INGUINAL HERNIA

 

An inguinal hernia is a protrusion of abdominal or pelvic contents through a dilated internal inguinal ring or attenuated inguinal floor into the inguinal canal and usually, but not always, out of the external inguinal ring, causing a visible or easily palpable bulge.

Presents with visible or easily palpable swelling in the groin, often with discomfort during strenuous exercise or heavy lifting.

Complications are rare but include incarceration, bowel obstruction, and strangulation.

Diagnosis is usually clinical; imaging may be helpful where there is doubt about diagnosis, but also identifies many clinically insignificant apparent hernias.

Surgical repair remains the mainstay of therapy, although watchful waiting is reasonable in adults with minimally symptomatic or asymptomatic inguinal hernia.

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Model for End-Stage Liver Disease (MELD) score

 Model for End-Stage Liver Disease (MELD) score is a prognostic scoring system, based on laboratory parameters, used to predict 3-month mortality due to liver disease

MELD scores range from 6 to 40; the higher the score, the higher the 3-month mortality related to liver disease

The MELD score does not accurately predict survival in all patients with cirrhosis; conditions such as liver cancer, hepatopulmonary syndrome, and porto-pulmonary hypertension, are associated with a higher mortality rate than MELD score would reflect. Therefore, patients with these conditions may receive additional MELD points when listed for liver transplantation

Recommendations

• Calculate a MELD score every 3-6 months in all patients with cirrhosis to repeatedly assess their score
• Consider referral for liver transplantation in patients with MELD score of 10 or higher
• Consider using MELD score to assess mortality in patients with acute liver failure or acute variceal bleeding
• Calculate MELD scores for patients who have:
• cirrhosis and are undergoing surgery (abdominal, orthopedic, cardiac, etc.)
• cirrhosis and are being considered for TIPS
• alcoholic hepatitis and are being considered for steroids
• acute liver failure or acute variceal bleeding

Appropriate Use of the MELD

• The original MELD calculator was used to predict mortality in those undergoing placement of a transjugular intrahepatic portosystemic shunt (TIPS)
• The MELD score has been validated to predict short-term survival in patients with cirrhosis waiting for liver transplantation, but it also was found to be useful in predicting liver-related mortality in patients with alcoholic hepatitis, acute liver failure, acute variceal hemorrhage, or postsurgical procedures
• MELD is useful in determining when a patient should be evaluated for transplant; the benefit of liver transplantation outweighs the risk once MELD score is 15 or higher
• In patients with alcoholic hepatitis, MELD score of >20 identifies severe disease, when steroid treatment should be considered
• Patients listed for liver transplantation will have their MELD scores updated at regular intervals (from every 7 days if 25 or greater, to every 1-3 months

Understanding the MELD Score Calculation

• When inputting values, laboratory values of less than 1 are rounded to 1
• A score of 40 is set as the upper limit regardless of how high the inputted laboratory values may be.

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“Courvoisier's law”

In 1890, Ludwig Courvoisier described his observation that patients with painless jaundice and a palpable gallbladder often have a malignant obstruction of the common bile duct; this is known as “Courvoisier's law.” Painless jaundice and a palpable gallbladder are present in 50%–70% of patients with periampullary cancer or carcinoma of the head of pancreas. The gallbladder with stones is usually chronically fibrosed and so, incapable of enlargement.

 

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Asymptomatic microscopic hematuria

 The prevalence of asymptomatic microscopic hematuria in adults ranges from 0.19 to 21 percent. Patients with asymptomatic microscopic hematuria or with hematuria persisting after treatment of urinary tract infection also need to be evaluated. Because upper and lower urinary tract pathologies often coexist, patients should be evaluated using cytology plus intravenous urography, computed tomography, or ultrasonography. When urine cytology results are abnormal, cystoscopy should be performed to complete the investigation.

Microscopic hematuria generally is defined as one to 10 red blood cells per high-power field of urine sediment. The American Urological Association (AUA) defines clinically significant microscopic hematuria as three or more red blood cells per high-power field on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens. May be associated with urologic malignancy in up to 10 percent of adults.

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Antiarrhythmic Medications

 Antiarrhythmic Medications - Vaughan-Williams Classification

 • Class I (Ia, Ib, Ic)

 • Class II

 • Class III

 • Class IV

 • Other anti-antiarrhythmic drugs: Adenosine, Digoxin, Ivabradine

Satyendra Dhar, MD 

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D-dimer & interpretation

D-dimer is the smallest fibrinolysis-specific degradation product found in the circulation. The D-dimer is very sensitive to intravascular thrombus and may be markedly elevated in disseminated intravascular coagulation, acute aortic dissection, and pulmonary embolus. Because of its exquisite sensitivity, negative tests are useful in the exclusion venous thromboembolism. Elevations occur in normal pregnancy, rising two- to fourfold by delivery. D-dimer also rises with age, limiting its use in those > 80 years old. There is a variable rise in D-dimer in active malignancy and indicates increased thrombosis risk in active disease. Elevated D-dimer following anticoagulation for a thrombotic event indicates increased risk of recurrent thrombosis. 

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Lactic acid & interpretation

 

Lactic acid was first found & described in sour milk by Karl Wilhelm Scheele in 1780. German physician–chemist Johann Joseph Scherer (1841–1869) demonstrated the occurrence of lactic acid in human blood under pathological conditions in 1843 & 1851.

Lactic acid is essentially a carbohydrate within cellular metabolism and its levels rise with increased metabolism during exercise and with catecholamine stimulation. Glucose-6-phosphate is converted anaerobically to pyruvate via the Embden-Meyerhof pathway. Pyruvate is in equilibrium with lactate with a ratio of about 25 lactate to 1 pyruvate molecules. Thus, lactate is the normal endpoint of the anaerobic breakdown of glucose in the tissues.

The causes of lactic acidosis can generally be divided into those associated with obviously impaired tissue oxygenation (type A) and those in which systemic impairment in oxygenation does not exist or is not readily apparent (type B). However, there is frequently overlap between type A and type B lactic acidosis. In sepsis, for example, there is both an increase in lactate production resulting from microcirculatory failure and also a decrease in lactate clearance that is not solely due to diminished oxygen delivery.

Satyendra Dhar MD, 

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Monkeypox

 Monkeypox is a viral zoonotic infection that results in a rash similar to smallpox. However, person-to-person spread outside the household and mortality from a monkeypox infection are significantly less than for smallpox. The rash of monkeypox can also be similar in appearance to more common infectious rashes, such as those observed in secondary syphilis, herpes simplex infection, and varicella-zoster virus infection.

WHO has activated its highest alert level for the growing monkeypox outbreak, declaring the virus a public health emergency of international concern.

Monkeypox is a rare disease caused by infection with the monkeypox virus. Monkeypox virus is part of the same family of viruses as variola virus, the virus that causes smallpox. Monkeypox symptoms are similar to smallpox symptoms, but milder, and monkeypox is rarely fatal. Monkeypox is not related to chickenpox.

Symptoms of monkeypox can include:

• ·         Fever
• ·         Headache
• ·         Muscle aches and backache
• ·         Swollen lymph nodes
• ·         Chills
• ·         Exhaustion
• ·         Respiratory symptoms (e.g. sore throat, nasal congestion, or cough)
• ·         A rash that may be located on or near the genitals (penis, testicles, labia, and vagina) or anus (butthole) but could also be on other areas like the hands, feet, chest, face, or mouth.

o   The rash will go through several stages, including scabs, before healing.

o   The rash can look like pimples or blisters and may be painful or itchy.

Source : CDC/WHO

Satyendra Dhar MD

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