10th Batch MBBS IIUM Blog

For those yg tak dpt attend.. this are just stuff i found interesting, not the whole thing cos blaja je... any corrections bgtau

1) Recent Advancement in DM control by Dr. Alexander Tan

- Hypoglycaemia increase risk of CV event (highest compared to other risk factors)
- Benefit of glycaemic control is seen longterm (>15 yrs)
- Glycaemic control depends on individual…. For example a 25 y.o we can reduce HBA1c <6.5, but if a 75 y.o with hx of stent/bypass and poor control, reduce <8… coz aggressive reduction predispose to hypoglycaemia which in turn increases risk of CV event…

Based on intensive glycaemic control in the ACCORD and ADVANCE trial…

link : http://www.nejm.org/doi/full/10.1056/NEJMe0804182 New approach= incretin (baca la sendiri ye..)

2) Battle against Obesity – Dr Adie Nuar

Just to remind revised BMI for asians
Underweight : <18.5 kg/m2
Normal :18.5- 22.4 kg/m2
Overweight:23 -27.4 kg/m2
Obese : => 27.5 kg/m2

3) Approach to joint pain – Dr. Ainon Mohd Mokhtar

Diognostic Criteria for Gout (2 or more)
a- clear hx of at least 2 attacks of acute severe joint pain with complete resolution in 2 weeks
b- clear hx of podagra
c- presence of tophus
d- rapid response to colchicines within 48 hours
Definite – crystals of monosodium urate in synovial fluid sample

Indications of hyperuricaemic drugs i.e. Allopurinol
a- Frequent and disabling attacks of gouty arthritis (3 =>attacks/yr)
b- clinical or radiographic signs of erosive gouty arthritis
c- presence of tophaceous deposits
d- urate nephropathy
e- urate nephrolithiasis
f- impending cytotoxic chemo/radiotherapy for leukaemia/lymphoma (tumour lysis syndrome)

ATTN! new criteria for RA diagnosis… yg the usual seven tu dah tak pakai sgt sebab that criteria will detect late stage RA… the new criteria is better to detect early RA… but I think for exam purposes.. remember the old but mention ada new... nak hafal mampos la.. ada score2...

ACR/EULAR rheumatoid Arthritis Classification Criteria 2010

Link : Skip to page 6 for the criteria… http://www.rheumatology.org/practice/clinical/classification/ra/2010_revised_criteria_classification_ra.pdf

4) Per-rectal bleeding – AP Dr Mohd Zailani

Perrectal bleeding- MANDATORY endoscopy
<40 yrs =" flex">40yrs = full endoscopy

Specific IX
-upper lower endoscopy
-Nuclear scan technetium 99 tagged RBC scan – sensitive but not specific.. detect bleeding of 0.1 ml/ hr (MCQ pernah kuar kan?)
-Angiography – less sensitive but specific.. detect bleeding of 0.5 ml/hr (again.. MCQ penah kuar)
-capsule endoscopy

HTAA gonna start a direct access to scope rooms for Primary care J

5) Diabetic retinopathy – Dato’ Dr Vasanth

Recap pathophysio…. Leakage + occlusion

Leakage -> macula oedema -> stretching of the nerve fibers and receptors -> ineffective impulse transfer -> scarring

Occlusion-> increase VEGF -> angiogenesis ->at disc + iris(iris rubiosis) ->bleeding ->scarring ->retinal detachment

Frequency of eye examination
<30 y.o (type I) – 1st exam 5 yrs after onset – repeated annually
>30 y.o (type II)- 1st exam at time of dx- repeated annually
DM complicating pregnancy – unsure (sapa sempat .. tak dgr la yg nie)

6) Tinnitus – Prof Din Suhaimi Sidek

Tinnitus + bleeding postnasal discharge =>rule out NPC(common gak in Msia kan)

7) Management of asthma – Prof Roslina Abd Manap

Untreated asthma causes reduce lung function long term! Caused by subepithelial fibrosis

So, ICS is important, safe to be used long term…

Treatment still ikut the one in GINA.. yg stepwise tu

Adding a LABA is better than >=2x increase of ICS..but must not be used alone, causes increase mortality.. with ICS

New treatment => combination treatment (formoterol +budesonide)..can be used for maintenance and rescue i.e. symbicort (diorg sponsor kot.. haha)

How to increase compliancy? since pt will say that they are asymptomatic and refuse to cont… instead of saying like ‘yes, I know but u still need to use it’ which is so not convincing kan?…use the asthma control scoring, afew recommended by GINA…. So say like ‘look here, yes u might feel asymptomatic but according to this score u r ?? and we need to reach ?? so u still need to cont the med’.. ok of course gentle2 la :P

8)Hep B – Dr Tee Hoi Poh

HBV carriers with increase risk of HCC
-Asia male >40 y.o, female >50 y.o
-Hx of chirrosis
-Hx of HCC
- Carrier with increase ALT or increase HBV DNA lvl > 2000 IU/L

Now ALT upper normal limit is 19 U/ml

Indication for Rx (Ada 3 study tp I only take the asia pacific…)
- ALT 2x upper normal limit and persist after 3-6 months
- HBV DNA >20 000 IU/L if HBeAg (+)
- HBV DNA >2000 IU/L if HBeAg (-)

Indication for Liver biosy
- ALT 1-2 x upper normal limit
- HBV DNA 2000-20000 IU/L
- Age >40 yrs old

Difference between =(acute hepatitis B) /(chronic hepatitis B with flare)
IgM core antibody = (+) / (-)
HBV DNA = (reduce)/(increase)
HBeAg= (reduce)/(increase)

Targets of Rx (descending pattern)
1- HBsAg Seroconversion – hard to achieve
2- HBeAg Seroconversion – the next best thing
3- HBV DNA suppression
4- Normalisation of ALT
5- Histological improvement


Rx
1) Peg-IFN alpha 2a (immune modulator ) – cannot be used in chirrotic
2) Nucleos(t)ide analogue