This is default featured slide 1 title

NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .


NIMS(Nepal Index Of Medical Specialities) has been design to provide information on drugs that are marketed in Nepal by Pharma company from around the world .

Saturday, December 26, 2015



1. All are hypercoaguable states, except

a. protein C resistance
b. Factor V leiden deficiency
c. Antipholipid antibody
d. Polycythemia

Ans; b. Factor V leiden deficiency 

Facor V leiden mutation (or increase factor V leiden levels ) are associated with a hypercoaguable state and not a Facot V leiden deficiency.

2. All of the following conditions predispose to thrombosis except;

a. paroxysmal nocturnal hemoglobinuria 
b. homocystinurea
c. hypomagnesemia
d.behcets syndrome

c. hypomagnesemia

All conditions other than hypomagnesemia are known predisposing causes of thrombosis.

3.predisposing factor for arterial thrombosis;

a. AT III deficiency 
b. Protein S deficiency
c. Protein C deficiency
d. Homocystenemia

Homocystenemia is associated with increased risk of arterial thrombosis.

4.All of the following statements are true about Hemolytic Uremic syndrome except;
d.Positive coomb's test

d.Positive coomb's test : coomb's test is characteristically negative in patients with HUS;

HUS is characterised by a microangiopathic hemolytic anemia, and thrombocytopenia. The LDH is usually elevated out of proportion to degree of hemolysis, and the coomb's test is negative .

5. commonest cause of Budd Chiari syndrome is 

a. Valve in the IVC
b, hepatocellular carcinoma
c. Paroxysmal nocturnal hemoglobinuria
d. Renal cell carcinoma

c. Paroxysmal nocturnal hemoglobinuria

PNH is the most common cause of budd chiari syndrome amongst the options provided.

6. blood transfusion should be completed within how many hours

a. 1 hour
b. 4 hour
c. 8 hour
d. 12 hour

ans is B 4 hour . blood transfusion  should be completed in less than 4 hours because of the dangers of bacterial proliferations , which may occur as blood warms to room temperature. 

14-month-old baby in China suffers from a rare disease

A 14-month-old baby in China suffers from a rare disease that causes the fatty tissues of the body to become inflamed.

Known as Weber-Christian disease, the condition can cause the skin to die in the inflamed areas, become infected and leave behind sunken scars that ooze a yellowish discharge.

The case was highlighted by a STOMP (a journalism website for citizens) reader jl who came across an online report about the baby, named Yang Xin:

"Read online news about this 14-month-old infant with a rare disease known as Weber-Christian Disease, which involves inflammation of the fatty tissues.

"Blood supply can be cut off from the affected areas, and the skin can die, leaving a yellowish discharge.

"There is no known cause or cure to the disease.

"According to online articles, the baby and his parents are now at a hospital in Beijing.

"Latest reports today (21 Dec) have stated that he is not in a good condition.

"He is in pain and can only be comforted by his mother's embrace at times.

"If the condition worsens, Yang Xin might lose his life.

"It is probably best that everyone take note of this so they can take early action if they notice something amiss."

Weber-Christian disease is most commonly seen in women aged between 30-60 years, and usually affects their legs and thighs.
It is extremely rare in infants, according to medical websites. The disease is difficult to treat, and often results in permanent scars.

Thursday, December 24, 2015

image challange 70

Nevus of Ota in a 20-year-old woman. Hyperpigmentation around the orbita. The hyperpigmentation extends into the sclera.

Hyperpigmentation around orbit            Hyperpigmentation extends into sclera

Nevus of Ota. Ota’s nevus (nevus fuscocaeruleus ophthalmomaxillaris) was first described by Ota in
1939.It is characterized by blue–black or gray–brown dermal melanocytic pigmentation and typically occurs in areas innervated by the first and second branches of the trigeminal nerve. Mucosal pigmentation may occur involving conjunctiva, sclera, and tympanic membrane (oculodermal melanocytosis),  or other sites.

It is most frequently seen in the Asian population, has a female predominance, and is usually congenital, although appearance in early childhood or at puberty has been described. Nevus of Ota is now subclassified as mild (type 1), moderate (type 2), intensive (type 3), and bilateral (type 4). Bilateral cases should be differentiated from Hori nevus, which is acquired, does not manifest mucosal involvement and is less pigmented .

Malignant melanoma may rarely develop in a nevus of Ota. This necessitates careful follow-up of the lesion, especially if it occurs in Caucasian patients, in whom malignant degeneration seems to be more frequent. Malignant melanocytic tumors in association with nevus of Ota have been shown to arise in the chorioidea, brain, orbit, iris, ciliary body, and optic nerve. In addition, association with ipsilateral glaucoma and intracranial melanocytosis has been described .

Wednesday, December 23, 2015

80-year-old female patient complains of a 3-day history of a painful rash

An 80-year-old female patient complains of a 3-day history of a painful rash extending over the right half of her forehead and down to her right eyelid. There are weeping vesicular lesions on physical examination. Which of the following is the most likely diagnosis?

zoster :multiple pleomorphic lesion on right side of face

a. Impetigo
b. Adult chickenpox
c. Herpes zoster
d. Coxsackie A virus
e. Herpes simplex

The answer is c.  A painful vesicular rash in a dermatomal distribution strongly suggests herpes zoster, although other viral pathogens may also cause vesicles. Herpes zoster may involve the eyelid when the first or second branch of the fifth cranial nerve is affected. Impetigo is a cellulitis caused by group A β-hemolytic streptococci.

It often involves the face and can occur after an abrasion of the skin. Its distribution is not dermatomal, and while it may cause vesicles, they are usually small and are not weeping fluid. Chickenpox produces vesicles in various stages of development that are diffuse and produce more pruritus than pain.

Coxsackievirus can produce a morbilliform vesiculopustular rash, often with a hemorrhagic component and with lesions of the throat, palms, and soles. Herpes simplex virus causes lesions of the lip (herpes labialis) but does not spread in a dermatomal pattern.

Monday, December 21, 2015

Confluent Rash on a Child

Confluent Rash on a Child

A 2-year-old boy with no medical history presents to the emergency department with complaints
of a diffuse rash over his bilateral lower extremities  for the past 2 days that is now progressing to his trunk and  upper extremities. He otherwise appears playful and well with no complaint of itching or fever. His parents deny new detergents, creams, or drug exposures. They do, however, report mild upper respiratory symptoms 1 week ago.

