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Saturday, October 13, 2018

Friday, June 8, 2018

QUIT SMOKING QUOTES.

I hate you. Because you smoke. QUIT SMOKING.
I hate you. Because you smoke. QUIT SMOKING.
I may not matter to you. you matter to many. Quit Smoking.
I may not matter to you BUT you matter to many. SO Please Quit Smoking. 

Be an Inspiration for Life not for death. Smoking Kills.
Be an Inspiration for Life not for death. Smoking Kills. 

I cant help you, if you cant Help Yourself. Smoking kills. I care for you. Take care of yourself.
I cant help you, if you cant Help Yourself. Smoking kills. I care for you. Take care of yourself.
Think now. Before it is too late. SMOKING KILLS.
Think now. Before it is too late. SMOKING KILLS.

Saturday, May 12, 2018

Neurogenic Bladder: UMN vs LMN: Physiology made easy.

Basic Physiology of Micturition

Micturition is a spinal reflex modulated by CNS.
Neural control of micturition.
Source: http://physiologyplus.com/micturition-reflex-steps/

The pre-frontal cortex is responsible for the cognitive control of the micturition which analyses the signals from bladder and conveys signals according to void or not to void depending on the social setting.

The higher control of micturition is mediated by pontine micturition centre (PMC) from where nerve fibre arise and travel along the lateral columns bilaterally. It is the mechanical control of micturition. It coordinates the function of baldder and sphincter.

The Sympathetic fibres are thoracolumbar (T10-L2) outflow of nerve fibres and terminate in the hypogastric ganglion.

The Parasympathetic fibres are sacral (S2-S4) outflow.

The voluntary control over the external urtheral spincter is mediated by somatic fibres of Pudendal nerve. 
Intact Spinal cord is essential for normal micturition as it serves as a intermediate relay between the brain and the sacral center of micturition. Sacral reflex center is the primitive voiding center which is responsible for infants diaper need, since there is a continuous cycle of bladder filling and voiding. The higher mental function gradually enhances in kids as they are growing and accordingly they are trained to use toilet with their enhanced higher mental function.


Sympathetic
ParaSympathetic
Bladder (Detrusor Muscle)
Relaxation
Contraction
Bladder Neck
Contarction
Relaxation

The bladder wall is relaxed and the neck constricted with sympathetic stimulation which allows for retention of urine. The parasympathetic stimulation causes bladder wall to contract and sphincter to relax easing the voiding of urine.

Analogy of Skeletal Muscle contraction and Bladder
Character  UMN Type  LMN Type   Spastic Bladder Flaccid Bladder Tone  Hypertonic (Increased) Hypotonic (Decreased) Volume  Normal or small Large Detrussor contraction  Involuntary intermittent contractions (Overactiity) Absent  (Underactivity)  Pressure  High  Low Incontinence type Urge  Overflow  Symptom Urgency and Frequency  nocturia  Leaking of urine  Dribbling of urine  Erectile edysfunction in men  Retention  Incomplete bladder voiding  (Detrussor-Sphincter Dyssynergia) Uncoordinated bladder contraction and sphincter relaxation Detrusor Aflexia  Conditions  Spinal Cord damage above T12 Cerebrovascular accidents   Spinal cord damage at S2-S4 Peripheral Nerve injury  Acute Stage of spinal cord injury  Cauda Equina, Conus medullaris
LMN vs UMN Lesion : Effect on Bladder

There is a lot of analogy between skeletal muscle contraction and bladder.

In the absence of higher control, overdistension of bladder causes reflex detrusor contraction. Similar to     the muscle stretch reflex mediated by spindle fibre in skeletal muscle.

The upper motor neuron lesion of the brain and the spinal cord causes features similar to that of the UMN lesion of in the muscle characterized by Spastic bladder/ Hypertonic baldder.This is due to the reflex detrusor contraction. There is increased tone of the detrusor muscle. However, the bladder contracts with overdistension, the sphincter does not relax causing bladder sphincter dyssyenrgia. This causes urgency and urge incontinence. The volume of residual urine in the bladder is increased which causes high risk for UTI and chronic renal failure due to obstructive uropathy. The site of the lesion is generally the Spinal cord or pons or higher. There is no gross dilatation of the bladder due to the reflex contraction which results in low volume high pressure inside the bladder.




