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*✌✌ HEARTIEST CONGRATULATIONS ✌✌* To *Dr Aqsa nizamani* For passing MRCP UK part 1. We wish her the best for her future.

*✌✌ HEARTIEST CONGRATULATIONS ✌✌* To *Dr MM Mohamed Sufad* For passing MRCP UK part 1. We wish him the best for his future.

👉 *IMPORTANT 652* 👈 *Few complications of aneurysmal SAH* Re-bleeding (in around 30%) Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) Seizures Good Luck

👉 *IMPORTANT 651* 👈 *Few lines about treatment of Subarchanoid Haemorrhage* The treatment in spontaneous SAH is in accordance with the causative pathology Intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours Most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon Until the aneurysm is treated, the patient should be kept on strict bed rest, well controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt Good Luck

👉 *IMPORTANT 650* 👈 *Few investigations for the diagnosis of Subarchanoid Haemorrhage* *Confirmation of SAH:* Computed tomography (CT) head Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system. CT is negative for SAH (no blood seen) in 7% of cases. Lumbar puncture (LP) Used to confirm SAH if CT is negative. LP is performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown). Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure) Referral to neurosurgery to be made as soon as SAH is confirmed After spontaneous SAH is confirmed, the aim of investigation is to *identify a causative pathology* that needs urgent treatment: CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM) +/- digital subtraction angiogram (catheter angiogram) Good Luck

👉 *IMPORTANT 649* 👈 *Few Clinical features of Subarchanoid Haemorrhage* Classical presenting features include: Headache: typically sudden-onset (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’) and occipital Nausea and vomiting Meningism (photophobia, neck stiffness) Coma Seizures Sudden death ECG changes including ST elevation may be seen Good Luck

👉 *IMPORTANT 648* 👈 *Few causes of Subarchnoid Haemorrhage* The most common cause of SAH is head injury and this is called traumatic SAH . In the absence of trauma, SAH is termed spontaneous SAH . The rest of this note focuses on spontaneous SAH. Intracranial aneurysm* (saccular ‘berry’ aneurysms): this accounts for around 85% of cases. Conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta Arteriovenous malformation Pituitary apoplexy Arterial dissection Mycotic (infective) aneurysms Perimesencephalic (an idiopathic venous bleed) Good Luck

👉 *IMPORTANT 647* 👈 *Few causes of weight gain* Depression Hypothyroidism Corticosteroids: side-effects Chronic heart failure Polycystic ovarian syndrome Chronic kidney disease Sulfonylureas: side-effects Cushing's disease Focal segmental glomerulosclerosis Membranous glomerulonephritis Minimal change disease Good Luck

👉 *IMPORTANT 646* 👈 *Brief management of Wilson,s disease* penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future Zinc has also been used. tetrathiomolybdate is a newer agent that is currently under investigation Good Luck

👉 *IMPORTANT 645* 👈 *Few investigations for Wilson’s disease* Reduced serum caeruloplasmin Reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) increased 24hr urinary copper excretion Good Luc

👉 *IMPORTANT 644* 👈 *Some clinical features of Wilson’s disease* The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration, speech, behavioural and psychiatric problems are often the first manifestations. Also: asterixis, chorea, parkinsonism, dementia Kayser-Fleischer rings renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails Good Luck

👉 *IMPORTANT 643* 👈 *Some info about Wilson’s disease* Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. *Pathophysiology* Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13. Good Luck

👉 *IMPORTANT 642* 👈 *Few differentials for Jaundice* Gilbert's syndrome Biliary colic Ascending cholangitis Infectious mononucleosis Intrahepatic cholestasis of pregnancy Pancreatic cancer Hepatocellular carcinoma Primary biliary cholangitis Primary sclerosing cholangitis Hepatitis A Acute liver failure Cholangiocarcinoma Hepatitis B Autoimmune hepatitis Acute fatty liver of pregnancy Malaria (Falciparum) Hereditary spherocytosis Good Luck

👉 *IMPORTANT 641* 👈 *Some treatment options for Achlasia* pneumatic (balloon) dilation is increasingly the preferred first-line option,less invasive and quicker recovery time than surgery patients should be a low surgical risk as surgery may be required if complications occur surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects Good Luck

👉 *IMPORTANT 643* 👈 *Some info about Wilson’s disease* Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. *Pathophysiology* Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13. Good Luck

👉 *IMPORTANT 642* 👈 *Few differentials for Jaundice* Gilbert's syndrome Biliary colic Ascending cholangitis Infectious mononucleosis Intrahepatic cholestasis of pregnancy Pancreatic cancer Hepatocellular carcinoma Primary biliary cholangitis Primary sclerosing cholangitis Hepatitis A Acute liver failure Cholangiocarcinoma Hepatitis B Autoimmune hepatitis Acute fatty liver of pregnancy Malaria (Falciparum) Hereditary spherocytosis Good Luck

👉 *IMPORTANT 641* 👈 *Some treatment options for Achlasia* pneumatic (balloon) dilation is increasingly the preferred first-line option,less invasive and quicker recovery time than surgery patients should be a low surgical risk as surgery may be required if complications occur surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects Good Luck

Dear coalleagues I regret to inform you that our tomorrow's Zoom session will not be possible due to sudden unexpected travelling. *Our next session ( no 88 ) will be on next Sunday 21st of May.* Please excuse me for any inconvenience.

👉 *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 Good Luck

👉 *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 Good Luck