Systemic Lupus Erythematosus: Classification Criteria

Differential Diagnosis of Lymphadenopathy

Syndromes in Rheumatoid Arthritis

1. Sjogren's syndrome (common):
keratoconjunctivitis sicca and xerostomia (dry eyes and mouth)

2. Felty's syndrome (rare):
arthritis, splenomegaly, neutropenia

3. Caplan's syndrome (rare):
multiple pulmonary nodules and pneumoconiosis

Only DMARDs (not analgesics or NSAIDs) alter the course of rheumatoid arthritis !!!

Malaysia: Health Human Resources 2011

Source: Health Facts 2012 by Malaysian Ministry of Health

Mnemonic for Ankylosing Spondylitis

Extra-articular Manifestations of Ankylosing Spondylitis
6 "A's"
Atlanto-axial subluxation
Anterior uveitis
Apical lung fibrosis
Aortic incompetence
Amyloidosis (kidneys)
Autoimmune bowel disease (UC)

Consider AS in the differential for causes
of aortic regurgitation!!!

Rule of 2s
AS occurs in
0.2% of the general population
2% of HLA-B27 positive individuals
20% of HLA-B27 positive individuals
with affected family member

汤姆叔叔的小屋 (Uncle Tom's Cabin)

　　１８５１年，斯陀夫人(Harriet Beecher Stowe)在丈夫体弱多病、家境极其贫寒的情况下写成其生平最有影响的作品--《汤姆叔叔的小屋》。评论界认为本书在启发民众的反奴隶制情绪上起了重大作用，被视为美国内战的起因之一。林肯总统后来接见斯陀夫人时戏谑地称她是“写了一本书，酿成了一场大战的小妇人”，这一句玩笑话充分反映了《汤姆叔叔的小屋》这部长篇小说的巨大影响。

　　《汤姆叔叔的小屋》通过汤姆叔叔、乔治夫妇等黑奴们曲折经历的描述，揭发和控诉了黑暗的奴隶制度，在当时的美国社会背景下，不失为引发、推动废奴运动的惊世之作。这部享有盛誉的世界文学名著，自问世至今一个半世纪，但今天读来依然那么促人深思、催人泪下，足见作品的深刻内涵和艺术的魅力。作为一部作品，它早已列入世界名著之林，其巨大的成就和影响越来越受到文学界的重视和承认。

　　构成那次巨大战争--南北战争导火线的，想不到竟是这位身材矮小的、可爱的夫人。她写了一本书，酿成了伟大的胜利。--美国总统　林肯

　　斯陀夫人的《汤姆叔叔的小屋》是文学史上最伟大的胜利。--美国著名诗人　亨利·郎费罗
　
　　故事从一个奴隶主与一个奴隶贩子的讨价还价中开始。美国肯塔基州的奴隶主谢尔比在股票市场上投机失败，为了还债，决定把两个奴隶卖掉。一个是汤姆，他是在谢尔比的种植场出生的，童年时就当伺候主人的小家奴，颇得主人欢心，成年后当上了家奴总管，忠心耿耿，全身心维护主人利益。另一个要卖掉的奴隶是黑白混血种女奴伊丽莎的儿子哈利。伊丽莎不是一个俯首贴耳死心塌地听主人摆布的奴隶，当她偶然听到主人要卖掉汤姆和自己的儿子哈利后，就连夜带着儿子在奴隶贩子的追捕下跳下浮冰密布的俄亥俄河，逃到自由州，再往加拿大逃奔。她丈夫乔治·哈里斯是附近种植场的奴隶，也伺机逃跑，与妻子汇合，带着孩子，历经艰险，终于在废奴派组织的帮助下，成功地抵达加拿大。

