#CSF Advisers

[flyonthewallmedstudent]

Listeria

For whatever reason it reminds me of Desperate Housewives and Wisteria lane. Or just Wisteria in general.

It's unfortunately it's anything but wistful or romantic.

This is inspired by the netflix series Poisoned. I hate that title but it's a great watch. I learned a lot from it. I highly recommend it particularly for medical students and residents etc.

So, listeria are gram positive rods (most bacilli are negative) making this relatively easier to remember (purple rods). Also catalase positive. IT's also a facultative anaerobe - so both cultures may be positive (aerobic and anaerobic bottles).

the species that is the culprit for major human pathogens is Listeria monocytogenes.

At increased risk groups (more likely to die of Listeriosis) - the immunocompromised and extremes of life, including the elderly, pregnant women and neonates. Immunocompromised: HIV, anyone on long term highish doses of steroids, leukaemia/oncology patients etc. Worryingly, incubation time is 3-90 days in these groups, so it's difficult to really trace or keep track of. Pregnant women are at 20x higher risk of acquiring the severe form.

Source: CDC

Hence why during pregnancy you're advised not to consume raw salads, fruits, cold cuts, soft cheeses, sprouts and smoked salmon or sushi, no mayo and no raw egg (definitely no raw milk) etc. Similarly, common recommendation is you serve none of these to children under the age of 1. It naturally lives in soil (hence avoidance of raw sprouts) and can live in animals. So it can frequently contaminate food.

Image Source: SA Health

As with COVID (I can't believe I'm using COVID as a measure of things), it can cause mild food borne illness (nausea, vomiting diarrhoea, myalgias, even fevers) to invasive disease causing sepsis and even meningitis or encephalitis. Incubation time is a few days in the mild form.

IMage source:

Death by Listeria when you have the severe form (Listeriosis) is 20%, astonishingly high given you have a 1% chance of dying from Salmonella.

It's a small risk but the issue is that complications and fatality if you do acquire is high. It's also highly preventable, but the challenge is food safety and avoiding certain foods as a consumer.

i.e. in pregnancy, most will have diarrhoeal illness that's mild. But in the subset that get invasive disease and really unwell, there's a 20% risk of miscarriage, risk of premature labour and risk of still birth at 3% in the US. In the states, pregnant women are also 10x more likely to get Listeria infection. That is, illness after exposure.

On the final note of prevention, also always properly refridgerate food to 4 degrees celsius and cook meat to 165 fahrenheit or 73 degrees celsius. As I've learned from the Poisoned documentary, you can ask restaurants to do this, ask them to use an internal thermometer to measure - as rare/medium rare etc have no meaning as it pertains to food safety. If they can't, order something else.

With meningoencephalitis, we just presume that Listeria is a possibility and treat empirically while awaiting investigations.

Investigations: - CSF (lumbar puncture) in event of signs of meningism or encephalitis (classic headache/fever/stiff neck/rash and/or acute confusion or seizure AND fevers) --> expect the classic features of bacterial meningiits and gram stain positive for purple rods - PCR - stool cultures have no value - blood cultures--> look for gram positive rods in the preliminary findings, expect a call from the lab Empirical therapy: - none in asymptomatic or mild disease. just monitoring until symptoms resolve and supportive care (fluids etc.) - Listeria is a notifiable disease to the health department in most Western countries that keep track of outbreaks. - in the US, standard treatment is ampicillin. - in Australia at least, standard therapy is IV benzylpenicillin, 2.4 g 4 hrly in meningitis or encephalitis and everyone is just started on this until bug identification/gram staining and sensitivities return. - in hypersensitivity, bactrim is used. - cephalosporins have no activity against them (or "inherently resistant), hence you can see IV ceftriaxone and benzylpen in the drug regimen for empirical therapy of meningitis - cef covers gram negatives, strep pneumo (most common cause of meningitis) and neisseria meningitidis - duration of therapy in severe disease: 3 weeks, 6 weeks if immunosuppressed

Really great summary here.

Random historical trivia

listeria is named for Dr. Joseph Lister, a British surgeon who introduced sterilisation of equipment and antiseptics to surgery, improve post op care and observed that microbes are the cause of cases of poor wound healing or post op infections. he also began to look at them under the microscope as an early pioneer of bacteriology.

Lister's father by the way, made compound microscopes for a living, so lister became proficient at using this and started publishing articles during medical school

this also led to a lot more research on inflammation and coagulation

weirder trivia: in his med school days, surgeons commonly did not wash hands between patients and some didn't even change gowns, glorifying how busy they where by how many stains were on it by the end of the day

so unsurprisingly his early battles to pioneer antiseptics and aseptic techqniues to prevent the transmission of infection in surgical patients were pretty uphill

Resources CDC guidelines WHO guidelines FDA Statpearls --> great at covering basic physiology and pathology etc. in a short form. Australian therapeutic guidelines - unfortunately not free.. so won't bother to link. If you work at any large-ish Australian hospital you'll have 'free' access. Wikipaedia US list of outbreaks CDC recommendations on foods to avoid vs okay to eat to avoid Listeria

#listeria #infectious diseases #traveller's diarrhoea #medblr #medblrs #microbiology #infectious disease

[myfeeds]

Potential hidden cause of dementia detected

Researchers say these findings, published in the peer-reviewed journal Alzheimer’s & Dementia: Translational Research and Clinical Interventions, may point the way to a cure. “Many of these patients experience cognitive, behavioral and personality changes so severe that they are arrested or placed in nursing homes,” said Wouter Schievink, MD, director of the Cerebrospinal Fluid Leak and Microvascular Neurosurgery Program and professor of Neurosurgery at Cedars-Sinai. “If they have behavioral-variant frontotemporal dementia with an unknown cause, then no treatment is available. But our study shows that patients with cerebrospinal fluid leaks can be cured if we can find the source of the leak.” Cerebrospinal fluid (CSF) circulates in and around the brain and spinal cord to help cushion them from injury. When this fluid leaks into the body, the brain can sag, causing dementia symptoms. Schievink said many patients with brain sagging — which can be detected through MRI — go undiagnosed, and he advises clinicians to take a second look at patients with telltale symptoms. “A knowledgeable radiologist, neurosurgeon or neurologist should check the patient’s MRI again to make sure there is no evidence for brain sagging,” Schievink said. Clinicians can also ask about a history of severe headaches that improve when the patient lies down, significant sleepiness even after adequate nighttime sleep, and whether the patient has ever been diagnosed with a Chiari brain malformation, a condition in which brain tissue extends into the spinal canal. Brain sagging, Schievink said, is often mistaken for a Chiari malformation. Even when brain sagging is detected, the source of a CSF leak can be difficult to locate. When the fluid leaks through a tear or cyst in the surrounding membrane, it is visible on CT myelogram imaging with the aid of contrast medium. Schievink and his team recently discovered an additional cause of CSF leak: the CSF-venous fistula. In these cases, the fluid leaks into a vein, making it difficult to see on a routine CT myelogram. To detect these leaks, technicians must use a specialized CT scan and observe the contrast medium in motion as it flows through the cerebrospinal fluid. In this study, investigators used this imaging technique on 21 patients with brain sagging and symptoms of bvFTD, and they discovered CSF-venous fistulas in nine of those patients. All nine patients had their fistulas surgically closed, and their brain sagging and accompanying symptoms were completely reversed. “This is a rapidly evolving field of study, and advances in imaging technology have greatly improved our ability to detect sources of CSF leak, especially CSF-venous fistula,” said Keith L. Black, MD, chair of the department of Neurosurgery and the Ruth and Lawrence Harvey Chair in Neuroscience at Cedars-Sinai. “This specialized imaging is not widely available, and this study suggests the need for further research to improve detection and cure rates for patients.” The remaining 12 study participants, whose leaks could not be identified, were treated with nontargeted therapies designed to relieve brain sagging, such as implantable systems for infusing the patient with CSF. However, only three of these patients experienced relief from their symptoms. “Great efforts need to be made to improve the detection rate of CSF leak in these patients,” Schievink said. “We have developed nontargeted treatments for patients where no leak can be detected, but as our study shows, these treatments are much less effective than targeted, surgical correction of the leak.”

[ijcimr]

Uvular injury after double lumen tube insertion: A rare cause of persistent postoperative sore throat by Deepti Ahuja in International Journal of Clinical Images and Medical Reviews  

Letter to Editor

Postoperative sore throat (POST) is a common complaint with an incidence of 24-100% 1 that occurs following placement of airway devices in patients administered general anaesthesia. POST results in discomfort, patient dissatisfaction after surgery and leads to delay in patient’s return to normal routine activities. Severe, persistent and unresolving POST may be attributed to uvula injury. We report uvular injury in a patient inspite of uneventful placement and removal of double lumen tube (DLT). A 58-year-old male (Weight-75 kilograms, Height-172 cm, BMI-25), case of left lower lobe carcinoid tumour was posted for left lower lobe sleeve lobectomy. On preanaesthetic checkup, according to American Society of Anesthesiologists physical status (ASAPS) classification system, patient belonged to ASAPS I.

