some genes that fight cancer and switching off others that fuel tumors.
This study published in the Public Library of Science journal PLoS, is the first human trial investigating the potential biological mechanism at work.
Prostate is the second-leading cancer killer of men after lung cancer. Each year, some 680,000 men worldwide are diagnosed with the disease and about 220,000 will die from it.
24 men with pre-cancerous lesions that increase prostate cancer risk were split in 2 groups and were given four extra servings of either broccoli or peas each week for a year.
The researchers took tissue samples over the course of the study and found that men who ate broccoli showed hundreds of changes in genes known to play a role in fighting cancer.
The benefit would likely be the same in other cruciferous vegetables that contain a compound called isothiocyanate, including brussel sprouts, cauliflower, cabbage, rocket or arugula, watercress and horse radish.Broccoli, however, has a particularly powerful type of the compound called sulforaphane, which could have given it an extra cancer-fighting kick.
"When people get cancer some genes are switched off and some are switched on"What broccoli seems to be doing is switching on genes which prevent cancer developing and switching off other ones that help it spread."
The broccoli eaters showed about 400 to 500 of the positive genetic changes with men carrying a gene called GSTM1 enjoying the most benefit. About half the population have the gene.
Events to Look for
Events to look for:
JUN 02 ARPIT Bday
JUN 03 ELSA Bday
JUN 04 Muthu – Vinodh MP Wedding Anniversary
JUN 05 ANOOP-SHERIN wedding anniversary; ABHA Bday
JUN 07 AJAY Bday
JUN 09 SATHEESH-KAVIN wedding anniversary
JUN 11 MADHAVI Bday
JUN 14 BASU Bday
JUN 16 SUJOY Bday
JUN 18 AMARJEET Bday & GEETHA SANGEETHA Bday
JUN 19 Salome – Prince Wedding Anniversary
JUN 22 MD ABRAR Bday
JUN 27 Mary – Dawson Wedding Anniversary
JUN 29 ARPITA Bday
JUL 05 ANTON JOB Bday
JUL 07 TONY Bday
JUL 08 SUCEENA Bday
JUL 20 ANUGRAH Bday
JUL 24 MESHACH Bday
JUL 28 DINAKAR M.J. Bday
JUL 30 SUJITH Bday
AUG 02 Kiran – Kaveeta Wedding Anniversary
AUG 15 GEORGENE Bday
AUG 16 JESSIE Bday & MARY JESSIE Bday
AUG 18 SAMEER Bday
AUG 19 Suman – Anu Wedding Anniversary
AUG 22 BASU-RANI wedding anniversary
AUG 22 ABHAY Bday & AMIT DUTTA Bday
CME
CME TOPICS
Chronic Diarrhea
Definition.
Loose stools with or without increased stool frequency persisting for more than 4 weeks.
Etiology: Infection. Giardiasis, amebiasis, Clostridium difficile, Cryptosporidium
Whipples disease, caused by Tropheryma whippleii, is a unique cause of diarrhea. Begins as a nondeforming arthritis in middle age, which may be manifest for years before GI symptoms begin. The illness progresses to include abdominal pain, diarrhea, weight loss, fever, lymphadenopathy, and occasionally CNS symptoms. Diagnosis is by biopsy of the small intestine yielding the offending organism.
Inflammation. Ulcerative colitis, Crohns disease, ischemic colitis, diverticulitis, AIDS-related chronic diarrhea, collagenous colitis (very common in middle-aged and elderly women), microscopic (lymphocytic) colitis.
Drugs. Laxatives, antibiotics, NSAIDs, magnesium-containing antacids, alcohol.
Malabsorption. Short bowel syndrome, celiac sprue (gluten sensitive enteropathy), carbohydrate malabsorption, pancreatic insufficiency, bacterial overgrowth.
Endocrine. Hypothyroidism or hyperthyroidism, diabetes, adrenal insufficiency, hypoparathyroidism, Zollinger-Ellison syndrome.
Motility disorders. Irritable bowel syndrome, dumping syndrome.
Infiltrative disorders. Amyloidosis, diffuse intestinal lymphoma, scleroderma.
Hormone-producing tumors. VIPoma, carcinoid tumor, pheochromocytoma, ganglioneuroma, villous adenoma, medullary thyroid carcinoma or systemic mastocytosis.
Others. Fecal incontinence, food allergy, radiation enteritis or colitis.
Most patients with chronic watery diarrhea and abdominal pain have no identifiable cause for diarrhea except for irritable bowel syndrome.
Evaluation
History. Inquire about diurnal variation, relationship to meals, weight loss, and character of stools (such as foul-smelling or greasy stools characteristic of malabsorption or chronic bloody stools and abdominal pain or tenesmus suggestive of inflammatory bowel disease or tumor). Absence of stools at night suggests (but does not prove) a non-organic etiology.
Physical examination. Look for abdominal tenderness, distension, organomegaly, anal fistulas, rectal mass, and hyperactive bowel sounds.
Laboratory analyses.
1. CBC with differential. Anemia is suggestive of chronic blood loss, infection, malabsorption, or neoplasm. Eosinophilia may be secondary to parasitic disease or allergic reaction. Megaloblastic anemia may result from vitamin B12 or folate malabsorption.
2. ESR, C-reactive protein. If elevated, may indicate chronic inflammation.
3. Serum electrolytes, magnesium, iron, renal function, albumin, cholesterol. Calcium, phosphate, and alkaline phosphatase levels to evaluate for parathyroid disease. A fasting or random glucose can be used to screen for diabetes. Carotene levels may be low because of fat malabsorption. PT/PTT may be abnormal because of decreased vitamin K absorption. Thyroid function abnormalities should be ruled out. Hypocalcemia may be due to vitamin D malabsorption.
4. Stool exam for occult blood, leukocytes, and ova and parasites. A stool specimen should be sent for culture and sensitivity; one culture is sufficient. Stool antigen test (sensitivity 92%, specificity 98%) is available for Giardia organisms and is more sensitive than an "O & P." The same type of test is available for Cryptosporidium. Generally 3 stools are sent of ova and parasites.
5. Special tests.
1. A 72-hour fecal fat quantitation or Sudan staining of stool if steatorrhea (fat malabsorption) is suspected.
2. d-Xylose absorption (decreased in disorders of proximal small intestine).
3. A stool pH <5.3>
4. Small intestinal biopsy (useful for Whipples disease, celiac sprue, regional enteritis, some parasitic infestations).
5. Smooth muscle endomysial antibody titers may be positive in celiac sprue/gluten insensitivity. Tissue transglutaminase is starting to be utilized as an alternative test (see Sprue below).
