His fire wont be quenched but it wont flash what toll is there

Though his stain of sweat often gets washed with the rolls of tear

But hold it there, if a cause is fueled by loss

Can you ignore the supply of fuel and the cost

He claims to fight the roots of evil by planting hate across

But the growth of both is certain so why wouldn’t a sickle make it stop

His son climbs the same stairway like border of broken bricks on the big charred bombed wall

Which other kids use as steps to climb and often tumble

Written by:

Sameer Aryal

KIST Medical College

Systemic Lupus Erythematosus ACR Criteria

1. Serositis: Pleuritis (inflammation of the membrane around the lungs) or pericarditis (inflammation of the membrane around the heart); sensitivity = 56%; specificity = 86% (pleural is more sensitive; cardiac is more specific).

2. Oral ulcers (includes oral or nasopharyngeal ulcers).

3. Arthritis: nonerosive arthritis of two or more peripheral joints, with tenderness, swelling, or effusion; sensitivity = 86%; specificity = 37%.

4. Photosensitivity (exposure to ultraviolet light causes skin rash, or other symptoms of SLE flareups); sensitivity = 43%; specificity = 96%.

5. Blood—hematologic disorder—hemolytic anemia (low red blood cell count) or leukopenia (white blood cell count<4000/µl), class=”mw-redirect”>lymphopenia (<1500/µl) sensitivity =” 59%;” specificity =”">

6. Renal disorder: More than 0.5g per day protein in urine or cellular casts seen in urine under a microscope; sensitivity = 51%; specificity = 94%.

7. Antinuclear antibody test positive; sensitivity = 99%; specificity = 49%.

8. Immunologic disorder: Positive anti-Smith, anti-ds DNA, antiphospholipid antibody, and/or false positive serological test for syphilis; sensitivity = 85%; specificity = 93%. Presence of anti-ss DNA in 70% of cases (though also positive with rheumatic disease and healthy persons)

9. Neurologic disorder: Seizures or psychosis; sensitivity = 20%; specificity = 98%.

10. Malar rash (rash on cheeks); sensitivity = 57%; specificity = 96%.

The mnemonic to remember the 11 symptoms is ‘SOAP BRAIN MD’.

Some people, especially those with antiphospholipid syndrome, may have SLE without four criteria, and also SLE may present with features other than those listed in the criteria.

The three germ consiting of Ectoderm, mesoderm and endoderm give rise to all the organs and structures in the body. The list of structures developed from 3 primitive germ layers in given below.

Developing embryo

Skin Ectoderm-

• Epidermis, hair, nails,
• Cochlear duct, semicircular ducts,
• Enamel of tooth,
• Adenohypophysis,
• Lens of eye,
• Parotid gland,
• Mammary gland,
• Epithelial lining of lower anal canal.

Neuroectoderm:

• All neurons within brain and spinal cord
• Retina
• Neurohypophysis
• Astrocytes, Oligodendrocytes

Neural Crest-

• Adrenal medulla
• Ganglia- Sensory , Autonomic
• Pigment cells
• Schwann cells
• Meninges- Pia and arachnoid mater
• Pharyngeal arch cartilage
• Ondontoblasts
• Parafollicular C cells
• Aorticopulmonary septum
• Endocardial cushions

MESODERM-

• Muscle ( Smooth, cardiac, skeletal)
• Extraocular muscles ( Preotic somites)
• Muscles of the tongue( occipital somites )
• Connective tissue, dermis of skin
• Bone, cartilage
• Blood and lymph vessels
• Heart
• Adrenal cortex
• Spleen’Kidney’Duramater
• Testes and ovaries

Notocord- Nucleus pulposus

ENDODERM-

1. Epithelial lining of Gastrointestinal tract, Trachea, bronchi, lungs
2. Biliary apparatus
3. Urinary Bladder, Urethra
4. Vagina
5. Auditory tube
6. Middle ear cavity
7. Parenchyma of :- Liver, Pancreas, Submandibular glands, Sublingual gland,Thyroid,Parathyroid

Aedes - dengue fever

Two cases of dengue fever have been found in Kathmandu. Dengue is caused by dengue virus (DenV), a mosquito-borne flavivirus. It is transmitted by Aedes mosquitos.

“This is the first discovery of dengue fever in the Kathmandu Valley even though the disease was detected in the Tarai and inner-Tarai districts some five years ago,” according Sukraraj Tropical and Infectious Disease Hospital, Teku.