　　汤姆却是另一种遭遇。他知道并支持伊丽莎逃走，但是他自己没有逃跑。由于他从小就被奴隶主灌输敬畏上帝、逆来顺受、忠顺于主人这类的基督教说教，对主人要卖他抵债也没有怨言，甘愿听从主人摆布。他被转卖到新奥尔良，成了奴隶贩子海利的奴隶。在一次溺水事故中，汤姆救了一个奴隶主的小女儿伊娃的命，孩子的父亲圣·克莱从海利手中将汤姆买过来，当了家仆，为主人家赶马车。汤姆和小女孩建立了感情。不久小女孩突然病死，圣·克莱根据小女儿生前愿望，决定将汤姆和其他黑奴解放。可是当还没有来得及办妥解放的法律手续时，圣·克莱在一次意外事故中被人杀死。圣·克莱的妻子没有解放汤姆和其他黑奴，而是将他们送到黑奴拍卖市场。从此，汤姆落到了一个极端凶残的“红河”种植场的奴隶主莱格利手中。莱格利把黑奴当做“会说话的牲口”，任意鞭打，横加私刑。汤姆忍受着这非人的折磨，仍然没有想到要为自己找一条生路，而是默默地奉行着做一个正直人的原则。这个种植场的两个女奴为了求生，决定逃跑，她们躲藏起来。莱格利怀疑汤姆帮助她们逃走，把汤姆捆绑起来，鞭打得皮开肉绽，死去活来。但是汤姆最后表现出了他对奴隶主的反抗，什么都没有说。在汤姆奄奄一息的时候，他过去的主人、第一次卖掉他的奴隶主谢尔比的儿子乔治·谢尔比赶来赎买汤姆，因为汤姆是小谢尔比儿时的仆人和玩伴，但是汤姆已经无法接受他过去的小主人的迟来的援手，他遍体鳞伤地离开了人世。乔治·谢尔比狠狠地一拳把莱格利打翻在地，就地埋葬了汤姆。回到家乡肯塔基后，小谢尔比以汤姆大叔的名义解放了他名下的所有黑奴，并对他们说：“你们每次看见汤姆大叔的小屋，就应该联想起你们的自由。”

　　《汤姆叔叔的小屋》这本书通过对汤姆和乔治·哈里斯夫妇这两种不同性格黑奴的描述，告诉读者：逆来顺受、听从奴隶主摆布的汤姆难逃死亡的命运，而敢于反抗、敢于斗争的乔治夫妇得到了新生。因此，《汤姆叔叔的小屋》对社会发展起到了积极的作用，特别是对美国废奴运动和美国内战中以林肯为代表的正义一方获得胜利，产生了巨大的作用。 --《世界文学史》

（摘自：《一生必读的60本书》）

The 2·3 Pattern of Smoking Cessation

• Onset of withdrawal is 2-3 hours after last cigarette

• Peak withdrawal is at 2-3 days

• Expect improvement of withdrawal symptoms at 2-3 weeks

• Resolution of withdrawal at 2-3 months

• Highest relapse rate within 2-3 months

Androgen replacement therapy

Indications:
hypogonadism(=impaired production or function of gametes or sex hormones or both

Contraindications:
1. prostate cancer
2. breast cancer
3. hematocrit >52%
4. congestive heart failure (CHF)

Types:
1. oral
-testosterone undeconate
-more negative effect on liver

2. muscular
-mixture of testosterone esters
-testosterone isobutyrate
-testosterone undeconate
-once every 2-3 weeks

3. buccal
-mouth patch/mucoadhesive polymer with testosterone

4. transdermal
patch(andropatch)
-testosterone patches are worn either on the body or on the scrotum
-body patch application is rotated between the buttocks, arms, back or abdomen
-applied once a day
gel(testogel)
-testosterone gels that are applied daily to the shoulders, upper arms, or abdomen.

5. implantation of testosterone capsule
-about 6 months

Monitor/follow:
1. Prostate-Specific Antigen (PSA)
2. Digital rectal examination (DRE)
3. lipid
4. liver function test (LFT)
5. hematocrit

Adverse effects:
1. benign prostatic hyperplasia (BPH)
2. prostate cancer
3. gynecomastia
4. fluid retention--> worsen hypertension and heart failure
5. liver damage
6. headache
7. polycythemia--> myocardial infarction, stroke, clot development
8. sleep apnea

4 cardiovascular drugs which are used for more than 50 years

1. Aspirin
-antiplatlet

2. Warfarin
-vitamin K antagonist

3. Digoxin
-cardiac glycosides

4. Spironolactone
-aldosterone antagonist

Needlestick Injury and Infection

Risk of Developing Infection from a Hollow Needle Puncture

Hepatitis B Virus (HBV) 30%
Hepatitis C Virus (HCV) 3%
HIV 0.3%

Gastric Ulcer vs Duodenal Ulcer

Gastric Ulcer

-more frequent in older patient, male:female 1:1
-epigastric pain
-food intake exacerbates pain
-patient tends not to eat --> weight loss
-risk of cancer (always perform biopsy!!)

