|EXPLANATIONS - 2010 "AND EXPLA 100. Answer is D (Compressed air pushed in front of the current): Concise Textbook of Forensic Medicine & Toxicology’ by Sharma 2™ (Elsevier) / 73 Lightening may cause injury by compressed air pushed before the current (not in front of the current). This is called the ‘sledge hammer blow" effect of Lightening as described by Spencer. ‘Spencer’ described four factors in a lightening flash which affect human body and surroundings namely; ‘the direct effect of high voltage current’, ‘effect of expanded and repelled air’, ‘burning by superheated air’ and ‘blow by compressed air pushed before the current (Sledge hammer blow)’ Mechanism of Injury eaused by Lightening Flash ——— [|Factors in tightening flash that cause human injury | [Mechanism of Lightening related death and injury |,as described by Spencer (Fowr factors) as described by Cooper and Andrews (1995) 1, The direct effect of high voliage current 1. Direct strike 2. Burning by super heated air 2. Side Flash |3. Effect of expanded and repelled air 5 3. Step voltage 4. Sledge hammer and blow death by compressed air pushed before the current 7 Taken from ‘Concise Textbook of Forensic medicine & Toxicology’ by Sharma 4, Blunt trauma (Sledge hammer effect) 5, Surface are discharges and touch 101. Answer is B (Section 176 CrPc): Reddy 29"/6; Parikh 6"/1.7; Forensic Medicine by Vij 4/10 ‘Section of Law that concerns with the inquiry by a magistrate into the cause of death (dowry death) is 176 CrPC Death of a woman within seven years of marriage under suspicious circumstances suggests a ‘dowry death’. Due to the peculiar circumstances associated with a dowry death, such deaths should be investigated by a magistrate (Magistrate inquest). Section 176 CrPC concerns with the inquiry by a magistrate into the cause of death “IPC section 304 —B IPC section 498-A ‘Due to the peculiar circumstances associated with dowry death, such deaths should be investigated by a magistrate with a magistrate inquest Magistrate inquest is conducted in certain special circumstances including + Death of a convict in jail Death of a person in police custody Death as a result of police shooting Husband or Relatives willbe tied ‘under section 304B, IPC if'a ‘woman dies due to burns or bodily injury in suspicious circumstances within seven years of marriage and itis shown that just before her death she was subjected to cruelty or harassment by her husband or his relatives in connection with demands for Husband or relatives will be tried under section 498-A, IPC for cruelty which is defined as any willful conduct which drives the ‘woman to commit suicide or grave ‘mental or physical injury to her or harassment with view to coerce her for dowry Exhumation cases dowry (such deaths will be Dowry deaths known as dowry deaths) Section CrPC 174 deals with inguiry | | \{ Imprisonment of not less than | |[ Imprisonment for a term into the cause of death by police or 10 years, which may extend to || || which may extend to 3 years lice inguest life imprisonment 102. Answer is A (Mercury): Reddy 279/486 The patient in question is presenting with characteristic features of chronic mercury potsoning with the classic triad of excessive salivation and gingivitis, tremors and neuropsychiatric changes (disturbed personality and insomnia)eco a Metallic taste in mouth® and a blue black line on gums® as with lead soning may be seen Other Gastroimestinal manifestations include anorexia, ‘sore mouth, loasening of teth and weight loss * Mercuria Lentis® : Discoloration of capsule of the lens of the eye due to deposit ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS -2010 Chronic Mercury Poisoning int Neuropsychiatric changes” ‘© Danbury Tremors + Hatter’s shake / Glass blower's shake Course intentional tremor that affects the hands, arms, tongue and later the legs ‘The most severe form in which patient is unable to dress himself is called concussio- mercuri (Early symptom) (No effect on visual acuity) + Nephritis® : Membranous Glomerulonephritis? , Necrosis of Proximal Convoluted Tubule. + Acrodynia® * Abortion® is common Erethism® Peculiar disturbance of Personality characterized by shyness, irritability, tremors, oss of memory and insomnia. (Common in workers of mirror industry) n of mercury * Minimata disease® is a type of organic mercurial poisoning due to eating of fish poisoned by mercury. 103, Answer is C (Increased BP): Reddy 29/560; Parikh 6"/10.65 Aconite poisoning is characterized by hypotension and not increased BP Tingling, munbness, hypersalivation and chest pain may all be sen in cases of aconite poisoning 875 Contact with any preparation of Aconite produces immediate singling & numbness which extends over the whole body sensation in lips, mouth tongue and pharynx '+ Hypersativation J+ Nausea, vomiting, diarrhea /+ Abdominal pain S eee ee ee + Limbs become weak and the patient is + Hypotension, cardiac unable to stand or walk. Twitching of archythmias and AV ‘muscles & convulsions may occur along block occurs with paraesthesias (initially there is Respiratory paralysis may occur tachycardia but in later J+ Headache, Giddiness and Ataxia stages, bradycardia + Impaired speech (Slurred) ‘occurs due to AV }+ Impaired vision (Vision becomes dim) blockage) ‘Alternate contraction and dilatation of ]+ Chest pain may be pupils (Called hippus)® is seen during present early stages. In later stages pupils remain dilated + ‘Mind usually remains clear till the end. 104. ‘Scopolamine may. ‘* Scopolamine * Sodium Pentathal |= Sodium Amyral + Sodium Seconal i Answer is C (Scopolamine) : Reddy 29"/445; ‘Forensic Medicine’ by Karmakar 3/542 ‘be used for Narcoanalysis.106. Answer is C (Social Mobility): Park 23°/688; PSM by Sunderlal, Adarsh & Pankaj 2/18 Social mobility refers to movement of individuals/families across different socioeconomic levels. mnge over a period of time with attainment of literacy, better ‘occupation and enhanced income. Person/family of low socioeconomic status may move to a higher socioeconomic ‘status or from a higher socioeconomic status to lower socioeconomic status over time. This phenomenon is termed as social mobility. Indian society 1s largely a ‘closed society’ with limited social mobility due to restriction based on other factors like cast ‘or religion. There are other societies known as ‘open class” societies where movement across the social ladder is unrestricted and solely based on achievement and economic status. Open class societies are therefore more progressive ‘where people based on their achievement and ability can go up the ladder without restrictions. In ‘closed class system’ itis difficult to make reforms without meeting resistance of people. ‘Social upliftment refers to encouragement and improvement or betterment of previously disadvantaged sections of the society ‘Social equality is a social state of affairs in which different people have the same status in certain respect such as access to education, health care, social securities etc. Social insurance is a government run insurance programme that offers protection against various economic risks and provides economic assistance to unemployed, elderly or the sick and disabled; within a population, Such programs are funded by taxes or premiums paid by the participants (Participation is often compulsory). Answer is C (Practice): Refer text below Practice (Habit) is associated with emotional valence and is most likely to be influenced by motivation. Practice (Syn. Habit) Practice refers to an established way of doing things It isthe usual way of action and an accustomed act performed without thinking (While the term Habit is used for individual actions, the term Practice is generally used for a set of fixed habits). Practices (Habits) are usually formed as a result of positive emotional valence. Examples of Habit/Practice in the field of health may include washing hands prior to attending patients or eating food. It takes time to establish good and healthy practices (habits) and a strong emotional stimulus is often involved. Motivation is an important tool for bringing about a positive change from harmful practices (habits). The key is to tap into the emotion that stimulates the drive needed and to keep them engaged until they experience the positive emotion of new success anchored to new practice (or habit). An attitude is defined as a relatively enduring organization of beliefs around an object, subject or concept which predisposes one to respond in some preferential manner. They are more or less permanent ways of behaving. Once ‘formed attitudes are extremely difficult to influence or change. Beliefs may be defined as strong, fixed, firm and stable views that are permanent and almost unchanging. These are usually derived from people we respect (parents, grandparents etc.), and are accepted without trying to prove that they are true. Beliefs are held strongly and are extremely difficult to influence or change. ‘Emotional Valence means the intrinsic attractiveness (positive valence) or aversiveness (negative valence) of an event, object, or situation. Ifyou look at the anatomy of a habitipractice, it often starts ou innocent enough and is often something that brings some level of satisfaction. Iti often part of a creative data gathering process where the results give a good feeling. The action and memory ofthis process/result are given an emotional of satisfaction by the brain. The next step, is recreating that feeling of satisfaction by repeating the action. As long as the action keeps generating the feeling, we keep repeating the action. This is implicit ofa subroutine forming in the brain.107. 