“Aedes mosquitos are found in cold water, freeze, cooler houses and other cold places and rich people are vulnerable to dengue fever,” said Dr Bashu Dev Pandey at Teku Hospital on Monday.

He said the disease is communicable from one person to another and its symptoms are high fever, bleeding and unconsciousness. “If an infected person is not treated on time, the patient may die,” he said.

Aedes mosquitos also breed on water collections in artificial containers such as plastic cups, used tires, broken bottles, flower pots, etc. Dr Pandey advised people to keep their freezes and cooler houses clean and treated water to remain safe from the disease.

Dengue fever is acute febrile disease which normally occurs in the tropics. It is also known as break-bone fever and can be life-threatening. There is no tested and approved vaccine for the dengue flavivirus. Prevention of dengue mainly resides in mosquito control. Dengue may also be transmitted via infected blood products including blood transfusions, plasma, and platelets.

Source : www.thehimalayantimes.com

From Nepalnews.com

Cases of dengue fever and Leptospirosis have been detected in various parts of the country including Kathmandu, Chitwan, Dhangadi, Nepalgunj, Kanchanpur, Bhairahawa, Tanahu and Dhading in the recent days, Kantipur daily reported.

The disease is spread from a kind of mosquito that breeds in fresh water. Tests have shown the two diseases are spreading fast in Chitwan.

Out of 72 samples of patients suffering from viral fever sent from Chitwan for special tests at the central laboratory in Kathmandu, ten samples tested positive for Leptospirosis, three for Dengue and one for both.

“Of the samples we found Leptosporis in ten, dengue in three and both in one,” said Dr Geeta Shakya, director of the central laboratory. “There is a need to investigate further on these diseases.”

Dr Basuedev Pande, a specialist doctor at Shahid Shukraraj Tropical and Contagious Diseases Hospital in Teku, warned of an epidemic if preventive measures are not taken soon.

“The cases of dengue has been found in many places of the country,” said Dr Pande. “It will invite an epidemic if it is not controlled on time.”

Dr Pande claimed two persons from Kathmandu were undergoing treatment for Dengue at Tribhuvan University Teaching Hospital (TUTH) and two Japanese nationals had also contracted the disease in Chitwan.

Dr Pande further said, 40 percent of the patients who are undergoing treatment for Typhoid in Teku hospital have also suffered from Leptospirosis.

Director at Epidemiology and Disease Control Division, Dr GD Thakur, takes the occurrences as sporadic. “There are few cases of Lepto and Dengue in Chitwan,” he said. “It can’t be termed an outbreak.”

www.nepalnews.com

Lecture notes

Obesity , as known from various Studies, is an associated cause for increase in morbidity and mortality. There is  50–100% increase in risk of death from all causes compared to normal weight people, mostly due to cardiovascular causes. Mortality rates rise as obesity increases, particularly when obesity is associated with increased intraabdominal fat . Life expectancy of a moderately obese individual could be shortened by 2–5 years, and a 20- to 30-year-old male with a BMI > 45 may lose 13 years of life. It is also apparent that the degree to which obesity affects particular organ systems is influenced by susceptibility genes that vary in the population.

Insulin Resistance and Type 2 Diabetes Mellitus

Obesity  is a major risk factor for diabetes, and as many as 80% of patients with type 2 diabetes mellitus are obese.

Hyperinsulinemia and insulin resistance are pervasive features of obesity, increasing with weight gain and diminishing with weight loss . Insulin resistance is more strongly linked to intraabdominal fat than to fat in other depots. The molecular link between obesity and insulin resistance in tissues such as fat, muscle, and liver has been sought for many years.

Major factors under investigation include:

(1) insulin itself, by inducing receptor downregulation;

(2) free fatty acids, known to be increased and capable of impairing insulin action;

(3) intracellular lipid accumulation; and

(4) various circulating peptides produced by adipocytes, including the cytokines TNF- and IL-6, RBP4, and the “adipokines” adiponectin and resistin, which are produced by adipocytes, have altered expression in obese adipocytes, and are capable of modifying insulin action.

Weight loss and exercise, even of modest degree, are associated with increased insulin sensitivity and often improve glucose control in diabetes.
Also read Dieting for weight control : good or bad

Reproductive Disorders

Males-

• Male hypogonadism is associated with increased adipose tissue, often distributed in a pattern more typical of females.
• In men >160% ideal body weight, plasma testosterone and sex hormone–binding globulin (SHBG) are often reduced, and estrogen levels  are increased.
• Gynecomastia.

