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Metabolic syndrome diagnostic criteria

The WHO diagnostic criteria for metabolic syndrome[37] include:

  • Insulin resistance as identified by 1 of the following:
    • Type 2 diabetes
    • Impaired fasting glucose
    • Impaired glucose tolerance
    • Glucose uptake below the lowest quartile for background population under investigation under hyperinsulinemic, euglycemic conditions (in patients with normal fasting glucose levels < 110 mg/dL)
  • Plus any 2 of the following:
    • Antihypertensive medication and/or systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg
    • Plasma triglycerides ≥ 150 mg/dL;
    • HDL cholesterol < 35 mg/dL in men or < 39 mg/dL in women;
    • Body mass index > 30 kg/m2 or waist-hip ratio* > 0.9 in men or > 0.85 in women
    • Urinary albumin excretion rate ≥ 20 mcg/min or albumin/creatinine ratio ≥ 30 mg/g


The American Diabetes Association (ADA) criteria for the diagnosis of diabetes

The American Diabetes Association (ADA) criteria for the diagnosis of diabetes are any of the following: [1]

  • A hemoglobin A1c (HbA1c) level of 6.5% or higher; the test should be performed in a laboratory using a method that is certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assay, or
  • A fasting plasma glucose (FPG) level of 126 mg/dL (7 mmol/L) or higher; fasting is defined as no caloric intake for at least 8 hours, or
  • A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75-g oral glucose tolerance test (OGTT), or
  • A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic symptoms of hyperglycemia (ie, polyuria, polydipsia, polyphagia, weight loss) or hyperglycemic crisis diabetes555

systemic lupus erythematosus (SLE) Classification Criteria

A consensus group of experts on SLE, the SLICC, has proposed revised criteria for SLE , Classification as having SLE by the SLICC criteria requires either that a patient satisfy at least 4 of 17 criteria, including at least 1 of the 11 clinical criteria and one of the six immunologic criteria, or that the patient has biopsy-proven nephritis compatible with SLE in the presence of antinuclear antibodies (ANA) or anti-double-stranded DNA (dsDNA) antibodies. SLICC-Criteria

Anion Gap and its utility in diagnosis

Anion Gap
The anion gap provides an estimation of the unmeasured anions in the plasma and is useful in the setting of arterial blood gas analysis. It is especially useful in helping to differentiate the cause of a metabolic acidosis, as well as following the response to therapy. Its basic premise is based on the fact that electroneutrality must exist in the body, or in other words the net charges of serum anions, which includes albumin, bicarbonate, chloride, organic acids and phosphate must equal the net charges of the serum cations, which includes calcium, magnesium, potassium and sodium.
In clinical practice, the anion gap is calculated using three lab values (Na+, Cl-, and HCO3-).

Anion Gap = Na+ – (Cl- + HCO3-)

[Occasionally, you may see an alternative equation:
Anion Gap = [Na+] + [K+] – [Cl-] – [HCO3-]. This equation is preferred by some nephrologists, because of the wide fluctuations that may occur with potassium in renal disease. ]

Serum sodium represents over 90 percent of the extracellular cations, whereas chloride and bicarbonate represent approximately 85 percent of the extracellular anions. It follows then, that the anion gap in normal conditions will be a positive number since the sum of the serum anions used in the calculation represent a smaller value compared to the serum sodium concentration. The normal value for the anion gap is 12 +/-4.

In order to grasp the utility of this equation, lets assume a patient has developed a lactic acidosis. The addition of an organic acid (anion) will automatically reduce the serum bicarbonate level based on a simple acid – base interaction. When we calculate the anion gap in this patient, we will notice that the anion gap has increased or in other words the unmeasured anions have increased relative to the measured anions. In clinical practice, we usually group the condition of metabolic acidosis into two groups: normal anion gap metabolic acidosis, and elevated anion gap metabolic acidosis.
Over the years, several useful tables have been developed to help differentiate these two conditions. Here are some examples:

Typical causes of an elevated anion gap metabolic acidosis
Diabetic ketoacidosis.
Paraldehyde, phenformin.
Iron, isoniazid, inhalants.
Lactic acidosis.
Ethylene glycol, ethanol (alcoholic ketoacidosis).
Salicylates, solvents, starvation.

Pneumonic: MUDPILES
Other causes of an elevated anion gap: Increased Unmeasured Anions: metabolic acidosis, dehydration, therapy with Na+ salts of unmeasured anions (Na citrate, lactate, acetate), alkalosis. Decreased unmeasured cations: hypocalcemia, hypokalemia, hypomagnesemia.

Typical causes of a normal anion gap metabolic acidosis
Gastrointestinal bicarbonate loss: diarrhea, Pancreatic fistula. Hyperalimentation. Posthypocapnia. Renal tubular acidosis. Ureteroenterostomy. Drugs: ammonium chloride, hydrochloric acid.
Typical causes of a low anion gap
hypoalbuminemia, hypercalcemia, hyperkalemia, hypermagnesemia, lithium toxicity, multiple myeloma.

