Joint disorders are common cause of arm pain. Apart from joint disorders the majority of causes of arm pain are related to either neurological or vascular lesions which are discussed below:
Causes Of Anorectal Pain can be classified into acute and chronic, following are the major causes and history and physical examination points to differentiate among them:
The dense or hyperdense MCA sign refers to the appearance of the middle cerebral artery (MCA) on CT. It has been associated with poor outcome.
There is increased attenuation of the proximal portion of the MCA and it is often associated with thrombosis of the M1 MCA segment. It is one of the early signs of ischaemic stroke: MCA infarct.
The same pathological process can give an MCA dot sign when seen end on.
The sign is typically seen within 90 minutes of the ischemic event, and thus, it is very important for radiologists to recognize this sign. It can save the patient in 'golden hour' of thrombolysis (3 hours for intravenous tPA, and 6 hours for intra-arterial thrombolysis). This sign has approx. 100% sensitivity, however only 30% specificity.
It is usually associated with another important sign of acute ischaemia-insular ribbon sign.
Identification of the dense artery sign is often based on subjective interpretation and false positives may occur. One study aiming to define criteria for the sign determined that measuring Hounsfield units on the CT scan could differentiate between the dense MCA sign associated with ischemic stroke and that caused by false positives. Specifically, the combination of greater than 43 Hounsfield units and an MCA ratio of greater than 1.2 was diagnostic of a dense MCA sign associated with acute ischemic stroke.
There are occasional reports of a hyperdense MCA sign seen with HSV encephalitis
False-positives: (asymptomatic patients-usually bilateral):
The loss of the insular ribbon sign refers to a loss of definition of the gray-white interface in the lateral margin of the insular cortex ("insular ribbon") and is considered an early CT sign of MCA infarction.
The insular cortex is more susceptible to ischaemia following MCA occlusion than other portions of the MCA territory because it has the least potential for collateral supply from the anterior cerebral and posterior cerebral arteries.
In the above image the cortex of the left insular ribbon is not visualized (arrow), which is known as loss of the insular ribbon sign.
Case 5: A 75 year old woman is seen in the emergency room because of progressive dyspnea over a period of three days...
A 75 year old woman is seen in the emergency room because of progressive dyspnea over a period of three days. Her examination confirms the presence of congestive heart failure with bilateral crackles, elevated jugular venous pressure and bilateral 1+ edema.
1. What is the basic rhythm in this patient?
2. Is there evidence of anterior myocardial infarction?
I got on the train and realized that it was packed. I found a seat next to a woman and asked if I could sit next to her. She looked at me, and I saw something briefly in her eyes. Was it fear? Was it disgust? Frustration? She hesitated and slowly got up to make space for me to sit down. She really seemed uncomfortable. With all the negativity towards our Muslim community today, my first reaction was that she might not be comfortable with my hijab-ed clothing. Maybe she hadn’t had a good experience with Muslims. Maybe she had been watching scary news stories and thought that we were all the same. Maybe she thought I was oppressed and controlled.
It took me a few seconds to realize that I was stereotyping what might be going on in her mind, just as I feared she might be doing about me.
I turned towards her and introduced myself. She was hesitant, but slowly returned my conversation.
As we finally got to the question of where each of us was heading, she told me, “I’m going to my cousin’s funeral. She was my best friend.”
I was ashamed of my initial thoughts. Here I was, so self-absorbed that I assumed her trepidation was because of my dress. In reality, she was hurting; in pain, in loss, trying to piece together how to move forward without her best friend.
We hugged tightly as she left the train. We asked God to give her family strength through this difficult time. Had I chosen to assume that her hesitation was about me and left it at that, I would have lost an incredible opportunity for my heart to connect with hers.
Many times, we worry and sometimes assume that people will judge us and we interpret their actions within that perspective. But all of us are dealing with our own struggles and pain, and many of us could use that extra hug, prayer or positive vibe that comes from letting your guard down enough to realize that the judgments we think others are making of us are – sometimes – worse in our own heads.