109. Answer is A (Village): Park 23/449; 20822, 385, 379, 380 ASHA or ‘Accredited Social Health Activist’ are positioned at village level, * Pillage Health Guide Village Health Guide Scheme ‘¢ Anganwadi Worker Integrated Child Development Scheme ~ ICDS '* Local dai Rural Health Scheme '# Accredited Social Health Activist (ASHA) National Rural Health Mission: NRHM As Launched as part of National Rural Health Mission (NRHM) to strengthen primary health care at village level. ‘* ASHA will be a health activist in the community who will create awareness on health, ‘The general norm of selection will be one ASHA for 1000 population. A woman (married/widow/divorced) in the age group of 25-40 years ‘Should have received formal education upto class VII ‘Should have good communication skills and leadership qualities. Answer is A (Janani Suraksha Yojana): Park 23/455 ‘“USY’ stands for ‘Janani Suraksha Yojana’. ‘* “Janani Suraksha Yojana’ is @ 100 percent centrally sponsored scheme offering Maternity benefit ‘+ Itwas launched in 2005 as a modification of the National Maternity Benefit Scheme. Objectives of JSY ‘+ Reducing maternal mortality and infant mortality through encouraging delivery at health institutions. Focusing at institutional care amongst women in below poverty line families. Answer is B (Alma ~ Ata Declaration): Park 23°/857; WHO website; Provision of primary health care was made in the Alma — Ata declaration of 1978 following an international conference at Alma-Ata (USSR). Alma-Ata Declaration (1978) Provision for ‘Primary Health care” LEE Bhore Commitee (1946) Introduced concept of ‘Comprehensive health care’ Shrivastava Committee (1975) Group on Medical Education and support manpower ‘National Health Policy (1983): Commitment to achieve Health for All ‘The Al of 1978 emerged as the major mile stone in the field of public health as it identified primary health care as the Key to the attainment of the goal of “Health for All’. Before Alma-Ata declaration, primary health care was regarded synonymous with ‘basic health services’, ‘first contact care’, “easily accessible care’ etc. ‘Alma- Ata Declaration: Definition of Primary Health Care ‘Primary Health Care’ is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost, the community and country can afford’. Answer is B (Cost effectiveness): Park 23/871 Cost effectiveness is not included amongst the eight essential components of Primary Health Care. 1. Education concerning prevailing health problems and the methods of preventing and controlling them; 2. Promotion of food supply and proper nutrition 3. An adequate supply of safe water and basic sanitation7. Appropriate treatment of common dise 8. Provision of essential drugs. ‘and ‘means’ are taken by the community. Levels of Community Participation: 4. Maternal and child health care, including family planning 5. Immunization against major infectious diseases 6. Prevention and control of locally endemic diseases ‘and injuries; and | J11, Answer is B (Community Participation): Park 23/22 The current trend in health care involves ‘community participation’ and ‘individual self care’. Emphasis has shifted from health care for the people to health care by the people. ‘The current trend is to ‘demedicalize’ health and involve the communities in a meaningful way’ ~ Park “A recent trend in health care is self care’. ~ Park Individual Responsibility ‘Self care" Community Responsibilt ‘Community participation Emphasis has shifted from Health Care for the people to health care by the people. 112. Answer is A (Planning of intervention by community): Park 23/22; WHO Official Websites; |utp:/www.euro.who.int/datalassets/pdf file/0013/101065/E78652,pdf Highest level of community participation lies in community empowerment wherein key decision in planning ‘goals? Levels of community participation are best described in accordance with ‘Arnstein’s ladder of citizen partnership” Has control Organization asks community to identify the problem and make all key - decisions on goals and means. Willing to help community at each step to a, accomplish goals Has delegated authority | Organization identifies and presents a problem to the community. Defines er limits and asks community to make a series of decisions which can be Coated poe) embodied in a plan which it will accept Plans jointly Organizatin presents tentative plan subject to change and open to change (Pannerhip) from those affected. Expects to change plan at leat slightly and perhaps ‘more subsequently Advises Organization presents a plan and invites questions. Prepared to change plan (Placation) only if absolutely necessary. Isconsulted Organization tres to promote a plan. Seck to develop support to facilitate acceptance or give sufficient sanction to plan so that administrative sCorentoaion). compliance ean be expected. Receives information | Organization makes plan and announces it. Community is convened for (laforming) informational purposes. Compliance is expected. None Community told nothing 113. Answer B (Denominator includes still births and abortions): Park 23/557 Denominator for Maternal Mortality Rate is the total number of live births (and not still births & abortions).‘AIPGME EXAMINATION ANSWERS AND EXPLANA Maternal Mortality Rate measures the risk of women dying while pregnant or within 42 days of delivery from a puerperal cause, Totalno.of émale deaths due tocomplications of pregnancy, childbirth or within 42 days of delivery fom "puerperal causes" in an area during a given year Totalno. of livebirthsin thesame area and year MMR = 1000 © The denominator includes total number of live births. ‘© The maternal mortality rate is expressed as rate per 1000 live births. ‘in developed countries, MMR has declined significantly. Because ofthis decline, they use the multiplying factor 100,000 instead of 1000 to avoid fractions in calculating MMR. 114, Answer is A (Still borns and death within 7 days of birth): Park 23°/563 Perinatal mortality includes both late fetal deaths (still births) and early neonatal deaths. Still births /late foetal deaths can be defined as deaths of fetus weighing 1000g at birth or death after 28 weeks of gestation while early ‘neonatal deaths are defined as deaths during first seven days of births. Perinatal Mortality includes both late foetal deaths (still birth) and early neonatal deaths. foetal Death /Still Birth [Barly Neonatal Deaths ‘Death ofa fetus weighing over 1000g at birt, or 4. | Deaths occurring during first seven days from birth, Death ofa fetus after 28 weeks of gestation (equivalent) | WHO Definition for developing countries where vital | Morality in and around infancy records of still birth are not well established 3 Tafant mortality ‘Late fetal deaths (28 weeks gestation and more) Fosvnconsal PMR = Seay neonatal deaths (frst week) none Year 999 jah ive ints in thesame year ‘Neonatal death ‘ate sonal 1 death | WHO definition for developed countries and for Bey international comparisons peut (ote that there is difference in denominator) 4 tage eae rey | PMR=2ver1000gat bith cg, si bina] H : Totalivebirths weighing over 1000g a bin — i 28weeks Birth Tdays — 28days year of gestation 115, Answer is D (Treatment is aimed at more than one disease at a time): Park 23/459, 576; Indian Pediatrics 2007; 44:169-171; MOHFW Official publication IMNCI does not differ from IMCI with regard to focus on treatment of more than one disease at the same time. Both IMCI and the Indian Version IMNCI aim at treating more than one disease at the same time ‘The idea if Integrated management of more than one common disease at the same time is particularly important as ‘many children present with more than one condition atthe same time and the management should involve integrated treatment of the ‘child’ as a whole rather than one illness at a time. Approach to management of one disease ata time is referred to as a ‘vertical disease ~ specific approach’, while an ‘approach to managing multiple diseases in the same child at the same time is referred to as ‘horizontal (integrated) ‘approach’. Both IMNCI and IMC1 involve an integrated and horizontal approach in the management of sick children.116. STION ANSWERS AND EXPLANATIONS - 2010 Both provide the means of detecting more than one problem in a child during the same consultation and managing these problems through an integrated approach. > Verical apprach focuses on aressing one + nterated or Horizont” approach focuses on dressing more han one illness/disease a a time, and providing a illness disease atthe same time and providing an intervention or set of given intervention or set of intervention for interventions for all the identified conditions. the specific (single) condition + This is based on the observation that many children present with more than ‘Examples