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*Announcement for Online Session No 62* *7 August 2022* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Today we will have an online session on Zoom discussing 2 station 5 ( BCC )* regarding our preparation for MRCP PACES ( UK ) TIMINGS : Saudia Arabia: 4 pm Pakistan : 6 pm Bangladesh : 7 pm India : 6 30 pm Singapore : 9 pm Hong Kong : 9 pm Malaysia : 9 pm Egypt : 3 pm Libya : 3 pm Bahrain : 4 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 pm UAE : 5 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. Interested candidates may send a personal message to take a case. *Unfortunately we will not be able to record the session so make sure you attend it.* GOOD LUCK.

*Announcement for Online Session No 62* *7 August 2022* DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE : *Tomorrow we will have an online session on Zoom discussing 2 station 5 ( BCC )* regarding our preparation for MRCP PACES ( UK ) TIMINGS : Saudia Arabia: 4 pm Pakistan : 6 pm Bangladesh : 7 pm India : 6 30 pm Singapore : 9 pm Hong Kong : 9 pm Malaysia : 9 pm Egypt : 3 pm Libya : 3 pm Bahrain : 4 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 pm UAE : 5 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm ( please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. Interested candidates may send a personal message to take a case. *Unfortunately we will not be able to record the session so make sure you attend it.* GOOD LUCK.

*Important investigations for Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* 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

*Referral criteria for Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* 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. Good Luck

*Important Management points for Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* 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. Good Luck

*Few clinical features of Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* 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%) Good Luck

*A brief aetiology of Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* 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 Good Luck

*A brief introduction of Hodgkin Lymphoma by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* Hodgkin’s lymphoma is a rare haematological malignancy (accounts for<1% of all cancers in the UK) caused by the uncontrolled proliferation of B-lymphocytes. These cells travel through the lymphatic system and build up in the lymph nodes causing lymphadenopathy. They can also spread to other organs such as the spleen or bone marrow. Hodgkin’s lymphoma is differentiated from non-Hodgkin’s lymphoma based on its histological appearance of huge multinucleated lymphocytes called Reed-Sternberg cells. Chemotherapy +/- radiotherapy are the main treatments of Hodgkin's lymphoma, and overall patients have a good prognosis with a 5-year survival rate of 80-90% in the early stages and 40-80% in the advanced stages. Good Luck

✌️✌️ *HEARTIEST CONGRATULATIONS* ✌️✌️ To *Dr Samina* For passing *PACES MRCP ( UK )* from India. She has been a keen member of our PACES group. We wish her the best for her future.

*METHOTREXATE info by courtesy of Dr Toqeer Bhatti. Thanks a lot dear dr* *Monitoring while Prescribing methotrexate* Methotrexate is a drug with a high potential for patient harm. It is therefore important that you are familiar with guidelines relating to its use Methotrexate is taken weekly, rather than daily FBC, U&E and LFTs need to be regularly monitored. The Committee on Safety of Medicines recommend 'FBC and renal and LFTs before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months' Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose The starting dose of methotrexate is 7.5 mg weekly (source: BNF) Only one strength of methotrexate tablet should be prescribed (usually 2.5 mg) Good Luck

*METHOTREXATE info by courtesy of Dr Toqeer Bhatti. Thanks a lot dear dr* *Adverse effects* Mucositis Myelosuppression Pneumonitis Pulmonary fibrosis Liver fibrosis *Contraindications:* Pregnancy Women should avoid pregnancy for at least 6 months after treatment has stopped The BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment *Interactions* Avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia High-dose aspirin increases the risk of methotrexate toxicity secondary to reduced excretion Good Luck

*METHOTREXATE info by courtesy of Dr Toqeer Bhatti. Thanks a lot dear dr* *Mechanism of action* Inhibits dihydrofolate reductase *Indications* Inflammatory arthritis, especially rheumatoid arthritis Psoriasis Some chemotherapy acute lymphoblastic leukaemia Good Luck

*Few other conditions associated with a positive RF by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* Other conditions associated with a positive RF include Sjogren's syndrome (around 100%) Felty's syndrome (around 100%) infective endocarditis (= 50%) SLE (= 20-30%) systemic sclerosis (= 30%) general population (= 5%) rarely: TB, HBV, EBV, leprosy Good Luck

*Few extraocular complications of rheumatoid arthritis (RA) by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* A wide variety of extra-articular complications occur in patients with rheumatoid arthritis (RA): respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression Less common Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis Good Luck

*The management of rheumatoid arthritis (RA) by courtesy of Dr Toqeer Bhatti. Thanks a lot dr* The management of rheumatoid arthritis (RA) has been revolutionised by the introduction of disease-modifying therapies in the past decade. Patients with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible. Other important treatment options include analgesia, physiotherapy and surgery. *Initial therapy* In 2018 NICE updated their rheumatoid arthritis guidelines. They now recommend DMARD monotherapy +/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step. *Monitoring response to treatment* NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment *DMARDs* methotrexate is the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis sulfasalazine leflunomide hydroxychloroquine *TNF-inhibitors* the current indication for a TNF-inhibitor is an inadequate response to at least two DMARDs including methotrexate etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis adalimumab: monoclonal antibody, subcutaneous administration *Rituximab* anti-CD20 monoclonal antibody, results in B-cell depletion two 1g intravenous infusions are given two weeks apart infusion reactions are common *Abatacept* fusion protein that modulates a key signal required for activation of T lymphocytes leads to decreased T-cell proliferation and cytokine production given as an infusion not currently recommend by NICE Good Luck

*Few investigations for Primary hyperaldosteronism ( Conn,s Syndrome )by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* the 2016 Endocrine Society recommend that a plasma aldosterone/renin ratio is the first-line investigation in suspected primary hyperaldosteronism should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone) following this a high-resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess Adrenal Venous Sampling (AVS) can be done to identify the gland secreting excess hormone in primary hyperaldosteronism Good Luck.