DV's Random Notes

PAEDIATRICS: CAH

- The main short term regulator of steroid hormone synthesis: StAR (Steroidogenic Acute Regulatory protein).
- The rate limiting step of adrenal steroidogenesis is incorporation of cholesterol across the mitochondrial inner and outer membrane.
- IMAGe syndrome: intrauterine growth retardation, metaphyseal dysplasia, Adrenal insufficiency, Genital abnormalities.
- Ambiguous genitalia in girls- 21Alpha hydroxylase deficiency.
- Ambiguous genitalia in girls with hypertension- 11 Beta hydroxylase deficiency.
- Ambiguous genitalia in boys, postnatal virilization in girls- 3BetaHydroxy Steroid Dehydrogenase deficiency.
- Ambiguous genitalia in boys, lack of puberty in both sexes with hypertension- 17Alpha hydroxylase deficiency.
Steel-Richardson syndrome: Progressive supranuclear palsy

Dv's Random Notes 1

VESICOURETERIC REFLUX
International classification
- 1- Partial filling of an undilated ureter
- 2- Total filling of an undilated ureter
- 3 – Dilated calyces but fornices sharp
- 4 – Blunted fornices and degree of dilatation greater
- 5 - Massive hydronephrosis and tortuosity of the ureters
INDICATIONS FOR SURGERY IN VUR
- 1. Break through infections
- 2. Anatomic abnormalities at the junction
- 3. 4&5 reflux in lower pole of duplex system
- 4. Persistent reflux in adolescence
- 5. Grade 5 reflux
- 6. Noncompliance with medical management
- 7. Associated with ureteral obstruction
Hypospadias
- Rx MAGPI
- Duckett’s Chordee correction.
Cerebral Blood Flow & Its Regulation
- Inhaled nitrous oxide (N2O) (Kety method). The average cerebral blood flow in young adults is 54 mL/100 g/min. The average adult brain weighs about 1400 g, so the flow for the whole brain is about 756 mL/min. In resting humans, the average blood flow in gray matter is 69 mL/100 g/min compared with 28 mL/ 100 g/min in white matter.
- Because brain tissue and spinal fluid are essentially incompressible, the volume of blood, spinal fluid, and brain in the cranium at any time must be relatively constant (Monro–Kellie doctrine).
- In the brain, auto regulation maintains a normal cerebral blood flow at arterial pressures of 65–140 mm Hg.
- O2 consumption by the human brain (cerebral metabolic rate for O2, CMRO2) averages about 3.5 mL/ 100 g of brain/min (49 mL/min for the whole brain) in an adult. This figure represents approximately 20% of the total body resting O2 consumption.
- Glucose enters the brain via GLUT 1 in cerebral capillaries.
- Blood Flow in Various Parts of the Brain – Best is P.E.T (2 Deoxy Glucose).
- CPP = MAP – CVP/ICP (whichever is higher), (Normal CPP 80-100 mmHg, ICP <10 mmHg).
- Most important extrinsic influence on CPP is Arterial pCO2.
- Cerebral Blood Flow changes by 5-7 % with 10C change of temperature.
The Renin–Angiotensin System
- Renin is an aspartyl protease, contains 340 AA, t ½ < 80 min.
- After Nephrectomy the prorenin levels may actually rise (from ovaries), but rennin falls to 0.
- Angiotensinogen is found in the 2-globulin fraction.
- Angiotensinogen -> AT-I (decapeptide) -> (ACE) AT-II (octapeptide) in Lungs. ACE is a dipeptidyl carboxypeptidase that splits off histidyl - leucine from the physiologically inactive angiotensin I. AT II t ½ 1-2 minutes. The normal PRA in supine subjects eating a normal amount of sodium is approximately 1 ng of angiotensin I generated /mL/hr. The plasma angiotensin II concentration in such subjects is about 25 pg/mL (approximately 25 pmol/L).
- Dry Cough in ACEI is d/t increased Bradykinin.
- AT1 receptors are serpentine receptors coupled by a G protein (Gq).
- 1. JG cells (granular cells) - in the media of the afferent arterioles – intra renal pressure sensor, 2. Agranular lacis cells those are located in the junction between the afferent and efferent arterioles in the mesangium, 3. Macula densa (part of tubule – start of DCT, senses Na+) All 3 constitutes JGA.
- GOLDBLATT Hypertension – Syn. Renal Hypertension – decreased blood supply to one kidney -> increased renin.
Gilbert's syndrome - mutation in the UGT1A1 gene promoter- reduced UGT1A1- ADR with 1. Tranilast (in post CABG patients to prevent restenosis), 2. Irinotecan, a prodrug, SN-38 active metabolite, potent Topoisomerase Inhibitor - Leucopenia, Neutropenia and Diarrhoea
Digenic inheritance - retinitis Pigmentosa. XLD – Incontinentia Pigmentosa – lethal to males.
Teratogenicity:
- 1. Lithium – Ebstein’s Anomaly.
- 2. Pencillamine – Cutis Laxa.
- 3. Misoprostol – Mobius Sequence.
- 4. Warfarin – Chondrodysplasia
Free Water Clearance = CH2O = V x [1 – Uosm/Posm], V is Urine production in mL/min.
Atrial Natriuretic peptide is degraded by Neutral Endopeptidase.