On physical examination, he has multiple confluent lesions  with central clearing diffusely. The lesions are present on his palms and soles but are most prominent on his bilateral lower extremities. There is no conjunctival injection, and there are no sores in or around his mouth or genital area.

Question: What is the next most appropriate management strategy at this time?
A. Obtain a complete blood count (CBC) and blood culture, administer ceftriaxone, and admit for

B. Obtain a CBC and blood culture, but do not treat with antibiotics

C. Discharge to home with diphenhydramine as needed for itching

D. Consult dermatology emergently

E. Administer subcutaneous epinephrine immediately

Answer: C
Diagnosis: Erythema multiforme (minor)
Discussion: Erythema multiforme (EM) is an acute and typically self - limited hypersensitivity reaction that manifests as a diffuse eruption with characteristic lesions. The lesions are usually symmetric, involve the palms of the hands and the soles of the feet, and predominate on the
extensor surfaces of the upper and lower extremities.

Although these are characteristic locations, lesions can be found anywhere on the body. The rash of EM can look macular, urticarial, or vesicobullous, but the prototypical lesion is a target lesion with a dusky center.

Often the rash changes from one form of lesion to another as the disease progresses. The rash itself generally lasts for at least 1 week, but can last up to 6 weeks. Patients are often otherwise asymptomatic, although they can also have itching associated with the lesions or involvement of the oral mucosa.

The causes of EM in children are most commonly infectious, whereas in adults the condition is much more frequently related to drug reaction or malignancy. The most common infectious agent attributed to EM is herpes simplex virus. The differential diagnosis of EM includes pemphigus, bullous pemphigoid, urticaria, or other viral exanthems.

Treatment for EM minor may involve cessation of inciting agents but is mainly supportive, including antihistamines and/or nonsteroidal anti - infl ammatory drugs. Systemic glucocorticoids are sometimes used, although there are no randomized trials showing clear benefi t. Recurrent cases may be treated with antiviral medications including acyclovir, valacyclovir, or famciclovir.

Classically, EM has been thought to be part of continuum of more serious illness such as Stevens – Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), but increasingly EM is being considered a distinct diagnosis, albeit with a similar pathophysiology to that of the more severe syndromes. It is important on physical examination to evaluate mucosal surfaces to differentiate between  EM and SJS or TEN.

EM involves the skin and only one other mucosal surface, usually the mouth. In contrast, SJS involves the eye, oral cavity, genital mucosa, upper airway, or esophagus. SJS and TEN are much more serious conditions with signifi cantly higher mortality rates.

Treatment for these conditions is frequently compared to burn care, and hospital admission is required. It is important to keep these other entities in mind even in cases of EM because patients and their families should be discharged with clear instructions about signs to look for that may indicate progression to more serious disease.

Sunday, December 20, 2015

Rapamycin helps reverse premature aging effects and possibly cure Progeria

Rapamycin helps reverse premature aging effects and possibly cure Progeria

  • Rapamycin, also known as the “forever young drug”, can help stop or reverse the aging effects and may possibly be a first step in curing a terrible disease like Progeria. A new study presented in the Science Translational Medicine, showed that the premature aging drug can extend the life for patients with Progeria as well as for people with a good general health state, Medical News Today informs.

The drug called Rapamycin is obtained from a substance found in the soil of Easter Island. It is also known as Sirolimus and, according to the scientists, it can reverse the effects of premature aging. Some say that it can do even more than that: it can add up to 10 years to our life. Sirolimus was first administered as an antifungal agent. Then it was administered after organ transplants because of its immunosuppressant characteristics, in order to prevent the rejection of the new organs. Its quality of inhibiting the cell growth led to detailed research.
First discovered in Rapa Nui, Easter Island, the substance is a result of the bacterium called Streptomyces hygroscopicus. It was first tested on mice in the lab and it has proven to be effective in extending their lifespan.
The latest study in the field was conducted on childred with Progeria (Hutchinson-Gilford Progeria Syndrome), a genetic condition in which the cells in the body accumulate a great quantity of a protein called Progerin, that causes accelerated aging. This way, people with Progeria age 10 times faster than normal. So by the time a person reaches 10 year of age, the body is and feels like 100 years.
Rapamycin inhibits the accumulation of Progerin, which delays the effects of aging, adding a significative amount of time to the lifespan of these children. The researchers have concluded their study report by saying: “Our findings suggest an additional mechanism for the beneficial effects of rapamycin on longevity and encourage the hypothesis that rapamycin treatment could provide clinical benefit for children with HGPS.” One of the authors of the study, Dr. Francis Collins says: “ We found it pretty exciting that this drug has such a profoundly positive effect on cell cultures .”                      
Progeria affects 1 in every 8 million babies. The risk of the disease is the same regardless of the sex, ethnicity, or geographical localization. The signs don’t show up from the beginning, leaving parents thinking they have a perfectly healthy and normal baby. By the age of 12 months, the symptoms start showing. They include aging of the skin, hair loss, weight loss, atheroscletosis, hip dislocation and many more. The lifespan for those affected is between 8 and 13 years old.
For starters, Rapamycin treatment could add at least 10 years to their life.

image spot dx 68

Nijmegen breakage syndrome

facies of nijmegen breakage

Other DNA repair defect disorders include Nijmegen breakage syndrome (NBS), an autosomal recessive disorder described in the Dutch town of that name, and characterized by microcephaly
with mild to moderate mental retardation, ‘bird-like’ facies, immunodefi ciency, clinical radiation sensitivity and chromosomal instability. Bacterial sinopulmonary infection is common, as is
hypogammaglobulinaemia and CD4+ T lymphopenia with diminished T-lymphocyte proliferative responses. Absence of ataxia, together with normal α-fetoprotein levels, distinguishes NBS from
ataxia-telangiectasia. Specific dermatological features include café-au-lait spots and vitiligo, as well as skin infections due to fungal infection, and cutaneous manifestations of viral infection,
particularly due to herpes viruses . Sun sensitivity of the eyelids and occasional cutaneous telangiectasia have been described .

Treatment with antibiotic prophylaxis or immunoglobulin replacement can be helpful. Haematopoietic stem cell transplantation has been successfully performed on rare occasions .