of vertical programmes include ‘one condition atthe same time with overlapping clinical signs. Integrated Control of Diartheal Diseases (CDD). Acute __ management expects to increase the probsbilty of detecting and treating Respiratory Infection (ARI) programme, all major disease tthe same time thereby reducing the probability that ‘malaria control programme, Nutrition children would receive correct treatment of one disease and die from programmes et, another unrecognized cause + Key integrated approach is the IMCI approach or its Indian version IMNCI. IMNCI strategy (Indian version of IMCI) has been adopted to put extra emphasis on management of ‘neonates (over sick older children), The initiative behind launching an Indian version was the recognition that a large proportion of infant deaths in India were ‘new born’ deaths mostly in the first week (first 7 days) of life. India thus required extra emphasis to save new borns, IMNCI strategy (Indian version) includes the management of 0-7 days neonates, malaria and anemia INCI refers to the Indian version of IMCL + Itisa central pillar of child health intervention unde the RCH IL strategy +The generic IMCI (WHO) guidelines were adapted and the Indian version was named Integrated Management of Neonatal and Childhood Illness (IMNCI). The initiative behind launching an Indian version was the recognition that a large proportion of infant deaths in India were ne orn’ deahs most theft week (rt 7 days) of fe tnd thus required extra emphasis ta save new barns ‘© Incorporation of Early Neonatal care Inclusion of frst seven days of life inthe algorithms (0-7 days age) Reversal of order of raining, with training of heath personnel starting from the young infant (0-2 months) and proceeding 10 the older child (2 months ~ 5 years). ‘© Dedication of 50% of training time on younger infants (0-2 months). The total duration of training time was reduced from I days to 8 days out of which half of the training time was earmarked for management of young infants, (0-2 months), which ‘contributes a lot tothe mortality rate. Incorporating national Guidelines on Malaria, Anemia, Vitamin A supplementation and Immunization schedule Inclusion of home based care of newborns and young infant ‘Skill Based. Answer is B (Leprosy): Park 23/323, 274, 309, 342; ‘Bacterial Infections and Humans’ 3/3 Chemotherapy’ by Finch (Elsevier) 2003/814 Mass Chemoprophylaxis is not recommended for the control of Leprosy in endemic area. ‘Mass chemoprophylaxis/ treatment approach is recommended for Yaws, Fi areas. “A mass treatment approach is used in control of certain diseases viz Yaws, Pinta, Bejel, Trachoma, Filaria and iis and Trachoma in highly endemic ‘malaria’, ~ Park 20°%41 as Hyperendemic areas (>10 percent prevalence) Penicillin Prat 20/257) Mas chenepropitxishreamen recommended or entre population nding cases Mesoendemic ares (5-10 percent prevalence) Tuvenle mass chemoprophylaxisireatment is recommended to all cases and all children under 13 years of age and other obvious contacts is ‘Hyperendemic area / Highly endemic areas z DEC 20236) Mass chemoprophylaxisiireamen is recommended for entire population including caves (Diethyl : irrespective of whether they have microfilaremia ‘carbamazine)117, Answer is B (Tuberculosis): ‘Textbook of Community Medicine’ by Sunderlal, Adarsh and Pankaj 2/419; Textbook 118, ‘Trachoma, | Hyperendemic / Highly endemic area (> 5 percent prevalence) Tetracycline! (Park 20"7271) Mass chemoprophylaxis/treatment is recommended for all children of a community witha Erythromycin prevalence of > 5 percent of severe & moderate trachoma in children under 10 years of age a eae asf sy i 1 Mass chemoprophylaxis isnot recommended for Leprosy Chemoprophylaxis as a measure of leprosy contol has been attempted in several studies however ‘the general applicability of chemoprophlaxis as a means of preventing leprosy and its contol is stil to be determined’ + Chemoprophylaxis has been shown to offer < 60% protection against leprosy and WHO at this time does not 0 recommend any form of chemoprophylaxis to prevent leprosy ee © Chemoprophylaxs in Leprosy may be considered for close household contacts but i is certainly not recommended ee for mass chemoprophylaxis. ps of Public Health and Community Medicine 1" (2009)/1105 No difference in the prevalence of tuberculosis has been demonstrated between rural and urban population in India. Lung cancer, Mental illness and Chronic bronchitis have all been reported to be more common in urban population. ‘Tuberculosis Disease Prevalence: Indian Scenario The only authentic survey on a country wide basis is the National Sample Survey (1955-1958) conducted by the Indian Council of Medical Research (ICMR). This survey revealed no rural-urban difference in the rate of Tuberculosis in India. ‘Rural population suffered equally as urban population from tuberculosis ‘+ Elderly population suffered more than younger ones ‘0.4% (4in 1000) were having active pulmonary tuberculosis disease and were sputum postive. + 1.6% (16 in 1000) were having active and probably ative tuberculosis disease based on radiological evidence or X ray positive. Answer is B (1% ARI corresponds 75 new cases of smear positive TB/100,000 population): Park 23/179 In developing countries (India) every 1% of Annual Rate of Infection (ARI) is said to correspond to 50 new cases (not 75 new cases) of smear positive pulmonary tuberculosis per year for 100,000 population ~ Park 20"/162 Annual Risk of Infection (ARI): Tuberculosis «© ARI represents the Percentage of population that gets newly infected or reinfected with tubercle bacilli over the course of one year. It indicates the annual risk of acquiring tubercular infection in a given community and represents the attacking force of Tuberculosis in that community. * Its believed to be most sensitive epidemiological indicator of TB burden in the community as it expresses the overall impact of various factors affecting the transmission of tubercle bacilli, ic. the load of infectious cases in the community, duration of infectiousness and efficacy of case finding and treatment programme. ‘+ tis often used to study the trend of tuberculosis in a community and to evaluate the efficacy of case finding and treatment umes for control of Tuberculosis, ‘* ARI is most commonly calculated through ‘Tuberculin Surveys’ in children that estimate the incidence of tuberculous infection. The estimated ARI has actually been observed to be the same as incidence of infection when worked out by repeat testing of the same population under Indian conditions ‘© Currently, the average ARI in the country as a whole is estimated to be 1.5% Although the most accurate and recent estimated national ARI value is 1.5, a value of 1.7 % continues to be used 4s a national average for evaluation of several control programmes (Therefore an ARI value of 1.7 % can be ‘accepted as correct for purpose of this question) ‘National annual risk of TB infection (ARD survey conducted between (2000-2003) by National Institute of Tuberculosis, Bangalore and Tuberculosis Research Centre, Chennai derived a National ARI of 1.5% from Zonal estimates in children ‘age group 1-9 years. ARI in different Zones varied from 10-19% This study has provided robust data on the epidemiology of TB in India and will serve as the baseline data for calculating case detection rates in future and the assessment of the long- term epidemiological impact of RNTCP © Ithas been estimated that for every 1% annual risk of tuberculosis infection, there are about 50 new pulmonary ‘Sputum smear positive (NSP) cases per 100,000 population per year. (Ths means that, with the current ARI of 13 there wil be7S new smear postive cases per 100,000 population per year119, AIPGMEE 2010 - 3 120. 121. a EXPLANATIONS - 2010 Answer is C (Transmitted when adult mites feed on hosts): Harrison 17/1064: Park 23/300, 781; Ananthnarayan 7/416 Adult mites are free living in the soil and do not feed on vertebrate hosts, Scrub typhus is transmitted when the larval ‘stage (Chiggers) feed on vertebrate hosts. ‘Scrub Typhus is caused by infection with O.Tsutsugamushi ‘The causative agent of serub typhus is Orienta Tsutsugamushi (Formerly called Rickettsia Tsutsugamushi) Mites act as Reservoirs of infection The true reserwir of infection isthe ‘wombiculid mite” belonging to the genus “Leptotrombidium™ The infection is maintained in nature trans-ovarally from one generation of mite to the next. ‘The larval stage of mite serves both, as a reservoir and as a vector for infecting humans ‘Transmission occurs when tage (not adult) of mites, feed on vertebrate hosts The parasite is transmitted via the bite of mites inthe larval stage only Adult stages ofthe mite are free living in the soil and do not feed on vertebrate hosts.OF the various stages of development, only larval stage (Chiggers) is infectious to ‘humans and other mammals, because this stage alone requires a tissue fluid meal for development Scrub typhus occurs when infected larval mites (Chiggers) encounter humans as a source of tissue fluid meal through a skin bite, (The larval stage mite feeds on the serum of warm blooded animals only once during its cycle of development) Mite ————+ Rats /Mice ————+ Mite. ———+ Rats Mice (larval stage/chiggers) (larvae/chiggers) Humans for scrub typhus ‘Tetracycline is the drug of choice. With proper therapy the mortality is nil’ - Park Answer is A (Drug Resistance in host): ‘Emergency Infections’ by Scheld, Craig, Hughes (Volume 2) I" (1998)/20; Cecil Textbook of Medicine (Chapter 366) Section XXIII; ‘British Medical Bulletin’ on Malarial Vaccines (http://omb. Oxfordjournals.org/egi/reprint/61/1/59) Drug resistance in host has no role in the resurgence of malaria. Major factors responsible for resirgence include izectiide eistance in vctr onl ug rexsance nthe parasite and not ‘* Increasing Insecticide Resistance in the vector © Increasing and often multiple drug resistance in the parasite ‘* Increasing instability in populations with large & unpredictable population migration = Urbanization and formation of new slums = Movement of reference population = Travel by non-immune expartties Increasing atmospheric carbon accumulation increasing the climatic suitability for transmission. Deteriorating public health system in endemic countries Diversion of funds/Inadequate funding for malaria control Several environmental factors including cultivated land, irrigation intensity, cropping intensity, rainfall, ‘construction and repair of canals & roads, shallow earth wells, ponds flooded fields etc. Antigenic variability is a major challenge in development of an effective malarial vaccine and hence may indirectly ‘contribute to resurgence. Answer is C (60 days): Park 23/204; WHO and IAP Official Publications Every case of Acute Flaccid Paralysis must be observed for a minimum of 60 days to check for residual paralysis, ‘Followup of all cases of AFP should be arranged at 60 days to check for residual paralyses’ — Park 204/182 AEP Surveillance ‘© Acute flaccid paralysis (AFP) is defined as any case of new onset of hypotonic weakness in a child aged less than 15 years of age. ‘© Acute Flaccid paralysis(AFP) is an important presentation of poliomyelitis122, 123. Poliomyelitis snot the only couse Jor AFP. Other possible causes of AFP include Gullian-Barré syndrome, iransverse ‘meliis, traumatic neuritis, viral infections caused by other enteroviruses, toxins and tumours. Inthe early stages of the disease polio may be difficult to differentiate from other forms of AFP. Therefor, to ensure that no case of polio goes undetected surveillance has been extended 0 all cases of AFP. ‘The objective of AFP surveillance is to detect poliovirus wherever it may still circulate. It is also the key to detecting re-importation of poliovirus into polio-free areas AFP surveillance is essential for the eradication initiative, The quality of AFP surveillance forms the basis ofthe documentation needed for certification of polio-free status n fore (1) Surveillance should be sensitive enough to detect at least one case of non-polio AFP for every 100,000 children under-15 years of age. (2) Atleast two stool samples, taken 24 hours apart and within 14 days of the onset of illness should be collected from at least 80% of these cases. (3) Detailed investigation of suspected polio cases should include clinical, epidemiological and virological examination as well as a follow-up examination for residual paralysis after 60 days. (4) A final classification of the case should be made by a committee of experts on the basis of these examinations. 1, A non-Polio AFP rate of 1/100,000 should be adopted as bench mark for adequacy of AFP surveillance "2. Active community based surveillance should be considered. +3. State and Centre level Technical Expert Commitice be set up to oversee the process of AFP surveillance. 4. Scope of AFP surveillance should be expanded progressively to include contact surveys and environmental surveys. . 5. The LAP and IMA should be actively involved in the process of AFP surveillance. 16. Special effors must be made to ensure coverage of shildren between the age of 12 and 15 who may not be reporting tothe Department of Pediatrics of various reporting unis 7. Inta-typing differentiation of all eases of AFP must be proved to clinicians reporting the index cases. & Clinicians must follow all cases of AFP for minimum of 60 days to check for residual paralysis and correlate wth virus intra-ing. 9. very case or AFP-which do not have wild vrs, mus be sruinized by echnical expert commitee Answer is D (Filariasis) : Park 23°/873 India aims to eliminate Filariasis by 2015 according to ‘The National Health Policy’, 2002 ‘National Health Policy 2002 goals to be achieved by 2015: | Eradicate Polio and Yaws aaa Eliminate Leprosy 2005 Reduce morality by $0% on account of TB, Malaria and other 2010 vector and water borne diseases ‘Reduce prevalence of blindness to0.5% = i: ‘Reduce IMR to 30/100 and MMR to 100/lakh 2010 Answer is B (High Risk screening): Source: Manual on Diabetic Retinopathy published by National Programme for Control of Blindness (NPCB);Vision 2020 India Programme huip://www.vision2020india.org/dr_manual pdf The current screening strategy for prevention of blindness due to Diabetic Retinopathy involves screening of all high risk diabetic cases in the general population Prevention of blindness due to diabetic retinopathy requires information on the prevalence of diabetic retinopathy in the general population, identifving the high risk groups amongst diabetics, using cost effective screening methods such as ophthalmoscopy or fundus photography. ‘+ Toreach the needy (diabetics) people where they are ‘+ To involve the community (voluntary organisations and primary care physicians) in Diabetic Retinopathy awareness creation. To screen the high risk diabetic cases in the general population for Diabetic Ret hy.124. '* Create awareness about diabetes mellitus in the community. The early symptoms of polydipsia and polyuria need to be highlighted. People with a family history of diabetes need to undergo blood glucose testing. © Create awareness about ocular complications of diabetes mellitus in the population. © The General physicians, who are the frst contact for the vast majority of the population, need to be oriented. The importance of early detection needs to be emphasised. The relationship between uncontrolled diabetes and retinal changes requires special mention (High Risk). © The primary care physicians need to be supported by a strong referral system. The diabeties referred by them (High Risk) should be properly examined by the ophthalmologists. Laser facilities have to be available and accessible ‘The role of primary care physicians in ensuring regular follow-up of the diabetics is of paramount importance. Answer is D (95% confidence interval will cover 2 standard errors around the mean): ‘Essentials of Biostatistics’ by Sullivan (2008)/94, 95; ‘Applied Biostatistics for Health Sciences" by Rossi Wiley) 2009/232, 233 95% confidence limit /interval covers 1.96 (approx 2.S.E.) around the mean. 95% confidence limit /interval covers 1.96 (approx 2 S.E.) around the mean © Confidence inte ‘an estimate that gives the range within which one can expect the true population parameter to be located ‘* The bounds of the confidence interval are termed as confidence limits © 95% confidence limivinterval is the most conventionally used statistic in scientific literature and correspond 10 a ‘p’ value of 0.05 which is used to atribute ‘significance’ The confidence interval generally extends on either side of the estimate by multiples of the standard error. ‘Confidence Interval/Limit = Sample mean 2 Margin of Error Value for varies with confidence ‘where, Margin of Error = Z x Standard Error e rn as i Confidence Interval/Limit = Sample mean + Z x Standard Error For 90% CI: Z = 1.645 where, Standard Error = For 99% Cl: Z = 2.576 Thus, at a confidence level of 95%, the 95% confidence Interval/Limit will cover about 2 Standard Errors around the mean. N Higher confidence levels have larger Z values (see above) which translate into larger margins of error (Z x standard error) and wider confidence Interval. The margin of error is larger when confidence interval/imit/level is higher. f Date, Ne size a nce level on Confidence Interv: [Confidence Level Variability of the Sample] [__ ‘Sample size | Larger confidence levels Less variability in the sample Larger the sample size narrower will Jarger will be the confidence narrower will be the confidence be the confidence interval interval interval | 4 Information will become less Information will be more precise Information will be more precise precise ‘Margin of error will be larger “Margin of error will be smaller For a constant confidence level (eg 95%) the width of the confidence interval depends essentiall tors i.e. ‘the sample size and variability in data. The information can be made more precise and margin or error can be reduced by increasing the sample size (as there is no control over variation in data). = ‘Complete Idiot's Guide to Statistics" by Donnelly 1" (2004)/190, 191; ‘Medical Statistics at a Glance’ 3/34, 35125. Answer is B (Normal Distribution): Research Methods & Statistics 3"/126; Statistics for Behavioural Sciences 8"/174; Statistics in Plain English 2"/33, 34 A ‘score’ is simply the number of standard deviations a score of interest lies from the mean of a normal distribution. The ‘z-score’ is also termed as the ‘standard normal score’. raw value (observed ‘AZ’ score can be defined as a statistical tool to represent how many standard devi score) is above or below the mean of a normal distribution. «A sstandard ‘2’ score can be calculated if you know the mean and standard deviation of a score following normal distribution by a simple mathematical formula. z score (standard score) = Given Score - Mean Score Standard deviation zscore = 22H where x= Given score; z= Mean; o= Standard deviation 7 * Because normal distribution is measured with respect o the standard deviation, one can use the 'z score’ to convert ‘raw data into their associated probabilities of occurances with reference to the mean © The calculation of a standard ‘z score’ allows researchers to understand where an individual score falls in relation to ‘other scores, and allows better comparison of individual scores in the distribution. The process of converting individual scores into ‘z’ scores is called ‘standardization’. 