Duodenal Ulcer

-more frequent in younger patient, male:female 3:1
-pain in right umbilical area(duodenal area)
-vomiting tend to relieve pain
-pain more frequent during hunger/night time/early morning
-food intake relieves pain
-patient tends to eat more --> no weight loss or weight gain
-lower risk of cancer
-bleeding more frequent (more ulcers)

Drug treatment for tuberculosis

Rifampin is the drug of choice for treatment; in most cases, the treatment duration is at least 18 months without rifampin

Ethambutol (EMB) is used to prevent rifampin resistance if the organism is resistant to isoniazid (INH); EMB can be discontinued as soon as the organism is found to be susceptible to rifampin and INH.

Pyrazinamide is used for the first 2 months of treatment to decrease the treatment duration from 9 months to 6 months if the organism is susceptible to rifampin and INH

Urine alkalinisation

1. Salicylate poisoning
- recommended in all symptomatic patients with regard of hypokalemia (common in salicylate poisoning)
- Diamox should NEVER be used as for acidemia and subsequent increased toxicity
- Urinary alkalinization by PO NaHCO3 enhances the elimination of weak acids: salicylates, phenobarbital, chlorpropamide, chlorophenoxy herbicides, formic acid, and methotrexate

2. Pure uric acid stones
- dissolved with oral alkalinization, K citrate, Na bicarbonate --> urinary pH 6.5-7

3. Rhabdomyolysis
- IV bicarbonate

4. Hemoglobinuria (heatstroke)

Bi- and Trifascicular Block

Bifascicular block or one-and-a-half block = Left Anterior Fascicular Block (LAFB)/ Left Posterior Fascicular Block (LPFB) + Right Bundle Branch Block (RBBB)

Trifascicular block = LAFB/LPFB + RBBB + First degree AV block

Wolff-Parkinson-White (WPW) Syndrome

Had practical lesson in Arrhythmia-ICU today. Dr. Valek kicked off the session with some ECGs for us to interpret. I am quite satisfied with myself for not knowing 'only' 4 of them, LOL. I must really thank Dr. Thaller :)

I was quite amazed by the multiple ECGs of a same patient with WPW syndrome.

Something I read about WPW syndrome but did not realised its importance:

-if there is short PR interval, wide ORS with delta wave but patient doesn't have paroxysmal tachycardia, the patient has only preexcitation and this is called WPW pattern.

-if there is WPW pattern(as mentioned above) and patient has history of paroxysmal tachycardia, it is then only called WPW syndrome

-the most common arrhythmia in WPW syndrome is Atrioventricular Reentrant Tachycardia(AVRT)

-there are two forms of AVRT: orhtodromic AVRT and antidromic AVRT (depending on how the impulse goes in the reentrant circuit)

-Vagal maneuvre can be used to terminate AVRT as it transiently blocks AVN

-Atrial Fibrillation and Atrial Flutter can occur too

-Rx: antiarrhythmics

-Do not use calcium channel blocker, digoxin or beta blocker!!

-iv procainamide for AF and AFL in patient with bypass tract. Electrical cardioversion can be considered

-radiofrequency cathether ablation (95% success rate)

*Study Lown-Ganong-Levine Syndrome too!

Abdominal Aorta Aneurysm (AAA)

Lucky to see a case of abdominal aorta aneurysm(AAA)on Thursday but maybe not so lucky for that patient because in case of aneurysm rupture, the mortality is quite high. Managed to see and feel what is written on textbook--- pulsatile abdominal mass above the umbilicus. It amazed me! We saw the CT angiography with 3D reconstruction too. Wow, it is just so unbelievable that such a big aneurysm has developed in his abdomen and produces so many 'bends' or 'kinks'. The patient is going to have endovascular treatment---a stent graft will be placed into his abdominal aorta to prevent the rupture.



