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Medicine.Digest, Dhaka (2026)

07/06/2026

Scoring tools in non variceal Upper GI bleeding

03/06/2026

Rome IV vs Rome V IBS criteria, based on latest 2026 updates.

03/06/2026

🧬 EASL Recommendations: HCV Treatment in Transplant Recipients
🎯 General Principles
All HCV-infected transplant recipients should be treated with DAAs
Aim: SVR (cure) → improves graft and patient survival �
Interferon is contraindicated (risk of rejection)
Use interferon-free DAA regimens only
⏱ Timing of Therapy
🫀 Liver Transplant
Before transplant:
If feasible → reduces post-trans recurrence
After transplant:
Treat all patients with recurrent HCV infection
🧠 Other Solid Organs (Kidney, Heart, Lung)
Treat after transplant once stable
💊 Recommended Regimens (EASL 2020 Final Update)
✅ Pangenotypic First-line Options
Sofosbuvir + Velpatasvir (SOF/VEL)
12 weeks
All genotypes
Safe in most transplant recipients
Glecaprevir + Pibrentasvir (GLE/PIB)
12 weeks (preferred in transplant)
All genotypes
Sofosbuvir + Velpatasvir + Voxilaprevir
12 weeks
For DAA-experienced / failure cases
👉 These regimens achieve SVR >95% even post-transplant �
🫀 Organ-Specific Recommendations
🧠 1. Liver Transplant Recipients
Indication: Recurrent HCV infection (universal if viremic)
Regimens:
SOF/VEL (12 weeks)
GLE/PIB (12 weeks)
⚠️ Decompensated graft cirrhosis:
Avoid protease inhibitors (GLE/PIB, VOX)
Use:
SOF/VEL ± Ribavirin
🧂 2. Kidney Transplant Recipients
If eGFR ≥30 ml/min:
Any DAA (including sofosbuvir-based)
If eGFR 95%
Improved:
Graft survival
Liver function
Overall mortality �

01/06/2026

APPROACH TO ACUTE LIVER FAILURE (ALF) — CLINICAL GUIDE

📌 Acute Liver Failure (ALF) is a rapidly progressive syndrome characterized by:

✅ Acute liver injury
✅ Coagulopathy (INR ≥1.5)
✅ Hepatic encephalopathy
✅ No pre-existing cirrhosis

⚠️ It is a medical emergency with high mortality and requires urgent recognition and management.

━━━━━━━━━━━━━━━━━━━━
🚨 STEP 1 — RECOGNIZE ACUTE LIVER FAILURE

Suspect ALF in a patient with:

✅ Jaundice
✅ Altered mental status/confusion
✅ Easy bruising or bleeding
✅ Nausea & vomiting
✅ Right upper quadrant pain
✅ Rapid clinical deterioration

Key diagnostic criteria:

🔹 Evidence of acute liver injury
🔹 INR ≥1.5
🔹 Any degree of hepatic encephalopathy
🔹 Illness duration

31/05/2026

🧠 APPROACH TO PARKINSONISM — CLINICAL GUIDE

📌 Parkinsonism is a clinical syndrome, not a diagnosis.

It is characterized by:

✅ Bradykinesia (mandatory)

PLUS at least one of:

✅ Rest tremor
✅ Rigidity
✅ Postural instability

A systematic approach helps distinguish Parkinson disease (PD) from atypical and secondary causes.

━━━━━━━━━━━━━━━━━━━━

🩺 STEP 1: CONFIRM PARKINSONISM

Look for:

🐢 Bradykinesia

• Slowness of movement
• Decreased amplitude on repetitive movements
• Difficulty initiating movement

💪 Rigidity

• Lead-pipe rigidity • Cogwheel rigidity

🤝 Rest Tremor

• Typically 4–6 Hz • "Pill-rolling" tremor • Improves with action

⚖️ Postural Instability

• Usually appears later in PD • Early falls suggest atypical parkinsonism

📌 Bradykinesia is essential for diagnosis.

━━━━━━━━━━━━━━━━━━━━

🩺 STEP 2: IS IT PARKINSON DISEASE?