126. Answer is A (33%): Park 23°/139 The sensitivity of this new test is calculated as 33%. Parameters for calculation of sensitivity for the new test ‘* Total number of True positives = 40 ‘© Total number of False positives = 80-40 = 40 ‘© Total number of True Negatives = 9840 ‘+ Total number of False Negatives = 9920 - 9840 = 80 Calculation for Sensitivity Sensitivity is the ability ofa test to identify correctly all those who have the disease (True positives) Sensitivity can be calculated as percentage by the following formula True Positives Sensiti ooo aes 100 'VIY = “Trae Positives( False Negatives - Sensitivity = —42— 5.100 =33% 400180 The sensitivity of the new testis thus 33 percent. Calculations for Specificity ‘Specificity is defined as the ability ofa test to identify correctly those who do not have the disease (True Negatives) Specificity can be calculated as a percentage by the following formula 9840 9840040 The specificity of the new testis thus 99.59 percent. Specificity of this test 100=99.59 127. Answer is A (133): Park 23/60 The incidence of tuberculosis in the above population is 133 per 10 lakh population (10,00,000).| AIPGMEE 2010 - EXPLANATIONS | 128, 129. Parameters for calculation of incidence Total number of new cases during the time period = 22 Total population during the described time period = 1,65000 ‘Incidence is defined as the number of new cases occurring in a defined population during a specified period of time. ‘The Incidence is normally calculated per 1000 population by the following formula, Incidence __ Number of New cases duringa given timeperiod 499 (Per 1000) “Total population (at risk) during that period ‘This gives us the incidence of Tuberculosis per 1000 population. ‘To calculate the incidence of Tuberculosis per 10,00,000 we shall use a multiplier of 10,00,000 in place of 1000. Incidence | _ Number of New eases duringa given timeperiod , 19.49 999 (Per 10,00,000) ‘Total population (at risk) during that period nn Incidence 22 __.19,00,000= 133 (Per 10,00,000) ~ 1,68, The Incidence of tuberculosis in the above population per 10,00,000 is therefore = 133. Answer is B (Can be used by personnel of United Natinas Organization (UNO)): Source: Red cross official websites; http://chapters.redcross.org/ok/oke/OKCBombingRecovery/emblem. htm; ‘http://w. indianredcross.org/emblam. htm Red cross emblem cannot be used by personnel of United Nations Organizatin (UNO). nntains a vertical and horizontal bar of equal length The Red Cross emblem consists ofa red cross on a white background. The length of the vertical and horizontal bars of the cross is equal The Red Cross Emblem came into existence in Geneva The Red Cross organization and its red cross symbol were established at the Geneva Convention (Geneva) in 1864. ‘The Red Cross emblem cannot be used by all UNO members.(Who can use the red cross emblem) The Geneva Conventions limit the use of the Red Cross emblem and the words "Red Cross" and "Geneva Cross" in ‘both war and peacetime to identify the following ‘facilities for the care of the wounded and sick members of the military; © armed forces medical personnel and equipment; ‘© military chaplains; ‘© the International Committee of the Red Cross; * the League of the Red Cross Societies (The International Federation of the Red Cross; and the various national Red Cross societies, including the Indian Red Cross) Misuse of the Red Cross Emblem is punishable by Indian Law ‘To ensure universal respect for the protective nature of the Red Cross symbol, the Geneva Conventions of adhering governments to prohibit the unauthorized use of the name and emblem in both war and peacetime. ‘Each government that is a party to the treaties enacts laws to protect the Red Cross name and emblem within its boundaries. ‘© The Indian law regulating the use of the emblem is called the Geneva Conventions Act and it became a law in 1960. According to Section 12 and Section 13 (under Chapter IV) of the Act, the misuse of the emblem is a punishable offence. Answer is A (DDT): Park 23/783; Goldfrank's Toxicological Emergencies 8/1529 DDT is not a synthetic Pyrethroid compound.DDT (Dichloro-Diphenyl-Trichloroethane) is a synthetic insecticide belonging to the class of organochlorine compounds. Synthetic Pyrethroids are synthetic derivatives of naturally occurring pyrethrins which are taken from pyrethrum, the oleo-resin extract of dried chrysanthemum flowers. © Synthetic Pyrethroids are available as commercial insecticides. + Newly developed synthetic pyrethroids have been observed to be more effective (upto 10 times) than naturally ‘occurring pyrethrins, * Synthetic pyrethroids may offer a number of advantages over natural Pyrethrins = More potent + Photostable = Longer Acting + Less expensive ‘© Synthetic pyrethyroids have evolved through several generations, making them more potent, more photostable and longer acting with each generation. [No more potent or Tncrease Potency and | | Increased Poteney, [photostable than but not much more Photostable Photostable & feature pyrethroids | | shotostable | |(@rotostabitity is hallmark) | | longer lasting. + “Allehrin” [+ Prothrin + Fenvaterate + Cyfluthrin + Proparthrin J= Permethrin + permethrin J+ Phenothrin + Deltamethrin ‘+ Resmethrin + Cyalothrin + Dimethrin + Bifenthrin i + Tetramethrin + Imiprothrin ' ‘MEDICINE 130, Answer is A (Iron Deficiency Anemia): Wintrobe's Hematology 12/795 4; Harrison's Manual of Oncology (2007)/ 138 Microcytic Hypochronic Anemia (4MCV, 4MCH) with an elevated Red cell distribution width (Nomal RDW < 14.5%) suggests a diagnosis of Iron deficiency anemia ‘Among microcytic anemias, the red cell distribution width (RDW) distinguishes between iron deficiency anemia (TRDW) and thalassemia (Normal RDW)'- Harrison's Manual of Oncology (2007)/138 ‘RDWis particularly useful in characterizing microcytic anemia, allowing to distinguish between uncomplicated ir deficiency anemia (High RDW, Normal to Low MCV) and uncomplicated heterozygous thalassemia (Normal RDW, Low MCV)’ Wintrobe's Hematology 12"/-4 Red Cel Distribution Width (RDW) and Evaluation of Anemia SES ‘+ Red cell distribution width is a measure of anisocytosis and quantitates cellular volume heterogeneity + An increased RDW suggests a state of increased anisocytosis as seen early in iron deficiency anemia, and is especially useful in charachterizing microcytic anemias. ‘+ MCV and RDW, together can be used to classify various types of anemias ‘+ The normal RDW is less than 14.5% + Anisocytosis is an early and prominent finding in iron deficiency, often detectable before significant microcytosis, hypochromia or anemia is apparent and hence RDW tends to be elevated early in iron deficiency anemia, In contrast, anisocytosis tends to be mild or absent in Thalassemia, + An increased RDW tends to be 90% to 100% sensitive for iron deficiency anemia (Although itis only 50% to 70% specific).sTIONS - 2010 MCV 1 RDW RDW ] RDW co, c 1 c 1 Nommal | [High Normal Wigh Normal Tigh © Thalassemia + Tron © Hereditary + Combined deficiency Acquired» Folate Bz Trait Deficiency spherocytosis 6 Anemic deficiency + Thalassemia Anemia + Anemia of Hemoglobinopathy * Autoimmune Minor + Thalasremia chronic disease (sickle cll) Hemolysis + Anemiaof = Major ‘+ Non Anemic © Sideroblstic anemia chronic lhemoglobinopa + Early iron deficiency disease thy anemia ‘Note: Aithough a high RDW may be seen in Thalasemia major, the clinical presentation of this patient with haemoglobin of 70 atthe age of 16 years is not consistent with a diagnosis of Thalassemia major. 