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👉 *IMPORTANT 640* 👈 *Important Investigations for Achlasia* oesophageal manometry excessive LOS tone which doesn't relax on swallowing considered the most important diagnostic test barium swallow shows grossly expanded oesophagus, fluid level 'bird's beak' appearance chest x-ray wide mediastinum fluid level paceUrMRCP.

👉 *IMPORTANT 639* 👈 *Some clinical features of Achlasia* dysphagia of BOTH liquids and solids typically variation in severity of symptoms heartburn regurgitation of food - may lead to cough, aspiration pneumonia etc malignant change in small number of patients paceUrMRCP.

👉 *IMPORTANT 638* 👈 *Some info about Achlasia* Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women. paceUrMRCP.

👉 *IMPORTANT 637* 👈 *Few Differntials for ODYNOPHAGIA* Viral upper respiratory tract infections Acute tonsillitis Peritonsillar abscess (quinsy) Infectious mononucleosis Influenza Oesophageal cancer Acute epiglottitis paceUrMRCP.

👉 *IMPORTANT 636* 👈 *Few differential diagnosis of dysphagia* Laryngopharyngeal reflux Oesophageal cancer Eosinophilic oesophagitis Peritonsillar abscess (quinsy) Gastric cancer Achalasia Subacute (De Quervain's) thyroiditis Pharyngeal pouch Thyroid cancer Acute epiglottitis Ludwig's angina Myasthenia gravis Motor neuron disease Dermatomyositis Polymyositis paceUrMRCP.

👉 *IMPORTANT 635* 👈 *Few important complications of extrensic allergic alveolitis* Fibrotic and emphysematous changes following inflammation in the lung during an acute period may lead to fibrosis, which has long term effects. Studies have found that 20% of patients with farmer’s lung (EEA secondary to occupational exposure to hay dust or mould spores) developed emphysema. Chronic oxygen requirement Widespread fibrosis may result in chronic hypoxaemia requiring long-term oxygen therapy at home Decreased lung function will lead to a reduced ability to carry out physical activities and activities of daily living paceUrMRCP.

👉 *IMPORTANT 634* 👈 *Some info about management of extrensic allergic alveolitis* British Thoracic Society (BTS) guidelines on interstitial lung disease (2008) underline the key factor in management is the identification and avoidance of the precipitating agent. Identification by a thorough clinical history including occupational hazards and correlation with symptom timeline of the patient. A causative agent may not be able to be identified in up to 25% of cases BAL cytology or antigen testing of the blood may confirm the causative agent Once identified, the removal of the causative agent is the most important part of management, and symptoms should resolve following this. Liaison with the employer and occupational health if the agent is work-related, and with the provision of respiratory masks and other protective equipment may be necessary Corticosteroids A trial of corticosteroids e.g. oral prednisolone can help with symptoms, mostly in patients with equivocal clinical presentation, as EEA tends to be steroid-responsive, whereas idiopathic pulmonary fibrosis does not This should then be tapered over a period of several weeks Patients with chronic EEA may benefit from long-term low dose prednisolone paceUrMRCP.

👉 *IMPORTANT 633* 👈 *Important clinical features of extrensic allergic alveolitis* A thorough clinical history is essential. This must include an occupational history, as certain jobs are associated with exposure to agents that can cause EEA: Farmers Particularly mushroom and potato workers, compost workers Animal cleaning/breeding Particularly avian species Chemical industry Working with paints, powders Smelters and hard metal workers A particular focus on exposure at home or at work to moulds is important, including in ventilators, air conditioners, hay or wood as this is a common causative agent. The presentation may be acute, with symptoms presenting 4-8 hours after exposure to causative agent and subsiding within 24-48 hours, or chronic, usually following long term low-exposure to a causative agent. Acute EEA typically presents, alongside a suggestive occupational/exposure history, with: Cough (productive or non-productive) Dyspnoea Fever Malaise Chest tightness Acute type 1 respiratory failure may develop in severe cases Chronic EEA presents more insidiously, alongside a suggestive occupational/exposure history, with: Insidious cough/dyspnoea symptoms Weight loss Clubbing (50% of cases) More widespread fibrotic changes mimicking idiopathic pulmonary fibrosis On auscultation of the lungs in both cases, bilateral midzone inspiratory crepitations will likely be heard to a greater or lesser extent depending on the severity of the condition. paceUrMRCP.

