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emometalhead · 3 years ago

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Hey again. i’m the homophobia anon 👋 I don’t wanna bother you but I had like two other question. What Did u mean by evidence of the Guns guys supoorting the lgbtq+ communit? I hope im not bothering you, I’m just curious because I heard One in a million for the first time a while back and it was umm 🤔 interesting to say the least. And you know the song Same Opd Situation by Mothey Crue. It’s about lesbian, but do you think Motley meant it in a supportive or homophonic way? Sorry for all the questions

Hi anon! No worries about the questions!! I'm happy to clarify things for you 👍

One In A Million is a song that many fans do not support. I've never even listened to it, due to the offensive lyrical content. The band no longer endorses the songs. They unanimously agreed to exclude it from a modern re-release of the album. Slash has stated to have always considered the song offensive. The song also does not get performed, so the band is not defending it or promoting it in the modern era.

Slash was vocally supportive of gay marriage in 2008 when the state of California was voting on whether or not to make it legal. He spoke in interviews about how everyone should have the right to get married, and made a video with his then wife to encourage people to vote against Prop 8 (which was the proposition to make gay marriage illegal).

Steven is very comfortable with his sexuality, to say the least. There's been conversations in GN'R fan forums going as far as to suggest he is bisexual. He has talked about the attractiveness of men, and doing acts with men (though he may have been joking there) on several occasions. Since he is so comfortable putting himself in conversations like that, it seems likely that he is just generally chill with LGBT+ people. There is no evidence of him being homophobic.

Duff has stated in interviews that he is accepting of everyone. He has punk roots, and said the scene was very inclusive in his experience.

As for Izzy, there's no reason to suggest he's homophobic, but there's also no evidence toward him being supportive of LGBT+ people. He really just hasn't commented on anything.

With Mötley Crüe, based on how they described S.O.S. when it was released, I do not believe they intended for the song to be homophobic. I've never considered the song homophobic, personally. As far as Crüe's songs go, this one isn't one of the more offensive lol. There could definitely be an argument made about the fetishization of lesbians by the band, but I don't think they are homophobic. (Also worth noting that I am a lesbian, but also I don't speak for every lesbian so take what I say with a grain of salt!)

There's no evidence (to my knowledge) of the band currently being homophobic. Nikki has stated himself to be in support of the LGBT+ community. Though it doesn't mean he's supportive, he has also stated to have gay friends, and that his daughter has helped him learn more about the LGBT+ community. Though a controversial piece of literature, Tommy had a section of his book that highlighted thoughts from his lesbian friends. So, same situation as what I said with Nikki.

On the flip side, Nikki has been quoted as using the f-slur in the past, and Tommy once made a Tweet using gay as an insult. However, Nikki has also called other people out for homophobia, and Tommy clarified after his Tweet that his wording did not mean he felt negatively about actual gay people. Make of that what you will. I honestly don't have any information regarding Mick or Vince 🤷‍♀️. All I can say on Vince is that he was on an episode or Queer Eye for the Straight Guy, but again that's not substantial evidence of anything.

I know none of this is like totally concrete anything. This is the situation to my understanding though! I do not personally consider either band to be currently homophobic, but there's definitely been past instances of homophobia that I do not want to dismiss. You're entirely allowed to form your own opinions based on my response! Hope this was educational.

#this became so long lol #I wanted to cover all of the bases #asks #anon

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juniperpublisherscasestudies · 4 years ago

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Juniper Publishers- Open Access Journal of Case Studies

Elderly Saudi male patient with Osteomalacia presented to ER (first presentation) with recurrent focal Seizures due to severe hypomagnesemia

Authored by Abdalla Khalil

Abstract

Vitamin D deficiency and Osteomalacia are common among Middle East and Saudi Arabia population with a higher prevalence among females than in males. Hypocalcemic Seizures secondary to severe vitamin D deficiency have been reported as an extremely rare presentation in Pediatrics and adolescents. We are presenting an elderly Saudi male patient who came to our ER with a first presentation of recurrent multifocal motor seizures.

His neurological investigations were all normal together with absence of any urinary or gastrointestinal magnesium wasting. However, his biochemical studies were constant with osteomalacia besides significant low serum magnesium. Off note, we could not find any hypomagnesemic seizures in patient with osteomalacia in our literatures search. Checking serum electrolytes including magnesium is an essential work up for all ER patients with seizures.

Keywords: Osteomalacia ; Vitamin D deficiency; Focal seizures motor; Hypomagnesmia

Abbreviations: ER: Emergency room; EEG: Electro Encephalo Gram; PVC: Premature Ventricular Contraction; RBBB: Right Bundle Branch Block; OPD: Out Patient Department; ECG: Electro Cardio Gram; MRC: Medical Research Council scale of muscle strength

Introduction

The Institute of Medicine has recommended that serum 25(OH)D is adequate when it is higher than 50nmol/l [1]. However, Clinical vitamin D deficiency only occurs when serum 25(OH)D is lower than 25nmol/l.

In a review of vitamin D levels globally, vitamin D levels below 75nmol/L were prevalent in different regions of the world, whereas vitamin D levels <25nmol/L were more common in South Asia and the Middle East than in other regions [2]. Off note, the lowest serum 25(OH)D was seen in an old study of older persons in Saudi Arabia with a mean of 9nmol/l [3].

In a study between 2011 and 2016, the prevalence of vitamin D deficiency (<50nmol/l) in Saudi Arabia among different populations (adults, children and adolescents, newborns and pregnant/lactating women) was 81.0% [4].

In the Saudi Health Interview Survey (SHIS), 62.65% of female Saudis and 40.6% of male Saudis aged 15 years and above are deficient in vitamin D. Out of them, less than 1% males and less than 2% females consume vitamin D supplements [5].

The clinical picture includes muscle weakness, bone pain and fractures, while in children joint swelling and deformations prevail. In patients with rickets and osteomalacia serum 25(OH)D usually is lower than 15nmol/l or even below the detection limit [6].

The clinical manifestations of osteomalacia may include bone pain and tenderness, muscle weakness, difficulty walking, and a waddling gait.

Case Presentation

A 63-year-old Saudi male patient was brought to ER of the IMC hospital by his companions with a history of twitching of left side of the face followed by convulsions of both left upper and lower limbs, loss of consciousness and stools incontinence. It was an acute episode occurred at home 30 minutes before reaching the hospital.

While he was in ER, another episode of twitching of left side of face and convulsions of left side of the body happened which lasted for 2 minutes. Ten minutes later, he became conscious, able to communicate and give history, yet he was complaining of headache and muscle pains.

He was complaining of left side numbness, dizziness (light headiness not spinning) and unsteadiness for two weeks preceding this attack of seizure. Consequently, he was seen by a neurologist in a private clinic and a CT brain was done which was reported normal. Because he is claustrophobic to MRI machine, MRI scan was not done.

There was no history of previous loss of consciousness, head injury or seizures. Furthermore, he did not have a history of fever, loose motions, palpitation, chest pain, sweating or shortness of breath and no gastrointestinal complaint.

Apart from mellitus type I and essential hypertension, the patient has no other medical illness or surgical procedure. His drug list includes, Lisinopril 5mg once daily orally, insulin glaigrine 12units subcutaneously at bed time, regular insulin 4units subcutaneously before meal and aspirin 81mg once daily orally.

He has no history of herbal medicine, alcohol or illicit drug intake. He had no family history of Epilepsy and he was not aware of any inherited disease in his family members. His pulse was 80/min and regular, BP 110/70, temperature was 36.6 C, Respiratory Rate 20/min, oxygen saturation was 98% at room air and capillary blood glucose was 9mmol/l.v On examination, he had a mild facial muscles weakness on the left lower quadrant and his power on left upper and lower limb was 4/5 according to MRC scale. The rest of his neurological exam was normal together with unremarkable respiratory and cardiac review.