131. Answer is A (Presence of JAK-2 mutation): Wintrobe’s Clinical Hematoogy 12"/ 1991, 1992; The Merck Manual: chapter 141/ section 11; William's Hematology 7/790; Harrison's 19" 673 Presence of JAK-2 mutation is a Major criterion for diagnosis of polycythemia Vera according to the proposed new WHO criteria for the diagnosis of Polycythemia Vera. Low Erythropoetin levels, Thrombocytosis and increased LAP scores are all minor criteria for diagnosis of polycythemia Vera, JAK-2 is a member of an evolutionarily well conserved, non receptor {yr0 cognate tyrosine kinase for the erythropoietin receptors + A mutation in the tyrosine kinase JAK-2 appears to have a central role in the pathogenesis of PV by causing constitutive activation of the kinase + The presence of JAK -2 mutation thus allows for the exclusion of a reactive erythrocytosis. The 2001 WHO criteria for diagnosis of PV were however developed prior tothe discovery of this important mutation and hence revised WHO criteria have been developed that include presence of JAK-2 mutation as a major criterion for diagnosis of PV N “Tough prsence of JAK:2 mucin isa major crterion for agate of PY. he pretence of JAK-2 mation lon mot ‘diagnostic of PV. JAK-2 mutations may also be seen in other myeloproliferative disorders such as Essential Thrombocytosis (ET) and Chronic Idiopathic Myelofibrosis (CIMF). ‘Various major and minor criteria used for the diagnosis of polycythemia vera in various classification systems (WHO criteria (revised and old / Polyeythemia vera study group criteria ‘kinase family and serves as the '* JAK2 V617F mutation ‘© Thrombocytosis (> 400 x10) ‘© Hemoglobin >18.5 g/l. inmen, 16.5 g/dl in « Lewcoeytosis (WBC > 12 x 10°) women + Increased leukocyte alkaline phosphatase (LAP > 100U) ‘© Increased red blood cell mass + Increased serum B 2/binders © Splenomegaly (B12 > 900 pam; unbound B12 binding capacity > 2200 pg/mi) © Clonal genetic abnormality other than Low serum erythroprotein levels. Philadelphia chromosome or BCR/ABL in marrow © Panmyelosis with prominent erythoid and megakaryocytic ‘© Endogenous erythroid colony formation in vitro ‘hyperplasia on bone marrow biopsy. ‘© Normal arterial 02 saturation (92%) Revised WHO criteria (Proposed) for the diagnosis of Polyevthemia vera [ERE¥ised WHO criteria (Proposed forthe diagnosis of Polyeythemia vera.) Major Criteria ¢ Hemoglobin > 18.5 gl in men,> 16. pl in women or evidenced on increased red cell volume Presence of JAK2 mutation ‘Minor Criteria # Hypercellulr bone marrow biopsy wih panmyeloss with prominent erythroid, granlocyic, and megakaryocytic hyperplasia ¢ Low serum erythropoietin level {Endogenous erytrod colony formation in vito.132. ‘AIPGME EXAMINATION ANSWERS AND EXPLANATIONS - 2010 © { ‘Red blood cell mas > 25% above mean normal predicted value, or Hb > 18.5 g/dl in men, 16.5 g/l in women, ‘© Splenomegaly on palpation ‘© Clonal genetic abnormality other than Philadelphia chromosome or BCR/ABL. in marrow. ‘Endogenous erythroid colony formation in vitro Minor Criteria + Thromboeytosis > 400 10%. © WBC> 12 « 10°. fecal throne tens ends hypeplta on bone mao boyy © Low serum erythropoietin levels. Answer is A (Autosomal dominant inheritance): Harrison's 19" /664; API Textbook of Medicine 8°/828, 829; Wintrobe's Hematology 12"/1173, 1174 Fanconi’s anemia is primarily inherited as an autosomal recessive disorder and not as an autosomal dominant disorder Fanconi’s At inherited as an Autosomal Recessive /X- Linked disord There are currently 13 known subtypes of fanconi's Anemia. With the exception of one subtype (Subtype B) which is X- linked recessive, all other subtypes of Fanconi’s anemia follow an autosomal recessive pattern of inheritance. ~ Wintrobe’s Hematology Fanconi’s Anemia is associated with Pancytopenia and Hypocellular Bone Marrow “Once pancytopenia develops, the bone marrow is hypocellular’ — API Textbook of medicine Fanconi’s anemia is associated with progressive bone marrow failure? Pancytopenia® develops insidiously and presents in most cases between the ages of 5 and 10 years Bone marrow may show normal cellularity initially, however with progressive bone marrow failure pancytopenia develops and the bone marrow becomes hypoceltular. i's an ally normochronie, normocytic or macrocytic ‘Fanconi’s anemia is a form of inherited hypoproliferative aplastic anemia. “The hypoproliferative anemias are normochromic, normocytic or macrocytic and are charachterized by a low reticulocyte count’ ~ Harrison's 174663 ‘Fanconi’ Anemia | Normochromic- Normocytic > Normochromic ~ Macro Fanconi’s Anemia is associated ral congenital disorders Fanconi's Anemia manifests as congenital developmental anomalies, progressive pancytopenia and an increased risk of ‘malignancy Harrison's 171665 ‘© Autosomal Recessive? Inherited chromosomal instability syndrome? © Positive Family Histor? ‘+ The diagnosis of FA is based on the demonstration of increased chromosomal breakage inthe presence of DNA cros- linking agents such as mitomycin C (MMC) or Diepoxybutane (DEB) ‘Congenital Anomalies + Skeletal ‘Fanconi’s anemia isa Short stature ‘Premalignant state Radial ray anomalies (thumbs, hands, radi) + Patents with FA ae at Hip and spine anomalies increased rik of (May be Normochromic + Skin developing Myelodyspasia Macroeytc) yperpigmentaton (café au lit spots) (MDS) ordcute Mieloid Hypopigmentation Leukemia AML , }+ Genitourinary J+ Paints with FA are at Renal structural anomalies increased risk of ypogonadism developing solid eumours? + Craniofacial particularly squammous Microepbaly cell carcinoma ofthe head Ophthalmic anomalies (microphthalmia, epicanthal ols) and neck, ski, GIT & Otic anomalies (estemal and mile ear anomalies, deafness) | | genital act + Gassntestinal malfomations Esophageal atresia or tacheoesophagea! fistula Iperforate anus Candie alfommatons135. Answer is B (Direct Coomb’s test): Harrison's 19° /138e4; Clinical Hematology & Oncology’ (Church Livingstone) 2003/4338 A direct Coomb’s test or direct antiglobulin test (DAT) on post-transfusion blood sample from patient should be done 10 detect antibodies directed against the transfused red blood cells A positive direct antiglobulin test (positive direct Coomb's test) that develops during a red blood cell transfusion or immediately following a transfusion strongly suggests that the patient has an antibody directed against the transfused red cells. This is consistent with a hemolytic transfusion reaction, Blood bank ted action for every suspected case of mismatched blood transfusion + Every suspected case of mismatched blood transfusion should be reported tothe blood bank. * —Acorrectly labeled post transfusion blood sample and any untransfused blood should be sent back to the blood. ‘bank for analysis. + At the blood bank the post transfusion specimen should be tested for evidence of hemolysis (serum haptaglobin, LDH, hemoglobin and bilirubin) and a direct antiglobulin test (direct Coomb’s test) should be performed. A positive direct Coomb's test confirms the presence of antibodies / complement directed against the transfused RBCs and confirms a hemolytic transfusion reaction. Answer is C (Mu heavy chain disease): Harrison's 174/707, Refer text below Bence Jones Proteinuria may be seen in ‘Mu’ heavy chain disease due to excretion of kappa light chains in urine Bence Jones proteins (free light chains) are characteristically absent in alpha and gamma light chain diseases but ‘ay be seen in mu heavy chain disease. The presence of Bence Jones light chains in urine particularly kappa light chains is a distinguishing feature to identify mu heavy chain disease. “The only features that may distinguish patients with mu heavy chain disease are the presence of vacuoles in malignant Iymphocytes and excretion of kappa light chains in urine’ — Harrison ‘Bence Jones Protein is absent in alpha and gamma light chain diseases but has been reported in mu heavy chain disease’ - Clinical Biochemistry (Churchill Livingstone) I" (1995) /502 ‘Although mu chain is not found in the urine of patients with mu heavy chain disease, Bence Jones light chains are commonly (50%) found in urine particularly kappa chains. The latter while still produced in mu heavy chain disease are not assimilated because of heavy chain gene aberrancies leading to truncated forms - Pathology and Genetics of Tumors of Haemopoetic and Lymphoid Tissue (WHO classification of Tumors) 201/155 ‘Heavy chain diseases are rare ymphoplasmacytic malignancies that exclusively produce monoclonal heavy ‘chains and no light chains. Heavy chains diseases are classified as Alpha, Gamma and Mu heavy chain diseases based on the defect in synthesis of alpha, gamma or mu heavy chains, respectively (Delta and Epsilon ‘heavy chain diseases are extremely rare and have not been reported). The diagnosis of heavy chain diseases depends on demonstration of the specific monoclonal heavy chain in serum or tissues by electrophoresis, immunoelectrophoresis or immunofixation techniques Answer is C (Gamma Globulins): Harrison's 19" /1859; Primer on kidney diseases 4"/256; clinical Laboratory medicine 6/350 Bence Jones proteins are composed of light chains of the type found in normal or pathological gamma globulins ‘= Bence Jones Proteins are abnormal proteins charachteristically found in the urine of patients with multiple myeloma (and other paraprotenemias) + These proteins have been shown to be composed of only of immunoglobulin light chains (Normal complete immunoglobulins comprise of both heavy chains and light chains and hence Bence one Proteins are believed to represent Incompete Immunoglobulins + Since Bence Jones proteins respresent light chains found in normal immunoglobulins, these proteins also belong to the category of gamma globulins like normal immunoglobulins ‘+ In multiple myelma (and some other paraproteinemisa) there is excessive production of light chains over heavy chains. These light chains are eliminated in urine as Bence Jones proteins136. + Bence ones proteins can be detected in urine by a charachteristic heat coagulabiltytes!