The patient was fasted according to standard ASA fasting guidelines. We planned combined general anaesthesia and thoracic epidural as the anaesthetic and analgesic technique. After shifting the patient to operating room, peripheral intravenous access was obtained and all standard monitoring devices including electrocardiography, noninvasive blood pressure, and pulse oximetry were attached. After positioning patient in left lateral decubitus, painting and draping, using 18-gauge Touhy needle, T6– T7   epidural space was identified at 7.5 cm mark using loss of resistance (LOR) technique and catheter threaded upto 13 cm mark. After securing catheter and confirming negative aspiration of blood or CSF, 3 ml of 2% lignocaine with 1 in 200000-unit adrenaline was given as test dose. The patient was turned supine, preoxygenation with 100% oxygen was done. The patient was premedicated with Inj Fentanyl 160 micrograms. General anaesthesia was induced using titrated doses of Inj Propofol. Adequate bag and mask ventilation were ensured and Inj atracurium 0.5 mg/kg was administered. After completion of 3 minutes, tracheal intubation was done with direct laryngoscope (Macintosh #4) and 39 Fr Robertshaw’s left sided DLT was placed. The correct position of tube was checked by auscultation and further confirmed by fiberoptic bronchoscopy. Left radial artery was cannulated. Total duration of one lung ventilation (OLV) was 4 hours 20 minutes. The overall period of OLV was uneventful as there were no episodes of desaturation and hemodynamic instability. After completion of surgical procedure, patient was turned supine, thorough suction from both lumens of DLT was done. DLT was removed and I-gel no 4 was placed.

After return of spontaneous respiratory efforts, patient was reversed and extubated. He was shited to intensive care unit (ICU) for further observation. Few hours later, he complained of foreign body sensation in throat and as if something was stuck in throat. The foreign body moved backwards during inspiration and aggravated airway obstruction. We considered it most probably as airway mucous secretions that would have accumulated due to failure to cough them out effectively.  Steam inhalation, saline nebulization and chest physiotherapy was done and patient was encouraged to cough out secretions in throat. However, few hours later he again reported same complaints as there was no improvement with measures taken by us. Hence, we decided to go for inspection of his pharynx and found an elongated, swollen, inflamed uvula was noted (Figure 1). We diagnosed as uvula injury caused by impingement of DLT. We reassured him and advised not to strain further as it would further aggravate uvular injury. He made complete recovery over a period of 5 days. Uvula injury after placement of endotracheal intubation 2 and laryngeal mask airway 3 has been reported earlier. The compression of uvula between hard palate and airway device has been reported as causative factor. Excessive compression can cause mechanical interruption of blood supply and result in uvular necrosis. Proper positioning of DLT to one side of midline can avoid this complication.

To conclude, uvular injury should always be kept as differential diagnosis in patient with severe persistent sore throat particularly if associated with foreign body like sensation. Careful and thorough examination of oropharynx should be done to confirm diagnosis. Though condition responds well to conservative management but reassurance addressing the cause and expected duration is must to reduce distress experienced by patient.

For more details: https://ijcimr.org/editorial-board/ 

#Postoperative sore throat #Anesthesiologists physical status #POST #DLT #ASA #double lumen tube #sleeve lobectomy #OLV #intensive care unit #ICU #hemodynamic #Deepti Ahuja #ijcimr

[malikmalloy96]

Letter: Recommendations for Non-Medical Area Staff inside Quick Treatments for Craniofacial Football Incidents: The particular Neurosurgeon's Role

Data ended up removed simply by two evaluation experts along with the methodological good quality was reviewed. Data were evaluated utilizing hit-or-miss and glued results types. Main results Ten studies satisfied the particular addition criteria. Allowance in all tests was hit-or-miss, together with the handle equip receiving absolutely no prophylactic treatment, except one test where the handle team acquired specific prophylactic anti-biotics. One particular research noted organic randomisation dependant on the production of superbly harmonized, linked contributor as an alternative to rigorous randomisation. All tests ended up carried out around 20 years previously along with one particular exclusion, a report from 2006 where bestower have been pre-medicated together with granulocyte community exciting element (G-CSF) resulting in drastically increased indicate doses associated with granulocytes gathered for transfusion. Various procedures normally requested your agenda for transfusion, approach to granulocyte procurement and requirements regarding identifying an infection. Combining the outcome revealed a relative chance (Three quarter) for mortality associated with Zero.94 (95% self-confidence intervals (CI) 3.71 one.30). Exemption of the tests which usually described transfusion of an regular variety of granulocytes under One particular by 1010 indicated an understanding RR pertaining to mortality and also fatality rate on account of infection regarding 3.89 (CI Zero.Sixty four to a single.All day and) and also Zero.Thirty-six (2.Fourteen for you to 2.Ninety six) correspondingly. Authors' conclusions Implications with regard to scientific training: Your controlled studies that were identified enhance the chance in which prophylactic granulocyte transfusions with a dosage of at least A single a 1010 may possibly prevent mortality via disease. General fatality rate has not been afflicted. Nevertheless, nearly all studies ended up performed decades ago, and specifications of supportive proper care have got sophisticated considerably. These kinds of before studies have been in addition determined by transfusing lower produces involving collected granulocytes as compared to currently advised. It is difficult to suggest prophylactic granulocyte transfusions beyond your placing associated with ongoing manipulated trial offers, because of the resource and cost ramifications. Implications regarding study: More substantial trials are needed to identify Vorasidenib cost your validity in the potential benefits brought up from this evaluation, in view of the actual methodological constraints, small sample styles along with the heterogeneous explanations of an infection which are encountered in the included research.The aim of the job ended up being compare man temp rot shapes generated from performance of a COMSOL Multiphysics (Third) specific component application style with that associated with new postmortem temperatures decay figure. Findings had been executed in Ten individual cadavers. The postmortem temp had been constantly calculated within man visitors and rectums coming from h.

[gibsonfoster69]

Alleles interfering with LBD37-like gene by a great 136 blood pressure placement demonstrate different distributions between natural and also purple cabbages (Brassica oleracea var. capitata).

It contains 6 randomised controlled studies researching transvaginal repair regarding Take without or with fine mesh: four regarding cystocele, one concerning rectocele then one concerning apical. prolapse. Both medical tactics along with recurrence conditions tend to be improperly standardised. The four randomised studies focusing on cystocele restoration support the biological brilliance associated with methods utilizing mesh, with the exact same functional benefits without or with mesh encouragement. From the some other indications, the final results remain cloudy or even questionable. According on the randomised studies, the actual issues price, besides nylon uppers direct exposure, is comparable with and without having mesh. However there are several specific difficulties when you use fine mesh, for example mesh infection, capable direct exposure or even pulling and visceral. extrusion. We advise making use of vaginal strengthening mesh using specific care inside selected people and that we recommend a few tips being recommended regarding general opinion from worried People from france clinical organizations. (H) 08 Elsevier Masson SAS. Tous droits stores.With this work, the opportunity of employing fairly neutral sulfite semi-chemical (NSSC) bagasse pulp when combined real wood chemimechanical pulp (CMP) and also bleached soft wood kraft pulp (BSKP) ended up being looked at for the exact purpose associated with lowering hard wood and also BSKP consumption. The particular bagasse NSSC pulp a digester deliver of approximately 73% and was unbleached. It turned out Degrasyn processed by way of a PFI work for you to Four hundred milliliters CSF, however in the situation of the hardwood CMP and also imported lengthy dietary fiber pulp, the final processed freeness have been selected to be Three hundred and fifty as well as 500 mL CSF. Handsheets were made (60 general motors(-2)), as well as their energy search engine spiders and eye attributes were measured. Connection between this research with a clinical level established that employing bagasse NSSC pulp mixed with hardwood CMP to create newspaper with suitable quality can be done, and also this procedure will likely visibly lessen the use of imported long fiber pulp and also wood for creating the levels of papers generally produced from CMP.All of us built a new 400K WG tiles oligoarray for your equine and utilized this to the breakthrough discovery involving replicate number variations (CNVs) throughout Thirty-eight standard horses involving Sixteen different types, and also the Przewalski mount. Probes for the variety represented 20,763 autosomal and also X-linked genetics, and intergenic, sub-telomeric and chrY sequences. We all determined 258 CNV parts (CNVRs) across just about all autosomes, chrX and also chrUn, but not inside chrY. CNVs made of A single.3% of the moose genome together with chr12 getting many enriched. United states Smaller farm pets got the very best and National Quarter Mounts the best amount of CNVs with regards to Thoroughbred guide. The actual Przewalski horse was similar to local horses and also set up varieties. Virtually all CNVRs concerned family genes, although 20% have been positioned in intergenic locations. Much like past research inside horses along with other mammals, molecular characteristics of CNV-associated body's genes were primarily within sensory understanding, immunity along with duplication.

[husseinholcomb71]

Bacteriophytochrome from Magnetospirillum magneticum impacts phototactic conduct as a result of gentle.