Serum alkaline phosphatase was high 150u/l (40-100u/l), yet the rest of liver functions including serum albumin were normal. Serum calcium was mildly low 1.90mmol/l (2.10-2.55mmol/l), serum phosphorus was also low 0.43mmol/l (0.87-1.45mmol/l), whereas serum magnesium was substantially low 0.09mmol/l (0.7mmol/l -1.45mmil/l), thus a second sample was double checked by our chemistry lab to confirm.

Vitamin D total (25OH vitamin D3+25OH vitamin D2) was significantly low 10nmol/l (80-170nmol/l) and Para thyroid hormone was 8.0pmol/l (1.50-6.80pmol/l). Complete blood count with differential and Coagulation profile were normal. His chloride was 96mmol/l (98-111mmol/l) CO2 venous in renal function was 22mmol (22-28mmol/l). Blood urea nitrogen was normal and serum creatinine was 111umol/l (55-110umol/l). Serum sodium, potassium, serum creatinine kinase and troponin were normal.

CT brain without contrast was normal and ECG showed normal sinus rhythm with occasional PVCs, incomplete RBBB and normal QT interval. Based on magnesium level, intravenous infusion was started in ER. The provisional diagnosis was focal seizures for investigation; as a consequence, he was reviewed and admitted by neurology team with endocrinology and internal medicine co-management. MRI brain was unremarkable and normal awake to drowsy EEG recording.

His urinary magnesium in 24 hours (sent out of hospital chemistry test) was 20 mg/24 hours (50- 250 mg/24 hours). Intravenous magnesium infusion continued with repeated serum levels of calcium, magnesium and phosphorus. He was also on oral cultrate tablets (calcium elemental 600 mg & vitamin D 400units) orally tree time’s daily and vitamin D cholecalciferol 50.000 units once weekly.

Fortunately, the patient had not any more seizures, dizziness, muscle twitching, or weakness and he was ambulating with a good balance. His serum magnesium level improved with intravenous magnesium and he was switched to oral magnesium oxide tablets 800 mg bid. Four days later, he was discharged home on his oral medications. On internal medicine outpatient clinic follow up, his serum magnesium level was maintained and oral magnesium was stopped after 2 weeks. His vitamin D level was normalized after 5 months and his serum magnesium was normal without supplements.

Case Discussion

Hypomagnesmia is a common problem among patients admitted to hospital with a higher percentage among intensive care units’ patients (up to 65%) [7]. Seizures in severely hypomagnesemic patients may be generalized tonic clonic or multifocal motor [8]. Low vitamin D level has been reported among patients with hypomgnesemia [9]. Hypocalcemic Seizures has been reported with osteomalacia in pediatrics and adult medicine [10,11].

In our electronic search, we could not find any seizures due to severe hypomagnesemia among patients with vitamin D deficiency in adults or Pediatrics. Our elderly male patient was seen in ER with first focal motor seizure. His work up showed biochemical markers for severe vitamin D deficiency osteomlacaia. His serum calcium was slightly low which cannot be incriminated for the seizures, but magnesium was significantly low which is explaining the occurrence of repeated focal motor Seizures. In addition, there was no history of diarrhea or having malabsortion symptoms to point out gastrointestinal loss. His 24 hours magnesium was normal, so magnesium urinary wasting was also rolled out.

This association between severe hypomagnesemia with osteomalacia and focal Seizures has not been reported before in literature. It is essential to check serum electrolytes including sodium, calcium and magnesium for all patients coming to ER with seizures to complete work up for seizures assessment [12].

For more Open Access Journals in JuniperPublishers please click on: https://www.linkedin.com/company/juniper-publishers

For more articles in Open Access Journal of Case Studies please click on: https://juniperpublishers.com/jojcs/ To know more about Open Access Journals Publishers To read more…Fulltext please click on: https://juniperpublishers.com/jojcs/JOJCS.MS.ID.555607.php

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lupine-publishers-sjpbs · 5 years ago

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Lupine Publishers | Psychiatric and Medical Comorbiditiesinpatients With Bipolar Disorder: A Hospital Based Study

Psychology And Behavioral Sciences

Lupine Publishers | Psychology And Behavioral Sciences

Abstract

The two most common bipolar disorders are bipolar I disorder and bipolar II disorder. Comorbid psychiatric disorders usually precede the onset of bipolar disorder. Bipolar disorder often coexists with other Axis I and Axis II disorders. Studies have shown that patients with mood disorders have more comorbid medical illnesses. Research has suggested that that there may be underlying biological mechanisms linking mood disorder and many medical illnesses.The current study will determine the psychiatric and medical disorders in a sample of patients with bipolar affective disorder in a general hospital setting.

Aims and Objectivest: study the socio-demographic profile of patients with Bipolar affective disorder, to study the prevalence of psychiatric comorbidities in patients with Bipolar affective disorder and to study the prevalence of medical comorbidities in patients with Bipolar affective disorder.

Methodology: This cross-sectional study was conducted at the department of Psychiatry, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Medical College and hospital, Bemina, Srinagar, Jammu and Kashmir. Psychiatry department at SKIMS-MC is a General Hospital Psychiatry unit.

Results: In the present study the mean age of patients was 34.3 years, Majority of patients were females, married. In this study, obesity/ weight gain (n=52), chronic headache (n=45), hypertension (n=30), elevated serum lipids (n=28), thyroid disorders (n=19), diabetes (n=12), GERD (n=9), CAD (n=4), epilepsy (n=2), COPD (n=2), bronchial Asthma (n=1), Parkinson’s disease (n=1), CKD (n=1) were among the medical comorbidities. In this study the most prevalent psychiatric disorders in patients with BPAD were Substance use disorder (n=32), somatoform disorders (n=18), Generalized anxiety disorder (n=12), obsessive and compulsive disorder (n=11), panic disorder (n=9), simple phobia (n=7), eating disorders (n=5), social phobia (n=4), and PTSD (n=2).

Conclusion: The current study suggested that patient suffering from bipolar affective disorder are at increased risk of developing medical or psychiatric comorbidities. It is very important for the treating physician to be aware of the prevalent medical and psychiatric conditions patients with bipolar affective disorders and knowledge of these comorbidities help in prevention, early detection and treatment of such illnesses as well will improve treatment response and prognosis in bipolar patients itself. Awareness among healthcare professionals about the risks to which patients withaffective disorders are exposed is of great importance, as the medical illnessesare likely to coexist with a mood disorder, which may help to improvediagnostics and management and therefore clinical and social care for patients. Overall, the presence of comorbidities in BPD has negative prognostic implications for psychological health and for medical well-being and longevity. In order to improve quality of life, prognosis and life expectancy for those with these illnesses, it is important that further researches on this topic should be continued.