Typical Features of PD

✅ Asymmetric onset

✅ Rest tremor present

✅ Gradual progression

✅ Excellent response to levodopa

✅ Hyposmia (loss of smell)

✅ Constipation

✅ REM sleep behavior disorder

✅ Micrographia

✅ Reduced arm swing

━━━━━━━━━━━━━━━━━━━━

🚩 STEP 3: LOOK FOR RED FLAGS (ATYPICAL PARKINSONISM)

Presence of these features should prompt reconsideration of the diagnosis:

❌ Early recurrent falls

❌ Early severe autonomic failure

❌ Early dementia

❌ Vertical gaze palsy

❌ Cerebellar signs

❌ Pyramidal signs

❌ Rapid progression

❌ Symmetric onset

❌ Poor levodopa response

━━━━━━━━━━━━━━━━━━━━

🧩 STEP 4: IDENTIFY THE CAUSE

1️⃣ Parkinson Disease (Most Common)

Features:

✅ Asymmetric symptoms

✅ Rest tremor

✅ Good levodopa response

━━━━━━━━━━━━━━━━━━━━

2️⃣ Drug-Induced Parkinsonism

Common Culprits:

💊 Antipsychotics • Haloperidol • Risperidone

💊 Antiemetics • Metoclopramide • Prochlorperazine

Clues:

✅ Symmetric symptoms

✅ Temporal relation to medication

━━━━━━━━━━━━━━━━━━━━

3️⃣ Vascular Parkinsonism

Clues:

🦵 Predominantly lower-body involvement

🚶 Gait difficulty

🧠 History of stroke

🩻 Multiple vascular lesions on MRI

━━━━━━━━━━━━━━━━━━━━

4️⃣ Multiple System Atrophy (MSA)

Clues:

⚡ Severe autonomic dysfunction

• Orthostatic hypotension • Urinary dysfunction • Erectile dysfunction

⚠️ Poor levodopa response

━━━━━━━━━━━━━━━━━━━━

5️⃣ Progressive Supranuclear Palsy (PSP)

Clues:

👀 Vertical gaze palsy

🚶 Early falls

🧍 Axial rigidity

💬 Dysarthria

━━━━━━━━━━━━━━━━━━━━

6️⃣ Dementia with Lewy Bodies (DLB)

Clues:

🧠 Dementia develops before or within 1 year of motor symptoms

👁️ Visual hallucinations

🔄 Fluctuating cognition

━━━━━━━━━━━━━━━━━━━━

🧪 STEP 5: INVESTIGATIONS

Routine Tests

✅ CBC

✅ Electrolytes

✅ Glucose

✅ Liver function tests

✅ Thyroid function tests

✅ Vitamin B12

Neuroimaging

🩻 MRI Brain if:

• Atypical presentation • Early falls • Rapid progression • Focal neurological signs

Dopamine Transporter Imaging (DaT Scan)

May help when diagnosis is uncertain.

━━━━━━━━━━━━━━━━━━━━

💊 STEP 6: MANAGEMENT

Non-Pharmacological

🏃 Regular exercise

🧘 Balance training

🦵 Physiotherapy

🗣️ Speech therapy

🥗 Nutritional support

━━━━━━━━━━━━━━━━━━━━

Pharmacological

Mild Symptoms

💊 MAO-B inhibitors • Rasagiline • Selegiline

Significant Motor Symptoms

💊 Levodopa/Carbidopa ➡️ Most effective treatment

Younger Patients

💊 Dopamine agonists • Pramipexole • Ropinirole

(Used selectively due to impulse-control and neuropsychiatric adverse effects)

━━━━━━━━━━━━━━━━━━━━

🚨 RED FLAGS REQUIRING SPECIALIST REFERRAL

🔴 Diagnostic uncertainty

🔴 Early falls

🔴 Rapid progression

🔴 Early cognitive decline

🔴 Severe autonomic dysfunction

🔴 Poor response to levodopa

━━━━━━━━━━━━━━━━━━━━

🎯 EXAM PEARL

Parkinsonism =

Bradykinesia + (Rest Tremor and/or Rigidity and/or Postural Instability)

Think Parkinson Disease when:

✅ Asymmetric onset

✅ Rest tremor

✅ Good levodopa response

Think Atypical Parkinsonism when:

❌ Early falls

❌ Early dementia

❌ Autonomic failure

❌ Vertical gaze palsy

❌ Poor levodopa response

━━━━━━━━━━━━━━━━━━━━

📚 Clinical Pearl

"First confirm parkinsonism → identify red flags → distinguish Parkinson disease from atypical or secondary causes → start individualized therapy and rehabilitation."

27/05/2026

APASL 2026 updated Hepatitis B Guidelines

26/05/2026

Wilson disease

26/05/2026

Chronic pancreatitis Management

25/05/2026

Evidence-based algorithm for managing Anti-TB Drug-Induced Hepatitis (ATDH), synthesizing guidelines from major global health organizations like the WHO, EASL, AASLD, and APSAL.

24/05/2026

H.Pylori Treatment Update.

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