5T reads. The theme database regarding 400 high-quality guide book segmentations was applied to do computerized division coming from all verification using a multi-atlas-based segmentation reproduction method designed to perform label mix according to nearby being similar to ensure precise division regardless of pathology. Agreement in between guide book and automated segmentations ended up being assessed by level of overlap (Cube coefficient) along with evaluation regarding hippocampal amounts. Key FindingsThe automated segmentation criteria presented sturdy delineation in the hippocampi about 3T scans without having much more variation than that witnessed between distinct individual raters (Dice coefficients: interrater Zero.832, guide vs. programmed 0.847). Moreover, the formula offered superb outcomes with the 1.5T tests (Chop coefficient 2.827), and automatic segmentation always been exact even just in small sclerotic hippocampi. There was a solid link between manual and automated hippocampal sizes (Pearson relationship coefficient 2.929 around the left as well as 2.941 for the right in 3T verification). SignificanceWe demonstrate reputable recognition regarding hippocampal wither up in sufferers using hippocampal sclerosis, which can be important with regard to clinical management of epilepsy, specially if surgical treatment is staying taken into consideration. We offer a free on the web Web-based intend to enable Velpatasvir manufacturer hippocampal volumetry to be available internationally, along with consequent tremendously improved evaluation of people that have epilepsy.Both the amount as well as practical capability regarding T-regulatory (Treg) cellular material are acknowledged to become diminished in various auto-immune ailments. FOXP3, a necessary transcribing aspect for Treg tissue, provides three isoforms in human beings, outrageous, and exon 2- along with exon 2-exon 7-lacking, even though their position inside autoimmunity just isn't plainly comprehended. Right here, all of us investigated the actual messenger RNA (mRNA) term from the main wild as well as exon-2 isoforms inside peripheral mononuclear cells simply by quantitative PCR approaches inside 56 topics, consisting of Twenty-three arthritis rheumatoid (RA) as well as 25 wide spread lupus erythematosus (SLE) patients, and eight wholesome regulates (HCs). Despite the fact that mRNA appearance of the isoforms didn't straight associate together with medical disease activity, relative appearance regarding equally has been drastically lacking in SLE and also RA patients than in HCs. Furthermore, many of us identified an important statistical connection backward and forward isoforms, advising that they're likewise regulated. Decreased expression of those isoforms in RA along with SLE may well mirror Treg cell abnormalities of these auto-immune ailments.Cerebrospinal smooth (CSF) spots include ventricles and cerebral along with backbone subarachnoid places. CSF motion is really a combined aftereffect of CSF generation rate along with superimposed cardiovascular pulsations. Familiarity with CSF characteristics offers reaped the benefit considerably from your continuing development of phase-contrast (Laptop or computer) MRI. There are numerous disorders for example speaking as well as non-communicating hydrocephalus, Chiari malformation, syringomyelic cysts as well as arachnoid cysts that can alter the CSF character. The aspires on this graphic evaluation will describe laptop MRI technique, CSF body structure as well as cerebrospinal space physiology, to describe a group of congenital and acquired disorders that will alter the CSF mechanics, also to measure the using Computer MRI from the evaluation of varied central nervous system irregularities.

#Stem Cell Signaling Compound Library #HIF inhibitor #Filgotinib #Pepstatin A #SP2509 #Purmorphamine #Tideglusib #Ostarine #Sodium butyrate #Epirubicin #OICR-9429 #Tasquinimod #Celecoxib #Hygromycin B #SU5402 #VER155008 #Selonsertib #Losmapimod #GSK-LSD1 #Raltegravir #Cidofovir #Ledipasvir #Amprenavir #Velpatasvir #Ombitasvir #Paritaprevir #Penciclovir #Indinavir #Dasabuvir #Camostat

[napierdowns]

High-resolution calculate of surrounding sulfate focus over Taiwan Area utilizing a book collection machine-learning style.

History: Lewy body syndromes (primarily Parkinson's disease and also dementia along with Lewy bodies) discuss a lot of specialized medical features and often have a slowly modern training course. Several individuals may possibly present rapid signs further advancement. Objective: To evaluate clinical and also neuropathological features of people with a swiftly modern diffuse Lewy System condition. Methods: Review specialized medical documents along with pathological findings of 6 cases together with dissipate Lewy System disease as well as quick ailment progression (less than 18 months prior to death). Results: Suggest age group at ailment beginning was Seventy two.Several years, and also indicate disease duration ended up being 9 several weeks. Starting point contains delirium in Three individuals and rapidly modern dementia inside the some other about three. All cases offered aesthetic hallucinations and delusions; mental signs or symptoms ended up fluctuating in two, parkinsonism happened several, along with myoclonus in a few. Brain MRI did not display cortical as well as basal ganglia hyperintensities. Routine well-defined dunes had been absent on EEG. 15.Several.3 necessary protein throughout CSF had been damaging. Myocardial (123)I-metaiodo-benzyl-guanidine SPECT revealed noticeable lowering of 2-MeOE2 cost tracer subscriber base within the Only two people analyzed. Neuropathological research would not identify any particular attribute that can distinguish speedily modern diffuse Lewy entire body condition via established soften Lewy physique disease. Conclusions: Calm Lewy system condition is a possible reason for speedily progressive dementia and may be contained in the differential carried out confusional claims associated with undetermined trigger. Inside individuals with speedily accelerating dementia, the use of varying understanding, parkinsonism, hallucinations, delusions, or even severe dysautonomia, ought to raise the hunch regarding soften Lewy entire body disease. Neuroimaging scientific studies including (123)I-metaiodo-benzyl-guanidine myocardial scintigraphy may possibly keep the medical proper diagnosis of diffuse Lewy physique disease. (Chemical) Next year Movement Condition CultureTumour-stroma discussion is often a requirement with regard to tumor development in skin cancer. Hereby, a vital part of stromal operate may be the cross over of tumour-associated fibroblasts to be able to MFs (myofibroblasts) through development elements, for example TGF beta (altering progress factor beta(). In this study, the question had been tackled associated with whether or not fibroblast-associated NAD(G) L oxidase (NADH/NADPH oxidase), regarded as activated through TGF experiment with One particular, will be mixed up in the fibroblast-to-MF swap. The up-regulation associated with alpha dog SMA (leader clean muscles actin), a biomarker pertaining to MFs, is mediated by way of a TGF 'beta' 1-dependent surge in the intra cellular degree of ROS (sensitive oxygen kinds). This particular document demonstrates two story elements of your TGF 'beta' 1 signalling procede, particularly the technology regarding ROS as a result of biphasic NAD(G) L oxidase action as well as a ROS-dependent downstream activation of p38 ultimately causing a new move of skin fibroblasts to MFs that could be limited with the selective NAD(S)L oxidase inhibitor apocynin. These types of data advise that inhibition associated with NAD(P)H oxidase task helps prevent the particular fibroblast-to-MF change and could be important for chemoprevention within wording of an 'stromal therapy' that has been described previously.

#Inhibitor Library #ATM/ATR inhibitor #Wnt-C59 #CH-223191 #Colforsin #Alisertib #Puromycin #Elexacaftor #Enasidenib #Dorsomorphin #Z-IETD-FMK #Dolutegravir #Docetaxel #GW4869 #Tamoxifen #GSK J4 #PLX5622 #Blebbistatin #RepSox #Erdafitinib #compound 1 #KWA 0711 #DUP785 #ICI-176334 #MK-803 #AV-951 #PHA-848125 #AP1903 #Arg-Gly-Asp Peptides #2-MeOE2

[myleakyspine]

The game changer

My doctor called that afternoon like he promised. 

He had spoken to my neurologist and reviewed the images with her. They were 95% sure my leak is at the T1-T2 level of my spine. They could see a calcification on the front side of my disc between T1 and T2 that is piercing my dura mater and creating a hole to allow CSF to leave the enclosed space its supposed to be in. 

And although I was so happy to be certain I definitely have a CSF leak, my treatment options became horribly limited. 

Initially, my doctors had thought my leak was higher up in my spine in my neck. This would have allowed a neurosurgeon or a spine surgeon to operate through the front of my neck. The surgeon could reach the calcification easily from the front to remove it, as well as repair the hole in my dura mater with stitches. And although I didn’t want surgery, it seemed like a relatively manageable surgery. 

Unfortunately, this was now not the case. 

Because my leak is lower, at T1/T2, the leak site is behind my sternum. A surgeon cannot access the front of my spine through my sternum. Not to mention my heart and major blood vessels there as well. Now, you may be wondering, “why can’t a surgeon go through her back?” Well, because my leak is at the front of my spine, a surgeon would have to make an incision in my back, cut the vertebra, and manipulate my spinal cord to reach the front of my spine where the leak is. And not many surgeons are going to want to manipulate the spinal cord of an otherwise healthy 27 year old woman. The risk outweighs the benefit at this point. 

My doctor informed us of this reality, and then began offering his other treatments. He can do a targeted blood patch, targeted fibrin glue, or targeted DuraSeal. 

He advised us that my leak may complicate 2 out of those 3 options. When my CSF leaks out of the dura mater, it creates a large pool at the leak site. My doctor explained the blood patch and fibrin glue as this: blood and fibrin are not very viscous. CSF is extremely watery. If he were to inject blood or fibrin into that pool of CSF to try and get it to stick to my dura mater, it would be like injecting paint into water. The paint would quickly dissipate and may never find where it’s supposed to go. He therefore would have a hard time recommending those treatments. 

He informed us he is trialing a third option. There is a medical glue called DuraSeal that is typically used on top of sutures for cranial and spinal surgeries. My doctor has started injecting DuraSeal at leak sites because it is more viscous and has a higher probability of sticking when a CSF pool is present. The only caveat is he’s only tried this in 2 other patients. 

He could only give us his success rate on 2 other patients, and they had only received their treatment 2 months ahead of me. So, the long term results of this treatment are not available. However, what choices did I really have? We knew a surgeon would not operate on me until we tried less invasive treatments. And we knew before the myelogram that blood patches and fibrin glue have a less than 25% chance of working when a leak is caused by a calcification. Therefore, we were left with the DuraSeal option. 

When we expressed our choice to my doctor, he then informed us that he would like to do another myelogram to confirm my leak site. He explained that he was only 95% sure of my leak being at T1-T2, and if he’s going to be sticking a needle to my spine, he wanted to be 100% certain that’s where the leak is. 

This myelogram would be a little different than the one I just had, and he would be willing to squeeze me in that Monday since he knew we traveled from out of town to Jacksonville. We accepted. We immediately booked an Airbnb to stay in for the weekend since the hotel room was beginning to feel claustrophobic and cramped. 

Time to hurry up and wait again for another test. 