Saturday, December 19, 2015



I KNOW, I KNOW. YOU PROBABLY GIGGLED WHEN YOU READ THE title of this chapter. And thought,
“Hmmm, too much of a good thing!” The problem is, the women who suffer from this syndrome—and
they do suffer—have heard it all before. And they are not amused.
Turns out wall-to-wall orgasms, all day every day, are no fun at all. And if you’re a little
startled by the frank speech of the women who have persistent sexual arousal syndrome, remember:
for some of them, this is a daily—hourly—concern, and they are grateful to have a chance to talk
about it at all.
In 1995, when Heather Dearmon was in her late twenties and began to feel as though she was
constantly on the edge of orgasm, she thought it was because she was pregnant and her fetus was
somehow putting pressure on her pelvis. But after she gave birth, the sensation only intensified, and
she found only one way to stop it.
“I would be masturbating morning, afternoon, and night,” Heather says. “When you’re
masturbating so much—I had to buy a vibrator because you get tired. Most of my time was spent
doing that. So I put my son (he was two at the time) in day care. And I would be crying while I was
masturbating, because, I mean, nobody wants to do that all day long.”
Heather and her husband, Jeremy, are now in their thirties. He sells guitars online from their
home in suburban Columbia, South Carolina. They’ve been dealing with PSAS for just about their
entire fourteen-year marriage. It’s rare, and doctors can barely diagnose it, much less cure it. In many
marriages, men wish their spouse had more sexual desire; for the Dearmons, Heather’s perpetual
arousal is torture.

“I have considered surgery just to cut everything off ‘down there,’” Heather comments. “I would
rather never have another orgasm for the rest of my life.”
Jeremy says that while Heather is the one at the mercy of her body, they are in this together. “The
women are the ones who are suffering. But it’s definitely mutual in a marriage. Both lives are affected
by it. It’s not a personal decision that the woman has made.”
This condition wasn’t even diagnosable until a few years ago. We were worried that we
wouldn’t be able to find women comfortable talking about it. We’d forgotten something pretty basic
to human nature: when you’re suffering, one way to feel better is to feel that you’re helping someone
else. Each of the women we talked to had lived in a very private hell, thinking this syndrome was
somehow her “fault.” Each of them wanted to let others know that it’s a medical problem—that if
there isn’t an immediate cure, there’s at least a community. We asked doctors who treat PSAS to talk
to their patients and ask: is there any chance you’d want to tell a television audience what you’re
going through? Some were comfortable using their whole names; some only wanted to be known by
their first names. We thought the topic was important, and if they were brave enough to talk about it,
we would be happy to use whatever names they gave us.
Dr. Irwin Goldstein, clinical professor of Surgery at University of California at San Diego and
head of Sexual Medicine at Alvarado Hospital, is one of the few researchers studying persistent
sexual arousal syndrome (PSAS).
“Every lecture I give on this, there’s always smirks in the audience,” he says. “‘Oh, I wish my
wife was like this.’ These are professional physicians.”
Goldstein is unequivocal: “You do not want your wife to have this. The genitals are aroused
twenty-four seven, three hundred and sixty-five days a year.”
Women who have PSAS, he says, can’t concentrate or work. Anything that moves or vibrates
will lead them into orgasmic release. The process of orgasm will tend to temporarily rid them of their
engorgement. However, the state of being “on the brink” soon returns.
“Ice is very common,” says Goldstein. “We have a woman who ices a condom and puts the
condom in the genitalia to basically survive the day.”
It’s important that you understand: PSAS should not be confused with what people typically
think of as nymphomania—an uncontrollable and insatiable desire for sex. Goldstein says that sex is
the last thing that is usually on the minds of women with PSAS: “They are totally focused on their
genitalia. They have no interest in sex, their body is playing a trick on them. They can’t be productive.