ORTHOPAEDICS
· Radiological evidence of Callus formation: 3 weeks after the fracture.
· ‘Creeping substitution’ is seen in healing of cancellous bone.
· Hormones increasing Callus formation: Calcitonin and GH. (Cortisone decrease callus).
· Thyroxine/PTH: increase remodeling.
· Wolf”s Law – “Increased callus formation when there is increased stress”.
· Healing time of a fracture can be predicted by using Perkin’s Time table
· Low ultrasound inc. Ca2+ incorporation, results in stiffer, stronger callus, Accelerated enchondral ossification.
· Member of TGF- family which stimulates mesenchymal cells into osteochondroblastic lineage - Bone Morphogenic Protein (Urist 1965). BMP 2,4 and 7 play a crucial role in bone healing.
· Classification for ankle fractures –LAUGE HANSEN CLASSIFICATION, DANIS-WEBER CLASSIFICATION amplified by A.O (based on level of fracture in relation to syndesmosis).
· Special X Ray taken for Ankle injuries: Internal Rotation of 15-200. MORTISE view.
· MAISONNEUVE FRACTURE: special type of ankle, a spiral fracture around the neck of fibula above the level of syndesmosis -which need not be internally fixed.
· Enchondroma, Osteochondroma ( Exostosis )

Psychiatry Notes 3 by DV

1. In synesthesia, the stimulation of one sensory modality produces a sensation belonging to another sensory modality (a color is perceived as a smell).
2. The capacity to generalize and to formulate concepts is called abstract thinking. The inability to abstract is called concreteness and is seen in organic disorders and sometimes in schizophrenia.
3. Huntington’s disease- progressive neurodegenerative, AD, 35- 40 yrs, manifested by progressive dementia, choreoathetoid movements and psychiatric symptoms. CT/MRI demonstrates gross atrophy of the putamen and the caudate.
4. Nonsuppression/ elevated cortisol in Dexamethasone Suppression test is seen in 40-50% of depressive patients and in 90% of psychotic depression.
5. Looseness of associations refers to a string of thoughts that are disconnected in content and are illogical in their sequence, sometimes called as ‘word salad’, seen in schizophrenia and mania.
6. Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes. Such thinking is due to an unrealistic understanding of the relationship between cause and effect.
7. Obsessions are recurrent thoughts, ideas, or impulses that cannot be eliminated from consciousness by reasoning or desire to stop them. Obsessions are characteristic symptoms of obsessive-compulsive disorder and are usually ego-dystonic. A compulsion is a repetitive behavior or a ritual that is performed to avoid future unpleasant events. Compulsions have an urgent quality and resisting them generates anxiety.
8. The appearance of regressive behaviors and fears during the oedipal period as an attempt to withdraw from the conflicts caused by the intensity of the oedipal longing for the parent of the opposite sex is called as Infantile Neurosis, in Freudian psychoanalytic theory.
9. An inherited set of personality traits such as adaptability, intensity of reaction, threshold of responsiveness and others is known as temperament, difficult temperament of the child results in impaired parent-child relationship.