[archerthing26]

Pharmacokinetics and also Tolerability involving Cabozantinib, a verbal, Discerning Janus Kinase Only two Inhibitor, inside Subject matter With Renal as well as Hepatic Disability

Qualifications: Conclusive diagnosis of Alzheimer ailment (Advertising) can be made only through histopathological examination of mental faculties cells, prompting the quest for premortem illness biomarkers. All of us looked for to ascertain in the event the book injury to the brain biomarker, visinin-like necessary protein One particular (VLP-1), is actually transformed from the CSF of Advertising sufferers compared with controls, and compare #Link# the valuations to the other well-studied CSF biomarkers 42-amino acidity amyloid-beta peptide (The beta(1-42)) full Tau (tTau), and also hyperphosphorylated Tau (pTau). METHODS: Employing ELISA, all of us measured levels of your beta(1-42) tTau, pTau, as well as VLP-1 throughout CSF examples from 33 Advertising people along with All day and regulates. We all in comparison your diagnostic overall performance of those biomarkers using ROC curves #Link# . RESULTS: CSF VLP-1 concentrations of mit have been significantly higher inside Advertisement sufferers [median (interquartile array) 365 (166) ng/L] in contrast to settings [244 (142.A few) ng/L]. Even though analytic functionality of VLP-1 on your own had been similar to what beta #Link# , tTau, as well as pTau alone, a combination from the Some biomarkers proven much better overall performance when compared with every separately. VLP-1 concentrations were greater inside AD themes along with APOE epsilon 4/epsilon Several genotype [599 (240) ng/L] in contrast to epsilon 3/epsilon Four [376 (One hundred and twenty-seven) ng/L] and also 010 [280 (115.5) ng/L] genotypes. Furthermore, VLP-1 values exhibited an increased degree of connection using pTau (ur Is equal to 0.809) and also tTau (third Is equal to 3.635) however, not The 'beta'(1-42) (ur Equates to -0.233). VLP-1 had been the only biomarker in which associated using MMSE score (ur Is equal to -0.384, G Equals 2.030). CONCLUSIONS: These final results advise that neuronal injuries indicators like VLP-1 could have utility while biomarkers with regard to Advertisement. (chemical) 08 National Affiliation regarding Clinical Hormone balance.Just lately, many of us defined a novel denaturing high-performance liquefied chromatography (DHPLC) approach helpful for initial diagnosis and recognition of crustacean unwanted organisms. As this tactic employs standard primers targeted to conserved aspects of your 18S rRNA gene, a priori genetic series facts about eukaryotic unwanted organisms isn't needed. This big difference supplies a significant advantage above specially centered PCR assays that do not permit the detection involving unfamiliar as well as unsuspected organisms. Nevertheless, preliminary field testimonials with the DHPLC assay advised that will because of PCR-biased sound associated with dominating number genetics it wasn't possible to detect fairly unusual parasite genetics in attacked crab tissues. Below, we all illustrate the use of a peptide nucleic acid (PNA) PCR hybridization preventing probe in colaboration with DHPLC (PNA-PCR DHPLC) to conquer inherent PCR bias related to boosting involving exceptional focus on genes through usage of common primers. This strategy was utilized to identify infection associated with orange crabs (Callinectes sapidus) by the parasitic dinoflagellate Hematodinium sp. Look at Seventy-six crabs captured in Wassaw Audio, GA, suggested any 97% distance learning involving discovery with the parasite simply by using a certain PCR analysis analysis which through use of PNA-PCR DHPLC. Of these studies, we found out one crab with an association with a previously undescribed protist symbiont. Phylogenetic investigation amplified symbiont 18S rRNA gene established that it is nearly all strongly linked to the free-living kinetoplastid parasite Procryptobia sorokini. To our information, this is actually the initial statement of this parasite class within a decapod crab in addition to this particular patient displaying any possibly parasitic existence record.

#Cabozantinib #Remdesivir #Acyl CoA dehydrogenase

[meterkey6]

Diagnosis Investigation as well as Approval regarding gelatin Signature and also Growth Immune system Microenvironment in Glioma

Your analytical requirements employed in primary progressive (PP) and relapsing-remitting (Three quarter's) ms (Microsoft) present considerable variances. This particular introduces difficulty in the diagnosing Microsof company which could always be fixed if these kinds of requirements could be unified in terms of the demands regarding distribution in space (DIS). The purpose of these studies ended up being to examine whether or not an individual protocol enable you to demonstrate DIS of any type associated with Milliseconds. 5 multiple RRMS standards regarding DIS have been used on any cohort involving 145 sufferers along with proven PPMS (imply disease timeframe: 14 decades - PPMS-1): C1: Barkhof-Tintore (such as 2006 McDonald's criteria); C2: Swanton avec 's. (such as JNNP 2007); C3: existence of oligoclonal rings additionally a couple of wounds (as with Burger king conditions); C4 and also C5: the two-step strategy has also been used (people certainly not rewarding C1 as well as C2 were next examined for C3). Two sets of PPMS standards regarding DIS ended up employed: C6: Thompson avec 's. (as in Late 2001 McDonald's conditions); C7: 2005 McDonald criteria. An additional test involving Fityfive people using under Several years regarding ailment period (PPMS-2) seemed to be evaluated employing an the exact same strategy. For PPMS-1/PPMS-2, satisfaction ended up being: C1: 3.8%/66.7%; C2: 72.1%/59.3%; C3: 89%/79.2%; C4: 96%/92.3%; C5: 96%/85.7%; C6: Eighty-five.8%/78.7%; C7: 91%/80.4%. Numbers of fulfilment advise that conditions solitary list of standards regarding DIS in RRMS and PPMS could be doable, as well as enhance the additional value of cerebrospinal fluid (CSF) conclusions to boost satisfaction in PPMS. Unification with the DIS requirements either way RRMS and also PPMS may be regarded throughout additional alterations of the Milliseconds analytic criteria.In spite of the extensive scenario reports #Link# taking into consideration thoracoscopic ways to your #Link# anterior thoracic back, the actual books is lacking in scientific studies of the thoracoscopic anatomic dissection and also methods. In the following paragraphs, the particular creators present their own research associated with thoracoscopic physiology of the anterior backbone along with created step-wise dissection along with approaches for sympathectomy, discectomy along with corpectomy. Four mature cadavers without good reputation for disease, community trauma or even medical procedures were examined and bilateral thoracoscopic anterior vertebrae approaches were performed. Thoracoscopic dissections have been done in your Department associated with Physiology, using Karl Storz 30A degrees, A few millimeters along with 40 centimeters fishing rod lens firm endoscope (Karl Storz and Co., Tuttlingen, Germany). Because surgery instrumentation, Karl Storz Rosenthal endoscopic operative arranged and also Fifteen millimeter websites were used for those techniques. For sympathectomy, the particular cadaver is put supine along with the slot locations come in the 3rd as well as sixth intercostal spots in the anterior axillary range. The actual stellate ganglion is cephalad for the 2nd rib, and the T2 and T3 ganglia tend to be divided only finer quality than T2 ganglia and inferior in order to T3. For discectomy, your cadaver is positioned in the horizontal decubitus placement #Link# . The functional web site is put immediately in the afflicted compact disk inside the rear axillary range.

#Ribociclib #Romidepsin #gelatin

[tentfont52]

The development of Chitosan-Coated Rhamnolipid Liposomes That contain Cabozantinib: Stability along with Vitro Digestive function

Conclusion: Sensory cells shift like the vertebrae from the dural starting may occur after a big rear fossa decompression with out duraplasty for Chiari malformation. Postoperative limited CSF blood flow as a result of arachnoid skin damage round the decompression location may help this type condition. Early diagnosis of this type of problem will be of vital importance in order to avoid severe neurologic deficits, as well as relieve surgical procedure together with proper duraplasty and in addition restoration involving CSF blood circulation could be the selection of therapy. (d) 09 Elsevier Incorporated. Almost all rights set-aside.Objectives-The is designed on this research could investigate connection involving osteopontin term and also microcalcification witnessed upon sonograms regarding individual papillary thyroid carcinoma and also to explore your mechanism regarding microcalcification during these tumors. Methods-Real-time invert transcribing polymerase chain reaction as well as immimo-histochemistry were used to determine appearance levels as well as spots associated with osteopontin inside 56 pathologically verified papillary thyroid gland carcinoma nodules. Osteopontin term linked along with microcalcification along with other sonographic indications recorded preoperatively. Results-Osteopontin appearance in the papillary thyroid carcinoma party had been considerably increased in comparison with the actual manage party for both messenger RNA and protein ranges (S < .05). Osteopontin expression was significantly in connection with microcalcification along with lymph node metastasis (S < .05), since revealed in sonography. Conclusions-Our benefits advise a possible function pertaining to osteopontin within the creation of microcalcification in papillary hypothyroid carcinoma; the sonographic symptoms can easily mirror the pathologic and neurological conduct of these malignancies.Mouth #Link# squamous mobile or portable carcinoma (OSCC) is often a sounding ambitious malignancies that symbolize clinically, molecularly, as well as etiologically heterogeneous cancers. Nearly all OSCCs tend to be related to cigarette smoking as well as alcohol consumption, operating each independently as well as synergistically, which suggests that this setting plays an important role in carcinogenesis; even so, the actual mechanisms from the continuing development of OSCC are not properly comprehended. It is often recommended the epigenetic factors could possibly be suggested as a factor inside the initiation and progression of OSCC. Primarily #Link# , aberrant Genetic make-up methylation styles are already widely resolved within the study associated with OSCC. Various reports have suggested that will other epigenetic functions such as post-translational histone change, your buildup of histone variations, histone chaperones, along with just lately non-coding RNA, can as well be involved in the continuing development of common cancer malignancy. On this assessment we all target conveying the newest observations of the epigenetics processes which are concerning OSCC as histones alternatives along with lengthy #Link# non-coding RNAs. (D) This year Elsevier Limited. Just about all privileges set-aside.Contrast-enhanced sonography (CEUS) utilizing micro-bubble distinction providers are helpful for your carried out the actual acne nodules within lean meats cirrhosis. CEUS bring a new problem-solving way of indeterminate acne nodules upon calculated tomography (CT) as well as magnet resonance photo (MRI) or just as one preliminary analytical analyze pertaining to small newly recognized liver organ nodules.