6. Small bowel culture for bacterial overgrowth.
7. Stool test with phenolphthalein (test for factitious laxative abuse). Bring stool pH to 8.0. If the specimen turns maroon in color, this indicates the presence of phenolphthalein, an ingredient in over-the-counter laxative products. Urine tests are available to detect aloes, senna alkaloids, and bisacodyl.
8. Sigmoidoscopy should be done to detect inflammation of the colon or rectum, neoplasms, and parasites.
9. Radiographic studies. Plain abdominal radiography and barium studies of the upper GI tract, small intestine, and colon.
Treatment
Should be directed toward underlying cause of the chronic diarrhea.
Occasionally, when a definitive diagnosis cannot be made, one might empirically try:
Dietary restriction. Restricting lactose, gluten, or long-chain fatty acids in the diet. Restrictions should be done systematically so that if symptoms improve, the restricted factor can be identified and removed permanently from the diet. Lactase replacements (such as Lactaid caplets) are available OTC for patients intolerant to lactose.
Pancreatic enzyme supplementation (Creon [pancrelipase] capsules) for suspected pancreatic exocrine deficiency (such as cystic fibrosis, chronic pancreatitis).
Increase dietary or supplemental fiber.
Cholestyramine, which tends to have a constipating effect.
Antimicrobials (such as metronidazole).
Judicious use of antidiarrheal medication may be appropriate for symptomatic relief in some patients. Avoid opiates in the treatment of chronic diarrhea. See acute diarrhea section for dosages and cautions
Sarcoidosis
A multisystem granulomatous disorder of unknown etiology, characterized histologically by noncaseating epithelioid granulomas involving various organs or tissues, with symptoms dependent on the site and degree of involvement.
Sarcoidosis occurs mainly in persons aged 20 to 40 yr and is most common in Northern Europeans and American blacks. The lifetime risk of developing sarcoidosis is particularly high among Swedish men (1.15%), Swedish women (1.6%), and American blacks (2.4%).
A single provoking agent or disordered defense reactions triggered by various insults may be responsible, and genetic factors may be important. The characteristic histopathologic findings are multiple noncaseating epithelioid granulomas, with little or no necrosis, occurring commonly in mediastinal and peripheral lymph nodes, lungs, liver, eyes, and skin and less often in the spleen, bones, joints, skeletal muscle, heart, and CNS. These granulomas may resolve completely or proceed to fibrosis. Although similar granulomas can occur in various infections, hypersensitivity reactions, pneumonia, and foreign body reactions, characteristic patterns of involvement indicate sarcoidosis.
SYMPTOMS AND SIGNS
Symptoms depend on the site of involvement and may be absent, slight, or severe. Fever, weight loss, and arthralgias may occur initially. Persistent fever is common with liver involvement. Peripheral lymphadenopathy is common and usually asymptomatic; even insignificant nodes may contain granulomas. Organ function may be impaired by the active granulomatous disease or by secondary fibrosis. Cough and dyspnea may be minimal or absent.
Skin lesions (plaques, papules, subcutaneous nodules) are frequently present in patients with chronic sarcoidosis, and nasal and conjunctival mucosal granulomas may occur. Erythema nodosum, often with fever and arthralgias, is commonly the presenting symptom in Europeans but less commonly in Americans.
Hepatic granulomas are found on percutaneous biopsy in 70% of patients, who may be asymptomatic with normal liver function tests. Hepatomegaly is noted in <>
Granulomatous uveitis occurs in 15% of patients; it is usually bilateral and, if untreated, may cause severe vision loss due to retinal involvement, severe vitreitis, or secondary glaucoma. Lacrimal gland enlargement, conjunctival and eyelid infiltrations, and keratitis sicca occasionally are present.
Myocardial involvement, noted in 5 to 10% of patients, may cause angina, heart failure, or fatal conduction abnormalities.
Acute polyarthritis may be prominent; chronic periarticular swelling and tenderness may be due to osseous changes in the phalanges. Acute periarticular ankle inflammation often occurs without cutaneous lesions and is often not recognized as a presentation of sarcoidosis.
CNS involvement is of almost any type, but cranial nerve palsies (especially facial paralysis) are most common, affecting 5% of patients.
Diabetes insipidus may occur. Hypercalcemia and hypercalciuria (the result of increased 1,25-dihydroxyvitamin D production by alveolar macrophages and sarcoid granulomas) may cause renal calculi or nephrocalcinosis with consequent renal failure, but prednisone has reduced the frequency of disordered Ca metabolism. Hyperparathyroidism appears to be unusually frequent and should be considered when hypercalcemia does not promptly respond to corticosteroids.
LAB FINDINGS AND DIAGNOSIS
Chest x-ray abnormalities occur in 90% of patients. Mediastinal adenopathy often is discovered on routine chest x-ray. X-ray findings of bilateral hilar and right paratracheal adenopathy are virtually universal (90% of patients), although adenopathy occasionally is unilateral. Pulmonary infiltration may have a diffuse, fine, ground-glass appearance on x-ray. It may accompany or follow adenopathy; occur without visible adenopathy; occur as reticular or miliary lesions; or be present as confluent infiltrations or large nodules resembling metastases. Cough and dyspnea may be minimal or absent. Pulmonary fibrosis, cystic changes, and cor pulmonale are late results of progressive disease.
Leukopenia is frequently present, and serum uric acid elevation is common, but gout is rare. Serum alkaline phosphatase and gamma-glutamyl transpeptidase levels may be elevated as a result of liver involvement. Depression of delayed hypersensitivity is characteristic, but a negative second-strength tuberculin reaction reliably excludes complicating TB. Hypergammaglobulinemia is common in blacks.
Pulmonary function tests show restriction, decreased compliance, and impaired diffusing capacity. CO2 retention is uncommon, although airway obstruction is common in patients with endobronchial disease or in late stages with pulmonary fibrosis or bullae. Serial pulmonary function tests are important for assessing disease progression and guiding treatment.
Sarcoidosis may be diagnosed in asymptomatic patients with typical chest x-ray findings but should also be considered with normal findings when the symptoms and signs described above occur. Because the differential diagnosis includes lymphoma and fungal infections (eg, histoplasmosis, coccidioidomycosis), tissue biopsy with microbiologic and histologic examination is essential if symptoms are present and if corticosteroid therapy is indicated. When superficial or palpable lesions (eg, in skin, lymph nodes, or conjunctiva) are present, biopsy is positive for sarcoidosis in > 85% of such specimens.
When peripheral sites are not available for biopsy, transbronchial biopsy by fiberoptic bronchoscopy is the best initial procedure for securing histologic evidence of sarcoidosis; granulomas can be seen in 50 to 80% of patients regardless of whether the chest x-ray reveals pulmonary infiltration or hilar adenopathy alone. Lung tissue can also be sampled via thoracoscopy.