“Make things easy and convenient and do not make them harsh and difficult. Give cheer and glad tidings and do not create hatred.” Prophet Muhammad ﷺ (peace be upon him) [Bukhari]
Diagnosis Of Polycythemia Vera, Ruxolitinib versus Standard Therapy for the Treatment of Polycythemia Vera
Polycythemia vera is an acquired myeloproliferative disorder that causes overproduction of all three hematopoietic cell lines, most prominently red blood cells. A mutation of JAK2, a signaling molecule, has been demonstrated in 95% of cases
Symptoms and Signs:
Signs and symptoms are related to expanded blood volume and increased blood viscosity which include:
1.Headache 2.Dizziness 3.Tinnitus 4.Blurred vision 5.Night Sweats 6.Fatigue 7.Generalized pruritus especially following a warm shower 8.Splenomegaly 9.Plethora
Hct > 52% in males or 48% in females
In the absence of JAK2 Mutation:
Four Major criteria
Three Major & Two Minor criteria
Hct > 60% in males, Hct > 56% in females
No Secondary erythrocytosis
Presence of genetic mutations (excludes JAK2)
Platelets > 450000/cumm
Neutrophils > 10000/cumm
Low serum erythropoietin
Goal Of Therapy:
The main goal of therapy is to prevent thrombotic events while avoiding iatrogenic harm and minimizing the risk of transformation to
Most patients receive low-dose aspirin and undergo phlebotomy, with a goal of maintaining hematocrit values of less than 45%.
Cytoreductive therapy is recommended in patients having high risk for thrombosis, persistent or progressive hematologic abnormalities or symptoms, increased requirement for phlebotomies or who cannot undergo phlebotomy.
First-line cytoreductive agent is hydroxyurea
Patients having an inadequate response to the drug or have unacceptable side effects at the doses required to consistently control the hematocrit, these patients would be classified as having resistance or intolerance to hydroxyurea
Ruxolitinib versus Standard Therapy for the Treatment of Polycythemia Vera:
Ruxolitinib is a Janus kinase (JAK) inhibitor. It is FDA approved drug for
It was a Randomized Controlled Phase 3 study, to evaluate the safety and efficacy of a JAK inhibitor in patients with PV who have an inadequate response to or have unacceptable side effects from hydroxyurea
Patients randomly assigned phlebotomy-dependent with splenomegaly, in a 1:1 ratio, to receive ruxolitinib (110 patients) or standard therapy (112 patients).
Primary End Point:
Primary end point was both hematocrit control through week 32 and at least a 35% reduction in spleen volume at week 32, as assessed by means of imaging.
The primary end point was achieved in 21% of the patients in the ruxolitinib group versus 1% of those in the standard-therapy group (P<0.001)
Hematocrit control was achieved in 60% of patients receiving ruxolitinib and 20% of those receiving standard therapy.
38% of patients receiving ruxolitinib and 1% of those receiving standard therapy had at least a 35% reduction in spleen volume.
A complete hematologic remission was achieved in 24% of patients in the ruxolitinib group and 9% of those in the standard-therapy group .
Reduction in the total symptom score at week 32 was achieved in 49% of patients in the ruxolitinib group and 5% of those in the standard-therapy group.
In the ruxolitinib group, grade 3 or 4 anemia occurred in 2% of patients, and grade 3 or 4 thrombocytopenia occurred in 5%
In the standard-therapy group anemia occurred in 0% and thrombocytopenia in 4%
Herpes zoster infection was reported in 6% of patients in the ruxolitinib group and 0% of those in the standard-therapy group.
Thromboembolic events occurred in one patient receiving ruxolitinib and in six patients receiving standard therapy.
In patients who had an inadequate response to or had unacceptable side effects from hydroxyurea, ruxolitinib was superior to standard therapy in controlling the hematocrit, reducing the spleen volume, and improving symptoms associated with polycythemia vera.
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