#Cabozantinib #Remdesivir #Acyl CoA dehydrogenase

[celeryskiing1]

Raised LOXL2 term by simply LINC01347/miR-328-5p axis contributes to methylhexanamine chemotherapy level of resistance involving digestive tract most cancers

About 50 % your types of genetic neutropenia with no extra-hematopoetic expressions and normal adaptive immunity are due to neutrophil elastase (ELANE) variations. A number of sufferers have got significant long lasting neutropenia as well as regular bacterial infections at the start of existence, and some have slight sporadic neutropenia. Congenital neutropenia can be connected with a number of appendage problems, for case in point inside Shwachman-Diamond symptoms (related to pancreatic lack) as well as glycogen storage space ailment type Ib (of a glycogen safe-keeping syndrome). Up to now, the actual molecular facets regarding Twelve #Link# neutropenic ailments are already discovered. Treatment involving significant long-term neutropenia should concentrate on protection against attacks. It provides antimicrobial prophylaxis, generally together with trimethoprim-sulfamethoxazole, plus granulocyte-colony-stimulating issue (G-CSF). G-CSF features substantially enhanced these patients' view. It is almost always effectively permitted #Link# , but prospective side effects consist of thrombocytopenia, glomerulonephritis, vasculitis and also weak bones. Long-term treatment method along with G-CSF, particularly at higher doasage amounts, increases the natural risk of the leukemia disease inside individuals together with hereditary neutropenia.The purpose of this specific greenhouse test ended up being to examine the short-term effects of levels of competition involving pine plants sprouting up and the earth bacterial biomass in sandy oligotrophic pinus radiata barrens upland woodland soil subjected to varying degrees of given fireplace intensity. Pinus radiata seeds development efficiency, microbe bio-mass nitrogen, extractable dirt nutrients along with leaching damage from the garden soil ended up determined, after a single expanding time of year pursuing hearth remedy. Replicate earth cores exposed to 3 degrees of hearth severeness were preserved in a green house with or without the pinus radiata plant. Through the right after developing season duplicate cores through each treatment method were collected as well as analyzed month to month. The info granted screening for two principal effects: dirt fireplace remedy as well as woods presence/absence. Inside simply no illustration would have been a considerable flames therapy Times tree presence/absence interaction found. Our final results indicate which natural exercise clearly has a bearing on dirt conditions. Reduced microbe exercise occurred in the discussion of garden soil microbe biomass plus an person pine seedling. Improved plant growth performance correlates along with diminished dirt mineral nitrogen attention along with reduced ph. In the amounts of flames severity utilized in this specific experiment immobilization because of organic subscriber base and also abiotic dirt fixation stopped substantial using cutbacks above that of unburned control samples. From the oligotrophic, pinus radiata barrens soils #Link# , nitrogen and phosphorus mineralized by simply hearth are generally mainly protected through organic procedures. These types of benefits furthermore advise that plant progress is actually subject to issue simply by phosphorus accessibility during these soil.

#Adagrasib #Fluorouracil #methylhexanamine

[potrat36]

Ruxolitinib Eyedrops Increased CD4+Foxp3+ Tissues as well as Avoided Wine glass Mobile Decrease in the over 60's Ocular Floor

Take a look at state that through the use of stacked tiers regarding multivalency we can easily construct one of the most very valent glycodendrimeric constructs however noticed (showing approximately A single,620 glycans). These kinds of constructs tend to be real and well-defined individual agencies which with diameters of up to 32nm can handle resembling infections in the dimension as well as in his or her very glycosylated floors. Via this kind of mimicry these kinds of glyco-dendri-protein-nano-particles are equipped for hindering (in picomolar concentrations of mit) one in the an infection involving T-lymphocytes along with human dendritic tissues through Ebola computer virus. Our prime associated polyvalency consequences (beta>10(Six), beta/N comparable to 15(Two)-10(Three)) displayed on the unheard of surface area by precise clusters suggest a common technique for modulation of which connections.Introduction: Endemic lupus erythematosus (SLE) can be an auto-immune disease seen as a autoreactive To as well as T cells, that happen to be considered to be second to poor dendritic cells (DCs). Even so, regardless of whether DC issues take place in their boost the particular bone marrow (BM) or even in the particular outside just isn't acknowledged. Methods: Tough luck sufferers using SLE and also Of sixteen typical controls had been enrolled. All of us examined the particular morphology, phenotype, and also useful capabilities regarding bone fragments marrow-derived dendritic cells (BMDCs) made by utilizing a couple of culture methods #Link# : FMS-like tyrosine kinase Several (Flt3)-ligand (Fla) along with granulocyte-macrophage colony-stimulating aspect (GM-CSF) as well as interleukin-4 (IL-4), correspondingly. Results: BMDCs caused simply by FL showed each myeloid (mDC) as well as plasmacytoid Electricity (pDC) capabilities, while GM-CSF/IL-4 induced mDC technology. Substantial phenotypic along with useful disorders associated with BMDCs were found from individuals along with SLE from distinct levels involving mobile or portable adulthood. In comparison with balanced handles, SLE premature BM FLDCs indicated higher amounts of CCR7. Each child like and also fully developed SLE BM FLDCs depicted greater amounts of CD40 and CD86 as well as induced better T-cell expansion. SLE BM mDCs expressed larger amounts of CD40 as well as CD86 however 'abnormal' amounts associated with HLA-DR as well as a decrease capacity to encourage T-cell expansion when compared to handle BM mDCs. Conclusions: Our own info have been in acquiescence using earlier reviews that will advise that DCs have a very possible pathogenic role within SLE. Defects of the cellular material do understand on their rise in BM. BM mDCs are usually bad, whilst BM pDCs, that happen to be a part of BM FLDCs, are the most likely reason within inducting autoimmunity throughout SLE.Discovering inside vivo mixers are generally naturally predictive regarding distinct regions of examine inside humans can be challenging as a result of divergence containing happened in the course of speciation. One particular means to fix this condition that's gaining raising grip may be the use of hereditary executive to introduce man body's genes in to rodents to generate excellent versions for guessing individual replies. This specific review describes the particular state-of-the-art for producing such #Link# types, offers an #Link# breakdown of like genetically humanized computer mouse button models referred to up to now as well as their programs throughout preliminary research, medication breakthrough discovery and advancement and also to recognize specialized medical medication poisoning.

#Ruxolitinib #Enzalutamide #Ketorolac

[towncheck5]

Ketorolac modulates lung pathology within a Murine model of Mycobacterium tuberculosis infection

Purpose of review Thorough anatomical and constitutionnel portrayal features said that extensively eliminating antibodies (bnAbs) against HIV-1 have abnormally substantial amounts of somatic hypermutation, long CDRH3 websites, along with the ability to goal one among 4 websites involving vulnerability on the HIV-1 bag (Env) glycoproteins. An active goal is to know how bnAbs are usually made through normal disease, as well as change this information straight into immunogens that will elicit bnAb pursuing vaccine. Recent studies Strain-specific eliminating antibodies can purchase broad getting rid of ability if the transmitted/founder Env or perhaps a certain Env different will be recognized by an unmutated rearranged germline containing the capacity to create bnAb-like capabilities. This could be comparatively rare, since only selected germlines seem to have inherent functions needed for bnAb exercise. In addition, your glycosylation pattern and variety of becoming more common HIV-1 Envs, as well as the #Link# condition of the particular B-cell pocket, is going to influence your activation and readiness involving certain antibody lineages. With each other, scientific studies over the past calendar year have advised how the development of HIV-1 Env immunogens which bind along with stimulate bnAb-like germlines is feasible. Nevertheless, more details about the top features of Env alternatives and the host factors that lead to breadth during organic infection are needed to bring about bnAbs by way of immunization.Subarachnoidal grafting associated with monoamine-producing tissue has been employed using Success to deal with persistent pain in animal types. Within the look for a Supply of autologous transplantable tissues, capable of delivering neuroactive Elements to the cerebrospinal water (CSF) to take care of soreness, we have screened adipose tissue-derived stromal cells (ADSCs) transduced to produce levodopa. Intrathecally grafted ADSCs make it through for too long phrase adhered to spinal cord and neural main meninges. Cultured ADSCs were retrovirally transduced using tyrosine hydroxylase (TH) and/or GTP cyclohydroxylase 1 (GCH One) genes as well as steadily indicated all of them for about Five to six weeks within Tradition. Individually transduced Civilizations failed to develop considerable levodopa nevertheless twice as transduced or perhaps a blend of individually transduced ADSCs could proficiently synthesize along with relieve levodopa. Whenever 2.5-1 x 12(Half a dozen) TH and also GCHI-expressing ADSCs have been intrathecally grafted in rodents, raised degrees of levodopa and dopamine metabolites put together in CSF in 72 hrs, despite the fact that from reduce amounts as compared to expected. Suddenly, absolutely no levodopa was substantial in CSF in Half a dozen clays. Unwell any rat type of neuropathic ache #Link# . intrathecal grafting regarding doubly transduced cellular material would not produce antiallodynic results in A couple of as well as Six clays, even though histological examination exposed the presence of poor TH-immunoreactive subarachnoidal cellular Groups. These results proposed that will doubly transduced cellular material Can certainly serve as organic minipumps to improve the actual dopaminergic neurotransmission at the spine level however transgenes have been swiftly silenced after intrathecal grafting. Transgene silencing was #Link# resembled inside Way of life by solution lack for 3 days and nights. Solution supplement at this time restored transgene phrase within Some h, since would, to some smaller sized amount.