Other possible biopsy sites include normal-appearing conjunctiva or the mediastinum, which can be approached by mediastinotomy or mediastinoscopy. Liver biopsy shows granulomas in 70% of cases. Local sarcoid reactions in a single organ (eg, liver) and pulmonary granulomas due to infection, hypersensitivity reaction, or foreign body reaction must be excluded. In questionable cases, more than one site should be biopsied to thoroughly search for an infection or foreign body reaction.
The Kveim reaction, a granulomatous reaction appearing 4 wk after intradermal injection of sarcoid spleen or lymph node extracts, is positive in 50 to 60% of patients, but reliable antigens are not available in the USA because of FDA restrictions on the use of human material for diagnostic testing.
Serum ACE activity is elevated (> 2 standard deviations) in 60% of patients, presumably reflecting macrophage activity. It can also be elevated in patients with histoplasmosis, acute miliary TB, hepatitis, or lymphoma and is thus nonspecific. Liver disease slows the metabolic excretion of serum ACE and results in increased ACE activity. Increased CSF ACE may be useful in diagnosing CNS sarcoidosis. Tissue ACE activity is highest in sarcoid lymph nodes rather than in pulmonary tissues.
Bronchoalveolar lavage shows lymphocytosis in most patients with active sarcoidosis but is rarely indicated because patients with hypersensitivity pneumonitis show similar lymphocytosis. However, the CD4/CD8 ratio on bronchoalveolar lavage is elevated in sarcoidosis and reduced in hypersensitivity pneumonitis. Bronchoalveolar lavage analyses were advocated to determine the need for corticosteroid therapy, but recent studies do not support this use.
Whole-body gallium scanning, a sensitive but nonspecific indicator of sarcoidal inflammation, may be used for diagnosis in patients with normal chest x-rays or otherwise atypical presentations. Patients with symmetric increased uptake in mediastinal and hilar nodes (lambda sign) and in lacrimal, parotid, and salivary glands (panda sign) have a pattern pathognomonic for sarcoidosis. Gallium scanning may indicate useful sites for biopsy and may help determine whether radiologic densities represent reversible inflammation or fibrosis in long-standing pulmonary sarcoidosis. Gallium uptake is extremely sensitive to corticosteroids; a negative result in patients taking prednisone is unreliable.
TB, aspergillosis, cryptococcosis, histoplasmosis, coccidioidomycosis, and Hodgkin's disease must be differentiated from sarcoidosis. It is uncertain whether the typical sarcoid granulomas found in 5% of liver biopsies performed for staging of Hodgkin's disease indicate two concurrent diseases or a sarcoid reaction to the neoplasm.
CLINICAL COURSE AND PROGNOSIS
Evaluating treatment is difficult because spontaneous improvement or clearing is common. Even massive hilar adenopathy and extensive infiltrates may disappear in a few months or years. Mediastinal adenopathy may sometimes persist without change for many years. In one study, recovery was observed on x-ray at the end of 5 yr in 82% of Swedish patients with hilar adenopathy alone and in 57% of patients with pulmonary opacities. In another study, recovery was observed at the end of 9 yr in 85% of white patients and 65% of black patients with pulmonary sarcoidosis. Race and extrapulmonary sarcoidosis help predict the likelihood of recovery in patients with pulmonary sarcoidosis: 89.4% in whites with no extrathoracic disease; 69.7% in whites with extrathoracic disease; 76% in blacks with no extrathoracic disease; and 46.4% in blacks with extrathoracic disease.
The prognosis is better for patients who have adenopathy without radiologic evidence of pulmonary disease. The most reliable indicator of a favorable outcome of sarcoidosis is onset with erythema nodosum.
About 10% of patients develop serious disability from ocular, respiratory, or other organ damage, but mortality from sarcoidosis is <>
TREATMENT
Patients with few or no symptoms should not be treated, regardless of radiologic or laboratory abnormalities (except for sustained hypercalcemia). Abnormal ACE activity, gallium scanning, and other laboratory tests are useful in assessing symptoms, but abnormal test results alone do not justify therapy. No available drugs have consistently prevented pulmonary fibrosis.
Corticosteroids accelerate clearance of symptoms, physiologic disturbances, and x-ray changes. However, little difference is demonstrable in long-term outcome between treated and untreated patients, and relapse is common when treatment ends. Corticosteroids should be given to suppress severe symptoms (eg, dyspnea, arthralgia, fever) or hepatic insufficiency, cardiac arrhythmia, CNS involvement, hypercalcemia, ocular disease uncontrolled by local drugs, or disfiguring skin lesions. A good starting dose is prednisone 15 to 20 mg/day po or methylprednisolone 12 to 16 mg/day po. Prednisone 60 mg/day po or methylprednisolone 48 mg/day po is often used when a prompt effect is desired, but such doses are poorly tolerated by many patients. Patients with acute disease (eg, severe erythema nodosum) may need treatment for only a few weeks, but most of those requiring therapy have chronic sarcoidosis and need treatment for >= 1 yr. Maintenance doses of prednisone as low as 5 mg/day po control symptoms and radiologic lesions and may be needed indefinitely in a few patients. Inhaled corticosteroids may provide palliation of mild or moderate respiratory symptoms. Because relapse occurs in 50% of cases, clinical and laboratory examination should be repeated every 2 to 3 mo after the drug is stopped.
About 10% of patients requiring therapy are unresponsive to tolerable doses of a corticosteroid and should be given a 6-mo trial of methotrexate starting at 2.5 mg/wk po and increasing in increments of 2.5 mg/wk to a total of 10 to 15 mg/wk as tolerated by a WBC > 3000/mm3. After 8 wk of methotrexate, the corticosteroid can be reduced and then often discontinued. Serial blood counts and liver enzyme tests should be performed every 6 wk.
Although immunosuppressive drugs are often more effective in refractory cases, relapse is frequent after their cessation. The safety of long-term use of drugs other than methotrexate has not been established. Immunosuppressive drugs are frequently required in patients with neurosarcoidosis and other severe forms of the disease. Hydroxychloroquine 200 mg bid po is more effective than corticosteroids for treatment of disfiguring skin sarcoids. Retinal damage is rare, but serial ophthalmologic examination should be performed every 6 mo.
FEB-MAR-APR 2002 EDITION
THYROID DISORDERS - INTRODUCTION
Thyroid disorders include euthyroid goiter, euthyroid sick syndrome, hyperthyroidism, hypothyroidism, thyroiditis, and thyroid cancers. Discussion of the synthesis and physiology of thyroid hormones and of the laboratory testing of thyroid function are prerequisites to a thorough understanding of these disorders.