The lower motor neuron lesion to the fibre supplying bladder causes overflow incontinence. This occurs because bladder is overdistended however the reflex detrusor contraction doesnot comes into play. So what happens is the bladder leaks over time when it is beyond its holding capacity without the detrusor muscle contracting. The bladder is grossly dilated resulting in high vomule and low ressure inside the bladder.This can be described as flaccid or atonic bladder similar to flaccid paralysis of muscles in LMN lesion.The patient cannot initiate the micturition. The site of injury is generally the sacral fibres or peripheral nerve fibres

The last type of neurogenic bladder ocuurs due to injury in the prefrontal cortex which is responsible for social control of micturition. It allows us to find us to micturate in appropriate place. The patient doesnot have the sense of bladder fullness. They have trouble initiating micturition and they micturitate at inappropriate places.

Character
UMN Type
LMN Type

Spastic Bladder
Flaccid Bladder
Tone
Hypertonic (Increased)
Hypotonic (Decreased)
Volume
Normal or small
Large
Detrussor contraction
Involuntary intermittent contractions
(Overactiity)
Absent
(Underactivity)
Pressure
High
Low
Incontinence type
Urge
Overflow
Symptom
Urgency and Frequency
nocturia
Leaking of urine
Dribbling of urine
Erectile edysfunction in men
Retention
Incomplete bladder voiding
(Detrussor-Sphincter Dyssynergia)
Uncoordinated bladder contraction and sphincter relaxation
Detrusor Aflexia
Conditions
 Spinal Cord damage above T12
Cerebrovascular accidents

Spinal cord damage at S2-S4
Peripheral Nerve injury
Acute Stage of spinal cord injury
Cauda Equina, Conus medullaris
  
Source: Davidson, Merck’s Manual, Medscape

Monday, May 7, 2018

Sensitivity, Specificity, PPV, NPV


Sensitivity is TRUE POSITIVE RATE.
 Diseased (TD) Healthy (TH)  Test Positive True positive (TP) False Positive (FP) PPV = ((TP))/((TP)+(FP)) Test Negative False Negative (FN) True negative  (TN) NPV = ((TN))/((FN)+(TN))  Sensitivity =((TP))/((TP)+(FN)) Specificity  =((TN))/((FP)+(TN))
2x2 table 
Sensitive test picks all diseased and also sometimes without disease. That means it won’t miss the disease.
Sensitivity is a measure of  test positive out of total diseased. 

Specificity is TRUE NEGATIVE RATE.
Specific test picks only the diseased one but may sometime miss the disease itself.
Sensitivity and specificity are not dependent upon the disease prevalence rate.
Specificity is measure of true negative out of total healthy patient. 

Predictive values depend upon the prevalence of disease and accuracy of the test.
Positive Predictive Value is the proportion of the people with positive test who actually have disease.
Negative Predictive Value is the proportion of the people with negative test who actually do not have disease.


PPV
NPV
Definition
% that a person with positive test is actually diseased.
% change that a person with negative test is actually disease free.
Use
Proceed with a patient with positive test
Proceed with a patient with negative test
Relation to prevalence
Low prevalence low PPV
High prevalence high PPV
High prevalence low NPV
Low prevalence High NPV

Thursday, May 3, 2018

Difference between temporal bone fracture types: Longitudinal Vs Transverse: Made Easy


The temporal bone fracture are common with head injury accounting for 30 % of all head trauma and 75 % of all motor vehicle accident. 31% of temporal bone fracture are associated with Motor vehicle accident. 

Longitudinal fracture are common fracture caused by lateral forces over the mastoid and temporal squamosa and fracture line parallels petrous pyramid axis. It is generally anterior and extra-labyrinthine.



NEURAL SYMPTOMS WITH TRANSVERSE #

PHYSICAL SYMPTOMS WITH LONGITUDINAL #


Parameter   Longitudinal Fracture Transverse Fracture   Direction Of  Fracture  Along The Axis Of Petrous Pyramid Perpendicular To Petrous Pyramid  Incidence  More Common (80%) 20%  Mechanism  Parieto Temporal Trauma Fronto Occipital Trauma  Otoraghia PHYSICAL DAMAGE Common Rare  Hemotympanum  Common Possible  TM Perforation  Common Rare  CSF Otorrhoea  Common Occasional  Hearing Loss  Conductive Sensorineural NEURAL DAMAGE Facial Nerve Injury   Less Common (20%) Often Temporary Delayed Onset More Common (50%) Often Permanent Acute Onset  Vertigo  Common (Less Intense) More Intense  Nystagmus  Common (Less Intense) Common Third Degree
Difference between temporal bone fracture types: Longitudinal Vs Transverse
Nerve Injury or neural component more common with transverse # Facial nerve injury(VII), vertigo(VIII: Vestibular Nerve), Sensorineural hearing loss(VIII: Auditory Nerve) and Nystagmus (vestibular Nerve/ CNS component) are more common and intense with transverse fracture.