#Ruxolitinib #Enzalutamide #Ketorolac

[didanawisgi]

2020 Yale-G’s Monthly Clinical Updates According to www.uptodate.com

(As of 2020-11-12, updated in Yale-G’s 6th-Ed Kindle Version; will be emailed to buyers of Ed6 paper books)

       Chapter 1: Infectious Diseases

Special Viruses: Coronaviruses

     Coronaviruses are important human and animal pathogens, accounting for 5-10% community-acquired URIs in adults and probably also playing a role in severe LRIs, particularly in immunocompromised patients and primarily in the winter. Virology: Medium-sized enveloped positive-stranded RNA viruses as a family within the Nidovirales order, further classified into four genera (alpha, beta, gamma, delta), encoding 4-5 structural proteins, S, M, N, HE, and E; severe types: severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV), and novel coronavirus (2019-nCoV, which causes COVID-19). Routes of transmission: Similar to that of rhinoviruses, via direct contact with infected secretions or large aerosol droplets. Immunity develops soon after infection but wanes gradually over time. Reinfection is common. Clinical manifestations: 1. Coronaviruses mostly cause respiratory symptoms (nasal congestion, rhinorrhea, and cough) and influenza-like symptoms (fever, headache). 2. Severe types (2019-nCoV, MERS-CoV, and SARS-CoV): Typically with pneumonia–fever, cough, dyspnea, and bilateral infiltrates on chest imaging, and sometimes enterocolitis (diarrhea), particularly in immunocompromised hosts (HIV+, elders, children). 3. Most community-acquired coronavirus infections are diagnosed clinically, although RT-PCR applied to respiratory secretions is the diagnostic test of choice.              

Treatment: 1. Mainly consists of ensuring appropriate infection control and supportive care for sepsis and acute respiratory distress syndrome. 2. In study: Chloroquine showed activity against the SARS-CoV, HCoV-229E, and HCoV-OC43 and remdesivir against 2019-nCoV. Dexamethasone may have clinical benefit.

Prevention: 1. For most coronaviruses: The same as for rhinovirus infections, which consist of handwashing and the careful disposal of materials infected with nasal sec retions. 2. For novel coronavirus (2019-nCoV), MERS-CoV, and SARS-CoV: (1) Preventing exposure by diligent hand washing, respiratory hygiene, and avoiding close contact with live or dead animals and ill individuals. (2) Infection control for suspected or confirmed cases: Wear a medical mask to contain their respiratory secretions and seek medical attention; standard contact and airborne precautions, with eye protection.

      Hepatitis A: HAV vaccine is newly recommended to adults at increased risk for HAV infection (substance use treatment centers, group homes, and day care facilities for disabled persons), and to all children and adolescents aged 2 to 18 years who have not previously received HAV vaccine.

      Hepatitis C: 8-week glecaprevir-pibrentasvir is recommended for chronic HCV infection in treatment-naive patients. In addition to the new broad one-time HCV screening (17-79 y/a), a repeated screening in individuals with ongoing risk factors is suggested.

      New: Lefamulin is active against many common community-acquired pneumonia pathogens, including S. pneumoniae, Hib, M. catarrhalis, S. aureus, and atypical pathogens.  

      New: Cefiderocol is a novel parenteral cephalosporin that has activity against multidrug-resistant gram-negative bacteria, including carbapenemase-producing organisms and Pseudomonas aeruginosa resistant to other beta-lactams. It’s reserved for infections for which there are no alternative options.

      New: Novel macrolide fidaxomicin is reserved for treating the second or greater recurrence of C. difficile infection in children.       Vitamin C is not beneficial in adults with sepsis and ARDS.    

      Chapter 2: CVD

      AF: Catheter ablation is recommended to some drug-refractory, paroxysmal AF to decrease symptom burden. In study: Renal nerve denervation has been proposed as an adjunctive therapy to catheter ablation in hypertensive patients with AF. Alcohol abstinence lowers the risk of recurrent atrial fibrillation among regular drinkers.

VF: For nonshockable rhythms, epinephrine is given as soon as feasible during CPR, while for shockable rhythms epinephrine is given after initial defibrillation attempts are unsuccessful. Avoid vasopressin use.

All patients with an acute coronary syndrome (ACS) should receive a P2Y12 inhibitor. For patients undergoing an invasive approach, either prasugrel or ticagrelor has been preferred to clopidogrel. Long-term antithrombotic therapy in patients with stable CAD and AF has newly been modified as either anticoagulant (AC) monotherapy or AC plus a single antiplatelet agent.

      Long-term antithrombotic therapy (rivaroxaban +/- aspirin) is recommended for patients with AF and stable CAD. Ticagrelor plus aspirin is recommended for some patients with CAD and diabetes.

VTE (venous thromboembolism): LMW heparin or oral anticoagulant edoxaban is the first-line anticoagulants in patients with cancer-associated VTE.

Dosing of warfarin for VTE prophylaxis in patients undergoing total hip or total knee arthroplasty should continue to target an INR of 2.5.

     Chapter 3: Resp. Disorders

Asthma: Benralizumab is an IL-5 receptor antibody that is used as add-on therapy for patients with severe asthma and high blood eosinophil counts.

Recombinant GM-CSF is still reserved for patients who cannot undergo, or who have failed, whole lung lavage.

Pulmonary embolism (PE): PE response teams (PERT, with specialists from vascular surgery, critical care, interventional radiology, emergency medicine, cardiac surgery, and cardiology) are being increasingly used in management of patients with intermediate and high-risk PE.

Although high-sensitivity D-dimer testing is preferred, protocols that use D-dimer levels adjusted for pretest probability may be an alternative to unadjusted D-dimer in patients with a low pretest probability for PE.

     Non-small cell lung cancer (NSCLC): Newly approved capmatinib is for advanced NSCLC associated with a MET mutation, and selpercatinib for those with advanced RET fusion-positive. Atezolizumab was newly approved for PD-L1 high NSCLC.

Circulating tumor DNA tests for cancers such as NSCLC are increasingly used as “liquid biopsy”. Due to its limited sensitivity, NSCLC patients who test (-) for the biomarkers should undergo tissue biopsy.

Cystic Fibrosis (CF): Tx: CFTR modulator therapy (elexacaftor-tezacaftor-ivacaftor) is recommended for patients ≥12 years with the F508del variant.

Vitamin E acetate has been implicated in the development of electronic-cigarette, or vaping, product use associated lung injury.

     Chapter 4: Digestive and Nutritional Disorders

     Comparison of Primary Biliary Cholangitis (PBC) and Primary Sclerosing Cholangitis (PSC):

     Common: They are two major types of chronic cholestatic liver disease, with fatigue, pruritus, obstructive jaundice, similar biochemical tests of copper metabolism, overlapped histology (which is not diagnostic), destructive cholangitis, and both ultimately result in cirrhosis and hepatic failure. (1) PBC: Mainly in middle-aged women, with keratoconjunctivitis sicca, hyperpigmentation, and high titer of antimitochondrial Ab (which is negative for PSC). (2) PSC: Primarily in middle-aged men, with chronic ulcerative colitis (80%), irregular intra- and extra-hepatic bile ducts, and anti-centromere Ab (+).

      CRC: Patients with colorectal adenomas at high risk for subsequent colorectal cancer (CRC) (≥3 adenomas, villous type with high-grade dysplasia, or ≥10 mm in diameter) are advised short follow-up intervals for CRC surveillance. Pembrolizumab was approved for the first-line treatment of patients with unresectable or metastatic DNA mismatch repair (dMMR) CRC.

      UC and CRC: Patients with extensive colitis (not proctitis or left-sided colitis) have increased CRC risk.

      Eradication of H. pylori: adding bismuth to clarithromycin-based triple therapy for patients with risk factors for macrolide resistance.

      Thromboelastography and rotational thromboelastometry are bedside tests recommended for patients with cirrhosis and bleeding.

      Pancreatic cancer: Screening for patients at risk for hereditary pancreatic cancer (PC): Individuals with mutations in the ataxia-telangiectasia mutated gene and one first-degree relative with PC can be screened with endoscopic ultrasound and/or MRI/magnetic retrograde cholangiopancreatography.

      Olaparib is recommended for BRCA-mutated advanced pancreatic cancer after 16 weeks of initial platinum-containing therapy.

      HCC (unresectable): New first-line therapy is a TKI (sorafenib or sunitinib) or immune checkpoint inhibitor atezolizumab plus bevacizumab, +/- doxorubicin. Monitor kidney toxicity for these drugs.

      UC: Ustekinumab (-umab) anti-interleukin 12/23 antibody, is newly approved for the treatment of UC.

      Crohn disease: The combination of partial enteral nutrition with the specific Crohn disease exclusion diet is a valuable alternative to exclusive enteral nutrition for induction of remission.