Keywords: Bipolar Disorder; Psychiatric Comorbidity; Medical Comorbidity; Anxiety Disorders; Substance Abuse

Background

A complex, chronic mood disorder involving repeated episodes of depression and mania/hypomania is referred as Bipolar disorder [1]. The two most common bipolar disorders are bipolar I disorder and bipolar II disorder. The lifetime prevalence of MDD Is around 12.2% to 16.2% [2,3] while as the prevalence of bipolar disorder are significantly lower, ranging from 0.9% to 4.4% [4,5]. In Bipolar disorder I prevalence has been found to range from 0.8% to 3.3% [6,7] while as in Bipolar disorder II prevalence has been estimated at around 0.5% to 1.1% [8] The presence of more than one disorder in a person, for a defined period of time is referred as Comorbidity[9] Comorbidity can be of three main types:[10]

1. Comorbidity of physical and psychiatric disorders, e.g. depression and hyperthyroidism;

2. Comorbidity of related disorders, e.g. anxiety and depression; and

3. Comorbidityof disorders indirectly related, e.g. psychotic depression and substance abuse.

Comorbid psychiatric disorders usually precede the onset of bipolar disorder. Bipolar disorder often coexists with other Axis I and Axis II disordersand studies have found that psychiatric comorbidity in bipolar disorder range from 50% to 70% [11], In a Study with bipolar disorder, 65% patients met DSM-IV criteria for at least 1 comorbid lifetime Axis I disorder, whereas 42% had 2 or more Axis I comorbidities, and 24% had 3 or more [12]. Bipolar patients with psychiatric comorbidity had more mixed features, depressive episodes, and suicide attempts; poorer outcome and treatment compliance [10]. In another study, substance use disorders also follow the onset of bipolar disorder [13]. Sixty percent of premature deaths in those with serious mental illness are as a result of general medical conditions [14]. Studies have shown that patients with mood disorders have more comorbid medical illnesses. Researchhas suggested that that there may be underlying biological mechanisms linking mood disorder and many medical illnesses [15-18].

The current study will determine the psychiatric and medical disorders in a sample of patients with bipolar affective disorder in a general hospital setting.

Aims and Objectives

a) To study the socio-demographic profile of patients with Bipolar affective disorder.

b) To study the prevalence of psychiatric comorbidities in patients with Bipolar affective disorder.

c) To study the prevalence of medical comorbidities in patients with Bipolar affective disorder.

Material and Methods

This cross-sectionalstudy was conducted at the department of Psychiatry, Sher-I-Kashmir Institute of Medical Sciences(SKIMS),Medical College and hospital, Bemina, Srinagar, Jammu and Kashmir. Psychiatry department at SKIMS-MC is a General Hospital Psychiatry unit. The study was approved by institutional ethical committee.

The patients attending the hospital outpatient department giving a voluntary consent were included in the study. The present study was conducted on patients with bipolar affective disorder. The sample comprised 100 patients attending psychiatry OPD diagnosed as Bipolar Affective Disorder using ICD 10 during the period of june 2017 to june 2018 [19]. The diagnosis for the study group was confirmed by M.I.N.I (Mini International Neuropsychiatric Interview) [20]. The following inclusion and exclusion criteria were used in the study.

Inclusion Criteria for patient:

a) Patients should fulfill ICD -10 criteria for Bipolar affective disorder.

b) Age of the patient should be 18 years or above.

c) Illness duration of at least 12 months.

d) Patients who are able to provide informed consent.

Exclusion Criteria for patient:

a) Patients aging below 18 years of age.

b) Patients who are not willing to participate.

c) Patients who had medical or psychiatric illness before the diagnosis of BPAD.

Methodology

Instruments:

a) Demographic profile and clinical data sheet of patients. Intake data of each patient was recorded on a specially designed proforma. This consisted of details about age, sex, marital status, educational status, occupation, socioeconomic status, residence, type of family.

b) International Classification of Mental and Behavioral Disorders (ICD-10)

[19] Based on the clinical assessment, the diagnosis was made according to ICD-10 clinical descriptions and diagnostic guidelines.

c) Mini-International Neuropsychiatric Interview (M.I.N.I) [20]

The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders.

Results

In the present study the mean age of patients was 34.3 years, Majority of patients i.e. 31% (n=31) were from 30-39 years of age group followed by 26% (n=26) of patients in the age group of 20-29 years ,17% (n=17) in ≥ 50 years,14% (n=14) in the age group of 40-49years and 12% (n=12) < 20years. Majority of BPAD patients were females i.e. 53% (n=53) and males were 47% (n= 47). Among 100 patients most of them were married 63% (n=63) and 37% (n= 37) were unmarried with no formal education i.e. 36% (n=36) , 32% (n=32%) had secondary education, 26% (n=26) were graduate and 6% (n=6) had primary education. Majority of the patient in our study belonged to low socioeconomic status i.e.60% (n= 60) and 40% (n=40) belonged to middle socioeconomic status. Most of patients i.e. 86% (n=86) had rural residence and 14% (n=14) had urban residence (Tables 1-5) and (Figure 1).

Figure 1: Psychiatric comorbidty in BPAD.

Table 1: Showing socio-demographic distribution of patients.

Table 2: Showing socio-demographic distribution of patients.

Table 3: Showing socio-demographic distribution of patients.

Table 4: Showing socio-demographic distribution of patients.

Table 5: Showing socio-demographic distribution of patients.

In 82% (n=82) of patients there was no family history of psychiatric illness and in 18% (n=18) of patients, mental illness in any other family member was present. In present study, 87% (n=87) of patients, no medical illness was present in family member and 13% (n=13) of patients had medical illness present in family In this study, obesity/ weight gain (n=52), chronic headache (n=45), hypertension (n=30), elevated serum lipids (n=28), thyroid disorders (n=19), diabetes (n=12), GERD (n=9), CAD (n=4), epilepsy (n=2), COPD (n=2), bronchial Asthma (n=1), Parkinson’s disease (n=1), CKD (n=1) were among the medical comorbidities. In this study the most prevalent psychiatric disorders in patients with BPAD were Substance use disorder (n=32), somatoform disorders (n=18), Generalized anxiety disorder (n=12), obsessive and compulsive disorder (n=11), panic disorder (n=9), simple phobia (n=7), eating disorders (n=5), social phobia (n=4), and PTSD (n=2).

Discussion

This study examined the Medical and psychiatric comorbidity in patients with Bipolar Disorder. Bipolar disorder (BPD) is highly prevalent disorder by the presence of comorbid conditions and these comorbidities has negative prognostic implications for psychological and medical well-being and longevity.[16,17] Bipolar disorders are associated with psychiatric and medical comorbidities and simultaneous diagnosis and their treatment is equally important [21,22]. Most patients suffering from bipolar disorder met criteria for 3 or more lifetime psychiatric disorders. Patients with bipolar disorder has impairment even during the period of remission due to physical and psychiatric comorbidities and can lead to disability. WHO classification of disability have placed BPD seventh in the disability cause [23-26], The complex mechanisms underlying the comorbidity in Bipolar disorders may suggest that the causal relationships are likely to be bidirectional [27,28].

In our sample the medical conditions associated with bipolar disorder were Obesity/weight gain(52%), Headache (45%), Hypertension (30%), Elevated serum lipids (28%), Thyroid disorders (19%), Diabetes (12%), GERD (9%), Coronary artery disease (4%), Epilepsy and COPD 2% each, Parkinson’s disease, Bronchial Asthma, and chronic kidney disease 1 % each.

Burden of overweight has increased rapidly over the past decades globally. Obesity/Overweight are emerging as an important public health problem in India [29,30]. In India reported prevalence of overweight in range of 1.5%–24.0%in general population and showed rapid increase [31]. In our study the 53% patients showed weight gain which is higher than the prevalence in general population, Patients with Bipolar disorder tend to be overweight and reason could be the treatment of bipolar disorder especially valproate, carbamazepine, Lithium and antipsychotics which may also increase the risk of other comorbid medical disease [32-36].

Another reason for could be the comorbid eating disorder which includes the excessive carbohydrate consumption and low rates of exercise [37,38]. Headache is prevalent in every country affecting both genders and all socioeconomic levels. In general the percentages of the adult population with an active headache is 46% [41,42].

In our study 47% patients were suffering from headaches which is almost similar to the prevalence of general population. The connection between migraines and bipolar disorder is so strong that over one-third of people living with bipolar suffer from migraines [43,44]. Researchers think that there may be a genetic abnormality in serotonin, dopamine and glutamine neurotransmitters that contributes to both migraine headaches and bipolar disorder [45]. Hypertension is an important public health problem in developed and developing nations [46,47].The prevalence of hypertension in general population is 20.9% and in our study 30% patients with BPAD was suffering from hypertension which is higher than the general population [48]. The link between bipolar affective disorder and hypertension depends upon various factors such as Life styles, obesity and psychotropic medicines in particular second-generation antipsychotics are likely to play a role [49-51].