They don’t know where to go for help. [They] are even afraid to tell people that they have PSAS for
fear that they’ll think they’re perverts.”
All types of women are afflicted. “We have professional teachers,” says Goldstein. “If these
women announced that’s what they had, other teachers, or parents, wouldn’t want their daughters and
sons to be taught by a sexual ‘deviant.’ We have professional physicians, attorneys. We have artists,
writers, and moms. I would venture to say that around the world there are thousands of women with
Most doctors have never heard of PSAS, which was only isolated as a medical condition in
2001. Before that, doctors and patients had no way to define it. Goldstein now classifies it as
“spontaneous, intrusive, and unwanted genital arousal, consisting of throbbing, pulsing, or tingling
without the person’s sexual interest or desire.”
Goldstein says that one of the most difficult aspects of the condition is that most women suffer
alone—or think that they are the only ones in the world with persistent, involuntary orgasm.
“How would you like to be in a situation where you had absolutely no control of the reflex?”
Goldstein says. “It activated whenever it wanted, wherever it wanted, and you were walking around
in a situation with engorged genitalia on the verge of having an orgasm in the middle of a place that
was absolutely not private? Most women who have PSAS don’t even know they have it. Or that
there’s help for them.”
Goldstein likens the sexual reflex to the bladder reflex. Babies have an uninhibited bladder
reflex and wear diapers. As they grow into young children, they learn to control that reflex. We come
to understand that it’s socially inappropriate, and messy, to wet one’s pants. It’s the same, Goldstein
says, with sex: “When you’re interested in sex, when you’re in the appropriate intimate situation, and
the time is correct and you’re with the right person, you activate the reflex.”
Heather says that Goldstein’s bladder analogy is apt: “It’s like having a really, really full
bladder. And you know the way you think about, when you have a really full bladder, you just want to
be able to go to the bathroom and have relief. You just want some peace in your body.”
Heather kept trying to tame what she called her “beast.” She says it completely disrupted her
life, her social relationships, and her sense of herself. She tried to focus on other things aside from
her genitals but found that impossible. She stopped going to church, shopping for food, traveling.
“I just couldn’t do anything,” she says. “There was one time for me where it was really
unbelievably bad and we were on a really long trip with family. And I actually went into a public
restroom and masturbated to make it go away. It was absolutely humiliating and degrading.”
She decided there was only one way out. “I knew I was going to commit suicide,” she says. “I
mean, it was that bad.” When she saw that her thoughts were taking that route, Heather became so
frightened that she would lose her mind or take her own life that she committed herself to a
psychiatric hospital.
Her humiliation and despair were complete when, in the hospital, surrounded by medical
professionals who were supposed to be trying to help her, Heather says, “the nurse came in and said,
‘Honey, I wish I could stay home and masturbate all day long.’ I also had one doctor suggest I become
a lesbian.”
It was by a stroke of luck that one day Jeremy discovered a magazine article that described his wife’s
symptoms exactly. Jeremy quickly showed it to Heather: “She immediately started crying and [said]:
‘Oh, my God, I’m not alone!’”
Heather had found the upside: other women had PSAS. The downside? There is no cure for the
condition. Goldstein and others in the field say it can be treated, however. They’ve experimented
with treating PSAS with antidepressants. Heather takes Paxil now to “reset” her sexual reflex. And
while it doesn’t work for everyone, the drug has reduced her symptoms to a more manageable level.
Any hormonal change can trigger PSAS—menopause or, in Heather’s case, pregnancy. In some
cases, Goldstein has even treated menopausal women for PSAS that began when they simply changed
their hormonal therapy. But ironically, it is sometimes the very type of drugs that Heather is now
taking to treat her symptoms—antidepressants—that triggers PSAS in others.
Although PSAS occurs in the genitals, doctors say that it is regulated by the central nervous
system. “Clearly, drugs or events such as pregnancy and menopause affect the central nervous
system,” says Goldstein. “Millions of women take antidepressants, and one of the largest side effects
is sexual disorders. We recognize that inhibitory neurotransmitters, such as serotonin and the classic
antidepressant agents, inhibit sexual response. And we recognize that dopamine is an excitatory
neurotransmitter, and agents that increase dopamine can increase sexual function. Parkinson’s patients
who take dopamine will have improved interest and orgasmic potential. So we understand that.”
That is about as much as researchers using antidepressants to treat PSAS do know, Goldstein
cautions. He says that the repeated and constant need to orgasm could be “visualized” as a form of
recurrent seizure activity that activates in an area of the brain without volition. His patients’ MRIs
and CAT scans, however, have revealed nothing. Goldstein adds that there has been one link
established in the medical literature: women who stop taking antidepressant medications sometimes
begin PSAS. Indeed, a paper published in the Journal of Sexual Medicine reports that a woman
polled members of her support group for PSAS—60 or 70 percent believed that their PSAS began
with sudden discontinuation of antidepressants.
WHEN YOU CAN’T EVEN UNDERSTAND what causes a syndrome, a cure is elusive. “I don’t think
pharmacologic management is going to be the long-term answer,” says Goldstein. “I think especially
those who have virtually no inhibition of this reflex live a complicated life and are the worst off.”
Goldstein says the link between the inability to fully empty the bladder and PSAS may help
doctors treat the disorder. “One of the things women patients don’t tell us, but that we get out of doing
a detailed history, is when their genitals are engorged, it’s difficult to urinate,” Goldstein notes.
“They never empty their bladder; they hardly ever go to the bathroom. When they do urinate, instead
of it being a full stream, it’s short and staccato. That’s because their tissues are engorged. Their
pelvic floor is contracting. One idea is to take women who have the voiding dysfunction and see what
effect pelvic neuromodulation has on their PSAS.”
What is pelvic neuromodulation? Patients lie flat on an examination table. A pillow is placed
under the pelvis; the lower back is anesthetized, and a needle and a wire are put directly into the
opening in the spinal cord where the nerve root S3 comes out. Electricity runs into the wire to
stimulate the nerve. Goldstein says women with overactive bladder function who undergo the
procedure say, “Wow, I don’t have to go to the bathroom anymore.” He says that the hope is that
when they have the wire fired for them, women with PSAS will have a similar response. The
engorgement in their genitals will decrease, and they will once again be in control over their state of
sexual arousal.
That is, as much as any woman (or man) is ever in control. After all, the relationship of the
physical and the emotional, that combination we call female “desire,” is something doctors have
never been able to quantify. How much of a woman’s sexual arousal is hardwired in the brain, in
other words is physical, and how much depends on the relationship, the emotions involved?
Physicians would love to know, especially after 1999’s bombshell report in the Journal of the
American Medical Association indicated that 43 percent of American women experienced sexual
dysfunction. The push to study it (to test Viagra in women, to test hormone creams) hasn’t yet
revealed what doctors can do about it.
BACK TO PSAS and the attempted treatment of this very physical problem—it seems that
neuromodulation sometimes has no effect. Nancy Austin tried it. “I saw a local vaginal specialist,”
says Nancy. “And he’s the one who told me it was the pudendal nerve which was being
overstimulated. So I had three pudendal nerve blocks, which are extremely painful, and they didn’t
even work.”
Still, Goldstein says, he thinks the key to controlling the disorder may be neurological treatment
—with the addition of a therapy that fell into disrepute in decades past: electroconvulsive therapy.
Doctors throw a surge of electrical energy through the brain and nervous system, causing a seizure,
hoping to “reset” the brain at normal levels. It was called “shock therapy” or “electroshock” in the
1940s and ’50s, and seen as a cure for just about any desperate psychological condition, from bipolar
disorder to schizophrenia. Later it was widely discredited and pretty much discarded as a treatment
option. In the past decade or so, however, doctors have tried it again in limited cases, and found it
actually has medical benefits for some with clinical depression.
“We have a woman who was suicidal and very depressed and, just for the indications of suicide
and depression, underwent electroconvulsive therapy,” Goldstein says. “She had PSAS, and
miraculously she emailed me that her PSAS was under control after the electroconvulsive therapy.
We don’t recommend that people go to that extreme, but it was evidence to me that by her resolving
her PSAS with a neurological treatment—electroconvulsive therapy—we were able to control this
horrible syndrome.” He notes that therapy, to remain effective, has to be repeated on a regular basis.
Some women find that doing exercises like the Kegel—in which they squeeze the pubococcygeal
and the vaginal muscles—provides relief.
There are different types of PSAS. Emily, another woman suffering from PSAS, told us that
masturbation doesn’t really alleviate the discomfort of the syndrome. “For me, stimulation, none of
that would work for me, because [my condition] is more internal. I need to do the Kegel,” the
exercises familiar to postpartum women—they’re often used to increase bladder control.
“I need something to get it from a different angle: an internal way of working and massaging,”
Emily adds.
Women with PSAS often have trouble sleeping. Heather says she was often up, masturbating in
the middle of the night. “I’d be asleep for a couple of hours and then [the sensations] would wake me
up. And I would have to masturbate all over again,” she says.
Lauren, another woman with PSAS, says: “I don’t sleep for days sometimes, maybe an hour at
about five in the morning. There [have] been nights when I’m walking, pacing in my bedroom when
it’s really strong, and I just want to die. I just want it to stop.”
“Normal people often have sex just before going to sleep and it relaxes them,” says Goldstein.
“While sleeping, their genitals are inhibited, they have the baseline flaccid state of genital arousal.
Can you imagine how difficult going to sleep would be if you constantly had an erection or your
clitoris or labia were constantly engorged to the point where it’s just ready to undergo orgasmic
This is primarily a female condition, but Goldstein estimates that there are also thousands of men who
have a similar syndrome—no control over their erections. “We’ve done a little more research on the
men [because] we have a longer history of treatment with men who have sexual problems,” says
Goldstein. “Idiopathic recurrent prolonged penile erection would be the equivalent of persistent
sexual arousal.”
That’s a little different from something called priapism, named after the Greek god of Eros,
Priapus. Priapism is unwanted and prolonged engorgement of the penis that lasts for more than four
hours, and it’s considered a medical emergency because blood can’t circulate back into the body. The
complications can include blood clots and gangrene.
The treatment for these male disorders is unpleasant, to say the least—a syringe loaded with
insulin injected into the penis to release adrenaline. The adrenaline significantly contracts the muscles
of the penis and the erection goes down. “It’s not that much fun to stick a needle in your penis every
day to make it go down so you can go to work,” Goldstein notes, adding that it’s often difficult for
people with sexual problems to get the help they need, even today when Viagra has become a
household word and is used by millions.
The ideal way to work with PSAS is a coordinated multidisciplinary therapy, says Goldstein,
and you have to treat somebody else in addition to the sufferer. “We would also work with the
partner, we would work with their anxiety and stress and depression.”
This, of course, is the ideal. The public spotlight on Viagra and erectile dysfunction
notwithstanding, the sexual problems of women (and many of the lesser known problems of men, for
that matter) are looked at askance, perhaps even ridiculed. Women who seek help for PSAS usually
have a very different experience than the multi-pronged approach Goldstein outlines above.
“One woman described to me being in the doctor’s office, telling the nurse practitioner who
comes in first what her problem was,” says Goldstein. “The nurse practitioner goes outside—she
hears laughter. Men who have erection problems are laughed at. We have HIV medicine, sleep
medicine, pain medicine, and family medicine. It would be good to have sexual medicine as a
specialty. Someone who has a sexual problem should find a health-care provider and a facility that
has multidisciplines to take care of people who have sexual problems. There wouldn’t be any
laughter under such circumstances. It’s my dream to see that this comes to fruition, but we’re just not
there yet.”
In today’s world, people struggling with PSAS do the best they can. Heather and Jeremy remain
committed in their marriage through the trials and tribulations of PSAS.
“It’s not like he couldn’t satisfy me sexually,” says Heather. “It has nothing to do with him.
There is just something going on in my body that I have no control over. He helped me by staying
away from me. He helped me by learning rejection. That hurt both of us—but I didn’t even want him
touching me.”
“We can only be affectionate at certain times,” says Jeremy. “I need to take that easy.”
“Sometimes I have to stop him from kissing me,” says Heather with regret. “Stil