👉 *IMPORTANT 632* 👈 *Pathophysiology of extrensic allergic alveolitis* It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase. paceUrMRCP.

👉 *IMPORTANT 631* 👈 *Some info about extrensic allergic alveolitis* Extrinsic allergic alveolitis (EAA, also known as hypersensitivity pneumonitis) is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. *Classification* Examples bird fanciers' lung: avian proteins farmers lung: spores of Saccharopolyspora rectivirgula (formerly Micropolyspora faeni) malt workers' lung: Aspergillus clavatus mushroom workers' lung: thermophilic actinomycetes paceUrMRCP.

👉 *IMPORTANT 630* 👈 *Few words about prognosis of Hodgkin Lymphoma* The Ann Arbor staging system helps determine prognosis and the intensity of treatment, with stage I and II patients having a better prognosis. Stage I and II Hodgkin's lymphoma Certain prognostic factors subdivide stage I and II lymphoma into favourable and unfavourable groups, including the presence of B symptoms, extra-nodal involvement and high erythrocyte sedimentation rate (ESR) levels. Patients in stage I/II favourable group have a prognosis of around 85-90%, and that in the unfavourable group 80-90%, after receiving a combination of chemo- and radiotherapy treatments. Stage III and IV Hodgkin's lymphoma The prognosis of stage III/IV lymphoma is affected by a set of risk factors that correlate with poorer prognoses: male, age >45, leukocytosis, lymphopenia, low haemoglobin, low albumin and high ESR levels. The 5-year survival rate of patients in this group ranges from 42% (with >5 risk factors) to 84% (without any risk factors). paceUrMRCP.

👉 *IMPORTANT 629* 👈 *Few Complications of Hodgkin Lymphoma* Complications of Hodgkin's lymphoma are usually chemotherapy or radiotherapy related. Thyroid disorders Around 50% of the patients who received radiotherapy experience symptoms of hypothyroidism. Other possible thyroid disorders include thyroid cancer and hyperthyroidism. Therefore safe netting and regular monitoring of thyroid function should be done in patients receiving radiotherapy. Chemotherapy drugs, especially alkylating agents are associated with secondary malignancies such as acute myeloid leukaemia and paraneoplastic syndrome. Secondary leukaemia is seen in around 3% of patients receiving the BEACOPP regimen (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone). Radiotherapy, on the other hand, is associated with an increased risk of solid tumours especially lung cancer and breast cancer. Cardiac abnormalities Patients receiving anthracyclines e.g. doxorubicin are at a higher risk of developing cardiomyopathy. Patients can develop acute pericarditis shortly after receiving radiotherapy, or valvular heart disease or coronary heart disease in the long-term (around 5-10 years post-radiotherapy). According to BMJ Best Practice (Oct 2019), baseline cardiac function should be established by performing echocardiogram or multi-gated acquisition (MUGA) scans before starting anthracyclines. The article also suggested administrating lower doses of radiotherapy as well as managing cardiovascular risk factors to minimise complications. Pulmonary toxicity About 20% of patients receiving the ABVD regimen (doxorubicin, bleomycin, vinblastine, dacarbazine) develop bleomycin-related pulmonary toxicity. Radiation-induced pneumonitis can also occur post-radiotherapy. BMJ Best Practice (Oct 2019) emphasised on the importance of monitoring pulmonary functions by assessing FEV1 and transfer factor for carbon monoxide (TLCO). Infertility Infertility can occur in over 50% of both male and female patients with Hodgkin's lymphoma, depending on various factors e.g. treatment dose, regimen and age of the patient. The use of chemotherapy in female patients over the age of 30 with advanced Hodgkin's lymphoma is more likely to result in a reduced ovarian function comparing to younger patients. Low doses of radiotherapy (1-2Gy) can lead to infertility in men. In terms of chemotherapy regimen, ABVD has a lower risk of infertility in this gender group. Counselling should be offered to discuss the risk of infertility and explore alternative options. Infections Patients with Hodgkin's lymphoma are often immunocompromised at the point of diagnosis. This can be caused by underlying conditions or certain genetic predispositions (e.g. human leukocyte antigen (HLA)) which impair the immune systems and make the patients more susceptible to Hodgkin's lymphoma. Neutropenia is common in patients taking chemotherapeutic regimens such as ABVD, and almost all patients receiving BEACOPP are neutropenic. paceUrMRCP.