Important tip: Always consider other factors that may affect the calculated anion gap. A perfect example would be a patient with ethylene glycol toxicity and hypoalbuminemia. In this case, the patient may have a normal anion gap even though toxic levels of ethylene glycol are present.


5 types of doctors you will meet on social media

Twitter is a communication platform, and, therefore, it is a neutral medium. It’s not the medium itself, but how you use the medium that makes Twitter “good” or “bad.” In my five years of being an anonymous and five months of being a named individual on Twitter, I have come to realize that different people use Twitter for different purposes. In general, these are the five people (or doctors) I have met on Twitter. They have enriched my experience on social media and taught me much about life and doctoring.

1. The knowledge distributor. These are the ones who frequently tweet and retweet various information, news, latest studies, guidelines, and opinions. Following a few of these people will add to your knowledge base. They often have tens of thousands of followers, and they usually have tens of thousands of tweets. They are good at disseminating information. Their timeline is full of information. The downside? They read like a newsfeed and therefore often lack the personal and social engagement that is an enjoyable part of Twitter. But they serve their purpose well. I learn lots of new things from them.

2. The court jester. The court jester is the one who entertains, enlightens and yet educates at the same time. They’re the ones who put up a mirror to our faces. They poke fun at important issues, sometimes even taboos, and bring up a very important message. They are often the ones behind the mask who would tell the truth when no one else would. They provide the behind-the-scenes look at the medical industry (or any industry) and challenge the status quo. As you can guess, they’re often anonymous. They’re the ones the lawyers and administrators warn you about. But I see great value in following them. Because they tell the truth behind their masks, I reckon every industry needs some of these, with respect of course. I can think of a few doctors who are anonymous who make a massive impact through their tweets and blogs.

3. The social collaborator. They are fun to hang out with. They are one of the main reasons for joining social media. It is social after all. There are lots of conversations about life. Lots of food photos and baby photos. And cat photos, of course. One must never forget the abundance of cat photos on Twitter. Sometimes, in their eminently sociable space, the line between public and personal lives get crisscrossed. Raw emotions, anger, bitterness and hurts make their way into their tweets. It can be painful to watch. Sometimes downright unprofessional. But I love following them, because at the end of the day, we’re human. I need to always be in touch with the raw and unpredictable nature of human emotions and relationships.

4. The relentless commentator. The devil’s advocate. They seem to have an opinion on and a comment for anything and everything. Some of them good, some of them very critical and negative. They always provide a contrasting view, and they’re happy to let loose with their opinions. You’ll find them debating certain issues with passion and their timeline reads like an angry verbal joust. It’s good to follow them because there are always many sides to any story, and you get to learn from them. However, the line between respectful difference versus discourteous disagreement can be very thin at times. The first rule of Twitter: Be respectful of others.

5. The thought leader. Here’s the one everyone wants to be. The person who leads the world with contemporary ideas and tweets their sophisticated perspective to everyone. Twitter truly adds to their impact and in some immeasurable ways, they are truly changing the world. They are examples of what’s good on Twitter. The synthesis and harnessing of people and expertise. There are not too many of them around, true thought leaders. When you’ve found them, they’re a treasure to follow as they enrich your days with colorful thoughts and perspectives. I’m certain that they would be as amazing in real life as they are on Twitter.

It would be great to follow a few of these different kinds of tweeps to challenge your thinking and enhance your perspective. What about yourself? What kind of a twitter person are you? My guess is that most of us would be a bit of all of them. Who we are on Twitter is probably defined by who we are in real life and what our purposes are in joining social media.

Eric Levi is an otolaryngologist in Australia who blogs at his self-titled site, Dr Eric Levi.  He can be reached on Twitter @DrEricLevi.

Stop saying these 7 shaming words in medicine. Right now.

In medicine, our motto is first do no harm. Words matter. Choose them wisely. Here are 7 words that shame, blame, and injure people who need our help.

1. Don’t say COMMITTED suicide. Committed implies a crime. Committed rape, burglary, murder. Suicide is not a crime; it’s a medical condition that has been taboo for too long. Let’s come out of the dark ages and use proper language to discuss the cause of death. It’s died OF pneumonia, heart attack, stroke, suicide. Say died OF suicide (ordied BY suicide).

2. Don’t say she IS bipolar. People are people first. Some get physical and/or mental health conditions. The health condition is not their identity. She HAS pneumonia, heart disease, depression, not she IS pneumonia, heart disease, depression. Say she HAS bipolar disorder (or she is a person WITH bipolar disorder).

3. Don’t say he IS an addict. As in #2, people are people first. He is not a disease. He is not a behavior. Thus, he is not a substance abuser or an addict. He is a person who may have an addiction or a substance abuse disorder. Say he HAS an addiction.

4. Don’t say patient IS NON-COMPLIANT. Non-compliant blames the patient for not following a plan that she may have not understood or agreed to follow. Maybe she simply did not have money to buy the medication or the recommended treatment. Be precise and accurate with words, especially when placed in a permanent medical record. Don’t blame or shame. Be curious and engaging. Ask, “IS THE TREATMENT WORKING?” 