® due to their very distinctive chemical character. “These proteins (Bence Jones / Light chains) precipitate when heated to between 40°C and 60°C, dissoive an boiling (90°C- 100°C) and repreciptate when cooled back to between 40°C and 60°C” ‘This unusual heat solubility property of Bence Jones protein is used as a screening test for the presence of urinary Bence Jones proteins. Answer is A (Occurs due to rapid filling of the ventricles during atrial systole ): ‘urs: 124270,271:Harrison 19° 1448 Third heart sound occurs at the end of early rapid filling phase of the ventricle but not at the time of atrial systole. The heart sound associated with ventricular filling during atrial systole is the fourth heart sound (S4) Fourth Heart sound occurs in association with an effective atrial contraction® (It is presumably caused by in-rush of blood into the ventricles when the atria contracts and hence it is also called the ‘Atrial Heart Sound’) D “A pathological S3 is often present in large left to right shunts due to high flow across the mitral valve with VSD or Patent ductus arteriosus and with high flow across the tricuspid valve with ASD. The presence of this sound in these conditions does not imply congestive heart failure, and such patients may maintain normal myocardial contractility for years after the S3 is detected’- ‘Hurst: The Heart’ 11/271 Pathologi may be associated with Cons cardi Constrictive pericarditis is characterixstically associated with pericardial knock which is a distinct form of third heart sound (S,) “Pericardial knock is S, that occurs earlier (0.1 t0 0.12 after A2) and is higher pitched than normal. Its presence depends upon the restrictive effects of the adherent pericardium which halts diastolic filing abruptly’ — Harrison Children © Ventricular: (LVERVE) I ‘© High cardiac output cand lie - pressure = Fever? ~ Idiopathic dilated cardiomyopathy = Pregnancy® + Ischemic heart disease = Thyrotoxicosis? > Valvular hear disease = AV fistulas? = Congenital hear disease ~ Systemic and pulmonary hypertensi = Hyperkinetic states ~ Anemia = Thyrotoxicosis, - Arteriovenous fistula = Atrioventricular valve incompetence - Left to right shunts (VSD, PDA and ASD) + Restrictive myocardial or pericardial dis + Constricive pericarditis (pericardial knock) «+ Restrictive cardiomyopathy + Hypertrophic cardiomyopathy.137. 138. 139. Answer is A (Myxomatous degeneration): Harrison's 19" /1546 Presence of midsystolic click in an asymptomatic female suggests a diagnosis of Mitral Valve Prolapse (MVP). MVP is associated with myxomatous degeneration of the mitral valves. ‘Ruptured chordae tendinae may be seen in MVP but these patients are usually symptomatic with significant Regurgitation (MR). © Also known as Barlow's syndrome’ ® or 'Billowing mitral valve'® or ‘Floppy valve syndrome’ ®. © Itis most common in females & ‘Most commonty seen in young adults (15 to $0 years) (MVP may be seen inolder individuals > $0 yrs. When seen in older individuals most patients are males and MR is more ‘common and severe and requires surgical treatment) ‘© Inheritance in familial cass is autosomal dominant ® '¢ The clinical course is usually benign © Patients are > usually asymptomatic ® = may present with non specific ches pain, dyspnea. fatigue and palpitations. @ Auscultatory findings ae characteristic and most important: = Characteristic mid systolic ® or late systolic non ejection ® clicks © which may be multiple ® = _ Late systole ejection murmur (Often but not always) |= Accentuation of inings by Valsata and standing. ® = Diminished by squating and isometric exercises. Diagnosis : = Investigation of choice is echocardiography. © = ECG in most cases is normal. © ‘Myxomatous degeneration of mitral valve (less commonly in tricuspid and aortic valves) Elongated, Redudant or Ruptured chordae tendinae (patients with ruptured chordac tendinae are usually symptomatic with significant regurgitation ~ MR) Dysfunction and ischemia of papillary muscles Progressive dilatation and calcification of mitral valve annulus = Transient ischemic atack ® + Infective endocarditis ® Answer is B (Cardiac Tamponade): Harrison's 19" /1573 Beck’s triad is a feature of cardiac tamponade. Answer is B (Myocardial Reperfusion): ACS Essentials ‘2010° 3" (2009) /132, Harrisons 19 /1609; Hurstl2th/ 1014; Braunwald 84/-864-865-895-896-1278; ‘Problem Oriented Approach in Interventional Cardiology’ by Colombo (2007)/109 Accelerated Idioventricular Rhythm is the most common arrhythmia seen after successful reperfusion of a blocked coronary vessel and hence is often also termed as a ‘reperfusion rhythm or reperfusion arrhythmia’. ‘Arrhythmias are common afier reperfusion. The most common post reperfusion arrhythmia is Accelerated Idioventricular Rhythm (AIVR)" - Problem Oriented Approach in Interventional Cardiology “Accelerated Idioventricular Rhythm is considered a reperfusion rhythm as itis ofien seen immediately after a successful reperfusion’ - Washington manual of ertical care /116 Myocardial Reperfusion, Dilated cardiomyopathy, Digitalis matoxication and Myocarditis may all produce Accelerated Idioventricular Rhythms (AIVR), however AIVR is the most common arrhythmia seen after myocardial Reperfusion, AIVR is also the most charachteristic aryhythmia seen after reperfusion has begun and hence Myocardial ‘Reperfusion is the single best answer of choice.140, ‘APGMEEXAMINATION ANSWERS ANDEXPLANATIONS—2010. + 883 i ‘ AIVR is an automatic rhythm originating within the ventricle with rates between 40 to 120 beats / min + AIVR is believed to be caused by abnormal automaticity and is considered to be a brief self limiting archythmia, that does not usually require any specific treatment unless the patient is symptomatic + The onset of this arrhythmia is gradual (non paroxysmal) and occurs when the rate of ventricular tachycardia exceeds the sinus rate because of sinus slowing or SA / AV block + AIVRis a characteristic feature of myocardial reperfusion, and when it occurs in the setting of myocardial infarction and coronary reperfusion itis also called ‘Reperfusion Arrhythmia’ or ‘Reperfusion Rhythm’. “Icommonly occurs at the moment of reperfusion of an occluded coronaryartery’'~ Braunwald + AIVR can be seen in the absence of any structural heart disease but is usually seen in patients who have an sale structure heart disease. + Acute coronary syndromes “Arrhythmias are common after + Acute Myocardial Infarction Reperfusion. The most common post © Myocardial Reperfusion reperfusion arrhythmia is Accelerated ‘+ Cardiomyopathy Idioventricular Rhythm’ = Dilated cardiomyopathy = Interventional cardiology = Ischemic cardiomyopathy + Mocardis (Acute myocarditis) Rheumatic / Congenital Heart Disease + Digitalis Intoxication (477 spat he most common arrythmio seen ler Digi tcp) + Cocaine Intoxication = Rate, 4010 120 beats/min “Although the ventricular rate in AIVR by definition can ‘+ Wide QRS complex (> 0.12 sec) (Bizzare) ‘be upto 120 beats / min, this is usualy less than = Fusion beats 100/min. A rate between 100 to 120 may represent VI = Capture beats ‘and hence should be treated as VT. oi AV dissociation + Rhythm: Regular tis ust ired (No treatment in Asymptomati Since the ventricular rate usually ranges the same as sinus rhythm, hemodynamic compromise does not occur Also the ‘condition is self limiting and transient and does not appear to affect the patients clinical course or prognosis. % Hence no specific treatment is required although these patients should be observed 4 ‘+ Atropine or Atrial pacing may suppress the ATVR by simply increasing the sinus rate ++ Lidocaine may be used for suppressive therapy Answer is A (Intracranial malignancy): Braunwald’s 8/1237 Malignant Intracranial Neoplasm is an absolute contraindication for Thrombolysis (Streptokinase / Urokinase). Contraindications and Cautions for Fibrinolytic Use in STEMI ‘Any prior intracranial hemorthage ‘+ History of chronic severe poorly controlled hypertension ‘+ Known structural cerebral vascular lesion + Severe uncontrolled hypertension on presentation (eg, arteriovenous malformation) (SBP > 180 Hg or DBP > 110 Hg) + Known malignant intracranial neoplasm « History of prior ischemic stroke > 3 months, dementia, or known. (primary or metastatic) intracranial pathology not covered in contraindiations + Ischemic stroke within 3 months + Traumatic or prolonged (+10 min) CPR or major surgery (<3 wk) (Except acute inschemic stroke within 3 hr.) ‘+ Recent (within 2-4 week) internal bleeding + Suspected aortic dissection ‘+ Non compressible vascular punctures + Active bleeding dathesis (excluding menses) ‘+ For streptokinase/anistrepase: prior exposure (>5 days ago) or «Significant closed head or facial trauma within 3 mo, prior allergic reaction to these agents «Pregnancy * Active peptic uleer ‘© Current use of anticoagulants (the higher the INR, the higher the risk of bleeding)|AND EXPLANATIONS - 2010 141, Answer is D (Metabolic Acidosis): Texthelow, Oxford Hand book of Medicine 5/684 The patient in question has a primary respiratory alkalosis with compensatory metabolic acidosis (VHCO ; ). Since the question specifically asks about the compensatory mechanism, metabolic acidosis isthe single best answer The confusing part in the question is the fact that the primary acid base disorder has not been asked. On the | contrary the examiner wants to know the compensatory mechanism involved.The compensatory mechanism here is metabolic acidosis which isthe single best answer of choice. a ee Yet Metabolic Acidosis(4COy) ‘Respiratory Allalosis (4PCO;) IRE i se emo DN mi Reprton Acidosis (TPCO) ‘Metabolic Alkalosis (THCOS ) THCO§ reabsorption by kidneys With pH of 7.5 (> 7.45) alkalosis is confirmed as the primary disorder. ‘Since change in PCO; (Jed) is in keeping with the change in pH (alkalosis) the primary disorder is Respiratory (Respiratory Alkalosis) ‘Since change in (JHCO;} is opposite with the pH (There is alkalosis and HCO; is reduced), the metabolic component (HCO;) is compensatory. The patient therefore has primary Respiratory Alkalosis with Compensatory Metabolic Acidosis ‘Remember = Acidosis is inkeeping with Decreased HCO, and Raised pCO? ‘Remember : Alkalosis is inkeeping with Increased HCO, and Decreased pCO? ‘change in HCO; is termed as metabolic (Normal HCO3. 