Psychiatry Notes by DV 2

1.

Consensus Guidelines for Drug Treatment of Acute Mania and Bipolar Depression
Condition Preferred Agents
Euphoric mania Lithium
Mixed/dysphoric mania Valproic acid
Mania with psychosis---- Valproic acid with olanzapine, conventional antipsychotic, or risperidone
Hypomania --- Lithium, lamotrigine, or Valproic acid alone
Severe depression with psychosis---Venlafaxine, bupropion, or paroxetine plus lithium plus olanzapine, or risperidone; consider ECT
Severe depression without psychosis----Bupropion, paroxetine, sertraline, venlafaxine, or citalopram plus lithium
Mild to moderate depression---Lithium or lamotrigine alone; add bupropion if needed

2. 4-2-1-1 rule for diagnosis is used for Somatoform disorder. 4 pain, 2 GI, 1 sexual and 1 pseudoneurological symptom.
3. Dramatic, chronic, or severe factitious illness is termed as Munchausen’s Syndrome.
4. Minnesota Multiphasic Personality Inventory (MMPI) consists of 566 T/F questions
5. Konrad Lorenz- Described attachment behavior of geese after hatching, Ethology, ‘early experience helps to shape social behavior in adulthood.’
6. William Cullen- Neurosis.
7. Binet- IQ test.
8. Cade - Lithium.
9. Delay and Deniker- Chlorpromazine.
10. Manfred Sakel: Insulin Coma Therapy.
11. Cerletti and Bini: Electro Convulsive Therapy.
12. Wilhelm Wundt- Structuralism.
13. William James- Functionalism in psychology.
14. John Bowlby- Infant Attachment.
15. Erickson’s eight psychosocial developmental stages.
16. Margaret Mahler: ‘Ego Psychology’, Theory of Infant Development, known for’ Theory of Separation Individualization’.
17. Piaget: Theory of Cognitive Development.
18. Kohut- Importance of early interpersonal experiences in the development of a cohesive and stable sense of self.
19. D.W.Winnicott- Concept of Transitional Object .e.g. - Blanket or toy which can substitute mother for some time.
20. Karl Kahlbaum: ‘Catatonia’.
21. Unipolar depressive disorder is the psychiatric disorder with maximum YLD years of life lived with disability.
22. “Performance improves as a function of anxiety up to a threshold beyond which there is a fall off in performance”, this law is known as Yerkes-Dodson law.
23. Alzheimer’s disease: Involves cholinergic system arising in basal forebrain, nucleus basalis of Meynert. Chromosome 21, chr.14 with severe form.

SCHIZOPHRENIA
24. The rate of schizophrenia in the general population is ~1%. When one member of a monozygotic twin pair is diagnosed with schizophrenia, the other twin, who is genetically identical, has nearly a 50% chance of also manifesting the disease, for dizygotic twin risk is 17%. A first-degree relative of an affected has a 9% risk of schizophrenia. One parent 17%, two parents 46%.
Genes associated with Schizophrenia: disrupted in schizophrenia (DISC1), distrobrevin-binding protein 1 (DTNBP1); and neuroregulin 1 (NRG1).
Potential risk factors: maternal malnutrition, IU infection, advanced paternal age, migration and urban birth. Serial structural MRI in Schizophrenia shows accelerated loss of gray matter. Echo de la pensee or gendankenlautwerden- ‘Thought echo’. Classification of Schizophrenia by CROW types 1(+) and 2(-). Emil Kraepplin (Father of Modern Psychiatry) – ‘Dementia Praecox’, Eugen Bleuler- Coined the term, Kurt Schneider- First Rank Symptoms of Schizophrenia. About FRS- 58% of patients show atleast 1 FRS, 20% of patients do not show FRS and 10% of normal persons can show FRS.