👉 *IMPORTANT 628* 👈 *Important investigations for Hodgkin Lymphoma* The investigations suggested below form part of the workup for patients with suspected Hodgkin's lymphoma: Blood tests Full blood count (FBC): Patients with Hodgkin's lymphoma are often anaemic, lymphopenic and thrombocytopenic, which can be associated with bone marrow involvement. Evidence of neutrophilia and anaemia indicate a poorer prognosis. There is inadequate research on the sensitivity and specificity of FBC in Hodgkin's lymphoma. However studies have shown that an abnormally low absolute lymphocyte count at the point of diagnosis is a negative prognostic factor in patients with Hodgkin's lymphoma. Baseline renal and liver function Erythrocyte sedimentation rate (ESR): Non-specific but tends to be elevated and indicates a poorer prognosis when the ESR level is >50 mm/hour in patients without B symptoms or >30 mm/hour in those with B symptoms. Lactate dehydrogenase (LDH): correlates with disease activity Viral screen e.g. Hepatitis B, C and HIV Lymph node excision biopsy is the definitive diagnosis for Hodgkin's lymphoma. It reveals the characteristic Reed-Sternberg cells (owl's eye appearance), or other distinctive Hodgkin's cells such as lacunar cells or popcorn cells. Core biopsy and fine-needle aspiration can rarely confirm the diagnosis due to inadequate Hodgkin's cells within the specimens PET or PET-CT scans The BMJ Best Practice (Oct 2019) recommends PET scans (93% sensitivity, 87% specificity) for both staging and assessing treatment response post-chemotherapy. Fluorodeoxyglucose (FDG)-PET scans can also be used for detecting bone marrow involvement. Contrast CT chest, abdominal and pelvis, chest x-rays and gallium scans can also help with staging Bone marrow biopsy can be considered in patients with B symptoms or advanced (stage III-IV) Hodgkin's lymphoma paceUrMRCP.

👉 *IMPORTANT 627* 👈 *Referral criteria for Hodgkin Lymphoma* NICE cancer referral guidelines for Hodgkin's lymphoma suggest the following: Hodgkin's lymphoma in adults Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for Hodgkin's lymphoma in presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus, weight loss or alcohol‑induced lymph node pain. Hodgkin's lymphoma in children and young people Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for Hodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy. When considering referral, take into account any associated symptoms, particularly fever, night sweats, shortness of breath, pruritus or weight loss. paceUrMRCP.

ANNOUNCEMENT FOR ONLINE COURSE NO 41 ( 24 June 24—12 July 24 ) Hello and salam everyone. We are pleased to announce admissions for our July 2024 online course ( 15 days ) for PACES MRCP (UK) and CLINICAL EXAM MRCPI . We will start from 24th of June 24 and finish on 12th of July 24. Active slots available on first come--first served basis. Listener slot available too. At least 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions. After the performance detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exams in coming diet. Interested candidates may send a personal message for details. WhatsApp No: +923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

ANNOUNCEMENT FOR ONLINE COURSE NO 41 ( 24 June 24—12 July 24 ) Hello and salam everyone. We are pleased to announce admissions for our July 2024 online course ( 15 days ) for PACES MRCP (UK) and CLINICAL EXAM MRCPI . We will start from 24th of June 24 and finish on 12th of July 24. Active slots available on first come--first served basis. Listener slot available too. At least 90 Important exam cases ( including recent diets cases ) will be practiced and discussed as we do in our weekly Sunday sessions. After the performance detailed feedback will be given to elaborate the weak skills. It is equally beneficial for those who are beginners or have exams in coming diet. Interested candidates may send a personal message for details. WhatsApp No: +923346036496. Email: drtanzeelbukhari@gmail.com GOOD LUCK.

