Rheumatoid Lung Disease

• RA-associated interstitial lung disease (RA-ILD).
• Pleural disease (pleural thickening/effusions).
• Airway disease (Both upper & lower airway).
• Rheumatoid nodules
• Drug-induced lung toxicity (i.e., Methotrexate-induced lung injury)
• Fibro-bullous disease
• Thoracic cage immobility
• Venous thromboembolic disease
• Vasculitis
• Pneumonia.

RHEUMATOID EFFUSION:

• WCC <5000/mm3
• Fluid glucose <60 mg/Dl
• Pleural fluid to serum glucose ratio < 0.5
• pH < 7.3
• High pleural LDH level (ie, > 700 IU/L)
• Cytology: Slender or elongated multinucleated macrophages, round giant multinucleated macrophages, and necrotic background debris.

Pulmonary function testing in ILD (PFT):

• Reduced VC, lung volumes, & DLCO.
• Oxygen desaturation during exercise.
• Restrictive abnormalities common (poor muscle strength or kyphosis due to osteoporosis rather than ILD).

 

Infographics

Albuminuria

• Indicator of kidney damage and / or a biomarker of systemic diseases dates back to 1969, when elevated albumin levels were first demonstrated in the urine of patients with newly diagnosed diabetes.

• Urine dipstick is a relatively insensitive marker for albuminuria, not becoming positive until albumin excretion exceeds 300-500 mg/day. 
• Normal rate of albumin excretion is < 30 mg/day (20 mcg/min).
• Persistent albumin excretion between 30-300 mg/day (20 to 200 mcg/min) is called moderately increased albuminuria (formerly called "microalbuminuria").
• Excretion > 300 mg/day (200 mcg/min) represents overt or dipstick positive proteinuria (severely increased albuminuria [formerly called "macroalbuminuria"].

• Albuminuria reflects functional and / or structural changes in the glomerular filtration membrane that allow increased leakage of albumin into primary urine in amounts exceeding the reabsorption capacity of the proximal nephron tubules. 
• Albuminuria considered as an indicator of early damage (dysfunction) of the vascular endothelium (including the glomerular vessels), which leads to increased permeability of the vascular wall. 

• Relationship between albuminuria and cardiovascular risk has been shown in studies of the general population. 
• It is linear and risk is independent of eGFR. 
• Associated with arterial stiffness assessed by the pulse wave velocity measurement

Infographics

Lactate Dehydrogenase.

• Cytoplasmic enzymes present in tissues throughout the body.
• Oxidoreductase, enzyme of the anaerobic metabolic pathway.
• Heart, muscle, kidney, lung, and RBC’s have the highest concentration.
• Upon tissue damage, the cells release LDH in the bloodstream.
• Drugs that can increase LDH include alcohol, aspirin, fluorides, narcotics, anesthetics, clofibrate, mithramycin, and procainamide.
• Cancer cells employ LDH to increase their aerobic metabolism (glycolysis, ATP production, & lactate production): Warburg effect.
• CSF LDH increases in bacterial meningitis (normal in viral meningitis).
• Cancer cells undergo LDH mediated energy production to fulfill the demand for fast cellular growth (marker of metastases, prognosis, survival rates., and radiosensitivity).
• LDH serves as a general indicator of acute and chronic diseases.
• LDH helps in distinguishing exudate from transudate effusions.
• Isozymes, named LDH-1 through LDH-5, have differential expression in different tissues.

Infographics

Bile acids

 

Role of Bile acids

• Bile acids play a key role in the absorption of lipids in the small intestine. 
• Contribute to cholesterol metabolism by promoting the excretion of cholesterol. 
• Denature dietary proteins, thereby accelerating their breakdown by pancreatic proteases. 
• Direct and indirect antimicrobial effects. In this capacity, recent evidence suggests bile acids are mediators of high-fat diet-induced changes in the gut microbiota. 
• Act as signaling molecules outside of the gastrointestinal tract.

The primary bile acids—cholic acid and cheno-deoxycholic acid—are synthesized from cholesterol in the liver.

The maximal rate of bile acid synthesis is on the order of 4 to 6 g/day.

Infographics

Horseshoe Kidney

Horseshoe kidneys are often asymptomatic with incidence of approximately 1 in 500 in the normal population with a male preponderance of 2:1.

The isthmus connecting the two renal masses may be positioned in the midline or laterally resulting in an asymmetric horseshoe kidney, 70% of which are left dominant.

The isthmus consists of renal parenchyma in about 80% of cases with the remainder being composed of a fibrous band.

In more than 90% of cases, fusion occurs at the lower pole, although fusion may occur at the upper pole in a small minority of cases.

Higher incidence of UPJ obstructions, nephrolithiasis, and reflux compared to the general population. Increased frequency of some common renal cancers including transitional cell tumors (three to four times more common), Wilms tumor (twice as frequently), and an extremely large increase in very rare tumors such as carcinoid (62 to 82 times).

Infographics

Polycystic kidney disease (ADPKD)

Autosomal Dominant, M = F, by 60 yrs-50% need renal replacement therapy

Multisystem & progressive disease with cysts formation

Kidney enlargement with other organ involvement (liver∼ 80%, pancreas 7-36%, spleen)

Intracranial aneurysms in ∼6% of pts without family history & ∼20% with a family history (rupture in 65-75%, usually before age 50)

Cardiac Valve abnormalities in 25-30%

Infographics

Urinary Bladder and Micturition

• First sensation of bladder filling at 100–150ml in an adult.
• Feeling of need to pee at 200 - 350 ml of urine
• Can comfortably hold between 300 - 450 ml
• Wall pressure of 5 - 15 mm Hg creates a sensation of bladder fullness while 30 mm Hg & beyond is painful.
• Most people pee 6 or 7 times/ 24 hours (4 -10 times daily is healthy).
• Normal 24-hour Urine output is 800 - 2000 ml/day (at normal fluid intake of about 2 liters/day).

Infographics

Calot’s Triangle (CT)

Calot's triangle is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct must be identified before ligation and division to avoid intraoperative injury.

Borders

• Medial – common hepatic duct.
• Inferior – cystic duct.
• Superior – inferior surface of the liver.
  

The above differ from the original description of Calot’s triangle in 1891 – where the cystic artery is given as the superior border of the triangle. The modern definition gives a more consistent border (the cystic artery has considerable variation in its anatomical course and origin).

Contents

• Right hepatic artery
• Cystic artery
• Cystic lymph node (of Lund)
• Connective tissue
  
  
  
• Lymphatics
• Occasionally accessory hepatic ducts and arteries

Significance

• Cystic artery arises from Right Hepatic Artery in the Calot's triangle in 75%
• Cystic artery origin & course vary in 25% of population.
  
  
  

Infographics