Physical damage like bleeding demonstrated as  Hemotympanum and otorraghia , fractures seen as  CSF otorrhea, Conductive hearing loss due o disruption of ossicles and Tympanic membrane perforation, are common with longitudinal fracture. Neural component less common or less intense than it’s contrary.

Differential diagnoses of various otological symptoms

Parameter

Longitudinal Fracture
Transverse Fracture

Direction Of  Fracture
Along The Axis Of Petrous Pyramid
Perpendicular To Petrous Pyramid
Incidence
More Common (80%)
20%
Mechanism
Parieto Temporal Trauma
Fronto Occipital Trauma
Otoraghia
PHYSICAL DAMAGE
Common
Rare
Hemotympanum
Common
Possible
TM Perforation
Common
Rare
CSF Otorrhoea
Common
Occasional
Hearing Loss
Conductive
Sensorineural
NEURAL DAMAGE
Facial Nerve Injury

Less Common (20%)
Often Temporary
Delayed Onset
More Common (50%)
Often Permanent
Acute Onset
Vertigo
Common (Less Intense)
More Intense
Nystagmus
Common (Less Intense)
Common Third Degree





Thursday, April 5, 2018

12 Steps of Cesarean section




Preoperative preparation
·         Investigations: Blood : Hb, Coagulation profile, Serology, Blood group, Renal Fucntion test
·         Arrange II pint of whole blood and Cross match
·         Take Consent
·         Inform Anaesthesiologist
·         Inform Neonatologist/ Pediatrician

Intra operative preparations
·         Position: Supine
·         Wide bore canulation
·         Catherization
·         Preoperative medications including Antibiotics, gastroprotective agents
·         FHS Monitoring
·         Anaesthesia: Spinal/ General

Surgical Steps
Painting and draping  Lower abdominal inscision Soft tissue dissection and abdominal cavity reached. Doyen’s retracter is introduced and abdominal cavity is packed.  Identification of lower uterine segment and extraperitoneal incision is made over the uterine muscle. Membarane is ruptured, liquor suctioned and muscles spilt across. Fetal head  identified, doyen’s retracter removed and  baby  delivered. Doyen’s retractor reintroduced. Controlled cord traction of placenta.  Wound margin picked using hemostatic clamp  Uterine incision is sutured in 3 layers continuously using absorbable suture. Skin is closed in layers and dressing done. Wound packed.
12 steps of Cesarean section
1.       Painting and Draping
2.       Incision : Lower abdominal (Pfennestial) / midline vertical/ paramedian vertical
3.       Soft tissue dissection and opening of peritoneal cavity
4.       Doyen’s retracter is introduced and abdominal cavity is packed.
5.       Identification of Lower uterine segment and extraperitoneal incision is made over the uterine muscle.
6.       Membarane is ruptured, liquor suctioned and muscles spilt across.
7.       Fetal head is identified, Doyen’s retracter removed and  baby is delivered. Cords clamped and cut. Baby transferred.
8.       Doyen’s retractor reintroduced.
9.       Controlled cord traction performed and placenta removed. IV oxytoics provided.
10.   Wound margin picked using four Allis Forceps or green Armytage hemostatic clamp
11.   Uterine incision is sutured in 3 layers continuously using absorbable suture.
12.   Skin is closed in layers and dressing done. Wound packed.

Post operative care
·         Monitor: BP, Pulse, RR, Temperature, Fluid Input, Urine Output, Abdominal distension
·         Provide IV fluid, analgesics, Antibiotics, Oxytoxics
·         Breastfeed as early as mother is stable.
·         Ambulate as early as mother can tolerate
·         Start on sips as bowel sound appears, increase gradually to soft to solid food over 2-3 days.
·         Avoid coughing, straining and exertional work.
·         Wound dressing every 3-4 days and suture removal on Day 5-7.
·         Patient can be discharged once patient is stable and can take care of wound and diet.