Females-

• menstrual abnormalities in women, particularly in women with upper body obesity.
• increased androgen production, decreased SHBG, and increased peripheral conversion of androgen to estrogen.
• may be associated with polycystic ovarian syndrome (PCOS), with its associated anovulation and ovarian hyperandrogenism; 40% of women with PCOS are obese.
• lower body obesity  may contribute to the increased incidence of uterine cancer in postmenopausal women with obesity.

Cardiovascular Disease

• coronary disease – Read on Acute MI
• stroke
• and congestive heart failure (CHF).

The waist/hip ratio may be the best predictor of these risks.

• Obesity-induced hypertension is associated with increased peripheral resistance and cardiac output, increased sympathetic nervous system tone, increased salt sensitivity, and insulin-mediated salt retention; it is often responsive to modest weight loss.

Pulmonary Disease

• Reduced chest wall compliance,
• increased work of breathing,
• increased minute ventilation due to increased metabolic rate,
• and decreased functional residual capacity and expiratory reserve volume
• Severe obesity may be associated with obstructive sleep apnea and the “obesity hypoventilation syndrome” with attenuated hypoxic and hypercapnic ventilatory responses

Gallstones

higher incidence of gallstones, particularly cholesterol gallstones

Cancer

• Males-

cancer of the esophagus,colon,rectum,pancreas,liver, and prostate

• Females -

cancer of the gallbladder, bile ducts, breasts, endometrium, cervix, and ovaries.

Bone, Joint, and Cutaneous Disease

• Obesity is associated with an increased risk of osteoarthritis, no doubt partly due to the trauma of added weight bearing and joint malalignment.
• The prevalence of gout may also be increased
• Among the skin problems associated with obesity is acanthosis nigricans, manifested by darkening and thickening of the skin folds on the neck, elbows, and dorsal interphalangeal spaces. Acanthosis reflects the severity of underlying insulin resistance and diminishes with weight loss.
• Friability of skin may be increased, especially in skin folds, enhancing the risk of fungal and yeast infections. Finally, venous stasis is increased in the obese.

Source: Harrison’s Internal Medicine Book

An Atmosphere of haze,

Cold earth

Blurring the eyes that gaze.
The Humid sun vaporizing,
The mist and the fading.
The Earth never sweats,
But showers in rain till it abates

Hypnotised by the sight,
Beauty of this shining blaze
Blueness of the skies in light,
Palm trees form pretty maze.
Calmness of the breeze,
Behind the sea among the trees.

Coming down from the sky,
Where the lazy angels lie,
Upon the immensity of this land,
Upon the soft and silky sand,
Pretending hard to be..
Some creature of the sea…

Struggling and suffocating,
On the land so cold and freezing.
Wandering for destiny..
Desperate to be loved,
Desperate to be touched..
Lying near the land,near the sand,
But left ignored and mourned..

Disgraced and poignant ,
It’s hard to keep strong,
He’s only a remnant,
Fragile like the glacier,
Broken to fragments.
There is on love here..
There is no love here…

Lost upon the glories,
Of the past , of the seas
But men are all weird here..
Among the trees of qualm and fear,
Some purity so alluring ,
Some warmth that is healing
Are never found here in the land..
Beyong the sea, all is sand.

( Copyright 2010 medchrome )

Objective 1:

• To list the important causative agents of meningitis.

TYPES OF MENINGITIS

• Acute Pyogenic Meningitis
• Aseptic Meningitis
• Chronic Meningitis
  • Tuberculous
  • Fungal
  • Syphillitic
  • Protozoal
  • Helminthe

Causative agents of acute pyogenic meningitis

• Neonates
– Escherichia coli
– Group B streptococci
– Listeria monocytogenes
– Streptococcus pneumoniae

• Children
– Neisseria meningitidis
– Streptococcus pneumoniae,
– Haemophilus influenzae

• Adults
– Streptococcus pneumoniae,
– Neisseria meningitidis

• Elderly
– Listeria species

Causative Agents of Aseptic meningitis

• Common:
- Enteroviruses
- Herpes simplex virus 2 (HSV 2)
- Arthropod borne viruses (Tickborne, West Nile, Murray Valley, Japanese B)
- HIV (Human Immunodeficiency Virus)

• Less common
- Varicella zoster virus (VZV)
- Epstein Barr virus (EBV)

Causative Agents of Chronic Meningitis

Tuberculous meningitis

• Mycobacterium tuberculosis

Syphillitic meningits

• Treponema pallidum

Fungal meningitis

• Cryptococcus neoformans (most common in HIV patients)
• Candida albicans
• Mucor species
• Aspergillus fumigatus
• Coccidioides immitis
• Histoplasma capsulatum
• Blastomyces dermatitidis

Protozoal

• Toxoplasma gondii
• Trypanosoma
• Acanthamoeba

Helminthes

• Taenia solium

Objective 2:

• To outline laboratory diagnosis of bacterial meningitis.