30 meq Biking withthe pl (either is cides and COs decreased he pb {is opposite with the pH (if there is acidosis and HCO; is inereased or normal) s compensatory metabolic. 1 change is CO; is termed as respiratory (Normal pCO2 = 38 ~ 45 mm#lg) is in keeping with the pl (iin acidosis COs is raised) the problem is termed respiratory is opposite with the pH (if there is acidosis and CO; is decreased or normal) compensatory respiratory. ‘STEP 1: What is the pH. j= 14S 18 Final deduction Because Respiratory component is primary and metabolic component is compensatory the acid base disorder in this patient is Primary Respiratory Alkalosis with compensatory Metabolic Acidosis. The compensatory mechanism in this ‘patent therefore is Metabolic Acidosis. 142. Answer is B (Primary pulmonary hypertension): Harrison 19 /1655; ‘Spiral manual of pulmonary medicine (Lippincott's)' 6/444143. Reduced exercise tolerance and drop in oxygen saturation from 92% to 86% on exercise with a normal FVC and FEV /FVC is consistent with a diagnosis of Primary Pulmonary Hypertension. The most common symptom attributable to pulmonary hypertension is exertional dyspnea and reduced exercise capacity — Harrison Primary pulmonary hypertension is neither a restrictive nor obstructive pulmonary disease, and hence spirometry results are essentially normal with both FVC and FEVI / FVC ratio > 80% of predicted | Obstructive disease ST TTI Restrictive disease ‘FEVI /FVC is characterstically < 80% of predicted FVC is characterstically < 80% of predicted Interstitial lung disease does not present with a normal FVC Interstitial lung disease should present with a restrictive pattern on ‘pulmonary function tests” with a reduced FVC to values less than 80% of predicted. A forced vital capacity of 90% (FVC = 90%) is normal and hence makes a diagnosis of interstitial lung disease unlikely Primary Alveolar Hypoventilation does not present with dyspnea and exercise intolerance Patients with primary pulmonary hypoventilation may have normal pulmonary function test with a normal FEV1 and normal FVC/FEV1. However, dyspnea or shortness of breath is remarkably absent or extremely uncommon despite severe arterial blood gas derangements presumably because of impaired chemoreceptor and ventilatory drive. Also ‘exacerbation of hypoxemia or drop in oxygen saturation is characteristically seen during sleep and not on exercise. ‘Despite severe arterial blood gas derangements is uncommon’ — Harrison “Dyspnea is remarkably absent" - Spiral Manual of pulmonary Medicine (Lippincott) 6/444 Anxiety disorder: Hyperventilation does not present with exercise intolerance Patients with Anxiety associated Hyperventilation may also present with normal spirometry results with a normal FVC and FEVI/FVC. Dyspnea may also be a presenting feature; however such patients do not show features of exercise intolerance. “Patients with psychogenic hyperventilation typically complain of dyspnea at rest, but not during mild exercise. During mild or moderate exercise their hyperventilation tends to disappear’ - Harrison Answer is B (Pneumocystis carinii Pneumonia): Harrison's 19" /1358; Textbook of Pulmonary Medicines by Behera 2/413; Fishman’s Pulmonary Diseases & Disorders #"/ 1108, 2353, 2356, 2358 Presence of prolonged fever, weight loss and bilateral reticulonodular infiltrates in a person at increased risk of HIV (Long distance Truck drivers in India) suggests a diagnosis of Atypical pneumonia due to pneumocystis carinii infection. Pneumocystic pneumonia is one of the most common AIDS — defining opportunistic infections and should be considered in any patient presenting with atypical pneumonia who is at increased risk of acquiring HIV (eg Professional sex workers, Homosexuals men, Intravenous drug users and Long distance Truck drivers in India) Presentation of patient is consistant with diagnosis of Pneumocystic Pneumonia ‘+ Pneumocystis carini is an important cause of Atypical Pneumonia in immunocompromised states especially AIDS ‘+ Pheumocystic Pneumonia is recognized as one of the most common AIDS defining oppostunistic infections. ‘A diagnosis of Pneumocystic pneumonia should be considered in any patient presenting with sings /symptoms of Appical Pneumonia in a patient who is at increased risk of acquiring HIV infection’ ‘Long Distance Truck Drivers in India are considered a high risk population for contracting the HIV virus (Nag. 1996) ‘© Charachteristic clinical manifestations include si icant weight loss, fever, non productive cough and dysponea, | Profound weight loss (~ 100%) «Fever (~ 97%) |= Dyspnea (~ 63%) = |» Non Productive cough (~ 75%) | + The most charachteristic finding an chest X-Ray is bilateral diffuse infiltrates beginning in the perihilar region although various atypical manifestations including nodular lesions, cavitatory lesions etc have also been reported The classic finding om chest radiography consists of bilateral diffaseinfilirates beginning in the periilar region ‘However no radiographic pattern is pathognomic for pneumacystic pneumonia.EXPLANATIONS - 2010 ‘Tuberculosis is unlikely as it usually present with productive cough and the patient in question has a non productive dry cough. Also, bilateral diffuse reticulonodular infiltrates are not charachteristic of Tuberculosis. Interstitial Lung Diseases is unlikely as these disorders usually do not present with fever and weight loss, although bilateral reticulonodular infiltrates may be seen on chest x-Ray. ‘With most interstitial lung diseases, constitutional symptoms like fevers, chills and weight loss are absent’ = Fishman’s Pulmonary Diseases #%/1108 ial Pneumonias (Type of ILD) may present with the a similar clinical and radiological | Lung Diseases (< 1%), ‘Notes Patients with Acute Interst Picture, but these disorders constitute only a small fraction of Interstt Pneumococeal Pneumonia is unlikely as it presents with ypical features of pnewmonia including productive cough and ‘consolidation on chest x-rays. The patient in question has a form of atypical pneumonia. AIR Space Penumonia (Typical Pneumonia) _ -Exudate in alveoli ic. consolidation ‘No exudate, alveoli are ait filled Le. no ri “ngiltate is primarily of neutrophils (PMN) are extracellular are intracellular ‘Chest X-ray shows alveolar pattern ‘Chest X-ray shows interstitial pattem Answer is B (Staphylococcal pneumonia): Robbins 7/ed 383, 385; Oxford Hand book of Medicine 6"/ed 174; Differential Diagnosis is conventional Radiology 3"4/ 574 Cavitatory lesions and /or Pneumatoceles are characteristic of staphylococcal pneumonias Primary Pulmonary tuberculosis does not usually present with cavitatory lesions. Cavitatory lesions are a feature of ost-primary or secondary tuberculosis Cavitation is characteristic of Staphylococcal Pneumonia Cavitation suggests aggressive bacterial infections by bacteria such as Staph.aureus (and gram negative bacilli) 5 Covi? ipgle o Natipl k waled cvs) (maybe Batra + Preumatoceles” (Thin walled cystic spaces that may contain ar fluid levels) Pleural Ejfusion®/ Empyema® with or without bronchopleural fistulas (Pyopneumothorax) Abscess formation® ‘Bacterial Preumonas associated with cavitation: Review + Staphylococcus? + Kleibsella® + Pseudomonas? Anaerobic bacteria imary Tuberculosis The chorachteristic lesion in primary Tuberculosis is the fibrocasseous Ghon focus which presents as an area of consolidation on Radiographs Cavitation is rare in primary tuberculosis (although it may be seen) ‘Cavitation may be seen in primary tuberculosis but it isa rare feature’ ~ Robbins ‘Tuberculous Primary Infection 4 Gaciidsion en (CGrnfias) ‘Consolidation (Ghon focus: Unilateral solitary area of tuberculous consolidation under the pleura in the lower par of upper lobe) a \ Hilar Lymphadenopathy + Heals by flbrosis or calcification Interstitial lun 1 Pheumoconios h eavitatory lesions