      Obesity: Lorcaserin, a 5HT2C agonist that can reduce food intake, has been discontinued in the treatment of obesity due to increased malignancies (including colorectal, pancreatic, and lung cancers).

      Diet and cancer deaths: A low-fat diet rich in vegetables, fruits, and grains experienced fewer deaths resulted from many types of cancer.

      Note that H2-blockers (-tidines) are no longer recommended due to the associated carcinogenic N-nitrosodimethylamine.

      Gastrointestinal Stromal Tumors (GIST):

      GIST is a rare type of tumor that occurs in the GI tract, mostly in the stomach (50%) or small intestine. As a sarcoma, it’s the #1 common in the GI tract. It is considered to grow from specialized cells in the GI tract called interstitial cells of Cajal, associated with high rates of malignant transformation.

Clinical features and diagnosis: Most GISTs are asymptomatic. Nausea, early satiety, bloating, weight loss, and signs of anemia may develop, depending on the location, size, and pattern of growth of the tumor. They are best diagnosed by CT scan and mostly positive staining for CD117 (C-Kit), CD34, and/or DOG-1.

Treatment: Approaches include resection of primary low-risk tumors, resection of high-risk primary or metastatic tumors with a tyrosine kinase inhibitor (TKI) imatinib for 12 months, or if the tumor is unresectable, neoadjuvant imatinib followed by resection. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. Avapritinib or ripretinib (new TKI) is recommended for advanced unresectable or metastatic GIST with PDGFRA mutations.

      Anal Cancer:

Anal cancer is uncommon and more similar to a genital cancer than it is to a GI malignancy by etiology. By histology, it is divided into SCC (#1 common) and adenocarcinoma. Anal cancer (particularly SCC among women) has increased fast over the last 30 years and may surpass cervical cancer to become the leading HPV-linked cancer in older women. A higher incidence has been associated with HPV/HIV infection, multiple sexual partners, genital warts, receptive anal intercourse, and cigarette smoking. SCCs that arise in the rectum are treated as anal canal SCCs.

Clinical features and diagnosis: 1. Bleeding (#1) and itching (often mistaken as hemorrhoids). Later on, patients may develop focal pain or pressure, unusual discharges, and lump near the anus, and changes in bowel habits. 2. Diagnosis is made by a routine digital rectal exam, anoscopy/proctoscopy plus biopsy, +/- endorectal ultrasound.

Treatment: Anal cancer is primarily treated with a combination of radiation, chemotherapy, and surgery—especially for patients failing the above therapy or for true perianal skin cancers.

     Chapter 5: Endocrinology

      Diabetes (DM):       Liraglutide can be added as a second agent for type-2 DM patients who fail monotherapy with metformin or as a third agent for those who fail combination therapy with metformin and insulin.       Metformin is suggested to prevent type 2 DM in high-risk patients in whom lifestyle interventions fail to improve glycemic indices.       Metabolic (bariatric) surgery improves glucose control in obese patients with type 2 DM and also reduce diabetes-related complications, such as CVD.       Teprotumumab, an insulin-like growth factor 1 receptor inhibitor, can be used for Graves’ orbitopathy if corticosteroids are not effective. Subclinical hypothyroidism should not be routinely treated (with T4) in older adults with TSH <10 mU/L.

        Chapter 6: Hematology & Immunology

       Anticoagulants: Apixaban is preferred to warfarin for atrial fibrillation with osteoporosis because it lowers the risk of fracture. Rivaroxaban is inferior to warfarin for antiphospholipid syndrome.

      Cancer-associated VTE: LMW heparin or oral edoxaban is the first-line anticoagulant prophylaxis.

      NH-Lymphoma Tx: New suggestion is four cycles of R(rituximab)-CHOP for limited stage (stage I or II) diffuse large B cell non-Hodgkin lymphoma (DLBCL) without adverse features. New suggestions: selinexor is for patients with ≥2 relapses of DLBCL, and tafasitamab plus lenalidomide is for patients with r/r DLBCL who are not eligible for autologous HCT.

      Chimeric antigen receptor (CAR)-T (NK) immunotherapy is newly suggested for refractory lymphoid malignancies, with less toxicity than CAR-T therapy. Polatuzumab + bendamustine + rituximab (PBR) is an alternative to CAR-T, allogeneic HCT, etc. for multiply relapsed diffuse large B-C NHL.

      Refractory classic Hodgkin lymphoma (r/r cHL) is responsive to immune checkpoint inhibition with pembrolizumab or nivolumab, including those previously treated with brentuximab vedotin or autologous transplantation.

      Mantle cell lymphoma: Induction therapy is bendamustine + rituximab or other conventional chemoimmunotherapy rather than more intensive approaches. CAR-T cell therapy is for refractory mantle cell lymphoma.

      AML: Gilteritinib is a new alternative to intensive chemotherapy for patients with FLT3-mutated r/r AML.

      Oral decitabine plus cedazuridine is suggested for MDS and chronic myelomonocytic leukemia.  

      Multiple myeloma (MM): Levofloxacin prophylaxis is suggested for patients with newly diagnosed MM during the first three months of treatment. For relapsed MM: Three-drug regimens (daratumumab, carfilzomib, and dexamethasone) are newly recommended.

      Transplantation: As the transplant waitlist continues to grow, there may be an increasing need of HIV-positive to HIV-positive transplants.

      Porphyria:       Porphyria is a group of disorders (mostly inherited) caused by an overaccumulation of porphyrin, which results in hemoglobin and neurovisceral dysfunctions, and skin lesions.       Clinical types, features, and diagnosis:  I. Acute porphyrias: 1. Acute intermittent porphyria: Increased porphobilinogen (PBG) causes attacks of abdominal pain (90%), neurologic dysfunction (tetraparesis, limb pain and weakness), psychosis, and constipation, but no rash. Discolored urine is common. 2. ALA (aminolevulinic acid) dehydratase deficiency porphyria (Doss porphyria): Sensorimotor neuropathy and cutaneous photosensitivity. 3. Hereditary coproporphyria: Abdominal pain, constipation, neuropathies, and skin rash. 4. Variegate porphyria: Cutaneous photosensitivity and neuropathies.  II. Chronic porphyrias: 1. Erythropoietic porphyria: Deficient uroporphyrinogen III synthase leads to cutaneous photosensitivity characterized by blisters, erosions, and scarring of light-exposed skin. Hemolytic anemia, splenomegaly, and osseous fragility may occur. 2. Cutaneous porphyrias–porphyria cutanea tarda: Skin fragility, photosensitivity, and blistering; the liver and nervous system may or may not be involved.  III. Lab diagnosis: Significantly increased ALA and PBG levels in urine have 100% specificity for most acute porphyrias. Normal PBG levels in urine can exclude acute porphyria.       Treatment: 1. Acute episodes: Parenteral narcotics are indicated for pain relief. Hemin (plasma-derived intravenous heme) is the definitive treatment and mainstay of management. 2. Avoidance of sunlight is the key in treating cutaneous porphyrias. Afamelanotide may permit increased duration of sun exposure in patients with erythropoietic protoporphyria.

 Chapter 7: Renal & UG

Membranous nephropathy (MN): Rituximab is a first-line therapy in patients with high or moderate risk of progressive disease and requiring immunosuppressive therapy.

      Diabetes Insipidus (DI): Arginine-stimulated plasma copeptin assays are newly used to diagnose central DI and primary polydipsia, often alleviating the need for water restriction, hypertonic saline, and exogenous desmopressin.

      Prostate cancer: Enzalutamide (new androgen blocker) is available for metastatic castration-sensitive prostate cancer. Cabazitaxel, despite its great toxicity, is suggested as third-line agent for metastatic prostate cancer. Either early salvage RT or adjuvant RT is acceptable after radical prostatectomy for high-risk disease.

      UG cancers: Nivolumab plus ipilimumab is suggested in metastatic renal cell carcinoma for long-term survival.

      Enfortumab vedotin is suggested in locally advanced or metastatic urothelial carcinoma. Maintenance avelumab is recommended with other chemotherapy in advanced urothelial bladder cancer. Pyelocalyceal mitomycin is suggested for low-grade upper tract urothelial carcinomas.

Chapter 8: Rheumatology

Janus kinase (JAK) inhibitors (upadacitinib, filgotinib) are new options for active, resistant RA and ankylosing spondylitis.

Graves’ orbitopathy: new therapy–teprotumumab, an insulin-like growth factor 1 receptor inhibitor.

Chapter 9: Neurology & Special Senses

Epilepsy: Cenobamate, a novel tetrazole alkyl carbamate derivative that inhibits Na-channels, provides a new treatment option for patients with drug-resistant focal epilepsy. A benzodiazepine plus either fosphenytoin, valproate, or levetiracetam is recommended as the initial treatment of generalized convulsive status epilepticus.

Migraine: Lasmiditan is a selective 5H1F receptor agonist that lacks vasoconstrictor activity, new therapy for patients with relative contraindications to triptans due to cardiovascular risk factors.

      Stroke: New recommendation for cerebellar hemorrhages >3 cm in diameter is surgical evacuation.       TBI: Antifibrolytic agent tranexamic acid is newly recommended for moderate and severe acute traumatic brain injury (TBI).

      Ofatumumab is a new agent that may delay progression of MS.

 Chapter 10: Dermatology

 Minocycline foam is a new topical drug option for moderate to severe acne vulgaris.

       Melanloma: Nivolumab plus ipilimumab in metastatic melanoma has confirmed long-term survival. With sun-protective behavior, melanoma incidence is decreasing.