The effect of psychotropic medications and associated weight gain or the complications of treatment with some atypical antipsychotics may lead to diabetes as well as a marked increase of serum lipids [52]. A bipolar disorder and metabolic disorders, such as coronary artery disease and diabetes type 2, have strong genetic links and may share some common pathophysiological pathways [53]. The comorbidity of thyroid disorder in individuals with bipolar disorders has a well-established link. Lithium a mood stabilizer which is a common treatment for bipolar disorder can also lead to thyroid disorders as a common side-effect of the drug [54]. A higher burden of medical illness is indicative of a more severe illness course, with greater impairment in functioning which has been also seen in previously reported findings.The presence of a medical condition increases the risk of developing a mood episode/ disorder and vice versa [49]. Bipolar disorder often coexists with other Axis I disorders.In our study the psychiatric disorders associated with bipolar affective disorders were Substance use disorder (32%), somatoform disorders (18%), Generalized anxiety disorder (12%), obsessive and compulsive disorder (11%), panic disorder (9%), simple phobia (7%8), eating disorders (5%), social phobia (4%), and PTSD (2%).

Psychiatric disorders with bipolar disorder compared to their rates in the general population are higher and can pose a therapeutic challenge as well as a diagnostic dilemma [55]. A careful assessment, accurate history form bipolar patient is a challenge due to overlap between symptoms of BPAD and other psychiatric conditions.

Comorbid Substance use disorder was found to exist in 48- 61% of patients with bipolar affective disorder in some studies [56-58]. The significant indicator for the course of bipolar disorderisdrug abusewith regard to the individual and in relation to family history of drug abuse. Patients with bipolar affective disorder are at higher risk for anxiety disorders including generalized anxiety disorder, simple phobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and panic disorder [59,60]. Substance use and anxiety disorders are higher in patients with bipolar disorder than in general population, similar results were found in our study [61,62].

Conclusion

The current study suggested that patient suffering from bipolar affective disorder are at increased risk of developing medical or psychiatric comorbidities. It is very important for the treating physician to be aware of the prevalent medical and psychiatric conditions patients with bipolar affective disorders and knowledge of these comorbidities help in prevention, early detection and treatment of such illnesses as well will improve treatment response and prognosis in bipolar patients itself.Awareness among healthcare professionals about the risks to which patients withaffective disorders are exposed is of great importance, as the medical illnessesare likely to coexist with a mood disorder, which may help to improvediagnostics and management and therefore clinical and social carefor patients. Overall, the presence of comorbidities in BPD has negative prognostic implications for psychological health and for medical well-being and longevity. In order to improve quality of life, prognosis and life expectancy for those with these illnesses, it is important that further researches on this topic should be continued.

#https://lupinepublishers.com/psychology-behavioral-science-journal/fulltext/psychiatric-and-medical-comorbiditiesinpatients-with-bipolar-dis #https://lupinepublishers.com/psychology-behavioral-science-journal/pdf/SJPBS.MS.ID.000136.pdf #For more Lupine Publishers Open Access Journals Please visit our website: https://lupinepublishersgroup.com/#For more Psychology And Behavioral Sciences Please Click Here:#https://lupinepublishers.com/psychology-behavioral-science-journal/

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siva3155 · 5 years ago

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300+ TOP PEDIATRICS Objective Questions and Answers

PEDIATRICS Multiple Choice Questions :-

1.Visual acuity reaches adult acuity by the age a) 7 b) 9 c) 5 d) 3 2.Abstract thinking occur at the age of a) 2 years b) 3 years c) 9 years d) 12 years 3.A six week old infant cannot a) Grasp dangling objects b) Fix gaze c) Lift and hold head d) Turn head towards sound 4.Number of deciduous teeth is a) 20 b) 24 d) 32 c) 28 5.Shakir tape is used for a) measurement of height b) measurement of length of infant c) measurement of midarm circumference d) measurement of skin pad thickness 6.Height increases (mean) in children from 2 to 10 years peryear is a) 2 cms b) 4 cms c) 6 cms d) 8 cms 7.The commonest cause of Enuresis in children is a) Urinary tract infection b) Spina bifida c) Psychologic stress d) Diabetes mellitus 8. Water content in infant a) 60-70% b) 75-80% c) 80-90% d) >90% 9.The upper segment: Lower segment ratio at 2 years of age in a normal child is a) 1.8:1 b) 1.5:1 c) 1.25:1 d) 1.12:1 10.Which one is not unfavorable for fetal development a) Herpes b) Rubella c) Alcohol d) Tetracycline