Specimens

• CSF
• Blood
• Sample
• Nasal swab
• Peticheal lesions
• Autopsy

A. Examination of CSF

Macroscopy
• CSF is cloudy under increased pressure and blood may be seen.

CSF is centrifuged and following methods are used:

• Microscopy
• Culture

Microscopy

Unstained preparations: wet mounts

Stained smears:

• Common stains: Gram stain, Ziehl-Neelsen stain
• Fluorescent dyes: Acridine orange, Auramine rhodamine

Gram stain (left) and ZN stain (right)

Culture

Culture Media

• Enriched solid media- blood agar, chocolate agar
• Selective solid medium- MacConkey agar
• Robertson Cooked meat broth (for anaerobes)

Steps:

• CSF inoculated in culture media
• incubation at 35-36°C under 5-10% CO2
• Colonies appear after 18-24 hours, identified by morphology and biochemical reactions.

B. Blood culture

• incubated for 4-7 days, with daily subcultures

C. Nasopharyngeal Swab

• Useful for detection of carriers
• Done without contamination with saliva

D. Petechial lesions

Menigococci may be demonstrated by microscopy and culture

E. Autopsy

• Specimen from meninges, lateral ventricles, or surface of brain and spinal cord
• Within 12 hours of death of patient
• Smear or culture

Biochemical tests

• Catalase test
• Oxidase test
• Indole test
• Urease test
• Coagulase test
• Citrate Utilization test
• Triple sugar iron agar

Agglutination test:

• Direct slide agglutination test with specific antisera
• Latex agglutination test
• Immunoflourescence test
• Other rapid identification methods
• Molecular diagnosis – PCR test

Various changes in Acute Pyogenic Meningitis:

References:

• Textbook of Microbiology
• Diagnostic Microbiology

Prepared and Presented for Correlation Seminar in Kist Medical College by:

Body normally stores Reserve energy in form of fat, and utilizes it in time of starvation or hunger. Fat in fact is a good friend of human that can be worst foe as well. Obesity is one of the most concerning problem in the developed countries. Obesity itself is a social embarrassment, but above that it is the etiology to many problems in the future. The Body mass Index or BMI grading can be used to measure how fit you are. Calculate your BMI here.

In a program on Discovery channel, topic was “Obesity”, I found it rather informative and a way to raise public awareness about the possible consequence of Obesity. It also emphasized on  “ Dieting an Unhealthy way for weight loss”. As we generally think, the body loses fat after a fasting or Dieting, which is true but not completely, as body is prone to gain more weight soon after that.

The story about an Ex-Sumo Wrestler struggling to lose weight in his thirties was touching. How Obesity could affect your day to day living was shown through his story. He weighed more than 650 pound, which was like carrying 2 person with him all the time. That lead to the erosion of cartilage of his knee joint leading to a condition called Osteoarthritis. About 20 million American are living with osteoarthritis today, so I don’t think it is a new topic in USA. He fears he won’t make to the next decade if he doesn’t do something soon to lose his weight. He is under diet control and exercise. Losing 30 pounds was a light of Hope for him, but he needs to lose 300 pounds more to get to his target. He has Type 2 Diabetes and he’s under constant threat of many fatal diseases.

The ultimate decision he has to make, go through Bariaticsurgery “ A process where stomach size is reduced and part of intestine is bypassed’. It could drastically reduce weight but is not free from severe sight effects. He thinks he won’t make it through the surgery so he denies undergoing surgery. It was in fact a touching story that left me thinking, he should have undergone the surgery, looking at the results of few other similar patients.

Female store fat in different parts of the body. Men store most of the fat inside their abdomen, surrounding the vital organs, Liver, Adrenals, and Intestine etc. This affects the endocrinal system in Men. Such type of Obesity is more prone to predispose Diabetes Type II. Obesity in men is more fatal than that in Women.