SYNTHESIS AND RELEASE OF THYROID HORMONES
Iodide, which is ingested in food and water, is actively concentrated by the thyroid gland, converted to organic iodine by thyroid peroxidase, and incorporated into tyrosine in intrafollicular thyroglobulin within the colloid at the basal cell surface of the thyroid follicular cell. The tyrosines are iodinated at one (monoiodotyrosine) or two (diiodotyrosine) sites and then coupled to form the active hormones (diiodotyrosine + diiodotyrosine tetraiodothyronine [thyroxine, T4]; diiodotyrosine + monoiodotyrosine triiodothyronine [T3]. Another source of T3 within the thyroid gland is the result of the outer ring deiodination of T4 by a selenoenzyme: type I 5-deiodinase (5D-I). Thyroglobulin, a glycoprotein containing T3 and T4 within its matrix, is taken up from the follicle as colloid droplets by the thyroid cells.
Lysosomes containing proteases cleave T3 and T4 from thyroglobulin, resulting in release of free T3 and T4. The iodotyrosines (monoiodotyrosine and diiodotyrosine) are also released from thyroglobulin, but only very small amounts reach the bloodstream. Iodine is removed from them by intracellular deiodinases, and this iodine is used by the thyroid gland.
The T4 and T3 released from the thyroid by proteolysis reach the bloodstream, where they are bound to thyroid hormone-binding serum proteins for transport. The major thyroid hormone-binding protein is thyroxine-binding globulin (TBG), which has high affinity but low capacity for T4 and T3. TBG normally accounts for about 75% of the bound hormones. Other thyroid hormone-binding proteins--primarily thyroxine-binding prealbumin, also called transthyretin, which has high affinity but low capacity for T4, and albumin, which has low affinity but high capacity for T4 and T3--account for the remainder of the bound serum thyroid hormones. About 0.03% of the total serum T4 and 0.3% of the total serum T3 are free and in equilibrium with the bound hormones. Only free T4 and T3 are available to the peripheral tissues for thyroid hormone action.
All reactions necessary for the formation of T3 and T4 are influenced and controlled by pituitary thyroid-stimulating hormone (TSH), also called thyrotropin, which stimulates follicular cells in the thyroid gland. TSH binds to its thyroid plasma membrane receptor on the external follicular cell surface and activates the enzyme adenylate cyclase, thus increasing the formation of adenosine 3:5-cyclic phosphate (cAMP), the nucleotide that mediates the intracellular effects of TSH. Pituitary TSH secretion is controlled by a negative feedback mechanism modulated by the circulating level of free T4 and free T3 and by conversion of T4 to T3 in the pituitary thyrotropic cells. T3 is the metabolically active iodothyronine. Increased levels of free thyroid hormones (T4 and T3) inhibit TSH secretion from the pituitary, whereas decreased levels of T4 and T3 result in an increased TSH release from the pituitary. TSH secretion is also influenced by thyrotropin-releasing hormone (TRH), a 3-amino acid peptide synthesized in the hypothalamus. TRH, released into the portal system between the hypothalamus and pituitary, binds to a specific TRH receptor on the thyrotropic cells of the anterior pituitary and causes the subsequent release of TSH. The precise regulation of TRH synthesis and release is not clear, although thyroid hormones do play a role.
About 20% of the circulating T3 is produced by the thyroid. The remaining 80% is produced by monodeiodination of the outer ring of T4 (5D-I), mainly in the liver. Monodeiodination of the inner ring of T4 (5-deiodinase [5D-III]) also occurs in hepatic and extrahepatic sites to yield 3,3,5-T3 (reverse T3 or rT3). This iodothyronine has minimal metabolic activity but is present in normal human serum and in insignificant amounts in thyroglobulin. About 99% of the circulating rT3 is generated by inner ring deiodination of T4 in peripheral tissues. rT3 levels increase in many instances in which serum T3 levels fall because of decreased activity of outer ring 5D-I (eg, chronic liver and renal disease, acute and chronic illness, starvation, and carbohydrate-deficient diets). This increase in rT3 occurs primarily because of decreased outer ring (5D-I) activity, which markedly decreases the clearance of rT3. These states of chronic illness, therefore, result in decreased production of the active hormone, T3, and in increased serum rT3 levels due to decreased rT3 clearance. The decreased production of T3 might be an adaptive response to illness.
EFFECTS OF THYROID HORMONES
Thyroid hormones have two major physiologic effects: (1) They increase protein synthesis in virtually every body tissue. (T3 and T4 enter cells, where T3, which is derived from the circulation and from conversion of T4 to T3 within the cell, binds to discrete nuclear receptors and influences the formation of mRNA.) (2) T3 increases O2 consumption by increasing the activity of the Na+, K+-ATPase (Na pump), primarily in tissues responsible for basal O2 consumption (ie, liver, kidney, heart, and skeletal muscle). The increased activity of Na+, K+-ATPase is secondary to increased synthesis of this enzyme; therefore, the increased O2 consumption is also probably related to the nuclear binding of thyroid hormones. However, a direct effect of T3 on the mitochondrion has not been ruled out. T3 is believed to be the active thyroid hormone, although T4 itself may be biologically active.
LAB TESTING OF THYROID FUNCTION
Measurement of serum thyroid-stimulating hormone (TSH): Measuring serum TSH is the best way to determine thyroid dysfunction. Normal test results essentially rule out hyperthyroidism or hypothyroidism, except in hyperthyroidism secondary to a TSH-secreting pituitary adenoma or pituitary resistance to thyroid hormone and in some patients with central hypothyroidism due to disease in the hypothalamus and/or pituitary gland. These conditions are discussed briefly below. The serum TSH level also defines the syndromes of subclinical hyperthyroidism (suppressed serum TSH) and subclinical hypothyroidism (elevated serum TSH), both associated with normal serum T4, free T4, T3, and free T3 levels.
New serum TSH assays using immunometric assay methodology are far more sensitive and accurate than the first-generation assay using radioimmunoassay. This sensitivity allows differentiation between the extremely low or undetectable levels found in true hyperthyroidism and the below-normal levels found in certain patients, eg, patients with euthyroid sick syndrome (see below). Second-generation immunometric assays (IEMAs, IFMAs, and ICMAs) have a functional sensitivity of 0.1 to 0.2 mU/L. Third-generation assays (some ICMAs) have a functional sensitivity of 0.01 to 0.02 mU/L. Fourth-generation assays in development have a functional sensitivity of 0.001 to 0.002 mU/L.