PEDIATRICS MCQs 11.A three year old child can do which of the following except a) Ride a tricycle b) Build a tower of ten cubes c) Knows his age and gender d) Use scissors to cut out pictures e) Count three objects correctly 12.Average birth weight of Indian child is a) 2.9 Kg b) 2.8 Kg c) 3.3 Kg d) 2.5 Kg 13.Taste perception of baby develops at a) Birth b) 4 months c) 6 months d) 8 months 14.Increase is length in the first year of life is a) 12 cms b) 15 cms c) 25 cms d) 35 cms 15.A child with mental age of seven and a chronological age of seven years has an I.Q of a) 100 b) 120 c) 145 d) 80 16.Milestones at 10 months of age are a) Pincer grasp b) Arranging 3 cubes c) Walks few steps without support d) Says mama dada 17.Child changes Rattle from one hand to another at the age of a) 3 months b) 6 months c) One year d) 2 years 18.IQ (Intelligence quotient) of a child means a) The creative efficiency of the child b) The capability of the child to perform intellectual tasks in relation to other children of same age c) The efficiency of memory of child d) Qualification of the learning ability of child 19.Normal height with decreased bone age is seen in a) Cushings syndrome b) Hypothyroidism c) Thanatotrophic dwarfs d) Down’s syndrome 20.In asymmetrical IUGR which organ is not affected ? a) Subcutaneous fat b) Muscle c) Liver d) Brain 21. A two year old child was brought to the OPD by his parents with complaints of not eating anything On amination her weight is 11.5 kg (50lh percentile of normal)and height 75 percentile of normal management is a) Advise multivitamin Tonic b) Force to eat c) Investigate for UTI d) Ask parents to stop worrying 22. Which of the following acts can a one year old child perform ? a) Sits down from standing position b) Drinks from cup c) Speaks one or two words with meaning d) Rings bell purposefully 23. Prenatal diagnosis is possible for all of following except a) Sickle cell trait b) Beta Thalassemia c) Ectodermal dysplasia d) Duchennes muscular dystrophy 24. A 7 year old boy with reduced height and weight for age for past one year is likely to have a) Malnutrition b) Lymphoma c) Chronic infection d) Measles 25. Intra uterine growth retardation can be caused by all except a) Nicotine b) Alcohol c) Propranolol d) Phenothiazine 26. Which of the following childhood disorder improves with increase in age a) Conduct disorder b) Emotional problems c) Temper tantrum d) Sleep disorder 27.A normal infant sits briefly leaning forward on her hands, reaches for and grasps a cube and transfers it from hand to hand. She babbles but cannot wave bye-bye nor can she grasp objectives with the finger and thumb. Her age is a) 4 months b) 7 months c) 10 months d) 14 months 28.Atavism is when a child resembles his a) Parents b) Grand parents c) Cousin d) Twin 29. Two carpal bones are radiologically seen in the wrist X-ray of most of the children by the end of a) 1 year b) 2 years c) 3 years d) 4 years 30. An infants sits with minimal support, attempts to attain a toy beyond reach, rolls over from supine to prone position and does not have pincer grasp is at a development of a) 3 months b) 4 months c) 6 months d) 8 months 31.A patient presents with scorbutic rosary, bone pains and X-ray reveals Frenkel’s lines. a) Scurvy b) Achondroplasia c) Syphilis d) Rickets 32.Vitamin K deficiency occurs in the following except a) Biliary obstruction b) Artificial milk feeds c) Oral antibiotic Therapy d) Malabsorption . 33.Breast feeding is best for the baby a) But has no effect on the mother b) But is likely to affect the mothers appearance significantly c) But may cause breast cancer in the mother d) And is also good for the mother 34.Excess of vitamin K in a new born causes a) Bleeding tendencies b) Hyperbilirubinemia c) Vomiting d) Hemolysis 35. Costochondral junction swelling are seen in a) Scurvy b) Rickets c) Chondrodystrophy d) all of the above 36.Kwashiorkor is diagnosed in growth retarded children along with a) edema and mental retardation b) Hypopigmentation and anemia c) edema and hypopigmentation d) hepatomegaly and anemia 37.Which one of the following contains least fat content in the milk a) Human milk b) Goat milk c) Buffalo milk d) Cow milk 38.Earliest sign of rickets is a) rickety rosary b) craniotabes c) bow legs d) Harrison’s groove 39. The normal calorie requirement for a 5 year old child is a) 800 calories b) 1000 Calories c) 1500 Calories d) 2000 Calories 40. In an infant exclusively on breast feed all are seen, except a) GI bleeding due to vitamin K deficiency b) Relative prolongation of physiological jaundice c) Evening colic d) Golden colour stools 41.A 18-month old baby presents with recurrent episodes of excessive crying followed by cyanosis, unconsciousness and occasional seizures since 9 months of age. The most likely diagnosis is a) Epilepsy b) Anoxic spells c) Breath holding spells d) Vasovagal attack 42.Which among the following is not expected in a 3 year old child a) Draw a circle b) Talk in sentence c) Climb down stairs d) hop 5 steps 43.By years all milk teeth are erupted a) 1.5 b) 2 c) 2.5 d) 3 44.I-elayed dentition is most characteristic of a) Mongolism b) Acromegaly c) Cretinism d) Malnutrition 45.A new born baby has a head circumference of 35 cms at birth. His optimal head circumference will be 43 cms at a) 4 months of age b) 6 months of age c) 8 months of age d) 12 months of age 46.Normal heart rate at birth is a) 120-160/min b) 100-120 c) 160-180 d) is always less than 100 47.Fetal growth is maximally affected by a) Insulin b) Growth Hormone c) Cortisol d) Thyroxine 48.A child can walk up and down the stairs alternating his feet by a) 12 months b) 24 months c) 36 months d) 48 months 49.Gender of external genitalia of foetus becomes clearly distinguished by a) 10 weeks b) 16 weeks c) 12 weeks d) 20 weeks 50.A child can copy a circle first at a) 2 years of age b) one and half year c) 4 years d) 3 years PEDIATRICS Objective Questions with Answers 51. Fetal Respiratory movements occur earliest at a) 12 wks b) 16 wks c) 20 wks d) 11 wks 52. Vocabulary of IViyear old child is a) 1-10 words b) 10-20 words c) 20-30 words d) 30-40 words 53.The antenatal diagnosis of all of the following conditions is feasible except a) Huntington’s chorea b) Down’s syndrome c) Severe combined immunodeficiency syndrome d) Anencephaly 54.Order of development of secondary gender characteristic in male a) Testicular development — pubic hair — Axillary hair — beard b) Pubic hair — testicular development — axillary hair — beard c) Testicular development — beard — pubic hair — axillary hair d) Axillary hair — beard — pubic hair — testicular development 55. Which is incorrect about Thumb sucking a) Can lead to malocclusion b) is a source of pleasure c) is a sign of insecurity d) must be treated vigorously in the first year 56.Head control is possible in an infant by _____ months a) 1 b) 2 c) 3 d) 6 57.IQ between 50-70 indicates a) Mild mental retardation b) Moderate retardation c) Severe retardation d) Profound retardation 58.Preference of use of one hand (handedness) is evident by a) 6 months b) 1 year c) 2 years d) 3 years 59.Fetal bradycardia is defined as a) Less than 100 beat/min b) between 100 and 200 beat/min c) Less than 120 beat/min d) Less than 120 beat/min for a period of 15 min of continuous monitoring 60.Regarding “breath holdinaspells” in children, one of the following statements is not true (KAR 94) a) It is fairly common in the first 2 years of life b) It does not contribute to increased risk of seizure disorders c) Parents are advised to ignore and not to reinforce these attacks d) It must be immediately attended to prevent hypoxia and onset of seizures 61.Neonatal period extends up to a) 21 day s of life b) 30 days of life c) 28 days of life d) 35 days of life 62.First permanent tooth to erupt is a) 1 st Premolar b) 1 st Molar c) 1st Incisor d) 2nd premolar 63.How many digits can a five year old child remember a) 4 b) 5 c) 8 d) 10 64.Increase in height in first year is by a) 40% b) 50% c) 60% d) 75% 65.The average B.P of a 1 year old child is a) 120/80 b) 75/50 c) 95/65 d) 60/30 66.Delayed speech in a 5 year old child with normal motor and adaptive development is most likely due to a) Mental retardation b) Cerebral palsy c) Kernicterus d) Deafness 67.Anthropometric assessment which does not show much change in 1-4 years a) Mid arm circumference b) Skin fold thickness c) Chest circumference: Head circumference ratio d) Height 68.A 5 year old child is assessed to have developmental age of one year. His developmental quotient would be a) 100 b) 80 c) 60 d) 20 69.True breath holding attacks generally do not occur after a) 1 year b) 5 years c) 2 years d) 18 months 70.Sitting Height is equal to a) Head circumference b) Chest Circumference c) Upper segment d) Crown-rump lengui 71.When a child is not able to perform the following motor functions such as skipping, walking on heels, hopping in place or going forwards in tandem gait, his motor development is considered to be below a) 3 years b) 4 years c) 6 years d) 7 years 72.Birth weight of a child doubles at five months of age while the birth length doubles at the age of a) 1 year b) 2 years c) 3 years d) 4 years 73.Breathing movements and swallowing movement seen in the foetus by a) 13-14weeks b) 18-24 weeks c) 15-18 weeks d) >30weeks 74.Length of a neonate is a) 40cm b) 50cm c) 70cm d) 100 cm 75.A child takes self decisions at the age of_____years. a) 3 b) 5 c) 7 d) 9 76.Child is not expected to do at 40 weeks of life a) Creeps crawl b) Walks with one hand held c) Sits up alone d) Pulls to standing position 77.Breast feeding is recommended at least for a) 4 months b) 6 months c) 9 months d) 1 year 78.The most important factor to overcome protein energy malnutrition in children less than 3 years is . a) Supply of subsidized food from ration shop b) Early supplementation of solids in infants c) Immunization to the child d) Treatment of anaemia and pneumonia in infant and toddlers 79.A 2 year old child has a weight of 6.4 kg and has vitamin A deficiency. What is the grade ofmalnutrition in this child ? a) First degree b) Second degree c) Third degree d) Fourth degree 80.Wind swept sign/deformity is seen in a) Scurvy b) Rickets c) Achondroplasia d) Osteoporosis 81.Breast feeding is contraindicated if the mother is taking a) Propranolol b) Broad spectrum antibiotics c) Sulfonyl ureas d) Insulin 82.Fatty Acid necessary during 0to6 months of age is a) Linolic acid b) Linolenic acid c) Arachidonic acid d) Palmitic acid 83.Which one is wrong about human milk a) Gives energy of 67 Kcal/L b) Carbohydrate forms 40% of total energy c) Fats form > 50% of total energy d) Proteins form 33% of total energy 84.One of the following is not reported to be a clinical manifestation of zinc deficiency state in children a) Dwarfism and hypogonadism b) Liver and spleen enlargement c) Impaired cell mediated immunity d) Macrocytic anaemia 85.The composition of breast milk, per 100ml a) 67 calories, 3.5 protein, 3.5g fat and 4.5 g carbohydrate b) 67 calories, 1.2g protein, 4 g fat and 4.5 g carbohydrate c) 67 calories, 1.2g protein, 4g fat and 7 g carbohydrate d) 100 calories, 3.5 protein, 4g fat and 7 g carbohydrate e) 100 calories, 3.5g protein, 3.5g fat and 4.5 g carbohydrate 86. The following are radiographic features of Rickets except a) Increased in width of growth plate b) Decreased bone density c) Rickety rosary d) Subperiosteal bleeding 87. Breast milk at room temperature stored for a) 4 hrs b) 8hrs c) 12hrs d) 24hrs 88.Which vitamin deficiency is not seen in newborn ? a) E b) c c) D d) K 89.A 4 year old boy derives most of his caloric requirements from a) Carbohydrates b) Proteins c) Fats d d) Minerals 90.Perioral rash, pigmentation of skin creases and neuritis is seen in deficiency of a) Zinc b) Copper c) Magnesium d) Biotin 91. The most common site of pulmonary atelactasis in children is: a)Right upper lobe b)Right middle lobe c)Right lower lobe d)Left upper lobe 92.When and where did the pediatrician complete medical school and residency? 93.How long has the pediatrician been in practice? 94.What hospitals does the pediatrician have privileges at? We were looking for them to have privileges at one specific hospital. 95.How soon after the baby is born will the pediatrician come to see it at the hospital? 96.Is there a line at the office that I can call if I have a “new mom” question? 97.What are the office hours and are there any early morning or late evening hours? 98.How long in advance must you book appointments? 99.Can you get in the same day if you need a sick visit? 100.Is there a specific time during the day that the doctor will take phone calls, and how does the office handle your phone-in questions? 101.How does the office deal with after-hours emergencies? 102.Is there a 24-hour answering service that can connect you to a doctor? 103.Who covers for the doctor when he/she is on vacation? 104.What books does the doctor recommend for new parents to read? 105.What are the doctor’s views on: sleep, vaccines, breastfeeding and other philosophies PEDIATRICS Questions and Answers pdf Download Read the full article