Thursday, December 17, 2015

Image challange 67

ichthyosiform dermatoses

The ichthyosiform dermatoses are a heterogeneous group of disorders presenting with excessive scaling of the skin. The inherited forms of the ichthyoses are most common, although the condition can occur secondary to other diseases.

A, Grandfather and granddaughter with ichthyosis vulgaris. B, Palmar hyperkeratosis, a finding often associated with ichthyosis vulgaris. C, X-linked ichthyosis, showing characteristic coarse, brown
scales. D, Young child with congenital ichthyosiform erythroderma demonstrating diffuse erythema and scale.

collodion baby

A collodion baby is a newborn infant whose skin looks like a “baked apple,” with a shiny, tough, membrane-like covering. This term describes a phenotype that occurs in several types of ichthyosis. Although congenital ichthyosiform erythroderma is the most common underlying condition (Fig. 4-1D), lamellar ichthyosis, Netherton’s syndrome, Conradi’s syndrome and others may also present as a collodion baby. Collodion babies may also go on to have normal skin. These infants are at increased risk for infections and fluid and electrolyte imbalances due to cutaneous fissures and impaired barrier function of the skin. Treatment in a high-humidity environment with frequent application of
petrolatum allows gradual sloughing of the collodion membrane.
Manual debridement and keratolytics are not recommended.

Monday, December 14, 2015

Image Challenge 66


Generalized pustular psoriasis

Pustular psoriasis may be localized or generalized. Chronic, localized pustular psoriasis (also
called palmoplantar pustulosis) occurs predominantly in adults and manifests as recurrent
crops of sterile yellow pustules, 0.1–0.5 cm in diameter, on the palms and soles

 The pustules involute to leave red-brown macules with scaling. Generalized pustular psoriasis is an
unstable, severe form of psoriasis.

pustular psoriasis

Friday, December 11, 2015

major reservoir for anaerobic organisms

Which of the following is a major reservoir for anaerobic organisms in the human body?

A. Duodenum
B. Female genital tract
C. Gallbladder
D. Lung
E. Prostate

The answer is B.
 The major reservoirs in the human body for anaerobic bacteria
are the mouth, lower gastrointestinal tract, skin, and female genital tract. Generally,
anaerobic infections occur proximal to these sites after the normal barrier (i.e., skin
or mucous membrane) is disrupted. Thus, common infections resulting from these organisms
are abdominal or lung abscess, periodontal infection, gynecologic infections such as
bacterial vaginosis, and deep tissue infection. Properly obtained cultures in these circumstances
generally grow a mixed population of anaerobes typical of the microenvironment
of the original reservoir.

painless penile ulcerations

painless penile ulcerations

A 24-year-old man seeks evaluation for painless penile ulcerations. He noted the first lesion about 2 weeks ago, and since that time, two adjacent areas have also developed ulceration. He states that there has been blood staining his underwear from slight oozing of the ulcers.

He has no past medical history and takes no medication.