People undergo dieting as a therapy to lose weight. Body has tendency to maintain certain amount of fat as static reserve. When person is dieting, the body considers the stage of fasting as starvation. After the fasting, the body tends to restore the used fat. Moreover body takes extra precaution and keeps the static reserve of fat at a higher level than before.  So next time the person feels immense hunger and the food taken subsequently results in more storage of fat and weight gain. Person who periodically undergoes dieting, can ultimately fall into a vicious cycle of dieting and weight gain. So dieting is not at all a healthy way of weight loss.

Best Weight loss  technique is to reduce the Calorie intake and Exercise more. (Remember : When we eat , we usually underestimate the calorie provided by the food, we may be taking double the normal calorie requirement  that we need.)

Synopsis Article

Angela Gossow Screaming

“We rehearsed and rehearsed. Then I lost my voice completely before our first Japan tour. I got diagnosed with nodules. Bad news… All these years of screaming without any technique at all had finally taken its toll on my vocal chords and struck me in the worst possible moment. I had to take 6 months off and re-learn everything. Speaking, breathing and screaming.” – Angela Gossow (Arch Enemy)

What is vocal cord nodule (vocal fold nodule or singer’s nodule)?

A vocal cord nodule is a small, inflammatory or fibrous growth that develops on the vocal cords (vocal folds) of people who constantly strain their voices. Typically it appears on the junction of the anterior and middle 2/3 of the vocal fold, where contact is most forceful. The nodules appear as symmetrical swellings on both sides of the vocal cords. People who use their voices a great deal, such as singers, teachers, auctioneers, lecturers, and politicians are the most susceptible ones.

Why singing death/black metal may give rise to nodules?

Most of the times when we are trying to sing these songs, we are doing it in a wrong way. Growls that are not performed properly may lead to permanent damage of vocal cords. If you persistently feel pain while growling, you must stop it and re-evaluate your technique because it is probably wrong.

The vocal cords in your throat are not originally intended for growling vocals. Too much involvement of throat while screaming and growling puts too much strain on vocal cords leading to nodule formation.

Bert McCracken (vocalist of “The Used”), Angela Gossow (vocalist of “Arch Enemy”), Matthew Sanders or M.Shadows (vocalist of “Avenged sevenfold”), etc. were known to have these nodules.

What is the correct way of singing these songs ?

This powerpoint presentation explains very well about the techniques.

• Hoarseness of speech
• Painful speech production
• Frequent vocal breaks
• Reduced vocal range

Treatment of vocal nodules :

• Vocal training
• Speech therapy
• Vocal rest
• Surgery

The posterior inferior cerebellar artery also known as PICA is the largest branch of the vertebral artery, passes on an irregular course between Medulla and Cerebellum.  It is one of the 3 major arteries supplying  the cerebellum. It supplies the posterior part of inferior surface of Vermis, Central nucleii of Cerebellum and undersurface of Cerebellar hemisphere.It also supplies  Medulla ( branches of PICA along with medullary branches of Vertebral artery) and Choroid Plexus of 4 th ventricle.

Cause :-

• It results from thrombosis of Posterior Inferior Cerebellar Artery.
• Causing lateral part of the medulla oblongata to infarct.
• The most commonly affected artery is the vertebral artery, followed by the PICA, superior middle and inferior medullary arteries.

Lateral Medullary syndrome of Wallenberg

Signs and Symptoms that are Characteristic of Wallenberg Syndrome are-

1. Dysphagia and Dysarthria ( Due to paralysis of Ipsilateral palatal and laryngeal muscles- Innervated by Nucleus Ambiguus)
2. Analgesia and Thermaesthesia on the Ispsilateral side of the face ( Due to lesion of Nucleus and Spinal tract of Trigeminal nerve)
3. Vertigo, Nausea, Vomiting and Nystagmus. ( Lesion of Vestibular nucleii)
4. Ipsilateral Horner Syndrome ( due to lesion of Descending Sympathetic fibres)   Mnemonic- “Horny PAMELa” for Ptosis, Anhydrosis, Miosis, Enophthalmos and Loss of ciliospinal reflex
5. Cerebellar Symptoms and Signs-

• • Cerebellar Ataxic/ Drunken Gait
  • Dysdiadochokinesia ( unable to perform quick alternative repeated actions like pronation/supination)
  • Pendular knee jerk
  • Nystagmus
  • Dysmetria
  • Intention Tremor ( Tremor increases as fingers arrive the target)
  • Hypotonia
  • Rebound phenomenon
  • Scanning speech