Friday, March 23, 2018

HIV Awareness Street play: Plot, Screenplay and Script

This is a story I crafted combining all the small role plays made by three different team members while I was training for Training of Peer Educator (TOPE) HIV and AIDS in South Sudan. I myself was a medical officer of peacekeeping force contingent and team leader of one of the groups. However, I am not sure either due to the conflict in idea between me and the chief trainer or prejudice that he held against me made this story ever be performed. However, I am never disappointed with such and  moved forward hoping that this plot can be used my many other social educators to educate people and societies, especially the underprivileged ones about HIV and AIDS. Hope this story is relevant to you and can take the message you want to give the society. If anyone makes any drama out of this plot, I hope they will share the link of the footage with me to make sure that it has affected the life of some people sitting in some corner of the world.


Role Play: Awareness on HIV and AIDS
Son, am I a Lion ?
Characters
Father (Johny), Mother, Kids, Friends, and Girls on the bar, Doctor
Narrator: It’s a story of a peacekeeper, the one who goes to maintain peace in a different part of the world, far from family and far from home. But what happens when the peace of his mind and family is lost when he contracts HIV. A brief story of how he acquires HIV, how he feels, how he responds and lives positively.

Stage 1
(Setting: Airport where the family has gathered to see off the peacekeepers. The father holding an backpack)
Mother: Hope to see you soon papa.  You are going for a long time. Hope you will take care of your self.  
Kids: You are going to Africa, papa. Africa is famous for lions and elephants. Get me some of those for me.
Father: Sure my son, sure. Mommy don’t worry about me. I will take care of myself and you too take care of your self and your kids. It is just a matter of few months. Our bad times will be off when I get back from there.
Mother: (In a Satirical tone) I hope so. I hope you don’t get a mistress from there. Like the last time you got me gonorrhea when you were there in BOR.
Father: Don’t make fun of me. I hope you guys will be fine here, when I am there.
Mother: bye dear
Kids: Bye papa bye  
(The stage closes as the family bids off each other)

(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and  chanting slogan)
OUNCE OF PREVENTION IS BETTER THAN POUND OF CURE

Stage 2:
Narrator: Few months later, he is working now in the mission area. All alone, so enjoying the freedom of being away from home. The boozes don’t stop on the weekends and so does the catch of the fish. He visits friends and sex workers indiscrimately for sex.
(Music playing in the background.  Group of men and women are dancing in the club, drinking alcohol and enjoying. A girl passes in a seductive dress and gesture to attract men.)
Friend :   See that chick, she is so hot. May be I should go and catch her. Do you know wvery time I drink beer, I feel so Powerful. So strong that I can kill a bear.
Johny: Hahaha. You can kill a bear, i can tear the bear, I can ditch the bitch and suck the bloody leech as well.
(Hahaha… there is a big laughter) 
(Johny approaches the girl in the middle of the stage)
Johny: May I join you?
Girl: Why not. How do you do?
Johny: I am having a good time. Are you having a good time.
Girl: yaa... I am having a very good time.
Johny: You want to make it even better.
Girl:  Only if you have condom.
Johny: No No I don’t have a condom. And I don’t like it as well. I hate the plastic between the meats. I want to go between your thighs, skin to skin.
Girl: No that’s not good. You have to be careful. You can contract Sexually transmitted diseases and even the incurable HIV. I can get pregnant without the use of condom.
Johny: I can pay the amount you want if you have sex as I want it. And I want it without the condom.
Girl: No condom no sex. I am not interested in your offer. Thank you.
Johny: Fine then I will find someone who will give me what I want.
(Johny winks at another girl, catches her and leaves. She presents him with a condom which he throws towards the audience and moves to the back of the stage.)
 
(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and chanting slogan)
USE CONDOM: Stay Safe

Stage 3:
Narrator: The next day
Friend: how was last  night my friend?
Johny: It was all good. I had a very good time.
Friend: Are not you worried my friend? You are having unsafe sex practices. You don’t use condoms, you have sex with anyone you find. Are not you worried about your family, your wife, and your kids? 
Johny: She looked all okay. She was healthy, she was fine. Why should I be worried?
Friend: No my friend its not that. People living with HIV look all normal. Only in the later stages when their immunity is badly damaged by the virus, they will have disease. Otherwise they look like you… fair… bold and sexy. Sometimes even if you do know you have HIV, you can have it even when your test is negative. It’s called the window period. That’s the scariest of all. May be you should get tested.
Johny : lets see. I am not sure but I will think about it. 