Measurement of total serum T4: Total serum T4 is most commonly measured by immunometric assay using isotopic (IRMA) or nonisotopic labels, including an enzyme (immunoenzymometric assay [IEMA]), a fluorophor (immunofluorometric assay [IFMA]), or a chemiluminescent compound (immunochemiluminometric assay [ICMA]). Immunometric assays measure total T4, both bound and free hormone, although almost all T4 is protein-bound. These assays are simple, inexpensive, and rapid. Total T4 is a direct measurement of T4, unaffected by contaminating non-T4 iodine. However, changes in serum-binding protein levels produce corresponding changes in total T4, even though the physiologically active free T4 is unchanged. Thus, a patient may be physiologically normal but have an abnormal total serum T4 level.
Thyroxine-binding globulin (TBG) is most commonly increased in pregnancy, by estrogen therapy or oral contraceptives, and in the acute phase of infectious hepatitis. TBG may also be increased genetically by an X-linked abnormality.
TBG is decreased primarily by anabolic steroids, including testosterone, and by excess amounts of corticosteroids. TBG may also be decreased genetically. Finally, large doses of drugs such as phenytoin and aspirin and their derivatives displace T4 from its binding sites on TBG, thereby falsely lowering the total serum T4 level.
Direct measurement of free T4: Since free thyroid hormones are available to peripheral tissues, directly measuring serum free T4 avoids the pitfalls of interpreting total T4 levels, which are influenced by the level of the binding proteins. Thus, serum free T4 levels more accurately diagnose true thyroid function than total T4. Direct measurement of serum free T4 level is most accurately assessed by equilibrium dialysis, which is time-consuming, expensive, technically demanding, and unavailable in most commercial laboratories. This method separates bound from free hormone. The gold standard for measuring serum free T4 is overnight equilibrium dialysis of serum containing 125I-T4; the percentage of free T4 is calculated by determining the total counts in the dialysate divided by the total 125I-T4 added to the serum multiplied by the total T4 concentration. A simplified version is available in kit form; free T4 is measured in the dialysate by immunoassay.
Indirect estimation of free T4: These measurements are readily available, are simpler, and compare extremely well with the methods for measuring direct free T4 mentioned above. Index methods require two independent tests, one measuring total serum T4 and the other measuring thyroid hormone-binding ratio or T3 resin uptake. The free T4 index is then calculated using the total T4 and the TBG level, the thyroid hormone-binding ratio, or T3 resin uptake. The index is directly proportional to the free T4 level. Immunoassay methods are standardized against a direct measurement of free T4 by equilibrium dialysis, thus results are reported in absolute units (ng/dL or pmol/L). The two most commonly used methods are a two-step and a one-step immunoassay method using a T4 analog. These assays are not completely free of the influence of binding proteins or substances in serum that may result in false increases or decreases in the free T4 levels.
Measurement of total serum T3 and free T3: Since T3 is tightly bound to TBG (although 10 times less than T4) but not to transthyretin, total serum T3 levels measured by the same methods described above for total T4 will be influenced by alterations in the serum TBG level and by drugs that affect binding to TBG. Free T3 levels in the serum are measured by the same direct and indirect methods described above for T4.
Testing with thyrotropin-releasing hormone (TRH): Serum TSH is measured before and after an IV injection of 500 g synthetic TRH. Normally, there is a rapid rise in TSH levels of 5 to 25 U/mL, reaching a peak in 30 min and returning to normal by 120 min. The rise is exaggerated in primary hypothyroidism. The TRH test may be useful in distinguishing pituitary from hypothalamic hypothyroidism. Patients with hypothyroidism secondary to a pituitary deficiency have an absent or impaired TSH response to TRH. Patients with a hypothalamic disorder who have deficient TRH reserve and a normal pituitary reserve will usually release normal amounts of TSH in response to TRH, although the release may be delayed and prolonged, resulting in a shift in the time of release. In hyperthyroidism, TSH release remains suppressed, even in response to injected TRH, because of the inhibitory effects of the elevated free T4 and free T3 on the pituitary thyrotroph cell. However, with newer TSH assays, the TRH test is rarely needed to diagnose thyroid dysfunction because the basal serum TSH is proportional to the TSH response to TRH.
Measurement of thyroid autoantibodies: Autoantibodies to thyroid peroxidase and, less commonly, to thyroglobulin are present in almost all patients with Hashimoto's thyroiditis, and thyroid peroxidase autoantibodies are usually detected in patients with Graves' disease. Both these antibodies are commonly measured by enzyme immunoassays; a thyroid peroxidase autoantibody test has replaced the older tanned red cell agglutination test for thyroid antimicrosomal (M) autoantibodies. Hyperthyroidism in Graves' disease is caused by an autoantibody directed against the TSH receptor on the thyroid follicular cell (TRAb). Two general methods are used to measure TRAbs. TSH binding-inhibition assays determine the ability of serum IgG to inhibit the binding of 125I-TSH to solubilized TSH receptors. Thyroid-stimulating antibody assay measures the ability of these IgGs to stimulate cAMP generation or 125I uptake in different biologic systems, ie, monolayer cultures of isolated thyroid cells, cultured rat thyroid follicular cells (FRTL-5), or thyroid cells from human or porcine tissue. Finally, antibodies against T4 and T3 may be found in patients with autoimmune thyroid disease and may affect T4 and T3 measurements but are almost never clinically significant.
Measurement of thyroglobulin: The thyroid is the only source of this iodinated high molecular weight glycoprotein, which is readily detectable in normal patients and is usually elevated in patients with nontoxic and toxic goiter. The principle use of serum thyroglobulin is in evaluating patients after near-total or total thyroidectomy with or without 131I ablation for differentiated thyroid cancer. Normal or elevated serum thyroglobulin values indicate the presence of residual normal or malignant thyroid tissue in patients receiving TSH suppressive doses of L-thyroxine or after withdrawal of L-thyroxine. The major problem with the current immunometric assay and radioimmunoassay methods in measuring serum thyroglobulin is the presence of thyroglobulin antibodies, which usually results in an underestimation of serum thyroglobulin.
Testing for radioactive iodine uptake: This test has disadvantages in cost, time, and patient inconvenience. The isotope of choice is 123I, which exposes the patient to vanishingly small radiation. It is valuable in the differential diagnosis of hyperthyroidism, which is discussed below. The thyroid 123I uptake varies widely with iodine ingestion and will be low in patients exposed to excess iodine. The thyroid 123I uptake may be helpful in calculating the dose of 131I in the treatment of hyperthyroidism.
Scanning of the thyroid: Scanning with radioiodine or technetium-99m is not routine. It is useful in delineating structural abnormalities of the thyroid and in evaluating modular thyroid disease, especially a solitary nodule, to determine its functional state, ie, hot vs. cold.
JAN 2002 EDITION
DYSPHAGIA
A subjective awareness of difficulty in swallowing caused by impaired progression of matter from pharynx to stomach.
The usual complaint is that food "gets stuck" on the way down, which may be accompanied by pain. Dysphagia is caused by impeded transport of liquids and solids by organic lesions of the pharynx, esophagus, and adjacent organs or by functional derangements of the nervous system and musculature. The cause of dysphagia should always be carefully sought.