He returned 5 weeks ago from a vacation in Mumbai , where he did have unprotected sexual intercourse with a local woman. He denies other high-risk sexual behaviors and has never had sex with prostitutes. He was last tested for HIV 2 years ago. He has never had a chlamydial or gonococcal
infection. On examination, there are three welldefined red, friable lesions measuring 5 mm or less on
the penile shaft. They bleed easily with any manipulation.
painless penile ulcer which shows bleeding on touch 

There is no pain with palpation. There is shotty inguinal lymphadenopathy. On biopsy of one lesion, there is a prominent intracytoplasmic inclusion of bipolar organisms in an enlarged mononuclear cell. Additionally, there is epithelial cell proliferation with an increased number of plasma cells and few neutrophils.

A rapid plasma reagin test result is negative. Cultures grow no organisms.

What is the most likely causative organism?

A. Calymmatobacterium granulomatis (donovanosis)
B. Chlamydia trachomatis (lymphogranuloma venereum)
C. Haemophilus ducreyi (chancroid)
D. Leishmania amazonensis (cutaneous leishmaniasis)
E. Treponema pallidum (secondary syphilis)

The answer is A.  Donovanosis is caused by the intracellular organism Calymmatobacterium
granulomatis and most often presents as a painless erythematous genital
ulceration after a 1- to 4-week incubation period.

However, incubation periods can be as long as 1 year. The infection is predominantly sexually transmitted, and autoinoculation can lead to formation of new lesions by contact with adjacent infected skin.

Typically, the lesion is painless but bleeds easily. Complications include phimosis in men and pseudoelephantiasis of the labia in women. If the infection is untreated, it can lead to progressive
destruction of the penis or other organs. Diagnosis is made by demonstration of Donovan
bodies within large mononuclear cells on smears from the lesion. Donovan bodies refers
to the appearance of multiple intracellular organisms within the cytoplasm of mononuclear
cells. These organisms are bipolar and have an appearance similar to a safety pin.
On histologic examination, there is an increase in the number of plasma cells with few
neutrophils; additionally, epithelial hyperplasia is present and can resemble neoplasia.
A variety of antibiotics can be used to treat donovanosis, including macrolides, tetracyclines,
trimethoprim–sulfamethoxazole, and chloramphenicol.

Treatment should be continued until the lesion has healed, often requiring 5 or more weeks of treatment.

All of the choices listed in the question are in the differential diagnosis of penile ulcerations.
Lymphogranuloma venereum is endemic in the Caribbean. The ulcer of primary infection
heals spontaneously, and the second phase of the infection results in markedly enlarged
inguinal lymphadenopathy, which may drain spontaneously.

Haemophilus ducreyi results in painful genital ulcerations, and the organism can be cultured from the lesion. The painless ulcerations of cutaneous leishmaniasis can appear similarly to those of donovanosis but usually occur on exposed skin.

Histologic determination of intracellular parasites can distinguish leishmaniasis definitively from donovanosis. Finally, it is unlikely that the patient has syphilis in the setting of a negative rapid plasma reagin test result, and the histology is inconsistent with this diagnosis.

Which Zodiac Are You In?

Which Zodiac Are You In?