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priyastandon · 6 years ago

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PGI- A TEMPLE OF HEALING

Looking out of the window of a private ward room in the PGI, I heard a Gypsy's hooter sound "Woooo – woooo – woooo ...” My memory flew back thirty five years. May ’84- My Mom had just had a surgery and was convalescing in this very ward of the PGI. I was her caregiver. Terrorism was at its peak in Punjab. My father Justice Punchhi, was hearing all the cases registered under TADA-Terrorist and Disruptive Activities (Prevention) Act. (The Operation Blue Star in Amritsar happened in first week of June ’84). Chandigarh too was under curfew for long hours. In the midst of all this, my grandma died!

Her funeral was planned at a non-curfew time. And a Police-Gypsy was to lead the funeral procession from our home in sector 8, through the road dividing PGI and the Government College for Boys, up to the cremation ground in sector 25 … Mama and I, wanted to pay our last respects to my grandma. In the absence of mobile phones, the Gypsy hooting, “Woooo-Woooo-Woooo,” was our que to slip out of the room to the balcony through a slender window that spanned from floor to roof. She had a catheter, a cannula, a drain and all sorts of tubes in and out of her. I shudder to think how we did it … Well!

Ironically, staying in the PGI in the same block, felt pretty much the same as it did thirty five years ago. The beds, the assorted chairs of various heights and widths, the rolling sound of the trolleys that come to serve meals in steel utensils, were unchanged! The taste and the look of the soup, porridge, paneer gravy, dal and even the chappattis was strangely, the same! But somethings had changed. Let me give you a sneak peek...

The attitude of the doctors, nursing staff, attendants etc. was pleasantly improved … and considerably so! Everyone was more affable, better-spoken and more willing to offer help and comfort. The ward was cleaner; the bedsheets were spotless and colour-coded to the days of the week. The nursing staff wore smiles and looked neat, clean and crisp. A leaking tap in the loo was fixed in half an hour. It was a pleasure to compare!

Truly Doctors are akin to Demi-Gods. They can diagnose, treat, cut, stitch, amputate and do so much more! If you think about the process of a surgery, it is no less than a miracle … even the before and after of it!

The knife in the hands of a dacoit serves a very different purpose; in the hands of a chef it cooks up another story; whereas a lancet in the hands of a surgeon can give relief by process of elimination etc! The sharpness of the blade is the same ... What matters is, who is using it and how!

The relationship between a doctor and a patient is one of trust. One goes into anesthesia in an operation theatre only on the basis of trust. How else can one explain the complete giving in, into the hands of a doctor?

Looking closely at the life of the doctors at the PGI, really made me marvel at the way they conduct themselves. Duty hours are long and arduous. The lectures and exams go side by side. The stream of patients and their woes are unending.

For a patient, it may be one episode of excruciating pain in the head, heart, tummy, foot or wherever. It may be a matter of life or death, but for the doctors and para medical staff, it’s a story that gets repeated every day; several times a day; day after day… Yet they are supposed to put up smiling faces and listen with rapt attention as if it were the first time such a thing had ever happened.

I marveled at the way the doctors were in the operation theatre punctually at eight in the morning. Doing OPD's, rounds, prescriptions, lectures and even visiting patients in their rooms, late in the night … everything went like clockwork.

I wanted to give a little tip to the attendants who had been serving us. Why not? Don't we tip the waiters when we eat at restaurants? So why not here? The grey haired lady attendant, who pushed the wheel chair up to the car, smiled and declined the favour saying, "I don't take tips from anyone. It is my principle.” My head lowered down with respect. I recalled what Sai Baba says, "Duty without love is deplorable. Duty with love is desirable. Love without duty is Divine."

By now, my heart is welling up with emotion and mind is over-flowing with thoughts of gratitude. As the cerebral juices flow and the words form in tandem with the ink in my pen, my tears join in to punctuate the stream of gratitude with blessings for all those who make the clock tick in this iconic place called PGI which I prefer to call, “A Temple of Healing!”

This piece was published by The tribune on 31.1.2019

#PGI #service to man is service to god #hands that help are holier than lips that pray #gratitude

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echotunes · 2 months ago

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echo \o/!! you’re getting close to the end of opd, how are you feeling about it all?

WSD!!! I'm feeling very. ough. the end of episode 17/start of 18 (with the letter) was a Lot (by which i mean FUCKED UP AND EVIL). and the Kaiser death scare in episode 18 was also very evil but I enjoyed threatening Cellbit through my screen for it at least! and well in general I feel a bit ominous because the Finale Is Approaching and that's scary but also I'm excited to see what ends up happening!!

(also I made it to the end of the like 8 full episodes of haunted mansion so I'm glad about that. we're free. or well technically we're in the basement now but I'm not counting that as the mansion anymore. you understand)

#also once i'm done i can watch opc yayyyyy #which i am also looking forward to!#echo.asks #wsdanon #ordemlb #<- again not a liveblog but for other people's spoiler blocks

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thekneeclinic-blog · 6 years ago

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Anterior Cruciate Ligament (ACL) Treatment

What is an ACL Injury?

The anterior cruciate ligament, or ACL, is the most important ligament of the knee to prevent the knee from sliding forward or rotating anterolaterally. Patients who sustain an ACL tear often have problems with twisting and turning activities, such as in playing kabaddi, football or badminton, and will often require an ACL reconstruction to provide stability to their knee.