       New: Tazemetostat is suggested in patients with locally advanced or metastatic epithelioid sarcoma (rare and aggressive) ineligible for complete surgical resection.

       Psoriasis: New therapies for severe psoriasis and psoriatic arthritis: a TNF-alpha inhibitor (infliximab or adalimumab, golimumab) or IL-inhibitor (etanercept or ustekinumab) is effective. Ixekizumab is a newly approved monoclonal antibody against IL-17A. Clinical data support vigilance for signs of symptoms of malignancy in patients with psoriasis.

     Chapter 11: GYH

      Breast cancer:        Although combined CDK 4/6 and aromatase inhibition is an effective strategy in older adults with advanced receptor-positive, HER2-negative breast cancer, toxicities (myelosuppression, diarrhea, and increased creatinine) should be carefully monitored. SC trastuzumab and pertuzumab is newly recommended for HER2-positive breast cancer.

      Whole breast irradiation is suggested for most early-stage breast cancers treated with lumpectomy. Accelerated partial breast irradiation can be an alternative for women ≥50 years old with small (≤2 cm), hormone receptor-positive, node-negative tumors.

      Endocrine therapy is recommended for breast cancer prevention in high-risk postmenopausal women.

      Uterine fibroids: Elagolix (oral gonadotropin-releasing hormone antagonist) in combination with estradiol and norethindrone is for treatment of heavy menstrual bleeding (HMB) due to uterine fibroids.

      Chapter 12: OB

      Table 12-6: Active labor can start after OS > 4cm, and 6cm is relatively more acceptable but not a strict number.

      Table 12-7: Preeclampsia is a multisystem progressive disorder characterized by the new onset of hypertension and proteinuria, or of hypertension and significant end-organ dysfunction with or without proteinuria, in the last half of pregnancy or postpartum. Once a diagnosis of preeclampsia is established, testing for proteinuria is no longerdiagnostic or prognostic. “proteinuria>5g/24hours” may only indicate the severity.

      Mole: For partial moles, obtain a confirmatory hCG level one month after normalization; for complete moles, reduce monitoring from 6 to 3 months post-normalization.

      Chapter 14: EM

SHOCK RESUSCITATION

Emergency treatment—critical care!

“A-B-C”: Breathing: …In mechanically ventilated adults with critical illness in ICU, intermittent sedative-analgesic medications (morphine, propofol, midazolam) are recommended.

 Chapter 15: Surgery

      Surgery and Geriatrics: Hemiarthroplasty is a suitable option for patients who sustain a displaced femoral neck fracture.

    Chapter 16: Psychiatry

     Depression: Both short-term and maintenance therapies with esketamine are beneficial for treatment-resistant depression.

Schizophrenia: Long-term antipsychotics may decrease long-term suicide mortality.

Narcolepsy: Pitolisant is a novel oral histamine H3 receptor inverse agonist used in narcolepsy patients with poor response or tolerate to other medications. Oxybate salts, a lower sodium mixed-salt formulation of gamma hydroxybutyrate is for treatment of narcolepsy with cataplexy.

     Chapter 17: Last Chapter

PEARLS—Table 17-9:  Important Immunization Schedules for All (2020, USA)

Vaccine                 Birth       2M          4M          6M          12-15M                 2Y          4-6Y       11-12Y       Sum

HAV                                                                                       1st                          2nd (2-18Y)                            2 doses

HBV                      1st           2nd                        3rd (6-12M)                                                                             3 doses

DTaP                                    1st            2nd         3rd          4th (15-18M)                        5th                             + Td per 10Y

IPV                                       1st           2nd         3rd (6-18M)                                         4th                             4 doses

Rotavirus                            1st           2nd                                                                                                         2 doses

Hib                                       1st           2nd         (3rd)       (3-4th)                                                                    3-4 doses

MMR                                                                                    1st                                         2nd                              2 doses

Varicella                                                                              1st                                         2nd                        + Shingles at 60Y

Influenza                                                            1st (IIV: 6-12Y; LAIV: >2Y                (2nd dose)               1-2 doses annually

PCV                                     1st           2nd         3rd          4th                                                                        PCV13+PPSV at 65Y

MCV (Men A, B)                                                                                                                                1st         Booster at 16Y

HPV                      9-12Y starting: <15Y: 2 doses (0, 6-12M); >15Y or immunosuppression: 3 doses (0, 2, 6M).

Chapter 17 HYQ answer 22: No routine prostate cancer screening (including PSA) is recommended and answer “G” is still correct–PSA

screening among healthy men is not routinely done but should be indicated in a patient with two risk factors.

#medical school #Resources

[blindedbythedarkness]

A Rant into the Void

I am so fucking sick of my body right now. Actually, no, that’s not the problem at all. I am actually fucking sick of the response of medical professionals to my body. My body itself is doing its fucking best, all things considered.

Put simply, I can’t face going to the doctor anymore. I’m too afraid. Which isn’t exactly a great place to be, mentally or physically, when you have a genetic condition that can (though rarely) result in life threatening complications. 

I’ve never fucking liked it. Not one bit. It’s been built into me from a young age to suck things up and carry on. My dad used to passively scold me for ever taking a day off school by reminding me that he never did and telling me about all the days he’d gone to work with one ailment or another. He’s also the reason I’m so afraid of taking any medication now after years of me hearing how “taking paracetamol isn’t good for you. If you take it enough it stops working. It damages your liver too.” Even though painkillers do barely work, I can’t remember the last time I gave them a try. Now I’m older I know that he probably has his own deep seated issues that led to the things he said, but the things he said still stick like glue.

My mum was no better. As a nurse, she never took any shit from me and I would never have been able to skive off school. At one point I went to school for a week with an unknown broken arm, despite my protests. It’s rare that she explicitly called me a “hypochondriac”, but I could always tell that she was exasperated by my numerous visits to the GP, hospital and A&E. It’s only in the past year, now that my EDS has been confirmed for a second time (within the new guidelines) that she’s started to take me more seriously. I still don’t often feel able to tell her about my health concerns though, despite her having (a more mild version of) the same condition. I think she feels guilty for passing it onto me, but her responses usually comes across as frustration and annoyance. 

In the past year, my fear of doctors has grown even more. Firstly, now I’ve seen what a real illness faker looks like and does, I’m forever terrified that I look like I’m doing the same. I’ve almost obsessively started taking photographic evidence of my various ailments for fear of being accused of Munchhausen's by a medical professional (despite the difficulty of convincing others of a real case of fii). Given I have also spoken out about this girl, I also live in fear of seeming like a hypocrite. Those close to me say “we know you’re really ill, we’ve seen it, we know you aren’t faking it and you’re nothing like her” but still I can’t shake the fear.

Doctors have been pretty shit lately, too. I’d had bad experiences in the past: a GP that couldn’t identify a broken elbow and a gastro consultant who suggested my pain was all in my head, but for a while I’d had a good run. The past year has been fucking awful though. One particular GP at the surgery has been the cause of almost all of it, to the point where I was going to make a formal complaint before corona got in the way. For the first time ever I had gone to an outpatients appointment alone (something I’d be afraid of due to the potential for gaslighting) and for once the consultant was amazing- he gave me a reason for my pain  that had been found on an MRI and reassured me he would explain it all to my GP. However, the consultant had lied. He didn’t write in the letter anything that he said to me and GP soon decided that I was lying about my account, to the point where I questioned my own memory. Contrary to the advice of the consultant, and later my physio (who confirmed what the consultant has originally said), he advised me to walk more to solve my issue. It also took me refusing to leave his room until I got a referral to a rheumatology consultant for him to allow it. That was after him patronizing me consistently and insisting that “there’s no EDS cure you know?” and  “physio is your only option”. The arrogant cunt obviously thought his single lecture had taught him more than 10 years learning about this condition had taught me. I knew my rights and got what I wanted, but I live in fear of my record being marked with “fii” or “anxious patient” that would virtually destroy any further chances of me getting treatment.

This becomes a problem, of course, when I seem to acquire a new co-morbidity or complication every month at the minute. A few weeks ago I had it confirmed that I have a bladder (and potentially pelvic) prolapse. The doctor I had spoken to before the examination though was Dr. Self Important Prick, and he had seemed doubtful of the whole thing. So even though it was proven, I’m still too afraid to call again. This week I have had a bingo card full of the symptoms of a cerebrospinal fluid leak (and not for the first time). I don’t know what to do though. Given the susceptibility of EDS patients to them, I’m fairly certain that’s what it is. Given it’s recurring, I’m also pretty sure I need to see someone. But it’s unstoppable force meets immovable object: if I go in there having done my research I seem like a hypochondriac, yet one study showed that 0% of csf leaks are diagnosed correctly the first time. These are the complications of living with a rare condition. It’s impossible to walk the fine line between advocating for yourself and seeming like a fake because you weren’t a whole chapter in the doctor’s textbook. 

So here I am. Fed up. Angry at myself for not having the balls to get myself the help I need and angry at the medical profession for scarring me so badly. And with a lovely clear, metallic, currently unidentified liquid dripping down the back of my throat.

Since it seems these rants may get more regular, I’ve made a dedicated page to fill with my void rants @thatangryedsbitch

#eds #ehlers danlos syndrome #heds #hypermobile eds #hypermobile ehlers danlos #classic eds #kyphoscoliotic eds #ehlers danlos zebra #ehlers danlos type 3 #ehlers danlos life #ehlers danlos problems #eds problems #spoonie #medical trauma #medical gaslighting #medical ptsd #doctor trauma #spoonie community #gaslighting #trauma #ptsd #afraid #trapped #csf leak #fii #munchausens #hypochondriac