👉 *IMPORTANT 626* 👈 *Important Management points for Hodgkin Lymphoma* Chemotherapy alone or in combination with radiotherapy are the main types of treatment for Hodgkin's lymphoma. This depends on the staging and type of lymphoma. Stage I/II classical Hodgkin's lymphoma Certain prognostic factors subdivide stage I/ II lymphoma into favourable and unfavourable groups, including the presence of B symptoms, extra-nodal involvement and high erythrocyte sedimentation rate (ESR) levels. Chemotherapy followed by radiotherapy Main treatment regimen: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + radiotherapy BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone) followed by ABVD and radiotherapy can sometimes be considered in stage I/II unfavourable group . However BEACOPP is found to have a higher risk of secondary leukaemia than ABVD. Chemotherapy alone may be useful in patients with non-bulky Hodgkin's lymphoma (mediastinal mass ratio <1/3). Stage I/ II nodular lymphocyte-predominant Hodgkin's lymphoma Involved-field radiotherapy alone is the main treatment for this group of patients with excellent clinical benefit. Stage III/ IV classical Hodgkin's lymphoma Chemotherapy alone ABVD or BEACOPP A randomized phase 3 trial published on the New England Journal of Medicine in 2017 (updated in 2018) showed that brentuximab vedotin with ABD is shown to have 5% greater 2-year modified progression-free survival rates than ABVD alone (82.1% vs 77.2%). Stanford V chemotherapy (doxorubicin, vinblastine, chlormethine, vincristine, bleomycin, etoposide, prednisolone) may be used to minimise the risk of bleomycin pulmonary toxicity. Stage III/ IV nodular lymphocyte-predominant Hodgkin's lymphoma Regular monitoring is adequate in asymptomatic patients. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) is administered in symptomatic patients or those with rapid disease progression . Relapsed or refractory Hodgkin's lymphoma Management of relapsed or refractory Hodgkin's lymphoma varies between patients based on certain factors including age, past medical history, disease progression and previous treatments. Chemotherapy followed by autologous stem cell transplantation (ASCT) may be useful if chemotherapy and radiotherapy aren't successful. Immunotherapeutic agents can be considered: Brentuximab vedotin is approved for relapsed and refractory Hodgkin's lymphoma. NICE guidelines stated in 2018 that, for patients with CD30-positive Hodgkin's lymphoma, brentuximab vedotin is only recommended if: they have already had ASCT, or they have already had 2 other treatments and can't undergo ASCT or chemotherapy. NICE recommended in 2017 that nivolumab can be used for treating this group of patients after ASCT and brentuximab vedotin treatment In 2018 NICE published further guidelines regarding the use of pembrolizumab in patients with relapsed or refractory Hodgkin's lymphoma: it is recommended in those who have already received brentuximab vedotin and can't undergo ASCT, only if pembrolizumab is taken for less than 2 years if the patient has an ASCT. However, pembrolizumab is not recommended in patients who have received both ASCT and brentuximab vedotin treatments. The use of allogeneic transplantation in relapsed patients following ASCT remains limited and debatable. paceUrMRCP.