(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and  chanting slogan)
They all look the same…… HIV don’t discriminate…. Practice Safe Sex

Narrator: Johny being convinced with his friends argument gets himself tested. And to the worst of his fortune, he finds out that he is HIV positive.
Stage 4
Monologue:
My son wanted me to bring an elephant; what did I get for him, a disease as big as elephant that I cannot defeat.  He wanted a lion but now he will be scared of me. I will become a lion to him.
How can I forgive myself !!!
May be I should have ABSTAINED while I was away from my home.
May be I should have BEEN FAITHFUL to my Wife.
May be I should have USED CONDOM.
My life ends here. I am a siner.

(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and  chanting slogan)
Abstain , Be faithful, use condom ,Discipline, Early testing
A-B-C-D-E : Prevention is the KEY

Stage 5:
Narrator: Johny visits doctor and his counsellor many times. He got a good support from them. He finally has accepted his condition and has learned to live positively with it. He has now started taking Anti-retroviral therapy. One drug per day and that’s it. He looks fit and fine. He is now conscuious on his behavior and has been abstaining since then. He returns home after the completing his mission. But breaking the bad news is never easy.
Wife: My dear! You are back home after a long time and why are not you loving me? What happened? You don’t find me sexy anymore. Or you find someone more beautiful than me.
Johny: It’s not like that dear. There is something that’s holding me back and  I wanted to talk something serious with you.
Wife:  Why? What happened?
Johny: I want you to get tested.(asks softly)
Wife: Tested ? tested for what ? (Suspicioulsy )
Johny:  HIV
Wife: Why?  What have I done? Don’t you trust me !!! Am I not your wife? Do do you think I go and sleep with men other than you while you were not here.
Johny: Sorry my love, it’s not about you. It’s about me. I found out that I am HIV positive. And want to make sure that you do not have it. 
Wife: WHAT? OH MY HOLY GOD… My life is wasted. What about my kids. You will kill me and my kids. I thought you will bring me bread and a beautiful home to our kids from mission. Rather you brought this illness and destroyed the little world of ours.
Johny:  No dear. No, it’s not that bad as you think. I was also disappointed and destroyed initially.
Wife: You will die soon. AIDS will kill you.
Johny: Wifey, I don’t have AIDS. I am only HIV positive. That means I am only infected. As long as you are with me, a loving wife, a good healthy environment and charming kids. Nothing is going to happen to me. HIV is not a death sentence. It takes years and years before I develop AIDS. AIDS is not a disease per se, but a group of illnesses that develops when the soldiers in the body fighting the disease are destroyed. And it will take years before HIV does that to my soldiers. I am rather killing those invaders with the drugs I am taking.
Wife: What about me then?
Johny: We can go and get you tested. Till then we can abstain. If you are not infected, you will be totally fine. You do not have to worry. Even Kids are safe because sharing common food, utensil and common bathroom doesnot infect them. It is only the exchange of blood, blood product, semen and vaginal fluids that can cause the infection. If we use protective measures it is all safe.

(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and  chanting slogan)
HIV is not a KNIFE……You STILL have a LIFE……… So Live positively

Stage 6:
Narrator: The both of them go to hospital and get the test done. The good news was
Doctor: You are so lucky my lady. Lucky that you have not acquired the infection. The best thing is you still can practice safe sex and take PRE EXPOSURE PROPHYLAXIS that will prevent you form acquiring the disease.
Johny: I was never told about this sir, tell me something about that.
Doctor: there are some medications your partrner who is sero different can take and prevent herself from being infected with disease.
Wife:  Will my family be safe sharing the same kitchen, utensils, bathroom and all.
Doctor: Absolutely. It is all safe.
Wife: how long will he live?
Doctor:  NO, NO NO.  Don’t stigmatize HIV. Its not the HIV that Kills you. It is the AIDS that kills. Having HIV is just having the virus inside your body. If you keep a positive attitude towards life, took medications properly and take care of your overall health and hygiene. Have a good nutrition. I don’t think you will have any trouble living a normal life.
Wife: What if they discriminate me and my family because he has HIV?
Doctor comes out of the stage and ask the key figure/ chief guest of the show and asks the same question.

(A group of participants cover the stage displaying playcards, clapping the hands, bangings the shoes and  chanting slogan)
HIV is no more a threat ……It can be treated……Long life is for sure……But it has no cure …….
Improvisations and modifications to meet the demand of the audience is highly recommended.
Thank you J