25. Bleuler’s 4As: 1. Ambivalence 2. Affect flattening 3. Association loosening 4. Autism.
26. Male=Female ratio is 1. Excess dopaminergic activity in mesolimbic and cortical pathways
27. In Catatonia patient resists attempts to change position, in waxy flexibility patient maintains the body position into which they are placed.

Psychiatry Notes by DV 1

PSYCHIATRY NOTES 1
1. Circumstantiality: communication of unnecessary details before finally arriving at the central idea.
2. Delusion of reference refers to events, objects, or persons in one’s environment that are believed to have particular personal significance.
3. Retts Disorder (a Pervasive developmental Disorder): seen only in females, very rare, normal prenatal and post natal development with subsequent regression of milestones and severe to profound mental retardation, severe language defects with stereotyped hand movements(hand wringing or hand washing) decelerated head growth during 5 to 30 months. HC is normal at birth.
4. Functional imaging in depression showed abnormal excessive activity of Brodman area no: 25, subgenual prefrontal cortex. Patients with obsessive-compulsive disorder tend to show hyperactivity in the head of the caudate.
5. All antipsychotic drugs in current use block or diminish the action of dopamine at its D2 receptors. Drugs useful in depression act by increasing synaptic levels of serotonin, norepinephrine, or less commonly dopamine.
6. Cognitive-behavioral psychotherapy: mild to moderately severe depression, fear-based anxiety disorders, and obsessive-compulsive disorder.
7. DSM IV 5 Axes I- Major mental disorder, II- Underlying personality disorder, III- general medical condition, IV- psychosocial and environmental problems that preceded mental disorder or symptoms and axis V- overall rating of general psychosocial functioning based on therapist’s view.
8. Acute panic attacks appear to be associated with increased noradrenergic discharges in the locus coeruleus. I.V. Sodium Lactate, Yohimbine (an alpha 2 blocker), CO2 inhalation and cholecystokinin- 4 evokes panic attack. R­­­­X is with SSRIs, Fluoxetine, Paroxetine and Sertraline.
9. Narcissistic personality disorder is preoccupied with perfection, but usually they are convinced of having already reached it. Individuals with obsessive-compulsive personality disorder, instead, are rarely satisfied with themselves.
10. R­­­­X for GAD Generalized Anxiety Disorder: BZD not more than 6 weeks, Buspirone 5-HT1A partial agonist (especially in patients with head injury or dementia), Escitalopram, Paroxetine and Venlafaxine.
11. Phobic Disorders RX for performance anxiety- Propranolol 20-40mg, 2hrs prior to event. For Social anxiety- MAOIs, others Venlafaxine, Sertraline and Paroxetine.
12. ‘Flashback episodes’ are seen in PTSD. There is excessive release of norepinephrine from the locus coeruleus in response to stress and increased noradrenergic activity at projection sites in the hippocampus and amygdala. Treatment of PTSD- Amitryptiline, Imipramine, Phenelzine (MAOI), Prazosin, Trazadone and SSRI. 30% recover completely.
13. Major depression is defined as depressed mood on a daily basis for a minimum duration of 2 weeks. 6–8% of all outpatients in primary care settings satisfy diagnostic criteria for the disorder. Approximately 4–5% of all depressed patients will commit suicide. 2:1 for female: male.
14. TCA with maximum toxicity is Desipramine.
15. Inner sense of restlessness and anxiety in addition to increased motor activity is called as AKATHISIA.
16. Hyper stimulation of brainstem 5HT1A receptors and characterized by myoclonus, agitation, abdominal cramping, hyperpyrexia, hypertension, and potentially death is called as ‘SEROTONIN SYNDROME’.
17. SSRIs can produce angina due to vasospasm and prolongation of PT.
18. The most specific SSRI currently available is Escitalopram.
19. Mainstay of treatment of Bipolar disorder is Lithium Carbonate. Excreted 95% through kidneys within 24hrs, therapeutic blood level is 0.8- 1.2mEq/L. Side effects: GI discomfort, diarrhea, wt gain, polyuria, edema, alopecia and acne.