PREESOPHAGEAL DYSPHAGIA
Difficulty emptying bolus material from the oral pharynx into the esophagus.
Preesophageal dysphagia occurs with abnormal function proximal to the esophagus, most often in patients with neurologic or muscular disorders that affect skeletal muscles (eg, dermatomyositis, myasthenia gravis, muscular dystrophy, Parkinson's disease, oculogyric crises associated with phenothiazine therapy, amyotrophic lateral sclerosis, bulbar poliomyelitis, pseudobulbar palsy, other CNS lesions). The patient frequently presents with nasal regurgitation or tracheal aspiration followed by coughing.
ESOPHAGEAL DYSPHAGIA
Difficulty passing food down the esophagus, possibly caused by obstructive or motor disorders.
Esophageal dysphagia is sometimes associated with obstructive disorders (eg, cancer, benign peptic stricture, lower esophageal ring). Obstructive disorders usually produce dysphagia for solids alone by mechanically reducing the esophageal lumen. Meat and bread are often singled out as the major offenders, but some patients cannot tolerate any solids, only liquids. Patients who complain of dysphagia in the lower esophagus are usually correct in terms of origin, whereas patients who complain of dysphagia in the upper esophagus are often incorrect. Dysphagia can be intermittent (eg, from lower esophageal ring), progress rapidly over weeks to months (eg, from esophageal cancer), or progress over years (eg, from peptic stricture). In cases of peptic stricture, dysphagia is preceded by a prominent history of gastroesophageal reflux disease (GERD).
Dysphagia caused by obstructive disorders has extrinsic and intrinsic causes. Extrinsic obstruction results when tumors or adjacent organs compress the esophagus, which may occur with an enlarged left atrium, aortic aneurysm, aberrant subclavian artery (Dysphagia Lusoria), substernal thyroid, bony exostosis, or extrinsic tumors--most commonly lung. Diagnosis is usually made on x-ray, and prognosis depends on the cause. Intrinsic obstruction is usually caused by esophageal cancer. Mechanical obstruction may also be caused by esophageal involvement by lymphoma, leiomyosarcoma, or (very rarely) metastatic cancer.
Esophageal dysphagia is sometimes associated with motor disorders (eg, achalasia, symptomatic diffuse esophageal spasm, scleroderma). Motor disorders involve dysfunction of the smooth muscle of the esophagus. They produce dysphagia for both solids and liquids by impairing esophageal peristalsis and lower esophageal sphincter function, thus interrupting the smooth esophageal transport of a bolus. The presence of dysphagia for both liquids and solids accurately distinguishes motor from obstructive causes.
Dysphagia should not be confused with globus sensation (globus hystericus), a feeling of having a lump in the throat, which is unrelated to swallowing and occurs without impaired transport. Often noted in association with anxiety or grief, globus sensation is mainly emotional in origin.
DEC 2001 EDITION
HEADACHE
Headache (cephalalgia) is a common symptom, often associated with disability, but rarely life threatening. Headaches may be a primary disorder (migraine, cluster, or tension headache) or a secondary symptom of such disorders as acute systemic or intracranial infection, intracranial tumor, head injuries, severe hypertension, cerebral hypoxia, and many diseases of the eyes, nose, throat, teeth, ears, and cervical vertebrae. Sometimes no cause is found.
Headaches may result from stimulation of, traction of, or pressure on any of the pain-sensitive structures of the head: all tissues covering the cranium; the 5th, 9th, and 10th cranial nerves; the upper cervical nerves; the large intracranial venous sinuses; the large arteries at the base of the brain; the large dural arteries; and the dura mater at the skull base. Dilation or contraction of blood vessel walls stimulates nerve endings, causing headache. The cause of most headaches is extracranial rather than intracranial. Stroke, vascular abnormalities, and venous thromboses are uncommon causes of headache.
Diagnosis
The frequency, duration, location, and severity of the headache; the factors that make it better or worse; associated symptoms and signs, such as fever, stiff neck, nausea, and vomiting; and special studies help identify the cause of headache.
Secondary headaches may have specific characteristics. An acute whole-cranial, severe headache associated with fever, photophobia, and stiff neck indicates an infectious process, such as meningitis, until proved otherwise. Subarachnoid hemorrhage also causes acute headache with symptoms and signs of meningeal irritation. Space-occupying lesions often cause subacute, progressive headache. New-onset headache in an adult > 40 yr always requires thorough evaluation. With space-occupying lesions, the following may occur: headache on awakening or at night, fluctuation of headache with postural changes, and nausea and vomiting. Additional neurologic complaints, such as seizure, confusion, weakness, or sensory changes, may occur late and are ominous.
Tension headache tends to be chronic or continuous and commonly originates in the occipital or bifrontal region, then spreads over the entire head. It is usually described as a pressure sensation or a viselike constriction of the skull. Febrile illnesses, arterial hypertension, and migraine usually cause throbbing pain that can occur in any part of the head.
Useful tests include CBC, STS, serum chemistry profile, ESR, CSF examination, and, for specific symptoms, ocular tests (acuity, visual fields, refraction, intraocular pressure) or sinus x-rays. If the cause of recent, persistent, recurrent, or increasing headache remains in doubt, MRI and/or CT is appropriate, especially if abnormal neurologic signs are present.
Treatment
Many headaches are of short duration and require no treatment other than mild analgesics (eg, aspirin, acetaminophen) and rest.
Treatment of primary headaches is discussed under the specific disorders, below. Alternative approaches, such as biofeedback, acupuncture, dietary manipulations, and some less conventional modes, have been advocated for these disorders. None of these treatments has shown clear-cut benefits in rigorous studies. However, to the extent that an alternative treatment poses little risk, it may be tried, with the idea that effective headache management is multidimensional.
Treatment of secondary headaches depends on treatment of the underlying disorder. For meningitis, prompt antibiotic therapy is critical. Subsequently, symptoms can be relieved with analgesics, including acetaminophen, NSAIDs, or opioid narcotics. Certain disorders require more specific treatment; eg, temporal arteritis is treated with corticosteroids, and headache due to benign intracranial hypertension is treated with acetazolamide or diuretics and weight loss. Subdural hematomas or brain tumors may be treated surgically.
Stress management taught by a psychologist often reduces the incidence of headaches. However, most patients are helped by an understanding physician who accepts the pain as real, sees the patient regularly, and encourages discussion of emotional difficulties, whether they are the cause or the result of chronic headaches. The physician can reassure the patient that no organic lesion is present and recommend environmental readjustments and the removal of irritants and stresses. For particularly difficult problems, a team composed of a physician, psychotherapist, and physiotherapist is most effective in managing chronic headache.