In addition to its stability role in the knee, the ACL also provides protection for the menisci of the knee. When the knee continues to have instability episodes, it is not uncommon to have either a medial or lateral meniscus tear. However, when menisci tear there is much higher risk of the development of osteoarthritis. Because of this, Dr. Sheth usually recommends ACL surgery and that an ACL reconstruction be performed in young or otherwise active patients and in almost all patients who report instability with twisting or turning activities.

An ACL injury is classified by the amount of injury to the ligament:

• Grade I: a partial ACL tear • Grade II: near complete ACL tear • Grade III: a complete ACL tear – the ligament is non-functional

Patient’s age, activity level and grade of tear will determine the correct treatment option.

Description of ACL Reconstruction

An ACL surgery requires precise knowledge of the anatomy of the knee, attachment sites of the ACL and knowledge on the other ligaments and structures of the knee. If one fails to replace an anterior cruciate ligament at its correct attachment sites or if other concurrent injuries are not treated, there is a much higher risk of failure of the ACL graft.

While there are two bundles of the ACL, the anteromedial and posterolateral bundles, there is still controversy as to whether both should be reconstructed as a single ligament or as two separate ligament grafts. While the double-bundle ACL reconstruction technique appeared very promising initially, many research groups have significantly narrowed the indications for double-bundle ACL surgery and found there is very little difference between a single and double-bundle ACL reconstruction for the vast majority of patients.

The most important technical issue is to have the ACL reconstruction graft placed in the correct position. On the tibia (shinbone), the tunnels should be in line with the posterior margin of the anterior horn of the lateral meniscus. On the femur (thigh bone), the reconstruction tunnel should be placed at the midpoint of the attachment bundles of the anteromedial and posterolateral bundles, with the main portion of the reconstruction tunnel being posterior to the lateral intercondylar ridge (resident’s ridge).

A large number of ACL reconstruction graft failures are in those patients who have the graft placed too posterior (central) on the tibia with an inability to control rotation of the knee or too anterior on the femur (anterior to resident’s ridge) or too central on the femur (effectively only reconstructing the anteromedial bundle), which leads to either stretching of the reconstruction graft or failure to control knee rotational laxity.

Are you a candidate for an ACL Reconstruction?

There are two ways to initiate a consultation with Dr. Sheth:

1. You can provide X-rays and/or MRIs for a clinical case review with Dr. Sheth.

2. You can schedule an OPD consultation.

REQUEST CASE REVIEW OR OPD CONSULTATION

(Please keep reading below for more information on this treatment.)

ACL Surgery Technique

The technique of ACL reconstructions has changed dramatically over the last decade in orthopaedics. ACL reconstruction grafts performed prior to 5-10 years ago were usually placed more centrally on both the tibia and femur and many of these patients have continued problems with rotation instability. This problem became recognized through extensive clinical and biomechanical research and the surgical technique has currently changed dramatically to where the reconstruction tunnels are now placed more anatomically to provide better stability to the knee.

Dr. Miten Sheth’s primary surgical reconstruction technique involves using a hamstring autograft (from the patient’s own tissues) during ACL surgery. The reconstruction tunnel is drilled at the anatomic attachment site of the ACL on the tibia and a tunnel is drilled at the ACL attachment site on the femur. The graft is pulled into the joint and fixed in place with a fixed or adjustible loop on the femur and an interference screw or suture disc on the tibia. The utilization of fewer incisions results in less pain post-operatively for the patient, while the use of the autograft allows the patient to return to activities sooner with a lesser risk of reconstruction graft failure.

Post-Operative Protocol for ACL Reconstruction

It is absolutely essential for a physical therapist to be consulted and to work with one’s surgeon post-operatively following ACL surgery. Reactivation of the quadriceps mechanism, edema control, patella mobilization, maintenance of full knee extension and regaining knee motion are absolutely essential to obtaining optimal post-operative outcomes.

In our practice, we strongly suggest and require patients remain in touch to work with our team of physical therapists for a minimum of 28 days post-operatively to make sure they are having appropriate care and also so that their rehabilitation will advance to higher levels sooner.

Frequently Asked Questions

When to have ACL surgery after injury?

Persons who have any difficulty with twisting, turning, or pivoting after an ACL tear should consider having their ACL reconstructed. This is because repeated twisting and turning mechanisms can damage both the cartilage in the joint and also the menisci. The medial meniscus is the most at risk to injury with an ACL tear because the medial meniscus takes over a lot of the function of the ACL when it is torn to prevent the knee from slipping forward. In addition, patients who may have a repairable meniscus tear at the time of their ACL tear should consider surgery to prevent the tear from becoming non-reparable. In general, most people who tear their menisci will be developing arthritis and having symptoms within 8-10 years after their ACL tear. Thus, one of the main reasons for the general public to consider having an ACL reconstruction is both to repair any meniscal tears which are repairable, and also to prevent meniscal tears from developing if their knee is unstable.

What is ACL reconstruction surgery?

ACL reconstruction surgery consists of replacing a torn ACL with another ligament or tendon. This can be from one’s own body (an autograft) or from a donor (an allograft). In an ACL surgery, tunnels are reamed at the normal attachment site of the ACL on both the femur and tibia and the graft is secured either inside or outside these tunnels.

How is an ACL reconstruction done?

An ACL reconstruction is done by replacing the torn ACL with tissue that is placed at the normal attachment sites of the native ACL. This involves reaming a tunnel in the femur (posterior to the lateral intercondylar ridge) and also in the tibia (adjacent to the anterior horn of the lateral meniscus) and then securing the graft within those tunnels. There are multiple ways to secure the graft, and this can include fixation within the tunnels with metal or bioabsorbable/plastic screws or through a loop and button placed on the outside of the tunnels. In general, the fixation of the grafts is performed according to the way the surgeon was originally taught, with the gold standard being screws placed within the tunnels for patellar tendon grafts and looped sutures with cortical buttons or screws within tunnels for hamstring ACL reconstruction grafts.

When should an ACL be repaired?

The main time that ACLs can be repaired is when an ACL is torn with a piece of bone, usually off the tibia, which is much more common than when torn off the femur. In this circumstance, if there is not a lot of intrasubstance stretch within the torn ACL, the bony can be refixed at its normal attachment site and secured such that early motion can be started. In those instances where the tissue is not strong enough to allow early motion, there is a much higher risk of stiffness if immobilization is required after surgery.

In terms of a repair of the ACL, there are perhaps 10% of patients who may have injury only to the attachment site on the femur or tibia and sutures can possibly be placed in to do a repair. In those circumstances, research is still ongoing to try to improve outcomes because attempts at repairs in the literature previously have not shown good outcomes over time. Thus, more research is necessary to define better techniques to perform ACL repairs in those circumstances. It is important that these techniques be based upon good science and not on marketing by device companies because previous attempts at ACL repairs did not show failures until after two years after surgery.

How long is an ACL surgery recovery?

One of the most important things for preventing a retear of an ACL reconstruction is to ensure that the patient has gone through the proper recovery phase after surgery. In the past, many surgeons tried to get their patients back to full activities by 5 or 6 months. However, more recent data has suggested that waiting up to 9 months may be more advantageous in that the rate of retear goes down significantly after the 9-month timeframe for a return to activities after ACL surgery. In general, it is important to make sure that an athlete has a full return of proprioception, strength, agility, and endurance to minimize their risk of reinjury.

When can I run after ACL surgery?