5. Don’t say PROVIDER. A provider is a person who provides something. How nebulous. In medicine, a provider is an economic term used to lump all the revenue-generators together into one pile (often to see how much more money can be squeezed out of them). It’s a dehumanizing word that lacks precision and, honestly, it’s offensive to the people who have spent so many years of their lives to achieve mastery in their chosen profession. Use proper terminology. Say NURSE PRACTITIONER, MIDWIFE, PHYSICIAN. If you must use a collective term, say HEALTH PROFESSIONALS. Sometimes, I say HEALERS.

6. Don’t say MIDLEVEL. What is that? Maybe it’s when an elevator gets stuck between two floors? Again (see #5) this is a word used by health care administrators to describe revenue generators who are somewhere halfway between a nurse and a doctor (I think). Use proper terminology. Say PHYSICIAN ASSISTANT or NURSE PRACTITIONER.

7. Don’t say BURNOUT. Physician burnout is a term of oppression that blames the doctor for not keeping up with an inhumane schedule (30-hour shifts, 120-hour work weeks) in a toxic workplace that may include hazing, bullying, and no time to eat or take bathroom breaks. Even on their so-called time off, doctors may still be working on chart notes at home in bed on the weekends. Burnout blames the victim and deflects attention from the perpetrator. Speak the truth. Say HUMAN RIGHTS VIOLATION or HUMAN RIGHTS ABUSE. Don’t say burnout, say ABUSE.

Know of any other shaming words that should be lost from our lexicon? Add your comment below.

Medical School Pharmacology: All About Drugs and Pills

What is Medical School Pharmacology?

In pharmacology, you will be learning all about drugs, from how they work (mechanisms of action), to their side effects, to reasons for taking the drugs (indications). Like pathology, this is one of the two most important classes you will be taking in the second year of medical school. Why is pharmacology that important?

Reason #1. This subject is heavily tested on the Step 1 board exam. So if you want to a good score, know pharmacology well.

Reason #2. The things you learn in this course will be very useful when it comes to clinical years (third and fourth years) and after. Patients will be on drugs. Sometimes lots of drugs. And you should have an idea of what the drugs are based on their name. (To be fair, you will most likely carry around a drug reference during your clinical years so there is really no need to know every single thing about all the drugs. But definitely have an idea of what they are, such that heparin is an anti-coagulant and is used as a deep venous thrombosis prophylaxis.)

This course started out with a bang. The sympathetic and parasympathetic drugs were taught by the best teacher I have ever had in UMDNJ. But sadly, he only taught one block. And although pharmacology was overall a well-taught course, it did not quite compare to the way it started.

Pharmacology was taught by many different teachers. And almost all of them were pretty good, at least for second year medical school professors.

My major complaint is how the important drugs (antibiotics, anti-virals, anti-parasitics) were not taught until April, when the school year was almost over and when the board exam was quickly approaching. The reason for the delay in teaching was because clinical medicine took up too much time so the teaching of the important drugs had to be moved back to late in the second year. You can read more about what I think about that in the clinical medicine section.

How to Succeed in Medical School Pharmacology?

What you have to realize is that pharmacology is mostly memorization. There really is not too much to understand. Memorize how the drug works, what it is used for, when you should not use it, and its side effects.

Attending class is not necessary as there is not much to understand. It would be a better use of your time to skip class and just do practice problems.

Towards the end of the second year, I stopped going to pharmacology class. I did not even read the lecture slides because that took up too much of my time. Instead, there were awesome people in my class who created review sheets and sent them out to the whole class. I just studied from the review sheets.

With the extra time from not going to class, I did practice questions. If you can find old exams do them. If you scroll down to the Additional Medical School Pharmacology Resources, you can find an excellent, free online source for practice questions.

By following the advice shown above, I did fairly well in the class; I high passed.

Study Tips

  • skip class
  • study from lecture slide or review sheet
  • do practice problems

Additional Medical School Pharmacology Resources

There were two main additional resources I have used, aside from the lecture slides, to learn pharmacology well. One is a book and the other is a website.


First Aid was as good as gold for learning about pharmacology. I learned pretty much all I know about antibiotics, anti-virals, anti-parasitics from the book. I felt like I knew them cold. I did not have to read through paragraphs and paragraphs to find out what I had to know. Everything was pretty much in chart or list format, so it is quick to go over.
By studying from First Aid, it helps prepare you for the first board exam as well. Make sure you do practice questions instead of just reading First Aid. It will help you solidify your knowledge of the various drugs.

You can read more about my review of First Aid in the medical school bookssection.

Online Resource(s)

The best online resource I have found for pharmacology is the website of Tulane University’s pharmacology department, which is full of quizzes. What makes the quizzes so great is that it explains why a particular answer is right or wrong. It is an excellent tool for learning. I highly recommend it.

Hey, you! Do you want to know how an accountant, without a science background, made it through medical school without any difficulty? Do you want to know how I memorized a sea of information without cracking my skull in half and dumping the books into my brain? No, I did not slave away all night studying in the library either. If you want to know my complete study system, check out The Secret of Studying.

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