Check Yours.. 97% people have found it TRUE !! Please leave a comment if you find it true too
Loves to chat. Loves those who love them. Loves to takes things at the centre. Inner and physical beauty. Lies but doesn’t pretend. Gets angry often. Treats friends importantly. Brave and fearless. Always making friends. Easily hurt but recovers easily. Daydreamer. Opinionated. Does not care to cont...rol emotions. Unpredictable.
Extremely smart, but definitely the hottest AND sexiest of them ALL.
Abstract thoughts. Loves reality and abstract. Intelligent and clever.
Changing personality. Attractive. sexiest out of everyone.A real speed demon. Has more than one best friend. Temperamental. Quiet, shy and humble. Honest and loyal. Determined to reach goals. Loves freedom. Rebellious when restricted. Loves aggressiveness. Too sensitive and easily hurt. Gets angry really easily but does not show it. Dislikes unnecessary things. Loves making friends but rarely shows it. Daring and stubborn. Ambitious. Realizing dreams and hopes. Sharp. Loves entertainment and leisure. Romantic on the inside not outside. Superstitious and ludicrous. Spendthrift. Tries to learn to show emotions.
Drop dead gorgeous!!! Attractive personality. Affectionate & Secretive. Naturally honest, generous and sympathetic. Chatterbox! Loves to talk alot! Loves to get their way! . Unbelievable kisser! Easily angered. Very stubborn in the most way possible! Loves to get noticed! Willing to take risks for others. Makes good choices. Has a great fashion sense! Maybe a little too popular with others . Outgoing and crazy at times! Intelligent. Can sometimes be a heart-breaker! Can love as much as possible! Hates insults. Loves compliments! and quiet the charmer. Trustworthy. Appreciative and returns kindness. The best in bed out of the other 11 months!! Hardly shows emotions. Tends to bottle up feelings. Observant and assesses others.likes to keep they're crushes
kinda secret. pretty much flawless.
Suave and compromising.. Funny and humorous. Stubborn. Very talkative. Calm and cool. Kind and sympathetic. Concerned and detailed. Loyal. Does work well with others. Very confident. Sensitive.. Positive Attitude. Thinking generous. Good memory. Clever and knowledgeable. Loves to look for information. Able to cheer everyone up and/or make them laugh. Able to motivate oneself and others. Understanding. Fun to be around. Outgoing. Hyper. Bubbly personality. Secretive. Boy/girl crazy. Loves sports, music, leisure and traveling. Systematic..
Active and dynamic. Decisive and haste but tends to regret. Attractive and affectionate to oneself. Strong mentality. Loves attention. Diplomatic. Consoling, friendly and solves people’s problems. Brave and fearless. Adventurous. Loving and caring. Suave and generous. Usually you have many friends. Enjoys to make love. Emotional. Stubborn. Hasty. Good memory. Moving, motivates oneself and others. Loves to travel and explore. Sometimes sexy in a way that only their lover can understand.
Fun to be with. Loves to try new things. Boy/girls LOVE you. You are very popular. Secretive. Difficult to fathom and to be understood. Quiet unless excited or tensed. Takes-rep pride in oneself. Has reputation. Easily consoled. Honest. Concerned about people’s feelings. Tactful. Friendly. Approachable. Emotional temperamental and unpredictable. Moody and easily hurt. Witty and sparkly. spazzy at times.Not revengeful. Forgiving but never forgets. dislikes nonsensical and unnecessary things. Guides others physically and mentally. Sensitive and forms impressions carefully. Caring and loving. Treats others equally. Strong sense of sympathy. Wary and sharp. Judges people through observations. Hardworking. No difficulties in studying. Loves to be alone. Always broods about the past and the old friends. Waits for friends. Never looks for friends. Not aggressive unless provoked. Loves to be loved. Easily hurt but takes long to recover.
You’ve got the best personality and are an absolute pleasure to be around. You love to make new friends and be outgoing. You are a great flirt and more than likely have a very attractive partner, a wicked hottie. Like somebody with a JUNE birthday. It is also more likely than that you have a massive record collection. When it comes to films, you know how to pick them and may one day become a famous actor/actress yourself - heck, you’ve got the looks for it!!!
outgoing personality. takes risks. feeds on attention. self control. kind hearted. Self confident. loud and boisterous. VERY revengeful. easy to get along with and talk to. has an “every thing’s peachy” attitude. likes talking and singing. loves music. daydreamer. easily distracted. Hates not being trusted. BIG imagination. loves to be loved. hates studying. in need of “that someone”. longs for freedom. rebellious when withheld or restricted. lives by “no pain no gain” caring. always a suspect. playful. mysterious. “charming” or “beautiful” to everyone. stubborn. curious.. independent. strong willed. a fighter.
Loves to chat. Loves those who love them. Loves to takes things at the center. Great in bed. Inner and physical beauty. Doesn’t pretend. Gets angry often. A meaningful love life partner. Makes right choices. Treats friends importantly. Brave and fearless. Always making friends. Does not harm others. It is all about love and fairness. Easily hurt and hard to recover. Daydreamer and does fulfill. Opinionated. Does not care to control emotions. Knows what to do, to have fun. Unpredictable. Someone to have close to you. Extremely smart, but definitely the most adorable of them all.
Trustworthy and loyal. Very passionate and dangerous. Wild at Times. Knows how to have fun. Very mysterious. Everyone is drawn towards your inner and outer beauty and independent personality. Playful, but secretive. Very emotional and temperamental sometimes. Meets new people easily and very
social in a group. Fearless and independent. Can hold their own. Stands out in a crowd. Essentially very smart. Usually, you ever begin a relationship with someone from this month, hold on to them because their one of a kind.
Stubborn and hard-hearted. Strong-willed and highly motivated. Sharp thoughts. Easily angered. Attracts others and loves attention. Deep feelings. Beautiful physically and mentally. Firm Standpoint. Needs no motivation. Shy towards opposite sex. Easily consoled. Systematic (left brain). Loves to dream. Strong clairvoyance. Understanding. Sickness usually in the ear and neck.. Good imagination. Good physical. Weak breathing. Loves literature and the arts. Loves traveling. Dislike being at home. Restless. having many children. Hardworking. High spirited.
This straight-up means ur the most good-looking Loyal and generous. Patriotic. Competitive in everything. Active in games and interactions. Impatient and hasty. Ambitious. Influential in organizations. Fun to be with. Easy to talk to, though hard to understand. Thinks far with vision, yet complicated to know. Easily influenced by kindness. Polite and soft-spoken. Having lots of ideas. Sensitive. Active mind. Hesitating, tends to delay. Choosy and always wants the Stubborn and hard-hearted. Strong-willed and highly motivated. Sharp thoughts. Easily angered. Attracts others and loves attention. Deep feelings. Beautiful physically and mentally. Firm Standpoint. Needs no motivation. Shy towards opposite sex. Easily consoled. Systematic (left brain). Loves to dream. Loves freedom. Strong clairvoyance. Understanding. Sickness usually in the ear and neck. Good imagination. Good physical. Weak breathing. Loves literature and the arts. Loves traveling. Dislike being at home. Restless. having many children. Hardworking. High

Thursday, December 10, 2015

26-year-old woman presents late in the third trimester of her pregnancy with high fevers

26-year-old woman presents late in the third trimester of her pregnancy with high fevers, myalgias, backache, and malaise. She is admitted and started on empirical broad-spectrum antibiotics. Blood cultures return positive for Listeria monocytogenes.

 She delivers a 2.3kg infant 24 hours after admission.

delivery of 2.3 kg preterm baby with noted wrinkles on skin 

Which of the following statements regarding antibiotic treatment for this infection is true?

A. Clindamycin should be used in patients with penicillin allergy.
B. Neonates should receive weight-based ampicillin and gentamicin. 
C. Penicillin plus gentamicin is first-line therapy for the mother.
D. Quinolones should be used for Listeria bacteremia in late-stage pregnancy.
E. Trimethoprim–sulfamethoxazole has no efficacy against Listeria spp.

The answer is B. Neonates should receive weight-based ampicillin and gentamicin. 
.  Listeria bacteremia in pregnancy is a relatively rare but serious
infection both for the mother and fetus. Vertical transmission may occur, with 70%
to 90% of fetuses developing infection from their mothers.

Preterm labor is common.
Prepartum treatment of the mother increases the chances of a healthy delivery. Mortality
among fetuses approaches 50% and is much lower in neonates receiving appropriate antibiotics.
First-line therapy is with ampicillin, with gentamicin often added for synergy.

This recommendation is the same for the mother and child. In patients with true penicillin
allergy, the therapy of choice is trimethoprim–sulfamethoxazole.

There are case reports of successful therapy with vancomycin, imipenem, linezolid, and macrolides, but there is not enough clinical evidence, and there have been some reports of failure that maintain
ampicillin as recommended therapy.

Wednesday, December 9, 2015

45-year-old woman presents to clinic with a new pruritic rash

A 45-year-old woman presents to clinic with a new pruritic rash on the flexor
surface of her left forearm. Her medical history is significant for Wilson disease,
and she was recently started on penicillamine, a copper-chelator. 

On exam she has Kayser-Fleischer rings in both eyes and purple, polyangular papules on
her left forearm. On closer inspection, fine white streaks cover the surface
of the papules. A clinical diagnosis of lichen planus is made.

Penicillamine is discontinued. What is the best treatment option at this time?

