Atrial fibrillation is characterized by disorganized electrical activity in the atria leading to irregular heartbeat. Risk factors include increasing age, hypertension, diabetes, obesity, sleep apnea, smoking, and family history. Symptoms include irregular pulse and murmurs. Diagnosis is made through ECG and echocardiogram. Treatment involves rate or rhythm control with medications, catheter ablation, anticoagulation to prevent stroke, and treating any underlying causes. Guidelines from AHA and ESC provide recommendations on management strategies.
LECTURE ON ATRIAL FIBRILLATION TO 9TH TERM MEDICAL STUDENTS REFERENCES: DAVIDSON(2018) HARRISON 20TH ED OF MEDICINE AND 2020 EUROPEAN HEART GUIDELINES ON AF
LECTURE ON ATRIAL FIBRILLATION TO 9TH TERM MEDICAL STUDENTS REFERENCES: DAVIDSON(2018) HARRISON 20TH ED OF MEDICINE AND 2020 EUROPEAN HEART GUIDELINES ON AF
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
Atrial Fibrillation is the most common arrhythmia encountered by a physician. The global prevalence is increasing because of aging population and better detection methods. Prediction of new onset AF is possible. AF is also a lifestyle disease. Lifestyle therapy, rate or rhythm control and stroke risk stratification are are four main pillars of AF management.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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2. Definition
• AF is characterised by disorganised, rapid, and irregular atrial
activation with loss of organized atrial mechanical contraction
and with an irregular ventricular rate that is determined by AV
nodal conduction
3.
4. RISK FACTORS
• INCREASING AGE
• HYPERTENSION
• DIABETES MELLITUS
• MI
• VHD
• HF
• OBESITY
• OBSTRUCTIVE SLEEP APNEA
• CARDIOTHORACIC SURGERY
• SMOKING
• EXERCISE
• ALCOHOL
• HYPERTHYROIDISM
• INCREASED PULSE PRESSURE
• EUROPEAN ANCESTRY
• FAMILY HISTORY
• GENETIC VARIANTS
• ECG- LVH
• 2D ECHO
– LA ENLARGEMENT
– DECREASED LV FRACTIONAL SHORTENING
– INCREASED LV WALL THICKNESS
• BIOMARKERS
– CRP
– BNP
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES 2016
16. Vitals ?
Hemodynamically unstable
Hypotension
Cardiac ischemia
Pulmonary edema
DC cardioversion
Start anticoaguation immediately
and continued for 4weeks
f/u after 4weeks to decide for
long term anticoagulation
New onset AF
DC Cardioversion
150 to 200 J to start with,
may go up to 360J
Highly effective (95 %)
If fails, start Ibutilide infusion
before next shock
17. Vitals ? • <48hrs – cardioversion f/b
3-4weeks anticoagulation
• >48hrs/not known
early cardioversion after
excluding thrombus by TEE
3-4 weeks anticoagulation f/b
cardioversion and anticoagulation
• Electrical cardioversion is more
effective than pharmacologiacal
New onset AF
Hemodynamically stable
AF with FVR
Ventricular Rate control
Cardioversion
19. Ventricular Rate control
What are the drugs ?
How to choose ??
Dose Side effects
Metoprolol 2.5-10mg IV
100-200mg daily oral
Bradycardia, AV block,
lethargy, headache,
upper respiratory tract
symptoms
Carvedilol 3.125-50mg BD
Nevibolol 2.5–10 mg OD
Diltiazem 15-25 mg bolus IV
60-120mg TDS
dizziness, lethargy,
headache, edema
Digoxin 0.0625–0.25 mg OD gastrointestinal
Upset, arrhythmia
Amiodarone 200 mg daily Pulmonary toxicity,
thyroid dysfunction,
corneal deposits
20.
21. Rhythm control
• What are the Drugs
Dose Side effects
Propafenone Oral 150-300 TDS Arrhythmia, blurring
of vision
Flecainide 100-150mg BD Arrhythmia,
confusion
Sotalol 80-160mg BD Arrhythmia
Amiodarone IV -15mg/min x 10min, 1mg/min
x 3hrs, 0.5mg/min up to 24 hrs
Oral- 600 mg in divided
doses for 4 weeks, 400 mg
for 4 weeks, then 200 mg
once daily
Arrhythmia
Lung disease
Corneal deposit
Thyroid disorder
Dronedarone 400mg BD Arrhythmia,
transient rise in Cr.
24. Amiodarone is most effective,
In view of extracardiac adverse effects, should be
kept as last resort in recurrent AF/AF with heart
failure
25. Catheter ablation
Indications-
• symptomatic persistent AF
not responding to AAD
• Can be considered as first line
therapy in young symptomatic AF
considering patient choice, risk, benefit, side effects of AAD
Challenges-
• Arrhythmia substrate is poorly understood, widespread,
variable between patients, progressive
recurrence
29. Oral anticoagulants
VKA
INR monitoring
Drug interaction
Delay in onset and weaning of action
Narrow therapeutic range
NOAC (Non VKA Oral
Anticoagulants)
• Rivaroxaban
• Apixaban
• Edoxaban
• Dabigatran
Usually preferred over VKA
Not recommended in mechanical
heart valve and mod-severe MS
Renal dose modification
High cost
30. Secondary prevention
TIA- start anticoagulation after 1
day
Stroke- start anticoagulation
after 3-12 days considering
severity of stroke
31. Risk of bleeding- HASBLED score
Should be used as cautionary “yellow flag” for more stringent
monitoring with more severe score
32. Left atrial appendage occlusion/exclusion
• In case of contraindication to long term anticoagulation
• Surgical excision or closure by suturing/stapling is successful
only in 40% of cases
• Post op TEE should rule out thrombus before discontinuation
of anticoagulation
• Percutaneous left atrial appendage occlusion device- newer
method (LAAO)
• Non inferior to warfarin
(PROTECT-AF trial)
33. References
• AHA guidelines for AF 2014 and 2019 update
• ESC guideline for AF 2016
• Harrison’s Internal medicine 21st edition
• UpToDate 2022
AHA/ACC/HRS AF GUIDELINES 2014, ESC AF GUIDELINES
2016