The ability to return to running after an ACL surgery is dependent upon many factors. If the surgery is only the ACL, and there are no other ligaments or meniscus tears treated, and the cartilage surfaces are intact, then one has to go through a proper rehabilitation program first. In general, we feel that an athlete has to wait a minimum of 4 months after their ACL reconstruction to return to running. In addition, they should have appropriate quadriceps strength. Our main goal is to be able to have them perform a single-leg squat with no bending of the knee inwards (valgus collapse) during the single leg squat. In these circumstances, if the patient has a good return of function, good motion, and does not have a valgus collapse when performing a single-leg squat, they are generally able to initiate a return to their running program at about the 4-month timeframe. This allows the quadriceps mechanism to be strong enough to prevent extra stress on the knee which can lead to knee swelling (effusions) and possibly damage the cartilage which would not be noticed until several years later.

What causes ACL reconstruction failure?

The number one cause of ACL reconstruction failure in all of the literature is improperly placed ACL grafts at the initial surgery. This can cause extra stress on an ACL reconstruction graft which can lead to its failure. In addition, any other missed meniscus or ligament problem at the time of ACL surgery can also put significant stress on an ACL reconstruction graft, which can lead to its failure. Other factors include patients that have hyperlaxity. These patients who have a significant increase of heel height (more than 4-5 cm), have a much higher risk of having grafts stretch out and would be better off with an additional ligament procedure (lateral extra-articular tenodesis). Other factors include patients with a large increase in their posterior tibial slope (sagittal plane tibial slope) which can cause an ACL graft to be overloaded and stretch out over time.

Patellar tendon ACL reconstruction versus Hamstrings ACL reconstruction

Patellar tendon ACL reconstructions have been considered the gold standard for almost 30 years. This is because they are the graft of choice for surgeons who cover professional teams and high level athletes. However, hamstrings grafts are considered to be appropriate for a majority of patients. Hamstrings grafts would be most appropriate for patients with open growth plates and in those patients who may have lower levels of activity desired after an ACL reconstruction. In general, a patellar tendon ACL reconstruction should not be performed in patients with anterior knee pain (around kneecap), or may have had a previous patellar tendon harvest. In general, large database series have shown that the rate of retear is the same with a patellar tendon reconstruction compared to a hamstrings ACL reconstruction. A well done ACL reconstruction with either graft can be appropriate for majority of patients.

#KneeReplacement #kneetreatment #kneesurgery

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ourhaileydavies · 5 years ago

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Unilateral Bleeding Polyp in a Child: Lobular Capillary Hemangioma-Juniper publishers

Abstract

Epistaxis, though being common, always attracts special attention from medical professionals due to the nature of bleeding involved in the process. Children presenting with unilateral epistaxis warn otolaryngologists as the cause can vary from nasal foreign bodies to life threatening hemangiomas and angiofibromas. We present a rare case of lobular capillary hemangioma originating from nasal septum in a child who presented with episodes of profuse bleed. Early diagnosis and management with total excision was awarding. The occurrence is rare, however it should be in the differential diagnoses of unilateral nasal bleed in outpatient and emergency settings and strong suspicion is warranted.

Keywords: Unilateral bleeding polyp in children; Nasal bleeding polyp; Unilateral nasal bleed; Lobular capillary hemangioma; Hemangioma of nose; Unilateral epistaxis

Introduction

Lobular capillary hemangioma (LCH) is an acquired benign vascular proliferation of unknown origin, which was first described as human botromycosis by Poncet and Dor in 1897 [1]. Skin of head and neck and mucos membrane of the oral cavity are common sites but LCH is rare in the nasal cavity of children. The nasal septum is the most common affected nasal site, vestibule and middle turbinate being the other involved sites [2,3]. We present a case of lobular capillary hemangioma in a nine year old child who had presented with unilateral nasal bleed.

Case Report

A nine year old child presented to the outpatient department of otolaryngology and head and neck surgery with 5 months history of recurrent nasal bleeding from left nasal cavity and left sided nasal obstruction. History of frequent nose picking present. On anterior rhinoscopy, single red fleshy lobulated mass of size 1.5x1.5cm was present in the left nasal cavity surrounded with blood clot. Contrast enhanced Computed tomography (CECT) of Paranasal sinus revealed a heterogeneously enhancing soft tissue lesion attached to the cartilaginous part of nasal septum (Figure 1). Rest of the head and neck and systemic examination was normal. Hence provisional diagnosis of a vascular nasal mass was made. Patient was planned for endoscopic excision under general anesthesia.

Under general anaesthesia, after decongestion of bilateral nasal cavity, evaluation of the nasal mass was done. Endoscopic evaluation revealed a pinkish nasal mass which was arising from the cartilaginous part of the nasal septum (Figure 2). Stalk of the nasal mass was cauterized with bipolar cautery and the tumour was removed into to with sacrifice of 0.5cm surrounding mucosa at the site of attachment of the lesion. Adequate haemostasis was achieved. Anterior nasal packing was done. Anterior nasal packs were removed after 24 hours and patient was discharged. The follow up of the patient was uneventful, Histopathological examination revealed the diagnosis of lobular capillary hemangioma. Microscopic examination showed biopsy tissue lined by focally ulcerated stratified squamous epithelium with underlying lobular arrangement of capillaries surrounding a large central vessel. The lumen of these capillaries varied from barely visible to large vascular spaces. The spindle shaped pericytic cells were seen in the periphery. No atypical mitotic figure or evidence of necrosis (Figure 3 & 4).

Discussion

Lobular capillary hemangioma (LCH) was thought as pyogenic granuloma in earlier times but later denoted as misnomer because of non-infectious and non granulomatous nature. Present terminology of LCH is based on the characteristic histopathological findings described by Miller [4].

Incidence of LCH is more in females as compared to males and is common in third decade of life [5]. Nasal cavity is an unusual site for LCH. Gingiva is a common site of lobular capillary hemangioma. Among the nasal sites, anterior septal mucosa and tip of turbinate's are the most frequent involved sites [1]. The presented case is that of a 9 year old male child who presented with a bleeding polypus of the anterior nasal cavity and which turned out to be LCH. The lesion in this case was found to be attached to the septal cartilage.

Natural history and progression of LCH involves many contributing factors. These include trauma, hormonal imbalances, viral oncogenes, arterioveno malformation and angiogenic growth factors etc [6]. This child had a history of frequent nasal pricking, which could have led to repeated microtrauma and proliferation of vessels to form LCH attached to the nasal septum anteriorly. LCH have also been described as pregnancy tumour [7] due to increased associations with high levels of estrogen and progesterone during pregnancy.

LCH usually presents with various symptoms such as unilateral epistaxis, nasal obstruction, nasal discharge, facial pain, headache etc depending on the site of lesion [6]. This patient had presented to our OPD with repeated episodes of left sided nasal bleed especially after nose pricking. Father of the child had noticed a small red mass in the left nasal cavity for which he brought the child into our outpatient department.

CECT of the nose and paranasal sinuses is the preferred investigation for diagnosis of vascular lesions. Magnetic Resonance Imaging (MRI) with T2 weighted images reveal vascular soft tissue lesions with multiple flow voids [8].

Criterion standard treatment in LCH has always been complete surgical excision of the lesion. Surgical technique and instrumentation used for such kind of lesions include cold instrumentation (with or without preoperative embolization), electrocoagulation, cryotherapy and LASER [9]. We did endoscopic excision of the hemangioma followed by cauterization of its base at the nasal septum which had the feeding vessels in it.

Recurrences of the lobular capillary hemangioma are a rare occurrence. However, evidence in literature report a recurrence rate of 0 to 42% depending on the location, extent of removal and time of follow up [10]. This case has been followed up for 4 months till date and there is no evidence of recurrence of the lesion.

Conclusion

Lobular capillary hemangioma of the nasal cavity is a rare entity especially in a male child in first decade of life. However, it should be considered as one of the differential diagnoses of unilateral epistaxis in children. High index of suspicion is the key for identifying such a lesion. Endoscopy guided complete surgical excision of the lesion is the management of choice for nasal lesions. Recurrence is rare with no malignant transformation reported till date.

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