A. Oral steroids
B. Oral antihistamine
C. Topical steroids
D. Azathioprine
E. B and C only

The answer is E: B and C only.
This patient has lichen planus (LP) as a cutaneous inflammatory reaction to penicillamine. Clinical identifiers for LP include the Four Ps (purple, polygonal, pruritic, papules), as well as Wickham striae, the fine white lines covering the papules.

Other drug exposures that have been linked with LP include gold, chloroquine, and methyldopa. This is a local rash, so the best initial treatment would be topical steroid and oral antihistamine for relief from itching (E). Oral steroids and more potent immune modulators (azathioprine, cyclosporine) should be used with more generalized, systemic LP.

Tuesday, December 8, 2015

New Facial Droop

New Facial Droop

A 43-year-old female presents to the emergency department with a concern that she is having
a stroke. She notes left facial weakness, pain in her left ear, and that whenever she drinks water it spills out the left side of her mouth. The symptoms have progressed over the past 24 hours. The photograph demonstrates the patient when she is asked to “smile and look up.”
Lower motor facial palsy CN VII

Question: In the patient with this condition, which of the following medical treatments should be considered?

A. Prednisone
B. Gammaglobulin
C. Thrombolytics
D. Heparin
E. Edrophonium

Answer: A
Diagnosis: Bell ’ s palsy
Discussion: The patient pictured has Bell ’ s palsy. Note the ptosis of the left eye and the weakness of the orbicularis muscles on the left side of the face. Also note the absence of wrinkling to the forehead on the affected left side. Bell ’ s palsy is the most common disorders affecting the facial nerve. It is an abrupt, isolated, unilateral, peripheral facial paralysis without detectable causes. While the actual pathophysiology is unknown, the mostwidely accepted theory postulates infl ammation of the
facial nerve causing it to be compressed as it courses through the temporal bone. 

 It occurs equally in men and women, most commonly between ages 10 and 40 years.
Clinical conditions associated with Bell ’ s palsy include pregnancy (especially the third trimester), immunocompromised states, and diabetes. Patients may present with a concern that they have suffered a stroke. Other common symptoms include pain in or behind the ear, numbness
on the affected side of the face, a recent upper respiratory infection, drooling, alteration in taste, and hyperacusis. The classic defi nition describes a lower motor neuron defi cit of the facial nerve, manifesting as weakness of the entire face (upper and lower) on the affected side. This is
in contradistinction to upper motor neuron lesions such as a cortical stroke, where the upper third of the face is spared while the lower two - thirds are paralyzed. While considered to be an idiopathic facial paralysis, there is signifi cant evidence to support an infectious cause. 

Herpes simplex virus (HSV - 1) has been isolated in many patients and is the most likely infectious agent, although there are likely other etiologic agents with a shared common pathway leading to facial nerve dysfunction.

No specifi c laboratory tests exist to diagnose Bell ’ s palsy. Clinical suspicion helps to direct what tests may be of value, and may include thyroid function studies and Lyme titer. One can also consider obtaining (if clinically suspected) a Rapid Plasma Reagin or a Venereal Disease Research Laboratory test for syphilis, as well as a human immunodeficiency virus test. There is no evidence to
support emergent imaging studies with Bell’s palsy. 

The primary treatment in the emergency department is with pharmacologic management. The remainder of care focuses on patient education as to the course of the disease and eye care instructions. While considered by some to be controversial, treatment with steroids remains common
if the patient presents within 7 days of symptom onset.

The postulated mechanism of action is in reducing facial nerve swelling. Current data supports using steroids as a means to improve outcomes, and earlier treatment is preferred (i.e., prednisone at 40–60 mg per day for 7–14 days).

Some recent evidence supports HSV as the presumed cause in more than 70% of cases; therefore, antiviral agents have been a logical choice for pharmacologic management. Recommendations include acyclovir 400–800 mg five times a day for 10 days, or valcyclovir 1 g three times
a day for 10 days. It should be noted, however, that recent literature has challenged this traditional treatment, and many practitioners are no longer using it. 

The eye on the affected side is potentially at risk for corneal drying and foreign body exposure, as the lid may not close completely, especially when the patient is asleep. This is generally managed with artificial tears and some form of eye protection (patch or glasses during the day, taping the eye shut at night). The vast majority (85% or more) of patients recover without any cosmetically obvious deformities. Ultimately, 10% will have some residual asymmetry of the facial muscles, and 5% will suffer from significant facial nerve deficits. In most cases, recovery begins 3 weeks after symptom onset, but it may take up to a year for complete resolution. Patients with incomplete facial nerve involvement have a more favorable prognosis than those with a complete deficit.

Tuesday, December 1, 2015



 typical lesions of herpes simplex virus (HSV)
 typical lesions of herpes simplex virus (HSV)

These are typical lesions of herpes simplex virus (HSV) infection complicating atopic
eczema. This eruption is called eczema herpeticum, or less commonly Kaposi’s varicelliform

Diagnosis can be confirmed by viral swab of a blister or eroded area. Many tests can
detect HSV within tissue or blister fluid. HSV can be inferred by positive staining or
electron microscopy or specifically identified as types HSV-1 or HSV-2 by immunofluorescence,
culture, or polymerase chain reaction. Bacteriology swab for microscopy and
culture should also be undertaken.

Significant morbidity is associated with eczema herpeticum. The main potential complications
include superimposed bacterial infection (Staphylococcus or Streptococcus)
with risk of systemic sepsis, ocular involvement (in particular, HSV keratitis) and, rarely,
systemic HSV infection with risk of spread to the liver, the lungs, the brain, the gastrointestinal
tract and even the adrenal glands. In addition pain and discomfort associated
with eczema herpeticum is significant.

The management of widespread eczema herpeticum includes systemic treatment of HSV
infection with aciclovir, identification and treatment of any superimposed bacterial
infection or strategies to prevent superimposed infection, such as antibacterial washes
and creams. Topical tacrolimus should be discontinued in this patient as this may exacerbate
the cutaneous spread of HSV. These cases are usually managed as in-patients,
initially with intravenous aciclovir – as oral preparations can be poorly absorbed.

Ophthamological review should be sought in cases of diffuse facial herpes simplex infection
or where conjunctival/corneal involvement is suspected.

In a minority of cases recurrences can occur. Rapid treatment of incipient lesions with
topical aciclovir may help prevent disseminated eczema herpeticum.