CLUSTER HEADACHE
Headache that lasts 15 to 180 min, is severe, is unilateral, is located periorbitally and/or temporally, occurs up to 8 times per day, and is associated with at least one of the following: tearing, red eye, stuffy nose, facial sweating, ptosis, or miosis.
Men have cluster headache more often than women. Triggers include alcohol, sleep, and barometric pressure change. The pathophysiology is unknown but may be similar to that of migraine.
Diagnosis is based on symptoms and the exclusion of intracranial pathology. Treatment is prophylactic, abortive, or analgesic. The calcium channel blocker verapamil and the serotonin antagonist methysergide are used for prophylaxis. Sumatriptan and ergots are used for abortive treatment. Indomethacin is uniquely effective for cluster headache.
TENSION HEADACHE
Headache that lasts 30 min to 7 days and is nonpulsating, mild to moderate in severity, bilateral, not aggravated by exertion, and not associated with nausea, vomiting, or sensitivity to light, sound, or smell.
Tension headache can be thought of as a state of cranial hyperalgesia with reduced endogenous pain modulation and enhanced pain potentiation. It has many causes; comorbid migraine, mood disorders, sleep dysfunction, and anxiety states contribute.
Treatment with mild analgesics is helpful: acetaminophen 650 mg po q 4 h, aspirin 300 to 600 mg, or another NSAID, such as ibuprofen or naproxen. For chronic or recurrent headache, many physicians empirically supplement analgesics with tricyclic antidepressants (eg, amitriptyline 10 to 125 mg/day po) or, occasionally, benzodiazepines (eg, diazepam 2 to 5 mg po qid), but regular use may cause habituation.
More disabled patients require a multidimensional approach as described above. Recognition of comorbid illness is essential. Migraine is often associated with chronic tension headaches, so treatments overlap.
NOV 2001 EDITION
MIGRAINE HEADACHE
Headache that lasts 4 to 72 h, is throbbing, is moderate to severe in intensity, is unilateral, becomes worse with exertion, and is associated with nausea, vomiting, or sensitivity to light, sound, or smell.
Only three or four of the above criteria must be present for accurate diagnosis.
About 24 million Americans have migraines. Migraines may occur at any age but usually begin between ages 10 and 40, more often in women than in men. Headaches often partially or completely remit after age 50. More than 50% of patients have a family history of migraine.
Etiology and Pathophysiology
The cause is unknown, and the pathophysiology is not fully understood. Changes in brain and scalp arterial blood flow occur, but whether vasodilation and vasoconstriction are a cause or an effect of the migraine is unclear. Cortical spreading depression (fundamental changes in the brain cortex in which a crest of hyperpolarization is followed by depolarization) may induce neurogenic inflammation, with vasodilation, activated WBCs and permeable capillaries. The inflammation leads to irritation of perivascular trigeminal sensory fibers. A cascade of events follows, causing changes in blood flow and the severe headache. Intracranial vascular malformations are a rare cause of migraine-like headaches.
The mechanism for migraines is not well defined, but several triggers are recognized. Cycling estrogen, a significant trigger, may explain why there are three times as many women with migraines as men. Evidence of estrogen's role as a trigger includes the following: During puberty, migraine becomes much more prevalent in females than in males; migraines are particularly difficult to control in the premenopausal period; and oral contraceptives and estrogen replacement therapy often make migraine worse. Other triggers include insomnia, barometric pressure change, and hunger. The association of diet and migraine is usually overstated. No prospective study has proved an association.
Symptoms, Signs, and Diagnosis
Migraine may be preceded by a short prodromal period of depression, irritability, restlessness, or anorexia and may be associated with an aura (in 10 to 20% of occurrences). An aura usually precedes the headache by no more than 1 h but is often concurrent. An aura is a transient, reversible neurologic visual, somatosensory, motor, or language deficit. Most persons report visual auras, including flashing lights, scintillating scotoma, and fortification spectrums.
Symptoms usually follow a pattern in each patient, except unilateral headaches may not always occur on the same side. The patient may have attacks daily or only once every several months. Diagnosis is based on the symptom patterns when there is no evidence of intracranial pathologic changes. Migraine is more probable when the patient has a family history of migraine or of visual prodromata. No diagnostic tests are useful, except to exclude other causes.
Treatment
Treatment depends on the frequency of attacks and the presence of comorbid illness. In general, treatment can be classified as prophylactic, abortive, or analgesic.
If a person has more than one migraine a week, long-term prophylaxis should be considered. -blockers, calcium channel blockers, tricyclic antidepressants, or anticonvulsants may be used. The choice is empiric but is guided by the presence of comorbid illness. For example, if hypertension coexists, -blockers or calcium channel blockers would be most efficient. If depression or sleep dysfunction coexists, tricyclic antidepressants should be tried first.
Abortive drugs are used for acute treatment. A new class of drugs that activate serotonin receptors (5-hydroxytryptamine [5-HT] 1B/1D agonists) block neurogenic inflammation and can abort migraine pain in about 70% of patients. Sumatriptan, the prototype, is available in oral and subcutaneous injection forms. Subcutaneous dosing is more effective but has more adverse effects, which include flushing, nausea, esophageal constriction, and, rarely, coronary artery constriction. Caution is advised in prescribing sumatriptan to men > 55 yr, postmenopausal women, or persons with a history of heart disease. The next generation of 5-HT 1B/1D agonists (eg, eletriptan, naratriptan, rizatriptan, zolmitriptan) promises to increase the benefits and reduce the adverse effects. Ergot alkaloid derivatives, such as ergotamine tartrate and dihydroergotamine, in oral and parenteral preparations can be used effectively. Dopamine antagonist antiemetics, such as metoclopramide and prochlorperazine, are effective, even if nausea is not prominent.
Analgesics should be used sparingly. They are effective in some patients but cause rebound headache with dose escalation in others. NSAIDs are probably best for mild to moderate headaches. Opioids should be avoided except under special circumstances and strict guidelines
PREVIOUS MCQs OF THE MONTH
DEC 2001 EDITION
>Ramesh, a 30 yrs old chronic asthmatic, on oral theophylline comes with symptoms of Respiratory tract infection. Which of the following antibiotics should not be used in this patient?
1. Amoxicillin
2. Erythromycin
3. Doxycycline
4. Cephalexin
5. Levofloxacin
ERYTHROMYCIN-THEOPHYLLINE COMBINATION CAN CAUSE SEIZURES. (JUST THINK HOW?)