👉 *IMPORTANT 625* 👈 *Few clinical features of Hodgkin Lymphoma* Hodgkin's lymphoma can affect patients of any age, but it has a bimodal distribution in age groups: 20-30 years and >50 years. 30% of the patients diagnosed with Hodgkin's lymphoma are between the 20-34 age group. Patients with Hodgkin's lymphoma commonly present with lymphadenopathy which is: Painless Asymmetrical Cervical nodes or mediastinal involvement in 60% If mediastinal lymph nodes are involved, this can compress the airway and lead to dyspnoea, chest pain, and dry cough. It may also cause superior vena cava obstruction. Can also occur in the spleen (27%), and the axillary (14%), abdominal (11-14%), hilar (12%) or inguinal-femoral (1-3%) lymph nodes Alcohol-induced pain at lymph node regions is a non-specific symptom as it can also occur in patients with alcohol intolerance and carcinoid syndrome. There's a lack of research regarding alcohol-induced pain in Hodgkin's lymphoma, but a paper published in 1983 estimated the incidence to be 1.5-5%. B symptoms are presented in up to 30% of patients: Fever >38ºC Night sweats Unintentional weight loss of >10% over 6 months Other clinical features include Pel-Ebstein fever - cyclical fever followed by periods of being afebrile for 1-2 weeks (rare) Abdominal pain (if abdominal lymphadenopathy is involved) Pruritus (30%) Clinical hepato/splenomegaly is rare (although liver and spleen involvement determined by laparoscopy/laparotomy occurs in up to 30% of the patients) Bone marrow involvement (5-8%) paceUrMRCP.

👉 *IMPORTANT 624* 👈 *A brief aetiology of Hodgkin Lymphoma* The exact aetiology of Hodgkin's lymphoma is still being investigated, but it is thought to be multifactorial: Epstein-Barr virus (EBV) infection (40%) : EBV infection (infectious mononucleosis) often precedes Hodgkin's lymphoma by a median time of 4 years. It is thought that a history of EBV infection greatly increases the risk of Hodgkin's lymphoma, Immunosuppression Organ transplantation Immunosuppressant therapies Patients with HIV Autoimmune conditions e.g. rheumatoid arthritis, systemic lupus erythematosus and sarcoidosis Familial (5%): same-sex siblings of patients with Hodgkin's lymphoma are 10 times more likely to develop the condition paceUrMRCP.

paceUrMRCP-Part 1 SUCCESS STORIES We are thankful to our respected colleagues who have made us proud by their success in MRCP ( UK ) Part 1 We believe that this number will keep on increasing. 57.Dr Minam Akbar 56.Dr Dhanub Andaranayake 55.Dr Jesanda Sirelkhatim 54.Dr Adil Maqbool 53.Dr Stalin P John Benz 52.Dr MM Mohamed Sufad 51.Dr Aqsa Nizamani 50.Dr Kanta 49.Dr Munmun Nipa 48.Dr Suleman khan 47.Dr Sana Rafique 46.Dr Ali 45.Dr Izza 44.Dr Kerolos Wagdy 43.Dr Bushra 42.Dr Mubaraq Mustapha 41.Dr Bajrang Kumawat 40.Dr Iffat 39.Hotchand 38.Dr Banan Rasool 37.Dr Shilpi Shukla 36.Dr Usman 35.Dr Hasseeb 34.Dr Meena 33.Dr Ahmad 32. Dr Bushra Hossain 31.Dr.Mahwish Mustafa 30.Dr.Mehak Lakhani 29.Dr Nabil 28.Dr Zakia Zulfiqar 27.Dr Laxmikant Chavan ( MRCPI ) 26.Dr Hussain Baloch 25.Dr Jeevan Kumar 24.Dr Muhammad Usman Majeed 23.Dr Muhammad Shoaib Niazi 22.Dr Ahmed Abdelakher 21.Dr Sowndhariya 20.Dr Fatema 19.Dr Asifa 18.Dr Shabbir Ahmed 17.Dr Kiran 16.Dr Cindy Heaster 15.Dr Harshini 14.Dr Shiasta Qamar 13.Dr Jay Dev 12.Dr Nasir 11.Dr Jamila Noor 10.Dr Aparajita Day 9.Dr Haleem Baksh 8.Dr Salman 7.Dr Rabia 6.Dr Manjunath 5.Dr Barkas Khadija 4.Dr Afsana 3.Dr Imran 2.Dr Anam Qadeer 1.Dr Joyce Phua