Risk factors:
smoking, hypertension, age over 70 years old, family history of AAA

Symptoms:
75% asymptomatic
in case of acute expansion or disruption of wall: pain(abdominal, back, flank pain), hypotension, pulsatile abdominal mass rarely partila intestinal obstruction, ureteric obstruction and hydronephrosis, GI bleeding(duodenal mucosal hemorrhage, aortoduodenal fistula), aortocaval fistula, distal embolisation(blue toe)

Diagnosis:
pulsatile abdominal mass, bruits on auscultation, abdominal USG, CT, MRI, Doppler

Treatment:
smoking cessation, HTN control, DM control, hyperlipidemia control
surgery or endovascular options(stent graft)

努尔哈赤

上星期看了CCTV5的五集纪录片《努尔哈赤》，心里有一些感想。

努尔哈赤像

先说说谁是努尔哈赤吧，很多人都知道康熙乾隆可是不是并不是所有人都知道努尔哈赤是中国最后一个朝代清朝的开国皇帝。努尔哈赤是女真/满人（到皇太极登基时女真人改称满人），出生于中国东北，属于女真三大分支之一的建州女真。当时主宰中国的是明朝。这时的女真四分五裂，常常爆发战争，而明朝对这些少数民族所采取的就是“以夷制夷”的战略。清朝之所以能成为清朝，努尔哈赤可说是功不可没。我个人欣赏他当时的先进思想。试想想，一个长期处于四分五裂状态并且长时期地自相残杀和相互掠夺的民族，竟然出了个统一各个部落和勇敢挑战比自己强大十几倍的国家（明朝）的领袖。当然，努尔哈赤并不是史上第一人，成吉思汗就是一例。

努尔哈赤以“十三副铠甲”起兵，先后打败了建州女真的各个大小部落、以少胜多打败了扈伦四部的九部联军、之后也成功吞并海西女真和野人女真，完成了对女真的统一，建立了金国，史称后金（女真族的前身就是与宋朝、辽国同时期的金国；后金在皇太极被改作清）。再后来在萨尔许大战中，努尔哈赤“任尔几路来，我只一路去”打败了明朝的四路十万大军，再一次的以少胜多。如果没有将才、没有政治才能，这些都是不可能的。

努尔哈赤还创立了满人独有的八旗军-这是一个满族特有的军事制度，根据女真人传统的狩猎编制而演变而成，分成八个部分，即八旗，由皇族贵族带领，以骑兵为主。行军打仗时通常分成两个兵种-一是敢死队，负责冲锋陷阵；二是督战队，凡是退却的兵士杀无赦，也因为这样当时的八旗军所向披靡、战无不胜。

八旗铠甲

努尔哈赤也使女真族第一次拥有了自己的文字。

在萨尔许大战之后，后金从防守转为进攻，努尔哈赤以“七大恨”开始讨伐明朝。后金军接连攻下了明朝多个城镇，但是人数远比汉人少的后金难以找到治理这些汉人的绝佳方法。不公平待遇使这些汉人揭竿而起-下毒、暗杀、造反等。努尔哈赤忍无可忍，结果下了一个决定-屠城。

我对努尔哈赤的敬佩写了这里就有了大打折扣。

这些汉人，不管男女老少，通通被杀。再后来后金所攻下的城-几乎所有的明朝军民也皆被杀害。如此残暴的君主，连妇女小孩都不放过，即使再多成就，也不值得令人尊敬了。

再后来战无不胜的努尔哈赤终于在宁远吃了败仗。打败他的是袁崇焕，这还是袁崇焕第一次行军打仗。

袁崇焕

努尔哈赤打算故技重施-利用首先渗入城中的间谍制造混乱和打开城门、督战强攻等攻下宁远城。可是袁崇焕早有准备，他强化防守设施、揪出后金间谍和改变明朝一贯的战略不再出城迎战而是坚守城池。宁远城也配备了从澳门进口的红夷大炮。一方坚守、一方强攻，结果后金军在明军坚守和红夷大炮的强烈炮火下损失惨重、即使后有督战队准备格杀逃跑者或怯战者，后金军再也不敢冲锋了。
宁远大战图

努尔哈赤无奈地宣布退兵，战无不胜的他终于败了。此后袁崇焕声明大振，而努尔哈赤从此郁郁寡欢，终于在几年后逝世了。

明朝到了1644年也就是努尔哈赤孙子顺治皇帝时终于被灭。

Pioneers in Radiology

Curie - radium
Laterbur - MRI
Hounsfield - CT
Dotter - angiography
Cannon - GI radiology

'Disorders of calcium metabolism' and 'God doesn't like you very much'

Today we had a lecture on 'Disorders of calcium metabolism' with Prof. Broulik.

One of the slide was about 'DiGeorge's syndrome'.

He said 'This is bad luck.'

and the next slide was about 'Polyglandular Autoimmune syndrome'.

The comment he gave this time was:

'This is again bad luck. God doesn't like you very much.'


HAHAHAHAHAHAHAHAHAHA