>Ramani, 30 years old lady presents to the casualty with acute onset of severe abdominal pain. She also gives history of two spontaneous abortions in the past. She has been taking Oral Contraceptive pills of late. A diagnosis of Ischemic colitis was made based on the barium study. The classical appearance is termed as
1. cobblestone appearance
2. applecor appearance
3. Eagle claw appearance
4. thumbprint appearance
5. coffee bean appearance
ISCHEMIC COLITIS ON BARIUM STUDY IS CLASSICALLY DESCRIBED TO HAVE A THUMB-PRINT APPEARANCE
>Which of the following ATT drugs should not be used in a HIV positive patients taking Indianvir, Didanoside and AZT?
1. INH
2. Rifampicin
3. Ethambutol
4. Pyrazinamide
5. Streptomycin
USE OF RIFAMPICIN IS CONTRAINDIACTED WITH MANY PROTEASE INHIBITORS
>Which of the following beta blockers have minimal
metabolic side effects?
1. Propranolol
2. Nadolol
3. Acebutalol
4. Pindolol
5. Timolol
THE ANSWER IS ACEBUTALOL. ACEBUTALOL IS A CARDIOSELECTIVE BETA BLOCKER WITH PARTIAL AGONIST ACTIVITY. THOSE BETA BLOCKERS WITH PARTIAL AGONIST ACTIVITY HAVE LESS METABOLIC SIDE EFFECTS THAN PURE ANTAGONISTS. THE USUAL METABOLIC SIDE EFFECTS ARE INHIBITION OF LIPOLYSIS AND A DECREASE IN THE HDL/LDL RATIO.
>Which is the DNA virus that can multiply entirely in
the cytoplasm of the cell without entering the
nucleus?
1. Hepatitis B virus
2. Adenovirus
3. Pox virus
4. Herpes virus
5. Parvovirus B19
POX VIRUSES ARE DNA VIRUSES THAT HAVE THEIR OWN DNA POLYMERASE ENZYME AND ALSO REPLICATE IN THE CYTOPLASMOF THE CELL WITHOUT ENTERING THE NUCLEUS.
>Which of the following aneurysm are associated with a
inherited disease characterised by multiple cysts in
the kidney and liver?
1. Renal artery aneurysm
2. Abdominal aorta aneurysm
3. Berry aneurysm
4. Dissecting aneurysm of aorta
5. Mycotic aneurysm of the Aorta between the renal
artey and the coeliac plexus
POLYCYSTIC KIDNEY DISEASE IS ASSOCIATED WITH BERRY ANEURYSM OF THE CIRCLE OF WILLIS.
>In the absence of N-acetyl transferase enzyme, intake
of one of the following drugs will result more
commonly in a lupus like syndrome. Which is the drug?
1. Procainamide
2. Rifampicin
3. Probucol
4. Fenfluramine
5. Indapamide
LACK OF N-acetyl transferase RESULTS IN DECREASED CONVERSION OF Procainamide TO N-acetyl procainamide
(NAPA). THIS RESULTS IN SLE LIKE SYNDROME.OTHER DRUGS CAUSING SIMILAR SYNDROME ARE INH AND HYDRALLAZINE
>Which of the following NSAIDs is better tolerated by
Acid peptic disease patients?
1. Piroxicam
2. Nabumetone
3. Indomethicin
4. Propionic acid derivatives
5. Phenylbutazone derivatives
NABUMETONE IS A KETONE NSAID THAT IS CLAIMED TO HAVE MUCH LESS INCIDENCE OF GI SIDE EFFECTS THAN OTHER NSAIDs.
>Which of the following diseases have the
characteristic pathologic feature of Ballooning
degenration of cells
1. Pemphigus
2. Epidemolysis Bullosa
3. Steven Johnson Syndrome
4. Herpes simplex
5. Dermatitis herpetiformis
BALLOONING DEGENRATION IS CHARACTERISTIC OF HERPES SIMPLEX INFECTION.
>BCYE agar is the specific media for which of the following microbes?
1. Leptospira icterohemorrhagica
2. Campylobacter jejuni
3. Bacillus anthracis
4. Legionella pneumophila
5. Bacillus cereus
BCYE AGAR IS SPECIAL MEDIUM FOR LEGIONELLA PNEUMOPHILA
NOV 2001 EDITION
>Examination of the carotid pulse of a patient revealed two impulses or peaks during the ventricular systole. which of the following physical findings probably would be associated with this finding?
1. diastolic murmur beginning after an opening snap.
2. decrease in systolic arterial pressure during inspiration
3. systolic murmur increasing during Valsalva manoeuver.
4. Right sided third heart sound.
ANSWER IS <3> WHICH IS CHARACTERISTIC FINDING IN HOCM WHICH ALSO HAS PULSUS BISFERIENS THAT IS DESCRIBED IN THE QUESTION. THE OTHER DISEASE WHERE THE MURMUR INCREASES DURING VALSALVA IS MVP
>On examining the eyes of a patient for refractive errors in a dark room using a concave mirrorplaced at 1 m distance from the patient's eye positioned so as to reflect the light from a source just above the patient's head onto the patient's eye, the medical student finds that on moving the mirror to one side, the shadow in the patient's pupil also moved to the same side. The correct interpretation of this finding is?
1. emmetropia
2. hypermetropia > 1D
3. hypermetropia <> 1D
6. myopia < myopia =" 1D.">A 38 year old man came to casualty with alleged history of having been mugged by a group of naxalites and was hit with logs of wood and iron rods on the chest, back, buttocks. After initial resuscitation, Xrays were taken. He was found to have multiple fractures involving the forearm bones, scapula, ribs, iliac bone, etc. He was stable and was shifted to the Orthopedics ward. In the ward after 2 days he became restless, irritable, developed tachypnea and dyspnea. His pulse was 120/min. On examination, he was found to have a peculiar rash occuring particulary on the nondependant areas . His Hb was 9.8gm% and platelet count = 40,000/cu.mm. of blood. What is the most likely diagnosis?
1. Pulmonary pneumothorax
2. Hemopneumothorax
3. Fat embolism
4. Sepsis with DIC
5. Hemolytic Uremic syndrome
THIS IS A TYPICAL CASE HISTORY OF A PATIENT WITH FAT EMBOLISM. THE RASH IN THE NONDEPENDANT AREAS IS SUPPOSED TO BE CHARACTERISITIC OF FAT EMBOLISM
>Which of the following is an absolute indication for Caeserian section in pregnancy associated with heart disease?
1. Pulmonary stenosis
2. Coarctation of Aorta
3. Eisenmenger's syndrome
4. Ebstein's anomaly
SURPRISED? COARCTATION OF AORTA IS !!
>Pappe's rule is associated with?
1. burns
2. bullet injury
3. illegal abortion
4. Pupil in post mortem state
PAPPE RULE HELPS IN FINDING OUT THE SEQUENCE OF GUN SHOTS THROUGH THE SKULL!
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